Every finding on record at Sunrise Skilled Nur & Rehab

Based on interview and record review, the Facility failed to follow its abuse policy by reporting and investigating all allegations of abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.Findings include:1.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and delusional disorder.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, used wheelchair and was dependent for transfer.R2's Hospital Records dated 12/6/25 documented R2 expressed concerns of sexual abuse in the Facility and requested transfer to a different facility after hospital discharge.The Facility's Statement dated 12/8/25 at 2:00 PM documents V5, Case Manager, contacted the Facility regarding an allegation made at the hospital.On 12/10/25 at 12:00 PM, V1, Administrator, stated V5 notified the Facility of R2's sexual abuse allegation in the hospital. R2 made a similar allegation back in May 2025 that was reported and investigated but this allegation was not reported and investigated due to being an old allegation.On 12/10/25 at 1:15 PM, V5 stated she informed V2, Director or Nursing (DON), of R2's sexual abuse allegation, and V2 stated R2 had a similar allegation back in May. V5 stated R2's allegation happened two to three weeks prior to hospitalization while in the Facility, and R2 was unsure of the perpetrator's identity. On 12/10/25 at 2:49 PM, V4, Hospital Social Worker, stated R2 reported she was sexually abused while sleeping in the Facility two or three weeks prior to hospitalization and was unsure of the perpetrator's identity. V5 reported this to the Facility, and V2 told V5 this allegation had been reported before.On 12/10/25 at 3:30 PM, V2 stated they did not report and investigate R2's allegation of abuse, as the same allegation was previously reported and investigated.On 12/15/25 at 8:47 AM, V1 stated she expects the Facility to follow its abuse policy regarding reporting and investigating abuse. The Facility's Abuse Policy revised 1/9/24 documents, The facility immediately and thoroughly investigates all allegations of abuse to include but not limited to interviews or {sic} residents and staff, visitors, Vendors. The facility will timely report all allegations of abuse Initial/Final to IDPH according to the state and federal guidelines. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on interview and record review, the Facility failed to report allegations of abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.Findings include:1.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and delusional disorder.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, used wheelchair and was dependent for transfer.R2's Hospital Records dated 12/6/25 documented R2 reported sexual abuse while in the Facility and requested transfer to a different facility upon discharge.The Facility's Statement dated 12/8/25 documents V5, Case Manager, contacted the Facility regarding an allegation made by R2 at the hospital.On 12/10/25 at 12:00 PM, V1, Administrator, stated V5 notified the Facility of R2's sexual abuse allegation that was made during her recent hospitalization. V1 stated R2 made a similar allegation back in May 2025 that was reported, but this allegation was not reported due to being the same allegation that was previously reported.On 12/10/25 at 1:15 PM, V5 stated she informed V2, Director of Nursing (DON), of R2's sexual abuse allegation that was made in the hospital, and V2 stated R2 had a similar allegation back in May. V5 stated R2's allegation of sexual abuse reportedly occurred two to three weeks prior to hospitalization, and R2 did not know the perpetrator's identity. On 12/10/25 at 2:49 PM, V4, Hospital Social Worker, stated R2 reported she was sexually abused while sleeping in the Facility two or three weeks prior to hospitalization and was unsure of the perpetrator's identity. V5 reported this to the Facility, and V2 told V5 this allegation had been reported before.On 12/10/25 at 3:30 PM, V2 stated they did not report R2's allegation of abuse, as it was previously reported.On 12/15/25 at 8:47 AM, V1 stated she expects the Facility to follow its abuse policy regarding reporting of abuse. The Facility's Abuse Policy revised 1/9/24 documents, The facility will timely report all allegations of abuse Initial/Final to IDPH according to the state and federal guidelines.

Based on interview and record review, the Facility failed to investigate allegations of abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.Findings include:1.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and delusional disorder.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, used wheelchair and was dependent for transfer.R2's Hospital Records dated 12/6/25 documented R2 reported sexual abuse in the Facility and requested transfer to a different facility upon discharge.The Facility's Statement dated 12/8/25 documents V5, Case Manager, contacted the Facility regarding an allegation R2 made at the hospital.On 12/10/25 at 12:00 PM, V1, Administrator, stated V5 notified the Facility of R2's sexual abuse allegation that was made during her recent hospitalization. V1 stated R2 made a similar allegation back in May 2025 that was investigated but this allegation was not investigated due to it being the same allegation that was already investigated. On 12/10/25 at 1:15 PM, V5 stated she informed V2 of R2's sexual abuse allegation, and V2 stated R2 had a similar allegation back in May. V5 stated R2's alleged sexual abuse occurred two to three weeks prior to hospitalization, and R2 did not know the perpetrator's identity. On 12/10/25 at 2:49 PM, V4, Hospital Social Worker, stated R2 reported she was sexually abused while sleeping in the Facility two or three weeks prior to hospitalization and was unsure of the perpetrator's identity. V5 reported this to the Facility, and V2 told V5 this allegation had been reported to them before.On 12/10/25 at 3:30 PM, V2 stated they did not investigate R2's allegation of abuse because it was previously investigated.On 12/15/25 at 8:47 AM, V1 stated she expects the Facility to follow its abuse policy regarding reporting and investigating abuse. The Facility's Abuse Policy revised 1/9/24 documents, The facility immediately and thoroughly investigates all allegations of abuse to include but not limited to interviews or {sic} residents and staff, visitors, Vendors.

Based on Interview, and Record Review, the facility failed to properly transfer 1 of 4 residents (R2), reviewed for appropriate safe transfers in the sample of 4. This failure resulted in R2 having a fall, sustaining a right hip fracture and ultimately passing away. The Findings Include: R2's admission Record, dated [DATE], documents R2 was originally admitted to the facility on [DATE] and was discharged on [DATE] with diagnosis of Cerebral Atherosclerosis, Dementia, Anemia, Hypertension, Atherosclerosis of Aorta, Generalized Anxiety Disorder, Major Depressive Disorder, Abdominal Aortic Aneurysm, Osteoporosis, Disorders of bone density and structure, Personal history of (healed) traumatic fracture left humerus.R2's Care Plan, dated as complete on [DATE], documents R2 has a Self-Care Deficit as Evidenced by: Needs max to dependent assistance with functional abilities related to dementia, history of fracture, impaired balance, pain, weakness, limited mobility. Interventions: Transfer: two-person physical assistance required, Bed Mobility - two-person physical assistance required, Toilet Use: two-person physical assistance required, Out of Bed Positioning: Sits in wheelchair.R2's Care Plan, dated [DATE], documents R2 has a history of self-transferring. Interventions: Provide support during transfers. It continues R2 is at risk for falls related to impaired mobility, requiring extensive assistance with transfers. Interventions: [DATE]: (full body mechanical lift device) with two assists, keep call light within reach, keep environment clutter free, keep personal belongings within reach, provide adequate lighting, (non-slip pad) for chairs, provide/reinforce use of non-skid footwear, [DATE] low bed, [DATE] mat at bedside, [DATE] night light placed in room. It continues R2 Self-Care Deficit as Evidenced by: Needs max to dependent assistance with functional abilities. Interventions: [DATE] Bed Mobility - two-person physical assistance required, [DATE] Transfer: (full body mechanical lift device) transfer with two assists.R2's Minimum Data Set (MDS), dated [DATE], documents R2 had a severe cognitive impairment and was dependent on staff for all Activities of Daily Living (ADLs).R2's Hospice admission Note, dated [DATE], documents to admit R2 to (Local Hospice) with diagnosis Cerebral Atherosclerosis.The Facility's Fall Log for the past three months, documents R2 had a fall on [DATE].R2's Fall Risk Assessment, dated [DATE], documents R2 was a High Fall Risk. R2's Fall Occurrence Note, dated [DATE] at 6:24 PM, documents Incident Description: While Certified Nursing Assistant (CNA) was transferring resident she began to buckle her legs, so CNA stated she lowered her safely to the floor. Resident statement on what was being attempted when fall occurred N/A. Resident Description of Fall: unable to give statement. Date/Time of Incident: [DATE] at 5:20 PM. Resident is alert. Residents Orientation: Person, Resident Is Exhibiting Usual Level of Orientation. Vitals: BP (blood pressure) -120/67, T (temperature) -98.2, P (pulse) -75, R (respirations) -16, SPO2 (oxygen saturation) -95. Injury Observed: Skin tear to the right elbow. Physician/Provider notified, Resident Representative notified; Resident Son, DON (Director of Nursing) notified.R2's Fall Investigation, dated [DATE], documents Incident Description: Writer was notified by CNA that resident was on the floor. CNA stated that while she was transferring resident, she had buckled her legs, and she was unable to hold resident and had to safely lower her to the floor. While lowering her to the floor, resident did hit her right elbow on the railing resulting in a skin tear. Description of Action Taken: Resident was transferred from floor to wheelchair via (full body mechanical lift device). Skin tear assessed, cleaned and treated. Note Text: IDT (interdisciplinary team) met to discuss this resident lowering to the ground. Staff was transferring resident into bed from wheelchair when her knees buckled. Aide states that resident then grabbed on to her and she lowered her to the floor. Nurse was notified and immediately assessed. MD (medical doctor) and POA (Power of Attorney) aware. Resident has a skin tear noted to her R (right) elbow. Elbow was cleaned and dry dressing applied. Wound nurse to follow. Will monitor until healed. Resident originally denied of pain initially, but the next day started to c/o (complain of) pain to the left leg. MD made aware, POA present, hospice aware - orders received for order and x-ray. PRN (as needed) Morphine utilized. Resident was assisted off floor and assisted to bed. Staff aware resident will now be a (full body mechanical lift device) lift. Padding to side rail placed for increased protection. CP (care plan) updated. No Fx. (fractures) noted, all parties aware.R2's Nursing Note, dated [DATE] at 12:56 PM, documents Resident's son is here and is concerned about the resident's complaints of pain to the left leg, explained that she had Tylenol this am and that she had not complained at all until the hospice CNA was here and bathed her yesterday and she was given morphine at that time. When this nurse asked the resident about pain this am she denied need for pain medication until the CNAs were removing her from the dining room, and she started complaining of pain to her left leg at that time and Tylenol was given and resident was returned to bed. No noted deformities or bruising noted to the leg. Morphine given at 1250 (12:50 PM) today. Discussed that hospice nurse was going to call him last evening and he reported that she did call and stated that he didn't feel that there was anything to gain by obtaining an X-ray as there is not anything they would do to treat an injury such as a fracture, so he feels that it is best to keep her comfortable at this time. Will monitor and update as needed.R2's Nursing Note, dated [DATE] at 3:19 PM, documents Order received for X-Ray of left hip, left knee, and left femur.R2's X-Ray report, dated [DATE], documents R2's x-rays of Left Hip, Pelvis, Left Femur, and Left Knee all showed Negative Fractures. It continues with R2's Pelvis: Examination reveals mild demineralization and degenerative arthritis changes with left hip pinning and flexion deformity of the right hip with follow-up examination of the right hip to adequately evaluate the right femoral neck and no evidence of recent fracture or dislocation.R2's Nursing Note, dated [DATE] at 5:24 PM, documents Resident had x-rays done by (local radiology company) @ (at) 1212 (12:12 PM) of left hip, pelvis, femur, and knee with no findings of fracture or dislocation noted. Spoke with son (V5) and informed him of findings. Resident seems to be having pain and tugging on left thigh. PRN (as needed) Morphine is being administered as needed. Will fax report to Dr. (doctor) for further advise. Will continue to monitor Resident.R2's Hospice Note, dated [DATE] at 3:15 PM, documents Writer notified by hospice aide of change in resident status, sounds congested and gurgling. writer checked vitals and called hospice nurse requested a call back.R2's Hospice Note, dated [DATE] at 5:08 PM, documents Writer went to assess resident and get new VS (vital signs) and found the resident had passed away. Writer called hospice again to find out why there was no return call from hospice or a visit, and to notify of death. On-call placed a stat (emergent) visit with on-call nurse, writer also informed them to notify family and start calls for notification. R2's Death Certificate, dated [DATE], documents R2's cause of death include Pulmonary Thromboembolism, Deep Vein Thrombosis, and Fracture of Right Hip. R2's Autopsy Report, dated [DATE], documents in part Findings: 1. Pulmonary thromboembolism due to deep vein thrombosis as a consequence of fracture of the right hip: A. Thromboemboli occluding branches of the left pulmonary artery. B. Thrombosis of deep veins in the soft tissues of the right hip. C. Pulmonary edema. D. Fracture of the right femoral neck. E. History that the decedent reportedly suffered a ground level fall on [DATE]st, 2025, while she was being transferred from a wheelchair to her bed. Conclusion: Based on the information available to me, and on the autopsy findings, it is my opinion that (R2), an [AGE] year-old, white woman, died as a result of pulmonary thromboembolism due to deep vein thrombosis as a consequence of fracture of the right hip. Hypertensive and arteriosclerotic cardiovascular disease is a significant contributingcondition.On [DATE] at 1:20 PM, V6, Executive Director at (Local Hospice), stated that the Hospice Nurse was not available but documented that R2 had a fall and was complaining of pain to her left leg. V6 stated when the hospice nurse went to assess R2, R2 was sound asleep and when she attempted to put a BP cuff on her, R2 yelped a little, then went back to sleep with VS stable at that time. V6 stated the facility called Hospice to notify them of R2's x-rays which were negative with no acute fractures seen. V6 stated the hospice nurse did talk to the coroner and tell him that R2 had a recent fall, and the coroner refused to release the body until he got to the facility to assess the situation. On [DATE] at 1:42 PM, V7, (Local County) Coroner, stated that the Hospice company flagged him to investigate R2's death because they believed that R2 had a fracture from a recent fall. V7 stated they did an autopsy on R2, and the Pathologist found a right hip fracture on R2. V7 stated R2 was previously x-rayed by an outside company and those x-rays were negative. V7 stated that he believes that R2's Death Certificate showed an accidental death due to complications from a fall. V7 stated usually a hospice person does not get an autopsy, but when he got the heads up on R2 that something was not right, he felt like he had to investigate it further. V7 stated the Pathologist told him that R2's right hip was a new and fresh fracture.On [DATE] at 1:50 PM, V15, Physician/Medical Director, stated he took care of R2 up until she was placed on Hospice. V15 stated R2 was on hospice/comfort care only and the goal was to keep her comfortable. V15 stated if the family wanted R2 to be on an anticoagulant (AC) or to have surgery, they could have done so, but her hospice would have been retracted. V15 stated he understands the pathologist findings, however, R2 had several other co-morbidities that he feels contributed to her death, such as severe dementia which could have caused her to fall more. V15 stated he would not have done anything but make her comfortable if he had found out she did indeed fracture her hip during that fall.On [DATE] at 2:19 PM, V14, Pathologist, stated he was only advised that they were doing an autopsy on R2 because she had a recent fall, days before her death. V14 stated when he moved R2 over to the autopsy table, that R2's right leg appeared shortened and was rotated outward, and to him appeared to be a fractured hip. V14 stated because of that, he cut open R2's right hip and visibly saw the fractured right femoral neck (hip). V14 stated as he proceeded with the autopsy, he found that R2 had embolisms around her fractured right hip and numerous DVTs of her legs, usually from immobilization. V14 stated he proceeded with R2's lungs and found she had Thromboemboli that were occluding the branches of her left pulmonary artery. V14 stated that it sounds reasonable that R2 could have fallen on her left side, but since that was already pinned from previous fracture, that the force caused her right side to fracture. V14 stated in his professional opinion, R2 was on hospice, a very frail woman, and had a fall with a fractured hip, developed a DVT and a pulmonary embolism, which all contributed to R2's death. On [DATE] at 8:55 AM, V10, CNA, stated I have taken care of (R2) before and I remember that she was a (full body mechanical lift device) transfer towards the end of her stay here. Before that, she was a two-person transfer assist and would stand and pivot for us. I would not have transferred (R2) by myself, she always needed two people to transfer her.On [DATE] at 10:31 AM, V5 (R2's son) confirmed, that should he have been aware that R2 had suffered a right hip fracture, his goal most likely would have been for R2 to just remain comfortable and receive pain control in response to her hip fracture. V5 state he had been in contact with hospice service regarding if he wanted R2 to remain under hospice care or seek hospital and additional medical treatment. V5 stated it was decided they would wait and see what the x-rays showed and how R2 was doing, then decide from there. V5 stated he was never given the opportunity to make that choice as R2 expired approximately one week after the fall. On [DATE] at 12:57 PM, V18 (Hospice Physician) stated that he was the physician caring for R2 under Hospice care. V18 stated that he believes he was notified of the x-ray results but cannot specifically recall if he personally viewed them as they may have just been sent to the fax machine. V18 stated that if a resident under hospice care suffers a fracture, generally pain management is the treatment of choice. V18 stated that if a fracture is unstable or the resident is experiencing pain that is not resolved with medication, other treatment may be recommended. V18 stated that this would be a treatment plan that would need to be discussed between the resident and/or their representative, along with the hospice team. V18 stated more extensive testing, such as for emboli would not be generally completed under hospice care. V18 stated it should also be noted that decreased mobility a hospice resident can result in embolism formation even without a fracture, although he recognizes a fracture would increase the risk. V18 stated to his knowledge the facility responded appropriately by providing effective pain management to the resident, who remained under hospice care until her death. The Facility's Fall Prevention Program/Protocol Policy, dated [DATE], documents in part Purpose is to provide guidance to facility staff regarding the prevention/limitation of falls within the facility. Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview and record review the Facility failed to ensure residents were supervised to prevent accidents for 1 of 3 residents (R2) reviewed for falls in the sample of 5. This failure resulted in R2 being left unsupervised in bed in the high position on a low airloss mattress causing R2 to fall from the bed sustaining multiple fractures to both legs.Findings include: R2's July 2025 Physician Order Sheet (POS) document a displaced comminuted fracture of shaft of left fibula subsequent encounter for closed fracture with routine healing (dated 7/28/2025); osteomyelitis of vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus without complications, unspecified fracture of lower end of left tibia, subsequent encounter for closed fracture with routine healing (start date 7/28/2025), unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing (start date 7/28/2025); displaced fracture of second metatarsal bone right foot, subsequent encounter for fracture with routine healing (start date7/28/2025); muscle wasting and atrophy; abnormalities of gait and mobility; other lack of coordination; Fournier gangrene; cutaneous abscess of back; local infection of the skin and subcutaneous tissue; unspecified fracture of right calcaneus sequela, renal osteodystrophy; end stage renal disease; and weakness. R2's Minimum Data Set (MDS) dated [DATE] document R2 was cognitively intact for decision making of activities of daily living. R2's MDS documents R2 has impairments on both sides, uses a wheelchair, and is dependent on staff for most Activities of daily living and has two stage 3 pressure ulcers. R2's MDS documents for him to roll from left to right he is dependent on staff; helper does all of the work. R2‘s Care Plan with a Target Date of 10/26/2025 does not address falls.R2's Follow Up Occurrence Note dated 7/11/2025 at 9:00 AM, Note Text: Incident Note: Resident on floor. Says he rolled out of bed. Denies hitting head. Neuro check WNL (within normal limits). VSS (vital signs stable). Says he has pain to rt (right) elbow and rt (right) and lt (left) ankles. No new skin issues. ROM (Range of motion) present to all extremities as per resident normal. Resident moved rt arm bending at elbow and both ankles rotated per resident. Nurse Practitioner here and saw resident post fall. Extra Norco ordered to be given for c/of (complaint of) of pain. Nurse Practitioner also said to send an extra Norco to Dialysis with resident per his usual request when going to Dialysis. Resident gotten up off floor with mechanical lift per staff. R2's Investigation does not address the root cause of his fall (lack of supervision).R2's Progress Notes dated 7/11/2025 at 4:32 PM, Note Text: Resident called facility driver to tell him he is in the ER (emergency room) and was sent from dialysis. Writer called ED (emergency department) who confirmed resident was there and was sent over for L (left) ankle pain. They confirmed that there was a L (left) tibia fracture and that they are awaiting ortho to consult to determine if they will admit or splint and send back tonight. PCP (primary care physician) and wife made aware.R2's Progress Notes dated 7/11/2025 at 6:49 PM, Note Text: Writer called for update- res (resident) will be admitted for fx (fracture). They don't know if he will need surgery yet or not.R2's Verification of Incident Report date of incident 7/11/2025 at 9:00 AM, Resident rolled out of bed at 9 AM. Resident sent to ER (emergency room) there. ER was called for a status updated and was made aware of fractures. Immediate Action: Nurse Practitioner in building and assessed. Extra dose of Norco provided for pain management. Bolsters added to resident mattress. POA (Power of Attorney), IDPH and Ombudsman notified. Summary of investigation: Resident had a fall after rolling out of bed. Resident was seen by the wound nurse and wound NP prior to rolling out of bed. Resident was ready to get up for the day, wound nurse notified CNA (Certified Nurse's Assistant) that resident was ready to get up. When aide entered room, resident was observed on the floor. CNA notified nurse who immediately assessed. No altered skin integrity noted. Does complaint of pain to right elbow and right ankle. Resident was able to move all extremities himself with no issues, rotated ankles and moved his arms and bending them at the elbows, resident denies hitting his head. Wife was present in the room at the time of the incident and states he did not hit his head. Resident was assisted up off the floor with (mechanical lift). Placed in bed, aid got him ready for dialysis then assisted to wheelchair via (mechanical lift). Primary care NP (Nurse Practitioner) was making rounds, who also assessed resident. NP ordered an extra dose of Norco to be given and ordered for one to be sent with resident to dialysis. Resident lays on a low loss mattress, and when he rolled over, the air in the mattress went to the opposite side, causing him to roll out of bed. Bolsters were placed on air mattress for boundary awareness and as a safety intervention. CP (Care Plan) updated. Transportation driver reported that the resident had no complaints on the ride to dialysis. Once at the dialysis, resident complained of pain to BLE (bilateral lower extremities), dialysis then sent resident to the ED (emergency department). Nurse called the ED for status update, and they confirmed resident did have a fracture of the left and right distal tibia as well as the 2nd metatarsal. Resident was admitted to the (hospital) for further evaluation.R2's Hospital Records dated 7/11/2025 R2 had a mechanical fall and suffered from an acute left distal tibial diaphysis fracture; Acute left distal fibular fracture; Acute fracture of the distal right tibial diaphysis and acute fracture of the neck of the 2nd metatarsal of the right foot and was admitted to the ortho bed and neurology was consulted for management. R2's Progress Notes dated 7/25/2025 at 7:04 PM, Note Text: Resident returned from Hospital. Resident asked to lay dawn. Resident was (mechanical lift) into bed with assist of 2. Resident became very agitated and yelled hey watch my legs! Don't move them! Resident is in the sling appropriately, staff guided him into bed. Was provided by reassurance in a calming voice by nurse in room and let resident know that he is safe and ok. Resident hollered no it's not ok!On 7/29/2025 at 4:00 PM, R2 stated, I use to be at another facility and at that facility I developed wounds on my back and buttocks. When I got here, two staff members, I am not sure of their names came into my room to change my dressings. They had me roll to the side and slide down so they can get to the wounds better. They pulled me towards the end of the bed and had me roll to my left side. After the nurse was done, she left the room. The other staff (not sure of her name) she was changing the linen because of the drainage from the wound, and I was still laying on my left side and the bed was high up in the air because they just finished doing the treatment. The girl changing the sheets said she needed a draw sheet because it was dirty from the wound draining on it. She said she would be right back. I was holding on to the bar and was on my left side waiting. The staff left the room, but I waited as long as I could, and I just could not hold on any longer and when I let go, I fell from the bed being up high in the air to the floor. I just couldn't hold on any longer. I think the staff forgot about me. They came back and put me on one of those (mechanical lifts) and put me back into the bed. I was in a lot of pain. My wife shared a room with me, and she saw the whole thing too. I was in the hospital for two weeks and had 2 breaks in the right leg and one break in the left leg. Both of my legs were broken. I get dialysis on Mondays, Wednesday and Friday. I feel like they should not have left me like that and should have sent me to the hospital right away. They gave me some pain medicine but when I got to dialysis it was so bad they sent me out to the hospital and that is when I found out I had broken both of my legs. On 7/29/2025 at 4:12 PM, R4, wife and roommate of R2, stated I was in the room at the time they were treating (R2), and he fell out of bed. The nurse left the room as soon as (R2's) treatment was done. They were changing (R2's dressing). When the nurse was done, she left the room. The other girl was changing the sheets. (R2) was on his side and was holding on to the bar. The girl left the room, and she said she would be right back but (R2) waited and waited and he could not hold on any longer and the bed was up really high, and he fell and broke both of his legs with one leg have two fractures. After he fell, they came in and used that machine to put him back into bed and then later the Nurse Practitioner came and looked at him and gave him pain medication.On 7/30/2025 at 10:42 AM, V8, Hospital Social Service Worker stated, (R2) was admitted to the hospital on [DATE] and he had an extended admission and was not discharged until 7/25/2025. So, he was here for a while. I was the consultant towards the end of this visit and (V9, Palliative Care Social Worker) was with him when he was first admitted . (R2) told me he had a pressure ulcer on his back and buttocks and was receiving care from the wound Nurse and they had his bed high in the air. (R2) stated he was rolled to his side, and he grabs onto the side rails. The lower rail was missing on the bed. The Nurse member left the room because she was done with the treatment. The agency staff told him she would be right back because she was changing the sheets and needed a drawsheet and left the room with him on his side, no lower bed rail and she did not reposition him. He said he waited and waited but she did not come back, and he could no longer hold on and he fell from the bed in the high position to the floor.On 7/30/2025 at 11:01 AM, V9, Hospital Palliative Social Worker stated, When I first saw (R2) at the hospital he told me they were doing a dressing change on him, and he had rolled to his side and was holding on to the side rail. The bed was in the high position because of the treatment. The bottom side rail was missing on the bed. He said the nurse had finished the wound treatment and the agency CNA was cleaning up the sheets and she did not put him back on his back, and she told him she would be right back and left the room because she wanted to get a drawsheet. His wife was in the room with him. The CNA did not come back and (R2) said he became weak and could not hold on any longer and he fell off the bed between the bed and wall. Staff then came in and checked on him and even the NP came in to see him. They asked him if he was hurt and put him in a (mechanical Lift) and transferred him to his wheelchair, gave him some pain medicine and eagerly rushed him off to dialysis. (R2) said he was in shock and when he got to dialysis the nurse there said his color was off and asked if he was feeling okay and he said he was in a lot of pain and had fallen and they sent him to the hospital where he was admitted . (R2) had two broken legs, 2 breaks in the left leg, and one break in the left leg.On 7/30/2025 at 11:48 AM, V2, Director of Nursing stated, (V7, Registered Nurse, RN) was the person responsible for (R2's) fall report. She wrote it up and investigated. I know we asked (R4, wife and roommate) if (R2) had hit his head and she said no. I was not present at the time of the fall. I know the Nurse Practitioner (V18) was here and she went and put eyes on (R2) so we could do an intervention, and we put boosters on his bed. That is all I know you will have to talk to (V7). If staff are doing treatment and put the bed up, I would expect staff to put the bed down after the treatment is finished. I would expect staff to never leave any resident unattended or left laying on their side. I would expect staff to reposition the resident, so they are safe, go and get what they needed and then return. I would not expect staff to leave a resident with the bed up, laying on their side. This is the first I am learning of it.On 7/30/2025 at 11:47 AM, Dialysis center called back and read V10's, Dialysis Center's Registered Nurse, RN, notes from that day. The notes document, Patient arrived to dialysis with complaints for pain to BLLE (bilateral lower extremities). Patient stated he fell out of bed prior to coming to the facility and the bed was elevated. Pain too high to do treatment. EMS (emergency medical services) called to transport. 911 was called. On 7/30/2025 at 2:13 PM, V10, Dialysis RN stated, We got a call from the (Facility) telling us (R2) had fall and that he was still going to make his appointment. When (R2) arrived, he was grimacing, and I could tell he was in a lot of pain, so I called 911 just to be safe.On 7/30/2025 at 12:56 PM V7, Registered Nurse, RN/Floor Nurse stated I am the one that made the incident report for (R2's) fall. I did ask (R2) and (R4) because they share a room if (R2) hit his head and they said no. I did not get any statements from them. It's all in the report. I remember the CNA came and got me and told me (R2) was on the floor and she said he had rolled out of bed. I went and assessed him, and he said he was having pain in his arm and ankle. I got another CNA, and he said he could move his ankles. We used the (mechanical lift) and put him back into his wheelchair. I asked him if he was hurting anywhere else and he said he was alright. He then said he didn't feel like going to dialysis and I told him it was important not to miss any days. We then sent him out to dialysis, and I found later he had injured himself. Nobody ever told me anything else. I didn't get any written statements from anybody. I just thought he fell out of bed.On 7/30/2025 at 1:26 PM, V4, Agency Certified Nurse's Aide, CNA, stated, We were passing out breakfast trays. The Wound nurse was in (R2's) room providing treatment and then she walked out. I grabbed the breakfast tray and asked the Wound Nurse if they were done. I asked her if she could give (R2) his food. I looked in the room a little later and no staff was in the room. The resident was laying on his left side and the bed was not down and was high up and even then, I knew he was a fall risk. The Wound Nurse was not in the room, and he was in up high, and I went to try and find the Wound Nurse and she was on her phone on the other hall. Then I heard a loud help, help and help. I saw the wound nurse and asked why she would leave the bed all the way up and he fell, and he was yelling. The Wound nurse left the bed all the way up, and the other nurse and I said why would she do that. The Wound Nurse was the last one in the room. Why did she tell him to hold on to the bed? The Wound Nurse was the last person in that room. Me and the other CNA found him on the floor.On 7/30/2025 at 2:14 PM, V16, CNA stated, I was working the day (R2) fell. (R2) had just had his wounds done. The Wound Doctor and the ADON (Assistant Director of Nursing) were doing the treatments. His bed was up high, and he was on his side. His wife was in the room too. Me and (V4) found (R2) after he had fallen. The bed was still up high. (V7, Registered Nurse/Floor Nurse) came and assessed him and looked him over. We were told to use the (mechanical lift) and put him in his wheelchair. He said he was in a lot of pain. (R2) did not want to go to dialysis. The Nurse Practitioner told him how important dialysis was for him and send him some pain medicine to take with him because he said he didn't want to go and was hurting. She said he might have some bruising and would be sort and she sent him some pain medication. On 7/31/2025 at 9:50 AM, R2 was wearing plastic splints/boots with Velcro on the side that goes up to the knee on both legs.On 7/31/2025 at 3:32 PM, V6, Medical Director stated, I would expect staff to always lower residents' bed after raising the bed. I am not sure how (R2) landed but I know he did have some broken bones. No fall is ever good for any resident. The bed should always be lowered. On 7/31/2025 at 3:11 PM, R2's bed was placed in the high position with V17, Maintenance Director and the V3, Assistant Director of Nursing, ADON. The bed was measured from the high position to the floor and measured 36 inches. R2's bed has a low air mattress on it.On 7/31/2025 at 3:12 PM, R2 was asked if the (V3) was the staff that left him alone in the room with his bed high and said she would return and he replied no, he thinks it was the agency CNA (certified nursing assistant). He was not sure, but it was not (V3). On 7/31/2025 at 3:13 PM, V3, stated, (V4) was the person in the room with us when we were doing treatment. This is the first I am learning the bed was high and (R2) was left lying on his side waiting for staff to return and he was not able to hold and a fell. I would expect staff to always put the bed down. (R2) has a remote so he can move his bed up and down. I did not realize staff left (R2) unattended and left the room.On 7/31/2025 at 4:12 PM, R2 stated that he fell from this bed with the same mattress, but after his fall the (Facility) added the bolsters.The Fall Policy with a revision date of 9/7/2023 documents, To provide staff with guidelines for investigating reporting and recording, Accidents and Incidents. All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. The MDS nurse shall update the Care Plan with implemented interventions and communicate interventions with line staff.

