Every finding on record at Sunny Hill Nursing Home of Will County

Based on interview and record review, the facility failed to follow the care plan interventions of two-person care and as a result, R1 fell from the bed during personal care and sustained a fracture. This applies to 1 of 3 residents (R1) reviewed for accidents. The findings include:The facility's 06/05/26 Initial Report to the State Agency showed Resident-R1 had a fall incident this morning, complained of pain to left hip and right knee. She (R1) was sent out to the hospital and was admitted with bilateral distal femoral fractures. Full report to follow. On 06/27/26 at 9:30 AM, R1 was in bed. R1 had a left-hand contracture. R1 stated a few weeks ago, she was receiving a bed bath, being done by V4 (CNA/Certified Nursing Assistant). R1 stated V4 did not have any other staff assisting her with the bed bath. R1 stated she was in bed, lying on her left side. R1 stated V4 rolled her too far away from her, causing her to fall from the bed, onto the floor. R1 stated she was not holding on to the side rail for support. R1 stated while on the floor, her feet, hips, leg, and head were hurting. R1 stated she was sent to the hospital, where she had to undergo surgery. V4's written statement was reviewed. V4 stated, To Whom it May Concern: I, (V4's Name) CNA was giving R1 a bed bath as usual, she had a very large bowel movement. She was on her left side facing the window. R1 was holding on to the right bed rail with her right hand. while I was cleaning her backside with my right hand while my left hand was holding her. R1's left foot slid off the bed causing her to fall forward. I tried to grab her to pull her backwards, but she was naked, and her weight was too much. I had on gloves, so her body was slippery she slid off the bed. Everything happened so fast. This is our normal routine, as I reflect on what happened, the only thing that could have changed what has occurred was another person CNA.R1's ADL (Activities of Daily Living) self-care performance deficit related to weakness and limitations in ROM (Range of Motion) related to contracture of bilateral ankles, foot drop, CVA (Cerebral Vascular Accident) with left hemi care plan showed: Interventions-Bathing/Showering: I am totally dependent on two staff for bathing. I prefer to have a bed bath only dated 12/20/13. Bed Mobility: I need a two person assist for turning and repositioning in bed dated 12/20/13. Risk for falls care plan dated 12/20/13 showed Ensure that I am always positioned in the middle of the bed, dated 05/10/22. On 06/27/26 at 12:40 PM, V3 (Assistant Director of Nursing/Restorative Nurse) stated she was the restorative nurse for R1. V3 stated R1 requires two persons assist with bed mobility, transfers, and bathing. V3 stated on 06/05/26, V4 was the only one person assisting R1 with bathing and bed mobility when she rolled out of bed onto the floor. V3 stated if V4 had read R1's care plan, she would have known that she requires two people to provide care. V3 stated R1 had been a two person assist since 2014 which was documented in the care plan.On 06/27/26 at 4:00 PM, V1 (Administrator) stated V4 was alone, giving R1 a bed bath when she slid out of bed and fell onto the floor. V1 stated she looked at R1's care plan after the fall and saw that R1 required two people to assist with bed mobility, transfers, and showers since 2013. V1 stated V4 was placed on paid administrative leave pending the investigation. V1 stated V4 was subsequently terminated for failure to follow the care plan for R1.On 06/27/26 at 2:00 PM, V2 (Director of Nursing) stated she expects the staff to go over the care plan before a resident is touched for the day. V2 stated she expects the staff to follow what the care plan says. R1's MDS (Minimum Data Set) dated 06/23/26 showed R1 was dependent upon staff for bathing, toileting, and transferring. The same MDS showed R1 required substantial to maximal assistance with rolling from left to right and returning to back while in bed. R1's Emergency Department Physician Report dated 06/05/26 showed, (R1's age) female presents with a fall out of bed; she said she was at the nursing home; they were changing her. Stated when they rolled her, she rolled out of bed. [NAME] abrasion present, she says both femurs and both knees hurt her. Diagnosis bilateral distal femur fractures. R1's Diagnostic Imaging Report from (Hospital) dated 06/05/26 showed Radiology/Xray Femur Right, there is impacted comminuted distal femoral fracture at the meta diaphysis. No angulation or displacement. Diagnostic Imaging Report dated 06/05/26 showed, Radiology/Xray Femur left, Xray knee left, there is comminuted impacted distal femoral shaft fracture at the meta diaphysis. Impression: Distal Femoral Fracture. R1's Operative Report dated 06/07/26 showed, Open treatment right distal femur fracture with retrograde femoral rod without intra-articular extension. Open treatment left distal femur fracture with intercondylar extension with headless compression screws and retrograde rod.On 06/27/26 at 3:00 PM, V9 (Medical Doctor) stated he was the doctor for R1. V9 stated R1 had a fall and sustained fractures to both her legs due to the fall. V9 stated the fall, and fractures could have been avoided if V4 had followed the care plan and had two staff members giving the bed bath and repositioning R1 instead on one person. V9 stated he expects the staff to follow the care plans. The facility's Care Plans, Comprehensive Person-Centered Policy, dated 03/08/26, showed Policy: It is the policy of (Facility Name) to develop and implement a person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs for each resident at periodic intervals. The Nursing-CNA Assignments Policy, dated 02/24/03, showed Policy: It is the policy of (Facility Name) to assure CNA functional duties are based on residents assessed needs as identified in the resident's Care Plan and additional duties as assigned/directed are completed. D) Review the resident care plan on PCC (Point Click Care) daily. E) Follow care plan and assure all resident needs are met. The Fall Prevention and Management Policy, dated 09/12/05, showed Policy: It is the policy of (Facility Name) to ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) each resident receives adequate supervision and assistive devices to prevent accidents. Procedure: 4) Residents that are to be determined to be a high risk of falling will be alerted to staff. 7) All staff is responsible to review and follow all individualized resident care plan approaches and interventions.

Based on observation interview and record review the facility failed to protect a resident from a fall during care activities. This applies to 1 of 3 residents (R126) reviewed for falls in a sample of 29.The findings include:On 03/03/2026 at 11:07 AM, R126 stated he fell in the shower when he slipped off the shower chair. R126 stated only one staff member was with him when he fell. On 03/05/2026 at 9:56 AM, R126 stated he did not recall if he was wearing a safety belt while on the shower chair.On 03/05/2026 at 10:03 AM, V16 CNA (Certified Nursing Assistant) stated R126 was placed on the bath chair with the assistance of another staff member, but that person did not stay for the whirlpool bath. V16 stated she placed R126 in the whirlpool tub while he was seated on the bath chair to complete his bath. V16 stated when she opened the tub door to help R126 out of the tub, he slid off the bath chair and fell between the tub and tub door and onto his left hip. V16 stated she did not recall placing the safety belt on R126 while he was on the chair. V16 stated if a belt had been on R126, he wouldn't have fallen off the chair. V16 stated her intention was to dry and dress R126 while he was sitting on the bath chair. On 03/05/2026 at 10:20 AM, the bath chair on R126's unit had only half of the black safety belt on it. On 03/05/2026 10:40 AM, V15 ADON (Assistant Director of Nursing) stated she recently had white safety straps placed on the bath chairs because the previous ones were soiled. V15 denied knowledge prior to current day of the safety straps missing or in disrepair.On 03/05/2026 at 10:26 AM, V17 (Maintenance) stated if the safety straps on the bath chair needed to be replaced, he would have received a work order from V15 or have a request submitted from nursing on the request log. V17 stated he did not recall receiving any requests to repair the bath chair. No repair requests were written on the maintenance repair log/clipboard on the breakroom wall on R126's unit.The bath chair instruction manual states all residents must always be securely safety belted at the waist when using any of the lift systems. Warning- Failure to secure the resident properly with the safety belt could result in injury to the resident or operator.The facility policy Preventative Maintenance Responsibilities dated December 13, 2024, states it is the policy of the facility to maintain a safe physical environment for the comfort of our residents.The Facility Policy Fall Prevention and Management dated January 12, 2026, states it is the policy of the facility to ensure that (1) the resident environment remains as free from accident hazards as possible and (2) each resident receives adequate supervision and assistive devices to prevent accidents.

Based on interview and record review, the facility failed to honor the wishes of a POA (Power of Attorney) by not administering an antidepressant medication. This applies to 1 of 1 resident (R3) reviewed for medications.The findings include: R3's admission Record showed R3 was admitted to the facility on [DATE]. R3 had multiple diagnoses which included congestive heart failure, cognitive communication deficit, major depressive disorder, and osteoarthritis.On 12/31/25 at 3:28 PM, V10 (RN/Registered Nurse) stated on 12/03/25, she received an order from the NP (Nurse Practitioner) to give R3 Zoloft (Antidepressant medication). V10 stated the order was delegated to the next shift, and the order was carried out. V10 stated she spoke with R3's POA and he stated he did not want Zoloft administered to R3. V10 stated she forgot to discontinue the medication from the EMR (Electronic Medical Record). V10 stated R3's POA did not give consent for Zoloft, but the medication was started a few days later. On 12/31/25 at 4:02 PM, V2 (DON/Director of Nursing) stated V10 did not discontinue the order for Zoloft. V2 stated V10 forgot about it and the medication was still on the MAR (Medication Administration Record) and the LPN's (Licensed Practical Nurse) gave the medication without consent. V2 stated R3's POA found out that R3 had been taking Zoloft at the care plan meeting. R3's Order Audit Report dated 12/31/25 showed Zoloft 25 mg (milligrams), give one tablet by mouth at bedtime was ordered on 12/03/25. The same report showed Zoloft 25 mg was discontinued on 12/18/25 per R3's POA's request. The MAR (Medication Administration Record) for December 2025 showed R3 was administered Zoloft 25 mg at bedtime on 12/05-12/17/25. R3's Progress Notes dated 12/03/25 at 5:11 PM, showed Resident seen by (Name) NP this morning with new orders to start Zoloft 25 mg one tablet PO (by mouth) nightly. Progress Notes dated 12/04/25 at 11:00 AM, showed Spoke with resident's POA (Name) about the new order of NP (Name) Zoloft for depression. (Name) declined the new medication, he verbalized his uncle has been verbalizing negative/depressive thoughts for years. POA does not want additional medications now. R3's Progress Notes dated 12/18/25 at 1:38 PM, showed During care plan meeting, while going over medication Zoloft, POA became upset stating he declined this medication so it should not have been given. POA stated I do not want to attend these meetings any longer. These meetings are not effective, your staff just does the opposite of what I request.The facility's Psychotropic Medication Policy reviewed date 12/20/23 showed, Nursing: 1. Obtains all consent for as required by regulation from the POA.

Based on observation, interview and record review, the facility failed to follow guidance from the State and local health authority to control the spread of a respiratory infection. This has the potential to affect all 142 residents living in the facility. The findings include:On 8/21/2025 at 12:37 PM, V5 (CNA-Certified Nurse Assistant) was observed going into R9's room, wearing only a surgical mask and gloves. R9 was on contact and droplet precaution. V5 said she is only serving lunch and is not providing direct care, so she does not need to wear a gown. She said if she provides care, she will wear a gown.On 8/22/2025, V10 (Rehab Nurse) was observed walking down the hallway of the wing where the majority of the cases of respiratory infection were, without a mask. At 10:06 AM, V10 was seen, still without a mask, on a wing where there were no cases of respiratory infection.On 8/22/25 at 9:50 AM, V14 (LPN-Licensed Practical Nurse) was seen passing medication and was not wearing a mask. She slowly applied her mask while this writer was talking to her. On 8/22/25 at 9:56 AM, residents were observed being brought out to the main dining room for activities. No residents were wearing masks.On 8/21/25 at 11:00 AM, Facility's 2025-2026 Acute Respiratory Illness Line List was reviewed with V2 (DON-Director of Nursing) and V3 (ADON-Assistant Director of Nursing). They are currently in charge of the facility's Infection Control procedures. V3 stated the first case of respiratory infection was on 7/14/25. She said there is a total case count of 42 with 19 hospitalizations. V3 said R2 manifested respiratory symptoms on 8/20/25 (the day before) and is currently on contact and droplet isolation. She said R3 manifested signs and symptoms of respiratory infection on 8/21/25, the day of the interview.On 8/22/2025 at 11:00 AM, V2 said use of appropriate PPE (Personal Protective Equipment) is important in stopping the spread of infections. She said appropriate PPE to be worn in a contact and droplet isolation room is gown, face mask, face shield, and gloves. She said all staff should wear face masks in all care areas.On 8/22/25 at 11:58 AM, V16 (Will County Communicable Disease Investigator III) said she recommended universal source control to limit spread of infection starting 7/25/25. On 8/22/25 at 11:39 AM, V17 (IDPH Regional Infection Control Coordinator) said since the etiology of the outbreak is unknown, the facility should have started universal source control, meaning masking of all residents, visitors and staff, as V16 recommended on 7/25/25. On 8/22/25 at 1:00 PM, V1 (Administrator) said infection has been an ongoing issue. She said all staff are required to wear mask in all care areas. She said visitors are encouraged to wear a mask when they enter the facility, but facility cannot force them to wear face mask. She said resident masking has not been enforced and is hard to enforce because of resident illness and cognitive function. Facility Policy on Influenza Outbreak /Pandemic Policy effective 11/4/2009 and revised on 4/24/20 has no information on following guidance from the State and local health department to stop the spread of infection.

