Every finding on record at Tower Hill Healthcare Center

Based on interviews and record reviews, the facility failed to ensure residents that were cognitively impaired were free from physical abuse. This applies to 2 of 10 residents (R2 and R4) reviewed for physical abuse. The findings include: 1.Review of the Electronic Medical Record (EMR) showed that R2 was admitted to the facility on [DATE]. R2 was a [AGE] year-old female with diagnoses that included dementia, schizophrenia, delusional disorder, auditory hallucinations, hemiplegia, neuropathy, legal blindness, and hearing loss. R2 was assessed as alert and oriented times one to two, with impaired memory, judgment, and decision-making abilities, and severe cognitive impairment. Review of the EMR further showed multiple psychiatric and nursing notes documenting intermittent delusions, paranoia, medication refusal, and periods of tension. However, there was no documented history of physical aggression toward peers or staff. Review of the EMR showed that R1 was admitted to the facility on [DATE]. R1 was a [AGE] year-old male with diagnoses that included Parkinson's disease, dementia, psychosis, Alzheimer's disease, and cerebrovascular-related memory deficits, with severe cognitive impairment. The EMR documented behaviors including verbal agitation, wandering into hallways and other residents' rooms, restlessness, and refusal of care. Further review showed that on June 5, 2025, R1 struck another resident and was transferred to a behavioral health facility for evaluation and treatment. Additional records documented aggressive behavior toward staff during care on August 5, 2025; destruction of property on September 17, 2025, when R1 pushed a television off a dresser; and agitation with refusal of care on April 23, 2026.The facility incident report dated April 23, 2026, documented that R1 was ambulating in the hallway and passed R2, who was seated calmly in a wheelchair near the second-floor dining room entrance and was not interacting with R1. The report documented that R1 unexpectedly raised his hand and struck R2 on the back of the head and left upper arm. There was no identified trigger, verbal exchange, or physical interaction preceding the incident. Staff immediately intervened and separated the residents. Both residents were assessed, and no acute injuries or distress were identified. R1 was subsequently placed on one-to-one supervision due to behavioral concerns and referred for behavioral health placement.The facility investigation summary documented that V7 (Licensed Practical Nurse) witnessed R1 strike R2 on the upper left arm and back of the head. V8 (Certified Nursing Assistant) reported hearing a slapping sound and hearing R2 scream, although V8 did not witness the initial contact. R2 later reported that R1 slapped her. The facility substantiated the allegation of abuse based on the witnessed incident.On May 9, 2026, between approximately 10:00 a.m. and 11:00 a.m., V7 stated she witnessed the April 23, 2026, incident involving R1 and R2. V7 stated that R1 was ambulatory and walked past R2 while she was seated near the second-floor dining room entrance, at which time R1 slapped R2 on the back of the head. V8 stated she was near the nurse's station adjacent to the second-floor dining room when she heard R2 scream that R1 had slapped her. Both V7 and V8 stated there were no injuries noted, the residents were immediately separated, and R1 was placed on one-to-one supervision prior to transfer to a behavioral health facility. 2. Review of the EMR showed that R4 was admitted to the facility on [DATE]. R4 was a [AGE] year-old female, with diagnoses that included Alzheimer's disease, dementia with anxiety, cognitive communication deficits, and impaired decision-making abilities. Psychiatric evaluations throughout the admission documented R4 as generally pleasant and cooperative, without acute psychiatric or behavioral disturbances, although occasional pacing, verbal agitation, and inappropriate comments toward peers were noted. Review of the EMR showed that R3 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included dementia with severe cognitive impairment, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and hypertension. Further review of the EMR showed behavioral and psychiatric documentation consistently describing R3 as pleasant, calm, cooperative, and without significant behavioral disturbances. Psychiatric evaluations from November 2025 through April 2026 documented no aggression, combativeness, refusal of care, or peer altercations.The facility incident report documented that on May 2, 2026, R3 struck R4 in the face while both residents were present in the resident lounge. Staff immediately separated the residents. R4 was assessed and found to have no injuries. R3 was placed on one-to-one supervision pending psychiatric evaluation. The report documented that V5 (Certified Nursing Assistant) witnessed R3 strike R4 on the right cheek near the entryway of the resident lounge. Follow-up interviews revealed that neither R3 nor R4 could explain the incident. The facility substantiated the allegation of abuse based on the witnessed event.On May 9, 2026, at approximately 11:00 a.m., V1 (Administrator) and V2 (Director of Nursing) stated the facility takes necessary measures to prevent abuse and neglect and remain committed to maintaining an abuse-free environment.

Based on observation, interview, and record review the facility failed to serve a resident with multiple sclerosis and dementia hot coffee in a safe manner for 1 of 6 residents (R1) reviewed for safety in the sample of 6.The findings include:On 4/24/26 at 10:02 AM, R1 was sitting in his wheelchair in the dining room watching a movie. R1 said he liked the coffee at the facility. R1 said a few days ago he spilled coffee in his lap, but it was all healed up now. R1 said the coffee is not too hot; he likes it just the way it is. On 4/24/26 at 8:45 AM, V6 Wound Licensed Practical Nurse said R1 was accidently burned when he spilled coffee in his lap. V6 said R1 sustained a second degree burn to his left inner thigh. V6 said R1 was in dining room when it happened, and staff immediately brought him to his room and removed his pants and applied ice to the area. V6 said she was notified and responded to R1's room. V6 said R1's left inner thigh was just red at that time and ice and silver burn cream was applied. V6 said the area did later form two small blisters and has been treated since. V6 said R1's burn is almost healed. R1's Skin/Wound Note dated 4/8/26 shows R1 sustained a second-degree burn. Upon assessment, writer applied an ice pack to the affected area to help prevent further skin breakdown. On 4/24/26 at 11:12 AM, R1 was sitting in the dining room for the noon meal. R1 was served coffee in a plastic coffee mug with a handle. R1 added powdered creamer to the mug and stirred the coffee. R1, with one hand on the handle of the mug and the other hand on the other side of the mug, drank the coffee. R1's hold on the cup appeared secure and R1's hands were not shaky. On 4/2426 at 12:45 PM, V3 Assistant Director of Nursing said R1 does not need feeding cues or any assistance to eat or drink. V3 said R1 has not had any issues with drinking coffee in the past. V3 said R1 was served coffee that day in a Styrofoam cup, which didn't have any handles. V3 said the facility didn't have enough handled mugs so Styrofoam was being used. V3 said the facility has since ordered more handled mugs and residents will not be served hot beverages in Styrofoam cups. R1's Facesheet shows R1 has diagnoses of multiple sclerosis and dementia.R1's Wound assessment dated [DATE] shows left inner thigh burn, 100% granulation, measure 3.50 x 2.80 x 0.10. R1's Wound assessment dated [DATE] shows left inner thigh, burn, 90% intact skin, 10% pale pink non-granulating, measures 0.8 x 0.5 x 0.10.The facility's Hot Beverage Policy dated 2017 shows Hot beverages are provided to the clients in a safe manner.

Based on observation, interview, and record review, the facility failed to ensure a resident, who was at risk for skin breakdown, was kept clean and dry, and did not develop a pressure ulcer.This failure resulted in the development of a stage 2 pressure ulcer to the resident's buttock. This applies to 1 or 3 residents (R1) reviewed for improper nursing care in the sample of 8. Findings include: R1's electronic medical record showed R1 to be [AGE] years old and admitted to the facility with diagnoses that include muscle weakness, unsteadiness on feet, other lack of coordination, acute kidney failure, dysphagia, schizophrenia, schizoaffective disorder, generalized anxiety disorder, and syncope and collapse. R1's Minimum Data Set (MDS) dated [DATE], showed R1 to have severe cognitive impairment. R1's MDS also showed R1 required substantial/maximal assistance with toileting hygiene.R1's most recent readmission assessment dated [DATE], showed that R1 was at risk for developing pressure sores and showed he did not have any wounds on his buttocks on admission. R1 had the following care plans: 1) R1 is incontinent of bowel and bladder. 2) R1 has a potential for skin integrity impairment dated January 23, 2026, with interventions to observe skin during routine care and report alteration to the nurse and to provide peri-care and barrier cream after incontinent episodes. 3) R1 was at risk for alteration in skin integrity dated November 9, 2023, with one of the interventions being to provide per-care after each incontinent episode and apply barrier cream. R1's most recent skin assessment/bath/skin checklist provided by the facility was dated April 14, 2026, and showed R1 had no skin breakdown. On April 21, 2026, at 12:00 PM, R1 stated he had not gotten out of bed yet today and he was not certain when the last time he had been checked for incontinence.On April 21, 2026, at 12:50 PM, V9 (Certified Nursing Assistant, CNA) came to check R1 for incontinence. V9 stated the last time she checked R1 for incontinence care was at 10:00 A M. During incontinence care, R1 had a wet incontinence brief, and a very large, dried bowel movement that was stuck between R1's buttocks. The bowel movement had adhered to R1's skin. R1 was not cleaned thoroughly during the incontinence care and had to be prompted to complete the cleaning. There was also the presence of a new stage 2 pressure ulcer on R1's right buttock. There was also redness on R1's buttocks and scrotum. V9 confirmed it was a new open wound that she had not seen previously. On April 21, 2026, at 1:17 PM, V16 (Licensed Practical Nurse/LPN) stated that R1 did not have any wounds that she was aware of. R1's electronic medical record was reviewed with V16 and V16 confirmed R1 had no wounds. R1's progress notes dated April 21, 2026, at 2:35 PM written by V16 showed that staff noted opening on the right buttock of R1.R1's progress note dated April 21, 2026, at 4:41 PM and written by V11 (Wound Care Nurse) showed the following: Writer was informed by the [nurse on duty] that the resident has a small open area on the right buttock. The resident was assessed by the wound nurse, who contacted the wound care physician and received order for [medical] honey and foam dressing to open area and zinc cream to redness.R1's wound evaluation & management summary initial evaluation dated April 22, 2026 and written by V10 (Wound Care Doctor) showed that R1 had a facility acquired stage 2, partial thickness pressure ulcer on the right buttock, measuring: 1.2 centimeters (cm) Length X 0.9 cm Width x 0.1 cm depth; Surface area: 1.08 cm (centimeters); exudate: moderate Sero-sanguinous; dermis: open areas with exposed dermis. On April 21, 2026, at 4:51 PM, V2 (Director of Nursing) stated incontinence care should be provided to residents every 2 hours or more often as needed. V2 stated staff should be cleaning residents thoroughly and removing visible stools. V2 stated incontinence care is important for preventing infection and for sanitation. V2 stated not cleaning a resident thoroughly puts them at risk of skin breakdown. V2 stated residents should be left clean after incontinence care. V2 stated, the way you want to be left is how you should leave someone else.On April 22, 2026, at 2:03 PM, V10 stated that R1's urine incontinence and stool found on R1 yesterday as described could be a contributing factor to R1's moisture associated dermatitis and the stage 2 wound he diagnosed. V10 stated, it is important to check R1 consistently because R1 doesn't know when he has been incontinent. V10 stated you can't wait to remove stool from the skin. V10 stated stool can irritate the skin. The facility's Skin management policy revised September 2024 showed the following: It is the facility's policy that a resident does not develop pressure injury unless clinically unavoidable.

Based on observation, interview, and record review, the facility failed to ensure a resident, who was at risk for skin breakdown, was kept clean and dry. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 8.Findings include: R1's electronic medical record showed R1 to be [AGE] years old and admitted to the facility with diagnoses that include muscle weakness, unsteadiness on feet, other lack of coordination, acute kidney failure, dysphagia, schizophrenia, schizoaffective disorder, generalized anxiety disorder, and syncope and collapse. R1's Minimum Data Set (MDS) dated [DATE], showed R1 to have severe cognitive impairment. R1's MDS also showed R1 required substantial/maximal assistance with toileting hygiene.R1's most recent readmission assessment dated [DATE], showed that R1 was at risk for developing pressure sores, and it showed R1 did not have any wounds on his buttocks. R1 had the following care plans: 1) R1 is incontinent of bowel and bladder. 2) R1 has a potential for skin integrity impairment dated January 23, 2026, with interventions to observe skin during routine care and report alteration to the nurse and to provide peri-care and barrier cream after incontinent episodes. 3) R1 was at risk for alteration in skin integrity dated November 9, 2023, with one of the interventions being to provide peri-care after each incontinent episode and apply barrier cream. R1's most recent skin assessment/bath/skin checklist provided by the facility was dated April 14, 2026, and showed R1 had no skin breakdown. On April 21, 2026, at 12:00 PM, R1 stated he had not gotten out of bed yet today and he was not certain when the last time he had been checked for incontinence.On April 21, 2026, at 12:07 PM V9 (Certified Nursing Assistant/CNA) stated she had changed R1 in the morning when she first got to the facility. V9 stated she changed V9 last at 10:00 AM this morning.On April 21, 2026, at 12:50 PM, V9 came to check R1 for incontinence. V9 removed the front of R1's brief and started cleaning around the genitalia. V9 had not turned resident yet and stated that R1 only had urine. V9 was asked to show R1's incontinence brief. V9 turned R1 and stated, oh he does have stool. R1's buttocks were red, purplish, and gray in areas. R1 had a large dried solid stool that was stuck/adhered to the length of the intergluteal cleft (inner part) of R1's buttocks. The fecal matter looked dried and was stuck in the buttocks folds with width of the stool being about 2 inches near the scrotum and about 5 inches wide in the middle. R1's incontinent brief was soaked with urine from the back to halfway up the front on the brief. V9 could not remove the stool readily and stated that she needed to go get some help. V9 came back with V8 (CNA) and V8 cleaned the front of R1 again and cleaned under the scrotum where redness was observed. V9 turned R1 and removed the large hardened fecal matter then proceeded to remove several layers of remaining fecal matter that had adhered to R1's skin around the anus and the inner sides of the buttocks. She filled up about 1/3 of small garbage with wipes. V9 took off gloves. Then V9 got a clean incontinence brief and was about to put it on R1. [NAME] fecal matter could still be seen within the inner sides of R1's buttocks near the anus. When V9 was cleaning R1, the wipes had not come out without having fecal matter on them yet. V9 was asked if they were done cleaning R1 and V9 replied Yes. V9 was asked if she could wipe R1 again to see if R1 was thoroughly cleaned. V9 did so and then removed more layers of fecal matter from R1's buttocks. V9 used and discarded more than 4 wipes that were stained with fecal matter. R1 then had a small bowel movement of soft stool, and more wipes were used to clean R1. No barrier cream or any emollient was applied to the red areas of R1's buttocks. R1's buttocks were red, mostly on right buttock and there was a small open wound observed on the right buttocks. V9 said it was a wound, and she didn't see it there earlier in the day.On April 21, 2026, at 3:15 PM, V9 was asked why she hadn't checked and cleaned R1 between 10:00 AM and 12:50 PM. V9 stated that it took longer for her to get to R1 because she noticed that two of her residents' lunch trays had not been passed and she had to feed three residents. V9 stated that her group was hard, including R1 and his roommates (R5, R6, and R7). V9 stated that her group consists of residents who are heavy wetters, require whole body mechanical lifts, have contracted limbs, and one resident who fights sometimes. V9 stated she asked V8 to help feed R3 and V8 did help her, but she still had two other residents to feed. On April 21, 2026, at 4:51 PM, V2 (Director of Nursing) stated incontinence care should be provided to residents every 2 hours or more often as needed. V2 stated staff should be cleaning residents thoroughly and removing visible stools. V2 stated incontinence care is important for preventing infection and for sanitation. V2 stated not cleaning a resident thoroughly puts them at risk of skin breakdown. V2 stated, residents should be left clean after incontinence care. V2 stated, the way you want to be left is how you should leave someone else.R1's wound evaluation & management summary initial evaluation dated April 22, 2026, and written by V10 (Wound Care Doctor) showed that R1 had a new diagnosis of Irritant Dermatitis from body fluid to bilateral buttocks. Treatment: use house moisturizing cream as directed. On April 22, 2026, at 2:03 PM, V10 stated that R1 urine incontinence and stool found on R1 yesterday as described, could be a contributing factor to R1's moisture associated dermatitis and the stage 2 wound he diagnosed. V10 stated that the moisture associated dermatitis may have been prevented by applying a barrier cream. V10 stated, it is important to check R1 consistently because R1 doesn't know when he has been incontinent. V10 stated you can't wait to remove stool from the skin. V10 stated stool can irritate the skin. The facility's incontinence care policy revised January 2022, showed the following: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible.

Based on interview and record review the facility failed to ensure a grievance was reported and resolved for a resident's missing items. This applies to 1 of 10 residents (R5) reviewed for grievances in the sample of 10. The findings include: R5's nursing note dated 3/20/25 by V12 (RN) documents (R5) stated he has clothes and money missing and no one is doing anything. On 3/27/26 at 1:45 PM, V12 (RN) said she documented the note on 3/30/25 regarding R5's missing clothes and money. If a resident reports missing items she reports the items to V9. V12 said she could not recall if she reported the missing items to V9. On 3/27/26 at 1:52 PM, V9 (Social Services) said when a resident reports missing money or clothes. She takes 48 hours trying to find the item. After 48 hours if she cannot locate the item, she will file a grievance form and replace the item. V9 said she was not aware of R5's reported missing items on 3/30/25. She has educated staff to report to her if a resident reports missing items. If she doesn't know what's missing, she can't follow up. The facility's Grievance Complaint Log dated January 2025 through October 2025 shows there was no grievance filed for R5's missing clothing or money reported on 3/30/25. The facility's undated Grievance/Complaint Policy states, A resident has the right to voice grievances without discrimination or reprisal and prompt efforts by the facility to resolve the grievance.the disposition of grievances and/or complaints will be recorded on the grievance and complaint log.the grievance/complaint will have a disposition within in 7 working days of the filed grievance.

Based on observation, interview, and record review the facility failed to ensure residents were free from physical abuse for 2 of 8 residents (R1, R3) reviewed for abuse in the sample of 10. The findings include:The facility's Initial Incident Report shows It was reported that R1 grabbed papers from R2. In R2's attempt to get them back, R2 struck R1 in the face, right side of cheek. Both residents were immediately separated and assessed for injuries. On 3/27/26 at 9:20 AM, R1 was sitting in a wheelchair in her room. R1 was dressed and well groomed. When asked about any concerns with other residents, R1 said she got hit in the face by a male person. R1 appeared anxious, with shaking hands, and said it was scary. R1 became quiet and didn't respond to questions about the details of the incident but did state that she has not seen the man since. R1 said she has not been bothered by anyone before or since. On 3/27/26 at 10:26 AM, V7 Certified Nursing Assistant (CNA) said she saw R2 standing next to R1 who was in her wheelchair in front of R2's room. V7 said R2 grabbed something from R1's hand and then punched R1 in the face. V7 said V6 Licensed Practical Nurse and V8 CNA were present at the time. V7 said R1 was brought to the nurses' station and R1 seemed confused. V7 said R1 had redness to the apple of her cheek, but she did not see a bruise or any other injuries. V7 said V6 asked R2 what happened and R2 said that R1 grabbed his papers and when he pulled them back from her he did what he did. On 3/27/26 at 10:34 AM, V8 CNA said she was at the nurses' station doing paperwork and saw R1 going down R2's hallway. V8 said she heard a commotion and when she looked up, R1 had papers in her hand which R2 was trying to grab back. V8 said when R2 got the papers, he swung and hit R1 in the face. On 3/27/26 at 11:37 AM, R2 was in his room on another floor. When asked about the situation with R1, R2 said he was trying to take his menus to the nurses' station and R1 grabbed them out of his hand. R2 said R1 ripped the papers and he got mad about it and hit her in the face. R2 stated I shouldn't have hit her. On 3/27/26 at 12:19 PM, V1 Administrator said the investigation for the incident with R1 and R2 was substantiated physical abuse. R1's Physical Aggression Initiated Report dated 3/7/26 shows Nurse on duty (NOD) heard aides working at the nurses' station stating, don't hit her! He hit her! NOD ended call and asked what was going on. They stated R2 was walking past R1 in the hallway and they saw him hit her in the right side of the face with a closed fist. The two CNAs who'd been working at the nurses' station stated they saw R2 strike R1 on the right cheek with a closed fist. The NOD went to R1 immediately. R1 was in her wheelchair in the hallway. R2 was also in the hallway, NOD told him to go back to his room, and he did so without complaint or difficulty. The NOD assessed R1 from head to toe and observed a red mark on the right side of R1's face near her temple and hairline. The facility's Incident Report findings show The facility conducted a thorough investigation pertaining to an allegation of abuse. As the alleged incident was witnessed, the facility has substantiated abuse. 2. On 3/27/26 at 10:28 AM, V13, Certified Nursing Assistant (CNA), said around midnight, R4 said R3 keeps waking him up and he was bothered by R3 keeping him awake. V13 said every time she went into R3 and R4's room, R4 would complain about it. V13 said R4 stated, Someone needs to keep him quiet. V13 said R4 was upset and he seemed frustrated. V13 said R3 and R4 were both in their beds asleep around 2:00 AM. V13 said around 5:00 AM, she saw R4 standing above R3 then he walked over to his own bed and sat down. V13 said she was about to change R3 when she noticed blood around his nose. V13 said she thought R4 had hit R3. V13 said she informed the nurse, V19, Licensed Practical Nurse (LPN), and then immediately wrote a statement about what happened. V13 said she cannot remember everything and said her statement was accurate since she wrote it right after the incident. V13's written statement provided by the facility (undated) shows V13 entered R3 and R4's room and found R4 standing over R3's bed. R4 kept saying, He kept me up all night making noises. R4 kept repeating, I should hit him and he kept me up all night. R3 could not give a clear response when she asked if he was hit. On 3/27/26 at 4:49 PM, V19 said V13 informed him that she cleaned blood off R3's face. V19 said he went to assess R3. V19 said he saw a very small reddened area on R3's nose but did not see any bleeding since the CNA had already cleaned it. V19 said R3 appeared confused and indicated he didn't know what happened. V19 said he asked R3 a couple of times what happened and sometimes R3 didn't answer at all. V19's documentation in R3's Progress Notes dated 3/4/26 at 5:08 AM, shows R3 was noted with discoloration to the bridge of his nose. Then on 3/4/26 at 5:52 AM, V19's note shows observed bloody nose, cleaned and assessed. On 3/27/26 at 11:19 AM, V16, CNA, said she came into the facility to work in the morning (on 3/4/26) and walked down the hall looking in on her residents before she even took her coat off. V16 said she saw R3's foot off his bed and went in to put it back on the bed. She glanced at R3's face, saw some bruising to the bridge of his nose, his lip was split and he had a runny, somewhat bloody nose. V16 said she went to the day shift nurse, V17, LPN, to see if he had fallen. V16 said V17 said there was an incident reported but she didn't have all the information. V16 said she went to take off her coat and ran into V13 and asked what happened to R3. V16 said V13 told her when she went into R3 and R4's room, R4 was standing over R3, and R4 said he was going to kick his ass. V13 told V16 she thought R4 hit R3. V16 said she thought maybe R4 did hit R3 because two days prior R4 told her he couldn't get any sleep the previous night because R3 was keeping him up all night. V16 said R3 and R4 had only been roommates for about a week at the time. V16 said R3 never said anything as he almost never verbally speaks and when he does it is random words and gibberish or curse words. On 3/27/26 at 11:41 AM, V17 said she came in the morning (3/4/26) and was told that R4 was standing over R3 and R3 had bruising to his face. V17 said R3 is not cognitively intact and could not say what happened. V17 said they moved R4 to another unit. R3's Nursing Note dated 3/4/26 at 11:25 AM documented by V17 shows a full body assessment was completed and noted bruising to the bridge of his nose and right side of his face in the temporal area. On 3/27/26 at 12:19 PM, V1, Administrator, said V19 reported a bruise to R3's nose. V1 said when she got to facility, she went to see R3 and he had bruising to the bridge of his nose and noted blood on his linens which she assumed was from his nose. On 3/27/26 at 10:54 AM, V15, Social Services Assistant, said R4 was moved to another room because R3, his roommate, had a bruise on the bridge of his nose with swelling and there was no reason for the injury. V15 said out of precaution, they moved R4 out of their room for safety reasons. V15 said both R3 and R4 have dementia. On 3/27/26 at 1:03 PM, V21, R3's wife, said the facility called and told her R3's nose was bleeding, and not to worry about it as they took care of it. V21 said she was told they thought R3 had bumped into something. V21 said she wondered if someone else did something to R3 because it was a strange place to bump oneself. V21 said, Someone somewhere down the line mentioned that there was a discipline problem with R4, so it crossed her mind that maybe he had done something to R3. V21 said she saw R3 the next day (3/5/26) and there was a red mark across the bridge of his nose and to the right of his nose. V21 said R3 can not tell you what happened. R3's admission Record dated 3/27/26 shows his diagnoses include, but are not limited to Alzheimer's disease, muscle weakness, anxiety, and restlessness and agitation. R3's current care plan initiated on 1/26/26 shows R3 is at risk for abuse related to a behavior problem and will be free from harm. R3 has impaired cognitive function/dementia or impaired thought processes related to dementia. R4's admission Record dated 3/27/26 shows he resides in the Memory Care unit and his diagnoses include, but are not limited to, dementia. The facility's Abuse Prevention Program Policy (reviewed 1/2019) shows the facility affirms the right of their residents to be free from abuse. Abuse means any physical injury inflicted upon a resident other than by accidental means. Physical abuse includes hitting, slapping, pinching, and kicking.

