Every finding on record at South Shore Rehabilitation

Based on observation, interview, and record review, the facility failed to follow the fall care plan for one resident (R2) out of three residents who were reviewed for falls. The facility failed to put a floor mat next to R2's bed and subsequently R2e fell on the floor in his room, next to his bed and sustained a laceration above his left eyebrow.Findings Include: On 08/08/2026 at 10:14AM, R2 was sitting in a geriatric chair located next to V3 in the third-floor dining room. R2 was observed with a laceration above his left eye. R2's laceration is observed to be approximately one inch in horizontal length with minimal serosanguineous drainage and swelling approximately the size of a golf ball. V5 (Certified Nurse Aide) stated R2 fell this morning while inside of his room. R2 stated he fell but is noted with confusion and unable to give surveyor further details. On 08/08/2026 at 10:45AM, V5 (CNA) stated she arrived at 6:00AM this morning. V5 stated she began performing her rounds to check on the residents. V5 stated upon doing her rounding, she observed R2 lying face down on the floor inside of his room next to his bed. V5 stated V4 (Licensed Practical Nurse) assessed R2 and applied ice to his eye. V5 stated she and V4 then placed R2 into a geriatric chair. On 08/08/2026 at 10:26AM, V4 (Licensed Practical Nurse/LPN) stated the third floor is the memory care unit and consists of residents with memory issues. V4 stated when she arrived this morning at approximately 7:00AM, V5 (CNA) informed V4 that R2 was on the floor inside of his room. V4 stated when she arrived at R2's room, she observed that R2 was on the side of his bed, face down on the floor. V4 stated sometimes R2 tries to get out of bed on his own. V4 stated she observed that R2 had a laceration over his left eye with swelling. V4 stated R2 did not have floor mats in place when she arrived at R2's room. V4 stated she assessed R2 further and called the doctor. V4 stated the doctor did not give orders to send R2 to the hospital. V4 stated she received orders to apply an ice pack to R2's laceration and perform neuro checks. R2's MDS/Minimum Data Set, dated [DATE], documents R2 has a BIMS/Brief Interview for Mental Status of 12/15, indicating that R2 is mildly cognitively impaired.R2's care plan dated 06/18/2026 documents R2 is at low risk for falls. R2's care plan documents that R2 had an actual fall on 06/23/2026 with interventions to include Floor mats and staff to ensure R2 is safely positioned in bed.R2's Fall Risk assessment dated [DATE] documents that R2 is at high risk for falls. R2's progress note dated 08/08/2026 at 6:48PM written by V4 (LPN) documents in part, Upon arrival to shift, CNA notified writer that R2 had an un-witnessed fall. Writer immediately went to R2's room and observed R2 lying face down on the floor beside the bed. No visible blood noted. R2 was awake and actively speaking. writer assessed resident and instructed CNA to obtain vital sign equipment and computer. Resident was assessed prior to being repositioned. CNA assisted writer with turning resident over for further assessment. Resident noted with small, raised area to left forehead near eyebrow. No other visible raised areas or bleeding, or obvious injuries noted at time of assessment. Resident were alert and oriented to name and date of birth . Pupils assessed and appeared equal/reactive. Extremities assessed with no obvious abnormalities noted. Resident able to communicate with staff. MOD/manager on duty notified and came to assess resident and instructed writer to call physician. Writer contacted physician and was instructed to apply ice therapy and continue to do neuro checks. On 08/09/2026 at 2:48PM, V10 (Fall Coordinator/LPN) stated if a resident's fall precaution interventions are not implemented, then this can cause the resident to be at risk for having another fall incident. V10 stated if a resident experiences a fall, and their floor mats are not in place, the resident could fall and injure themselves. Facility policy dated 01/2026 titled Falls-Clinical Protocol documents in part, Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

Based on observations, interviews, and record reviews, the facility failed to do a complete skin assessment and monitor a resident's (R1) skin issue, failed to have treatment orders in place, failed to have the wound physician evaluate R1's wound, and failed to identify a new skin issue for 1 (R1) out of 6 residents reviewed for Quality of Care. Findings include: R1's admission Record documents in part diagnoses of aphasia (communication impairment) following a stroke, right side weakness and paralysis, heart failure, chronic obstructive pulmonary disease, hypertension (high blood pressure), hyperlipidemia (high cholesterol, and epilepsy. R1's 4/6/2026 MDS (Minimum Data Set) assessment documents in part that R1 is severely cognitively impaired. R1 is dependent on staff for toileting, bed mobility, and grooming/hygiene. R1's 6/9/2026 lower extremity scans document in part significant arterial stenosis. On 6/23/2026 at 12:44 PM, survey team along with V9 (2nd Floor Unit Manager) observed R1 lying in bed. There was a gauze dressing wrapped from R1's right knee down to the foot. R1's left ankle also had gauze dressing wrap. V9 was not familiar with all of R1's wounds. On 6/24/2026 at 11:42 AM, V8 (Wound Care Coordinator) performed R1's wound care with assist from V24 (Wound Care Tech). During wound care, red drainage noted coming from behind R1's right knee. V8 stated it was a new skin issue. Per R1's wound assessments, V8 measured it to be 1.5cm (centimeter) (length) x 1.20cm (width). The left ankle had multiple skin issues. Left medial (inside) ankle with two skin issues. The central (top) wound was scabbed, but the distal (bottom) wound was draining. Per R1's wound assessments, V8 measured it to be 8.5cm x 2.0cm. V8 stated the left outer/lateral ankle wound was new. Per R1's wound assessments, V8 assessed it to be a full thickness wound with slough measuring 3.8cm x 2.0cm. V8 and V24 completed wound treatment to wound behind right knee and left ankle wounds. Did not observe V8 perform wound care treatment to R1's right heel which surveyor observed a dark, circular skin issue. V8 and V24 placed foam heel protectors and sheet over R1. Surveyor asked V8 if there were any wound treatments to R1's right heel or if facility leaves it open to air. V8 was confused and thought surveyor meant to ask about R1's left ankle wounds. Surveyor reiterated question regarding R1's right heel. V8 removed R1's sheet and right foam boot. V8 stated did not notice the right heel skin issue. V8 stated skin issue is new. V8 tried to rub it off but it remained. Per R1's wound assessments, V8 assessed it to be a full-thickness wound measuring 2.0cm x 1.0cm. V8 stated last seeing R1 and doing R1's wound care on Monday (6/22/2026). V8 stated did not do a full skin assessment at that time and did not notice the skin issues behind R1's right knee, right heel, or left lateral ankle. V8 stated V28 (Wound Doctor) has not seen R1's lower extremity wounds but was scheduled to see them on 6/26/2026. V8 stated that typically V8 will inform the primary doctor about any new issues. Depending on the type of skin issue, V8 will recommend referral to V28 (Wound Doctor) to see the resident. Facility's Daily Floor Assignment sheets documents in part that R1 was due for a bath on 6/22/2026. During a telephone call on 6/25/2026 at 1:07 PM, V12 (CNA, Certified Nurse Assistant) stated V12 provided R1 with a bed bath on 6/22/2026 and caring for R1 on 6/23/2026. V12 stated V12 did skin assessment during bed bath but could not note any new wounds to R1's lower extremities because they had wound dressings. On 6/25/2026 at 2:45 PM, V2 (Director of Nursing) stated staff should perform body/skin checks during showers/baths. V2 stated the wound care team should be taking care of and assessing whatever is wrapped up when they unwrap the dressings. During a telephone interview with V27 (R1's Primary Physician) on 6/30/2026 at 10:02 AM, V27 stated R1 is very high risk for skin wounds related to vascular insufficiency. V27 stated V27 could not recall if facility informed [V27] of every wound for R1. V27 stated that V28 (Wound Doctor) was part of R1's care team. V27 stated the expectation was for the wound care team to communicate to V28 and to have V28 treat R1's wounds. During a telephone interview with V28 on 6/30/2026 at 11:30 AM, V28 stated V28 conducted initial assessment of R1 (6/5/2026) for a post-surgical wound to abdomen. V28 stated did not know about R1's lower extremity wounds until surveyor called on 6/25/2026. V28 stated typically facilities will notify V28 of new skin issues during rounds with the wound nurse at the facility. V28 stated wound care team did not bring up any other issues for R1 during 6/19/2026 rounds. V28 stated expectation is for wound care team to address wounds until V28 can assess them in person and make recommendations. V28 stated V28 did not reassess R1 until 6/26/2026. V28 stated R1's wounds were unavoidable due to vascular insufficiency and is prone to additional wounds until vascular insufficiency is fixed. Regarding skin assessments, V28 stated that whoever unwraps R1's leg dressings are responsible for observing any new skin areas prior to replacing the bandages. R1's progress note dated 6/9/2026 5:42 AM and 8:25 AM, documents in part that V42 (Nurse) observed intact blisters to R1's left inner lateral lower leg and open skin to outer lateral left ankle. Progress notes read that V42 notified V27 and the wound care team. R1's progress notes or wound assessments do not contain a complete assessment (wound measurements/appearance) or updated weekly assessments regarding the open skin to R1's outer lateral left ankle. R1's Order Summary Report also did not contain any wound care orders to the left lateral leg/ankle until 6/24/2026 (time of survey). On 6/24/2026, R1's left lateral ankle had a full thickness wound with slough measuring 3.8cm x 2.0cm. R1's wound summary of the left lower medial ankle documents, in part, that the facility identified it on 6/8/2026 measuring 8.5cm x 2.8cm. 6/09/2026 picture of left medial ankle shows a reddened top area. The bottom area is larger with blistering. On 6/17/2026, facility described it as a partial thickness wound measuring 8.5cm x 4.0cm. No documentation that this wound was referred to V28 during 6/19/2026 rounds. R1's Care Plan Report documents, in part, that R1 has potential for skin integrity impairment related to multiple comorbidities (initiated 3/31/2026). Interventions initiated 3/31/2026 include to observe skin during routine care and report alteration to the nurse, skin check on shower days and [as needed], and assessed by wound [Medical Doctor] as needed. R1's Care Plan Report also reads that R1 has potential/actual impairment to skin integrity (initiated 3/30/2026 and revised 6/24/2026). Intervention initiated on 3/30/2026 reads weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Requested facility's skin care program, skin assessment policy, or wound care policy from V1 (Administrator) and V2 (Director of Nursing). Facility provided Prevention of Pressure Wounds policy. Although R1's wounds were characterized as arterial wounds, policy documents in part: The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown.

Based on observation, interview, and record review the facility failed to follow infection control protocol by not displaying the correct isolation sign for two residents (R66 and R143); failed to ensure that Enhanced Barrier Precaution (EBP) sign was visibly posted for three residents (R209, R210 and R211) who require EBP; and failed to ensure staff perform hand hygiene during dining for three residents (R125, R130 and R190). Theses failures affected eight residents (R66, R125, R130, R143, R190, R209, R210, and R211) reviewed for infection control and has the potential to place all 198 residents at risk for the spread of infection.Findings include: #1 On 08/04/2025 at 12:28pm on the 4th floor dining/activity room, V11 (Activity Aide) set up R11's food tray. After setting up R11’s food tray, V11 moved R11’s wheelchair closer to the table. On 08/04/2025 at 12:30pm, V11 took another food tray from the food cart without performing hand hygiene and set up the food tray in front of R190. After setting up the food in front of R190, this surveyor inquired about hand hygiene. V11 stated she is supposed to sanitize her hands before setting up her (R190) food tray but she forgot. On 08/05/2025 at 12:15pm, V22 (Infection Preventionist/LPN) stated the expectation is for the staff to wash their hands after contact with the resident’s wheelchair prior to serving another resident’s tray to prevent from passing on any type of contamination or germs. V22 added “We need to have clean hands when we serve food.” R11’s (Active Order as of: 08/05/2025) Order Summary Report documented R11’s Diagnoses: (include but not limited to) history of falling, hemiplegia and hemiparesis, and asthma with acute exacerbation. R11’s (06/26/2025) Minimum Data Set documented, in part “Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06.” Indicating R11’s mental status as severely impaired. Section GG0170. Q5. Does the resident use a wheelchair and/or scooter: 1- Yes.” R190’s (Active Order as of: 08/05/2025) Order Summary Report documented R190’s Diagnoses: (include but not limited to) epilepsy, muscle wasting and atrophy, and mild protein malnutrition. R190’s (06/11/2025) Minimum Data Set documented, in part “Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 07.” Indicating R190’s mental status as severely impaired. The (undated) Passing Meal Trays documented, in part “Policy: Nursing will be responsible for preparing residents for scheduled meal service. Policy Specifications: Dining Room Meal Service: Designated Staff will be responsible for distributing the beverages prior or during meal service. 3. Sanitize hands routinely.” The (08/05/2025) email correspondence with V2 (Director of Nursing) documented, in part “Staff should utilize the hand sanitizer in dining room, after touching wheelchairs hands should be sanitized.” The (8/2024) Standard precautions Guidelines documented, in part “Standard Precautions are used for all patient care. They’re based on a risk assessment and make use of common sense practices and personal protective equipment used protect healthcare providers from infection and prevent the spread of infection from patient to patient. Implementation of standard precautions constitutes the primary strategy for preventing healthcare associated transmission of infectious agents among resident and healthcare personnel. Appropriate infection control measures should be used in each resident interaction. Standard Precautions include but not limited to hand hygiene. Equipment or items in resident environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents. Standard precautions are also intended to protect a residents by ensuring healthcare personnel do not carry infectious agents to residents on their hands or via equipment used during resident care.” The (undated) handwashing/Hand Hygiene Policy documented, in part “It is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infections among residents. Policy Specifications: 4. When hands are not visibly soiled, employees may use an alcohol-based hand rub containing at least 60% alcohol in all of the following situations: n. during resident meal service: in between tray pass if contact with resident is made, hand hygiene should be used.” #2 On 08/04/2025 at 11:19am, R209 was seated on a chair. R209’s right foot was covered with [NAME] sheet, supported by a half cast, and wrapped with ace bandage. R209 stated he was on a car accident and the hospital put 2 screws in his right foot. This surveyor went outside the room, there was no EBP (enhanced barrier precaution) sign posted by R209’s door and no PPE bin available. On 08/04/2025 at 2:41pm with V5 (Unit Manager/LPN) by R209’s door. V5 stated there was no EBP sign posted by R209’s door and no PPE bin outside of the room. On 08/04/2025 at 2:47pm, V22 (Infection Preventionist/LPN) stated if a resident came in with surgical incision, the expectation is to place the resident on EBP (enhanced barrier precaution) to keep the wound from getting infected. There should be an EBP sign posted by his door and PPE bin available, so the staff is aware of what to wear when doing ADL (Activities of Daily Living) care. On 08/05/2025 at 3:23pm, there was an EBP sign posted by R209’s door and PPE bin across the room. V5 stated the EBP sign should have been posted and PPE bin available on 08/01/2025, the day he was admitted . On 08/06/2025 at 12:45pm, V2 (Director of Nursing) stated the resident has a surgical incision and should be placed on EBP. R209's admission Record documented R209's admission date was on 08/01/2025. R209’s (Active Order as of: 08/05/2025) Order Summary Report documented, in part “Diagnoses: (include but not limited to) pathological fracture, hypertension, and Opioid abuse. Order Summary. Maintain Enhanced Barrier Precautions to prevent infection r/t (related to) surgical incision. Order Date: 08/05/2025.” Of note, order was placed 4 days after admission. R209’s (08/01/2025) Hospital External Transfer Report documented, in part “Diagnosis: Motor vehicle collision. Closed nondisplaced fracture of right calcaneus (heel bone). Surgery Performed: 7/26/2025 Right calcaneus ORIF (open reduction internal fixation). [NAME] (Active Wounds, Airways, Lines, Drains, Ostomies): Surgical/Procedure: Surgical Incision Posterior Right heel. Hospital course and therapy. Underwent ORIF right calcaneus.” R209 (08/05/2025) care plan documented, in part “requires Enhanced Barrier Precautions d/t surgical incision. Enhanced Barrier Precautions will reduce the spread of the infectious agent, minimize the transmission of the infection, and reduce the risk of colonization. Interventions: Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc. Gown and glove use when performing high-contact resident contact activity. Have adequate PPE available. Practice good handwashing.” The (03/21/2024) Enhanced Barrier Precautions documented, in part “It is the practice of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug resistant organisms. Definitions: “Enhanced Barrier Precautions” refer to the use of gown and gloves for use during high contact resident care activities for resident known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices. Explanation and Compliance Guidelines: 1. Prompt Recognition of need: c. Clear signage will be posted on the door or wall outside of the resident room indicting the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions – b. implement Enhanced Barrier Precautions for resident with unhealed surgical wounds. 3. Implementation of Enhanced Barrier Precautions – a. make gowns and gloves available immediately outside of the resident’s room.” R66’s Face sheet shows R66 has diagnosis which include but not limited to infection and inflammatory reaction due to other internal prosthetic devices, implants, and grafts, presence of heart assist device, viral infection, and resistance to vancomycin. R143’s Face sheet shows R143 has diagnosis which include but not limited to presence of heart assist device, other mechanical complication of other cardiac and vascular devices and implants subsequent encounter, and acute osteomyelitis. R210’s Face sheet shows R210 has diagnosis which include but not limited to encounter for surgery aftercare following surgery on the digestive system. On 08/04/25 at 10:38 am, R66 and R143’s room door was observed with a sign stated, “Enhanced Barrier Precaution (EBP).” R66 and R143 were both observed with LVAD (left ventricular assistive device) next to R66 and R143’s bed side. R143 was observed with and IV (intravenous) pump next to R143’s bedside did not have any IV medication infusing into R143. R143 was observed with a PICC (Peripherally Inserted Central Catheter) to R143’s right arm. R143 stated R143 was receiving IV antibiotics for infection. On 08/04/25 at 10:49 am, R210’s room door was observed with Personal Protective Equipment (PPE) and without any visible signage posted (EBP or isolation sign). V13 (Registered Nurse, RN) stated, “He is on Enhanced Barrier Precaution (EBP) I took his sign down and threw it in the trash today because it was ripped and needed to be replaced. I just asked V22 (Infection Preventionist, Licensed Practical Nurse, LPN) to print another sign.” Surveyor and V13 then observed the trash can V13 stated she had thrown R210’s ripped EBP sign in and Surveyor and V13 did not observe any isolation signs ripped in the trash can(s) on the fourth-floor unit. V13 then stated she was going to get R210 a EBP sign for R210’s door. V13 explained residents should have the proper isolation signs on the residents door, so staff know what type of isolation the resident requires before entering the room. V13 then explained if residents don’t have the proper signage on the residents door it may cause a cross contamination. On 08/05/25 at 3:21 pm, Surveyor and V22 (Infection Preventionist, Licensed Practical Nurse, LPN) observed R66 and R143’s room with a sign on the door stated, “Enhanced Barrier Precaution” V22 stated R66 and R143 were on EBP precautions for having a LVAD (Left Ventricular Assist Device). When V22 was asked regarding R210 with no EBP sign on R210’s door, V22 stated, “R210 moved from the first floor to the fourth floor and his EBP sign did not go with him.” V22 explained every resident on isolation and EBP should have a sign visibly posted on the residents door regarding the residents isolation or EBP. V22 also explained residents on isolation and EBP should have an order for EBP on the residents Physician Order Sheet (POS) regarding the residents isolation or EBP type to prevent transmission of infection and so staff know what precautions to take with the residents during care. R66 Physician Order Sheet shows active orders as of 08/04/25 with orders for “Maintain contact/isolation for VRE/MDRO (vancomycin-resistant enterococci/ Multidrug-Resistant Organisms) of driveline site. However, surveyor and V22 observed R66’s room with EBP sign posted on R66’s door. R143 POS show active orders as of 08/04/25 with orders for “Maintain contact/isolation for MDRO (Multidrug-Resistant Organisms) Candida Auris of driveline site. However, surveyor and V22 observed R143’s room with EBP sign posted on R143’s door. R210 POS show active orders as of 08/06/25 with orders for Maintain enhanced barrier precautions to prevent infection r/t (related to) _ colostomy every shift. However, surveyor did not observe R210 with a EBP sign posted on R210’s door. The facility policy dated 01/20/2024 and titled “Enhanced Barrier Precautions” documents, in part: “Guideline: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms … c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precaution, required personal protective equipment (PPE), and the high-contact resident care activities require the use of gown and gloves.” The facility policy dated 01/20/2024 and titled “Isolation Categories for Transmission-based Precautions” documents, in part: “Purpose: Identify appropriate transmission-based precautions … Policy Interpretation and Implementation: 2. Signage must be placed near entry to resident room when Transmission-based Precaution are necessary to indicate type of precaution and PPE (Personal Protective Equipment) needed.” The facility undated document titled “Enhanced Barrier Precaution/Contact isolation shows R66, R143 and R210 is on Enhanced Barrier Precaution/Contact isolation. The facility undated document titled “Contact Isolation” does not show R66 and R143 receiving contact isolation. On 8/5/25 at 12:42 pm, Surveyor conducted the laundry tour with V30 (Housekeeping Director) and observed the following: Upon entry of the laundry door, next to the folding table on the floor, 4 linen blankets. V30 stated. “I don’t know why these are on the floor.” Upon entry of the laundry door to the left underneath a table on the floor 2 flat linen sheets holding up a fan. V30 stated, “They are using the sheets to prop of the fan and get some air.” Next to the linen carts 3 bags of residents personal laundry on the floor. V30 stated, “These are clean. They were just washed. I know they shouldn’t be on the floor.” On 08/05/25 at 12:50 pm, V30 stated, “Nothing should be on the floor. is cross contamination.” The facility policy dated 11/01/2023 and titled “Laundry Services Policy” documents, in part: “Policy: It is the policy of this facility to provide and in-house laundry service for linens and resident personal laundry in a safe and sanitary manner … Policy Specifications: To ensure proper handling of soiled and clean linen and personal laundry to prevent spread of infection disease … 6. Resident personal laundry will be identified by sew-on labels or indelible ink, by the facility staff. Personal clothing and belongings shall be handled, stored, processed, and transported to ensure safe keeping and timely return to the resident in good condition. 7. The laundry staff shall store, process, and transport all linens and resident personal laundry in accordance with procedures which ensure safety and sanitary conditions to prevent the spread of infection … 13. The Laundry Department shall adhere to all infection control policies and procedure including those established for isolation.” The facility undated job description titled “Laundry Aide” documents, in part: “Summary: the primary purpose of this job position is to assist in providing exceptional cleaning services to our residents. The incumbent will work with all departments to ensure our residents are receiving the highest caliber of service during their stay. Essential Duties and Responsibilities: adhere strictly to rules regarding health safety and be aware of any company related practices.” R125’s medical diagnoses include but are not limited to chronic obstructive pulmonary disease, cognitive communication deficit, feeding difficulties, essential hypertension. R130’s medical diagnoses include but are not limited to pneumonia, Alzheimer’s disease, lack of coordination, weakness, schizoaffective disorder. R211’s medical diagnoses include but are not limited to pain in left foot, immunodeficiency, interstitial pulmonary disease, essential hypertension. R211’s care plan dated 07/25/25 documents in part, “R211 has an arterial/ischemic ulcer of the left toes 2-5 r/t (related to) peripheral arterial disease…R211 will be free form infection or complications related to arterial ulcer through review date.” R211’s physician order dated 07/28/25 documents in part, “Left foot: Cleanse with NS (normal saline), apply betadine and Abd pad, wrap with kerlix one time a day ever Monday, Wednesday, Friday for promote wound healing.” On 08/04/25 at 12:29pm V7 (Certified Nursing Assistant/CNA) observed pushing R130’s wheelchair to table. V7 then observed picking up a lunch tray and delivering lunch tray to R125. V7 did not perform hand hygiene between activities. V7 then observed adjusting R125’s body alignment then going back to lunch cart to continue passing tray without performing hand hygiene. On 08/04/25 at 12:31pm V7 (CNA) stated she should have performed hand hygiene between assisting residents. V7 stated everything she touches is considered contaminated. On 08/04/25 at 3:05pm, R211 observed with left foot bandage. No EBP (Enhanced Barrier Precaution) sign observed on R211 room door. On 08/04/25 at 3:06pm V14 (Licensed Practical Nurse/LPN) stated R211 has a wound. V14 stated there is no EBP posted for R211, and staff should be using PPE (personal protective equipment) when caring for R211. On 08/06/25 at 10:14am V22 (Infection Prevention Nurse/IP) stated residents with wounds should be placed on EBP and PPE should be worn when caring for these residents. Facility’s policy titled “Handwashing/Hand Hygiene Policy” dated 03/2020 documents in part, “Policy: It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids…4. When hands are not visibly soiled, employees may use an alcohol-based hand rub (foam, gel, liquid) containing at least 60% alcohol in all of the following situations:…b. after direct contact with a resident but prior to direct contact with another resident…k. after contact with objects such as medical devices or equipment in the immediate vicinity of a resident may be potentially contaminated:…during resident meal service: in between tray pass if contact with resident is made hand hygiene should be used; when removing trays hand hygiene should be used before contact with fresh tray or with a resident.” Facility’s policy titled “Enhanced Barrier Precautions” with revision date 03/21/24 documents in part, “it is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms….Definitions: “Enhanced barrier precautions” refers to the use of gown and gloves for use during high-contact resident care activities for residents know to be colonized or infected with a MDRO (multi-drug resistant organism) as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices)…Explanation and Compliance Guidelines: 1. Prompt recognition of need:…c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities require the use of gown and gloves…2. Initiation of Enhanced Barrier Precautions…b. Implement enhanced barrier precautions for residents with any of the following: i. Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers).”

Based upon observation, interview and record review, the facility failed to empty the lint compartment and lint filter in an effort to provide safe environment to residents. This failure has the potential to affect all 198 residents in the facility. Findings include: On 08/05/25 at 12:42 pm, Surveyor and V30 (Housekeeping Director) toured the laundry area and observed dryer number 1 with the lint compartment that had a large amount of lint visible and not emptied. V30 stated the laundry staff is expected to check the lint traps and empty the lint every two hours. V30 stated the lint traps cleaning is signed off and logged by the staff every two hours. V30 stated that the lint traps should be cleaned every two hours to prevent a fire.On 08/05/25 at 12:45 pm, Surveyor and V30 observed the lint trap logbook with no staff signatures, not completed for 08/05/25.The facility document dated 11/01/2003 and titled Laundry Services Policy documents, in part: It is the policy of the facility to provide and in-house laundry services for linens and residents personal laundry in a safe and sanitary manner . Standards: Monthly quality assurance audits include inspection of the removal of lint and external dry ducts. Inspections are recorded and monitored by the Environmental Services Director . 18. Cleaning schedules for laundry equipment and area are in writing, posted for staff and adhere to. The facility document dated August 2025 and titled Lint Trap Cleaning Log shows no signatures for lint traps being checked on 08/05/25.The facility undated job description titled Laundry Aide documents, in part: Summary: the primary purpose of this job position is to assist in providing exceptional cleaning services to our residents. The incumbent will work with all departments to ensure that our residents are receiving the highest caliber of service during their stay. Essential Duties and Responsibilities: adhere strictly to rules regarding health safety and be aware of any company related practices.

Based on observation and interview, the facility failed to maintain a safe homelike environment. This failure affected four residents (R3, R19, R20, and R158) reviewed for maintenance of a safe home like environment in a sample of 77. Findings include:On 8/4/2025 at 11:53 am, R19's brown bathroom door was observed with a hole in the middle of the door and another hole below it covered with a white substance. On 8/4/2025 at 11:58 am, R158's wall behind the head of the bed was missing crown molding and the wall had paint chippings.On 8/4/2025 at 12:08 pm, R20's wall behind the head of the bed was missing crown molding and the wall had paint chippings. On 8/4/2025 at 12:13 pm, R3's wall had a large hole in the wall. On 8/4/2025 at 12:48 pm, V6 (Maintenance Director) stated he (V6) is aware of the repairs and can only make repairs with the supplies he has on hand. V6 stated the facility has discontinued their contract with [NAME] for painting supplies and now must purchase painting supplies from Home Depot. On 8/6/2025 at 2:47 pm, V1 (Administrator) stated staff usually puts in a work order with maintenance and maintenance is required to make repairs. V1 stated maintenance can repair walls, doors, and replace crown molding throughout the facility and maintenance conducts rounds daily on all the units and floors in the facility. Facility Policy titled Preventive Maintenance reviewed October 2024 documents in part, To assure that all equipment included in the Preventative Maintenance program includes testing, maintenance and repair information at the established intervals and The Maintenance Department checks for preventative maintenance program equipment work orders and evaluates/repairs the malfunction described. Facility Maintenance Director Job Description undated documents in part, The Maintenance Director will repair facility/resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Also ensure that services provided by outside vendors are properly completed/supervised in accordance with contract/work orders.

