Every finding on record at Thrive of Lake County

Based on interview and record review, the facility failed to inform the resident or his or her representative of their right not to sign the arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and failed to explained the agreement to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands for 4 of 4 residents (R25, R83, R159 and R172) reviewed for arbitration agreements in the sample of 31.The findings include:1. R25's Face Sheet shows she was admitted to the facility on [DATE] and resides on the dementia unit. R25's Brief Interview for Mental Status, performed on 5/19/26, shows she has a memory problem and is moderately impaired in making decisions regarding tasks of daily life. R25's Arbitration and Limitation of Liability Contract shows she agreed to arbitration and the contract was signed by herself on 2/19/26. On 6/8/26 at 2:22 PM, R25 stated, What is an arbitration agreement? I never agreed to arbitration.2. R83's Face Sheet shows he was admitted to the facility on [DATE]. R83's Brief Interview for Mental Status performed on 1/12/26 shows his cognition is moderately impaired. R83's Arbitration and Limitation of Liability Contract shows that he agreed to arbitration and the contract was signed by himself on 11/17/25. On 6/10/26 at 10:55 AM, R83 resident stated he does remember signing things when he came into the facility and does not remember anyone talking about what lawyer he wanted to use. R83 said that he did not know what the word arbitration meant and his primary language is Tajlogy (Philippines).3. R159's Face Sheet shows he was admitted to the facility on [DATE]. R159's Brief Interview for Mental Status (BIMS) performed on 3/25/26 shows his cognition is moderately impaired. R159's Arbitration and Limitation of Liability Contract shows he agreed to arbitration and the contract was signed by himself on 3/25/26. On 6/10/26 at 10:04 AM, R159 said he does not remember the admission process or if they talked to him about an arbitration agreement. R159 said he does not even remember anything from yesterday. 4. R172's Face Sheet shows he was admitted to the facility on [DATE]. R172's Arbitration and Limitation of Liability Contract shows he agreed to arbitration and the contract was signed by himself on 6/2/26. On 6/9/26 at 12:30 PM, R172 said he does not remember signing anything during the admission process and he does not remember the facility saying anything about an arbitration agreement. On 6/9/26 at 1:35 PM, V16 (Human Resources Assistant) said the admission contract is on her tablet and she verbally goes through the contract with newly admitted residents and fills in all of the required information for them, and then the resident or resident representative signs on her tablet at the end and it puts their signature in all of the appropriate places for them. V16 said if the resident is not verbal, cannot physically sign, or has a BIMS below 10 (moderate impairment), she has the resident's representative verbally go through the forms with her and sign. V16 said for the Arbitration Agreement Form she states to the resident, This is a litigation question. If legal action needs to take place, would you like your own lawyer or the facility's lawyer? V16 said if they say the facility's lawyer, she marks that they accept to the Arbitration Agreement and if they say they would want to use their own lawyer, she marks that they decline the arbitration agreement. V16 said she does not verbally provide any other information or details about the agreement to them.V1 (Administrator) said that the facility does not have a policy on Arbitration Agreements.

Based on observation, interview, and record review, the facility failed to ensure residents that needed a Level 2 PASARR assessment received a Level 2 PASRR for 4 of 8 residents (R52,R130,R134,R97) reviewed for Pre-admission Screening and Resident Review in the sample of 31.The findings include: 1. On 06/08/2026, R52 was on a locked unit in the facility. On 06/10/2026 at 1:36PM, V11, admission Director, said R52 does not have a level 2 PASARR. R52's Medical Record on 06/08/2026 shows R52 was admitted to the facility on [DATE] with a diagnosis of depression. On 11/15/2023, R52 was given diagnoses of restlessness/agitation, anxiety disorder, and insomnia. R52's PASARR dated April 25, 2023 shows, No level 2 required-No severe mental illness. 2. On 06/08/2026, R130 was on a locked unit in the facility. On 06/10/2026 at 1:36PM, V11, admission Director, said R130 does not have a level 2 PASARR. On 06/08/2026, R130's Medical Record shows R130 was admitted to the facility on [DATE], with a diagnosis of anxiety disorder. R130's PASARR, dated 4/24/25 shows no level 2 required-No severe mental illness. 3. On 06/08/2026, R134 was on a locked unit in the facility. On 06/10/2026 at 1:36PM, V11, admission Director, said R134 does not have a level 2 PASARR. R134's Medical Record on 06/08/2026 shows multiple diagnoses including a diagnosis of psychosis on 02/27/2017. R134's PASARR, dated 11/20/25, shows no level 2 Required-No Severe Mental Illness. 4. R97's electronic medical records showed R97 was admitted to the facility on [DATE]. R97's PASARR Level I screening outcome report, dated 7/18/22, showed R97 had mental health diagnoses including major depression and anxiety. The report showed, A 30 day or less stay in the nursing facility is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the nursing facility beyond the authorization timeframe. On 6/9/26 at 12:05 PM, V11, Director of Admission, stated, PASARR I screening should be completed on all residents prior to admission to the facility. Ifa PASARR I shows the resident needs a PASARR II, the PASARR II is to be ordered and completed as soon as possible to ensure the resident receives the required services for their diagnosis of serious mental illness or developmental disability. A repeat PASARR I and an initial PASARR II were never completed on (R97). (R97) should have had a PASARR II done due to her diagnosis of serious mental illness. On 6/10/26 at 12:46 PM, V1, Administrator, stated the facility did not have a policy on PASARR screenings.

Based on interview and record review, the facility failed to ensure a current and accurate PASARR 1 screening (Preadmission Screening and Resident Review screening) was completed on a resident for 1 of 8 residents (R13) reviewed for PASARR I screenings in the sample of 31.The findings include:R13's admission report showed R13 was admitted to the facility on [DATE], with diagnoses including major depression, unspecified psychosis, and schizophrenia. R13's PASARR I screening, dated 11/17/2018, showed R13 had no serious mental health diagnoses at that time of the screening.On 6/9/26 at 12:05 PM, V11, Director of Admission, stated, PASARR I screening should be completed on all resident, prior to admission to the facility to ensure a resident is placed in the appropriate setting to treat not only their medical needs but also for treatment of any mental health disorders. If a PASARR I showed the resident needs a PASARR II screening due to a diagnosis of serious mental illness, the PASARR II should be ordered and completed as soon as possible to ensure the resident receives the required services for their diagnosis of serious mental illness. (R13) should have had a repeat PASARR I assessment completed prior to her admission in May 2020 due to her new mental health diagnoses of depression, psychosis, and schizophrenia.On 6/10/26 at 12:46 PM, V1, Administrator, stated the facility did not have a policy on PASARR screenings.

Based on observation, interview, and record review, the facility failed to provide hand hygiene and nail care to a resident for 1 of 31 residents (R14) reviewed for activities of daily living (ADLs) in a sample of 31.The findings include:R14's Facility Assessment, dated 3/1/26, showed R14 was admitted to the facility with diagnoses which included hemiplegia affecting left side. This assessment showed R14 needs assistance with personal hygiene and has no behaviors of refusing cares.On 6/8/26 at 11:00 AM, R14 was in bed. R14's right hand fingernails were approximately a half inch long. R14's fingernail cuticles were stained brown with brown and tan stains on the underside of the nails. R14's nails on her left hand were half to three-fourth inch long and jagged, with significant areas of thickening. R14 stated she did everything with her right hand because she could not move her left hand.On 6/9/26 at 8:50 AM, V14, Certified Nursing Assistant, acquired washcloths and was entering R14's room. V14 stated she was cleaning up R14 and changing her gown, and R14 would be available soon.On 6/9/26 at 10:35 AM, R14 was in bed. R14's nails were the same condition as on 6/8/26.R14's current Care Plan showed R14's ADL care plan intervention is to provide nail care a needed.On 6/10/26 at 11:10 AM, V2, Director of Nursing, stated resident's fingernails should be clean and maintained. The facility's ADL Policy, dated 12/2024, showed nail care will be provided as needed. CNAs or Nursing can reduce fingernails.

Based on observation, interview, and record review, the facility failed to ensure staff wore the correct Personal Protective Equipment (PPE) when caring for residents on Enhanced Barrier Precaution (EBP) isolation room, which applies to 1 of 31 residents reviewed for infection control in a sample of 31.The findings include:R14's Facility Assessment, dated 3/1/26, showed R14 uses a urinary catheter and has a diagnosis which included history of Escherichia Coli (E. Coli).On 6/9/26 at 8:45 AM, R14 had an EBP sign displayed on the room's door frame. A small 3-drawer cart was next to the doorframe with PPE in it. V14 (Certified Nursing Assistant) was in the hallway gathering washcloths and then entered R14's room without putting on a gown.On 6/9/26 at 12:10 AM, V14 stated she was changing R14's gown and cleaning her up after she spilled some of her breakfast. V14 stated she should have put on a gown to care for R14.On 6/9/26 at 12:30 PM, V13 (Licensed Practical Nurse-LPN) stated EBP is used when a resident has a device (central line, catheter, dialysis catheter) or chronic wounds. PPE for EBP is a gown and gloves when providing care for a resident.On 6/9/26 12:37 PM, V2 (Director of Nursing) stated you must wear gown and gloves-when coming in close contact with the patient. High contact care activities include changing clothes, changing dressings, and providing residents hygiene.The facility EBP Policy, dated 3/2024, showed wearing PPE when entering a resident's room on EBP includes a gown and gloves needs to be worn when performing high-contact resident care.

Based on observation, interview, and record review, the facility failed to ensure a resident was served the noon meal in the ordered form for 1 of 31 residents (R4) reviewed for diets in the sample of 31. The findings include:R4's Physician's Order Sheet shows she is on a pureed diet. R4's Meal Ticket showed she was on a pureed diet. The Diet Spreadsheet for the noon meal shows residents on a pureed diet should receive a pureed dinner roll.On 6/8/26 at 12:08 PM, the kitchen staff were plating the noon meal for delivery to the units. R4's tray was in the transportation cart and had a regular dinner roll on the tray. A plate or pureed food was placed on R4's tray. At 12:30 PM, V15 (Certified Nursing Assistant) served R4 her lunch tray with the regular dinner roll still on the tray. V15 stated to the resident, You have a roll here too and started unwrapping the roll. On 6/8/26 at 12:54 PM, V5 (Dietary Manager) said residents on a pureed diet should have received pureed roll for the noon meal and not a regular roll. V5 said the kitchen staff should serve the diet type that is listed on the meal ticket. The facility's Diets and Diet Order Policy shows, Food and nutrition services will serve standard diets which correspond to the diet column on the menu spreadsheet.Pureed-The texture and consistency of the general/regular or therapeutic diet is modified. Food is pureed to a pudding-like consistency.The facility's Diet Orders Policy shows, If the diet received for the resident is different than the order, the nursing staff will alert the dietary department and retrieve the correct diet.

Based on observation, interview, and record review, the facility failed to ensure R18's as needed psychoactive medication had a stop date for 1 of 5 residents (R18) reviewed for chemical restraints in the sample of 31. The findings include:On 06/08/2026 at 10:00AM and on 06/09/2026 at 1:10PM, R18 was on a locked unit of the facility sitting in a wheelchair, calm and relaxed. On 06/10/2026 at 10:40 AM, V6, RN-Registered Nurse, said, The stop date on the medication ensures the resident is re-evaluated by the physician for the continued need of the medication. R18's Physician Order, start date 02/03/2026 End date, indefinite shows lorazepam oral concentrate 2 milligrams per milliliter give 0.25 milliliter by mouth every 4 hours as needed for RESTLESSNESS OR AGITATION. R18's Medication Administration Record, dated 6/1/26, to 6/30/26, Resident Specific Targeted Behavior shows, R18 has no documented behaviors from 6/1/26 through 6/8/26.

Based on observation, interview, and record review, the facility failed to ensure an insulin pen and an inhaler were dated upon opening, and failed to ensure medications were stored in a secure manner and not accessible to residents to 3 of 31 residents (R48, R56, R161) reviewed for medication storage in the sample of 31.The findings include: 1. On 6/10/26 at 9:08 AM, V9 (Registered Nurse-RN) checked the medication cart for 1000 unit. R48's insulin pen of Lispro (long-acting insulin) was opened but not dated. V9 (RN) said R48 has an order for 70 units of Lispro to be given at bedtime. (V9) said insulin pens should be dated when opened because insulins are only good for 28-30 days after open date. 2. R56's inhaler of Anoro Elipta for 1 puff daily for COPD was also opened but was not dated. V9 (RN) said inhalers were only good for 30-40 days after they were opened. V9 said there was a nurse that used to check the medication carts but was not sure if that was still being done. On 6/10/26 at 11:20 AM, V2 (Director of Nursing-DON) said all medications carts will be audited to ensure all medications including insulin and inhalers were all labelled with the date opened. The facility Policy entitled Medication Labeling and Storage, dated 1/2020, shows medications are labeled as in accordance with facility requirements and state and federal laws. 3. A physician order for R161, dated 2/6/26, showed an order for R161 to be administered Advair Diskus (asthma inhaler) inhale one puff orally once a day. The order showed no documentation that R161 could self-administer the medication. A facility Self Administration of Medication Evaluation form for R161, dated 2/9/26, showed R161 was assessed to self-administer medications. The form showed R161 could safely self-administer vitamins, nasal spray, and eye drops only. The form showed no documentation that R161 could self-administer any inhalers. On 6/8/26 at 9:55 AM, R161 was in bed. An Advair Diskus inhaler was noted on R161's bedside table. R161 pointed to the inhaler and stated, That's my inhaler. I keep it in here. I take it once a day. On 6/9/26 at 9:27 AM, R161 was in bed. Her Advair Diskus inhaler remained on her bedside table. On 6/9/26 at 10:49 AM, V3 (Assistant Director of Nursing) stated R161 had been assessed to safely self-administer her vitamins, a nasal spray, and eye drops only. V3 stated R161 had never been assessed to self-administer any inhalers. V3 stated, Residents can only self-administer meds and keep meds in their rooms if they have been assessed to do so and we have a physician order to do it. The facility's Self Administration of Medications and Treatments policy, dated 11/2024, showed, Self-administration of medications and treatments is determined by physician order after determining that the resident is able to self administer. Medications and treatments for self administration are kept in a locked drawer in the resident room.

Based on observation, interview, and record review, the facility failed to ensure a peripherally inserted central catheter (PICC) line dressing was changed according to standard of care for 1 of 2 residents (R94) reviewed for PICC line care in the sample of 31.The findings include:On 6/8/26 at 9:47AM, R94 was in bed with ongoing total parenteral nutrition (TPN) of multivitamins running at 72.71 milliliters (ml) per hour for 24 hours connected to peripherally inserted central catheter (PICC) line in R94's left upper arm. R94's PICC line dressing was noted to be soiled, and the date of the dressing was 5/21/26 (approximately 2 weeks ago). At 10:30 AM, V9 (Registered Nurse-RN) confirmed R4's PICC line dressing change was last 5/21/26, the date written in the PICC line dressing. V9 (RN) said PICC line dressings are done weekly to prevent infection and keep the site clean and secure. On 6/8/26 at 11 AM, V2 (Director of Nursing-DON) said PICC line dressings should be changed every week and as needed to assess insertion site for signs of infection and to ensure the dressing was clean, dry and intact.The facility policy entitled Central Line Care, dated 11/2020, shows, to ensure the care and management of central venous access device and dressing changes will be completed according to standard care. Following the initial 24-hour dressing change at minimum weekly or anytime the dressing becomes moist, loosened or soiled.

Based on observation, interview, and record review, the facility failed to ensure a resident's enteral (tube) feeding was administered as per physician order for 1 of 2 residents (R10) reviewed for tube feeding in the sample of 31.The findings include:R10's current care plan showed R10 required enteral feedings via his gastrostomy tube. R10's enteral feedings were his only source of nutritional support/intake. R10 was NPO (ate/drank nothing by mouth). R10 was severely cognitively impaired and dependent on staff for all cares due to his diagnoses of anoxic brain injury and quadriplegia. The care plan showed nursing staff were to administer R10's enteral feedings as ordered.R10's physician order, dated 3/12/25, showed an order for R10 to receive continuous enteral feedings, daily via feeding pump, of Jevity 1.5 (liquid nutritional tube feeding) at 70 milliliters per hour (ml/hr) from 7:30 AM-12:30 PM, 5:30 PM-10:30 PM, and 12:30 AM-5:30 AM. R10's Dietary/Nutrition note, dated 4/22/26, showed R10's enteral feedings were to be administered at 70 ml/hr, during the prescribed times, as per physician order. On 6/8/26 at 9:48 AM, R10 was in bed with his enteral feeding infusing via his gastrostomy tube. R10's enteral feeding pump showed his feeding was infusing at 90 ml/hr, not 70 ml/hr. On 6/9/26 at 9:28 AM, R10 was in bed with his enteral feeding infusing. R10's enteral feeding pump showed R10's feeding was infusing at 90 ml/hr, not 70 ml/hr. On 6/9/26 at 1:15 PM, V10 (Dietician) stated enteral feedings should be administered as per physician order. V10 stated if a continuous enteral feeding is infused at a higher rate per hour than prescribed, it could cause a resident to gain weight due to overfeeding. V10 stated, It could also cause a resident's liver enzymes to elevate and/or cause fluid overload. The facility's Tube Feeding policy, dated 11/2024, showed, An order by the physician or nurse practitioner contains the type of formula and rate. Turn on feeding pump, set prescribed rate and start feeding.

Based on observation, interview, and record review, the facility failed to ensure a resident, with a history of significant weight loss and continued insidious weight loss, received nutritional supplements as prescribed for 1 of 6 residents (R2) reviewed for weight loss in the sample of 31.The findings include:R2's current care plan showed R2 was at risk for weight loss due to her history of previous significant weight loss and diagnosis of dementia.R2's Weights and Vitals Summary report showed R2 sustained a significant weight loss from 1/3/26-2/12/26 after being diagnosed with Influenza A. The report showed R2 continued to have an insidious weight loss of 3.65% (4.9 pounds) from 4/11/26-5/7/26. R2's Nutrition Assessment, dated 2/22/26, showed, Nutrition Problem: At increased nutritional risk secondary to weight loss, suboptimal PO (oral) intake, diuretics, labs, meds, and diagnoses. Add Magic Cup at lunch for additional nutrition.A physician order, dated 2/22/26, showed an order for R2 to receive Magic Cup (nutritional supplement) every day for lunch.On 6/8/26 at 12:20 PM, R2 was seated in the main dining room with her lunch tray in front of her. No Magic Cup was noted on R2's tray. R2 had consumed a cup of juice and a half bowl of soup off her tray. R2 had not consumed any of her main entree. Staff were present in the dining room but did not offer R2 any encouragement to eat. At 12:55 PM, R2 remained seated in the dining room with her lunch tray in front of her. No Magic Cup was noted on her tray. R2 had consumed approximately 25% of lunch.On 6/9/26 at 12:54 PM, R2 was seated in a wheelchair in her room. Staff delivered R2's lunch tray to R2 in her room. No Magic Cup was noted on R2's lunch tray. R2 was observed from 12:54 PM-1:06 PM. During that time, R2 consumed a small amount of mashed potatoes. R2 did not eat any of the meatloaf, buttered carrots, or brownie on her tray. At no time, were staff present in R2's room. R2 never received her Magic Cup. On 6/9/26 at 1:15 PM, V10 (Dietician) stated she added Magic Cup daily at lunch for R2 after she sustained a significant weight loss in February 2026 due to her contracting Influenza A. V10 stated, I added Magic Cup to give (R2) additional calorie and nutrition because she wasn't eating enough. V10 stated all residents should receive nutritional supplements as ordered. The facility's Supplements policy (undated) showed, Nutritional supplements will be provided as ordered to clients whose nutrient needs may be increased.

Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner and failed to ensure fall interventions were in place to residents on high risk for falls to 3 of 31 residents, (R141, R82, R24) reviewed for safety in the sample of 31.The finding's include: 1. R141's facility assessment, dated 5/26/26, with BIMS (Brief Interview for Mental Status) of 14; R141 has no cognitive impairment. R141's Fall risk assessment, dated 6/6/26, shows R141 is high risk for falls On 6/8/26 at 9:50 AM, R141 said she had a fall last Saturday (6/6/26) after having a shower. R141 said she was about to be transferred to her bed when the staff helping her could not hold onto her. R141 stated, The staff was telling me repeatedly just fall on your knees! Fall on your knees! So, I did! R141's fall incident report, dated 6/6/26, documents, Pt (patient) was getting to bed with the CNA (Certified Nursing Assistant), [R141] feeling weak and was lowered to the floor slowly, no complaints of pain of injury. On 6/9/26 at 10:21 AM, V8 (Certified Nursing Assistant-CNA) said last 6/6/26, she gave R141 a shower in the shower room located in R141's room. After the shower, R141 was wheeled by her bed in the shower chair. As R141 proceeded to stand up to be transferred to bed, V8 said she pulled the shower chair away from R141 and went behind R141. R141's knees were giving out and R141 wanted to sit. V8 said she was using a gait belt but had to let go of the gait belt to use her arm around R141 as she was lowered to the floor. V8 said R141 used to be a mechanical lift transfer. V8 said R141 needs 2 staff assist for transfer for R141's safety. R141's care plan, dated 3/30/26, shows, The resident has ADL self-care performance deficits and limitations in physical mobility r/t (related to) heart failure, hypertension, requires total x2 assistance for transfers. On 6/10/26 at 10 AM, V2 (Director of Nursing) said R141 will be reassessed by Therapy for safe transfer ability. The facility policy on Fall Prevention, dated 11/2020, shows, A fall is defined as an incident in which the resident intentionally was unable to maintain balance and descended to a lower level. Each resident residing at this facility will be provided with services and care that ensure that the residents' environment remains as free from accidents hazard as possible and its resident receives adequate supervision and assistive devices to prevent accidents. 2. R82's Face Sheet, printed on 6/9/26, showed R82 has diagnoses which include Dementia with other behavioral disturbances, muscle weakness, and acquired absence of right foot. R82's last 3 Fall Risk Assessments, dated 1/23/26, 4/25/26, and 6/1/26, showed R82 has a high risk for falling. These assessments were completed after R82 had a fall on those dates. On 6/8/26 at 9:50 AM, R82 was lying in bed. The fall mat between the beds in the room was on its side (vertical) next to R84's bed. The other fall mat was on its side away from the bed with clothing, an empty wash basin, and a bag of towels on top of it. R84 was alone in the room. At 11:45 AM, the fall mat between the beds was still in the same position. On 6/9/26 at 9:15 AM, R82's fall mattresses were in the same location as they were on 6/8/26. R82 was alone in his room. On 6/9/26 at 9:20 AM, V20 (Registered Nurse) stated R82's fall mats should be lying flat on the ground not turned on their side standing vertically. V20 stated the thick fall mats (R82's) are usually ordered by hospice. R82's Care Plan, printed on 6/9/26, showed fall mats as a fall prevention intervention. On 6/10/26 at 11:10 AM, V2 (Director of Nursing) stated fall mats should be flat on the floor to be a fall intervention. The facility's Fall Policy, dated 11/2024, showed a received adequate supervision and assistive devices to prevent accidents. 3. On 6/8/26 at 1:50PM, R24 was lying in bed. R24's bed frame was not in the low position. R24's fall mat was leaning against the wall by the entry way to the room. On 6/8/26 at 1:56 PM, V6 (RN-Registered Nurse) said, (R24's) bed is not low. (R24) is a fall risk. R24's Care Plan on 6/8/26 shows R24 is at risk for falls. R24's interventions to prevent falls include floor mat initiated 5/26/22 and maintain bed at lowest possible position while in bed initiated 1/5/24.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion had orthotics (splints) in place for treatment of and/or prevention of contractures for 2 of 12 residents (R95, R14) reviewed for range of motion/restorative services in the sample of 31.The findings include: 1. R95's current care plan showed R95 requires the use of splint for contracture management of left hand . The plan showed R95 was to wear the hand splint at night and have it off during the day. The plan showed R95 had hemiparesis and hemiplegia to his left arm and left leg caused by a previous stroke. R95's restorative assessment, dated 5/26/26, showed R95 required daily range of motion exercises and use of a hand splint as part of his restorative programming for treatment of his left-hand contracture. On 6/8/26 at 9:44 AM, R95 was seated in a wheelchair in his room. R95 wore no splint on his left hand. All of R95's fingers on his left hand, except for this thumb, were contacted into the palm of his left hand. R95 was only able to move his thumb on his left hand. R95 stated, I used to have a splint for my hand, but it didn't fit anymore. My fingers became so bent over that the splint didn't fit right. R95 stated he had not worn a splint on his left hand for months. On 6/9/26 at 9:33 AM, R95 was in his room. No splint or padding was noted to the contractures on his left hand. When R95 was asked if he wore a splint on his left hand at night, R95 stated, No, I told you the splint doesn't fit. I haven't worn it a night for at least three months. I'm not even sure where the splint is. On 6/9/26 at 11:21 AM, V11, Restorative Nurse, stated R95 had contractures to his left hand that required the use of a splint to make sure his contractures don't get worse. V11 stated he performed R95's restorative assessment on 5/26/26 but did not assess R95's left hand splint that day to ensure the splint still fit R95's hand. R95 stated on 5/26/26, I didn't even see the splint. 2. R14's Facility assessment, dated 3/1/26, showed R14 is cognitively intact with diagnoses which include hemiplegia affecting left side and bilateral contractures to the ankles. This assessment showed R14 is dependent with assistance for lower body dressing, putting on/taking off footwear, and turning in bed. This assessment also showed that R14 had no behaviors for rejecting care from staff. R14's Physician Orders Sheet, printed on 6/9/26, showed an order for Bilateral ankle brace skin checks before and after use every shift for as tolerated in bed. On 6/8/26 at 11:00 AM, R14 was in bed. R14 had no ankle braces on, and her feet were pointing toward the end of the bed (foot drop). When asked to move her feet, R14 was only able to wiggle their toes on her right foot. R14 stated she does have ankle braces but did not remember the last time she wore them. R14's ankle braces were located in the top shelf of her clothes wardrobe. On 6/9/26 at 8:50 AM, V14, Certified Nursing Assistant (CNA), exited R14's room after providing care. R14's feet could be seen from the doorway. R14 did not have any ankle braces on. R14's ankle braces were in the wardrobe in the same position as seen on 6/8/26. On 6/9/26 at 10:35 AM, R14 did not have her ankle braces on. R14 stated V14 was in earlier to help her change her gown. R14 stated she did not ask or attempt to put on her ankle braces. On 6/9/26 at 11:00 PM, V14 stated R14 does not like to wear her ankle braces and refuses all the time. R14 stated the ankle braces are kept in the cabinet. When we put braces on a resident or if the resident refuses to have braces put on, we document it in their chart. On 6/9/26 11:21 AM, V11 (Restorative Nurse) stated R14 had new order for ankle braces after R14's last hospitalization. V11 stated he was aware R14 would ask staff to take off her ankle braces after having them on but had not been told by other care staff she was refusing to wear them. On 6/9/26 at 1:30 PM, V18, Director of Therapy, stated R14 was on therapy services after her last hospitalization from 2/24-3/20, which included education, stretching (passive range of motion) and placement of R14 ankle braces. The braces in R14's case are to prevent any further contractor from getting worse. R14's Restorative History Report, printed on 6/10/26, showed no entries for resident refusals for the last 30 days (5/11/26). This report also had only 1 entry for R14 wearing the braces for 15 minutes on 5/30/26. On 6/10/26 at 11:10 AM, V2, Director of Nursing, stated braces/splints should be placed as ordered. If a resident refuses to were a brace it should be documented and to let the nurse know of the refusal. At the time of the survey, the facility did not present a Braces/Splint Policy.

Based on interview and record review, the facility failed to ensure resident care was safely provided to 1 of 3 residents (R1) reviewed for falls in the sample of 5.The findings include:R1's face sheet shows she has diagnoses including Alzheimer's Disease, Osteoarthritis, Osteoporosis, and abnormality of gait and mobility. R1's current care plan shows she has a cognitive deficit, is at high risk for falls, incontinent of bowel and bladder, and requires extensive assistance for bed mobility.R1's Fall Risk Evaluation completed on 12/9/25 shows she is at high risk for falls.A fall incident report completed by V3 (Licensed Practical Nurse/LPN) on 3/15/26 at 7:00 PM states, while nurse aide (V4) was changing resident, she slid off the side of the bed. Resident was transferred to a local hospital for further evaluation.R1's Electronic Medical Record shows R1 is still at a local community hospital. R1's X-ray report of her left foot, from a local community hospital, shows the following, Osteopenia and Chronic Arthritic changes present involving the interphalangeal joints of the digits. This is most evident at the second PIP joint with at least partial bony fusion present. Impression: Fracture deformity distal medial aspect second proximal phalanx of indeterminate age but cannot exclude acute injury.On 3/25/26 at 10:50 AM, V3 (LPN) said when (R1) fell a (Certified Nursing Assistant/CNA (V4)) came and got me and said she had been changing (R1) and her sheets were lumpy and she had to pull on them and (R1) ended up falling out of bed on the right side facing the door. I did a full assessment and (R1) had no complaints of pain and said she was fine, but per protocol and because (R1's) daughter wanted, we sent (R1) to the hospital for evaluation. Generally, we only need 1 staff member for turning and repositioning (R1). (R1) had chronic feet/toe pain and had lidocaine patches on both feet prior to her fall. On 3/25/26 at 1:05 PM, V4 (CNA) said, I was the only one in the room and I was changing (R1's) incontinent brief. I was beside the bed on her left side, and her brief was partially undone; I told her to roll over to the right side and grab the bar, and she rolled off the bed. I had the bed at elevated height to work with her and turn her. I didn't have time to grab her. She fell off to the right side of her bed. It could be she was too far over on the bed, or she turned so quickly that she fell off the bed. (R1) said she was fine. On 3/25/26 at 1:09 PM, V7 (Restorative Nurse) said, When staff are turning residents in bed, they should be standing on the side of the bed they are turning the resident too not behind the resident to be a barrier to help prevent rolling off the bed. V7 said in this case, V4 should have walked around the bed and been on the right side of R1 when R1 was turning over.On 3/25/26 at 1:51 PM, V8 (R1's daughter) said, I was called by the nurse (V3) that a CNA had been changing mom, and the CNA pulled the sheet and she rolled off the bed. The CNA should have been standing in from of her not behind her and she would not have fallen. Mom is still at the hospital because of pneumonia and pain control. On 3/26/26 at 12:40 PM, V9 (Physician) said she was aware of R1 being rolled out of bed, however, based on the information, she cannot definitely say that the left toe fracture happened during this fall. The facility provided Fall Prevention policy, dated November 2020, states, Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as possible.Hospital records for R1 were requested but not received prior to the exit of the survey.

Based on interview and record review, the facility failed to ensure a resident was safely turned and positioned during incontinence care for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4.The findings include: R1's admission Record, dated 11/19/25, shows R1's diagnoses include, but are not limited to type 2 diabetes, morbid obesity, presence of a cardiac pacemaker, hypertension, polyneuropathy, restless and agitation, and a history of falling.R1's Minimum Data Set, dated [DATE], shows R1 has impairment to her functional range of motion on one side to her lower extremity (hip, knee, ankle, foot), has moderate cognitive impairment and is dependent (meaning the helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity.) on staff to provide toileting hygiene and to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed.).R1's current care plan provided by the facility shows R1 has ADL (activities of daily living) self-care performance deficits and limitations in physical mobility and has a history of being resistant to care such as refusing to be changed, uncooperative and resistant to treatments due to agitation. R1's care plan shows she is at high risk for falls due to her debility/need for assistance with ADLs and acute illness.R1's Progress Notes written on 11/17/25 at 1:45 AM by V6, Licensed Practical Nurse (LPN), shows the CNA, V7, called V6 to R1's room where R1 was lying on her left side on the floor on the right side of the bed. V6 said she was told by V7 the following, while changing this resident, I positioned her on her right side, and told her not to turn any further, I proceeded to clean her when I noticed she started sliding down the right side of the bed, so I grabbed the draw sheet in an attempt to prevent her from falling but I was unable and instead assisted in guiding her down to the floor, she landed on her left side without hitting her head.The facility's State Report regarding R1, dated 11/19/25, shows R1 had a witnessed fall on 11/17/25. It shows R1 has a history of falling and non-compliance with medication and refusing treatment and care.R1's After Visit Summary from the hospital, dated 11/17/25, shows R1's height is five feet five inches, and her weight is 283 pounds 4.7 ounces. R1 had a CT scan of her cervical spine, abdomen, pelvis and head and x-rays of her left knee and was diagnosed with a fall.On 11/19/25 at 9:57 AM, R1 said on Monday night (11/17/25) around 1:30 AM, a female CNA (Certified Nursing Assistant) whose name she cannot remember was changing her. R1 said the CNA, later identified as V7, was rolling her onto her right side and all the sudden said, Don't move, or you're gonna (sic) fall off the bed and no sooner than she said it, she had already fallen out of bed onto her knees. R1 said she didn't actually fall, she was pushed. R1 said V7 called for help and a nurse came. R1 said she was taken to the hospital, and she returned the same night with a bruised knee. R1 showed her left knee which had a light green half dollar coin sized bruise. R1 said there were no fractures or other injuries.On 11/19/25 at 12:06 PM, V5, CNA, said R1 is a two assist for turning in bed; she is heavy.On 11/19/25 at 12:14 PM, V2, Director of Nursing (DON), said that during care, the CNA (V7) had R1 turned to her side and R1 kept shifting herself. The CNA asked R1 to stay still so she could clean her, but the resident shifted again and started to slowly slide down the bed. The CNA grabbed the sheet to keep the resident from falling, but couldn't stop the fall, so the CNA lowered R1 slowly to the floor. V2 said the ADON (V3 -Assistant Director of Nursing) spoke to R1 and they updated her care plan and added education on body position and alignment in bed.On 11/19/25 at 12:23 PM, V7 said she was changing R1 and had R1 turned to her right side, and she was behind her on the left side of the bed. V7 said R1 was scooting toward the edge of the bed, and she told R1 to stop scooting because she was going to fall, but R1 scooted a little and she could see R1's legs going over the edge of the bed. She reached for R1 to keep her from falling, but couldn't get her stopped in time, so she grabbed her by the waist and eased her down towards the floor and R1 ended up on the floor. V7 said R1 can help turn her upper body but needs help crossing her (left) leg over to turn her lower body. V7 said if there were two people in the room, it would have prevented the fall. V7 said after R1 fell, she now uses two people to turn R1. On 11/19/25 at 2:38 PM, V6 said V7 yelled for help from R1's room. When she entered R1's room, she noted R1 on the floor. V6 said V7 told her she was changing R1 and told R1 to roll over to her side, then her legs went too far over the side and R1 started to slide down, so V7 grabbed the sheet to stop the fall, but wasn't able to, so she guided R1 and the sheet to the floor.

Based on observation, interview, and record review, the facility failed to administer medication as ordered by a physician for 1 resident (R1), failed to ensure medications were stored in their original packaging prior to administration for 5 residents (R7,R8,R9,R10,R11). These failures apply to 6 of 8 residents reviewed for medications in the sample of 11.The findings include: 1) R1's electronic face sheet dated 8/20/25 showed R1 has diagnoses including but not limited to Alzheimer's disease, hypothyroidism, asthma, and hypertension.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment.On 8/20/21 at 10:21AM, R1 was in her bed laying on her left side with a white patch dated 8/19 stuck to her bed linens. Surveyor reported findings to V4 (Registered Nurse). Surveyor and V4 entered R1's room and V4 stated, Oh, that's her lidocaine patch. She gets one on her left shoulder. I haven't put her new one on yet this morning, but it was supposed to be put on around 8:00AM, I think. This patch should have been removed last night because it gets put on in the morning and then removed at night.R1's medication administration record (MAR) for August 2025 showed, Lidocaine External Patch 4%. Apply to left shoulder topically one time a day for pain and remove per schedule. R1's MAR showed R1's Lidocaine patch is to be placed on at 9:00AM and removed at 8:59PM every day.R1's medication administration audit report dated 8/20/25 showed V4 signed off that she applied R1's new lidocaine patch at 8:32AM. (V4 previously stated she had not placed R1's new lidocaine patch on yet).On 8/20/25 at 12:55PM, V2 (Director of Nursing) stated, When a nurse is administering a patch to a resident, they should be verifying that the patch is in the correct spot and dated correctly. Lidocaine patches are typically dated, and they should be done as ordered to have the therapeutic amount given to them.The facility's policy titled, Administration of Medications dated February 2018 showed, General: All medications are administered safely and appropriately to aid residents and to help overcome illness, relieve, and prevent symptoms, and help in diagnosis.17. If medication is not administered, record reason on the eMAR (Electronic Medication Administration Record) and notify physician or Nurse Practitioner.2) On 8/20/25 at 12:33PM, V8 (Registered Nurse) was in the middle of a medication pass. Inside the top drawer of the medication cart were 5 medication cups with room numbers and pills inside each cup. V8 stated he prepped the medications earlier because he has 20 residents to take care of and it makes his medication pass faster. Upon review of the medication cups with V8, it was found the medications belonged to R7,R8,R9,R10, and R11.R7's medication cup consisted of amiodarone 400mg and gabapentin 300mg scheduled for 2:00PM administration.R8's medication cup consisted of Norco 5/325mg scheduled for 2:00PM administration.R9's medication cup consisted of midodrine 5mg scheduled for 3:00PM administration.R10's medication cup consisted of gabapentin 300mg scheduled for 2:00PM administration.R11's medication cup consisted of midodrine 10mg scheduled for 3:00PM administration.On 8/20/25 at 12:55PM, V2 stated, Medications should not be pre-poured as this could lead to a medication error. If (V8) had to leave, we wouldn't be able to confirm that the medication is correct and if he gets busy, he could give the incorrect medication.The facility's policy titled, Administration of Medications revised February 2018 showed, .13. Hit prep on the eMAR as the medication is prepared. Hit confirm on the eMAR once the medication is popped out.16. Remain with the resident to ensure the resident swallows the medication. Once resident takes the medication, hit save on the eMAR.

Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin to 1 of 3 residents reviewed for unknown origin in the sample of 4. The findings include: R1's electronic face sheet accessed last 7/9/25 documents, R1 96 y/o readmitted to the facility last 4/2/25 with diagnoses that include acute respiratory failure, kidney failure hypertension and diabetes. R1's progress notes dated 4/6/25 by V3 (RN) show [R1] refused to eat and drink, no urine output, family requested to send resident to the hospital. R1 was sent out to the ER. R1's Hospital Records dated 4/6/25 documents, 96 y/o presenting with decreased output, ordered hip X-ray. R1's radiology report dated 4/7/25 with final result -left femoral neck fracture. R1's hospital records dated 4/8/25, R1 underwent surgery -left hip hemiarthroplasty (left hip replacement) On 7/9/25 at 11:30 AM, V7 (R1's daughter) said she was told in the hospital that R1 had a new hip fracture to her left hip. V7 said that was the reason why R1 needed surgical repair because of this new left hip fracture. V7 said she called the Nursing Home and asked them to investigate how R1's left fracture came about. V7 said from 4/2/25 when she came back to the Nursing Home, until 4/6/25 when R1 was sent back to the ER, no one told her that R1 had a fall at the facility, but even if R1 did not fall, did it happen during care? or when she was being turned?, I do not know, I just need them to tell me what they've found in their investigation. On 7/9/25 at 1:47 PM, V2 (Director of Nursing-DON) said when R1 was found to have a left hip fracture but had no falls at the facility, it was assumed that it was the same hip fracture that R1 sustained in the past. V2 (DON) then showed this surveyor a document dated 5/5/21 (approximately 4 years ago) that show closed fracture of left pubis. When asked if V2 spoke to any hospital staff to ask more information about R1's hip fracture, V2 said she did not call the hospital to clarify if the fracture was old or new, since it was the same side as the old one. V2 also said she spoke to some staff but not all staff that took care of R1, since we thought it was the same fracture R1 sustained way back in 2021. V2 said R1 was also on therapy but she did not interview any of the therapists that took care of R1. V2 said she did not know R1 had hip surgery last 4/8/25 until she started reading R1's hospital records. The Facility Reported incident as Final dated 4/6/25 documents, 96 y/o readmitted back on 4/2/25 .On 4/6/25 guest (R1) was observed eating less and refusing drink fluids. MD was notified with order to sent R1 to the hospital for evaluation. R1 was admitted with diagnosis of urinary retention and closed fracture of left hip .CT pelvis showed old fracture of left hip (hospital records does not support this statement of old fracture.) Dexabone density was done 12/7/2008 (approximately 17 years ago) indicating osteoporosis and risk for bone fractures. The Facility Policy on Abuse (undated) under Investigation documents, . Every staff member working on the specific unit that the resident resides, who was working or present during the period of time of the allegation will be interviewed.

Based on interview and record review the facility failed to accurately bill and issue a refund for an overpayment to a resident in a timely manner for 1 of 3 residents (R1) reviewed for billing in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE]. On 1/1/2023 R1's payer source changed to hospice medicaid which it remained until the time of her passing on 7/3/2024. On 4/3/25 at 10:20 AM, V3 (Senior [NAME] President of Business Office) said she became involved a few weeks in the issue with R1's bill. V3 said that its very time consuming and she will have to go back over every single payment that was made and everything billed for R1 since 2023 but the best she can tell is that R1 did have an overpayment and was due a refund back in 2023. She believes the reason was that R1's spouse {V10} had a financial change and as a result the amount medicaid paid and the amount he was liable for R1's bill had changed so a former business office employee identified as V5 should have followed a process and send a 1156 form to medicaid and then completed a form to send to the senior vice president and a refund should have been issued. V3 said she could see where V5 made a notation in R1's Electronic Medical Record (EMR) that she had started that process but no notation was made that it was ever followed up on and no refund had been issues to R1's Power of Attorney (V10). V3 said 2 years is to long for this to take to get resolved, it should have taken about 6 weeks. V5 was attempted to be contacted by this surveyor on 4/3/25 with no return call. On 4/3/25 at 10:45 AM, V4 (Assistant Business Manager) went over R1's billing inquiry with this surveyor. V4 said based on the statements anything in parenthesis is a refund to the payee. There are various different totals in for R1 from 1/1/23-12/1/23 with the average being about $1,143.00 V4 said she was new to this role so she doesn't totally know everything yet but based on the information there was an overpayment in 2023 and R1 was due a refund. A Transaction report for R1's bill in her EMR shows a note completed by V5 on 9/20/2023 at 2:31 PM that states, income book has been incorrect. Income was not diverted to the spouse in the community. 1156 will be completed to reflect PL change. Spoke with the husband and he is aware there is a process that needs to be taken before he receives the refund. An account generation note on the same report shows on 12/6/23 the identified amount of the refund due for R1 was $9,290.10. On 4/3/25 at 11:10 AM, V9 (R1's son) was contacted at the request of V10 (R1's spouse). V9 explained that his dad (V10) had a financial change in 2023 and due to that his amount due for R1's bill had become less however the facility continued to bill him the same amount for R1's care. V9 said they have went through an attorney who has been attempting to get the refund for his dad but the facility does not respond back and they have not received the refund that was due in 2023. A facility provided Resident Refund policy last revised on 7/2023 shows the process the facility should follow to initiate a payment for a refund due to a resident or a residents POA. That policy shows that accounts payable should process the refund and the chief financial officer should release the payment within 10 business days.

Based on interview and record review, the facility failed to ensure a resident was supervised for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4. This failure resulted in R1 falling and sustaining fractures to her pelvis. The findings include: On 3/25/25 at 12:01 PM, V3, Licensed Practical Nurse (LPN), said she was R1's nurse on 3/6/25. V3 said V3 said R1 kept trying to get up out of her wheelchair and she kept reminding R1 to sit back down. V3 said she stepped away from the dining room where R1 was sitting with other residents and the next thing she knew; a hospice nurse was telling her that R1 had fallen. V3 said R1 needed one on one monitoring; you cannot really take [your] eyes off her. V3 said the Certified Nursing Assistants (CNAs) were monitoring the dining room, but they were busy, and they were not present at the time. On 3/25/25 at 1:35 PM, V4, CNA, said she was assigned to care for R1 when R1 fell on [DATE]. V4 said she was passing meal trays in the dining room with V3 and V7, CNA, where R1 was eating. V4 said she told V3 she was going to leave the dining room to feed residents in their rooms. V4 said she returned to the dining room after feeding a resident in their room and R1 was on the floor. V4 said she did not see R1 fall. V4 said she heard V3 say she was just there (in the dining room) five minutes ago. V4 said she had been told to monitor R1 more closely in report. V4 said R1 would try to get up out of her wheelchair and they would have to remind her to sit back in the chair. On 3/25/25 at 3:00 PM, V7, CNA, said she was assigned to R1's unit when R1 fell in the dining room (on 3/6/25). V7 said V4 was R1's CNA. V7 said she was with some residents; she heard commotion and then saw everyone going toward R1. V7 said she did not see R1 fall. V7 said staff should always monitor residents when they are in the dining room. V7 then said she does not remember what happened, she cannot recall everything since it's been such a long time. V7 said if she gave a statement at the time, it must be correct. On 3/25/25 at 2:26 PM, V2, Director of Nursing (DON), said R1 was a frequent faller. V2 said she investigated the fall. R1 was found on the floor in the dining room on 3/6/25 around 1:20 PM. V2 said V3 said she was passing medications and did not see anything. V2 said it was an unwitnessed fall and R1 was not able to describe what happened. V2 said residents are supposed to be monitored by staff when they are in the dining room. V3 documented the following excerpt in R1's Progress Notes on 3/6/25 at 3:07 PM, This resident since the beginning of the shift has been trying to get up from her wheelchair and every attempt to redirect her failed. On 3/25/25 at 1:55 PM, V6, R1's Daughter, said R1 fell on [DATE]. V6 said she was told R1 kept trying to get out of her wheelchair. V6 said R1 had x-rays on 3/7/25 and again on 3/10/25 which did not show any fractures. V6 said R1 would continue to scream with pain upon movement, so they pushed for a CT scan which was scheduled on 3/21/25. V6 said the CT scan showed two fractures. V6 said she feels there should be more safety precautions for the residents; more frequent checking or alarms or something. On 3/25/25 at 3:09 PM, V8, R1's Orthopedic Surgeon, said R1 sustained pubic rami fractures which have shifted or moved according to her CT results. V8 said the fractures are definitely acute and were sustained within the last six weeks. V8 said these types of fractures occur after some type of trauma. R1's CT of her pelvis dated 3/21/25 shows she has fractures of her right superior and inferior pubic rami. R1's Fall Risk Evaluations done on 12/27/24, 2/28/25, 3/2/25 and 3/6/25 all show she is a high risk to fall. R1's Care Plan initiated on 12/27/24 shows R1 is a high risk for falls related to impaired cognition and poor safety awareness. The same care plan shows R1's diagnoses include, but are not limited to vascular dementia, a history of falling, osteoporosis, and vitamin D deficiency. The facility's Witness Statement dated 3/6/25 provided by V3 shows she was informed that R1 had fallen by a hospice nurse who happened to be seeing another patient on the unit. The facility's Witness Statement provided by V7 dated 3/10/25 regarding R1's fall on 3/6/25 shows V7 said that she was not assigned to R1's unit. The facility's Initial and Final State Report dated 3/21/25 shows R1 is alert and oriented to self and has moderate cognitive impairment. The facility's Fall Prevention Policy (last revised 11/2024) shows, Each resident residing at this facility .receives adequate supervision .to prevent accidents.

Based on interview and record review, the facility failed to ensure a resident's pain medications was provided for 1 of 2 residents (R133) reviewed for pain management in the sample of 32. These failures resulted in R133 experiencing unrelieved pain and was not unable to fully obtain restful sleep for three days. The findings include: On 03/11/25 at 10:35 AM, R133 said for the last 3 nights on the 8th through the 10th, she did not receive her muscle relaxer (tizanidine) as requested and indicated she needed that the most because she usually takes the muscle relaxer with norco in the morning and at night. R133 was told by staff that the medication was ordered, and they would follow-up with pharmacy. She said that no one followed up with her regarding the status of the medication. R133 then said the muscle relaxer came last night (03/10/2025) and that she received the medication this morning (03/11/2025). R133 added that V4 (Licensed Practical Nurse) told her that he had reordered the medication when there was 5 pills left. Review of R133's medication administration record for January 2025 showed R133 was administered tizanidine 2mg tablet on the 1st-5th, 8th, 10th-14th, 16th-19th, 21st-24th, 26th-28th, and the 30th. Review of R133's medication administration record for February 2025 showed R133 was administered tizanidine 2mg tablet on the 1st-3rd, 7th, 9th, 11th, 13th-16th, 18th-19th, 21st, 23rd-26th, and the 28th. Review of R133's medication administration record for March 2025 showed R133 was administered tizanidine 2mg tablet on the 1st-2nd, 5th-9th, and the 11th-12th. Review of R133's pain assessments for last 3 months showed that during the 3 days resident said she did not receive her muscle relaxer (tizanidine), a pain level of 5 was documented on 03/08/2025 at 08:57 AM and on 03/09/2025 at 08:58 AM. Pain levels of 8 were documented on 03/10/2025 at 09:39 AM and 09:42 AM, and a pain level of 5 was documented on 03/10/2025 at 08:04 PM. Pain level of 7 was documented on 03/11/2025 at 08:08 AM On 03/12/25 at 01:52 PM, surveyor informed resident that medication administration record showed she was administered the medication on 03/08/2025 and 03/09/2025. R133 became visibly upset then said, that's a damn lie. R133 again indicated that she did not receive her muscle relaxer from the 8th through the 10th, and finally received her muscle relaxer on 03/11/2025. Review of R133's medical record indicated resident last admitted to the facility on [DATE] with a past medical history not limited to: hypertension, bilateral osteoarthritis of knee, other specified postprocedural states, morbid obesity, and muscle weakness. Review of R133's care plan documented resident has the potential for pain initiated on 11/18/2024 with interventions that included but not limited to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. R133's Minimum Data Set (MDS) dated [DATE] documented in Section C for cognitive patterns that R133 has no cognitive impairment with an assessment score of 15/15. Section J for health conditions documented R133 requires pain management and receives scheduled and as needed pain medications. Review of R133's active orders as of 03/13/2025 showed orders for pain evaluation every shift, hydrocodone-acetaminophen (norco) 5-325 milligram (mg) tablet every 8 hours as needed for pain, and tizanidine hcl 2mg tablet every 8 hours as needed for muscle spasm. On 03/12/2025 at 01:52 PM, R133 who appeared visibly distraught said when she didn't take her muscle relaxer medication (tizanidine) with norco for those 3 days (3/8-3/10/2025), her pain was not fully controlled, and she was having muscle spasms to the front of her legs which made it hard for her to sleep during those 3 days. R133 said she had asked for the tizanidine several times but was told by the nurses that she didn't have any left and could only get norco. At 01:56 PM, R57 (R133's roommate) said a few mornings ago, she was awoken by R133 who was moaning out loudly in her sleep. R57 then said, I felt so bad for her (R133) because I knew she was hurting bad. On 03/13/2025, review of R57's Brief Interview for Mental Status (BIMS) Evaluation dated 02/4/2025 indicated R57 has no cognitive impairment/ intact cognitive response with assessment score of 15. On 03/12/2025 at 02:05 PM, V5 (Licensed Practical Nurse) said R133 usually requests her tizanidine medication (muscle relaxant) daily in the morning and at night. V5 then said R133's tizanidine medication was reordered last on 03/08/2025 and 15 capsules were received on 03/10/2025. Reviewed R133's medication card for tizanidine with V5 that showed a dispensed date of 03/10/2025. On 03/13/2025 at 11:11 AM, V4 (Licensed Practical Nurse) said that he reordered R133's tizanidine medication on 03/04/2025 and R133 had 3 or 4 capsules left on her medication card when he reordered. On 03/13/2025 at 01:00 PM, V2 (Director of Nursing) said her expectation of staff is to manage a resident's pain by administering their pain medication as ordered and as needed. V2 added that staff should reorder a medication when there's a week's supply left and if a medication is unavailable, they should utilize the facility's automated medication dispensing system. On 03/13/2025, review of facility's automated medication dispensing system list of supplied medications did not include the medication tizanidine. V1 (Administrator) also provided in-service records dated 03/12/2025 and 03/13/2025 for medication administration. On 03/13/2025 at 01:43 PM, surveyor requested from V1 (Administrator) the contact information for V23 (Registered Nurse) to clarify her documented administrations of tizanidine to R133 on 03/08/2025 and 03/09/2025 during the 3 days that R133 was told she had none left and had previously indicated not receiving the medication. V23's contact information was not provided during survey or upon survey team exiting the facility. On 03/13/2025, facility provided order detail report for R133's tizanidine medication that documented 3 capsules were dispensed on 03/03/2025 then medication was not dispensed again until 03/10/2025 with 15 capsules dispensed on the same date. Administration of Medications policy last revised 02/2018 reads in part: all medications are administered safely and appropriately to aid residents to and help in overcome illness, relieve and prevent symptoms and help in diagnosis .if a medication is ordered but not available, check to see if it was misplaced and then call the pharmacy to obtain the medication . Pain Management policy last revised 10/2024 reads in part: to ensure the resident's pain is managed effectively. It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management. This facility recognizes that residents may have decreased sensations or perceptions of pain .Chronic pain may produce anorexia, lethargy, depression, immobility, social isolation .Each and every resident has a right to the assessment and management of pain. Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the resident experiencing pain enhances the healing and promotes both physical and psychological wellness.