Based on observation, interview and record review the facility failed to ensure residents were free from physical abuse. This applies to 3 of 4 residents (R2, R4, R5) reviewed for abuse in the sample of 13. The findings include: 1. The facility's undated Final Abuse Investigation shows (R4) is male resident with diagnoses including unspecified dementia, restlessness and agitation, generalized muscle weakness, vascular dementia, and osteoarthritis. (R4) is alert and oriented x1 with severe cognitive impairments with short- and long-term memory, judgement and decision-making abilities. He relies on staff for cueing and redirection, often paces the facility and has exit seeking behaviors. He tends to wander around the unit and requires frequent redirection.(R5) is a female resident with diagnoses including other psychotic disorder, major depressive disorder, generalized anxiety, glaucoma, and cognitive communication deficit. (R5) is alert and oriented x 1-2 with severe cognitive impairments and also has impaired short- and long-term memory, judgement and decision-making abilities. On 9/29/25, V14 (Certified Nursing Assistant-CNA) responded to (R5's) room due to sounds of screaming. V14 witnessed (R4) strike (R5) in the chest.(R5) reported (R4) kept coming into her room and wouldn't leave. (R5) stated she tried to physically get (R4) to leave her room and scratched him trying to get him out. (R5) stated she grabbed (R4) to pull him out of the room and (R4) punched her. (R4) reported (R5) attacked him and that he attempted to stop her. On 01/7/26 at 9:12 AM R5 was in her room sitting in her bed. R5's room was located across the nurse's station. R5 was alert to self and forgetful. She said she was trying to get away from a man and she was not going to let the man hurt her. R5 was not able to recall the details of the incident but stated, I wanted to get away from him. On 01/7/26 at 11:10 AM, V3 (Social Services) said R4 has a history of wandering, aggressive, verbal and physical behaviors. R4 is an elopement risk with impaired cognitive deficits. On 9/29/25, R4 wandered into R5's room and put his hands on R5. A staff member witnessed R4 punch R5 in the chest. We do our best to monitor residents, but we can't keep eye on everyone. R4 should be monitored when he is out of his room because of his behaviors. R5 has dementia as well and gets very confused and has a history of past experiences of abuse and probably felt threatened by R4. R4 was sent out for his behaviors and was transferred to another facility. On 01/7/26 at 12:50 PM, V10 (Licensed Practical Nurse-LPN) said on 9/25/25, she was informed by V14 (CNA) R4 wandered into R5's room. R5 was trying to shove R4 out of her room and she witnessed R4 punch R5 in the chest. R4 has a history of wandering and is high risk of elopement. R4 is cognitively impaired with behaviors of agitation towards staff and can be difficult to redirect at times. On 1/7/26 at 1:35 PM, V1 (Administrator) said she is the abuse coordinator. Any allegations of abuse should be reported immediately. Residents are separated immediately if staff witness abuse. V1 confirmed R4 and R5's incident was witnessed by staff and physical abuse was substantiated. 2. The facility's undated Final Abuse Report shows (R2) is a female resident with diagnoses including dementia, anxiety, insomnia, GERD, rheumatoid arthritis, and spinal stenosis. (R2) is alert and oriented x2 with moderate cognitive impairment. (R3) is a female resident with diagnoses including vascular dementia with behavioral disturbances, unspecified psychosis, muscle weakness and cognitive communication deficit. (R3) has a history of both verbal and physical aggression (primarily towards late husband and staff).On 10/25/25, V1 (Administrator) received a message from second floor nurse (V9-Licensed Practical Nurse) that (R3) hit (R2) in the face (left side).it was not witnessed by staff but (R2) reported the incident.(R2) was observed with redness to the left cheek.(R2) reported (R3) wanted to set at the table she was at but there was no room.(R3) got mad and then hit her. On 1/7/26 at 9:19 AM, R2 was in her room sitting in her wheelchair. She was alert and oriented x2 with forgetfulness. R2 had difficulty recalling the incident in October 2025. On 1/7/26 at 11:52 AM, V9 said on 10/25/25, she was doing her med pass and residents were in the dining room. R2 said she got hit by R3. R3 punched R2 on the left side of her face. R2's left eye bruised right away and the next day it was dark purple. R2 reported it happened and R13 was the tablemate and said R3 got agitated and hit R2. R3 is very confused and I'm pretty sure she acted out of aggression. On 1/7/26 at 12:10 PM, R13 said he was at the table when it happened. The one that came over in the wheelchair and punched R2 was wanting her to move from the table. R2 told her (R3) no, this is my spot and (R3) punched her in the eye and gave her a black eye. R2 was in pain, and she was saying oh she punched me. R13 said the incident was unprovoked really and she was just being mean. R13 said the one who punched R2 had a mean streak and had prior verbal altercations with staff and residents.The facility's Abuse Policy dated 2019 states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment .physical abuse is the infliction of injury on a resident that occurs other than by accidental means.physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to ensure a resident was transported via wheelchair in a manner to prevent a resident fall for 1 (R5) of 3 residents reviewed for safety and supervision in the sample of 13.The findings include:R5's resident assessment dated [DATE] showed R5 was severely cognitively impaired.R5's care plan dated 6/18/25 showed R5 was at risk for falls related to her poor safety awareness and impulsiveness due to her impaired cognition. R5 also had diagnoses of glaucoma, previous falls with fractures, anxiety, unspecified psychotic disorder, and a cognitive communication deficit which contributed to R5's increased risk of falling.R5's progress note dated 9/15/25 showed R5 was being pushed in her wheelchair by a restorative certified nursing assistant (CNA) when R5 suddenly planted her feet down on the ground as her wheelchair was moving, causing R5 to fall forward out of her wheelchair, onto the floor. R5 landed on her knees and then rolled over onto her back on the floor. The note showed R5 was sent to a local hospital for an evaluation. R5 was assessed in the hospital and found to have no injuries from her fall. R5 returned to the facility on 9/15/25.R5's IDT (interdisciplinary team) note dated 9/16/25 showed the root cause of R5's fall on 9/15/25 was related to patient safety. The note showed, Intervention and Care plan updated: Reinforce to the staff safety awareness and techniques of proper observation and use of gait belt during transfer and placement of footrest during transport of all patients.On 1/7/26 at 9:22 AM, V17 Restorative Nurse stated R5's fall on 9/15/25 was caused by R5's wheelchair foot pedals not being down and in place for R5 to rest her feet on as she was being pushed in her wheelchair. V17 stated, (R5's) wheelchair pedals were not down and in place to support (R5's) feet so when she planted her feet on the ground as she was being pushed, she fell forward out of her wheelchair. Her feet should have been on the foot pedals of her wheelchair which would have prevented her from putting them on the floor and causing her to fall. On 1/7/26 at 11:01 AM, V22 Restorative CNA stated on 9/15/25, he didn't realize R5's wheelchair foot pedals were not in place as he pushed R5 in her wheelchair. V22 stated, I didn't realize her feet were dragging on the floor under the wheelchair. She put her feet flat on the floor as I was pushing her which made her fall out of the wheelchair. I should have made sure her feet were on the pedals before I started pushing her. The facility's Safe Resident Lifting Policy dated July 2025 showed, All residents that utilize a wheelchair and/or Broda chair for mobility will have appropriate leg/footrests during transfers unless the resident self-propels.

Based on interview and record review, the facility failed to ensure antidepressant medication was obtained from the pharmacy in a timely manner to prevent a resident from missing medication doses as ordered by the physician.This applies to 1 of 3 residents (R1) reviewed for quality of care in the area of missing antidepressant medications in the sample of 5.The findings include:The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], and was discharged to home on July 1, 2025. R1 had multiple diagnoses including, traumatic brain injury with loss of consciousness, anoxic brain damage, other specified depressive episodes, Parkinsonism, psychoactive substance dependence, generalized anxiety disorder, depressive episodes, atrial fibrillation, and anemia. R1's MDS (Minimum Data Set) dated June 30, 2025 shows R1 had moderate cognitive impairment, required setup assistance with toilet hygiene and showering, and supervision with all other ADLs (Activities of Daily Living). R1 was always continent of bowel and bladder. A Plenary Letter of Office Guardian for Disabled Person shows R1 as a disabled person and V13 (Mother of R1) and V15 (Father of R1) as the permanent guardians for R1.The EMR shows the following order dated April 16, 2025: Venlafaxine Hydrochloride (Effexor) (antidepressant medication), Extended-Release 24-hour. Give 37.5 mg. (milligrams) by mouth one time a day for depression. The order was discontinued by facility staff on June 14, 2025 at 11:43 AM.The EMR shows the following order dated June 16, 2025: Venlafaxine HCL (Hydrochloride) ER (Extended-Release) 24-hour 37.5 mg, give 1 tablet by mouth one time a day for depression.On May 6, 2025, at 11:55 AM, V9 (RN-Registered Nurse) documented, Venlafaxine HCl ER Tablet Extended-Release 24-hour 37.5 mg. Give 1 tablet be mouth one time a day for depression. On Order.On May 21, 2025, at 9:30 AM, V8 (LPN-Licensed Practical Nurse) documented, Venlafaxine HCl ER Tablet Extended-Release 24-hour 37.5 mg. Give 1 tablet be mouth one time a day for depression. NA (Not Available).On June 11, 2025, at 9:24 AM, V9 (RN) documented, Venlafaxine HCl ER Oral Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for depression. Not available.On June 10, 2025, at 9:28 AM, V8 (LPN) documented, Venlafaxine HCl ER Oral Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for depression. NA.On June 13, 2025 at 1:57 PM, the facility's pharmacy sent the following notification to the facility dated June 13, 2025: Attention Medication Coordinator: The medication prescribed is not covered by insurance or may require a prior authorization. Resident: R1. Medication prescribed: Venlafaxine Tab 37.5 ER, Give 1 tablet by mouth daily for depression. The Resident's insurance prefers the following alternative medication(s): Venlafaxine Cap 37.5 ER. Please have the provider review alternative medications. If approved, discontinue order, and send a new order for the alternative medication. Please reply by email or fax if: No changes - reason. Please send prescribed medication. I am aware of the issue referenced above. Please note, facility may incur bill of $21.88. Admin/DON (Director of Nursing) Name and Signature. Please note lack of action may result in delays in receiving medication.On June 14, 2025, at 11:56 AM, V11 (LPN) documented, Venlafaxine HCl ER Oral Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for depression. Medication reorder to capsule instead of tablet.The facility's Order Audit Report dated June 14, 2025, at 11:41 AM shows V11 entered the following order for R1: Venlafaxine HCl ER Oral Capsule Extended-Release 24-Hour, Give 1 mg. by mouth one time a day for depression.The pharmacy sent a second notification to the facility regarding R1's Venlafaxine, dated June 14, 2025. The notification shows the medication order needed clarification because the Venlafaxine was ordered as 1 milligram by mouth one time a day. The above prescribed medication needs clarification from the prescriber: Verify dose, 1 mg. is not available in the market.On June 15, 2025, at 8:16 PM, V12 (RN) documented, Resident returned from pass with his parents.Mother (V13) also asked if Effexor had been received and as of yet, it has not been received. Mother would like [V14] (NP-Nurse Practitioner) to see [R1] in the morning regarding Effexor.The facility's Order Audit Report dated June 16, 2025, at 3:29 AM shows V19 (LPN) entered the following order for R1: Venlafaxine HCl ER Oral Capsule Extended-Release 24-Hour. Give 37.5 mg. by mouth one time a day for depression.On June 16, 2025, at 8:33 AM, V12 (RN) documented, Called pharmacy to follow-up on delivery of Effexor and per pharmacy they have it showing to be delivered today at 11:00 AM. Will check then to ensure delivery.On June 16, 2025 at 11:00 AM, V10 (LPN) documented: Venlafaxine HCl ER Oral Capsule Extended-Release 24-hour. Give 37.5 mg. by mouth one time a day for depression. NA. Ordered from pharmacy will be delivery today.Pharmacy documentation shows R1's Venlafaxine was delivered to the facility on June 16, 2025 at 3:44 PM. The facility does not have documentation to show R1 received his dose of Venlafaxine on June 16, 2025.On June 16, 2025 at 11:50 AM, V14 (NP) documented, The patient (R1) was seen and evaluated today. He appeared slightly anxious and expressed concern regarding his current care, specifically related to a lapse in his medication regimen. The patient reported that his Effexor was abruptly discontinued due to pharmacy complications, resulting in an unplanned cessation for approximately five days without tapering.On August 11, 2025 at 11:53 AM, V2 (DON) said, [R1's] parents brought medications from home when he was admitted . Our policy shows there must be a physician order to use home medications. We did not have a physician order to give medications from home to R1. At some point the family requested we obtain the medication for [R1] from our pharmacy. When it was time for us to get the medication from the pharmacy, the pharmacy was not covering the tablet form of the medication. Once we ordered the capsule form, we received the medication. I was not in the building at the time of this situation, and I am not sure who was handling the pharmacy notifications in my absence.On August 11, 2025 at 12:13 PM, V16 (Pharmacy Customer Service Representative) said, We sent the Venlafaxine capsules to the facility on June 16, 2025. We sent a 30-day supply. That was the first time we ever sent that medication to the facility.On August 11, 2025 at 12:21 PM, V18 (Pharmacist) said, the pharmacy sent a fax to the facility on June 13, 2025 for clarification of R1's Venlafaxine order due to R1's insurance refusing to pay for the tablet form of the medication and preferring to pay for the capsule form. The facility ordered the medication, but with the wrong dosage, and the pharmacy had to send a second form to the facility to clarify the Venlafaxine order since the order was sent to the pharmacy as 1 milligram and 1 milligram is not a dosage available in the market for Venlafaxine. V18 said, We had to wait to get a response from the facility before we filled the medication. The facility finally responded on June 16, 2025 with an order for the capsules, and then we filled the prescription that same day.The facility's policy entitled Medications Not Covered by Third-Party Payers, revised January 2018 shows: Policy: When a non-covered (non-formulary) medication is ordered for a resident eligible for medication-related benefits under Medicaid, Medicare, or other third-party payer programs, the provider pharmacy attempts to have the order changed to a covered (formulary) medication or to have the medication covered under a medical necessity waiver or other procedure, as state law allows. Payment coverage determinations shall not delay timely availability of medications unless the prescriber authorizes the medication to start when it becomes available. Procedures: A. When non-covered medications are ordered, the provider pharmacy or licensed nurse consults with the resident's physician to seek a change to a covered item. B. If the physician elects not to change the order, and if appropriate, the physician is asked to document medical necessity according to the process set forth by the third-party payer. The pharmacist then attempts to obtain coverage following third-party payer procedures. C. If coverage is not available and third-party rules permit, the pharmacy bills the resident or responsible party, or the facility, as allowed by state law and per the facility's pharmacy provider agreement.

Based on interview and record review, the facility failed to prevent abuse between two residents. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in a sample of 5. The findings include: R1 and R2's initial report dated 6/9/25 that was reported to IDPH (Illinois Department of Public Health) shows the following: (R1) allegedly struck (R2) this morning near a common area. Both residents were immediately separated and assessed for any injuries. Police were called and report filed. Medical doctors and Power of attorneys were made aware of the alleged incident. Full investigation to follow. R1and R2's final report shows the following: On 6/9/25, (V4-CNA/Certified Nursing Assistant) was in another resident's room providing care to that resident. Upon exiting the room, she overheard (R1) and (R2) engaged in what appeared to be a physical altercation at the opposite end of the building (West Hallway). (V4) also witnessed (R2) who was standing out of his wheelchair and back to (V4) swinging his arms at (R2). (V4) yelled down the hall to V5 (LPN-Licensed Practical Nurse) and V7 (LPN) that there was an altercation. Both nurses were at the medication room located on the front of the west hallway getting ready to start their medication passes. Both (V5) and (V7) ran to the end of hallway to intervene and separate (R1) and (R2). As the nurses approached, (R1) was observed striking (R2) in the face. (R1) and (R2) were separated immediately and assessed for injuries. (R2) was noted with a small laceration and redness to the left eye/eyebrow area and a bruise to his left hand around his thumb. (R2) reported forearm pain. (R1) was not noted with any injuries and denied pain. (R1) and (R2) were placed on 1:1. The police were contacted along with medical doctors and POA (Power of Attorneys)/Guardian of each resident. (R2)'s doctor gave the order to send him to the hospital for evaluation. Medical doctor for (R1) gave order to send him to a behavioral health hospital for evaluation and treatment. (R1) and (R2) are not interviewable due to their cognitive impairments, however staff attempted to determine a root cause to the incident. (R2) had no recollection of being involved in an altercation and (R1) shrugged his shoulders in response to questioning. Findings: The facility is substantiating abuse as staff did witness (R1) strike (R2) in the face. (R2) has visible injuries while (R1) did not have any. On 6/24/25 at 9:53 AM, R2 stated he did not remember what happened to him and R1. R2's face sheet shows diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, Alzheimer's disease, unspecified, and memory deficit following unspecified cerebrovascular disease. R2's MDS(Minimum Data Set) assessment dated [DATE] shows that R2 is severely cognitively impaired. On 6/24/25 at 9:59 AM, R1 was unable to be interviewed. R1 was very confused and severely cognitively impaired. R1's face sheet shows diagnoses of Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, delusional disorders, and anxiety disorder. R1's MDS (Minimum Data Set) 4/15/25 shows that he is severely cognitively impaired. On 6/24/25 at 10:25 AM, V3 (ADON-Assistant Director of Nursing) stated, On Monday 6/9/25, I was at home. The incident happened in the early morning hours during the night shift. Staff called me at home. They told him that (R1) hit (R2) near the common area. The staff separated them. The nurses did an assessment. (R2) was sent to the ER (Emergency Room). He had a laceration and redness to his left eye-brow area and a bruise to his left thumb area. (R2) had no pain or injuries. He was sent to the behavioral health unit of a hospital. (R1) and (R2) don't have a history of aggressive behaviors. We changed (R1)'s room to the first floor. It's our job to prevent abuse among our residents. On 6/24/25 at 11:00 AM, V1 (Administrator) stated, On 6/9/25, I was at home when I got the call. I think the incident happened between 5 AM and 5:10 AM. I was not at work yet. (V5-LPN/Licensed Practical Nurse) and (V7-LPN) were the nurses that day and they were getting medications ready. V4 (CNA-Certified Nursing Assistants) was coming out of another resident's room. She saw both (R1) and (R2) at the end of the hallway. She saw (R1) swinging at (R2). Contact was made. She yelled and both nurses responded. They all broke up the fight. (R1) hit (R2) in the face. Full assessments were done. (R2) had laceration on his left eye area and a bruise on his hand near his thumb. (R2) had no injuries. (R2) was sent to the ER for evaluation and returned 2 hours later. (R1) remained on 1:1 and then was sent to a different hospital for psychiatric evaluation and treatment. We did a room change for (R1). I came to the facility and started an investigation. The police were already gone when I got to the facility. (R1) is nonverbal. (R2) is nonsensical. None of them have a history of aggression. (R2) gets agitated with care. (R1) shrugged his soldiers when we tried to interview him and (R2) didn't recall. It is definitely the facility's job to prevent abuse. On 6/24/25 at 11:52 AM, V4 (CNA) stated, I was coming out of another resident's room. I had just provided care to the resident. In the furthest end of the hallway, I had seen (R1) fighting (R2). I called out for help. The nurses went first and separated them. I had to throw out the garbage from that resident's room. Then I joined them. (R2) had scratches to his face. I don't know about (R1). This is the first time I'm seeing aggressive behavior from (R1). I left for home before they went to the hospital. On 6/24/25 at 12:01 PM, V5 (LPN-Licensed Practical Nurse), Me and the other nurse (V7) heard (V4) yelling that (R1) and (R2) were fighting. We ran to the hallway where they were. We broke up the fight. On (R2)'s left temple, there was bleeding and redness. (R1) didn't have any injuries. They were both sent to different hospitals. (V6-Social Services Aide) filled out the involuntary petition paperwork. On 6/24/25 at 12:31 PM, V6 (Social Services Aide) stated, Yes, (R1) and (R2) had a physical altercation. (R1) punched (R2) in the face. Neither of them has a history of aggression. I did the involuntary petition. (R1) was sent to the hospital and had psychiatric treatment, while R2 was sent to the emergency room. We also moved (R1) to the first floor. R1's Petition for Involuntary/Judicial admission form dated 6/9/25 shows the following: (R1) who is asserted to be a person subject to involuntary in patient admission to a facility and for whom this petition is being initiated by reason of: Emergency inpatient admission by certificate. (R1) is a person with mental illness who because of his illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person of another in physical harm or in reasonable expectation of being physically harmed. (R1) is in need of immediate hospitalization for the prevention of such harm. CNA came out of another resident's room and saw (R1) punching another peer in the face causing injury to his face and pain in his arm. (R1) is currently on 1:1. Facility Abuse Prevention Program, revised 1/2019, shows, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (whether or not actually given) . Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment

Based on interview and record review the facility failed to complete neurological assessments following a fall. This applies to 1 of 3 (R1) resident reviewed for falls. The findings include: On 4/28/2025 at 9:01AM, R1 was observed laying in his bed with the head of bed elevated watching his computer with headphones on. R1 did not appear to have any bruising or swelling on his head. On 4/28/2025 at 9:01AM, R1 said he fell out of bed a day or two after he arrived at the facility. R1 said he hit his head when he fell . R1 said he went out to the hospital and returned the same day. On 4/28/2025 at 12:13PM V7 Restorative Nurse said neuro checks are done for 72 hours post fall. V7 said neuro checks should have resumed when [R1] returned from the hospital. On 4/28/2025 at 11:36AM, V2 Director of Nursing (DON) said neuro checks are done for an unwitnessed fall or when a resident hits their head for 72 hours after the fall. V2 said neuro checks are important because they help identify changes in condition. V2 said neuro checks should be continued when a resident returns from the hospital. R1's Progress notes from 4/17/2025 state his fall occurred at 6:00AM and the resident returned from the hospital at 12:00PM. The facility provided Neurological Assessment does not show an initial incident time and does not begin charting beginning until 10:30PM on 4/17/2025. The Neurological Assessment sheet shows initial x1, every 15 mins x6, every 30 mins x4, every hour x4, and every shift until the checks are completed 72 hours post fall. R1's progress notes state the resident fell at 6:00AM and returning to the facility at 12:00PM. Two hourly checks were missed one at 12:30PM and the second one at 1:30PM.

Based on interview and record review the facility failed to maintain a residents dignity by not answering a call light in a timely manner for 1 of 3 residents (R1) reviewed for dignity and resident rights in the sample of 5. The findings include: On 3/18/25 at 10:00 AM, V15 (R1's great - granddaughter) stated her and a relative were visiting R1 on 3/9/25. When she arrived around 11:30 AM, R1 needed to use the bathroom and her call light was on. V15 stated they went to the nurse's station to get a staff member because no one came to help. V15 stated she went and asked again because no one had come to help R1 and was told they would be down in a few minutes. V15 stated no one came to R1's room to toilet her. V15 stated she went and asked for assistance again and was told they were in the middle of lunch, needed to pass trays, and had other people to help. V15 stated by the time she got back to R1's room, R1 had wet herself. V15 stated R1 had to sit like that for awhile (10-20 minutes) and that is not right. V15 stated no one should have to sit in it. V15 stated it took 40 minutes - 60 minutes for anyone to come and help her. V15 stated R1 gets embarrassed about things like this and it upsets her. V15 stated R1 has dementia so she would not remember the incident but it does embarrass R1. V15 stated R1 uses a bedpan for toileting and knows when she has to use the toilet. On 3/18/25 at 1:34 PM, V11 (R1's daughter/emergency contact) stated, it can take between 5 minutes - 45 minutes for R1's call light to be answered when R1 remembers to use it. Recently my brother and granddaughter were there to see R1. They said R1 had to go to the bathroom and it took three times asking for help before R1 got any help and by that time R1 had wet herself. On 3/18/25 at 2:02 PM, V16 (Activity Director) stated, at the February (2025) resident Council Meeting there were complaints about call lights. They said it takes longer for their call lights to be answered after meals. On 3/18/25 at 2:19 PM, V3 DON (Director of Nursing) stated, the facility does not have a system in place to track call light response time. V3 stated staff try to answer call lights as soon as possible and have a CNA (Certified Nursing Assistant) designated in each group to answer call lights. V3 stated on average it takes 3 minutes to 10-15 minutes to answer a call light. V3 stated there is a manager that walks the floor that can answer the call lights. V3 stated if a call light is not answered in 45 minutes or longer it is not acceptable. V3 stated when a call light goes off it should be answered right away. If staff say they are going to be there in a few minutes to help the resident then they should honor that. The Rehabilitation Nurse Practitioner Progress Note dated 3/13/25 for R1 showed R1 requires maximum assistance for bed mobility and transfers. R1 has impaired mobility, transfers, and activities of daily living. R1's Interim Care Care Plan (no date) for her admitted [DATE] did not show a plan in place for activities of daily living including toileting needs and/or incontinence. The Face Sheet dated 3/18/25 for R1 showed diagnoses including encephalopathy, muscle weakness, unsteadiness on feet, repeated falls, hypothyroidism, hypertension, chronic kidney disease, bradycardia, heart failure, morbid obesity, and diverticulosis. The facility's Dignity policy (3/2024) showed, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: promptly responding to the residents request for toileting assistance

Based on observation, interview, and record review, the facility failed to ensure residents were prevented from having access to a room where medical equipment in need of repair was being stored. This applies to 1 of 3 residents (R4) reviewed for accidents in the sample of 5. The findings include: The EMR (Electronic Medical Record) shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, cerebral infarction, lack of coordination, reduced mobility, muscle weakness, unsteadiness on feet, abnormal gait, cognitive communication deficit, repeated falls, gastrostomy, right shoulder pain, fatty liver, dysphagia, hemiplegia and hemiparesis of the right dominant side, dizziness and giddiness, and dementia. R4's MDS (Minimum Data Set) dated November 27, 2024 shows R4 is cognitively intact, requires supervision with eating, oral hygiene, dressing, and personal hygiene, partial/moderate assistance with showering, and substantial/maximal assistance with toilet hygiene, bed mobility, and transfers between surfaces. R4 is occasionally incontinent of bowel and bladder. On February 26, 2025 at 11:50 AM, R4 was self-propelling her wheelchair in the hallway, just outside of an unlocked room with a sign posted on the wall that showed Ice Machine. No other signs were posted outside of the ice machine room. R4 had a large, empty plastic cup in her hand, and was asking for her cup to be filled with ice from the ice machine. R4 had an elastic compression wrap bandage on her right lower leg. The bandage had slid down her leg and was bunched up close to her ankle. R4 said, I will never go in that ice machine room again. I went in there to get ice and a pole fell on my leg and it really hurt me. R4 had difficulty remembering if the incident happened a week ago or yesterday. R4 demonstrated how she was able to open the door to the ice machine room by turning the door knob and pushing the door open. As R4 opened the door, she had to push hard against the door due to a self-closing device on the door. Inside the ice machine room was a large ice machine with a lid that opened from the bottom and swung upwards. The lid was approximately three feet wide by one foot, from the top of the lid to the bottom of the lid. Directly next to the ice machine were three IV (Intravenous) poles. The IV poles were approximately five feet in tall. Each pole was mounted to a stand with wheels. Three oxygen concentrators were also in the room, approximately four feet from the ice machine. R4 pointed to the IV pole and said, That pole fell and hit my leg when I came in to get ice. R4 pointed to an IV pole with a small IV pump attached to the pole. The IV pump was approximately four inches by four inches by one inch deep and was attached to the pole, approximately two feet from the top of the pole. Two of the three IV poles were extremely wobbly, including the IV pole with the IV pump attached to it, and the two IV poles swayed when moved or touched the slightest bit. The poles appeared loose at the point where the IV pole attached to the wheeled base. R4 said, when the incident happened, she had pushed the lid to the ice machine up so she could reach inside the machine to retrieve ice. R4 said as she lifted the ice machine lid, the lid to the ice machine hit one of the IV poles and caused the IV pole to fall and hit her right shin. On February 26, 2025 at 12:37 PM, R4 was sitting in her wheelchair in the hallway. V2 (DON-Director of Nursing) approached R4 and asked about the elastic compression bandage on R4's right lower leg. R4 said, Yesterday, I was in the ice machine room and a pole fell on my leg. R4 denied falling. V2 removed the elastic compression bandage from R4's right lower leg. The front of R4's right lower leg was bright red in color on her shin, approximately two inches wide, from just under her right knee to her ankle. No open skin areas were noted. V2 touched R4's right reddened shin area and said the area was not warm to the touch. R4 flinched when V2 touched her right shin. V2 rewrapped R4's right shin with the elastic compression bandage and asked R4's nurse to provide R4 with her ordered narcotic pain medication. V2 continued to say she heard commotion in the ice machine room the day before. V2 said she saw R4 come from the ice machine room but was not aware R4 had been injured. On February 26, 2025 at approximately 4:00 PM, R4 was sitting in her wheelchair in her room, sorting her colored pencils. R4 said the pain in her right lower leg had improved since she took the narcotic pain medication earlier. R4 again said, I did not fall. My leg got hurt in the ice machine room when a pole fell and hit my leg. R4's hospital discharge records dated February 25, 2025 show R4 was treated for a contusion to her lower extremity. The discharge instructions show to apply rest, ice, compression, and elevation to her lower extremity. R4's X-ray results of her right tibia and fibula dated February 25, 2025 show: Clinical indication: Bruising anterior mid-shaft right tibia. Findings: Two views right tibia and fibula were obtained. No fracture or dislocation is seen. Bones are intact. Hospital physician documentation shows: Right anterior shin tenderness and soft tissue swelling. There is ecchymosis. No erythema. No open wounds, bleeding, or lacerations. No palpable warmth. There is no obvious deformity. On February 26, 2025 at 1:42 PM, V14 (RN-Registered Nurse) said, I was the nurse on duty yesterday. I worked a double. I worked day shift and afternoon shift. [R4] came up to me and she told me she went into the ice room, and she bumped her leg on something. We offered to do an X-ray, but she said no, and the family called me after that. The family member called the doctor and the doctor said send her out. She went out to the hospital and when she came back from the hospital, the paperwork said she just had bruises. It looked like she bumped her leg. It was red. There were no black and blue marks. She did not fall. On February 27, 2025 at 8:07 AM, V20 (Maintenance Director) said, I was not aware there were any IV poles that were wobbly or needed to be repaired. That is a simple fix. There is a screw under the base that needs tightening to keep the pole from wobbling. Sometimes we have been running out of storage space, and temporarily we have been storing stuff in the ice machine room. There was an issue with the door knob, and I put a temporary one on the one door. The new door knob did not have a lock on it. The room is meant to be locked and residents are not supposed to access the room. On February 27, 2025 at 11:36 AM, V2 (DON) said, Residents are not supposed to go into the ice machine room. The room is usually locked, but the lock was broken. We should not have been storing equipment in that room.

