Every finding on record at Southgate Health Care Center

Based on interview, observation, and record review, the facility failed to provide dependent residents timely ADL (Activities of Daily Living) assistance with toileting/incontinence care for 1 of 3 residents (R1) reviewed for ADL assistance in the sample of 11. R1's admission Record (print date 6/24/26) documented an original admission date of 8/2/23 and included diagnoses of cognitive deficit due to cerebral infarction, Alzheimer's disease, anemia, arthritis, cognitive communication deficit, and repeated falls.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe cognitive impairment. This MDS documents R1 is frequently incontinent of urine and bowel, is dependent upon staff for toileting hygiene, and R1 needs substantial/maximum assistance for toilet transfer. R1's most current Care Plan documents R1 has an ADL self-care performance deficit related to Alzheimer's, impaired balance, and limited mobility (initiated on 10/23/24, revised on 4/29/26). Corresponding interventions for this focus area document R1 requires substantial/maximum assistance by one staff for toileting and R1 requires substantial/maximum assistance of 1 staff to move between surfaces. R1's Care Plan documents another focus area for impairment to skin integrity and pressure ulcer related to generalized weakness, Alzheimer's, decreased mobility, anemia, pain and use of medications (initiated 1/16/24 and revised 4/2/26). Corresponding interventions for this focus area include keeping skin clean and dry (initiated 1/16/24 and revised 12/11/25).R1's Electronic Health Record (EHR) daily documentation in the Tasks tab for monitoring for incontinence of bowel and bladder document R1 is mostly always incontinent and sometimes frequently incontinent for the dates reviewed of 4/25/26 - 6/24/26.R1's EHR daily documentation in the Tasks tab for monitoring for ability to transfer documents R1 is usually dependent upon staff for transfer from bed to chair and going from sitting to standing position and sometimes a substantial/maximum assist for both activities for the dates reviewed of 4/25/26-6/24/26.On 6/24/26 at 4:46 PM, V5 (Family Member) stated she witnessed R1 left in bowel incontinence for a long period of time on Sunday, 6/21/26 via the camera she had installed in R1's room. V5 stated the CNA (Certified Nurse Aide) staff got R1 up for supper about 4:30 or 5:00 PM. V5 stated she arrived at the facility about 7:00 PM the same evening, and when she sat down beside R1 she noticed R1 smelled like bowel incontinence. V5 stated she (V5) provided incontinence care to R1, but stated if she had not done it then, CNA staff wouldn't have gotten to R1 before 8:30 PM or so. V5 stated yesterday, 6/23/26 she noted on the camera installed in R1's room CNA staff had gotten her up for breakfast at approximately 7:30 AM, and the CNA staff had not laid R1 down to provide incontinence care or attempted to toilet her up until the time V5 arrived at about 12:00 PM.On 6/24/26 at 11:28 AM, V5 was present in R1's room with R1 sitting in her recliner with her feet and legs elevated. V5 stated she had been in the facility with R1 for about the past hour and there had been no staff come in to offer to toilet R1 or offer/provide incontinence care. V5 has two cameras set up in the room for electronic monitoring. V5 showed this surveyor camera footage from 9:31 AM this morning to present and R1 had not been toileted or provided incontinent care in that 2-hour span of time. R1 had not left the room during this time either.On 6/24/26 at 12:28 PM, this surveyor observed a sign in R1's room taped to the wall in plain sight reading, (Name of resident/R1) to be toileted every two hours while awake during waking hours. R1 remained in her recliner awake covered in a blanket. On 6/24/26 at 12:43 PM, V5 returned to the facility and was in R1's room. V5 showed this surveyor the recording of footage from R1's room from 9:31 AM to present time and there were no staff observed in her room to provide incontinence care or toileted in that 3-hour period and R1 had not left the room during this time. On 6/24/26 at 1:23 PM, V6 (CNA) verified she was assigned to R1's hall and stated incontinence care should be provided at least every 2 hours, but it gets done more frequently than that. V6 stated the last time she had provided incontinence care or toileted R1 was on Monday 6/23/26, her last shift before this one. V6 stated she had not provided incontinence care to R1 today. V6 stated she was not sure if anyone else had provided incontinent care or toileted R1, but states staff probably had at some point.On 6/24/26 at 1:34 PM, V7 (CNA) verified she was assigned to R1's hall and stated CNA staff should offer toileting or incontinence care at least every 2 hours and prior to and after meals. V7 stated she assisted in the transfer of R1 out of bed to her wheelchair this morning at about 7:00 AM but did not provide any incontinence care or toilet her today at all. V7 stated she was not sure if any other staff had toileted or provided incontinent care to R1 but thought they probably had at some point. V7 stated she has been working in other halls today as well, so she was not sure what all care had been provided to R1. On 6/24/26 at 1:45 PM, V3 (CNA) verified she was assigned to work R1's hall and stated the last time she checked R1 for incontinence or offered her the toilet was at approximately 9:30 AM before she assisted V6 (CNA) with R1's transfer from her wheelchair to her recliner. V3 stated R1 made it known she did not want to sit on the toilet, and she had not had any incontinence of bowel or bladder. V3 stated she made sure to check R1 for incontinence by opening R1's incontinence brief and visually checking.The camera footage this surveyor reviewed of R1 from 9:31 AM to 12:43 PM did not show V3 manually opening R1's incontinence brief and checking her for incontinence of bowel or bladder.On 6/24/26 at 2:04 PM, this surveyor again spoke to V5 (Family Member) via phone. When asked if camera footage revealed any staff coming into the room offering or providing toileting or incontinence care to R1 since last review of the camera footage at about 12:43 PM, V5 stated audio and visual footage from cameras in R1's room showed no staff had been in R1's room from 12:30 PM - 2:10 PM, indicating the last possible time R1 had been toileted or provided incontinence care was at the time she was cleaned and provided incontinence care prior to getting out of bed for breakfast at about 7:30 AM that morning. V5 stated R1 had never left the room during this time.On 6/25/26 at 9:59 AM, V8 (CNA) stated incontinence care/toileting should be offered/provided at least every two hours and more often if needed. V8 stated even if family is in the room, V8 still offers incontinence care/toileting every 2 hours. V8 denied any concerns with CNA staffing of the facility. V8 stated they do have enough staff to provide the care residents need.On 6/25/26 at 10:24 AM, V11 (Licensed Practical Nurse/LPN) stated toileting/incontinence care should be provided/offered every 2 hours and as needed even if family were here visiting. V11 agreed that 4 hours was too long to wait between offering incontinence care/toileting residents. On 6/25/26 at 11:54 AM, V13 (CNA) stated incontinence care or toileting should be provided every two hours and as needed for all residents. V13 stated waiting four hours for incontinence care was unacceptable. V13 stated she believed CNA staffing was adequate at this time to provide the care the residents needed.On 6/25/026 at 12:05 PM, V14 (CNA) stated incontinence care or toileting should be provided every two hours or as needed for the residents. V14 stated even if family were in the room, it would not prevent her from offering toileting/incontinence care. V14 stated CNA staffing is currently adequate to provide the needed care residents require.On 6/25/26 at 1:59 PM, when asked why she did not offer or provide incontinence care to R1 during the time frame of 9:30 AM - 2:10 PM, V6 stated it was because she simply forgot to pop in and check on her. V6 stated, It was an oversight. I didn't mean to but just did. I should have checked on her during that time frame and provided incontinence care.On 6/25/26 at 2:09 PM, when asked why incontinence care was not provided to R1 during the time frame of 9:30 AM - 2:10 PM on 6/23/26, V7 stated I don't know why nobody made it to that room to provide incontinence care. V7 agreed 9:30 AM-2:10 PM was too long a period to not offer incontinent care or toileting for any dependent resident.On 6/25/26 at 2:23 PM, when asked why R1 was not provided incontinence care between the hours of 9:30 AM - 2:10 PM on 6/23/26, V3 (CNA) stated I was off the floor between 10:00 AM - 10:30 AM and 1:00 PM and 1:30 PM, but besides that I don't know what or why incontinence care was not given. Her family could have asked us to do that or put her call light on. V3 stated the reason she did not offer it was because R1 was visiting with her daughter. V3 stated the next time she remembered providing incontinence care to R1 was sometime after 1:30 PM when she laid her down for the nurse to do a skin assessment. On 6/25/26 at 3:04 PM, V2 (Director of Nurses/DON) stated residents should be offered incontinence care and/or toileting every 2 hours. V2 agreed R1 should have been offered incontinence care or toileted sooner than sometime after 1:30 PM on 6/23/26, since the last time it was reportedly offered before that was at 9:30 AM.The facility's policy for Urinary Continence and Incontinence-Assessment and Management dated revised 8/2022 documents, If the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. As appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a 'check and change' strategy. A 'check and change' strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin.

Based on interview and record review the facility failed to notify a medical provider of abnormal vital signs for 1 (R1) of 3 residents reviewed for change in condition in a sample of 6.Findings include:R1's admission Record documented an admission date of 3/19/24 with diagnoses including Parkinson's disease, dementia, and anxiety disorder. R1's 5/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 was severely cognitively impaired.R1's 5/19/26 at 12:30 AM progress noted authored by V6 (Licensed Practical Nurse/ LPN) documented in part . BP (Blood Pressure) 89/82, P (Pulse) 45, R (Respirations) 20, T (Temperature) 102.3 (degrees Fahrenheit), O2 (Oxygen Saturation) 90 (90%) . Sweating, shallow breathing, bilat (bilateral) arm tremors noted. Pupils equal reactive to light and accommodation. Minimal repose when addressing, no words given, only audible gasps made. Tylenol 500 mg given, fluids encouraged.R1's 5/19/26 at 6:12 AM progress note documented in part .: BP 113/84, P 62, R 17, T 98.1, O2 93. Sweating, shallow breathing, bilat arm tremors no longer observed. Pupils equal reactive to light and accommodation. Fully responsive when addressed, able to speak when spoken to.On 5/28/26 at 2:44 PM, V6 said she was the nurse taking care of R1 during the night shift on 5/19/26. V6 said the CNA reported to V6 R1 had a fever and V6 had administered Tylenol to R1. V6 said the CNAs had obtained the first set of vital signs and when they were reported V6 thought they were exaggerated and I thought all of it was strange with the vital signs. V6 stated When I went back to check her, her fever was gone and I thought they were making a bigger deal than it was. I waited about an hour and a half before checking on her again but forgot to chart until I was about to leave and that is why they are charted at 6:12 AM.On 5/28/26 at 9:15 AM, V12 (Regional Clinical Consultant) said she was reviewing R1's Electronic Medical Record (EMR) and noted R1's 5/19/26 progress note authored by V6. V12 said she called V6 to get a statement. V12 presented a typed statement signed by V2 (Director of Nursing/ DON) and V12. The statement documented in part . on 5/19/2026 at 0030 (12:30 AM), CNA alerted nurse of resident's temperature being 102.3, Nurse (V6) assessed resident to find bilateral tremors, which are normal for resident related to diagnosis of Parkinson's, sweating, and shallow breathing. Nurse assessed pupils to find reacting to light and accommodation. Nurse administered Tylenol. About an hour later nurse went to re-assess resident to find resident resting peacefully with prior symptoms subsided. Nurse stated that she did not feel like this was a significant change for the resident as she slept and rested well throughout the shift. On 5/29/26 at 11:26 AM, V4 (Physician) was read R1's 5/19/26 at 12:30 AM progress note and was asked if V4 would have expected that nurse to contact him and V4 said yes. V4 said he was contacted on 5/19/26 at 10:25 AM about R1's change in condition and gave orders for a chest x-ray and a urinalysis. V4 said he did not think there would have been a change in R1's outcome if V6 had contacted him on 5/19/26 at 12:30 AM except he would have told V6 to wake R1 up and check the vital signs because he did not believe they were accurate. R1's 5/19/26 at 10:25 AM progress note documented in part .Resident's voice is hoarse and cough noted during breakfast. MD (Medical Doctor) notified and gave new orders as follows: Chest x-ray encouraged; oxygen nc (nasal cannula) keep 90-98% start 2L (Liters). Resident's POA (Power of Attorney) at bedside and notified or new orders and resident's current condition.R1's 5/20/26 at 3:54 PM progress note documented in part . MD in the facility to see resident and gave new orders as follows: CBC (Complete Blood Count) & Cipro 250mg BID x 7 days (2 times a day for 7 days) if worse send to ER (Emergency Room). POA at bedside and aware of new orders and resident's current condition.R1's 5/20/26 at 8:15 PM progress note documented in part . This nurse went to give resident HS (bedtime) medication. Prior to pulling medication, this nurse went into room to assess resident and get vitals. Upon assessment, resident is noted to be pale, diaphoretic. Resident did not respond to verbal ques and could not open eyes upon request. This nurse was able to ask resident if she was in pain and she muttered no. This nurse tried to give resident a drink of water with a straw and resident was unable to drink. This nurse then completed vitals. Resident was exhibiting lethargy and labored breathing at this time. Vitals completed manually and documented as so. Blood pressure 88/38mmhg, 100.8 temp, respirations 24, pulse, 79bp O2 sat on 2 liters of O2 via nasal canula 83%. This nurse encouraged resident to take some deep breaths. Unable to get a pulse ox reading higher than 88% on oxygen. This nurse had CNAs sit with resident while this nurse called (V4) about status and decline of patient. (V4) advised to send resident out.R1's 5/24/26 hospital Discharge Summary documented in part . admission Diagnoses: 1. Acute Hypoxic Respiratory Failure in setting of CAP (Community-Acquired Pneumonia) 2. CAP 3. UTI (Urinary Tract Infection) . Summary of History and Physical . Husband at bedside to provide HPI (History of Present Illness). States that on Saturday (5/16/26) he noticed the patient had developed a dry cough. Over the past several days, the cough has persisted and felt that she was more pale than normal. (V4) saw the patient on 5/19. A chest x-ray was obtained and showed cardiomegaly with mild CHF (Congestive Heart Failure). Patient does not have a hx (history) of CHF and no signs present. Chest x-ray showed left sided pneumonia.The facility's revised February 2021 Change in a Resident's Condition or Status policy documented in part . Out facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/or status. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): d. significant change in the resident's physical/ emotional/mental condition; e. need to alter the resident's medical treatment significantly.

Based on observations, interviews, and record reviews, the facility failed to provide effective pain management for 3 of 3 residents (R1, R2, and R3) reviewed for pain in a sample of 4. This failure resulted in R1, who has a diagnosis of Multiple Myeloma and at the end-of-life stage, not receiving an ordered narcotic pain medication for 6 hours and R1 experiencing intense pain and suffering prior to her death.This failure resulted in Immediate jeopardy, which was identified to have begun on [DATE] when the facility ran out of R1's oral Dilaudid pain medication resulting in R1 experiencing uncontrolled pain. V1 (Administrator), V21 (Regional Clinical Coordinator), V2 (Director of Nursing, and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 2:10PM. The immediacy was removed on [DATE], but non-compliance remained at a Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training.Findings Include:1.R1's admission Record documents an admission date of [DATE] and an admission date to hospice care on [DATE] with diagnoses of Multiple Myeloma and Pulmonary Embolism. Other documented diagnoses include Asthma, Spinal Stenosis, Chronic Pain, Gastro-Esophageal Reflux Disease, Hyperlipidemia, Hypertension, Osteoporosis with pathological fractures, Acute Respiratory Failure, and Fibromyalgia. R1's admission Record documents a date of discharge of [DATE].R1's Minimum Data Set (MDS) dated ([DATE]) documents a Brief Interview for Mental Status (BIMS) score of 7, indicating R1 has moderate cognitive impairment. Section J- Health Conditions documents no for the following: Received scheduled pain medication regimen; received PRN (as needed) pain medications or was offered and declined; and received non-medication intervention for pain? Section N- Medications documents that R1 is taking an Opioid medication. Section O- Special Treatments, Procedures, and Programs documents that R1 is receiving hospice care.R1's Care Plan documents a Focus area of R1 has actual/potential for pain (date initiated [DATE]) with a Goal of R1 will report satisfactory pain control (date initiated [DATE].) Documented interventions include evaluate for non-verbal indicators of pain, evaluate pain, evaluate the effectiveness of pain interventions every shift, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impacted on functional ability and impact on cognition, monitor for factors/activities that precipitate or aggravate pain, monitor/record pain characteristics every shift and as needed, monitor/report/record complaints of pain or request pain treatment, monitor/record/report signs and symptoms of nonverbal pain: changes in breathing, vocalizations, and mood/behavior (date initiated [DATE] and revision date of [DATE].)R1's Physician's Orders documents the following orders for pain management: Fentanyl Patch 25MCG/HR every 72 hours with order date of [DATE], Dilaudid oral liquid give 2 milliliters every 2 hours with order date of [DATE], Hydrocodone 5/325mg every 12 hours as needed for breakthrough pain dated [DATE].On [DATE] at 12:34PM, V9 (Family Member) stated R1 was dying on [DATE] and the facility could not get her medication Dilaudid in all that day and R1 suffered all day because she was out of her medications. V9 stated it was so bad and other family members were there like my aunt and R1's son. V9 stated R1 was in so much pain that she kept crawling out of the bed and we were having to hold her as best we could to keep her from falling out of the bed. V9 stated it was absolutely the worst thing I have ever seen. V9 stated we kept calling hospice ourselves to see when they could bring her medications and we kept getting told that they were on their way. This went on all day long. V9 stated this was all so bad and not only hard on R1, but it was also hard on the family to watch.On [DATE] at 12:42PM, V11 (Family Member) stated she was with R1 a lot and was there on [DATE] in the afternoon. V11 stated the staff said they thought they had more Dilaudid for R1, but they didn't. V11 stated she knows the hospice nurse called a local pharmacy, we waited and waited. V11 stated R1 was thrashing all over the bed, trying to get out of bed and she was not comfortable at all, and we could not make her comfortable. V11 stated R1's nurse, V14, was trying but she stated she worked for a different company and was just filling in there for the day. V11 stated R1 was dying, and she died roughly because she did not have her medications she needed, and nobody was doing anything for a long time. V11 stated even after the medications came that evening it took a long time to get R1 settled back down to rest and then she died later.On [DATE] at 1:22PM, V10 (Family Member) stated he was there on [DATE] as R1 was in the process of dying and other family members were present as well. V10 stated it was so horrible, and I will never forget the suffering my mother had to endure because people did not do what they should and provide her with medication to relieve the pain. V10 stated we normally did not leave R1 alone because if she wouldn't ask for medications when R1 was in pain then she would not have ever gotten any pain medications. V10 stated R1 had a pain pump with Dilaudid for 5 years due to back pain. V10 stated they had been cutting down the dose because they were substituting the Dilaudid with the liquid form because R1 was no longer going to be on the pump due to hospice providing the medications. V10 stated the pump was barely delivering any medication if any so that is why R1 needed the liquid Dilauudid by mouth. V10 stated when R1 died it was the worst thing to watch, and it was so bad that he would not let R1's grandchildren come and say their goodbyes because it would have been hard for them to see, and they would not understand. V10 stated the thrashing in the bed was so bad and R1 was so miserable. V10 stated this was no way to treat a human being and let them suffer like that. V10 stated the nurse on [DATE] was V14 and she was trying her hardest to get the medication brought to the facility. V10 stated he even called local hospital emergency room to see if there was anything they could do to help R1 get some pain control. V10 stated he was told by the hospital that R1 could be sent to the emergency room, but they transferred the phone call to the hospice department, but nobody answered. V10 stated hospice came to the facility that morning and stated they were trying to figure out why the Dilaudid did not come in. V10 stated this was an experience that no resident or family should ever have to go through. V10 stated we did everything we knew to do and called hospice and even hospitals to try to get R1 some help but nothing helped. V10 stated finally in the evening the medicine came in and the nurse gave it to her. V10 stated it still took a few hours to get R1 settled down and then about midnight R1 passed away, she was just worn out from struggling all day long. V10 stated R1 should not have had to struggle like that while dying.On [DATE] at 3:40PM, V20 (Hospice Registered Nurse) stated she was R1's hospice nurse for [DATE] and [DATE]. V20 stated when she was in the facility to see R1 on [DATE] she noted that R1's Dilaudid was almost empty and would not have enough available to make it through [DATE]. V20 stated she talked with the nurse and was told by the facility nurse if she got the orders to the facility's pharmacy by 3:00PM that the pharmacy would deliver the medication that evening. V20 stated I sent the orders to the facility's pharmacy before noon and instructed the nurse that if the medication did not get delivered that evening to notify hospice immediately so they could get the medication from another pharmacy and get it to the facility in time for there to be no breaks in the medication's availability for the resident. V20 stated she never received a call, so she assumed the medication had arrived as planned. V20 stated she was not made aware the medication did not get delivered until the medication was depleted. V20 stated she went to the facility as soon as she was notified and checked on R1 and at that time R1 was resting and had no signs of pain, but this was right after the 10:00AM dose of Dilaudid was given. V20 stated she instructed V14 to give R1 a dose of her Hydrocodone around 11:00AM to help with pain until she could get the medication (Dilaudid) in the facility. V20 stated it took a while to get the medications back in the facility and felt so bad for R1 and the family. V20 stated without R1 getting the Dilaudid it caused R1 to be in pain and uncomfortable. V20 stated she also told V14 to increase the Fentanyl Patch to 25mcg/hr (micrograms/hour) but was unsure if they had the 25mcg/hour in their emergency drug kit. V20 stated the family had called her that morning and was asking for an increase in R1's anxiety medications so she got the Ativan increased. V20 stated the family was also calling about the Dilaudid not being available. V20 stated it took a while to find a pharmacy open then I had to get a signed script from the doctor then I headed out of town to get the medication. V20 stated when I finally got to that pharmacy, the pharmacist was on lunch, so I had to wait for them to get back. V20 said once I finally got the meds I headed back to the facility, and we initiated a dose of the Dilaudid as soon as I got the medication checked in. V20 stated it must have been a little after 3:00PM or so when I got the medication back to the facility. V20 stated the family was very upset and rightly so and V20 stated she apologized several times to the family, and she felt bad that this had happened. V20 stated she knew R1 had to be in pain and feeling discomfort without her pain medications. V20 stated R1 then started relaxing about 5:30ish and another dose was given at 6:00PM. V20 stated she knew R1 had a Dilaudid pump but the medication in the pump was being tapered down and was to be discontinued on [DATE]. V20 stated R1 passed away a little after midnight.On [DATE] at 6:20 PM, V23 (LPN) stated she worked on [DATE] on day shift. V23 stated that V20 came in on [DATE] between 12:45PM and 1:00PM and they checked R1's Dilaudid and there was 12-14mL remaining. V23 said that R1 was mottled and anxious so V20 increased R1's Dilaudid to 2mL every 2 hours. V23 said that V20 thought R1 would expire before her Dilaudid ran out but ordered more to be safe. V23 said she called the pharmacy and they stated as long as they had the script for the Dilaudid by 3:00PM, it would be delivered with that days shipment. V23 sometimes their medication deliveries do not arrive until midnight or 1:00 am. V23 said during shift report, she told the night shift nurse to notify hospice if R1's Dilaudid was not delivered. V23 said she could not recall the nurse's name that she reported it to but is was a nurse from the staffing agency.On [DATE] at 7:08PM, V24 (Agency Licensed Practical Nurse) said that she worked the night shift on [DATE]. V24 stated that she does not recall being told in report to notify hospice if R1's Dilaudid was not delivered. V24 said that if she would have known that, she would have notified hospice because pain medication is important for hospice patients.On [DATE] at 1:37PM, V14 (Licensed Practical Nurse/LPN) stated she was the nurse in charge of R1 on [DATE]. V14 stated that she gave R1 what was left of her Dilaudid for 10:00AM on [DATE] and sated it was probably not a full dose at all. V14 stated R1's Dilaudid 2 milliliters (ml) was ordered every 2 hours routinely. V14 stated she searched for another bottle of Dilaudid but there was none. V14 stated she was in contact with hospice requesting Dilaudid be delivered to the facility. V14 said hospice had told her they would see why R1 was out of Dilaudid and get her some to the facility. V14 stated the hospice nurse came to the facility and saw R1 and then started working on finding a pharmacy available to fill the prescription of Dilaudid. V14 stated V20 (Hospice Registered Nurse) stated she would have to run to an out-of-town pharmacy to get the medication due to the Pharmacy in town being closed. V14 stated this was right around 10:00AM on [DATE]. V14 stated she kept waiting on V20 to bring the medication, but it was taking a long time. V14 stated while they were waiting, she felt so bad for R1 because she was throwing her legs out of the bed and trying to get out of bed. V14 stated the family was at bedside and were really upset at the lack of pain control for their loved one. V14 stated she works through an agency so she is not in the facility too often but was unsure how the resident's medications could just run out without being refilled in a timely manner. V14 stated she spoke to a nurse manager at one point for direction, but she wasn't sure who it was and no solution to the problem was given. V14 stated she even gave R1 a pain pill (Hydrocodone-Acetaminophen 5/325 milligrams) that was ordered every 12 hours but that did not offer hardly any pain relief and only settled R1 for a very short time. V14 stated she felt so bad for R1 as she was so uncomfortable and agitated due to pain. V14 stated she really thought about just calling an ambulance to send R1 out to the nearest emergency room for some pain relief but R1 was in such pain. V14 felt it would make R1's pain even worse and R1 would not tolerate the move very well, so V14 stated she just kept waiting and hoping the medication would be delivered soon. V14 said that finally 6 hours later, V20 walked through the door, and it was around 4:00PM and V14 stated, I grabbed the medicine and ran to (R1's) room and administered her dose of Dilaudid. V14 stated it still took an hour and a half to two hours to get R1 settled down and rest a little bit. V14 stated she kept thinking that if this would have been one of her loved ones that she would have been having a fit and this was hard on the family as well. V14 stated R1 was receiving Ativan as ordered every 2 hours but was not making a difference with the agitation and pain.On [DATE] at 2:03PM, V16 (Licensed Practical Nurse/LPN) stated she was working on [DATE]. V16 stated V14 came to her and asked what she should do with R1 being out of medications and did not have another dose to give. V16 stated this was right after the last dose was given around 10:00 AM. V16 stated she went to V14's hall and looked at the narcotic book to check on the Dilaudid and she asked her if hospice ordered the medication, and if she had checked out allergies to see if R1 could get Morphine, but R1 had Morphine as an allergy. V16 stated we were at a standstill. V16 stated this was after the 10AM dose so R1 was resting and curled up on her side. V16 stated V20 (Hospice Registered Nurse) came in and checked R1 and started messaging the hospice physician and trying to find a pharmacy that was open. V20 reported that she had to go to an out-of-town pharmacy to get medication. V16 stated it took V20 a little while to find a pharmacy that was open. V16 stated they went ahead and gave R1 a Hydrocodone to help with her pain. V16 stated the facility's pharmacy does not make deliveries on Sundays. V16 stated there was an order put in at some point that day for an increase in Fentanyl 25mcg, so they checked the e kit and there was a Fentanyl patch, so they put it on R1 but was not sure of the time frame. V16 stated hospice usually does a narcotic check on their patients when they are in the facility but was unsure how this one got missed. On [DATE] at 2:19 PM, V18 (Certified Nurse Assistant/CNA) stated she was working on [DATE] and helped care for R1. V18 stated R1 was hurting, tired and not doing her best. V18 stated R1's family was at her bedside. V18 stated when she went in the family was complaining that R1 was in pain. V18 stated the family stated they thought R1 was nauseated too. V18 stated the family told her they had asked for pain medication but could not get it but she didn't know why. V18 stated R1 was grimacing and restless at different times throughout the day on [DATE].On [DATE] at 3:22PM, V19 (CNA) stated she took care of R1 on [DATE] and R1 was not doing great, and she would not eat anything. V19 stated she went in and checked R1 every 2 hours. V19 stated she knows R1 just kept scooting herself around the bed and R1 seemed weak and in pain. V19 stated the family kept asking for pain medications for R1. R1's Hospice Visit Note dated [DATE] authored by V20 documents .Dilaudid ordered from (name of pharmacy). Requested that saff call hospice if it is not delivered so other arrangements could be made to refill Rx (prescription)R1's Hospice Discharge-Transfer Summary Report dated [DATE] documents that R1's date and of death as [DATE] at 1:45 AM. This same report documents that R1 had an intrathecal pump (surgically implanted device delivering medications to the spinal fluid) delivering Dilaudid 0.25 mg daily, in addition to the Dilaudid 1mg/mL oral liquid dose of 2mL every 2 hours. The last decrease adjustment to the intrathecal pump is documented as being completed on [DATE] at (name of clinic) and was due for another adjustment [DATE]. R1's Progress Notes dated [DATE] document the following:9:15AM- documents Dilaudid Oral Liquid 1 mg/ml: give 2 ml by mouth every 2 hours for Pain/Shortness of Breath. Last dose in bottle administered, hospice notified. Authored by V14. 9:20 AM- Hospice notified of medication needing refilled, family also requesting Ativan increased from every 4 hours to every to every 2 hours, relayed message to hospice, awaiting response. 11:56 AM- Give 2 ml by mouth every 2 hours for pain/shortness of breath, out of medication, hospice notified and is obtaining medicine from pharmacy.1:34PM- hospice on way with medication. 3:20PM- New order received from hospice to change fentanyl patches to 25mcg/hr. Will have to pull patches from emergency kit and call for code before pulling from kit until arrival from pharmacy. Remove both patches AM of [DATE] and apply 25mcg/hr patch from emergency kit. Continue order of Ativan and Dilaudid every 2 hours. If resident is still not comfortable at 9:00PM this afternoon [DATE] then call hospice again for increase in dosage of Dilaudid. 5:38PM- Fentanyl Patch 72 hours for pain Rotate site and remove per schedule patch already in place, to be removed in AM [DATE] per hospice and apply 25mcg/hr patch from emergency kit. Authored by V14. R1's Progress Note dated [DATE] at 12:30AM documents Res has no breath or heart sounds detected, verified with another nurse. Hospice notified and will be coming into facility. Resident has family member present at bedside. Extended family have elected not to come in to visit resident before the funeral home arrives. (V13 Primary Physician) has been informed by this writer of resident status. (V2 Director of Nursing/DON) notified. CNA to complete postmortem care on residents. No further issues at this time. Authored be V22 (Licensed Practical Nurse/LPN.) R1's Narcotic count sheet for Dilaudid 1mg/ 1ml solutions documents on [DATE], R1 received Dilaudid 2 milliliters as ordered at 8:00AM and 10:00AM and documents that 10:00AM was the last dose with V14's initials.R1's Medication Administration Record (MAR) dated [DATE]-[DATE] documents on [DATE] at 10:00 AM R1 was administered Dilaudid 2mL as ordered with a pain level of 0 and V14's initials. R1's 12:00 PM and 2:00 PM dose on [DATE] documents an administration code of 9 and document a X for R1's pain level and V14's initials. The Chart Codes on the MAR documents that a 9 indicates Other/ See Progress Notes Ineffective. The 4:00 PM dose on [DATE] of Dilaudid is documented as being administered by V14 and documents a pain level of 0.On [DATE] at 2:00PM, V3 Assistant Director of Nursing (ADON) was asked if she was made aware of the situation on [DATE] and V3 stated she was not made aware of the situation of the Dilaudid on [DATE]. V3 was asked if the nurse could have sent the resident to the emergency room to get some pain control and V3 stated (R1) was hospice and if she had gotten sent out, (R1) would have lost her services from hospice. V3 stated we generally do not send hospice patients to the hospital because they are under the care of hospice. V3 stated she was not on call that weekend so she will have to look into this issue. V3 said pain assessments are documented on the MAR and are done every shift or three times a day.On [DATE] at 9:30AM, V13 (R1's primary physician/medical director) was asked if he was notified on [DATE] of R1 being out of her Dilaudid medication and having increased pain. V13 checked his phone and his computer and stated, no, I was not notified and was not aware of that occurrence at all. V13 stated the notification I do have is that R1 expired on [DATE]. The facility policy titled Pain Assessment and Management dated [DATE] documents the purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. Recognizing Pain 2. Possible Behavioral Signs of Pain, include negative verbalizations and vocalizations such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, set., behaviors such as resisting care, distressed pacing, irritability, depressed mood, participation in usual physical and/or social activities, guarding, rubbing or favoring a particular body part. 5. Review the medication administration record to determine how often the individual request and receives PRN (as needed) pain medication, and to what extent he administered medications relieve the resident's pain.A Pharmaceutical Service Agreement dated [DATE], documents under section Pharmacy Supplies and Services C. Pharmacy agrees to deliver to Facility once daily, six days a week, Monday through Saturday, and any emergency deliveries 24 hours a day seven days per week; except for circumstances and conditions beyond its control, which shall expressly include, but not limited to, out-of-stock situations, to which Facility will notify. 2. R2's admission Record documents an admission date of [DATE] and includes diagnoses of Multiple Sclerosis, Local Infections of the skin and subcutaneous tissue, Type 2 Diabetes Mellitus, Paralytic Syndrome following Cerebrovascular Disease, Convulsions, Major Depressive Disorder, and Dysphagia.R2's MDS dated [DATE] documents a BIMS score of 12 indicating R2 has moderate cognitive impairment. Section J- Medical Conditions documents that R2 receives a scheduled pain medication regimen. Section N- Medications documents that R2 receives an opioid medication.R2's Care Plan documents R2 has potential for pain and discomfort and pain to bilateral feet/toes related to contractures dated [DATE]. Documented interventions include administering medications as ordered dated [DATE], anticipating the resident's need for pain relief and responding immediately to any complaint of pain, monitor/record/report to nurse any signs or symptoms of nonverbal pain, monitor record and report to nurse resident complaints of pain, turn and reposition every 2 hours to help alleviate pain dated [DATE].On [DATE] at 9:58AM, R2 was observed sitting in bed. R2 stated he is on Hospice care. R2 was asked if he has pain and R2 stated yes. R2 stated they will give me a pain pill when I ask for it, and sometimes I forget to ask then my pain gets really bad. R2 was asked if the staff usually ask him if he is in pain and R2 stated no, I don't remember them asking me and I have to ask them.On [DATE] at 10:05AM, V8 (Registered Nurse/treatment nurse) came into R2's room and stated she would be changing out R2's dressing during his bath. R2 was complaining of pain during care.On [DATE] at 12:29PM, V4 (Hospice Certified Nursing Assistant) stated she always asks R2 about his pain and he always states that he is in pain, and he said she is the only one that ever asks him about his pain. R2's MAR dated [DATE]-[DATE] documents R2 receives Norco Oral Tablet 10/325mg, give 1 tablet by mouth three times a day for pain. Scheduled times of medication are 6:00AM, 2:00PM, and 10:00PM. Pain level for these doses for [DATE]st through [DATE]th show 0 for pain level throughout the entire days documented. R2 has an order for Dilaudid Oral Liquid 1mg/ml, give 2 ml by mouth every 3 hours as needed for moderate to severe pain, dyspnea dated [DATE]. R2's MAR documents no dosages were administered for the dates of [DATE]-[DATE].3. R3's admission Record documents R3 was admitted to the facility on [DATE] and was admitted to hospice care on [DATE] with diagnoses of Parkinson's Disease, Dementia Severe, Palliative Care, Heart Failure, Major Depressive Disorder, Anxiety Disorder, and Adult Failure to Thrive.R3's MDS dated [DATE] documents a BIMS score of 3 indicating R4 has severe cognitive impairment. Section J-Health Conditions documents that R3 receives PRN (as needed pain medication or was offered and declined. Section N- Medications documents that R3 is taking opioid medications. R3s undated Care Plan documents R3 has the potential for pain and discomfort related to Parkinson's Disease and Diabetes with interventions of: Monitor/record/ pain characteristics every shift and as needed; monitor/report/record to nurse residents' complaints of pain or request for pain treatment; notify the physician of interventions are unsuccessful or if current complaints is significant change from residents past experience from pain; nursing to administer medications as ordered; observe/record/report to nurse any signs or symptoms of non-verbal pain changes in breathing, vocalization, facial expression (sad, crying, worried, scared, clinching teeth and grimacing).R3's MAR dated [DATE] to [DATE] documents an order for Hydromophone HCL 1mg/ml every 4 hours as needed with no doses recorded for the month of [DATE]. R3's MAR also has order for Oxycodone HCL 10mg four times a day for pain every 6 hours with start date of [DATE]. R3's MAR dated [DATE]-[DATE] documents Pain assessments every shift for days, evenings, and night shift with documentation of pain scale at 0 for all three shifts from [DATE]-[DATE] dayshift.On [DATE] at 12:29 PM, V4 stated R3 has complaints of pain at times with her and she always has to go tell the nurses.On [DATE] at 11:37AM, R3 was sitting in a geri chair outside of his room. R3 was observed with flinching in his legs and was grimacing and gritting his teeth. R3 was noted to be trying to adjust both feet. R3 was unable to answer any questions at this time. The Immediate Jeopardy that began on 38/26 was removed on [DATE] when the facility took the following actions to remove the immediacy.At 12:00 pm on [DATE], V2(Director of Nursing/DON, V3 (Assistant Director of Nursing/ADON), and floor nurses immediately began assessing residents for pain using standardized scale. Residents with pain received immediate intervention. Physicians notified and new orders obtained as needed.V2, DON began to re-educate the licensed staff on [DATE]. Education included medication inventory and physician notification. V2, DON educated licensed staff that they are to notify Physician if any medication is not available. Nurses are to notify V2, DON immediately if mediation is not available or if there will be a delay in receiving ordered and reordered medications immediately upon discovery of medication shortage. All notifications and order changes are to be documented in real time.V2, DON and V3,ADON will complete medication audits on Monday and Thursday to ensure residents always have an adequate amount of pain medications available. If less than four days of medications are noted, then an order/reorder will be submitted to the physician, this audit to include hospice residents.Licensed staff that were unable to attend were education via phone per V2, DON and V3, ADON as a witness. On [DATE] a message was sent out to all licensed staff via Mediprocity with the education.V2, DON/designee initiated real-time audits.On [DATE] V2, DON and V3, ADON completed a 100% house wide audit completed with pharmacy dispensed medication orders for pain management. Inventory checked and reorders processed and delivered. Orders clarified/updated, if needed. Care plans revised, if needed.V2, DON/Designee will complete biweekly audits x 4 weeks.V1, Administrator and V2,DON will submit plan to QA (Quality Assurance) for monthly review.QAPI (Quality Assurance and Performance Improvement) committee will review and offer recommendations, if needed, until compliance is met. This committee is made up of Administrator, DON, ADON, MDS, Maintenance, Social Services, Therapy, Admin Assistant, Housekeeping Supervisor, Dietary Manager, Activity Director, and Business Office Manager.

