Alden Lincoln Rehab & H C Ctr

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that nursing staff was in facility as assigned on their schedule; this failure resulted in residents having to receive medications and treatments with a delay. This failure effected four (R2, R6, R7, R8) out of eight residents reviewed for nursing services. Finding include:R2's face sheet dated 02/24/2026 documents in part that R2 was admitted on [DATE] with diagnosis of Diabetes mellitus, neuropathy, essential hypertension, urinary tract infection, peripheral vascular disease, human immunodeficiency virus, bipolar disorder, hyperlipidemia, sleep disorder, malignant neoplasm prostate.R2's Minimum date set section C for brief mental status dated 12/30/2025 displays that R2 has a score of 12 which means R2 is cognitively intact.R6's face sheet dated 02/25/2026 documents in part that R6 was admitted [DATE] with diagnosis of Chronic diastolic heart failure, tachycardia, major depressive disorder, insomnia, protein calorie malnutrition, anemia, palpitations.R6's Minimum date set section C for brief mental status dated 12/22/2025 displays that R6 has a score of 15 which means R6 is cognitively intact.R7's face sheet dated 02/25/2026 documents in part that R7 was admitted on [DATE] with diagnosis of Cervical spinal cord, asthma, benign prostatic hyperplasia, peripheral vascular disease, essential hypertension, diabetes mellitus, muscle spasms.R7's Minimum date set section C for brief mental status dated 02/09/2026 displays that R7 has a score of 15 which means R7 is cognitively intact.R8's face sheet dated 02/25/2026 documents in part that R8 was admitted on [DATE] with diagnosis of Diabetes mellitus, essential hypertension, benign prostatic hyperplasia, glaucoma, insomnia, long term use of insulin, back pain, hyperlipidemia, post-traumatic stress disorder.R8's Minimum date set section C for brief mental status dated 12/02/2025 displays that R8 has a score of 15 which means R8 is cognitively intact.On 02/25/2026 at 10:23 AM, V7 (Activity Director) stated after resident council all the concerns are either given to the administrator or the director of nursing to follow up with. V7 stated that the residents did express that there were no nurses on the night shift, either the resident did not see the nurse, or the resident could have been sleep when the nurse came by, but I do not have anything to do with staffing. Resident council meets monthly and if they have any concerns the residents inform me and then the concern is given to the appropriate department. The last time the residents informed me that they had concerns with there not being a nurse on the unit was a concern form written on [DATE], meeting.On 02/25/2026 at 10:35 AM, R7 stated he is the resident council vice president and there was one day that there was only one nurse in the facility running all three floors and other times the nurses come in late. R7 stated he cannot remember the exact dates.On 02/25/2026 at 10:49 AM, R8 stated that he is the resident council president. R8 stated few months ago there were some concerns with nurses not being on the unit at the start of night shift, but the concerns have been fixed since then. R8 stated he became the resident council president about a month ago and suggested if there was no nurse on the unit that a nurse from another unit should come downstairs and administer the medication. The reason I was concerned because I am a diabetic and received my insulin late on a few times in the past, it did not cause me to become sick because I know how to manage myself, but it could have resulted in a major concern if it continued to happen. R8 stated he spoke to the administrator and director of nursing; they both told me that they would take care of it. R8 stated when the concern of no nurse on the unit or nurses arriving late it was happening often. R8 stated he did not want it to happen again, so I addressed it for myself and the other residents. R8 stated since I brought the concern to their attention there has been a nurse present daily to pass medications and address the residents' concerns.On 02/25/2026 at 11:06 AM, R6 stated that he has concerns with there not being a nurse on his unit several times on night shift when he has come out to the nursing station to request for something, R6 stated normally he would just ignore it but it has happened so much that it has begun to frustrate him. R6 stated last week he needed pain medication and came to the nursing station around 11:30 PM and was informed that he would have to wait to be medicated because the night nurse had not arrived to facility yet. R6 stated he then went downstairs to another unit and informed a nurse that he was in pain and needed to be medicated, R6 stated the nurse from the first floor came upstairs with him and administered him his pain medication and informed him that the night nurse was running late and would be in soon. R6 stated he is not sure of the time that the nurse arrived because he went to bed after receiving his medication. R6 stated he informed the administrator and director of nursing of his concerns.On 02/25/2026 at 11:59 AM, V8 (Registered Nurse) stated she has worked on the first floor since December 2025. V8 stated she could not remember the date but last week on night shift around 11:40 PM, R6 came down to the first floor and informed me that there was no nurse on his unit and he needed pain medication. V8 stated she went upstairs and gave R6 his medication. R8 stated that the nurse for the third floor unit was running late and arrived close to 12:00 AM. V8 stated this was the first time that I experienced such a thing related to having to administer medication on another unit because a nurse was running late, and no residents have told me that they had concerns related to late medication administration or a nurse not being available during my shifts.V8 stated R6 is not her assigned resident but she was just helping out since the nurse was not in the facility.On 02/25/2026 at 12:58 PM, V1 (Administrator) stated that he was made aware of the concern on 10/27/2025, the issue was addressed about attendance and calling in late with nursing staff and informing nursing staff who to notify when they are running late. V1 stated I have noticed that there was a trend of the nurses running late and it was addressed immediately, and it has been improving lately. V1 stated the nurses run late less than an hour some 15-20 minutes to my knowledge. Nursing directors address the nurses and in-services were done. If nurses are running late or calling off, they would notify myself and nursing director. V1 stated the 9/29/2025 resident council concern were reviewed by checking the staffing schedule and for call ins and nothing reflected that there were no nurses on the shifts. I spoke with the residents who had the concerns and they said they eventually saw the nurse.On 02/25/2026 at 1:17PM, V2 (Director of Nursing) stated it was brought to my attention by the residents that staff were coming in late and not notifying the nursing directors. My expectation is that if a nurse is coming in late, they need to also call the facility to inform the staff. Also, the assistant administrator would call the facility to notify the building so if a resident needs something on another floor the staff are aware that they need to go to the unit and assist the resident with the need and or pass the medication until the nurse arrives. This doesn't happen much but is a concern that the facility is addressing on a constant basis by in servicing and educating the staff on attendance policies and disciplinary actions that can result in continued behavior. V2 stated V8 does not work on the unit R6 resides on but it is the expectation if a nurse is not available on the unit another nurse is to go and assist the resident with their medication needs. Reviewed facility resident council minutes dated September 29, 2025, documents in part; residents state there were no nurses on a couple of night shifts. Residents listed as attending the meeting were as follows R6, R7, R8 who had concerns with nurses not being available on night shift.Reviewed facility in service dated October 2025, topic documents in part : Attendance, call ins, lateness attached with a facility guideline titled absenteeism and tardiness standards.Reviewed facility concern form dated 10/27/2025 documents in part with R6 name on it , nature of concern: nurse is not coming on time causing R6 to receive his medications late.10/28/2025 V2( Director of Nursing) documented that she spoke with R6 regarding his medication administration concerns and that the nurses were educated.Reviewed R6's medication administration record which reflected that V8 completed pain assessment on 2/18/2026 and administered him medication .On 02/26/2026 at 2:01 PM, V1 stated the facility does not have a policy for staffing. The facility ensures that they meet the minimum staffing ratios.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to provide supervision during a shower. This failure resulted in one (R1) resident sustaining a fall with injury in a sample of eight reviewed for falls.Findings include:R1's face sheet dated 02/24/2026 documents in part that R1 was admitted on [DATE] with diagnosis of Multiple fractures of the pelvis, non-displaced fracture of posterior wall of right acetabulum, chronic diastolic heart failure, diabetes mellitus, atrial fibrillation, muscle weakness, poly osteoarthritis, major depressive disorder, malignant neoplasm prostate, cardiac defibrillator.R1's Minimum date set section C for brief mental status dated 1/16/2026 displays that R1 has a score of 14 which means R1 is cognitively intact; section GG Functional abilities dated 10/24/2026 documents in part that R1 required partial/moderate assistance for showers/bathes which means staff does less than half the effort, staff lifts, holds or supports trunk or limbs to assist R1 but provides less than half the effort.R1's progress note dated 01/07/2026 at 10:47 AM, documents in part that [ R1 was found in right lying position in shower at approximately 1030 AM. Vital signs taken BP of 179/79. Patient able to answer questions and stated, I think I hit my head. Full body check done, no bruising, lacerations, swelling, or bleeding noted. Initial Neuro check completed with no deficits. Proper grip strength in all extremities, neuro orientation at baseline, PERRLA intact. Patient made remarks of 3/10 RLE pain at anterior thigh. Pain medication offered and denied, Cold pack denied. R1 assisted to wheelchair with assistance of CNA and R1 escorted back to room by CNA. R1 assisted into bed by staff, NP (V9) called with orders to send R1 to hospital due to being on multiple blood thinners. ambulance called immediately with ETA of 1115.Neuro checks completed per protocol at 1030, 1045, 1100, 1115, and 1145. Patient left facility at approximately 1150 escorted by two paramedics. Patient stable upon exit of facility.] Progress noted documented by V12 (Registered Nurse).R1's progress noted dated 01/07/2026 at 9:25 PM, documents in part that R1 was admitted to hospital with multiple fractures to right hip.R1's hospital records dated 01/07/2026 documents in part that; R1 sustained right acetabular/pubic rami fracture, displaced fracture right iliac bone with fractures roof and medial aspect right acetabulum, displaced fracture lateral right ischium, displaced fractures right superior and inferior pubic rami because of mechanical fall in shower from standing position. R1 is not a candidate for surgery at time of surgical consult.R1's care plan dated 1/13/2026 documents in part; R1 is noted to have limitations in range of motion related to presence of pain to Right hip due to fracture, decrease in physical activity, generalized muscle weakness and diagnosis of Major Depressive Disorder, 01/12/2026, R1 requires assist from staff to dress related to non-weight bearing status to right lower extremity due to Right hip fracture and poor balance.R1's physician order sheet documents in part: 01/13/2026 pain management/modalities hot/cold pack to right hip as needed; physical therapy to begin for four to six weeks. 02/04/2026 weight bearing status toe touch right lower extremity. 02/23/2026 Norco tablet 5-325 milligrams every 12 hours for pain to right hip.On 02/23/2026 at 12:18 PM, R1 stated on 01/07/2026 he was trying to take a shower, and I could not get my sock off my foot, V4 left the shower room and said she would be back. R1 stated he leaned over and fell on the floor. I do need help in the shower; staff normally stay with me in the shower in case I need help. When I fell no one was in shower room with me, I was in pain, and the nurse came and looked at me then sent me to the hospital. I was receiving pain medication for my pelvic fracture, but I have stopped taking it because the pain medication causes me to have constipation which is more painful. I still have pain now, but I just bear with the pain. R1 stated he normally can remove his socks in the shower room with staff present but these socks were too small and very tight, so it was hard to remove. R1 stated since I am no longer able to walk around with my rollator, and I must depend on staff more for my care. This makes me feel helpless. R1 stated the nurse met with him and would be giving him a stool softener that should give him some relief.On 02/23/2026 at 12: 29 PM, V3 ( Certified nursing assistant (CNA) stated she is the CNA who takes care of R1 and that R1 requires extensive assistance for showers, two staff members are required to assist him and we use gait belt because of his restrictions. R1 does not do any of his care, staff does all care. R1 uses wheelchair now since he has fractures.On 02/24/2026 at 10:25 AM, V4 (CNA) stated at 10:25 am I was accompanying R1 to shower, and he was using his rollator that is when I saw the call light was going off and I went to answer the call light. I instructed R1 to wait for me, normally I go in and set R1 up in the shower room. R1 told me that he was standing up and trying to remove his sock and that's when he tumbled over. V4 stated I wanted him to wait next to shower room while I went to answer another call light, normally I would have his towels, soap and gowns set up for him. R1 is a supervision and R1 normally removes footies while staff is in there. V4 stated her understanding of supervision is if R1 needs some assistance staff would be present to assist for care needs, I don't think R1 would have fallen if someone was with him. V4 states R1 receives showers twice a week and normally she is supposed to tell the nurse before she enters the shower room with a resident so the nurse can be aware to respond to the shower room light so they can check the residents skin. V4 stated it slipped her mind to inform the nurse. V4 stated she could have asked another staff member to answer the light but she thought she could answer the light quickly then attend to R1 because normally he would wait for me.On 02/24/2026 at 12:05 PM, V12 (Registered Nurse) stated R1 was not to be left unattended by staff in shower room. V12 stated he was not made aware by certified nursing assistant (CNA) that R1 was going into the shower. The CNA came and informed me that R1 was lying on the shower room floor, I went and assessed R1. R1 stated he was in pain and I asked him if he wanted Tylenol or cold pack and R1 declined, he was not sure if he hit his head but R1 takes blood thinners, the day of the incident was the first time I ever worked with R1. V12 stated the CNA should have stayed with R1 and another staff member could have assisted and completed the other task she went to do, she could have asked myself or another aide to answer the call light to decrease the risk of R1 falling if she was present with him.On 02/24/2026 at 12:58 PM,V9 (Nurse Practitioner) stated he was informed on the date of the incident 01/07/2026 that R1 sustained an unwitnessed fall in the shower room and that R1 is on blood thinners and was uncertain if he his head or not. That is why he gave orders to have him evaluated at the hospital. V9 stated a staff member should have been with R1 in the shower room to break the fall and decrease R1 from slipping. V9 stated the fractures that R1 sustained, normally takes healing around eight weeks or more but R1 is being seen by Orthopedic clinic, R1 is a diabetic and that can slow down the healing process. R1 has been transferred to skilled unit for increased staff supervision related to his fractures, because R1 requires more assistance from staff at this timeOn 02/24/2026 at 1:35 PM, V2 ( Director of Nursing) stated she is the person that does restorative programs in the facility and prior to R1's fall on 01/07/2026, he was able by himself with the rollator but since the fall and fractures occurred R1 has restriction now of toe touch and is not ambulating and not using rollator. R1's transfer status: toe touch, gait belt and pivot avoiding touching that effected extremity. V2 stated staff offer oversight for showers, prior to the incident staff would alert R1 and he would gather his own things for the shower. Staff always offers help. Staff stay in shower room area if residents need assistance. Staff should assist R1 after shower to walk him back to room and make sure R1 has everything he needs and in case there is water on floor staff are present to assist to decrease risk of accidents. After the fall R1 was moved to skilled unit on the 3rd floor, for more therapy and increased supervision, R1 appears to be happier on the unit. Prior to incident R1 was completing active range of motion and no deficits were present and was using rollator.On 02/24/26 at 1:46pm, V2 (Director of Nursing) stated it is her expectation of the staff that resident's safety is always maintained to decrease risk of falls and injuries. Staff are required to make sure they have everything that is needed for showering of a resident prior to entering the shower room. Residents are encouraged to be independent but staff should not leave residents alone in the shower room who require supervision. V2 stated the shower room is designed with a separate area where staff can provide the resident with privacy but still be in the room close enough to assist the resident if help is needed. V2 stated the certified nursing assistant (CNA) should have asked someone else to answer the other light and proceed to assist R1 to decrease risk of fall and injury and the nurse should be informed by the CNA so they are aware of the residents who are going into the shower room and to be alert if the shower light rings so the nurse can come and complete a body assessment.On 02/25/26 at 11:19 AM, V10 ( Physical therapist) stated R1 has multiple fractures and is currently toe touch weight bearing for the next six weeks, it is hard for R1 to adjust to this modified way of movement because he was used to moving with rollator independently but R1 tries his best. V10 stated prior to fall with fractures R1 was modified independent for transfers, mobility and using a rollator but now R1 is minimum contact guard assistance for transfers from bed to chair with use of mechanical lift do to R1's restrictions, healing takes times but R1 is progressing well.-Facility document presented by V2 titled falls has R1 listed as having a fall on 01/07/2026.-Facility policy dated 08/2020, titled Management of falls documents in part; The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the residents plan of care to minimize the risks for fall incidents and/or injuries to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the provider's order and care plan intervention for one (R1) resident out of three reviewed for wound care treatments. Findings Include:R1's clinical records show an admission date of 4/10/25 with included diagnoses but not limited to non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, chronic diastolic (congestive) heart failure, and lymphedema. R1's Minimum Data Set assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R1's comprehensive care plan documents in part (date initiated on 4/11/25): [R1] has an actual skin alteration and at risk to develop pressure injury related to altered some ADL [Activities of Daily Living] function and decreased mobility. R1 has right leg-non pressure. Goal: Site(s) will not become infected through next review (date initiated 9/16/25; target date 10/13/25). Intervention reads in part: Treatment as ordered (date initiated 9/16/25).R1's right leg wound notes electronically signed by V11 (Wound Care Nurse Practitioner) with treatment recommendation on 9/22/25 reads in part: Daily and as needed clean with normal saline Calcium Alginate with silver foam dry dressing for 30 days. R1's Order Summary Report with active orders as of 11/23/25 reads in part: Calcium Alginate-Silver External Pad 4 (Calcium Alginate-Silver) Apply to right leg topically every day shift for skin condition cleanse with saline then apply Calcium Alginate with Silver and cover with foam or dry dressing (ordered 9/23/25). R1's September Treatment Administration Record (TAR) shows blank and unsigned on 9/23/25. R1's progress notes on 9/23/25 does not document R1's refusal to her wound treatment and no documentation related to the status of R1's right leg wound/treatment.On 11/23/25 at 10:27 AM, R1 stated that a wound doctor checked her right leg wound in September and put a dressing. R1 said that her right leg wound treatment was supposed to be done daily, but on 9/23/25, it was not done. R1 said, I don't know what happened that day, but it was not changed. I did not go out that day or refuse the wound care treatment. [V15 (Licensed Practical Nurse/LPN)] does my wound dressing. [V15] does it when she's here. [V15] was my nurse, but I don't know what happened that day. [V15] was probably got caught with something. I told [V10 (LPN) that it was not changed in the morning, but he did not do it. [V10] was the second shift nurse. R1's right leg was noted wrapped with dressing. R1 refused for the dressing to be removed.On 11/23/25 at 1:29 PM, V15 (Licensed Practical Nurse) stated, that the nurses are doing the residents' wound treatments. V15 said, After I finish passing meds then I do my treatment. I follow the doctor's order. If the treatment is ordered once a day in the morning, the treatment should be done in the morning shift. From 7:00 AM to 3:30 PM. After I do the treatment, I sign the TAR that it's done. If I don't sign the TAR, it means I did not do it. I make sure I sign it off before I leave for the day at the end of my shift. [R1] prefers to do the wound treatment in the hospital. I can't remember what really happened in September.On 11/23/25 at 1:45 PM, a phone interview was conducted with V10 (Licensed Practical Nurse) and stated, I do wound treatments if it's assigned to me. I haven't done any wound treatment for [R1] because the treatment order is not assigned to me. I don't remember it being assigned maybe it was done the day before. I don't remember her [R1] asking me to do the wound treatment.On 11/23/25 at 12:10 PM, V2 (Director of Nursing) stated that the nurses are doing the residents' wound care treatments and V11 comes weekly to monitor the wounds and see if the treatments are appropriate. V2 said that the nurses change the dressing, they document that the dressing is changed and what they assess on the wound. In progress notes they will document. V2 said if the dressing is done, it should be documented in the TAR. It should be signed off. In the TAR it should be signed that it's done. V2 said if the resident refuses, it should also be documented in the progress notes. V2 said that if it's not signed off in the TAR it means, it's not done; and the documentation should also be part of the progress notes.On 11/23/25 at 1:52 PM, a phone interview was conducted with V11 (Wound Care Nurse Practitioner). V11 stated, I cannot really tell if [R1's] wound is getting worse. I don't have my notes with me. If there is a change in measurement and if it's getting bigger then I would say it's getting worse. I do my initial assessment and I do weekly follow up if I'm consulted. If I have a treatment recommendation I would include it in my wound notes. I talk to the nurse and I will send the process notes to the [V2] to make sure my recommendations are carried out. It's important that my wound treatment recommendations are followed because if it's not followed the wound will get worsen. The wound treatment order for [R1] is daily dressing so that the nurses can check and see the status of her wound. They can inform me if there is a change in the wound. If they don't follow the order, it can make the wound worse. It should be done everyday and when it's soaked it's done as needed.The facility's PREVENTION AND TREATMENT OF PRESSURE INJURY AND OTHER SKIN ALTERATIONS policy and procedure dated 3/2/21 documents in part: Implement preventative measures and appropriate treatment modalities for pressure injuries and/or skin alterations through individualized resident care plan. At least daily, staff should remain alert for potential changes in the skin condition during resident care.The facility's Staff Nurse (Registered Nurse/License Practical Nurse) Job Description documents in part: Prepare and administer medications and treatments if appropriate as ordered by the physician.

Based on interview and record review, the facility failed to report the allegation of sexual abuse for one resident (R1) within the stipulated two hours time frame. Findings Include: On 9/11/25 at 10:05 AM, V1 (Administrator) stated that at approximately 1:00 PM on 9/9/25, the facility was notified via email by V15 (Ombudsman) that she received a call from V3 (Wound Nurse/Licensed Practical Nurse/LPN) about a possible sexual abuse towards R1. V1 stated that he is the abuse coordinator, it is his expectation that all allegations of abuse will be reported to him immediately for investigation, and the initial reportable should be sent to Illinois Department of Public health/IDPH within two hours of notification. V1 stated that V3 should have reported the allegation to him, and he should have sent the initial reportable to IDPH around 3pm and not at 5:44 PM, because he must still follow two hours of reporting allegation of abuse. On 9/11/25 at 12:38 PM, via telephone, V3 (Wound Nurse/LPN) stated that she has been in the facility since March 28, 2025, and she attended in-service on types of abuse, who and when to report an abuse.On 9/11/25 at 1:16 PM, V2 (Director of Nursing/DON) stated that she has been in the facility since April 2024. She knows that the initial investigation should have been reported to IDPH within the first two hours of notification, but V1 oversees the reporting process. Documents reviewed for this investigation are not limited to the following: Initial Incident Report Form dated 9/9/25 faxed to IDPH at 5:44 PM above the two hours time frame.Abuse in-service attendance record dated 5/14/25 with V3's signature.Copy of email dated 9/9/25, sent to V1 at 12:59 PM related to the allegation of abuse.Facility's Abuse Policy documents in part: Filing accurate and timely investigation reports.

