Every finding on record at Aliya of Evanston

Based on interview, and record review, the facility failed to provide appropriate treatment and services for an indwelling urinary catheter for one resident (R1), resulting in a 4-hour period without nursing assessment or intervention when the catheter was not draining urine, leading to bladder distention and a traumatic bleeding insertion site injury that required immediate hospitalization. Findings include: R1 is a [AGE] year-old resident with a Brief Interview for Mental Status (BIMS) score of 15/15, and medical diagnosis including but not limited to paraplegia, complete; encounter for fitting and adjustment of urinary device; cystitis, unspecified with hematuria; hydronephrosis with ureteropelvic junction obstruction; acute kidney failure, unspecified; and calculus of kidney with calculus of ureter.On 02/18/2026 at 1:00 PM, R2 said R1 called him from the hospital one night when he was asleep and said V3 (LPN), a nurse from another floor, went to his room to change his catheter because his own nurse, V4 (RN), refused to do it. R2 said R1 told him after V4 refused to change his catheter, V3 took over an hour to change it, used the wrong catheter, and blood came out.On 02/19/2026 at 11:15 AM, R1 said on 02/04/2026, he requested a new catheter because his urine was overflowing. R1 said at about 11:45 PM, V3- LPN (Licensed Practical Nurse) inserted a new catheter, and V4-RN (Registered Nurse) gave him no explanation why she could not do it. R1 said no urine came out, R1 then asked V3 if it was put in correctly, to which V3 replied, yeah, give it some time, just drink water. R1 said at 12:20 AM, he still had no urine output; so, he pushed his call light for help, but no one responded. R1 said at 12:27 AM, he called the building phone number, which rung at the nurse's stations after-hours, but no one answered. R1 said at 12:31 AM, he called the building line for a second time, and V3 answered, and asked R1 to give him 25 minutes and he'd be there. R1 said at 2:02 AM, he called the building line a third time, and no nurse answered, however, V3 arrived in R1's room and said, I'm sorry, I fell asleep. R1 said at 2:54 AM, he called the building line a fourth time, then heard V3 and V4 discussing in the hallway who would, fix the problem. R1 said V3 said to him, let's make her (V4) do her job. R1 said V4, then, entered his room, deflated his catheter's balloon, and blood gushed into and on top of the catheter bag. R1 said, it was like I was urinating blood, and added V4 got startled and called V3 back into his room. R1 said at about 3:27 AM, he called the building line a fifth time because blood had gushed into the catheter bag, all over the sheets, on his diaper, and all over him. R1 said when V3 saw him, he said, oh wow, then heard him tell V4 in the hallway, it wasn't bleeding when I left; call the DON. R1 said both nurses then reentered his room, and he told them not to touch him but to call the ambulance. R1 said paramedics arrived after he called 911, and said to him, let's hurry up and get you out of here; let's get your vitals in the car; let's go now. This Surveyor asked R1 how he obtained such precise phone call times, and R1 said they were all recorded on his cell phone.On 02/24/2026 at 2:25 PM, V3-LPN said on 02/04/2026 he was working on his own floor at night, and super busy, when he was asked by V4 to insert an indwelling catheter for R1 on V4's floor.On 02/24/2026 at 11:36 AM, V7 (CNA) said that on 02/04/2026 he had been doing his rounds, when R1 pushed his call light; so, he went to R1's room at about 11:00 PM; then, R1 told him he wanted to see V4. V7 said he told V4 about it, and she went to his room, then came back out.In separate interviews on 02/19/2026 at 11:42 AM and 02/24/2026 at 10:42 AM, V1 (Administrator) said she was not aware of the severity of R1's injury until reading R1's hospital diagnosis of traumatic urethral bleeding during a clinical meeting. V1 said R1 called 911 himself on 02/05/2026. V1 said she asked V4 if R1's indwelling catheter was out the morning of 02/05/2026, and she said she could not get in to see because there were a lot of paramedics in R1's room, but when R1 was placed on the gurney, she did see blood in the catheter line. V1 said she asked V4 why she had not told anyone about the severity of R1's event, and V4 replied, you don't know he does this? V1 said she didn't know V4's mindset and did not feel V4 thought R1's event of 02/05/2026 was an emergent situation. V1 said V4 resigned a few days later.On 02/24/2026 at 4:53 PM, V9 (Nurse Practitioner) said she believed R1's new indwelling catheter was inserted, but not all the way in and in the wrong place, by V3, on 02/04/2025. V9 said there were no nursing progress notes by either V3 or V4 detailing what happened to R1 on 02/04/2026 and 02/05/2026 between 11:30 PM and 3:00 AM, which could have provided essential information of R1's care that night and morning.On 02/18/2026 at 2:09 PM, V2 (Director of Nursing) said on the morning of 02/05/2026, she got a call from the nurse on duty, V4, saying R1 called 911, and we (along with V3) reinserted his catheter. V2 said the next day, she gave V3 a re-competency to make sure he knew how to insert a catheter. V2 said V4 was not available, so she did not re-competency her. V2 said she was not sure what caused R1's bleeding. V2 said V4 told her she told V3 she was not comfortable with male catheters; so, she asked him for help. V2 said R1's diagnosis from the hospital said urethral bleeding. V2 said V3 and V4 should have documented the event better than they did.On 02/24/2026 at 5:33 PM, V10 (Medical Director) said V3 and V4 should have documented R1's catheter care on 02/04/2026 and 02/05/2026 because, if you're going to be accused of something, it's a good idea to document.On 12/19/2026 at 11:30 AM, Surveyor reviewed video footage R1 shared on his cellphone and claimed he took the morning of 02/05/2026, as soon as V4 had deflated his catheter balloon and had stepped out to get V3. The video, lasting about sixteen seconds, was recorded from the perspective of a person lying down on a bed, and displayed blood on the person's diaper and significant blood inside a catheter bag and tubing.On 02/24/2026 at 9:21 AM, Surveyor called V4 but there was no answer. A voicemail message was left, with no reply.R1's hospital progress notes by V11 (Attending Radiologist) on 02/05/2026 at 7:45 AM, contained the following remarks:1. CT scan results 02/05/2026: Patient (R1) presenting with traumatic indwelling catheter insertion at SNF, bleeding continuously in ED, with CT abdomen/pelvis with contrast showing indwelling catheter balloon inflated in the bulbar urethra with free air and extravasation consistent with active bleeding. A large amount of blood is also present in the urinary bladder which is distended. The bladder also contains air, presumably related to indwelling catheter placement.2. Hgb (Hemoglobin) dropped from 13.2 to 6.5.3. Patient became hemodynamically unstable with hypotension and tachycardia consistent with hemorrhagic vs. less likely septic shock, initially not fluid responsive, temporarily required Levo and ICU admission.R1's entire nursing progress notes documenting R1's catheter care of 02/04/2026 and 02/05/2026 were as follows:1. Progress Note, 02/05/2026 4:19 AM, V4: R1 sent out to hospital for indwelling catheter reinsertion.2. Progress Note, 02/05/2026 11:12 AM, V12 (LPN): R1 sent to hospital via 911 by self.3. Progress Note, 02/05/2026 7:29 PM, V13 (LPN): hospitalized .4. Progress Note, 02/05/2026 7:30 PM, V12: Writer called hospital. R1 is admitted for Traumatic Urethral Bleeding.Reviewed R1's electronic medical health record, including progress notes. No documentation of R1 having ever removed his own indwelling urinary catheter was found.R1's care plan, dated 12/18/2025, included the following interventions: Catheter monitoring and care as ordered; monitor and document intake and output as per facility policy; monitor for signs/symptoms of discomfort on urination and frequency; monitor/document for pain/discomfort due to catheter; and 10/08/2025 R1 was transferred to hospital due to hematuria on urine; returned to facility with stent placement.Reviewed R1's active medication orders, noting one anticoagulant medication, Enoxaparin Sodium, which R1 was prescribed to prevent blood clots.Reviewed a progress note from 10/08/2025 by V14 (Nurse): R1's indwelling catheter was changed, no urine drainage into bag, blood observed draining, catheter was removed, bleeding stopped, peri care complemented for resident, advice to wait few minutes before insertion of catheter again, but resident called 911 to be sent out. At 1:53 AM, medics arrived (5), transported resident to hospital, face sheet taken along with them. At 2:00 AM, POA notified via a phone call. DON notified via a text message.The facility's Catheterization of the Urinary Bladder Guideline, last reviewed 05/01/2025, states in part, chart in the progress notes the size, procedure, urine color, amount, consistency, odor and resident response, and if the output for the shift is less than 200cc, the nurse should check the catheter for any kinks or leaks. If this is not the problem the physician or nurse practitioner should be notified of the low output.

Based on interview, and record review, the facility failed to ensure nursing staff possessed and demonstrated the competencies necessary to timely recognize, assess, and respond to a resident's acute change in condition and urgent call for help. This resulted in actual harm (significant bleeding requiring emergency hospitalization) for one resident (R1) who experienced a traumatic complication from an indwelling catheter insertion. R1 is a [AGE] year-old resident with a Brief Interview for Mental Status (BIMS) score of 15/15, and medical diagnosis including but not limited to paraplegia, complete; encounter for fitting and adjustment of urinary device; cystitis, unspecified with hematuria; hydronephrosis with ureteropelvic junction obstruction; acute kidney failure, unspecified; and calculus of kidney with calculus of ureter.On 02/18/2026 at 1:00 PM, R2 said R1 called him from the hospital one night when he was asleep and said V3 (LPN), a nurse from another floor, went to his room to change his catheter because his own nurse, V4 (RN), refused to do it. R2 said R1 told him after V4 refused to change his catheter, V3 took over an hour to change it, used the wrong catheter, and blood came out.On 02/19/2026 at 11:15 AM, R1 said on 02/04/2026, he requested a new catheter because his urine was overflowing. R1 said at about 11:45 PM, V3 inserted a new catheter, and V4 gave him no explanation why she could not do it. R1 said no urine came out, then asked V3 if it was put in correctly, to which V3 replied, yeah, give it some time, just drink water. R1 said at 12:20 AM, he still had no urine output; so, he pushed his call light for help, but no one responded. R1 said at 12:27 AM, he called the building phone number, which rung at the nurse's stations after-hours, but no one answered. R1 said at 12:31 AM, he called the building line for a second time, and V3 answered, and asked R1 to give him 25 minutes and he'd be there. R1 said at 2:02 AM, he called the building line a third time, and no nurse answered, however, V3 arrived in R1's room and said, I'm sorry, I fell asleep. R1 said at 2:54 AM, he called the building line a fourth time, then heard V3 and V4 discussing in the hallway who would, fix the problem. R1 said V3 said to him, let's make her (V4) do her job. R1 said V4, then, entered his room, deflated his catheter's balloon, and blood gushed into and on top of the catheter bag. R1 said, it was like I was urinating blood, and added V4 got startled and called V3 back into his room. R1 said at about 3:27 AM, he called the building line a fifth time because blood had gushed into the catheter bag, all over the sheets, on his diaper, and all over him. R1 said when V3 saw him, he said, oh wow, then heard him tell V4 in the hallway, it wasn't bleeding when I left; call the DON. R1 said both nurses then reentered his room, and he told them not to touch him but to call the ambulance. R1 said paramedics arrived after he called 911, and said to him, let's hurry up and get you out of here; let's get your vitals in the car; let's go now. This Surveyor asked R1 how he obtained such precise phone call times, and R1 said they were all recorded on his cell phone.On 02/24/2026 at 2:25 PM, V3 said on 02/04/2026 he was working on his own floor at night, and super busy, when he was asked by V4 to insert an indwelling catheter for R1 on V4's floor.On 02/24/2026 at 11:36 AM, V7 (CNA) said that on 02/04/2026 he had been doing his rounds, when R1 pushed his call light; so, he went to R1's room at about 11:00 PM; then, R1 told him he wanted to see V4. V7 said he told V4 about it, and she went to his room, then came back out.In separate interviews on 02/19/2026 at 11:42 AM and 02/24/2026 at 10:42 AM, V1 (Administrator) said she was not aware of the severity of R1's injury until reading R1's hospital diagnosis of traumatic urethral bleeding during a clinical meeting. V1 said R1 called 911 himself on 02/05/2026. V1 said she asked V4 if R1's indwelling catheter was out the morning of 02/05/2026, and she said she could not get in to see because there were a lot of paramedics in R1's room, but when R1 was placed on the gurney, she did see blood in the catheter line. V1 said she asked V4 why she had not told anyone about the severity of R1's event and V4 replied, you don't know he does this? V1 said she didn't know V4's mindset and did not feel V4 thought R1's event of 02/05/2026 was an emergent situation. V1 said V4 resigned a few days later.On 02/24/2026 at 4:53 PM, V9 (Nurse Practitioner) said she believed R1's new indwelling catheter was inserted, but not all the way in and in the wrong place, by V3, on 02/04/2025. V9 said there were no nursing progress notes by either V3 or V4 detailing what happened to R1 on 02/04/2026 and 02/05/2026 between 11:30 PM and 3:00 AM, which could have provided essential information of R1's care that night and morning.On 02/18/2026 at 2:09 PM, V2 (Director of Nursing) said on the morning of 02/05/2026, she got a call from the nurse on duty, V4, saying R1 called 911, and we (along with V3) reinserted his catheter. V2 said the next day, she gave V3 a re-competency to make sure he knew how to insert a catheter. V2 said V4 was not available, so she did not re-competency her. V2 said she was not sure what caused R1's bleeding. V2 said V4 told her she told V3 she was not comfortable with male catheters; so, she asked him for help. V2 said R1's diagnosis from the hospital said urethral bleeding. V2 said V3 and V4 should have documented the event better than they did.On 02/24/2026 at 5:33 PM, V10 (Medical Director) said V3 and V4 should have documented R1's catheter care on 02/04/2026 and 02/05/2026 because, if you're going to be accused of something, it's a good idea to document.On 12/19/2026 at 11:30 AM, Surveyor reviewed video footage R1 shared on his cellphone and claimed he took the morning of 02/05/2026, as soon as V4 had deflated his catheter balloon and had stepped out to get V3. The video, lasting about sixteen seconds, was recorded from the perspective of a person lying down on a bed, and displayed blood on the person's diaper and significant blood inside a catheter bag and tubing.On 02/24/2026 at 9:21 AM, Surveyor called V4 but there was no answer. A voicemail message was left, with no reply.R1's hospital progress notes by V11 (Attending Radiologist) on 02/05/2026 at 7:45 AM, contained the following remarks:1. CT scan results 02/05/2026: Patient (R1) presenting with traumatic indwelling catheter insertion at SNF, bleeding continuously in ED, with CT abdomen/pelvis with contrast showing indwelling catheter balloon inflated in the bulbar urethra with free air and extravasation consistent with active bleeding. A large amount of blood is also present in the urinary bladder which is distended. The bladder also contains air, presumably related to indwelling catheter placement.2. Hgb (Hemoglobin) dropped from 13.2 to 6.5.3. Patient became hemodynamically unstable with hypotension and tachycardia consistent with hemorrhagic vs. less likely septic shock, initially not fluid responsive, temporarily required Levo and ICU admission.R1's entire nursing progress notes documenting R1's catheter care of 02/04/2026 and 02/05/2026 were as follows:1. Progress Note, 02/05/2026 4:19 AM, V4: R1 sent out to hospital for indwelling catheter reinsertion.2. Progress Note, 02/05/2026 11:12 AM, V12 (LPN): R1 sent to hospital via 911 by self.3. Progress Note, 02/05/2026 7:29 PM, V13 (LPN): hospitalized .4. Progress Note, 02/05/2026 7:30 PM, V12: Writer called hospital. R1 is admitted for Traumatic Urethral Bleeding.Reviewed R1's electronic medical health record, including progress notes. No documentation of R1 having ever removed his own indwelling urinary catheter was found.R1's care plan, dated 12/18/2025, included the following interventions: Catheter monitoring and care as ordered; monitor and document intake and output as per facility policy; monitor for signs/symptoms of discomfort on urination and frequency; monitor/document for pain/discomfort due to catheter; and 10/08/2025 R1 was transferred to hospital due to hematuria on urine; returned to facility with stent placement.Reviewed R1's active medication orders, noting one anticoagulant medication, Enoxaparin Sodium, which R1 was prescribed to prevent blood clots.Reviewed a progress note from 10/08/2025 by V14 (Nurse): R1's indwelling catheter was changed, no urine drainage into bag, blood observed draining, catheter was removed, bleeding stopped, peri care complemented for resident, advice to wait few minutes before insertion of catheter again, but resident called 911 to be sent out. At 1:53 AM, medics arrived (5), transported resident to hospital, face sheet taken along with them. At 2:00 AM, POA notified via a phone call. DON notified via a text message.The facility's Catheterization of the Urinary Bladder Guideline, last reviewed 05/01/2025, states in part, chart in the progress notes the size, procedure, urine color, amount, consistency, odor and resident response, and if the output for the shift is less than 200cc, the nurse should check the catheter for any kinks or leaks. If this is not the problem the physician or nurse practitioner should be notified of the low output.