Based on observation, interview, and record review, the facility failed to properly label/date/store food items, remove expired items, and wear hair restraints in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents the total census was 142 residents. On [DATE] at 10:20 AM, V12 (Dietician/Dietary Manager) said there are 2 NPO (Nothing by Mouth) resident; all other residents eat from the facility kitchen. On [DATE] starting at 9:31 AM, the facility kitchen was toured in the presence of V12 (Dietician/Dietary Manager). For the duration of the kitchen tour, V12's hair restraint was not covering her bangs; therefore, her hair was not properly restrained. During the kitchen tour the following was found: In walk-in cooler: 1. An opened bag of shredded carrots with manufacturer use by date of [DATE] and a staff handwritten date in marker of [DATE]. V13 (Cook) said [DATE] is the date the bag of carrots was opened and served to the residents. Carrots were served to residents after the expiration date. 2. 31 4-ounce fat free milks with expiration date [DATE], expired. 3. An opened bag of celery with milky liquid in the bottom and best by date of [DATE]. 4. A large bag of pre-diced/cut potatoes with a use by date of [DATE]. Expired. 5. 2 large trays of what V13 (Cook) said were smoked breakfast sausage with no label or date. 6. 2 large trays of biscuits with no label or date. On [DATE] at 10:06 AM, V14 (Dietary Aide) was seen preparing food with her hair restraint not covering her bangs; therefore, her hair was not properly restrained. On [DATE] at 10:26 AM, V13 (Cook) was seen preparing food with her hair restraint not covering her bangs; therefore, her hair was not properly restrained. On [DATE] at 11:10 AM, V12 (Dietician/Dietary Manager) stated all foods in the kitchen should be labeled and dated for food safety; so, the kitchen staff know when products are delivered and when they expire because the staff do not want to serve expired food and put the residents at risk for food borne illness. V12 stated expired foods should be removed from food storage by the expiration date because if they are kept in food storage past their expiration date, they may be served to the residents and cause sickness. V12 stated if there was milky looking liquid in the bottom of the celery, it should have been thrown away. V12 stated all staff working in the facility kitchen need to wear a hair restraint that is covering all the hair on their head. V12 stated all staff member's bangs need to be restrained under the hair net. The facility's policy titled, Labeling and Dating Foods revised 2017 states, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods are labeled with the date received, the date opened and the date by which the item should be discarded .Refrigerated Food . Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by . The facility's policy titled, Hair Restraints/Jewelry/Nail Polish last reviewed [DATE] states, Policy: It is the policy of Sunny Hill Nursing Home that FNS employees shall wear hair restraints . Procedure: Hairnets will be worn at all times in the kitchen .

Based on observation, interview, and record review, the facility failed to follow fall interventions for residents who were high risk for falls. This applies to 4 of 5 residents (R99, R51, R107, R24,) reviewed for accidents and supervision in a sample of 30. The findings include: 1. On January 28, 2025, at 11:56 AM, R99 had a falling star sign outside her room door. At 1:19 PM, R99 was in bed, and she had one thick fall mat on the ground on the right side of her bed. R99 did not have a call light on the left side of the bed. On January 29, 2025, at 3:12 PM, R99 was lying in bed and her adaptive call light was on the side table, out of reach. R99 only had one thick fall mat on the right side of the bed and nothing on the left side of the bed. R99's face sheet showed she was admitted to the facility with parkinson's disease, dementia, contracture on the left wrist and left hand, cognitive communication deficit, and adult failure to thrive. R99's MDS (Minimum Data Set) dated November 20, 2024, showed R99 had moderate cognitive impairment. R99's care plan showed she was high risk for falls related to Parkinson's, history of falls. February 26, 2023, found lying on the floor, no injury. R99's interventions included to Be sure my call light is within reach and encourage me to use it for assistance as needed. Floor mattress to the right side of the bed. I have a red star outside my bedroom door to alert staff to my high fall risk. 2. On January 28, 2025, at 10:31 AM, R51's room door did not have a falling star sign outside her room door, but her room had one fall mat folded and placed against the wall. On January 29, 2025, at 2:16 PM, R51 was lying in bed. R51 did not appear alert or oriented and was talking to herself. R51 had a fall mat on the right side of her bed. R51's bed was not pushed against the wall on either side. R51's face sheet showed she was admitted to the facility with diagnoses including alzheimer's disease, restlessness and agitation, dementia, anxiety disorder, and contractures of the right knee and left knee. R51's MDS dated [DATE], showed R51 had severe cognitive impairment. R51's care plan showed R51 was high risk for falls related to dementia, diabetes mellitus, hypertension, and history of falls. R51's interventions included I have the right side of my bed against the wall. 3. On January 29, 2025, at 11 AM, R107 was lying in bed. R107's fall mats were folded and placed against the wall. R107's bed was in a high position, and neither side of the bed was against the wall. R107's face sheet showed she was admitted to the facility with diagnoses including dementia and history of falling. R107's MDS dated [DATE], showed R107 had severe cognitive impairment. R107's care plan showed R107 was high risk for falls related to gait/balance problems, incontinence, psychoactive drug use, history of falls, dementia, history of self-transfers despite safety educations. R107 had falls on February 7, 2021, March 22, 2021, April 23, 2021, March 28, 2021, May 8, 2021, June 5, 2021. R107's interventions include I have a floor mat next to both sides of my bed when I am in bed. I have a red star outside my bedroom door to alert staff to my high fall risk. 4. On January 28, 2025, at 10:23 AM, R24 had a falling star sign outside her room door. On January 29, 2025, at 2:13 PM, R24 was lying in bed, and she had one thick fall mat on the right side of the bed and no pad or mattress on the left side of the bed. R24's face sheet showed she was admitted to the facility with diagnoses including cognitive communication deficit, dementia, seizures, osteoarthritis, and personal history of traumatic brain injury. R24's MDS dated [DATE], showed R24 had severe cognitive impairment. R24's care plan showed I am high risk for falls related to deconditioning, gait/balance problems, incontinence, vision/hearing problems, seizure disorder. I have been falling and last fall was few weeks ago. I tend to roll from my bed onto mattress next to my bed. I am incontinent. R24's interventions included I have a mattress to the left side of my bed and a floor mat to the right side. I have a red star outside my bedroom to alert staff to my high fall risk. On January 29, 2025, at 2:52 PM, V16 (Restorative CNA/Certified Nurse Assistant) stated the residents in the wing were all high risk for falls and it was indicated with the red falling star. V16 sad R51 must have fallen out of bed on the right side so they placed the mat on the right side. V16 stated R51 was not alert or oriented and was not able to get out of bed. V16 stated she used the mechanical lift to put R51 back into bed and then put the one fall mat in place. V16 stated R24 was a high fall risk resident as well. V16 stated she had a fall mattress because she must have fallen out of bed at some point, so only had one fall mat. On January 30, 2025, at 12:41 PM, V2 (DON/Director of Nursing) stated the fall mats are used for residents who have had repeated falls or get out of bed. V2 stated the call lights should be placed within the residents' reach. On January 30, 2025, at 1:07 PM, V23 (Restorative Nurse) stated the residents with one fall mat in the room should have the other side of their bed against the wall. V23 stated if the care plan showed the residents' bed should be against the wall, they should be placed against the wall. V23 stated R99 used to be in a semiprivate room and her bed was against the wall and that was why she only had the one fall mat, but now that she was alone, she should have two fall mats or the bed against the wall. V23 stated R99 could use the adaptive call light and it should be placed within reach. V23 stated R24 should have two fall mats in place. The facility's Fall Prevention and Management policy revised on December 6, 2023, showed All staff is responsible to review and follow all individualized resident care plan approaches and interventions. The Red star serves to alert all staff, including clinical (medical, nursing, restorative, dietary, social service, clerical, environmental services, activities, laundry, and maintenance) to observe the resident closely and to intervene if the resident shows unsafe behaviors. 46409

Based on observations, interviews, and record reviews, the facility failed to follow its catheter care policy by not having the catheter tube secured and not using warm water and soap to provide catheter care. The facility also failed to use new catheter bags and leg bags instead of reusing them and to have a resident in bed with a leg bag instead of a standard drainage bag to prevent backflow. This applies to 5 of 5 residents (R19, R59, R69, R126, and R132) reviewed for catheter care in a sample of 30. The findings include: 1.R19 is an [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/28/25 at 1:50 PM, R19 was observed with an indwelling catheter with urine leaks and staining on the incontinent brief. On 1/28/25 at 1:57 PM, V6 (Certified Nursing Assistant/CNA) provided incontinent care to R19 and V6 stated that the indwelling catheter shouldn't be leaking. On 01/29/25 at 9:50 AM, V3 (Assistant Director of Nursing/ADON) stated, The indwelling catheter for R19 was changed at 4:08 AM today (1/29/25). The order says to change the indwelling catheter and tubing as needed. The CNA should have reported the indwelling catheter leak to the nurses so they could promptly change the catheter. The general guidelines on the facility presented urinary catheter care policy (reviewed on 12/13/23) document: 1. Follow the aseptic insertion of the urinary catheter and maintain a closed drainage system 2. If the aseptic technique breaks, disconnection, or leakage occurs, replace the catheter and collecting system using the aseptic technique and sterile equipment, as ordered. On 1/28/25 at 2:00 PM, V6 provided indwelling catheter care by using cleaning wipes to wipe down the labia, catheter insertion site, and catheter. R19 verbalized, Oh. My vaginal area is itching and burning. On 1/30/25 at 9:31 AM, V2 (Director of Nursing / DON) stated that the staff should have used soap and warm water to provide indwelling catheter care per our policy. A review of the facility presented Urinary Catheter Care policy reviewed on 12/13/23 document: For a female resident: Use a washcloth with warm water and soap to cleanse the labia. 2. R59 is an [AGE] year-old female with severe cognitive impairment as per the MDS dated [DATE]. On 01/28/25 at 10:38 AM, V15 (Charge Nurse) checked on R59, with an indwelling urinary catheter whose tubing was not secured. On 01/30/25 at 09:31 AM, V2 stated, The indwelling catheter tubing should be secured with a stat lock or tape. If the tubing is not secured, it can cause tension at the insertion site. A review of the facility presented Urinary Catheter Care policy document: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. 46409 3. On January 28, 2025 at 10:32 AM, R126 was lying in bed and stated she had a urinary catheter leg bag on, and they switch her to the urinary catheter bag after dinner and then again at 8 AM. R126's bathroom had a plastic bag in it and there was a urinary catheter bag inside of it. On January 29, 2025 at 10:51 AM, R126 was lying in bed on the left side. R126 stated she had her leg bag on, and the staff changed it this morning. R126's bathroom had the plastic bag and the urinary catheter bag was inside of it. R126's face sheet showed she was admitted to the facility with diagnoses including neuromuscular dysfunction of bladder, personal history of other diseases of the female genital tract, and personal history of urinary tract infections. R126's POS showed an order to Change foley catheter every 8th of the month. R126's care plan showed I have an indwelling catheter due to neurogenic bladder with potential for complications, with interventions including, Change catheter (monthly) and (As Needed). 4. On January 28, 2025 at 1:01 PM, R69 stated she had a catheter and was wearing the leg bag. R69's bathroom had a plastic bag with another leg bag in it. R69's face sheet showed she was admitted to the facility with diagnoses including neuromuscular dysfunction of bladder, need for assistance with personal care, dementia, retention of urine, and encounter for fitting and adjustment of urinary device. R69's POS (Physician Order Sheet) showed an order showing to Change foley catheter every 30 days and for system failure leakage. Foley catheter change [As Needed] based on clinical indications such as infection, obstruction or when closed system is compromised. R69's care plan showed she was admitted with indwelling catheter related to urinary retention, potential risk for CAUTI (Catheter Associated Urinary Tract Infection) with interventions which showed to Change foley catheter monthly. 5. On January 28, 2025 at 1:20 PM, R132 stated he had a catheter and was wearing the leg bag. R132 stated he wore the urinary catheter bag at night before he went to bed and wore the leg bag during the day. R132's bathroom had a plastic bag with a urinary leg bag and a urinary catheter bag inside of it. R132's face sheet showed he was admitted with diagnoses including urinary tract infection, chronic kidney disease, obstructive and reflux uropathy, encounter for fitting and adjustment of urinary device. R132's care plan showed I have an indwelling foley catheter, with interventions to change foley drainage tubing and drainage bag (As Needed). On January 28, 2025 at 1:50 PM, V17 (CNA/Certified Nurse Assistant) showed the surveyor R132's plastic bag with the unused urinary catheter bags. V17 stated they detach the catheter bag and place it inside the plastic bag. V17 stated the plastic bags are changed every day. V17 stated the staff rinse the inside of the bag out. V17 stated they were told to use the bags for three to seven days. V17 stated she did not know how often they were supposed to replace the bag. On January 28, 2025 at 3:19 PM, V18 (CNA) stated the residents with catheters are switched from the urinary bag to the leg bag every day. V18 stated they clean both ends of the tubing with alcohol pads and put it in the bathroom in the plastic bag until it was ready to be used again. V18 stated the catheter bags were good for seven days, but she looks at the bag and would throw it away when it was stained or soiled. On January 30, 2025 at 12:41 PM, V2 (DON/Director of Nursing) stated they do not throw the catheter bags away. V2 stated they cap the end of the tubing to keep it a clean, closed system. V2 stated she had not looked at the packaging but if the package shows the bags were sterile and single use, they should follow the manufacturer guidelines. V2 also stated the residents should not be lying in bed if they have a leg bag on because it could cause the urine to go back into the resident. On January 30, 2025 at 1:07 PM, V23 (Restorative Nurse) stated the catheter bags should probably not be reused. The facility's Catheter Care, Urinary policy reviewed on December 13, 2023 showed If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. The facility's Urinary Catheter bags and leg bags showed symbols indicating the bags were sterile, do not re-sterilize, and should not be reused.