Based on observation, interventions, and record reviews, the facility failed to provide appropriate incontinence care and oral care to 3 (R1, R2, R3) of 4 residents reviewed for Activities of Daily Living (ADL's) in a sample of 4. Findings include:.1. R2's admission Record documents an admission date of 2/26/2022 and includes diagnoses of Multiple Sclerosis, local Infections of the skin and subcutaneous tissue, Type 2 Diabetes Mellitus, Paralytic Syndrome following Cerebrovascular Disease, Convulsions, Major Depressive Disorder, and Dysphagia. R2s Physician Order sheet documents R2 was placed on hospice on 2/27/26.R2's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 12 suggesting moderate cognition impairment. Section GG documents R2 is dependent for all activities of daily living including oral care. Section H- Bladder and Bowel documents R2 has an ileostomy, and is always incontinent of bowel, and urinary continence is not rated. R2's Care Plan documents R2 has an ADL self-care performance deficit related to limited mobility, limited range of motion, and Multiple Sclerosis date initiated 12/22/2022.On 3/17/2026 at 10:05AM, V4 (Certified Nurse Assistant/CNA with Hospice) was observed in R2's room preparing supplies for a bed bath. V4 proceeded to remove the depends and R2 was noted to have a medium size bowel movement with noted dried bowel movement on R2's buttocks. V4 stated, This is really dried on there and it will take a bit to get this off. V4 used warm soap and water to get the dried bowel movement off R2. V4 asked R2 if he was checked all night or early this morning and R2 stated, no I do not believe so. Observation of bed bath and personal care did not include oral care for R2. On 3/18/2026 at 12:29PM, V4 was asked if she had ever seen dried bowel movements on residents on hospice patients that she cares for at this facility. V4 stated, all the time. V4 stated, I always find dried poop on R2, every time I come in to give R2 a bed bath, it never fails and his stools are normally formed. On 3/18/2025 at 1:00PM, R2 was asked if he has dried poop left on him very often. R2 stated, I believe so, at least that is what they tell me anyway. Sometimes I have to wait awhile to be changed, and it just dries. R2 stated he does not get oral care very often and he is not able to do it himself.2. R1's admission Record documents an admission date of 10/16/2025 and an admission date to hospice care on 2/27/2026 with diagnoses of Multiple Myeloma and Pulmonary Embolism. Other documented diagnoses include Asthma, Spinal Stenosis, Chronic Pain, Gastro-Esophageal Reflux Disease, Hyperlipidemia, Hypertension, Osteoporosis with pathological fractures, Acute Respiratory Failure, and Fibromyalgia. R1's admission Record documents a date of discharge of 3/9/26.R1's Minimum Data Set (MDS) dated (2/27/2026) documents a Brief Interview for Mental Status (BIMS) score of 7, indicating R1 has moderate cognitive impairment. Section GG- Functional Abilities documents R1 required partial to moderate assistance with transfers and substantial/maximal assistance with position changes from sitting to lying and lying to sitting. Section H -Bladder and Bowel documents R1 is always incontinent of bowel and occasionally incontinent of urine. R1's Care plan documents R1 has actual/potential for ADL functional decline, diagnosis of multiple myeloma, asthma and respiratory failure.On 3/17/2026 at 12:34PM, V9 (Family member) stated while visiting R1on 3/8/26 it was noted that R1 had had a bowel movement and it was pasted to her bottom. On 3/19/2026 at 1:54PM, V17 (CNA) stated she worked on 3/8/2026 and helped take care of R1. V17 stated we figured she was dying. V17 stated we tried to go in and turn her and when I seen her she was resting. On 3/18/2026 at 12:29PM, V4 (CNA with Hospice) V4 was asked if she had ever seen dried bowel movement on R1 and V4 stated, I sure have and that was sort of a normal thing. V4 stated R1 was usually complaining of pain off and on during her care and V4 stated she would report the pain to the charge nurse. V4 stated she is in the facility on Tuesdays and Thursdays to provide personal care to her hospice patients. V4 stated, it is heartbreaking to see the patients in the condition that I find them in some days. 3. R3's admission record documents R3 was admitted to the facility on [DATE] and was admitted to hospice care on 7/26/2025. R3's admission record documents diagnoses of Parkinson's Disease, Dementia Severe, Palliative Care, Heart Failure, Major Depressive Disorder, Anxiety Disorder, and Adult Failure to Thrive. R3's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 3 indicating R4 has severe cognition impairment. Section GG-functional abilities documents R3 is dependent on staff for Activities of Daily Living including transfers and oral care. Section H-Bladder and Bowel documents R3 is always incontinent of urinary continence and R3 is always incontinent of bowels. R3 MDS documents R3 is not on a bowel program. R3's care plan documents R3 has an ADL self-care performance deficit related to confusion, dementia, impaired balance and Parkinson's. R3 is totally dependent on 1 staff for personal hygiene and oral care. R3 is not toileted. On 3/17/2026 at 11:37AM, R3 was sitting in a geri chair outside of his room. R3 was unable to answer questions at that time. R3 had poor oral hygiene noted. Teeth were covered in whitish yellow fuzzy like substance all over teeth. R3 was observed with flinching in his legs and was grimacing and gritting his teeth. R3 had just received personal care which did not include oral care.On 3/18/2026 at 12:29PM. V4 (CNA with Hospice) stated she has found dried poop on R3 several times. V4 stated R3 is usually soaked in urine too. On 3/19/2026 at 2:19, V18 (CNA) was asked if she has ever found dried bowel movement on any of the residents and V18 stated yes but not too often but it does happen from time to time. V18 stated oral care should be part of AM care for the residents. On 3/19/2026 at 1:30PM, V15 (CNA) was asked if he has ever came in and found residents with dried bowel movements on the residents, V15 stated yes I have come in and found that on different residents. V15 was asked if he felt that was because of staffing, V15 stated no it is because some do not have compassion for the residents and do not need to work in this field. Policy named Perineal Care dated February 2018 documents the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin.

Based on observation, interview, and record review the facility failed to ensure authorized licensed personnel administered medications and failed to ensure accurate documentation of the personnel administering the medications. This failure has the potential to affect all 91 residents residing in the facility.Findings include: On 1/16/26 at 11:16 AM, V1 (Administrator) presented surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of her pocket, opening the medication cart, popping medications into medication cups, taking the medication cups to resident rooms for administration, and opening the medication room door without a nurse present. V5 is observed to be documenting medications administered on a facility laptop computer. V1 said V5 did not have a log in for the Electronic Medical Record (EMR) and was unsure how V5 was documenting the medications.On 1/16/26 at 12:24 PM, V1 presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM showing V5 taking a cup of medications to R1's room, 9:11 PM V5 taking a cup of medications to R2's room, 9:46 PM V5 taking a cup of medication to R3's room. V1 said V5 was supposed to be working with another nurse and should not have been administering medications to residents.1.R1's Administration Record documented an admission date of 8/18/25 with anemia, atrial flutter, and hypertension. R1's 1/9/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact.R1's January 2026 Medication Administration Record (MAR) documented on 1/15/26 at 2000 (8:00 PM) V7 (Licensed Practical Nurse/ LPN) had administered Atorvastatin 40 mg, Melatonin 2 mg, Tamsulosin 0.4 mg, Iron Sulfate 325 mg, Metformin 250 mg, and Protonix 20 mg. On 1/16/26 at 9:45 AM, R1 said V5 brought him his medications the evening of 1/15/26 and R1 did not see another nurse with V5. R1 said he did not know V5's name but it was the dark-haired girl that had previously been a CNA in the facility. R1 said V5 had finished her courses and now she in a nurse. R1 said V5 was now working independently.2. R3's admission Record documented an admission date of 8/14/24 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, and fibromyalgia. R3's 12/13/25 MDS documented a BIMS score of 15, indicating R3 was cognitively intact.R3's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7 had administered Hydrocodone/ Acetaminophen 3/325 mg 2 tablets, Olanzapine 2.5 mg, Rosuvastatin 40 mg, Docusate sodium 100 mg, Lactulose 10 mg/ 15 ml 15 ml, Lamictal 100 mg, Oxcarbazepine 150 mg, Potassium 20 meq, and Reglan 5 mg.On 1/16/26 at 9:25 AM, R3 said she believed V5 had brought her medications to her on the night of 1/15/26. R3 said V5 had been working with another nurse previously but hadn't been lately. R3 said she did not see another nurse with V5, the only other people she saw were the CNAs when V5 brought R3 her medications.3. R4's Administration Record documented an admission date of 8/18/25 with diagnoses including type 2 diabetes, hyperlipidemia, and spinal stenosis. R4's 11/25/25 MDS documented a BIMS score of 15, indicating R4 was cognitively intact.R4's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7 had administered Simvastatin 20 mg, Depakote 250 mg, Depakote 500 mg, Docusate sodium 100 mg, Acetaminophen 650 mg, and Gabapentin 400 mg.On 1/16/26 at 9:31 AM, R4 said the new girl (V5) gave me my medications last night. R4 said he did not see V5 working with another nurse on 1/15/26.4. R2's admission Record documented an admission date of 6/3/21 with diagnoses including osteomyelitis, vasculitis, and chronic pain syndrome.R2's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7 had administered Trazodone 50 mg, Cephalexin 500 mg, Memantine 5 mg, Sennosides-Socusate sodium 8.6- 50 mg, MS Contin 15 mg, and Pregabalin 200 mg.On 1/16/26 at 10:49 AM, V5 said she did not work independently on 1/15/26 and V7 had been present while V5 was administering medications to residents. V5 said she did hold the keys to the medication cart and medication room. V5 said she and V7 set up the resident medication cups at the medication cart in front of the nurse's station and V5 took the medications to the residents. V5 said V7 did not accompany V5 to the resident rooms. V5 was asked if she completed any of the charting in resident's EMRs and V5 said she did not because she did not have a log in for the EMR.On 1/20/26 at 10:19 AM, V7 said she had given V5 her EMR log in and V5 had taken the computer. V7 said she was not present while V5 was administering medications to residents. V7 said it was not typical for V7 to give her EMR log in to other employees to document under her name, but V7 trusted V5. V7 said if it had been another person other than V5 V7 probably wouldn't have given them her log in information.On 1/16/26 at 11:55 AM, V2 (Director of Nursing/ DON) said she expected another nurse to be present when V5 was administering medications to residents and V2 had told V5 she could not administer medications to residents. V2 confirmed that V5 was not a licensed nurse. V2 said she would not expect a nurse to give their EMR log in to another employee to document in resident's EMRs. V2 said the nurse administering the medications should be the person documenting it in the resident's EMR. The facility's revised May 27, 2025 Administering Medications policy documented in part . 1. Only persons licensed or permitted be this state to prepare, administer, and document the administration of medications may do so. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.The facility's revised November 2022 Documentation of Medication Administration policy documented in part . 1. A nurse or certified aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). 3. Documentation of medication administration includes, as a minimum: g. initials, signature and title of the person administering the medications.The facility's 10/25/25 Job Description and Duties for the Job Title: Charge Nurse (LPN or RN) documented in part . The LPN and RN provide and oversees nursing care on their assigned unit/ hall. The LPN an RN ensure care is delivered according to resident care plans, administers medications and treatments, and monitors residents for changes in condition. The LPN and RN ensure compliance with the Department of Public Health and CMS regulations, maintains accurate documentation, and supports a safe, compassionate, and resident-centered environment. Key Responsibilities: 3. Accurately administer and document medications and treatments in compliance with facility policy, CMS and state regulations. 8. Maintain clear and timey documentation in the electronic medical record (EMR) per facility and regulatory standards. 18. Initials medication/ treatment administration records accordingly.The facility's 1/16/26 Daily Census documented 91 residents residing in the facility.

Based on observation, interview, and record review the facility failed to only permit authorized individuals access to drugs, biologicals, and controlled Schedule II drugs. This failure has the potential to affect all 91 residents residing in the facility. Findings include:On 1/16/26 at 11:16 AM, V1 (Administrator) presented surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of her pocket, opening the medication cart, popping medications into medication cups, taking the medication cups to resident rooms for administration, opening the schedule II controlled medication box, popping schedule II medications into medication cups, signing out schedule II medications in the schedule II count binder, and opening the medication room door without a nurse present.On 1/16/26 at 12:24 PM, V1 presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM showing V5 taking a cup of medications to R1's room, 9:11 PM V5 taking a cup of medications to R2's room, 9:46 PM V5 taking a cup of medication to R3's room. V1 said V5 was supposed to be working with another nurse and should not have been administering medications to residents.R1's Administration Record documented an admission date of 8/18/25 with anemia, atrial flutter, and hypertension. R1's 1/9/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact.1. R1's January 2026 Medication Administration Record (MAR) documented on 1/15/26 at 2000 (8:00 PM) V7 (Licensed Practical Nurse/ LPN) had administered Atorvastatin 40 mg, Melatonin 2 mg, Tamsulosin 0.4 mg, Iron Sulfate 325 mg, Metformin 250 mg, and Protonix 20 mg. On 1/16/26 at 9:45 AM, R1 said V5 brought him his medications the evening of 1/15/26 and R1 did not see another nurse with V5. R1 said he did not know V5's name but it was the dark-haired girl that had previously been a CNA in the facility. R1 said V5 had finished her courses and now she in a nurse. R1 said V5 was now working independently.R3's admission Record documented an admission date of 8/14/24 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, and fibromyalgia.R3's 12/13/25 MDS documented a BIMS score of 15, indicating R3 was cognitively intact.R3's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7 had administered Hydrocodone/ Acetaminophen 5/325 mg 2 tablets, Olanzapine 2.5 mg, Rosuvastatin 40 mg, Docusate sodium 100 mg, Lactulose 10 mg/ 15 ml 15 ml, Lamictal 100 mg, Oxcarbazepine 150 mg, Potassium 20 meq, and Reglan 5 mg.R3's hydrocodone/ Acetaminophen 5/325 mg tablet Controlled Drug Record documented on 1/15/26 at 2005 (8:05 PM ) 2 tablets was removed from the count with V5 and V7's signature.On 1/16/26 at 9:25 AM, R3 said she believed V5 had brought her medications to her on the night of 1/15/26. R3 said V5 had been working with another nurse previously but hadn't been lately. R3 said she did not see another nurse with V5, the only other people she saw were the CNAs when V5 brought R3 her medications.3. R4's Administration Record documented an admission date of 8/18/25 with diagnoses including type 2 diabetes, hyperlipidemia, and spinal stenosis. R4's 11/25/25 MDS documented a BIMS score of 15, indicating R4 was cognitively intact.R4's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7 had administered Simvastatin 20 mg, Depakote 250 mg, Depakote 500 mg, Docusate sodium 100 mg, Acetaminophen 650 mg, and Gabapentin 400 mg.On 1/16/26 at 9:31 AM, R4 said the new girl (V5) gave me my medications last night. R4 said he did not see V5 working with another nurse on 1/15/26.4. R2's admission Record documented an admission date of 6/3/21 with diagnoses including osteomyelitis, vasculitis, and chronic pain syndrome.R2's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7 had administered Trazodone 50 mg, Cephalexin 500 mg, Memantine 5 mg, Sennosides-Socusate sodium 8.6- 50 mg, MS Contin 15 mg, and Pregabalin 200 mg.R2's Pregabalin 200 mg capsule Controlled Drug Record documented on 1/15/26 at 1920 (7:20 PM ) 1 capsule was removed from the count with V5 and V7's signature.On 1/16/26 at 10:49 AM, V5 (Certified Nursing Assistant/ CNA) said she did hold the keys to the medication cart and the medication room on 1/15/26. V5 said while administering medications to residents on 1/15/26 V7 (Licensed Practical Nurse/ LPN) had been present. V5 said she and V7 had both signed the schedule II medications out in the schedule II count binder.On 1/20/26 at 10:19 AM, V7 said she had not been present when V5 was administering medications to residents on 1/15/26. V7 said she signed the schedule II medication count binder at the end of the shift when V7 and V5 counted the schedule II medications, but had not been present when V5 was administering schedule II medications to residents on 1/15/26. On 1/16/26 at 11:55 AM, V2 (Director of Nursing/ DON) said she expected the medication cart and medication room keys were only to be accessible to licensed nurses and V5 was not a licensed nurse. V2 said unlicensed individuals should not have access to any medications or schedule II-controlled medications.The facility's revised November 2022 Controlled Substances policy documented in part . The facility complies with all laws, regulations, and other requirements to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) .Handling Controlled Substances. 1. Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substance maintained on premises. Storing Controlled Substances. 2. All keys to controlled substance containers are on a single key ring that is different from any other keys. 3. The charge nurse on duty maintains the keys to controlled substance containers.The facility's 10/25/25 Job Description and Duties for the Job Title: Charge Nurse (LPN or RN) documented in part . The LPN and RN provide and oversees nursing care on their assigned unit/ hall. The LPN an RN ensure care is delivered according to resident care plans, administers medications and treatments, and monitors residents for changes in condition. The LPN and RN ensure compliance with the Department of Public Health and CMS regulations, maintains accurate documentation, and supports a safe, compassionate, and resident-centered environment. Key Responsibilities: 20. Ensures all medications and treatments are stored safely and appropriately.The facility's 1/16/26 Daily Census documented 91 residents residing in the facility.

Based on observation, interview, and record review the facility failed to ensure employees working as a licensed staff member had an active professional license. This failure has the potential to affect all 91 residents residing in the facility.Findings include:On 1/16/26 at 11:16 AM, V1 (Administrator) presented surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of her pocket, opening the medication cart, popping medications into medication cups, taking the medication cups to resident rooms for administration, opening the schedule II controlled medication box, popping schedule II medications into medication cups, signing out schedule II medications in the schedule II count binder, and opening the medication room door without a nurse present.On 1/16/26 at 12:24 PM, V1 presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM showing V5 taking a cup of medications to R1's room, 9:11 PM V5 taking a cup of medications to R2's room, 9:46 PM V5 taking a cup of medications to R3's room. V1 said V5 was supposed to be working with another nurse and should not have been administering medications to residents.On 1/16/26 at 9:45 AM, R1 said V5 brought him his medications the evening of 1/15/26 and R1 did not see another nurse with V5. R1 said he did not know V5's name but it was the dark-haired girl that had previously been a CNA in the facility. R1 said V5 had finished her courses and now she in a nurse. R1 said V5 was now working independently. R1's 1/9/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact.On 1/16/26 at 9:25 AM, R3 said she believed V5 had brought her medications to her on the night of 1/15/26. R3 said V5 had been working with another nurse previously but hadn't been lately. R3 said she did not see another nurse with V5, the only other people she saw were the CNAs when V5 brought R3 her medications. R3's 12/13/25 MDS documented a BIMS score of 15, indicating R3 was cognitively intact.On 1/16/26 at 9:31 AM, R4 said the new girl (V5) gave me my medications last night. R4 said he did not see V5 working with another nurse on 1/15/26. R4's 11/25/25 MDS documented a BIMS score of 15, indicating R4 was cognitively intact.On 1/16/26 at 10:49 AM, V5 (CNA) said she finished the LPN (Licensed Practical Nurse) program on 12/15/25 and was scheduled to sit for boards on 1/23/26. V5 said she was working as LPN License Pending in the facility. V5 said she was not supposed to be working independently and was supposed to be shadowing another nurse.On 1/20/26 at 10:19 AM, V7 (LPN) said she had not been present on 1/15/26 when V5 was administering resident medications. V7 said V5 had been working independently as a licensed nurse in the facility for about a week prior to this survey. V7 said she had been told V5 was working on a provisional license and could work as a licensed nurse independently. On 1/16/26 at 11:55 AM, V2 (Director of Nursing/ DON) said V5 was working in the facility as a Licensed Practical Nurse License Pending. V2 said License Pending means you don't have your license yet but can work under another nurse. V2 stated you would think you would have to sit for boards (National Council Licensure Examination/ NCLEX) before working license pending. V2 stated I know (V5) was scheduled to sit for boards but I'm not sure if (V5) has yet or not. V2 said V5 had not presented anything to V5 indicating V5 had passed the NCLEX. V2 said V5 was supposed to be being supervised by V7 on 1/15/26.The facility's licensed nurse schedule from 1/1/26 through 1/15/26 documented on 1/15/26 V5 was assigned a portion of the facility's resident population, and no specific licensed nurse was assigned to oversee V5.The 2024 Illinois Nurse Practice Act documents in part .2024 Illinois Compiled StatutesChapter 225 - PROFESSIONS, OCCUPATIONS, AND BUSINESS OPERATIONS225 ILCS 65/ - Nurse Practice Act.Article 55 - Nursing Licensure-Licensed Practical Nurses. Sec. 55-10. LPN licensure by examination. (d) A licensed practical nurse applicant who passes the Department-approved licensure examination and has applied to the Department for licensure may obtain employment as a license-pending practical nurse and practice as delegated by a registered professional nurse or an advanced practice registered nurse or physician. An individual may be employed as a license-pending practical nurse if all of the following criteria are met: (1) He or she has completed and passed the Department-approved licensure exam and presents to the employer the official written notification indicating successful passage of the licensure examination. (2) He or she has completed and submitted to the Department an application for licensure under this Section as a practical nurse. (3) He or she has submitted the required licensure fee. (4) He or she has met all other requirements established by rule, including having submitted to a criminal history records check.https://law.justia.com/codes/illinois/chapter-225/act-225-ilcs-65/article-55/The facility's 10/25/25 Job Description and Duties for the Job Title: Charge Nurse (LPN or RN) documented in part . The LPN and RN provide and oversees nursing care on their assigned unit/ hall. The LPN an RN ensure care is delivered according to resident care plans, administers medications and treatments, and monitors residents for changes in condition. The LPN and RN ensure compliance with the Department of Public Health and CMS regulations, maintains accurate documentation, and supports a safe, compassionate, and resident-centered environment. Job Requirements: 1. Maintain current state nursing licensure (LPN or RN) in good standing.The facility's 1/16/26 Daily Census documented 91 residents residing in the facility.

Based on observation, interview, and record review the facility failed to maintain safe water temperatures for 3 residents of 12 (R10, R11, R12) reviewed for water temperatures in the sample of 12. This failure has the potential to affect 45 confused and ambulatory residents of the 90 residents residing in the facility.Findings include:On 1/20/26 at 1:35 PM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit.On 1/20/26 at 1:50 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the hand sink of the A hall shower room registered 121.4 degrees Fahrenheit (F). At that time the A hall hot water heater mixing valve was set at 104 degrees Fahrenheit.On 1/20/26 at 2:18 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the hand sink of the 200-hall shower room registered 128.0 degrees F and slowly dropped below 110 degrees F after approximately one minute. At that time the 200-hall hot water heater mixing valve was set at 126 degrees F.On 1/20/26 at 2:37 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the hand sink of the B hall shower room registered 119.6 degrees F. At that time the B hall hot water heater mixing valve did not have a gauge present so the temperature it was set to was unable to be determined. V8 (Maintenance Director) said the B hall mixing valve was the old style and only had a knob with the temperatures documented on it to know what temperature the mixing valve was set at. V8 said the knob had broken off the mixing valve so there was no way to know what the temperature was set at.On 1/20/26 at 3:02 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the hand sink of a R10, R11 and R12's personal bathroom on 200 hall registered 120.7 degrees F.On 1/20/26 at 3:35 PM, V1 (Administrator) said she was going to call corporate and get someone to the facility to look at the hot water heaters as soon as possible. V1 said no residents had been burned due to the hot water.On 1/22/26 at 12:43 PM, V8 (Plumber) said he had been to the facility to assess the hot water heaters. V8 said B hall and 200 hall's hot water heater's recirculation pumps had been incorrectly plumbed. V8 said due to the way the recirculation pumps had been put in the mixing valves were irrelevant to the water temperatures because the recirculation pumps bypassed the mixing valves causing the temperature to be too high. V8 said the mixing valve on B hall was not working at all. V8 said he had turned B hall's mixing valve all the way down then turned it all the way up and the water temperature had not changed.On 1/20/26 at 2:11 PM, V8 said he completed hot water temperature checks weekly and kept the log in his office.The facility's Weekly Water Temperature Log documented hot water temperatures were checked on all the halls on 1/2/26, 1/9/26, and 1/16/26 with none being higher than 110 F.On 1/20/26 at 3:45 PM, V1 (Administrator) presented a 1/19/26 Daily Census with Confused and ambulatory or w/c (wheelchair) written at the bottom of the page. V1 highlighted 45 of the 90 residents residing as the facility to indicate those residents were confused and ambulatory. On this list R10 and R12 were noted to be confused and ambulatory. This census sheet also documents R10, R11 and R12 reside in rooms next to each other that have a shared bathroom.On 1/23/26 at 12:47 PM, V1 stated the facility did not have a hot water temperature policy.

Based on observation, interview and record review the facility failed to maintain the kitchen free from roaches. This failure has the potential to affect all 94 residents residing in the facility.Findings include:On 11/18/25 at 10:25 AM, a cockroach was crawling across the back of the hand washing sink in the kitchen.On 11/18/25 at 10:33 AM, a cockroach was crawling along the wall under the 3-compartment sink in the kitchen.On 11/18/25 at 11:28 AM, two cockroaches were crawling along the wall next to the three-compartment sink in the kitchen.On 11/18/25 at 10:28 AM, V3 (Cook) said the kitchen had a lot of cockroaches and had been trying to get rid of them since V3 started in January of 2025. V3 said a pest control company would come to the facility once a month and the cockroach problem would get better, but they would slowly return. V3 said staff tried to keep the kitchen as clean as possible to decrease the cockroach population.On 11/18/25 at 3:50 PM, V4 (Chief Executive Officer) said the dietary manager should have told us there were roaches in the kitchen and he would have called the exterminator to come back and spray. V4 said he had called the pest control company to ask what they were using to exterminate the cockroaches and question why kitchen was still infested. V4 said the pest control company told him the kitchen was large, and they had been trying to exterminate the cockroaches and V4 said he told the pest control company they were going to have to try harder because this was unacceptable.The facility's 11/18/25 Pest Control policy documented in part .This policy establishes standardized procedures for preventing, identifying, reporting, and treating pest activity within the facility. Reporting. 1. Staff must report any pest activity immediately to: Maintenance Director. 3. Maintenance will notify the contracted pest control provider if immediate treatment is required outside of their monthly inspection. The facility's 11/18/25 Daily Census documented 94 total residents living in the facility.

Based on observation, interview, and record review, the facility failed to ensure life sustaining measures were initiated to 1 (R1) of 3 residents reviewed for Cardio-Pulmonary Resuscitation (CPR) in a sample of 6. The findings include: R1's Admission Record documents an admitted [DATE] with diagnoses including Encounter for Palliative Care, Chronic Pain Syndrome, Amyotrophic Lateral Sclerosis (ALS), Anxiety, Major Depressive Disorder. Special instruction document Residential Hospice of Southern Illinois. R1's Hospice Initial Plan of Care dated [DATE] documents a start of care date of [DATE] with a Terminal Diagnosis of Amyotrophic Lateral Sclerosis (ALS). This same document is marked yes under the category of DNR (Do Not Resuscitate). R1's facility Care Plan documents a Focus area of R1's wish is to be resuscitated and CPR to be initiated if his heart stops with an initiation date of [DATE]. Interventions documented include: all staff should perform Heimlich maneuver if choking and proceed with CPR, all staff should provide CPR if R1 goes into cardiac arrest, if R1 should be hospitalized for routine tests/treatments/procedures please send copy of written CPR orders/signed POLST (Practitioner Order for Life Sustaining Treatment) with other orders, and nursing please ensure R1's chart is marked with a blue dot to indicate CPR status and obtain POLST from physician. R1's Practitioner Order for Life Sustaining Treatment (POLST) form dated [DATE] documents yes under Section A. Orders for Patient in Cardiac Arrest next to CPR. Under Section B. Orders for Patient Not in Cardiac Arrest is marked Selective Treatment: Primary goal is treating medical conditions with limited medical measures. This form is signed by V9 (Power of Attorney) and dated [DATE]. R1's Progress Note dated [DATE] at 8:42PM by V4 (Licensed Practical Nurse/LPN) documents, this nurse entered resident room at approximately 8:20PM to administer bedtime meds to resident and his roommate this nurse noted that resident was pale in color and skin was cold to the touch and resident did not appear to be breathing. No pulse detected. This nurse had CNA (Certified Nursing Assistant) to get 2nd nurse to verify. Both nurses confirmed at 8:25PM by auscultation of apical pulse for one minute. That resident had expired at 8:25PM. This nurse notified family at 8:35PM, administrator at 8:40PM, hospice at 8:38PM, and VA at 8:47. On [DATE] at 11:06AM, V4 stated she worked on [DATE] and her shift started at 6:00PM. V4 stated as she was passing her evening medications, she entered R1's room around 8:15PM-8:20PM and just glanced at R1 in bed 1, and noted he appeared to be sleeping on his back with his arms on top of the blankets, and head of bed elevated 45 degrees. V4 stated she went over to Bed 2 and administered his medications and spoke with the family for a couple of minutes. V4 stated as she was leaving the room she looked at R1 and his skin was very ashen in color. V4 stated she then went to the bed side and noted R1's hands were ice cold, and she felt to see if R1's chest was rising at all. V4 stated she next checked for a pulse in R1's wrist and neck and could not feel a pulse. V4 stated she then stepped at the doorway and seen a CNA and asked them to get the other nurse and have her bring in the stethoscope. V4 stated V6 (LPN) arrived, and they both checked pulses and for 1 full minute and no pulse was detected. V4 stated she then left the room to make the phone calls to family, MD and Administrator. V4 stated I assumed (R1) was a DNR because he was under Hospice care. On [DATE] at 10:12AM, V9 (Power of Attorney) stated R1 was once a DNR but then changed to a Full Code with CPR only and no tubes (intubation). V9 stated she talked to R1 about this, and this is what they decided to do. V9 stated I feel like (R1) only had a few weeks left, but God knew that was the day for him to go home and he took him. V9 stated she was not so upset over the CPR not being done and if he was extremely cold it would not have helped anyway. V9 stated ALS has 5 stages and the last time R1 was evaluated he was stage 4, but he progressed quickly to the last stage. On [DATE] at 9:56AM, V12 (Medical Doctor/MD) stated he was R1's physician. V12 stated R1 had ALS that was progressing quickly as of recently. V12 stated he had seen R1 just 2 days before he expired and he noted increased weakness, and condition progressing quickly. V12 stated he suspects R1 passed from a Pulmonary Embolism, Cardiac Arrest, or a mucous plug due to his diagnosis. V12 stated he was aware that R1 was a Full Code status without intubation. V12 stated from what was reported to him, R1 was found extremely cold to touch. V12 stated he was not present but if he was here, he could not have done CPR on R1 with that observation of resident being extremely cold and without vital signs, as it would be ethically immoral. V12 stated he is 95% sure R1 would not have survived even with CPR and is 100% sure R1 would not have survived without intubation. V12 stated CPR would have only damaged R1's chest cavity for no reason. R1's Certificate of Death documents a date of death of [DATE] and documents the causes of death as a. Cardiopulmonary Arrest b. Respiratory Failure c. Amyotrophic Lateral Sclerosis. A facility Final Report dated [DATE] documents On the afternoon of Tuesday ,d+[DATE] about 2:30pm this writer was made aware of concerns about if CPR was performed on a Full code Hospice resident that had expired on the evening of ,d+[DATE] at 8:20pm. Full investigation began. After multiple interviews, witness statements, camera review and interview with Nurse in question, it was noted that (R1) was discovered dusky and cold at about 8:20pm on the evening of [DATE] and CPR was not performed. The facility policy titled Code Blue/DNR Procedures with an effective date of [DATE] and a revision date of [DATE], documents Responsibilities: It is the responsibility of the current nurse on staff to verify and adhere to each resident's code/DNR status.

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices while providing incontinence care and handling contaminated linens for 2 (R19 and R23) of 8 residents reviewed for incontinence and contact precautions. Findings include: 1. R19's Admission Record documented an admitted [DATE] and included diagnoses of methicillin staphylococcus aureus infections as the cause of the diseases classified elsewhere, osteomyelitis unspecified, vasculitis limited to the skin unspecified, and major depressive disorder, single episode, unspecified. R19's Quarterly Minimum Data Set (MDS) dated [DATE] documented R19 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R19 is cognitively intact. R19's MDS Section for Functional Abilities and Goals documented impairment under range of motion in her lower extremities on both sides. R19's MDS Section for Active Diagnoses documented R19 having an Infection of a Multidrug-Resistant Organism (MDRO). R19's Care Plan documented a focus area of R19 is at risk for a urinary tract infection related to history of urinary tract infection, indwelling catheter. On 4/15/2025 at 11:15 AM, R19's door was noted to have a red contact isolation sign that alerts staff and visitors of precautions and what personal protective equipment (PPE) to wear prior to entering the room, which included gloves, gown, mask, and shoe protectors. In the hallway outside of R19's door was a plastic bin with PPE supplies. On 04/15/25 at 11:40 AM, V3 (Resident Assistant/RA) entered R19's room to complete a bed linen change. V3 was changing R19's bed linen while wearing gloves, mask, and shoe covers. V3 did not wear a gown during bed linen change. On 04/17/25 at 10:57 AM, V3 (RA) stated, R19 does have contact isolation precautions in place. V3 stated she did enter R19's room to complete a bed linen change. V3 stated she entered R19's room with gloves, mask, and shoe covers on. V3 said there was no gown in the PPE bin outside the room for her to put on, but she should have worn a gown during contact with the bed linen change. On 04/17/25 at 10:30 AM, V4 (Infections Preventionist/IP) stated R19 currently has an active urinary tract infection with a culture result documenting a carbapenem-resistant enterobacterales (CRE). V4 stated R19 will maintain on contact precautions until she gets 3 negative UA's (urinalysis) each a week apart starting 48 hours after the last dose of antibiotic. V4 stated, R19 is under contact precautions with appropriate signage and supplies available. V4 stated, any staff member that encounters R19's bed linen should wear personal protective equipment that included gloves and a gown. R19's Urine Culture results dated 4/08/2025 documented a heavy growth of Providencia [NAME] with a colony count >100,00 colony-forming units (CFU)/milliliters. The facility Infection Control Policy/Procedure for CRE (undated) documented under Policy, It is the policy of (name of facility) to use standard precautions/contact isolation precautions for residents who are known to be infected with an antibiotic resistive infection or staph infection. Under Procedure, Gown For Contact Isolation Precautions, gown for all direct contact with the patient or the environmental surfaces, including the patient sink which is potentially contaminated. 2. R23's Admission Record documented an admitted [DATE] and included diagnoses of nontraumatic intracerebral hemorrhage unspecified, chronic viral hepatitis c, limitation of activities due to disability, and need for assistance with personal care. R23's Significant Change MDS dated [DATE] documented R23 has a BIMS score of 3, indicating R23 has severe cognitive impairment. R23's MDS Section for Functional Abilities and Goals also documented impairment under range of motion in her upper and lower extremities on both sides. Under Self-Care, R23's MDS documented dependent on staff care for toileting hygiene. R23's Care Plan documented a focus area of having a potential risk for urinary tract infection related to history of a urinary tract infection. On 04/17/25 at 09:23 AM, V2 (Certified Nurse Assistant/CNA) provided incontinence care to R23. V2 removed R23's soiled incontinence brief and had R23 turn on her right side. V2 then removed 4 wet wipes from R23's bedside table and laid them directly on R23's left bedside rail with no barrier. V2 then started to clean R23 with the wipes. On 04/17/25 at 10:30 AM, V4 (IP) stated, incontinence care items should have a barrier placed for supplies, including wipes. V4 stated the staff should not be directly lying incontinence wipes on a resident's bedside rail. On 04/17/25 at 10:34 AM, V2 (CNA) stated she did not follow the facility policy and procedure for providing incontinence care to R23 and should not have directly laid the wipes on R23's bedside rail. On 04/17/25 at 11:10 AM, V1 (Administrator) stated her expectations are for all facility staff to follow the infection prevention policy and procedures. The facility Perineal Care Policy and Procedure (reviewed 5/10/2024) documented under Purpose Staff at (name of facility) will ensure proper cleaning of the perineum to prevent infection and odor.

