Every finding on record at Warren Barr Gold Coast

Based on interviews and record reviews, the facility failed to ensure adequate supervision and assistance during toileting hygiene for one resident (R2) out of three residents who required maximum to dependence assistance and contact support during toileting hygiene. This failure resulted in R2 rolling off the edge of the bed and falling to the floor.FINDINGS: R2's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates she is cognitively intact. R2's Electronic Health Record/EHR, noted she is [AGE] year-old, she was initially admitted on [DATE] with diagnoses not limited to secondary malignant neoplasm of other parts of the nervous system, malignant neoplasm of unspecified site of left female breast, secondary malignant neoplasm of bone, displaced subtrochanteric fracture of left femur, anxiety, disorder, and pathological fracture in neoplastic disease left femur subsequent encounter for fracture with routine healing as at 09/17/25. R2's weight was 304.6 pounds as at 06/09/26. On 07/14/26 at 10:55 AM, R2 stated that on 06/21/26 at approximately 4:15 am, an unknown female staff identified as V16 (Certified Nurse Assistant/CNA) came to her room to change her diaper. R2 was holding onto the bed rail and initially turned to her right. When she turned back to the left, V16 was pulling the fitted sheet from the right corner of the mattress. R2 stated that she told V16 she was close to the edge of the bed, but V16 continued pulling the fitted sheet. R2 stated that she then fell off the bed onto her left side. V16 left the room to get another unknown female CNA and brought a mechanical lift with a sling. R2 stated she was in excruciating pain, and then an agency nurse identified as V18 (Agency Licensed Practical Nurse/LPN) arrived and told her multiple times that she was calling paramedics right away. R2 stated she remained on the cold floor for two hours before four Paramedics arrived. She was transferred to the stretcher, transferred to the hospital where she was diagnosed with broken left femur, and she had surgery on 06/22/26. R2 also stated that she called the Illinois Department of Public Health/IDPH on 06/24/26, and 06/25/26 for the same complaint because she was unsure if IDPH received her initial complaint made on 06/24/26. On 07/14/26 at 2:01 PM, V15 (Supervisor Registered Nurse/RN) stated that on the 11pm-7am shift of 06/20/26 at about 5:00 AM of 06/21/26, V18 (LPN) called her to the unit. She saw R2 on the floor by her bed, and two unnamed CNAs with her. R2's left leg was positioned to the side with the knee slightly bent. V15 called 911/Paramedics, she did not use the Hoyer lift because R2 reported pain. R2 still had a brief, and a gown on, she was provided with a pillow, and a blanket. V15 also stated that R2 was not on the floor for two hours. On 07/15/26 at 11:29 AM, V16 (CNA) stated that on 06/21/26 at around 5:00 AM she was providing incontinent care to R2. She instructed R2 to turn to her left so she could pull the fitted sheet and pad from under her because R2 does not need assistance to turn in bed, but R2 was holding onto the side rail. As R2 was turning, R2 rolled her legs over the edge of the bed and fell before V16 could reach her. V16 stated that she immediately called V18 (LPN) to assess R2. Four paramedics arrived at approximately 5:30 AM and transferred R2 onto the stretcher. V16 also stated that she was not holding or supporting R2 at any time during the toileting hygiene and at the time of the fall.On 07/15/26 at 12:02 PM, V24 (Restorative Licensed Practical Nurse/LPN) stated that for any resident who is care planned as weight bearing assist during toileting hygiene, staff are expected to provide contact assist. V24 also stated that R2 requires maximum assistance to dependence with toileting hygiene, V16 should provide contact support during toileting care for safety and to prevent falls.On 07/15/26 at 1:20 PM, V25 (R3's Attending Physician) stated that she has been attending to residents in the facility for fifteen years. R2 was admitted for post acute care in September 2025, and she has a history of pathological fractures and bone metastasis. R2's recent fracture is not traumatic; it could be pathological due to bone cancer. V25 also stated that she cannot definitively say that the fracture of the left femur occurred because of the fall, and determining whether the fracture resulted from the fall is difficult due to R2's history of pathological left femoral fracture and metastatic bone disease. On 07/16/26 at 11:16 AM, V35 (RN/Clinical Care Coordinator) stated that weight bearing means the caregiver is touching the resident during care. If a resident is dependent for toileting hygiene it is imperative for the staff to touch/support during care for safety. According to the quarterly MDS of 04/12/26 before the fall, R2 was coded dependent/total care for toileting hygiene, which requires contact guard support for safety. Documents reviewed for this investigation are not limited to the following: R2's Electronic Health Record/EHR: Progress notes dated 06/21/26 document in part, The resident (R2) remained in a supine position on the floor, pillows and blanket were provided for comfort and warmth while awaiting paramedics' arrival. Patient (R2) was sent out to hospital around 5:30 am. Patient was admitted to the hospital for left hip fracture. Care-planned level of assistance for toileting hygiene at the time of the incident, documented, R2 requires weight bearing assistance. Self-care Functional Abilities (GG) completed on 04/24/26 and 06/10/26 noted dependent on toileting hygiene. R2's hospital notes dated 06/22/26 to 06/28/26 documents in part; Mechanical fall from bed (wo LOC) without loss of consciousness or head strike. Ctb. (Computed Tomography) negative. Likely related to bony metastasis below. Impression: innumerable pelvic and femoral lytic metastases. Extensive bony metastasis in pelvis, and proximal femurs with unchanged pathological fractures. Postoperative diagnosis: Pathologic left subtrochanteric femur fracture. Centers for Medicare and Medicaid Services/CMS Resident Assessment Instrument/RAI Version 3.0 Manual dated October 2025 document in part: Coding: GG0130C would be coded 01, Dependent. Rationale: The assistance of two helpers was needed to complete the activity of toileting hygiene. Facility policy titled, General Care, dated 07/07/26. Document in part. It is the facility's policy to provide care for every resident to meet their needs. Facility CNA Job Description, dated 05/09/2019, document in part. The CNA safeguards the health, safety, and welfare of all guests under their care.

Based on interview and record review, the facility failed to administer medication as ordered by the physician and failed to notify the physician of missed doses for one resident (R3) out of three residents reviewed for improper nursing care.Findings Include:R3's clinical records show R3 was admitted in the facility on 3/18/26 and discharged to the hospital on 4/18/26. R3's included diagnoses but not limited to Bipolar Disorder, Cerebral Infarction, Gastrostomy Status, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, and Severe Protein-Calorie Malnutrition.R3's Order Summary Report includes the following medication order: Piperacillin Sod Tazobactam Solution Reconstituted 3 0.375 GM. Use 3.375 grams intravenously every 8 hours for infection for 7 days, ordered on 4/13/26. R3's electronic Medication Administration Record (EMAR) shows no check mark indicating that this medication was administered on 4/16 and 4/17/26, at 6:00 AM; on 4/17/26, at 2:00 PM and 10:00 PM; and on 4/18/26, at 6:00 AM and 2:00 PM.R3's progress notes dated 4/17/26 at 2:44 PM, documented by V11 (Registered Nurse/RN), states in part that the staff were awaiting for midline to be placed.R3's progress notes dated 4/18/26 at 5:56 AM, documented by V22 (Licensed Practical Nurse/LPN), also notes that they were awaiting for midline insertion.R3's progress notes dated 4/18/26 at 2:45 PM, documented by V10 (RN), states in part that intravenous (IV) medication would be administered after the midline had been inserted.On 7/14/26 at 12:13 PM, V10 (RN) stated that R3 missed the 2:00 PM IV antibiotic dose. V10 stated she did not inform V8 (R3's Nurse Practitioner) because there was an order for midline insertion already, but the family did not consent and requested it be done in the hospital instead.On 7/15/26 at 9:58 AM, a phone interview was conducted with V22 (LPN). V22 stated that she does not recall R3. V22 stated she documents medications after the resident takes them. V22 stated refusals or missed doses would be documented in both the MAR (Medication Administration Record) and the progress notes. V22 stated if the MAR is left blank it could indicate that the medication was probably not given or that it was a missed dose.On 7/14/26 at 1:38 PM, a phone interview was conducted with V17 (Agency LPN). V17 stated he worked on 4/17/26 evening shift and was assigned to R3. V17 stated that R3 had pulled out his IV line. V17 stated he did not notify R3's physician because he notified the supervisor (V15), who handled the required notifications. V17 stated that V15 informed him that a midline had been ordered. V17 stated that a technician arrived around 8:00 PM to attempt the midline insertion, but they were unable to place it and scheduled the procedure for the following morning. V17 stated that R3 appeared stable and not in distress.On 7/14/26 at 2:20 PM, a phone interview was conducted with V15 (RN Supervisor). V15 stated she worked as the nurse supervisor from 4/17/26 at 7:00 PM to 7:00 AM of 4/18/26. V15 reported that she did not recall many details but remembered that R3 had pulled out his IV line. V15 stated that her usual process would be to ask staff to reinsert the IV; if unsuccessful, the midline company would be called. V15 stated she was not aware that R3 had missed two doses of IV antibiotics. V15 said that if he had missed those doses, nursing staff should have notified the NP (Nurse Practitioner) sooner rather than waiting until multiple doses were missed. V15 stated she did not recall being informed of any missed doses. V15 added that efforts would normally be made to restart the IV internally or call [midline technician], typically arriving first thing in the morning.On 7/14/26 at 12:38 PM, a phone interview was conducted with V12 (RN). V12 stated that when she began her shift on 4/18/26, R3 did not have an IV line, and staff were waiting for the midline team to insert a midline. V12 stated she called the NP on call and obtained an order for antibiotics to be given via gastrostomy tube.On 7/15/26 at 9:23 AM, a phone interview was conducted with V21 (LPN). V21 stated that the doctor and nursing supervisor are notified if a medication is refused, not available, or not administered for any reason. The MAR will indicate patient refusal, and the supervisor is notified. According to V21, the doctor is notified if there is a delay in medication administration. V21 explained that if the MAR is blank, it means the medication was not administered. V21 stated if it is not documented, it means it was not done.On 7/14/26 at 11:33 AM, a phone interview conducted with V8 (R3's Nurse Practitioner). V8 stated that R3 had a history of recurrent aspiration pneumonia even prior to admission to the facility. V8 stated that R3 was receiving intravenous (IV) antibiotics for aspiration pneumonia, prescribed by V9 (R3's physician) on 4/13/26. V8 stated she was not informed until the afternoon of 4/18/26 that R3 had missed doses of the IV antibiotic due to having no IV access. V8 stated she did not know the timing of R3's last antibiotic dose, which had been scheduled every eight hours. V8 stated she then ordered an antibiotic to be administered through the gastrostomy tube. R3 was sent to the hospital due to V5's (R3's Family Member) refusal to insert the midline access to R3. V8 stated that R3 was admitted with aspiration pneumonia, the same condition for which he had already been receiving treatment in the facility.On 7/15/26 at 1:41 PM, V9 (R3's Physician) stated that R3 had a history of recurrent aspiration pneumonia and multiple recurrent CVAs (Cerebrovascular Accidents) prior to admission to the facility. V9 explained that her partner, V26 (R3's Physician), initially ordered the IV antibiotic for R3's aspiration pneumonia. V9 stated she began seeing R3 on 4/14/26, the antibiotic had already been started. V9 stated she does not recall being notified that R3 had missed doses of the IV antibiotic. V9 noted that staff may have contacted her regarding the need for a midline. V9 described R3 as confused, with very poor mental status, and reported that he exhibited behaviors such as pulling out his IV line. V9 stated she likely had been informed about the midline but does not remember being notified about missed antibiotic doses. V9 said she would have considered administering the antibiotic through an alternative route if necessary. V9 stated that R3 was already hospice-appropriate upon admission. V9 reported that R3 was very congested and aspirating from the beginning coming in the facility. V9 explained that R3 had already received four days of IV antibiotics and that if improvement were expected, it would likely have been evident by then. V9 stated the missed doses would not significantly change R3's clinical condition or cause a decline.On 7/16/26 at 10:03 AM, V3 (Director of Nursing/DON) stated that the expectation for all nurses during medication administration is that they follow the five rights of medication administration: the right dose, right frequency, right time, right medication, and the right route. V2 stated nurses are required to document medications in the electronic medical record (EMAR) immediately after the resident has taken the medication. A check with the nurse's initials in the EMAR means the medications are administered. V3 stated that for residents receiving IV medications, if there is no IV access, the nurse must attempt to establish access. If the medication still cannot be administered, the nurse must notify the physician and follow the physician's orders. V3 stated that notifying the physician is important so that the provider can adjust the dose, issue new orders, or identify an alternative route of administration if needed.The facility's Nurse Job Description reads in part: Communicate the condition of residents to physicians, other caregivers and supervisors, verbally and by use of 24-hour reports and other established means, in an accurate, timely, and effective manner.The facility's Medication Variance Report dated 7/2/26 reads in part: It is the policy of this facility to report in a timely manner and properly complete a report summary in the event of a medication variance and/or upon identification of a medication variance.