Based on interview, and record review, the facility failed to follow its Residents Rights Policy by not ensuring the resident felt safe in the facility. This deficient practice affected one resident (R3) out of three residents reviewed for Resident Rights within a total sample of 3 residents.R3 is a [AGE] year-old male admitted to the facility on [DATE]. R3s medical diagnosis on the admission record are, but are not limited to, other cervical disc degeneration at C5-C6, mild intermittent asthma, type 2 diabetes mellitus, disorders of urethra, acute kidney failure, hypertension, hyperlipidemia, dementia with other behavioral disturbances, bipolar disorder with psychotic features, alcohol abuse, depression, and adult failure to thrive.On 12/31/2025 at 11:05AM, R3 was observed in his room, sitting upright in his room. R3 states R3 usually receives his scheduled morning medications around 8:00AM-9:00AM. R3 states on Christmas day 12/25/2025 he had his breakfast and had not received his scheduled morning medication. R3 stated the CNA was being rude to R3 because he voiced his concerns about there not being a second-floor nurse and not receiving his medications. R3 stated he didn't feel safe and felt abandon in the facility on Christmas Day. R3 stated he was worried because R3 did not have a nurse until way after breakfast and had not received his medication.On 12/30/2025 at 1:45 PM V1 (Director of Nursing/ DON) stated she will have an on-Customer Service.On 12/31/2025 at 9:47 V5 (Staffing Director/ Certified Nurses Assistant/ CNA) stated they have in service on customer service, respect the patient's rights.On 12/31/2025 at 11:04AM, V8 (Admissions Director) stated, we had an in-service regarding customer service. On 12/31/2025 at 12:15PM V7 (Administrator) stated she has disciplined a lot of staff regarding customer service and some staff have been dismissed.The Resident Rights Policy provided by the facility was reviewed and documents your rights to safety: you must not be abused, neglected

Based on interview and record review, the facility failed to follow their policy and procedure and offer pneumococcal vaccinations to new residents within seven days. This failure applied to four (R16, R25, R32, and R45) of six residents reviewed for vaccinations.Findings include:R16 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R16 has multiple diagnoses including but not limited to the following: cerebral infarction, type II DM, obesity, epilepsy, sleep apnea, and acute kidney failure.R25 is an [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R25 has multiple diagnoses including but not limited to the following: rhabdomyolysis, protein calorie malnutrition, HTN, cellulitis, CAD, and depression.R32 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R32 has multiple diagnoses including but not limited to the following: muscle disorder, gait and mobility abnormalities, lack of coordination, intracerebral hemorrhage, HTN, hemiplegia, dysphagia, and anxiety.R45 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R37 has multiple diagnoses including but not limited to the following: venous insufficiency, gait and mobility abnormalities, protein calorie malnutrition, acute respiratory failure, Type II DM, and COPD.R16, R25, R32, and R45's Immunization Report shows no pneumococcal vaccine was offered or given since admission.On 11/19/2025 at 1:32PM, V12 (Infection Preventionist) said we do not offer the pneumococcal vaccine to new admissions immediately upon entering our facility. Our process is to offer them at a scheduled clinic at a later date. I have been in this role for about six months and since then we have not had a vaccine clinic. We have our first vaccine clinic in about two weeks, and we will offer multiple vaccinations, including pneumococcal.Facility policy titled Pneumococcal Vaccinations with review date of 1/6/2025 states in part but not limited to the following: 1. All current residents or the resident's responsible party will be screened and offered the pneumonia vaccine within the first week of admission and annually, if eligible.

Based on interview and record review, the facility failed to follow its policy to inform and obtain consents prior to the administration of psychotropic medication for two residents (R4 and R42) reviewed for psychotropic medication.Findings include:R4 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R4 has multiple diagnoses including but not limited to the following: type II DM, cellulitis of face, multiple fractures, sleep apnea, hyperlipidemia, sciatica, alcohol abuse, schizoaffective disorder, and cocaine abuse.Per Physician Order Summary Report, R4 started Quetiapine Fumarate (Antipsychotic) on 10/8/2025 and continues to receive medication. Per Psych: Consent for Antipsychotics was signed and dated 10/15/2025. It is to be noted that R4 received an antipsychotic medication for seven days before consenting to the medication.R42 is an [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R42 has multiple diagnoses including but not limited to the following: toxic encephalopathy, dysphagia, cognitive communication deficit, need for assistance with personal care, multiple fractures, paranoid schizophrenia, and dementia.Per Physician Order Summary Report, R42 started Clozapine on 9/9/2025 and continues to receive medication. Per Psych: Consent for Antipsychotics was signed and dated 9/17/2025. It is to be noted that R42 received an antipsychotic medication for eight days before consenting to the medication.On 11/19/2025 at 12:15PM, V2 (Interim Director of Nursing) said orders for psychotropic medications should not be put in prior to obtaining a consent. I obtained the consent for R4 and R42 at their care plan meeting, which is usually held 3-7 days after admission.Facility policy titled Psychotropic Medication Program with review date of 1/2025 states in part but not limited to the following: The purpose of this policy is to ensure the resident and/or resident representative are aware of the potential side effects and the facility obtains an informed consent for the use of psychotropic medications. If a new order for psychotropic medication is obtained, the resident or representative must be informed of the risks and benefits of the medication. The facility must obtain informed consent. Once consent is obtained, the order will be entered into the medical record.

Based on observation, interview, and record review, the facility failed to administer medications as ordered and follow the manufacturer's instructions for use. There were 25 opportunities with four errors resulting in a 16% (percent) error rate. This failure applied to two (R18 and R29) of four residents observed during medication administration.Findings include:R18 is an [AGE] year-old, female, admitted in the facility on 06/08/23 with diagnoses of Bilateral Primary Osteoarthritis, Other Asthma, and Essential Hypertension. R18's POS (Physician Order Sheet) documented:06/08/23: Advair Diskus Aerosol Powder Breath Activated 250-50 mcg/dose (microgram per dose) (Fluticasone-salmeterol) 1 (one) inhalation inhale orally every 12 hours.12/03/23: Spironolactone tablet 50 mg (milligram) give 1 tablet by mouth one time a day.08/12/25: Voltaren Gel 1% (percent) (Diclofenac Sodium) apply to both knees and feet topically two times a day for pain 2 (two) gram dose. On 11/17/25 at 10:50 AM, V11 (Registered Nurse, RN) was observed passing medication on R18. It was observed that Advair Diskus was not administered. V11 stated he already administered it and showed surveyor the inhaler. The inhaler that was shown to surveyor was the Incruse Ellipta and not the Advair Diskus. In the MAR (medication administration record), V11 signed Advair as given but did not actually give during medication pass. Spironolactone was also not given because the medication was not available during medication pass. V11 stated Spironolactone was ordered last 09/25/25 and still waiting to be delivered to facility. At 11:43 AM, V11 is about to administer the Voltaren Gel on R18. V11 donned gloves, took the Voltaren Gel and squeezed an ample amount to gloved hand and rubbed the gel onto R18's right knee. Subsequently, he (V11) again squeezed a desirable amount to his gloved hand and rubbed it on her (R18) left knee. Voltraren Gel was not applied to R18's feet as ordered. Also, the amount applied on R18's knees did not indicate a 2 gram dose as ordered. R29 is a [AGE] year-old, male, admitted in the facility on 04/17/23 with diagnoses of Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery and Type 2 Diabetes Mellitus with Hyperglycemia.R29's POS dated 10/24/24 documented: Insulin Lispro Injection Solution 100unit/ml (unit per milliliter) inject 4 (four) units subcutaneously (SQ) with meals for hyperglycemia AND inject as per sliding scale: if 150-199 =2; 200-249 = 3; 250-299 = 4; 300-349 = 5. Call MD (Medical Doctor) if >350 mg/dl (milligram per deciliter), subcutaneously with meals for hyperglycemia. On 11/17/25 at 12:00 PM, V6 (RN) was observed administering Insulin Lispro 2 units on R29. V6 stated that only 2 units should be given to R29 because his blood sugar level was 167, and per sliding scale, only 2 units will be given. V6 was asked regarding the Insulin Lispro 4 units SQ with meals as standing order. V6 replied, I only give the 2 units, I just followed the sliding scale order, and not the other order of 4 units. The 4 units is just a reminder of the sliding scale order. They actually go together. Review of progress notes showed no documentation related to Insulin Lispro 4 units as to why it was not given. R29's care plan regarding diagnosis of Diabetes Mellitus insulin dependent recorded:Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. On 11/18/25 at 3:04 PM, V2 (RN/Interim Director of Nursing) was asked regarding administration of Voltaren Gel and insulin orders. V2 replied, For the Voltaren Gel, we have this card dose where we put the gel for the ordered dose. If it's for knees and feet, that will be two grams per application. For insulin orders, if there is a standing order for 4 units and sliding scale of let's say 2 units, the two units should be given along with the 4 units. Nurse should follow the orders. V2 was also asked regarding medications not given. V2 stated, When we give the medication, we sign. If the medication is not available at the time of administration, we document in the MAR that it was not given. Then we call the doctor and document any orders. Facility's policy titled Medication Administration dated 3/2025 stated in part but not limited to the following:General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline:1. An order is required for administration of all medication. 7. Read each order entirely. 13. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. 14. Prepare or pour each dose of medication using an appropriate measuring device. 22. If medication is not given as ordered, document the reason on the MAR and notify the Health Care provider if required. Manufacturer's guidelines in dosage and administration of Voltaren Gel, dated July, 2009 documented in part but not limited to the following:2. Dosage and administration2.1 Dosing cardThe proper amount of Voltaren Gel should be measured using the dosing card supplied in the drug product carton. The dosing card is made of polypropylene, like the tube cap containing Voltaren Gel, but without the white colorant. The dosing card should be used for each application of drug product. The gel should be applied within the oblong area of the dosing card up to the 2 gram or 4 gram line (2 g for each elbow, wrist, or hand, and 4 g for each knee, ankle or foot). The dosing card containing Voltaren Gel can be used to apply the gel. The hands should then be used to gently rub the gel into the skin. After using the dosing card, hold with fingertips, rinse and dry. If treatment site is the hands, patients should wait at least one (1) hour to wash their hands. Patient Instructions for UseApplying Voltaren Gel to knees, ankles, and feet:2.To measure the right amount of Voltaren Gel, place the dosing card on a flat surface so that you can read the print. If the print is backwards, flip dosing card over.3.Squeeze Voltaren Gel onto the dosing card evenly up to the 4 gram line, making sure the gel covers the entire 4 gram area of the dosing card.4.Apply the Voltaren Gel to your foot, ankle or knee. You can use the dosing card to apply the gel. The hands should be used to gently rub the gel into the skin. Do not share the dosing card with another person.Make sure to cover your entire foot, ankle or knee area with the gel. For example, cover the skin above, below, inside and outside the knee cap. Remember that the foot includes the sole of your foot, the top of your foot and your toes.