Based on observation, interview, and record review the facility failed to ensure pressure injury dressings were changed when soiled, failed to ensure the prescribed dressings were applied when changed, failed to report a new pressure injury, and failed to ensure pressure relieving interventions were in place. This applies to 5 of 8 residents (R113, R96, R72, R10 & R21) reviewed for pressure injuries in the sample of 32. The findings include: 1. R113's face sheet shows he is an [AGE] year old man with diagnoses to include: type II diabetes mellitus, peripheral vascular disease and chronic kidney disease. On 1/22/2024 at 10:16 AM, V33 Licensed Practical Nurse (LPN) was changing R113 and getting him ready to eat breakfast. She stated, she just cleaned up R113's bottom and needed to change his wound dressing on his sacrum. V33 LPN left the room to get supplies. When V33 LPN returned she stated, she didn't have the right supplies to put on R113's sacral wound. She turned R113 on his right side. The dressing on his sacral wound was heavily soiled with a brown like substance. He had a golf ball size deep wound on his sacrum. The tissue inside of the wound was black in color. R113 cleaned the wound with normal saline and applied a foam dressing. She stated, she didn't have the right stuff and was just putting a foam dressing on right now and the wound care nurse could come and change it later. On 1/24/2024 at 9:42 AM, V39 Certified Nursing Assistant (CNA) rolled R113 over. R113's sacral dressing was heavily soiled with a brown substance. The dressing was coming off. The dressing was dated 1/23/2024. V39 CNA stated, his wound drains all the time. She reported it to the nurse but the nurse won't change it and will wait for the wound care nurse to change it. On 1/24/2024 at 10:54 AM, V33 LPN and V6 Wound Care Nurse (WCN) were changing R113's sacral wound. It was still the same dressing that was on at 9:42 AM with V39 CNA. V6 WCN removed the dressing. The dressing remained heavily soiled with a brown substance. The brown substance had gone through the foam dressing onto the adult diaper. There was a strong odor with the wound. V6 WCN stated, the wound care doctor had seen R113 the day before and had ordered a wound vac for the wound. They were waiting for the wound vac to come and then they would put it on. The wound care doctor had said that was ok and to continue the same dressing until the wound vac arrived. The wound was a large deep golf ball size wound on R113's sacrum. The tissue inside the wound was black and stringy. V6 WCN said the tissue inside the wound was slough (dead tissue). V6 WCN also stated, the floor nurses can change the dressings. There is no reason to wait to be changed. On 1/25/2024 at 2:09 PM, V41 Wound Care Doctor stated, R113's wound is improving in size. He needs to be debrided but V41 can not do it in the facility. The first time he debrided the wound, R113 bled really bad so V41 stated, he is trying the wound vac and if in 10 days the wound remains the same as it is now, he will send R113 to the hospital to be debrided in the hospital setting. He stated, he did see the wound on January 23, 2024 and he has not treated it with antibiotics at this time. He felt the wound vac would help with the slough and odor. R113's wound assessment details report dated 1/25/2024 shows, active stage 3 pressure ulcer to his sacral- right buttock. The wound measures 9.00 cm (centimeters) X 6.50 cm X 2.50 cm (Length X width X depth). There is also heavy drainage. R113's wound care progress notes by V41 Wound Care Doctor dated 1/23/2024 shows, 1/23: The patient was seen today for follow-up of sacral pressure ulcer. The wound is improving. No s/s (signs or symptoms) of infection. No fevers or chills. No recent falls and hospitalization s . Wound Assessment: Wound #1 sacral is a stage 3 pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 9 cm length X 6.5 cm width X 2.5 cm depth . No undermining has been noted. There is a moderate amount of serous drainage noted which has a strong odor. The patient reports a wound pain of level 1/10. The wound margin is well defined wound bed has 26-50%, pink, granulation, 26-50% slough; no eschar and no epithelialization present. The wound is improving. Wound Orders: General Notes: 1/23: The patient was seen today for follow up of wound care. The wound is improving. There are no s/s of infection. No procedures performed today. SN (skilled nurse) to continue wound care as ordered . The same progress note also shows, orders for a wound vac to be applied and to continue same dressing until wound vac is available. R113's current order summary report shows, Sacrum/R (right) buttock: Cleanse with NS (normal saline) and apply medihoney with silver alginate and cover with foam dressing every day shift and as needed. R113's care plan initiated on 12/28/2023 shows, Focus: The resident has actual impairment to skin integrity r/t (related to) pressure injury on sacral-right buttock re-admission on 12/11/23. Interventions: .Evaluate and treat per physicians orders . The facility's wound policy & procedure policy dated March 2020 shows, Policy: .Any resident with a wound receives treatment and services consistent with the resident's goals of treatment . A commitment to the wound management program is demonstrated by implementation of processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. 34506 2. R96's Order Summary Report dated 1/22/2024 shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, morbid obesity, contracture left ankle, left knee contracture, neuromuscular dysfunction of bladder, Parkinson's, and bipolar disorder. R96's Care Plan shows she is at risk for alteration in skin integrity related to decreased mobility, potential side effects of medications, bowel incontinence, diabetes, and history of pressure injury, monitor skin with care/bathing every shift and as needed, and report any changes/notify medical doctor of any worsening of wounds/increased or persistent edema. R96's Pressure Injury Risk dated 12/14/2023 shows she is at risk for developing pressure injuries. On 1/22/2024 at 10:01 AM, V3 CNA (Certified Nursing Assistant) provided incontinence care to R96. R96 had a two inch long sore to her right upper thigh. V3 said she thought the sore was from R96's catheter tubing. On 1/24/2024 at 10:06 AM, V7 LPN (Licensed Practical Nurse/R96's nurse for the day), said he was not aware that R96 had an open area on her right thigh. At 10:15 AM, V5 CNA said if a new open area is found on a residents' skin, then the nurse should be notified right away. On 1/24/2024 at 11:26 AM, V6 Wound Care Nurse said he was not aware that R96 had a sore on R96's right upper thigh. V6 said staff should report to him if staff find a new open area on a residents' skin. On 1/24/2024 at 11:55 AM, V6 Wound Care Nurse assessed R96's skin. V6 said the wound is a pressure injury to her right upper thigh. V6 said most likely due to the catheter or the incontinence brief. R96's Wound Assessment Details Report dated 1/24/2024 shows R96 has an unstageable pressure injury to her right inner thigh. The facility's Wound Policy and Procedure dated May 2023 shows, Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. 34117 3. R72's Wound Physician Progress note dated 1/17/24 documents she is a [AGE] year old female with a stage 4 pressure ulcer to the left lateral thigh measuring 11 cm (centimeters) x 4 cm x 3 cm. Necrotic and adipose tissue exposed, there is a large amount of sero-sangineous drainage. The treatment orders include to cleanse wound with normal saline, apply collagen, cover wound with 4x4 gauze and abdominal pad and cover with boarded gauze dressing, Change dressing as needed for soiling and saturation. R72's Physician Order Sheets dated January 2024 shows order dated 1/18/24 left lateral thigh: cleanse with normal saline and apply collagen and foam dressing (it does not include to apply the 4x4 gauze and abdominal pad). On 1/22/24 at 9:47 AM, R72 said she has a sore on her thigh and the dressing gets changed every three days. On 1/22/24 at 10:06 AM, V6 (Wound Nurse) went in to provide wound care to R72. R72's foam dressing to her left thigh was heavily saturated with sero-sangineous drainage. The foam dressing was not secured to her thigh; it was hanging loosely from one side of the dressing. R72's top sheet and incontinent pad was soiled with drainage from the wound. V6 removed the soiled dressing and a large deep open wound to her left thigh was reddened and small black area around the wound bed. At 10:19 AM, R72 said the bandage does not stay on and the wound has been leaking. V6 cleansed the wound and applied collagen and a foam dressing (V6 did not apply the 4x4 gauze and abdominal pad) V6 said the treatment is collagen and the foam dressing. On 1/22/24 at 11:21 AM, V6 (Wound Nurse) said R72 has a stage 4 pressure ulcer to her left thigh. Anytime the treatment is soiled the dressing should be changed. It increases the risk for infection and could delay the wound healing. V6 confirmed R72's treatment dressing was saturated with drainage and should have been changed prior to today. V6 said he is not here on the weekends and the floor nurse should be checking on the resident's wound. The treatment orders should be followed. 4. R10's Wound assessment dated [DATE] documents a unstageable left buttock pressure ulcer measuring 1.0 cm x 1.0 cm with treatment orders to cleanse with normal saline and cover with foam dressing. On 1/22/24 at 11:23 AM, V6 (Wound Nurse) went into R10's room to provide wound care. R10 was observed lying in bed. V6 assisted to R10 on her side. A small open area was observed to her left buttock without a protective dressing in place. V6 said she's supposed to have foam dressing in place, I'm not surprised there's no dressing in place. It's Monday. V6 said he is the only wound nurse and works Monday thru Friday. The floor nurse should be changing and applying a residents treatment order during the weekends. 37232 5. R21's face sheet showed R21 had diagnoses of contractures to both ankles and weakness. A facility assessment done on 12/14/23 showed R21 did not refuse care and had limited mobility on his lower extremities. R21's care plan showed he was at risk for skin alterations because of limited physical mobility. Listed under interventions was to off-load heels. On 01/22/24 at 10:51 AM, 12:00 PM, and 1:40 PM R21 was in bed. R21's heels were resting directly on the mattress and were not being off-loaded. On the chair next to R21's bed were heel protector boots. On 01/24/24 at 09:20 AM, R21 was in bed, R21's heels were resting directly on the mattress and were not being off loaded. On the chair next to R21's bed were heel protector boots. On 01/24/24 at 11:26 AM, V6 (Wound Care Nurse) said off-loading heels is a pressure injury intervention and can be done with heel protector boots or pillows.

Based on observation, interview, and record review the facility failed to ensure a resident's diet orders were followed and supervised as prescribed by the physician. This failure resulted in R106's diet orders not being followed by receiving bread and needing the Heimlich maneuver for choking on bread pudding. The facility also failed to ensure residents were supervised during meals who require close supervision. This applies to 2 of 32 residents (R106 & R17) reviewed for safety/supervision in the sample of 32. The findings include: 1.R106's face sheet shows she is a [AGE] year old female with diagnoses to include: Parkinson's disease, dementia and dysphagia (difficultly swallowing). R106's speech therapy evaluation and plan of treatment dated August 22, 2023 shows, Current referral: Reason for referral/current illness: Patient referred to speech therapy for clinical bedside swallow evaluation due to a choking incident at her daughter's home resulting in need for administration of Heimlich {SIC} maneuver and need to call 911 . Reasons for therapy: Clinical impressions/reason for skilled services: Choking episode appears to be on bread item while patient home with family. Tolerance of mech-soft-ground solid trials is noted with mild residue, however pt (patient) with good control and clearance with use of liquid wash and/or lingual sweep. Patient benefits from cues to slow rate of self feed and size of bolus presentation by staff, as recommended previously. Continue mech-soft/thin liquid diet with NO BREAD items with close supervision while eating . R106's choking incident report dated October 10, 2023 shows, Incident description: Writer had walked on the unit and was notified that patient had choked on bread pudding. ADON (assistant director of nursing) had performed Heimlich maneuver {SIC (statement is correct)} and had successfully dislodge food . R106's order summary report shows a diet order dated June 28, 2022, Dietary-Diet: Regular diet, Mechanical soft texture, Thin consistency, No bread. The facility's current diet spreadsheet shows, bread pudding with vanilla sauce on the rotating menu during week 3. The facility's bread pudding with vanilla sauce recipe lists ingredients as eggs, milk, sugar, cinnamon, vanilla extract, bread, white sliced, dry, cubed with crust, pudding mix, vanilla and cold milk. R106's speech therapy evaluation and plan of treatment dated October 12, 2023 shows, Reason for referral/current illness: Pt is a long term resident of this facility and well known to these services. She was referred for a clinical swallow evaluation following a full airway obstruction incident requiring staff administration of the Heimlich maneuver {SIC} to clear. Per staff report, pt was given bread pudding despite documented bread restriction as per previous VFSS (Videofluoroscopic Swallow Study). CXR (chest x-ray) negative. R106's registered dietitian progress note dated October 10, 2023 shows, Guest is to receive a mechanical soft diet with added restriction of no bread per SLP (speech language pathologist). Guest noted choking on a piece of bread pudding. Heimlich was successful and MD (medical doctor) and POA (power of attorney) were made aware of the incident. Other than discomfort from Heimlich guest has no other issues, lungs were clear upon RN (Registered Nurse) examination. Food Service Director to in-service staff on importance of tray card monitoring and compliance with what is to be given. R106's care plan initiated May 1, 2023 shows, Focus: The resident is at risk for injury related to h/o (history of) choking incident. Interventions: .Monitor resident when eating and monitor meal being served . R106's care plan initiated January 1, 2024 shows, Focus: The resident has a swallowing problem r/t )related to) dysphagia. On January 24, 2024 at 10:07 AM, V47 Speech Therapist stated, even though the bread pudding presents like a pudding there are still chunks of bread in it. R106 should not have been served the bread pudding. On January 25, 2024 at 10:12 AM, V42 R106's MD stated, the facility told her that R106 choked on bread. On January 25, 2024 at 10:33 AM, the facility served their bread pudding. The bread pudding was a cake like square piece that had bread in it. The facility's menu service policy dated May 2023 shows, Procedure: .8. When the tray is delivered, the staff ensures that the correct tray is given to the correct resident and the diet on the card matches what is on the tray. 2. R17's face sheet shows she is a [AGE] year old woman with diagnoses to include: dementia and dysphagia. On January 22, 2024 at 9:58 AM, R17 was in lying in bed. The head of the bed was up about 90 degrees. Her bedside table was over the bed in front of her. Her breakfast tray was in front of her on the table. There was a half eaten piece of toast on the tray. She was half asleep with a brown thick consistency hanging out of her mouth. She was coughing. V37 Registered Nurse (RN) was outside her room passing medications to other residents. This surveyor asked V37 RN if R17 was ok. V37 RN and V33 Licensed Practical Nurse (LPN) (who was also outside R17's room in the dining room) went into check on R17. V37 RN confirmed the substance hanging out of R17's mouth was chewed up toast. R17 was very sleepy and would not wake up for V37 RN or V33 LPN. V33 LPN cleaned up R17 and took her tray out of her room. At 12:35 PM, the noon meal, R17 was eating in her room again. She was still asleep in bed and her lunch tray was sitting in front of her on the bedside table. She had half eaten noodles hanging out of her mouth. She was coughing. Her meal ticket showed, close supervision. R17's meal ticket shows, Notes: .close supervision. On January 24, 2024 at 9:26 AM, R17 was asleep lying in bed. The head of the bed was up 90 degrees. She had IV (intravenous) fluids going. Her breakfast tray was sitting in front of her not touched. V33 LPN came in and tried waking R17 up. R17 didn't wake up and didn't want to eat her breakfast. V33 LPN removed her tray from the room. On January 24, 2024 at 9:26 AM, V48 Nurse Practitioner stated, she ordered some labs, and IV fluids, a chest x-ray and a urinary test because the nursing staff reported that R17 hasn't been eating, was congested and not arousable. R17's chest x-ray dated January 24, 2024 shows, Impression Chest: Heart is within normal limits with interstitial infiltrates left lung base and in the right upper lung field. On January 25, 2024 at 10:12 AM, V42 R17's Medical Doctor stated, her chest x-rays show pneumonia. She is not sure if it is aspiration pneumonia or not. Usually with aspiration pneumonia it would only be on one side. R17 has been declining. She also ordered for speech therapy to evaluate her. R17's current order summary report shows, Dietary-Diet: No Added Salt (NAS) diet, pureed texture, thin consistency with a start date of January 25, 2024. Her diet was downgraded from mechanically soft. R17's speech evaluation and plan of treatment dated July 14, 2023 shows, Reason for referral/Current illness: R17 is a long term resident at this facility and well known to these services. MD (medical doctor) order received for SLP swallow evaluation to r/o (rule out) aspiration. Per 7/13 (July 13, 2023) RN note, lungs bilateral congested afebrile, pt with nonproductive congested cough . R17's speech discharge summary dated July 24, 2023 shows, Supervision: How often does the patient require supervision/assistance at mealtime d/t swallow safety? = 91-100% of the time (close supervision when eating). R17's speech evaluation and plan of treatment dated January 8, 2024 shows, Reason for referral: Patient is a memory care resident of the LTC (long term care) facility with referral for St evaluation due to coughing reported after mealtimes. Patient is a previous patient of ST with d/c mech soft/thin (mechanically soft/thin liquids). On January 24, 2024 at 10:24 AM, V47 Speech Therapy stated, she was seen by speech in July 2023 for aspiration concerns. Her diet was a mechanical soft diet with chopped texture. R17 was discharged from speech on July 24, 2023 with compensatory strategies: upright in bed at 90 degrees, slow rate, small bites and sips, alternating bites with sips and close supervision. Close supervision means she needs to be supervised 90-100% of the time by a staff member. She was also seen on January 8, 2024 for coughing after eating. Her recommendations were not changed at that time. On January 24, 2024 at 11:47 AM, V39 Certified Nursing Assistant (CNA) stated, R17 has been requiring more help with eating. She stated, close supervision means you need to be close while residents are eating. R17's care plan initiated January 16, 2024 shows, Focus: The resident has a swallowing problem r/t dysphagia.

Based on interview and record review the facility failed to treat and manage a resident's pain after a resident sustained a fall resulting in injury for 1 of 3 residents (R1) reviewed for pain in the sample of 7. This failure resulted in R1 suffering excruciating pain with movement during cares and therapy. R1's fall resulted in a fractured pelvis and subdural hematoma. The finding include: R1's fall investigation report dated May 18, 2023, showed, on May 17, 2023, at 11:45 PM, R1 was found on the floor in the bathroom of her room. A laceration was noted above R1's right eye. The report showed R1 was assessed by staff immediately after the fall. R1's was found to have no significant pain to R1's extremities during range of motion exercises, and steri-strips were applied to R1's head laceration. R1's physician (V18) and V4 (Power of Attorney/Family of R1) were immediately notified of R1's fall. The report showed V4 (Family of R1) refused to have R1 sent to the hospital at that time. The report showed R1 began to complain of increased pain during the morning of May 18, 2023. V4 was notified of R1's increased pain. V4 agreed, at that time, to have R1 sent to the hospital for an evaluation. At the hospital, R1 was evaluated and diagnosed with a pelvic fracture and subdural hematoma (brain bleed), as a result of her fall. R1 was hospitalized until May 22, 2023, and then transferred back to the facility. The report showed R1 was severely cognitively impaired, related to her diagnoses of dementia and Alzheimer's disease, prior to her fall. On June 5, 2023, at 12:40 PM, V4 (Family of R1) stated, When (V5 Registered Nurse/RN) called me after (R1) fell (on May 17, 2023), he said he was going to give her some medication for pain because she had begun complaining of general pain. I am not sure if he ever gave it to her When (R1) returned to the facility, from the hospital on May 22,2023, (V7 Physical Therapist) came in to do an assessment on (R1), around lunch time. During the assessment, (R1) was in terrible pain, yelling out every time (V7) tried to move her. I finally asked (V7) to stop doing the assessment. R1's May 2023 Medication Administration Record showed two physician order's for Tylenol. One order showed Tylenol 325 mg (milligrams), give 2 tablets by mouth every 4 hours as needed for pain. The second order showed Tylenol 325 mg, give 2 tablets once a day, at 9:00 AM. The record showed R1 received no Tylenol for pain, after her fall on May 17, 2023 at 11:45 PM, until 9:00 AM on May 18, 2023. On June 6, 2023, V5 RN stated, I was called to (R1's) room by (V6 CNA) when he found her on her bathroom floor. She had a small laceration above her left eye. Aside from her head wound, she had no obvious other injuries or deformities. She moved all of her extremities without complaints of pain. I called her physician and notified her of (R1s) fall. The physician wanted to send her to the hospital at that time but when I called (V4 Family of R1) to inform her of the fall, (V4 ) refused to have (R1) sent to the hospital at that time. (R1) began complaining of increased pain to her hips, later on in my shift. I again called the doctor and got an order to do an X-ray of (R1's) hips. I called (V4) a second time, to let her know (R1) was having increased pain . When V5 RN was asked if he medicated R1 for pain, at any time after her fall, V5 stated, I thought I gave her Tylenol that night. R1's Admission Summary note dated May 22, 2023, at 10:55 AM, showed R1 was readmitted to the facility, from the hospital. The note showed R1 was complaining of pain upon readmission. R1's May 2023 Medication Administration Record showed R1 had a physician order for Norco 5/325 mg (narcotic pain medication), one tablet every 6 hours as needed for pain, at 1:01 PM on May 22, 2023. The record showed R1 did not receive a dose of Norco until 4:34 PM, on May 22, 2023. On June 6, 2023, at 10:05 AM, V7 Physical Therapist stated, For therapy, we coordinate with nursing to make sure pain medications are given at least one hour before a resident's therapy session. I saw (R1) on May 22, 2023, shortly after she was readmitted to the facility. There was a physician order for her to have a physical therapy assessment completed upon readmission to the facility. When I entered her room, (R1) was in bed with her eyes closed. She would respond to verbal commands. Every time I moved her, she was in pain. She would try to pull away. She would moan. I tried to sit her up and get her to stand. I know she was on a pain pill. I am not sure when she got it . If a resident is in a lot of pain, we normally stop the therapy assessment. We talk with the nurse about pain control. If a resident's pain isn't under control, therapy is useless. It's like torturing patients at that point . When (V7) was asked why she did not stop R1's therapy session when R1 began complaining of pain, V7 stated, I thought (R1) had already received pain medication but I was not 100% sure. V7 also stated she never reported R1's complaints of pain to R1's nurse. V7 stated she never spoke with R1's nurse to ensure R1 received any pain medications prior to her therapy assessment. On June 6, 2023, at 11:54 AM, V2 Director of Nursing stated, The goal with pain management is maintain a resident's pain at a manageable level. R1's May 2023 Medication Administration Record with reviewed with V2. V2 stated, If (R1) began complaining of pain, after her fall, she should have gotten something for pain. Even if she just got Tylenol. I see there is no documentation that (R1) got any Tylenol after her fall on May 17, 2023, until 9:00 AM on May 18, 2023 If a resident is still having breakthrough pain while already on pain medications, staff should notify the physician of the pain . When (R1) was readmitted to us, she was in quite a bit of pain, anytime we tried to move her . Pain medication should have been given to (R1) prior to any cares due to her pain with movement . On June 6, 2023 at 1:10PM, V18 (R1's Physician) stated, I expected her (R1) to have pain due to her injuries that is why I prescribed the Norco every 6 hours. The pain should be reasonable (level) so they can perform cares and therapy. The facility's Pain Management policy dated May 2023, showed, It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management . Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain .Strategies for pain management include .Identifying and using specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on resident-specific assessment, preferences and choices, a pertinent clinical rational, and resident's goals and using medications judiciously to balance resident's desired level of pain relief with avoidance of unacceptable adverse consequences .