Based on observation, interview, and record review the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was visibly posted for two residents requiring Enhanced Barrier Precaution; and failed to ensure that staff had Personal Protective Equipment (PPE) bin available for staff use. These failures affected two residents (R5 and R10) and has the potential to affect all 35 residents residing on the third-floor unit. Findings include: R5 has a diagnosis which includes but not limited to: multiple sclerosis, dysphagia, fracture of left femur, and thrombocytopenia.R5's Brief Interview for Mental Status (BIMS) dated 03/13/2026 shows a score of 15 which indicated that R5 is cognitively intact.R5's Physician Order Sheet (POS) does not show orders for EBP for R5 however does show wound care orders for Medi honey/foam every day shift every Mon, Wed, Fri (Monday, Wednesday, Friday) for R (right) glute (gluteal) cleanse with NSS (normal saline solution) pat dry, apply Medi honey and cover with border foam.R5's wound care plan dated 6/8/26 documents in part: Focus is on Enhanced Barrier Precautions for right gluteal wound . Interventions: Ensure that gown and gloves are used during high-contact resident care activities. R10 has a diagnosis which includes but is not limited to heart failure, restlessness and agitation, adult failure to thrive, and history of COVID-19.R10's Brief Interview for Mental Status (BIMS) dated 04/10/2026 does not document a BIMS score for R10 and indicates that R10's memory is okay.R10's Physician Order Sheet (POS) does not show that R10 have orders for EBP however does show that R10 has wound care orders for Medi honey/Foam dressing every day shift for sacrum (pressure) cleanse with NSS, pat dry, apply skin prep to peri wound, Medi honey to wound bed and cover with a foam dressing.R10's wound care plan dated 6/8/26 documents in part: Focus is on Enhanced Barrier Precautions for right gluteal wound . Interventions: Ensure that gown and gloves are used during high-contact resident care activities. On 6/8/26 at 1:00 pm, Surveyor observed R5 in her room, in bed. Surveyor did not observe R5's room door with an EBP sign on the door or a PPE bin available for staff use.On 6/8/26 at 1:03 pm, Surveyor observed R10's in her room, in bed. Surveyor did not observe R10's room door with an EBP sign on the door or a PPE bin available for staff use.On 6/8/26 at 1:15 pm, Surveyor brought these observations to V11 (Registered Nurse, RN, Wound Care Nurse) and V11 stated that she performs wound care dressing changes for R5 and R10's wounds daily. V11 then stated that R5 and R10 are not on EBP and do not require Personal Protective Equipment (PPE) to be worn during care or a EBP sign posted for their rooms. V11 then stated EBP is for residents who are at risk for acquired infections. Surveyor and V11 reviewed the signage for residents who require EBP which stated, Enhanced Barrier Precaution: Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact resident care activities . wound dressing change. V11 then stated, Looks like they require EBP and that I should be wearing PPE (personal protective equipment). I am not sure who is responsible for placing the EBP sign.On 6/8/26 at 2:24 pm, V24 (Infection Preventionist ,IP, Registered Nurse, RN) stated residents with wounds should have an EBP sign placed on the door and staff should be donning Personal Protective Equipment (PPE) (gown and gloves) when performing high contact care such as wound care. V24 then stated that the EBP is to prevent staff and the resident from transmitting infection and to reduce the spread of possible infection to others during high contact care.On 6/10/26 am at 9:24 am V24 (IP, RN) stated that residents with EBP do not require a physician's order and that V24 will verbally tell staff when a resident is on EBP. V24 then explained that a residents physician order sheet is what the nurses refer to regarding the care and orders for a resident. During this investigation surveyor requested the facility policy for PPE bins for EBP residents and the facility was unable to provide. The facility document dated 6/9/26 and titled Enhanced Barrier Precautions presented by V24 shows that R5 and R10 requires EBP.The facility document dated 9/16/25 and titled Enhanced Barrier Precautions documents, in part: Policy: The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug-resistant organisms in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDROs as well as residents with wounds and/or indwelling medical devices . Procedures: 1. EBP will be used for any resident in the facility - with open wound/s (pressure ulcer, diabetic ulcer, venous ulcer, arterial ulcer, unhealed surgical wounds, etc. (etcetera) . 3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDROs (Extensively Drug-Resistant Organism) to staff hands and clothing . 7. An EBP sign should be posted on the doors of each resident on EBP.The facility document dated 6/30/25 and titled Infection Prevention and Control documents, in part: Policy Statement: The facility has established a policy to identify, record, investigate, control, test and prevent infections in the facility. Procedures: 8. A sign will be provided outside the room for residents on transmission-based precautions indicating the type of the precautions (Contact, Droplet, or EBP).

Based on interview and record review, the facility failed to provide specialized rehabilitative services per resident's physician order for one (R13) resident out of five residents reviewed for quality of care in a total sample of 16 residents. This failure has the potential to affect a resident from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional and psycho-social well-being.Findings include:On 04/07/2026 at 1:16 PM, R13 stated that the concern R13 has is that it has been over a month and R13 has not had much rehab therapy even though R13's physician told R13 that R13 would be referred to rehabilitation therapy. R13 stated I (R13) am trying to figure out what is going on with my therapy. I told my physician that comes once a month, and the physician told me Let me go and talk to them. R13 stated this about a month ago. R13 stated that one day a therapist came and never came back that week. R13 stated that it is Tuesday today and R13 asked the CNA (certified nursing assistant) if R13 was scheduled to get up for therapy since R13 needs assistance with getting out of bed. R13 stated that the CNA told R13 that R13 was not on the therapy schedule. R13 stated that since March until now, R13 has had a total of two or three therapy sessions. R13 stated that she feels therapy would help her with R13's arthritis and knee pain.04/08/2026 at 2:21 PM, V7 (Therapy Director) stated that R13's primary therapist has been on vacation since last Thursday. V7 stated but we always have staff, so whenever a therapist is not here, someone covers. V7 stated I (V7) believe R13 was referred to therapy sometime in March and I know we evaluated her on March 17th. V7 stated that R13 has had three visits already since March 17th. Right now, she is scheduled for Tuesday, but we rescheduled for Thursday and Friday. I cannot pull up why she was not seen on Tuesday and why she is rescheduled for Thursday and Friday. V7 stated that R13 was seen for evaluation on March 17th. V7 stated that on March 22nd and March 31st, R13 was seen for therapy treatment. V7 stated R13's physician order notes that R13 is ordered for 2-3 times a week. V7 stated R13's order is being followed, but usually if there are scheduling conflicts, things happen, my therapist calls off, if we cannot see them on a particular day we reschedule. V7 stated per the visits that she has received they weren't able to follow the doctor's order. V7 stated that R13's goal is to be able to do bed mobility tasks with supervision to touching assistance. On evaluation, R13 could not do that level, and she was rolling with moderate assistance.R13's face sheet documents R13 is a [AGE] year-old individual with diagnoses not limited to: bilateral primary osteoarthritis of knee.R13's MDS/Minimum Data Set, dated [DATE] documents that R13 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R13 is cognitively intact.R13's active physician order set documents in part, physical therapy: 2-3 times a week for 41 days since 03/17/2026.R13's physical therapy evaluation and plan of treatment dated 03/17/2026 documents in part frequency 2 to 3 time (s)/week, duration 41 days. Clinical Impressions/Reason for Skilled Services: Based upon examination of patient's body regions, systems and structures, patient presents with balance deficits, decreased dynamic balance, decreased functional capacity, pain, strength impairments, decreased safety awareness and decreased static balance and in consideration of history, personal factors, and functional limitations documented in this eval summary, patient requires skilled PT services to increase functional activity tolerance, increase LE ROM (Lower Extremity Range of Motion) and strength, promote safety awareness, improve dynamic balance, facilitate discharge planning and facilitate independence with all functional mobility , in order to decrease level of assistance from caregivers, increase performance skills with functional tasks and facilitate safe transition to next level of care . Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: immobility, falls, decrease in level of mobility, decreased leisure task participation and decreased participation with functional tasks.R13's physical therapy treatment encounter notes are dated 03/17/2026, 03/22/2026, and 03/31/2026.Facility document dated 2025 titled pain documents in part policy provision of rehab services. Therapist will follow the physician approved plan of care established for the resident/patient. The therapist will ensure all rehabilitation services will follow the accepted practices and guidelines for each rehabilitation discipline. Therapists will deliver care as per plan, and in accordance with state and federal laws and best practice techniques. Physician orders will include specific activities, interventions and procedures to be implemented, specific frequency and duration.

Based on interview and record review the facility failed to complete neurological monitoring following an alleged head injury. This failure affected one resident (R1) in the sample of five residents reviewed for accidents and incidents. Findings include: R1 has diagnosis which include but are not limited to: traumatic subarachnoid hemorrhage without loss of consciousness subsequent encounter, history of falling, syncope and collapse, unspecified asthma uncomplicated, hemiplegia hemiparesis following cerebral infarction affecting right dominant side, atherosclerotic heart disease of native without angina pectoris, type 2 diabetes mellitus without complications R1's Brief Interview for Mental Status (BIMS) dated 12/25/25 shows a score of 14 which indicates that R1 is cognitively intact. The facility's Initial Reportable Incidents dated 1/12/26 at 6:21 am, documents in part: On 1/12/26 at approximately 5:40 am, V7 (RN) nursing supervisor reported to V1 (Administrator) the resident R1 stated CNA hit her head while she was being changed. A head-to-toe assessment was initiated immediately with no redness bruising or injuries noted. CNA TV was suspended immediately pending investigation of this alleged incident physician and family were contacted regarding the alleged incident. The facility's Final Reportable Incidents dated 1/126/26 at 6:32 am documents in part: V1 interview V8. V8 stated that she would never intentionally harm a resident. V8 stated that she takes her job seriously, is becoming a nurse, and cares deeply for her residence . At this time, we were unable to substantiate the allegation of abuse. On 2/18/26 at 9:53 am, V8 (Certified Nursing Assistant, CNA) stated that she has worked at the facility for the past two years on the night shift. V8 stated that she recalls R1 at the facility and explained that R1 was alert, oriented, able to make needs known, incontinent of bowel and bladder, one person assist resident who was verbally combative at times during care. V8 then explained that she provided care for R1 multiple times at the facility prior to 1/12/26. V8 further explained that on 01/12/26 around 4:30 am, she was providing incontinence care to R1, she cleaned the front of R1's peri area and R1's right side of her buttocks area while R1 was laying on her right side. V8 continued to explain while she attempted to reposition R1onto her left side, she (R1) was holding onto the bedrail on her left side to assist V8 with repositioning R1 when R1 suddenly stated that she felt that V8 bumped her head on the headboard of R1's bed. V8 then stated that she immediately ceased care with R1 and reported R1's allegations to V15 (Registered Nurse, RN) and V7 (RN, Nursing Supervisor). V8 then explained that she informed V7 and V15 regarding R1's allegations of her (V8) bumping her head. V8 stated that after she reported the incident to V15, V15 completed R1's perineal care while V8 was at the nurses station. V8 also stated that R1 did not have a roommate during the time of this incident and then explained that V7 sent R1 home after informing V8 that there would be an investigation conducted. V8 then stated that V1 (Administrator) called her 30 minutes later asking V8 about R1's allegations. V8 finally explained that she was off work for about five days after R1's allegations of V8 bumping her head and that she no longer saw R1 from that day forward. On 2/18/26 at 10:49 am, V15 (Registered Nurse, RN) stated that she has worked at the facility for about one year on the evening and night shift. V15 then stated that she recalls caring for R1 at the facility and explained that she came into R1's room on 1/12/26 around 4:00 - 5:00 am, after V8 (Certified Nursing Assistant, CNA) called her to R1's room. V8 further explained that V8 stated that R1 said she hit her. V15 then explained that she asked V8 what happen and V8 explained that she was just changing R1 and R1 said that V8 hit her head. V15 then explained that she then asked V8 if she hit R1's head and V8 stated, No. Not that I'm aware of. V15 further stated that she went into R1's room and asked R1 what happened and that R1 stated that V8 hit her head on the bed and on the right side of her face and that V8 also punched R1 in the face. V15 then explained that she assessed R1 head and did not find any bruising, swelling, bleeding or obvious injuries. V15 also explained that R1 did not complain of any pain to touch. V15 explain that she assessed R1 alone and that V7 (Registered Nurse, RN, Supervisor) was not present. V15 further explained that R1 explained that V8 was being rough while changing her (providing incontinence care) and then punched her (R1) in the face. V15 then stated that she informed R1 that she would report R1's allegations to V7 (RN, Nursing Supervisor). V15 explained that she then informed V7 of R1's allegations and instructed V8 to complete a report regarding R1's incident. V15 further explained that she completed a risk assessment reports, a physical injury incident report, and a pain assessment report. V15 was asked regarding R1's neurological assessment and monitoring and V15 stated that R1 did not lose consciousness and did not show any physical injury thus V15 did not complete a neurological assessment for R1. V15 then explained that neurological monitoring should be conducted anytime there is a report of a head injury or suspected head injury. V15 further explained that a neurological assessment is conducted for head injuries because there might be complications from a head injury and the resident may need to be sent to the hospital right away. V15 also explained that she informed R1's physician and the R1's family regarding R1's incident of alleged head injury and that she did not make a progress note regarding R1's incident with the details of the conversations because she was instructed by risk management at the facility not to complete a progress note and to only complete the risk assessment forms that V15 completed.On 2/18/26 at 11:41 am, V2 ( Director of Nursing, DON) stated that R1 is alert, oriented times three with dysphagia and was at the facility recovering from sub arachnoid hemorrhage stroke with right side weakness. V2 then stated that R1 required one person assist for her Activities of Daily Living (ADL's). V2 explained that on 1/12/26, R1 alleged that her head was hit on her bed while V8 (CNA) was providing care. V2 explained that V15 (Registered Nurse, RN) , V7 (RN) both conducted a pain, skin assessment, incident report and a post altercation allege abuse follow up form for R1's incident. V2 stated that when she spoke with R1, it was the next day and R1 stated that during care her head was hit but she did not feel it was intentional. V2 stated that she asked R1 if she felt safe and R1 stated that she has received good care and felt safe at the facility. V2 further stated that she assessed R1's head and she did not see any bumps or discoloration, and she told R1 to let staff know right away if she does not feel safe. V2 then stated that R1 did not have any further concerns after R1's allegation of her head being hit. V2 explained that a risk management form was completed. V2 explained that for a suspected head injury, the facility should check orientation, cognition, the residents vital signs, and pain. When V2 was asked regarding R1's neurological assessment monitoring from R1's 1/12/26 reported head injury V2 stated that she did not complete one. V2 then explained that a witness or unwitnessed head injury requires the residents neurological status to be monitored with neurological checks for 72 hours for change of condition and should be treated appropriately. V2 also explained that unwitnessed head injury should be especially monitored for a change of condition. V2 also explained that checking the residents vital signs is not the same as performing neurological checks. V2 stated that if a reported head injury does not receive neurological monitoring the resident could suffer complications and die.R1's Post Altercation/Alleged Abuse assessment dated [DATE] at 6:25 am, reviewed and shows assessment incomplete with no neurological checks conducted. R1's Accident/Incident Report dated 1/12/26 reviewed and shows no neurological checks conducted. R1's Risk Management dated 1/12/26 reviewed and shows no neurological checks conducted. R1's progress notes dated 01/12/26 through 1/15/26 with no documentation of neurological checks documented or performed. The facility's policy dated 07/2/25 and titled Neurocheck documents, in part: Procedures: The nurse will inform the physician of the incident and will follow physicians orders including a neurocheck on the resident.

