Every finding on record at Thryve of South Holland

Based on observations, interviews, and record review, the facility failed to maintain an environment free of accidental hazards, failed to provide an appropriate level of supervision, and failed to ensure the availability and use of an assistive device required for safe mobility for one (R1) of four residents reviewed for falls in a sample of four. This failure resulted in R1 sustaining a fractured hip, which required hospitalization and surgical intervention.Findings include:R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia, Unspecified Severity with other Behavioral Disturbance; Anemia; Peripheral Vascular Disease; Essential (Primary) Hypertension; Abnormalities of Gait and Mobility; Anxiety Disorder; Bilateral Primary Osteoarthritis of Hip; Vitamin B12 Deficiency Anemia; and Vitamin D Deficiency.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, R1's Sit-to-stand and Chair/bed-to-chair transfer ability requires partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort); R1 requires manual wheelchair as a mobility device.R1's risk fall assessment dated [DATE] shows score of 13 indicating R1 is at high risk for fall. R1's care plan initiated on 3/15/2024 reads in part, Resident requires restorative walking program due to her limitation in walking due to impaired balance r/t (related to) dementia and age-related osteoporosis. Interventions: Provide adaptive equipment as needed, (e.g. wheelchair, walker, rolling walker, gait belt, cane, quad cane); Provide appropriate footwear; Provide staff assist with ambulation at level resident requires, (e.g. set up, oversight, encouragement, cueing, physical assistance); Remind resident to not ambulate without assistance. On 1/2/2026 11:07 AM Surveyor observed R1's room. Bed in the low position, in locked position, fall mat on the left side of the bed, room free of clutter, call light attached to the headboard, no mobility devices present. R1 observed sitting in the chair, in the day room, watching TV. R1 clean and dressed appropriately; however, not wearing shoes, wearing regular socks. Surveyor did not observe R1's mobility device within R1's immediate vicinity. R1 said, I remember that I fell. I don't remember how it happened. I hurt myself. R1 pointed to her left leg and grimaced. R1 unable to answer clarifying questions, appears disoriented and forgetful. On 1/3/2026 at 9:41 AM Surveyor observed R1 watching TV in the day room wearing regular sock on her right foot and having her left foot bare. Surveyor did not observe R1's mobility device within R1's immediate vicinity. On 1/2/2026 at 11:16 AM V3 (Certified Nurse Assistant/CNA) said, I am regularly assigned to take care of R1. I was not here when R1 fell (on 9/20/2025). R1's mood varies, she's forgetful, but physically strong for her age. R1 is able to walk independently, without assistive devices. R1 freely walks around the unit. R1 requires total assistance with ADLs (Activities of Daily Living) though. Total assistance means 1-person assist and sometimes 2-person assist if R1 gets agitated. We don't really use a fall mat for R1, it was brought by the hospice staff, but R1 doesn't really need it. R1 is compliant for the most part but she will try to get up or get out of bed unassisted. I often hear in the hand off report, that R1 was getting out of bed at night. R1 is not a fall risk resident; however, we provide additional monitoring after R1's fall. There are no additional fall prevention interventions for R1. R1 had couple of instances of balance loss after her fall, so it looks like she's still recovering from the fall.On 1/2/2026 at 11:28 AM V8 (Registered Nurse/RN) said, On 9/20/2025, between 2:00 PM and 2:30 PM, I was at the desk when V4 (CNA) called me for help. V4 (CNA) was in the bathroom assisting R1's roommate (R3). I think R1 was walking into the room, and she fell to the floor. I think it had to do with an unlocked bed, but I don't know, I wasn't in the room. When V4 (CNA) heard R1, she came out of the bathroom and saw R1 sitting on the floor. I came right when V4 called me. I think I saw R1 sitting on the floor with her back against the bathroom door, it's been long time ago, so I don't remember all the details. I assessed R1, checked her vital signs and range of motion, and she seemed fine. We helped R1 to the wheelchair and placed her in the day room. R1 denied any pain. I notified V2 (Director of Nursing), V9 (Medical Doctor), and R1's family. R1 doesn't listen to anybody, she stands up whenever she wants, but R1 is safe to walk around without assistance. R1 wants to move around constantly. R1 is a fall risk resident, but I'm not sure if she's at high risk for fall. We keep R1's bed in the lowest position and encourage her to use a call light to prevent potential falls, but R1 is not compliant. R1 is mean and curses people out. You can't make R1 do anything. When surveyor asked why R1 is not wearing appropriate footwear, V8 (RN) didn't directly answer; however, asked V3 (CNA) the same question, and V3 (CNA) headed to R1's room to look for R1's shoes.On 1/2/2026 at 12:09 PM V4 (CNA) said, I have been working in the facility for 10 years. I normally work in the memory unit, so I'm very familiar with R1. R1 was assigned to me on 9/20/2025. After lunch, I was doing my rounds. I was assisting R1's roommate and R1 followed me into the room. I was in the bathroom with doors closed, and that's when I heard R1 make a noise like Ouch. I am not sure if she was trying to sit on the bed and missed it or what happened, I'm not sure, I was in the bathroom, I didn't see it. When I opened the bathroom door, I noticed R1's roommate's bed was shifted and R1 was sitting with her back against it. That's how I realized the bed was not in a locked position. I don't know who left the bed unlocked and for what reason, but it wasn't me. I yelled for V8 (RN) for help. V8 (RN) came in and assessed R1, R1 seemed ok. We then lifted her up, R1 was able to walk, I didn't see any issues while R1 was walking to the dining room. R1 wasn't complaining nor grimacing, just being her normal self. R1 sat in the chair until the end of my shift (3:00 PM). R1 is not a fall risk resident. R1 walks all day long, doesn't use any assistive devices. After R1 fell, we started using a fall mat and wedges. We place wedges on both sides of the bed. There is a fall mat on the left side only, because that's where R1 likes to lean towards. There is nothing else we do for her as far as preventative measures. R1 is not compliant, she does what she wants to do anyway.On 1/2/2026 at 2:24 PM V7 (Licensed Practical Nurse/LPN) said, I worked in the afternoon on 9/20/2025. R1 didn't want to eat dinner that evening. I tried to ask R1 what was wrong. R1 said that her legs were hurting. I was made aware that R1 fell on the morning shift but that there was nothing wrong with R1. I gave R1 pain medication and called hospice. When we were trying to put R1 into bed, R1 couldn't stand up and that's not normal for R1. Once R1 was in bed, I performed assessment, I didn't see any swelling or asymmetry but R1 was in a lot of pain. I actually gave R1 pain medication twice on my shift but there was not much relief. I called hospice to give them an update. The hospice nurse came in and performed their own assessment and suggested that we should send out R1 to the hospital. I called the transport ambulance to send R1 to the hospital. I didn't call 911 because it was not life or death, or emergency situation. The family and V9 (Medical Doctor) where notified. I called the hospital a little later and got an update that R1 had a fractured hip. R1 was not a fall risk resident before the fall but she is now. R1 walks fine, she doesn't use assistive devices. I believe now, CNAs make sure R1's bed is locked because that was the cause of her fall, and the bed is in the lowest position, R1 also has a fall mat on the side of her bed.On 1/3/2026 at 10:43 AM V2 (Director of Nursing/Fall Coordinator) said, I got a call from V8 (RN) on 9/20/2026, stating that R1 was found on floor in her room. I was told that R1 attempted to sit on the bed, but bed was not in a locked position, moved away from R1, and she fell to the floor. At first, R1 didn't display any pain and did not show an abnormal assessment but later, during the afternoon shift, R1 started exhibiting sings of pain and discomfort, and was sent out to the hospital where she was diagnosed with a fractured hip. After the incident, the interdisciplinary team met and established that all beds have to be locked. We also updated R1's care plan and we provided additional supervision to R1. It is hard because R1 does what she wants to do, for example does not want to wear shoes.On 1/3/3026 at 11:14 AM V9 (Medical Doctor) said, I believe I was notified about R1's fall on 9/20/2025. R1 is considered a high risk fall resident. If a bed was unlocked, it should definitely be in a locked position and R1 should be wearing non-slip footwear. R1's fracture appears to be fall related. I don't believe this fall will result in R1's long-term issues or decline in her level of assistance.R1's progress note dated 9/20/2025 10:11 PM written by V7 (LPN) reads in part, Received resident (R1) in dining room in wheelchair post fall. Resident started to c/o (complain of) pain after dinner. Resident stated that pain was in both legs. Hospice came for a visit and recommended that resident is to be sent to the ER for evaluation. Pain medication administered. Family made aware. (Ambulance) transport is transporting resident to (local) hospital.R1's neurological assessment dated [DATE] 2:30 PM shows R1's vital signs and neurological assessment were within normal range. R1's pain assessment dated [DATE] 4:38 PM shows R1 having no pain upon assessment.R1's hospital record dated 9/21/2025 shows, R1 was diagnosed with A subcapital fracture is seen in the right femoral neck with slight impaction. R1's right hip fracture followed by right hip ORIF (Open Reduction & Internal Fixation) procedure.The facility Falls and Fall Risk, Managing (no date) reads in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture.

Based on observation interview and record review, the facility failed to prevent an avoidable wound for R32 who was identified as high risk for skin breakdown and dependent on staff for turning and repositioning, and failed to ensure air mattress pumps were appropriately set to the resident's weight per manufacture recommendations. This affected three of three residents (R32, R3, and R64) all reviewed for pressure ulcer prevention. This failure resulted in R32 having a facility acquire stage (3) three pressure wound of the left ear measuring 1.00 cm (length) x 0.50 (width) x 0.00 (depth).Findings include: R32's Braden scale for predicting pressure sore risk dated 6/26/25 documents: high risk. Mobility: very limited: makes occasional slight changes in body or extremely position but unable to make frequent or significant changes independently. Nutrition: adequate. Friction and Shear: problem: requires moderate to maximum assistance in moving. Tissue test dated 6/27/25 documents: Resident requires more frequent turning and positioning then every 2 hours: No. Minimal data set section GG (functional abilities) date 7/2/25 documents: dependent with rolling left and right. Wound assessment detail report dated 7/30/25 documents: Wound: left ear, Status: active, Type: trauma, Classification: abrasion, Source: facility acquired. Date Identified: 7/30/25 Clinical Stage: partial thickness, Exudate: Scant: Type: serous (clear, watery fluid), Measurement: 1.00 cm (centimeters) x 0.50 cm x 0.00cm (LengthxWidthxDiameter). Progress note dated 7/30/25 documents: Noted abrasion to left ear, 100% red, small amount, no odor, serous drainage and intact. On 07/30/2025 1:39 PM, R32 was observed in bed on laying on the right side towards the door with the call light cord across the upper left body, laying on chest and clamped on the right side of her gown. R32 had an opened boarder gauze dressing on the left ear dated 7/30/25. V6 (nurse) removed the opened dressing. R32 was observed with an open area on the left upper cartilage of her ear that was white on the open outer portion of the opening and red in middle. V6 (nurse) said, R32 did not have this wound yesterday. V6 said, R32 has a facility acquired pressure stage two ulcer to the ear. On 7/31/25 at 10:36am, V5 (wound nurse) said, when she entered R32's room yesterday. R32 was down lower in the bed, R32 was lying on a pillow without a pillowcase. R32's left ear wound is facility acquired. R32's wound could be caused by trauma or pressure. R32's wound came from R32 laying on the pillow without a pillowcase. V5 said, R32's wound was caused by the top of the fabric folds when it was gathered under R32's head. On 7/31/25 at 10:54am, V11 (CNA/Certified Nurse's Assistant) said, R32 is dependent on staff for being turned and repositioned. V11 said, when she did her wound rounds with V5 yesterday when they found R32's left ear wound, R32 was in bed, facing the window, on her left side, on the air mattress and her head was not on the pillow. V11 said, R32's pillow had a pillowcase on it. V11 said, when R32 was turned she saw R32 with a white area on the cartilage (curved prominence of cartilage located on the outer ear) of the left ear that wasn't there the day before. On 7/31/25 at 11:09am, R32 was observed in bed laying on the right side towards the door with the call light cord across the upper left body, laying on chest and clamped on the right side of her gown. V5 said, this is the pillow R32 had in place yesterday. V5 removed the pillow from R32's head. V5 removed R32's pillowcase. R32's pillow was observed with a blue loosely covered outer plastic soft pillow. R32's pillow was observed without thick seams consistent with R32's left ear wound indentation. The plastic covering on R32's pillow was easily gathered and moveable. V5 gathered the plastic to demonstrate the folds/creases that R32 was laying on when she found the wound. V5 said, when she entered the room yesterday, R32 wasn't laying on any cords. V5 lifted R32's call light cord and placed it above (without touching the wound) R32's wound in the same direction of the wound. V5 said, R32's wound has a similar width measurement as R32's call light cord. V5 said, R32's wound was classified as an abrasion until the wound doctor visits. V5 said, R32 was not turned every two hours as required to prevent her ear wound. On 7/31/25 at 11:37am, V5 (wound nurse) said, R32's wound on the ear was avoidable. On 7/31/25 at 12:20pm, V3 (DON/Director of Nursing) said, R32's left ear wound came from not being turned and repositioned by staff. V20's (Wound Doctor) Wound Physician Evaluation dated 8/1/25 documents: Stage (3) three pressure wound of the left ear full thickness. Etiology: Pressure. Pressure/Skin Breakdown – clinical protocol dated 1/2017 did not apply. 2. On 7/29/25 at 11:18AM R3 was seen in bed. Air mattress pump was at 200. R3 nonverbal to respond. On 7/30/25 at 10:15AM accompanied by V5, R3's air mattress observed at 200. V5 said it is set at 200 pounds. Record reviewed R3 most current weight is 117 pounds. On 7/29/25 at 10:52 am observed R64 in bed. R63 not answering surveyors questions. Air pump on mattress set at 280. On 7/30/2025 10:15AM accompanied by V5, Wound Nurse, observed and said R64's air mattress is set at 280 pounds. R64's current weight in her chart is 63.6 pounds. On 7/30/25 at 10:17AM V5, Wound Nurse, said the mattress is not benefiting the patients at risk for pressure ulcers if they are at the wrong settings. On 7/30/25 at 10:41AM V12, Maintenance, said our department puts out the mattress. V12 said the settings on the mattress are set according to the residents' weights. If the setting is too high then it's too hard. If it's too low it's too soft. V12 said I will be in servicing my staff on how to properly set the mattress. We don't have a policy for this. I was told how to set the mattress by the nurses. On 7/30/25 at 1:03PM V5 said R64 is at risk for pressure ulcers. She has a history of contractures. V5 said R3 is at risk for developing pressure ulcers. She has contractures that contribute to her risk.

Based on observation, interview, and record review the facility failed to follow their policy and practice to ensure that medications are labeled with an open and expiration date, failed to ensure all medication was stored in a package with a label, and failed to remove expired medication from the medication cart. This affects six of six (R56, R97, R51, R5, R88, R55) residents and has the potential to affect all residents' that use house stock medication from the facility. On 7/29/2025 at 2:26pm during observation of the medication carts on unit 300, with assist from V2 (Director of Nursing) The following was observed: R56's Lantus Insulin pen had a dispense date of 12/5/2024, there was no open date or expiration noted on the pen. V2 said insulin expires 28 days after opening. House stock acidophilus capsules had a manufactures expiration date of 5/2025. House stock Bisacodyl 5mg (milligram) tabs had a manufactures expiration date of 6/2025. There were thirteen tan colored pills in a clear medicine cup, no label noted, V2 could not identify the pills. R97's Latanoprost eye drops did not have an open date or expiration date. V2 confirmed that the medication was in use for R97. V2 said he has to determine what the expiration date is for the eye drops. R51's Latanoprost eye drops did not have an open date or expiration date. V2 confirmed that the medication was in use for R51. R5's Aspart Insulin pen did not have an expiration date noted on the label. V2 said the insulin pen should have an expiration date noted, V2 confirmed that the pen is in use for R5. R5's Lantus insulin pen did not have an expiration date noted on the label. V2 said the insulin pen should have an expiration date noted, V2 confirmed that the pen is in use for R5. On 7/29/25 at 2:45pm, the medication cart on unit 100 was observed with V6 (Licensed Practical Nurse). Magnesium Oxide 400mg tablets had a manufactures expiration date of 6/2025.On 7/9/25 at 3:02pm, the medication cart on unit 200 was observed with V19 (Registered Nurse). R88's Latanoprost eyedrops had an open date 6/9/2025 and expired date 7/2/2025. R55's Incruse inhaler (umeclidinum) had an open date 5/29/2025, no expiration date noted. V19 said inhalers expire 28 days after opening. Facility policy titled Storage of Medications effective date 10/25/2014 denotes in-part medications and biologicals are stored safely securely and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible only by licensed nursing personnel pharmacy personnel or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Medication label for individual residents are stored separately from floor stock medications when not in the medication card. Expiration dating expiration dates of dispense medications shall be determined by the pharmacist at the time of dispensing. Drugs dispensed in a manufacturers original container will be labeled with the manufacturer's expiration date. Certain medication or package types such as IV solution multiple dose injectable valves are found mix nitroglycerin tablets blood sugar testing solutions and strips once open require an expiration date shorter in the manufacturers expiration date to ensure medication purity and potency. Drugs dispensed in the manufacturers original container will carry the manufacturers expiration date. Once open these will be good to use until the manufacturer's expiration date is reached unless the medication is in a multi dose injectable vial and ophthalmic medication an item for which the manufacturer has specified a usable life after opening. The original seal of a manufacturers container or vial is initially broken the container or vial will be dated. The members shall place a date open sticker on the medication and enter the date open and the new date of expiration. The expiration date of the bio or container will be 30 days unless the manufacturer recommends a murder D or regulation/guidelines require different dating. The nurse will check the expiration date of each medication before administering. no expired medications will be administered to a resident. All expired medication will be removed from the active supply and destroyed in the facility regardless of amount remaining the medication will be destroyed in the usual manner. Disposal of any medication prior to the expiration dating will be required if contamination or decomposition is apparent. Nursing staff should consult the dispensing pharmacies for any questions related to medication expiration dates.

Based on observation, interview and record review the facility failed to have an effective policy and practice for eliminating odors in the facility. This has the potential to affect all residents, staff, and visitors of the facility. On 7/29/25 during the survey tour, there were strong odors noted in the hallways and on the care unit three hundred.7/29/25 V13 (Facility Ombudsmen) said the odors in the facility has been an going issue.On 7/31/25 at 2:12pm V2 (DON/Director of Nurses) said the facility has contracted a company to clean the carpets, but the smell remains. 7/31/25 at 2:46pm V12 (Maintenance supervisor) said the odors are from the carpets. Things are spilled on the carpets, and residents have accidents sometimes. V12 said the carpets were cleaned by a service company 3 months ago. V12 said he uses the carpet extractor (Carpet Cleaner Machine) between having the carpet cleaned by a service company. V12 said the facility's carpet extractor is broken. V12 said the extractor has been broken for a while. Facility policy titled housekeeping services effective date January 2017 denotes in-part it is the policy of this policy to maintain a clean older free comfortable and orderly environment in all health care and public areas which meet the sanitation needs of the facility and resident rights were safe clean and comfortable like environment. The department shall routinely claim the environment of here to keep the facility free from offensive orders the accumulation of dust rubbish dirt and hazards.

Based on interviews and records reviewed the facility failed to obtain PASARR (Preadmission Screening and Resident Review) screening for one resident (R30) with diagnosis of Intellectual Disability. This affected one of three resident s (R30) reviewed for PASARR. This failure has resulted in a delay to move R30 to another facility. The findings include:On 7/29/25 at 12:15PM the surveyor attempted to speak with R30. R30 only said hello but would not verbally respond. R30 only shrugged her shoulders and turned away.On 7/29/25 at 11:24AM V13, Ombudsman, said R30's family has been waiting for a PASSR II to be done get her transferred to another facility. V13 said the family has been waiting for over 2 months.On 07/30/2025 at 1:15PM V8, Senior Social Service Director, said in May she called and asked about the PASSR II to be completed for R30. V8 said she was told that R30 requires a different PASSR II to be done and they have to send a state person out to do it. V8 said they didn't give her a turnaround time. On 7/30/25 at 11:52AM V1, Administrator, said we are trying to get a level II for R30. V1 said the family wants to move her to another facility, but the facility won't accept her until the Level II PASSR is completed.On 7/31/25 at 1:37PM the surveyor contacted V18, PASSR Help Desk. V18 said the level II requires an external assessment and this cannot be completed until the facility enters the correct information related to R18's prior community address. V18 said currently the facility has listed the facility address, and this is incorrect. V18 said once this is corrected, we can get her screening done, and it usually takes about 2 weeks. V18 said without the previous address we cannot complete the screening. (The call with V18 lasted 5 minutes, enough time to be told the information in the portal needs to be corrected.)Most recent PASSAR was completed for R30 on May 29, 2025 indicating referral for level II.Progress note dated 5/20/25 states pending accepting facility notified facility a level 2 screen related to R30's diagnosis of intellectual disability.Progress note dated 6/24/25 states writer contacted PASSAR assessment company regarding Level 2. Writer was notified that R30 required a state representative to perform the screening. (Last note over 30 days since contacted.)

Based on interview and record review, the facility failed to follow their urinary catheter care policy for indwelling catheter by not securing it to the residents leg. This affected one of one resident (R32) reviewed for catheter care. Findings Include: R32's physician order sheet dated 7/30/25 documents: Catheter in place for diagnosis for Neurogenic Bladder. On 07/30/2025 at 1:39PM, R32 was observed lying in bed on her left side with her indwelling catheter tubing positioned in between R32's posterior legs towards R32's buttock with brown stains on the folded statlock (indwelling catheter stabilization device designed to minimize catheter movement and accidental removal) on the tubing and not secure onto R32's leg. V6 (Nurse) said, R32's indwelling catheter was not secure to R32's leg and the statlock is dirty and undated. V6 said, R32's catheter should secured and clean. V6 said, she would replace the statlock today. On 7/31/25 at 10:31AM, V2 (Director of Nursing/DON) said, he expects staff to follow the facilities urinary catheter care policy. V2 said, indwelling catheters should be secure to the resident's legs with a statlock for stabilization. Urinary Catheter Care dated 2005 documents: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: Catheter tubing should be strapped to resident's inner thigh.