Based on interview and record review, the facility failed to obtain physician ordered laboratory testing in 1 of 3 residents (R2), reviewed for medication monitoring in the sample of 9. This failure resulted in R2 being admitted to the hospital on 5/8/25, where he remains. R2 was diagnosed in the hospital with Supratherapeutic INR (Initial Normalized Ratio) with a level greater than 10 (target range is between 2-3) and had to receive medication to reverse the effects from the anticoagulant, Warfarin, that R2 was receiving in the facility for a diagnosis of Pulmonary Embolism. This failure resulted in an immediate jeopardy when the facility failed to obtain laboratory testing to monitor R2's anticoagulant levels to ensure a therapeutic level was obtained. The Immediate Jeopardy began on 4/23/24, when the facility failed to obtain a PT(Prothromin Time)/INR to ensure a therapeutic level was obtained due to the use of an anticoagulant. On 5/21/25 at 9:35 AM, V1, Administrator, V7, Regional Director of Operations, and V8, Chief Operating Officer, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 5/22/25, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 5/20/25 at 10:30 AM, V5, R2's Sister, stated R2 is currently in the hospital preparing for surgery to remove a large cancerous mass in his intestines. V5 stated she is concerned about R2's Coumadin not being checked at the facility like it is supposed to be, it is to be checked weekly and hasn't been checked since March 2025. V5 stated when R2 was in the ER (emergency room ) his blood count was 3 and his INR which is supposed to be between 1-2 was greater than 10. V5 stated this is not acceptable and whoever is to be checking to make sure his INR is being checked failed, the bedside care and the nurses are good at the facility and have saved R2's life a few times, but this is unacceptable. R2's ER (emergency room ) Notes, dated 5/8/25, document R2's INR was greater than 10, R2 was started on Vitamin K and Kcentra (medication used to reverse the effects of Warfarin). Admit to ICU (Intensive Care Unit) for multiple problems, critically ill patient. Impression: Sepsis, Leukocytosis, GI (Gastrointestinal) Bleed, Elevated Lactic Acid Level, Elevated INR. R2's History and Physical, dated 5/8/25, documents the following: Impression - Acute Blood Loss Anemia, Probable GI Bleed, Supratherapeutic INR, Hx of PE. Reversal of Coumadin with Kcentra. R2's Hospital Laboratory Results, dated 5/8/25, document R2's Hgb (Hemoglobin) level was 3.8 (normal range is 14 - 18); PT (Prothrombin Time) level of greater than 80 seconds (normal range is 11.6-14.5); INR level of greater than 10 (normal range is 0.9-1.1 with a suggested therapeutic range of 2-3); FOB (Fecal Occult Blood) was positive. R2 received four blood transfusions on 5/9/25 and one on 5/13/25. R2's Final pathological diagnosis from the colon biopsies, dated 5/15/25, documents a colon/cecal mass that is an invasive moderately differentiated adenocarcinoma, the colon showed fragments of tubulovillous adenoma. R2's Colorectal Surgery Consult, dated 5/15/25, documents R2 has a history of DVT(Deep Vein Thrombosis)/PE on Warfarin, Hgb 3.8, Supratherapeutic INR greater than 10, reversal with Kcentra. admitted to ICU. EGD (Esophagogogastroduodenoscopy) and colonoscopy revealed a large cecal mass as well as a foreign body within the cecum, likely a bone. R2's Cardiology Consult, dated 5/17/25, documents R2 has a history of subsegmental PE (Pulmonary Embolism), admitted for acute blood loss anemia with a Supratherapeutic INR greater than 10. Continue holding Coumadin (Warfarin). R2's Face Sheet, Undated, documents R2 has a diagnosis of Pulmonary Embolism and Atherosclerosis of the Arteries of the Bilateral Lower Extremities. R2's Physician Order Sheet (POS), has the following orders: 3/6/25 Warfarin 6 mg (milligrams) every evening for Pulmonary Embolism and 4/23/25 Check a PT/INR (Prothrombin Time/Initial Normalized Ratio) weekly on Mondays. R2's Care Plan, dated, 9/23/22, documents R2 is at high Risk For Abnormal Bruising or Bleeding Related to Anticoagulant Therapy with Warfarin and an intervention to conduct therapeutic lab monitoring and report results as ordered by physician or anticoagulant clinic. R2's last PT/INR was completed on 3/26/25. There were no other PT/INR results completed after this date. A fax to V6, R2's Physician, dated 4/23/25, from V2, DON (Director of Nurses), documents that R2 had not had a PT/INR since 3/26/25 and V6 ordered a PT/INR to be completed weekly. On 5/20/25 at 11:50 AM, V6, R2's Physician, stated verified that he gave an order on 4/23/25 to check R2's PT/INR weekly. V6 stated R2 is on Warfarin and a residents therapeutic INR level is dependent on what they are on it for. V6 stated he would need to re-evaluate R2's Warfarin. V6 stated an INR of 10 is not ideal because it allows bleeding and could lead to a person bleeding to death. V7, RDO (Regional Director of Operations), stated V2, DON, identified a problem with the PT/INR's not being drawn so they did a past non-compliance, have in-serviced and are completing audits. On 5/20/25 at 12:49 PM, V2, DON, stated R2's PT/INR's should have been drawn weekly after 4/23/25 as they were routine. V2 stated R2 should have been drawn on 5/5/25 and wasn't. V2 stated she called the lab and was told that it wasn't drawn because there was no carbon copy with the lab requisition, but that it still should have been drawn. The Anticoagulant Policy/Procedure, dated 11/4/20, documents the following: The facility shall provide anticoagulation medications and perform surveillance as directed by the primary care physician and/or facility medical director. The Physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant, and/or monitor the PT/INR very closely while the individual is receiving Warfarin, to ensure that the PT/INR stabilizes within a therapeutic range. They physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. If Warfarin is used the staff should use a Warfarin flow sheet or come comparable means to follow trends in anticoagulant dosage and response in individuals on Warfarin. The Immediate Jeopardy that began on 4/23/25 was removed on 5/22/25, when the facility took the following actions to remove the immediacy: 1) Immediate actions taken for residents identified: R2 was hospitalized for Supratherapeutic INR on May 7th, 2025, and received medication to reverse the effects from the anticoagulant, Warfarin. An audit of all resident laboratory orders was completed on May 9th, 2025, by V2, Director of Nursing. An audit of all residents that have physician orders for Warfarin were identified and have active lab orders for PT/INRs to monitor for therapeutic effectiveness was completed by V2, Director of Nursing, on May 9th, 2025. 2) How the facility identified other residents who could potentially be affected: All residents have the potential to be affected by the alleged deficient practice. 3) Measures put into place/ System changes: Facility licensed nursing staff were educated by phone or in person in the following categories: Obtaining laboratory testing as ordered by the physician, with special consideration for those residents on Warfarin on May 9th, 2025, by V2, Director of Nursing. Audit of all scheduled labs was completed on May 9th, 2025, including PT/INRs by V2, Director of Nursing. Audit of all residents with Warfarin medication orders were ensured to have scheduled laboratory testing of PT/INRs to monitor for therapeutic effectiveness by V2, Director of Nursing on May 9th, 2025. V2, Director of Nursing, initiated a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary. Licensed agency staff will not work at the facility until they are educated by the Director of Nursing/Designee on the importance of ensuring PT/INR levels are ordered with Warfarin to monitor for therapeutic effectiveness. The facility will educate all Agency and Facility licensed nursing staff on a quarterly basis and during orientation on the order process for labs, with emphasis on the need for therapeutic monitoring for effectiveness for residents with medication orders for Warfarin, by the Director of Nursing or Designee. 4) Those that reviewed policies were: V19, Chief Nursing Officer, V7, Regional Director of Operations, and V8, Chief Operating Officer 5) How the corrective actions will be monitored: The Director of Nursing or designee has put into place a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary. The Director of Nursing or designee will complete random audits of scheduled laboratory testing as ordered by the physician, with special consideration for those residents on warfarin for 12 weeks until compliance is achieved. Results of the above reviews will be discussed at a weekly quality assurance meeting that the Administrator is the head of/holds for a period of 12 weeks and will provide additional education as needed and implement interventions for improvement until resolution.