Based on interview and record review, the facility failed to provide written bed hold policy to resident and/or their representative prior to the resident transfer to the hospital. This applies to 1 resident (R103) reviewed for hospital transfers in a sample of 30. The findings include: R103's Face sheet shows an initial admitted [DATE]. R103's Incident Note dated 10/11/24 at 13:15 shows R103 had an unwitnessed fall. R103's Health Status Note dated 10/11/24 at 14:25 shows R103 was transferred to the hospital. R103's Health Status Note dated 10/11/24 at 18:28 shows R103 was admitted to the hospital with hyponatremia. There is no documentation of bed hold notice being provided to resident or resident representative prior to transfer to the hospital. On 1/30/25 at 11:52 AM, V10 (Assistant Administrator) stated the facility did not send the bed hold notice to R103's family for her 10/11/24 hospital transfer. The facility's policy titled, Bed Hold Policy last reviewed 1/21/25 states, Policy: It is the policy of Sunny Hill Nursing Home of Will County to inform residents and/or resident representatives in writing of the bed-hold and return policy prior to transfers and therapeutic leaves .Interpretation and Implementation: .3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. The details of the transfer (per the notice of the transfer) .

Based on observations, interviews, and record reviews, the facility failed to implement services to prevent further decline in range of motion and contractures for R59. This applies to 1 of 1 resident (R59) reviewed for restorative nursing in a sample of 30. The findings include: R59 is an [AGE] year-old female with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 01/28/25 at 10:38 AM with V15 (Charge Nurse) R59 was noted with a right-hand contracture with no palm protector in place to prevent contraction. V15 stated that the palm protector should be on R59's right hand. V15 then added that she would put a towel roll in the hand and notify the therapist to get a palm protector. On 1/30/25 at 9:31 AM, V2 (Director of Nursing/DON) stated that the staff should have applied a palm protector to R59's right hand to prevent deterioration with her palm contraction. A review of the ADL self-care deficit care plan document interventions including: Apply palm protector to right hand if resident permits, may remove for hygiene.

Based on observation and interview the facility failed to label, store, and dispose of medications to facilitate a safe administration to residents. This applies to 2 of 2 residents (R41 and R114) reviewed for safe medication storage in a sample of 30. Findings include: 1. R41 diagnosis includes type 2 diabetes mellitus with unspecified diabetic retinopathy. R41's current physician's orders includes insulin Glargine inject 10 units subcutaneously at bedtime hold if blood sugar is less than 60. On 01/30/25 at 10:51 AM, the 1st Avenue medication cart was reviewed with V27 LPN (Licensed Practical Nurse). A vial of insulin Glargine had an opened-on date of 11/21/24 and an expiration date of 12/19/24. V27 stated she labels insulin with the manufacture's expiration date. She did not label the vial but know it should be thrown out in 28 days after opening. 2. R114 diagnoses includes type 2 diabetes mellitus with diabetic nephropathy. R114's current physician orders include insulin Aspart inject as per sliding scale subcutaneously before meals. On 01/30/25 at 11:14 AM, the 4th Avenue medication cart was reviewed with V37 LPN (Licensed Practical Nurse). A vial of insulin Aspart was opened on 12/29/24. No use by date was written on the vial. V37 LPN stated the insulin was probably good for 31 days. V37 stated the insulin is still on the current orders for R114. On 01/30/25 at 01:54 PM, V2 DON (Director of Nursing) stated she did not know how long insulins are good for after they have been opened. It's not my job to give insulin. The nurses should make sure they aren't administering outdate medications. On 01/30/25 at 05:22 PM, V34 Pharmacist stated insulins are good for 28 days after opening. Insulins degrade and are not as effective after 28 days. The facility policy Insulin Administration dated December 22, 2023, states check the expiration date, if drawing from an opened multi dose vial. If opening a new vial record the expiration date and time on the vial. The facility provided policy Storage of Medications dated November 2020 states certain medications or package types require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. The facility did not provide a policy that has specific directions as to when to discard Glargine and Aspart insulins after they have been opened.

Based on observation, interview, and record review, the facility failed to follow infection control practices. This applies to 3 of 5 residents (R52, R451, R19) reviewed for infection control in a sample of 30. The findings include: 1. On January 29, 2025, at 2:11 PM, V16 (Restorative CNA/Certified Nurse Assistant) was in R52's room without wearing a mask. V16 took R52 to the bathroom. At 2:46 PM, V16 re-entered R52's room without a mask on, and assisted R52 out of the bathroom. On January 29, 2025, at 2:52 PM, V16 stated the facility had residents with flu and norovirus but was not aware if they had COVID-19. V16 stated she should have been wearing a mask. R52 was admitted to the facility with diagnoses including anxiety disorder, insomnia, hypertension, long term use of antibiotics, and history of falling. 2. On January 30, 2025, at 9:25 AM, R131 was sitting in the dining room and R131 stated he had COVID-19 and he had to stay in his room. R131 stated the staff told him he needed to wear a mask in the hallways. On January 30, 2025, at 9:31 AM, V19 (RN/Registered Nurse) stated R131 was positive on January 17, 2025, and his isolation ended on January 27, 2025. V19 stated the isolation for positive residents was ten days. V19 stated the facility policy was to only put positive residents with positive residents. V19 stated they should not put a negative resident with a positive resident. On January 30, 2025, at 9:43 AM, V21 (CNA) stated R131 had COVID-19 and had a new roommate for one day. V21 stated R131's roommate went to the hospital for chest pain. On January 30, 2025, at 12:41 PM, V2 (DON/Director of Nursing) stated R451 was not in the facility for even 24 hours. V2 stated R451 did not have COVID-19. V2 stated R451 should not be placed in a room with a resident with COVID-19. V2 stated in the process of trying to get R451 admitted to the facility, they did not realize R131 was positive for COVID-19. On January 30, 2025, at 12:52 PM, V22 (Admissions and Marketing Coordinator) stated it was not appropriate for R451 to be admitted to a room with a COVID-19 positive resident. V22 stated she forgot to mark on her sheet that R131 was positive, and it was the last remaining male bed available. V22 stated she notified the family, and the family were upset and had made a complaint. On January 30, 2025, at 11:13 AM, V8 (Infection Preventionist) stated masks were mandatory in the building because they were in an outbreak status. V8 also stated whoever did the screening for admission should have asked the resident and family if they would be ok with admitting to a room with a COVID-19 positive roommate and should have given them a choice and let them decide for themselves. On January 30, 2025, at 1:52 PM, V1 (Administrator) stated R451 was admitted on [DATE], at 7 PM and then went out by ambulance on January 25, 2025, at 7:18 PM. V1 stated she had questioned her staff why R451 was admitted to the same room as R131, who was COVID-19 positive. V1 stated they did not have another bed to move him to. R451 was admitted to the facility on [DATE]. R451 was admitted to the same room as R131. R451's progress notes dated January 24, 2025, at 10:19 PM showed the following: At 7:18 PM, [resident] was admitted to room [Number] via stretcher transferred by 2 EMTs [Emergency Medical Team]. He's alert to person, place, time, and situation, pleasant and cooperative. [Diagnoses] Acute exacerbation of diastolic heart failure (fluid overload), Lupus, [Status Post] abdominal surgery (exploratory per res) [with] 14 staples in place and dehiscent areas. Dressing changed as ordered. R131's progress notes were reviewed and showed a note on January 16, 2025, at 11:43 AM, which documented the following: Resident is on contact and droplet isolation due to exposure to roommate positive with covid. On January 16, 2025, at 6:01 PM, a progress note showed the following, A nonproductive cough was observed this evening and a rapid COVID-19 test done and resulted (+). R451's face sheet showed she was admitted with diagnoses including chronic embolism, anxiety disorder, hypertension, congestive heart failure, and gastro-esophageal reflux disease. A Concern Investigation Form was filled out on January 25, 2025, at 10:49 AM, which showed the following, R451 expressed concern about admitting to a COVID positive room. The facility's Masking Policy reviewed on January 8, 2025, showed It is the policy of this facility to don (put on) a mask in accordance with Standard and Transmission-based Precautions. Masks may also be required or recommended for source control to reduce the spread of certain respiratory infections. Staff, visitors, and family will wear a mask to protect the nose and mouth. Masks are to be worn when caring for residents in Droplet Precautions or when designated by the Infection Preventionist. 34410 3. R19 is an [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/28/25 at 1:57 PM, V6 (Certified Nursing Assistant/CNA) provided incontinent care to R19. On 1/28/25 at 2:00 PM, V6 removed gloves after incontinent care, wore a new set of gloves without sanitizing hands, and proceeded with indwelling catheter care. On 1/28/25 at 2:05 PM, V6 stated that she should have performed hand hygiene between incontinent care and indwelling catheter care. On 1/30/25 at 9:31 AM, V2 (Director of Nursing / DON) stated that the staff should have sanitized her hands in between incontinent care and catheter care. A review of the facility's Hand-Washing Policy (reviewed on 12/20/23) document: Perform hand hygiene before applying non-sterile gloves. 46003

Based on interview and record review, the facility failed to provide written notice of reason for transfer to resident and/or their representative before resident transferred to the hospital. This applies to 3 residents (R103, R137, and R20) reviewed for hospital transfers in a sample of 30. The findings include: 1. R103's Face sheet shows an initial admitted [DATE]. R103's Incident Note dated 10/11/24 at 13:15 shows R103 had an unwitnessed fall. R103's Health Status Note dated 10/11/24 at 14:25 shows R103 was transferred to the hospital. R103's Health Status Note dated 10/11/24 at 18:28 shows R103 was admitted to the hospital with hyponatremia. There is no documentation of written notice of hospital transfer reason or place of transfer being provided to the resident or their representative. 2. R137's Face sheet shows an admitted [DATE]. R137's Health Status Note dated 10/9/24 at 13:11 shows R137 was admitted to hospital with diagnosis of chest pain. R137's Health Status Note dated 11/5/24 at 15:55 shows resident complaining of left chest pain and requesting to go to the hospital. R137's Health Status Note dated 11/5/24 at 16:32 shows ambulance picked up resident to transfer to hospital. R137's Health Status Note dated 12/26/24 at 17:20 shows Nurse Practitioner gave order to send R137 to the hospital for critically high white blood cell count. R137's Health Status Note dated 12/26/24 at 17:54 shows resident was taken by ambulance to hospital. There is no documentation of written notice of reason or place of hospital transfers being provided to the resident or their representative. On 1/30/25 at 11:39, R137 said facility staff has not ever told him or his representative why, in writing, he was being transferred to the hospital. On 1/29/25 at 2:52 PM, V11 (RN/Registered Nurse) stated when a resident is transferred to the hospital, they are told verbally why they are being transferred and the family is notified by phone, but not in writing. On 1/30/25 at 10:54 AM, V2 (DON/Director of Nursing) stated she doesn't think the family is sent a written copy of why the resident is transferred to the hospital and the resident is not given a written notice of why they are being transferred to the hospital. On 1/30/25 at 11:52 AM, V10 (Assistant Administrator) stated she does not have any proof that family is sent reason for hospitalization . V10 stated the facility does not send the reason for hospitalization to the family because the resident is sent out based on facility staff observation and they do not get a diagnosis until the resident gets to the hospital. The facility's policy titled, Bed Hold Policy last reviewed 1/21/25 states, Policy: It is the policy of Sunny Hill Nursing Home of Will County to inform residents and/or resident representatives in writing of the bed-hold and return policy prior to transfers and therapeutic leaves .Interpretation and Implementation: .3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: .d. The details of the transfer (per the notice of the transfer) . 48526 3. R20's Face Sheet showed R20 was admitted to the facility on [DATE]. R20 had multiple diagnoses which included atherosclerotic heart disease, diabetes, dementia, hypertension, chronic kidney disease, and hemiplegia/hemiparesis. R20's MDS dated [DATE] showed R20 had severe cognitive impairment. R20's progress notes showed the following: 08/28/24 at 5:25 PM Doctor in to see residents and ordered to go to (Hospital) for blood in his urine. 08/28/24 at 6:17 PM Resident left with Ambulance, paperwork given and report. 08/29/24 2:42 AM Called emergency room and resident is admitted with dx (diagnosis) hematuria. 09/10/24 at 1:07 PM Resident came on stretcher by Ambulance from (Hospital). Wife updated on residents return. 09/12/24 6:10 PM Called attention per caregiver, resident observed CVC (CVC/Central Venous Catheter) line in resident's hand. No bleeding noted. Call to on call and ordered to send resident to ER (ER/emergency room ) for CVC line replacement. 09/12/24 at 6:40 PM Ambulance here, took resident to (Hospital) ER. 09/13/24 at 12:56 AM 1230 AM resident came back from (Hospital) ER for s/p PICC (PICC/Peripheral Inserted Central Catheter) line placement transported by a stretcher with two paramedics. The electronic medical record showed no documentation of written notice of reason for transfer or discharge to the hospital given to the resident's representative. The facility was unable to provide written documentation given to the resident's representative.

