Every finding on record at Allure Of Zion

Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors. This applies to 2 of 3 residents (R1, R2) reviewed for medications in the sample of 3. The findings include: R1's face sheet shows diagnoses including sepsis, heart failure, COPD/Chronic Obstructive Pulmonary Disease, anxiety, hypertension and urinary tract infection. On 8/21/26 at 9:40 AM, R1 was in her room lying in bed. R1 said she was hospitalized recently for an infection in her urine. R1 said there was a delay in receiving her IV/intravenous antibiotic because nursing stated they were waiting on the pharmacy to deliver the medication. On 8/21/26 at 10:25 AM, V4 (RN/Registered Nurse) said medications are delivered from pharmacy within 24 hours. The facility has stocks medications that can be administered if the medication has not been delivered from pharmacy. Nursing should also call pharmacy to get an update on the expected time for delivery. On 8/21/26 at 11:57 AM, V3 (ADON) and this surveyor went into the medication room where the convenience box was located. The box listed meropenem vial; the IV medication that was prescribed for R1. V3 stated, V6 (R1's daughter) called her and expressed concern about R1 not receiving the medication. V3 stated she was unaware the facility had the medication in the convenience box to give. On 8/21/26 at 12:35 PM, V2 (DON) said pharmacy delivers medications daily. If the medication is not available nursing should check the convenience box and pull it from the box. There is a list of all medications they have available. At 1:50 PM, V2 confirmed R1's antibiotic was available, and nursing should have checked the box and administered the medication. R1's Medication Administration Record (MAR) dated August 2026 shows orders dated 8/13/26 meropenem intravenous solution 1 GM (gram) to be given every morning and at bedtime for infection for two days. R1's MAR shows it was not administered at the scheduled time for two occurrences on 8/13/26 at 9:00 PM and 8/14/26 at 9:00 AM. The facility's undated list of IV antibiotics emergency box shows there are two Meropenem 1 GM vials available in the facility. 2. On 8/21/26 at 9:34 AM, R2 was observed in her room lying in bed. R2 said she has an infection in her foot and is at the facility to receive IV antibiotics. R2's MAR orders dated August 2026 shows orders to administer ceftriaxone sodium injection 2 GM intravenously one time a day for osteomyelitis. The MAR shows it was not administered on 8/14/26. On 8/21/26 at 1:50 PM, V2 said R2's antibiotic was available in the convenience box and nursing should have checked the box and administered the medication. The facility's undated IV antibiotics emergency box shows Ceftriaxone 2 GM vial is available in the facility. The facility's undated Medication Administration Policy states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician.

Based on interview and record review the facility failed to ensure the state agency was notified of an allegation of abuse immediately but not later than two hours for 1 of 3 residents (R3) reviewed for abuse in the sample of 5.The findings include:The facility's Abuse - Investigative Protocol Checklist dated 8/12/26 for R3 showed on 8/7/26 at 1:00 PM it was reported to the facility that R3 said his wallet went missing but he couldn't remember when the last time was that he saw it. The contents of the wallet were $200.00, a debit card, and a state identification card. The notification log on the form showed the administrator was notified on 8/7/26 at 3:19 PM and the State Agency was notified on 8/7/26 at 6:18 PM.On 8/14/26 at 9:30 AM, V2 (Regional Director of Operations) reviewed the abuse investigation for R3 and his missing wallet. V2 went over the form and confirmed the form showed it was documented that the allegation of misappropriation of resident property was reported on 8/7/26 at 1:00 PM. V2 stated she doesn't know who reported it. V2 confirmed it was documented that V1 (Administrator) was notified on 8/7/26 at 3:19 PM and the State Agency was notified at 6:18 PM. V2 stated that the State Agency should have been notified within 2 hours.On 8/14/26 at 10:11 AM, V2 stated the 1:00 PM time that the allegation was reported on the Investigative Protocol Checklist dated 8/12/26 was an error. V2 stated V4 (Business Office Manager) stated it was reported to her at 3:19 PM and that is when she told V1 (Administrator). V2 stated it was still reported late to the State Agency because it was not reported until 6:18 PM. V2 stated it was supposed to be reported within 2 hoursThe facility's Abuse, Neglect and Exploitation policy (2026) showed reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (e.g. law enforcement when applicable) within timeframes: a. immediately, but not later than two hours after an allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on interview and record review the facility failed to ensure mail is delivered promptly for 1 of 2 residents (R1) reviewed for a resident's right to mail delivery. The findings include:On 7/26/26 at 9:05 AM R1 stated she had to get a replacement debit card after having her previous card stolen. R1 stated the new card was mailed to her, but she never received it. R1 stated she called her bank and they told her it was delivered on 7/16/26 so she started asking staff at the facility about it and nobody knew anything. R1 stated she had to order another card. R1 stated then someone came yesterday and told her they found the replacement card/letter on the floor under a desk or something. R1 stated she doesn't feel safe at the facility anymore.The Minimum Data Set, dated [DATE] for R1 showed no cognitive impairment.The Incident Report dated 7/23/26 for R1 showed the resident reported she is unable to locate a piece of mail that she believes was delivered to the facility for her. Investigation Initiated. The Misappropriation Allegation Investigation for R1 showed on 7/23/26 R1 stated that a new debit card was ordered and already delivered on 7/22/26 and was missing. Then when speaking to the bank on 7/24/26 it was validated that the debit card was delivered on 7/16/26 at 10:55 AM instead. A video analysis was done by the facility for 7/16/26 and showed at 10:57 AM the United Parcel Service - UPS delivery man was at the main entrance. He was noted to be carrying 2 boxes and a parcel. He delivered the boxes, left right away, and left the parcel on top of the boxes. A statement dated 7/23/26 from V4 (Social Services Director) showed, she was following up on the allegation made of a missing debit card. It was reported to her on 7/23/26. V1 (Administrator) and V4 spoke with R1 and while speaking to her she stated she spoke to the bank yesterday and confirmed the date and time it was delivered. R1 initially said she requested the care 7/16/26 but had not received it. R1 called the bank at 10:55 AM on 7/24/26 with V4 and V1 present. The bank stated they sent out the new debit card to this address, and it was delivered on 7/16/26 at 10:55 AM via UPS and gave the tracking number. After speaking with the resident V4 checked in with V1 who was reviewing the cameras. V1 saw the UPS (United Parcel System) package being delivered to the reception desk. V4 went and searched the reception area and found the UPS package unopened. It was confirmed the debit card was in the package, unopened. On 7/26/26 at 10:50 AM, V1 (Administrator) stated he learned last Thursday (7/23/26) and investigated it. V1 stated V4 found the parcel with R1's card in it in the reception area. V1 stated they are going to work on their mail delivery system. V1 stated normally the mail is delivered to the facility. The business office manager gets the mail and then activity staff deliver the mail. V1 confirmed R1's card was delivered to the facility, and she received the mail late.The facility's Resident Rights policy (2026) showed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident

Based on observation, interview and record review the facility failed to ensure shower water temperatures were at a comfortable temperature for 4 of 4 residents (R7, R8, R9 and R10) reviewed for clean, comfortable and homelike in the sample of 16.The findings include:On 6/24/26 at 9:50 AM, V8 (Maintenance) and this surveyor turned the water on in the 200 hall shower. The water felt cold when turned on. The water was kept on and turned to the hottest setting and was checked again at 9:55 AM. The water temperature was between 75 and 80 degrees Fahrenheit. The water was kept in the on position until 10:00 AM and the water temperature was 73 degrees Fahrenheit. This was verified by V8. V8 said that the water was too cold and should be around 110 degrees Fahrenheit. 1.On 6/24/26 at 11:40 AM, R7 said that he does use the 200-hall shower room. R7 said that the water temperature in the shower is too cold. R7 said that it has been cold for about one and a half to two months. 2.On 6/24/26 at 11:42 AM, R8 said that he does use the shower in the 200-hall shower room. R8 said that the water is cold and not very comfortable. R8 said that it has been like that for a while. 3.On 6/24/26 at 11:45 AM, R9 said that she uses the 200-hall shower, but she has to wash up really quick because the water is cold and not very comfortable. R9 said that it has been that way for a couple of months.4.On 6/24/26 at 11:50 AM, R10 said that he uses the 200-hall shower. R10 said that he does not like it because the water is too cold and it is not comfortable. R10 said that it has been that way for a while.On 6/25/26 at 12:19 PM, V14, Certified Nursing Assistant (CNA) said that a couple months ago the 200-hall shower water temperature was a little colder, but maintenance fixed it to the best of their ability. V14 said that some residents would say that it was still not warm enough. On 6/25/26 at 11:10 AM, V2 (Interim Director of Nursing) said that a shower at 75 degrees would not be very comfortable. V2 said that if staff are aware that the water is not getting warm, they should notify maintenance and use a different shower until it is fixed. The facility's Safe and Homelike Environment Policy shows, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview, and record review the facility failed to ensure scheduled nebulizer medications were administered as ordered (R1) and failed to ensure medications were administered at the scheduled time (R7, R8, R15, R16) for 5 of 6 residents reviewed for medication administration in the sample of 16.The findings include:1. On 6/24/26 at 10:20 AM, R1 was lying in bed. R1 had a nebulizer machine with an attached mask on her nightstand. R1 said she was on the nebulizer treatments for a bad chest cold and it was the only thing that has really helped her feel better. R1 said that's really the main issue she has had. R1 said for some reason she was not getting her nebulizer treatment in the afternoon. R1 said she would call and call to get the nurse to give her nebulizer. R1 said this was happening several times a week, but she didn't know why. R1 stated I'd have to call and call to make sure someone gives it (nebulizer) to me, and I shouldn't have to do that. One day I got so frustrated I called [V17 - Nurse Practitioner (NP)] and she talked to the nurses. I also told my daughter, and she talked to management about it. R1's Facesheet dated 6/25/26 showed diagnoses to include but not limited to displaced left tibia fracture; age-related osteoporosis; gout; stage 3 CKD (chronic kidney disease); cognitive communication deficit; need for assistance; muscle wasting and atrophy; osteoarthritis, nonrheumatic mitral valve insufficiency, GERD (gastro-esophageal reflux disease) and preglaucoma.R1's facility assessment dated [DATE] showed she was cognitively intact. R1's Physician Order Sheet showed she had a chest X-ray on 5/26/26 to rule out pneumonia and orders for Ipratropium-Albuterol nebulizer and Albuterol nebulizers for cough and shortness of breath, several orders were entered between 5/27/26 and the date of the survey 6/24/26. R1's May 2026 Medication Administration Record (MAR) showed R1 had an order for Ipratropium-Albuterol nebulizer every 12 hours for cough and shortness or breath. This was scheduled for 9 AM and 9 PM. This medication showed a 9 (which means medication was not administered and see progress notes for explanation) on 5/28 at 9 PM and the 5/29 9 PM dose was not blank (not administered). This record showed R1 had an additional order for Albuterol nebulizer three times a day, scheduled at 9 AM, 12 PM, and 6 PM. This medication showed was documented with a 9 for 6 PM doses on 5/28 and 5/29. (There were no corresponding progress notes for these 4 missed medication doses).R1's June 2026 MAR showed R1 had an order for Ipratropium-Albuterol nebulizer twice a day that was changed to three times a day on 6/13/26. This medication was not administered and there was no corresponding progress note for 9 PM doses on 6/2, 6/6, and 6/11. (Documented on MAR as 9). This document showed the order was changed to three times a day on 6/13/26. This medication was not administered and there was no corresponding progress note for 6 PM doses on 6/17, 6/18, and 6/19.On 6/25/26 at 10:55 AM, V12 (Receptionist) said she does get calls from R1 at the front desk about getting her breathing treatment. V12 said it seems like R1's calls are mostly in the afternoon.On 6/25/26 at 12:22 PM, V4 (previous Director of Nursing (DON) said V17 (NP) mentioned that the nurses on duty were refusing to give R1 her nebulizer treatment because they didn't have time. V4 said V17 was upset that the nurses weren't following her orders, and she had to put in an order for the treatment to be done three times a day because they weren't doing it twice a day. V4 said she follow-up and noticed it was the same male nurse that was not giving the nebulizer. V4 said that is just wrong, the nebulizers should have been administered as ordered in the first place. On 6/26/26 at 11:11 AM, V3 (Assistant DON - ADON) said R1's daughter did come to her about R1's nebulizer treatment a week or two ago. V3 said R1's daughter reported that R1 was only getting the morning nebulizer and not the one scheduled later in the day. V3 said she expects the nurses to follow the physician's orders and administer the treatment at the scheduled times. V3 said if the nurse charts 9 on the MAR that means the medication was not administered and there should be a progress note explaining why it was not administered. V3 said it was important to provide an explanation for not administering R1's treatment. V3 said if nothing is charted, then it is hard to know what happened. V3 said R1 was alert, oriented, and able to make her needs known. On 6/26/26 at 12:35 PM, V17 (NP) said R1 was on the nebulizer treatments to treat an upper respiratory infection. V17 said R1 contacted her and said she wasn't getting her nebulizer as ordered. V17 said she increased the frequency from twice a day to three times a day to ensure that R1 at least got two treatments a day. V17 said she expects the nurses to provide the treatments as ordered, but she is not in the facility every minute to ensure it is done. The facility's undated Medication Administration Policy showed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This policy showed the medication should be signed out on the MAR after it is administered and any refusals should be documented. 2. On 6/24/26 at 10:04 AM, V11 (Licensed Practical Nurse - LPN) was preparing medications at the cart. V11's computer screen showed several residents names in red. The surveyor asked V11 what it meant when the residents' names were red like that. V11 replied, I'm late, that's why they are red. I still have a lot of medications to give. V11 revied her screen with the surveyor and said she still had to administer medications to R7, R8, R15 and R16. V11 said the facility policy is to administer medications within an hour before and an hour after the scheduled medication time. R7's Medication Admin Audit Report for 6/24/26 showed R7's iron, vitamin B12, omeprazole, diltiazem, miralax, and aspirin were scheduled at 9 AM and were administered at 10:13 AM. R7's antibiotic was ordered every 12 hours, was scheduled for 9 AM and was administered at 2:01 PM. R8's Medication Admin Audit Report for 6/24/26 showed R8's eyelid cleansers (ordered twice a day), thiamine, pyridoxine, cyanocobalamin, vitamin C, Eliquis (blood thinner ordered twice a day), zyprexa (medication for psychosis ordered twice a day), furosemide, and multivitamin were scheduled for 9 AM and were administered between 10:26 and 10:38 AM. R15's Medication Admin Audit Report for 6/24/26 showed R15's oxybutynin (medication for overactive bladder ordered twice a day), aspirin, and Keppra (seizure medication ordered twice a day) were scheduled for 9 AM and administered at 10:16 AM.R16's Medication Admin Audit Report for 6/24/26 showed R16's Eliquis (blood thinner ordered twice a day), levothyroxine, [NAME] (heart medication ordered twice a day), aspirin, digoxin, multivitamin, and metoprolol succinate were scheduled at 9 AM and were administered between 10:36 and 10:38 AM. On 6/25/26 at 9:31 AM, R7 was lying in bed. R7 said his medications were a little late yesterday, but there are times it had been as late as 11-11:30 AM. On 6/25/26 at 11:11 AM, V3 (ADON) said medications should be administered within 1 hour before and 1 hour after the schedule time. V3 said it's important the staff administer the medications as the doctor orders them. V3 said it's especially important when a medication is ordered more than once a day, you want to make sure there is enough time between the dose to prevent double dosing the resident and make sure it stays stable in their body.

Based on observation, interview and record review the facility failed to ensure resident finger nails were cleaned and trimmed for residents needing assistance with activities of daily living (ADLs) for 2 of 3 residents (R6 and R10) reviewed for ADLs in the sample of 16.The findings include:1.R6's Minimum Data Set assessment dated [DATE] shows that he is alert and oriented, has no rejection of care behaviors and needs substantial to maximal assistance with personal hygiene. On 6/24/26 at 10:25 AM, R6's finger nails were long and had brown debris under them. R6 said that he just had a shower Saturday but they did not trim his nails. R6 said that he can not trim his nails himself and they really need to be cleaned. 2.R10's Minimum Data Set assessment dated [DATE] shows that he is alert and oriented, has no rejection of care behaviors and is dependent on staff for personal hygiene.On 6/24/26 at 11:50 AM, R10's finger nails were long and had brown debris under them. Some of the nails were broken off and had jagged edges. R10 said that his nails keep breaking off because they are too long and they have not cut them recently. On 6/25/26 at 12:19 PM, V14 (CNA) said that fingernails should be cleaned and trimmed on the resident's shower days or as needed. The facility's Nail Care Policy shows, Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care to include trimming and filing, will be provide on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises.