Based on observations, interviews, and records review, the facility failed to provide sufficient nursing staff (Registered Nurses/Licensed Practical Nurses) to the third and fourth floors. This failure has the potential to affect 71 residents residing on these floors. Findings include: On 07/08/2025, at 12:45 PM, V12 (Licensed Practical Nurse-LPN) stated she is the only nurse on the third floor, and she was feeling overwhelmed. Medications were passed late this morning. She is not able to give the residents the attention and care they deserve because she is the only nurse taking care of 35 residents. V12 stated she started working full time at the facility in January and this change of having one nurse on the third floor was recently implemented but it is not working. V12 stated she has informed V2 (Director of Nursing) and her supervisor that she is overwhelmed and was told the supervisors would help. V12 stated she was not able to attend to of all her resident needs this morning. The morning medications were late for some residents. V12 stated she has enough Certified Nursing Assistants (CNAs) but they cannot perform nursing duties and are also asking her questions when residents need help that the CNAs cannot assist with. V12 stated even though this unit is a long-term unit, the residents have needs and a lot of medications to be administered. One nurse is not enough to do all the work and take care of residents' needs. On 07/08/2025, at 12:56 AM, V17 (Licensed Practical Nurse-LPN) stated she is the only nurse on the fourth floor. She is not able to provide and administer the residents morning medications on time or take care of the residents' needs at the same time. V17 stated she has 36 residents today and she was feeling overwhelmed. V17 stated she found out she would be working alone today when she came to work. V17 stated she was told the supervisors would help, but the supervisors are not always available to assist on the units. V17 stated she cannot provide quality care to the residents when she is alone and does not think one nurse is enough to work on the fourth floor with 36 residents. V17 stated she has three CNAs working on the fourth floor. That is enough CNAs but they cannot do nursing work therefore they cannot help V17 with her work. On 07/08/2025, at 3:00 PM, V22 (Staffing Coordinator) stated the facility staffs each floor with a different number of nursing staff. V22 stated each floor has three Certified Nursing Assistants (CNAs) in the morning, three on the evening shift and two for overnight. V22 stated on the third and fourth floors the nurses do 12-hour shifts. These two units are staffed with one nurse per floor. V22 stated on July 1st, 2025, there were 36 residents on 3rd floor, on 7/2/2025, 7/3/2025, 7/4/2025, 7/7/2025, 7/8/2025, there were 35 residents. On 7/5/2025 and 7/6/2025, there were 36 residents on the unit. V22 stated the third-floor houses long term residents therefore she was instructed by V2 (DON) to start staffing the units with only one nurse. V22 stated the fourth floor also houses long term residents. On 7/1/2025, 07/02/2025, 07/03/2025, 07/04/2025, there were 37 residents on the floor and on 7/05/2025, 07/06/2025, 07/07/2025, 07/08/2025, there were 38 residents. V22 stated she gets the directions on how to staff nurses from V2 (Director of Nursing). For the CNAs V22 does the math by dividing the three CNAs scheduled by the number of residents on the floor. V22 stated the nurses on the 3rd and 4th floor have complained to her that the 3rd and 4th floors are heavy for one nurse. V22 reported to V2 because she cannot make any decisions to add nurses because she is not a nurse herself. V22 stated there are supervisors to assist the agency nurses on the floors. On 07/08/2025, at 4:00 PM, V2 (Director of Nursing-DON) stated the 3rd and 4th floors have always had one nurse because these floors hold long term residents. V3 stated the nurses on these floors work twelve hour shifts from 7:00 AM to 7:00 PM. V2 stated before, the third and fourth floors each had a nurse working 8:00 AM to 5:00 PM to assist the nurses on these floors. V2 stated the 3rd and 4th floors were transitioned last week from having a helping nurse to having only one nurse on the unit working twelve hours. V2 stated this one nurse assignment on the 3rd and 4th floors started on Sunday, 7/6/2025. V2 stated even before this change was implemented, the nurses were already complaining that one nurse for the third and fourth was not enough because the workload was too much during the morning shift, which has the heaviest medication pass. V2 stated she told the nurses working on the 3rd and 4th floors to give it a try because the 7:00 AM medications and the 9:00 PM medications are almost similar. V2 stated the morning shift is busy because there are a lot of resident activities such as appointments, facility doctors rounding on residents, giving orders, phone calls from doctors to nurses, families calling the nurses, as well as CNAs asking nurses to assist with residents' needs that the CNAs cannot take care of. V2 stated today the nurses on third and fourth floor notified her (V2) that they were overwhelmed with the loads of the medications to pass and other work assignments. V2 stated she told the CNAs if they needed anything not to bother the nurses but go to her for assistance. V2 stated she knows the assignments are overwhelming on the third and fourth floors but there is support from the nursing management team. V2 stated if the nurses on third and fourth floors are complaining they are overwhelmed, the residents are not getting the proper care they deserve. V2 stated she will evaluate the situation because she wants the residents to get quality care. V2 stated she is the one who implemented the one nurse schedule for the third and fourth floors because she tried it herself and she was able to complete her work as a floor nurse on these units. V2 stated it was her fault that she implemented this schedule and reduced the nurses working on these two floors to one nurse per floor. Reviewed nurse staffing schedules from 07/01/2025 that document one nurse each for the third and fourth floors. Reviewed staffing policy dated 8/19/24 that documents: -It is the facility's policy to provide adequate staff to meet the needs of the residents which is the requirement under the federal regulations.

Based on observation, interview, and record review, the facility failed to administer resident's prescribed medications in a timely manner according to the physician orders. This failure affects 29 (R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35) residents in a total sample of 35 residents. Findings include: On 07/08/2025, at 11:42 AM, surveyor located on the fourth floor of the facility with V17 (Licensed Practical Nurse/LPN). V17 states to surveyor that she started her scheduled shift at the facility at 7:00 AM. V17 states she began administering medications to residents at approximately 8:00 AM. V17 states she is the only nurse assigned to work on the fourth floor of the facility today. V17 states she was informed by V2 (Director of Nursing/DON) sometime last week that the staffing on the fourth floor would change from two nurses to one nurse. V17 states she was not aware of when the change would take effect. V17 states she has been off work for the past 5 days. When she returned to work today, she was the only nurse assigned to work on the fourth floor. V17 states she is still in the process of administering morning medications to residents. V17 states some of the resident's medications are late and have turned red in color on the eMAR/electronic medication record. On 07/08/2025, at 11:45 AM, surveyor observes the eMAR that is deployed on the laptop computer attached to V17's medication cart. Surveyor observes the following resident's eMARs are red in color: R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21. On 07/08/2025, at 12:07 PM, V10 (Registered Nurse/RN) arrived on the fourth floor and states she is assigned to help assist V17 (LPN) with the medication administration pass on the fourth floor. V10 states she will now continue administering medications for the residents who have not received their morning medications. V10 states she recently clocked in and was called by V2 (DON) to come to assist in the facility. On 07/08/2025, at 12:20 PM, surveyor located on the third floor of the facility with V12 (Licensed Practical Nurse/LPN). V12 states she is the only nurse assigned to work on the third floor of the facility today. V12 states she was informed that this was a new nursing schedule that was being implemented. V12 states as of last week, there were 2 nurses assigned to work on the third floor of the facility. V12 states it now takes her longer to complete the morning medications pass due to only one nurse being scheduled to work on the third floor. V12 states some of the resident's medications are considered late and have turned red in color on the eMAR. V12 states she has not administered all scheduled medications to the resident's residing on the third floor of the facility. V12 states the time frame to administer resident's medication is one hour before the scheduled time and one hour after the scheduled time. V12 states if medication is administered an hour after it is scheduled, then it is considered late. On 07/08/2025, at 12:23 PM, surveyor observes the eMAR that is deployed on the laptop computer attached to V12's medication cart. Surveyor observes the following resident's eMAR is red in color: R5, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35. Medication Audit Report dated 07/08/2025, documents that R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35's scheduled medications were administered late. Facility policy undated titled Medication Administration: General Guidelines documents in part, FIVE RIGHTS- Right resident, right drug, right dose, right route and route time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration. Administration 2. Medications are administered in accordance with written orders of the prescriber. 10. Medications are administered within 1 hour before or after scheduled time. Unless otherwise specified by the prescriber. Facility policy dated 04/12/2024 titled, Patient-Centered Medication Pass Clinical Guidelines documents in part, 4. Nurses will administer and document the resident medications based on the established medication administration window.

Based on interviews and records review, the facility failed to provide one (R4) resident of three reviewed with access to medical records in a total sample of six. Findings include: R4's current face sheet documents R4's medical conditions to include but not limited to: cerebral infarction due to embolism of right middle cerebral artery, chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris. R4 is a closed record and was not residing in the facility during this investigation survey. On 07/08/2025, at 10:36 AM, V4 (R4's daughter) via phone stated she did not have POA (Power of attorney) paperwork but had surrogate for health paperwork which she had been able to use at other facilities without any issues. V4 stated V3 (Medical Records) told her without the POA paperwork on file at the facility, he was not able to give her any information regarding R4. V4 stated to date, she has not received R4's medical records from the facility. On 07/08/2025, at 1:44 PM, V3 (Medical Records Director) stated V4 requested for R4's medical records via email to V3 on 03/25/2025, which was after R4 had been discharged from the facility on 3/11/2025. V3 stated when he received R4's medical records request form, the POA (Power of Attorney) paperwork was missing. V3 stated he replied to V4 on the same day requesting V4 to send the POA paperwork. V4 responded she would work on that and on 4/28/2025, V4 sent V3 a document-Surrogate Decision (SD) form that stated V4 was R4's surrogate decision maker. V3 stated he sent R4's surrogate decision form to the corporate office on 5/12/2025 for them to review and tell V3 what to do. V3 stated on May 15th, 2025, corporate responded via mail and said she could not find the POA paperwork or the equivalent surrogate decision form. V3 stated he had attached the surrogate form on the email. V3 stated the facility accepts surrogate decision form for a person to be a resident's decision maker/POA. V3 stated he assumed the corporate office saw the surrogate decision form he attached to the email, but he thinks corporate only looked at the first page and did not open the other attachments. The surrogate decision form is accepted by the facility to release a resident's medical records to the person listed as a surrogate on the form. V4 stated he did not follow up with the corporate office to see why the document was not deemed legit. V4 stated someone in facility corporate office dropped the ball. V3 stated he reached out to V4 on 5/19/2025. V4 told her the surrogate document was not varied as a power of attorney document/surrogate form. V4 stated she had sent a surrogate decision form to V3 that was already completed to facilitate her (V4) in receiving R4's medical records from the facility. After V3 completed the interview with surveyor and surveyor reviewed R4's documents, V3 came back after approximately an hour and gave the surveyor a concern form dated 07/08/2025. The form stated V3 reviewed the surrogate decision maker form and received approval to release medical records to V4. V3 stated there were not new documents added by V4 and the documents reviewed were the same ones V3 had sent to corporate on 5/15/2025 for approval. V3 stated the documents were approved today and V3 has sent to V4 R4's medical records. V3 stated R4's medical records should have been sent to V4 in May when V4 requested because V4 had sent the legal documents the facility accepts to release a resident's medical records to a surrogate. Surveyor reviewed an email sent to the corporate office on 3/25/2025, with attachments of Health Care Surrogate Act Physician Documentation and Certification. Reviewed Health Care Surrogate Act Physician Documentation and Certification signed by V4 on 3/15/2025 and the physician on 4/22/2025. It was given to V3 who sent it to the facility corporate office via email on 3/25/2025. Policy titled Medical Records Request and access dated 8/16/24, documents: -The resident or regal representative of the resident will be allowed access to inspect resident's medical records within 24 hours of a valid or oral or written request to the Administrator excluding weekends or holidays.