Based on interview and record review, the facility failed to ensure a resident's environment was free of accident hazard. This failure affected 1 (R1) resident reviewed for falls in the total sample of 4 residents.
Findings include:
Review of R1's and R4's census lists documented R1 and R4 were roommates beginning 11/20/2024.
On 06/20/2025 at 10:57am, R1 was walking slowly from the activity/dining room to her room. R1 stated, I had fallen but I cannot tell how. I forgot already.
On 06/20/2025 at 1:19pm, V7 (Licensed Practice Nurse) stated, I know (R1). She fell before and she has a left hip fracture. She is limping when she walks. Before the recent fall on 05/14/2025, she was allowed to walk in the unit without supervision. On 05/14/2025 at dinner time, (R4) was in the dining room but she (R1) was not. I (V7) did not see her (R1) in the dining room at that time, at 4:30pm. Then at around 4:50pm, I heard her screaming aray! in her room. Which translates as ouch!. I went to her room, and I observed her sitting on the floor, between her bed and her roommate's (R4) bed. She was wearing her crocs shoes or rubber shoes. I did not see how she fell, and she did not say what happened. She could have tripped on her roommate's floor mat. It was on the floor between their (R1 and R4) beds. Floor mats should be placed on the sides of the bed when residents are in bed. These should not be laid on the floor when residents are ambulating in the room because these gives the residents instability when they are walking. Floor mats are a tripping hazard. I assessed her and there was a 1-inch swelling on the right side of her head.
On 06/20/2025 at 2:13pm, V2 (Director of Nursing) stated, Our fall interventions include floor mats so when a resident falls, it cushions the landing. Floor mats should be placed on the sides of the bed when the resident is on the bed because floor mats pose as tripping hazard. The floor mats should not be on the floor when a resident is ambulating in the room to protect the resident because it is a potential tripping hazard.
R1's admission Record documented R1's Diagnoses: (include but not limited to) disorder of brain, history of falling, amnesia, and dementia.
R1's (05/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating R1's mental status as severely impaired. Section GG. Functional Abilities> GG0170. I. Walk 10 feet: 5 - Set up assistance. J. Walk 50 feet with two turns: 04 - Supervision assistance. K Walk 150: 04 - Supervision.
R1's (05/14/2025) progress notes documented, in part Writer was alerted by resident's scream. On entry to the room, resident noted sitting on the floor, right side of her head on a chair nearby. Resident's head was lifted and noted swelling on the R (right) parietal side of the head, able to walk but complains of R hip pain. NP (Nurse Practitioner) ordered to send resident to hospital for evaluation and mgmt. (management). Authored by: V7 (Licensed Practice Nurse).
R1's (05/14/2025) After Visit Summary indicated the following diagnostic exams were performed including CT of Cervical Spines without contrast; CT of chest, abdomen, and pelvis without contrast; and CT of head without contrast; x rays of Chest AP and PA views; XR of hips bilateral view and pelvis with no notes of injury.
R1's (05/15/2025) Fall Risk Assessment documented, in part 0. Reason for Assessment. e. Post Fall.
R1's (Initiated: 05/22/24) care plan documented, in part Focus: at risk for falls r/t (related to) impaired cognition, weakness, unsteady gait, reduced activity tolerance and DX (diagnoses) of dementia, Hx (history) of falling, amnesia, and left hip fracture. Goal: will be free from injury related to falls (initiated: 5/14/2025).
R4's admission Record documented that R4's Diagnoses: (include but not limited to) history of falling, hypertension, and dementia.
R4's (06/12/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating R4's mental status as severely impaired.
R4's (Initiated: 08/09/2024) care plan documented, in part Focus: at high risk for falls. Intervention: Floor mats will be placed when (R4) is in bed.
The (08/2020) Management of Falls documented, in part Policy: The Facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident.
The (06/20/2025) Untitled Facility provided document indicated, in part Floor mats should be removed from the bedside and stored in a(n) appropriate place when the resident is not in bed. The purpose is to maintain resident safety.

Based on interview and record review, the facility failed to develop a careplan for a resident ' s known behavior and failed to ensure fall interventions were implemented. These failures affected 2 (R1 and R3) residents reviewed for careplan in the total sample of 5 residents.
Findings include:
On 05/23/2025 at 2:25pm, V7 (Certified Nursing Assistant) stated I know (R1) ' s incident was after supper, on the second floor dining room, as I was wheeling her (R1) out and before I made a turn to the exit, out of the dining room, she grabbed the wheel of (R5) ' s wheelchair. Her (R1) left hand got caught on the wheel of (R5) ' s wheelchair and she lunged and fell.
On 05/23/2025 at 2:45pm, V7 stated I am familiar with her (R1). When I first came in, the senior CNAs told me that she grabs on to things and to be careful. The first time I was assigned to her, I already noticed behaviors of grabbing onto things each time I wheel her out of the dining room to her bed, she will hold onto something like the rail. She grabs stuff all day long. If you have to toilet her and change her diaper, she would grab the table with her hands spread out. I think it should be care planned to prevent incidents that happened on that day (04/23/2025).
On 05/23/2025 at 4;21pm, V6 (Licensed Practice Nurse) stated I am familiar with the resident (R1). I observed her grabbing onto things when we wheel her out of the dining room. When you wheel her, she would spread her arms and start grabbing whichever is closer to her like a chair or wheelchair. When she came to the second floor, she already exhibited the behavior of grabbing on things when she wheeled out. I think she had that behavior while she was on the 3rd floor. I don ' t know if she was care planned for that behavior. It could have helped if the behavior of grabbing on to things was care planned so interventions could be implemented.
On 05/23/2025 at 3:11pm, V16 (Resident Care Coordinator) stated if a resident has a behavior of grabbing things like wheelchair and tables, it should be care planned so it can be addressed to prevent injury to the resident and to other residents. It should be care planned the moment they observe the resident exhibiting the behavior right there and then so the behavior could be addressed.
On 05/23/2025 at 3:36pm, V8 (Memory Care Director) stated the behavior of grabbing onto things should be care planned when the behavior was first noted and to make sure staff is aware of the behavior. So, if it continues to occur, we can help prevent the behavior. It is a safety concern. We can help prevent the behavior and we can keep the resident safe.
On 05/23/2025 at 3:49pm, V2 (Director Of Nursing) stated the behavior should be care planned when it was first noted. Basically, we want to be able to identify how the resident acts, and we will put in different interventions and monitor the effectiveness of the interventions. This surveyor showed V2 R1 ' s 4/24/2025 careplan which was initiated a day after the incident. V2 stated if care planned before the incident, we could have potentially prevented the incident.
R1 ' s (Printed: 05/23/2025) census list documented that R1 was moved from the third floor to the second floor on 11/20/2024.
R1 ' s (Active Order as Of: 05/23/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) history of falling, hypertension, and dementia.
R1 ' s (03/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 2. Indicating R1 ' s mental status as severely impaired.
R1 ' s (Date Initiated: 04/24/2025) careplan documented, in part Focus: noted to continue to stand while in wheelchair and at dining room table and attempt to grab items while being transported in wheelchair. Goal: will be free from injury. Of note, care plan was initiated after the fall incident.
R3 ' s (05/23/2025) Fall Risk Assessment documented, in part Reason for Assessment: e. Post Fall.
R3 ' s (Target Date: 07/06/2025) care plan documented, in part Focus: AT RISK for falls related to hx (history) of falling, use of Indwelling foley catheter, Bowel incontinence, poor balance, unsteady gait, impaired cognition, use of wheelchair and RW, poor vision, and Dx (diagnosis) of Hx of displaced apophyseal Fracture of Left femur, Dementia, BPH and HTN. has poor safety awareness and has impulsive behavior. Intervention: Do not leave in bed while awake.
On 05/23/2025 at 12:07pm, V13 (Licensed Practice Nurse) stated we have 2 nurses and 2 CNAs working this shift.
On 05/23/2025 at 12:24pm, V15 (Certified Nursing Assistant) responded to R3 ' s call device. V15 went inside R3 ' s room. After responding to R3 ' s call device, V15 left R3 ' s room.
On 05/23/2025 at 12:25pm, no staff was present in R3 ' s room. R3's stated I am okay, I am okay. This surveyor went by R3's door and requested for assistance.
On 05/23/2025 at 12:27pm at the doorway of R3 ' s room, V15 came in and after a short interview, V15 left.
On 05/23/2025 at 12:29pm by the nurse ' s station, inquiring who was assigned to R3. V13 stated she (V14 - CNA) stepped out for few minutes.
On 05/23/2025 at 12:31pm, the call device overhead light indicator on R3's room was lit.
On 05/23/2025 at 12:33pm, V14 went inside the room and informed R3 that staff are getting ready to serve lunch. The overhead call device indicator light turned off and V14 exited the room.
On 05/23/2025 at 12:34pm, inside R3's room, no staff was present. R3 attempted to get out of the bed. This surveyor called V13 for assistance.
On 05/23/2025 at 12:35pm, V13 went inside the room and stayed in the room.
On 05/23/2025 at 4:02pm, V2 (Director Of Nursing) stated I expected the care plan to address the need of the resident and implementing the interventions is the best way to keep our resident safe.
On 05/23/2025 at 4:03pm, V2 (Director Of Nursing) stated we do encourage (R3) to stay in the dining room. If he is in the bed and awake, he tries to get out of the bed. At this time, this surveyor handed V2 R3 ' s careplan and informed V2 that R3 was in the room awake with no staff present in the room. V2 stated we are not following the intervention. This intervention is to prevent him from falling.
R3 ' s admission Record documented that R3 ' s diagnoses (include but not limited to) hypertension, severe dementia and age-related cataract.
R3 ' s (04/07/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 04. Indicating R3 ' s mental status as severely impaired. Section GG. Functional Abilities. GG0130. Self-Care. C. Toileting hygiene and I. Personal hygiene: 2 - substantial/maximal assistance.
R3 ' s (05/223/2025) Fall Risk Assessment documented, in part Reason for Assessment: e. Post Fall.
R3 ' s (Target Date: 07/06/2025) care plan documented, in part Focus: AT RISK for falls related to hx (history) of falling, use of Indwelling foley catheter, Bowel incontinence, poor balance, unsteady gait, impaired cognition, use of wheelchair and RW, poor vision, and Dx (diagnosis) of Hx of displaced apophyseal Fracture of Left femur, Dementia, BPH and HTN. has poor safety awareness and has impulsive behavior. Intervention: Do not leave in bed while awake.
The (05/24/2025) email correspondence with V1 (Administrator) documented, in part Behavior would constitute a change in residents plan of treatment, so expectation would be to update the care plan accordingly, to include a focus, goals, and intervention reflective of the behavior. Care plans should be updated routinely (initial, quarterly, annually, readmit, sig changes) and or if new behavior is observed. The reason is so that goals and interventions can be created to then be able to further assist with caring for resident.
The (9/2016) Memory Care Director Job Description documented, in part Job Summary: The memory care director is directly responsible for the initial and continual development and monitoring of the holistic, therapeutic, present centered memory care program on the memory. The Memory Care Director will achieve and maintain the highest quality of life for each resident, either diagnosis or disease that causes dementia residing in or under the care of the facility. Essential Duties: L. Become knowledgeable of each individual resident ' s Behavioral care needs and preferences in detail to develop and ensure an appropriate person centered plan of care.
The (11/2017) Comprehensive Care Plans documented, in part An individualized, person centered comprehensive care plan, including measurable objectives with timetables to meet the resident ' s physical, psychosocial and functional needs, is developed and implemented for each resident. Procedure: 1.) the interdisciplinary team will develop and implement a person centered, comprehensive plan of care. 2. The Interdisciplinary team includes b. A nurse and nurse ' s aide that have responsibility for the resident. 6.) the comprehensive person-centered care plan will b. Describe the services that are to be provided to attain or maintain the highest practical physical, mental and psychosocial well being.

Based on interview and record review, the facility failed to institute interventions for a resident ' s known behavior to provide safety for the resident and other residents. This failure resulted in a resident falling and sustaining a closed fracture of the phalanx (small bone) of index finger and contusion of the head. This deficient practice affected 1 (R1) resident reviewed for quality of care in the total sample of 5 residents.
Findings include:
On 05/23/2025 at 2:25pm, V7 (Certified Nursing Assistant) stated I know (R1) ' s incident was after supper, on the second floor dining room, as I was wheeling her (R1) out and before I made a turn to the exit, out of the dining room, she grabbed the wheel of (R5) ' s wheelchair. Her (R1) left hand got caught on the wheel of (R5) ' s wheelchair and she lunged and fell.
On 05/23/2025 at 2:45pm, V7 stated I am familiar with her (R1). When I first came in, the senior CNAs told me that she grabs on to things and to be careful. The first time I was assigned to her, I already noticed that behavior of grabbing onto things each time I wheel her out of the dining room to her bed, she will hold onto something like the rail. She grabs stuff all day long. If you have to toilet her and change her diaper, she would grab the table with her hands spread out. Whenever I am assigned to her, I always wheel her out of the dining room last, so the exit is clear; no chairs and no wheelchair because I know she likes to grab things when I wheel her out. On that evening, she (R1) was the first one to leave the dining room because she was sleepy, (R5) was still in the dining room by the exit. I did not move anyone. I just wheeled her out (R1).
On 05/23/2025 at 4;21pm, V6 (Licensed Practice Nurse) stated I am familiar with the resident (R1). I observed her grabbing onto things when we wheeled her out of the dining room. When you wheel her, she would spread her arms and start grabbing whichever is closer to her like a chair or wheelchair. When she came to the second floor, she already exhibited the behavior of grabbing on things when she wheeled out. I think she had that behavior while she was on the 3rd floor. I don ' t know if she was care planned for that behavior. It could have helped if the behavior of grabbing on things was care planned so interventions could be implemented. If the CNA knew about this behavior, I expected I her to clear the path with nothing to grab on to and to wheel her to safety. My back was turned, and I did not see the fall. I heard a loud bang on the floor. I assessed her and there was swelling on her midline forehead about 1.5 inches x 1.5 inches, and she was also complaining of pain on her left hand second digit.
On 05/23/2025 at 3:11pm, V16 (Resident Care Coordinator) stated if a resident has a behavior of grabbing things like wheelchair and tables, it should be care planned so it could be addressed to prevent injury to the resident and to other residents. It should be care planned the moment they observed the resident exhibiting the behavior right there and then so the behavior could be addressed.
On 05/23/2025 at 3:36pm, V8 (Memory Care Director) stated the behavior of grabbing onto things should be care planned when the behavior was first noted and to make sure staff is aware of the behavior. So, if it continues to occur, we can help prevent the behavior. It is a safety concern. We can help prevent the behavior and we can keep the resident safe.
On 05/23/2025 at 3:49pm, V2 (Director Of Nursing) stated the behavior should be care planned when it was first noted. Basically, we want to be able to identify how the resident acts, and we will put in different interventions and the effectiveness of the interventions. This surveyor showed V2 R1's 4/24/2025 careplan which was initiated a day after the incident. V2 stated if care planned before the incident, we could have potentially prevented the incident.
On 05/23/2025 at 3:53pm, V2 stated if the CNA has knowledge of the behavior, my expectation is to maintain the resident's safety, call for help to move other residents out of the way of this resident so the incident could have been prevented.
R1 ' s (Printed: 05/23/2025) census list documented that R1 was moved from the third floor to the second floor on 11/20/2024.
R1 ' s (Active Order as Of: 05/23/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) history of falling, hypertension, and dementia.
R1 ' s (03/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 2. Indicating R1 ' s mental status as severely impaired.
R1 ' s (04/23/2025) Pain management Evaluation documented, in part Reason for Evaluation: Post Occurrence. Location of Pain. Site: Left hand- swollen 2nd digit. Face - contusion hematoma forehead. Authored by: V6.
R1 ' s (04/23/2024) Local Hospital Emergency Department Patient Visit Information documented, in part You were seen today for: Concussion without loss of consciousness, Contusion of head and Closed fracture of phalanx of index finger.
R1 ' s (04/23/2025) Xray Report documented, in part Abnormal findings. Radiograph of the left hand. Findings: An avulsion fracture is seen at the base of the proximal phalanx of the index finger.
R1 ' s (04/23/2025) CT (Computed Tomography) Scan documented, in part Findings: Soft tissue: there is a significant soft tissue swelling over the midline frontal calvarium.
R1 ' s (Date Initiated: 04/24/2025) careplan documented, in part Focus: noted to continue to stand while in wheelchair and at dining room table and attempt to grab items while being transported in wheelchair. Goal: will be free from injury. Of note, care plan was initiated after the fall incident.
The (05/24/2025) Email correspondence with V1 (Administrator) documented, in part Behavior would constitute a change in residents plan of treatment, so expectation would be to update the care plan accordingly to include a focus, goals, and intervention reflective of the behavior. Care plans should be updated routinely (initial, quarterly, annually, readmit, sig(significant) changes) and or if new behavior is observed. The reason is so that goals and interventions can be created to be able to further assist with caring for resident.