Based on interview and record review the facility failed to ensure that the Minimum data set (MDS) assessment was recorded with accurate information for 5 of 5 residents (R1, R14, R45, R113 and R18) reviewed for accuracy of MDS.Findings include: 1. R1's MDS dated [DATE], section I for active diagnosis, show psychiatric mood disorders, no is checked for depression. Review of R1's medical diagnosis there are no diagnosis for psychiatric illness. R1's progress notes from psychotherapist denotes diagnosis: generalized anxiety disorder and major depressive disorder, recurrent, moderate. 2. R14 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, anemia, alcohol abuse, and cerebral infarction R14's preadmission screening and resident review (PASRR) level II outcome dated 5/10/24 documents approved without specialized services. Under PASRR grouping documents: You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. That diagnosis is: a serious mental health condition. R14's Minimum data set (MDS) dated [DATE] under section A preadmission screening and resident review (PASRR) which asks is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability, or a related condition. The response documents a code of 0, which indicates no by V8 (SSD/Social Service Director). On 7/31/25 at 1:11PM, V8 said she completes section A PASRR screening sections in the minimum data set for residents. V8 said she was unaware of R14's level II screening prior to surveyor requesting information. V8 said the MDS should be coded to indicate a level II screening was conducted and R14's MDS was coded incorrectly. 3. R45 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction affecting right dominant side, dementia, hypothyroidism, chronic obstructive pulmonary disease, and anemia. R45's hospice certification dated 4/22/25 documents R45 is terminally ill with a life expectancy of 6 months or less if the disease process runs its normal course and signed by physician on 4/23/25 R45's Minimum data set (MDS) dated [DATE] under section J1400 prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months documents a code 0 which indicates No by V10 (Minimum data set, MDS nurse). R45's Minimum data set (MDS) dated [DATE] under section J1400 prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months documents a code 0 which indicates No by V10. On 7/31/25 at 11:03AM, V10 said for any resident receiving hospice services their Minimum data set (MDS) should reflect that hospice services are being received in section J if paperwork is available. V10 said section J1400 should be marked a yes for R45 after reviewing the hospice certification signed 4/23/25 for MDS on 4/28/25 and 7/30/25. 4. On 07/31/2025 at 1:02 PM V15, LPN (Licensed Practical Nurse), said Resident R113 is on hospice. V15 said both the nurse and the CAN (Certified Nurses Assistant) were here to see her today, I saw them. On 7/31/25 at 1:08PM V9, MDS Nurse, said R113 was not marked Hospice on her MDS due to an error on our part. Review of R113's care plan includes intervention for her hospice care plans. Review of R113's census states she is on hospice. Review of R113's MDS May 2025 has no 0 for hospice. R113 Hospice Certification and Plan of Care states start of care 1/17/2024. 5. R18's diagnosis face sheet does not include Bipolar diagnosis or ICD9 code. R18's MDS dated [DATE] Section I I5900 Bipolar diagnosis is marked. The surveyor requested documentation of R18 diagnosis of Bipolar. On 7/31/25 V15 said she cannot find a written diagnosis. 07/31/2025 11:15 AM V2 (DON/Director of Nurses) said R18 is not Bipolar, she does not have a diagnosis of Bipolar.

Based on interviews and record reviews the facility failed to follow their policy and procedure for fall prevention by not ensuring the fall intervention of providing two-person assistance for transfers was implemented while providing care for a resident who is totally dependent on staff for transfers. This failure applies to one of four residents (R3) reviewed for falls. Findings include: R3 is an [AGE] year-old male with a diagnoses history of Rhabdomyolysis, Polyneuropathy, Presence of Left Artificial Knee Joint, History of Falling, and Generalized Arthritis who was admitted to the facility 06/07/2023. On 07/23/2025 at 11:34 AM Observed R3 in his room lying in his bead, R3 confirmed he had a fall on 07/18/2025, R3 stated he was being brought back to his room from a shower, the nursing aide placed the shower table next to his bed, and when a nursing aide was sliding him from the shower table to his bed he slid down to the floor. R3 stated he received a cat scan while at the hospital and he has bruising on his lower back. R3 stated he told them not to take him to the shower in that manner and that he preferred a bed bath, he is afraid of falling again that way, and he has asked them not to transfer him that way again. R3 stated the incident has caused him a little anxiety feeling that this may happen again. R3's Current care plan documents he is totally dependent on staff for assistance with activities of daily living, requires mechanical lift with two-person assistance for transfers, is at risk for falls and injury related to falls due to history of fall resulting in a fracture. R3's progress note dated 7/18/2025 at 3:51 PM documents he was observed on the floor next to his bed lying on his back, the nurse practitioner (NP) was notified promptly and per the NP's order, the resident was transferred to the hospital; at 8:44 PM it was noted R3 returned to the facility from the Hospital via stretcher, he complained of mild aches and lower back pain and discomfort, and was diagnosed with acute lower back pain. R3's Fall Incident Report dated 07/18/2025 at 12:00 PM documents he was observed on the floor in his room next to his bed and reported he slid off the shower bed when he was transferred from the shower chair to the bed, he was transferred to the hospital for a fall. R3's Hospital Discharge summary dated [DATE] documents he was seen for a fall and his discharge diagnosis included acute midline lower back pain. R3's physician progress note dated 7/23/2025 documents patient presents following a recent fall incident, Physical examination reveals minor bruising, the patient's musculoskeletal system review confirms the presence of bruising related to the fall. On 07/24/2025 at 1:40 PM V13 (Certified Nursing Assistant) stated on 07/18/2025 she was giving R3 a shower by herself, she asked somebody for help, and she thinks the young lady who was working with her on that unit went on break, then her nurse V5 (Licensed Practical Nurse) told her to ask her for help if she didn't find anyone, and she forgot to ask V5 for help. V13 stated she placed the shower bed towards the R3's bed and locked it, she usually takes a sheet and pulls it so she can transfer R3 to the bed and she guesses she didn't do it correctly, so she had to come around the other side of the bed to make sure R3 didn't fall. V13 stated she broke R3's fall a little but not entirely, R3 still complains about his back pain and she feels bad, V2 did speak with her about R3's fall and she was suspended for it and she was educated by V2 and moving forward she must have two person assistance for transfers, when she was preparing to transfer R3 the aide was on break the nurse was passing medications, and she didn't find any other aides around. On 07/24/2025 at 1:50 PM V2 (Director of Nursing) confirmed there should have been two-person assistance with transferring R3 on 07/18/2025 and that he did suspend V13 (Certified Nursing Assistant) for not asking for assistance with transferring R3. The facility's Fall Policies received 07/28/2025 states: The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident. Fall Prevention is achieved through an IDT (Interdisciplinary Team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls.Systems Approach - Tips for Compliance includes: Fall Management (Determination of risk)Develop and implement interventions.

Based on observation, interview and record review, the facility failed to follow two residents fall care plan and failed to transfer two residents (R1, R2) in a safe manner using a wheelchair and mechanical lift in a sample of three. These failures resulted in R1 sustaining an avoidable fall out of wheelchair and R2 sustaining a fall while using a mechanical lift resulting in R2 being sent to hospital due to constant headache, left hip, left elbow and left leg pain for three days. Findings include: R2 is a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not limited to quadriplegia cervical 1-cervical 4 complete, anxiety disorder and spinal stenosis cervical. R2's Minimum Data Set (MDS) section C0500 dated 4/4/2025 documents Brief Interview for Mental Status (BIMS) score = 15 which suggests cognition is intact. MDS section GG0130 dated 4/42025 documents resident is dependent on staff for the following: eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. R2's Fall Risk Observation form dated 4/7/2025 documents fall risk low with score of 9. On 6/16/2025, at 10:48 AM R2 stated I had a fall about 3 weeks ago it was a Friday. I was in the Mechanical lift and I ended up on the floor. The strap was not put right in the hook, I think. I hurt my elbow and my hip and my head. I went to the hospital Monday after the fall Friday due to the pain. They took x-rays and everything was ok. No injuries. I do not have any bruises any longer from it, but I did have. Only the left side unhooked. V6 CNA (Certified Nurse Assistant) and someone else (V8) were the CNAs that were here when it happened. They asked if I wanted to go to the hospital and I said not today. On 6/17/2025, at 10:49 AM R2 stated I had the fall with the Mechanical lift before Memorial Day that Friday. The lifts are not broken, they just did not hook it right that is what happened. I did have a lot of pain in my left elbow, left hip, and head. Pain level was 8/10 to head for 3 days. The elbow pain was about an 8/10. The hip did not have much pain at all. I had bruises to left elbow and left hip. The CNA name was (V6) the one that hooked up the loops to the machine. At 10:55AM as surveyor was speaking with R2, V10 CNA and V11 CNA entered R2's room to help move R2 from bath bed to chair. Surveyor observed both CNAs place Mechanical lift pad and place R2 in lift. R2 stated he wanted black loop on legs and green on the top. Bar placed across chest. Mechanical lift legs were not opened to wide base while lifting R2 with mechanical lift. Legs of Mechanical lift was then opened slightly to lower resident in chair. R2 noted to instruct CNAs on Mechanical lift use every step of the way. V11 stated we are supposed to widen the legs of the lift prior to lowering the patient. When asked if needed to widen the legs to lift patient V11 stated there is no need to widen the legs to lift the patient from bath bed if the lift fits it fits. V10 CNA stated I was only aware of widening the legs of the lift when getting in front of chair to lower resident. R2's care plan dated 4/4/2024 documents focus: The resident is at risk for falls related to Deconditioning, Gait/balance problems, Paralysis. Goals: The resident will be free of minor injury through the review date. o The resident will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs. o Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. o Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility o ensure even weight distribution, when using H**** lift/sling (mechanical lift) d/t (due to) patient's spasms/quadriplegia o Follow facility fall protocol. On 6/16/2025, at 12:53 PM, V5 Licensed Practical Nurse (LPN) stated I was here the day R2 had a fall from the Mechanical lift. The CNAs were V8, and the other person was a restorative aide V6. So, I was sitting at the nurse's station charting and V6 CNA came by the door and waved for me to come here and R2 was on the floor in between the Mechanical legs. R2 was completely out of the sling on the floor. The Mechanical lift was like halfway up/down like in the middle. I assessed R2. I helped get R2 back in the bed. I called V2 and the Doctor. The doctor asked if he was in pain. R2 had denied pain and did not want to be sent out to the hospital. A few days later I was R2's nurse again and he was complaining of pain, and I sent R2 out to hospital then and they did a full work up with no findings. I do not know how or why R2 fell out of the Mechanical lift. It makes no sense to me. R2's progress note dated 5/23/2025 documents: Note Text: Patient fell out of H**** lift (mechanical lift) during transfer. R2's incident report dated 5/23/2025 documents: witnessed fall. Resident description: resident stated they fell out of H**** lift (mechanical lift) during 2-person transfer. R2's skin assessments dated 5/27/2025, 5/30/2025 and 6/3/2025 show skin intact and no abnormalities marked. R2's hospital records dated 5/26/2025 document reason for visit: Fall. Imaging tests Computed Tomography (CT) cervical spine without contrast, CT head without contrast, X-ray elbow left 2 views, and x-ray hip left 2 views. CT head wo contrast results documents history: post traumatic headache. CT cervical spine wo contrast documents history: posttraumatic cervical spine pain. X-ray elbow left 2 views documents history: elbow pain. X-ray hip left 2 views results document history: posttraumatic left hip pain. ED (emergency department) triage notes documents: Patient comes to ED via EMS (emergency medical services) for a fall that occurred 3 days ago. Patient denies any LOC (loss of consciousness). Per patient, nursing staff was using a (mechanical lift) and dropped patient on his left side. Patient has a constant headache, left hip pain, and left leg pain. Pt denies any blood thinner at this time. ED (emergency department) provider notes documents: He experiences pain in his left elbow, hip and head following an incident where he was dropped from a (mechanical lift) at facility. the pain is localized to the left side, with specific mention of elbow and hip. He has difficulty with movement, expressing both ' I can move and 'I can't move' indicating some level of immobility or discomfort. No changes in leg color were noted, as he confirms it is normal for him. ED Provider notes also document Fifty male with history of present illness above, differential includes acute traumatic injury versus sequelae. On 6/16/2025, at 1:10 PM, V6 (Restorative Aide/CNA) stated I do recall working the day R2 had a fall from the Mechanical lift. So, I was going in there to assist the CNA (V8) to get R2 up. We did all of R2's ADL (activities of daily living) care, got R2 dressed and was getting R2 up to get in his chair and were using the Mechanical lift. R2 was very specific as to wanting the green straps (of Mechanical lift pad) at the top and the black straps at the bottom. This Mechanical lift we were using did not go up very high so the other CNA V8 (she no longer works here) was lowering the bed and holding R2's feet as I was pulling the Mechanical lift out. R2's body started tipping a little and when I was pulling R2 out V8 CNA had his feet and somehow some way the strap came out of the Mechanical lift, and I was able to grab it and lower R2 down to the floor so he did not hit so hard. R2 did hit his left elbow and left hip. We immediately asked him if he was ok he said yes. V8 CNA went and got the nurse V5 (LPN). V5 assessed R2 and asked if he was ok and he said yes and that he just hit his elbow on the Mechanical lift leg. R2 did not want to go out to the hospital and said he was fine. Myself, V8 CNA and V5 LPN got R2 back in bed. V5 LPN reported it to V2, Director of Nursing (DON). V2 came around and checked on R2 and he was fine. R2 wanted us to use the same Mechanical lift again to get him up and I told him I did not feel comfortable using that same Mechanical lift. It had to be a Mechanical lift malfunction. It seemed like one of the arms were loose or something. I am not sure if that same Mechanical lift is here or not. R2 did not get hurt because I was able to grab the Mechanical lift pad as it was going down so R2 did not hit as hard as he would have if I didn't. Surveyor went with V6 to look at Mechanical lifts in the building. Mechanical lift with outside company stickers and battery with no brand name has no safety clips but does not appear to initially have them. V6 stated the other Mechanical lift we used is similar to this one and I think the side hook was loose. Surveyor noted nut holding the side plate with hooks. Mechanical lift observed and did not have safety clips and area to put loops on was smaller. V6 stated I think they got rid of that Mechanical lift. V2 and upper management were looking at the Mechanical lifts after the incident and I think they tightened the bolt and got rid of that lift. On 6/16/2025, at 1:32 PM, V2 DON stated I was in my office with the ADON (Assistant DON) and restorative nurse having a meeting and V5 LPN came and said R2 had a fall from the Mechanical lift. We all went down there to see what had happened. So, I checked to see if R2 was ok. R2 said he was fine. I came back and spoke to R2 later that day when it was just him and R2 told me it was an accident, and I am fine. I called V15 Nurse Consultant and me, the 2 CNAs (V6 and V8) and V15 Nurse Consultant went back to R2's room and connected him up to the same Mechanical lift they said they used. The aides claimed the Mechanical lift arm was loose, but I didn't think the arms were that loose. So, I took it (Mechanical lift) out of use sent it back to the company. I did have V13 (Maintenance Assistant) tighten up the nut on the arm just in case it got used before it got picked up from the company. V13 said it didn't tighten much but it did tighten some. Those arms are made to swivel. R2 did say what color loops he wanted where, and they hooked it up the same way they did earlier, and it did not sway how the girls (V6 and V8) said it did. One of the hooks from the head area had come undone and that is how he had fallen out. It was not one of the legs. R2 did not tell me that the CNA's did not hook it all the way. R2 complained that the bar on top wasn't wide enough on that Mechanical lift and that is why he was swinging. R2 kept telling me it was an accident. I also talked to him separately when the staff was not there so R2 could tell me anything confidentially. We also did education on staff on what Mechanical lift pads to use with the correct machine. The pad they used that day was the correct one for the correct lift. The one Mechanical lift that has the missing clips is a rented Mechanical lift and I am waiting for the company to pick it up. I needed it to lift a larger resident. On 6/16/2025, at 2:37 PM, V2 stated for the fall with the Mechanical lift for R2 the CNAs were V6 and V8. V8 resigned the day after the incident. V8 was upset when we were asking questions, I don't know if it scared her or what. My expectation of staff regarding things out of the ordinary happening is it should be reported. Proper lifting techniques, proper transfer techniques, etc. Once R2 fell they reported it right away. We as upper management were just making sure we are following our procedures. That is why I got V15 Nurse Consultant because it did not compute in my head how he could have had a fall from a Mechanical lift. On 6/16/2025, at 2:50 PM, V1 Administrator stated my expectation of staff regarding falls is to prevent falls as much as possible. Once a fall occurs is to call the nurse and have the nurse assess, ensure resident is ok and report to administration to investigate fall. My understanding of a reportable is that we report abuse, fall or injury especially an injury of unknown origin. I would not consider these two falls reportable. In R2's case in the initial reporting of the incident he was lowered to the floor when the sling was coming unloose. V6 said she got him and assisted to the floor, and he did not have any injuries. When R2 was interviewed R2 said they did not let me fall. Then later R2 said they dropped me. V15 Nurse Consultant stated it was not reportable. We still did the fall incident in the computer. We always report abuse and if we don't know how it happened. But if we know how it happened and no injury, we don't report it. When asked by surveyor if reporting includes unusual occurrences V1 stated I understand I can see that they could be considered unusual occurrences. I don't see how him being assisted to the floor is an unusual occurrence though. R2 calls the state on us when he does not get his way. If I thought, they willfully did something or negligent I would have reported it. I am not sure what to think of the Mechanical lift fall. To be totally honest the equipment here is completely different to what I am used to. We did not have all of this equipment and I am not familiar with how they work. On 6/17/2025, at 9:59 AM, V8 CNA stated I previously worked at facility for about 2 months. I quit working there the last week of May. I do remember working when R2 fell from the Mechanical lift. So basically, I was assigned to that set. R2 likes to get up like 10 am. I went to go get V6 CNA to help me because a Mechanical lift is a 2-person lift. We did all his ADLs changed him and got him dressed. I went to go get the regular Mechanical lift and could not find the one I usually use. I got the other one and R2 likes us to use a certain color loop on top and a certain color on bottom. I told him we needed to put on the different colors because it was a different Mechanical lift. The Mechanical lift was broke and it was not working properly. The things that you put the loops on was swinging and it can literally flip all the way around. I told him I did not want to use this Mechanical lift but he wanted to get up. There was another Mechanical lift in the building, but it would not charge, and we could not find the battery for that one. So, we ended up using the broken Mechanical lift. R2 likes green and black loops. R2 would not let us use the different color loops R2 wanted the green and black. We hooked R2 up and V6 CNA was holding his top half and pulling the Mechanical lift away from the bed and I was holding R2's feet. The Mechanical lift would not lift R2 completely off the bed. R2's buttocks was still touching the bed. So, I was lowering the bed. I am moving R2's legs and V6 CNA started pulling the Mechanical lift and V6 seen the loop come off of the hook because the thing was swinging. R2's weight was swinging. R2 was not in the normal sitting position. It was not the right way; I knew it was not the right way. V6 seen that and tried to catch R2 in the Mechanical lift pad before he went to the floor. V6 was able to kind of catch R2 but R2 hit his shoulder and his hip on the floor. R2 hit his head on V6's foot. So, R2 did not fall as hard as he could have but R2 did fall. That is not even the first time they had an incident with this Mechanical lift. After this happened, they magically found another Mechanical lift that worked. R2 told me that the facility told them several times that they were not going to fix the (mechanical lift). I had not ever reported that Mechanical lift not working. That was the first time I had used that Mechanical lift. I usually used the other one, and that one worked. That day the battery would not charge on the other one. We could not find a battery that worked. I did not tell management about that prior to using the broken (mechanical lift). We told V2 after the fact about the battery not charging so he knew. What would have prevented this from happening would be if we would have had a different Mechanical lift or if the arms weren't loose and if we would have paid more attention to the state of the Mechanical lift before using it. The last time I was trained on the Mechanical lift was when I got hired around March. I always knew it was a 2-person job. If we see a fall or know of a fall, we are to report to the nurse right away. On 6/17/2025, at 11: 26 AM, V6 Restorative Aide/CNA stated, regarding the Mechanical lift used the day R2 had a fall, the Mechanical lift that we used that day, I was not aware of it being broken prior to us using. We looked for the Mechanical lift we normally used for R2 and could not find it. I did not notice prior to using the Mechanical lift that the arm was swinging more than it should have until he was in the sling. I was the one that hooked R2 up to the Mechanical lift that day. I did not and do not recall V8 telling R2 not to use the black and green loops for the Hoyer that day. There were 2 other Mechanical lifts here that day but did not have batteries to charge them. The batteries were dead. We had to plug them in. I do not know how long it normally takes to charge the batteries. I think they were the Mechanical lifts that they are renting. I do not think they came with any battery exchange. So, they only had the one it came with. V8 CNA no longer works here. V8 is my daughter. I don't know if V8 knew the lift was broke before I came in to help her. I did not know that it was broken prior to using it. I know R2 was adamant to get out of the bed because he was in the bed for the 2 days prior from his preference. R2 still wanted to use the same Mechanical lift after the fall and I refused. We did end up finding the other Mechanical lift we normally use for him after the fact. In my opinion if they checked the Mechanical lift more often to see if they are working properly this would have not happened. And making sure they are charged pretty much that is it. I do not know how often they check the Mechanical lifts. If they are broken or not charging, we let V2 know and take down to maintenance door and they will look at it. On 6/17/2025, at 11:44 AM, V2 stated, on the floor we have four Mechanical lifts in the building. We had more but parts broke, they were old we had to pull them out. It costs less to buy a new Mechanical lift than to get them fixed. Regarding the CNA Mechanical lift transfer trainings they should be done annually. The records show the last Mechanical lift training was done for all CNAs on 12/6/2023. I started some trainings for the CNA's that were here on the day of the Nurses training fair on 4/3/2025. Schedule requested from V2 for 4/3/2025. The Mechanical lift competency training for most of CNA's is past due about 6 months. I have a skills fair I am planning for September for CNA's. Maintenance logs provided to surveyor for six pieces of equipment. V2 stated some may be sit-to-stands and some Mechanical lifts. I do not think they have maintenance logs for the rented Mechanical lift . Surveyor requested to go with V2 to go match up serial numbers from maintenance logs with Mechanical lifts in the building. On 6/17/2025, at 11:49 AM, Surveyor went with V2 to look at all Mechanical lifts and match up serial numbers with Mechanical lifts from maintenance logs. 2 Mechanical lift and 1 sit to stand lift noted on (hall) (3). Medicare area noted to have 2 Mechanical lifts in that area. V2 stated there are 4 Mechanical lifts in the whole building. The other two maintenance logs are for sit to stand lifts. Surveyor asked V2 to provide surveyor with a report showing how many residents need to use the Mechanical lift. On 6/17/2025, at 2:22 PM, Surveyor reviewed list of residents who are care planned to use mechanical lift with 2-person transfer or mechanical lift and there are 18-24 residents in the building who use this type of lift per provided list. On 6/17/2025, at 11:55 AM, V7 Maintenance Director stated we do not do maintenance on rented Mechanical lifts as they are rented. I think we have 3 Mechanical lifts in the building. I do not know how many residents use Mechanical lifts in the building. On 6/17/2025, at 12:44 PM, training records provided to surveyor for 18 CNA's showing annual competencies completed on 4/3/2025 including total body lift including V6 CNA and V8 CNA. On 6/18/2025, at 1:00 PM, Administrator provided surveyor a list of current CNA's showing a total of 48 CNA's currently employed. On 6/17/2025, at 1:16 PM, V7 stated, we currently have 4 Mechanical lifts in the building currently all owned by us. We do monthly checks on those lifts unless staff notified us that there is a problem then we check them whenever staff brings to us or tells us about it. V14 Scheduler/Ancillary Clerk lets me know when we have a rental Mechanical lift in the building. I do not do any type of maintenance on those lifts. If anything goes wrong with them, we call the company and they come out and service or replace them right away. The lift that R2 fell from I did not tighten any screws to that lift unless my assistant did that, we are not supposed to do any maintenance on these lifts or equipment. We are not even supposed to touch them lifts. When surveyor told V7 that the staff stated maintenance tightened the screws V7 stated I am going to have to get on V13 Maintenance Assistant about that then. Anything the other companies bring we call them for maintenance on that, we are not supposed to touch them. On 6/17/2025, at 1:30 PM, V13 stated the Mechanical lift that R2 fell out of staff did bring that Mechanical lift down to me to tighten the screws. I did tighten the screws on it. I did tighten the screws on it after the fall. This was a rental Mechanical lift . The screws were loose and it had more play in it than we would like. We normally do not work on the rental equipment that is why I suggested it to be sent back. I did not know if they were going to come with a new rental or not and wanted it to be operational and safe that is why I tightened the screws on that (mechanical lift). As soon as that happened, we took it off the floor. When asked why you tightened the screws if you pulled the lift off of the floor right away V13 stated when I tightened the screws I had not talked to V2 at that point, but my suggestion was to get it replaced. I spoke to V2 and that is when it got taken off the floor. V7 stated I am not sure how long it usually takes to pick up or service equipment that would be V14. The companies do not come out and service their equipment unless we call them. I am not sure if they have a contract to do upkeep on their equipment on a certain schedule. That would be a V14 question. I have not seen them come out and just check on equipment that does not have any problems. On 6/17/2025, at 1:40 PM, V14 stated I am in charge of ordering rental equipment and notifying companies when their equipment needs servicing. Usually, it takes about a day or two to come and pick up or service equipment. Unless we have a problem with the equipment, the companies do not come out and maintain the equipment like Mechanical lifts, beds, broda chairs, floor mats, etc. The companies that provided oxygen and CPAP machines do come out about every 2 months and check on their equipment. We are not supposed to do any maintenance on outside company equipment. Surveyor asked is there anything that could have been done to prevent R2's fall from Mechanical lift. V14 stated in my opinion me being a CNA for umpteen years I would have noticed the arm being loose. Maybe a newer CNA would not have noticed that. R1 is a [AGE] year-old resident initially admitted to facility on 4/25/2023 with diagnoses including but not limited to: transient cerebral ischemic attack, vascular dementia unspecified severity with behavioral disturbance and major depressive disorder. R1's Minimum Data Set (MDS) section C0500 dated 4/30/2025 documents Brief Interview for Mental Status (BIMS) score = 06 which suggests severe cognitive impairment. MDS section GG0130 dated 4/30/2025 documents resident needs set up or clean up assistance with eating. Resident needs substantial/maximal assistance with lower body dressing, putting on/taking off footwear, and personal hygiene. Resident is dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, and upper body dressing. R1's Fall risk assessment dated [DATE] documents resident is a high falls risk with score of 15. R1's Progress note dated 6/6/2025 documents: Note Text: Staff brought resident while in his wheelchair to the nurses cart and stated that the resident almost fell, (V4) CNA (certified nursing assistant) states that resident was standing while holding onto the side rails of the wall and as an attempt was made to sit down in his wheelchair resident missed the wheelchair and V4 CNA assisted resident to the floor with no injuries, no injuries noted. Resident assessed, vitals WNL, denies pain, no further actions required at this time. On 6/16/2025, at 10:55 AM, R1 noted to be sitting in wheelchair in front of nursing station. Surveyor asked staff to see if R1 would talk to surveyor in his room. R1 agreed to talk to surveyor in his room. R1 noted to be sleepy sitting in wheelchair with eyes opening and closing during wheelchair transfer to room by staff. R1 stated he was ok. R1 stated he did not have a fall recently. Everyone treats me ok. When asked if anyone pulled the wheelchair out from underneath R1 he stated yes and stated the first name of V4 when asked who did that. When R1 was asked if he fell when the wheelchair was pulled from underneath R1 he stated yes. I do not remember what day she (V4) pulled the wheelchair from underneath me. Resident could not answer why V4 pulled the chair from underneath of R1 or if it was an accident or on purpose. R1 clean and well groomed. No foul odors noted. On 6/17/2025, at 10:42 AM, R1 was in dining room alone at a table close to doors by nursing station. R1 stated I did not fall out of my wheelchair recently. Someone pulled the chair out from underneath of me. It was the nurse. R1 stated her name was the first name of V4. When asked how it happened R1 stated I was sitting down. She (V4) was trying to push me out of the dining room. She (V4) was pushing me backwards in the wheelchair. I fell to the ground. She (V4) helped me back up. I did not get hurt. I did not have any pain or bruises. On 6/16/2025, at 11:58 AM, V4 stated I do recall an incident with R1 almost falling out of the wheelchair. I do not recall the exact date. I think it was a Thursday about a week and a half ago. I am pretty sure it was a Thursday. All that happened was that R1 was trying to stand up and was trying to grab on to a door handle and R1 is a high fall risk. So, I went over to R1 and tried to sit him down and he grabbed on to the handrailing and was holding on really tight and so I went to move the chair because the chair was stuck. R1 was standing up at that point, and I went to move the chair and R1 started wobbling and he lowered himself to the floor as I was standing by him. R1 was taken to the nurse (V3) Registered Nurse (RN) and I let her know R1 had an assisted fall to the floor and everything was witnessed. No one else that I am aware of witnessed the fall besides me. I was already guiding R1 to sit down when this happened, so it was an assisted lowered to the floor. R1 landed on one of his knees. There were no visible injuries. R1 was acting normal. No complaints of pain. R1 was taken straight to the nurse. The nurse was V3. R1 is a high fall risk. R1 constantly tries to stand up and we have to assist him or redirect him to sit down. R1 was close to the nurse's station but by the corner. R1 is usually at the nurse's station for higher visibility. But R1 can wander around a little bit, but he does not go too far. We all keep an eye and watch closely the high fall risk residents. R1 was my resident that day. That is my normal assignment. I have had R1 every day I have worked for like a year and a half, so I know him very well. On 6/16/2025, at 1:32 PM, V2 Director of Nursing (DON) stated my expectation of staff regarding documentation is that staff should document incidents before their shift is over. Obviously patient care comes first. There should not be an incident that is documented the next day. For R1, I got a note under my door that a staff member seen resident on the floor, but no incident was reported. I went and talked to all staff members noted in the area that day. My investigation revealed there was a CNA (V4) that was caring for R1 and was rolling him backwards through the door and he grabbed the door frame, and he slid out of the chair. V4 picked him up and put him back in the chair but did not report. The CNA V4 told the nurse V3, get your resident he almost fell. So now I am interviewing everyone and trying to investigate and see what happened. The CNA V4 did not want to get in trouble and did not report so we opened up the incident the next day because we now knew R1 actually fell. V4 was the CNA, and she was terminated after the investigation. Once I got everyone's statements, I suspended V4 for 3 days pending investigation and then terminated her the following Wednesday. We looked at the camera and it doesn't show the area. You can see everyone going over there but cannot see the incident. That is when I started getting statements from everyone I seen in the camera. So, R1 did have a fall, it was not assisted to the floor. V4 was pulling him backwards and R1 put his arms on both sides of door jambs, and R1 braced himself on the door and fell out of wheelchair. R1 was not standing up, V4 was bringing him out of the dining room. I don't think it was intentional, if V4 would have just reported it we would not have a problem. Surveyor asked to see cameras and to see the termination paperwork. V2 DON provided discipline form recommending termination dated 6/10/2025 signed by V4 CNA. V2 DON stated we brought V4 back from suspension and the same day terminated her. On 6/16/2025, at 2:06 PM, V2 DON stated the camera only records for 24 hours and it cycles so we do not have the footage unless maintenance can pull it up. When I looked at it, it was still in the 24 hours. V2 showed surveyor the live footage of the area and where R1 was, which is out of screen view but just to give you an idea of where he was and where it happened. I will go see if maintenance can pull it up for you. On 6/16/2025, at 2:11 PM, V2 DON and V7 Maintenance Director. V7 stated the cameras only loop for 24 hours. After 24 hours there is no access that we can get. Surveyor asked what happens if something happens on the weekend and now you do not have access to check the cameras. V2 DON stated I think it is the package they bought for the cloud I have been asking them to upgrade it for that reason. On 6/17/2025, at 12:18 PM, V3 Registered Nurse (RN) stated I was working when R1 had his fall. I did not witness it. It (fall) was on a Thursday. I charted on 6/6/2025. I was notified of an incident that he almost fell, and they brought R1 to me on 6/5/2025. On 6/6/2025 I was notified that R1 did have a fall on 6/5/2025 and told to put in my progress note and open an incident on it. R1's Care plan dated 3/3/2024 documents focus: Resident is at risk for falls and injury related to falls due to history of falls, decreased safety awareness due to altered mental status and Dementia. He also has weakness, decreased mobility, and utilizes psychotropic medications. Goals: The resident will not sustain serious injury through the review date. Interventions: Ask the resident every one to two hours if he needs to use the bathroom. o Dycem in place o Ensure the transfer path is clear and\or resident is not grabbing stationary objects during transfer. o Give resident verbal reminders not to ambulate/transfer without assistance. o Keep bed in lowest position with brakes locked. o Keep call light in reach at all times. o Keep personal items and frequently used items within reach. o Keep wheelchair out of reach of resident. o Monitor for proper positioning when in bed o Monitor pt closely when in wheelchair. o Observe frequently o Orient [TRUNCATED]