Based on interview and record review, the facility failed to have protocols in place to utilize an assessment tool or management algorithm for residents who may receive antibiotics. This applies to all 166 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated February 3, 2025, showed the facility's census was 166 residents. On February 5, 2025, at 9:31 AM, V4 (Infection Preventionist) said when a resident has an infection and an antibiotic is used, V4 does not utilize an assessment tool or criteria when assessing if a resident is appropriately receiving an antibiotic. V4 said she reviews antibiotic orders with the providers to ensure there is an indication for use. On February 5, 2025, at 10:56 AM, V4 provided Infection Surveillance Monthly Reports for December 2024, January 2025, and February 2025. V4 said she did not have an assessment tool for any of the antibiotics prescribed during those months. V4 said she does not complete an assessment tool for any antibiotics prescribed to residents in the facility. V4 said since she does not complete an assessment tool for antibiotic use, she does not discuss inappropriate antibiotic use at Quality Assurance and Performance Improvement meetings. The December 2024 Infection Surveillance Monthly Report showed 34 antibiotics were prescribed to facility residents. The January 2025 Infection Surveillance Monthly Report showed 35 antibiotics were prescribed to facility residents. The February 2025 Infection Surveillance Monthly Report showed 14 antibiotics were prescribed to facility residents. The facility does not have documentation to show an assessment tool was used to monitor for if the prescribed antibiotics were indicated. On February 5, 2025, at 2:27 PM, V2 (DON/Director of Nursing) said V4 should be using an assessment tool when residents are prescribed antibiotics to ensure an antibiotic is required. V2 said the antibiotic stewardship program is to assess if antibiotics are required for a resident. The facility's policy titled Antibiotic Stewardship dated December 2016, showed Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and Implementation: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community . 11. When a culture and sensitivity is ordered laboratory results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued . The facility's policy does not contain a procedure for utilizing a standardized tool and criteria for assessing antibiotic use.

Based on observation, interview, and record review, the facility failed to prepare mechanical soft consistency diets for residents that had a diet order for the same. This applies to 4 of 4 residents (R27, R108, R111, R136) reviewed for dining in the sample of 33. The findings include: Facility Fall/Winter Menu week at a glance for mechanical soft (week 2, Tuesday, February 4) showed ground BBQ (barbeque) pork shoulder as the main entree for lunch meal. On February 4, 2025 at 9:41 AM, the preparation for mechanical soft consistency BBQ pork was observed in the facility kitchen. V9 (Cook) took several slices of cooked pre sliced pork and placed it on a cutting board and when asked if he is going to grind it, V9 stated that he is going to shred it into small pieces and add some broth and barbeque sauce which would make it soft. V9 then diced the pre sliced cooked pork into small pieces (about an inch) on a cutting board with a knife. V9 was notified that after preparation, the final consistency will be checked to see if appropriate for mechanical soft consistency. Prior to preparation for mechanical soft consistency, V9 was seen roughly chopping cooked BBQ pork into varying pieces and stated that it was for regular consistency diets. On February 4, 2025 at 11:15 AM, during tray line service, V9 was plating the food to the residents. When asked where the mechanical soft consistency BBQ pork was, V9 stated that he mixed it in with the regular consistency diets as he thought that it was all shredded. The mixed BBQ pork had varying sizes of meat and R27, R108, R111 and R136 received the same. V8 (Dietary Manager) who was present in the area, was notified that the consistency for mechanical soft diet called for ground meat on the menu spreadsheet. On February 5, 2025 at 11:37 AM, V12 (Dietitian) stated that the mechanical soft diets should receive ground meat as shown on the menu. Recipe for BBQ Pork Shoulder included to place BBQ pork in food processor and grind to appropriate consistency. Diet order listing showed that R27, R108, R111 and R136 were on mechanical soft diet.

Based on observation, interview and record review, the facility failed to maintain central venous catheter dialysis access site in accordance with infection control standards and their policy. This applies to 1 of 4 residents (R119) reviewed for dialysis in the sample of 33. The findings include: R119 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease with dependence on renal dialysis, diabetes, essential hypertension, chronic pain syndrome, and secondary and unspecified malignant neoplasm of lymph nodes, multiple regions. R119's MDS (Minimum Data Set) dated January 16, 2025, showed R119 was moderately cognitively impaired and required assistance with ADLs (Activities of Daily Living) including set up assistance with eating, personal, oral, toilet hygiene and toilet transfer. R119's care plan for dialysis created January 9, 2024, showed to monitor access site for signs of infection but did not address care of insertion site for the central venous catheter device. R119's physician order summary dated February 5, 2025, showed R119 has an order to administer hemodialysis through in facility vendor and to monitor access site dressing and change PRN (as needed). The order did not include the type of dressing that should be used. On February 3, 2025, at 11:26 AM, R119 was observed sitting in his wheelchair in his room, just coming out of the bathroom self-propelling his wheelchair. R119 stated he did not go to dialysis that day because he was having diarrhea and could not sit in the dialysis chair without having to use the bathroom. R119 moved his shirt to reveal his dialysis access catheter. It was a central venous catheter inserted in his right chest and there was not a dressing covering the insertion site. R119 was touching the catheter to manipulate it. V17 (LPN/Licensed Practical Nurse) was made aware that the R119 did not have a dressing over the catheter site. On February 4, 2025, at 11:40 AM, R119 was in his room sitting in his wheelchair and there was no dressing over the central venous catheter insertion site on the right chest. V15 (RN/Registered Nurse) was informed. At 11:50 AM, V15 stated she put a gauze dressing over the insertion site and at the end of the catheter tip because there was no cap. On February 5, 2025, at 9:30 AM, V13 (Dialysis RN) stated R119 came to dialysis that day with no dressing over the right chest central venous catheter access site. V13 stated it is very important to maintain a dressing over the catheter site to prevent infection. V13 stated R119 had come to dialysis many times without a dressing to the access site. V13 stated the access site dressing should be a border foam dressing covered with a transparent dressing to discourage R119 from picking at the site or removing the dressing. V13 provided documentation of the dialysis treatment. The dialysis treatment record dated February 5, 2025, showed under access site assessment, [R119] came with no dressing on catheter site. [R119] well aware of the dangerous situation of infection. The dialysis progress note dated November 1, 2024, showed [R119] came with no dressing on catheter site and [R119] was scratching the catheter site. [R119] was advised not to scratch the site, but still continued to scratch. MD (Medical Doctor) aware and will continue to monitor. The facility uses a communication tool to share clinical information between the facility nursing staff and the dialysis treatment staff for each dialysis treatment. Staff from the facility and staff from dialysis both document on the form, before dialysis and after dialysis. The communication form showed a statement regarding the care of CVC (Central Venous Catheters). The communication tool showed For Catheters CVC the dressing must remain intact and clean and dry at all times. If removed by the patient or is soiled, make sure the limb clamps are closed and catheter caps are in place. Cleanse the exit site with alcohol pad, chloral prep or betadine swab and apply sterile dressing after cleansing agent has dried. Promptly notify dialysis staff if this occurs. R119's hospital discharge summary dated October 22, 2024, showed R119 was treated for sepsis due to MRSA (Methicillin Resistant Staff Aureus) MDRO (Multidrug Resistant Organism) of the blood. On February 5, 2025, at 11:03 AM, V2 (DON/Director of Nursing) stated the CVC dialysis catheter insertion/exit site should always remain covered. V2 stated nurses need to monitor and reinforce or change the dressing as needed. The Facility's policy titled Dialysis Protocol dated 10/24, showed Guideline .4. Residents who have CVCs; the dressing must remain intact and clean and dry at all times. If removed by the resident or soiled, make sure the limb clamps are closed and catheter caps in place. Cleanse exit site with alcohol prep pad, Chlora prep pad or betadine swab and apply a sterile dressing after cleansing agent has dried. Promptly notify dialysis staff if this occurs .5. CVC dialysis dressing should be monitored every shift.

Based on interview and record review the facility failed to follow their policy to have the physician respond in a timely manner to the pharmacist's monthly Medication Regimen Review recommendations. The facility also failed to follow their policy to conduct monthly Medication Regimen Reviews for a resident. This applies to 3 of 5 residents (R39, R122, and R128) reviewed for unnecessary medications in the sample of 33. The findings include: 1. The EMR (Electronic Medical Record) showed R122 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation, depression, muscle weakness, and history of falling. R122's MDS (Minimum Data Set) dated November 29, 2024, showed R122 had moderate cognitive impairment. The MDS continued to show R122 had not received any as needed pain medication and did not have any pain present. R122's Order Summary Report dated February 5, 2025, showed an order dated April 2, 2024, for hydrocodone-acetaminophen (narcotic pain medication) oral tablet 5/325 mg (milligrams), give one tablet by mouth every six hours as needed for pain. R122's Consultant Pharmacist Recommendation to Prescriber dated November 30, 2024, showed Recommend discontinue of [as needed] [hydrocodone-acetaminophen] order due to no use in 30 plus days. The recommendation continued to show no physician addressed the pharmacist recommendation. The facility does not have documentation to show a physician was notified of the pharmacist recommendation. On February 4, 2025, at 3:24 PM, V2 (DON/Director of Nursing) said she does not have documentation to show R122's physician was notified of the pharmacist recommendation, or the recommendation was addressed by the physician. V2 continued to say the hydrocodone-acetaminophen order is still active on R122's order summary. 41855 2. R39's EMR (Electronic Medical Record) showed R39 was admitted to the facility on [DATE], with diagnoses that included vascular dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, unspecified psychosis not due to a substance or known physiological condition, and anxiety. R39's MDS (Minimum Data Set) dated November 8, 2024, showed R39 had severe cognitive impairment. R39's care plan identified her use of anti-anxiety medication, anti-depressive medication, and anti-psychotic medication. Interventions included attempt dosage reduction gradually as able and pharmacy consultant review as indicated. R39's POS (Physician Order Set) showed Ativan 0.5 mg, give one tablet by mouth in the evening for anxiety. Mirtazapine 15 mg, give one tablet at bedtime for depression. Risperidone 0.25 mg, give 1 tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. The Facility was unable to provide MRRs for May 2024, June 2024, July 2024, August 2024, September 2024, and October 2024. 3. R128's EMR showed R128 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease and major depressive disorder. R128's Psychiatrist note from October 2, 2024, showed R128 had major neurocognitive disorder without behavioral disturbances, anxiety disorder, unspecified psychotic disorder with delusions due to known physiological condition. R128's MDS dated [DATE], showed R128 had severely impaired skills for daily decision making. R128's care plan showed R128 uses anti-anxiety medication related to anxiety. R128 uses antidepressant medication related to major depressive disorder. R128 uses psychotropic medications related to psychosis. R128's POS showed Quetiapine (Seroquel) 50 mg, 1.5 tablet two times a day for antipsychotic. Bupropion (Wellbutrin) 150 mg ER (Extended Release), one tablet by mouth daily for antidepressant. Sertraline (Zoloft) 100 mg, two tablets by mouth daily for antidepressant. Clonazepam (Klonopin) 0.5 mg, one by mouth three times a day for anxiety, agitation. Mirtazapine (Remeron) 7.5 mg, give one tablet by mouth at bedtime for depression. Facility provided the pharmacy consultant regimen review for R128 from April 1, 2024, to present. On April 30, 2024, the MRR showed the pharmacist noted [R128] is receiving the following antipsychotic and an approved indication was not found at the time of review to support its use. Seroquel for antipsychotic .if indication is unknown, please assess for a dosage reduction trial and monitor for increased behaviors and/or psychiatric symptoms. There was no physician signature on form to indicate anyone had reviewed it. On June 30, 2024, the MRR showed, Indication for Seroquel is needed to support its use-is the indication Depression? There was no physician signature on form to indicate anyone had reviewed it. On August 31, 2024, the MRR showed, [R128] . Nursing, recommend updating the indication to support Seroquel with medication order in EMR, it currently reads 'for antipsychotic.' There was no documentation to show anyone reviewed the recommendation. The facility provided their undated policy titled Role of the Consultant Pharmacist. The policy showed Procedure: .2. The consultant pharmacist will complete Medication regimen Reviews at least monthly (as per agreement). Recommendations will be made based on the information available in the resident's health record at the time of the review .4. The consultant pharmacist will provide a report noting any irregularities to the Director of Nursing and/or Administrator at the completion of the review. The facility must ensure the attending physician and/or Medical Director are provided with copies of the recommendations and the response is timely in accordance with the accepted clinical practice.

Based on observation, interview and record review, the facility failed to provide grooming assistance for residents that needed extensive assistance from staff. This applies to 2 of 5 residents (R3, R58) reviewed for ADLs (activities of daily living) in the sample of 33. The findings include: R3's face sheet included diagnoses of cerebral infarction, functional quadriplegia, paraplegia, dysarthria following cerebral infarction, hemiplegia, unspecified affecting left nondominant side. R3's quarterly MDS (minimum data set) dated November 8, 2024 showed that R3 was moderately impaired in cognition and was dependent on staff for personal hygiene. On February 3, 2025 at 11:34 AM, R3 was seated in her bed and both her hands appeared contracted with the left hand more pronounced. R3's right hand fingernails appeared very long and thick with few curling in and rubbing against her palms. R3 was holding a washcloth on her left hand and the fingernails on the same hand was not visible. When asked, R3 stated that she would like her fingernails cut. On February 3, 2025 at 4:05 PM, V3 (Assistant Director of Nursing) was called to the room to view R3's finger nails on both hands and R3's right hand finger nails remained very long. V3 agreed that they were very long and needs to be cut. R3's care plan revised August 21, 2019 included that R3 has an actual ADL self care deficit related to impaired mobility and comorbidities. Interventions included that R3 will have the proper level of assistance provided with the following ADL needs: personal hygiene: extensive assistance, one person physical assist 2. R58's face sheet included diagnoses of need for assistance with personal care, other lack of coordination, cognitive communication deficit, difficulty in walking, not elsewhere classified. R58's annual MDS dated [DATE] showed that R58 was moderately impaired in cognition and required substantial maximal assistance for personal hygiene. On February 3, 2025 at 10:24 AM, R58 was noted to have long facial hair on chin and upper lip. Some of the nails on R58's contracted left hand had blackish substance underneath especially the thumb. V7 (R58's Power of Attorney) stated I have done it (cut nails and take off facial hair) before but they can do it if I can. R58 agreed with V7. R58's nursing care plan dated November 20, 2023 showed that R58 had self-care deficit, require assist with ADLS related to muscle weakness, unsteadiness on feet, difficulty in walking. Interventions included extensive- 1 person for personal hygiene. On February 5, 2025 at 2:53 PM, V2 (Director of Nursing) stated that the CNAs should provide assistance to the residents for personal hygiene every shift or as needed.

Based on observation, interview and record review, the facility failed to change residents' central venous catheter dressing in a timely manner to prevent the spread of infection. This applies to 2 of 2 residents (R310 and R309) reviewed for intravenous catheter dressing changes in the sample of 33. The findings include: 1. R310's face sheet showed her to be an [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Infection following a procedure, superficial incisional surgical site, subsequent Encounter, Presence of Left Artificial Hip Joint, and Unilateral Primary Osteoarthritis, Left hip. On February 4, 2025 at 12:35 PM during medication administration observation, V23 (Licensed Practical Nurse), observed R310's central line dressing was dated January 8, 2025, and was dingy, loosened, and detached from her skin on the top right side of her right arm. R310 stated that the dressing was placed on her arm on January 8, 2025 and no one has changed the dressing since then. R310 stated they just put another dressing on top. V23 stated there was a problem with R310's central line dressing not sticking to her skin and they reinforced it. V23 stated it is the responsibility of the night nurse to change the dressing and he did not know what the policy was for changing the central line dressings. R310 Intravenous Medication care plan dated January 13, 2025 showed the following: Check dressing at site daily. R310 has an physician order dated January 11, 2025 that showed the following: IV Therapy - check intravenous site every 8 hours for unusual redness, drainage, skin irritation, site pain, etc., and document it's condition every 8 hours. 2. R309's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Multiple Sclerosis, Sepsis, and Bacterial infections of unspecified site. On February 4, 2025 at 10:37 AM, R309 was observed with a right upper arm central line with a dressing that was dated February 3, 2025 and the dressing was loose and not attached to R309's arm on the right upper area of the dressing. On February 5, 2025 at 12:01 PM, R309 was observed in hallway and near the nursing station and his central line dressing was dated February 3, 2025 and the dressing was even more loose and detached from his right arm. The entire right side of the central line dressing was detached from his right arm. On February 5, 2025 at 3:39 PM, V2 (Director of Nursing) stated that central line catheter dressings should be changed every 7 days minimally and as needed to prevent infections. V2 stated for example, if the dressing comes undone or is soiled then the central line catheter dressing should be changed. R309 has an order dated February 2, 2025 to insert a midline central venous catheter to start antibiotic therapy. The facility's Care and Maintenance of Central Venous Catheters dated December 2024 showed the following: All vascular devices (peripheral and Central Venous) can be a source for blood stream and infection. Strict aseptic technique should be maintained at all times during insertion, dressing changes, medication administration and accessing of intravascular device: Guideline: 4. Replace semipermeable dressing every 7 days and as needed. 5. Replace gauze dressing every 2 days. 6. Replace the dressing if it becomes damp, loosened, or visibly soiled or when inspection of the site is necessary.

Based on observation, interview, and record review, the facility failed to manage a resident's complaint of severe pain. This applies to 1 of 3 residents (R41) reviewed for pain in the sample of 33. The findings include: R41 face sheet showed her to be an [AGE] year old female admitted to the facility on [DATE] with diagnoses including Fracture of shaft of right Tibia, subsequent Encounter for closed fracture with routine healing, Low back pain, , Pain in Left hip, chronic pain, pain in right hip, and Unspecified Osteoarthritis. As of February 5, 2025 at 10:25 AM, R41 did not have a care plan for pain. On February 3, 2025 at 10:33 AM, R41 stated she had pain in her right leg pain at 10 on a scale of 0 to 10 (0 being no pain and 10 being severe pain). R41 stated the facility does not give her pain medication timely. R41 stated she takes Hydrocodone and it helps if it is given on time. On February 3, 2025 at 10:40 AM, V23 (Nurse) stated that he already gave R41 pain medication this morning but he would check on her. Asked V23 what was R41's pain level at that time and V23 stated he could not recall. V23 then stated R41 is always in pain and the minute you give her some medication and the next time you see her, she is still in pain. Review of R41's medication administration record did not show any pain medication was administered to R41 on V23's shift that day before 10:43 AM. On February 4, 2025 at 3:10 PM, R41 stated her right leg pain was 10 out 10 (10/10). R41 stated V23 gave her pain medication around 11:00 AM today. On February 4, 2024 at 3:11 PM, surveyor informed V23 regarding R41's pain. V23 stated the doctor is aware that R41 is always in pain. V23 stated again, if you give her pain medication and go back to check on her she still says she is in pain all the time. Surveyor asked V23 had the doctor considered scheduling her medication. V23 stated he will contact the doctor about R41's pain medication. On February 5, 2025 at 11:54 AM, R41 had just arrived back from a dental appointment. R41 stated she is always in pain because they don't stay on top of her pain. R41 stated they say they will come but don't come. R41 stated she waited all day yesterday for pain medication. R41 stated yesterday they gave her pain medication around 11 AM and didn't give her another pain pill until 11:00 PM that night. R41 stated she kept asking the nurse for pain medication. R41's daughter (V24) was present and stated the facility has not been controlling her mother's pain. V24 stated she has been telling the staff and that they need to give her mother (R41) the pain medication she was prescribed. V24 stated R41 has hydromorphone 2 mg every 4 hours that they could give R41. V24 stated the doctors changed it in the hospital from 4mg every 8 hours to 2mg every 4 hours. V24 stated I told the staff she (R41) can handle the medication. R41 stated she was waiting for the nurse to give her (R41) some pain medication now. R41's Medication administration record showed R41 received Hydrocodone Acetaminophen 5-325 MG on February 4, 2025 at 12:06 PM and then not again until 11:10 PM. On February 5, 2025 at 1:49 PM, V10 (Licensed Practical Nurse) stated she gave R41 some Acetaminophen for a pain level of 6/10. V10 stated she gives hydrocodone or something stronger for pain of 7/10 and up. On February 5, 2025 at 1:52 PM, R41 (with V24 present) stated that when she got back from her dentist appointment today, she told V10 her pain level was an 8/10. R41 stated her pain level is now an 8/10 also and getting worse. On February 5, 2025 at 11:55 AM, Surveyor informed V10 (LPN) of R41's pain. Shortly after at 11:59 AM Surveyor and V10 entered R41's room. R41 daughter (V24) was still in the room. R41 told V10 that her pain was now 10/10 in her right leg. On February 5, 2025 at 3:11 PM, R41 stated that a tolerable level of pain is 4-5/10. R41 stated if they maintain her pain medication and give it around every 4 hours then the pain is not bad and it stays at a comfortable level, it's high because they don't consistently give her pain medication. R41 daughter was still present in the room. As of February 5, 2025 at 10:25 AM, R41 did not have a care plan for Pain Management R41 has orders for the following pain medication: 1) Acetaminophen 20.3 ml via G-tube every 6 hours as needed for pain dated November 19, 2024. 2) Hydrocodone-Acetaminophen 5-325 Milligrams (MG), give 1 tablet by mouth every 4 hours as needed for pain dated November 19, 2024. 3) Hydromorphone HCL oral tablet 2 MG, give 1 tablet by mouth every 4 hours as needed for pain. On February 5, 2025 at 3:39 PM, V2 (Director of Nursing) stated that staff should address a resident's pain right away. V2 stated that if a resident has pain level of over 5/10 then nurses should give the resident something stronger than an over the counter acetaminophen. The facility's Pain Management policy dated May 2024 showed the following: The pain management program is based on a facility-wide commitment to resident comfort. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical and established treatment goals. Pain management is a multidisciplinary care process that includes the following: b. effectively recognizing the presence of pain, e. developing and implementing approaches to pain management, g. monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary.

Based on interviews and record reviews, the facility failed to protect residents from abuse per their facility abuse prevention program. This applies to 3 of 4 residents (R1, R3 and R4) reviewed for abuse in the sample of 6. The failure resulted in R1 experiencing ongoing head, neck and shoulder pain as a result of R2 hitting R1. The findings include: 1. Face sheet, dated 5/15/24, shows R2's diagnoses included dementia, psychosis, muscle weakness, malignant neoplasm of bladder, cognitive communication deficit, reduced mobility, and history of falling. The MDS (Minimum Data Set), dated 2/3/24, shows R2's cognition was severely compromised. Face sheet, dated 5/15/24, shows R1's diagnoses included dementia, cognitive communication deficit, mild cognitive impairment, abnormal gait/mobility, and unsteadiness on her feet. The MDS, dated [DATE], shows R1's cognition was severely impaired. On 5/16/24 at 11:46 AM, R1 stated a week ago Sunday R2 punched her in her chin. R1 stated her chin, neck, and shoulders continued to hurt for over a week and her neck continued to hurt. On 5/5/14 at 11:20 AM, V4 (Registered Nurse) stated she heard yelling between R1 and R2 but did not know what they were yelling about. V4 stated she walked over to R1 and R2 and moved R2 away because she was aware R2 could become aggressive and get physical. V4 stated R1 later told her that R2 punched R1 in the chin. V4 then interviewed R2 and R2 stated she did hit R1. On 5/5/24 at 4:44 PM, V5 (Nurse Practitioner) stated after R1 was hit by R2, R1 complained of moderate head and neck pain upon movement. V5 stated R1 was not complaining of head, neck or shoulder pain prior to R2 hitting R1 and the pain was the result of R2 hitting R1. V5 stated he monitored R1's pain for a few days to see if it would subside which it did not and V5 prescribed steroids to treat R1's pain. V5 stated if the steroids did not alleviate R1's pain, his next step would be to order imaging of R1's neck to evaluate the source of the pain. V5's (Nurse Practitioner) progress note, dated 5/6/24, shows R1 was seen and stated she was still upset about the encounter the other day however R1 expressed she was not in pain. V5's (Nurse Practitioner) progress note, dated 5/8/24, shows R1 expressed she was still upset regarding the encounter and stated she was experiencing neck and shoulder pain for which steroid treatment was discussed. The note shows R1 was prescribed steroid 20mg (milligrams) for 5 days for neck and shoulder pain related to recent encounter with other resident. V5's (Nurse Practitioner)progress note, dated 5/10/24, shows R1 expressed minor improvement in neck pain. When asked about pain patient discussed incident again and is still upset/angry about the encounter. Witness statement, dated 5/5/24, shows V7 (CNA- Certified Nursing Assistant) came to the nursing station to respond to the incident and help separate R1 and R2. The statement shows V7 wrote that R1 stated R2 punched R1 in the chin and that the incident began because R2 was taking too long in the bathroom and R1 was trying to get R2 out of the bathroom to take a turn. Progress note, dated 5/5/24, shows R1 had a verbal altercation with her roommate and R1 was removed from the area. The note shows shortly after the altercation, R1 informed the nurse on duty that R2 punched R1 in the chin. The note shows the nurse on duty asked R2 if she punched R1 in the face and R2 responded by saying yes. The note shows R1 later complained of neck pain shortly after the assault. Incident report, dated 5/5/24, shows R1 reported that R2 hit her on the chin however the incident was not witnessed by staff. The report shows R2 stated R1 was yelling at R2 to get out of the bathroom because R2 was taking too long and R2 swatted R1 to leave her alone. The report shows R2 admitted to striking R1 after a verbal altercation and the police were called. The report shows R2 was sent to the hospital for evaluation and remained on 1:1 supervision until she left the facility. Facility staff were interviewed and no other witnesses were identified. The report shows the allegation of the abuse was substantiated by the facility investigation. Police Violation Notice, date 5/5/24, shows R2 received a citation for Disorderly Conduct - fighting (assault or battery.) Facility Abuse Prevention Program document, reviewed 1/2019, shows, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The document shows, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident . This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish . The term 'willful' in the definition of 'abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment 2. Face sheet, dated 5/15/24, shows R3's diagnoses included dementia, delirium, alcohol abuse, cannabis abuse, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, Alzheimer's disease, visual hallucinations, restlessness and agitation, aphasia, and apraxia. MDS, dated [DATE], shows R3's cognition was moderately impaired. Face Sheet, dated 5/15/24, shows R4's diagnoses included Wernicke's encephalopathy, psychosis, dementia, depression, altered mental status, and alcohol dependence. Progress note, dated 5/8/24, shows R4's diagnoses also included major neurocognitive disorder. MDS, dated [DATE], shows R4's cognition was moderately impaired. On 5/15/24 at 1:15 AM, V3 (CNA- Certified Nursing Assistant) stated she was assigned to be 1:1 supervising both R3 and R4 in their room. V3 stated R3 was confused, often walks around the facility, and V3 was having to redirect R3 while supervising him. V3 stated both R3 and R4 were ambulatory. V3 stated R3 attempted to get into R4's bed and R4 yelled, Get the f*** out of my bed [R3]! V3 stated she tried to get between R3 and R4 when R3 reached around V3 and hit R4 in the nose. V3 stated R4 then hit R3 in the chest. V3 stated staff then came to the room to assist and both residents were sent out to the hospital after the incident. V5's Nurse Practitioner note, dated 5/4/24, shows R3 was exhibiting aggressive behavior, struck a resident, and was sent out. Nursing note, dated 5/4/24, shows a CNA (Certified Nursing Assistant) reported to the nurse that R3 struck another resident on the nose and as a result the other resident struck back and hit R3 on the chest. The note shows R3 was unable to give a description of what happened. Nursing note, dated 5/4/24, shows a CNA (Certified Nursing Assistant) reported R4 was struck by a resident in the nose and R4 struck back at the resident on the chest. The progress note shows R4 stated, He hit me in my nose so I hit him back. Incident report, dated 5/4/24, shows R3 and R4 were roommates and the two residents were in their room with a sitter at the time of the incident. The report shows V3 (CNA) was assigned as R3 and R4's sitter. The report shows R3 then attempted to lay down in R4's bed, R4 yelled at R3 to get out of his bed, V3 attempted to get in between the two residents, and R3 struck R4 in the face/nose. R4 then reached around and struck R3 in the chest. The residents were then then separated and no injuries were identified. The report shows both residents were placed on 1:1 monitoring, police/physician/responsible parties were called, and R3 and R4 were sent out for evaluation. The report shows the police did not pursue any further action and both residents were sent to the hospital for evaluation. The report shows the allegation of abuse was substantiated.