Based on observation, interview, and record review, the facility failed to ensure the call device was placed within a resident ' s reach and failed to ensure staff inquired what a resident needed when responding to a call device. These failures affected 2 (R2 and R3) residents reviewed for call devices in the total sample of 5 residents.
Findings include:
On 05/23/2025 at 12:15pm, R2 ' s call device was behind the nightstand, not within her reach. V13 (Licensed Practice Nurse) checked the call device string and stated it is tangled. V13 untangled the call device string and clipped to R2 ' s left side. V13 stated placement of the call light should be within R2's reach. So, we can know when she needs assistance.
On 05/23/2025 at 12:20pm, V14 (Certified Nursing Assistant) stated the last time I went to her room was an hour ago. I did not check for the placement of R2's call light.
On 05/23/2025 at 12:31pm, the call device overhead light indicator on R3 ' s room was lit.
On 05/23/2025 at 12:33pm, V14 went inside the room and informed R3 that staff are getting ready to serve lunch. V14 did not ask what R3 needed. The overhead call device indicator light was turned off and V14 exited R3 ' s room. This surveyor inquired if V14 asked R3 what kind of assistance R3 needed. V14 stated I did not ask R3 what he needs.
On 05/23/2025 at 3:44pm, V2 (Director of Nursing) stated the purpose of call light is for the resident to be able to ask for assistance. My expectation is the call light should be placed within reach of the resident. I want them to be able to use it, have access to it. My expectation is to answer the call light immediately, within 2-3 minutes, and to ask the resident what he or she needs; what type of assistance he or she needs.
On 05/23/2025 at 4:01pm, V2 stated if the resident rings the call light, they must be needing something, and we have to accommodate the need of the resident.
R2 ' s (Active Order as of: 05/23/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) history of falling, hypertension, and age-related osteoporosis.
R2 ' s (03/21/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating R2 ' s mental status as moderately impaired.
R2 ' s (Target Date: 06/20/2025) care plan documented, in part at High RISK for falls related to HX (history) of fall incident in the community, repeated falls and History of repeated falls. She is modified independent with transfers, ambulation, and ADL, and she completes tasks on her own without calling for assistance. Interventions/Tasks: Promote placement of call light within reach.
R3 ' s admission Record documented that R3 ' s diagnoses (include but not limited to) hypertension, severe dementia and age-related cataract.
R3 ' s (04/07/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 04. Indicating R3 ' s mental status as severely impaired. Section GG. Functional Abilities. GG0130. Self-Care. C. Toileting hygiene and I. Personal hygiene: 2 - substantial/maximal assistance.
R3 ' s (05/23/2025) Fall Risk Assessment documented, in part Reason for Assessment: e. Post Fall.
R3 ' s (Target Date: 07/06/2025) care plan documented, in part Focus: AT RISK for falls related to hx (history) of falling, use of Indwelling foley catheter, Bowel incontinence, poor balance, unsteady gait, impaired cognition, use of wheelchair and RW, poor vision, and Dx (diagnosis) of Hx of displaced apophyseal Fracture of Left femur, Dementia, BPH and HTN. has poor safety awareness and has impulsive behavior.
The (03/2023) Certified Nursing Assistant Job description documented, in part Job Summary: Provides residents with daily nursing care in accordance with current federal, state, and local standards, guidelines and regulations, facility policies as may be directed by the Charge Nurse, Supervisor, Assistant Director Of Nursing, Director Of Nursing Or Administrator to ensure that the highest degree of quality care is maintained at all times. Essential Functions: P. Answer call lights promptly. AA. Keeps the nurse ' s call system within easy reach of the resident.
The (09/2020) Use of Call light documented, in part Purpose: To respond promptly to resident ' s call for assistance. Procedure: 3. Answer all call lights in a prompt, calm and courteous manner; turn off the call light as soon as you enter the room. 4. Never make the resident feel you are too busy to give assistance; offer further assistance before you leave the room. 7. B sure call lights are placed within the resident reach at all times.
The (08/2020) Fall Management Program documented, in part Policy: The facility is committed to minimizing resident falls and or injury so as to maximize each resident ' s physical, mental, and psychosocial well-being. While preventing all resident falls is not possible, it is the facility ' s policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies, and facilitate a safe environment. Procedure: 3. Educate staff members to check during room rounds the 4 P ' s. d. Personal needs. 5. b. At the time of admission, and in accordance with the plan of care. The resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident ' s reach. c. Call lights are to be answered promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to follow the functional abilities assessment and transfer care plan for 1 resident (R1) who sustained left femur fracture, out of 1 resident of a total sample of 4 residents reviewed for nursing care.
Findings include:
R1 is [AGE] years old, currently living in facility. R1's initial admission date was 08/24/2024 with medical diagnosis of severe dementia, major depressive disorder, history of anterior displaced type II Dens fracture on 11/16/2023.
On 01/30/2025 at 12:16 PM, R1 was seen with neck collar, and was non-verbal when name was called. R1 does not respond to verbal stimuli. V8 (Certified Nursing Assistant) went inside the room to turn off the call light. V8 was asked how R1 transfers. V8 replied that R1 needs mechanical lift during transfer and uses Geri-chair, not wheelchair if needed to be transferred from bed to chair. V8 stated that R1 needs stretcher when going out to an appointment and does not use wheelchair. V8 stated because R1 needs stretcher, ambulance need to be used to go to an appointment. V8 was asked about R1's leg because the sheet looks elevated and not flat. V8 took off the sheet that covers R1's legs. R1's legs looks contracted and the right leg crossing over the left leg with purple foam in the middle. V8 stated that the foam is for R1's comfort.
Incident / Accident Notification initial report sent by facility to State agency dated 11/17/2024 documents that on 11/17/2024, R1 was X-Rayed for left femur fracture with some demineralization and degenerative arthritis changes in the joint. After a nursing staff was notified that R1's left knee appeared larger than the right knee. Incident / Accident Notification final report sent by facility to State agency dated 11/22/2024 documents that R1 is non-ambulatory and needs assistance with bed mobility, transfers, ADL (Activities of Daily Living) care, feeding but she is noted to be able to sit up on the side of the bed by herself and able to lay back in bed as well as move her upper and lower extremities when she chooses to. R1 was observed sitting at the edge of the bed and put herself back as well as moving around bed. R1's X-Ray result dated 11/17/2024 that documents fracture of the distal left femur was provided by V1 (Administrator).
Investigation interviews provided by the facility documents that multiple nursing staff considers R1 able to perform bed mobility without assistance. V10 (Certified Nursing Assistant) stated R1 can sit up on the side of the bed and can lay herself back. V11 (Certified Nursing Assistant) stated R1 able to sit up on the side of the bed on her own and lay down by herself. V6 (Certified Nursing Assistant) who took care of R1 the night before V9 (Certified Nursing Assistant) noticed that the left leg of R1 was larger than the right leg stated R1 sometimes sits up at night in her bed facing the door. R1 is able to do that by herself and she can lay by herself.
R1's minimum data set (MDS) with target date 11/17/2024 under Section C cognitive patterns documents that R1's cognition is severely impaired. Under Section GG functional abilities all functions of R1 were assessed as dependent. Dependent means helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity, including bed mobility that includes roll left and right, sitting to lying, lying to sitting on side of the bed, sit to stand, and transfers from bed to chair and vice-versa. R1 was also assessed as non-ambulatory.
R1's care plan on ADL (Activity of Daily Living) dated 08/24/2023 documents that R1 has performance self-care deficit. R1's intervention is to use gait belt for transfers and ambulation. And to cue R1 to grasp side rail and pull self-up to a sitting position or to the side of bed. And R1's care plan related to transfers documenta that on 02/23/2024 the date initiated, R1 requires use of mechanical lift for transfers (Hoyer Lift) as assessed of being dependent on all ADLs. Per date-initiated use of mechanical lift supersedes use of gait belt, and use of mechanical lift contradicts use of gait belt for transfers and ambulation. R1 was non-ambulatory with lower extremities contractures.
On 01/30/2025 at 12:40 PM, V7 (Assistant Director of Nursing/Restorative Nurse/Registered Nurse) stated that prior to R1's fracture, R1 was non-ambulatory, uses Geri-chair, needs 2-person assist on ADLs (Activity of Daily Living) and dependent on bed mobility. V7 stated that R1's bed mobility means that in order to turn R1, nursing staff needs to roll her because she is not assisting in any way. V7 said, R1 was dependent, and the only thing that she can do is touch you. Even with feeding she cannot do it; she needs to be fed. V7 stated that R1 has contractures and positions herself in a fetal position that makes it hard for her to do bed mobility. Based on written interviews of staff provided by V1 (Administrator). V7 identified V5 (Licensed Practical Nurse) and V6 (Certified Nursing Assistant) as the staff who took care of R1 the night before R1 was found to have left leg fracture. V7 was informed that based on the same written interviews, nursing staff regarded R1 as capable of bed mobility. It was documented that R1 was able to sit on the side of the bed. V7 stated that R1 cannot do all of those things. And that she (V7) did an in-service on proper positioning and proper transfers. V7 was asked if endorsement is being done by CNAs (Certified Nursing Assistants) during change of shift as nurses do? V7 replied, that CNAs do not have endorsement like nurses. And transfer status of residents are being assessed and should been communicated to nursing staff. V7 was informed that all function assessment of R1 prior to the incident were assessed as dependent. That means R1 cannot do any of bed mobility and transfers. V7 stated that R1 was dependent per assessment. V2 (Director of Nursing) came inside the room and was informed about the conversation with V7. V2 stated that all residents were evaluated including bed mobility and transfers. V2 stated that R1 was being transferred with 2-persons assist. V2 was informed about R1 assessment as dependent on all ADLs. V2 stated that when a resident is assessed as dependent resident should be treated as total assist. Both V2 and V7 were informed about R1's care plan ADLs and transfers inaccuracies. Per care plan, R1 will use gait belt with transfers and ambulation. V2 stated that R1 does not ambulate and only one person needs to assist when using a gait belt. V2 stated that these are old care plan and needs to be removed. R1's care plan also requires Hoyer Lift not 2-persons assist, and that R1 has contractures on lower extremities. V2 said, We will review the care plan.
On 01/30/2025 at 02:04 PM, V6 (Certified Nursing Assistant) stated that she was taking care of R1 the night before the left leg fracture. V6 stated that R1 is not able to walk but able to sit up by herself. And R1 can reposition herself, can follow instruction to turn from side to side, and use side rail to position herself by placing her hand on it. V6 stated that she only needs to make sure R1 is in good position. V6 stated that she works mostly on evening shift or 2:00 PM to 10:00 PM. And during the time she works on that shift she has to placed R1 from chair to bed. V6 was asked how she transfers R1 from chair to bed. V6 stated, I was doing the 2 persons assist when transferring R1 not the Hoyer lift, because Hoyer was not always available. Yes, Hoyer lift is not always available.
On 01/30/2025 at 02:24 PM, V5 (Licensed Practical Nurse) stated that she remembers working the night before R1 had a fracture. V5 stated that R1 needs 2 people to change her and needs to be reposition. But with R1's transfers, she was not sure how R1 transfers. V5 stated that her CNAs (Certified Nursing Assistants) never asked her about R1's transfers. V5 said, No one ever asked me. If they need to know they can talk to each other. I mean the CNAs can talk to each other.
Hospital Records dated 11/20/2024 documents, based on information the hospital received during transfer of R1. R1 is non-verbal and non-ambulatory at baseline. R1 gets up to the wheelchair with assist. R1 went for evaluation of left leg due to left distal femur fracture with unknown cause or etiology. R1 has history of bilateral lower extremities contractures.
Per Transfer Techniques policy dated 02/2022, reads: The purpose is to safely transfer the resident from bed to chair or from one location to another. Proper equipment, like mechanical lift needs to be use if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide a person-centered plan of care that is consistent of functional abilities to meet the needs of 1 (R1) out 1 resident for a total of 4 residents reviewed for care plan.
Findings include:
R1 is [AGE] years old, currently living in facility. R1's initial admission date was 08/24/2024 with medical diagnosis of severe dementia, major depressive disorder, history of anterior displaced type II Dens fracture on 11/16/2023.
On 01/30/2025 at 12:16 PM, R1 was seen with neck collar, and non-verbal when name was called. R1 does not respond to verbal stimuli. V8 (Certified Nursing Assistant) went inside the room to turn off the call light. V8 was asked how R1 transfers. V8 replied that R1 needs mechanical lift during transfer and uses Geri-chair, not wheelchair if needed to be transferred from bed to chair. V8 stated that R1 needs stretcher when going out to an appointment and does not use wheelchair. V8 stated because R1 needs stretcher, ambulance needs to be used to go to an appointment. V8 was asked about R1's leg because the sheet looks elevated and not flat. V8 took the sheet that covers R1's legs. R1's legs looks contracted and the right leg crossing over the left leg with purple foam in the middle. V8 stated that the foam is for R1's comfort.
R1 sustained a left femur fracture on 11/17/2024 based on X-Ray done in the facility. Per investigation interviews provided by the facility documents that multiple nursing staff considers R1 able to perform bed mobility without assistance. V10 (Certified Nursing Assistant) stated R1 can sit up on the side of the bed and can lay herself back. V11 (Certified Nursing Assistant) stated R1 is able to sit up on the side of the bed on her own and lay down by herself. V6 (Certified Nursing Assistant) who took care of R1 the night before V9 (Certified Nursing Assistant) noticed that left leg of R1 was larger than right leg stated R1 sometimes sit up at night in her bed facing the door. R1 is able to do that by herself and she can lay by herself.
R1's minimum data set (MDS) with target date 11/17/2024 under Section C cognitive patterns documents that R1's cognition is severely impaired. Under Section GG functional abilities all functions of R1 were assessed as dependent. Dependent means helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity, including bed mobility that includes roll left and right, sitting to lying, lying to sitting on side of the bed, sit to stand, and transfers from bed to chair and vice-versa. R1 was also assessed as non-ambulatory.
R1's care plan for ADL (Activity of Daily Living) dated 08/24/2023 documents that R1 has performance self-care deficit. R1's intervention is to use gait belt for transfers and ambulation, and to cue R1 to grasp side rail and pull self-up to a sitting position or to the side of bed. R1's care plan related to transfers document that on 02/23/2024 the date initiated, R1 requires use of mechanical lift for transfers (Hoyer Lift) as assessed of being dependent on all ADLs. Per date-initiated use of mechanical lift supersedes use of gait belt, and use of mechanical lift contradicts use of gait belt for transfers and ambulation. R1 was non-ambulatory with lower extremities contractures.
On 01/30/2025 at 12:40 PM, V7 (Assistant Director of Nursing/Restorative Nurse/Registered Nurse) stated that prior to R1's fracture, R1 was non-ambulatory, uses Geri-chair, needs 2-person assist on ADLs (Activity of Daily Living), and is dependent on bed mobility. V7 stated that R1's bed mobility means that in order to turn R1, nursing staff needs to roll her because she is not assisting in any way. V7 said, R1 was dependent, and the only thing that she can do is touch you. Even with feeding she cannot do it; she needs to be fed. V7 stated that R1 has contractures and positions herself in a fetal position that makes it hard for her to do bed mobility, based on written interviews of staff document provided by V1 (Administrator). V7 identified V5 (Licensed Practical Nurse) and V6 (Certified Nursing Assistant) as the staff who took care of R1 the night before R1 was found to have a left leg fracture. V7 was informed that based on the same written interviews, nursing staff regarded R1 as capable of bed mobility. It was documented that R1 was able to sit on the side of the bed. V7 stated that R1 cannot do all of those things, and that she (V7) did an in-service on proper positioning and proper transfers. V7 was asked if endorsement is being done by CNAs (Certified Nursing Assistants) during change of shift as nurses do? V7 replied, that CNAs do not have endorsement like nurses, and transfer status of residents are being assessed and should been communicated to nursing staff. V7 was informed that all function assessment of R1 prior to incident were assessed as dependent. That means R1 cannot do any of bed mobility and transfers. V7 stated that R1 was dependent per assessment. V2 (Director of Nursing) came inside the room and was informed about the conversation with V7. V2 stated that all residents were evaluated including bed mobility and transfers. V2 stated that R1 was being transferred with 2-persons assist. V2 was informed about R1 assessment as dependent for all ADLs. V2 stated that when a resident is assessed as dependent resident should be treated as total assist. Both V2 and V7 were informed about R1's care plan ADLs and transfers inaccuracies. Per care plan, R1 will use gait belt with transfers and ambulation. V2 stated that R1 does not ambulate and only one person needs to assist when using a gait belt. V2 stated that these are old care plans and need to be removed. R1's care plan also requires Hoyer Lift not 2-persons assist, and that R1 has contractures on lower extremities. V2 said, We will review the care plan.
On 01/30/2025 at 02:04 PM, V6 (Certified Nursing Assistant) stated, I was doing the 2 persons assist when transferring R1 not the Hoyer lift, because Hoyer was not always available. Yes, Hoyer lift is not always available.
On 01/30/2025 at 02:24 PM, V5 (Licensed Practical Nurse) stated that she remembers working the night before R1 had a fracture. V5 stated that R1 needs 2 people to change and reposition her. But with R1's transfers, she was not sure how R1 transfers. V5 stated that her CNAs (Certified Nursing Assistants) never asked her about R1's transfers. V5 said, No one ever asked me. If they need to know they can talk to each other. I mean the CNAs can talk to each other.
Review of Care Plan policy dated 11/2017, reads: Each resident care plan shall be reviewed by Interdisciplinary Team (IDT). IDT is responsible in maintaining current care plan for each resident. Periodic review and adjustments of the care plan is significant change on condition. And when there are treatment, goals and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to determine and assess a resident to determine if self-administration of medications is appropriate, failed to obtain a physician's order for medication self-administration, failed to develop a person-centered care plan addressing self-administration of medications, failed to obtain physician orders for resident's medications, and failed to follow-up on the medication administration for 1 (R1) out of 3 residents reviewed.
Findings Include:
On 10/29/24 at 10:37 AM, R1 was sitting up in [R1's] bed alert and able to verbalize needs. R1 showed Surveyor multiple loose pills inside a small clear pouch on top of R1's bedside table. When Surveyor asked what those pills are, R1 answered, These are my 6:00 AM and 9:00 AM medications. I have here three pills of Sevelamer, one Losartan, one Eliquis, one antibiotic, two 25 mg of Metoprolol, and one renal vitamin. I have not taken these because I haven't eaten anything yet.
On 10/29/24 at 10:58 AM, Surveyor entered R1's room with V5 (Licensed Practical Nurse/LPN). V5 was about to administer three tablets of Sevelamer 800 mg to R1 that was scheduled at 11:00 AM when V5 saw the loose pills inside the clear pouch on top of R1's bedside table. V5 stated, You did not tell me that you did not take your 9AM meds yet. I did not give those to [R1] the night shift nurse did. Those are [R1's] 6AM and 9AM meds. [V7/Registered Nurse] was the night shift nurse. [V7] gave these to [R1] before [R1] went for dialysis. Maybe we should call the Doctor to change the timing of your medications. Surveyor and V5 also observed the following medications at R1's bedside on top of R1's nightstand:
-
One bottle of Neuriva. R1 stated, I take two tablets of those a day.
-
One bottle of Prevagen. R1 stated R1 takes one tablet once a day.
-
One bottle of Areds. R1 stated R1 takes one tablet twice day.
-
Levalbutirol inhaler. R1 stated R1 takes one puff every 4 hours.
-
Wixela inhaler. R1 stated R1 takes one puff twice a day.
-
Fluticasone inhaler. R1 stated R1 takes 2 puffs at nighttime.
On 10/29/24 at 12:45 PM, Surveyor reviewed R1's electronic health records. R1 was admitted on [DATE] with included diagnoses not limited to Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and End Stage Renal Disease. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact. R1's physician orders with active orders as of 10/29/24 shows no order for self-administration of medications. There were also no assessments or re-evaluations found in R1's records to determine if R1 is appropriate to self-administer R1's own medications. R1's care plan does not address if medication self-administration is appropriate for R1. R1's physician orders show medication orders for Apixaban 5 mg 1 tablet every 12 hours; Fluticasone-Salmeterol inhalation 1 inhale orally two times a day; Levalbuterol Inhalation 1 inhale orally via nebulizer every 4 hours; Losartan 12.5 mg one time a day; Metoprolol 50 mg one time a day every Monday, Wednesday, Friday, and Sunday; Renal Multivitamin 1 tablet one time a day; Sevelamer 800 mg 3 tablets three times a day; and Wixela Inhalation 1 inhale orally two times a day. There were no physician orders found for Neuriva, Prevagen, and Areds.
On 10/29/24 at 3:13 PM, a phone interview was conducted with V7 (Registered Nurse). V7 stated [V7] never completed job orientation in the facility. V7 stated [V7] worked the 3rd floor night shift (10/28/24) until morning of 10/29/24. V7 stated it was V7's first time on the third floor and didn't know the residents there. V7 stated V7 did not know R1 was going to dialysis early in the morning. V7 stated, [R1] came up to me after 2:00 AM and asked me to give [R1] all [R1's] 9:00 AM medications. [R1] said [R1] is going to the dialysis and [R1] needed to take [R1's] meds with [R1]. [R1] directed me what medications [R1] wanted to take with [R1]. I checked the EMAR [Electronic Medication Administration Record]. I gave all of [R1's] 9:00 AM meds to [R1] in the clear pouch, and [R1] took the meds with [R1] to dialysis. [R1] told me [R1] would take them at 9:00 AM.
On 10/30/24 at 10:04 AM, Surveyor reviewed R1's progress notes on 10/29/24. No documentation found if R1's missed morning medications on 10/29/24 were followed up with V8 (R1's Physician). R1's progress notes dated 10/29/24 at 10:43 AM written by V5 reads in part: During meds round, the nurse noticed that the patient still had the medication that the nurse from the night shift had given to him to take with him to dialysis. The patient was re-educated about the importance of taking the medication at the correct time.
On 10/30/24 at 11:40 AM, inspected R1's medications inside 3rd floor team 1's medication cart with V9 (LPN). R1's inhalers and eye drops were not in the medication cart. V9 stated R1 keeps all [R1's] eye drops and inhalers at bedside and takes them on his own.
On 10/29/24 at 1:05 PM, V2 (Director of Nursing) stated that nurses have to check from the resident's EMAR what medications they are administering to the residents. They have to wait until the resident takes the medications. They are not supposed to leave the resident's room without making sure that the resident took the meds. V2 stated that if residents are not monitored and made sure that the resident had taken their medications, then the resident could potentially take the medications with other medications that could double the dose. V2 stated that if the medications are refused or they miss a dose, nurses have to call the physician and they have to check the full vital signs to check if the resident is stable from missing medications and find out how many times it's occurred. V2 stated V2 expects the nurses to follow the physician orders for medication administration. V2 stated V2 is not aware of the facility's policy regarding self-administration of medications because there are no resident currently residing in the facility that is self-administering their own medications. V2 stated that if a resident would like to self-administer their own medications, then there should be an evaluation or assessment to show that the resident is eligible and is safe to administer their own medications. V2 stated that resident evaluation should be done prior to giving the permission to the resident to self-administer own medications. V2 stated that the nurses need to do a lot of resident teaching and observation that the resident is taking the medication correctly. V2 stated that the education and assessment should all be documented in the resident's chart and needs to be re-assessed quarterly to make sure that the residents who are self-administering medications still have the ability to do that. V2 stated that self-administration of medication should be ordered by the physician. V2 stated that R1 is not self-administering their own medications and the nurses should be providing R1's medications and making sure that R1 is taking [R1's] medications. V2 stated that R1 is not allowed to keep [R1's] own medications at bedside. V2 stated all residents' medications should be securely stored in the medication carts. V2 stated, As far as I know there is no one here that is self-administering their own medications.
The facility's SELF-ADMINISTRATION OF MEDICATIONS policy dated 9/20 reads in part: Residents will not be permitted to administer or retain medications in their rooms unless so ordered by the attending physician, assessed for their cognitive, physical, and visual ability to self-medicate, and approved by the care planning team. The Self- Medication Training Program will consist of the following: resident request to self-medicate, self-medication assessment completed initially and quarterly, MD order to participate in the program, plan of care with quarterly documentation to the progress of the established goal, and completion of the self-medication daily flow sheet.
The facility's MEDICATION ADMINISTRATION policy dated 9/20 reads in part: Drugs must be administered in accordance with the written orders of the attending physician.