Based on interview and record review the facility failed to report to state agency two unusual occurrences for two (R1, R2) of three residents reviewed for incidents and accidents. This failure resulted in R1 and R2 sustaining avoidable falls and R2 being sent to hospital with constant headache, left hip pain, left elbow pain and left leg pain. Findings include: R1 is a [AGE] year-old resident initially admitted to facility on 4/25/2023 with diagnoses including but not limited to: transient cerebral ischemic attack, vascular dementia unspecified severity with behavioral disturbance and major depressive disorder. R1's Minimum Data Set (MDS) section C0500 dated 4/30/2025 documents Brief Interview for Mental Status (BIMS) score = 06 which suggests severe cognitive impairment. MDS section GG0130 dated 4/30/2025 documents resident needs set up or clean up assistance with eating. Resident needs substantial/maximal assistance with lower body dressing, putting on/taking off footwear, and personal hygiene. Resident is dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, and upper body dressing. R1's Fall risk assessment dated [DATE] documents resident is a high falls risk with score of 15. R1's Progress note dated 6/6/2025 documents: Note Text: Staff brought resident while in his wheelchair to the nurses cart and stated that the resident almost fell, (V4) CNA (certified nursing assistant) states that resident was standing while holding onto the side rails of the wall and as an attempt was made to sit down in his wheelchair resident missed the wheelchair and V4 CNA assisted resident to the floor with no injuries, no injuries noted. Resident assessed, vitals WNL (within normal limits), denies pain, no further actions required at this time. On 6/16/2025, at 10:55 AM, R1 noted to be sitting in wheelchair in front of nursing station. Surveyor asked staff to see if R1 would talk to surveyor in his room. R1 agreed to talk to surveyor in his room. R1 noted to be sleepy sitting in wheelchair with eyes opening and closing during wheelchair transfer to room by staff. R1 stated he was ok. R1 stated he did not have a fall recently. Everyone treats me ok. When asked if anyone pulled the wheelchair out from underneath R1 he stated yes and stated the first name of V4 when asked who did that. When R1 was asked if he fell when the wheelchair was pulled from underneath R1 he stated yes. I do not remember what day she (V4) pulled the wheelchair from underneath me. Resident could not answer why V4 pulled the chair from underneath of R1 or if it was an accident or on purpose. R1 clean and well groomed. No foul odors noted. On 6/17/2025, at 10:42 AM, R1 was in dining room alone at a table close to doors by nursing station. R1 stated I did not fall out of my wheelchair recently. Someone pulled the chair out from underneath of me. It was the nurse. R1 stated her name was the first name of V4. When asked how it happened R1 stated I was sitting down. She (V4) was trying to push me out of the dining room. She (V4) was pushing me backwards in the wheelchair. I fell to the ground. She (V4) helped me back up. I did not get hurt. I did not have any pain or bruises. On 6/16/2025, at 2:37 PM, V2 Director of Nursing (DON) stated in my mind what constitutes a reportable is someone getting hurt, anything out of the ordinary. The other occurrence with staff causing a fall should have been reported to IDPH as well since that is out of the ordinary. On 6/17/2025, at 12:18 PM, V3 Registered Nurse (RN) stated I was working when R1 had his fall. I did not witness it. It (fall) was on a Thursday. I charted on 6/6/2025. I was notified of an incident that he almost fell, and they brought R1 to me on 6/5/2025. On 6/6/2025 I was notified that R1 did have a fall on 6/5/2025 and told to put in my progress note and open an incident on it. R2 is a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not limited to quadriplegia cervical 1-cervical 4 complete, anxiety disorder and spinal stenosis cervical. R2's Minimum Data Set (MDS) section C0500 dated 4/4/2025 documents Brief Interview for Mental Status (BIMS) score = 15 which suggests cognition is intact. MDS section GG0130 dated 4/42025 documents resident is dependent on staff for the following: eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. R2's Fall Risk Observation form dated 4/7/2025 documents fall risk low with score of 9. On 6/16/2025, at 10:48 AM R2 stated I had a fall about 3 weeks ago it was a Friday. I was in the Mechanical lift, and I ended up on the floor. The strap was not put right in the hook, I think. I hurt my elbow and my hip and my head. I went to the hospital Monday after the fall on Friday due to the pain. They took x-rays and everything was ok. No injuries. I do not have any bruises any longer from it, but I did have bruises. Only the left side unhooked. V6 CNA and someone else (V8) were the CNAs that were here when it happened. They asked if I wanted to go to the hospital and I said not today. On 6/16/2025, at 12:53 PM, V5 Licensed Practical Nurse (LPN) stated I was here the day R2 had a fall from the Mechanical lift. The CNAs were V8 and the other person was a restorative aide V6. So, I was sitting at the nurse's station charting and V6 CNA came by the door and waved for me to come here and R2 was on the floor in between the Mechanical legs. R2 was completely out of the sling on the floor. The Mechanical lift was like halfway up/down like in the middle. I assessed R2. I helped get R2 back in the bed. I called V2 and the Doctor. The doctor asked if he was in pain. R2 had denied pain and did not want to be sent out to the hospital. A few days later I was R2's nurse again and he was complaining of pain, and I sent R2 out to hospital then and they did a full work up with no findings. I do not know how or why R2 fell out of the Mechanical lift. It makes no sense to me. R2's progress note dated 5/23/2025 documents: Note Text: Patient fell out of H**** (mechanical lift) lift during transfer. R2's incident report dated 5/23/2025 documents: witnessed fall. Resident description: resident stated they fell out of H**** (mechanical lift) lift during 2-person transfer. R2's hospital records dated 5/26/2025 document reason for visit: Fall. Imaging tests Computed Tomography (CT) cervical spine without contrast, CT head without contrast, X-ray elbow left 2 views, and x-ray hip left 2 views. CT head wo contrast results documents history: post traumatic headache. CT cervical spine wo contrast documents history: posttraumatic cervical spine pain. X-ray elbow left 2 views documents history: elbow pain. X-ray hip left 2 views results document history: posttraumatic left hip pain. ED triage notes documents: Patient comes to ED (emergency department) via EMS (emergency medical services) for a fall that occurred 3 days ago. Patient denies any LOC (loss of consciousness). Per patient, nursing staff was using a H**** (mechanical lift) and dropped patient on his left side. Patient has a constant headache, left hip pain, and left leg pain. Pt denies any blood thinner at this time. ED (emergency department) provider notes documents: He experiences pain in his left elbow, hip and head following an incident where he was dropped from a H**** lift (mechanical lift) at facility. the pain is localized to the left side, with specific mention of elbow and hip. He has difficulty with movement, expressing both ' I can move and 'I can't move' indicating some level of immobility or discomfort. No changes in leg color were noted, as he confirms it is normal for him. ED Provider notes also document Fifty male with history of present illness above, differential includes acute traumatic injury versus sequelae. On 6/17/2025, at 9:05 AM, V1 Administrator stated we do not have a policy for reportables we just follow IDPH guidelines for reporting. Facility was not able to provide policy during course of survey.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate assistance with activities of daily living. This failure applies to five of five residents (R1, R2, R3, R4, and R7) reviewed for ADL's (Activities of Daily Living). Findings include: 1. R1 is an [AGE] year-old female with a diagnoses history of Alzheimer's Disease, Lung Cancer, Severe Protein Calorie Malnutrition, and Encounter for Palliative Care who was admitted to the facility 02/18/2022. R1's current care plan documents she has an ADL (Activities of Daily Living) performance deficit related to Alzheimer's and is totally dependent on staff for activities of daily living. On 05/05/2025 at 10:26 AM R1 is observed in her room sitting in her wheelchair. Observed multiple piles of dead ants on the floors behind chairs and on two large square velcro attachments on the wall behind her bed. 2. R2 is an [AGE] year-old female with a diagnoses history of Recurrent Major Depressive Disorder, Anxiety Disorder, Bipolar Disorder, Heart Failure, Peripheral Vascular Disease, and Morbid Obesity who was admitted to the facility 02/27/2018 and readmitted [DATE]. R2's Current Care Plan documents she has an ADL (Activities of Daily Living) self-care performance deficit related to Musculoskeletal Impairment and is totally dependent on staff for activities of daily living and does not document that she refuses care. On 05/05/2025 at 11:21 AM R2 is observed in her room lying in her bed wearing a gown and her hair greasy. R2 stated she has been wearing the same gown since yesterday and it is stained. Observed R2's gown with a large stain on the front of it. R2 stated she sometimes goes all day without receiving incontinence care and has a sore behind now. R2 stated she doesn't have any wounds on her behind area but has soreness. R2 stated she was told she would be changed every two hours. R2 stated she could turn on her call light and it could stay on all night. 3. R3 is a [AGE] year-old female with a diagnoses history of Recurrent Major Depressive Disorder, Generalized Anxiety Disorder, Partial Paralysis due to Stroke, COPD, and Blindness in Right Eye who was admitted to the facility 01/31/2019. R3's current care plan documents her ability to perform ADLs (Activities of Daily Living) and mobility is impaired and has an ADL self-care performance deficit related to partial paralysis and is totally dependent on staff for activities of daily living. 4. R7 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Stroke, Alzheimer's Disease, Dementia, Parkinson's Disease, and Peripheral Vascular Disease who was admitted to the facility 02/23/2022. R7's current care plan documents she has an ADL (Activities of Daily Living) self-care performance deficit related to disease process, Parkinson's Disease, and Partial Paralysis and requires assistance with most activities of daily living. On 05/05/2025 at 10:31 AM R3 stated she sits in her own poop a lot due to having diarrhea and having to wait for hours after pressing the call light. R3 stated she has baby ants in her room. R3 stated when housekeeping mops, they don't mop the areas around or near her bed. Observed small piles of dead ants on each side of her heater underneath her window. Observed R3's and her roommate R7's room floor sticky and R7 lying in her bed with heavy buildup of residue and particles underneath. 5. R4 is a [AGE] year-old male with a diagnoses history of Anxiety Disorder and Quadriplegia who was admitted to the facility 03/21/2014. R4's Current Care Plan documents he has an ADL (Activities of Daily Living) self-care performance deficit related to Activity Intolerance and Quadriplegia and is totally dependent on staff for activities of daily living. The facility's Wound Report dated 05/05/2025 documents R4 has a moisture associated incontinence wound to his right posterior thigh that is facility acquired and was identified 04/25/2025. Grievance forms from January - April 2025 document concerns on 01/03/2025 regarding long call light response; on 01/08/2025 regarding call light response time and incontinence care; on 01/13/2025 regarding housekeeping, activities of daily living regarding changing the resident and the residents linens; feeding assistance; on 01/27/2025 regarding food quality; on 03/11/2025 regarding showers/bathing/grooming, incontinence care, and not having bed linens; on 03/24/2025 regarding showers, housekeeping, and assistance with activities of daily living of dressing resident; on 03/28/2025 regarding call light response time; and on 04/22/2025 and regarding incontinence care and ants. On 05/14/2025 1:35 PM V2 (Director of Nursing) stated indicators of not enough assistance with activities of daily living would include poor grooming, cleanliness of rooms, body odors, their appearance etc. V2 stated multiple complaints regarding activities of daily living lead to in-services, monitoring the residents care more closely via observations and documentation. V2 stated he identifies trends in issues through observations of call lights ringing, poor grooming, and other nursing care observations as well as nursing reports. V2 stated R4 has a moisture associated wound because he uses a catheter but refuses to have it at night and he can't feel when he's wet. V2 stated to prevent R4 from developing a wound barrier cream is applied overnight, and staff are instructed to still conduct rounds and check him at night although he doesn't wish to be woken up. V2 stated R4 requires more frequent incontinence checks to prevent a wound from developing. V2 stated R4 has never refused incontinence care. On 05/14/2025 at 1:35 PM V2 (Director of Nursing) stated housekeeping may not have returned to cleaned up the piles of dead ants in R1 and R3's rooms after pest treatment was provided. The facility's ADL (Activities of Daily Living) policy dated 02/2023 and received 05/15/2025 states: In accordance with the comprehensive assessment, our facility provides care and services for the following activities: Hygiene (bathing, dressing, grooming). The facility's Housekeeping Services Policy received 05/15/2025 states: It is the policy of this facility to maintain a clean environment in all healthcare and public areas, which meet the sanitation needs of the facility and residents' rights for a safe, clean, comfortable, and homelike environment. Policy Specifications: To ensure that the facility and resident rooms are maintained in a sanitary manner; to provide a comfortable environment. Responsibility: Housekeeping Supervisor and Housekeeping Personnel. The department shall routinely clean the environment of care, to keep the facility free from the accumulation of dust, rubbish, and dirt.