Based on interview and record review the facility failed to assure that one resident (R2) with intact skin, received the necessary treatment and services to prevent the development pressure wounds. This failure resulted in R2's development and worsening of two pressure ulcers, requiring hospitalization for wound infection and surgical intervention of wound. Findings include: R2's medical diagnoses include but are not limited to intraspinal abscess and granuloma, neuromuscular dysfunction of bladder, unsteadiness on feet, secondary malignant neoplasm of colon, neoplasm of unspecified behavior of endocrine glands and other parts of nervous system, essential hypertension. R2's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R2's cognition is intact. R2's Care plan dated 02/19/25 documents in part, R2 has an ADL (Activities of Daily Living) self-care performance deficit and Impaired mobility .R2 will be assisted with ADLs as needed .Toilet hygiene: I require total assistance to maintain perineal hygiene .Bed mobility: I require weight bearing assistance to move to and from a lying position, turn side to side, and position while in bed or alternate sleep furniture .Ambulation: I am non ambulatory. R2's care plan dated 02/20/25 documents in part, R2 has impaired ability in moving to and from a lying position, turning side to side, and positioning self in bed due to generalized weakness, decreased endurance, limited ROM (range of motion) and forgetfulness related to cognitive impairment .R2 will participate in turning and repositioning program to remain free of complications related to immobility, including contractures, thrombus formation skin-breakdown .Place pillows for positioning as needed. R2's care plan dated 02/20/25 documents in part, R2 was admitted with a scar on his upper back, R2 is at risk for impairment to skin integrity due to comorbidities and a Braden scale score of 14 .resident will continue to have skin intact .High risk - skin check every shift. Report abnormalities to the nurse. Keep skin clean and dry. LAL (low air loss) mattress .Turn and reposition at least every 2 hours and as needed. R2's progress note with date of service dated 02/20/25 documents in part, Skin: warm and dry, intact, no open wound. R2 wound assessment dated [DATE] documents in part, Skin Alteration #1 .1. Is this a New skin alteration: Yes .Site: Right buttock, Type: Pressure, Length: 4 centimeters, Width: 5 centimeters, Depth: 0.1 centimeters, Stage: Unstageable .Skin Alteration #2 .1. Is this a New skin alteration? Yes .Site: Left heel, Type: Pressure, Length: 5 centimeters, Width 5 centimeters, Depth 0.1 centimeters, Stage 2. R2 wound assessment dated [DATE] documents in part, Skin Alteration #1 .1. Is this a New skin alteration: Yes .Site: Right buttock, Type: Pressure, Length: 10 centimeters, Width: 6 centimeters, Depth: 0.1 centimeters, Stage: Unstageable .Skin Alteration #2 .1. Is this a New skin alteration? Yes .Site: Left heel, Type: Pressure, Length: 5 centimeters, Width 5 centimeters, Depth 0.1 centimeters, Stage 2. On 03/17/25 at 12:55pm, R2 stated that he was admitted to the facility with no wounds and his skin was 100% intact. R2 stated that he has no control over his body and was unable to reposition himself in bed. R2 stated that he needed assistance from the nursing staff to be repositioned in bed. R2 stated that the facility's staff did not check on him regularly. R2 stated that after his wounds developed, staff still never checked on him and repositioned him regularly even when asked. R2 stated that he was admitted to the hospital with symptoms of fever and chills and was told he had a flesh-eating bacteria. R2 stated that he already had pain from the cancer that he has but has been experiencing more pain since the development of the wounds. R2 stated that he feels horrible and anxious because he is not able to continue treatment for his cancer until the wound heals. On 03/16/25 at 12:21pm V11 (Licensed Practical Nurse/LPN) stated that R2 never refused to be cleaned or repositioned. V11 stated that sometimes when she went to give R2 medications that he would ask to be repositioned. V11 stated that R2 was incontinent of bowel and bladder and would put on the call light when he needed to be cleaned. On 03/16/25 at 2:05pm V13 (Wound Care Director) stated that a bedbound resident should be repositioned every 2 hours. V13 stated that R2 was admitted to the facility on [DATE] with intact skin. V13 stated that she was informed on 02/26/25 that R2 had developed two new wounds. V13 stated that R2 had developed a wound to his right buttock and left heel. V13 stated that R2 never refused care. V13 stated that on 03/03/25, R2's wound had gotten worse, so an air mattress and heel protectors were ordered for R2. V13 stated that if an air mattress would have been ordered on the day that the R2's wound was first discovered, R2's wound may not have gotten worse. V13 stated that on 03/09/25, she was informed by another wound nurse that R2's wound didn't look good. V13 stated that at that point she went to assess R2's wound herself and noticed purulent drainage and a strong odor from the wound. On 03/17/25 at 11:22am V15 (Wound Care Nursed Practitioner) stated that she first assessed R'2 skin on 02/20/25 and R2's skin was intact. V15 stated that the wound care team was first notified of R2's new wound on 02/26/25. V15 stated that she first assessed R2's new wound on 03/03/25. V15 stated that R2 had limited bed mobility and was dependent on the staff to reposition him. V15 stated that based on her assessment, R2 developed a pressure ulcer due to not being repositioned, possibly not being cleaned, along with his comorbidities as a risk factor. R2's physician progress note dated 02/20/25 documents in part, decreased sensation to both legs .patient has risk for developing contractures, pressure ulcers, poor healing or fall if not receiving adequate therapy and pain control. R2's Nurse Practitioner (NP) progress note dated 02/26/25 documents in part, On admission skin assessment, patient has no open wounds or skin issues .continue with turning and repositioning schedule per protocol for pressure prevention. R2's progress note dated 03/03/25 documents in part, Wound care team was notified of new wounds. Upon assessment, patient had an unstageable pressure injury on the right buttock and a stage 2 pressure injury on the left heel .The patient is at increased risk for developing skin breakdown and moisture associated skin damage due to fecal and urinary incontinence, inability to perform self-care. Patient is at moderate risk for pressure ulcer formation related to decreased mobility, comorbidities, incontinence of urine and stool. R2's physician hospital note dated 03/09/25 documents in part, Large paramedian right gluteal ulcer with scattered subcutaneous air tracking into the right gluteal subcutaneous soft tissue and gluteus maximum muscle. Findings can be seen in the early necrotizing fasciitis .purulent, malodorous right gluteal wound .Plan: General surgeon on consult status post I&D (incision and drainage) at bedside today, plan for OR (operating room) tomorrow for more extensive I&D. Facility's policy titled Wound Care Guidelines dated 01/23/25 documents in part, Overview of the Program .The goal of this care guidelines is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in the facility .1. Procedures: .C. Each risk factor and potential causes identified should be reviewed individually and addressed into the resident's care plan. D. Facility shall develop a plan of care and implement intervention according to the resident's Braden Scale and Clinical Evaluation or identified individual risk factors .3. Prevention of skin breakdown includes but not limited to: B. Daily regular skin hygiene. C. Inspection of the skin every shift with care for signs of breakdown. H. Administration of scheduled shower/bath and documentation of completion and findings in Task/POC .4. Activity, Mobility, and Positioning .B. Establish an individualized turning and repositioning schedule if the resident is immobile or with impaired physical functioning. C. While in bed, resident should be turned/repositioned at least every 2 hours or as indicated in the residents' plan of care. While resident sitting in wheelchair, resident should be turned/repositioned at least every hour or as indicated in resident's plan of care. D. While in a sitting position and/or if the head of bed is elevated greater than 30 degrees, resident should be repositioned at least every 2 hours or as indicated in the plan of care .J. Off load elbows and heels as needed. K. Elevate resident heels off the bed as indicated .5. Skin Protection .E. Assess and treat incontinence. As part of incontinent care, apply protective ointments, moisture barriers and other products to the skin to counteract effects of excessive moisture on the skin. 9. Documentation .C. The care plan shall be evaluated and revised based on resident's response to treatment, treatment goals and outcomes Facility's policy titled Skin Care Regimen and Treatment Formulary dated 01/24/25 documents in part, It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown .Procedures .6. Residents who are not able to turn and reposition themselves will be turned and repositioned at least every 2 hours unless otherwise specified by the physician.

Based on observation, interview, and record review the facility failed to serve adequate food portions as documented on the menu and meal tickets. This failure has the potential to affect all 213 residents receiving food prepared in the facility's kitchen. Findings Include: On 02/23/25 at 8:45 AM, surveyor entered kitchen and observed the breakfast tray line still in progress. Observed a 4-ounce ladle being used to portion out the grits and oatmeal for all of the diet (regular, ground and pureed) and a number 12-scoop used to portion out pureed toast. On 02/23/25 at 8:50 AM, V14 (Cook) stated she is the one who sets up the tray line with the serving utensils which should be used to portion out the resident's food. V14 stated she looks at the meal tickets to determine the correct portion sizes to be served. V14 stated the meal tickets do not say which serving utensil should be used, it only gives portion measurements. V14 stated for example, the meal ticket will read 3/4 cup portion for grits/oatmeal, it does not say to use a 6-ounce ladle which is what we use to serve the hot cereal. V14 stated because she has been working in the kitchen for a long time, she knows which serving utensil gives what portion. V14 stated there used to be a diagram/poster guide which listed the different scoop numbers and the servings they each yielded but that is not up anymore. V14 stated, it must have fallen off the wall. On 02/23/25 at 8:57 AM, reviewed with V14 the serving utensils being used on the tray line. V14 observed the 4-ounce ladle being used to portion out the grits and oatmeal. V14 stated that is a 4-ounce ladle and it should be a 6-ounce ladle. V14 observed all of the pureed food items being portioned out with a number 12-scoop. V14 stated those are not the correct serving utensils and they are a mistake. V14 stated the kitchen should be using the correct serving utensils so the residents can get the full portion of food they are supposed to base on the menu created for them. On 02/23/25 at 9:00 AM, observed large container of different serving utensils including number ten scoops and six-ounce ladles. On 02/23/25 at 1:22 PM, V23 (Dietary Director) stated it is the cook's responsibility to set up the tray line with the correct serving utensils to be used to portion out the food. V23 stated they should be looking at the Diet Manual Spreadsheet to check which serving utensils are needed and that these are kept in a binder in the kitchen for their reference. V23 stated the Diet Manual Spreadsheets are based on menus which are created by and approved by a corporate Registered Dietitian. V23 stated it is important for the kitchen to follow the Diet Manual Spreadsheets to determine which serving utensil should be used to make sure the resident's nutritional needs are being met. V23 stated if the kitchen staff is using the wrong serving utensil when portioning out the resident's food then the residents may not be receiving enough food which as the potential to lead to malnutrition and weight loss. Facility provided list of resident's diet orders based on census on 02/23/25. There are six residents who receive nothing by mouth (NPO). Facility provide policy titled, Menus dated October 2019 which documents in part, 1.) it is the center policy that menus are planned in advance, and to meet the nutritional needs of the residents/patients, will be developed utilizing an established national guideline. 2.) The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. 3.) Menus are served as written. Facility document titled in part, Illinois Diet Guide Sheet Sunday (Day 15) Breakfast documents in part for 3/4 cup grits to be served to regular, chopped, and ground consistencies and for pureed diet consistencies to receive number 6-scoop of grits and number 10-scoop of pureed toast. Facility provided document titled, Portion Control Chart dated 12/29/2021 which documents in part, number 6-scoop to provide 5.33 ounces, number 10-scoop to provide 3.2 ounces and number 12-scoop to provide 2.58 ounces. Facility provided recipe titled, Great Grits which documents portion size as 3/4 cup.

Based on observation, interview and record review, the facility failed to ensure residents were notified, invited, and engaged to attend meaningful activities that incorporate residents' interests for 2 (R1, R4) out of 3 residents reviewed for residents' rights. Findings Include: On 2/23/25 at 8:55 AM, R1 was observed lying in bed alert and able to verbalize needs. R1 is blind and can't read. R1 can only see contrast and forms. R1 stated R1 would like to go to activities like bingo but staff does not tell R1 of what activities are going on in the facility each day. R1 stated that R1 also likes to go to church and listens to gospels. R1 stated staff used to hand out a sheet about activities, but it's been a while since R1 gotten one. R1 stated R1 does not know what other things are going on in the facility for today. On 2/23/25 at 10:30 AM, R4's up in bed alert and able to verbalize needs. R4 was interviewed about activities in the facility. R4 stated, Since I've been here nobody tells me what activities are going on in the facility. I've been here for 3 months. I would like to do some activities if something interests me. On 2/23/25 at 11:01 AM, Surveyor observed V11 (Activity Aide) conducting yoga/meditation session on the third floor for activities. R1 and R4 were not in attendance. On 2/23/25 at 11:06 AM, interviewed V11 and stated that there are activities in the facility every day held on third floor or fourth floor. The calendars are posted on the board. V11 stated, We go around to all residents and invite residents of what activities I'm doing. We let them know every morning. V11 stated V11 did not stop by this morning to notify and invite R1 about today's activities. V11 stated V11 did not stop by this morning to invite R4 to activities either. On 2/23/25 at 11:46 AM, interviewed V2 (Activity Director) and stated that R1 refuses to go to activities. V2 stated activity calendars are posted on every floor. V2 stated V2's staff and [V2] invite the residents to activities and encourage them to attend every day. V2 stated V2 did not invite R1 to go to activities this morning. V2 stated there's one activity staff [V11] in the facility today and not sure if V11 invited R1 to activities. V2 stated, That is the goal is to invite each resident to attend activities every day. We visit [R1] we encourage [R1] to attend activities. [R1] said [R1] likes bingo. We explain to [R1] that we have bingo some days. Normally [R1] just refuses to go to activities. We don't have other things for [R1] to do besides the one on the calendar. V2 stated that R4 does not attend activities either. V2 stated, I can't remember if I invited [R4] for activities this morning. On 2/23/25 at 2:07 PM, Surveyor observed V11 (Activity Aide) conducting activities of gospel hour and puzzles on the third floor. R1 and R4 were not in attendance. V11 stated V11's the only activity aide in the building doing activities. On 2/23/25 at 2:22 PM, R1's still in bed alert and awake. R1 stated V2 (Activity Director) just left and just gave R1 a sheet of the week about activities. R1 stated, [V2] told me that there are activities from 10:30 AM to 3:00 PM. Surveyor asked R1 if R1 is aware of the activity gospel hour that started at 2:00 PM listed on the activity calendar for today. R1 stated, I would like to do gospel hour. I didn't know about that. Nobody invited me to that. I would have had them get me dressed and attend to that one. R1 stated that R1 would also have attended Zumba and daily chronicles this morning if staff had invited R1 to attend. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15 and is total dependent on staff assistance for transferring from bed to chair. R1's progress notes dated 2/3/25 at 12:55 PM documented by V13 (Licensed Clinical Social Worker) reads in part: R1 has diagnosis of adjustment disorder with mixed anxiety and depressed mood. R1 continues to have depression and anxiety due to being in the facility and loss of independence and home. R1 has significant mobility decline. Specific goal for R1 is to engage in at least one facility activity one time per week to reduce isolation and depression. R4's MDS dated [DATE] shows R4 is cognitively intact with BIMS of 15 and can walk with supervision. R4's activity care plan initiated 2/23/25 shows R4 engages in leisure/recreation pursuits: Music, Social interaction, Television, Movies with one intervention documents in part: Encourage R4 to pursue formal and informal leisure interest opportunities. The facility's February Activities calendar shows on the 23rd activities include Zumba mix at 10:30 AM, daily chronicles at 11:00 AM, gospel hour at 2:00 PM, puzzle mania at 3:00 PM, and pop in visits at 4:00 PM. The facility's Activity Policy dated 7/12/24 documents in part: It is the facility's policy to provide meaningful activity to residents. Provide group activities to residents that appeal to their interest on a daily basis. Activities may be based on specific needs, or interests, or culture, or background, etc. Program of Activities includes a combination of large and small group, one-to-one, and self-directed activities.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, c.) equipment used for food preparation not properly sanitized, and d.) dishwasher temperatures not reaching at least 160 degrees Fahrenheit during the wash/rinse cycle. These deficient practices have the potential to affect all 183 residents receiving food prepared in the facility kitchen. Findings include: On [DATE], at 10:15 AM, during initial kitchen tour with V21 (Dietary Manager), the following food items were found in the walk-in cooler: 1. 3 beverage dispensers and 2 beverage pitchers filled with red colored juice, no preparation date, expiration date, or use by date labeled on dispensers or pitchers. 2. 1 plastic container of individual margarine spreads with a use by date of [DATE]. 3. 1 opened box of semi-sweet chocolate chips, no expiration or use by date. 4. 1 opened package of hard-boiled eggs, no expiration or use by date. On [DATE], at 10:29 AM, the following items were found in the walk-in freezer: 1. 1 opened box of striped pangasius fillet fish, no open date, no expiration date. 2. 1 opened box of bread, no open date, no expiration date. 3. 2 plates covered with aluminum foil, no preparation date, no expiration or use by date. On [DATE], at 10:37 AM, the following items were found in the dry storage area: 1. 1 opened 25-pound bag of instant nonfat dry milk sitting on a shelf. On [DATE], at 10:40 AM, V21 states that the beverage dispensers and pitchers were filled with fruit punch juice. V21 states the fruit punch juice was prepared on [DATE]. V21 states that she was made aware that if beverages were prepared on the same day it was intended to be used, then it does not have to be labeled with a date. Surveyor inquires to V21 about how the preparation date is determined if there is no date labeled on the juice dispensers. V21 then observed searching the facility policies and later states that she is unable to find this verbiage pertaining to labeling the juice dispensers in the facility policy. V21 states the plastic container of individual margarine spreads were expired and should have discarded after seven days. V21 states the plastic container of individual margarine spreads should not be stored in the walk-in cooler for resident use. V21 states the opened 25-pound bag of instant nonfat dry milk should be stored in an airtight container. V21 states that all food items stored in the cooler and freezer should have an open and expiration date written on the packaging and always covered/wrapped. On [DATE], at 10:45 AM, during tour of the dish washing area with V21 (Dietary Manager), surveyor requested V21 to test the temperature of the cleaning cycle. V21 places a testing strip on a cup and put it inside the dishwasher and ran the cycle. As the dishwasher cycle ran, the wash temperature gauge was observed at 130 degrees Fahrenheit, and the rinse temperature gauge was observed at 138 degrees Fahrenheit. Once the dishwasher cycle completed, the testing strip remained white in color and did not turn black in color. V21 states if the dishwasher reaches the correct temperature, then the testing strip will turn black in color to indicate that the dishware has been sanitized properly. V21 states the final temperature should reach at least 160 degrees Fahrenheit. V21 then places another testing strip on a cup and ran the dishwasher cycle again, the second testing strip does not turn black and remain white color. V21 signs her name and dates both test strips that did not turn black and remained white in color. On [DATE], at 11:08 AM, V21 tests the dishwasher temperature again and a third testing strip does not turn black, indicating the correct dishwasher temperatures were not reached. V21 states she will contact the dishwasher manufacturer company to make them aware of the need for the dishwasher to be repaired. V21 states this is the only dishwasher in the facility. V21 states if the correct temperatures are not reached for the dishwasher, then dishware will not be sanitized properly, and residents could potentially get food poisoning. On [DATE], at approximately 4:30 PM, V1 (Administrator) states the dishwasher manufacturer came to the facility today to service the dishwasher and the dishwasher is now working properly. On [DATE], at 4:50 PM, with V1 present, V21 (Dietary Manager) tests the dishwasher temperature again. V21 places a testing strip on a plate and put it inside the dishwasher and ran the cycle. As the dishwasher cycle ran, the wash temperature gauge was observed at 110 degrees Fahrenheit, and the rinse temperature gauge was observed at 130 degrees Fahrenheit. Once the dishwasher cycle completed, the fourth testing strip remained white in color and did not turn black in color. V21 then places another testing strip on a plate and ran the dishwasher cycle again, the fifth testing strip does not turn black and remain white color. V1 states she will contact the dishwasher manufacturer company again to make them aware of the need for the dishwasher to be repaired. V1 states the facility will serve the residents' dinner on disposable dinnerware this evening. On [DATE], at 10:54 AM, V19 (Cook), V21 (Dietary Manager), and surveyor located next to the three-compartment sink inside of the kitchen. V19 observed washing a pan in the three-compartment sink. V19 observed submerging the pan in the sanitize sink for approximately 8 seconds. V19 states she submerged the pan in the sanitize sink for approximately 10 seconds. On [DATE], at 11:07 AM, V19 states she should have submerged the pan in the sanitizing solution for 20 seconds. V19 states she does not have a reason for not submerging the pan in the sanitizing solution for the required time to sanitize the pan. Facility document dated [DATE], titled Diet Type Report documents that a total of eight residents residing in the facility have a diet order for NPO/nothing by mouth and does not receive food prepared in the facility kitchen. Facility policy dated ,d+[DATE], titled Food Storage- Dry Goods documents in part, 5. The Dining Service Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. Facility policy dated ,d+[DATE], titled Food Storage: Cold documents in part, 5. The Dining Service Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled, and dated and arranged in a manner to prevent cross contamination. Facility documents undated, titled TCS Foods & 7-Day Labeling documents in part, Temperature Control for Safety (TCS) foods can grow harmful bacteria if stored or labeled in correctly. TCS foods include items like meat, eggs, fish, dairy, rice, and cut or prepped fruits and vegetables. Labeling TCS foods we prepare helps us know when they were made and when they might spoil. We must label and use TCS foods within 7 days from preparation to stay safe. Facility documents undated, titled TCS Food Labeling Guide documents in part, TCS food labels must include these 4 things: 1. Item 2. Prep Date 3. Use by date 4. Your initials. Facility policy dated ,d+[DATE] titled, Ware washing documents in part, 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Facility document titled Hi Temp Warewash Instructions documents in part that the dishwasher temperature gauge should be as follows: Prewash: 100- 130 degrees Fahrenheit Wash: ,d+[DATE] degrees Fahrenheit Power Rinse: ,d+[DATE] degrees Fahrenheit Final Rinse: ,d+[DATE] degrees Fahrenheit Dish washer testing strips documents when the indicator turns black, stated temperature has been achieved. The testing strip documents 160 degrees Fahrenheit as the stated temperature. Facility policy dated ,d+[DATE] titled, Operation of the Three Compartment Sink documents in part, 5. Completely submerge pots/pans in the sanitizing solution . items should be in contact with the sanitizing solution for 30 seconds or per manufacturers' recommendation.

