Every finding on record at Taylorville SKLD Nur & Rehab

Based on observation and interview the facility failed to secure handrails to the wall in a safe and secure manner. This deficiency has the potential to affect all 79 residents/visitors and employees in the facility by compromising their safety when grabbing ahold of the handrails. Findings Include:On 06/01/2026 at 9:45 AM the handrail between rooms [ROOM NUMBERS] was loose and moved easily.On 06/03/2026 at 10:00 AM the handrail between rooms [ROOM NUMBERS] was loose and moved easily, at 10:03 AM the handrail outside of room eight was loose and moved easily, at 10:06 AM the handrail outside of room [ROOM NUMBER] was loose and moved easily, at 10:07 AM the handrail outside of room [ROOM NUMBER] was loose and moved easily and at 10:09 AM the handrail outside of room [ROOM NUMBER] was loose and moved easily.On 06/03/2026 at 1:55 PM V11, Maintenance Director, confirmed that the handrails were loose and easily moveable between rooms [ROOM NUMBERS], between rooms [ROOM NUMBERS], outside of room eight, outside of room [ROOM NUMBER], outside of room [ROOM NUMBER], and outside of room [ROOM NUMBER].The Midnight Census Report provided by V1 Administrator on 6/1/26 at 9:30 AM documents 79 residents reside in the facility.

Based on observation and interview, the facility failed to provide a homelike environment by failing to repair a damaged wall for five of five residents (R7, R11, R12, R17, R75) reviewed for homelike environment in the sample list of 40.Findings include:On 06/01/2026 at 09:30 AM, R75's exterior wall, lower six inches, was not painted, plaster was crumbling and missing in spots where the wall and floor intersect and there was no base board trim in place.On 06/01/2026 at 09:33 AM, R12's exterior wall, lower six inches, was not painted, plaster was crumbling and missing in spots where the wall and floor intersect and there was no base board trim in place.On 06/01/2026 at 09:35 AM, R11's exterior wall, lower six inches, was not painted, plaster was crumbling and missing in spots where the wall and floor intersect and there was no base board trim in place.On 06/01/2026 at 09:40 AM, R7's exterior wall, lower six inches, was not painted, plaster was crumbling and missing in spots where the wall and floor intersect and there was no base board trim in place.On 06/01/2026 at 09:42 AM, R17's exterior wall, lower six inches, was not painted, plaster was crumbling and missing in spots where the wall and floor intersect and there was no base board trim in place.On 06/02/2026 at 03:42 PM, R75 stated R75's room does not feel homelike because the walls are not finished and they put a board over it today trying to hide it. R75 stated it feels institutional in here.On 6/2/26 at 4:15 PM, R17 stated due to the wearing of the floor along the walls, it does not feel like home in the facility.On 06/03/2026 at 09:35 AM V11, Maintenance Director, confirmed R75, R12, R11, R7 and R17's rooms were missing the paint, the baseboard trim and the rooms had crumbling plaster exposed where the wall and the floor meet. V11 stated when the PTAC units (self-contained heating and air conditioning unit) were installed the trim had to be removed and has not been re-installed.

Based on observation and interview, the facility failed to provide adequate electrical outlets in resident rooms for three of three residents (R14, R76, R8) reviewed for accident hazards in the sample list of 40.Findings Include:On 06/03/2026 at 12:27 PM R14's room contained two power strips were being used. One power strip was plugged into a two-receptacle outlet with three devices plugged into it. The other power strip was plugged into a two-receptacle outlet with three devices plugged into it.On 06/03/2026 at 12:32 PM R76's room contained a multi-port that was plugged into a two-receptacle outlet. Two devices and one two wire extension cord were plugged into the multi-port.On 06/03/2026 at 12:32 PM R8's room contained a power strip that was plugged into a two-receptacle outlet. Two devices were plugged into the power strip.On 06/03/2026 at 11:30 AM V11, maintenance director, confirmed there were multiple rooms, including R14, R76 and R8's rooms, with multiple multi-plug power strips in use. V11 also confirmed there were multiple rooms with two wire extension cords connecting appliances to the power strip. V11 stated the facility does not have a policy with regards to power strip use.

Based on observation, interview and record review the facility failed to provide dignified dining services while maintaining resident's rights for three of three (R20, R35 and R50) residents reviewed for dining meal service in the sample list of 40.Findings include:1. R20's Care Plan dated 6/3/2026 documents R20 has a diagnosis of Dementia. This Care Plan also documents an admission date of 01/03/2025.R20's Care plan dated 3/12/2026 documents to provide feeding/dining assistance as needed.R20's Care plan dated 3/12/2026 documents R2 has impaired cognitive function related to the Brief Interview for Mental Status (BIMS) score and dementia.R20's Minimum Data Set (MDS) dated [DATE] documents R20 has severe cognitive impairment.R35's Care Plan dated 6/3/2026 documents R35 has a diagnosis of Alzheimer's Disease. This Care plan also documents an admission date of 02/01/2025.R35's Care Plan dated 2/5/2026 documents R35 has impaired cognitive function/Dementia or impaired thought processes related to Alzheimer's.R35's Minimum Data Set (MDS) dated [DATE] documents R35 has severe cognitive impairment.On 6/1/2026, during a one-hour continuous dining service observation conducted from 12:00 p.m. to 1:00 p.m. R20 and R35 were sitting next to each other at a table in the middle of the dining room underneath the air conditioning unit (AC) vent that was leaking clear liquid from the condensation. Condensation continued to drip from the vent from 12:00 p.m. to 1:00 p.m. onto the table while R20 and R35 were eating their lunches. Drops of water were on the table next to R20 and R35's plates of food all throughout R20 and R35's mealtime. During this time, no staff member checked on R20 and or offered an alternative table.On 6/3/2026 at 8:40 a.m., V19 Dietary Aide stated the AC has been leaking from the condensation and no residents should sit or eat on the table directly under the leaking vent.On 6/3/2026 at 12:51 p.m. V21 Kitchen Manager stated if the AC was leaking, residents should not sit directly under the AC vent.On 6/4/2026 at 9:05 am V1 Director of Nursing (DON) stated if there was a water leak from the AC condensation and residents were seated underneath, staff members should move the residents and re-arrange the tables and then call for the housekeeping to clean the area.2. R50's Care Plan dated 6/3/2026 documents a diagnosis of Transient Ischemic Attack (TIA) and Aphasia. This Care plan also documents an admission date of 04/30/2026.R50's Care Plan dated 5/4/2026 documents R50 has impaired communication related to a diagnosis of Sensorineural Hearing Loss.R50's Minimum Data Set (MDS) dated [DATE] documents R50 has severe cognitive impairment.On 6/2/2026 during lunch service from 12:00 p.m. to 12:35 p.m., R50 was sitting at the dining table with two other residents. The other two residents were served meal trays at 12:04, however R50 did not receive a meal tray at that time. R50 received R50's meal tray at 12:24 p.m., 20 minutes later than the other two residents sitting at the same table. The other two residents were already finished eating their lunch when R50 received R50's meal tray. On 6/2/2026 at 12:24 p.m. R50 was not interviewable. On 6/2/2027 at 12:25 p.m., V7 Certified Nurse Assistant (CNA) stated meal trays should be served per table and all residents at the table should be served at the same time. On 6/3/2026 at 8:40 a.m., V19 Dietary Aide stated kitchen staff should serve the meal trays per table and make sure all residents at the table get meal trays at the same time and don' t leave anyone out. On 6/3/2026 at 12:51 p.m. V21 Kitchen Manager stated kitchen staff serve the meal trays per table. V21 stated all residents at a table should be served all at the same time. V21 stated even the residents that just rolled up were served a meal tray immediately to make sure no one was left out at the table.Facility's Meal Distribution Policy dated 9/1/2021 documents meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner.

Based on observation and interview and record review, the facility failed to ensure appropriate positioning during enteral feeding and failed to ensure the enteral feeding bottle was labeled with all of the required information for two of two (R1 and R85) residents reviewed for enteral feeding in the sample list of 40.Findings include:R85's Care Plan dated 6/2/2026 documents R85's diagnosis of Dysphagia. This Care Plan also documents an admission date of 5/28/2026.R85's Care Plan dated 5/29/2026 documents to administer enteral nutrition per physician orders.R85's physician's order dated 5/28/2026 documents an order for Enteral Feed every shift. Administer Jevity 1.5 via an Enteral Pump and Infuse at 45 ml/hr (milliliters/hour) X (times)24 hrs (hours).R85's Minimum Data Set (MDS) dated [DATE] documents R85 has moderate cognitive impairment.On 6/1/2026 at 10:04 a.m., R85 was lying supine (flat) in bed with the enteral feeding attached to R85's Percutaneous Endoscopic Gastrostomy (PEG) tube and the feeding was running. Enteral feeding bottle was noted to be unlabeled at this time.On 6/3/2026 at 8:25 a.m., R85 was lying in bed supine, and enteral feeding was attached to R85's PEG tube and was running.On 6/1/2026 at 10:04 a.m., V3 Licensed Practical Nurse (LPN) confirmed tube feeding was not labeled for R85. V3 stated the tube feeding should be labeled with the resident's name, date, time, rate, route and room number. V3 confirmed R85's head of bed was supine and should be at a semi-Fowlers (elevated at 30-45 degrees) or high fowlers (elevated at 60-90 degrees).On 6/3/2026 at 8:47 a.m., V18 Licensed Practical Nurse (LPN) confirmed R85's bed was at a supine position at this time. V18 stated R85's head of bed should be elevated to at least 30 degrees to prevent aspiration.On 6/2/2026 at 11:40 a.m., V15 Assistant Director of Nursing (ADON) stated all residents enteral feeding bottles should be labeled with the resident's name, room number, date and time, route, method and rate of administration. V15 stated all residents on enteral feeding should have their head of bed elevated to at least 30 to 40 degrees at all times to prevent aspiration.2. R1's Care Plan dated 6/2/2026 documents R1's diagnosis of Dysphagia. This Care Plan further documents an admission date of 4/23/2026.R1's Care plan dated 4/24/2026 documents R1 has an impaired gastrointestinal status related to Crohn's disease, surgery to place Percutaneous Endoscopic Gastrostomy (PEG) tube and Intestinal Obstruction.R1's physician's order dated 4/23/2026 documents an order for Enteral Feed five times a day. Administer Osmolite 1.5 via bolus 300 ml/hr. 5x daily. Total 1500 ml /2250 total calories, total free fluid 1143 ml, per day via G tube (Gastrostomy tube). As well as 1200ml fluids from flushes for a total of 2343ml fluids/day.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively impaired.On 6/3/2026 at 9:00 a.m., V18 Licensed Practical Nurse (LPN) performed enteral feeding via syringe on R1. Enteral feeding bottle was opened and was not labeled except for a date of 6/3 at this time.On 6/3/2026 at 9:15 a.m., V18 confirmed the bottle had a label with incomplete information. V18 stated the enteral feeding bottle should have resident's name, room number, date and time, and rate of administration.Facility's Gastrostomy Policy dated 8/14/2023 documents the facility shall care for residents receiving artificial nutrition by means of gastrostomy tube, under the direction of the resident's primary physician and following nursing best standard of care. This policy documents an implementation of resident's head of bed shall be elevated at all times.Facility's Enteral Tube Feeding via Syringe (Bolus) procedure policy (undated) documents a general guideline to check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID and room number, b. type of formula, c. date and time the formula was prepared, d. route of delivery, e. access site, f. method (pump, gravity, syringe); and g. rate of administration milliliters per hours (ml/hour).

Based on observation, interview and record review, the facility failed to place an oxygen in use warning sign at the room entrance door to three of three (R31, R58 and R85) residents reviewed for respiratory care in the sample list of 40.Findings include:1. R31's Care Plan dated 6/3/2026 documents a diagnosis of Acute and Chronic Respiratory Failure with Hypercapnia, and Dependence on Supplemental Oxygen. This Care plan also documents an admission date of 5/21/2026.R31's Order Summary Report dated 5/21/2026 documents a physician's order for oxygen at two liters per minute via nasal cannula continuously.R31's Minimum Data Set (MDS) dated [DATE] documents R31 is cognitively intact.On 6/01/2026 8:55 a.m., R31 was lying in bed with oxygen on at two liters via nasal cannula. There was not a no smoking/oxygen in use sign at the room door at this time.On 6/1/2026 at 10:41 a.m., V4 Certified Nurse Assistant (CNA) confirmed there was no warning sign at R31's room door. V4 stated there should be a sign at the door warning R31 was on oxygen.On 6/1/2026 at 10:41 a.m., V5 Certified Nurse Assistant (CNA) confirmed there was no warning sign at R31's door. V5 stated there should be a sign at the door.2. R58's Care Plan dated 6/3/2026 documents R58's diagnosis of Chronic Obstructive Pulmonary Disease (COPD). This Care Plan also documents an admission date of 4/03/2026.R58's Care Plan dated 2/13/2026 documents R58 has an impaired respiratory status related to COPD.R58's Order Summary Report dated 4/2/2026 documents a physician's order for oxygen at two liters per minute via nasal cannula continuously.R58's Minimum Data Set (MDS) dated [DATE] documents R58 has severe cognitive impairment.On 6/1/2026 at 9:10 a.m., R58 was sitting in a recliner in 58's room with oxygen on at two liters via nasal canula. There was no no smoking/oxygen in use sign at the room door at this time.On 6/1/2026 at 11:07 a.m., V7 Certified Nurse Assistant (CNA) confirmed there was no warning sign at the door, V7 stated there should be a no smoking sign at the door for R58.3. R85's Care Plan dated 6/3/2026 documents R85's diagnosis of Chronic Obstructive Pulmonary Disease (COPD). This Care Plan also documents an admission date of 5/28/2026.R85's Order Summary Report dated 5/28/2026 document for oxygen at two liters per minute via nasal cannula continuously.R85's Minimum Data Set (MDS) dated [DATE] documents R85 has moderate cognitive impairment.On 6/1/2026 at 10:04 a.m., R85 was lying in bed with oxygen on at two liters via nasal cannula. There was not a no smoking/oxygen in use sign at the room door at this time.On 6/1/2026 at 10:04 a.m., V3 Licensed Practical Nurse (LPN) confirmed there was no warning sign at the door for R85. V3 stated there should be a no smoking/oxygen in use sign at the door for all residents that are on oxygen.On 6/2/2026 at 11:40 a.m., V15 Assistant Director of Nursing (ADON) stated all residents that have oxygen in their room should have a no smoking/oxygen in use warning sign on the door.Facility's Oxygen Administration Policy dated 3/17/2022 documents oxygen therapy will be administered to the resident upon the written order of a licensed physician or may be given in an emergency life-sustaining situation without an order, until an order may be obtained by a licensed physician. This policy documents a procedure to place the Oxygen in Use sign on the outside of the room entrance door.

Based on observation, interview and record review, the facility failed to properly store an inhaler in a safe location for one of one (R40) resident reviewed for medication storage in the sample list of 40.Findings include:R40's Care Plan dated 6/3/2026 documents R40's diagnosis of Chronic Obstructive Pulmonary Disease (COPD). This Care Plan also documents an admission date of 5/15/2026.R40's Care Plan dated 5/26/2026 documents R40 had impaired cognitive function related to Brief Interview for Mental Status (BIMS) score of (10 out of 15).R40's Minimum Data Set (MDS) dated [DATE] documents moderate cognitive impairment.R40's Order Summary Report dated 5/15/2026 documents a physician's order for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (micrograms/actuation) (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally one time a day related to COPD.On 6/1/2026 at 9:00 p.m., R40 was sitting on R40's recliner in the room. Trelegy Ellipta Inhalation Aerosol Powder was noted at the over the bed table next to R40. R40 stated nurses always leave it with R40 to use by R40's self.On 6/1/2026 at 2:00 p.m., V8 R40's family member was visiting with R40 at this time and confirmed the inhaler was in the room when V8 entered the room.On 6/1/2026 at 2:52 p.m., V3 Licensed Practical Nurse (LPN) stated the inhaler should not be in R40's room. V3 stated medications should be in locked storage or medication rooms.On 6/1/2026 at 2:52 p.m., V3 LPN confirmed inhaler was on R40's bedside table. V3 stated R40 does not have order for medication self-administration and the inhaler should not be at R40's bedside.On 6/4/2026 at 11:38 a.m., V2 Director of Nursing (DON) stated the medications should be in the locked storage and not at resident's room unless there were physician's orders.The Facility's Medication Storage Policy dated 8/23/2022 documents a purpose to provide guidance to facility nursing staff on the proper storage of medication. The facility stores all drugs and biologicals in a safe, secure and orderly manner and in accordance with state and federal regulations. The policy interpretation and implementation documents drugs and biological used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only people authorized to prepare and administer medications may have access to locked medications.

Based on observation, interview, and record review the facility failed to ensure hand hygiene was performed during incontinent cares for one (R21) of three residents reviewed for infection control in the sample list of 40. Findings include:R21's electronic medical record documents an admission date of 9/7/2024. R21's Minimum Data Set (MDS) dated [DATE] documents R21's cognitive skills for daily decision making as severely impaired. R21's MDS dated [DATE] documents R21 is always incontinent and that R21` is totally dependent on caregivers to provide toileting assistance. On 6/2/2026 at 11:45 AM, V10 (Certified Nursing Aid, CNA) entered R21's room to provide perineal care. V10 entered the room with gloves already on and brought two washcloths, a package of disposable wipes, and a disposable incontinence brief with V10 into R21's room. V10 went to the bathroom faucet and turned on the water and placed the two wash clothes in the sink under the running water. V10 then removed R21's pants and tossed them on the floor next to the bathroom door. V10 stated R21 had an incontinence episode and R21's incontinence brief and pants were wet. V10 opened a package of disposable perineal wipes. V10 unfastened R21's incontinence brief and began to wipe R21's perineal area from front to back. V10 tucked the soiled wipes into the brief and folded it downward wrapping the wipes inside. V10 used the soiled gloved hands and removed V10's glasses and set them down on R21's bed. V10 wiped V10's nose with soiled gloved hands and returned V10's glasses to V10's face. V10 removed a plastic trash bag out of V10's pants pocket and placed the soiled brief inside. V10 removed the soiled bed pad, folded it up and tucked it under V10's left arm. With the same pair of gloves on, V10 placed a new brief under R21 and fastened it closed. V10 pulled out another plastic trash bag from V10's pants pocket and placed the soiled pad in the bag, picked up the wet pants off the floor and placed them in the bag. As V10 picked up the bag with the soiled wipes, one wipe fell out onto the floor and V10 picked it up and placed it back into the bag.V10 stated they use hallway hampers and trash containers. V10 confirmed V10 threw the pants on the floor so they didn't get mixed up with the clean ones, they looked identical. V10 opened R12's door and placed the bags of trash and dirty laundry in the hallway containers. V10 removed V10's soiled gloves, without performing hand hygiene, V10 shut off the sink faucet and wrung out the washcloths then placed them on the bedside table. V10 stated the washcloths were for R21's face. V10 left the room. V10 stated V10 was unaware of the handwashing policy.On 6/2/2026 at 12:15 PM, V12 (Housekeeping Manager) stated throwing soiled linens on the floor would be breeching infection control. On 6/2/2026 at 1:40 PM, V2 (Director of Nursing, DON) stated the expectation for hand hygiene is to perform hand hygiene before and after entering a resident's room, with each glove change or when gloves are soiled, and when going from clean to dirty or dirty to clean. V2 states the expectation for soiled linens and trash is to place them into plastic bags and carry them out to the hallway bins. On 6/2/2026 at 3:20 PM, V17 (District Manager) stated housekeeping was alerted to clean R21's floor a second time for the day because there was a bag of soiled linens on the floor. V17 stated they did not clean or wipe anything else down. The facility Incontinence Care Policy dated 5/16/2022 documents to perform hand hygiene before, during and after perineal care as required to prevent cross-contamination.