Based on observation, interview, and record review the facility failed to immediately report a suspicion of physical abuse for 1 of 36 residents (R102), and failed to ensure and allegation of verbal abuse was immediately reported for 1 of 32 residents (R80) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1.On 03/13/24 at 1:46 PM, R102 was lying in bed on his back, with the head of the bed elevated at a thirty-degree angle. R102 had a bruise to the left cheek. On 03/13/24 at 1:46 PM, R102 said, One man hurt me here. I was grabbed and my face went into the side rail, and he punched me. I have pain to my left cheek and left arm. On 03/14/24 at 9:06 AM, V38, CNA, said, (V37, CNA) had (R102) the night of Friday (03/08/24) to Saturday (03/09/2024). At 12:30AM, (V37) asked for assistance with a combative resident. I went in to change (R102). (R102) did throw his hands up, maybe he began to resist, I could not tell, because (V37) had already grabbed (R102) and pinned him down. He had the resident's hands balled up and pinned to (R102's) chest. (R102) can be angry, but I have never seen him combative. Most people know to walk away. The next incident happened at 5:30AM. (V37) asked for help. I went to (R102), and asked him to give me five minutes to change him. (R102) agreed. (R102) usually refuses the first bed check. We just report to the nurse, then in the morning, (R102) allows it. (R102) threw his hands up and said ok. I took his hands being up as (R102) submitting to be changed. (V37) then pinned (R102's) hands to this chest. It looked like he was choking him, except he was pushing (R102's) crossed hand onto (R102's) chest instead of being around his neck. Then (V37) put more weight on him. (V37) told (R102) to turn. I said, '(V37) let him go', then I said it again. I went to get (V40, LPN-Licensed Practical Nurse). (V37) was being too aggressive, too rough. (V37) should not take care of residents anymore. (R102) looked scared; I was scared also. He looked more scared the second time as (V37, CNA) tried to provided care than the first time. I think that is why (R102) threw his hands up. He was surrendering. I had never seen (R102) like that. During that time, (V40, LPN) was doing her med pass. The nurse did not know what the protocol was. (V40, LPN) said she was going to ask the other nurse. The other nurse said, 'We need to talk to (V2, DON)'. I told the nurse he put all his weight on (R102). (V37) became aggressive and put all his weight on (R102). If the patient says 'I don't want to be touched', we leave them alone. I reported the abuse to (V40, LPN-Licensed Practical Nurse). (V40, LPN) said she did not know the protocol. I then went to the first floor and reported the incident to (V39, Charge Nurse). The first time (V37) provided care to (R102) he was too aggressive, I thought I should say something. The second time I knew I needed to say something. On 03/14/24 at 9:37 AM, V39, RN Charge Nurse, said, I am the charge nurse. (V38, CNA) let me know about the incident. The incident was reported to me (03/09/2024) between 6:15 AM to 6:30 AM, (approximately six hours after the first event was witnessed). Because it was abuse, I contacted (V1-Administrator). I followed her instruction. I called the police to make a report. I did not assess (R102). The nurse on the floor did the check, I think it was (V40, LPN). I did not make any changes to the assignment sheets. We pulled (V37, CNA) off the floor when I was told, and called the police so he could talk with police, and I could get a statement from him. I pulled him off the floor around 6:30 AM to 7:00 AM, (Approximately one hour after second allegation of abuse was observed and reported to (V40, LPN), when we brought him to the office. On 03/14/24 at 9:55 AM, V40-LPN said, The incident was never brought to my attention. If I would have known, I would have charted it. I believe I was (R102's) nurse; I was (R102's) nurse; I cannot recall. I do not work there anymore. I quit Monday (03/11/2024). On 03/14/2024 at 10:54 AM, V41, RN-Registered Nurse, said, (V40, LPN) told me there was an incident where (V37, CNA) was restraining a resident. (V35, CNA) and I went to see (R102). (R102) told me that he was punched with a closed fist. (R102) had redness and swelling to the left cheek and his left arm was hurting. (R102) said (V37, CNA) was rough with care. (R102) never complained of forearm pain before. I would report a patient being pinned down; I would say that is abuse. The facility's assignment sheet, dated 03/08/2024 at 11:00PM through 03/09/2024 at 7:00 AM, shows, V40, LPN, was assigned to R102. The facility's Abuse Policy, dated 01/2019, shows, employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. The facility's Final Investigation Report on R102's abuse allegation of 03/09/2024 shows abuse has been substantiated. The Immediate Jeopardy that began on 03/09/2024 was removed and the deficient practice corrected on 03/14/2024 when the facility took the following actions to remove the immediacy and correct the noncompliance. 1. All staff will be educated on all types of abuse, 03/13/2024. 2. All staff will be educated on the standard of immediately reporting abuse, 03/13/2024. 3. All staff will be educated on protecting residents after an alleged abuse, 03/13/2024. 4. All staff will be educated on the components of the abuse policy, 03/14/2024. 5. All Residents will be re-evaluated for the potential at risk for abuse or neglect, 03/14/2024. 6. As all current staff are educated, new hires will be trained accordingly and an Abuse Prevention Training Program-Post Test will be completed to assess for comprehension, 03/14/2024. 7. Any/All allegations of abuse will be brought to the IDT in Morning Meetings and reviewed in detail at weekly IDT Meetings, 03/14/2024. 8. Any/All Abuse allegations will be reviewed and monthly QAPI/Quarterly QA, 03/14/2024. 34490 2. On 3/12/24 at 9:04 AM, this surveyor was in the hall by the doorway of R125's room. V32 (Registered Nurse) went into R125's room to provide him with medication. R125 started yelling at V32 that he needed to see the doctor so he could go home. V32 exited the room and R125 followed her. When R125 get to his doorway, R80 walked to his doorway which is across the hall from R125's room and told R125 to be quiet. R125 then went around V32 who was still standing in his doorway and went into the hallway. R125 stuck his middle finger up at R80 and stated, F**k you, mind your f***ing business. R80 was still standing in his doorway, and put up both of his fists in a fighting position. V32 then went to R125 and directed him back to his room. At the same time, V28 (Certified Nursing Assistant) assisted R80 back into his room. When R125 got to inside his doorway, he stated, I'm going to tear his f***ing larynx out. V32 was standing in R125's doorway when it was stated. R125's Nursing Notes, dated 3/12/24 at 9:21 AM, shows, Resident in hallway started to yell loudly saying he wants to go home, asking for doctor, other resident opposite to his from [sic] got irritated and started to talk back/yelled at this resident. Staff tried to calm him down, redirect to his room but couldn't. After a while he himself went back to his room. NOD (Nurse on Duty) informed social services and DON (Director of Nursing) R125's Social Service Note, dated 3/12/24, at 2:33 PM shows, Writer was informed about a verbal argument between 2 cognitively impaired male residents. Writer met with resident due to verbal aggression towards another male resident. 03/12/24 10:12 AM, V1 (Administrator) said she has had one allegation of abuse reported to her about a resident alleged abuse from a CNA the night prior, but no other incidents were reported to her. On 3/12/24 at 12:20 PM, R80 was in his room laying in bed. R80 said that this morning he heard that guy yelling, so he went to the doorway and told him to be quiet. R80 said R125 then started yelling at him and threatening him. R80 said he (R125) is very violent and he gets ticked off by the smallest things and starts yelling. On 3/12/24 at 12:23 PM, V32 said R125 has a history of yelling when he is upset. V32 said she texted V15 (Memory Care Director) about the incident. (R80 and R125 do not reside on the secured Memory Care Unit). On 3/12/24 at 12:30 PM, V15 (Memory Care Director) said V32 texted her at 9:08 AM, but she did not see it until about 10:00 AM, and said that two residents had verbal aggression between each other that was initiated by R125. V15 said she told V32 to keep them separated and she would have R125 see the psychiatrist the next day. V15 said she did not let V1 (Administrator/Abuse Coordinator) know of the incident, because it was just verbal aggression, and was not a physical altercation. V15 said she had not had a chance to speak with R125 yet. On 3/12/24 at 1:47 PM, V7 (Social Services) said types of abuse include: physical, verbal, financial and sexual. V7 said all allegations or witnessed abuse needs to be investigated right away, so the story does not change. V7 said abuse can happen between anyone, staff to residents, or resident to resident. V7 said examples of verbal abuse include: yelling at someone, downgrading them, being very disrespectful to them or being aggressive towards them. V7 said if staff see or hear about abuse they should go and tell the manager on duty or the abuse coordinator right away. V7 said she just got wind of the incident that happened between R125 and R80 a few minutes ago, and V15 is working on an investigation. On 3/13/24 at 9:49 AM, V1 (Administrator/Abuse Coordinator) said types of abuse include: physical, mental, sexual, involuntary seclusion, verbal and misappropriation of property. V1 said verbal abuse includes: derogatory remarks, verbal threats of physical harm or any verbal response that could cause mental anguish to someone. V1 said abuse can be between staff and residents or between a resident and resident. V1 said even if a resident has dementia, they can still verbally abuse another resident. V1 said staff have been educated to report any allegation of abuse they see or hear about immediately to her or the manager on duty if she is not available, and the manager will notify her immediately. V1 said an investigation is initiated immediately, and a report is sent to the State Survey Agency with two hours. V1 said she heard about the incident between R125 and R80 after this surveyor had interviewed V15 (on 3/12/24 at 12:30 PM). V1 said at that time, she spoke to corporate, and they instructed her to do an abuse investigation. V1 said the initial incident report was sent to the State Survey Agency around 1:00 PM on 3/12/24. An email provided shows V1 received confirmation that a Facility Reported Incident was received on 3/12/24 at 1:32 PM regarding R125. The facility's Abuse Prevention Program reviewed on 1/2019 shows, This facility is committed to protecting our residents from abuse .by anyone including, but not limited to, facility staff, other residents .verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of an individual's age, ability to comprehend, or disability .Employees are required to report any incident, allegation or suspicion of potential abuse .they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer .Any allegation of abuse will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse.

Deficiencies at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to protect R102 from physical abuse, resulting in R102 having muscular skeletal pain to his left arm and redness and swelling to his left cheek for 1 of 32 residents (R102) reviewed for abuse in the sample of 32. The Immediate Jeopardy began on 03/09/2024 at 5:30AM, when V37, CNA-Certified Nursing Assistant, became aggressive with R102, by pinning R102's hands to his chest and bearing all his weight on to R102. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 03/13/24 at 1:46 PM, R102 was lying in bed on his back, with the head of the bed elevated at a thirty-degree angle. R102 had a bruise to the left cheek. On 03/13/24 at 1:46 PM, R102 said, One man hurt me here. I was grabbed and my face went into the side rail and he punched me. I have pain to my left cheek and left arm. On 03/14/24 at 9:04 AM, V37, CNA, was contacted by phone. A message was left requesting V37, CNA, to call back. V37, CNA, has not returned call prior to exiting from the facility. On 03/14/24 at 9:06 AM, V38, CNA, said, (V37, CNA) had (R102) the night of Friday (03/08/24) to Saturday morning (03/09/2024). At 12:30AM, (V37) asked for assistance with a combative resident. I went in to change (R102). (R102) did throw his hand up, maybe he began to resist, I could not tell, because (V37) had already grabbed (R102) and pinned him down. He had the resident's hands balled up and pinned to (R102's) chest. (R102) can be angry, but I have never seen him combative. Most people know to walk away. The next incident happened at 5:30AM. (V37) asked for help. I went to (R102), and asked him to give me five minutes to change him. (R102) agreed. (R102) usually refuses the first bed check. We just report to the nurse, then in the morning, (R102) allows it. (R102) threw his hands up and said ok. I took his hands being up as (R102) submitting to be changed. (V37) then pinned (R102's) hands to this chest. It looked like he was choking him, except he was pushing (R102's) crossed hand onto (R102's) chest instead of being around his neck. Then (V37) put more weight on him. (V37) told (R102) to turn. I said, '(V37) let him go', then I said it again. I went to get (V40, LPN-Licensed Practical Nurse). (V37) was being too aggressive, too rough. (V37) should not take care of residents anymore. (R102) looked scared; I was scared also. He looked more scared the second time as (V37, CNA) tried to provide care than the first time. I think that is why (R102) threw his hands up. He was surrendering. I had never seen (R102) like that. During that time, (V40, LPN) was doing her med pass. The nurse did not know what the protocol was. (V40, LPN) said she was going to ask the other nurse. The other nurse said we need to talk to (V2, DON-Director of Nursing). I told the nurse (V37) put all his weight on (R102). (V37) became aggressive and put all his weight on (R102). If the patient says I don't want to be touched, we leave them alone. I reported the abuse to (V40, LPN-Licensed Practical Nurse). (V40, LPN) said she did not know the protocol. I then went to the first floor and reported the incident to (V39, Charge Nurse). The first time (V37) provided care to (R102) he was too aggressive, I thought I should say something. The second time I knew I needed to say something. On 03/15/24 at 10:01 AM, V35, CNA, said, I spoke with (R102) on 03/09/24. He told me (V37, CNA) came into his room and punched him in the face. The second time (V37, CNA) came in the room, he tossed him toward the side rail of the bed. On 03/14/2024 at 10:54 AM, V41, RN-Registered Nurse, said, (V40, LPN) told me there was an incident where (V37, CNA) was restraining a resident. (V35, CNA) and I went to see (R102). (R102) told me that he was punched with a closed fist. (R102) had redness and swelling to the left cheek, and his left arm was hurting. (R102) said (V37, CNA) was rough with care. (R102) never complained of forearm pain before. I would report a patient being pinned down; I would say that is abuse. R102's Progress Notes, dated 03/09/2024 at 7:40AM, created 03/11/2024 at 1:40AM, by V41, RN-Registered Nurse, shows, received resident at 7:00 AM. Informed by night shift LPN that an incident occurred between CNA and resident during early AM hours of care before 7:00 AM. Two police officers here in building doing an investigation and interviewing staff. Resident is alleging that he was struck in the left side of his face with a closed fist by the CNA and that he was being rough during care. Resident complained of pain to his left arm. Upon assessment left cheek looks slightly swollen with a small amount of redness. Assessed left arm pain. Resident continues to have AROM (Active Range of Motion) to both upper extremities. Able to flex and extend both arms without pain. Able to lift arms above head and squeeze RN fingers without pain. Only complaint of muscle pain to top of forearm. No swelling or redness noted at this time to either arm. Informed daughter of incident. Shortly after the daughter arrived and was at bedside. RN explained at this time we will manage pain with scheduled acetaminophen and if pain worsens or other symptoms arise the RN can obtain X-Ray for left arm but at this time it is not necessary. Informed Nurse Practitioner. R102's Aggravated Battery Police report, dated 03/09/2024 at 6:41AM, shows, responding officer spoke with (V37, CNA), who provided the following information. (V37, CNA) had his first encounter with (R102) at approximately 0030 (12:30AM) hours. (V37, CNA) was changing (R102's) diaper and in the process, (V37, CNA) requested help from (V38, CNA) since he knew the history of (R102) being combative. (R102) was pinned down in anticipation of being combative. On the second occasion, at approximately 0530 hours (5:30AM), (V37, CNA) changed (R102's) diaper. (V38, CNA) saw (V37, CNA) and assisted in the process. (V37, CNA) then held (R102) by the wrist to prevent from him being combative. Responding Officer then spoke with V38, CNA, who provided the following information. V38, CNA, was assisting V37, CNA, at approximately 0030 hours. V38, CNA, noticed V37, CNA, pinning down R102. She told V37, CNA, to get off R102, and not use that amount of force. She kept telling V37 numerous times to get off and she saw R102 look at her. She explained R102 looked at her in a manner that hinted that he was scared and if the excessive force of V37 CNA was justified. In the heat of the moment, V38, CNA, walked away since she was afraid of V37, CNA. The second incident occurred at approximately 0530 hours. V37, CNA and V38, CNA were changing R102`s diaper. As V38, CNA, was changing the diaper, V37, CNA, stepped in and held R102's down by the wrist against his bed while using the full weight of his body. V38, CNA, thought this was excessive due to R102 having both of his legs amputated and due to weighing 100 Lbs. or less. V38, CNA, stated that R102 was not combative and did not need to be restrained. Responding Officer spoke with R102 and was given the following information. R102 was having his diaper changed by V38, CNA, at approximately 0030 hours. During that time, he was pinned down with his arms crossed. R102 stated he did feel pain in his arms when being pinned down. In the second incident, R102 was having his diaper changed by V37, CNA and V38, CNA. As V38, CNA, was changing him, V37, CNA, stepped in and held R102 by the wrist on the bed. R102 advised responding officer he was punched by V37, CNA, in the upper torso. Responding Officer asked R102 what time frame that occurred between the two incidents, but R102 did not know an approximate time of when it happened. Responding Officer checked R102 for any signs of injuries including marks or bruises. Responding Officer did not notice any bruises, but did notice redness and a small cut on R102's left upper cheek. Responding Officer took pictures of the cut and both arms that were a result of being held down by V37, CNA. The facility's Final Report on R102's abuse allegation of 03/09/2024 shows abuse has been substantiated. The facility's Policy, dated 01/2019, shows, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The Immediate Jeopardy that began on 03/09/2024 was removed on 03/14/2024 when the facility took the following actions to remove the immediacy. 1. V37 was removed from the schedule on date of alleged incident pending investigation. 2. V37's employment from facility is terminated. 3. All staff will be educated on all types of abuse, 03/13/2024. 4. All staff will be educated on the standard of immediately reporting abuse, 03/13/2024. 5. All staff will be educated on protecting residents after an alleged abuse, 03/13/2024. 6. All staff will be educated on the components of the abuse policy, 03/14/2024. 7. All Residents will be re-evaluated for the potential at risk for abuse or neglect. 8. As all current staff are educated, new hires will be trained accordingly and an Abuse Prevention Training Program-Post Test will be completed to assess for comprehension, 03/14/2024. 9. Any/All allegations of abuse will be brought to the IDT in Morning Meetings and reviewed in detail at weekly IDT Meetings, 03/14/2024. 10. Any/All Abuse allegations will be reviewed and monthly QAPI/Quarterly QA. 33760 B. Based on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse (R61), and failed to ensure residents were free from verbal abuse (R80 and R52), for 3 of 32 resident reviewed for abuse in the sample of 32. 1. The Facility Reported Incident (FRI) as Final Report, dated 3/5/24 with date of incident as 3/1/24, shows (R61) was observed to have his hand on (R132's) breast. Both residents were on 2nd floor. (R132) was up and about, while (R61) was sitting in his wheelchair able to wheel himself around. Both were in the nurse station on 2nd floor, several staff were behind the nurses station documenting. Upon looking, it was observed that (R61) had his hand on (R132's) left breast. Upon observation, staff immediately intervened and separated the two residents. R132 is a 73 y/o female with diagnoses of Alzheimer's disease, hyperlipidemia, major depression recurrent, muscle weakness unsteadiness on feet . alert and oriented x1, with impaired memory judgement and decision making abilities. R132 is unable to make her wants and needs knows and relies on staff to anticipate needs. R132 does speak and mumbles but is generally non-.sensical. R132 has severe cognitive impairment as evidenced by her most recent BIMS and is a long term care resident since 11/23. R132's careplan shows Resident may be a potential risk for abuse related to behavior problems as evidenced by aimless wandering in and out of other resident rooms, and walking up closely to other residents, impaired safety awareness. R61 is a 73 y/o male with diagnoses of displaced fracture of left femur, hemiplegia, abnormalities of gait and mobility, alert and oriented x 2 with impaired memory judgement and decision making abilities. R61 has moderate cognitive impairment and is a long term care resident since 1/2023. On 3/11/24 at 9:15 AM, R132 was up and about in the hallways, mumbling to herself. When asked by this surveyor if she was ok, R132 smiled and continued to walk around the 2nd floor. On 3/11/24 at 12:30 PM, R61 was in his room with a sitter. R61 stated, I got the idea to touch her (R132) cause she lifted her shirt up and a I saw a bare breast. I am a man. Staff all saw it and got upset about it, but no one said the other resident got upset. I should have known this was wrong. We have to respect each other in a nursing home. Never done this before, no. After it happened, I was admitted to the hospital on a psych unit. I know it was wrong for me to do this, yes. I wasn't thinking the resident may not be in her right mind. This statement was witnessed by R61's sitter (V13, Restorative CNA) On 3/12/24 at 12:10 PM, V16 (License Practical Nurse-LPN) said she was the nurse working on 3/1/24 when the incident happened. V16, LPN, said she was sitting at the nurses station. R61 was sitting in his wheelchair, and R132 was standing by the nurses station. V16 said when she looked up, she saw R61's hand was under R132's shirt touching her left breast. V16 said she told R61 to take his hands off R132. R61 did not remove his hands. V16 stated, I had to get up and physically remove (R61's) hand from (R132's) breasts. (R132) did not react to what happened and seemed unaware. (R61) was provided 1:1 immediately. V16 said she reported the incident to V15 (Dementia Director), both families, and their physician. R61 was sent out to the psych ward. R61 was back at the facility but on a different floor. V16 said, When a resident touches another resident inappropriately, that is sexual abuse. On 3/11/24 at 11 AM, V15 (Dementia Unit Manager) said on 3/1/24, it was reported to her R61 touched R132's breast. Both residents were separated. R61 was provided 1:1 until he was sent out to the psych ward. V15 said she reported the incident to V1 (Administrator), the Abuse Coordinator. R132 was now back at the facility, but was moved to first floor with a sitter. On 3/13/24 at 9AM, V1 (Administrator) said she takes abuse seriously and abuse was not allowed at the facility. V1 said she was working on R61's discharge. The facility Policy entitled Abuse Prevention Program, date review of 1/2019, shows, Definitions: Abuse [NAME] any physical or mental injury or sexual assault inflicted upon a resident other than by accident means. Abuse is the willful infliction of injury unreasonable confinement intimidation or punishment resulting in physical harm, pain, or mental anguish to a resident. This also includes deprivation by an individual, including caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Sexual abuse- includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. 34490 2. On 3/12/24 at 9:04 AM, this surveyor was in the hall by the doorway of R125's room. V32 (Registered Nurse) went into R125's room to provide him with medication. R125 started yelling at V32 that he needed to see the doctor so he could go home. V32 exited the room and R125 followed her. When R125 got to his doorway, R80 walked to his doorway, which is across the hall from R125's room, and told R125 to be quiet. R125 then went around the nurse and into the hallway and stuck his middle finger up at R80 and stated, F**k you, mind your f***ing business. R80 was still standing in his doorway and put up both of his fists in a fighting position. V32 then went to R125 and directed him back to his room. At the same time, V28 (Certified Nursing Assistant) assisted R80 back into his room. When R125 got to inside his doorway, he stated, I'm going to tear his f***ing larynx out. R125's Nursing Notes, dated 3/12/24 at 9:21 AM, shows, Resident in hallway started to yell loudly saying he wants to go home, asking for doctor, other resident opposite to his from [sic] got irritated and started to talk back/yelled at this resident. Staffs tried to calm him down, redirect to his room but couldn't. After a while he himself went back to his room. NOD (Nurse on Duty) informed Social Services and DON (Director of Nursing) R125's Social Service Note, dated 3/12/24 at 2:33 PM, shows, Writer was informed about a verbal argument between 2 cognitively impaired male residents. Writer met with resident due to verbal aggression towards another male resident . On 3/12/24 at 12:20 PM, R80 was in his room laying in bed. R80 said that this morning he heard that guy yelling, so he went to the doorway and told him to be quiet. R80 said that R125 then started yelling at him and threatening him. R80 said that he (R125) is very violent and he gets ticked off by the smallest things and starts yelling. On 3/12/24 at 12:23 PM, V32 said R125 has a history of yelling when he is upset. V32 said she texted V15 (Memory Care Director) about the incident. (R80 and R125 do not reside on the secured Memory Care Unit). On 3/12/24 at 12:30 PM, V15 (Memory Care Director) said V32 texted her at 9:08 AM, but she did not see it until about 10:00 AM, and said the two residents had verbal aggression between each other that was initiated by R125. V15 said she told V32 to keep them separated and she would have R125 see the psychiatrist the next day. On 3/12/24 at 1:47 PM, V7 (Social Services) said some types of abuse include: physical, verbal, financial and sexual. V7 said abuse can happen between anyone, staff to residents or resident to resident. V7 said examples of verbal abuse include: yelling at someone, downgrading them, being very disrespectful to them or being aggressive towards them. On 3/13/24 at 9:49 AM, V1 (Administrator/Abuse Coordinator) said types of abuse include: physical, mental, sexual, involuntary seclusion, verbal and misappropriation of property. V1 said verbal abuse includes: derogatory remarks, verbal threats of physical harm or any verbal response that could cause mental anguish to someone. V1 said abuse can be between staff and residents or between a resident and resident. V1 said that even if a resident has dementia, they can still verbally abuse another resident. The facility's Abuse Prevention Program, reviewed on 1/2019, shows, This facility is committed to protecting our residents from abuse .by anyone including, but not limited to, facility staff, other residents .verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of an individuals age, ability to comprehend, or disability. 40085 3. R52's 1/2/24 Minimum Data Set assessment shows her cognition and memory are intact. R52's active care plan shows she requires staff assistance with her activities of daily living, can become incontinent of urine and is a stand by assist for toileting. The care plan also shows she can has the potential to be a victim of abuse. On 3/12/24 at 10:37 AM, R52 said she had a problem with the CNA (later identified as V8) last night who yelled at her. R52 said, I am mostly independent, but sometimes have a problem with incontinence, so last night I got up to use the bathroom and didn't grab a pull up on the way, so I put my light on for the CNA to get me one. The CNA got mad at me and started going off on me, saying I should have got the pad before I went to the bathroom and she didn't have time for my nonsense. She then tossed the pad at me, refused to get me new pants, slammed the door, and left. On 3/12/24 at 10:45 AM, V7 (Social Worker) said it was reported to her at 8:35 AM, that a potential abuse incident occurred between R52 and a CNA. She went and talked to her right away and started to obtain statements from the CNA and the resident and R52's roommate (R98). On 3/12/24 At 12:32 PM, R52 said she did file a report with her Social Worker who came right away to talk to her. R52 also said she felt totally disrespected by V8, and was so upset she cried herself to sleep. On 03/12/24 12:34 PM, R98 said she never saw the CNA (V8), but she heard the incident and she was very rude to R52 and slammed the door. On 3/12/24 at 1:56 PM, V7 said based on her interviews, she considers what V8 said and did to R52 a form of verbal abuse. V7 said yelling, downgrading, and disrespecting a resident is a form of abuse. V7 said V8's statement she refers as not being serious and joking about it. V7 said, In my opinion, this is grounds for termination, not just suspension. On 3/13/24 at 9:49 AM, V1 (Administrator) said she is still working on the investigation and has not yet determined if the abuse is substantiated. The facility provided witness statements from the investigation show V8 emailed V7 her statement which states exactly as written, So yesterday at around 7/8 O clock (R52) put her light on, I went to go answer her light. She was fine but I grabbed the pull up for her & as I'm handing it to her, I simply suggested/asked why she doesn't grab her (incontinence brief) before she goes into the bathroom & that it would be easier for her in case while others are on break & I happen to be with someone else so she is not waiting on the toilet for while. I don't know if she was having a bad day or something but she starting going on an entire rant of why does everyone ask her this all the time and why am everyone is so mean to her. I responded and told her it wasn't meant to be that serious & that it was just a question. The facility provided investigation submitted to the Illinois Department of Public Health (IDPH) on 3/14/24 by V1 (Administrator) states, The facility conducted a thorough investigation pertaining to an allegation of abuse. Staff members and residents were interviewed as part of the investigation. Based on conducted interviews and review of The Abuse Prevention Program-Policy, the facility is making the determination to substantiate the allegation of abuse. V8 was attempted to be contacted by phone during the survey with no return call. The facility provided Abuse policy reviewed 1/2019 identified verbal abuse as oral, written, or gestured language that willfully includes disparing and derogatory terms to residents or families. Mental abuse includes, humiliation, harassment, threats of punishment or deprivation by a licensee, employee or agent.