Based on interview and record review, the facility failed to accurately complete Fall Assessments for 2 residents (R2, R3). This failure has the potential to affect 2 residents reviewed for resident injury.
Findings include:
R2's Facility Reported Incident (IL178510), that occurred on 8/6/24, documents, in part, On 08/06/2024 at approximately 10:45 pm, resident was observed by staff on the floor in the hallway . NP (nurse practitioner) gave orders to send her (R2) to ER (emergency room) for evaluation. Facility was notified on 08/07/2024 that resident was admitted for left shoulder and left hip fracture .
Upon review of R2's post fall, Fall Risk Assessment, dated 8/6/24, completed by V5 (Licensed Practical Nurse/LPN), it was observed that question #5 History of Falls (past 3 months) was not answered (incomplete).
R2's face sheet, documents, in part, diagnosis including but not limited to displaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing; unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with routine healing; unspecified dementia, unspecified severity, with agitation; difficulty in walking, not elsewhere classified; and muscle weakness. R2's BIMS (Brief Interview of Mental Status), dated 8/21/24, is 5 which indicated R2's cognition is severely impaired.
R2's Care Plan, dated 8/09/24, documents, in part, (R2) is at RISK for falls r/t (related to) disorder of the brain, cardiac murmur, pain in left fingers, unspecified displaced fracture of first cervical vertebra, CKD (chronic kidney disease) stage 3, spinal stenosis in cervical region, amnesia. Recent left hip fracture and left clavicle fracture. Interventions/Tasks: Encourage appropriate use of walker. Promote placement of call light within reach. Provide proper, well maintained footwear. Use proper fitting, non-skid footwear.
On 10/01/24 at 11:24am, V2 (Director of Nursing-DON) stated, A couple things we use to see what types of fall precautions a person needs. There's Gait issues, cognitive issues. 'The Fall Assessment' identifies those things. We (staff) put things in place for resident to be as mobile as possible and at the same time as safe as possible. We (staff) do frequent rounds and use a gait belt to transfer for a resident with an unsteady gait for example. When they (residents) are on fall precautions, it (fall precautions) is put it in the Care Plan and there is also a fall binder on each unit that shows what is in place for each resident. When the Fall assessments are done all questions may not be answered, only questions that are applicable. When asked about question #5 on R2's post fall Fall Risk Assessment, dated 8/6/2024, V2 replied, It should have been answered. When asked the reason for answering the question, V2 replied, So the resident is on the right level of fall precautions for safety. When asked what is proper maintained footwear, V2 replied, Looking for shoes, nonskid, non-slide able bottoms. We have different types of shoes here and sometimes residents prefer different ones. We ask for nonslip soles.
On 10/02/2024 at 11:01am, when asked about R2's post fall, Fall Risk Assessment, dated 8/6/24, V5 replied, I (V5) meant to go back and fill it out after I (V5) looked up the information. It should be completed. Each question has points and the higher the total score is the more fall precautions the resident will be on. For their (residents') safety.
R3's Facility Reported Incident (IL178511), that occurred on 9/23/24, documents, in part, On 9/23/24 at approximately 8:00 am, resident was observed by staff coming out of room bent forward and fall in the hallway, and staff immediately went to assist resident . MD (physician) gave order to send her (R3) to ER (emergency room) for evaluation. Facility was notified at approximately 5:00 pm that resident will be transferred to (Hospital) for bilateral subdural hematoma .
Upon review of R3's post fall, Fall Risk Assessment, dated 9/23/24, completed by V5 (Licensed Practical Nurse/LPN), it was observed that question #5History of Falls (past 3 months) was not answered (incomplete).
R3's face sheet, documents, in part, diagnosis including but not limited to Alzheimer's disease with early onset; traumatic subdural hemorrhage without loss of consciousness, initial encounter; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; aphasia and insomnia. R3's BIMS (Brief Interview of Mental Status), dated 9/23/23, is 99 which indicates R3 was unable to complete the interview.
R3's Care Plan, date initiated 9/13/24, documents, in part, (R3) requires assistance with ambulation. Resident requires task segmented directions to participate in ambulation activities with staff. Balance problems, Risk for falls, Weakness related to impaired cognition. Interventions/Task: Stand alongside of resident to provide verbal cues/guidance/assist while ambulating . Interventions/Tasks: Monitor for changes in ability to navigate the environment.
On 10/02/2024 at 11:01am, when asked about R3's post fall, Fall Risk Assessment, dated 9/23/24, V5 replied, Maybe I (V5) missed it. She (R3) came from another facility, so I (V5) didn't have the fall history. I (V5) didn't fill it out because I (V5) didn't have the history. I (V5) meant to contact the POA (power of attorney) and go back to it, but I (V5) forgot.
On 10/2/24 at 12:48pm, V1 (Administrator) said, Initial Fall Assessment to determine what the person can do, and then quarterly, annually, post incident and also significant change. Yes, Fall Assessments should be completely and accurately done.
Facility policy titled, Fall Management Program, dated 8/2020, documents, in part, While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment . 1. Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post fall, quarterly and annually.
Facility policy titled, Management of Falls, dated 8/2020, documents, in part, . 1. Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include . history of fall incidents .
Facility policy titled, Dementia Care, dated 8/2022, documents, in part, The facility will provide appropriate treatment and services to meet the highest practicable physical, mental, and psychosocial well-being of residents diagnosed with dementia.
Facility job description titled, Administrator, dated, 12/2019, documents, in part, The Administrator must operate the facility according to all Facility policy and procedures, and State and Federal Regulations. This shall include overall accountability for driving the business to successful outcomes both clinically and fiscally . B. Assure that all procedures are followed in accordance with established policies.
Facility job description titled, Director of Nursing, dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times. Assure all Nursing procedures and protocols are followed in accordance with established policies. Audits charts for deficiencies. Make daily rounds to ensure nursing personnel are performing required duties and to ensure that appropriate procedures are being followed. Review nurses' notes/EHR to ensure they are informative and descriptive of the nursing care being provided, and they reflect the customer's response to the care.
Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times . Assume all Nursing procedures and protocols are followed in accordance with established policies . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the customer, as well as the customer's response to the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their facility's change in condition policy and failed to follow the Care Plan for one resident (R3) reviewed for resident injury. This failure resulted in R3 falling and sustaining bilateral subdural hemorrhages; and, R3 was admitted to the intensive care unit.
Findings include:
R3 no longer resides in the facility. R3 was discharged to the hospital on 9/23/24.
R3's Facility Reported Incident (IL178511), that occurred on 9/23/24, documents, in part, On 9/23/24 at approximately 8:00 am, resident was observed by staff coming out of room bent forward and fall in the hallway, and staff immediately went to assist resident . MD (physician) gave order to send her (R3) to ER (emergency room) for evaluation. Facility was notified at approximately 5:00 pm that resident will be transferred to (Hospital) for bilateral subdural hematoma .
R3's face sheet, documents, in part, diagnosis including but not limited to Alzheimer's disease with early onset; traumatic subdural hemorrhage without loss of consciousness, initial encounter; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; aphasia and insomnia. R3's BIMS (Brief Interview of Mental Status), dated 9/23/23, is 99 which indicates R3 was unable to complete the interview.
R3's Care Plan, date initiated 9/13/24, documents, in part, (R3) requires assistance with ambulation. Resident requires task segmented directions to participate in ambulation activities with staff. Balance problems, Risk for falls, Weakness related to impaired cognition. Interventions/Task: Stand alongside of resident to provide verbal cues/guidance/assist while ambulating . Interventions/Tasks: Monitor for changes in ability to navigate the environment.
R3's progress note, dated 9/22/24 3:40pm, by V5 (Licensed Practical Nurse/LPN), documents, in part, Patient came accompanied by (V12-R3's family), very anxious and with unusual behavior.
R3's progress note, dated 9/23/24 at 7:11am, by V9 (Registered Nurse/RN), documents, in part, Patient woke with high anxiety, walking very fast from room to room appeared as if she was looking for an exit. She was howling while pacing when someone would try to restrain her from the fast pace. Call to (Physician) and to (Nurse Practitioner) with request for patient to be evaluated by family hospice. Asked for order of Lorazepam. NP (Nurse Practitioner) text back order for Psych consult. Patient after 2 hours of movement fell asleep on bed.
R3's progress note, dated 9/23/24 at 9:25am, by V5 (Licensed Practical Nurse/LPN), documents, in part, Resident transferred out by 2 (ambulance) paramedics via stretcher to (hospital) for evaluation at 09:20 am. Resident left unit stable and responsive.
R3's progress note, dated 9/23/24 1:05pm, by V5 (Licensed Practical Nurse/LPN), documents, in part, Writer was handing out medication and noticed R3 sleeping in bed, a few minutes later the CNA (certified nursing assistant) called and said she saw R3 come out of the room bent forward and fall in the hallway hitting her head on the floor. Patient able to sit and pivot holding her head, NOD (nurse on duty) assessed from head to toes, no bleeding noted, no skin tear, Able to move all extremities. NOD noted a lump visible on patient left side of the forehead. Writer called V14 w/(with) orders to send resident to (Hospital), orders noted and carried out, resident POA (power of attorney) made aware. DON (director of nursing) made aware. Will continue to monitor per staff.
R3's Hospital Records, documents, in part, H&P (History and Physical) Notes, dated 9/23/24, documents, in part, The patient (R3) was taken out of the nursing home over the weekend for a visit with (V12-R3's family). (V12) reports she (R3) was her usual self until yesterday AM, when patient (R3) seemed anxious and restless and began running around my house. (V12) took the patient back to the NH (nursing home) and alerted staff of patient's (R3) anxiety/restlessness. Per reports, she (R3) did not settle down and was up most of the night, getting out of bed, walking around still unassisted, but much more hurried and unsteady appearing. Staff put her (R3) back to bed a few times, but she (R3) got up again early this AM and fell in the hallway, hitting her head .
R3's CT (computed tomography) of the brain, dated 9/23/24, documents, in part, 1. Mixed density right subdural hemorrhage with internal septations along right frontoparietal convexity. Another small isodense subdural collection along left frontoparietal convexity. No midline shift.
2. Left frontal scalp hematoma.
On 10/01/24 at 11:24am, V2 stated, A couple things we use to see what types of fall precautions a person needs. There's Gait issues, cognitive issues. The Fall Assessment identifies those things. We (staff) put things in place for resident to be as mobile as possible and at the same time as safe as possible. We (staff) do frequent rounds and use a gait belt to transfer for a resident with an unsteady gait for example. When they (residents) are on fall precautions, it (fall precautions) is put it in the Care Plan and there is also a fall binder on each unit that shows what is in place for each resident. When the Fall assessments are done all questions may not be answered, only questions that are applicable. When asked about question #5 on R2's post fall Fall Risk Assessment, dated 8/6/2024, V2 replied, It should have been answered. When asked the reason for answering the question, V2 replied, So the resident is on the right level of fall precautions for safety. When asked what is proper maintained footwear, V2 replied, Looking for shoes, nonskid, non-slide able bottoms. We have different types of shoes here and sometimes residents prefer different ones. We ask for nonslip soles.
On 10/1/24 at 12:50pm, V8 (Certified Nursing Assistant/CNA) said, I (V8) was working that floor that day R3 fell. I (V8) was by the nurse's station and heard her (R3) scream. The whole morning R3 was restless and running around. I (V8) heard her (R3) scream and seen R3 walking fast out of her (R3) room and leaning forward, and she (R3) fell. It seemed she (R3) hit headfirst. She (R3) didn't use her (R3) hands to cushion her fall. I (V8) went over there, and she's (R3) not really that responsive normally . she (R3) was her (R3) regular self. She (R3) normally doesn't hold conversations. She (R3) just had a bump ahead. We were keeping extra eyes on her (R3). Last time I (V8) seen her (R3) she (R3) was in room asleep. When she (R3) was restless she (R3) was leaning forward the entire morning. We were worried that she (R3) was going to fall that's why we were trying to get her (R3) to sit down and lay down. Leaning forward was something new for R3. R3 did not normally lean forward while walking.
On 10/1/24 at 1:56pm, V11 (Nurse Practitioner) stated, I (V11) know her (R3). I (V11) last seen her 9/17/24, I (V11) believe. She (R3) was sent out that 23rd of September. The family took R3 that weekend. When she (R3) came back, she (R3) was aggressive, anxious, walking back and forth. I (V11) told the nurse (V9, Registered Nurse/RN) to have her (R3) seen by psych because they wanted to do Lorazepam and hospice. She's (R3) ambulatory with steady gait. She (R3) would not pass for hospice. Before Lorazepam, I (V11) wanted her (R3) to be seen by psych. Lorazepam would make her (R3) fall. I (V11) wanted her (R3) to be seen by psych to see if they can prescribe a better med than Lorazepam. If she (R3) was wheelchair bound that would be a different story. I (V11) was not notified that she was leaning forward while pacing for 2 hours before falling asleep. I (V11) was not notified that R3's gait was different. I (V11) would have had them put her (R3) in a closer room. If her (R3) gait is somewhat acute I (R3) would have sent her out, ordered a wheelchair, close monitoring. Giving a [NAME] (benzodiazepine) with that would make her at a higher risk. I (V11) would have asked more about the leaning. Is it right sided, send them out. They might come back but we at least we have an evaluation from the ED (emergency department). Even without the leaning forward, I (V11) feel that anyone that is confused and leaning forward will eventually fall. She (R3) was admitted subdural hematoma. I (V11) mean if she (R3) has subdural hematoma, yeah, it caused harm to her (R3). Any ambulatory person, even us, will fall eventually with a forward leaning gait. I (V11) rely on the nurse for thorough report of the patient, especially phone calls. If they are in distress, I (V11) say send them out. I (V11) ask if this is new, send them out.
On 10/2/24 at 10:23am, V9 (Registered Nurse/RN) said, She (R3) was very, very not sociable at all. I (V9) was able to gain her (R3) trust and she (R3) would walk down the hallway with me. That day (9/23/24) she (R3) was overly agitated and walking very fast. Faster than her (R3) usual. I (V9) seen it (R3's fast pace) as being fearful. She (R3) didn't want to be touched. She (R3) almost looked like she (R3) was looking for an exit. She (R3) was up most of the night pacing and I (V9) let her pace. I (V9) thought she (R3) would get tired and lay down. She (R3) got more agitated, and the aide (V15, Certified Nursing Assistant/CNA) was worried about her falling due to the walking of the back and forth. V15 sat with her (R3) for a while in the community room. Meanwhile I (V9) called the NP (V11, nurse practitioner) and no response. I (R3) called the doctor (V14, Medical Director) and no response so I (V9) left a message. Was thinking maybe hospice and get some Ativan. I (V9) called V11 (nurse practitioner) again and no response. Then V11 texted me later to get a consult for psychology. I (V9) thought that would take too long. I (V9) walked R3 to her room and she (R3) collapsed in bed like she (R3) was exhausted and fell asleep. I (V9) talked with V5 (Registered Nurse/RN), the new nurse for day shift, and gave her (V5) report. R3 was agitated, not violent but walking very fast. It was different from her (R3) usual walking, almost like she (R3) was scared. V15 thought she (R3) was leaning more, but I (V9) thought it was the way she (R3) was moving so fast. R3's gait was just moving a lot faster, kinda scary, like if she (R3) bumped into something she would fall. Before R3's gait was slower and steady. This was more of a [NAME]. I (V9) don't think she (R3) was leaning forward. She (R3) leans more towards her left. My aide (V15) thought it was more. I (V9) was more concerned for anxiety. Her (R3) gait was different. It was fast. She's (R3) so tiny. If she (R3) falls over she (R3) would hurt self. She (R3) was more tilted to the left. I (V9) thought maybe something happened when she (R3) was with her (R3) family, so I (V9) checked her (R3) skin and there were no bruises. I (V9) did not mention anything to V11 about R3's gait. I (V9) was more concerned with anxiety. I (V9) might have said I (V9) was afraid she (R3) might fall. I (V9) can't remember. I (V9) was hoping to get an order to send her (R3) out or at least for some Ativan but V11 just ordered for psychology to see her (R3).
Upon review of R3's post fall, Fall Risk Assessment, dated 9/23/24, completed by V5 (Licensed Practical Nurse/LPN), it was observed that question #5History of Falls (past 3 months) was not answered (incomplete).
On 10/02/2024 at 11:01am V5 (Licensed Practical Nurse/LPN) said, Yes, I'm familiar with (R3). I (R3) came. I (R3) was first shift. Came at 7am. She (R3) was sleeping in bed. I (V5) started passing meds. Checked on her (R3) one more time and she (R3) was sleeping. I (V5) went to other side to pass meds and V8 (Certified Nursing Assistant/CNA) said R3 had a fall. I (V5) examined her (R3). No bleeding. Alert, vitals were within normal range, called doctor and put ice pack. And called ambulance. Ice on left side of head cause of lump. I (V5) called a regular ambulance not 911. I (V5) called the ambulance right after I (V5) hung up with the doctor, V14 (Medical Administrator). She (R3) had a little lump on left forehead. Per V8 she fell on her head when she (R3) stepped out of room and bent herself and fell. I (V5) did not see her (R3) walking at all. She (R3) was sleeping the whole time. For that reason, we sent her out to see if she had a head injury. No mental status change. Didn't look like a head injury. When asked about question #5 on R3's post fall, Fall Risk Assessment, dated 9/23/24, being left blank and not answered V5 replied, Maybe I (V5) missed it. She (R3) came from another facility, so I (V5) didn't have the fall history. I (V5) didn't fill it out because I didn't have the history. I (V5) meant to contact the POA (power of attorney) and go back to it, but I (V5) forgot.
On 10/2/24 at 1:03pm, V2 stated, Yes, subdural hematomas are serious injuries but those are diagnosis not made within house. When this surveyor inquired about a change of condition in a resident, V2 replied, I (V2) expect that the nurses are going to do a full assessment, notify physician, and let them know exactly how they're (resident) doing. Get a full set of recent vitals. Have the injury location and appearance of the injury upon calling physician, then take orders and carry out those orders. Do all the required documentation and notify family. When asked if there was a change in a resident's gait would that be considered a change of condition for the resident and should the physician be notified, V2 replied, All information on the resident should be reported to the physician if it is a change for their norm (baseline). When inquired about the interventions and tasks for Care Plans, V2 replied, All interventions implemented are to be followed. If there is a change or something is not working, we need to be made aware so we can adjust accordingly.
On 10/2/24 at 12:48pm, V1 (Administrator) said, Initial Fall Assessment to determine what the person can do, and then quarterly, annually, post incident and also significant change. Yes, Fall Assessments should be completely and accurately done. Change of condition and notify physician of change in condition. Uh, yes, subdural hematoma is a serious injury, we don't diagnose it here. For resident's that have a change of condition, I (V1) expect them to notify the doctor so the doctor can clearly state what to do for the resident. A change in gait? . I (V1) consider that a change in condition and they should notify the doctor of the change in condition and then the doctor can notify them on what to do. Employees should be following interventions in resident's care plans and then notify us on whether it is working and not working so we can make changes and make it person centered.
On 10/3/24 at 2:51pm, V15 (Certified Nursing Assistant/CNA) said, I (V15) am very familiar with R3. On September 23 when she (R3) got up, she (R3) was moving too fast for me (V15). I (V15) don't like the way she (R3) moving. She (R3) moving too fast. I (V15) sat with her (R3) like 2 times. She (R3) was extra busy. Just moving too fast, just extra. More than normal. I (V15) don't remember how long R3 was moving like that. I (V15) just wanted to slow her (R3) down. She (R3) move a lot. Then nurse (V9, Registered Nurse/RN) took her (R3) to room, and she (R3) fell asleep.
Facility policy titled, Change of Condition (Resident), dated 9/2020, documents, in part, Purpose: To ensure that the resident's physician/physician on call /NP and responsible party is kept informed regarding the resident's change in condition. 1. Attending physicians or physicians on call /NP and responsible party will be notified of all changes in condition . 5. Place call to responsible party to notify them of the resident's change in condition.
Facility policy titled, Comprehensive Care Planning, dated 11/2017, documents, in part, An individualized, person centered comprehensive care plan, including measurable objectives with timetables to meet Resident's physical, psychosocial and functional needs, is developed and implemented for each Resident . Interdisciplinary team will develop and implement a person centered, comprehensive plan of care. Care plans are comprised of Focus statements, Goals, and Interventions. The Resident's comprehensive, person-centered care plan will be kept consistent with the Resident's rights to participate in the development and implementation of his or her plan of care, including the right to: . f. Receive the care and services as outlined in the plan of care; . The comprehensive person centered care plan will: . Describe the services that are to be provided to attain or maintain the highest practical physical, mental and psychosocial well-being.
Facility policy titled, Dementia Care, dated 8/2022, documents, in part, The facility will provide appropriate treatment and services to meet the highest practicable physical, mental, and psychosocial well-being of residents diagnosed with dementia. 5. Facility staff will collaborate with other providers, that may include but not limited to: primary care, psychiatry, specialists, physical/occupational therapy to manage the resident's dementia and co-occurring conditions, as applicable.
Facility policy titled, Incident/Accident Reports, dated 9/2020, documents, in part, Physical harm would include a broken bone, or blood flow not stopped by a band-aid or hospital or emergency room treatment that involves more than diagnostic evaluation.
Facility policy titled, Fall Management Program, dated 8/2020, documents, in part, . it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment.
Facility policy titled, Management of Falls, dated 8/2020, documents, in part, 7. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident.
Facility policy titled, Resident Rights, dated 11/17, documents, in part, The facility will respect and uphold residents' rights.
Facility job description titled, Administrator, dated, 12/2019, documents, in part, The Administrator must operate the facility according to all Facility policy and procedures, and State and Federal Regulations. This shall include overall accountability for driving the business to successful outcomes both clinically and fiscally . B. Assure that all procedures are followed in accordance with established policies.
Facility job description titled, Director of Nursing, dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times. Assure all Nursing procedures and protocols are followed in accordance with established policies. Make daily rounds to ensure nursing personnel are performing required duties and to ensure that appropriate procedures are being followed. Review nurses' notes/EHR to ensure they are informative and descriptive of the nursing care being provided, and they reflect the customer's response to the care. Ensure changes in customer condition are reported to family and attending physicians.
Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times . Assume all Nursing procedures and protocols are followed in accordance with established policies . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the customer, as well as the customer's response to the care . Contact the customer's physician for: Nursing assessment of change of condition.
Facility job description titled, Certified Nursing Assistant, dated 3/2023, documents, in part, Makes rounds to assure customers are safe and comfortable . S. Observes customer's physical condition, attitude, reactions, appetite, etc., and reports any changes and/or unusual findings to the Nurse/RCC so care plan can be updated.