Based on interview and record review the facility failed to follow discharges policy and change in resident condition policy by not informing the resident in advance of planned hospital transfer (Involuntary Petition), failed to obtain a physicians order for a transfer and failed to document the transfer in the medical record. This failure affects one resident (R1) of three residents reviewed for resident rights. Finding Include: R1 was admitted in the facility on 10/30/24. A [AGE] year old male resident with a BIMS of 15/15. R1 has diagnoses of but not limited to osteoarthritis of Right hip, Type 2 Diabetes, Morbid obesity, and Nicotine Dependence. R1 has a BIMS of 15 (Intact Cognition). On 5/6/25 at 11:32AM, R1 reported that he was sent out last April at 3:30AM, R1 stated he was sound asleep in his room when this night nurse woke him up and said he is going to the hospital. He refused to go because no one told him why he was being transferred to a hospital. R1 reported calling 911 because he wanted the police to get involve and have everything on the record. The police came and explained to him that he is being transferred for a psych evaluation and that R1 can return. R1 changed his mind and ended up going to the hospital. And stated that there was nothing wrong with him and that he was sent right back to the facility. Nursing Progress Note dated 4/13/25 at 3:29AM reads in part: EMS arrived at 2:49am and proceeded to R1's room. They tried convincing R1 to go with them for which R1 blatantly refused. R1 himself went ahead and called 911 and stated that R1 is about to be taken out against R1's own will. The cops called the nurse's station and writer explained the situation to them. They asked if they could come over to help move him out, writer responded in the affirmative. The cops arrived at 3:20am and told R1 that he will have to be restrained if he did not comply. After much talking and convincing, he eventually dressed up and left at 4am this morning. On 5/6/25 at 1PM V1 stated that she received a call on Saturday (4/12/25) afternoon from her Manager on duty and V6 (Receptionist) stating that R1 was verbally aggressive towards other residents in the dining area. V1 stated we followed our protocol, investigated and reported the incident to IDPH (Illinois of Department Health). The Nurse and the Social worker informed the resident, it's just that they forgot to document. On 5/6/25 at 3:45PM V6 (Receptionist) stated that the restorative nurse told V6 that R1 was verbally aggressive towards her and other residents. V6 called V1 (Administrator) and as V6 made V1 aware of the situation, R1 was still aggressive at the time and V1 can even hear R1 in the background when V6 was giving report to V1. V1 said V1 will email V6 the petition. V6 received the petition and gave it to the nurse (V3) before 6pm, R1 was already on one to one monitoring with V3 in the dining room. On 5/6/25 at 12:30PM, V2 (Director of Nursing) stated that their process is that resident's with behaviors, social services will assess the resident and have a talk with the administrator and decide if an involuntary petition is necessary. We'll then get an order from the doctor to send the resident out for evaluation. The nurse is to inform the resident and POA (Power of Attorney) or the responsible party and document in resident's chart. Behaviors shall be documented in the chart also. On 5/6/25 at 2:30PM V3 stated that she called the doctor and received an order to send the resident out via involuntary petition, V3 informed R1 but states I just forgot to document. Facility Reported Incident dated 4/12/25, reads in part: Allegedly R1 made inappropriate statements toward 2 residents. Summary of investigation: on 4/12/25, following scheduled activities, R1 and 2 other residents stayed in the day room waiting for smoke break. The three residents were having conversations about economy and the cost of different items. The discussion became intense between the residents, R1 began to use vulgar language while speaking to the other residents. R1 became verbally aggressive to staff members. Staff immediately separated the other residents from the day room. R1 was placed in 1:1 with staff until transportation arrived. CNA stated we walked in to see what was going on, and R1 just attacked me. Resident interview stated it was a intense conversation but then he just started yelling. Activity Aide interviewed stated that she was in the day room the entire time, R1 became angry at the incoming staff. Resident's Involuntary Petition dated 4/12/25, V6 signed the form, V3 signed as the witness. There was no signature for R1, also the form reads in part: sister was informed and that R1 is experiencing an increase in symptoms. R1 is becoming agitated and verbally aggressive with peers and staff. R1 is difficult to direct. R1 poses a threat to self and others in the facility. On 5/7/25 at 10:30AM, V5 (SSD) stated that R1 does not have a POA (Power of Attorney). R1 is responsible to self. R1 has one emergency contact but not listed as a POA. Reviewed of Progress Note (April 2025) and there is no documentation in R1's chart with any behavior, nor contacting the doctor and getting an order to send the resident out to the hospital. Facility unable to provide nurse's documentation regarding doctor's order and informing R1 of the hospital transfer. Discharge Policy with a review date of 1/2025, reads in part: To establish a plan on how to discharge a resident from the facility to home, another facility or the hospital. Hospital Transfer: notify the physician regarding a change in resident status and obtain an order for transfer to the hospital. This maybe direct admit or an emergency room admission. Inform the resident and resident's responsible party of the transfer. Document in Progress Notes that condition of the resident, who was notified of the transfer, where the resident is going, mode of transportation, disposition of resident belongings and medications, notification to all parties of the discharge. Change in Resident Condition Policy with a review date of 1/2025, reads in part: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. POLICY: Nursing will notify the resident's physician or nurse practitioner when: There is a significant change in the resident's physical, mental or emotional. It is deemed necessary or appropriate in the best interest of the resident. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents. Facility provided Resident Rights Booklet, reads in part: As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to participate in your own care. You may be informed, in advance of changes to the plan of care.

Based on interview and record review, the facility failed to prevent and protect a resident from resident-to-resident verbal abuse. This failure affected two (R1, R2) of five residents reviewed for abuse. Findings include: Facility reported incident (FRI) dated 3/29/2025 documents: During activities, R1 made inappropriate comments about R2. R1 [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: sleep apnea, obesity, diabetes, hypertension, and Congestive heart failure. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 15, which suggests R1 is cognitively intact. R2 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to fibromyalgia, chronic obstructive pulmonary disease, obesity, and diabetes. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 has a Brief Interview for Mental Status (BIMS) score of 15, which suggests that R2 is cognitively intact. On 3/29/2025 at 3:55 PM during smoking activities R1 and R2 made inappropriate comments to each other. R2 could no longer deal with name-calling and became very upset. R1 called R2 names referring to her weight in Spanish and R2 said she could not take it anymore. Both R1 and R2 confirmed that both call out each other inappropriate names. On 3/31/2025 at 3:06 PM, R2 said, I could not take it anymore and I want the name-calling to stop. I don't want to be called fat in English or Spanish. On 4/1/2025 at 9:25 AM R1 said, I usually make joking comments to R2 about her weight and her cleanliness; on 3/29/2025 during smoking activity, I had an argument with R2 and R2 scooted toward me in her wheelchair and R1 placed the ashtray in between to keep them apart from each other. We both made inappropriate comments about being fat to each other. I did use a Spanish word to refer to being fat toward R2. On 3/31/2025 at 3:15 PM, V6 (Activity Aide) said, that R1 and R2 usually call out inappropriate names referring to their weight I was able to redirect them, and both would stop. R1 was watching a movie with other residents that had nudity and violence that R2 did not like and R1 was verbally aggressive towards me when I tried to unplug the television. On 3/31/2025 at 3:32 PM V5 (Activity Director) said, R1 and R2 sometimes call out names to each other. R1 will call R2 fat and R2 will call R1 fat. R1 uses Spanish words toward R2 that I do not understand. But both are redirectable and will stop. During smoking time, there is always someone supervising. On 3/29/2025 R1 got agitated and was calling R2 names and R2 was calling R1 names. R1 pushed the astray towards him and the Aide pushed back R2. Both residents always resolved their differences, and it is an ongoing issue that got worse on 3/29/2025. I had to notify V1(Administrator) and report verbal abuse. On 04/01/2025 at 11:00 AM V7 (Activity Aide) I was doing activities over the weekend on Saturday 3/29/2025 when R1 and R2 were smoking outside. R1 and R2 started calling each name. Both called each other fat. R2 scooted over towards R1 during the argument and R2 grabbed the ashtray and placed it in the middle between them. I called my supervisor and was notified of the name calling and R2 was very upset with the name calling. Both residents have called fat names to each other in the past but would stop after being redirected, but not this time. I separated them and pushed out R2. R1 and R2 never touched themselves or got physical at all, only calling out fat to each other. On 04/01/2025 at 2:35 PM V8 (Registered Nurse) said, R1 was very aggressive after R1 cornered the activity aide during activity, I called V1 and called the nursing practitioner and received orders to transfer R1 out to be evaluated. R1 and R2 usually say profanity to each other, but usually, I can redirect them. That did not happen this weekend. R1 is vocal when someone doesn't agree with him. R1 will belittle others. On 3/31/2025 at 4:00 PM V1(Administrative) said, V5 (Activity Director) reported to me that R1 was verbally abusive to R2 during the smoke outing on 3/29/2025 at 3:45 PM, R2 reported that R1 was yelling and aggressive. I gave directions to separate them and place R1 on one-to-one monitoring. On Sunday 3/30/2025 during the movie, R2 said felt uncomfortable with the movie that was showing and told V6 to intervene. R1 took the remote control and V6 unplugged the television. R1 got out of control and got to V6's face and said, You better watch out. I contacted the nurse and the nurse said that R1's behaviors were escalating and out of control. R1 was evoking fear in others staff and residents and is refusing psychiatric consultations. An involuntary petition was created and R1 went to the hospital in the morning. Transportation was here at 08:00-10:30 AM and R1 was refusing to go to the hospital. R1 started yelling in the community room and the nurse called 911. The police came in and R1 agreed to go to the hospital to be evaluated. On 04/01/2025 at 10:37 R5 said that on 3/29/2025 heard R1 and R2 yelling at each other names like, you are fat, and the other said you are fat too. I was working on my computer when I heard R1 and R2 arguing. On 04/01/2025 at 10:45 AM R3 said, R1 and R2 are an ongoing issue here and the staff try to keep them separated and away from each other. R1 intimidates staff and residents. R1 and R2 call each other inappropriate names. On 04/01/2025 at 10:50 AM R4 said, R1 and R2 call out names to each other all the time and on 3/30/2025, R1 picked a movie with the guys and R2 did not like the movie selection because of the violence and nudity and had a disagreement. R1 calls R2 fat and chicharron in Spanish fat pig and R2 calls R1 fat. On 04/01/2025 at 3:45 PM V9 (Administrator Preceptor) and V1(Administrator) both verbalized that they would have expected the facility staff to have placed interventions in place to separate R1 and R2 during activity to prevent name calling or interaction. On 4/1/2025 at 2:02 PM, V1 provided Facility Policy Titled, Abuse Policy and Prevention Program (dated 10/2022), includes: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual ' s age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, and saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again.

Based on interview and record review, the facility failed to ensure resident (R3) was free of abuse from (R2). This failure affected two of two (R2, R3) residents reviewed for abuse causing emotional distress. Findings include: According to the Electronic Health Record (EHR) R3 had diagnoses including osteoarthritis of knee, type 2 diabetes mellitus, morbid obesity, hyperlipidemia, sleep apnea, and long-term use of hypoglycemic agents. The Minimum Data Set (MDS) dated [DATE] showed R3's cognition was intact. On 3/28/2025 at 10:27 AM, R3 stated that sometime in the morning of February 26, 2025, while he was standing by the microwave in the dining room, R2 rolled in his wheelchair right past him so R3 started to move to the side to give way when R2 stated Don't move, it's not something I would have done to you Master. I was just reversing roles. R3 responded saying You mean, I'm supposed to be your slave? R3 stated that R2 alluded to him as a slave. R3 stated he was very upset and distraught about the incident so he went downstairs to the receptionist and was telling the receptionist what happened, and that the receptionist said that V2, Former Administrator, was not in the building yet but that she would inform him as soon as V2 arrives. On 3/28/2025 at 4:14 PM, V5, (Receptionist), confirmed that R3 had reported the incident to her on the same day. V5 stated that upon hearing R3's complaint, she immediately informed V2, (Former Administrator), when he arrived. V5 recalled that V2 assured her that he would speak with both R3 and R2 and address the issue. A progress note by V7, (Registered Nurse), dated 2/26/2025, indicated that R2 had been referred for an inpatient psychiatric evaluation due to escalating non-compliant behaviors and episodes of aggression. The note specifically mentioned that R2 had been vocalizing racial slurs and insults towards other residents, creating a significant safety concern. V7 also documented that R2 had verbalized self-harm and instigated altercations with other residents. The behavior was reported as alarming and required immediate assessment for inpatient psychiatric evaluation. On 3/28/2025 at 1:05 PM, V2, (Former Administrator), acknowledged that he had not been made aware of the allegations regarding R2's comments to R3. V2 stated that, had he known about the incident, it would have been treated as an abuse allegation, and an investigation would have been initiated immediately. However, no formal investigation or report regarding this specific incident was provided by the facility. On 3/28/2025 at 2:28 PM, V7, (Registered Nurse), explained that although she did not witness the altercation between R2 and R3, she had observed R2 vocalizing racial slurs towards other residents and staff members. V7 noted that R2 had a preference for being cared for by specific ethnicities and would make derogatory remarks regarding other ethnicities. V7 stated that she took these comments seriously and that's why team decided to have him referred to in patient psychiatric care. On 3/28/2025 at 4:24 PM, V1, (Administrator), confirmed that no formal report or investigation had been initiated regarding the incident involving R3 and R2. V1 stated that had the incident been reported to her, she would have ensured that an investigation was conducted and appropriate action was taken. R2's history of aggression, including vocalizing racial slurs and engaging in other disruptive behaviors, was well-documented, yet no preventive measures or immediate interventions were put in place to protect R3 or other residents from harm. While the receptionist (V5) reported the incident to the former Administrator (V2), there is no clear documentation that the incident was reported and investigated and effectively addressed, nor was the current Administrator (V1) aware of the incident until after the fact. An undated facility Abuse Policy and Prevention Program policy documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. VII. Internal Investigation 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.