Based on interview and record review, the facility failed to insure a preventative fall alarm was working to prevent a fall for 1 of 3 residents (R5) reviewed for falls. Findings include: R5's Face Sheet, print date of 5/5/25, documents R5 was admitted on [DATE] with diagnoses of Dementia and Alzheimer's Disease. R5's Minimum Date Set, dated 1/16/25, documents R5 is severely cognitively impaired and requires partial to moderate assistance for transfers. R5's General Note, dated 2/4/2025 3:00 PM, documents, Patient found laying on floor in room on back at (2:10 PM) by staff. Patient moaning. Staff called RN (Registered Nurse) to assess patient. RN assessed body, no injury or redness noted. Patient vitals taken and transferred to bed with bed alarm in place. Patient did have alarm on her in recliner, but was not attached to box. Hospice was in earlier to give patient bath but did not connect up alarm correctly. Updated staff to frequently check alarm boxes. R5's Quality Assurance Report, print date of 5/5/25, documents Incident date of 2/4/25 root cause: resident attempted to stand, alarm box malfunction. New intervention: alarm box to be checked every shift. The policy Accidents and Incidents, dated 9/7/23, documents, To provide staff with guidelines for investigating, reporting, and recording Accidents and Incidents. POLICY: All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. DEFINITION: An accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve injury or damage to property. It may involve residents, visitors, or volunteers. On 5/5/25 at 11:30 PM, V9, Regional Director, stated the alarm should have been plugged back in. We owned up to that and educated staff.

Based on interview, observation, and record review, the facility failed to store medications at an appropriate temperature and dispose of expired multi-dose/stock medications. This failure has the potential to affect all 83 residents in the facility. Findings include: On [DATE] at 12:05 pm the South-East medication room was entered with V8 LPN (Licensed Practical Nurse). The medication refrigerator contained two thermometers that read 50 degrees Fahrenheit . The temperature log for [DATE] was posted on the front of the refrigerator. This temperature log did not have temperatures recorded on the following dates [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. This form documented a temperature of 48 degrees Fahrenheit on [DATE]. The refrigerator contained the following medications: 11 basaglar 100 u/ml (units per milliliter) insulin kwikpens for R12, 4 basaglar 100 u/ml insulin kwikpens for R19, 3 trulicity .75 mg insulin pens for R22, 5 lantus insulin pens 100 u/ml for R54, 2 lantus 100 u/ml for R57, 1 bottle of liquid vancomycin 2mg/ml for R179, and 3 IV (intravenous) bags of daptomycin 500 mg/100 ml for R180. This refrigerator had an open vial of TB solution (tuberculin purified protein derivative) with an open date of [DATE]. On [DATE] at 12:22 pm the South medication cart was inspected. This medication cart contained one bottle of expired thiamin vitamin b-1 100mg tablets with an expiration date of ,d+[DATE]. On [DATE] at 12:28 pm V8 stated that the tuberculin solution and the vitamin b-1 are stock medications that are used for all residents if needed or they have an order. On [DATE] at 12:27 pm V1 Administrator stated that she replaced the refrigerator in the South-East medication room because it wasn't staying cool enough. V1 stated that she would expect the medication refrigerator temperature to be below 40 degrees. V1 also stated that an open vial of TB solution is considered expired after 30 days. The facility's Storage of Medications policy, dated ,d+[DATE], documented medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. It continues, Temperature 1. All medications are maintained within the temperature ranges noted in the United States Pharmacopeia. It continues, c. Refrigerated: 36 degrees Fahrenheit to 46 degrees Fahrenheit with a thermometer to allow temperature monitoring. It continues, 4. b. drugs dispensed in the manufacturer's original container will carry the manufacturer's original expiration date. Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached. It continues, 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating.

Based on interviews, observations, and record reviews the facility failed to provide timely and complete incontinent care including improper glove changes and hand hygiene for 3 out of 6 residents, (R7, R8, R9) reviewed for incontinence care in a sample of 41. The findings include: 1. R9's Face Sheet, undated, documents R9 was admitted to the facility on [DATE] and has diagnosis of Metabolic Encephalopathy, Atrial Fibrillation, Hypertensive Chronic Kidney disease (CKD), Major depressive disorder, Bipolar, Dementia, Pacemaker, and Hypertension. R9's Care Plan, dated 6/28/24, documents R9 has Self-Care Deficits As Evidenced by: Needs moderate to dependent assistance with functional abilities. Interventions: Toilet Use - One-person physical assist required. It continues R9 is incontinent of Bowel/Bladder. Interventions: Assist with toileting: as needed. R9's Minimum Data Set (MDS), dated [DATE], documents R9 has a severe cognitive impairment and is dependent on staff for toileting, bathing, and personal hygiene. R9 is always incontinent of both bowel and bladder. On 7/23/24 at 11:45 AM, V4, Certified Nursing assistant (CNA), and V13, CNA, provided peri-care to R9. While wiping feces from R9's anal area, V4 used the same soiled gloves and put her hands into the basin of water to get another wet washcloth, squeezed the water from the washcloth, and used that cloth on R9. V4 did this same process three different times, each time using the same soiled gloves, contaminating the clean water that she was using to further clean R9. On 7/24/24 at 2:50 PM, V3, Assistant Director of Nursing (ADON), stated that I would expect the staff to perform timely and complete incontinence care including proper hand hygiene and gloves changes when appropriate. [NAME]: 2. On 7/24/24 at 11:48 AM, V19, CNA, and V15, Health Information Management (HIM), enter R9's room for peri care. R9 is on contact precautions for Extended-Spectrum Beta-Lactamase (ESBL) of urine. V19 removed R9's bed sheets and rolled her to her left side while V15 helped hold R9's right thigh. R9 did not have a brief on, there was a slightly saturated bed pad under R9. V19 took a wet towel and sprayed it with peri wash then wiped starting in R9's vaginal region back to her anal region, then placed the dirty towel on the dirty pad and grabbed a new wet towel. V19 took the new wet towel, sprayed it with peri wash and wiped to the left of R9's vaginal fold back to her left buttock and placed the dirty towel on top of the other dirty towel and rolled the pad over them. V19 took another wet towel, sprayed it with peri wash and wiped to the right of R9's vaginal fold back to her right buttock and placed the dirty towel with the other dirty towels in the rolled up dirty pad. V19 then took a dry towel to R9s vaginal region back to her buttock padding it dry. V19 tucked a clean brief and pad under R9's old pad then V19 and V15 rolled R9 onto her back. V19 took a wet towel, sprayed it with peri wash and wiped R9's midline vaginal region front to back, placed the dirty towel in the dirty rolled up pad and grabbed another wet towel. V19 sprayed the new wet towel with peri wash and wiped R9's left groin top to bottom. V19 repeated the same process and wiped R9's right groin. No hand hygiene or glove changes between wipes. V19 and V15 rolled R9's to her right side. V19 removed the dirty pad and unrolled the new brief and pad under R9. V19 helped V15 secure R9's brief and cleaned up the dirty linen. 3. R7 was admitted to the facility on [DATE] with diagnosis of, in part, encephalopathy, and benign prostatic hyperplasia with lower urinary tract symptoms. R7's MDS completed on 6/6/2024 documents R7 as being severely cognitively impaired. R7 MDS further documents R7 is dependent on toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, shower/bathe self: the ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) and toilet transfer: the ability to get on and off a toilet or commode. R7 was admitted to the hospital on 5/27/24 with a diagnosis of Sepsis tachycardia with leukocytosis and a right foot and thigh cellulitis. R7 was discharged back to the facility 6/1/24. On 7/1/24 a wound culture was collected and resulted on 7/10/24 with heavy growth of Escherichia Coli - Extended Sprectrum Beta Lactamase (ESBL). R7's current care plan with a completion date of 6/12/2024, documents R7 needs moderate to total assistance with functional abilities related to a history of Cerebral Vascular Accident (CVA), hemiparesis with right side weakness with interventions as follow: Personal Hygiene-One-person physical assist required. R7's care plan further documents R7 has potential for impaired skin integrity related to urinary and bowel incontinence with intervention to monitor incontinence. R7's Physician Orders, it documents to apply Triad paste to scrotum due to maceration, to be completed on every shift, from 6/12/24-7/9/24 and on 7/9/2024 with no end date. On 7/23/24 at 1:50 PM, R7 was heard from hallway stating, please help me, someone please help me. V13, CNA, responds to R7 at 1:53 PM and asked him what was wrong. R7 stated he has been trying to get help from someone to go take a poop for an hour. V13 stated she will have to get someone to help her transfer him to the toilet and will return. At 1:59 PM, V13 and V4, CNA, arrive to R7's room with a sit-to-stand transfer device. V13 and V4 attached R7's sling to the sit-to-stand. Once R7 was attached to the transfer device, both V13 and V4 move R7 over to the toilet. V4 removed R7's pants and a urine saturated brief before lowering him down to sit on the toilet. V4 removed R7's pants and stated they were wet. V13 and V4 detached the sling from the device while R7 had a bowel movement. When R7 finished his bowel movement, V13 and V4 hook him back up to the transfer device, put a new brief and new pants on his legs and raised him up. While R7 was raised up, V4 takes a wet towel with peri wash and wiped R7's buttock. As V4 wiped R7, R7 yelled out load and grimaced in pain. R7 stated that it hurt. V4 then took another wet towel and wiped his midline anal region, R7 yelled again and continued to grimace with his face. V13 stated R7 has had issues with his peri skin rubbing creating some irritation. V4 took a tube of antifungal cream and applied it to his buttock and scrotum. V4 and V13 transfer R7 to his bed for a skin check. Once R7 was lying in his bed turned on his left side, his peri region was seen. Red, raised, fragile skin was located on his scrotum, in between his scrotum and thighs, on his penis and in his anal region. A skin tear to his left buttock and two skin tears to his anal region were present. Stool was still present. V4 takes another wet towel and wiped the stool off R7's anus. R7 yelled and grimaced again. V4 took another wet towel and wiped the left back side of his scrotum front to back, and then took another wet towel and wiped his right back scrotum front to back. No hand hygiene completed or glove changes between wipes. V4 then took antifungal cream and applied it to R7's scrotum and buttock. V4 and V13 help R7 pull is new brief and pants up in place. Both V4 and V13 hook R7 back up to the sit-to-stand to transfer him into his recliner. No peri care was completed to R7's penis or front groin after having a urine saturated brief. On 7/24/24 at 10:50 AM, V19, CNA, stated peri care is supposed to be done anytime a resident needs to be changed, or technically every 2 hours. V19 stated gloves are supposed to be changed after every swipe from dirty to clean and hand hygiene when changing from dirty to clean areas. On 7/24/24 at 3:14 PM, V22, Licensed Practical Nurse (LPN), stated she was not aware of R7 having any skin issues, she did not have to complete any peri care on him, she was running around all day, and was not aware of any special orders in place for creams to be applied other than what the CNA's do. On 7/24/24 at 3:15 PM, V19 stated she noticed R7's peri region was red and blotchy. V19 stated when she did peri care on R7 earlier that day, he yelled in pain when she wiped the area. V19 stated she applied barrier cream to the irritated peri region on R7 but did not notify anyone of the situation because the nurse should already know. 40701 4. R8's Face Sheet dated 7/24/2024 documents R8 has a diagnosis of bladder disorder. On 7/22/2024 at 9:57 AM, there was an odor. V6, Certified Nursing Assistant (CNA) and V7, CNA, began providing incontinent care to R8. V7 stated R8 did not have any open areas on her skin. R8's pants, bottom of her shirt, and the mechanical lift sling were soiled with a wet substance. After removing R8's pants it was verified R8 had a large bowel movement. V7 began cleaning/wiping the feces from R8's backside. R8's right and left upper buttocks had quarter sized reddened areas. At this time V6 stated the reddened areas were caused by R8 sitting in her poop. It really hurts her. She got up (out of bed) about 6:30 (AM). V6 further stated breakfast trays come about 8 (AM) or after. On 7/24/2024 at 11:24 AM, R8 was located in her wheelchair in the dining area of the unit. At this time V18, CNA stated she will lay R8 down (in bed) after lunch to check her for incontinence. V18 stated she last checked R8 for incontinence after breakfast but wasn't sure what exact time it was. R8's Minimum Data Set (MDS) dated [DATE] documents R8 is severely cognitively impaired, always incontinent of urine, and frequently incontinent of bowel. R8's Care Plan dated 3/3/2021documents R8 is incontinent of bowel and bladder. It further documents, Toilet upon rising and before or after meals. The Facility's Incontinent Care Policy, dated 5/16/22, documents All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Procedure: 1. Assemble Equipment. 5. Perform hand hygiene, apply gloves. 8. Wash all soiled skin areas and dry very well, especially between skin folds: changing gloves and performing hand hygiene as required to prevent cross-contamination.

Based on interview, observation, and record review, the facility failed to change gloves and perform hand hygiene during resident care and to wear appropriate Personal Protectant Equipment (PPE) for a resident on isolation for 5 of 24 residents (R7, R9, R17, R18, R179) reviewed for infection control in the sample of 41. The findings include: 1. R179's Face Sheet, undated, documents R179 was admitted to the facility on [DATE] with diagnosis of Sepsis, Urinary Tract Infection (UTI), Methicillin Resistant Staphylococcus Aureus (MRSA), and Enterocolitis due to Clostridium Difficile (C-DIFF). R179's Care Plan, dated 7/14/24, documents R179 has C. Difficile related to loose stools. Interventions: Contact Isolation: Wear gloves and gown and PRN (as needed) masks when coming into contact with body fluids and when changing contaminated linens, bag linens and close bag tightly before taking to laundry, disinfect all equipment used before it leaves the room, educate resident/family/staff regarding preventive measures to contain the infection, place in private room with contact isolation precautions. It continues R179 has a Potential for Weight Loss and Dehydration related to positive Stool Culture - C. Difficile with abdominal pain, abdominal tenderness, appetite loss, watery diarrhea. Interventions: Contact Isolation-Wear minimum of gown and gloves when providing care that comes in contact with body fluids, ensure hands and clothes do not touch surfaces potentially contaminated; ex. Bedrails, table, door knobs, faucets, etc. R179's Minimum Data Set (MDS), dated [DATE], documents R179 is cognitively intact and is dependent on staff for toileting, bathing, and transfers. R179 is always incontinent of both bowel and bladder. R179's Lab Result, dated 7/10/24, documents R179 was positive for C-Diff. On 7/22/24 at 11:08 AM, V4, Certified Nursing Assistant (CNA), was seen in R179's, room with no PPE on. V4 walked out of the room, used hand sanitizer from wall and did not wash her hands. V4 stated that R179 is on contact isolation for C-Diff and that she was supposed to wear a gown when going into the room, but R179 dropped something on the floor so she just went in and picked it up for him and forgot to put the gown or gloves on. V4 was then seen going in and out of other resident rooms. On 7/25/24 at 9:28 AM, V20, CNA, stated There are several types of isolation, but we should at least wear a gown, gloves, mask, and face shield if required to enter a isolation room. If it is a C-Diff room, we have to put a gown and gloves on to enter the room. After we do resident care and before we leave the room, we need to take our gown and gloves off and wash our hands with soap and water in the sink. On 7/24/24 at 2:50 PM, V3, Assistant Director of Nursing (ADON), stated I would expect all staff to don appropriate PPE upon entering any resident room and providing care for that resident while on isolation. If it is an isolation room with a resident with C-Diff, staff should be washing their hands with soap and water and not just use hand sanitizer. 2. R9's Face Sheet, undated, documents R9 was admitted to the facility on [DATE] and has diagnosis of Metabolic Encephalopathy, Atrial Fibrillation, Hypertensive Chronic Kidney disease (CKD), Major depressive disorder, Bipolar, Dementia, Pacemaker, and Hypertension. R9's Care Plan, dated 6/28/24, documents R9 has Self-Care Deficits As Evidenced by: Needs moderate to dependent assistance with functional abilities. Interventions: Toilet Use - One-person physical assist required. It continues R9 is incontinent of Bowel/Bladder. Interventions: Assist with toileting: as needed. R9's MDS, dated [DATE], documents R9 has a severe cognitive impairment and is dependent on staff for toileting, bathing, and personal hygiene. R9 is always incontinent of both bowel and bladder. On 7/23/24 at 11:45 AM, V4, CNA, and V13, CNA, provided peri-care to R9. While wiping feces from R9's anal area, V4 used the same soiled gloves and put her hands into the basin of clean water to get another wet washcloth, squeezed the water from the washcloth, and used that cloth on R9. V4 did this same process three different times, each time using the same soiled gloves, contaminating the clean water that she was using to further clean R9. 49494 3. R18's face sheet, dated 7/25/24, documented R18 has diagnoses of glaucoma, myasthenia gravis, COPD (Chronic Obstructive Pulmonary Disease), type 2 diabetes mellitus, trigeminal neuralgia, hypertension, heart disease, and diplopia. On 7/23/24 at 8:53 am V9 RN (Registered Nurse) was administering medications to R18. V9 did not perform hand hygiene prior to dispensing R18's medication. V9 handed R18 his cup of medications and R18 dropped a pill on his lap. V9 then got down on her knees and was touching R18's lap and the floor as she was looking for the missing pill. V9 then touched the pill with her bare hands that was on R18's lap and placed it in his medication cup. V9 then retrieved R18's bottle of Brimonidine Tartrate Ophthalmic Solution 0.2% eye drops and pushed R18 to his room. V9 then instilled 1 eye drop into R18's left eye without the benefit of hand hygiene nor glove use. V9 then left R18's room without performing hand hygiene. 4. R17's face sheet, print date 7/24/24, documented R17 was admitted [DATE]. R17's face sheet documented diagnoses of left femur fracture, dementia, Alzheimer's disease, atherosclerotic heart disease, hypertension, and history of urinary tract infections. R17's MDS (Minimum Data Set), dated 4/26/24, documented that R17 is severely cognitively impaired and requires substantial/maximum assistance from staff with mobility. On 7/23/24 at 9:30 AM, V11, CNA (Certified Nurse Assistant) and V12, COTA (Certified Occupational Therapy Assistant) entered R17's room with a mechanical lift and transferred R17 from her wheelchair and into her bed. V11 and V12 did not perform hand hygiene upon entering R17's room nor prior to transferring R17 into her bed. V11 and V12 then repositioned R17 three times to ensure R17 was in a comfortable position and then pulled R17's blankets up over her. V11 and V12 then left R17's room without the benefit of hand hygiene and proceeded to care for other residents. On 7/24/24 at 12:30 PM, V1, Administrator stated that she would expect the staff to perform hand hygiene before, during if needed, and after providing care for the residents. The facility's Handwashing/Hand Hygiene policy, undated, documented the facility considers hand hygiene the primary means to prevent the spread of infection. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It continues, 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled, and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures, it continues h. Before moving from a contaminated body site to a clean body site during resident care. It continues, the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hygiene is recognized as the best practice for preventing healthcare-associated infections. The Facility's Incontinent Care Policy, dated 5/16/22, documents All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provided as required. Procedure: 5. Perform Hand Hygiene, apply gloves. 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. The Facility's Initiating Isolation Precautions, dated 12/6/21, documents 3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): d. Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. e. Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. f. Ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room.