Based on interview and record review the facility failed to complete a resident's assessment and transmit data to the CMS (Centers for Medicaid and Medicare) system within 14 days after resident discharged from the facility for one (R151) resident reviewed in a sample of 35 residents. Findings include: 12/05/24 at 3:39 PM, V34 (MDS/Clinical Coordinator) states that she is familiar with R151, when residents go to the hospital, MDS completes the discharge return anticipated assessment and plan needs to be completed per MDS guidelines. V34 states that she has to check R151's assessments. V34 states that when residents are admitted MDS completes an entry assessment. V34 states that if the resident gets sent out to the hospital an assessment must be completed within 14 days. With V34, R151's MDS assessment reviewed and V34 states that R151's discharge assessment was not completed. V34 states that R151's discharge assessment will be completed today. R151's MDS assessment documents in part Discharge complete by 08/5/2024- 122 days overdue. Facility document note dated title RAI OBRA- required assessment summary documents in part, discharge assessment return anticipated non-comprehensive MDS completion date + 14 calendar days.

Based on interviews and record review, the facility failed to refer one resident (R143) of seven residents reviewed with serious mental disorders for a Preadmission Screening and Resident Review (PASARR) level 11 assessment in a sample of 35. Findings include: R143 current face sheet documents R143 is a [AGE] year-old individual with medical diagnosis dated 4/11/2024 include but not limited to: schizoaffective disorder, unspecified, anxiety disorder, unspecified, depression, unspecified. Brief Interview for Mental Status (BIMS) dated 10/15/2024, does not document R143's BIMS. R143's Preadmission Screening and Resident Review (PASRR) 1 Screening dated 04/09/2024 documents R143 does not have suspected of known mental diagnosis. On 12/05/2024, at 1:02 PM, V2 (Director of Nursing-DON) said R143 has mental health diagnosis of schizoaffective disorder, depression, and anxiety and should have been evaluated for PASARR 11 so R143's behavior can be monitored as well as the medications he is taking for behavioral health. V2 further stated if PASARR 11 is not completed, there could be an Issue with not taking care of R143's mental issues as they might not be properly addressed. On 12/05/2024, at 2:42 PM, V1(Administrator) stated the facility relies on the hospitals to send the correct information of residents regarding PASARR 11 and the hospital documented R143 did not have any mental health diagnosis. V1 further stated the staff member in the facility's admission office is not a nurse, therefore he/she did not look at R143's diagnosis to determine R143 needed a PASARR 11 screening. V1 stated after surveyor notifying the facility R143 does not have a PASARR 11, she (V1) has reached out to the screening agency to screen R143. PASSAR Policy titled PASSAR Screening of Residents with Mental Disorders or Intellectual Disability, dated 8/16/2024 documents: -It's the facility policy to ensure that residents with Mental Disorder and those with Intellectual Disorder will receive PASSAR Screening within the timeframe allowed. 1. The facility will not allow admission from the hospital without a preadmission screening which includes OBRA Screen 1 and OBRA Screen 2 (PASSAR Screening) for those with mental or intellectual Disorder.

Based on observation, interview and record review, the facility failed to ensure pressure ulcer preventative measures were accurately applied for three residents (R3, R26 and R49) in a sample of 35 residents reviewed for pressure ulcer. Findings include: 12/4/24, at 12:24 PM, observed R49 low air loss mattress setting at approximately 310 LBS (pounds). 12/4/24, at 12:27 PM, observed R3 lying on a low air loss mattress. The mattress had a flat sheet on it and there was a fabric chuck/pad underneath R3 and R3 was wearing an adult brief. 12/3/24, at 1:15 PM, observed R26 low air loss mattress setting at 90 LBS. There was a fitted sheet on the mattress and a fabric chuck/pad underneath R26 and R26 was wearing an adult brief. 12/4/24, at 1:27 PM, V31 (Registered Nurse) verified there was a fitted sheet on R26's low air loss mattress and a pad that is referred to as a chuck and R26 was wearing an undergarment/adult brief. V31 stated R26 has a low air loss mattress for wounds. The general purpose of the low air loss mattress is to prevent wounds and keep wounds from getting worse. V31 stated there can be a fitted or flat sheet on the mattress. There should be only one layer on the mattress. V31 verified there are three layers between the mattress and R26 and that is too many layers. 12/4/24, at 1:38 PM, V32 (Certified Nursing Assistant) stated there should be only one layer between the low air loss mattress and the resident. V32 verified there was a fitted sheet on R26's mattress that should not be there. It should be a flat sheet. V32 verified there was a fabric chuck that should not be there. V32 stated R26 can have on a brief. The brief is not considered a layer. V32 stated the purpose of the low air loss mattress is to prevent bed sores for incontinent patients on boney prominences. Too many layers may make the mattress less effective. 12/5/24, at 1:00 PM, observed R49's low air loss mattress setting. V8 (Licensed Practical Nurse) verified R49's low air loss mattress setting was at 310 LBS-318LBS. 12/5/24, at 12:15 PM, V23 (Wound Care Coordinator) stated we have our own air mattresses. The weight setting should be set at the patients approximate weight. The facility weighs the resident to obtain correct weight. Initially, supply staff sets up the mattress, adjusts the weight according to resident weight. On wound cares next round on patients with low air loss mattress, we check on the setting and functioning of the mattress. The wound techs/CNAs (Certified Nursing Assistants) round to check that the mattress is functioning, and the weight settings are correct. If the resident is incontinent, then we use an incontinent pad/chuck, flat or fitted sheet on the mattress, and the resident can be in an adult brief. That would be three layers. If the resident is not incontinent then we use underwear/pullup, chuck and a flat or fitted sheet on the mattress. That would be three layers. The purpose of the mattress is to relieve pressure. It's important as a preventative measure for pressure wounds. The three layers are not impeding the purpose of the mattress. 12/5/24, at 5:30 PM, V2 (Director of Nursing) stated the low air loss mattress settings should be according to the patient's weight. Generally, there is supposed to be only one layer on the mattress. If the resident is incontinent, we can use a brief, chuck and a flat or fitted sheet, three layers. Purpose of the mattress is pressure ulcer prevention and aiding in pressure ulcer healing. If the low air loss mattress is not set correctly, it does not serve the purpose for proper intervention to aide in wound healing or prevention. Can have no more than three layers. According to R3's physician order summary provided by facility 12/5/24, R3 has active order LAL (low air loss) mattress, order date 12/20/2022. According to R26's physician order summary provided by facility 12/5/24, R26 has active order LAL mattress, order date 10/16/2024. According to R26 weights and vitals summary provided by facility 12/5/24, R26 weight on 11/6/24 was 148.4 LBS. According to R49 physician order summary provided by facility 12/5/24, R49 has active order LAL mattress, order date 10/25/2020. According to R49 weights and vitals summary provided by facility 12/5/24, R49 weight on 10/8/24 was 227 LBS. Proactive Medical Products Operation Manual, no date, reads in part: Installation Instructions Step 2 You may place a thin cotton sheet over the overlay top cover. Operating Instructions Step 5 Patients can directly lie on the overlay or cover with a sheet and tuck loosely to increase the comfort of the patient. Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit. [NAME] Medical Operating Instructions Manual, no date, reads in part: Operating Instructions 4. Once the mattress or overlay pad is inflated to its normal size, set mode key to STATIC therapy. Using the comfort control keys set the required patient weight position.

Based on observations, interviews and records review, the facility failed to keep record of receipt and disposition of one controlled drug in sufficient detail to enable an accurate reconciliation in a medication cart that serves 23 residents on the 8th floor and failed to keep an account of all controlled drugs is maintained and accurate for three (R61, R117, R429) in a sample of 35 reviewed. Findings include: 12/03/2024 at 10:20 AM, V5 (Registered Nurse) states that she is an agency nurse. After reviewing narcotics in the medication cart, there was one Hydromorphone 2mg (milligram) tablet in a three-tablet bingo card, appeared as if it was cut into this section, with no resident name and no controlled substance record form. V5 states that when she counted the narcotics with the previous nurse, V5 states that she was informed that it was an extra medication. V5 states that this medication should not be in the cart and unaccounted for. V5 states that there is no controlled substance record form to account for this medication (Hydromorphone 2mg one tablet). V5 states that she does not know if V2 (Director of Nursing) is aware. 12/5/24, 1:10 PM, V17 (Registered Nurse) states that she is from agency. V17 states, she picks up a lot of shifts for the facility. V17 states, that she just finished medication pass and she didn't sign the narcotic book. V17 states that it should be signed. V17 states that she was trying to finish giving other medications. Three residents' narcotic medications do not tally as to the records and the actual count of medicines: R 429's Hydrocodone record has 18, actual count of tablets has 17. R 429's Pregabalin record has 20, actual count of tablets has 19. R61's Pregabalin record has 13, actual count of tablets is 12. R117's Clonazepam record has 12, actual count of tablets is 10. V17 states that she gave R117 the medication twice today and has not signed it. V17 states that it is important to have the correct narcotic count so you don't give it again and can have proper count. V17 states that she knows that it is supposed to be accounted for in the narcotic records. V17 states that she just wanted to get her blood sugar monitoring done and then do her documentation. 12/05/2024, 3:15 PM, V2 (Director of Nursing) states that the narcotic medication (hydromorphone) 2mg that was unaccounted was used for one of the residents that didn't have their supply in yet. V2 states that all narcotics are supposed to be accounted for and documented on a controlled substance sheet. Facility document dated 7/26/2024, title Controlled Medications Count documents in part, it is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R89, R427) of six residents reviewed for medication administration resulting in a 6.67% error rate in a sample of 35 reviewed. Findings include: 12/04/2024, 8:40 AM, observed V7 (Registered Nurse/RN) administer the following medication: V7 primed tubing, connected to machine, wiped lumen, no bubbles, connected to resident. V7 states it should run over 55 minutes. Surveyor observed pump set at 166ml/hr. Vancomycin 750mg/150ml. Label says infuse at 120ml/hr. nurse dated it with date and time. R427's current Physician Order Sheet document in part: Vancomycin HCI 750 MG/150ML Solution premixed vancomycin 750mg in 150ml water. Infuse intravenously at 120ml/hr (hour) over 75mins. Every other day for bone and joint infection until 12/31/24. 12/04/24, 9:57 AM, V7 (RN) states that nurses usually choose the intravenous (IV) medication dose in the pump, and the pump will set up the rate. V7 states that's the procedure. We put in the dose and the machine will give us the rate per hour. V7 states that she will notify V2 and call the pharmacy regarding R427's IV antibiotic medication. Surveyor questioned V7 if there is an option to change the rate on the IV pump. V7 responded I am not sure to be honest, I would have to check and get back to you. 12/04/2024, 1:16 PM, V15 (Medical Director) states that nursing staff talked to the pharmacist regarding the vancomycin administered at a faster rate. V15 states only need to watch out for local area, monitor site every shift. V15 states that R427's IV medication rate and order is still staying as is. V15 states that he looked at R427's IV site and did not observe any adverse reactions. V15 states that nursing should be following the orders including right rate. V15 states that the ordering dose was administered, V15 states but just went in a little faster. V15 states that pharmacy recommended only to monitor the site. V15 states that no level of harm occurred. 12/04/24 8:58 AM, V9 states that she works through agency, and she has worked in the facility before. Observed V9 (Licensed Practical Nurse) administer medication to R89: Vitamin D 1000 IU (UNIT) 1 tablet given. R89's current Physician Order Sheet document in part: Cholecalciferol Tablet 1000 UNIT Give 2 tablet by mouth 12/04/2024, 8:00 AM, one time a day for supplement. Facility document dated 8/16/2024, titled Medication Pass documents in part, it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.