Based on observation, interview and record review, the facility failed to provide urinary catheter care and services, and failed to provide incontinence care in a manner that would prevent the potential development of infection and to maintain hygiene. This applies to 4 of 6 residents (R20, R36, R42 and R130) reviewed for catheter and incontinence care in the sample of 30. The findings include: 1. R20 had multiple diagnoses including neuromuscular dysfunction of the bladder, hydronephrosis and calculus of the kidney, based on the face sheet. R20's electronic records showed that R20 had history of UTI (urinary tract infection). R20's quarterly MDS (minimum data set) dated January 23, 2024, showed that the resident was cognitively intact. R20's MDS showed that the resident required total assistance from the staff with regards to toileting hygiene. The same MDS showed that R20 had an indwelling urinary catheter and was always incontinent of bowel function. On February 20, 2024, at 11:17 AM, R20 was in bed, alert, oriented and verbally responsive. R20 had a urinary catheter and the catheter tubing had white sediments. R20 stated that the nurses kept on flushing her urinary catheter because of the sediments and also stated that there are times that her urine would leak. R20 had a strong urine odor. On February 21, 2024, at 11:08 AM, R20 was in bed, alert, oriented and verbally responsive. R20's urinary catheter bag and tubing was directly on the floor under her bed, which was visible from the hallway and door. On the same location where the urinary catheter bag and tubing were, multiple tissue papers were on the floor beside the trash container. At 11:14 PM, V24 (Certified Nursing Assistant) went inside R20's room to open the window per resident's request and then left the room without picking up the catheter drainage bag and catheter tubing to keep it off the floor. On February 21, 2024, at 11:16 AM, V28 (Licensed Practical Nurse) went inside R20's room per resident's request to open the other window per resident's request. After opening the other window, V28 picked up the multiple tissue papers on the floor that were beside the urinary catheter bag and tubing. However, V28 did not pick up the catheter drainage bag and the catheter tubing that was on the floor to keep it off the floor. At 11:26 AM, V28 again went inside R20's room to give the resident cups of water. It was only during that time that V28 picked up the catheter drainage bag and tubing off the floor and hung it under R20's bed frame. On February 21, 2024, at 11:28 PM, V29 (Certified Nursing Assistant) emptied R20's urinary catheter bag and obtained 500 ml of yellow cloudy urine. At 11:29 AM, R20 stated that her disposable brief was wet. While R20 was on her back, V29 unfastened R20's disposable brief. R20 had an indwelling urinary catheter and V29 stated that R20's brief was slightly wet with urine. With her gloved hands, V29 used disposable wet cloths and cleaned R20's pubic area and bilateral groin area. V29 then cleaned the visible part of R20's urinary catheter (portion away from the insertion site) but did not separate the resident's labial folds to clean the area and also did not clean the urinary opening/catheter insertion site and the catheter tubing closer to the opening. On February 22, 2024, at 12:37 PM, V2 (Director of Nursing) stated that a resident's urinary catheter bag and urinary catheter tubing should never be directly resting on the floor to prevent potential UTI. V2 stated that during incontinence and catheter care, the Certified Nursing Assistant and/or nurses should make sure to open the female labial folds to clean the area and make sure to also clean from the urinary opening to the catheter tube for good hygiene and to prevent UTI. The facility's urinary catheter policy and procedure last reviewed by the facility on December 13, 2023, showed that it is the policy of the facility to prevent catheter-associated urinary tract infections. The procedure showed in-part, under infection control, 2. Maintain clean techniques when handling or manipulating the catheter, tubing, or drainage bag b. Be sure the catheter tubing and drainage beg are kept off the floor. The same policy under steps in the procedure showed in-part, 13. With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure. 14. Assess the urethral meatus. 15. For a female resident. Use a washcloth with warm water and soap to cleanse the labia . and cleanse around the urethral meatus .17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 36567 2. R36's face sheet included diagnoses of neuromuscular dysfunction of bladder, urinary tract infection, site not specified, presence of urogenital implants. R36's Physician Order Sheet showed an order for indwelling urinary catheter change as needed based on clinical indications such as infection, obstruction or when closed system is compromised (revised December 18, 2023). R36's care plan revised January 2, 2024, included that R36 was admitted back with Indwelling Catheter related to Neurogenic bladder with potential for complications. The same care plan included that urine culture done on December 20, 2023, showed evidence of urinary tract infection. On February 21, 2024, at 1:35 PM, R36 was in her room with urinary catheter bag in privacy bag that was hooked on to her wheelchair. The tubing of the catheter was noted almost touching the floor and had yellow colored urine that was cloudy with thick sediments. On February 21, 2024, at 1:52 PM, R36 was seen wheeled down the hallway by V8 (R36's family). R36's catheter tubing which contained cloudy urine with thick sediments was seen dragging on the floor. V8 then stopped to ask questions to V6 (Licensed Practical Nurse). Other staff were noted to be around R36. After the conversation with V6, V8 resumed wheeling R36 down the hallway and V6 was notified about the catheter tubing dragging on the floor. V6 agreed that the catheter should be off the floor and proceeded to put it back in the privacy bag. On February 22, 2024, at 12:06 PM, V2 (Director of Nursing) stated that urinary catheter bag and tubing should be kept below the bladder but above the floor for infection prevention. 29562 3. On February 21, 2024, at 12:17 PM, R130 was in his bedroom, sitting in his wheelchair. R130's urinary catheter bag and tubing was touching the floor. On February 21, 2024, at 1:35 PM, V18 (Certified Nursing Assistant/CNA) assisted R130 to the bathroom. After R130 used the toilet, V18 wiped his back perineum and pulled his pants back up without cleaning his frontal perineum and catheter. Then R130 propelled back to the bedroom, his urinary catheter tube and bag was observed touching/dragging on the floor. 4. On February 21, 2024, at 1:25 PM, V17 (CNA) provided incontinence care to R42 who was heavily saturated with urine which overflowed to her (R42's) pants and wheelchair cushion. V17 used wet wipes to clean R42's pubic area. V17 turned R42 on her left side and proceeded to clean the back perineum. V17 did not clean the labia and the rest of the frontal perineum and applied a new incontinence brief. Facility's Policy and Procedure for Perineal Care with review date of December 20, 2023 shows: Policy: It is the policy of this facility to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Procedure: For a female resident: b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and clean washcloth. For a male resident: b. Wash perineal area starting with urethra and working outward. c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.

Based on observation, interview and record review, the facility failed to serve pureed meat portions and pureed soup and garlic bread as shown on the menu spreadsheet for the lunch meal. This applies to 4 of 4 residents (R37, R47, R140 and R145) observed for dining in the sample of 30. The findings include: Facility Fall/Winter 2023-2024 daily spreadsheet for Week 4 Wednesday lunch meal for the pureed meal included as follows: Pureed Beef Vegetable Soup (6 oz/ounce), pureed Veal Parmesan #6 scoop +1 oz/ounce sauce), pureed Linguini (#8 scoop) OR pasta of choice (#8 scoop), Italian Beans (#12 scoop, swirl pudding 1/2 cup, pureed garlic bread (#16 scoop). An alternate lunch choice of pureed pork (#8 scoop) was also shown on the menu. Facility scoop/disher and portion control charts showed that #6=5+1/3 oz, #8 =4 oz, #12 =2.875 oz, #16=2 oz. On February 21, 2024, at 9:35 AM, V10 (Cook) stated that the pureed items she prepared for the lunch meal included pureed Veal Parmesan, pureed pasta, and pureed Italian beans. On February 21, 2024, at 12:03 PM, during lunch meal service, V9 (Dietary Aide) was observed platting the food on the 1st Avenue steam table. V9 used a #8 scoop (4 oz/ounce per scoop) to serve the pureed meat (Veal Parmesan). When asked what the meat was, V9 stated that he thinks its turkey or pork. The other menu items on the steam table for the pureed meal included pureed green beans, pureed pasta, and a pre-plated pudding in a bowl for dessert. No pureed soup or pureed garlic bread was seen on the steam table. R37, R47 and R140 received the 4-ounce scoop of pureed meat along with a serving as shown on menu spreadsheet of pureed green beans and pureed pasta for lunch meal in the dining room. R145 also received the same serving portions in his room. The same residents were also offered a bowl of pre-plated pudding in a bowl for dessert. On February 22, 2024, at 9:26 AM, V10 stated that she prepared only two pureed soups for the residents on the 6th avenue, and she did not prepare the garlic bread for pureed diets as she ran out of time. On February 21, 2024, at 2:14 PM, and February 22, 2024, at 9:56 AM, V4 (Director of Food and Nutrition Services) stated that she spoke to the Dietitian Consultant who oversees the menus and she (Dietitian) stated that a 6 oz portion of veal =3 oz portion of protein which was the serving portion for the lunch meal. V4 stated that since the veal had breading and thickening/liquid added in pureed preparation, a 6 oz portion for the pureed should be served to get the 3 oz protein. V4 stated that the residents on pureed should also receive the additional planned menu of pureed soup and pureed garlic bread. Facility Diet Type Report showed that R37, R47, R140 and R145 were on pureed diets.

Based on observation, interview and record review, the facility failed to maintain a unit refrigerator under sanitary conditions. This applies to 7 of 7 (R45, R67, R68, R83, R87, R107, R121) observed for dining in the sample of 30. The findings include: On February 20, 2024, at 12:28 PM, during lunch meal service, the refrigerator in the 2nd Avenue was noted to have smears and smudges of food debris and other miscellaneous substance on and around the handle of the refrigerator door. V11 (Dietary Aide) was seen wearing gloves and opening and closing the refrigerator to take items out for meal service in between handling plates to plate the food. V11 was notified of the cross contamination related to the same. On February 20, 2024, at 3:32 PM, the same refrigerator was monitored in presence of V12 (Certified Nursing Assistant). All the storage shelving (on the inside of the refrigerator) had areas of rust like substance along with multiple blackish colored spots of unknown substance. Multiple food items consisting of thickened juice containers, regular juices and prepared juices including closed packages of unknown items were stored on the top shelves. V12 stated that the packaged items belonged to residents in the unit. The leftover bowls of fruit cocktails from the lunch meal service were placed on the refrigerator on one of the middle shelves covered with a saran wrap. The bottom shelf had multiple individual milk and juice containers stored over a surface that had extensive debris/spills blackish and rust like substance. V12 added that this refrigerator stored foods that was distributed to the residents on the 2nd Avenue. V12 was not sure what the blackish and brown substance inside the refrigerator was. On February 20, 2024, at 3:40 PM, on inspection of the refrigerator, V4 (Director of Food and Nutrition Services) stated that the brownish substance is a lot of rust and the black substances looked like something exploded inside. When the black substance was wiped with a paper towel, smears of greyish powdery substance came off on the paper towel. V5 (Food Service Manager) who was also present, stated that the black substance could be related to the moisture in the refrigerator. V5 added that the refrigerator is old, and a work order is placed for replacement. V4 and V5 were notified that food in the refrigerator was not safe to serve with presence of unknown substance. On February 22, 2024, at 9:36 PM, V5 stated that the nursing department is responsible for the temperature monitoring and cleaning of the inside of the refrigerator. V5 added that the house keeping is responsible for cleaning the outside of the refrigerator. Residents that received the lunch meal served from the 2nd Avenue were identified as R45, R67, R68, R83, R87, R107 and R121.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and changing gloves during provisions of care. This applies to 4 of 6 residents (R20, R42, R54 and R84) reviewed for infection control during provisions of care in the sample of 30. The findings include: 1. On February 21, 2024, at 11:34 AM, V14 and V15 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R54 who had a bowel movement. V14 cleaned R54's back peri-area, removed soiled items, applied new sheets and incontinence brief, and repositioned R54 while wearing the same soiled gloves. V14 removed her gloves and continued to straighten the clean bed linen and adjusted the bed position without hand hygiene. 2. On February 21, 2024, at 1:25 PM, V17 (CNA) provided incontinence care R42 who was heavily wet with urine. V17 cleaned R42 from the front to back and while wearing the same soiled gloves she applied barrier cream, placed new incontinence brief, and straightened the bed linens. After completing the incontinence care, while wearing same soiled gloves, V17 carried R42's soiled pants to the soiled linen cart in the hallway. V17 removed her gloves and without performing hand hygiene went to the clean linen cart to obtain some linens. 3. On February 21, 2024, at 1:50 PM, V14 and V15 (Both CNAs) rendered incontinence care to R84 who was wet with urine. V15 cleaned her from the front to back, applied new incontinence brief, removed soiled gloves and without performing hand hygiene straightened the bed sheet/linen and repositioned R84. On February 22, 2024, at 12:19 PM, V2 (Director of Nursing/DON) stated that staff must perform hand hygiene and change gloves, before and after care, in between task from dirty to clean tasks, to prevent spread of infection and cross contamination. Facility's Hand Washing Policy and Procedure with review date of December 20, 2023, shows: Policy: It is the policy of the facility to ensure that the proper handwashing technique is used for the prevention and transmission of infectious diseases and is the cornerstone of all infection control practices. Procedures: 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care. i. After contact with a resident's intact skin. j. After contact with blood or body fluids. m. After removing gloves. 7. Hand hygiene is the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace hand washing/hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 16746 4. R20 had multiple diagnoses including neuromuscular dysfunction of the bladder, hydronephrosis and calculus of the kidney, based on the face sheet. R20's quarterly MDS (minimum data set) dated January 23, 2024, showed that the resident was cognitively intact. R20's MDS showed that the resident required total assistance from the staff with regards to toileting hygiene. The same MDS showed that R20 had an indwelling urinary catheter and was always incontinent of bowel function. On February 21, 2024, at 11:29 AM, R20 stated that her disposable brief was wet. While R20 was on her back, V29 (CNA/Certified Nursing Assistant) unfastened R20's disposable brief. R20 had an indwelling urinary catheter and V29 stated that R20's brief was slightly wet with urine. With her gloved hands, V29 used disposable wet cloths and cleaned R20's pubic area, bilateral groin area and the visible part of R20's urinary catheter. V29 then applied a new disposable brief to R20 using the same gloves that she used to clean R20. After applying the new disposable brief, V29 turned R20 on her left side (facing the window). R20 had pasty stool, using the same gloves, V29 cleaned R20's buttocks and anal area, then positioned R20 back on her back, fastened the resident's disposable brief, repositioned R20's left boot (was on the resident's left lower leg), fixed R20's gown and lines and used the bed remote to lower R20's bed, while using the same soiled gloves. During the entire catheter and incontinence care, V29 used only one gloves from dirty to clean procedure without changing gloves and performing hand hygiene. After the above procedure, V29 removed her soiled gloves inside R20's room, did not perform hand hygiene, went out of the resident's room to dispose of the soiled supplies. V29 had to be prompted to perform hand hygiene/wash her hands because V29 was about to go to another resident's room to provide care. On February 22, 2024, at 12:37 PM, V2 (Director of Nursing) stated that all the nursing staff are expected to remove their gloves, perform hand hygiene either hand wash or use of alcohol/sanitizer and re-gloved after performing dirty to a clean procedure. According to V2, the CNA should have removed her soiled gloves after providing incontinence care to R20, performed hand hygiene, and then put on a new pair of gloves, before applying new brief, before repositioning the resident and before touching any other supplies and/or equipment such as resident's gown, linens, and bed remote. V2 stated that performing hand hygiene and making sure that a clean glove is used after a dirty to a clean procedure should be performed to prevent cross contamination and prevent infection. The facility's policy and procedure regarding infection control-gloves last reviewed by the facility on January 20, 2024, showed that it is the policy of the facility for staff to use gloves for maintaining health and for monitoring infection control. Under the procedure it showed in-part, When wearing gloves, change or remove gloves in the following situations: during resident care if moving from a contaminated body site to another body site (including a mucous membrane, non-intact skin or a medical device within the same resident or the environment). Under the same procedure it showed in-part, Glove use and need for hand hygiene: When an indication for hand hygiene follows a contact that has required gloves, hand rubbing, or hand washing should occur after removing gloves. When an indication for hand hygiene applies while the health-care worker is wearing gloves, then gloves should be removed to perform hand rubbing or handwashing.