Based on observation, interview and record review, the Facility failed to ensure the Illinois Department of Public Health deficiencies findings were readily available for review, as well as post signage indicating where the report was located. This failure has the potential to affect all 81 residents residing in the Facility. Findings include: On 1/14/2025 at 10:15 AM, R7, R8, R12 and V23 stated they were unaware where to locate the survey results binder or what the results of the last survey were. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact. R8's MDS dated [DATE] documents R8 is mildly cognitively impaired. On 1/15/2025 at approximately 11:00 AM, V19, MDS coordinator stated R8's cognition has improved since her last MDS assessment. R12's MDS dated [DATE] documents R12 is cognitively intact. R23's MDS dated [DATE] documents R23 is cognitively intact. On 1/14/2025 at approximately 11:00 AM V22, Medical Records, was asked where the survey results binder was located. V22 opened a cabinet in the front lobby and provided a binder. Upon review, the last survey results included in the binder were from 2020. On 1/14/2025 at 3:45 PM, V1, Administrator, stated the posting with the location of the survey binder should be posted on the bulletin board by the employee break room. At this time, the posting was not observed to be posted on the bulletin board. On 1/15/2025 V1 confirmed there was no signage or posting to notify residents or visitors where the survey results binder was located. V1 continued to state that the Facility does not have a policy on posting/survey results, but she would expect the regulation to be followed. The Facility's CMS (Central Management Services) Form 671 dated 1/13/2025 documents there are 81 residents residing in the Facility.

Based on observation, interview, and record review, the Facility failed to properly store medications and ensure timely disposal of a multi dose vial. This failure has the potential to affect all 81 residents residing in the Facility. Findings include: 1. On 1/13/2025 at 1:34 PM, the North Hall medication storage room was inspected with V20, Licensed Practical Nurse (LPN). There was a medication refrigerator that contained an open vial of Apilisol (A solution used to adminster TB skin tests) that had an open date of 11/20/2024. The sticker on the vial documented, Discard in use vials after 30 days. On 1/16/2024 at approximately 9:45 AM, V2, Director of Nursing stated V3, Assistant Director of Nursing (ADON) administers the TB skin tests. On 1/16/2025 at 10:19 AM, V3 verified the Apilisol vial observed in the medication storage room refrigerator was the only vial at the Facility on 1/13/2025 but they had since discarded it and ordered 2 more vials, one for each medication room. The document provided by V2, titled Aplisol- Tuberculin Purified Protein Derivative, Diluted [Stabilized Solution] documents, Storage- Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The Facility's CMS (Central Management Services) Form 671 dated 1/13/2025 documents there are 81 residents residing in the Facility. 32874 2. On 01/13/25 at 09:45 AM South hall medication cart checked with V4, Licensed Practical Nurse (LPN) Two separate medication cups inside top drawer of cart with opened medication s in each cup. One medication cup had R286's last name written on outside of cup with 8 medications in the cup. The second medication cup contained 7 medication with R68's last name written on cup. V4 initially stated both residents were in therapy and then later stated R68 at dialysis. On 1/15/2025 at 2:30PM V2, Director of Nursing (DON) stated medications are to not be stored in medication cups. The Facility Policy Medication Storage dated, revised 8/23/2022 documents the facility stores all drugs and biological's in a safe, secure, and orderly manner and in accordance with state and federal regulations. The policy documents drugs and biological's are stored in the packaging, containers, or dispensing systems in which they are received. The policy documents the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review, the Facility failed to ensure food was served at an appealing temperature for 7 of 24 residents (R7, R23, R32, R38, R66, R73, and R283) reviewed for dietary services in the sample of 36. Findings include: 1. On 1/14/2025 at 10:10 AM, R7 stated she eats her meals in her room and the food is cold 99% of the time. It won't even melt butter. Yesterday I only ate half of my spaghetti. Every bite was gross because it was cold. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact. 2. On 1/14/2024 at 10:15 AM, R23 stated, Most of the time it's cold (the meals). I usually get cold eggs but I eat them. I just cover them with mayo. R23's MDS dated [DATE] documents R23 is cognitively intact. The Facility's Resident Council Meeting Minutes dated 10/25/2024 documents residents had dietary concerns of the food temperatures and Some residents' food is still cold- on the hall. 50908 3. R66 was admitted to the facility on [DATE] with diagnosis of, in part, cirrhosis of the liver, hepatic encephalopathy, and type two diabetes mellitus. R66's Minimum Data Set (MDS) dated [DATE], documented she is cognitively intact. On 1/13/25 at 9:32 AM, R66 stated the food is cold when it gets to her room, and she has told staff she refuses to eat her food cold. R66 stated she often will leave her cold meal uneaten on the bedside table. R66 stated she will purchase food to keep in her room to eat. 4. R38 was admitted to the facility on [DATE] with diagnosis of, in part, congestive heart failure (CHF), type two diabetes mellitus, and depression. R38's MDS dated [DATE], documented she is cognitively intact. On 1/13/25 at 11:37 AM R38 stated the food is cold whenever she eats in her room, so she tries to make it to the dining room to eat if she can. 5. R73 was admitted to the facility on [DATE] with diagnosis of, in part, osteomyelitis, closed fracture of left tibia and fibula, and type two diabetes mellitus. R73's MDS dated [DATE], documented she is cognitively intact. On 1/13/25 at 9:50 AM, R73 stated she eats in her room because it is really hard to get up and with her hardware in her leg, she prefers not to go to the dining room. R73 stated her food is always cold when it gets to her. 6. R283 was admitted to the facility on [DATE] with diagnosis of, in part, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD) and pneumonia. R283's MDS dated [DATE], documented he is cognitively intact. On 1/13/25 at 10:05 AM, R283 stated the food is usually cold when it gets delivered to his room. 7. R32 was admitted to the facility on [DATE] with diagnosis of, in part, nonrheumatic mitral valve disorder, type two diabetes mellitus, and malignant neoplasm of prostate. R32's MDS dated [DATE], documented he is cognitively intact. On 1/13/25 at 10:05 AM, R32 stated the food is always cold when it gets to his room. R32 stated he is a bit of a loner and prefers to eat in his room. R32 stated he sees the tray warmers being brought down the hall without being plugged in to stay warm and thinks the staff don't know how to use it properly. On 1/14/25 at 11:45 PM, lunch was put onto the steam table in the kitchen. At 12:06 PM, while serving the dining room lunch, V14, kitchen staff, heated up chicken noodle soup for a resident in the microwave, then placed it on a tray to be served. V14 stated he did not check the temperature of the soup. This surveyor checked the temperature of the soup, and it was 101.9 degrees Fahrenheit. V15, kitchen staff, continued to serve the soup when this surveyor notified V13, Regional Dietary Manager, of the temperature. V14 told V13 not to serve the soup. V13 asked V14 how he checked to see if the soup was warm enough to serve. V13 stated it felt warm. On 1/14/25 at 12:50 PM, the south food cart left the kitchen to be served to the remaining residents in their rooms. The tray warmer was not plugged in for the last 4 trays being served. The last food tray to be served was at 1:11 PM. The food on the last tray had temperatures as follows: Lo Mein Noodles 113.9 degrees Fahrenheit, and Sweet and Sour Chicken 123.4 degrees Fahrenheit. On 1/15/2025 at 11:25, V1, Administrator, stated the cold meals has been a complaint in the past but there hasn't been as much lately. V1 stated we do need to do better, and that she will work with staff to improve that. The facility's Safe Food Handling Policy dated 9/1/2021, documented the dining services director will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit, or per state regulation.

Based on observation, interview and record review the facility failed to provide assistance/cueing for 1 of 3 residents (R11) reviewed for meal assistance in the sample of 36. Finding include: 1. On 1/13/2025 at 12:24PM R11 observed sitting at table in dining room asleep. R11's green beans are in bowl, with a roll in it. R11's spaghetti is in a bowl with a built up handled fork in spaghetti. On 1/13/2025 at 12:32 PM V21, Licensed Practical Nurse (LPN) asked R11 who was sleeping if R11 was getting enough to eat. R11 had not touched his food. V21 LPN did not cue R11 to eat. On 1/13/2025 at 12:37PM V21, LPN did place R11's drink in front of R11. At 12:40PM R11 observed drinking hot chocolate from cup and pouring it down his shirt. 12:42PM R11 got bowl of spaghetti and holds in left hand while scooping spaghetti with fork and spilling it on clothes. R11 then starts eating spaghetti out of bowl with his hands. At no time does staff provide cueing or assistance to R11. At 1:11 PM V21, LPN asks R11 if wants dinner roll and places in R11's hand. R11 eats 100% of dinner roll. R11 is never provided assistance with green beans or eats green beans. On 1/13/2025 at 1:20 PM V21, LPN sits at table with R11, working on meal tickets, but never cues R11 to eat. R11's Face Sheet dated 1/14/2025 documents in part a diagnosis of qualified visual loss both eyes. R11's Care Plan dated, revised 11/2023 documents R11 has a self care deficit as evidenced needs assistance wit ADSl's related to blindness. R11 Care plan documents the following interventions; eating set up only /cueing required 5/6/2021. The facility policy Meal Assistance dated, revised 2/17/20 documents residents shall received assistance with meals in a manner that meets the individual need of each resident.

Based on interview and record review, the Facility failed to prevent hair contamination for 2 of 24 residents (R7, R23) reviewed for Dietary Services, in the sample of 36. Findings include: 1. On 1/14/2025 at 10:10 AM, R7 stated, I found a hair in my mashed potatoes about a month ago. I love mashed potatoes and gravy and I'm trying to gain weight. I didn't finish eating them. I told someone, I don't know who, someone in the kitchen. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact. 2. On 1/14/2024 at 10:15 AM R23 stated, I've also had hairs in my food. I felt something in my mouth and there was a hair on my hamburger. It wasn't a short one like mine, it was long. They (Dietary staff) wear hairnets but it still happens occasionally. R23 stated she did not finish eating her hamburger because she lost her appetite. On 1/15/25 at 3:24 PM, V1, Administrator stated she was unaware of complaints of hair in food but she would look into it. The Facility's Safe Food Handling Policy dated 9/1/2021 documents, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.

Based on observation, interview and record review the facility failed to properly monitor personal food storage for four of four residents (R25, R63, R65, and R17) reviewed for environment in the sample 35. 1. R25's face sheet, dated 1/31/24, documented that R25 was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure, Osteomyelitis, chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, paroxysmal atrial fibrillation, cardiomyopathy, anxiety disorder, osteoarthritis, and chronic gout. R25's MDS (Minimum Data Set), dated 1/16/24, documented that R25 is severely cognitively impaired. On 1/29/24 at 9:15 AM, R25 was observed resting in bed. R25 had a small refrigerator sitting on his nightstand. The nightstand was within reach of R25. The refrigerator had a thermometer that read 78 degrees. The contents in the refrigerator included a gallon of chocolate milk that was half full and warm to touch, individually wrapped homemade caramels, a jar of pickles that had been partially consumed, condiments, and cans of V8. There was food debris and water on the bottom shelf. The refrigerator had a foul sour odor coming from it and multiple gnats were observed flying around the refrigerator and throughout the room. On 1/30/24 at 9:40 AM, the refrigerator thermometer read 80 degrees and the same ingredients were observed within the refrigerator. There was a foul odor coming from the refrigerator and multiple gnats were observed flying around the refrigerator and throughout the room. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R25's refrigerator dated January 2024. V1 stated that the housekeeping department was responsible for checking the refrigerators everyday and for monitoring the temperatures. The January 2024 temp log documented that R25's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. 2. R63's face sheet, dated 1/31/24, documented that resident was admitted to the facility on [DATE] with diagnosis of osteoarthritis, type 2 diabetes, bipolar disorder, anxiety disorder, hyperlipidemia, gastro-esophageal reflux disease, and restless leg syndrome. R63's MDS, dated [DATE], documented that resident is cognitively intact. On 1/30/24 at 9:22 AM, R63 was sitting in his recliner in his room. R63 stated that he uses his refrigerator every day, and he could not recall the last time it had been cleaned or inspected. The refrigerator had a large amount of food debris on the bottom shelf. There was no thermometer in the refrigerator. The refrigerator contained an open package of lunch meat that did not have a date of when it was opened. The refrigerator also contained cheese, applesauce, and condiments. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R63's refrigerator dated January 2024. The January 2024 temperature log documented that R63's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. 3. R65's face sheet, dated 1/31/24, documented that R65 was admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy, chronic obstructive pulmonary disease, type 2 diabetes, Parkinson's disease, dementia, hypertension, and peripheral vascular disease. R65's MDS, dated [DATE], documented that R65 is moderately cognitively impaired. On 1/30/24 at 9:28 AM, R65 was observed resting in bed. There was a small refrigerator next to his bed within his reach. The refrigerator did not have a thermometer in it. There was a jar of salad dressing that was half full. The refrigerator contained a package of opened ham with no opened date. The refrigerator also contained nutritional shakes and soda. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R65's refrigerator dated January 2024. The January 2024 temperature log documented that R65's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. 4. R17's face sheet, dated 1/31/24, documented that R17 was admitted to the facility on [DATE] with diagnosis of emphysema, chronic kidney disease, major depressive disorder, anxiety disorder, hypertension, and dementia. R17's MDS, dated [DATE], documented that R17 is cognitively intact. On 1/30/24 at 9:35 AM, R17's room had a small refrigerator sitting on the floor. The refrigerator had soda spilled on the bottom shelf. There was an undated and unlabeled disposable cup containing a liquid substance with a straw in the refrigerator. R17 stated that he did not know what was in the cup. There was no thermometer in the refrigerator. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R17's refrigerator dated January 2024. The January 2024 temperature log documented that R17's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. Facility Food and Nutrition policy dated 9-1-21 documents in part, The use and storage of food brought to residents by family and other visitors must be monitored to ensure safe and sanitary storage, handling, and consumption. Guidelines. 1. Temperature records or each cold storage unit maintained to ensure temperatures remain at or below 40 degrees for refrigerator . 2. Daily temperatures will be recorded. 3. An accurate thermometer will be kept in each refrigerator and freezer .

Based on observation, interview, and record review, the facility failed to ensure catheter care was provided as scheduled and failed to provide complete incontinent care for 3 of 4 residents (R9, R15, R49) reviewed for incontinent care/catheter care/urinary tract infections in the sample of 41. This failure resulted in R49 having recurrent urinary tract infections requiring Intravenous (IV) antibiotics and Contact Isolation; and, causing discomfort/pain to the resident. Findings include: 1. The Facility's Monthly Infection Control Log dated 12/2022 documents R49 had culture on 12/21/2022 which was positive for Extended-spectrum beta-lactamases (ESBL) of the urine. The Facility's Monthly Infection Control Log dated 1/1/2023 to 1/31/2023 documents R49 had an infection of the urine. The Facility's Monthly Infection Control Log dated 2/1/2023- 2/28/2023 documents (R49) Date of onset: 2/21/2023, organism: ESBL. R49's Face sheet dated 12/27/2023 documents, Diagnosis Information: Extended-spectrum beta-lactamases (ESBL) Resistance. R49's Minimum Data Set (MDS) dated [DATE] documents R49 is cognitively intact and has an indwelling urinary catheter. R49's Care Plan dated 9/22/2023 documents, High Risk for Urinary Tract Infection due to: Indwelling Catheter (cath). Provide cath care every shift. It further documents, 1/31/2022- Provide Catheter/Peri-care QS (Every shift). R49's Lab Results Report, collection date 2/22/2023 and 2/27/2023 as the reported date. It further documents, Positive for ESBL Isolation precautions may be required. Please refer to your Infection Control Policy. R49's Care Plan dated 2/27/2023 documents, (R49) has a Urinary Tract Infection (UTI). R49's Care Plan dated 2/28/2023 documents, Potential for infection R/T (related to) Midline IV (intravenous) cath. R49's Physician's Order Sheet (POS) dated 2/27/2023 documents, Contact isolation due to ESBL to urine. It continues to document on 2/28/2023, R49 was started on an IV antibiotic three times a day for UTI for 10 days. On 2/27/2023 at 3:30 PM, noted that R49 and her belongings had been re-located to another room. On 2/28/2023 at 10:30 AM, V2, Director of Nursing (DON), stated she was attempting to obtain IV access for R49's infection, but was unsuccessful. On 2/28/2023 at 10:35 AM, R49 stated, They don't even do this once a day(regarding catheter care). Night shift didn't do it last night. I've had a bladder infection for over a year. They should just keep me in isolation all the time since I have them so much. If they did clean it more often, I think it would reduce the chances of it coming back. It is very painful, in my mons pubis (pubic area), and the flank of my back. On 2/28/2023 at 10:40 AM, V14, Certified Nursing Assistant (CNA), stated R49's peri-care spray was still in her previous room, and she would have to have someone get it. On 2/28/2023 at 11:05 AM, V14 stated catheter care should be done every-time they do peri-care. At that same time, V15, CNA, stated catheter care should be done at least once a shift. On 2/28/2023, R49 verified she was moved to her new room on 2/27/2023 around 2 or 3 in the afternoon. R49's Untitled Document dated [DATE] documents, Catheter Care Time: Q (Every shift) 0600-1800 (6 AM-6 PM), 1800-0600 (6 PM-6 AM). It further documents, 1- Was catheter care provided? Y- Yes, N-No It continues to document either blanks or an X 2/6/2023, 2/8/2023, 2/14/2023, 2/17/2023, 2/20/2023, 2/23/2023 and 2/28/2023, indicating no catheter care was completed on 1800-0600 shift. The Facility's Catheter Care Daily (Female) Policy dated 1/9/15/2019 documents, Policy Catheter care will be provided daily and as needed care. It is the responsibility of the Nursing Assistant to provide daily and as needed catheter care. 44556 2. On 03/01/23 at 11:40 AM, V21, CNA, and V22, CNA, performed incontinent care for R15. V21 unfastened and pulled down R15's incontinent brief which was noted to be slightly wet. V22 cleansed R15's right and left peri area and outer labia with no-rinse peri wash and a wet cloth. V22 failed to separate the outer labia and wash the inner labia. R15 was assisted onto her side and V22 cleansed R15's right and left buttocks and anal area. V21 and V22 applied a clean incontinent brief without applying any protective skin lubricant. R15's Admission Record, dated 03/02/23, documents R15 has a diagnosis of Personal history of Urinary Tract Infections (UTI), Hemiplegia and Hemiparesis following Cerebral infarction (stroke) affecting left non-dominant side, and Unspecified Sequelae of Cerebral Infarction. R15's MDS, dated [DATE], documents R15 is cognitively intact, and requires extensive assistance, 2 plus person physical assist with bed mobility, toilet use, personal hygiene, and is always incontinent of bowel and bladder. R15's Care Plan, with an admitted [DATE], documents R15 is incontinent of Bowel / Bladder related to decreased mobility, stress incontinence, late effects of Cerebral Vascular Accident (CVA). It also documents clean peri-area with each incontinence episode. It further documents R15 is at risk for a Urinary Tract Infection due to frequent history of, urinary incontinence related to (r/t) CVA, need for assistance with toileting tasks, and check frequently for incontinence. Wash, rinse, and dry soiled areas. On 03/02/23 at 11:15 AM, V2, DON, stated she would expect the CNAs to follow the policy when performing incontinent care. 44967 3. R9's Admission Record, dated 3/2/23, documents that R9 was admitted to the facility on [DATE]. R9's Care Plan, dated 2/8/22, documents (R9) is incontinent of Bowel / Bladder related to (dementia). Interventions: Check & change during personal care, Monitor and record bowel & bladder patterns each shift, Use Preferred Elimination Mode(s): Incontinence Pads/Inserts Incontinence Briefs, Assist with toileting: 2+ persons physical assist, Regularly assess Bowel & Bladder status and management programs, Observe/document/report PRN (as needed) any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects, Clean peri-area with each incontinence episode. R9's MDS, dated [DATE], documents that R9 has severe cognitive impairment and requires total dependence of two staff members for toileting and bathing. R9 requires extensive assistance from two staff members for personal hygiene. R9 is always incontinent of bowel and bladder. On 2/28/23 at 10:49 AM, V8, CNA, and V10, CNA, performed Peri Care for R9. Both CNA's washed hands and donned gloves, all supplies on bedside table with clean towel down. R9's incontinent brief was untaped and tucked between her legs. With R9's legs together, V8 used a washcloth with a no-rinse foam cleanser on the cloth, wiped once down R9's right groin, using a new washcloth, wiped once down R9's left groin, then using a new washcloth, V8 wiped once down the middle of vagina. V8 did not separate and cleanse between R9's inner labia. R9 was turned over to her right side. V8 used new cloth with foam cleanser and wiped right buttock, then wiped left buttock, then wiped once from front to back in between R9's buttocks. V8 obtained a clean incontinence brief and placed it under R9. V10 pulled the clean incontinent brief up between R9's legs and secured it. R9 was not dried off after cleansing and V8 used the same pair of gloves the entire process. The Facility's Incontinence Care Policy, dated 5/16/23, documents All incontinent residents will receive incontinence care in order to keep skin clean, dry, free of irritation and odor. Incontinence care will be provided as required. It continues, Procedure: 5. Wash hands, apply gloves, It also documents, 8. Wash all soiled skin areas and dry very well, especially between skin folds. It further documents Equipment: E. Lotion/Vaseline It also documents, Procedure: 8. Wash all soiled skin areas and dry very well, especially between the skin folds. 9. Apply protective skin lubricant and rub well into skin.

