Every finding on record at Aliya of Oak Lawn

Based on interviews and record review, the facility failed to update R2's comprehensive wound care plan when new wounds were identified on May 13, 2026. This failure affected one resident (R2) in a sample of four residents reviewed. On 6/9/2026 at 10:43 AM, R3 stated that no complaints regarding staffing and reported that staff are consistently available to assist her with her care needs, including providing assistance with changing her dressing. R3 further stated that she previously had wounds on her left leg that have since healed. On 6/9/2026 at 10:48 AM, R4 stated that he has been residing at the facility for approximately one month and said that everything has been going well thus far. R4 stated that he was admitted with a wound on his right foot and reported that the wound care team provides treatment on a daily basis. R4's right foot wound was observed dressed appropriately.On 6/9/2026 at 11:21 AM, R6 stated that he has served as the resident council president for an extended period of time and reported that the council meets regularly once a month. R6 added that the facility has a strong wound care team, which he observes conducting daily rounds. R6 stated, They keep a list of residents they see on a regular basis. R6 further stated, I am very comfortable here, staff are respectful and I do the same. I have no complaints.On 6/10/2026 11:03 AM, V10 (Certified Nursing Assistant/CNA) said that she cared for R2 and was very familiar with her needs. V10 attested that the wound care team regularly came to assess and treat R2's wounds and address any other care needs she had. R2 had a bedside commode and liked to get up early, so she was usually one of the first or second residents she assisted in the morning. At times, R2 would be heavily incontinent of urine due to use of water pill. V10 said R2 was never neglected. On 6/10/2026 at 11:21 AM, V12 (Registered Nurse/RN), stated that R2 was stable during the times she provided care. V12 reported that the wound care team evaluated and treated R2's wounds on a daily basis and routinely monitored her skin condition. R2 was assisted on a regular basis and that staff attended to her care needs appropriately. Regarding concerns that medications were not administered as ordered, V12 stated that she did not recall any incidents involving missed medications. She explained that R2's blood pressure fluctuated at times and that blood pressure medications were administered in accordance with physician orders and established clinical parameters. V12 added that she routinely explained medications to R2 and answered questions regarding their purpose and administration.On 6/10/2026 at 12:00 PM, V13 (Wound Care Director), and V5 (Wound Care Nurse), were interviewed together regarding R2's lower-extremity skin condition and wound care treatment. The wound care team reported that the bilateral lower-extremity blisters were identified on 5/13/2026. According to the wound care team, the blisters were believed to be related to fluid retention and edema resulting in increased fluid accumulation in the lower extremities. R2 was subsequently transferred to the hospital on 5/17/2026. Wound care services were provided during the period between identification of the blisters and the hospital transfer. R2's daughter was present during the skin assessment and was made aware of the findings at that time. The wound care team added that education was provided to R2's family regarding the wound treatment plan, including that dressing changes were scheduled three times per week and additionally as needed. Staff explained that dressings would be changed whenever clinically indicated, such as when dressings became soiled or compromised. According to the wound care team, the daughter requested dressing changes much more frequently; however, staff explained that hourly dressing changes were not clinically indicated or practical. Staff stated that dressings were changed whenever assessment findings warranted intervention.On 6/10/2026 at 1:31 PM V15 (Registered Nurse/RN) stated that the drainage from the resident's legs was not saturating the dressings and that there was nothing observed that suggested an acute emergency or significant deterioration in condition at the time of R2's send out. V15 added that R2 herself did not express complaints to the staff member. V15 denied that R2 was neglected. According to V15, R2 followed a normal daily routine that day. R2 was assisted with morning care, transferred to her chair, provided meals, and monitored throughout the day. The staff member recalled that shortly before the daughter's concerns arose, R2 appeared comfortable, was eating, and exhibited no signs that anything was seriously wrong.Record review revealed the following:eMAR (Electronic medication administration) and TAR (Treatment administration record) records indicated that medications and treatments were administered in accordance with provider orders.R2's wound was assessed and evaluated upon identification, and documentation reflects that the nurse practitioner and family were notified.R2 has a Brief Interview for Mental Status (BIMS) score of 12, dated 4/16/2026.Nursing documentation and resident education records indicate that R2 was provided with updates regarding her medications and treatments.Record review of physician and nurse practitioner (NP) visits showed that R2 was referred, seen, and evaluated on multiple occasions in the facility prior to transfer out to the hospital. Specialty providers and nurse practitioners involved in R2's care included Cardiology, Nephrology, Physiatry, Wound Care, Pulmonary, and Primary Care services.The nurse practitioner (NP) visited R2 on May 16, 2026. According to the NP's documentation, R2 presented with swelling and weeping of the right lower extremity, and staff charting noted the presence of blisters. A venous ultrasound was completed, which showed no evidence of deep vein thrombosis (DVT).Upon reviewing the wound assessment details report provided by the wound care team on 6/10/2026, R2 has other wounds: Blister on left lower leg and blisters on right lower leg. It also describes that R2's legs were noted swollen with fluid filled blisters.R2's Wound care plan was also reviewed. R2's wound care plan on wounds that was initiated on 4/10/2026 with a revision date of 5/6/2026 states that R2 has MASD/Moisture Associated Skin Damage to abdominal fold and right hip. The care plan was not addressing the newly identified wounds on both lower extremities. In a follow up interview to V13 (Wound Care Director) on 6/10/2026 at 1:12 PM, V13 acknowledged the presence of R2's wounds and confirmed that R2's care plan had not been updated. V13 stated that the resident's care plan should be updated immediately whenever there is a significant change in condition, including the development of acquired blisters or new skin integrity issues. V13 acknowledged that timely updates are necessary to ensure that appropriate interventions, monitoring, and treatment measures are identified and implemented. V13 added, I will re-educate them on updating care plan. According to [NAME] Health Care Policy on Baseline Care Plan, dated 1/2023 with a review date of 1/2026, state that Because the baseline care plan documents the interim approaches for meeting the residents immediate needs, it should also reflect changes to approaches, as necessary, resulting from significant changes condition or needs, occurring prior to the development of the comprehensive care plan.

Based on observation, interview and record review the facility failed to ensure medications were administered as ordered by the physician for three of three residents (R2, R3 and R4) reviewed for medication administration. Findings include:On 5/16/26 at 10:45AM, R2 observed in hallway, R2 said he is waiting for his morning medications, said he usually gets them by 8:30am, but has not received them today and said he needed pain medication as well. On 5/16/26 at 11:15AM, V4 (Licensed Practical Nurse) said she has not administered R2 morning medications due at 9:00AM. On 5/16/25 at 11:30AM, Observed V7 (Licensed Practical Nurse) giving R3 morning medications due at 9am. On 5/16/25 at 11:30AM, V7 said that she was called at 9am to cover a shift at the facility, and medication administration has not been given yet. V7 said she has not administered medications to R4 either. On 5/16/26 at 12:00PM, V3 (Assistant Director of Nursing) made aware of above findings. V3 said that medication administration should be given as ordered and may be given one hour before and one hour after the scheduled time, V3 said medications scheduled at 8:00am should not be given at 11:15am or 11:30am. An order summary report indicates that R2 has a physician order for Amlodipine Besylate 5mg tablet, Give 1 tablet by mouth one time a day for Hypertension, Aspirin 81mg, Give 1 tablet by mouth one time a day for peripheral vascular disease, Heparin Sodium (Porcine) Solution 5000 UNIT/ML, Inject 1 ml subcutaneously every 12 hours for prevent deep vein thrombosis, Jardiance Oral Tablet 10mg one time a day for type 2 Diabetes Mellitus, Metformin Tablet 1000mg 1 tablet by mouth two times a day for diabetes, Sitagliptin Phosphate Tablet 100mg 1 tablet by mouth one time a day for diabetes. Medication Administration Record for May 2026 indicates no pain medication administered per R2 request. An order summary report indicates that R3 has a physician order for Metoprolol Succinate ER Tablet Extended Release 24Hour 25mg 1 tablet by mouth one time a day for atherosclerotic heart disease of native coronary artery, Pantoprazole Sodium Tablet Delayed Release 40mg 1 tablet by mouth one time a day, ProSource Oral Liquid (Nutritional Supplements) Give 30 ml by mouth two times a day for nutrition support, Senna-S Tablet 8.6-50 MG (Sennosides-Docusate Sodium) 1 tablet by mouth two times a day for Constipation, Tab-A-Vite Tablet (Multiple Vitamin) 1 tablet by mouth one time a day for Nutritional Supplement, Tamsulosin HCl Capsule 0.4mg 1 capsule by mouth one time a day for benign prostatic hyperplasia, Zoloft Tablet 25mg 1 tablet by mouth one time a day for help manage alterations in mood state. An order summary report indicates that R4 has a physician order for Aspirin Oral Tablet Chewable 81mg 1 tablet by mouth one time a day for heart healthy, Losartan Potassium Tablet 100 MG Give 1 tablet by mouth one time a day for hypertension, Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension, Nifedipine ER Tablet Extended Release 24 Hour 90 mg 1 tablet by mouth one time a day for hypertension, Omeprazole 40mg Capsule delayed release 1 capsule by mouth in the morning for Heartburn Indigestion, Renal-Vite Oral Tablet 0.8mg 1 tablet by mouth in the morning for supplement, Sevelamer Carbonate Oral Tablet 800mg give 1600 mg by mouth three times a day for End stage renal disease.Facility Policy on Medication AdministrationGeneral: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis.Level of Responsibility: RN, LPNGuideline:An order is required for administration of all medication.Medications are administered by licensed personnel only.6. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident and time.13. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.22. If medication is not given as ordered, document the reason on the MAR and notify the health care provider if required.

Based on interview and record review, the facility failed to notify the State Agency of the initial and final report after one resident (R2) was emergently transferred to a local hospital and diagnosed with an acute and displaced right femoral neck fracture.Findings include:R2 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to: left femur fracture, anxiety disorder, bipolar disorder, lupus, and dependent on hemodialysis. According to the Minimum Data Set (MDS) dated [DATE], R3 has a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognitively intact.On 1-24-2026 at 11: 10 AM, R2 said, I had a fall on 12-27-2025 at 5:15 AM in the bathroom, and I broke my right hip. I was getting ready for the day, and no one was with me at the time of the fall. The paramedics picked me up from the floor and took me to the hospital.On 1-24-2026 at 2:20 PM, V2 (Director of Nursing) said, we did not report the incident to IDPH. We only report if the fall is unwitnessed; R2 was observed by the nurse on the floor.Per local hospital documentation dated: 12-27-2025 at 6:32 AM reads R2 very tearful and in severe right hip/thigh pain. Computed tomography scan (CT) without contrast, final findings and impression: Basicervical fracture of the right femoral neck impacted up to about 1 centimeter (cm). X-Ray of right femur final results: Acute and displaced right femoral neck fracture.On 1-24-2026 at 2:40 PM, V1 (administrator) said, since R2 had a pathological fracture, we do not need to report it to the State Agency. I am not sure, let me check the policy.At 2:50 PM, V1 presented policy title: Fall prevention and management dated: 7-2025 reads: All incidents and accidents with Serious Physical Injury will be reported to the State Agency within 24 hours. A full written investigative report is required by the State Agency within seven days of the incident.

Based on interview and record review, the facility failed to follow their dialysis policy by not communicating to their IN -HOUSE Dialysis Company that a new resident who was diagnosed with acute kidney failure and dependent on renal dialysis was admitted into the facility. This affected one of three residents (R159) reviewed for hemodialysis. This resulted in R159 missing treatments, subsequently R159 central venous catheter clotted requiring two hours of anti-clog therapy and having to remain in the dialysis chair for a total of four hours and forty-six minutes which caused R159 to have extreme leg pain.Findings include: Hospital paperwork service date 10/1/25 documents: Impressions/Recommendation-planning daily hemodialysis times three with incrementing time- third hemodialysis today three hours then will keep on Monday, Wednesday and Friday for now. R159 was admitted to the facility on [DATE] with the diagnosis of heart failure, chronic kidney disease stage four (CKD4) and diabetes. admission evaluation dated 10/10/25 documents: renal insufficiency, renal failure and end stage renal disease. Does resident receive dialysis: Yes. Type of dialysis: Hemodialysis. Dialysis access type and location of access site: Right subclavian port double lumen. Physician order dated 10/10/25 documents: Resident will receive dialysis IN-HOUSE on Monday, Wednesday, Friday. R159 care plan initiate on 10/22/25 documents: R159 needs dialysis (hemodialysis) related to CKD4. On 11/20/25 at 10:30am, V10 (dialysis nurse) said, he was not aware of R159 admission on [DATE]. V10 said, R159 was in the facility for six days without dialysis. V10 said, he had email corresponding that read R159 was going to be admitted to the facility. V10 said, he was never informed by medical record or any facility staff prior to 10/16/25 that R159 was admitted . V10 said, he was not given electronic access to R159 medical record. V10 said, dialysis does not have a way of knowing if a pending dialysis resident has been admitted to the facility unless dialysis is verbally informed or given electronic access to the resident chart by the facility. V10 said, dialysis is only granted access to dialysis residents by the facility. V10 said, dialysis cannot go in the facility electronic record to search for a resident. V10 said, he just happened to be in the hallway, taking another dialysis resident back to their room when V18 (nurse) asked him, when R159 was going to be dialyzed. V10 said, he replied, when was R159 admitted . V10 said, he returned to the dialysis unit, checked the computer and did not have access to R159's chart. V10 said, he went to R159's room, asked R159 if she receives dialysis, to which R159 replied, no. V10 said, he asked R159 if he could check for a dialysis catheter. V10 said, he unzipped R159 sweater and saw R159's dialysis catheter without a dressing located on her right chest wall. V10 said, R159 missed two scheduled days of dialysis due to the facility not notifying the dialysis unit that R159 arrived at the facility. V10 said, R159 was dialyzed without him having access to R159's electronic record. V10 said, V11 was called, updated about R159 missing two schedule treatments. V10 said, V11 ordered, R159 to run on low after having missed two treatments. V10 said, running low dialysis is done in order not to shift fluid to much fluid of the resident too fast. V10 said, due to R159 missing two scheduled days of dialysis, R159 had to have dialysis two days in roll and her catheter was clogged. Facility email to dialysis dated 10/7/25 documents: R159 is clinically and financially approved for HD (hemodialysis). Facility email 10/10/25 at 11:36am documents: Hey patient is ready to admit today ETA (estimated time of arrive) pick up 7:00pm. Dialysis email to facility dated 10/10/25 at 12:51pm documents: Fantastic!! Please keep us posted on the patient's arrival so our unit know when to place her (R159) on the schedule. On 11/20/25 at 12:35pm, V2 (Director of Nursing/ DON) said, admission is primary responsible for notifying dialysis that a resident needs dialysis. On 11/20/25 at 12:44pm, V12 (admission) said, the admission nurse is given a notice that a resident with hemodialysis, had been admitted . V12 said, she is responsible for notifying the dialysis unit via email that a dialysis resident was admitted into the facility. On 11/20/25 at 1:04pm, V12 was asked who makes dialysis aware of a dialysis resident that is scheduled to arrive at 7::00pm. V12 said, she does not know who would make dialysis aware, she does not work at 7:00pm and she is not clinical. On 11/20/25 at 2:00pm, V11 (nephrologist) said, R159 was admitted to the facility but dialysis was not informed R159 was in the building. V11 said, the dialysis nurse is his contact to the facility. V11 said, dialysis is important to manage electrolytes. V11 said, dialysis treatments are done at a slow rate to prevent seizures and a quick drop in blood pressure related to complication associated with dialysis. On 11/20/25 at 2:17pm, R159 who was assessed to be alert and orient to person place and time, said she did not have dialysis when she first arrived to the facility. R159 said, a male staff member asked if had dialysis in the facility, to which she replied no, then that staff member asked if he could check for her dialysis catheter. R159 said, she was a new dialysis patient. R159 said, she did not know her dialysis days. R159 said, she was so confused when she was in the hospital. R159 said, the first day of dialysis was when a male staff member came into her room and asked to check her dialysis catheter. R159 said, she guess the facility realized that she had a dialysis catheter and took her to dialysis. R159 said, her legs were swollen with fluid filled blisters. R159 said, after dialysis her legs hurt so bad she cried all night. R159 said, she did not receive the care she needs. R159 said, she was treated poorly. On 11/20/25 at 4:30pm, V18 (nurse) said, when R159 returns from dialysis, she complained of pain to her legs from sitting in the dialysis chair so long. V18 said, R159 had weeping wounds on her legs. V18 said, R159 was provided pain management. Hemodialysis Treatment Flowsheet dated 10/16/25 documents: Patient arrived in wheelchair, alert and oriented times three, no apparent distress noted and denied complaints. CVC has no dressing intact, no sign or symptoms of infection or bleeding.Communication report dated 10/16/25 documents: Post treatment duration two hours and thirty minutes. Patient condition or events during/post dialysis: stable central venous catheter/CVC malfunctions required activase (used to dissolve blood clots in central venous access device (CVAD) for restoration of function to CVC. Hemodialysis Treatment Flowsheet dated 10/16/25 documents: Discharge to nursing home. Daily notes (general): patient tolerated treatment well but CVC malfunction prolonged HD session considerably. Hemodialysis Treatment Flowsheet Notes documents: Treatment initiated at 1616 (4:16pm); Treatment started without complications; during treatment at 1652 (4:52pm); Pt alert, no distress noted during treatment at 1723 (5:23pm);Pt alert, watching TV no complaints voiced at 1725 (5:25pm); Treatment pause for Cathflo administration during treatment at 1747 (5:47pm); Patient off treatment cathflo dwelling 1833 (6:33pm); Patient remains off treatment while Cathflo dwells during treatment at 1942 (7:42pm); Patient alert no complaints. Treatment resumed during treatment 2013 (8:13pm); Patient alert, denies complaint, access and lines visible during treatment 2044 (8:40pm); Alert patient watching TV no distress noted treatment ended 2101 (9:01pm); Treatment completed, blood returned post blood pressure sitting 2110 (9:10pm) On 11/21/25 at 2:57pm, V30 (dialysis registered nurse) said, she was not notified of R159 admission until the 11/16/25. V30 said, she goes by her dialysis schedule for admission due to not having access to the resident's chart until the facility gives them access to the electronic record. R159 was a pending admission on their sheets Dialysis schedule dated 10/10/25 Friday, 10/13/25 Monday, 10/15/25 Wednesday documents: admit status: pending; patient: R159; date approved: 10/7/25; anticipated admission: [DATE]On 11/21/25 at 3:40pm, V2 (Director of Nursing/ DON) provide surveyor with a newly created Dialysis Acknowledgment Workflow which documents: admission Director will notify Dialysis Intake of any/new dialysis Admission. admission audit to be done by Unit Manager including Dialysis Orders. Unit Manager initiate and sign the Dialysis Acknowledgement Form. Once signed, Unit Manager hand the form to Dialysis Nurse to acknowledge and sign the form. Completed form will be submitted to the DON to verify and ensure that resident is added to the schedule. Dialysis Protocol dated 1/2023 documents: Dialysis in a facility. Receive home hemodialysis (HHD) or peritoneal dialysis (PD) treatment in nursing home, by trained and qualified staff who have received training and competency from dialysis facility. Shared communication between the facility and the dialysis facility. The care of the resident receiving dialysis service will reflect ongoing communication, coordination and collaboration between the facility and the dialysis staff. The communication process includes how the communication will occur, who is responsible for communicating and where the communication and responses will be document.

Based on interview and record review, the facility neglected to follow established clinical protocols, manufacture's guidance, internal training guidelines, and to follow their policy and procedures outlined in the Subacute Rehabilitation (SAR) Long-Term Acute Care (LTAC) Ventricular Assist Device (VAD) Training Manual, Heart Failure (HF) Left Ventricular Assist Device (LVAD) HF-LVAD HeartMate-3 Patient Guide, VAD Emergency Guide, LVAD Pocket Reference Guide. This affected one of one resident (R1) reviewed for providing services for a resident utilizing a LVAD. This neglectful practice resulted in R1 LVAD batteries not being monitored or changed when reached 50% capacity, R1 batteries depleted the pump stopped, R1 sent to hospital for cardiac arrest, R1 expired.The Immediate Jeopardy which began on [DATE] when R1's Left Ventricular Assist Device batteries were not changed resulting in depletion of the external batteries and internal back up battery then the heart pump stopped running. Subsequently R1 was found unresponsive, sent to emergency room for cardiac arrest, resuscitation efforts unsuccessful, R1 expired. V5 (Administrator) was notified of the immediate Jeopardy on [DATE] at 3:13pm The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include: R1's face sheet diagnoses encounter for surgical aftercare following surgery on the Circulatory System, unsteadiness on feet, Cognitive Communication Deficit, Type 2 Diabetes Mellitus without complications, Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Congestive Systolic Heart Failure, Ventricular Tachycardia, and presence of heart assist device. R1's Minimum Data Set (MDS) dated [DATE] shows Brief Interview for Mental Status (BIMS) score of 11 (Cognitive Deficits). R1's progress note dated [DATE] denotes in-part, [AGE] year-old male admitted to facility Alert (A) x Orient (O) x3 sometimes forgetful, NKA (No Known Allergies), room air. PMHX: (past medical history) Coronary Artery Disease (CAD) status post (s/p) Coronary Artery Bypass Grafting (CABG) and stent with End Stage Heart Failure with ejection fraction (EF) 15% (heart failure s/p Implantable Cardioverter-Defibrillator (ICD) HeartMate 3 on 8/2021, COPD without oxygen, Type 2 Diabetes Mellitus (DM), End Stage Renal Failure (ESRF) stage 3. Head to toe assessment completed, Pupils' Equal Round Reactive Light Accommodation (PERRLA), lungs clear, active Range of Motion (ROM) for all extremities, left upper arm fracture (refusing to wear sling), active bowel sounds, last bowel movement (BM) 07/2024. Skin intact, drive line insertion site Left Lower Quadrant (LLQ) with anchor on (RLQ Right Lower Quadrant, scattered bruising, drive line dressing change Monday, Wednesday, Fridays (M, W, F). LVAD needs to be checked twice a day (BID). RN (Registered Nurse) spoke with LVAD nurse (name noted) giving numbers in case of needing to be contacted, (phone number listed) during office hours, after hours, or emergency number (phone number listed). Resident very pleasant and cooperative, cell phone, shoes, clothes, LVAD batteries (6), LVAD battery charger, LVAD wall power unit, battery holders (4) all at bedside within reach. Call light, bed controller, and TV remote within reach next to resident. R1's emergency room records dated [DATE] denotes in-part patient coming from the nursing home, report from Emergency Medical Service (EMS), noted an unwitnessed cardiac arrest. The patient has an LVAD (Left Ventricular assist device). According to EMS when they arrived Cardiopulmonary Resuscitation (CPR) was in progress. EMS continued CPR. Assessment of the patient HeartMate 3 shows that the patient is on battery backup, that there is no power to this his unit. CPR continued. The patient's HeartMate 3 was connected to power source and began operating. Of note the advance heath care team stated that the patient had been on battery backup for over 300 minutes prior to arrival. On [DATE] at 1:10pm, V13 (emergency room Nurse) stated R1 arrived at the hospital for cardiac arrest, with EMS (Emergency Medical Service.) V13 stated that R1's Left Ventricular Assist Device's, batteries and the backup battery were dead upon arrival to the Emergency Room. V13 explained that the LVAD system is designed to pump blood to the heart because R1 has heart failure. V13 said the batteries should never be allowed to deplete. The event log file for R1's LVAD system denotes in part: the event log captured low voltage advisory and few voltage hazard events on battery power 9/15 at 3:55am through 4:20am, then the patient changed to charged batteries. Also noted a lone low flow event 09/15 at 3:56am with flow noted at 2.0. looked to be patient related as this was associated with elevated Pulsatility Index (PI) values. Further low voltage advisory events on battery power noted 09/16 at 12:59 which progressed into low voltage hazard events 09/16 at 3:28am. Battery power depleted 09/16 at 4:51am which enabled the EBB (emergency backup battery) in the controller and ran the VAD at the low limit of 5200 RPM until the EBB depleted as well on 09/16 at 6:48am, resulting in the VAD turning off. Unable to determine the time the VAD was off due to the timestamp being reset to [DATE] once the power was restored to the VAD. On [DATE] at 2:43pm, V19 Licensed Practical Nurse (LPN) said he was R1's nurse on the 3:00pm to 11:00pm pm shift on [DATE], he was orientating a new nurse V18 (LPN). V19 said he checked R1's LVAD, he (V19) checked the connections, he (V19) checked the batteries, and the aide assessed the vital signs. V19 said this was completed prior to him (V19) discharging an unrelated resident, that resident was discharged around 8:00pm. V19 said both of R1's LVAD's external batteries had three green bars. V19 said he did not change R1's batteries at that time. V19 said he did not change R1's LVAD's batteries during his shift, V19 said he did not plug R1's LVAD to the wall outlet prior to him (V19) leaving his shift. V19 said he left at 11:30pm. V19 said he reported to V3 (RN) the oncoming nurse to monitor R1 because R1 had an LVAD and R1 was an elopement risk. V19 said R1 has cognitive deficits. V19 said V18 completed all of the documentation for R1 because V18 was in orientation. V19 said he did not get training at [NAME] Oak Lawn for LVAD patients. V19 said V18 documented N/A -alarms and system check for LVAD, that was an error, the time is correct. V19 said N/A was for the dressing change, the facility did not have the correct dressing for R1's LVAD, and he (V19) did check the batteries and ensured the drive lines were connected. V19 said he did not complete a system check for R1's LVAD during his shift. V19 said he worked with LVAD patients in the past at another facility and he would complete a system check of the LVAD, V19 describes there's a button on the controller, and you press it, and it will take you through all the systems in the controller. V19 said he did not plug R1's LVAD into the wall outlet because R1 could let him know when he's going to bed, and could request to be plugged in.Facility presents timecard for V19 denoting V19 punched out at 12:45am on [DATE].This supports that V19 had the opportunity to change R1's LVAD external batteries during his shift, V19 remained on duty for 7 hours after he observed R1 LVAD batteries at three bars.On [DATE] at 12:42pm, V18 (LPN) said he was on orientation and V19 was the preceptor, V18 said his shift was on [DATE] on the 3:00pm-11:00pm shift, V18 stated he did not get training at [NAME] Oaklawn for LVAD patients. V18 said he observed V19 check R1's LVAD's batteries. V18 said he completed the documentation for R1's care, and he documented N/A for LVAD-alarms and system check, V18 said that was an error, and the N/A documentation was for the dressing change. V18 said the time does reflect when the batteries were checked. V18 said the LVAD is for heart failure.R1's progress notes denotes V18 documented at 5:01pm on [DATE], for the LVAD alarms and system check.The Facility presents a timecard for V18 denoting V18 punched out at 12:45am, on [DATE].This supports that V18 had the opportunity to change R1's LVAD's batteries during his shift, V18 remained on duty for 7 hours after the LVAD batteries was observed at three bars.On [DATE] at 11:13am, V3 (RN) said she was R1's nurse during the night shift (11pm-7:00am) on [DATE], V3 said she was familiar with R1, and she knew who R1 was. V3 said she was prompted to enter R1's room because the medication administration record showed orders to check R1's LVAD. V3 said she checked R1's blood pressure, it was low, but she wasn't concerned because R1's blood pressure usually runs low. V3 omitted checking R1's heart rate, respirations, and temperature. V3 stated that she documented the vital signs in the record. V3 said she hooked R1 up to the small charger (portable power unit/ wall outlet charger) at 3:30am and unhooked R1 at 6:00am. V3 stated that she spoke to R1, R1 even told her not to remove his batteries and to plug the pump into the portable charger. V3 said she knew the batteries were charged because the light was green. V3 described there's a button on the battery that you can be pressed, and it will illuminate. V3 said she has worked with LVAD systems in the past at another facility, but she did not receive training at the [NAME] Oak Lawn nursing home for LVADs. At 3:43pm, during a follow up interview V3 stated she was confused, and she switched R1's batteries out and did not charge R1 batteries by connecting the LVAD to the portable power unit (wall out charger). V3 said she was confused during the first interview. V3 said she switched the batteries out at 3:30am. V3 omitted completing a system check for R1's LVAD, V3 said she did not connect R1's LVAD to the wall outlet to charge during the night. Review of R1's physician order sheet for R1 does not have any orders to check the LVAD at night, as V3 stated that is what prompted her to enter R1's room. V3 stated she completed R1's vital sign assessment, however V3's documentation on the asthma/ COPD record date and time of [DATE] at 6:10am, denotes V3 used vital signs results dated [DATE] at 7:22 am completed by V10 Certified Nursing Assistant (CNA).On [DATE] at 12:12pm, V11 (CNA) said she was the aide for R1 on [DATE] during the night shift, and saw R1 around 10:30pm or 11:00pm, R1 said he wanted a sandwich and R1 got a sandwich from the nurse station and went to his room. V11 said she rounded on R1 during the shift by walking pass his room. V11 said she did not go into R1's room to check on R1, R1 was a resident that wandered, and if he's sleeping you don't wake him. V11 said she thought the Nurse gave R1 some good medicine to sleep all night. V11 said she doesn't check the LVAD because she is not a Nurse.On [DATE] at 2:10pm, V4 (RN) said she was R1's nurse for the morning shift of [DATE], V4 said upon arrival to the unit she did rounds, she (V4) always checked on the residents that have intravenous medications, and she checked on R1. V4 said R1 was okay, she entered his room to check on him, she observed R1's chest rise and fall. V4 said she did not check R1's LVAD because V3 (RN) reported to her that R1 was okay, and that she (V3) charged R1 batteries, and it was full. V4 said she just took V3 (RN) words for fact. V4 said she has not received any training on LVAD system at the [NAME] Oak Lawn. During this interview, V4 was asked to demonstrate how to check the LVAD batteries to determine the capacity, V4 picked up the gray battery, V4 could not identify where the button was located on the battery to determine if the battery was charged or not. V4 was observed to flip the battery over and over, V4 did not identify the button on the front of the battery to check the battery capacity. V4 stated she did not check R1's LVAD system or batteries when rounding on R1 upon the start of the shift on [DATE]. V4 observed on video surveillance, V4 did not enter R1's room as stated during the interview to observe that R1 chest was rising and falling. On [DATE] at 10:01am, V2 (CNA) said she was going to assess R1's vitals and observed R1 with no pulse, V2 said she notified V1, and immediately returned to start CPR on R1.On [DATE] at 11:23am, V7 (RN) stated that she cared for R1 quite often when R1 was on the back wing, on the Med bridge unit. V7 said she worked 16 hours often (first and second shift), and she changed R1 batteries at the beginning of each shift. V7 said there was 5 bars on the battery and when she changed them, the batteries, there would be 2 bars remaining. V7 said R1 often would mess with his LVAD and remove the batteries. V7 said the stationary charger was at R1's bedside on the table within R1's reach. V7 said R1 was verbal, always stated he wanted to go and smoke, and R1 wandered, wanting to go home. V7 said R1 had cognitive deficits. V7 said all the nurses were aware that R1 would remove his batteries, and the unit manager was aware also. V7 said she checked R1 more frequent because of this behavior. V7 said more frequent was about every two hours. V7 described entering the room, checking the batteries capacity and LVAD connections. V7 said she was a cardiac nurse from (hospital name) and she was familiar with the LVAD. V7 said she was off duty when the facility offered the training in [DATE], and when she returned to duty, she received a packet, and someone went over the packet with her. V7 said she doesn't recall who the person was that went over the packet with her.The unit manager was not available for interview during this survey, per V5 (Administrator) she resigned effective immediately on [DATE].On [DATE] at 12:41pm, V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with LVAD systems. V6 said she expects her staff to complete rounds on the residents initially upon coming on for the shift, and then every few hours after that. V6 said initially she was under the impression that V3 did complete rounds on R1 but after reviewing the facility surveillance she learned that V3 did not enter R1's room from 1:00am to the time she left duty. V6 said her expectation is that staff complete vital assessments on the residents, check the LVAD system to ensure the system is functioning and the batteries are full, and to change the batteries. V6 said she does not have any documentation that the staff received LVAD training in [DATE]. V6 said R1's family was upset by his death and had concerns about the LVAD system. V6 said she is learning during this survey that staff did not receive training for the LVAD.On [DATE] at 11:44am, V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said she received her training in February or March of 2025, she was not sure. V17 said the staff received LVAD training hosted by the (hospital name LVAD contact person). V17 said the webinar was held in the conference room, and other nursing staff was responsible to review the webinar while at the Nurse's station on the Med bridge unit. V17 said all the LVAD patients are assigned to the Med-bridge unit. V17 said the staff had the LVAD binder during the webinar. V17 said the policy/protocol/practice is for staff to use the binder located at the nurse's station for reference. V17 said staff should familiarize themselves with the patient that has the LVAD and familiarize themselves with the machine. V17 said staff is made aware of the patient with an LVAD during nurse-to-nurse report at the start of the shift. V17 said the staff should ensure that the batteries are charged by using the buttons and using the controller. V17 said if the light is green, it is ok, and staff should proceed with routine care. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 said if the alarm sounds staff should go to the patient, look at the monitor, check what alarms has triggered, the lights would appear, silence the alarm by clicking the blinking light, this allows the nurse to check the connections from patient to the monitor, once connections are checked the Nurse should push the button again. If the alarm remains off the Nurse can proceed with routine care. If the alarm continues contact the Tech from the LVAD company to receive further instructions. V17 said at night the resident's LVAD should be plugged into the wall outlet. V17 said during an emergency, if a resident is found unresponsive the Nurse should check the LVAD connections, batteries and check if the LVAD is running, V17 said the Nurse should replace the batteries if the batteries are not charged. V17 said she does not know how to run a system check on the LVAD, V17 said she has never seen R1's LVAD system, she has never entered R1's room to observe R1's LVAD system. V17 said she is not competent in LVAD training, policy/procedures. V17 said she recommends that herself and the nursing staff have hands on training with the LVAD system. V17 said there is not a stop order in place for admitting LVAD patients. V17 said she did not inform the Nursing staff that she was the LVAD preceptor because she did not feel competent in her role as the preceptor. V17 said she informed the Director of Nursing of this today. V17 said resident rounds should be conducted every two hours, staff should go inside the room, assess the patient, check for breathing, look for rise and fall in chest, observe for changes in condition, changes in breathing, check if resident is perspiring excessively, these signs could indicate a change in condition. V17 said she was aware that R1 was admitted with and LVAD in [DATE].On [DATE] at 12:57pm, V15 (Medical Doctor/ Medical Director) said R1 was planning to discharge home, R1 had heart failure with some functioning capacity, V15 stated that if the batteries to R1's LVAD was depleted it would exacerbate R1's death. V15 stated that there should be at least one Nurse on duty that is trained on the LVAD. V15 said the facility did not inform him of the occurrence. On [DATE] around the start of 5:25-5:30pm review of facility video surveillance with assist from V5 (Administrator), V5 made the surveyor aware that the time stamp was incorrect, and that the video was one hour behind. Video surveillance for the Med bridge unit was reviewed from 1:00am until 7:02am (V3 was observed to leave the unit with her bag). V3 did not enter R1's room between the hours of 1:00am to 7:02am. V3 was observed on the video sitting at the nurse's station, using V3's personal phone, blowing kisses while on the phone, laughing, observed rocking back and forth in a chair at the nurse station, walking down the hall waving her hands in the air, V3 was observed walking down the hall with her phone in her hand. V3 was also observed at the medication cart while on her phone. V3 observed to adjust the phone ensuring to prop the phone up while she was at the medication cart. Video shows V3 entering a room on the right-hand side of the hall (front facing the bistro). V5 zoomed into the video, there was three black hand sanitizer pumps on the wall, V3 entered the room between the second and third hand sanitizer pump. Immediately after video observation, during a tour with V5 to identify what room V3 entered, the room was identified as room number seven. That was not R1's room that V3 entered. V3 was observed to enter a room on the left-hand side of the hall, and rooms on the back unit. V3 observed to handle medications that was dropped off by pharmacy. V3 observed talking to V9 (LPN) at the nurse station several times. V3 observed to remove her white jacket and leave the unit and return. Video surveillance shows V4 (RN) entering the unit, V4 was observed to fully enter multiple rooms on the left-hand side and when V4 got to R1's room, V4 poked her head in the door frame briefly. V4 did not enter R1's room (this was identified by the placement of the black hand sanitizer pumps on the wall). Review of R1's asthma/ COPD assessment completed by V3 (RN) with effective date of [DATE] at 6:10am, it is denoted that R1 was alert, required head of bed to be elevated, shortness of breath or trouble breath when lying down, most recent pulse, 63- regular, dated [DATE] at 7:02am. Respiration 15, dated [DATE] at 7:22am. Blood pressure 88/64 dated [DATE] at 7:22am. Auscultation clear bilaterally.Review of R1's vital sign assessment log, the above vital signs was completed by V10 (CNA) on [DATE] at 7:22am and not V3.Review of R1's baseline care plan with V6, R1 did not have any goals and interventions listed for the LVAD.Review of R1's comprehensive care plan with V6, R1 did not have a comprehensive plan of care developed with goals and interventions for the LVAD.Review of R1's physician order sheet, order dated [DATE]; check LVAD two times a day for LVAD alarms and system checks.Review of R1's Medication Administration Record for the LVAD order, it is denoted that R1's LVAD was being checked at 9:00am and 5:00pm.There are no orders, for checking the alarms and system during the night shift. There is no plan of care for monitoring, assessing, and managing R1's LVAD at night.Facility policy/ procedures/ protocol for Ventricular Assist Device SAR/LTAC Training, denotes in-part, how to contact VAD team, heart failure, a ventricular assist device (VAD) is a continuous flow pump implanted to assist a failing native heart by taking blood from the left ventricle. Flowing through the pump into the outflow graft to the ascending aorta. VAD reduce the need of the native heart to pump vigorously to eject blood via the aortic valve, thereby reducing workload and oxygen demands of the native heart. General component; pump, driveline, controller and power x2. Driveline-Electrical line that communicates between the pump and the controller, LIFELINE- DO NOT CUT, DO NOT DISCONNECT FROM SYSTEM CONTROLLER OR THE PUMP WILL STOP!!!! Must ALWAYS be covered with sterile occlusive dressing. Battery power- Batteries can last from 8-17 hours depending on type of VAD, press button on battery to tell how much charge is left, change batteries if down to two lights (50%), always bring all batteries/wall power with patient if being transported/transferred. Every VAD patient must have back-up equipment due to the possibility of malfunction/equipment damage!! Back-up equipment includes extra system controller, extra Batteries clips (HM 2/3), Cell Phone to call hospital contact. Heart Ware Power Sources- one battery is expected to last 7-8 hours, Each, battery drains individually, once one battery drains to less than 25% it automatically switches to the other battery, Batteries are intended for daytime use, the AC adapter will always be the primary source of power if connected, Patients are to always sleep connected to AC adapter and one fully charged battery. While in the hospital the AC adapter should always be plugged into the red outlets. Power module/ mobile power unit aka wall power, patient always sleep on the wall power, assures continuous power, must be plugged into 2-prong grounded outlet (use red outlets if available) amplifies alarms of systems controller with heartmate 2 or 3. Patient will have either mobile power unit (small box only for home use) or power module (big box). In case of a power outage switch to batteries immediately. Keep power modules plugged in at all times to keep the internal battery charged. Batteries HeartMate 3 last 10-17 hours (batteries drain simultaneously). Monitoring battery power- change to fully charged batteries or plug into wall power if power gets to 2 green bars! Switch Power Sources one at a time never double disconnect power sources. Nursing care of VAD patient- patient assessment check vital signs and VAD parameters every shift, controller and power module self-test to be performed every morning, daily weights in the morning. Weights should be consistently with clothing/equipment, contact VAD team of weigh increase greater than 5 pounds in one week. Strict intake and output. Assess driveline site every shift- make sure anchor devices is in place, perform sterile dressing changes as ordered (call VAD team with any abnormalities). Blood pressures (BP)- an automatic blood pressure cuff may not work and the preferred way to check a BP is using the doppler method. Viewing pump and systems perimeters-press display button - pump speed, press display button twice- pump flow in liters per minute, press display button three times- Pulsatility index, press display button four times-power in [NAME] , press display button five times- charge status of the backup battery in the system controller-1.charged-2.charging-3.fault, press display button six times, blank screen indicates the screen is off, which is normal. Driveline dressing. Facility Abuse policy and prevention program dated 10/22 denotes in-part this facility affirms the right of all 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 and misappropriation of property and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that it has within its control to prevent occurrence of abuse neglect exploitation misappropriation of property deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse neglect exploitation misappropriation of property and mistreatment by anyone including but not limited to facilities app or the residents' consultants' volunteers' staff from other agencies providing services to the individual family members or legal guardians friends or any other individuals. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm pain or mental anguish neglect means a facility's failure to provide or willful withholding of adequate medical care mental health treatment psychiatric rehabilitation personal care or assistance with activities of daily living that is necessary to avoid physical harm mental anguish or mental illness of a resident including deprivation of goods and services by staff. 3.Orientation and training of employees; during orientation of new employees, the facility will cover at least the following topics, sensitivity to the residents and resident's needs, what constitute abuse, neglect, exploitation, and misappropriation of resident's property. 4.Establishing a resident sensitive environment the facility desires to prevent abuse neglect exploitation mistreatment deprivation of goods and services by staff and mistreatment of residents' property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following resident assessment as part of the resident's life history on the admission assessment comprehensive care plan and NMDS assessments staff will identify residents with increased vulnerability for abuse neglect exploitation his treatment history of trauma or misappropriation of residence property who have needs triggers and behaviors that may lead to conflict. Through the care plan processing staff will identify any problems goals and approaches which will reduce the chance of abuse neglect exploitation mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Staff supervision supervisors will monitor the ability of the staff to meet the needs of residents including that assigned staff have knowledge of individual residents' care needs. Situations such as inappropriate language and sensitive handling or impersonal care will be corrected as they occur incidents that do not meet the definition of abuse neglect exploitation misappropriation of property or mistreatment will be handled through counseling training and if necessary or repeated the facility progressive disciplinary action. In summary there were multiple staff on duty on [DATE] and [DATE] (night shift) that could have checked, changed and ensured that R1's LVAD batteries had adequate voltage to run the pump thereby circulating blood to R1's heart. The facility policy/procedures/protocol reflects to change the batteries at 50% capacity, the policy does not mention to wait for an alarm to sound before addressing, checking and changing the batteries.The Facility Assessment Tool dated [DATE] denotes in-part our resident profile, diseases/conditions, physical and cognitive disabilities- categories-heart/circulatory system, congestive heart failure. Decisions regarding caring for residents with conditions not listed above, facility resources including but not limited to staff skill sets and material resources. Mandatory in-services related to specific diagnoses or equipment, involvement of Medical Director, corporate resources. Services and care the facility offers based on our residents' needs, resident support needs, other special needs, dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care, LVAD. Provide person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents. Training topics, competencies: general staff-Abuse, Neglect and Exploitation. Nurses- Left Ventricular Assist Device. On [DATE] at 2:40pm, facility presented policy titled 'Left Ventricular Assist Device' dated 01/2025, review date 09/2025 denoting general: to provide guidance on the care of resident with LVAD. Responsible party Nursing staff, when a resident is admitted with in LVAD it will be noted in the medical record. Nurse will enter orders for LVAD care and monitoring based on discharge instructions from hospital or from LVAD clinical directly. All prothrombin time/international normalized ratio PT/ INR results, changes in resident condition, and equipment concerns will be directed to the LVAD clinic to which the resident is assigned. Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not present when request was made to review the LVAD policy, procedures, and or protocol on [DATE], [DATE] and [DATE].The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:1. Regional Director of Operations in-serviced the Administrator regarding the facility's Abuse/Neglect Policy and Procedure on [DATE] including neglect. The Administrator is the abuse coordinator and is responsible for ensuring all residents including R1 are free from neglect. The neglect on [DATE] was not reported to the Illinois Department of Public Health and an investigation was not sent until [DATE]. The nurse was the identified staff member that was the alleged perpetrator of neglect towards R1. The nurse was immediately suspended pending investigation. The nurse was terminated from the facility after the investigation was completed due to her failure to provide a clear and accurate report regarding the incident during her shift on [DATE]. The facility in-serviced the facility staff on the neglect/abuse policy and properly rounding and checking on residents at least every 2 hours starting on [DATE] 2. The nurse did not check on or complete vitals on R1 during her 11pm-7am shift on [DATE]. The nurse failed to check the LVAD battery of R1 during her shift on [DATE]. The Director of Nursing and Nurse Managers conducted in-services starting [DATE] regarding LVADs and properly checking for batteries and alarms. The nurse failed to ensure the LVAD was connected to the wall outlet to ensure proper levels of the battery. The Director of Nursing and Nurse Managers conducted LVAD training with licensed staff on [DATE] through [DATE] that included to ensure LVADs are connected to the wall outlet at night to ensure that battery [TRUNCATED]