Based on observation, interview and record review, the Facility failed to prevent pressure ulcer development, implement preventative measures and follow physicians orders for 1 of 2 residents (R8) reviewed for skin integrity, in the sample of 41. Findings include: R8's Face Sheet dated 7/24/2024 documents R8 has a diagnosis of Dementia and disturbances of skin sensation. R8's Minimum Data Set (MDS) dated [DATE] documents R8 is severely cognitively impaired, always incontinent of urine, frequently incontinent of bowel, requires assistance for turning/bed mobility, and has one unstageable pressure area. R8's Care Plan dated 2/22/2021 documents R8 is at risk for impaired skin integrity due to cognitive deficits, impaired mobility, and requires assist with turning and repositioning. R8's Skin Inspection assessment dated [DATE] documents, Current skin concerns. It further documents R8 had an open area to her coccyx. R8's Skin and Wound Evaluation dated 6/18/2024 documents R8 had an unstagable pressure wound that was acquired in house (at the facility) that began on 4/25/2024. On 7/22/2024 at 9:57 AM, there was an odor in R8's room. V6, Certified Nursing Assistant (CNA) and V7, CNA, began providing incontinent care to R8. V7 stated R8 did not have any open areas on her skin. R8's pants, bottom of her shirt, and the mechanical lift sling were soiled with a wet substance. After removing R8's pants it was verified R8 had a large bowel movement. V7 began cleaning/wiping the feces from R8's backside. R8's right and left upper buttocks had quarter sized reddened areas. At this time V6 stated the reddened areas were caused by R8 sitting in her poop. It really hurts her. She's up (out of bed) about 6:30 (AM). V6 further stated breakfast trays come about 8 (AM) or after. On 7/24/2024 at 11:30 AM, V3, Assistant Director of Nursing (ADON) stated R8 did develop a pressure sore to her coccyx/sacrum (buttocks) area while at the facility on 4/25/2024 but they had healed on 6/18/2024. V3 stated she completed a skin check on R8 last week and she did not have any open areas. On 7/24/2024 at approximately 9:00 AM, R8 was located in her room, sitting in her wheelchair. On 7/24/2024 at 11:24 AM, R8 was located in her wheelchair in the dining area of the unit. At this time V18, CNA stated she will lay R8 down (in bed) after lunch. V18 stated she last checked R8 for incontinence after breakfast but wasn't sure what exact time it was. On 7/24/24 at 1:40 PM, R8 was observed laying on her back in bed with both heels laying flat on bed. R8's Progress Notes dated 7/21/2024 documents a CNA reported R8's right heel was soft and mushy; the area was assessed with no open area noted. R8's Skin Inspection assessment dated [DATE] documents, Right heel: apply skin prep every shift for 14 days then reassess. Float heels while in bed as preventative. The Facility's Pressure Ulcer policy dated 8/31/2023 documents, To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers.

Based on observation, interview and record review, the facility failed to ensure care plan interventions were followed, assess resident smoking risk to prevent injury and provide appropriate supervision to prevent falls for 3 of 6 residents (R17, R46, R64) reviewed for safety and supervision in the sample of 41. Findings include: 1.R17's face sheet, dated 7/24/24, documented R17 was admitted to the facility on [DATE]. R17's face sheet documented R17 has diagnoses of left femur fracture, dementia, Alzheimer's disease, atherosclerotic heart disease, hypertension, and history of urinary tract infections. R17's MDS (Minimum Data Set), dated 4/26/24, documented that R17 is severely cognitively impaired and requires substantial/maximum assistance from staff with mobility. R17's fall risk assessment, dated 7/17/24, documented that R17 is high risk for falls. R17's care plan, undated, documented that R17 is to have the following fall interventions in place; dycem to wheelchair initiated 3/22/24, offer to toilet before meals initiated 5/22/24, drop wheelchair seat initiated 7/2/24, keep environment clutter free initiated 3/21/24, mat at bedside when in bed initiated 4/26/24, pressure alarm to bed initiated on 6/21/24, proper footwear at all times initiated 6/16/24, and provide adequate lighting initiated 3/21/24. The facility's incident log, dated 7/23/24, documented that R17 had falls on 5/22/24, 6/15/24, and 7/2/24. On 7/23/24 at 9:30 am R17 was transferred from her wheelchair onto her bed. R17 did not have dycem placed in her wheelchair as care planned to help reduce the risk of falls. On 7/23/24 at 2:53 pm R17 was observed resting in bed. R17 did not have a pressure alarm on as care planned. On 7/23/24 V11 CNA (Certified Nurse Assistant) stated that R17 does not have a pressure pad, nor has she ever been told she is supposed to have one. V11 stated that she was aware that R17 did not have the dycem in her wheelchair earlier in the day, but she now has it placed. On 7/24/24 at 12:28 pm V1 Administrator stated that she would expect fall interventions to be in place as care planned. 2. R46's face sheet, dated 7/24/24, documented that R46 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of supraglottis, esophageal obstruction, emphysema, dysphagia, and osteoarthritis. R46's MDS, dated [DATE], documented R46 is cognitively intact. R46's care plan, undated, documented R46 requires supervision to moderate assistance with ADLS (Activities of Daily Living). R46's Safe Smoking Screening, dated 6/24/24, is incomplete and does not document the level of supervision that is required for R46 when she is smoking. R46's Safe Smoking Screening, dated 7/24/24, is incomplete and does not document the level of supervision that is required for R46 when she is smoking. R46's care plan, undated, documented R46 has recently exhibited unsafe smoking practices on 7/18/24. This care plan has a revision date of 7/23/24. R46's incident report, dated 7/18/24, documented CNA reported that resident was outside smoking and fell asleep and burnt small amount of hair on L (left) side of head. CNA asked resident to give her the cigarette so she wouldn't cause injury and resident refused. Writer went to speak with resident, and she stated I am not giving up my cigarette. This incident report also documented, IDT (Interdisciplinary Team) note: resident put cigarette too close to her hair and singed a piece of her hair. Root cause: Resident not paying attention where she placed her cigarette as she got distracted. New intervention: will continue supervised smoking and use a smoke apron. On 7/22/24 at 8:55 am R46 was observed outside in front of the facility smoking a cigarette. R46 was unsupervised. No facility staff were observed outside nor near the front entrance. R46 did not have a smoke apron on her. On 7/23/24 at 11:00 am R46 stated that she singed her hair a little bit while she was smoking a cigarette and that it did not burn her skin. On 7/23/24 11:18 am V14 Regional Director stated that there was already an incident completed on R46 when she burned a small amount of her hair from smoking on 7/18/24. V14 stated that there was not another smoking assessment completed after the 7/18/24 until today (7/23/24) and after the surveyor requested the incident for the 7/18/24. Surveyor informed V14 that R46 was out smoking unsupervised when surveyors entered on 7/22/24 and V14 replied you caught me, she shouldn't have been unsupervised after she burned her hair. The Facility's Smoking Policy, dated 9/1/19 and date revised 3/11/24, documented 1. Smoking is only allowed in designated areas, during designated smoking times established by management. 2. Residents who smoke will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. The facility shall complete Smoking Safety Assessments upon admission, a quarterly basis, and as needed. 3. Desire to smoke, as well as supervision required for smoking, shall be included in the resident's individualized care plan. It continues, the facility recognizes the potential harm that may result from careless, hazardous smoking and has implemented this policy to maintain a safe living environment. 44967 3. R64's Face Sheet, undated, documents R64 was admitted to the facility on [DATE] with diagnosis of Neurocognitive disorder with Lewy Bodies, Dementia, Malignant neoplasm of prostate, Hemangioma, and Anxiety disorder. R64's Care Plan, dated 6/30/24, documents R64 is at risk for falls and injuries related to Parkinson's Diagnosis, impaired cognition, and antidepressant use. Interventions: 6/13/24 Trial with motion sensor in room, 1/9/24 Wear shower shoes when taking shower, 3/3/24 low bed when in bed, 5/23/24 Wear proper footwear at all times, 5/7/24 grabber/reacher, encourage use of call light, keep call light within reach, keep environment clutter free, keep personal belongings within reach, observe for unsteady gait and balance, provide adequate lighting, provide/reinforce use of non-skid footwear. R64's MDS, dated [DATE], documents R64 has a severe cognitive impairment and requires supervision/touching assistance for all Activities of Daily Living (ADLs). R64 is occasionally incontinent of both bowel and bladder. On 7/23/24 at 8:45 AM, R64's door was closed and upon entrance to his room, R64 was seen on the floor next to his bed. R64's fall mat was seen folded up and against the wall and his call light was on his roommate's side of the room underneath an oxygen concentrator and not within reach or eyesight of R64. A large white bed/pad alarm was seen sitting on top of the bed and was not on. Staff was notified of R64's fall. On 7/23/24 at 8:50 AM, R64's Roommate, R42 witnessed R64's fall and stated, 'He tried to get up on his own and just plopped down on his butt. On 7/23/24 at 8:53 AM, V4, CNA, was asked how R64 can call for help if needed, V4 stated We just keep a close eye on him. The facility's fall log for the past 3 months, documents R64 has had falls on 5/7/24, 5/23/24, and 6/12/24. R64's Admission Fall Risk Assessment, dated 7/5/23, documents R64 as a Low Fall Risk. R64's Nursing Note, dated 5/7/24 at 1:17 PM, documents Resident was noted to be sitting upright on the floor leaning against his recliner with an abrasion above his right eyebrow and a swollen lip. He had one shoe on and one shoe off. His roommate said he had fallen and hit his head on the floor. ROM (Range of Motion) done without difficulty and assessed for further injuries. Resident assisted up and was sitting on his bed and then laid back to rest. Administrator, ADON (Assistant Director of Nursing), Wife and Dr. (doctor) notified. Neuro checks WNL (within normal limits). R64's Fall Risk Assessment, dated 5/7/24, documents R64 as a Low Fall Risk. The facility's fall investigation, dated 5/7/24, documents Incident Description: Writer was called to the resident's room, and he was noted to be sitting upright leaning on his recliner with blood above his right eyebrow and a swollen lip. It appears that resident was leaning over while sitting on his bed to put his shoes on because he only had one shoe on and when he leaned over to put the other shoe on his sheet slipped causing him to fall forward. He did say he hit his head on the floor. R64's Nursing Note, dated 5/23/24 at 8:15 AM, documents 0500 Writer was called to room by CNA informed nurse that when she answered call light resident's roommate informed her that client fell and hit his face. Client placed self back in bed. Bleeding noted from mouth, Asked resident what happened he stated I stopped floor with my face. Nurse assessed client - a/o (alert and oriented) times 3, PERRLA (pupils are equal, round and reactive to light and accommodation), able to move all extremities passively without c/o (complaint of) pain, laceration to right elbow, lacerations to lower lip and right cheek inside mouth, face cleansed, ice applied, VS (vital signs) WNL (within normal limit), Nuero checks started per protocol. 0530 lips still bleeding Dr informed, recommended ER (emergency room ) eval for continued bleeding to mouth and unwitnessed fall with facial injury. 0540 Wife called informed of above and agreed, Ambulance called for transfer to (Local Hospital). 0610 client transferred to (Local Hospital) via ambulance. There was no fall risk assessment completed after the fall on 5/23/24. The facility's fall investigation, dated 5/23/24, documents Incident Description: CNA informed nurse that when she answered call light resident's roommate informed her that client fell and hit his face. Client placed self back in bed. IDT Note: CNA informed nurse that when she answered call light resident's roommate informed her that client fell and hit his face. Client placed self back in bed. Nurse assessed client - a/o times 3, PERRLA able to move all extremities passively without c/o pain. Laceration to right elbow, lacerations to lower lip and right cheek inside mouth, face cleansed, ice applied, VS WNL, Dr. informed, recommended ER eval for continued bleeding to mouth and unwitnessed fall and facial injury. Wife called informed of above and agreed, ambulance called for transfer to hospital. BIMS: 6. Root cause: resident having increased shuffling of feet. New intervention: proper footwear at all times. R64's Fall Risk Assessment, dated 5/31/24, documents R64 as a High Fall Risk R64's Nursing Note, dated 6/12/24 at 4:35 PM, documents Summoned to room by staff. (R64) seen sitting on the side of bed with staff at side. Assessment finds dark purplish area with small abrasion to right elbow. No other injuries seen. DON (Director of Nursing) aware. Call placed to POA (Power of Attorney) and updated on (R64). Communication sent to Dr. and hospice with update on res. R64's Fall Risk Assessment, dated 6/12/24, documents R64 as a High Fall Risk. The facility's fall investigation, dated 6/12/24, documents Incident Description: Summoned to room [ROOM NUMBER] by staff. (R64) seen sitting on the side of bed with staff at side. IDT Note: Resident witnessed trying to ambulate independently in room. Root Cause: attempted to ambulate without assistance and lost balance and fell . New Intervention: Trial with motion sensor in room. The facility's fall investigation, dated 7/23/24, documents Incident Description: Resident on floor in his room sitting with back against side of bed. VSS (vital signs stable). Neuro check wnl (within normal limites). [NAME] (unknown). No injury. Denies pain. Roommate says he tried to get up and fell . IDT Note: Resident observed on floor next to his bed. Roommate stated he tried to get out of bed unassisted and fell . Root Cause: Resident attempted to self-transfer without assistance out of the bed. New Intervention: Bed alarm when in bed. Fall interventions were not in place to help prevent R64 from falling. This includes the call light on the floor and out of reach, the fall mat folded up and lying against the wall, bed alarm sitting on top of the bed and not on, and the resident's door was closed where staff was not able to put eyes on R64. On 7/24/24 at 2:50 PM, V3, Assistant Director of Nursing (ADON), stated I would expect all staff to ensure that the residents fall precautions/interventions are in place to help prevent resident falls. The facility's Fall Prevention/Safe Patient Handling Implementation Plan, undated, documents 'Fall Prevention Policy: 1. Audit medical records to be sure all residents have up to date Fall Risk Assessment completed. 2. Review MDS of residents to see who triggered Fall CAA for other at-risk residents. 3. All resident who scores 10 or higher on the Fall risk Assessment will be placed on the Fall Prevention Program. 4. All preventative measures will be put in place for at risk residents including: a. Identifier visual aide beside door to alert staff of fall risk. b. Identifier visual aide on wheelchair to alert staff if wheelchair bound. c. Notify family or responsible party of fall risk. d. Put in place all needed preventative interventions. Ensure proper facility environmental safety and transfer equipment inspection rounds are done at least weekly to ensure safety for all in the facility. Ensure that interventions relating to prevention of falls are communicated to line staff and followed through. Ensure new interventions are put in place with each new fall and communicated to the care plan. Ensure that the facility Safe patient handling program is implemented and utilized.

Based on interview and record review, the facility failed to prevent the use of an unnecessary antibiotic for 1 of 3 residents (R3) reviewed for unnecessary medication in the sample of 4. Findings include: R3 Order Summary Report, print date of 1/2/24, documents that R3 was admitted on [DATE] with the diagnosis of End Stage Renal Disease. R3's Progress Note, dated 12/1/23, documents, Orders received back from (V8, Physician Assistant) from U/A (urinalysis), urine culture for Macrobid (Nitrofurantoin) 100mg (milligram) po bid (by mouth twice a day) x 7 days. Send Urology and Nephrology copy of report. R3's Medication Administration Report, print date of 12/28/23, documents, Macrobid Oral Capsule 100 mg. Give 100 mg by mouth two times a day for UTI (Urinary Tract Infection) Order date of 12/01/23. R3's Urine Culture, Final Report date of 11/29/23, documents, Gram Negative rods less than 10,000 COL (colony)/ ML (milliliter). In V8's handwriting, 1. Macrobid 100 mg BID x 7 d (day). 2. Send culture. 2. copy to nephrology / urology. R3's Urine Culture, Final Reported date of 11/30/23, documents, Providencia rettgeri greater than 100,000 COL/ML. Proteeus mirabilis greater than 100,000 COL/ML Nitrofurantoin R (resistant). On 1/2/24 at 12:10 PM, V7, Infection Preventionist, stated, I called the provider (V8) and questioned him on why R3 got Macrobid when the organism was resistant to Macrobid. He is just as perplexed as we are. I have found some documentation that had not been scanned into the system yet. I found where the Dialysis center did send a fax over to us stating to change the Macrobid because of his End Stage Renal Disease but by this time he (R3) had finished the antibiotic. I usually go back and check that the organism is sensitive to the antibiotic. This one just got past me. On 1/2/24 at 12:33, V2, Director of Nurses, stated, We just found V8's fax response and it looks like V8 ordered the Macrobid before the culture came back. We did send to Nephrologist (Dialysis Center Doctor) but by the time they answered the antibiotic was finished. The Antibiotic Stewardship Policy / Procedure, dated 3/9/23, documents, Antibiotic Time 'time - out At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration for antibiotic [NAME], duration, selection, and de-escalation potential.

Based on interview and record review, the facility failed to ensure an antibiotic was appropriate for the organism of a urinary tract infection for 1 of 3 residents (R3) reviewed for antibiotic stewardship in the sample of 4. Findings include: R3 Order Summary Report, print date of 1/2/24, documents that R3 was admitted on [DATE] with the diagnosis of End Stage Renal Disease. R3's Progress Note, dated 12/1/23, documents, Orders received back from (V8, Physician Assistant) from U/A (urinalysis), urine culture for Macrobid (Nitrofurantoin) 100mg (milligram) po bid (by mouth twice a day) x 7 days. Send Urology and Nephrology copy of report. R3's Medication Administration Report, print date of 12/28/23, documents, Macrobid Oral Capsule 100 mg. Give 100 mg by mouth two times a day for UTI (Urinary Tract Infection) Order date of 12/01/23. R3's Urine Culture, Final Report date of 11/29/23, documents, Gram Negative rods less than 10,000 COL (colony)/ ML (milliliter). In V8's handwriting, 1. Macrobid 100 mg BID x 7 d (day). 2. Send culture. 2. copy to nephrology / urology. R3's Urine Culture, Final Reported date of 11/30/23, documents, Providencia rettgeri greater than 100,000 COL/ML. Proteeus mirabilis greater than 100,000 COL/ML Nitrofurantoin R (resistant). On 1/2/24 at 12:10 PM, V7, Infection Preventionist, stated, I called the provider (V8) and questioned him on why R3 got Macrobid when the organism was resistant to Macrobid. He is just as perplexed as we are. I have found some documentation that had not been scanned into the system yet. I found where the Dialysis center did send a fax over to us stating to change the Macrobid because of his End Stage Renal Disease but by this time he (R3) had finished the antibiotic. I usually go back and check that the organism is sensitive to the antibiotic. This one just got past me. On 1/2/24 at 12:33, V2, Director of Nurses, stated, We just found V8's fax response and it looks like V8 ordered the Macrobid before the culture came back. We did send to Nephrologist (Dialysis Center Doctor) but by the time they answered the antibiotic was finished. The Antibiotic Stewardship Policy / Procedure, dated 3/9/23, documents, Antibiotic Time 'time - out At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration for antibiotic [NAME], duration, selection, and de-escalation potential.

Based on interview and record review, the facility failed to trim toenails for 1 of 6 residents (R4) reviewed for Activities of Daily Living (ADLs) assistance in the sample of 9. Findings include: R4's Admission Record, print date of 6/29/23, documents that R4 was admitted on [DATE] and has diagnoses of Parkinson's Disease and Dementia. R4's Minimum Data Set, dated dated [DATE], documents that R4 is severely cognitively impaired, requires supervision and set up help for bed mobility, transfer, ambulation, eating, extensive assistance of 1 staff member for dressing, toileting, hygiene, dependent of 1 staff member for bathing and is frequently incontinent of bowel and bladder. R4's Care Plan, dated 9/28/22, documents, Self-Care Deficit As Evidenced by: Needs extensive assistance with ADLs (Activities of daily Living) Related to poor balance, weakness, limited mobility, impaired cognition, tremors, Parkinson's Disease. Personal Hygiene - One-person physical assist required. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. R4's Shower Sheets, dated 5/17/23 - 6/23/23, were reviewed. On 6/20/23 and 6/23/23 it was noted that R4's toenails needed to be put on the list for podiatry to see. On 6/29/23 at 9:00 AM, V1, Administrator, stated, I think I know what this is about. Over the weekend our Corporate Nurse (V9) called, apparently, she and (R4's) son (V5) are friends and (V5) called her and said that he was a little disappointed in how (R4's) toenails looked. We looked into it and actually (V4 Certified Nurse's Aide, CNA) marked on her shower sheet that R4 needed to be put on the list for podiatry to see. On 6/29/23 at 9:18 AM, V4 stated, I noticed her toenails 2 showers ago and I circled on the sheet that she needed to be put on the list for podiatry to see. Her nails were thick and growing sideways over the other nail. They were extremely long. Her nails were weird they grew out then sideways. I was not comfortable cutting them myself. On 6/29/23 at 9:28 AM, V5, R4's son, stated, (R4's) toenails were very long and thick. They were about an inch long and growing sideways into her other toes. On 6/29/23 at 10:30 AM, V10, Licensed Practical Nurse (LPN), stated, The aides would help her (R4) with incontinent care and bathing. I would do skin checks on her to check her heels to see if they were boggy or breaking down. I really don't remember what her toenails looked like. The CNAs will cut toenails as long as they are not diabetic which (R4) was not. On 6/29/23 at 11:28 AM, V11, Social Service Director, stated, Anytime someone wants to be put on the podiatry list, I get a signed consent form and then send it to the podiatry office. (R4) had never seen the podiatrist before and I did not have a consent for her. Nobody told me that she needed her toenails clipped until after the fact that she was in the hospital and now she is not coming back here so I can't do anything about it. The podiatrist was just here on 6/20/23. On 6/29/23 at 11:00 AM, V3, Assistant Director of Nurses, stated, On Sunday (6/25/23) I got a call from (V9), and she told me that (V5) had called her and complained about (R4's) toenails. She told me she wanted a toenail check done on the whole building and that is what we are working on now. The CNAs can cut toenails if they are not a diabetic. We do have a podiatrist that will come and the residents that sign up for that service get seen about every 60 - 90 days. On 6/29/23 at 2:00 PM, V8, CNA, stated, I will cut residents toenails myself if they are not diabetic. If diabetic I let the nurse know so they can get on the podiatry list. On 6/29/23 at 2:20 PM, V7, CNA, stated, I will write it on the shower sheet if a resident needs their toenails cut and tell the nurse. I will cut them if they aren't diabetic. The Nail Care (Fingers & Toes) policy, dated 9/15/2019, documents, Policy: Nail care will be provided for all residents in order to provide cleanliness, prevent spread of infection, for comfort, and to prevent skin problems. Residents' nails will be kept neat and clean. Responsibility: It is the responsibility of all Nursing staff to ensure that nail care is provided to all residents as needed. It is the responsibility of the Podiatrist or charge Nurse to provide toenail care for diabetic residents.