Based on interview and record review the facility failed to ensure there were sufficient staff to provide timely care and assistance to its residents. This has the potential to affect all 91 residents who currently reside at the facility. Findings Include: The facility Daily Census Report dated 3/6/25 documents 91 residents reside at the facility. 1. R2's Admission Record with a print date of 3/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart disease, and muscle weakness. R2's MDS (Minimum Data Set) dated 2/22/25 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. R2's current Care Plan with a Focus area of, (R2) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity Intolerance, Impaired balance, Limited ROM (Range of Motion) Date Initiated: 10/28/2024. This Focus area include interventions of, Bathing/Showering: (R2) requires extensive assistance by x1 (times 1) staff with bathing/showering twice a week and as necessary. CNA's (Certified Nursing Assistants) to ensure that (R2) receives at least one shower per week, if the two are unable to be given. R2's Shower Skin Assessment forms document R2 did not receive a shower/bath on 2/28/25 and went from 2/25/25 to 3/4/25 (six days) without a shower. On 3/5/25 at 11:31 AM, R2 stated they don't have enough staff to meet her needs timely. R2 stated she sometimes doesn't get her showers because they are short staffed. R2 stated she didn't get on Friday 2/28/25 because they didn't have enough staff to do it. R2 stated last night (3/4/25) her and her roommate (R3) had to wait two hours to get assistance to the bathroom. R2 stated she woke up to R3 calling out for help to go to the bathroom. R2 stated R3 had her call light on. R2 stated R3 started hitting her call light on the bedside table to get the attention of staff. R2 stated she called the facility and spoke with V19 (RN/Registered Nurse) who transferred her call to her nurse's station, and no one answered. R2 stated no one answered the phone so she called again and V19 transferred her call again. R2 stated she started calling around 12:00 AM and it was 1:30 AM before they got assistance. R2 stated they only had one CNA working on her hall. 2. R3's Admission Record with a print date of 3/6/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include heart failure, cognitive communication defect, diabetes, and adult failure to thrive. R3's MDS dated [DATE] documents a BIMS score of 15, which indicates she is cognitively intact. This same MDS documents R3 requires partial to moderate assist for toilet hygiene, toilet transfer, showers, and is occasionally incontinent of bowel and bladder. R3's current Care Plan documents a Focus area of (R3) has an ADL self-care performance deficit r/t (related to) Impaired balance, Limited Mobility. Date Intimated: 10/17/2024. This Focus area includes an intervention of, Bathing/Showering: (R1) requires extensive assistance by x (times) 1 staff with showering twice a week and as necessary. CNAs to ensure that (R1) receives at least one shower per week, if two are unable to be given. R3's Shower Skin Assessment forms document R3 did not receive a shower on 2/28/25 and went from 2/25/25 to 3/4/25 (six days) without a shower. On 3/6/25 at 1:00 PM R3 stated she doesn't always get showers when she is supposed to. When asked if she had issues getting her call light answered on 3/4/25, R3 stated she did. R3 stated she put her call light on, and no one answered for a long time. R3 stated she yelled out and still no one answered, and her roommate (R2) was trying to get help also. R3 stated she had to go to the bathroom but did not have an incontinence episode due to the delay. On 3/5/25 at 3:44 PM, V19 (RN) stated she got a phone call from R2 on the night shift that began on 3/4/25 who asked her to get a hold of her nurse. V19 stated R2 called her twice. On 3/5/25 at 11:08 PM, V22 (CNA) stated he worked on R2 and R3's hall on the night of 3/4/25. V22 stated he answered their call light, but he was working by himself on the unit with no nurse. V22 stated his nurse was responsible for two units that night and was on the other unit from 12 AM to 2 AM. V22 stated he was trying to answer R2 and R3's call light but in the process, he had other alarms going off and knew those residents were at risk of falling and had to prioritize fall risks over toileting/incontinence care. V22 stated it may have taken 45 minutes to answer R2 and R3's call. V22 stated he felt bad for the resident. V22 stated they don't get a discount if they have to wait. On 3/6/25 at 9:58 AM, V2 (Director of Nurses) stated V1 watched the camera to determine how long it took for a staff member to answer R2 and R3's call light. V2 stated V22 was in the room from 1:33 AM to 1:56 AM. When asked if any staff entered R2 and R3's room from 12:00 AM to 1:24 AM when V2 stated V13 (LPN) entered the room, V2 stated, No. 3. R12's Admission Record with a print date of 3/6/25 documents R12 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia, and hypertension. R12's MDS dated [DATE] documents R12 has a severe cognitive impairment. This same MDS documents R12 is dependent on staff for bathing. R12's current Care Plan does not document a Focus area and/or interventions for bathing. R12's Shower Skin Assessment forms document R12 did not receive assistance with bathing from 1/25/25 to 2/5/25 (10 days) and from 2/12/22 to 2/22/25 (9 days) or from 2/26/25 to 3/6/25 (7 days). On 3/5/25 at 9:23 AM, R12 was sitting in a wheelchair in the hallway. R12 did not respond verbally when asked questions. On 3/5/25 at 2:39 PM, V12 (CNA/Certified Nursing Assistant) stated lately they have been short staffed. V12 stated they were not able to get R12's shower done on 3/5/25. On 3/5/25 at 3:04 PM, V15 (CNA) stated they were able to get one shower done today 3/5/25 but weren't able to get R12's done. 4. R14's Admission Record with a print date of 3/6/25 documents R14 was admitted to the facility on [DATE] with diagnoses that include diabetes, legal blindness, diabetes, and hypertension. R14's MDS dated [DATE] documents a BIMS score of 15, which indicates R14 is cognitively intact. This same MDS documents R14 requires supervision/touching assistance for bathing. R14's Shower Skin Assessment forms document R14 did not receive assistance with bathing from 1/28/25 to 2/13/25 (16 days) and from 2/23/25 to 3/6/25 (11 days). On 3/5/25 at 1:30 PM, V4 (CNA) stated it depended on the day if they had enough staff to meet the needs of the residents timely. V4 stated they weren't able to get the showers done on 3/5/25. V4 stated they didn't do R14's shower. When asked why they didn't get the showers done V4 stated it was too busy with only two CNA's. On 3/5/25 at 1:39 PM, V6 (CNA) stated they didn't have enough staff to meet the needs of the residents timely. V6 stated they weren't able to the four showers done today including R14's because of staffing. On 3/5/25 at 9:15 AM, R14 was lying in bed and stated he gets showers on Wednesday and Saturdays, and he got one yesterday. On 3/5/25 at 1:49 PM, V7 (Resident Assistant) stated she didn't think they had enough staff to meet the needs of the residents timely. V7 stated she didn't think showers were done as they should be. On 3/5/25 at 2:02 PM, V8 (CNA) stated sometimes they had enough staff to meet the needs of the residents timely. V8 stated when they don't have enough staff showers don't always get done. On 3/5/25 at 2:05 PM, V9 (LPN/Licensed Practical Nurse) stated they didn't have enough staff to meet the needs of the residents timely. V9 stated showers didn't always get done as they should. V9 stated they didn't have enough staff to do the showers on her unit on 3/5/25. On 3/5/25 at 3:13 PM, V18 (CNA) stated they didn't have enough staff to assist residents with bathing as they should. On 3/6/25 at 9:58 AM, V2 (Director of Nurses) stated they did have some staffing issues and she had recently hired new staff, but they hadn't started yet. V2 stated when they are short, staffed administration will work the floor. V2 stated staff can always get the basic needs met but sometimes things like showers were delayed. On 3/6/24 at 1:33 PM, V1 (Administrator) stated she hadn't had any complaints/concerns related to showers. V1 stated they had plenty of staff working on 3/5/25 to meet the needs of the residents timely and to assist with showers. V1 stated residents should be assisted with bathing twice a week but they always absolutely get showers weekly. V1 stated they have seen where someone missed a shower or where the CNAs didn't have time to give a shower because someone called in. Reviewed with V1 the R2, R3, R12, and R14's Shower Skin Assessment forms that document R2 and R3 didn't get showers from 2/7 to 2/18 and on 2/28/25, R12 didn't get a shower from 1/25 to 2/5/25, 2/12 to 2/22/25, 2/26/to 3/6/25, and R14 didn't get a shower from 1/28/25 to 2/13/25 and from 2/23/25 to 3/6/25. V1 stated she would check to see if there were any more forms. After searching for more Shower Skin Assessment forms V1 stated she was not able to locate any other reproducible evidence of more showers for R2, R3, R12, and R14. The undated Facility Assessment documents, .A staffing plan will be developed for each nurse's station to provide adequate staffing based on the number and acuity level of the resident's served by each nurse's station .The specific needs of the residents will determine how to calculate and staff by each nurse's station

Based on interview and record review the facility failed to ensure showers were provided and residents received timely toileting assistance 4 of 6 residents (R2, R3, R12, and R14) reviewed for showers in the sample of 14. Findings Include: 1. R2's Admission Record with a print date of 3/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart disease, and muscle weakness. R2's MDS (Minimum Data Set) dated 2/22/25 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 requires partial to moderate assistance of staff for toilet transfers. R2's current Care Plan with a Focus area of, (R2) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity Intolerance, Impaired balance, Limited ROM (Range of Motion) Date Initiated: 10/28/2024. This Focus area include interventions of, Bathing/Showering: (R2) requires extensive assistance by x1 (times 1) staff with bathing/showering twice a week and as necessary. CNA's (Certified Nursing Assistants) to ensure that (R2) receives at least one shower per week, if the two are unable to be given. R2's Shower Skin Assessment forms document R2 did not receive a shower/bath on 2/28/25 and went from 2/25/25 to 3/4/25 (six days) without a shower. On 3/5/25 at 11:31 AM, R2 stated they don't have enough staff to meet her needs timely. R2 stated she sometimes doesn't get her showers because they are short staffed. R2 stated she didn't get one Friday 2/28/25 because they didn't have enough staff to do it. R2 stated last night (3/4/25) her and her roommate (R3) had to wait two hours to get assistance to the bathroom. R2 stated she woke up to R3 calling out for help to go to the bathroom. R2 stated R3 had her call light on. R2 stated R3 started hitting her call light on the bedside table to get the attention of staff. R2 stated she called the facility and spoke with V19 (RN/Registered Nurse) who transferred her call to her nurse's station, and no one answered. R2 stated no one answered the phone so she called again and V19 transferred her call again. R2 stated she started calling around 12:00 AM and it was 1:30 AM before they got assistance. R2 stated they only had one CNA working on her hall. 2. R3's Admission Record with a print date of 3/6/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include heart failure, cognitive communication defect, diabetes, and adult failure to thrive. R3's MDS dated [DATE] documents a BIMS score of 15, which indicates she is cognitively intact. This same MDS documents R3 requires partial to moderate assist for toilet hygiene, toilet transfer, showers, and is occasionally incontinent of bowel and bladder. R3's current Care Plan documents a Focus area of (R3) has an ADL self-care performance deficit r/t (related to) Impaired balance, Limited Mobility. Date Intimated: 10/17/2024. This Focus area includes an intervention of, Bathing/Showering: (R1) requires extensive assistance by x (times) 1 staff with showering twice a week and as necessary. CNAs to ensure that (R1) receives at least one shower per week, if two are unable to be given. R3's Shower Skin Assessment forms document R3 did not receive a shower on 2/28/25 and went from 2/25/25 to 3/4/25 (six days) without a shower. On 3/6/25 at 1:00 PM R3 stated she doesn't always get showers when she is supposed to. When asked if she had issues getting her call light answered on 3/4/25, R3 stated she did. R3 stated she put her call light on, and no one answered for a long time. R3 stated she yelled out and still no one answered, and her roommate (R2) was trying to get help also. R3 stated she had to go to the bathroom but did not have an incontinence episode due to the delay. On 3/5/25 at 3:44 PM, V19 (RN) stated she got a phone call from R2 on the night shift that began on 3/4/25 who asked her to get a hold of her nurse. V19 stated R2 called her twice. On 3/5/25 at 11:08 PM, V22 (CNA) stated he worked on R2 and R3's hall on the night of 3/4/25. V22 stated he answered their call light, but he was working by himself on the unit with no nurse. V22 stated his nurse was responsible for two units that night and was on the other unit from 12 AM to 2 AM. V22 stated he was trying to answer R2 and R3's call light but in the process, he had other alarms going off and knew those residents were at risk of falling and had to prioritize fall risks over toileting/incontinence care. V22 stated it may have taken 45 minutes to answer R2 and R3's call. V22 stated he felt bad for the resident. V22 stated they don't get a discount if they have to wait. On 3/6/25 at 9:58 AM, V2 (Director of Nurses) stated V1 watched the camera to determine how long it took for a staff member to answer R2 and R3's call light. V2 stated V22 was in the room from 1:33 AM to 1:56 AM. When asked if any staff entered R2 and R3's room from 12:00 AM to 1:24 AM when V2 stated V13 (LPN) entered the room, V2 stated, No. 3. R12's Admission Record with a print date of 3/6/25 documents R12 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia, and hypertension. R12's MDS dated [DATE] documents R12 has a severe cognitive impairment. This same MDS documents R12 is dependent on staff for bathing. R12's current Care Plan does not document a Focus area and/or interventions for bathing. R12's Shower Skin Assessment forms document R12 did not receive assistance with bathing from 1/25/25 to 2/5/25 (10 days) and from 2/12/22 to 2/22/25 (9 days) or from 2/26/25 to 3/6/25 (7 days). On 3/5/25 at 9:23 AM, R12 was sitting in a wheelchair in the hallway. R12 did not respond verbally when asked questions. On 3/5/25 at 2:39 PM, V12 (CNA/Certified Nursing Assistant) stated lately they have been short staffed. V12 stated they were not able to get R12's shower done on 3/5/25. On 3/5/25 at 3:04 PM, V15 (CNA) stated they were able to get one shower done today 3/5/25 but weren't able to get R12's done. 4. R14's Admission Record with a print date of 3/6/25 documents R14 was admitted to the facility on [DATE] with diagnoses that include diabetes, legal blindness, diabetes, and hypertension. R14's MDS dated [DATE] documents a BIMS score of 15, which indicates R14 is cognitively intact. This same MDS documents R14 requires supervision/touching assistance for bathing. R14's Shower Skin Assessment forms document R14 did not receive assistance with bathing from 1/28/25 to 2/13/25 (16 days) and from 2/23/25 to 3/6/25 (11 days). On 3/5/25 at 1:30 PM, V4 (CNA) stated it depended on the day if they had enough staff to meet the needs of the residents timely. V4 stated they weren't able to get the showers done on 3/5/25. V4 stated they didn't do R14's shower. When asked why they didn't get the showers done V4 stated it was too busy with only two CNA's. On 3/5/25 at 1:39 PM, V6 (CNA) stated they didn't have enough staff to meet the needs of the residents timely. V6 stated they weren't able to the four showers done today including R14's because of staffing. On 3/5/25 at 9:15 AM, R14 was lying in bed and stated he gets showers on Wednesday and Saturdays and he got one yesterday. On 3/5/25 at 1:49 PM, V7 (Resident Assistant) stated she didn't think they had enough staff to meet the needs of the residents timely. V7 stated she didn't think showers were done as they should be. On 3/5/25 at 2:02 PM, V8 (CNA) stated sometimes they had enough staff to meet the needs of the residents timely. V8 stated when they don't have enough staff showers don't always get done. On 3/5/25 at 2:05 PM, V9 (LPN/Licensed Practical Nurse) stated they didn't have enough staff to meet the needs of the residents timely. V9 stated showers didn't always get done as they should. V9 stated they didn't have enough staff to do the showers on her unit on 3/5/25. On 3/5/25 at 3:13 PM, V18 (CNA) stated they didn't have enough staff to assist residents with bathing as they should. On 3/6/25 at 9:58 AM, V2 (Director of Nurses) stated they did have some staffing issues and she had recently hired new staff, but they hadn't started yet. V2 stated when they are short, staffed administration will work the floor. V2 stated staff can always get the basic needs met but sometimes things like showers were delayed. On 3/6/24 at 1:33 PM, V1 (Administrator) stated she hadn't had any complaints/concerns related to showers. V1 stated they had plenty of staff working on 3/5/25 to meet the needs of the residents timely and to assist with showers. V1 stated residents should be assisted with bathing twice a week but they always absolutely get showers weekly. V1 stated they have seen where someone missed a shower or where the CNAs didn't have time to give a shower because someone called in. Reviewed with V1 the R2, R3, R12, and R14's Shower Skin Assessment forms that document R2 and R3 didn't get showers from 2/7 to 2/18 and on 2/28/25, R12 didn't get a shower from 1/25 to 2/5/25, 2/12 to 2/22/25, 2/26/to 3/6/25, and R14 didn't get a shower from 1/28/25 to 2/13/25 and from 2/23/25 to 3/6/25. V1 stated she would check to see if there were any more forms. After searching for more Shower Skin Assessment forms V1 stated she was not able to locate any other reproducible evidence of more showers for R2, R3, R12, and R14. The facility Bath and Shower policy dated 1/3/24 documents, Purpose: Staff at (name of facility) will ensure all staff (sic) are offered baths/showers twice a week or as often as requested to cleanse and refresh the resident, skin assessments, and promote increased circulation

Based on interview and record review the facility failed to ensure allegations of abuse were reported timely to the Administrator and to the State Survey Agency for 2 of 3 (R1 and R13) residents reviewed for abuse in the sample of 14. Findings Include. 1. R1's Admission Record with a print date of 3/6/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple fractures, osteoarthritis, and hypertension. R1's MDS (Minimum Data Set) dated 3/5/25 documents R1 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates R1 is cognitively intact. On 3/5/25 at 11:45 AM, R1 stated V13 (LPN/Licensed Practical Nurse) came in his room talking louder than normal and handed him about 16 pills in one cup. R1 stated he sat the pills down and asked for a list of his medications and V13 stated she didn't have time to get him the list and walked around to the other side of his bed. R1 stated V13 picked up his left hand and started to do an accu check. R1 stated he gave V13 his right hand and told her he wanted it done on the right hand not the left. R1 stated V13 called him hateful and left the room immediately. R1 stated he called the police and reported elder abuse after V13 left his room. R1 stated she came back to his room and grabbed a hold of the door and stated she wasn't able to come in his room by herself, they had to have two staff members provide care to him now. R1 stated he asked the police to come to the facility and write a report, but they didn't, and they alerted the staff about his call. R1 stated he later saw V13 and V3 (Quality Assurance Nurse/QA) come into his room. R1 stated V3 was a little easier to talk with. R1 stated V13 has worked since the incident occurred and he believed it occurred on Saturday, March 1. R1 stated V13 has been in his room one time since the incident to give him the list of medications he requested. When asked if he felt safe at the facility, R1 stated he contacted Veteran's Affairs regarding the incident, and they asked him if he wanted to move to a different facility. R1 stated he told them he did. R1 did not directly answer the question about feeling safe at the facility. On 3/5/25 at 12:53 PM, V5 (Police Dispatch) stated she took a call from the facility on 3/1/25 at 10:41 AM. V5 stated R1 called and stated he resided at the facility and advised he was being abused by a nurse (V13). V5 stated R1 reported the nurse (V13) grabbed his arm and told him she didn't have time for him. V5 stated R1 reported after the nurse (V13) grabbed his arm she grabbed his hand to do a blood sugar and he told her they use the other hand. V5 stated R1 reported the nurse threw his hand down on the bed and told him she didn't have time for him. R1's Progress Notes document the following. 3/1/25 10:51 AM, Note Text: (V13), floor nurse called this nurse manager (V3) and stated that the police department had called her stating this resident called 911 stating he had been assaulted. (V13) explained she went to give his meds (medications) and he wanted a list of all medications, and she told him she would get him a list when she was finished passing (sic) her medications. He (R1) then became very agitated and would not let her do his accu check. This nurse (V3) notified (V1), Administrator. Orders for 2 people at all times when providing care or administering medications. On 3/5/25 at 1:25 PM, V1 (Administrator) stated she was notified on Sunday night R1 had called the police. V1 stated V3 (QA Nurse) called her and reported it. V1 stated when she came in on Monday she thought since the police had been called, they probably should have reported the allegation but because of who the resident was she didn't think she needed to. V1 stated she didn't start an investigation and didn't interview any other staff or residents. V1 stated no one had a conversation with R1 about what had occurred other than V3 (QA Nurse) and V13 (LPN) was present when V3 spoke with R1. The facility Initial Report sent to the Illinois Department of Public Health dated 3/5/25 documents, On 3/1/25 at approx (approximately) 10:51 am on call nurse (V3) was notified by floor nurse that resident had called police and stated that he had been assaulted, when nurse had attempted to check his blood sugar. (V3) notified (V1) administrator received (sic) instructions to ensure 2 staff were in room at all times when providing care including nursing. Investigation initiated, final to follow. 2. R13's Admission Record with a print date of 3/6/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include diabetes, major depressive disorder, repeated falls, and hypertension. R13's MDS dated [DATE] documents a BIMS score of 02, which indicates R13 has a severe cognitive deficit. On 3/5/25 at 3:56 PM, R13 was sitting in a wheelchair in the facility common area. R13 denied any concerns with care and didn't exhibit signs or symptoms of distress. On 3/5/25 at 2:57 PM, when asked about abuse, V14 (Resident Assistant) stated she had witnessed staff to resident mental abuse. V14 stated V17 (CAN/Certified Nursing Assistant) and V16 (CNA) were the staff members and she reported it to V26 (Business Office Manager) because V1 (Administrator) and V2 (Director of Nurses) were not in the facility. V14 stated she witnessed V17 being rude to R13. V14 stated V17 told R13 to shut up and no one was going to get him out of bed. V14 stated it happened on 3/2/25 between 6 am and 2 pm. V14 stated she didn't have a specific incident that occurred with V16 (CNA) but she was just rude at times. On 3/6/25 9:41 AM, V26 (Business Office Manager/BOM) stated she was the manager on duty, and she spoke with V14 (Resident Assistant) and she reported V17 (CNA) was standing in the hallway at R13's door yelling at R13 and being rude and hateful or having an attitude. V26 stated she assured V14 they would discuss it on Monday in morning meeting and she would let V1 (Administrator) know about the allegation. V26 stated she wrote it on a piece of paper and gave it to V1 on Monday morning. V26 stated she didn't know if R13 was interviewable. V26 stated she did not check on R13 after V14 reported the incident to her. On 3/5/25 at 3:17 PM, V1 (Administrator) stated on Monday 3/3/25 she was told, V17 (CNA) had an attitude. V1 stated it was reported V17 was in the hallway outside R13's room, raised her voice to R13 and was rude. V1 stated she hadn't talked to V14 (RA) who reported the allegation and she wished they would report these things to her before the survey agency enters the facility. V1 stated V14 had worked the past two days and hadn't approached V1 about the incident. V1 stated she hadn't attempted to speak with V14 regarding the incident and didn't begin an investigation. The facility Initial Report sent to the Illinois Department of Public Health dated 3/5/25 documents, On 3/5/25 at approximately 305 pm was notified by surveyor that an employee had reported a complaint of alleged verbal abuse on 3/2/25 to manager on call. Investigation initiated, Final to follow. The facility Abuse Policy dated 3/5/25 documents, Purpose: Each resident has the right to be free from mistreatment, neglect, and misappropriation of property 4. Identification a. If any employee suspects that a resident has been a victim of abuse, they should report this information to their immediate supervisor and directly to the facility administrator as soon as possible .d. When suspected abuse is reported, the administrator and DON (Director of Nurses) should be notified immediately, and the administrator or DON should make a report to (State Survey Agency) within 24 hours

Based on interview and record review the facility failed to ensure allegations of abuse were thoroughly investigated and residents were protected from possible further abuse for 2 of 3 (R1 and R13) residents reviewed for abuse in the sample of 14. Findings Include. 1. R1's Admission Record with a print date of 3/6/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple fractures, osteoarthritis, and hypertension. R1's MDS (Minimum Data Set) dated 3/5/25 documents R1 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates R1 is cognitively intact. R1's current Care Plan documents a Focus area of (R1) has potential for a behavior problem R/T (related to) making false allegations toward staff of assault during routine cares, or bullying, yelling, being belligerent, not cooperative with care at times. Date Initiated: 03/05/2025. The interventions included for this Focus area include, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/05/2025, Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date Initiated: 03/05/20205, If reasonable discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date Initiated: 03/05/2025, Staff to enter resident's room with 2 staff members at all times including nurses' aides, therapy to do anything at all. Document any behaviors. Date Initiated: 03/05/2025. On 3/5/25 at 11:45 AM, R1 stated V13 (LPN/Licensed Practical Nurse) came in his room talking louder than normal and handed him about 16 pills in one cup. R1 stated he sat the pills down and asked for a list of his medications and V13 stated she didn't have time to get him the list and walked around to the other side of his bed. R1 stated V13 picked up his left hand and started to do an accucheck. R1 stated he gave V13 his right hand and told her he wanted it done on the right hand not the left. R1 stated she called him hateful and left the room immediately. R1 stated he called the police and reported elder abuse after V13 left his room. R1 stated she came back to his room and grabbed a hold of the door and stated she wasn't able to come in his room by herself, they had to have two staff members provide care to him now. R1 stated he asked the police to come to the facility and write a report, but they didn't, and they alerted the staff about his call. R1 stated he later saw V13 and V3 (Quality Assurance Nurse/QA) V3 was a little easier to talk with. R1 stated V13 has worked since the incident occurred and he believed it occurred on Saturday, March 1. R1 stated V13 has been in his room one time since the incident to give him the list of medications he requested. When asked if he felt safe at the facility, R1 stated he contacted Veteran's Affairs regarding the incident, and they asked him if he wanted to move to a different facility. R1 stated he told them he did. R1 did not directly answer the question about feeling safe at the facility. On 3/5/25 at 12:53 PM, V5 (Police Dispatch) stated she took the call from the facility on 3/1/25 at 10:41 AM. V5 stated R1 called and stated he resided at the facility and advised he was being abused by a nurse (V13). V5 stated R1 reported the nurse (V13) grabbed his arm and told him she didn't have time for him. V5 stated R1 reported after the nurse (V13) grabbed his arm she grabbed his hand to do a blood sugar and he told her they use the other hand. V5 stated R1 reported the nurse threw his hand down on the bed and told him she didn't have time for him. On 3/5/25 at 2:45 PM, V13 (LPN/Licensed Practical Nurse) stated she went into R1's room on Saturday 3/1/25 in the morning with medications and to do his accu check. V13 stated R1 asked what was in the medication cup and she told him the same thing he had been taking. V13 stated R1 asked for a copy of his medications, and she told him she would get it for him when she was done with the medication pass. V13 stated she picked up R1's left hand to do an accu check and R1 jerked it back and screamed at the top of his lungs and it scared her. V13 stated she left and finished the medication pass and was at the nurse's station when the police called. V13 stated she called V3 (QA Nurse) and told her what happened and then took an unknown CNA/Certified Nursing Assistant with her when she went in his room. V13 stated R1 seemed fine after that. V13 stated the next morning, R1 put his call light on, and she went to his room. V13 stated he needed his urinal emptied. V13 stated she told him she would have a CNA come with her since she couldn't be in his room alone. V13 stated R1 was angry and wanted to know why they had to have two staff. V13 stated she got V3 (QA Nurse) and they went in and talked to R1. V13 stated R1 was better in the afternoon. V13 stated he didn't seem aggressive. V13 denied any other physical contact with R1. V13 stated she didn't throw down his hand or jerk his arm or call him hateful. V13 stated she did tell R1 she wouldn't be spoken to that way. V13 stated she charted the incident in R1's progress notes. V13 stated no one in administration asked her any questions related to the incident after she told V3 what happened. V13 stated V3 was working at the time of the incident. V13 stated V3 told her she would notify V1 (Administrator). On 3/5/25 at 1:12 PM, V3 (QA Nurse) stated she was working when V13 (LPN) told her the police had called. V3 stated R1 had called the police with an abuse allegation. V3 stated the police told them they weren't coming to the facility, and she called V1 (Administrator) and reported it. V3 stated they decided two people needed to go in R1's room for care since he had made the allegation. V3 stated V13 told her she had in no way abused R1. V3 stated V13 reported, R1 wanted a list of medications, she started to do his accu check and told R1 she would get a list of his medications for him. V3 stated V13 reported R1 became hostile and started yelling and screaming. V3 stated V13 reported she started to do R1's accu check and he jerked his hand back and wouldn't let her do the accu check. V3 stated V13 reported she walked out and shortly after she left R1's room the local police called her. V3 stated V13 explained to the police what had happened, and they didn't believe abuse occurred. V3 stated after the incident and the local police called the facility, R1 put his call light on to have his urinal emptied. V3 stated she went with V13 and told R1 two people had to be in his room. V3 stated R1 wanted to know why, and she explained to him due to the allegation there would be two people in his room. V3 stated R1 told her V13 yelled at him from the door and told him he was hateful. V3 stated she explained to R1 administration would be at the facility on Monday and he could ask them questions. V3 stated she documented the incident in the progress notes. V3 stated she didn't ask any other residents and/or staff if they witnessed anything. V3 stated R1's roommate was not in his room and wouldn't be able to answer questions if he had been. R1's Progress Notes document the following. 3/1/25 10:51 AM, Note Text: (V13), floor nurse called this nurse manager (V3) and stated that the police department had called her stating this resident called 911 stating he had been assaulted. (V13) explained she went to give his meds (medications) and he wanted a list of all medications, and she told him she would get him a list when she was finished passing (sic) her medications. He (R1) then became very agitated and would not let her do his accu check. This nurse (V3) notified (V1), Administrator. Orders for 2 people at all times when providing care or administering medications. On 3/1/25 1327, Note Text: This writer (V13) entered resident's (R1) room at 0915 to administer morning medications. Resident requested a list of medications he was taking. Resident was told he would get a copy once the morning medications were passed. This writer picked up resident's right (hand) for his accu check, resident immediately and aggressively jerked his hand away, and started screaming angerly and incoherently at this writer. Resident was instructed his accu check would be completed a different time when he was compliant. This writer received a call from (name of local police department) regarding to resident calling the police. On call nurse (V3) was notified of resident's action. Anyone entering resident's room from this point forward is to enter room [ROOM NUMBER] at a time, this includes all staff. On 3/2/25 4:18 PM, Note Text: Resident's call light was on, this writer went down to this room, and from the doorway resident stated he needed his urine emptied, resident was informed that when a CNA (Certified Nursing Assistant) was available we would enter the room together to take care of his bedside urinal. Resident became verbally aggressive. CNA (V15) entered room with this writer, resident requested to know why we was not allowed to enter his room alone. I told this resident I would get my nursing supervisor to speak with him. Resident again became verbally aggressive. (V3 LPN) was notified of resident's actions and enter room with this nurse. Resident continued to be verbally aggressive while LPN (V3) was explaining to him why needed to enter his room two at time. On 3/5/25 at 1:02 PM, V2 (Director of Nurses) stated she hadn't had any abuse investigations since January 2025. V2 stated R1 yelled assault, to the local police. V2 stated V3 (QA Nurse) was in the facility at the time and her and V13 (LPN) talked to R1. V2 stated R1 called the police but she didn't consider it an allegation. V2 stated then on Monday she got a call from Veterans Affairs that R1 had called them and wanted moved out of the facility. V2 stated on Monday she got R1 the medication list he had requested and when she took it to him the only thing, he was concerned about was his cardiac medications and his cardiac appointment. V2 stated she discussed those concerns with him and his trip to his home that was scheduled for Friday. V2 stated she didn't discuss the allegation with R1. On 3/5/25 at 1:25 PM, V1 (Administrator) stated she was notified on Sunday night R1 had called the police. V1 stated V3 (QA Nurse) called her and reported it. V1 stated when she came in on Monday she thought since the police had been called, they probably should have reported the allegation but because of who the resident was she didn't think she needed to. V1 stated she didn't start an investigation and didn't interview any other staff or residents. V1 stated no one had a conversation with R1 about what had occurred other than V3 (QA Nurse) and V13 (LPN) was present when V3 spoke with R1. The facility Initial Report dated 3/5/25 documents, On 3/1/25 at approx (approximately) 10:51 am on call nurse (V3) was notified by floor nurse that resident had called police and stated that he had been assaulted, when nurse had attempted to check his blood sugar. (V3) notified (V1) administrator received (sic) instructions to ensure 2 staff were in room at all times when providing care including nursing. Investigation initiated, final to follow. 2. R13's Admission Record with a print date of 3/6/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include diabetes, major depressive disorder, repeated falls, and hypertension. R13's MDS dated [DATE] documents a BIMS score of 02, which indicates R13 has a severe cognitive deficit. On 3/5/25 at 3:56 PM, R13 was observed sitting in a wheelchair in the facility common area. R13 denied any concerns with care and didn't exhibit signs or symptoms of distress. On 3/5/25 at 2:57 PM, when asked about abuse, V14 (Resident Assistant) stated she had witnessed staff to resident mental abuse. V14 stated V17 (CNA) and V16 (CNA) were the staff members and she reported it to V26 (Business Office Manager) because V1 (Administrator) and V2 (Director of Nurses) were not in the facility. V14 stated she witnessed V17 being rude to R13. V14 stated V17 told R13 to shut up and no one was going to get him out of bed. V14 stated it happened on 3/2/25 between 6 am and 2 pm. V14 stated she didn't have a specific incident that occurred with V16 (CNA) but she was just rude at times. On 3/6/25 9:41 AM, V26 (Business Office Manager/BOM) stated she was the manager on duty, and she spoke with V14 (Resident Assistant) and she reported V17 (CNA) was standing in the hallway at R13's door yelling at R13 and being rude and hateful or having an attitude. V26 stated she assured V14 they would discuss it on Monday in morning meeting and she would let V1 (Administrator) know about the allegation. V26 stated she wrote it on a piece of paper and gave it to V1 on Monday morning. V26 stated she didn't know if R13 was interviewable. V26 stated she did not check on R13 after V14 reported the incident to her. On 3/6/24 at 12:42 PM, V17 (CNA) stated she had never witnessed and/or she herself had never told R13 to shut up and/or they weren't going to provide care. On 3/5/25 at 3:17 PM, V1 (Administrator) stated on Monday 3/3/25 she was told, V17 (CNA) had an attitude. V1 stated it was reported V17 was in the hallway outside R13's room, raised her voice to R13 and was rude. V1 stated she hadn't talked to V14 (RA) who reported the allegation and she wished they would report these things to her before the survey agency enters the facility. V1 stated V14 had worked the past two days and hadn't approached V1 about the incident. V1 stated she hadn't attempted to speak with V14 regarding the incident and didn't begin an investigation. The facility Initial Report dated 3/5/25 documents, On 3/5/25 at approximately 3:05 pm was notified by surveyor that an employee had reported a complaint of alleged verbal abuse on 3/2/25 to manager on call. Investigation initiated, Final to follow. The facility Abuse Policy dated 3/5/25 documents, 5. Investigation .b. When an incident or suspected incident of resident abuse, neglect, misappropriation of resident's property, or injury of unknown origin is reported, the administrator will appoint a staff member to investigate the incident Protection: a. Any employee suspected of abuse or that has been alleged in a potentially abusive situation will be put on leave without pay until the investigation has been completed.