Based on interviews and record reviews, the facility failed to provide adequate supervision for residents who are at risk for falls, with a history of falling; and they failed to implement effective fall interventions. This failure applies to two of two residents (R5 and R6) reviewed for falls. Findings include: R5 is a [AGE] year-old male with a diagnoses history of Vascular Dementia; Peripheral Vascular Disease, Metabolic Encephalopathy, Presence of Cardiac Pacemaker, and Lack of Coordination, who was admitted to the facility 01/06/2024. On 05/06/2025 at 9:53 AM R5 in observed in his room lying in his bed in the lowest position with confusion and his call light closed up in his nightstand drawer behind him. R5's Current Fall Care Plan initiated 03/02/2024 documents he has history of falling related to altered thought process, poor safety awareness, restlessness, and impaired mobility with interventions initiated 03/02/2024 of Give resident verbal reminders not to ambulate/transfer without assistance; widen and extend bed; intervention initiated 03/04/2024 of Keep bed in lowest position with brakes locked; intervention initiated 03/08/2024 of observed frequently; interventions initiated 05/03/2024 of Attempt to keep resident on the same routine; Keep resident in view during high risk times if possible; intervention initiated 09/09/2024 of bolsters and floormates in place; intervention initiated 01/27/2025 of Educate patient to ask for assistance to retrieve dropped items; intervention initiated 02/10/2025 of Monitor for proper positioning while in bed; intervention initiated 03/07/2025 of When resident shows signs of restless, staff will transport resident to nursing station for close monitoring; intervention initiated 03/11/2025 of Engage resident in activities of his liking to keep occupied; intervention initiated 04/04/2025 of When up in geriatric wheelchair keep reclined for safety, due to poor trunk control; and intervention initiated 04/06/2025 of provide comfort and repositioning when restless in bed. R5's Current Care Plan initiated 08/01/2024 documents he displays moderate impairment with daily decision making and requires cues and supervision with interventions of Provide cues, assistance, and supervision with ADLs (Activities of Daily Living) and all facility activities. R5's Current Care Plan initiated 04/06/2025 documents he doesn't have much active movement and requires dependent assistance from staff with interventions including monitor the patient throughout the shift more often; Keep resident clean and dry throughout the shift; Help with ADL care and assist with feedings; Keep resident near nursing station for frequent monitoring. R5's Current ADL (Activities of Daily Living) Care Plan documents he has an ADL self-care performance deficit related to Disease Process, Nervous System Inflammation, Impaired balance, and Limited Mobility and is totally dependent on staff for activities of daily living. R5's progress note dated 12/10/2024 at 4:19 PM documents the nurse observed him lying on the floor on his right side next to the wheelchair in the lounge area and he stated, he tried to transfer from the wheelchair to another chair. R5's Fall Risk Management Report dated 12/10/2025 documents he experience an unwitnessed fall in the lounge. R5's Fall Risk Management Report dated 01/23/2025 documents he had an unwitnessed fall in the dining room while trying to pick up glasses. R5's progress note dated 2/10/2025 at 02:30AM documents he was observed on the left mat next to the bed and was placed back in bed by two aides. R5's Fall Risk Management Report dated 02/10/2025 documents he had an unwitnessed fall in his room and stated he slipped out of bed. R5's progress note dated 3/6/2025 at 02:00 AM documents he was observed lying on the floor mat on the left side of the bed and was picked up and placed in bed with a mechanical lift. R5's Fall Risk Management Report dated 03/06/2025 documents he had an unwitnessed fall in his room and stated he rolled out of his car. R5's progress note dated 3/11/2025 at 12:24 PM documents Writer was called to the lounge by staff and upon entering R5 was observed on floor near his geriatric wheelchair on his right side. Writer asked R5 what happened, and he stated, I just slipped. R5 was placed back in geriatric wheelchair and was positioned in front of nursing station for close monitoring. R5's Fall Risk Management Report dated 03/11/2025 documents he had an unwitnessed fall in the lounge. R5's progress note dated 4/4/2025 at 9:25 PM documents he fell out of the wheelchair in the hallway, after lunch. R5's Fall Risk Management Report dated 04/04/2025 documents he had an unwitnessed fall in the hallway near the nurses station and may be tired of staying in the wheelchair for a long period of time. R5's progress note dated 4/6/2025 at 3:24 PM documents he was observed lying supine on the floor and when asked what happened resident stated I don't know, I'm just on the floor. R5's Fall Risk Management Report dated 04/06/2025 documents he had an unwitnessed fall in his room. R6 is a [AGE] year-old female with a diagnoses history of Epilepsy, Hypotension, Stroke, Disorder of Muscle, Abnormal Posture, Abnormalities of Gait and Mobility, Lack of Coordination, and History of Falling who was admitted to the facility 12/10/2024. On 05/06/2025 at 9:46 AM Observed R6 in her room alone standing with one pant leg on the wrong leg attempting to put on her pants. Observed R6 to be crying and stating she was upset with her daughter because she forgot about her on Mother's Day. Observed R6 with her right foot bare and left foot with a sock on. R6's Current Care Plan initiated 12/10/2024 documents The resident is at risk for falls related Gait/balance problems, Incontinence, Unaware of safety needs with interventions initiated 12/10/2024 of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; Follow facility fall protocol; intervention initiated 03/03/2025 of educate resident to ask for assistance with dressing needs; intervention initiated 03/08/2025 of educate patient to lock wheelchair brakes; and intervention initiated 04/08/2025 of Anticipate and meet The resident's needs. R6's Current Care Plan initiated 12/12/2024 documents she has an ADL (Activities of Daily Living) self-care performance deficit related to arthritis, high cholesterol, stroke without residual deficit, atrial fibrillation (irregular heartbeat), therapy, seizures, cirrhosis, gastrointestinal blood vessel condition, hypertension, and heart medications and requires assistance most activities of daily living. R6's Current Care Plan initiated 01/23/2025 documents she is limited in ability to transfer herself related to weakness and requires a restorative transfer program. R6's Current Care Plan Initiated 03/04/2025 documents she is resistive to care related to adjustment to nursing home and thinking she does not need assistance with ADL care with interventions including Allow the resident to make decisions about treatment regime, to provide sense of control; Encourage as much participation/interaction by the resident as possible during care activities. R6's Fall Risk Management Report dated 12/17/2025 documents she had an unwitnessed fall in her room and was found lying on her left side next to her bed. R6 stated she was reaching for the call light when she fell . R6's progress notes dated 1/9/2025 at 03:00 AM documents she was observed sitting on her buttocks on the side of her bed. R6's Fall Risk Management Report dated 01/09/2025 documents she had an unwitnessed fall in her room, the nurse on duty responded to the call light and R6 was found sitting on her buttocks on the floor next to her bed and stated she was getting ready to go to the bathroom but denied falling. R6's progress notes dated 3/1/2025 at 01:02 AM documents she was observed on the floor. R6 stated she was trying to put her pants on and slid on the floor. R6's Fall Risk Management Report dated 03/01/2025 documents she had an unwitnessed fall in her room and was observed sitting on the floor in front of the wheelchair. R6's progress notes dated 3/8/2025 at 08:00 AM documents the nurse was summoned to R6's room and observed her sitting in front of her wheelchair. R6 stated she was reaching for her pull-ups and slid to the floor. R6 was placed back in her bed with two person's assistance. R6's Fall Risk Management Report dated 03/08/2025 documents she had an unwitnessed fall in her room. R6's progress notes dated 4/8/2025 10:16 PM documents she was observed lying near the end of the bed on the floor. R6 has to be constantly re-educated throughout the day to use assistive devices, walker or wheelchair. Family came to visit and she was fine. When the family left, she wanted to get out of her chair to use the restroom. R6 was placed back in bed and attempted to get up again. R6 refuses to use the call light, refuses to stay in bed and follow simple direction from staff. R6's Fall Risk Management Report dated 04/08/2025 documents she had an unwitnessed fall in her room attempting to use the bathroom. R6's census report documents her room was changed on 04/10/2025. R6's progress notes dated 4/30/2025 at 03:24 AM documents there was a noise heard in room; R6 was observed on the floor lying on left side and placed back in bed per facility protocol. R6's Fall Risk Management Report dated 04/30/2025 documents she had an unwitnessed fall in her room and stated she slid out of bed. R6's progress notes dated 5/2/2025 at 08:30 AM documents This Writer was called to R6's room and upon entering the room she was noted sitting on the floor in a small space between the bed and the wall. When asked what happened R6 stated that she was trying to get her shoe off the floor. (R6's shoes were on the other side of the bed). R6 was assisted off the floor into the bed. R6's Fall Risk Management Report dated 05/02/2025 documents she had an unwitnessed fall in her room. The facility's fall reports from December 2024 - May 2024 documents 86 unwitnessed falls with R5 and R6 each having 7 unwitnessed falls. On 05/14/2025 at 1:35 PM V3 (Restorative Nurse/Licensed Practical Nurse) stated she is the fall coordinator which includes care plan reviews, quality assurance investigation for every fall ensuring all components are in place, and audits fall interventions and equipment. V3 stated the facility does not provide one on one observation or monitoring, nor use restraints or fall alarms. V3 stated R5 is very confused and has very poor safety awareness and staff would not be able to reach him quick enough to prevent a fall. V3 stated R5 is very impulsive and falls just happen. V3 stated one of R5's falls were due to him reaching for his glasses that were already on his face. V3 stated you can't prevent a fall and they have a right to fall. V3 stated you can modify fall care plans when asked by surveyor how can falls be prevented. V3 stated she wouldn't say R5 requires more supervision than the facility can provide and he's like a lot of the facility's patients with dementia with impulsivity and safety awareness. V3 responded absolutely when asked by the surveyor if the facility's goal is to prevent falls. When asked by the surveyor if a resident continues to have repeated falls what does that indicate. V3 responded we continue to address the plan of care and put in an intervention that will prevent that fall. V3 stated R6 does not like coming out of her room so that was an issue, and one recent approach was having activities to go in her room and offer her one to one and we also did a room change where she was moved directly across the nurses station for closer supervision. V3 stated R6's previous room is down the middle hall almost the furthest away from the nurses station. V3 stated she did a restorative modification for R6 for transfers because many of her falls were due to attempt to self-ambulate without assistance. V3 stated R6 is very confused, she has good and bad days and there are days where she doesn't recall time, place, or year and there are times where she is more alert but won't recognize that she has had incontinence episode. V3 stated R6 does not have good awareness of her physical limitations where she thinks she can walk without assistance when she can't and during restorative therapy they do a lot of safety cueing with her. V3 stated R6 refuses care and thinks she can do things for herself and she refuses medications. V3 stated R6 is definitely impulsive and so used to doing everything on her own and caring for everyone else she doesn't know how to accept that kind of help from others. V3 stated R6 has a deficit that is either related to a psychiatric diagnosis or cognitive impairment. When asked by surveyor how can staff monitor R6 adequately from outside her room, V3 stated constant cueing when they see R6 while walking by the rooms and staff do go in and check on her constantly and anticipate her needs. V3 stated she considers R5 and R6's fall interventions successful due to the root causes of her falls constantly changing. V3 stated attempting a routine would be an appropriate fall intervention for R6. On 05/14/2025 at 1:35 PM V2 (Director of Nursing) stated if the fall incident listed on the fall report does not have a Y marked under the section for witnessed, it is an unwitnessed fall however it does not categorize those falls under the unwitnessed fall category due to the way in which the incident is logged in the system. V2 stated if residents continue having incidents despite constant attempts to modify interventions this may indicate they need to be transferred to another facility that may provide one on one care or more supervision. V2 stated if R5 has multiple falls the same way that's when he would say fall interventions are unsuccessful. V2 agreed all of R5's falls have the common theme of him attempting to move and stated R5 attempts to do things on his own. V2 stated R5 has some trunk control and uses a geriatric wheelchair. V2 stated the primary cause of R5's falls is him trying to do things on his own and he doesn't have the cognitive awareness that he is not capable of performing these activities independently. V2 stated R5's mental and physical abilities are not on the same level and a lot of time this is the root cause of his falls. V2 could not explain what an effective intervention would be for this behavior and he doesn't think there is an applicable intervention for this behavior. V2 stated if R5 has his call light he believes he can use it although he may not be sure of what he is using it for, and his call light should be in reach. V2 stated it is important to keep commonly used items in reach for R5 and other residents. V2 agreed all of R6's falls are related to attempting to perform activities of daily living and she doesn't understand she needs to ask for assistance. V2 stated R6 has intermittent confusion and at night she heavily Sundowns. V2 stated the right to fall means the facility can't restrain them from moving. V2 stated if staff observe R5 trying to get up staff should respond as soon as possible and attempt to assist him. V2 stated you would want to increase observations, when R5 is out of bed to ensure he is where he can be easily seen. V2 stated if a resident falls in common areas it could be asked if there were staff present and if so where were they located. V2 stated an indication that fall interventions for R5 or R6 are effective would be a reduction in falls, and not having the same type of falls or falling due to the same causes or contributing factors.

Based on observations, interviews, and record reviews the facility failed to ensure resident rooms were clean and free of clutter, trash, dust, food particles, soiled linens, substances, and chemical buildup. This failure applied to four of four residents (R1, R2, R3, and R4) reviewed for environment. Findings include: 1. R1 is an [AGE] year-old male with a diagnoses history of Dementia, Parkinson's Disease without Dyskinesia, Traumatic Brain Injury, Chronic Kidney Disease, Urine Retention, Urinary Tract Infections, Dysphagia, Disorder of Muscle, and Blindness in Right Eye who was admitted to the facility 04/16/2025. On 04/21/2025 at 10:19 AM V9 (Family Member of R1) stated yesterday she observed food particles in R1's bed and she observed red stains that looked like blood and the nursing aide told her it was Jello. On 04/21/2025 at 10:34 AM, R1 is in his room sitting on his bed. Observed R1's room floors to be sticky and with some trash on it, several red particles on his bed sheet, and a gown left on his bed. R1's bedside table is sitting in front of him with a sticky substance on most of it. A clean brief is seen sitting in the chair in R1's room, a small cup with a thick cream like substance and a clean brief left sitting on a nightstand near his room window, and a gown and linens left sitting on a taller nightstand near his window. R1's Current Care Plan initiated 04/17/2025 documents he has multiple diagnoses that impede his ability to perform activities of daily living at his prior level of functioning. R1's Current Care Plan initiated 04/18/2025 documents has an ADL (Activities of Daily Living) self-care performance deficit related to a decrease in functional mobility, decreased coordination, decrease in strength, falls/fall risk, increased need for assistance from others and functional limitation with ambulation. 2. R2 is an [AGE] year-old male with a diagnoses history of Encephalopathy, Lung and Brain Cancer, Disorder of Muscle, and Cognitive Communication Deficit who was admitted to the facility 02/20/2025. On 04/21/2025 at 11:34 AM, R2 is observed in his room lying in his bed. R2's blanket is on his bed stained, the nightstand near R2's bed has a pair of latex gloves, multiple greeting cards, a clean brief, a plastic bag, and box of tissue sitting on it. Observed a chair near R2's bed with clothes sitting on the back of it along with multiple heel booties sitting in it. Observed multiple clean briefs sitting on a bedside table against the wall between R2's room closet and his bed. Observed a chair near R2's closet with two wedge pillows sitting in it. Observed a rolled mattress with a foot splint sitting on it in front of R2's room closet. R2's Current Care Plan initiated 02/21/2025 documents he has an ADL (Activities of Daily Living) self-care performance deficit related to impaired sitting balance, impaired standing balance, impaired endurance; impaired functional use, impaired strength, and impaired range of motion of left upper extremity; Impaired cognition, decreased safety awareness, and hospice care. 3. R3 is a [AGE] year-old female with a diagnoses history of Partial Paralysis Following a Stroke, Dysphagia, Breast and Brain Cancer, and Stage 2 Chronic Kidney Disease who was admitted to the facility 03/17/2025. On 04/21/2025 at 11:03 AM, R3 is observed in her room sitting up in her bed unable to speak. Observed a pillow sitting in a chair near R3's bed, a bag of clothes with clothes on top of it sitting in a chair near R3's window, her room floor sticky, food in her hair, on her gown, and on her bed, a hair cover and house shoes on the night stand next to her bed, a clean brief sitting out on a night stand near her bed, and a light urine odor near her. R3's Current Care Plan initiated 03/18/2025 documents she has limited physical mobility Related to a Contracture of her right hand, fingers, and wrist. R3's Current Care Plan initiated 03/21/2025 documents she has an ADL (Activities of Daily Living) self-care performance deficit related to Confusion, Impaired balance, Limited Mobility, and Stroke. 4. R4 is a [AGE] year-old female with a diagnoses history of Dementia, Partial Paralysis following a stroke, Adult Failure to Thrive, Dysphagia, Disorder of Muscle, and Polyneuropathy who was admitted to the facility 01/31/2025 and was readmitted [DATE]. On 04/21/2025 at 10:54 AM, R4 is observed in her room lying in her bed asleep. Observed trash on various parts of the floor around R4's bed, a pair of non-skid socks strewn across the floor, unfolded clothes sitting on top of a basin on the nightstand near her bed, and a dead fly and dust on her window seal. R4's Current Care Plan initiated 03/06/2025 documents she has an ADL (Activities of Daily Living) self-care performance deficit related to impaired mobility, and cognitive deficit. On 04/21/2025 at 11:13 AM V5 (Housekeeper) stated the floors are sticky and the stickiness is from a chemical used to treat the floors. V5 stated warm water is used to mop to help remove the stickiness of the floors. On 04/21/2025 at 3:33 PM V2 (Director of Nursing) stated he instructs the nursing staff to ensure the residents have linens such as blankets during rounds and to observe when resident's need their linens changed. V2 stated nursing staff should remove food particles from resident's beds if they eat in their room. V2 stated there should not be any trash found on the floor in resident's rooms and on the resident's shower days aides are also instructed to clean the resident's room which includes putting clothes away and clearing the bedside tables and nightstands. V2 stated there should not be cluttered items in the residents rooms, in their chairs, or on their nightstands. V2 stated clean briefs should not be left on the resident's nightstands and should be put away. V2 stated this is especially true for residents such as R2, R3, and R4 who depend on staff to clean their rooms for them. On 04/22/2025 at 12:36 PM V1 (Administrator) informed per V8 (Housekeeping Supervisor) if there is stickiness on the floors, they hot mop the floor and then put it on the strip /wax schedule. The facility's Laundry Services Policy received 04/21/2025 states: [NAME] Responsibility belongs to Laundry and Nursing Personnel. Soiled linen will be placed in labeled, nonporous containers and transported to the soiled linen area for laundry. The facility's Housekeeping Services Policy received 04/21/2025 states: It is the policy of this facility to maintain a clean, odor free, comfortable and orderly environment in all healthcare and public areas, which meet the sanitation needs of the facility and residents' rights for a safe, clean, comfortable home-like environment. Policy Specifications are To ensure that the facility, equipment, furnishings and resident rooms are maintained in a sanitary manner; to provide a comfortable environment, and to prevent the development and transmission of infection. The department shall routinely clean the environment of care to keep the facility fee from offensive odors, the accumulation of dust, rubbish, dirt and hazards.

Based on observations, interviews, and record reviews, the facility failed to provide assistance for residents assessed to need assistance with activities of daily living and failed to provide assistance and/or supervision with feeding. These failures applied to three of three residents (R1, R3, and R4) reviewed for activities of daily living. Findings include: 1. R1 is an [AGE] year-old male with a diagnoses history of Dementia, Parkinson's Disease without Dyskinesia, Traumatic Brain Injury, Chronic Kidney Disease, Urine Retention, Urinary Tract Infections, Dysphagia, Disorder of Muscle, and Blindness in Right Eye who was admitted to the facility 04/16/2025. R1's Current Care Plan initiated 04/17/2025 documents he has multiple diagnoses that impede his ability to perform activities of daily living at his prior level of functioning with interventions including assist with eating as needed. R1's Current Care Plan initiated 04/18/2025 documents has an ADL (Activities of Daily Living) self-care performance deficit related to a decrease in functional mobility, decreased coordination, decrease in strength, increased need for assistance from others and functional limitation with ambulation with interventions including requiring supervision assistance by staff to eat. On 04/21/2025 at 12:30 PM, R1 is observed in his room eating his lunch with no staff present. On 04/21/2025 at 12:38 PM, R1 has finished his lunch meal without staff assistance or supervision and with a brownie still on his meal tray to his right. When asked by surveyor if R1 was going to eat his brownie R1 asked what brownie and surveyor observed him to be unable to see the brownie or locate it with his hands. Observed R1 to locate the brownie with his hands when verbally guided by the surveyor. Observed R1 pick up the brownie and begin eating it. R1's Point of Care Eating Reports from 04/16/2025 - 04/21/2025 document he ate multiple meals independently and multiple meals with set up or clean up assistance only. 2. R3 is a [AGE] year-old female with a diagnoses history of Partial Paralysis Following a Stroke, Dysphagia, Breast and Brain Cancer, and Stage 2 Chronic Kidney Disease who was admitted to the facility 03/17/2025. On 04/21/2025 at 11:03 AM, R3 is observed in her room sitting up in her bed with her breakfast meal sitting on the bedside table in front of her and her breakfast barely eaten and no staff assisting her with eating. Observed food particles in R3's hair, on her gown, and on her bed. On 04/21/2025 at 11:50 AM, R3 is observed sitting in her bed with food particles in her hair and on her bed and her barely touched breakfast tray sitting on a table near the wall away from R3. On 04/21/2025 at 12:56 PM V3 (Certified Nursing Assistant/CNA) stated R3 doesn't eat sometimes but will eat everything if you feed her. R3's Admission Minimum Data Set Functional Abilities Section assessment dated [DATE] documents she requires supervision or touching assistance when eating. R3's Current Care Plan initiated 03/18/2025 documents she has limited physical mobility Related to a Contracture of her right hand, fingers, and wrist. R3's Current Care Plan initiated 03/19/2025 documents she has a potential nutritional problem related to a mini nutrition assessment score of 9 and is at risk for malnutrition with interventions including Monitor/document/report as needed any symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. R3's Current Care Plan initiated 03/21/2025 originally reviewed by surveyor 04/21/2025 documents she has an ADL (Activities of Daily Living) self-care performance deficit related to Confusion, Impaired balance, Limited Mobility, and Stroke with interventions including requiring supervision assistance by staff to eat which was revised upon receipt from facility on 04/22/2025 to one to one feeder. R3's dietary progress note dated 4/9/2025 documents her current body weight 94.2 pounds with a Body Mass Index of 17.2 indicating she is underweight; Presents with significant weight loss of -5.5% in 7 days from 99.7 pounds 03/26/2025 and -6.2% from 100.4 pounds 03/17/2025; Her weight loss is undesired and unplanned. Noted resident is a one-to-one feeder. R3's current physician orders document an order effective 04/09/2025 for one-on-one feeding assistance. R3's Point of Care Eating Reports from 04/01/2025 - 04/21/2025 document she receives setup or cleanup assistance only for most of her meals. 3. R4 is a [AGE] year-old female with a diagnoses history of Dementia, Partial Paralysis following a stroke, Adult Failure to Thrive, Dysphagia, Disorder of Muscle, and Polyneuropathy who was admitted to the facility 01/31/2025 and was readmitted [DATE]. On 04/21/2025 at 12:33 PM, R4 is observed left alone with her lunch tray, leaned over in her bed struggling to grab her milk and food. Observed R4's hands and arms to be trembling when attempting to grab items from her tray. On 04/21/2025 at 12:40 PM, R4 is observed alone in her room with her lunch meal barely touched. R4 stated she needs a little bit of help but she'll do it on her own. On 04/21/2025 at 12:48 PM, R4 is observed alone in her room with her lunch meal barely touched. R4 stated they help her eat sometimes, it is hard to grab things and if they don't help her there is nothing she can do. On 04/21/2025 at 12:51 PM, observed V4 (CNA) in the hall near R4's room and when asked if she was available V4 stated she was about to respond to another resident's call light and collect some trash. V4 responded thank you when the surveyor informed her that R4 needed some help with eating. Observed V4 approach R4's room. R4's Admission Minimum Data Set Functional Abilities Assessment 03/10/2025 documents she requires supervision or touching assistance with eating. R4's Current Care Plan initiated 03/06/2025 documents she has an ADL (Activities of Daily Living) self-care performance deficit related to impaired mobility and cognitive deficit, wounds with interventions including requiring supervision assistance by staff to eat. R4's Current Care Plan initiated 03/07/2025 documents she has a nutritional problem related to her mini nutrition assessment score indicating malnutrition; she was recently discharged from this facility 2/22 and significantly deconditioned while home & now presenting with significant weight loss from previous admission with interventions including Monitor/document/report as needed any signs and symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. R4's Point of Care Amount of Food Eaten Reports from 04/01/2025 - 04/21/2025 document she ate independently multiple times and eats with setup or cleanup assistance only for most of her meals. R4's dietary progress note dated 4/16/2025 at 11:30 AM documents staff reports she continues to eat poorly, and needs significant encouragement to eat; was seen by the registered dietitian 4/9/2025 for weight loss, her current body weight is 126.3 pounds as of 04/09/2025 with a Body Mass Index of 20.4 which is within normal limits but less than desirable for age. 04/21/2025 3:33 PM V2 (Director of Nursing) stated eating supervision includes setup and cueing if needed and monitoring because the staff have to record how much is eaten. V2 stated R1 can feed himself although he may need some cueing or someone observing him while he's eating and may be more suitable for eating in the dining room when he's up. V2 stated supervision during eating for R1 would include dining room eating or someone coming back and forth and checking him to make sure he's feeding himself. V2 stated staff should make sure R1 is clean after he eats meals. V2 stated R3 became a feeder due to weight loss and staff should be feeding her. V2 stated R3 normally eats in the dining room and should be fed. V2 stated it's best that residents eat in the dining room to prevent food from being left in their room area and for supervision and assistance. V2 stated it's difficult to supervise residents when they are in their rooms eating. V2 stated R4 needs a lot of encouragement to eat and sometimes refuses feeding assistance. V2 stated R4 should have supervision and cueing to eat and should be up and in the dining room eating. Guidelines for feeding assistance provided on 04/21/2025 in response to surveyors request for Feeding Assistance Policies states: A patient who can't self-feed is susceptible to malnutrition. Feeding a patient improves nutritional intake and clinical outcomes. Various disabilities and conditions may prevent a patient from self-feeding, including cognitive deficits, neuromuscular disease, cancer, obstructive lung disease, and traumatic brain injury. Position a chair next to the patient's bed so you can sit comfortably if you need to feed the patient. To help a blind or visually impaired patient feed, describe the placement of various foods on the plate in relation to the hours on a clock face. Provide verbal encouragement to participate in eating by talking about the food's taste and smell and providing verbal prompts to chew and swallow. If the patient is a risk for aspiration, monitor closely. When the patient finishes eating, remove the tray. If necessary, clean up spills and change the bed linens. The facility's Activities of Daily Living Policy received 04/22/2025 states: In accordance with the comprehensive assessment, together with respect for individual needs and choices, our facility provides care and services for the following activities: Dining - Eating including meals.

Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for catheter care by not ensuring residents catheters were positioned properly to prevent contamination. This failure applies to two of three residents (R1 and R5) reviewed for catheter care. Findings include: 1. R1 is an [AGE] year-old male with a diagnoses history of Dementia, Parkinson's Disease without Dyskinesia, Traumatic Brain Injury, Chronic Kidney Disease, Urine Retention, Urinary Tract Infections, Dysphagia, Disorder of Muscle, and Blindness in Right Eye who was admitted to the facility 04/16/2025. R1's Current Care Plan initiated 04/17/2025 documents he has an Indwelling Catheter related to obstructive Uropathy with interventions including check tubing for kinks each shift. On 04/21/2025 at 10:34 AM, R1 is observed in his room sitting on his bed on top of his catheter tubing, his catheter tubing and bag is sitting directly on the floor in front of his bed, and R1's catheter bag is without a privacy cover on it. On 04/21/2025 at 12:30 PM, R1 is observed sitting on his catheter tubing. 2. R5 is a [AGE] year-old male with a diagnoses history of Dementia, Partial Paralysis due to Stroke, and Urinary Tract Infection 04/09/2025 who was admitted to the facility 05/04/2023. R1's Current Care Plan initiated 05/28/2024 documents he is at risk for developing a Urinary Tract Infection; R1's Current Care Plan Initiated 04/16/2025 documents he has an Indwelling Suprapubic Catheter related to Obstructive Uropathy. On 04/21/2025 at 3:23 PM, R5 is observed ambulating in his wheelchair near the nurses station on the unit where his room is located with his catheter tubing rubbing directly across the floor and half of his catheter bag out of the privacy bag rubbing directly across the floor. R5 stated he had pain in his groin area from his catheter yesterday and this morning and the pain is now gone after they adjusted it. 04/21/2025 3:33 PM V2 (Director of Nursing) stated ideally catheter bags and tubes should not be on the floor. V2 stated R5 is in a chair and moves around frequently and depending on how he moves the chair his catheter bag may move, and he just received his catheter a week ago. V2 stated he has ordered a protective bag that will seal and cover the catheter. V2 stated the catheter tubing needs to be hooked appropriately to prevent it from being dragged across the floor. V2 stated sitting on catheter tubing could cause kinks and prevent free flow and draining and nursing staff should examine the tubing to ensure there are no kinks. V2 stated if the staff position R1 correctly, he shouldn't be able to sit on his catheter tubing because it's in front of him. V2 stated R1 sitting on his catheter tubing could cause urine backflow and this would be an infection control issue. The facility's Catheter Care, Urinary Policy received 04/21/2025 states: Check the resident frequently to be sure he or she is no lying on the catheter and to keep the catheter and tubing free of kinks. Be sure that catheter tubing and drainage bag are kept off the floor.

Based on interview and record review the facility has failed to follow their fire watch policy by not reporting to IDPH (Illinois Department of Public Health) that the sprinkler system is not working in all four units of the facility. This has the potential to affect all 117 residents residing at the facility. Findings Include: Facility's census dated 4/3/25 denotes 117 residents. Facility Fire Watch Policy denotes to establish a process for fire safety in the event that the fire protection system fails or is not operating (includes service being performed on system). When the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Facility incident report dated 1/23/25 denotes on 1/22/25 description of occurrence: Facility is on Fire Watch related to broken pipe. Fire Dept (Department) has been made aware. Occurrence resolution: Facility on Fire Watch related to a broken pipe. The broken pipe affected the sprinklers on one unit only. 1/28/25 Fire protection plumbing company A came out and fixed the pipe and reconnected the sprinklers on the one unit. Facility incident report dated 1/29/25 denotes description of occurrence: Facility is on Fire watch related to sprinkler system on one unit being offline. Fire department has been made aware. Fire plumbing company B will be in 1/30/25 to address the issue. Occurrence resolution: Facility is on Fire Watch related to sprinkler system on one unit being offline. Fire department is aware. Fire protection plumbing company B came out 1/30/25 and identified the issue are awaiting on part to be delivered. Facility incident report dated 2/3/25 denotes description of occurrence: Facility is on Fire watch related to sprinkler system on one Long term care unit being offline. Fire department has been made aware. Occurrence resolution: Facility is on Fire Watch related to sprinkler system on one unit being offline. Fire department is aware. Fire protection plumbing company B came out 1/30/25 and are awaiting on part to be delivered. On 4/2/25 at 6:30 pm, V2 (Maintenance Director) stated he has been a maintenance director for [AGE] years and this facility for over a year. V2 stated a pipe that was in the back of the building over the laundry room froze then busted on 1/22/25 and one unit of the facility was effected however that unit was vacant of residents. V2 stated the Fire Department came and they were instructed by the local fire department to go on Fire Watch until issue could be resolved. V2 stated they called the plumbing services (A) and they came to fix the broken pipe. V2 stated on 1/29/25 another pipe busted and it affected the Medicare unit where residents did reside. V2 stated the local fire department came and told them to continue the Fire Watch program. V2 stated at that time he was instructed by corporate to use fire protection plumbing company B instead of the one they were contracted with before. V2 stated they contacted fire protection plumbing company B that he was instructed to use by corporate and they came to the facility the next day on 1/30/25 to assess the situation. V2 stated he was told by fire protection plumbing company B that the clapper for the sprinkler needed to be changed out in order to fix that part of the sprinkler system and they would order it. V2 stated on 2/3/25 a couple of sprinkler heads started leaking in the long term unit where residents resided. V2 stated the local fire department came to the facility and told them to stay on fire watch until the sprinkler system is fixed. V2 stated fire protection plumbing company B came out to the facility that day also. V2 stated fire protection plumbing company B drained the water from the whole sprinkler system which included the long term care unit, memory care unit, the Medicare unit, and the vacant unit. V2 stated fire protection plumbing company B told them there was nothing they could do until the parts came in. V2 stated the fire alarm system never malfunctioned until after 3/2/25 when the fire alarm panel was sending false alarms to the emergency call center and then the local fire department would come to the facility. V2 stated the main issue with the sprinkler system is that the clapper in the sprinkler head was damaged. V2 stated the part was supposed to be delivered to fire protection plumbing company B 3/28/25 but got notice on 4/3/25 from them that the part will not be available until mid-May. V2 stated they have been doing fire watch and have to walk the whole building every 30 minutes and log it. V2 stated after hours when maintenance is not in the facility the nurse managers on duty do the Fire Watch and log it in the Fire Watch book. V2 stated the roof had never caved in or was structurally damaged from the leaking pipes. V2 stated they did have to put up new drywall in the ceilings where the pipes had leaked. On 4/3/25 at 6:15 pm, V1 (Administrator) stated they were instructed by corporate to use fire protection plumbing company B to service the sprinkler system and fire alarm panel instead of fire protection plumbing company A that the facility was using and were contracted with before. V1 stated she is responsible for reporting the facility incidents which included the incidents that happened related to the leaking pipes of the sprinkler system to IDPH. V1 stated when she sent the incident reports on 1/23/25 and 1/29/25 she did not name the specific unit that was affected by the sprinkler system but did on the 2/3/25 incident report. V1 stated did not remember or recall if she included in her last incident report sent to IDPH on 2/3/25 that she included that all four units in the facility do not have a working sprinkler system and the duration.

Based on interview and record review the facility failed to follow their practice and ensure to transcribe a physician order to include the right dose, right diagnosis, and duration for prednisone 60mg (milligram) tablets, and failed to complete an order for Norco 7.5mg-325mg for 3 days for one of one resident (R1) reviewed for physician orders. Findings include: R1's face sheet shows R1 has diagnosis of osteoarthritis, aftercare following joint replacement, COPD, weakness, lack of coordination, low back pain, and hypertension. On 11/13/24 at 1:46pm V2 (Director of Nursing) said the physician order Prednisone 60 mg by mouth for 5 days for R1 on 6/14/24 was for COPD exacerbation. V2 said the Nurse should have clarified the order with the physician, and transcribed the order as given. V2 said if the nurse was not sure of the order, she should have contacted her (V2) or the physician for clarification. V2 said the Nurse needs reeducation on transcribing verbal orders. V2 said the order for prednisone 1mg (60mg) is not correct as transcribed by the nurse on the medication administration record and physician order sheet. V2 said the pharmacy sent prednisone 10 mg and 50 mg for a total dose of 60 mg. V2 said she does not have supporting documentation denoting that the pharmacy sent 10 mg and 50 mg prednisone, and R1 received 10 mg and 50 mg tablets for a total dose of 60 mg. V2 said when a resident is admitted to the facility with an order for a narcotic, the facility practice is to notify the physician for orders or recommendations, obtain orders from the physician, and have the physician send the prescription over to the pharmacy for the narcotic. V2 said the physician can fax or call in the prescription. V2 said once the pharmacy receives the prescription, they will fill the order/prescription. V2 said the pharmacy will give the Nurse an authorization number that allows them to retrieve the medication from the convivence box until the pharmacy delivers the medication. R1's physician order sheet and medication administration record was reviewed with V2, there is no documentation denoting that the pharmacy dispensed 10 mg and a 50 mg tablet. The order is transcribed for 1 mg tablets daily. R1's medication administration record shows Prednisone oral tablet, give 1 mg by mouth one time a day for corticosteroids 60 mg, start 6/15/24. During this survey the facility failed to present the correctly transcribed order for prednisone and failed to present documentation that R1 received the right dose of prednisone 60 mg. R1's physician order sheet dated 6/7/24 shows orders for Norco oral tablet 7.5-325 MG (Hydrocodone-Acetaminophen), give one tablet by mouth every four hours as needed for Pain. R1's progress notes dated 6/11/24 denotes in part a prescription for Norco 7.5mg/-325mg was sent to the pharmacy on 6/11/24. Facility policy for physician orders dated 2/2014 denotes in-part all telephone and or verbal orders must be read back to the licensed personnel taking the order to ensure the information is clearly understood and transcribed. Orders for medication must include name of physician giving order, date and time the order was received, signature of licensed personnel receiving/transcribing the order, name and strength of the drug, dosage and frequency of administration, form or route of administration, reason or problem for which given/diagnosis, quantity to duration of therapy, if any order is determined to be incomplete, illegible or unclear the licensed personnel must clarify the order with the prescribing provider.

Based on observation, interview, and record review the facility failed to provide ADL (activity of daily living) care to a dependent resident and provide incontinence care at least every two hours, and failed to ensure residents are provided a bath per facility policy. This affected four of four residents (R1, R3, R4, and R6) reviewed for activity of daily living. Findings include: 1. On 10/1/24 at 11:50am R6 was observed alert and orientated to person, place, time, and situation. R6 said she had not been changed for hours. R6 said she was changed at 11:00am, and prior to that she was changed at 5:30am. R6, with assist from V1 (CNA/Certified Nurses Aide) showed surveyor her gown, shirt, and mattress, R6's shirt, gown and mattress was observed soiled in urine and smelled of urine. 10/3/24 at 2:26pm V9 (ADON-Assistant Director of Nursing) said staff should be checking and changing residents every two hours, they should apply skin barrier cream as appropriate to prevent moisture from breaking down the skin. R6's care plan dated 4/13/24 denotes resident has ADL care performance deficit related to DX (diagnosis) of adult failure to thrive, weakness, abnormalities of gait and mobility and lack of coordination and abnormal posture. Check resident for incontinence every two hours. Provide one person assistance for ADL cares. Provide incontinence care as needed. Provide verbal cues, supervision, set and assistance as needed for bed mobility, transfers, eating and toileting. Facility activities of daily living with effective date of 2/2023 denotes in part purpose the base on a comprehensive assessment of the resident and with the resident needs and choices, our facility provides necessary care and services to ensure that a residence's abilities and activities of daily living do not diminish unless the circumstances of the individual's clinical condition demonstrates that such guidelines were unavoidable. In accordance with the comprehensive assessment together with respect for individual residents needs and choices our facility provides care and services for the following activities, hygiene mobility, elimination, dining, and communication. 40066 2. On 10/1/24 at 11:54AM V5, CNA, said showers are given based on shower day on the list. V5 said we get the resident into the shower room or some people want a bed bath. V5 said we let the nurse know who wants a bed bath or if they are shower refusals. On 10/2/24 at 9:17AM V7, LPN (Licensed Practical Nurse), said for refusals of care the staff should report to the nurse. V7 said I would then try to explain to the resident the reason for it to be done. V7 said if the resident still refuses, then we document the patient refusals. V7 said we document so that staff is aware of her condition. On 10/1/24 at 12:32PM V4, (Infection Preventionist), said if a resident refuses their shower, then we should document and call the family. V4 said I looked for documentation on R4's shower and I didn't see anything. On 10/2/24 at 9:42AM V9 (ADON), said the shower policy is that each resident gets at least one shower a week, but our culture is to give them two a week. V9 said showers are documented on shower sheets and nurses are to double check that they are completed. V9 said refusals are supposed to be documented in the nurses notes. V9 said the main tracking tool for showers are the sheets to track completion. V9 said shower refusals are to be documented on the shower sheet and the notes. V9 said the CNA is to report to the nurses any refusals. V9 said the residents are expected to get a shower on the shower day. V9 said if we are made aware the showers have not been done, we will give the resident a shower. V9 said a resident should go no more than 1-2 days without a shower, past the assigned shower day, water needs to touch them in some way. V9 said sometimes the person refuses showers and wants a bed bath instead. V9 said a bed bath is acceptable. V9 said bed baths will be documented on the same shower sheet. V9 said if it is a continued problem with a particular resident, the shower sheet comes to the Director of Nursing (DON) or myself. V9 said the purpose is so we can track if the showering is getting done or not. V9 said at the moment everyone has been getting their showers. V9 said a bathing preference is not documented, no one has said they prefer bed bath or showers, but it would be in the care plan if they said. V9 said all the supplies are available for showers. The surveyor asked V9 about the showers documented and V9 said the CNAs forget to fill out shower sheets. V9 said we would know if a shower was missed if we get a complaint from the family or the resident. V9 said some residents can't tell us. The surveyor requested documentation of shower refusals that her or the DON followed up on. At 10:10AM V9 said I have no documentation for us looking at showers that were refused. V9 said yes to the surveyor when asked if the residents should be getting a minimum of 8 showers a month. R1's diagnosis include, but are not limited to Hypertensive Heart and Chronic Kidney Disease, Chronic Kidney Disease, Osteoarthritis, Benign Neoplasm of meninges, Dementia, Depression, Alzheimer's Disease, and Heart Failure. According to census, R1 has been on the same unit and room since 8/27/24. R1's Cognitive Patterns dated 8/14/24 BIMS (Brief Interview for Mental Status) score is 4. R1 has no behavior of rejection of care on 8/14/24. Functional Abilities and Goals, Shower/bathe: the ability to bathe self Dependent - helper does all of the effort. On 9/27/24 the surveyor attempted to interview R1, she makes eye contact, but does not answer verbally or nod her head to questions. R1's Bath and Skin Report Sheet September 2024 indicates bed baths performed 3 days in September. 9/3 and 9/6 documentation address R1's wound dressing. Room and Shower list notes R1 scheduled for a shower on Wednesday and Saturday. The dates provided do not correlate with the schedule dates. R1's charting for bathing does not indicate the bathing was complete. Progress note reviewed for September does not include record of bathing refusals. R1's care plan does not have intervention for bathing refusals. R4's diagnosis include but are not limited to Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Sequelae of Cerebral Infarction, Diabetes Mellitus, Chronic Kidney Disease, and Dementia. On 10/1/24 at 1:25PM R4 said I don't want to get up into the shower room. R4 said I wash up or they help me to wash up in the bed. R4 said I don't know when I last did that. The surveyor noted R4 has body odor during interview. The odor increased the longer in the room with R4. R4's charting for bathing does not indicate that bathing was completed for the month of September, bed bath or shower. Document presented is not completed. Room and Shower list notes R4's shower days are Wednesday and Saturdays. Cognitive Patterns dated 9/13/24 BIMS score is 11. R1 has no behavior of rejection of care on 9/13/24 assessment. 9/13/24 Functional Abilities and Goals, Shower/bathe: the ability to bathe self Dependent - helper does all of the effort. No care plan for bathing refusals was provided and no progress notes related to bathing attempts or interventions. R3's diagnosis include but are not limited to Hemiplegia following Cerebral Infarction, Hypertensive Heart Disease, Convulsions, Diabetes, Major Depressive Disorder, Anxiety, Altered Mental Status, Weakness, and Bell's Palsy. R3's Cognitive Patterns dated 7/25/24 BIMS score is 15. R1 has no behavior of rejection of care on 7/25/24 assessment. 7/25/24 Functional Abilities and Goals, Shower/bathe: the ability to bathe self Dependent - helper does all of the effort. R3's Bath and Skin Report Sheet for September 2024 indicates 3 showers or bed baths were provided. 9/9/24 documents a refusal, no nurse signature. 9/30 does not indicate what care was provided. R3's progress notes do not include record of shower/bed bath refusal or interventions offered. R3's charting for bathing does not indicate bathing was completed. Progress note reviewed for September does not include record of bathing refusals. R3's care plan does not have intervention for bathing refusals. Room and Shower list notes R3 is scheduled for a shower on Monday and Thursday. R3's showers were documented on Mondays, no documentation for Thursdays in September was found. The facility policy on Shower/Tub Bath dated August 2002 states the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The following information should be recorded if the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting: Notify the supervisor if the resident refuses the shower/tub bath. The facility policy on Refusal of Medications and Treatments dated 11/2023 states it is the resident's right to refuse medication, treatments and care. Standards: Second and third efforts to administer medications, treatments, and care should be made. The resident should be given a full explanation verbally and in writing of the consequences of the refusal. In the event of continued refusal despite education, will be documented in the residents care plan and/or progress notes. Each refusal shall be documented in the nurses progress notes and include, at a minimum, the following data: date and time of attempt, treatment attempted, resident response and reason for refusal, name of the person attempting to administer treatment.

Based on observation, interview and record review the facility failed to provide supervision during smoking breaks for a resident (R8) identified to require supervision. This affected one of three residents (R8) reviewed for safety during smoking. Findings include: On 10/1/24 11: 20am R8, R9, R10 were observed smoking outside on the patio. Staff was observed inside the facility. V13 (Activity aide) said she was monitoring the resident but had to step away. R8 was observed with holes in his shirt and pants. There was no ash tray observed for R8, R9, R10 to use while smoking. Greater than 200 cigarettes butts were observed on the ground. There was a brown flowerpot observed melted (place on the ground), half of the flowerpot was missing. There was a circular burn area noted on the metal table with melted debris on the table and ground. V13 said the residents were putting their cigarettes out in that flowerpot. V13 said she did not report that to anyone. V13 said there was an ash tray just out here, V13 was asked where the ash tray was, V13 said that's a good question, there was one here. R8, R9, and R10 smoked their cigarette and did not have an ashtray to extinguish their cigarette. 10/1/24 R8 observed alert to person place and situation. R8 said the holes in his clothing was from his cigarettes. R8 was asked if he was able to get the cigarette ash off him when it fell on him. R8 said the cigarette ash did not burn his skin. R8's smoke assessment dated [DATE] denotes R8 has cognitive loss, no visual deficits, no dexterity problems, R8 smokes 2-5 cigarettes a day, supervised smoking times, safe to smoke with supervision. R8's MDS (Minimum Data Set) dated 8/16/24 denotes BIMS (Brief Interview for Mental Status) score of 15. R8's care plan dated 5/14/24 denotes R8 smokes tobacco, R8 will smoke safely as evidence by following the facility smoke policy. 10/1/24 at 1:25pm V11 (Activity Director) said she was not aware of the melted flowerpot, no one informed her that the residents were putting their cigarettes out in the flowerpot. V11 said she should have been made aware of the incident. V11 said the activity aide is responsible for monitoring the patio during the supervised smoke breaks. V11 said staff should be outside with the residents and not inside. V11 said staff is monitoring for safety. On 10/3/24 at 12:35pm V12 (Social Services Director) said upon admission residents are assessed for smoking safety, the facility policy is reviewed with the residents at that time. V12 said the smoking assessment is reviewed and updated upon admission, quarterly and as needed. V12 said the facility does not have residents' that are independent with smoking, V12 said the facility only have supervised smoking breaks for residents. V12 said the residents are supervised for safety reasons, residents are not allowed to have smoke material in their possession, residents can light their own cigarettes and staff must retrieve the lighter from the resident immediately after. V12 said the staff should be monitoring for residents that use devices when smoking, residents that are displaying weakness when holding the cigarette, residents that are not dumping the cigarette ash, residents that allow cigarette ash to fall on their clothing, and staff should be monitoring for residents that have burn holes in their clothing. V12 said when the resident is done smoking their cigarette, the resident should extinguish the cigarette in the ash tray, and then put the cigarette butt in the metal garbage can. V12 said the ash tray is provide by the facility. V12 said if a resident has burn holes in their clothing the resident would be reassessed for safe smoking and provided a smoke apron. V12 said no one informed her of R8 having burn holes in his clothing, V12 said V13 did not inform her that residents were putting cigarettes in the flowerpot, V12 said she was not aware of the melted flowerpot on the patio. V12 said she was not aware of the large number of cigarette butts on the patio ground. V12 said cigarette butts should not be discarded on the ground. V12 was asked how the staff is monitoring residents sufficiently when they are inside the facility and the residents are outside, cigarette butts are discarded on the ground, there's no ash tray for extinguishing cigarettes, R8 observed with burn holes in his clothing, and it's not reported to her (V12) so that she can follow up. V12 said she will talk to the staff. V12 said if she was aware of the burn holes in R8 clothing, she would have followed up with R8, reassessed R8 for safe smoking, and implemented a smoke apron and she would have updated R8's plan of care for smoking.