Based on interview, observation, and record review, the Facility failed to ensure that proper Nurse skills were provided according to standard of practice related to wound care. This has the potential to affect all 75 residents in the facility. Findings include: R56's Admission Record, dated 3/1/23, documents that R56 was admitted to the facility on [DATE]. R56's Diagnosis: Complete lesion of unspecified level of lumbar spinal cord, Osteomyelitis, Emphysema, Type 2 DM (Diabetes Mellitus), COPD (Chronic Obstructive Pulmonary Disease), Malignant Neoplasm of Prostate, Dementia, Pathological Fracture in Neoplastic Disease - shaft of humerus left arm, Anxiety Disorder, Wedge fracture of lumbar vertebra, Aortic Valve Stenosis, Fracture of Sacrum, Disorder of Kidney and Ureter, HTN (Hypertension), Mild Cognitive Impairment, Obstructive and reflux uropathy, Anemia, Kidney Failure. R56's Care Plan, dated 2/14/23, documents (R56) has an Actual Pressure Ulcer; Site(s): coccyx. Requires assist with turning and repositioning, two assist, Acquired, Poor Nutritional status. Interventions: 9/20/22 Treatment Ordered: See current treatment order in EHR (electronic health record) orders, Monitor for pain indicators, Pain medication prior to wound care if indicated, Check dressing placement q shift, Monitor for s/s (signs/symptoms) of infection daily-increased warmth of surrounding tissue, redness, swelling, pain, purulent drainage, foul odor. Notify MD (Medical Doctor) if identified, Assess pressure ulcer weekly by licensed nurse, Notify MD as needed if ulcer fails to shows progress in healing, Provide off loading of ulcer site, Monitor incontinence and provide peri-care after each incontinent episode, Medications as ordered, Shower 2x/week, Encourage PO (oral) meal intake, Encourage fluid intake, Diet as ordered, Encourage (R56) to reposition as able, Repositioning every two hours and PRN (as needed), Provide pressure redistribution therapeutic device as ordered, Low Air Loss Mattress. 10/13/22 Supplement. R56's Minimum Data Set (MDS), dated [DATE], R56 has a severe cognitive impairment with a BIMS (Brief Interview for Mental Status) of 4. R56 requires extensive assistance from two staff members for most of his ADL's (Activities of Daily Living). R56 requires extensive assistance from one staff member for bathing and personal hygiene. R56 has urinary catheter and is frequently incontinent of bowel. On 2/28/23 at 9:17 AM, R56 stated I have had a sore on my butt for a long time. It flares up from time to time and they put some medicine and bandages on it. I turn myself while I'm in bed whenever I need to. R56's Physician Order, dated 1/6/23, documents Sacrum: cleanse area with wound cleanser. Apply calcium alginate with silver to wound bed. Monitor for s/s of infection. Every shift for treatment and as needed for soiled. R56's Physician Order, dated 12/8/22, documents Low air loss mattress. R56's Physician Order, dated 12/5/22, documents Morphine Sulfate (Concentrate) Solution 20 MG (milligram)/ML (milliliter). Give 0.5 ML by mouth every four hours as needed for pain. R56's Physician Order, dated 8/1/22, documents Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet by mouth every six hours as needed for mild to moderate pain. R56's Wound Physician Note, dated 2/24/23, documents Wound Sacrum, Stage 4, at least 125 days duration, Moderate Serous Exudate. Wound size 3 CM (centimeters) X1.7 CM X1.8 CM with surface area 5.10 CM, Undermining 0.5 CM at 5 O'clock, 100% granulation, Wound progress improved. 2/28/23 at 1:18 PM, V13, Wound Nurse, and V3, ADON (Assistant Director of Nurses), in R56's room to provide wound care to R56's coccyx wound. V13 did hand hygiene, then walked to the door, where wound supply cart was located, put her clean hands in her pocket and pulled out her keys, then opened the cart and gathered supplies. V13 came back into the room and had V3 wipe off the bedside table with a wet wipe, while V13 held the dressings, Derma Cleanse wound cleanser, and a clean towel in her now contaminated hands. Before letting the table dry, V13 spread the towel over the bedside table and laid the supplies on top of it. Using her bare contaminated hands, V13 opened the Calcium Alginate and the 4X4 dressing packaging and left them lying on towel. V13 then stated she needed to wash her hands and went into restroom and washed her hands. V13 donned gloves as V3 rolled R56 to his left side with R56 moaning of pain and stated, Be careful while moving me, that hurts. V13 removed an old dressing dated 2/28/23 which had slight amount of oozing noted. R56 has a large open wound which appears to have a center hole. V13 doffed gloves, hand sanitizer used, donned clean gloves, sprayed wound cleanser on a 4X4 and gently patted wound by first touching the center of the wound and then patting a few times around the wound. V13 doffed gloves, hand sanitizer used, donned clean gloves, held the sterile Calcium Alginate dressing outside the package used a pair of scissors that were taken out of procedure cart and was not seen cleaned, to cut the Calcium Alginate and then placed that piece onto the open wound and was not packed inside the wound. V13 doffed gloves, used hand sanitizer, donned clean gloves, and then placed an occlusive dressing over the wound site. V13 did not date/time/initial the dressing before V3 attached R56's incontinence brief and rolled him back over. Neither nurse asked R56 if he needed pain medication prior to the dressing change. R56's MAR and progress notes do not show any pain medication administered to R56 up to this procedure time. On 3/2/23 at 10:55 AM, V24, RN, stated (R56) does turn and position himself when he needs to. He can actually get himself up to his chair if he wants to. I have change (R56's) dressing before and I don't recall him complaining of any pain during the procedure. He will occasionally complain of pain and can get pain medication, but he really doesn't complain much. On 3/2/23 at 1:00 PM, V2, DON, stated I would expect the nurses providing wound care to maintain cleanliness, hand hygiene, and appropriate procedures for wound care. I would expect the staff to perform hand hygiene before, during, and after resident care. I would expect the staff to change gloves when going from dirty to clean areas during resident care. The Facility's Dressings, Dry/Clean Policy/Procedure, undated, documents Steps in the procedure: 1. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. It continues, 5. Perform hand hygiene. 6 Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Perform hand hygiene. 9. Open dressing equipment using clean technique. 10. Label tape or dressing with date, time and initials. Place on clean field. 11. Perform hand hygiene. It also documents, 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initials to top of dressing. It further documents, 19. Remove disposable gloves and discard into designated container. 20. Perform hand hygiene. Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form. 1. The date and time the dressing was changed. 2. The name and title (or initials) of the individual changing the dressing. 3. The type of dressing used, and wound care given. 4. Any problems or complaints (e.g., pain or discomfort) made by the resident related to the procedure. The Resident Census and Conditions of residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.

Based on observation, interview and record review, the Facility failed to ensure food items are stored in a manner that prevents food borne illness and potential contamination. This has the potential to affect all 75 residents in the facility. Findings include: 1. On 2/27/2023 at 9:37 AM, V16, Dietary Manager, stated, Excuse the mess. At this time, there was a large pan covered with aluminum foil. There was no label or date on the pan or foil. V16 stated, That's the cake I told her to label. Did she? Nope. I was using it for snacks. There was also a plastic bag of salad. It was open, not entirely sealed, only wrapped partially with saran wrap. The salad inside the bag was wilted and some pieces were brown. There was no date to indicate when the bag was opened. The bag had an expiration date of 2/25/2023. There was also a clear container, unlabeled and undated, with a yellow fluffy substance in it. V16 stated they were eggs from the previous day. There were 3 bags of peas in the refrigerator that were thawed and sweating. On the bag it was printed Keep frozen until ready to use. On 2/27/2023, V16 verified it was Day 23-Week 4 on the Week at a Glance menu. On 3/2/2023 at 10:20 AM, an unknown staff member was telling residents peas were being served for dinner. On 3/4/2023 at 12:05 PM, V16 stated she would expect all items in the refrigerator to be labeled and dated when opened. V16 also stated pea salad was served for Residents Choice supper on Day 26 (Three days after 3 bags of frozen peas were observed thawing in the refrigerator). The Resident Census and Conditions of Residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.

Based on interview and record review, the facility failed to identify falls as a facility issue for their Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 75 residents living in the facility. Findings include: On 03/02/2023 at 10:28 AM, V2, Director of Nurses (DON), stated that Quality Assurance was working on Wounds. She continued to state that everyone on the committee is invited and if they are unable to attend in person they can call in or if they can't make it, they are given the report. Sometimes they have an extra meeting like for wounds this past month. 03/02/23 10:36 AM, V1, Administrator, stated they meet quarterly and go over all grievances and facility issues. The facility's QAPI Program Meeting Verification, dated 01/11/2023, does not document any issues with fall prevention or management. The facility's Quality Assurance Performance Improvement (QAPI) Charter, dated 02/15/2023, documented, Quality Issues Identified: Increase in acquired pressure ulcers. It did not document any issues with falls. The facility's Quality Assurance and Performance Improvement (QAPI) Policy and Procedure, dated 2019, documented, C. Program activities. It continues, ii. The activities will track medical errors and adverse resident events, analyze their causes, and implement preventive action and mechanisms that include feedback and learning throughout the facility. The Resident Census and Conditions of residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.

Based on interview and record review, the facility failed to conduct ongoing review of antibiotic use to ensure residents are prescribed the appropriate antibiotic. This has the potential to affect all 75 residents living in the facility. Findings include: 1. The facility's Monthly Infection Control Log, dated 02/01/2023 to 02/28/2023, documented that R38 did not meet infection criteria for being placed on an antibiotic. R38's Physician's order, dated 2/9/2023 documented, Obtain UA (urinalysis) one time only for UA for 1 day. R38's Progress note, dated 02/09/2023 at 8:36 PM, documented, (V28, R38's Doctor) was here to see resident and ordered labs, UA, and a chest xray to be done. R38's Progress note, dated 02/16/2023 at 5:31 PM, documented, (Office worker from V28's office), office called after reviewing UA and started resident on Cipro (antibiotic) 500 BID (2 times a day) for 7 days. R38's Progress note, dated 02/17/2023 at 9:52 AM, documented, dr. notified that antibiotic needed to be changed for his UTI (urinary tract in, he ordered Macrobid 100mg (milligrams) bid for 7 days, order has been put in the computer and resident notified of this. 2. The facility's Monthly Infection Control Log, dated 02/01/2023 to 02/28/2023, documented that R49 did not meet infection criteria for being placed on an antibiotic. R49's Progress notes, dated 02/17/2023 at 9:12 AM, documented, resident has a (indwelling urinary catheter) and it is draining yellow colored urine, she has no issues with it at this time. R49's Progress notes, dated 02/21/2023 at 10:35 AM, documented, Resident has a (indwelling urinary catheter), it is draining dark colored urine, she is having no complaints with at this time. R49's Physician Order, dated 02/28/2023, documented, Piperacillin Sod-Tazobactam So (antibiotic) Solution Reconstituted 4-0.5 GM. Use 4.5 gram intravenously (IV) three times a day for UTI for 10 Days 3. The facility's Monthly Infection Control Log, dated 02/01/2023 to 02/28/2023, documented that R15 did not meet infection criteria to be placed on antibiotic. R15's Physicians Order, dated 02/23/2023, documented, Obtain UA with C&S (culture & sensitivity) if indicated. R15's Progress note, dated 02/23/2023 at 1:05 PM, documented, Writer approached by (R15's son) whom requests for orders to be obtained for UA with C&S if indicated, he feels she is more confused than her usual. Order obtained from nurse at (V27, Medical Director) office. R15's Progress note, dated 02/24/2023 at 10:15 AM documented, MD (physician) nurse called at 0915 with new orders on UA that was obtained and sent to (hospital), MD wants IV Ertapenem (antibiotic) 1gram daily x 10 days. Writer placed 22g (gauge) peripheral IV in posterior right hand, attempt x 1, tolerated well, flushes without difficulty. Ertapenem pulled from cubex (automated dispensing smart cabinets for medications) and IV abt (antibiotic) started. IV running without issues at this time. Call was placed to POA (power of attorney) to updated on new orders, no answer at this time, message left. 4. The facility's Monthly Infection Control Log, dated 01/01/2023 to 01/31/2023, documented that R7 did not meet infection criteria for use of antibiotics. R7's Progress note, dated 01/03/2023 at 3:30 AM, documented, .Resident voices discomfort around (Gastrostomy Tube) site related to tubing stitched close to skin. Split gauze sponge placed between skin and (Gastrostomy Tube) for comfort. Resident is permitted to eat a regular diet as tolerated. Resting comfortably in bed at this time with call light in reach. Will continue to monitor. R7's Progress note, dated 01/04/2023 at 2:46 PM, documented, . (Physician Assistant) here to see resident today and ordered wound culture of g-tube site, begin Keflex (antibiotic) 500mg QID (4 times a day) x7 days and continue to provide dressing cares to site. Culture obtained and sent to (hospital) lab for testing. First dose of po (oral) ABT administered with lunch today. R7's Physician order, dated 01/04/2023, documented, Keflex Capsule 500 MG (Cephalexin) Give 1 capsule via G-Tube four times a day for drainage from g-tube insertion site for 7 Days. R7's Physician order, dated 01/07/2023, documented, Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Inject 1 gram intramuscularly one time a day for Infection Mix with Lidocaine. On 03/02/2023 at 02:08 PM, V2, Director of Nurses (DON), stated that R49 did not meet McGeer Criteria and that their next step would be to let the doctor know. As per the facility's Antibiotic Stewardship Protocol, dated 08/10/2022, when asked where are the policies that have been written and revised according to Action- Policies shall be written, monitored and revised as needed to improve the proper antibiotic usage within the facility V2 stated that she will have to ask. On 03/02/2023 at 2:13 PM, V2, DON stated that McGeer Criteria is used when tracking and analyzing infections for Antibiotic Therapy Stewardship and when there is a N on the Monthly Infection Control Log it means that the resident did not meet the criteria for an infection needing antibiotics. V2 continued to state that they have trouble with the doctors and the Medical Director adhering to the Antibiotic Stewardship and that the Medical Director has told her that he knows his residents best and he continues to order Urinalysis and treat with antibiotic even though the residents do not meet the criteria and that he is aware of the regulation. V2 continued to state that the Medical Director does QAPI (Quality Assurance and Performance Improvement) and review the pharmacy and lab reports related to infections and antibiotic use but does not follow the Antibiotic Stewardship program. She stated that the doctor is aware that R49 appears to be colonized for ESBL (extended-spectrum beta-lactamases) and that he still orders antibiotics for her. V2 stated that she would have to look for any documentation from the Medical Director or the Medical Doctor as to why they are not following the antibiotic stewardship program and that the only tracking document she has was the monthly infection tracking log. On 03/06/2023 at 09:05 AM, V27, Facility Medical Director, stated that McGeer Criteria is good but hasn't been updated since like 2009. They (him and the facility) will try and talk during their meetings about antibiotic stewardship in the future, but McGeer is not the only method the facility uses. They have residents that get septic very quickly and they try and safeguard those residents. For example, (R15) she has been known to go septic quickly and Ertapenem works for her. He continued to state that yes, he knows his residents best and that is why he automatically prescribes an antibiotic before cultures come back. The facility's Antibiotic Stewardship Policy, dated 08/10/2022, documented, Leadership Commitment- antibiotic use shall be appropriately administered. 1. Diagnostics shall be obtained, as appropriate, prior to administration of antibiotics. 2. Infections shall be evaluated (through s/sx [signs and symptoms], McGeer's criteria, lab results, diagnostics, etc.) to determine if infection meets criteria of a 'true' infection. 3. Physicians shall be notified of findings of those results. Education may be provided where appropriate. It continues under Accountability, 3. Discuss with medical director and /or facility physicians the importance of the antibiotic stewardship program. It continues, Tracking- Surveillance shall be on-going to monitor the successful use or and the outcome of the use of antibiotics within the facility. It continues, 3. QAPI plan shall be initiated when trend is identified. The Resident Census and Conditions of residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.