Based on observation, interview and record review, the facility failed to implement a resident's (R36) care planned fall precaution intervention by maintaining the bed height in the lowest position and failed to perform a resident's (R36) fall risk assessment quarterly which affected one resident (R36); and failed to secure a resident's (R131) oxygen tank in a holder which affected R131 and has the potential to affect all 29 residents residing on the 1st floor.Findings include: 1. R36’s admission Record documents, in part, diagnoses of type 2 diabetes mellitus, dementia, dysphasia, reduced mobility, need for assistance with personal care, mild cognitive impairment, hyperlipidemia, pseudobulbar affect, anemia, hypothyroidism, hypertension, lymphedema, and difficulty in walking. R36’s Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R36 has severe cognitive impairment. On 8/4/2025 at 11:38 AM, R36 observed lying in bed with the bed height level visibly high from the floor. This surveyor standing next to R36's bed and marking the top of R36’s bed mattress height at approximately 2 and 1/2 feet from the floor. On 8/4/2025 at 2:26 PM, R36 observed lying in bed with the same bed height level visibly high from the floor. R36’s bed controller for the height of bed is observed out of R36's reach hanging from the foot of the bed. On 8/5/2025 at 9:43 AM, R36 observed lying in bed with the bed height level visibly high from the floor. This surveyor asked V28 (CNA, Certified Nursing Assistant) asked about R36’s elevated bed height from the floor, and V28 stated that R36 is care planned for the bed being high. On 8/6/2025 at 9:12 AM, R36 observed lying in bed still with the height level of bed visibly high from floor. This surveyor standing next to R36's bed and marking the top of R36’s bed mattress height at approximately 2 and 1/2 feet from the floor. R36’s bed controller for the height of bed is out of R36's reach hanging from the foot of the bed. R36 stated that the bed height goes up and down, but I (R36) can't do it and that the staff does it. On 8/5/2025 at 12:56 PM, this surveyor requested from V1 (Administrator) and V2 (Director of Nursing, DON) for R36’s two most recent fall risk assessments and current complete care plan. R147’s two most recent fall risk assessment provided are titled “Fall Risk Observation – V2” with dates of 1/24/2025 and 10/24/2024. R36’s “Fall Risk Observation – V2,” dated 10/24/2025 and 1/24/2025, document, in part, that R36 has intermittent confusion; requires use of assistive devices; confined to chair or wheelchair (unable to ambulate without assistance); needs assistance to and from, on and off toilet/commode for elimination and or with cares; uses antidepressants and antihypertensives; and has neuromuscular/functional, psychiatric or cognitive conditions. R36’s Care Plan dated 4/19/2019 documents, in part, a focus of R36 “at risk for fall related to co-morbidities” with an intervention of “bed in lowest position when lying in bed (11/2/2021).” In review of R36’s current complete care plan (printed 8/5/2025), no interventions are noted for R36 being care planned for a high bed. On 8/6/2025 at 11:46 AM, V33 (Restorative Director, LPN, Licensed Practical Nurse) stated that V33 is responsible for the facility’s fall prevention program. V33 stated that one of the general fall prevention interventions for residents is to ensure that the bed is in lowest position. When asked the purpose of having the bed in the lowest position, V33 stated, “So, if they (residents) do happen to fall out of bed, there won’t be much damage. If resident were to have injury, it would reduce risk of major injury.” V33 stated that fall risk assessments are performed for all residents on admission, readmission, quarterly or when a resident has a fall incident. V33 stated that the quarterly fall risk assessments are performed because residents’ fall risk needs may change over time, and it helps to distinguish the level of fall risk by looking at predisposing factors such as cognition, needing assistance with toileting, types of medications, and any falls previous. V33 stated that performing these fall risk assessments every 3 months allows staff to identify and determine changes in the residents’ medical, mental or physical status. Facility policy titled “Falls Guideline” and dated August 2024 documents, in part, “Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and developed an organization-wide ownership for fall prevention to: To achieve each resident’s maximum potential of physical functioning. To prevent or reduce injuries related to fall. To enhance residents’ dignity and self-worth. To rehabilitate residents to their fullest potential of function. Falling is an unintentional change in position coming to rest on the ground floor or onto the next lower surface … The intent of this guideline is the (to) ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following processes: I. Identification of hazards and risks II. Evaluation III. Implementation IV. Monitoring V. Analysis. Responsible Party: IDT (Interdisciplinary Team). Fall Risk evaluation: A fall evaluation is used to identify individuals who have predicting factors for falls. This is evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventable measures shall be taken to decrease the number of falls whenever possible. Purpose: 1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately. 2. To Achieve each resident’s maximum potential of physical functioning. 3. To Prevent or reduce injuries related to falls. 4. To enhance residents’ dignity and self-worth. 5. To rehabilitate residents to their fullest potential of function. 6. Individualize interventions for each resident. Evaluation May Include: residents with recent surgery or new admissions; psychotropic drug use; fall history; appropriate clothing and footwear; visual deficit; impaired mobility functional status; incontinence; change of environment; cognitive status; mood or behavior indicator; underlying illness and disease processes; sensory status; orthostatic hypotension … implement resident specific interventions/precautions.” Facility job description (undated) titled Certified Nursing Assistant documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . Adhere to professional standards, company policies and procedures. 2. On 08/04/25 V2 (Director of Nursing, DON) presented a facility census of 29 residents on the first-floor unit. On 08/04/25 at 11:52am, Surveyor observed 2 oxygen cylinder tanks in R131's room leaning up against the wall behind a chair and not in a holder. On 08/04/2025 at 11:53am, R131 stated those are empty oxygen tanks that the hospital loaned him on his last visit. On 08/04/25 at 11:58am, surveyor brought this observation to V3 (Staffing Coordinator) attention. V3 stated oxygen tanks should not be free standing and should be in a holder and V3 proceeded to remove the oxygen tanks from the room with no holder. On 8/06/2025 at 11:18am V35 (Licensed Practical Nurse) stated empty oxygen tanks should be stored in the oxygen room with a tag on it and it should be in a holder. V35 stated storing a free standing oxygen tank could fall and be a big problem. On 8/06/2025 at 3:15pm V2 (Director of Nursing-DON) stated oxygen tanks are supposed to be stored in a holder and the purpose of storing them in a holder is to ensure the safety of all residents. Policy and Procedure for Portable Oxygen with an updated date of 5/21/2020 documents, in part, all E cylinders must be placed in carrier device before use and follow all safety precautions when using and storing E cylinder. All empty tanks go on a specific empty tank rack.

Based on observation, interview and record review, the facility failed to contain oxygen equipment (nebulizer masks) per facility's policy. This failure affected four residents (R11, R47, R113, R143) reviewed for oxygen equipment, in a total sample size of 77 residents.Findings include: R11’s medical diagnoses include but are not limited to chronic pulmonary embolism, essential hypertension, asthma with acute exacerbation. R113’s medical diagnoses include but are not limited to chronic obstructive pulmonary disease, pleural effusion, heart failure, chronic atrial fibrillation, shortness of breath. R113’s physician order dated 11/13/2023 documents in part, “change nebulizer administration device.” On 08/04/25 at 10:30am R11’s nebulizer face mask observed on R11’s nightstand not contained in a bag. On 08/04/25 at 10:33am R113’s nebulizer face mask observed on R113’s nightstand not contained in a bag. On 08/04/25 at 10:37am V5 (Unit Manager) stated that R11’s nebulizer face mask is not in a bag. V5 stated that R11’s face mask should be in a bag for infection control reasons. V5 stated that R113’s face mask is not contained and should also be in a bag. Facility’s undated policy titled “Oxygen Therapy and Devices” documents in part, “Purpose: Oxygen is a basic human need. Without it, we would not survive. The air that we [NAME] contains approximately 21% oxygen. For most people with healthy lungs, this is sufficient, but for some people with certain health conditions whose lung function is impaired the amount of oxygen that is obtained through normal breathing is not enough. Therefore, they require supplemental amounts to maintain normal body function…4). Simple Mask… f. Place in a labeled bag when not in use.” R47’s face sheet dated August 6,2025 documents in part, “R47’s initial admission date was 2/24/2022 and diagnosis listed: Benign neoplasm of meninges, seizures, migraines, diabetes mellitus, mild protein calorie malnutrition, major depressive disorder, essential hypertension, hypertensive heart disease, anemia, acute kidney failure, gastro esophageal reflux disease. R47’s Physician order summary report dated 8/4/2025 documents in part, that R47 is receiving medication for the treatment of pneumonia; “Azithromycin 500 milligram (mg) 1 tablet in the morning every day x 5 days for pneumonia dated 7/30/25 until 8/4/2025,Amoxicillin-Pot Clavulanate Oval tablet 875-125 mg give 1 tablet by mouth every 12 hours for pneumonia dated 7/30/25 until 8/5/2025”;Ipratroplum-Albuterol Solution 0.5-2.5 (3) mg/milliliters (ml), 3 ml inhale orally every 6 hours as needed for shortness of breath or wheezing via nebulizer”. R47’s Cognitive Patterns/brief interview for mental status dated May 5, 2025 documents in part, that “R47 has a score of 10 which means R47 has moderate cognitive impairment”. R47’s care plan dated 8/5/2025 documents in part, “R47 has oxygen therapy/ nebulizer treatment orders as needed related to Pneumonia and respiratory illness; staff to administer nebulizer treatments per physician’s orders”. On 8/4/25 at 11:50am, R47’s was not in room her nebulizer machine was plugged into the wall socket and mask was sitting on bedside table not contained in any bag or covering over the device. On 8/4/25 at 11:51am, V17 Registered Nurse stated she was the nurse for R47 and that she wasn’t aware that the mask was not contained because she did not give her a treatment this morning. V17 said there are infection control concerns because the mask could become contaminated with dust or could possibly fall on the floor. V17 went to retrieve a plastic bag to cover the mask. On 8/4/2025 at 11:53am, V16 Licensed Practical Nurse/ Unit manager stated the mask for R47 should be contained in a plastic bag to decrease risk of contamination of the mask which could result in R47 becoming sick with respiratory issues, staff is aware that mask should be contained in plastic bag when not in use. On 8/4/25 at 11:56am R47 was observed in 2nd floor dining room watching television she was alert and responsive and reported that she does use oxygen and nebulizer treatments when she becomes short of breath at times and the nurses provide the treatments to her. R47 stated she is aware that she has pneumonia and is receiving antibiotic treatment that will be over in a few days. On 8/6/25 at 11:54am, V2 Director of Nursing stated nebulizer mask should be stored in plastic bag for infection control purposes, nebulizer mask should be contained and if nebulizer mask is not contained it could possibly result in infection to residents. R143’s Face sheet shows that R143 has diagnosis which include but not limited to chronic obstructive pulmonary disease, presence of heart assist device, other mechanical complication of other cardiac and vascular devices and implants subsequent encounter, heart failure, and primary pulmonary hypertension. R143’s Brief Interview for Mental Status (BIMS) dated 07/13/25 shows that R143 has a BIMS score of 15 which indicates that R143 is cognitively intact. R143 Physician Order Sheet (POS) shows active orders as of 08/04/25 with orders for Ipratropium Bromide inhalation solution 0.02% (Ipratropium Bromide) 2.5 inhalation inhale orally four times a day for shortness of breath/dyspnea related to heart failure, unspecified (150.9) Chronic obstructive pulmonary disease unpacified (j44.9). On 08/05/25 at 10:45 am, Surveyor observed R143’s nebulizer mask on top of R143’s Left Ventricular Assist Device (LVAD) not contained in a bag. R143 stated R143 uses R143’s nebulizer machine daily and sometimes R143’s nebulizer mask is placed in a bag and sometimes it is not. R143 could not recall the last time R143’s nebulizer mask was placed in a plastic bag when it was not in use.

Based on observation, interview and record review, the facility failed to lock the 3rd floor emergency crash cart and failed to double lock refrigerated controlled substances which affected R6, R8, R10 and R174 and has the potential to affect the 58 residents residing on the 3rd floor when reviewed for medication storage. Findings include:On [DATE] at 11:23 AM, this surveyor observed the 3rd floor emergency crash cart unlocked with the latch handle opened, and no facility staff observed in front of or near this cart. The 3rd floor emergency crash cart is observed in the 3rd floor hallway positioned outside the dining room doorway closest to the elevator.On [DATE] at 11:27 AM, this surveyor requested that V25 (Registered Nurse, RN/Nurse Supervisor) come over to the 3rd floor emergency crash cart, and upon arrival to this cart, V25 observed and stated that this cart is unlocked. When asked what contents were inside the 3rd floor emergency cart, V25 opened each one of the 4 drawers, showing this surveyor (while saying the name of each item aloud) all of the emergency medical items found which are listed on the 3rd floor emergency cart checklist (oxygen masks, tubing and airways; suction equipment; vital signs equipment; medical supplies; intravenous (IV) supplies; IV fluid bags; PPE (personal protective equipment); and general equipment). V25 stated that nurses, including V25, are responsible for locking the 3rd floor emergency crash cart to ensure that all emergency supplies are present, available, and not missing, if a resident has any medical emergency, like a code blue, on this floor. V25 stated that nurses perform daily checks with the emergency cart checklist to ensure that all supplies are in the cart, will fill out the check list and then will lock the emergency cart with a cable tie lock so the drawers cannot be opened. V25 stated that it's important that nurse monitor this cable tie lock on the 3rd floor emergency cart due to some of the floor's dementia residents walking by and thinking that it's a toy.Facility document titled 3rd Floor: Emergency Cart Check List dated for [DATE] documents, in part, the following items in the 4 drawers (indicated by check marks on dates [DATE] to [DATE]): adult oxygen mask, non-rebreather mask, adult nasal cannula, oxygen meter adapter, adult airway, flashlight, extra batteries, Yankauer suction tube, blood pressure cuff, stethoscope, oxygen sensor, suction catheter kits, 2 bottles of saline, band aids, alcohol wipes, tongue depressors, roll tape, primary IV tubing, extension sets, 1 liter Normal Saline bag, IV start kits, J loops, IV angiocaths, red bags, sharps container, PPE, gloves, and electrical cord. On [DATE] and [DATE], there are blank spots (no check marks) noted for the two entries of cart cleaned and locked and breakaway lock intact and in place.On [DATE] at 1:00 PM, V26 (RN) observed with keys on V26's person and requested to perform a check of V26's medication cart which V26 stated is the east medication cart. V26 used one of the keys on the ring to open the east medication cart. V26 and this surveyor viewed the controlled substances in this medication cart. V26 flagged 5 pink pharmacy sheets in the controlled substance folder to continue the controlled substance check in the 3rd floor medication room, since these 5 controlled substances are stored in the refrigerator in the locked medication room. V26 opened the medication door with a key from the key ring, and then V26 opened the refrigerator door by lifting up the latch from the top of the refrigerator where there is a key lock. V26 did not insert a key into the lock to open the latch. V26 opened the refrigerator and pulled out the 5 refrigerated controlled substances and sets them on top of the counter. V26 showed this surveyor each of R6's (2 Lorazepam elixir containers), R8's (1 Lorazepam elixir container), R10's (1 Lorazepam elixir container), and R174's (1 Lorazepam elixir container) for accurate controlled substance counts while verifying each amount on R6, R8, R10 and R174's individual controlled substance records of 30 milliliters. V26 placed the 5 controlled substances (Lorazepam) back into the refrigerator, and this surveyor asked V26 about the refrigerator lock. V26 stated that V26 will lock it now. V26's tried to put each key into the refrigerator lock's hole to lock it with no success. V26 opened the medication room door and asked V27 (Licensed Practical Nurse, LPN) at the nurse's station for V27's keys. V27 observed handing V27's keys to V26, who then tried each one of these keys with no success. V27 next tried to insert V27's keys into the refrigerator lock to lock it with no success. V27 stated that the refrigerator lock key is a silver key, and it's usually on the set of V26's key ring (with no silver key noted).On [DATE] at 1:21 PM, V25 (RN/Nurse Supervisor) stated that the refrigerator lock has been broken for a few days, and I (V25) am getting it fixed.R6's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml {milligrams/milliliter}) with a date received of [DATE] and has a quantity received of 30 ml. R6 also has another Individual Controlled Substance Record (with a #6 hand written on the top of the page) which documents, in part, that Lorazepam (concentration of 2 mg/ml) with a unclear date received (the month is not clearly written-not readable-followed by a forward slash and 22) and has a quantity received of 30 ml. No Lorazepam doses have been documented as given on either of R6's Individual Controlled Substance Record documents.R6's admission Record documents, in part, diagnoses of dementia, combined systolic (congestive) and diastolic heart failure, polyneuropathy, major depressive disorder, hypertension, acute embolism and thrombosis of vein, atherosclerotic heart disease, schizophrenia, and senile degeneration of brain.R8's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml) with no date received and has a quantity received of 30 ml. No Lorazepam doses have been documented as given.R8's admission Record documents, in part, diagnoses of dementia, hypertension, type 2 diabetes mellitus, atrial fibrillation, hyperlipidemia, dermatitis, acute embolism and thrombosis of unspecified deep veins of lower extremities, reduced mobility, unsteadiness on feet, and dysphagia.R10's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml) with no date received and has a quantity received of 30 ml. No Lorazepam doses have been documented as given.R10's admission Record documents, in part, diagnoses of dementia, adult failure to thrive, lack of coordination, unsteadiness on feet, malignant neoplasm of breast, hyperlipidemia, and hypertension.R174's Individual Controlled Substance Record documents, in part, that Lorazepam (concentration of 2 mg/ml) with a date received of [DATE] and has a quantity received of 30 ml. No Lorazepam doses have been documented as given.R174's admission Record documents, in part, diagnoses of dementia, Alzheimer's disease, personal history of transient ischemic attack (TIA), muscle wasting and atrophy, speech and language deficits following other cerebrovascular disease, primary open-angle glaucoma, blindness right eye category 3, peripheral vascular disease, lack of coordination, hypertension, bullous keratopathy, and pressure ulcer of left hip.On [DATE] at 1:28 PM, V2 (Director of Nursing, DON) stated that controlled substances are to be stored under double locks. V2 stated that if a controlled substance is refrigerated in the medication room, the nurse must lock the medication room door and lock the refrigerator lock for the double lock to be in place. V2 stated that the emergency crash cart is to be locked at all times when not in use.Facility resident roster titled Midnight Census Report and dated [DATE] documents, in part, that 58 residents reside on the 3rd floor.Facility policy (undated) titled Pharmaceutical Storage Policy documents, in part, Policy: it is the policy of this facility that drugs and biologicals shall be stored in a safe, sanitary and orderly manner at the proper temperatures. Policy Specification: To establish guidelines for the control and storage of drugs and biologicals. Responsibility: Consultant Pharmacist, Director of Nursing, Licensed Nurses, Qualified Medication Aide. Standards: . 4. Medication and treatment cabinets or shall be locked at all times . 5. Only authorized personnel shall handle, distribute or administer drugs and biologicals . 8. Individually prescribed Schedule II drugs, shall be in separate containers under double lock and stored in a substantially constructed box, cabinet or mobile drug storage unit.Facility policy (undated) titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) documents, in part, Purpose: The purpose of his procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. Preparation: . 3. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times.

Based on interview and record review the facility failed to refer two residents (R14 and R17) to the appropriate state designated authority for PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination and failed to perform additional screening for one resident (R17) diagnosed with a new mental disorder. This deficient practice affected two residents (R14 and R17) in a total sample size of 77 residents.Findings include: 1. R17’s Omnibus Budget reconciliation Act (OBRA) dated 12/4/20 documents in part, “Screening indicates nursing facility services are appropriate; based upon all information and data available R17 has no reasonable basis for suspecting Developmental delay or Mental illness diagnosis.” R17’s admission to facility was 12/7/2020 and readmission date to the facility was 8/7/2022. R17’s medical diagnosis includes but are not limited to Schizophrenia 1/4/2021, diabetes mellitus, epilepsy, chronic kidney disease, hypertension, gastro esophageal reflux disease. R17’s Physician order summary report dated 8/8/2023 documents in part that R17 takes Risperdal oral tablet 0.25mg by mouth at bedtime related to Schizophrenia. On 8/5/25 at 3:54pm, V31 admission Director stated the facility utilizes two major diagnoses to identify if a resident would need a PASARR 2 completed, and these two diagnoses that qualify a resident are major depressive disorder and Schizophrenia. V31 stated that normally a resident is sent from the hospital with PASARR 2 and that she is responsible for handling the process to have PASARR’s completed. V31 stated that in the morning meeting (intradisciplinary team present) or care plan conference meetings, residents are discussed who may have new diagnosis that needs to be reviewed for further assessments. V31 stated that if a resident received a new diagnosis of Schizophrenia, the referral for assessment should be sent to the designated agency so the resident can be assessed and reviewed for further evaluation. V31 stated that R17 does not currently have a PASARR 2 in chart. On 8/6/25 at 9:31am, V1 Administrator stated a resident should have a PASARR 2 when they have a new mental health diagnosis or if they were screened from hospital with a major mental health disorder. V1 stated that Schizophrenia is a major diagnosis that qualifies a resident to have a PASARR 2 completed. V1 stated that the purpose of resident with major mental health diagnosis being assessed is to give the facility an idea of the treatment plan and services that resident may need, and if the PASARR 2 was not completed, it is a possibility that treatment plan of R17 was not completed accurately. On 8/6/2025 at 11:45 am, V31 submitted a document titled “Notice of Preadmission Screening and Resident review (PASRR) Level Screen Outcome,” which documents, in part, that a PASRR Level 1 Determination: Refer for Level 2 Onsite; Mental health diagnosis: Schizophrenia, current; Outcome: reviewer documented R17 referred for level 2 screening; rationale: A PASRR level 2 evaluation must be conducted. That evaluation will occur as an onsite/face-to-face evaluation. Suspected or confirmed PASRR condition: Mental health disability. 2. R14’s admission Record documents, in part, diagnoses of chronic obstructive pulmonary disease, end stage renal disease, type 2 diabetes mellitus, heart failure, anemia, hyperlipidemia, dementia, delusional disorders, difficulty in walking, lack of coordination, hypertension, and cognitive communication deficit. On 8/5/2025 after requesting for R14’s PASSAR (Pre-admission Screening and Annual Resident Review) screening(s), V1 (Administrator) presented this surveyor with R14’s one page document (2536) titled “Interagency Certification of Screening Results” certified by the Department on Aging and dated 10/17/2018 documents, in part, that this screening indicated nursing facility services are appropriate. On 8/5/2025 at 12:56 PM, this surveyor requested from V1 for R14’s PASARR screening(s) due to R14’s “Interagency Certification of Screening Results” not indicating the physical and mental condition of R14 or the level of services that R14 requires to be provided by the facility. On 8/6/2025 at 10:56 AM, V1 (Administrator) stated that the facility performed an audit about one year ago for all residents, which included R14, who have been residing in the facility prior to the new state designated authority’s process for electronic submission for resident PASARR evaluation and referral screenings. V1 stated that V1 does not have further PASARR screenings, including a Level 1 for R14. On 8/6/2025 at 11:04 AM, V29 (Social Services Director) stated that R14's Interagency Certification of Screening Results is not the same as a PASARR Level 1 screening. V29 stated that the state designated authority will perform a separate assessment for the PASARR Level 1 screening to determine if there is suspicion for mental condition(s) that would require a more in-depth screening (Level 2) which tells the facility what mental programs or therapies that the resident should have in the facility. V29 stated that to my (V29's) knowledge, R14 does not have a PASARR Level 1 screening done. On 8/6/2025 at 12:23 PM, V29 provided this surveyor with a document, with R14’s name on it, and V29 stated that it was a screenshot from V29’s computer where V29 has logged into the electronic system for the state designated authority for PASARR evaluations and screenings. This document indicates a Level 1 Screen for R14 with a status of “Queued for Review” with no determination date and was started by V31. On 8/6/2025 at 12:30 PM, V31 (Admissions Director) stated that every current resident should have a PASARR Level 1. V31 stated that today (on 8/6/2025), V31 initiated for R14’s PASARR Level 1 screening via the state designated authority’s electronic submission process. V31 stated that since there is this new state designated authority’s electronic submission process that was implemented in 2022, V31 is “getting it together” to ensure that all residents have a PASARR Level 1 screening, which will then indicate if a resident should have additional screening for a Level 2. Facility’s policy dated 10/06/2023 titled PASARR, documents in part; It is the policy of this facility to conduct a preadmission screening and resident review (PASARR) prior to admitting a new resident. The screening will be obtained so that the facility can make appropriate decisions regarding care and placement; Responsibility: Admissions director, Administrator; Procedure: 1.Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid pre -admission screening and resident review program (PASARR).7.Should the resident require a PASARR update after admission the facility will contact the state agency to update the PASARR; the facility will document attempts to contact the agency and update the PASARR. Facility’s undated job description titled admission director, documents in part “ Essential duties and responsibilities: Admit, transfer, and discharge residents in accordance with established policies and procedures; Attach preadmission documentation to admission papers as appropriate; refer admission problems to proper authority, nursing service and social services; keep abreast of current Medicare/Medicaid regulations governing admission/ discharge requirements of health care facilities; Assist the MDS Coordinator in scheduling resident assessments; collect, assemble, and check admission papers, forward to appropriate departments.

Based on observation, interview, and record review the facility failed to ensure that medications were signed out when administered for one residents (R143). This failure affected one out of 77 residents in the sample. Findings include:On 08/04/25 at 1:00 pm, R143 was observed with a PICC (Peripherally Inserted Central Catheter) to R143's right arm with medication infusing. R143 stated, I usually get my IV (Intravenous) medication around 9:00 am but I did not get it today. On 08/04/25 at 1:25 pm, V5 (Licensed Practical Nurse, LPN, Unit Manager) stated, I signed R143's IV medication out this morning but I did not give it. V5 explained that medications should be signed out when administered to avoid a medication error. R143's Medication Administration Record (MAR) presented by the facility on 8/04/25 shows R143 has orders for Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml solution administered by V5 at 10:01 am, however at on 08/04/25 at 1:00 pm R143 stated that R143 did not receive any IV medications (Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml) at 10:01 am.R143's Medication Administration Audit Record (MAAR) presented by the facility on 8/04/25 Vancomycin HCL (hydrochloride) intravenous solution 1250 mg (milligram)/250 ml solution administered by V5 at 10:01 am, however on 08/04/25 at 1:00 pm, R143 stated that R143 had not receive Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml.On 8/05/25 at 9:09 am, V2 (Director of Nursing, DON) was asked regarding the facility's policy for medication administration and V2 stated, Medication should be signed out immediately after the medication is given to prevent a medication error. V2 explained that if a medication is not administered the nurse should not sign the medication on the MAR.R143's Face sheet shows that R143 has diagnosis which include but not limited to presence of heart assist device, other mechanical complication of other cardiac and vascular devices and implants subsequent encounter, and acute osteomyelitis. R143's Brief Interview for Mental Status (BIMS) dated 07/13/25 shows that R143 has a BIMS score of 15 which indicates that R143 is cognitively intact.R143 Physician Order Sheet (POS) shows active orders as of 08/04/25 with orders for Vancomycin HCL (hydrochloride) intravenous solution 1250 mg(milligram)/250 ml (milliliter) (Vancomycin HCL) use 1.25 gm (gram) intravenously every 48 hours related to OTHER cardiomyopathies. The facility's policy dated October 2023 and titled Medication Administration Policy documents, in part: Policy: To authorize licensed nursing personnel (RN, LPN) (Registered Nurse, Licensed Practical Nurse) and Qualified Medication Aides (QMA) to prepare ad administer drugs and biologicals. Policy Specifications: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. 2. All licensed nurses assigned the responsibility of administering and recording of medications must meet the requirement of the state in which the facility operates . 20. Medications shall be recorded on the MAR promptly after each administration by the individual who administered the drug.The facility's undated document titled The Licensed Practical Nurse (LPN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . Prepare and administer medications as ordered by the physician.The facility's undated document titled Registered Nurse (RN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . Prepare and administer medications as ordered by the physician.