Based on observation, interview and record review the facility failed to assess and provide adaptive device to residents, to prevent further reduction in ROM (range of motion). This applies to 2 of 6 residents (R83 and R129) reviewed for range of motion in the sample of 30. The findings include: 1. R129 face sheet indicates multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R129's quarterly MDS (minimum data set) dated January 4, 2024, showed that the resident was severely impaired with cognition. R129's MDS showed that the resident had functional limitation in ROM on one side of both upper and lower extremities. The same MDS showed that R129 required maximum to total assistance from the staff with most of his ADLs (activities of daily living). On February 20, 2024, at 12:34 PM, R129 was in bed, alert and verbally responsive. R129's left hand and wrist were contracted. R129 was not able to extend his left-hand fingers without the assistance of his right hand, and even with the assistance of his right hand, R129 was still having difficulty, extending his left-hand fingers. According to R129, he does not use any device or splint on his left hand/wrist. On February 21, 2024, at 1:56 PM, R129 was in bed, alert and verbally responsive. R129's left hand and wrist were contracted. R129 was not able to extend his left-hand fingers without the assistance of V3 (Assistant Director of Nursing/Restorative Nurse). R129 had no device or splint on his left hand/wrist. V3 stated that she was not aware of R129's left hand contracture because the last time she had assessed the resident his left hand was flaccid. V3 was prompted to request the therapy department to screen and/or evaluated R129 to determine the need for a device or a hand splint and any therapy services. R129's skilled therapy screening form dated February 21, 2024, created by V19 (Occupational Therapist) showed, [Patient] presents [with] increased tone in [left] hand/wrist. [Patient's] wrist presents in flexed position [with] digits 1-5 in extension position. [Patient] can benefit from [left upper extremity] resting hand splint to improve ROM in [left] hand and in prep for overnight wear. On February 21, 2024, at 3:39 PM with V20 (Rehab Director), V19 stated that she had screened R129 that day at around 2:30 PM per physician's order and V3's request. Upon screening, R129's left wrist was in a flexed position and his left fingers were extended and was not able to bend. R129's left wrist was tight and was not able to move his left wrist and left fingers with staff assistance, and even with staff assistance, R129 was not able to have a full range of motion. V19 stated that she recommended a left resting hand splint for R129 to prevent contracture and further decline of the left hand/wrist, to improve the resident's ROM on the left hand and for the staff to provide hand hygiene and monitor the skin on the hand. According to V19, R129 definitely needed the left resting hand splint because the resident's left hand/wrist ROM had declined. During the same interview, R129 stated that on February 22, 2024, R129 will be evaluated to determine the need for therapy services. R129's OT (occupational therapy) evaluation dated February 22, 2024, showed that the resident will be receiving occupational therapy services to increase the resident's functional level of independence and improve quality of life. The same OT evaluation showed in-part, [Patient] can benefit from LUE (left upper extremity) resting hand splint to improve ROM in [left] hand/wrist and prevention of contractures. On February 22, 2024, at 9:50 AM, V3 (Assistant Director of Nursing/Restorative Nurse) stated that she last assessed R129's left hand sometime in December 2023 and during that time the resident's left hand was flaccid. According to V3 she was not notified by the staff about the decline in R129's left hand ROM. V3 stated, I would have thought the CNA (Certified Nursing Assistant) would have caught it. On February 22, 2024, at 12:34 PM, V2 (Director of Nursing) stated that the nursing staff are expected to inform the nurses, Director of Nursing, Assistant Director of Nursing and/or restorative nurse when a resident's ROM changed or declined to ensure that proper assessment could be done and appropriate device, splint or any adaptive equipment can be used to improve, maintain or prevent further decline in ROM. 36567 2. R83's face sheet included diagnoses of C5-C7 incomplete quadriplegia and right-hand contracture. R83's quarterly MDS dated [DATE], showed that R83 was cognitively intact. The same MDS showed that R83 has impairment on one side for functional limited range of motions with upper extremity. On February 20, 2024, at 10:32 AM, R83 was lying in bed and noted to have his right-hand fingers (except thumb) curled into his palm. When prompted, R83 was unable to open his fingers. R83 stated My right hand is not real good. R83 also stated that he does not recall wearing any devices to his right hand. On February 20, 2024, at 2:39 PM, R83 was seated upright in a wheelchair in his room with V12 (Certified Nursing Assistant) seated by his side. R83 received two hot dogs per request and did not touch his meal. R83 stated that he is mostly right-handed but able to use left hand to feed self. No devices seen on both hands. V12 was not aware of R83 using any devices and stated that she is not familiar with R83. On February 21, 2024, at 10:38 AM, V7 (Restorative Nurse) stated He should have a splint on while he is up in chair. It can be applied by the CNAs or CRA/Certified Restorative Aides. (V12) was from agency and that was the problem. R83's care plan revised November 6, 2023, showed that R83 has an ADL/activities of daily living self-care performance deficit related to generalized weakness, history of seizures, osteoarthritis, and incomplete quadriplegia due to lesion of C5-C7 level. The goal for this focus included that R83 will wear right resting hand splint daily without complications through next review target date March 27, 2024.

Based on observation, interview, and record review, the facility failed to ensure that a resident who was receiving gastrostomy tube (g-tube) feeding was not lying flat in bed while tube feeding was being administered. This applies to 1 of 3 residents (R54) reviewed for enteral feeding in the sample of 30. The findings include: On February 21, 2024, at around 11:25 AM, R54 was lying in bed with Jevity infusing at 40 ccs (cubic centimeters) per hour through the g-tube. R54's head of bed was elevated less than 30 degrees. On February 21, 2024, at 11:34 AM, V14 and V15 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R54 who had a bowel movement. R54 was lying flat in bed and the g-tube feeding was running while R54 was being cleaned. During the care R54 was turned to her right side and left side flat while the g-tube feeding was still running. After completing the incontinence care, V15 and V16 elevated R54's head of the bed (HOB) to about 25 to 30 degrees. On February 21, 2024, at 11:49 AM, V16 (Wound Care) stated that HOB/head of bed should be 45 degrees and the g-tube feeding should be put into pause prior to care to prevent potential aspiration. On February 22, 2024, at 12:07 PM, V2 (Director of Nursing/DON) stated that staff should turn off the g-tube for 30 minutes prior to provision of care to avoid aspiration. The head of bed should be elevated to 45 degrees and up. Care plan shows that R54 has gastrostomy tube feeding, and she requires the head of bed elevated to 45 degrees during and thirty minutes after tube feeding.

Based on observation, interview and record review the facility failed to use safe transfer technique during a mechanical lift transfer. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3. This failure resulted in R1 incurring a laceration of her lip requiring sutures. Findings include: R1's Admission Record dated 8/21/2023 documents R1 with diagnoses to include Anxiety, Ataxia, Stroke, Paralytic Syndrome, and Blind left eye. On 8/21/2023 at 11:20 AM R1 was transferred by facility staff from an adaptive reclining chair to her bed using a mechanical lift. R1 was noted with a healed wound to her upper left lip, both legs were contracted with her knees drawn up and with spastic movements to her upper body. A facility Final Investigative Report dated 8/10/2023 documents on 8/6/2023, R1, who utilizes a mechanical lift due to poor trunk control and limited range of motion, slipped from the mechanical lift sling as she was being transferred from her bed to an adaptive reclining chair. This report documents R1 was transferred to the hospital for evaluation and treatment, returning with steri strips to her left eyebrow and sutures to her left upper lip. 8/21/2023 3:22 PM V6 (Nursing Assistant) stated she provided morning care to R1, placed the mechanical lift sling pad under her and attached the sling loops to the lift machine before V5 (Nurse) came to the room to assist with the transfer. V6 stated she attached the red loops for the upper body and the black strap loops to the bottom body portion of the sling. V6 stated as she lifted R1 up with the machine and moved her over the bed they began to turn her towards the adaptive reclining chair. As R1 was being turned V5 yelled, She is falling, she is coming out of the sling and R1 fell on to the floor. V6 stated she positioned the sling loops on the black strap loop so that her legs extended out. V6 confirmed all 4 sides of the sling loops were attached and the sling remained attached to the lift machine during the transfer. 8/22/2023 8:32 AM V7 (Restorative Nurse) stated she conducts all the training for use of the mechanical lift machines. V7 stated slings have 3 colored loops to attach during a transfer and the black strap loop is a safety strap to ensure if one of the colored loops breaks the black strap will catch on the machine. V7 stated the black strap loop is not supposed to be hooked up and used during a transfer. V7 stated, R1's lower body is very contracted, further stating, she is not sure how V6 could be extending her legs out. V7 confirmed placing the bottom part of the sling on the black strap loop would place her lower body in a much lower position than her upper body and would likely be the cause of the fall. On 8/21/2023 at 8:55 AM V2 (Director of Nursing) confirmed if R1 was placed correctly in the sling she should not have slipped out. On 8/22/2032 at 11:32 AM V18 (Nurse Practitioner) stated she evaluated R1 after the fall from the lift and she had sutures to her lip and some bruising. V18 stated she expects the facility to use correct safety interventions to prevent residents from slipping from or falling out of the mechanical lift sling during use. A Health Status Progress Note dated 8/6/2023 documents R1 returning from the emergency room with 4 sutures to her upper left lip, steri-strips to her left eyelid laceration and swelling to her left side of her face. R1 was provided pain medication for left shoulder and facial pain rating a 7 out of 10. R1's Care Plan dated 10/22/2021 documents R1 with deficits due to Cerebellar Ataxia, Stroke, Dementia and Blindness requiring the use of a mechanical lift for transfers. The facility policy, Electric Lift Transfer, last reviewed 1/20/2023 documents it is the policy of the facility to use the electric lift appropriately to facilitate safe resident transfers.

Based on interview and record review the facility failed to implement timely treatment for a Urinary Tract Infection (UTI). This applies to 1 of 3 residents (R1) reviewed for Urinary Tract Infections in a sample of 11. Findings include: R1's Admission Record dated 6/12/2023 documents diagnoses to include UTI (4/6/2023) and Urine Retention. R1's Progress Notes dated 4/5/2023 documents R1 readmitted from the hospital with diagnoses to include UTI with orders for Antibiotics to continue after re-admission. R1's Progress Notes dated 4/28/2023 documents R1 with confusion; V6 (Nurse Practitioner) was notified and ordered a Urinalysis and Urine Culture. R1's Lab Results Report documents R1's Urine sample was collected for testing on 4/28/2023 with a final result reported on 5/1/2023. The Urine Culture report documents R1 with 70-90,0000 Extended Spectrum Beta Lactamase Resistant organisms (ESBL). R1's Progress Notes on 5/1/2023 document V20 (Physician) was contacted regarding R1's Urinalysis and Urine Culture report and ordered the Infectious Disease practitioner be consulted. This note further documents the result was faxed to the Infectious Disease office. R1's Progress Notes on 5/2/2023 document the facility is waiting for a response from the Infectious Disease office and R1 continues on contact isolation due to ESBL infection in her Urine. On 6/12/2023 at 10:55 AM V7 (Infection Preventionist) stated the results of the Urine Culture and Urinalysis report were faxed to the Infectious Disease office on 5/1/2023 and on 5/2/2023 V7 communicated with a Registered Nurse in this office to provide a history of R1's recent infections and Antibiotic use. V7 stated she reported R1 had no condition changes so R1 was placed on V19's (Infectious Disease Nurse Practitioner) list for rounding on 5/3/2023. V7 stated she was unaware of R1's condition changes, including confusion, as documented in R1's nurse progress notes. R1's Progress Note dated 5/3/2023, completed by V19, documents R1 was evaluated for a positive Urine Culture showing ESBL. This note documents R1 with increased confusion, with tenderness to deep abdominal palpation, and pus in her urine. V19 ordered initiation of an Intravenous Antibiotic which started on 5/3/2023. On 6/9/2023 at 1:07 PM V5 (Nurse) stated when a positive Urine Culture is resulted the primary Physician or Nurse Practitioner are notified who sometimes refer to the Infectious Disease office. V5 stated if she needs to notify the Infectious Disease practitioners of an abnormal Urine Culture, she notifies them via phone promptly and will continue to make notifications until they are reached for further direction. R1's Brief Interview of Mental Status on 4/12/2023 documents R1 as cognitively intact. On 6/12/2023 at 9:07 AM V19 stated the facility usually will call her or the office to get orders and to report abnormal Urinalysis/Culture results. V19 confirmed good practice is to make timely notification to the Physician or herself for all positive Urine Cultures to determine a treatment plan, especially because she was symptomatic.