Based on observation, interview, and record review, the facility failed to follow their abuse policy and procedure by not protecting R102 from abuse by not removing a staff members who's observed actions were suspected to be abusive, and not performing a full body assessment of a resident who was suspected of being abused for 1 of 36 residents (R102) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 03/14/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 03/13/24 at 1:46 PM, R102 was lying in bed on his back, with the head of the bed elevated at a thirty-degree angle. R102 had a bruise to the left cheek. On 03/13/24 at 1:46 PM, R102 said, One man hurt me here. I was grabbed and my face went into the side rail, and he punched me. I have pain to my left cheek and left arm. On 03/14/24 at 9:06 AM, V38, CNA, said, (V37, CNA) had (R102) the night of Friday (03/08/24) to Saturday (03/09/2024). At 12:30AM. (V37) asked for assistance with a combative resident. I went in to change (R102). (R102) did throw his hands up, maybe he began to resist, I could not tell, because (V37) had already grabbed (R102) and pinned him down. He had the resident's hands balled up and pinned to (R102's) chest. (R102) can be angry, but I have never seen him combative. Most people know to walk away. The next incident happened at 5:30AM. (V37) asked for help. I went to (R102) and asked him to give me five minutes to change him. (R102) agreed. (R102) usually refuses the first bed check. We just report to the nurse, then in the morning, (R102) allows it. (R102) threw his hands up and said ok. I took his hands being up as (R102) submitting to be changed. (V37) then pinned (R102's) hands to this chest. It looked like he was choking him, except he was pushing (R102's) crossed hand onto (R102's) chest instead of being around his neck. Then (V37) put more weight on him. (V37) told (R102) to turn. I said, '(V37) let him go', then I said it again. I went to get (V40, LPN-Licensed Practical Nurse). (V37) was being too aggressive, too rough. (V37) should not take care of residents anymore. (R102) looked scared; I was scared also. He looked more scared the second time (V37, CNA) tried to provided care than the first time. I think that is why (R102) threw his hands up. He was surrendering. I had never seen (R102) like that. During that time, (V40, LPN) was doing her med pass. The nurse did not know what the protocol was. (V40, LPN) said she was going to ask the other nurse. I told the nurse he put all his weight on (R102). (V37, CNA) became aggressive and put all his weight on (R102). If the patient says I don't want to be touched, we leave them alone. I reported the abuse to (V40, LPN-Licensed Practical Nurse). (V40, LPN) said she did not know the protocol. I then went to the first floor and reported the incident to (V39, Charge Nurse). The first time (12:30AM) (V37, CNA) provided care to (R102) he was too aggressive, I thought I should say something. The second time (5:30AM), I knew I needed to say something. On 03/14/24 at 9:37 AM, V39, RN Charge Nurse, said, I am the charge nurse. (V38, CNA) let me know about the incident. The incident was reported to me (03/09/2024) between 6:15 AM to 6:30 AM, (approximately six hours after the first event was witnessed). Because it was abuse, I contacted (V1-Administrator). I followed her instruction. I called the police to make a report. I did not assess (R102). The nurse on the floor did the check, I think it was (V40, LPN). I did not make any changes to the assignment sheets. We pulled (V37, CNA) off the floor when I was told, and called the police so he could talk with police, and I could get a statement from him. I pulled him off the floor around 6:30 AM to 7:00 AM. (approximately one hour after allegation of abuse was reported), when we brought him to the office. On 03/14/24 at 9:55 AM, V40-LPN, R102's Nurse said, The incident was never brought to my attention. If I would have known, I would have charted it. I believe I was (R102's) nurse; I was (R102's) nurse; I cannot recall. I do not work there anymore. I quit Monday (03/11/2024). On 03/14/2024 at 10:54 AM, V41, RN-Registered Nurse said, (V40, LPN) told me there was an incident where (V37, CNA) was restraining a resident. (V35, CNA) and I went to see (R102). (R102) told me that he was punched with a closed fist. (R102) had redness and swelling to the left cheek and his left arm was hurting. (R102) said (V37, CNA) was rough with care. (R102) never complained of forearm pain before. I would report a patient being pinned down; I would say that is abuse. On 03/18/24 at 1:36 PM, V38, CNA, said, I started in November of 2023. I have never received new hire orientation. The facility never provided me with abuse training until after the incident between (R102) and (V37, CNA). The facility requested that I amend my report. I was told I could quit, or they would terminate me for abuse and report me to the state. The facility's assignment sheet, dated 03/08/2024 through 03/09/2024, shows V40, LPN, was assigned to R102. R102's Medical Record, dated 03/09/2024, shows, R102 was not assessed for injury until after 7:40AM. The assessment was not documented until 03/11/2024 at 1:40AM. R102's Progress Notes, dated 03/09/2024 at 7:40AM, created 03/11/2024 at 1:40AM, by V41, RN-Registered Nurse, shows, received resident at 7:00 AM. Informed by night shift LPN that an incident occurred between CNA and resident during early AM hours of care before 7:00 AM. Two police officers here in building doing an investigation and interviewing staff. Resident is alleging that he was struck in the left side of his face with a closed fist by the CNA and that he was being rough during care. Resident complained of pain to his left arm. Upon assessment left cheek looks slightly swollen with a small amount of redness. Assessed left arm pain. Resident continues to have AROM (Active Range of Motion) to both upper extremities. Able to flex and extend both arms without pain. Able to lift arms above head and squeeze RN fingers without pain. Only complaint of muscle pain to top of forearm. No swelling or redness noted at this time to either arm. Informed daughter of incident. Shortly after the daughter arrived and was at bedside. RN explained at this time we will manage pain with scheduled acetaminophen and if pain worsens or other symptoms arise the RN can obtain X-Ray for left arm but at this time it is not necessary. Informed Nurse Practitioner. The facility's Abuse Policy, dated 01/2019, shows, employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately. Orientation and Training of Employees: during orientation of new employees, the facility will cover at least the following topics: What constitutes abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property; how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; an employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement; the time frames for reporting; and management's obligation to prohibit retaliation against anyone who makes a report. Physical Abuse, Conduct a full body exam, particularly in areas of resident complaint. The facility's Final Investigation Report on R102's abuse allegation of 03/09/2024 shows abuse has been substantiated. The Immediate Jeopardy that began on 03/09/2024 was removed and the deficient practice corrected on 03/14/2024 when the facility took the following actions to remove the immediacy and correct the noncompliance. 1. All staff will be educated on all types of abuse, 03/13/2024. 2. All staff will be educated on the standard of immediately reporting abuse, 03/13/2024. 3. All staff will be educated on protecting residents after an alleged abuse, 03/13/2024. 4. All staff will be educated on the components of the abuse policy, 03/14/2024. All Residents will be re-evaluated for the potential at risk for abuse or neglect, 03/14/2024. 5. As all current staff are educated, new hires will be trained accordingly and an Abuse Prevention Training Program-Post Test will be completed to assess for comprehension, 03/14/2024. 6. Any/All allegations of abuse will be brought to the IDT in Morning Meetings and reviewed in detail at weekly IDT Meetings, 03/14/2024. 7. Any/All Abuse allegations will be reviewed and monthly QAPI/Quarterly QA, 03/14/2024.

Based on observation, interview, and record review, the facility failed to assess and identify a sacral pressure injury for R13, failed to assess and identify a pressure injury to left heel and left elbow for R73,and failed to ensure a wound did not get worse to 3 of 7 residents (R13, R73 and R31) reviewed for pressure injury in the sample of 32. This failure resulted in R13 having a stage 3 acquired pressure injury, and R73 having a deep tissue injury (DTI). The findings include: 1.R13 face sheet shows R13 is [AGE] year old who was originally admitted to the facility on [DATE], with diagnoses that include dementia, diabetes, stroke and chronic kidney disease dependent on dialysis,. R13's Braden scale (predicting pressure score risk), dated 1/11/24 , shows R13 is at high risk for developing pressure. R13's skin admission assessment, dated 1/11/24 shows R13 had no pressure injury. R13's Wound Assessment details report, dated 3/8/24 show, wound sacrum, type pressure (injury), facility acquired, date identified 3/8/24 stage 3 measuring 3.0 centimeters (cm) x 1.8 cm x 0.10 cm. On 3/11/24 at 10:30AM, V17 (Wound Nurse) was in R13's room providing wound treatment to R13's sacral open wound. R13 said she has a sore in her bottom and does not how she got it. V17 said R13 was admitted to the facility with no skin irritations and no open areas. V17 said when she was informed R13 had an open area to her bottom, R13's open area was already a stage 3. V17 said she then ordered a low air loss mattress and reminded staff to turn and reposition R13. V17 confirmed there were no thorough skin assessments done to R13 prior to when R13's open area stage 3 was found. 2. R73's face sheet show R73 is [AGE] years old, who was admitted to the facility in 2019 with diagnoses that include stroke with left side paralysis hypertension and diabetes. R73's Braden scale, dated 2/16/24, shows R73 is high risk to develop pressure injury. R73's Wound Assessment details report shows, wound left heel type: pressure (injury), facility acquired, date identified 2/9/24 deep tissue injury measuring 4.0 centimeters (cm) x 2.5 cm x 0.10 cm Another R73's Wound Assessment details report shows, wound left elbow type: pressure (injury), facility acquired, date identified 3/8/24 deep tissue injury measuring 3.0 centimeters (cm) x 2.5 cm x 0.10 cm On 3/11/24 at 9:45 AM, R73 was in bed alert and pleasant. R73 said said she has wounds on both her left heel and left elbow. R73 said had pain and told the staff. The staff said the pain was due to her rubbing her heels in bed. R73 said she requested staff to check her heels, and was told she has a wound in her left heel. R73 stated, Last week when my left elbow was hurting, I requested staff to check my left elbow. Sure enough, I have a wound there too! R73 said her elbow rests in the bed since she can't move her left hand (contracted). V17 (Wound Nurse) showed this surveyor R73's left heel and left elbow that was both with deep purple discoloration, V17 said both wounds were already deep tissue injury (DTI) when discovered, and these wounds were facility acquired. R73's skin assessments for 2/24 and 3/24 did not identify R74's pressure injury until it was a DTI as confirmed by V17 (Wound Nurse) . On 3/13/24 at 9:15 AM V2 (Director of Nursing) said residents skin should be inspected daily Skin assessments should be documented in the residents medical records with the findings and not just initials. On 3/13/24 at 10AM, V21 (Wound Doctor) said, Residents that are immobile are prone to open areas. It was important to check their skin often and turn them side to side to prevent them from having pressure injuries. 45540 3. R31's Admission Record shows an admitted [DATE]. R31's MDS (Minimum Data Set) dated 1/31/2024 section GG - A. roll left and right - The ability to roll from lying on back to left and right side and return to lying on back on the bed. Admission performance coded as 02 - is listed as Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R31's Progress Notes from 1/24/2024 states resident is alert and oriented x3. Progress note states resident needs extensive assistance with ADLs and toileting. R31's Initial Wound Evaluation and Management Summary, dated 1/31/2024, shows a sacral wound stage 3 measuring 1.0 x 0.8 x 0.1 cm (L x W x D). R31's Wound Evaluation and Management Summary measurements are as follows: 2/14/2024 shows a sacral wound stage 3 measuring 2.0 x 1.1 x 0.1 cm (L x W x D) 2/21/2024 shows a sacral wound stage 3 measuring 4.2 x 2.0 x 0.1 cm (L x W x D) 2/28/2024 shows a sacral wound stage 3 measuring 4.5 x 1.0 x 0.1 cm (L x W x D) 3/6/2024 shows a sacral wound stage 3 measuring 5.6 x 2.8 x 0.1 cm (L x W x D) On 3/13/2024 at 10:30AM, R31 said facility staff do turn her, but not always every two hours. R31 said the wound doctor was in to see her and said her wound is getting worse. R31 said the doctor told her she should be turned every two hours. On 3/13/2024 at 10:02AM, V21, Wound Doctor, said R31's sacral wound was acquired outside of the facility, and has gotten worse, increasing in size since admission. V21 said he couldn't say if the wound was avoidable or unavoidable. V21 said R31 is at risk for skin breakdown. On 3/12/2024 at 12:35PM, V17, Wound Nurse, said R31 does not refuse care, and is compliant with dressing changes. V17 said she does the dressing changes normally Monday - Friday, and the nurse on duty does the dressing changes on the weekends. V17 said she is unsure why there was no documented dressing change on 3/9/2024. V17 said R31's dressing change order was changed to daily dressing changes on 3/7/2024, and should be completed daily. 3/13/2024 at 10:26AM, V12, Registered Nurse (RN), said she is assigned to R31, and she doesn't refuse treatments or medications. The facility policy entitled Skin Management Program, dated 8/23/23, shows, it is the policy that a guest (resident) does not develop pressure injury unless clinically unavoidable.

Based on observation, interview, and record review, the facility failed to ensure residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R281 requiring a re-hospitalization for [CONDITION(S)]. The findings include: 1. R281's Admission Record shows she was initially admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R281 was readmitted to the facility on [DATE]. R281's Care Plan, initiated 4/5/22, shows, The resident has [CONDITION(S)]. Monitor/document/report to MD as needed any signs/symptoms of exacerbation: dependent [CONDITION(S)] of legs and feet, peri-orbital [CONDITION(S)], short of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rated, lethargy and disorientation. R281's Care Plan, initiated 5/4/22, shows R281 is on daily weights for [CONDITION(S)]. Obtain and monitor weight report for any significant change. R281's Progress Notes, dated 8/1/22 at 2:11 PM, shows, POA (Power of Attorney) was concerned regarding resident swelling in bilateral arms and legs. MD (Medical Doctor) was informed of swelling prior labs were done and she is on a daily weight. MD order to monitor resident. Resident is stable no shortness of breath noted or discomfort. POA was still concerned and wanted resident to be evaluated at the hospital. MD gave order to send to ER (emergency room ) for evaluation and treatment. Transportation was called around 12:30 PM and will arrive in 30 minutes. POA was present and informed. Transportation arrived around 1:15 PM and was transported to [local hospital], writer called ER to give report. R281's Progress Note, dated 8/1/22 at 4:46 PM, shows, Resident admitted to [local hospital] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R281's Progress Note, dated 8/4/22 at 6:33 PM, shows R281 was readmitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R281's Progress Noted, dated 8/5/22 at 2:20 PM, shows R281 still had swelling on her legs and arms and R281 was on a diuretic. R281's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . This same record also showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R281's Weights and Vitals summary, dated 7/1/22-8/31/22, shows R281 did not have a weight done on 8/5/22, 8/11/22, and 8/13/22. R281's weight on 8/7/22 was 180 pounds. R281's weight on 8/14/22 was 188.8. (8.8 pound weight gain in seven days) R281's Practitioner Note by V25, dated 8/11/22 at 4:58 PM, shows, Patient with [CONDITION(S)] noted to bilateral hands right greater than left. She states hands have been 'puffy'. R281's Nursing Note, dated 8/15/22 at 10:11 AM, shows, Writer received call from POA requesting resident to be sent out to [said hospital] related to continued swelling and ongoing nose bleed .resident transported to [said hospital]. MD made aware of situation and agree with family. R281's Nursing Note, dated 8/15/22 7:54 PM, shows the ER nurse stated R281 will be admitted , but they are waiting for results of some labs before she gets a diagnosis. R281's Nursing Note, dated 8/27/22 at 4:00 PM, shows R281 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/30/22 at 9:29 AM V23, MD (Medical Doctor), said R281 has daily weights ordered for monitoring of her [CONDITION(S)]. V23 said daily weights is a standard order. V23 said if a weight gain is noticed, then he would increase the residents diuretic or put them on one if they are not on one already. V23 said the whole point of daily weights for [CONDITION(S)] residents is to prevent re-hospitalization s. 2. R116's Order Recap Report, dated 8/1/22-8/31/22, shows R116 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R116's Discharge instructions provided by the hospital when R116 was readmitted to the facility, dated 6/21/22, shows, Follow instruction for the Heart Failure Transfer sheet. R116's Heart Failure Transfer instructions, dated 6/21/22, shows, Daily weight. Report weight gain of three pounds in a day or five pounds in a week. R116's Order Audit Report shows an order was entered on 6/21/22 for check weight weekly x 4, then monthly one time a day every Tuesday for one month. R116's Order Recap Report shows an order was entered on 7/7/22 for Weekly weight related to [CONDITION(S)], in the morning every Friday. R116's Discharge Education sheet provided by the hospital when R116 was readmitted to the facility, dated 8/11/22, shows, If you have every been diagnosed with [CONDITION(S)], weight yourself every day and record. Notify your physician if you gain over two pounds per day or five pound in one week. R116's Order Recap Report, dated 8/1/22-8/31/22, shows an order was entered on 8/11/22 for check weight weekly x 4, then monthly one time a day every Thursday. R116's Weights and Vitals summary, dated 8/31/22, shows R116 was weighed on 6/7/22, 7/7/22, 7/8/22, 7/12/22, 7/22/22, 7/29/22, 8/5/22, 8/12/22, and 8/25/22. The facility's Weight policy reviewed on 6/21/22 shows, To establish a policy for the consistent, timely monitoring and reporting of resident weights. The facility's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. R119's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R119's Facility assessment, dated 8/5/22, show R119 has no cognitive impairment. On 8/29/22 at 9:30 AM, R119 was in bed alert. R119's left hand was contracted and was drawn to her chest. R119's left hand was tightly closed to a fist. R119 said her hand hurts, pointing to her contracted left hand. R119 said she has a sore in the palm of her left hand. On 8/30/22 at 9 AM, V5 (Wound Nurse) said R119 has a wound in her contracted left hand. The wound was a facility acquired wound. V5 said it was from R119's ring finger digging in her hand or the nails from the ring finger. R119 said the wound was discovered last 6/22, and it is still open up to now. V5 said she does R119's treatments, and the wound has not healed. R119's progress notes, dated 6/29/22, show Noted with open area with minimal bleeding and yellowish drainage. R119's electronic treatment administration record (TAR), dated 8/22, shows, Cleanse left palm with normal saline, pat dry, apply antibiotic ointment cover with foam. The TAR also show skin check weekly. There were no further assessment done on R119's wound since the last one that was done last 6/29/22, as confirmed by V5 (Wound Nurse). On 8/30/22 at 9:30 AM, V5 said R119 has no further wound assessments. V5 said the last time R119's wound assessment was when it was discovered on 6/22. On 8/31/22 at 8:55 AM, V2 (Director Of Nursing/DON) said any resident with wound should be assessed at least weekly to know if the wound had any improvement or got worst and if there is a need to change the treatment. R119's latest careplan [R119] is at risk for breakdown in skin integrity r/t impaired mobility, occasional incontinence and comorbidities including: [CONDITION(S)] w/ Lt sided residual, PVD, DM II, [CONDITION(S)], protein-calorie malnutrition, CKD stage 3, depression, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. [R119] has an open area on left hand due to contracture. The facility policy entitled Wound Evaluation and Documentation, dated 1/22, shows, 6. wounds will be evaluated, a photo taken and evaluated/assessed every 7 days. 4. R67's Wound Evaluation and Management Summary Report, dated 8/24/22, shows she has a wound on her left leg measuring 5.8 cm (centimeters) x 4.3 cm x 0.1 cm. R67's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/22 at 9:05 AM, R67's left lower leg had a dressing on it, dated 8/27/22. On 8/30/22 at 10:18 AM, V5 (Wound Nurse) said R67's dressing is supposed to be changed daily. V5 said she does not know why R67's dressing was not changed. The facility's Skin Management: Dressing Application Policy, revised on 12/19, shows, Dressings are changed as ordered by the physician or NP (Nurse Practitioner).

Based on observation, interview, and record review, the facility failed to transcribe an ordered medication, resulting in R91 missing her antidepressant medication for 14 doses for 1 of 26 residents reviewed for medications in the sample of 26. This failure resulted in R91 being sad, irritable, anxious, and wanting to cry and stay in bed all the time. The findings include: R91's Physician Order Sheet (POS), dated 8/22, shows R91 was admitted to the facility on [DATE], with admitting diagnoses including severe [CONDITION(S)] and [CONDITION(S)]. The same POS shows R91 had been an antidepressant since admission. R91's order of : [MEDICATION(S)] ER 150 MG CAP, Give 1 capsule by mouth one time a day for Depression, with original order date of 05/30/2020. R91's progress notes, dated 8/12/22, show R91 was sent to the hospital. R91 was readmitted to the facility on [DATE]. R91's hospital discharge orders, dated 8/17/22, show Summary of Discharge Medications- order resume [MEDICATION(S)] XR 150 mg 24 hour capsule ([MEDICATION(S)] XR) for depression On 8/29/22 at 9:30 AM, R91 was sitting in her wheelchair in her room. R91 said she cannot understand herself; she has been feeling down and depressed lately, and just wanted to cry all the time. On 8/30/22 at 8:30 AM, V13 (License Practical Nurse-LPN) and this surveyor went through R91's medications, and reviewed R91's electronic medication administration record (EMAR). The record shows from 8/17/22 through 8/30/22, R91's [MEDICATION(S)] XR 150 mg capsule one time a day was blank (not given), and was confirmed by V13 (LPN) V13 said R91 used to get the [MEDICATION(S)], but it has not been being given since R91's readmit on 8/17/22. On 8/30/22 at 9:30 AM, V10 (Registered Nurse-MDS) said the facility made a huge error. V10 said R91's prescribed ordered antidepressant medications of [MEDICATION(S)] ER was not carried out. V10 said R91 has not been getting her antidepressant since she came back from the hospital 8/17/22 (14 days ago) V10 said if this surveyor did not bring the error to their attention, R91 would still be not be getting her antidepressant medication up to now. On 8/31/22 at 8:50 AM, R91 was in the dining room and asked to speak to this surveyor. R91 said she was told yesterday afternoon they (staff) made a mistake on her medications. R91 said they have not been giving her antidepressant medications for 2 weeks now . R91 stated no wonder I have been been feeling different. I did not understand myself. I was sad, irritable, anxious and wanted to cry and stay in bed all the time. R91 said she had to call her brother so the brother can convince her to get out of bed even now. R91 said she told the staff how she felt. I was honest with them, I felt horrible R91's [MEDICATION(S)] Information, dated 8/31/22, provided by the facility show, Venlafexine brand name [MEDICATION(S)] is an antidepressant medication. It is used to treat major depressive disorder, anxiety and panic disorder. Due to its short half life, withdrawal symptoms are possible after abrupt discontinuation . Withdrawal symptoms include: anxiety, agitation, confusion, irritability A Medication Error Report, dated 8/30/22, shows, Type of error-missed medication upon readmission. Original Order-[MEDICATION(S)] ER 150 mg capsule one time a day. Medication given-none. Precaution taken to prevent similar error-Medication reconciliation upon admission. R91's careplan, dated through 9/6/22, shows, [R91] taking antidepressant daily related to depression. [R91] admitted to this facility with this order (2020) with intervention that include, administer antidepressant medications as ordered by physician. On 8/31/22 at 11 AM, V2 (Director Of Nursing) said R91's admitting order of her antidepressant was not carried out. All orders should be double checked to prevent medication errors. Missing doses of antidepressant medications can affect the mood and behavior of the resident and can cause withdrawal symptoms. On 8/31/22 at 11:45 AM, V23 (R91's physician) said all prescribed medications should be carried out as ordered. V23 said the Director of Nursing and Admission Nurse should have a process that all prescribed medications are carried out to prevent medication errors.