Based on interview, record review, and policy review, the facility failed to provide appropriate, person-centered care and treatment to ensure the highest practicable physical, mental, and psychosocial well-being of 1 of 1 resident's (R1) reviewed with a Left Ventricular Assist Device (LVAD), who was found unresponsive. The facility failed to follow its own emergency response protocol, resulting in a failure to identify that R1's LVAD system had stopped functioning due to depleted batteries, contributing to cardiac arrest and subsequent death.The Immediate Jeopardy which began on [DATE] when the facility failed to follow their policy/practice/protocol to check the Left Ventricular Assist Device for functioning, if the device is running during an emergency when a resident R1 was observed unresponsive contributing to cardiac arrest and subsequent death. V5 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 3:13pm The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1's face sheet diagnoses of encounter for surgical after care following the Circulatory System, unsteadiness on feet, Type 2 Diabetes Mellitus, Ventricular Tachycardia, presence of heart assist device, Cognitive Communication Deficits, COPD, Acute and Chronic Congestive Systolic Heart Failure. R1's MDS dated [DATE] shows BIMS score of 11 (Cognitive Deficits). Physician order sheet shows orders for full code. R1's progress note dated [DATE] denotes in-part, [AGE] year-old male arrived at facility skin intact, drive line insertion site Left Lower Quadrant (LLQ) with anchor on Right Lower (RLQ) Quadrant, scattered bruising, drive line dressing change Monday-Wednesday-Friday (M, W, F). LVAD needs to be checked twice a day (BID). Registered Nurse spoke with LVAD nurse (name) giving numbers in case of needing to be contacted, (phone number listed) during office hours, after hours or emergency number (phone number listed). Resident very pleasant and cooperative, cell phone, shoes, clothes, LVAD batteries (6), LVAD battery charger, LVAD wall power unit, battery holders (4) all at bedside within reach. R1's emergency room records dated [DATE] denotes in-part patient coming from the nursing home report from EMS noted an unwitnessed cardiac arrest. The patient has an LVAD (Left Ventricular Assist Device). According to EMS when they arrived CPR was in progress EMS continued CPR. Assessment of the patient HeartMate 3 shows that the patient is on battery backup that there is no power to this his unit. CPR continued. The patient HeartMate 3 was connected to power source and began operating. Of note the advance heath care team stated that the patient had been on battery backup for over 300 minutes prior to arrival. On [DATE] at 1:10pm, V13 (emergency room Nurse) stated R1 arrived at the hospital in cardiac arrest, with Emergency Medical Service (EMS). V13 stated that R1 Left Ventricular Assist Device, batteries and the backup battery were dead upon arrival to the emergency room. V13 explained that the LVAD system is designed to pump blood to the heart because R1 has heart failure. V13 said the batteries should never be allowed to deplete. The event log file for R1's LVAD system denotes in part battery power depleted 09/16 at 4:51am which enabled the EBB (emergency backup battery) in the controller and ran the VAD at the low limit of 5200 RPM until the EBB depleted as well on 09/16 at 6:48am resulting in the VAD turning off. Unable to determine the time the VAD was off due to the timestamp being reset to [DATE] once the power was restored to the VAD. On [DATE] at 10:01am, V2 (CNA) said she was going to assess R1's vitals and observed R1 with no pulse, V2 said she notified V1 (LPN), and immediately returned to start CPR on R1. V2 said she remember getting tired when doing chest compressions and she switched out with V1. V2 said when they were in the room, she heard someone say that the LVAD was not plugged up and some said that's okay as long as the batteries are attached. V2 said she doesn't know the name of the person because she is fairly new to the facility. V2 said she did not check the LVAD, and she did not check the batteries. V2 said she has not had any training for emergency response to a patient with an LVAD.On [DATE] at 4:09p.m, V1 (LPN) said she was made aware by V2 that R1 was not responding, V1 said she got V4, (RN) attention, and they rushed into the room. V1 said she assisted with chest compressions and bagging R1 when V2 got tired. V1 said she did not check R1, LVAD for function, she did not check the batteries. V1 said V9 (LPN), V4 (RN), V20 (LPN), and V21 (LPN) all responded to the code blue for R1. V1 said she did not receive training on emergency response to a patient with an LVAD.On [DATE] at 2:10pm, V4 (RN) said she was R1's nurse for the morning shift of [DATE], V4 said when she heard the code blue she ran to get the crash cart, V4 said she did not assist with CPR efforts for R1, the other Nurses did CPR. V4 said she did not check the LVAD for functioning when she returned with the crash cart, she did not check the batteries. V4 said she left the room to see if the papers were being printed, V4 said she was not printing them, V9 (LPN) was printing. V4 said she was checking to ensure they were being printed. V4 said she was there when the medics took R1 to the hospital for further evaluation. V4 said she heard the medics say, R1 had a pulse and got R1 out fast. V4 said she did not receive training on emergency response to a patient with an LVAD at the [NAME] Oak Lawn.On [DATE] at 1:33pm, V9 (LPN) said she immediately called 911 when she heard code blue. V9 said she observed a nurse doing CPR, one nurse was writing, and one was doing vitals. V9 said she did not check R1's LVAD for functioning and she did not check the batteries. V9 said she went to print papers for R1's transfer to the hospital. V9 said she did not receive training on emergency response to a patient with an LVAD at the [NAME] Oak Lawn.On [DATE] at 1:48pm, V20 (LPN) said she heard the code blue announcement, she responded. V20 said she did compressions. V20 said she did not check R1's LVAD for functioning, she did not check the batteries. V20 said she worked with R1 in the past, she was aware that R1 had an LVAD. V20 said she has not received any training/ in-service for LVAD patients at the [NAME] Oak Lawn. V20 said a nurse showed her what to do for R1 when she worked with R1. V20 said she doesn't recall the name of that nurse. V20 said V21 (LPN) did respond to the code blue for R1. V20 said she did not receive training on emergency response to a patient with an LVAD at [NAME] oak lawn.On [DATE] V21 (LPN) said she can't remember if she responded to the code blue for R1.On [DATE] at 12:41pm, V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with a LVAD systems. V6 said she does not have any documentation that the staff received LVAD training in [DATE]. V6 said R1's family was upset by his death and had concerns about the LVAD system. V6 said she is learning during this survey that staff did not receive training for the LVAD/ LVAD emergency response. V6 said the LVAD should be checked for functioning during a code blue emergency situation.On [DATE] at 11:44am, V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said she recommends that herself and the nursing staff have hands on training with the LVAD system. V17 said there is not a stop order in place for admitting LVAD patients. V17 said during an emergency response when a resident is found unresponsive and the resident has a LVAD, the nurse should check the LVAD to ensure it is running (making a humming sound), they should check the batteries and if the batteries are not charged, they nurse should quickly change the batteries. V17 said any nurse that respond to the code blue can check the batteries and change them.R1's physician order sheet, order date [DATE] shows orders for full code.R1 does not have an individualized plan of care for the full code status, there is not an individualized plan of care with goals and interventions to implement when and if R1 is found/observed to be unresponsive, there are no plan of care with goals and interventions to implement for the LVAD when and if R1 is found/observed unresponsive.R1's plan of care for R1 what's admitted to the facility for a skilled stay requiring physician ordered medically necessary services, including direct therapy services, skilled nursing care management, and evaluation of the patient care plan observation and assessment of the patient's condition and or teaching and training activities related to the reason for stay or in preparation for transition to a lesser care environment. R1 requires skill services related to primary diagnosis aftercare s/p (status post) LVAD.Facility policy/protocol/ procedures for LVAD Patient Emergency Assessment denotes in-part: call rapid response team or 911. LVAD functioning? Auscultate left lower chest, continuous humming sound equals pump is working. No initiate: ACLS (advance cardiac life support) protocol, controller will probably be alarming: device check: check VAD parameters, controller alarm lights/sounds, continuous tone: urgent. Check power source. Check all cables connections. Change controller if instructed by VAD team. Transport urgently to ER (emergency room).Facility Emergency Response, denotes in-part VAD hazard alarm, call VAD team immediately (number listed) If patient is unresponsive: is VAD running? (listen for hum and check VAD numbers) YES: Treat underlying cause (patient could be unresponsive for other reasons; respiratory, stroke, blood sugar) NO: 1st attempt to get pump running quickly if unable to quickly okay to administer CPR and/or defibrillate. DO NOT disconnect VAD. If patient is responsive: Step 1-Check the connection between the system controller and the LVAD, (driveline), Step 2-Check the connection between the system controller and the batteries or between the system controller and power-based unit. Step 3-If the device still fails to operate and patient is stable, call VAD coordinator: (phone number listed). The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Emergency Protocol and Procedure for a resident with an LVAD on [DATE]. The Director of Nursing and Nurse Managers completed education with nurses on the facility's Emergency Protocol and Procedure for a resident with an LVAD. The Director of Nursing and Nurse Managers also completed the education provided by the manufacturer (via Teams) to the facility nurses. 2. The Director of Nursing was in-serviced on [DATE] by the Regional Nurse Consultant regarding emergency response for LVAD system and specialized device care. The Director of Nursing provided education on [DATE] through [DATE] to licensed and unlicensed nursing personnel on emergency response for LVAD system. The emergency response procedure will be placed in the resident care plan and at the bedside. 3. The Director of Nursing and/or Nurse Managers will provide education to current nursing department staff with competency exams when facility admits any specialty care resident specifically LVAD. This process will be included in the new hire onboarding/orientation process. The facility nurses will also receive training competencies at minimum quarterly and as needed for staff caring for residents with specialty care needs.4. The facility has revised its staffing protocols on [DATE] to ensure that at least one staff member trained in LVAD management is always on duty, including during all shifts, weekends, and holidays when there is an LVAD in the facility. The schedule is now maintained to verify proper coverage and trained staff assigned are being routinely audited by DON/designee. 5. The Director of Nursing and/or designee has educated licensed nursing staff on [DATE] on recognizing and appropriately responding to LVAD-related emergencies including prioritization of device functions assessment during a code situation. Mock code drills incorporating LVAD scenarios will be conducted monthly, with documentation and debriefing to reinforce staff knowledge and readiness. Date: [DATE]

Based on interview and record review the facility failed to follow their baseline care plan policy and develop an individualized baseline plan of care to include physician orders for a left ventricular assist device for a resident, This affected one of two residents (R2) reviewed for care plans and LVAD. R2 was admitted to the facility on [DATE], R2 face sheet shows diagnosis of chronic systolic congestive heart failure, atrial fibrillation, and presence of heart assist device. R2 facility census shows admission date 09/12/2025 and discharge date [DATE].R2 progress notes show R2 sent to hospital for change in condition on 09/15/2025.R2 third eye heath note dated 09/13/2025 at 10:09am denotes in-part patient name-R2. Initial stabilization visit, [AGE] year-old male admitted from the hospital after hypoglycemic event with sepsis currently on Bactrim DS twice a day for two more days past medical history of hypertension diabetes mellitus. Patient was admitted to the facility today and is awaiting full H and P (history and physical) and review by primary team. The nurse consulted third eye health to assess the patient to review discharge medication and orders and to ensure safe transition of care. Review of available paperwork and consultation with patient nurse was completed to identify high risk medication while awaiting evaluation by primary team. Physical exam findings per nurse and video observation physical exam medication review hospital discharge orders reviewed and updated as appropriate condition is stable medication review medication orders reviewed clarifications made see orders medication orders review no clarifications made patient is at risk for polypharmacy recommend that primary team review medications and eliminate unnecessary medications antibiotics diabetes repeated falls. Does the patient have any acute symptoms or any additional conditions that were addressed? today no. Orders available documentation review orders and medications approved until patient is evaluated by primary team obtain and review current relevant hospital documentation and orders with primary team when available start house start probiotics for 10 days twice a day. Fall precautions per facility policy. Point of care glucose checks three times a day before meals and at bedtime. Notify a clinician of any change in condition. Disposition: of stay at facility. Audio and video with patient and nurse present. Statement of medical necessity- yes. Sign date September 13, 2025 9:05 AM, provider V28.R2 initial stabilization visit completed by the provider, does not address the plan of care for R2's LVAD. Review of R2 physician order sheet for September 2025 there are no orders noted for R2 LVAD, no orders for VAD parameters every shift, no orders for controller and power module self-test to be performed every morning. 09/30/2025 V6 presents the admission evaluation, stating that the baseline care plan is included in the admission evaluation, V6 said there are no specific plan of care for R2's LVAD. During a follow-up interview on 10/3/25 at 4:46pm V6 (Director of Nursing) said she is now the LVAD preceptor for LVAD's, she is working with V5 (Administrator) to establish an order set for patients with an LVAD. R2 admission evaluation dated 09/12/2025, completed by the Nurse denotes in-part disease conditions contributing to admission- heart failure, devices- other- LVAD. Cardiovascular, ventricular assist device- yes is checked. Review of the baseline plan of care included in the admission evaluation, there are no goals or interventions noted specifically for the LVAD, there are no orders for checking/monitoring the alarms, system, or batteries. Review of R2 comprehensive plan of care with V12 (MDS coordinator), V12 stated that she edited/ revised the care plan during this survey on 09/18/2025 to include the LVAD, V12 stated she knew the surveyor was reviewing for LVAD's. V12 was asked, what's the specific goals and interventions for the patient with the LVAD, V12 said the floor nurse are supposed develop a plan of care for baseline care needs upon admission within 24 hours, and the MDS team will review the comprehensive plan of care after. V12 did not give a response of what the baseline care needs are for a resident with an LVAD. V12 said she should not edit a resident record after they have discharged from the facility. On 09/24/2025 at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 omitted what orders should be in-place for a patient with an LVAD.Facility policy titled baseline care plan dated 01/2023 last revision date 01/2025 denotes in-part to provide The staff with guidance on completion of comprehensive person-centered care baseline care planning. The facility will develop and implement A baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of residence admission into the facility. The baseline care plan will include at a minimum of the following necessary information to properly care for a resident elopement risk fall risk supervision needs behavior interventions activities of daily living needs initial goals based on admission orders physician orders dietary orders therapy services social services pass our recommendations if applicable. Person centered care means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. The baseline care plan must reflect the residence's stated goals and objectives and include interventions that address his or her current needs it must be based on admission orders and information about the resident available from the transferring provider and discussions with the resident and resident representative if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs it should also reflect changes to approaches as necessary resulting from significant changes in conditions or needs occurring prior to the development of the comprehensive care plan.Facility policy titled physician services dated 01/2023 review date of 01/2025 denotes in-part to outline the responsibility of the physician to the resident ad determine the alternative contact if the physician cannot be reached. The physician is responsible for completing the admitting history and physical within 72 hours of admission. The physician is responsible for reviewing the treatment plan, signing all orders in the medical record, as well as completing the medical record upon discharge. When an attending physician designates an on-call physician to cover in his or her absence (who is not currently permitted to provide care, treatment and services at the facility) the medical director and the attending physician determines that on the call physician can perform the required, treatment and services. Facility policy/ procedures/ protocol for Ventricular Assist Device SAR/LTAC Training, denotes in-part, how to contact VAD team, heart failure, a ventricular assist device (VAD) is a continuous flow pump implanted to assist a failing native heart by taking blood from the left ventricle flowing through the pump into the outflow graft to the ascending aorta. Nursing care of VAD patient- patient assessment check vital signs and VAD parameters every shift, controller and power module self-test to be performed every morning, daily weights in the morning. Weights should be consistently with clothing/equipment, contact VAD team of weigh increase greater than 5 pounds in one week. Strict intake and output. Assess driveline site every shift- make sure anchor devices is in place, perform sterile dressing changes as ordered (call VAD team with any abnormalities).On 10/3/2025 at 2:40pm facility presented policy titled 'Left Ventricular Assist Device' dated 01/2025, review date 09/2025 denoting general: to provide guidance on the care of resident with LVAD. Responsible party Nursing staff, when a resident is admitted with in LVAD it will be noted in the medical record. Nurse will enter orders for LVAD care and monitoring based on discharge instructions from hospital or from LVAD clinical directly. All PT/ INR results, changes in resident condition, and equipment concerns will be directed to the LVAD clinic to which the resident is assigned. Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not presented when request was made to review the LVAD policy, procedures, and or protocol on 09/17/2025, 09/19/25 and 09/23/2025. During this survey the surveyor was not able to identify what the specific orders should be in-place for a resident with an LVAD.