Based on observation, interview and record review the facility failed to properly store medications, discard expired medication, and label tuberculin multi dose vial. This has the potential to effect all 78 residents living in the facility. Findings include: On [DATE] at 9:50 AM, the facility's North Wing Medication Storage Room was inspected. The medication room contained the following medication: 1. 1 open bottle of Gerikot 8.5 milligram (mg) with expiration date ,d+[DATE]. 2. 1 bottle of Niacinamide 500mg with expiration date of ,d+[DATE]. The refrigerator located in the North Wing Medication Storage Room was inspected. The refrigerator contained: 3. 2 Multidose Vials of Tubersol (TB) with no open date. On [DATE] at 1:57 PM, V5, Licensed Practical Nurse (LPN), stated that the tubersol was open and in use. V5 stated that the vial of Tubersol should have an open date. V5 stated that Tubersol has a different expiration date once the bottle is opened but unsure what that date is. V5 stated that placing the open date on the multidose vials tells them when the expiration date is. V5 stated that the Tubersol is not specific to one resident and is used for all the residents admitted to the facility. V5 stated that each resident is given a series of TB unless they have an allergy and that the Tubersol in the refrigerator is used for this process. V5 stated that the 1 open bottle of Gerikot 8.5mg was open and expired. V5 verified that the medication was open on [DATE]. V5 stated that the Gerikot was a stock medication and used for all residents in the facility. V5 stated that if the residents had an order and did not have an allergy, the gerikot would be used. V5 stated that the bottle of Niacinamide 500mg was expired. V5 stated that this medication must have been brought in by a family because he did not recognize the brand. V5 stated that the expired medication should be destroyed. On [DATE] at 3:15 PM, V3, Assistant Director of Nursing (ADON), stated that the TB has a different expiration date when opened. V3 stated that she expects her staff to label the multidose vials when opened with an open date. V3 stated that the expired medication should be destroyed and not kept in the medication storage room. V3 stated that the stock medication and the multi dose vial of TB are used for all residents as long as they have an order and don't have an allergy. The facility's Storage of Medication policy, dated [DATE], documents that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 4. Discontinued, outdated, or deteriorated drugs or biologicals are returned tot he dispensing pharmacy or destroyed. The Resident Census and Condition of Residents form (CMS 672), dated [DATE], documents that the facility has 78 residents living in the facility.

Based on interview, observation and record review, the facility failed to provide dining assistance and assistance with hygiene for 6 of 18 residents (R5, R8, R45, R46, R59, R64) reviewed for assistance with a activities of daily living (ADLs) in the sample of 45. Findings include: 1. On 06/20/23 at 12:26 PM, R64 was in the dining room eating lunch. R64 got up from the table and started to walk out. V15, Certified Nurse Assistant (CNA), assisted R64 while R64 walked to her room by walking arm in arm with her. V15 asked if she needed to use the restroom, R64 stated, Yes. They both entered the room, R64 went into the bathroom. V15 did not follow R64 but closed the door leaving a small opening in the door for observation outside of the bathroom. V15 stated, She is going to the bathroom. R64 was heard using the toilet and flushing the toilet. V15 asked if R64 was finished, R64 did not say anything. V15 opened the door all the way and stated, Ok, lets go back and finish lunch. V15 entered the bathroom and got R64's arm and walked her out of the bathroom into the dining room so R64 could finish her lunch. V15 failed to remind R64 to wash her hands after using the restroom. On 06/27/23 at 10:32 AM, V3, Assistant Director of Nurses (ADON), stated, Staff should always help and remind residents to wash their hands after using the toilet. R64's Admission Record, print date of 6/26/23, documents that R64 was admitted on [DATE] with diagnoses of Alzheimer's Disease and Dementia. R64's Minimum Data Set (MDS), dated [DATE], documents that R64 is severely cognitively impaired and requires extensive assistance of 1 staff member for hygiene. 42108 2. R45's Care plan, dated 4/28/22, documents that R45 has a Self-Care Deficit As Evidenced by: Needs extensive assistance with ADLs Related to weakness, fracture, limited mobility. It continues Eating - Setup help only / Cueing required. R45's MDS, dated [DATE], documents R45 requires supervision and set up assistance for eating. On 6/20/23 at 12:48 PM, R45 sitting in recliner with meal setting on overbed table in front of resident. R45's lunch meal was setting in front of R45. R45 picked up chicken cutlet and attempted to bite it without success. R45 then set the chicken on the plate and attempted to cut the chicken with her fork. This attempt was unsuccessful. R45 again pick up chicken with the fork and attempted to bite the chicken and again was unsuccessful. R45's white plastic fork was lying on the white napkin and per R45 she could not find the knife. R45 then grabbed a hold of the plastic knife and attempted to cut the chicken without success. R45 then placed chicken on the plate and did not eat it. On 6/20/23 at 12:55 PM, R45 stated that she would have liked to eat the chicken but it was tough. R45 stated that she was not able to cut the chicken with the plastic fork or bite into the chicken. R45 stated that she could use some help but no one is here but her. On 6/27/23 at 11:00 AM, V3, Assistant Director of Nursing (ADON), stated that R45 is alert and will talk with you. V3 stated that you have to initiate it. V3 stated that she is not sure why R45 had a plastic knife. V3 stated that R45 does not have any behaviors that would cause her to need a plastic knife. V3 stated that R45 should have had a regular knife. V3 stated that she expects staff to assist the residents as they need it. On 6/27/2023 at 11:54 AM, V4, Dietary Manager, stated that he is not sure why R45 had a plastic fork. V4 stated that they have knives. V4 stated that the residents should have gotten a regular knife. 3. R5's MDS, dated [DATE], documents that R45 is cognitively intact and requires supervision and set up assistance with meal. On 6/21/2023 at 1:12 PM, during Resident Council, R5 stated that she eats in the dining room. R5 stated that the staff leave the dining room and there is no one there to ask for help. R5 stated that she needs help with cutting her meat at times and that sometimes there is no one there to ask for help. R5 stated that during those times, she just doesn't eat it. R5 stated that she would eat more if she had help. R5 stated that when they bring you the food, they ask if you need help. R5 stated that after that they are gone. R5 stated that if you find out that you do need help, no one is there. On 6/27/2023 at 11:00 AM, V3, ADON, verified that R5 needs help with her meal. The facility's Resident Council Minutes, dated 6/5/2023, documents, Once dining room is served dietary staff leave and they don't come back till its time to clean up. Don't ask if anyone needs refills or a sub. 4. On 6/21/2023 at 1:08 PM, during Resident Council, R46 stated that she eats in the dining room. R46 stated that the staff leave the dining room and there is no one there to ask for help. R46's Minimum Data Set (MDS), dated [DATE], documents that R46 is moderately impaired with no short term or long term memory impairment. 5. On 6/21/2023 at 1:10 PM, during Resident Council, R59 stated that she eats in the dining room. R59 stated that the staff leave the dining room during the meal and there is no one to ask for help. R59 stated that she doesn't need much but there are others that do. R59's MDS, dated [DATE], documents that R59 is cognitively intact with no short term or long term memory impairment. 6. On 6/21/2023 at 1:18 PM, during Resident Council, R8 stated that she eats in the dining room. R8 stated that there are multiple people that require assistance. R8 stated that R5 needs help with cutting meat and that there is no one there. R8 stated that its not just the dietary staff it's the nursing staff as well. R5 stated that they should have a monitor in the dining room. R5 stated that you don't know that you need help until you need help. R8's MDS, dated [DATE], documents that R8 is cognitively intact. The facility's ADL Support policy, dated 5/2/23, document Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview, observation and record review, the facility failed to identify a restraint and have written risks versus benefits for 2 of 2 residents (R69, R73) reviewed for restraints in the sample of the sample of 45. Findings include: 1. On 06/20/23 at 10:28 AM, R69 was sitting in the dining room in her wheelchair with a lap buddy in place. On 6/20/23 at 11:45 AM, R69 was sitting in the dining room with a wheelchair lap buddy in place. V19, Certified Nursing Assistant (CNA), was asked to ask R69 to remove the lap buddy. R6 was unable to understand the question and made no attempts to remove the lap buddy. V22, CNA, stated, Oh, she can remove it when she wants to. R69's Admission Record, print date of 6/26/23, documents that R69 was admitted on [DATE] and has diagnoses of Alzheimer's Disease, Anxiety and Delirium. R69's Minimum Data Set (MDS), dated [DATE], documents that R69 is severely cognitively impaired. R69's Physical Restraint Assessment, dated 6/8/23, fails to document that R69 has a (lap cushion) and the risk versus benefits of using a (lap cushion). This Physical Restraint Assessment documents, C. Is this device a restraint? No. If no, explain why: the Resident can self release the (lap cushion) if she desires to. It continues, D. Informed Consent Obtained with risks and benefits explained to RP (representative). 2. On 6/20/23 at 10:27 AM, R73 was sitting in the dining room in her wheelchair with a lap buddy in place. On 6/20/23 during continuous observation from 11:42 AM through 11:47 AM, R73 was sitting in the dining room in her wheelchair with a lap buddy in place. R73 was attempting to remove the lap buddy and stand up form her wheel chair. R73 was visibly trying to remove the device to stand. On 6/20/23 at 11:48 AM, R73 was questioned if she could remove the lap buddy. R73 stated, I can't get it. On 6/20/23 at 11:49 AM, V22, Dementia Unit Director / CNA, stated, She picks at it all the time. V22 was questioned if R73 can remove the lap buddy, V22 stated, No, she can't. R73's Admission Record, print date of 6/26/23, documents that R73 was admitted on [DATE] and has diagnoses of Alzheimer's Disease, Anxiety and Dementia. R73's MDS, dated [DATE], documents that R73 is severely cognitively impaired. R73's Physical Restraint Assessment, dated 6/9/23, fails to document that R69 has a (lap cushion) and the risk versus benefits of the use of a (lap cushion). This Physical Restraint Assessment documents, C. Is this device a restraint? No. If no, explain why: She id able to remove (lap cushion) several times a day when asked. It continues, D. Informed Consent Obtained with risks and benefits explained to RP (representative). On 6/26/23 at 11:30 AM, V3, Director of Nurses (DON), stated, R73 and R69 both could take off the (lap cushion) when she assessed them. (V22) should have came to me and told me. I did not know that the Physical Restraint Assessment that we fill out on the residents for the (lap cushion) needed to have the risk and benefits written. We just explain the device to the families and explain how it will help them. I really don't see any risks for the use of a (lap cushion). We use it because both of them are confused, impulsive and it makes them feel secure to have something around their waist lap area. The Physical Restraint Policy, dated 9/15/2019, documents, Procedure: 1. Physical restraint shall be used by this facility only when it is has been determined by the Interdisiplinary Care Plan Team that they are required to treat a resident's medical symptoms or as a therapeutic Care Plan Team that they are required to treat a resident's medical symptoms or as a therapeutic intervention, as ordered by a physician, and based on an overall assessment, physical restraint assessment, and the care planning process has been completed. 2. The facility shall only apply a physical restraint after obtaining the informed consent of the resident, the resident's guardian, or other authorized representative. Informed consent shall include documented information about the potential negative outcomes of the specific devices / methods use. Consents will be reviewed and renewed annually per state regulation.

Based on observation, interview and record review the facility failed to ensure safe transfers for 2 of 7 residents (R59, R31) reviewed for falls in the sample 45. Findings include: 1. 06/22/23 at 8:24 AM, V7, Certified Nurse Aide (CNA), transferred R59 from her bed to her wheelchair with hands on assist. R59's Care Plan, initiated date of 6/4/21, documented R59 requires two staff with physical assistance during transfers, toileting and bathing, also, R59 has a history of falls due to weakness , limited mobility and pain. R59's Minimum Data Set (MDS), dated [DATE], documented R59 has mild impaired memory cognition. R59's Fall Risk assessment dated [DATE], documented balance problems while standing and as high risk for falls. On 6/20/23 at 9:30 AM, R59 stated she requires assistance for transferring and only one nursing staff assist and they do not put a belt around her, they just hold her arm and transfer where she needs to go. On 6/20/23 at 11:15AM, V12, CNA, stated R59 is transferred with one assist, no gait belt. On 6/22/23 at 10:32 AM, V14, Occupational Therapy, states, (R59) should be transferred with a gait belt, especially due to her body size and if she was to lose balance and go down on to the floor. 42108 2. R31's Care Plan, dated 5/14/19, documents that R31 has Self-Care Deficit As Evidenced by: Needs extensive assistance with ADLs (activities of daily living) Related to history of L3 spinal fracture, weakness, occasional pain It continues Transfer: One person physical assistance required R31's MDS, dated [DATE], documents that R31 requires extensive assist of 1 staff for transfer. On 6/20/23 at 12:48 PM, V5, CNA, assisted R31 to the toilet, in the bathroom inside her room. V5 grabbed R31 under her left arm and pulled R31 into a standing position. R31 balance unstable, waving back and forth when attempting to stand. V5 grabbed R31 around the waist and pulled down R31's clothing and assisted R31 to sit on the toilet. At 12:57 PM, V5 grabbed R31 under the arm and assisted R31 into a standing position and assisted with cleaning R31. V5 pulled up R31's clothing and assisted R31 into her wheelchair. V5 did not apply gait belt prior to transfer and did not use during transfer. R31's gait belt was hanging on the back of the door in her room. On 6/22/2023 at 3:20 PM, V3, Assistant Director of Nurses (ADON), stated that when a staff manually transfers she expects them to use a gait belt. The facility's Gait Belt Policy, dated 10/1/22, documents It is the facilities responsibility to assure that the use of gait belts are used with all transfers and transports of a resident, to assure safety for the residents and staff. C.N.A.'s are expected to use the gait belt whenever ambulating or transferring a resident for safety of the resident and employee. Gait belts must be used when helping the resident move from the bed, chair, or commode/toilet.

Based on interview, observation and record review, the facility failed to perform hand hygiene before donning gloves, in between glove changes and after removing gloves for 3 of 14 residents (R17, R21, R69) in the sample of 45. Finding include: 1. On 6/20/23 at 11:23 AM, V19, Certified Nurse Aide (CNA), and V22, CNA, assisted R69 out of her wheelchair and walked her from the dining room to her bathroom to use the restroom. Once in the bathroom, R69's pants, hip protectors and incontinent brief were pulled down. R69 was assisted onto the toilet. R69's incontinent brief was soiled with urine. V19 used washed cloths to cleanse the perineal and rectal area. When V19 would finish wiping, she would place the soiled cloths onto the back of the toilet seat. Once the care was finished, the soiled cloths were left on the back of the toilet seat. V19 and V22 walked R69 out of her room to the dining room. At the beginning of incontinent care, V19 and V22 donned gloves without hand hygiene, during care V19 changed gloves 3 times without hand hygiene between. V22 changed gloves 2 times without hand hygiene in between. At the end of care, V19 removed her gloves without hand hygiene and assisted R69 to the dining room. On 6/27/23 at 10:28 AM, V3, Assistant Director of Nurses (ADON), stated, Staff should always wash their hands before donning gloves, in between glove changes and after they remove the gloves. V3 further stated that soiled linens should not be left on the toilet seat. 40650 2. On 6/21/23 at 3:10 PM, V2, Director of Nurses (DON), entered R17's room, sanitized both hands, applied clean gloves, removed old wound dressing of clear tape, then removed dirty gloves, applied clean gloves, without benefit of hand hygiene. V2 then opened a clean package of the drainage dressing/tubing and then removed her dirty gloves, went to resident's door opened to request a waste receptacle bag, from a nearby nursing staff. She then returned to the resident's bed, applied clean gloves, without benefit of hand hygiene, opened a clean wound equipment packet, cut pieces of clear tape that was applied around the parameter of the wound of R17's left heel. V2 then measured R17's heel wound using the same gloves. V2 then removed dirty gloves, applied clean new gloves, without benefit of hand hygiene, cut pieces of the vacuum black foam which was applied to the heel wound that was open to air at this time, and being applied to the heel wound with the foam and covered with clear tape. V2 then removed her dirty gloves and applied clean gloves, without benefit of hand hygiene, with the same gloves, R17's left foot was secured with a clean new vacuum tubing that was connected to the wound vacuum pump machine. 3. On 06/22/2023 at 3:40 PM, V2, DON, performed hand hygiene, donned gown and gloves and entered R21's room with wash cloths and dressing supplies. R21's door had a sign on it documenting enhanced barrier precautions. V2 wetted the wash cloths, cleaned R21's floor that had feces on it, removed gloves, donned new gloves, exited room and returned with more gloves. At 4:00 PM V2, with a soap and wetted wash cloth, cleansed the bowel movement off the side of R21's left foot, removed gloves and donned another pair of gloves without benefit of hand hygiene. V2 took bottle of wound cleanser, sprayed left outer ankle pressure ulcer, and patted it dry. V2 removed her gloves, took santyl ointment out of the bag it was stored in and without performing hand hygiene, donned a pair of clean gloves. V2 then opened the package of calcium alginate, took scissors out of her pocket, and cut a piece to fit the R21's wound bed. V2 then applied the santyl ointment to the calcium alginate dressing, replaced the cap to the santyl ointment and then applied, with the same gloved hands, the dressing to R21's left outer ankle pressure ulcer. V2 then, doffed gloves, removed the border dressing out of the package, initialed and dated it, donned gloves without benefit of hand hygiene and then placed it on R21's left outer ankle pressure ulcer. V2 removed her gloves and gown and exited R21's room. The facility's policy, Handwashing/Hand Hygiene, undated, documented,7. Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: It continues, D. Before performing any non-surgical invasive procedures. It continues, G. Before handling clean or soiled dressings, gauze pads, ect. H. Before moving from a contaminated body site to a clean body site during resident care; I. After contact with blood or bodily fluids; J. After handling used dressing, contaminated equipment, ect; K. After contact with object (e.g., medical equipment) in the immediate vicinity of the resident; L. After removing gloves. It continues, 8. Hand Hygiene is the final step after removing and disposing of personal protective equipment.