Based on observation, interview, and record review the facility failed to ensure a resident received an ordered pain medication in a timely manner for 1 of 3 residents (R2) reviewed for pain the sample of 16. The findings include:On 6/24/26 at 9:39 AM, R2 was lying in bed watching television. R2 said she has chronic pain all over her body from lymphedema. R2 said she takes scheduled Tylenol, has two pain patches, and can have Tramadol every eight hours if she needs it. R2 said there was an issue with her Tramadol. R2 said she had pain and asked the nurse for her Tramadol, and she said she didn't have it. The surveyor asked R2 when this occurred. R2 pulled her phone out of her purse and said let me look, I put a note in here. R2 said she didn't have Tramadol from 10:35 PM on 6/16/26 until 2:30 PM on 6/17/26. R2 said she kept asking the nurse, but she said the medication wasn't there. R2 said she called the front desk to speak to management and left voicemails. R2 said she called V16 (Social Services Director) and then V4 (previous Director of Nursing - DON) came down. R2 said V4 was able to obtain the Tramadol from the emergency box and gave it to her at 2:30 PM. R2 asked, Why didn't the other nurse do that?R2's Facesheet dated 6/25/26 showed diagnoses to include but not limited to metabolic encephalopathy; hepatic failure; dysphagia; morbid obesity; lack of coordination; abnormalities of gait and mobility; chronic pain; localized edema; depression; mood disorder; and lymphedema.R2's Physician Orders dated 6/25/26 showed she had an order for 50 mg Tramadol every eight hours as needed. R2's June Medication Administration Record showed R2 received a dose of Tramadol at 10:30 PM on 6/16/26. There were no documented Tramadol doses on the MAR until 6/17/26 at 10:30 PM. R2's Progress Notes dated 6/17/26 showed V4 (previous DON) administered Tramadol out of the C (Control box) at 2:35 PM.R2's Care Plan initiated 8/14/24 showed R2 was on pain medication therapy related to back pain. The interventions include administering analgesic medications as ordered by the physician.On 6/25/26 at 10:55 AM, V12 (Receptionist) said R2 does call the front desk frequently. V12 said R2 does call for pain medication and she will send a nurse to her room. V12 said R2 does call and asked to be transferred to V1 (Administrator) or V16 (Social Service Director). On 6/25/26 at 12:22 PM, V4 (previous DON) said she was asked to go to R2's room because she was complaining that she couldn't get her Tramadol. V4 said R2 told her that the nurses were telling her that the Tramadol wasn't in the building. V4 said R2 reported she was in pain, but she wasn't crying or showing signs of severe distress. V4 said she was able to access the emergency C (Control) box and obtain the Tramadol. V4 said she had to call pharmacy and get a code, but there were three Tramadol in the box. V4 said there is no reason that R2 had to wait for Tramadol to be delivered. V4 said any of the nurses could have accessed the C box like she did. V4 said R2's Tramadol should have been reordered from pharmacy before she ran completely out. V4 said she confirmed with the pharmacy that the medication was ordered and was on its way. On 6/25/26 at 11:11 AM, V3 (Assistant DON - ADON) said she didn't remember anything regarding R2's Tramadol, but it was likely that V4 (previous DON) handled that. V3 said the facility does have a C box with extra medications. The surveyor asked if Tramadol was in the C box. V3 said she wasn't sure, but we could go look. The surveyor accompanied V3 to the medication room. V3 obtained the C Control Box from a locked drawer. The label on the outside of the box showed there were 3 Tramadol 50 mg tablets inside. V3 said all the nurses are trained in obtaining medications from the C box. V3 said there are three Tramadol tablets inside. V3 said there would be no reason R2 had to wait for the Tramadol to be delivered if it was available in the C box. V3 said R2 has been on Tramadol for a while and there's no good reason for her to run out completely. V3 said the nurses should re-order medications early enough to allow pharmacy delivery without the resident missing doses. The facility's undated Pain Management Policy showed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Based on observation, interview, and record review, the facility failed to ensure resident valuables were protected from misappropriation for 2 of 5 residents (R1, R2) reviewed for abuse in the sample of 5.The findings include:1.On 5/4/26 at 10:36 AM, R1 said on a Saturday in the last two to three weeks, she asked one of the CNAs (certified nursing assistants) to get some food for her. R1 said she checked her wallet, and all of her cash was missing. R1 said she reported the missing cash to one of the nurses, the police were called, and they came and took her statement. R1 said she has been getting cash from her (trust) account and was saving up for a while. R1 said she gets $60 a month and had two months' worth of cash in her wallet. R1 said she leaves her room for activities and meals. R1 said she later received an email from her financial institution that there was unusual activity on her debit card and referenced a charge of $98.89 made at a department store on 4/21/26 at 12:25 ET (eastern time). R1 shared this email with surveyor 40798 and it showed the information as described above related to R1's debit card. R1 said she did not make the debit card purchase in question. R1 said she has not reported the unusual activity on her debit card to the facility at this time.On 5/4/26 at 11:07 AM, V5, CNA, said R1did tell her about missing $120, but had already reported it to a nurse at that time.On 5/4/26 at 11:52 AM, V6, Business Office Manager, said R1 takes money (cash) out of her trust account every month. V6 said R1 has taken $380 since January 9, 2026.On 5/4/26 at 12:02 PM, V3, Assistant Director of Nursing (ADON), said V14, Licensed Practical Nurse (LPN), reported that R1 told a CNA that her money was missing on 4/18/26. V3 said she spoke to R1 and R1 told her that $120 was missing from her black wallet. V3 said she checked R1's wallet and there was nothing (no money) in her wallet and nothing in her drawers.On 5/4/26 at 12:55 PM, V8, Activities Director, said the residents have not gone on the trips to the discount department store for quite a while; probably four to five months. V8 said R1 has not been on a discount department store trip with activities in months, and definitely not in April 2026. V8 said R1 will give her a list of what she needs with cash for activities to purchase for her at the discount department store. V8 said she will bring back her change and a receipt. V8 said R1 never gave her a debit card to purchase her items.On 5/5/26 at 11:48 AM, V18, CNA, said she could hear R1 crying hysterically on 4/28/26 at about 2:05 PM. V18 said she went to R1's room to see what the matter was. R1 said she was missing $120. V18 said she remembers it because it was only her second day of work at the facility, and she had clocked in at exactly 2:00 PM, and was still in training. V18 said she reported R1's missing money to the second shift nurse, V14.On 5/5/26 at 9:05 AM, V14 said R1 reported missing items to V18 who reported it to her on 4/18/26. V14 said she spoke to R1 who told V14 she had $120 missing from her wallet. V14 said R1 told her it was all the money she had. V14 said R1 could not give her a time frame of when she had last seen her cash. On 5/5/26 at 1:16 PM, V1, Administrator, said one of the nurses, possibly V14, called him at home on a Saturday and told him that R1 reported $120 missing, so they started the investigation process. V1 said he is not aware of any suspicious charges on R1's debit card; R1 never reported that. V1 said we're no different than a hotel, we can't keep an eye on everything 24 hours a day, that's why we encourage residents/family to keep valuables at home. V1 said he does not know if dentures, glasses, hearing aids, cell phones, and/or jewelry get put on the residents' inventory list. V1 said he will have to double check with the nurses. V1 said it is his expectation for staff to know what items people come in with and to remind residents to take them home. V1 said he tells families they should feel comfortable keeping their valuables at home and valuables left here (in the facility) can be kept in the facility's safe.R1'S Police Incident Details report dated 4/18/26 at 6:56 PM shows R1 reported missing cash in the amount of $120 which she last saw on 4/16/26.R1's current care plan provided by the facility shows she is a vulnerable adult living with uncertainty about her future. Staff are to provide reassurance to R1 to remind her she is safe and secure. R1's care plan does NOT show any behavior of making false allegations or diagnoses of dementia. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively intact with no hallucinations, delusions, rejection of care, or wandering behaviors and NO neurological diagnoses including Alzheimer's disease and/or Non-Alzheimer's dementia. 2.On 5/5/26 at 9:49 AM, V16, Director of Admissions/Marketing, said V19, R2's son, called her and said R2 had $60 and a ring missing. V16 said V19 knew the money was missing because every time he came to visit, R2 would ask for money, and he would show her the $60 in her purse. V16 said she didn't ask for any further details and would report it to V12, as they need to do an investigation. V16 said this issue is recurrent, there is always somebody missing something, and it's unacceptable. V16 said patients' privacy, care, and respect is number one, and to her it's embarrassing. V16 said they entrust us to care for them and provide safety and security.On 5/4/26 at 2:20 PM, V12 SS Director, said V16 informed her that R2's son, V19, had called her (V16) and told her there were $60 and a wedding band missing from R2's room.On 5/4/26 at 12:02 PM, V3 said she remembers she, V1, Administrator, and V17, Social Services (SS) Associate were all in the room when they got the message that R2's family reached out to V16, Director of Admissions/Marketing and said R2's money and her ring were missing. V3 said she and V17 went, with R2 present, and looked through R2's drawers, closet, and purse, and didn't find anything (ring or cash).On 5/5/26 at 10:55 AM, V17 said one of R2's sons reported to V16 that R2 was missing $60 and a ring. V16 was not in the building, so she called V12 who was also not in the building, and therefore, called her. V17 said she, V1, and V3 were on speaker phone with V12 and were told that V19 reported R2 was missing $60 and a ring and had no other details. V17 said she and V1 called V19. V19 told them he last saw R2's $60 on Sunday, 4/19/26. V17 said she and V3 checked R2's room and the medication cart for R2's missing items but didn't find anything. V17 said R2 has dementia and cannot speak well for herself.On 5/5/26 at 2:09 PM, V19 said R2 has been in the facility for about a month now. V19 said R2 has dementia and asks him for money when he visits, and he shows her the $60 he gave her. V19 said about a week after R2 was in the facility, the money was gone and all the pockets in her purse were open. V19 said R2 can't really even open her purse, and she cannot use a phone. V19 said he didn't say anything at the time, he was upset but didn't report it at that time. V19 said it wasn't worth saying anything, as he was worried if they grilled the staff, it could affect R2's care. V19 said later when his brother and sister-in-law went to do R2's nails, his sister-in-law noticed that R2's ring was missing. V19 said as he was speaking to V16, he mentioned to her that the money and ring were missing, but he didn't want to make a big deal out of it. R2 said no one at the facility ever told him they had a safe available or encouraged him to keep R2's valuables at home.R2's Police Incident Details report dated 4/24/26 shows claims were made about stolen money and V19 stated R2 is missing money.R2's current care plan provided by the facility shows she has cognitive challenges including poor awareness, concentration, energy and attention with disrupted/poor judgment and reduced cognitive processing speed. R2 has deficits in executive functions such as abstract reasoning, planning, and problem solving. R2's diagnoses include, but are not limited to dementia, adult failure to thrive, and age-related physical debility. R2's Progress note dated 4/24/26 at 6:13 PM shows V19 notified staff that R2 was missing $60 and a ring.The facility's Abuse, Neglect and Exploitation Policy (not dated) shows, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview and record review, the facility failed to report allegations of abuse for 1 of 5 residents (R4) reviewed for abuse in the sample of 5.The findings include:On 5/5/26 at 12:43 PM, R4 said he is missing a ten-dollar ($10) bill. R4 said his niece brought the ten-dollar bill in with two packs of cigarettes and left it on his bedside table. R4 said he was half asleep and when he woke up the $10 bill was gone, and the cigarettes were still there. R4 said his niece later confirmed it was a $10 bill that she had left. R4 said he reported it to V1, Administrator. Staff came in his room to look for the money but did not find it. R4 said he is not sure if they told the police, but police never spoke to him about it. R4 said he reported it in case this person is stealing from other people too.On 5/5/26 at 10:55 AM, V17, Social Service (SS) Associate, said on a Tuesday two weeks ago she went to V1's office where R4 was also present. R4 said he was missing $10 or $20. R4 said he found his cash missing and a paper he keeps in his wallet was out of the wallet next to the wallet. R4 said his niece brought him a pack of cigarettes and either $10 or $20. V17 said she and R4 went to his room and looked for the money. V17 said she called R4's sister to try to contact R4's niece since they didn't have the niece's contact information in order to get clarification on how much money was left. V17 said she doesn't know if the allegation was ever reported to the police. V17 said when they report an incident, they bring it up to the whole IDT (interdisciplinary team), if it's a grievance it's different. V17 said if its reported, it's a full investigation with the state being notified, if it's a grievance, it's not a full investigation with the state being notified. V17 said V1does the state reporting. V17 said since they didn't have all the details for R4's allegations and couldn't get all the details from his sister, V1 said it should just be a grievance. V17 confirmed she had written (typed) a statement regarding V4's allegations on 4/29/26. V17's statement (undated) shows R4 reported either $10 or $20 was had been taken from his wallet on 4/16/26.A written statement dated 4/27/26 by V6, Business Office Manager, shows R4 had requested cash from his trust fund on 3/16/26 for $60 and on 4/14/26 for $60.On 5/5/26 at 1:16 PM, V1 said R4's allegations were not reported because R4 could not even say there was money there. V1 said R4 said he couldn't remember if it was $10 or $20. V1 said from his perspective, he feels R4 was trying to get some money, but there was no indication that there was any money to begin with, so he left the allegations as a grievance. V1 said he did not report R4's allegations to the police or the state, he just left it as a grievance. V1 said he must report any allegations of abuse including physical, misappropriation, sexual, seclusion, and emotional abuse to the state as well as injuries of unknown origin.R4's Minimum Data Set, dated [DATE] shows R4 is cognitively intact with no hallucinations, delusions, rejection of care, or wandering behaviors and NO neurological diagnoses including Alzheimer's disease and/or Non-Alzheimer's dementia. R4's current care plan provided by the facility shows R4 is cognitively intact and independent [has no apparent memory loss, is oriented, and able to recall or retain information (i.e. recent events, directions, time, place of situation.)] R4 Makes safe judgments and functions appropriately in social situations with decisions about his care and environment. -The facility's abuse investigations were reviewed from the past three months and R4's allegations were not among the files.The facility's Quality Improvement Form (grievances) shows R4's allegations of missing money were noted on 4/15/26.The facility's Abuse, Neglect and Exploitation Policy (not dated) shows an immediate investigation is warranted when reports of abuse occur. The facility will have written procedures that include reporting of all alleged violations to the state agency and other required agencies such as law enforcement.

Based on interview and record review the facility failed to ensure psychotropic medication ordered as needed had a duration/stop date for 1 of 3 residents (R3) reviewed for psychotropic medications in the sample of 5. The findings include: R3's Face Sheet printed on 2/17/26 listed anxiety as a diagnosis.R3's Order Summary Report printed on 2/17/26 showed an order for lorazepam (psychotropic medication) to be given every 4 hours as needed for anxiety. There was no duration/stop date for the order. On 2/27/26 at 10:23 AM, V13 (Pharmacist) said an as needed psychotropic medication such as lorazepam needs a stop date.The facility's Use of Psychotropic Medication(s) undated policy showed as needed psychotropic medications shall be limited to no more than 14 days unless the attending physician believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician for the rationale for the extended time period and indicate a specific duration.

Based on interview and record review the facility failed to monitor dementia residents with wandering behaviors. The facility failed to immediately intervene and redirect dementia residents exhibiting wandering and dementia related behaviors. These failures apply to 2 of 3 residents (R1, R2) reviewed for dementia care in the sample of 4.The findings include:A facility report dated 12/8/25 showed V13 Certified Nursing Assistant (CNA) observed R1 lying next to R2 in R2's bed. R1 and R2 were fully dressed. The report showed video surveillance of the incident, reviewed by V1 Administrator, showed R1 entered R2's room at 5:31 AM on 12/8/25. R1 was not removed from R2's room by facility staff until 6:03 AM. R2 exited her room at 5:52 AM, on her own will. The report showed R1 and R2 both had a diagnosis of dementia.R2's admission record showed R2 was admitted to the facility on [DATE] and discharged home with family on 12/17/25. R2's care plan dated 11/24/25 showed R2 was cognitively impaired related to her diagnosis of dementia. R2's progress notes dated 11/22/25, 11/24/25, and 11/30/25 showed R2 would attempt to get up on her own and could propel herself in her wheelchair throughout the facility. R2's 11/30/25 note showed R2 was confused, keeps on going to other resident room, calling other male resident her husband.R1's care plan dated 10/16/25 showed R1 was severely cognitively impaired related to his diagnosis of dementia. The plan showed R1 wanders aimlessly throughout the building. The plan showed facility staff were to distract R1 from wandering, offering him pleasant diversions, and intervene as appropriate. Progress notes dated November 7, 16, and 29, 2025 showed R1 was found wandering at night throughout the facility.On 12/18/25 at 9:08 AM, this surveyor attempted to interview R1 about the incident on 12/8/25 however R1 could not be interviewed due to his impaired cognition. R1 was confused to person, place and time. R1 stated he didn't know R2. R1 denied any recollection of the incident on 12/8/25, stating, I don't remember anything.On 12/18/25 at 9:35 AM, V8 CNA stated on 12/8/25 she found R1 lying in R2's bed, fully dressed. V8 stated R2 was dressed, seated in her wheelchair, next to R1 as he laid in her bed. V8 stated she tried to get R1 out of R2's bed but R2 got verbally aggressive with V8. V8 stated she left R2's room and reported her findings to V9 Registered Nurse (RN) but (V9) was busy passing meds so I waited for the day shift to come in so they could help me get (R1) out of the bed. V8 stated she had no idea how long R1 had been in R2's room.On 12/18/25 at 9:49 AM, V9 RN stated on 12/8/25 he observed R1 lying in R2's bed. R2 was seated in a wheelchair in the room. V9 stated he did not immediately attempt to intervene or remove R1 from R2's bed because while V9 was aware R1 and R2 were severely cognitively impaired related to their dementia diagnoses, V9 stated, I didn't know if they were in some type of relationship. V9 stated he had no idea how long R1 had been in R2's room. V9 stated he knew both R1 and R2 had a history of wandering behaviors.On 12/18/25 at 12:28 PM, an attempt to contact V13 CNA via phone for an interview was unsuccessful.On 12/18/25 at 12:05 PM, V1 Administrator stated the facility no longer had video of the incident on 12/8/25 involving R1 and R2 for this surveyor to review. V1 stated he watched facility video recorded on 12/8/25. V1 stated the video showed R1 wandering all over the place for about an hour in the facility. V1 stated no staff were present during that time. V1 stated the video then showed R2 coming out of her room into the hallway to speak to R1. V1 stated, You see them talking in the hall. Then you see (R1) go into (R2's) room with her. Both residents are fully clothed. They are in (R2's) room for about 10-15 minutes. Our cameras only record what is in the hallway, not in resident rooms. Then you see (R2) propelling herself out of the room in her wheelchair. On 12/18/25 at 10:53 AM, V11 Family of R2 stated, (R2) is very confused. Her dementia is getting worse. She thinks every man is her husband. She could get around in her wheelchair. I asked her what happened (on 12/8/25). She told me (R1) laid with her on the bed. Both were fully clothed. The facility knew (R2) had these behaviors and were supposed to watch her, but I guess they weren't watching her that morning.On 12/18/25 at 11:40 AM, V3 Assistant Director of Nursing (ADON) stated if staff see a dementia resident wandering, they are to intervene and redirect the resident immediately. V3 stated facility staff were aware of R1 and R2's wandering behaviors prior to the incident on 12/8/25. The facility's Elopements and Wandering Residents policy (undated) showed, This facility ensures that residents that exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factor contributing to wandering or elopement risk.The facility's Dementia Care policy (undated) showed, it is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide incontinence care to a resident (R1) that is dependent on staff for incontinence care. This applies to 1 of 3 residents reviewed for ADL's (Activities of Daily Living) in the sample of 3.The findings include: R1's electronic face sheet printed on 12/4/25 showed R1 has diagnoses including but not limited to Parkinson's Disease, congestive heart failure, major depressive disorder, hallucinations, and anxiety disorder.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, is incontinent of bladder, and requires staff assistance for personal hygiene.R1's care plan dated 7/22/24 showed, I have bladder incontinence .clean perineal area with each incontinence episode.On 12/4/25 at 10:10AM, R1 was sitting up in her (reclining wheelchair). The front of R1's pants were wet with an unknown substance and R1 had a strong urine odor.On 12/4/25 at 10:37AM, V4 (R1's daughter) stated, I have concerns with my Mom not being changed every 2 hours. She uses a (full body mechanical lift), and when they lift her up her pants are usually wet and the brief, she is wearing is brown and soaking wet.On 12/4/25 at 11:41AM, R1 was sitting up in her (reclining wheelchair) in the same position. The front of R1's pants were still wet. Surveyor notified (V5-Certified Nursing Assistant-CNA) that R1's pants were soiled.On 12/4/25 at 11:54AM, V5 came into R1's room and began wheeling her down the hallway. V5 stated R1 was not assigned to her; however, she believes R1 may have been changed around 8AM today. Surveyor questioned V5 as to if R1 gets changed in her room or the community bathroom and V5 stated, I will change her I guess but we usually change after lunch. V5 then brought R1 back to her room with V6 (CNA) and performed incontinence care. R1 was lifted up out of her chair and a strong urine odor was present. The front, back, and sides of R1's pants were wet. V5 and V6 removed R1's pants, revealing R1 was wearing 2 disposable incontinence briefs. V5 stated this is normal for R1 and that staff always put 2 briefs on her. When V5 removed R1's incontinence brief is was heavily soiled with urine and had a strong urine odor. At 12:23PM, V7 (CNA) stated she is assigned to care for R1 today and she has not provided incontinence care to R1 since her shift started at 8:00AM. V7 stated R1 is a night shift get up and is up before day shift arrives at 6:00AM every day.On 12/4/25 at 2:00PM, V2 (Interim Director of Nursing) stated, (R1) should not wear 2 incontinence briefs because that is just a way for staff to not have to change her as often. Her family never requested that. In my opinion, 6 hours is too long for a resident to go without being changed and even repositioned. This could contribute to urinary tract infections and skin breakdown.The facility's policy titled, Incontinence dated 2025 showed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive the appropriate treatment and services.4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place, failed to ensure skin tear prevention measures were in place. These failures apply to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3.The findings include:R1's electronic face sheet printed on 12/4/25 showed R1 has diagnoses including but not limited to Parkinson's Disease, congestive heart failure, major depressive disorder, hallucinations, and anxiety disorder.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, has skin tears, utilizes a chair alarm, and has experienced falls since admission to the facility.R1's care plan revised 10/10/25 showed, The resident is at risk for falls related to deconditioning/gait/balance problems .R1's care plan revised 10/27/25 showed, I have the potential impairment to skin integrity related to fragile skin .skin tears 8/1/25, 8/22/25, 9/3/25, 9/29/25, 10/10/25, 10/27/25 . (protective sleeves) in place to right and left arm .R1's physician's orders dated 1/6/25 showed, Clip alarm at all times.R1's physician's orders dated 10/9/25 showed, Apply (protective sleeves) to bilateral upper extremities for protection.R1's fall risk evaluation dated 9/1/25 showed R1 is at risk for falls.On 12/4/25 at 10:10AM, R1 was sitting up in her reclining wheelchair. One alarm was located on the back of each side of her chair, with the clips hanging down on either side, not clipped to her. R1 had a protective sleeve to her left arm but not her right arm. There was a protective sleeve in the chair next to her. On 12/4/25 at 11:41AM, R1 continued to have a protective sleeve on her left arm but not her right arm. R1's skin appears thin and dry with multiple areas of healed scabs and small, healing bruises.On 12/4/25 at 11:54PM, V5 (Certified Nursing Assistant-CNA) stated R1 is supposed to have 1 alarm clipped to her but she does not know why there are 2 alarms on her chair. V5 stated the alarms help to ensure staff are alerted when R1 leans too far forward or tries to get up so they can respond quickly and prevent her from falling. V5 stated R1 is supposed to have protective sleeves on her arms because she has fragile skin and has recently had multiple skin tears.On 12/4/25 at 2:00PM, V2 (Director of Nursing) stated, (R1) requires the use of an alarm at all times because she has a history of falls. I'm not sure why she would have had 2 alarms on her chair, but she does need 1 of them hooked to her at all times. She definitely needs the protective sleeves on because she has had several skin tears over the last few months due to her extremely fragile skin.The facility's policy titled, Accidents and Supervision dated 2025 showed, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .1. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes .e. Ensuring that the interventions are put into action .