Based on interview, record review the facility failed to follow professional standards of care for residents requiring LVAD (Left Ventricular Assist Device). This affected two of two residents reviewed for LVAD. This failure resulted in the facility failure to assess and monitor the battery level for R1 LVAD and failure to intervene when the batteries depleted and failed to ensure R2 had physician orders in place in the medical record. 1.R1 face sheet diagnosis of encounter for surgical after care following the circulatory system, unsteadiness on feet, type 2 diabetes mellitus, ventricular tachycardia, presence of heart assist device, cognitive communication deficits, COPD, acute and chronic congestive systolic heart failure. R1 MDS dated [DATE] shows BIMS score of 11 (cognitive deficits)Skin intact, drive line insertion site LLQ (left lower quadrant) with anchor on RLQ (right lower quadrant, scattered bruising, drive line dressing change M, W, F (Monday, Wednesday, Fridays). LVAD (left ventricular assist device) needs to be checked BID (twice a day). R1 emergency room records dated [DATE] denotes in-part patient coming from the nursing home report from EMS noted an unwitnessed cardiac arrest. The patient has an LVAD (Left Ventricular assist device). According to EMS when they arrived CPR was in progress EMS continued CPR. Assessment of the patient heartmate shows that the patient is on battery back up that there is no power to this his unit. CPR continued. The patient heartmate was connected to power source and began operating. Of note the advance heath care team stated that the patient had been on battery backup for over 300 minutes prior to arrival. [DATE] at 1:10pm V13 (emergency room Nurse) stated R1 arrived at the hospital for cardiac arrest, with EMS (emergency medical service.) V13 stated that R1 Left Ventricular Assist Device, batteries and the backup battery was dead upon arrival to the emergency room. V13 explained that the LVAD system is designed to pump blood to the heart because R1 has heart failure. V13 said the batteries should never be allowed deplete. The event log file for R1'S LVAD system denotes in part the event log captured low voltage advisory and few voltage hazard events on battery power 9/15 at 3:55am through 4:20am then the patient changed to charged batteries. Also noted a lone low flow event 09/15 at 3:56am with flow noted at 2.0. Looked to be patient related as this was associated with elevated PI values. Further low voltage advisory events on battery power noted 09/16 at 12:59 which progressed into low voltage hazard events 09/16 at 3:28am. Battery power depleted 09/16 at 4:51am which enabled the EBB (emergency backup battery) in the controller and ran the VAD at the low limit of 5200 RPM until the EBB depleted as well on 09/16 at 6:48am resulting in the VAD turning off. Unable to determine the time the VAD was off due to the timestamp being reset to [DATE] once the power was restored to the VAD.On [DATE] at 2:43pm V19 (LPN) said he was R1's nurse on the 3:00pm -11:00pm pm shift on [DATE], he was orientating a new nurse V18 (LPN). V19 said he checked R1 LVAD, he checked the connections, he checked the batteries, and the aide assessed the vital signs. V19 said this was completed prior to him discharging an unrelated resident, that resident was discharged around 8:00pm. V19 said both of R1 LVAD external batteries had three green bars. V19 said he did not change R1 batteries at that time. V19 said he did not change R1 LVAD batteries during his shift, V19 said he did not plug R1 LVAD to the wall outlet prior to him leaving his shift. V19 said he left at 11:30pm. V19 said he reported to V3 (RN) the oncoming nurse to monitor R1 because R1 had an LVAD and R1 was an elopement risk. V19 said R1 has cognitive deficits. V19 said V18 completed all of the documentation for R1 because V18 was in orientation. V19 said he did not get training at [NAME] Oak Lawn for LVAD patients. V19 said V18 documented N/A -alarms and system check for LVAD, that was an error, the time is correct. V19 said N/A was for the dressing change, the facility did not have the correct dressing for R1 LVAD, and he did check the batteries and ensured the drive lines was connected. V19 said he did not complete a system check for R1 LVAD during his shift. V19 said he worked with LVAD patients in the past at another facility and he would complete a system check of the LVAD, V19 describes there's a button on the controller, and you press it, and it will take you through all the system in the controller. V19 said he did not plug R1 LVAD into the wall outlet because R1 could let him know when he's going to bed, and could request to be plugged in. Facility presents timecard for V19 denoting V19 punched out at 12:45am on [DATE].This supports that V19 had the opportunity to change R1's LVAD external batteries during his shift, V19 remained on duty for 7 hours after he observed R1 LVAD batteries at three bars. [DATE] at 12:42pm V18 (LPN) said he was on orientation and V19 was the preceptor, V18 said his shift was on [DATE] on the 3:00pm- 11:00pm shift, V18 he did not get training at [NAME] Oak Lawn for LVAD patients. V18 said he observed V19 check R1 LVAD batteries. V18 said he completed the documentation for R1 care, and he documented N/A for LVAD-alarms and system check, V18 said that was an error, and the N/a documentation was for the dressing change. V18 said the time does reflect when the batteries were checked. V18 said the LVAD is heart failure. R1 progress notes denotes V18 documented at 5:01pm on [DATE] for the LVAD alarms and system check. Facility presents timecard for V18 denoting V18 punched out at 12:45am on [DATE].This supports that V18 had the opportunity to change R1's LVAD batteries during his shift, V18 remained on duty for 7 hours after the LVAD batteries was observed at three bars. On [DATE] at 11:13am V3 (RN) said she was R1's nurse during the night shift (11pm-7:00am) of [DATE], V3 said she was familiar with R1, and she knew who R1 was. V3 said she was prompted to enter R1 room because the medication administration record showed orders to check R1's LVAD. V3 said she checked R1's blood pressure, it was low, but she wasn't concerns because R1 blood pressure usually runs low. V3 omitted checking R1 heart rate, respirations, and temperature. V3 stated that she documented the vital signs in the record. V3 said she hooked R1 up to the small charger (portable power unit/ wall outlet charger) at 3:30am and unhooked R1 at 6:00am. V3 stated that she spoke to R1, R1 even told her not to remove his batteries and to plug the pump into the portable charger. V3 said she knew the batteries was charged because the light was green. V3 described there's a button on the battery that you can be press and it will illuminate. V3 said she has worked with LVAD systems in the past at another facility, but she did not receive training at the [NAME] Oak Lawn nursing home for LVAD. During a follow up interview V3 stated she was confused and she switched R1's batteries out and did not charge R1 batteries by connecting the LVAD to the portable power unit (wall out charger). V3 said she was confused during the first interview. V3 said she switched the batteries out at 3:30am. V3 omitted completing a system check for R1's LVAD, V3 said she did not connect R1 LVAD to the wall outlet to charge during the night. Review of R1 physician order sheet R1 does not have any orders to check the LVAD at night, as V3 stated that is what prompted her to enter R1's room. V3 stated she completed R1 vital sign assessment, however V3 documentation on the asthma/ COPD record date and time of [DATE] at 6:10am, denotes V3 used vital signs results dated [DATE] at 7:22 am completed by V10 (CNA). [DATE] at 12:12pm V11 (CNA) said she was the aide for R1 on [DATE] during the night shift, V11 said saw R1 around 10:30pm or 11:00pm, R1 said he wanted a sandwich and R1 got a sandwich from the nurse station and went to his room. V11 said she round on R1 during the shift by walking pass his room. V11 said she did not go into R1 room to check on R1, R1 was a resident that wandered, and if he's sleeping you don't wake him. V11 said she thought the Nurse gave R1 some good medicine to sleep all night. V11 said she don't check the LVAD because she is not a Nurse.On [DATE] at 2:10pm V4 (RN) said she was R1's nurse for the morning shift of [DATE], V4 said upon arrival to the unit she did rounds, she always checked on the residents that have intravenous medications, and she checked on R1. V4 said R1 was okay, she entered his room to check on him, she observes R1 chest rise and fall. V4 said she did not check R1's LVAD because the V3 reported to her that R1 was okay, and that she (V3) charged R1 batteries, and it was full. V4 said she just took V3 words for fact. V4 said she has not received any training on LVAD system at the [NAME] Oak Lawn. During this interview V4 was asked to demonstrate how to check the LVAD batteries to determine the capacity, V4 picked up the gray battery, V4 could not identify where the button was located on the battery to determine if the battery was full or not. V4 was observed to flip the battery over and over, V4 did not identify the button on the front of the battery to check the battery capacity. V4 stated she did not check R1's LVAD system when rounding on R1 upon the start of the shift. V4 observed on video surveillance, V4 did not enter R1's room as stated during the interview to observe that R1 chest was rising and falling. [DATE] at 10:01am V2 (CNA) said she was going to assess R1 vitals and observed R1 with no pulse, V2 said she notified V1, and immediately returned to start CPR on R1. [DATE] at 11:23am V7 (RN) stated that she cared for R1 quite often when R1 was on back wing on the Med bridge unit, V7 said she worked 16 hours often (first and second shift), and she changed R1 batteries at the beginning of each shift. V7 said there was 5 bars on the battery and when she changed them the batteries, there would be 2 bars remaining. V7 said R1 often would mess with his LVAD and remove the batteries. V7 said the stationary charger was at R1's bedside on the table within R1 reach. V7 said R1 was verbal, always stated he wanted to go and smoke, and R1 wandered, wanting to go home. V7 said R1 had cognitive deficits. V7 said all the nurse was aware that R1 would remove his batteries, and the unit manager was aware also. V7 said she checked R1 more frequent because of this behavior. V7 said more frequent was about every two hours. V7 described entering the room, checking the batteries capacity and LVAD connections. V7 said she was a cardiac nurse from (hospital name) and she was familiar with the LVAD. V7 said she was off duty when the facility offered the training in [DATE], and when she returned to duty, she received a packet, and someone went over the packet with her. V7 said she don't recall who the person was that went over the packet with her. On [DATE] at 12:41pm V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with a LVAD systems. V6 said she expects her staff to complete rounds on the residents initially upon coming on for the shift, and then every few hours after that. V6 said initially she was under the impression that V3 did complete rounds on R1 but after reviewing the facility surveillance she learned that V3 did not enter R1's room from 1:00am to the time she left duty. V6 said her expectation is that staff complete vital assessment on the residents, check the LVAD system to ensure system is functioning and the batteries are full, and to change the batteries. On [DATE] at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said she received her training in February or March of 2025, she was not sure. V17 said the staff received LVAD training hosted by the (hospital name LVAD contact person). V17 said the webinar was held in the conference room, and other nursing staff was responsible to review the webinar while at the Nurse station on the Med bridge unit. V17 said all the LVAD patient are assigned to the Med-bridge unit. V17 said the staff had the LVAD binder during the webinar. V17 said the policy/protocol/practice is for staff to use the binder located at the nurse station for reference. V17 said staff should familiarize themselves with the patient that has the LVAD and familiarize themselves with the machine. V17 said staff is made aware of the patient with an LVAD during nurse-to-nurse report at the start of the shift. V17 said the staff should ensure that the batteries are charged by using the buttons and using the controller. V17 said if the light is green, it is ok, and staff should proceed with routine care. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 said if the alarm sound staff should go to the patient, look at the monitor, check what alarms has triggered, the lights would appear, silence the alarm by clicking the blinking light, this allows the nurse to check the connections from patient to the monitor, once connections are checked Nurse should push the button again. If the alarm remains off the Nurse can proceed with routine care. If the alarm continues contact the Tech from the LVAD company to receive further instructions. V17 said at night the resident LVAD should be plugged into the wall outlet. V17 said during an emergency, if a resident is found unresponsive the Nurse should check the LVAD connections, batteries and check if the LVAD is running, V17 said the Nurse should replace the batteries if the batteries are not charged. V17 said she does not know how to run a system check on the LVAD, V17 said she has never seen R1 LVAD system, she has never entered R1 room to observed R1 LVAD system. V17 said she is not competent in LVAD training, policy/procedures. V17 said she recommends that herself and the nursing staff have hands on training with the LVAD system. V17 said there is not a stop order in place for admitting LVAD patients. V17 said she did not inform the Nursing staff that she was the LVAD preceptor because she did not feel competent in her role as the preceptor. V17 said she inform the Director of Nursing of this today. V17 said resident rounds should be conducted every two hours, staff should go inside the room, assess the patient, check for breathing, look for rise and fall in chest, observed for changes in condition, changes in breathing, check if resident is perspiring excessively, these signs could indicate a change in condition. V17 said she aware that R1 was admitted with and LVAD in [DATE]XXX[DATE] at 2:17pm V15 (Medical Doctor/ Medical Director) said R1 was planning to discharge home, R1 had heart failure with some functioning capacity, V15 stated that if the batteries to R1 LVAD was depleted it would exacerbate R1 death. V15 stated that there should be at least one Nurse on duty that is trained on the LVAD. V15 said the facility did not inform him of the occurrence. [DATE] at 5:25-530pm review of facility video surveillance with assist from V5 (Administrator), V5 made surveyor aware that the time stamp was incorrect, and that the video was one hour behind. Video surveillance for the med bridge unit was reviewed from 1:00am until 7:02am (V3 was observed to leave the unit with her bag). V3 did not enter R1's room between the hours of 1:00am to 7:02am. V3 was observed on the video sitting at the nurse station, using personal phone, blowing kisses while on the phone, laughing, observed rocking back and forth in a chair at the nurse station, walking down the hall waving her hands in the air, V3 was observed walking down the hall with her phone in hand. V3 was also observed at the medication cart while on her phone. V3 observed to adjust the phone ensuring to prop the phone up while she was at the medication cart. Video shows V3 entering a room on the right-hand side of the hall (front facing the bistro). V5 zoomed into the video, there was three black hand sanitizer pumps on the wall, V3 entered the room between the second and third hand sanitizer pump. Immediately after video observation, during a tour with V5 to identify what room V3 entered, the room was identified as room number seven. That was not R1's room that V3 entered. V3 was observed to enter a room on the left-hand side of the hall, and rooms on the back unit. V3 observed to handle medications that was dropped off by pharmacy. V3 observed talking to V9 (LPN) at the nurse station several times. V3 observed to remove her white jacket and leave the unit and return. Video surveillance shows V4 (RN) entering the unit, V4 was observed to fully enter multiple rooms on the left-hand side and when V4 got to R1's room, V4 poked her head in the door frame briefly. V4 did not enter R1's room (this was identified by the placement of the black hand sanitizer pumps on the wall). Review of R1's asthma/ COPD assessment completed by V3 (RN) with effective date of [DATE] at 6:10am it is denoted that R1 was alert, required head of bed to be elevated, shortness of breath or trouble breath when lying down, most recent pulse, 63- regular, dated [DATE]at 7:02am. Respiration 15 dated [DATE] at 7:22am. Blood pressure 88/64 dated [DATE] at 7:22am. Auscultation clear bilaterally. Review of R1's vital sign assessment log, the above vital signs was completed by V10 (CNA) on [DATE] at 7:22am and not V3. Review of R1's baseline care plan with V6, R1 did not have any goals and interventions listed for the LVAD. Review of R1's comprehensive care plan with V6, R1 did not have a comprehensive plan of care developed with goals and interventions for the LVAD. Review of R1's physician order sheet, order dated [DATE]; check LVAD two times a day for LVAD alarms and system checks.Review of R1's Medication Administration Record for the LVAD order, it is denoted that R1 LVAD was being checked at 9:00am and 5:00pm. There are no orders, for checking the alarms and system during the night shift. There is no plan of care for monitoring, assessing, and managing R1's LVAD at night. Facility policy/ procedures/ protocol for Ventricular Assist Device SAR/LTAC Training, denotes in-part, how to contact VAD team, heart failure, a ventricular assist device (VAD) is a continuous flow pump implanted to assist a failing native heart by taking blood from the left ventricle. Flowing through the pump into the outflow graft to the ascending aorta. VAD reduce the need of the native heart to pump vigorously to eject blood via the aortic valve, thereby reducing workload and oxygen demands of the native heart. General component; pump, driveline, controller and power x2. Driveline-Electrical line that communicates between the pump and the controller, LIFELINE- DO NOT CUT, DO NOT DISCONNECT FROM SYSTEM CONTROLLER OR THE PUMP WILL STOP!!!! Must ALWAYS be covered with sterile occlusive dressing. Battery power- Batteries can last from 8-17 hours depending on type of VAD, press button on battery to tell how much charge is left, change batteries if down to two lights (50%), always bring all batteries/wall power with patient if being transported/transferred. Every VAD patient must have back-up equipment due to the possibility of malfunction/equipment damage!! Back-up equipment includes extra system controller, extra Batteries clips (HM 2/3), Cell Phone to call hospital contact. Heart Ware Power Sources- one battery is expected to last 7-8 hours, Each, battery drains individually, once one battery drains to less than 25% it automatically switches to the other battery, Batteries are intended for daytime use, the AC adapter will always be the primary source of power if connected, Patients are to always sleep connected to AC adapter and one fully charged battery. While in the hospital the AC adapter should always be plugged into the red outlets. Power module/ mobile power unit aka wall power, patient always sleep on the wall power, assures continuous power, must be plugged into 2-prong grounded outlet (use red outlets if available) amplifies alarms of systems controller with heartmate 2 or 3. Patient will have either mobile power unit (small box only for home use) or power module (big box). In case of a power outage switch to batteries immediately. Keep power modules plugged in at all times to keep the internal battery charged. Batteries heartmate 3 last 10-17 hours (batteries drain simultaneously). Monitoring battery power- change to fully charged batteries or plug into wall power if power gets to 2 green bars! Switch Power Sources one at a time never double disconnect power sources. Nursing care of VAD patient- patient assessment check vital signs and VAD parameters every shift, controller and power module self-test to be performed every morning, daily weights in the morning. Weights should be consistently with clothing/equipment, contact VAD team of weigh increase greater than 5 pounds in one week. Strict intake and output. Assess driveline site every shift- make sure anchor devices is in place, perform sterile dressing changes as ordered (call VAD team with any abnormalities). Blood pressures (BP)- an automatic blood pressure cuff may not work and the preferred way to check a BP is using the doppler method. Viewing pump and systems perimeters-press display button - pump speed, press display button twice- pump flow in liters per minute, press display button three times- pulsatility index, press display button four times-power in [NAME] , press display button five times- charge status of the backup battery in the system controller-1.charged-2.charging-3.fault, press display button six times, blank screen indicates the screen is off, which is normal. Driveline dressing. Facility Abuse policy and prevention program dated 10/22 denotes in-part this facility affirms the right of all 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 and misappropriation of property and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that it has within its control to prevent occurrence of abuse neglect exploitation misappropriation of property deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse neglect exploitation misappropriation of property and mistreatment by anyone including but not limited to facilities app or the residents' consultants' volunteers' staff from other agencies providing services to the individual family members or legal guardians friends or any other individuals. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm pain or mental anguish neglect means a facility's failure to provide or willful withholding of adequate medical care mental health treatment psychiatric rehabilitation personal care or assistance with activities of daily living that is necessary to avoid physical harm mental anguish or mental illness of a resident including deprivation of goods and services by staff. 3.Orientation and training of employees; during orientation of new employees, the facility will cover at least the following topics, sensitivity to the residents and resident's needs, what constitute abuse, neglect, exploitation, and misappropriation of resident's property. 4.Establishing a resident sensitive environment the facility desires to prevent abuse neglect exploitation mistreatment deprivation of goods and services by staff and mistreatment of residents' property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following resident assessment as part of the resident's life history on the admission assessment comprehensive care plan and NMDS assessments staff will identify residents with increased vulnerability for abuse neglect exploitation his treatment history of trauma or misappropriation of residence property who have needs triggers and behaviors that may lead to conflict. Through the care plan processing staff will identify any problems goals and approaches which will reduce the chance of abuse neglect exploitation mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Staff supervision supervisors will monitor the ability of the staff to meet the needs of residents including that assigned staff have knowledge of individual residents' care needs. Situations such as inappropriate language and sensitive handling or impersonal care will be corrected as they occur incidents that do not meet the definition of abuse neglect exploitation misappropriation of property or mistreatment will be handled through counseling training and if necessary or repeated the facility progressive disciplinary action. In summary there were multiple staff on duty on [DATE] and [DATE] (night shift) that could have checked, changed and ensured that R1's LVAD batteries had adequate voltage to run the pump thereby circulating blood to R1's heart. The facility policy/procedures/protocol reflects to change the batteries at 50% capacity, the policy does not mention to wait for an alarm to sound before addressing, checking and changing the batteries. The Facility Assessment Tool dated [DATE] denotes in-part our resident profile, diseases/conditions, physical and cognitive disabilities- categories-heart/circulatory system, congestive heart failure. Decisions regarding caring for residents with conditions not listed above, facility resources including but not limited to staff skill sets and material resources. Mandatory in-services related to specific diagnoses or equipment, involvement of Medical Director, corporate resources. Services and care the facility offers based on our residents' needs, resident support needs, other special needs, dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care, LVAD. Provide person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents. Training topics, competencies: general staff-Abuse, Neglect and Exploitation. Nurses- Left Ventricular Assist Device. On [DATE] at 2:40pm facility presented policy titled 'Left Ventricular Assist Device' dated 01/2025, review date 09/2025 denoting general: to provide guidance on the care of resident with LVAD. Responsible party Nursing staff, Nursing staff will check to ensure that the battery backup is charged. Facility LVAD training for nurses will be completed through LVAD clinic.This policy was not presented when request was made to review the LVAD policy, procedures, and or protocol on [DATE], [DATE] and [DATE].2. R2 was admitted to the facility on [DATE], R1 face sheet shows diagnosis of chronic systolic congestive heart failure, atrial fibrillation, and presence of heart assist device. R2's facility census shows admission date [DATE] and discharge date [DATE].R2's progress notes show R2 sent to hospital for change in condition on [DATE].R2's third eye heath note dated [DATE] at 10:09am denotes in-part patient name-R1. Initial stabilization visit, [AGE] year-old male admitted from the hospital after hypoglycemic event with sepsis currently on Bactrim DS twice a day for two more days past medical history of hypertension diabetes mellitus. Patient was admitted to the facility today and is awaiting full H and P (history and physical) and review by primary team. The nurse consulted third eye health to assess the patient to review discharge medication and orders and to ensure safe transition of care. Review of available paperwork and consultation with patient nurse was completed to identify high risk medication while awaiting evaluation by primary team. Physical exam findings per nurse and video observation physical exam medication review hospital discharge orders reviewed and updated as appropriate condition is stable medication review medication orders reviewed clarifications made see orders medication orders review no clarifications made patient is at risk for polypharmacy recommend that primary team review medications and eliminate unnecessary medications antibiotics diabetes repeated falls. Does the patient have any acute symptoms or any additional conditions that were addressed? today no. Orders available documentation review orders and medications approved until patient is evaluated by primary team obtain and review current relevant hospital documentation and orders with primary team when available start house start probiotics for 10 days twice a day. Fall precautions per facility policy. Point of care glucose checks three times a day before meals and at bedtime. Notify a clinician of any change in condition. Disposition: of stay at facility. Audio and video with patient and nurse present. Statement of medical necessity- yes. Sign date [DATE], 9:05 AM, provider V28.R2's initial stabilization visit completed by the provider, does not address the plan of care for R2's LVAD. Review of R2's physician order sheet for [DATE] there are no orders noted for R2 LVAD, no orders for VAD parameters every shift, no orders for controller and power module self-test to be performed every morning. [DATE] V6 (Director of Nursing) presents the admission evaluation, stating that the baseline care plan is included in the admission evaluation, V6 said there are no specific plan of care for R2's LVAD. During a follow-up interview on [DATE] at 4:46pm V6 (Director of Nursing) said she is now the LVAD preceptor for LVAD's, she is working with V5 (Administrator) to establish an order set for patients with an LVAD. R2 admission evaluation dated [DATE], completed by the Nurse denotes in-part disease conditions contributing to admission- heart failure, devices- other- LVAD. Cardiovascular, ventricular assist device- yes is checked. Review of the baseline plan of care included in the admission evaluation, there are no goals or interventions noted specifically for the LVAD, there are no orders for checking/monitoring the alarms, system, or batteries. Review of R2's comprehensive plan of care with V12 (MDS coordinator), V12 stated that she edited/ revised the care plan during this survey on [DATE] to include the LVAD, V12 stated she knew the surveyor was reviewing for LVAD's. V12 was asked, what's the specific goals and interventions for the patient with the LVAD, V12 said the floor nurse are supposed develop a plan of care for baseline care needs upon admission within 24 hours, and the MDS team will review the comprehensive plan of care after. V12 did not give a response of what the baseline care needs are for a resident with an LVAD. V12 said she should not edit a resident record after they have discharged from the facility. On [DATE] at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 omitted what orders should be in-place for a patient with an LVAD.Facility policy titled baseline care plan dated 1/2023 last revision date 01/2025 denotes in-part to provide the staff with guidance on completion of comprehensive person-centered care baseline care planning. The facility will develop and implement A baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will be developed within 48 hours of residence admission into the facility. The baseline care plan will include at a minimum of the following necessary information to properly care for a resident elopement risk fall risk supervision needs behavior interventions activities of daily living needs initial goals based on admission orders physician orders dietary orders therapy services social services pass our recommendations if applicable. Person centered care means that the facility focuses on the resident as the center [TRUNCATED]

Based on interview and record review the facility failed to follow their facility assessment and ensure that staff received in-service and training to provide care and service for residents with a left ventricular assist device. This affected two of two resident reviewed ( R1, R2). 1.R1's face sheet indicates diagnoses of encounter for surgical after care following the circulatory system, unsteadiness on feet, Type 2 Diabetes Mellitus, Ventricular Tachycardia, presence of heart assist device, cognitive communication deficits, COPD, Acute and Chronic Congestive Systolic Heart Failure. R1's MDS dated [DATE] shows BIMS score of 11 (cognitive deficits).2. R2 was admitted to the facility on [DATE], R2 face sheet shows diagnoses of Chronic Systolic Congestive Heart Failure, Atrial Fibrillation, and presence of heart assist device.On 09/17/2025 11:13am V3 (RN) said she did not receive training at the [NAME] Oak Lawn nursing home for LVAD. On 09/17/2025 at 1:33pm V9 (LPN) said she did not received training on emergency response to a patient with an LVAD at the [NAME] Oak Lawn.On 09/17/2025 at 2:10pm V4 (RN) said she V4 said she has not received any training on LVAD system at the [NAME] Oak Lawn. During this interview, V4 was asked to demonstrate how to check the LVAD batteries to determine the capacity, V4 picked up the gray battery, V4 could not identify where the button was located on the battery to determine if the battery was charged. V4 was observed to flip the battery over and over, V4 did not identify the button on the front of the battery to check the battery capacity. V4 stated she did not check R1's LVAD system or batteries when rounding on R1 upon the start of the shift on 9/16/25.On 09/17/2025 at 4:09p.m V1 (LPN) said she did not received training on emergency response to a patient with an LVAD.On 09/18/2025 at 10:01am V2 (CNA) said she has not received any training on LVAD system at the [NAME] Oak Lawn. On 09/18/2025 at 12:41pm V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with a LVAD systems. V6 said she does not have any documentation that the staff received LVAD training in July 2025. V6 said she is learning during this survey that staff did not received training for the LVAD. On 09/18/2025 at 2:17pm V15 (Medical Doctor/ Medical Director) V15 stated that there should be at least one Nurse on duty that is trained on the LVAD. On 09/19/2025 at 12:12pm V11 (CNA) said she did not get training at the [NAME] Oak Lawn nursing home for LVAD. On 09/24/2025 at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said all Nursing staff should have training for the LVAD, V17 said she would like the training to consist of return demonstration to allow for hands on training, V17 said watching videos is not enough training to learn about the LVAD. On 09/24/2025 at 2:43pm V19 (LPN) said he did not get training at [NAME] Oak Lawn for LVAD patients. On 09/24/2025 at 12:42pm V18 (LPN) said he, V18 he did not get training at [NAME] Oak Lawn for LVAD patients. On 09/25/2025 V21 (LPN) said she can't remember if she responded to the code blue for R1. V21 said she remember that the training was offered in July, she doesn't recall the participating in the training. On 09/26/2025 at 1:48pm V20 (LPN) said she did not received training on emergency response to a patient with an LVAD at [NAME] oak lawn.The Facility Assessment Tool dated 08/29/2025 denotes in-part our resident profile, diseases/conditions, physical and cognitive disabilities- categories-heart/circulatory system, congestive heart failure. Decisions regarding caring for residents with conditions not listed above, facility resources including but not limited to staff skill sets and material resources. Mandatory in-services related to specific diagnoses or equipment, involvement of Medical Director, corporate resources. Services and care the facility offers based on our residents' needs, resident support needs, other special needs, dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care, LVAD. Provide person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents. Training topics, competencies: general staff-Abuse, Neglect and Exploitation. Nurses- Left Ventricular Assist Device.

Based on interview and record review, the facility failed to follow their abuse policy and prevent resident-to-resident sexual inappropriateness. This affected two of three residents (R1 and R2) reviewed for abuse. This failure resulted in R2 touching, groping and fondling R1 inappropriately resulting in R1 feeling helpless, scared, tearful and feeling uncomfortable. Findings Include:R1 was admitted to the facility with diagnoses of reduced mobility and functional quadriplegia. R1s Minimal data set (MDS) section C (cognitive patterns) dated 7/14/25 documents: a score of fifteen which indicates cognitively intact. Section GG (functional abilities) documents: R1's is dependent on staff to roll left to right, sit to lying and lying to sitting on the side of bed. R1's care plan initiated on 07/13/2025 documents: ABUSE/NEGLECT: My comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase my susceptibility to abuse/neglect AEB/as evidenced by on 08/18/25 R1 was touched inappropriately by another male resident. Nursing note dated 8/18/25 documents: Writer heard resident (R1) yell out for help, writer got up to go to the yelling. Writer observed R1 in his bed with another resident near the bedside. Resident (R1) stated, he did not know what he was doing or if he (R2) was touching him because he couldn't feel it. On 8/23/25 at 2:45pm, R1 who was assessed to be alert and oriented to person, place and time, said he was in bed when R2 entered his room via wheelchair. R1 said, R2 rolled on the side of his bed, stopped his wheelchair, stood up, lifted R1's gown and ripped opened R1's adult brief. R1 said, R2 put his hand around his penis and started rubbing it. R1 said, he was scared, he yelled for help and R3 saved his life. R1 said, he felt uncomfortable. R1 said, he does not have sexual activities with men. R1 said, he is not like that. R1 said, the facility needs security. On 8/20/25 at 11:15am, R3 who was assessed to be alert and oriented to person, place and time, said R1 was yelling for about four minutes. R3 said, he walked to R1's room. R3 said, he saw R2 standing up on the side of R1's bed with his right hand on R1's penis moving up and down while holding his (R2's) penis while moving his left hand moving back and forth. R3 said, R2 is aware of his behavior. R3 said, R2 rolls through the hallway looking for bedbound residents. R2 does not bother residents that can walk. R2 has touched other bedbound residents before. R2 waits and watches until staff is not looking, go into resident's room and touch them inappropriately. R3 said, R1 is contracted with his arms up by his head and his legs are stuck open, knee up and apart. R1 could only yell for help. R3 said, V6 (certified nursing assistant/CNA) was the first to enter R1's room. On 8/20/25 at 2:12pm, video watched with V1 (administrator), V4 (assistant administrator) and V14 (director of nursing/ DON). V1 said, the video time is an hour ahead. R1 was seen entering R2's room at 11:17am per the recording time on the video but it was actually 12:17 per V1. R2 was seen exiting R1's room at 11:19am per the recording time on the video but it was actually 12:19 per V1. On 8/20/25 at 12:26pm, V6 (cna) said, said when she entered R1's room. R1 was observed with his gown up. R2 pulled up R1's gown, pushed R1's adult brief to the side and touched R1's penis. R3 called the nurse. V6 said, she had to fix R1's adult brief and pull down R1's gown. V6 said, R1 was crying when she entered his room. V6 said, R1 reported not feeling safe at the facility and wanting to die. V6 said, R1 reported he has never been touch by a man before. V6 said, R1 reported R2 had his hand in R1's adult brief touching his penis. Nursing note dated 8/20/25 documents: Patient (R1) is going to be admitted for sexual assault.On 8/26/25 at 1:34pm, V5 (nurse) said, she was the reporting nurse for R1. V5 said, she was aware that R1 has a history of inappropriate touching other residents. V5 said, R1 reported, that R2 touch his anus. Nursing note dated 7/17/25 documents: RN (V5) noticed resident (R2) kept going into another resident room. The resident (R2) is trying to inappropriately touch the other resident and tell him he loves him. On 8/26/25 at 2:45pm, V12 (R2's power of attorney/POA) said, R2 has dementia and a history of same sex relationships. V12 said, she received a call about R2's incident with R1. V12 said, she has received calls from the facility prior to R1's incident about R2 inappropriate touching other residents. V12 said, the facility has been so patient with R2. Now the facility is acting like they do not have any patience with R2, like they can tolerate R2 anymore. R2 will do the same thing at any facility. The current facility found a new facility for R2 but they refused to accept him after R2's recent inappropriate touching incident with R1.R2's Behavior note created on 8/18/25 documents: Behavior Description: Inappropriately touching another resident. Behaviors: resident (R2) observed inappropriately touching a resident (R1). Nursing note dated 8/18/25 documents: Writer heard a resident (R1) yell out for help, writer got up to go to the yelling. Writer observed above resident (R2) in his wheelchair bending and reaching over to a resident (R1) in bed. Resident (R2) being petitioned to the hospital for inappropriate sexual behavior towards his peer. On 8/20/25 at 1:45pm, V2 (social service) said, she was made aware, R2 inappropriately touched R1 during the morning meeting. V2 said, she was informed, R2 opened R1's adult brief and had his hand in R1's brief. R1 reported he felt uncomfortable because he was not a homosexual. On 8/20/25 at 2:31pm, V3 (nurse practitioner) said, she was informed on Monday 8/18/25 that another resident touched R1. V3 said, she saw R1 on Tuesday. V3 said, R1 reported R2 lifted his gown and grabbed his penis. R1 reported he can't get erect because he is paralyzed. R1 said, he was not gay. R1 was crying. V3 said, she suggested R1 go to the hospital. On 8/20/25 at 11:49am, V10 (restorative aide) said, she was instructed to move R1 to a different room. V10 said, R1 requested that she stay with him because R1 reported being scared. V10 said, she was informed R1 was inappropriately touched by R2. On 8/20/25 at 11:59am, V11 (cna) said, she saw R1 crying. V11 said, she asked R1 was he okay. V11 said, R1 replied, please don't leave him. V11 said, R1 was scared to be left alone. V11 said, R1 is contracted and dependent on staff for assistance. V11 said, she was informed R2 took off R1's adult brief. On 8/20/25 at 12:12pm, V7 (nurse) said, she heard a resident yelling help, help, help. V7 said, staff started running towards the yelling. R1 was in bed on his back. R2 was standing by R1's bed, reaching under R1's gown. R1's adult brief was loose. V7 said, R1 reported he didn't know what R2 was doing. On 8/20/25 at 12:39pm, V8 (cna) said, she heard R3 telling R2 to get out of R1's room. R1 is contracted with his hands stuck behind his head. R1's legs are contracted opened. V8 said, R1 is dependent on staff for assistance. R2 is a wander. R2 should not have been in R1's room. Hospital Paperwork dated 8/19/25 documents: Patient (R1) present to emergency department for evaluation after an assault. R1 does not feel safe. Emergency Department diagnoses: Sexual assault of adult. Per emergency service: R1 was manually grouped by another resident, allegedly witness by another resident. (8/21/25) Case manager spoke with patient (R1) at bedside who was alert and orient times four, declined to discharge to long term care facility, states he just left a facility where he was molested. Police report dated 8/19/25 documents: office responded to nursing home in regard to a criminal sexual abuse report. R1 was lying in bed alone. While laying down, R2 entered R1's room in a wheelchair. R1 rolled his wheelchair next to R1's bed and came to a stop. R2 then stood up and opened R1's diaper. R1 related that R2 placed his right hand in R1's adult brief and began to groan. R1 does not have any sense of feeling below the waist and did not know exactly what R2 was doing to his genitals. R1 began to call for a nurse while R2 was moving his hand around R1's genitals. R3 entered the room and began to shout at R2 to stop. Abuse policy dated 10/2022 documents: The facility affirms the right of our residents to be free from abuse, neglect or exploitation. Sexual abuse includes but is not limited to sexual harassment, sexual coercion or sexual assault including non-consensual or non-competent to consent sexual activity.

Based on interview and record review the facility failed to follow its abuse policy by not reporting an allegation of abuse to the regulatory state agency within 24 hours. This affected two of three residents (R1, R2) reviewed for abuse policy. Findings Include:R2's Behavior note created on 8/18/25 at (12:49) documents: Behavior Description: Inappropriately touching another resident. Behaviors: resident (R2) observed inappropriately touching a resident (R1). Nursing note dated 8/18/25 documents: Writer heard a resident (R1) yell out for help, writer got up to go to the yelling. Writer observed above resident (R2) in his wheelchair bending and reaching over to a resident (R1) in bed. Resident (R2) being petitioned to the hospital for inappropriate sexual behavior towards his peer. On 8/20/25 at 3:45pm, V1 (administrator) said, if she is aware of an abuse allegation it should be reported to Illinois Department of Public Health within two to twenty-four hours. V1 said, she was informed of R1's incident by V4 (assistant administrator) followed by V14 (director of nursing) on 8/19/25. V1 said, R1's incident should have been reported if staff felt like it was abuse. V1 said, she did not report the incident due to being off but V4 should have because she was in the building. On 8/23/25 at 2:45pm, R1 who was assessed to be alert and oriented to person, place and time, said he was in bed when R2 entered his room via wheelchair. R1 said, R2 rolled on the side of his bed, stopped his wheelchair, stood up, lifted R1's gown and ripped opened R1's adult brief. R1 said, R2 put his hand around his penis and started rubbing it. R1 said, he was scared, he yelled for help and R3 saved his life. R1 said, he felt uncomfortable. R1 said, he does not have sexual activities with men. R1 said, he is not like that. R1 said, the facility needs security. On 8/20/25 at 11:15am, R3 who was assessed to be alert and oriented to person, place and time, said R1 was yelling for about four minutes. R3 said, he walked to R1's room. R3 said, he saw R2 standing up on the side of R1's bed with his right hand on R1's penis moving up and down while holding his (R2's) penis while moving his left hand moving back and forth. R3 said, R2 is aware of his behavior. R3 said, R2 rolls through the hallway looking for bedbound residents. R2 does not bother residents that can walk. R2 has touched other bedbound residents before. R2 waits and watches until staff is not looking, go into resident's room and touch them inappropriately. R3 said, R1 is contracted with his arms up by his head and his legs are stuck open, knee up and apart. R1 could only yell for help. R3 said, V6 was the first to enter R1's room. On 8/20/25 at 12:26pm, V6 (cna) said, said when she entered R1's room. R1 was observed with his gown up. R2 pulled up R1's gown, pushed R1's adult brief to the side and touched R1's penis. R3 called the nurse. V6 said, she had to fix R1's adult brief and pull down R1's gown. V6 said, R1 was crying when she entered his room. V6 said, R1 reported not feeling safe at the facility and wanting to die. V6 said, R1 reported he has never been touched by a man before. V6 said, R1 reported R2 had his hand in R1's adult brief touching his penis. On 8/20/25 at 2:12pm, video watched with V1 (administrator), V4 (assistant administrator) and V14 (director of nursing/ DON). V1 said, the video time is an hour ahead. R1 was seen entered R2's room at 11:17am per the recording time on the video but it was actually 12:17 per V1. R2 was seen exiting R1's room at 11:19am per the recording time on the video but it was actually 12:19 per V1. Facility timeline documents: At 12:19, V6 (cna) was noted running from the east nurses' station area towards R1's room. V8 (cna) came from room [ROOM NUMBER] and noted walking towards R1's room. R3 was noted talking and pointing into R1's room while standing in the hallway. R2 out of R1's room with V7 (nurse) behind him. At 12:22pm, V14 (therapy director), V15 and R3 walked over to administrators' office to report that R2 was noted in R1's room standing over R1 by the foot of the bed. On 8/26/25 at 1:34pm, V5 (nurse) said, she was the reporting nurse for R1 on 8/18/25. V5 said, R1 reported, that R2 touch his butt hole. Facility reportable date of the incident 8/19/25 documents: Time of incident: 2:30pm: Sexual: Describe Alleged Incident: Nurse Practitioner who reported the resident, R1 reports to her that another resident (R2) was sexually inappropriate towards him, Hospital Paperwork dated 8/19/25 documents: Patient (R1) present to emergency department for evaluation after an assault. Emergency Department diagnoses: Sexual assault of adult.Police report dated 8/19/25 documents: office responded to nursing home in regard to a criminal sexual abuse report. R1 was lying in bed alone. While laying down, R2 entered R1's room in a wheelchair. R1 rolled his wheelchair next to R1's bed and came to a stop. R2 then stood up and opened R1's diaper. R1 related that R2 placed his right hand in R1's adult brief and began to groan. R1 does not have any sense of feeling below the waist and did not know exactly what R2 was doing to his genitals. R1 began to call for a nurse while R2 was moving his hand around R1's genitals. R3 entered the room and began to shout at R2 to stop. Abuse policy dated 10/2022 documents: Internal reporting requirement and identification of allegations. Employee are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observed, hear about, or suspect to the administrator or the compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Any allegation of abuse or any incident that results in serious bodily injury will be reported to Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported with in twenty-four hours.