Based on observation, interview, and record review the facility failed to safely transfer 4 (R1, R2, R3, R11) of 5 residents reviewed for transfers in a sample of 11. This failure resulted in R1 sustaining a large hematoma to the chest wall and requiring a 5-day hospitalization in the Special Care Unit for monitoring and pain management. Findings include: 1. R1's document titled Admission Record documents an admitted [DATE] and includes diagnoses of fracture of femur, Atherosclerotic Heart Disease, Hyperlipidemia, Abnormal Posture. R1's MDS (Minimum Data Set) dated 9/9/2024 includes a BIMS (Brief Interview for Mental Status) score is 5 indicating sever cognitive impairment. Section GG of MDS documents Functional Limitation in Range of Motion R1 has impairment to both sides of upper extremities, and impairment on one side of Lower extremity. Mobility devices used is a wheelchair. Documentation includes R1 is Dependent for Bed mobility, sit to lying, lying to siting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and tub/shower transfer. R1 is dependent on staff for wheelchair mobility. R1's Care plan documents Focus R1 requires restorative nursing for dressing and /or grooming related to decreased ability to perform ADLs (Activities of Daily Living) with revision date of 2/29/2024, Intervention encourage and assist R1 in performing upper and lower body dressing and or grooming with set up and verbal cues as often the opportunity present itself. R1's Order Summary Report dated 10/11/24 documents in part, Eliquis Oral Table 5 MG (milligram) .give 1 tablet by mouth two times a day for suspected DVT (Deep Vein Thrombosis) in right popliteal vein . Start date: 5/23/24. Incident report for R1, on an untitled document dated 10/3/2024 at 7:30 PM document's Location: Shower, Person reporting incident was V26 (Registered Nurse/RN), Incident description: Bruise to left chest/breast noted upon shower. Resident denied any complaints of pain to area with palpitation. Resident denies knowing how bruise occurred. Immediate action taken description: MD (Medical Doctor), POA (Power of Attorney), and administration on call notified. Predisposing factors include Environmental, Psychological, and Situation, all areas document None. Under notes on this same document dated 10/5/2024, documents, After review of incident statements and knowledge of resident's overall condition, it was reported that resident had large bruise to left breast, originally night nurse felt it was from gait belt. Later that morning day shift nurse came and got DON (Director of Nursing) to eval (evaluate) area. Assessment showed large bruise discoloration to entire left breast, appeared to be very enlarged/swollen, as well with an area protruding around clavicle area. Was also some bruising/discoloration to right breast and side. This discoloration and swelling were a concern, floor nurse instructed to notify MD and send her (R1) to hospital for eval. On 10/9/2024 at 8:50 AM, V1 (Administrator) stated R1's family member transferred her from the wheelchair to the bed then bruising occurred. R1 was sent out to the hospital due to bruising. V1 stated now the family is taking R1 to a different facility. V1 stated the bruising is also from R1 being on a blood thinner. On 10/9/2024 at 10:25AM, V8 (RN) stated she worked on 10/4/2024 the morning that R1 was sent to the hospital for bruising on her chest. The CNA's called me to the room. The areas to R1's chest were dark purple in color and the left breast had what appeared to be a hematoma. V8 stated the incident report was already done by the night nurse. V8 stated there were no reports of falls. V8 stated that R1 was confused. V8 stated we reported to the DON (Director of Nursing), and we sent R1 out to the hospital. V8 stated that R1 was in a lot of pain when she saw her. R1's EMS (Emergency Medical Service) Report dated 10/4/2024 documents at 7:33AM. Responded to (Facility Name) (resident room #) for a [AGE] year-old female with bruising and pain. Upon arrival the patient was in bed, in her room laying on her right side. Nursing staff reported in her rib cage bilaterally and under her breasts and arms bilaterally. Nursing staff did admit to using an under the arm lifting method to transition the patient from the bed to wheelchair. Patient was going to local hospital for evaluation and possible pain control. The patient was responsive to pain, but otherwise did not communicate due to being very hard of hearing. Patient had bruising to above mentioned areas. No vital signs were assessed on the patient during transport due to her pain and lack of communication. The patient did not have any other traumatic injuries noted during the assessment. On 10/9/2024 at 11:44 AM, V10 (emergency room /RN) stated she was the nurse in charge of care for R1 on 10/4/2024. V10 stated R1 was in severe pain to the point it hurt her to even remove the covers to assess her. V10 stated the bruising was really bad and the left breast was swollen at least double the size of the right breast. V10 stated the paramedics that brought R1 in stated the staff informed them that the resident is transferred by way of a bear hug or arm to arm transfer. V10 stated the only way the pain could be controlled was with Fentanyl and stated actually the resident probably needed more pain relief but with her age it would have been too dangerous to give her more. V10 stated R1 was finally able to rest if nobody touched her. V10 stated R1 was admitted to SCU (Special Care Unit) in the hospital for monitoring. V10 stated R1 was on Eliquis which made the bruising probably spread more but it did not cause the actual bruising and swelling. V10 stated R1 was admitted to SCU for close monitoring and pain control. On 10/10/2024 at 8:15 AM, V19 (Primary Care Physician) stated he was the Primary Physician for R1, but R1 was seen by hospitalist V20 (Nurse Practitioner/NP) V20 and V29 (NP) during her hospitalization but he was consulted about the bruising. V19 stated that Eliquis does not cause spontaneous bruising and the bruising had to start with some type of trauma. V19 stated R1's hemoglobin also dropped during the hospital stay and the Eliquis was stopped. V19 stated R1 was in a lot of pain with the areas to the chest wall. V1 stated he was not sure what caused the trauma, but he knows something happened. V19 stated the hematoma even extended into the pectoris muscle. On 10/10/2024 8:20AM, V20 (NP) stated she took care of R1 during her last few days of hospitalization . V20 stated Eliquis does not develop spontaneously bleeding like this. V20 stated, I have not been told what happened to R1 but something trauma related happened, maybe not intentional though. V20 stated it could be someone handled her wrong or transferred her wrong. V20 stated R1's hemoglobin dropped from 8.1 to 7.2 during hospitalization . V20 stated R1 will be discharging to a different facility and on Hospice. V20 stated R1 was in pain that we were controlling with Fentanyl in the ER (emergency room ) and Morphine and Vicodin while in SCU (Special Care Unit). On 10/14/2024 at 12:05 PM, V18 (NP) stated she saw R1 in the emergency roiagnom on [DATE]. V18 stated R1 was in pain and was noted to laying in the fetal position with her hands over her face. V18 stated R1 appeared sleepy due to the IV (Intravenous) medication of Fentanyl that was given for pain. V18 stated the bruising was all over the chest but more significant in the left breast with a hematoma noted. V18 stated the family was very upset and was concerned that by the bruising, someone had held down the resident. V18 stated the resident was admitted to the hospital due to the bruising / hematoma, to monitor pain control and to arrange for a safe discharge as family did not want R1 returning to the Long-Term Care facility where she was living. V18 stated R1 is on Eliquis, and this may have made it worse, but some type of injury happened to the left chest/breast for sure. V18 stated some kind of injury occurred to the chest especially the left chest/breast. V18 stated the injury is unknown at this time as the facility denied any type of fall, they had no explanation of how the injury occurred, and this is not bruising from any type of gait belt due to the markings. V18 stated pictures were taken in the emergency roiagnom on [DATE], but on 10/5/2024 the bruising was worse and even up into the left shoulder. V18 stated R1's kidney function was good for her age and stayed at R1's baseline during hospitalization and platelets were within normal range. V18 stated if this would have been from a blood thinner than the bruising would not have been to this extent and would have been noted over the whole body but this is not from spontaneous bleeding, plus R1's clotting factors were within normal range. V18 stated when R1 was turned she would have discomfort. V18 stated R1 received pain medications during hospitalization . V18 reported R1 received Morphine 1mg per IV (intravenous) push 2 times on the 5th, 1 time on the 6th, 2 times on the 7th, and had doses on the 8th and the 9th for pain. V18 stated R1 also received Norco 5mg a total of 3 doses throughout hospitalization for pain. V18 stated R1 needed pain medications because when she had to be checked or turned, she would have discomfort. V18 stated R1 had low fluid and food intake during hospitalization and discussion was held with the family about the low intake and pain and family agreed to Hospice Care. V18 stated resident had a decline and with her age Hospice was the best choice and they could control her pain. V18 stated R1 was discharged to a different Long Term Care Facility under Hospice care for Pain control. R1's Imaging Report Cat (computed tomography) Scan of Chest with contrast dated 10/4/2024 for Hematoma of the chest. Findings: There is extensive ground -glass in the subcutaneous fat with collection in the left subcutaneous soft tissues with appears to extend to or potentially involve the left pectus measuring 8.2x4.2x8.9 centimeters. Impression: Large left chest subcutaneous hematoma which may involve the left pectoralis muscle. There is no acute osseous abnormality or fracture identified. R1's emergency room Emergency Progress Notes dated 10/4/2024 documents, Physical Exam, Pain Distress: Moderate, Skin: Reports warm, dry, and other (Extensive bruising on anterior chest wall, more on left breast with tense hematoma. Some bruising noted on the left lateral chest wall and extending to the right side and some of the upper abdomen. Medications given in the emergency room were Fentanyl Citrate 50 mcg (Micrograms) IVP (Intravenous Push) 10/4/2024 at 8:14 AM, Zofran 4mg (Milligrams) IVP 10/4/2024 at 8:14AM, last dose of Fentanyl 50 mcg IVP documented 10/4/2024 at 8:29AM and last dose of Zofran 4mg IVP 10/4/2024 at 8:28AM. R1's Physician Progress note dated 10/6/2024 documents Chief Complaint: Acute Dehydration, Hydronephrosis, and Hematoma of breast. Documents patient is uncomfortable when turning or getting cleaned up. Moans often. Doesn't converse. Significant bruising noted across chest. Hematoma/tense area of left breast. Provider documented as V18. R1's Discharge Summary dated 10/9/2024 include admission diagnoses of Chest Wall Hematoma, Severe right sided Hydronephrosis, history of Deep Vein Thrombosis, Hypertension, Hyperlipidemia. Discharge diagnoses include, Chest wall hematoma (unknown etiology), Severe right sided hydronephrosis, hypoglycemia, low bicarb, history of deep vein thrombosis, hypertension, hyperlipidemia, right foot wound, and Alzheimer's disease. Document includes Primary Care Physician as V19. R1's Progress notes dated 10/7/2024 documents Sodium remains low despite fluids; Hemoglobin continues to trend down. Continue to hold Eliquis. Pain Control. Referral to a different Long Term Care facility. Patient not eating or drinking and recommended hospice at this time. R1's Discharge Summary dated 10/9/2024 documents R1 discharged to a different Long Term Care facility under hospice care. Prescriptions sent for Morphine and Ativan. Documented Acute Posthemorrhagic Anemia. Document signed by V20. On 10/9/2024 reviewed photos taken in the emergency roiagnom on [DATE], R1's left lateral chest area with noted bruising with non-bruised line in between bruising. Bruising to this area was noted to be red in color. Photo of Chest show dark red/purple bruising to the left breast, the left breast has edema noted, under the left breast and discoloration up to the anterior axilla area and down left inner aspect of left arm. Bruising noted to the middle of the chest as well. Bruising dark red / purple bruising noted right side of Chest area involving the right breast, under the right breast into the abdominal area and up to the anterior part of the chest above the breast up to the top of the shoulder to the right chest. On 10/10/2024 at 11:00 AM, V23 (Certified Nurse Assistant/CNA) stated she was working the morning of 10/4/2024 and saw the bruising on R1's breast. V23 stated she left her in bed and went to get the nurse because R1 was in so much pain we could not even touch her. V23 stated the nurse got the DON and then the resident was sent out to the hospital. V23 was asked how she normally transferred her, and she stated, we always use 2 people and we each get under her arm and under her knee and move her that way. V23 stated this is the safest way to transfer the resident. V23 stated she doesn't use a gait belt very often while transferring residents. On 10/9/2024 at 11:16 AM, V12 (CNA) was asked if he cared for R1 on 10/3/2024 or 10/4/2024. V12 stated he did not care for R1 on 10/3/2024 but came in on 10/4/2024 and saw all the bruising and reported to the nurse. V12 stated he was told the bruising was found on 10/3/2024 on the evening shift. V12 stated R1 was in severe pain and couldn't hardly tolerate being touched. V12 stated he did not know how the bruising happened. V12 was asked how he transferred R1 to the bed or wheelchair. V12 stated, I always do the arm and arm transfer with her by myself. V12 stated like a bear hug, he places his arms under R1's arms and they are facing each other, and he lifts and turns to place her in the bed or in the wheelchair. V12 stated it really depends on how busy we are too. V12 was asked if he has a gait belt available and he stated , Not on me. I have one probably in my car. V12 was asked why he does not use a gait belt to transfer R1 and V12 stated, I usually don't have time, nor do we have the staff to take the time and do that. V12 was asked if he had gait belt training and he stated, The last time was in CNA class, and I have not had any training here. V12 stated on the morning of 10/4/2024, I know R1 was crying in pain, and it did look really bad. On 10/10/2024 at 10:30 AM, V12 stated he was working the morning R1 was transferred out and R1 was in horrible pain and could not stand to be touched. V12 stated he helped transfer R1 to the stretcher with EMS (Emergency Medical Services) and they had to use a draw sheet to move her because of the pain. V12 stated he explained to the medics how the resident is normally transferred, and he explained that he uses the bear hug technique when he puts his arms under her arms and lifts, and she puts her arms around him like a hug and then he lifts and turns. On 10/10/2024 at 10:50 AM, V25 (CNA) stated she laid R1 down on 1/3/3034 after lunch and she used a gait belt. V25 stated, I usually get someone to help but I can safely transfer her by myself. V25 stated she didn't remove R1's sweater and she did not notice any type of bruising and R1 did not complain of any pain. On 10/10/2024 at 5:27 PM, V26 (Registered Nurse/RN) stated he was working on 10/3/2024 when he was summoned to the shower room to look at R1's left breast. V26 stated R1's left breast was swollen and had some bruising and slight bruising under the left arm. V26 stated he palpated the left breast and R1 didn't show signs of pain. V26 stated he felt the bruising was all superficial and it wasn't a big concern because the resident was on Eliquis. V26 stated he checked on R1 throughout the night by peeking in her room and R1 was resting in bed with no signs of pain or discomfort. V26 stated he last checked on R1 around 4;30AM and she was resting. V26 stated he notified the MD and DON early morning on the 4th and could not reach the family. On 10/10/2024 at 5:41 PM, V27 (CNA) stated, I went to get R1 up for a shower after supper and she was sitting in her room in her wheelchair, so I took the shower chair back to the shower room and went back and pushed R1 in her wheelchair to the shower room. I asked V24 to help with the transfer as the shower chair is higher than the wheelchair. V27 stated the transfer went fine but no gait belt was used. V27 stated, I then started undressing R1 and that is when I saw the bruising. V27 stated, I had gotten R1 up for supper, but she still had on a sweater, and I did not see her chest or any upper body parts. V27 stated, I transfer R1 usually by myself and I have her to hug me, and I wrap my arms around R1 under her arms and pull the back of her pants and turn. V27 stated it is a smooth transfer. V27 stated, I asked someone to get the nurse when I saw the bruises and I got clearance from the nurse to complete the shower and so I completed the shower and put the resident to bed. V27 stated there were no complaints of pain at that time. V27 stated the grand daughter had been there during supper meal and pushed R1 back to her room but did not put her to bed. On 10/10/2024 at 6:10 PM, V28 (CNA) stated she worked on 10/3/2024 but she did not get R1 out of bed for supper. V28 stated she was in the shower giving another resident a shower when she heard another CNA state come her and look at this bruise on R1. V28 stated she went over and looked at the bruise on R1's left breast. V28 stated it was bad and it was swollen. V28 stated her breast were lop sided. V28 stated the nurse came into the shower room and looked at the breast and said to continue shower and then they took her to bed. V28 stated when she does transfer R1 she always has someone help her and they lift under the arms. V28 stated, We never use a gait belt. On 10/10/2024 11:40 AM, V24 (CNA) stated she was working the night of 10/3/2024 when the bruise to R1's left breast was noted. V24 stated she was summoned to the shower room to help with transfer to shower chair. As R1 was being undressed she and the other CNA noticed the bruise to the left breast and called for the nurse. V24 stated she never uses a gait belt when transferring residents. V24 stated when she transfers R1 she always gets help because she is fragile. On 10/15/2024 at 9:54 AM, V29 (ER/Physician) stated he took care of R1 while she was in the ER. V29 stated there was much bleeding noted with the bruising and the hematoma to the left breast. V29 stated R1 was in bad pain, and it was controlled with IV (Intravenous) medications. V29 stated R1 mostly laid in the fetal position on her right side with her hands over her face. V29 stated he is not sure what happened, and he could not say if the bruising was from a traumatic or non-traumatic injury. V29 stated with R1 being on Eliquis, the bleeding and bruising was probably worsened due to the blood thinner. 2. R2's Admission Record includes admitted [DATE] and diagnoses of ST Elevation Stemi (ST-segment Elevation Myocardial Infarction), Pneumonitis, Atherosclerotic Heart Disease, Aortocoronary Bypass Graft, Dependence of Supplemental Oxygen. R2's MDS (Minimum Data Set) dated 9/18/2024 includes a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. Section GG Functional Abilities and Goals document R2 requires partial/moderate assistance with toileting, shower, upper body dressing and lower body dressing. R2 requires supervision/or touching assistance with car transfer, walking 10 feet, 50 feet, and 150 feet, transferring to toilet, sit to stand. R2's Care plan documents R2 is a potential risk for falls and injury due to shortness of breath, weakness, pain, hypertension, hard of hearing, confusion, diabetes, oxygen dependence. Care plan documents on 10/3/2024 at 1630 (4:30pm) with Fall transport van (minor injury) revision date 10/8/2024. R2's Witnessed Fall Report dated 10/3/2024 at 4:30 PM documents, Incident location: out of facility/during transport and person preparing report is V8 (DON). Incident description: On 10/4/2024 at approximately 9:30 AM it was reported to DON that resident was stating that while she was being transported back to facility via transport van that her wheelchair tipped all the way over backwards. This was not reported to nursing staff that she had a fall in van. R2 stated My chair tipped over backwards; girl lifted me back up. Immediate action taken: After speaking to CNA/transport driver (V5) she stated that yes, her wheelchair tipped all way over backwards when she hit her breaks. Floor nurse was notified of resident's statement that she had fallen in wheelchair yesterday. She was assessed by nurse immediately after being informed, noted bruise to back of shoulder, no swelling, did complain pain at site. MD (Medical Doctor) notified for x-ray, obtained. Documents MD notified on 10/4/2024 at 10:00AM and Family member notified on 10/4/2024 at 2:00PM. Written statement signed by V5 documents incident occurred on 10/3/2024 at approximately 3:30PM. Incident described in written document including R2 did complain that her shoulder hurt, and she checked her shoulder to see if anything was wrong with it, there was nothing wrong. Document also includes documentation of Did not report incident to the nurse. On 10/9/2024 at 10:20 AM, R2 was being transferred into bed with assistance of V3 (Certified Occupational Therapy Assistant/ COTA) using a gait belt. R2 was asked if she had any pain anywhere and R2 stated my shoulder is a little sore and a little bruised. R2 stated she fell back and sideways in her wheelchair while in the van coming back from a doctor's appointment. R2 stated, 'they didn't strap me down very good. R2 stated, I told my daughter when she came to visit, and she didn't know anything about it. R2 stated then the nurses came and checked her out and then she had an x-ray of her shoulder. R2 stated V3 came in the room when her daughter was there visiting, and my daughter told her about it. On 10/9/2024 at 10:24AM, V3 COTA stated she came in the room on 10/4/2024 and the daughter was in the room and R2 had told her about the incident in the van. V3 then stated she reported it as well. V3 stated the shoulder has not affected R2's therapy at all. V3 stated R2 doesn't complain of pain to her during therapy. On 10/9/2024 at 10:00AM observed R2 in room with light colored old bruising noted to back of right shoulder. On 10/10/2024 at 1:00PM, V1 stated she had never been told there was an issue with the van or with the red light not functioning properly. V1 stated V5 did not report to any staff upon return with R2, that an incident occurred. V1 stated V5 was terminated because of not reporting the incident. On 10/9/2024 at 1:38PM, V5 (Transportation/CNA) stated she had strapped R2 in the back with the straps in place. V5 stated as she was pulling out from a stop light the wheelchair flipped back and the resident stayed in the wheelchair and fell backwards. V5 stated she was on the interstate, so she had to pull off and help the resident back into the wheelchair. V5 stated R2 denied any pain or injuries. V5 stated when she returned to the facility, she took R2 to her room and helped her into bed. V5 stated she forgot to tell anyone about the incident. V5 stated the next day she told the Administrator, Director of Nursing and Maintenance that the red light on the white van was not working properly to let you know if the wheelchair is secure. V5 stated she was terminated for not reporting the incident when she returned to the facility. R2's Progress Notes dated 10/4/2024 at 9:07 AM documents R2 complained of right shoulder pain, Oxycodone HCL 5mg (milligram) tablet given. Note dated 10/4/2024 at 11:16 AM documents R2 complained of right shoulder pain, MD (Medical Doctor) notified, orders for mobile x-ray. Family at bedside and notified. Note dated 10/6/2024 at 12:18PM documents X-ray results received noting no fracture or dislocation. Family notified. 3. R3's Admission Record includes an admitted [DATE] and includes diagnoses of Acute Kidney Failure, Repeated Falls, Anemia, Major Depressive Disorder, Muscle weakness Type 2 Diabetes Mellitus, Hypertension. R3's MDS (Minimum Data Set) dated 10/1/2024 includes a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. Section GG documents R3 uses a manual wheelchair, R3 requires supervision with toileting hygiene, partial to moderate assist with shower/bathing, lower body dressing, and putting on/taking off footwear. R3 requires set up assistance with eating, oral hygiene, and upper body dressing. Partial/moderate assistance with sit to stand, chair/bed-to chair transfer, shower transfer, and walking. R3 is independent with wheelchair mobility. R3's Care plan documents Focus R3 is at risk for falls and injury, Interventions supervise resident and assist appropriately with transfers with revision date of 9/21/2023. On 10/9/2024 at 1:15PM, R3 stated when the staff help her to and from bed, they do not use any type of belt for transfers. R3 stated they just get my arms and help me. R3 stated she has not had any injuries from transfers. On 10/10/2024 at 1:00PM observed V7 (CNA) and V25 (CNA) transfer R3 from wheelchair to bed with assist of 2 and the proper use of a gait belt. No concerns noted. At that time R3 stated What is that thing you are putting around me, are you going to hang me or something. 4. R11's Admission Information documents admitted [DATE] with diagnoses of Nondisplaced fracture of right Femur, Severe Protein-Calorie Malnutrition, Heart Failure, Anxiety Disorder, Chronic Kidney Disease stage 3. R11's MDS (Minimum Data Set) dated 10/9/2024 includes a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. Section GG documents R11 requires Partial/moderate assistance with Shower/bathing, toileting hygiene, upper body dressing, lower body dressing, putting on/off footwear, and personal hygiene. R11 also requires Partial/moderate assistance with sit to stand position, chair/bed transfer. On 10/9/2024 at 1:50PM observed V6 (Licensed Practical Nurse) transfer R11 from wheelchair to bed with no gait belt. Facility's Policy and Procedure for Gait Belt Use undated, documents in part, Always use a Gait Belt unless it is contraindicated: A) Bone cancer involving the spine. B) Fractured ribs. C) Over an ostomy. D) Over an open healing incision. E) If it causes pain or fear.

Based on interviews and record review the facility failed to notify a family member and physician of a change in condition due to injuries of 2 of 4 resident (R1 and R2) in the sample of 11. Findings include: R2's Admission Record includes admitted [DATE] and diagnoses of ST Elevation (Stemi) Myocardial Infarction, Pneumonitis, Atherosclerotic Heart Disease, Aortocoronary Bypass Graft, Dependence of Supplemental Oxygen. R2's Responsible party was listed as V30 (family member). R2's MDS (Minimum Data Set) dated 9/18/2024 includes a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. Section GG Functional Abilities and Goals document R2 requires partial/moderate assistance with toileting, shower, upper body dressing and lower body dressing. R2 requires supervision/or touching assistance with car transfer, walking 10 feet, 50 feet, and 150 feet, transferring to toilet, sit to stand. R2's current Care plan documents R2 is a potential risk for falls and injury. The care plan documented on 10/3/2024 at 4:30PM, fall transport van (minor injury) revision date 10/8/2024. On 10/9/2024 at 7:20AM, V30 (family member) stated she came out to visit R2 on 10/4/2024 and R2 told her about an incident that occurred on 10/3/2024 during transporting back to the facility via the facility van. V30 stated R2 said while she was sitting in the back of the facility van, suddenly, her wheelchair tipped all the way backwards and she fell with the chair. V30 stated R2 complained of pain to her right shoulder and there was some bruising noted to the right shoulder. On 10/9/2024 at 8:50 AM, V1 (Administrator) stated transportation aid did not report an incident that occurred on the transportation van with a R2 on 10/3/2024. V1 stated R2 reported the incident to V30 and that is how we found out about it and started an investigation. On 10/9/2024 at 10:20 AM, R2 was asked if she had any pain anywhere and R2 stated my shoulder is a little sore and a little bruised. R2 stated she fell back and sideways in her wheelchair while in the van coming back from a doctor's appointment. R2 stated, They didn't strap me down very good. R2 stated, I told my daughter when she came to visit, and she didn't know anything about it. R2 stated then the nurses came and checked on her she had an X-ray of her shoulder. R2 stated V3 (Certified Occupational Therapy Assistant/COTA) came in the room when her daughter was there visiting, and my daughter told her about it. On 10/9/2024 at 10:24AM, V3 stated she came in the room on 10/4/2024 and the daughter was in the room and R2 told her about the incident and V3 reported it as well. V3 stated the shoulder has not affected R2's therapy at all. V3 stated R2 doesn't complain of pain to her during therapy. On 10/9/2024 at 1:38PM, V5 CNA/Transportation (Certified Nurse Assistant) stated she had strapped R2 in the back of the van with the straps in place. V5 stated as she was pulling out from a stop light the wheelchair flipped back and the resident stayed in the wheelchair and fell backwards. V5 stated she was on the interstate, so she had to pull off and help the resident back into the wheelchair. V5 stated R2 denied any pain or injuries. V5 stated when she returned to the facility, she took R2 to her room and helped her into bed. V5 stated she forgot to tell anyone about the incident. Document titled Witnessed Fall dated 10/3/2024 at 4:30 PM documents, Incident location: out of facility/during transport and person preparing report is V8 DON (Director of Nursing). Incident description: On 10/4/2024 at approximately 9:30 AM it was reported to DON that resident was stating that while she was being transported back to facility via transport van that her wheelchair tipped all the way over backwards. This was not reported to nursing staff that she had a fall in van. R2 stated My chair tipped over backwards; the girl lifted me back up. Immediate action taken: After speaking to CNA/transport driver she stated that yes, her wheelchair tipped over backwards when she hit her breaks. Floor nurse was notified of resident's statement that she had fallen in wheelchair yesterday. She was assessed by nurse immediately after being informed, noted bruise to back of shoulder, no swelling, did complain pain at site. MD (Medical Doctor) notified for x ray, obtained. Documents MD notified on 10/4/2024 at 10:00AM and Family member notified on 10/4/2024 at 2:00PM. Written statement signed by V5 documents incident occurred on 10/3/2024 at approximately 3:30PM. Incident described in written document including R2 did complain that her shoulder hurt, and she checked her shoulder to see if anything was wrong with it, there was nothing wrong. Document also includes documentation of Did not report incident to the nurse. 2. R1's Admission Record documents an admitted [DATE]. Document titled Medical Diagnoses include fracture of femur, Atherosclerotic Heart Disease, Hyperlipidemia, Abnormal Posture, R1's MDS (Minimum Data Set) dated 9/9/2024 includes a BIMS (Brief Interview for Mental Status) score is 5 indicating severe cognitive impairment. Section GG of MDS documents Functional Limitation in Range of Motion R1 has impairment to both sides of upper extremities, and impairment on one side of Lower extremity. Mobility devices used is a wheelchair. Documentation includes R1 is Dependent for Bed mobility, sit to lying, lying to siting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and tub/shower transfer. R1 is dependent on staff for wheelchair mobility. R1's Care plan documents Focus R1 requires restorative nursing for dressing and /or grooming related to decreased ability to perform ADLs (Activities of Daily Living) with revision date of 2/29/2024, Intervention encourage and assist R1 in performing upper and lower body dressing and or grooming with set up and verbal cues as often the opportunity present itself. Incident report for R1, on an untitled document dated 10/3/2024 at 7:30 PM document's location: Shower, person reporting incident was V26 (Registered Nurse/RN). Incident description: Bruise to left chest/breast noted upon shower. Resident denied any complaints of pain to area with palpitation. Immediate action taken description: MD (Medical Doctor), POA (Power of Attorney), and administration on call notified. The same document documents the actual times and dates the notifications were made, on 10/4/2024 at 5:58 AM, V8 DON and Physician notified, and POA notified at on 10/4/2024 at 5:59AM. R1's Progress Notes dated 10/4/2024 at 5:45 AM documents, Large purple bruise noted to the left chest/breast area with shower. Resident denies pain to area with palpation. Resident denies any knowledge of cause when asked. MD notified. POA called and left message to return call. Admin on call notified. Author V26 RN. On 10/9/2024 at 8:50 AM, V1 (Administrator) stated she wasn't notified of R1's bruising until the morning of 10/4/2024 when the resident was getting sent to the hospital. V1 stated she wasn't aware there was an issue until the family came to the facility on [DATE]. V1 stated she did not get to see the bruising herself. On 10/10/2024 at 5:27PM, V26 (Registered Nurse) stated he was working on 10/3/2024 when he was summons to the shower room to look at R1's left breast. V26 stated R1's left breast was swollen and had some bruising and slight bruising under the left arm. V26 stated he palpated the left breast and R1 didn't show signs of pain. V26 stated he felt the bruising was all superficial and it wasn't a big concern because the resident was on Eliquis. V26 stated he checked on R1 throughout the night by peeking in her room and R1 was resting in bed with no signs of pain or discomfort. V26 stated he last checked on R1 around 4:30AM and she was resting. V26 stated he notified the MD and DON early morning on the 4th and could not reach the family. Facility Policy and Procedure named Accident/Injury/ Change in Condition review date 4/20/2024 reviewed. Documentation for Purpose: It is the policy of the facility to notify the resident's physician of any accident, injury, or significant change in condition. If unable to notify the resident personal physician, the staff will notify the Medical Director. Documentation for Responsibility: It is the responsibility of the staff nurse on shift to notify the family and physician of any accident, injury, or significant change in condition. Documentation of Procedure: 1. The resident's nurse will notify the personal physician of any accident, injury, or change in condition. 2. The resident's nurse will notify the family member and /or guardian of any accident, injury, or change in condition.

Based on observation, interview, and record review, the facility failed to monitor weights and implement interventions to prevent weight loss for 1 of 3 (R3) residents reviewed for nutrition in a sample of 8. This failure resulted in R3 sustaining 9.5% weight loss in less than 1 month and. a 14% weight loss in less than 3 months. Findings include: R3's Admission Record documents an admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Mild protein-calorie malnutrition, Pulmonary Hypertension, Parkinson's Disease, and Repeated Falls. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13 indicating R3's cognition is intact. Section GG, Functional Abilities, indicates R3 requires set up or clean up assistance with eating. Section K, Swallowing/Nutritional Status, documents that R3 weighs 180 lbs, R3 has had a gain of 5% or more in the last month or a gain of 10% or more in the last 6 months, and R3 is not on a physician-prescribed weight-gain regimen. R3's Monthly Weight Report documents a weight for August 2024 of 181.2 lbs September 2024 of 174 lbs. R3's Weights and Vitals Summary in the Electronic Health Record documents R3's weight on 7/1/24 was 189.2 lbs, 7/8/24 was 187 lbs, 7/15/24 of 183 lbs, 7/22/24 of 180 lbs, 8/5/24 of 181.2 lbs, 8/26/24 was 179 lbs (pounds), on 9/6/24 was 174 lbs, on 9/10/24 was 170.4 lbs, and on 9/23/24 was 166 lbs. A handwritten note on this same report documents a corrected weight of 162 lbs on 9/24/24. The documented weights from 8/26/2024 to 9/24/2024 indicate that R3 had a 9.5% weight loss in less than 1 month. The documented weights from 7/1/24 to 9/24/24 indicate that R3 had a 14% weight loss in less than 3 months. R3's Care plan includes a focus area (with a revision date of 4/27/2024) of R3 was admitted with history of weight loss with frequent poor intakes and diagnosis of malnutrition. IBW (Idea Body Weight) is 151 pounds-163 pounds. The documented Goal (with revision date of 8/14/2024) of R3 will maintain weight of 154 pounds or more through next review with target date of 11/15/2024. R3's Order Summary Report with active orders as of 9/24/24, documents diet of Mechanical Soft Texture, honey consistency liquids and ground meat with an order date of 9/23/2024 and an order dated 9/24/24 for Arginaid 2 times a day for wound healing. There were no other orders documented on the Order Summary Report for nutritional supplements. R3's Most recent Nutritional assessment dated [DATE], documents assessment as Annual Assessment. R3's weight documented on assessment is 186.2 lbs, height 70 inches with BMI of 26.7. Ideal Body Weight 149 pounds-183 pounds. Diet is documented as Regular, mechanical soft with honey thick liquids. The same assessment documents there have been significant weight changes, marked as weight gain of 1.5% in one month. R3's feeding ability is marked as self-fed after tray set up and documents a goal of weight maintenance by monitoring weekly weights. This Nutritional Assessment is signed by V 15 (Registered Dietitian). On 9/24/2024 at 12:50PM, R3 was observed resting in bed, refused interview. R3's bedside table was observed with a snack within reach. R3 had tray on the bedside table with approximately 25% of food consumed. There were no dietary supplements noted on R3's tray. On 9/24/2024 at 2:50PM, V15 (Registered Dietitian) was asked for notes for R3 in relation to his weight loss over the last 3 months from 187.6 to 162.0 as of today 9/24/2024. V15 was asked if she has seen R3 over the last 3 months due to his weight loss, V15 stated I am seeing him today. V15 was asked how she determines who she sees. V15 stated she gets a list from the dietary manager. V15 was asked if she was aware of the weight loss over the last 3 months, V15 stated I guess I don't, but you should know to expect a weight loss on a resident with Parkinson's. On 9/24/2024 at 2:55 PM, V16 (Dietary Manager) stated she makes the list of residents for V15 to see with her visits to the facility. The list provided was reviewed with V15 and V16 and R3 was not on the list to be seen for the last 3 months. V16 stated R3 does get ice cream at times and puddings but was aware there is no order to show this is being offered on a routine basis to promote weight gain. On 9/24/2024 at 3:00PM, V2 (Director of Nursing) provided a folder that contained monthly list of residents to be seen by V15 upon visits and verified R3 had not been placed on the visit list for V15 for the last 3 months. R3's nutritional assessment dated [DATE] was reviewed with V2. V2 stated R3 should have those assessments done quarterly. V2 stated she will make sure the weights are managed better and the list will reflect any weight losses. V2 verified R3 has ice cream under the task of the EHR (Electronic Health Record) but is not ordered to receive on a regular basis for weight promotion. V2 stated the weights were managed by V19 (Assistant Director of Nursing) who recently quit her job and V2 had to get weights caught up and reviewed appropriately. V2 stated R3 is on daily weights but was unsure when this was put into place and if so when this was used as an intervention. V2 was asked if R3's weight loss would be considered a significant weight loss and V2 stated yes, it is. V2 stated R3 has had frequent readmissions, and the ice cream and pudding did not get reinstated on one of the readmissions, we just missed it. On 9/24/2024 at 4:50 PM, this surveyor met with V2 and V4 (President/Owner) V4 stated V1 (Administrator) would be taking over the weight monitoring meetings and work with V2 to make sure the issues are addressed properly. V2 stated she was getting an order for ice cream and pudding for R3. The facility policy titled Weight Loss dated 3/31/2024, documents under Purpose that the facility will ensure that each resident maintains acceptable parameters of body weight, unless the resident's clinical condition demonstrates that this is not possible. Responsibilities documents, it is the DON, Quality Assurance, and Dietary manager to monitor the weight loss of residents. Under the section titled Procedure, #2. e) Calculate weight losses and notify the resident's physician and dietitian if there has been a 1.) 5% weight loss in one month, 2) 7.5% weight loss in 3 months, 3) 10% weight loss in 6 months.