Based on observation, interview, and record review, the facility failed to provide toenail care with trimming for a resident with lengthy and jagged toenails which affected one resident (R147) in the sample of 77 residents reviewed for activities of daily living. Findings include:On 8/4/2025 at 12:48 PM, R147 observed lying in bed with no shoes or socks on, and R147 observed with long (3/4 to 1 inch long) toenails with jagged edges. This surveyor communicating with R147 via R147's Polish communication board in room, and R147 saying that nails are long and wants them cut. On 8/5/2025 at 9:47 AM, R147 observed lying in bed with no shoes or socks on, and R147 observed with the same length (long) and jagged toenails. R147's left toes observed with 4 long and jagged toenails, and the left 2nd toe (next to big toe) with the discolored toenail growing more outwards instead of upwards towards tip of toe. R147's right toes observed with 4 long and jagged toenails besides the left 2nd toe (next to big toe) with the nail short and jagged. R147 remains saying that R147 wants them cut. On 8/5/2025 at 9:53 AM, this surveyor requested that V26 (Registered Nurse, RN) come view R147's toenails. V26 stated that R147 has some long and jagged toenails, and stated, They can be cut. V26 stated that toenails are offered to be cut every shift and when needed by the nursing staff, except if the resident is a diabetic, then there is a referral to the podiatrist. V26 stated that V26 doesn't believe that R147 is a diabetic but has to check R147's chart. On 8/5/2025 at 10:03 AM, V26 confirmed via R147 electronic health record (EHR) that R147 is not a diabetic. V26 stated that staff responsible for cutting R147's toenails since R147 is not a diabetic are the nurses and the CNAs (Certified Nursing Assistants). V26 stated that nail clippers are kept on the nursing units in the clean utility room. R147's admission Record documents, in part, diagnoses of delirium, dysphagia, unsteadiness on feet, lack of coordination, reduced mobility, cognitive communication deficit, and person injured in unspecified motor-vehicle accident, traffic, subsequent encounter.R147's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R14 has severe cognitive impairment. R147's Functional Abilities for Self-Care for personal hygiene, lower body dressing, putting on/taking off footwear and shower/bathe self are coded as 4 which indicates that supervision or touching assistance from staff may be provided throughout the activity or intermittently. R147's Care Plan, initiated 5/15/2025, documents, in part a focus that R147 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to weakness with interventions to provide assistance with bathing/showering as necessary and to monitor, document, report to doctor, as needed, any changes, reasons for self-care deficit, expected course or declines in function. Facility document titled Foot Assessment Documentation and dated 8/4/2025 documents, in part, 12 residents' names which includes R147's name. In the column for Skin Issue? a notation of All Pts (patients) need toenails trimmed is documented with an arrow extending down all 12 residents names, including R147.On 8/6/2025 at 1:28 PM, V2 (Director of Nursing, DON) stated that CNAs are responsible for assessing residents' toenails during ADL care and that toenail checks are to be done every day. V2 stated that nursing staff, including V2, will then provide trimming of a residents' lengthy or jagged toenails. V2 stated that if a resident is diagnosed with diabetes, the facility refers the resident to the podiatrist for toenail trimming. V2 stated that R147 is not a diabetic resident.Facility policy titled Care of Fingernails/Toenails and dated April 2007 documents, in part, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the toenails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Nail Clippers; 2. Nail file or emery board; 3. Towel; 4. Orange sticks; 5. Line protector (disposable or plastic), as necessary; 6. Hand lotion (as permitted or prescribed); 8. Paper towels; and 8. Personal protective equipment . Documentation: The following information should be recorded in the resident's medical record, if applicable: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care . 6. If the resident refused the treatment, the reason(s) why and the intervention taken. 7. The signature and title of the person recording the data.Facility job description (undated) titled Certified Nursing Assistant documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . Provide assistance in personal hygiene . Adhere to professional standards, company policies and procedures. Facility job description (undated) titled Licensed Practical Nurse (LPN) documents, in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistants . Performs other duties as assigned.Facility job description (undated) titled Registered Nurse (RN) documents, in part, Summary: The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistants . Performs other duties as assigned.

Based on observation, interview and record review the facility failed to ensure ADL's (Activities of Daily Living) were completed for two residents (R202, R204) to allow the residents to maintain their dignity. This failure affected 2 residents out of a sample of 77.Findings include: Findings include: R202 has a diagnosis of but not limited to Syncope and Collapse, Muscle Weakness, Lack of Coordination, Need for Assistance with Personal Care, Weakness and Hypertension. R202's Brief Interview of Mental Status score is 6 which indicates severe cognitive impairment. R202 Minimum Data Set section GG-Functional Abilities documents, in part, 02 (Substantial/maximal assistance) and Personal hygiene: the ability to maintain personal hygiene, including shaving. R202's Care plan focus for ADL's dated 08/06/2025 documents, in part, R202 has an ADL Self Care Performance Deficit related to muscle weakness and Personal Hygiene: R202 requires total staff assist with shaving facial hair. On 8/04/2025 at 11:28am, surveyor observed R202 with medium length gray hair extending from R202's chin. On 8/04/2025 at 11:30am, R202 stated she knows they (chin hairs) are there but can't cut them and no one has asked her if she (R202) wants them cut. R202 stated she wants them (chin hairs) cut off. On 8/04/2025 at 11:35am, V4 (Certified Nursing Assistant-CNA) stated with every shower or bed bath we offer to shave facial hair to all residents. On 8/06/2025 at 11:18am, V35 (Licensed Practical Nurse) stated facial hair shaving is offered to residents as soon as we see facial hair and it's a dignity issue. On 8/06/2025 at 11:22am, V34 (CNA) stated we offer to shave all residents when showers are given or when stumble is seen and if the resident allows us (CNA's) to shave the facial hair. On 8/06/2025 at 3:15pm, V2 (Director of Nursing) stated all residents are shaved as needed and when showers are given including female residents. Shaving the Resident Procedure with a revised date of March 2004 documents, in part, the purpose of this procedure is to promote cleanliness and to provide skin care. Activities of Daily Living (ADL) with an effective date of 2/2023 documents, in part, Purpose: based on a comprehensive assessment of the resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) do not diminish unless the circumstances of the individual's clinical condition demonstrates that such decline was unavoidable. Job description titled Certified Nursing Assistant documents, in part, the Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents and provide assistance in personal hygiene by giving shaves. R204’s diagnoses include but are not limited to acute osteomyelitis, lack of coordination, muscle wasting and atrophy. R204’s Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 14, indicating that R204’s cognition is intact. On 08/04/25 at 10:26am R204 observed with a moderate amount of facial hair. On 08/04/25 at 10:26am R204 stated that he had been asking the staff to shave him. R204 stated that when he asks the staff to shave him, the staff tell him that they will get to it but haven’t got to it yet. On 08/04/25 at 10:37am V5 (Unit Manager) stated that she sends some of the residents down to be shaved by the wound care technician. V5 stated that staff know to look at the resident’s face and if the resident looks like they need to be shaved, then the staff should shave the resident. On 08/04/25 at 12:40pm V8 (Wound Care Technician) stated he cuts the resident’s hair and shave the resident’s whenever he is available, which is hardly ever.

Based on observation, interview, and record review the facility failed to redistribute pressure by maintaining the air mattress pump at the correct weight setting to prevent pressure wounds. This failure has the potential to effect one resident (R7) in a sample of ­­­­77.Findings Include: R7 was observed lying in bed on a low air mattress with an air mattress pump at the foot of the bed set on Firm which is one setting past 360lbs (pounds). On 8/4/2025 at 11:24 am, V17, RN (Registered Nurse/Agency) verified R7's air mattress pump was set past 360lbs (pounds) on firm. V17 stated she (V17) was not aware of the facilities protocol for the air mattress setting. V17 verified R7's current weight was 150.8lbs. On 8/4/2025 at 11:47 am, V8, WCT (Wound Care Technician) stated only a nurse, wound care coordinator, or the wound care tech can change the setting on a resident's air mattress pump. V8 stated an incorrect air mattress pump setting can cause a pressure ulcer wound to develop. On 8/6/2025 at 12:34 pm, V24 WCC (Wound Care Coordinator) stated R7's family requested R7 remain on a low air mattress for comfort measures since she was on one in the hospital; low air mattresses are used to promote wound healing; incorrect low air mattress settings can cause a decline in a wound; and a low air mattress is not needed for a resident who doesn't have a wound. R7's Face Sheet dated 8/6/2025 documents a diagnosis of but not limited to CEREBRAL INFARCTION, UNSPECIFIED, HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE, ENCOUNTER FOR ATTENTION TO GASTROSTOMY, MILD NEUROCOGNITIVE DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITHOUT BEHAVIORAL DISTURBANCE, AND DYSPHAGIA FOLLOWING OTHER CEREBROVASCULAR DISEASE.R7's Physician Order Sheet dated 8/6/2025 documents no order for a low air mattress.R7's weight summary dated 8/4/2025 documents a weight of 150.8lbs (pounds) on 7/8/2025 at 10:44 AM.R7's Care Plan dated 7/28/2025 documents a focus for Risk for alteration in skin integrity R/T self-care deficits, impaired mobility and comorbidities and to pressure redistribution mattress, apply pressure redistribution cushion when up in chair/wheelchair, reposition/Shift weight at frequent intervals to resident's comfort, remind/Assist resident to reposition frequently.R7's Minimum Data Set Section GG dated 7/20/2025 documents in part, R7 is dependent eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. On 8/6/2025 at 2:30 pm, V2, DON (Director of Nursing) stated the purpose of a low air mattress is to properly redistribute weight on a resident which ensures the resident doesn't have any skin breakdown; the low air mattress setting is determined by a residents weight; incorrect low air mattress weight setting can cause improper redistribution of pressure; and V2 is unsure if a physician's order is needed for a low air mattress. Facility Policy titled Low Air Mattress dated 7/2012 documents in part, to provide features of a mattress support system that provides a flow of air to assist in managing the heat and humidity (Microclimate) of the skin. Low air loss mattresses will be utilized for residents with Stage III, IV, and unstageable pressure ulcers of the trunk as well as residents with multiple Stage II pressure ulcers. Low Air Mattress Manufacturers User Manual REV3.6.5.17 documents in part, Static Control-Press to set the air mattress in static mode according to the weight of the patient and turn the pressure adjust knob to set a comfortable pressure level using the weight scale as a guide.

Based on interview and record review the facility failed to assess, monitor, identify and intervene promptly for one resident (R2) who was responsive but became unresponsive. This failure resulted in R2 being sent to the hospital and led the R2's death.Based on interview and record review the facility failed to assess, monitor, identify and intervene promptly for one resident (R2) who was responsive but became unresponsive. This failure resulted in R2 being sent to the hospital and led the R2's death.Findings include:The immediate jeopardy began on [DATE], when R2 had a change of condition was not immediately addressed. The administrator, Director of Nursing, and Regional Nurse Consultant were notified of the immediate jeopardy on [DATE] at 2:08pm.An abatement plan was provided on [DATE] at 4:23pm. This plan was sent back for corrections.An abatement plan was provided on [DATE] at 11:56am. This plan was sent back for corrections.An abatement plan was provided on [DATE] at 3:10pm. This plan was accepted on [DATE] at 4:28pm.Based on observation, interview, and record review, the immediacy was removed on [DATE]. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation.R2's diagnoses heart failure, paroxysmal atrial fibrillation, hyperlipidemia, hemiplegia, shortness of breath, acute embolism and thrombosis of deep veins of right upper extremity, type 2 diabetes, schizophrenia, epilepsy.R2's Minimum Data Set (MDS) dated [DATE]) has R2's Cognitive Skills for Daily Decision Making scored as Severely Impaired.On [DATE] at 1:29pm V8 (Certified Nursing Assistant/CNA) stated V5 (Licensed Practical Nurse/LPN) instructed V8 to sit in the dining area with R2 and to keep calling R2's name to try to keep R2 awake. V8 stated R2 had previously been responsive and talking but the day R2 was sent out ([DATE]), R2 was unresponsive. V8 stated she informed V5 R2's breathing was labored and V5 told her R2's breathing was normal and to just stay there and keep calling R2's name.On [DATE] at 2:08pm V5 (LPN) stated she noticed a change in R2's condition on [DATE] late afternoon. V5 stated R2 was sweating while being under the fan. V5 stated she informed V10 (Wound care coordinator/Manager on duty) she feels R2 had a change of condition and asked V10 what should she do. V5 stated V10 instructed her to just monitor R2. V5 stated she was told by V9 (Wound care nurse) V10 was waiting on the doctor.On [DATE] at 2:52 pm V9 (Wound Care Nurse), V9 reviewed text messages and calls between V9 and V10 (Wound care coordinator/Manager on duty) and verified communication regarding R2's change of condition happened at noon on [DATE].On [DATE] at 2:52pm V9 (Wound care nurse) stated on [DATE] at approximately noon, V9 noticed R2 did not look good. V9 stated R2 was not responsive and R2's eyes were rolling. V9 stated before [DATE], R2 was able to talk and verbalize his needs. V9 stated she informed V5 (LPN) to let the doctor know of R2's change of condition. V9 stated she informed V10 (Wound care coordinator/Manager on duty) R2 was not responding and looked like R2 needed to be sent out to the hospital. V9 stated V10 stated she was waiting to hear back from R2's doctor.On [DATE] at 3:17pm V10 (Wound care coordinator/Manager on Duty) stated on the morning of [DATE], R2's nurse informed her R2's room was warm. V10 stated she went to check R2's room and it was hot, so she provided R2 with a fan. V10 stated R2 had heavy breathing and was asleep. V10 stated she was informed by V9 in the afternoon R2 was lethargic. V10 stated she told V9 to get R2's vital signs and inform the doctor. V10 stated she never told V5 nor V9 she would call to inform R2's doctor of his change in condition. V10 stated she did not call the doctor regarding R2's change of condition. V10 stated she never went to see R2 after she was informed of R2's change of condition.On [DATE] at 10:05am V11 (LPN) stated she was informed at the beginning of her shift (7pm) R2 did not look good. V11 stated she assessed R2, called the doctor and received orders to transfer R2 out to the hospital.On [DATE] at 12:44pm V2 (Director of Nursing/DON) stated a change in level of consciousness would be considered a change of condition. V2 stated after a true change of condition is identified, the doctor should be called immediately. V2 stated if there is a problem with a resident, the manager on duty should go look at the resident. V2 stated V5 (LPN) telling V8 (CNA) to continuously call R2's name was not an appropriate intervention. V2 stated the physician should have been made aware at the time R2's altered mental status was discovered.On [DATE] at 5:36pm V15 (Medical Doctor/MD) stated she was on call until 5pm on [DATE]. V15 stated she was never made aware of R2's change of condition. V15 stated if she would have been made aware, she would have had the nurse to triage R2 and depending on R2's vital signs and symptoms, gave orders.R2's progress note dated [DATE] at 8:05am documents in part, Resident is alert and oriented, able to make needs known.R2's progress note dated [DATE] at 7:54pm documents in part, Shortness of breath, unresponsiveness, seems different than usual .weak, confused, or drowsy at the time of evaluation.Review of R2's record shows no entry before the change of condition note dated [DATE] at 7:54pm for R2's change of condition. Review of R2's records show no indication R2's physician was notified before the change of condition note entered on [DATE] at 7:54pm.R2's hospital record dated [DATE] documents in part, Nursing home patient presents by the paramedics in cardiac arrest. Paramedics called the nursing home for mental status changes and found the patient lethargic, hypoxic and agonal breathing. Patient lost heart rate and respirations at the nursing home. Patient intubated en route . Present asystole with no pulse . Disposition: Expired.R2''s care plan dated [DATE] documents in part, Resident has the following advance directives: Living Will, POLST (Physician Orders for Life Sustaining Treatment) CPR (Cardiopulmonary Resuscitation) . Resident is a FULL CODE - if resident becomes unresponsive, call for help immediately and begin Basic Life Support sequence.Facility's policy titled Resident Rights Guideline dated 11/2024 documents in part, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times .Our facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility protects and promotes the resident of the residents .All residents have the right to equal access to quality care regardless of a diagnosis, severity of condition, or payment source.Facility's policy titled Acute Condition Changes - Clinical Protocol dated 08/2008 documents in part, Assessment and Recognition .1. As part of the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; the Nurse shall assess and document/report the following: a. Vital signs b. Neurological assessment c. Change in level of consciousness, memory, or mood . f. Onset, duration, severity .5. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response.Facility's job description titled Licensed Practical Nurse (LPN) undated, documents in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations govern our facility, and as may be required by the Director of Nursing to ensure the highest degree of quality care is always maintained.Based on interview and record review the immediacy was removed on [DATE]. The facility took the following steps to remove the immediacy.1. On [DATE]rd, 2025, all 196 residents were immediately assessed by a licensed nurse, and attending physician immediately notified with any acute changes of condition. No additional residents were identified with an acute change of condition. These actions were completed by the DON (Director of Nursing) and all nurse managers.2. The DON and six nurse managers have conducted a comprehensive review on 196 residents to identify any other residents who may be at risk for change of condition.3. The facility has ensured all residents identified as at-risk, both new and readmitted , have individualized care plans specifically addressing any residents with an acute change of condition.4. Full house in-servicing (clinical, and non-clinical staff) and training on acute condition change, notification of change guidelines for recognizing a change of condition, and E-interact Stop and Watch. Any agency and nursing staff (nurses and aides) who have not been scheduled to work (PRN staff), vacation or medical leave must complete acute change in condition in-service/education prior to working. Agency staff will be educated prior to working. This training was initiated on [DATE] and completed by [DATE].5. Audit all transfers, both emergent, and non-emergent daily X 14 days then 3X weekly for 4 weeks to ensure staff have followed policy and procedure for resident acute change of condition, and MD notification. Audit process began on [DATE] and is ongoing. Audit will consist of resident name, date of transfer, type of transfer, change of condition, Stop/watch tool completion, timely notification of MD/NP (Nurse Practitioner) notification. These audits completed by DON and six nurse managers.6. Documentation will be reviewed daily through the facility's 24-hour report to monitor for any acute change of condition and ensure prompt provider notification. The audit will include the following: confirmation the 24-hour report was reviewed, whether any change of condition was noted, and if so, whether the Stop and Watch tool was completed, the eINTERACT assessment was completed. The audit process began on [DATE] and is ongoing for 14 days daily, then three times weekly for four additional weeks. Review will be done by DON and nurse managers.7. Ad Hoc (for this situation) QAPI will be completed upon acceptable abatement8. 1:1 training was done for V5 (LPN) regarding recognizing and reporting changes of condition, escalation process for emergent clinical changes, and timely documentation and physician notification and V9 (RN) regarding recognizing and reporting change of condition, and timely MD notification.9. All staff educated and in-serviced by DON and nurse managers on acute changes of condition, emergent clinical changes, and timely notification of MD with any acute resident changes. Employees who have not worked, will receive education prior to start of next shift.

Based on interview and record review, the facility failed to update resident care plans to accurately identify isolation needs. These failures have the potential to affect 4 residents (R1, R2, R4, and R5) reviewed for isolation. Findings include: Record review of R1's physician orders document an active order for contact isolation precautions. Record review of R1's care plan does not document care planning for R1's isolation needs. Record review of R2's physician orders document an order for contact and droplet isolation precautions. Record review of R2's care plan does not document that the isolation needs were care planned during R2's stay in the facility. Record review of R4's physician orders document an active order for contact isolation precautions. Record review of R4's care plan does not document care planning for R4's isolation needs. Record review of R5's physician orders document an active order for contact isolation precautions. Record review of R5's care plan does not document care planning for R5's isolation needs. On 5/2/2025 at 12:14 PM, V2 (Director of Nursing) affirmed that when a resident is on isolation, the care plan must be updated to reflect their isolation status. Record review of facility policy titled, Care Plans (Comprehensive) (10/2022) documents in part, .Policy: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident . 5. Care plans are revised as changes in the resident's condition dictates.

Based on observation, interview and record review, the facility failed to ensure personal protective equipment (PPE) was readily available for use for residents that require enhanced barrier precautions and transmission-based precautions; failed to ensure linen cart was covered. These failures have the potential to affect 6 residents (R1, R4, R5, R6, R8, R9) reviewed for infection control. Findings include: 1) On 5/2/2025 at 10:30 AM, enhanced barrier precaution signs (noting that providers and staff must wear gown/gloves when providing high-contact resident care activities) were noted on the doors to resident's rooms. No personal protect equipment (PPE) was noted to be readily accessible outside the rooms. V6 (Certified Nursing Assistant) affirmed that there was no PPE available for use. V6 stated that V6 would be unable to provide care to those residents due to the lack of required PPE. On 5/2/2025 at 10:32 AM, V2 (Director of Nursing) affirmed that there was no PPE available for the staff to use for residents that require enhanced barrier precautions for the resident's rooms. V2 stated, I (V2) think they (the staff) brought all the containers downstairs to refill them. Record review of facility provided document titled ENCHANCED BARREIR PRECAUTION (undated) documents in part that the four resident's rooms require enhanced barrier precautions. 2) On 5/2/2025 at 10:48 AM, a contact precaution sign (noted that everyone must clean their hand prior to entering/exiting the room, and don gown/gloves prior to entering the room) was noted to R1's door. No gloves were noted in R1's isolation bins. V11 (Psychosocial Rehabilitation Services Coordinator) observed the isolation bin on R1's door and affirmed that there were no gloves. V11 stated, there should be gloves in there, and it's missing hand sanitizer too. V11 walked down the hallway and approached V8 (Restorative/Rehab Nurse, Licensed Practical Nurse) and asked for gloves from V8's medication cart. V8 responded, I don't have any. V11 then grabbed the last box of gloves from a PPE bin located near the end of the hallway, (leaving that bin without gloves) and placed the box of gloves in R1's isolation bin. No hand sanitizer was placed in R1's isolation bin. 3) On 5/2/2025 at 11:15 AM, a contact precaution sign (noted that everyone must clean their hand prior to entering/exiting the room, and don gown/gloves prior to entering the room) was noted to R4's door. No gloves were observed in R4's isolation bin. V12 (Licensed Practical Nurse) observed R4's isolation bin and affirmed there were no gloves in the isolation bin. V12 stated, there are some here after entering the room to get to another box located inside the threshold of the room. 4) On 5/2/2025 at 11:17 AM, the first-floor linen cart was observed uncovered. V12 (Licensed Practical Nurse) stated that the linen cart should be always covered. V12 pulled the flap down to cover the linen cart and turned the cart's opening to the wall. V12 explained that covering the linen cart is important to ensure the linen remain clean and have less exposure to germs. Record review of facility policy titled, Isolation- categories for Transmission-Based Precautions (1/2024) documents in part Contact Precautions . Use personal protective equipment (PPE) appropriately, including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment. [NAME] PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens. The policy does not include procedures regarding the availability of personal protective equipment. Record review of facility policy titled, Infection Prevention and Control Program(1/24/24) documents in part, Mission of program: The primary mission is to establish and maintain an effective Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 5. A system for linen handling to prevent the spread of infection includes handling, storing, processing and transporting linen .

Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions as stated in the care plan for residents at risk for pressure ulcers. This failure has the potential to affect six residents (R2, R3, R4, R5, R6, and R7), reviewed for wheelchair cushions as a pressure ulcer prevention intervention for residents. Findings include: On 1/15/25 at 11:50am during observation of residents in the fourth-floor dining room, R2 and R3 were observed sitting in the wheelchair without pressure relieving cushion. At 12:13pm, both residents were still in the wheelchairs without cushions. At this time, V9 (CNA/Certified Nurse Assistant) who was with the residents at the time was notified and stated that she (V9) would ask Restorative. V9 stated that residents need the cushions in the wheelchair to prevent wounds. V3 (Unit Manager) also stated that she (V3) would find cushions for the wheelchairs immediately she finishes assisting the resident with lunch. On 1/15/25 at 12:18pm during observation of residents in the third-floor dining room, R4, R5, R6, and R7 were observed sitting in the wheelchair without pressure relieving cushion. At 12:27 pm, all 4 residents were still in the wheelchair without cushion. At this time, V12 (Wound Care Technician) was notified and stated, I am the Wound Care Tech. They need cushions in the wheelchairs to keep the buttocks from breakdown and from having pressure ulcer. I will put the cushions in the wheelchair. On 1/15/25 at 1:00pm, V13 (Wound Care Nurse) stated, Residents' wheelchairs should have cushions to prevent pressure ulcers. We will in-service them. R2's records show the following: Multiple diagnoses which include but are not Limited Mobility. Pressure Ulcer Risk assessment dated [DATE] shows that R2 is at risk for pressure ulcer. MDS (Minimum Data Status) section M dated 11/3/24 states that R2 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 12/16/20 states: R2 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R3's records show the following: Multiple diagnoses which include but are not limited generalized muscle weakness and reduced mobility. Pressure Ulcer Risk assessment dated [DATE] shows that R3 is at risk for pressure ulcer. MDS section M dated 11/30/24 states that R3 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 8/3/21 states: R3 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R4's records show the following: Multiple diagnoses which include but are not limited generalized muscle weakness and reduced mobility. Pressure Ulcer Risk assessment dated [DATE] shows that R4 is at risk for pressure ulcer. MDS section M dated 11/3/24 states that R4 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 11/9/22 states: R4 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R5's records show the following: Multiple diagnoses which include but are not limited generalized muscle weakness and reduced mobility. Pressure Ulcer Risk assessment dated [DATE] shows that R5 is at risk for pressure ulcer. MDS section M dated 10/25/24 states that R5 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 4/18/24 states: R5 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R6's records show the following: Multiple diagnoses which include but are not limited generalized muscle weakness and difficulty walking. Pressure Ulcer Risk assessment dated [DATE] shows that R6 is at risk for pressure ulcer. MDS section M dated 11/25/24 states that R6 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 1/13/20 states: R6 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. R7's records show the following: Multiple diagnoses which include but are not limited Dementia and Difficulty Walking. Pressure Ulcer Risk assessment dated [DATE] shows that R7 is at risk for pressure ulcer. MDS section M dated 1/3/25 states that R7 is at risk of developing pressure ulcers/injuries and should have a pressure reducing device for chair. Care plan dated 7/3/23 states: R7 is at risk for impaired skin integrity. Intervention states to provide cushion to wheelchair. Facility's policy titled Pressure Ulcer and Wound Prevention/Management Program with latest revision date 12/5/06, states under Purpose: To identify residents who are at risk for pressure ulcers and skin breakdown, and to prevent pressure ulcers and skin breakdown. #7 states: The residents plan of care is audited at least quarterly or more frequently when change in condition occurs by the interdisciplinary team. Each intervention is analyzed to determine if the intervention is still appropriate and is actively provided. Interventions are added or changed as necessary to prevent further breakdown and promote healing as necessary. #8: The preventative measures from residents at risk will be implemented based on Braden Score and as deemed necessary based on clinical condition by the interdisciplinary team.