Based on observation, interview, and record review, the facility failed to ensure one resident (R377) had a functioning call light within reach, and ensure two residents (R14, R24) had access to the call light system in a total sample of 35 residents reviewed. Findings include: 1. On 12/03/2024, at 3:23 PM, surveyor located inside of R14's room and observes that R14's call light is not within reach. R14's call light cord observed wrapped twice around her bed frame and hanging down beside her bed. Surveyor inquires to R14 if she can use her call light and R14 answers yes. On 12/03/2024, at 3:25 PM, surveyor makes V20 (Certified Nursing Assistant/CNA) aware that R14's call light is not within her reach. V20 now located inside of R14's room and observes that R14's call light is hanging and wrapped around the bed and not within R14's reach. V20 then observed unwrapping R14's call light cord from around the bed and placing R14's call light device within her reach. R14 then return demonstrates the use of her call light by squeezing her call light. Surveyor then hears an audible sound when R14's call light is activated. V20 states she started her shift at 2:00 PM and should have placed R14's call light within her reach when she made her rounds earlier. V20 states R14 would not be able to call for help if her call light is not placed within her reach. R14's Facesheet documents that R14 has diagnoses not limited to: Multiple sclerosis, cerebral infarction, aphasia, and lupus erythematosus. R14's Minimum Data Set/MDS dated [DATE], documents that R14 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R14 is cognitively intact. R14's MDS documents that R14 is dependent with ADL/Activities of Daily Living care and has an impairment on one side of upper extremities. R14's care plan dated 11/19/2024, documents in part, Be sure R14's call light is within reach and encourage R14 to use it for assistance as needed. R14 needs prompt response to all requests for assistance. R14's call light evaluation dated 11/12/2024, documents that R14 is cognitively able to use her call light. On 12/05/2024 at 4:09PM, V2 (Director of Nursing/DON) states a resident who can use their call light would not be able to call for help or have their needs met if their call light is not within their reach. Facility policy dated 07/26/2024, titled Call Light Policy documents in part, Policy Statement: It is the policy of this facility to ensure that there is prompt response to the residents' call for assistance. 5. Be sure call lights are placed within reach of residents who are able to use it at all times. 45111 2. R377's current face sheet documents R377 is a [AGE] year old individual with medical diagnoses that include but not limited to: cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, right/left shoulder, postprocedural cerebrovascular infarction following other surgery, disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, unspecified. Brief Interview for Mental Status (BIMS) dated [DATE] is documented as 03/15, indicating R377 has severe cognitive impairment and R377's Functional Abilities document R377 requires Partial/moderate assistance with eating and oral hygiene, dependent on Toileting hygiene, Lower body dressing, Putting on/taking off footwear, Shower/bathe self, requires Substantial/maximal assistance with Upper body dressing, and supervision and touching assistance with Personal hygiene. R377 uses a wheelchair for mobility. 12/03/24, 2:58 PM, R377 was observed in her room and laying in bed and was observed trying to use her call light. R377, in a very faint voice and using one word at a time stated her call light does not work and she needs help with getting her phone charger which was entangled on the bed frame. R377 was observed trying to detangle the call light but was not able to. R377 stated her call light has not worked all day. R377 pressed the call light but it did not work. R377 stated she needed to charge her phone, but she could not. On 12/03/2024, at 3:02 PM, Surveyor asked V14 (Certified Nursing Assistant-CNA) to come to R377's room and check R377's call light to see if it was working. V14 pressed R377's call light and it did not turn on and stated R377's call light should be working so that R377 call reach staff when she has a need. V14 stated R377 can slide out of bed and fall trying to reach or detangle her phone charger if R377's call light is not working to reach staff. V14 stated if R377 fell out of bed, she can get injured. V14 stated staff should check every resident's call light to make sure its working and if it is not working, staff should notify maintenance to fix it so that residents can reach staff as needed. On 12/04/2024, at 10:51 AM, V2 (Director of Nursing-DON) stated that call lights in residents' rooms should be checked regularly to make sure they are working so that residents can reach staff when needed. V2 stated R377's call light should be working so that R377 can reach staff when needed. V2 further stated staff should round frequently to make sure call lights are working and if a call light is not working, staff should notify maintenance to repair the call light. Call Light policy dated 7/24/204 documents: -Nursing staff should check all call lights daily and report any defective call light to the administrator / maintenance immediately for repair. -If a call light is not functional, evaluate and provide another means in order for the resident to call for assistance (i.e bell) until the call light is fix. 49666 3. 12/03/2024, 1:35 PM, R24's call light not within reach, noted on the floor next to R24's bed, nearest to the room door. When questioned R24 if she can reach for her call light, R24 states no. 12/03/2024, 2:08 PM, V12 (Licensed Practical Nurse) states that R24's call light should be within reach and should not be on the floor. V12 placed R24's call light within R24's reach. V12 states that it is important for residents to have their call light within reach because they can call for help. 12/03/2024, 2:11 PM, V13 (Certified Nursing Assistant) states that she is the assigned nursing assistant for R24. V13 states that she didn't get a chance to check if R24's call light was within her reach because she started work at 2:00 PM and she has not done rounds yet. 12/05/24, 3:03 PM, V2 (Director of Nursing-DON) reports that R24 needs a lot of assistance. V2 states that R24 is alert and oriented and has a BIMS (Brief Interview for Mental Status) score of 14/15 which makes her cognitively intact. V2 reports that R24 can use the call light. Facility document dated 7/26/24 titled Call Light Policy documents in part it is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. Be sure call lights are placed within reach of residents who are able to use it at all times.

Based on interviews and review of records the facility failed to provide planning of care related to oral/dental care for 1 (R1) of 3 residents reviewed for improper nursing care. Findings include: R1 is [AGE] years old, initially admitted on [DATE], with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1 is cognitively intact as assessed on 8/27/2024 with a BIMS (Brief Interview of Mental Status) of 15. On 10/15/2024 at 1:07 PM, R1 was seen laying on bed in her room. R1 was alert and verbally able to express her thoughts within topic during conversation. R1 stated that her tooth does not bother her as much as before. R1 stated that her tooth problem is located at the top left area in her mouth and now she does not chew on the left side where she used to chew and she knew that there was a problem on her tooth when she felt a sharp end on her tooth. R1 said, At first it was terrible, and it was swollen. It started around the second week of September. R1 had a food tray in front of her and was barely eating her food. R1 was seen focusing on eating the dark green vegetable without touching the rest of her food. Per review of R1's progress notes, R1's tooth problem was first noted on 9/11/2024 by V18 (Medical Doctor) that R1 has a tooth pain and V18 ordered for R1 to be seen by a dentist. Per V3 (Registered Nurse) notes dated 9/12/2024, R1 was seen by the dentist and documented that Social Worker team to follow up for rescheduling. Progress notes dated 9/17/2024 by V4 (Registered Nurse) documented that R1 verbalized pain 8 out of 10, with 10 being the highest rate of pain. Pain went down to 3 after giving Tylenol medicine. Progress notes dated 8/19/2024 by V5 documents R1 enjoys eating as she finds this her only pleasure being in the facility. Progress notes dated 9/19/2024 by V5 (Licensed Clinical Social Worker) documents that R1 verbalized concern about tooth infection and how to cope with the situation. Progress notes dated 10/15/2024 by V5 (Licensed Clinical Social Worker) documents R1 anxiety persist due to tooth infection. R1 talked about how she needs to alter the way she chews her food. R1 also talks about more aches and pain she has been having and this contributes to her depression. On 10/15/2024 R1's care plan were reviewed and does not include identified problem of her tooth. On 10/16/2024 after request of full care plan, oral/dental health problems related to tooth pain was included and dated 10/16/2024. On 10/16/2024 at 12:05 PM with V2 (Director of Nursing) stated that R1 has a tooth problem. V2 said, I think her tooth was broken and she complained of pain. Per V2, R1 was seen by the dentist on 9/12/2024 and recommended tooth extraction. R1 was scheduled to go out to an outside dental clinic but was cancelled due to transfer problem. R1 uses Hoyer lift for transfer and the dental clinic does not have equipment to transfer R1 from the wheelchair or stretcher to dental chair. Dental clinic was concerned about the safe transfer of R1. V2 said, that R1 has an appointment on 10/18/2024 for in-house tooth extraction and that R1's diet was changed from regular to mechanical soft. R1's Tylenol medication schedule was changed from as needed to every 8 hours. V2 was handed R1's full care plan to review. After full review, V2 pointed and acknowledged the care plan for oral/dental health problems related to tooth pain dated 10/16/2024. V2 stated that it was just done today and R1 did not have a care plan for oral/dental health problem until today. V2 stated that R1's care plan needs to be comprehensive enough to address all issues included in the interventions including pain, diet, and other areas that may be affected by R1's tooth problem. On 10/17/2024 at 11:24 AM, V1 (Administrator) explained that R1 was scheduled for an appointment going to outside dental clinic but was unable to go due to transfer issue. Dental clinic cannot accommodate because it is hard to transfer R1 from wheelchair or stretcher to the dental chair because R1 needs Hoyer lift. V1 was made aware that care plan was not started until today (10/16/2024) to address these concerns and contingencies such as the issue she (V1) just mentioned in case interventions by facility failed related to R1's dental/oral care. V1 stated that she was aware and will address the issue. Care Plan policy dated 7/26/2024, reads: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with federal regulations. Under procedures, after the comprehensive assessment is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. These will be periodically reviewed and revised by a team of qualified persons after each assessment. Per policy of the facility, care plans are in conjunction with federal regulation. Under Code of Federal Regulation Title 42 dated 10/16/2024 on Care Plan, it reads: S483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by the regulation. The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality.

Based on observation, interview and record review, the facility failed to implement fall precaution interventions for two (R2, R4) residents identified as a fall risk out of three residents reviewed for fall precautions. Findings include: 1. On 08/31/2024 at 11:54AM, surveyor observes R2 lying in R2's bed resting inside of R2's room in a supine position with head of bed elevated at 45 degrees. Surveyor observes R2's bed alarm pad hanging on the rails at the top/head of R2's bed. R2 is verbal and noted with confusion. On 08/31/2024 at 12:00PM, V5 (Registered Nurse/RN) now located inside of R2's room and observes R2's bed alarm pad. V5 states R2's bed alarm pad should not be there and V5 is not sure why R2's bed alarm pad is hanging over the top/head of R2's bed. V5 states R2's bed alarm pad should be placed underneath R2's body while R2 is in bed. V5 states if R2's bed alarm pad is not in place then R2 could move while in bed and fall. V5 states R2 could potentially injure herself or fracture a bone if R2 sustained a fall in the facility. V5 states R2 is assigned to have a CNA inside of R2's room monitoring R2 and providing 1:1 care for R2. V5 states with 1:1 care, a CNA should be inside of R2's room at all times monitoring R2. On 08/31/2024 at 12:04PM, V6 (Certified Nursing Assistant/CNA) enters R2's room and states she is the CNA assigned to R2's room to provide 1:1 care for R2. V6 states she just returned from her 30-minute break and informed another CNA staff member to monitor R2 during V6's break. Surveyor inquires to V6 about R2's bed alarm pad and its placement prior to V6 entering R2's room. V6 states she is not sure how R2's bed alarm pad was placed hanging on the rails at the top/head of the bed. R2's comprehensive care plan dated 08/15/2024 documents that R2 is care planned for risk for falls with interventions that include: Mobility alarm provided. R2's Nursing progress note dated 08/26/2024 at 2:05PM, documents in part, Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Pain in left thigh with no relief, 2. This started on: 08/26/2024, 2a. Since this started, it has gotten: Stayed the same, 5. This condition, symptom, or sign has occurred before? No, 6. Is the change in condition related to an incident (fall, skin alteration or injury of unknown origin)? Yes, 7. Other relevant information: R2 was stuck in between bed and side rail. A0x1 confused at baseline. 2. On 08/31/2024 at 1:14PM, R4 located inside of her room lying in bed. R4 is verbal and noted with confusion and is a poor historian. On 08/31/2024 at 1:29PM, V7 (CNA) located inside of R4's room and observes that R4's bed alarm pad is in place underneath R4's body but R4's bed alarm pad is not plugged in. V7 takes the gray phone cord plug off the floor and places it into the bed alarm and surveyor hears an audible alarm once R4's bed alarm is plugged in. R4's bed alarm is labeled as follows: Deluxe Pad Alert, Do Not Disconnect. V7 states she was scheduled to start her shift at 6AM today but started her shift around 8AM and was not aware that R4 had a bed alarm. V7 states since R4's bed alarm was not plugged in, R4 could have fallen and the facility would not have known that R4 fell because the alarm was not plugged in. V7 states there is potential for R4 to hurt herself during a fall at the facility. On 08/31/2024 at 1:36PM, V8 (Licensed Practical Nurse/LPN) states, R4's fall precaution interventions include R4's bed being in the lowest position, floor mats in place, and R4 having a bed alarm in place. V8 states if a resident's bed alarm is not plugged in, then the staff would not be able to hear the resident's alarm if the resident falls. V8 states a resident could possibly injure themselves if they fall in the facility. V8 states R4 has a history of falls in the facility. R4's comprehensive care plan dated 07/17/2024 documents that R4 is care planned for risk for falls with interventions that include: Bed alarm provided upon admission. R4's fall risk assessment dated [DATE] documents R4 has a fall risk score of 13, indicating R4 is at high risk for falls. Facility policy dated 07/26/2024 titled Fall Occurrence documents in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure- 2. Those identified as high risk for falls will be provided fall interventions. 8. The Falls Coordinator will add the intervention in the resident's care plan.