Based on observation, interview, and record review the facility failed to ensure a resident call light is within reach. This deficiency affects one (R44) of three residents in the sample for 26 reviewed for Accommodation of needs and Resident safety. Finding include: On 8/13/24 at 12:15PM, Observed R44 lying in bed. His call light is placed on top of his bedside tray table away from him and unable to reach. He is alert and oriented, able to verbalize needs to staff. R44 said the CNA (Certified Nurse Assistant) transferred him back to bed after his therapy this morning. He said that if he cannot reach his call light he will yell for help until someone comes to his room. Called V24 RN (Registered Nurse) and showed observation made. V24 said that his call light should be within his reach. She moved the bedside tray table next to his bed and placed the call light within reach. On 8/13/24 at 1:01PM, Informed V2 DON (Director of Nursing) of above observation and asked for policy. R44 is admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and Hemiparesis following Cerebral infarction affecting right dominant side, Abnormal posture, Lack of coordination. Comprehensive care plan indicates he is at high risk for fall related to incontinence, paralysis, unaware of safety needs. Intervention: Be sure the resident's call light is within reach. Facility's policy on Call light revised August 2008 indicates: Purpose: To respond to the resident's requests and needs. General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 10. Call light must be accessible to residents from their bed.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcer/pressure injury (PU/PI) development for residents who were admitted without PU/PIs and totally dependent on staff for care and assessed to be at increased risk for PU/PI development; the facility also failed to provide ongoing skin assessments for these residents. This failure affected three (R4, R5 and R7) of four residents reviewed for pressure ulcers and resulted in R4 developing a stage 4 facility acquired wound to the right buttock, R5 developed a stage 3 facility acquired wound to the coccyx, and R7 developed a stage 3 facility acquired wound to the sacrum. Findings include: R4 is an [AGE] year-old male who was admitted to the facility August 4, 2022 with diagnoses that include malignant neoplasm of the prostate pressure ulcer of right lower back stage for retention of urine other core compression, secondary malignant neoplasm of bone, atherosclerotic, heart disease, paraplegia, spinal stenosis, hyperlipidemia, history of falling, anemia, neuromuscular dysfunction of the bladder gastroesophageal, reflux disease, essential, hypertension, osteoarthritis, and weakness. MDS (minimum data set) dated March 8, 2023, indicates R4 requires extensive two person staff assist with bed mobility and toileting, extensive one person staff assist with dressing and personal hygiene. 5/17/23 3:36 PM R4 stated, I got a bedsore on my butt, and it healed about this month, the last month I got it while I was here. I think they weren't cleaning me properly. The staff doesn't come and reposition me when they come to change me. That's the only time I get repositioned and that's only about two or three times a day because I have the catheter. Braden score assessment dated [DATE] scored R4 as 12.0 high risk, initial skin assessment dated [DATE] documented no skin issues. 5/22/23 3:24 PM V19 (RN Wound Care) said that R4 was admitted in August he will sit up in his chair for long periods of time. He did have a chair cushion, but he can't feel anything from the waist down. The woman started as a deep tissue injury. He was already at risk for pressure ulcer development because, he is paralyzed a DT high is considered a pressure injury and he developed it about a month after he was admitted every once in a while I spot check residence just to make sure their skin is OK I'm the one who discovered the wounds according to my notes, it was 90% read 10% scan with some bleeding it was identified September 5, 2022 and we marked it as an unstageable wound November 28th, 2022 the wound opened and it was stage IV. It was covered with yellow or gray slough. DTIs can sometimes heal without opening and sometimes it will soften up, and the tissue will slowly deteriorate meaning the necrotic tissue starts to come off and granulation tissue forms. Granulation tissue is beefy red, healthy tissue, and is an indication of healing if there were other increases of redness surrounding the wound and increased tissue necrosis would mean that the wound is deteriorating. This wound eventually healed and it was a very slow process. I can't explain why the wound developed if we had interventions put in place to prevent this. Whenever they were changing him, they should have been repositioning to take off pressure. He also had a skin tear on the tip of his penis where the catheter laid up against the skin, and when we saw that we told the nurses that they have to make sure that the anchor is in place so that it is not causing pressure he's still at risk for developing pressure ulcers even though the side has healed right now, he has a protective dressing on the sacrum and Ischium, where the scar is The doctor said the strength of the tissue is never going to be 100% so he can re-open quite easily residence with pressure. Ulcers are susceptible to more pain in the open wound and makes the resident at risk for infection. I would expect the nurses and CNA's to conduct daily skin checks, regular repositioning, air mattress and heel protectors to remain in place as interventions. I checked his skin this morning and he didn't have his heel protectors on, but I didn't notice any new openings. R5 is a an [AGE] year-old female who was admitted to the facility on [DATE] with medical history including, but not limited to Unspecified dementia, unspecified severity with other behavioral disturbance, hypertensive heart disease without heart failure, weakness, fibromyalgia, anxiety disorder, hyperlipidemia, history of falling, etc. 5/17/2023 at 9:30AM, R5 was observed in her room, awake and alert with some confusion. Resident was noted with lots of redness and bruising on her legs and arms, staff is not sure if resident is on a blood thinner. At 9:38AM, observed wound care for resident with V6 (LPN/Wound care) and noted a quarter size opening on the resident's sacrum, V6 stated that the wound is facility acquired, and has been documented as stage 3, they always stage wounds as stage 3 until it is healed. Admission progress note dated 1/21/2023 documented the following skin issues; Skin tear to Rt forearm 0.5x1.5cm, 100% red, small amt. bleeding, no odor, peri wound intact. Skin tear to Rt lateral shin, 2.0x2.0cm, 100% red, small amt. bleeding, no odor serous drainage and intact. Braden score dated 1/20/2023 coded R5 as 16, mild risk for skin breakdown. R5 has an active order for Skin assessment daily, turn and reposition q 2hrs, q shift, & PRN, and was assessed as requiring staff assistance for all Activities of daily living (ADLs). Review of shower sheets for the month of May for R5 did not show any documentation of resident receiving a shower, and no documented skin assessments. Wound management report for R5 documented a facility acquired pressure ulcer to the coccyx, identified on 3/21/2023, measuring 0.6x0.6 with a depth of 0.1, moderate serous exudate, and was described as a stage 3. R7 is a [AGE] year-old female who have resided at the facility since 2018, with past medical history of type 2 diabetes mellitus with diabetic neuropathy, unspecified psychosis not due to a substance or known physiological condition, sepsis, gastritis, dementia, dysphagia oral phase, anxiety, etc. Review of resident's record showed a Braden score assessment dated [DATE] with a score of 11, high risk for alteration in skin impairment, skin assessment dated [DATE] documented no bruises and no open areas. R7 also has an order for daily skin assessment and to be turned and repositioned every 2 hours and as needed. Review of shower sheet for the month of May did not show a documentation of any showers given or skin assessment done as ordered. 5/17/2023 at 9:38AM during wound care observation, V5 (LPN/Wound care) was asked if she has any wound treatment for R7 and she said that the resident just got a pressure ulcer to her right buttocks that was identified last night. At 9:55AM, surveyor did a skin check for R7 with V5 and noted with a nickel size open area to her sacrum, V5 said that she classified it as a stage 3 pressure ulcer with slough in the wound bed. V5 added that the wound doctor will see resident on Friday, when asked if resident gets out of bed, V5 said that she does not know, she is not familiar with the resident. R7's care plan dated 8/17/2019 states Resident is at risk for further skin breakdown R/T impaired mobility, incontinence, potential problem for friction and shear, Hx. (history) healed wound, interventions include Avoid shearing resident's skin during positioning, transferring, and turning, Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences, Provide incontinence care after each incontinent episode, etc. 5/17/2023 at 2:47PM, V3 (RN Supervisor) said that skin assessment should be done during showers, everyone has a scheduled shower date, showers should be documented in the shower sheets. If a shower sheet is empty and nothing is documented, then it is not done. If residents do get their scheduled showers, they will not be clean and that will be an indication of poor hygiene and could lead to skin breakdown.

Based on observation, interview, and record review, the facility failed to provide supervision and assistance for a resident assessed to require assistance with toileting. This failure applied to one (R3) of one resident reviewed for accidents and supervision and resulted in R3 having a laceration to her back and being sent to local hospital for evaluation and treatment. Findings include: R3 is an [AGE] year-old-female who was admitted to the facility on [DATE] for skilled nursing/24 hours observation, with past medical history of Nontraumatic subarachnoid hemorrhage unspecified, insomnia, anxiety disorder, weakness, difficulty walking, chronic kidney disease stage 3, history of falling, primary pulmonary hypertension, etc. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) scored R3 with a BIMS of 12 (moderate cognitive impairment), section G (functional) coded R3 as requiring extensive assistance with 2-person physical assist for bed mobility and transfer, and extensive assistance with one-person physical assist for toileting and personal hygiene. Section H (bowel and bladder) of the same assessment indicated that R3 is frequently incontinent of bowel and bladder. 2/17/2023 11:55AM, While conducting rounds in the unit, observed the paramedics in the unit stating that they are here to transport a resident to the hospital. They spoke to V3 (LPN) who is the assigned nurse for the resident, V3 stated that resident had an unwitnessed fall in her room last night and sustained a laceration to her back, was sent to the hospital for further evaluation and the hospital sent her right back without doing anything. The wound care team assessed resident and the doctor ordered for the resident to be sent back to the hospital. At 12:00PM, R3 was observed in her room in bed, alert and awake, R3 said that she is not doing well. She stated that she is hungry and tired, she fell last night while trying to go to the bathroom, R3 was asked if her call light was on and she said yes, no one came. R3 said, you turn that thing on for a long time and no one comes, I just got up and tried to do it by myself. When the paramedics pulled up resident's clothes to assess the wound, resident was noted with a large area on her back covered with a dressing, one of the paramedics pulled back the dressing and resident had some steri strips under the dressing, area still actively bleeding. Progress not documented by V6 (LPN) dated 2/17/2023 at 7:01AM reads: Writer heard resident calling out and went to resident's room writer note the resident's bed side table was hold open bathroom door writer noted that resident was sitting on floor of bathroom next to toilet writer asked resident what happened resident stated that she got out of and used bed side table to walk to bathroom and once in the bathroom side tried to turn around and lost her balance and slid to the floor writer also state that she hit her back on something resident was transferred to wheelchair resident was assessed and writer that resident has laceration to mid back area resident cleaned up and dressing place to laceration son called and voice mail was full Resident sent to the hospital ER for further evaluation and treatment. Facility fall log provided by V2 (Director of Nursing) documented the time of the fall as 4:04AM. 2/17/23 at 3:46PM, V6 (LPN) said that R3 called out, she went to the room and noticed that the bedside table was propping the bathroom door open and the resident was on the floor. R3 does not go to the bathroom by herself, she is a fall risk and staff are supposed to be monitoring her very often and remind her to use her call light. V6 said that she last saw the resident at 12:15AM, the C.N.A saw her at 12:00AM and she was toileted at that time. Resident was put in bed at 9:00PM, she wears incontinence brief and not able to use the bathroom by herself. 2/17/2023 at 4:10PM, V9 (C.N.A) said that she usually sits with R3 in her room, she was sitting with her till she fell asleep and then she left her around 11:30AM to 12:00AM. V9 said that the nurse saw the resident when she fell , V9 was in another room assisting another resident, she saw R3 last around 2:15AM when she walked past the room and resident was still in bed sleeping. V9 said she has worked with resident for about one year, she has fallen before, resident knows how to put on the call light and will put it on sometimes, R3 is a fall risk and the only intervention she is aware of is frequent checks, maybe every 30 minutes. Progress note dated 4/4/2022 states: Certified Nurse Assistant (C.N.A) notified nurse that resident slid on floor from bed. Resident stated to writer she was sitting on side of the bed and slid out of bed to the floor. IDT (Interdisciplinary Team) Fall Review: Resident fell on [DATE] states I needed to go to the bathroom. Per resident she states she does not always need to go to the bathroom at night or in the morning. Resident states she did put the call light on. Fall care plan dated 3/10/2022 states in part, resident is at risk for falling. Interventions include observe frequently and place in supervised area when out of bed, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes on, etc. 2/17/2023 at 3:26PM, V2 (DON) said that residents who are at risk for falls are supposed to have their bed to the lowest position, call light within reach, and fall care plans are individualized according to resident needs. For R3, V2 said that she is supposed to be frequently monitored by staff. A document presented by V2 (DON) titled falls-clinical protocol (undated) states that as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The same document states in part under treatment and management that based on preceding assessment, the staff and physician will identify pertinent interventions to try and prevent subsequent falls and to address risk of serious consequences of falling.

Based on observations, interviews, and records reviewed the facility failed to have effective fall prevention interventions to prevent or reduce the risk falls and fall related injury for 1 of 3 residents (R6) reviewed for falls with injury. The facility also failed to intervene to prevent a verbal altercation from escalating into a physical altercation for 2 of 3 residents reviewed for supervision. This failure resulted in R6 being found on the floor and sustaining an injury to the head that required 6 sutures. Findings include: a.R6 is [AGE] years old with diagnosis of Dementia, Weakness, Hypertensive Heart and Kidney Disease, and Dysphagia following [CONDITION(S)] Disease. On 3/4/22 at 11:36AM R6 was observed in his room, in his bed, in a nightgown, and with the privacy curtain pulled so R6 is not easily visible from the hall. R6's room is the last room on the left side of the hallway, furthest from the nurses' station. On 3/4/22 at 12:53PM R6's lunch tray was delivered to his room by V13, Certified Nursing Assistant (CNA). On 3/4/22 at 12:04PM V11, Registered Nurse, said R6 is a fall risk and has Dementia. V11 said she was working when R6 fell on [DATE]. V11 said she sent R6 to the hospital and he required sutures. V11 said R6 told her he was trying to get from his bed to his truck. On 3/8/22 at 12:23PM V17, CNA, said she did not get R6 out of bed on the morning of 2/8/22. V17 said she had seen R6 scooting in his bed on 2/8/22 before lunch time, at least 3 times. V17 said at lunch time she was assigned to be in the dining room and was not able to see R6 from the dining room. V17 said she reported to the nurse that R6 was not out of bed and in his chair and the nurse did not verbally respond. V17 said if the nurse had given him a new intervention to follow when she reported that R6 was still in bed, then she would have carried it out. On 3/8/22 at 12:50PM V2, Director of Nursing, said on 2/8/22 V11 had told V17 to get R6 up and into his chair because he was a fall risk. V2 said we know if R6 stays in his bed he starts fidgeting. V2 said R6 was supposed to be in his chair on 2/8/22. On 3/8/22 at 1:13PM V11 said she had seen R6 with his feet out of bed on the morning of 2/8/22 and she repositioned him back into the bed. V11 said at lunch time R6 should have been in his chair and in the lounge because he was a fall risk. V11 said she was informed between 12:15 and 12:30PM on 2/8/22 that R6 had fallen. V11 said she issued a write up to V17 for not not getting R6 up. V11 said R6 was sent to the hospital and returned with sutures on his head. On 3/8/22 at 1:25PM V2 said R6 returned to the facility with 6 sutures to his forehead after his fall on 2/8/22. Review of R6's Fall Event Report dated 2/8/22 notes R6 was noted on the floor in his room. R6 had been in his bed prior. R6's Progress Note dated 2/8/22 at 1:43PM written by V11 note R6 observed on the floor bleeding from his face. Laceration to the forehead. R6's Progress Notes dated 2/8/22 at 8:04PM written by V11 note R6 was sent to the hospital and was returning to the facility with sutures. R6's care plan start date 8/23/19 notes R6 is at risk for falls related to gait and balance problems. The Corrective Action Notice for V17 dated 2/8/22 notes resident was left in bed on morning shift and patient had a fall. According to the Action Notice the aide stated resident was dizzy and combative. The Falls Clinical protocol revised August 2008 note 3.The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Risk factors for subsequent falling include lightheadedness or dizziness. b.R2 is [AGE] years old with diagnosis including but not limited to Hypertensive Heart Disease, Major Depressive Disorder, and Personal History of Traumatic Brain Injury. On 3/3/22 at 2:13PM R2 said she got into a fist fight with R3. R2 said I threw a cup of water at R3. R2 said R3 hit her in the face. R2 said we were yelling at each other and then we got into it. R2's Cognitive Patterns assessment dated [DATE] notes R2 has a score of 15, cognitively intact. R2's Care plan for Psychosocial Well - Being start date 9/6/19 R2 is at risk for abuse due to an altercation with another resident. Interventions start date 9/6/19 notes staff to monitor for changes in mood. R2's Care plan for Behavioral Symptoms start date 9/6/19 resident had an incident of physical aggression towards a peer. Interventions start date 9/6/19 notes staff will re-direct and/or intervene during periods of increased agitation/confusion. According to Fall Event Documented created by V7, Registered Nurse (RN), notes R2 said R3 was causing trouble. R2 said R3 hit her on the head. R2 told V7 she hit R3 on her head and her glasses flew off. V7 documented R2 and R3 were separated. c.R3 is [AGE] years old with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, [CONDITION(S)], Major Depressive Disorder, and Chronic Pain Syndrome. R3 was discharged from the facility on 2/14/22. R3's Cognitive Patterns assessment dated [DATE] notes R2 has a score of 15, cognitively intact. According to Fall Event Documented created by V7 notes R3 said she and R2 were arguing and said R2 threw a pitcher of water at me. V7 documented that R3 got up and hit [R2] twice with my right hand. Facility Incident Report Form dated 1/28/22 notes R2 and R3 were involved in a physical altercation. R2 threw a pitcher of water on R3. R3 hit R2 in the back of the head. The residents were immediately separated. On 3/4/22 at 10:45AM V8, Social Worker, said R2 can be rude and likes to intimidate her room mates, she can be a bully, in the past R2 has made her room mates cry. On 3/4/22 at 11:00AM V10, Certified Nursing Assistant (CNA), said I don't know what started the verbal altercation between R2 and R3, but they were loud. V10 said when he walked into the room both residents were in wheel chairs on their side of the room. V10 said R2 and R3 were going back and forth calling each other liars. V10 said he left the room to call for assistance. V10 said by the time I made it back to the room [R3] was on [R2's] side of the room. V10 said R3 was standing over R2 and they were swinging at each other. V10 said R2 threw the first swing. V10 said R2 is known for throwing water at residents and staff. On 3/8/22 at 11:58 V8, Social Service Director, said if residents are encountered during an altercation staff should try to deescalate the situation. V8 said staff should not leave the residents together alone while getting help. V8 said you can call out for help or take the mobile resident with you. On 3/8/22 at 2:10PM V2 said if residents are involved in a verbal altercation staff should not leave the room if the situation can not be deescalated. V2 said the residents should be immediatley seperated. The facility policy for Unmanageable Residents revised August 2008 notes each resident will be provided with a safe place of residence.

Based on interview and record review, this facility failed to follow their abuse policy and prevent a facility staff member from twice slapping the face of a resident and wrestling over the call light. This affected 1 of 3 residents (R1) reviewed for abuse. This failure resulted int R1 saying she felt unsafe, badly, and in fear of the staff member who slapped her. Findings include: R1 was admitted with end stage [CONDITION(S)] and dependence on renal [CONDITION(S)]. R1's Minimum Data Set (MDS) section G Functional Status dated 2/2/21 documents: R1 requires extensive of one person physical assist with bed mobility. R1 had a BIMS (Brief Interview for Mental Status) score which indicates moderate impairment. On 5/5/21 at 12:26pm, V5 (Certified Nursing Assistant/CNA) stated, The call light was on in R1's room. I noticed R1 sliding out of the bed. I hurried to reposition R1 back into the center of the bed. R1 scratched my right arm during the repositioning. I was suspended based on an abuse allegation. On 5/5/21 at 12:33pm, V6 (Director of Nursing/DON) stated, R1 informed me staff slapped her twice in the face. R1 reported the staff member was wearing green pants and a white flowered top. V5 (CNA) wore green paints and white flowered top. On 5/5/21 at 12:59pm, R1 was alert and orient to person, place and time for this interview. R1 stated, The CNA wearing the white top and green pants hit me on both sides of my face with an opened hand. I felt bad. On 5/5/21 at 3:33pm, V10 (pm Supervisor) stated, R1 stated 'She hit me in the face twice.' R1 couldn't remember who hit her. I informed V6 (DON) of the allegation. I told V6 that R1 reported wrestling with someone resulting in a fall. V5 was R1's CNA. V5 (CNA) had on a white top and green pants. V5 denied wrestling with or any issues with R1. On 5/5/21 at 3:57pm, V11 (CNA) stated, R1 will ask staff to reposition and turn her. I was informed by V4 (Nurse) that R1 had a fall. I picked R1 up off the floor. R1 stated someone hit her. On 5/6/21 at 12:04p, V12 ([CONDITION(S)] Nurse) stated, R1 reported being hit twice in the face by an aide at the facility. R1's right cheek was slightly swollen. I wrote the allegation on the bottom of our [CONDITION(S)] communication form. On 5/6/21 at 4:30pm, R1 stated, I put my call light on. I asked V5 (CNA) to turn me on my left side. V5 gave me the bed control so I could reposition myself. V5 told me which buttons to push. I didn't know how to use the bed controller. I grabbed the call light. V5 grabbed the call light as well. We both were pulling on the call light cord. V5 was trying to take the call light from me. I tried to hold on to the call light but the pulling back and forth was hurting my hand. V5 took the call light from me, hit me in the face and didn't say a word. V5 hit me on both side of my face with an open hand. V5 took the call light and hung it on the wall out of my reach. V5 walked to the door, looked back at me and closed the door. I started calling the nurse. I couldn't reach the call light. I knew the nurse could not hear me with the door closed. I got out of bed and fell to the floor. I was going to crawl to the door for the nurse to hear me. I talked to V6 (DON). V6 told me the CNA didn't hit me. I told V6 she did. I have never complained about being hit by staff. I felt sad, hopeless, bad and unsafe. On 5/7/21 at 12:57pm, V5 (CNA) stated, The day I worked with R1, I had on a white top with butterfly print and [NAME] green pants. Nursing notes dated 5/4/21 document: At approximately 4:45am, R1 was on floor when entering the room. R1 states she was wrestling with CNA over the call light. Facility statement dated 5/4/21 documents: R1 states the nurse hit her twice in the face. R1 stated, I just want you do something about her. [CONDITION(S)] communication from dated 5/4/2021 documents: R1 reports she was hit twice by an aide while in the nursing home. Multidisciplinary Note dated 5/4/2021 documents: Upon arrival, swelling on the right cheek of the face. R1 reports she was hit twice by the aide in the nursing home. Psychosocial Progress notes from the [CONDITION(S)] center dated 5/4/21 document: R1 reports mistreatment at the nursing home. R1 stated, They stated I can turn myself over; she hung up the call light where I could not reach it. Staff hit me twice. Staff hit me on each cheek. R1's cheek appeared swollen. Facility Incident Report dated 5/4/2021 documents: Individual allegedly involved: R1 and employee: Description of occurrence: R1 alleged that staff member was providing care that is inconsistent with facility standards. Investigation initiated. Abuse Prevention Policy dated 2/2017 documents: This affirms the right of our residents to be free from abuse. Establishing an environment that promotes resident security and prevention of mistreatment. Abuse means any physical or mental injury which results in physical harm or mental anguish to a resident.