Based on observation, interview, and record review, the facility failed to ensure completely trained, qualified Certified Nurse Aide staff were present to provide routine care and meet residents' needs, including safe transfer/ambulation assistance for 1 of 3 (R2) residents reviewed for falls in the sample of 7. Findings include: R2's Admission Record documents admitted [DATE] including diagnoses of Muscle weakness, lack of coordination, abnormal posture, Cerebral Infarct followed by aphasia, dysphagia, abnormalities of gait and mobility, and Alzheimer. R2's MDS (Minimum Data Set) dated July 24th, 2024, includes BIMS (Basic Interview for Mental Status) score of 4 indicating severe cognitive impairment. Section GG indicates R2 is a set up for eating, partial/moderate assistance is needed for toileting, bathing, dressing and personal hygiene. R2 requires supervision or touching assistance with ambulation. R2's Care plan includes a focus date 3/14/2024, that documents R2 requires restorative nursing for ambulation to maintain or increase current level of function related to limited ability to ambulate. Interventions include ambulate R2 with a wheeled walker as often as opportunity presents itself daily dated 3/14/2024. Care plans focus for falls documents; R2 is at potential risk for falls and injury due to right tibia fracture, unsteady gait/mobility, generalized weakness, Alzheimer's, history of stroke, pain, use of medications with interventions that include R2 to ambulate to dine and to bathroom with supervision, stand by assist with front wheeled walker and to ambulate using front wheeled walker to bathroom with CNA (Certified Nurse Assistant). R2's MORSE Fall Scale reports dated 9/7/2024, 7/25/2024, 4/24/2024, and 1/15/2024 assessment scores indicating R2 has been a high fall risk on all assessments. R2's Fall During Staff Assist dated 9/7/2024, documents nursing description: resident being walked by staff with a gait belt back to her room following dinner. Resident got to her doorway and legs gave out and resident was lowered to the floor. Resident description: resident stated that she was not hurt, and she didn't know why her legs gave out, resident stated her shoes were not slick. Document states no injuries observed at time of incident. Document titled Incident Witnessed Statement dated 9/7/2024 at 7:30 PM documents I was walking her to her room with her walker, gait belt on her and she started getting weak as we went into her doorway, so I slowly lowered her to the ground and waited for a CNA (Certified Nurse Assistant) to come help and then she got the nurse, and we helped her back into bed. This document is signed by V9 RA (Resident Assistant). On 9/11/2024 at 3:15 PM R2 was observed lying in bed with O2 on at 2 liters per minute via Nasal Cannula. R2 was noted to be in Isolation due to COVID positive test. Noted walker in room as assistive device. Observed bed in lowest position and non-skid socks on resident. At that time an attempt was made to interview R2, but R2 was non interviewable. On 9/11/2024 3:45 PM, V2 DON (Director of Nursing) stated R2 uses a rolling walker and has someone to walk her to and from the bathroom and to and from the dining room for safety. On 9/10/2024 at 4:05 PM, V1 (Administrator) was asked if RA's (Resident Assistants) are qualified to assist residents with ambulation that uses assistive devices and requires assistance at times, On V1 stated No they are not qualified to do that. On 9/11/2024 at 1:34 PM, V21 RA (Resident Assistant) states she knows R2 requires a CNA to walk with her, with a walker to and from the dining room for safety, so she don't fall. On 9/11/2024 at 12 :51 PM, V19 (CNA/ Certified Nurse Assistant Instructor) stated the RA's (CNA students) have only had one class so far. V19 was asked if the students have been checked off on feeding residents, transferring residents, incontinence care, assisting residents with ambulation, dressing resident. V19 stated no they have not, and they should not be performing those duties, and they all know this. V19 stated the only skills they have been checked off on so far is Pulse/respirations, hand washing, nail care and PPE (personal protective equipment) donning and doffing. V19 stated the students cannot perform any duties without being trained, return demonstration/observation, and checked off if they pass the skills. On 9/11/2024 at 12:48PM, V1 and V2 were asked if there was a checklist of skills for the CNA (Certified Nursing Assistant) students from their instructor. V2 stated no we do not have a check list, but we have talked to her, and she informed us the students have only been checked off on nail care, PPE (personal protective equipment), handwashing and taking pulse and respirations. V2 stated the instructor stated this is all the skills the students should be allowed to do. V2 described RA's assisting residents to and from dining area as pushing wheelchairs and redirecting when residents are confused as to where their room is. On 9/11/2024 at 8:55 AM, V16 CNA (Certified Nursing Assistant) stated RAs (Resident Assistants) help change people and help them get dressed. V16 stated, I see the RAs transfer residents on their own and with a CNA. On 9/12/2024 at 3:35 PM, V9 RA (Resident Assistant) stated she was assisting R2 while ambulating. V9 stated R2 had on a gait belt and was using a walker. V9 was asked if she performs duties such as assisting resident with eating, incontinence care, turning and repositioning residents, transferring residents, and dressing, V9 stated Yes. V9 stated she was told she can't do those duties since she hasn't been checked off by her instructor in class, so she won't be doing those anymore. An undated document titled RA duties documented, 1. Make beds as CNA's are getting residents up for meals. 2. Ice should be passed twice a shift and as requested. 3. Assist residents to and from dining area. 4. Answer call lights and inform appropriate staff of resident needs. 5. Straighten resident rooms. Remove excess linens, briefs, and wipes. 6. Document meal intakes. 7. Pass trays in dining room or hall trays. 8. Stock linen cares during your shift and prior to the oncoming shift. 9. Empty barrels at the end of shifts. 10. Vitals (if you are checked off on them).

Based on interview and record review, the facility failed to provide a safe mechanical lift transfer to prevent falls for 1 of 3 residents (R3) reviewed for accidents in the sample of 7. This past non-compliance occurred between 7/25/24 and 8/9/24. The findings include: R3's Admission Record documents that R3 was admitted to the facility on [DATE]. The same Admission Record also documents some of R3's diagnoses as repeated falls, cerebral infarction due to unspecified occlusion or stenosis or left posterior cerebral artery, difficulty in walking, not elsewhere classified. R3's care plan notes a focus area of R3 has a potential for falls and injury, non-ambulatory, history of falls, requires assist with all ADL's (Activities of Daily Living). One of the interventions listed is mechanical lift with assist of 2 as needed for transfers. R3's MDS (Minimum Data Set) dated 8/3/24 documents R3 is dependent for transfers which indicates the helper does all the effort, resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity. The same MDS documents R3 has a BIMS (Brief Interview of Mental Status) of 09, which indicates R3 has moderate cognitive impairment. On 8/9/24 at 1:00pm, V5 (CNA/Certified Nurse Assistant) said she was working on 7/25/24 when an incident with R3 occurred. V5 stated that her and another CNA were getting ready to transfer R3 from chair to bed using a mechanical lift. V5 stated that they realized that R3 was not in her sling good and said that they had not lifted her yet. V5 stated that they had 2 hooks on the lift and R3 then slid out the chair landing on the footrests and legs of the wheelchair. On 8/9/24 at 1:15pm, V10 (CNA) statedd she was working with V5 when an incident occurred with R3. V10 said she was the standby person helping since she cannot operate the lift due to being only [AGE] years old. V10 stated they had 2 of the hooks hooked to the lift when R3 began to slide out of the sling. V10 was sitting in her chair. V10 stated that when R3 slid out, she landed on the footrests and legs of the wheelchair causing a small scratch to the back of her right thigh. V10 stated she grabbed R3 to ease her landing on the wheelchair leg and footrests. V10 said they had not lifted the lift when R3 slid out of the chair. On 8/13/24 at 8:55am, V11 (Licensed Practical Nurse/LPN) stated the CNA's had R3 hooked to the top of the mechanical lift and went to hook the bottom and R3 just slid down out of her chair. V11 stated after she assessed R3, she only had a scratch on the back of her thigh. V11 stated she thinks the nylon on the sling made it easier for R3 to slide and she just slid right out. V11 also said R3 did not hit anything, she landed on the legs and footrest of the wheelchair. V11 said they had not raised the lift or hooked the last 2 hooks. Facility undated Policy and Procedure of Mechanical Lifts documents in part .Center the sling under the resident (the lower edge of the sling should be behind the knees). Prior to this survey date, the facility took the following actions to correct the non-compliance: 1. All staff were in-serviced on 8/9/24 on preventing falls. Reviewed use of lift for safe transfers, and proper positioning of resident and sling before attempting to transfer a resident using the lift. QA (Quality Assurance) team will be checking all staff off on safe lift transfers over the next 2 weeks. 2. QAPI (Quality Assurance and Performance Improvement) goal setting workshop was held on 8/9/24 on safe positioning and use of mechanical lifts. Goal listed is to ensure safe transfers of resident's requiring mechanical lift transfers. All nursing staff competency with use of mechanical lifts. The measure used will be competency check off with demonstration of safe use of mechanical lifts. The target date for achieving this goal is 8/23/24 completion of competency check off's with all CNA's.

Based on interview and record review the facility failed to ensure a resident received continuous oxygen therapy during a shower for 1 (R3) of 3 residents reviewed for physician's orders in the sample of 3. This failure resulted in R3 becoming unresponsive requiring emergent care with subsequent hospitalization and admission during which time R3 expired. The Findings Include: R3's hospital Discharge Summary record documents in part - Admission: [DATE]; Discharge: [DATE]. Discharge Diagnoses: micturition syncope, syncope and collapse, elevated troponin level not due to acute coronary syndrome, weakness, pulmonary fibrosis, and chronic respiratory failure with hypoxia . Hospital Course: He has a history of pulmonary fibrosis and is on chronic oxygen at ,d+[DATE].5 L (liters) at all times . he worked with physical therapy who recommends disposition to skilled nursing facility. The patient was agreeable to placement . R3's Face Sheet documents R3 was admitted to this facility on [DATE] with admission diagnoses to include - Pulmonary fibrosis, chronic respiratory failure, COPD (chronic obstructive pulmonary disease), and dependence on supplemental oxygen. R3's admission MDS (Minimum Data Set) dated [DATE] section C (cognitive patterns) documents a BIMS (brief interview for mental status) of 15, indicating R3 was cognitive. Section G (function status) documents R3 required limited physical assistance of one person for all ADLs (activities of daily living) and supervision/set-up only for meals. R3 is also assessed to require the physical assistance of one person in part for bathing activity. R3's Care plan dated [DATE] includes - Focus: (R3) has an ADL self-care performance deficit r/t (related to) impaired balance, limited mobility, supplemental oxygen dependency. Goal: (R3) will improve current level of function through the review date. Interventions/Tasks: BATHING/SHOWERING: Avoid scrubbing & pat dry sensitive skin; Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse; (R3) is able to wash his face; (R3) requires extensive assistance by one staff with showering twice a week and as necessary. CNAs (Certified Nursing Assistant) to ensure that (R3) receives at least one shower per week, if two are unable to be given; provide sponge bath when a full bath or shower cannot be tolerated . Date Initiated: [DATE]. Revision on: [DATE]. Canceled Date: [DATE] . Focus: (R3) has COPD, pulmonary fibrosis, chronic resp (respiratory) failure - guaifenesin 1200mg (milligram) 1 tab every 12 hours congestion/COPD; pro-air inhalation 90 base 2 puffs every 4 hours as needed for COPD/Pulmonary fibrosis; albuterol inhalation 2 puffs every 4 hours as needed for COPD/pulmonary fibrosis/shortness breath . Goal: . will display optimal breathing patterns daily through review date. Interventions/Tasks: . OXYGEN SETTINGS: O2 (oxygen) via concentrator at (@) 2L NC (liters nasal cannula) with all activity. Date Initiated: [DATE]. Revision on: [DATE]. Target Date: [DATE]. Canceled Date: [DATE]. R3's [DATE] Physician's Order Sheet included an order for O2 via concentrator @ 2L NC with all activity every shift (Use Code: C-Continuous, I-at Intervals, N - Not in Use) with a start date of [DATE] and discontinued on [DATE]. R3's progress note dated [DATE] at 5:51 PM documents - Therapy notified this nurse resident O2 was dropping in the 80's when they were trying to work with him and while he was sitting. This nurse checked resident tubing for kinks and checked O2 stat, it was 98% (percent) on 2L NC. Resident was anxious and kept holding breath O2 started dropping in the high 80's. Therapy asked if resident had anything for anxiety this nurse could give and then resident requested anxiety medication. This nurse had resident answer questions and O2 went to 93%. Checked MAR (Medication Administration Record) and resident has Buspirone 10 mg TID (three times daily) for anxiety but no PRN (as needed) medication. Notified V14's (Primary Care Physician- PCP) office. (V14's) office called back and said new order for O2 on 3L NC. Order entered and O2 put on 3L. No new order for anxiety medication. Will continue to monitor. R3's new order for O2 via concentrator @ 3L NC with all activity every shift (Use Code: C-Continuous, I-at Intervals, N - Not in Use) was started [DATE], discontinued on [DATE]. R3 is prescribed ProAir HFA (hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (microgram per actuation solution for inhalation) (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for bronchospasms, start date [DATE]. R3's [DATE] MAR confirms R3 was receiving oxygen therapy per physician's orders documented predominantly as continual use with intermittent interval use of oxygen recorded mainly in the morning hours. R3's progress note dated [DATE] at 5:56 PM documents, This nurse was on hall passing medicines when a CNA (Certified Nursing Assistant) came to get me telling me need a nurse. I went into (hall) shower room and found resident non-responsive. I immediately called 911. The CNA told this nurse he had wanted a shower. I had another CNA go get his Oxygen concentrator this nurse put 3L O2 nasal cannula on resident. Had another nurse check code status and determined he was a DNR (do not resuscitate). This nurse waited with resident to monitor him till EMS (emergency medical services) could arrive. EMS arrived approximately (8:20 PM) then left with resident approximately ten minutes later. Notified (V14) via on call service. Notified family via telephone. Author: (V6) Licensed Practical Nurse/LPN. R3's local hospital Ambulance Report dated [DATE] contains the following information - Dispatched AS: Unconscious/Fainting . Date: [DATE], . Onset: 8:08 PM (approximate); At Patient: 8:14 PM; Leave Ref: 8:27 PM; . Transfer Care Destination: 8:46 PM; Available: 9:03 PM; Call Completed: 9:03 PM . Narrative: 911 Dispatch to (nursing home) . for a [AGE] year-old male unresponsive agonal breathing. Upon arrival to nursing home staff brought EMS (emergency medical service) to bathing room where EMS found patient sitting in shower chair with CNA holding patient up with nasal cannula with oxygen going at 2 LPM (liters per minute). Staff state patient was taking a shower and talking with no problem. CNA stated she turned around to grab a towel and turned back and patient head was slumping down and not responding to stimuli. Patient loaded on stretcher and secured with straps, times 5, and loaded and secured in ambulance. Unit 14 with (V20 - Medic) responding and (V21 - Medic) along with (local) first responders. V20 got in ambulance to assist with care of patient. V20 started IV (intravenous) normal saline 18 gauge in left AC (antecubital). Accu check was 151. Patient placed on cardiac monitor showing sinus tachycardia. Initial oxygen saturation was 80%. Patient placed in non-rebreather 15 LPM (liters per minute) with a SP02 (saturation of peripheral oxygen) increase to 97%. Patient blood pressure is elevated, and a repeat was done to confirm BP (blood pressure). Patient pupils are 3 with no response to light. Sternum rub done with no response to painful stimuli. Nursing staff was able to get paperwork together with medical history and a state issued DNR (do not resuscitate) for patient. EMS continued to monitor patient with oxygen decreased to 10 LPM and SP02 continuing at 97%. Patient transported to (hospital) ER (emergency room ) due to possible signs of stroke. Continue to monitor patient with no other changes noted. Patient care and report given to (hospital) ER nursing staff (RN) without incidence. Patient placed in ER room [ROOM NUMBER] at (hospital). All times are approximate . Impression/Diagnosis: Altered level of Consciousness. Initial Patient Acuity: Emergent (yellow) . On [DATE] at 2:06 PM, V3 (CNA) stated on [DATE] she went to R3's room and told him it was his shower day. V3 stated, I asked if he wanted a bed bath or shower. R3 looked at me and stated, you know I haven't had a shower since I've been here, I'm sticky. I want a shower. V3 stated he had bed baths but there's nothing like a shower and today he felt like getting one. V3 stated she took R3 from him room without his oxygen to the shower room. V3 stated from his room to the shower room, to the time he became unresponsive, it was about 10 minutes. I did a quick one for him because I know the oxygen situation. He wanted his head washed really good. He was greasy. I know oxygen patients can't be off of oxygen long. I'm terrified to take the oxygen machine into the shower because of electrical concerns. I monitored his 02 stats the whole time and they were high (mid to high 90's). I don't do that kind of paperwork, but I used the 02 sat monitor on his finger. He was talking with me the whole time and he said, Baby, are we about done? I told him yes and we were drying off and getting dressed. I had him out of the shower, he was in the shower chair. I turned to my left to grab his shirt and went to put his shirt on, and he had his arms up to put the sleeve holes, I got his arms in and then his arms fell into his lap. I called for help immediately. I stuck my head in the hall and V10 (CNA) was right there in the hall (we were using that shower room because they were working on skilled back shower room water). I told him to get the nurse STAT - unresponsive. I never left him alone in the shower. Not even a minute later V6 came in. I'm pretty sure someone took his vital signs, but I don't remember. I think that someone could stay off oxygen for 10 minutes, but in my experience, I didn't think 10 minutes would be that long. What scared me was that he had been talking to me. When asked what electrical concerns one might have with portable oxygen, V3 stated was thinking of the concentrator machines in the room. V3 stated she was not aware she could take a portable with her. V3 stated, I did not know that that R3 was required to be on continuous oxygen . We have residents who take their oxygen off to go to the dining room, but I was assuming he was the same way. This was the second time I had ever worked with R3, and it was never conveyed to me he was continuous oxygen. When asked if R3 had ever sustained a fall while a resident, V3 stated not that she knew of. On [DATE] at 11:50 AM, V6 (LPN) stated she was assigned to the skilled back hall on [DATE] when she was called to the 300-hall shower room by V3 (Certified Nursing Assistant - CNA) stating they needed her assistance with a resident in distress. V6 stated when she entered the shower room R3 was sitting in the shower chair just outside the shower itself. His dentures were protruding from his mouth. V6 stated V3 relayed to her that she was drying R3 off and he started not breathing very well. V6 noted R3's oxygen was not with him in the shower room and stated she immediately told the male staff to go and get his oxygen, then V6 called 911. When asked if R3 had experienced a fall at any time, V6 stated he had not, he remained in the shower chair until EMS (emergency medical services) got there. V6 confirmed R3 had not moved from that spot. V6 was also not aware R3 had ever experienced a fall while a resident. V6 continued to state she asked V3 what R3's code status was, but V3 did not know how to read the board. V6 explained each resident hall had a status board color coded to reflect DNR (Do Not Resuscitate) or Full Code status. V6 stated, at this time the nurse working the 300-hall was able to confirm R3's code status was DNR. The male staff returned with R3's 02 concentrator (it seemed to be approximately ,d+[DATE] minutes from the time I walked in the shower room until it was placed back on him). When R3's 02NC (oxygen per nasal cannula) concentrator was placed back on, his color returned. V6 stated she kept calling R3's name and he would gasp but did not speak. V6 stated, He was still in distress, and I was praying the ambulance would get there quick. V6 stated this was her account of the incident from the time she became involved until the time EMS arrived to transport R3 to the hospital. V6 added that prior to this incident, R3 was a cognitive resident with confusion, but could hold a conversation with her and could tell her exactly how he liked his pills. V6 confirmed R3's shirt was on when she entered the shower room, but no pants at that time. When asked if any vitals were taken during the incident, V6 stated no, she had been on the phone with 911. EMS did take R3's vitals and V6 thought 02 was 100% on NC. R3 was not a dirty man, and you could tell he took care of himself. It's routine for CNAs to give showers while nurses give medications. V6 stated, Had I realized he was being taken down to the shower room, I would have suggested he have his 02 with him. I would have rather he stayed in bed and had a bed bath because he gets out of breath with movement, but he has that right to a shower, and wanted one. R3's hospital ED (emergency department) to hosp (hospital) admitted d [DATE] at 9:13 PM includes - . History of Present Illness: Patient is unable to provide any history. History is obtained from . over the phone, and by EMS, as well as nursing home staff. Nursing home staff states that the patient went to go take a shower and they found him unresponsive on the shower floor. They state they sat him up and then noticed that he was still unresponsive and was not doing anything so call EMS. EMS states that his blood sugar was okay however he has just been moaning . On [DATE] at 2:40 PM, V2 (Director of Nursing - DON) was asked about R3's hospital records documenting on HPI (history of present illness) that R3 was found on the floor unresponsive, as reported in part by nursing home staff. V2 reiterated R3 never sustained a fall, especially on [DATE] and the information obtained was either misunderstood or recorded incorrectly in the report. R3's hospital ED (emergency department) record dated [DATE] at 9:13 PM documents in part that upon re-assessment at approximately 11:49 PM, R3 began to become more awake and started pulling at his tube. told him that we would try him on the ventilator for a bit longer until we can blow off more C02. Patient nodded yes to this and (family) was agreeable with this plan in the ER. Soon after this the patient was extubated to Vapotherm (non-invasive high-flow respiratory support system) and is in no acute distress. He stated that he thought he was still in the nursing home. He is alert and oriented to person and time. He appears comfortable. He has no respiratory distress. He is given antibiotics for possible aspiration pneumonia. Patient was admitted stable to the floor under comfort care/palliative measures . R3's Admission H & P (history and physical) dated [DATE] includes - . patient was found unresponsive but had a pulse. There was no report of vomiting or diarrhea, seizure-like activity, fever or chills, chest pain or palpitations. Patient was in acute respiratory failure requiring intubation on ED presentation. (Blood gas) showed hypercapnic respiratory failure, chest x-ray showed interstitial versus chronic fibrotic lung changes. After discussion with . according to ER report, patient was extubated and made a DNR/DNI (do not resuscitate/do not intubate). Patient placed on high flow oxygen instead and recommended to be admitted for non-aggressive medical management . Disposition: Patient can be discharged back to nursing home with oxygen supplementation if needed, if he shows clinical signs of improvement . R3's progress note dated [DATE] at 8:30 AM documents V2 was updated on R3's condition and plans by family . resident would be going home on hospice and not returning to facility. R3's Discharge/Death Summary from (hospital) dated [DATE] to [DATE] includes - Presenting Problem/History of Present Illness: acute respiratory failure, unspecified whether with hypoxia or hypercapnia. Final Death Diagnosis: Acute on chronic respiratory failure with hypoxia and hypercapnia; community acquired pneumonia; C02 (carbon dioxide) narcosis; severe malnutrition; generalized weakness; pulmonary fibrosis; usual interstitial pneumonitis . Hospital Course: The patient is a [AGE] year-old male who presented to (hospital) with acute on chronic respiratory failure with hypoxemia and hypercapnia, underlying pulmonary fibrosis and new infiltrates consistent with overlapping pneumonia. Presented distressed and was initially intubated until code status clarified with family in ER. Decision to extubate and provide comfort measures. He remained in the company of family and passed away in comfort on [DATE]. R3's Death Certificate records - . 2. date of death : [DATE], . Cause of Death: a. Acute on Chronic Respiratory Failure (2 days). b. Community Acquired Pneumonia (4 days). 29. Manner of Death: Natural . On [DATE] at 1:23 PM, V8 (CNA) stated if a resident required continuous oxygen, you would make sure to take the portable 02 with the resident in the shower and only remove while washing the face to ensure the oxygen was off as short a time as possible because some residents have COPD (chronic obstructive pulmonary disease) and things like that. On [DATE] at 1:30 PM, V9 (CNA) confirmed if a resident required continuous 02 you would take the portable to the shower and work around it. You would never not take the 02 with them to the shower, stating, they could meet Jesus on the way. On [DATE] at 3:05 PM, V16 and V17 (CNAs) were preparing shower sheets for their upcoming shift. When asked how a CNA would determine whether a resident required oxygen and whether it would be intermittent, as needed, or continuous, both stated the easiest thing would be to ask the nurse and that's what they would do. When asked how they would handle a situation in which a resident who was ordered continuous 02 for all activities asked for a shower, V16 and V17 both stated they would take the portable oxygen tank. The portable tanks do not need to be plugged in and residents use those all the time on the back of their wheelchairs, if necessary. On [DATE] at 03:20 PM, V18 (CNA) stated CNAs access resident information on the kiosk or tablet Kardex where they do their charting. V18 was not sure if their information would define whether or not a resident required 02, but most CNAs would ask the nurse. V18 confirmed if a resident required continuous 02 for all activities, he would take a portable tank to the shower room. V18 stated he would be afraid to take them out of their room for the fear they may become short of breath, but if they requested a shower, he definitely would not take them without some form of 02. On [DATE] at 8:19 AM, V11 (LPN) was in the back dining room at this time talking with two CNAs. V11 stated no residents in the dining room are currently ordered continuous 02. V11 showed this surveyor the room where portable 02 tanks are kept. V11 stated all staff are aware of this room and it's accessible to all who need it. On [DATE] at 8:22 AM, V12 (CNA) was assisting a resident with mealtime. V12 stated if she had any questions regarding a resident's orders, she would ask the nurse. She stated if orders were for continuous 02 and that resident was up for a shower, she would take the portable 02 tank. On [DATE] at 8:25 AM, V13 (CNA) was at the hall kiosk charting on a resident. She stated currently there were no resident on continuous 02 on her hall. V13 stated she asks the nurse regarding resident orders because they can't always see them. V13 confirmed she would not take a resident ordered continuous 02 for all activities to the shower room without a portable 02 tank. V13 confirmed all staff are aware of where the tanks are if there is not one in the resident's room. On [DATE] at 2:45 PM, V14 (Primary Care Physician) was provided information received through interviews with V3 and V6 who were involved in R3's incident on [DATE]. This surveyor relayed V3 estimated R3 was without his oxygen about 10 minutes from the time R3 left his room for the shower until the time he became unresponsive and 02 was placed back on R3 in the shower room. When asked if V14 felt being off oxygen during this time would have contributed to an acute respiratory distress event, V14 stated, In my mind the main thing with (R3) was he had end stage lung disease/pulmonary fibrosis. V14 stated that if R3 was without oxygen longer than 10 minutes, he would definitely think that could trigger an event. V14 stated anything less than 10 minutes would not contribute to acute respiratory distress. When asked if he thought this could have contributed to R3's death on [DATE] while in the hospital, V14 did not think the incident on [DATE] would directly relate to R3's death. V14 reiterated the time frame he was concerned R3 would have been without oxygen, stating R3 was oxygen dependent, and he had a terminal illness.