Based on interview and record review, the facility failed to effectively monitor and supervise a resident with a diagnosis of dementia from wandering into another resident's room without permission and sexually touching another resident. This affected two of three residents (R1, R2) reviewed for supervision of resident with dementia.Findings Include:On 8/23/25 at 2:45pm, R1 who was assessed to be alert and oriented to person, place and time, said he was in bed when R2 entered his room via wheelchair. R1 said, R2 rolled on the side of his bed, stopped his wheelchair, stood up, lifted R1's gown and ripped opened R1's adult brief. R1 said, R2 put his hand around his penis and started rubbing it. R1 said, he was scared, he yelled for help and R3 saved his life. R1 said, he felt uncomfortable. R1 said, he does not have sexual activities with men. R1 said, he is not like that. R1 said, the facility needs security. On 8/20/25 at 11:15am, R3 who was assessed to be alert and oriented to person, place and time, said R1 was yelling for about four minutes. R3 said, he walked to R1's room. R3 said, he saw R2 standing up on the side of R1's bed with his right hand on R1's penis moving up and down while holding his (R2's) penis while moving his left hand moving back and forth. R3 said, R2 is aware of his behavior. R3 said, R2 rolls through the hallway looking for bedbound residents. R2 does not bother residents that can walk. R2 has touched other bedbound residents before. R2 waits and watches until staff is not looking, go into resident's room and touch them inappropriately. R3 said, R1 is contracted with his arms up by his head and his legs are stuck open, knee up and apart. R1 could only yell for help. R3 said, V6 was the first to enter R1's room. On 8/20/25 at 2:12pm, video watched with V1 (administrator), V4 (assistance administrator) and V14 (director of nursing/ DON). V1 said, the video time is an hour ahead. R1 was seen entered R2's room at 11:17am per the recording time on the video but it was actually 12:17 per V1. R2 was seen exiting R1's room at 11:19am per the recording time on the video but it was actually 12:19 per V1. On 8/20/25 at 12:26pm, V6 (cna) said, said when she entered R1's room. R1 was observed with his gown up. R2 pulled up R1's gown, pushed R1's adult brief to the side and touched R1's penis. R3 called the nurse. V6 said, she had to fix R1's adult brief and pull down R1's gown. V6 said, R1 was crying when she entered his room. V6 said, R1 reported not feeling safe at the facility and wanting to die. V6 said, R1 reported he has never been touched by a man before. V6 said, R1 reported R2 had his hand in R1's adult brief touching his penis. Nursing note dated 8/20/25 documents: Patient (R1) is going to be admitted for sexual assault.On 8/26/25 at 1:34pm, V5 (nurse) said, she was the reporting nurse for R1. V5 said, she was aware that R1 has a history of inappropriate touching other residents. V5 said, R1 reported, that R2 touch his butt hole. Nursing note dated 7/17/25 documents: RN (V5) noticed resident (R2) kept going into another resident room. The resident (R2) is trying to inappropriately touch the other resident and tell him he loves him. On 8/26/25 at 2:45pm, V12 (R2's POA) said, R2 has dementia and a history of same sex relationships. V12 said, she received a call about R2's incident with R1. V12 said, she has received calls from the facility prior to R1's incident about R2 inappropriate touching other residents. V12 said, the facility has been so patient with R2. Now the facility is acting like they do not have any patience with R2, like they can tolerate R2 anymore. R2 will do the same thing at any facility. The current facility found a new facility for R2, but they refused to accept him after R2's recent inappropriate touching incident with R1.R2's Behavior note created on 8/18/25 (12:49) documents: Behavior Description: Inappropriately touching another resident. Behaviors: resident (R2) observed inappropriately touching a resident (R1). Nursing note dated 8/18/25 documents: Writer heard a resident (R1) yell out for help, writer got up to go to the yelling. Writer observed above resident (R2) in his wheelchair bending and reaching over to a resident (R1) in bed. Resident (R2) being petitioned to the hospital for inappropriate sexual behavior towards his peer. On 8/20/25 at 2:31pm, V3 (nurse practitioner) said, she was informed on Monday 8/18/25 that another resident touched R1. V3 said, she saw R1 on Tuesday. V3 said, R1 reported R2 lifted his gown and grabbed his penis. R1 reported he can't get erect because he is parlayed. R1 said, he was not gay. R1 was crying. V3 said, she suggested R1 go to the hospital. On 8/20/25 at 12:39pm, V8 (cna) said, she heard R3 telling R2 to get out of R1's room. R1 is contracted with his hands stuck behind his head. R1's legs are contracted opened. V8 said, R1 is dependent on staff for assistance. R2 is a wander. R2 should not have been in R1's room. Hospital Paperwork dated 8/19/25 documents: Patient (R1) present to emergency department for evaluation after an assault. R1 does not feel safe. Emergency Department diagnoses: Sexual assault of adult. Per emergency service: R1 was manually grouped by another resident, allegedly witness by another resident. (8/21/25) Case manager spoke with patient (R1) at bedside who was alert and orient time four declined to discharge to long term care facility, states he just left a facility where he was molested. Police report dated 8/19/25 documents: office responded to nursing home in regard to a criminal sexual abuse report. R1 was lying in bed alone. While laying down, R2 entered R1's room in a wheelchair. R1 rolled his wheelchair next to R1's bed and came to a stop. R2 then stood up and opened R1's diaper. R1 related that R2 placed his right hand in R1's adult brief and began to groan. R1 does not have any sense of feeling below the waist and did not know exactly what R2 was doing to his genitals. R1 began to call for a nurse while R2 was moving his hand around R1's genitals. R3 entered the room and began to shout at R2 to stop.

Based on observations, interviews, and record reviews, the facility failed to follow its policy and provide showers/complete bed bath for residents requiring moderate assistance to total dependence of staff for bathing and failed to remove a bedpan from underneath a resident for approximately 35 minutes. This affected four of four residents (R1, R3, R4, and R7) out of 4 reviewed for ADL (Activities of Daily Living) care Findings include: On 3/31/25 at 2:00 PM, R3 was observed to have a brown substance embedded underneath R3's fingernails. On 3/29/25 at 9:05 AM, R4 stated that R4 is not receiving showers/complete bed baths. R4 stated that he does not recall the last time he was bathed. R4 stated that it takes up to an hour for staff to answer his call light. R4 stated that he has to wait his turn. R4 stated that there are others worse off than he is. R4 stated that he tries to do things for himself but it is not working too good. On 3/29/25 at 10:16 AM, R7 stated that R7 has not received a shower/bath since admission to this facility on 3/20/25. R7 stated that R7 washed himself in the bathroom today as best he could. On 3/29/25 at 3:00 PM, R1 stated that R1 has not received a complete bed bath since returning from hospital on 3/15/25. R1 stated that this facility does not have any barrier cream, the staff informed R1's family member that he would need to speak with the wound care nurse to get some barrier cream. R1 stated they are always shorthanded here, the Certified Nursing Assistant/CNAs have more than 20 residents each. R1 stated that she activated her call light at 1:30 PM and at 2:30 PM she still was not changed. On 3/31/25 at 2:00 PM, R3 stated that R3 has not received a shower/bath since admission to this facility on 3/25/25. R3 stated that R3 is starting to smell. R3 stated that if he can smell himself, he knows others smell him too. R3's family member was present at bedside and stated that R3 was given a bedpan to have a bowel movement. R3 stated that he was unsure how long he was on the bedpan waiting to have it removed and get cleaned up before his family member came in. R3's family member stated that it took 35 minutes after she arrived to get staff to assist R3. On 3/29/25 at 11:05 AM, V2 DON (director of nursing) stated that residents receive showers/complete bed baths twice a week, one on day shift and one on evening shift. V2 stated that residents can receive shower/complete bed bath when requested. Resident shower sheets for February and March 2025 requested on 3/29/25 at 2:00 PM and again on 3/31/25 at 11:33 AM. Shower sheets were not made available to this surveyor to review during the survey. R1's MDS (minimum data set), dated 2/20/25, notes R1 is totally dependent on staff for bathing, toileting, and personal hygiene. R3's functional abilities assessment, dated 3/26/25, notes R3 requires substantial/maximum assistance with bathing and toileting. R4's MDS, dated [DATE], notes R4 requires substantial/maximum assistance with bathing and toileting. R7's MDS, dated [DATE], notes R7 requires moderate assistance with bathing and toileting. This facility's bathing policy, revised 3/17/25, notes all residents are offered a bath or shower at least one time per week. More frequent bathing or showering is given as needed or requested.

Based on observations, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were available to meet the needs of its residents. This affected four of four residents (R1, R3, R4, and R7) and rooms on the east and northeast unit. Findings include: On 3/29/25 at 8:45 AM, the assignment sheet notes no CNA was assigned to residents in rooms on the east and northeast unit. Thirteen residents reside in these rooms. On 3/29/25 at 9:30 AM, V5 CNA was observed being informed by V9 CNA that V5 needed to take an assignment because one CNA did not come to work today. V5 stated that V5 is supposed to be transporting residents to and from dialysis. On 3/29/25 at 10:00 AM, V17 (restorative aide) stated that V17 was just informed V17 needed to pick up an assignment. V17 was observed to start providing care to residents in rooms on the east and northeast unit. On 3/31/25 at 2:00 PM, R3 was observed to have a brown substance embedded underneath R3's fingernails. On 3/31/25 at 2:00 PM, R3 stated that R3 has not received a shower/bath since admission to this facility on 3/25/25. R3 stated that R3 is starting to smell. R3 stated that if he can smell himself, he knows others smell him too. R3's family member was present at bedside and stated that R3 was given a bedpan to have a bowel movement. R3 stated that he was unsure how long he was on the bedpan waiting to have it removed and get cleaned up before his family member came in. R3's family member stated that it took 35 minutes after she arrived to get staff to assist R3. R3's family member stated that she expressed a concern on 3/26 regarding call lights and the wait time for staff to come to R3's room. R3 and R3's family member stated that there has been no improvement in the care provided. R3's family member pointed to a large pile of dirty linens on a chair and stated this has been here since he was admitted to this facility. R3's functional abilities assessment, dated 3/26/25, notes R3 requires substantial/maximum assistance with bathing and toileting. R3's BIMS (brief interview of mental status) score was 12 out of 15. On 3/29/25 at 9:05 AM, R4 stated that R4 is not receiving showers/complete bed baths. R4 stated that he does not recall the last time he was bathed. R4 stated that it takes up to an hour for staff to answer his call light. R4 stated that he has to wait his turn. R4 stated that there are others worse off than he is. R4 stated that he tries to do things for himself but it is not working too good. R4's MDS, dated [DATE], notes R4 requires substantial/maximum assistance with bathing and toileting. R4's BIMS score is 11 out of 15. On 3/29/25 at 10:16 AM, R7 stated that R7 has not received a shower/bath since admission to this facility on 3/20/25. R7 stated that R7 washed himself in the bathroom today as best he could. R7's MDS, dated [DATE], notes R7 requires moderate assistance with bathing and toileting. R7's BIMS score is 15 out of 15. On 3/29/25 at 3:00 PM, R1 stated that R1 has not received a complete bed bath since returning from hospital on 3/15/25. R1 stated they are always shorthanded here, the CNAs have more than 20 residents each. R1 stated that she activated her call light at 1:30 PM and at 2:30 PM she still was not changed. R1's MDS (minimum data set), dated 2/20/25, notes R1 is totally dependent on staff for bathing, toileting, and personal hygiene. On 3/29/25 at 12:00 PM, V4 (staff scheduler) stated that staffing is based on the facility's census. V4 stated that they are budgeted for 28 CNAs (certified nurse aides) and 21 nurses per day for 140 residents. V4 stated that typically there are 11 CNAs on day shift, 11 on evening shift, and 7 on night shift. V4 stated that typically there are 6 nurses on day shift, 6 on evening shift, and 5 on night shift. V4 stated that the day shift for nurses and CNAs 6:30 AM. V4 offers no explanation why staff assignments changed three times between 6:30 AM and 10:00 AM or why no staff was assigned to one set of rooms on the east nursing unit until 9:30 AM. On 3/29/25 at 12:08 PM, V5 CNA stated that V5 was scheduled to work as dialysis transporter today. V5 stated that V5 works weekdays from 12:00 PM-8:00 PM and weekends from 9:00 AM-5:00 PM. On 3/29/25 at 12:15 PM, V6 CNA stated that V6 is working on the west nursing unit today. When questioned if V6 is able to meet the needs of assigned residents, V6 stated that it depends on the number of CNAs working that day. V6 stated that if there are only two CNAs working on the west nursing unit, then each CNA has 17 or more residents. V6 stated that V6 is not able to complete showers, respond to call lights, toilet/provide incontinence care, turn/reposition residents, and chart. V6 stated that there is no definite assignment until 9:00 AM routinely and they start at 630 AM. V6 stated that sometimes V6 is informed of assignment changes. V6 stated that yesterday one CNA called off so only had two CNAs on the west nursing unit. On 3/29/25 at 12:25 PM, V7 CNA stated that if a CNA calls off, assignment will change until another CNA comes in. V7 stated that yesterday nobody showed up for front set on the northeast nursing unit in the morning. V7 stated that V7 stayed in her area but helped the nurse passed breakfast trays to the front set residents until staff came in. On 3/29/25 at 12:50 PM, V8 CNA stated that V8 floats to all nursing units. V8 stated that for the past one month she has worked on west nursing unit. V8 stated that most of the time V8 is assigned to 17 residents. V8 stated that the assignments change routinely, sometimes V8 is not told. V8 stated that V8 does not start her assignment until she knows for sure she isn't going to be pulled to another unit. V8 stated that previously V8 would start her work and then get pulled to another area and is required to chart on both assignments.

Based on observations, interviews, and record reviews, the facility failed to follow its policy and ensure that residents had physician orders for medications stored at the bedside and were assessed for self-administration of medications. This affected two of three residents (R1, R7) reviewed for self-administration of medications Findings include: On 3/29/25 at 10:16 AM, R7 was observed to have a bottle of refresh eye drops on bedside table. R7 stated that the nurses have been administering this medication to him twice a day since his admission to this facility. R7 stated that he is not able to self-administer this medication. R7 stated that he is waiting for the nurse to administer eye drops. On 3/29/25 at 3:00 PM, R1 was observed to have a container of oral antidiarrheal medication on bedside table. R1 stated that R1 has diarrhea intermittently due to medical condition and has asked the nurse to have medication ordered. R1 stated that when R1 asks for this medication, the nurse informs R1 that the facility does not have any antidiarrheal medication. R1 stated that R1's family member brought in this medication so R1 can self-administer when needed. On 3/29/25 at 11:05 AM, V2 DON (director of nursing) stated that before a resident can self-administer medications, a skill assessment needs to be done. V2 stated that if the resident's BIMS (brief interview of mental status) is high enough and if the resident can demonstrate how to administer medication safely to themself, a physician order would be obtained. R7's BIMS, dated 3/27/25, notes R7's score is 15 out of 15. R7 is cognitively intact. R7's POS (physician order sheet) does not note an order for refresh eye drops, an order to self-administer or store these eye drops at bedside. R1's BIMS, dated 2/20/25, notes R1's score is 12 out of 15. R1's cognition is moderately impaired. R1's POS does not note a current order for loperamide (antidiarrheal) oral medication. There is no order to self-administer or store this medication at bedside. This facility's self-administration of medications by residents' policy, undated, notes an interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment, in part: the resident is instructed in the medication, the resident is requested to read the label, and demonstrate the steps involved in self-administration of the medication. A further assessment of the safety of bedside medication storage is conducted. If the interdisciplinary team approves the resident to self-administer and store medications at bedside, a physician order will be obtained.

Based on observation, interview, and record review the facility failed to have a functioning call light system and failed to develop an effective plan for the residents to call for assistance on the North unit, this affects 28 of 28 resident (R1, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, and R30) reviewed for functioning call system. Findings include: On 3/8/25 at 11:12am V4 (Administrator) stated the call light system is not working in the North unit. V4 stated the call light system has not been working for one week, and that the part to fix the issue has been ordered. V4 stated the facility has implemented hand bells, and frequent rounding for residents. 3/8/25 at 11:22am V1 (Maintenance Assistant) stated the call light system is not working and the call lights system on the North unit has not been working for 3 to 4 weeks. V1 stated there's an electrical issue, and it's bigger than replacing a part. V1 stated the facility has implemented frequent rounding and hand bells for the residents to use. 3/8/25 at 11:32am R1 observed alert to person, place, time, and situation. R1 stated she yells out for help when she needs something. R1 stated she cannot use the hand bell that the facility put in place. R1 stated she must yell loud, and she also hears other residents yelling out for assistance. R1 stated she shouldn't have to yell out for help. R1 face sheet denotes in-part R1 has diagnosis of multiple sclerosis, and quadriplegia. R1 soft touch call light was pressed, the light did not come at the bedside, the light did not come on at the doorway, there were no sound activated at the nurse station. 3/8/25 at 11:13am R29, observed alert to person, place and situation stated the staff don't respond to that bell when he uses it, it doesn't work! 3/8/25 V8 (Nurse Manager) identified R1, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, and R30 all residing on the North unit that use/ activate a working call light. 3/8/25 at 2:23pm V6 (Maintenance Director) stated the call lights system on the North unit stop working on 2/14/25. V6 stated the button that the resident press to activate the light and sound at the nurse station is not working. V6 stated the company informed him that there is a shortage in the main power line on the north unit. V6 stated that the call light was not working to the administrator on 2/14/25. V6 present logbook documentation for call light system, twenty-four resident rooms on the north unit failed during the week of 2/14-2/18, twenty-four resident rooms on the north unit failed during the week of 2/18-2/22, twenty-four resident rooms on the north unit failed during the week of 2/23-2/27, and twenty-four resident rooms on the north unit failed during the week of 3/3-3/8. During a follow up interview on 3/9/25 at 10:45am with V6, V6 stated the call lights are for resident to use when they need assistance. The facility should always have a functioning call light system. It's the method for the residents to summons the staff when they need help or care.

Based on observation, interview, and record review the facility failed to follow the resident food preference for one of 3 residents (R2) reviewed for food preference not being followed. Findings include: On 3/8/25 at 9:21am R2 was observed in the bed, R2 stated he did not eat his meal. At 9:30am R2 observed alert to person, place, date, and situation. R2 stated he refuses to go hungry because the facility can't get his meal right. R2 stated when he requests the regular meal, he gets a salad (substitute), and when the aides bring the wrong meal. R2 stated someone comes reviews the menu with him daily and they continue to get it wrong. At 9:23am surveyor observed R2 breakfast tray with assist from V9 (CNA), V9 stated he was R2's aide, and R2 ate most of his meal. V9 retrieved R2 tray and there were two boiled eggs (uneaten), 2 slices of bacon (uneaten), unopened milk, bowl of hot cereal (uneaten) noted on R2's (tray that was being sent back to the kitchen). V9 said he stated R2 ate his meal because R2 usually eats his meal, V9 stated he did not review what R2 ate before he placed the tray to be returned to the kitchen. R2 meal ticket was retrieved from the breakfast tray, it is denoted that R2 dislikes are bacon, cereal, mushrooms, and scramble eggs. R2 care plan denotes dietary consult to modify meal and snack plan related to known food allergies or intolerances, and honor food preferences. On 3/9/25 at 9:35am V10 (Dietary Manager) said R2 meal ticket shows R2 has a dislike for bacon, V10 stated R2 should not receive food items that he dislikes.

Based on observations, interviews, and records reviewed the facility failed to provide bathroom/toileting assistance to 2 (R1 and R8) dependent residents. This failure affected 2 of 3 residents reviewed for toileting assistance. The findings include: A. On 2/18/25 at 10:34AM R8's call light on, lit, beeping. At 10:39AM call light remains on. A staff member entered the room and R8's family requested assistance to take R8 to the washroom. Staff member left to get nursing assistance. At 10:40AM V4, Certified Nursing Assistant/CNA, entered R8's room and stated I got to get help and V4 left R8's room. At 10:53AM the surveyor asked V14, R8's family if they had been assisted. V14 stated the CNA said she is coming back she has to get help. R8 in the bed. At 11:04AM V14 stated we are still waiting, he (R8) has to have a bowel movement and they need 2 staff to help him. R8 stated yes, I gotta go. The call light has been turned off and is not lit or beeping anymore. The surveyor was standing outside of R8's room within hearing distance and in sight of the door. On 2/18/24 at 11:02AM V4, CNA, stated the computer system shows us the level of assistance needed by the resident, therapy will tell us, or the off going CNA will tell us. On 2/18/25 at 11:08AM V15, Nurse, stated he, R8, can't stand, the family has been told he is a mechanical lift. V15 stated he will just have to go and we will have to change his diaper. The surveyor left the unit after interviewing V15. R8 was still in his bed and had not been assisted to the toilet. The surveyor observed R8 waiting 34 minutes for assistance in using the washroom to have a bowel movement. On 2/19/25 at 12:53PM V4 stated on 2/18/25 R8's granddaughter stated R8 wanted to use the toilet, I told her he is a more than one person assist. V4 stated R8 can't stand at all. V4 stated I left the room and went to find an aide to help me, I didn't find one. V4 stated I told the nurse, V15, then we went and got him on the toilet. V4 stated V15 helped me get R8 into the bathroom V4 stated when I got in the room R8 was in wheelchair. V4 stated I didn't put R8 in the wheelchair. V8 stated I could have offered a bed pan. V4 stated R8 is a 2 person assist, not a mechanical lift. V4 stated we stood R8 up and he pivoted onto the toilet. V4 stated she assisted R8 onto the toilet in like 10 minutes from when she had entered the room. (The surveyor spoke with V15 at 11:08AM and R8 had not been assisted. V4 was in R8's room at 10:40AM.) On 2/19/25 10:47AM V10, Assistant Administrator, stated a resident can get on the toilet from a mechanical lift or use a side commode. V10 stated for R8 a solution is not to let him be incontinent and then change him. V10 stated if the resident can use the toilet staff are expected to assist. V10 stated the staff could have offered a bed pan to R8. R8's diagnosis includes, but are not limited to Disc Disorder with Myelopathy, Cognitive Communication Deficit, and Dementia. Functional Abilities and Goals dated 2/12/25 identifies on admission R8 is dependent on staff for toileting hygiene. Transfers requires partial to moderate assist. Actual toilet transfers were not attempted at the time of the assessment. The assessment does not indicate R8 requires a mechanical lift for transfers, nor does R8's care plan. CNA charting (Documentation Survey Report) for 2/18/25 shows R8 was incontinent of bowel and bladder at 12:36PM, documented by V4. B. R1's diagnosis include, but are not limited Benign Neoplasm of Left Ovary, Unsteadiness on Feet, Protein-Calorie Malnutrition, and Post Surgical Aftercare Following Surgery on the Genitourinary System. R1 admitted to the facility on [DATE]. R1's cognitive score is 12, moderately impaired. On 2/18/25 at 10:28AM R1 stated the bed was really wet and I had had a bowel movement in the bed. R1 stated it was miserable and uncomfortable waiting for help. R1 stated they just didn't come to help me when I asked after lunch. On 2/18/25 at 12:59PM V9, R1's family, stated I went to visit R1 on 2/7/25 and when I got there R1 grabbed my hand and was crying, saying I don't want to be here. V9 stated the staff had not cleaned R1 up after lunch and she had been left that way for some time. V9 stated I talked to V10, Assistant Administrator, about my concerns for that day. On 2/18/25 at 1:15PM V6, CNA, stated I had just gotten here on 2/7/25, it was around 2:38PM-2:40PM. V6 stated R1's daughter stated my mom has been waiting to be changed. V6 stated R1 was not on my set, but I went to change her. V6 stated R1 was soaking wet and in feces, it looked like it was there for quite a bit. V6 stated the sheets were a little brown and had been there for some time. V6 stated the sheets and R1's gown was so wet, so the sheet got wet, and it changed to a brown color where it was. V6 stated I told the nurses, V11 was one of them. On 2/19/25 10:47AM V10, Assistant Administrator, stated I did not speak to V6 about R1's care. V10 stated V9 did not report concerns except about a meal try not picked up. V10 stated I expect staff to check and change residents regularly and change as needed. V10 stated visible indications that a patient has not been changed can include if the patient has wet clothing or the bed is wet. V10 stated the color of the sheets is different, the smell is strong. V10 stated the sheets change color to a tinted brown to yellow shade. V2, LPN, and V11, RN, working on 2/7/25 both stated they don't remember R1, or any concerns reported to them related to R1. R1's care plan dated 2/5/25 states rounding at a minimum of every 2 hours and prompt or assist for change on position, toileting, offer fluids, and ensure resident is warm and dry. R1's MDS assessment dated [DATE] for Functional Ability (Section GG) identifies R1 is dependent for toileting hygiene. Requires substantial to maximal assistance with bed mobility and transfers, including toilet transfers. Bowel and Bladder assessment (Section H) identifies R1 is occasionally incontinent of urine and frequently incontinent of bowel R1's CNA charting (Documentation Survey Report) for 2/7/25 bowel/bladder continence, eating, and bed mobility nothing documented for 6:30am-2:30pm shift. The facility Certified Nurse's Aide basic function states, in part, to provide assigned resident with routine daily nursing care in accordance with established nursing care procedures. 5. Keep incontinent residents clean, dry, and odor free. 6. Assist residents with bowel and bladder functions. 8.Keep residents dry, changing clothes and gown when wet or soiled. 9.Make beds and change linens when soiled. 15. Maintain records accurately and timely. 16. Chart timely and accurately in (computer system.)

Based on interviews and records reviewed the facility failed to monitor and provide supervision during a smoking break. This affected two of three residents (R2, R3) reviewed for supervision. This failure resulted in a resident to resident-to-resident altercation. The findings include: The facility reported investigation dated 2/6/25 states R2 and R3 were in disagreement and exchanged words. On 2/18/25 at 11:16AM R3 stated R2 didn't like what I was saying to her. R3 stated R2 was calling me a B*%ch N*&&#% (derogatory, cursing, racist words). R3 stated R2 was standing and lost her balance. R3 stated R2 did not fall but lost her balance. R3 stated I did not push her; I waved her hand out of my face. On 2/19/25 at 9:35AM R2 stated on Thursday 2/6/25 I was outside on the smoking patio, after the 1:00PM smoking time opened. R2 stated R3 came to me and stated he didn't like the way I treat him. R2 stated I told R3 to leave then, if you don't like it go and I was pointing to the door. R2 stated instead R3 came at me and lifted me by my shirt and threw me, I hit the wall and went running inside and told the activity staff right away. R2 is in her 50's with diagnoses including Legal Blindness and Depression. R3 is in his 50's with diagnoses including Post Traumatic Stress Disorder and Major Depressive Disorder. On 2/18/25 at 11:34AM V3, Social Services, stated R3 was placed on wellbeing checks for an altercation with another patient. V3 stated I heard R2's and R3's versions of the story. V3 stated R2 claimed they exchanged words. R3 stated R2 put her finger in his face. V3 stated I was made aware by being called into the office and notified by V5, Director of Nursing/DON. V3 stated both R2 and R3 have cussed staff out in the past. V3 stated R2 has periods of agitation, she is verbally aggressive with staff and can be with residents when things don't go her way. On 2/19/25 at 9:50AM V11, Registered Nurse/RN, stated smoking is done by activity department. V11 stated there is a time for smoking. V11 stated the residents have a designated places to smoke and are monitored. On 2/19/25 at 11:29AM V12, Activity Aide, stated for smoking one of us, activity staff, watch the residents. V12 stated the residents smoke outside the north dining room area, on the patio, or they go out for fresh air. V12 stated it depends on the weather if I will go outside and watch them smoke or watch from the window. V12 stated on 2/6/25 R3 and R2 were outside. V12 stated I was at the door watching them, from inside. V12 stated I had patients inside doing my activity. V12 stated I turned around talking to the other patients. V12 stated R2 ran in the door saying, you better come get him (R3), he put his hands on me. V12 stated my back was turned and I didn't see what happened. V12 stated R2 was hollering and screaming. V12 stated I asked R2, who put his hands on you. V12 stated R2 replied R3, and I want to press charges, he put his hands on me. V12 stated R2 was screaming and using profanity. V12 stated R3 came to the door and stated, you all better get her. V12 stated R2 said he pushed her against the wall. V12 stated I had seen them talking but I didn't see him put his hands on her. V12 stated then V13, Activity Director, came and took R2 in the office to calm her down. V12 stated the other activity aid was off that day. V12 stated V13 was in an office not in the area when it happened. On 2/19/25 at 11:42AM V13, Activity Director, stated I was in my office and heard the commotion. V13 stated I was told R2 and R3 were on the patio. V13 stated R2 said R3 muffed me he like pushed her. V13 said this occurred during smoke break. V13 said if we are not outside with the residents, then we are in the area watching. V13 said for this incident it was not effective supervision. On 2/19/25 at 12:24PM V5, Director of Nursing, stated on 2/6/25 I was told there was a commotion with R2. V5 said R2 wanted the police called and complained about her shoulder hurting. V5 stated at baseline R2 has argumentative moments, they are verbal, she antagonizes the other residents and stirs up things. V5 stated R2 said R3 was acting funny. V5 said the staff told me R3 doesn't do things like this. On 2/20/25 at 11:33AM V16, Social Services, said we have a smoking contract for smokers we have a designated area. V16 said the activities will open the smoking time and staff should be present when smoking. I don't know if they will require increased supervision with smoking if the resident violates the smoking contract. V16 said in the past R2 has been caught with a lighter in her room. V16 said after R2 was caught smoking in a non-designated area we updated the care plan. On 2/20/25 at 12:03PM V17, Psychiatry Nurse Practitioner, stated I was asked to see R2 and R3 because they had an altercation. V17 said R3 said R3 came up to him and got in his face. V17 said R2 said R3 was the instigator. On 2/20/25 at 1:21PM V10, Assistant Administrator, said R3 stated R2 called him negative, derogatory, and racist words and had her finger in his face. V10 said R3 said he moved R2's hand out of his face. V10 said I was not told R2 lost balance during the altercation. V10 said R2 came in yelling and then she went back to smoke. V10 said residents should not be putting hands on other residents. V10 said there were not staff that saw what happened. V10 said staff should be outside with the residents to try to stop situations from escalating. V10 said smoke monitoring is done by activity department. R2's care plan dated 1/14/25 identifies she will be monitored or placed in the supervised smoking program. R2 demonstrates noncompliance with safe smoking regulations, smoking at non-designated times, smoking in rooms and other non-designated areas. Care plan identifies R2's memory is impaired and has difficulty with decision making, insight, logic, planning and organization of thoughts. R2's Safe Smoking Evaluation dated 1/24/25 identifies R2's non-compliance with smoking policy is a moderate problem. R2 is potentially unsafe smoker. R3's care plan created 9/19/25 and updated on 2/7/25 identifies he is verbally aggressive and displays agitation episodes towards staff and other residents. Interventions include intervene when behavior is observed. Statements taken from related to the incident document by V13 identifies R2 yells and screams when she wants. V12 written statement identifies R2 has a temper and argues with other residents. (Occurrence date on form is 3/7/25. V7, Administrator, stated the statements should be dated for February.) The facility Smoking Policy dated January 2024 states, in part, some residents may require more intensive supervision staff supervision while smoking. These residents smoke separately from other residents, under the supervision of a staff member specifically designated to assist them. Behaviors that may trigger additional supervision while smoking include but are not limited to using smoking materials in an inappropriate manner. Smoking is permitted only in designated areas.

Based on observation, interview, and record review, the facility failed to 1. Label and date opened food in the freezer, 2. Follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net and failing to use a beard restraint while in the kitchen, 3. Maintain infection control by placing a pair of oven gloves and a package of gravy inside clean and sanitized pots in the food preparation area and clean a whisk used during meal preparation, 4. Follow their policy on use of standardized recipes by not using a recipe during food preparation for lunch, and 5. Follow their policy on maintaining the proper sanitation level in the three compartment sink. These failures have the potential to affect all 151 residents who receive oral meals from the facility's kitchen. Findings include: On 1/13/24 at 10:28 AM, during review of the freezer noted one clear bag of food with no label or open date. V4 Dietary Manager/DM was inquired of the bag. V4 DM stated, It's potatoes, I'm not sure when it was opened, had to be over the weekend. It should have a use by date on it. On 1/14/25 at 9:24 AM, V7 Dietary Aide is in the kitchen and is not wearing a hair net. V9 Dietary Aide has a moustache and beard and is wearing a surgical mask while in the kitchen. On 1/14/25 at 9:38 AM a large cooking pot hanging on a rack in the food preparation area has two oven gloves sitting inside of the pot. A medium cooking pot hanging on a rack in the food preparation area has a 22.6-ounce (1/2 used) bag of chicken gravy inside of the pot. On 1/14/25 at 9:41 AM, V4 Dietary Manager was inquired of the items found inside the cooking pots. V4 DM stated, It shouldn't be in there. It's contaminating the pots. On 1/14/25 at 10:09 AM, V14 [NAME] put an unmeasured amount of salt, black pepper, and melted butter into two separate metal containers and filled them with water. V14 then placed both containers on the steam table and covered them with lids. V14 [NAME] was inquired of the containers. V14 [NAME] stated, I'm preparing my water for the cheesy mashed potatoes. V14 [NAME] is not using a recipe or measuring spices/ingredients while preparing the cheesy mashed potatoes. V14 was asked which residents would be receiving the cheesy mashed potatoes for lunch? V14 [NAME] stated, Regular, mechanical soft and puree residents except those who can't have cheese. V14 stated I'm making regular and enhanced mashed potatoes. V14 [NAME] was inquired of enhanced mashed potatoes. V14 [NAME] stated, It has whole milk and cheese. On 1/14/25 at 10:19 AM, V14 [NAME] poured 8 ounces of whole milk, an unmeasured amount of melted butter, and water in a pan and put it on the stove. V14 [NAME] opened a large bag of cheese and with a gloved hand put two handfuls of cheese into the pot. V14 [NAME] then poured an unmeasured amount of powdered mashed potatoes into the pot and mixed it with a large whisk. V14 put the whisk into a pitcher of water sitting in the food preparation sink. V14 [NAME] is not using a recipe or measuring utensils to prepare the enhanced mashed potatoes. V14 [NAME] did not wash the large whisk. On 1/14/25 at 10:25 AM, V14 [NAME] put an unmeasured amount of salt, black pepper, melted butter, and water into a metal container and placed it onto the stove. V14 [NAME] added an unmeasured amount of powdered mashed potatoes into the container. V14 [NAME] removed the large whisk from the pitcher of water in the food preparation sink and began to stir the potato mixture. V14 put the whisk into a pitcher of water sitting in the food preparation sink. V14 [NAME] is not using a recipe or measuring utensils to prepare the mashed potatoes. V14 [NAME] did not wash the large whisk. On 1/14/25 at 10:26 AM V14 [NAME] was inquired of his preparation. V14 stated, I'm making plain mashed potatoes. On 1/14/25 at 10:29 AM, V14 put an unmeasured amount of water into a metal container and placed it onto the stove. V14 [NAME] removed the large whisk from the pitcher of water in the food preparation sink, tapped the whisk on the inside of the food preparation sink and used it to stir an unmeasured amount of brown gravy mix into the water on the stove. V14 put the whisk into a pitcher of water sitting in the food preparation sink. V14 [NAME] is not using a recipe or measuring utensils to prepare the gravy. V14 [NAME] did not wash the large whisk. On 1/14/25 at 10:33 AM, V8 Director of Rehab entered the kitchen from the main dining room with a food tray and handed it to a dietary aide. V8 is not wearing a hair net. V8 was inquired of entering the kitchen. V8 stated, Oh, I should have on a hair net, I was just helping out. There are no hair nets available at the kitchen entrance from the main dining room. On 1/14/25 at 10:38 AM, V14 [NAME] was inquired of meal preparation. What should be used to ensure accurate amounts of seasoning or ingredients are used during food preparation? V14 stated, It's the recipe. I failed to use it to know what to put in. How do you know how much seasoning was put into each container while preparing the food? V14 stated, I should use measuring cups, but I taste it after it's done. V14 showed this surveyor measuring cups and spoons he removed from the drawers at the food preparation table. V14 [NAME] was inquired of using the whisk. After using a cooking utensil what should be done to ensure it's safe to use again? V14 [NAME] state, I should change the whisk, it needs to be cleaned. It could be contaminated, but I soak it in hot water. On 1/14/25 at 10:46 AM, V9 Dietary Aide has a moustache and beard and is wearing a surgical mask under his chin. He is receiving and removing clean dishes from the dishwashing machine. V9 was inquired of his mask. V9 stated, I don't have to cover my beard in the kitchen, only out in the building because of the residents and visitors. On 1/15/25 at 8:50 AM, V7 Dietary Aide is in the kitchen and is not wearing a hair net. On 1/15/25 at 9:34 AM, V4 Dietary Manager was inquired of hair net usage. V4 stated, Everyone should wear a hair net, so hair doesn't fly into the food. V4 stated anyone with a beard should wear a beard cover because hair can get into the food or anywhere. V4 was inquired of V14 [NAME] meal preparation regarding use of a recipe. V4 stated, V14 should follow a recipe so the meal comes out properly and for the resident's diet. I have measuring cups and spoons. On 1/15/24 at 9:40 AM, V9 Dietary Aide is at the three-compartment sink washing pots and pans. V9 tested the three-compartment sink for the sanitation level. V9 dipped the chemical test strip which indicated 100 ppm (parts per million) of quaternary solution. V4 Dietary Manager was asked what the chemical solution concentration should indicate for proper sanitation. V4 said, It should be 200. Quaternary sanitizer solution concentration range is 200 ppm per the posted manufacturer guidelines above the three-compartment sink. On 01/15/25 02:08 PM, V4 Dietary Manager was inquired of the kitchen infection control policy. V4 said, We are still looking for one. V4 DM did not provide a policy for infection control. The 2020 Guideline & Procedure Manual Labeling and Dating Foods (Date Marking) policy states in part: Procedure: All foods stored will be properly labeled according to the following guidelines. 3. Date marking for freezer storage food items- once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. The 2020 Guideline & Procedure Manual Hair Restraint policy states in part: Guideline: Hair restraints shall be worn by all dining services staff when in food production areas, dishwashing areas, or when serving food. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. The 2020 Guideline & Procedure Manual Storing Utensils, Tableware, and Equipment policy states in part: Guideline: Employees will store utensils, tableware, and equipment according to the following guidelines. Procedure 1. Cleaned and sanitized utensils and equipment will be stored at least six inches off the floor in a clean, dry location in a way that keeps them from contamination by splash, dust, or other means. 5. Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination. The June 2024 [NAME] Healthcare Kitchen Policy Food Safety & Sanitation Standard Recipes policy states in part: Standardized recipes will be available in the kitchen and used for food preparation according to the menu and spreadsheets unless signed off for subs by a dietitian. Procedure: All foods will be prepared using standardized recipes that coincide with the menu cycle spreadsheets. Standardized recipes include number of servings, serving sizes, ingredients, and preparation instructions. The undated facility three compartment sink policy states in part: policy: the facility will clean and sanitize food service equipment, pots and pans, utensils, dishes, and tableware using three compartment sink using the proper procedure. Procedure: 5. Sinks will be prepared as follows: c. Sink three- iv. Add the appropriate amount of sanitizer to the water according to the manufacturer's guidelines: 3. Quaternary Ammonium: 200 PPM (parts per million). Test the water in the sink using the manufacturer's suggested test strips to ensure appropriate concentration s noted above. Record concentration on a Sanitizer Concentration Log.