Based on observation, interview, and record review, the facility failed to ensure glove changes were performed during incontinence care for a resident with a history of ESBL (Extended-spectrum beta-lactamase) in the urine. This applies to 1 of 3 residents (R1) reviewed for incontinence care in the sample of 3.The findings include:R1's electronic face sheet printed on 12/4/25 showed R1 has diagnoses including but not limited to Parkinson's Disease, congestive heart failure, major depressive disorder, hallucinations, and anxiety disorder.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, is incontinent of bladder, and requires staff assistance for personal hygiene.R1's physician's orders dated 1/8/25 showed, Enhanced Barrier Precautions due to history of ESBL in urine .R1's care plan dated 7/31/25 showed, The resident requires Enhanced Barrier Precautions related to history of ESBL (Extended-Spectrum Beta-Lactamases) in the urine .wear personal protective equipment properly .On 12/4/25 at 11:54AM, V5 and V6 (Certified Nursing Assistants) provided incontinence care for R1. V5 removed R1's incontinence brief soiled with urine, cleansed R1's perineal area, applied a clean incontinence brief, assisted R1 with clean clothing, grabbed the mechanical lift remote, and combed through R1's hair without changing her gloves. V5 stated she was just nervous being observed and should have changed her gloves more often. V5 stated she can't remember why R1 is on precautions.On 12/4/25 at 2:00PM, V2 (Director of Nursing) stated, The aides should be changing their gloves when going from a dirty to clean task. She has a history of ESBL in her urine and we don't want to spread that around. They definitely shouldn't be touching surfaces of shared items with the same gloves either, that is an infection control concern.

Based on interview and record review, the facility failed to supervise a resident at high risk for falls for one of six residents (R1) reviewed for safety/supervision in the sample of six. This failure resulted in R1 experiencing a fall and rib fracture that resulted in R1 transferring to the local hospital. The findings include: R1's Discharge paperwork from the local hospital shows R1 was admitted to the local hospital from [DATE]-June 13, 2025, with diagnoses of wet gangrene, osteomyelitis, and dementia. R1's admission Record dated June 25, 2025, shows he was admitted to the facility on [DATE] with diagnosis of vascular dementia. R1's Fall Risk assessment dated [DATE], shows R1 was a high risk for falling with a score of 16. On June 25, 2025, at 12:44 PM, V9 Registered Nurse (RN) stated R1 arrived in the facility prior to her getting to the facility for her shift that started at 3:00 PM. V9 stated when she arrived for her shift, R1 had not been admitted by a nurse yet. V9 stated she did rounds on R1 first since he was not officially admitted by a nurse yet. V9 stated during report she (V9) was told R1 was a high fall risk. V9 stated she gave R1 a urinal, oriented R1 to his room and asked R1 to use the urinal and his call light. V9 stated she was at the nurse's station when the Certified Nursing Assistant (CNA) came and got her because R1 had fallen. V9 stated R1 reported head and back pain. V9 stated R1 was sent to the hospital since the fall was unwitnessed and R1 reported that he hit his head. On June 25, 2025, at 1:31 PM, V10 CNA stated she got to work at 2:00 PM and got report from the other CNA. V10 stated she got report that there was a new admission, but he had not been checked in by the nurse or CNA. V10 stated she asked the day nurse who was going to do R1's admission, and the day nurse said the 2nd shift nurse was going to do R1's admission. V10 stated that R1 was at the facility before her shift started at 2:00 PM. V10 stated the nurses get to the facility at 3:00 PM. V10 stated that at the time of R1's fall on June 13, 2025, she was performing incontinence care to R1's roommate. V10 stated she could hear R1 trying to get up from his bed because she could hear the mattress creaking. V10 stated she looked around the privacy curtain and asked R1 if he needed something. V10 said that R1 was sitting on the edge of the bed. V10 said that R1 told her that he needed to use the bathroom. V10 said she told R1 to use his urinal. V10 said she did not know if R1 could walk or not because he had not been evaluated by the nurse yet. V10 said there was a walker by R1's closet but she was not sure if it was R1's or not. V10 said she asked R1 if he wanted to use the walker and unfolded it. V10 said that R1 was still trying to get up without the walker when V10 left the room to throw away the trash from R1's roommate. V10 said, Obviously he did not wait for me. I heard a loud noise and the resident across from the hall from R1's room said R1 fell. V10 said R1 was on the floor in the fetal position. V10 said she thought R1 hit his head. V10 said that R1 was sent to the local emergency room. On June 24, 2025, at 4:32 PM, V11 (R1's daughter) said R1 was admitted to the facility June 13, 2025. V11 said R1 fell the day he got to the facility. V11 stated on June 13, 2025, she was waiting for a phone call from the facility telling her that R1 arrived at the facility because she knew that R1 would be disoriented and needed V11 to be at the facility. V11 said, Next thing I know, about 5:00 PM, the facility called me and stated my father had fallen and the ambulance was on its way. V11 stated the facility said that R1 hit his head so it was protocol to send him to the local hospital. V11 stated the hospital just did a cat scan on R1's head that came back negative and R1 was sent back to the facility. V11 stated her father has advanced dementia. V11 said she saw her father about mid night at the facility when he came back from the hospital on June 14, 2025. V11 said she saw her father in the evening on Saturday June 14, 2025, and her father was grabbing his side. V11 stated she demanded X rays from the facility because when she saw her father on June 15, 2025, R1 was still in pain and holding onto his right side. V11 stated her father was in pain each time he took a deep breath. V11 stated she never saw her father like this. V11 stated the facility got X rays done and the facility called her and said R1 had a broken rib. The facility told V11 that they were sending R1 back to the local hospital. On June 25, 2025, at 2:00 PM, V3 Assistant Director of Nursing stated R1 had a fall shortly after he arrived at the facility. V3 stated the facility called R1's daughter (V11) and told her about the fall. V3 stated that V11 told her that R1 should have been 1:1. V3 stated the facility was not aware of that and the hospital that R1 came from did not report that to the facility staff. R1's Medication Administration Record shows he received tylenol 650 mg (milligram) for pain rated at a 5/10 on June 14, 2025. R1's Progress Notes dated June 15, 2025, by V8 RN shows, At approximately 11:30 AM, the resident's daughter arrived at the facility and informed the nurse on duty that the resident was experiencing pain on the right side near the rib area, as well as in both hips. Nurse Practitioner ordered a stat bilateral rib x ray and bilateral hip x ray. R1's Radiology Results Report dated June 15, 2025, shows, Minimally displaced fracture of the right eighth rib laterally. The facility's Accidents and Supervision policy dated 2024 shows, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents.

Based on interview and record review, the facility failed to administer medications as ordered by the physician for one of six residents (R1) reviewed for medications in the sample of six. The findings include: R1's Discharge Instructions from the local hospital dated June 13, 2025, shows R1 was admitted to the local hospital on June 4, 2025, with diagnoses including wet gangrene, osteomyelitis, and dementia. Amoxicillin-clavulanate (Augmentin 500 mg(milligram)-125 mg oral tablet/antibiotic) one tablet every eight hours with next dose due on June 13, 2025, at 5:00 PM was ordered by the discharging physician. R1's Physician Orders shows an order was entered for Augmentin one tablet three times per day for toe amputation with a start date of June 13, 2025. R1's Physician Orders show that R1 was admitted to the facility on [DATE]. R1's Medication Administration Record shows Augmentin was not administered until June 15, 2025, at 9:00 AM. On June 26, 2025, at 11:26 AM, via telephone interview with V2 Director of Nursing (DON), V2 stated R1's Augmentin was not delivered yet when the day nurse came on June 14, 2025. V2 stated the day nurse went to the facility's convenience box to look for Augmentin, but did not know the facility's convenience box had Augmentin in the box. V2 said R1's Augmentin was not delivered until the evening of June 14, 2025. V2 stated the facility's convenience box does contain Augmentin. At 11:47 AM, V3 Assistant Director of Nursing (ADON) stated V8 RN updated R1's Augmentin order on June 14, 2025, because the pharmacy said the medication was not available. R1's Administration Notes dated June 14, 2025, at 8:59 AM and 11:18 AM shows the Augmentin was not available. The facility's Medication Administration Policy dated 2025 shows, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on interview and record review the facility failed to ensure residents were free of misappropriation of money for 4 of 4 residents (R1-R4) reviewed for misappropriation of property in the sample of 4. The findings include: 1. On 6/4/25 at 9:30 AM, R1 said that one night around midnight she was sleeping in bed when she awoke to a tall African American female going through her top nightstand drawer. R1 said that she said Hi to her and she immediately left the room. R1 said that that morning she checked her nightstand drawer and noticed her money missing. R1 said that she notified the staff, and they took care of it and she has not seen that staff member since. R1 said that she gets $60 a month and saves it in her top drawer of her nightstand. On 6/4/25 at 10:07 AM, V4 (Social Service Director) said that on 5/23/25, R1 was brought to her by a nurse and R1 said that she was missing around $200. V4 said that R1 told her that she saw a tall African American female in her room going through her belongings and the next morning is when she noticed the money was missing. On 6/4/25 at 10:35 AM, V3 (Assistant Director of Nursing) said that R1 is alert and oriented. V3 said that after they heard about the missing money, an investigation was initiated immediately and V8, Certified Nursing Assistant (CNA) was identified as the perpetrator due to her being R1's CNA that night and fit the description of who R1 described. V3 said that R1 discussed the incident with multiple staff members and the police, and the incident description was unchanged. On 6/4/25 at 10:31 AM, V2 (Director of Nursing) said that based on R1's description of who was in her belongings and V8 being assigned R1 the morning of 5/23/25, she felt strongly that V8 took the money so V8 was terminated. On 6/4/25 at 10:12 AM, V1 (Administrator) said that she interviewed V8 and V8 denied ever going into R1's room during her shift on 5/23/25. V1 said that V8 said that she checked on V8 by going to the doorway and looking in at her and was never by her personal belongings. V1 said that through her investigation, it was determined that there was money missing from R1, V8 was assigned to R1 that evening, V8 fit the description that R1 gave and via video footage, V8 did enter R1's room on 5/23/25 so V8 was terminated. The facility's undated Final Investigation Report shows, [R1] reports that on 5/23/25 at about 12 am she saw a tall African American female staff going through her personal items. Resident states that when she asked the staff what she was doing, the staff left the room. Resident reports that she is missing $200 in cash post incident. Staff schedule reviewed and CNA [V8] placed on suspension pending investigation .After full investigation it was determined that [R1] does keep her own personal money in her room at the bedside. Resident had a total of $240 wrapped in two money wraps with equal amounts in each wrap. The resident states that $30 was left in singles, however she states she originally only had big bills. The total amount determined to be missing is $210 [V8] fits the description provided by the resident and was assigned to [R1] for the shift in question [V8] has been terminated 2. The facility's Undated Final Incident Report related to allegation of missing money from [R4] shows, [R4] made an allegation of missing money from her room Upon investigation, [R4]'s daughter .reported to the Social Services Director that resident was missing $46 from her purse on Tuesday April 1. There were two enveloped, each with $23 inside for [R4] to get her hair done and pay the beautician. Per [R4]'s Daughter the money was in her room on March 19, 2025 and was noticed missing on March 29, 2025 when [R4] went to get her hair done .On Friday April 4, [R4]'s daughter reported to Social Service Director that [R4] had 4 envelopes of money totaling $86 in a zipper pocket of her purse that was located in her rollator and they were missing On 6/4/25 at 12:08 PM, V2 (Assistant Director of Nursing) said that R4's daughter brings in money for her and puts it in envelopes. V2 said that when R4 went to pay for her hair appointment, she noticed the money was missing. R4's daughter did not report the incident at that time and brought in more money in envelopes. V2 said that after the money came up missing for the second time, R4's daughter reported it to the previous Social Service Director. 3. On 6/4/25 at 12:00 PM, R2 said that she did have money come up missing out of her bedside dresser drawer that her friend had brought her but had never seen anyone going through her personal belonging or taking her money. The facility's undated Final Incident Report shows, [R2] reported during the resident interview process on April 9 that last week she had $35 come up missing that her POA (Power of Attorney) had brought her to buy pop and snacks with [R2]'s POA .reported that she had left $35 for [R2] in her bedside nightstand. On 6/4/25 at 12:43 PM, V4 (Social Service Director) said that she was conducting resident interviews for different theft investigation when R2 told her that she was missing $35. V4 said that her personal belongings were searched for the money, but nothing was found. V4 said that she contacted R2's POA and the POA verified that she did bring R2 $35. 4. On 6/4/25 at 12:35 PM, R3 said that he had $40 missing from his pouch that he carries around. R3 said that he had never seen anyone going through his personal belonging or taking his money and he keeps his pouch with him at all times. R3 said that he puts the pouch on his wheelchair next to his bed when he sleeps at night. The facility's undated Final Incident Report shows, On Thursday, April 10, [R3] came to the Life Enrichment office and reported to [V4], that he had money missing totaling around $40 When asked on April 9, [R3] reported no missing items or money. Staff were interviewed and confirmed that [R3] had money in his pouch on April 9 but were unaware of the amount [R3]'s room was searched, and no money was found. On 6/4/25 at 12:43 PM, V4 said that R3 is alert and oriented, and he keeps his money and important things in a pouch. V4 said that R3 came to her and said that he went to use his money at the vending machine and noticed that it was missing. V4 said that she does remember that he had money prior to that because she routinely takes him to the vending machine. On 6/4/25 at 12:43 PM, V2 (Director of Nursing) said that misappropriation of a resident's money is abuse and abuse should not happen at the facility. The facility's undated Abuse, Neglect and Exploitation Policy shows, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

Based on interview and record review the facility failed to implement their Abuse Policy regarding reporting and investigating an alleged misappropriation of money for 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4. The findings include: A Quality Improvement Form dated 4/1/25 shows that R4's daughter reported to V9 (Previous Social Service Director) that she left two envelopes containing $23 for her to pay to get her hair done. The envelopes were in the room on 3/19/25 and noticed both missing on 3/22/25. The form shows that the administrator was notified. A Quality Improvement Form dated 4/4/25 shows that R4's daughter reported that the resident was missing 4 envelopes of money totaling $86 that were in a zipper pocket of her purse that was located in her rollator walker. The form shows that the administrator was notified. An untitled document dated 4/7/25 to Illinois Department of Public Health (IDPH) shows that R4 reported that she has had money missing, an investigation has been initiated and a five-day final is to follow. The undated Final Investigation related to allegation of missing money from R4 shows, Upon investigation, [R4]'s daughter .reported to the Social Services Director [V9] that resident was missing $46 from her purse on Tuesday April 1. There were two envelopes, each with $23 inside for [R4] to get her hair done and pay the beautician. Per [R4]'s Daughter the money was in her room on March 19, 2025, and was noticed missing on March 29, 2025 when [R4] went to get her hair done [V9] called Administrator [V10]. [V9] reported to [V10] about the allegation of [R4]'s missing $46 On Friday April 4, [R4]'s daughter reported to Social Service Director [V9] that [R4] had 4 envelopes of money totaling $86 in a zipper pocket of her purse that was located in her rollator and they were missing [V9] completed a Grievance Form to notify [V10] of additional funds missing On April 7, during leadership meeting, Social Service Director, [V9], reported to IDT (Interdisciplinary Team) regarding [R4]'s missing money. Director of Nursing [V2] and [V10], Administrator, immediately initiated full investigation. On 6/4/25 at 12:08 PM, V2 (Director of Nursing) said that she was informed about R4's missing money for the first time on 4/7/25 (6 days after the allegation) during their morning meeting. V2 said that V9 gave her report of what was going on in the facility and she said that R4 was missing money. V2 said that the allegation was not reported to IDPH nor investigated until she heard about it on 4/7/25. V2 said that the facility should always follow their Abuse Policy for any allegations of abuse. V2 said that misappropriation of money is abuse and should not happen. V2 said that all allegations of misappropriation of money should be reported immediately to the administrator and to IDPH and a full investigation should be started immediately. The facility's undated Abuse, Neglect and Exploitation Policy shows, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property The facility will have written procedures that include: Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