Based on observation, interview and record review, the facility failed to investigate falls, reassess residents who have fallen and determine a root cause, revise care plan interventions, and implement interventions for residents with histories of falls. These failures resulted in R1 experiencing excruciating pain and a right periprosthetic femur fracture after a fall. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. Findings include: 1. Face sheet, dated 2/3/21, shows R1's [DIAGNOSES REDACTED]. MDS (Minimum Data Set), dated 1/27/21, shows R1's cognition was severely impaired. Fall care plan, initiated 9/20/19, shows R1 was at risk for falls related to [DIAGNOSES REDACTED]. Fall Monitoring Log, dated 12/2020 and 1/2021, show R1 fell at the facility on 12/14/20 (sustaining a right [MEDICAL CONDITION]), 1/6/21, 1/8/21 (sustaining a skin tear), and 1/15/21 (sustaining a right leg fracture). R1's clinical record failed to show any fall investigations, root cause analyses, or any new fall interventions implemented to attempt to prevent further falls after R1's 1/6/21 and 1/8/21 falls. Incident Note, dated 1/15/21 at 10:30 PM, shows, At 9:20 PM a loud noise was heard in patient's room, and the staffs ran down and patient was noticed laying on the floor with head against the door and laying on his right side with legs stretched out, with his upper body pinched between the bathroom door and the room door. Upon assessment he was in excruciating pains On 2/3/21 at 1:25 PM, V2 (Director of Nursing) stated during 1/15/21 fall she heard a loud noise and she and the staff found him on the floor caught between two doors. When R1 was assessed, R1 was expressing facial grimacing. V2 stated R1 had non-skid socks on and there were 2 floor mats in place. Nursing note, dated 1/16/21, shows the local hospital emergency department informed the facility that R1 had a right femoral spiral fracture and R1 was being transferred to another hospital for further plan of care. Hospital physician note, dated 1/16/21, shows R1 was transferred to the hospital after an unwitnessed fall at the facility causing a subsequent right periprosthetic femur fracture. The note shows R1 also experienced an unwitnessed fall in December 2020 resulting in a right intertrochanteric fracture requiring an open reduction internal fixation surgery. On 2/4/21 at 2:20 PM, V7 (Physician) stated the fractures R1 acquired on 12/14/20 and 1/15/21 were the result of R1's falling and not of any confounding health variables. V7 stated he expected the facility to follow best practices and, in every case, conduct a fall investigation, perform a root cause analysis, and implement new interventions to attempt to prevent future falls for a resident. On 2/3/21 at 1:30 PM, V2 (Director of Nursing) provided R1's care plan which showed no implementation dates for any of the fall interventions. On 2/3/21 at 8:19 PM, V1 (Administrator) provided an updated care plan for R1. The updated care plan shows two fall care plan interventions, both originally initiated on R1's electronic medical record care plan and implemented for R1 on 11/27/19, were rewritten as shown: Anticipate and meet the residents needs as needed - 1/6/21; and Ensure the resident's call light is within reach and encourage the resident to ask for assistance as needed - 1/8/21. Facility Accidents and Incidents document, effective/revised 8/29/20, shows, Care Plan review .: b. The safety committee will review the incident report and preliminary investigation and implement new intervention(s) based on the environmental and/or resident conditions which may be the root cause of the accident, along with staff interview and MD (Physician) recommendation. C. If a fall or fall event continues despite new interventions, analysis will be performed to determine the appropriateness of the current interventions and implement new interventions or provide rationale as to why the current plan remains relevant. The MD should be part of this process. D. Ensure any new interventions have been entered on the resident's plan of care. 2. Nursing note, dated 1/20/21, shows R1 was readmitted to the facility with an admitting [DIAGNOSES REDACTED]. R1's weight bearing status was non-weight bearing to his right lower extremity and R1 had an incision site along his lateral right thigh with 71 staples. Serious Injury Incident report, dated 1/20/21, shows R1's care plan was updated to include the following fall interventions: 1. Resident on 1:1 staff close monitoring, 2. Floor mat placed on both sides of the bed as a landing mat . Fall care plan intervention, provided 2/3/21 at 8:19 PM, shows the care plan was updated on 2/3/21 to include R1's intervention of floor mats to be placed on both sides of his bed and R1 to receive 1:1 monitoring by staff. However, witness statements, dated 1/8/21 and 1/15/21, shows R1 had the floor mat intervention previously initiated and in place at the time of his 1/8/21 and 1/15/21 fall and prior to his care plan being updated on 2/3/21. On 2/3/21 at 11:24 AM, R1 was lying in his bed with one floor mat on the floor on the left side of his bed. There was no floor mat on the right side of R1's bed. R1 was wearing a white and gray sock on his left foot with no visible non-skid material on the bottom. V6 (Certified Nursing Assistant/CNA) was sitting in a chair in R1's doorway with her back facing R1 typing on a computer placed on a table in front of her. V6 stated she was providing 1:1 observation of R1 due to his recent fall. When asked why R1 only had one floor mat beside his bed, V6 walked to R1's bed, looked under the bed, and pulled out a rolled up floor mat which was tucked under R1's bed. V6 unrolled the floor mat and placed the floor mat on the floor to the right of R1's bed. V6 stated the mat should have been in place on the floor to right side of R1's bed. V6 examined R1's sock and stated the sock was not a non-skid sock. V6 pulled back R1's cover over his right foot and R1 was wearing a plastic boot on his right foot. On 2/3/21 at 2:00 PM, V1 and V2 stated R1 should have had a total of two floor mats in place - one on each side of R1's bed. V1 and V2 stated fall mat interventions include a fall mat placed on the right and left side of a resident's bed unless otherwise specified in a resident plan of care. V1 and V2 could not think of any residents in the facility who required only one fall mat in place.

Based on observation, interview, and record review the facility failed to ensure two residents were protected from being physically assaulted by another resident with a history of aggressive behaviors. This failure resulted in R9 punching R14 in the face and punching R15 in his chest. This applies to 2 of 3 resident (R14, R15) reviewed for abuse in the sample 15. Findings include: The facility's Abuse Investigation dated October 29, 2020, documents (R9) was found coming out of another resident's room (R14, R15) and was alleged to have been physically aggressive towards two other residents hitting (R14) in the face and hitting R15 in his chest. V17 (Certified Nursing Assistant/CNA) heard yelling coming from R14 and R15's room. R14 is alert, oriented, and bed bound. R14 reported (R9) came into his room and hit (R15) first on his chest then came towards him swinging at his face. R15 is alert and oriented and reported (R9) entered his room and hit him on the left side of his chest. On November 20, 2020 at 1:30PM, R14 was lying in his bed. R14 said, I was attacked. R14 said (R9) came into his room and punched him in the face. R14 said, He gave me a good one. R14 said he was scared and couldn't defend himself. R14 said (R9) also hit his roommate (R15). On November 20, 2020 at 3:45 PM, V17 (CNA) said on October 29, 2020 she heard R14 and R15 yelling for help. V17 said she saw R9 leaving R14 and R15's room. V17 said R14 and R15 both were upset when she entered the room. R14 and R15, both alert and oriented residents, reported R9 hit them. R14 reported (R9) hit him in his face. R15 reported (R9) hit him in his chest. V17 said after the incident R9 punched her several times in the head, stomach, and shoulder. V17 said R9 has a history of wandering and aggressive behaviors. On November 20, 2020 at 1:00 PM, V2 (Interim Director of Nursing/DON) confirmed R9 punched R14 and R15. V2 said R9 used to reside in that room and has wandering behaviors. V2 said R14 reported it was a free for all and R9 was hitting them all over the place. V2 said R9 then punched V17 (CNA) repeatedly in her stomach, face and shoulder. R9's face sheet shows he is a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set assessment dated [DATE] shows his cognition is impaired and displays verbal behaviors towards others that occur 4 to 6 days per week. R9's Wandering Risk assessment dated [DATE] shows he is a high wandering risk. R9's current care plan shows he has a history of physical and verbal aggression towards staff and co-residents with interventions include for staff to intervene before agitation escalates. The facility's Abuse Prevention Program Facility Procedures (undated) Policy states, Establishing a Resident Sensitive Environment . The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.

Based on observation, interview, and record review the facility failed to ensure safety interventions were in place for a resident who has a history of falls with injury. This failure resulted in R10 falling in her room and sustaining a right [CONDITION(S)]. This applies to 1 of 3 residents (R10) reviewed for safety in the sample of 15. Findings include: R10's face sheet shows diagnoses including displaced fracture of the neck of right femur, abnormalities of gait and mobility, lack of coordination, weakness, difficulty walking, Alzheimer's and dementia. R10's Minimum Data Set, dated dated dated [DATE] shows her cognition is severely impaired, has behaviors of wandering occurring 1 to 3 days, and is a one person assistance with transfers, bed mobility, and walking. R10's current care plan shows R10 is at risk for falls related to gait/balance problems, diagnoses of muscle weakness, and dementia. R10's care plan shows she has a history of falls. R10's interventions include to have bilateral fall prevention floor mats, offer assistance to the bathroom every two hours, and provide a safe environment, free from clutter, and adequate lighting. R10's nurse's notes dated February 15, 2020 shows R10 was found on the floor bleeding from her face. R10 was sent out to the local hospital and returned with sutures to her lip and sustained facial fractures. R10's Fall Risk assessment dated [DATE] shows she is a high risk for falls. The facility did not reassess R10's fall risk assessment after this date. On November 20, 2020 at 10:15 AM and 1:40 PM, R10 was lying in her bed. R10 did not have floor mats beside her bed. R10 was in a three person room with her bed in the middle. R10's room was cluttered. Multiple dressers were against the wall, and a chair was against the wall across from her bed. A wheelchair was beside her bed to the right, and her bedside table was to the left of her bed leaving minimal walkway in between her bed and her roommate's beds. The facility's undated Incident Report documents on September 14, 2020 at 3:30 AM, (R10) was observed on the floor in a sitting position facing her bed. The nurse immediately assessed and found no bruising, swelling or deformity, or sign of injury. At 9:30 AM, R10 had complaints of pain, stating she had a fall overnight. R10 was sent to the emergency room and found to have a displaced fracture of the neck of her right femur and required surgical intervention. The nurse's note dated September 14, 2020 (entered in at 2:43 PM approximately 13 hours later) documented V13 (Registered Nurse/RN) was called to check on (R10) at 330 AM. R10 was sitting on the chair in her room and was assisted by another nurse from a sitting position on the floor on the side of her bed with both legs extended. Denies hitting her bed and reports no pain or discomfort. R10's range of motion is in place with no shortening/lengthening and she is able to bear weight on both legs. R10 said she was going to the toilet and lost her balance getting out of bed. (R10) was assessed for signs of injury with none noted. The nurse's note dated September 14, 2020 at 8:45 AM, shows V14 (Licensed Practical Nurse/LPN) documented she medicated R10 for severe pain to her right lower extremity. At 8:50 AM, V14 documented she was alerted by the CNA (R10) was complaining of right leg pain. R10 was lying supine in her bed with her lower body twisted to the left with her right leg bent at 90 degrees. V14 asked R10 if she could move her right leg. R10 said No, not anymore. V15 notified the physician with orders received for a STAT x-ray. At 10:24 AM orders were received to send R10 to the local hospital. At 3:43 PM, V14 documented R10 was admitted to the local hospital with a right [CONDITION(S)]. The hospital records dated September 14, 2020 documents This is an [AGE] year old female resident with a history of dementia and reportedly had a fall earlier today and is complaining of right hip pain. (R10) has significant dementia and is unable to provide any reliable history. (R10) complains of pain with attempted gentle passive range of motion and with log rolling. The x-ray shows an impacted sub-capital fracture of the right femoral neck and R10 requires urgent surgical repair of her right hip. On November 20, 2020 at 1:35 PM, R13 (R10's roommate) said on September 14, 2020 around 3 AM, she was woken up by R10 screaming. R13 said when she woke up, she saw R10 lying on the floor next to the chair against the wall. R13 said she called for help and two staff members came in and lifted her on to the chair against the wall and left the room. R13 said R10 was left on the chair screaming in pain for a while until her nurse came in. R13 said two other staff members came in later and lifted her from the chair to her bed. R13 said R10 was in pain during that night. On November 20, 2020 at 2:43 PM, V15 (RN) said he was one of the nurse's on September 14, 2020. V15 said another resident was yelling out for help. V15 said he came into R10's room and she was on the floor screaming and crying. V15 said he helped R10 off the floor with another staff member and lifted her up and placed her in the chair. V15 said V13 (R10's nurse) was not in the building when R10 fell . V15 said he reported to V13 when she came back in the building of R10' fall and told her to do a further assessment. On November 21, 2020 at 8:35 AM, V13 (RN) said on September 14, 2020 she was on break when R10 fell . V13 said V15 notified her of R10's fall. V13 said when she entered R10's room she was sitting on the chair upset. V13 said she asked R10 if she hit her head or if she was having pain. V13 said R10 is only alert to herself and could not recall the events of the fall. V13 said R10 did not want to go back to bed and she left R13 sitting in the chair. V13 said when she came back to R10's room she was in her bed. V13 said she did assess R10's range of motion or if she could bear weight. V13 said R10 is not a fall risk and can get up by herself to use the bathroom. On November 20, 2020 at 2:38 PM, V14 (LPN) said she was R10's dayshift nurse on September 14, 2020. V14 said V13 reported to her R10 had fall during her shift and said she was refusing pain meds. V14 said she was alerted by a CNA of R10 complaining of pain. V14 said she entered R10's room and she was complaining of pain to her right hip. V14 said R10 could not move her right leg. V14 said she notified the physician and R10 was sent out to the local hospital. On November 20, 2020 at 1:00 PM, V2 (Interim Director of Nursing/DON) said for residents who have a fall, staff should notify the physician and assess the resident. V2 said if a resident sustains an injury they should be sent out to the local hospital. V2 said residents who are a fall risk should have fall interventions in place. The facility's Falls-Clinical Protocol Policy revised March 2018 states, The physician will help identify individuals with a history of falls and risk factors for falling . In addition the nurse shall assess and document/report the following: a. vitals, b. recent injury, especially fracture or head injury c. observing for change in normal range of motion .f. pain .based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls .

Based on observation, record review and interview the facility failed to supervise and implement fall prevention measures for a resident deemed high risk for falls. The facility also failed to follow therapy recommendations. This failure led to R1 falling and sustaining a right [MEDICAL CONDITION]. This applies to 1 of 4 residents (R1) reviewed for incidents/accidents in a sample of 10. Findings include: The Face Sheet documents R1 is [AGE] years old and has [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 5/18/2020 documents R1 has cognitive impairment and requires extensive assistance from staff for ambulation and transfers. Speech pattern - rarely or never understood. The Fall Risk Assessments dated 1/24/2020 and 5/13/2020 document R1 is high risk for falls. The Care Plan for falls documents R1 is at risk for falls related to decreased cognition, unaware of safety needs, wandering, pacing, and the use of [MEDICAL CONDITION] medication. Follow facility fall prevention policy. The incident reports show R1 fell on the following dates: 1/28/2020 at 12:05 PM - noted lying on the floor in a side lying position, Location - resident's room, no injury, no witnesses; 3/4/2020 at 10:35 AM - noted lying on the floor on her back, in pain, Location - resident room, no injury; no witnesses; 3/20/2020 at 4:00 PM - found in a sitting position in another resident's room, no injury, no witness; 5/30/2020 at 7:15 PM - heard loud noise, found resident on floor next to wheelchair, resident does not use wheelchair, Location - resident room, no witness, injury - [MEDICAL CONDITION] requiring surgery; 6/23/2020 at 13:31 PM - sliding from wheelchair - lowered to floor by staff, Location - nursing station On 8/28/2020 at 3:26 PM, V2 (Director of Nursing) was interviewed about R1's falls and care plan interventions. V2 stated R1 is non-verbal and has cognitive impairment, dementia and [MEDICAL CONDITION]. R1 requires supervision. V2 stated R1 has both receptive and [MEDICAL CONDITION]. R1 is fearful of everybody and must be shown redirection. V2 also stated R1 wanders. Prior to fall 1/28/2020, V2 stated interventions in R1's plan of care included assisting R1 to nursing station, chair and toilet. Regarding R1's fall on 1/28/2020, V2 stated R1 fell in her room and it was an unwitnessed fall. V2 stated the fall intervention was to encourage and assist to nursing station, although this intervention was already in place. Also, physical therapy referral for unsteady gait. The Care Plan also includes intervention 1/28/20 refer to physical therapy for unsteady gait. However, there was no therapy documentation in R1's medical record for this time period. The physical therapy evaluation note shows R1 was not referred until 3/4/20, after she sustained another fall. Regarding R1's fall on 3/4/2020, V2 stated R1 fell in room, the fall was unwitnessed, and R1 displayed guarding, pain. R1 was unable to communicate her needs, just says ouch. V2 stated she does not see any interventions for this fall. The care plan documented no new interventions for R1 continuing to fall in her room unwitnessed. Regarding R1's fall 3/20/2020 in which R1 was found in another resident's room on the floor, V2 stated she does not see interventions for this date. The care plan did not document interventions for this fall. Regarding R1's fall on 5/30/2020, V2 stated R1 again had an unwitnessed fall in her room. This time, R1 sustained a fractured left hip for which she was sent to the emergency room 2 days later. V2 stated V26 was the CNA (Certified Nursing Assistant) working with R1 on 5/30/20. The hospital H&P (History and Physical) dated 6/1/2020 documents: Patient has left [MEDICAL CONDITION]. This occurred 2 days ago. The left leg shortened and externally rotated, moaning with movement. Severe dementia and cannot tell what happened. The H&P dated 6/2/2020 reads: This patient requires inpatient hospital services for medical treatment or medically required diagnostic studies. The reason the patient requires hospital services is because of left [MEDICAL CONDITION]. The surgical report dated 6/2/2020 shows R1 had ORIF (Open Reduction and Internal Fixation) of displaced left intertrochanteric fracture. R1 had another fall on 6/23/2020 as a result of sliding out of chair by nursing station. V2 stated staff lowered R1 to the floor. When asked if the facility reviewed R1's fall interventions in Quality Assurance meeting and made any adjustments, V2 could not provide the information. On 8/27/2020 at 1:00 PM, V22 (Certified Nursing Assistant/CNA) was at the bedside feeding R1 lunch. R1 did not speak when spoken to. V22 stated R1 is non-verbal and confused. On 8/27/2020 at 12:15 PM, V21 (Nurse) stated R1 is confused and requires supervision. R1 ambulates per self but can go in her room alone. V21 stated R1 does not look where she is walking and just goes anywhere. V21 stated R1 does not speak and she does not know if R1 is a fall risk. On 9/3/2020 at 2:19 PM, V25 (Physical Therapist) stated there was no therapy referral for R1 on 1/28/20. R1 was referred to physical therapy on 3/5/2020 according to V25. V25 stated R1 was discharged to restorative on 3/24/2020 because she reached her maximum capacity. V25 also stated R1 was ambulating 150 ft with therapists. R1 was treated for [REDACTED]. V25 stated R1 has cognitive impairment and requires supervision for ambulation and contact guard assist with transfers. V25 also stated recommendations were given to nursing on 3/18/2020 for ambulation and range of motion restorative programming. The Electronic Health Record (EHR) did not show documentation of R1 receiving ambulation programming. The physical therapy discharge summary for 3/24/20 reads: Treatment [DIAGNOSES REDACTED]. Discharge to Long Term Care nursing and restorative. The restorative nursing recommendation dated 3/18/20 reads: Restorative and/or maintenance programs recommended at time of discharge. Please check all that apply - ambulation, active and passive range of motion. On 9/3/2020 at 3:02 PM, V10 (Restorative Nurse) stated R1 has been on active range of motion and bed mobility programming since 4/16/20. V10 stated those are the only programs R1 has been on this year. V10 checked the EHR and stated there is no other programming. V10 stated she recently started working with R1 but does not see programming for ambulation. Although V2 stated V26 was R1's assigned CNA when she sustained the fracture, on 9/3/2020 at 3:50 PM V26 stated she was not working with R1 on 5/30/20. V26 stated R1 is confused and prior to the fracture R1 would wander into other resident rooms. R1 would also ambulate in her room alone. V26 stated R1 needed everyone to keep an eye on her. On 9/2/2020 at 11:26 AM, V5 (Medical Director) stated the facility should be updating care plan interventions when residents sustain a fall. V5 added nothing is 100%, but prevention is the key. The best policy is to intervene before something happens. V5 also stated he is on the Quality Assurance Committee and does not recall the facility informing him of R1's falls. The policy for Falls reads: Treatment/Management 1). Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2). The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 4). If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current intervention.

Based on interview and record review the facility failed to implement interventions for a resident at high fall risk. This failure resulted in the resident falling while walking unattended and sustained facial fractures and a laceration to the forehead requiring stitches. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 12. The findings include: According to the Electronic Health Record (EHR) R1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] showed R1 needed extensive assistance of one staff member for walking and used either a walker or wheelchair for ambulation. The MDS showed R1 had one fall without injury since the previous MDS assessment. The MDS showed R1's cognition was severely impaired. A care plan dated 05/13/19 showed R1 was alert and oriented to person only and ambulates. A care plan dated 02/24/19 showed (R1) is risk (for) falls due to confusion, unaware of safety needs, wandering, vision impairment, ([DIAGNOSES REDACTED].She is able to ambulate independently. The fall care plan had interventions including Physical Therapy to evaluate and treat dated 04/25/19 and Physical Therapy to evaluate and treat dated 05/19/19. The care plan did not show any changes in interventions to include the Physical Therapy recommendations dated 05/06/19 for R1 to have hand hold and contact guard assistance during walking. An updated care plan for R1 having a self care deficit with interventions including to walk in the corridor with extensive one person physical assistance was not initiated until 06/11/2019, more than three weeks after R1's fall with facial fractures. The Nursing Progress Notes showed R1 had a fall on 01/18/19 in which R1 sustained a laceration to the left forehead; a fall on 04/25/19; and a fall on 05/19/19 in which R1 sustained a laceration and facial fractures. A Morse Fall Scale assessment dated [DATE] showed R1 was a high risk for falling with a score of 65. The Morse Fall Scale shows a score equal to or higher than 51 the person was at a high fall risk with an action to implement high fall risk prevention interventions. The assessment showed R1's gait was weak, stooped but able to lift head without losing balance, steps are short, resident may shuffle. The hospital emergency room records show R1 had a three centimeter laceration to the right superior orbital ridge repaired with six sutures. A Computerized [NAME]ography (CT) scan dated 05/19/19 showed R1 had right sided maxillary antral and posterior wall fractures. The posterior wall fracture was minimally displaced. R1 had a mildly depressed [MEDICAL CONDITION] orbital floor, large volume sided hemosinus, and a nasal bone fracture. The Physical Therapy evaluation dated 04/17/19 showed R1 was referred to skilled Physical Therapy due to a recent decline noted with transfers and gait. The evaluation shows R1's current level of functioning was ambulating 50 feet with minimal assistance with hand hold physical assist for safety. The Physical Therapy Progress and Discharge Summary dated 05/06/19 showed R1 needed hand held physical assist and contact guard assist due to unsteadiness when walking. The analysis of functional outcome clinical impression showed R1 was able to ambulate up to 200 feet with hand held assistance and contact guard assistance. On 07/03/2019 at 11:00 AM V10, Physical Therapist (PT), said R1 needed somebody to walk with her and they would be holding her hand for added stability. When R1 was discharged from therapy on 05/06/19 she needed hand held contact guard assist meaning someone would always be with her and they would be touching the resident at the waist and also on the arm or hand. R1 would need a gait belt at all times when ambulating. V10 said when R1 was discharged from therapy on 05/06/19, R1 was referred to restorative nursing. V10 said she would expect the care plan and care to reflect that R1 needed someone to walk with her and giving constant verbal and tactile cues for safety. At 1:49 PM V10 said the Discharge Summary mobility sections walking 50 feet with two turns and walking 150 feet may seem a little vague because they are based on a drop down box which was chosen closest to the residents current level. V10 said the drop down box does not mention hand hold or contact guard assistance so the PT recommendation for R1 was listed on the first page for Gait, Assistive Device and Gait, Level Surfaces which R1 would need hand held physical assist and contact guard assist (contact with patient due to unsteadiness). On 07/02/2019 at 2:38 PM V6, Certified Nursing Assistant (CNA), said R1 was walking down the hall on her own because she wanders. V6 said they (V6 and R1) were headed down the hallway at the same time but V6 was not assisting R1. V6 said she went into another resident room and had been in the room for approximately five minutes. When V6 returned to the hallway R1 was lying on the floor. R1 was awake and bleeding from the forehead. R1 doesn't really talk but seemed a little shaky, kept blinking her eye and trying to touch the area. On 07/02/2019 at 3:56 PM V7, Licensed Practical Nurse (LPN), recalled seeing R1 leaving the dining room after dinner with the CNA holding her hand. A couple minutes later V7 was alerted by the CNA that R1 was on the floor. When V7 arrived at R1 in the hallway she was bleeding from the forehead and another nurse was applying pressure to R1's right forehead above the eyebrow. V7 said R1 was ambulating well and was not on the list of residents needing ambulatory assistance so V7 was unsure why the CNA was holding her hand while she was walking with her. V7 said R1 did not need assistance of a walker or a wheelchair at that time. V7 said R1 was sent to the hospital emergency room and returned from the hospital the same night before the end of the shift. V7 said the CT scan did show that R1 had facial fractures. V7 said R1 was not impulsive. On 07/03/2019 at 9:46 AM V11, Registered Nurse (RN), stated R1 was ambulating in the west hallway after dinner. V11 said she was near the dining room when a CNA called out that R1 was lying on the floor toward the end of the west hallway. V11 could see blood on the floor from where she was at and immediately got the treatment cart and brought it to R1. R1 had a gash above her eyebrow and there was quite a bit of blood. V11 said R1 didn't need anyone with her and was independent for ambulation. V11 said the CNAs will ask the nurses about the type of assistance the residents need and they also have in the computer what a residents transfer and mobility status are. On 07/03/2019 at 10:15 AM V12, LPN Restorative Nurse, said the CNAs get their information from a computer program kardex tasks which were tied to the care plan. V12 said when care plan was updated then the kardex tasks are updated. V12 said R1 needed extensive assistance of one person which would need a gait belt. V12 said staff could use a gait belt for a person with limited assistance also to guide a person in the right direction. V12 said the (MONTH) 2019 MDS showed R1 needed extensive assistance of one person for walking which meant R1 needed one person to actually walk with her. According to V12, when a resident was discharged from therapy they give their recommendations to restorative and then it would be put into the residents care plan to let staff know what they should be working on with the resident. The facility's Incident Report dated 05/19/19 showed R1 ambulates independently with a steady gait. The report showed V6 (CNA) saw R1 ambulating down the middle of the hallway toward her room. On 07/03/2019 at 11:49 AM V2, Director of Nursing (DON), said R1 was ambulating independently at the time of the fall on 05/19/19. V2 said she didn't know if R1 would allow someone to hold her hand when she was walking. V2 thought R1 had always been an independent walker and was unsure if R1 needed hand held physical assist or contact guard assistance at the time of her fall. V2 said R1 just needed supervision with someone keeping an eye on her and maybe some contact guard assistance. V2 agreed that contact guard assistance would mean someone was within reach of R1 to be able to touch her. V2 said just because it said that on paper (referring to the MDS and the PT discharge summary) didn't mean that was what R1 needed on a day to day basis. V2 said the MDS was an assessment of the highest level of assistance she needed during the look back period and not necessarily what R1 needed everyday. V2 was unsure when R1 would have went from needing hand hold physical and contact guard assistance at the completion of therapy on 05/06/19 to being an independent walker when R1 fell on [DATE]. V2 was unsure what prompted R1 to need physical therapy starting 04/17/19. On 07/03/19 at 1:14 PM V2 said R1 needed the PT evaluation on 04/17/19 due to a decline in her mobility. V2 stated R1's ambulating independently care plan was reviewed and signed off 06/03/19 so that would mean R1 was ambulating independently as of that date. The care plan reviewed on 06/03/19 indicated R1 was ambulating independently, two weeks after the fall with fractures. A care plan dated 06/11/19 showed R1 needed extensive assistance of one person physical assistance with the use of a gait belt and a rolling walker with a wheelchair to follow. V2 said she did not know how to answer how R1 was ambulating independently on 06/03/19 two weeks after the fall but then needed extensive assistance of one person on 06/11/19 without any other incidents. V2 wasn't sure if the PT recommendations of the hand hold and contact guided assistance dated 05/06/19 were to taken into account or any interventions were implemented for R1. V2 said the Physical Therapy discharge note seemed to be contradictory. V2 said if there was confusion about what was meant, then she would refer to a nursing assessment for R1's ability for walking. V2 did not say she would ask therapy for clarification. V2 was unsure if a care conference was done regarding R1's mobility status after the fall. On 07/03/2019 at 12:23 PM V13, Doctor of Osteopathic Medicine (DO), said if R1 was a high fall risk and therapy made recommendations for hand holding assistance and a staff member to be walking with her to give constant verbal and tactile cues, then he would expect the staff to be following the physical therapy recommendation and have somebody walking with her. V13 said R1's fractures were caused by the fall. The facility's undated Fall Prevention Policy included once a comprehensive fall risk assessment is completed, care interventions will be planned to reverse or address each risk identified on the falls assessment instrument. Individualized fall prevention approaches will be implemented by staff and reviewed quarterly for appropriateness and as needed after each incident of fall.