Based on observation, interview, and record review the facility failed to ensure a resident's rights (R11) were promoted and protected by cutting a residents's hair without permision. The facility failed to ensure a resident (R1) was treated with respect and dignity when care was provided. This failure resulted in psychosocial harm to R11 on 12/27/22 when a staff member cut R11's hair after he told her no and tried to push her away. This applies to 2 of 6 residents (R11 & R1) reviewed for resident rights in the sample of 15. The findings include: 1. The facility's Final Incident Investigation Report dated 1/4/23 for R11 showed, Original allegation - Resident reported that he was uncomfortable with the care that he received by the staff. A staff member cut his hair and he did not like it. The daughter notified the center and an investigation was started. The Witness Statement dated 12/27/22 for R11 showed, V12 RN (Registered Nurse) stated that she talked with R11's daughter and told her that her dad looked disheveled. V12 reported that it was her responsibility to take care of the patients. V12 expressed that she felt the daughter wanted her to trim R11's hair. On 1/19/23 at 2:15 PM, V13 (R11's Sister) stated R11 called her and told her that he was forced to get his hair cut. V13 stated, R11 told me what happened. He was very upset and felt violated. R11 told her to stop cutting his hair. I don't know why they felt that they needed to do this. R11 said he was trying to push her away. The staff called but I don't remember who it was. They said an event occurred, someone cut his hair and he did not want it cut. They said V12 RN (Registered Nurse) was sent home. They said they were doing an investigation and would get back to me after five days with a resolution and they never did. R11 likes his hair long and was clearly upset by it. I never told anyone to cut R11's hair. He gets scheduled hair cuts. This wasn't necessary and I don't think it was appropriate. R11 has the right to say, No. They shouldn't just do this to him. V13 stated she is in Florida and hasn't seen R11's hair. V13 stated R11 doesn't have a daughter. On 1/20/23 at 9:10 AM, V1 (Administrator) stated, The family was calm about it. The daughter came in and saw it (R11's hair). V12 RN took it upon herself to cut R11's hair. V11 (Admissions Coordinator) and V3 ADON (Assistant Director of Nursing) interviewed the employee. V12 was sent home. On 1/20/23 at 9:39 AM, R11 was sitting up in bed in his room. R11's hair was cut short. R11 appeared anxious and upset when he was asked about the hair cutting incident with the nurse. R11 stated, I did not want her to cut my hair. I told her I did not want it cut and I tried to push the nurse away. She came at me twice with scissors. I held her hand to try and stop her. I said no. I called V13 (sister) to tell her what happened. I didn't want this to happen. I liked my hair the way it was. I am upset over this. On 1/20/23 at 10:00 AM, V11 (Admissions Director) stated, I was in the conference room with V3 ADON (Assistant Director of Nursing) when the therapist and V4 (Social Services Director) came in and said R11 reported his hair was cut against his wishes. R11 said the nurse did it. I pulled V12 RN off the floor, to the conference room and asked for her statement. I went and talked to R11 again. At this point he was calm but before that he was very upset. R11 had talked to V13 (R11's sister) and that calmed him down. R11 explained what happened. He likes his hair long; she cut it short against his wishes. V3 and I called V13 together. V12 told me someone had come in and said R11 looked disheveled and needed to be cleaned up. R11 said he did not want it done; he said no. On 1/20/23 at 1:31 PM, V17 CNA (Certified Nursing Assistant) stated when she came into work R11's hair was already cut. V17 stated R11 told her that he didn't want his hair cut. V17 stated R11 told her that he told V12 not to cut his hair but she insisted and cut it. V17 stated, R11 was upset about his hair. R11 always liked to style his hair long and curly; she cut him way too short. We are not supposed to cut hair. R11's MDS (Minimum Data Set) dated 11/13/22 showed no cognitive impairment; no physical, verbal or other behaviors; supervision needed for personal hygiene; extensive assistance needed for bed mobility, transfers, and dressing. The facility's Resident Dignity policy (November 2018) showed, This facility will promote care for elders of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality. Residents will be groomed as they wish including hair care and styled, facial hair shaved/trimmed as the resident wishes, nail care as the resident chooses. The facility's Resident Rights policy (April 2022) showed, Purpose: To ensure each resident is treated with dignity and respect. Our facility environment encourages self-selection to individualize needs, care, and routines in a dignified and [NAME] way to respect preferences and full exercise of rights. Our residents have rights to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. 41639 2. R1's electronic face sheet printed on 1/20/23 showed R1 has diagnoses including but not limited to chronic obstructive pulmonary disease, type 2 diabetes, chronic diastolic congestive heart failure, and osteoarthritis. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and requires 1 staff assist with toileting and personal hygiene. R1's nursing care plan dated 9/20/21 showed, Resident is occasionally incontinent of bowel and bladder .offer toileting regularly upon rising, before and after meal times, and at bedtime. On 1/20/23 at 9:25 AM, R1 stated, Earlier this week one of the night time CNA's (Certified Nursing Assistants) told me that my diaper wouldn't fit on me because I was too fat. I have to wait so long to go to the bathroom so they tell me just to go in my diaper and they'll change me. It's disgusting and makes me feel awful. During the day they take me to the bathroom with no problem so I don't understand why they can't take me during the night too. On 1/20/23 at 9:52 AM, V18 (R1's daughter) stated, My Mom has told me about the statement that the aide said to her the other night about being too fat for an incontinence brief. I'm ashamed for that person and they shouldn't be taking care of senior citizens if they feel they need to put them down like that. I don't know about her being told to go to the bathroom in her incontinence brief but my main concern for her is that she is taken to the bathroom when she needs to go and that she gets the right medications. On 1/20/23 at 10:32 AM, V14 (Registered Nurse) stated, It is a dignity issue if you tell a resident to be incontinent instead of taking them to the bathroom. That is wrong and no resident should ever be put through that. On 1/20/23 at 12:22 PM, V2 (Director of Nursing) stated, No resident should ever be told to be incontinent in their brief or be told they are too large for an incontinence brief to fit them. Those are dignity concerns and our staff have been trained to treat all residents with respect and dignity. The facility's policy titled, Resident Dignity dated 11/2018 showed, This facility will promote care for elders of the facility in a manner and an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality .All staff will exhibit respect for each resident at all times. Staff will speak respectfully to each resident.

Based on interview and record review the facility failed to ensure a resident's pain was managed in a timely manner. This failure resulted in R1 not receiving pain medication while experiencing severe pain for an extended period of time. This applies to 1 of 3 residents (R1) reviewed for Pain Management in a sample of 3. The findings include: R1's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was discharged from the facility on 10/20/22. R1's Progress Notes dated 10/7/22 at 5:05 PM state, Patient arrived at facility via wheelchair and admitted to (5000 wing). All vitals taken. Patient alert and oriented x 4 with complaint of pain in buttocks. Patient requesting [MEDICATION(S)] when scheduled at 4:00PM. Script faxed by (V7- Admissions) for stat delivery . R1's Progress notes dated 10/8/22 at 1:13 PM (20 hours after admission) state, Awaiting [MEDICATION(S)] ([MEDICATION(S)]/Acetaminophen) medication from pharmacy, resident in extreme pain. Script not sent, sending it now, pharmacy said it will be on the PM med drop off. R1's Occupational Evaluation and Plan of Treatment dated 10/8/22 states, Patient reports 9/10 pain to right glute. R1's Physical Therapy Evaluation and Plan of Treatment dated 10/8/22 states, Pain Intensity= 8/10; Frequency = Constant; Location=Right Buttocks 8/10, Left Pelvis 3/10; Palpation Assessment= Tender to touch. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This document also shows that the first dose of this medication was given on 10/9/22 at 6:02 AM (37 hours after admission) and R1's pain level was recorded as a 10 and a second dose was given at 10:39 AM and her pain was again recorded as a 10. On 10/25/22 at 12:00 PM V7 (Admissions) stated, [MEDICATION(S)] is not in our CubeX (Emergency medication supply)- I was with her when she came in and she said she was in pain. I told her I am going to fax your order to the pharmacy right now because there is a 4 hour window before they deliver. It did not come the same day. I don't know when it was delivered. On 10/25/22 at 12:30 PM V9 (Pharmacy Representative) stated, The first and only time we sent out the medication was on 10/9/22. We received a script dated 10/6 and a script dated 10/8 but we received both of them on 10/9 and the medication was sent out at that time. On 10/25/22 at 2:30 PM V11 (LPN) stated, I came in at 11:00 PM the night before (10/8/22). (R1) was very upset and was mad because she said she had been in pain all day. I told her I would call the pharmacy and do whatever I could to get her the medication that she needed. She was complaining all night and the medication finally came about 6:00 AM so I gave her one right away. Then I gave her one a little later. She was better by the time I left that day. On 10/25/22 at 12:15 PM V2 (Director of Nursing) stated, If pain meds are not available, we would need to get a script from the doctor and then fax it to the pharmacy. If we didn't get the med from the pharmacy- we would offer the patient Tylenol. We have emergency medication- but only [MEDICATION(S)] and Tramadal. So we could offer Tylenol and try non-pharmocological measures to relieve pain. Yes we could call the doctor and try to change the medication. If the doctor changes the order to [MEDICATION(S)] then we can use [MEDICATION(S)] from the CubeX. I wasn't aware of the pain medication needed at that time- very rarely do we get a [MEDICATION(S)] order. On 10/25/22 at 2:20 PM V3 (Social Worker) stated, R1's family did not bring concerns to me and I followed up with (R1). She had concerns about her medication and some dietary concerns but said they were from admission.(R1) was perseverating on the pain medication issue- we had an IDT meeting about that. Her main goals when she discharged was that she had her pain medications available. She really talked about how much pain she had been in and how she really needed her pain medication. The facility policy entitled Pain Management dated 4/2020 states, The goal is to facilitate resident independence, promote comfort and preserve resident dignity.

Based on observation, interview, and record review, the facility failed to follow recommended guidelines from Centers for Disease Control (CDC) by not wearing appropriate Personal Protective Equipment (PPE) when caring for residents exposed to known staff members' positive for COVID-19 and new admissions on transmission based precautions (contact/droplet precautions). The facility also failed to have appropriate signage up for residents that are on transmission based precautions (contact/droplet precautions). These failures have the potential to infect high risk residents with COVID-19 and spread COVID-19 to negative residents. This has the potential to affect all 123 residents residing in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on April 15, 2021 when the facility did not have the appropriate CDC recommended PPE in place for staff taking care of residents after the residents were exposed to a known COVID-19 positive staff member. The Immediate Jeopardy was identified on April 26, 2021. V1 Administrator was informed of the Immediate Jeopardy on April 27, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on April 27, 2021; however noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The isolation list provided by the facility on April 27, 2021 shows, all of 4000 unit, 5000 unit, 7000 unit, and 8000 unit/hallways are on contact/droplet isolation for COVID-19 exposure. The facility's vaccinated staff and residents as of April 26, 2021 shows, staff: 56.95%; residents: 71%. On April 26, 2021, at 9:33 AM, R10 (7000 unit/hallway) stated, the whole hallway was on quarantine for COVID-19 exposure. There was no sign on his door or any other resident's door stating the unit (7000 and 8000 units/hallways) were on any type of isolation/transmission based precautions. The doors to the 7000 unit (divides them from the 6000 unit) were closed. There were no signs on the doors to state that the unit was on any type of isolation/transmission based precautions. On April 26, 2021, at 9:36 AM, V6 Licensed Practical Nurse (LPN) for the 7000 unit/hallway stated, both hallways (7000 and 8000 units/hallways) were on quarantine because they were exposed to a positive staff member. She stated, they do not wear gowns because no one is positive on the units (7000 & 8000 unit/hallways). On April 26, 2021, at 9:33 AM, V5 Registered Nurse (RN) for the 8000 unit/hallway, was passing medications to the residents residing on the 8000 unit. He was going in and out of resident rooms, not wearing a gown or gloves. He also was wearing a surgical face mask under an N95 face mask. On April 26, 2021, at 9:47 AM, V7 Certified Nursing Assistant (CNA) was in R14's (8000 unit/hallway) room. She was not wearing a gown or gloves. When she came out of the room she stated, the residents were on quarantine because a student who comes here and provides direct care from nursing school was tested positive for COVID-19. They have been on quarantine for a week now. She stated, they only have to wear a gown if they are providing direct patient care. On April 26, 2021, at 9:56 AM, V8 CNA was in R64 and R55's room (7000 unit/hallway). She was not wearing a gown or gloves. On April 26, 2021, at 9:57 AM, V9 housekeeper, was cleaning R103 and R58's room (7000 unit/hallway). She was wearing a surgical mask and face shield. She did not have on an N95 mask, gown, or gloves. When she was done cleaning R103 and R58's room she went to R25 and R75's room to clean. She did not put on a gown or gloves to go into their room. At 10:42 AM, she was in R11 and R44's room (7000 unit/hallway), cleaning. She did not have on a gown or gloves. She stated, she cleans 6000 unit (not on quarantine/transmission based precautions), 7000 unit, and half of 8000 unit during her shift. The other housekeeper who cleans the memory care unit (not on quarantine/transmission based precautions) does the other half of the 8000 unit. She stated, that she was only wearing a surgical mask because they told her she didn't need an N95 face masks. She wasn't close enough to the residents (just cleaning their rooms). She also stated, she does not wear a gown because their doors do not have a sign on them showing that she needs to wear one. If the room had a sign on it, I would wear a gown. On April 26, 2021, at 9:57 AM, V4 Infection Control Nurse stated, the 7000 and 8000 unit/hallway was on quarantine for being exposed on April 15, 2021 to a nursing student that tested positive for COVID-19. The 4000 and 5000 unit/hallway (New admission/PUI (persons under investigated)) unit is also on quarantine because they were exposed to a positive staff member who test positive for COVID-19 on April 22, 2021. The new admission/PUI unit (4000 & 5000 units/hallway) was/is already on contact/droplet isolation because of the guidelines for COVID-19 so they just continued with that until their exposure date is up (14 days past exposure). She also stated, there are signs on the doors on the 4000/5000 unit, alerting staff to isolation precautions. On the 7000/8000 unit, she stated, the staff just know they are on quarantine. She was the person that is supposed to put the signs up. She hadn't put any signs up on the 7000/8000 unit/hallway. She also stated, that all staff should be wearing N95 face masks, face shields, gowns, and gloves because we don't know if they are infected or not. On April 26, 2021, at 10:11 AM, the 5000 unit/hallway resident rooms did not have any signage on the doors saying they are on contact/droplet isolation. On April 26, 2021, at 10:12 AM, V12 housekeeper, was cleaning R46's (on 4000 unit/hallway) room. She was wearing 2 surgical masks. She was not wearing an N95 face mask. She stated, she was not given an N95 face mask to wear. She also stated, she cleans all of the rooms on the 4000 and 5000 unit/hallway. On April 26, 2021, at 11:01 AM, V10 laundry aide was delivering laundry to the residents on the 7000 unit/hallway. She was walking in and out of rooms without a gown or gloves on. She was wearing a surgical face mask. She was not wearing an N95 face mask. She stated, she delivers laundry to all of the residents in the facility. On April 26, 2021, at 11:04 AM, V11 Restorative CNA came out of a resident room on the 7000 unit/hallway. She stated, she works in restorative but if they are short on the floor, they pull her from restorative and she works the floor. She works wherever they need her too. Last week she worked on 7000 unit/hallway and on the memory care unit. She also stated, they don't wear anything in the resident's room on the 7000 or 8000 unit/hallway, just their face masks and face shields. On April 26, 2021, at 11:09 AM, V13 Social Worker, was in R103's room (7000 unit/hallway) helping him with some of his stuff. She was looking through CD's and talking with the resident. She was wearing a surgical mask and face shield. She did not have on a gown, gloves, or N95 face mask. She stated, she is the social worker for the 6000, 7000, & 8000 unit/hallways. On April 26, 2021, at 12:50 PM, V3 Nurse Liaison stated, that residents on quarantine (7000 & 8000 unit/hallway) are on contact/droplet precautions for being exposed to a nursing student. The residents on 4000 and 5000 unit/hallway are also on quarantine in addition to their isolation precautions for being new admits. All staff should be wearing full PPE (gown, gloves, N95 face masks, and face shields). On April 27, 2021, at 8:58 AM, V1 Administrator stated, they have not had any problems with PPE. We have been fortunate with PPE. The CDC's Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination last updated on March 10, 2021 shows, 2. Work restriction for asymptomatic healthcare personnel and quarantine for asymptomatic patients and residents. The following recommendations are based on what is known about currently available COVID-19 vaccines. These recommendations will be updated as additional information, including regarding the ability of currently authorized vaccines to protect against infection with novel variants and the effectiveness of additional authorized vaccines, becomes available. This could result in additional circumstances when work restrictions for fully vaccinated HCP are recommended . Fully vaccinated inpatients and residents in healthcare settings should continue to quarantine following prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with [CONDITION(S)]-CoV-2 infection; outpatients should be cared for using recommended Transmission-Based Precautions. This is due to limited information about vaccine effectiveness in this population, the higher risk of severe disease and death, and challenges with physical distancing in healthcare settings. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The facility's reopening plan dated March 22, 2021 shows, 8. Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene). The same policy does not address the transmission based precautions/isolation precautions for COVID-19. The facility's care of a resident with COVID-19 policy dated July 17, 2020 shows, 2. If you have a suspected resident or resident become positive with COVID-19: .ensure signage is posted for droplet precautions . 6. PPE: .For non COVID units with exposed residents: Required PPE: surgical masks unless N95 warranted, gloves, prioritization, eye protection (face shield or goggles) for the care of all patients/residents. The facility's droplet isolation policy dated April 20, 2020 shows, Standard: Droplet transmission involves contact with an infectious organism of the conjunctiva, or mucous membranes of the nose or mouth. Droplets are generated from the source during coughing, sneezing or talking and during such procedures as suctioning. Transmission requires close contact between source and recipient, as droplets do not remain suspended in the air and generally travel short distances, 6 feet or less . Procedure: 2. Gloves and handwashing, 3. Mask, 4. Goggles, 5. Gowns . The Resident Census and Condition of Residents, CMS (Centers for Medicare and Medicaid) Form 672, for the facility shows there are 123 residents residing in the facility. The Immediate Jeopardy that began on April 15, 2021 was removed on April 27, 2021 when the facility took the following actions to remove the immediacy. 1. Appropriate signage has been placed on the doors of residents that are on transmission-based precautions as of 4/26/21. 2. Facility staff will follow CDC recommendations for PPE utilization including gowns and N95 masks when caring for residents exposed to a known staff member with COVID-19 and new admissions on transmission-based precautions as of 4/26/21. 3. Random audits will be conducted weekly for one month to ensure compliance with CDC recommendations for PPE utilization. 4. All facility staff will be re-educated by the DCSS (Director of Clinical Safety Services), ADCSS (Assistant Director of Clinical Safety Services), and ICP (Infection Control Preventionist) on the CDC requirements for PPE utilization before returning to work by 4/27/21. 5. The DON & Administrator will evaluate audits weekly for negative trends and address one on one with identified staff. 6. Findings will be reported to the QA Committee for review on an ongoing basis until resolution.