Based on interview and record review the facility failed to follow their Bed Bath and Repositioning Policies and failed to use a 2 person physical assist while providing activities of daily living (ADL) care for 1 of 3 residents (R2) reviewed for bed mobility in a total sample of 7. This failure resulted in R2 rolling out of bed while receiving care and suffering a bruise to the jaw and a laceration to the right forehead requiring sutures. Findings Include: The Incident Report dated 10/31/19 documents that a staff member was assisting R2 with a bed bath. R2 was rolled onto the side while being cleaned. Staff was reaching for wipes and the resident was observed rolling off the bed and onto the floor. R2 was transferred to the local hospital for evaluation and treatment. Hospital Records dated 10/31/19 documents that R2 was admitted with bruising to the right side of the face and a 3.5cm laceration to right side of the forehead that required 9 sutures for repair. On 11/27/19 at 1:30pm V6 (Certified Nursing Assistant/CNA) stated I went into the room and proceeded to provide care. I got R2 in position and rolled the resident over onto the side. I took my hands off the resident to get the wipes I needed to clean R2 up. The wipes were laying on the bed and I was getting the wipes out and the resident started rolling. I could see R2 falling but I couldn't stop it from happening. The nurse came in and we got R2 up. The resident was bleeding from a cut on the head and was sent out to the hospital. R2 does roll and I usually move the resident by myself. The care plan dated 9/4/19 documents that R2 usually requires a 2 person assist with ADLs and the Quarterly Minimal Data Set ((MDS) dated [DATE] documents that R2 requires 2 person physical assist with bed mobility and ADLs. The facility's policy on Bed Baths and Repositioning a Resident documents that staff should review the resident's care plan to assess for any special needs of the resident (e.g., the amount of assistance needed, limitation in positions or activity).

Based on interview and record review the facility failed to use a footrest while transporting a resident in a wheelchair for 1 of 4 residents (R1) in a total sample of 4. This failure resulted in R1 hitting the left ankle on the bedframe while being transported and sustaining a left ankle fracture. Findings Include: The Face Sheet documents that R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Incident Report dated 7/11/19 documents that V6 (CNA) was pushing the resident in the wheelchair when R1's ankle twisted. R1 had complaints of pain and an x-ray was done that showed a displaced [MEDICAL CONDITION] ankle. The Physician was notified and R1 was transferred to the local hospital for evaluation. On 7/11/19 an investigation was done and V6 stated that R1 was being pushed in the wheelchair so that the resident could be taken out of the room. R1 then complained of ankle pain. V6 observed that the resident's foot was not on the footrest of the wheelchair. IDPH was notified of the incident and V6 was terminated from the facility for not using a footrest while pushing a resident in a wheelchair. The radiology report dated 7/11/19 shows an acute fracture involving left distal fibula and distal tibia with minimal displacement. The Hospital records dated 7/11/19 documents that R1 presented with complaints of left ankle pain. Family states that the resident was put into a chair and hit the left ankle on the bed. No other injuries noted. X-ray shows acute fracture involving left distal fibula and tibia with associated soft tissue swelling. R1's leg immobilized with a splint and the resident was referred for an orthopedic consult. The Orthopedic Consult dated 7/18/19 documents that R1 should wear an ankle immobilizer during transfers related to the left ankle fracture. On 9/18/19 at 1:25pm V2 (Director of Nursing/DON) stated V6 walked in to get the resident up out of bed. V6 got the resident up in the wheelchair and did not put the footrests in place. V6 was rolling the resident out of the room when R1's foot hit the bottom of the roommates' bed. R1 yelled 'Ouch' and V6 saw what happened and got the resident back in bed. We got an x-ray done that showed a [MEDICAL CONDITION] and the resident was sent out to the hospital. The family refused surgical intervention so the resident now wears a boot at night. V6 got the resident up with no problem but forgot to put the footrest in place. The resident should have had a footrest for safety because the resident was being pushed in the wheelchair. V6 was terminated because the footrest was not used. Footrests were not documented on the care plan at the time. The care plan has been updated to include using footrests when the resident is being pushed in the wheelchair. All residents are now assessed for footrests on admission.

Based on record review and interview the facility failed to follow their policy to have two staff members present while operating a mechanical lift and properly securing the standing lift's lower leg straps while transferring from bed to wheelchair for 1 of 3 residents (R1) reviewed for transfers. This failure resulted in R1 sustaining a full thickness oblique [MEDICATION NAME] femoral metaphysis with mild angulation with posterior direction of the fracture apex. Findings include: On 5/10/19 at 10:04 V3 (Licensed Practical Nurse/LPN) stated on 5/2/19 the CNA came and asked her to come in R1's room. V3 said R1 was sitting on the floor when she entered the room. V3 said during range of motion (ROM) to R1's leg (unsure which leg) R1 screamed and said her upper leg hurt. V3 said she notified the doctor and obtained orders for an x-ray because of pain during the ROM. V3 said R1 remained alert at this time, with her baseline of confusion. V3 said she did not think R1 had a fracture from being lowered to the floor and thought the pain may have been related to arthritis. On 5/10/19 at 10:30AM V2 (Director of Nursing) stated the facility policy is to have 2 CNAs (or nurses) present during a mechanical lift transfer. V2 said 2 persons should have been with the resident when the button was pressed for the transfer. V2 said the purpose of 2 persons is for safety. V2 said at orientation and throughout the year staff is trained on the safe use of the mechanical lifts. V2 said when the results of the x-ray were reported to the physician he gave the order to transfer the resident to the hospital for evaluation. On 5/10/19 at 10:50AM V4 (Certified Nursing Assistant/CNA) stated on 5/2/19 while transferring R1 from her bed to the wheel chair R1's leg slipped off of the foot rest. V4 said when she noticed she could not put R1's leg back up in the foot rest, R1 was screaming. V4 said at the same time R1 began to slide out of the sling. V4 said she lowered R1 to the ground and unhooked the sling. V4 said she assisted R1 to sit down on the floor with her left foot under her right thigh. V4 said she did not use the leg belt on the mechanical lift to secure R1's legs during the transfer, because she was in a rush. V4 said she does use the leg belt with other residents. V4 said she was operating the mechanical lift alone. V4 said she was suspended following this incident. V4 said she had been trained on the safe use of the mechanical lifts prior to 5/2/19. On 5/10/19 at 11:08AM V5 (CNA) said she helped V4 lower R1 to the ground. V5 said she was in another room with another patient when V4 came to get her. V5 said when she entered R1's room she saw R1 next to the bed on the floor. V5 said she will transfer residents using 2 or 3 people when using the mechanical full body lift. V5 said uses assistance for the residents comfort and safety while using the mechanical lift. V5 said R1 only said her knee hurt (V5 is unsure which knee). On 5/10/19 V14 (Physical Therapist) stated based on his clinical opinion, when using the standing lift to transfer R1 the staff should use the leg harness to help stabilize R1's position and support R1's knees given her history of knee pain. V14 said he would recommend 2 person assistance while using the mechanical lift. On 5/10/19 at 11:48 AM V18 (CNA) said she always operates the mechanical lift with 2 staff persons. On 5/10/19 record review of R1's x-ray completed on R1's left hip, left tibia/fibula, left femur, and left knee on 5/2/19. The results of the left femur denote an acute distal femur fracture. Results of the left knee denote an acute distal femur fracture. On 5/10/19 at 2:20PM V13 (Nurse Practitioner) stated she is very familiar with R1 and said she is not surprised that R1's legs gave out during the transfer on 5/2/19. V13 said the expectation is that 2 staff members should have been in the room while operating the mechanical lift. On 5/14/19 at 10:27AM V15 (Physician) stated once he was notified of R1's fracture he ordered for R1 to be transferred to the hospital and was then seen by an orthopedic. V15 said R1 had surgery for [REDACTED]. On 5/14/19 Record review for R1 denote on 4/24/19 the Minimum Data Set (MDS) for R1 indicates R1 required extensive assistance from 2 or more persons for transfers. R1's most recent Brief Interview for Mental Status (BIMS) score was 13, cognition intact . R1's care plan at the time of discharge denotes R1 requires assistance with transfers using 2 person mechanical lift. On 5/14/19 hospital records were obtained for R1. According to a 3-view x-ray performed on R1's left knee on 5/3/19 the impression is a full thickness oblique [MEDICATION NAME] femoral metaphysis with mild angulation with posterior direction of the fracture apex. The facility policy for Using a Portable Lifting Machine reads: The portable lift should be used by two staff members. The Instructions for use of the standing mechanical lift reads: Foot Support: For positioning before and supporting the resident's feet during raising and transferring. Lower Leg Straps: Accessory used to ensure that the lower parts of the residents legs stay close to the knee support. Warning: The resident's feet shall always remain in full contact with the foot support. When raising check to ensure that the resident's feet do not lift from the foot support. If they do, lower the resident immediately until resident's feet fully reach the foot support.

Based on interview and record review the facility failed to follow the current MDS (Minimum Data Set) assessment and Kardex and utilize 2 person assist for bed mobility while providing direct care to 1 of 3 residents (R1) reviewed for safe bed mobility. This failure resulted in R1 being turned/repositioning by 1 staff person and R1 falling out bed and sent to hospital and diagnosed with [REDACTED]. Findings include: R1's facility face sheet/clinical records show R1 is [AGE] year old person with [DIAGNOSES REDACTED]. A review of facility incident report dated 02/25/2019 time stamp of 5:39pm documents: Witnessed fall, resident (R1); incident location: resident's room; person preparing report: V8 (Nurse); during position change and perineum check resident (R1) rolled to floor. Evaluated by NP (Nurse Practitioner)/(V7), abrasion above right eyebrow. BP (Blood pressure) 107/76, P (Pulse) 99, po2 (pulse oximetry) 98% room air, NP (V7) giving orders to send out to hospital. Family notified. Resident (R1) taken to hospital: Y (yes). Injuries at time of incident: No injuries observed. Pain level 0, mental status: orientated to person; injuries reported post incident: no injuries observed post incident; predisposing environmental factors: none; predisposing physiological factors: confused, incontinent; predisposing situation factors: none; witnesses: no witnesses found; agency notified: physician. R1's progress notes dated 02/25/19 at 09:41pm documents resident (R1) admitted to local hospital. R1's progress notes dated 02/25/19 at 5:40pm documents see nurse note on incident. R1's progress notes dated 02/25/2019 at 03:26pm shows V7 documented: Asked by nursing to urgently evaluate 76 y/o female (R1) who sustained a fall out of the bed while she was being turned. Upon entry to the room, the bed was noted lowest position and patient was laying on the floor. Patient is obese and staff was unable to get her up from the floor. Patient is also unable to reposition herself at all, 911 called and arrived to facility within minutes to transport her (R1) to nearest facility for further evaluation. I (V7) spoke with daughter/ POA and notified her of situation. I (V7) told her I don't have any specific information regarding the fall or where she will be sent. Nurse will call her back and provide full details of the situation. PMHx (past medical history), comments: [MEDICAL CONDITION], Afib ([MEDICAL CONDITION] Fibrillation), GI (gastrointestinal) bleed, dysphagia, [MEDICAL CONDITIONS], obesity, gerd, SOB (shortness of breath), [MEDICAL CONDITION] - ileus, depression, [MEDICATION NAME], [MEDICAL CONDITIONS], DM (Diabetes Mellitus),[MEDICAL CONDITION](hypertension), gout. Family hx: unknown; comments: lives LTC (long term care), non-smoker, non ETOH (alcohol); ROS (Review of systems) not performed due to severity of situation, complaining of facial pain, vitals: BP (Blood pressure) 107/76, HR (heart rate) 76, R (respirations) 22.0, temp: 98.1, SpO2 (Oxygen Saturation) 98%. Objective - GEN (generalized) in distress, laying on floor, blood coming from nose, RESP (respiratory) lungs clear to auscultation, CV (cardiovascular): RRR (regular rhythm, rate), BLE (bilateral lower extremities) - trace [MEDICAL CONDITION], GI + BS (bowel sounds): non tender to palpitation, obese abdomen, Derm ([MEDICAL CONDITION]): skin warm to touch and dry, MUSC (musculoskeletal): limited ROM (range of motion), Psych AOx2 (alert and oriented), assessment - facial injury: unspecified injury to face; initial encounter modified 25 (MONTH) 2019. Plan - facial injury, send out 911 for further evaluation. V7- FNP (Family Nurse Practitioner). On 3/28/19 at 01:15pm reviewed R1's diagnosis/abbreviations and progress notes dated 2/25/2019 with V7. R1's progress notes dated 02/25/2019 at 2:21 p.m documents late entry - all care needs met by staff, tolerated fair. A/O (alert and oriented) 2-3 at this time with periods of confusion. Ate good for meal time, taking fluids well. [MEDICAL CONDITION] care as ordered - tolerated well. During position change - resident (R1) fell on floor - evaluated by V7. BP (blood pressure) 107/76, P (Pulse) 99, SpO2 (Pulse oximetry) 98% room air. Noted nickel size abrasion above right eyebrow - tip of nose with several scratches; 911 called as well as family. A review of R1's hospital records dated 02/25/2019 document: Chief complaint: patient presents with fall, [AGE] year old female presents to ER (emergency) via EMS (emergency medical services) after being found on the ground next to her bed. Patient states she (R1) rolled over and fell out of bed. Patient is poorly mobile. She has bilateral heel pads and is morbidly obese. She states currently that her left knee is uncomfortable. She is unsure if she lost conscious but believes she did not. She has not ambulated in 5-6 years. Physical exam: facial abrasion. Imaging results dated 02/25/2019 - XR knee bilateral 3 view final results: there is communicated fracture involving the distal diaphyseal region of the right femur with displacement of the distal right femur anteriorly; there is associated soft tissue swelling. Arthritic changes noted to the right knee joint. There is communicated fracture involving the distal diaphyseal region of the left femur with associated soft tissue swelling. Arthritic changes noted to the left knee joint. Impression: diffuse [MEDICAL CONDITION], bilateral displaced comminuted fractures involving the distal bilateral femurs. R1's MDS (Minimum Date Set) dated 01/04/2019 section G0110 documents that R1 requires extensive assist with two person physical assist with bed mobility, transfer, toilet use and personal hygiene. On 3/26/2019 at 10:30a.m V2 (Director of Nursing) said on 02/25/2019 V3 (Certified Nursing assistant/CNA) was providing incontinence care to R1. V2 said as V3 turned R1, R1 rolled out of the bed. V2 said V3 turned R1 by herself and R1 requires extensive assist with two persons with turning. V2 said there should have been two people to assist with turning R1. V2 said the CNAs should check the resident's Kardex/miniature care plan daily, prior to care to review the care needs. On 3/26/19 at 01:40p.m V3 (CNA/Certified Nursing Assistant) said on 02/25/19 she went to R1's room to provide incontinence care. V3 said she asked for assist from V9 (CNA). V3 said while waiting on V9, she (V3) had completed half of the task (cleaning the front area of body/perineum) and so she thought she could turn R1 by herself. V3 said while standing to the right side of R1's bed she pulled the sheets toward her. V3 stated, I could not pull too much because R1 has a large body size and see how short I am? (V3 stated she is 4'9 tall.) V3 said she then turned R1 on her left side; V3 said she had to use force to turn R1 by herself. V3 said once she turned R1, R1 held on to the chair's arm rest that was next to her bed for support. V3 said she washed R1's back and R1 fell out the bed. V3 said she could not stop R1 from falling. V3 said R1's upper body rolled out of the bed first and her lower body followed. V3 said she often uses the chair for support for R1 because there are no bed rails. V3 said she is aware that R1 requires extensive assist of two people for turning/bed mobility. V3 said she reviewed R1's Kardex/care plan at least monthly and it shows R1 needs two person assist. V3 said she used poor judgement when turning R1 by herself. On 3/26/19 at 10:30 a.m. request was made to review R1's Kardex/miniature care plan. On 03/26/19 V2 stated she cannot view the kardex and she will contact the consultant regarding the issue. On 3/27/19 at 11:00a.m V2 stated she cannot provide the kardex/miniature care plan and the consultant was not able to access that kardex. V2 stated the consultant did not give rationale on why the kardex/miniature care plan was not accessible. On 3/28/2019 1:00p.m a request made for a screen shot of task page showing bed mobility with a letter K next to it. V2 said the K next to the word bed mobility shows that bed mobility is on the kardex and on the kardex it will show many people are required for bed mobility, which is two person assist. On 3/28/19 at 01:15p.m V7 said that R1's injuries could have resulted from a fall. V7 said that it is not a good practice to have any resident holding onto a chair for support during care. V7 said R1 should be turned/repositioned with assist of two persons. V7 said R1 would not have been able to support herself due to her physical weakness, limited range of motion in extremities and [MEDICAL CONDITION]. Review of facility policy titled turning resident on his/her side (dated (MONTH) 2008) documents: Purpose of this procedure are to provide comfort to the resident, to prevent skin irritation and breakdown and promote good body alignment. Preparation: Review the resident care plan to asses for any special needs of the resident. On 3/27/19 at 1:00 p.m. V2 asked about policy for two or more person assist turn; V2 said the facility does not have a policy for two or more person assisted turn. On 03/28/19 at 01:18 p.m. V2 stated the facility does not have a policy on how to turn a resident using two person assist. V2 said she is responsible for training the staff and preceptors on turning/repositioning. V2 said the facility practice is that there should be a pad/pull sheet underneath the resident to allow for easy positioning, there should be one person on each side of the bed (left and right), and the resident should be repositioned/pulled nearest the opposite side of the bed that the staff is planning to turn. V2 said the resident's arm should be placed on top of the body and the resident's leg should be crossed over. V2 said the staff on the side that the resident is planning to turn should grab hold of the pad/sheet and start the turn, while the second staff guide the turn by placing the one hand nearest the resident's shoulder and one hand nearest the resident's hip area. V2 said this action is to allow for proper body alignment and safety. V2 said the rationale for bringing the resident to the opposite side of the bed prior to turning is to allow room for the turn, so that the resident does not fall from the bed.

Based on observation, interview and record review the facility failed to monitor and assess a resident's skin condition for the development of a pressure ulcer for appropriate treatment and failed to assist a resident with turning or repostioning for one resident (R339) in the sample. This failure resulted in R339 developing an unstageable pressure ulcer wound. Findings include: 09/18/18 11:01 AM R339 said, I am supposed to be turned every 2 hours; the only time I can remember being turned is when I have a bowel movement. They said I am refusing to be turned and therapy, but I am not. 09/18/18 03:50 PM R339 said, I have sores on my bottom and I did not have them when I came in here. 09/18/18 03:55 PM V3 (Certified Nurse Aide) said, I started seeing redness to R339's bottom about two weeks ago. Now there is skin break down. 09/19/18 10:06 AM V4 (Wound Care Nurse) said R339 had an abrasion on the left buttock that has resolved and now has an unstageable wound to the coccyx measuring 4cm x 11cm. V4 said, The wounds on R339's bottom could have been avoided if R339 could really fully turn. The staff helps turn and reposition but R339 said it is more comfortable laying on her back. 09/19/18 12:30 PM R339 said, I have not refused to be turned; it is very painful and I do scream. 09/19/18 03:28 PM V1 (Administrator) stated the Skin Practice Guide Process Flowchart is used as the wound care policy. 09/20/18 09:07 AM V5 (Wound Nurse Practitioner) said, I am seeing R339 for the first time. I deal with pressure ulcers, any facility acquired wounds, arterial, and venous wounds but I do not see every type of skin impairment. R339 got the left buttocks wound here; it could not have been prevented if R339 was not turning because of the pain. I can't say that the wound was developed over two days. With a deep tissue injury you cannot tell what is under there until the epidermis comes off, then you can stage the wound. That is an unstageable wound. V5 stated to R339, What you have here is an unstageable pressure ulcer; you are on an air mattress and need to turned more frequently. 09/20/17 09:10 AM during a wound treatment the surveyor observed V4 (Wound Care Nurse) turn R339 to right side. The pressure ulcer had slough (yellow tissue) noted to the bed of wound of sacral area. 09/20/18 09:48 AM V4 (Wound Care Nurse) said, No one made me aware of the wound; Tuesday was the first time I saw it. The floor nurse will assess the wound then I come the next day. If the (Certified Nurse Assistant) saw the wound during bedside care they should have notified me. Skin checks are done twice a week on shower days. Initially if the resident does not have any skin issues, the floor nurse will do the skin checks. It would have helped if a pillow were to be used to relieve some of the pressure. The last time the dressing was changed for R339's skin tear was Tuesday and I changed it either Saturday or Sunday. It took four days for me to be notified of the initial left buttocks skin tear. 09/20/18 10:01 AM V9 (Registered Nurse) stated, Skin assessments are done every shift to make sure there is no broken skin, bruises or abrasions. If there are any skin alterations we call the doctor, they let us know how to treat it and we do a wound care consult. There were no changes on R339 skin last week, except for left buttocks skin tear. 09/20/18 11:13 AM V4 (Wound Care Nurse) said, I saw the new opening Tuesday because the left buttocks dressing change was due and R339 had an unstageable wound. It can develop fast. I was shocked myself because the last time I saw R339 the wound was not there. Residents can develop pressure wounds if they are not able to turn and reposition. I knew R339 was resistant to turning and repositioning. Certified Nurse Assistants provide daily ADL care and they are expected to do skin checks. 09/20/18 01:16 V6 (Certified Nurse Aide) said, I was helping V7 (Certified Nurse Assistant) with R339's bed bath on 09/10/18. Both stated that they noticed what looked like a large pink skin tear to R339 coccyx area. We told V8 (Registered Nurse), who said she would report it to the wound nurse. 09/20/18 V2 (Director of Nursing) stated when a resident is found to have a skin issue it is to be reported to the nurse. The nurse does an assessment, notifies the doctor and the wound care nurse. V2 left a message on V8's (RN) answering service of need to speak with surveyor with no response. R339's Admission Screen - V3 (nurse) dated 9/1/18 showed there were no noted skin alterations. R339's Minimum Data Set (MDS) assessment 3.0 Section M - Skin condition dated 09/08/2018 noted Resident has no stage 1 or greater, scar over boney prominence, or a non-removable dressing/device. R339's care plan dated 9/19/18 reads, Focus: At risk for alteration in skin integrity. Intervention: Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. R339's Skin worksheet dated 9/10/18, 9/13/18, and 9/17/18 reads: open area noted to sacral area on diagram. The facility Shower List had R339 scheduled 7am to 3pm on Monday and Thursday. Electronic treatment administration record (ETAR) dated 9/1/18-9/30/18 reads: R339 Body audit on shower days every day shift every Mon, Thu for skin observation, initialed 9/10/18, 9/13/18 and 9/17/18. R339's ETAR dated 9/1/18-9/30/18 also reads: Apply to Lt (left) buttock topically every shift every other day for wound - cleanse with wound cleanser, cover with foam dressing, initialed 9/12/18, 9/14/18 and 9/16/18. R339's Progress note dated 9/10/18 shows V4 documented: Assessed Lt buttock per nurse request. Noted 4.0 x 2.0cm, 100% red, no odor or drainage and intact periwound. R339's Progress note dated 9/15/18 shows V8 documented: Pt has ulcers to both buttock areas. R339's Progress note dated 9/19/18 shows V4 documented: Unstageable wound to more on coccyx area 4.0 x 11.0cm 100% yellow slough, wound edges pink, moist, periwound intact. ETIOLOGY: Pressure. Policy Titled Skin Practice Guide Process Flowchart dated 2013: Diagramed to Assess - Complete skin risk section of admission - Is patient at risk for skin breakdown? - Braden Scale weekly x 3 more times - change in condition - Wound team to evaluate - Is the skin alteration a pressure ulcer? - Initiate skin alteration record - Contact physician for orders Policty Titled Skin practice guide dated 2013: Phase 1: Assess Patient positioning: can assist with reducing the risk for breakdown. The Braden scale is completed for four (4) weeks total (at the time of admission and then weekly for the next three (3) weeks. A weekly skin evaluation is completed by the licensed nurse for those patients identified as at risk for skin breakdown that do not have a pressure ulcer. Patients admitted with skin alterations or those who develop new alterations are ideally evaluated by a qualified health professional within 24 hours or as soon as practicable, after admission or new skin alteration identified. Nursing assistants perform daily skin observations with routine care. The skin worksheet is completed by the nursing assistant at least two times per week with the patient's bath. Results are submitted to the licensed nurse for review and follow-up as needed. Patients at risk have a head-to-toe skin evaluation weekly by a licensed nurse. If a change in patient condition occurs, such as skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents findings in the clinical record.