Based on observation, interview, and record review, the facility failed to recognize the urgency of a worsening wound and seek immediate evaluation and treatment after noting a significant change in the condition of the wound for 1 (R38) of 7 residents reviewed for wound care in a sample of 77. This failure resulted in R38 developing gas gangrene with underlying osteomyelitis requiring emergent trans-metatarsal amputation and subsequent Chopart's (forefoot and midfoot) amputation and R38 has been placed on hospice care. The Immediate Jeopardy began on [DATE] when R38 was observed to have a significant change to an existing necrotic wound of the left 2nd toe. The new, necrotic area was observed starting between the previous necrotic left 2nd toe, migrating over between the left great toe and down to the bottom of the left foot. V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on [DATE] at 1:55pm. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the inservice training. Findings include: R38's Face Sheet documents admission to this facility on [DATE] with diagnoses to include type 2 diabetes without complications and blindness in right eye. Additional diagnoses incurred on [DATE] include type 2 diabetes with foot ulcer, type 2 diabetes with other specified complications, acute osteomyelitis, left ankle and foot, and partial traumatic amputation of left foot. R3's annual Minimum Data Set (MDS) dated [DATE] documents R38 to be totally dependent for activities of daily living requiring 2 plus staff for transfer via mechanical lift. R38 is severely cognitively impaired, incontinent of bowel, and has an indwelling foley catheter. R38's Quarterly MDS dated [DATE] and Significant Change MDS dated [DATE] indicate R38's cognition and required assistance needs had not changed from the previous MDS. R38's Braden Assessments include: On [DATE], R38 is assessed to be at very high risk with a score of 9 (at risk ,d+[DATE], moderate risk ,d+[DATE], high risk ,d+[DATE], very high risk 9 or below); On [DATE], R38 is assessed to be at moderate risk with a score of 13. On [DATE], R38 is re-assessed to be at very high risk for skin breakdown, scoring a 9. R3's care plan dated [DATE] includes the following: Focus: (R38) has potential for altered skin integrity, decreased mobility r/t (related to) CVA (cerebrovascular accident), unable to make needs known, communication deficit, foley to DD (down drain), diabetes brittle. Goal: (R38) will maintain or develop clean and intact skin by the review date. Date Initiated: [DATE], Revision on: [DATE], Target Date: [DATE]. Intervention/Tasks: (R38) has a pressure reducing mattress on bed to protect and prevent skin breakdown while in bed. Keep skin clean and dry. Use lotion on dry skin. Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etcetera to MD (Medical Doctor). Obtain blood work such as CBC (complete blood count) with Diff (differential), Blood Cultures and C&S (culture and sensitivity) of any open wounds as ordered by Physician. (Pressure relief cushion) in chair at all times to protect and prevent skin break down while in chair. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, type of tissue and exudate and any other notable changes or observations. Focus: The resident has infection of gangrene of the left foot; Ceftriaxone sodium injection solution reconstituted 2 GM (gram) use 2 gram intravenously one time a day for infection left foot, gangrene for 32 days, date initiated [DATE]; [DATE] Levaquin 500 mg (milligrams) daily x (times) 10 days. Date Initiated: [DATE]. Revision on: [DATE]. Goal: The resident will be free from complications related to infection through the review date. Date Initiated: [DATE]. Target Date: [DATE]. Intervention/Tasks: Administer antibiotic as per MD orders. Monitor temperature/pulse as per facility protocol. Monitor/document/report to MD s/sx of delirium: Changes in behavior, Altered mental status, Wide variation in cognitive function throughout the day, Communication decline, Disorientation, Periods of lethargy, Restlessness and agitation, Altered sleep cycle. Date Initiated: [DATE], Revision on: [DATE]. Focus: (R38) is on IV (intravenous) Medications R/T infection to left foot, S/P (status post) Chopart's amputation, osteomyelitis left foot. Date Initiated: [DATE]. Revision on: [DATE]. Goal: (R38) will have not have any complications related to IV therapy through the review date. Date Initiated: [DATE]. Revision on: [DATE]. Target Date: [DATE]. Intervention/Tasks: IV Dressing: Nursing change PICC (Peripherally Inserted Central Catheter) dressing to left arm weekly and PRN (as needed) as indicated. Monitor site daily for S/S infection. Monitor/document/report PRN s/sx of infection at the site: Drainage, Inflammation, Swelling, Redness, Warmth. Monitor/document/report PRN s/sx of leaking at the IV site: Edema at the insertion site, Taut, shiny or stretched skin, whitening/blanching or coolness of the skin, slowing or stopping of the infusion, leaking of IV fluid out of the insertion site. Nursing administer IV meds via PICC as ordered by MD. Date Initiated: [DATE]; Focus: (R38) has an ADL (activities of daily living) self-care performance deficit r/t hx (history) Stroke and impaired vision. Goal: (R38) will maintain current level of function through the review date. Intervention/Tasks: .Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: [DATE]. R38's Wound - Weekly Observation Tool worksheet and Treatment Nurse Weekly Note assessments include: [DATE]: A. Communication. 1a. Date MD/Alternate Notified/Last Updated: [DATE]; 1b. Details (Who, how, what, and by whom?) V12 (Primary Care Physician/PCP/Medical Director) .; 2a. Date Family/NOK(next of kin)/POA Notified/Last updated: [DATE]; .3. Special Equipment/Preventative measures (i.e., gel mattress/pad, special bed/mattress, side rails, etc.) Bil (bilateral) heel lift boots, resident is on turning and repositioning routine; B. Observations/Data. 1. Location: Left 2nd toe. 2a. Indicate whether this site was acquired during the resident's stay or whether it was present on admission: Acquired. Date Acquired: [DATE]. 3a. Diabetic/Ischemic . 5. Visible Tissue: 5a. First observation, no reference . 5e. Necrotic tissue present (brown, black, leather, scab-like) . 5g. Dry. 5h. [DATE] sent to ER (emergency room ) with orders for Bactroban ointment twice daily. 5i. Describe the extent (% - percentage) of necrosis and/or slough in the wound bed. [DATE] whole length/circumference left 2nd toe; 6. Drainage: Type. 6a. None . 7. Odor: 7a. No . 8. Wound Measurements: 8a. Length (mm) 40. 8b. Width (mm) 30. 8c. Depth (mm) 0. 8d. Describe the extent of tunneling and/or undermining: 0 . 10. Infection: 10a. Infection suspected? (bright red surface, swelling, induration, erythema, fever, increased size, undermining, probing to the bone, increased drainage, foul odor, etc.) Blank. [DATE]: R38's Weekly Wound Observation Tool assessment is unchanged from [DATE], other than the following - 5. Visible Tissue: 5a. Overall Impression is marked as c. Unchanged; 11. Inflammation: 11a. Inflammation/Induration present? No . 11c. Treatment: Describe any changes to treatment plan in the last week: [DATE] Bactroban ointment discontinued per V12 (PCP). 2. Current treatment plan: [DATE] skin prep to left 2nd toe every shift; and D. Evaluation: Wound Progress: [DATE] No change, [DATE] new-whole length/circumference of the left 2nd toe. [DATE]: R38's Weekly Wound Observation Tool assessment remains unchanged, other than the following - D. Evaluation: Wound Progress. [DATE] no change - Remains dry/necrotic appearing. [DATE]: R38's Treatment Nurse Weekly Note assessment includes - C. Preventative Treatments Used - 1. (Pressure relief cushion) . 6. Pressure relieving mattress . (Foam boots to both feet for protection, float heels off bed on pillow) . E. Plan of Care. 1. Changes to treatment order? . 1.2. No . 2. Skin condition improving? . 2.3. Not applicable. [DATE]: R38's Treatment Nurse Weekly Note assessment documents no change. Toe remains dry/necrotic appearing. [DATE]: R38's Weekly Wound Observation Tool assessment documents no change. Whole toe remains dry/necrotic appearing. [DATE] - R38's Treatment Nurse Weekly Note assessment at 2:29 AM documents no new skin issues at this time. [DATE]: R38's Weekly Wound Observation Tool assessment at 11:24 AM documents . A. Communication. 1a. Date MD/Alternate Notified/Last Updated: [DATE]; 1b. Details (Who, how, what, and by whom?) V12 .; 2a. Date Family/NOK(next of kin)/POA Notified/Last updated: [DATE]; .3. Special Equipment/Preventative measures (i.e. gel mattress/pad, special bed/mattress, side rails, etc.) Bil (bilateral) heel lift boots, resident is on turning and repositioning routine; B. Observations/Data. 1. Location: Between left great and left 2nd toe down to bottom of foot. 2a. Indicate whether this site was acquired during the resident's stay or whether it was present on admission: Acquired. Date Acquired: [DATE]. 3a. Diabetic/Ischemic . 5. Visible Tissue: 5a. First observation, no reference . 5e. Necrotic tissue present (brown, black, leather, scab-like) . 5g. Dry. 5h. [DATE] new necrotic area between left great toe/left 2nd toe down bottom foot. 5i. [DATE] 100% dry/necrotic area. 6. Drainage: Type. 6a. None . 7. Odor: 7a. No . 8. Wound Measurements: 8a. Length (mm - millimeter) 45. 8b. Width (mm) 12. 8c. Depth (mm) 0. (Included in this assessment is a separate measurement specifically to bottom of left foot as - Length (mm) 12. Width (mm). Depth (mm) 0.) 8d. Describe the extent of tunneling and/or undermining: 0 . 10. Infection: 10a. Infection suspected? (bright red surface, swelling, induration, erythema, fever, increased size, undermining, probing to the bone, increased drainage, foul odor, etc.) Blank. 11. Inflammation. 11a. Inflammation/Induration present? No. C. Treatment . 2. Current treatment plan: [DATE] MD aware has not given specific treatment orders for area - does want resident seen by wound care. D. Evaluation. Wound progress: [DATE] New. [DATE]: R38's Weekly Wound Observation Tool assessment includes 8. Wound Measurements: 8a. Length (mm) 40. 8b. Width (mm) 30. 8c. Depth (mm) 0. (Included in this assessment is a separate measurement specifically to bottom of left foot as - Length (mm) 12. Width (mm) 12. Depth (mm) 0.) 8d. Describe the extent of tunneling and/or undermining: 0 . 10. Infection: 10a. Infection suspected? (bright red surface, swelling, induration, erythema, fever, increased size, undermining, probing to the bone, increased drainage, foul odor, etc.) Blank. 11. Inflammation. 11a. Inflammation/Induration present? No. C. Treatment. 1. Describe any changes to treatment plan in the last week: [DATE] Bactroban ointment discontinued per MD. 2. Current treatment plan: [DATE] skin prep to left 2nd toe every shift. D. Evaluation. Wound progress: [DATE] resident remains in the hospital at this time. [DATE] resident in hospital at this time. [DATE] no change. [DATE] no change - whole toe remains dry/necrotic appearing. E. Comments: [DATE] resident has wound care appointment at Veteran's hospital wound clinic on [DATE]. Prior to and during the period of time when R38's wound was first discovered on [DATE] and worsened on [DATE], R3's record under Vital Signs indicate he did experience intermittent fluctuations/elevation in temperature as follows: [DATE] 9:57 AM - 99.4; [DATE] 5:49 AM - 99.8 (tympanic); [DATE] 5:31 PM - 100.0 (tympanic); [DATE] 10:53 AM - 99.6; [DATE] 12:04 AM - 100.3 (tympanic); [DATE] 5:01 PM - 99.4; [DATE] 11:57 PM - 99.1 (tympanic); [DATE] 12:29 AM - 100.8 (tympanic); [DATE] 1:49 AM - 99.5; [DATE] 4:27 AM - 101.7; and [DATE] 12:27 AM - 100.0 (rectally). On [DATE] at 10:34 AM, V2 (Director of Nursing/DON) stated, R38 did have a urinary tract infection during this time and receiving antibiotic treatment, but we attributed the elevation in temperature to this. Other than the change in R38's wound on [DATE], there really was no other change, no odor, no drainage, and no inflammation. V2 continued that while R38 was out for his appointment with the veteran's hospital on [DATE] they sent him over to the emergency room due to the condition of his toe. The veteran's emergency room transferred R38 to another hospital, where R38 was a direct admit the same day. V2 stated V2 does not think there is anything more the facility could have done to prevent this from happening. R38's progress notes include: On [DATE] at 11:16 AM, V3 (Licensed Practical Nurse/LPN/Wound Care Nurse) writes, Res (resident) left 2nd toe is noted to be black, dry and what appears to be necrotic from tip of the left 2nd toe to base of the left 2nd toe. (V12/Primary Care Physician/PCP) to be in facility this evening and to evaluate. [DATE] at 5:49 PM - MD here on rounds. Necrotic left digit noted new orders to send to ER for eval and treat (evaluation and treatment). Spoke with V23 (Family Member/Representative) request (hospital). EMS (emergency medical services) called for transport at approx (approximately) 545p (5:45 PM). (Hospital) ER called with update spoke with (nurse). R38's ER record dated [DATE] to [DATE] included: History of Present Illness: .peripheral vascular disease with gangrene of the (right) second toe, which is chronic . Physical Exam: .distal pedal pulses are palpable .chronic appearing (right) second toe gangrene. With the tissue sloughing off, no evidence of cellulitis .On examination of the skin there is no is no evidence of any skin breakdown, there is no evidence of cellulitis .he is not in very good hygienic condition from the nursing home .patient's toe will auto amputate. It cannot be revascularized. We will place him on topical antibiotics and discharge him home and have him follow-up with his primary MD . Final Diagnoses: Gangrenous toe . Of note, documentation through this ER record references the right toe. V2 (DON) and V3 confirmed it is R38's left toe and the ER record contains a misprint when documenting the right toe. R38's progress notes dated [DATE] and [DATE] document he returned to the facility on [DATE] with new orders to apply a topical antibiotic ointment three times a day for 7 days. On [DATE], V12 discontinued the topical antibiotic ointment this day and gave a new order to apply skin prep topically every shift, as noted on R38's progress note and POS (Physician's Order Sheet). R38's progress note dated [DATE] at 8:00 AM documents: There is a new 4.5 cm (centimeter) x 1.2 cm x 0 necrotic appearing area noted now starting between the previous necrotic left 2nd toe and the left great toe and a 1.2 cm x 1.2 cm necrotic appearing area to bottom of left foot just below this area . V12 (PCP) notified by V3 (LPN/Wound Nurse). On [DATE] at 8:15 AM, R38's progress notes continue to document, (V24/LPN) along with treatment nurse to evaluate resident's necrotic left 2nd toe. Upon evaluation, this nurse contacted MD regarding the worsening of necrotic toe and possibility of diabetic ulcer forming on bottom of left foot. MD gave new order to refer to (out of state wound care clinic) .contacted Veteran's hospital .regarding this matter and proper paperwork will be sent to Veteran's hospital to attempt prior authorization for treatment at (out of state wound care clinic) waiting on authorization from the veteran's association to wound care. R38's progress note dated [DATE] indicates V12 was in the facility doing rounds. R38's progress note dated [DATE] at 12:15 PM contain, (R38) to veteran's association for wound care appointment .; [DATE] at 2:30 PM, Transport aide called and reported that while resident was at wound care, office decided he needed to go to the ER for eval of his toe. Resident is currently at ER at (hospital). R38 was a direct admit from the ER to the hospital on [DATE]. R38's facility progress notes continue to document: [DATE] at 2:30 PM - Resident is currently at (name of hospital) .Resident is currently in the ICU (Intensive Care Unit) for DKA (diabetic ketoacidosis) and on an insulin drip. ICU nurse stated once he comes out of DKA he will be able to be admitted to a step-down unit XXX[DATE] at 10:57 AM, resident continues to be inpatient at (hospital) Resident is on the third floor, came out of ICU on[DATE]. Update from his nurse today was, patient is eating very little, his left foot still has an infection, and gangrenous. His nurse today told me, there is no plans for discharge anytime soon XXX[DATE] at 4:25 PM - update from (out of state hospital) Resident is in inpatient care after partial amputation of left foot. Nurse that called to give update stated, the infection was not clearing up and the next step was amputation of the entire left foot. R38's Veteran's Hospital Consultation Results at wound clinic dated [DATE] authorized by V22 (Podiatrist) include: Physical Exam: To clinic per (tilt back) chair. Follows simple commands. Limited vocabulary. Entire second toe of the left foot with dry necrosis and strong, foul odor. Copious drainage on old dressing. 2nd metatarsal head also necrotic. 2 cm of peri-wound erythema that is tender to touch. DP (dorsalis pedis) pulse cannot be palpated nor auscultated. R38's hospital record dated [DATE] by V15 (Podiatry) included: Reason for Consultation: Gas gangrene left 2nd toe .Chief Complaint/History of Present Illness: R38 is a [AGE] year old male with past medical history of diabetic retinopathy, epilepsy, bilateral cataracts, traction detachment of retinal left eye, hyperlipidemia, deep vein thrombosis bilateral lower extremities .pressure ulcerations to heel and buttock, diabetes mellitus I, ileus, hemiplegia from cerebral vascular accident, neurogenic bowel, megacolon who presented to local veteran's hospital from outlying nursing home to evaluate the left 2nd toe. Patient was direct admitted to (hospital) for further evaluation . Exam: .Skin: left 2nd toe ulceration with malodorous drainage extending up the foot . Extremities: left 2nd toe ulceration with malodorous drainage noted . Vascular: Dorsalis pedis and posterior tibial pulses diminished bilaterally . Assessment/Plan: Patient presents to (hospital) from the local veteran's hospital with ulceration to the left 2nd toe. Patient is unable to give medical history due to vascular dementia. Upon exam, the patient has diminished pedal pulses, bilaterally. Ulceration to the left 2nd toe with malodorous drainage. Gas gangrene noted. Therefore, we will proceed with left trans metatarsal amputation . Diagnosis: Necrotic toes left foot. Chopart's Amputation for Osteomyelitis of the Midfoot - Staged Surgical Approach - Midfoot amputation secondary to acute infection is often performed in a staged manner. The first stage is an incision and drainage procedure or partial foot amputation which is left open for initial management of the infection. Care is taken to completely excise the ulceration while draining any abscess collection, as well as copious irrigation of the wound. A bone biopsy is procured if osteomyelitis is suspected. The second stage is typically performed ,d+[DATE] days later allowing the remaining tissues to demarcate and vascular intervention if needed. During the stage 2 operation, Chopart's amputation is performed and closed as outlined below. Source: https://musculoskeletalkey.com/choparts-amputation-for-osteomyelitis-of-the-midfoot/. What Is Gas Gangrene? Gangrene is the death of body tissue. Clostridial myonecrosis, a type of gas gangrene, is a fast-spreading and potentially life-threatening form of gangrene caused by abacterial infection from Clostridium bacteria. The infection causes toxins to form in the tissues, cells, and blood vessels of the body. These bacteria will release toxins that cause tissue death and release a gas. Most gangrene infections occur in situations where open wounds from an injury or surgery are exposed to bacteria. Non-traumatic gas gangrene, a more rare form of gas gangrene, can develop when blood flow to body tissues is compromised and bacteria gets inside. There is a greater risk in people who have a peripheral vascular disease, atherosclerosis, or diabetes mellitus. Gas gangrene can occur anywhere on the body, but it most commonly affects the arms or legs. Common symptoms include increased heart rate, fever, and air under the skin. Skin in the affected area also becomes pale and then later changes to dark red or purple. These symptoms usually develop six to 48 hours after the initial infection and progress very quickly. Treatment may include antibiotics and surgery to remove the dead tissue. Occasionally a hyperbaric oxygen chamber may be used. Surgery consists of debridement (removal of dead tissue) and sometimes amputation. Gas gangrene is a rare condition. However, it can quickly become a life-threatening infection when it goes untreated. You should call 911 or go to the nearest emergency room right away if you are experiencing symptoms of gas gangrene. Source: https://www.healthline.com/health/gas-gangrene#symptoms. Overview - Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes the bone to germs. Smokers and people with chronic health conditions, such as diabetes or kidney failure, are more at risk of developing osteomyelitis. People who have diabetes may develop osteomyelitis in their feet if they have foot ulcers. Although once considered incurable, osteomyelitis can now be successfully treated. Most people need surgery to remove areas of the bone that have died . After surgery, strong intravenous antibiotics are typically needed. Source: Osteomyelitis - Symptoms and causes - Mayo Clinic. On [DATE] at 9:30 AM, R38's wound care was observed with V3 (LPN/Wound Nurse) and V21 (LPN) providing care. R38's left foot appeared consistent with recently having undergone surgical amputation as documented in his hospital records above. During observation, V3 commented R38 did have a soft spot at the suture line where the staples previously were removed. V3 also stated that during R38's hospital follow-up appointment with V13 (Infectious Disease Physician) earlier this month, V3 relayed that the documentation indicated this wound would most likely not heal. R38's post-surgical left foot amputation documentation from V13 (Infectious Disease Physician) dated [DATE] includes: History of Present Illness: .I saw him in (hospital) in January for left diabetic foot infection, presented with gas gangrene and osteomyelitis .Wound culture grew MSSA (methicillin-susceptible staph). Patient was discharged to nursing home on Ceftriaxone and oral Flagyl. He received almost 6 weeks of intravenous antibiotics . He still has wound at the amputation site, with some purulent drainage .Patient has severe peripheral artery disease and prognosis is poor. Unlikely the wound will heal. He needs below-knee amputation, but the family continue to refuse . MSSA infections are usually treatable with antibiotics .MSSA Bacteremia occurs when the MSSA bacteria enter your bloodstream. This is a serious infection that has a high risk of complications and death. Once it's in the bloodstream, the infection often spreads to other organs and tissues within the body such as the heart, lungs, or brain. Source: https://www.webmd.com/skin-problems-and-treatments/what-is-mssa-bacteremia. On [DATE] at 9:40 AM, V5 (Certified Nursing Assistant/CNA) and V6 (CNA) stated they did not recall anything significant regarding R38's left foot. Both stated they were aware that he had surgery on his left foot earlier this year and have been involved in (his) care since that time. V5 and V6 stated R38 can be combative and resistant to care but do not recall anything emergent. On [DATE] at 1:00 PM, V3 (LPN/Wound Care Nurse) confirmed she became involved with and has performed R38's wound care to the left 2nd toe since [DATE]. V3 stated that to her knowledge, R38's left toe/foot had never had any odor, drainage, or bleeding as she documented in her wound care assessments. On [DATE] at 2:22 PM, V13 (Infectious Disease Physician) stated he consulted with R38 during his hospital stay on [DATE] after undergoing a partial left foot amputation on [DATE]. When told R38's weekly skin inspection report documents no skin issues on [DATE], then on [DATE] indicated that his left 2nd toe was observed by the facility wound nurse to be necrotic from tip to base, he stated a digit can become necrotic in a fairly short amount of time, sometimes even hours, but it is a case-by-case situation. When asked what the timeframe would be for R38 to have developed osteomyelitis of the left 2nd toe and left ankle, he stated osteomyelitis typically develops over a period of several weeks but recommended speaking to the actual surgeon regarding further comments on gas gangrene and osteomyelitis. On [DATE] at 3:15 PM, V23 (Family Member/Representative) stated she feels like the facility had just let him go .(R38's) feet were already dark when he admitted to the nursing home but not like that. I don't feel like there was enough movement to keep the blood flow going and it just got worse. When he was in the hospital, they explained to me that nothing could be done for his foot except to amputate below the knee. I suggested to just take his foot above the ankle but was told they could not do that. They wanted to go further up. I told them if the infection was not that far up his leg don't amputate. I was basically told that this would not get any better and they would just have to keep cutting, and I didn't see the sense in that. He (R38) went on hospice on [DATE] . On [DATE] at 4:31 PM, V15 (Podiatrist/Surgeon) stated he does remember R38 presenting to the hospital on [DATE], recalling he performed surgery late that same night. V15 stated the doctor called him from the veteran's hospital and said he was transferring a patient that needs emergent surgery. V15 accepted the transfer. R38's x-ray showed gas on the x-ray positive for gas gangrene. V15 stated, R38 is really frail and we had a lot of trouble getting labs on him. R38 was not able to give history, and it was very difficult to get labs because he was very sick. We did emergent surgery. V15 stated, I met him at 8:00 PM and was done with surgery at 9:30 PM. We drained 75 ml (milliliters) of pus from the foot. V15 continued, Basically when I met him (R38), he was in pretty rough shape. When you're not a good historian and have a lot of comorbidities, these things can happen really quick,, but this would not have developed overnight. From my standpoint, he was indeed needing surgical intervention to get rid of the infection. For that much pus, it would definitely have been beneficial to have been seen when the changed occurred on [DATE]. For something like this it would have been best to be referred at the first sign of change. He had a fluid collection abscess of pus. Had he been verbal, he might have said it hurt or been able to communicate. Since he is not, you would need a high index of inspection to catch that. I generally do not perform surgery. Hindsight is ,d+[DATE], however there is a possibility we might have been able to save his foot had he been seen right away. On [DATE] at 1:01 PM, V12 (PCP/Medical Director) stated R38's necrosis to the left 2nd toe was initially observed on [DATE]. V12 was notified and gave orders to refer to the emergency room for evaluation and treatment. V12 stated R38 was diagnosed with necrosis and chronic gangrene and sent back to the facility with a prescription for topical antibiotic. V12 stated he changed that order to skin prep on [DATE]. When asked about R38 experiencing an elevation in temperature intermittently between [DATE] and [DATE], V12 stated (R38) had a couple of urinary tract infections and was on antibiotics, which could account for the elevation in temperature. V12 also stated that one particular antibiotic R38 was prescribed has also been historically used to treat osteomyelitis. V12 stated he was again notified on [DATE] of the change in R38's wound and condition, at which time he referred R38 to be seen by wound care. V12 stated he was in the facility making rounds on [DATE] and was notified of R38's worsening wound. When asked if V12 would have expected R38 to be seen by wound care sooner than [DATE], 9 days after the initial change, V12 stated he believed R38 was seen in a timely manner. V12 continued that R38 had multiple medical problems including uncontrolled diabetes, and a combination of vascular and diabetic issues. V12 stated R38 would have benefited from being on hospice a long time ago. V12 confirmed there would have been no way to know the depth or underlying presentation of the wound until it was opened up. When asked if he thought it might have been beneficial for R38 to be evaluated at the emergency room prior to his appointment made at the veteran's hospital on [DATE] in light of his wound worsening, V12 stated he does not believe it would have done any good since he was already evaluated at the emergency roiagnom on [DATE] and nothing was done. V12 stated he believed the emergency room would not have done anything and just sent R38 back to the facility like they did in December. On [DATE] at 2:00 PM, V2 (DON) stated, R38's referral to a wound specialist began on [DATE] in an attempt to get him to a nearby wound care facility, who we normally send our residents to. Normally, the VA (veteran's affairs hospital) will approve right away, but this time we were having trouble getting prior authorization approval. If it would have been deemed necessary, he could have gone back out to the ER, but we did not receive an order to do that. We would still have to notify the VA, but we don't need prior approval to send to the ER. They prefer we not send residents to the ER unless it is an emergent situation, and then we would send R38 to the local ER. V12 was updated and involved in R38's condition up until the time he went to the Podiatry appointment at the VA on [DATE]. When asked if there was a wound doctor at the veteran's hospital R38 would have seen, V2 stated, No, he only saw the Podiatrist there. On [DATE] at 2:35 PM, this surveyor contacted the veteran's hospital to speak with the Podiatrist who saw R38 on [DATE]. The receptionist stated R38 was actually seen at the wound clinic, who sent him to their emergency room , then transferred to another hospital for treatment. This surveyor requested any documentation for that date of service. The receptionist commented that they always do a write-up and would speak with the nurse to fax that to this surveyor via the facility at the end of clinic today. This surveyor spoke with V2 (DON) again at this time, who stated she thought R38 saw the Podiatrist but learned that he was seen in wound clinic instead. On [DATE] at 10:52 AM, V25 (Surgical Services Nurse Practitioner) stated she has known R38 for many years. V25 stated, Outside of his left toe, he has remained relatively the same. He experienced a stroke as a young man, he is aging, but his toe was bad. It was smelly and bad. That's why I got V22 (Podiatrist), and she sent him out. The toe probably should ha[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure resident's fall interventions were in place to prevent falls for 3 of 5 residents (R3, R5, and R8) reviewed for falls and fall interventions in a sample of 8. This failure resulted in R3 sustaining a traumatic closed minimally displaced fracture to the right distal ulna (long bone between wrist and elbow), R3 sustaining a scalp laceration requiring staples, and R5 sustaining a scalp laceration requiring staples. Findings include: 1. R3's face sheet documented an admitted [DATE] with diagnoses including: anxiety disorder, difficulty in walking, abnormal posture, muscle weakness, reduced mobility, age- related [CONDITION(S)]. R3's 8/29/22 Minimum Data Set documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. R3's 11/19/21 through 10/9/22 Morse fall scale documented R3 was a high risk for falling. R3's current care plan documented in part . has potential for falls and injury, has hx (history) of falls prior to admission, recent hospitalization r/t (related to) falls . Interventions: 6/6/19 [R3] requires pad alarms in bed at bedtime, alarm box on tamper resistant mode at all times, & monitor for placement, r/t [R3]will remove and hide them . and . has had an actual fall with continue to have falls, unaware of safety . removes and shuts off alarms, often closes door to room so can't hear alarms to see [R3's] movement. Currently will unfasten seatbelt alarm and set listen to it ring, waiting for staff, and as soon as they fasten it she removes it again and again when [R3] is in one of [R3's] moods. 1/2/22 U/Fall (unwitnessed fall) room (major injury), 2/1/22 U/Fall room (no injury), 2/26/22 U/Fall room (major injury), 6/3/22 U/Fall room (no injury), 8/10/22 U/Fall room (no injury), 8/24/22 U/Fall (no injury), 10/9/22 U/Fall room (minor injury), 10/28/22 U/Fall room (major injury) 11/10/22 U/Fall room (no injury) . On 11/17/22 at 9:40 AM, V13 (R3's Power of Attorney (POA)) stated R3 has been in the facility for several years and is progressively getting worse. Back in February of 2022 [R3] had a wrist fracture from a fall and recently has had a laceration to [R3's] head that required staples. I think the only thing they are doing is putting alarms on her and not actually checking on [R3]. I'm afraid [R3] is going to get seriously injured from one of these falls. R3's 12/30/21 unwitnessed fall investigation documented in part . CNA (Certified Nurse's Assistant) came to this nurse . stated this nurse was needed in resident's room as [R3] was in the floor. CNA stated alarms were not sounding . After review of incident . the safety committee has ensured that pad alarms have new batteries in them and sound to alert staff when resident is attempting to ambulate or transfer without assist . R3's 2/26/22 unwitnessed fall investigation documented in part . This nurse was alerted to resident's room. Resident on floor by [R3's] couch in [R3's] room . resident c/o (complained of) R (right) hand/ wrist pain upon palpation Slight bruising noted. ROM (Range of Motion) limited d/t (do to) pain . [R3's] alarms were located in [R3's] closet, where [R3] had placed them . R3's 2/27/22 right forearm X-ray report documented in part .Oblique fracture distal ulna is noted . R3's 10/29/22 unwitnessed fall investigation documented in part . Found resident sitting in the floor, bleeding from top right of head area . complains of headache . physician notified for orders to send to ED (Emergency Department) . R3's 10/29/22 progress note documented in part . [hospital nurse] stated . resident had to get staples on right side of head due to laceration from fall . and . Resident has four staples on right side of head . The facility's 10/31/22 Interdisciplinary Fall Committee Meeting Minutes documented in part . [R3] 10/29/22 0400 u/fall (unwitnessed fall) . Major injury . Res (resident) stated fell out of bed . alarm not sounding . will look for tamper proof alarms . On 11/15/22 at 10:05 AM, V4 Licensed Practical Nurse (LPN) said the Certified Nurse's Assistants (CNA) were responsible for ensuring resident's alarms were intact and functioning appropriately. V4 said R3 will take her alarm off frequently and hide it around the facility. V4 said R3 was not alert and oriented. On 11/15/22 at 10:35 AM, V5 (CNA) said staff can find if a resident has an order for an alarm on the resident's Kardex in the resident's Electronic Medical Record (EMR). V5 said any resident with an alarm ordered should have the alarm on and functioning. On 11/17/22 at 1:09 PM, V16 (CNA) said CNAs were responsible for ensuring resident's alarms are intact and functioning. V16 said R3 would pull the alarm pad out of R3's bed while up in the wheelchair and hide it around the facility. V16 said when assisting R3 to bed staff should check R3's bed to be sure the alarm pad is present because it does go missing sometimes. On 11/18/22 at 10:20 AM, V1 Director of Nursing (DON) said R3 had behaviors of shutting off her alarms, hiding the alarms in her room, and hiding her alarms around the facility. V1 said R3 did not have alarms functioning at the time of the 2/26/22 and 10/29/22 falls with major injuries. V1 said she expected staff to follow all safety interventions on a resident's care plan including making sure alarms were functioning and present. On 11/17/22 at 11:37 AM, V2 (R3's Medical Provider/ Family Nurse Practitioner) said he expected the facility to have interventions in place to keep R3 from falling. V2 said if R3 had a fall intervention of having alarms in place he expected the alarms to be in place and functioning. V2 said he expected staff to have all safety interventions in place if listed in the care plan. 2. R5's face sheet documented an admitted [DATE] and diagnoses including: Alzheimer's disease, [CONDITION(S)], repeated falls, and hypertensive heart disease. R5's 10/9/22 MDS section C documented a BIMS score of 2, indicating severe cognitive impairment. R5's care plan documented in part . potential for injury: Resident is at risk for falls . 3/15/22 u/fall (unwitnessed fall) room (major injury) . Interventions: . 12/21/20 [R5] requires chair and bed pad alarms at all times . ensure the device is in place as needed . R5's 3/15/22 unwitnessed fall investigation documented in part . found lying on back on floor with head against wall . has laceration to back of head approximately 1 inch in length . EMS (Emergency Medical Services) called . After review of incident . agency aide had put resident to bed, alarm pad was on bed, she did not make sure was functioning prior to leaving room. CNA educated on use of alarms and being sure that they are functioning prior to leaving resident unattended. Box was not synced to pad on bed . R5's 3/15/22 progress note documented in part . returned to facility per transport from ER (emergency room ) has 6 visible staples to back of head . 3. R8's face sheet documented an admitted [DATE] and diagnoses including: major depressive disorder, [CONDITION(S)], heart failure, history of falling, unspecified dementia, dysphasia, unsteadiness on feet, cognitive communication deficit, [CONDITION(S)], muscle weakness, difficulty in walking. R8's 9/2/22 MDS section C documented a BIMS score of 5, indicating severe cognitive impairment. R8's Physician Order Sheet (POS) documented a 8/14/20 order for pad alarm at all times while in chair or wheelchair. On 11/17/22 at 2:24 PM, R8 was observed to be sitting in a recliner in R8's room. R8's pad alarm box was hanging on the handrail outside of R8's room and the light not in use was on. V10 (CNA) said R8's pad alarm was in R8's wheelchair and not under R8 in the recliner. V10 said R8 was supposed to have a pad alarm on when R8 was out of bed. V10 said she was not sure why R8 did not have a pad alarm on because V10 had just arrived at the facility. The facility's 12/20/21 Falls- Prevention and Risk Reduction policy documented in part .1. The MDS Coordinator will: A. Complete a comprehensive care plan for all residents who are identified at risk for falls. B. Communicate the falls care plan to the health care team . D. Update interventions on the falls care plan with any new occurrences of falls . The facility's 12/20/21 Falls, Post- Fall Protocol policy documented in part . 7. The health care team will discuss the resident's fall . and agree on at least one new intervention for the resident's fall risk care plan .

Based on interview and record review, the facility failed to develop and/or implement necessary interventions to effectively supervise a wandering resident for 1 of 1 resident (R39) reviewed for supervision in the sample of 59. This failure resulted in R39 entering R67's room, and R67 pushing R39, which caused R39 to fall. The fall resulted in a closed fracture to the left femur and subsequent hospitalization . Findings include: R39's Electronic Health Record (EHR), under the section titled, Resident Dashboard, documents R39 was admitted to this facility on 10/13/2021, with a diagnosis of Alzheimer's Disease, Altered Mental Status, Dementia with Behavioral Disturbance, among others. R39's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03, indicating R39 has severe cognitive impairment. R39's Care Plan with initiation date of 10/13/2021 documents that she is an elopement risk/wanderer related to disoriented to place, impaired safety awareness, enters other residents' rooms and takes their belongings. Interventions include: 1) Apply wanderguard, assess for fall risk, change wanderguard bracelet every 90 days and as needed, check wanderguard bracelet daily, and monitor for fatigue and weight loss (Initiation date: 10/13/2021). 2) Attempt to redirect resident from entering other residents' rooms; offer snacks, beverages, puzzles, and magazines to distract (Initiation date: 2/28/2022). R39's Care Plan had no interventions listed for wandering in other residents' rooms prior to 2/28/2022. A progress note in R39's EHR written by V11 (Licensed Practical Nurse/LPN) and dated 2/01/2022 at 9:07 a.m. describes R39 entering residents' rooms and was redirected multiple times. R39 attempted to enter R67's room and was redirected away from R67's door. R67 came to the doorway and yelled at R39, stating to R39, You belong in a damn mental institution! and slammed his door. A subsequent progress note, in R39's EHR written by V19 (LPN) and dated 2/27/2022 at 1:05 p.m. documents that R39 entered R67's room and R67 pushed R39, resulting in R39 falling to the floor. R39 began screaming that she hurt. Head to toe assessment was completed with external rotation of left hip. R39 was sent out to the hospital and admitted with a closed fracture of left femur. A hospital document dated 2/27/2022, at 2:47 p.m., documents that R39 has a comminuted 7 trochanteric fracture of the left femur. A progress note, in R39's EHR, dated, 1/03/2022, at 1:45 p.m., written by V12 (Social Services Director/SSD), describes R39 ambulating down A Hall and attempted to enter another resident's (R67) room, was told by (R67) that R39 was in the wrong room and R39 continued to enter the room until (R67) became angry and slammed his door. R39 was redirected toward the dining room. A progress note in R39's EHR, dated, 12/18/2021, at 5:59 p.m., written by V15 (Activities), describes R39 wandering into residents' rooms and going through the residents' belongings, bullied and took things from other residents, stuck her hands in family's food that was visiting and tried to take another resident's food, dumped her meal tray onto another's resident's meal tray while they were eating, flashed others her breasts, cursed at visitors, and tried to take items off the med cart. R39 was not easily directed and refused anything offered to her. A progress note in R39's EHR, dated, 11/26/2021, at 5:24 p.m., written by V17 (LPN), describes R39 attempting to get into med cart, take applesauce, and carry water pitcher away. V17 and V12 (SSD) have tried to redirect R39 numerous times. R39 has wandered in and out of residents' rooms needing 1 on 1 attention most of the night. R39 is easy to redirect but redirection does not last long. A progress note in R39's EHR, dated, 11/16/2021, at 5:04 a.m., written by V18 (LPN), describes R39 got up between rounds and crawled into another's resident bed while that resident was occupied in it. When staff noticed that R39 was in another's resident's bed, they took R39 back to her room, but she would not stay there. R39 followed staff around until she got interested into some paperwork. R67's EHR, under the section titled, Resident Dashboard, documents R67 was admitted to this facility on 2/25/2000, with diagnoses of [CONDITION(S)], Major Depressive Order, Alcohol Dependence with Alcohol-Induced Dementia, among others. R67's MDS dated [DATE] documents R67 has a BIMS score of 12, R67 has moderate cognitive impairment. R67's EHR has a Progress Note dated 2/1/2022, at 9:07 a.m., written by V11, (LPN) that describes R67 resting in his room when R39 entered his room and R67 yelled at R39 and slammed the door after R39 was redirected out of the room. A subsequent progress note dated 2/27/2022 at 2:30 p.m. and written by V19, (LPN) documents R67 becoming angry when R39 entered his room and R67 pushed R39 resulting in R39 falling to the floor. R67's Care Plan with an initiation date of 6/11/2013 documents that he has a history of behavioral problems related to verbal altercations with residents or staff. He can become verbally aggressive towards other residents. He also isolates himself to his room, is paranoid and has fixed delusions at times, and thinks that others including staff are out to get him. Interventions include: 1) Intervene as necessary to protect the rights and safety of others. Approach/Speak to R67 in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. (Revision date: 11/16/2017). 2) Caregivers will provide me with opportunities for positive interaction, and attention. Stop and talk with me as passing by (Revision date: 2/20/2018). 3) If reasonable, discuss my behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to him (Revision date: 2/20/2018). 4) Nursing staff and Social Services will monitor my behavioral episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes (Initiation date: 6/11/2013). There are no new interventions implemented to R67's Care Plan after his verbal altercation with R39 that occurred on 2/01/2022. On 3/15/2022, at 10:00 a.m., V19 (LPN) stated that on 2/27/2022, at 12:56 p.m., R39 entered R67's room and R67 had pushed R39 resulting in R39 falling to the floor. V19 stated that this incident was witnessed by V20, (Housekeeping). V19 stated she assessed R39 and external rotation of the left hip was noted. V19 stated that R39 was screaming out that she hurt. V19 stated the physician was notified and R39 was sent out to the hospital and was admitted with a diagnosis of closed fracture of left femur. V19 stated that R39 wanders frequently in and out of residents' rooms. V19 stated that she usually redirects R39 by offering her a soda and she sits in the dining room to be monitored. V19 stated that R67 gets very irritated if anyone enters his room without permission. V19 stated that she has never witnessed R67 being physically aggressive with anyone. On 3/16/2022, at 1:10 p.m., V21 (MDS/ Care Plan Coordinator) stated that she has only worked at the facility for approximately 3 weeks or so. V21 stated that she has seen R39 wander in and out of residents' rooms. V21 stated that she has never seen R67 be physically aggressive with anyone since she has worked here. On 3/17/2022, at 9:15 a.m., V22 (Certified Nurse Assistant/CNA) stated that on 2/27/2022, at 12:56 p.m., she heard someone yell and went down the hall and saw R39 lying in the floor. V22 stated that R67 is cognitively intact and knows that hitting or pushing someone is not the right thing to do. V22 stated that R67 can get very irritated if someone enters his room without permission. V22 stated that she has never seen R67 be physically aggressive with anyone. V22 stated that R39 wanders frequently in and out of residents' rooms and usually is easily redirected but it only lasts for a short while. On 3/17/2022, at 9:45 a.m., V5 (Activity Assistant) stated that R39 wanders frequently in and out of residents' rooms. V5 stated that she has never seen R67 by physically aggressive with anyone. On 3/17/2022 at 12:00 p.m., V20 (Housekeeping) stated that on 2/27/2022, at 1:00 p.m., she heard R67 yell at R39 to get out of his room and then witnessed R67 push R39 up against the wall and R39 fell to the floor. V20 stated that R39 wanders frequently into other residents' rooms. On 3/17/2022 at 12:30 p.m., V2 (Director of Nursing) stated that she was notified on 2/27/2022 that R67 pushed R39 causing R39 to fall onto the floor and that R39 was sent out to the hospital related to her having an external rotation of her left hip and increased pain and was admitted to the hospital with a closed fracture of left femur. V2 stated that on 2/28/2022, a Velcro STOP sign was placed on R67's doorway to help keep other residents from entering his room. V2 stated that an IDT (Interdisciplinary Team) meeting was held on 3/9/2022, and it was discussed to have R67 moved to different hall. V2 stated that R67 was moved to the men's hall on 3/14/2022. V2 stated that she has never seen R67 be physically aggressive with anyone and that R39 wanders frequently in and out of residents' rooms. V2 stated that R39 is redirected out of residents' rooms and placed elsewhere and given something else to do like coloring, a drink or snack, etc. On 3/17/2022 at 3:00 p.m., V1 (Administrator) stated that he was notified by the staff nurse on 2/27/2022 of the incident of R67 pushing R39 which resulted in R39 falling to the floor. V1 stated that R39 was sent out to the hospital and was admitted with a fracture of the left hip. V1 stated that on 2/28/2022, a Velcro STOP sign was placed on R67's doorway to deter any residents from entering his room. V1 stated that on 3/9/2022, an IDT meeting was held, and it was further discussed to have R67 moved to a different hall. V1 stated that R67 was moved to the men's hall on 3/14/2022. V1 stated that R67 has been at the facility for a long time, and he has never seen him be physically aggressive to anyone. V1 stated it is R67's normal behavior to be verbally aggressive especially when someone enters his room unannounced.

Based on interview and record review, the facility failed to administer prescribed pain medication as ordered to effectively manage the pain for 1 of 3 residents (R9) reviewed for pain in a sample of 59. The failure resulted in R59 experiencing a severe level of pain for over 24 hours. Findings include: R9's Electronic Health Record (EHR) in the section titled Resident Dashboard documents that R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Medication Review Report dated 3/17/22 documents that R9 has an active order for [MEDICATION(S)]/Acetaminophen 7.5-325 milligram (mg) tablet every 4 hours as needed (PRN) for pain with an order date of 7/15/21. On 3/15/22 at 1:00 PM, R9 who was alert to person, place and time said that she went over 24 hours without pain medication because the facility ran out of it. R9 said that she received a dose of the pain medication on Sunday evening, 3/13/22, and did not receive another dose until Tuesday morning, 3/15/22. R9 said that she was hurting so bad on Monday night, 3/14/22, that R9 was unable to get out of bed to change her clothes and put pajamas on. R9 said that this isn't the first time that the facility has ran out of R9's pain medication. R9 said that they wait until she runs out of medication to order it from the pharmacy and has to wait for it to come in. R9 also stated that sometimes it takes 2 to 3 hours to get her pain pill when R9 asks for it because the nurses get busy and forget. R9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The next documented dose on the March MAR for [MEDICATION(S)]/ Acetaminophen is 3/15/22 at 2:29 AM. R9's pain level is documented at a 7 on a 1-10 pain scale at the time the medication was administered on 3/15/22. On 3/16/22 at 12:45 PM, V11 (Licensed Practical Nurse) said that R9 ran out of her pain medication on Sunday (3/13/22) and they didn't get any in until Tuesday morning, 3/15/22. V11 states that R9's [MEDICATION(S)]/Acetaminophen requires R9's physician's authorization to refill and R9's physician is often hard to get ahold of. V11 said that the facility does keep that medication in stock in their emergency supply and that it requires a pharmacist's approval to use the facilities emergency supply. V11 said that she attempted to contact the pharmacy on Monday, 3/14/22, to receive authorization and the pharmacy's receptionist said that all pharmacists were on the phone and unable to take calls at that time. V11 said that she told the pharmacy's receptionist that she would just call back later. V11 said that she forgot to call back but did pass the information along to the nurse on the next shift. R9's Care Pan (last updated 9/13/21) documents goals for R9 to exhibit no signs and symptoms of pain and will not have an interruption in normal activities related to pain with interventions of administration of pain medications as ordered and monitor for effectiveness. R9's Minimum Data Set (MDS) assessment completed on 12/8/21 in Section J: Health Conditions documents that R9 has pain frequently and documents yes for being on a scheduled pain medication regimen and receiving PRN pain medications. The facility policy titled Pain Management Policy/ Procedure (undated) in the section titled Policy Statement documents that Each resident has the right to obtain optimal pain relief to attain the highest practical physical, mental, and psychosocial well-being. Nurses caring for the residents have the ethical obligation to ensure exploration of all possible alternatives including pharmacological and non-pharmacological interventions.