Based on interviews and record review, the facility failed to notify resident representative of a worsening condition to a coccyx wound for 1 (R2) out of sample of 3 and failed to consult with Physician and/or Physician's Assistant. This failure resulted in R2 being sent to the emergency room for treatment per family request. Findings include: 1.) R2's diagnosis include essential tremors, hypothyroidism, peptic ulcer, anxiety, and osteoporosis. R2's Minimum Data Set, (MDS), dated [DATE] documents, a mental status of 14 which indicates R2 is cognitively intact. MDS documents, that R2 requires supervision with eating, dressing, toileting, transfers, and personal hygiene. On 03/08/23 at 10:25am, V12, (R2's POA), states she nor her husband received notification about the burn on 02/28/2023. V12 states, she received notification on 03/04/23, when she called the facility. V12 states, she was told at that time that R2 had a small blister on her bottom. Staff were applying ointment to it, and it should be healed in a few days. V12 states, she was told that the Doctor saw the wound on 03/01/23. V12 states, she came to the facility on [DATE] to look at the wound herself. After looking at it, she demanded R2 be sent to the hospital for evaluation of what she called a burn. V12 states, that on 03/08/23, she was told by V11, LPN, (License Practical Nurse), that the area on her bottom was due to pressure. R2's Progress Noted dated, 03/06/23 at 9:30am documents, R2's sister-in-law was here and upset regarding res., (residents), bottom. She wanted res. sent to the burn unit at (Local Hospital), Local Ambulance here and took res to Hosp. R2's Progress Note dated, 02/28/23 17:34pm, documented by V6, (Registered Nurse), documents while in bedroom, bedside table was knocked over and hot coffee spilled onto residents back & buttocks. Redness is present with a slight blister to coccyx. No pain reported. No s/s, (signs and symptoms), of distress. DON, (Director of Nursing), MD, (Medical Doctor), & Administrator notified of incident. On 03/08/23 at 9:50am, V4, DON states, she expected V6 RN, (Registered Nurse), to notify the Doctor and family about R2's condition in skin change. She expected V6 to call Doctor not to send a fax. On 03/07/23 at 3:15pm, V6, RN states, V5, (Certified Nursing Assistant), came to her and told her that R2 had coffee spilled on her. V6, RN, observed a red area to R2's back side. V6 states, she observed the bottom area later in the evening, and R2 had a blister forming. V6 RN, states, she did not call the Doctor that night, but did fax him. V6 states, she attempted to call the family, but no one answered. Facility policy titled Accidents and Incidents, documents it is the responsibility of the charge nurse to complete the accident and incident in PCC, (Physician's Computer Company), and notify attending Physician and responsible parties and documents information accordingly. 2.) Facility document titled, Skin Inspection Assessment completed by V4, DON, dated 02/23/23, for R2 documents redness to coccyx, barrier cream applied. On 03/08/23 at 9:50am, V4 states, R2 had redness to her coccyx on 02/23/23, when she had assisted R2 to the bathroom. V4 stated, she completed the weekly skin checks and noted about the redness. V4 stated, she did not measure the redness on 02/23/23. V4 stated CNAs were to apply barrier cream. On 3/7/2023 at 3:15pm V6 (RN) stated, she did not call the Doctor on 02/28/23. Facility fax document dated 03/01/23 documents during dinner bedside table was knocked over and hot coffee was spilled onto R2's back/buttocks. Area red and starting to slightly blister V/S, (vital signs), stable-no pain reported. V9 (Doctor) signature notes on note and an order to monitor. R2's Treatment Administration Record dated 03/2023, documents Monitor bilateral buttock for proper healing and s/s of infection r/t, (related to), burn order date 03/01/23, start date of 03/02/23, with the following dates 03/02/23, 03/03/23, 03/04/23, 03/05/23 containing nurses' initials. On 03/07/23 at 3:30pm V7, CNA, stated, R2 had a red area and blistering on 03/01/23 on her coccyx that was starting to bleed. V7 stated, R2's skin was skin starting to peel and that she applied barrier cream. On 03/08/23 at 9:50am V4 stated she observed R2's coccyx on 03/01/23 and the skin was starting to peel. On 03/08/23 at 11:20am V11, LPN, stated, the first time he saw R2's wound, on her coccyx was on 03/02/23, stated, it was pink/red and with some open blisters on the left side of coccyx. V11 states he saw the wound again on 03/02/23 and it was more red. On 03/08/23 at 11:40am, V10, CNA, stated, the first time she saw R2's coccyx was on 03/02/23 and she had two white bandages it. V10 stated, on 03/03/23 it was red and bleeding and had open areas. V10 stated, she told the nurse, that is looked horrible. V10 stated, she did not apply any barrier cream because, she thought the nurses had a treatment for it. On 03/09/23 at 2:20pm, V14, CNA stated, she took care for R2 on the dates of 03/03/23, 03/04/23 and 03/05/23 from 7pm-7am. V14 stated, R2's coccyx was red, and skin was peeling with bleeding and spots of discoloration on 03/03/23, V14 stated she notified the nurse, unknow which one. V14 stated on 03/04/23 and 03/05/23 it looked about the same. V14 stated, I did not put barrier cream on area because, I thought the nurses were treating it. R2's Treatment Administration record dated 03/23, documents, Silvadene External Cream 1%, (Silver Sulfadiazine). Apply to sacral/buttocks topically every shift for wound, for 5 Days. Active 03/04/23, started 03/05/23 end 03/10/23. R2's only entry on Treatment Administration Record was documented on 03/05/23 which includes a Nurse Note documenting, Silvadene External Cream 1% topically applied to Foot - Both feet. R2's Physicians Orders, dated 03/07/23, documents, wash lower back/sacrum every day with warm soapy water, ok to take baths. Apply Santyl to bum, cover with Xeroform gauze and ABD, (abdominal), pad dressing. Secure with tape or mesh underwear every evening shift. V8's, (Wound Doctor), initial wound evaluation, dated 03/08/23 documents, R2 had a coffee spill and there was question whether the area on her sacrum was caused by the burn of the coffee, to me the wound looks like a very typical pressure sore not a burn. Necrosis was very adherent and not ready to be removed. Deep tissue injury is still progressing, will let Santyl work and will reassess next week for possible debridement. Off load wound, reposition per facility protocol. Limit sitting to 60 minutes, twice per day, 2 hours max. chronic stable wound with insignificant amount of necrotic tissue with no signs of infection. Monitor closely for now. Wound measures at 11.5 X 15.5 with light serous drainage, 60% necrotic tissue, 30% devitalized necrotic tissue and 10% granulation tissue. On 03/07/23 at 9:00am V3, Physician's Assistant, (PA), stated, the last time he saw R2 was 01/17/23. V3 stated, he expects nursing staff to notify him and report any new concerns, with residents. V3 stated, he is in the facility at least every week and willing to see any residents if a needed. V3 stated, he expects the nurses to tell him if someone needs to be seen. On 03/09/23 at 12:45pm, V9, Physician, stated on 03/08/23 was the first time that he saw R2's wound on her coccyx. V9 stated, that he was not notified of a red area to R2's coccyx on 02/23/23. V9 stated, himself or V3, PA, are at the facility twice or more a week and that he expects staff to notify them when a resident needs to be seen by one of them. V9 stated, he relies on the nurses to keep him updated of changes and any needs of the residents. V9 stated, he relies on the nurse's judgement to determine that. Facility provided document titled Pressure Ulcer Prevention, Identification and Treatment documents the following: the Physician is to be notified when A) pressure ulcer develops B) when there is a noted lack of improvement after a reasonable amount of time C) and/or upon signs of deterioration.

Based on observations, interviews and record review the facility failed to provide treatment for for 1 of 3 (R2, R5, R6) residents reviewed for wounds. This failure resulted in R2 being sent to the emergency room for treatment per family request on 3/6/2023 and wound specialist consultation on 3/8/2023 with diagnosis of deep tissue injury measuring 11.5 x 15.5 with 60% necrotic tissue, 30% devitalized necrotic tissue. Findings include: R2's diagnosis include essential tremors, hypothyroidism, peptic ulcer, anxiety and osteoporosis. R2's Minimum Data Set, (MDS), dated [DATE] documents a brief interview of mental status of 14 which indicates R2 is cognitively intact. MDS documents that R2 requires supervision with eating, dressing, toileting, transfers and personal hygiene. Facility document, titled Skin Inspection Assessment, completed by V4, (Director of Nursing), dated 2/23/2023, R2 documents redness to coccyx, barrier cream applied. On 3/8/2023 at 9:50am V4, stated, R2 had a redness to her coccyx on 2/23/23, when V4, CNA, assisted her to the bathroom. V4 stated, she completed the weekly skin checks and noted the redness on the Skin Inspection Assessment. V4 stated, she did not measure the redness on 2/23/23. V4 stated, the CNAs were to apply barrier cream. R2's Progress Note, dated 2/28/2023, at 5:34pm documents, while in her room the bedside table was knocked over and hot coffee spilled onto R2's back & buttocks. Redness is present with a slight blister to coccyx. No pain reported. No s/s of distress. DON, MD & Administrator notified of incident. On 3/7/2023 at 3:15pm V6, (RN), stated, she did not call the Doctor, on 2/28/2023. Facility fax document dated 3/1/2023 documents, during dinner, (in room), bedside table was knocked over and hot coffee was spilled onto R2's back/buttocks. Area is red and starting to slightly blister V/S stable-no pain reported. V9, (Doctor), signature and order to monitor. On 3/8/2023 at 9:50am V4 stated, she expected V6 to notify Doctor and family about R2's condition changes. V4 stated, she expected V6 to call Doctor not to send a fax. R2's Treatment Administration Record, dated 3/2023 documents, monitor bilateral buttock for proper healing and s/s of infection r/t burn, Order Date 03/01/2023 start date of 3/2/2023 with the following dates 3/2/2023, 3/3/2023,3/4/2023, 3/5/2023 containing nurses' initials. On 3/7/2023 at 3;30pm V7, CNA stated, R2 had red area and blistering on 3/1/2023 to coccyx that was starting to bleed. V7 stated, R2's skin was starting to peel and that she applied barrier cream as told. On 3/8/2023 at 9:50am V4 stated, she observed R2's coccyx on 3/1/2023 and the skin was starting to peel but, she did not see any blisters. On 3/8/2023 at 11:20am V11, LPN, stated, the first time he saw R2's wound on her coccyx was on 3/2/2023, states it was pink/red and some an open blister on the left side of coccyx. V11 states, he saw the wound again on 3/2/2023 and it was more red. On 3/8/2023 at 11:40am V10, CNA, stated, the first time she saw R2's coccyx was on 3/2/2023 and she had two white bandages on her. V10 stated, on 3/3/2023 it was red and bleeding and had open areas. V10 stated, she told the nurse that is looked horrible. V10 stated, she did not apply any barrier cream because, she thought the nurses had a treatment for it. On 3/9/2023 at 2:20pm V14, CNA, stated, she cared for R2 on the dates of 3/3/2023, 3/4/2023 and 3/5/2023 from 7pm-7am. V14 stated, R2's coccyx was red, and skin was peeling, and it was bleeding with spots of discoloration on 3/3/2023, V14 stated, she notified the nurse. V14 stated, on 3/4/2023 and 3/5/2023 it looked about the same. V14 stated, I did not put barrier cream on her because, I thought the nurses were treating it. On 3/7/2023 at 9:00am V3, (Physician's Assistant), stated, the last time he saw R2 was 1/17/23. On 3/9/2023 at 12:45pm V9, (Physician), stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. R2's treatment administration record dated 3/2023 documents Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to sacral/buttocks topically every shift for wound for 5 Days Active 03/04/2023 start 03/05/2023 end 03/10/2023. R2's only entry on Treatment Administration Record, (TAR), is for 3/5/2023 which includes nurse note documenting Silvadene External Cream 1 % topically applied to Foot - Both feet. R2's progress noted dated 3/6/2023 at 9:30am documents R2's sister-in-law was here and upset regarding res., (resident), bottom. She wanted res. sent to the burn unit at hospital. Ambulance here and took res. On 3/8/2023 at 10:25am V12 (R2's POA) stated, she came in on 3/6/2023 and saw wound on coccyx and demanded R2 be sent to the hospital for evaluation of her burn. V12 stated, that on 3/8/2023 she was told by V11 that the area on her bottom was due to pressure. R2's Physicians Orders dated 3/7/2023 documents Wash lower back/sacrum every day with warm soapy water. Ok to take baths. Apply Santyl to bum. Cover with Xeroform gauze and ABD, (Abdominal), pad dressing. Secure with tape or mesh underwear every evening shift. R2's Progress Notes dated 3/7/2023 from V3 documents, there is a large sacral wound, (see nursing measurements), symmetrical full thickness with erythema and no blanching dermas centrally. Perirectal area/vaginal area not included in wound. Dx sacral wound. ER referral to [NAME]. On 3/8/2023 at 9:00 am V8, (Wound Doctor) stated, wound looks like a deep tissue injury. V8's initial wound evaluation dated 3/8/2023 documents, R2 had a coffee spill and there was question whether the area on her sacrum was caused by the burn of the coffee, to me the wound looks like a very typical pressure sore not a burn. Necrosis was very adherent and not ready to be removed. Deep tissue injury is still progressing will let Santyl work and will reassess next week for possible debridement. Off load wound, reposition per facility protocol. Limit sitting to 60 minutes twice per day 2 hours max. chronic stable wound with insignificant amount of necrotic tissue an no signs of infection. Monitor closely for now. Wound measures at 11.5 X 15.5 with light serous drainage, 60% necrotic tissue, 30% devitalized necrotic tissue and 10% granulation tissue. On 3/7/2023 at 9:00am V3 stated, he expects nursing staff to notify him and report any new concerns with residents. V3 stated, he is in the facility at least every week and is willing to see any of residents if a need arises. V3 stated, he expects the nurses to tell him if someone needs to be seen. On 3/8/2023 at 9:50am V4 stated, that she expects her staff to notify Doctor of condition of wound. V4 stated, she was aware of the order from R2's primary Doctor to monitor wound and she expected her nurses to monitor the wound. 3/9/2023 12:45pm V9 stated, he defers the wound care to the Wound Doctor, that he agrees with deep tissue injury and the care that the Wound Doctor has ordered. V9 stated, that he was not notified of a red area to R2's coccyx on 2/23/2023. V9 stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. V9 stated, himself or V3 are at the facility twice or more a week and that he expects staff to notify them when a resident needs to be seen by one of them. V9 stated, he relies on the nurses to keep him updated of changes and any needs of the residents. V9 stated, he relies on the nurse's judgement to determine that. Facility provided pressure ulcer policy documents includes the following: it is the responsibility of the charge nurse/designee to care for pressure areas and provide treatments as ordered. It is the responsibility of the charge nurse/designee to measure and document on the pressure areas weekly. It is the responsibility of the charge nurse/designee to monitor for healing progress and ensure appropriate treatment are in use. It is recommended that DON/Designee make frequent pressure ulcer rounds with the charge nurse. It is the responsibility of the CNA to report any skin conditions to the charge nurse immediately upon identification. When a pressure ulcer is identified whether in house or upon a resident's admission the area will be assessed using the skin and wound assessment and initial treatment started per Physicians' Orders.

Based on observations, interviews and record review the facility failed to provide treatment for a pressure ulcer for 1 of 3 (R2, R5, R6) residents reviewed for pressure ulcers. This failure resulted in R2 being sent to the emergency room for treatment per family request on 3/6/2023 and wound specialist consultation on 3/8/2023 with diagnosis of deep tissue injury measuring 11.5 x 15.5 with 60% necrotic tissue, 30% devitalized necrotic tissue. Findings include: R2's diagnosis include essential tremors, hypothyroidism, peptic ulcer, anxiety and osteoporosis. R2's Minimum Data Set, (MDS), dated [DATE] documents a brief interview of mental status of 14 which indicates R2 is cognitively intact. MDS documents that R2 requires supervision with eating, dressing, toileting, transfers and personal hygiene. Facility document, titled Skin Inspection Assessment, completed by V4, (Director of Nursing), dated 2/23/2023, R2 documents redness to coccyx, barrier cream applied. On 3/8/2023 at 9:50am V4, stated, R2 had a redness to her coccyx on 2/23/23, when V4, CNA, assisted her to the bathroom. V4 stated, she completed the weekly skin checks and noted the redness on the Skin Inspection Assessment. V4 stated, she did not measure the redness on 2/23/23. V4 stated, the CNAs were to apply barrier cream. R2's Progress Note, dated 2/28/2023, at 5:34pm documents, while in her room the bedside table was knocked over and hot coffee spilled onto R2's back & buttocks. Redness is present with a slight blister to coccyx. No pain reported. No s/s of distress. DON, MD & Administrator notified of incident. On 3/7/2023 at 3:15pm V6, (RN), stated, she did not call the Doctor, on 2/28/2023. Facility fax document dated 3/1/2023 documents, during dinner, (in room), bedside table was knocked over and hot coffee was spilled onto R2's back/buttocks. Area is red and starting to slightly blister V/S stable-no pain reported. V9, (Doctor), signature and order to monitor. On 3/8/2023 at 9:50am V4 stated, she expected V6 to notify Doctor and family about R2's condition changes. V4 stated, she expected V6 to call Doctor not to send a fax. R2's Treatment Administration Record, dated 3/2023 documents, monitor bilateral buttock for proper healing and s/s of infection r/t burn, Order Date 03/01/2023 start date of 3/2/2023 with the following dates 3/2/2023, 3/3/2023,3/4/2023, 3/5/2023 containing nurses' initials. On 3/7/2023 at 3;30pm V7, CNA stated, R2 had red area and blistering on 3/1/2023 to coccyx that was starting to bleed. V7 stated, R2's skin was starting to peel and that she applied barrier cream as told. On 3/8/2023 at 9:50am V4 stated, she observed R2's coccyx on 3/1/2023 and the skin was starting to peel but, she did not see any blisters. On 3/8/2023 at 11:20am V11, LPN, stated, the first time he saw R2's wound on her coccyx was on 3/2/2023, states it was pink/red and some an open blister on the left side of coccyx. V11 states, he saw the wound again on 3/2/2023 and it was more red. On 3/8/2023 at 11:40am V10, CNA, stated, the first time she saw R2's coccyx was on 3/2/2023 and she had two white bandages on her. V10 stated, on 3/3/2023 it was red and bleeding and had open areas. V10 stated, she told the nurse that is looked horrible. V10 stated, she did not apply any barrier cream because, she thought the nurses had a treatment for it. On 3/9/2023 at 2:20pm V14, CNA, stated, she cared for R2 on the dates of 3/3/2023, 3/4/2023 and 3/5/2023 from 7pm-7am. V14 stated, R2's coccyx was red, and skin was peeling, and it was bleeding with spots of discoloration on 3/3/2023, V14 stated, she notified the nurse. V14 stated, on 3/4/2023 and 3/5/2023 it looked about the same. V14 stated, I did not put barrier cream on her because, I thought the nurses were treating it. On 3/7/2023 at 9:00am V3, (Physician's Assistant), stated, the last time he saw R2 was 1/17/23. On 3/9/2023 at 12:45pm V9, (Physician), stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. R2's treatment administration record dated 3/2023 documents Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to sacral/buttocks topically every shift for wound for 5 Days Active 03/04/2023 start 03/05/2023 end 03/10/2023. R2's only entry on Treatment Administration Record, (TAR), is for 3/5/2023 which includes nurse note documenting Silvadene External Cream 1 % topically applied to Foot - Both feet. R2's progress noted dated 3/6/2023 at 9:30am documents R2's sister-in-law was here and upset regarding res., (resident), bottom. She wanted res. sent to the burn unit at hospital. Ambulance here and took res. On 3/8/2023 at 10:25am V12 (R2's POA) stated, she came in on 3/6/2023 and saw wound on coccyx and demanded R2 be sent to the hospital for evaluation of her burn. V12 stated, that on 3/8/2023 she was told by V11 that the area on her bottom was due to pressure. R2's Physicians Orders dated 3/7/2023 documents Wash lower back/sacrum every day with warm soapy water. Ok to take baths. Apply Santyl to bum. Cover with Xeroform gauze and ABD, (Abdominal), pad dressing. Secure with tape or mesh underwear every evening shift. R2's Progress Notes dated 3/7/2023 from V3 documents, there is a large sacral wound, (see nursing measurements), symmetrical full thickness with erythema and no blanching dermas centrally. Perirectal area/vaginal area not included in wound. Dx sacral wound. ER referral to [NAME]. On 3/8/2023 at 9:00 am V8, (Wound Doctor) stated, wound looks like a deep tissue injury. V8's initial wound evaluation dated 3/8/2023 documents, R2 had a coffee spill and there was question whether the area on her sacrum was caused by the burn of the coffee, to me the wound looks like a very typical pressure sore not a burn. Necrosis was very adherent and not ready to be removed. Deep tissue injury is still progressing will let Santyl work and will reassess next week for possible debridement. Off load wound, reposition per facility protocol. Limit sitting to 60 minutes twice per day 2 hours max. chronic stable wound with insignificant amount of necrotic tissue an no signs of infection. Monitor closely for now. Wound measures at 11.5 X 15.5 with light serous drainage, 60% necrotic tissue, 30% devitalized necrotic tissue and 10% granulation tissue. On 3/7/2023 at 9:00am V3 stated, he expects nursing staff to notify him and report any new concerns with residents. V3 stated, he is in the facility at least every week and is willing to see any of residents if a need arises. V3 stated, he expects the nurses to tell him if someone needs to be seen. On 3/8/2023 at 9:50am V4 stated, that she expects her staff to notify Doctor of condition of wound. V4 stated, she was aware of the order from R2's primary Doctor to monitor wound and she expected her nurses to monitor the wound. 3/9/2023 12:45pm V9 stated, he defers the wound care to the Wound Doctor, that he agrees with deep tissue injury and the care that the Wound Doctor has ordered. V9 stated, that he was not notified of a red area to R2's coccyx on 2/23/2023. V9 stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. V9 stated, himself or V3 are at the facility twice or more a week and that he expects staff to notify them when a resident needs to be seen by one of them. V9 stated, he relies on the nurses to keep him updated of changes and any needs of the residents. V9 stated, he relies on the nurse's judgement to determine that. Facility provided pressure ulcer policy documents includes the following: it is the responsibility of the charge nurse/designee to care for pressure areas and provide treatments as ordered. It is the responsibility of the charge nurse/designee to measure and document on the pressure areas weekly. It is the responsibility of the charge nurse/designee to monitor for healing progress and ensure appropriate treatment are in use. It is recommended that DON/Designee make frequent pressure ulcer rounds with the charge nurse. It is the responsibility of the CNA to report any skin conditions to the charge nurse immediately upon identification. When a pressure ulcer is identified whether in house or upon a resident's admission the area will be assessed using the skin and wound assessment and initial treatment started per Physicians' Orders.