Based on interview and record review the facility failed to ensure a resident at risk for falls, with recent falls, was adequately supervised and failed to ensure additional fall risk interventions were implemented to prevent further falls. This failure resulted in a resident (R2) continuing to have falls and receiving lacerations to the head requiring emergency room treatment and staples. This applies to 1 of 3 residents reviewed for safety supervision in the sample of 6. Findings include: R2's face sheet shows the admitted to the facility was 3/13/2016. R2's [DIAGNOSES REDACTED]. R2's 8/17/2020 facility assessment shows that she has a severe cognitive impairment, requires the use of a wheelchair, is not able to walk, and needs extensive assistance from staff for transfers, bed mobility, and toileting. On 8/24/2020 at 9:30 AM, V6 (Certified Nursing Assistant/CNA) said that R2 has had several recent falls. V6 said, We try to get residents who are fall risks up and not have them in their room. On 8/24/at 10:00 AM, V5 (Memory Care Director) said that R2 has had several recent falls and one resulted in staples to her head. When asked why R2 has not been moved closer to the nursing station, V5 replied that those rooms have males in them closer to the nursing station. On 8/24/2020 at 10:05 AM, R2 was observed in the hallway of the memory care unit outside of her room. R2's room is approximately 3/4 of the way down the hallway. It is not closest to the nursing station or day room area. There are 5 rooms in between. She is also the second bed in the room and is by the window, not the doorway. The hallway R2's room is on is not the main entrance to the unit and there would be less staff coming and going from the hallway where R2's room is located. R2's incident report investigation dated 5/22/2020 and completed by V1 (Administrator) shows that on 5/18/2020, R2 was found on the floor of her room. Upon nursing assessment, a laceration was noted to the top of her head. An order was received from her physician to send her to the emergency room . She returned to the facility with sutures in her head. R2's incident report dated 7/24/2020 at 4:40 PM, states that R2 was observed on the floor in her bathroom, noted [MEDICAL CONDITION] and moderate bleeding from head wound, cleansed, wrapped around and ambulance called. The same report shows that she also sustained a skin tear to her right elbow. R2's nursing progress fall incident progress note dated 7/25/2020 at 12:16 AM, states only [MEDICAL CONDITION], 7 staples on head. R2's final incident report investigation dated 7/31/2020 completed by V1 shows that R2 was observed on 7/24/2020 seated on the floor in the bathroom. She had a laceration to her head and was sent to a local ER for treatment. She returned with 7 staples to her head. R2's incident report completed by V3 (Registered Nurse/RN) and dated 7/27/2020 at 11:20 PM, shows that R2 had a laceration to her forehead that is about an inch long. R2's incident progress notes completed by V3 at 11:31 PM, states, According to CNA resident bumped head on the cart from the kitchen causing a laceration. On 8/24/2020 at 1:14 PM, V3 when asked by this surveyor about the incident on 7/27/2020 indicating that R2 ran into a kitchen cart, when asked how that would happen, V3 said, That's just what the CNA told me happened. V3 additionally said she is not sure what has been done for R2 to prevent falls. R2's incident report completed by V8 (RN) dated 8/11/2020 at 9:55 PM, states, Heard resident {R2} yelling for help found sitting on floor holding head bleeding right upper forehead once cleaned bleeding stopped and md called await response cleaned with sterile technique and steri strips applied. The same document shows that R2's physician (V9) gave an order to send her to the (ER). R2's fall incident progress note timed for 10:15 AM (an error in the entry) shows that she was sent to the ER at 11:00 PM. R2's nurses note dated 8/12/2020 4:10 AM, shows that she returned from the emergency room with an open area on her forehead. R2's incident report completed by V8 (RN) dated 8/13/2020 at 4:29 PM, states, Someone from the kitchen saw resident sitting on the floor in room alerted director who brought her to me. no bumps lumps or bruises or bleeding noted to head but small abrasion to right elbow was noted. R2's Orders-General Note from eRecord progress note completed by V8 and timed for 5:24 PM, states, This writer spoke with md informed we are getting ua cs but he wants further ways of maintaining safety he wants DON to call him. Information relayed to DON to call MD on 8-13. The same note shows that the resident was currently at the nursing station for 1:1. On 8/24/2020 at 12:57 PM, V8 said that when she spoke with V9 about R2's falls V9 told her something has to be done about R2 falling. V8 said that he indicated to her as stated above that he wants a call from the DON about all these falls and how to keep R2 safe. V8 said she relayed that message to V2. V8 said that all the staff have discussed their concerns about R2 falling and have given other suggestions such as a helmet and keeping her out of her room more. On 8/25/2020 at 10:20 AM, V9 stated, I am gravely concerned about all the falls R2 is having; these falls need to stop. Any one of these could be life threatening situations. V9 also said he has called and expressed his concerns with V2 and spoken with V5 about it as well. V9 said he gave an order for [REDACTED]. V9 said that he has indicated that more supervision is needed, maybe even a 1:1 staff, as well as some sort of protective device helmet. V9 also said to this surveyor Are you aware she had yet another fall last night and is in the emergency room again? Every time she falls and hits her head, she has to be sent out to rule out a brain bleed. R2 is a very fragile resident and I think she also needs some sort of helmet. R2's incident report dated 8/25/2020 at 12:27 AM, states, found resident in the hallway outside her room w blood on her forehead. Found 2 cuts measuring 1x1 and the other is 1x2. R2's nurses note dated 8/25/2020 at 9:39 AM, shows that R2 was transferred to a local ER by ambulance at 8:30 AM. The next nursing note on 8/25/2020 at 2:44 PM, shows that R2 returned from the ER at 12:30 PM with steri strips to her [MEDICAL CONDITION]. On 8/25/2020 at 2:10 PM, V10 (R2's Power of Attorney) said that she is very concerned with all the recent falls R2 is having. V10 also said the behavior with R2 scooting on the floor is not new; it has been happening for a long time. V10 said that the falls are getting worse, not better and the only additional thing they tell her they are doing is physical therapy and she does not know how that will help with the falls. V10 said, I got very little explanation on how R2 would have hit her head on a food cart in the dining area. In my head I am thinking if she has fallen this much there should be more interventions in place. V10 said when these falls happen, R2 is hitting her head each time. V10 said she had spoken with V9 earlier in the day and he told her he was concerned about the falls also. V10 stated, I keep waiting for the call that she has hit her head again and this is it. On 8/25/2020 at 11:00 AM, V1 confirmed that R2 fell again during the night and was currently in the ER. V1 said that R2 has the history of scooting herself on the floor. When asked why she had not been moved closer to the nursing station V1 said, As we discussed yesterday, due to the bed availability and isolation we could not move her sooner. When asked if they had increased staffing to help monitor R2, V1 stated, We feel the unit is appropriately staffed. On 8/25/2020 at 11:05 AM, V2 said that she had spoken with V9 about his concerns with R2 falling. V2 said, We cannot do 1:1's, or alarms because it is a restraint. We are encouraging 15-minute checks for R2 if doable. These checks are not documented anywhere in the medical record. V2 additionally said that R2 had fallen again last night. She was found on her floor scooting out of her room into the hallway. R2's care plan shows that she is at risk for falls. The care plan provided by the facility shows that the only recent intervention added was on 8/12/2020 and that intervention is to assist back to bed after meals. A care plan with a detailed intervention list showing dates all interventions were added was requested on 8/25/2020 via phone conference with V1 and V2 and not received during this investigation. R2's current physician's orders [REDACTED].

Based on interview and record review, the facility failed to provide necessary care and services by not ensuring recommended swallowing precautions were implemented for a resident who is at risk for aspiration. This failure resulted in R1 choking on meat in R1's room and expiring on (MONTH) 6, (YEAR). This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: The facility's Final Incident Investigation Report dated (MONTH) 13, (YEAR) shows on (MONTH) 6, (YEAR) R1 experienced a choking episode. R1 was eating in his room with his roommate. R1 was alert and oriented, on a general diet and had no swallowing precautions. Nursing staff was alerted that resident was having a choking episode and responded and performed the [MEDICATION NAME] maneuver. Upon the third thrust a food particle was expelled. R1 then lost consciousness and CPR (Cardio [MEDICAL CONDITION] Resuscitation) was initiated and 911 called. CPR continued by paramedics as R1 was transferred out of the facility. Per the local hospital R1 expired. The Physician order [REDACTED]. POS shows R1 is on a low concentrated sweet diet. The Minimum Data Set assessment dated (MONTH) 26, (YEAR) shows R1 requires setup during meals and has no swallowing disorders. R1's Speech Evaluation by V12 (Speech Therapist) dated (MONTH) 14, (YEAR) shows R1 at risk for Aspiration related to physical impairments and functional deficits. The same report showed R1 demonstrates Mild Oral Phargenal Dysphagia (a condition that weakens your throat muscles, making it difficult to move food from your mouth into your throat and into your esophagus when swallowing. You may choke, gag or cough when you try to swallow. Neurologic disorders can cause this disorder). R1 is recommended to have occasional supervision, sit upright, and eat slow during meals. V12 identifies R1 has behaviors impacting safety including impulsiveness and complaints of odynophagia (painful swallowing). The facility did not provide evidence of a later speech screening or evaluation for R1 after (MONTH) 14, (YEAR). R1's Speech Evaluation report dated (MONTH) 14, (YEAR) showed it was faxed to V15 (Physician) on (MONTH) 19, (YEAR). The same report showed it was signed by V15 on (MONTH) 19, (YEAR) and faxed back to the facility on (MONTH) 20, (YEAR). (The POS dated through (MONTH) showed the swallowing recommendations were not on the POS.) R1's menu card dated (MONTH) 6, (YEAR) shows for the dinner meal he was served included BBQ Pork, rice, stewed tomatoes, and a fruit cup. The nurse's notes for (MONTH) (YEAR) showed R1 took his medications with applesauce. R1's Care Plan dated through (MONTH) (YEAR) shows R1 has self care deficit related to [MEDICAL CONDITION], fatigue, impaired balance, limited mobility. R1 requires extensive assist with most activities of daily living. Feeds self after set up. R1's care plan interventions were last revised on (MONTH) 31, (YEAR). R1's care plan does not include R1 is at risk for aspiration or include V12's recommendations for R1 to have supervision and cueing to eat slowly during meals. R1's Care Plan dated (MONTH) (YEAR) shows his preference's include choosing his own clothing, choosing his bedtime, having snacks available, taking a shower, caring for personal belongings, using phone in private, and having a place to lock up items. R1's care plan does not show a preference that R1 prefers to eat in his room. On (MONTH) 22, (YEAR) at 4:00 PM, V16 (Physician) said he was not surprised (R1) choked. R1 had a [DIAGNOSES REDACTED]. Their swallowing abilities are progressive as they age. V16 said he would expect staff to follow the speech recommendations. On (MONTH) 15, (YEAR) at 11:00 AM, V4 (resigned CNA) said she was R1's CNA on (MONTH) 6, (YEAR). R1 was served BBQ pork. V4 said she opened R1's milk and cut up his pork and left the room. V4 said R1 always ate his meals in his room, but she did not know why. V4 said she did not cue or observe R1 during meals. V4 said she heard a yell on (MONTH) 6, (YEAR) and went to R1's room. V3 (RN) was performing the [MEDICATION NAME] maneuver. V4 said, R1 looked at me with eyes 'to help me.' V4 said she performed the [MEDICATION NAME] maneuver too. V4 said V3 continued with the [MEDICATION NAME] maneuver and a piece of meat was expelled. V4 said it didn't seem like it all came out; R1 was still choking. V3 told her to call 911. V4 said she called 911 and did not return to R1's room. On (MONTH) 14, (YEAR) at 10:00 AM, V3 (RN) said she was R1's nurse on (MONTH) 6, (YEAR). V3 said R1 was eating dinner in his room. She heard R5 (R1's roommate) scream R1's choking. V3 said at 5:48 PM she entered R1's room it was obvious he was choking. R1 was sitting in R1's wheelchair with his hands gripped to the wheelchair arms gasping for air. V5 said V5 performed the [MEDICATION NAME] maneuver on R1 with the third thrust a piece of pork was expelled. V5 said R1 was still choking after the piece of pork was expelled. V5 said V4 (Certified Nursing Assistant) performed the [MEDICATION NAME] maneuver on R1, but was unsuccessful. V3 said R1 would always eat in his room, was not a risk for aspiration, and did not have any swallowing problems. V3 said she was not sure why R1 would eat in his room. V3 said maybe because he had some dexterity issues related to his [MEDICAL CONDITION]. On (MONTH) 15, (YEAR) at 1:05 PM, V14 (Visitor) said on (MONTH) 6, (YEAR) she was visiting her mom at the facility during dinner. V14 said she heard someone screaming and she saw V3 (Registered Nurse-RN) running down the hall. V14 said she entered R1's room and V3 was performing the [MEDICATION NAME] maneuver on R1. R1 was not breathing and looking lifeless. On (MONTH) 14, (YEAR) at 11:20 AM, R5 (R1's roommate) said he had been R1's roommate for about 3 weeks. R1 would eat in the room during meals. R5 said on (MONTH) 6, (YEAR) during the dinner meal R1 started choking. R5 said he yelled out for staff. Staff came performed the [MEDICATION NAME] maneuver and a piece of meat came out. Staff performed CPR on the floor then the paramedics arrived. On (MONTH) 14, (YEAR) at 9:15 AM, V7 (CNA) said R1 would eat in his room. R1 needed help cutting up his food. On (MONTH) 14, (YEAR) at 8:55 AM, V8 (CNA) said R1 would eat in his room. R1 was impulsive; staff had to remind him to use his call light for assistance. R1 did not follow direction well. R1 had to be reminded repeatedly not to get up without assistance. V8 said she had not observed R1 during meals. On (MONTH) 14, (YEAR) at 9:00 AM, V9 (CNA) said R1 was alert but needed frequent reminders not to get up by himself. Staff would have to remind R1 all the time. R1 needed staff to cut up his food. V9 said she did not supervise R1 or cue him during meals. V9 said she did have to remind R1 to slow down when drinking liquids. V9 said R1 had a poor appetite. I guess he did have problems swallowing. Maybe that's why R1 did not eat much. V9 said she was not sure why R1 ate in his room; she thought maybe because he was a messy eater. On (MONTH) 14, (YEAR) at 1:10 PM, V13 (Speech Therapist) said she did not perform R1's speech evaluation on (MONTH) (YEAR). V13 said she had not assessed R1 yet for any swallowing problems. V13 said she started in (MONTH) (YEAR) and had not screened R1 for any swallowing problems. V13 was asked what occasional supervision means recommended by V12 (former speech therapist). V13 said occasional supervision is not a routine recommendation, residents either need supervision or not. V13 confirmed the speech evaluation recommended cueing and eat slowly. V13 said maybe R1 was impulsive. She said she would expect staff to remind R1 to eat slowly during each meal. V13 said the same report showed R1 had a [DIAGNOSES REDACTED]. R1 was at risk for Aspiration with swallowing precautions including supervision, sit upright, cueing to eat slow during meals and lots of care giver education. V13 said these should be in R1's care plan. The EMS report on (MONTH) 6, (YEAR) showed the call was dispatched at 5:50 PM. On the way to the call dispatch was notified R1 was now having CPR. On arrival to the scene at 6:02 PM, R1 was on the floor, non responsive and blue. R1 was transported to the local hospital. The Hospital Records dated (MONTH) 6, (YEAR) showed at 6:27 PM, a large foreign body 5x4 cm (centimeters) of undigested food was removed from R1's trachea by the physician. The same report showed R1 was pronounced dead at 6:35 PM. The facility's Aspiration Precautions Policy dated (MONTH) (YEAR) states, Aspiration precautions are determined by the Speech Therapist and Provider Speech therapy will determine the aspiration precautions that are necessary for the guest, in collaboration with the provider .Notify Provider with swallowing concerns .

Based on interview and record review the facility failed to assess a resident's left leg deformity and increased pain following a fall on July 25, 2017. This failure contributed to R1 experiencing untreated pain and a delay in treatment for 2 days for a fractured left femur. This applies to 1 of 24 residents (R14) reviewed for necessary care and services in the sample of 24. The findings include: R14's Physician order [REDACTED]. R14's Minimum Data Set assessment dated [DATE] shows R14's cognition is severely impaired. R14 is always incontinent of bowel and bladder and she is dependent on staff for hygiene. On October 31, 2017 at 9:07 AM E28 (RN) Registered Nurse/wound care, E10 (CNA) Certified Nursing Assistant and E12 CNA were rolling R14 from side to side in the bed to apply an incontinence brief. R14 was screaming loudly. A fresh incision was noted on R14's left hip. There was no dressing covering the incision. The Resident/Accident Report dated July 25, 2017 at 7:55 PM shows R14 fell from her wheelchair on her left side in the solarium. The report shows R14 can move all her extremities and has no apparent injury. R14 is unable to verbalize what happened. R14 was lifted using a mechanical lift back in her wheelchair. R14's follow up care includes neuro-checks. On November 1, 2017 at 11:45 AM, E4 (Memory Care Director) said on July 27, 2017 E26 (Certified Nursing Assistant) reported to her R14 was having pain and something was not right. E4 said R14's left leg looked crooked and R14 was verbalizing pain and grimacing. E4 said nursing did not report to her R14's condition. E4 said she then notified Z1 (physician) of R14's pain. Z1 was on the unit at this time. Z1 ordered an x-ray and showed R14 had a left [MEDICAL CONDITION]. On November 6, 2017 at 11:30 AM, E11 (CNA) said she cared for R14 on July 27, 2017 during the day shift. E11said the night shift staff had transferred R14 into her wheelchair. E11 said sometime after breakfast she tried to provide care to R14. Anytime R14 was repositioned she started screaming. E11 said she reported this to E25 (Registered Nurse). E11 said she did not know why R14 was screaming; she said someone told her she fell a couple days ago. E11 said she tried to transfer R14 back into bed using a mechanical stand lift but it did not work. E11 said she was scared. E14 was screaming. On November 6, 2017 at 11:52 AM, E25 (RN) said she cared for R14 on July 27, 2017 during the day shift. E25 said a CNA told her R14 was having a lot of pain before lunch time. E25 said R14 was in the wheelchair at this time and when she moved R14's left leg she would scream. E25 said she did not know R14 had a fall two days prior. E25 said if a resident falls, routine vitals and neurocheck assessments are done for 72 hours. E25 said she did not assess R14's left leg or perform a skin assessment to her left side. E25 said if she was aware of the fall she would have performed an assessment to the injured area. On November 1, 2017 at 10:40 AM, E2 (Director of Nursing) said staff should monitor a resident's neurochecks following a fall. No additional assessments are needed for a resident with no injury. On November 1, 2017 at 1:15 PM, E27 (RN) said following a fall, nursing should perform a head-to-toe assessment of a resident for 72 hours to monitor for injury. On November 6, 2017 at 11:45 AM E26 (CNA) said she could not recall the incident with R14. On November 6, 2017 at 10:38 AM E24 (RN) said he cared for R14 on July 26, 2017 during the night shift. E24 said if a resident falls nursing should perform neuro check assessments for 72 hours. E24 said if the CNA does not report any changes to him, he would not do a head to toe assessment on a resident. E24 said he did not remember any changes with R14 during his shift. Z1's physician progress notes [REDACTED]. Reported that no injury by staff. R14 today is sleepy and seems in pain. R14 is moaning when the left hip is moved. R14 is very tense and anxious. Will check X-ray, pain meds and discussed with E4. R14's Physician order [REDACTED]. The P.O.S. shows R14 did not receive pain medication on July 25-27th 2017. E4, E11, E25 and Z2 reported R14 was screaming and moaning of pain on July 27, 2017. The Nurse's notes on July 26, 2017 at 5:00 AM shows R14 denied any pain or discomfort. R14 was on neuro check assessments. The Nurse's notes on July 26, 2017 at 1:30 PM, shows Z1 was informed of R14's fall with no injury. The Nurse's notes On July 27, 2017 at 5:00 PM, shows R14 slept well through the shift. R14 denies any pain or discomfort. The nurse's notes from July 26, to July 27, 2017 show no documentation of assessment or monitoring of R14's left extremity. Radiology Report dated July 27, 2017 at 7:47 PM, shows R14 has a left femoral fracture with modest angulation and displacement