Based on interview and record review, the facility failed to report an allegation of abuse to the State Survey Agency. This failure affected one (R3) of one resident reviewed for Abuse. Findings include: According to the Electronic Health Record (EHR) R3 had diagnoses including osteoarthritis of knee, type 2 diabetes mellitus, morbid obesity, hyperlipidemia, sleep apnea, and long-term use of hypoglycemic agents. The Minimum Data Set (MDS) dated [DATE] showed R3's cognition was intact. On 3/28/2025 at 10:27 AM, R3 stated that sometime in the morning of February 26, 2025, while he was standing by the microwave in the dining room, R2 rolled in his wheelchair right past him so R3 started to move to the side to give way when R2 stated Don't move, it's not something I would have done to you Master. I was just reversing roles. R3 responded saying You mean, I'm supposed to be your slave? R3 stated that R2 alluded to him as a slave. R3 stated he was very upset and distraught about the incident so he went downstairs to the receptionist and was telling the receptionist what happened, and that the receptionist said that V2, Former Administrator, was not in the building yet but that she would inform him as soon as V2 arrives. On 3/28/2025 at 4:14 PM, V5, Receptionist, confirmed that R3 had reported the incident to her on the same day. V5 stated that upon hearing R3's complaint, she immediately informed V2, Former Administrator, when he arrived. V5 recalled that V2 assured her that he would speak with both R3 and R2 and address the issue. On 3/28/2025 at 1:05 PM, V2, Former Administrator, stated that he had not been made aware of the allegations regarding R2's comments to R3. V2 stated that, had he known about the incident, it would have been treated as an abuse allegation, and an investigation would have been initiated immediately. No formal investigation or report regarding this specific incident was provided by the facility. On 3/28/2025 at 4:24 PM, V1, Administrator, confirmed that no formal report or investigation had been initiated regarding the incident involving R3 and R2. V1 stated that had the incident been reported to her, she would have ensured that an investigation was conducted and appropriate action was taken. An undated facility Abuse Policy and Prevention Program policy documents in part: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation

Based on interview and record review, the facility failed to investigate an allegation of abuse. This failure affected one (R3) of one resident reviewed for abuse. Findings include: According to the Electronic Health Record (EHR) R3 had diagnoses including osteoarthritis of knee, type 2 diabetes mellitus, morbid obesity, hyperlipidemia, sleep apnea, and long-term use of hypoglycemic agents. The Minimum Data Set (MDS) dated [DATE] showed R3's cognition was intact. On 3/28/2025 at 10:27 AM, R3 stated that sometime in the morning of February 26, 2025, while he was standing by the microwave in the dining room, R2 rolled in his wheelchair right past him so R3 started to move to the side to give way when R2 stated Don't move, it's not something I would have done to you Master. I was just reversing roles. R3 responded saying You mean, I'm supposed to be your slave? R3 stated that R2 alluded to him as a slave. R3 stated he was very upset and distraught about the incident so he went downstairs to the receptionist and was telling the receptionist what happened, and that the receptionist said that V2, former Administrator, was not in the building yet but that she would inform him as soon as V2 arrives. On 3/28/2025 at 4:14 PM, V5, Receptionist, confirmed that R3 had reported the incident to her on the same day. V5 stated that upon hearing R3's complaint, she immediately informed V2, Former Administrator, when he arrived. V5 recalled that V2 assured her that he would speak with both R3 and R2 and address the issue. On 3/28/2025 at 1:05 PM, V2, Former Administrator, stated that he had not been made aware of the allegations regarding R2's comments to R3. V2 stated that, had he known about the incident, it would have been treated as an abuse allegation, and an investigation would have been initiated immediately. On 3/28/2025 at 4:24 PM, V1, Administrator, confirmed that no formal report or investigation had been initiated regarding the incident involving R3 and R2. V1 stated that had the incident been reported to her, she would have ensured that an investigation was conducted and appropriate action was taken. No formal investigation or report regarding this specific incident was provided by the facility. An undated facility Abuse Policy and Prevention Program policy documents in part: VII. Internal Investigation 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.

Based on observation, interview, and record review, the facility failed to adhere to the resident right to privacy by staff not knocking on the door before entering a resident's room. This failure affected two (R1, R4) of four residents reviewed for privacy. Findings include: R1 is [AGE] year-old male admitted to the facility on [DATE] with medical diagnosis that includes and not limited to hypertension, sleep apnea, obesity, right hip osteoarthritis, abnormal, gait and mobility, chronic and congestive heart failure. R4 is [AGE] year-old male admitted to the facility on [DATE] with medical diagnosis that includes and not limited to blindness, hypertension, diabetes, right eye surgery, Left eye surgery, Vitrectomy bilaterally. On 2/10/2025 at 12:00PM R1 said, I have concerns with staff coming into my room without knocking on the door or telling who they are. On 2/10/2025 at 12:20PM R4 said, I am blind, and I would like the staff to knock on the door and wait to come in, and when they come in introduce themselves and say their names. Some people I know by their voices, but I don't know everyone in the facility. There is sign on the door and staff still don't knock on the door and wait until I let them in. I like to have my privacy. On 2/10/2025 at 1:13PM V16 (Housekeeping) was removing garbage from R1 and R4's room; it was observed that V16 did not knock on the door before going inside. R4's room has sign posted indicating that R4 prefers to have staff knock on the door before entering. V16 said, I know I am supposed to knock on the door but I did not do it. On record review of facility grievances form dated 11/11/2024, R1 and R4 both had expressed that staff are not knocking on the door and waiting for a response before coming in. On 2/10/2025 at 1:15PM V6 (Nursing Manager) said, I expect the staff to knock on the door and wait for the resident to respond before the staff go in. On 2/10/2025 at 3:15PM V2 (Regional Director of Operations) said, I expect staff to knock on the door and wait for the resident to respond before going in. On 2/10/2025 at 3:15PM V3 (Interim Director of Nursing) said, I expect staff to knock on the door and only go inside when the resident responds. On 2/10/2025 at 3:20PM V3 provided facility policy titled, Illinois Long-term Care Ombudsman Program, Residents' Rights for People in the Long-Term Care Facilities Your rights to Privacy and Confidentiality (undated), which reads in part (but not limited to): Facility staff must knock before entering your room.

Based on observation, interview and record review the facility failed to discard expired opened medications from 2nd floor medication room. This failure has the potential to affect all 51 residents residing in the facility. Findings include: On 1/21/24 at 10:00am during medication room inspection on the 2nd floor, surveyor observed an open house stock Tuberculin purified Protein Derivative (TB) (5TU/0.1ml) 5ml (milliliters) vial that was about 75-80% full in the medication fridge on the 2nd floor. The vial had an open date of 9/26/24. During medication cart inspection on the 2nd floor, surveyor also observed a bottle of house stock acetaminophen 500mg (milligrams) with no expiration date. During an interview on 1/21/25 at 10:00am, V4 (Registered Nurse) stated that the opened TB vial should be discarded after 30 days and expired medications should be returned to the return bin for pharmacy to pick it up. Facility policy dated 1/2024 reads, medication storage in the facility. Responsible party: Nursing Procedure: 14. outdated, .drug will be immediately withdrawn from stack by facility. They will be disposed of according to drug disposal procedures and reorder from the pharmacy if a current order exit. Facility's document Medication storage information Best Practices reads. Product: PPD (Tubersol) Storage: Refrigerate Expiration Date: 30 days.

Based on observation, interview, and record review the facility failed to follow their 3 compartment sink policy by not submerging used utensils in the quat (Quaternary Ammonium Compounds) solution for 60 seconds and the facility failed to follow the Labeling and Dating Foods (Date Marking) Policy by not ensuring sandwiches were dated. This failure has the potential to affect all residents receiving nutrition from the kitchen. Findings include: 1. On 1-22-25 at 11:05 AM, surveyor observed V13 (Cook) submerge used utensil (scraper) into the 3-compartment sink (water compartment) for approximately 2 seconds. Surveyor observed V13 did not submerge the used utensil for 60 seconds in the quat solution. Surveyor observed V13 place the used utensil back into the workstation and then used it to make pureed stuffing. On 1-23-25 at 9:06 AM, V12 (Dietary Supervisor) said the purpose of submerging items in quat solution for 1 minute and air drying to eliminate any bacteria. On 1-22-25 at 11:20 AM, V13 (Cook) said she did not submerge the utensil in the quat solution for 60 seconds. V13 said she usually sanitizes in the quat solution for 60 seconds but did not do it this time. Three Compartment Sink Policy (no date) documents: Sanitize items in the 3rd sink. Submerge items for at least 60 seconds, or per the manufacturer's guidelines. Washing Procedures dated 2016 documents: 4. After rinsing ware, submerge into sanitizer sink for at least 1 minute. 2. On 1-21-24 at 10:30 AM, surveyor and V12 (Dietary Supervisor) noted 2 individually wrapped Ham and Cheese sandwiches without a label date. V12 immediately pulled the sandwiches and applied a label dated of 1-21-25. On 1-23-25 at 9:06 AM, V12 (Dietary Supervisor) said prepared food is good for 72 hours. V12 said the purpose of labeling food is to know the use by date of the food. Labeling and Dating Foods (Date Marking) Policy (no date) documents: Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food guidelines or by the manufacturers expiration date.

Based on observation, interview and record review the facility failed to monitor the temperature of the refrigerator unit in resident's room for four of four residents (R2, R3, R13, R16) reviewed for food safety in a sample of 18. Findings include: 1. On 1/21/25 at 10:30am during patient encounter, R3's refrigerator was observed with no temperature log. R3's refrigerator was observed with oranges, blueberries, and nuts. During an interview on 1/21/25 at 10:30am, V6 (Restorative Aide) and V7 (CNA-Certifed Nursing Assistant) all stated that housekeeping checks the resident's refrigerator temperature. During an interview on 1/21/25 at 10:30am, V5 (Housekeeping Director) stated that housekeeping monitor the resident's refrigerator in their rooms. V5 stated that the logs are kept in his office downstairs but was unable to produce any logs as requested. 2. On 1/21/25 at 10:30am during patient encounter, R16's refrigerator was observed with no temperature log. R16's refrigerator was observed with peanut butter. During and interview on 1/21/25 at 10:30am, V6 (Restorative Aide) and V7 (CNA) all stated that housekeeping checks the resident's refrigerator temperature. During an interview on 1/21/25 at 10:30am, V5 (Housekeeping Director) stated that housekeeping monitors the resident's refrigerator in their rooms. V5 stated that the logs are kept in his office downstairs but was unable to produce as requested. 3. On 01/21/2025 at 10:23AM during unit rounds, R2's refrigerator did not have temperature log and R2's refrigerator temperature was at 48 degrees Fahrenheit (F). On 01/21/2025 at 10:52AM during observation with V3 (Registered Nurse), V3 was unable to locate R2's refrigerator temperature log and R2's refrigerator temperature was at 48 degrees Fahrenheit. R2's refrigerator had an unlabeled and undated cup with black fluid in it and a bottle of soda. On 01/21/2025 at 10:52AM during interview with V3, V3 stated that R2's refrigerator temperature should be checked daily. On 01/22/2025 at 9:30AM during interview with V1 (Administrator), V1 stated that all the refrigerator temperature logs are in V5's (Maintenance Director) office because sometimes the residents lose it. V1 also stated that R2's refrigerator temperature should be checked daily and the food item in R2's refrigerator should be dated and labeled. V1 also stated that all resident refrigerators should be cleaned by housekeeping daily. Facility unable to provide R2's refrigerator temperature log. 4. On 01/21/2025 at 10:44AM during unit rounds, R13's refrigerator did not have temperature log and R13's refrigerator temperature was at 14 degrees Fahrenheit (F). On 01/21/2025 at 10:48AM during observation with V3 (Registered Nurse), V3 was unable to locate R13's refrigerator temperature log and R13's refrigerator temperature was at 14 degrees Fahrenheit. R13's refrigerator had 3 boxes of 2% milk with sell by date of 01/14/2025, 1 box of 2% milk with sell by date of 01/07/2025, one unlabeled and undated cup with white viscous liquid inside, and unlabeled and undated food item wrapped in a paper towel. On 01/21/2025 at 10:52AM during interview with V3, V3 stated that R13's refrigerator temperature should be checked daily. On 01/22/2025 at 9:30AM during interview with V1 (Administrator), V1 stated that all the refrigerator temperature logs are in V5's (Housekeeping Director) office because sometimes the residents lose it. V1 also stated that R13's refrigerator temperature should be checked daily, and the food items in R13's refrigerator should be dated and labeled. V1 also stated that all resident refrigerators should be cleaned by housekeeping daily. Facility unable to provide R13's refrigerator temperature log. The facility's policy entitled Refrigerator and Resident Appliance Maintenance Service revised on 08/19/2024 documents: Policy Statement: It is the policy of this facility to provide maintenance services for refrigerator units in resident rooms, common areas/dining rooms and nurses station. Procedures: 1. The maintenance department or the facility designee is responsible for maintaining that resident appliance, e.g. refrigerators are safe, clean and operable at all times. a. Refrigerator in resident room 2. The facility will perform the following refrigerator checks: c. Temperature is maintained below 41F and above 32F using a thermometer with +-3 degrees temperature variance. d. Proper labeling, storage and disposition of food items. e. Ensure proper dating and disposition of outdated food items including food brought by family and resident from the outside.