Based on observation, interview and record review the facility failed to provide adequate supervision, and implement progressive interventions to prevent further falls for 1 of 3 residents (R2) reviewed for accidents in the sample of 4. This failure resulted in multiple falls, 2 of which required Emergency Medical Services for evaluation for head injury with multiple bruises and lacerations to her face and head. Findings include: R2's Undated Face Sheet documents she was admitted to the facility on [DATE] Diagnoses included Alzheimer disease, anxiety disorder, rheumatoid arthritis, cerebral infarction, and urinary tract infection. R2's Admission Fall Risk Assessment, dated 7/26/2022 documents she was a low risk for falls. R2's Minimum Data Set (MDS), dated [DATE] documents she has severely impaired cognition, requires extensive assistance of two for Transfers, Locomotion on unit, Toileting. R2's Balance during Transitions and Walking not steady only stable with staff assistance, and has history of falls. R2's Fall Incident Reports document dates of falls: 10/13/2022 no injury, 10/22/2022 no injury but sent to local hospital emergency room (ER) related to R2 hitting her head, 11/14/2022 no injuries, 11/28/2022 hematoma to back of head, hematoma to left side of face, laceration to face, 12/2/2022 no injuries, 12/7/2022 no injuries, 12/14/2022 bruise to right front of shoulder, 12/19/2022 no injuries, 12/20/2022 hematoma to back of head, 12/21/2022 unable to determine injury to face, 12/25/2022 bleeding hematoma to face, and 12/30/2022 no injuries. R2's Care Plan, dated 11/15/2022 documents no progressive fall interventions for the falls on 11/14/2022, 12/2/2022, 12/14/2022, 12/19/2022, 12/20/2022, 12/21/2022, and 12/25/2022. R2's Care Plan dated 12/2/2022 documents R2 has severely impaired cognition and /or wandering behavior related to diagnosis to Dementia. Interventions dated 10/13/2022 include provide ensure resident transfers into dining room chair for meals, Put sign above bed (R2's) bed so she knows which bed is hers, keep call light within reach, keep environment clutter free, PT (Physical Therapy), OT (Occupational Therapy), ST (Speech Therapy) to eval (evaluate) and treat. R2's Progress Note, dated 10/13/2022 at 11:41 AM, documents resident had a fall and was on the floor. Upon entering the Dining room resident was observed sitting on her butt, back leaning against the wall with her leg stretched out in front of her. The floor was dry, she had gripper socks on feet, there was a empty wheelchair at the table and she was sitting on a soft collapsible floor sign. R2's Incident Report, dated 10/22/2022 at 6:50 AM, documents resident fell in another residents room and was on her left side. Incident report states Certified Nurse Aide (CNA) thinks resident hit her head. Order received to send resident to local Emergency Department (ED) for evaluation and treatment for fall. R2's Progress Note, dated 10/22/2022 2:32 PM, documents call received from local ER (emergency room ) stating resident was ready to return to facility. Resident has Urinary Tract Infection (UTI) and was given IV (intravenous) antibiotic in the ER and will return to facility with orders for Cefelexin (oral antibiotic). R2's Incident Report, dated 11/14/2022 at 9:59 AM, documents resident sitting on her buttocks in front of dining room chair in activity room on the special care unit. R2's Fall Incident Report, dated 11/28/2022 at 7:34 PM, documents resident was sitting on the floor in front of the toilet leaning on her arm. Another resident was leaving the dining room and stated I think someone needs help. 911 was called. Hematoma to face, hematoma to back of head, laceration on her face. Resident was transferred to local ED. R2's Progress Note, dated 11/28/2022 at 11:50 PM, documents resident returned to facility via stretcher per Ambulance. Resident incontinent of urine. Hematoma to left side of head and bruising around left eye. Multiple small lacerations to left forehead and nasal area. R2's Fall Incident Report, dated 12/2/2022 at 12:15 PM, documents resident was sitting on her buttocks with legs stretched out in front of her asking staff to help her up. Resident was in the door way to the activity room with the door to her left side and facing the dining area. The food cart was directly behind resident in the doorway. Staff member was standing at the tables gathering up dishes and when the staff turned to take the dirty dishes to the food cart resident was standing directly behind the staff. That staff person bumped into resident and resident lost her balance and fell into the door. Resident hit her head on the door and slid to the floor. R2's Fall Incident Report, dated 12/7/2022 at 11:30 AM, documents resident was sitting on her buttocks on the floor in the dining room. Agency CNA witnessed the fall and stated she R2 hit her head on the right side. R2's Fall Incident Report, dated 12/14/2022 at 2:10 PM, documents resident was sitting on her butt next to the air conditioner in the activity room scooting towards the doorway. Resident was bleeding on the left side of her face. 911 was called for an ambulance. Bruise was forming on the top of her left shoulder. Previous hematoma had re-opened and was bleeding. R2's Fall Incident Report, dated 12/19/2022 at 6:00 PM, documents resident was on her left side on the hallway floor. There was blood on the floor next to resident. Resident had a bloody nose, and an old skin tear above the eye had re-opened. R2's Fall Incident Report, dated 12/20/2022 at 5:30 PM, documents resident was found lying on her back in another resident's room and she has a bump on the back of her head. R2's Fall Incident Report, dated 12/21/2022 at 8:33 PM, documents resident was on the floor sitting upright. Unable to determine injury to her face. R2's Fall Incident Report, dated 12/25/2022 at 1:30 PM, documents resident was observed lying flat in a prone position with her left arm under her head and right arm out in front of her body. Legs were straight. She was lying with her back against the bathroom door, head towards the hall door in another residents room. Resident did have visible blood coming from a previous hematoma on her forehead. Bleeding from hematoma from previous hematoma to her forehead. R2's Fall Incident Report, dated 12/30/2022 at 6:32 AM, documents resident was sitting on another resident's floor mat next to her bed. Her feet went towards the door, bottom on the floor. No injuries observed at time of incident. On 12/27/2022 at 12:04 PM, V4, MDS/Care Plan Coordinator, stated they talk about new interventions for falls in morning meetings that they typically have Monday thru Friday. V2, Director of Nursing (DON), and V5, Assistant Director of Nursing (ADON), does the investigations and sometimes has the root cause for the fall before the meeting, Sometimes the nurse on the floor making the fall report will document new interventions (progressive interventions) V4 stated she does not put a new intervention in place until its discussed in the meeting. Sometimes root cause analysis is discussed in morning meeting, sometimes not. On 12/27/22 at 12:43PM, V8, Special Care Coordinator/CNA, stated they have falls back there on the unit and have to redirect constantly. V8 stated R2 is constantly getting up and walking by herself. They try to redirect as much as they can. They are working with her on medications, with ativan she doesn't sleep well at night and she wanders, paces, and then she gets tired from pacing the hallway and will fall, she wanders in other residents' rooms too. On 12/27/22 at 1:03 PM, V8 was walking R2 in the hallway without a gait belt and holding R2's hand. R2 walked with tiny steps, shuffling gait, and wobbly at times, gait unsteady. V8 stated she wasn't really sure about the policy of using a gait belt. On 12/27/22 at 1:37 PM, V11, CNA, stated, We have (R2) that falls a lot and wants to walk the hallways and she paces at a fast walk. Those bruises on her face is from one of her falls and when she falls she seems to fall on her face. I try my best to keep an eye on her but she is so fast at getting up. We do not get any new interventions for (R2) to keep her from falling again. Nurse gives us report when resident falls but no report of any new interventions for falls. On, 12/27/2022 at 1:54 PM, V12, Licensed Practical Nurse (LPN), stated R2 has advanced dementia and has had frequent falls where she has gotten bruises, lacerations, and abrasions on her face. She has a history of exit seeking, and aggression with other residents. She is just so exhausted from up pacing the halls and going in and out of residents rooms. V12 stated he is at his wits end she falls, falls, falls. Don't know what to do with her and her falls. V12 stated, We can't strap her down. As far as interventions, the management team tells us if any new interventions, but we haven't been told of any new interventions with (R2) with her falls. On 12/27/22 1:57 PM, V1, Administrator, stated not really sure of R2's root cause of her falls. V1 stated, We sent her to psych (psychiatric) hospital for medication adjustment, she came back zonked, she was sleeping all the time. We called her MD (medical doctor) and weaned her back off the medications. V1 stated that R2 does not require assistance, she is independent with her walking. On 12/27/22 2:05 PM, V2, DON, stated, she agreed with V1's statement except V2 stated R2 requires extensive assistance and is not independent. On 12/27/22 at 3:34 PM, R2 was sitting in her recliner trying to get up. Her recliner was near her bed. V13, CNA, and V14, CNA, applied gait belt around resident's waist to transfer from her recliner to ambulate her to the bathroom. Both CNA's had their hands on the gait belt during ambulation. R2 had an unsteady gait, wobbling, she walked with tiny steps and shuffling gait. On 12/28/22 at 8:00 AM, R2 was up ambulating by herself in the hallway carrying a glass of juice in her left hand (hand is noted to be shaking) R2's gait was unsteady, wobbly, and walks with tiny steps and shuffling gait. Two CNA's were in the dining room assisting other residents while R2 was walking the hallway unassisted. Another resident was in her wheelchair and this resident pushed her feet making her wheelchair roll backwards to the point it almost hit R2 while walking in the hallway alone. V16, CNA, saw what was happening and ran over to stop the other resident from running over R2. V12, LPN, was standing at the med cart passing medications and did not see what happened. On 12/28/22 at 8:09 AM, V17, CNA, took R2 by the hand and walked R2 down the hallway without a gait belt. Placed R2 in her recliner, V17 CNA lifted R2 underneath her arms to scoot resident back in the recliner. R2's gait is unsteady gait, wobbly, staggered, took tiny steps and shuffling gait while walking. On 12/28/22 at 8:11 AM, R2 got back up from her recliner unassisted. R2 walked into another resident's room continues with short steps, shuffling gait, wobbling with unsteady gait. No staff was watching over R2 at this time. On 12/28/22 at 8:17 AM, V10, CNA, saw R2 up and stated her gait is not steady, walked to R2 placed a gait belt on R2 and walked her in the hallway. R2's gait is unsteady, wobbly, she continues to take little steps and walks with shuffling gait. V10 took R2 to her room and requested that V12, LPN, help to assist R2 to bed and scoot R2 up in the bed. On 12/28/22 at 10:48 AM, V18, facility Beautician/ R2's daughter in law, stated she visits R2 in the evenings after she gets done with work at the facility. V18 stated she takes in food and drinks for R2 and sits one on one and feeds her supper at times. V18 stated this facility has zero interventions they put in place for R2. V18 stated they sit her down in the recliner, or lay her in the bed, her anxiety is high and always has been before she got dementia. V18 stated many times when she goes in the unit during the evening, R2 is up walking in the hallway and very unsteady on her gait, she wobbles a lot when she walks. V18 states she sees CNA's on their phones most of the time or talking to each other instead of watching or taking care of the residents. On 12/28/22 at 3:45 PM, V15, CNA, stated she works as a float throughout the facility and the unit at times. V15 stated she witnessed R2 fall on Tuesday and Wednesday evening. V15 stated on Tuesday, she was in the hallway and heard another resident yell out R2's on her back on the floor crying. R2 fell down and hit her head, R2 had a huge knot on the back of her head, no bleeding. R2 fell in another resident's room. V15 called V2, DON, back to the unit and they moved R2 to a wheelchair. R2 did not go to ER, family did not want her sent out. V15 stated on Wednesday, R2 fell again. R2 had been sleeping in her bed, woke up and was wobbling out of her room. V15 stated she was charting outside of R2's room in the hallway. R2 had walked down to the locked door and had been knocking on the doors, she turned around wobbling, fell forward and her face hit the floor, there was blood coming from her forehead, her nose was bleeding from inside of her nose. V15 stated she yelled for V14 to use the intercom to call a nurse stat (immediately) to the unit. They applied pressure on her nose. R2 did not go to ER. V14 CNA and V15 CNA both stated Management gives us no new interventions or communication for any new interventions do the best we can with what staff we have. Family will come in at times especially the daughter in law she works here and will sit and feed her in the evenings. We need staff here to help Activities is here at times till 5pm on the unit but not daily. On 12/29/22 at 10:09 AM, V7, Primary Physician, stated he was not aware that R2 had that many falls - he asked how many falls she had exactly because he was not aware. V7 then stated it upsets him that the facility did not put further interventions in place for R2 prior to giving her medications. V7 stated giving Ativan and Morphine increasingly puts R2 who has dementia at higher risk for falling. V7 stated he felt the facility should be doing more activities to keep R2's mind occupied, increase staffing in the unit, walking her with a gait belt, alarms. On 12/29/2022 at 11:06 AM, V19, Nurse Practitioner, for V27, Psychiatrist, stated she saw R2 on 12/9/22 at the facility for psychiatric evaluation. She had multiple medication changes per medical doctor orders and hospital visit without my knowledge. V19 stated, I did not get notification of all falls nor medication changes. By reviewing above doses with only one fall in all the 13 doses of Ativan administered, it is in my professional opinion that the Ativan is not a contributor to falls on 12/20/22 or 12/25/22. The use of Ativan with Morphine when used together may cause increased sedation affect fall rates. After reviewing the medical chart, it does not appear she was given these two medications at the same time. On 12/29/22 at 1:04 PM, V24, Physician Assistant (PA), for V7, Primary Physician, for R2, stated regarding R2's falls, he did not know that she had so many frequent falls. V24 stated he thought she had a few and was not of aware of all those falls. Went back to the clinic to discuss with V7 her falls and medications. But again neither one of us was aware of the number of falls she sustained. I did know she was placed on ativan for 14 days but again would not have given the ativan or morphine with her having dementia and all those falls. Ativan and Morphine puts R2 at a higher risk for falls with her dementia and falls. The facility's Fall Risk Assessment policy and procedure, dated March 2018, documents, The nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident - centered falls prevention plan based on relevant assessment information. While many falls are isolated individual resident, some individuals fall repeatedly. Information and observation assist in identifying patterns and may illustrate underling case. After a first fall the staff (and physician, if possible) will refer the individual to therapy services to identify patterns of gait, balance, strength and other factors that may benefit from retraining, or strengthening. Therapy will make recommendation to the physician or staff about opportunities to reduce risk and improve safety. The interdisciplinary team, therapy team, nursing or physician will recommend specific interventions to reduce identified factors that increase risk for falling. The interdisciplinary team, nursing, physician will recommend specific interventions that may reduce the probability of serious injury in the event a fall does occur. Nursing is responsible for implementation these interventions. Nursing and MDS are responsible for assuring timely and accurate Care Planning to assure full assessment and interventions implementation.