Based on observation, interview, and record review, the facility failed to ensure equipment used after bladder irrigation were discarded after use in an effort to prevent cross contamination. This failure affected 1 (R8) resident reviewed for indwelling catheter care in the total sample of 45 residents.
Findings include:
On 07/22/2024 at 11:44am, there was an EBP (enhanced barrier precautions) sign posted by R8's room. On top of R8's dresser was a piston syringe dated 7/6/24 and a bottle of .9% Saline solution dated 6/29/24 with R8's identifier.
On 07/22/2024 at 11:50am, this surveyor requested V8 (Licensed Practice Nurse) to check the dates on R8's piston syringe and saline solution bottle. V8 stated the piston syringe was dated 7/6/24 and the bottle of saline has an open date of 6/29/24. The piston syringe should be changed every 72hours and the saline solution should be discarded after 30 days upon opening to prevent infection.
On 07/24/2024 at 10:30am, V2 (Director of Nursing) stated the saline solution used for irrigating the bladder should be discarded after use to reduce the incident of infection and to prevent compromising the resident's wellbeing.
On 07/25/2024 at 10:44am, V2 stated the piston syringe used for irrigation should be discarded after use, basically, not to introduce bacteria to the resident to prevent infection.
R8's (Active Order As Of: 07/23/2024) Order Summary Report documented, in part Diagnoses: benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of bladder, encounter for fitting and adjustment of urinary device. Catheter: May use indwelling urinary catheter due to neuromuscular dysfunction of bladder. Order Status: Active. Order Date: 06/06/2023. Start Date: 07/05/2023. Sodium Chloride Irrigation Solution 0.9% Use 30ml via irrigation every shift related to Neuromuscular Dysfunction of Bladder. Order Status: Active. Order Date: 03/16/2024. Start Date: 03/17/2024.
R8's (06/19/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 07. Indicating R8's mental status as severely impaired.
R8's (Target Date: 09/17/2024) Care plan documented, in part Focus: requires the use of indwelling catheter related to Urinary retention secondary to Neurogenic Bladder. Goal: will show no complications. Interventions: Irrigate the indwelling catheter every shift per MD order.
THE (09/2020) EQUIPMENT CHANGE SCHEDULE documented, in part POLICY: Equipment will be changed following established schedules to prevent cross contamination. 3. FOLEY: c. Foley catheter irrigation sets are one time use only. 8. DISTILLED WATER AND NORMAL SALINE: b. 250ML/1000ML containers of sterile water/sterile saline used for sterile irrigation of the bladder must be used only once and the unused portion discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the nebulizer equipment was changed weekly on 1 resident (R8), failed to label with date the nasal canula on 3 residents (R49, R53 & R333) and failed to label with date the humidifier bottle for 1 resident (R333). These failures have the potential to affect 4 residents (R8, R49, R53 and R333) reviewed for respiratory care in the total sample of 45 residents.
Findings include:
On 07/22/2024 at 11:44am, R8's nebulizer tubing was dated 7/8/24. The tubing was attached to a nebulizer mask that was inside a plastic container.
On 07/22/2024 at 11:50am, this surveyor requested V8 (Licensed Practice Nurse) to check the date on R8's nebulizer tubing and stated the nebulizer tubing is dated 7/8/24. I (V8) have to check our policy on when to change the nebulizer tubing.
On 07/24/2024 at 10:27am, V2 (Director of Nursing) stated the nebulizer set up includes the nebulizer machine, tubing, and mask. The nebulizer tubing and mask should be changed every 7days and as needed to make sure it is sanitary and safe to use to prevent infection control issues.
R8's (Active Order As Of: 07/23/2024) Order Summary Report documented, in part Diagnoses: Chronic Pulmonary Embolism. Order Summary: DuoNeb Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally via nebulizer every 6 hours as needed for SOB (shortness of breath) and wheezing. Order Status: Active. Order Date: 04/02/2024. Start Date: 04/02/2024.
R8's (06/19/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 07. Indicating R8's mental status as severely impaired.
R8's (Target Date: 09/17/2024) Care plan documented, in part Focus: has potential for shortness of breath due to breathing problem. Goal: Will demonstrate improved breathing post treatment. Interventions: Provide respiratory treatments per physician's order.
THE (09/2020) EQUIPMENT CHANGE SCHEDULE documented, in part POLICY: Equipment will be changed following established schedules to prevent cross contamination. 10. INDIVIDUAL RESIDENT EQUIPMENT: 11. Nebulizer setups for bronchodilator therapy changed weekly and PRN (as needed).
On 7/22/24 at 10:27am, R53 was observed in the dining room, sitting up in a wheelchair, with oxygen at 5L nasal cannula and the oxygen tubing was not labeled.
R53 was unable to be interviewed.
R53's diagnosis includes but are not limited to chronic obstructive pulmonary disease, unspecified asthma, chronic diastolic heart failure and senile degeneration of the brain. R53's BIMS (Brief Interview for Mental Status) Summary Score: 03, dated 4/20/24, suggests severe cognitive impairment.
R53's Order Summary Report, dated 7/23/24, documents in part, RESPIRATORY: OXYGEN PER NASAL CANNULA @ 2-6 LITERS PER MINUTE FOR SOB (shortness of breath) as needed.
R53's Care Plan, date initiated 4/25/2024, documents, in part, (R53) requires oxygen therapy PRN (as needed) to help relieve shortness of breath related to diagnosis of COPD (chronic obstructive pulmonary disease) and asthma.
On 7/22/24 at 10:35am, V7 (Registered Nurse/RN) stated, Night shift changes the oxygen tubing. They are supposed to label it with a piece of tape with the date they changed it and wrap it around the tubing. Yeah, there is not date on R53's tubing. I will change it. V7 changed R53's nasal cannula tubing at 10:39am and placed a piece of tape with the date around the tubing.
On 7/24/24 at 9:15am, V2 (Director of Nursing/DON) stated, I (V2) would have to check the policy in regard to changing nasal cannulas. The nasal cannula should be labeled with tape and the date of when it was changed. I think its 7 days and PRN (as needed). Nasal cannulas need to be changed per policy or for example if I see it hanging over the concentrator or dresser or something because I couldn't be sure if it hit the floor or not, so it would not introduce organisms into their body.
Facility Policy titled, OXYGEN THERAPY DEVICES - NASAL CANNULA, dated 09/2020, documents, in part, A nasal cannula will be changed monthly and prn (as needed).
Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times .Assume all Nursing procedures and protocols are followed in accordance with established policies. Make daily rounds to ensure nursing personnel are performing required duties, and to ensure appropriate procedures are being followed .Prepare and administer medications and treatments if appropriate as ordered by the physician . Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, care of the dead/dying, etc., as required.
Facility job description titled, Director of Nursing, dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times . Assure all Nursing procedures and protocols are followed in accordance with established policies . Make daily rounds to ensure nursing personnel are performing required duties and to ensure that appropriate procedures are being followed. Make physical rounds on all customers daily . Monitor medication passes and treatment schedules to ensure medications are being administered as ordered and treatments are provided as scheduled.
On 07/22/24 at 10:32 am R333 observed with nasal cannula oxygen tubing not dated and connected to humidity bottle also not dated.
On 07/22/24 at 10:36 am V15(LPN) stated, R333 does not have a date on the oxygen tubing or the humidifier bottle. The bottle is full, so they (staff) probably just put it (humidifier bottle) this morning. The oxygen tubing and humidifier bottle should have a date on it.
On 07/22/24 at 10:45 am, R49 observed with portable oxygen tank at bedside with oxygen tubing not dated.
On 07/22/24 at 10:48 am, V15 stated, there is not a date on the oxygen tubing because the resident (R49) changes the tubing himself. There should be a date on it (oxygen tubing).
R49's diagnosis includes but are not limited to Chronic Obstructive Pulmonary Disease (COPD), Atrial fibrillation, End Stage Renal Disease, Benign Prostatic Hyperplasia, Chronic Respiratory Failure, Dependence on Supplemental Oxygen.
R49's active physician order dated 3/27/24 documents in part, Respiratory: Change O2 (Oxygen) tubing monthly and PRN (As Needed).
R49's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15 indicating R49 is cognitively intact.
R49's care plan dated 6/6/24 documents in part, R49 requires oxygen therapy to help relieve shortness of breath related to COPD.
R333's diagnosis includes but are not limited to dependence on supplemental oxygen, Presence of other Cardiac Implants, solitary Pulmonary Nodule, Atrial Fibrillation.
R333's active physician order dated 7/19/24 documents in part, Respiratory: Oxygen per Nasal Cannula at 1 liter per minute continuous Change O2 tubing monthly and PRN.
R333's care plan dated 7/23/24 documents in part, Resident requires oxygen therapy .Administer oxygen per MD (medical doctor) orders.
R333's admission date 7/19/24, MDS in progress, no BIMS score recorded.
Facility's policy titled Oxygen Therapy Devices High Humidity dated 09/2020 documents in part, Policy: Oxygen delivered with high humidity or high humidity without O2 (oxygen) will be set up to enhance humidification of mucous membranes .4. High humidity devices and tubing will be changed monthly and PRN (as needed).
Facility's policy titled Oxygen Therapy Devices-Nasal Cannula dated 09/2020 documents in part, Policy: Oxygen delivered per nasal cannula, will be used to prevent or reverse hypoxia and improve tissue oxygenation .A nasal cannula will be changed monthly and PRN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/22/24 at 10:30 am, Surveyor observed R50's room with a sign that read Stop: Enhanced Barrier Precautions (EBP): 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: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing and an isolation bin with PPE supplies (gown, gloves, mask) outside of R50's room. Upon entering R50's room, surveyor observed V12 (Certified Nursing Assistant, CNA) performing ADL (Activities of Daily Living) care with R50 (changing R50's incontinence brief) without wearing a gown.
On 07/22/24 at 11:09 am, Surveyor questioned V12 regarding the EBP sign on R50's room and V12 stated that the EBP sign on R50's room is so that staff knows what the necessary PPE (gown, gloves, and mask) is required to wear so that staff can protect themselves from residents who are sick that staff may come in contact with. When surveyor asked V12 regarding not wearing PPE while providing ADL care to R50, V12 stated there was no PPE in the isolation bin outside of R50's room. Surveyor and V12 then observed the PPE bin outside of R50's door with PPE supplies (gown, gloves, and mask). V12 then stated, Oh well, I should have checked with the nurse first. There have been times they (referring to the residents) did not require us (referring to staff) to wear a gown.
On 07/24/24 at 9:02 am, V2 (Director of Nursing, DON) stated that V2 is the facility's Infection Preventionist at the facility. V2 stated, EBP precautions are to give the residents an extra layer of precautions, for the residents who are prone or subjected to infections. V2 explained that residents with EBP are residents with G-Tubes, wounds, and indwelling catheters. V2 then explained that staff are expected to wear gloves and gown during high contact care such as dressing, grooming, toileting, bathing, administering medications during IV access, inserting indwelling catheters and flushing G-tubes. When V2 was asked regarding the importance of EBP V2 stated, It is to make sure we are not introducing the resident to any infections.
R50's face sheet shows that R50 has a diagnosis which includes but not limited to : non pressure chronic ulcer of other part of left lower leg, quadriplegia, radiculopathy cervical region, unspecified injury at unspecified with bleeding, peripheral vascular disease, and chronic obstructive pulmonary disease.
R50's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 14 which indicates that R50 is cognitively intact.
Facility's document dated 07/22/24 order description: EBP shows that R50 requires EBP for chronic wound.
The facility's document dated 12/14/23 and titled Enhanced Barrier Precautions documented, in part: Enhanced Barrier Precautions (EBP) are infection control intervention designed to reduce transmission of multidrug- resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDRO's including resident with a chronic wound or an indwelling medical device. Guidelines: 1. EBP involves gown and gloves use during high-contact resident care activities for residents known to be infected or colonized with MDROs when a contact precaution do not otherwise apply. As well as residents with a chronic wound and/or indwelling medical device. Procedure 1. High-Contact Resident Care Activities include the following: . b. Bathing/Showering . e. Providing hygiene. f. Changing briefs or assisting with toileting.
R50's care plan shows that R50 is receiving antibiotic therapy indicated for wound infection of the non-pressure chronic ulcer of RLL (right lower leg), LLL (left lower leg) with necrosis of muscle . Interventions: Enhanced Barrier Precautions will be implemented during high contact resident care activities.
R50's Physician Order Sheet (POS) dated 05/15/2 shows order for EBP for Chronic Wound.
The facility's undated document titled, Enhanced Barrier Precautions documents, in part: 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: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing.
Based on observation, interview, and record review the facility failed to perform hand hygiene in between assisting one resident (R49) during dining service and failed to don Personal Protective Equipment (PPE) when performing care on one resident (R50) on Enhanced Barrier Precautions (EBP) isolation in an effort to prevent the spread of infectious microorganisms. These failures affected two residents (R49 and R50) in the sample of forty-five residents reviewed and have the potential to affect all thirty residents residing on the third floor.
Findings include:
On 07/22/24 at 12:30 PM V12 Certified Nursing Assistant (CNA) observed in 3rd floor dining area wiping spilled liquid from table. V12 then observed grabbing 2 sandwiches while still holding wet paper towels from spill and proceeded down the hall.
On 07/22/24 at 12:34 PM V12 stated Those sandwiches were for R49. I shouldn't have been holding the sandwiches for another resident while finishing cleaning up another resident's spill.
On 07/24/24 at 12:33 PM V2 Director of Nursing (DON) stated Hand hygiene should be performed before entering a resident's room, before medication pass, and before and after passing trays. Bacteria can be spread from resident to resident when hand hygiene is not performed.
R49's diagnosis includes but are not limited to Chronic Obstructive Pulmonary Disease (COPD), Atrial fibrillation, End Stage Renal Disease, Benign Prostatic Hyperplasia, Chronic Respiratory Failure, Dependence on Supplemental Oxygen.
R49's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15 indicating R49 is cognitively intact.
R49's active physician order dated 5/16/2024 documents in part, EBP for device care or use of urinary catheter.
Facility's policy titled Hand Washing and Hand Hygiene dated 6/4/2020, documents in part, Purpose: Appropriate hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings .Guidelines: 1. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items. Specific examples include but are not limited to: c) Before touching medication or food to be given to a resident .i) Between contacts with different residents .2. Alcohol-based hand rub (ABHR) is the preferred method for hand hygiene.
Facility's policy titled Job Description Certified Nursing Assistant dated 03/2023 documents in part, IV. A. Ensure that all nursing procedures and protocols are followed in accordance with established policies.

Based on observation, interview and record review, the facility failed to ensure that a resident's call light was accessible and within reach to call for staff assistance which affected 1 (R25) resident in the sample of 45 residents reviewed for accommodation of needs.
Findings include:
On 7/22/24 at 10:50am, R25 was observed in his room, sitting up in a wheelchair, watching television. R25's call light was observed wrapped around R25's dresser drawer behind R25 not within R25's reach. When asked where the call light was, R25 replied, I don't know. Somewhere back there (pointing behind him). I cannot reach it. I just yell for staff if I cannot find the call light. I always need help from the staff.
On 7/22/24 at 10:55am, while in R25's room, V2 (Director of Nursing/DON) was asked if R25 can reach the call light. V2 replied, No, R25 cannot reach it. The call light needs to be within R25's reach. V2 took the call light and secured it to R25's gown and R25 said, That's a good idea.
R25's face sheet documents, in part, diagnoses of history of falling, unequal limb length tibia and fibula, unsteadiness on feet, difficulty in walking, need for assistance with personal care, unspecified lack of coordination and muscle weakness. R25's BIMS (Brief Interview for Mental Status) Summary Score: 10, dated 7/11/24, which suggests moderate cognitive impairment.
R25's Care Plan, date initiated, 4/07/2017, documents, in part, (R25) is at risk for falls related to poor balance, inability to walk independently, limitation in ROM (range of motion), left leg shorter than right leg, use of assistive wheelchair, use of indwelling catheter, use of colostomy, diabetic medications and weakness .Intervention/Tasks: Promote placement of call light within reach.
On 7/24/24 at 9:15am, V2 (Director of Nursing/DON) stated, Call lights should be answered in a timely manner. Call lights should be within reach of the resident.
Facility policy titled CALL LIGHT, USE OF, dated 09/20, documents, in part, When providing care to residents, position the call light conveniently for the resident's use. Tell the resident where the call light is and show him/her how to use the call light and provide reminders to use the call light as needed Be sure call lights are placed within resident reach at all times.
Facility job description titled, Director of Nursing, dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times . Assure all Nursing procedures and protocols are followed in accordance with established policies . Make daily rounds to ensure nursing personnel are performing required duties and to ensure that appropriate procedures are being followed. Make physical rounds on all customers daily . Monitor medication passes and treatment schedules to ensure medications are being administered as ordered and treatments are provided as scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label opened multi dose vials. This failure has the potential to affect one resident (R66) and all 24 residents on the first floor (total of 25 residents) reviewed for medications in the sample of 45 residents.
Findings include:
Facility document titled, (Facility) Daily Census [DATE] shows a total of 24 residents residing on the first floor.
On [DATE] at 10:38am, with V26 (Licensed Practical Nurse/LPN), during observation of medication storage on the 1st floor, the following was observed:
1st floor medication refrigerator had an opened house stock vial of Tuberculin Purified Protein Derivative with no label of when it was opened.
When this surveyor inquired about the missing open date, V26 (LPN) replied, I think we just go by the expiration date on the medication. I'll have to check with pharmacy. If a medication is expired it is no good, it doesn't work like it's supposed to.
On [DATE] at 11:02am, with V17 (Registered Nurse/RN), during observation of medication storage on the 2nd floor, the following was observed:
R66's Travoprost eye drops were opened with no label of when it was opened.
When this surveyor inquired about the missing open dates, V17 (Registered Nurse/RN) stated, Ugh. Yeah, I don't know why someone didn't label those meds. They have a different expiration date after they are opened. The medications won't be as good.
R66's diagnosis includes but are not limited to primary open-angle glaucoma, bilateral, mild stage. R66's BIMS (Brief Interview for Mental Status) Summary Score: 05, dated [DATE], suggests severe cognitive impairment.
R66's Order Summary Report, dated [DATE], documents in part, Travoprost Solution 0.004% instill 1 drop in both eyes at bedtime related to PRIMARY-ANGLE GLAUCOMA, BILATERAL, MILD STAGE.
On [DATE] at 9:15am, V2 (Director of Nursing/DON) stated, multi-dose medications should be dated upon being opened. Stickers go on the vials with the date you open it. Once you pop the top off it has a different expiration date.
The manufacturing manual inside the box of Tuberculin Purified Protein Derivative, revised date 03/16, documents, in part, vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.
Facility policy titled, Multi-Dose Vials, Use Of, dated 01/2022, documents, in part, multi-dose vials (MDVs) contain a preservative, so that they may be used multiple times. The opened and beyond-use (expiration) dates will be noted and initialed at the time the vial cap is removed. In general, MDVs may be used for 28 days after the initial opening of the vial . If this is a new vial, remove the cap from the vial. Using an ink pen, write the opened and expiration dates, as well as the nurse's initials, on the vial's label .
Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times .Assume all Nursing procedures and protocols are followed in accordance with established policies. Make daily rounds to ensure nursing personnel are performing required duties, and to ensure appropriate procedures are being followed .Prepare and administer medications and treatments if appropriate as ordered by the physician.
Facility job description titled, Director of Nursing, dated 1/2015, documents, in part, The objective is to ensure the highest degree of quality care is maintained at all times . Assure all Nursing procedures and protocols are followed in accordance with established policies . Make daily rounds to ensure nursing personnel are performing required duties and to ensure that appropriate procedures are being followed. Make physical rounds on all customers daily . Monitor medication passes and treatment schedules to ensure medications are being administered as ordered and treatments are provided as scheduled.