Based on observation, interview and record review, the Facility failed to implement progressive interventions to prevent falls and elopement for 5 of 8 residents (R33, R34, R56, R40, R274) reviewed for supervision to prevent accidents in the sample of 41. Findings include: 1.R33's Minimum Data Set (MDS) dated [DATE] documents R33 requires supervision of one staff member and one-person physical assistance for walking in her room. R33's Care Plan, initiated 4/5/22, documents R33 is at risk for falls and injury due to medications, arthritis, weakness, and hospice/end of life care. The Facility's Incidents by Type Log dated 2/27/2023 documents R33 had two falls on 10/21/2023. The Facility's untitled document dated 10/21/2022 at 3:15 (AM) documents R33 had an unwitnessed fall in her room. It documents, Heard a noise and went into resident room. Resident was on the floor laying on left side with feet towards the door. Reports hitting head off metal bed frame. It further documents R33 stated, I was trying to go to the bathroom. It continues, Immediate Action Taken: Full head to toe assessment completed. ROM (Range of Motion) WNL (within normal limits). Resident does have a goose egg on the back left side of head. Ice pack applied and vital (signs) obtained. Denies any other injuries or pain. Injuries Observed at Time of Incident: Hematoma: back of head. Level of consciousness: Lethargic (Drowsy) Mobility: Ambulatory with assistance. It continues to document, 10/21/2023- IDT (Inter Disciplinary Team) reviewed incident. Resident was in bed and attempted to self-transfer to WC (Wheelchair) to go to bathroom. Call light was not activated. Resident states her leg gave out on her when transferring. Nonskid strips next to bed. Encourage bed in lowest position. Transfer changed to assist x (times) 1 from independent. R33's Progress Notes dated 10/21/2022 at 1:19 PM documents, Physician's office to request x-ray, got orders to right foot and hip. R33's Progress Notes dated 10/21/2022 at 1:45 PM documents, Called (hospice) to request a floor mat and an alarm. Inform(ed) them of bruising and pain in foot and x-rays are ordered. R33's Progress Note dated 10/21/2022 at 2:16 PM documents, Mistaken Entry- Nurse returned called and stated that alarm and mat are ordered, and alarm will be here on Tuesday since they are waiting for them to be delivered. R33's Progress Notes dated 10/21/2022 at 2:18 PM documents, Hospice nurse returned call and stated that they will get floor mat and alarms ordered for resident. Informed them of fall and x-ray as well. R33's Progress Notes dated 10/21/2022 at 3:43 PM documents, Resident continues hospice care. Resident has declined and has increased confusion. Resident is now an assist of 1 instead of independent. Resident fell last night. Monitoring her for that. Resident complaining of pain in foot awaiting x-rays. Vitals remain within normal limits. Will continue to monitor. The Facility's untitled document dated 10/21/2023 at 16:49 (4:49 PM) documents R33 had another unwitnessed fall. It documents, Writer called into room by (nurse) who found resident lying on floor. When writer approached resident was confused and stated that foot and hip hurt. Writer found resident laying on L (left) side with head towards bed and feet towards the bathroom. Resident has co (complaints of) pain to R (Right) foot and R hip from previous fall. Resident also has a hematoma to back of head from previous fall. Resident toileted by (nurse) and writer approximately hour prior. ROM to all extremities except R foot. Resident is able to move ankle. Immediate Action Taken: Pain/Skin assessment, VS (vital signs). Resident had grip sock on bilateral feet. Strips are in place at bedside and bed is in low position. Pressure alarm in place and in working condition. Notes: Resident has a pain of 7 (on a 1-10 scale, 10 being excruciating) due to previous fall injuries to foot, right hip and hematoma to back of head. No new injuries at this time. It continues to document, 10/24/2022 IDT reviewed incident. Resident noted to attempt to get out of bed per self. Call light not activated. Resident alert and able to voice needs. General decline due to Dx (diagnosis). Currently on hospice care. Continue with low bed. Strips at bedside. Continue assist for transfers and toileting. Alarm placed after fall. R33's Progress Notes dated 10/22/2022 at 22:09 (10:09 PM) documents, Resident continues with hospice and has had a recent decline in condition. Resident is unable to self-ambulate, requires assist of 2. Resident requires assistance completing all ADLS (Activities of Daily Living). Resident receives scheduled morphine effective for pain management. Post fall observation continues. (Portal x-ray) present this evening to obtain x-ray of right foot and right hip. Results have been returned showing right metatarsal fracture. On 3/01/23 at 11:28 AM, V20, Minimum Data Set (MDS) Coordinator stated, We go over falls in our morning meetings and come up with an intervention. There should be an immediate invention, like offering to take her to the bathroom every 2 hours. On 2/28/2023 at 9:45 AM, R33 was observed in her room, ambulating from the bathroom to her bed independently. There was no alarm sounding. On 3/1/2023 at 10:06 AM, V2, Director of Nursing (DON) stated, One of her (R33's) falls was early morning. She was trying to go to bathroom and had been independent prior. She still thinks she's capable and she is very anxious. We changed her to assist of one. That was the one (fall) where she had the hematoma. Neither falls were witnessed. (R33) is one who just tends to do what she wants. Later that evening she was found sitting on the floor next to bed. She said she didn't remember what she was doing. We continued with the prior interventions and assist with transfers. The nurse placed an alarm on her then. She is currently still a one assist and does have the alarm. On 3/1/2023 at 10:57 AM, V26, Licensed Practical Nurse (LPN) stated, (R33) gets up by herself. She transfers to the wheelchair to go potty (by herself). She doesn't need help. On 3/1/2023 at 11:00 AM, V14, Certified Nursing Assistant (CNA) stated, (R33) ambulates independently but not too far, mostly from wheelchair to bed or to the bathroom. She has an alarm so if we hear it, we go down there. On 3/01/23 at 1:41 PM V2 stated, They made her (R33) a one assist. That is no different than a resident who is confused. We still have to check on them every 2 hours. Staff knew she was a one person assist. She just gets up without assist. She is still supposed to be a one assist. Residents can still fall even when they are one assist. She was found sitting next to the bed. 44556 2. R40's Admission Record, dated 03/02/23, documents she has diagnoses of Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and osteoarthritis. R40's MDS, dated [DATE], documents R40 is severely cognitively impaired and requires extensive assistance, 2 plus person physical assist with bed mobility, transfer, toileting, and personal hygiene. R40's MDS documents R40 is always incontinent of bowel and bladder. It also documents R40 is not steady on her feet and unable to stabilize without assistance from staff. R40's Care Plan, with an admitted [DATE], documents R40 is at risk for falls and injuries related to (r/t) Medications: Psychotropic Medications (Meds)/Cardiovascular Meds. Medical Factors: Depression, anxiety, osteoarthritis, and dementia. R40's Incident Report, dated 09/19/22 at 11:53 PM, was reviewed and documents R40 had an unwitnessed fall in her room. The Incident Report documents R40 was found by staff sitting upright with her back against the bed and legs outstretched in front of her on the floor mat. It further documents R40 doesn't know what happened. The Report documented Immediate action taken was a skin assessment, pain assessment, Power of Attorney (POA) called, Primary Care Physician (PCP) notified. There was no documentation that new immediate interventions were put into place to ensure that R40 did not fall again. A new intervention was not put into place on the care plan until 09/20/22 which was therapy to assess for strengthening. R40's Incident Report, dated 11/01/22 at 3:15 AM, was reviewed and documents R40 had a witnessed fall in her room. R40's Report documents a Certified Nurse's Assistant (CNA) was restocking the cart and witnessed R40 sliding out of bed (OOB) and on to the floor mat. The Report documented Immediate action taken was Vital Signs (VS) obtained, resident assessed for injury, resident assisted back to bed. No new immediate interventions were put into place at the time of the fall. It documents in the notes section, on 11/01/22 IDT (Interdisciplinary Team) reviewed incident. It documents Resident was in bed and CNA was in hallway and observed resident slid out of bed before she could get to her. Continue with all fall interventions. Added scoop mattress to bed to assist with defining bed parameters. Care plan documents it was updated on 11/01/22 but there was no time noted. R40's Incident Report, dated 11/23/22 at 6:45 PM, was reviewed and documents R40 had an unwitnessed fall in her room. The Report documented R40 was found by the CNA sitting on her buttocks beside her bed. The Report documented Immediate action taken was vital signs (vs) obtained, resident assessed for injury, assisted back to bed, Range of Motion (ROM) Within Normal Limits (WNL), and denies pain. No new immediate interventions were put into place to ensure that R40 did not fall again. The notes section of the incident report document on 11/25/22 intervention put into place is toileting program at night due to incontinence at time of fall. The care plan documents no new intervention was put into place until 11/25/22. R40's Incident Report, dated 12/25/22 at 12:26 AM, was reviewed and documents R40 had an unwitnessed fall in her room. The Report documented a CNA found R40 with her upper body by the nightstand and R40 was yelling for help. The Report documented when the nurse entered the room R40 was lying on her back, her right eye was swelling, and bottom lip had a little blood on it. The Report documented Immediate action taken documents ROM WNL, no signs of pain, neuro checks initiated. No new immediate interventions were put into place. In the note section of the incident report, it documents on 12/27/22, IDT team reviewed the incident. Resident was confused and disoriented at the time of incident. Resident thought she was fighting someone and attempted to get out of bed. Urinalysis (UA) completed, and side table removed from next to bed. Medication review requested from MD (Medical Doctor). The care plan documents that on 12/27/22 it was updated with the new intervention. On 03/06/23 at 11:50 AM, V20, Minimum Data Set (MDS) coordinator stated the nurse should put an immediate intervention into place when someone has a fall, they are supposed to do something right away. 44967 3. R34's Admission Record, dated 3/1/23, documents that R34 was admitted to the facility on [DATE]. R34's Electronic Medical Record documents that R34's diagnoses include Hemiplegia, COVID-19, Cerebral Aneurysm, Osteoarthritis, HTN (Hypertension), Major Depressive Disorder, Dysphagia, Orthopnea. R34's Care Plan, dated 11/18/22, documents (R34) At risk for falls and injuries related to Medications: Psychotropic Meds/ Diuretic Meds/ Cardiovascular Meds/ Pain Meds/ Other Medications. Medical Factors: Interventions: 11/18/21 Toileting program added. 11/25/21: Therapy to screen for wheelchair positioning. 2/20/23 Bolster cover to bed to assist with defining bed parameters. 2/24/22 Staff to supply body pillow to assist with positioning for comfort. Encourage use of call light. Fall 12/6/22: Bariatric bed to provide resident with more space in bed. Keep call light within reach. Keep environment clutter free. Keep personal belongings within reach. Low bed. Mat at bedside when in bed. Provide adequate lighting. Resident known to lay in incorrect positions in the bed. R34's MDS, dated [DATE], documents that R34 has a moderate cognitive impairment with a BIMS (Basic Interview for Mental Status) of 7. R34 MDS documents R34 requires extensive assistance from two staff members for all of her Activities of Daily Living and is always incontinent of both bowel and bladder. R34's Progress Note, dated 2/19/23, documents Resident yelling out with pain to left upper leg and left hip due to normal leg contractures. Unable to do neuro check to lower extremities. Resident yells out in pain when writer touched her upper leg and hip area no distention noted to hip or upper leg area. Resident states 'I rolled over and rolled out of bed onto floor.' Neuro-check completed to upper extremities WNL (within normal limits) to upper extremities. Resident states 'I didn't hit my head.' No c/o (complaint of) back pain or neck pain resident transferred to (local hospital) for evaluation due to severe pain to left upper leg and hip area. R34's Progress Note, dated 2/20/23 at 00:42 AM, documents Returned to facility from (local hospital) per ambulance no factures per (local hospital) ER (emergency room ) per report from (local hospital) ER resident given Fentanyl 50 MCG (microgram) per IV (intravenous) in ambulance when enroute to (local hospital) ER Morphine 4 MG (milligram) per IV given at 11:17 PM in ER and Norco 5-325 MG given PO (orally) before being transferred back to facility and Lidocaine patch to hip area POA (Power of Attorney) was at (local hospital) ER and is aware of results and treatment of pain meds, resident Orientated X 2 able to make needs known skin warm and dry color WNL (within normal limit) states only her left leg only hurts a little now, denies back neck or headache, neuro check WNL, bed in low position, mat next to bed, call light in reach, reminded resident to use call light if she needs to turn, not to roll by herself, staff needs to assist her, she said she understands. On 2/27/23 at 9:15 AM, R34 was sitting in wheelchair watching TV, (full body mechanical lift device) sling under her, a fall mat sitting on the floor by the side of her bed. R34 had mattress with bolsters. On 2/28/23 at 8:46 AM, R34 was brought back to her room from dining room, sitting in wheelchair with a pair of regular fuzzy socks on and did not have the non-slip socks on. A fall mat was on the floor by the side of her bed. R34 was sitting at foot of her bed with her call light tied to her bed rail by the head of her bed and was not reachable. On 3/1/23 at 8:38 AM, R34 sitting in her wheelchair with her tray table and drink sitting next to her. R34 now has non-skid socks on, call light sitting in her lap, fall mat on the floor. R34's wheelchair was half on and half off the mat, causing her wheelchair to tilt. On 3/2/23 at 10:52 AM, V24, Registered Nurse (RN), stated (R34) usually sits in her wheelchair towards the foot of her bed to watch her television. We usually stretch the call light over to her chair. Her fall mat should be folded up if she is out of bed to keep it from being a hazard. If she is out of bed, she should have the non-slip socks on and not fuzzy socks. On 3/2/23 at 12:55 PM, V2 stated I would expect the staff to keep the resident's call light within reach at all times. 4. R56's Admission Record, dated 3/1/23, documents that R56 was admitted to the facility on [DATE]. The Record documents R56's has the following diagnoses: Complete lesion of unspecified level of lumbar spinal cord, Osteomyelitis, Emphysema, Type 2 DM (Diabetes), COPD (Chronic Obstructive pulmonary disease), Malignant Neoplasm of Prostate, Dementia, Pathological Fracture in Neoplastic Disease - shaft of humerus left arm, Anxiety Disorder, Wedge fracture of lumbar vertebra, Aortic Valve Stenosis, Fracture of Sacrum, Disorder of Kidney and Ureter, HTN (hypertension), Mild Cognitive Impairment, Obstructive and reflux uropathy, Anemia, Kidney Failure. R56's Care Plan, dated 2/14/23, documents (R56's) Care Plan, dated 2/14/23, documents (R56) is at risk for falls and injuries related to Medications: Pain Meds. Medical Factors: Compression fractures, impaired mobility, weakness. Interventions: 1/27/22 Provide adequate lighting, keep personal belongings within reach, keep environment clutter free, keep call light within reach, Encourage use of call light, 8/2/22 Bed and Chair alarm. 8/3/22 Offer toileting in the morning upon waking, before and after meals, and at bedtime, assess toileting needs. 11/9/22 Hospice to provide bolsters and low bed. 11/10/22 Low Bed. 1/27/23 Dycem in the bed. R56's MDS, dated [DATE], R56 has a severe cognitive impairment with a BIMS of 4. R56 MDS documents R56 requires extensive assistance from two staff members for most of his ADL's. R56's MDS documents R56 requires extensive assistance from one staff member for bathing and personal hygiene and has urinary catheter and is frequently incontinent of bowel. R56's Fall Risk Assessment, dated 1/27/22, documents that R56 is a low fall risk with a score of 2. A score of 10 or higher indicates that the resident is at risk for falls. R56's Fall Risk Assessment, dated 7/13/22, documents that R56 is a High Fall Risk with a score of 13. A score of 10 or higher indicates that the resident is at risk for falls. R56's Progress Note, dated 11/9/22 at 2:56 PM, documents Resident slid out of bed trying to roll over. Resident complaining of some side pain. Called hospice and requested x-rays and bolsters, and a bed for resident. They are sending out a nurse to evaluate him. R56's Physician order, dated 12/28/22, documents Chair/Bed alarm. Monitor for proper functioning. R56's Progress Note, dated 1/26/23 at 7:23 AM, documents Writer called to resident's bedside by resident's roommate where he was noted to be lying on the floor next to his bed without his alarm sounding. Skin tear noted to left elbow. Alarm not sounding as it was not turned on. Resident was assessed and then assisted back into bed by staff. Physician and POA notified of the incident. Hospice CNA and nurse notified as well. On 2/27/23 at 9:50 AM, R56 was lying in bed with his call light hanging on rail and down to the floor. R56's bed/chair alarm hanging on rail but not clipped to R56 as the alarm box was secured to bedrail with the cord hanging on floor. R56 had a fall mat on the floor side of bed, a Call-Don't Fall sign on the wall, and bolsters on his mattress. On 2/28/23 at 9:17 AM, R56 was lying in bed with the bed in lowest position, a fall mat lying on the floor on the side of his bed, a Call-Don't Fall sign on the wall, the call light hanging on his bedrail dangling to the floor, and his bed alarm was attached to R56's shirt and secured to the bedrail. On 3/1/23 at 8:50 AM, R56 was sitting up in his bed with his tray table over the bed while he was eating breakfast. R56's call light was seen hanging over bedrail and down to the floor. R56's bed alarm was attached to a bedrail with the cord hanging to the floor and not to R56. R56's fall mat was folded and sitting by the head of his bed. On 3/2/23 at 10:45 AM, R56 was lying in bed with his call light hanging off his bedrail and to the floor. R56's bed alarm was attached to the bedrail with the cord hanging to the floor and not attached to R56. On 3/2/23 at 10:55 AM, V24, RN, stated (R56) should always have his tag alarm attached to him at all times, in his bed and in his chair. On 3/2/23 at 12:55 PM, V2, DON, stated I would expect the staff to keep the resident's call light within reach at all times. If a resident has a bed or chair alarm, I would expect the staff to keep that alarm attached to the resident for their safety. I would expect the nurses providing wound care to maintain cleanliness, hand hygiene, and appropriate procedures for wound care. The Facility's Fall Prevention Program/Protocol Policy, dated 2/1/23, documents 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. It continues 1. The interdisciplinary will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk (based on the falls assessment results) or with a history of falls. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, discontinue ineffective interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, the team will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. The resident and/or responsibility, the physician and therapy department may be involved in the process for a holistic evaluation. 7. The team shall identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. It continues Early prevention and fall risk detection: 3. Rounds shall be completed at least daily to ensure fall interventions remain in place. 4. Resident's individualized fall interventions shall be accessible to all staff for quick review. Monitoring subsequent falls and fall risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 5. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The Facility's Fall Prevention Program/Protocol dated 2/1/23, documents Fall Risk Factors: 1. Environmental factors that may contribute to the risk of falls include: f. Footwear that is unsafe or absent. 2. Resident condition s that may contribute to the risk of falls include: c. Delirium and other cognitive impairment, e. Lower extremity weakness, f. Poor grip strength, g. Medication side effects, i. Functional impairments, k. Incontinence. 3. Medical factors that may contribute to the risk of falls include: a. Arthritis, d. Neurological disorders, e. Balance and gait disorders. 5. R274's Admission Record, dated 3/1/23, documents that R274 was admitted to the facility on [DATE]. R274's Electronic Medical Record, documents that R274's diagnoses include Respiratory Failure, Dementia, Cardiac Murmur, Alzheimer's Disease, and Aortic valve stenosis. R274's Baseline Care Plan, dated 2/23/23, documents (R274) is at risk for falls and injuries related to Medications: Psychotropic Meds/ Diuretic Meds/ Cardiovascular Meds/ Pain Meds/ Other Medications. Interventions: There are no interventions placed in R274's Care Plan for falls and there was nothing in R274's Care Plan about her Elopement Risk. R274's MDS, has not been completed yet. R274's Fall Risk Assessment, dated 2/23/23, documents that R274 is a low fall risk with a score of 6.0. A score of 10 or higher indicates the resident is at risk. R274's Elopement Risk Assessment, dated 2/23/23, documents that R274 is a High Elopement Risk with a score of 10. A score of 10+ means a Resident is considered at High risk for elopement. Document IDT's determination if ankle alarm bracelet (elopement risk) or other intervention is appropriate and update care plan as necessary. If IDT determines ankle alarm bracelet is appropriate, complete Physical Restraint Assessment and obtain consent. If facility does not have an ankle alarm bracelet system, place on 1:1 monitoring. Document contact with responsible party to discuss options for placement in a secure unit or other appropriate facility. On 2/27/23 at 9:12 AM, R274 was seen sitting on the side of her low bed with the side rails up X 2. R274 had an ankle alarm bracelet on her right lower leg and regular socks on and did not have non-slip socks on. On 2/27/23 at 10:45 AM, R274 was seen ambulating in/out of other resident's rooms. Staff assisted her to the dining room to sit at a table. On 2/28/23 at 9:12 AM, R274 was seen wandering in/out of several residents' rooms. Staff noticed her and assisted her to the dining room for activities. On 3/1/23 at 8:55 AM, R274 was sitting in a chair by the front nurse's desk holding a stuffed animal and mumbling incoherently. R274 had an alarm bracelet on her right ankle. On 3/2/23 at 10:50 AM, V24, RN (Registered Nurse), stated (R274) has tried a few times that I know of, to get out the front doors. She wears the ankle bracelet that goes off when she tries to get out. I guess we are just keeping a close eye out on her, keeping her close to the nurse's desk, and taking her to activities. It should be in her Care Plan. I see that there is nothing in the Care Plan about her elopement. The Facility's Wandering/Elopement Policy, dated 10/18/22, documents The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified is at risk for wandering or elopement; the resident's care plan will include strategies and interventions that shall in implemented to maintain the resident's safety, including but not limited to, electronic monitoring device, room placement, frequent checks, etc.

Based on observation, interview and record review, the Facility failed to follow the standard of care by failing to ensure comfort measures were available and given for a hospice resident in the dying process for 1 of 1 resident (R33) reviewed for hospice services, in the sample of 28. This failure resulted in R33 receiving no medications for palliation of symptoms and enduring discomfort and shortness of breath without relief as he died . Findings include: R33's Progress Notes dated [DATE] documents, Resident was admitted to hospice. New orders received. R33's Hospice Telephone/Verbal Order Form dated [DATE], documents, Admit to (company name) hospice. It further documents, [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg (milligrams) by mouth every 4 hours (hrs) as needed for anxiety, restlessness, or nausea. Under Hospice covers, it documents yes. It continues, [MEDICATION(S)] concentrate (MS) 20 mg/ml (milliliters) 0.25 mL every 4 hrs as needed for moderate pain or SOB (Shortness of Breath), by mouth. Under Hospice covers, it documents Y (yes). It also documents, [MEDICATION(S)] concentrate 20 mg/mL 0.5 mL every 4 hrs as needed for severe pain or SOB, by mouth. Under Hospice covers, it documents Y. It also documents this order was received [DATE] at 11:00 AM. R33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It further documents on [DATE], R33's pain level was rated at a 5, indicating moderate pain. On [DATE] and [DATE], R33's pain level was rated at a 4. R33's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2 PM, V5, Certified Nursing Assistant (CNA), and another CNA were repositioning R33. R33's respirations were 34 respirations per minute (increased) and were visibly labored. On [DATE] at approximately 2:15 PM, V8, Licensed Practical Nurse (LPN), and V18, LPN, confirmed that R33 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:34 PM, V22, CNA, was observed in R33's room, holding his hand. R33's Progress Notes, dated [DATE] at 11:32 AM documents, Resident's condition is noted to be declining, very lethargic, not opening eyes, unable to eat and drink, unable to get resident to take meds (medications), some SOB noted. Continues on oxygen therapy. R33's Progress Notes, dated [DATE] at 11:35 AM, documents that the hospice company was called concerning R33's medications and to notify them that R33 has declined in condition. It further documents R33's respirations were 30 (above normal range). R33's Progress Notes, dated [DATE] documents at 2:53 PM, Writer contacted Director of Hospice, regarding resident's comfort medication orders and delivery of medication to the facility immediately due to resident's condition. The director asked 'Well, is he in pain?' Writer reiterated that their nurse as well as ours have assessed him and his decline. He is supposed to be kept comfortable with the medications provided by hospice. Writer and DON (Director of Nursing) will continue to follow up until the medications arrive in the facility. DON also placed a call directly to the Medical Director (V28) of (hospice company) to get the medications. R33's Progress Notes, dated [DATE] at 3:25 PM, that R33 had no pulse or respirations, indicating that R33 has expired. On [DATE] at 11:45 AM, V30, Hospice Nurse, stated, Normally upon admission we encourage the facility to have the medications ordered and ready from the start. On [DATE] at 1:52 PM, V2, Director or Nursing (DON), stated, (R33's) decline was quick. We should have had MS and [MEDICATION(S)] available at that time. Our Emergency Kit has ([MEDICATION(S)]), but no MS. R33's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 8:53 AM, V22 stated, I am familiar with hospice residents being given MS and [MEDICATION(S)]. He probably would have benefited from those meds. On [DATE], V29, (LPN), stated, It is standard of care to start of MS and [MEDICATION(S)] when someone is admitted to hospice. I would expect them to be readily available the day they are ordered. I cannot speak to (R33's) level of distress because I wasn't there, but generally MS and [MEDICATION(S)] would have helped alleviate (R33's) discomfort as he passed away. The Facility's Nursing Facility Hospice Services Agreement dated [DATE] documents, When Nursing Facility Personnel are responsible for administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the Plan of Care, the Nursing Facility personnel may administer the therapies, if permitted by state law and as specified by the Nursing Facility. It continues, Nursing Facility has familiarized itself with the administrative, record keeping, and personal-care needs of residents patients. Nursing Facility is, and will be, fully competent and able to perform its obligations under this Agreement in accordance with recognized professional standards for the care of terminally ill patients. It further documents under 2.10 Provision of Hospice Services: Hospice Responsibilities. Hospice is responsible for: (c) furnishing medical supplies, durable medical equipment, the drugs necessary for the palliation of pain and symptoms associated a Resident Patient's terminal illness and related conditions. It continues, Hospice will make nursing services, physician services, and drugs and biologicals routinely available on a twenty-four (24) hour basis seven (7) days a week.