Based on interviews and record review, the facility failed to follow its policy and properly transfer a resident with a mechanical lift device during a transfer procedure for one (R1) resident out of three residents reviewed for resident safety. This failure resulted in R1 sustaining a fracture of the right knee while being transferred in the facility. Findings include: Face sheet dated 09/12/2024, documents R1 is an [AGE] year-old female with diagnoses not limited to: Osteitis deformans, chronic embolism and thrombosis, hypothyroidism, hyperlipidemia, chronic kidney disease, hypertension, and vitamin D deficiency. R1's MDS (Minimum Data Set) dated 08/20/2024, documents R1 has a BIMS (Brief Interview for Mental Status) of 04/15 indicating R1 is severely cognitively impaired. R1's Activities of Daily Living (ADL) Assistance documents R1 is dependent with ADL care. R1 is dependent with transferring from bed to chair. R1's MDS documents walking activity for R1 did not occur. The activity of walking 10 feet was also not attempted for R1 due to R1's medical condition or safety concerns. On 09/12/2024 at 10:02AM, R1 observed sitting in the second floor dining room fully dressed and sitting in a Geri chair. R1 stated she fell while walking in the facility when she was in the basement. R1 stated she did not sustain any injuries. R1 noted with confusion during interview. On 09/12/2024 at 10:18AM, V2 (Director of Nursing) stated R1 did not experience a fall in the facility. V2 stated R1 was improperly transferred with a mechanical lift device by a CNA staff member (identified as V4/CNA). V2 stated V4 was a new staff member who was recently hired at the facility. V2 stated she was informed by the nurse (V3/LPN) R1 was reporting right knee pain, so the facility ordered an x-ray of R1's knee the same day. V2 stated R1's x-ray report documented R1 had a right knee fracture. V2 stated she then reported to the state agency R1 had an injury of unknown origin. V2 stated she then started an investigation and found out during her investigation V4 transferred R1 with a mechanical lift device alone without any assistance from other staff. V2 stated R1 requires the use of a mechanical lift device to be transferred and this requires two person assistance. V2 stated V4 terminated her own employment by not coming back to the facility after providing V2 with a statement. V4 no longer works at the facility. On 09/12/2024 at 10:39am V3 (Licensed Practical Nurse/LPN) stated she was assigned to work on the second floor of the facility and assigned to care for R1 on 08/13/2024. V3 stated she was made aware by the CNA (identified as V5/CNA) R1 was complaining of knee pain. V3 stated she went to R1's room and performed an assessment and R1's right knee was swollen. V3 stated she contacted R1's nurse practitioner/NP and made R1's NP aware of R1's knee status. V3 stated R1's NP was located inside of the facility during time and assessed R1 in person and ordered an x-ray to be performed on R1. V3 stated the x-ray company performed an X-ray on R1 the same day. V3 stated she administered pain medication to R1 while awaiting the ordered x-ray. V3 stated she asked R1 what happened but R1 was unable to give an account of what happened to R1's knee. V3 stated R1 is often confused. V3 stated she was made aware by R1's NP R1's x-ray report showed R1 had a fracture. V3 stated R1's NP order a knee brace for R1's right knee and ordered orthopedic appointments for follow up care. V3 stated she carried out the NP orders. V3 stated she contacted R1's POA/power of attorney and made her aware of R1's knee status. V3 stated R1's NP also gave orders to send R1 out to the ER to be evaluated. V3 stated R1's POA stated she did not want R1 to go to the ER but just wanted R1 to wait for her follow up appointment with the orthopedic. On 09/12/2024 at 11:23AM, V2 (DON) stated during her investigation, V2 spoke with V4 (CNA) via telephone to inquire about R1's knee. V2 stated V4 informed her V4 transferred R1 to a Geri chair without any assistance by pivoting R1's body into the chair. V2 stated she asked V4 the reason for pivoting R1 without assistance during transfer when R1 requires the use of a mechanical lift device with two person assistance. V2 stated V4 said V4 was aware R1 required the use of a mechanical lift device for transfers. V2 stated she made V4 aware she needed V4 to come into the facility to speak with V2. V2 stated V4 agreed to come into the facility but never came back into the facility to speak with her. V2 stated she still has not heard from V4 since then. V2 stated she believes the pressure from V4 pivoting R1 is what caused R1's right knee fracture. V2 stated R1's resident care card is kept in R1's room and visible for staff to see. An attempt to contact V4 (Certified Nursing Assistant/CNA) was made on 09/12/2024 at 12:05PM, unable to leave voicemail due to voice mail being full. On 09/12/2024 at 12:11PM, V5 (CNA) stated she was the CNA responsible for caring for R1 on 08/13/2024. V5 stated while she was performing rounds, R1 groaned and told V5 R1 was in pain. V5 stated she asked R1 where her pain was located and R1 took her right hand and pointed to R1's right leg. V5 stated she then went to get the nurse (identified as V3/LPN) and informed V3 R1 was complaining of pain. V5 stated V3 immediately followed V5 back to R1's room. V5 stated she observed V3 questioning R1 about what happened and observed V3 assessing R1. V5 stated she heard R1 tell V3 R1 was in pain. V5 stated she then left R1's room and resumed caring for her other assigned residents. V5 stated she later received a phone call from V2 (DON) inquiring about R1's knee and what happened during the time V5 was caring for R1. V5 stated she informed V2 she was not aware of what happened with R1's knee and only reported to V3 (LPN) what R1 had reported to V5. V5 stated R1 requires a two person assist when being transferred with a mechanical lift device. V5 stated the protocol for using the mechanical lift device is to always call another staff member to help transfer a resident who requires a mechanical lift device. V5 stated if a staff member operates the mechanical lift device without the assistance from another staff member while transferring a resident, the mechanical lift device can tilt over, and the resident could fall and injure themselves. V5 stated while operating the mechanical lift device, one staff member should be located at the back of the mechanical lift device and one person should be located in the front of the mechanical lift device. V5 stated this procedure helps to prevent resident injuries. On 09/12/2024 at 3:05PM, V6 (Staff Coordinator) stated she was made aware R1 was injured due to a transfer in the facility. V6 stated she was asked by V2 (DON) to contact V4 (CNA) via telephone to ask V4 to come into the facility to give a statement. V6 stated V4 told her V4 could not come to the facility because V4 was informed V4 was taken off of the schedule and was under investigation because V4 transferred R1 alone without any staff assistance. V6 stated she then asked V4 if V4 transferred R1 improperly and V4 stated yes. V6 stated she continuously tried to text and call V4 for several days after the initial phone call but V4 never answered V6's calls or texts afterwards. V6 stated V4 never returned to the facility to follow up on V4's employment at the facility either. Nursing progress note dated 08/12/2024 at 3:35PM written by V3 (LPN) documents, Writer was called into R1's room, writer noted R1's right knee with swelling and pain. PRN pain medication given and tolerated. NP/Nurse practitioner is in the facility, new orders for X-ray of the right given. All orders noted and carried out. Nursing progress note dated 08/13/2024 at 10:29AM written by V3 (LPN) documents, X-ray company is in the facility to perform X-ray on R1's right knee. NP is also in the facility to assess R1. Nursing progress note dated 08/13/2024 at 3:29PM written by V3 (LPN) documents, X-ray results were relayed to NP, new orders were given to send R1 out to ER. Family was made aware of orders, POA/Power of Attorney stated she does not want R1 to go out to the emergency room , she does not want R1 to have to be sitting and waiting for long periods of time and they won't do anything. She stated she wants R1 to wait on her Dr. appointment. R1 has an outpatient Ortho appointment on 8-21-24 @8am. NP is aware of family wishes. Per facility reported incident dated 08/13/2024, R1 sustained a right knee fracture while at the facility. Facility witness statement dated 08/14/2024 written by V2 (DON) documents V4 informed V2 V4 transferred R1 from the bed to the chair without the use of the required mechanical lift devices. R1's X-ray report dated 08/13/2024 documents R1 has an acute fracture of the mid patella with 1cm separation of fracture fragments. Facility nursing schedule dated 08/10/2024 documents V4 (CNA) was assigned to the 2nd floor during the 10PM-6AM shift. Facility CNA assignment sheet dated 08/10/2024 documents V4 (CNA) was assigned to care for R1. R1's resident care card documents R1 requires the use of a mechanical lift device with two person assistance. R1's care plan dated 06/07/2022 documents in part, R1 requires assist with ADL'S related to Impaired Mobility. Transfer from bed to w/c and vice versa with use of Hoyer Lift x 2 staff. Facility policy undated, titled, Safe Lifting and Movement of Residents documents in part, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents. 1. Mechanical lifting devices shall be used for any resident needing a two person assist. Except during an emergency situation or unavoidable circumstances, manual lifting is not permitted.

Based on interviews and record reviews, the facility failed to supervise and use the appropriate shower equipment for one (R147) resident out of a total sample of 36 residents reviewed for falls. This failure resulted in R147 falling out of the shower chair and sustaining a closed nondisplaced fracture of the greater trochanter of the right femur. Findings include: R147's Admission Record documents in part medical diagnoses of dementia, seizures, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side. R147's 5/10/2024 Fall Risk Screen documents in part that R147 is at moderate risk for falls. R147's comprehensive care plan documents in part that R147 has a potential for falls and is at risk for injury from falls (initiated 10/02/2023). Intervention includes to Anticipate and meet resident's needs (initiated 10/21/2022). It documents in part that R147 had an actual fall on 6/26/2024 resulting in right trochanter fracture. On 7/23/2024 at 1:09 PM, R136 (R147's roommate) stated R136 was in the hallway when R136 saw V29 (Certified Nurse Aide-CNA) bring R147 from the shower room to the bedroom. R136 stated, [R147] was in the shower chair, then I just heard staff say [R147] was on the floor. Facility's working schedule for 6/26/2024 documents in part that facility assigned V29 to care for R147 that morning. On 7/23/2024 at 1:13 PM, V24 (Nurse) stated V24 has been taking care of R147 since May 2024. V24 stated R147's trunk/upper body control was not good. V24 stated R147 doesn't tolerate the shower chair and needs a shower bed. V24 stated this was R147's baseline status. On 7/23/2024 at 2:36 PM, V25 (CNA) stated V25 has been taking care of R147 for three out of five shifts a week for the past year. V25 stated R147's cannot sit up in a chair per baseline. V25 stated for bathing [V25] would bath R147 in a bed because R147 cannot sit in a shower chair. On 7/23/2024 at 2:40 PM, V26 (CNA) stated facility assigns [V26] mostly to the first floor. For the past 20 days, V26 has taken care of R147 four to five days out of the week. V26 stated R147 is bed bound and cannot sit up in a chair. V26 stated, [R147] can help sit up but beyond sitting upright by [self] [R147] can't. V26 stated that on the day of R147's fall, V29 asked [V26] for assistance to put R147 into the shower chair. After the shower, V29 took R147 back to the bedroom while V26 attended to another resident. V29 told V26 that during the time [V29] went to get linens for R147's bed, R147 fell out of the shower chair. V26 stated staff are not to leave residents unattended while on the shower chair including R147. On 7/24/2024 at 11:17 AM, V29 (CNA) stated during date of fall [V29] gave R147 a shower with V26's assistance. V26 and V29 used a shower chair for R147. After the shower, V29 took R147 back to the bedroom while V26 attended to another resident. While R147 was sitting in the shower chair by the bedside, V29 went to the linen cart in the hallway. V29 stated the cart was sitting by the door. I came to grab a sheet out of the cart. Once I grabbed the sheet, I turned around and [R147] was on the floor. [R147] just kind of slid out the chair. V29 stated R147 was sitting on [R147's] bottom with upper body leaning backwards towards the shower chair. During a witnessed interview among other surveyors on 7/23/2024 at 2:50 PM, V27 (Restorative Director) stated worked as the Restorative Director/Nurse since 10/2023 but worked at facility as floor nurse since 12/2022. V27 stated R147 cannot use a shower chair due to poor trunk control and one-sided weakness. V27 stated, [R147] has been like that since I've been working here. V27 stated R147 is not able to hold self-up even when sitting upright on the bed. V27 stated being part of the interdisciplinary team that investigated R147's recent fall on 6/26/2024. V27 stated, they shouldn't have utilized a shower chair. [R147] was improperly transferred and the wrong equipment was used for [R147]. V27 stated staff were supposed to use a shower bed for R147's showers. V27 stated facility did care plan for it. However, when reviewing R147's care plan, facility did not include shower bed intervention until 6/27/2024-after the fall. V27 stated after the fall R147 went to the hospital where they diagnosed R147 to have a right trochanter fracture. R147's 6/27/2024 hospital records and discharge papers document in part an acute nondisplaced fracture of the right greater trochanter. Facility's 8/2008 Falls-Clinical Protocol documents in part: As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk.

Based on interview and record review, the facility failed to have a policy and procedure in place on how to provide beneficiary notifications such as NOMNC (Notice of Medicare Non-Coverage) and ABN (Advanced Beneficiary Notice) to its residents. This failure could potentially affect 182 Medicaid / Medicare eligible residents residing in the facility with 2 residents under private pay for a total census of 184 as of 7/23/24. The findings include: On 7/23/24 at 1:10 PM facility provided a list of residents who were discharged from Medicare covered Part A stay in the past 6 months. On 07/24/24 10:40 AM V3 (SSD/ Social Service Director) said she started working in the facility January 2023 and transitioned as SSD in May 2024. V3 said NOMNC was not given for Medicare residents, it is only given for managed care / insurance residents. V3 stated she is not aware about ABN. At 11:06 AM V58 (Social Service Consultant) stated ABN should be provided to residents staying in the building and not covered by Medicare. V58 said NOMNC should be given to Medicare eligible residents within 48-72 hours before the last cover day. V58 said there is no process yet with regards to NOMNC and ABN notification. At 11:48am reviewed residents who were discharged from Medicare covered Part A stay in the past 6 months reviewed with V1 (Administrator) and stated no NOMNC or ABN were provided to residents. V1 stated no process yet regarding Beneficiary notification - ABN / NOMNC. V1 said moving forward, the facility will follow guideline or instructions for Beneficiary notifications provided by CMS (Center s for Medicare and Medicaid Services). Form completed by facility titled Beneficiary Notice - Residents discharged within the last 6 months listed 16 residents. Facility Census dated 7/23/24 showed 182 residents under Medicare / Medicaid and 2 residents under private pay for a total census of 184. Facility was not able to provide policy and procedure for Beneficiary notification (NOMNC and ABN). Facility provided Form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 and documented in part: A Medicare provider must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries / enrollees receiving covered skilled nursing. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Provider must deliver the NOMNC to all beneficiaries eligible for the expedited determination process. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Facility provided Form instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018) documented in part: Medicare requires SNFs (Skilled Nursing Facility) to issue the SNF ABN to original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. The SNF ABN provides information to the beneficiary so that she / he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility.

Based on interviews and record reviews, the facility failed to follow their abuse policy by failing to ensure resident was safe from abuse by failing to immediately report an allegation of sexual abuse made by R4 regarding employee (V23/CNA); facility failed to protect R4 from additional abuse/trauma by allowing V23 to continue to work after R4 reported the allegation of sexual abuse to a staff member; failed to protect R4 from harm when she initially reported to CNA, prior to incident on 1/11/24 that she did not want V23 to provide care for her anymore. This affected one resident (R4) of 5 residents reviewed for physical abuse. These failures resulted in V23 re-entering resident's room after R4 made an allegation of sexual abuse against V23. R4 expressed amplified feelings of anguish and panic, in addition to the trauma R4 experienced during the alleged incident. This was identified as an immediate jeopardy situation which began on 01/11/2024. On 01/24/2024, the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 01/26/2024. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: R4's Factsheet documents R4 is a [AGE] year-old female. R4's diagnoses are but not limited to major depressive disorder, weakness, post-traumatic stress disorder, and heart failure. R4' s BIMS (Brief Interview for Mental Status) dated 12/05/2023, notes R4 has a score 0f 15, indicating R4's cognition is intact. R4' s MDS (Minimum Data Set) dated 12/05/2023, notes R4 is dependent upon staff for care. R4's Care plan (dated 09/16/2024) documents R4 has an ADL self-care performance deficit r/t impaired balance. On 01/11/2024, R4, a bed ridden female resident alleged V23 (certified nursing assistant) was providing incontinence care to R4. R4 alleged when V23 was cleaning R4's vaginal area, V23 inserted and penetrated R4's vagina with his fingers. R4 alleged that R4 started screaming stating V23 is hurting her and V23 needs to stop and after that R4 put on her call light. V21 (certified nursing assistant) entered R4's room while V23 was still present. R4 told V21 that V23 hurt R4 and V21 asked V23 to leave R4's room. R4 was hysterical and reported to V21 that V23 penetrated his fingers into R4's vagina and R4 does not want V23 to provide care for R4. V21 left R4's room and told R4's nurse that V20 (licensed practical nurse) R4 had something to tell her. V21 went home, failing to report sexual abuse to the administrator and R4's nurse. R4 was left alone in her room, and V23 was still in the facility. R4 reported R4 was traumatized and frantic after the incident occurred, and 15 minutes later V23 re-entered R4's room, which caused R4 to experience a panic attack and additional trauma. R4 stated about 3 weeks prior to this incident, V23 rubbed R4's face and told her she was beautiful. R4 stated she reported this to staff and told staff R4 did not want V23 to provide care for her. Staff failed to report this abuse to the administrator, which potentially could have prevented R4 from any further sexual abuse. Facility's Final Investigation Report (dated 01/19/2024) states in part: On 01/11/2024, nurse manager received a phone call from R4's husband, who stated, The guy in the room just stuck his finger in my wife's vagina. According to the husband, R4 had called him to report that information. Nurse manager immediately went to R4's room to assess R4. R4 stated to nurse manager, the male C.N.A. just put his fingers in my vagina. Reassurance was provided, police were notified as well as provider who ordered resident to be sent to the ER for evaluation. Hospital records indicate alleged she was getting washed up for the night and a male attendant was cleaning her buttocks and peri area had bowel movement between crevices and peri area when she stated the male C.N.A. stuck his fingers in her vagina for a second or two. R4 also stated she saw another staff member walking past the room during the incident and yelled for assistance. R4 states she has had care performed by V23 (C.N.A) previously with no issues or concerns. Based on a complete and thorough investigation the facility has determined the allegation of sexual abuse is unfounded. It is believed resident perceived this sensation during ADL care when R4 was pushing the brief down between her legs to begin the process of changing her. R4 remains in the facility at this time without concern and will only have care provide by female staff. Her abuse risk assessment, sexuality assessment, and ADL care plans have been updated. R4's Health Status Note (dated 1/11/2024) documents, Informed by staff member R4 was mishandled. R4's Physician note (dated 1/15/2024) documents, R4's is a [AGE] year-old female patient who presents for medical evaluation. Thursday night R4 reported sexual assault. R4 stated she was being cleaned after urinating. R4 stated V23 was rough. R4 reports there was no bowel movement, only urine. R4 said V23 stated she was beautiful. R4 told V23 to stop and called for help. R4 reports having a panic attack, and 911 was called. R4 went out to local hospital. R4 stated a swab was done, unclear where, which showed she was having some bleeding. R4 reports also having scar tissue. R4 states she had nightmares about the event. Since this event happened, R4 has had some burning with urination. R4 stated she has never had anything like this happen before but does have PTSD (post-traumatic stress disorder) from witnessing her son's murder and recently worsened depression from her cousin's death from cancer. R4 ' s Hospital Records (dated 1/12/2024) documents, R4 is being treated for a urinary tract infection. There was mild blood noted on the swab, for gonorrhea and chlamydia rape kit. There was no active bleeding. On 1/13/2024, at 11:05 AM, V8 (Director of Nursing) stated, In the last sixty days, there have not been any other allegations of sexual assault. The police took the alleged perpetrator, V23 (certified nursing assistant) to jail. It is protocol to call the police. V27 (Night Supervisor) was writing down V23's statement. V27 called me and stated V23 had been arrested. I came in and the detectives arrested him. I thought they were going to release V23 that night. I just heard yesterday V23 was still incarcerated. I found out from one of his friends V23 is still in jail. R4 is alert and oriented. I interviewed R4. R4 told me she turned on her call light because she was wet. V23 came into the room. She told V23 she was wet. V23 asked her if she was wet. V23 went to go get a towel. V23 started to clean R4 up. V23 started washing up underneath her abdomen. As he was washing her, V23 stated she was dirty. She told V23 it was urine. V23 started to clean R4's vaginal area. While V23 was cleaning R4, V23 was explaining to R4 what V23 was doing. I also asked R4 if the door was open or closed. She stated it was open. R4 said V23 began cleaning her vagina area and inserted his fingers into her vagina area. R4 stated 'you're hurting me'. V23 said, I am trying to clean you. R4 stated she did not see a towel while V23 was doing this. V23 did have gloves on. R4 started screaming for V21 (Certified Nursing Assistant). V21 came into the room. R4 told V21 that V23 was hurting her. V21 said V21 asked V23 to leave. R4 asked V21 to put lotion on her legs. Then, R4 told V21 she does not want V23 cleaning her up. R4 told V21 that V23 put his hands in her vagina. V21 went to tell V20 (Licensed Practical Nurse) something was going on with R4 and V20 needed to follow up. R4 called her husband. The husband called the facility and spoke with V27 (Night Supervisor). V27 activated the abuse protocol. V27 called me, the police, and separated V23 to write V23's statement. V27 told me V23 was arrested. V21 stated about 9:30 PM, she was coming back upstairs from her locker. V21 was on her way to make sure R4 was alright before she left the facility. When V21 came up, V21 saw the linen cart in front of R4's room. V21 went into the room and V23 was adjusting R4 in bed. V21 did not hear any yelling in the hallway. I had social services go talk to other residents. Previously, I was told by R4 that V23 had rubbed her face and stated she was beautiful. R4 told her husband but does not recall if she mentioned this to a staff member. I have not had any other allegations from other residents concerning V23. On 1/13/2024, at 12:40 PM, R4 stated, It did not start yesterday. It started about a week ago. V23 always in came in my room and stated I was a beautiful young lady. He told me you're so beautiful my sister and started rubbing my face. I told him not to do it. Every time V23 came in my room, I told another aide I did not want him. But that day I did not have a choice. He did not knock before coming into my room. He came in my room, and I told him I was wet. He said I am going to change you. He asked if I had a bowel movement. I told him I urinated. He said I want you to be clean and smell good. I told him I do smell good. He got a towel and wiped under my belly. He told me I was dirty. I told him it is just urine. Then, he cleaned me between my legs on both sides. He said again I am dirty. I told him again is just urine. Then, he washed between the creases of my vagina. He did not use a towel; he threw it on the side. He put his fingers in my vagina and penetrated me. I started hollering. I screamed it hurt. I have a urinary tract infection as well. It hurt bad. After that, I saw another aide. I told V21 to come in. V21 asked me what was wrong. I told V21 that V23 touched me, and I started screaming and hollering. V21 told V23 to get out of my room. V23 said he did not do anything. I told V21 that V23 hurt me, and I had a panic attack. I called my husband because I was on the phone with my niece. My niece said call 911. My family came. The facility notified my family of the incident. The police came and V23 was in the waiting room. The police said let's arrest V23 before he leaves. V23 tried to come back in. I started screaming and the nurses came running in. I could not stop crying. The ambulance took me to the hospital. They did a swab and found out I was bleeding. V23 had penetrated me a bit. The hospital stated that after the swab I was bleeding. I have had a hysterectomy and I have not had a period in years. My husband does not touch me either. The detectives asked me piece by piece what V23 did. I am disabled and over 60. I am totally dependent, and I have a wheelchair. I had a very bad stroke because I saw my son get shot seven times in front of me. The police came and arrested V23. The detective interviewed my son in law. The staff were going to clean me up, but the police told them not to. My bed was still soaking wet because V23 did not clean me. The police asked me if I wanted V23 arrested, and I said yes. I did not have a roommate during this time. I was in the room by myself. I have had nightmares because I cannot have any men change me. I get scared and urinate all over myself. My family is looking for another facility. On 1/13/2024, at 2:00 PM, V26 (R4's Family Member) stated, R4 declined a rape kit. She stated the gentleman had gloves. I told her it did not matter. That is when the officer called on the portable radio to transfer R4 to do the rape kit. The officer left. All these people came in to ask if she was ok. I told the nurse she was not going to clean R4 up because R4 was going to the hospital and needed evidence. The nurse told me V23 (certified nursing assistant) came into the room to clean her. V23 told R4 she was pretty and rubbed on her face. When V23 went to clean R4, V23 told R4 that R4 had to be extra clean and inserted his fingers into R4. After this occurred, V23 was able to come back into the room to linger over R4 and tell R4 that V23 did not do anything to R4. I did not see anything but R4 called me and told me this happened. This is what R4 told me on the phone, and I called the facility and reported this to the night shift supervisor. On 1/13/2024, at 2:32 PM, V20 (Licensed Practical Nurse) stated, I was working the day this allegation occurred. I was working on the same floor as R4. I was her nurse for the day. She did not tell me anything. She reported this to V27 (Night Supervisor) and V28 (Staffing Coordinator) came up the elevator. V27 asked me if R4 was alert and oriented, I stated yes. I said R4 stated someone raped her. V27 and V28 went to go interview R4. I asked her if I could examine her. The family was there. When I attempted, the police stated I could not because the ambulance was on the way. The police called the fire department. R4 is alert and oriented. V27 informed me R4 was raped. This is what I meant by mishandled because I do not use words like that. On 1/17/2024, at 2:21 PM, V21 stated, I did not hear R4 screaming. R4 never reported to me she did not want V23 not to be her aide before the incident occurred. On 1/13/2024, at 2:39 PM, V21 (certified nursing assistant) stated, V23 was R4's aide the day of the allegation. I did not witness anything. But I did answer her (R4's) call light because she saw me walk by. When I got back on R4's unit, there was a cart by her door. I assumed she did not need changing. It was almost time to go home. I went to check on R4 to make sure she was alright. V23 was already done cleaning her up. I was wondering if V23 needed any help in there. I put some lotion on R4's legs. She asked where V23 was at. She told me V23 had fingered her. I said the nurse is right behind me. The nurse is coming in to give you your medication. When I walked out, I told V20 that R4 had something to tell her. After that, I went home. R4 is alert and oriented. On 1/17/2024, at 9:34 AM, V27 (night supervisor) stated, R4's husband told me to go see her (R4) right away. When I got there, she was hysterical. She told me during incontinence care, she felt uncomfortable with the way she was being changed. I went to see who was attending to her. I separated V23 from her to prevent harm. She pointed towards her incontinence brief. She stated the way she was wiped was inappropriate. She stated V23 was wiping her up and down and said that she was beautiful at the same time. She did not tell me V23 had penetrated her. I asked V23 for a statement, but he never gave me one. I have had no other complaints from any other residents about V23. On 1/17/2024, at 11:49 AM, V23 (certified nursing assistant) stated, I was covering day from 2:00 PM to 10:00 PM. The schedule was for me to work on the second floor. The assignment given to me by the charge nurse was to cover rooms . Just like all other residents in my care, I must make sure they are clean and dry. Mostly, by changing their diaper. I got to R4's room because the call light was on. I started attending to her. I asked her if she was ready to be changed. She said yes. My cart and my dirty linen cart were close to her room. I took the necessary material to her room. I soaked the towels and added some soap to water. The temperature must be ok before attending to her. Normally, I must start from the front. Her stomach was extended, and she helped me to lift her stomach so I could clean it. When I cleaned her, I showed her that she was clean. I cleaned between where her legs and torso meet down to her leg. I showed her just for her to know she is clean. There are reports residents say they are not cleaned well. That is why I did all of this. Next, I rolled her incontinence brief down before I started cleaning. I cleaned from her abdominal all the way down to the front of her vagina. I dried her with the other side of the towel at every step of the cleaning. I could not get the soiled brief off until after she rolled over. I cleaned the back of her buttocks. She cooperated with turning. I gave her a boost to turn. She did not complain of anything. I cleaned her buttock. I cleaned from the clean to dirtiest as I was taught. That was all I did. As I was cleaning, she had a very small bowel movement. I did not see this when I was cleaning the front. I cleaned her everywhere. When I remove the dirty incontinence brief, I noticed the bed pad was wet as well. Even it is not wet, she had been on it for some time. I needed to change it. I changed it along with the brief. That was all I did. I closed the new brief on both sides. There was no complaint or screaming and I left. I had no other staff because she only requires one person because she can be cooperative with care. When I was cleaning her, I did not stick my fingers inside of her vagina at all. I did not touch her inappropriately in any way. This was not the first time I had taken care of her. She did not complain. More than three weeks ago, I saw her crying. I asked her what the problem was. I encouraged her not to cry. That was all. I did not touch her face. I patted her on the arm. I did not mean any harm to her; just to encourage her. I did not touch her on the face or anything. On the day of the allegation, I was doing my charting in the dining room. Before that, V27 called me, she came with another person. I was trying to let V28 (Staffing Coordinator) know it would be good for them to have four aides on the floor at a time because the floor is too heavy. I did not know something was going on. After some time, V28 called me and told me there was a complaint against me. The husband called the police. V28 told me to continue my charting in the dining room. The police came. They arrested me there and took me away. The police asked me to get up and they handcuffed me to the back. They took me to a police station. I was there for some hours. I was taken to another police station. They told me it was the second district. They searched me. I was in jail from the 11th until the 13th. They told me there was no charge against me. On the second day, two detectives came. They took me upstairs in a room. They wanted to interrogate me. They read some of my rights to me including taking a lawyer. On 1/17/2024, at 1:30 PM, V8 (Director of Nursing) stated, The detective informed me the alleged perpetrators are held for 48 hours and then they are let go. When I talked to R4, she told me she could not recall reporting the face rubbing to anyone. She reported to the detective as well. V23 has been taking care of her for a while and she has never reported anything like this to staff before. If she had reported this, V23 would not have been taking care of her. Currently, R4 does have a urinary tract infection. Some burning and bleeding may occur. On 1/17/2024, at 1:55 PM, R4 stated, I do not remember names of the staff I talked to about the face touching. I do not remember what staff member I said I did not want V23 to be my aide before the incident occurred. On 1/17/2024, at 2:57 PM, V28 (Staff Coordinator) stated, V27 and I knocked on the door and went in the room. R4 was in the room lying in bed. I came in and asked her what was going on. She said V23 was fingering her. I asked her what you mean fingering you? Was V23 in the process of cleaning you? She stated he was, but he started fingering me. I asked if he stopped when you asked him. She said that he stopped. I said he is the aide, are you sure it was fingering or cleaning? Do you think he was cleaning you because you had a bowel movement. She said no he was fingering me. She made a [NAME] with her finger of him going in and out of her vagina. I looked at V27 and told her we must call V1 (Administrator). We let V1 know, and we did not leave. At this time, we noticed R4's call light was next to her. I asked her if she put her call light on in the process of this. She said no. She said she called her husband. She never pulled the call light or told us. The husband called the facility and told us. She said she called her husband. I told her the call light is next to her and it is to alert us. We told her he would not be back. We told him not to go by her room or in it. At this time, were coming down the elevator. The receptionist stated the police were coming. V27 called V1 and the V8. The police did not come right away. I have not heard any complaints from the residents about V23. On 1/18/2024, at 9:21 AM, V29 (Police Detective) stated, If a victim has signed complaint, then the offender can be placed into custody. This is not new; this can happen at any point. Police hold them for 72 hours before the alleged perpetrator is in front of a judge. On 01/22/2024 at 10:01am V1 (Administrator) stated, I am the abuse prevention coordinator. All facility employees receive abuse prevention training upon hire and as needed. When a resident reports being sexually abused, we have to make sure the alleged perpetrator is not around. For instance, when a resident says an alleged perpetrator sexually abused them, we have to immediately remove the alleged perpetrator from the premises. After that, we have to assess the victim. The nurse on duty must assess the resident and do the interview of what occurred. The nurse must determine who needs to be called, for example the law enforcement, determine if the resident needs to be sent to the hospital, family and physician notification. The investigation process must be started immediately, and we must make sure the resident is safe. Staff must report the abuse allegation immediately to me. When a resident reports being sexually abused by a staff member, and the perpetrator leaves the victims room, the alleged perpetrator must be sent home immediately, the perpetrator must leave the facility immediately and be suspended immediately so the resident was abused feels safe. The alleged perpetrator is never allowed to re-enter the victims room. The alleged perpetrator is never allowed to continue to work once the abuse is reported. The alleged perpetrator is not allowed to keep working once abuse was reported and they must leave the facility and they are immediately removed from the schedule. When R4 reported being sexually assaulted, they removed the staff member and R4 was sent to the hospital. V23 (certified nursing assistant/alleged perpetrator) was not immediately sent home by the staff, he was removed from the facility by the police. Per the facility police, the perpetrator should have been sent home immediately, but he was not, he was removed from the building by the police. We don't allow the alleged perpetrator to continue to work. When a resident reports abuse, it is the responsibility of the person who the victim reported the abuse to, to report the abuse allegation to me. On 01/22/2024 at 11:12am V8 (Director of Nursing) stated, The event occurred on 01/11/2024 and the detectives returned to the facility the next day and interviewed R4. R4 stated R4 never had a problem with V23 (certified nursing assistant) in the past except R4 stated to the detectives V23 rubbed her face and called her beautiful in the past and she reported this to her husband and a staff member, but she could not remember who the staff member was. R4 could not remember for sure if R4 reported the face rubbing to a staff member. On 01/11/2024, V27 (night supervisor) received a call from R4's husband informing V27 R4 was sexually abused. When V27 received the call from the husband, V27 rushed to the 2nd floor to interview the resident. R4's nurse on duty, V20, did not assess R4 because V20 was not made aware of the sexual abuse allegation. V27 assessed and interviewed R4 after R4's husband notified her the alleged abuse occurred. V20 (licensed nurse practitioner) did not assess or interview R4 the time R4 reported the incident. V27 was notified by R4's husband the incident occurred and then V27 went to interview R4. Police removed V23 from the facility, because R4's husband called the police and reported the sexual abuse allegation. On 01/22/2024 at 11:20am V30 (social worker) stated, I have been following up with R4. R4 has not expressed any anxiety or any feeling of distress. I follow up with R4 and she says she is fine and she's doing good. R4 wants to discharge to another facility so she can be close to her son. R4 is doing good, and we have been following up with her since the incident occurred on 01/11/2024. Abuse Prevention Policy (undated) states: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Internal Reporting Requirement and Identification of Allegations; Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or the designated individual in the administrator's absence. The surveyor confirmed through observation, interview, and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 01/24/2024, V1 (Administrator) informed surveyor V23 (certified nursing assistant/alleged perpetrator) no longer works in the facility. R4 remains in-house, having her needs met without further concern. V1 stated R4 receives care from female staff to ensure R4's safety and comfort. 2. The social service and nurse managers have conducted a comprehensive review to identify other residents who may be at risk for abuse. The staff conducted interviews of residents and staff to determine if there have been other residents who were affected by the alleged perpetrator or any other staff. 3. On 01/24/2024, the administrator and the director of nursing started reeducating/ in-servicing staff on how to effectively respond to allegations of abuse and maintain the safety of residents by immediately removing the accused person from the facility and not allow the accused to return into the facility until a thorough investigation is completed. 4. On 01/24/2024, staff were in-serviced on the importance of reporting allegations in detail for immediate intervention, including prompt notification to family/responsible parties, physicians and Np's, and police. 5. On 01/24/2024, the facility started providing an in-service and training to in-house staff, agency nurses and agency certified nursing assistants and PRN staff regarding abuse, abuse prevention and reporting, emphasizing on the importance of immediately removing the alleged perpetrator with no re-access to the floors and specific focus on reporting detailed information on what is alleged. The in-service was completed on 01/25/2024. 6. The new hires will be educated during the core orientation process, prior to starting. If unable to reach the employee, the employee will not be allowed to return to work until education is completed. 7. V21 (certified nursing assistant) received 1:1 education regarding abuse, abuse prevention and immediate detailed reporting. Based on observation, interview, and record reviews conducted on 01/26/2024, the facility completed all measures on the abatement plan. Therefore, the abatement plan could be approved on 01/25/2024.