Based on observation, interview and record review the facility failed to follow their policy and procedures to ensure signage outside of the resident's room indicating Enhanced Barrier Precaution (EBP) was posted; failed to ensure PPE (Personal Protective Equipment) was made available and accessible outside of the resident's room or nearby and failed to ensure proper PPE were worn by staff when providing high contact resident care activities to 1 (R1) resident. These failures have the potential for cross contamination to 29 residents residing on the 2nd floor as of census 5/5/24.
The findings include:
R1's health record documented admission date on 2/14/24 with diagnoses not limited to Unspecified dementia, severe, with other behavioral disturbance, Adult failure to thrive, Encounter for attention to gastrostomy, Type 2 diabetes mellitus with diabetic chronic kidney disease, Unspecified severe protein-calorie malnutrition, Chronic combined systolic (congestive) and diastolic (congestive) heart failure, Hypertensive heart and chronic kidney disease with heart failure, Diaper dermatitis, Schizoaffective disorder bipolar type, Pneumonia, Dysphagia oropharyngeal phase, Body mass index [bmi] 19.9 or less, Ocular pain left eye, Gastro-esophageal reflux disease without esophagitis, Personal history of COVID-19, Age-related osteoporosis without current pathological fracture, Restlessness and agitation, Peripheral vascular disease, Long term (current) use of insulin, Chronic kidney disease stage 2 (mild), Primary insomnia, Personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits, Vitamin d deficiency, Iron deficiency anemia, Long term (current) use of oral hypoglycemic drugs, Unspecified psychosis not due to a substance or known physiological condition, Hyperlipidemia, Long term (current) use of anticoagulants, Post-traumatic stress disorder, Epilepsy, Paroxysmal atrial fibrillation, Aphasia.
On 5/5/24 at 1:03pm Surveyor observed R1's room with no door signage indicating Enhanced Barrier Precautions (EBP). No Personal Protective Equipment (PPE) supplies (like gowns) were accessible to staff or made available near R1's room. Enteral feeding and flushing administration observation conducted with V3 (Registered Nurse / RN) assisted by V5 (Certified Nursing Assistant / CNA). V3 and V5 donned gloves, not wearing gown. R1 wearing abdominal binder, G-tube site with dressing dry and clean. Observed V3 checked gastric residual then administered Fibersource HN 1.2 250ml bolus enteral feeding and flushed with 150ml water.
V3 (Registered Nurse / RN) stated there are 29 residents residing on the 2nd floor with 3 CNAs and 1 nurse working.
At 3:18pm Interviewed V2 (Director of Nursing / DON), V2 stated resident with G-tube feeding would be under EBP (Enhance Barrier Precautions) and staff is expected to wear proper PPE (Personal Protective Equipment) such as gown and gloves when administering G-tube feeding and flushing or any other high contact care activities. There should be a signage posted by the door to identify that resident is on EBP. V2 said PPE supplies should be in the bin, set up by room entrance for easy access to staff when providing high contact care activities. Staff is expected to wear proper PPE to prevent spread of infection or cross contamination.
Facility's enhanced barrier precautions (EBP) policy dated 12/14/23 documented in part:
-
EBP involves gown and gloves use during high-contact resident care activities for residents with indwelling medical device.
-
High contact resident care activities include the following: Device care or use - feeding tube.
-
Residents that have indwelling medical devices, regardless of MDRO (Multi Drug Resistant Organism) status, will be on EBP. Some examples may include: Feeding tube.
-
Post CDC EBP sign outside of the resident's room.
-
Make PPE available and accessible outside of the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility:
1. Failed to ensure Registered Dietician/Clinical Dietician's enteral feeding recommendation was implemented.
2. Failed to notify Nurse Practitioner (NP) or physician that enteral feeding recommendation was not carried out.
3. Failed to ensure that enteral feeding and flushing were administered as ordered by physician.
These failures resulted in R1's significant / severe weight loss of 11.3lbs (pounds) = 10.7% x 30 days and elevated BUN (Blood Urea Nitrogen) level reviewed for improper nursing care in a sample of 3.
The finding include:
R1's health record documented admission date on 2/14/24 with diagnoses not limited to Unspecified dementia, severe, with other behavioral disturbance, Adult failure to thrive, Encounter for attention to gastrostomy, Type 2 diabetes mellitus with diabetic chronic kidney disease, Unspecified severe protein-calorie malnutrition, Chronic combined systolic (congestive) and diastolic (congestive) heart failure, Hypertensive heart and chronic kidney disease with heart failure, Diaper dermatitis, Schizoaffective disorder bipolar type, Pneumonia, Dysphagia oropharyngeal phase, Body mass index [bmi] 19.9 or less, Ocular pain left eye, Gastro-esophageal reflux disease without esophagitis, Personal history of COVID-19, Age-related osteoporosis without current pathological fracture, Restlessness and agitation, Peripheral vascular disease, Long term (current) use of insulin, Chronic kidney disease stage 2 (mild), Primary insomnia, Personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits, Vitamin d deficiency, Iron deficiency anemia, Long term (current) use of oral hypoglycemic drugs, Unspecified psychosis not due to a substance or known physiological condition, Hyperlipidemia, Long term (current) use of anticoagulants, Post-traumatic stress disorder, Epilepsy, Paroxysmal atrial fibrillation, Aphasia.
On 5/5/24 at 1:03pm Enteral feeding and flushing administration observation conducted with V3 (Registered Nurse / RN) and V5 (Certified Nursing Assistant / CNA). R1 sitting up in wheelchair, wearing abdominal binder, Gastrostomy tube (G-tube) site with dressing dry and clean. Observed V3 checked gastric residual then administered Fibersource HN 1.2 250ml bolus enteral feeding and flushed with 150ml water.
At 3:18pm Interviewed V2 (Director of Nursing / DON) and V2 said nurses are expected to follow doctor's order in administering G-tube feeding and flushing. Nurses are expected to document or sign off on the MAR (Medication Administration Record) after administering g-tube feeding and flushing. If MAR was not signed or documented, task was not done, G-tube feeding and flushing was not administered. If G-tube feeding and flushing were not administered or were missed could potentially lead to weight loss or dehydration.
On 5/6/24 at 8:02am interviewed V17 (Clinical Dietician / Registered Dietician), stated R1 had weight change in April, weight loss of 10% x 30 days, 5% and above considered as significant weight change x 30 days. Recommended increasing the tube feeding to elevate volume and concentration. V17 said Fibersource 1.2 1250ml per day was not adequate to meet R1's needs, recommended to increase enteral feeding to1800ml / day on 4/20/24. Recommendation was calculated based on R1's ideal body weight and R1 is underweight with history of malnutrition. V17 said was informed that his recommendation was not put through because the family (POA) needed to okay the recommendation. Stated that his goal for his recommendation was to meet R1's nutritional needs through enteral feeding. R1 is on pleasure feeding but not eating enough about 0-50% per staff documentation. If R1 continues to receive enteral feeding of Fibersource 1250ml/day will continue to lose weight due to not enough for his nutritional needs. He said during weight meeting, he was informed that R1 with issue of diarrhea. Fibersource will help with diarrhea. R1 significant weight loss is contributed with: 1. enteral feeding not meeting his nutritional needs. 2. Diarrhea - due to altered bowel function. 3. Loss of fluids due to his diarrhea. V17 said enteral water flushing order is 150ml 5x per day, total of 750ml per day. He said R1's fluid needs is 1900-2200ml/day. R1 is getting his hydration needs from enteral feeding of 1010ml /day, 120ml from medication flushing and 120ml from supplements. Total of 2000ml/day. V17 said R1's nutritional needs, calculated with his ideal body weight of 142lbs. Calorie intake 30-35kg came out to 1928-2249cal/day. Current order of enteral feeding (Fibersource 1.2 1250ml/day) provides 1500cal/day. R1's oral intake = 0-50%. V17 said if g-tube water flushes were missed could potentially elevate the BUN level and needs not being met as R1 with very poor oral intake. If enteral bolus feeding were missed or not given could contribute to significant weight loss, based on current regimen, anything missed would be detrimental. R1's hydration and nutritional needs is dependent to enteral feeding and flushing.
At 9:19am Interviewed V18 (Nurse Practitioner / NP), stated he is aware of R1's significant weight loss of 10% for 30days and the recommendation to increase enteral feeding to 1800ml/day and was okay with it but was not aware that order was not in place at this time. If enteral feeding recommendation was not carried out, it would contribute to further significant weight loss, any missed enteral feeding can also contribute to weight loss. V18 said missed enteral water flushing could potentially elevate BUN level. Depending on how many times R1 missed his G-tube flushes will depend how elevated the BUN level would be. R1 is getting his hydration and nutritional needs through G-tube flushes and feeding so it is important to give G-tube feeding and flushing as ordered and recommended.
Minimum Data Set (MDS) dated [DATE] showed R1's cognition was severely impaired. He needed total assistance or Dependent with eating, oral, toileting and personal hygiene, shower/bathe self; Substantial / maximal assistance with upper and lower body dressing; Partial / moderate assistance with chair/bed transfer. MDS showed R1's weight was 105lbs, had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, not prescribed weight loss regimen and R1 with feeding tube.
Reviewed R1's weight and documented in part: 4/17/2024 = 94.7 Lbs (pounds); 3/28/2024 = 105.0 Lbs; 3/21/2024 = 106.0 Lbs; 3/14/2024 = 105.0 Lbs; 3/12/2024 = 108.0 Lbs.
R1's laboratory results reviewed and documented in part (BUN reference range = 7-23):
3/25/24: BUN = 36; 4/1/24: BUN = 29; 4/10/24: BUN = 40; 4/18/24: BUN = 34; 4/19/24: BUN = 28.
R1's MAR (medication administration record) reviewed:
-
Enteral feed order five times a day flush feeding tube with 125ml H2O with each bolus feed - not signed as administered on 4/10/24 at 6am.
-
Enteral feed order five times a day flush feeding tube with 150ml H2O with each bolus feed - not signed as administered on 4/18/24 at 2pm.
-
Enteral feed order five times a day flush feeding tube with 175ml H2O with each bolus feed - not signed as administered on 4/11/24 at 10pm.
-
Enteral feed order five times a day tube feeding (BOLUS FEED): Fibersource HN 1.2 250ML 5X per day - not signed as administered on 4/10/24 at 6am, 4/18/24 at 2pm
R1's POS (physician order sheet) reviewed with active order not limited to:
-
Enteral Feed five times a day flush feeding tube with 150ml with each bolus feeding.
-
Enteral Feed five times a day tube feeding (BOLUS FEED): Fibersource HN 1.2 250ml 5x per day 1,250ml/daily.
V17's Nutrition notes dated 4/20/2024 documented in part: Weight: 94.7, -5.0% change [ 10.7%, 11.3lbs] x 30d; -7.5% change [ 16.9%, 19.3] x 90d; -10.0% change [ 20.4%, 24.3] x 180d. 04/20/2024; BMI 15.3 reflects underweight for age. Diet: Pleasure Feeding diet, Mechanical Soft texture, thin consistency; Meal intakes 0-50%; wt. (weight) loss likely inadequate kcal intakes and/or inadequate Enteral infusion; Start EN (enteral nutrition) Fibersource HN 1.2 to infuse1800 mL/d @ 90 mL/h, continuous; Flush @ 145mL q6h, bolus.
R1's monthly enteral assessment dated [DATE] documented in part: Dietary recommendations - Start EN (Enteral Nutrition) Fibersource HN 1.2 to infuse 1800ml/day at 90ml/hour, continuous via PEG (Percutaneous Endoscopic Gastrostomy); Flush at 145ml every 6hours, bolus via PEG. EN provides 2160kcal, 97g, 1454ml free water.
R1's electronic health record reviewed no documentation showed that dietary recommendation was carried out or implemented. No documentation indicated that Nurse Practitioner or Physician was notified that RD's enteral feeding recommendation was not implemented.
Facility's enteral nutritional feeding policy dated 9/2020 documented in part: Verify MD (Medical Doctor) orders for feeding. Document on MAR (medication administration record) with initials verifying that feeding was running on that shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to maintain assessment, monitor, and addressed in the plan of care resident lower leg and feet per policy on prevention and treatment of skin alteration. Facility also failed to consistently document as being performed physician order for antibiotic treatment on resident lower leg and feet for 1 resident (R1) out of 4 residents reviewed for nursing care. These failures affected 1 resident (R1) that was transferred to the hospital diagnosed with gangrene on the feet.
Findings include:
R1 was initially admitted on [DATE] with diagnosis of diabetes mellitus, venous insufficiency, peripheral vascular disease.
R1's physician order for treatment of lower extremities (below the knee and feet):
Bacitracin ointment antibiotic are as follows:
-
Dated 11/29/2022 until 2/28/2023 to apply on left foot once daily.
-
Dated 2/28/2023 - 7/13/2023 to apply on both feet (left and right) once daily.
-
Dated 7/13/2023 - 8/24/2024 to apply on both feet (left and right) twice daily.
-
Dated 8/24/2023 - 4/2/2024 to apply on both feet (left and right) and penile area twice daily.
R1's Treatment Administration Record (TAR) for bacitracin antibiotic ointment for the months from September 2023 to February 2024 documents that on multiple days physician order for antibiotic ointment bacitracin was not signed as being performed.
On 4/10/2024 at 12:51 PM, V6 (Licensed Practical Nurse) stated that she was the regular nurse of R1. And that R1 had the gangrene since admission or when R1 was transferred from 3rd Floor to 1st Floor (current location). V6 stated that R1 stayed on the room where she pointed at an open door where a bed can be visually seen with a resident lower leg and feet closest to the Nurse Station. V6 stated that antibiotic ointment bacitracin was given to R1's penial area and not to his (R1's) feet. V6 said that she applies A and D ointment not bacitracin antibiotic ointment. V6 stated that every time she performs treatment she always chart or document in the TAR (Treatment Administration Record). And nurses need to document when they perform treatment.
On 4/11/2024 at 10:05 AM, V3 (Assistant Director of Nursing) stated when he started working in the facility, he noticed R1's leg from knee down to R1's feet are colored black. V3 explained that black means mottling or appearance when a hospice person is about to die. V3 said that although skin has dark pigmentation it was intact or no skin opening. And that on the upper portion of the lower leg has dark mottling patches. The feet black color is more prominent than the leg. And treatment that was done should be signed off on the treatment administration record (TAR). V3 said that if it is not documented, it is not done remembering what was thought during nursing school. R1 went to an appointment for urinary catheter change when during that appointment R1 was transferred to the hospital for legs discoloration. V3 said that he is not sure what the admitting diagnosis when R1 went to the hospital on 4/2/2024. After showing V3 the progress notes dated 4/2/2024 by V14 (Licensed Practical Nurse) documenting that R1 was admitted at the hospital for dry gangrene on the feet. V3 then stated, I think he has that gangrene before. V3 was asked for assessment, treatments, or any documentation that R1 had been taken care due to gangrene on the feet. V3 said there was no documentation for the treatment of gangrene on the feet. Request for initial and 2 current assessments of R1's lower extremities. No assessment from the facility was received. Only document presented was a progress note of V15 (Advance Practitioner Nurse) dated 12/27/2023 that reads: Diffuse desquamation of bilateral lower extremities (BLE) and discoloration of both feet.
On 4/11/2024 at 11:20 PM, V9 (Wound Care Nurse) stated that no records that R1 was seen by V10 (Nurse Practitioner Wound). Wound consult will be done after referral then I review all referral, it is my job to audit the referral. After review of his record, V9 stated, No referral for R1 to be seen by Wound Nurse Practitioner on my end. V9 said after performing each treatment it should be documented on the TAR and needs to be signed every time it is done. V9 said, If there is no documentation as to the treatment, I cannot really say that I did the treatment.
On 4/11/2024 at 1:26 PM, V11 (MDS Coordinator / Resident Care Coordinator) after reviewing all care plans of R1 stated that she might have missed placing a care plan for 11/29/2022 when R1 started using bacitracin antibiotic ointment on his left leg. And due to lack of progress of R1's bilateral lower extremities it should have been addressed on the wound care section of the plan of care. Care plan of R1 for antibiotic ointment use of bacitracin for bilateral feet was initiated on 3/1/2023. Per initial physician order, R1 was ordered to receive the same medication for the left foot on 11/29/2022. And care plan does not address bilateral lower extremities in a quarterly basis.
Policy on Prevention and Treatment of Pressure Injury and Other Skin Alterations dated 3/2/2021, reads:
Policy includes to implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Procedure includes evaluation of resident actual skin alterations on admission and readmission by utilizing the initial nursing assessment. Skin alterations will be assessed weekly or as needed by facility staff or consultant clinician, by utilizing a WASA (facility wound assessment) or other consulting clinicians' evaluation. Non-pressure skin alterations will be documented weekly on a skin progress note if using HER (Electronic Health Record). Develop a Care Plan for either actual or potential alteration in skin integrity and change as needed. At least daily, staff should remain alert for potential changes in the skin conditions during resident care. Revise Care Plan approaches as needed based on resident's response and outcomes.

Based on observation, interview and record review, the facility failed to ensure (R2's) functional assessment was accurate, failed to timely revise (R3's) care plan (post fall) to prevent an additional fall, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, and failed to provide supervision for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in the following: R3 fell on 3/9/24 and sustained a head laceration requiring staple repair. R3 also fell on 3/10/24 (the following day) and sustained a laceration to bridge of nose, laceration to upper lip, nasal fracture and (left) 3rd-8th rib fractures. R2 fell on 1/15/24 and sustained a head laceration requiring staple repair. R1 fell on 3/4/24 and sustained an eyebrow laceration.
Findings include:
R3's diagnoses include dementia, epilepsy, history of falling and traumatic brain injury.
R3's (1/11/24) BIMS (Brief Interview Mental Status) determined a score of 4 (severe impairment).
R3's (1/11/24) functional assessment affirms supervision or touching assistance is required for walking.
The facility fall log affirms R3 fell on 3/9/24 and 3/10/24 (the following day).
R3's (11/10/22) care plan states resident is at risk for falls related to history of fall, use of psychotropic medications, poor safety awareness, unsteady gait, poor balance, incontinence, and diagnoses of epilepsy and dementia. Interventions: Encourage appropriate use of walker. Monitor for changes in gait or ability to ambulate. Keep bed in lowest position. Keep floor mats while in bed. Use proper fitting, non-skid footwear (initiated 3/9/24). Staff will monitor resident during meals in dining room (initiated 3/10/24). [supervision or touching assistance provided while walking is excluded]
R3's progress notes state (3/9/24) at 4:30pm, I was informed that resident fell. When I arrived to dining room, resident was laying on the floor in supine position with blood coming from her head. Pressure was applied with a towel. Resident was transferred to (hospital). 7:57pm, Report received from (hospital) resident will be returning to facility tonight with laceration to head, closed with staples. (3/10/24) at 10:06am, upon making round, CNA (Certified Nursing Assistant) noticed resident on the floor, on the left side of her body. Noticed resident with active bleeding on left side of face and from her nose and mouth. Called 911, resident transferred to (hospital) for evaluation and treatment. (3/11/24) Received report from Nurse at (hospital) resident was admitted for fall with diagnoses of laceration of upper lip, nose fracture and left 3rd-8th rib fracture. Bruising noted on left upper back, left upper arm and face.
R3's (3/9/24) hospital history and physical affirms patient brought from nursing home for unwitnessed mechanical fall. Patient fell backward, laceration noted to back of head. Procedures: laceration repair.
R3's (3/10/24) hospital history and physical states patient brought from nursing home for unwitnessed fall. [R3's (3/10/24) fall incident report affirms No witnesses found]. Per EMS (Emergency Medical Service) patient was being fed breakfast by nursing assistant, and nursing assistant had stepped away to attend to something else. When he returned after a few minutes, patient was found on the floor. Patient presents with laceration to bridge of nose and upper lip. Patient with similar presentation yesterday, did sustain a laceration to posterior scalp which required a staple.
R3's (3/11/24) after visit summary includes nasal bone fracture.
On 3/18/24 at 3:34pm, surveyor inquired about R3's cognitive status V9 (Licensed Practical Nurse) stated She's (R3) alert and oriented times 1 or 2. She (R3) can respond to their name and sometimes answer questions but sometimes not appropriate. R3 was subsequently observed seated at a table in the dining room, V10 (CNA/Certified Nursing Assistant) was sitting next to R3. Surveyor inquired about R3's fall prevention interventions V10 stated Um, make sure her (R3) bed is low, make sure someone is always by her so she doesn't fall however additional interventions were excluded. R3's face was severely bruised from the eyebrows to the chin, scab was noted across the bridge of R3's nose and R3's (left) hand was also severely bruised. Surveyor inquired about R3's bruises V9 responded She got 2 falls. She (R3) fell on her face on the 10th (3/10/24). She (R3) fell and hit the back of her head March 9th (2024). Surveyor inquired about R3's fall prevention interventions, V9 replied She's (R3) supposed to have the bed in low position, the walker and call light within reach, and assisted when taking a shower. [R3 was in the dining room however a walker was not present]. V9 instructed R3 to sit in a wheelchair nearby however she had difficulty standing up and refused to do so at this time. Surveyor inquired if R3's fall care plan was revised on 3/9/24 (post fall) V9 accessed R3's EMR (Electronic Medical Records) and responded No. Surveyor inquired what should have been added (3/9/24) to R3's care plan to prevent the (3/10/24) fall and V9 replied We should go and check the room and make sure the environment is safe if we want to prevent it from happening again. This person (R3) needs assistance with getting around and call light instruction for needing help, move closer to nursing station or put on a 1 to 1 monitor [none of which are on R3's fall care plan]. Surveyor inquired if R3 is currently on 1 to 1 supervision V9 stated No she's (R3) not a 1 to 1, I don't think we have a staff for that, but she needs a lot of attention, we need to monitor [supervision and/or frequent rounds to ensure resident safety are also excluded from R3's fall care plan].
On 3/19/24 at 1:19pm, surveyor inquired about R3's (3/10/24) fall/injuries V6 (LPN/Licensed Practical Nurse) stated The social worker called me to help out with the patient (R3). When I (V6) went there (2nd floor), the CNA told me (V6) this lady (R3) was on the floor, so I rushed into the room and see her (R3) laying on the left side. I (V6) could see her (R3) bleeding, her whole face was full of blood and there was blood on the floor. I (V6) think she (R3) had a small cut on her lip, it's more like laceration so I initiated 911 and informed the NP (Nurse Practitioner). I (V6) did not know she (R3) fell the day before until someone told me later.
On 3/20/24 at 1:21pm, surveyor inquired about R3's (3/9/24) fall, V11 (CNA) stated I (V11) told (R3) it's time to eat so I ushered her (R3) to the seat, she (R3) was sitting before I left her. I (V11) was out of the dining area and heard screaming. Surveyor inquired if the dining room was supervised by staff when R3 fell, V11 responded There were only 2 CNAs and both of us were passing trays and affirmed there was not. Surveyor inquired about R3's cognitive status. V11 replied She's (R3) demented and usually walks and cries that's why I (V11) was 1 on 1 with her, that was the first time I left her. I cannot be there and be doing 2 things at the same time, everybody needs to be served. Surveyor inquired about R3's fall prevention interventions. V11 stated We usually have her on 1 on 1 in the dining room and I always sit beside her. Somebody is there whenever I go and attend to other residents, that's all I know. Surveyor inquired if resident fall prevention interventions are accessible to CNAs, V11 responded I don't know about that, all I know is I ask the nurse on duty.
On 3/20/24 at 1:46pm, surveyor attempted to interview R3 however she was crying stating Take me home. Surveyor inquired how R3 fell, R3 responded Help me. Surveyor inquired again how R3 fell, R3 pointed to herself and replied, Stupid.
On 3/25/24 at 1:13pm, surveyor inquired about potential harm to a resident that sustains a fall V12 (Medical Director) stated You are going to have fractures, you are going to have bleeding or something like that.
R2's diagnoses include vascular dementia, hemiplegia and hemiparesis affecting right dominant side.
R2's (2/28/24) BIMS determined a score of 9 (moderate impairment).
R2's (1/15/24) fall risk assessment determined a score of 5 (at risk).
R2's care plan includes (10/6/23) high risk for falls due to use of psychotropic medication, impulsivity, impaired cognition, incontinence, and diagnosis of dementia. Interventions: Promote placement of call light within reach. Ensure that the bed is in the appropriate lowest position. (12/6/23) Resident requires assistance with ambulation. Encourage resident to ambulate with staff assist as needed.
R2's (2/28/24) functional assessment states resident can walk independent however R2's diagnoses include hemiplegia/ hemiparesis and R2's care plan affirms assistance is required - therefore inaccurate.
The facility fall log affirms R2 fell on 1/15/24 and 1/18/24.
R2's (1/15/24) incident report states resident was observed on the floor (in residents' room) in a sitting position. Laceration sustained on resident's head actively bleeding. Resident stated, I tripped because of my shoe.
R2's (1/15/24) initial facility reported incident states Nurse Practitioner gave orders to send her to ER (Emergency Room) for evaluation. Resident returned to facility with a laceration on posterior head measuring 2cm and containing 4 staples.
On 3/18/24 at 3:05pm, R2 was lying in bed in high position without a call light in reach [R2's call light was behind the curtain and on the floor]. Surveyor inquired if R2 recently fell at the facility, R2 stated I fell and they took me to the hospital after that I don't know nothing, every little bit I remember something. They tell me I fell here in the hall. I lost a lot of blood. A large scar and lump were noted on the back of R2's head at this time.
On 3/18/24 at 3:23pm, surveyor inquired about R2's cognitive and functional status V9 (LPN) stated (R2) is oriented times 2 to 3 with periods of confusion and delusions. She's ambulatory, she uses a walker, and she's a fall risk. Surveyor inquired about R2's fall prevention interventions V9 responded She has a walker, and her bed is usually in the low position and the call light within reach [staff assistance with ambulation was excluded]. Surveyor inquired about the location of R2's call light, V9 searched behind the curtain and replied, It's here, I found it hanging on the side behind the curtain and affirmed it was on the floor. V9 subsequently handed the call light to R2. R2 stated It's the first time I saw this in 2 days. Surveyor inquired about the height of R2's bed, V9 responded Her bed right now is not in the low position, its thigh level. V9 attempted to lower R2's bed with a handheld device however the bed did not move. V9 stated It's not even working. R2 responded No work, it broken. No working, never work.
On 3/18/24 at 3:48pm, surveyor observed R2 walking near the Nurse's station, V9 was present however provided no assistance or redirection at this time.
On 3/18/24 at 2:38pm, R1 was observed in his room with family members present. V7 (Family) stated (R1) recently sustained a head injury (of unknown origin) while residing in the facility and presented a (cell phone) picture of R1 with forehead bruising/edema. R1 was non-verbal at this time.
R1s diagnoses include dementia with severe behavioral disturbance.
R1's (3/11/24) BIMS states resident is rarely/never understood. Cognitive skills for daily decision making moderately impaired.
R1's (3/11/24) functional assessment affirms toilet transfer, sit to stand, walk were not attempted due to medical condition or safety concerns. Resident uses a wheelchair.
R1's (11/28/20) care plan states resident is at high risk for falls related to history of falling, dementia, vision impairment, weakness, poor judgment, impulsivity, and lack of coordination. Intervention: (2/15/24) Place resident near nurses' station to always be within sight of staff.
The facility fall log affirms that R1 fell on 2/15/24 and 3/4/24.
R1's (3/4/24) incident report states upon round making, resident is noticed in prone position on his right side, next to his bed [therefore not near the nurse's station and/or within sight of staff]. Noticed a small cut at area above his right eyebrow. Resident unable to give description. Injury type: laceration. No witnesses found.
The (08/2020) management of falls policy states the facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the residents plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Develop a plan of care to include goals and interventions which address resident's risk factors. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. Review and /or modify the residents plan of care at least quarterly and as needed in order to minimize risk for fall incidents.