Based on interviews and record review, the facility failed to immediately transfer a resident (R2) on blood thinning medication to a local hospital for emergent services after a fall with head injury. This failure affected one resident (R2) of three reviewed for falls and as a result, there was a delay of 39 minutes in R2 receiving treatment for an acute subdural hematoma and subsequently died nine days later. Findings include: According to Electronic Medical Record, R2 is [AGE] year old with diagnosis including but not limited to: Unsteadiness on feet, Lack of coordination, Venous Insufficiency, Chronic Venous Hypertension, Heart Failure and Unspecified Right Bundle- Branch Block. R2 was admitted to the facility on [DATE] and assessed to be a High risk for falls based on assessments dated [DATE] and [DATE]. On [DATE] during investigation, Surveyor inquired about R2's fall incident that occurred on [DATE]. On [DATE] at 10:55 AM, V12 (R2's daughter) said, My mom (R2) passed on [DATE] at 2:54 PM in the hospital. She (R2) fell twice in the facility on [DATE] and [DATE]. My mom passed after the [DATE] fall. On that day ([DATE]) at 7:51 PM, V16 (LPN/Licensed Practical Nurse) called me to say that there was a horrible accident with my mom. V16 said that after my mom was put to bed, he (V16) witnessed her (R2) standing up from her bed after her bed alarm went off. My mom (R2) was stumbling towards the bathroom. He (V16) tried to run and catch my mom (R2) but it was too late. My mom (R2) had fallen and hit the right side of her head on the floor. V16 told me that my mom had fallen ,d+[DATE] minutes before he called me and that he had to follow protocol and call administration and the doctor before sending her (R2) to the hospital. At that time, I asked to speak with my mom. She (R2) got on the phone and said, 'Its cold, I just want to get off the floor and in the bed'. I (V12) asked V16 why my mom (R2) was not sent to the hospital. At 8:09 PM, V16 told me that he had to get off of the phone because the EMT (Emergency Medical Technicians) were there. I (V12) later found out that the EMT did not arrive to the facility until 8:23 PM, and my mom fell before V16 called me at 7:51 PM. When I (V12) later retrieved the medical records from the hospital, it stated that my mom (R2) had arrived at the hospital at 8:55 PM on [DATE]. After my mom (R2) had arrived at the hospital, I received a call at 10:28 PM, informing me that an emergency brain scan revealed hemorrhaging all over her (R2's) brain and that she will need surgery. Shortly after the first call, V23 (Neurosurgeon) called me back at 11:05 PM and said that there was too much bleeding and swelling and that there was nothing that could be done. Surgery would not make a difference. My mom was placed on hospital hospice service on [DATE] and passed on [DATE] in the hospital. On [DATE] at 1:10 PM, V16 (LPN/ Licensed Practical Nurse) said, On [DATE], I was not assigned to R2, but I was looking after her because the other nurse was on break. I am not really familiar with R2 and was not sure of her capabilities. I (V16) knew that she (R2) was a fall risk. R2's room was across from the nurses' station. I heard an alarm and when I came out of the nurses office (in back of the nurse's station) I saw R2 standing near her bed. I ran to go to her room. R2 had already taken a couple of steps and had fallen on the floor. I (V16) know that R2 hit her head because she fell on her right side. The protocol in our facility is that when a person is on blood- thinner, we send the patient out 911. R2 was on blood thinners and had a hematoma on the right side of her head. I started to take R2's vitals and make sure she was ok. I called the daughter, I called the Doctor, and I called 911. I think that she was on the floor around 30 mins. I gave her a pillow and made sure she was still conscious. R2 was on the phone with her daughter the entire time before she left the facility. Surveyor inquired about the time of R2's fall versus the time of the fall documentation. On [DATE] at 1:10 PM, V16 (LPN) said, I documented the fall after R2 left the facility to the Hospital but I don't remember what time R2 fell . I was able to change the time on my documentation to 7:38 PM. I believe this was the time that R2 fell . Whatever time is on the report is the time that she fell . I'm not sure what time she left the facility. On [DATE] at 10:42 AM, V19 (Nurse Practitioner) said, V16 (LPN) let me (V19) know that R2 had fallen and was a little confused. I (V19) remember that R2 had a prior recent fall and was on lovenox (blood thinner) so I (V19) gave V16 orders to send R2 out 911 (emergency). I (V19) don't remember if R2 had hit her head. I'm not sure what time V16 called but it is documented on the incident report. Surveyor inquired about the expectations regarding the order to send R2 out 911. On [DATE] at 10:42 AM, V19 said, I would expect that 911 be called as soon as the nurse hung up the phone with me because it was an emergency. The results could be delayed medical attention and care. On [DATE] at 11:02 AM V20 (Medical Doctor) said, I am familiar with R2. Her daughter was so involved with her mom and was here all the time. V19 (NP) did what she was supposed to do. V19 gave order to send R2 out 911 for CT scan to rule out bleed or fracture. Surveyor inquired about the expectations regarding the order to send R2 out 911. On [DATE] at 11:02 AM V20 (Medical Doctor) said, Immediately. 911 should be notified right away. With the blood thinner and head trauma, the risk for bleeding is increased. On [DATE] at 3:10 PM, V14 (Director of Nursing) said, I (V14) remember receiving a call about R2's fall. I was not here but I know that she was sent to the hospital. When a patient has a head injury and a patient is on blood thinners, they are sent out 911 because they are at increased risk for bleeding. R2's Physician Order Sheet documents orders for the following medication: Enoxaparin Sodium Injection daily (anticoagulant/ blood thinner); and Aspirin daily (Antiplatelet). R2's care plan dated [DATE] documents, R2 has potential for bruising, hemorrhage due to anticoagulant use. R2's care plan dated [DATE] documents, R2 is at risk for falls. Facility's Fall report documents the following: R2 fell at 7:38 PM on [DATE]; R2 noted with bump to right side of head; Alert and oriented x ,d+[DATE] with confusion. Facility's Post- Incident report documents, V19 (Nurse Practitioner) was notified of R2's fall on [DATE] at 7:44 PM. Facility's Post- Incident report documents, V12 (R2's daughter) was notified at R2's fall on [DATE] at 8:10 PM. (Per V16/ LPN, Daughter spoke with R2 on the phone at that time). Local Fire Department Patient Care Report documents the following timeline on [DATE]: Dispatch called at 8:17 PM; EMT (Emergency Medical Technicians) arrived on scene (Nursing Facility) at 8:23 PM, EMT left the facility at 8:42 PM, Patient (R2) transfer of care (to Emergency Department Staff) at 8:54 PM. Per documentation, 911 was called approximately 39 minutes after the witnessed fall. Hospital Medical record dated [DATE] documents, R2's date of service [DATE] at 8:53 PM; R2 brought in by EMS (Emergency Medical Services) from her SNF (Skilled Nursing Facility) after a witnessed fall. R2 fell from standing with positive head strike but no LOC (Loss of consciousness). Hospital progress note authored by V23 (Neurosurgeon) documents, On arrival, R2 was responsive, denying headaches or chest pain. R2's exam progressively worsened until she (R2) became unresponsive. CT brain showed a multi-compartment acute ICH (Intracerebral hemorrhage). Neurosurgery responded to the ICH code. R2 on aspirin 81 milligrams daily and lovenox (blood thinner) prophylaxis. Hospital progress note dated [DATE] at 11:27 AM documents the following: Spiritual Care Service with family; Emotions of Grief/ Loss. Facility Reported Incident dated [DATE] authored by V14 (DON) documents, hospital records by neurology team says Acute Multi-compartmental Intracranial Bleed could be secondary to trauma versus stroke in setting of antiplatelet and prophylactic anticoagulant use complicated by interventricular extension with communicating Hydrocephalus. Patient (R2) still at the hospital. No surgical intervention recommended and plan to transition to hospice care. Facility Reported Incident dated [DATE] authored by V14 (DON) documents, V19 (Nurse Practitioner) made aware of fall and ordered to send to hospital for evaluation. Time Physician was notified: 7:44 PM. Facility policy titled Head and Hip guidelines documents, It is the policy of this facility to send residents to the hospital for further evaluation in an event where an incident or accident occurs which involve overt signs of injuries on their head or hip; Notify the resident's attending physician immediately and transfer the resident to the hospital ER (emergency room ) for further evaluation and management.