Based on observation, interview, and record review the facility staff failed to follow their policy to ensure a safe resident transfer using a total body mechanical lift. This failure resulted in the total body mechanical lift falling during use and the resident sustaining a Left Femur Fracture requiring surgery. This applies to 1 of 3 (R1) reviewed for transfers with a mechanical lift in the sample of 3. The findings include: According to the Electronic Health Record (EHR) R1 had diagnoses including Displaced Comminuted Fracture of Left Femur Shaft, [CONDITION(S)], Acute [CONDITION(S)], [CONDITION(S)], Polyneuropathy, history of falling, Amputation of Toes, Non-Pressure Chronic Ulcer of Left Lower Leg, Diabetes, [CONDITION(S)] and [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Hypertension, Depressive Disorder, Anxiety, Right Leg Below Knee Amputation, history of Malignant [CONDITION(S)], age-related [CONDITION(S)]. The Minimum Data Set (MDS) dated [DATE] showed R1 needed extensive assistance of two people for bed mobility; was totally dependent on two people for transfers and toilet use. R1 was 5 feet 4 inches tall and weighed 240 pounds. The MDS showed R1's cognition was intact. A care plan showed R1 was a high risk for falls due to Left Sided Weakness from a [CONDITION(S)] with interventions including to use two people for repositioning in bed and make sure bed was locked prior to transfers. On 04/25/2022 at 1:18 PM, R1 was awake, lying-in bed watching television wearing a left leg immobilizer. R1 had a splint on her left hand which she stated she wore due to a stroke [AGE] years ago and she continued to have weakness on her left side. R1 stated a CNA (Certified Nursing Assistant) was transferring her from the bed to the wheelchair approximately eight feet away from the bed. The CNA was the only person in the room, she didn't have anyone else helping her. R1 stated once she was up in the total body mechanical lift and the CNA was starting to move it, the CNA seemed to be having some trouble moving the lift, it was like stuttering when she was moving it then the whole machine tipped over. R1 thought she landed on her back but denied hitting her head. R1 stated usually there are two people who help me get up using the total body mechanical lift. R1 stated she was in a lot of pain. R1 stated she needed surgery to place a rod in her leg. R1 stated she hasn't been able to get out of bed since surgery, not even to get into her chair. Prior to the fall, R1 would go to the dining room for meals and would participate in all of the facility activities but was unable to participate in any of it right now. R1 stated both of her legs are hurting all the time and she needs pain medication about twice a day. According to R1, prior to the fall and surgery she hardly ever asked for pain medication. On 04/25/2022 at 4:43 PM, V6 (CNA agency) stated she was transferring R1 from the bed to the wheelchair after providing incontinence care for a bowel movement. V6 stated she did not have assistance from anyone else during incontinence care or with the transfer from the wheelchair to the bed. V6 stated R1 was able to help a little bit to roll during incontinence care and didn't ask anyone else to assist with the transfer or the incontinence care. V6 stated after placing R1 on the sling and hooking it to the total body mechanical lift, she raised R1 off the bed and began to turn it toward the wheelchair. V6 stated the lift seemed to stutter a bit before it bent and fell over. V6 did not think there was anything on the floor in the way of the mechanical lift and did not think the lift or R1 had hit anything while she was moving it. V6 stated it happened very fast and R1 fell on the floor with the mechanical lift laying on the side, before she was able to lower R1 to the wheelchair. On 04/26/2022 at 10:10 AM, V7 (Registered Nurse/RN) stated she was passing medications to a resident across the hallway when V6 (CNA) had called her to R1's room. V7 stated R1 was lying on top of the mechanical lift body sling on the floor and the total body mechanical lift was lying next to R1. V7 stated R1 needed a two-person assistance with transfers using the total body mechanical lift. V7 stated the total census was approximately 22 or 23 residents and there were four CNAs working on the unit. V7 stated the CNAs receive report from the off going CNAs and the nurses. The assignment sheets usually have the residents transfer status on it as well as a card on a board above the residents' bed. V7 stated I don't know why the CNA didn't ask someone else for assistance. V7 stated they had kept R1 comfortable on the floor until 911 paramedics arrived to transfer her to their stretcher. On 04/25/2022 at 1:29 PM, V8 (CNA) and V9 (CNA) stated residents who need to be transferred using any kind of mechanical lift always need to have two people present to assist. During the transfer using a mechanical lift, the CNAs should always keep a hand on the resident, while one person guides the legs, the other person used the controller and placed a hand on the resident's back. The body sling the resident was on should also use the same-colored loops to secure it to the mechanical lift hooks. V8 and V9 stated the CNAs should determine how the residents are to be transferred by the Kardex/plan of care in the computer as well as the sign on the wall above the resident's head of the bed. On 04/25/2022 at 4:04 PM, V5 (Maintenance Director) stated he had inspected the total body mechanical lift after the incident and could not find anything physically wrong with the machine and he could not replicate the machine to tip over. The total body mechanical lift used during the incident was observed and was back in service for the residents. R1's body weight was well below the 400-pound maximum capacity of the total body mechanical lift. On 04/25/2022 at 4:25 PM, V4 (Restorative Nurse) stated they had tried recreating how the mechanical lift could have tipped over. V4 stated during testing the mechanical lift, V5 had accidentally dropped a washcloth onto the floor and when V4 was moving the mechanical lift, the machine had started to tip when the wheels hit the washcloth. V4 could not recall any linens being on R1's floor after the incident. On 04/26/2022 at 11:32 AM, V3 (Director of Nursing/DON) stated during the investigation both V6 (CNA) and R1 stated the sling started swinging prior to the total body mechanical lift falling. V3 stated V6 (CNA) had plenty of help available to her since they were not short staffed that day. The large blue full body sling was inspected, and no tears, frays, or rips were found. The sling was from the same manufacturer as the total body mechanical lift and the weight limit listed was the same as the mechanical lift. A hospital X-Ray of the Left Femur and Pelvis dated 4/11/2022 showed R1 had a Comminuted Fracture involving the Distal Left Femoral Shaft. A hospital physician note dated 04/17/2022 showed a Magnetic Resonance Imaging (MRI) was negative for [CONDITION(S)] in R1's left leg. A hospital Physician Note dated 04/13/2022 showed a Computerized Tomography revealed R1 had a Fracture of the Distal Left Femoral Metaphysis. The hospital Discharge Instructions showed R1 had a Hip Fracture requiring an Open Reduction and Internal Fixation (ORIF). The facility's Transfer Electric Lift policy dated 12/31/2021 included At least two (2) people are present during transferring the resident. You MUST have HANDS ON the resident at ALL times during the transfer. One of the persons MUST have HANDS ON CONTACT with the resident during the ENTIRE transfer. The policy also indicates a Staff Alert to not lock the wheels when lifting a resident.

Based on observation, interview and record review, the facility failed to monitor resident's skin condition, provide treatment, and notify the physician regarding the resident's pressure injury. This resulted in R93 acquiring an unstageable pressure injury. This applies to 1 of 5 residents (R93) reviewed for pressure injury in the sample of 31. The findings include: R93 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/6/18 at 9:25 AM, V5 (Wound Treatment Nurse) and V4 (Wound Treatment Nurse) were observed for R93's wound care treatment. V5 identified the wound on the right ischium as unstageable with measurements of 1.25 cm (centimeter) x 1.0 cm x 0.6 cm. Another excoriated area was identified on the left inner buttock (1.0 cm x 0.8 cm x 0.2 cm). On 2/5/18 at 2:20 PM, V4 (Wound Treatment Nurse) stated a nurse called her last Friday night 2/2/18 but unable to recall the name of the nurse. V4 stated R93 has fragile skin and has scar tissue on the perianal area. Barrier cream was being applied to prevent excoriation. No documentation was found in the electronic medical records of the pressure injury on the right ischium, when the pressure injury was initially identified and when and who contacted V4 on 2/2/18. V24 stated she was not able to find any documentation of the pressure injury in the medical records. The latest Braden Scale for Predicting Pressure Sore Risk dated 12/19/17 showed a score of 12 (high risk). The (MONTH) (YEAR) and (MONTH) (YEAR) Treatment Administration Record lacked signatures to indicate that skin protectants were applied after incontinence care. On 2/6/18 at 9:55 AM, V11 (Licensed Practical Nurse/LPN) stated she was the nurse assigned to care for R93. V11 stated she was not aware and did not receive any report that R93 had a pressure injury, only that she had a protective dressing on her buttocks. Staff who were identified working on 2/2/18 in the Nursing Daily Shift Assignments were interviewed. On 2/6/18 at 4:10 PM, V7 (Certified Nursing Assistant/CNA) stated she was the assigned CNA to R93 on 2/2/18. V7 stated she did not see any pressure injury on R93's buttocks. On 2/6/18 at 4:15 PM, V8 (Registered Nurse (RN) Unit Supervisor) stated she did not receive any report that R93 had an open skin. On 2/6/18 at 4:40 PM, V9 (RN Supervisor) stated that on Saturday, 2/3/18 during the 3PM-11PM shift, V10 (RN) reported that V26 (R93's family) was visiting when R93 complained of pain on her buttocks. When V9 checked R93's buttocks, a foam dressing was found. V9 stated the treatment nurse had been putting the protective dressing. V9 stated R93's family member wanted to know why they were not notified of the skin condition and was upset. V9 stated she informed V4 (Treatment Nurse) on 2/3/18 and not on 2/2/18 as V4 stated. V9 stated she did not document this event. On 2/7/18 at 3:50 PM, V10 (RN) stated that on Saturday 2/3/18 during the evening shift, V26 (family) requested if V10 could transfer R93 back to bed due to R93's complaint of burning sensation on her buttocks. R93 was transferred to bed and V10 removed the brief. V10 stated she saw a soiled dressing without date on the coccyx. V10 peaked under the dressing and saw an open wound with yellowish slough. V10 stated there was no treatment order for the wound. V10 applied a wet to dry dressing. V10 stated she was informed by a treatment nurse in the past to apply this type of dressing if there was no order and until an order can be obtained. V10 stated V26 asked when the pressure injury started. V10 told V26 that she will ask the supervisor. V10 stated she informed V9 (Nurse Supervisor) who also did not know when the pressure injury was initially identified. V10 stated V9 instructed her to inform V26 that facility staff were aware of the condition and was being addressed and the reason there was a dressing on the wound. V26 asked if there was someone she can talk to regarding the pressure injury. V10 informed V26 that the wound treatment nurse was not at the facility but can call the treatment nurse on Monday 2/5/18. V10 stated she endorsed the information to V9 (Nurse Supervisor) who was going to contact V4 (Wound Treatment Nurse). V10 stated she did not document this event. On 2/8/18 at 10:20 AM, V28 (Nurse Practitioner) stated she was not on call during the past weekend. V28 did not receive any notification regarding R93's pressure injury and did not give any treatment order over the week-end. On 2/6/18 at 2:30 PM, V5 (Wound Treatment Nurse) stated when nurse notifies the wound treatment nurse of an open skin area, the treatment nurse would assess and obtain an order for [REDACTED]. The facility policy titled, Skin and Pressure Ulcer Identification and Prevention, revised (MONTH) 18, 2014, requires, Pressure Ulcer Reporting .3. The charge nurse will document in the nurses notes and report to the wound care nurse and to oncoming shift nurses the finding and interventions in place. Forward all Bath and Body/Skin Condition Report forms to the wound care coordinator or her designee. Put on the 24 Hour Report. Start treatment and Braden Scale for Predicting pressure sore risk immediately . Pressure Ulcer Documentation .All pressure ulcers shall be documented upon finding pressure ulcer on the wound care Treatment Progress Report (TPR).