Based on record review and interview the facility failed to provide a descriptive summary of an abuse allegation to IDPH (Illinois Department of Public Health) including names/titles of staff, substantiated/unsubstantiated outcome of investigation, termination or return of accused staff, and failed to ensure that staff report abuse allegations immediately to the abuse coordinator and/or designee for one of three residents (R3) reviewed for abuse, this failure has the potential to affect 84 residents.
Findings Include:
The (3/17/24) facility census includes 84 residents.
On 3/7/24 at 3:12pm, IDPH received the Initial Incident/Accident Notification Report which states Date of Occurrence: 3/1/24. On 3/7/24, facility was informed by a former employee that (R2) informed her that a male staff member hit (R3) last Friday (6 days prior). [Names and/or titles of staff were excluded].
On 3/12/24 at 5:04pm, IDPH received the (3/1/24) Final Incident/Accident Notification Report which excludes outcome of the investigation (substantiated/unsubstantiated) and whether the accused staff member was terminated or returned to work. The Final Incident/Accident Notification also states, Staff were re-in serviced on abuse policy.
On 3/18/24 at 1:30pm, surveyor inquired about the regulatory requirement for abuse, V1 (Administrator) stated Whenever I'm notified of abuse, I (V1) have to respond within 2 hours and report to IDPH, then I have 5 days to submit the investigation on the final report. Surveyor inquired if the aforementioned abuse allegation occurred on 3/7/24 or prior to that date. V1 responded It occurred prior to that date, she V3 (Activity Aide) was stating it occurred the prior Friday I believe it was March 1st. I was notified on March 7th by (V3). She (V3) said that resident (R2) said she seen a male CNA that was Hispanic or Filipino hit resident (R3). We (Facility) determined that she (R2) was referring to (V4/Certified Nursing Assistant) because he (V4) was working that particular floor that day, she (V3) said it happened on Friday (3/1/24). I asked if she (V3) had told anybody she said no. Surveyor inquired if the (3/1/24) abuse allegation was substantiated V1 replied No, it was not substantiated. Surveyor inquired if (V4) was terminated or returned to work V1 stated He returned to work I believe it was 3/13/24. Surveyor inquired why V3 was terminated, V1 responded She (V3) was termed for her performance and was under the 60-day probationary period. She (V3) wasn't following her duties as scheduled, wasn't following instructions by her supervisor and called the supervisor incompetent. She (V3) worked that Friday (3/1/24) and didn't tell anyone about the incident, that's why we re-in serviced the staff on the abuse policy to avoid stuff like this from happening again.
The (09/20) abuse policy states employees are required to immediately report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or the administrator. Within 5 working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Illinois Department of Public Health.

Based on record review and interview the facility failed to revise the comprehensive care plan with appropriate preventive interventions for one of three residents (R3) reviewed for falls.
Findings include:
The (08/2020) fall management program states the facility is committed to minimizing resident falls and/or injury to maximize each resident's physical, mental and psychosocial wellbeing. While prevention of all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Procedure: Plan of care reviewed and updated at time of occurrence, quarterly and as needed in order to minimize risk for fall incidents.
R3's (1/11/24) functional assessment affirms supervision or touching assistance is required for walking.
R3's (11/10/22) care plan states resident is at risk for falls related to history of fall, use of psychotropic medications, poor safety awareness, unsteady gait, poor balance, incontinence, and diagnoses of epilepsy and dementia. Interventions: Encourage appropriate use of walker. Monitor for changes in gait or ability to ambulate. Keep bed in lowest position. Keep floor mats while in bed. Use proper fitting, non-skid footwear. Staff will monitor resident during meals in dining room. [supervision or touching assistance provided while walking is excluded].
The facility fall log states R3 fell on 3/9/24 and 3/10/24 (the following day).
On 3/18/24 at 3:34pm, surveyor inquired about R3's cognitive status. V9 (Licensed Practical Nurse) stated She's alert and oriented times 1 or 2. She can respond to the name and sometimes answer questions but sometimes not appropriate. Surveyor inquired if R3's fall care plan was revised on 3/9/24 (post fall), V9 accessed R3's EMR (Electronic Medical Records) and responded No. Surveyor inquired what should have been added (3/9/24) to R3's care plan to prevent R3's (3/10/24) fall, V9 replied We should go and check the room and make sure the environment is safe if we want to prevent it from happening again. This person (R3) needs assistance with getting around and call light instruction for needing help, move closer to nursing station or put R3 on 1 to 1 monitor [none of which are on R3's fall care plan]. Surveyor inquired if R3 is currently on 1 to 1 supervision V9, stated No she's not a 1 to 1, I don't think we have staff for that, but she needs a lot of attention, we need to monitor [supervision and/or frequent rounds to ensure resident safety are also excluded from R3's fall care plan].
The (11/2017) review of care plans policy states the interdisciplinary team is responsible for periodic review and adjustments to the plan of care: when there has been a significant change in the resident's condition; when the resident has been readmitted to the facility after a hospital stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a behavioral plan of care was put in place timely and failed to provide the necessary Psychiatric Services for one (R1) of three residents (R1, R2 and R3) reviewed for behaviors.
Findings include:
R1 is [AGE] years old with BIMS score of 7 which means that R1 has severe cognitive impairment. R1 was initially admitted on [DATE].
On 10/19/2023 at 11:23 AM, R1 was seen sitting on her wheelchair in the dining room. V5 (Certified Nursing Assistant) who was in the dining room stated that R1 has no problem with eating things that are not food. V5 said to her knowledge, it is R2 that eats things that are not food if it is in front of her. V4 (Certified Nursing Assistant) who stated that she was assigned to R1 and that R1 eats things that are not food when it is colored white like tissue. V3 (Registered Nurse) at the Nurse's Station stated that R1 eats her clothing by tearing it into pieces. R2 eats things that are not food if it is placed in front of her. Between R1 and R2, R1's eating disorder is more severe.
On 10/19/2023 at 11:43 AM, at the Memory Care office, V6 (Memory Care Director) stated that she started working in the facility in April 2023 and R1's eating problem was already present during that time. V6 stated that there is no specific assessment for PICA disorder when a person eats things besides food. What is being done is to care plan R1's eating disorder and place an intervention as soon as it is identified.
R1's care plan related to eating disorder was initiated on 05/22/2023, it documents (R1 has been noted to eat none-food items: Plastic, clothing, and shoes). V6 stated, Yes, R1's eating disorder already existed before April. On progress notes of R1 dated 03/01/2023 by V7 (Wound Care Nurse / Licensed Practical Nurse), it documents that R1 eats her clothing.
On 10/19/2023 at 12:40 PM, V2 (Director of Nursing) stated he did not know that R1 and R2 have eating problem. V2 said, No one informed me, it is only today that it came to my attention. I think they (R1 and R2) were seen by a psychiatrist. (Psychiatric notes were requested for both R1 and R2). After a few minutes, V2 and V1 (Assistant Administrator) returned. V2 stated that both R1 and R2 were not seen by a Psychiatric Doctor and an appointment was not scheduled for R1 and R2 to be seen by a psychiatrist. R1 and R2 were not assessed by a psychiatrist. V2 stated that R1's eating problem should have been care planned immediately once a problem is identified and any resident with an eating disorder like R1 should have been referred to and seen by psychiatrist. Psychiatric services can help with R1 and R2's eating disorder.
National Eating Disorders Association dated 2016, reads: [NAME] is an eating disorder that involves eating items that are not typically thought of as food and that do not contain significant nutritional value. [NAME] disorder warning signs includes the following: Eating or swallowing substances that are not food. An obstruction or perforation (hole) in the intestines. These may be caused by nonfood substances building up in or perforating the intestines. Heavy metal poisoning, caused by the ingestion of metal-based substances.

Based on interview and record review, the facility failed to provide the services of a registered nurse at least 8 hours a day, seven days a week. This failure affected all 78 residents residing in the facility reviewed for lack of staff.
Findings include:
On 06/07/2023 at 2:43pm, V15 (Assistant Administrator/Staffing Coordinator) stated If there is a call off then we try to get coverage and call other staff members, we do not use agency to staff. Since I've been doing the schedule, there has always been a Registered Nurse/RN in the building. V1 (Administrator) told me that there needs to be an RN in the building at all times because an RN has a broader knowledge of health care and has undergone more training than an LPN (Licensed Practical Nurse). RN's can provide more care because they have a greater skill set than an LPN. An RN is in the facility to supervise an LPN.
Facility RN time sheets and payroll-based journal (PBJ) reviewed for the past 9 months and documents that there was not an RN who worked in the facility on the following dates: 10/01/2022, 10/02/2022, 10/29/2022, 10/30/2022, 11/06/2022, 11/12/2022, 11/13/2022, 11/26/2022, and 11/27/2022.

Based on observation, interview and record review, the facility failed to ensure call lights were placed within reach at all times for 4 residents (R14, R46, R62, R227) and failed to ensure 1 resident (R69) had a call light.
Findings include:
On 6/6/23 at 11:05 AM, in R227 and R69 room, observed R227 bed to have a red string coming from the call light switch clipped to the left side, head of bed. R227 was seated in a wheelchair on the right side at the foot of the bed unable to reach the string. Surveyor did not observe a second string coming from the call light switch to R69 bed. R69 was lying in bed.
On 6/6/23 at 11:07 AM, R227 said I don't have a call light. No one gave me a call light. I'm paralyzed on the right side. R227 demonstrated limited mobility in the left leg and left arm and hand. R227 said R227 had been in the facility since Friday.
On 6/6/23 at 11:13 AM, R69 said There is no call light for this bed. I have to scream if I need help. On the other side of the curtain there is a string, but I can't reach it. Someone would have to give it to me.
On 6/6/23 at 1:00 PM, observed R227 and R69 room/call light with V17 (Certified Nursing Assistant). V17 said R227 cannot reach the call light. The string is too short. V17 said there is no call light at all for R69. There is nothing R69 can do to get assistance. V17 said in case the resident needs help or is in distress, if there is no call light, they can't tell staff they need help.
On 6/6/23 at 11:54 AM, in R62 room, observed R62 bed to have a string coming from the call light switch clipped to the right side, head of bed. R62 was sitting in a high-back chair on the left side at the foot of the bed unable to reach the string.
On 6/6/23 at 11:54 AM, R62 said I cannot walk. I wait until I see somebody if I need help. R62 said R62 cannot reach the call light on the other side of the bed.
On 6/6/23 at 12:45 PM, in R14's room, observed R14 bed to have a string coming from the call light switch clipped to the left side, head of bed. R14 was sitting in a high-back wheelchair on the left side at the foot of the bed unable to reach the string.
On 6/6/23 at 12:47 PM, R14 said I cannot reach back. I can't reach the call light. My knees are shot. I can't stand. I have to move the chair to reach the call light.
On 6/6/23 at 1:19 PM, observed R14 room/call light with V18 (Activities Director). V18 said R14 cannot reach the call light. V18 said when residents need assistance, they pull the call light for us to assist them. If R14 were in distress, R14 would not be able to move R14's chair to reach the call light.
On 6/7/23 at 10:30 AM, V2 (Director of Nursing) said call lights should be placed within reach of the resident at all times. Staff can make the call light longer or move the resident to a position where they can reach it. Maintenance can make the call light longer for the resident. If the resident cannot access the call light, they will not be able to alert us to their distress and that's a danger.
Facility policy, Call Light, Use of, date 9/20, documents in part: 5. When providing care to residents, position the call light conveniently for the residents use. Tell the resident where the call light is and show him/her how to use the call light and provide reminders to use the call light as needed. 7. Be sure call lights are placed within resident reach at all times.
On 06/06/2023 at 11:00 AM, surveyor observed R46 laying on her bed. R46's bed is in high position. Call light was laying on the floor. R46 stated, that she cannot walk and that she cannot reach the call light.
On 06/07/2023 at 11:05 AM, V7 (Assistant Director of Nursing/Restorative Nurse) stated that she is the falls coordinator. V7 stated depending on the resident, each resident has their own individual intervention to prevent them from falling based on their fall risk assessment. V7 stated that R46 is at risk for falls because she is an extensive assist and using the hoyer lift for transfers. Interventions for her include, wheelchair locked, Q2 hourly rounds, non slid socks, call light within reach, bed in low position. V7 stated that if R46's bed is not in low position, she could fall and hit her head.
R46's care plan documents in part (3/22/2023): Ensure call light is within reach.
Facility's Call light policy (09/2020) documents in part: Be sure call lights are placed within resident's reach at all times.

Based on observations, interview and record review, the facility failed to follow their policy to follow the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident for 1 (R46) out of 6 residents reviewed for falls in a sample 18.
Findings include:
On 06/06/2023 at 11:00 AM, surveyor observed R46 laying on her bed. R46's bed is in high position. Call light was laying on the floor. R46 stated, that she cannot walk and that she cannot reach the call light.
On 06/06/2023 at 12:37 PM surveyor observed V4 (Certified Nursing Assistant) feeding R46's roommate in R46's room.
On 06/06/2023 at 01:05 PM, surveyor again observed R46 laying in her bed, still in high position. Surveyor did not observe any CNA or nurse in the room changing the resident. Surveyor asked V3 (Registered Nurse) to come with him to R46's room. At the room, surveyor asked V3 if R46's bed is high position. V3 stated yes and then went in and lowered the bed. V3 stated R46 is a high fall risk, and the bed should have been in low position.
On 06/07/2023 at 11:00 AM, V7 (Assistant Director of Nursing/Restorative Nurse) stated that she is the falls coordinator. V7 stated depending on the resident, each resident has their own individual intervention to prevent them from falling based on their fall risk assessment. V7 stated that R46 is at risk for falls because she is an extensive assist and using the hoyer lift for transfers. Interventions for her include, wheelchair locked, Q2 hourly rounds, non slid socks, call light within reach, bed in low position. V7 stated that if R46's bed is not in low position, she could fall and hit her head.
R46's care plan documents in part (3/22/2023): Ensure bed is in the appropriate lowest position for the patient and ensure the bed is locked as appropriate.
Facility's Management of Falls (08/2020) documents in part: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for falls incidents and/or injuries to the resident. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: Contributing diseases/disorders, history of falls, incontinence, medications and gait issues.

Based on observations, interviews and records review, the facility failed to safely secure controlled medications. This deficiency has the potential to affect four residents (R22, R15, R14, R54) residents residing on the first floor.
Findings include:
On 06/06/23 10:08am, first floor medication cart and storage room were inspected with V11(Licensed Practical Nurse). In the cart's narcotic storage box was R22's bingo card with medication tramadol 50 mg tablets. Medication 27's security seal on the bingo card was broken, and the medication was taped back on the bingo card with a brown bandage. V11 said I did not open the medication. I don't know who opened and taped it back. Once medication is opened, it is supposed to be discarded if not used. On the first-floor medication storage room was a medication fridge which was observed to have no lock. Inside the fridge was a medication box that was not locked. V11 said this fridge is never locked, and the narcotic box does not have a key to lock it, therefore we leave it open. Inside the narcotic box was observed:
R15's medication-Lorazepam 30 mL vial, not opened
R14's medications-Lorazepam 30 mL vial, not opened
Emergency Ativan 2mg/mL, 3 vials, not opened
R22's tramadol 50mg tablet number 27 on bingo card -security seal broken. Medication taped back on the bingo card with bandage.
On 6/6/2023 at 10:56am, while inspecting the 3rd floor medication storage room with V10(LPN), observed the medication fridge was not locked and inside the medication fridge was a medication box containing R54's medication: Morphine Sulfate (Concentrate) Solution 20 MG/ML. V10 said this box should be locked. Whoever put the medication there should have locked it because this is a narcotic, and it is supposed to be in a locked box so that no one other than the nurses can have access to it. If narcotics are not secured correctly, people who should not have access to them can have access and misuse the medications.
On 6/7/2023 at 10:18am, V2(Director of Nursing-DON) accompanied by V12, (Nurse Consultant) said narcotics should be kept in a double lock system for security reasons. V2 said that at the facility, the first lock is the locked door to the medication room and the second lock is the locked box inside the fridge. V2 said the narcotic boxes inside the fridge should have been locked, and he further said that new lock boxes that can be locked with keys will be purchased to make sure there is a double lock system to prevent misuse/theft of narcotic medications and to ensure medication is safe and ready for resident use. V2 said if a narcotic is opened by mistake, it should not be taped back on the narcotic bingo card. It should be wasted by two nurses and documented as wasted in the narcotic sheet. He (V2) further commented that when a medication is opened and taped back, there is a potential of it being contaminated. The opened medication is not guaranteed to be the same medication as ordered. V2 said giving a medication that is open to the resident breaks/does not follow the five rights of medication administration and this can lead to a resident not receiving the medication ordered, and it is also a risk for potential infection.
Policy titled Storage/Labeling/Packaging of Medications, dated 3/2021 documents:
-Schedule 11 controlled medications are stored under double-lock system accessible only to authorized staff.
-Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. Reorder from pharmacy as applicable.

Based on observations, interviews and records review, the facility failed to follow the infection control process by failing to clean/sanitize a multi-resident use pill crusher during medication administration to one resident (R54). This failure has the potential to affect twenty-seven residents receiving medications on the third floor.
Findings include:
On 6/6/2023 at 12:39pm V7(Assistant Director of Nursing-ADON, Restorative, Licensed Practical Nurse-LPN) and V8 (LPN on Orientation) during medication administration observation were observed taking the multi-resident use pill crusher to R54's room to crush and administer medication carbidopa- levodopa 25-100 mg. The pill crusher has multiple plastic pill crusher sleeves stored on the side in an open compartment within the pill crusher. Once in R54's room, V7 instructed V8 to crush the medication and then give it to R54. R54 took his medication and V7 and V8 left R54's room with the pill crusher and set on top of the medication cart. Surveyor observed V7 and V8, and none of them cleaned the pill crusher after coming out of R54's room. Surveyor asked V7 if multi resident pill crusher with multiple pills crushing sleeves should be taken to resident rooms. V7 said there is only one pill crusher and V7 said she likes to crush medications in front the residents. V7 did not clean the pill crusher after using it/or taking it to R54's room.
On 6/7/2023 at 10:35am V2(Director of Nursing-DON) said the multi resident use pill crusher, should not be taken into individual residents' rooms because it stores pill crusher sleeves for use when crushing residents' medications. V2 said if the pill crusher is taken to a resident room, it should be sanitized after it comes out of the resident room. If taken to resident room it should not have extra pill crusher sleeves because it is an infection control issue, and germs can move from resident room to resident room. It has the potential for spreading infections from resident to resident and increases the risk for infection.
On 6/7/2023 at 10:53am, V7 said when she took the pill crusher to R54's room to crush his medications, she should have cleaned and sanitized the pill crusher once she got out of the room to prevent cross contamination. V7 said she should not have taken the medication/pill crusher sleeves in R54's room because the sleeves became contaminated since they were in a resident's room. V54 said the sleeves cannot be sanitized, therefore they should have been thrown away and the pill crusher sanitized. V7 said a contaminated pill crusher increases the risk of spreading germs from one resident room to the next one and this can cause infection transmission from resident room to resident.
Policy titled Medication Administration: General Guidelines, dated 03/2021 document: -Infection control policies are followed at all times during medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a homelike environment by changing soiled mattress linens and by cleaning dirt around a window in a resident's room which affected R34 and R73 in the sample of 45 residents reviewed for environment.
Findings include:
R73's Minimum Data Set (MDS), dated [DATE], Section C, documents, in part, a Brief Interview of Mental Status (BIMS) score of 4 which indicates that R73 has severe cognitive impairment.
On 5/2/22 at 10:48 am, during the initial tour, this surveyor entered R73's room and observed R73's fitted mattress sheet with large, dark brown bowel movement stains, which appeared old, noted in the center on R73's bed sheet. R73 was sitting next to the bed in a wheelchair and reaching for papers on top of soiled mattress sheet.
On 5/2/22 at 12:40 pm, V7 delivered R73's lunch meal tray into R73's room.
On 5/2/22 at 12:41 pm, this surveyor entered R73's room and observed the same bowel movement stains on R73's fitted mattress sheet.
On 5/2/22 at 12:43 pm, V7 (Certified Nursing Assistant, CNA) brought clean linens into R73's room, collected R73's papers off the mattress and changed R73's bed linens.
On 5/2/22 at 12:50 pm, V7 (CNA) stated V7 does rounds on R73 every time I go down the hallway. (V7) will look in. When V7 was informed of this surveyor's observation on 5/2/22 at 10:48 am, V7 stated that on previous rounds on 5/2/22, V7 did see the soiled linen, but that (V7) didn't have any clean linen. It (clean linen) actually just came up and (surveyor) beat (V7) in there (R73's room).
On 5/4/22 at 10:04 am, V5 (Maintenance Director) stated that V5 oversees laundry services for the facility. V5 stated each floor is stocked with a specific number of linens (sheets, towels, gowns) on the carts and that when nursing staff on resident floors run low on linens, the nurse or CNA will call downstairs to the laundry staff to ask for more linens. V5 was asked if resident on a floor has an incontinent episode in bed and there's no more clean sheets on the linen cart, what is to happen? V5 stated, They (nursing staff) have to change it. V5 stated that the nurse or CNA can come down to the laundry department to come right away to get it (clean linen).
On 5/4/22 at 1:58 pm, V2 (Director of Nursing, DON) was asked if a flat sheet is soiled with bowel movement material, what should nursing staff do? V2 stated, Change that (soiled sheet) right then. When asked if there are no clean linens available on the resident floors, V2 stated, Go downstairs to get in the laundry room.
R73's Care Plan, documents, in part, a focus of (R73) experiences . incontinence related to impaired cognition, advancing disease process, recently diagnosed with brain CA (cancer), confusion, functional incontinences and physical limitations with an intervention of check residents for incontinence.
Facility job description dated 1/2015 and titled, Certified Nursing Assistant, documents, in part, I. Job Summary: Provides residents with daily nursing care in accordance with current federal, state and local standards, guidelines and regulations, facility policies . to ensure that the highest degree of quality care is maintained at all times . IV. Essential Functions: . F. Makes rounds to assure customers are safe and comfortable. G. Maintains an atmosphere of warmth, personal interest, and positive emphasis . O. Makes occupied and unoccupied beds, changes bed linens.
Findings include:
On 05/02/2022 at 11:05am, there was an accumulation of dust on R34's windowsill and the window curtain was dirty.
On 05/02/2022 at 11:11am, V3 (Resident Care Coordinator) checked R34's windowsill and curtain, per surveyor's request, and stated, There's hardened dust on the sill. The curtain is dirty, needs replacement.
On 05/02/2022 at 11:30am, V5 (Maintenance Director) checked R34's windowsill and curtain, per surveyor's request and stated, The windowsill and curtains are dirty.
On 05/04/2022 at 11:4am, surveyor inquired about home like environment. V9 (Nurse Consultant/Infection Preventionist) stated, The resident's room should be conducive. It should be clean, everything should be in order, no clutter. Dirty windowsill and curtain is not a homelike environment.
R34's (printed: 05/03/2022 Order Summary Report documented, in part Diagnoses: . Hypertensive Heart disease with heart failure.
R34's (02/25/2022) Resident Assessment Instrument documented, in part Section c. Brief Interview for Mental Status (BIMS) score: 14. R34 is mental status was cognitively intact. Section G0110. Activities of Daily (ADL) Assistance. A. Bed mobility: 3/3 coding Extensive assistance / Two+ persons physical assist.
The Facility Policy and Procedure (8.14) Housekeeping Department documented, in part A. Policy. The facility will follow an effective plan to maintain a clean, safe, and orderly environment.
The Facility Policy and Procedure (Rev.8.14) Cleaning Methods documented, in part 1. Resident rooms, bathing rooms, and toilet rooms are to be cleaned using the 3 step, 6 step, and 8 step method. a. iii. Spot clean any spills and debris on floors or other surfaces which can cause odors, falls, or contamination of other surfaces if carried on the feet or hands of residents or staff. 3. Clean . windows with the AMS approved glass cleaner.
The Facility (05/03/2022 and 05/04/2022) In-Service/Meeting Attendance Record documented, in part Topic: Provide Homelike environment to residents. Replace curtains when dirty. Keep resident's bedside and room clean .