Based on interview and record review, the facility failed to refer to appropriate state-designated authority for Level II PASARR (Pre-Admission Screening and Record Review) evaluation and determination for one of five residents (R27) reviewed for PASARR in a sample of 18. Findings include: During record review, R27's Minimum Data Set, dated dated dated [DATE] indicated R27 is not currently considered by the state level II PASRR (Pre-Admission Screening and Record Review) process to have serious mental illness and/or intellectual disability or a related condition, and active diagnosis of bipolar disorder. On 01/23/2025 at 12:20PM during interview with V17 (Admissions Director), V17 stated all residents coming into the facility must have PASRR Level I from the hospital before being admitted into the facility. V17 stated that she only reviews the determination and if the determination says No Level II Required, she is okay with it. V17 also stated that if the determination says that Refer for Level II Onsite, she informs V9 (Social Service Director) so she can request for Level II because V17 has no access to requesting Level II. On 01/23/2025 at 1:33PM during interview with V9, V9 stated that she reviewed R27's entire Notice of PASRR Level I Outcome. V9 stated that if R27 was found to have a bipolar disorder, a new level I should been requested for R27. Review of R27's Notice of PASRR Level I Screen Outcome dated 10/31/2024 indicated the following: - PASRR Level I Determination: No Level II Required - No SMI/ID/RC (serious mental illness/intellectual disability and/or related condition) - Mental Health Diagnoses: No mental health diagnosis is known or suspected - Substance Related Diagnoses: No - Ascend Outcome Rationale: The Level I scree indicates that a PASRR disability is not present because of the following reason: There is no evidence of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. Review of R27's Progress Notes indicated admitted d of 11/01/2024, diagnoses of not limited to alcohol use, unspecified with withdrawal and bipolar disorder, current episode depressed, severe, without psychotic features, notes by Medical Practitioner dated 11/04/2024 that indicated R27 has PMHx (past medical history) that includes Hx (history) of ETOH (alcohol) abuse and Bipolar who was recently hospitalized from 10/11/2024 to 11/1/2024 due to alcohol abuse with withdrawal delirium. Review of R27's Progress Notes by Social Service dated 11/06/2024 indicated R27 is being followed up on aggressive behavior towards others/staff and during staff interventions exhibited on 11/05/2024. Review of R27's Progress Notes by Social Service dated 11/08/2024 indicated R27 dx (diagnoses) are bipolar d/o (disorder) unspecified, major depression d/o, cognitive communication deficit, delirium d/o, alcohol abuse unspecified d/o, and other medical conditions. It also indicated that R27 has also displayed behaviors or episodes of anxiety thoughts or actions, aggression towards staffs or during staff interventions, depressive thoughts or mood distress, episodes of cognitive decline or communication deficits, feelings of helplessness/hopelessness, and grieving of loss of control over his community independent lifestyle.

Based on observation, interview and record review, the facility failed to follow physician's order on oxygen administration and to replace and safely store oxygen nasal cannula for two of two residents (R7, R35) reviewed for respiratory care in a sample of 18. Findings include: 1. On 01/21/2025 at 10:22AM during unit rounds, R7 was lying flat on bed, and R7's oxygen nasal cannula was on the floor and not in a plastic bag. R7's oxygen nasal cannula was also not dated, and the oxygen humidifier indicated a date of 12/15/2024. On 01/21/2025 at 10:50AM during observation with V3 (Registered Nurse), R7's oxygen nasal cannula was not in a plastic bag and was on the floor. Also, R7's oxygen nasal cannula was not dated, and the oxygen humidifier indicated a date of 12/15/2024. V3 picked up R7's oxygen nasal cannula and put it in a bag without changing it. At 11:19AM during record review with V3, R7's oxygen order is to administer oxygen at 2 liters per minute to maintain O2 (oxygen) saturation at 95% or greater every day and night shift for SOB (shortness of breath). At 11:20AM, V3 proceeded to check R7's oxygen level. Between 11:20AM - 11:25AM, R7's oxygen level is at 87%. V3 did not administer oxygen to R7. On 01/21/2025 at 10:50AM during interview with V3, V3 stated that R7's oxygen nasal cannula should be placed in a bag after each use. V3 stated that R7's oxygen is to be given only as needed by R7. V3 also stated that R7's humidifier and oxygen nasal cannula should be dated and changed weekly. On 01/24/2025 at 9:44AM during interview with V2 (Acting Director of Nursing), V2 stated that all oxygen humidifiers and nasal cannulas are expected to be changed in a weekly basis for infection control. V2 also stated that the nurses are expected to administer the oxygen to the residents as prescribed by the physician. V2 also stated that if the resident had any change in condition during their shift, the nurses are expected to manage the resident first then inform the attending physician for further management and document it in the resident's chart. Review of R7's Order Summary Report dated 01/22/2025 indicated R7 was admitted at 03/04/2020 with diagnoses of not limited to Chronic Respiratory Failure with Hypoxia, Obstructive Sleep Apnea, Morbid (Severe) Obesity with Alveolar Hypoventilation and Chronic Obstructive Pulmonary Disease (COPD), order to change O2 tubing and humidifier weekly every night shift every Sunday for Infection Control with order date of 08/17/2024, and order for oxygen at 2 liter per minute to maintain O2 (oxygen) saturation at 95% or greater every day and night shift for SOB with order date of 09/08/2024. Review of R7's Care Plan revised 11/21/2024 indicated R7 has COPD, sleep apnea, and hx (history) of resp. (respiratory) failure with interventions including to administer O2 as ordered and to HOB (head of bed) elevated when lying flat as R7 has SOB when lying flat. 2. On 01/21/2025 at 10:25AM during unit rounds, R35's oxygen was at 4 liters per minute, nasal cannula was not dated, and the oxygen humidifier indicated a date of 12/15/2024. On 01/21/2025 at 11:15AM during observation with V3 (Registered Nurse), R35's oxygen was at 4 liters per minute, nasal cannula was not dated, and the oxygen humidifier indicated a date of 12/15/2024. On 01/21/2025 at 11:20AM during interview with V3, V3 stated that R35's humidifier and oxygen nasal cannula should be dated and changed weekly. On 01/24/2025 at 9:44AM during interview with V2 (Acting Director of Nursing), V2 stated that all oxygen humidifiers and nasal cannulas are expected to be changed in a weekly basis for infection control. V2 also stated that the nurses are expected to administer the oxygen to the residents as prescribed by the physician. V2 also stated that if the resident had any change in condition during their shift, the nurses are expected to manage the resident first then inform the attending physician for further management and document it in the resident's chart. Review of R35's Order Summary Report dated 01/23/2025 indicated R35 was admitted on [DATE] with diagnoses of not limited to Acute Respiratory Failure with Hypoxia, Acute on Chronic Systolic (Congestive) Heart Failure and dependence on supplemental oxygen, and order for oxygen at 2 LPM (liters per minute) with order date of 12/06/2024. Review of facility's policy entitled Oxygen Safety/Use reviewed on 01/2024 indicated the following: General: 9. Oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use. Chart as nursing order on treatment administration record. Procedure: 2. Turn flow control knob on oxygen unit clockwise until prescribed flow rate is visible in the knob window.

Based on observation, interview, and record review the facility failed to follow transmission-based practices for one of three residents (R204) reviewed for infection control in a sample of 18. Findings include: On 01/21/2025 at 10:55AM during unit rounds, V18 (Nurse Practitioner) was going out of R204's room with isolation gown on. R204's room has sign that reads Droplet Precaution. On 01/21/2025 at 10:58AM during interview with V18, V18 stated that she left R204's room with isolation gown on but she should have removed it before coming out or R204's room. On 01/23/2025 at 12:40PM during interview with V2 (Acting Director of Nursing), V2 stated that all personal protective equipment should be removed inside the resident's room. V2 stated that R204's room should have both contact and droplet precaution sign. Review of R204's Order Summary Report documents an admitted [DATE], diagnoses of not limited to influenza due to identified novel influenza A virus with other respiratory manifestations and order of contact/droplet isolation dx (diagnosis) positive influenza A with order date of 01/17/2025 (discontinued on 1/23/25). Review of R204's laboratory results dated [DATE] indicated Influenzae A detected. Review of facility document entitled How to Safely Remove Personal Protective Equipment (PPE) Example 1 indicated to remove all PPE before exiting the patient room except a respirator if worn. Review of facility document entitled How to Safely Remove Personal Protective Equipment (PPE) Example 2 indicated to remove all PPE before exiting the patient room except a respirator if worn.

Based on interview and record review the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 5 residents (R1) reviewed for abuse in the sample of 5. The findings include: The facility abuse allegation dated 11/8/24 states, Around 8:30 AM Administrator received call from nurse that resident reported CNA (V4) hit him in the shoulder- full body assessment completed, no bruising noted, investigation started Final: After interviewing staff and residents abuse cannot be substantiated because there was no evidence observed by nurse that CNA hit resident. Resident is mildly confused and is a poor historian. On 12/27/24 at 9:50AM, R1 stated, (V4- CNA) told me he was a boxer and he kept like fake swinging at me. I reported it several times and no one would listen. Then I got transferred over here from (Facility with the same name, different city location) and about a month later he got transferred over here too. That night (11/8/24) he threw a couple of cross punches at me and he hit me on the arm. (Surveyor asked R1 why V4 hit him) He hit me on the arm, you know like guys do. Then that same night he was changing me and he was fondling my balls and started hitting my penis back and forth. I told him to stop. I heard he got fired. I heard they had a meeting with him and then they fired him- I haven't seen him since. (Asked R1 to describe V4) He is Indian, medium build, good physique. R1 stated he had no issues with anyone else. R1's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including Bipolar and Dementia. On 12/27/24 at 2:45 PM V4 (CNA) stated, I used to care for him when he was on the first floor. Then I went on vacation for a month. One the first floor, we had a routine. We would transfer him with the (Mechanical Lift) and he was always trying to get out of the bed or the chair. One time I had to grab him to keep him from falling on the floor and he said I grabbed him too tight. He asked me if I was a boxer. Then when he moved to the second floor he saw me and he said he recognized me and said that I am a boxer. I told him I am not a boxer. That night about 6:30 AM I changed his diaper and he was dirty, everything was fine. Then I got a call and they said (R1) said that I touched his penis. That was in November. I have not talked to (V1- Administrator) today. He said I punched him on the shoulder and I touched his penis. I had to stay home for a week and then they said I could come back but I do not work with (R1) anymore. I have never been accused of abuse before. On 12/27/24 at 11:10 AM V1 (Administrator) stated, It was a Friday morning and the nurse called me about 8:30 AM and told me that (R1) had reported to her that (V4) had punched him. He said it happened about 6:30 AM and his shift ended at 7:00 AM so he was not in the facility. I spoke to (V4), he told me he did provide care about 6:30 AM but said he didn't hit (R1). I spoke to (R1) and he told me that (V4) had punched him on the shoulder. I asked him why and he said he just hit me and then he left. I reported it to my boss, (V3- Regional Director of Operations) and I sent the initial report to (State Department). I had the nurse do a skin check and look for physical signs of abuse. (R1) said that (V4) hit him pretty hard so I would think there would be some redness or bruising but the nurse didn't see anything. (V4) said- I didn't hit him. I suspended (V4) right away while we did the investigation. I interviewed other residents and no one had any complaints about (V4) or about abuse in the facility. (V4) still works here I just don't have him work on the same floor as (R1). We did not substantiate the abuse- there was no evidence of abuse and no pattern and no one saw anything. At 12:00PM V1 stated, I don't believe (V4) and (R1) were together in another facility. There is no (Facility with the same name in the city mentioned), It does not exist. (V4) mentioned that he did change (R1) but (R1) never said anything about him touching is penis. This is the first I am hearing about that. The facility Incident Report of 12/27/24 states, Around 11:45 AM on 12/27/24 surveyor mentioned to me that (R1) reported that (V4) had played with his genitals on 11/8/2024. Surveyor said resident described employee as Indian, and that CNA followed resident from (Facility with the same name in another city). (Facility with the same name in the city mentioned) does not exist. The facility policy entitled Abuse Policy and Prevention Program dated 10/2022 states, Internal Investigation: 1. All incidents will be documented, whether or not abuse , neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any Incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.

Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 5. The findings include: R1's electronic face sheet printed on 11/9/24 showed R1 has diagnoses including but not limited to fracture of 2nd lumbar vertebrae, cerebral infarction, bipolar disorder, schizophrenia, and hypertension. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and requires substantial assistance for transfers. R1's care plan dated 12/28/18 showed, (R1) is at high risk for falls related to impaired mobility, history of cerebrovascular accident, history of falls, and psychotropic drug use .requires use of floor mat to prevent injury from falls, place call light within reach, use wheelchair for locomotion and mobility and ensure device is operable. On 11/9/24 at 10:28AM, R1 was in his bed with his wheelchair and over the bed table next to his bed. R1's floor mat was folded up and leaning against the wall by his door. R1's wheelchair had both wheels locked; however, surveyor was able to move the wheelchair around due to the right brake not locking completely. On 11/9/24 at 11:05AM, V3 (Registered Nurse) stated, (R1) should have his call light within reach and a fall mat next to his bed at all times. He just had a fall with a fracture in his vertebrae, so we need to ensure we have all precautions in place for him. He is noncompliant at times asking for help, so we at least need to make sure everything is in place. Surveyor then accompanied V3 to R1's room where she visualized and confirmed that R1's floor mat was not in place and then attempted to activate R1's call light and it was not lighting up to alert staff if he needed assistance. On 11/9/24 at 1:50PM, V2 (Regional Nurse Consultant) stated, Fall prevention measures should be in place for all residents that have a care plan for these items. The measures are implemented to prevent injury and hopefully prevent falls. If (R1) does not have a working call light, he cannot call for help. If his fall mat is not in place, then he could potentially be injured during a fall. We were not aware that (R1's) wheelchair was not locking all the way. This potentially could have contributed to his last fall, but we cannot be sure as (R1) does not really recall his most recent fall. R1 was interviewed regarding his most recent fall and was unable to provide details of the fall. The facility's policy titled, Fall Prevention and Management dated 1/2024 showed, While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe environment as possible .

Based on observation, interview, and record review facility failed to provide a hazard free environment by allowing resident to be exposed to a stationary floor block heater near resident's bed after a fall for 1 of 3 residents (R1) reviewed for accidents/hazards in the sample of three. As a result of this failure, R1 laid on the floor for an undetermined amount of time in contact with the heat source. R1 was emergently sent to the hospital, and treated for second-degree burns and pain management. This was identified as an immediate jeopardy. The immediate jeopardy began on 01/02/2024 when R1 fell and came in contact with a heat source as R1 was positioned between the bed and the radiator. The immediacy was removed on 01/09/2024. V1 (Administrator), V10 (Nurse Consultant/acting DON), and V13 (Regional Consultant) were notified on 01/04/2024 at 11:40 AM of the immediate jeopardy. The facility presented the department with an initial removal plan on 01/04/2024. However, an acceptable removal plan was received on 01/09/2024. The surveyor conducted an onsite investigation on 01/09/2024 to confirm the removal plan was implemented. Although the immediacy was removed the facility remains out of compliance at severity level II until the facility can install a permanent protective cover for the radiators within the resident's rooms and evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: According to R1's face sheet, R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to severe dementia, Alzheimer's disease, anxiety, and diabetes. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 4 indicating severely impaired cognition. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, show R1's functional ability is Dependent - helper does all of the effort, to roll left and right on the bed. Fall assessments dated 11/24/2023, 11/27/2023, and 01/02/2024 place R1 in category: At Risk For Falls. R1's fall care plan dated 12/01/2021 reads in part, Educate resident/family/caregiver of possible negative outcomes r/t (related to) non-compliance; Encourage resident to be compliant with care. Based on R1's MDS assessments, these interventions may have been inappropriate due to R1's lack of cognitive capability. According to R1's progress note dated 01/02/2024 2:00 AM written by V6 (Licensed Practical Nurse) reads in part, When (V7 CNA) was doing rounds, (V7 CNA) found the resident on the floor close to the heater and called (V6 LPN) attention. (V6 LPN) went to check on resident immediately, head to toe assessment was done noted resident blister formation and redness of the right side of her body. Resident was unable to describe what happened. (V8 NP) was also made aware with new orders made to send out resident to ER (emergency room ) for evaluation. According to R1's progress note dated 01/02/2024 10:24 AM written by V11 (MDS Registered Nurse) reads in part, Writer called (local) hospital, and got information that resident was transferred at the Burn Center of (local) Medical Center. The resident is at their Burn Intensive Care Unit. On 01/02/2024 at 11:10 AM Surveyor observed R1's room. Bed in the lowest position, scoop mattress present, fall mat on the left side of the bed, bed placed parallel to the wall underneath the window with radiator adjacent to the right side of the bed frame. Radiator warm to touch. Floor block radiator about 4 inch thick with metal, factory cover in place. Bed positioned about 8 inches away from the radiator, creating about 12 inch gap between wall and R1's bed. Radiator exposed to the environment, no additional cover present at this time to prevent any resident from coming in contact with the surface. R1 currently at the hospital, not available for observation or interview during this investigation. V3 (Plant Operations Manager) presented room and radiator temperature log dated 01/02/2024 (no time) that showed temperature in R1's room at 72 degrees Fahrenheit and radiator temperature at 83 degrees Fahrenheit. On 01/02/2024 at 11:32 AM Surveyor observed V3 checking radiator temperatures with IRT207 infrared thermometer: R1's room radiator temperature: 81 degrees Fahrenheit. Operation Manual for IRT207 infrared thermometer reads in part: The product can only be used to measure body temperature simply for reference. On 01/02/2023 at 11:18 AM Surveyor interviewed V4 (Registered Nurse) who related the following in summary: When I came in this morning (01/02/2024) at 7:00 AM, V5 (Licensed Practical Nurse) relayed in the hand off report that R1 fell to the right side of the bed. V5 (LPN) said they found R1 with superficial redness to the right side and called 911. V5 (LPN) did not specify details of the incident. R1 was sent out to the hospital around 2:30 AM. R1's bed is positioned right against the wall; however, the radiator is somewhat thick and creates a gap between the bed and the wall. R1 has dementia, does not speak fluent English, and generally does not talk. Even when we assess R1 for pain, we go by facial grimacing. R1 is not able to use a call light or call for help, that's why she is in the room across from the nursing station to constantly check on her. Nurses check on R1 throughout the shift, during medication administration, blood glucose checks, tray delivery, and feeding assistance. There is no particular schedule for rounding; however, R1 requires more attention, so we check on her more often than every two hours. R1 was doing just fine when I was leaving yesterday (at 7:00 PM). On 01/02/2024 at 12:01 PM Surveyor interviewed V3 (Plan Operations Manager) who related the following in summary: Our heating system contains of a boiler that is set to ambient temp of 73-80 degrees Fahrenheit. There is a differential of 7 degree, for example, if the temperature outside drops, the differential will go up by 7 degrees. Boiler temperature never goes over 80 degrees Fahrenheit or below 73 degrees Fahrenheit, that's how temperature is maintained in the whole building. When I came in this morning (01/02/2024), and measured temperatures in the whole building, radiator temperatures were somewhere between 75 - 79 degrees Fahrenheit. We just started monitoring radiator temperatures today. On 01/02/2024 at 12:48 PM Surveyor interviewed R2 (R1's roommate) who related the following in summary: R1 moved around in the bed a lot, that's why they have this mat on the floor. R1 can barely talk, and if she does, it's very soft and hard to hear. Even if R1 called for help, I wouldn't be able to hear her. I didn't hear R1 fall, but I had TV on, so that's probably why. I don't remember if there was anybody coming into the room throughout the night to check on us. On 01/02/2024 at 3:02 PM Surveyor requested to review video of the hallway adjacent to R1's room from the night of the incident to verify frequency of monitoring R1 by night staff, V1 (Administrator) said, I cannot let you access our system; you can't review the recording. On 01/03/2023 at 10:05 AM Surveyor interviewed V6 (Licensed Practical Nurse) who related the following in summary: I worked night shift 01/01/2024 to 01/02/2024, at the time of the incident. I worked with one CNA that night. Normally we have two CNA's at night. We had no chance to take a break and neither of us fell asleep that night. I initially saw R1 around 7.30 PM during my rounds. I then saw R1 around 9:00 PM during blood glucose check and insulin administration, and then again around 00:15 AM when I assisted R1's roommate back to bad. At all times, R1 was laying on her back in the middle of the mattress. Generally, R1 sleeps overnight and doesn't move around that much; however, R1 has enough strength to roll off the bed. R1 is at risk for falls, so her bed was in the lowest position. V7 (Certified Nursing Assistant) was doing rounds around 2 AM that night and told me that R1 fell . I went into R1's room and I saw her laying on the floor, on the right side of the bed, between the bed and the radiator with her right side touching the radiator. V6 (CNA) and I pushed the bed further away and moved R1 to prevent her from touching the radiator. I assessed R1 while she was on the floor. I saw redness and blisters on her right side. I quickly notified V2 (DON) and V8 (Nurse Practitioner), and I was instructed to call 911. I also notified R1's Power of Attorney while waited for the ambulance. I don't remember the exact time of 911 call, but it was immediately after I assessed R1 and spoke to V8 (NP). The ambulance arrived around 3:00 AM. There was nothing unusual about positioning of R1's bed on my shift. We always had some space between the bed and the radiator to make sure the bed is not touching it. I'm not sure why the bed was supposed to be away from the radiator. I am not sure how hot was the radiator that night, but we don't control its temperature. On 01/03/2024 11:01 AM Surveyor interviewed V7 (Certified Nursing Assistant) who related the following in summary: I have been working in the facility for five years now. R1 was admitted about 3 years ago. R1 has never been able to talk, and she prefers to speak Polish. Generally, R1 sleeps at night but she has tendency slide off the bed. That is why, R1's bed is always in the lowest position with fall mat on the left side of the bed. There is not enough space on the right of the bed to place a fall mat. The bed is not too close to the wall on the right side because there was a concern that R1 might get burnt from the radiator, that is to the right of the bed. When I came in (on 01/02/2024) at 11:00 PM, R1 was in bed. Then I checked on her around 1:00 AM was in the bed. Both times R1 was in the middle of the bed, laying her back. At around 2:00 AM, I found R1 laying on the floor with her right side touching the radiator. I called V5 (LPN), we picked her up and put her back in the bed. V5 (LPN) then did his assessment and notified V2 (DON), V8 (NP), and R1's Power of Attorney. I am not sure what time the ambulance came, I don't remember; I saw R1's injury, the redness, and imagined the pain she must have been in. I burnt myself while I was cooking, so I know how painful that is. On 01/03/2023 at 12:40 PM Surveyor interviewed V8 (Nurse Practitioner) who related the following in summary: Facility staff called me on 01/02/2024 around 2.30 - 2.45 AM. They said that R1 had fallen out of the bed but had no head injury. I decided to send her to the hospital for further evaluation because, in the past couple of weeks, R1 was dehydrated, needed some IV fluids, and her conditioned declined all together. I wanted to stay on the safe side. I wasn't made aware R1 sustained 2nd degree burns during the fall incident, this is the first time I hear about it. R1 could have sustained 2nd degree burns from touching radiator within 10-15 minutes or even less. R1 had extra fat tissue but not a lot of muscle which would make her more at risk to sustain severe burns. On 01/03/2024 2:32 PM Surveyor interviewed V9 (Burn Intensive Care Unit Nurse Practitioner) who related the following in summary: I have been taking care of R1 since she was admitted to the burn unit earlier today (01/02/2024). R1 was admitted with diagnosis of burn - 2.5% of body surface area. R1 had to be transferred from the local hospital to higher level of care due to the burn injury itself. R1 sustained partial thickness with some full thickness burns and had to be evaluated in our burn unit. R1 has scattered burns to her back side and chest, including right armpit, right breast area, right upper and lower flank. Majority of those are partial thickness with some full thickness burns. R1 did not need to be exposed to the radiator for extended period of time, her age alone and limited mobility would increase her risk to sustain 2nd degree burns. R1's hospital record dated 01/02/2024 reads in part, R1 was taken via ambulance to the emergency roiagnom on [DATE] at 3:48 am and was diagnosed with superficial partial thickness burn of the abdominal wall, upper extremity: right shoulder, right arm, right flank, right breast, and right lower flank. Approximately 10% partial thickness thermal burns, (R1) found near the radiator. Pain management:1. At 4:51 am with fentanyl solution 50mcg (micrograms), 2. At 7:28 am Morphine Sulfate 2mg/ml (milligrams/milliliter). R1 was transfer to a local hospital (2) burn Intensive Care Unit at 8:35am (higher level of care). On 01/03/2024 at 2:58 PM Surveyor interviewed V10 (Nurse Consultant/ acting DON) who related the following in summary: I came into the facility on the morning of 01/02/2024. V1 (Administrator) and I spoke to both, V6 (LPN) and V7 (CNA) who were both working at the time of the incident. Our investigation included: log sheet of all radiator and room temperatures including audits; statements from V6 (LPN), V7 (CNA), and family; risk management; facility wide fall risk audit; and blueprint of all the rooms and bed placements. Based on initial investigation there is no conclusion that pertains to what had happened. I have been a nurse for [AGE] years and I have never come across anything similar in my career. We had R1's bed in low position, fall mat, scoop mattress, and round on her; therefore, interventions that were implement were satisfactory, but something still went wrong. I think it is a tragic accident, but staff fulfilled my expectations. I don't think this is anything we could have been predicted. We try to keep beds away at safe distance from the radiators. If R1 returns to the facility, she will be placed in another room. R1's bed was moved for contractor to have access to the radiator. The family is very upset and doesn't want R1 to come back to the facility. On 01/03/2024 at 3:28 PM Surveyor interviewed V1 (Administrator) who related the following in summary: The incident was brought to my attention yesterday (01/02/2024) at 8:00 AM. I was told that V2 (former DON) was involved and R1 was sent out to the hospital. It was a terrible accident. We don't have any conclusion to our investigation; however, we cannot be in the residents' room all the time or have heat off in the wintertime. I don't think this could have been prevented. My expectation for staff is to continue to monitor residents and radiators' temperatures to make sure this doesn't happen again. V1 (Administrator) said that there is no Radiator Safety and/or Heating System policy per surveyor's request. V1 (Administrator) presented Fall Prevention Program policy dated 11/21/2017 that reads in part, The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and plan of care. The surveyor confirmed via observation, record review, and interview that the facility did the following to remove the immediacy: 1. Nursing staff in serviced on fall policy and interventions - education initiated on 01/02/2024 at 09:00 AM, completed 01/02/2024 at 2:00 PM; staff interview completed on 01/09/2024 at 1:40 PM. 2. Maintenance and Administrator in serviced on checking temperature Radiator every shift Maintenance and or Administrator in serviced on checking Room Temperatures - maintenance logs reviewed. 3. Resident affected will not be returning due to incident family called to inform facility 1/2/24 - interview with R1's family completed on 01/09/2024 at 12:20 PM, family confirmed R1's discharge was initiated upon their request, R1 remains at the local hospital and will have surgical intervention to the burn site today (01/09/2024). 4. Maintenance and or Administrator to check Radiator temp and room temp every shift. Maintenance / Administrator during week, manager on duty on weekends - maintenance logs reviewed. 5. Angel Rounds all mangers are looking and assessing each room to ensure bed placement are correct and radiator temp is accurate and protective covers are in place being done daily This is a daily audit to ensure bed placement radiator covers and temps are being checked - audit tool reviewed. 6. Audit will be conducted daily to ensure fall risk are completed and interventions are in place and after any fall occurs x 6 months and discussed in daily meeting - audit tool reviewed. 7. All Residents will be checked for the 4 Ps every 2 hours and PRN for fall intervention: Pain, Positioning, Potty and Possessions within reach follow care plan accordingly to resident's needs - audit tool and walking rounds reviewed/observed; staff interview completed on 01/09/2024 at 1:40 PM. 8. Nursing management assessed current residents for fall risk precautions and ensured interventions place for residents at risk 47 residents total inhouse - EMR and walking rounds reviewed/observed 9. Nurses and CNA in serviced on high-risk residents and frequent rounding - education log reviewed; staff interview completed on 01/09/2024 at 1:40 PM. 10. Resident with fall will be assessed for injury - assessment reviewed. 11. Emergency QAPI plan has implemented. Any IDT member unavailable will be call via phone. Monthly QAPI meeting will continue will monitor compliance for falls with injury and surface of heaters away from any vulnerable resident for 6 months or until 100 compliance - interview with medical director completed on 01/09/2024 at 12:00 PM, medical director confirmed that emergency QAPI meeting occurred on 01/02/2024. 12. Nurses in serviced on completing new fall risk after fall interventions are updated and care plan is updated DON and Nurse consultant will audit each new fall with record review and observation to ensure in compliance weekly x 6 months - education log reviewed; staff interview completed on 01/09/2024 at 1:40 PM. 13. Additional Daily Random audit being conducted to check bed placement /Gaps / Entrapment risk (One room daily ) - audit tool reviewed. 14. Fall policy updated to ensure residents bed are safe distance from any heat source - fall policy reviewed. 15. Placement of all beds in relation to the heating element have been assessed and addressed/moved as needed. Bed will not be placed against radiator length wise to prevent resident proximity to heat source - bed placement observed and verified on 01/09/2024. 16. Heat protective radiator cover placed on affected residents' room Temporary Heat protective radiators placed in all residents' rooms 1/3 pending custom made radiator covers - temporary radiator protective covers observed and verified on 01/09/2024 including permanent radiator protective cover in R1's room that was installed on 01/08/2024, the rest of the facility radiators remain on pending status; interview with carpenter completed on 01/09/2024 at 11:26 AM, carpenter confirmed radiator assessment provided and work order completion. 17. Nursing staff in serviced on rounding on residents every 2 hours for safety and fall interventions and the 4 Ps (potty pain possessions and positioning) This order added to MAR as record for sign off - order verified; staff interview completed on 01/09/2024 at 1:40 PM.