Based on observation and interview the facility failed to ensure that precautions were taken to prevent a potential accidental burn to residents. The hot buffet steam table in the main dining room was not kept from access by cognitively impaired residents. This had the potential to effect cognitively impaired mobile residents in the facility who could potentially be accidentally burned. The immediate jeopardy began on 3/14/2013 at 3:45pm when surveyors observed that the buffet/ steam table in the dining room had surface temperatures as high as 147 F. with no staff in attendance to ensure residents do not have access to the hot surfaces in reach. The area had an opening that anyone could walk through with a single chain not locked and easily removed. There was also a space between a Plexiglass guard and the top of the serving line that residents could reach through and touch a hot surface. The administrator was informed immediate jeopardy at 5:00pm. The immediate jeopardy was removed on 3/14/13 at 6:00pm, the deficient practice was corrected on 3/14/13. This applies to seven of ten residents reviewed for ambulation and impaired cognition in the sample of thirty. R5, R10, R27, R12, R20, R21 and R25. Findings include: This facility has a large main dining room on the upper level floor where residents come from all the nursing units. Residents from second avenue, third avenue, fifth avenue on the first floor, and forth and and first avenue on the lower level all are welcome to eat in this dining room for breakfast lunch and dinner. The majority of the 208 residents in the facility eat in this dining room while some remain on their units for a continental breakfast or for lunch and/or dinner for a tray served to them. The buffet line has 2 steam tables along with space for other items, one has 3 wells, and the other has 4 wells. The steam table is turned on about 5:30 am according to E9 one of the dietary service supervisor and remains on until after the dinner meal about 6:30pm. On March 14, 2013, at 3:45 pm the survey team noticed the steam tables in dining room were on. The surface of the steam table was measured to be as hot as 147 F.. This surface is accessible to residents who could put their hands between the acrylic glass sneeze guard and the surface of the steam table. The temperature control gauge on the table has a numerical setting instead of a temperature setting. E9 the dietary supervisor said that the steam tables are turned to high before meal service to number 8 , and turned to the middle point 4 or 5 between meals. On 3:34pm on 3./14/.13 E 38 from the maintain department measured the surface of the steam table with a laser type thermometer. There are two sections that have hot tables. The surface temperatures of the table that has 3 wells showed various temperatures when measured, the center of the wells have alluminum covers when they are not serving food. The center of the covers measured 135 F., 113 F. and 141 F. The edges of the table measured 88-89F. At this time the table control was set at 4. The other steam table has 4 wells, with alluminum covers. These temperatures varied from 124. 123, 144, 145,147, 141 and 133 Fahrenheit. The dietary cafeteria buffet style policy and procedure number FBS-393 dated 10/1/12 indicates the following meal times: a. Breakfast is served in the main dining room from 7:30am to 9:30am. b. Lunch : 11:30am - 1:00pm c. Supper: 4:30pm to 6:00pm While dietary and nursing staff are in the dining room to supervise residents at meal times, the two hours between breakfast and lunch, and the three and 1/2 hours between lunch and supper are not necessarily supervised by anyone. There are activities in the dining room, but not for this entire time, and no one has been specifically assigned to this duty according to interview with E1 on 3/14/13 at 5:00pm. This was confirmed during an interview with E1 administrator on 3/14/13 at 4:15 pm. R24 stated during an interview on 3/14/13 at the dinner meal at 5:25 pm that " she likes to come to the dining room at about 6:30am to 6:45 am. R24 said there is no one around. Sometimes it's hard to get a cup of coffee." R25 was observed on 3/14/13 at the dinner meal at 5:35 pm to be seated in her wheel chair wandering in the dining room with no staff present to redirect, R25 is cognitively impaired and requires supervision to prevent accidents. Review of the State Operations Manual (SOM) interpretive guidelines for F323 regarding the hazards of hot water, revealed the following taken from "Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns...Table 1. Time and Temperature Relationship to Serious Burns." Review of this Table revealed that for a water temperature of 148 degrees Fahrenheit, the time required for a third degree burn to occur was two seconds and for a water temperature of 140 degrees Fahrenheit, the time required for a third degree burn to occur was five seconds. When measured on 3/14/13 the top cover of one of the steam table was in access of 140 F. The facility has residents who have cognitive impairment, many of whom may be ambulatory. Part of the MDS ( minimum data assessment) tool used for all residents has a section called Brief Interview for Mental Status (BIMS). The BIMS is a brief screening tool that aids in detecting cognitive impairment. This is according to the state operations manual (SOM) appendix-P. The SOM defined unreviewable residents as one who has sufficient memory and comprehension to be able to coherently answer questions, and make day to day decisions in a fairly consistent and organized manner. Residents with BIMS scores of 8 to 15 are identified as unreviewable, and residents with 0-7 or 99 are not considered interviewable. The facility report printed at the time of this survey shows BIMS scores for 201 residents. This report indicates 64 residents fall below 8, with a acore between 0 and 7, 13 were unable to answer, and 20 had this section skipped. This report would suggest that at least 64 residents have cognitive impairment,and 33 others are not known. Cognitively impaired residents are more at risk to be accidently burned. There were ten residents in the sample who had scores of less than 8 on the BIMS, and of these seven were ambulatory, R5, R10, R27, R12, R20, R21 and R25. This information was obtained by reveiw of MDS (minimum data set) assessments for these ten residents in in the sample of thirty. On 3/14/13 at 6:10pm surveyors confirmed that the facility developed the following policies to remove the immediacy of the situation: Effective immediately, portable steam table will be removed from the facility ' s main dining room area and placed inside the kitchen doors with doors being closed after each meal, unless Food & Beverage staff supervision is available. While steam table is in the main dining room area, it will be supervised by facility Food and Beverage Services Staff at all times. Currently, as of March 15, 2013, the Food and Beverage Supervisor has inserviced 23 staff members of the 32 department employees. The remaining nine Food & Beverage staff members that have been identified as not being inserviced due to not being on the work schedule on March 14, 2013 and March 15, 2013, but will be reporting to work within the next 14 days will be inserviced prior to starting their assigned shift by the Food & Beverage Service supervisor. At least one of the three Food & Beverage Service Supervisors will be present during hours of operation until a long-term solution completed. The facility altered the buffet serving line in the main dining room by adding a gate (chain link type) with a lock. This closes off the access to the hot surfaces by anyone who does not have a key for the lock. The Plexiglas sneeze guard was adjusted to fit closer to the tray line. This opening is small enough so that the hot surfaces could not be reached. This was observed to be in place on 3/26/13.

Based on observation, interview and record review, the facility failed to develop a comprehensive assessment to address the risk factors for developing pressure ulcers, develop and consistently implement a specific plan of care to promote healing and prevent the development of additional pressure ulcer, evaluate and implement an individualize repositioning plan base on tissue tolerance, assess and correctly identify the type of wound (pressure versus arterial) for 1 (R10) resident. This applies to 1 residents (R 10 ) reviewed for acquiring pressure ulcer in the facility, in the sample of 30. These failures resulted in R 10 ' s development of facility acquired - avoidable Stage III pressure ulcer on the left foot. Findings include: R 10 readmitted to the facility 12/23/2012 with an ankle foot orthotic (AFO) device in place. A review of the nurse ' s notes for R 10 dated 12/29/2012 at 2:30 p.m. (E 20) RN treatment nurse documents : R 10 is noted with open area to left lateral foot due to trauma from " Prafo " boots wound measures 1.6 cm x 2.2 cm x 0.2 cm. The wound bed with 60% granulation and 40% yellow slough. There is minimal serous drainage and no odor. R 10 has [DIAGNOSES REDACTED]. The " Prafo " boot was discontinued and a soft heel suspension boot when in bed and " Darco " shoes when R 10 is up in chair was added. Record review of the wound or pressure sore for 2/5/2013 and 2/13/2013 identify the wound to have 80% slough thick adherent deviated necrotic tissue. In addition, the wound is classified as Arterial / Neuropathic /Diabetic. On 3/18/2013 at 10:30 am the interview with (E 14) RN, Treatment Nurse, Asked how the wound is arterial when the 12/29/2012 nurses notation identified the wound was caused by the boot. E 14 said she would reevaluate the wound. Arterial studies were recommend and refused by power of attorney and Hospice. On 3/19/2013, E 14 submitted a wound report for R10 ' s left lateral foot and identified the wound as a pressure ulcer acquired in the facility. The wound was observed on 3/19/2013 with E 14. E 14 identified the wound as a stage III pressure sore. Measuring 0.5 cm x 0.5 cm x 0.3 cm with small amount serous exudates. A review of the plan of care there is no plan identified to address the AFO device. There is no individualized plan or assessment of the risk factor to prevent this avoidable pressure sore.

Based on observation, review of records and interviews, the facility failed to assess and evaluate the cause of R1's continued complaints of pain and decline in ambulation. This was for 1 of 3 sampled residents (R1) who was diagnosed with [REDACTED]. Examples include: R1 was transferred to the hospital emergency roiagnom on [DATE] at 3:30 a.m. Z1 (primary care physician) completed a history and physical on 9/27/12 that read: Chief complaint, Pain...transferred for evaluation of fever, temperature 101 degrees...complaining of hip pain at the nursing home...x-ray done...showed dislocation left hip...patient with shortened left hip and rotation...recent hip surgery. E8 (certified nursing assistant) CNA on 10/24/12, verified being R1's direct care giver from 10:45 p.m. on 9/26/12 to 3:30 a.m. on 9/27/12. E8 stated being assigned to take R1's temperature and vital signs. E8 stated the night nursing supervisor was making rounds at the time she began to change R1's brief around 2:30 a.m. E8 said when R1's incontinent brief was pulled back she began to scream in pain. E8 said I could not touch, turn or move her. "The left hip looked out of place and you could tell there was something did not look right." E6 the nursing supervisor was making rounds and coming down the hall, I asked her to come into R1's room. E8 said E6 saw the hip and we both were asking what happened. E 8 stated not knowing the condition of R1's leg until the brief was removed. E8 stated the brief covered the hips, so you would not be able to see the hip bones if the brief was not removed. E8 stated examining the color strip on the incontinent brief earlier in the shift and R1's brief was not wet. E 8 stated the strip on the brief will change colors from blue to green if the resident is wet. A interview with E6 was conducted on 10/23/12 and a review of the nurses notes documented by E6 at 2:30 a.m., on 9/27/12. E 6, stated was making rounds on the units and was told by E7 ( charge nurse) that R 1 had a temperature and it was not coming down. E6 documented, " assessment done and resident is very weak and slow to response, skin flushed and warm to touch, lungs diminished...slight labored breathing...left leg internally rotated and left hip protruded compared to the right hip and resident screaming out aloud in pain during movement of left leg." E6 stated telling E7 to notify the physician at 2:30 a.m. Interview with E 7 on 10/24/12 showed, R1 was found to have a temperature ( 101.3) and E7 said was concerned that R1's temperature was not coming down. E7 stated medicating R1 at 12:a.m. for the elevated temperature, temperature taken again at 1:a.m. was still 101.3 said E7. E7 stated informing E6 around 2:30 a.m. when she was making rounds about R1's elevated temperature and documented this at 2:30;a.m. as 100.7. E7 stated not being aware of the condition of R1's left leg and hip. E7 stated and documented several attempts were made to notify the Z5 the physician ( 2:30 a.m., 2:55 a.m., 3:25 a.m.) with no call back. E7 stated R1 was sent to the hospital after consent from Z6. Z3 ( physical therapy assistant), on 10/25/12, stated R1 receives physical therapy five times a week. R1's, "Therapy Progress Notes", notes completed by Z3 were reviewed. Z3 stated R1 was ambulating with a rolling walker 25 to 35 feet with minimal assistance before the fall on 9/23/12. Z3 said after R1's fall she complained of increased pain and was no longer able to participate as before in the physical therapy sessions. Z3 stated notifying R1's nurse each time the resident complained. Z3 documented on 9/25/12, R1 was given sit to stand training at the parallel bars with minimal assistance and sat down right away and complained of pain. R1 reported the pain was 7/10 on scale of 1-10. Z3 said R1's nurse was notified and it was documented in the therapy note. There was no assessment found that the facility had evaluated R1's decline on 9/25/12. Review of the MAR for 9/25/12 and the nurses notes show that no pain medication was documented administered on this day. The nurses notes do not indicate the facility being informed the resident had pain in therapy. The nursing note document, R1 complained of pain at 12 p.m.: however there were no nursing interventions documented or an assessment of the pain R1 was experiencing. Further review of Z3's therapy notes document on 9/26/12 , R1 "complained of pain in left lower extremity, so nurse was notified and administered pain medication for left hip to help decrease the pain, R1 still complained of pain, so nurse notified again, no standing or walking given due to pain". Z3 documented R1's pain as 9/10 on scale of 1-10. Z3 stated telling the physical therapy supervisor about R1's increase pain and was directed to examine R1's left extremity. Z3 stated, R1's left hip felt odd and the bony prominence was sticking out. Z3 stated R1 was transported back to the unit. Z3 stated being the one who spoke with the nurse E13, about R1's inability to perform therapy due to pain in the left extremity and that the hip felt odd and the bony prominence was sticking out. On 10/24/12, E21 (day nurse) assigned to R1 on the day shift and, stated that R1, did not complain about pain on 9/26/12. E21 recalled being told by therapy staff Z3, after R1 returned from therapy and administered pain medication. I assessed R1 and everything looked all right. The medication administration (MAR) record showed that R1 was given pain medication after therapy by E21. The MAR read pain pill administered at 13:17 by E21. E21 scored R1's pain at 6 of 10 on pain scale of (1-10). R21 was could not recall a conversation taking place between the therapist Z3 and self about R1's pain and inability to participate in therapy on 9/26/12. E21 was unable to describe the type of pain, location of the pain or the condition of R1. E21 did not document anything in the nurses on 9/26/12 for this resident to indicate a assessment of the pain and a assessment of left extremity was conducted. E10 (evening nurse) on 10/23/12 stated remembering administering pain medication to R1 on 9/26/12. Review of the nurses notes document that [MEDICATION NAME] one tablet was given for R1's complaint of pain to back and left hip at 9:30 p.m. E10 stated "I did not examine R1's leg at that time." E10 stated not being able to recall how much pain R1 was experiencing. The medication administration record was reviewed with E10 for the date 9/26/12. E10's documentation show, R1 with zero documented for pain. A review of the physicians order show that R's physician Z1, increased the [MEDICATION NAME] on 9/25/12 from 25 mcg/hr to 50 mcg/hr to be changed every 72 hours an administered to treat R1's pain after the fall on 9/23/12. The facility's nursing staff did not document the occurrence surrounding why R1's pain medication needed to be increased. There were no physical assessments documented describing the the nature of R1's experience with pain by the facility nursing staff. Interview with Z1 on 10/24/12 said R1 showing signs of increased pain could be a symptom that there was something different happening with the left extremity. Z1 stated R1 has complaints of chronic pain. The pain last pain assessment completed by the facility prior to the fall was 8/20/12. This pain assessment documented R1's pain to be left leg & knee, as a 4 of 10 on pain scale of 1-10. The pain assessment had not been revised or updated with R1's current pain related condition after the fall on 9/23/12. E13 (nurse supervisor) reviewed R1's pain assessment that are documented in the MAR for each resident. E13 said nursing staff are to assess and document the pain that R1 is experiencing on every shift. The MAR from the dates prior to the fall 9/11/12 to 9/26/12 were all zeros, denoting no pain experienced. Documented on the MAR for 9/24/12 are scores of 4 on the day shift and a score of 5 on the evening shift for pain. The remainder of the shifts for 9/25/12 and 9/26/12 were zeros. There were no pain assessments documented. R1 has has multiple [DIAGNOSES REDACTED]. R1 is assessed by the facility to require total assistance in all areas of activity of daily living as documented in the care plan and assessment. R1 was observed in bed on 10/23/12 at 11 a.m. alert and oriented and able to recall the fall on 9/23/12. R1 stated she thought she could walk, got up and fell . R1 could not provide information about how the left leg became dislocated. R1 was queried about the frequency of pain. R1 stated on a scale of 1-10 her pain is usually a 12. R1 stated always being in pain and never pain free. R1 stated usually after the pain medicine her pain becomes a eight. R1 stated at the time of interview her pain in the back was a 12. R1 requested pain medication and the nurse was notified. The facility's Occurrence report dated 9/23/12 for R1 was completed by E5 (nurse risk manager). The report was reviewed with E5 on 10/23/12 and 10/24/12. The report documented, R 1 was found on the floor in room laying on the right side at 1:05 p.m., wheelchair facing bed, R1 stated, " I was trying to sit on the bed and fell , sustained a skin tear to the right elbow". E5 stated on 10/25/12 that an investigation was not completed and the cause of the R1's left hip dislocation on 9/26/12 had not been investigated.