Based on observations, interviews and record review, the facility failed to develop and implement progressive interventions to prevent falls, provide supervision for those at risk for falls and provide safe transfer techniques to prevent injuries for 5 of 10 residents (R5, R6, R23, R24 and R25) reviewed for supervision to prevent fall/accidents in the sample of 10. This failure resulted in R24 falling and sustaining a left hip contusion and left 8th rib fracture. Findings include: 1. R24's Face Sheet, undated, documented he had a [DIAGNOSES REDACTED]. R24's MDS dated [DATE] documents that R24 requires extensive physical assistance of one staff person for transfers, walking in room and corridor and toileting. The MDS documents R24 is not steady and requires staff assistance to stabilize when turning around, moving on and off toilet. from a seated to standing position and walking. R24's Care Plan, initiated on 8/26/19, documents he needs limited to extensive assist of staff related to weakness, decreased mobility, poor balance and impaired cognition and the inability to recognize his physical limitations. The Care Plan interventions, initiated on 9/4/19, documents Transfer: One person physical assistance required; Ambulation-to and from bathroom with gait belt, front wheeled walker and assist of one or two; Toilet Use- One to two physical assist required due to weakness and poor balance. R24's Care Plan, initiation dated 8/26/19, documents At risk for falls and injuries due to weakness, poor balance, impaired cognition and lacking safety awareness, [MEDICATION NAME] use, will try and self transfer, will refuse assist with toileting or go when offered at times and to lay down in bed in the afternoon when tired. R24's Situation, Background, Assessment, Recommendation (SBAR) form, dated 1/31/2021, documents R24 was getting up from toilet with unsteady gait. Briefly describe the nature of occurrence: Resident found on floor sitting on buttocks in front of toilet. Assisted up and into wheelchair no injuries noted. R24's Care Plan Intervention, dated 1/31/21, documents Staff educated to stay with resident while on toilet. R24's SBAR, dated 2/14/21, documented on 2/14/21 at 6:50 PM, Writer heard yelling while in the middle of med pass, went looking around to see who and what it was walked past resident room and see resident sitting on the floor legs out in front of him leaned up against the w/c. left arm bleeding. Roommate state resident tried to stand up and feet slid out and he fell on his bottom. Resident and roommate denied hitting of head. The SBAR documented Resident is very impatient when it comes to bed. CNAs were 3 doors down working their way to him. Writer informed resident he needed to wait for the girls to help him in bed. The SBAR documented Root Cause: Resident attempted to self transfer from wheelchair to bed. Interventions: Resident encouraged to be in common area until staff assist to bed. Resident states he prefers to go to bed around 7pm. R24's General Note, dated 2/14/21, documented Resident did receive a skin tear to his left forearm, measures 4 cm (centimeters) x (by) 0.5 cm and couple small non measurable areas around the main area. There was no documentation, R24's Care Plan was not updated with new interventions to address his fall on 2/14/21 or to prevent him from future falls. R24's General Note, dated 2/17/2021 at 10:59 AM, documents Writer was called to resident's room to assess resident post fall. Resident was laying on his L (left) side in the BR (bathroom). Denies pain and hitting his head. Able to move all extremities w/o (without) issue. Able to bear weight on BLE's (bilateral lower extremities). New skin tear noted to L (left) elbow. Area was cleansed and steri strips applied. Resident did have tennis shoes on. Call light was not on. Resident was sitting on the toilet, the aide had went to get wash cloths and resident was trying to self-transfer back to w/c. MD and POA (power of attorney) made aware. Aides were educated that resident is to no longer be left unattended while in BR (bathroom). R24's Care Plan, revised on 2/17/21, documented Staff education. Resident not to be left unattended in bathroom. R24's Unwitnessed fall investigation dated 2/18/2021 documents Resident observed ambulating in room without assist just as resident fell on to his left side on floor in doorway of room. The Investigation documented Root Cause resident ambulating without staff assistance. Interventions: New order for UA (urinalysis) and labs obtained due to actions/behaviors that are unusual for resident. R24's General Note, dated 2/23/2021, Writer called PCP (Primary care physician) to notify about left pupil at a 4 and right eye is pinpoint. PCP would like him to be sent out due to recent falls. R24's General Note, dated 2/23/2021, documents Resident returned from (local hospital) to facility at approximately (10:10 PM) via ambulance. CT (Computed Tomography) and X-Rays performed. NNO (no new orders). fx (fracture) to left rib. contusion to left hip. no other injuries noted. R24's emergency room Report, dated 2/23/21, documents R24 had a fall 5 days prior. The ER Report documented an x-ray was taken and R24 sustained a left 8th rib fracture. The ER Report Clinical Impression documents 1. Single left rib fracture; 2) Single contusion to left hip; and 3) Fall. On 3/8/2021 at 12:12 PM, V23, Physical Therapist Assistant/PTA, stated R24 uses a walker with a sit to stand and always with staff assistance. On 3/16/2021 at 11:15 AM, V12, LPN stated, No, staff should not leave (R24) alone on toilet. V12 stated that R24 would transfer himself from the toilet at times. V12 stated that staff does have to assist R24 with transfers. On 3/16/2021 at 2:20 PM, V26, Nurse for V24 (R24's Physician), stated Someone needs to be with (R24) while he is on the toilet. 2. R23's physician's orders [REDACTED]. R23's Fall Risk assessment dated [DATE] documents that R23 is at high risk for falling. R23's MDS dated [DATE] documents R23 requires extensive assistance from 2-persons for ambulation in room. The MDS documents he requires extensive physical assistance of one staff for locomotion on unit and one-person physical assistance for toilet use. R23's MDS also documents his balance is not steady when moving from seated to standing positions, walking, turning around, moving on and off toilet and surface-to-surface transfers. The MDS documents he is only able to stabilize with staff assistance. R23's Care Plan dated 2/2/2021 documents R23 has self-care deficit as evidence by needing assistance with Activities of Daily Living (ADLS) related to dementia, impaired decision-making, recent infection and history of falls. The Care Plan Intervention, dated 2/2/21, documented Transfer: One-person physical assistance required. The Care Plan Intervention, dated 2/2/21, documents Toilet Use: One-person physical assist required. R23's Care Plan, initiated on 2/2/21, documents R23 is at risk for falls related to medication use and medical factors. R23's Unwitnessed fall investigation dated 2/3/2021 documents Writer heard a noise from resident's room entered room observed resident sitting on floor next to recliner and bed. Resident sitting upright holding onto siderail of bed and arm of recliner, states 'I fell '. Writer asked resident what he was doing he stated he was trying to move the cord to the IV pump around the bed. The Investigation documents Root cause: Resident states he was attempting to move power cord to IV pump around the bed. The Intervention documents Staff to place power cord behind bed or recliner. R23's Care Plan Intervention, revised on 2/4/21, documents staff would place power cord behind bed or recliner. R23's Unwitnessed fall investigation dated 2/4/2021 documents, Staff passed by resident's room at approximately (5:00 AM) and observed resident sitting on floor next to recliner on buttocks. Resident had IV pole tipped over. Resident wearing nonskid socks. The Investigation documents States he doesn't know why he was trying to get up. The Root Cause on the Investigation documents Resident attempted to transfer self from bed without assist. The Intervention documents Tab alarm when in bed or recliner. R23's Care Plan Intervention, revised on 2/4/21, documents Tab alarm placed due to confusion and anxiety leading to falls. R23's Situation Background Assessment Recommendation (SBAR), dated 2/12/21 documents R23 fell on [DATE] at 10:30 PM. The SBAR documents Heard loud crash, writer ran down to resident room, resident sitting on floor legs out in front of him towards the bed. When writer asked resident what happened resident state 'I slipped, but I'm fine.' The SBAR documented Root cause: Resident attempted to self transfer and lost balance due to weakness and lack of activity tolerance. Intervention: Call don't fall sign placed in room and discussed with resident. R23's General Note, dated 2/12/21at 10:40 PM documents Roommate stated he (R24) did not hit his head and he went to stand up and just fell down. R23's Care Plan Intervention, dated 2/12/21 documents low bed. R23's Unwitnessed fall investigation dated 2/16/2021 documents Writer entered room observed resident sitting on floor in front of WC on buttocks. Resident states he slipped so he pulled himself out of chair using bed rail. Alarm not sounding, call light not activated. The Investigation documented Root cause: Resident states he was slipping out of chair and grabbed bedrail to pull himself up. Intervention: Pressure alarm applied to wheelchair. R23's Care Plan Intervention, revision dated 2/16/21, documented Pressure alarm applied to wheelchair. R23's Unwitnessed fall Investigation dated 2/18/2021 documents Writer walking down hallway and observed resident sitting on floor between wall and bed. Resident states he was trying to go home. Resident has removed all clothing and slipper socks, had removed his alarm, and had it hidden under blankets and pillows. Resident had used his bed remote and raised bed into air, as staff had bed in low position. The Investigation documents Resident assisted X 2 staff to w/c and brought to nurses' station for observation. The Investigation documented Tab alarm removed and replaced with pressure alarm. Bed remote to be placed out of reach after resident is assisted to bed and positioned to his liking. R23's Care Plan Intervention, revision date 2/18/21, documents Tab alarm removed and replaced with pressure alarm. Bed remote to place out of reach after resident is assisted to bed and positioned to his liking. R23's Care Plan, initiation date 2/19/21, documents, This resident has a behavior problem (will remove alarm and shut off) r/t (removes safety devices. The Interventions, dated 2/19/21, documented to administer medications as ordered, anticipated the meet the residents needs and explain all procedures prior to implementation. R23's Unwitnessed fall investigation dated 2/22/2021 documents Staff walking by resident's room and observed resident sitting on floor next to roommate's bed. Resident had disabled his alarm. Bed was in low position. Resident had removed clothing and gripper socks. Resident had knocked over IV pole. The Investigation documented Intervention: large surface area pressure alarm applied to bed. R23's PT daily treatment note dated 2/25/2021 documents Writer instructed in gait training with ptnt (patient) only ambulation x15 feet with moderate assistance and close wheelchair follow. Writer provided maximal verbal prompts to keep stance within BOS (base of support) of AD (assistive device) and to shift weight forward due to strong posterior lean. (R23) bearing weight through heels and keeping toes off of floor despite maximal cues and education. (R23) had little to no corrections despite maximal verbal cues and educations being provided. On 3/8/2021 at 12:10 PM V8, Physical Therapist, stated that R23 fell a lot at night or early in the morning. V8 PT stated that R23 was max assist when contact made. 3. R25's Face Sheet, undated documents R25 has [DIAGNOSES REDACTED]. R25's MDS dated [DATE] documents R25 has severely impaired cognition, requires extensive assistance of one staff person for transfers and toilet use. The MDS documents he is not steady when moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfers but is able to stabilize without staff assistance. R25's Care Plan, initiated on 2/23/20, documents he is at risk for fall related to medications, weakness, unsteady gait balance and cognitive issue. R25's Fall Investigation dated 1/5/2021 documents Resident ambulating in room without walker, lost balance and fell to floor onto buttocks. The Investigation documented he sustained a skin tear to the back of his right hand. R25's Care Plan Intervention, revision 1/7/21, documents Sign placed in room to remind resident to use walker, room cleaned and free of clutter. Staff educated on removal of dishes after meals. R25's Unwitnessed Fall Investigation dated 1/6/2021 Facility staff heard a loud noise and went to resident's room finding resident lying at foot of bed, on his back, slipper socks on. Staff noted pool of blood under resident's head. Resident alert per baseline. States that he slipped going around the corner of bed. Resident log rolled to right side while holding head and neck and noted to have laceration to back of head with moderate to heavy bleeding. R25's General Note, dated 1/6/21 at 9:30 PM documented that R25 fell and was found with pool of blood under head. The Note documented R25 had a laceration to the back of his head. The note documented R25 was sent to ER. R25's General Note, dated 1/7/21 at 12:15 AM, documented he returned to the facility with six stitches and 3 staples to the back of his head. R25's Care Plan Interventions, revision 1/7/21, documented Telemed visit with primary MD. [MEDICAL CONDITION] medications decreased. Labs ordered. R25's Unwitnessed Fall investigation dated 2/10/2021 documents Writer entered room observed resident on knees next to recliner. The Investigation documents Root Cause: resident lacks safety awareness, cognition varies R/t his medical diagnosis. Resident reports he climbed out of recliner to 'look under there'. R25's Care Plan, dated 2/10/21, documents Continue current CP (care plan) interventions. The facility did not document any progressive interventions after this fall. R25's Unwitnessed Fall investigation dated 3/3/2021 Writer at nurse's station heard loud noise observed resident laying on stomach by snack machine, jeans around resident's ankle. Resident was ambulating without assist. R25's Care Plan Intervention, initiated on 3/5/21, documents New pants elastic waist pants purchased for resident. 4. R6's MDS dated [DATE] documents that R6 was admitted to facility on 11/20/2019 with [DIAGNOSES REDACTED]. R6's MDS documents that R6 requires extensive assistance 2-person physical assistance for transfers. R6's Care Plan dated 3/17/2020 documents R6 has self-care deficits. The Care Plan documents Needs assistance with ADLs (Activities of Daily Living) related to pain, weakness, [MEDICAL CONDITIONS], Diabetes, [MEDICAL CONDITION], arthritis in right knee, and Alzheimer's. R6's Care Plan interventions, revised on 1/8/2020, documents Transfer: Mechanical lift required sit to stand, and Two-person physical assist required. On 3/5/2021 at 10:00 AM, R6 stated, They don't get enough employees to work here. R6 stated, If there is only 1 person, then 1 person gets me up, because I can't walk anymore. R6 stated, That don't make sense only 1 person working. R6 was alert and oriented and answered all questions appropriately. On 3/8/2021 at 9:55 AM, V5, CNA and V3, Assistant Director of Nursing (ADON/LPN), were in R6's room. V5 used a mechanical lift (sit to stand) and lifted R6 from his wheelchair. V5 proceeded to take? R6 bathroom and R6 was hanging by arms, with his legs bent. R6 was unable to support his own weight. V3 stated, Not ideal transfer. (R6) needs to be a little higher. On 3/8/2021 at 12:10 PM, V8, Physical Therapist (PT), stated, I would have expected staff to cue resident to stand while using the sit to stand. The User Manual for 'Stand Up Patient Lift' section 4- Lifting the Patient (undated) documents, Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur. 5. R5's MDS dated [DATE] documents that R5 was admitted to facility on 11/19/2020 with a [DIAGNOSES REDACTED]. R5's Care Plan, initiated on 9/19/2019, documents that R5 is at risk for falls due to weakness, medication use and history of falls. On 3/8/2021 at 7:50 AM, R5 was walking down hallway using a walker with regular socks on feet until he reached the shower room. R5 stated, I don't dress myself. They dress me. R5 stated, I leave the same clothes on until my next shower. On 3.8/21 at 7:55 AM, V5 stated (R5) should be wearing non-skid socks, but he walked down here to the shower room by himself. On 3/8/2021 at 9:10 AM, R5 was walking down hallway from shower room with walker wearing regular socks and not nonskid socks. On 3/8/2021 at 1:40 PM, V3, ADON, stated, I would expect residents to wear non-skid socks to prevent falls. Facility's Policy and Procedure Falls and Fall Risk, Managing dated 2018 documents Policy Statement: 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. Fall risk factors: f. footwear that is unsafe or absent e. lower extremity weakness g. medication side effects i. functional impairments In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, interview and record review the facility failed to provide supervision and progressive interventions to prevent falls for 3 of 3 residents (R1, R2, R3) reviewed for falls in the sample of 5. This failure resulted in R2's fall sustaining fractures to her ribs, hip and pelvis. Findings include: 1. R2's Face Sheet titled Transfer/Discharge Report dated 12/16/2020 documents R2 was admitted to the facility 7/13/2020. R2's Care Plan dated 7/15/2020, documents that R2 is at risk for falls. Interventions include: Encourage use of call light and Ensure call light is within reach. R2's Care plan further documents that R2's Care Plan was Revised on 12/15/2020 to include Tennis balls placed on walker. The Facility's Fall Log documents that R2 fell on [DATE] and again on 12/1/2020. R2's Fall Investigation dated 11/5/2020 at 4:15 PM, documents that R2 was witnessed standing in the hallway, attempting the go back to her room and tripped on her walker. This event was witnessed by V4, Registered Nurse (RN). It further documents that R2 had no injuries, was able to get up while denying assistance. It further documents, Root cause-Resident tripped over walker because resident was standing at ambulance door for a length of time. Intervention: Is to offer resident a chair to sit in if she insists on looking at ambulance door. R2's Care Plan, reviewed on 12/15/2020, does not reflect this intervention or any other interventions added after R2's fall on 11/5/2020. The Facility's Abuse Log documents that on 12/1/2020, R2 had a fall with injury. R2's Report Form- IDPH (Illinois Department of Public Health) Notification dated 12/1/2020 at 7:10 AM, documents, (R2) had a non-fatal accident and that (R2) was sent to the ER (emergency room ) for evaluation. R2's Verification of Incident Investigation/Administrative Summary dated 12/1/2020 documents, Type of incident: Fall with injury. The investigation further documents, Brief Description of Incident/Event: resident sustained [REDACTED]. It further documents, Immediate Actions Taken: Head to toe assessment completed. Skin tear noted to left elbow. ROM (Range of Motion) assessed and WNL (Within Normal Limits) for resident. Resident noted to be barefoot, non-skid socks applied. Resident continued to ambulate with wheeled walker. R2's Care Plan, reviewed on 12/16/20, does not reflect this intervention or any other interventions added after R2's fall on 12/1/2020. The Initial and Final Report with Investigation and Conclusion documents, On 12/2/2020, resident voiced complaints of increased pain to back and leg stating that she had fallen at Wal-Mart parking lot. MD (Medical Doctor) notified of increased pain. Order obtained to send resident to ER for evaluation and treatment. ER called to inform nurse on duty that resident had sustained fractures of left ribs #2, 3, and 7, as well as an acute inferior and superior pubic ramus (pelvic) fracture. Report from ER also reads there is hardware fixation of the left femoral neck with persistent fracture (not yet united). Admission history and physical shows that left hip fx (fracture) and pinning were addressed in June of 2020. MD and POA (Power of Attorney) agreed that hip will be treated non-operatively. Resident returned to facility on 12/2/2020 with incentive spirometry and orders for [MEDICATION NAME] and [MEDICATION NAME] to be given per label instructions. R2's X-ray report from the hospital, dated 12/2/2020, documents, Impression: Nondisplaced lateral left 2nd, 3rd, and 7th ribs at the lateral aspect. R2's CT (Computerized Tomography) report, dated 12/2/2020, documents, Impression: 1. Minimally displaced fracture the left superior and inferior pubic ramus (pelvis). R2's physician's orders [REDACTED]. On 12/15/2020 at 1:00 PM, R2 was observed in her bed, up against the wall and one side rail raised on the opposite side. There was no fall mat present. R2's call light was tied to the side rail but was dangling down towards the floor. R2's wheeled walker with tennis balls on the bottom of it, was observed in the room, out of R2's reach. An attempt to interview R2 was initiated at this time. R2 stated, My left side is dead. I can't walk anymore. I'm ready to go with my mom again. I had a good life. I fell at Wal-Mart. On 12/15/2020 at 2:10 PM, V6, Certified Nursing Assistant (CNA) came into R2's room to see if she would go to the bathroom. R2 declined. At this time, V6 stated, She can still ambulate with our help. She uses her call light. V6 then left R2's room. R2's call light was still in the same position as it was before (dangling off the side rail, on the floor) at 1:00 PM. R2 grimaced and stated that her pain comes and goes. When asked if she could use her call light to get help, R2 did not acknowledge the question but instead complimented the surveyor on her outfit. On 12/15/2020 at approximately 2:15 PM, V11, Licensed Practice Nurse (LPN), came into R2's room with pain medication for R2. R2 stated her pain was at an 8 after V11 explained the 1 to 10 pain scale. V11 left the room after administering R2's pain medication. R2's call light remained on the floor. On 12/15/2020 at approximately 3:00 PM, V8, Care Plan/ MDS Nurse, stated, I have not done the MDS (Minimum Data Set) on her. I am still working on them. Her (R2's) Care Plan is a mess. I'm not going to lie to you. On 12/16/2020 at 8:56 AM, V4, RN, stated, I worked the day after (R2's) fall (12/2/2020). (R2) was complaining about pain in her left hip and leg and side. She had fallen and broken her left previously before coming to the nursing home, so she did have some pain in the left hip before. Did she say she fell at Wal-Mart? She did before. She'll tell you she's fine and doesn't want bothered. I think it was shift change (When R2 fell on [DATE]) and (V5, RN) was the nurse when she fell . (V5) stayed over to assess her. I read fall report. It said she got up by herself with walker. (R2) does not use her call light. (R2) would just get up on her own and did fine with walker. On 12/16/2020 at 11:45 AM, V3, Assistant Director of Nursing (ADON), stated, After (R2's) fall on 11/5/2020, we put a chair by the door. She likes to look out (ambulance door) in case she wanted to sit down. We added the tennis balls to her wheelchair before today, but I have no way of proving that. We added it to the Care plan yesterday as we (V2, Director of Nursing, DON, and V3) were going over falls. On 12/16/2020 at 4:02 PM, V12, CNA, stated, I worked day shift the day (R2) fell but I didn't witness it. I was down the hall with another resident. I didn't notice anything different. (R2) was up and walking like she normally does. I was told she (R2) has fractures in her hip and ribs. I do not know of any other changes other than she (R2) has been staying in bed more. (R2) can get up with two assist and walker now. I am not sure how long the tennis balls have been on her walker. There is not usually a chair by the ambulance door because we don't want anything blocking the doors. (R2) doesn't use call light very often. On 12/17/2020 at 8:05 AM, V5, RN, stated, My relief was late the morning of (R2's) fall. There was another fall before hers (R1). I was standing at the nurses' station charting on (R1's) fall. (R2) was in her room standing up from her bed. She was talking to her roommate and her lost balance. She's not completely with it and doesn't always use walker correctly. (R2) is able to use her call light, but I don't think she ever presses it. (R2) likes to do things herself. After (R2's) fall, I was taking her vital signs and treating the skin tear to her elbow, she was fighting me, wanting to stand up. She then walked from roommates' side of the room and sat down and wanted coffee and breakfast. I was very, very surprised to find out she had all those fractures. There are a lot of falls. I'm being completely honest with you. Supervision/staffing is most definitely an issue as well as the acuity of the residents. On 12/17/2020 at 11:58 AM, V14, R2's Medical Doctor (MD) stated, The facility called me. At first it didn't seem too serious until she developed pain. I then gave the order to send (R2) to the ER for an x-ray and that's what they found the fractures. The ER did not admit her. The goal is to keep (R2) comfortable. I was not there, so I did not investigate how she fell . I do know that before she was able to freely walk around. I don't know if her condition deteriorated. I think the NH (nursing home) is stressed due to [MEDICAL CONDITION], so that may affect the level of care. 2. The facility's Fall Log documents R3 fell [DATE], 10/3/2020, 10/7/2020, and 10/26/2020. The Fall Log documents that 2 falls of R3's were unobserved. R3's Care Plan dated 10/2/2020, documents, At risk for falls and injuries related to medications. She will refuse to wear slipper socks or any-thing on feet, prefers to go barefoot, Dementia, she wanders quickly around the halls, has [MEDICAL CONDITION] disorder, weakness, HX (history) of falls. R3's Care Plan had no progressive interventions related to each of R3's falls listed on The Facility's Fall Log. R3's Care Plan documents the last intervention for falls was added on 9/21/2020 and was for physical therapy to evaluate for strengthening. R3's Care Plan documents on 6/1/2020 an intervention was added to R3's Care Plan, Room move due to roommate will ask (R3) to get up and do things for her. R3's MDS dated [DATE], documents that R3 requires extensive assist of one staff to walk in the corridor. On 12/15/2020 at 12:45 PM, R3 was observed wandering the halls wearing a gown and a pair of socks, unsupervised. On 12/15/2020 at 1:55 PM, R3 was observed walking by herself in hallway, unsupervised. On 12/15/2020 at 2:15 PM, R3 was observed pushing her roommate in her wheelchair down the hall, without supervision or redirection of staff. On 12/15/2020, R3 asked this surveyor, Will you hold my hand and walk with me? This surveyor redirected the resident by asking R3 to show the surveyor where her room was. R3 took this surveyor to her room and R3 sat in her recliner. R3 was able to show the bottom of R3's socks which were the non-skid type. On 12/16/2020 at 11:45 AM, V3, ADON, stated, (R3) ambulates independently without a walker. What are you supposed to do with someone who is independent? (R3's) MDS is not true. V3 continued to state, (R3) pushes her roommate. The roommate is the brains, (R3) is the feet. V3 continued to state, There were interventions in place, they just weren't on the Care Plan. (V8) MDS/Care Plan Nurse, is still new. On 12/17/2020 at 8:00 AM, V5, RN, stated, (R3) is confused and wanders. (R3) will walk around until she falls. We attempt to re-direct her, but it doesn't always work. It's not safe, but she doesn't understand. The Facility's Fall Management policy and procedure, dated 11/7/19, documents, Fall Prevention Procedure: 1. Evaluate risk factors for sustaining falls upon admission, with comprehensive assessments and while conducting interdisciplinary care plan reviews 2. Initiate a fall prevention care plan, when appropriate, with strategies to minimize risk and/or potential for injury 3. Review, revise and evaluate care plan effectiveness at minimizing falls and injury during care plan reviews and as needed. 3. R1's Electronic Health Record (EHR) documents that R1 was admitted to facility on 11/12/2020 with a [DIAGNOSES REDACTED]. On 12/15/2020 at 12:30 PM, R1 was observed lying in a scoop mattress, bed low to floor and a mat was located on left side of bed. R1 stated that she wanted a hot cup of coffee. R1 was alert to self. R1 observed with a large fading bruise to right forehead area. On 12/15/2020 at 1:30 PM, V3, ADON, stated (R1) falls all the time. V3 stated, (R1) falls are all documented on SBAR (Situation background assessment recommendation) and not in R1's progress notes. On 12/16/2020 at 10:12 AM, V7, Pending Certified Nursing Assistant (PCNA), stated, (R1) has had a lot of falls, I have been told about them. V7 stated, (R1) is very unstable and that there is 2 staff to assist with transfers. V7 stated, (R1) doesn't completely understand (directions). On 12/16/2020 at 10:05 AM, V4, RN, stated (R1) is full care. V4 stated when giving (R2) directions, I don't think it's 'clicking'. V4 stated, No, (R1) didn't have enough supervision the night she fell . V4 stated, When (R1) came to facility she was a wanderer, (R1) was all over the place. R1's SBAR dated 11/19/2020 at 08:45 AM, documents unwitnessed fall in hallway, unable to communicate what happened. (R1) sustained no physical injuries. R12's SBAR documents that (R1) was found on floor near bathroom, (R1) wandering, resident in and out of isolation bins and anything in the hall. (R1) leaned forward resulting in (R1) sliding out of WC (wheelchair) onto floor onto buttocks. No injuries noted. ROM (range of motion) WNL (within normal limits). Able to move all extremities. R1's Care Plan dated 11/12/020 had no new interventions for the fall that occurred on 11/19/2020. R1's Care Plan dated 11/12/2020 documents, (R1) is at risk for falls and injuries r/t (related to) medications: [REDACTED]. Medical Factors: Is on IV ABT (IV antibiotics) due to wound infection of the left hip. Interventions: Encourage use of call light (initated 11/12). (non slip device) on top of wheelchair cushion. She does remove (non slip device) quite often on her own. Please encourage to leave in. (initated 11/29). Toilet after all meals Date Initiated: 11/21/2020. Foot boards for wc (wheel chair) provided Date Initiated: 12/09/2020. Keep call light within reach.Date Initiated: 11/12/2020. Keep environment clutter free Date Initiated: 11/12/2020. Keep personal belongings within reach Date Initiated: 11/12/202. Provide adequate lighting Date Initiated: 11/12/2020. Tab alarm applied to resident Date Initiated: 11/13/2020 R1's SBAR dated 11/21/2020 at 1:50 PM documents Unwitnessed fall from wheelchair. Function Level Prior to Incident: Needs Assistance. Unable to communicate what occured. Oriented to Person. Briefly describe the nature of occurrence: Writer called to room by CNA when arriving resident sitting in doorway of room on the floor in front of her wheelchair. (R1) on her buttocks legs extended out, no complaints of pain. mae (moves all extremities). no physical trauma noted. when asking resident what she was doing resident states, 'I don't know' let resident know she needed to call for help her response 'what for' (R1) assisted to bed at this time. R1's intervention for 11/21/2020 Fall: Toilet after meals. R1's SBAR dated 11/29/2020 at midnight documents, (R1) was reaching for an item on a bedside table when she scooted too close to the edge and slid to the floor. Denies pain. (R1) has a red mark down the left flank area from a part on the wheelchair (foot pedal). Foot pedals were on at time of fall. Alarm not sounding due to resident having on a housecoat and the coat went up her back not allowing for the alarm tab to pull. A dycem (non slip) sheet was also placed under her cushion. Alarm failure or device removal. R1's interventions for 11/29/2020 fall documents, Fall Intervention: Dycem on top of wheelchair cushion. (R1) does remove Dycem quite often on her own. Please encourage to leave on. R1's SBAR dated 12/01/2020 at 6:20 AM documents, 'Writer called to room, (R1) was sitting upright in front of bed on floor mat, bed was completely lowered to the floor. Alarm failure or device removal. Call light not activated. Assessment: Unable to communicate what occurred. R1's Care Plan has no new interventions for the fall that occurred on 12/01/2020. R1's SBAR dated 12/08/2020 at 8:30 PM documents, Un-witnessed fall in R1's room. (R1) appears to have sat on side of bed and slide off mattress onto floor mat no injuries noted no c/o (complain of) restless anxious alarm in place resident place in wheelchair and taken to nurses station alarm in place. R1's SBAR dated 12/8/2020 at 8:55 PM documents, Un-witnessed fall in hallway. (R1) unable to communicate what happened. Briefly describe: Heard alarm and loud noise immediately came out of another room and saw (R1) laying on right side with lower part of wheelchair underneath her alert to name. (R1) able to make needs known no laceration or skin tear noted (R1) c/o discomfort to hip and lower legs and to lower back no SOB (shortness of breath) even neuro check WNL (within normal limits). Transfer to Emergency Department for evaluation. R1's Care Plan has no new fall interventions for the falls that occurred on 12/8/2020. R1's progress note dated 12/8/2020 documents, (R1) returned to facility via ambulance alert to name able to make needs known neuro checks WNL hematoma noted to right side of head ice applied as ordered no c/o alarm in place bed in low position no fx (fracture) noted at hospital POA (power of attorney) aware was at hospital with mother. On 12/16/2020 at 12:11PM, V9 (R1's POA) stated, A couple of times I don't think that the facility called me when (R1) fell a couple of times, the last 3 weeks for sure. V9 stated, Yes, six falls is alot. On 12/16/2020 at 3:30 PM, V10, R1's Physician, stated effective (care plan) interventions and adequate supervision would have prevented R1 from falling.