Based on observation, interviews and record reviews, the facility failed follow facility policies and failed to provide adequate supervision and monitoring of a resident with cognitive impairment and behavior of wandering for one (R1) of four residents reviewed for accidents and supervision. This deficiency resulted in R1wandering into R2's room, was found on the floor and sustained a comminuted displaced right femoral neck fracture. R1 underwent a surgical procedure called right hip hemiarthroplasty. Findings include: R1 is an [AGE] year-old, female, admitted in the facility on 02/21/2020 with diagnoses of Polyosteoarthritis, Unspecified; Unspecified Diastolic (Congestive) Heart Failure; Paranoid Schizophrenia; Alzheimer's Disease with Late Onset; Anxiety Disorder, Unspecified; Age-Related Osteoporosis without Current Pathological Fracture and Paranoid Personality Disorder. Incident report dated 02/16/23, R2 allegedly pushed R1. R1 was wandering and went to R2's room. V3 (Certified Nurse Assistant, CNA) heard R2 saying go to your room. V3 went to R2's room and found R1 on the floor. R1 stated (R2) pushed (R1). R1 was assisted back to (R1's) room and positioned in bed and started complaining of left hip and shoulder pain. On 02/22/23 at 1:50 PM, V3 was asked regarding incident on 02/16/23 between R1 and R2. V3 stated, On 02/16/23, (R1) was not assigned to me. It was V11 (CNA) who was assigned to (R1). I went on break at 1:13PM, came back at 1:43PM. When I came back, (V11) was on break. V8 (Registered Nurse, RN) went on break too. It was only me on the floor. There were no other staff on the floor. (R1) was in (R1's) room. I went to another resident's room for assistance. When I came back, I went to the nurses' station, I heard R2 saying go to your room. When I entered R2's room, I saw R1 on the floor. R2 was standing in front of R1. R2 looked upset at R1. I helped R1 up and brought (R1) to (R1's) room and put (R1) to bed. When V8 came back, I told her about the incident. On 02/22/23 at 3:05 PM, R2 was asked regarding the incident with R1. R2 did not answer. Instead, R2 stated, It is not a good day today. R2 was observed mumbling with words, unable to keep a conversation and was very confused. V8 was interviewed on 02/23/23 at 10:36 AM regarding R1 and R2. V8 replied, On 02/16/23, I was on break. V3 was on the floor, and she told me that she found R1 inside one of the resident's room sitting on the floor. I went to (R1) and did an assessment, took vital signs and assessed for pain. (R1) was touching (R1's) left hip and left shoulder. I gave (R1) pain medication and reported to V1 (Administrator), Social Services, V2 (Director of Nursing), V9 (Nurse Practitioner) and family. V9 ordered for a STAT (immediately) X-ray of the shoulder and hip but V10 (Family Member) wanted R1 to be sent out. Hospital records dated 02/16/23, Emergency Medicine Note: R1 presented to the emergency department s/p (status post) altercation and fall. (R1) was in unwitnessed altercation with another NH (nursing home) resident and fell . Was found on the floor. The following diagnostic procedures were performed on (R1), with results: X-ray of hip: Impression - Findings suspicious for a non-displaced subcapital femoral neck fracture. CT (computed tomography) of hip without contrast: Impression - Displaced, foreshortened and slightly comminuted proximal right femoral neck fracture. X-ray femur right: Acute fracture of the right femoral neck. (R1) underwent a surgical procedure to repair the fracture called right hip hemiarthroplasty on 02/17/23. Per records also, (R1) had history of left hip fracture following fall s/p ORIF (open reduction internal fixation) in 2019. Progress notes dated 12/20/22, it was documented: R1 was noted entering another resident's room and rummaging the other resident's stuff. R1 also tried to take away stuff/things from the room. R1 was told that she cannot go in that room and cannot take other resident's personal belongings, but R1 became combative and angry. R1 is unable to understand instructions and redirections, will continue to monitor behavior. Progress notes dated 09/08/22 also documented: R1 was found sitting on the toilet seat in the common bathroom area, doing nothing. R1 was observed sitting with pants still on. R1 was asked if she's using the toilet to go and needs privacy so door could be closed but R1 replied no and I just want to sit. R1 was told that another resident was waiting to use the bathroom. R1 was assisted back to her room. Progress notes dated 08/23/22 recorded that R1 was observed lying on the bathroom floor by staff. R1 denied falling and stated she was just lying down in order to sleep. She was redirected and reoriented to her room. Staff members were notified to make frequent rounds on R1. V3 (CNA) and V8 (RN) were interviewed regarding R1. 02/22/23 at 1:50PM V3 stated, (R1) is alert but confused. Unable to find her room. When (R1) is redirected she will say that her room was in another area. (R1) walks in the hallway all the time. (R)1 goes from one resident's room to another. When (R1) goes to another room, (R1) refuses to be redirected. (R1) wants to stay in that room. But calmly speaking to (R1) will make her go to her room. Sometimes, (R1) understands me but most of the time, (R1) is confused. When I am not busy, I assist (R1) during walking and redirect to (R1's) room. There are times that I attend to other residents' needs, that I am not able to follow (R1). On 02/16/23, I was the only one on the floor, the other staff were on break. We have to monitor here to check if (R1) is in (R1's) room and not wandering around all the time. At the same time V8 (RN) mentioned, (R1) is alert to person, to self only. She has a wandering history and is physically aggressive. She walks in the hallways, enters other residents' rooms but we were able to redirect her right away. On 02/16/23, I was on my break. R1 is a wanderer and needs to be monitored. We don't have a specific timing for her monitoring. Whenever I see R1 go out in her room, I redirect her. CNAs know about R1's behavior as well. That time, when I asked V3, she said she was inside one of the residents' room. She just heard something and went to room and saw her R1 on the floor. If there was another CNA on the floor, the incident should have been prevented. I was on break, V11 (CNA) and V12 (CNA) were also on break. It was only V3 working on the floor at the time. V11 was supposed to come back from break but she did not. On 02/22/23 at 3:09 PM, V4 (RN), V5 (RN) and V6 (RN) were interviewed regarding monitoring R1. V4 stated during interview, (R1) is alert, oriented to person. (R1) has a behavior of wandering. We try to redirect (R1), offer food, offer snack, engage in activities and ongoing monitoring - rounds every now and then. (R1) has a behavior of going inside other residents' rooms and taking stuff and stuff from nurses' station. (R1) is very confused. During breaks, I make sure that two staff are present on the floor. Like if I am going for a break, I endorse residents who wanders around for monitoring. I heard about the incident that she was allegedly pushed by (R2) when she wandered, and she fell on the floor. The nurse was on break and was only notified after the break. (R2) has a withdrawn behavior, resistive to care, does not want to talk to anyone, (R2) will just ask what (R2) needs. He does not wander. He probably got agitated when he saw (R1) in his room because he is not familiar with (R1). That is why I always make sure that one staff is at the station or roaming around the floor/hallway to monitor (R1). She is our number one priority and she usually sleeps in other residents' bed. And the other residents get agitated with her. V5 also mentioned, I usually ask CNAs regarding break times. There should be one nurse and one CNA on the floor. If I am going to take a break, both CNAs should be on the floor. R1 is confused, violent for no reason. She wanders a lot. Sometimes she goes from one room to another, we have to prevent it because it makes other residents agitated. Whenever I am working on the floor, I will be at the station, do my rounds randomly and have CNA or CNAs do rounds. Usually, CNAs are there to catch (R1), redirect (R1) back to (R1's) room. (R2) is someone not used in hurting people. (R2) has no behavior with me. (R2) is usually in (R2's) room. I think (R2) got agitated when (R1) was in (R2's) room. V6 also stated, When we take breaks, there should be two staff on the floor while the other one is taking a break. Never leave one staff on the floor. (R1) is a wanderer. We redirect (R1), reorient to go back to (R1's) room. (R1) will follow you. Then after 20 minutes, she will wander again, so just redirect her. On 02/23/23 at 11:29 AM, V9 (Nurse Practitioner) was interviewed regarding R1. V9 stated, She is alert to self and to regular staff, disoriented due to Dementia. She does have a history of agitation. She does wander, walks steady. She wanders in the hallways, staff always do a redirection. On 02/16/23, I was told that she went to R2's room.(R2's) room is very close to nurses' station. (R1) should have been stopped by staff from entering the room. She should have been monitored and supervised whenever she is not in her room. V1 was also asked regarding expectations on staff in preventing falls and injury. V1 replied, Staff presence, staff should be visible in the hallway all the time to redirect residents who wanders. If residents have behavior like wandering, identify the triggers. Ideally, there should be at least two staff monitoring residents if other staff went on breaks. If there is only one staff, they are trained to call assistance from supervisors and restorative aides. R1's care plan on Wandering/Elopement, date initiated 11/15/2021 documented: Intervention: Make rounds/room checks per facility protocol to minimize chance of unauthorized leave. R1's care plan on impaired cognitive function possibly related to diagnosis of Alzheimer's, Dementia, Paranoid Personality disorder., Anxiety disorder; Insomnia, revision date 01/18/23: Intervention: Cue, redirect and supervise as needed (revision date 01/25/21). R1's care plan on risk for injury or fall related to dementia, insomnia, impaired mobility, poor safety awareness, osteoporosis, osteoarthritis, wandering behavior, date initiated 03/18/2020: Intervention: Resident has Dementia and has episodes of confusion, redirection provided and redirected to go to her room (date initiated 08/22/22). Facility's policy titled Fall Prevention Program revision date 11/21/17, documented in part but not limited to the following: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Facility was requested to present policy on Wandering/Elopement but facility has no exiting policy.