Based on record review, interview and observation the facility failed to ? Prevent the development of three areas of avoidable pressure ulcers to R 16 & R 9. ? Re-evaluate treatment modalities that have not been effective in preventing recurring pressure sores for their effectiveness and develop and implement individualized interventions based on the identified needs of R16 and 9. ? Prevent worsening of R 9's pressure ulcer. These failures resulted in R16 and R9 acquiring multiple avoidable pressure ulcers and the worsening of the acquired pressure ulcer on R9's coccyx which had developed into an unstageable; recurrent pressure ulcers to R16's ankle due to orthotic cast and then becoming infected [MEDICAL CONDITION]. This is for two residents identified with pressure ulcers in the sample of 30. Findings include: Review of admitting face sheet shows R16 is [AGE] years old and has been a resident at this facility for almost [AGE] years. Care plan dated 2/22/10 and 11/4/11 shows R16 wears a padded ankle foot orthotic (AFO) clamshell brace to her right lower extremity. R16 has a history of pressure ulcers, blisters and petechial areas developing under this brace on the lower extremity. This care plan also states the "clamshell brace is to be on 23 hours a day, circulation is to be checked every shift and the charge nurse is to take the clamshell off every morning for one hour, wash and dry leg and foot. Apply [MEDICATION NAME] powder and a clean dry cotton stockinette is to be placed under brace." Review of pressure sore documentation shows R16 redeveloped a pressure sore to the right outer aspect of ankle on 8/30/11. It was found at a stage III measuring .6 x 1 cm. By 10/4/11 it was a dark necrotic area and by 12/9/11 it contained 80% slough. R16 found to have facility [MEDICAL CONDITION] in this wound on 12/23/11. E4 (assistant dir of nursing ) stated on 2/16/11 at 10:00am that R16 has been on antibiotics for [MEDICAL CONDITION] in this wound since then. The care plan interventions/approaches noted above have not been evaluated for their effectiveness nor have they been revised since R16 redeveloped this pressure ulcer. A progress note by the orthotic company who supplies and adjusts R16's AFO (clamshell) dated 7/14/11 states that R16 "appears to have a lot of [MEDICAL CONDITION] and is not controlled this am with use of either AFO or compression garment (not on patient). " Podiatry progress note dated 9/19/11 states left ankle ulcer from brace pressure. Interview and observation on 2/16/12 at 10:30am along with E20 (wound nurse) found R16 alert and oriented, sitting in her wheelchair in her room. R16 is unable to verbalize due to prior stroke but is capable of answering yes and no. R16 had the right leg slightly elevated on a footrest and the AFO was applied. E20 removed the AFO and the elastic stocking. The lower extremity, including the entire foot and toes, was very [MEDICAL CONDITION] with 3+ [MEDICAL CONDITION]. The pressure area was observed to have a very thin layer of bluish-red tissue. Also noted was a quarter size reddened area on the inner aspect of the right heel that had what appeared to petechiae. There was slight spotting apparent on the padding inside the clamshell. There was no documentation regarding this area in the medical record. 2. Review of face sheet shows R9 is [AGE] years old, admitted to facility on 8/4/07. Care plan dated 8/13/10 and 12/21/11 states R9 requires assist in turning and postioning in bed and transferring out of bed. Review of pressure sore documentation dated 12/12/11 shows a stage II was found on the coccyx measuring 2.8 x 5 x .1 cm with serosanguineous drainage. One week later it had declined to an Unstageable wound with 85% slough and measuring 3.5 x 3.0 cm with a bridge. E23 (nurse's aide) stated on 2/16/12 at 1:20pm that R9 does like to be in bed and use to sit up in her wheelchair all day. This was repeated by E24 (wound nurse) on 2/16/12 at 2:00pm who also stated R9 developed a heel wound that recently closed and also the current pressure ulcer to the coccyx. During this observation of R9's pressure sore to the coccyx, it was observed to be healing with small areas of slough and a bridge of healthy tissue running in the center. E3 (director of nursing) stated on 2/17/12 at 10:10 am the facility has not followed its own policy and procedure and has not had labs drawn to assist in analyzing if dietary issues were also a cause of this ulcer.

Based on observation, record review and interview, the facility failed to have preventative measures in place to prevent development of new pressure ulcers, for a resident identified as severely at risk for pressure ulcers. This applies to 1 of 6 residents (R2) reviewed for pressure ulcers, in a total sample of 18. Findings include: R2's [DIAGNOSES REDACTED]. R2's current significant change MDS (Minimum Data Set) dated 2/17/12 assessed R2 as dependent on staff for all activities of daily living, including turning and positioning. R2's Skin Risk assessment dated [DATE] assessed R2 at severe risk for developing pressure ulcers. R2 has an indwelling catheter due to [MEDICAL CONDITION] and is in isolation [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) of the Urine. Physician order [REDACTED]." Wound care notes of 4/2/12 at 9:00AM, denotes, "observed during wound care, clear fluid filled blister to left inner upper thigh 0.5 centimeter (cm) x .5 cm. Treatment started per order." POS dated 4/2/12 denotes an order to clean left inner thigh with normal saline, apply skin prep cover with padded dressing daily and as necessary (prn). Nurse notes of 4/4/12 at 9:45 PM denotes, "CNA informed this writer that R2 has sore on right inner knee measuring 4 cm x 2 cm. Treatment started." POS dated 4/4/12 denotes an order, "cleanse right inner knee with normal saline, apply [MEDICATION NAME] and padded dressing daily and prn. Wound Care note dated 4/15/12 denotes: Reassessed right inner knee (7.0 cm x 4.0 cm x 0.2 cm) with bridge open blister. R2 denies pain. Treatment started. Intervention to place pillow between R2's knees while in bed. Will continue to monitor. Treatment order obtained on 4/5/12 included to cleanse right inner knee with normal saline apply collagen cover with foam dressing daily and prn. R2's treatment sheet lacks documentation that the right inner knee received the ordered treatment on 4/9/12. On 4/10/12, during wound care treatment with E5 (wound care nurse), a thin pillow was between R2's right and left knee. The area of the left inner thigh was healed. E5 remove an undated dressing from the right inner knee. R2's right knee was very bony. There was clear drainage on the pillow case. The wound was very reddened with moderate amount of slough on wound bed. Wound progress note written on 4/10/12 measured the wound as 7.0 cm x 3.5 cm x 0.2 cm with bridge, small amount of serosanguineous drainage, 20% slough and 80% granulation. E5 stated she will notify the physician regarding the slough and will get an order change. A new treatment order was obtained on 4/10/12, to clean right inner knee with normal saline, apply collagen to granulation area, and santyl ointment to slough tissue and cover with foam dressing daily and prn. Continue with preventative measures-pillow in between knees and ankles at all times. On 4/11/12, E4 (Wound treatment coordinator) was asked why R2's acquired wounds were not identified on the facility weekly pressure ulcer report from 3/31/12 to 4/6/12. E4 stated "we did not consider the wounds as pressure ulcers, I consider the wounds were from shearing." R2's pressure ulcer care plan dated 1/17/12 addressed R2's blister to the left inner thigh of 4/2/12, but did not address R2's right inner knee wound of 4/10/12. There were no interventions in place to alleviate direct pressure to R2's knees to prevent skin breakdown. Facility Wound or Pressure Sore Identification Policy states: It is the policy of the facility to ensure that residents admitted to the facility without pressure sores will not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable. The policy further requires that residents identified with Acquired Pressure Ulcer shall have the following investigative protocol: Comprehensive Assessment, evaluate the resident's clinical condition and pressure ulcer risk factors, define and implement interventions that are consistent with resident's needs, resident's goal and recognized standard of practice, monitor and evaluate the impact of the interventions and revise the approaches as needed. On 4/11/12 at 10:00 AM, E4 stated that she did not do a comprehensive skin assessment as required per policy.

Based on observation, record reviews and interviews the facility failed to follow manufacturer's operating instructions to ensure a safe transfer for 1 (R1) of 5 residents reviewed for falls, with the use of a mechanical lift. This failure resulted in the mechanical lift tipping over while transferring R1 from wheelchair to bed on 9/5/11. R1 sustained an injury to the right leg that required hospitalization and surgery. R1 was diagnosed in the hospital with right hip fracture. Findings include: R1 has multiple [DIAGNOSES REDACTED]. R1's quarterly MDS (Minimum Data Set) dated 8/11/11 indicated that R1 has good recall and was oriented to the month and day of the week. The same MDS indicated that R1 required total dependence x two or more persons physical assist during transfers. R1's fall risk care plan dated 8/22/11, indicated that the resident uses a full body sling and a mechanical lift with 2 person assist with all transfers. R1's fall risk evaluation dated 8/11/11 reflects a score of "9", indicating that the resident is a moderate risk for fall. R1's weight log calendar indicated that the resident weighed 206 pounds on 9/3/11. On 11/22/11 at 1:20 PM, R1 was observed in bed, awake, alert and verbally responsive. R1 was noted to be leaning on her left side. On an interview held at the time of this observation, R1 stated that she has weakness on the right side of her body and she leans towards the left side of her body. R1 stated that she remember her fall from the lift but was not able to give detailed information. R1's occurrence report dated 9/5/11 (10:10 PM) reflects, "While transferring resident with mechanical lift - mechanical lift tipped over to right side & fell with resident in mechanical lift. CNA (Certified Nursing Assistant) her her head so it wouldn't hit the bed or floor. resident c/o (complained of) severe right hip pain." The facility's follow up investigation of the accident dated 9/8/11, indicated that on 9/5/11 at 9:45 PM , two (E4 and E5) CNA's were transferring R1 with a full body sling from her electric wheelchair to bed with the mechanical lift. Both staff (E4 and E5) stated that the 2nd loop of the sling was used to attach the sling to the mechanical lift and that they double checked to make sure it was the same on all sides. The investigation report indicated, "#1 C.N.A stated that she proceeded to move the mechanical lift with the resident in the sling toward her bed. #2 C.N.A stated that she held on to the straps on the back of the sling because and to address the fact that R1's disabilities cause her to naturally lean to the left. #1 C.N.A attempted to move the mechanical lift under the bed at which point the other C.N.A yelled stop she is slipping. #1 C.N.A pulled the mechanical lift backwards slightly to clear of the bed and when she did so the mechanical lift began to tip to the left side and R1 landed on the floor on her right side in the sling still attached to the top of the Hoyer." The investigation indicated that the nurses' came and assessed R1. "They observed R1 on the floor on her right side still in the sling with the mechanical lift lying on its left side. R1 was alert and oriented x 3 she denied hitting her head. The staff together unhooked the sling and positioned R1 in the supine position. The RN performed a physical assessment. Vital signs: B/P 145/80 P 98 R 24 T 97.9. R1 complained of pain with range of motion to her right leg. An obvious deformity was noted to the right leg. 911 were called and R1 was transported at 10:28 PM by the paramedics via ambulance in stable condition." Further review of the investigation report indicated that R1 arrived at the hospital ER (emergency room ) with a shortened and internally rotated right leg. An x-ray was taken at the hospital ER showing a mid shaft fracture of the right femur. R1 was admitted to the hospital and a surgery was performed to repair the fracture of her right femur using trochanteric nailing. On separate phone interviews held on 11/22/11 at 3:00 PM and at 4:35 PM , E4 stated that she was not the assigned CNA to take care of R1 on 9/5/11. Per E4, between 9:00 and 9:30 PM, R1 requested to go back to bed. Since R1's assigned CNA was not available, she (E4) and another CNA (E5) attempted to transfer R1 from her electric wheelchair to bed. According to E4, R1 had specific instructions as to how she (R1) wanted the staff (E4 & E5) to assist her, which they followed. Per E4, they hooked R1 on to the mechanical lift, lifted the mechanical lift and moved the lift with R1 on it towards the bed. E4 stated that during this procedure the base of the mechanical lift was wide open, she was at the control, steering the lift while E5 was on the left side of R1 guiding. Per E4, when the mechanical lift was near R1's bed, she readjusted the spread of the base by closing it, to make the base of the mechanical lift fit under R1's bed, "I closed the base to push the lift, to get under the bed, we pushed a little, then the lift tipped with R1 still on it. The lift tipped over to my left side, which was R1's right side." According to E4, she attempted to protect R1's head from hitting the bed frame and the floor, so she went down with the resident, subsequently injuring her left collar bone in the process. Per E4, the mechanical lift did not malfunction but had tipped over, after she readjusted the spread of the base to a close position to fit under R1's bed. On 11/23/11 at 9:40 AM, E2 (Assistant Administrator) and E3 (Director of Nursing) was informed of E4's interview. E3 stated that all facility nursing staff were aware that the base of the lifts should be kept on a wide position for stability. E3 also stated that E4 and E5 should have stopped the transfer procedure and checked why the base of the mechanical lift cannot fit under R1's bed, instead of, closing the spread of the base. During an observation made on 11/23/11 at 10:00 AM, R1 was in bed, alert, oriented and verbally responsive. With R1's permission, E3 attempted to wheel the base of an empty mechanical lift under R1's bed. After E3 readjusted the height of R1's bed. E3 was able to place the mechanical lift base under R1's bed without any problem and or difficulty. Review of the manufacturer's manual entitled, "How To Use A Patient Lifter. A Positioning and Transfer Guide" indicated on page page 5, "To reduce the hazard of tipping over, spread adjustable base lifters to their widest position before lifting anyone." Review of the Hydraulic Patient Lifters's user manual, under operating instructions located at page 7, "WARNING Lifters can tip over. Keep base widened for stability."