Based on interview and record review the facility failed to ensure that an alleged misappropriation of resident money was reported immediately to the State Survey Agency for 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4. The findings include: A Quality Improvement Form dated 4/1/25 shows that R4's daughter reported to V9 (Previous Social Service Director) that she left two envelopes containing $23 for her to pay to get her hair done. The envelopes were in the room on 3/19/25 and noticed both missing on 3/22/25. The form shows that the administrator was notified. A Quality Improvement Form dated 4/4/25 shows that R4's daughter reported that the resident was missing 4 envelopes of money totaling $86 that were in a zipper pocket of her purse that was located in her rollator walker. The form shows that the administrator was notified. An untitled document dated 4/7/25 to Illinois Department of Public Health (IDPH) shows that R4 reported that she has had money missing, an investigation has been initiated and a five-day final is to follow. The undated Final Investigation related to allegation of missing money from R4 shows, Upon investigation, [R4]'s daughter .reported to the Social Services Director [V9] that resident was missing $46 from her purse on Tuesday April 1. There were two envelopes, each with $23 inside for [R4] to get her hair done and pay the beautician. Per [R4]'s Daughter the money was in her room on March 19, 2025 and was noticed missing on March 29, 2025 when [R4] went to get her hair done [V9] called Administrator [V10]. [V9] reported to [V10] about the allegation of [R4]'s missing $46 On Friday April 4, [R4]'s daughter reported to Social Service Director [V9] that [R4] had 4 envelopes of money totaling $86 in a zipper pocket of her purse that was located in her rollator and they were missing [V9] completed a Grievance Form to notify [V10] of additional funds missing On April 7, during leadership meeting, Social Service Director, [V9], reported to IDT (Interdisciplinary Team) regarding [R4]'s missing money. Director of Nursing [V2] and [V10], Administrator, immediately initiated full investigation. IDPH was notified with initial report On 6/4/25 at 12:08 PM, V2 (Director of Nursing) said that she was informed about R4's missing money for the first time on 4/7/25 during their morning meeting. V2 said that V9 gave her report of what was going on in the facility and she said that R4 was missing money. V2 said that the missing money should have been reported immediately to V1 and herself and an initial report should have been sent to IDPH immediately. V2 said that all allegation of misappropriation of money should be reported immediately to the administrator and to IDPH. The facility undated Abuse, Neglect and Exploitation Policy shows, The facility will have written procedures that include: Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury

Based on interview and record review the facility failed to initiate an investigation of an alleged misappropriation of money 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4. The findings include: A Quality Improvement Form dated 4/1/25 shows that R4's daughter reported to V9 (Previous Social Service Director) that she left two envelopes containing $23 for her to pay to get her hair done. The envelopes were in the room on 3/19/25 and noticed both missing on 3/22/25. The form shows that the administrator was notified. A Quality Improvement Form dated 4/4/25 shows that R4's daughter reported that the resident was missing 4 envelopes of money totaling $86 that were in a zipper pocket of her purse that was located in her rollator walker. The form shows that the administrator was notified. An untitled document dated 4/7/25 to Illinois Department of Public Health (IDPH) shows that R4 reported that she has had money missing, an investigation has been initiated and a five-day final is to follow. The undated Final Investigation related to allegation of missing money from R4 shows, Upon investigation, [R4]'s daughter .reported to the Social Services Director [V9] that resident was missing $46 from her purse on Tuesday April 1. There were two envelopes, each with $23 inside for [R4] to get her hair done and pay the beautician. Per [R4]'s Daughter the money was in her room on March 19, 2025, and was noticed missing on March 29, 2025 when [R4] went to get her hair done [V9] called Administrator [V10]. [V9] reported to [V10] about the allegation of [R4]'s missing $46 On Friday April 4, [R4]'s daughter reported to Social Service Director [V9] that [R4] had 4 envelopes of money totaling $86 in a zipper pocket of her purse that was located in her rollator and they were missing [V9] completed a Grievance Form to notify [V10] of additional funds missing On April 7, during leadership meeting, Social Service Director, [V9], reported to IDT (Interdisciplinary Team) regarding [R4]'s missing money. Director of Nursing [V2] and [V10], Administrator, immediately initiated full investigation. On 6/4/25 at 12:08 PM, V2 (Director of Nursing) said that she was informed about R4's missing money for the first time on 4/7/25 during their morning meeting. V2 said that V9 gave her report of what was going on in the facility and she said that R4 was missing money. V2 said that the missing money should have been reported immediately to V1 and herself and an investigation should have been started immediately. V2 said that all allegation of misappropriation of money should be reported immediately to the administrator and a full investigation should be started immediately. The facility undated Abuse, Neglect and Exploitation Policy shows, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

Based on observation, interview, and record review, the facility failed to identify areas of pressure for 2 of 3 residents (R45, R56) reviewed for pressure in the sample of 24. This failure resulted in R45 developing two stage 4 pressure injuries, one on each heel, requiring surgical debridement to remove non-viable tissue, and R56 developing an unstageable pressure injury to her left hip requiring debridement. The findings include: 1. R45's Admission Record, provided by the facility on 7/11/24, showed she had diagnoses including a stage 4 pressure ulcer of right heel, and a stage 4 pressure ulcer of left heel, protein-calorie malnutrition, acute embolism, and thrombosis of unspecified deep veins of left lower extremity, and bilateral primary osteoarthritis of knees. R45's 6/10/24 facility assessment showed R45 had severe cognitive impairment, required substantial/maximal assistance from staff for toileting, personal hygiene, upper and lower body dressing, rolling side-to-side in bed, and transfers. R45's care plan initiated on 5/1/24, showed she had the potential for impaired skin integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk. High risk for pressure ulcer. The care plan showed Evaluate skin integrity .Provide skin care per facility guidelines and as needed. On 7/11/24 at 9:24 AM, V11 (Wound Nurse/LPN) performed a dressing change to the wounds on R45's bilateral heels. V11 stated he thinks the wounds on R45's heels were there for a while before he noticed them and did his assessment. V11 stated no one notified him of the wounds. V11 stated R45 has MRSA (Methicillin-resistant Staphylococcus aureus-an infection that's become resistant to many of the antibiotics used to treat ordinary staph infections) in her wounds and was currently receiving antibiotics. The wound on R45's right heel was about the size of a dime. The border of the wound had white, moist tissue all around the edge of the wound bed. V11 cleaned the wound with normal saline-soaked gauze, dried the area, and applied an ointment used to remove damaged tissue from the wound bed. V11 applied calcium alginate dressing (a dressing that can absorb excess moisture and promote wound healing) to the wound, then covered the wound with foam dressing and wrapped R45's heel and foot with kerlix gauze. V11 removed the dressing from R45's left heel. R45's left heel was at least twice the size of the right heel. The wound bed was not as red/beefy looking like the right heel. V11 cleansed R45's left heel wound and applied the same treatment as the right heel. At 11:54 AM, V11 said both of R45's heel wounds were identified at the same time. V11 stated he thinks he saw R45's skin sheet and it showed something on her heels, so he checked her heels and saw the open areas. At 12:07 PM, V11 stated he would expect staff to identify an area of skin concern prior to it becoming a stage IV pressure ulcer and report it to him right away so he could assess it and start interventions. V11 stated no staff reported it to him. he saw the skin sheet in his mailbox on 6/4/24 and assessed her. When asked about his initial assessment identifying R45's wounds as unstageable. V11 stated he does not stage the wound; he lets the wound doctor/nurse practitioner stage the wounds. V11 provided surveyor with R45's skin sheet dated 6/3/24 showing both heels circled. The skin sheet showed Open Wound. V11 was asked to provide skin sheets for R45 prior to the 6/3/24 skin sheet. No additional skin sheets were provided prior to exiting the facility. R45's Wound Observation Tool, electronically signed by V11 on 6/5/24, showed a facility acquired unstageable pressure area to her left heel effective as of 6/3/24 measuring 2.2 cm (centimeters) long x 2.5 cm wide x 0.1 cm depth. Infection suspected. Moderate serous drainage, odor, and inflammation/induration (localized hardening of soft body tissue) present. R45's Wound Observation Tool, electronically signed by V11 on 6/5/24, showed a facility acquired unstageable pressure area to her right heel effective as of 6/3/24 measuring 2.7 cm in length x 4.0 cm in width x 0.1 cm in depth. Infection suspected. Moderate serous drainage, odor, and inflammation/induration present. R45's 6/7/24 Initial Wound Evaluation and Management Summary performed by V13 (facility contracted Wound Doctor) showed a stage 4 pressure wound of the right heel measuring 2.3 cm x 2.2 cm x 0.1 cm. The evaluation also showed a stage 4 pressure wound of the left heel measuring 3.0 cm x 4.0 cm. The evaluation showed the depth of the wound was not measurable due to presence of nonviable tissue and necrosis (thick adherent black non-viable skin tissue). The evaluation showed 100% necrotic tissue (eschar). A surgical debridement procedure was performed to remove the thick adherent eschar and devitalized tissue, establish the margins of viable tissue, and remove infected tissue. V13's procedure note showed surgical excision of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.3 cm to R45's left heel. The evaluation also showed a deep wound culture of the stage 4 pressure wound on R45's left heel was recommended by V13 on 6/7/24. R45's 7/9/24 Wound Evaluation and Management Summary by V13 showed the pressure wound to her left heel measured 2.5 cm x 2.3 cm x 0.2 cm, and the pressure wound to her right heel measured 0.9 cm x 0.8 cm x 0.2 cm. The evaluation showed MRSA positive wound culture to R45's right heel. The evaluation also showed X-Ray pending on pressure wound of the heel as of 7/9/24. The Radiology Results Report dated 7/9/24 showed X-rays were performed on R45's left and right heels. The results showed no osteomyelitis (inflammation of the bone caused by infection spreading from nearby tissue) was seen. On 7/11/24 at 12:56 PM, V2 (Director of Nursing) stated the CNAs (Certified Nursing Assistants) usually alert first regarding skin concerns and put the information on the resident's shower sheet. V2 stated the CNAs have to report the concern to her. She (V2) lets V11 (Wound Nurse) know, and he will do an assessment. V2 stated she would expect the nurses and the CNAs to identify an area of skin concern, prior to it becoming a stage 4 that looked infected. V2 added, Clearly there would have been something there prior. On 7/12/24 at 8:59AM, V18 (Nurse Practitioner) stated, (R45) is definitely at increased risk for pressure ulcers with all of her comorbidities. She is dependent on the staff for her cares and repositioning so this should have been caught way sooner. I got a call from an agency nurse that they found pressure ulcers and I just couldn't believe it. I feel bad because I thought we were on top of her care and obviously the skin checks weren't being done otherwise we would have caught it sooner. It is unacceptable to find a wound when it is at a stage 4. At this point, we are back-peddling and trying to play catch-up with her wound care to try and heal it because it is more advanced. When you catch a wound in its earlier stages it is much easier and quicker to heal but now this will take some time and diligence with wound care. Weekly skin checks should be done on all residents that are at high risk for skin breakdown and these 2 residents are high risk residents. (R56) already has a surgical wound on her right hip and now we have to try and heal her left hip pressure ulcer. It makes me sad that these 2 residents are going through this because I thought we were really on top of their care. Both of these wounds should have been identified sooner and I believe they would have been if we were doing the weekly skin checks and observing their skin more closely during daily cares. R45's June 2024 Medication Administration Record (MAR) showed she was started on Keflex 500 mg (milligrams) every 12 hours for 10 days on 6/4/24, for prophylaxis for wound infection. The June MAR showed that order was discontinued, and she was started on Bactrim DS 800-160 mg twice daily on 6/11/24 through 6/21/24 for MRSA in wound. R45's June 2024 Treatment Administration Record showed an order on 6/3/24 to apply santyl (a debridement ointment) and cover with a dressing to bilateral heels. The TAR showed on 6/5/24 orders were changed to Cleanse with normal saline, pat dry, apply Santyl, apply alginate calcium once daily and as needed. Gauze island with border dressing, apply once daily and as needed for right and left heels. The facility's February 2023 policy and procedure titled Skin Audits by Nursing Assistants showed It is the facility's policy to communicate changes in skin condition to appropriate personnel as part of their systematic approach for pressure injury prevention and management. 1. Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. 2. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. 3. Skin conditions that shall be reported include but are not limited to: a. Redness b. Bruising c. Swelling d. Rashes, hives e. Blisters (clear or blood-filled) f. Skin tears g. Open areas, ulcers, lesions. 41639 2) R56's electronic face sheet printed on 7/11/24 showed R56 has diagnoses including but not limited to dementia with behaviors, sciatica, bipolar disorder, osteoarthritis, pressure ulcer of left hip-unstageable, and non-pressure chronic ulcer of left buttock. R56's facility assessment dated [DATE] showed R56 has no cognitive impairment and has no pressure injuries. R56's care plan dated 6/19/24 showed, The resident has pressure ulcer or potential for pressure ulcer development related I have 2 wounds and am being seen by the wound doctor/nurse. (SITE 6) unstageable (due to necrosis) of the left hip. 6/21/24 this is now a stage 4 .Follow facility policies/protocols for the prevention/treatment of skin breakdown. Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage R56's physician's orders for May 2024 showed no orders for R56 to have weekly skin assessments. R56's May 2024 skin checks showed R56 had 1 skin check for the month of May on 5/30/24 (the same day R56's unstageable wound was identified). R56's wound assessment dated [DATE] showed, Unstageable left hip pressure ulcer. 100% thick adherent black necrotic tissue. 2.5x3.6 cm (centimeters). R56's wound assessment dated [DATE] showed, Stage 4 left hip pressure ulcer 2.9 x 1.3 x 0.2 cm . moderate serous exudate (clear drainage) Surgical Excision Debridement Procedure: Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. On 7/11/24 at 2:08PM, V11 (wound care nurse) stated, (R56's) pressure ulcer started as a blister that was not opened. I can't say how it developed but we applied a foam dressing until the wound care nurse practitioner could evaluate it on 5/31/24. The wound care physician debrided it and found it to be a stage 4 pressure ulcer. I was notified by the nursing staff on 5/30/24 that she had the blister, so I went down and assessed it and notified the wound care nurse practitioner and she came and saw her on 5/31/24. The only weekly assessments I have is the one I gave you for 5/30/24. The staff should have been doing weekly skin assessments on (R56) due to her high risk for skin breakdown and existing surgical wound on her other hip. I can't say why they didn't do the weekly assessments but perhaps we could have caught this before it developed into an unstageable wound and had to be debrided. The facility's policy titled, Pressure Injury Prevention and Management dated February 2023 showed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .e. nursing assistants will inspect the skin during bath and will report any concerns to the resident's nurse immediately after the task .

Based on observation, interview, and record review, the facility failed to perform weekly weights as ordered by a physician for 1 of 7 residents (R58) reviewed for nutrition in the sample of 24. This failure resulted in R58 experiencing a significant weight loss of 7.96% within a 3-month period before it was identified by facility staff and R58 was referred to the facility dietician. The findings include: R58's electronic face sheet printed on 7/11/24 showed R58 has diagnoses including but not limited to traumatic subdural hemorrhage, type 2 diabetes, unspecified protein-calorie nutrition, anemia, and history of pneumonia. R58's facility assessment dated [DATE] showed R58 has severe cognitive impairment and has weight loss of 5% or more in the last month or 10% or more in the last 6 months. R58's care plan contained no problems or interventions for R58's weight loss. R58's physician's orders dated 8/24/23 showed, Weight every day shift every Thursday. R58's medication administration record (MAR) for April 2024 showed R58 weighed 120.6lbs on 4/19/24. No weight was obtained for R58 the following week on 4/25/24. R58's MAR for May 2024 showed no weight was obtained for R58 on 5/2/24. 3 weeks passed without weekly weights being obtained for R58. On 5/9/24, R58 weighed 114lbs. This was a 5.47% weight loss within less than one month. R58's weight as of 7/6/24 was 111lbs which is an additional 3lb weight loss since May 2024. R58's dietician assessment dated [DATE] showed, Weight 5/6/24 114lbs. comparative weight loss 10.5% within 6 months Weight no lower desired. On 7/11/24 at 1:54PM, V2 (Director of Nursing) stated, The dietician is here at least once a week. I believe she is seeing (R58). We have a risk meeting every week and review all of the weekly weights and any concerns. For this week, (R58) is not on the list that the dietician reviewed. I can see where this is an issue. Staff should have been documenting the weights and obtaining them as ordered. (V17-lead certified nursing assistant) is the one who puts the weight list out for the aides on the floor, so they know who needs to be weighed. V17 then entered the room for the interview and stated she was unaware that R58 needed to be a weekly weight and she has not been notifying staff to weigh her weekly; therefore, there are no weekly weights being done for R58. On 7/11/24 at 2:38PM, V13 (Dietician) stated, I go through the weights each month and look at who needs to be assessed by me. (R58's) nurse practitioner wanted me to see her and have weekly weights done on her because she has lost more weight. I haven't followed up on the last weight they were supposed to do earlier this week. (R58 had no weekly weight done as of 7/11/24). In May she was on my list, so I added a supplement for her. If she triggers on the weight change or MDS (minimum data set) then I would see her. Whatever comes up on the weights and exception report on (computer system) is who I see, and I don't recall her being on that. Obviously if there were weights ordered weekly that's what they should have been doing so we could have maybe caught this prior to it becoming significant. I suppose she wouldn't show up on the weight report if they aren't doing the weights and entering them so that is also a problem. The facility's policy titled, Weight Monitoring dated February 2023 showed, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .Weight can be a useful indicator of nutritional status. Significant unintended changes in weight or insidious weight loss may indicate a nutritional problem .4. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status .5. A weight monitoring schedule will be developed upon admission for all residents: c. residents with weight loss-monitor weight weekly.

Based on interview and record review, the facility failed to complete skin assessments for 4 weeks prior to identifying a resident's pressure injury that was unstageable when identified. This failure applied to 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 4. The facility's failure to assess the resident's skin led to staff not identifying the resident's pressure injury until it was unstageable and then progressed to a Stage 4, which required wound debridement. The findings include: R1's face sheet shows R1 is [AGE] year-old with diagnoses that include diabetes mellitus, liver cirrhosis and stroke. R1's facility assessment dated [DATE] show R1 has moderate cognitive impairment. R1's Braden scale (predicting pressure score risk), dated 11/3/23, shows R1 is at risk for developing pressure ulcers/injuries. R1's Skin Evaluation dated 11/3/23 shows a skin issue-pressure ulcer/injury, location-coccyx, unstageable measuring 2.0 centimeters (cm) x 1.0 cm, wound bed with slough (yellow white material in the wound bed). A Wound Physician note dated 11/8/23 shows R1's pressure injury was now at a stage 3 measuring 1.8 cm x 0.6 cm x 0.3 cm. to sacral area (coccyx). A Wound Physician note dated 12/13/23 shows R1's sacral wound had deteriorated to stage 4 measuring 2.0 cm x 0.3 cm x 0.3 cm and a surgical excisional wound debridement done due to necrotic tissues in the wound. On 4/1/24 at 11 AM, V5 (R1's granddaughter-POA-power of attorney) stated R1 was now in the hospital due to R1's large wound in her back. The wound in R1's back had developed at the nursing home. R1 was now at a local hospital on hospice as R1's family decided for R1 to be made comfortable. V5 stated during her visits, R1 would be laying on her back for long periods of time. V5 stated she was aware of R1's wound but was not aware how large the wound was, the bone was exposed. V5 stated the hospital told her that it was possible the wound was infected. R1's care plan with date initiated 11/6/23 shows: Stage 4 sacrum with goal: wound will show sign of improvement and remain free from deterioration or infection, intervention to include: educate the resident/family caregivers as to the causes of skin breakdown including transfer/ positioning requirements, good nutrition, and frequent repositioning. On 4/1/24 at 1PM, V4 (Facility Wound Physician) stated she had seen R1's facility-acquired sacral wound weekly at the facility until the week prior to R1 being sent to the hospital. R1's wound had gotten worse as the depth was greater. V4 stated she had debrided R1's wound more than once and adjusted R1's wound treatments. V4 stated she cannot say if R1's wound was avoidable or unavoidable. V4 stated residents with pressure injuries should be turned and repositioned every 2 hours- offloading is important for wound healing. On 4/3/24 at 12PM V2 (Director of Nursing-DON) confirmed with this surveyor that R1 had no skin assessments performed and signed off by nurses for approximately 4 weeks prior to the discovery of R1's sacral wound as unstageable to stage 3 and eventually declined to stage 4. (R1's last skin assessment was done on 10/3/23 then not again until 11/3/23 when R1's sacral wound was discovered.) V2 DON stated she will again implement skin assessments weekly and as needed. The Facility Policy Entitled Pressure Injury Prevention and Management (undated) show, The facility is committed to the prevention of avoidable pressure injuries unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcer/injuries.