Based on observation, interview and record review, the facility failed to follow policy and procedure in utilizing a mechanical lift during transfer for one (R4) of six residents reviewed for accidents and supervision in the sample of 13. This failure resulted in R4 sustaining a deep laceration that required an emergent transfer to the hospital, laceration required 10 sutures. Findings include: R4 is a [AGE] year-old, female, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. MDS (Minimum Data Set) dated 09/08/2017 documented a BIMS (Brief Interview for Mental Status) score of 15 which means intact cognition. Per MDS also, R4 requires extensive assistance from two persons physical assist during transfer. Care plan related to falls, dated 03/18/2017 documented, Follow facility fall protocol. Care plan related to ADL (activities of daily living) self-care performance, dated 03/18/2017 documented, Transfer: The resident requires Stand Up Lift with X 2 staff assistance for transfers. Progress Notes dated 07/08/2017 documented that R4 sustained a deep cut on the back of left leg during transfer that led to bleeding. R4 was transferred to a local hospital for further management. Incident Report dated 07/08/2017 documented that R4's left leg was observed to be bleeding during transfer. The incident report revealed that R4 scraped left leg on wheelchair during transfer and sustained a laceration to the left leg. The incident report also stated in part, Nurse assessed laceration and applied a pressure dressing and basic first aid. Hospital Records dated 07/08/2017 under History and Physical (H and P) Note documented that R4 was seen at the hospital due to trauma to left leg when she was being placed in a wheelchair in the nursing home. The H & P note also indicated that suturing of the cut on the left leg was required. Per progress notes dated 07/09/2017, R4 was readmitted back into the facility. Per physician progress notes [REDACTED]. On 09/18/2017 at 10:30 AM, R4 was interviewed regarding the incident in which she sustained a cut to her left leg and on how staff performed the transfer from wheelchair to bed or vice versa. R4 stated, I was hospitalized before because the wheelchair cut my left leg and it was bleeding and it was not stopping, so they sent me to the hospital. R4 also stated that staff holds her under the arms when transferring her to bed. R4 further stated, Staff are not using any machine. They transfer me manually. Staff are having a hard time transferring me using the machine where I need to stand. On 09/18/2017 at 1:10 PM, E4 (Certified Nurse Aide, CNA) and E8 (CNA) were about to transfer R4 to bed. E4 took the stand up lift machine and placed the base near R4's wheelchair. E4 wrapped the sling around R4's back and under arms, hooked the sling onto the machine's hooks and started the lifting process. During this process, R4 suddenly shouted, My shoulder hurts, my shoulder hurts. E4 and E8 stated that they will transfer R4 using the gait belt. E4 took the gait belt and wrapped it around R4's chest area. E8 grabbed R4 under the arms and swung R4 onto the bed, with E8's assistance. E4 and E8 were interviewed on 09/19/2017 at 11:40 AM regarding R4's transfer and incident related to a cut on left leg . E4 stated that R4 needs to be transferred using the sit stand lift machine and requires two persons assist during the transfer. E4 continued, the sling for the sit stand lift machine will be wrapped around (R4's) back and under arms, hook the sling into the handle bars and start the lift. (R4) usually complains of pain with this machine so we do the transfer using the gait belt. E4 was asked on how to do the transfer using the gait belt. E4 stated, the belt strap is place around (R4's) breasts and tighten it a bit, lift her (R4) and do the transfer. E8, on the other hand, stated that R4 usually has a problem with the sit stand machine, that manual transfer using a gait belt is always implemented. E8 verbalized, Gait belt is applied around the waist, grab (R4's) both sides and do the transfer. Both E4 and E8 mentioned no knowledge of the incident regarding R4's cut on the left leg. On 09/19/2017 at 11:55 AM, E6 (Licensed Practical Nurse, LPN) was asked how R4 is to be transferred. E6 stated that R4 needs a sit stand lift machine. E6 stated, In doing this, legs of the machine needs to be spread out near (R4's) chair, put the sling on her (R4) back, then using the remote control, lift it up and do the transfer. E10 (CNA) was also asked on 09/20/2017 at 11:30 AM regarding R4. E10 stated, We transfer (R4) using gait belt. (R4) is usually not comfortable with the sit stand lift machine. For the sit stand machine - this transfer requires two person assist. A sling is applied onto (R4's) waist, (R4) needs to stand up making sure she fits into the lift and raise it up. For the gait belt - it needs to be applied around (R4's) waist, grab the sides of the gait belt, then do the transfer. I was not here when (R4) had a cut on her left leg during transfer. E2 (Director of Nurses, DON) was interviewed on 09/20/2017 at 2:45 PM regarding R4's transfer and left leg cut sustained during transfer. E2 stated, (R4) needs to be transferred using the sit stand lift machine, as what her (R4) care plan indicated. We did an in-service training to staff on how to use the sit stand machine and the use of gait belt. I was made aware of the incident related to a cut on (R4's) left leg during transfer by Z2 (family member). I was not the DON at that time when the incident occurred. But (E10) was the staff who was involved in that incident. I think, I need to do a re-education of the staff on the use of gait belt and the sit stand lift machine. An inservice sign-in sheet dated 03/09/2017 regarding procedure and training of using sit stand device transfer was reviewed. E4, E6, E8 and E10 attended this inservice. An inservice sign-in sheet dated 09/09/2017 regarding procedure and training on the use of gait belt was also reviewed. E4, E6, E8 and E10 attended this inservice. Z4 (Nurse Practitioner) was interviewed on 09/20/2017 at 3:10 PM regarding R4. Z4 stated that she was made aware that R4 sustained a cut on her (R4) left calf during transfer. Z4 also stated, (R4) is on anticoagulant, so the cut was bleeding, unable to stop, so she was sent to the hospital where sutures were made on the cut, maybe 8-10 sutures to stop the bleeding. Z4 also stated that facility staff should make sure that during residents' transfer, any hazards especially wheelchair legs should be completely out of the way to prevent any damage or injury. Z4 continued, Staff needs to be more trained with the equipment used in transferring residents and to be more careful when transferring residents from wheelchair to bed or to shower chair. On 09/21/2017 at 12:30 PM, Z6 (Medical Director) was interviewed regarding R4 and recent cut on the left leg while being transferred. Z6 stated that safety is the number one concern while residents in the facility are being transferred. Z6 also added, Every resident in the facility should be periodically assessed, and facility staff should go by the need and should follow facility protocol on falls. Facility's policy titled Fall Prevention Program, review date 1/1/2015, documented in part, Policy: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The policy also addressed that transfer conveyances shall be used to transfer residents in accordance with the plan of care. Facility's policy titled, Gait Belt, undated, stated in part, Purpose: To provide support and safety during ambulation, lifting, or transferring residents. Procedure: 2. Place belt around resident's waist. Make certain belt fits snugly. Leave enough room so that you can get both hands around webbing. 3. Grasp belt webbing securely at resident's right or left side to support resident balance during transfers. Facility's policy titled, Limited Lifting Resident Handling Policy, stated in part, Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of residents. Policy: 6. Resident transferring and lifting needs shall be documented in care plans and reviewed via care plan time frame and as needed. Facility's policy titled, Sit Stand Lift Transfer Instructions documented the following: Patient must be in sitting. Place the sling under their arms at mid-back level. Fasten buckle around chest and adjust strap securely, snug but not tight. Ask patient to position feet on footplate; assist only if necessary. Adjust shin pad, if needed. Ask patient to lean forward and securely attach sling straps to hooks on lift. Instruct patient to lean forward and securely attach sling straps to hooks on lift. Instruct patient to hold onto both handles and keep feet flat on footplate. Ensure patient's arms are outside the sling straps. Instruct patient to stand as the lift rises.

Based on observations, interviews and record reviews, the facility failed to analyze the circumstances of falls, re-evaluate for effectiveness of intervention, implement interventions and supervise resident to minimize the risks for recurring falls and serious injuries for two residents (R1,R3) from a sample of four residents reviewed for high fall risk. This failure resulted in R1 being sent to the hospital due to sustaining a head laceration after fall incident. Findings include: 1). On 3/29/12 at 1:40PM, E4(LPN) stated that she was on the second floor the morning of 1/17/12 at approximately 5:25AM when E5(CNA) came to get her because a resident had fallen in her room on the first floor. E4 stated that she found R1 on the floor, responsive but R1 was lying in lots of blood from right side of R1's forehead. E4 stated she grabbed a towel and applied pressure to R1's forehead to stop the bleeding. E4 stated she assessed R1, as she was alert, asking for help and complaining of pain. E4 stated that another staff member called 911 and the attending physician. E4 stated that she and CNA placed resident in bed and provided support until ambulance came. E4 stated that R1 could sit up in bed and would sit at side of bed but could not walk and had never walked. E4 stated that there was no mat at resident bedside that morning. On 3/29/12 at 1:55PM, E5(CNA) stated on the morning of 1/17/12 she was making her 4th round when she heard a loud boom. E5 stated she went to R1's room and saw her lying on the floor. E5 stated she called out to R1 and R1 answered, "Pick me Up" E5 stated resident had a bump on her head and was bleeding. E5 stated R1 could not walk but could sit up in bed or turn in bed if you ask her. E5 stated resident would ask for extra blankets at night and for her night hat to be placed on her head. E5 stated that R1's bed was in the low position. On 3/29/12 at 2:10PM, E2(DON) stated that she was notified at about 6:00AM the morning of the incident. E2 stated that she was informed by E4 that R1 had fallen out of bed, hit her head and was sent to the hospital. E2 stated she was told that there was a lot of blood on the floor and that E4 stated to her that the ambulance driver was yelling at her and she did not know why. E2 stated that she was not aware that R1's niece had requested a mat be placed at R1's bedside. E2 stated that a fall mat was placed at the bedside after this fall incident when resident returned back from hospital. E2 stated that R1 was a High Fall Risk for arising from wheelchair but not for bed. On 3/29/12 at 3:15PM, E6(MDS Coordinator) stated that a floor mat should have been in place at resident bedside according to residents fall care plan dated 9/13/2011 due to resident's history of falls and being observed on floor. We don't know what happened and I was not here. E6 stated we educate restorative and CNA's about these things. On 3/29/12 at 3:30PM, E2 stated that the MDS coordinator knows about the mat because she puts in the care plan and should tell staff to provide it. Review of incident report dated 1/17/12 indicates resident sustained [REDACTED]. Report indicates that R1 is confused at times, unaware of safety issues, has poor vision and no gait balance,uses wheelchair. Review of physician's orders [REDACTED]. According to physician's notes dated 1/18/12, R1 admitted on [DATE] after a fall at the nursing home, assessment results indicate abrasion to left knee, right eye/orbit swelling, no skull fractures, small amounts of fluid in left and right maxillary sinuse, sutures placed to right eye and patient confused. Review of consultant caridologist notes dated 8/29/11 indicates R1 at risk for falls due to cardiac ischemia. Psyhiatric evaluation dated 2/22/11 indicates R1 with poor to limited insight, judgement and easily becomes distracted and confused. Several attempts to call different doctors, none were available to being off or out of town. Review or resident fall care risk assessment dated [DATE] indicated resident fall risk score was an 8 and on 7/19/11 assessment score was 18, and on 8/17/11 indicate resident assessment score was 16(at risk for falls-no score), 8/30/11 assessment socre (not at risk for falls- no score) on 9/14/11(not at risk for falls), 10/15/11 and 11/02/11(at risk for falls- no scores). On 11/07/11 falls assessment indicates score(16) resident at risk for falls due to intermittent confusion, no able to maintain any gait/balance and is chair bound. On 11/26/1 fall assessment indicates R1 is oriented times to name, place and time, fall score(7) and resident has history of falls within past 3 months, change in gait pattern when walking, jerking or unstable when making turns and resident taking 3-4 medications. On 12/02/11 fall assessment indicates R1 at risk for fall(no score). Lastly, On 1/17/12 fall risk assessment indicates that R1 is dioriented x3 all of the time, chairbound, vision poor score(16). Review of fall risk assessments are inconsistant and implementation of intervention in care plan(mat placement) was not implemented. 2). On 3/29/12 at 3:45PM, R3 was sleeping in bed with no mat at bedside. The mat was across from her bed lying against the wall near her wheelchair. On 3/29/12 at 4:00PM with E7(CNA) noted that R3's mat was not at R3's bedside while R3 was asleep in bed. On 3/29/12 at 4:00PM, E7 asked should it be on the floor. At 4:25PM with E1(Administrator)R3 remained asleep. At this time R3 was positioned on her right side with arms and legs hanging over the side of bed. R3 is [AGE] year female with history of falls on 12/19/11 and 1/15/12 (hospitalization due to injury). R3 has [DIAGNOSES REDACTED].