Based on observation, interview, and record review, the facility failed to assess, monitor the effectiveness of interventions and implement interventions while providing adequate supervision for 2 of 5 residents (R1, R2), reviewed for falls in a sample of 13. This failure resulted in R2 sustaining an epidural hematoma, multiple facial fractures, and non-displaced fracture of the spine. Findings Include: 1. The Admission Record documented R2 was admitted on [DATE]. The Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Mental Interview Status(BIMS) score of 15, indicating cognition intact. The MDS documented R2 required extensive assist with all ADLs (Activities of Daily Living), except eating. The MDS documented R2 used a walker and wheelchair for ambulation, and was incontinent of bladder. The MDS documented R2 had the following partial Diagnoses: [REDACTED]. The Care Plan initiated on 3/9/2016 and revised on 3/7/17 documented in part, Focus: (R2) resistive to care at times due to self transferring and safety issues. Removes her alarm and will fold it so it won't go off or hide it. The Care Plan further documented R2 had repeated attempts to walk unassisted. The Care Plan, revised on 8/16/17, documented R2 had a fall with injury to her left hand. The Care Plan further documented in part, R2 was at risk for falls and injuries related to Osteoporosis, Parkinson's Pain, Weakness, and having a history of falls. Care Plan documented R2 had the following falls: 1/10/17, 3/6/17, 3/23/17, 5/21/17, 6/21/17, 6/24/17, 7/7/17, 7/15/17, and 8/16/17. The only interventions listed for the 8/16/2017 fall was to toilet R2 before and after going to beauty shop appointments. The Care Plan did not document the 8/21/17 fall in which R2 suffered a epidural hematoma, multiple facial fractures, and non-displaced fracture of the spine, or list any interventions related to the 8/21/17 fall. On 8/22/2017 updated information on R2's Care Plan documents in part, (R2) refuses care from certain staff members at times and tells them to get out of her room. Fall Risk assessment dated [DATE] documented R2 as having a history of falls, having weak gait, and R2 may shuffle her feet. R2's assessment documented R2 was at high risk for falls, scoring 80, with a score of 45 or higher indicating high risk for falls. An Situation Background Assessment Recommendation (SBAR) dated 8/16/17 at 2:10 PM, documented R2 had an unwitnessed fall while ambulating to the bathroom. The SBAR documeted possible contributing factors as Other. 1a. Specify Other: Unsteady balance, noncompliant with assistance. 2. Additional Circumstances b. Alarm failure or device removal. f. Call light not activated. Description of occurrence documented in part, (R2) self transferred to toilet, no call light activated, personal alarm was removed while resident was in beauty shop and not replaced, resident stated she lost her balance. The SBAR indicated R2 suffered a bruise to her left hand from the fall. The SBAR documented as an intervention for R2 to continue to use the alarm and ensure the device was in place as needed. There was no documentation in R2's record the facility reassessed /re-evaluated current interventions for effectiveness or implemented new interventions to prevent R2 from falling in the future. An SBAR dated 8/21/2017 at 8:45 PM, documented R2 had an unwitnessed fall from bed while ambulating to the bathroom. The SBAR documented possible contributing factors which included 1. Other. Failure to comply with asking for assistance. 2a. Refused assistance from male caregiver. Assessment. 2. Mental Status a. Alert a. Person, b. Place. 2b. Orientation is: Normal for this resident. 4. Injury d. Laceration or cut e. Bruising f. Discoloration h. External head injury or trauma j. Extremity. Nature of Occurrence: Resident found on floor near bathroom. SBAR further documented in part that R2 called out at 8:40 PM. E8, Registered Nurse/RN, answered the call light. R2 stated there was nothing E8 could do for resident. The SBAR documented Shortly after words, resident fell hitting her head on the bedside table, while attempting to go to the bathroom by herself. The chair alarm was barely audible outside the bedroom door. (R2) didn't get tangled in blankets or cords. Anti-skid/slip socks were on. The SBAR documented (R2) refuses help from male caregivers Additional information on Section Care P of the SBAR documents in part, 1. Episodic Fall Care Plan: The resident will resume usual activities without further incident through next review. The resident uses electronic alarm to wheelchair, bed, recliner. Ensure the device is in place as needed. Tab alarm when in w/c. The SBAR fails to provide documentation for R2's Neurological Assessment for Complete this Section only for: Unwitnessed Fall or Fall with Head Involvement, or updated interventions for R2. Nurses Progress Note dated 8/21/2017 at 10:16 PM documents in part, (R2) fell attempting to go to the bathroom by herself. At 2045 (8:45PM), (R2) stated, 'You can't help me at all.' (E8) exited the room and was a few steps away when (E8) heard a loud noise coming from her room sounding like a watermelon being dropped to the floor. (R2) was lying on her left side with her back to her reclining chair and her head on the floor next to the bedside table. Her head was in a pool of blood. Active bleeding was noted coming from both nares. Bleeding controlled and wounds cleansed for assessment. 4 cm (centimeters) laceration noted to left eyebrow, 2 cm puncture wound noted to left zygomatic arch area and a 5 cm hematoma noted to left elbow. Assessment of spine shows no step downs, no pain to palpitation. Pelvis was stable with no pain to rocking or palpation. R2's Hospital History and Physical dated 8/22/2017 documents in part, [AGE] year old female (R2) with Parkinson's and frequent falls after another fall. L(NAME) (level of consciousness) unknown. Computed Tomography (CT) Scan of head, face, and spine reveals the following, CT head - Acute hemorrhage to represent an epidural hematoma. Hemorrhage within the left maxillary sinus. CT face - Nondisplaced fracture of the left inferior orbital wall. 2. Multiple fractures of the left maxillary sinus. 3. Nondisplaced fracture through the anterior inferior wall of the right maxillary sinus. 4. Minimally-displaced fracture of the alveolar process of the left maxilla. CT c spine - Acute nondisplaced fracture through the anterior aspect of the inferior endplate of C3. On 8/29/17 at 3:30 PM, E8, Registered Nurse (RN), stated he was the nurse on duty when R2 fell . He stated he went to answer R2's call light and that R2 refused his help. E8 stated he asked R2 if she wanted to go to the bathroom and he left the room to get a female caregiver, because that is what R2 likes. E8 stated he wasn't five steps down the hallway, and (R2) fell . He stated there was a pool of blood under R2's head, and he didn't move R2. E8 stated R2's alarm was set to voice only, and (E8) switched to an actual alarm. Voice could be mistaken for the TV. E8 stated the charting for the SBAR was new to him and he clicked R2 was in bed (prior to fall), but that she was in her recliner when he exited the room that night. On 9/1/17 at 12:45 PM, E18, CNA, stated she was working on the night R2 fell on [DATE]. She stated she attached R2's alarm string to her shirt. She stated she was in another room assisting another resident when R2 fell . E18 stated she couldn't hear the voice alert alarm because if the TV is up, alarms are difficult to hear. E18 confirmed R2 had a voice activated alarm on 8/21/17. On 8/30/17 at 8:34 AM, E9, Certified Nurse's Aide (CNA) stated that alarms are supposed to be checked every shift, but that she only checks the alarms when they don't sound. She stated R2 had a voice alert alarm and that staff doesn't hear the voice alert alarms. E9 stated We (staff) want alarms that are loud and scream so we go running to answer them. On 8/29/17 at 10:00 AM, E1, Administrator, stated All electronic alarms are checked for functionability after care on a daily basis by direct care staff, including making sure you can hear the alarm from down the hall, even the voice alert ones. On 8/30/17 at 9:45AM, E10, Corporate Nurse, stated in part she does not consider alarms an intervention, and that the alarms only alert staff that a resident has fallen. On 8/30/17 at 10:30AM, E4, Care Plan Coordinator, stated there were only two residents that had voice alert alarms in the building, and those residents were R1 and R2. On 8/31/17 at 2:45PM, E4 stated she did not do a Fall Risk Assessment or reassess R2 after she fell on [DATE]. On 8/29/17 at 5:03 PM, an onsite visit was made to another facility where R2 currently resides. She was admitted to this facility after her hospitalization . R2 was sitting up in a high back chair, with her feet elevated, and she had bilateral positioning devices to the side of her body. R2 had a cervical collar around her neck, yellow bruising to her right and left front knees. There was noticeable facial brusing to both the left and right side of R2's face. R2 stated she doesn't remember the fall in detail, but remembers the staff, wanting me to go to bed, after dinner. On 8/29/17 at 5:30 PM, Z5, Administrator at new facility where R2 currently resides, stated R2 now required a full mechanical lift in order to transfer and does not make any attempts to rise from the high back chair. On 8/29/17 at 1:18 PM, Z3, R2's Power of Attorney, stated that R2 fell on [DATE] and 8/21/17. She was informed R2 suffered a brain bleed, with the subsequent fall, and that prior to the 8/21/17 fall, R2 had always been so sharp, and now her condition is not the same, and R2 had removed the alarms prior to the 8/16/17 and 8/21/17 falls. On 9/1/17 at 3:02PM, Z6, R2's physician, stated the injuries sustained from R2's recent fall could have contributed to the decline in R2's condition, and that he found R2 to be confused upon examination. 2. R1's EHR (Electronic Health Record), undated, documents R1 was admitted to the facility on [DATE]. R1's Care Plan, dated 3/20/17, documents in part, R1 was at risk for falls related to having [DIAGNOSES REDACTED]/Paresis, Cognitive Impairment, Incontinence, History of Falls, and Poor Safety Awareness. The Care Plan also documented R1 had repeated attempts to walk unassisted, and having fallen while in recliner and/or wheelchair on 3/25/17, 5/15/17, 5/22/17, 5/27/17, 7/5/17, and 8/12/17. The Care Plan documented interventions 1. 5/23/17, non-skid pad to wheelchair and a low bed. 2. 8/15/17, Occupational and Physical Therapy to evaluate and treat, and a Call Don't Fall sign to be placed on R1's bathroom door, and to be toileted daily at 4:00PM. 3. 8/25/17, R1 received a chair and bed electronic voice activated (alert) alarm. R1's MDS, dated [DATE], documented R1 having a BIMS of 2, indicating severely impaired cognition, is incontinent of bowel and bladder, and requires extensive assist for all ADLs. The MDS further identifies R1 having in part the following Diagnoses: [REDACTED]. R1's Fall Risk Assessment, dated 8/30/17, documents R1 having a score of 55, with a score of 45 or higher, indicating high risk for falls. R1's SBAR, dated 8/25/17 at 4:10 PM, documents in part, (R1) Un-Witnessed or Suspected Fall. Pt (patient) on floor on his left side. Recliner noted to be in raised position with wheelchair close to resident. Pt unable to communicate what occurred but stated his head hurts. Unable to tell specifically where or describe pain. Hematoma noted to left side of head and bruising to left upper arm. R1's Hospital Computed Tomography (CT) scan, dated 8/25/17 at 05:49 AM, documents in part, There is redemonstration of a small amount of subarachnoid hemorrhage along the right frontal and left parietal regions also, left cerebral subdural hematoma. On 8/29/17 at 1:15 PM, Z2, R1's family, stated the facility called her on 8/25/17 to state R1 got out of personal recliner chair to self transfer to wheelchair, and was being sent to the hospital because of an injury to R1's head. Z2 also stated since admission, R1 has not been able to understand the use of the call light due to his poor cognition, is dependent on staff for all care, and has always used his electronic controls to his recliner to rise and lower the chair, even prior to the 8/25/17 fall. Z2 further stated R1 has always needed to be busy with his hands. Z2 stated she visits R1 about every other day from about 2:00 PM until after dinner, and has not noted staff to toilet R1 at 4:00 PM on a daily basis. Based on 15 minutes or less observation intervals on 8/30/17 from 3:30 PM to 4:30 PM, R1 was sitting in his wheelchair with his wife in the main dining room. No attempts from staff to toilet R1 was made during the observation period. At that time, Z2 stated R1 had not been toileted during their time in the dining room. The facility staff did not implement the intervention of toileting at 4:00 PM to prevent R1 from falling as noted in R1's Care Plan. On 8/30/17 at 4:45PM, E13, CNA, stated she had not toileted R1 during her shift, as she had just arrived for her shift around 3:00PM. E13 further stated she toilets R1 only when R1 requests to be toileted, and not at a specific time frame. On 8/29/17 at 8:30 AM, E15 (CNA), stated alarms are checked by the Department Heads and that E4 (Care Plan Coordinator) is responsible for maintenance of the alarms. On 8/29/17, at 10:00 AM, E1, Administrator stated that all alarms are checked to ensure they are functioning on a daily bases by direct care staff. E1 stated this included making sure staff can hear the alarms from down the hall, even the voice alert alarms. On 8/30/17, at 9:45 AM, E16 (CNA), stated the personal alarms are checked by E4. E16 stated she also checks the alarms at the beginning of her work shift. On 8/30/17, at 4:15 PM, E13 (CNA), stated the personal alarms are checked by her only during the beginning of her shift. On 8/31/17, at 12:00 PM, E4, Care Plan Coordinator, stated Every am (morning), all department heads check alarms devices, and during off hours, staff is aware on holidays and weekends, locations of batteries. Day staff is aware if non-functional device come to me. On 8/31/17, at 12:50 PM, E7 and E17 (CNAs) transferred R1 to the toilet from the wheelchair. E17 removed the chair pad alarm from the wheelchair and placed it in R1's reclining chair. At no time did E17 check the alarm to see if it was functioning. After toileting, E7 and E17 transferred R1 to the reclining chair, E17 and E7 left the room. The Facility Policy entitled Alarms, Use of Personal, dated 2008, documented Purpose: To minimize the risks of falls associated with unsafe transfer attempts. The Policy documented Assessment Guidelines : Fall Risk Assessment, Appropriateness for the use of the personal alarm. The Procedure section of the policy documented 1. Assess resident for the appropriateness of using a personal alarm. The Policy documented 5. Verify alarm function prior to placement. Facility Policy dated 2006, entitled Resident Assessment, documents in part, Purpose: To develop a comprehensive plan of care for the resident. Care Plan Documentation Guidelines. Problem: Identify the resident's problems and strengths. Goal: List MEASURABLE goal(s) to be accomplished. Approaches: Establish a measurable, time-limited, long-term goal. Establish measurable, time-limited, short-term goals for each problem identified. Facility Policy dated [DATE], entitled Fall Management, documents in part, Purpose: To evaluate risk factors and provide interventions to minimize risk, injury, and occurrences. Assessment Guidelines: Fall Risk Factors/Fall History, Post-fall Evaluation and Observation. Fall Prevention Procedure: 1. Evaluate risk factors for sustaining falls upon admission, while conducting interdisciplinary (IDT) care plan reviews. 3. Review, revise, and evaluate care plan effectiveness at minimizing falls and injuries during IDT walking rounds and as needed. Care Plan Documentation Guidelines: Identify fall risk and associated risk factors. Outline fall prevention strategies and approaches. Facility Policy revised on November 2016, entitled Incident Management Policy, documents in part, Procedures: All incidents will be reviewed and investigated to identify any underlying risk factors, precipitating events, contributory conditions, or environmental issues that may need to be addressed in order to reduce recurrence and contribute to a safer environment.

Based on observation, interview, and record review, the facility failed to implement effective interventions and provide adequate supervision for 2 of 9 residents (R6, R12) reviewed for falls in the sample of 15. This failure resulted in R6 sustaining a left femur fracture. Findings Include: 1. The Admission Record documents R6 was admitted on [DATE]. The Minimum Data Set (MDS), dated [DATE], identifies R6 as having long/short term memory deficits with severe cognitive impairment. The MDS documents R6 requires extensive assist of 1 staff for bed mobility and transfers. The fall risk assessment, dated 5/2/17, identifies R6 to be at high risk. The Care Plan, dated 5/24/17, identifies R6's risk for falls due to medication, arthritis, cognitive impairment, dementia, history of falls, and poor safety awareness. The Care Plan documents R6 fell on [DATE], 5/10/17, 5/17/17 and 5/20/17. The Interventions on admission include: encourage to use call light, keep call light within reach, keep environment clutter free and personal items within reach in part. An SBAR (Situation Background Assessment Recommendation), dated 5/4/17, documents at 2030 (8:30 PM), R6 had an unwitnessed fall while ambulating without assistance in her room. Possible contributing factors checked include clutter, footwear, and restlessness. The call light was documented as not activated. The report also documents R6 is unable to communicate what occurred although the report documents under a brief description resident did say she had to use the bathroom when asked. Interventions checked are keep frequently used items within reach, non-skid footwear, and tab alarm when in w/c (wheelchair) and bed. There is no intervention addressing R6's remark that she was going to the bathroom. An SBAR, dated 5/10/17 at 6:00 AM, documents R6 had an unwitnessed fall from bed while self ambulating in her room going to the bathroom. The report documents the alarm was sounding. The report documents staff heard disturbances and voices from her room and found R6 sitting on the floor closer to the room mates bed than her own. The report documents R6 stated I was just trying to go to the BR (bathroom). Response includes low bed and mat on floor, and to continue the alarm. New interventions include a toileting schedule. An SBAR, dated 5/17/17 at 1:00 PM, documents R6 had an unwitnessed fall in her room. The report documents the alarm was again sounding and call light not activated. Under relevant information, the report documents R6's alarm slid with R6 when she tipped the wheelchair forward possibly trying to get out of the recliner. The facility failed to identify the causative factor of R6's falls, failed to address R6's impulsiveness and repeated attempts to get up unassisted, and the need for staff to respond immediately to the alarm to avoid further falls within her falls prevention plan of care. An SBAR, dated 5/20/17 at 7:00 PM, documents R6 had an unwitnessed fall from bed when she attempted to self ambulate. The report documents R6 was found on the floor near bathroom and was on her left side with left arm under her. The report documents they are unaware of what she was doing prior. The report documents the leg showed deformity. The physician was notified and R6 was sent to the hospital where she was diagnosed with [REDACTED]. On 7/13/17 at 8:45 AM, E1, Administrator, stated the facility did place interventions following each fall, but was unable to provide information regarding sufficient staff to respond to R6's alarm when it sounded. E1 did state that both staff on that hall were providing care to another resident when R6's alarm sounded on 5/20/17 and wasn't able to respond in a timely manner. The facility was unable to provide an assessment towards why the alarm was chosen as an appropriate intervention for fall prevention given R6's cognitive inability to recognize it as a reminder to sit back down and ask for assistance. The facility also did not have any documentation as to how often R6 attempts to get up that staff are able to respond in a timely manner. On 5/11/17 at 10:30 AM, R6 was transferred from her wheelchair to her bed via the use of a full mechanical lift by E4 and E5, Certified Nurses Aide (CNA.) The MDS, dated [DATE], documents a decline for R6 since her falls that include transfers, incontinence of bowel and bed mobility. On 7/13/17 at 12:30 PM, E11, Unit Director, stated R6's alarm would sound often when she resided on the unit before falling and fracturing her femur. E11 stated the alarm sounding did not deter R6 from continuing to get up. On 7/13/17 at 12:35 PM, E13, CNA, stated R6's alarm would go off often. On 5/11/17 at 10:30 AM, R6 was in her wheelchair at bedside. E4 and E5 entered R6's room with a full mechanical lift. The CNAs hooked R6's sling to the lift. The wheelchair was approximately 6-7 feet away from the foot of the bed at an angle. E5 used the lift mechanics and as she lifted R6 up out of the wheelchair, E4 picked up R6's alarm out of her wheelchair with her left hand and with her right, gently guided R6 as she was moved towards the bed. R6 was leaning far to the right with E4 stating She favors her left side. E5 moved the lift over the bed and lowered R6. Neither staff had control of R6 as she was lifted from the wheelchair and moved to the bed. The Manufacturer's information provided by the facility gave no directives to full body mechanical lift use. 2. On 07/12/17 at 12:00 PM, R12 was sitting in a chair that was pushed up very close to the table. At 12:20 PM, R12 got up from the chair in the dining room unassisted and ambulated approximately four feet with no assistance. R12 had an unsteady gait and only used a toe touching method with the right foot. E10, CNA, noticed R12's limping unsteady gait and stated Why are you walking like that? The Physician order [REDACTED]. The MDS, dated [DATE], documented R12 was severely cognitively impaired and required extensive of at least two staff for bed mobility and transfers, and extensive assist of one staff for dressing, toilet use, eating, hygiene and bathing. The Care Plan, dated 04/17/17, documented R12 was at risk for falls and had behaviors of wandering and impaired cognitive function. The interventions listed, in part as, staff to assist R12 to and from the dining room, new wheelchair and cushion, toileting schedule and not to push chair up too close to table. The Verification of Incident Investigation/Administrative Summary, dated 10/19/16, documented R12 fell due to sitting down and missing the chair in the activity room. On 10/24/16, the intervention was for staff to assist R12 while in activity room. The SBAR, dated 12/19/16, documented R12 fell out of bed and had no injuries. There were no interventions put into place. The Verification of Incident Investigation/Administrative Summary, dated 01/28/17, documented R12 fell while ambulating in the activity room. There was no injury and no interventions put into place. A Nurse's Note, dated 01/28/17, documented R12 fell while attempting to sit in chair. The Verification of Incident Investigation/Administrative Summary, dated 02/15/17, documented R12 fell while ambulating in the dining room. There was no injury. A Nurse's Note, dated 02/15/17, documented R12 had tripped on the leg of another resident's wheelchair and fell on her left side hitting head on the floor. The intervention was to assist residents in and out of the dining room so that the doorway is not blocked. The Verification of Incident Investigation/Administrative Summary, dated 02/22/17, documented R12 fell while ambulating in the hallway. It documented R12 had swelling of the right ankle. A Nurse's Note documented R12 had tripped over wet floor cone and landed on her right ankle. On 02/22/17, an X-ray of the right ankle revealed a questionable fracture. A follow up X-ray was obtained on 03/01/17 that revealed no fracture noted to the right ankle. A collapsible wet floor sign was the intervention put into place. The Verification of Incident Investigation/Administrative Summary, dated 02/24/17, documented R12 fell while ambulating in the resident room. It documented no injury. The intervention was to monitor R12's blood pressure and hold blood pressure medication until 03/06/17. The Verification of Incident Investigation/Administrative Summary, on 03/22/17, documented R12 fell while ambulating in another resident's room. The intervention put into place was to monitor and provide emesis basin. The Verification of Incident Investigation/Administrative Summary, on 03/30/17,documented R12 fell while ambulating in her room. It documented staff heard loud noise that sounded like someone hitting head on the door and found R12 on the floor with the bed alarm sounding. A Nurse's Note, dated 03/30/17, documented R12 had verbal and physical signs of pain. R12 was sent to the emergency department for evaluation. The report documented R12 had an X-ray to the left hip that indicated an age indeterminate fracture at T5, T12, L1 and L4. No new orders were given. The intervention was to toilet resident between 4:30 and 5:00 AM. The Verification of Incident Investigation/Administrative Summary, on 04/05/17, documented R12 fell in the dining room. A Nurse's Note, dated 04/05/17, documented R12 knocked over chair when standing up and fell . The intervention was to evaluate R12 for a walker per Power of Attorney (POA), re-educate staff not to the push chair up too close to the table so R12 has room to stand with out pushing her chair back farther. The Verification of Incident Investigation/Administrative Summary, on 04/12/17,documented R12 fell while getting up unassisted from her wheelchair and tripping over foot pedals. It documented alarm sounded. The intervention was to discontinue the right ankle immobilizer and to get R12 a new wheelchair and new cushion. The facility's Incident Management Policy, revised on November 2016, documents in part, All incidents will be reviewed and investigated to identify any underlying risk factors, in order to reduce recurrence and contribute to a safer environment.