Based on observation, interview, and record review the facility failed to implement dressing change orders for a resident admitted with an open wound. This applies to 1 of 4 residents (R501) reviewed for pressure/treatment interventions in the sample of 6. The findings include: On 5/6/2024 at 9:33AM, R501 stated she was admitted in the last two weeks and came in with a wound on her backside. On 5/6/2024 at 10:25AM, R501 stated she is unsure when the dressing change was started after she was admitted to the facility. On 5/6/2024 at 12:16PM, V7 Wound Care Nurse stated he was not told about the resident's wound upon admission. V7 stated if a wound is identified by the admitting nurse, they can call the primary physician and have orders placed for the resident until the wound doctor rounds on the patient. On 5/6/2024 at 12:47PM, V4 Registered Nurse (RN) stated she took care of R501 on 4/27/2024 and 4/28/2024. V4 stated she did not do a dressing change on R501 because there was no order to do one on the Treatment Administration Record (TAR) or Medication Administration Record (MAR). V4 stated she did not see R501's backside when she took care of her. V4 stated she did not receive any report from the night shift nurse that R501 had a wound. On 5/6/2024 at 12:53PM, V3 Wound Care Doctor stated I saw the resident for the first time on 5/3/2024. V3 stated if a resident comes in with or has an open area/wound staff should address it that same day it was identified. V3 stated she is available on days she is not rounding at the facility for a telemedicine visit and is willing to put in orders for a resident. V3 stated it the physician's job to stage the wound. R501's admission Record shows R501 was admitted to the facility on [DATE]. R501's Minimum Data Set, dated [DATE], Section C shows a BIMS (brief interview for mental status) score of 14 cognitively intact. R501's admission Progress Notes on 4/26/2024 show R501 was admitted with an open wound, location coccyx, no dimensions listed. R501's Order Summary Report active as of 5/6/2024 shows an order for buttock wound. Cleanse with normal saline, pat dry, apply santyl, alginate calcium and cover with 4x4 foam dressing daily and prn (as needed) started on 5/3/2024. R501's Order Summary Report does not show any orders for wound dressing changes prior to 5/3/2024. R501's TAR dated 5/1/2024 to 5/31/2024 shows an order buttock wound. Cleanse with normal saline, pat dry, apply santyl, alginate calcium and cover with 4x4 foam dressing daily and prn/as needed one time per day for buttock wound started on 5/3/2024. R501's TAR dated 4/1/2024 to 4/31/2024 shows no orders for dressing changes. The facility provided Wound Observation Tool dated 5/3/2024 shows a stage 4 pressure ulcer 1.5cm x 1 cm x 0.1 cm completed by V7 on 5/4/2024 lists the wound as First Observation, no reference under Overall Impression.

Based on observation, interview, and record review, the facility failed to have pressure relieving devices in place and failed to perform ordered treatments for a resident with pressure injuries for one of three residents (R1) reviewed for pressure injuries in the sample of eight. This failure contributed to R1's worsening pressure injuries. The findings include: R1's Order Summary Report dated December 27, 2023, shows R1 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, urinary tract infection, and restlessness and agitation. Orders for apply pressure relieving mattress on bed and pressure relieving cushion on chair every shift and float heels while in bed were entered on February 28, 2023. R1's Pressure Injury Risk dated November 3, 2023; shows she is at risk for developing pressure injuries. R1's Care Plan initiated on May 1, 2023, shows ensure that pressure relieving boots are on resident at all times while in bed. R1's Wound Evaluation and Management Summary dated November 20, 2023, shows R1 had a Stage III pressure injury on her sacrum that measured 1.2 cm long by 0.5 cm wide and 0.3 cm deep and an unstageable deep tissue injury to her right heel that measured 2.0 cm long by 4.0 cm wide. Recommendations were to off load the wounds and float heels in bed. Treatment for R1's sacrum wound was alginate calcium with silver, gauze island dressing daily and skin prep to the peri wound daily. Treatment for R1's unstageable right heel wound was betadine apply once daily for 30 days. R1's Treatment Administration Record (TAR) dated November 1, 2023-November 30, 2023, shows R1 treatment to her sacrum was not documented as being done on November 24-26, 2023, and November 28, 2023. R1's TAR shows her treatment was not documented as being done on November 25-26, 2023, and November 28-30, 2023. R1's Wound Evaluation and Management Summary dated December 20, 2023, shows R1 has a stage IV pressure injury on her sacrum that measures 4.0 cm long by 2.5 cm wide and 0.3 cm deep. Treatment recommendations include alginate calcium with silver and gauze island with border dressing once daily and as needed. Off load wound. R1 has a stage III pressure injury to her right heel that measures 1.5 cm long by 3.0 cm wide, and 0.3 cm deep. Treatment recommendations for alginate calcium with silver, gauze roll, and skin prep daily and as needed. Off load wound, float heels in bed. On December 26, 2023, at 11:18 AM, R1 was sitting in her wheelchair. There was no cushion in R1's wheelchair. R1 said her buttocks hurt. R1 said she used to have a cushion in her wheelchair. At 2:00 PM, R1 was taken to the bathroom to be toileted. V10 CNA (Certified Nursing Assistant) said R1 got up in the wheelchair before breakfast. There was no cushion in R1's wheelchair. R1's right heel did not have a gauze roll in place. On December 27, 2023, at 10:20 AM, R1 was laying in bed. R1's heels were directly on the mattress. There still was no gauze roll in place to R1's right heel. V9 CNA said she does not remember R1 having a wheelchair cushion. On December 28, 2023, at 1:02 PM, V1 Administrator said R1's wheelchair cushion needed to be clean and another one was not put in place while it was getting cleaned. The facility's Wound Treatment Management policy dated 2023 shows, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The facility will follow specific physician order for providing wound care, and treatments will be documented on the treatment administration record or in the electronic health record. The facility's Pressure Injury Prevention and Management policy dated February 2023 shows, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Evidence based interventions for prevention will be implemented for all resident who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) and provide appropriate, pressure redistributing, support surfaces.

Based on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place and failed to supervise a resident with a history of falls for one of three residents (R1) reviewed for safety/supervision in the sample of eight. This failure resulted in R1 experiencing a fall that required a local emergency room transfer and sutures to her head. The findings include: R1's Order Summary Report dated December 27, 2023, shows she was admitted to the facility on [DATE], with diagnoses including history of falling, urinary tract infection, anxiety disorder, altered mental status, diabetic polyneuropathy, mood affective disorder, encephalopathy, and restlessness and agitation. R1's Fall Risk Evaluation dated November 27, 2023, shows R1 is at risk for falls, has had three or more falls in the past three months, is chair bound, has poor vision, and requires use of assistive devices. R1's Care Plan initiated March 14, 2023 shows R1 sustained a fall on March 13, 2023 while attempting to transfer from her wheel chair to the toilet unassisted, March 30, 2023 related to sliding out of the wheelchair, June 12, 2023 while attempting to transfer from the wheel chair to bed unassisted, September 20, 2023 while attempting to toilet herself unassisted, November 26, 2023 while trying to ambulate out of bed, and November 27, 2023 while trying to ambulate unassisted. Interventions/Tasks: Is at risk for falls due to history of falls and chronic ulcers of bilateral feet with necrosis of muscle. Resident has a history of not asking staff for assistance when needed and fall interventions are: provided 1:1 education on preventing additions falls that could result in serious injury, encourage to ask for assistance when help is needed. March 31, 2023-anti slip sheet placed under resident's wheelchair cushion. R1's Progress Notes dated December 19, 2023, at 11:28 AM and entered by V3 LPN (Licensed Practical Nurse) shows, [R1] went to her room by herself, advised her do not go to her bed, wait for the CNA (Certified Nursing Assistant). One PT (Physical Therapist) called that [R1] was on the floor. Called 911 at 9:55 AM. On December 27, 2023, at 11:10 AM, V3 LPN said R1 is alert but confused. V3 said R1 always screams for help. V3 said that R1 wanted to go to bed before her fall and V3 told R1 to stay near V3 while V3 finished passing out her morning medication pass. V3 said R1 wheeled herself to her room. V3 said she let V4 and V5 (both CNAs) know that R1 wanted to go to bed, but V4 and V5 were finishing up feeding residents. V3 said that V4 and V5 were very busy and she doesn't know if V4 or V5 went into R1's room prior to the fall. V3 said V6 Physical Therapist came and told V3 that R1 was on the floor. V3 went into R1's room and saw R1 on the floor laying on her right side and R1's head was on the ground. V3 said there was a lot of blood and called 911. V3 said R1 now has sutures in her head. V3 said that R1 has transferred herself in the past. On December 27, 2023, at 2:14 PM, V6 PT said he was walking past R1's room and saw her laying on the floor and immediately went and told V3. On December 27, 2023, at 1:50 PM, V4 CNA said he was helping another resident with a mechanical lift transfer with V5 CNA prior to R1's fall. V4 said right before they were getting ready to transfer the other resident, V3 LPN came into the resident's room and said that R1 was on the floor. V4 said that R1 was laying near the foot of her bed. V4 said he remained with R1. V4 said that prior to the fall, R1 was asking for her daughter and was not oriented. V4 said that V3 mentioned to him to put R1 back to bed, but V4 said he let V3 know that he was working with another resident. V4 said that there was blood around R1's head which was on the floor. V4 and him and V5 were trying to help other residents prior to R1's fall, because other residents were waiting. On December 27, 2023, at 2:17 PM, V5 CNA said her and V4 were working on the hall together. V5 said it was busy with just the two of them. V5 said R1 fell after breakfast and after V4 and V5 finished gathering the breakfast trays. V5 said her and V4 were in another resident's room when the nurse came in and said that R1 was on the floor in her room. V5 said she followed V3 and V4 into R1's room and saw that R1 was on the floor with her right face and right shoulder on the ground. V5 said that R1 was bleeding. V5 said V3 asked her to take care of the other residents that had a call light on, so she left R1's room. R1's emergency room visit notes dated December 19, 2023, shows R1 was seen due to fall and blunt head trauma. R1's medical doctor progress note dated December 20, 2023, shows, fall yesterday trying to stand unassisted, resulting in scalp laceration and emergency room visit. She was noted to have bruising/selling/pain to right hand on return, unsure if this was evaluated in the emergency room . She has bilateral periorbital hematomas. Discontinue sutures at seven days. On December 26, 2023, at 11:18 AM, R1 was observed sitting in her wheelchair in the dining room with other residents present, but no staff were present. There was no cushion or anti slip sheet in R1's wheelchair. R1 was calling out for help. R1 said her buttocks hurt. R1's entire face was covered in a yellow/blue color. R1 had a dressing intact to the middle of her forehead. R1 was trying to push against the table but was not able to. R1 was still yelling for help at 11:32 AM. At 11:39 AM, V10 CNA gave R1 some water to drink. At 12:29 PM, R1 was eating her lunch. No staff were present at this time. The facility's Fall Prevention Program dated October 2022 shows, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Implement universal environmental interventions that decrease the risk of resident falling, implement routine rounding schedule, monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.

Based on interview and record review the facility failed to clarify a resident's pain management orders with the primary care physician prior to administering additional opiate pain medications and failed to discontinue a residents pain patch. These failures resulted in R2 experiencing a mental status change, lethargy, and required emergent hospitalization for suspected opiate overdose. This applies to 1 of 6 residents (R2) reviewed for pain management in the sample of 13. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/10/23, when V20 (Registered Nurse/RN) failed to clarify R2's Morphine (pain medication) plan of care prescription from a pain consultant with her primary care physician prior to carrying out the order. R2 received 11 doses of morphine 15 milligrams (mg.) every 6 hours from 8/11/23 until 8/14/23. This was in addition to a Fentanyl 12 mcg (microgram)/hr (hour) patch that R2 was already receiving. On 8/14/23 an order was given by (V8) Nurse Practitioner to immediately decrease the scheduled dose of R2's morphine and to remove R2's Fentanyl pain patch. The pain patch was not removed until 8/15/23. The Immediate Jeopardy was identified on 10/18/23. V1 (Administrator) was notified of the Immediate Jeopardy on 10/18/23 at 10:20 AM. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/18/23 however, noncompliance, remains at a level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R2's face sheet shows she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: low back pain, and a fracture in her spine. R2's electronic medical record (EMR) shows she was discharged from the facility to an inpatient hospice center on 9/8/23. R2's EMR shows her weight on 8/3/23 was 110 lbs. R2's nursing progress notes show she went for an appointment with an outside provider V28 (consulting physician) on 8/10/23. A plan of service report for R2 completed by V28 on 8/10/23 shows his plan was to discontinue R2's scheduled Norco (pain medication) and add on Morphine 15 mg. every 6 hrs. and Voltaren 75 mg. (anti-inflammatory medication) every 12 hours. There is no mention in V28's report of being aware R2 was also receiving a Fentanyl (opiate pain medication) patch. R2's physician order summary shows the Morphine order was entered into the system using V19 (R2's primary care physician) as the prescribing doctor (not V28 the actual prescribing physician) and the medication began on 8/11/23. R2's nursing progress notes have no documentation that V19 was contacted prior to the facility starting the Morphine on 8/11/23. R2's Medication Administration Record (MAR) shows she received the following pain medications between 8/11/23 and 8/14/23 Fentanyl pain patch change every 3 days, 7 doses of diclofenac (generic for Voltaren), 4 lidocaine patches on in am and off in pm, and 11 doses of Morphine sulfate 15 mg. R2's nursing progress note completed by V31 (Nurse Practitioner) on 8/14/23 at 4:20 PM, states. Patient seen this morning for a rehab follow-up in her room laying in bed, daughter and son in law are at bedside visiting and are concerned she is lethargic and not very interactive and asking about her pain medication regimen. They mention she saw a back doctor last week who ordered Morphine and diclofenac. She is able to answer some of my questions but doesn't stay engaged and appears very lethargic. Discontinue Fentanyl patch, decrease MSO4 (Morphine) to 1/2 tablet every 8 hours due to lethargy. R2's physician order note states, Please take off Fentanyl patch today 8/14/23, pt (patient) is lethargic on current pain regimen. An EMAR note signed by V23 (RN) on 8/14/23 at 9:13 PM, documents unavailable to remove the Fentanyl patch. R2's nursing progress note completed by V20 on 8/15/23 states, At 10:55 AM, resident noted very lethargic, confused. Seen by {V8 Nurse practitioner} at the same time. New order, send to local community hospital ER (emergency room ) by 911. Resident sent to local community hospital ER at 11:07 AM via 911. A nursing progress note on 8/15/23 shows R2 was admitted to the hospital. R2's records from a local community hospital show the following: A physician History and Physical note completed on 8/15/23 shows R2 was admitted through the emergency department and was found to have Acute Encephalopathy- suspected incidental opioid overdose. The notes says that R2 was receiving large amounts of opiates at the skilled nursing facility and had both oral Morphine and Fentanyl patches applied. A hospital consultation notes for R2 completed on 8/16/23 states R2 had Opioid overdose because of cognition Morphine and Fentanyl. She became agitated over the past 24 hours, for which she received Ativan. R2's hospital records show her pain medications were adjusted and she returned to the facility on [DATE]. A Medication Error Reported completed on 8/15/23 by V2 (Director of Nursing) shows that R2's Fentanyl patch was not removed until 8/15/23 and was supposed to be removed on 8/14/23. On 10/16/23 at 11:36 AM, V2 said (R2) was seen by an outside provider and was on multiple pain medications prescribed by two different providers. She started experiencing altered mental status and went to the hospital. She was alerted by (V8) Nurse Practitioner who discovered the Fentanyl patch that was supposed to be removed on 8/14/23 was not removed. When she asked the nurse (V23) why the patch was still on she told her she didn't see the patch. On 10/17/23 at 12:13 PM, V2 said the nursing staff should have consulted with the R2's Primary Care Physician (V19) before starting the Morphine that was prescribed by V28. She said V8 was furious when she found out about the Morphine being started without consulting their office and (V19) first. V2 said she feels the Morphine was the cause for R2's altered mental status. On 10/16/23 at 3:08 PM, V8 (Nurse Practitioner) said R2 was experiencing a lot of back pain from a fracture but she was not aware of R2 being prescribed the high doses of Morphine until V31 (Nurse Practitioner) called her and told her about it. She said no one contacted their office from the facility about the Morphine and they should have before they started it. V8 said they would not prescribe that high of a dose of Morphine on top of a Fentanyl patch because of the risk of overdose and death could occur from Opiate overdose. V8 said when she saw R2 on 8/15/23 she was very lethargic, and she suspected a Opiate overdose as the cause and she also discovered the Fentanyl patch was still on her. She had the facility call 911 and sent her to the emergency room . On 10/17/23 at 9:35 AM, V19 R2's (Primary Care Physician) said he was not contacted by the facility about the Morphine orders. He said the facility should have called me prior to starting the medication because she was already on a Fentanyl pain patch, and I am not sure if the consulting physician (V28) knew that. V19 said he wasn't aware that the facility used his name as the prescribing physician for the Morphine, but he did not, and would have not ordered that pain medication because it is a risky medication. V19 said R2's lethargy was likely the result of the high dose of the pain medication Morphine and Fentanyl combined. On 10/17/23 at 9:25 AM, V20 (RN) said she carried out the Morphine order that V28 had prescribed without consulting V19. She said they facility nurses don't call to consult orders they just carry them out because they are from a physician. V20 said when R2 returned from the appointment she entered the Morphine orders in the computer using V19's name because she could not select V28 as he is not in their system since he is outside physician. She said after the initiation of the Morphine R2 did begin to have lethargy and they called to report it to the Nurse Practitioner. When this surveyor asked V20 if she was aware the facility policy states any outside provider orders should be clarified with the residents Primary Care Physician, she indicated she was not. On 10/17/23 at 11:10 AM, V22 (Licensed Practical Nurse/LPN) said it is the policy of the facility to clarify medication orders and a Morphine order should not just be started without clarifying it with the Primary Care Physician first. On 10/17/23 at 2:08 PM, V23 (RN) said she went to remove R2's pain patch after the Nurse Practitioner told her it needed to be stopped but she looked all over R2 and did not see it. V23 also said the nurses should always reconcile medication orders from an outside provider and not just start the medications. A pain policy was requested from the facility, and they provided the F697 citation text from the State Operations Manual/ SOM which states, The facility must ensure that pain management is provided to the residents who require such services, consistent with professional standards of practice . The facility provided policy titled Consulting Physician/Practitioner Orders says the facility should call the attending physician in a timely manner to verify consulting physician/practitioner orders. The Immediate Jeopardy that began on 8/10/23 was removed on 10/18/23 when the facility took the following actions to remove the immediacy: 1. All staff nurses were re-educated on the process of clarifying medication orders with the primary care physician. The process for dating, securing and removal of pain patches was also re-educated to all nursing staff and completed on 10/18/23. 2. All agency and float pool nurses will be educated about clarifying medication orders and pain patch removal and identification prior to the start of the shift. 3. The facility Medical Director and Director of Nursing have compiled a list and audited all charts of residents with current opioid pain medications to ensure doses are within appropriate levels. Completed on 10/18/23. 4. An emergency QA meeting was held on 10/18/23 and included the Medical Director. 5. Facility policies and procedures for pain management and opioid medication orders were reviewed. 6. The Director of Nursing will conduct audits weekly for 4 weeks, then monthly for 3 months to ensure compliance with opiate medications. These audits will also ensure that the Primary Care Physician was consulted prior to administration of medications from outside providers.