Based on interview and record review the facility failed to provide an anticonvulsant medicine for 1 of 3 resident (R2) reviewed for medications in the total sample of 8. This failure resulted in R2 having severe convulsions/[MEDICAL CONDITION] and sent out to hospital and placed into hospice. Findings include: R2's Electronic Health Record (EHR) documents that R2 was admitted to facility on 12/27/2019 with a [DIAGNOSES REDACTED]. R2's progress note dated 9/7/2020 07:21 AM documents: Administration Note: [MEDICATION NAME] Tablet 100 MG (anticonvulsant) Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant backup pharm would not send d/t already being filled by our pharmacy. Awaiting med. R2's progress note dated 9/14/2020 19:19 PM documents: Orders - Administration Note: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant waiting on delivery. R2's progress note dated 9/28/2020 10:22 AM documents: Orders - Administration Note: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant waiting on script. R2's progress note dated 9/28/2020 19:28 PM documents: Orders - Administration Note: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant waiting for signed script. R2's progress note dated 9/29/2020 08:04 AM Orders - Administration Note: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant awaiting script. R2's progress note dated 9/29/2020 18:49 PM documents:Orders - Administration Note: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant waiting for delivery. R2's progress note dated 10/1/2020 19:45 PM documents: Orders - Administration Note: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant Have not received from pharmacy. R2's progress note dated 10/2/2020 18:28 PM documents: Orders - Administration Note: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant Have not received from pharmacy. R2's progress note dated 10/3/2020 11:41 AM documents: Orders - Administration Note Note Text: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant Awaiting delivery from pharmacy. R2's progress note dated 10/4/2020 07:33 AM documents: Orders - Administration Note Note Text: [MEDICATION NAME] Tablet 100 MG Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant Awaiting delivery from pharmacy. R2's progress note dated 10/4/2020 09:40 AM documents: General Note: call made to pharmacy regarding [MEDICATION NAME] script. pharmacy states needs new script as script did not transfer over from omnicare. pharmacy states they will call dr. R2's progress note dated 10/4/2020 12:51 pm documents: Change of Condition / TransferNote Text: (R2) was transferred on a gurney via ambulance to acute care hospital Sent To: HOSPITAL Date: 10/04/2020 0:12 Sent From: (Name of Facilty) Unit: Unit South Reason(s) for Transfer: [MEDICAL CONDITION]. MD notified of transfer. See Transfer Form for other details. R2's Physician order [REDACTED].*Controlled Drug*Give 2 tablet by mouth every morning and at bedtime for Anticonvulsant. R2's Care plan dated 4/29/2020 documents: (R2) He has a [MEDICAL CONDITION] disorder. INTERVENTIONS: Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness. On 10/9/2020 at 7:43 PM, V12 Registered Nurse (RN) stated, We try to do ahead of time so when we reach the last row of pills on med card, then we reorder. V12 stated, Sometimes Pharmacy says too soon. On 10/10/2020 at 11:40 AM, V2 Director of Nursing (DON) stated, I was unaware that R2 was out of his [MEDICAL CONDITION] medication. V2 stated, No one informed me that R2 was out of his [MEDICAL CONDITION] medication, until he was sent out to local hospital. V2 DON stated, If I don't know what is going on, how can I help. V2 DON stated, This was a refill not a new script. V2 DON stated, Our facility was changing over to a new pharmacy and they would not honor a refill for narcotics and requested that a new script be written. V2 DON stated that the facility's oncall Neurologist stated, We would have to go back to the prescribing neurologist. V2 DON stated, That neurologist office kept advising the new script was sent to pharmacy then R2's [MEDICAL CONDITION] happened. V2 DON stated, R2 was placed on Hospice after this episode. On 10/10/2020 at 1:30 PM, R1 (R2's roommate) stated, I saw R2 jerking in his wheelchair, he was convulsing and gasping for air. R1 stated, I used my call light to call staff, I told them something is wrong with (R2). R1 stated, Ever since (R2) has come back from hospital he's different. On 10/13/2020 at 11:40 AM, V16 Pharmacist stated, We stopped filling scripts for that facility about 6-8 weeks ago. V16 stated, No, I wouldn't expect a resident to go without this medication, it is an anticonvulsant, could trigger a [MEDICAL CONDITION]. V16 stated, This medicine is used strictly for [MEDICAL CONDITION]. V16 stated, I would not stop this medication without doctors orders and monitoring. On 10/13/2020 at 11:50 AM, V17 (Nurse for R2's Physician) stated, R2's doctor is not in the office. V17 stated, We wouldn't have expected R2 to go without this medication. V17 stated, If facility was out we could have filled a 7 day script for R2 if we had known. On 10/13/2020 at 1:00PM, V18 (R2's wife) stated, The ER doctor called me and asked me, Why my husband (R2) wasn't getting his [MEDICAL CONDITION] medication? V18 stated, He's (R2) in a nursing home. V18 stated the facility did not call me and tell me that (R2) wasn't getting his [MEDICAL CONDITION] medicine because I would have ran out and got him some. V18 stated, I called the nurse and it was Sunday (10/4) and the nurse stated that (R2) hadn't received his [MEDICAL CONDITION] medication since last Tuesday (9/29). V18 stated that (R2) had started this medication about a year ago and it was controlling his [MEDICAL CONDITION]. V18 stated, I know (R2) had to have it. V18 stated, (R2) had a craniotomy last year and lost the use of his legs. V18 stated, The ER doctor stated, they could send (R2) back to Springfield, but if did surgery again it would cause more damage. V18 stated, It took the ER a long time to get the [MEDICAL CONDITION] under control. V18 stated, Decision was made to place (R2) into Hospice Care. V18 stated, (R2) is not himself, not real friendly. Facility's Policy and Procedure 'Drug Orders from Pharmacy' (undated) documents: Refills: A. All drugs are to be monitored daily during administration. Sufficient supply must be available for at least five days. The pharmacy may be closed on weekends. If there is a delay in ordering drugs from an outside pharmacy, follow facility policy to order from the contracted pharmacy as an emergency measure. If this is done, it should be reported to the business office for clarification on the next billing. Facility's Policy and Procedure 'Administration of Medications dated 9/15/2019 documents: Residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility polices. It is the responsibility of the Charge Nurse to ensure that all medications are passed within a timely manner. Facility's Policy and Procedure 'Accidents & Incidents dated 9/15/19 documents: If there is a Serious incident or injury (according to section 300.690 Administrative code) the DON shall file a report with the Illinois Department of Public Health by email, fax, or phone within 24 hours of each serious accident/incident. Narrative summary shall be sent to IDPH within 7 days of the occurrence.

Based on observation, record review, and interview, the facility failed to provide supervision and new effective interventions to prevent falling for 1 of 3 residents (R4) reviewed for falls in the sample of 28. This failure resulted in R4 falling multiple times, hitting her head causing lacerations requiring staples, hematoma, 7th rib fracture and right [MEDICAL CONDITION] on three separate falls and being sent to the emergency room (ER) for treatment. Findings include: On 12/18/19 at 12:35 PM, R4 was observed transferring herself from a wheelchair to her bed in her room. R4 stated she did not require any assistance from staff to do so. On 12/19/19 at 1:10 PM, R4 was observed lying in her bed with the wheelchair next to her bed. R4 stated she got into bed herself. On 12/01/19, the physician's orders [REDACTED]. On 10/16/19, the fall risk assessment for R4 was documented as a score of 80 or high risk for falls. On 10/21/19, the Minimum Data Set, (MDS), documented R4 had a Brief Interview for Mental Status was scored at 6 or moderately impaired cognition. It documented R4 required supervision for bed mobility and transfers; limited assist of one staff for ambulation; extensive assist of one staff for dressing; and supervision with set up for eating, toileting and hygiene. It documented R4 was identified with no limitations of upper or lower extremities and required wheeled walker or wheel chair for locomotion. On 12/02/19, the Care Plan documented R4 required assistance of two staff with transfers, ambulation and toileting. On 03/23/19, a Situation Background Assessment Recommendation, (SBAR), report documented, R4 was found on the floor in the hallway and stated, I hurt everywhere. The report documented no injury noted. The Interdisciplinary Team, (IDT), follow up documented R4 was impulsive without safety awareness, refuses help or assistance at times and non-compliant with the use of a call light. The intervention was for 30-minute monitoring checks, for stand by assist with ambulation. On 05/02/19, the SBAR report documented, R4 was found on the floor in her room with a large hematoma to back of head. It documented once up, R4 was leaning to right and unable to pick up right leg to ambulate, placed in bed by staff. R4 insists she was able to ambulate. Staff placed R4 in a wheelchair for safety. R4 was sent to Emergency Department, (ED), for evaluation and diagnosed with [REDACTED]. The intervention was for 30-min monitoring due to non-compliance with call light. On 05/16/19, a SBAR report documented, R4 was found on the floor in her room on her buttocks, incontinent of stool, it documented no injury. SBAR documented R4 continues to self-transfer, not to use the call light. R4 has poor safety awareness and refuses care and assistance from staff at times. The intervention was for frequent checks and visualization from staff and offer toileting every two hours. On 05/21/19, a SBAR report documented, R4 was found on the floor in her room with a [MEDICAL CONDITION] and bleeding and right leg deformity. SBAR documented R4 was rating pain 10 out of 10 for her leg. R4 was sent to the ED for evaluation and diagnosed with [REDACTED]. No new interventions were listed on the SBAR. On 06/23/19, a SBAR report documented, R4 was found on the floor next to her bed. It documented R4 slid from bed to floor, no injury noted. The intervention was to add sensor alarm to bed to alert staff that R4 was attempting to self-transfer. On 12/01/19, a SBAR report documented, R4 was found on the floor in her room with an abrasion to the mid back. R4's walker was found in the bathroom. SBAR documented, R4 was non-compliant with use of call light, using walker or wheel chair and will not use safety alarms, removes or hides alarms. The intervention was to offer toileting every two hours. On 12/02/19, a SBAR report documented, R4 was found on the floor in her room with a laceration to back of the head. R4 was sent to the ED for evaluation and treated with two staples to the [MEDICAL CONDITION]. The SBAR documented, R4 was independent with ambulation. The intervention was to change R4 from independent to a two person assist with transfers and ambulation and add alarm to bed and chair. The policy and procedure titled, Fall Management was reviewed. It documented under, Purpose: To evaluate risk factors and provide interventions to minimize risk, injury and occurrences. And under, Fall Prevention Procedure: 3. Review, revise and evaluate care plan effectiveness at minimizing falls and injury during care plan reviews and as needed. On 12/20/19 at 9:40 AM, an attempt was made to contact R4's Physician for interview. The Physician's office stated he would be out of the country for the next two weeks and unavailable for interview. On 12/19/19 at 1:20 PM, V9 Certified Nursing Assistant, (CNA), stated R4 was alert and oriented and could make her needs known. She stated R4 often gets up unassisted and does not ask for help. She stated R4 did not usually use her call light for assistance.