Based on observation, interview and record review, the facility failed to 1) ensure a resident identified with aggressive behavior and history of hitting other residents and staff is supervised. This failure resulted in R2 assaulting a resident (R1) who sustained a black eye and bilateral nasal bone fractures. The facility also failed to 2) implement fall interventions, revise specific interventions to prevent further falls and failed to monitor and supervise a resident. As a result of this failure, R4 sustained a small laceration on top of the head from the fall on 2/14/2015 and re-fractured her right shoulder, sustained facial/periorbital swelling and right black eye after a fall on 2/28/15. This applies to one of three residents (R4) reviewed for falls and one of three residents (R2) reviewed for incidents of aggressive behavior. The findings include: 1. R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's care plan initiated on 02/28/15 showed R2 was admitted from the hospital with [DIAGNOSES REDACTED]. R2 was hospitalized for [REDACTED]. Prior to hospitalization , R2 lived in a Senior Living facility where he attacked another resident after being agitated. This care plan did not provide how the facility would monitor behavior to prevent incidents with other residents. R2's care plan dated 02/26/15 stated Resident non compliant at times, can become physically aggressive with staff without warning. This care plan did not have a measurable goal and the facility did not provide interventions as to how they would monitor R2's behavior to prevent aggressive behavior. R2's care plan initiated 03/12/15 identified Problematic manner in which R2 acts by ineffective coping; verbal/physical aggression, striking out others, kicking and hitting related to: Cognitive impairments/physical changes in brain due to [DIAGNOSES REDACTED]. This care plan did not have any intervention to indicate how the facility would monitor R2's aggressive behavior. R2's nurse's note dated 02/26/15 showed While doing last rounds on resident, resident kicked CNA (Certified Nursing Assistant) on the chin. Supervisor made aware and talked to resident. A nurse's notes dated 02/27/15, combative and hit CNA while clothing changed. On 3/1/15 at 06:30 nurse's notes showed R2 continued to become physical with staff during care. Nurse's notes dated 03/7/15 (5 PM) showed documentation R2 was swinging/hitting staff. R2's incident report dated 5/11/15 showed R2 went inside R1's room and hit R1 on the face and head. R2 was sent out to the hospital for behavior evaluation and treatment. The facility cannot provide any evidence including documentation this incident was investigated. R1's nurse's note dated 05/11/15 showed R2 went into R1's room and when R1 asked R2 to leave, R2 started pounding on her (R1). R1 was assessed with [REDACTED]. R1 was sent to the hospital where she was diagnosed with [REDACTED]. Further review of R2's nurses' notes and care plan did not show any monitoring or supervision of the resident leading to the incident. Incident report dated 3/13/15 at 10:15 AM, showed R2 struck E18 in the forehead and E18's neck snapped back while giving care. On 5/20/15 at 12:50 PM, R1 was observed sitting in the bed. R1 had bruises on the face, nose and scratches on the left side of her neck. R1 stated in the morning of 5/11/15 while she was standing near the sink inside her room, a resident came running inside her room from the hallway, yelling, This is my room, and started beating her on the face and head. Per R1 she started yelling for help, staff came to her room and took R2 away. On 06/02/15 at 1:25 PM, E8 (Nurse) stated she did not see the incident happen, but E9 (Housekeeper who no longer works in the facility) told her (E8) R1 and R2 were fighting. E8 said when she got to R1's room, R2 was leaving the room so she attended to R1 who was bruised. R2's physician progress notes [REDACTED]. 2. R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility incident reports indicate that R4 had fallen 10 times for the period of 4 months from 01/10/15 to 05/09/15 as follows: - On 1/10/15 (2:18 PM), R4 was observed on the floor next to toilet in the hall bathroom. New intervention was to offer toileting upon rising, before meals/after meals, bedtime, PRN (as needed), keep in common areas. Corrective action taken immediately: Reinforced safety awareness - On 1/20/15 (1:30 PM), R4 was observed on the floor next to toilet. New Intervention was to try and keep in common areas and 3 day bowel and bladder, always incontinent of Bowel and Bladder. Corrective action taken immediately: Resident was told to always use the call light and call for staff assistance. - On 2/13/15 (9:00 PM), R4 was observed on the bathroom floor. New intervention was to follow fall protocol. - On 2/14/15 (5:45 PM), R4 was observed sitting on the floor next to his wheel chair in his room. R4 had a small skin tear on right elbow and superficial laceration on top of R4's head. New intervention: Place belongings within reach. Corrective action taken immediately: Seat belt locked and put at table. - On 2/10/15 (9:00 PM), R4 was observed slipped from wheel chair to pick up something off the floor. New intervention: Non skid material in wheel chair and keep environment picked up. - On 2/25/15 (8:30 PM), R4 slid on the floor in his room. New intervention: Keep in common areas, Non skid material in wheel chair. - On 2/28/15 (9:55 PM), R4 was observed on the bathroom floor wedged between toilet and wall laying on right side. R4 had small abrasion on right elbow and complained of pain on right shoulder. R4 was sent to the hospital emergency room for evaluation. R4 came back to facility with a right arm sling and was diagnosed with [REDACTED]. R4 also had facial/periorbital swelling and right black eye. - On 4/05/15 (3:05 PM), R4 was found on the floor next to low bed on floor mat. New intervention: Continue current intervention. - On 4/20/15 (12:35 PM), R4 was found on the floor next to low bed. New intervention: continue current intervention. Cause/probable cause: Resident did not call for staff assistance or use the call light. Intervention to be implemented: Resident advised to always use the call light and to call for staff assistance. - On 05/08/15 (10:55 AM), R4 was found in the bathroom floor in shower room. Per R4, he was trying to toilet himself. New intervention: continue current intervention. MDS (Minimum Data Set) dated 2/15/15 showed R4 had a BIMS ( Brief Interview for Mental Status ) score of 2, indicating that R4 had severe cognitive impairment. The same MDS showed R4 required extensive assistance with one person physical assist for toilet use and transfer. R4 was also coded as always incontinent with bowel and bladder functions. Review of current fall risk assessment dated [DATE] showed R4 is high risk for falls, has poor safety awareness and had [DIAGNOSES REDACTED]. As indicated above, R4 had cognitive impairment, confusion, language barrier and functional limitations. The current care plan showed no specific intervention how to monitor and supervise R4 to prevent further fall. As a result of this failure, R4 sustained a small laceration on top of the head from the fall on 2/14/2015 and re-fractured right shoulder, sustained facial/periorbital swelling and right black eye after a fall on 2/28/15. On 5/21/15 at 12:30 PM, R4 was observed up in wheel chair inside his room with wheel chair alarm disconnected. E10 (Nurse) and E11 (CAN/Certified Nursing Assistant were present during this observation. E10 stated R4 just came back from therapy and that the alarm should be connected at all times. E11 stated probably the PT (Physical Therapist) deactivated the alarm because it was disconnected. E11 further stated you have to push the reset button to stop the beeping and I did not remember it was beeping when found disconnected. On 5/21/15 at 12:45 PM, E12 (Physical Therapist) stated she brought R4 back to his room from therapy at 12:10 PM and connected the alarm before leaving R4 alone in his room. On 6/02/15 at 11:30 AM, R4 was observed up in wheel chair inside the therapy room. R4 was noted to be seating on layers of chair cushion, non-skid pad, wheel chair pad alarm and on top was a towel. The non skid pad was covered defeating its purpose of preventing R4 from slipping down. The facility did not follow R4's care plan intervention.

Based on interview and record review, the facility failed to ensure that a resident was not subjected to a mental and emotional abuse. This applies to one of three residents (R1) reviewed for abuse allegations. This failure resulted in R1 being forcibly removed from her room against her will and wheeled down the hall in shower chair covered only with a sheet. This failure also resulted in R1 feeling emotionally abused, embarrassed and violated. The findings include: The facility Preliminary 24-Hour Incident Investigation Report dated [DATE] showed that approximately two weeks ago, R1 was being readied for the shower by E5 (CNA - Certified Nursing Assistant). Both R1 and E5 were in the resident's room. According to R1, E5 took off her clothes and place her in the shower chair. E5 covered her with a sheet and began to take R1 out into the hallway to the shower room. R1 told E5, "I won't go out there like this." The CNA responded, "Yes you will." R1 stated that when E5 pushed the chair into the doorway, R1 put her hands onto the door jambs to prevent her from going through the door. R1 repeated, "I'm not going out there." E5 repeated, "Yes you are." E5 then forced the chair through the doorway against the resident's will. R1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's quarterly MDS (Minimum Data Set) dated [DATE] and [DATE] showed under Cognitive Patterns: BIMS (Brief Interview for Mental Status) score of 15 that indicates that R1 was alert and coherent and able to express herself. E3 (Director of Nursing) stated during Daily Status Report on [DATE] at 4:00 PM that R1 was alert, coherent and oriented. E3 also verified that R1's BIMS score was 15. E3 (Director Of Nursing) also stated that on [DATE], Z1(R1's family member) informed her that R1 felt mentally, emotionally abused and that her rights were violated when E5(Certified Nurse Assistant) had given shower to R1 on [DATE]. On [DATE] at 11:30 AM, R1 stated that few weeks ago, the CNA (E5) brought the shower chair to the room in preparation for R1's shower that afternoon. R1 said that E5 was upset about something and bad mouthing the administration. R1 stated that E5 placed her in the shower chair in spite of her protest that the shower seat was open and not covered. R1 also said that E5 did not listen to her questions and protest and continued to undress her, wrapped her body with a sheet. R1 stated that when E5 pushed the shower chair towards the door, she resisted by placing her hands on both door jambs to prevent from going through the door. R1 continued to protest but E5 did not listen and forced the shower chair through the door against R1's will. R1 said that she did not report the incident to anyone right away but called her POA (Power of Attorney). R1 told another CNA (E10) about what happened few days later. R1 also told E10 that she did not want E5 to take care of her. E10 told E4 (LPN - Licensed Practical Nurse) of R1's wishes. E10 then approached the resident and verified that R1 did not want E5 to take care of her. R1 did not tell E4 the reason why because E4 knew why. R1 further said that she felt mentally and emotionally abused when E5 forcibly pushed the chair into the hallway against her will. R1 felt that everybody can see her bare behind (buttocks). R1 also felt that her rights were violated. On [DATE] at 2:40 P.M.,E10(Certified Nurse Assistant) stated that sometime around the 3rd or 4th week of [DATE], R1 was "obviously very upset, mad, embarrassed, humiliated and noted with increased shakiness." E10 stated that at that time, R1 made a complaint to E11(Registered Nurse, Nurse Supervisor) regarding E5. As E10 added, R1 informed her that E5 had taken R1 to the shower room in a manner that R1 felt humiliated, embarrassed and was partially clothed while taken to the shower room. E10 also added that R1 informed her that E5 insisted to take R1 to the shower room by pushing R1's on a shower chair while R1 placed her hands against the door jams to prevent going out of the room. E10 also added that she did not report the potential abuse to E3(Director of Nursing), E1(Administrator) and E2(Assistant Administrator) as R1 already notified E11. On [DATE] at 3:30 P.M., E11(Registered Nurse/Nurse Supervisor) stated that sometime the 3rd or 4th week of [DATE], R1 informed her that she was mistreated by E5. E11 also added that R1 was visibly upset how E5 treated her and did not abide by her wishes. E11 also added that she did not report this potential abuse to E1, E2 and E3. On [DATE] at 3:00 P.M., E4 (Licensed Practical Nurse) stated that on [DATE] and [DATE], R1 refused E5 to be her caregiver. E4 also stated that R1 did not show behavior of refusing care from E5 not until that time on ,[DATE] and [DATE]. E4 further stated that she did not asked R1 the reason why she refused care from E5. On [DATE], at 4:00 P.M., E1, E2 and E3 had all stated that they were not notified by any staff regarding R1's potential abuse. On [DATE] at 4:10 P.M. , Z2(Attending Physician) stated R1 informed her as of today ([DATE]) that a CNA had taken her to a shower room using a shower chair and that R1 was only covered with a sheet. Z2 also added that R1 had informed her that R1 resisted by placing her hands against the door jams, however, the CNA still insisted of taking R1 out of the room against her will. Z2 further stated that "I believe (R1) and there was no reason not to believe her. (R1) is cognitively intact and reliable." As a result, there was a delay of investigation and had subjected R1 and other residents at the facility to a possible potential mistreatment from E5. The attendance record showed that E5 had continued to work at the facility as a CNA until [DATE]. The facility's "Abuse Prevention" policy with a revised date of ,[DATE] and ,[DATE] states that "Any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge to the administrator." The policy also defines abuse as, "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish." The policy further defines mental abuse as "humiliation, harassment, threats of punishment or deprivation."

Based on observation, record review and interview the facility failed to develop and implement individualized interventions for the prevention of falls; failed to monitor and supervise residents to prevent from falling; failed to transfer resident using mechanical lift according to manufacturer's recommended guidelines; and failed to prevent a resident with dementia from obtaining potentially hazardous items. This is for 5 of 9 residents (R23, R7, R10, R12, R13) reviewed for falls/supervision in the sample of 25. These failures resulted in R12 falling and sustaining a fractured femur. Findings include: 1. R12's fall care plan dated 1/13/13 shows R12 is a known risk for falls, stating "at risk for falls related to requires extensive assist with mobility. Has history of fall/hip fracture and compression fracture." An incident report dated 4/11/13 states R12 "was on toilet and called for help and cna (certified nurse's aide) turned around as resident (R12) fell to the floor." The fall care plan was up dated on 4/12/13 stating, "Don't leave resident alone on toilet. Staff to monitor." Staff failed to follow this intervention as shown in an Incident Report dated 5/20/13 in which R12 had a second fall off the toilet after being left unattended on 5/20/13. The incident report states the nurse's aide "put resident (R12) on the toilet and walked away for towels to get ready to put her to bed." As a result of this fall, R12 sustained a "transverse fracture of the basocervical femur, with minimal varus angulation at the fracture site" per review of an Xray dated 5/21/13. E1 stated on 10/24/13 at 10:40am the staff person involved was disciplined for leaving R12 unattended. 2. R23's 9/21/12 admission Minimum Data Set (MDS) shows triggered problems including falls. The trigger legend states to see the Care Area Assessment (CAA) to locate thorough information. R23's fall CAA shows check marks indicating R23 has difficulty maintaining balance, displays impaired balance, cognition impairment, agitation, dementia, incontinence, perceptual deficit, hearing impairment and uses antipsychotic medications. The facility did not evaluate these risk factors to determine if they could be modified nor did they utilize these risk factors to guide them in the process of developing individualized interventions. R23's 10/5/12 fall care plan interventions are not specific to R23's cognition. For example: (a) instruct R23 to ask for assistance, (b) place call light within easy reach. It is unclear how this is an appropriate intervention considering R23's documented cognitive deficits. R23's accident and incident reports from 11/10/12 through 4/28/13 showed R23 fell 12 times (11/10/12 twice, 12/8/12, 1/6/13, 2/1/13, 2/3/13, 2/22/13, 4/8/13, 4/10/13, 4/11/13, 4/24/13 and 4/28/13). On 11/10/12 at 9:30 pm R23 was found on floor beside his wheel chair. Also on 11/10/12 at 11:05 pm, R23 was found on the floor near the nurses' station. The hospital 11/11/12 X-ray report showed he had nondisplaced cortical fracture distal radius dorsally and nondisplaced ulnar styloid fracture. On 11/10/12 wheel chair and bed alarm was added to 10/5/12 fall prevention care plan, but R23 continued to fall (12/8/12, 1/6/13, 2/1/13, 2/3/13, 2/22/13, 4/8/13, 4/10/13) with a bed alarm being in place. The facility did not evaluate the circumstances surrounding R23's falls for further interventions such as sliding from chair and bed, undesirable behaviors or if the bed and chair alarm were effective interventions. On 4/11/13 incident report showed R23 fell on [DATE] sustaining a bump to the right side of his head, left arm bruising, swollen and tender to touch. The incident report also showed R23 also fell on [DATE] and sustained a large bruise on left forearm. At the hospital, a 4/11/13 X-ray report showed R23 sustained an oblique fracture of the distal left ulnar shaft and his left arm was placed in cast. There is no evaluation to show if the fracture occurred from R23's fall on 4/8/13 or 4/10/13. The facility did not analyze the circumstances surrounding R23's falling. On 4/24/13 at 11:00 pm R23 fell from his bed (sitting on his floor mat with his back against his bed). On 4/28/13 at 3:20 pm R23 slid from his wheel chair and sat on the floor. It was documented daily in R23's nurse's notes that he exhibits physical and verbal aggression towards staff and is resistive to care. The facility did not evaluate why R23 was exhibiting physical aggression and undesirable behaviors nor did they revise nursing interventions to address his behaviors in attempts to keep him from falling. On 5/20/13 R23 was admitted to the hospital with [REDACTED]. R23 did not return to the facility. On 10/25/13 at 2:00 pm the facility assistant administrator, E2, and director of nurses (E3) stated these incidents occurred before their time in the facility; and could not locate any record to show why R23 was falling repeatedly or what was done to monitor and supervise to prevent R23 from falling. 3. R7's admission record showed he was originally admitted to the facility on [DATE] and readmitted on [DATE] after he underwent right below knee amputation (BKA) at the hospital on [DATE]. R7 has [DIAGNOSES REDACTED]. R7's 5/21/13 significant change MDS showed he has short term memory problems, requires one person assistance for all his activities of daily living and is at risk for falling. R7's fall CAA shows he has risk factors including difficulty maintaining sitting balance, impaired balance during transition, use of diuretics, circulation problems, cognition impairment, dementia, anemia and BKA. The facility did not analyze these risk factors as how these risk factors contribute to R7's falls and what specific interventions could be to implemented to prevent him from falling. R7's 5/18/13 3:08 pm nurses notes shows staff heard him yelling and found him sitting on the floor in front of the bath room door. R7 stated he slipped and went down to the floor. R7 continued to complain of pain. On 5/20/13 staff noticed bruising and R7 complained he is hurting since he fell on [DATE]. R7's X-ray on 5/20/13 at 4:09 pm showed mildly displaced fracture involving the anterior aspect of the 10th rib. R7's 5/20/13 at 9:30 pm nurses notes showed staff found him on the floor next to bed, screaming for help, "I hurt my self." On 5/25/13 at 8:15 am nurses notes showed R7 was found lying on floor on his right side crying and moaning. At the hospital 5/25/13 9:25 am Computerized Tomography (CT) showed R7's right sided 7th, 8th and 9th ribs fractured. R7's accident and incident reports showed on 6/18/13 at 5:25 am staff heard his alarm sound, found R7 on the bath room floor with half of his body off the toilet with his buttocks two feet off the floor. R7's accident and incident report showed on 7/13/13 at 5:25 am staff found him on floor by the the closet with his alarm going off. On 10/6/13 R7's incident showed he reported he fell a couple of days ago while trying to get out of bed, hit his stump on floor and the blister on his stump was bleeding. R7 has edema and purple yellow bruise on his inner knee cap area. The facility did not develop fall care plan until 5/29/13. This care plan interventions are not specific and not effective to prevent R7's falling. For example: (1) The intervention was to ensure the bed and chair alarm are in working order at all times, resident has history of removing alarms. This intervention was not effective because he fell on ,[DATE], 5/20, 5/25, 6/18, 7/13 and 10/6/13. (2) The intervention was to place call light within easy reach, give cues to ask for assistance. This intervention was not effective because R7 has memory impairment, it was not clear as to how the staff will ensure R7 will initiate his call light. (3) The intervention was for R7 to be up in his wheel chair daily with alarm and monitored closely by the nursing station. This intervention was not effective, because R7 was in his room and in the bathroom (in wheelchair) alone on 10/22, 10/23 and 10/24/13. The facility added an intervention on 6/28/13 to apply out locks to the wheel chair, use scoop mattress. The facility did not determine if lack of these interventions was the reason for R7's falling. On 10/24/13 at 2:15 pm E13 (restorative nurse) stated R7 had his right BKA, he used to be independent in the facility, thinks he can get up and walk independently, even after his amputation, and does not ask for help. The care plan did not address how to deal with R7's habit of getting up without assistance. There no teaching on record if the facility taught R7 or the extent of reiteration required to accept his limitations from BKA. On 10/22/13 at 12:30 pm R7 was in his room in wheel chair, shaving at the sink. R7 did not apply breaks to his chair, he wheeled himself, bumping between the beds walls. R7 was not able to recall when he had undergone the amputation. 4. On 10/23/13 at 10:15 am E9 transferred R10 from his wheel chair to the toilet with the sit to stand mechanical lift. E9 did not follow manufacturer's recommendation for the application of the sling. The manufacturer recommendation on page six instructs to position the sling around the resident's back so the bottom of the sling lies horizontally about two inches or five centimeters above the resident's waist line, with the resident's arms outside the sling. E9 applied the sling on R10's upper back. When E9 operated the mechanical lift, to lift R10, the sling was about to slide off his shoulders. R10 was unable to bear weight on his legs causing him to be at risk for sliding out of the sling and falling. E9 stated he could use the mechanical lift, but the lift does accommodate R10. E9 was not aware what size sling needs to be use. On 10/23/13 at 11:30 E13 (restorative nurse) stated she will schedule training for E9. The facility April 2009 accidents / falls policy and procedure addresses procedures related to fall risk assessment (#1 and #2); development of care plan (#3, #4, and #5); documentation and investigation of incident / accident (#7); revision of care plan (#10). 5. Review of R13's nurse's notes dated 03/25/2013 at 10:30 reads: Resident took a piece of artificial flower and was chewing it. Encouraged to spit out but was uncooperative with staff. After a while did remove it. Review of R13's nurse's notes dated 06/12/2013 at 10:00 reads: Activity CNA reported R13 was hit by another resident for trying to take food from their tray. Review of R13's nurse's notes dated 09/20/2013 at 2010 reads: CNA when putting R13 to bed noted a box of miniature GE light bulbs in R13's pocket. There are 4 bulbs in box of 10 bulbs. Review of R13's Accident/Incident report dated 09/20/2013 at 2210 reads the same as the nurse's notes. On 10/23/2013 E14 (CNA) stated she is unaware of R13 taking non food items and placing in mouth but does take food. E14 states "He likes to eat." On 10/24/2013 E10 (LPN) stated R13 will put things in a pocket. Is usually food but sometimes even gloves. 10/24/2013 E12 (Unit Director) stated the lights found in R13's pocket were mini lights "Christmas light size". E12 stated she does not know where the lights came from. E12 stated there is no policy on contraband items for unit, facility has individualized resident approach for such items/behaviors.