Based on observation, interview and record review, the facility failed to ensure the indwelling catheter drainage bag was covered. This failure affected 1 (R46) resident reviewed for privacy and dignity in the sample of 45 residents.
Findings include:
On 05/02/2022 at 10:22am, R46's indwelling catheter drainage bag had no cover.
On 05/02/2022 at 10:23am, surveyor inquired about the indwelling catheter drainage bag. V3 (Resident Care Coordinator) stated, It is not in privacy bag. It should be in a privacy bag for dignity.
On 05/04/2022 at 11:36am, surveyor inquired about covering for indwelling catheter drainage bag. V2 (Director of Nursing) and V9 (Nursing Consultant) stated, The indwelling catheter drainage bag should be in a privacy bag for dignity. We don't have a policy specific for privacy bag for indwelling catheter drainage bag.
R46's (Printed: 05/03/2022) Order summary Report documented, in part Diagnoses: Encounter for fitting and adjustment of urinary device . benign prostatic hyperplasia with lower urinary tract symptoms. Order Summary: CATHETER: MAY CHANGE CATHETER BAG AS REQUIRED DUE TO SEDIMENT, STAINING, OR CONTAMINATION .
R46's (03/15/2022) Resident Assessment Instrument documented, in part Section C. Brief Interview for Mental Status (BIMS) score: 15. R46's mental status is cognitively intact. Section H. H0100. Appliances check all that apply. A. Indwelling catheter.
R46's (date initiated: 06/13/2019) Care plan documented, in part Focus: (R46) is at risk for alteration in skin integrity related to . use of indwelling foley catheter. Goals: R46's skin will remain intact. Focus: (R46) is at risk for bladder distention, incomplete emptying of the bladder and/or UTI secondary to benign prostatic hypertrophy. Goals: R46 will not exhibit signs of urinary tract infection and demonstrate consistent ability to Urinate .
The (Rev. 11/17) Residents' rights documented, in part a. Policy. The facility will respect and uphold residents' rights. Dignity. You have the right: To be valued as an individual, to maintain and enhance self-worth. To be treated with courtesy, respect and dignity . Privacy: You have the right: To personal privacy during care and treatment.

Based on observation, interview and record review, the facility failed to ensure that two nurses document together on the shift-to-shift controlled substances count sheet which has the potential to affect 49 residents on the first and third floors of the facility.
Findings include:
On 5/2/22 at 2:46 pm, V8 (Licensed Practical Nurse, LPN) and this surveyor performed a controlled substances audit of the first floor's medication cart. V8 unlocked the medication cart and then unlocked the controlled substance box within the cart. After the audit was completed, this surveyor reviewed the red binder containing the controlled substance shift count sheets for May 2022 which documented V8's initials pre-signed as the off-duty nurse for 5/2/22 for the second shift (3:00 pm to 11:00 pm). When V8 was asked when the controlled substance shift count is performed, V8 stated, It's done in the morning at 7:00 am, 3:00 pm and at night at 11:00 pm. V8 stated, I (V8) have to do it (controlled substance shift) with my reliever nurse. Two nurses, and we will check the medications together. We do this after we give shift to shift report. When asked if V8 has performed the controlled substance count for the end of V8's shift (7:00 am to 3:00 pm), V8 stated, I (V8) haven't done the count with (V13, LPN, on-coming nurse). We will do another count after this. I (V8) will then sign it (controlled substance count sheet) after the count is done. This surveyor then showed V8 the controlled substance count sheet for May 2022 with V8's name (initials) pre-signed as off going nurse for 5/2/22 for second shift, and V8 verified V8's initials as pre-signed.
Facility document dated May 2022 and titled, Controlled Substance Shift Count Documentation: 1st Floor, documents, in part, on 5/2/22 for the off-duty nurse for the 2nd shift, V8's initials documented under the signatures box.
On 5/4/22 at 1:33 pm, V21 (LPN) and this surveyor performed a controlled substances audit of the third floor's medication cart. V8 unlocked the medication cart and then unlocked the controlled substance box within the cart. After the audit was completed, this surveyor reviewed the red binder containing the controlled substance shift count sheets for May 2022 which documented a blank space for on-coming nurse for 1st shift (7:00 am to 3:00 pm), and a signature of the off-going nurse (V24, LPN, night nurse from 5/3/22). V21 then takes out an ink pen and signs V21's initials on the on-coming spot (previously blank) for 5/4/22 as 1st shift, and signs initials for off-going nurse on 5/4/22 for the 2nd shift (3:00 pm to 11:00 pm). V21 stated, I (V21) am about to get off (my shift). This surveyor verified the current time of 1:33 pm with V21 and asked when V21's shift ends, and V21 stated, 3 o'clock. When asked should both nurses (on and off going) be together during the shift-to-shift controlled substance count, and V21 said Yes. V21 stated that both nurses will then sign the audit sheet. V21 stated that V21 did the controlled substance check at the start of V21's shift with V24, but didn't sign the audit sheet saying, Maybe I just missed it. V21 stated, The moment (V24) counted with me (V21), I (V21) should have signed it.
Facility document dated May 2022 and titled, Controlled Substance Shift Count Documentation: 3rd Floor, documents, in part, on 5/4/22 for the off-duty nurse for the 2nd shift, V21's initials documented under the signatures box.
On 5/4/22 at 1:58 pm, V2 (Director of Nursing, DON) stated the purpose of nurses performing shift to shift controlled substance counts is to make account of the medications. V2 stated, Whoever has control of that (medication) cart must count off with the incoming nurse because they are responsible for that medication. V2 stated that it's the responsibility of the nurse with keys (off-going nurse) to do the count together with the on-coming nurse.
On 5/4/22 at 12:47 PM, V9 (Nurse Consultant) stated that the process for controlled substance audits for shift-to-shift nurses is done when the out-going and in-coming nurses come together and will do an audit of medications (controlled substances) to see if there's a discrepancy. V9 stated that once all of the medications are accounted for, the out-going and in-coming nurse will sign the shift count sheet. V9 stated that V9 is aware that V8 pre-signed the controlled substance shift count sheet on 5/2/22, and stated, (V8) is fully aware of mistake (V8) made.
Facility job description, dated 1/2015 and titled, Staff Nurse (Registered Nurse/Licensed Practical Nurse), documents, in part, I. Job Summary: Responsible to provide direct nursing care to the customer . The objective is to ensure the highest degree of quality care is maintained at all times . IV. Essential Functions: . C. Assume all Nursing procedures and protocols are followed in accordance with established policies.
Facility census report, dated 5/2/22, documents that 49 residents are actively residing on the 1st and 3rd floors of the facility.

Based on observation, interview and record review, the facility failed to ensure the indwelling catheter drainage bag is not touching the floor in an effort to prevent the spread of infectious microorganisms. This failure affected 1 (R46) resident reviewed for infection control in the sample of 45 residents.
Findings include:
On 05/02/2022 at 10:22am, R46's indwelling catheter drainage bag has no cover and was touching the floor.
On 05/02/2022 at 10:23am, surveyor inquired about the indwelling catheter drainage bag. V3 (Resident Care Coordinator) stated, It's touching the floor. It should not be touching the floor; it is an infection control issue.
On 05/04/2022 at 12:06pm, surveyor inquired if indwelling catheter drainage bag should be touching the floor. V2 (Director of Nursing) stated, The bag should not be touching the floor. It is an infection control issue.
R46's (Printed: 05/03/2022) Order summary Report documented, in part Diagnoses: Encounter for fitting and adjustment of urinary device . benign prostatic hyperplasia with lower urinary tract symptoms. Order Summary: CATHETER: MAY CHANGE CATHETER BAG AS REQUIRED DUE TO SEDIMENT, STAINING, OR CONTAMINATION .
R46's (03/15/2022) Resident Assessment Instrument documented, in part Section C. Brief Interview for Mental Status (BIMS) score: 15. R46's mental status is cognitively intact. Section H. H0100. Appliances check all that apply. A. Indwelling catheter.
R46's (date initiated: 06/13/2019) Care plan documented, in part Focus: (R46) is at risk for alteration in skin integrity related to . use of indwelling foley catheter. Goals: (R46)'s skin will remain intact. Focus: (R46) is at risk for bladder distention, incomplete emptying of the bladder and/or UTI secondary to benign prostatic hypertrophy. Goals: (R46) will not exhibit signs of urinary tract infection and demonstrate consistent ability to Urinate . Interventions: Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine).
The Facility (Reviewed 04/2021) Infection Prevention and Control Program documented, in part Mission of Program: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Elements of the program include: Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. Responsibilities. 3. Training: d. Task-specific infection prevention and control training is discipline and task specific (e.g., insertion of urinary catheter.
The Facility Policy and Procedure (09/20) Indwelling Catheter documented, in part Policy: Indwelling Catheters will be utilized to facilitate urinary drainage when medically necessary. Procedure: 9. A sterile, continuously closed drainage system will be maintained for indwelling and suprapubic catheter systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R80's Minimum Data Set (MDS), dated [DATE], Section C, documents, in part, a Brief Interview of Mental Status (BIMS) score of 12 which indicates that R80 has moderate cognitive impairment. R80's MDS, Section M, documents, in part, for skin and ulcer/injury treatments, R80 has a pressure reducing device for bed.
On 5/2/22 at 11:00 am, R80 was observed laying supine in bed on a low air loss (LAL) mattress.
On 5/2/22 at 12:35 pm, V26 (Family Member) was at R80's bedside. When asked about the status of R80's skin integrity, V26 pulled back R80's top flat sheet, and this surveyor observed R80 laying supine on a flat sheet with a quadruple folded flat sheet and a thick incontinence pad on the LAL mattress.
On 5/3/22 at 11:36 am, V10 (Certified Nursing Assistant, CNA) was called into R80's room for an incontinence check. V10 turned R80 to the right side, pulled back R80's incontinence brief and R80's left buttock and sacral wound dressings were observed as intact. This surveyor observed R80's linens on top of the LAL mattress were a flat sheet with a quadruple folded flat sheet.
On 5/4/22 at 2:30 pm, V8 (Licensed Practical Nurse, LPN) stated that one flat sheet is to be used without layering on R80's LAL mattress which allows the wound to breath.
R80's Care Plan, dated 6/15/2018, documents, in part, a focus of an alteration of skin integrity with an intervention of treatment as ordered. R80's Care Plan documents, in part, diagnoses of dementia without behavioral disturbance and incontinence without sensory awareness.
In R80's wound care progress note, dated 4/19/22, V25 (Wound Nurse Practitioner) documented, in part, that R80 has a Group 1 mattress (pressure reducing support surface) and that the plan for R80's left and right buttock wounds are continue with skin ulcer prevention protocol of the facility.
Facility policy dated 3/2/21 and titled, Prevention and Treatment of Pressure Injury and Other Skin Alterations, documented, in part, Policy: . 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan.
On 05/02/2022 at 11:05am, R34 was lying on a Low Air Loss Mattress.
On 05/02/2022 at 11:15am, V3 (Resident Care Coordinator) checked R34's linens, per surveyor's request, and stated, She (R34) has a flat sheet and there's a twice folded blanket underneath her (R34). She (R34) is also wearing an incontinence brief. It should be just a flat sheet. The blanket defeats the purpose of the Low Air Loss Mattress.
On 05/04/2022 at 11:54am, surveyor inquired about the expectation with regard to layering of linens for resident using the Low Air Loss Mattress. V2 (Director of Nursing) stated, Expectation is to layer the resident with a flat sheet and incontinence pad or incontinence brief.
On 05/02/2022 at 11:55am, surveyor inquired about the importance of layering the resident using a Low Air Loss Mattress with a flat sheet and incontinence pad or brief. V2 stated, Not to defeat the purpose of the Low Air Loss Mattress.
On 05/04/2022 at 11:56am, surveyor inquired about the purpose of the Low Air Loss Mattress. V2 stated, To help with healing the wound. For pressure redistribution.
R34's (printed: 05/03/2022 Order Summary Report documented, in part Diagnoses: . Hypertensive Heart disease wit heart failure and Pressure ulcer of sacral region, Stage 4. Order Summary. For Wound Care Consult, Evaluation and treatment with MD/NP/PA- to manage the wound until healed. 12/27/2021. Low air Loss Mattress. 05/02/2022.
R34's (02/25/2022) Resident Assessment Instrument documented, in part Section c. Brief Interview for Mental Status (BIMS) score: 14. R34 is mental status was cognitively intact. Section G0110. Activities of Daily (ADL) Assistance. A. Bed mobility: 3/3 coding Extensive assistance / Two+ persons physical assist.
R34's (Date initiated: 12/03/2021) Care plan documented, in part Focus: (R34) has an actual alteration in skin integrity with . pressure ulcer to sacrum. Goals: No further skin alteration . Interventions: Low air loss mattress for pressure relief.
R34's (05/03/2022) Wound Note documented, in part skin problem sites: . sacral . HPI (History of Present Illness) Wound #4 - sacral, exudate is Moderate . Comments: Preventive measures in Place Mattress- has LAM (Low Air Mattress).
The Facility Policy and Procedure (10/2018) Guideline for Bed Making documented, in part Guideline for linen usage for specialty support surfaces, (Low air loss, overlay, gel, water): May use: 1 sheet and 1 pad or incontinence brief between the skin and support surface.
Based on observation, interview and record review, the facility failed to ensure that the Low Air Loss (LAL) mattresses were not layered with multiple layers of linens for two residents (R34 and R80) and failed to provide wheelchair pressure reduction cushions for four residents (R4, R24, R28, and R62), reviewed for pressure ulcer prevention in the sample of 45 residents.
Findings include:
On 05/02/22 at 10:18 am, Surveyor toured the facility's second-floor unit. At 10:21 am, R24 was observed sitting in a wheelchair outside of R24's room without a wheelchair pressure relieving cushion in place. At 10:44 am, R28 was observed sitting in a wheelchair inside of R28's room without a wheelchair pressure relieving cushion in place. At 10:46 am, R4 was observed sitting in a wheelchair inside of R4's room without a wheelchair pressure relieving cushion in place.
On 5/02/22 at 10:47 am, R62 was observed sitting in a wheelchair inside of R62's room without a wheelchair pressure relieving cushion in place.
On 05/04/22 at 10:31 am, V11 (Licensed Practical Nurse, LPN) was interviewed regarding wheelchair pressure relieving cushions for residents and V11 stated that all residents who sit in a wheelchair should have a wheelchair pressure relieving cushion to prevent pressure ulcers. At 10:35 am, Surveyor and V11 made rounds on the second-floor unit and observed the following residents sitting in a wheelchair without a wheelchair pressure relieving cushion in place: R24 sitting in a wheelchair in the hallway outside of R24's room with no wheelchair pressure relieving cushion in place, R28 sitting in a wheelchair inside R28's room with no wheelchair pressure relieving cushion in place, and R4 and R62 sitting in a wheelchair inside a room with no wheelchair pressure relieving cushion in place to R4 and R28's wheelchairs. When V11 was questioned regarding no pressure relieving cushion for (R4, R24, R28, and R62's) wheelchairs V11 stated, I don't know. I will bring it (referring to the residents who were observed with no wheelchair pressure relieving cushions to the residents' wheelchairs) to their (referring to V1 (Administrator) and V2 (Director of Nursing, DON) attention that no one (referring to R4, R24, R28 and R62) has a wheelchair cushion.
On 05/04/22 at 12:46 pm, V9 (Nurse Consultant) was interviewed regarding pressure relieving wheelchair cushions and V9 stated that wheelchair cushions are used for pressure ulcer prevention and every resident using a wheelchair should have a wheelchair cushion. V9 also stated that if a resident does not have a wheelchair cushion, they can develop skin alterations from sitting in a wheelchair without a wheelchair cushion. V9 explained that the nurses on the floor are responsible for making sure that every resident who uses a wheelchair has a wheelchair pressure relieving cushion.
R4's Minimum Data Set (MDS), dated [DATE], documents, in part, that R4's Brief Interview for Mental Status (BIMS) score is a 03 which indicates that R4 has a cognitive impairment.
R24's Minimum Data Set (MDS), dated [DATE], documents, in part, that R24's Brief Interview for Mental Status (BIMS) score is a 99 which indicates that R24 was unable to complete the interview.
R28's Minimum Data Set (MDS), dated [DATE], documents, in part, that R28's Brief Interview for Mental Status (BIMS) score is a 04 which indicates that R28 has a cognitive impairment.
R62's Minimum Data Set (MDS), dated [DATE], documents, in part, that R62's Brief Interview for Mental Status (BIMS) score is a 09 which indicates that R62 has moderate cognitive impairment.
Residents care plan documents, in part: Interventions: Pressure reduction sitting/wheelchair surface for:
R4's care plan initiated dated 07/08/2016.
R24's care plan initiated dated 07/12/2016.
Residents care plan documents, in part: Interventions: Pressure reduction support on wheelchair for:
R28's care plan initiated dated 11/01/17.
R62's care plan initiated dated 08/20/18.
R4's Pressure Ulcer Risk assessment dated [DATE] documents a score of 17 indicating that R4 is at mild risk for developing a pressure ulcer.
R24's Pressure Ulcer Risk assessment dated [DATE] documents a score of 14 indicating that R24 is at moderate risk for developing a pressure ulcer.
R28's Pressure Ulcer Risk assessment dated [DATE] documents a score of 16 indicating that R28 is at mild risk for developing a pressure ulcer.
R62's Pressure Ulcer Risk assessment dated [DATE] documents a score of 18 indicating that R62 is at mild risk for developing a pressure ulcer.
Facility's document dated 03/02/01 titled Prevention and treatment of pressure injury and other skin alterations documents, in part: Policy: 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a smoking risk assessment quarterly for a smoking resident which affected one (R64) resident reviewed for smoking in the sample of 45 residents.
Findings include:
Facility undated document, titled (Facility) Smoking Hours, Areas, Residents, documents, in part, Residents Who Smoke: . (R64).
On 5/3/22 at 9:29 am, this surveyor requested from V1 (Administrator), V2 (Director of Nursing, DON) and V9 (Nurse Consultant) for R64's last three smoking risk assessments. R64's most current smoking risk assessment was dated 7/12/21.
On 5/4/22 at 11:52 am, V23 (Social Services Director) stated that V23 is assigned to the residents on R64's floor in the facility. V23 stated that V23 performs MDS assessments for social services assessments which are done on admission, quarterly and annually. When asked who is responsible for performing the smoking risk assessment for residents, and V23 stated, Nursing.
On 5/4/22 at 12:47 pm, V9 (Nurse Consultant) stated that smoking risk assessments are done by social services staff.
R64's document, dated 7/12/21 and titled, SSD (Social Services Director) . Smoking Risk Assessment - Initial, Annual, Sig (Significant) Chg (Change)/PRN (Whenever Needed), documents, in part, that R64 smokes cigarettes and for risk factors such as High-Risk Behaviors: Leaves smoking materials behind; litters cigarette butts and/or matches onto the ground; drops onto self/others; burns finger tips; attempts to light things on fire; smokes near oxygen, R64 is assessed as an unsafe smoker.
R64's Minimum Data Set (MDS), dated [DATE], Section C, documents, in part, a Brief Interview of Mental Status (BIMS) score of 9 which indicates that R64 has moderate cognitive impairment. R64's MDS, Section J, documents, in part, a code of Yes for current tobacco use.
R64's Care Plan, dated 6/5/2015, documents, in part, a focus of (R64) is assessed to be a non-safe smoker. (R64) has a history of dropping lit cigarettes/ash on (R64's) self and not following the facility's smoking schedule (attempting to smoke during non-smoking hours) with an intervention of Monitor (R64) for adherence to smoking guidelines.
Facility policy dated 11/2017 and titled, Smoking Assessment and Safety Protocol (Formally Smoking At Risk Program), documents, in part, A. Policy: (Facility) strives to maintain the dignity and respect of residents at all times, while ensuring their safety throughout their stay . B. Procedure: . 2. Smokers will be evaluated by a designated inter-disciplinary team member at admission (within 24 hours), quarterly and annually, as well as if unsafe smoking behaviors/cognitive decline that affects smoking behaviors occur, to determine their ability to comply with safety rules . b. 'Unsafe Smokers' are those residents who have been assessed to be potentially unsafe or careless while smoking or have a severe cognitive deficit.
Facility job description dated 1/2015 and titled, Social Service Director, documents, in part, I. Job Summary: Responsible for performing assigned social work duties and responsibilities within the facility. Plan, develop, organize, oversee and run the overall operation of the Social Service Department in accordance with current (Facility) policies and procedures, federal, state and local standards, guidelines and regulations . IV. Essential Functions: . M. Conduct, oversee, and complete initial and all on-going assessments and MDS, and CAAs (Care Area Assessments) . N. Completing assigned sections of the MDS and CAAs and completing the comprehensive set of social services assessments to be completed . re-evaluation of the resident on a quarterly basis.