Based on interview, observation, and record review, the facility failed to prevent a fall during ambulation for one of 5 residents (R3) reviewed for falls and transfers in a sample of 5. R3 falling and fracturing left hip and needing surgical repair. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R3 to have severe cognitive impairment and requires extensive assist of one staff for transfer and ambulation in/out of her room. The Care Plan dated 3/13/19 documented R3 to be at risk for falls due to medications, Dementia, incontinence, the need for walker for ambulation, dizziness/[MEDICAL CONDITION], poor safety awareness and history of falls. A Fall Risk assessment dated [DATE] identifies R3 as being high risk for falls. A SBAR (Situation, Background, Assessment and Recommendations) form dated 5/15/19 entered by V3, Licensed Practical Nurse (LPN) at 8:30am, R3 fell while ambulating from dining room chair to bedroom after breakfast. Per V6, CNA (certified nurse assistant) and V5, MDS (MDS coordinator) resident did not hit head, resident lost balance falling onto left hip. Nurse assessed resident, c/o (complained of) pain to left hip, guarding hip. Left hip slightly externally rotated. The report documents R3's fall as an assisted ambulation note continues that V11, Physician, was notified at 8:35am. Nurses notes dated 5/15/19 at 10:58am document R3 was transferred on a gurney via ambulance to local acute care hospital. The Ambulance Report dated 5/15/19 documents they arrived at the facility at 8:56am. The patient care report section of the ambulance report documents arrived on scene found pt. (patient) in her room on her bed. Pt had bowel movement and was incontinent of urine. Staff states they did not want to move her to clean her up. Staff states pt. normally walks on her own. She gotten up from the dining chair and lost her balance and fell on her left side. Staff used a (full body mechanical lift) and picked her up and placed her in the bed. Pt has dementia and is unable to tell us where it hurt other than holding the area. Pt was placed on the cot and secured. Pt left leg did look rotated outwards. On 10/04/19 at 1:21pm, V12, R3's Power of Attorney/Family member stated she received a call from V3 the morning of 5/15/19 and was told that her mother had fallen, and they thought she'd fractured her hip. V12 stated R3 was yelling out with pain to left hip, as staff lowered her into bed. V12 stated she asked if they'd had a gait belt on her mother when she fell , and she was told by V13, Administrator at the time, that no gait belt was used but they were only used to guide the person. V12 stated staff often did not use a gait belt and she worried about her losing her balance and falling just like she did. V12 stated she discussed her mother's falls with V6 and V5 who were present during the falls. Hospital Records dated 5/15/19 documents R3 was admitted to the hospital with [REDACTED]. On 10/04/19 at 12:42pm, V3, LPN stated R3 was in the dining room when she fell and was being assisted by a CN[NAME] V3 stated she didn't remember if R3 had on a gait belt or not but did think her leg was rotated out. When asked why she would move R3 to her bed following the fall since she was showing some outward rotation, stated they didn't. This statement conflicts with the ambulance report. On 10/04/19 at 1:15pm, V6 CNA stated she helped R3 get up from the table because she was just supervision and was standing on R3's right side when she started to fall toward the left. V6 stated she grabbed at her pants but was unable to steady her balance and she fell to the floor. V6 stated she did not have a gait belt on R3 at the time of the transfer. V6 could not remember if they left R3 on the floor awaiting the ambulance or if they moved her to her bed in her room. On 10/15/19 at 1:33pm, V2 Director of Nurses (DON) stated it is the policy of the facility to use a gait belt on any pivot transfer or assisted ambulation. The facility's policy/procedure entitled Use of Gait Belt undated documents the purpose as It is the policy of this facility that staff will help control and balance (by using a gait belt) residents who require assistance with ambulation and transfer. On 10/15/19, V11 MD responded to questions asked whether he would have expected the staff ambulating R3 to use a gait belt and responded yes adding that R3 ambulated was once up with her walker with one assist. The facility's policy/procedure entitled Fall Management undated documents the purpose as To evaluate risk factors and provide interventions to minimize risk, injury, and occurrences. Under Procedure for responding to a fall, it documents prior to moving the resident, evaluate for signs and symptoms of physical injury or trauma and evaluate actual or suspected causal factors to prevent reoccurrences.

Based on interview, observations, and record review, the facility failed to identify, assess, treat and monitor pressure ulcers for 3 of 8 residents (R25, R32, and R33) reviewed for pressure ulcers in the sample of 26. This failure resulted in a decline of R32's pressure ulcer from a stage II to unstageable in one week. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], identifies R32, with [DIAGNOSES REDACTED]. R23 requires total assist of two staff for bed mobility, and care of incontinent of bowel movements and has a Foley catheter. The Skin Assessment documents R32, currently has a stage II pressure ulcer. To his right buttock that R23 was admitted with, from the hospital. The (MONTH) 2019, Physician order [REDACTED]. The POS, also, documents the order, Theraworks skin barrier, spray to bilateral buttocks for MASD (moisture associated skin damage) q 4 hours dated 12/13/18. At 9:50 am on 1/30/19, R32 was in his wheelchair, in his room at his bedside. R32 stated, he has a sore on his back side and currently, does not have a dressing on it. R32 stated he has been in his chair since before breakfast. At 9:55 am on 1/30/19, R32 was transferred to bed via a full body mechanical lift, by V7 and V8 Certified Nurse's Aides (CNA's). R32 had two larger braised scabbed areas across his sacrum, multiple open pinpoint areas across upper buttocks and an ulcer on inner right buttock, which was irregular in shape, with a beefy red, bloody area with slough (dark) area on the bottom of the wound. R32 had dried bowel movement, on his inner buttocks and on his scrotum, but did not have bowel movement on his incontinent pad at this time. V2, Director of Nurses (DON), who entered the room as the CNA's were preparing to provide incontinent care stated, They use Theraworks as a barrier to his bottom when asked about a dressing. Incontinent care was done by V7, who only used one wet wash cloth with no soap. V7 then sprayed barrier cream on R32's inner buttocks, by the rectum, but there was no ([MEDICATION NAME] dressing) on the area ordered or in the bed sheets or clothes. R32 had deep creases across bilateral buttocks, back and upper thighs, that remained red/white during the entire observation. No fluids were offered with care. On 1/30/18 at 10:10 am, V8, CNA, confirmed R32 was up at 7:15 am that morning and has not returned to bed, or repositioned in the 3 hours up. R32's Care Plan, dated 12/26/18, documents a Focus as Potential for impaired skin integrity related to: Requires assist with turning and repositioning: one to two person assist with bed mobility and two person assist with (mechanical lift), Impaired mobility, Incontinence impart and 6/22/18 readmission with two, stage 2 pressure areas noted, with need for monitoring and treatment, to assure proper healing 9/18/18 stage 2 open area right buttock, 11/1/18 moisture associated skin damage to coccyx/sacrum. The goal is for R32 to have No new pressure ulcers will develop in the x 90 days. Wounds will show signs of improvement by next review. Interventions include: 11/01/18 Treatment to MASD as ordered until healed. Dry under skin folds thoroughly each day. Risks: r/t (related to) obesity, head to toe skin assessment, weekly with bathing and PRN (as needed). Monitor skin daily with cares and report any changes to MD (Medical Doctor), keep heels afloat with pillow or bath blanket rolled, heels are not to touch bed. Treatment to impaired skin integrity areas as ordered. Monitor to assure dressings intact each shift. Notify MD of any s/s (Signs/Symptoms) of infection, failure to heal or deterioration in wounds, Pressure reducing mattress to bed, Pressure reducing cushion - wheelchair, apply Lotion to skin following bathing, observe skin integrity during am/PM care, Maintain HOB (head of bed) in lowest possible position, Notify MD promptly of skin breakdown, Encourage PO (oral) intake, Provide pericare, Evaluate Skin Weekly, and reposition frequently in bed. R32's Braden Risk Assessment, dated 12/5/18, for Pressure ulcer development is scored at moderate risk even though he currently has a pressure ulcer. A skin assessment, dated 1/31/19, documents R32's right buttocks has an acquired pressure ulcer, and on 1/24/19. Pressure ulcer is a stage II with granulation tissue present with no necrosis or slough measuring 2.5 cm (centimeter) x 3.5 cm x 0.1 cm. The order for the ([MEDICATION NAME] dressing) is to be continued. On 1/31/19 at 3:51 PM, V20, Registered Nurse/Wound Nurse, stated she does measurements ulcers only on Thursday and R32's pressure ulcer has really gotten bigger and declined since last week. V20 also stated he now has a new pressure ulcer, which measures 1 cm x 1 cm x 0.1 cm right below the other one. V20 stated the CNA's need to tell the nurse if the dressing is not in place and not get the resident up until it is. When told R32 had no dressing on the morning of 1/30/19 and had been up for extended time, V20 stated, That could explain the decline. On 2/4/2019 at 3:35 PM, V26, R32's Physician, stated he was aware, of R32's pressure ulcers and would expect the staff to follow treatment orders. 2. The MDS, dated [DATE], identifies R25 as having severe cognitive impairment and requires extensive assist of staff for bed mobility and total assist of two for transfers. The MDS documented R25 to be incontinent of bowel and bladder always. On 01/29/19 at 11:20 am, during a skin check, R25 had two areas on her feet not identified on the pressure ulcer list. One was on the right outer ankle that was brown/red in color and approximately 1 cm in circumference. The other was on top of her 5th digit, on left foot. R25's heel protectors were setting on her over bed table and not on her feet. She had a foam dressing to her right gluteal fold, dated 1/28/19. R25 had a quartered folded sheet and two cloth incontinent pads under her. R25 was not offered fluids by V4 or V5, CNAs, who provided care at that time. The (MONTH) 2019 POS documented an order for [REDACTED]. The most current care plan, documents R25, to be at risk for impaired skin integrity related to: Impaired mobility, Poor PO intake, Incontinence, History pressure ulcer, Non-Complaint with turning and repositioning- staff will reposition and res. will move self-back. Slides in bed and in wheel chair skinned area to side of face identifying on 9/30/18, a stage 2 ulcer was identified on her right ischium. The ulcer was documented as healed on 12/6/18 and then reopened. The care plan does not reflect the ulcers on her feet or the need to utilize the heel protectors. On 1/31/19 at 2:45, when V2 was asked if she observed the open areas on R25's feet, V2, DON, stated she did look and saw nothing. At 2:47 PM, R25's feet were observed, with V2, to have a brownish red scab on her outer right ankle. V2 responded, Well, I didn't see that because, I thought you said left side before. 3. According to the Admission Sheet, R33 was originally admitted to the facility on [DATE]. The MDS, dated [DATE], identifies R33 as cognitively intact with a BIMS score of 15 and requires one, staff assistance for most activities of daily living. On 1/30/2019 at 1:30 PM, V6, Licensed Practical Nurse (LPN), and V13, CNA, assisted R33 to stand up from the recliner. When V6 spread R33's butt cheeks, a curled up Duoderm was observed. V6 removed the Duoderm, unrolled it, and stated that the date on the Duoderm was 1/26/2019. R33 had an open area stage II pressure ulcer on her inner butt cheek. R33 requested to walk across the room and sit in another chair. Upon R33 sitting down, a white folded cloth was noted sticking out from between R33's legs. R33 stated that the CNA's place it there because, her urinary catheter has been leaking for approximately a month. V2, DON, stated, No, they place it there due to (R33's) upper thighs rub together causing blisters. V2 then removed the white pillow case from between R33's legs and a large stain was observed with a strong pungent urine odor was detected. V2 stated she would be replacing the catheter. R33's physician's orders [REDACTED]. R33's Care plan, dated 12/26/2018, documents Potential for pressure ulcer development related to Diabetes Mellitus, obesity; Instruct/assist with reposition in bed every 2 hours; Observe skin integrity during am/PM care; Duoderm q72 hours and prn to Right inner buttocks. R33's Treatment Administration Record (TAR) documents R33's Duoderm was changed 1/29/2019. On 1/30/2019 at 1:30 PM, R33 stated, My dressing (Duoderm) was not changed yesterday (1/29/19), it's been a few days back. Facility's Pressure Ulcer, Prevention of policy and procedure, dated 2006, documents the purpose, To prevent skin breakdown and development of pressure sores. The Procedure includes Apply moisture barrier gently to dry skin; Position with appropriate surfaces to protect bony prominence's; Establish a turning and positioning schedule in bed and chair to meet the resident's needs; Use pressure reducing or relieving devices as necessary.

Based on interview, observation , and record review, the facility failed to assess and monitor residents for range of motion limitations and failed to perform passive range of motion (PROM) correctly for 4 of 6 residents (R3, R25, R32, R33) reviewed for range of motion (ROM) services in the sample of 26. This failure resulted in decline in range of motion for R25 and R33. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], documents R25 to have severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 6. The MDS documents R25, has upper and lower bilateral limitation with ROM provided 7 days a week. The Care plan, dated 12/17/18, identifies a Decline with bilateral lower extremity leg, knee, foot, related to: contracture(s) of knees, and has arthritis. The care plan documents R25 will refuse at times. The goals are to To maintain and prevent further contractures: bilateral, lower extremity. Through review date resident has contractures to both bilateral lower extremities. Interventions include: Allow rest periods when needed, Monitor for contracture(s) and alert nurse to change, Monitor for signs of pain, or stiffness and alert nurse to change, Monitor for signs of redness or open areas and alert nurse to change, PROM #1 to: bilateral lower extremity at: 15 reps with no weight BID (twice daily) with one assist- Knee extension hold 10 seconds x 5 minutes each leg and Report any decline to therapy and nursing. On 2/1/19 at 11:30 am, V23, Therapy Director, provided the last assessment done on R25's knees for degrees of limitations. The Therapy Communication Report, dated 11/9/16, documents R25 is to have bilateral knee braces to prevent knee flexion beyond 90 degrees with approaches being passive slow stretch to bilateral knee extensions, hold 10 seconds each day, wear knee braces 45-60 minutes per day. V23 stated R25 often refused to wear the braces, but staff should be doing PROMs regardless. The MDS, dated [DATE], identifies only limitations of R25's lower extremities, but the MDS completed on 6/20/18 and subsequent MDS document R25 to have limitations bilateral upper extremities as well. There is no evidence the facility identified this change as a decline and notified the therapy, or physician. There is no further assessment done to determine why this decline occurred with R25 even though she was documented as receiving PROM's twice daily and no assessment to determine the degree of decline. On 2/1/19, V1, Administrator, stated the only assessment done was with the quarterly MDS and no assessment done which measures limitations. On 1/29/19 at 11:20 am, R25 was transferred to wheelchair using a full body mechanical lift. At 11:30 am, R25 propelled herself to dining room table from her room. Both feet were dangling from chair off the floor 4-5 inches with no support provided to her feet. 2. The MDS, dated [DATE], identifies R3 to be a [AGE] year old female with a BIMS score of 4 indicating severe cognitive impairment. The MDS documents R3 to be totally dependent on staff for all activities of daily living and limitations on bilateral lower extremities which she gets ROM 7 days/week. A Therapy Communication Form, dated 8/10/17, documents a Restorative Program for R3 with approaches for R3 to wear bilateral knee braces at all times, unless for hygiene need to decrease risk for further contracture on right knee and lessen chance for contracture development in left knee. R3 did not have knee braces on during observations made throughout the days on 1/29/19, 1/30/19 and 1/31/19. On 1/31/19 at 1:53 PM, V9, CNA, performed PROMs on R3. R3 was lying in bed on her back with her head elevated on her pillow, knees bent with feet resting on bed. R3 appeared to understand, when V9 explained she was going to do ROM exercises, with her by shaking her head. When asked if she could straighten her legs, shook her head no. V9 did 5 reps on three planes failing to do horizontal abduction/adduction, internal/external rotations and hyperextension on the shoulder joint. No elbow range of motion was completed. V9 failed to do ulnar/radial deviation and circumduction of the wrist joint. No ROM done for R3's finger joints, thumb joints, hip joints, ankles or toes. V9 stated she does the ROM three times daily. On 2/1/19 at 11:25 am, V23, Therapy Director, stated R3 would refuse to wear her braces and they haven't done any assessments since 8/10/17 on her. V23 stated staff should do range of motion on all joints in an effort to prevent further decline, reduce pain and maintain functional ability when possible. The care plan, dated 11/2/17, documents the Focus as being Decline with bilateral lower extremity leg, knee, foot related to contracture of right knee continues and history of left was resolved by therapy, joint mobility, weakness related to the [MEDICAL CONDITION], resident is non-compliant at times with ROM and straightening legs out at times. The goal to is maintain and prevent further contractures with interventions for AROM( active range of motion) to left extremity for 15 repetitions, monitor for contractures an any decline in contractures of knees and alert nurse of changes in part. On 2/1/19 at 1:30 PM, V1 provided the only assessment done for ROM for R3 which is an Interdisciplinary team assessment and progress note dated 1/31/19 which documents functional ROM limitations for one side upper extremity and bilateral lower extremities indicating a decline has occurred which includes limitations now on the upper extremity. Under other comment, it documents right knee slight contracture cont. (continued), unable to have full extension no decline. 3. The Minimum Data Set ((MDS) dated [DATE] identifies R32 as a [AGE] year old male with a [DIAGNOSES REDACTED]. On 1/30/19 at 9:55 am, R32 was transferred to bed by V7 and V8, Certified Nurse Aides (CNA's), using a full body mechanical lift. R32's feet were extremely [MEDICAL CONDITION] and foot drop was noted bilaterally. On 1/30/18 at 10:30 am, R32 stated no staff does ROM or any exercises on him. The Care Plan, revised on 8/2/17, documents R32 has a decline with bilateral upper and lower extremities related to joint mobility due to [DIAGNOSES REDACTED]. The goal is to maintain range of motion to bilateral upper and lower extremity thru next review. Interventions include monitoring for contractures and alert nurse to change, program to include encouraging resident to do ROM to upper extremities on his own, CNA assist as needed, PROM to upper and lower extremities BID (twice daily) 2 sets of 15 repetitions, and report any decline to therapy and nursing in part. On 1/31/19 at 1:45 PM, V7, CNA, failed to range all joints as indicated for R32. V7 failed to do abduction/adduction, flexion/extension and internal/external rotation of the shoulder joint, failed to do supination/pronation of the elbow joint, failed to do ulnar/radial deviation and circumduction of the wrist joint, abduction/adduction of the fingers, no range done for R32's thumb or hip joints, failed to do inversion/eversion of the ankle joints and flexion/extension of the toe joints. V7 only did 10 repetitions. V7 was finished at 1:49 PM. On 1/31/19 at 2:30 PM, V17, Licensed Practical Nurse (LPN)/MDS Coordinator, stated the facility does not have a restorative nurse and she completes the sections of the MDS for ROM, but does not do any other assessments. V17 stated she is unaware of any documentation done in regards to assess actual limitations. On 2/1/19 at 10:35 am, V1, Administrator, stated Physical Therapy would do assessments on admission and or if they went on Plan B Medicare or if they identified a need for a resident. On 2/1/19 at 11:25 am, V23, Therapy Director, stated they use to do annual screens for range of motion, but have not done them for a while now. V23 stated they last saw R32 in (MONTH) (YEAR), but that they would have recommended ROM to be done by nursing. V23 stated you would have to have an assessment regularly to be able to determine if a resident's ROM has increased, maintained and/or declined. When told ROM was observed to not be complete, V23 stated training is also necessary. V23 stated R32 has declined overall over the last year, but he would not be able to state whether or not the CNA's were doing exercises on him on a regular basis. V23 stated not only do contractures contribute to decline in functional ability, they are also painful. 4. According to the Admission Sheet, R33 was originally admitted to the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE] identifies R33 with a Brief Interview Status of 15 cognitively intact and requires, one staff assistance for most activities of daily living. There is no functional limitations, to upper or lower extremities identified on MDS. On 1/29/2019 at 10:35 AM, R33 was observed sitting in a recliner inside room. R33 stated that she has been at the facility for a few months and when she first arrived she received physical therapy but that ended on 12/28/2018 was her last day. R33 held up her right arm showing her right hand contractures fingers straight slightly pointing down with a arch in palm area stating I can't hardly move my fingers anymore, that's why staff has to help me stand up because of my right hand. R33 stated that no staff comes to help me move my arms or legs; I don't receive any therapy now. The staff is always putting me off, I will ask them to assist me in walking and they are always in a hurry and they will tell me that they will get back to me and sometimes it takes 2-2.5 hours then they wanted me to go down and weigh. I'm always last, they keep putting me off. Staff becomes perturbed with me when I tell them I'm not comfortable. R33's Care Plan dated 12/26/2018 documents in part; Decline with walking skill due to: decreased activity tolerance and decreased gait will be able to walk with front wheel walker, gait belt, and 1 staff assist with w/c following daily through next review Resident to walk with assist of 1 staff, using front wheeled walker with w/c to follow. Use of gait belt for all transfers and ambulation, Report any decline to therapy and nursing. R33's IDT Assessment & Progress Note V 2 dated 12/28/2018 documents FUNCTIONAL ROM LIMITATIONS One-side upper extremity Current RNA programs: Ambulation/locomotion and ROM RUE has OA with shoulder pain and decreased flexion. On 1/31/2019 at 11:24 AM V9 Certified Nurse Assistant (CNA) stated she thinks R33 receives range of motion and walking services. On 1/31/2019 at 1130 AM V15 Licensed Piratical Nurse (LPN) stated that she believed R33 received physical therapy for her hand but she doesn't receive physical therapy any longer. On 2/1/2019 at 9:17 AM V14 Medical Doctor (R33's doctor) stated 'I haven't noticed the contracture to R33's hand, but would expect the facility to provide physical therapy, or range of motion services to resident. Restorative Therapy Referral dated 12/28/2018 documents in part; Right upper arm has decreased range of motion due to pain. Goals: Pt. to complete HEP for RUE of AAROM and AROM. Pt. to ambulate 75 feet 2 to 3 times a day. Pt. to dress upper body with min assist. The Policy/Procedure entitled Nursing rehab/restorative care program services undated documents Range of motion exercise is a program of passive or active movement that is focused on maintaining flexibility and useful motion in the joints of the body. Range of motion is essential for the ability to perform activities of daily living. Limitations in range of motion can severely restrict functional abilities. Range of motion exercise is beneficial to prevent contractures. The policy documents the goals of ROM activities are to prevent the formation of a contracture, increase joint motion to the best possible range, improve circulatory status, and to promote body alignment, resident appearance, comfort, function, and health. The policy fails to include assessments and frequency of, monitoring ROM exercises for effectiveness of treatment and the resident's response and progress or lack of.