A. Based on observation, interview and record review, the facility failed to follow their plan of care to provide resident specific interventions, reevaluate the effectiveness of interventions and provide adequate supervision to prevent reoccurring falls. The facility also failed to ensure that fall preventions equipment was working properly. This is for 2 residents (R2 and R3) out of 11 reviewed for falls in the sample of 27 and 1 resident (R47) in the supplemental sample. These failures resulted in R2 falling and sustaining a laceration to the forehead requiring an emergency room visit and sutures, and R3 sustaining rib fractures on 05/29/12 and a blunt trauma of the head on 8/21/12 precipitated by fall incidents. The findings include: 1. R2 is an [AGE] year old resident with [DIAGNOSES REDACTED]. R2 has moderate cognitive impairment and requires extensive assistance from staff to perform all activities of daily living, according to the 6/5/12 MDS. R2 receives multiple psychotropic medication, including Haloperidol 1 mg 9:00 AM, Haloperidol 2 mg 9:00 PM, Zoloft 200 mg at 9:00 PM and Trazodone 100 mg at 9:00 PM. R2 is at high risk for falls, according to the fall risk assessment dated [DATE]. R2's fall risks include weakness, decreased safety awareness and history of falls from leaning forward in her wheelchair, according to the Fall care plan dated 6/1/12. R2 was found face down on the floor in her room on 8/11/12 at 1:20 PM with a laceration and contusion on her right forehead, according to the nursing notes. R2 was calling out for help, and the "chair alarm wasn't working" per documentation in the nursing notes dated 8/11/12. R2 was sent to the emergency room for treatment and received sutures to the right forehead, according to nursing notes. According to review of the Treatment Record and nursing notes, no documentation regarding the monitoring of the functioning of the wheelchair alarm was recorded. On 9/6/12 at 10:25 AM, E4 (Nurse) stated that she responded to R2 yelling out on 8/11/12. E4 said that the chair alarm was not sounding. E4 said that R2 has a history of leaning forward in her wheelchair, and that the alarm would sound so" we could stop her" from falling out of her wheelchair. E4 said that she changed the sensor pad and the batteries in the control unit after R2 fell on [DATE]. E4 said that she did not know the last time the batteries or sensor pad had been changed. E4 said she could not recall if their was a date on the sensor pad. E4 said that the nurses do not date the sensor pads when they are put in place. E4 said that documentation regarding the functionality of the wheelchair alarm should be in the Treatment Record. The fall investigation for this incident did not examine the reason that R2's wheelchair alarm was not working, according to review of the incident report dated 8/11/12. R2 was in her room sitting in a wheelchair on 9/5/12 at 3:25 PM. A control unit (alarm box) was noted attached to the back of the wheelchair. No flashing green light was noted on control unit. A green light should flash every 2 seconds to indicate the system is monitoring, according to the manufacturer's guide. The sensor jack did not fit securely into the control unit; the jack fell out of the control unit when lifted from the back of the wheelchair. E5 (Clinical Coordinator RN) was present and said that the jack should fit securely into the control unit. E5 tried to fit the jack securely into the control unit but it fell out again. On 9/5/12 at 3:30 PM, E5 (Clinical Coordinator RN) stated that R2 should have had a treatment order for the monitoring of the wheelchair alarm. E5 said that no documentation could be found for the monitoring of the functioning of the wheelchair alarm. E5 said she initiated an order to check the wheelchair alarm today (9/5/12). The chair sensor pads utilized by the facility are designed for one year of use according to the manufacturer's insert instructions. 2. R3 is a [AGE] year old with [DIAGNOSES REDACTED]. R3 was originally admitted to the facility on [DATE] from home. R3 sustained a subdural subarachnoid hemorrhage and fracture of occipital bone due to a fall incident at home on 12/26/11, a recent fall history prior to admission to the facility. Review of MDS (Minimum Data Set) dated 7/7/12 and 9/15/12 showed that R3 requires moderate to extensive assistance with 1 person physical assistance for transfer, mobility, hygiene and toileting needs. R3 had 12 fall incidents at the facility for a period of 7 months. Review of nurse's notes and occurrence reports documented that R3 had falls on the following dates: -01/14/12 at 9:30 P.M., " Heard alarm sounding. (R3) noted lying on floor mat." -01/30/12 at 2:20 P.M., "unwitnessed fall, (R3) lying on floor mat, bed alarm has gone off." -03/31/12 at 2:28 A.M., "Alarm sounding, CNA (Certified Nurse Assistant) responded, (R3) found on the floor." -04/05/12 at 3:30 A.M., " CNA entered room in response to alarm, (R3) on his knees on mat next to bed." - 04/10/12 at 4:45 A.M., "Alarm sounding, CNA entered room and (R3) was on his knees on floor mat holding on to bed." -04/11/12 at 4:30 P.M., " CNA responded to wheelchair alarm sounding and noted (R3) sitting on the floor in front of wheelchair. Unwitnessed fall." -05/14/12 at 12:15 A.M., "Alarm sounding, (R3)on floor." -05/22/12 at 2:15 P.M., "Found sitting on floor, alarm going off." -05/24/12 at 10:45 P.M., "On floor, skin tear right elbow and laceration to right side of head." -05/29/12 at 5:30 A.M., "(R3) found on floor, in room kneeling. (R3) sustained 4 inch skin tear on left upper arm. At 10:30 A.M., (R3) complained of left rib pain." X-ray result dated 5/29/2012 showed R3 sustained ribs (9th, 10th and 11th) fracture. -06/14/12 , " CNA heard alarm, (R3) fall backward in wheelchair." -08/21/12 at 7:20 P.M., "Nurse outside of (R3's ) room and heard a noise, found (R3) on floor on his left side at foot of bed. Unresponsive approximately 5 minutes. 911 called, sent to hospital and was admitted for blunt head trauma." R3 was readmitted back to the facility on [DATE]. Review of the incident reports showed that quality assurance by nursing department and interdisciplinary team had failed to determine appropriate interventions and failed to revise the care plan. The incident report also showed no evaluation to determine the cause of the incident to prevent further occurrence of fall. Review of R3's care plan from original to current admission showed no adjustment/changes in approaches, interventions or goals specific to R3's specific needs in order to prevent further fall. R3 has a bed/chair alarm monitor since the fall incident of 1/14/2012. Review of current care plan dated 9/6/2012 showed that R3 continued to have bed/chair alarm monitor and no revision of intervention despite of R3 sustaining multiple falls with an alarm sounding off. On 9/26/12 at 2:00 P.M., E5 (Clinical Coordinator) stated the she did not revise R3's care plan interventions for each fall incidents. E5 also conceded that the interventions were generalized and the care plan approaches were not resident specific. On 9/25/2012 at 2:20 P.M., R3's alarm monitor was sounding off. R3 was in the bathroom sitting on the toilet. R3's wheelchair was also in the bathroom and the alarm monitor that was attached to the wheelchair was alarming. There were no staff attending R3. E5 stated that R3 did not ask for assistance and had transferred himself to the toilet before a staff came to assist him. R3 was sitting in his wheelchair in the resident's hallway on 9/26/2012 at 12:30 P.M. R3's alarm monitor cord was not connected to the alarm monitor box. E17 (CNA) was alerted to this observation. E17 connected the cord to the unit box of the alarm monitor and stated "this cord should be connected to activate the sound alarm." 3. On 9/24/12 at 10:55 AM, R47 was in her room sitting in her wheelchair. The cord that connects the sensor pad to the wheelchair alarm box was disconnected from the alarm box and hanging down. E3 (Registered Nurse) was present for this observation. E3 stated that R47 is at risk for falls. B. Based on observation, interview and record review the facility failed to ensure that residents are transferred safely, and according to their policy, and failed to ensure that CNAs are knowledgeable regarding residents' transfer needs. This is for 2 residents (R24, R14) in the sample of 27 and 2 residents (R32, R36 ) in the supplemental sample. The findings include: 1. On 9/25/12 at 12:25 PM, E16 (Certified Nursing Assistant (CNA)), was observed using a maximum mechanical lift type device to transfer R24 from a chair to the bed. E16 stated that she was not sure whether R24 required 1 or 2 assists during the transfer using a maximum mechanical lift. E16 said "My understanding is that bigger people need 2 people when transferring." R24 has [DIAGNOSES REDACTED]. R24 is totally dependent on staff for all transfers according to the MDS. R24 has poor trunk control and safety awareness according to the Fall Care Plan (review date 10/16/12). The care plan dictates that R24 is to be transferred using a mechanical lift; however, the care plan does not state whether 1 or 2 people are required. According to the facility's policy titled Resident Handling - Limited Lift (09/10), 2 staff members are to be present during a transfer using a maximum mechanical lift device. The policy also states "The specified method for transferring...will be communicated to the healthcare providers by ensuring this information is included in their care plan and also is posted on the back of the bathroom door on the Mechanical Lift Assessment form...The information will also be included in Care Tracker and in AOD." 2. During the initial tour with E5 (Clinical Nurse Coordinator ) on 9/24/2012 at 10:00 A.M., R14 was transferred from bed to reclining wheelchair by E21(CNA). The total lift mechanical transfer device was next to R14's bed. E21 stated that she transferred R14 by herself. E21 also added that she did not ask for assistance from another staff to transfer R14 because they were short that day, since a CNA had called in. Review of MDS (Minimum Data Set ) dated 1/10/12 and 7/10/12 showed that R14 requires total assistance with 2 person physical assist for transfers. 3. On 9/25/12 at 1:00 PM, E11 (CNA) was observed taking the total mechanical lift out of R32's room. E11 stated on 9/25/12 at 1:10 PM, she transferred R32 back to bed by herself using the mechanical lift. E11 said that R32 was weak but it was okay. E11 said that R32 was not able to stand on his feet so she used the total lift. The admission MDS dated [DATE] indicated that for Section G: Function Status, R32 needed extensive assistance with 2 person assist. 4. On 7/5/12, E27 (CNA) did not properly position R36 prior to using a mechanical lift to transfer R36, according to the facilities incident investigation form dated 7/5/12. This caused R36 to exclaim "ouch" when her arm got caught in-between the bed rail and the lift and caused a 4 X 4.5 centimeter bruise to R36's right forearm. E27 did not receive any training in proper transfer technique, according to her in-service Attendance Record. E27 received 45 minutes of in-service training during 2012, according to the Attendance Record.

Based on observation, interview and record review the facility failed to adequately assess and describe an area of coccyx excoriation; failed to develop a care plan to address the excoriation, and failed to follow the physician's orders [REDACTED]. The findings include: R15 was re-admitted to the facility on [DATE]. According to the physician's orders [REDACTED]. R15's coccyx and buttock's area did not exhibit excoriation or skin breakdown upon readmission according to the nursing readmission assessment Body Audit conducted on 8/19/11. According to the Non-Intact Cutaneous Evaluation (NICE) dated 9/21/11, R15 was first noted with excoriation of the coccyx on 9/21/11 The NICE assessment does not adequately describe the extent of the excoriation, and no measurements were documented. The assessment simply describes the area as "pink." The subsequent assessments on 9/28, 10/5 and 10/12 also lack measurements and simply say "pink." R15 had a physician's orders [REDACTED]. R15 was due for a dressing change on 10/16/11 but there is no documentation in the treatment record to show that this treatment was done. On 10/18/11 a skin check was done on R15. The [MEDICATION NAME] on R15's coccyx was moist, and the ends were curling up. There was no date on the [MEDICATION NAME]. R15's coccyx was excoriated and there were 3 small open areas. E9 (Nurse) was present for this observation. E9 said that the openings were new. E9 confirmed that there was no documentation that a treatment was done on 10/16/11. Additionally, there was no care plan addressing R15's excoriation or skin condition in general. This was confirmed by E2 (Director of Nursing) on 10/20/11.

Based on observation and record review the facility failed to provide treatment and/or accurately document the development of a stage 4 open necrotic pressure sore for 1 of 9 residents reviewed for pressure sores (R8) out of a total sample of 26. This failure resulted in R8 not receiving treatment to a pressure sore until it was a stage 4 (necrotic) . Findings Include: During R8's treatment on 10/18/11 at 10:15 AM R8 had a stage 4 necrotic pressure sore to the right buttock/hip area. E10 stated (Licensed Practical Nurse) that area measures 7 cm. x 4 cm. x 0 cm. (Centimeter) The circumference of the pressure sore has dark necrotic tissue at the base from the 9 o' clock area through the 3 o'clock and a slightly lighter necrotic tissue at the upper circumference. The center area was open with a white area in the center and a depth of 2 cm. to 3 cm. R8 is a very thin resident. E10 cleansed the area with Normal Saline then applied Santyl ointment to the pressure sore. R8's dietary notes document that R8 is 5 feet 6 inches tall. R8 was admitted to the facility on [DATE] weighing 116.4 pounds. Presently R8 weighs 106.7 pounds. Further review of R8's medical record indicates R8 had no treatment for [REDACTED].

A. Based on interview and record review the facility failed to maintain the dignity of residents when they questioned residents about how they were going to spend their money before allowing them to withdrawal the money from their trust fund. This failure affects 105 residents who have their money managed by the facility, including R29, R31, R32, R33 and R20. This failure resulted in the 1 resident (R29) feeling emotionally distressed after she was disallowed from using her trust fund money to buy a birthday present for her daughter. The findings include: On 10/18/11 during the resident group interview R20, R29, R31, R32 and R33 all stated that E11 (Payables Clerk) will not give them their trust fund money until the residents tell E11 how they plan to spend the money. R29 said that she wanted to buy her daughter a birthday present but was told by E11 that she could only spend the trust fund money on herself and could not use it to buy a birthday present for her daughter. On a subsequent interview on 10/20/11, R29 stated that E11 (Payables Clerk) is rude to her when R29 requests to withdrawal money from her trust fund account. R29 said that she felt distressed when E11 told her she could not use her trust fund money to buy a present for her daughter. R29 said that she has worked hard all her life and doesn't feel that she has to tell E11 how she is going to spend her money, or that she should be restricted from how she can spend her money. On 10/19/11 at 1:35 PM E11 said that she does ask the residents what they plan to spend their money on before she gives them their money. E11 said that she does tell the residents that they are not allowed to spend their money on anyone else but themselves. E11 said that she did tell R29 that she could not use her money to buy her daughter a birthday present. E11 said that she was following a public aid rule. The facility manages funds for 105 residents who receive public aid according to the "RTF Bals" form dated 10/20/11. B. Based on observation and interview the facility failed to use the resident's name when speaking to the resident, and failed to knock on residents' doors and request to enter before entering residents' rooms. This failure affects R17 and the residents in the 2300 wing. The findings include: On 10/17/11 at 2:05 PM R17 was in room [ROOM NUMBER] (hallway bathroom) with E5 (CNA) and E6 (CNA). E5 repeatedly referred to R17 as " Mama. " E5 and E6 both said that they did not know R17's name. E5 and E6 said that they did not work on the 3300 wing. On 10/18/11 at 2:45 PM E3 (Laundry Clerk) was observed to enter multiple resident rooms on the 2300 wing without knocking and without asking permission to enter. The rooms include 2306, 2315, 2319, 2323, 2325 and 2320. Residents were observed in 3 of these rooms.