Based on interview and record review the facility failed to implement fall interventions and supervision to prevent falls for 2 of 3 residents (R1 and R2) reviewed for falls in a sample of 3. This failure resulted in R1 falling out of bed and sustaining a fracture of the left hip. Findings include: 1.R1's Electronic Medical Record denotes R1 is a [AGE] year-old female with diagnoses including: Chronic pain syndrome, repeated falls, scoliosis, [CONDITION(S)], lack of coordination, Dementia with behavioral disturbances, displaced fracture of base of neck of right femur and subsequent encounter for closed fracture with routine healing. R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R1's cognition is Severely Impaired. Section G-Functional Status for: Bed Mobility is documented as self-performance as extensive assistance with the assistance of two plus persons physical assist. Transfers are documented as self-performance as extensive assistance with assistance of two plus persons physical assist, Walk in Room is documented as, self-performance as limited assistance with assistance of two plus staff physical assist. R1's Morse Fall Scale dated 10/09/21 has a documented score of 65 which notes R1 is a High Risk for falling. R1's Morse Fall Scale dated 10/13/21 has a documented score of 55 and that R1 is a High Risk for falling. R1's Morse Fall Scale dated 10/31/21 has a documented score of 55 which denotes R1 is a High Risk for falling. R1's Morse Fall Scale dated 11/02/21 has a documented score of 65 which notes R1 is a High Risk for falling. R1's Morse Fall Scale dated 11/03/21 has a documented score of 55 which notes R1 is a High Risk for falling. R1's Morse Fall Scale dated 11/09/21 has a documented score of 55 which notes R1 is a High Risk for falling. R1's undated Care plan documents, R1 has potential for falls and injury, history of recurrent falls at home, recent fall with left sacral iliac fracture, use of pain medications daily, use of [CONDITION(S)] medications daily, requires assist of 1 with all ADL's (Activities of Daily Living) and documenting falls on 10/09/21, 10/31/21 and 11/03/21. Under goals states R1 will be free of injury related to falls through next review, documenting a date initiated as 02/20/2020, with a revision date of 02/24/2021 and a target date of 02/05/2022. Under Interventions, an intervention of; Bed against wall in low position with mat on floor is listed, with an initiated date of 11/01/2021 and a revision date of 11/04/2021. R1's Incident Report dated 11/03/2021 at 8:38 PM, documents an unwitnessed fall, with the Incident Location: Resident's room. The report documents under the section titled, Incident Description Note Text: R1 was yelling out at 8:08 PM, R1 had an unwitnessed fall to the floor, with the floor mat not being in place. R1 complained of left hip pain and left hip looks shorter than right on assessment. R1 cried out in pain when touched anywhere on left hip. The section titled, Level of Pain documents PAIN as 8; with breathing scored as 0, detailing, normal, Negative Vocalization scored at 2, detailing, repeated troubled calling out, loud moaning or groaning, crying. Facial Expression was scored at 2, detailing, facial grimacing. Body Language was scored at 2, detailing, rigid, fists clenched, knees pulled up, pulling, or pushing away or striking out. Consolability was scored at 2, detailing, unable to console, distract or reassure. R1's electronic medical record documents on 11/4/2021 12:50 AM Health Status Note: Note Text: Talked to ER charge nurse, (R1) resident is being admitted with a fractured hip. R1's hospital discharge report documents section Hospital Course: R1 is a [AGE] year-old female who presents to the emergency department after falling, R1 was found on the floor at nursing home after falling. R1 had pain and deformity of left hip so EMS called. This is the second fall she has had this month. Prior fall resulted in right hip fracture status post-surgery 3 weeks ago. Xray revealed left hip fracture. Ortho repaired and she has had no acute problems. Result Date: 11/04/2021, Exam: Xray of femur left (2 views), left intertrochanteric hip fracture. The CT scan of the left hip is performed without intravenous contrast enhancement. There is a moderately comminuted (breakage of the bone in two or more pieces) intertrochanteric fracture of the left proximal femur with moderate impaction. The hip articulations intact. There is moderate diffuse osteopenia (weakening & thinning of the bones). Atheromatous (accumulation of plaque) changes of the external iliac and common femoral artery are noted. R1's Incident Reports document falls on 10/09/2021, 10/31/2021, and 11/03/21 with the 10/09/2021 fall resulting in a right hip fracture and 11/03/21 resulting in a left hip fracture. The final Incident Report submitted to IDPH dated 11/10/21 states, During our in-house investigation it was discovered that fall mat had not been put in place during residents fall, but bed was in low position. On 12/20/21 at 12:15 PM, V2 (Director of Nursing/Care Plan Coordinator) stated, R1's mat by her bed was not in place at the time of the fall. On the fall on 11/03/21, R1 did fracture her left hip, she was in the hospital until 11/08/21. Staff have been re-educated on the importance of making sure safety measures are in place. On 12/20/21 at 10:55 AM, V5 (Certified Nurse Aide) stated, she was not here for R1's falls, she knows her bed is supposed to be in a low position with the mat next to it for fall prevention. On 12/20/21 at 11:30 AM, V6 (Licensed Practical Nurse) stated she was not here for R1 or R2's falls. She is aware that R1 is to have her bed in the low position and the mat by the bed, she also has pad alarms for her bed and wheelchair. On 12/16/21 at 2:30 PM, V4 (Certified Nurse Aide) stated she does not believe she was working when R1 fell . R1 did recently fracture her hip in her recent fall. She knows her bed is supposed to be in the low position with the mat at the bedside, and she also has a bed alarm and a chair alarm for her wheelchair. On 12/21/21 at 8:58 AM, V14 (Director of Rehabilitation) stated, R1 has never been independent with ambulation. Due to cognition and unsteady balance, she has always required complete assistance to minimal assistance with a wheeled walker with staff for ambulation. After R1's first hip fracture and at evaluation on 10/14/21, R1 required strengthening, bed mobility, transfers and to begin ambulation again with therapy with a rolling walker. Prior to this first hip fracture she was able to perform bed mobility modified independent. She was making gains in all areas. After R1 sustained her second hip fracture on 11/3/21 she had regressed requiring additional assistance in all aspects again. Her pain has been being managed and therapy works with nursing and pain management during her therapies. She is able to self-reposition in her wheelchair. She has been able to improve in her wheelchair mobility to which is at a supervision level with use of her lower extremities. Her weakness in lower extremities and discomfort that comes with a fracture in a lower extremity is what therapy is working with currently. R1's Electronic Health Record documents, 11/8/2021 1:03 Health Status Note: Note Text: Resident is resting in bed at this time with eyes closed. No signs or symptoms of distress. R1 is readmitted for skilled nursing services and physical therapy and occupational therapy evaluation and participation this shift following hospital stay at (local hospital) related to a fall resulting in left hip fracture. R1 arrived at facility at approximately 6:35 PM this shift via ambulance. R1 has one suture line present on upper outer left hip measuring 60 cm (centimeters) in length, 0 width, and 0 depth. There is no signs or symptoms of infection present. The area is glued with no visible sutures or staples present. R1 is now incontinent of bowel and bladder due to recent injury to left hip. R1 will use wheelchair for mobility, and to discontinue order due to R1 is weight bearing as tolerated. R1 has not been able to tolerate being out of bed since readmitted this shift. 2. R2's Electronic Medical Record documents R2 is a [AGE] year-old male with diagnoses including: Dementia without behavioral disturbances, Alzheimer's Disease, Major Depressive Disorder, Mononeuropathy, and Acquired absence of right leg below the knee. R2's MDS with a signed date of 11/03/21, documents a BIMS score of 6, indicating R2's cognition is Severely Impaired. R2's care plan documents: 10/26/18, R2 has been assessed with the operation of his new power chair, he is able to control the joystick of wheel chair with supervision, and occasional cues. May be up in power chair with supervision. Date initiated: 11/06/2018. Revision on: 05/06/2019. R2's Electronic Medical Record documents R2's Health status note on 12/08/21 at 5:40 PM stating, R2 had oral surgery on 12/08/21 removing eight teeth. R2 has gauze packing in place and ice pack rotated off and on. R2 has no complaints of pain at this time. R2 has no active bleeding noted. R2's face is slightly swollen bilaterally. R2's Electronic Medical Record documents Administration Note on 12/09/2021 at 7:45 AM [MEDICATION(S)]-Acetaminophen tablet 7.5-325 MG was given, order states, give one tablet by mouth every four hours as needed for pain with a maximum dose of 4g/24hr for recent teeth extractions. R2's incident report dated 12/9/2021 at 8:58 PM, documents an un-witnessed fall on 12/09/2021, Incident location: Resident's room. This report documents under section titled, Incident Description: Nursing Description: V3 (Licensed Practical Nurse/LPN) was assisting another resident off the floor when V4 (Certified Nursing Assistant/CNA) reported that R2 was on the floor. V4 (CNA) had recently put R2 in his room in R2's chair and noted seatbelt in place, when V4 (CNA) was called by V3 (LPN) to help assist with another resident. V3 (LPN) ran to R2's room and saw R2 laying on his left side by his motorized wheelchair. R2 was assessed with complaints of right and left shoulder pain, left wrist pain and [CONDITION(S)] noted to left posterior side of head. Neuro check is within normal limits. Immediate Action Taken section documents: EMS (Emergency Medical Service) called and R2 was sent to emergency room for further evaluation. On 12/20/21 at 12:15 PM, V2 (Director of Nursing/Care Plan Coordinator) stated R2 was left unsupervised in his wheelchair in his room. V4 went to assist another resident that had fallen and when V3 (LPN) and V4 (CNA) returned to his room, R2 was found on the floor next to his motorized wheelchair. V2 stated, he must be kept in visual range when in his wheelchair. On 12/16/21 at 2:30 PM, V4 (Certified Nurse Aide) stated, the fall that involved R2 happened in his room. She was taking R2 to his room to transfer R2 back to bed when she heard a yell that another resident (R4) needed urgent assistance, he had fallen and V3 (LPN) needed assistance. V4 (CNA) made sure his seat belt was secured and quickly went to help assist the other resident. When they returned, they found R2 on the floor next to his motorized wheelchair. R2 stated to staff, he was reaching for something and he fell . He was sent out for evaluation. V4 (CNA) stated, R2 was left unsupervised when staff had to leave to assist R4. V4 (CNA) stated, she does not believe he was found to have any injuries. R2's electronic medical record's progress notes documents: on 12/9/2021 at 9:49 PM Incident Note Late Entry: Note Text: V4 was present and assisting V3 (LPN) while she was assessing this resident. Note states, Floor staff all agree seat belt was in place and in proper position. Seat belt of chair noted to be dangling on each side of the chair. It appears as if seatbelt snapped open or resident undid seat belt before fall happened. R2's incident report dated 12/9/2021 documents under the section titled, Notes dated 12/13/2021 states, after review of incident, review of statements, review of medical records, and knowledge of resident's overall condition, the safety committee has reminded staff members that when this resident is up in his chair he needs to be in a public area and not unsupervised in his room. The policy titled Incident & Falls Tracking, Interventions, & Prevention policy and procedure dated 04/03/15 states, It is the policy of [NAME] Nursing and Rehabilitation Center to develop and maintain a system that ensures the safest possible environment for each resident using the least restrictive appliance or safety device with a personalized plan of care for each individual resident's needs. This tracking system was devised to monitor all incidents and falls to ensure appropriate interventions to each occurrence. 3. A Restraint/Safety Devices/ Positioning/ Mobility Device Assessment will be completed on each resident who uses a safety device or restraint that consists of personal data of each resident that will review possible causative factors that may include resident's history, diagnosis, current appliance or safety device and any changes in safety device or appliance that might be implemented. 9. Labels (for Bed) will be updated with any changes in safety device/appliance.

Based on interview and record review the facility failed to reschedule/obtain a follow-up appointment to timely address a post-surgical wound, communicate with the surgeon, evaluate/treat the wound, and seek medical treatment for 1 of 4 residents (R3) reviewed for wounds in the sample of 4. These failures resulted in an immediate jeopardy, which was identified to have begun on 2/16/21 when the facility failed to recognize that R3's post-surgical follow-up appointment was canceled without rescheduling, and without communicating with the surgeon to obtain interim instructions for wound care for over 6 weeks, resulting in a hospitalization , another surgery, hardware removal with infection in the screw holes, damage to the bone, a deep right lateral wound infection with [CONDITION(S)] and infected nonunion. These failures have the potential to affect one other resident (R5) residing in the facility, who is post-surgical. V1, Executive Director, V2, Director of Nursing, V16, Administrator, and V17, MDS Coordinator were notified of the Immediate Jeopardy on 4/1/2021 at 11:49 AM. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on 4/1/2021, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their interventions and in-service training. The findings include: According to the medical record, R3 is [AGE] years old, admitted into the facility for rehabilitation on February 9, 2021 from a local hospital after surgery due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Sets) assessment dated [DATE] documents R3 has a BIMS (brief interview for mental status) score of 9, indicating R3 has moderate cognitive impairment, has no behavioral symptoms that would prevent care being provided, and needs limited assistance of two staff with bed mobility, toilet use, and personal hygiene. This same MDS lists R3 as needing extensive assistance where staff provides weight bearing support of two staff with transfers and dressing; R3 having impairment on one side of his lower extremity, and was not receiving pain medication or hurting in the 5 days prior to the assessment. According to R3's local Hospital Discharge Summary from the January 31, 2021 admission instructions for care for the admission facility said to call the local hospital if R3 had redness, tenderness, or signs of infection (pain, swelling, redness, odor or green/yellow discharge around incision site, and for temperatures above 100.4). The post discharge dressing care on this same document says to leave in place until follow-up with V10 (Surgeon) in 2 weeks. A document entitled After Visit Summary from the local hospital for the admission of 1/31/2021 for R3 states Follow up with surgeon (V10) on 2/16/2021 at 9:00 AM and lists the name and address of the surgeon. According to R3's Medication Administration Records for February and March 2021, R3 did not receive any pain medication after admission to the nursing facility on 2/9/2021 through 2/18/2021. However, from 2/18/2021 to 3/18/2021, R3 received 15 doses of Acetaminophen 650mg for pain. On 3/24/2021 at 2:37 PM, V3 (Licensed Practical Nurse/LPN) said when R3 was admitted into the facility on [DATE] he had a follow up appointment on 2/16/2021 with V10. She said on 2/16/2021 the weather was so bad the appointment was canceled by V10's office, and the day they called the facility to cancel the appointment they did not provide another follow up appointment and she did not obtain another appointment for R3 at that time. V3 then said R3 became positive for COVID on 2/22/21 and was in quarantine for 14 days, so another appointment with the surgeon was not attempted until 3/4/2021. V3 said she called V10's office and told a scheduler (R3) was supposed to have a follow up appointment on 2/16/2021, but the first appointment available was 3/18/2021. V3 said she asked if they had anything sooner, and the scheduler (V3 did not obtain her name) said no. When asked if she checked R3's surgical site, V3 said she monitored his toes for color but did not look at the surgical site. When asked if she (V3) called the surgeon for further instructions after the follow up visit was canceled V3 replied no. According to R3's progress notes dated 3/1/2021 from 9:56 AM to 11:05 AM, V5 (Family Member) requested R3 be sent to a local hospital emergency room (ER) due to R3 experiencing a fever, not eating or drinking, low urine output, and increased respirations. R3's Hospital ER record dated 3/1/2021 says V8 (LPN) talked with the ER staff and told them she could not tell them which orthopedic surgeon R3 is to be following up with and feels R3's intake has been less over the last couple of days. He had been having fevers as high as 101.4, swabbed positive for COVID on 2/22/21, and had been having fatigue, generalized weakness, labored breathing and feels like his urine output has decreased. This same ER record lists R3's white count as elevated at 12.7 ug/ml (micrograms per milliliter) and listing a range of 4.8 - 10.8 per ug/ml as being normal. Documentation notes that R3 was sent back to the facility the same day with no further treatment orders. On 3/31/21 at 12:15 PM, V8 said when she called the staff at the emergency room (ER) on 3/1/21 regarding R3's transfer to the ER, she did not recall telling them that R3 had missed his orthopedic follow-up appointment on 2/16/21, and said she told them R3 was non-compliant because he was transferring himself and walking on his ankle when he was supposed to be non-weight bearing. On 3/31/21 at 1:24 PM, V15 (ER Physician) said according to R3's record he was being referred for COVID. There is documentation in the record about the physician's assistant calling the facility and he was told by the nurse at the nursing home that R3 had poor compliance with therapy and she did not know which orthopod R3 was supposed to be followed up by. V15 stated I would think if someone had missed their follow up appointment, the surgeon would be called to find how he wanted to proceed and I would think he would want a follow-up within the next week. On 3/25/2021 at 11:22 AM, V2 (Director of Nursing) said the nursing staff was given instructions not to bother the surgical dressing on R3's right lower extremity and stated We were to leave the 'cast' in place until the follow up with V10. V2 said the nursing staff did not have any indication R3 had an infection and when she worked night shift, she evaluated his right lower extremity as best she could and did not note any abnormal findings. When asked about the increase in pain complaints he was having, the elevated temperature and the elevated white blood cell count from the lab at a nearby hospital, she said all of those things could be contributed to other problems he was having at the time like COVID. V2 also said she was not aware he had staples to close the surgical wound as it was not in the documentation from the hospital. When asked if she called the surgeon for further instructions after the follow-up visit was canceled, V2 said no. On 3/24/2021 at 9:25 AM, V5 (Family Member) said after his initial surgery on 2/1/21, R3 went to the surgeon for a follow-up appointment on 3/18/21, which V5 attended. V5 stated R3 was sent directly to the hospital from the surgeon's office because he had an infection in the surgical site. V5 stated the odor was so bad under the cast, R3 had MRSA ([CONDITION(S)]-resistant staphylococcus aureus) in the surgical site and was admitted into the hospital for another surgery. V5 said when she called the facility and talked with V2, she was told the staff could not smell the odor due to wearing the N-95 masks they were wearing and they were not to do anything with the soft cast so they did not do anything with it. On 3/25/2021 at 12:35 PM, V8 (LPN) said she gave R3 pain medication for complaints of pain in his ankle, thought the pain was from him walking on his ankle, and did not examine the surgical site, or call the surgeon for further instructions. On 3/26/21 at 11:14 AM, V11 (LPN) said she gave R3 pain medication, he could not communicate very well, he would say yes or no in response to questions, but could not describe the type of pain he was having or what relieved it. V11 said she was not aware R3 had missed an appointment with the surgeon, and denied observing the surgical site, or calling the surgeon for further instructions. On 3/26/2021 at 12:23 PM, V13 (Certified Nurse Aide/CNA) said she did not see R3's ankle without the boot that was on the ankle and did not observe the surgical site. On 3/25/21 at 12:58 AM, V9 (Nurse of R3's surgeon) said V10 (Surgeon) did surgery on R3's ankle on 2/1/2021. R3 was to have a follow-up appointment within 2 weeks after surgery but did not have a follow up visit until 3/18/2021, 6 weeks past the surgery date due to weather and COVID. V9 also said as soon as she saw R3 she could smell the wound and knew it was infected. V9 said the follow up visits being canceled was unintentional but felt the nursing staff at the facility R3 was living at should have at the very least called V10 to determine if there was anything the nursing facility could be doing for the surgical wound in the interim. V9 said R3 had on the original dressing from 2/1/2021 when he arrived at the follow up visit on 3/18/2021. V9 also said R3 had a surgical splint in place, and a dressing over that. V9 said the staples were covered with a dressing as well under the splint and it was a plastic big bulky splint. V9 said when the splint was removed the skin was red, inflamed, hot, and the odor was bad. Some of the staples were removed in the office, the site was re-dressed and he was sent to the local hospital for more surgery. V9 said V10 told her he had to do an irrigation, debridement, staples were removed and an exploration surgery to determine if the infection was in the bone and to determine what condition the hardware was in that was placed in the ankle on 2/1/21. V9 said V10 had to remove part of the hardware out of the fibula, and (R3) had a chronic infection that did not just start on the day he was seen in the office on 3/18/21. V9 also said V10 told her (R3) will be on 6 weeks of antibiotics and will most likely have to have additional surgeries in the future. V9 said she felt like a nursing facility with nursing staff on duty 24 hours a day should at least call to see if here was anything that needed to be done since the follow-up visits were not kept for whatever reason. V9 also said a surgical dressing should not remain on a surgical site for 6 weeks without someone looking at the site. A history and physical emergency room document for R3 from a local hospital for an admitted [DATE] states under history of present illness Because of COVID breakdown in the nursing home, he was not taken to orthopedic appointment. He was taken to orthopedic appointment today and he was found to have infection at the surgical site and was admitted . This same document lists under assessment and plan Right leg wound/ [CONDITION(S)]. An Orthopedic consult document written by V10 from an admission into the hospital on 3/18/2021 states Plan is for I/D (incision and drainage) of right ankle today . Patient presented to our clinic 7 weeks post op (post-operative) from a right ankle ORIF (open reduction internal fixation). He had been in a nursing care facility since discharge and remained in his post op dressing. He had not had staples or sutures removed from the ankle. Once the dressing was taken down, we found a wound infection with significant induration and inability to even see the staples, we checked the skin and were able to find a few staples and sutures on the medial (inner) side were removed. R3's surgical note written 3/19/21 by V10, states Post operative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . (R3) presented to the office still in his postoperative splint with lateral wound infection with [CONDITION(S)] and some drainage and purulence with radiographic evidence of at least a couple of screws being loose suggesting infection at the bone level. Surgery is indicated to evaluate the severity of the infection, relieve any deep space infection, and debride any infected or devitalized tissue to facilitate healing with IV antibiotics or oral antibiotics and reduce the risk of spreading of the infection and associated morbidity. The surgical note continues to say R3's staples were overgrown with edematous inflamed tissue. There were 2 areas of some granulation tissue, one proximal and one central in the wound. The central area had purulent drainage with deep pressure. Multiple screws were loose. Most of the screw holes had lytic infection, damage to the bone especially at the fracture site and two of the distal holes .The patient's fracture had not healed. It was grossly mobile but well aligned. A Rehabilitation Services Consultation report dated 3/22/21 states Patient currently being managed for deep right lateral wound infection with [CONDITION(S)] and infected nonunion. A lab result on this same hospital document lists Light growth [CONDITION(S)]-resistant staphylococcus aureus. A hospital discharge summary dated 3/23/21 lists R3's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under hospital course states Orthopedics incision and drainage right lateral ankle wound including skin, subcutaneous tissue, muscle and bone with removal of hardware involving all of the lateral malleoius, plate and screws as well as multiple buried skin staples, wound grew MRSA, ID (infectious disease) was consulted an recommended [MEDICATION(S)] until 4/30/21. On 3/30/2021 at 2:21 PM, V10 said the splint that was placed on R3 the date of the original surgery on 2/1/21 could have been removed by the facility if the ace wrap was removed. V10 said a wrap was placed over a hard-plastic splint that had a dressing under it covering the staples from surgery. He said it would not have been easy to replace after removing it, but it could have been. V10 also said he strongly suspects the infection R3 had, was related to the staples from the original surgery not being removed for 7 weeks, and that the infection was more likely than not caused from that. V10 verified no one had contacted him regarding the follow up appointment being put off so long, and he felt like they should have at least called for additional instructions for the surgical wound, and the hardware in R3's ankle had to be removed. On 3/31/21 at 11:49 AM, V14 (R3's Primary Care Physician) said he was not aware of R3 missing his follow-up appointment with the orthopedic surgeon on 2/16/21, or that no one had observed R3's surgical site for 6 weeks. On 3/26/2021 at 11:43 AM, when asked if the nursing staff should have suspected R3 had an infection with a documented increase in pain, the fever, and an elevated white blood count at the hospital emergency room visit on 3/1/21, V2 verified the nurses at the facility should have contacted the surgeons office when the follow-up appointment did not occur as scheduled, and that once R3 became positive for COVID, she felt the nursing staff put their focus on that and not on the surgical wound on his ankle. On 3/31/21 at 12:22 PM, V5 said R3 was transferred to the hospital from V10's office on 3/18/21. R3 received surgery on 3/19/21. R3 was in that hospital until 3/24/2021 when he was transferred to another hospital for two days and was then transferred to another nursing home. She said he must be at this facility for 6 weeks bed ridden to receive antibiotics due to having MRSA in his surgical wound. V5 said the plan at this point is for R3 to go through another surgery to have the plate and screws reinserted and another 6 weeks of being bed ridden after that. V5 said R3's ankle was still fractured and not healed due to the infection in the bone, and the bone must heal prior to the screws being replaced. V5 also said the nursing facility R3 is at now is on lock down due to COVID, so she is having to face time R3. V5 added that R3 has had a [CONDITION(S)] in the past, has child-like behaviors and his communication skills are not very good. The Immediate Jeopardy that began on 2-16-2021 was removed on 4/1/2021 when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: On April 1st, 2021 at approximately 7:00 AM, wound care nurse began assessing all surgical wounds. All surgical wounds have been assessed by 3:58 PM, April 1st, by the wound care nurse to ensure each resident has an appropriate plan of care and that they are receiving treatment in accordance with their physicians' orders. All surgical wounds have been assessed and no issues have been noted. On April 1st, 2021 at approximately 7:00 AM, wound care nurse began assessing all wounds beginning with surgical wounds to ensure each resident has an appropriate plan of care and that they are receiving treatment in accordance with their physicians' orders. This will be completed no later than end of day at 5:00 PM on April 2nd, 2021. The facility has 4 residents as of 4/1/21 that are considered Surgical Post-op. Resident (Res) 1 (R7)- Res had mastectomy on 3/30/21 and returned to the facility the same day. The QA (Quality Assurance) nurse reviewed all her orders on 3/30/21 including post-surgical follow-up for 4/8/21. Wound Care nurse assessed the resident on 4/1/21 to ensure no issues were noted with surgical site. Res 2 (R5) - Res had Laparoscopic Cholecystectomy and was discharged back to the facility post op on 3/23/21 with JP drain. QA nurse reviewed orders including follow-up for post-surgical appointments. Resident went for follow-up appointment on 3/31/21 and again on 4/1/21. Resident has another follow up appointment on 4/13/21. She was also assessed by wound care nurse today to ensure no issues were noted with surgical site. Res 3 (R8) - Res had hip fx with surgery to repair and returned to facility on 3/26/21 for post op care. QA nurse reviewed orders and follow up appointments. Res physician assessed incision during physician visit on 3/31/21 and Resident has post-op follow up appointment scheduled on 4/9/21 with surgeon. Wound Care nurse assessed this Resident on 4/1/21 to ensure no issues were noted with surgical site. Res 4 (R6) - Res was admitted to facility on 3/30/21 after post-surgical Rt hip repair. On 3/31/21 QA nurse reviewed all orders and at 1346 called QA nurse left message for orthopedic surgeon for follow-up appointment and they called back with follow-up for post op on 4/26/21 at 7:40 AM. Wound Care nurse assessed this Resident on 4/1/21 to ensure no issues were noted with surgical site. On Thursday, March 15th, 2021, Surveyor expressed concern to President and DON regarding post-surgical wound care follow up. DON immediately reviewed and revised facility's wound care policy and procedures. DON educated all available nurses on March 26th, 2021 beginning at 10am regarding the updated wound care policies and procedures. Two nurses who were on not available were educated on Monday, March 29th, 2021. On April 1st, 2021, policies and procedures have been revised to include CNA's caring for surgical residents. And they will be educated beginning on April 1st, 2021 at 2pm on identifying and reporting signs and symptoms of infection or any problems for post-surgical care residents. All CNAs and nurses have been educated by end of day on April 2nd, 2021 by DON regarding updated policies and procedures on identifying and reporting signs and symptoms of infection or any problems or potential problems for post-surgical care residents. All staff that are not available will be educated prior to working their next shift. Facilities QA nurse is reviewing all new admissions and/or readmissions for any post-op follow-up appointments. If none are made by physician/surgeon, QA nurse is contacting them to schedule necessary appointments. Wound Care nurse is doing weekly assessments on all wounds including surgical wounds and giving DON a weekly report of findings.

Based on observation, interview and record review, the facility failed to ensure staff properly used a mechanical lift for transfer for 1 of 3 residents (R1) reviewed for safe transfers in the sample of 12. This failure resulted in R1's emergency transfer and hospitalization after falling from a mechanical lift during a transfer. R1 sustained a Subarachnoid Hemorrhage and Closed Fractures of 1st and 2nd Lumbar Vertebra and required a 2 day hospitalization . Findings include: R1 is an [AGE] year old resident with [DIAGNOSES REDACTED]. lift sling broke and R1 fell to the floor, landing on the legs of the mechanical lift. R1 was assessed by V12, Licensed Practical Nurse, and transferred to the hospital by ambulance. V12 documented that when she entered the room, R1 had eyes open with a blank stare and did not respond verbally, noting that she was unable to assess for pain as resident was not responding to her normal baseline. On 11-19-2020, at 3:05 PM, V12 stated she was called to R1's room where she observed R1 laying on her back with her neck on one of the lift's stabilizer legs and her lower extremities on the other stabilizer leg. She noted that the sling was still attached to 3 of the 4 hooks of the lift. V12 stated R1 had a 'flat look' on her face and wasn't responding initially. R1 did finally verbalize some pain and after the ambulance personnel arrived, R1 moaned some when they started moving her to the gurney. V12 stated that after R1 left the facility she inspected the sling that was used and noted that 1 of the 4 loops was torn which had then caused it to come off the hook. She noted that it was not the standard sling used with the mechanical lifts but a cloth sheet used for moving a resident in bed that has a looped like area at each corner which can be used to hold onto the sheet during assisted bed mobility. Hospital imaging reports dated 10-22-2020 document fractures of vertebrae L1 and L2, a right frontal lobe Subarachnoid hemorrhage and a probable small intraparenchymal hemorrhage. A hospital discharge summary dated 10-24-2020 documents R1 presented with back pain after a fall from a mechanical lift on 10-22-2020, it notes a principal problem of Subarachnoid bleed, and active problems which included Closed Fractures of the first and second Lumbar Vertebra. R1's nurse progress notes document R1 returned to the facility on [DATE]. R1 returned with orders for therapy evaluation and to treat as indicated. A 10-28-2020 nurses note documents an order was received for R1 to receive [MEDICATION NAME] 500 mg, two tablets twice daily, after therapy reported R1 was showing some signs of pain during therapy. R1 was observed on 11-20-2020 at 12:15 PM eating in room, up in a chair, mechanical lift sling under resident. The facility investigation's Narrative Summary documents that an examination of the 'sling' used during the attempted transfer was a looped 'slide sheet' and not a traditional 'hoyer sling' and that V7 reported that the sling broke as she started transferring R1 from the shower chair to her bed. The summary indicates V7 had received past re-education training regarding use of the mechanical lifts and had been observed during return demonstration. V7 was terminated for not following facility policy to have a second person to assist with the mechanical lift transfers and for improper use of equipment. On 11-17-2020 at 11:35 AM, V1 verified the accuracy of the narrative summary.