Based on observation, record review, and interview, the facility failed to recognize, evaluate and manage pain for 1 of 1 resident (R20) reviewed for pain management in the sample of 26. This failure resulted in R20 having uncontrolled severe pain of the right middle thigh after falling to the floor. Findings include: On 01/30/19 at 8:40 AM, R20 was lying in bed with a worried look on her face. R20 stated she was having severe pain of her right middle thigh after falling 01/29/19. R20 stated the pain was unbearable when her right leg was moved. On 01/30/19 at 9:15 AM, R20 was lying in bed and stated she was no better. She stated if she could lay still there was little or no pain. She stated when her right leg was even slightly touched she was in terrible pain. R20 rated the highest pain at seven or eight on a scale of ten. At 9:25 AM, V23, physical therapy, was observed during diathermy treatment to the right leg. R20 yelled out in pain when the right leg was slightly repositioned. R20 said she had just received a pain pill and it does not help when the right leg was moved. R20 stated she had to use a bed pan now when she was independent with toileting before the fall. The (MONTH) 2019 physician's orders [REDACTED]. It also documented an order for [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented R20 was cognitively intact was independent with set up only for bed mobility, transfers and dressing. It also documented R20 required extensive assist of one staff for ambulation, and supervision with set up only for toileting. The MDS, dated [DATE], documented R20 was independent with one staff for transfers, extensive assist of one staff for ambulation and supervision on one staff for toileting. The care plan, dated 11/05/18, documented R20 was identified as high risk for falls and intervention to monitor for pain and administer medications to treat. The fall risk assessment, dated 12/04/18, documented R20 was at high risk for falls. The (MONTH) 2019 Medication Administration Record [REDACTED]. At 9:34 PM, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 01/30/19 at 4:28 AM and 9:29 AM, R20 rated her pain at seven out of 10 with [MEDICATION NAME] 50 mg administered each time. At 3:56 PM, R20 rated her pain at six out of ten and administered [MEDICATION NAME] 50 mg. On 01/31/19 at 7:40 AM, the MAR indicated [REDACTED]. On 02/01/19 at 8:53 AM, documented R20 rated her pain at seven out of ten and given [MEDICATION NAME] 50 mg that was ineffective. At 2:16, R20 rated her pain at five out of ten and given [MEDICATION NAME] 50 mg. There were no follow up or post fall nurse's notes indicating that R20 continued to have severe pain with movement of the right leg. On 02/01/19 at 10:30 AM, V25, Licensed Practical Nurse, stated R20 had a portable x-ray done on 01/31/19 of the right leg and stated the result was negative. V25 stated R20 had no change in medications since the fall. V25 stated she was aware R20 had a lot of pain with movement, but very little just lying in bed. An attempt was made on 02/01/19 to interview V22, physician, but physician was not in the office. The policy titled, Covenant Care Operating Standard Pain Management Process, documented Practice: It is the responsibility of the licensed nurse to consistently assess, manage, and monitor pain for all residents. The results of the assessment, effectiveness of the pain intervention, and monitoring of behaviors are necessary components within the documentation.

Based on interview and record review the facility failed to properly operate a mechanical lift for 1 of 3 (R1) residents reviewed for mechanical lift transfers in the sample of 15. This failure resulted in R1 receiving bilateral lower extremity fractures. Findings include: R1's [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents in part, R1 is moderately impaired, requires extensive assistance of two or more staff with bed mobility and surface to surface to transfers and has impairment to one side of her upper extremity. R1's Care Plan revised on [DATE] documents in part, Self-Care deficit as evidence by: Needs assistance with ADL's (Activities of Daily Living) related to HX (history) of fracture arm, Pain-spinal stenosis, Weakness, Osteoarthritis, Osteoporosis, HX of falls, unsteady gait, balance, poor trunk control, FX (fracture) femur non-weight bearing. Prefers to stay in bed due to pain and comfort, fearful of mechanical lift, has severe Osteoporosis and Osteopenia. Interventions/Tasks: No weight bearing to left and right leg, Transfer: Two person physical assistance required. Mechanical lift required. Date Initiated [DATE]: (R1) has a pathological bone fracture related to Osteoporosis at risk for DVT (Deep Vein Thrombosis) and at risk for further FX due to Osteoporosis. Goal: (R1) will not develop complications or permanent loss of mobility related to fracture through review date. Interventions/Tasks: Handle gently when moving or positioning, Maintain body alignment. R1's Verification of Incident Investigation/Administrative Summary documents in part, Type of Incident: Fracture, Date of Incident : [DATE], Time of Incident: 9:00 AM, Pertinent Diagnosis: [REDACTED]. Left transverse fracture to the distal tibia/fibula. Brief description of the incident/event: (R1) was transferred to bed by 2 CNA's (Certified Nursing Assistants) and during transfer they heard a pop. Immediate actions taken: Assessment completed by E18, RN (Registered Nurse). Called the doctor and asked for x-ray. POA (Power of Attorney) and MD (Medical Doctor) notified. Resident information: (R1) is a [AGE] year old female resident admitted to the facility on [DATE]. (R1) has [DIAGNOSES REDACTED]. Interview with (E19), CNA: (E19) stated she and the other CNA, (E16), were transferring (R1) from the wheel chair to the bed with the mechanical lift. (E19) stated midway through the transfer the mechanical lift died . (E19) stated they had just changed the battery. (E19) said they could not get the emergency button released. (E19) stated both she and (E16) lifted the resident. (E19) was holding on the sling by (R1's) head and (E16) was holding underneath (R1's) knees when they lifted (R1) into the bed. (E19) heard a pop and (R1) complained of pain in her legs. Interview with (E16), CNA: (E16) stated after breakfast, she and her partner (E19) were transferring (R1) into bed with the mechanical lift. The battery on the lift died when (R1) was a couple of inches from the bed. (E16) stated she and (E19) lifted (R1) into bed. The sling had enough slack to be able to unhook (R1) once she was in the bed. (E16) heard a pop and reported it immediately to the nurse, DON (Director of Nursing) and ADON (Assistant Director of Nursing). Interview with (R22), roommate: (R22) has a BIMS of 14. (R22) stated the lift stopped working and the girls gently lifted her roommate into bed. (R22) heard (R1) cry out in pain. The CNA's took their time with her and were very gentle because she is fragile. Interview with (R1): (R1) stated she was in the lift after she came back from breakfast and the lift lost it's battery. The CNA's put her back in bed by hand. (R1) stated she did not remember how they lifted her, but she remembers feeling pain. (R1) stated her legs were not bumped on anything. R1's SBAR (Situation Background Assessment Recommendation) - Physical Injury Report of Incident dated [DATE] documents in part, Vital. 5. Pain on scale of ,[DATE] : 10, Situation. 2. The patient is noted to have: j. other, 2a. possible fracture, 2b. injury is located (site) : bilateral legs, 2c. Date and time when injury was observed: [DATE] 09:00, 3. The condition occurred in the: b. resident room, 4. Occurrence was: a. observed, 5. Function Level Prior to Incident: b. Needs Assistance. B. Background. 1. Pertinent Diagnosis/Conditions: c. Osteoporosis or Osteopenia, d. Fragile/Thin Skin, k. History of Fractures, L. History of Physical Injuries, 2. Etiology Identified as: c. Injury During Transfer. R1's Nursing Home to Hospital Transfer Form dated [DATE] documents in part, Reason for transfer: Pain (uncontrolled), Most recent pain level: 10 - Excruciating Pain, Assistive device: mechanical lift for transfers. On [DATE] at 10:02 AM, R1 stated that a couple of months ago she got an injury to her legs. R1 stated that it happened when they were using the lift. R1 then stated, The battery went bad and they dropped me. R1 then stated she is still wearing boots from hurting her legs and hasn't been out of bed for a while. On [DATE] at 3:03 PM, E2, DON stated that the batteries to the mechanical lift should be changed during every shift. E2 stated the mechanical lift has an emergency release valve that should and can be used if the battery goes dead during a transfer. E2 stated that the battery should beep if it is low and needs replaced. E2 then stated that if a battery goes dead during a transfer and the release does not work she would expect staff to call out for assistance immediately and replace the battery before continuing with the transfer. On [DATE] at 3:03 PM, E1, Administrator stated that she would expect staff to call for help if the battery on the mechanical lift went dead during a transfer. On [DATE] at 3:13 PM, E19, CNA stated that the battery died during a mechanical lift transfer with R1. E19 stated that the battery beeped once during the transfer and then completely died . E19 then stated that she tried to push the red button on the lift to release the sling but it was too hard to push in. E19 then stated that she and E16, CNA decided to move R1 to bed. E19 then stated that during an in-service after the event she learned the mechanical lift actually had two releases that can be used if the battery dies during a transfer. On [DATE] at 12:41 PM, E1, stated that the Facility uses the the manufacture's manual for instructions on how to use the mechanical lift. The Facility's Mechanical/Electrical Portable Patient Lift Manual dated 2011 documents in part, Activating a Mechanical Emergency Release: Primary Emergency Release - To activate the primary emergency release, insert a pen into the hole labeled emergency on the control box of the lift and push down on the boom at the same time. All lift actuators are equipped with a mechanical Emergency release. The mechanical release will enable the actuator to retract without power. The actuator will only retract while under load and the mechanical Emergency release is pulled. The release is colored reddish orange with the word Emergency spelled out in white. Second Emergency Release. It is recommended that the primary emergency release be used. The secondary emergency release is only a back-up to the primary emergency release. In cases where the primary release is either not functioning or unreachable, a secondary emergency release may be used. To activate the secondary release, pull up on the Emergency grip and push down on the boom at the same time. Charging the battery: An audible alarm will sound (horn will beep) when battery is low.

Based on record review, observation and interview, the facility failed to provide safe transfer(s), implement fall intervention(s) and assess, analyze the circumstances of falls and/or documented history , re-evaluate for the effectiveness of interventions and supervise risks to minimize the risk for recurring falls and serious injury for 3 of 8 residents (R1, R3, R10) reviewed for falls and transfers. This failure resulted in R1 sustaining a fractured leg during unsupervised toileting. This failure also resulted in R3 incurring a right hip and humerus fracture after unsupervised ambulation. R3 incurred a left hip fracture. Findings include: 1. R3's Minimum Data Set (MDS), dated [DATE], documented an admission date of [DATE], severe cognitive impairment, extensive assistance of one person with bed mobility, transfer, walking, locomotion and toileting and unsteady balance with walking and transitions. R3's Nursing Notes, dated 9-29-11, documented R3 was alert to person and alarms were placed on her wheel chair and bed. It was also noted R3 was up numerous times without assistance, would unclip her wheel chair alarm and not use her call light. R3's Nursing Notes, dated 10-1-11, 10-2-11, 10-3-11, 10-4-11, 10-8-11, 10-9-11 and 10-12-11 documented, in part, R3's repeated attempts of self ambulation and toileting, wandering, removing her alarm(s) and alarm(s) sounding before staff intervened. R3's Nursing Notes, dated 10-7-11 and 10-12-11 to 11-4-11, documented R3's repeated attempts of self ambulation, wandering, confusion and/or restlessness. R3's Verification of Incident Investigation/ Administrative Summary, dated 11-4-11, documented R3 fell and fractured her right hip and right humerus when she walked unassisted down a hallway. R3's Verification of Incident Investigation/Administrative Summary, dated 11-19-11, documented R3 was found sitting on the floor beside her bed. R3's Verification of Incident Investigation/Administrative Summary, dated 11-25-11, documented R3 removed her alarm, fell during self ambulation and fractured her left hip. It was also noted "non-compliant with care, removes alarms, agitated, restless at most times unaware of safety measures or personal limitations." R3's Verification of Incident Investigation/Administrative Summary, dated 12-22-11, documented R3 incurred a right cheek skin tear after removing her alarm and falling from bed. It was also documented "NO sense of safety measures." R3's chart did not document the facility's assessment, analysis of the circumstances of her falls and/or her documented repeated alarm removals and sounding alarms with attempted self-ambulation/toileting and re-evaluate the effectiveness of R3's alarms The facility's Falls Management policy and procedure, dated 10-10, documented, in part, "Purpose. To evaluate risk factors and provide interventions to minimize risk, injury and occurrences. Fall Prevention Procedure. 1. Evaluate risk factors for sustaining falls upon admission, with comprehensive assessments, and while conducting interdisciplinary care plan reviews. 2. Initiate a fall prevention care plan when appropriate with strategies to minimize risk and potential for injuries. 3. Regularly review, revise, and evaluate care plan effectiveness at minimizing falls and injuries." During observation of R3's transfer, on 2-8-11 at 11:35a.m., E15, Certified Nursing Assistant (CNA), and E6 (CNA), placed belt transfer device around R3's waist and transferred her from bed to wheel chair. R3 was not fully awake during the transfer and R3 did not completely bear weight as E15 and E6 slid R3 backwards while supporting her weight with the belt and holding her underneath her arms until R3 reached her wheel chair. E16 and E6 did not support her lower extremities. 2. R10's MDS, dated [DATE], documented severe cognitive impairment, total dependence of two plus persons physical assistance with mobility and locomotion and extensive assistance of two plus persons physical assistance with transfer. It was also noted functional limitation in range of motion for bilateral upper and lower extremities and only able to stabilize with human assistance during transfers. R10's Care Plan, dated 12-27-11, documented "transfer with assist of two and padded gait belt." During observation of R10's care, on 2-8-12 at 1:00p.m., E8 (CNA) and E15 (CNA) raised R10's bed and provided incontinent care. After redressing R10, E8 and E15 placed a transfer belt around R10 and transferred R10 from bed to chair without lowering R10's bed. R10's feet did not touch the floor. E8 and E15 supported R10's full body weight by holding underneath her arms and with the transfer belt. The facility's Transfer Activities procedure dated 2006, documented "Purpose. To transfer the resident from bed to chair, toilet or tub safely. 15. Depending on the amount of assistance required, the nurse may either support the resident on his/her affected side or stand in front of the resident. Support may be provided by use of a transfer belt. Do not support the resident under the arms as this prevents the resident from using his/her unaffected extremity." 3. The MDS dated [DATE] identifies R1 to have short/long term memory loss with severe cognitive impairment. The MDS documents that she requires extensive assist of one staff for bed mobility and extensive assist of 2 staff for transfers. The care plan dated 12/27/11 identifies R1 to be at risk for falls due to history, poor safety awareness, decreased cognition, poor balance and non-compliant with transfers and call light usage. Interventions dated 8/24/10 include call light in reach when in room, proper non skid-footwear at all times, sensor alarm in w/c (wheelchair) and recliner, check environment daily to ensure placement and functioning of w/c alarm among others. The care plan identifies two falls for R1 - 5/13/11 and 10/17/11. The Verification of Incident Investigation/Administrative Summary dated 5/16/11 indicates R1 "fell out of w/c (wheelchair) onto ground while being transported by CNA across sidewalk. W/c struck bump in walk + fell from w/c." The report continues that R1 was transported to the emergency room via ambulance for repair of lacerations sustained in the fall. The Description of the Occurrence section indicates R1 was outside of the building in the courtyard just prior to the fall. According to the followup actions taken section, staff were inserviced regarding proper transport techniques and areas of the sidewalk were closed pending repairs. On 2/10/12 at 11:45am, E1 Adminstrator stated everyone was outside for an event when R1 fell . E1 stated the side walk was cracked and the wheelchair tipped sideways causing R1 to fall forward out of the wheelchair. According to the Verification of Incident Investigation/Administrative Summary dated 10/27/11 description of Occurrence documents "Alarm sounding - resident in bathroom- while calling for additional help resident attempted to walk back to chair + fell ." Xray showed positive for a fractured arm. The summary of the investigation documents that the Administrator stated she heard alarm sounding + upon entering room noted res (resident) on toilet. Admin (Administrator) shut off alarm + attempted to get help. Res transferred self from toilet + resulted in fall in room. Res c/o (complained of) L (left) arm pain. Orders received for X-ray in house. X-ray revealed fx (fractured) L shoulder." On 2/10/12 at 10:50am, E1, Administrator stated she heard R1's alarm sounding and when she entered her room, her wheelchair/alarm was at bedside and R1 was on the toilet in the bathroom. She said she "told her to stay there." and left the room to go get help. E1 stated when she reentered the room, R1 was on the floor. Followup actions include toileting resident before/after meals, transfers status changed to full body left with 2 assists, move room closer to nurses station, and re-educate admin. importance of usage.