Based on interview and record review, the facility failed to follow their elopement policy for monitoring a cognitively impaired resident (R2) with severe mental illness, who was assessed to have cognitive impairment, and assessed to be at risk of elopement, failed to have a physician order for unsupervised outside pass, and failed to obtain consent from state guardian to be discharged from facility. These failures resulted in R2 eloping from the facility on 10/10/23. R2 was located at a restaurant 4 miles away from the facility and refused to go back to the facility and facility discharged R2 AMA (Against Medical Advice). This was identified as an immediate jeopardy situation which began on 10/10/23 when R2 eloped from the facility. On 12/5/2023 at 11:45 am, V1 (Administrator) and V2 (Director of Nursing, DON) were notified of the Immediate Jeopardy. The facility presented a removal plan on 12/5/23 at 6:02 pm, which was not approved. The facility presented a revised removal plan on 12/6/23 at 1:11 pm, which was not approved. The facility presented a revised plan on 12/6/23 at 8:16 pm, which was not approved. The facility presented a revised removal plan on 12/7/23 at 3:33pm, which was not accepted. The facility presented a revised removal plan on 12/11/23 at 12:10 pm, which was not approved. The facility presented a revised removal plan on 12/11/23 at 1:01 pm, which was not approved. The facility presented a removal plan on 12/11/23 at 3:21 pm, which was accepted on 12/12/23 at 5:10 pm. The survey team confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/13/23 based on the acceptable removal plan, however, noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's admission diagnoses include but not limited to schizophrenia, noncompliance with medications regimen, bipolar disorder, current episode depressed, severe with psychotic features and diabetes. R2's (10/10/23) BIMS (Brief Interview Mental Status) summary score was blank. R2's (10/9/23) Admission Clinical Evaluation with Braden Scale documented in part, 42. Risk Alerts: i. May attempt exit. 44. Impairments- General: a. Cognitive. 47. Trauma Exposure: B. other comments: Received A/O (Alert and Oriented) X3 (Time 3), verbally responsive, speech impaired, Ambulatory, gait unsteady. After arrival resident kept getting up unsupervised, responds to re-direct, doesn't last, must reiterate all instructions. C/O pain to LLE (Left Lower Extremity), comfort following Tylenol. PMH (Past Medical History) of falls, violent behavior tendencies, fall and elopement precautions initiated. Will continue to monitor. R2's Order Appointing Plenary Guardian of a Person with a Disability documents, in part, 4. In accordance with 11a-3 and 11a-12 of the Probate Act, by clear and convincing evidence, the Respondent is a person with a disability and: a. totally lacks sufficient understanding or capacity to make or communicate responsible decisions concerning the care of his or her person. 6. The appointment of a Guardianship ad litem WAS necessary for the protection of the Respondent or to make a reasonably informed decision on the Petition. Entered date 4/17/2023. On 11/28/23 at 10:40 am, V23 (Liaison) stated, (R2) was one of the patients the hospital wanted me to see. She (R2) had a sitter when I (V23) saw her. I explained, the sitter needs to be discontinued for 48 hours before the facility can take her (R2). She (R2) had a sitter for safety to monitor her (R2) for transfers. The Facility was able to accept (R2) after being without a sitter for 48 hours. The hospital sent hospital records and discharge paperwork to me (V23). I kept in contact with the social worker at the hospital and was not made aware of R2 having a guardian. I did speak to (R2), and she (R2) was aware of the facility and what type of facility it was. (R2) did a verbal consent that she (R2) agreed to come to the facility. I'm the one who accepts the residents that come to the facility. I speak to admissions and send over the paperwork notifying them of the admission. When I talked to (R2), she asked questions and answered questions appropriately. (R2) never discussed about wanting to go to a group home. On 11/28/23 at 3:30 pm, V3 (Hospital Social Worker) stated V3 was having a hard time placing R2 and V23 (Liaison) assisted with R2's placement and accepted the resident at the facility. V3 said, I sent a referral packet to (V23 Liaison). When the resident goes to the facility a packet goes with them also. Surveyor asked if V3 was aware of R2 having a guardian. V3 stated, Yes, I knew R2 had a guardian and had been in communication with the guardian. Surveyor asked V3 if the paperwork for the legal guardian was sent in the referral packet or in the documents sent to the facility. V3 stated, Everything in the chart was sent to the facility and I put in my notes that R2 had a guardian on several occasions. V3 stated she told V23 that R2 had a guardian. V3 said V23 knew V3 was having a hard time placing R2. The guardian wanted R2 placed in a facility. On 11/29/23 at 1:15 pm, V28 (Admissions Director) stated, I'm the acting admission director. During that time (referring to 10/9-10/10/23) the facility did not have an admission director. V28 stated, V28, V2 Director of Nursing (DON) and V23 (Liaison) reviewed the paperwork for R2. V28 stated V23 completed an in-person interview with R2 and that V23 can accept residents at the bedside. V28 said, We (V28, V2, V23) noticed R2 had a 1:1 sitter and requested she be cleared of a sitter for 24 to 48 hours prior to R2 being admitted because that is something we are unable to accommodate. The case was reviewed to see if R2 was taken off the 1:1 sitter. If any clinical concerns, we put it at a yellow. V2 was looking at the paperwork for clinical concerns. We (V28/V2) requested updates to be sent to see if R2 was stable. The updates came in on 10/9/23, before R2 came to the facility and was reviewed by me (V28) and V2. Surveyor asked if V28 was aware of R2 having a state guardian. V28 stated, I cannot recall if I was told about R2 having a legal guardian. The whole packet was reviewed including the nursing notes and case management notes by us (V28, V2, and V23). In that packet I did not notice any information about a guardian. We did not know a guardian was in place for R2. A resident with a guardian would not have the ability to say they want to leave if a guardian is in place without a guardian's consent. V28 stated, R2 was admitted to the facility between 6:00 pm and 7:00 pm on 10/9/23. On 11/28/23 at 2:05 pm, V2 DON stated, The liaison sends the referral packet to review, and I look at it to determine if the resident could come on a clinical level. The liaison can make the decision of who comes but I review all the paperwork before they get here. I reviewed R2 and she did have some behaviors noted. I told V23 if R2 does not have any behaviors in 24-48 hours then we can take her (R2). R2 was stable and within a day or two and R2 came into the facility. I was not aware of R2 having a guardian. I did not see that in the record. On 11/21/23 at 9:34 am, V16 LPN (License Practical Nurse) stated, I'm not sure what time R2 came into the facility. I did the admission for R2. R2 kept asking about a pass for the next morning. I told R2 she can ask social service about a pass tomorrow. R2 did say she (R2) did not want to be here. I did have to redirect R2 several times about a pass. R2 was at the nurse's station with other staff when I went to pass medications. Surveyor asked V16 what time V16 started to pass medication. V16 stated, I do not remember. I noticed (R2) was not at the nurse's station. I went to her (R2's) room, bathroom, the dining room, down the stairwell and elevators, to look for R2. Surveyor asked V16 what time V16 noticed R2 was not at the nurses' station and what time did V16 start to search for R2. V16 stated, I cannot remember the time. Staff searched the whole building; she (R2) was not there (in the building). A code yellow (elopement/missing person) was called. The supervisor (V15) heard the code yellow and came upstairs. I went outside to 71st/exchange and south shore drive, and I did not see her (R2). The police were called. When residents are high risk for elopement we monitor and post CNAs (Certified Nursing Assistant) in the hallway by their rooms. Surveyor asked V16 what time code yellow was called. V16 stated, I do not remember the time. On 12/6/23 at 7:47am V16 (LPN) stated, I did not assign any staff to watch R2. I did not hear any door alarms by the exits on the second floor go off. So, R2 must have gone down the elevator and out the front door. Surveyor asked V16 if a community skills assessment check list should have been completed on R2 before saying R2 is safe to go into the community. V16 stated, Yes, a community assessment should have been done by social service before we (facility) said R2 can go into the community safely. Surveyor asked V16 if V16 was aware R2 had a state guardian. V16 stated, No, I was not aware of R2 having a state guardian. On 12/18/23 at 12:45 pm, V37 (CNA) stated, I don't remember if I got a new resident referring to (R2) on 10/9/23. V37 stated, if a new resident comes into the group of rooms V37 is assigned to, then it would have been V37's admission. V37 stated she does not remember R2 being in the facility. On 12/7/23 at 5:32 pm V33 CNA (Certified Nursing Assistant) stated, R2 was there before my shift (10pm to 6am). R2 woke up at 4:00 am and came to the nurse's station. R2 said her house had caught fire and she (R2) needed somewhere to live and that is why she (R2) is here in the facility. R2 said she wanted to go to her cousin's house at 5:00 am and asked if the cousin could come pick her (R2) up. She (R2) kept asking for a pass. The nurse (V16) told R2 that she could not leave. R2 was fully dressed and had a coat on. R2 kept trying to go toward the elevator. I (V33) tried to distract her by talking to her and moving her away from the elevator. V33 stated, (R2) seemed like she (R2) was special needs. R2 had a speech impediment, walked with a limp, and had a certain look about herself (R2). Surveyor asked V33 to explain a certain look. V33 stated, R2 appeared to be mentally delayed. It was hard to understand what she (R2) was saying. Surveyor asked V33 if V16 told her that R2 was an elopement risk. V33 stated, V16 did not say she was an elopement risk or on any elopement precautions. V33 further stated, The way R2 was looking, I would not let R2 outside alone, but V16 did not tell me to watch R2. V33 (CNA) Time Log form dated 10/9/23 documented V33 clock in time at 10:00 pm and clock out time at 6:00 am. On 11/30/23 at 11:30 am, (V31) LPN stated, I was the oncoming nurse for the day of [DATE]th. I was running late that day, I got to work around 7:30 am. I set my work bag and coat down at the nurse's station and started making rounds on the floor because the nurse (V16) was still on the medication cart down the hallway. I started on the side that R2 was on. I looked in the room and the bed was messed up. Then I went to the other side to finish my rounds. After I finished my rounds, I asked the nurse (V16) was there someone assigned to that room because the bed is messed up and no one is in there. V16 said, 'Yes someone came in last night' so we (V31, V16) started looking for her (R2) and checked all rooms on the unit. The nurse V16 said she had just saw her (R2) at the nurse's station. The CNAs on the unit started looking for R2 in all rooms on the unit, and we alerted the night shift supervisor (V15) that R2 was missing. V15 (Night Supervisor) took over after that. A code yellow was called. The other staff on the other floors were saying no one was out of place on the other floors. When I (V31) came in that morning, I did not notice R2 at the nurse's station. There were two CNAs and an orientee CNA at the nurse's station. Surveyor asked if there were any staff at the front desk in the lobby when V31 entered the building. V31 stated, I am absolutely positive there was no one at the reception desk when I came in because it was still dark in the lobby. V31(LPN) Time Log form dated 10/10/23 documented V31 clock in time at 7:35 am. On 11/21/23 at 9:00 am, V15 (LPN/Night supervisor) stated, On 10/10/23 morning I was sitting in the lobby when I heard a code yellow called. I do not remember the time it was called. I ran upstairs and ask who (referring to eloped resident) it was. The staff said it was R2 the new admission. We (Staff) searched the building and grounds outside. We got into our cars to look for R2 but did not see R2. The CNAs were on foot in the neighborhood, and I was in my car looking for R2. 911 was called to make a missing person report. The CNA (Certified Nursing Assistant V20) who came in at 6:00 am, said R2 was at the nurse's station because they (V20) talked to her (R2). The CNA (V20) stated she turned their head then R2 was gone. R2's mother called the facility and said R2 was at M******* on 95th and [NAME]. I saw her at M******* eating food. R2 left out of M******* and went across the street to the dollar store then got on the bus. V5 (Social Worker) and V18 (Receptionist) came to 95th and convinced her (R2) to get off the bus. The police and fire department came to 95th street to assist with R2. R2 stated she (R2) did not want to go back to the facility and decided to go with the paramedic to the hospital. V15 stated she does not remember the time they went to 95th and [NAME]. V15 said, The nurse (V16) stated R2 had been asking about a pass. She did have a bus pass on her. R2 said it was in her shoe. V15 stated, high risk elopement residents are monitored. On 12/5/23 at 8:13 am V15, (LPN) stated, The front doors to the facility were opened at 6:00 am on 10/10/2023 and I was sitting in the lobby until the staff got here. I did leave the lobby to answer call lights. I was in the lobby when a code yellow was called. I do not remember what time the code yellow was called. I went outside and got in my car and looked for R2. I did not see her (R2). I came back to the facility and then I received a call at the desk that R2 was on 95th street. When I got to where R2 was, she did have on a coat, but I don't remember if she had her belongings with her. On 11/21/23 at 12:09 pm, V20 (CNA), stated, I came in around 7:00 am and I saw R2 at the nursing station. She (R2) was standing at the nursing station, and I asked her was she (R2) OK. R2, she said yes. She (R2) was pacing and got a chair and sat next to me (V20) and was talking and saying she was from around here and new to the area. She (R2) kept saying she wanted to leave. I got up to go make rounds and then we (staff) noticed we didn't see her (R2) anymore. We (Staff) started looking around for her (R2) in the rooms, bathrooms, and outside. No one could locate her (R2), that's when we (staff) noted she (R2) had eloped. A code yellow was called. I went outside to the neighborhood and looked. I did not see R2, so I came back into the facility. Surveyor asked V20 what time code yellow was called. V20 stated, I do not remember. On 12/5/23 at 11:30 am, V20 CNA stated, I asked the nurse was R2 a new person. The nurse V16 (LPN) said yes, and don't make R2 angry because R2 was agitated. R2 had sat next to me at the nurse's station and was agitated. (V16) said to keep an eye on her, but (V16) did not say she was an elopement risk. V16 did not assign me to watch R2 as a 1:1. I had other residents, and I was orienting a new CNA (V21). I did not keep a constant eye on R2 because I was charting and had the new CNA (V21). Surveyor asked V20 what does 'keep an eye on mean'? V20 stated, Just check in on her (R2) frequently. It's not a constant observation like 1:1. V20 stated, R2 was fully dressed that morning and that was unusual that early in the morning. R2 had a coat on at the nurse's station. V20 (CNA) Time Log form dated 10/10/23 documented V20 clock in time at 6:42 am. On 11/21/23 at 11:50 am, V19 stated, I came in that day around 6:00 am, and there was a conversation that a resident was missing, and I was asked if I saw her (R2) at the nurse's station. I do not remember seeing a resident at the nurse's station. A code yellow was called, staff looked around the building and outside. I did not leave the building. In report that morning I was told a new resident was here. I did have my assignment at that time. Once we get our assignment and report we go and check on the residents. I do not remember if she was in my group, but if a resident was missing out of my group, I would have reported it to the nurse. I do not remember anyone missing. I have had in-services on elopement on what to do and high-risk elopement residents will be on constant surveillance. V19 (CNA) Time Log form dated 10/10/23 documented V19 clock in time at 6:00 am. Facility daily floor assignment sheet for 6A-2P on 10/10/23 documents V19 was the assigned CNA for R2. On 11/20/23 at 1:30 pm V5 (SW/Social Worker/Duet Director) stated, R2's admission was in the evening on 10/9/23. V5 stated, I had not seen (R2). That morning when I got to work, the nurse told me R2 had left. When the nurse told me the name, I said I just saw her at the bus stop. I remembered (R2) from another facility. V5 stated, I got to work between 8 am and 9 am. I went to look for (R2) and saw R2 get on the bus. I followed the bus until it stopped. Me (V5) and (V18 Receptionist) another staff member, followed the bus. R2 got off the bus and got on another bus that was already there. R2 got off the bus on 95th street and went into M******* on 95th. I talked to R2 and tried to get her to come back. R2 ran out of M******* into the dollar store. The police were called. When the police came, R2 was at the bus stop again and got on the bus. We (V5 and V18) got on the bus to try to get R2 off the bus by talking to her with the police. R2 got off the bus. The fire department and the ambulance came and took R2 to the hospital. R2 refused to come back to the facility. I (V5) asked R2 why she came to the facility. She (R2) said the hospital told her she was coming to a group home not a nursing home and she did not want to be in a nursing home. R2 was trying to go to her (R2) brother's school. I called R2's brother on my cell phone and told him (R2's brother) R2 left the nursing home and is refusing to come back to the nursing home. The brother told R2 to go back to the hospital if she did not want to come back to the facility. R2 agreed to go to the hospital. R2 agreed to sign out of the facility as an AMA (Against Medical Advice). V5 stated, I was not aware of R2 having a state guardian. V5 stated, The purpose for the community assessment form is to see if a resident can navigate in the community safely and to assess if they know how to seek help if they get lost. The community assessment form was not completed because R2 came after hours and R2 had left before it could be completed. On 11/20/2023 at 3:23pm V18 (Receptionist) stated, I came to work around 7:15 am on 10/10/23. When I first got to work, I went to punch in, and staff said R2 was missing and not in the building. I asked staff for a description of R2 and what she was wearing. They said R2 had on grey and a big coat. I went riding around with my wife to see if I could locate R2. I did not see R2 and came back to the facility. I let V5 SW (Social Worker) know that R2 had left the facility. We did an elopement call, Code yellow (meaning elopement). The night shift staff said she (R2) left the building around 6 something that morning. The SW (V5) and I were riding around the neighborhood. The administrator (V1) called the SW and said the mother called and said (R2) was on 95th and [NAME] at M********. I (V18) do not remember the time V1 (Administrator) called. We (V5 and V18) started driving that way to M********. The overnight supervisor (V15) was already out looking for (R2). I went to 95th street with V5 (SW) to M******** and (R2) refused to get into the car. (R2) kelp walking away from us to one side of the street to the other side of the street, then got on the bus. The overnight supervisor (V15) told the bus driver to not pull off because our patient is on the bus. The police and paramedics were present at that time. She (R2) got off the bus and everyone was trying to encourage her to come back to the facility then the Paramedic told R2, let's go the hospital for a safe discharge and R2 agreed. R2 did talk to her brother at that time also. R2's brother told her to go to the hospital. R2 did get into the ambulance to go to the hospital. V18 stated, The facility doors are locked every day from 11:00 pm to 6:00 am because we don't have security at that time. V18 (Receptionist) Time Log form dated 10/10/23 documented V18 clock in time at 8:09 am. On 11/21/23 at 12:40 pm, V1 Administrator stated she was notified around 8:15/8:30 am that a code yellow was called, and everyone was looking for R2. V1 stated, When I (V1) got here, I talked to V20 (CNA) and V15 (Supervisor). R2's mother called the facility and said R2 had called and said she was at M******** on 95th and [NAME]. I called V5 (SW) and let her know that the mother said R2 was at M******** at 95th and [NAME]. R2's mother called back and said she (R2) had no idea R2 was in our building. V5 called and said the police and paramedic are here on 95th and R2 is refusing to come back to the facility. V1 stated V1 was concerned about making sure R2 was cognitively intact to make that decision on not coming back to the facility because R2 was a new resident. V1 stated, The paramedic determined R2's cognition and stated she (R2) was ok to make her own decisions. R2 went to local hospital with the paramedics. When V5 (SW) was on 95th on the bus, V5 (SW) had me on the phone and I heard R2 saying I don't want to go to a nursing home, I was raped in a nursing home. I'm not going back there. V1 stated, I was not aware of a state guardian until after R2 left the facility. On 11/21/23 at 9:40 am V24 (State Guardian Office) stated, R2's elopement was reported to the office by R2's mother. V24 stated, R2's mother called and said R2 had eloped and was at M********. V24 stated V24 had talked to the administrator after 8:30 am. V24 stated, R2 had become a ward of the state on 4/17/23. The medical report dated 3/11/23 stated R2 has a moderate intellectual delay with speech difficulty and is incapable of making personal and financial decisions. R2 is not able to sign her own consents. On 11/28/23 at 12:09 pm, V27 (R2's State Guardian) stated, R2 is not able to sign her (R2) own consents. R2 has been to a couple of facilities because of her (R2) violent behavior. V27 stated, I talked to someone at facility on Tuesday and that's when I found out R2 had left the facility and ended up at M********. The police were called to assist with R2. R2 should not be signing any consent and should not be in the community alone. On 11/29/23 at 10:30 am, V2 (DON) stated, I don't know why the nurse documented elopement precautions. For an elopement resident we have wonder guards (band around a wrist). Monitoring 1:1 and a locked unit. The nurse did the assessment and deemed her (referring to R2) to be alert and oriented. Surveyor asked V2 if V2 reviewed V16's assessment including that R2 had some cognitive impairments. V2 stated, I did not see that. I did not see that R2 had a guardian in the admission packet. V2 stated, R2 walked out of the front door. The camera system was down. R2 was not gone more than 45 minutes. On 12/5/23 at 1:40 pm, V32 (Maintenance) stated, I did not know the east wing alarm door had a timer. I just make sure it goes off. The door alarm is supposed to stay on until you put the code in. The purpose of the code is for the alarm to stay on until the code is put in. Surveyor requested V32 to look at the alarm on the second-floor east wing. V32 opened the door and the alarm sounded then went off without putting a code in. Surveyor inquired how long the [NAME] has not been working. V32 stated he is not aware of the [NAME] not working. R2's (10/10/23) Chicago Fire Department run sheet documented dispatch time for call at 10:06 am, arrived at patient at 10:17 am. Patient care report narrative documents in part, Dispatched to location for psychiatric emergency. S**** S**** staff on scene and states patient left their facility without being discharged and family is concerned for her wellbeing. Patient left hospital several days ago without being properly discharged . Patient (R2) states she needs her medication to feel mentally better but does not want to be placed back into the rehab facility. R2's progress notes on 10/9/23 at 6:47 am, V16 LPN (License Practical Nurse) documents, in part, R2 up at 5:00 am, wandering around unit, multiple warnings to not enter other resident's rooms, advised to sit in room or dining room. Perseveration regarding an outpatient pass. Advised to wait to 8/8:30am and speak with social services. Last seen seated at nurse's station at 6:30. R2's progress notes on 10/10/23 at 7:00 am, V16 (LPN) documented, Resident (R2) inquired about a pass. Upon last rounds noticed resident left facility on unauthorized pass. R2's progress notes on 10/10/23 at 7:30 am, V31 LPN documented, Upon making rounds this nurse noted the resident not in her (R2) room or the dining area. Upon further investigation this nurse was made aware by off going nurse (V16) that this resident (R2) is out of the facility on an unauthorized pass. R2's progress notes on 10/10/23 at 12:44 pm, V5 (Social Service) documented, in part, R2 was observed at the bus stop getting on the bus. Writer (V5) and other staff followed the bus until R2 got off the bus at 95th and [NAME]. R2 went into the M********. The writer parked the car and went into M******** to ask R2 to return to the facility. R2 stated that she was not coming back to a nursing home. The writer continued to encourage her to return to the facility. R2 became verbally and physically aggressive toward other staff members. Writer called 911 for assistance. R2 then ran across the street toward the bus and got on the bus and refused to get off. By the time the fire truck and police arrived on the scene. R2 finally got off the bus stop and spoke to the paramedics once they showed up R2 agreed that R2 would be discharged from the facility against medical advice .Writer received a call from R2's state guardian this morning inquiring about her admission to the facility . R2's (10/9/23) Elopement Screen form documents in part, 1. Upon Review (a) Is resident cognitively intact in making decisions to exit building (can go outside safely and return). If answer is Yes, skip rest of assessment. Documented YES on form. R2's community survival risk assessment form not completed upon admission. R2's Order Summary Report excludes an order for R2 to go outside unsupervised. R2's Psychiatry Evaluation dated 8/24/23 documents in part, R2 presents as a danger to self and others. Unpredictable and untrustworthy. Facility job description undated and titled Administrator, documents, in part, Administration functions: Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. Facility job description undated and titled, Director of Nursing, documents, in part, Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Facility job description undated and titled, Registered Nurse/RN, documents in part, Summary: The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistants. Meet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs and activities. Make written & oral reports/recommendations concerning the activities of the shift as required. Admit, transfer and discharge residents as required. Provide leadership to nursing personnel assigned to your unit/shift. Fill out and complete accident/incident reports and submit to Director as required. Facility job description undated and titled, License Practical Nurse/LPN, documents in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities. Direct the day-to-day functions of the nursing assistants. Meet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs and activities. Make written & oral reports/recommendations concerning the activities of the shift as required. Admit, transfer and discharge residents as required. Provide leadership to nursing personnel assigned to your unit/shift. Facility job description undated and titled, Certified Nursing Assistant, documents, in part, Safety and Sanitation: Immediately notify the Nurse Supervisor/Charge Nurse of any resident leaving/missing from the facility. Facility job description undated and titled, Social Worker, documents, in part, Participate in the facility assessment and assess individual social services needs a resource. Admission, Transfer and Discharge Functions: Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. Facility's policy titled, Elopement and Search Policy dated 1/23, documents in part, Standards: 1. All nursing personnel are responsible for knowing the whereabouts of residents they are assigned to care for. Department Directors and Licensed nurses are responsible for conducting resident rounds to monitor resident location and staff are responsible for keeping the nurse informed of a resident's whereabouts. In addition, routine walking rounds are made at the beginning and end of each shift by the oncoming an off going supervising nurses to observe or know the whereabouts of each resident. Other observations are made at approximately every two (2) hours by CNA's, during scheduled activity programs, at meals bedtime and during mediation and treatment administration. 3. Residents are not permitted to leave the building alone unless the attending physician approves in writing. 5. Residents who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an alert elopement device (arm or ankle bracelet) or be placed in area of the facility that has a door alarm device with audible sound. 6. When a resident is experiencing periods of confusion or agitation and makes continuous attempts to leave the building, the resident will be visibly observed every fifteen (15) minutes until the behavior is resolved or diminished. In the event the resident continues to attempt to leave the building, a staff member will be assigned to provide one/one supervision until alternative interventions are initiated. 13. The Administrator or a designated staff member is assigned the responsibi [TRUNCATED]