Based on interview and record review the facility failed to ensure residents were free from physical and verbal abuse. This failure resulted in R3 and R5 suffering mental anguish and psychosocial harm. This applies to 2 of 8 residents (R3, R5) reviewed for abuse in the sample of 13. The findings include: R3's face sheet shows she has diagnoses including anxiety disorder, heart failure, and lack of coordination. R3's cognition care plan initiated on 9/12/23 shows she is cognitively intact, has no apparent memory loss and is oriented. R3's care plan also shows she is able to recall and retain information such as events, directions, time and place of situations. R3's activity of daily living/ADL care plan initiated on 6/12/23 shows she has impaired balance and weakness and requires staff assistance with ADL's. On 10/16/23 at 9:40 AM, R3 said I have been in bed for a couple weeks following an incident where a CNA (Certified Nursing Assistant) who works for an agency was very rough with me. The CNA was very angry and mean spirited and when she was taking me to the bathroom, she ran my knee into the side of the door frame to the bathroom. After the CNA toileted me she then threw me into bed and I was crying out in pain. R3 said her roommate (R5) witnessed the whole incident and yelled at the CNA to Stop hurting {R3} and at that point the CNA then yelled out to shut up and mind your own damn business. She said she contacted her son the following morning and reported the incident, and she was so scared and fearful because of how angry the CNA's demeanor was. She also stated, I have also lost quality of life being in bed since this incident because my knee has been hurting. On 10/17/23 at 10:55 AM, this surveyor verified the date with R3, and she said there was only one incident with this CNA but she could not believe it had been a month ago already. On 10/16/23 at 9:52 AM, R5 said she witnessed the CNA ram (R3) into the door frame by the bathroom. She said R3 cried out in pain and then the CNA also threw R3 into bed and again she cried out in pain. R5 said she yelled at the CNA to stop hurting (R3) and at that point the CNA yelled at me to shut the hell up or we will see what will happen to you. R5 said she cannot recall exactly what date this happened. She said she was so scared she literally laid in bed and prayed that someone would come and help them. R5's 9/27/23 facility assessment shows her cognition is intact. A facility reported State of Illinois Serious Injury Incident and Communicable Disease Report form shows on 9/17/23 R3's son (V11) reported an incident that occurred on 9/16/23 where R3 received poor care from a CNA who was determined to be V25 (Agency CNA). The investigation file provided by V1 (Administrator) shows when R5 was interviewed she confirmed that she saw R3 being slammed against the door by V25. It also shows that she was told to shut the hell up. R3's interview by V1 shows she said she was thrown in bed by the CNA, and she was mean and rude. R3 said she was run into the side of the door by the CNA. The investigation refers to R3 as being very scared and wanted her son to come sit with her. On 10/16/23 at 10:25 AM, V17 (R3's physician) said he was not aware of the abuse incident involving R3, but the facility may have notified her Nurse Practitioner about it. He said R3 did report pain in her left knee, and it has been swollen. On 10/16/23 at 12:50 PM, V11 (R3's son) said his mom called him very upset about an incident where a CNA was rough with her. He said he came into the facility that day and spoke with his mom and R5. R5 had the same story about R3 being thrown into bed by the CNA and being told to shut up and mind her own damn business. V11 said he immediately told the nurse about the incident. V11 said R3 did ask him to come because she was fearful. On 10/16/23 at 11:30 AM, V1 (Administrator) said she investigated the abuse incident involving R3 and substantiated verbal abuse but not physical because. No injury or bruises were found on R3. She said the CNA (V25) was from an agency and was put on the do not return list. V1 did say that R3 and R5 both told her that R3 was bumped into the doorway and thrown into bed by V25. On 10/16/23 at 2:15 PM, V10 (Hospice Nurse) said R3 did tell her a CNA was rough with her during cares that during the transfer her leg was bumped. On 10/17/23 at 9:42 PM, V21 (Licensed Practical Nurse/LPN) said he was the one who got the report of R3's abuse incident. He said R3 confirmed that the CNA was rude, but he thought she told him her arm was bumped during the transfer. He said he checked her and did not note any injuries. On 10/17/23 at 10:06 AM, V18 (Nurse Practitioner/NP) said she was informed that R3 was being taken to the washroom and a CNA banged her left knee. She said R3 did report the CNA was rough with her. On 10/18/23 at 11:45 AM, V18 (NP) said I have serious concerns about this incident and the CNA. What if she did this to patients who were non-verbal. Progress notes in R3's electronic medical record show the following: 9/17/23 completed by V21 (LPN) at 3:53 PM, Got a call from patient son, (V11) complaining of (R3) being treated roughly by V25. 9/24/23 2:17 PM nursing note- resident (R3) complained of left knee pain. 9/27/23 2:33 PM, physician note completed by V18, says R3 complained of left knee pain from an injury sustained during a transfer. R3's progress notes document the pain to her left knee and referring it to an injury during a transfer continuing on the following dates: 10/2/23, 10/11/23, 10/16/23 and again on 10/17/23. The facility provided Abuse, Neglect and Exploitation policy revised 2/23 says all residents have the right to be free from abuse. The policy describes abuse as the infliction of injury, unreasonable confinement, intimidation and punishment with physical harm, pain or mental anguish.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident (R1), with left sided weakness, by not providing a wheelchair that was measured and properly fit. The facility failed to ensure fall interventions were implemented for a resident (R4) with history of falls for 2 of 7 residents (R1, R4) reviewed for falls in the sample of 13. This failure resulted in R1 falling from her wheelchair and sustaining a left hip fracture. The findings include: 1. The facility's Serious Injury Incident Report dated [DATE] shows Upon entering the R1's room, R1 was observed lying on her left side between the bed and the north wall. Resident reported pain to left hip ,d+[DATE]. Resident was transferred to Hospital. Resident sustained a non-displaced left intertrochanteric fracture (hip). R1's Hospital Papers dated [DATE] shows R1 is a [AGE] year-old with medical history of left hemiparesis from prior stroke and frequent falls presenting to the emergency room for evaluation of a fall. Patient reports she was sitting in her chair today when she went to reach for something causing her to fall off her chair and onto her left side. Reports pain primarily to the left thigh. Reports she recalls the entire event. X-ray of left hips shows left nondisplaced left intertrochanteric fracture. Power of Attorney reports R1 does not want surgical repair and plan for comfort measures. R1's Post Fall Evaluation dated [DATE] shows resident current medical condition contributing to the fall: left side paralysis from old CVA (cerebral vascular accident), resident did not have wheelchair locked, resident wearing socks (not non-skid) when reaching for something in her bureau, no footrests were in the way, and no safety evaluation or teaching was completed/documented prior to the fall. R1's weight 118.4 On [DATE] at 11:01 AM, V4 Registered Nurse said R1 had complaints about her wheelchair just not being comfortable. V4 said she inquired to management about why R1's wheelchair was changed but never got an answer. V4 said R1 went to management, and they did swap out R1's wheelchair but R1 was still not really happy with it. V4 said R1 was very alert and oriented and described her as a very [NAME] lady. V4 said she was working when R1 fell , and she heard R1 calling for help and when she entered the room R1 was on the floor on her left side. V4 said R1 told her she leaned forward reaching for something in a bottom drawer and fell . V4 said R1 could not bear weight on her left leg and did not have footrests on the wheelchair at the time of the fall. On [DATE] at 12:26 PM, V29 Certified Nursing Assistant (CNA) said R1 had been complaining to her that the wheelchair doesn't fit her, it was wider than her hips. V29 said when R1 fell she stated I told you it's the wheelchair. I kept asking to change the wheelchair, it's not right. On [DATE] at 12:34 PM, V30 CNA said when R1 fell , and she came to the room to help. V30 said R1 was saying the chair is all wrong, it's too big for me. I told everyone the chair is going to cause me to fall. V30 said R1 told the nurse she was reaching for something in the bottom drawer and slipped. V30 said there were no legs rests on R1's wheelchair. R1's Statement of Incident by V32 previous DON (director of nursing) dated [DATE]/23 shows resident alert and oriented and able to make her needs known at time of interview. Resident states she doesn't know why she fell today because she never had any issues with her old wheelchair. Resident became visibly upset at this time further mentioning that she never had a problem putting things into her drawer or getting things from different areas of her room. Resident began verbalizing concerns about her old wheelchair and how it was better for her than her current wheelchair. Historically the resident had been in the original wheelchair beginning [DATE]. On [DATE] the chair was swapped out for a larger size from 16 to 18. On [DATE] another swap was completed from an 18' to a 20 by restorative nurse at that time. On [DATE] restorative nurse ordered resident a new wheelchair. On [DATE] Quality Improvement form was received for resident complaints of wheelchair not being comfortable. Resolution: new in-house wheelchair offered; resident accepted. On [DATE] staff reported resident wanted the original wheelchair back and not the one that was supplemented in house. R1's Grievance Improvement Form dated [DATE] shows new wheelchair is not comfortable. The same form shows the resolution was a new wheelchair was provided. R1's Progress Notes dated [DATE] shows resident offered new wheelchair and accepted. R1's Progress Note dated [DATE] shows resident decided to go with the original wheelchair and did not want the new chair being offered. R1's Physician Orders dated [DATE] shows R1 has diagnoses of cerebral infarction, weakness, hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, and history of falling and an order Evaluate for wheelchair. Resident requires a wheelchair with leg support since left sided weakness and not able to move left lower leg and protect during ambulation. On [DATE] at 1:15 PM, V2 Director of Nursing (DON) said when she received R1's grievance about the wheelchair and she asked R1 what was wrong with her wheelchair. V2 said she learned that when the facility changed ownership, their medical supply company changed and so R1 received a wheelchair from the new company (V2 showed purchase order from supplier of 20-inch wheelchair) V2 stated from my understanding, R1's new wheelchair was identical to the old one and it was in R1's mind that is was different. V2 said she did have maintenance bring R1 another wheelchair (from the basement) that was the same size but R1 decided she didn't like that one and wanted to go back to the other one. V2 said R1 complained that she wanted to be lower to the floor so her feet didn't dangle so she could propel in her room better. V2 said R1's new wheelchair was not measured or fit it was just replaced with the same size as her previous one. V2 said R1's original wheelchair was measured by the previous Restorative Nurse. V2 said now moving forward therapy will measure and fit wheelchairs. On [DATE] at 1:42 PM, V7 Therapy Director said if a wheelchair is too big for a resident and/or the resident's legs dangle, it could cause a fall if the resident leans forward and they can't put their legs down to steady themselves. V7 said his department had not measured R1's wheelchair. On [DATE] at 10:45 AM, V7 said he was not aware of any physician order for R1 for wheelchair measurements. V7 said wheelchairs are ordered based on the width of the seat of the wheelchair and then the wheelchair is further adjusted for each resident. V7 said R1 was measured and fit for her wheelchair by the previous Restorative Nurse. V7 said R1 was not strong enough in her legs to stabilize herself if she leaned forward in the wheelchair due to left sided weakness from a cerebral vascular accident. V7 said if a wheelchair seat is too big, the resident can slip to the side in the seat and lose stability as well. On [DATE] at 11:30 AM, V7 said physical therapy did do an evaluation on [DATE] and R1 was not appropriate for further physical therapy. V7 said there were no measurements or fittings done by the therapy department for R1's wheelchair at that time. V7 said when a wheelchair is measured or fit in addition to the width of the seat, the back of the wheelchair is looked at to determine if a high back or low back chair is needed, you assess if the seat is too wide and the resident slides side to side in the chair, the seat height is assessed to make sure feet can touch the floor for stability, arm rests are adjusted, and the need for foot rests for leg impairment is assessed. V7 said these assessments are all resident specific to make sure the resident is in the best fit for comfort and safety. On [DATE] at 3:08 PM, V8 Nurse Practitioner said she had concerns regarding R1's fall from her wheelchair related to R1's complaints about the wheelchair being too big. V8 said she put orders in for R1 for a Physical Therapy Evaluation and Treatment and wheelchair assessment due to R1's complaints of her wheelchair not fitting (being too big). V8 said she was not sure if this was done or not, but it could have contributed to R1 falling out of the wheelchair. V8 said R1 fell out of her wheelchair, sustained a hip fracture, and went on hospice. On [DATE] at 11:25 AM, V24 Regional Consultant said they were unable to locate an admission fall risk assessment on R1. R1's Care Plan shows R1 had a cerebral infarction affecting left side, had activities of daily living deficits, and limited physical mobility related to hemiplegia and left sided weakness. This same Care Plan does not address R1's risk for falls until after R1's fall on [DATE]. R1's Progress Note dated [DATE] shows R1 returned to the facility from the hospital with order for palliative care and complete bed rest. R1's Progress Noted dated [DATE] shows R1 expired. 2. On [DATE] at 9:27 AM, R4 was in bed sleeping. R4's call light was clipped to the quarter side rail with the touch pad at the end of the cord tucked down between the mattress and the rail. R4's wheelchair was at the foot of the bed. R4's bedside table with food and personal items was approximately 3 feet away from R4's bed (not within reach). On [DATE] at 9:30 AM, V4 Registered Nurse said R4 is a fall risk and has had several falls from trying to get up by herself. On [DATE] at 10:28 AM, V5 Certified Nursing Assistant said R4 is a fall risk and has sight impairment and at times some confusion. V5 said R4 should have a clip alarm on her wheelchair but was not sure about fall interventions when in bed. On [DATE] at 10:38 AM, V2 Director of Nursing (DON) said when a resident falls and investigation is done to determine root cause. V2 said a fall risk assessment is done as part of the investigation and new interventions are determined. V2 said fall interventions should be updated with each fall and the resident's Care Plan is updated. V2 said the previous DON investigated R4's falls and should have put interventions in place. On [DATE] at 11:35 AM, V1 Administrator said she recalls that R4 was a fall risk and R4's falls were discussed in the morning meetings, but she could not recall what fall interventions were put in place. R4's most recent Care Plan shows R4 had a fall on [DATE] while attempting to move furniture in her room. Another fall on [DATE] while ambulating unassisted to open the door to let someone in. R4 is at risk for falls due to impaired vision (legally blind), unsteady gait, and generalized muscle weakness. Fall interventions are staff rearranged furniture to accommodate resident's preference. Keep call light within reach at all times. Requires for call for assistance when needed. (Date initiated [DATE]). No other interventions were added after [DATE] fall. The same Care Plan shows Risk for falls. If resident is a fall risk, initiate fall risk precautions. Resident had a fall occurrence on [DATE]. No interventions were added after [DATE] or [DATE] falls. R4's Progress Notes on [DATE] shows R4 had a fall at 12:00 AM from her wheelchair while in the dining room and then another falls later that same day in her room. The facility's Fall Prevention Program Policy dated 2022 shows each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. High risk Protocols: The resident will be placed on the facility's Fall Prevention Program-Implement interventions. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care: interventions will be monitored for effectiveness and the plan of care will be revised as needed.

Based on interview and record review the facility failed to ensure pain medication was administered to a resident experiencing pain after a fall. This failure resulted in (R45) experiencing uncontrolled pain for 4 hours. This applies to 1 of 18 residents (R45) reviewed for pain in the sample of 18. The findings include: R45's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, lack of coordination, and hypertension. R45's 3/28/23 facility assessment shows her cognition is mildly impaired. A post fall evaluation documented by V16 (Licensed Practical Nurse/LPN) on 6/10/23 at 1:57 PM, shows R45 had a fall in her room earlier that day at 7:30 AM. After the fall R45's left hip pain was documented to be a 8/10 on a 1/10 pain scale. The note states R45's pain is constant. R45's nursing progress note completed on 6/10/23 at 2:42 PM, by V16 states, till 12 noon X-ray has not arrived and resident still c/o pain to left hip. NP (Nurse Practitioner- V10) notified with orders to send to the ER. resident left facility with ambulance at 12:30 PM. R45's nursing progress notes show a Health Status Note documented on 6/10/23 at 3:55 PM, that states resident {R45} has a comminuted angulated mildly displaced intratrochanteric fracture of the left hip. Resident will be admitted to {local hospital} for further evaluation and treatment. R45's 6/10/23 and 6/11/23 hospital records show that an X-ray was completed for R45 on 6/10/23 and R45 was found to have a comminuted mildly displaced intratrochanteric fracture of the left hip. The same hospital records show R45 underwent surgical intervention for her hip fracture on 6/11/23. On 6/14/23 at 10:21 AM, V14 (Certified Nursing Assistant/CNA) said she was the CNA assigned to R45 on 6/10/23 the day she fell . V14 said after R45 had fallen (approx. 7:30 AM) she continued to complain of pain to her left hip and V14 told the nurse on duty. On 6/14/23 at 10:43 AM, V15 (CNA) said she was helping care for R45 on 6/10/23 the day she had the fall. V15 said R45 kept asking for pain medication because she was in a lot of pain after the fall that morning. V15 said pain medication was not administered right away and she knows this because R45 kept asking for pain medication after the fall. On 6/14/23 at 11:05 AM, V12 (Registered Nurse/RN) said she was going off duty on 6/10/23 when R45 had her fall. V12 said after R45's fall she was complaining of pain to her left hip. V12 said she did not personally administer pain medication to R45 and cannot speak for when R45 received pain medication. On 6/14/23 at 11:50 AM, V2 (Director of Nursing/DON) said she is still investigating R45's fall from 6/10/23. V2 said she had spoken with V16 (LPN) because there was no documentation that R45 had received any pain medication and V16 informed her that she did give R45 pain medication (Tylenol) at 11:30 AM. V2 was asked if R45 should have received the pain medication sooner after her fall and V2 responded it would have been appropriate to do that. On 6/14/23 at 11:13 AM, V10 (Nurse Practitioner/NP) said that R45 had an order for Tylenol 650 milligrams (mg.) for pain and she should have been given that. V10 said when she was called the second time (later that morning before noon) about R45's X-ray not being able to be done at the facility timely and that R45 was experiencing increased pain to her left hip, she decided to send her to the emergency room . At 12:15 PM, V10 said she was not aware that R45 was not given pain medication (Tylenol) until 11:30 AM and she could have gotten it sooner. On 6/14/23 at 12:02 PM, V11 (R45's daughter) said she was contacted by her mom (R45) at about 7:45 AM on 6/10/23 about having a fall. V11 said R45 was complaining about having hip pain at that time. On 6/14/23 at 1:00 PM, V16 (LPN) said she was the nurse assigned to R45 on 6/10/23 the day she had fallen. V16 said she recalls R45's fall to be around 7:15 AM. V16 said R45 was complaining of hip pain being an 8/10 after the fall and the CNA's also were reporting to her that R45 was continuing to have pain so she gave her Tylenol 650 mg. for the pain at 11:30 AM. (4 hours after R45's fall). V16 was asked by the surveyor if she called a physician for any additional pain medication orders and she said she did not. V16 was asked if there was any reason that R45 was not given the Tylenol for her pain sooner to which V16 replied, Uh No. A Medication Administration note completed by V16 on 6/12/23 at 3:34 PM, was documented as a late entry for 6/10/23 at 11:30 AM. That note shows R45 was given Tylenol 650 milligrams at 11:30 AM. R45's Medication Administration summary does not show any pain medication was given to R45 after her fall on 6/10/23. The facility provided Pain Management policy dated 2022 states, The facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain. 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and causes upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall.)