Based on observation, interview, and record review the facility failed to utilize a pressure ulcer risk assessment to individualized interventions for the prevention of pressure ulcers, and failed to provide care and services to prevent the development/or worsening of a pressure ulcer for one of 11 residents (R19) reviewed for pressure ulcers in a sample of 24. These failures resulted in R19 developing a stage 3 pressure ulcer to the coccyx which worsened to an unstageable pressure ulcer. Findings include: R19's Braden Scale for Predicting Pressure ulcer Risk dated 5/12/15 documents R19 is at very high risk for developing a pressure ulcer. R19's Minimum Data Set assessment ((MDS) dated [DATE] documents R19 is in a persistent vegetative state requiring total assistance from one to two staff members for all activities of daily living, including bed mobility. A Pressure Ulcer Prevention Pathway policy dated 2013 documents that a turn/reposition schedule should be initiated for residents at risk for pressure ulcers or residents who currently have pressure ulcers. R19's Skin Worksheets dated 7/02/15 to 7/13/15 document R19 had redness to the coccyx/buttocks on 7/02/15 which developed into an open area on 7/13/15. R19's Skin Worksheets dated 7/16/15 to 7/23/16 continue to document open areas to R19's coccyx/buttock. R19's wound care progress note dated 7/21/15 and signed by Z1 (Wound Physician) documents Z1 made an initial examination of R19's New coccyx stage 3 pressure ulcer on that date. The progress note also documents that at the time of Z1's examination, R19 was wearing a soiled incontinence brief with, .bed sheets soaked with urine, No dressing on coccyx. On 7/28/15 at 10:35a.m. Z1(Wound Physician) stated R19's pressure ulcer to the coccyx was preventable. Z1 stated R19 is totally dependent on staff for turning and repositioning. Z1 stated that despite R19 receiving nourishment through a gastrostomy tube, Z1 did not think poor nutrition was the cause of R19's pressure ulcer. Z1 proceeded to enter R19's room for a weekly examination of R19's pressure ulcer to the coccyx. Z1 pointed to a round wound to R19's coccyx measuring 2cm (centimeters) x 2.5cm x 0.5cm deep which had a yellow/tan wound bed. Following the examination, Z1 stated R19's wound had worsened from a stage 3 pressure ulcer to an unstageable pressure ulcer since Z1's initial examination of the wound 7/21/15. Z1 also pointed to an extensive, irregularly shaped, open area to R19's left buttocks which had a deep pink wound bed. Z1 stated Z1 was not certain if the open area to R19's left buttock was caused from incontinence, friction, or pressure. Z1's wound care progress note dated 7/28/15 documents R19's, New coccyx stage 3 pressure ulcer appears unstageable now.Etiology pressure, moisture. Increased in size. R19's care plan dated 5/13/15 includes interventions to address, Skin alteration at coccyx related to impaired mobility, incontinence, friction. The care plan does not include interventions specific to R19's stage 3 pressure ulcer to the coccyx. R19's care plan interventions include, Encourage and assist as needed to turn and reposition. The care plan does not include a turn/reposition schedule. On 7/28/15 during a continuous observation from 11:00a.m. to 2:00p.m. R19 was laying in bed with R19's lower body and pressure ulcer flat against the bed. R19 was not repositioned by staff during that time. On 7/29/15 at 10:10a.m. E2 (Director of Nurses) stated E2 is responsible for verifying the accuracy of residents' care plans. E2 also verified R19 requires total assistance of staff for activities of daily living. E2 stated R19 has pressure ulcers which requires R19 to be turned/repositioned every two hours by staff. E2 stated E2 was not aware R19's skin alteration to the coccyx, as was listed on the care plan, was actually a stage 3 pressure ulcer, or that R19's stage 3 pressure ulcer had worsened to an unstageable pressure ulcer.

Based on interview and record review facility failed to follow their falls practice guidelines for implementation of fall preventive interventions for one of four residents (R1) reviewed for falls, in a sample of four. This failure resulted in R1 falling out of bed and sustained a fracture of the arm (distal humerus). Findings Include: R1's care plan created 2-21-14 denotes at risk for falls due to unsteady gait and cognitive impairment. Broad chair for poor trunk control staff to make frequent rounds while in gerichair. R1's fall report dated 3-10-14 R1 rolled out of bed to floor mat and attempted to roll out 11:00 pm, nurse no injuries doctor notified. Added intervention 3-10-14 Offered body pillow to aide in positioning. R1's fall report dated 6-10-14 heard R1 screaming for help and found on knees near mattress 4:30 pm no injuries doctor notified. Added intervention 6-10-14 staff to frequent checks for toileting and positioning in bed. R1's fall report dated 6-20-14 found on floor next to her bed 1 am no injuries doctor notified. Added intervention 6-23-14 have common used items within reach and staff do frequent toileting and positioning when in bed. R1's fall report dated 8-24-14 found on floor next to bed 4:18 am no injuries noted, doctor notified. Added intervention 8-24-14 monitor residents condition in bed. R1's fall report dated 4-26-15 denotes observed R1 lying on the floor beside the bed, bed low bed linen on floor bedside R1. No head to toe body check, no visible injuries doctor notified, X-ray right hip- no fracture. Last toiled by CNA at 10:26 pm. Approximately 1:13 am nurse observed R1 lying on floor next to bed. R1 was soiled at the time. R1's intervention task sheet denotes last toileted on 4-26-15 at 2:00 pm. R1's incident report dated 4-29-15 denotes R1 was visited by hospice nurse R1 complained that her right elbow was hurting. Doctor notified and X-ray ordered. R1's radiology report dated 4-29-15 denotes right elbow lateral view there is an acute or subacute supracondylar fracture of the distal humerus with approximately 2 centimeters of overriding of the fracture fragments. With anterior displacement of the distal fracture fragment. Conclusion: Fracture of the distal humerous. Z1 (Doctor) stated on 5-13-15 at 12:40 pm that R1's injury (fracture) had to be from the previous fall not a transfer. Z1 stated that her bone had a slight crack after the fall and then subsequent moving of her muscles the fracture became displaced. E6 (Certified Nurse Aide/ CNA) stated on 5-14-15 at 11:20 was working the night shift (11-7) on 4-25/26-15 on the Medicare unit. E13 stated had started working for a few hours on the Medicare unit and was pulled to watch R1 and some other residents. E13 stated was told to come to R1's unit by the nurse because they were short staff. E13 stated was not assigned to R1 until after she had fallen. E8 (Registered Nurse) stated on 5-13-15 R1 is confused and disoriented non ambulatory had history of rolling out of her bed and falling on the floor. E5 stated on 4-25/26-15 was working the night shift heard R1 call out and found R1 on her side on the floor next to her bed. E8 stated got assistance, assessed R1 and they used the mechanical lift to put her back to bed also notified her doctor. E8 stated body pillow was not in place at the time of the fall or floor mat. E8 stated did not see any CNA go in R1' s room before the fall. E8 stated did not check if she was wet when she got to work at 11 PM because that's the duty of the CNA. E8 stated R1 was awake when she got to work and only asked her how she was doing but did not ask her if she needed to use the washroom. Facility's assignment sheet dated 4-25-15 (11-7) denotes E8 and E6 assigned to R1 for 11-7 shift on 4-25-15. E7 (Certified Nurse Aide) stated on 5-14-15 at 11:05 am was called to R1's room by the nurse (E8) and saw R1 on the floor next to her bed did not see a floor mat or body pillows. E7 stated nurse did assessment and rolled her onto the sling and they used the mechanical lift to transfer her to the bed. E7 stated did not see any bed bolster or body pillows. E7 stated was told that they could not use the floor mats and could not use the body pillows. E7 stated first time he saw R1 was that night was when she was found on the floor. E2 (Certified Nurse Aide) stated on 5-13-15 at 11:15 am worked the pm shift 3-11 mainly was told on today (5-13-15) to start using bed body pillows for R1. E2 stated has known R1 had history of rolling out of her bed and falling on the floor. E2 stated they have not been using floor mats or body pillows for her. E3 (Unit Manager) stated on 5-13-15 at 11:00am the body pillow was put in placed yesterday (5-12-15) for R1. E3 stated after each fall the resident is assessed then fall care plan is reviewed and new interventions should be in place or evaluated. E3 stated they do not use floor mats and bed alarms. E11 (Administrator) stated on 5-14-145 at 10:45 am that floor mats are not used unless clinically indicated. E11 stated does not know why the body pillows were not being used even though they were on R1 ' s care plan. E11 stated did not know if R1 needed the floor mats. Facility's falls practice guide denotes the purpose of the fall practice guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. The interdisciplinary team designs the patient' s care plan to focus on all the patient's issues including those associated with fall prevention and fall risk management. Regardless of the interventions that are put in place, key factor to success is the timely review of the interventions as the patient's condition and needs change. Provide nursing staff 24-hour access to supplies and equipment that may be needed for fall management interventions may include, but are not limited to low beds, bedside mats and positioning devices. The patient' s condition response to interventions and subsequent care provided is documented in the patient's clinical record.

Based on interview and record review, the facility failed to use the appropriate mechanical lift to transfer one resident (R1) of four residents reviewed for mechanical lift transfer out of a total sample of four. This failure resulted in R1 sustaining a left femur fracture. Findings include: R1's Physician order [REDACTED]. R1's MDS (Minimum Data Set) dated [DATE] documents R1 was non-ambulatory, and required the extensive assistance of at least two staff members to transfer. Facility incident report dated [DATE] documents R1 fell at 11:30am during transfer from her bed with the sit-to-stand mechanical lift. R1 let go of the handles of the lift while being transferred, and slid to the floor. Nursing note dated [DATE] at 7:42pm documents resident was on the floor in a sitting position, the mechanical lift in front of her. This nursing note also documents there were no apparent injuries, and R1's physician, Z2 (Friend) and Z3 (Friend) were contacted. R1's care plan was updated post fall to include new interventions of reporting to the physician the development of pain, bruises, change in mental status, ADL (Activities of Daily Living) function, appetite or neurological status. Facility incident report dated [DATE] documents R1 again fell at 8:30pm, while being transferred to bed via the sit-to-stand lift. Nursing note dated [DATE] at 8:30pm documents that upon entering the room, E10 (Nurse) observed R1 "lying on the floor on her back, blood and clear fluids were draining from right leg deep skin tear." This note further documents "advised the CNA's to get the mechanical, full body sling lift to lift R1 back to bed to be examined. The CNA's say that R1 slid off the stand up lift to the floor on her knees and then layed down on her back." This note further documents R1's physician and Z3 were notified, and R1 was sent to the hospital for evaluation. Nursing note dated [DATE] at 4:31am documents R1 was admitted to the hospital with [REDACTED]. E5 (CNA) stated [DATE] at 9:45am she was assigned to care for R1 the evening of [DATE], and enlisted the assistance of E6 (CNA) to help put R1 to bed. E5 further stated she had taken care of R 1 "a couple of times" in the past, and wasn't aware that the kardex/kiosk computer system informs CNA's of which lift to use for a resident. E6 also stated that upon trying to lift up R1 with the sit-to-stand lift, R1 was "in a panicky state, flailing her arms around, and resisting trying to stand up. E6 then stated R1 then slid under the lift's under arm sling, sliding to the floor. E6 further stated she saw other CNA's use a sit-to-stand lift for R1 in the past, so that's why she also decided to use it to transfer R1. E6 (CNA) stated [DATE] at 2:15pm she assisted E5 to attempt to transfer R1 the evening of [DATE], and stated she assumed E5 checked the kardex to see what type of mechanical lift should be utilized to transfer R1, since R1 was assigned to E5. E6 also stated R1 was "fighting every time we tried to lift her up with the machine to get her in a standing position, and began to slide out of the sling" upon her transfer [DATE]. E6 further stated that every time she assisted R1 to go to bed, "she would act the same way--fighting, combative." E6 further stated R1 was known to move around a lot during transfer, trying to get out of the mechanical lift, fighting to get into the lift, and once in, would often try to unfasten the strap closures in attempts to get out of it. Z2 stated [DATE] at 10:05am R1 continued to decline after hospitalization , and was transferred to in-patient hospice care at another hospital, where she expired [DATE]. E2 (Director of Care Delivery) stated [DATE] at 1:46pm that after R1's fall [DATE] from the sit-to-stand lift, her kardex was updated to say "use mechanical lift with sling to transfer". E2 further stated that upon questioning E5 and E6 after R1's fall from the sit-to-stand lift [DATE], both CNA's stated that it was unclear to them what type of lift to use, as all mechanical lifts have a sling. A copy of R1's kardex was requested by the surveyor, but was never provided. E2 further stated she was not aware who assessed R1 to be appropriate for a sit-to-stand lift. E1 (Administrator) stated [DATE] at 12:28pm falls are reviewed by the Quality Assurance Committee the next day, to try to discover the cause and put new interventions into place to prevent future occurrences. E1 further stated that after R1's fall from a sit-to-stand lift [DATE], R1's kardex was updated to say to use a "mechanical lift with sling" to transfer her, and CNA's are responsible to look at each resident's kardex to see which assistance devices are to be used for that particular resident's care. E1 further stated E5 and E6 did not understand that "mechanical lift with sling" meant to use a full body sling lift. E1 also stated nursing staff/therapy is responsible to assess which lifting device to use for each resident. Surveyor asked for a copy of R1's mechanical lift assessment, but was not provided one. E1 stated [DATE] at 10:30am new CNA's are oriented to the kardex/kiosk system upon their unit orientation, and are to use it to refer to perform their daily tasks in caring for each resident. Z1 (R1's Physician) stated [DATE] at 9:08am it's a nursing decision which type of lift to use to transfer a resident. This should based on the resident's physical and cognitive abilities, level of confusion, and cooperativeness. Z1 further stated that if a resident isn't capable of following directions or won't cooperate enough to use a sit-to-stand lift, a full body sling lift should be used. Nursing staff need to ensure the resident is transferred safely. Facility Policy titled "Mechanical Lift" states, in part "Introduce self, explain procedure. Connect sling straps attachment clips to attachment points on the spreader bar. Fold patient's arms on chest and instruct to keep arms close to body for safety." Facility policy titled "Falls Practice Guide" states, in part "Initiate/update patient information kardex, task list" post fall and "Develop/revise interdisciplinary care plan as applicable, including ongoing fall prevention strategies, patient/family and staff education."

Based on interview and record review, the facility failed to safely transfer one resident (R1) of four residents (R1-R4) reviewed for transfer via mechanical lifts. This failure resulted in R1 sustaining a fracture to the left femur. Findings include: R1 is the subject of this complaint. R1's Physician order [REDACTED]. R1's MDS (Minimum Data Set) dated [DATE] documents R1 was non-ambulatory, and required the extensive assistance of at least two staff members to transfer. Facility incident report dated [DATE]: R1 fell at 11:30am while being transferred from her bed via the sit-to-stand mechanical lift. R1 let go of the handles of the lift while being transferred, and slid to the floor. Nursing note dated [DATE] at 7:42pm documents resident was on the floor in a sitting position, the mechanical lift in front of her. This nursing note also documents there were no apparent injuries, and R1's physician, Z2 and Z3 (Friend) were contacted. R1's care plan was updated post fall to include new interventions of reporting to the physician the development of pain, bruises, change in mental status, ADL (Activities of Daily Living) function, appetite or neurological status. R1's care plan was updated [DATE] with a new intervention to transfer R1 utilizing a mechanical lift with a sling. Facility incident report dated [DATE]: R1 fell at 8:30pm, while being transferred to bed, via the sit-to-stand lift. Nursing note dated [DATE] at 8:30pm documents that upon entering the room, E10 (Nurse) observed R1 "lying on the floor on her back, blood and clear fluids were draining from right leg deep skin tear." This note further documents "advised the CNA's to get the mechanical, full body sling lift to lift R1 back to bed to be examined. The CNA's say that R1 slid off the stand up lift to the floor on her knees and then layed down on her back." This note further documents R1's physician and Z3 were notified, and R1 was sent to the hospital for evaluation. Nursing note dated [DATE] at 4:31am documents R1 was admitted to the hospital with [REDACTED]. E5 (CNA) stated [DATE] at 9:45am she was assigned to care for R1 the evening of [DATE], and enlisted the assistance of E6 (CNA) to help put R1 to bed. E5 further stated she had taken care of R 1 "a couple of times" in the past, and wasn't aware that the kardex/kiosk computer system informs CNA's of which lift to use for a resident. E5 also stated that upon trying to lift up R1 with the sit-to-stand lift, R1 was "in a panicky state, flailing her arms around, and resisting trying to stand up. E5 then stated R1 then slid under the lift's under arm sling, sliding to the floor. E5 further stated she saw other CNA's use a sit-to-stand lift for R1 in the past, so that's why she also decided to use it to transfer R1. E6 (CNA) stated [DATE] at 2:15pm she assisted E5 to attempt to transfer R1 the evening of [DATE], and stated she assumed E5 checked the kardex to see what type of mechanical lift should be utilized to transfer R1, since R1 was assigned to E5. E6 also stated R1 was "fighting every time we tried to lift her up with the machine to get her in a standing position, and began to slide out of the sling" upon her transfer [DATE]. E6 further stated that every time she assisted R1 to go to bed, "she would act the same way--fighting, combative." E6 further stated R1 was known to move around a lot during transfer, trying to get out of the mechanical lift, fighting to get into the lift, and once in, would often try to unfasten the strap closures in attempts to get out of it. Z2 stated [DATE] at 10:05am R1 continued to decline after hospitalization , and was transferred to in-patient hospice care at another hospital, where she expired [DATE]. E2 (Director of Care Delivery) stated [DATE] at 1:46pm that after R1's fall [DATE] from the sit-to-stand lift, her kardex was updated to say "use mechanical lift with sling to transfer". E2 further stated that upon questioning E5 and E6 after R1's fall from the sit-to-stand lift [DATE], both CNA's stated that it was unclear to them what type of lift to use, as all mechanical lifts have a sling. A copy of R1's kardex was requested by the surveyor, but was never provided. E2 further stated she was not aware who assessed R1 to be appropriate for a sit-to-stand lift. E1 (Administrator) stated [DATE] at 12:28pm falls are reviewed by the Quality Assurance Committee the next day, to try to discover the cause and put new interventions into place to prevent future occurrences. E1 further stated that after R1's fall from a sit-to-stand lift [DATE], R1's kardex was updated to say to use a "mechanical lift with sling" to transfer her, and CNA's are responsible to look at each resident's kardex to see which assistance devices are to be used for that particular resident's care. E1 further stated E5 and E6 did not understand that "mechanical lift with sling" meant to use a full body sling lift. E1 also stated nursing staff/therapy is responsible to assess which lifting device to use for each resident. Surveyor asked for a copy of R1's mechanical lift assessment, but was not provided one. E1 stated [DATE] at 10:30am new CNA's are oriented to the kardex/kiosk system upon their unit orientation, and are to use it to refer to perform their daily tasks in caring for each resident. Z1 (R1's Physician) stated [DATE] at 9:08am it's a nursing decision which type of lift to use to transfer a resident. This should based on the resident's physical and cognitive abilities, level of confusion, and cooperativeness. Z1 further stated that if a resident isn't capable of following directions or won't cooperate enough to use a sit-to-stand lift, a full body sling lift should be used. Nursing staff need to ensure the resident is transferred safely. Facility policy titled "Falls Practice Guide": "Initiate/update patient information kardex, task list" post fall and "Develop/revise interdisciplinary care plan as applicable, including ongoing fall prevention strategies, patient/family and staff education." Facility Policy titled "Mechanical Lift": "Introduce self, explain procedure. Connect sling straps attachment clips to attachment points on the spreader bar. Fold patient's arms on chest and instruct to keep arms close to body for safety." This policy does not address resident assessment for appropriate mechanical lift selection, or what to do when it's found that a certain lift is not safe for a particular resident.