Based on interview and record review, the facility failed to (a) ensure resident safety by allowing a resident (R6) with a history of alcohol dependence out on a community pass without a medical provider authorization/order and (b) failed to complete a community survival skills assessment for the same resident (R6) prior to allowing resident out on pass into the community. These failures affected one (R6) resident out of three residents reviewed. These failures resulted in R6 leaving the facility on an independent community pass and returning to the facility intoxicated. While intoxicated, R6 fell while inside the facility and sustained a right mandibular fracture and chin laceration. Findings Include: Face sheet dated 09/22/2023, documents R6 is a [AGE] year-old male with diagnoses not limited to: Malignant neoplasm of larynx, epilepsy, bipolar disorder, acquired absence of larynx, speech disturbances, major depressive disorder, dysphagia, and fracture of condylar process of right mandible. R6's MDS (Minimum Data Set) dated 05/11/2023, documents R6 has a BIMS (Brief Interview for Mental Status) of 15/15 indicating R6 is alert and oriented x3 and cognitively intact. R6's Activities of Daily Living (ADL) Assistance documents R6 requires supervision and set-up with ADL care. R6 is continent of bowel and bladder. R6's physician order sheet (POS) provided to surveyor on 09/22/2023 does not document a physician order for R6's community pass. R6's care plan dated 09/11/2023 provided to surveyor on 09/22/2023 does not document R6 is care planned for a community pass. R6's care plan dated 09/11/2023 documents R6 is care planned for: risk for falls, tracheostomy care, potential nutritional problems, risk for abuse, seizure disorder, psychotropic medication use, and antidepressant medication use. Review of R6's electronic medical record does not show a Community Survival Skills Assessment prior to 09/22/2023. Nursing Progress note dated 07/26/2023 at 4:35PM, written by V4 (Licensed Practical Nurse/LPN) documents, Writer sitting at nurses' station when heard a loud thump, found R6 in front of doorway near bathroom door lying on left side in fetal position with head faces hallway. Bright red blood coming from left side of R6 chin. R6 moved to comfortable position, laceration cleansed with normal saline, three steri strips applied. R6 now lying in bed resting, MD made aware, new order to send to hospital, ambulance called and notified all appropriate departments, will continue to monitor. R6's hospitalization records documents R6 was hospitalized from 07/26/2023-07/30/2023 with diagnoses and injuries includes: closed fracture of right condylar process of mandible, left chin laceration, missing teeth, and staples to neck. Nursing Progress note dated 07/30/2023 at 5:27PM, written by V8 (LPN/ 4th Floor Unit Manager) documents, R6 back from hospital transported by ambulance via stretcher. R6 is alert x 4 ambulatory and able to make needs known. R6 PERRLA, lungs sound clear, Abdomen soft to touch, upper extremities strong with grasp, lower extremities strong. R6 noted with sutures under the left side of the chin, and noted with swelling to right side of jaw. R6 returned back with a DX of closed Fracture of left condylar process of mandible with a diet of no chew diet for 4 weeks. all orders in and carried out. Facility Reported Incident dated 08/03/2023 documents R6 fell while in the facility on 07/26/2023 and sustained a mandibular fracture. On 09/21/2023 at 10:28AM, R6 stated he was drunk when he fell on [DATE]. R6 states he goes out on pass into the community and would sometimes stop and purchase alcohol at a local liquor store. R6 stated he has never brought alcohol into the facility but would get drunk before returning to the facility from his community pass. R6 said when he returned to the facility from being out on an independent community pass, R6 was intoxicated when he tried to ambulate to his bathroom, he fell on the floor. On 09/26/2023 at 9:37AM, V3 (Social Services Director) stated R6 goes out independently on pass into the community. V3 stated R6 is assigned to his caseload, and he is responsible for completing and documenting the community survival skills assessment in the resident's electronic health record. V3 stated he did not complete R6s' community survival skills assessment until 09/22/2023, after surveyor's request. V3 stated even if a resident does not have a physician order, the nurses are responsible for deciding rather or not a resident can go out on pass into the community. V3 states he is not familiar with the facility's community pass policy/procedures and does not know the purpose of the community survival skills assessment. V3 stated he was not trained on the procedures for allowing residents out on pass into the community. V3 stated he implements protocols he learned from his previous job and applies them to this facility. On 09/26/2023 at 12:22PM, V12 (Receptionist) stated the facility does not keep a list of residents who are allowed out independently on community pass. Instead, the facility keeps copies of the residents' community pass and it is provided to the resident by the nurse. The residents are required to present pass to the receptionist before they leave the facility. Record review of facility community pass log titled Destination Notification documents R6 leaves the facility and goes out on pass independently into the community. On 09/26/2023 at 1:10PM, V5 (Physician) stated he does not make the initial determination of which residents are allowed out on community pass. V5 stated he usually refers the residents to Social Services and let them make an assessment. Based on Social Services assessment and recommendations, V5 will authorize a physician order for the resident to go out on pass into the community. V5 stated he was informed by the facility R6 went out into the community, consumed alcohol, and was intoxicated and R6 fell and was sent to the hospital. On 09/26/2023 at 3:16PM, V13 (LPN/ 1st Floor Unit Manager) stated community passes are guided by physician orders. The doctor determines who can go out on pass into the community by authorizing a physician order. If a doctor approves a resident to go out on pass, then either the nurse or the doctor will put the order in the physician order sheet (POS) and the nurse is to verify the resident can go out on pass via the physician orders in the electronic record. If there is no order, then the nurse is to call the doctor to obtain the order. The nurse should inform the resident without a doctors' order the resident cannot go out on community pass until the doctor gives the order. Before a resident goes out on pass, the protocol is for the resident to obtain the pass from the nurse, then take the pass down to the receptionist to show them, then resident can leave the facility. V5 stated it is not the nurses' decision to allow the residents out on pass into the community. Facility policy titled Independent Community Pass Privileges dated 04/2004 documents in part, 1. Residents will be assessed for pass privileges by completion of the Community Skills Determination Assessment to determine if resident can independently go out on pass. 2. A pass order is obtained from the physician.

Based on interviews, and record reviews, the facility failed to keep 5 out of 9 [R2, R3, R4, R5, R6] residents free from abuse. This failure resulted in R2 sustaining a left forehead laceration and requiring emergency room evaluation. Finding Include, On 2/28/23 at 1:56 PM, surveyor observed R2 resting in bed, alert and oriented X1, confused and unable to sound out words, or articulate sentences. R2's medical record documents in part: admitted on [DATE] admitting diagnosis of dementia, peripheral vascular disease, osteoarthritis, rhabdomyolysis, and atherosclerotic heart disease. Social Service Potential for Abuse and Neglect assessment dated [DATE] indicates R2 may be at risk for potential abuse related to behaviors problems as evidenced by wandering Goal R2 to remain free of harm and to monitor R2's behavior. Minimum data set brief interview for mental status score = [0] indicated severely cognitively impaired. Physician order dated -2/10/23, Left side of Head: steri strips monitor for any abnormalities check daily and as needed. Medication Administration Record for February 2023; noted physician order dated 2/10/23 -Left side of head: steri strips monitor for any abnormalities check daily and as needed end dated 2/18/23. Wound care assessment details report dated 2/10/23 document in part- type [trauma], source [facility acquired], two steri strips in place holding skin together. R2's emergency evaluation documentation in part dated 2/8/23; The patient [R2] is a 78-year male with a past medical history of dementia who presents to emergency department with the chief complaint of alleged assault. Per triage notes patient [R2] arrived from facility following physical altercation with peer. Per NH [Nursing Home] staff, patient[R2] was hit over the head with a glass plate. Progress noted dated 2/8/2023, at 16:06-Health Status: Text: Pt [R2] involved in physical altercation with peer. Pt [R2] noted with laceration and raised area to left side of head. Pt [R2] has bleeding addressed, controlled and ceased. MD made aware, orders ice, and steri strips to area, send to hospital for evaluation and treatment. Ordered carried, Pt[R2] vitals present at 136/90bp [blood pressure], p84 [pulse], r20 [respirations], t97.8 [temperature], spo2 99 [oxygen saturation]. Pt [R2] denies pain, medicated prophylactically. Pt [R2] family contacted a numerous of times, all contacts on face sheet contacted with no avail, will continue to attempt. Ambulance gives one hour ETA [estimated time of arrival], hospital has report communicated too. Pt [R2] noted with staff with close monitoring. Care Plans: dated 8/22/22-R2 has severe impaired cognition required frequent cueing and redirection. Dated 8/22/22-R2 is risk for elopement related to dementia. Dated 8/22/22 R2 is confused and wanders the unit. Dated 8/22/22 R2 wanders into residents' rooms and take belongings; staff will monitor R2's behavior. Dated 2/8/23 R2 at risk for potential abuse related to behavior problems as evidenced by wandering, R2 involved in incident where another resident struck R2 after R2 wandered into the resident's room; R2 will remain free of harm; Assure R2 that he is in a safe and secure environment with caring professionals. On 2/28/23 at 2:00 PM, surveyor observed R1 sitting on the side of the bed, alert, and oriented X1-2. R1 was able to answer questions only for the present, he [R1] did not have any memory of the 2/8/23 incident. R1's medical record documents in part: admitted [DATE] with the medical diagnosis of chronic kidney disease, anemia, encephalopathy, dementia, memory deficit, and essential hypertension. Social Service Potential for Abuse and Neglect assessment dated [DATE] indicates R1 has a history of aggression. Minimum data set brief interview for mental status score = [03] indicates R1 is moderately cognitively impaired. Care Plan dated 2/8/23-R1 may be a risk for potential abuse related to behavior problems as evidence by striking other individuals when they enter into his room. Progress noted dated 2/8/23 16:50-Health Status/Progress Note Text: Pt [R1] involved in physical altercation with peer [R2]. Pt noted causing laceration and raised area to left side of other patient's head. Pt [R1] noted saying, Get out, get out, I'll end him, he came in my room, he doesn't know what he is doing, so I pushed him out.: Pt. separated immediately. Pt [R1] has no s/s of pain or injury. Pt [R1] vitals present at 119/72bp, p69, r18, t98, spo2 98. Pt MD made aware, orders pt. [R1] to be sent for psych evaluation. Pt family made aware. Elite gives one hour eta, pt. will be monitored until pick up. Emergency department notes:2/8/23 at 19:30 R1 was pacing back and forth, refused blood draw and R1 became verbally aggressive with staff. R1 received Haldol 5mg injection. 2/8/23 at 22:00 R1 becoming aggressive with staff. R1 received Ativan 1mg injection. On 2/28/23 at 12:08 PM, V5 (Registered Nurse) stated, I been working here at this facility for [AGE] years first as a Licensed Practical Nurse, then became a Registered Nurse in 2019. On 2/8/23 I was the nurse working. I was told by the Certified Nurse Assistant [V6] that the R1 was yelling and screaming for R2 to get out his room. R2 was noted with a laceration to the side of his forehead. I cleaned the area applied steri-strips and placed ice to the area. I asked R2 what happened, he was not able to cognitively answer me. R2 is normally alert 1-2 and has never been able to explain himself to me, that is his [R2] normal cognition. The physician, family, director of nursing and administrator was made aware of the incident and injury. I received orders for the physician to send R2 to the emergency room for further evaluation. R1 told me that R2 came in his [R1] room, and R2 did not know where he[R2] was going. R1 said that he [R1] pushed R2 out of his[R1] room. R1 did not say how R2 received the laceration to his [R2] forehead, R1 just kept saying I pushed him [R2] out, I pushed him out. I never got a clear understanding how R2 received the laceration to his forehead. Both residents were separated immediately, assessed R1 did not noted any injuries to R1, however R1's physician gave order for R1 to be sent out for a psych evaluation. The family, director of nursing and administrator was made aware of the incident and the order for R1 to be sent out for psych evaluation. R1 has behaviors of aggression due to non-compliance not wanting to do complete task that nursing needed him [R1] to do and becoming agitated. R2 has behaviors of pleasantly wandering around in other resident rooms, without any history of aggression. On 2/28/23 at 12:49 PM, V6 [Restorative Certified Nurse Assistant] stated, I worked on 2/8/23 and seen R2 walking into the employee's bathroom, I redirected R2 from the bathroom. Then I saw R1 upset telling me to keep R2 out of his room. R1 was angry, upset, and hyper. R1 said get him away from me before I end him and hurt him again. I asked R1 to calm down and I still had R2 near me. I looked at R2 and saw an open knot on the side of his [R2] forehead bleeding. I told V5 what I saw and V5 took over the situation. R2 was not able to tell me what happen. R2 is not normally able to formulate a sentence. R2 normally wanders around in other residents' room, staff tries to verbally redirect R2 out of resident's rooms. However, R2 always wander back in the rooms fidget with other resident's personal items, which can aggravate some of the other residents. R1 normally stay to himself and stay in his room. R1 is easily agitated, angry and moody. Both residents have dementia but at different progressions of dementia. R1 is alert and oriented X 2-3, he knows what he is doing at present time, but may not remember later. R2 is severely demented, he cannot put a sentence together, and do not know what he is doing at all. On 3/1/23 at 1:11 PM, V13 [Certified Nurse Assistant] stated, I been working here in this facility for 6 months, and I have been a certified nurse assistant for 4 years. R2 was my resident on that day, but I don't remember anything at all. I worked overtime that day, but I have no memory of what happened. I have received abuse training when I was hired. Some types of abuse are financial, verbal, physical, emotional, sexual, and seclusion. The abuse coordinator is the administrator. On 3/1/23 at 1:30 PM, V16 [Licensed Practical Nurse/Wound Care Nurse] stated, I been working her for 8 years. I picked up to work on the floor on 2/8/23 and I was the nurse for R1. During the time of the incident, I was completing wound care treatments. When I got to third floor to work as a staff nurse, both residents were on their way out to the hospital. During report from V5 there was resident to resident aggression between R1 and R2. I was told R1 hit R2, but I did not know what had happened. V5 was the nurse on the floor at the time of the incident and he [V5] completed the documentation. The next day as the treatment nurse I did assess R2's laceration to his forehead. The area was clean with two steri strips in place, and no active bleeding. I received abuse training about a month ago. Some types of abuse are verbal, physical, sexual, and mental. If abuse occurs, I will report it to the administrator. On 3/1/23 at 1:48 PM, V5 stated, I was R2's nurse on 2/8/23. I gave report of the incident to the ambulance [EMT] personnel when they arrived to transport R2 to the emergency room for an evaluation. I did not know what caused R2's forehead laceration. Sorry, I forgot that I did tell the EMT R2 was hit over the head with a glass plate. I did not witness the incident, but I saw the plate in R1's room, I cannot remember what made me think R2 was hit over the head with a glass plate. I received abuse training at least every year, sometimes more often. Some types of abuse are physical, mental, verbal, financial, and sexual. If I witness abuse, I will separate the persons and notify the administrator immediately. On 3/2/23 at 9:00 AM, V2 [Director of Nursing] stated, R1 and R2 abuse allegation findings was R1 pushed R2 out of his room and R2 sustained a laceration to his forehead. I was not made aware until today that the nurse told the ambulance personnel that R2 was hit over the head with a glass plate. R2 does have a history of wandering in other resident's room and elopement risk. The nursing staff is to monitor R2 closely and provide re-direction and activities to keep R2 attention occupied. The staff should at least check on R2 every hour and monitor him closely when R2 is starting to wander around the unit. R2 wandering behavior into other residents' room, when staff is not aware could potentially cause R2 to be abused by another resident. On 3/2/23 at 10:15 AM, V1 [Administrator] stated, The abuse investigation between R1 and R2 was substantiated. R1 stated that he pushed R2 out of his room and staff noted bleeding from R2's forehead. During my investigation, I was not told by anyone that R1 hit R2 in the forehead with a glass plate. I assume when R1 pushed R2 that he hit his head on the wall or door frame. I am not sure why V5 [Registered Nurse] told the ambulance drivers and the emergency room nurse that R2 was hit in the head with a glass plate. I think V5 assumed that because he over thinks every situation. R1 was sent out to the hospital for a psychiatric evaluation and R2 was sent out to the emergency room for an evaluation of the laceration to his forehead. Both residents' room are now on opposite wings of floor. All new hires receive abuse training upon hire and before they are allowed to with the residents. All other staff receives abuse training at least annually and with any abuse allegations. Policy-Documents in part dated 2/17 Abuse Prevention Program: -This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property or mistreatment of residents. 40061 R3's comprehensive care plan contains a focus initiated on 10/25/2022 that documents in part that R3 may be at risk for potential abuse related to mental and emotional challenges as evidenced by diagnoses of major depressive disorder and confusion. The goal was for R3 to remain free from incident through the next review date. A facility reportable documents in part: On 02/10/2023 at 7:30 PM, R3 was struck by R4 while in [R3's] room. Staff noted a dime-sized raised area to the bridge of R3's nose. V15's (Physician) progress note dated 02/10/2023 8:28 PM documents in part that R3 was assaulted by another resident. R3 was hit in the face. Staff reported R3's nose was swelling. V15's disposition was to transfer R3 to the hospital due to facial pain and assault. V5's (Nurse) progress note for R3 dated 02/10/2023 8:51 PM documents in part: Writer summoned to resident room, [V7, Certified Nurse Aide] states another patient aggressed set patient. [Patient] noted in bedroom, [patient] noted in physical altercation with another patient. [Patient] states '[R4] hit me in my nose, I got something for [R4] though,' [patients] separated, and monitored. On 02/28/2023 at 12:27 PM, V5 stated above progress note to be true to the incident in which R4 hit R3. V5 stated R3 sustained a dime-sized bump to the nose with no report of fracture from the hospital. On 02/28/2023 at 12:53 PM, V7 stated [V7] was providing care to R3's roommate when [V7] heard R3 state get the f*** out of my room. When V7 pulled the curtain back to see who R3 was talking to, it was R4. V7 stated, Before I can get there, [R4] charged at [R3] and hit [R3] in the middle of [R3's] face in [R3's] nose. V7 stated, [R3] is the floor bully. [R3] curses people out but nothing physical. V7 stated R4 is a wanderer and gets physically aggressive at times. V7 stated, By [R4] and [R3] being both my patients, I couldn't watch them like that. Their rooms were separated by one room. V7 stated R4 continued to be aggressive towards staff after separating the two residents. V7 stated after the incident, R3 sustained a scar at the center of [R3's] face near the nose. On 03/01/2023 at 10:36 AM, V8 (Social Services Director) stated R3 has a behavior of cursing residents out. V8 stated when R3 curses, it's meaningful but [R3] is more bark than bite. V8 stated, [R3's] dementia is mild so [R3] has meaning behind [R3's] words. When asked about R4, V8 stated, [R4] is more aggressive than verbal. There's more confusion. If a staff or resident approaches [R4] and [R4] doesn't know what it's about, it's more of a physical response than a verbal response. V8 stated R4 had previous aggressive incidents with staff and residents. During a telephone interview on 03/01/2023 at 4:46 PM, V17 (Nurse) stated [V17] did the aftercare for R3's injury. V17 stated R3 had swelling to the bridge of the nose. V17 described R4 as a little aggressive at times and can come out very agitated. V17 stated it sometimes takes a lot to calm R4 down because [R4] is hard to redirect. V17's progress note for R4 dated 02/10/2023 7:44 PM documents in part that R4 struck a lady in the nose. Facility petitioned R4 to the hospital for evaluation. R4's comprehensive care plan contains a focus initiated on 10/20/2022 that documents in part that R4 can become combative with staff and other residents and will strike others when staff attempts to redirect or even during moment where R4 is not provoked. Comprehensive care plan did not contain a focus for R4's potential for abuse and neglect until date of the incident. R5's comprehensive care plan contains a focus initiated on 07/06/2022 that documents in part that R5 may be at risk for potential abuse related to mental and emotional challenges. The goal was to remain free from harm through the next review date. R5's comprehensive care plan also contains a focus initiated on 10/20/2021 that documents in part that R5 has aggressive behaviors at times, verbal and physical abuse towards residents. The goal was for R5 to keep hands to self and walk away when [R5] feels angry. R5 was to be free of aggressive behavior and speak with social services when feeling provoked. R6's comprehensive care plan contains a focus initiated on 10/10/2022 that documents in part that R6 may be at risk for potential abuse related to mental and emotional challenges as evidenced by R6's interactions with other residents and staff members. The goal was to remain free from harm through the next review date. Facility reportable documents in part: On 1/12 around 5pm the elevator door open on the 4th floor when two residents were observed entangled, one of which was on the floor and the other on top. Both residents were holding each other at arm's length and yelling derogatory statements at each other. R5 yelled I'm going to get that motherf***er, watch. R6 stated, That's what you get for f***ing with me and I'm going to get you one day, you are going to stop playing with me. V17's (Nurse) progress note for R5 dated 01/12/2023 4:59 PM documents in part that R5 was physically aggressive towards a fell ow resident and V1 (Administrator). V17's progress note for R6 dated 01/12/2023 5:00 PM documents in part that R6 was physically aggressive towards a fell ow resident and V1. On 03/01/2023 at 10:36 AM, V8 (Social Services Director) described R5 as rambunctious, easily offended, and difficult to re-direct. V8 stated R5 can be verbally aggressive and abusive to both staff and residents. V8 stated R6 was also verbally aggressive at times. On 03/01/2023 at 12:24 PM, V12 (Nurse) stated R5 and R6 did not get along. During a telephone interview with V17 on 03/01/2023 at 4:46 PM, V17 stated R5 and R6 got into a physical altercation while in the elevator. V1 and staff tried to break the two up but V1 got hurt in the process. During a telephone interview with V1 on 03/02/2023 at 10:21 AM, V1 stated, I was in the building making rounds late that evening. I was leaving the floor when the elevator door opened, and they were holding each other and going off. I screamed and tried to pull them apart. I was trying to keep [R6] from coming out of [R6's] wheelchair. [R5] looked at me and was like 'no the f*** not' and [R5] just kicked me in my face. V1 stated, I didn't actually see them throw punches. They were kind of like in a standoff and holding each other. I don't know if they already got into it, were about to get into it or what. I don't know what stage their argument was in, but [R5] didn't want me to separate them. They still wanted to get into it with each other. V1 described both residents to have dominating personalities. V1 stated, I was trying to talk to them, and they were just going back and forth. They were not interview-able. They were too busy arguing. It was hard to redirect them. Facility's Abuse Prevention Program dated 02/07/2017 documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.