Based on observation, interview, and record review the facility failed to follow recommended guidelines from Centers for Disease Control (CDC) by not ensuring staff were wearing N95 face masks and isolation gowns per recommendations while caring for residents that are positive with COVID-19, residents on transmission based precautions (contact/droplet) because of a known exposure to a positive COVID-19 staff member, and while doing COVID-19 testing on staff members with an unknown COVID-19 status. The facility also failed to ensure staff are reporting known exposures to COVID-19 positive and signs of illness before working with negative COVID-19 residents. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to all 71 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on March 17, 2021 when V21 Laundry Aide did not report that she was exposed to a known positive COVID-19 family member and failed to report illness like symptoms before and during three scheduled shifts. The Immediate Jeopardy was identified on May 3, 2021. V1 Administrator was informed of the Immediate Jeopardy on May 5, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on May 5, 2021; however noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility's room/bed list provided on May 3, 2021 shows, there are 71 residents residing in the facility. The facility's COVID-19 resident list provided on May 3, 2021 shows, 6 residents were positive for COVID-19 but only R1 and R2 still reside in the facility. R6 was discharged home; R7, R8, & R9 were discharged to a local hospital and have not returned to the facility. R1 tested positive for COVID-19 on April 21, 2021. R2 tested positive for COVID-19 on April 25, 2021. Both residents are still in transmission based precautions (contact/droplet precautions) on the COVID-19 unit. The facility's resident COVID-19 vaccine record provided on May 3, 2021 shows, 79% of the residents are vaccinated for COVID-19. The facility's employee COVID-19 vaccine record provided on May 3, 2021 shows, 50% of the staff are vaccinated for COVID-19. 1. On May 3, 2021, at 10:26 AM, V3 Infection Control Nurse stated, two staff members knew they were exposed to COVID-19 outside of work and still came to work. She stated, that they are screened when they come into work and did not tell the truth when asked that they had been exposed to someone with COVID-19. The facility's employee sickness screening related to 2019 Novel Coronavirus for V21 Laundry Aide (no date) shows, she had symptoms of sore throat, headache, and diarrhea with a household contact with another lab confirmed COVID-19 case-patient. The same document has an email attached from V3 Infection Control Nurse dated March 21 & 22, 2021 about V21 showing, V21 had a recent exposure with her dad who was in town visiting and tested positive for COVID. 3/14: was with her dad. At the time, had no symptoms. When he got back home, stated having symptoms and got tested . 3/16: she was informed that he tested positive of COVID. 3/17: she went to work. During her shift, started having sore throat and headache. Didn't inform anyone of exposure or symptoms. Thought it was nothing since she often gets sick. 3/18: went to work. Didn't report of previous day's symptoms. 3/20: went to work. Didn't report any of her symptoms again. After work, started having diarrhea and nausea . The facility's employee sickness screening related to 2019 Novel Coronavirus for V8 Housekeeper (no date) shows, caught it from Auntie positive, Thursday/Friday 4/23/21, tested yesterday COVID at local hospital, worked on 4/26/21, reported no exposure. The same document has an email attached from V3 Infection Control Nurse dated April 28, 2021 about V8 Housekeeper showed, 4/23: had an exposure to Aunt who was positive of COVID, 4/26: came to work. Did not report he had a recent exposure, 4/27: called in. Started with chills. Went to local hospital and tested positive, 4/28: started feeling tired, had muscle aches, cough, headache. The facility's [CONDITION(S)]-COV-2 (COVID-19) Response and Readiness Plan last revised December 29, 2020 shows, Pandemic Response: Screen all prospective residents and employees to identify exposure to the novel virus. Screen for fever and any COVID-19 symptoms following exposure or suspected exposure following the recommended timeline from the CDC and/or IDPH. Evaluate residents, employees, contract employees, and essential visitors daily for symptoms; employees should be instructed to self-report symptoms and exposure. The CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities last updated March 29, 2021 shows, Evaluating and Managing Personnel and Residents: Evaluate and Manage Healthcare Personnel: HCP who report symptoms should be excluded from work and should notify occupational health services to arrange for further evaluation. In addition, asymptomatic HCP who report close contact with others with [CONDITION(S)]-CoV-2 infection might need to be excluded from work. If HCP develop fever (Temperature ?100.0°F) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. 2. The facility's resident COVID-19 line listing provided on May 3, 2021 shows, R6 became COVID-19 positive on April 13, 2021. The same report continues to show the following residents becoming positive for COVID-19 after R6: R1 positive on April 20, 2021, R2 positive on April 25, 2021, and R7, R8 & R9 all positive on April 27, 2021. For a total of 6 residents being positive for COVID-19. The same report shows, that all residents were residing on the same hallway (200 hallway; the observation/COVID unit). The facility's COVID-19 staff line listing provided on May 3, 2021 shows, 6 staff members (V5 Certified Nursing Assistant (CNA), V6 Wound Care Registered Nurse, V7 Dietary Aide, V8 Housekeeper, V9 Housekeeper, & V10 Licensed Practical Nurse) becoming positive for COVID-19 after R6. On May 4, 2021 at 9:40 AM, V3 Infection Control Nurse stated, through contact tracing she figured out that V6, V9, & V10 all worked on the 200 hallway (observation/COVID unit) after R6 was positive for COVID-19. The other 3 staff members (V5, V7, & V8) had exposures outside of work. On May 3, 2021 at 9:48 AM, V3 Infection Control Nurse stated, all staff were wearing N95 face masks with surgical masks over them because they were in an outbreak status. On May 3, 2021 at 9:49 AM, V11 & V12 both CNAs were working the COVID-19 unit on the 200 hallway. They had N95 face masks on with a surgical mask over them. V11 only had one strap on of the two straps for the N95 face mask. The second strap (the one not around her head) was hanging underneath her chin. V12's N95 was not strapped to her head at all. It was just sitting inside her surgical mask. V11 stated, the straps were too tight to the N95 around her chin so she only wore the one strap on her head. No one has ever told me I couldn't wear it like that. On May 3, 2021 at 9:49 AM, V14 Laundry Supervisor was on the observation unit (200 hallway) dropping off clean linen to the linen room. She was wearing an N95 face mask with a surgical mask over it. She only had one of the two straps on her head. The other strap was hanging under her chin. At the same time, V13 Housekeeper was on the COVID- 19 unit. He was also wearing an N95 face mask with a surgical mask over it. He did not have both straps strapped on his head. The second strap was hanging underneath his chin. He was cleaning a room on the COVID-19 unit. On May 3, 2021 at 9:58 AM, V16 CNA was in room [ROOM NUMBER] (100 hallway on observation/contact/droplet precautions for exposure to a known COVID-19 staff member) helping R10 pack some of her things into a plastic bag. She was wearing an N95 face mask with a surgical mask over it. The N95 was just resting in her surgical mask and not strapped to her head at all. There was not a tight seal on her face. She also was not wearing a gown or gloves. At the same time, V15 and V17 both CNAs were also wearing an N95 face mask with a surgical mask over it. Neither one had both straps strapped to their head. V15 stated that they only wear gowns and gloves when they are providing personal care to the residents otherwise they don't put one on. On May 3, 2021 at 11:00 AM, V4 executive director had the second strap of her N95 face mask hanging under her chin. Both straps were not on her head. On May 3, 2021 at 2:12 PM, V19 Registered Nurse was testing V20 CNA for COVID-19. She was not wearing a gown while testing her. V20 CNA had a surgical mask on with an N95 face mask over it. On May 3, 2021 at 1:52 PM, V3 Infection Control Nurse stated, that staff should have a closed tight fit when wearing an N95 face mask. She stated, that they should be using both straps on their heads to ensure the tight fit around their face. At 2:18 PM, she stated, that staff should be wearing full PPE when going into contact/droplet precaution rooms (N95 face mask, face shield, GOWN, and gloves). The facility's [CONDITION(S)]-COV-2 (COVID-19) Response and Readiness Plan last revised December 29, 2020 shows, Introduction: The facility recognizes the importance of awareness and preparation for global pandemic as outlined in the Emergency Preparedness Plan. Specific attention will be made to the Novel Coronavirus ([CONDITION(S)]-COV-2) which may develop into COVID-19 in infected persons. This plan has been developed utilizing guidelines developed by the Centers for Disease Control and Prevention (CDC), as well as recommendations and mandates published by the Centers for Medicare and Medicaid Services (CMS) and the Illinois Department of Public Health (IDPH) . The CDC's use of personal protective equipment (PPE) when caring for resident with confirmed or suspected COVID-19 shows, Preferred PPE- Use N95 or higher respirator (both straps attached to the person's head), face shield or googles, gloves, and isolation gown. The facility has these signs taped up on the walls randomly around the facility. The CDC's Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination last updated on March 10, 2021 shows, 2. Work restriction for asymptomatic healthcare personnel (HCP) and quarantine for asymptomatic patients and residents. The following recommendations are based on what is known about currently available COVID-19 vaccines. These recommendations will be updated as additional information, including regarding the ability of currently authorized vaccines to protect against infection with novel variants and the effectiveness of additional authorized vaccines, becomes available. This could result in additional circumstances when work restrictions for fully vaccinated HCP are recommended . Fully vaccinated inpatients and residents in healthcare settings should continue to quarantine following prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with [CONDITION(S)]-CoV-2 infection; outpatients should be cared for using recommended Transmission-Based Precautions. This is due to limited information about vaccine effectiveness in this population, the higher risk of severe disease and death, and challenges with physical distancing in healthcare settings. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, Collection of Diagnostic Respiratory Specimens: When collecting diagnostic respiratory specimens (e.g., nasopharyngeal or nasal swab) from a patient with possible [CONDITION(S)]-CoV-2 infection, the following should occur: Specimen collection should be performed in a normal examination room with the door closed. HCP in the room should wear an N95 or equivalent or higher-level respirator, eye protection, gloves, and a gown. Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated February 23, 2021 shows, Appendix: Additional Information about Airborne Infection Isolation Rooms, Respirators and Facemasks: Filtering Facepiece Respirators (FFR) including N95 Respirators: A commonly used respirator in healthcare settings is a filtering facepiece respirator (commonly referred to as an N95). FFRs are disposable half facepiece respirators that filter out particles. To work properly, FFRs must be worn throughout the period of exposure and be specially fitted for each person who wears one. This is called fit testing and is usually done in a workplace where respirators are used. Three key factors for an N95 respirator to be effective: 1. The respirator must be put on correctly and worn during the exposure. 2. The respirator must fit snugly against the user's face to ensure that there are no gaps between the user's skin and respirator seal. 3. The respirator filter must capture more than 95% of the particles from the air that passes through it. The Immediate Jeopardy that began on March 17, 2021 was removed on May 5, 2021 when the facility took the following actions to remove the immediacy. Proper PPE Usage: 1. Staff at Rolling Hills Manor will train and have information on the most current CDC recommendations regarding PPE for residents with COVID-19 and/or exposure to COVID-19, and while testing for COVID-19. Education will include the proper PPE usage, including donning, doffing, disposal and location of supplies in the building. New employees will have this training as part of their new hire orientation and agency staff will be given the training and handouts same as Rolling Hills employees. 2. All staff have been given this training by the Administrator, Director of Nursing, Assistant Director of Nursing, and Infection Preventionist. Disciplines have been issued and will continue to be issued if violating the proper PPE requirements. Administrator and Director of Nursing, or their designee will monitor staffing compliance with CDC regulations and guidance on PPE usage, weekly, in an on-going basis, and any staff who do not perform in accordance with the regulations and guidance will receive directed in-service re-training and/or performance reprimand. 3. All staff will be given this training prior to their next shift by the Director of Nursing, Assistant Director of Nursing, and Infection Preventionist. The PM shift supervisor and/or Charge Nurse will train over the weekends. Any personal who will return to work after the weekend will be called and reviewed with them prior to the start of the next scheduled workday. 4. Results of the PPE observations will be reported to the QAPI committee monthly and the QAPI committee will evaluate for trends and compliance at its quarterly meetings. 5. Completion Date: May 5, 2021 Staff Reporting: 1 All Staff meetings and in-service meetings have been held to communicate with staff about COVID-19 regulations, policy and procedures, changes to guidance, testing results since the pandemic started and IDPH implemented guidelines for Long Term Care facilities 3/9/2021. These meetings included front door screening and shift screening processes and the importance of honest reporting. Per CDC, CMS, and IDPH guidelines, Rolling Hills performs staff screening for signs and symptoms of illness, including temperature checks and questionnaires, for each staff at the beginning of their work shift. All staff meeting including specifics to front door screening process and importance of honesty was most recently held on 3/22/21, 3/24/21 and 4/20/21. Rolling Hills Manor maintains disciplinary policies and procedures in an employee handbook. A reminder was handed to staff on May 4, 2021 during COVID-19 testing to emphasis the repercussions of violating the policies and procedures relating to COVID-19 protocols. Any personal who missed the testing, the reminder is posted on the employee bulletin board. The Director of Nursing, Assistant Director of Nursing, and the Infection Preventionist will ensure that staff are reporting known exposures and any signs and/or symptoms of illness in relation to COVID-19. In-services and all staff meetings are done when necessary or at least weekly and will re-enforce the severity and importance of the screening and reporting process. 2. All staff will be given this training prior to their next shift by the Director of Nursing, Assistant Director of Nursing, and Infection Preventionist. The PM shift supervisor and/or Charge Nurse will train over the weekends. Any personal who will return to work after the weekend will be called and reviewed with them prior to the start of the next scheduled workday. 3. The Infection Preventionist will monitor the front door screening log on a weekly basis for compliance of reporting in combination with the contact tracing when exposure/illness is reported. 4. Results of the staff reporting will be conveyed to the QAPI committee monthly and the QAPI committee will evaluate for trends and compliance at its quarterly meetings. 5. Completion Date: May 4-5, 2021

Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the local health department regarding isolation of COVID-19 residents; regarding cohorting of COVID-19 residents; and proper Personal Protective Equipment (PPE) usage. This failure has the potential to infect high risk residents with COVID-19 and spread the disease to COVID-19 negative residents. This applies to 6 of 15 residents (R2, R4, R6, R8, R11, and R12) reviewed for infection control practices in the sample of 15. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility began receiving positive COVID-19 results. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE]. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE] ; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. The facility's COVID-19 Resident Line Listing, provided on [DATE], showed 29 residents were in isolation for positive COVID-19 test results. The report also showed that 6 residents died within days after being diagnosed with [REDACTED]. On [DATE] at 11:30 AM, R1 and R2 were seen in the same room together and both of their names were on the door. R2 was in her wheel chair with her lunch in front of her. R1 was in her wheelchair, near the window, with her lunch as well. Their door was not shut. The curtain was pulled halfway, and residents were within sight of each other. R2's COVID-19 test results, which were collected on [DATE] and reported on [DATE], showed the Result to be Not Detected. The lab result showed, A Not Detected (negative) test result for this test means that [DIAGNOSES REDACTED]-CoV-2 RNA was not present in the specimen above the limit of detection. R1's COVID-19 test results for the same dates as R2, showed the result to be Detected. The lab test showed, A Detected result is considered a positive test result for COVID-19. This indicates that RNA from [DIAGNOSES REDACTED]-CoV-2 was detected, and the patient is infected with [MEDICAL CONDITION], and presumed contagious. (R1 and R2 were together in the same room for 5 days after the facility was aware of positive test results) The facility's Room/Bed list showed R1 and R2 were roommates. 2. On [DATE] at 11:32 AM, R4 was observed in her room. R4's roommate, R3, was not in the room and R3's bed was stripped. On [DATE] at 3:53 PM, V5 Infection Preventionist stated, R3 was sent to the hospital on [DATE] for a fever, and an oxygen saturation of 88%. V5 stated she was admitted to the hospital with [REDACTED]. R3's COVID-19 test, collected on [DATE] and reported on [DATE] showed the result to be Detected. R4's COVID-19 test, collected on [DATE] and reported on [DATE] showed the result to be Not Detected. R3's [DATE] Nursing Notes showed, she was given 650 milligrams of [MEDICATION NAME] for a fever at 7:42 AM. ([MEDICATION NAME] lowers a persons fever) R3's Vital Signs showed a temperature of 100 degrees Fahrenheit on [DATE] at 1:38 AM. R3's [DATE] 8:10 PM Nursing Note showed, .Resident developed a temp of 100.7 around 17:45 (5:45 PM) and had a SpO2 at 88% (Oxygen saturation percentage). Resident noted with heavy congestion, and phlegm in oral airway. Suctioned performed .copious amounts of sputum suctioned . (R4 was her roommate during this time and had tested negative for COVID-19) The Centers for Disease Control and Prevention (CDC) website titled Preparting for COVID-19 in Nursing Homes updated [DATE] showed, Evaluate and Manage Residents with Symptoms of COVID-19. Ask residents to report if they feel feverish or have symptoms consistent with COVID-19. Actively monitor all residents upon admission and at least daily for fever (T=100.0 degrees Farenheit) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below. The facility's Room/Bed list showed R3 and R4 to be roommates. 3. On [DATE] at 2:20 PM, R5 and R6 were seen in the same room together. R5 and R6's names were on the door. R5 was sleeping in her bed closest to the door. R6 was in her bed closest to the window. The door to R5 and R6's room was open to the hallway. R5's COVID-19 test, collected on [DATE] and reported on [DATE] showed, the result to be Detected. R6's COVID-19 test, collected and reported the same dates as R5 showed, the result to be Not Detected. The facility's Room/Bed list showed R5 and R6 to be roommates. (5 days after positive test results) 4. On [DATE] at 2:10 PM, R7 and R8 were seen in the same room together. R8 was nearest the door sitting in her wheelchair and R7 was nearest the window working on a puzzle; neither resident wearing a mask. The door to R7 and R8's room was open. On [DATE] at 2:10 PM, R8 stated, No one asked me to move rooms .No one asked me to move because of COVID, if they did I would have to think about it. On [DATE] at 12:30 PM, V6, R8's Power of Attorney stated, she was never contacted about moving R8 or R8 refusing to move. V6 said I would remember that. V6 said, had she been notified that R8 had refused to move she would have attempted to persuade her to move. R7's COVID-19 test, collected on [DATE] and reported on [DATE] showed, the result to be Detected. R8's COVID-19 test, collected and reported the same dates as R5 showed, the result to be Not Detected. The facility's Room/Bed list showed R7 and R8 to be roommates. (5 days after positive test results) 5. On [DATE] at 2:25 PM, R9 and R12 were observed in a 4 bed room and to be in the beds closest to the door. R11's and R10's beds were not visible from the door due to the curtains being pulled; R11 and R10 were not visible. Outside the room, R9-R12's names were on the door. R9 was in bed and R12 was sitting at the edge of the bed attempting to get up to the bathroom on her own. On [DATE] at 3:53 PM, V5 Infection Preventionist stated, R11 is in the facility and is roommates with R9 and R12. V5 stated, R10 was sent to the hospital on [DATE] due to an X-ray showing atypical pneumonia. V5, said R10 was admitted to the hospital for pneumonia. R9's COVID-19 test, collected on [DATE] and reported on [DATE] showed the result to be Detected. R10's COVID-19 test, as documented on the facility Resident Line Testing showed she was Positive and the facility was aware on [DATE]. R11's COVID-19 test, collected on [DATE] and reported on [DATE], showed the result to be Not Detected. R12's COVID-19 test, collected on [DATE] and reported on [DATE], showed the result to be Not Detected. (R11 and R12 cohorted with two COVID positive residents.) The facility's Room/Bed list showed R9, R10, R11, and R12 to be roommates. On [DATE] at 1:05 PM, V5 stated she was aware that COVID-19 positive residents should not be roomed with COVID-19 negative residents and the roommates of COVID-19 positive residents she be separated and monitored for signs and symptoms of COVID-19. On [DATE] at 9:15 AM, V4 Lake County Contagious Disease Program specialist for Long-Term Care stated she had spoken with V5 on [DATE]. V4 said they had discussed the plan of action after receiving the COVID-19 positive results. V4 said, We discussed how important it was to cohort staff and residents on the COVID unit to try and prevent the further spread of COVID. We would never make that recommendation to keep a COVID positive resident with a COVID negative resident. That would be the definition of high risk exposure due to a confined room, no mask, and for greater than 15 minutes. On [DATE] at 12:58 PM, V3 Facility's Medical Director stated, It's an obvious, 'No,' they should not have a positive roommate, with a negative roommate. V3 said, If a resident tests positive and another tests negative then they should be segregating the two, to try and preserve the lack of infection in the negative resident. V3 said complications of COVID-19, besides mortality, include increased clotting which can lead to [MEDICAL CONDITION], and [MEDICAL CONDITION]; pneumonia; exacerbation of other health conditions such as heart failure; and if nothing else they come out the other side much weaker and drained. The facility wide testing conducted on [DATE] and reported to the facility on [DATE] showed R4, R6, and R12 were now Detected or positive for COVID-19. The Centers for Disease Control and Prevention (CDC) website titled Responding to COVID-19 Considerations for the Public Health Response to COVID-19 in Nursing Homes showed, If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents . The facility's COVID-19 Testing Plan and Response Strategy showed, If patents have been screened and their testing is Positive for COVID-19 .Private room or cohort with another symptomatic/positive patient. 6. On [DATE] during initial tour of the facility, COVID-19 positive residents and COVID-19 negative residents were observed on all 4 wings of the facility. COVID-19 positive rooms were seen with their door open to the hallway. The same staff were observed caring for both COVID-19 positive and COVID-19 negative residents. No plastic boundaries were observed, PPE requirements were not posted on resident doors, no specific COVID-19 unit was observed. Staff were observed sitting in alcoves on the units. On [DATE] at 2:25 PM, V7 Certified Nursing Assistant entered R9-R12's room to assist R12 (A COVID-19 positive room.) On [DATE] at 2:30 PM, V7 stated she cares for both COVID-19 positive and negative residents on her hallway. On [DATE] at 1:05 PM, V5 Infection Preventionist stated, We wanted to cohort the residents but the struggle was staffing. V5 said, the facility did not receive all of the test results until Friday, [DATE]. V5 stated, The DON (Director of Nursing) and I discussed what we were going to do on Friday we were going to have to move a lot of them . (Many COVID-19 results were available on [DATE] (Thursday) as of [DATE], 5 days later, COVID-19 residents and staff had not been cohorted.) On [DATE] at 9:15 AM, V4 Lake County Contagious Disease Program Specialist for Long-Term Care stated she had spoken with V5 on [DATE]. V4 said, We discussed that they needed to move the COVID positive residents to one wing; I believe we discussed the 400 wing, and move the roommates of the COVID positive to quarantine wing and keep close monitoring on them. I think we picked 400 wing because that was where most of the positives were. Our advice would be to leave COVID positive on that wing and to move the COVID negative to a quarantine wing with close monitoring. We discussed how important it was to cohort staff and residents on the COVID unit to try and prevent the further spread of COVID. On [DATE] at 12:58 PM, V3 Facility's Medical Director stated, The last I heard they did have a COVID unit, and when they had residents who were positive on the same unit as negative residents they were putting plastic over the door to contain the spread. On [DATE], observations made during intial tour, showed no plastic sheeting over resident door ways. The facility's COVID-19 Testing Plan and Response Strategy Revision date [DATE] showed, Focus on decreased staff rotation and cohort staff who work with symptomatic residents whenever possible .Identify additional isolation rooms limiting to single unit if possible, cohort like-cases if necessary (e.g., influenza with influenza, COVID-19 with COVID-19) . On [DATE] at 3:53 PM, V5 Infection Preventionst stated all of the residents who were negatvie for COVID-19 and were living with COVID-19 positive roommates, had been roomates as of [DATE] or earlier. 7. On [DATE] at 11:25 AM, V8 Certified Nursing Assistant (CNA) was observed on the 300 hall. V8 was wearing a face shield, N95, surgical mask over N95, washable gown, and a disposable gown over the washable gown. V8 entered 3 COVID-19 positive rooms, one of the rooms she left and entered a second time. Upon leaving the COVID-19 positive rooms, V8 did not remove her disposable gown. The 300 hall also houses COVID-19 negative residents. On [DATE] at 11:30 AM, V8 stated she only changes her disposable gown after she is finished caring for the COVID-19 residents. V8 stated she does care for negative and positive in the same day. V8 stated there has been a shortage of disposable gowns at the facility. On [DATE] at 1:05 PM, V5 stated, the facility has enough disposable gowns to meet their needs and has not had difficulty obtaining them. V5 said, staff should change their disposable gowns after caring for COVID-19 residents. The Centers for Disease Control and Prevention (CDC) website titled Responding to COVID-19 Considerations for the Public Health Response to COVID-19 in Nursing Homes updated [DATE] showed, Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated [DATE] showed, The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. On [DATE] the facility began seperating COVID-19 positive roommates from their COVID-19 negative roommates 2. On [DATE] the facility completed the process of cohorting COVID-19 positive staff and residents onto one unit. 3. On [DATE] the facility began training of staff and developed a plan to educate staff who were not on duty. Training included PPE usage, signage indicating COVID-19 positive residents, identification of COVID-19 signs/symptoms, and actions taken for COVID-19 like symptoms. 4. On [DATE] the facility developed plans for cohorting COVID-19 positive staff and residents. 5. On [DATE] the facility developed plans for to ensure policy and procedures were consistent with CDC guidelines regarding COVID-19 6. On [DATE] the facility developed a plan to minimize risk to COVID-19 negative residents on hallways with COVID-19 positive residents.

Based on observation, interview, and record review the facility failed to ensure safety during personal cares. This failure resulted in R1 sustaining a left humerus fracture and left [MEDICAL CONDITION]. This applies to 1 of 3 residents (R1) reviewed for safety. The findings include: The Final Incident Report Dated (MONTH) 3, (YEAR) showed on (MONTH) 30, (YEAR), R1 became combative during her shower. After lunch staff noticed R1's left arm looked different. After dinner staff noticed R1 was not standing well during transfers. Staff noticed R1's left arm had a bruise and was swollen. R1 had an x-ray showing a left humerus fracture and a left [MEDICAL CONDITION]. The report documents R1 did not have a fall. On (MONTH) 13, (YEAR) R1 was sitting in her reclining wheelchair. R1's left arm was in a sling. R1's left upper arm (inner and outer side) had a dark purplish bruise from her under arm pit down to her elbow. R1's left outer breast had a dark purplish bruise. R1's left top shoulder had a light yellowish bruising. On (MONTH) 13, (YEAR) at 9:00 AM, V5 (Certified Nursing Assistant-CNA) said on (MONTH) 30, (YEAR), he transferred R1 with V7 (CNA) from her bed. During the transfer V5 said R1's left leg did not follow and got caught on the draw sheet. V5 said R1 said ouch. V5 said he repositioned her leg and continued to transfer R1 using a mechanical stand lift. V5 said he gave R1 a shower, during the shower R1 became combative. R1 was trying to grab the shower hose with her right arm. V5 said he did not see R1 hit her left arm on the shower arm chair. He said he did see R1 leaning to the left side of the shower chair but did not reposition her. V5 said he had to hold R1's right arm during the shower because she was combative. V5 said he did continued with the shower as R1 continued to be combative. V5 said when a resident gets combative staff should stop and reapproach and report behaviors to nursing. V5 said he did not report R1's behaviors to the nurse, they know R1 has behaviors. On (MONTH) 13, (YEAR) at 9:42 AM, V7 (CNA) said she assisted V5 transferring R1 on (MONTH) 30, (YEAR), in the morning before R1's shower. V7 said she does not remember R1 saying ouch during the transfer. She does not recall the events of the transfer. V7 said after lunch she and V6 (CNA) transferred R1 back to bed. V7 said R1's left arm is usually positioned towards her body. V7 said V6 noticed R1's left arm looked different. V7 said R1 gets combative during showers. V7 said when R1 gets combative we give her time to calm down, stop cares and notify the nurse. On (MONTH) 13, (YEAR) at 10:50 AM, V6 (CNA) said R1 does not like showers she gets combative. Staff should notify the nurse when residents get combative. On (MONTH) 13, (YEAR) at 8:45 AM, V12 (Registered Nurse) said she was R1's day shift nurse on (MONTH) 30, (YEAR). V12 stated, no one reported anything to me regarding R1. Staff should report any condition change and resident behaviors. If a resident gets combative staff should stop and re-approach. V12 said R1 is usually quiet. On (MONTH) 14, (YEAR) at 12:36 PM, V13 (Orthopedic Surgeon) said it was reported R1 sustained a fall. These types of fractures (humerus and femoral) are most likely from a fall based on the x-ray images. The Radiology report dated (MONTH) 30, (YEAR) showed R1 had a left humerus fracture. The Radiology report dated (MONTH) 31, (YEAR) showed R1's reason for exam was due to pain after a fall. The report showed R1 had a [MEDICAL CONDITION] femoral neck (hip). The Investigation Report statement by V5 (CNA) dated (MONTH) 31, (YEAR) states, During the shower R1 was aggressive V5 held on of her arms to prevent (R1) from swinging at him. R1 complained of leg pain after the shower. The Physician order [REDACTED]. The Minimum Data set assessment dated (MONTH) 22, (YEAR) shows R1's cognition is severely impaired. R1 requires extensive assist with transfers and bathing and impairments of range of motion affecting her upper and lower extremity. R1's care plan dated through (MONTH) (YEAR) shows she can be violent, and resistive to cares. Interventions include if (R1) is combative or resistive with cares staff should come back for cares after a while, maintain resident's safety, and report to the nurse if resistive to cares. The facility's Investigation of Occurrence Report dated (MONTH) 2012 states, Regardless of how minor an accident or injury or incident may seem, including an unknown source they are reported to the primary nurse .

A. Based on observation, record review and interview the facility failed to provide resident specific interventions, reevaluate the effectiveness of interventions and provide adequate supervision to prevent reoccurring falls. This is for 3 of 11 residents sampled for falls in a total sample of 22. (R3, R16 and R12) This failure resulted in R16 sustaining a fracture of the left shoulder. Findings include; 1. On 2/1/12 R16 was in the main dining room at 11:00 AM after an activity ended. R16 was well groomed and agreed to talk to me. R16 stated that she broke her shoulder but does not remember how she broke it. R16's record contains an "Incident/Accident Report" dated 2/27/11 that denotes she was found on the floor with a skin tear to her left hand fourth finger. R16's record contains "Incident/Accident Report" dated 2/27/11 that denotes, "Resident found sitting on the floor on West Activity...Transferred resident with staff to her wheelchair." R16's record contains an "Incident/Accident Report" dated 4/16/11 that denotes, "found resident on floor of activity room facing west windows with her back against the front of her wheelchair, legs straight out in front of resident...Resident stated she slid down to the floor from her wheelchair..." R16' record contains an "Incident/Accident Report" dated 7/18/11 that denotes, "Found resident on floor beside bathroom door." R16's record contains an "Incident/Accident Report" dated 8/5/11 that denotes, "Resident was found on the floor sitting on her bottom grabbing onto the arm of the wheelchair trying to get up..." R16's record contained an "Incident/Accident Report" dated 9/21/11 that denotes, "Resident found seated on Mat legs out stretched back resting against the wall...Resident stated that she was trying to go to the bathroom." R16's record contains an "Incident/Accident Report"dated 12/16/11 that denotes, "Told by Nurse Walter that resident is on floor. Noted resident on floor in the 300 hall vestibule laying on the left side...complained of left shoulder and arm pain..." The investigation denotes an interview with E11, a resident helper, who states, "I was watching in the west activity room from 7 PM to * PM. It was around 7:50 PM, I was sitting in the middle area of the room, the only residents left were ...(three resident names). One resident was trying to leave through the 100 hall alcove door. I got up and grabbed her pushing her back to the table. When I looked noticed that R16 was trying to leave through the 100 hall alcove door. She was already passed the door when I got to her...Before I could even touch her she suddenly stood up, falling over hitting her left arm against the wall..." R16's record contains nursing documentation that denotes on 12/16/11 R16 was sent to the emergency room because of pain in her arm and leg after a fall. R16's record contains a discharge instruction sheet that states she had a fractured left clavicle. R16's record contains a Minimum Data Set assessment dated [DATE] that states she is a one person moderate assist with transfers. R16's care plan lacked resident specific interventions after each fall. For example; After the 9/21/11 fall the facility repeated an initial intervention, "Remind resident to use call light, Ensure call light is in reach." The facility failed to address R16's need for supervision until after the 12/16/11 fall with fracture when the care plan states, "Don't leave resident unattended while up in wheelchair." In an interview with two certified nurse assistants E12 and E13, they both stated that R16 requires supervision when up in the wheelchair and that R16 can be impulsive in her behavior. 2) R3 is [AGE] year old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of MDS 12/6/2011 identified R3 requiring moderate to extensive assistance with transfers, mobility and ambulation. Review of the "Fall Risk Assessment" dated 8/8/2011, 6/7/2011, 9/2/2011 and 12/6/2011 showed that R3 is a high risk for fall. Observation on 1/30/12 at 11:45 A.M. showed R3 was in her wheelchair in the dining room. R3's upper body was leaning forward and has poor trunk control. R3 has a shoulder strap/harness that was released. A review of the facility's incident reports, R3 fell in the facility 16 times from 4/8/09 through 12/17/2011. -4/8/09 = " fell on her way to doctor's appointment, son pushing wheelchair and she (R3) fell forward" - 5/16/09 = found kneeling on the floor - 6/1/09= found on the floor - 9/1/09= found on the floor - 2/27/2010= sustained hematoma at back of head, sent to emergency for evaluation - 7/21/2010= found lying on the floor - 1/8/2011 = found kneeling on floor - 4/4/2011= found kneeling on floor - 4/7/2011= found sitting on floor - 6/20/2011= rolled from bed to floor mattress - 7/11/2011= rolled from bed to floor mattress - 7/16/2011= rolled from bed to floor mattress - 7/17/2011= rolled from bed to floor mattress -10/8/2011= found on floor 10/8/2011 =R3 took shoulder strap/harness off and transfer self unassisted and fell 12/17/2011= found kneeling on floor Review of R3's current care plan did not include up-dated and revised specific interventions after each fall nor were the falls analyzed to find the root cause in an attempt to prevent further falls. During an interview on 2/2/12 at 1:30 P.M., E8 (restorative nurse) and E5 (Assistant Director of Nursing) stated that " we did not consider rolling from bed to floor was a fall incident, therefore care plan was not updated for interventions." E8 also stated that R3's interventions for fall preventions are as follows: shoulder strap/harness implemented on 9/17/2007; bed and chair clip alarm on 9/17/07 and restorative program on 3/20/2010. E8 further stated that there were no revision for specific approaches in order to prevent R3 for further falls. 3. R12's face sheet in the medical record, documents that R12 is a [AGE] year old female, with [DIAGNOSES REDACTED]. R12's Minimum Data Set ((MDS) dated [DATE] denotes her functional status for transfers as requiring 2 persons to physically transfer from the toilet. An incident investigation report initiated 12/13/11.states that on 12/13/11, at 9:00 am while being transferred off of the toilet, R12 was lowered to the floor by E9, a Certified Nurse's Assistant (CNA). R9's statement in the incident report documents that R12 stood up unassisted from the toilet; her feet started slipping so she, E9, lowered R12 to the floor. On 2/1/11 at 10:30am, in a visiting room in the facility, E9 stated that she was new to the unit where R12 lived and not familiar with R12's transfer needs. E9 elaborated that she was told by another staff member to take R12 to the washroom. When asked how many people does it take to transfer R12, she staid two. When asked how many staff were involved in transfer E9 said she transferred R12 by herself. At 11:00 am on 2/01/12, E2 (DON) was asked how staff are made aware of resident's needs. She answered that resident care cards are located in the shower rooms in the wing where a resident lives. When further asked about the result of the incident investigation, she said that E9 was given a written warning as a result of this incident. B. Based on observation and interview the facility failed to maintain environment that is free of accidents hazard by leaving medications unsupervised in the hallway. Finding include: During medication pass observation on 01/31/12 at 8:50 AM, E10 (Nurse) went to room 303 to give medication to R24. E10 left the medication cart in the hallway with a bottle of Acidophilus with pectin on top of medication cart with out E10 visual control. E10 was informed regarding this observation. E10 stated "you were there". Bottle label says " Keep out of reach of children." Confused residents were observed wandering on the hallway. During the same medication pass observation on 01/31/12 at 9:28 AM E10 gave medications to R23 in room 301 B. After giving the medications to R23, E10 went to room 300 bathroom to wash her hands. E10 left the medication cart in the hallway near room 301 unlocked and unattended. Medication cart was not in E10's visual control. E10 was informed regarding this observation after getting out of the bathroom. While E10 was pulling the medication cart, the medication cart drawers started to slide out. E10 was asked if there were confused and ambulatory residents that resides in this hall. E10 stated "yes" On 02/02/12 at 11:30 AM, E5 ADON (Assistant Director of Nursing) said that there are confused and ambulatory residents in this 300 hall.