Based on observation, record review and interview, the facility failed to implement appropriate and timely wound prevention measures; failed to identify, assess and implement treatment for [REDACTED]. These failures resulted in R365 sustaining a facility acquired deep tissue injury. This applies to 1 of 7 residents (R365) reviewed for pressure ulcers in a sample of 34. Findings include: The Face Sheet for R365 reads the following Diagnoses: [REDACTED]. admitted documented - initial 12/11/18, re-admit 12/27/18. The facility's wound report dated 01/07/19 documents R365 has a sacral coccygeal ulcer. There was no other skin impairment documented for R365. The skin risk assessment reads: R365 is high risk for skin breakdown. On 01/08/19 at 12:47 PM, R365 was in a wheelchair. R365 was wearing socks with no shoes. R365's legs were in a dependent position with the feet/heels pressing against the leg rests. On 01/08/19 at 1:00 PM, V7 (Care Plan Coordinator) was asked to provide R365's Care Plans. V7 stated, R365 only has Interim Care Plans. The Interim Care Plans did not document wound prevention measures. On 01/08/19 at 2:56 PM, V9 and V10 (Certified Nursing Assistant/CNAs) were asked to look at R365's skin. There was a large purple DTI (Deep Tissue Injury) noted to R365's right heel. R365's left leg was [MEDICAL CONDITION] and in a dependent position. The left lateral foot contained purple discoloration. V10 stated R365 had been placed in the chair by night shift and day shift starts at 7:00 AM. R365 was not wearing any anti-embolic/protective stockings. There was no offloading of R365's feet and no protective device for the heels noted. On 01/08/19 at 03:11 PM, V4 (Wound Care Nurse) stated, Residents are initially assessed by the floor nurse, then I look at everybody that comes in within 72 hours, the next day if I am available. V4 stated R365 has no other skin impairments other than the sacral wound. On 01/09/19 at 09:32 AM, R365 was sitting in a wheelchair. R365 was complaining of pain. R365's right heel was again pressing against the base of the foot rest and the left lateral foot was pressing against the side of the foot rest. R365 was only wearing socks on both feet. R365 had no offloading device and the legs were in a dependent position. V4 was asked to look at R365's feet. Located on R365's left lateral foot was purple bruising at the location where the foot was against the wheelchair. V4 lifted R365's right heel off the wheelchair and there was a large area of skin impairment that was purple around the outer edges and the center was brown. V4 stated, That's a Deep Tissue Injury (DTI). V4 measured the wound and stated, It's 1.7 X 3.5 cm. R365 stated, This has been going on and on. It has been bothering me since I've been here. I can't get my shoes on because the foot is swollen and my shoes are too tight. R365 stated R365 has been in the chair since early morning. R365 stated R365 has not had any special stockings on. V4 stated, R365 is supposed to have (tubular shaped) grip stockings on at all times and offloading of the feet. When asked what caused the DTI, V4 replied, I'm going to be honest. It's because R365 has [MEDICAL CONDITION] and is not properly offloaded. I will notify the wound doctor and order heel protectors. We don't document anything on the left lateral foot because it blanches. V4 then had R365 placed in the bed. V4 printed a Wound Care Plan for R365 which documented: 12/12/18 - R365 is at risk for breakdown in skin integrity related to mobility. Target Date: 03/12/19. There was no documented intervention related to (tubular shaped) grip stockings or offloading of R365's heels. On 01/09/19 at 09:59 AM, V9 (CNA) stated she got R365 up in the morning. V9 stated, R365 only get socks. R365 does not get any ted hose or (tubular shaped) grip stocking. I noticed the purple on R365's foot days ago. The nurses already know about it; they are aware. I've seen R365's foot swollen. V9 stated R365 did not have on stockings when she got R365 dressed. Upon re-entry into R365's room, R365 was in bed with the covers pulled up. R365s feet were on the mattress. R365's heels were digging into the mattress. R365's feet were not offloaded. V4 (Wound Nurse) stated R365 should have pillows to offload the extremities. R365's Nurse's Notes for Jan/2019 showed no documentation or assessment related to DTI. The POS (physician's orders [REDACTED]. Offload heels at all times. On 01/11/19 at 09:27 AM, R365 did not have a completed MDS (Minimum Data Set). The Electronic Health Record (EHR) listed R365's MDS as in progress for ARD (Assessment Reference Dates) of 1/3/19 (5 Day) and 1/10/19 (14 Day). V13 (MDS Coordinator) was then asked about the incomplete MDS for 1/3/19. V13 stated, The MDS should be done. I will work on it today. On 01/11/19 at 10:47 AM, V20 (Wound Care Physician) stated the facility informed him on 01/09/18 about the DTI on R365's heel. V20 stated he was not informed about discoloration on R365's left lateral foot but will reassess R365. When asked about preventive measures to protect R365's heels, V20 stated, R365 needs cradle boots and offloading. All of that was already in place. (Brand Name tubular shaped) grips (stockings) are standard (which were not implemented on 1/8-1/9, 2019). V20 stated R365 should have turning and repositioning every 2 hours. V20 also stated R365 has tissue perfusion. V20's Focused Wound Exam dated 1/10/19 reads: Unstageable DTI of the right, medial heel. Wound Size 1.5 X 2.0 cm, Surface Area: 3.00 cm, Blister: Blood filled. On 01/11/19 at 11:31 AM, V21 (Primary Care Physician) stated R365 requires elevated feet and antiembolic stockings. V21 stated R365 should have offloading to protect the heels. V21 stated the cause of the DTI could be related to the foot being against the wheelchair or banging against the furniture or something. The policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol reads: Documented assessment and protocol for pressure ulcers. The policy did not address preventive measures or types of pressure ulcers. On 01/11/19 at 01:56 PM, V2 (Director of Nursing) stated the facility has provided the entire wound care policy. V2 stated, There's nothing else.

Based on observation, interview and record review the facility failed to ensure that a resident was safely transferred by staff. This applies to 2 of 13 residents (R1 and R14) reviewed for falls in a sample of 14. This failure resulted in (R1) sustaining a Right Distal Femur Fracture. The findings include: 1. R1's Face Sheet shows resident is a [AGE] year old female with the following Diagnoses: [REDACTED]. R1's Minimum Data Set (MDS) assessment dated (MONTH) 1, (YEAR), shows R1's cognitive status is mildly impaired. The MDS also shows R1 has limited range of motion to bilateral lower extremities and is totally dependent on (2) staff members for transferring resident with mechanical lift. R1's Care Plan dated (MONTH) 11, (YEAR) shows R1 requires total assistance with transferring and not able to bear weight for a short period of time on bilateral lower extremities and requires (2) person assist with mechanical lift related to decreased mobility and abnormality of gait and mobility. The Facility's Incident Investigation Report faxed to the Illinois Department of Public Health shows R1 has bilateral lower extremity contractures. V14 CNA (Certified Nursing Assistant) came to R1's room at around 11 AM on (MONTH) 16, (YEAR) to get R1 out of bed. V14 stated she lowered R1's bed level to the level of her wheelchair, had the wheelchair positioned next to the bed and pivot transferred R1 out of bed to the wheelchair. In addition, on (MONTH) 17, (YEAR), R1 was interviewed by V2 (Director of Nursing) while at the hospital. R1 stated that V14 got her up for lunch, not at 8:00 AM as she originally told V3 (ER Physician). R1 stated V14 dropped her on the side of the bed and then V14 was able to pick her up and put her in the wheelchair. On (MONTH) 23, (YEAR) at 10:30 AM, V2 DON (Director of Nursing) stated R1 is to be transferred via mechanical lift which requires (2) staff members. V14 was the one who transferred R1 by herself doing a pivot transfer versus using a mechanical lift per R1's Care plan. V2 stated she spoke to V5 (R1's POA) and V2 told V5 the fracture did not necessarily happen from the transfer but could have been caused by movement such as the transfer. V2 stated V14 was hired on (MONTH) 24, (YEAR) and was terminated on (MONTH) 19, (YEAR) for improperly transferring R1 by herself instead of using a mechanical lift which requires (2) people. V2 stated V14 did not transfer R1 according to her care plan. V2 stated the only thing that was different in R1's routine on (MONTH) 16, (YEAR) was the improper transfer. On (MONTH) 23, (YEAR) at 3:00 PM, V8 (emergency room Case Manager) stated, R1 came to the emergency room at approximately 8:40 PM on (MONTH) 16, (YEAR). R1 stated she was dropped by the CNA (Certified Nursing Assistant) at approximately 8:00 AM. Facility told us in report they were unsure of how the resident broke her femur and the resident complained of pain to her lower extremities after lunch. The time frame of when she discussed her pain level with the nurse and when she came to the emergency room is a lot of uncounted hours and the major concern was the resident was on blood thinners. R1's X-ray report dated (MONTH) 16, (YEAR) faxed to the facility at 4:45 PM shows R1 has an old healed impacted fracture through the left distal femur and acute displaced impaction [MEDICAL CONDITION] distal femur. On (MONTH) 23, (YEAR) at 7:36 PM, V3 (emergency room Physician) stated, R1 was clear in saying that 'the CNA (Certified Nursing Assistant) helped me up by herself and did not use a lift and she dropped me.' V3 stated she moved R1 a little bit and she was having pain. V3 stated, I was confused if the resident had fallen in the morning why she is now just coming to the ER is the evening. The report to our hospital emergency room nurse was inconsistent on what happened to the resident. The facility nurse stated she did not know what happened to the patient of how or why her femur was broken. It is possible the transfer contributed to the resident's broken femur. V3 stated after consulting with the Orthopedic surgeon, I cannot see how the resident could break her femur because it is such a hard bone without some type of accident occurring. Another thing I was concerned about was the resident is on blood thinners and if the resident did have pain say in the afternoon why did it take till later in the evening to bring her to the emergency room . This whole issue with this resident is suspicious. The resident arrived to the emergency room at approximately 8:40 PM. R1's Hospital Orthopedic Consultation dated (MONTH) 17, (YEAR) documents the patient appears alert and orientated, though difficult to understand answers to some questions due to her speech pattern. The patient apparently is a non-ambulatory and has chronic bilateral lower extremity contractures and is wheelchair bound. The patient appears to have sustained a right distal fracture that is related to her fall. 2. R14's Face Sheet shows the resident with the following Diagnoses: [REDACTED]. R14's Minimum Data Set (MDS) assessment dated (MONTH) 1, (YEAR), shows R14's cognitive status is severely impaired and needs extensive assistance of 2 staff members for bed mobility, transfers, toilet use and bathing. R14's Care Plan dated (MONTH) 24, (YEAR) shows resident requires extensive assistance with transferring of 2 staff members related to decreased mobility and memory deficits. The Facility's Incident Investigation Report faxed to the Illinois Department Health shows on (MONTH) 20, (YEAR) at approximately 6:00 AM, V16 CNA (Certified Nursing Assistant) transferred R14 from her bed to the wheelchair, and during the transfer R14 became weak and V16 lowered her to the ground. V16 did not look at the transfer status of the resident. V16 stated she didn't think she needed to tell the nurse of this incident. On (MONTH) 25, (YEAR) at 9:00 AM, V2 DON (Director of Nursing) stated V16 did a one person pivot transfer on R14 and this resident is a 2 person staff member assist with a transfer belt. V2 stated if a CNA lowers a resident to the ground, they must tell a nurse and that nurse will assess that resident immediately for injuries. V16 was terminated for failure to transfer a resident in accordance with resident's plan of care and failure to report an incident involving a resident. The facility staff are reminded that no work shall be performed in an unsafe manner and employees must follow the policies and procedures of the facility. The Facility's Safe Lifting and Movement of Residents shows: In order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents . Staff responsible for direct resident care will have knowledge of residents' transfer, as well as how to tell what a resident's transfer status is . Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. The Facility's Fall Prevention Policy undated, shows individualized fall prevention approaches will be implemented by staff. The Facility's Accident and Incident Policy and Procedure undated, shows all accidents and significant injuries involving residents, staff and visitors will be documented and reported. A significant incident is defined as any incident that is unexpected or has an unexpected outcome. All employees, including contract personnel has to complete an incident report . Incidents include but is not limited to employee, resident, family members and or visitors resulting from accidents or errors.

Based on observation, interview and record review, the facility failed to conduct a comprehensive assessment to identify the root cause for the development of a resident's facility-acquired pressure sore, failed to develop an individualized plan of care and interventions to address the identified pressure sore and ensure physician orders [REDACTED]. These failures resulted in R5 acquiring unstageable bilateral heel pressure ulcers and R6 acquiring unstageable deep tissue injury vs stage 4 right heel pressure ulcer. This applies to 2 of 3 residents (R5, R6) reviewed for pressure sores in the sample of 19. The findings include: 1. On (MONTH) 12, (YEAR), R5 was sitting in his wheelchair wearing socks and shoes on his feet. V4 (CNA/Certified Nursing Assistant) and V5 (CNA) transferred R5 to his bed. V4 removed R5's shoes. R5's socks were soaked in the heel area of both feet with a pink colored fluid. V4 removed R5's socks. The dressing on R5's right heel was bunched up around R5's ankle, and a large wound was exposed and open to the air. V5 said, The dressing probably came off when his sock was put on this morning. Both heel dressings were dated 9/11. V4 and V5 covered R5 with a blanket and left the room. They did not replace R5's socks or offload R5's heels from the bed using a pillow or foam boots. R5 was continuously observed until 12:20 PM. R5's heels were not offloaded at any time during the observation period. On (MONTH) 12, (YEAR) at 11:45 AM, V4 said, I'm not sure if (R5) needs to wear foam boots while he's in bed. I think he just wears them at night. We did not put them on him this morning when I put him back to bed. I did not tell the nurse his dressing was wet or had come loose. The EMR (Electronic Medical Record) shows R5 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R5's MDS (Minimum Data Set) dated (MONTH) 13, (YEAR) shows R5 has severe cognitive impairment and requires extensive assistance by two facility staff members with transferring, bed mobility, and locomotion. R5 is totally dependent on facility staff for dressing, hygiene, bathing, and toileting, and is always incontinent of bowel and bladder. R5's POS (Physician order [REDACTED]. R5's care plan for risk for skin breakdown, initiated (MONTH) 22, (YEAR), shows: pressure injury of the left heel dated (MONTH) 9, (YEAR) and pressure injury to right heel dated (MONTH) 3, (YEAR). Interventions include identify/document potential causative factors and eliminate/resolve where possible. The facility did not have any interventions on the care plan to address offloading R5's heels or repositioning every 2 hours. V11's (Wound Doctor) documentation dated (MONTH) 17, (YEAR) shows: Initial Wound Evaluation and Management Summary. Unstageable (due to necrosis) of the left heel. Etiology: pressure. Wound size (Length x Width x Depth) 0.3 x 0.5 x 0.1 cm (centimeters). V11's documentation dated (MONTH) 7, (YEAR) shows: Site 1: Unstageable (due to necrosis) of the left heel. Wound size (L x W x D) 0.3 x 0.3 x 0.2 cm. Site 3: Unstageable (due to necrosis) of the right heel. Etiology: Pressure. Wound size (L x W x D) 4.0 x 6.0 x not measurable cm. V11's documentation showed R5's heel wound was debrided the same day. On (MONTH) 11, (YEAR) at 1:57 PM, V12 (Wound Nurse) documented the following measurements of R5's pressure ulcer: Right heel: 5.0 x 6.2 x unknown (L x W x D) centimeters. On (MONTH) 12, (YEAR) at 2:43 PM, V12 was observed providing wound care to R5. V12 removed R5's socks and observed the dressing on R5's heel bunched up over R5's ankle, and the wound on R5's foot completely exposed. The dressing was dated 9/11. V12 stated the dressings were wet with a pink-tinged fluid. V12 said she was not notified by any facility staff that the dressing was not in place earlier in the day. V12 said R5's heels should be offloaded at all times, and facility nursing staff should replace any dressings that come off or are wet with drainage. V12 assessed R5's right heel wound and said, This looks much worse than yesterday. The wound appears larger, and is beefy and red, and the skin around the wound also appears red. I will have to notify the physician and get different orders. V12 measured R5's right heel wound and obtained the following measurements: 6.80 x 6.70 x unknown centimeters. 2. On (MONTH) 12, (YEAR) at 9:44 AM, R6 was sitting in a high-back wheelchair. R6 had a foam boot on his right foot. R6 did not have a foam boot on his left foot. R6's right and left feet were resting against the foot rest of the high-back wheelchair. R6 was observed on (MONTH) 12, (YEAR) from 9:44 AM to 1:15 PM. R6 remained with a foam boot on his right foot, no foam boot on his left foot, and both feet resting against the foot rest of the high-back wheelchair. R6 was never observed moving his extremities, making position changes, or kicking his legs. On (MONTH) 12, (YEAR) at 1:00 PM, R6 was sitting in the dining room eating lunch. R6's diet ticket showed double protein portion. Facility staff said the resident had not eaten any food off the plate since it was served. V13 (Dietitian) and V14 (Assistant Dietary Manager) came to R6's table and confirmed R6 had not been served a double portion of protein. V13 said she recommended double protein portions for R6 to promote wound healing. The EMR shows R6 was admitted to the facility in (MONTH) 2013 with multiple [DIAGNOSES REDACTED]. R6's MDS dated (MONTH) 20, (YEAR) shows R6 is totally dependent on two facility staff for bed mobility, transfers, hygiene, bathing and toileting. R6 has an indwelling urinary catheter and is always incontinent of bowel. R6's POS shows an order dated (MONTH) 6, (YEAR): Off load heels at all times every shift and an order dated (MONTH) 30, (YEAR) for Vitamin C 500 mg. daily and add double portion protein with all meals and peanut butter and jelly sandwich with all meals. R6's care plan for risk for skin breakdown, initiated (MONTH) 14, (YEAR) shows: 7/16/2018 Pressure ulcer to right heel. Interventions added on (MONTH) 5, (YEAR) include off load heels as tolerated. The facility did not have interventions regarding repositioning R6 every two hours or keeping R6's heels from resting on the foot rest of the high-back wheelchair when R6 was out of bed. V11's (Wound Physician) documentation for R6 dated (MONTH) 20, (YEAR) shows: Initial Wound Evaluation and Management Summary. Site 1: Unstageable DTI (Deep Tissue Injury) of the right, posterior heel. Etiology: Pressure. Wound size (L x W x D) 5 x 6 x Not measurable cm. Blister: Blood filled. V11's documentation dated (MONTH) 7, (YEAR) shows R6 was provided with wound debridement of the right heel pressure ulcer. Site 1: Stage 4 Pressure Wound of the right, posterior heel. Etiology: Pressure. Wound size: 6 x 6 x not measurable cm. V13's (Dietitian) documentation for R6 dated (MONTH) 27, (YEAR) shows multiple recommendations due to the newly diagnosed deep tissue injury, including adding daily Vitamin C, double protein portions three times daily to promote wound healing. On (MONTH) 11, (YEAR) at 3:57 PM, V12 (Wound Nurse) said, (R5) developed heel wounds at the facility. (R6) stays up in the chair a lot, from breakfast to bedtime. He was in a smaller high-back wheelchair, but we ordered him a larger one because he is so tall. Both of heels are supposed to be offloaded. The plan is for him to lay down between meals. On (MONTH) 12, (YEAR), V11 (Wound Doctor) said, I would expect the facility staff to follow all recommendations, including offloading heels and dietary recommendations. Anywhere that is putting pressure on (R5's) heels will contribute to his wounds. If they weren't offloading his heels, that would be the cause of pressure ulcers. The same goes for (R6). He should be getting double protein portions to help with wound healing. I have noticed an increase in facility-acquired pressure ulcers on the same floor (R5) and (R6) reside. The residents need to be repositioned. On (MONTH) 13, (YEAR) at 1:28 PM, V3 (Medical Director) said, I would expect facility staff to follow physician orders [REDACTED].

Based on observation, interview, and record review the facility failed to conduct a pressure ulcer risk assessment and to analyze the root cause of R 4 ' s development of facility acquired pressure injury. Failed to develop an individualized plan of care and interventions to address the identified new areas of R 4 ' s pressure injuries and failed to provide off-loading devices to prevent the development of additional pressure injuries. This resulted in R 4 acquiring an unstageable pressure injury on the coccyx and deep tissue pressure injuries on R 4 ' s right and left elbow that the facility was not aware. This applies to one of one residents (R4) reviewed for acquiring pressure injury in the sample of 26. The findings include: On January 17, 2017 at 11:15 AM, R 4 was in bed alert and oriented. R 4 ' s head of bed was at 45-degree angle, with oxygen via nasal cannula. R 4's elbows were noted resting on the mattress; R 4 was also noted to use her elbows in trying to reposition self. R 4 explained, I was admitted here 3 months ago (November 3, 2016), then a month ago I was told (by the staff) that I developed a wound on my buttocks. I need assistance with almost everything even with repositioning. I easily get short of breath but waiting for staff to help is almost impossible. I know I am sitting directly on my sore (coccyx) and it hurts, I do the best I can to change my position but as I said I get tired easily. Yes, I turn my call light on but you wait and wait and wait for an hour or so before someone comes to help you. The facility most current weekly pressure ulcer report dated January 13, 2017 showed R 4 acquired an unstageable pressure injury on the coccyx on December 14, 2016 measured at 1.3 cm X 2.4 cm. On January 17, 2017 at 2:00 PM, E 8 (Treatment Nurse) explained that this wound (coccyx) was unstageable when it was initially noted; the wound was covered with yellow slough. On January 17, 2017 at 3:20 PM, E 8 (Treatment Nurse) was observed during skin assessment. E 8 identified the wound located on R 4 ' s coccyx, E 8 described the wound with 90% (thick) yellow slough measured at 2.1 cm X 2.3 cm (increased in size in 4 days). Two new areas of deep tissue pressure injuries were noted (1) right elbow measured at 2.2 cm X 2.3 cm and on the left elbow measured at 3.0 cm X 2.3 cm. E 8 explained that these areas on the elbows are new and she (E 8) was not informed or made aware of. E 8 also stated that the staff were supposed to do a skin check on the weekend, then the staff will give her the completed form (skin assessment) every Monday but she (E 8) has not received any form for R 4. E 8 expressed that these areas on the elbows could have been prevented if they were off loaded or if elbow protectors were applied. The face sheet showed R 4 was admitted at the facility on November 3, 2016 with [DIAGNOSES REDACTED]. R 4 ' s most current Minimum Data Set, dated dated dated [DATE] showed R 4 needs extensive assistance with 2 physical assist for transfer and of her activities of daily living ' s. R 4 ' s Braden scale for predicting pressure sore risk dated November 3, 2016 (upon admission) and on December 15, 2016 showed a score of 17 (at risk). The instruction on this form (Braden) showed that this form would be completed upon admission/ re admission and then weekly X 4 . On January 19, 2017 at 2:10 PM, E 2 (Director of Nursing) and E 8 agreed that the staff were supposed to do the risk assessment weekly for four weeks but this was not followed. E 8 stated that the facility has not conducted a comprehensive assessment to analyze the root cause for the development of R 4 ' s unstageable pressure injury on the coccyx. E 8 was unable to present a preventative skin care plan for R 4. E 8 stated, I am not sure if she has that. R 4 unstageable pressure injury (coccyx) care plan was not individualized based on R 4 ' s identified needs. On January 19, 2017 at 3:00 PM, the facility has not developed a plan of care on the new areas of pressure injuries on R 4 ' s elbows identified on January 17, 2017. On January 19, 2017 at 3:30 PM via phone, Z 1 (Nurse Practitioner), stated she was not informed by the facility about the deep tissue pressure injuries on R 4 ' s elbows. Z 1 said, of course it can be prevented!

Based on interview and record review the facility failed to prevent a fall with fracture for one resident. The facility also failed to incorporate fall interventions to prevent falls and injuries. This applies to one (R3) of three residents reviewed for falls with injury in the sample of six. This failure resulted in R3 sustaining a tibial plateau fracture and still unable to bear weight 4 months post fall. The findings include: R3 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15 on her 4/22/15 MDS(Minimum Data Set) showing her to be completely cognitively intact and interviewable. On 1/12/16 at 10:00 AM R3 stated on 8/24/15 she was in the shower room with a CNA(Certified Nursing Assistant). R3 stated she was transferring from her wheelchair to the shower chair by herself as she always did. R3 stated it was a newer shower chair and taller than the old ones and she could not get her buttocks onto the chair and fell to the ground. R3 stated she did not have a gait belt on and the CNA was not physically assisting her. R3 stated she broke the bone under her knee cap and now can't bear weight. R3 states she has not been to the shower room since the incident she just gets a bed bath now. R3 also stated she still can't bear weight on her leg so the staff have to use a mechanical lift to get her out of bed where as before the fall she was able to pivot and transfer from the bed to the chair. Incident report of 7/1/15 shows R3 was in the shower room with a CNA and lost her balance and fell sustained an abrasion to her back. There was no mention or use of gait belt. On 1/12/16 at 10:00 AM R3 stated she didn't use a gait belt. She would just hold onto the chair and pivot and turn to get to the shower chair. R3's 4/22/15 MDS under transfers documents R3 required extensive assistance from one person. The bathing section shows her to need physical assistance from one person for bathing. R3's care plan dated 12/29/15 documents R3 is at risk for injury related to falls due to decreased strength and endurance, right tibial fracture. One of the interventions dated 7/1/15 documents R3 needs the assistance of two for transfers during showers and then on 8/24/15 R3 is documented to need a mechanical lift for transfer. There is no other transfer information on the care plan. On 1/12/16 at 1:00 PM E2 (Director of Nursing) stated R3 required the assistance of one person for transfers with a gait belt. E2 stated she did not know if R3 had a gait belt on during the shower transfer on 8/24/15 but would expect the staff to use one when someone is determined to require the assistance of one person for transfers. E2 also stated R3 was listed as needing two persons to assist for shower transfers on 7/1/15 after the fall incident on 7/1/15 in the shower. Two person assistance for shower room transfers was added as the intervention but not shown to be discontinued. R3's fall risk assessment at that time showed her to have a fall risk score of 20 which is high risk. R3 was already a high fall risk with the 7/1/15 shower fall and no gait belt was shown to be used. R3 sustained a second fall again in the shower and no gait belt was used and she sustained a fracture. There is no documentation to support staff were inseviced on proper and safe transfers of residents. There were no care plan update interventions to support the prevention of falls and healing of R3's current fracture.