Based on observation, interview, and record review, the facility failed to obtain orders for urinary catheter and urinary catheter care; the facility also failed to implement care plan interventions related to urinary catheter care and monitoring, including monitoring for signs of urinary tract infection symptoms. This failure applied to one of three (R11) residents reviewed for catheter care and resulted in R11's emergent hospitalization and subsequent diagnosis of septic shock requiring intensive care unit admission. Findings include: R11 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including but not limited to Schizophrenia; Atherosclerotic; Heart Disease of Native Coronary Artery without Angina Pectoris; Chronic Kidney Disease; and Obstructive and Reflux Uropathy. According to R11's admission MDS (Minimum Data Set) assessment dated [DATE], under section H, R11 had indwelling urinary catheter present upon admission. Absent are any physician orders to show R11 had urinary catheter or required urinary catheter care. On 11/04/2024 at 11:46 AM Surveyor interviewed V22 (Registered Nurse) who stated in the summary, I started my shift on 10/16/2024 at 6:30 AM. I received a hand off report indicating that R11 had a fever and received fever medication overnight. V24 (Registered Nurse) who worked overnight, received an order to collect urinalysis and urine culture sensitivity test. R11's urine sample was collected and sent by the time I arrived. V24 (RN) stated that the last time she checked R11's temperature, it was 98.9 (degrees Fahrenheit). During my morning assessment, R11 was alert and oriented x(times) 3 and very talkative, as always. I asked if R11 needed pain medication, he denied pain and asked for cold water. I rechecked R11's temperature before giving morning medications and it was 100.1 (degree Fahrenheit), so I gave another dose of fever medication. When I rechecked R11's temperature an hour later, it was 104.1 (degree Fahrenheit). R11 kept asking for more water. The only abnormal vital sign was his temperature. I notified V27 (Nurse Practitioner) who gave orders for stat blood work. I told V27 (NP) that it will take up to 4 hours and I don't feel comfortable waiting, so V27 (NP) ordered to send R11 to the hospital. I decided to give a little more time before I send R11 out, because I wanted to see if the temperature will go down. I checked the temperature again; it was still 104 (degrees Fahrenheit) and that time R11 became confused. I called V27 (NP) again and she confirmed the second time that it is appropriate to send to R11 to the hospital. I didn't look at R11's urinary catheter, I hadn't fully assessed R11 that morning. R11's urinary catheter was special, and nurses were not supposed to touch it. Certified Nurse Assistants provide perineal care with every brief change, that's when they're supposed to provide urinary catheter care. Nurses are supposed to do urinary catheter assessments once a shift. It should be documented only if there are abnormalities related to the catheter. Nurses document urine output, but it's usually done if there is an order. I base my documentation on abnormalities, there is not enough time to document everything. Sequence of R11's documented temperatures and fever medication administration, per record review shows: - 10/16/2024 01:10 AM - 100.5 degrees Fahrenheit - fever medication administration documented at 00:45 AM - 10/16/2024 08:26 AM - 98.2 degrees Fahrenheit - 10/16/2024 10:06 AM - 99.2 degrees Fahrenheit - 10/16/2024 11:30 AM - 104.5 degrees Fahrenheit - - fever medication administration documented at 11:09 AM On 11/04/2024 at 12:01 PM Surveyor interviewed V23 (Wound Care Nurse/Licensed Practical Nurse) who stated in the summary, I went in after breakfast to change R11's dressings. R11 complained about pain to his penis. I opened his brief to conduct an assessment and observed a brown discharge from his penis. R11 was very cold and shaking but his body was warm to the touch. R11 generally complained of penis pain when we repositioned him. R11 had a penile implant that he was admitted with. R11 stated the implant placement procedure went wrong, hospital doctors suggested that it should have been removed, but R11 declined. Once I noticed the brown discharge, I notify V22 (RN). When I told V22 (RN), she came in to do her assessment, and I exited the room. I document in real time; therefore, the progress note shows the time when I saw R11, which was (10/16/2024) 11:47 AM. Last time I saw R11, before 10/16/2024 was on Monday 10/14/2024 and he appeared fine. On 11/04/2024 at 1:37 PM Surveyor interviewed V19 (Director of Nursing) who stated in the summary, R11 does not have urinary catheter order nor urinary catheter care order. Urinary care is part of ADL (Activities of Daily Living) and incontinence care, and it should be done every 2 hours and as needed, which is related to Certified Nurse Assistant duties. Nurses should assess urinary catheter and document every shift. Nurses were not supposed to change R11's urinary catheter due to penile implant, it had to be changed in the urologist office. Upon request from V19 (/Director of Nursing/DON) absent is any urinary catheter assessment to show R11 urinary catheter was assessed during R11's stay in the facility (08/21/2024 - 10/16/2024). On 11/04/2024 at 1:57 PM Surveyor interviewed V26 (Certified Nurse Assistant) who stated in the summary, as a CNA, I provide urinary catheter care with ADLs, every two hours or as needed. I document it in the task area in resident's electronic medical record under Bladder Continence tab. That should be documented every two hours. If there is blood in the tubing or bag, cloudiness, or change in urine appearance, it needs to be reported to the nurse on duty. R11's urinary continence sheet for October 2024 shows that urinary catheter care was provided 12 times in the entire month. On 11/04/2024 at 3:14 PM Surveyor interviewed V27 (Nurse Practitioner) who stated in the summary, I was on-site (in the facility) on 10/15/2024, when I saw R11 during my rounds, between 9:30a-10:00a. R11 complained about penile pain. I completed my assessment and ordered urinalysis and urine culture sensitivity test. I order R11's test verbally with nurse on duty (V29 Licensed Practical Nurse). There was no blood, and urine was flowing without obstruction; however, based on the labs, I was going to decide whether I should move R11's urology appointment sooner (originally scheduled for 11/4/2024). The following day, V22 (RN) called me and told me that the R11 has a fever. I told her that we have to send R11 out to the hospital if his temperature reaches 104 (degrees Fahrenheit). I talked to V22 (RN) later that day, and she told me that she sent R11 out. Surveyor asked V27 (NP) to clarify how R11 suffered from septic shock, V27 (NP) said, R11 had a chronic urinary catheter, which body recognized as a foreign object. In the process of trying to fight it, the body can go into a septic shock. Antibiotic treatment is detrimental in preventing septic shock. I specifically ordered R11's urine analysis on 10/15/2024 to monitor for UTI (Urinary Tract Infection) and order antibiotic if needed. Urinary assessment and care play also a big role in preventing infection and should not be undermined. On 11/04/2024 at 3:45 PM Surveyor interviewed V24 (Registered Nurse) who stated in the summary, On 10/16/2024 around midnight, I checked R11's temperature and it showed that he had some fever, I don't remember what it was, but it is in my progress note. I called the third-party provider and received orders for urinalysis and urine culture sensitivity test. I collected urine and left it for the lab to pick it up in the morning. I think the third-party provider ordered antibiotic to be started after the urine lab results come back. On 11/04/2024 at 3:57 PM Surveyor interviewed V29 (Licensed Practical Nurse) who stated in the summary, I took care of R11 on 10/15/2024 on day shift. R11 was his usual self that day. As a matter of fact, V27 (Nurse Practitioner) was there, and she looked at R11 as well. V27 (NP) told me that R11's urinary catheter is a special kind and was inquiring about R11's urology appointment. I think she ordered some labs that day, but I don't remember, there was so much going on. Normally, medical provider relay lab orders to me, I transcribe it into the resident's electronic medical record, print it and put it into the lab binder. If there are stat lab, I call the lab. I am not sure if V27 (NP) ordered any labs R11 that day (10/15/2024). Upon request from V19 (DON), absent are any R11's urine related labs ordered on 10/15/2024. R11's laboratory order dated 10/16/2024 3:13 AM reads in part, URINALYSIS, W/REFLEX CandS ** SENT Uncollected 10/16/24 3:14 AM CT ** one time only. R11's laboratory results showed: Collection Date: 10/16/2024 00:00 (AM); Received date: 10/16/2024 12:54 (PM); Reported Date: 10/22/2024 08:01(AM). Detected abnormalities include but are not limited to: BLOOD, SEMI-[NAME]. Large (presence). Escherichia coli ESBL GREATER THAN 100,000 COLONIES/ML. Enterobacter aerogenes GREATER THAN 100,000 COLONIES/ML. Progress note dated 10/15/2024 written by V27 (NP) reads in part, (R11) was seen and examined on this day for the above CC (chief complaint). (R11) was sitting on his bed when he reported to be doing well. (R11) reported pain in his penis, (R11) has a special foley and has an upcoming Urology appt, his (urinary catheter) has not been changed since admission. New verbal orders for UA/CS given to nursing. New order - UA&CS, Upcoming Urology services appt November 4th. Progress note dated 10/16/2024 1:10 AM written by V24 (RN) reads in part, (R11) c/o intermittent hot and cold, noted to be shaking. Temperature elevated at 100.5, (Urinary) catheter in situ. (R11) also hypertensive at 179mmHg systolic and hypoxic at 89% before supplemental O2 applied. Given (fever medication), (R11) now states he feels marginally better, but his feet are cold. Denies any dyspnea, states he has an infection in my penis. Progress note dated 10/16/2024 10:06 AM written by V22 (RN) reads in part, A & o X 2-3 febrile 99.2 prn (fever medication) given. noted (urinary) cath patent & intact output 240 ml cloudy & dark yellow. Ate 97% of his breakfast, AM meds well tolerated, drank 700 ml of cold water within 3 hrs. temp recheck @ 11:30 temp 104.5 & agitated. Informed NP likewise called 911.VS:BP 111/64 HR 95 RR 20 TEMP 104.5 SPO2 95% RA. Progress note dated 10/16/2024 11:37 AM written by V23 (Wound Care Nurse/LPN) reads in part, While performing wound care, (R11) complained of pain to penis, rated at 6/10. Upon assessment, (R11) noted with brown discharge from penis around (urinary) catheter site. Nurse in duty made aware. R11's hospital record dated 10/16/2024, (R11) is a [AGE] year-old male with (past medical history) significant for chronic (urinary catheter), HFrEF s/p AICD s/p cardiac arrest, CAD, HTN, HLD, asthma, presenting to the (local hospital) emergency department via EMS transfer from (the facility) for fever 104 (degrees Fahrenheit), penile pain, cloudy urine. (R11) arrived to the ED on 4L NC and is AOx4. Admission vitals febrile 103 (degrees Fahrenheit), tachypneic 24, hypotensive 84/54 satting 94%. (R11) reported ED physicians that he has had penile pain for the past 1 year approximately and has a chronic (urinary) catheter. Reports 2 days of weakness, fatigue, (R11) denies cough, shortness of breath, chest pain, abdominal pain, vomiting, diarrhea and only endorses some rhinorrhea. (R11) also endorsed chronic left leg wound but denies any pain. Urine from (urinary) catheter discolored and (R11) report condensed milk urine consistency in (urinary catheter) bag. Assessment and plan: [AGE] year-old male with PMH (past medical history) significant for chronic (urinary catheter), HFrEF s/p AICD s/p cardiac arrest, CAD, HTN, HLD, asthma admitted to MICU (medical intensive care unit) for urosepsis requiring pressors. R11's urinary catheter care plan dated 08/22/2024 reads in part, (R11) requires use of an indwelling catheter r/t (Obstructive uropathy) is at risk for of infection. (R11) Will remain free of complications and infection of foley catheter placement throughout next review. Interventions: Assess for continued need of indwelling catheter; Empty Foley bag every shift and as needed; Monitor for s/s UTI: flank pain, strong odor, increased temp, decreased output, hematuria. The facility Indwelling catheter care policy dated 01/2024 reads in part, Daily and PRN catheter care will be done to promote comfort and cleanliness. Responsible party: RN, LPN, CNA. Catheter bag to be emptied at the end of every shift, and PRN. Record output and catheter care in POC. Absent is laboratory related policy per V19 (Director of Nursing) statement. The facility Registered Nurse/Licensed Practical Nurse job description reads in part, Implement total nursing care plan through assessment, planning, and evaluation; Administer prescribed medications and treatments according to policy and procedures; evaluate treatment effectiveness on continuing basis; Recognize significant changes in the condition of residents and take necessary action; Document nursing care rendered, resident response , and all other pertinent and necessary data as outlined in facility's policies and procedures.

Based on interviews and record review, the facility failed to protect the resident ' s right to be free from sexual abuse by staff. This failure applied to one of three (R3) residents reviewed for sexual abuse that resulted in R3 being sexually abused by a facility RN (Registered Nurse). The Immediate Jeopardy began on 03/02/24 when R3 was sexually abused by a facility Registered Nurse (V14). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 03/07/24 at 1:15PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 3/11/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3 is an [AGE] year-old female with diagnoses that include history of Hereditary Hemochromatosis, Femur Fracture, Primary Generalized Osteoporosis, and Essential Hypertension who was admitted to the facility 03/02/2024. R3's past medical history does not include cognitive or psychological disorders. On 03/04/2024 at 11:45 AM observed R3 sitting in a chair in her room with a cast covering her entire left arm. R3 stated she fell on Saturday 03/02/2024 at her home and damaged her elbow and that is why she was admitted to the facility. In response to surveyor asking R3 about an allegation of sexual abuse, R3 stated she wants to forget about it. R3 stated there have been so many people coming to see her about it. R3 stated a male nurse observed her walking around in her room, walked her over to her bed sat her down, and told her he didn't want her walking around the room on her own. R3 stated he offered to help her undress because he saw she was in no condition to do it on her own with her arm being the way it was. R3 stated the male nurse left the room and returned. R3 stated the male nurse examined her mouth with his fingers and asked her if her teeth were hers and she answered yes. R3 stated the male nurse then began pulling her teeth as if to see if they were false and she assured him they were hers. R3 stated the male nurse then kneeled in front of her and placed his fingers in her pants and then inside her vagina and moved his finger around in a circular motion. R3 stated she stopped him there and didn't know what to make of what the male nurse had done to her. R3 stated the male nurse then told her I'm going to leave you now you're clean. R3 stated she asked the male nurse what that meant, and he stated it meant there was nothing in her that would cause her problems. R3 stated what the male nurse did made her feel dirty, angry, and violated. R3 stated she didn't realize what the male nurse was doing until it was over, and she then wondered if he would attack her next. R3 stated she then told another nurse, and the nurse called the police. R3 stated the male nurse was African or African American. R3 stated as a Christian what the male nurse did to her made her feel bad. R3 to appeared stressed, agitated, and sad while reporting the abuse allegation to the surveyor. On 03/05/2024 at 12:38 PM observed R3's facial expression change from relaxed and content to display a frown and discomfort when surveyor asked follow up questions about her sexual abuse allegation. R3 stated on 03/02/2024 V14 (Registered Nurse) told her he had to do what he was doing to her during the alleged sexual abuse incident, because it was his job and if he didn't do it, he would lose his job. R3 stated V14 had been in her room more than once that day telling her not to walk on her own which she didn't like. R3 stated during the incident V14 sat her on the bed, kneeled in front of her, and placed his hands in her pants. R3 stated she told the administrator she never wanted to see V14 again after the incident. R3 stated the administrator has since come back and talked to her about the incident and explained the process of admissions examinations and she told him she was not aware of that process because she had never been in a nursing home before. R3 stated she told the administrator what V14 did to her, and he didn't say much about it in response. Initial Abuse Investigation Reports dated 03/02/2024 documents: Administration received report at 7PM from the nurse on duty that R3 reported to her family member an allegation of inappropriate touching during her assessment by her admitting nurse. R3 stated a male nurse, V14 (Registered Nurse), touched her on or near her buttocks and genitalia during her initial body check assessment. The alleged nurse and reporting nurse stated the resident appeared confused about the events of the allegation during initial interview. The reporting nurse informed that the resident told her he touched her inappropriately, the alleged nurse and a female nurse aide completed the initial assessment as part of their routine care during an admission with the patient's consent, the alleged nurse denied the incident, his assisting nurse aide stated there was no inappropriate behavior on part of the nurse as well. The administrator spoke with V12 (Family Member) responsible party who received the report, to inquire about conversation with the resident. V12 stated R3 felt the nurse touched her inappropriately during the process. Administration informed them there would be an investigation immediately initiated, the staff member would be suspended, and local law enforcement would be notified for report. V14's (Registered Nurse) witness statement dated 03/02/2024 documents he explained to R3 that a head-to-toe assessment would be performed and obtained verbal consent from R3 to perform; attempt to perform complete assessment on R3 with a CNA (Certified Nursing Assistant) present for the entire assessment. V15's (Certified Nursing Assistant) witness statement dated 03/02/2024 documents she was the CNA assigned to R3, she went in R3's room to do a skin assessment with the nurse, R3 was told everything that was going to be done with her consent prior to initiating; she helped the nurse assess R3's skin from head to toe, helped dress R3 when done and the nurse left the room after. V15 stated the nurse never returned to R3's room, the nurse was only assigned to do the admission and she was there with the nurse for the entire assessment. Police Report dated 03/02/2024 documents at 7:04 PM police responded to the nursing home in regarding a criminal sexual assault report; R3 reported a male nurse penetrated her vagina with his finger. R3 could not confirm the time of the incident. R3 reported the nurse entered her room during the time she was using the bathroom. When she came out of the bathroom, she was unable to pull her pants up because of her broken arm, the male nurse assisted her to sit down on her bed. The male nurse then began asking questions about her teeth. After checking her teeth (possibly for dentures), the male nurse placed his hand in her pants and penetrated her vagina with his finger; R3 stated the male nurse moved his finger in a circular motion inside her vagina, she attempted to push the nurse away but couldn't then he left the room. R3 reported no one else was present during this incident. R3 described the nurse as darker skinned and speaking with an accent. The alleged perpetrator was identified as V14 (Registered Nurse) reported he went into R3's room with V15 (Certified Nursing Assistant) present to perform a full physical examination, both denied that V14 touched R3's vagina. V14 denied going into R3's room other than during the physical examination. V13 (Charge Nurse) was interviewed and confirmed an initial physical examination procedure does not involve examining the genital area; and that she observed V14 go into R3's room multiple times after the physical examination. She (V13) does not know why V14 was in R3's room; no one else was in the room with V14. V13 stated that V14 is no longer R3's nurse, and he will not be going into the room anymore. V13 told the police officer she has taken over as R3's nurse for the night. V13 was given the report number for her records. The officer went back to speak with R3 one more time. The officer explained to R3 that V14 is no longer her nurse and should not be in her room. R3's progress note dated 3/3/2024 6:04 PM documents a telehealth evaluation was conducted in response to an Allegation of Abuse. Patient reporting during admit that the male nurse inserted fingers into her vagina during exam. V14's (Registered Nurse) personnel file was reviewed 03/04/2024 and documents a hire date of 03/18/2019. A Healthcare Worker Criminal History Records Information Check was performed 02/27/2019. A Consumer Reporting Agency Background Application was performed 02/27/2019. An Illinois State Police background check was performed 03/13/2019. A Global Human Resources Research report was performed 02/28/2019. A National Sex Offender Search was performed 03/13/2019. An Illinois State Sex Offender search was performed 03/13/2019. An Illinois Department of Corrections check was performed 03/13/2019. An Abuse training was completed in 2019, and does not include any other background checks or abuse prevention trainings after these time frames. Statement from V2 (Director of Nursing) documents she interviewed R3 on 03/05/2024 in her room regarding the incident that occurred on Saturday 03/02/2024. R3 reported the (alleged) nurse escorted her into the building from the ambulance and sat her on the bed. R3 reported the (alleged) nurse asked her if she had dentures and asked her to open her mouth and proceeded to examine her mouth. R3 reported she didn't understand the need for his exam because she stated to him all her teeth were her own. R3 reported she was sitting at the side of the bed when the (alleged) nurse inserted his fingers in her vagina and scratched her and she knew it was wrong and asked him to stop because she is a virgin, and a man has never touched her down there. R3 stated the (alleged) nurse removed his hand and told her she was all clean and walked out of the room and never returned. V2 asked if the same man entered R3's room at all again with another worker, she stated no he never returned. Statement from V13 (Licensed Practical Nurse) dated 03/06/2024 10:19 AM documents On Saturday 03/03/2024, V13 received a call from V12 (Family Member) of R3. V12 informed V13 that R3 was sexually assaulted by a male, and this male worked at our facility. V12 then asked was this a normal thing that happens at the facility. V12 further stated that R3 has never been touched down there before. V12 was very upset, she demanded a call back from the administrator of the facility. V13 tried reassuring V12 there may have been a misconception or misunderstanding and explained the admissions process and requirement of having a physical assessment. V12 stated she understood this, but the nurse touched R3 inappropriately. V12 stated R3 told her that the male employee put his finger in her. V13 told V12 she would call the administrator and will give her a call. V13 reported to the administrator that V12 told her R3 informed her she was touched inappropriately and does not recall telling him that V12 stated the male put his finger in R3's vagina, however she did inform the doctor of this. V13 stated she was instructed to call the police and notify the physician. Statement from V10 (Assistant Director of Nursing) dated 03/06/2024 documents when R3 was asked about what occurred this weekend she (R3) stated when is this going to be over. V10 explained that it is not our intent to make her revisit this but just part of a thorough investigation and that clinical staff are mandated reporters and required to take the steps both the facility and the state are performing. R3 started to state that she shouldn't have said anything, and V10 reassured her that our goal is to make sure she feels safe and cared for. R3 then began describing how the nurse in question walked her in from the ambulance but it was a long way, he took her to the room, and she sat down on the edge of the bed, she then changed focus to the fall that resulted in her arm being fractured. Statement from V13 (Registered Nurse) dated 03/07/2024 at 10:00 AM documents in addition to her (V13) previous statement, she (V13) was also instructed to have the accused nurse (V14) to wait for the police to be questioned and while waiting, sit at the nurses station, write a statement, and not to move around the building. V13 was at the nurses station the entire time. After the conversation with the police the nurse punched out and exited the facility. Final Abuse Investigation report dated 03/08/2024 documents: The police were called at 7:04 PM and reported to the facility for investigation. Administration instructed V13 (Registered Nurse) to have V14 stop work and come off the unit away from resident contact to await police interview and sit with him until then. Per police records the officer arrived on scene at 7:24 PM, the officer interviewed the employees involved including V13, V14, and V15 (Certified Nursing Assistant) as well as R3. Per police record R3 reported that a male nurse had penetrated her vagina with his finger and stated this occurred sometime this afternoon but was unsure of the exact time. Upon interview V13 and V14 reported giving R3 a head-to-toe visual examination and both denied any touching of the vaginal area. V14 denied going into R3's room other than just for the assessment. The police interviewed V13, and she (V13) reported observing V14 go into R3's room multiple times after the initial exam and did not know the reason. V13 stated no one else went in the room with V14. V14 and V13 were in the nurse's station during the duration of the investigation while he was speaking with the officer and closing out his records to turn over his patients to his coworker V13. At 8:11PM, the administrator called the facility to check on the progress and asked V14 to stop his work and leave the premises since the police completed their interview with him. The police finished their interviews with all involved and left the facility at 8:42 PM. On Monday Morning 03/04/2024 the state survey agency came into the facility to conduct a facility reported incident review. V1 (Administrator), and V2 (Director of Nursing) interviewed R3, and they were informed of additional information including the allegation that V14 inserted his fingers into her vagina during an examination. R3 described the oral examination and body check and did not recall the witnessing nurse aide being part of the examination. R3 reported V14 did not return later, and this was the only incident. R3 reported she could not recall the time of the incident. On further follow up interviews with V14 during the course of the investigation, V14 reported he initially received the resident's admission paperwork from the ambulance company when she(R3) was admitted to the facility around 3PM. Shortly after R3's arrival V14 saw R3 down the hallway walking near the therapy gym and offered to assist her back to her room. While walking R3 to her room V14 reported he met V15 (CNA) at R3's doorway and she took over to assist her to her bed. Later in the shift between 4PM-5PM, V14 approached V15 and requested assistance with conducting a body assessment for R3. The allegation could not be substantiated; R3's assessment identified cognitive impairment and she could not remember the witnessing nurse aide as assisting the nurse during the body assessment. V14 was supervised by staff and in the presence of law enforcement and no contact with residents after the allegation was made. The initial confusion of the incident was contributed to cognitive impairment during her initial body assessment. The cognitive impairment of the resident is supported by the evaluation of social service, licensed speech therapist and documents from her most recent hospitalization . R3's Admission Clinical Hospital Reports dated 02/27/2024 documents she is an [AGE] year-old female with a past medical history of Hereditary Hemochromatosis, Hypertension, Osteoarthritis who was seen at the hospital for left elbow pain and reported that while she was at home with two of her family members she slipped and fell while outside doing yard work and trying to start the lawnmower. A Left elbow x-ray revealed a fracture of her left arm; she is neurovascularly intact, alert, and oriented x/times 3 (to person, place, and time), with normal speech. Physical Exam Neurological Status: Normal orientation, normal memory; the hospital Physician's Progress Note dated 02/28/2024 documents intervention options and potential risks and benefits of interventions for R3's fracture were discussed with her and her family members; R3 is an elderly individual with frail body habitus. She (R3) is a right-hand dominant individual who lives alone and is an active person. she also drives a car. She (R3) chose the surgical intervention to get the best possible outcome from this fracture. She understood the risks and benefits and understood that surgical complications can occur and may require additional interventions. R3 and her family members had many questions which were addressed, and it was believed they understood. R3 has signed the consent for the surgery. R3's hospital/clinical report which includes a CT scan (computerized tomography) of her head do not include a reference or note of cognitive impairment. R3's Admission Evaluation dated 03/02/2024 at 5:28 PM created by V14 (Registered Nurse) documents her mentation as alert and oriented x3. R3's neurological status as oriented to person, place, and time; has the ability to move her upper and lower extremities. R3 has no impairment in lower extremity range of motion, with steady sitting, standing, and gait balance. R3's admission progress note dated 3/2/2024 at 6:01 PM created by V14 (Registered Nurse) documents she is an [AGE] year-old female patient received from local hospital this afternoon accompanied by local transportation company. Admitting for post care after fall at home, resulting in an elbow fracture. Skin assessment completed, bruises noted on left knee area, right arm, and left breast side. Left mid back area bruises/redness noted. Redness noted on buttock area. Left arm cast noted (left elbow fracture). Safety maintained, call light and personal belongings in reach, bed in lowest position, all needs attended by staff. Report given to on floor nurse. R3's Current Physician Orders do not include cognitive or psychotropic medications. R3's admission social services comprehensive assessment section for trauma factors including abuse dated 03/03/2024 at 1:36 PM documents she has a history of abuse with no factors that increase the resident's vulnerability such as dementia, confusion, disorientation, poor insight/poor judgment, or poor communication skills and no psychiatric history and/or present mental health diagnosis, including psychotic symptoms (e.g., delusional thinking, hallucinations), or possible misinterpretation of events and the intentions of others. The community survival skills section documents R3 is sufficiently alert, oriented, coherent, and knowledgeable allowing her to be considered for independent outside pass privileges. R3 knows how to ask for/seek help in an emergent or problematic situation and appears to be capable of unsupervised outside pass privileges at this time. The section for Prior Living Arrangements/Discharge Potential documents, R3 previously lived at home alone independently, reported having 7 stairs to enter her home, 17 stairs inside her home leading down to the basement and approximately 15 upstairs, and has good discharge potential. R3's Minimum Data Set, dated dated dated [DATE] documents she has a Basic Interview for Mental Assessment score of 12 out of 15. R3's progress note dated 3/4/2024 14:02 created by V17 (Social Services Worker) documents social worker met with patient. Patient is a pleasant [AGE] year-old female admitted to the facility on [DATE]. Patient reports living alone in a bungalow style home with about 7 stairs into house and about 14 stairs into basement and to the second floor. Patient provided her primary care physician's name and phone number. It is the patients wish to go back to her home upon discharge. R3's Medical Practitioner Note Progress Note dated 3/8/2024 at 12:00 PM documents her neurological status as Grossly normal without focal neurological deficits. On 03/04/2024 at 1:25 PM V1 (Administrator) stated he did not send R3 to the hospital because he was originally told R3's alleged sexual abuse incident involved her being touched inappropriately on a surface level. V1 stated however after further conversation now it seems the nurse allegedly went further and touched her inwardly. V1 stated R3 wasn't aware there was CNA (Certified Nursing Assistant) with the nurse the entire time he was with her so there seems to be some confusion. On 03/04/2024 at 1:39 PM V12 (Family Member) stated on 03/02/2024 R3 told her that she was told a physical or body check needed to be performed and she didn't expect they had to touch her on her bottom and didn't expect a finger to go into her vaginal area. V12 stated after she received this report from R3, she called the facility and asked to speak with a female nurse to ensure she didn't get the male nurse who was alleged to have touched R3 inappropriately. V12 stated she spoke with V13 (Licensed Practical Nurse) and informed her of what R3 told her and V13 was appalled. V12 stated she asked V13 if sticking a finger in the vagina was a normal procedure and V13 stated it was absolutely not and was shocked of what was reported. V12 stated V13 advised she would inform the Administrator about what was reported. V12 stated V1 (Administrator) then contacted her. V12 stated V1 was concerned that R3 may be confused but she is a sharp lady and is never confused. V12 stated R3 even told her she is a single woman and has never been touched like that in her life. V12 stated V19 (Police Officer) from local police department contacted her as well. V12 stated on the day of the incident after V13 spoke with R3 she told her she needed to call the police. V12 stated the police came and spoke to R3 at the facility and then contacted her. V12 stated R3 doesn't have any children and was never married. V12 stated R3 didn't feel comfortable with a male nurse telling her how to go to the bathroom. V12 stated R3 did not mention anyone else being in the room during the incident, but the facility mentioned someone else was in the room which they should have been. V12 stated she is pretty sure she told V1 everything that R3 told her. On 03/04/2024 at 2:37 PM V13 (Licensed Practical Nurse) stated V12 (Family Member) reported to her Saturday 03/02/2024 that R3 informed her that a male placed his fingers inside her vagina. V13 stated she tried to explain the process of assessment to V12. V13 stated she was R3's nurse but V14 (Registered Nurse) performed the admission physical assessment and all procedures involved in admitting a resident to the facility. V13 stated she initially notified the administrator of what was reported to her and then the police. V13 stated she spoke to the police officer after he interviewed the alleged nurse and asked what she thought about the whole situation. V13 stated she responded that she wasn't sure what she thought about it because she wasn't familiar with the resident or employee. On 03/04/2024 at 4:33 PM V15 (Certified Nursing Assistant) stated while working the evening shift from 2-10PM on 03/02/2024, R3 was newly admitted and while getting R3 situated in her room V14 (Registered Nurse) asked her to assist him with completing R3's physical skin assessment. V15 stated R3 was wearing pants and a shirt that she was admitted in. V15 stated V14 asked R3 if it was ok to perform the skin assessment. V15 stated during the assessment she and V14 raised R3's shirt just above her breast and pulled her pants halfway down to observe for any abnormalities. V15 stated afterwards they also turned her on her side to check her back and bottom. V15 stated the whole process was explained to R3 as it was taking place. V15 stated V14 also continued speaking with R3 about her medications. V15 stated she doesn't recall V14 going back into R3's room after the assessment and he left the room when she did. V15 stated she later went back into R3's room when she pulled the call light and assisted R3 with removing tags from her clothes. V15 stated at approximately 5:30 PM R3 was up and around in the hallway. V15 stated she was assigned to 11 rooms on the unit where R3's room was located during her shift. V15 stated she also brought R3 her dinner around 6PM. V15 stated she last saw R3 when she collected her tray during which time, she was lying in her bed sometime at or after 7 or 8PM. V15 stated she did not have her eyes on V14 throughout her entire shift and could not be certain of his whereabouts at all times. On 03/05/2024 at 2:37 PM V2 (Director of Nursing) stated V14 (Registered Nurse) wasn't assigned to R3's room on 03/02/2024, however when there are multiple admissions the nurses' alternate admissions. V2 stated V14 normally works on the unit where R3's room is located. On 03/05/2024 at 3:14 PM V14 (Registered Nurse) stated that on 03/02/2024 he was working on another unit but there were multiple admissions on the unit where R3's room was located, and he was assigned to do admissions only on that unit. V14 stated he and a CNA (Certified Nursing Assistant) went to R3's room together to perform an assessment. V14 stated upon entering R3's room she was sitting on her bed and he and the CNA explained the assessment procedures and she consented to the procedures. V14 stated throughout the whole assessment the CNA was present. V14 stated after he left once the assessment was complete and the CNA continued to assist R3, and he never returned to the room again. V14 stated while he was working, he saw R3 walking in the hall on the other side of the unit where R3's room is located near a different room and told the CNA R3 was out of the room and asked them to redirect R3 back to her room. V14 stated when we explained to R3 about the head-to-toe assessment she (R3) seemed alert and oriented but after that we found her alertness to be on and off because after explaining safety protocols such as not trying to ambulate on her own or using the call light to call for assistance when she needed it, she continued to leave her room and was not using the call light. V14 stated R3 can walk by herself, but her gait was unstable. V14 stated after R3 was assessed by therapy to determine if she can ambulate with a walker or wheelchair etc. it would be safer for her to ambulate. V14 stated after speaking with the police he was taking care of his patients in the 17 rooms he was assigned until the administrator told him to clock out and go at approximately 8:15 to 8:30 PM. V14 stated his CNA was assisting him with working with the residents he was assigned to. V14 stated once he completed R3's admission assessment he provided the report to V13. V14 stated after the police officer's arrival he still needed to pass medications and perform other duties and was not aware of what was going on with the situation, so he continued working until he left the facility. V14 stated the police spoke with him and the CNA around 7 or so but before he left at 8:30 PM. On 03/05/2024 at 3:37 PM V16 (Certified Nursing Assistant) stated she has worked for the facility for approximately 4 weeks and has worked with R3 once on Sunday 03/05/2024 and has been assigned to her today. V16 stated R3 seems to be alert and does not appear confused at any time. On 03/05/2024 at 3:51 PM V17 (Social Worker) stated R3 lives alone in a bungalow style home and has been doing things all alone. When asked by surveyor about R3's discharge potential V17 stated R3 can likely go home with some home health services and home maker services. V17 stated R3 seems cognitively intact and was able to give me the last four digits of her zip code, was able to show her where all her contacts were written down in her room, and stated R3 expressed that she writes everything down to keep up with it. V17 stated R3 doesn't always want to press the call light for assistance but seems alert and oriented and has a BIMS (Basic Interview for Mental Status) score of 12. On 03/06/2024 at 3:35 PM V1 (Administrator) stated he wasn't in the building the day of the alleged sexual abuse incident with R3. V1 stated there were inconsistencies in what R3 reported regarding the sexual abuse allegation. V1 stated the inconsistencies in what R3 has reported to him when interviewing her with V2 (Director of Nursing) included stating there was only one instance when she saw V14 (Registered Nurse), V14 came into her room when she was attempting to use the bathroom. V14 came in and told her to stay in the chair or bed and he would assist her. That V14 came in and gave her an oral assessment, checked her teeth, did a body check on her then checked down in her genitalia and inserted his finger into R3's vagina, at which point she was stunned. He (V14) finished up and he left the room. V1 stated he interviewed V15 (CNA) to go over the situation and she stated the only other time she saw V14 with R3 was when R3 left her room either before or after the assessment, likely before. V1 stated V15 reported that R3 was down by therapy and likely lost, and V14 was going past at the time and V15 saw V14 redirect R3 back to her room, then she went in to assist him with the initial nursing assessment and helped R3 get set up for the assessment. V1 stated R3 doesn't remember that the CNA was there during her nursing assessment and reports V14 engaged in the extra activities with her by himself. V1 stated R3 also maintains she was only with V14 one time and it's confusing as to if this was during the initial assessment or any other time and the fact that she's reporting only seeing him the one time. V1 stated there is no way for him to know if R3's recollection of the moments involved in the alleged sexual abuse incident that day could be affected due to trauma. V1 stated there is evidence out there that trauma does affect the memories of people who have experienced sexual abuse. V1 stated there have been objective assessments that indicate R3 has cognitive impairment, social services staff did a BIMS (Basic Interview for Mental Score) assessment that show cognitive impairments, and there are also cat scans (computerized tomography) from R3's hospital records that indicate brain impairment so there's a lot going on and it's difficult to say where her cognition really lies. V1 stated the fact that R3 is also confusing her timeline of events also presents some issues. V1 stated R3 maintains only having one encounter with V14 and reports inconsistencies in the timeline of the events that took place. V1 stated it wasn't until Monday R3 reported to him that V14 placed his fingers inside her vagina. V1 stated the initial report from V13 (Licensed Practical Nurse) was that R3 was touched inappropriately and then later after having some more thought about it she added the additional detail of vaginal penetration. On 03/06/2024 at 3:58 PM V22 (Detective) stated he was just at the facility to go over the facts of the case with R3 and to do an additional interview of her recollection of the events. V22 stated It was initially reported R3 was coming out of the bathroom and having a difficult time pulling her pants up due to the condition of her arm. The nurse came in to assists her with pulling her pants up then digitally penetrated her and used his finger in a circular motion. V22 agreed that time, trauma of the event, and constant questioning may have an impact on R3's recollection of the events. V22 stated also due to R3 falling at the house, having surgery, and being transported to the facility for rehab. She (R3) may be unable to recollect the events in a clear manner. V22 stated he's no expert in recognizing a person's cognitive impairments however R3 spoke clearly and didn't seem to have any cognitive issues. V22 stated just as the surveyor inquired, R3 is getting tired of telling the story over and over. On 03/07/2024 at 12:40 PM V12 (Family Member) stated she called to check in on R3 at approximately 6:52