Based on interview and record review, the facility failed to prevent a fall by not implementing appropriate fall interventions for a dependent confused resident (R4) with a language barrier and history of falling. The facility also failed to follow fall prevention intervention to prevent a fall incident, to ensure that the appropriate side rails were used, and to ensure that the use of side rails was evaluated first before utilizing to a resident (R5) who was confused and at high risk for falls. These failures affected 2 (R4, R5) out of 3 residents reviewed for accidents and incidents. R4 had an unwitnessed fall incident. R4 was observed by facility staff on the floor by R4's bed and sustained a fracture of left hip transverse proximal femoral basicervical fracture with medial impaction. R5 had an unwitnessed fall incident. R5 was observed by facility staff lying flat beside R5's bed and sustained a subdural hematoma. Findings Include: 1.) R4's clinical records show R4 was admitted in the facility on 9/12/23 with listed diagnoses not limited to Spinal Stenosis, Congestive Heart Failure, Radiculopathy, and Congestive Heart Failure. R4's fall incident note dated 9/13/23 at 1:15 AM written by V30 (Registered Nurse) reads in part: R4 was observed in the bathroom sitting down with no visible injury noted. R4's fall incident note dated 9/14/23 at 9:15 AM written by V5 (Registered Nurse) reads in part: R4 was observed on the floor on R4's left side of R4's bed. R4 was alert and oriented x 1-2, no new pain, and no visible injuries noted. R4 was unable to provide description of what happened. R4's progress notes written by V24 (Nurse Practitioner) dated 9/14/23 at 11:00 AM reads in part: [R4] seen at the bedside, lying in bed. Reported pain to left thigh, which started today. Per nurse, [R4] had an unwitnessed fall this morning. [R4] was found lying on [R4's] left side next to bed. This note also indicates that R4 speaks Serbian. R4's hospital records dated 9/14/23 shows an X-ray was done on R4's left femur/hip with result that reads left hip transverse proximal femoral basicervical fracture with medical impaction. R4's Minimum Data Set (MDS) dated [DATE] shows R4 needed a Serbian interpreter to communicate with a doctor or health care staff. It also shows R4's cognitive status was not assessed and R4 required extensive one person assist for bed mobility, transfer, and toileting. R4's Fall Risk Evaluation dated 9/12/23 and 9/13/23 show R4 was at low risk for falls. R4's fall care plan initiated on 9/13/23 shows R4 was at high risk for falls related to status post fall, history of fall, worsening back pain, functional decline, and decreased balance and activity tolerance. On 10/17/23 at 11:33 AM, V5 (Registered Nurse) stated that on 9/14/23 at around 9:00 AM, V5 was passing medications and heard R4's bed alarm was going off. V5 stated V5 went inside R4's room and found R4 on the floor lying on R4's left side by R4's bed. V5 stated that R4's head was by the foot of R4's bed. V5 stated that R4's call light was not on and R4 did not speak English. V5 stated that V5 could not understand what R4 was saying and the only person that talks to R4 with the same language was V33 (R4's Son). V5 stated that R4 could not tell V5 what happened. V5 stated that that was the first time V5 had taken care of R4. V5 stated that R4 was high risk for falls and had fallen the day before. V5 stated that R4 was confused and did not know how to use the call light. V5 stated that V24 (Nurse Practitioner) saw R4 after the fall on 9/14/23 and ordered for R4 to be sent out to the hospital for complaint of left thigh pain. On 10/18/23 at 12:45 PM, an interview conducted with V17 (Certified Nursing Assistant). V17 stated that on 9/14/23 at around 8:30 AM, V17 went to R4's room with the breakfast tray. V17 stated V17 woke up R4 but refused to be changed and refused breakfast. V17 stated, [R4] was shooing me. I could not understand [R4]. [R4] did not speak English. [R4] was very confused. [R4] didn't go back to sleep. [R4] just stayed in bed and was very confused. [R4] did not push the button. [R4] didn't know how to use the call light. [R4] was very confused. [R4] won't let me do anything for [R4]. Like I said [R4] was shooing me so I left, and I went to the next patient. [R4] did not want to eat. I left the food set on [R4's] table covered up. V17 further stated that V17 was not aware that [R4] was high risk for falls. V17 stated, [R4] came the day before on our floor, but [R4] was not my patient. Then the next morning [R4] was assigned to me. Nobody told me if [R4] had fallen before. I am not sure if [R4] was high risk for falls. Nobody told me if [R4's] at risk. I don't think the nurse knew either. I'm not sure if [R4] had the star on [R4's] door. [R4] was new to the floor. If I knew [R4] was a high fall risk, I would make sure to check on [R4] often, but when I saw [R4] before [R4] fell , [R4] had her call light and all [R4's] personal belongings close to [R4]. [R4] had the bed alarm. The nurse heard the bed alarm and the nurse found [R4] on the floor. V17 stated R4 didn't know how to use the call light due to R4 was very confused. At 2:33 PM, an interview conducted with V2 (Director of Nursing). V2 stated that the staff should know if their residents are high risk for falls. V2 stated that it's in the resident's care plan if they are high risk for fall and the residents have a star by their name on the door. V2 stated that the Nurses and Certified Nursing Assistants (CNAs) should be doing frequent rounding and should always anticipate the resident's needs especially for confused residents that the staff have to make sure that their needs are anticipated. V2 stated that the staff should ask if they need to go to the toilet, check if incontinent, and ask what they need. V2 stated that if a resident has a language barrier that there should be a communication board at bedside or use staff that can interpret. On 10/19/23 at 10:56 AM, a second interview conducted with V5 (Registered Nurse). V5 stated that R4 did not speak English at all and V5 thinks R4 spoke Serbian. V5 stated that V33 (R4's son) would usually translate for R4. V5 stated that there was no staff that works in the facility that could speak Serbian. V5 stated that R4 was able understand basic hand gestures. V5 stated that there was no communication board in R4's room. At 12:23 PM, an interview conducted with V24 (Nurse Practitioner). V24 stated, That was my first time meeting [R4]. The nurse [V5] reported to me that [R4] had unwitnessed fall. The nurse told me [R4] was found lying on [R4] left side by [R4's] bed. As far I could see [R4] had no injuries when I assessed [R4] but at that time [R4] was holding on to [R4's] left thigh and [R4] was having facial grimacing. [R4] spoke Serbian. I tried as best as I could to communicate with [R4]. I could tell [R4] was in a lot pain. [R4] was trying to tell me that it hurts a lot. I instructed the nurse to give [R4] some Tylenol and to send [R4] right away to the ED (Emergency Department). 2.) R5's clinical records show R5 was admitted in the facility on 9/9/23 with listed diagnoses not limited to Dementia without behavioral disturbance, Essential Hypertension, History of Falling, Cerebral Infarction, and Congestive Heart Failure. R5's fall incident note dated 9/10/23 written by V7 (Licensed Practical Nurse) reads in part: [R5] was observed laying flat by bed by CNA (Certified Nursing Assistant). [R5] was responsive to name and touch, able to verbalize needs to staff. When asked, [R5] has stated that [R5] has a fall. The facility's incident report for R5 that was sent to the State Agency (SA) on 9/15/23 shows that on 9/10/23 at 4:00 AM, staff observed R5 lying flat beside R5's bed and when asked, R5 has stated that R5 fell . R5 was assessed with an opened skin on back of head and V23 (R5's Physician) was notified. R5 was sent to the acute hospital. R5's hospital records dated 9/10/23 shows R5 was presented to the emergency room (ER) after experiencing an unwitnessed fall and was found to have subdural hematoma. R5's Minimum Data Set (MDS) dated [DATE] shows R5 had moderately impaired cognition and required extensive one staff assistance with bed mobility, transfer, and toileting. R5's fall care plan initiated on 9/9/23 shows R5 is at risk for falls related to current medication use, poor safety awareness, unsteady gait, and disease process. One fall intervention reads in part: Side rails to prevent rolling out of bed. R5's electronic health record (EHR) does not show a side rail assessment was completed before R5's fall on 9/10/23. No side rail assessment found in R5's clinical records that would indicate the four side rails used were suited to R5's needs and condition. The only side rail assessment was completed and signed on 9/22/23 with an effective date of 9/12/23 and it shows R5 needed two half side rails. R5's progress notes dated 9/9/23 to 9/10/23 show no documentation of R5's side rail evaluation. On 10/17/23 at 12:50 PM, an interview conducted with V2 (Director Nursing). V2 stated that R5 was admitted on [DATE] and R5's Fall Risk Assessment score was 5 meaning low risk. V2 stated that 0-7 is low risk for falls. V2 stated that R5 came to the facility with history of fall with occasional confusion. V2 stated that R5 was a new resident and on 9/10/23, V18 (Certified Nursing Assistant) found R5 on the floor early in the morning. V2 stated that V7 (Licensed Practical Nurse) did an assessment and R5 had open skin on the back of R5's head. V2 stated R5 was sent to the hospital and the Computed Tomography (CT) scan result showed R5 sustained subdural hematoma. On 10/18/23 at 9:43 AM, a phone interview conducted with V7 (Licensed Practical Nurse). V7 stated that a CNA (V7 does not remember the name) found R5 on the floor around early in the morning on 9/10/23. V7 stated that the CNA called V7 that R5 was found lying on the floor. V7 does not remember if R5's call light was on. V7 stated that V7 assessed R5 right away and saw a crack on the side of R5's head. V7 stated that R5 had confusion. V7 stated that R5 could not recall how R5 fell . V7 stated that R5 already had multiple falls before coming to the facility and was unstable. V7 stated R5 would always try to move around but R5 was not supposed to. V7 stated V7 last saw R5 at around 2:00 AM and R5 was sleeping. V7 stated V7 does not remember if R5 knew how to use the call light. At 10:21 AM, a phone interview conducted with V18 (Certified Nursing Assistant). V18 stated that V18 worked night shift on 9/9/23 and found R5 on the floor close to 4:00 AM the next morning. V18 stated that when V18 found R5 on the floor, R5 said that R5 wanted to get up. V18 stated that V18 thinks R5 was trying to get up on his own. V18 stated that all four side rails were up when R5 was in bed and before R5 fell . V18 stated R5 did not have a bed alarm. V18 stated R5 did not yell for help. V18 stated, [R5] was a little bit restless that night. I talked to [R5] and told [R5] to relax. [R5] was confused. I think that was [R5's] first night in the facility. I think [R5] was trying to get up. Maybe that's why [R5] fell . [R5] was at risk for falling that's why [R5] was on a low bed and had all four side rails up. At 11:41 AM, V2 (Director Nursing) stated that before R5 fell , R5's fall interventions were to keep call light within reach, skilled therapy, restorative, and side rails up to prevent [R5] from rolling out of bed. V2 stated that it should only be two half side rails up not four. V2 stated, We do have bed with four side rails, but they should only be using two half side rails for [R5]. If all four side rails are up it's considered full. We don't use full side rails to the residents. They should only use two half side rails when [R5] is in bed to prevent [R5] from rolling out of bed and for bed mobility. Side rail assessment should be completed on admission and before using the side rails to determine the correct side rails and if it's appropriate to use for the resident. V2 stated that the side rail assessment should be in R5's electronic health records (EHR). V2 stated that the staff should not use all four side rails up to the residents. V2 stated that if a resident has some confusion and some restlessness and all four side rails are up, the resident could fall hard. V2 stated, They could potentially climb off the side rails and fall. V2 stated that R5 fell before coming in the facility. V2 stated that R5 had history of multiple falls and was considered high risk for falls upon admission. V2 stated that R5 had occasional confusion. At 2:03 PM, an interview conducted with V21 (Clinical Care Coordinator). V21 stated that the use of side rails should be completed upon admission of the resident to the facility. Surveyor reviewed R5's EHR with V21 and confirmed that R5's use of side rails was not evaluated on 9/9/23 to 9/10/23. On 10/19/23 at 11:15 AM, a phone Interview conducted with V23 (R5's Physician). V23 stated that R5 was quite sick and had previous falls before coming to the facility. V23 stated that R5 was at risk for falling and was in the facility for short term rehabilitation post fall to work on muscular deconditioning. V23 stated that R5 was confused, alert and oriented x 0-1. V23 stated that using two side rails up for R5 when in bed was appropriate for fall prevention not four side rails. V23 stated V23 cannot comment on if R5's subdural hematoma resulted from the fall. V23 stated it's a possibility. On 10/20/23 at 9:29 AM, the facility provided R5's baseline care plan that shows fall risk as one focus with siderails as part of the intervention. However, it does not detail that the use of side rails were evaluated for appropriateness and if it was determined if R5 had a medical symptom that must be treated with the use of the four side rails. R5's EHR also does not show a consent was obtained for R5's side rails. R5's physcian order sheet (POS) does not show side rails were ordered for R5 on 9/9/23 to 9/10/23. R5's POS shows half side rails up when in bed for position and support ordered on 9/12/23. The facility's policy titled; Fall Occurrence dated 7/17/23 reads in part: Policy Statement It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure 1. A Fall Risk Assessment form will be completed by the nurse or the Falls Coordinator upon admission, readmission, quarterly, significant change, and annually. 2. Those identified as high risk for falls will be provided fall interventions. The facility's policy titled; Side Rail dated 7/28/23 reads in part: Policy Statement It is the facility's policy to comply with the federal requirements on the use of side rails. Procedures 1. Prior to the use of side rails, alternative devices like pillows, wedges, foams, and other repositioning devices will be utilized first for residents in need of repositioning. 3.If the alternative devices failed to assist the resident in repositioning, the resident will be assessed for the use of side rails, to determine risk for entrapment and other potential danger to the resident. 4.If side rails are appropriate for the resident, a verbal or written consent will be obtained by the facility prior to the use of side rails. The facility's policy titled; Hazards dated 7/28/23 reads in part: Policy Statement It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents.

Based upon observation, interview and record review the facility failed to follow their wound prevention protocol and obtain a dietary consult for 1 of 8 residents (R5) all reviewed for pressure sore interventions, the facility also failed to follow their wound prevention protocol and ensure that low air loss mattress was utilized as recommended by the manufacture for 3 of 8 residents (R5, R6, R7) all reviewed for pressure relieving interventions. Findings include; R5's [DIAGNOSES REDACTED]. R5 is paralyzed below the waist and unable to turn/reposition without assistance. On 7/1/15, R5's [MEDICATION NAME] was critical low 2.4 (range 2.8-5.0). R5's nursing progress notes include the following; (7/1/15) New skin breakdown; left buttock pressure ulcer stage II (2.5 x 2.0 x 0.1). Stage II pressure ulcer to right buttock (2.6 x 2.2 x 0.1). On 7/9/15, an unstageable pressure ulcer was noted to R5's sacrum measuring 3.0 x 6.2 x 0.1. A nutritional assessment was not conducted on R5 until 8/12/15. The 8/12/15 assessment does not include R5's laboratory values from 7/1/15 and/or 7/29/15 both of which affirm low [MEDICATION NAME] levels. On 2/3/16 at 1:16pm, E8 (Registered Dietician) stated that comprehensive nutritional assessments are conducted on admission and yearly. Nutritional assessments are also conducted quarterly. Surveyor inquired about R5's nutritional assessment conducted post change in condition (7/1/15) E8 responded I don't do an assessment for new skin breakdown. I do my progress note and update my care plan for the patient. That's what I was taught here by the previous dietician. We do progress notes for new skin breakdown. Surveyor inquired if the facility had a policy and procedure for nutritional assessments E8 replied Not that I'm aware of. Surveyor inquired if a wound was considered a change in condition E8 stated I was never educated that a wound was considered a change in condition. On 12/7/15, R5's sacral wound measured 2.0 x 1.6 x 4.0 and was stage IV. Nursing progress notes (12/10/15) denote that R5 was running a fever (102.7) and was subsequently transferred to the hospital to rule [MEDICAL CONDITION]. R5's (12/10/15) hospital records include the following; [MEDICATION NAME] 2.1 (low), white blood cell 15.2 (high). Skin impairment description; deep stage IV pressure ulcer (sacral), bone exposed at the base. admitted for [MEDICAL CONDITION] and rehydration.[MEDICAL CONDITION] secondary to urinary tract infection and sacral acute osteo[DIAGNOSES REDACTED] (bone infection). Nutrition Diagnosis: [REDACTED]. On 2/2/16 at 1:14pm, R5 was lying on an air mattress, atop of the mattress was a sheet, an additional folded sheet (4 layers) and a disposable pad. E3 (Licensed Practical Nurse) stated You're not supposed to have a draw sheet because she has an air loss. She's not supposed to have any sort of .under her. Surveyor inspected the draw sheet E3 affirmed that there was 4 additional layers created by the draw sheet and replied It's four that's correct. On 2/3/16 at 1:01pm, E2 (Director of Nursing) stated that specialty mattresses are Used for stage III-IV decubitus. There should only be a thin sheet between the patient and the bed when using the mattress. E2 affirmed that nutritional assessments should be conducted Quarterly, annually or with significant change. On 2/7/16 at 9:45pm, R5 reported that she is supposed to be turned every hour and stated It's every two if I'm lucky. Tonight (2-10pm) I was turned maybe twice. According to the sign posted above R5 bed R5 was on a hourly turn schedule. ___ R6 was admitted to the facility on [DATE] with a (stage IV) sacral pressure ulcer measuring 8.4 x 9 x 3. On 12/28/15, R6 developed an additional wound documented as sacral/coccyx (stage IV) measuring 13 x 6 x 3.5. On 2/3/16 at 11:48am, R6 was lying on an air mattress and wearing a disposable brief. Atop of the mattress were two (2) fitted sheets, a folded sheet (2 layers), and a washable pad. E3 (Licensed Practical Nurse) stated That should have been removed as soon as she got back. On 2/7/16 at 6:01pm, surveyor entered R6's room and remained in the room until approximately 8:14pm. Upon arrival, R6 was lying in bed on her back with a pillow slightly beneath her left chest/hip area. Z3 (Family) stated that she arrived around 4pm, at that time R6 was lying on her back. At 8:06pm, Z4 (Agency CNA) checked R6's diaper, removed the pillow from her left side and placed it to her right side slightly beneath her chest/hip, R6 remained on her back. Surveyor inquired about repositioning of the pillow (not R6) Z4 responded I'm not sure what you want me to do. Surveyor inquired when R6 was last changed and repositioned Z4 responded What time did you get here? Z3 stated I got here at 4:00pm. Z4 replied I got here when she got here and did it then. Z4 was unable to reposition R6 by himself and asked the surveyor to call out in the hall for assistance. On 2/3/16 at 12:34pm, R7 was lying in bed on an air mattress atop of the mattress was a flat sheet and an additional folded sheet (4 layers). E4 (Registered Nurse) stated She's got a pad under her what's going on? E7 (Certified Nursing Assistant) responded They checked her for her weight so I guess they put a sheet on her. E4 removed the folded sheet from under R7 and affirmed that there were 4 additional layers atop of the flat sheet. E4 stated that she arrived at the facility at 6:30am and in-serviced all nursing staff (Nurses and CNA's) regarding use of the air mattress. On 2/7/16 at 8:21pm, Z5 (Agency CNA) affirmed that atop of R7's air mattress was a fitted sheet, pull pad and folded sheet (4 layers). On 2/7/16 at 8:44pm, E19 (CNA) stated that only a sheet should be on top of an air mattress. The facility's wound care policy and procedure (July 2014) includes but not limited to; Identification of risk factors; Serum [MEDICATION NAME] less than 3.5. Notify dietician of residents who has a pressure ulcer. Obtain order for nutritional supplements and use of protein supplements as indicated. The facility nutritional/dietary assessment policy and procedure (July 2014) includes but not limited to; Comprehensive assessments must be completed prior to developing the resident in-depth assessment and care plan and reviewed quarterly and revised as necessary. Nutritional assessment progress review will be updated by the dietician quarterly and as necessary with significant weight change. The facility turning and repositioning policy and procedure (August 2013) includes but not limited to; Nurse shall identify residents on admission who need assistance with turning and repositioning in accordance to the resident's functional assessment and (Brand name) scale evaluation (assessment for predicting pressure sore risk). Residents who are assessed to be high risk for pressure sore development should be turned and repositioned regularly at least every 2 hours or as needed.