Based on observations, interviews, and record reviews the facility failed to transfer one resident according to policy and procedures (R29) and failed to provide specific safety measures for a confused resident with numerous falls (R13) from a total of 10 residents reviewed for falls from a total sample of 29. As a result of these failures, R29 was transferred improperly and sustained a fracture of the right humerus. The Findings Includes: 1. Review of the closed record of R29 documented that the resident had a [DIAGNOSES REDACTED]. The radiology report dated 1-14-14 documents under findings, "There is a surgical neck fracture of the right proximal humerus." On 1/16/2014 at 10:15 AM E2 (Director of Nurses) stated during interview that the facility investigation had indicated that R29 had been inappropriately transferred by staff. E2 also added that staff did not use a gait belt when they transferred R29. E2 stated that she had interviewed the two staff persons involved and they demonstrated how they transferred R29 by holding the resident on the right arm and in the axilla area. Both E6 (Certified Nursing Assistant/CNA) and E8 (CNA) admitted to E2 that they had not used a gait belt during transfer of R29. E2 stated that E6 and E8 placed R29 into bed and R29 didn't complain of pain. E2 continued on to say that the CNA on 11 PM to 7 PM shift (E9-CNA Certified Nurse Aid) noticed R29's arm was swollen while giving morning care and reported it to the nurse who assessed the resident, notified the physician, and obtained orders for x rays of the area. The results of the report were a fracture of the right humerus. R29 was then discharged to the hospital for treatment. On 1/16/2014 at 1:10 PM E9 stated during interview that she had cared for R29 and was the person who found the right arm to be swollen when she was getting the resident up for the day. E9 stated that staff are instructed to use gait belts to help residents transfer and are randomly monitored to make sure they follow the policy. R29's care plan dated 12-11-13 documents under Problem, "requires extensive assistance with 2 staff at all times...she is noted with shakiness upon transferring." and under interventions, "Use a gait belt during all transfers." R29's MDS (Minimum Data Set) assessment dated [DATE] codes R29 as needing extensive 2 person assistance for transfers. The facility policy: Transfers Using Gait Belt (One or Two-Person Assist), on step 7 clearly instructs staff ... " (DO NOT hold under the arms) " . 2. R13's Admission Face Sheet showed she is a [AGE] year old female with [DIAGNOSES REDACTED]. The facility's Incident Report showed R13 fell on the following days: 12/14/13 at 9:30 AM, 12/07/13 at 10:45 AM, 10/17/13 at 4:30 AM, 8/09/13 at 12 AM, 7/31/13 at 3 AM, 6/16/13 at 2 PM, 5/05/13 at 9 PM and 5/25/13 at 3:45 AM. R13's care plan showed multiple fall occurrence was a focus of concern in her care. R13's care plan showed no nursing interventions/approaches to supervise or prevent R13 from falling. The approaches implemented focused on re-educating and reminders for R13 to call and wait for staff. R13 has Dementia and may not remember to follow safety instructions. R13's care plan showed chair and bed alarms were applied on 5/5/13 and 5/20/13, but R13 continued to have fall occurrences. The facility's Fall Policy, not dated, showed: While preventing all unusually occurrence is not possible, it is this facility's policy to act in a practical manner to identify and assess those residents at risk for incidents and accidents, plan for preventable strategies..." R13's CNA (certified nurses aide/E3) was interviewed on 1/23/14 at 12:15 PM. E3 said that R13 had periods of confusion, and R13 forgets. E3 stated, R13 can tell me when she needs to go to the bathroom but R13 tries to go to the bathroom by herself, or leave her room. R13's nurse (E4) was interviewed on 1/22/14 at 12 PM. E4 stated R13 is confused and at risk for falls. E4 said that R13 was not compliant with asking for help before transferring herself. The director of nursing (E2) was interviewed on 1/23/14 at 2:30 PM. E2 said she investigated all of R13's falls (listed above). E2 said she made changes to R13's care plan after each fall occurrence. E2 stated she re-educated R13, reminder R13 not to get up unassisted, and put alarms on her. E2 could not explain how the alarms prevented R13 from falling when she was already out of the chair when they sounded, and had not been effective in the past. E2 did not identify any other specific staff interventions/monitoring to prevent R13 from falling.

Based on observation, interview and record review the facility failed to identify and respond to significant and insidious weight losses, failed to ensure that nutritionally high risk residents received assistance with meals, failed to respond to dietary recommendations, failed to complete nutrition assessments, and failed to have care plans in place for nutritionally high risk residents and residents with weight loss. This applies to 16 of 16 residents reviewed for weight loss (R6, R15, R21, R19, R16, R14, R9, R18, R7, R12, R10, R23, R13, R17, R4, R25) in the sample of 27, and 34 residents (R43, R44, R45, R47, R48, R49, R50, R51, R52, R53, R28, R87, R30, R54, R41, R46 R73, R33, R89, R88, R90, R91, R92, R93, R94, R95, R96, R97, R98, R99, R100, R102, R103, R104) in the supplemental sample. The findings include: A total of 26 residents had significant weight losses in January 2013 and February 2013 based on data calculated from the facility's "Weight Report Form for 2/1/12 - 2/11/13." The following residents had a significant weight loss of 5% or greater in 1 month: R43, R15, R44, R45, R21, R47, R19, R48, R49, R50, R51, R16, R52, R53, R28, R87, R30, R54, R41, and R14. The following residents had a significant weight loss of 7.5% or greater in 3 months: R46 and R9. The following residents had a significant weight loss of 10% or greater in 6 months: R7, R73, R12, and R33. This represents 14.5 % of residents residing in the facility with significant weight loss. Additionally, there are 20 residents with insidious weight loss over the past 6 months - 1 year based on data calculated from the facility's "Weight Report Form for 2/1/12 - 2/11/13." These residents are: R10, R89, R88, R90, R91, R92, R93, R94, R95, R23, R6, R96, R97, R98, R99, R100, R102, R103, R13, and R104. The total number of residents with weight loss (significant + insidious) is 27.9 %. On 2/27/13 Z4 (Dietitian) stated that she is "not involved" in the facility's weight loss prevention program and does not attend any quality assurance meetings at the facility. 1. R14 is a [AGE] year old resident who had a significant weight loss of 6.6% in the last month (1/4/13 - 2/11/13) according to the facility's Weight Report Form dated 2/1-2/11/13. In November 2012 R14 also had a significant weight loss of 8.5% in 3 months. R14's current weight is 70 pounds (2/11/13). R14 has a current diet order for Pureed, No Concentrated Sweets, No Added Salt, Skim Milk at meals, and supplement orders for Resource 2.0, 120 milliliters (mL) 4 times a day, according to the February 2013 physician's orders [REDACTED]. R14 has also been on [MEDICATION NAME] 40 mg (milligrams), an appetite stimulator, since 10/28/12, according to the POS. The Dietitian (Z4) made recommendations to discontinue R14's dietary restrictions of No Concentrated Sweets, No Added Salt and Skim milk on 10/25/12, 11/27/12, and 12/13/12 in order to "encourage intake" according to Nutrition Notes. These recommendations were not acted upon. No rational was documented regarding the reason that these recommendations were not initiated. There is no care plan that addresses R14's nutrition or weight loss, according to review of all care plans for R14. R14 consumed 25 - 50% at most of her meals (75% of the time) from 12/30/12 - 2/2/13, according to review of the facility's Meal Intake Log. On 2/25/13 R14 was sent to the hospital because of mental status changes and was diagnosed with [REDACTED]. R14's BUN (blood urea nitrogen) was elevated at 32 (normal range 6-26), according to hospital lab records dated 2/25/13. During an interview with Z4 (Dietitian) on 2/27/13, Z4 stated that she does not have time to follow-up on her dietary recommendations. 2. R12 is an [AGE] year old resident with [DIAGNOSES REDACTED]. R12 entered the facility in 2007 and had a gastrostomy tube placed 12/29/09. Review of R12's records show that over the last 12 months from 2/7/12 until 2/6/13 she has had a severe weight loss of 11% in 6 months, and a total of a 26 pound weight loss altogether. R12 currently has orders for [MEDICATION NAME] 1.5 cal at 50 ml / hr, to run for 14 hours. R12 also has orders for puree pleasure feedings. R12 is a total care resident that requires staff assistance for all activities of daily living such as feeding. R12's current tube feeding provides 1080 calories and 46 grams of protein. R12 requires 1881 - 1950 calories according to the only two Nutrition Notes that estimate R12's calorie requirements (dated 2/16/11 and 5/20/11) , per review of notes dated 10/15/10 - 2/14/13. R12's protein requirements are not calculated at all per review of all Nutrition Notes. On 2/16/12 the Dietitian (Z4) recommended decreasing R12's tube feeding from 80 cc/hr to 60 cc/hr, according to Nutrition Notes dated 2/1/12. No rational is given for this significant reduction. On 3/8/12, Z4 recommended a further reduction in tube feeding to 50 cc/hr because R12 was refusing to eat at meal. The 3/8/12 Nutrition Note documents that this was at the request of the Power of Attorney (POA). Subsequent Nutrition Notes continued to document that this reduction in tube feeding was at the request of the POA. R12's tube feeding remains at this level to the current date. This level of feeding only meets 57 % of R12's calorie requirements. On 2/25/13 at 6:30 PM, during dinner observation on the second floor, R12 was not present in the dining room. E17 (Nurse Supervisor) was asked why R12 was not present and responded that she is only fed for breakfast and lunch because she has a tube feeding. There is no such restriction written into her physician's orders [REDACTED]. On 2/26/13, the lunch meal on the second floor was observed. It was noted that R12 was seated at the table with two other residents, all of whom needed to be fed. R12 was seated at the table since shortly after noon. At 12:25 PM, R12 was served her pureed diet. The food was placed on the table, the milk carton was opened, and staff left the table. Not until 12:50 PM did anyone sit down with R12 to attempt to feed her or encourage her to eat. The food was not reheated after waiting all this time. R12 took several spoonful then seemed to not want the food. Z4 was interviewed by phone on 2/28/13. When asked about the statement regarding the POA, Z4 admitted that she has not talked to the POA ever. Z4 said that this was conveyed to her by nursing staff. Z4 said she never conducted a calorie count on R12 to assess the amount of food she was taking in by mouth. On interview, Z5 (POA) stated that she was not aware of the severity of R12's weight loss, that no one had called to inform her from the facility. Z5 said that she had expressed concern about her mother (R12) gaining a lot of weight in 2011. At that time R12 had gone over 150 lbs. Z5 said that there had been no further discussion since that time. 3. R9 is a [AGE] year old resident who has had a significant weight loss over the past 3 months according to the facility's Significant Weight Change reports dated January 2013. R9 did not have a current weight loss or nutrition care plan in place, according to review of all care plans. R9 was not receiving any assistance with his dinner meal on 2/25/13 when observed at 6:13 PM, 6:32 PM, and 6:57 PM in the 2nd floor main dining room. R9 ate 25% of his meal. R9 was not receiving any assistance with his breakfast on 2/26/13 when observed at 8:45 AM, and 8:53 AM. R9 was observed on 2/26/13 with a new Stage II pressure ulcer on his left peri-rectal area. 4. R10 was initially admitted to the facility on [DATE] weighing 162.5 pounds according to the facility's weight report. R10 was hospitalized and readmitted twice (12/8/12 and 1/6/13) according to the weight report. R10 lost 10 pounds upon his readmission on 1/6/13 (153 pounds), and an additional 2 pounds by 2/6/13 (151). The last nutrition note is dated 12/13/12. The dietitian did not evaluate R10's weight loss or make any recommendations to prevent further weight loss. R10's Nutrition Status Care Area Assessment (not dated) for ARD (Assessment Reference Date) 11/10/12 states "May need to add fortified foods and/or supplements if intake and weights start to decline. Proceed to care plans." There was no nutrition or weight loss care plan in the medical record. On 2/26/13 at 3:04 PM, E23 (Care Plan Coordinator) stated that there was no nutrition or weight loss care plan developed for R10. On 2/27/13, Z4 (Dietitian) said she didn't see R10 when he was readmitted from the hospital on [DATE]. Z4 stated "I only see people who are readmitted if I have the time." Z4 also said "Sometimes I have to skip seeing residents because I don't have enough time." 5. R4 is a [AGE] year resident with dementia, history of gastrointestinal problems, and [MEDICAL CONDITION]. R4 was admitted to the facility in 2009. Review of facility Weight Report records show that since 2/7/12, R4 has lost 34 lbs. Review of his clinical record shows that there was no care plan to address R4's nutritional status, eating or weight loss. The Kardex only indicates "independent after set up." On 2/26/13 the lunch meal was observed on the second floor. R4 was eating his desert and drinking his milk from the carton with it spilling out of his mouth onto his clothing protector as he drank. No one offered him assistance or encouragement. The entree of ground meat and potato and spinach, was not touched by R4 except for about 1 spoonful of meat. After sitting there for more than 1/2 hour, R4 left the table. No staff intervention was ever initiated. 6. R15 is a [AGE] year old resident with multiple diagnoses, including [MEDICAL CONDITION] according to the Minimum Data Sets ((MDS) dated [DATE]. R15 is assessed to be independent with eating according to the MDS. R15 lost 33 pounds between January and February 2013 according to the facility's Weight Report Form for 2/1-2/11/3. R15 had no weight loss care plan and no new orders to address her weight loss. Additionally, R15 was not assessed by the Dietitian following her weight loss. R15 was observed during dinner on 2/25/13 between 5:56 PM - 6:30 PM in the 2nd floor dining room. R15 ate 25% of her dinner meal. R15 did not receive any staff encouragement to eat. R15 was observed during breakfast on 2/26/13 between 8:40 AM - 9:10 AM. R15 ate 25% of her meal. R15 did not receive any encouragement to eat. Direct care staff were not aware of R15's significant weight loss. On 2/27/13 at 2:15 PM, E17 (Nurse Supervisor) stated that R15 is independent with eating. E17 said she was not aware that R15 lost 33 pounds over the past 30 days. On 2/27/13 Z4 (Dietitian) stated that she did not assess R15 for her significant weight loss because she doesn't have enough time to see everybody. Z4 said she has to "prioritize her time." 7. R17 is an [AGE] year old resident with dementia, depression, hx of gout and Vit B12 and Vit D deficiency, and DJD ([MEDICAL CONDITION] joint disease). R17 has an order for [REDACTED]. On 2/28/13 at 8:50 am, R17 was observed being assisted by the nurse. R17 ate about 25% of the cereal and refused more. The annual nutritional assessment dated [DATE], identifies R17 as high risk nutritionally. The January 2013 nursing summary also identifies R17 as being at risk for skin breakdown. Recent labs of 2/25/13 show R17's Blood Urea Nitrogen to Creatinine ratio was 24 (reference range 12-20). The most recent note by the dietician is from 7/19/12, and the most recent annual nutritional assessment was from 1/12/12. No current nutritional care plans or interventions were in place for R17. 8. R18, [AGE] years old has a hx of Gastrointestinal problems, and is on a pureed diet with thin liquids. Review of the clinical record shows that the most recent annual nutritional assessment was done 7/28/11 and indicated that at that time R18 was at high risk nutritionally. The last dietary note was 7/26/12. 9. R13 was admitted to the facility on [DATE]. Since admission R13 has lost 10 lbs. R13 is on a mechanical soft diet currently . The nutritional assessment form dated 12/27/12 identifies R13 as high risk. There are no other notes acknowledging the weight loss or its cause. There has been no care plan developed or interventions to address the weight loss. 10. R25 was an [AGE] year old resident who was admitted to the facility 9/29/12 and discharged to the hospital on [DATE]. Nursing notes of 1/6/13 document a diminished consumption for meals. Review of the clinical record shows no dietary assessment, no dietary notes, no care plan for eating, or nutritional needs. Only one weight, that of admission, is in the record. The facility's Weight Monitoring for Gradual Weight Loss (2010) states that the facility will monitor the nutritional status of all residents, and will track "gradual and insidious weight loss."

Based on observation, interview and record review the facility failed to assess for dehydration, failed to monitor fluid intake, and failed to develop a dehydration care plan. These failures resulted in R14 being sent to the hospital on [DATE] and diagnosed with [REDACTED]. This applies to 3 of 12 residents (R14, R5, R7) reviewed for hydration in the sample of 27. The findings include: 1. R14 has multiple diagnoses, including heart failure and non-Alzheimer's Dementia according to most recent Minimum Data Sets ((MDS) dated [DATE]. R14 requires extensive, 1-person assist with eating/drinking according to the MDS. R14 has physician orders [REDACTED]. R14 did not have a Care Area Assessment for dehydration with her last MDS dated [DATE]. There was no dehydration assessment in the medical record. R14's Dehydration care plan dated 12/19/12 states "observe fluid intake during meals..." There is no documentation of R14's fluid intake in the medical record. R14 consumed 50% or less at most of her meals (75% of the time) from 12/30/12 - 2/2/13, according to review of the facility's Meal Intake Log. R14 weighs 70 pounds (2/11/13) according to the weight report. R14 had a significant weight loss of 6.6% from January to February 2013, according to the facility's weight report. On 2/25/13 at 6:01 PM, R14 was in bed being assessed by E17 (Nurse Supervisor) and E24 (Nurse). R14 appeared frail, with sunken eyes. E17 stated that R14 had a change in mental status. R14 was sent out to the hospital and diagnosed with [REDACTED]. R14 had 4+ bacteria and blood in her urine according to the Urinalysis report dated 2/25/13. R14's BUN (blood urea nitrogen) was elevated at 32 (normal range 6-26), according to hospital lab records dated 2/25/13. On 2/28/13 at 9:15 am, E25 (Nurse) stated that there is no fluid monitoring done on R14. E25 stated "I guess we could start I's (intakes) and O's (outputs)." E25 said that R14 had lost weight a couple months ago, but regained it after [MEDICATION NAME] was started. E25 was not aware that R14 currently had poor food intake and that R14 had a significant weight loss in February 2013. On 3/4/13 at 2:20 PM E2 (Director of Nursing) stated that a dehydration assessment had not been completed on R14. 2. R5 has a [DIAGNOSES REDACTED]. R5 has no dehydration assessment and no dehydration care plan, according to review of the medical record. R5's most current nutrition notes dated 1/19/12 and 6/12/12 do not address her hydration risk. R5 had a urinary tract infection on 2/11/13, according to review of the medical record. R5 was in her room on 2/25/13 at approximately 10:30 AM sitting in her wheelchair. R5 was repeatedly asking for water. On 2/25/13 at 12:56 PM R5 was in the dining room asking for water. When staff directed her to her thickened water, R5 pushed it away and yelled "I want my water (explicative)." On 2/25/13 at 4:15 PM, R5 was sitting in her wheelchair in her room asking for water. R5 repeated "C'mon, C'mon, give me water...I want water." R5 was observed during breakfast on 2/26/13 at 9:00 AM. R5 did not drink any of her liquids. On 2/28/13 R5 was observed during breakfast. R5 did not drink any of her liquids. On 2/28/13 at 10:21 AM, E23 (MDS/Care Plan Coordinator/Nurse) said that R5 did not have a dehydration care plan. E23 said that they only do a care plan if "they're on a diuretic and have an ongoing infection." On 2/28/13 at 9:25 AM, E25 (Nurse) stated that R5 does not like thickened water. E25 said she "cries out and won't always take it." E25 said that there is no fluid intake monitoring sheet for R5. E25 said she probably doesn't like it because it's warm. E25 said "I tasted it warm, it's terrible." E25 said that when she gives R5 water, she puts ice in it and R5 accepts it better. 3. R17 is an [AGE] year old resident with dementia, hypertension, and a history of UTI (urinary tract infection). On 2/4/13 R17 had a UTI with greater than 50,000 colonies of eschericia coli as the infecting organism. Lab results dated 2/25/13 indicate an elevated BUN of 24 mg/dl. The only dietary documentation in the clinical record are the annual nutritional assessment dated [DATE] and a note dated 7/19/12. The assessment identifies R17 as high risk nutritionally, but there are no care plans or interventions to address the hydration needs or the UTI's.

Based on observation, record review and interview, the facility failed to monitor resident's skin, prevent development of new pressure ulcers, promote healing of facility acquired pressure ulcers, ensure dietary recommendations are implemented for residents with new pressure ulcers and failed to provide assistance with feedings to residents at risk for pressure ulcers. This failure resulted in 2 of 14 residents (R3,R9) acquiring stage II pressure ulcers in a sample of 27. Findings include: 1. R3's [DIAGNOSES REDACTED]. R3's Minimum Data Set ((MDS) dated [DATE] assessed R3 as requiring extensive assistance in all activities of daily living and incontinent of bladder and bowel. R3's Norton Risk Assessment Scale dated 2/3/13 assessed R3 as at risk for pressure ulcers. Facility's pressure ulcer report for February 2013 identified R3 as having two acquired stage II pressure ulcers to the left and right buttock on 2/4/13. Initial measurements of the right buttock wound was 1.0 centimeter (cm) x 0.5 cm x 0.2 cm and measurements to the left buttock was 1.5 cm x 1.0 cm x 0.2 cm. Treatment orders for the right and left buttock dated 2/4/13, included cleanse with normal saline, apply hydrogel gauze, cover with foam dressing daily and prn (as necessary) till healed. Documentation on the treatment sheet indicates that R3's physician and dietary staff were notified of wounds on 2/4/13. Weekly pressure ulcer report dated 2/18/13 documented that the measurement of the stage II pressure ulcer on the left buttocks was 1.5 cm x 1.0 cm x 0.1 cm and the stage II pressure ulcer on the right buttocks was 0.7 cm x 0.5 cm x 0.1 cm. On 2/21/13 the treatment order for R3's wounds were changed. The new order was to apply saline moistened collagen pad, cover with border foam dressing daily and prn. On 3/5/13 at around 11:00 am E26 (wound care nurse) stated the treatment was changed to promote healing to wounds. On 2/26/13 during the noon meal, R3 did not receive assistance. Staff was assisting her tablemate. R3's 2 jellied sandwiches were still wrapped in wax paper. Facility's weight sheets indicate R3 had a 5.39% weight loss in 1 month from January -February 2013. Dietary notes dated 2/22/13 written by Z4 (Registered Dietician) documents R3 is on regular diet with thin liquids and receiving resource 120 cc three times a day, Zinc, Multi-vitamins and Iron and Vit C daily. A recommendation for Prostat 30 cc daily until healed was written on dietary notes. R3's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. POS dated 2/26/13 documents the Prostat was finally ordered on [DATE]. E2 (DON) stated when new or multiple pressure ulcer are discovered, the dietary manager is notified by the treatment nurse or nursing staff. E28 (Food Service Supervisor) stated on 3/5/13 at around 11:00 am, she is notified of pressure ulcers by the wound nurse and receives weekly wound sheet. E28 stated she e-mails wound report to Z4 weekly and /or calls and leaves message. When E28 was asked if there is a time frame for Z4 to see resident admitted with wounds or new wounds, E28 stated it usually does not take that long. E28 stated Z4's dietary recommendations are sent to ADON (E3). E3 stated on 3/5/13 at around 11:45 am, she did not receive the dietary recommendation for R3. On 2/26/13 at 11:30 AM, Z4 was reviewing records. Z4 was informed that R3 did not receive the Prostat as recommended on 2/22/13. Z4 responded " I don't have time to follow up on recommendations." R3's care plan for pressure ulcers dated 11/28/12 was not updated regarding R3's acquired pressure ulcers until 2/21/13 documenting R3 had stage II decubitus ulcers to left and right buttock and is a risk for additional breakdown due to decreased mobility and incontinence. R3's care plan interventions includes observe for adequate hydration and nutrition. 2. R9's [DIAGNOSES REDACTED]. R9's Minimum (MDS) data set [DATE] assessed R9 as requiring extensive assistance in all activities of daily living and incontinent of bowel and bladder. R9's Norton Risk Assessment Scale dated 1/21/13 assessed R9 as at risk for pressure ulcers. During the initial tour on 2/25/13 at 10:30 AM, R9 was observed lying in bed on his buttocks. On 2/26/13 at 11:45 AM R9 was again observed lying in bed on his buttocks. During an skin and incontinence check with E16, CNA at 11:50 AM, R9 diaper was soiled with stool and an opened area was observed to R9's left ischial area. E16 stated she did not notice the opened area earlier. E21 (RN) was asked to observe R9's buttocks and stated she was unaware of the open area. E26 (wound care nurse) was notified of observation on 2/26/13 and assessed the wound as a Stage II measuring 0.5 centimeters (length) (cm) x 0.3 cm (width) < (less) 0.1 in depth. R9's physician was notified and an order was obtained to apply [MEDICATION NAME] to peri/rectal area every shift and prn (as necessary ) until healed. On 2/25/13 at 6:17 PM during the evening meal, R9 ate only 25% of his meal and received only intermittent assistance. On 2/26/13 at 8:45AM, R9 received only minimal assistance with his meal. Facility's weight records documents R9 had a significant weight loss of 10% in the last 3 months. R9's current care plan for skin breakdown includes: assist resident as he needs to turn and reposition at least every two hours and prn when in bed-able to turn to left side using siderail: minimize friction or shearing by proper postioning, transferring and turning: provide incontinence care after each incontinent episode and apply Baza creme to buttocks every shift, and skin check daily. R3's care plan interventions also include observe for adequate nutrition and proper hydration.

Based on interview and record review, the facility failed to monitor the effectiveness of interventions and modify the interventions as necessary related to the use of the mechanical lift to prevent injury from a fall for one resident. This failure resulted in two falls in a 24 hour period and the resident sustained [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. Findings Include: R1 was a [AGE] year old resident admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. According to the facility's documentation, including initial incident reports and final investigative reports, R1 sustained falls on 10/28/12 and 10/29/12. On 10/28/12 at 2:15 PM R1 reportedly was being transferred from her wheelchair into her bed by 2 CNAs (E6, E14) using a mechanical lift. The lift requires the resident to be able to bear at least partial weight, hold onto 2 handles and follow instructions. At some point during the transfer R1 began to lose her grip on the handles and started to fall. According to one witness (E6) and the final investigative report, staff intervened and R1 was lowered to the floor. Upon the nurse's (E5) assessment R1 complained of right shoulder pain. There was no other observable injuries noted. On 10/29/12 at approximately 4:30 PM R1 sustained a second fall. The fall occurred while R1 was being transferred from her bed into her wheelchair. For the transfer 2 CNAs (E8, E9) used the same mechanical lift to transfer the resident as on the previous day. According to the final investigative report and the 2 CNAs that were present, at some point during the transfer, R1's knees began to give out or buckle. At that point E8 and E9 lowered R1 to the floor. Upon the nurse's (E7) assessment R1 showed no visible signs of injury and denied pain. R1 was subsequently returned to her wheelchair and taken to the dinning room. At about 5:00 PM R1's son (Z1) arrived in the facility. Shortly after arriving Z1 went to E7 and informed her that his mother was very drowsy and not responding as she usually does. After reassessing R1 E7 called 911 for transport to the emergency department (ED). R1 was transported to the ED at 5:45 PM. Review of emergency room records from 10/29/12 indicate that when R1's left thigh was palpated by the ED physician, "she winced in pain". Imaging of the left femur showed a very long oblique fracture from the hip to just above the knee. The report states that the leg was swollen and tender. Review of R1's mechanical lift assessment form from 9/13/12 and 10/29/12 indicated that there were no changes made after R1's fall on 10/28/12. The form was also inaccurate and incomplete. On item #6 of the form regarding patient conditions likely to affect the equipment and techniques needed for resident handling, two applicable areas of concern were left unchecked, including fall history and respiratory &/or cardiac compromise. In item #1 of the form it states, " If resident's ability to assist varies (from such factors as medical conditions, fatigue or medications), assess resident before each task. When in doubt, assume the resident can't assist with transfer." On 2/21/13 at approximately 3:00 PM the facility's Restorative Nurse (E4) stated that she didn't consider R1's fall history or cardiovascular status as indicated by the assessment form when determining if R1 was appropriate for continued use of the mechanical lift. E4 stated that because R1 was able to bear weight on 10/29/12 and didn't complain of pain, she considered the lift appropriate for continued use. She stated that she thought that the fall on the previous day may have been a one time occurrence. E4 also stated that she did not take R1's medication regimen into consideration or review the resident's care plan prior to reassessing the resident. R1's medication regimen included a antihypertensive (Amlodipine) and a psychotropic drug (Escitalopram) which according to the facility's initial fall assessment may contribute to increase risk for falls. In addition there was no consultation with physical or occupational therapy prior to E4's reassessment of R1. Review of R1's last Physical Therapy assessment (10/24/12) indicated that R1 presented with weakness and endurance deficits influencing her ability to perform functional mobility. On 2/20/13 at 2:41 PM, the Physical Therapist (E12) completing the above mentioned assessment stated that R1 had a recent admission to an area hospital. E12 stated that when R1 returned (10/20/12) to the facility she was more weak than during her previous admission. She stated that R1 was having problems with her knees, which often buckled during physical therapy sessions. On 2/21/13 at 10:00 AM, the consulting orthopedic surgeon (Z2) that saw the resident in the hospital after admission, stated that pain in this type of fracture is severe and immediate. Z2 stated that although R1 showed osteopenia the force required to cause this kind of fracture would be a severe impact from a fall to the ground or a direct impact such as in a collision. He stated that a resident assessed for such an injury would definitively exhibit pain. Z2 stated that the description of R1 being lowered to the floor is not consistent with this type of injury. Z2 also confirmed that this was not an old fracture.