Based on interviews and record review, the facility failed to follow their policy and procedures for preventing residents from further potential abuse by staff, after an allegation of staff to resident sexual abuse was made. This failure applied to one of three (R3) residents reviewed for sexual abuse investigation procedures and has the potential to affect the 126 residents currently in the facility. The Immediate Jeopardy began on 03/02/24 when R3 was sexually abused by a facility Registered Nurse (V14). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 03/07/24 at 1:15PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 3/11/24, but noncompliance remains at Level Three because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3 is an [AGE] year-old female with diagnoses that include history of Hereditary Hemochromatosis, Femur Fracture, Primary Generalized Osteoporosis, and Essential Hypertension who was admitted to the facility 03/02/2024. R3's past medical history does not include cognitive or psychological disorders. On 03/04/2024 at 11:45 AM observed R3 sitting in a chair in her room with a cast covering her entire left arm. R3 stated she fell on Saturday 03/02/2024 at her home and damaged her elbow and that is why she was admitted to the facility. In response to surveyor asking R3 about an allegation of sexual abuse, R3 stated she wants to forget about it. R3 stated there have been so many people coming to see her about it. R3 stated a male nurse observed her walking around in her room, walked her over to her bed sat her down, and told her he didn't want her walking around the room on her own. R3 stated he offered to help her undress because he saw she was in no condition to do it on her own with her arm being the way it was. R3 stated the male nurse left the room and returned. R3 stated the male nurse examined her mouth with his fingers and asked her if her teeth were hers and she answered yes. R3 stated the male nurse then began pulling her teeth as if to see if they were false and she assured him they were hers. R3 stated the male nurse then kneeled in front of her and placed his fingers in her pants and then inside her vagina and moved his finger around in a circular motion. R3 stated she stopped him there and didn't know what to make of what the male nurse had done to her. R3 stated the male nurse then told her I'm going to leave you now you're clean. R3 stated she asked the male nurse what that meant, and he stated it meant there was nothing in her that would cause her problems. R3 stated what the male nurse did made her feel dirty, angry, and violated. R3 stated she didn't realize what the male nurse was doing until it was over, and she then wondered if he would attack her next. R3 stated she then told another nurse, and the nurse called the police. R3 stated the male nurse was African or African American. R3 stated as a Christian what the male nurse did to her made her feel bad. R3 to appeared stressed, agitated, and sad while reporting the abuse allegation to the surveyor. On 03/05/2024 at 12:38 PM observed R3's facial expression change from relaxed and content to display a frown and discomfort when surveyor asked follow up questions about her sexual abuse allegation. R3 stated on 03/02/2024 V14 (Registered Nurse) told her he had to do what he was doing to her during the alleged sexual abuse incident, because it was his job and if he didn't do it, he would lose his job. R3 stated V14 had been in her room more than once that day telling her not to walk on her own which she didn't like. R3 stated during the incident V14 sat her on the bed, kneeled in front of her, and placed his hands in her pants. R3 stated she told the administrator she never wanted to see V14 again after the incident. R3 stated the administrator has since come back and talked to her about the incident and explained the process of admissions examinations and she told him she was not aware of that process because she had never been in a nursing home before. R3 stated she told the administrator what V14 did to her, and he didn't say much about it in response. Initial Abuse Investigation Reports dated 03/02/2024 documents: Administration received report at 7PM from the nurse on duty that R3 reported to her family member an allegation of inappropriate touching during her assessment by her admitting nurse. R3 stated a male nurse, V14 (Registered Nurse), touched her on or near her buttocks and genitalia during her initial body check assessment. The alleged nurse and reporting nurse stated the resident appeared confused about the events of the allegation during initial interview. The reporting nurse informed that the resident told her he touched her inappropriately, the alleged nurse and a female nurse aide completed the initial assessment as part of their routine care during an admission with the patient's consent, the alleged nurse denied the incident, his assisting nurse aide stated there was no inappropriate behavior on part of the nurse as well. The administrator spoke with V12 (Family Member) responsible party who received the report, to inquire about conversation with the resident. V12 stated R3 felt the nurse touched her inappropriately during the process. Administration informed them there would be an investigation immediately initiated, the staff member would be suspended, and local law enforcement would be notified for report. V14's (Registered Nurse) witness statement dated 03/02/2024 documents he explained to R3 that a head-to-toe assessment would be performed and obtained verbal consent from R3 to perform; attempt to perform complete assessment on R3 with a CNA (Certified Nursing Assistant) present for the entire assessment. V15's (Certified Nursing Assistant) witness statement dated 03/02/2024 documents she was the CNA assigned to R3, she went in R3's room to do a skin assessment with the nurse, R3 was told everything that was going to be done with her consent prior to initiating; she helped the nurse assess R3's skin from head to toe, helped dress R3 when done and the nurse left the room after. V15 stated the nurse never returned to R3's room, the nurse was only assigned to do the admission and she was there with the nurse for the entire assessment. Police Report dated 03/02/2024 documents at 7:04 PM police responded to the nursing home in regarding a criminal sexual assault report; R3 reported a male nurse penetrated her vagina with his finger. R3 could not confirm the time of the incident. R3 reported the nurse entered her room during the time she was using the bathroom. When she came out of the bathroom, she was unable to pull her pants up because of her broken arm, the male nurse assisted her to sit down on her bed. The male nurse then began asking questions about her teeth. After checking her teeth (possibly for dentures), the male nurse placed his hand in her pants and penetrated her vagina with his finger; R3 stated the male nurse moved his finger in a circular motion inside her vagina, she attempted to push the nurse away but couldn't then he left the room. R3 reported no one else was present during this incident. R3 described the nurse as darker skinned and speaking with an accent. The alleged perpetrator was identified as V14 (Registered Nurse) reported he went into R3's room with V15 (Certified Nursing Assistant) present to perform a full physical examination, both denied that V14 touched R3's vagina. V14 denied going into R3's room other than during the physical examination. V13 (Charge Nurse) was interviewed and confirmed an initial physical examination procedure does not involve examining the genital area; and that she observed V14 go into R3's room multiple times after the physical examination. She (V13) does not know why V14 was in R3's room; no one else was in the room with V14. V13 stated that V14 is no longer R3's nurse, and he will not be going into the room anymore. V13 told the police officer she has taken over as R3's nurse for the night. V13 was given the report number for her records. The officer went back to speak with R3 one more time. The officer explained to R3 that V14 is no longer her nurse and should not be in her room. R3's progress note dated 3/3/2024 6:04 PM documents a telehealth evaluation was conducted in response to an Allegation of Abuse. Patient reporting during admit that the male nurse inserted fingers into her vagina during exam. V14's (Registered Nurse) personnel file was reviewed 03/04/2024 and documents a hire date of 03/18/2019. A Healthcare Worker Criminal History Records Information Check was performed 02/27/2019. A Consumer Reporting Agency Background Application was performed 02/27/2019. An Illinois State Police background check was performed 03/13/2019. A Global Human Resources Research report was performed 02/28/2019. A National Sex Offender Search was performed 03/13/2019. An Illinois State Sex Offender search was performed 03/13/2019. An Illinois Department of Corrections check was performed 03/13/2019. An Abuse training was completed in 2019 and does not include any other background checks or abuse prevention trainings after these time frames. Statement from V2 (Director of Nursing) documents she interviewed R3 on 03/05/2024 in her room regarding the incident that occurred on Saturday 03/02/2024. R3 reported the (alleged) nurse escorted her into the building from the ambulance and sat her on the bed. R3 reported the (alleged) nurse asked her if she had dentures and asked her to open her mouth and proceeded to examine her mouth. R3 reported she didn't understand the need for his exam because she stated to him all her teeth were her own. R3 reported she was sitting at the side of the bed when the (alleged) nurse inserted his fingers in her vagina and scratched her and she knew it was wrong and asked him to stop because she is a virgin, and a man has never touched her down there. R3 stated the (alleged) nurse removed his hand and told her she was all clean and walked out of the room and never returned. V2 asked if the same man entered R3's room at all again with another worker, she stated no he never returned. Statement from V13 (Licensed Practical Nurse) dated 03/06/2024 10:19 AM documents On Saturday 03/03/2024, V13 received a call from V12 (Family Member) of R3. V12 informed V13 that R3 was sexually assaulted by a male, and this male worked at our facility. V12 then asked was this a normal thing that happens at the facility. V12 further stated that R3 has never been touched down there before. V12 was very upset, she demanded a call back from the administrator of the facility. V13 tried reassuring V12 there may have been a misconception or misunderstanding and explained the admissions process and requirement of having a physical assessment. V12 stated she understood this, but the nurse touched R3 inappropriately. V12 stated R3 told her that the male employee put his finger in her. V13 told V12 she would call the administrator and will give her a call. V13 reported to the administrator that V12 told her R3 informed her she was touched inappropriately and does not recall telling him that V12 stated the male put his finger in R3's vagina, however she did inform the doctor of this. V13 stated she was instructed to call the police and notify the physician. Statement from V10 (Assistant Director of Nursing) dated 03/06/2024 documents when R3 was asked about what occurred this weekend she (R3) stated when is this going to be over. V10 explained that it is not our intent to make her revisit this but just part of a thorough investigation and that clinical staff are mandated reporters and required to take the steps both the facility and the state are performing. R3 started to state that she shouldn't have said anything, and V10 reassured her that our goal is to make sure she feels safe and cared for. R3 then began describing how the nurse in question walked her in from the ambulance but it was a long way, he took her to the room, and she sat down on the edge of the bed, she then changed focus to the fall that resulted in her arm being fractured. Final Abuse Investigation report dated 03/08/2024 documents: The police were called at 7:04 PM and reported to the facility for investigation. Administration instructed V13 (Registered Nurse) to have V14 stop work and come off the unit away from resident contact to await police interview and sit with him until then. Per police records the officer arrived on scene at 7:24 PM, the officer interviewed the employees involved including V13, V14, and V15 (Certified Nursing Assistant) as well as R3. Per police record R3 reported that a male nurse had penetrated her vagina with his finger and stated this occurred sometime this afternoon but was unsure of the exact time. Upon interview V13 and V14 reported giving R3 a head-to-toe visual examination and both denied any touching of the vaginal area. V14 denied going into R3's room other than just for the assessment. The police interviewed V13, and she (V13) reported observing V14 go into R3's room multiple times after the initial exam and did not know the reason. V13 stated no one else went in the room with V14. V14 and V13 were in the nurse's station during the duration of the investigation while he was speaking with the officer and closing out his records to turn over his patients to his coworker V13. At 8:11PM, the administrator called the facility to check on the progress and asked V14 to stop his work and leave the premises since the police completed their interview with him. The police finished their interviews with all involved and left the facility at 8:42 PM. On Monday Morning 03/04/2024 the state survey agency came into the facility to conduct a facility reported incident review. V1 (Administrator), and V2 (Director of Nursing) interviewed R3, and they were informed of additional information including the allegation that V14 inserted his fingers into her vagina during an examination. R3 described the oral examination and body check and did not recall the witnessing nurse aide being part of the examination. R3 reported V14 did not return later, and this was the only incident. R3 reported she could not recall the time of the incident. On further follow up interviews with V14 during the course of the investigation, V14 reported he initially received the resident's admission paperwork from the ambulance company when she(R3) was admitted to the facility around 3PM. Shortly after R3's arrival V14 saw R3 down the hallway walking near the therapy gym and offered to assist her back to her room. While walking R3 to her room V14 reported he met V15 (CNA) at R3's doorway and she took over to assist her to her bed. Later in the shift between 4PM-5PM, V14 approached V15 and requested assistance with conducting a body assessment for R3. The allegation could not be substantiated; R3's assessment identified cognitive impairment and she could not remember the witnessing nurse aide as assisting the nurse during the body assessment. V14 was supervised by staff and in the presence of law enforcement and no contact with residents after the allegation was made. The initial confusion of the incident was contributed to cognitive impairment during her initial body assessment. The cognitive impairment of the resident is supported by the evaluation of social service, licensed speech therapist and documents from her most recent hospitalization . R3's Admission Clinical Hospital Reports dated 02/27/2024 documents she is an [AGE] year-old female with a past medical history of Hereditary Hemochromatosis, Hypertension, Osteoarthritis who was seen at the hospital for left elbow pain and reported that while she was at home with two of her family members she slipped and fell while outside doing yard work and trying to start the lawnmower. A Left elbow x-ray revealed a fracture of her left arm; she is neurovascularly intact, alert, and oriented x/times 3 (to person, place, and time), with normal speech. Physical Exam Neurological Status: Normal orientation, normal memory; the hospital Physician's Progress Note dated 02/28/2024 documents intervention options and potential risks and benefits of interventions for R3's fracture were discussed with her and her family members; R3 is an elderly individual with frail body habitus. She (R3) is a right-hand dominant individual who lives alone and is an active person. she also drives a car. She (R3) chose the surgical intervention to get the best possible outcome from this fracture. She understood the risks and benefits and understood that surgical complications can occur and may require additional interventions. R3 and her family members had many questions which were addressed, and it was believed they understood. R3 has signed the consent for the surgery. R3's hospital/clinical report which includes a CT scan (computerized tomography) of her head do not include a reference or note of cognitive impairment. R3's Admission Evaluation dated 03/02/2024 at 5:28 PM created by V14 (Registered Nurse) documents her mentation as alert and oriented x3. R3's neurological status as oriented to person, place, and time; has the ability to move her upper and lower extremities. R3 has no impairment in lower extremity range of motion, with steady sitting, standing, and gait balance. R3's admission progress note dated 3/2/2024 at 6:01 PM created by V14 (Registered Nurse) documents she is an [AGE] year-old female patient received from local hospital this afternoon accompanied by local transportation company. Admitting for post care after fall at home, resulting in an elbow fracture. Skin assessment completed, bruises noted on left knee area, right arm, and left breast side. Left mid back area bruises/redness noted. Redness noted on buttock area. Left arm cast noted (left elbow fracture). Safety maintained, call light and personal belongings in reach, bed in lowest position, all needs attended by staff. Report given to on floor nurse. R3's Current Physician Orders do not include cognitive or psychotropic medications. R3's admission social services comprehensive assessment section for trauma factors including abuse dated 03/03/2024 at 1:36 PM documents she has a history of abuse with no factors that increase the resident's vulnerability such as dementia, confusion, disorientation, poor insight/poor judgment, or poor communication skills and no psychiatric history and/or present mental health diagnosis, including psychotic symptoms (e.g., delusional thinking, hallucinations), or possible misinterpretation of events and the intentions of others. The community survival skills section documents R3 is sufficiently alert, oriented, coherent, and knowledgeable allowing her to be considered for independent outside pass privileges. R3 knows how to ask for/seek help in an emergent or problematic situation and appears to be capable of unsupervised outside pass privileges at this time. The section for Prior Living Arrangements/Discharge Potential documents, R3 previously lived at home alone independently, reported having 7 stairs to enter her home, 17 stairs inside her home leading down to the basement and approximately 15 upstairs, and has good discharge potential. R3's Minimum Data Set, dated dated dated [DATE] documents she has a Basic Interview for Mental Assessment score of 12 out of 15. R3's progress note dated 3/4/2024 14:02 created by V17 (Social Services Worker) documents social worker met with patient. Patient is a pleasant [AGE] year-old female admitted to the facility on [DATE]. Patient reports living alone in a bungalow style home with about 7 stairs into house and about 14 stairs into basement and to the second floor. Patient provided her primary care physician's name and phone number. It is the patients wish to go back to her home upon discharge. R3's Medical Practitioner Note Progress Note dated 3/8/2024 at 12:00 PM documents her neurological status as Grossly normal without focal neurological deficits. On 03/04/2024 at 1:25 PM V1 (Administrator) stated he did not send R3 to the hospital because he was originally told R3's alleged sexual abuse incident involved her being touched inappropriately on a surface level. V1 stated however after further conversation now it seems the nurse allegedly went further and touched her inwardly. V1 stated R3 wasn't aware there was CNA (Certified Nursing Assistant) with the nurse the entire time he was with her so there seems to be some confusion. On 03/04/2024 at 1:39 PM V12 (Family Member) stated on 03/02/2024 R3 told her that she was told a physical or body check needed to be performed and she didn't expect they had to touch her on her bottom and didn't expect a finger to go into her vaginal area. V12 stated after she received this report from R3, she called the facility and asked to speak with a female nurse to ensure she didn't get the male nurse who was alleged to have touched R3 inappropriately. V12 stated she spoke with V13 (Licensed Practical Nurse) and informed her of what R3 told her and V13 was appalled. V12 stated she asked V13 if sticking a finger in the vagina was a normal procedure and V13 stated it was absolutely not and was shocked of what was reported. V12 stated V13 advised she would inform the Administrator about what was reported. V12 stated V1 (Administrator) then contacted her. V12 stated V1 was concerned that R3 may be confused but she is a sharp lady and is never confused. V12 stated R3 even told her she is a single woman and has never been touched like that in her life. V12 stated V19 (Police Officer) from local police department contacted her as well. V12 stated on the day of the incident after V13 spoke with R3 she told her she needed to call the police. V12 stated the police came and spoke to R3 at the facility and then contacted her. V12 stated R3 doesn't have any children and was never married. V12 stated R3 didn't feel comfortable with a male nurse telling her how to go to the bathroom. V12 stated R3 did not mention anyone else being in the room during the incident, but the facility mentioned someone else was in the room which they should have been. V12 stated she is pretty sure she told V1 everything that R3 told her. On 03/04/2024 at 2:37 PM V13 (Licensed Practical Nurse) stated V12 (Family Member) reported to her Saturday 03/02/2024 that R3 informed her that a male placed his fingers inside her vagina. V13 stated she tried to explain the process of assessment to V12. V13 stated she was R3's nurse but V14 (Registered Nurse) performed the admission physical assessment and all procedures involved in admitting a resident to the facility. V13 stated she initially notified the administrator of what was reported to her and then the police. V13 stated she spoke to the police officer after he interviewed the alleged nurse and asked what she thought about the whole situation. V13 stated she responded that she wasn't sure what she thought about it because she wasn't familiar with the resident or employee. On 03/04/2024 at 4:33 PM V15 (Certified Nursing Assistant) stated while working the evening shift from 2-10PM on 03/02/2024, R3 was newly admitted and while getting R3 situated in her room V14 (Registered Nurse) asked her to assist him with completing R3's physical skin assessment. V15 stated R3 was wearing pants and a shirt that she was admitted in. V15 stated V14 asked R3 if it was ok to perform the skin assessment. V15 stated during the assessment she and V14 raised R3's shirt just above her breast and pulled her pants halfway down to observe for any abnormalities. V15 stated afterwards they also turned her on her side to check her back and bottom. V15 stated the whole process was explained to R3 as it was taking place. V15 stated V14 also continued speaking with R3 about her medications. V15 stated she doesn't recall V14 going back into R3's room after the assessment and he left the room when she did. V15 stated she later went back into R3's room when she pulled the call light and assisted R3 with removing tags from her clothes. V15 stated at approximately 5:30 PM R3 was up and around in the hallway. V15 stated she was assigned to 11 rooms on the unit where R3's room was located during her shift. V15 stated she also brought R3 her dinner around 6PM. V15 stated she last saw R3 when she collected her tray during which time, she was lying in her bed sometime at or after 7 or 8PM. V15 stated she did not have her eyes on V14 throughout her entire shift and could not be certain of his whereabouts at all times. On 03/05/2024 at 2:37 PM V2 (Director of Nursing) stated V14 (Registered Nurse) wasn't assigned to R3's room on 03/02/2024, however when there are multiple admissions the nurses' alternate admissions. V2 stated V14 normally works on the unit where R3's room is located. On 03/05/2024 at 3:14 PM V14 (Registered Nurse) stated that on 03/02/2024 he was working on another unit but there were multiple admissions on the unit where R3's room was located, and he was assigned to do admissions only on that unit. V14 stated he and a CNA (Certified Nursing Assistant) went to R3's room together to perform an assessment. V14 stated upon entering R3's room she was sitting on her bed and he and the CNA explained the assessment procedures and she consented to the procedures. V14 stated throughout the whole assessment the CNA was present. V14 stated after he left once the assessment was complete and the CNA continued to assist R3, and he never returned to the room again. V14 stated while he was working, he saw R3 walking in the hall on the other side of the unit where R3's room is located near a different room and told the CNA R3 was out of the room and asked them to redirect R3 back to her room. V14 stated when we explained to R3 about the head-to-toe assessment she (R3) seemed alert and oriented but after that we found her alertness to be on and off because after explaining safety protocols such as not trying to ambulate on her own or using the call light to call for assistance when she needed it, she continued to leave her room and was not using the call light. V14 stated R3 can walk by herself, but her gait was unstable. V14 stated after R3 was assessed by therapy to determine if she can ambulate with a walker or wheelchair etc. it would be safer for her to ambulate. V14 stated after speaking with the police he was taking care of his patients in the 17 rooms he was assigned until the administrator told him to clock out and go at approximately 8:15 to 8:30 PM. V14 stated his CNA was assisting him with working with the residents he was assigned to. V14 stated once he completed R3's admission assessment he provided the report to V13. V14 stated after the police officer's arrival he still needed to pass medications and perform other duties and was not aware of what was going on with the situation, so he continued working until he left the facility. V14 stated the police spoke with him and the CNA around 7 or so but before he left at 8:30 PM. On 03/05/2024 at 3:37 PM V16 (Certified Nursing Assistant) stated she has worked for the facility for approximately 4 weeks and has worked with R3 once on Sunday 03/05/2024 and has been assigned to her today. V16 stated R3 seems to be alert and does not appear confused at any time. On 03/05/2024 at 3:51 PM V17 (Social Worker) stated R3 lives alone in a bungalow style home and has been doing things all alone. When asked by surveyor about R3's discharge potential V17 stated R3 can likely go home with some home health services and home maker services. V17 stated R3 seems cognitively intact and was able to give me the last four digits of her zip code, was able to show her where all her contacts were written down in her room, and stated R3 expressed that she writes everything down to keep up with it. V17 stated R3 doesn't always want to press the call light for assistance but seems alert and oriented and has a BIMS (Basic Interview for Mental Status) score of 12. On 03/05/2024 at 4:14 PM V18 (Human Resource Director) stated she runs license checks yearly along with another database to check for any background or disciplinary issues regarding the nurse's license. V18 stated the database will also show you if a license was removed and reinstated as well as any licenses under your name. V18 stated she is not sure why these checks have not been conducted for V14 (Registered Nurse) since he was hired. V18 stated there have been a few transitions in the company, administration, and HR (Human Resources) personnel of the facility in the last two years. V18 stated she was trained to perform these checks while working at a previous facility. V18 stated she has not received any formal training on running employee background checks since she began working at this facility in July. V18 stated V1 (Administrator) asked her about what the background check policy is for this facility, and she text corporate to confirm if the practices she had been trained on at the previous facility were the same for this facility. V18 stated V20 (Corporate) advised her that licensing status and license related background checks should be ran yearly to ensure they are renewed and in good standing. V18 stated who knows what these people have done if we have only run their license checks every 2 years. V18 stated she is not sure why V14's background has not been run since he was hired but she has been cleaning up the workload from the previous HR staff and she is behind in running these checks on staff. V18 stated she will prioritize doing this based on becoming aware of V14's background check status being overdue. On 03/06/2024 at 3:11 PM V1 (Administrator) stated he asked V14 (Registered Nurse) to stay with the nurse who reported the abuse allegation until the police arrived and began interviewing them and he left after. V1 stated V14 was supposed to punch out after he was interviewed by the police. V1 stated he would have to look at the time record to confirm when V14 left the and is going through the process of confirming when V14 left. On 03/06/2024 at 3:35 PM V1 (Administrator) stated he wasn't in the building the day of the alleged sexual abuse incident with R3. V1 stated there were inconsistencies in what R3 reported regarding the sexual abuse allegation. V1 stated the inconsistencies in what R3 has reported to him when interviewing her with V2 (Director of Nursing) included stating there was only one instance when she saw V14 (Registered Nurse), V14 came into her room when she was attempting to use the bathroom. V14 came in and told her to stay in the chair or bed and he would assist her. That V14 came in and gave her an oral assessment, checked her teeth, did a body check on her then checked down in her genitalia and inserted his finger into R3's vagina, at which point she was stunned. He (V14) finished up and he left the room. V1 stated he interviewed V15 (CNA) to go over the situation and she stated the only other time she saw V14 with R3 was when R3 left her room either before or after the assessment, likely before. V1 stated V15 reported that R3 was down by therapy and likely lost, and V14 was going past at the time and V15 saw V14 redirect R3 back to her room, then she went in to assist him with the initial nursing assessment and helped R3 get set up for the assessment. V1 stated R3 doesn't remember that the CNA was there during her nursing assessment and reports V14 engaged in the extra activities with her by himself. V1 stated R3 also maintains she was only with V14 one time and it's confusing as to if this was during the initial assessment or any other time and the fact that she's reporting only seeing him the one time. V1 stated there is no way for him to know if R3's recollection of the moments involved in the alleged sexual abuse incident that day could be affected due to trauma. V1 stated there is evidence out there that trauma does affect the memories of people who have experienced sexual abuse. V1 stated there have been objective assessments that indicate R3 has cognitive impairment, social services staff did a BIMS (Basic Interview for Mental Score) assessment that show cognitive impairments, and there are also cat scans (computerized tomography) from R3's hospital records that indicate brain [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide effective and individualized fall interventions for a resident assessed to be at high-risk of falling. This failure affected one (R6) of one resident reviewed for falls which resulted in R6 requiring urgent hospitalization for pain, and subsequently being diagnosed with a fracture of the right hip. Findings include: R6 is [AGE] years old and admitted to the facility 1/5/24 with diagnoses that included Dysphagia, Cognitive Communication Deficit, Malnutrition, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Osteoporosis. R6 is assessed to be alert to person and situation, but has episodes of confusion, according to assessments in the electronic health record. R6 has had seven falls in the facility since admission (approximately five weeks) with the most recent fall on 2/16/24 resulting in a fracture of the right hip. Four of the seven falls were documented to have occurred while R6 was sitting in the wheelchair and while not being monitored by staff or in a highly visible area. Fall incident report dated 2/16/24 indicates that nursing staff had recently attended to R6, assisted R6 to the washroom and left R6 in the wheelchair inside the bedroom. Shortly after while nursing staff was rounding, R6 was found lying on the floor and R6 said R6 was trying to get to the restroom. (R6) was assessed to have hip pain and was placed in bed using a mechanical lift. The nurse on duty gave acetaminophen for the complaint of pain and called the provider to order portable x-ray. According to nursing progress note written following the shift on 2/17/24 at 1:40PM when the x-ray technicians reported to the facility, R6 demonstrated too much pain to carry out the procedure. R6 was then sent to the emergency room via 911. R6 was admitted to the hospital with diagnosis of Right Hip Fracture. According to hospital records dated 2/17/24, R6 underwent surgical intervention to treat the fracture and returned to the facility on [DATE]. On 3/5/24 at 1:05PM V23 COTA (Certified Occupational Therapy Assistant) said that they had been working with R6 since admission. V23 said that since the fall with fracture, R6 is less motivated to complete the exercises, likely because of pain and anxiety. V23 stated typically the nurse is asked to medicate prior to therapy sessions which occur at least five days during the week. Care Plan for falls was initiated 1/5/24 on admission and shows revisions after each fall, however, does not address prevention of falls occurring from the wheelchair. It is to be noted that after the fall on 2/16/24, the care plan shows the following added interventions: Provide nonslip wheelchair cover (Date Initiated: 2/16/24) and Evaluate multiple falls to determine commonalities or patterns (Date Initiated: 2/22/24). On 3/7/24 at 3:00PM V29 Restorative Nurse said, that R6's fall interventions were being managed as a joint effort from the nursing and restorative teams. V29 said, that they were not sure of all the interventions placed for R6 to prevent falls and referred surveyor to the electronic health record. On 3/11/24 at 12:10PM V31 Registered Nurse said, V31 was the nurse on duty when R6 fell on [DATE]. V31 said an intervention placed for falls was to have R6's room closer to the nurse's station and an anti-slip pad was placed in the wheelchair seat, but R6 fell because R6 was standing up out of the wheelchair to walk and then fell . V31 acknowledged that R6 was alone while sitting in the chair unsupervised and the fall was unwitnessed. Fall prevention and Management Policy revised 1/24 states in part; Guidelines: 2. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. Facility Guideline following a fall incident: 3. A fall risk evaluation is completed by the Nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall. 4. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. 46344

Based on observation, interview, and record review, the facility failed to maintain an available supply of pain medication as ordered for a resident. This failure applied to one of one (R6) resident reviewed for pain and resulted in R6 experiencing uncontrolled pain, rating 10 out of 10, related to a fracture of the right hip sustained while living in the facility. Findings include: R6 is [AGE] years old and admitted to the facility 1/5/24 with diagnoses that include Dysphagia, Cognitive Communication Deficit, Malnutrition, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, And Osteoporosis. R6 is assessed to be alert to person and situation, but has episodes of confusion, according to assessments in the electronic health record. A Comprehensive Pain Assessment was competed at the time of admitted d 1/5/24 which indicated R6 did not have any acute or chronic pain. According to the electronic medical record, seven falls have been documented for R6 since admission, with the most recent fall occurring 2/16/24 that resulted in hospitalization and surgical interventions to treat a fracture of the right hip. Hospital discharge medications ordered acetaminophen 325 milligrams (two tablets) and tramadol 50 milligrams every eight hours as needed for pain. Upon return to the facility, Physician's Order Sheet (POS) included two medications to be utilized for pain management- acetaminophen 325 milligrams (one tablet) every six hours for pain, and tramadol 50 milligrams every eight hours as needed for pain. While on the unit on 3/11/24 at 12:36PM, R6 was observed awake lying in bed and preparing to eat lunch. A CNA (Certified Nursing Assistant) was assisting and setting up the lunch tray and repositioning. While repositioning, R6 was observed to have facial grimacing and furrowed brow. R6 pointed to the right and said, my hip and butt hurt really bad. It seems like it hurts all the time- the nurses and the doctors don't do enough for me when I have asked them, so I just sit and live with it. At 12:43PM, V24 LPN (Licensed Practical Nurse) said, that R6 had not been given any medication or pain interventions at any time during the shift since 6:30AM. V24 went to assess R6 who stated a numerical pain scale of 10 out of 10. V24 returned to the medication cart and noted that the pain medication Tramadol was not available. V24 said that they remember giving the last tablet while working 3/8/24 but could not remember if it was reordered at that time. V24 said that the medications are usually ordered directly from the Medication Administration screen in the electronic chart and can be accessed when signing off on the medication. V24 acknowledged that the pain medication would not have been available after giving the last dose. On 3/5/24 at 1:05PM V23 COTA (Certified Occupational Therapy Assistant) said that they had been working with R6 since admission. R13 said since the fall with fracture, R6 is less motivated to complete the exercises likely because of pain, and anxiety and typically the nurse is asked to medicate prior to therapy sessions which occur at least five days during the week. The Medication Administration Record for February and March (to present date) shows nurse signatures for administering tramadol are absent, however, the medication was signed out on the controlled substance monitoring log for five tablets which was received by the facility on 2/21/24. Care Plan dated 2/22/24 lists nursing interventions that include, administer pain meds and treatments as ordered, assess effectiveness of pain medication, assess pain characteristic: duration, location, quality and monitor for nonverbal indicators of pain (moaning, crying, grimacing, wincing) On 3/12/24 at 12:40PM V2 Director of Nursing said that the nature of nursing is that any medications given should be documented on the medication administration record, and with as needed medications, the pain assessment should be documented when the medications are given. The nurse should be assessing the resident at least once per shift and when asking for pain medications, I am not sure why the controlled sheet does not correlate with the administration record, or why the medication was not ordered at the time the last pill was removed. The pain medication should always be available to be give as ordered. V2 also said, according to the hospital transfer record, R6 should have been receiving two tablets of acetaminophen unless expressly stated differently by the physician. V2 was unaware of the discrepancy between the transfer order and the current physician order sheet. Medication Administration Policy revised 1/24 states in part: Guideline- 24. Document reason and response for any PRN (as needed) mediation. Facility Policy-Pain Management revised 1/24 states in part: Guidelines: The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it and exists whenever he or she says it does. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition ad established treatment goals. Pain management is a multidisciplinary care process that includes the following: Observing for the potential for pain; Effectively recognizing the presence of pain; Identifying the characteristics of pain; Addressing the underlying causes of the residents pain; Developing and implementing approaches to pain management; Identifying and using specific strategies for different levels and sources of pain; Monitoring for the effectiveness of intervention; and modifying approaches as necessary. It is important to recognize cognitive, cultural, familial, or gender specific influences on the resident' ability or willingness to verbalize pain. For example, some cultures value stoicism and a high threshold for pain which may influence a resident's wiliness to report pain or accept pain-relieving interventions. Policy: 4. If nursing recognizes pain, the staff may attempt non-pharmacological intervention, physical modalities, body alignment, rehabilitation therapy, exercises, ad/ or cognitive/behavioral interventions. 5. Licensed Nursing may notify the Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors. 6. If pain has not been managed consistent with the resident's goals and needs, the interdisciplinary team may need to reconsider current interventions ad revise those interventions as needed; or if pain has been maintained and/or resolves, the nursing staff will work with the physician to taper or discontinue analgesics.