Based on observation, interview and record review the facility failed to a.) ensure 2 (R7, R8) of 3 (R3) residents reviewed for falls were free from injury and b.) ensure one (R9) resident environment remains as free of accident hazards as is possible to prevent the potential for injury. These failures resulted in R7 sustaining an injury requiring a suture to the left side of the head, R8 sustaining traumatic injuries with bilateral femur fractures and R9 sustaining an injury requiring three sutures to the bridge of the nose. Findings Include: R7 was admitted to the facility on [DATE] and has diagnosis not limited to Type 2 Diabetes Mellitus, Limitation of Activity Due to Disability, Hypoglycemia, Epilepsy, Cerebral Infarction, Dysphagia, Abnormalities of Gait and Mobility, Repeated Falls, Slurred Speech, Unsteadiness on Feet and Cardiac Pacemaker. R7 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R7 has sustained 7 falls in 13 months with one resulting in an injury that required a suture to the left side of the head. MDS Section G Functional Status document in part: B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position: Extensive Assist. Two + Person physical assist. Care Plan document in part: Actual Fall, with actual fall on 01/20/22 @ 20:27. IDT (Interdisciplinary Team) Fall Note: Actual Fall on 06/23/22 @ 07:47, actual fall on 08/14/22, 09/22/22, 01/15/23 01/25/23, 02/12/23. Date Initiated: 08/14/22 Created on: 01/21/22. Maintain bed in the lowest position, lock wheels to prevent the bed from moving. Progress note dated 01/20/22 at 19:45 document in part: Health Status/Progress Note Text: writer was called to R7 room by CNA (Certified Nurse Assistant) due to R7 being on the floor, writer noted R7 to be lying on the floor on R7 right side noted with an injury (skin tear) to R7 left thumb with blood present. Progress note dated 06/23/22 07:47 document in part: SBAR (Situation, Background, Assessment and Recommendation) Note Text: REASON FOR REPORT: recent unwitnessed fall. Progress note dated 06/24/22 09:48 document in part: Interdisciplinary Note Text: FALL NOTE: On 06/23/2022 @ 07:47 R7 had an unwitnessed fall with no injuries noted Resident was observed by staff lying in the prone position beside his bed. R7 stated that R7 rolled out of bed onto the floor on his stomach. Progress note dated 08/14/22 07:00 document in part: Health Status/Progress Note Text: Brought to writer's attention that R7 was noted on the floor in room. Writer went to room noting bed in a diagonal position, floor was wet from urine, resident noted in sitting position with back against the bed, resident noted with non-skid socks on, and wheelchair was pushed back near window. There is no documentation in the progress notes for the fall that occurred on 09/22/22. Progress note dated 01/15/23 15:10 document in part: Restorative Nursing Note Text: R7 was reported to be sitting up on the floor matt stated he was trying to get to his closet. Progress note dated 01/24/23 18:15 document in part: SBAR Note Text: REASON FOR REPORT: observed on floor in bathroom. Progress note dated 0 1/24/23 18:15 document in part: Health Status/Progress Note Text: was called to R7 room, where it was observed R7 was sitting in R7 bathroom on floor. Progress note dated 02/12/23 12:15 document in part: SBAR Note Text: REASON FOR REPORT: R7 had a fall NEW ORDERS: Resident sent to E.R (emergency room ) for Evaluation and Treatment. Progress note dated 02/12/23 17:30 document in part: Health Status/Progress Note Text: R7 return to facility from Hospital. R7 noted with 1 suture to left side of head. Fall Risk Screen dated 02/12/23 document in part: 3. History of falls within last six months 5. Multiple falls. Score 13. Document titled, Facility Reported Incident, dated 02/13/23, for the incident that occurred on 02/12/23 document in part: 02/12/23 R7 sustained a fall while attempting to self-transfer himself from the bed to the wheelchair. R7 sent to ER (emergency room for evaluation and treatment. Returned to facility with one suture. R8 was admitted to the facility on [DATE] and was discharged to the hospital on 01/11/23. R8 has diagnosis not limited to Nondisplaced fracture of proximal Phalanx of Left Lesser Toe(s), Limitation of Activities Due to Disability, Muscle Weakness (Generalized, Reduced Mobility, Morbid Obesity, Depressive Episodes, Heart Failure and Rheumatoid Arthritis. R8 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. MDS Section G Functional Status document in part: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture: Extensive Assist. Two + Person physical assist. Care Plan document in part: R8 requires assist with ADL'S (Activities of Daily Living) related to Impaired Mobility, Weakness, Rheumatoid Arthritis, Carpal Tunnel Syndrome, Morbid Obesity. Mobility, Toileting, Total assist x 2 staff with Transfer, non-ambulatory. R8 is at risk for fall related to Co- Morbidities. R8's Fall Risk Screen dated 01/11/23 document in part: 3. History of falls within last six months 5. Multiple falls. Progress note dated 01/10/23 22:40 document in part: Incident Follow up note: Upon rounds, I heard the bed being lowered. Upon entering room R8 noted with bed remote lowering bed. R8 was observed half on bed with legs bent back. I immediately adjusted R8 and lowered patient to floor for safety. Bed was currently in lowest position. Resident placed in bed. ROM (Range of Motion) initiated; resident complained of pain to bilateral knees. Received new orders for x-ray. Progress note dated 01/10/23 23:59 document in part: SBAR Note Text: REASON FOR REPORT: behavior, anxious, sliding self from edge of bed. Progress note dated 0 1/11/23 01:06 document in part: Incident Follow up note: resident in bed, c/o (complain of) right knee pain, resident sat up from recliner position, slid to edge of bed with c/o knee pain. Progress note dated 01/11/23 08:21 document in part: Incident Follow up note: Resident noted scooting to edge of bed. Progress note dated 01/11/23 09:30 document in part: Health Status/Progress Note: Called to room by CNA (Certified Nurse Assistant)-states she and the x-ray technician were attempting to reposition R8-R8 leaned forward and slid to floor. R8 with complaint of bilateral lower extremity pain. R8's Progress note dated 01/11/23 10:05 document in part: Health Status/Progress Note: x-ray results noted fx (Fracture) present. R8's Document titled, Nursing Home to Hospital Transfer Form, dated 01/11/23 document in part: reason for transfer: Fall. Document titled Report of Resident Incident/Accident dated 01/10/23 document in part: R8 sustained a fall in her room from her bed while attempting to get up. 01/11/23 X-ray results, Right knee acute oblique fracture of the distal femur. Radiology Results Report dated 01/11/23 document in part: Right Knee 1/2 views Acute oblique fracture of the distal femur. Moderate arthritic changes of the knee with acute distal femur fracture. Left Knee 1/2 views Acute oblique fracture of the distal femur. Acute distal femur fracture. R8's Hospital Records dated 01/11/23 document in part: Clinical Impression: 2. Age related osteoporosis, unspecified pathological fracture presence. 3. Fall, initial encounter. Chief Complaint: Patient presents with Fracture Multiple recent falls, x-ray showed bilateral femur fractures. Fall. Lower extremities fractures confirmed by x-ray. Principle/Secondary Diagnosis: Bilateral Hip Fractures, Acute Renal Failure and Hyperkalemia. Result date: CT (Computed Tomography Scan) Lower Extremity Left: Radiographs 01/12/23 Findings: comminuted fracture of the distal meta diaphysis of the femur with approximately one shaft's-width posterior and one-half shaft's-width medial displacement of the distal fracture fragment. Fracture appears to extend to the very superior aspect of the patellofemoral articulation. CT (Computed Tomography Scan) Lower Extremity Right Findings: Redemonstrated comminuted but predominately oblique fracture of the distal meta diaphysis of the right femur with approximately one shaft's-width anterolateral displacement and anterolateral angulation of the distal fracture fragment. Procedure(s) Performed 1. Retrograde intramedullary nailing of bilateral femur fractures. R9 was admitted to the facility on [DATE] with diagnosis not limited Dyspnea, Type 2 Diabetes Mellitus, Acute Kidney Failure, Heart Failure and Abnormal Posture. R9 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. MDS Section G Functional Status document in part: Walk in room - how resident walks between locations in his/her room: Supervision. Care Plan document in part: Potential for falls, R9 at risk for injury from falls. R9 sustained fall on 01/24/23 r/t (Related to) poor safety awareness. Document titled Facility Reported Incident dated 01/24/23 document in part: On 01/24/23 approximate time 1835. R9 attempted to retrieve his clothes from his bedroom closet, lost his balance and sustained a fall. New order to send resident to ER (emergency room ) for evaluation and treatment. 01/25/23 patient returned with 3 sutures to bridge of nose. Hospital Record dated 01/24/23 document in part: Laceration, Head Injury. On 02/28/23 at 12:58 PM V9 (Unit Manager 2nd Floor) stated, I was checking with the hospital to follow up on R8 care and see how R8 was doing. I was not present when R8 fell , R8 had her injury when I came to the unit. They were doing an x-ray at the time of the second fall and R8 went out to the hospital. The fall incident happened with the x-ray technician. I was notified R8 had the previous fall that night before and that is why the x-ray tech was there to do an x-ray. R8 fell twice to my understanding. When I came to the floor during the x-ray, R8 had a fall, and I was there for the aftermath. I observed R8 on the floor. V17 (Licensed Practical Nurse) was the night nurse. I did not witness R9 fall. Everybody was changing rooms that day. When I talked to R9, R9 said that he was reaching into the closet and stepped on the drawer inside of the closet. R9 stated something fell off the top shelf and hit him in the face and R9 had an opening to the bridge of his nose. R9 was sent out to the hospital got sutures and was sent back to the facility the same day. On 02/28/23 at 01:22 PM V10 (Registered Nurse) stated, R8 had fallen on the night shift. The x-rays were to be done on my shift and R8 had another fall when they were doing the x-ray of the bilateral knees. I don't think R8 complained of pain before sliding off the bed but R8 was complaining of Bilateral leg pain after she (R8) slid from the bed. The x-ray was completed, and the x-ray company called and reported that R8 had a thigh fracture. On 03/01/23 at 09:10 AM R9 was observed sitting on the bed. Two board were observed being stored on top of the closet cabinet with one board extending beyond the left edge positioned over the head of R9 bed. R9 stated they had to move me from the other room that I was in. They were taking too long, and I was pulling stuff out of the top of the closet cabinet, and I could not see on the top shelf. I was trying to help them out so that they could move me out of the room. I had pulled everything out of the closet except for the top shelf. The whole closet cabinet fell . The closet cabinet was not anchored to the wall. The back of my head hit the floor and I had a cut on my nose that I had to get 3 sutures. The nurses told me not to mess with the two boards that are now on the top of the cabinet closet. The boards on top of the cabinet closet are not safe and they could fall. My bed is directly below where the board would fall. On 03/01/23 at 09:40 AM the surveyor entered R9 room with V11 (Maintenance Director). Surveyor asked V11 what were the objects that were located on top of the closet cabinet next to R9 bed. V11 stated, That looks like the cork board and mirror. They were remodeling and have not put them back on the wall. They put R9 in this room too soon, we were not finished. Surveyor asked V11 what could potentially happen with the cork board and mirror being stored on top of the closet cabinet. V11 responded, Ma'am an accident in process. The closet cabinets are not anchored to the walls. We do not have instructions for instillation because the closet cabinets have been here for the duration of the building. Thank you for bringing that to my attention. V11 proceeded to remove the cork board and mirror from the top of R9 closet cabinet. On 03/01/23 at 11:41 AM V18 (Nursing Manager) stated, R8 did not like coming out of the room and would sit on the side of the bed. I worked the day that R8 fell , but I was not here when the first incident happened that morning. The initial fall happen on the midnight shift. I did assist the nurse when the x-ray tech came in and they were sending R8 out on 01/11/23. The x-ray tech came in to do R8 x-rays from the previous fall before R8 fell with the x-ray tech. I do not know what happen because I did not assist in anyway when they were x-raying R8 legs. On 03/01/23 at 01:11 PM V21 (Licensed Practical Nurse) stated, I was not a witness when R9 fell . I was called to the room and when I went to R9 room I assessed R9 lying on floor. R9 was transferring to another room and was climbing in the closet to get something off the top shelf of the closet. The entire closet fell and was beside R9. R9 ending up having a laceration across the bridge of the nose, went to hospital and had to get sutures. On 03/01/23 at 02:12 PM R7 was observed sitting in a wheelchair in the dining room. R7 stated, About 3-4 weeks ago I was asleep and fell out of bed. My head hit the floor and when I reached up and touched my head it was bloody. I put my hand on the floor to try to straighten up and there was blood on the floor. I called the Certified Nurse Assistant, and they made the decision that I needed to go to the hospital. On 03/01/23 at 02:16 PM V22 (Certified Nurse Assistant) stated, R8 sat in bed on the side of her bed. On 01/10/23 I was not aware that R8 had fallen until the staff got R8 up. R8 fell that night and again that morning. The morning of 01/11/23 when R8 had the second fall there was a female radiology tech with R8, and the Certified Nurse Assistant made me aware that R8 had fallen. On 03/01/23 at 04:26 PM V26 (Wound Care Coordinator/Licensed Practical Nurse) stated, I was getting my laptop and the aides were passing trays when housekeeping told the aide that R7 had fallen. R7 had a laceration to the left side of the head. R7 is alert and oriented x 2-3. The fall was during breakfast time. On 03/01/23 at 06:21 PM per telephone interview V23 (Certified Nurse Assistant) stated, R9 told me that he (R9) was standing with the closet open trying to get the items on top of the closet and the closet came down and hit R9 in the face. I did not witness the fall but R9 had a laceration to the bridge of his (R9) nose. On 03/02/23 at 10:31 AM V24 (Licensed Practical Nurse) stated, R9 stated that he was trying to get something off the top of the closet and the closet fell and hit him. I believe the closet fell over and I saw it on the floor. R9 had bleeding and an open cut on the bridge of R9 nose. On 03/02/23 at 10:44 AM V27 (Restorative Nurse) stated, R7 has the interventions to call don't fall that was initiated 09/22, encouraged to wait for assistance initiated 12/13/22 and bed lowest position initiated 11/12/21. R7 is at risk for falls and has had multiple falls. The last fall with injury was on 02/12/23. R7 was sent to hospital and came back with one suture to the left side of R7 head. Per nurse documentation R7 said he was trying to get up in his (R7) wheelchair. R7 is alert and oriented x2-3 with periods of confusion. Floor mats were implemented 01/11/23 and on 01/30/23 the floor mats were resolved. When we resolve an intervention, the intervention is removed from the care plan. With the floor mats, we were trying to figure out the pros and cons. The floor mats are a tripping hazard and that's why we removed that intervention. R7 cannot walk by himself. From R7 care plan R7 had 4 falls in 2022 and has had 3 falls 01/15/23, 1/25/23 and 02/12/23. The new intervention that was added for 01/15/23 is the resident to be in common areas during hours of awake. On 02/12/23 hipsters to be applied while in bed. Everyone is at risk for falls. R8 was extensive 2 assist with transfers, 1 with bed mobility, and a mechanical lift. R8 was at risk for falls. On 01/11/23 R8 went to the hospital. On 01/10/23 R8 was in bed and complained of knee pain. In the documentation the nurse said she heard the bed lowering and the nurse noticed R8 halfway on the bed and R8 legs were bent back. R8 does sit on the side of the bed. I don't know if R8 would fall asleep while sitting on the side of the bed. The x-ray was completed after the second fall. I cannot determine if R8 had the fractures after the first or the second fall. On 03/02/23 at 12:05 PM V2 (Director of Nursing) stated, My expectations of the staff are to prevent falls and make sure any fall interventions are in place. R7 fell out of bed trying to get in his wheelchair. We were doing a room change and R9 was trying to reach something on the top shelf of his closet. The shelf or part of the dresser hit R9 on the bridge of the nose. The administrator had the maintenance make sure the shelves were intact. There could be a potential for injury with the cork board and the mirror being stored on top of the closet. The staff gave me a call and I was told that V17 (Licensed Practical Nurse) heard R8 bed being lowered. V17 (Licensed Practical Nurse) went into R8 room and R8 was sitting on assuming the edge of the bed. R8 said she fell asleep. They positioned R8 and R8 bilateral legs were underneath her. R8 complained of pain to the bilateral knees, and they did the x-ray. The staff could not move R8 because R8 was a heavy lady and they had to put R8 on the floor to use the mechanical lift and put R8 back in the bed on 01/10/23. The X-ray tech came the next morning on 01/11/23. They reported to me that R8 sustained a fall when they were trying to reposition R8 to do the x-ray. R8 was sitting on the side of the bed. They would have had to lay R8 in the bed. When I did the original fall reportable the fractures must have come from the first fall that's why I just submitted that one. On 03/02/23 at 12:53 PM V11 (Maintenance Director) stated, I can see the shelves coming down in the closet cabinet, so I removed the shelves. The shelf lines up with the bridge of R9 nose. On 03/02/23 at 02:36 PM telephone interview attempted to contact V25 (Certified Nurse Assistant) that was caring for R8 on 01/11/23 x3 with no answer. Voicemail left with return contact information. On 03/02/23 at 02:37 PM telephone interview attempted to contact V17 (Licensed Practical Nurse) x2 that was caring for R8 on 01/10/23 with no answer. Voicemail left with return contact information. On 03/02/23 at 02:52 PM per telephone interview V19 (Radiology Technologist) stated on 01/11/23 when I first arrived to and entered R8 room to do the stat bilateral lower extremity x-ray R8 call light was on. R8 was sitting toward the foot of the bed with her gown hanging on her wrist and R8 chest was completely exposed. I introduced myself, adjusted R8 gown then went to get an aide to help reposition R8 in bed to do the x-ray. While waiting for the aide I started to get R8 history. R8 is a large woman and complained of pain from both legs just above the knee, more towards the lower femur. When the aide arrived to R8 room we both positioned ourselves on both sides of R8 and before we got a chance to touch R8, R8 leaned forward and shouted oh. R8 fell to her knees, elbows and forearms then rolled to the right side. When everyone came to get R8 up, it was 4-5 staff that sat R8 up. Two of the staff members grabbed R8 under each arm and two staff grabbed R8 by the lower part of the leg and transferred R8 to the bed. They did not us a mechanical lift. I was able to do some of the x-rays and I did partial views. A new order was entered after R8 fell the second time they added on the right lower leg, it was just bilateral knees, the right humerus and right forearm. Document titled Facility Assessment Tool reviewed 12/23/22 document in part: Physical environment and building/plant needs: Physical Resource Category: Physical equipment, room, and common space furniture. The facility maintenance and administrative team conduct visual inspections of the facility equipment during scheduled and random rounds. Maintenance and/or corrective actions are implemented based upon the outcome of rounds/inspections. Policy: Titled Falls Management review date 02/23 document in part: General: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Fall prevention Guidelines for all residents upon Admission/Re-admission: 2. Residents at risk for falls will have Fall Risk identified on the interim plan of care with interventions implemented to minimize fall risk. Titled Preventive Maintenance and Inspection undated document in part: I. Policy Guidelines: To provide a safe environment for residents, employees, and visitors a preventive maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition. Regular inspection, testing and replacement or repair of equipment and operational systems contribute to preservation of equipment and facilities assets. II. Definitions: Preventive Maintenance is the care and servicing by personnel for the purpose of maintaining equipment and facilities in a satisfactory operating condition by providing for systemic inspection, detection, and correction of incipient failures either before they occur or before they develop into major defects. C. Inspections: 1. A schedule is developed to delineate all inspections that are to be completed on a regular basis. Inspections verify that all equipment and furnishings are in working order and free from safety hazards.

Based on interviews and record reviews, the facility failed to provide adequate supervision for 1 (R5) of 4 residents reviewed for falls. This failure resulted in R5 falling and sustaining a right-sided zygomaticomaxillary complex fracture. Findings include: R5 is a resident of the facility. R5's face sheet, care plan and progress notes read diagnoses of [CONDITION(S)] and dementia. R5's Quarterly MDS (Minimum Data Set) assessment dated [DATE] documents in part that R5 requires supervision - oversight, encouragement or cueing with setup help only for toileting. R5 has impairment on both sides of lower extremities. R5's ADL (Activities of Daily Living) care plan initiated on 12/17/2021 documents in part: Allow adequate time to complete each task. Offer choice to encourage active participation in ADL's. Date Initiated: 12/17/2021. Assist with Toileting needs throughout the day PRN[as needed]/Upon Request. Date Initiated: 12/17/2021. Current ADL Functional Status: Supervision with Set Up for Bed Mobility, Transfer, Ambulation, Locomotion, Dressing, Eating, Toileting, Personal Hygiene, Bathing. Date Initiated: 12/17/2021. V15's (Nurse) progress note dated 5/25/2022 4:20 AM documents in part: upon room rounds writer noted resident sitting up right on floor near bathroom door, observed with laceration to outer right eye with bruising and swelling to right orbital/cheek area. V24's (Physician) progress note dated 5/26/2022 12:37 PM documents in part: Fall - Risks include dementia, peripheral [CONDITION(S)], polypharmacy. On 06/07/2022 at 1:33 PM, R5 stated [R5's] foot got stuck on the floor as [R5] was getting off the toilet. R5 stated [R5] fell and injured right side of face. R5 stated staff did not witness the fall. During a telephone interview with V15 on 06/09/2022 at 9:21 AM, V15 stated I was just making rounds. I didn't see [R5] in bed so I knocked in [R5's] bathroom door. I asked if [R5] was okay and [R5] said [R5] was fine. About half an hour later, I saw [R5] was outside of the bathroom. [R5] had a laceration on the right eye area. V15 stated staff did not witness the fall. V15 stated R5 was not someone that needed to be watched while using the bathroom. At 10:10 AM, V16 (Restorative Manager) stated R5 required supervision with toileting and continues to need supervision with toileting. V16 stated Supervision is standby to make sure that [R5] is doing things appropriately and safe for [R5]. V16 stated staff need to stand there and let [R5] toilet [R5] but they need to standby and assist as needed. R5's physician order sheets document in part: transfer to hospital emergency room for evaluation and treatment related to fall with head injury. Facility's Illinois Department of Public Health Report of Resident Incident/Accident documents in part: Resident was transferred out for evaluation at 3:45 AM and returned to the facility around 2 PM with 2 sutures to right brow and diagnosis of right cheek fracture (zygomatic). R5's facial imaging dated 5/25/2022 documents in part: Findings of a right-sided zygomaticomaxillary complex fracture as described. Facility's 'Activities of Daily Living' policy last revised 5/2021 documents in part: E. Elimination . b. Adaptive equipment, assistance and instruction are given as required. Facility's 'Falls Management' policy last revised 7/2014 documents in part: Residents at risk for falls will have Fall Risk identified on the interim plan of Care with interventions implemented to minimize fall risk.

Based on observation, interview and record review the facility failed to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R9's decreased hemoglobin 9.0 (reference range 12.0-16.0) and hematocrit 29.5 (reference range 37.0-47.0). Findings include: R9's 9/27/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's 7/23/21 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/29/21 at 11:04am, R9's urine output was dark red. V8 (Nurse Manager) inspected R9's indwelling urinary catheter (as requested) and stated, There's gross hematuria. On 9/30/21 at 1:59pm, gross hematuria was again observed in R9's catheter. R9's MAR (Medication Administration Record) affirms [MEDICATION(S)] was documented as administered on 9/29/21 and 9/30/21. On 10/4/21 at 10:58am, V14 (Licensed Practical Nurse) affirmed she was assigned to R9 on 9/30/21 and administered the [MEDICATION(S)]. Surveyor inquired if hold orders are inclusive on R9's [MEDICATION(S)]. V14 reviewed the Electronic Medical Record (EMR) and stated, No, there's no hold order. Somebody would have to put it in. On 10/4/21 at 11:31am, surveyor inquired if R9's [MEDICATION(S)] was held on 9/28/21 due to gross hematuria as directed. V8 (Nurse Manager) responded, No. On 10/4/21 at 11:57am, surveyor inquired if V16 (Medical Director) was made aware of R9's (9/29/21) gross hematuria. V16 reviewed the EMR and stated, Here it says resolved (referring to 9/27/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . V17 (Physician) responded, I was notified and affirmed she was notified on September 30th (the following day). Surveyor inquired about monitoring R9's labs. V16 (Medical Director) responded, We've been monitoring the blood counts. On 8/19/21 the hemoglobin was 9.5 and hematocrit 31.4 but stable (6 weeks prior to surveyor 9/29/21 inquiry). R9's (9/30/21) hemoglobin was 9.0 and hematocrit 29.5, both decreased from 8/19/21 results. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Update MAR (Medication Administration Record) with changes or new orders. The change in resident's condition policy (reviewed 6/21) states nursing will notify the resident's physician or nurse practitioner when: there is significant change in the resident's physical, or emotional status.

Based on observation, interview, and record review the facility failed to provide supervision in the dining room, failed to ensure that staff are aware of resident fall prevention interventions, failed to ensure that (R1) was assessed (post fall) prior to moving her, and failed to implement appropriate fall prevention interventions. These failures resulted in R1's (9/6/21) left femoral neck fracture which required surgical intervention. Findings include: R1's diagnoses include Alzheimer's disease, abnormalities of gait/mobility, and history of falling. R1's progress notes include the following documentation: (9/6/21) Patient stated she fell . While making rounds during am care patient stated she had pain in her left leg. (9/13/21) Hip replacement was done on 9/9/19. R1's (9/6/21) left hip CT (Computed Tomography) includes displaced and mildly comminuted left subcapital femoral neck fracture. On 10/4/21 at 12:21pm, surveyor inquired about fall prevention interventions for residents with history of falls. V16 (Medical Director) stated, They need to be on fall monitoring. Surveyor inquired if a resident sustains an unwitnessed fall what is the potential harm. V16 responded, They could suffer a fracture or get hurt. The fall incident report affirms R1 fell twice at the facility on 9/6/21. On 10/5/21 at 1:23pm, surveyor inquired about R1's (9/6/21) fall(s). V2 (Director of Nursing) stated, The first fall was in her room and was associated with a behavior. R1 will get out of bed and crawl around on the floor. They assessed her and got her back in the bed. Approximately 45 minutes later the same thing happened; R1 got back out the bed. Surveyor inquired why floor mats were not implemented immediately after the initial fall if R1 fell getting out of bed. V2 replied, I can't speak of why he didn't put a floor mat down. Surveyor inquired if R1 is able to walk. V2 stated, R1 can stand. R1's 9/20/21 functional status documents R1 requires extensive assistance with bed mobility and walking/locomotion did not occur. R1's care plan included an actual fall (9/6/21) related to poor safety awareness/impulsiveness. Interventions: apply (wedge) cushion between legs while up in chair as tolerated. On 9/30/21 at 2:02pm, R1 was observed sitting on the floor (in the dining room) in front of the wheelchair. A (flat) cushion was observed on top of R1's wheelchair and both foot pedals were missing. V10 (Certified Nursing Assistant/CNA) picked R1 up and placed her in the wheelchair prior to physical assessment and/or vital signs obtained. V11 (CNA) responded, You were not supposed to pick her up. The Nurse is coming. Surveyor inquired what happened. R1 stated, I don't know what happened. V10 (CNA) replied, I just got her up. We came in here and she was on the floor. Surveyor inquired who was supervising the dining room. V10 stated, The shift just changed, so nobody's here. Surveyor inquired about R1's fall prevention interventions. V10 responded, Floor mats, that's the only one I know. V11 (CNA) stated, I was at the Nurse's station charting. When I came in here she was sitting on the floor. Surveyor inquired about R1's fall prevention interventions. V11 (CNA) responded, Floor mats, bed in the lowest position and just to be monitored. Surveyor inquired about R1's fall prevention interventions. V12 (Licensed Practical Nurse/LPN) stated, They pulled me from another floor around 11:00am. The fall prevention that she has is that, they did tell me she fell earlier when the other nurse was here at maybe 9am. [9/30/21 progress notes affirm R1 was observed laying on the floor at 9:26am]. On 10/5/21 at 1:15pm, surveyor inquired about the facility fall prevention protocol. V18 (Restorative Nurse) stated, We assess everyone who falls. We will do a root cause analysis with probable cause and intervention. Surveyor inquired if CNAs are allowed to move residents post fall prior to Nurse assessment. V18 responded, No. Surveyor inquired if staff are assigned to supervise the dining room. V18 replied, Usually people are assigned to the dining room. Surveyor inquired about R1's cognitive status. V18 stated, Moderate to advanced dementia. R1's 9/20/21 cognitive assessment determined a score of 3/severe impairment. The falls management policy (reviewed 6/21) states residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk.

Based on observation, interview and record review, the facility failed to conduct a comprehensive skin assessment that include a visual inspection of the resident's skin integrity after pressure is relieved to prevent new pressure ulcers from developing for 3 (R18, R10, R13) of 5 residents reviewed for pressure sores in the sample of 19 residents. These failures resulted in R18 acquiring a stage 3 pressure ulcer on inner buttocks and an unstageable wound on left heel, R13 developed a stage 3 pressure ulcer on coccyx, and R10 who was compromised with numerous pressure sores upon admission, developed a pressure wound on sacrum which was not assessed or treated by staff. Findings include: 1. R18 is an oriented, non-ambulatory [AGE] year old male who was admitted to the facility on [DATE] and discharged from the facility with return anticipated on 8/5/21. R19 was admitted with intact skin and for skilled rehabilitation due to a fall at home per the nursing admission note dated 4/23/21. R18 is incontinent of bowel and bladder per nurses' notes. On 8/11/21 at 11:29 AM, V41 (R18's daughter) stated that R18 was calling her complaining about much he was declining, and no one is helping with exercises, getting up and out of bed and he is allowed to lay in urine and feces for long periods of time. V41 called the facility on 8/5/21and instructed the staff to send R18 to the hospital. On 8/12/21 at 10:48 AM, V34 (Physical Therapist) stated R18 was evaluated for skilled therapy on 4/24/21. V34 stated that R18 was assessed for the need of maximum assistance for bed mobility/rolling over in bed, and all other Activities of Daily Living (ADLs) required total assistance. V34 stated R18 was non-ambulatory and struggled to sit up at the bedside of the bed due to restriction in his hip range. V34 stated R18 was discharged from skilled therapy on 6/24/21 and at that time, R18 was moderate assist for transfers, contact guard for bed mobility and able to walk 10 feet on parallel bars with minimum assist. V34 stated R18 was then referred to restorative services. V34 stated that R18 returned to skilled therapy on 7/26/21 due to nurses' referral of significant decline in his ranges and ability. V34 stated when R18 returned to skilled therapy, R18 was maximum assist with bed mobility, total assist with ADLs, non-ambulatory and unable to sit at the bedside. On 8/11/21 at 11:53 AM, V15 (Wound Care Licensed Practical Nurse) stated R18 did have breakdown on his left heel and left inner buttocks, which were acquired in-house. V15 stated that pressure wounds are from failure to off load from a pressure area that is vulnerable to breakdown. V15 was instructed to bring physician documentation on why these wounds were unavoidable. Nurses' note 6/21/21 documents the sighting of a left skin tear on left buttocks and the left heel noted with dark discoloration. R18 was given heel protectors, skin tear treated, and an MRI scheduled to determine why R18 has the inability to walk and is weak. Review of R18's 6/22/21 pressure wound documentation Wound Assessment Details Report documents the left heel with a pressure ulcer which was acquired within the facility. The skin alteration to the left heel is noted with purple ecchymosis tissue and no drainage. Review of wound Treatment Administration Record (TAR) documents the heel is cleansed with normal saline, patted dry, apply [MEDICATION(S)] and cover with dry dressing from 6/22/21 to 8/2/21. There was a change in treatment on 8/3/21 to cleanse heel, pat dry, apply thera-honey and cover with dry dressing. This treatment continued to 8/9/21 even though R18 was discharged on [DATE] to the hospital. Review of R18's Wound Assessment Details Report dated 6/22/21 documents stage 3 pressure sore on the inner left buttock. It is facility acquired and is 1 centimeter (cm) X 1 cm X0.10 cm (L x W x D) with no undermining. The area was noted to be bright red tissue and some drainage. Review of the TAR documents an order to cleanse left inner buttocks with normal saline, pat dry, apply thera-honey and cover with a [MEDICATION(S)] dressing one time a day on Mondays, Wednesdays and Fridays. This treatment was continued until the wound healed on 7/14/21. No documentation was provided to explain why these pressure sores were unavoidable. 2. R13's record documented a [AGE] year-old admitted to facility on 1/12/2021. Minimum Data Set (MDS) for R13 upon admission noted he had no skin breakdown. R13 was non-ambulatory and required assistance of staff for all ADLs. R13's mental status was impaired with a BIMS (Brief Interview for Mental Status) score of 7. R13 was frequently incontinent of bowel and bladder and required total assistance from staff for incontinence care. BRADEN scale for skin breakdown for R13 was 14 on 6/2/2021, which is high risk for skin breakdown. Nurses' notes for 8/3/2021 at 10:57AM documented open area on peri area noting that resident was incontinent of bowel and bladder and dependent on staff for care and repositioning. The note documented, Upon observation site noted with small open area. Resident is incontinent of bowel and bladder. Dependent on staff for care. The wound was staged as Stage 3 on the wound report for R13 on 8/3/2021. On 8/11/2021 at 12:35PM, V15 (Wound Coordinator) said the open area on R13's coccyx area was because he was incontinent of bowel and bladder. Care plan for R13's wound care documented two specific intervention for R13, and they were to offload his heels and reposition as needed. On 8/10, 8/11, 8/12 and 8/13 while on unit, there was no offloading of his heels and R13 was always on his left side. 3. R10 was [AGE] years old and on hospice care. R10 was readmitted to facility on 5/21/2021. R10 depended on staff for all his ADL needs. R10 had several wounds about his body, some of which were present upon admission. Treatment to sacral wound which measured 8.5x 9.5x x0.10cm was to be done Mondays, Wednesdays and Fridays. On Wednesday 8/11/2021 at 1:15PM, R10 laid in bed on his left side. When he was repositioned, there was a pungent odor. The right hip wound had an old dressing on it with no date. The under pad had old drainage from the wound. The wound on R10s sacrum was observed without any dressing. On 8/11/2021 V10 (Certified Nursing Assistant/CNA) did not answer when asked about the last time she changed R10. Facility's Pressure Ulcer policy dated 12/2019 documented, Avoid prolonged periods of moisture. Also, Residents will be repositioned according to the individual's level of activity.