Based on interview and record review the facility failed to implement interventions to safely transfer 2 of 3 (R1 and R2) residents reviewed for transfers in the sample of 4. This failure resulted in a displaced fracture of R1's left arm and a fracture of R2's left leg. Findings Include: 1) R1's face sheet documents an admission date of [DATE] with [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated 6/13/2020 documents R1 has a BIMS (Brief Interview for Mental Status) score of 0, which indicates a severe cognitive impairment. The MDS documents under section G, R1 requires extensive two person assist with transfers. R1's restorative needs assessment dated [DATE] documents R1 is dependent on staff for transfers. R1's care plan documents a focus area of potential for injury related to gait balance problems with an intervention dated 1/18/18 to use a gait belt for all lifts and transfers. The intervention documents, DO NOT lift R1 by arms or under her arms. R1's progress notes document; 7/19/2020 a bruise was reported to R1's upper left arm with some swelling noted in the deltoid area passive range of motion is performed and R1 does not indicate pain. Radial pulse is good with normal capillary refill. 7/20/2020 resident is assessed by the hospice nurse and R1 is noted to be holding her left arm with her right hand and has the left arm crossed over her body. [MEDICAL CONDITION] and bruising are noted to the inner aspect of the upper left arm. The physician is notified and ordered x-rays to be done of the left arm. This progress note documents, Pt's daughter is upset and wants answers She stated she was going to speak to her brother to see what their legal options are for another agency to investigate and if she had to call State (sic) she would do so. 7/21/2020 1:02 AM .no FX (fracture) of distal humerus or elbow but displaced FX of proximal humerus. MD (physician), hospice et dtr (and daughter) aware of FX. 7/21/2020 1:16 AM .dtr told this writer that she didn't want mom to have a cast but was ok with sling. 7/21/2020 8:46 AM .Spoke with (name of daughter) again. She's very upset with the dx (diagnosis) of fracture. States her mother didn't do this to herself. It does still have a clear line of demarcation as though it was a b/p cuff, though an investigation for other answers is ongoing. R1's investigative narrative summary dated 7/23/2020 documents R1 requires extensive assist upon admission with most activities of daily living. The summary documents since 3/2020 R1 has experienced a deteriorating condition and was admitted to hospice on 7/8/2020. On 7/19/2020 CNA's (not named) went to get resident up for the day & (and) noted a large bruise to upper left arm & immediately came and reported bruise to the charge nurse at approximately 6:30 am. The summary documents staff was interviewed and V9 (Certified Nursing Assistant/CNA) stated she assisted V10 (CNA) in putting R1 to bed on the evening of 7/18/2020. V9 stated they transferred R1 by putting their arms under R1's arms and lifting her with the other arm by the pants. V9 stated they did not use a gait belt during transfer. The summary documents continues to document V9 stated she remembered being trained during orientation to use a gait belt when transferring residents. According to the summary, V10 was interviewed and stated she used a gait belt to transfer R1 on the evening of 7/18/2020. After being told it was reported they did not use a gait belt to transfer R1, V10 then stated they had not used the gait belt. The summary documents, Safety committee is unsure of how fx (fracture) actually occurred but it could be related to improper transfer without use of gait belt in combination with osteopenia A full staff re-education was initiated due to lack of gait belt usage, improper transfers, & further failure to follow this policy will result in termination. On 8/11/2020 at 2:02 PM, V14 (Certified Nursing Assistant/CNA) stated she and V15 (CNA) went into R1's room to provide morning care. V14 stated, when they pulled back the covers V15 noticed the bruise to R1's upper arm. V14 stated they reported it to the nurse immediately. On 8/11/2020 at 2:04 PM V15 (CNA) stated she went with V14 (CNA) to get R1 up, and when they pulled the covers back, they noticed the bruise to R1's left arm. V15 stated when she started to move R1's arm it did not feel right so they stopped what they were doing, and reported it to the nurse. V15 stated R1 did not appear to be in pain at first but then did appear to be in pain off and on. On 8/11/2020 at 4:37 PM V4 (Licensed Practical Nurse/LPN) stated she came to work on Monday and R1's left arm was swollen and bruised. V4 stated she got an order for [REDACTED]. On 8/11/2020 at 11:50 PM V12 (Licensed Practical Nurse) stated R1 had a bruise from her shoulder to mid-way down her arm. V12 stated there had been a sign in R1's room that stated she was not to be transferred using her arms. V12 stated the staff should have used a gait belt to transfer R1. On 8/11/2020 at 11:10 PM V9 (Certified Nursing Assistant/CNA) stated she was working the 2-10 PM shift on 7/18/2020, shadowing V10 (CNA). V9 stated they transferred R1 by putting their arms under her arm pits and lifting her into the bed. V9 stated R1 did not cry out or appear to be in pain during or after the transfer. V9 stated R1 was a two-person with gait belt transfer and they did not use a gait belt. When asked why, V9 stated she didn't think V10 used a gait belt. On 8/11/2020 at 12:26 PM V2 (Director of Nurses) stated it was reported to her in the morning on 7/19/2020 R1 had bruising on her arm. She assessed R1 and it looked like a blood pressure cuff may have bruised it. V2 stated R1 winced with range of motion so she reported it to the physician and got an order for [REDACTED]. At 12:57 PM on 8/12/2020, V11 (family member) stated she was not pleased at all with the care R1 had received. V11 stated R1 was not to be lifted by her arms due to a previously torn rotator cuff in her right arm. V11 stated they lifted R1 by her arms anyway and broke her left arm. V11 stated the only way to repair the arm was with surgery and they can't do that, so now R1 can't even scratch her nose. V11 stated she was allowed to see her because R1 was on hospice. V11 stated when she saw her on the day the injury was reported she did not think she would live a week. V11 stated R1's left arm was swollen three times its normal size and bruised from her shoulder to her elbow. V11 stated R1 was in a lot of pain and she felt it was detrimental to her physically as well as mentally. 2. R2's face sheet dated 8/12/2020 documents [DIAGNOSES REDACTED]. R2's order summary report dated 7/17/2020 documents an order to use mechanical lift for all transfers with an order date of 5/1/2020. R2's MDS (Minimum Data Set) dated 7/25/2020 documents R2 has a BIMS (Brief Interview for Mental Status) score of 9, which indicates a moderate cognitive impairment. R2's restorative needs assessment dated [DATE] documents R2 is dependent on staff for all transfers. Care plan documents a focus area, dated 11/28/2017, of potential for falls/injuries. Interventions listed include (mechanical) lift with assist of 2 for all transfers with an initiation date of 11/28/2017. R2's progress notes document; 7/17/2020 10:51 AM .Res (resident) calling out in pain. Upon assessing, this nurse noticed left foot was swollen and red. Res yelled out when foot was barely touched. When asked, CNA's said that resident's foot got caught when moving from bed to chair. DON (director of nurses) came down and looked and (sic) foot and established pedal pulse .MD (physician) notified and gave orders to send res to ER (emergency room ) . 7/17/2020 12:47 PM . (name of local hospital) called facility and reported res had a fracture of left tib (tibia) and fib (fibula) and that she was sent out to (name of regional hospital). This nurse called her POA (power of attorney) to notify him of her updated condition and new room number. POA was extremely unsatisfied and threatened to have this facility talk to his lawyers. All of this information was relayed to DON and administrator 7/18/2020 4:43 PM , .Returned to facility at 3:40 PM via ambulance. Placed in bed. No distress. Is alert with confusion per usual for her . Has cast to lle (left lower extremity) and ace wrap. Elevated on pillow at this time . 8/2/2020 .Resident is resting in bed at this time . Requires total care with all ADLS (activities of daily living). Transfers via (name of mechanical lift) with assist X2 (times 2). Is currently receiving skilled care r/t (related to) tib/fib (tibia/fibula) fracture. Has a splint cast on LLE .Turned q2hr (every two hours) No s/s (signs/symptoms) of pain or discomfort. R2's investigative narrative summary dated 7/17/2020 documents, On 7/17/20 at approximately 8:30 AM, it was noted that resident (R2) began to call out as if she were in pain. Nurse noted at that time that resident's left foot appeared slightly red and swollen. This nurse asked CNA's if they knew if anything had happened that may have caused this change in condition. They replied her foot had got caught during transfer from the bed to her chair. The DON (Director of Nurses) was notified and came down to look at foot immediately. Pedal pulse was found and VS (vital signs) were determined to be WNL (within normal limits). MD (physician) gave orders to send pt (patient) to local ER (emergency room ) .X-rays from (name of local hospital) were brought up and reviewed and reveal a displaced [MEDICAL CONDITION] tibia and fibula .Osteopenia is also noted in the x-rays as well. Under investigation this summary documents, All staff were questioned regarding the transfer. Resident has a care plan and order for a (mechanical lift) transfer. One of the CNA's (not named) was unfamiliar with the resident and did not follow facility protocol for transfer. The other 2 CNA's (not named) present were more familiar with the resident but did not correct the 3rd CNA in time to stop the process. All staff stated that resident did not immediately complain of any pain and no immediate changes were noted at the time of the transfer. At that time, they had no reason to assume there had been any injury until resident began to complain of pain approximately 1 hour later. R2's local hospital records dated 7/17/2020 documents NH (nursing home) patient presents with c/o (complaints of) injury/trauma of uncertain mechanism during transfer at NH with c/o pain and deformity to LLE (left lower extremity).The local hospital x-ray results document a comminuted displaced distal tibial and fibular fractures. R2's regional hospital record dated 7/18/2020 documents R2 was transferred from the local hospital after a fall with a left distal tibial fracture. The hospital record documents staff at nursing home were trying to stand her and her leg got stuck. Patient had splint casting to her left lower extremity and was seen by orthopedic consultant who recommended nonoperative treatment due to the fact R2 is nonweight bearing and has a weakness in her left lower extremity. The regional hospital recommendations were to continue with a splint to R2's left lower extremity and follow up with orthopedics. On 8/11/2020 at 5:50 PM, V6 (Certified Nursing Assistant/CNA) stated she took care of R2 on the day of the incident (7/17/20). V6 stated she and V7 (CNA) were in R2's room getting ready to transfer her using the mechanical lift when V5 (CNA) came into the room to get R2's vital signs. V6 stated V5 picked R2 up with his arms under R2's arm pits and put her in her chair. V6 stated as V5 was sitting R2 down in her chair R2's legs got caught on the the chair. V6 stated she was telling V5 that R2's legs were caught and R2 was yelling out during the transfer and saying no to V5. V6 stated V5 picked R2 up out of the chair and adjusted her leg so it was no longer caught on the chair and R2 stopped yelling. V6 stated R2 was crying and wanted her husband but they were not aware R2 was injured until approximately thirty minutes later when she cried out and said her foot was hurting. When asked how R2 should have been transferred V6 stated she should have been transferred using a mechanical lift. On 8/11/2020 at 1:25 PM, V7 (Certified Nursing Assistant) stated she and V6 were getting R2 up when V5 came into her room picked the resident up and transferred her to the chair. V7 stated V5 did the transfer so fast she didn't have the opportunity to stop him. V7 stated she knew R2's foot had gotten caught in the transfer but was unable to see how it happened. V7 stated she was unable to speak with the nurse until R2 was in the dining room. R2 began to complain of her toes hurting. V7 stated R2 has always been transferred with a mechanical lift. V7 states V5 no longer works at the facility. On 8/11/2020 at 3:17 PM, V16 (Licensed Practical Nurse) stated she heard R2 holler out early in the morning (approximately 7:00 AM). V16 stated she asked the CNA's to check on her at this time and they said R2 was wanting her husband. V16 stated approximately an hour and a half later she heard R2 yell again and was able to check her and R2 stated her leg was hurting. V16 stated she assessed R2's lower extremity and when she touched R2's sock she let out a howl and R2's foot was red and swollen. V16 stated she went to get the director of nurses and on her way V6 and V7 pulled her aside and told her they didn't use a mechanical lift to transfer and her foot got caught and they hadn't reported it because they were afraid they would be in trouble. V16 stated R2 should not have been transferred without a mechanical lift. On 8/11/2020 at 12:26 PM, V2 (Director of Nurses) stated V16 reported to her R2's foot got caught during transfer and she was yelling out. R2's foot had an external rotation and she yelled with range of motion. V2 stated R2 was transferred to the local emergency room for evaluation where it was determined she had a fracture and was sent to the regional hospital. V2 stated she later learned V5 had transferred R2 without using a mechanical lift. On 8/11/2020 at 2:07 PM, V3 (Assistant Director of Nurses) stated R2 is a total lift with a mechanical lift because of her condition. V3 stated V5 decided to lift R2 into her chair instead of using the mechanical lift and R2's foot got entangled. R2 started to complain of pain. R2 was sent to the local emergency room and found a fracture of her left leg. R2's husband opted for no treatment, so it was casted and wrapped and she returned here. The facility safe patient lifting policy dated 2/1/2013 documents under process and procedures, .Gait belt usage is mandatory for all resident handling with the exception of bed mobility & medial contraindication. The gait belt will be considered part of the certified nursing assistant's uniform .

Based on record review and interview, the facility failed to implement a fall prevention measure identified on the care plan to ensure a safe resident transfer was provided for 1 of 3 residents (R5) reviewed for transfers in the sample of 7. This improper transfer resulted in R5 being sent to the emergency room and diagnosed with [REDACTED]. Findings include: 1. R5 is an [AGE] year old resident with [DIAGNOSES REDACTED]. A 12/24/2018 Quarterly Minimum Data Set (MDS) assessment notes that R5 requires extensive assist of two for transfers. The current Care Plan has a problem area of Potential for Falls' and includes an approach with an initiation date of 11/1/14 for staff to use a gait belt for all transfers. A Nurse Progress Note dated 1/24/19 for 16:30 (4:30 PM) documented by V7 (Nurse) notes an incident where V6, Certified Nurse Aide (CNA) yelled for a nurse and V7 entered R5's room and found R5 on the floor. V6 stated on 2/1/19 at 2:40 PM that she had been in R5's room, getting R5 dressed as R5 laid in bed. V6 stated that she was trying to sit R5 up as she waited for another CNA to come assist with the transfer into the wheelchair. V6 stated that R5 started to slide off the edge of the bed, at which time she grabbed hold of her and slid her down my leg into the floor. V6 stated that R5 did not cry out or act as if in pain at the time this occurred and that she yelled for help with V7 coming into the room. After V7 had assessed R5, they together lifted R5, under her arms, into her wheelchair. V6 stated that she had not brought her gait belt into the room and no gait belt was used to assist in lifting R5 off the floor. V6 stated that at that time R5 started to cry and V7 asked her if she was ok with R5 stating yes. R5 was taken out to supper and during supper, R5 complained of her arm hurting. It was noted that R5 had 2 skin tears on her arm under her skin protector sleeves she was wearing. V7 documented in the 1/24/19, 4:30 PM note that V7 had helped V6 transfer R5 to her wheelchair and that after complaints of pain in her right arm, had given R5 Tylenol, ordered as needed for pain. V6 stated that R5 had continued to complain of pain and that the nurse (V7) had sent R5 to the hospital to be checked. V7 documented a note for 1/24/19 20:46 (8:46 PM) that after contacting the Doctor and family, R5 was transferred to the emergency room for evaluation, with R5 returning the same evening at 11:19 PM, with a [DIAGNOSES REDACTED]. R5 returned with orders for pain medication as needed. The hospital emergency room report included results of a CT (computerized tomography) scan of head and C-Spine which stated Chest with Displaced [MEDICAL CONDITION] clavicle adjacent to the Sterno clavicular joint and likely minimally displaced fracture of sternum. Instructions were to take medications as prescribed with an order for [REDACTED]. R5's PCP ordered a change in R5's pain medication after an allergy to [MEDICATION NAME] was identified, however there were no further instructions for R5's care. V3 CNA, stated on 2/1/19 at 1:21 PM that prior to the new order to use a mechanical lift for transfers, R5 was transferred with 2 staff and a gait belt. V3 stated they would dress R5 with her laying down, put the gait belt on her, chair, place R5's wheelchair beside the bed prior to the transfer (if moving her from bed to wheel chair) then lift R5 using the gait belt and placing their arms under R5's arms. V3 stated that R5 has not been able to bear weight for many years, and is not able to be sat up on the side of the bed. V3 stated that R5 has contractures and usually keeps her arms pulled up across her chest and that R5 is a total for feeding, basically for everything. V8 LPN (Licensed Practical Nurse) stated on 2-1-19 at 1:02 PM that R5 was a 2 person transfer prior to new order to use a mechanical lift. The 12/24/2018 Quarterly Minimum Data Set (MDS) assessment notes R5 needs total assist with eating. V2, Director of Nursing, (DON) stated on 2-1-19 at 3:00 PM that V6 should have had her gait belt with her and used it when sitting R5 up and when V6 and V7 lifted R5 from the floor.

Based on observation, record review, and interview, the facility failed to implement strategies to prevent falls in 5 of eleven residents reviewed for falls (R4, R7, R8, R14, R13) in the sample of twenty four. These failures resulted in a fractures of the left metatarsal and left fibula accompanied by decline in mobility for R14. Findings include: 1. On 03/13/14 at 9:45 am, R14 was observed unattended, sitting on the bedside commode. Her call light was within reach, but had not been activated. She did not have a pull tab alarm on. She had a cast on her left foot/lower leg. E8 and E9, both Certified Nursing Assistants, came in and, after cleaning R14, they both transferred R14 to the bed using a gait belt. An Incident Report dated 02/23/14 showed that on that date R14 fell while attempting to self transfer from the bedside commode to the bed. This report further stated, "Resident also has an order for [REDACTED]. It has been determined that the residents fall may have been avoided if all ordered safety interventions were in place. Additional information: On the 02/26/14 nurse's note, it was noted that the resident had been voicing inconsistent complaints of pain in her left foot and was sent to the emergency room for evaluation, the resident returned to the facility with a [DIAGNOSES REDACTED]."A Care Plan with a review date of 02/23/14 showed a problem area of "risk of falls". Interventions for this problem area included "pull tab alarm while up on bedside commode". On 03/13/14 at 9:30 am, E3, Assistant Director of Nurses, during interview, confirmed that R14 is to have on a pull tab alarm when on the bedside commode. On 03/13/14 at 9:50 am, E9, Certified Nurse Aide (CNA), stated that before R14 broke her foot and leg, she could be transferred by one staff member but now requires the assistance of two. During this same interview E8, CNA, acknowledged that R14 did not have a pull tab alarm in place on 3/13/14 2. An Occurrence Report dated 8/21/13, at 4:45 a.m. R7 was found lying on her side in front of her bedside commode with a 3 centimeter (cm) laceration to her forehead surrounded by purple bruising, complaining of pain in her right 4th and 5th toes. According to a Follow up Report dated 8/23/13, "(R7) is at high risk of falls," and "(R7's) plan of care states that (R7) is not to be left unattended on bedside commode for safety," and that in addition to the forehead laceration, R7 sustained fractures to the right 4th and 5th metatarsals. On R7's most recent Care Plan with a revision date of 8/2/1/13 the facility initiated the following intervention on 6/25/13 to prevent R7 from falling: Staff to keep a hand on resident at all times when she is on the bedside commode. According to the Follow up Report dated 8/23/13, on 8/21/13 at 4:45 a.m., E16 (Certified Nurses Aid (CNA) )stated that she had assisted R7 to the commode, and walked to the other side of the room while R7 was on the commode. The Follow up Report also states that E16, was "disciplined for not following the resident plan of care, resulting in a fall with injury." On 3/14/14 at 10:00 a.m., E15, CNA, stated that she recalled the accident and R7 did not suffer a decline, since R7 had been non-weight bearing prior to the fall. 3. On 3/11/14 at 2:30 p.m., R13 was propelling self down the hallway in a wheelchair with a pad alarm in place. R13's Minimum Data Sets ((MDS) dated [DATE] indicates a score of 2 (severe cognitive impairment) on the Brief Interview for Mental Status; normally uses a wheelchair for mobility and requires extensive assist with transfers. A Fall Risk assessment dated [DATE] states that R13 "Overestimates or forgets limits," and identifies R13 as high risk for falls. R13's Care Plan dated 9/30/14 with a revision date of 2/14/14 includes a Focus of Potential for Injury: Resident is at risk for falls due to unaware of safety needs, psychoactive drug use, gait/balance problems, and requires assistance with transfers. R13's Care Plan includes the following interventions for falls: 1. Anticipate and meet the residents needs; 2. Attempt to keep visible when out of bed; 3. Be sure the resident's call light is within reach and encourage to use it for assistance as needed; 4. Supervise resident and assist with transfers; 4. Respond promptly to request for assistance to toilet; and 5. The resident uses a pad alarm, ensure the device is in place as needed. An Incident Report of 1/9/2014 at 7:00 p.m. states resident was found sitting on the floor in another resident's room with urine noted in the floor surrounding her. No injuries were noted. Intervention: Staff counseled to remove resident from the dining room after meals and place her in highly visible area. No new interventions were added to R13's Care Plan. An Incident Report dated 2/06/14 at 3:20 p.m. states that R13 was found in the dining room sitting on the floor next to her wheelchair, and "Alarm was turned off." A note on the Incident Report dated 2/7/14 states, "It has been determined that the resident reached forward to pick up something off the floor and lost her balance. Alarm in place but turned to off position. Intervention: Staff counseled to ensure that residents alarms are on at all times for safety." No new interventions were added to R13's Care Plan. On 3/14/10 at 10:00 a.m., E12, CNA (Certified Nurses Aide), during interview stated that R13 is to always have the pad alarm on when R13 is in the wheelchair or in bed; that the alarm is turned off only when R13 is being assisted to the bathroom or transferring to bed at night, showering, etc. and then turned back on; and that R13 should not be left alone with pad alarm in off position. An Incident Report dated 2/12/14 at 7:00 p.m. states that " Resident was found on floor in room, at foot of bed". She stated, she was trying to get into bed. Wheelchair alarm sounding when found by CNA. A note on this report dated 2/14/14 states, "Encourage staff to keep resident visible when up in wheelchair". No new intervention was added to R13's Care Plan after this date. 4. On 3/13/14 at 9:00 a.m., R4 was sitting in a wheelchair in the hallway outside of his room with head down and eyes closed. This writer called R4's name several times in close proximity to his ear before he lifted his head. R4's physician's orders [REDACTED]. Medications for R4 listed on this document include Roxanol 10 milligrams every four hours for pain at 6 am, 10 am, 2 pm, 6 pm, and 10 pm. OxyContin 115 milligrams at 8 a.m. and 4 p.m. A Hospice Agreement for R4 was signed on 7/7/2013. A Fall Risk Evaluation for R4 dated 7/9/013 identifies R4 at high risk for falls with a score of 18 ( score of 10 or above represents high risk). R4's Minimum Data Set of 7/19/13 identifies R4 as using a wheelchair for mobility, requiring assistance of 2 persons for bed mobility and transfers. R4's Care Plan with initiation date of 7/7/2013 includes: Potential for Injury: Resident is at risk for falls due to balance problems. Interventions for fall reduction on R4's Care Plan include: 1. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. 2. Pad alarm at all times. 3. Supervise resident and assist appropriately with transfers (2 assist). 4. High-sided mattress. 5. Follow Facility Fall Protocol An Incident Report dated 7/7/2013 at 9:45 p.m. states that R4 was found lying in floor with head on pillow under the bed when nurse heard resident moaning. Report states alarm was not sounding due to resident laying on alarm and that R4 experienced no pain with range of motion. This report further states that R4 was admitted to the hospital on 7/8/2013 at 5 pm p.m. following complaints of pain to lower extremities and was admitted with a [DIAGNOSES REDACTED]. A note of 7/9/2013 of this report concludes that R4 sustained a fall while trying to get out of bed without assistance. All safety measures were in place at time of fall. Recommendation added to R4's Care Plan was" High-sided mattress due to safety awareness." An incident report dated 10/08/2013 states that at 10:45 a.m. R4 was sitting in the wheelchair in the hallway sleeping when he leaned forward and fell out of the wheelchair. R4 hit his head on the floor and was noted to have a large hematoma to the forehead. Pad alarm was sounding at the time of the fall. An intervention was added to R4's Care Plan on this date for "Staff to offer to lay resident down if he looks tired while up in wheelchair" An Incident Report dated 10/27/13 states that at 2:01 p.m.. that in response to an alarm sounding. R4 was found sitting on the floor in the room with back against the wall and legs extended straight out. Resident states " I fell out of wheelchair after I fell asleep." Reddened area with dark bruising and small abrasion noted to the right of R4's forehead. Intervention of " Encourage resident to sit in recliner after every meal for safety" was added to the Care Plan on 10/27/13. An incident report dated 12/5/2013 states that at 10:00 am, R4 was found sitting in the floor with his wheelchair behind him. Alarm was sounding. The breaks were not engaged. Small bruise noted to left hand. Recommendation : Anti roll-back device to wheelchair for safety. This recommendation does not appear on R4's Care Plan. An Incident Description dated 1/19/2014 states that on this date at 7:25 am R4 sustained a fall from the wheelchair in the. hallway. Alarm sounded. Raised bruised area noted to top of head. Resident stated ," I must have fell asleep" A note of 1/21/14 included on the report states that after review of the incident by the safety committee an intervention was recommended for Maintenance Department to" drop residents wheelchair seat in the back to create a slight decline for safety." This intervention does not appear on R4's Care Plan. On 3/14/14 at 9:05 a.m., when asked if R4's wheelchair was equipped with an anti-rollback device E13 Certified Nurses Aid stated she was not sure and but would check and located R4 in the hallway accompanied by this writer. E13 stated that there were no devices added to R4's wheelchair. On 3/14/14 at 1:50 pm E3 Assistant Director of Nurses accompanied this writer to R4's room to check for anti-rollback device and lowered wheelchair seat. R4 was in bed sleeping with the wheelchair next to the bed. E3 confirmed that anti-rollback devices were not present on the wheelchair and that the seat had not been lowered in the back. 5. On 03/13/14 at 9:35 am, R8 was observed in her wheelchair self propelling down the hallway. R8 had a personal safety alarm in place. When asked, R8 was unable to give her name, the date, or the name of the facility. An Incident Report dated 12/04/13 showed that on that date, R8 fell from a shower chair when she was left unattended in the shower room. The Incident Report further stated ," The Safety Committee has concluded that (E6, CNA) went to central supply and (E7, CNA) didn't hear (E6) tell her she was going to central supply" thus leaving the resident unattended. When E6 came back in the room the resident was unattended and lying on the floor in front of the shower chair. An undated Shower Policy/Procedure stated "Residents should never be left alone in the shower room." A Minimum (MDS) data set [DATE] showed that R8 is totally dependent on at least two staff for assistance with bathing. On 03/13/14 at 9:25 am, E3, Assistant Director of Nurses, confirmed that it is against facility policy to leave residents unattended in the shower room.

Based on observation, record review, and interview, the facility failed to implement strategies to prevent falls in 5 of eleven residents reviewed for falls (R4, R7, R8, R14, R13) in the sample of twenty four. These failures resulted in a fractures of the left metatarsal and left fibula accompanied by decline in mobility for R14. Findings include: 1. On 03/13/14 at 9:45 am, R14 was observed unattended, sitting on the bedside commode. Her call light was within reach, but had not been activated. She did not have a pull tab alarm on. She had a cast on her left foot/lower leg. E8 and E9, both Certified Nursing Assistants, came in and, after cleaning R14, they both transferred R14 to the bed using a gait belt. An Incident Report dated 02/23/14 showed that on that date R14 fell while attempting to self transfer from the bedside commode to the bed. This report further stated, "Resident also has an order for [REDACTED]. It has been determined that the residents fall may have been avoided if all ordered safety interventions were in place. Additional information: On the 02/26/14 nurse's note, it was noted that the resident had been voicing inconsistent complaints of pain in her left foot and was sent to the emergency room for evaluation, the resident returned to the facility with a [DIAGNOSES REDACTED]."A Care Plan with a review date of 02/23/14 showed a problem area of "risk of falls". Interventions for this problem area included "pull tab alarm while up on bedside commode". On 03/13/14 at 9:30 am, E3, Assistant Director of Nurses, during interview, confirmed that R14 is to have on a pull tab alarm when on the bedside commode. On 03/13/14 at 9:50 am, E9, Certified Nurse Aide (CNA), stated that before R14 broke her foot and leg, she could be transferred by one staff member but now requires the assistance of two. During this same interview E8, CNA, acknowledged that R14 did not have a pull tab alarm in place on 3/13/14 2. An Occurrence Report dated 8/21/13, at 4:45 a.m. R7 was found lying on her side in front of her bedside commode with a 3 centimeter (cm) laceration to her forehead surrounded by purple bruising, complaining of pain in her right 4th and 5th toes. According to a Follow up Report dated 8/23/13, "(R7) is at high risk of falls," and "(R7's) plan of care states that (R7) is not to be left unattended on bedside commode for safety," and that in addition to the forehead laceration, R7 sustained fractures to the right 4th and 5th metatarsals. On R7's most recent Care Plan with a revision date of 8/2/1/13 the facility initiated the following intervention on 6/25/13 to prevent R7 from falling: Staff to keep a hand on resident at all times when she is on the bedside commode. According to the Follow up Report dated 8/23/13, on 8/21/13 at 4:45 a.m., E16 (Certified Nurses Aid (CNA) )stated that she had assisted R7 to the commode, and walked to the other side of the room while R7 was on the commode. The Follow up Report also states that E16, was "disciplined for not following the resident plan of care, resulting in a fall with injury." On 3/14/14 at 10:00 a.m., E15, CNA, stated that she recalled the accident and R7 did not suffer a decline, since R7 had been non-weight bearing prior to the fall. 3. On 3/11/14 at 2:30 p.m., R13 was propelling self down the hallway in a wheelchair with a pad alarm in place. R13's Minimum Data Sets ((MDS) dated [DATE] indicates a score of 2 (severe cognitive impairment) on the Brief Interview for Mental Status; normally uses a wheelchair for mobility and requires extensive assist with transfers. A Fall Risk assessment dated [DATE] states that R13 "Overestimates or forgets limits," and identifies R13 as high risk for falls. R13's Care Plan dated 9/30/14 with a revision date of 2/14/14 includes a Focus of Potential for Injury: Resident is at risk for falls due to unaware of safety needs, psychoactive drug use, gait/balance problems, and requires assistance with transfers. R13's Care Plan includes the following interventions for falls: 1. Anticipate and meet the residents needs; 2. Attempt to keep visible when out of bed; 3. Be sure the resident's call light is within reach and encourage to use it for assistance as needed; 4. Supervise resident and assist with transfers; 4. Respond promptly to request for assistance to toilet; and 5. The resident uses a pad alarm, ensure the device is in place as needed. An Incident Report of 1/9/2014 at 7:00 p.m. states resident was found sitting on the floor in another resident's room with urine noted in the floor surrounding her. No injuries were noted. Intervention: Staff counseled to remove resident from the dining room after meals and place her in highly visible area. No new interventions were added to R13's Care Plan. An Incident Report dated 2/06/14 at 3:20 p.m. states that R13 was found in the dining room sitting on the floor next to her wheelchair, and "Alarm was turned off." A note on the Incident Report dated 2/7/14 states, "It has been determined that the resident reached forward to pick up something off the floor and lost her balance. Alarm in place but turned to off position. Intervention: Staff counseled to ensure that residents alarms are on at all times for safety." No new interventions were added to R13's Care Plan. On 3/14/10 at 10:00 a.m., E12, CNA (Certified Nurses Aide), during interview stated that R13 is to always have the pad alarm on when R13 is in the wheelchair or in bed; that the alarm is turned off only when R13 is being assisted to the bathroom or transferring to bed at night, showering, etc. and then turned back on; and that R13 should not be left alone with pad alarm in off position. An Incident Report dated 2/12/14 at 7:00 p.m. states that " Resident was found on floor in room, at foot of bed". She stated, she was trying to get into bed. Wheelchair alarm sounding when found by CNA. A note on this report dated 2/14/14 states, "Encourage staff to keep resident visible when up in wheelchair". No new intervention was added to R13's Care Plan after this date. 4. On 3/13/14 at 9:00 a.m., R4 was sitting in a wheelchair in the hallway outside of his room with head down and eyes closed. This writer called R4's name several times in close proximity to his ear before he lifted his head. R4's physician's orders [REDACTED]. Medications for R4 listed on this document include Roxanol 10 milligrams every four hours for pain at 6 am, 10 am, 2 pm, 6 pm, and 10 pm. OxyContin 115 milligrams at 8 a.m. and 4 p.m. A Hospice Agreement for R4 was signed on 7/7/2013. A Fall Risk Evaluation for R4 dated 7/9/013 identifies R4 at high risk for falls with a score of 18 ( score of 10 or above represents high risk). R4's Minimum Data Set of 7/19/13 identifies R4 as using a wheelchair for mobility, requiring assistance of 2 persons for bed mobility and transfers. R4's Care Plan with initiation date of 7/7/2013 includes: Potential for Injury: Resident is at risk for falls due to balance problems. Interventions for fall reduction on R4's Care Plan include: 1. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. 2. Pad alarm at all times. 3. Supervise resident and assist appropriately with transfers (2 assist). 4. High-sided mattress. 5. Follow Facility Fall Protocol An Incident Report dated 7/7/2013 at 9:45 p.m. states that R4 was found lying in floor with head on pillow under the bed when nurse heard resident moaning. Report states alarm was not sounding due to resident laying on alarm and that R4 experienced no pain with range of motion. This report further states that R4 was admitted to the hospital on 7/8/2013 at 5 pm p.m. following complaints of pain to lower extremities and was admitted with a [DIAGNOSES REDACTED]. A note of 7/9/2013 of this report concludes that R4 sustained a fall while trying to get out of bed without assistance. All safety measures were in place at time of fall. Recommendation added to R4's Care Plan was" High-sided mattress due to safety awareness." An incident report dated 10/08/2013 states that at 10:45 a.m. R4 was sitting in the wheelchair in the hallway sleeping when he leaned forward and fell out of the wheelchair. R4 hit his head on the floor and was noted to have a large hematoma to the forehead. Pad alarm was sounding at the time of the fall. An intervention was added to R4's Care Plan on this date for "Staff to offer to lay resident down if he looks tired while up in wheelchair" An Incident Report dated 10/27/13 states that at 2:01 p.m.. that in response to an alarm sounding. R4 was found sitting on the floor in the room with back against the wall and legs extended straight out. Resident states " I fell out of wheelchair after I fell asleep." Reddened area with dark bruising and small abrasion noted to the right of R4's forehead. Intervention of " Encourage resident to sit in recliner after every meal for safety" was added to the Care Plan on 10/27/13. An incident report dated 12/5/2013 states that at 10:00 am, R4 was found sitting in the floor with his wheelchair behind him. Alarm was sounding. The breaks were not engaged. Small bruise noted to left hand. Recommendation : Anti roll-back device to wheelchair for safety. This recommendation does not appear on R4's Care Plan. An Incident Description dated 1/19/2014 states that on this date at 7:25 am R4 sustained a fall from the wheelchair in the. hallway. Alarm sounded. Raised bruised area noted to top of head. Resident stated ," I must have fell asleep" A note of 1/21/14 included on the report states that after review of the incident by the safety committee an intervention was recommended for Maintenance Department to" drop residents wheelchair seat in the back to create a slight decline for safety." This intervention does not appear on R4's Care Plan. On 3/14/14 at 9:05 a.m., when asked if R4's wheelchair was equipped with an anti-rollback device E13 Certified Nurses Aid stated she was not sure and but would check and located R4 in the hallway accompanied by this writer. E13 stated that there were no devices added to R4's wheelchair. On 3/14/14 at 1:50 pm E3 Assistant Director of Nurses accompanied this writer to R4's room to check for anti-rollback device and lowered wheelchair seat. R4 was in bed sleeping with the wheelchair next to the bed. E3 confirmed that anti-rollback devices were not present on the wheelchair and that the seat had not been lowered in the back. 5. On 03/13/14 at 9:35 am, R8 was observed in her wheelchair self propelling down the hallway. R8 had a personal safety alarm in place. When asked, R8 was unable to give her name, the date, or the name of the facility. An Incident Report dated 12/04/13 showed that on that date, R8 fell from a shower chair when she was left unattended in the shower room. The Incident Report further stated ," The Safety Committee has concluded that (E6, CNA) went to central supply and (E7, CNA) didn't hear (E6) tell her she was going to central supply" thus leaving the resident unattended. When E6 came back in the room the resident was unattended and lying on the floor in front of the shower chair. An undated Shower Policy/Procedure stated "Residents should never be left alone in the shower room." A Minimum (MDS) data set [DATE] showed that R8 is totally dependent on at least two staff for assistance with bathing. On 03/13/14 at 9:25 am, E3, Assistant Director of Nurses, confirmed that it is against facility policy to leave residents unattended in the shower room.

Based on observation, interview and record review the facility failed to prevent an accident for 1 of 3 residents (R1) reviewed for accidents in the sample of 3. These failures resulted in R1 sustaining fractures to the distal tibia and fibula of the right and left legs. Findings include: R1 is an [AGE] year old resident with [DIAGNOSES REDACTED]. According to R1's Minimum Data Set assessment dated [DATE] in the clinical record R1 has severely impaired cognitive skills, long term memory loss, R1 is total staff care for transfers, has impaired range of motion in upper and lower extremities and R1 does not ambulate. On 10/4/2011 at 12:10 pm and 12:45 pm R1 was observed in a reclining chair in the dining room. R1 was noted with a cast to her right leg and the right leg was elevated on a pillow. At 3:00 pm on 10/4/2011 R1 was observed lying quietly in bed with the cast on her right leg and the right leg elevated on a pillow. On 10/5/2011 R1 was observed at 9:15 am and 12:45 pm lying in bed the cast remained on her right leg and the right leg was elevated on a pillow. Further observation at this time noted R1 to have yellow bruising to her left leg. E1 (Administrator) and E2 (Director of Nurses) were present when this observation was made. E1 (Administrator) and E2 (Director of Nurses) notified the physician of the bruising to the left leg and orders were received to transport R1 via ambulance to Massac Memorial Hospital for x-rays to the right leg. A review on 10/4/2011 of R1's clinical record notes the care plan dated 3/5/2008 and updated 9/27/2011 shows R1 has a potential for falls and is in a reclining chair for positioning and comfort. This care plan instructs staff to use Hoyer Lift or Sit to Stand Lift with two staff for transfers. The CNA Flow Sheet Signature Form certified with signature that staff has read and followed the plan of care for this resident. Nurses notes dated 9/25/2011 at 10:35 pm notes R1's right ankle and foot bruising with slight swelling. R1 complains of pain to the ankle and is unable to move the ankle but did raise the knee slightly without assist. Nurses notes dated 9/26/2011 at 4:15 am notes R1 yelling about pain in her foot and ankle stating "its back, ouch, it hurts bad." The facility's Occurrence Report conclusion dated 10/4/2011 notes that R1 sustained injuries during a transfer on 9/25/2011 when staff failed to follow R1's care plan to use the Hoyer Lift or Sit to Stand Lift when transferring R1. The x-ray report dated 9/29/2011 from Massac Memorial Hospital notes distal tibia and fibula fracture of the right leg. On 10/5/2011 a diagnostic report was received from the emergency room at Massac Memorial Hospital indicating distal fracture to the left tibia and fibula. An interview was conducted with E3 (Certified Nurse Assistant/CNA) on 10/4/2011 at 12:15P.M. in the conference room at the facility. E3 stated she did not know how R1 was injured and she reported the skin tear R1 received to E6 (Licensed Practical Nurse) as soon as she noticed it. E3 denied causing injury to R1 but E3 stated "no we did not use the Hoyer Lift or Sit to Stand Lift when we transferred her we each took her under the arm and moved her." When asked if she knew what was in R1's care plan for transferring E3 (CNA) stated "yes." An interview was conducted with E5 (Certified Nurse Assistant/CNA) on 10/5/2011 at 2:30 pm in the conference room at the facility. During this interview E5 (CNA) stated "no we did not use the Hoyer Lift or Sit to Stand Lift when we transferred her and most of the time we don't use it, but nothing like this happened before." E5 (CNA) added "we transferred her under her arm with the chair close to the bed, we lifted her over the arm of the chair on to the bed." When E5 (CNA) was asked what happened to R1's legs during the transfer E5 (CNA) stated "they are left just hanging there until we get her on the bed then one person picks up her legs and puts them on the bed." E5 (CNA) replied "yes" when asked if she knew the method to be used to transfer R1 as noted in the care plan. E4 (Licensed Practical Nurse/LPN) was interviewed on 10/4/2011 at 1:20 pm in the conference room of the facility. During this interview E4 described her role in conducting the investigation. E4 (LPN) stated after reviewing the information and after interviewing E3 (CNA) and E5 (CNA) the conclusion is that R1 "was injured when she was improperly transferred by E3 (CNA) and E5 (CNA)."