Based on observations, interviews and record reviews, the facility failed to adequately monitor a resident with advancing dementia and history of wandering, recent episodes of wanting to leave the facility unauthorized, and without facility staff knowledge. This affected one of three residents (R1) reviewed for supervision and monitoring. This failure resulted in R1 leaving the facility unauthorized, being found walking and falling on the sidewalk next to a busy street. A bystander notified EMS (emergency medical services) 911 for police assistance for R1. R1 was transported to the local hospital for further treatment. R1 sustained a laceration and nasal fracture. The immediate jeopardy started on 10/10/2023. V1 (interim administrator) and V12 (administrator) were notified on 10/24/2023 of the immediate jeopardy. The surveyor confirmed the immediacy was removed on 11/7/23 but remains at a level two because additional time is needed to evaluate the implantation and effectiveness of the in-service training. Findings include: Upon entering this facility on 10/17/23, this surveyor observed the main doors unlocked and no staff present at the front desk in the main lobby. There were no staff observed in the four offices across from the main desk. There were three residents outside unsupervised. Five minutes lapsed before a staff member came to the main lobby to assist this surveyor. On 10/17/23 at 12:00pm, V4 (director of rehabilitation) stated that R1 had cognitive issues. V4 stated that V4 saw R1 on 10/10/23 for physical therapy session. V4 stated that he tried to have R1 use a two wheeled walker, but R1 was noncompliant with its use. V4 stated that R1 walked without an assistive device; R1's balance was off, gait unsteady, and R1 was a fall risk. V4 stated that R1 would wander off the nursing unit, staff were able to re-direct R1. V4 stated that on 10/10/23, R1 exhibited elopement type behaviors. V4 stated that R1 has decreased safety awareness and needed line of sight monitoring for safety. V4 stated that he did communicate these cognitive and safety concerns with R1's nurse and social worker on 10/10/23. R1's physical therapy note, dated 10/10/23, notes R1 is at high risk for falls secondary to decreased safety awareness and requires line of sight supervision secondary to elopement type behaviors. Communicated to nursing and social worker about this concern. On 10/17/23 at 1:40pm, V5 CNA (certified nurse aide) stated that R1 was confused, ambulatory, balance off, and will hold on to walls at times. V5 stated that on 10/10/23, R1 was really confused, wandering on unit, re-directed to his room by staff several times. V5 stated that dinner is served between 6:30pm and 7:00pm. V5 stated that V5 last saw R1 before dinner. V5 denied seeing R1 leaving the facility. V5 stated that a police officer came in and spoke with R1's nurse, unsure of time. On 10/17/23 at 1:47pm, V6 (nurse) stated that R1 was alert and oriented x 1. V6 stated that when R1's family present, R1 was oriented x 2. V6 stated that R1 was not aware of what was going on around him. V6 stated that R1 ambulated and was a little off balance sometimes. V6 stated that on 10/10, R1 came out to the nurses' station once, stood near water fountain, stated he wanted to cook, was attempting to remove plastic covering from water fountain. V6 stated that R1 was re-directed back to his room. V6 stated that she doesn't think therapy gave her an update on R1. V6 stated that the main door is open/unlocked from 8:00am-8:00pm, other doors are always locked. V6 stated that she worked day shift on 10/10/23 and did walking rounds with the oncoming nurse between 2:15pm and 2:30pm; R1 was in his room and appeared calm at that time. On 10/18/23 at 12:20pm, V9 CNA stated that she worked the evening shift on 10/10/23. V9 stated that at the beginning of shift, V9 went into R1 and R4's room to obtain R4's vital signs and observed R1 sitting on his bed. V9 stated that she didn't think anything about it because she was only assigned to R4. V9 stated that a little before 7:00pm, she brought R1 his meal tray, R1 was not present in room. V9 stated that she didn't think anything about it because residents go out to smoke. V9 stated that the next thing she knew the police were at the nurses' station informing V7 (nurse) that R1 had fallen in the parking lot. On 10/18/23 at 1:00pm, V7 (nurse) stated that R1 was last seen by V7 between 6:15pm and 6:30pm when he passed medications to R1 and R4. V7 stated that R1 was laying in his bed at that time. V7 stated that he did not see R1 after that as he got a new admission at 6:30pm. V7 stated that he was in with new admit performing an assessment. V7 stated that when he came out, he went to the nurses' station and observed a police officer at the nurses' station. V7 stated that the officer asked him if he had a resident on this unit with that name and responded yes. V7 stated that the police officer informed him that he observed R1 in the parking lot and saw R1 fall sustaining a laceration to R1's head. Police officer called EMS (emergency medical services) 911 and R1 was transported to the local hospital. On 10/18/23 at 3:45pm, V3 (interim director of nursing) stated that if a resident is missing, all staff are expected to stop what they are doing, do head count of residents, and search facility for resident. V3 stated that residents exhibiting wandering/elopement type behaviors should be monitored more often by staff. V3 stated that the main doors are unlocked from 8:00am to 8:00pm and a receptionist is at the main desk during that time. V3 stated that during the day shift, the activity aide will monitor the front desk so receptionist can take a meal break. V3 stated that on the evening shift, the receptionist will call the nursing units to find a nurse or CNA that can cover the front desk. On 10/19/2023 at 2:00pm, V1 (interim administrator) presented a timeline of events involving R1 on 10/10/23. On 10/10/23 at lunchtime per staff interviews, R1 displayed confusion such as walking with his bags saying he was looking for his truck and staff were able to reorient R1. V1 confirmed this was an accurate timeline of events. On 10/18/23 at 4:05pm, V11 (receptionist) stated that she worked 4:00pm-8:00pm on 10/10/23. V11 stated that residents are supposed to sign in and out when they go outside to smoke, but usually they don't. V11 stated that she writes their names in the logbook as they go out and come back in. V11 stated that she did not see R1 exit the building that evening. V11 stated that she must call around to find staff that would be able to cover the main desk when she takes break. V11 stated that she does leave main desk unattended to use the bathroom as she is only gone a few minutes. V11 stated that sometimes it is difficult to distinguish residents from visitors by what they are wearing. R1's medical record notes R1 was admitted to this facility on 10/4/2023 with diagnoses including, but not limited to, metabolic encephalopathy, dementia with behavioral disturbances, and cerebral amyloid angiopathy. R1's BIMS (brief interview of mental status) score, dated 10/10/23, is 3 out of 15. This facility's fast track assessment, dated 10/3/23, was completed while R1 was still in the hospital. Per R1's family, R1 has slowly been having some confusion at baseline. R1 has got very confused since R1's primary caregiver (family member) went to the hospital and R1 has not been caring for himself. Met with R1 at bedside. On one occasion, R1 did leave his house and could not find his way home. R1's pre-admission hospital record, dated 9/29/23-10/4/23, notes R1 is confused. Speech intact. Progressively worsened dementia with intermittent confusion. R1 had sundowning and agitation in hospital. R1 is alert and oriented x 2, unable to provide much history. R1 was brought into the emergency room by a local police officer for wandering around the streets. R1 is acting more confused than normal, he typically knows his name, address, days of the week, and what is happening. Neurologist noted R1 was found wandering around the streets at the police department. MRI (magnetic resonance imaging) of brain compared with MRI of brain completed in April 2023 consistent with numerous chronic lobar micro-hemorrhages in the bilateral cerebral hemispheres which have increased. This is consistent with progression of cerebral amyloid angiopathy. R1's confusion is likely consistent with amyloid spell and worsening of his baseline dementia which could be vascular related. R1's pre-admission hospital physical therapy (PT) documentation notes R1 is alert, confused, oriented to person. R1's overall functional communication is impaired. Attention span is impaired. R1 can follow one step commands. Organization, sequencing, and problem-solving functioning is impaired. Memory is impaired, decreased recall of recent events, decreased short term memory. Safety Awareness/Insight - decreased awareness of need for safety and decreased awareness of need for assistance. Awareness of Deficits - assistance required to compensate for deficits and decreased awareness of deficits. Impairments that require further therapy intervention: executive functioning, safety awareness, cognition, strength, activity tolerance and balance. R1's EMS (emergency medical services) report, dated 10/10/23, notes dispatch was notified at 7:20pm of resident injury. Ambulance crew arrived on scene at 7:25pm. In summary, crew called to the scene for wellbeing check for R1 due to multiple falls. Upon arrival crews located R1 seated in rear seat of police squad car. R1 found alert and oriented x 2 with no obvious distress. R1 presents with obvious injury to right eyebrow with controlled bleeding. R1 reports multiple falls while walking on sidewalk. Unknown if loss of consciousness occurred. Police on scene report locating R1 walking down 95th street confused. Police called to the scene by passerby who witnessed falls and not on scene. Police made contact with R1's family member who arrived on scene shortly after ambulance crew's arrival. R1's family informed crew that R1 is currently residing at this facility, and she was not contacted by facility to notify of R1 missing from facility. R1 reports pain and burning to abrasion on right side of face and bilateral knees. R1 and R1's family request transport for evaluation to hospital. R1 assisted to stretcher and care provided in route to hospital without complications. This facility notified of R1's locations and transport by police on scene. R1's hospital medical record, dated 10/10/23, notes R1 presented to the emergency room at 7:55pm. R1's history obtained from EMS as R1 is confused. EMS states that bystander saw R1 fall multiple times, so they called EMS. Upon their arrival, police informed him that R1 was a resident at this facility. No missing person report had been filed. They noted bleeding from R1's forehead. Discharge summary from 10/4/23 was reviewed; R1 presented with altered mental status and confusion, which was thought to be due to worsening of R1's dementia. CT (computerized tomography) scan of R1's head noted nondisplaced fracture at the midline and right para midline nasal bone. The immediate jeopardy that began on 10/10/2023 was removed on 11/7/23 when the facility took the following actions to remove the immediacy: Immediate Action All windows were checked on 10/11/23 and confirmed they were secure. Door alarms were checked on 10/11/23 and confirmed they were secure. Identify all residents that have the potential to be affected. R1 was not identified as an elopement risk prior to the incident on 10/11/2023 and was not identified on a list of elopement risk residents. He was not care planned for being at risk for elopement. Per the hospital records and family interview, R1 was noted to have a UTI and the facility was informed that the wandering behavior was an isolated incident. Upon admission, Nursing completed their Initial Nursing Evaluation and behaviors of exit-seeking, etc were not noted. In addition, there were not any elopement attempts from his date of admission on 10/4/23 until the 10/10/23 incident. The facility maintained an ongoing list of elopement risk residents prior to the incident, and all current residents were assessed to determine if at high-risk for elopement on 10/11/23 and ongoing. Additional residents were added to the list of elopement risk residents at that time. The most recent update prior to 10/11/2023 is attached. Interventions that will be accomplished A list of residents At Risk for Elopement with names and pictures were updated on 10/11/2023 and placed at the nurse's stations and reception desk. This list is updated as new elopement risks are identified. Current protocol was updated to have all new admissions assessed by social services for elopement risk upon admission, quarterly, annually, and as needed based on behaviors on 10/11/2023. The admission department screens all new admissions to communicate with the interdisciplinary team and floor nurses any Residents that are newly incoming with identified elopement risk behaviors. They are evaluated for implementation of the elopement risk protocol that includes individualized care plan interventions. In addition, if the admitting nurse identifies elopement risk behaviors during the admission process, it will be communicated to the interdisciplinary team for individualized plan of care and to implement the elopement risk protocol. This was completed on 10/11/2023. Interventions that will be implemented to prevent high risk residents from eloping from front entrance while receptionist is present include High Risk Elopement List which includes pictures and name of resident. The High-Risk Elopement List will be placed at the front desk and at every nurse's station by the SSD. This was completed by the SSD facility on 10/11/23. Front Desk Education: The high-risk elopement list and the requirement to inquire the names of resident and to remind all visitors to sign visitor log. All front desk staff were educated on proper coverage of the front desk. Breaks and lunches are to be handed off to one of the non-clinical managers to maintain coverage of the front desk/reception area. Receptionists were educated starting on 10/11/23 and completed on 10/11/23 either in person or over the phone. The receptionists that were educated over the phone signed off on the education prior to their next scheduled working shift. This education will continue with any reception staff at the time of hire and regularly thereafter. Exit door checks weekly performed by maintenance director. This is an additional precaution taken by the facility in the case of any potential concerns for other exits not monitored by reception. The weekly checks are documented and shown to the administrator to ensure completion and compliance. The elopement policy and procedure was reviewed and updated on 10/11/23 to include communicating any elopement/wandering behaviors to the nurse and/or SSD Education On 10-11-2023 education was initiated and completed on 10/11/23 is on-going for all newly hired staff. This includes V5 and V7 regarding the Elopement policy and procedure. This was provided to all staff in house and through phone education if not in house. All new employees will be educated prior to working independently. Reception was educated on Elopement policy and procedure including the need to remind staff and visitors to sign appropriate log, redirect any high-risk elopement residents from the front door, maintain front desk coverage, and to communicate any elopement/wandering behaviors they may witness to social services. All new employees will be educated prior to working independently. Elopement Drills will be completed once a week for the first 4 weeks, then once every 2 weeks for the next 4 weeks, then once a month for 6 months and quarterly thereafter to ensure education staff competence and understanding of elopement education. QAPI Director of Specialized Services to audit new admissions 3x a week for the next quarter Medical Director was contacted on 10/11/23 and discussed the incident that occurred with R1, and facility plans to prevent further incidents. The Administrator or designee will audit for compliance to elopement policy five days a week for 4 weeks, and then 3 times a week for 4 weeks and then weekly for 4 weeks. Any deficiencies will be corrected immediately and reviewed accordingly.

Based on interviews and record reviews, the facility failed to monitor, re-evaluate the treatment plan for a resident's facility acquired wound, and revise treatment to reduce the risk of worsening or developing an infection. This affected one of three residents (R11) reviewed for wounds. This failure resulted in R11 developing a wound on top of right second toe on 9/11/23. On 9/22/23, R11 was admitted to the hospital with a wound infection with bone involvement requiring amputation of the toe. Findings include: On 10/26/23 at 8:45am, R11 who was assessed to be alert and oriented to person, place, and time, stated that he hit his right second toe on his bed frame, it was bleeding, and he informed the nurse. R11 stated that the nurse cleaned the toe and put a dressing on it and did not do anything else with his wound. R11 stated that he has decreased sensation to feet related to diabetes. R11 stated that he was not aware that his toe wound was worsening. R11 stated that he found out in the hospital his toe was infected to the bone and required amputation. On 10/26/23 at 11:15am, V22 (wound care nurse) stated that does not recall R11. V22 stated that wound care team (nurse and physician) sees all residents with pressure and non-pressure wounds. V22 stated that the wound care team would have continued to monitor and treat R11's right second toe wound once it was identified. V22 stated that if R11's initial treatment order was to apply betadine and leave open to air, R11 would have been seen 3 times a week by wound care nurse and once a week by the wound care physician. V22 stated that any wounds on the feet would require doppler study to rule out or in if wound was a pressure ulcer. On 10/26/23 at 12:40pm, V17 (nurse) stated that if the nurse identifies a new wound on a resident, the nurse is expected to report wound to the physician and the wound care nurse. V17 stated that the nurse is expected to obtain initial wound care treatment orders from the physician and provide wound care treatments until the resident is seen by the wound care team. V17 stated that she does not recall if the wound care team was providing wound treatments to R11's wound on top of right second toe. V17 stated that she performed some of the wound treatments and the wound did not look bad. On 11/3/23 at 10:30am, V14 (wound care coordinator) acknowledged that the wound care team should have been monitoring R11's right second toe wound between 9/12 and 9/22. On 11/3/23 at 12:40pm, V14 stated that she reviewed R11's chart and did not find any additional notes for R11, other than the ones on 9/11 and 9/12. V14 stated that she spoke with V17 (nurse) who performed some of the wound treatments, V17 does not recall the toe looking bad. V14 stated that she has no explanation for reason R11 went to the hospital with an infected right second toe wound to the bone, with purulent drainage, requiring surgical amputation. V14 stated that she was not working here at the time wound was identified and V31 (former wound care nurse) did not offer any further information. On 9/11/23, V31 (former wound care nurse) noted V31 made aware of R11's new skin impairment. Skin assessment completed. R11 is noted with a wound to his right second toe. R11 stated I keep bumping my foot on my bed's foot board and that is what caused my wound on my toe. Wound care provided and R11 tolerated well. On 9/12/23, V32 (wound care physician) noted R11 with wound to right second toe partial thickness. Wound measured 1.1cm (centimeters) x 2cm with dried fibrinous scab. Treatment plan betadine apply three times per week. There is no further documentation in R11's medical record noting R11's right second toe wound was monitored by the wound care team from 9/13/23 until hospitalization with right second toe infection on 9/22/23. On 9/12/23, V32 (wound care physician) noted R11 with wound to right second toe partial thickness. Wound measured 1.1cm (centimeters) x 2cm with dried fibrinous scab. Treatment plan betadine apply three times per week. There is no further documentation in R11's medical record noting R11's right second toe wound was managed by the wound care team from 9/13/23 until hospitalization with right second toe infection on 9/22/23. R11's TAR (treatment administration record), dated September 2023, notes V17 provided wound care treatment to R11's right second toe wound on 9/13, 9/15, and 9/18. There is no documentation found noting R11 received any further wound treatments between 9/18 and 9/22. Review of R11's medical record notes diagnoses including, but not limited to, osteomyelitis right ankle and foot, diabetes, sepsis, difficulty walking, generalized muscle weakness, amputation of toes left foot and right great toe. R11's POS (physician order sheet), dated 9/11/23, notes orders for an x-ray of R11's right foot wound, right second toe; podiatry consult related to right second toe wound; and right second toe-cleanse with normal saline or wound cleanser, paint with betadine, and leave open to air every Monday, Wednesday, and Friday. On 9/22 there is an order to send R11 to the hospital to rule out sepsis. R11's progress notes, dated 9/11/23, V17 (nurse) noted R11 seen by nurse practitioner. Right second toe tip open. R11 states he hit toe on foot of bed. Wound care nurse made aware. New orders for antibiotic oral x/times 7 days. On 9/22/23, V17 (nurse) noted temperature 100, blood pressure 160/88, heart rate 110 beats/minute, oxygen saturation level 97% on room air, respirations 18/minute. Order received to send R11 to the local hospital. R11 admitted for gangrene second toe. R11's hospital medical record, dated 9/22-9/28, R11 presented to the hospital with chief complaint of infection in right second toe, ulcer of right second toe, fever, and elevated heart rate. Podiatric surgery was consulted for evaluation of right digit with necrotic tissue and gangrenous changes. R11 noted with full thickness necrotic ulceration, right second digit at the distal tip extends plantarly to the IPJ (interphalangeal joint) with a necrotic base that measures approximately 2cm (centimeters) x 1cm. Surrounding skin with apparent sloughing of epidermal tissue. There is bogginess and crepitus noted upon palpation of the distal tip of the second digit. Mild purulence noted. Right second digit is also swollen and reddened. A sharp excisional wound debridement down to and including the level of the bone was performed on 9/22/23. Deep wound cultures were taken which noted proteus mirabilis, E. faecalis/VRE. R11 was very upset that R11 has to get the toe amputated due to infection in bone. Soft tissue necrotizing infection right second toe (x-ray of foot noted soft tissue emphysema to the distal tip of second digit). On 9/26/23, R11's right second toe was surgically amputated. 41156 Based on interviews, and record reviews. The facility to follow their physician order policy and failed to document administered medication in the MAR (Medication Administration Record). Facility failed to enter order for glucagon intramuscular injection (medication used for hypoglycemia) in physician order sheet and failed to document glucagon administration in resident's MAR. This deficient practice affects one resident (R4) of three residents reviewed for physician order and medication administration documentation. Finding Include: During record review R4 had a hypoglycemic (low blood sugar) reaction on 10/11/23. Documented on 10/11/23 that R4 had a blood sugar reading of 37 mg/dl and R4 unresponsive. Glucagon IM (intramuscular) given. Blood sugar went up to 39 mg/dl. Nurse practitioner made aware. Glucagon IM given again. Blood sugar went up to 59 mg/dl. R4 unresponsive and 911 was called. On 10/26/23 at 10AM, V20 (Nurse Practitioner) interviewed stated that V20 received a call from V17 registered nurse (RN) around 7-730am, nurse reported that R4 has low blood sugar, and that glucagon shot was already given. V20 gave order to give another shot of glucagon. And said she will be coming in the facility to see the resident. On 10/26/23 at 1:00PM, V17 (RN) confirmed that V17 gave 2 shots of glucagon taken from the east and northeast crash cart. V17 tried getting glucagon injection first from cubex (medication machine) but the computer was taking so long, so V17 grabbed the glucagon injections from the 2 crash carts. On 10/27/23 at 12PM re-interviewed V20 (Nurse Practitioner) stated that V20 reviewed documentation for that day and V20 documented that R4 received 4 glucagon injections in the facility. V20 does not recall who reported this to V20, but V20 stated that's what was documented as what we did to R4 while in the facility. If I documented 4 doses of glucagon was given, then R4 received 4 glucagon injections that day. What happened is what was documented in my notes. On 11/3/23 at 1:30 PM, V3 (Previous DON/Infection Control Nurse) stated that the facility has 3 emergency carts, and each cart has glycogen IM injection. They have Cubex (Electronic Medication Machine) that has 2 glucagon IM injection in there. For emergency, nurse should attend to resident's emergency needs, then call the attending doctor, enter the order in electronic charting physician order, and sign the MAR. It is expected to enter orders and sign the MAR for it is a form of documentation that a medication is administered to a resident. V20 documentation dated on 10/11/23, and uploaded in R4's chart on 10/27/23, reads in part: RN called this morning. R4 blood sugar is very low. Gave orders to give glucagon and recheck sugar. RN gave 4 shots of glucagon, APN in building R4 still not responding: RN at bedside. R4's blood sugar got as high as 59. R4 was still unresponsive. 911 called and R4 sent to ER (emergency room ). Physician order sheet and Medication Administration for October 2023 provided by the facility reviewed and there is no order for glucagon IM injection and documentation in MAR that the glucagon IM injection was given on 10/11/23. Medication Administration policy dated 1/2023, reads in part: All medications are administered safely ad appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. An order is required for administration of all medication. Physician Orders policy dated 2/20/23, reads in part: Drugs will be administered only upon a clean, complete and signed order of a person lawfully authorized to prescribe. Verbal orders will be received only by licensed nurses or pharmacist and confirmed in writing by the physician. Electronic orders transmitted via NCPDP Script 10.6 will be accepted. Each medication order is documented in the resident's medication record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in PCC and the Medication Administration Record (MAR) or Treatment Administration Record (TAR).

Based on interviews and record reviews, the facility failed to follow their skin care prevention policy. Facility failed to identify a skin alteration upon readmission in the facility and failed to have appropriate treatment for a pressure injury skin alteration. This affected one of three residents (R4) reviewed for pressure ulcer. This failure resulted in R4 being admitted to the facility with unassessed stage 2 pressure ulcer in the sacrum area on 8/25/23 R4 went without treatment and R4's stage 2 progressed into an unstageable by 9/5/23. Findings Include: R4 readmitted to the facility on [DATE]. Reviewed Admission/Readmission Evaluation dated 8/25/23: there is no documentation for any skin alteration in sacral and/or coccyx area for R4. Hospital record dated 8/23/23, reads in part: Coccyx stage 2 pressure injuries measures 4.0cm x 3.0 cm x 0.1 cm. scant serosanguinous drainage. Peri-wound notes with blanching erythema On skin progress notes dated 8/26/23, reads in part: Redness and discoloration observed to R4's sacral area. R4's Shower sheet reviewed from August 2023 to September 2023. On 8/27/23, sacral area was circled. Abnormal skin assessment was categorized in skin worksheet as: broken, bruised or reddened areas. On 8/27/23 to 9/23/23, the sacrum area was circled in the skin worksheet, indicating abnormal findings. New Skin Condition dated on 9/5/23, reads in part: Coccyx open area sacrum. Progress notes dated 9/5/23, reads in part: Nurse Practitioner and son made aware of new skin alteration and treatment in place. Facility wound doctor first documentation of sacral wounds was on 9/5/23, reads in part: Unstageable due to necrosis, wound size 3 x 2x 0.1 cm. Per-wound radius: surrounding DTI (deep tissue injury) (purple/maroon), maceration ecchymosis, Moderate serosanguinous. Physician Order Sheet reviewed, and Sacral wound has a treatment order on 9/5/23 to cleanse with Normal Saline Solution. Apply Thera honey, then cover with bordered gauze. Apply z-guard to peri-wound every Tuesday, Thursday, and Saturday, and as needed. R4's Braden assessment dated [DATE] shows 13 (Moderate Risk) for pressure sore. On 10/24/23 at 10:00 AM, V14 (wound nurse) stated that R4's wound on 9/5/23 was documented that the wound on sacral has opened/unstageable. Acquired in the facility. Treatment: thera honey. Prior to this sacral to open was just redness. Verified by V14 that there is no other documentation prior to 9/5/23 about the sacral wound, it was just redness. On 11/3/23 at 12:40pm V14 (wound nurse) stated that barrier cream is for redness only and not appropriate for any other skin alteration higher than stage 2. Expectation for the staff to do if there is a change in skin alteration is to notify MD and get appropriate treatment, informed the wound nurse, and do incident note. Upon admission our expectation is for the nurse to do a full body assessment and have treatment order for any skin issues. For unstageable necrotic pressure injury, it is not appropriate to have just barrier cream for treatment, most of the time the wound MD would place them in medihoney. If barrier cream is the treatment for an unstageable then it was not being treated appropriately. Skin Care Prevention policy dated 1/2023, reads in part: All resident will receive appropriate care to decrease the risk of skin breakdown. The nursing department will review all new admission/readmissions to put a plan in place for prevention based on the resident's activity level. Comorbidities, mental status, risk assessment and other pertinent information. All residents will be evaluated for changes in their skin condition.

Based on interview and record review the facility failed to adequately complete skin checks and assess one resident's (R4) foot for signs and symptoms of infection. This failure resulted in R4 sustaining sepsis due to an abscess on the bottom of his Right foot and subsequently requiring debridement to the bottom of the Right foot and to be discharged from the hospital with a wound vacuum. Findings include: R4 was an [AGE] year-old male who originally admitted to the facility on [DATE] and later expired on [DATE]. R4 has multiple diagnoses including but not limited to the following: osteomyelitis, depression, unsteadiness on feet, sepsis, abscess of Right foot, muscle weakness, subdural hemorrhage, muscle wasting, myocardial infarction, hyperlipidemia, hypertension (HTN), emphysema, chronic obstruction pulmonary disease (COPD), and coronary artery disease (CAD). R4's Podiatry note dated [DATE] states in part but not limited to the following: R4 states currently he is in pain along the Right foot and at time he notices drainage on his socks. Macerated area noted along the second toe head, bottom of the Right good. Purulent drainage noted upon palpation. Temperature was warm from the toes to the shin. Edema is present. Pain on palpation noted along the Right second toe. Due to the infected nature of the abscess present, patient was sent to the emergency department. On [DATE] at 1:35PM, V4 (Wound Care Nurse) was interviewed regarding R4's wound. V4 said I started in this role in the middle of February 2023. I was caring for R4 after he was readmitted here. From my understanding, the facility did not have a wound care nurse in place prior to my start date. R4 wanted to come back to the facility after his stay at the hospital. R4 was discharged from the hospital and admitted to another facility. We did not have a wound care nurse here at the time and probably felt as if they could not adequately care for him. At 3:25PM, V18 (Registered Nurse) was consulted due to R4's foot. V18 said R4 was complaining of pain to the bottom of his Right foot during therapy, so a podiatry consult was ordered. He had a callous on the bottom of his Right foot. When V10 (Podiatrist) came in to see him, she sliced away a piece of his skin and puss poured out of his foot. She immediately told me that he needs to go to the hospital. V18 said skin checks are done during shower days but then some residents have orders for daily or weekly skin checks. On [DATE] at 2:39PM, V10 (Podiatrist) was interviewed regarding R4 and evaluation on [DATE]. V10 said I was told by the staff that I was consulted due to a callous on the bottom of R4's Right foot. R4 told me there was a painful callous on his Right foot. When I saw R4's foot, it was warm in temperature, swelling was present, and it was red in color from his toes all the way up to his ankle. It was a clear and visible infection. It was not a callous. I peeled back the soft skin a bit and pus poured out of the bottom of his foot. He was complaining of pain during this procedure and was clearly uncomfortable. I think that the patient complained about a callous to the staff and the nurse never looked at his foot. I told the nurse on duty that we needed to send him to the emergency room immediately. On [DATE] at 12:05PM, V2 (Director of Nursing) was interviewed regarding skin checks within the facility. V2 said her expectation is that the staff is looking at the resident's skin every time they are providing care. However, full skin checks are completed at least two times a week on the resident's scheduled shower days. During this time, they are getting an in-depth observation of the resident's skin including every crevice and under every fold of their skin. Hospital records dated [DATE] state in part but not limited to the following: Admitting diagnoses: Right foot abscess and sepsis. Non-healing wound to Right foot, status post irrigation and debridement of Right foot. Magnet Resonance Imaging (MRI) shows ulcer, cellulitis, and osteomyelitis to the Right foot. Edema and myositis noted with fluid collection possibly an abscess. Recommendation for discharge wound vacuum at 125 mm hg and change three times weekly. Physician Order Sheet for R4 shows resident had order for body audit one time a day for seven days with start date of [DATE]. Skin checks were requested however no documentation was received. Reviewed shower report for [DATE] shows in part but not limited to the following that R4 had scheduled showers on Wednesdays and Saturdays. R4 received a shower on [DATE] as scheduled but did not receive a shower on scheduled day of [DATE]. Facility policy titled Skin Care Prevention dated ,d+[DATE] states in part but not limited to the following: All residents will receive appropriate care to decrease the risk of skin breakdown. Guideline: Dependent residents will be assessed during care for any changes in skin condition including redness, and this will be reported to the nurse. All residents will be evaluated for changes in their skin condition.