Based on interview and record review, the facility failed to safely transfer a cognitively impaired resident (R5). This failure resulted in R5 obtaining an open lower leg fracture that required surgical intervention. This failure affects one of three residents reviewed for accidents and incidents in a total sample of 19. Findings include: R5 is a [AGE] year old female. R5's diagnoses include but not limited to: fracture of both lower leg bones, reduced mobility, dementia, [CONDITION(S)], and difficulty walking. Review of R5's Brief Interview for Mental Status (BIMS), dated 11/2019, notes that R5 is not cognitively aware. R5 requires total dependence from staff and requires two people when she is transferred by staff. Fall investigation report dated 1/29/2020, notes V6 (Former Nurse) stated, I was called to R5's room by V7 (Certified Nursing Assistant/CNA). R5 had left lower leg deformity and bleeding. R5 was crying with her legs dangling to the floor. Initial report dated 1/29/2020, notes R5 who is not alert or oriented, was noted with her leg caught under the bed causing bleeding and deformity to left lower leg after transfer from the wheelchair to the bed by the aide. R5 was assessed by the nurse. Orders were received to send the resident out to a local hospital. R5 was admitted for left leg fracture. On 08/10/2021, at 12:10PM, R5 was in bed. R5 was unable to answer any questions pertaining to the incident of 01/29/2020. On 08/10/2021, at 2:42PM, V7 stated, I was transferring her by myself. I did not know how many people needed to transfer her. She had a very low bed. She stated that she did not want to be transferred. I was using a gait belt. I was transferring her from the chair to the bed. Her leg was caught under the bed when I was lowering her. That is when is I heard her scream. I lifted her up again. When I assessed her for injuries, I saw that her leg was broken, and some blood was on the floor. I ran to the nurse. The nurse came back with me. She went to make some calls. She called the ambulance, and they took her to a local hospital. She was given an x-ray. I am always transferring by myself. We are always short of staff. On 08/11/2021, at 1:30PM, V2 (Director of Nursing) stated, If the resident is a two person assist, I expect that resident to be transferred with two people. On 0812/2021, at 2:32PM, V31 (Physician) stated, R5's bones are brittle. She does have a diagnosis of [CONDITION(S)]. There should be attention to her transfers due to her multiple history of fractures. R5's care plan notes that she requires 24 hour supervision, needs assistance from staff, displays memory impairments, has impaired cognitive function with dementia, and has impaired mobility. X-ray dated 1/30/2020, notes R5 had an open lower leg fracture.

Based on observation, interview and record review the facility failed to follow their policy to provide a safe environment. The facility failed to ensure that the windows in the resident rooms were secured and free from potential accidents for one (R4) of three residents reviewed for falls with serious injuries in the sample of 5. This failure resulted in R4 falling out of a third floor window to the ground. R4 sustained multiple fractures to the left leg, pelvis and back. R4 was taken to the hospital and underwent two procedures to stop internal bleeding and surgery to the left leg. R4 is scheduled for a third surgery to the left leg. Findings include: R4 is a [AGE] year old with diagnoses of Dementia, Unspecified Behavioral Disturbances, [CONDITION(S)], Hypertension, Major Depressive Disorder, Recurrent, [CONDITION(S)] of Native Coronary Artery without [CONDITION(S)] Pectoris and Gout. Review of R4's Admission Record documents R4 was admitted to the facility on [DATE] after being discharged from the hospital. R4 was found wandering around her neighborhood. Her hospital stay was complicated by findings of chronic LBBB (Left Bundle Branch Block), chronic heart failure and an Acute Kidney Infection (AKI). R4 was discharged to LTC (Long Term Care) facility. Minimum Data Set (MDS) dated [DATE] scored R4 as 7/15 alert and able to be directed with cueing. Bed mobility, walking in and around the unit was scored as a 1 and 2, supervision with one person assist. Review of R4's care plan documents: Resident has severe cognitive impairment with a history of wandering; therefore, she is at risk for Elopement. The resident is an elopement risk/wanderer (6/2/21). R4 with actual fall on 5/30/21 r/t poor safety awareness/impulsiveness (6/1/21). During interview with V2 (Director of Nursing) on 6/3/2021 at 11:59 am, V2 said, I heard a noise as if someone fell . I thought a smoker may have fallen, I looked out my office window and could see a resident was on the ground. I ran out to the patio, and I saw the R4 lying on the ground on her left side on top of the screen. She was awake, alert and oriented x 2. I asked her what happened and 'Are you Ok?' R4 said 'They were chasing after me.' I asked who; R4 said again The people was chasing after me.' She attempted to get up; I said 'No don't get up.' I yelled 'Call 911.' V2 continued by saying, Paramedics arrived on the scene, R4's left ankle was bleeding with an open cut the size a regular mouse to the computer. Normal saline and gauze was applied to the wound site. I had never seen anything like this. R4 acted as though nothing had just happened. She wanted to get away from who was chasing her. Paramedics and the police arrived on the scene. Staff was looking out the windows at the incident. I yelled, 'Get out of those windows; this is not a show. Get back to work.' Progress notes dated 5/30/2021 at 2:17 pm by V7 (Nurse) on 5/30 21 at 11:20 am documents writer came into building and started to get things together. I went to the computer to print off the census to make rounds. Around 11:25 am as I was getting things together, writer hears a nurse needed to the patio STAT, via intercom system. I run downstairs to the patio. R4 was on the ground accompanied by staff members. Writer and staff members checked resident's skin, no new wounds noted except wound to left heel. A nurse cleaned the wound with normal saline and wrapped it with a nonstick dressing. Resident was alert to self, was able to tell staff her name, date of birth (DOB), and age. Resident notified staff that someone was trying to get her. Resident vital signs were within normal limits, strength strong to bilateral extremities, resident denies pain but facial grimacing noted. Family and Physician was notified. During phone interview with V8 (Paramedic) on 6/3/21 at 2:02 pm, V8 said, We were called and told a person had fallen from the 2nd floor balcony. When we arrived R4 was laying on top of a window screen on the ground. We looked up and an entire window was missing from the 3rd floor. I am not sure how a resident could fall from a third floor window. We were told the resident was trying to get out because someone was chasing her. We heard screaming, someone telling other people to get out of the windows, and all I could think of was is this going to happen again while we are here. Surveyor asked V8 what he meant by that and if he saw other residents hanging out of windows. V8 said, No I can't say that but people were yelling 'get out of the window;' it is possible. V8 said I feel the facility did not provide safety measures to keep this accident from happening. The third floor room where the accident occurred was empty. Surveyor checked the window to see if it was broken or repaired. The window did not look like it was repaired or damaged in any way. Surveyor checked the other windows on the 3rd and 4th floors to ensure that the other residents would be safe. The windows had been reinforced with a bracket and a set of nails at the top and bottom. The windows could only be slid opened to 4 inches wide. All windows had a screen in them. Surveyor was told the accident did not happen in R4's room but the room next to R4. During interview with V6 (Maintenance Director) on 6/3/21 at 12:32 pm, surveyor told V6 that upon assessment of the window, one side was completely removed. It was leaning against the other window from the inside. There were no residents in that room. Surveyor asked how R4 took the window off its frame and that surveyor was not aware the windows could be lifted up off the frames. The nail was only there to keep the windows from sliding open more than 4 inches. Surveyor asked V6 if all the windows in the building were able to be lifted up out of the frame and removed. V6 said Yes, they were before I put nails in the top of the windows, which will prevent a person from lifting the window up to remove it out of the frame. Surveyor asked V6 how long he had been employed with the facility. V6 stated A couple years. Surveyor asked if he inspects the windows for safety on a regular basis. V6 said Yes and told me he can present the quarterly check sheet for all the windows. V6 stated he was not aware that the windows could be lifted up and out of the window frame until this incident occurred on 05/30/2021. During phone interview with V10 (Physician) on 6/8/21 at 2:21 pm, surveyor asked V10 what she meant by the note on her 05/24/2021 assessment of R4 when she documented abnormal behavior. Surveyor asked if there were any indicators that may have warned the facility that R4 would try and hurt self or elope. V10 said on the assessment day R4 was very calm, polite and cooperative. Surveyor asked V10 if R4 displayed behaviors that may have been a precursor of the incident of harming self/elopement on 5/30/2021. V10 said No, and that the behavior displayed on 5/24/2021, which is worst in the afternoon, was that R4 would collect objects from around her room and try to sell them. V4 said increased paranoia was noted. During a phone interview with V13 (Family) on 6/8/21 at 4:52 pm, surveyor spoke with V13 regarding the injuries R4 sustained. Hospital records were not available for review during this investigation. V13 said R4 had 2 operations, one to stop the internal bleeding and the other surgery was to the left leg. The injuries that resulted from R4 falling out the 3rd floor window was a fractured Pelvis, Back, Left Leg, heel and ankle bones fractured. V13 said R4 is scheduled to have a third operation on the left leg again. R4 is still hospitalized and not aware of the fall. Facility's Policy: Special Care Unit Mission Statement - dated 6/02, revised 10/2014 General: To provide a mission statement and goals for the Special Care Unit. 2. Goal: To provide a comfortable, safe and structured environment that minimizes the need for chemical or physical restraints. To assure that care is provided by staff that is knowledgeable about the special needs of people with Dementia. Resident will be placed in an environment that is barrier free and structure to prevent falls and injuries that is a result of falls.

Based on interview and record review, the facility failed to ensure resident safety during a transfer for a resident who was assessed and identified to require the assistance of a minimum of two staff for all transfers. The facility failure to implement the use of two person assist during a transfer resulted in a significant injury for 1 of 3 residents (R1), who sustained a [MEDICAL CONDITION] leg requiring emergency medical treatment and services. Findings include: R1 is a [AGE] year old with [DIAGNOSES REDACTED]. unspecified dementia, without behavioral disturbance. R1's Minimum Data Set ((MDS) dated [DATE] under Functional Status indicated that she required total dependence of 2+ persons and physical assist during transfers. The current MDS completed by facility staff on 2/12/2020, under the Functional Status section, documented that R1 required extensive assistance of 2+ persons and physical assist during transfers. On review of the Fall Risk Screen dated 2/01/2020, facility staff identified that R1 was at high risk for falls. There was no documentation that facility staff completed a Fall Risk Screen assessment prior to the resident fall related incident of 1/29/2020. The resident care plan initiated on 11/17/2019 indicated Focus: R1 requires extensive assistance with activities of daily living (ADLs) related to weakness, impaired mobility and dementia. Interventions Current ADL function: extensive x1 with bed mobility, transfers, locomotion, personal hygiene, dressing, and supervision with meals. The care plan did not accurately reflect the resident's assessed and identified requirements for staff assistance during transfers. On review of the Certified Nursing Assistant's Plan of Care dated from December 2019- February 2020, the documentation reflects that R1 has received extensive assistance of one-person physical assist during staff transfers. On review of the Nursing Progress note dated 1/29/2020 at 8:30 PM, facility staff documented that R1 was sitting on her bed with legs over the side of the bed and feet on the floor, left leg was bleeding and deformity noted on left lower leg. Nursing Progress Note dated 1/29/2020 at 8:35 documented a physician order [REDACTED]. On review of the Nursing Progress Note dated 1/30/2020 at 1:50 AM, facility staff documented that R1 was admitted to community hospital with a [DIAGNOSES REDACTED]. According to the hospital medical record dated 1/29/2020, R1 presented with a left tibia open fracture and was admitted to the ortho team. The hospital record documented that R1's injury required surgical repair. On 2/25/2020 at 2:48 PM, V5 (Certified Nursing Assistant/CNA) stated that the day of the incident she was took R1 to her room. V5 stated that R1 was crying because the bed was too low. V5 stated that she was encouraging R1 not to cry. V5 stated that she proceeded to transfer R1 from the wheelchair to the bed by herself and when she was pivoting R1, R1's leg slid to the side and under the bed. V5 stated that R1 began to scream My leg, my leg. V5 said that when she saw R1's leg under the bed, she (V5) immediately called the nurse to assess R1. V5 stated that she had previously worked with R1 and was familiar with her (R1) care. On 2/26/2020 at 12:03 PM, V8 (Licensed Practical Nurse/LPN) stated that she was in the hallway passing medications when a CNA (Certified Nursing Assistant) asked her to come to the room. V8 locked medication cart and went to the room. V8 stated that R1 was sitting on her bed, not on the floor, her legs were extended to the floor, and there was an obvious deformity to the left lower leg. V8 said that she grabbed a towel to apply pressure to the leg, as there was a significant puddle of blood on the floor. V8 then called the physician, then called 911 and R1 was transferred to the hospital. V8 stated that she followed up with the hospital later that day and she was told that R1 was going to be admitted and R1 was given a [DIAGNOSES REDACTED]. V8 stated that at that time, R1 was safe to be a one-person transfer because R1 could bear weight and pivot. V8 failed to identify that R1 required the assistance of 2+ staff for transfers. On 2/27/2020 at 10:19 AM, V12 (Nurse Practitioner/NP) was asked if a one-person transfer was safe for R1. V12 stated that she could not say if one-person transfer should be safe for R1. V12 stated that physical therapy would be able to answer that question better. On 2/27/2020 at 10:26 AM, V13 (Physical Therapy Director) stated that R1's prior level of functioning was dynamic standing fair+. Bed mobility independent, transfer stand by assistance, which indicated that R1 could transfer but needs someone standing by. V13 stated that the physical therapy assessment was based on R1's functional status prior to her admission to the facility. V13 stated that while in the facility, R1 got sicker and her functional status changed, requiring more assistance during transfers of at least a 2-people assist. V13 further stated that upon readmission from hospital, R1's bed mobility changed to max assistance, which indicates the R1 can initiate the task but less than 25%. Transfer changed total assistance, which means R1 was able to do the task less than 10% and requires the use of a mechanical lift or 2+ person assist. On 2/27/2020 at 2:25 PM, V2 (Director of Nursing/DON) stated that R1 was a one-person transfer. During the interview, V2 was informed of the discrepancy of the care plan and transfer requirements as identified by facility staff on the MDS (Minimum Data Set). V2 stated that she was not aware of this issue and stated that R1's care plan should reflect MDS assessment.

Based on record review and interview, the facility failed to monitor blood glucose levels as ordered for one of three residents (R2) and failed to notify the physician of elevated blood glucose level(s) for two of three residents (R2, R13) reviewed for change in condition in a sample of 14. On 1/21/18, R2 was admitted to the hospital with [REDACTED]. Findings include: 1. R2's POS (Physician order [REDACTED]. On 1/21/18 at 10:24pm, R2's blood sugar was documented to be 450mg/dl (milligrams/deciliter). On 1/22/18, R2's blood glucose level was not documented (before breakfast). R2's (1/21/18) nursing progress notes state: 10:57pm, Blood sugar 450. (There is no documentation the physician was notified). (1/22/18) 9:30am, Resident observed with a mental status change. Blood sugar reading high. Resident physician in building came and assessed the resident. Received orders for resident to be sent to hospital. R2's (1/22/18) physician progress notes [REDACTED]. Glucose reading high. Patient glucose in 300-400's range last week and no medical doctor was notified. Altered mentation, acute. Likely 2/2 DKA given glucose >500. Unclear why medical doctor was not called during the week given her readings in the 400's. R2's (1/26/18) re-admission progress notes state resident presented to the emergency room with DKA; upon presentation her blood glucose level was 694. On 4/2/18 at 12:25pm, V15 (Case Manager) stated, We usually contact the doctor if the blood sugar is below 70 and over 250. V15 reviewed R2's EMR (Electronic Medical Record) and stated, The (1/21) 9am blood sugar was 300, 17:32 (5:32pm) was 300 and 22:24 (10:24pm) was 450. On the day in question looking at the nursing notes per the documentation, it looks like they did not notify. It looks like the next day after the doctor came in he was notified. 2. R13's POS includes (11/21/16) blood glucose check daily; call medical doctor if below 60 or above 250. On 3/18/18, R13's blood glucose was 350. There is no documentation that the doctor and/or nurse practitioner were notified. The change in resident's condition policy and procedure (10/03) includes but is not limited to: It is the policy of the facility, except in a medical emergency, to alert the resident's physician/nurse practitioner of a change in condition. Nursing will notify the resident's physician or nurse practitioner when: it is deemed necessary or appropriate in the best interest of the resident. Communication with the physician/nurse practitioner will be documented in the resident's medical record.

Based on interview and record review the facility failed to the plan of care transfer intervention and use (2) person and a mechanical lift while transferring from the wheelchair to the bed for 1 of 3 (R1) reviewed for transfers using a mechanical lift. This failure resulted in R1 sustaining a fractured left leg during a one person transfer from a wheelchair to the bed. Findings include: Face Sheet documents R1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Mobility Assessment 4/14/16 documents R1 is assessed as needing a mechanical lift for all transfers. Care Plan 12/14/15 for assistance with activities includes the intervention total assist x 2 staff with transfer (mechanical lift) and transfer from bed to wheelchair and vice versa with use of mechanical lift x 2 staff. Care Card documents R1 is a mechanical lift with 2 people. Nurse Progress Note 6/28/16 12:29pm documents there are no clean slings for the mechanical lift and R1 will be transferred once a clean sling is available. Incident Report 6/28/16 documents R1 was transferred out of bed by 2 staff members using a gait belt and transferred back to bed by 1 staff member without the use of any assistive devices. After the second transfer, R1 complained of pain to the left leg. R1 is assessed with [REDACTED]. X-ray results 6/29/16 document a fracture of the left lower leg bones. On 7/7/16 from 12:30-12:50pm, R1 sat in a wheelchair and had a cast on the left leg, from the mid foot all the way up to the mid-thigh. R1 stated that on 6/28/16 on the 2-10pm shift, Z4(Nurse Aide) and Z5(Nurse Aide) transferred her from the bed to the chair without using the mechanical lift. R1 stated they did not use the lift because there were no pads. The 6am-2pm shift knew this also and did not get R1 up on that shift. R1 stated that later at night, Z3(Nurse Aide) transferred her back to bed by himself, did not use a gait belt, mechanical lift, or another person. R1 asked Z3 not to lift her, but as he did R1's left leg hit or got caught in the siderail. R1 stated she told Z3 and Z5 that her left leg hurts, but the nurse didn't come to check on her until about 11pm. R1 stated I don't think (Z5) told anyone about the transfer and my leg pain. The following interviews took place on 7/7/16: At 10:20am, E2(Director of Nursing) stated Z5 asked Z4 to get R1 up to the chair on 2-10pm shift 6/28/16. Z5 asked Z3 to transfer R1 back to bed around 9pm 6/28/16. After the transfer back to bed, R1 told Z3 and Z5 of pain in the left leg. E2 stated the nurse did not know about R1's pain until about 1 hour later. At 11:50am, E4(Nurse) stated that on 6/28/16, R1 did not get up in the chair because there were no clean slings for the mechanical lift, and R1 needs the mechanical lift for transfers. E4 stated R1 cannot support her weight and pivot to assist during a transfer. E4 stated the female aide on the 2-10pm shift asked why R1 was still in bed. E4 replied that there were no slings for the mechanical lift. E4 stated the facility has a no lift policy, restorative assesses the patient for transfer status, and it is communicated on the care cards. At 1:55pm, E3(Nurse) stated that on 6/28/16 at 10:45pm, the night shift aide reported there was something wrong with R1's leg. Upon assessment, R1's left leg had a large bump below the knee and was in a lot of pain. E3 stated she called the physician, gave Tylenol, applied an ice pack, elevated the ;leg, and ordered an x-ray. E3 asked R1 what happened, and R1 replied that her left leg hit the siderail when Z3 put her back to bed. E3 stated sometimes slings for the mechanical lifts are not available, but R1 should not have been transferred without the mechanical lift. The following interviews took place on 7/13/16: At 12:25pm, Z4 stated R1 did not have a fall, R1 was transferred out of bed to the wheelchair by Z4 and Z5 using a gait belt. Z4 stated he knew R1 needed a mechanical lift, but thought it was OK to use 2 people plus a gait belt. Z5 did not tell Z4 why the mechanical lift was not used. At 1:20pm, E6(Nurse) stated she worked 11pm-7am on 6/28/16. E6 stated R1 was very upset about having a broken leg from the transfer. At 1:35pm, Z3 stated that on 6/28/16, R1 was transferred only by him around 9:45pm; Z3 put his arms underneath R1's arms and lifted her into the bed. After the transfer, R1 told Z5 that her leg hurts. Z3 stated he saw Z5 look at R1's leg, but then Z5 did not tell the nurse before leaving at the end of the shift. At 3:35pm, Z5 stated she assisted Z4 with R1's transfer from bed to wheelchair; they used 2 people and a gait belt because there were no clean slings for the mechanical lift, which happens all the time. Z5 stated if the aides can lift the patients, they don't use the mechanical lift if there are no slings available. Z5 stated R1 complained of left leg pain after the transfer, Z5 looked at it but did not see anything. Z5 stated she did not tell anyone that R1's leg hurt; Z5 already left at 10pm and it slipped my mind. On 7/14/16 at 10:45am, Z1(Physician) stated R1's fracture happened during the transfer by 1 nurse aide. R1 hit her left leg on the siderail during the transfer. Z1 stated R1 should not have been transferred by 1 person, R1 is totally dependent for transfers and cannot support her weight on her legs to perform a transfer. The incident investigation was reviewed and staff written statements are consistent with interviews conducted during the complaint survey. Safe Patient Lifting Policy - The Safe Patient Lifting Policy exists to ensure a safe working environment for resident handlers. The policy is to be reviewed and signed by all staff that perform or may perform resident handling. Initial screen will be performed on all residents to assess transfer and ambulation status. Disciplinary Actions: This policy is to be followed at all times.

Based on observation, interview and record review the facility failed to follow their management of wounds policy and assess risk for skin breakdown, failed to monitor skin, and failed to obtain treatment orders for an open area of skin breakdown for 5 of 6 residents (R1,R3,R6,R7,R8) reviewed for pressure sores in the sample of 37 . This failure resulted in a stage 2 pressure sore measuring 1.5 x 5 x 0 centimeters . Findings include: Nurse Note 2/15/13 5pm documents an open area to R3's right buttocks was identified in the shower, "wound care to be notified in the morning". CNA Skin Attention Forms 2/15/13, 2/17/13, and 2/19/13 document R3 has an open area to the right buttocks. 2/21/13 Physician Telephone Orders and February 2013 Physician order [REDACTED]. Wound Rounds Assessment 2/21/13 documents a stage 2 wound measurementing 1.5 x 5 x 0 centimeters (cm). There is no evidence of wound treatment orders prior to 2/21/13. Braden Assessments are completed on 12/4/12 and 3/8/13. There is no evidence of Braden Assesments upon the discovery of the new skin breakdown, as stated in the facility policy. On 5/8/13 at 2pm Z9 (Nurse Practitioner) stated if R3's wound isn't treated, it will get worse. On 5/6/13 at 10:50am, E16(Wound Nurse) performed wound care treatment to R8's sacral and right buttocks wounds. Nursing Admission and Assessment documents R8 was admitted to the facility on [DATE] with no open wounds on the skin. Bath and Skin Report 3/18/13 documents an open area to R8's coccyx area without measurements or further description. Physician Telephone Orders 3/20/13 documents an order to treat the open area, 2 days later. Treatment Record documents the treatment was started on 3/20/13, 2 days after the open area was identified. Wound Rounds 3/20/13 documents the open area as stage 2 measuring 4.5 x 2.7 x 0 centimeters (cm). R8's last Braden Scale Pressure Ulcer Risk Assessment from 1/31/13 score is very high risk for pressure sore development. April and May 2013 Daily Skin Assessment Forms were presented for R8. There is no other evidence that R8's skin was being assessed daily, monitored, or treated during that time. On 5/2/13 at 2pm, R6 was in bed. R6 stated she does have a bed sore on her coccyx. Nursing Admission and Assessment documents R6 was originally admitted to the facility on [DATE] without any wounds. R6 was re-admitted to the facility on [DATE] with an open area of skin breakdown to the coccyx, and re-admitted on [DATE] with an open area of skin breakdown to the right hip. R6 does not have Braden Scale Risk for Pressure Ulcer Assessment for the readmissions on 3/27/13 and 4/26/13. The last Braden scale is on 2/27/13 and scores R6 as "at risk for skin breakdown." On 5/2/13 at 2:25pm R7 was in bed. Nursing Admission Assessment 4/11/13 documents R7 was admitted with an open area to the coccyx. R7 was readmitted on [DATE] with a worsened open are to the coccyx and a new open area to the right hip. The last Braden Scale Risk for Pressure Ulcer Assessment is on 3/21/13. There are no Braden Assessments for the admissions on 4/11/13 and 4/26/13. Closed record indicates R1 was admitted on [DATE] with a lower leg ulcer and a sacral pressure sore. R1 has a Braden Scale for Pressure Ulcer Risk Assessment on 2/21/13. There is no evidence of the weekly for 4 weeks Braden Assessment was completed according to the facility policy. On 5/7/13 at 11:15am, E15(Wound Director) stated that a resident assessed as very high or high risk for pressure ulcer development gets a skin check every day. Daily Skin Assessment Forms were initiated in March 2013. E15 stated Braden Assessments are completed on admission, weekly for 4 weeks, quarterly, and if a new area of skin breakdown occurrs. E15 stated that if a wound goes without treatment, it will get worse. Wound Rounds Policy documents "If a wound is acquired in the building, the nurse who is notified of the wound will describe the wound and get a treatment order; as well as notify the wound team. The wound team will review the acquired wound within 24 hours of the wound being discovered and complete the Braden, wound descriptions, measurements, interventions, and review the treatment orders." Management of Wounds policy documents "Pressure Ulcer Risk Assessment - to be done on all residents on admission, weekly for the first 4 weeks for at risk residents, then quarterly." .