Based on interviews and record reviews, the facility failed to re-evaluate a resident's discharge plan and modify this plan when a resident had a change in condition to include elevated temperature, elevated white blood count and deteriorating stage 4 pressure sore. This affected 1 of 3 residents (R9) reviewed for change in condition on the sample list of 36. This failure resulted in R9 going to the hospital 48 hours post discharge and being admitted with an infected sacral pressure ulcer, osteomyelitis (bone infection) in wound, low blood pressure (73/63), elevated heart rate (101 beats/minute), increased respirations (24/minute), and diminished responsiveness to stimuli. Findings include: On 7/18/23 at 3:30pm, R9's family member stated that V17 (social services) telephoned him on 6/7/23 at 4:30pm to inform him R9 needed to be discharged the following day because insurance coverage was ending on 6/9/23. R9's family member stated that he does not recall being informed that he could appeal R9's discharge due to R9's sacral wound. R9's family member stated that he was not informed of R9's elevated temperature or elevated white blood cell count on 6/9/23 or that R9's sacral wound was infected. On 7/18/2023 at 10:15am, V20 (social services director) stated that social services, skilled therapy, nursing, and the resident's insurance make up the IDT (interdisciplinary team) involved in discharge planning. V20 stated that R9's family member was advised to come in for wound care training on 6/10/23. V20 stated that she believes R9's family member came in for this training. V20 stated that R9's family member did not express any concerns related to R9's discharge. V20 stated that she thought R9's family was okay with taking R9 home with a stage 4 sacral pressure ulcer. V20 did not follow up with R9's family member to ensure safe discharge home. V20 stated that IDT meet once a week to set discharge date s for residents. V20 stated that she relies on the nurses and nurse practitioners to inform her of a resident's wound status. V20 stated I'm sure that the clinical staff review wound care notes, but she doesn't review wound notes or speak with wound care team. V20 unable to articulate reason the wound care team is not involved with the discharge planning process. V20 stated that V20 set up for R9 to have a wheelchair provided for home use by an outside DME (durable medical equipment) company. V20 was informed that this surveyor contacted this DME company and there is no record of V20 contacting this company to request any medical equipment. V20 stated that she did not follow-up with the home health agency and confirm start date for daily wound care treatments. On 7/11/23 at 12:13pm, V67 (representative at DME company) stated that she could not find any referral for DME for R9. V67 stated that she checked their computer system four different ways to see if any requests were made, using R9's name, date of birth, phone number, and address. V67 stated that she is unable to find any requests made between 5/23/23 and 6/10/23 for R9. On 7/11/23 at 12:30pm, V68 (home health nurse) stated that the home health agency received a referral on 6/9/23. V68 stated that this agency was waiting for insurance approval for services. V68 stated that after received insurance authorization, R9's family member was contacted to set up first visit and she was informed that R9 was in the hospital with an infected sacral pressure ulcer. V20 presented an order form for R9's wheelchair request. This form does not note the name of the DME company request was made. There are no delivery or product request notes documented on this form. V20 was unable to present any documentation of the response to referrals sent to the home health agency and the DME company. On 7/18/23 at 11:00am, V51 (wound care physician) stated that he was not involved in R9's discharge planning process. V51 stated that he was not made aware of R9's elevated temperature or elevated WBC (white blood cell - increases due to infection or inflammation) results on 6/9/23. V51 stated that R9 was last seen on 6/6/23 when R9's sacral wound was observed to be deteriorating. V51 stated that he is present once a week for wound care rounds and to monitor wound progress. V51 stated that he was not aware R9 was being discharged to home on 6/10/23. V51 stated that he did not speak with V61 (attending physician) prior to R9's discharge but his notes are readily available in R9's electronic medical record for V61 to review. V51 (wound care physician) documentation, dated 5/30/23, noted R9's unstageable sacral pressure ulcer measured 6.7cm x 7.7cm x 0.2cm, 70% eschar (dead tissue), 10% slough, and 20% skin, moderate blood tinged drainage. On 6/6, R9's wound was reclassified as a stage 4 sacral pressure ulcer. Wound measured 11.8cm x 8.3cm x 0.6cm, 70% eschar, 10% slough, and 20% skin, moderate blood tinged drainage; wound deteriorating. On 7/18/23 at 2:30pm, V61 (attending physician) stated that V61 does not recall being notified of R9's abnormal laboratory results that were ordered urgently on 6/9/23. V61 stated that he does not think anyone contacted him. V61 stated that V61 expects communication from the nursing staff regarding any changes in a resident's medical condition. V61 stated that V51 (wound care physician) should notify V61 if V51 has any concerns with discharging a resident with wounds. V61 stated that V61 did not speak with V51 regarding R9's deteriorating stage 4 sacral pressure ulcer. V61 stated that V61 was aware of R9's temperature 101 degrees on 6/9/23, but temperature normalized after receiving fever reducing medication. When questioned if R9's discharge to home would have been postponed if V61 was made aware of R9's WBC (white blood cell count) had increased to 16.7 on 6/9, V61 responded it is hard to say because he would have to look at the whole clinical picture. V61 stated that he could have held R9's discharge to further evaluate reason for elevated WBC. V61 stated that the home health agency could have assessed R9's sacral wound and done further work-up regarding elevated WBC. V61 was informed that R9 did not receive any home health services due to being hospitalized after discharge from this facility with an infected sacral pressure ulcer. V61 stated that R9's transition to home would have been better if home health services had been done. Review of R9's medical record, dated 5/29/23, notes V20 (social services director) and representative from therapy had a care conference with R9 and R9's family member. R9 and R9's family member were provided with an update on how R9 has been doing in therapy and the recommendations for home. Review of R9's medical record, dated 6/9/23, notes V60 (nurse) notified V50 NP (nurse practitioner) that R9 is scheduled for discharge in the morning and was noted to have an elevated temperature of 101 degrees. New orders received for urgent complete blood count. There is no documentation found noting V60 notified R9's family member or V51 (wound care physician) of R9's change in condition on 6/9/23. There is no documentation found in R9's medical record noting V61 (attending physician) or V51 were notified of R9's abnormal laboratory results.

Based on interview and record review, the facility failed to follow their fall prevention and management policy to include developing and implementing fall prevention plan of care, failing to utilize two person assistance for toileting/bed mobility and transfers for three of three residents (R16, R15, and R20) reviewed for falls on the sample list of 36. This failure resulted in R15 falling from the bed, while receiving care from facility staff, and sustaining a laceration requiring three staples and a left parietal subdural hemorrhage. Findings include: 1) R16 was admitted to the facility on [DATE] with a diagnosis of repeated falls, unsteadiness on feet, dementia, osteoarthritis, major depressive disorder and hypertension. R16 facility reportable dated 3/1/23 documents: R16 was in pain at a scale of 8. R16 reported he had a fall during the early morning. Swelling and guarding was noted to right knee and R16 complained of pain to the front and back of his right leg. Unwitnessed fall occurred in resident's bathroom and R16 did not notify staff of incident. Resident admitted to local hospital with diagnosis of fracture of right femur. R16's pre admission documents dated 2/20/23 documents under safety: decreased awareness of need for assistance and decreased awareness of need for safety. Under history and physical documents: R16 presented to emergency room for frequent falls. Upon discussion with patient, he notes he has been falling more recently as much as two times today. Thinks falls are mechanical in nature states he does not always use his walker when going around the house. R16's hospital record dated 3/1/23 documents under CT of lower extremity right: acute basicervical femoral neck/intertrochanteric proximal femur fracture. Under history documents: He was discharged to rehab facility and coming today for a new mechanical fall that resulted in fracture. Per patient he was trying to go the bathroom and fell , and lied on the floor for at least 30 minutes. R16 medical record documents only on fall risk evaluation dated 3/1/23 which documents a score of 22 which indicates resident is at high risk for falls. There were no other fall risk evaluations in the medical record. R16's admission evaluation dated 2/20/23 under fall risk factors documents: none of the above. Under proceed to care plan there is nothing checked or documents for fall interventions. R16's plan of care alteration in musculoskeletal status related to weakness date initiated 2/21/23 with revision date of 3/7/23. Under interventions: assist the resident needs to change position frequently. Alternate rest with activity out of bed in order to prevent respiratory complications with date initiated 2/21/23, created date 2/21/23, revision date 3/7/23. Monitor for at risk for falls. Educate resident, family on safety measures that need to be taken in order to reduce risk for falls. Date initiated 2/27/23, created on 3/7/23, revision 3/7/23. R16's at risk for fall care plan was initiated and created on 3/7/23. On 7/12/23 at 12:50PM, V29 (Minimum data set, MDS nurse) said she was unable to provide any fall care plan for R16 prior to 3/7/23. Fall care plans are generated from the admission assessment of the nurse when patient is admitted . On 7/20/23 at 4:10PM, V2 (DON) said she did not see a fall care plan or interventions in place prior to R16's fall. V2 said all residents should have a fall care plan on admission. Facility fall prevention and management policy dated 1/2023 documents: a fall risk evaluation will be completed on admission, readmission and quarterly, significant change and after each fall. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP with interventions implemented to minimize falls. 2) R15 was admitted to the facility on [DATE] with a diagnosis of multiple myeloma, muscle wasting, anemia, acute kidney disease, and type II diabetes. R15 brief interview for mental status dated 1/16/23 documents a score of 13/15 which indicates cognitively intact. R15 minimum data set (MDS) under functional status dated 1/16/23 documents for bed mobility a score of 3 for self-performance which indicates extensive assistance and a score of 3 under support which indicates two plus persons for physical assist. For toilet use a score of a score of 3 for self-performance which indicates extensive assistance and a score of 3 under support which indicates two plus persons for physical assist. Under bladder and bowel documents under urinary incontinence care 2 frequently incontinent. R15's fall risk factors on admitted d 10/28/22 documents under fall history none of the above. R15's care plan dated 1/11/23 documents under Activities of daily living (ADL) Self care deficit as evidenced by physical deficits related to recent hospitalization due to shortness of breath and generalized weakness noted with diabetic ketoacidosis, hyperlipidemia, hypothyroidism, multiple myeloma and chronic kidney disease. Interventions: ADL assist: usually transfers with mechanical lift and two person assist. Facility final reportable dated 1/24/23 documents under summary of events: On 1/22/23 patient as sent to emergency room following an incident at facility resulting in scalp laceration. Records reports staples were applied to head laceration. Under type of injuries documents: scalp laceration and 0.8 cm left partial hemmorage. Under timeline documents: on 1/22/23 while facility staff were providing assistance with incontinence care, patient started rolling out of the bed and staff were unable to stop her from rolling out of the bed. Witness statement dated 1/23/23 for V16(certified nursing aide, CNA) documents: I was doing rounds around 9:00 PM- 9:15 PM. I went to change the resident after I had gathered the supplies. I took off the incontinence brief and washed her private area. I turned toward the door and she started to roll. I tried to stop her but she fell out of bed on the floor. R15's hospital record dated 1/22/23 documents under diagnosis laceration of scalp, closed head injury, hyperglycemia. Under CT head documents left parietal subdural 0.8 cm hemorrhage; scalp hematoma. Under history documents: Patient states she was at rehab center, she was getting changed when she rolled over and fell out of bed hitting her head. Patient has a scalp laceration received 3 staples in emergency room . R15's transfer notification progress note dated 1/22/23 documents: Patient was being changed by facility staff and accidentally fell out of the bed hitting her head. This injury resulted in significant bleeding from the head. On 7/12/23 at 2:41 PM, V15 (Nurse) who was identified as the nurse working with R15 at time of fall said V16(CNA) reported to him that she was changing R15's incontinence product, when she turned R15, she rolled off the bed. V15 said the bed was at waist level and there were no other staff in the room at time of incident. On 7/12/23 at 12:50 PM, V29 (Minimum data set, MDS nurse) said under section G functional status is determined by staff point of care charting. A score of 3 under supports indicates the patient required 2 or more person assist with the task. 41758 3) R20 was diagnosis with Dementia, Cognitive communication deficit, unsteadiness on feet and history of falls with injury. R20 required extensive assistance with two plus person physical assist with bed mobility and transfers. R20 required limited assist with one person physical assist for eating. R20 had lower extremity impairment on one side. Fast track report dated 4/17/23 documents: R20 was at risk for falls. Progress note dated 5/6/23 documents: Writer was called into room by aide for assistance. Upon arrival into the room, writer noticed resident (R20) was on the floor on her left side laying on a pillow with a small bowl close to her face. Resident not able to tell what happened due to cognitive impairment. Incident report dated 5/6/23 documents: Left eyebrow began to swell. Discharge to hospital. Predisposing Physiological Factors: confused, incontinent, weakness/fainted, gait imbalance and impaired memory. Predisposing situation factor documents: recent room change. On 7/11/23 at 2:49PM, V2 (DON) said, R20 was noted lying on the floor on her face. R20 rolled out of bed. R20 had some redness and bruising on her face. R20's fall interventions were to kept bed in the low position, to minimal risk just in case R20 happen to fall. I guess they felt like the intervention was a good one moment. On 7/12/23 at 12:54PM, V29 (MDS) said, R20 required one person physical assist with eating and two plus person physical assist with turning and repositioning which mean staff has to and will turn the resident for bed mobility. On 7/12/23 at 1:23PM, V18 (physical therapy) said, R20 was not able to roll from lying on her back to a side lying position. R20 was low level in cognition and physical function. R20 did not initiated any movements. R20 was maximum assist for bed mobility. R20 required ninety percent of staff assistance to turn and reposition in bed. Care plan initiated 4/26/23 documents: R20 was at risk for falls due to impaired balance/poor coordination, potential medication side effect, unsteady gait, history of falls and weakness. Interventions: bed in low position, encourage to transfer and change position slowly, provide assist to transfer and ambulated as needed and implement use of preventive device: non-skid socks. Rehabilitation evaluation status post functional decline dated 5/3/23 documents: R20 was referred for skilled therapy related to a noted functional decline, decrease in strength, transfers, ambulation and the ability to perform self- care ADL's. Past medical history: falls with a left femur fracture. Orientation: alert and orient to person, confused. Positive for generalized weakness and bilateral upper tremors. High fall risk: follow all facility fall precaution. Witness statement by V27 (cna) dated 5/7/23 documents: While during rounds and collecting lunch trays. I walked into R20's room at 1:20PM. R20 was noted on the floor on her left side with a pillow near her head. Hospital record dated 5/6/23 documents: R20 had an unwitnessed mechanical fall sustaining ecchymosis to left forehead. Fall Prevention and Management policy dated 1/2023 documents: The facility will identify and evaluate those residents at risk for fall, plan for prevention strategies, and facilitate as safe an environment as possible. 41156

Based on observation, interview and record review, the facility failed to follow physician order blood glucose parameters for the administration of insulin. This affected one of three (R35) residents reviewed significant medication error on the sample list of 36. This failure resulted in the facility administering 5 units of insulin to R35, whose blood glucose levels were not within physician ordered parameters, subsequently R35 was found verbally unresponsive, hard to arouse and hospitalized with the diagnosis of hypoglycemia. Findings Include: On 7/13/23 at 12:59PM, code blue was called to R35's room. R35's skin was observed pale and pasty. R35 was moaning with mouth opened wide while staff was doing the sternum rub. Emergency medical technician (EMT) service arrived and checked R35's blood glucose level which resulted at 44mg/dL (milligrams per deciliter) (normal range 70-100mg/dL). On 7/13/23 at 1:27PM, V44 (nurse) said, I took R35's blood glucose this morning. The result was 119mg/dL. V44 could not recall the exact time R35's blood glucose was taken or when insulin was given. I administered five units of insulin per R35's physician order. R35 was found unresponsive around lunch. I re-checked R35's blood glucose which resulted at 50 mg/dL. I administered two amples of glucagon which raised R35's blood glucose the mid to high fifties low sixties. On 7/13/23 at 3:55PM, V47 (R35's family) said, R35 was given too much insulin. R35's blood glucose was 44mg/dL. R35 doesn't eat much food. R35 had to be discharge to the hospital for medical evaluation. On 7/14/23 at 11:32AM, V2 (Director of Nursing) said, R35's incident yesterday was a reportable event and a medication error. Physician order sheet dated 7/11/23 documents: HumuLIN R Injection Solution 100 UNIT/ML. Inject five units subcutaneously one time a day for diabetes once daily if glucose > (greater than) 200. Medication administration record dated 7/13/23 at 10:07AM documents: V44 administered Insulin subcutaneously to R35's right upper quadrant (RUQ/abdomen). Progress note dated 7/13/23 documents: 9am Received patient (R35) in bed, blood sugar checked at 119 mg/dL. Five (5) units of Humulin R injection solution 100 unit/ml given subcutaneously in her RUQ abdomen. At 1:01pm while rounding noted (R35) verbally unresponsive and hard to arouse. Blood sugar/glucose checked at 50 mg/dL. Called Code Blue and 911. Glucagon 1mg/1ml (milligrams/milliliter) administered via subcutaneous to her right back of arm. Recheck blood glucose at 56 mg/dL. R35 was drowsy but aroused to sternal rub, open eyes, and mumbled words. Administered another dose of glucagon 1mg/1ml subcutaneous via left lower quadrant. Rechecked blood glucose at 62 mg/dl. R35 more awake and alert and verbally responsive. Oral dose of glucagon gel given by a fell ow nurse. Sternal rub continued to keep patient aroused. Patient verbally responding. Hospital paperwork dated 7/13/23 documents; Patient (R35) alert and oriented times four brought to ED (emergency department) from the nursing home with complaints of hypoglycemia. Per emergency medical service (EMS) registered nurse (RN) might have given the R35 too much insulin causing her blood glucose to be forty-four. R35 states that she had no preceding symptoms, felt well this morning, no light headiness, chest pain, syncope, shortness of breath, fever, nausea, vomiting or any other symptoms preceding receiving insulin. Emergency Department (ED) diagnosis: Hypoglycemia (low blood sugar) secondary to wrong insulin dose. Employee report dated 7/13/23 documents: V44 did not follow medication order as written. Diabetes Management date 1/2023 documents: To provide guideline for the management residents: Guideline: Residents with a diagnosis of diabetes with be managed per physician's orders.

Based on observation, interview, and record review, the facility failed to provide safe bed mobility during resident care for 1 of 3 residents (R1), reviewed for falls in the sample of 12. This failure resulted in R1 falling from bed and sustaining a left tibia and fibula fracture. The findings include: R1's Medical Practitioner Progress Note dated 7/16/20 documents R1 with limited mobility, contractures, and a history of cerebral hemorrhage. This note further documents R1 with contractures to bilateral lower extremities and hands. R1's December 18, 2020 Minimum Data Set showed R1 with severe cognitive impairments and totally dependent on two staff for bed mobility. On 2/27/21 at 10:55 AM, R1 was observed in bed with bilateral lower extremity contractures, a right arm contracture and a left hand contracture with limited use of the left arm. R1 also had an immobilizer boot to left lower extremity. A Facility Incident Report dated 1/26/21 documents a nursing assistant was changing R1's bed linen and incontinence brief when R1 began sliding off the bed and was lowered to the floor. On March 1, 2021 at 10:13 AM, V4 CNA (Certified Nursing Assistant) stated at the time of the fall on 1/26/21, V4 rolled R1 towards V4 to provide care, turning R1 onto R1's left side and at the edge of the bed. V4 stated R1's legs are very contracted and R1's legs started going over the edge causing R1 to slide off the bed and V4 had to assist R1 to the floor. V4 stated R1's bed is not big enough to position R1 properly while turning. On March 1, 2020 at 8:56 AM, V3 (Nurse) stated on 1/26/21, V4 had rolled R1 towards her in bed to provide care and R1 fell out of the bed. V3 stated R1 was a one person assist for bed mobility but confirmed R1 should have been a two person assist at the time of the fall. V3 stated R1 was changed to a two assist after this fall to ensure R1 does not fall from bed during care again. On 3/1/21 at 10:45 AM, V2 (Director of Nursing) stated if V4 had properly placed herself along side of R1's bed to guard R1 while providing care R1 may not have fallen out of bed when V4 was providing care. On 3/1/21 at 11:09 AM, V16 (Nurse Practitioner) confirmed R1 sustained a left tibia and fibula fracture after falling from the bed. R1's hospital After Visit Summary dated 1/27/21 documents R1 with a [DIAGNOSES REDACTED]. The facility policy Bed Positioning, dated 2/2019, documents when turning a resident from their back to a sidelying position move the resident so that when the resident is turned they are lying in the middle of the bed.

Based on interview and record review, the facility failed to notify the physician of worsening vital signs for 1 of 5 residents (R1) reviewed for physician notification in the sample of 10. This failure resulted in R1 developing severe respiratory distress and low blood pressure requiring emergency transfer to the hospital, where R1 became pulseless, stopped breathing, and died . Findings include: Incident Report [DATE] 12:45am documents R1 was found sitting on the bathroom floor. Neurological checks were initiated and 1am vital signs are noted to be abnormal compared to R1's usual vital signs: blood pressure is low at ,[DATE], respiratory rate is fast at 33 breaths per minute, and oxygenation is low at 85%. Vital Signs Summary Report documents normal vitals signs for R1 are a blood pressure greater than 120-,[DATE]-81, respiratory rate ,[DATE] breaths per minute, and oxygenation at 97%. Nurse Note [DATE] documents Z1(Physician) was notified of these initial vital signs and the administration of 2 liters oxygen by nasal cannula on [DATE] at 1:20am. Neurological Evaluation Flow Sheet 3am documents R1's oxygenation is higher at 89% and a respiratory rate of 27 breaths per minute. At 4am R1's vitals have worsened as evidenced by an even lower oxygenation level of 77%, a lower blood pressure of ,[DATE], and a faster respiratory rate of 33 breaths per minute. At 5am, R1's vital signs continue to decline as evidenced by a blood pressure of 80/palp, indicating that the bottom number is so low that it cannot be detected, an even lower oxygenation of 73 %, and a continued fast respiratory rate of 30 breaths per minute. Nurse Note [DATE] documents that at 5am, R1 had the low blood pressure of "80/palp", 911 was called, oxygen was increased to a nonrebreather mask at 5 liters, an intravenous line was started, and oxygen was 73%. There is no evidence that supports Z1 was notified at 4am when R1's vital signs worsened and continued to decline at 5am. On [DATE] at 10:40am, by phone, E9(Nurse) stated Z1 was notified of R1's initial vital signs after the fall. E9 stated she did not speak with or call Z1 again until after 5am, when 911 was called and R1 was transported to the hospital. On [DATE] at 1:50pm, by phone, Z1 (Physician) stated he was informed of R1's vital signs after the fall. The nurse on duty that morning (E9) told him that R1 needed 2 liters of oxygen, but that he was alright at that time. Z1 stated R1 had worsening vital signs and deteriorating condition from 3am to 5am, but he was not notified of this change. The fast respiratory rate and low oxygenation indicate a worsening pneumonia. Z1 stated that during the initial call, he told the nurse to call him with any changes or send R1 out to the hospital if his condition worsens. The staff should have called 911 earlier, increased the oxygen, or phoned him sooner. If they would have called him sooner, Z1 would have sent R1 to the hospital for treatment. Hospital records [DATE] document R1 became pulseless, stopped breathing, and died at 7:25am in the emergency room after an unsuccessful attempt at resuscitation. Policy and Protocol for physician notification of abnormal vital signs documents report the following vital signs immediately: respirations greater than 28, oxygen saturation less than 90%.

Based on interview and record review, the facility neglected to assess and provide nursing interventions to maintain stable vital signs and prevent a decline in condition for 1 of 5 residents (R1) reviewed for emergency response in the sample of 10. The facility failed to follow their policy and procedure by not notifying the physician of a decline in R1's condition and not providing additional oxygen during an emergency situation. This failure resulted in R1 developing severe respiratory distress and low blood pressure requiring emergency transfer to the hospital, where R1 became pulseless, stopped breathing, and died . Findings include: Incident Report [DATE] 12:45am documents R1 was found sitting on the bathroom floor. Neurological checks were initiated and 1am vital signs are noted to be abnormal compared to R1's usual vital signs: blood pressure is low at ,[DATE], respiratory rate is fast at 33 breaths per minute, and oxygenation is low at 85%. Vital Signs Summary Report documents normal vitals signs for R1 are a blood pressure greater than 120-,[DATE]-81, respiratory rate ,[DATE] breaths per minute, and oxygenation at 97%. Neurological Evaluation Flow Sheet 3am documents R1's oxygenation is higher at 89% and a respiratory rate of 27 breaths per minute. At 4am R1's vitals have worsened as evidenced by an even lower oxygenation level of 77%, a lower blood pressure of ,[DATE], and a faster respiratory rate of 33 breaths per minute. At 5am, R1's vital signs continue to decline as evidenced by a blood pressure of 80/palp, indicating that the bottom number is so low that it cannot be detected, an even lower oxygenation of 73 %, and a continued fast respiratory rate of 30 breaths per minute. Nurse Note [DATE] documents that at 5am, R1 had the low blood pressure of "80/palp", 911 was called, oxygen was increased to a nonrebreather mask at 5 liters, an intravenous line was started, and oxygen was 73%. There is no evidence that supports staff provided additional nursing care or interventions to maintain stable and normal vital signs between 4am and 5am when R1's vital signs worsened and continued to decline at 5am. On [DATE] at 10:40am, by phone, E9(Nurse) stated Z1 was notified of R1's initial vital signs after the fall. E9 stated she did not speak with or call Z1 again until after 5am, when 911 was called and R1 was transported to the hospital. E9 stated that [DATE] was the first time she was R1's nurse, did not know what were baseline vitals for R1, did not ask another staff member about R1's baseline, or look in the computer chart for past vital sign trends such as blood pressure, respirations, or oxygenation. E9 did not increase the amount of oxygen administered to R1 until 5am, the oxygen remained at 2 liters per nasal cannula. On [DATE] at 1:50pm, by phone, Z1 (Physician) stated he was informed of R1's vital signs after the fall. The nurse on duty that morning (E9) told him R1 needed 2 liters of oxygen, but that he was alright at that time. Z1 stated R1 had worsening vital signs and deteriorating condition from 3am to 5am, but he was not notified of this change. The fast respiratory rate and low oxygenation indicate a worsening pneumonia. Z1 stated during the initial call, he told the nurse to call him with any changes or send R1 out to the hospital if his condition worsens. The staff should have called 911 earlier, increased the oxygen, or phoned him sooner. If they would have called him sooner, Z1 would have sent R1 to the hospital for treatment. Hospital records [DATE] document R1 became pulseless, stopped breathing, and died at 7:25am in the emergency room after an unsuccessful attempt at resuscitation. Policy and Protocol for physician notification of abnormal vital signs documents report the following vital signs immediately: respirations greater than 28, oxygen saturation less than 90%.

Based on interview and record review, the facility failed to assess and provide nursing interventions to maintain stable vital signs and prevent a decline in condition for 1 of 5 residents (R1) reviewed for emergency response in the sample of 10. This failure resulted in R1 developing severe respiratory distress and low blood pressure requiring emergency transfer to the hospital, where R1 became pulseless, stopped breathing, and died . Findings include: Incident Report [DATE] 12:45am documents R1 was found sitting on the bathroom floor. Neurological checks were initiated and 1am vital signs are noted to be abnormal compared to R1's usual vital signs: blood pressure is low at ,[DATE], respiratory rate is fast at 33 breaths per minute, and oxygenation is low at 85%. Vital Signs Summary Report documents normal vitals signs for R1 are a blood pressure greater than 120-,[DATE]-81, respiratory rate ,[DATE] breaths per minute, and oxygenation at 97%. Neurological Evaluation Flow Sheet 3am documents R1's oxygenation is at 89% and a respiratory rate of 27 breaths per minute. At 4am R1's vitals have worsened as evidenced by an even lower oxygenation level of 77%, a lower blood pressure of ,[DATE], and a faster respiratory rate of 33 breaths per minute. At 5am, R1's vital signs continue to decline as evidenced by a blood pressure of 80/palp, indicating that the bottom number is so low that it cannot be detected, an even lower oxygenation of 73 %, and a continued fast respiratory rate of 30 breaths per minute. Nurse Note [DATE] documents that at 5am, R1 had the low blood pressure of "80/palp", 911 was called, oxygen was increased to a nonrebreather mask at 5 liters, an intravenous line was started, and oxygen was 73%. There is no evidence that supports staff provided additional nursing care or interventions to maintain stable and normal vital signs between 4am and 5am when R1's vital signs worsened and continued to decline at 5am. On [DATE] at 10:40am, by phone, E9(Nurse) stated Z1 was notified of R1's initial vital signs after the fall. E9 stated she did not speak with or call Z1 again until after 5am, when 911 was called and R1 was transported to the hospital. E9 stated that [DATE] was the first time she was R1's nurse, did not know what were baseline vitals for R1, did not ask another staff member about R1's baseline, or look in the computer chart for past vital sign trends such as blood pressure, respirations, or oxygenation. E9 did not increase the amount of oxygen administered to R1 until 5am, the oxygen remained at 2 liters per nasal cannula. On [DATE] at 1:50pm, by phone, Z1 (Physician) stated he was informed of R1's vital signs after the fall. The nurse on duty that morning (E9) told him that R1 needed 2 liters of oxygen, but that he was alright at that time. Z1 stated R1 had worsening vital signs and deteriorating condition from 3am to 5am, but he was not notified of this change. The fast respiratory rate and low oxygenation indicate a worsening pneumonia. Z1 stated that during the initial call, he told the nurse to call him with any changes or send R1 out to the hospital if his condition worsens. The staff should have called 911 earlier, increased the oxygen, or phoned him sooner. If they would have called him sooner, Z1 would have sent R1 to the hospital for treatment. Hospital records [DATE] document R1 became pulseless, stopped breathing, and died at 7:25am in the emergency room after an unsuccessful attempt at resuscitation. Policy and Protocol for physician notification of abnormal vital signs documents report the following vital signs immediately: respirations greater than 28, oxygen saturation less than 90%.

Based on interview and record review the facility failed to provide supervision during toileting for 1 (R1) of 3 residents reviewed for falls. As a result of no supervision R1 fell and sustained a hip fracture which required hip surgery. Findings Include: Face Sheet documents that R1 was admitted on [DATE]( [AGE] years old) with the following pertinent Diagnosis: [REDACTED]. Minimum (MDS) data set [DATE] and [DATE] both document that R1 was required extensive assist with 2 plus person physical assist with toilet use. Falls Care Plan dated [DATE] interventions include, " encourage to transfer and change positions slowly. Provide assist to transfer and ambulate as needed." Nursing Progress Note dated [DATE] states, " patient fell on shift while trying to move from toilet to bed. Doctor notified. Family notified. Patient was favoring left hip, stat x- ray ordered per medical doctor. Neurological checks in progress. 20 Milligrams Lasix ordered for 1 plus pitting edema. Will continue to monitor patient." Incident Report dated [DATE] states, R1 fell while trying to get off toilet. Investigation Report dated [DATE]- [DATE] states, R1 was admitted on [DATE] after recent hospitalization related to heart disease, dementia, kidney disease and gout." R1 is identified as a fall risk upon admission, low bed with mats implemented and R1 is kept out by the nurses' station when she is in her wheelchair for frequent observation." On [DATE] at 3:50 PM, E5(Nurse) said that she only relayed the x- ray results to the doctor. "R1 was in bed when I received her on the day of the fall. The doctor sent R1 to the hospital because R1 had a fracture. R1 was confused, R1 could not follow directions. R1 was kept at the nurses station to keep an eye on her." On [DATE] at 3:57 PM via telephone, E6(Nurse) said on [DATE] at about 6 PM R1 was at the nurses station and began to get up from her wheelchair. E6 said she took R1 to the toilet in R1's room and closed the bathroom door because R1 said that she wanted privacy. E6 further stated that she gave R1 the call light, closed the bathroom door and left the resident unattended because she had other things to do(another fall) and there was no staff available to observe R1. E6(Nurse) continued to state that 5 minutes had elapsed and R1 was on the floor next to her bed in her room wrapped in a comforter that was on her bed. E6 went on to say that R1 has been toileted alone by her in the same fashion previously and there was no problem and that she was aware that R1 needed supervision. E6 said that she then assessed R1. R1 did not have any problem until 2 hours later. The doctor was notified, X- ray ordered and family was made aware. Radiology Report dated [DATE] states, " Intertrochanteric fracture of the left proximal femur with slight displacment." On [DATE] at 4:35 PM, E4(Director of Care Delivery/Supervisor) said that R1 was much R3, requiring constant observation. E4(DCD) further stated that E6 should not have left R1 unattended in the bathroom, E6 could have taken R1 to a bigger bathroom next to the nursing station. On [DATE] at 2:11 PM, E7(Certified Nursing Assistant) said that she was assigned to R1 that day. There were 4 CNA's on duty and 2 nurses. No one knew where the other nurse was. E6 responded to the other nurses patient(R4) that fell and told us that she left R1 on the toilet alone. E7 continued to say that she never left R1 alone because R1 stayed at the nurses station for observation because of the fall risk. R1 could stand but she was unsteady. On [DATE] at 2:36 PM via telephone Z1(Medical Doctor) said that she took care of R1 and was familiar with R1. " it's too bad that R1 sustained a fracture from the fall". R1 was discharged to another nursing facility after the surgery, R1 returned because she was anemic. R1 tried to undergo a gastrointestinal procedure coded and died . "The death had nothing to do with the fall." Hospital Record date [DATE] through [DATE] document that R1 was admitted for a unwitnessed fall at the nursing home and had intramedullary rodding of left interochanteric femur fracture procedure(ORIF, Open Reduction and Internal Fixation) and was discharged to another nursing home on [DATE]. Falls Practice Guide dated ,[DATE] states, " If the patient is found to be at risk for falls, the phsysician is contacted for orders, as appropriate,an initial plan of care is developed adn individualized interventions are initaited."

Based on record review and interview, the facility failed to provide the necessary assistance for one of seven sampled residents (R5) in accordance with the plan of care, by failing to obtain assistance from another staff with resident care. Findings include: R5 is a [AGE] year old with a [DIAGNOSES REDACTED]. On 11/20/11 at 10:40am, E11 reported to the charge nurse that R5 fell on the floor during patient care washing. Stated R5 was turned, reached out hand, then R5 rolled out of bed. R5 on left side of bed on the floor, laying on R5's right side. Bleeding noted from right side of head, ice applied. At 10:45am, 911 called. 11/20/11 admitted to hospital with [DIAGNOSES REDACTED]. Per review of R5's clinical care profile, R5 is usually a two person assist with extensive level of assistance. An incident report dated 11/20/11 at 10:40am stated, CNA (E11) performing ADL (activities of daily living) and states patient reached out and rolled off side of bed. Assessment completed. First aid provided. Patient left in position till 911 arrived, to hospital per 911. An employee warning notice dated 11/21/11 stated, "Employee (E11) was rendering care to R5 while in bed. R5 identified as two person bed mobility per the PIW and POC (plan of care). Care was rendered independently and patient was turned away from employee (E11) resulting in patient rolling from bed to floor." Description of counseling received by employee, "B-6 comply with all health and safety standards including infection control and not commit unsafe conduct or acts which result in minor injury to self or others." Unable to interview E11 because E11 is no longer employed by the facility. Interview with E2 (nurse) about the 11/20/11 incident. E2 stated, "As identified on the 11/21/11 employee discipline E11 employee was rendering care independently in bed, patient (R5) is identified as a two person bed mobility. As a result patient (R5) reached beyond p _ _ _ p _ _ and fell to floor; 911 first aid rendered. Patient (R5) was to be cared for by two people while rendering care to a patient in bed. One person on each side of the bed while patient was being changed." According to hospital records, on 11/20/11 one of the [DIAGNOSES REDACTED].