Every finding on record at Alpine Care of Evanston

Based on interviews and record reviews, the facility failed to follow its mechanical lift policy by not using a mechanical lift for residents who are too heavy to lift or cannot assist with a transfer. This failure resulted in a metatarsal fracture in 1 of 3 residents (R2) reviewed for transfer and injury in a sample of 4.The findings include:R2 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE] and with an admitting diagnosis including hemiplegia secondary to cerebral infarction/CVA, seizure, and history of falling.On 7/11/26 at 9:50 AM, R2 was observed on his bed and stated, I can't walk. The lady (V3) tried to put me in the wheelchair, and I fell. I was heavy for her, and she was holding my hand to transfer. She was trying her best, and she didn't put any gait belt on me to transfer.A review of the facility reported incident dated 5/24/26 documented a left metatarsal fracture to R2 when V3 assisted R2 to transfer him to a wheelchair. The report also documented that R2 was sent to the ER (emergency room) at around 6:35 PM as he developed swelling in his left ankle.A review of the health status notes on 5/24/26 at 11:24 PM documented that R2 returned to the facility around 11:07 PM with a diagnosis of left metatarsal fracture. The health status notes also documented that an X-ray of the left foot confirmed the Metatarsal fracture.On 7/11/26 at 10:30 AM, V4 (R2's nurse on 5/24/26) stated, My certified nursing assistant/CNA (V3) attempted to transfer R2 to a wheelchair by herself. R2 is a mechanical lift transfer resident, and I don't know why V3 tried to transfer R2 to a wheelchair by herself and without using a mechanical lift. R2 has foot drop in both feet and left-sided weakness from a stroke.On 7/12/26 at 10:05 AM, R2 was observed on his bed along with V4. R2 is flaccid in the left lower extremity secondary to CVA.On 7/12/26 at 10:05 AM, V4 added that R2 had always been on a mechanical lift transfer, even before the incident on 5/24/26.On 7/11/26 at 11:45 AM, V8 (Restorative Nurse) stated, V3 assumed she could transfer R2 by herself. R2 requires 1-2 people with substantial assistance. V3 shouldn't have tried by herself.On 7/11/26 at 12:20 PM, V2 (Director of Nursing) stated, We suspended V3 after the incident on 5/24/26 and in-serviced her on the day she came back. R2's wife was also upset about the incident. V3 should have used a mechanical lift to transfer R2.The facility presented a mechanical lift transfer policy revised on 2/1/26, documented: A portable lifting machine should be used to help lift residents who may be too heavy to lift or who cannot assist with a transfer.

Based on interview and record review the facility failed to implement facility abuse policy post resident to resident physical altercation. This failure affected one (R2) of three residents reviewed for abuse. Findings include:Facility reported incident on 3/15/26 between R1 and R2, it was reported to administration that an altercation occurred, both residents separated immediately and nurse on duty completed head-to-toe assessments. Both residents sent to hospital for evaluation. MD and family notified. On 4/23/26 at 11:50AM, V1 (Administrator) said that abuse assessments and care plans should be updated at minimum quarterly, annually and post any incident or significant change. V1 said that facility abuse policy indicates resident assessment should be updated post incident to reassess residents. V1 said she is aware it was not completed for R2. On 4/23/26 at 12:03PM, V3 (Social Service Director) said that social services is responsible in updating abuse care plans and abuse assessments post any incident or significant changes. V3 said she is unsure why it was not completed for R2. On 4/23/26 at 2:40PM, V2 (Director of Nursing) said that the residents abuse care plan and assessments should be updated after incident to reassess and identify the risk levels for abuse, based on facility abuse policy. R2 is a [AGE] year old, admitted to facility on 1/23/26 with the following diagnosis in part but not limited to: encounter for palliative care, anemia, hypothyroidism, unspecified protein-calorie malnutrition, hypokalemia, Parkinson's disease, acute on chronic diastolic congestive heart disease, pleural effusion, gastro-esophageal reflux disease, pressure ulcer of sacral region, generalized edema, pneumonitis due to inhalation, chronic kidney disease.R2 Social Service Assessment/abuse screener dated 1/27/26- indicates low risk.R2 abuse care plan- not available. Facility Policy on Abuse and Retaliation- revised 1/2026GuidelineTo provide information for the facility on managing abuse. PolicyThis facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by:-establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. - identify occurrences and patterns of potential mistreatment.- immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property. - implementing systems to promptly ad aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. V. PreventionAbuse may be prevented by instituting the following systems:-Identify, assess and care plan appropriate interventions for residents with the following behaviors/situations:-verbally aggressive behavior- physically aggressive behavior The facility will take steps to prevent potential abuse while the investigation is underway, -Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to the separation of the residents. -Residents who are the victim of abuse will be examined for any signs of physical or psychological injury. Increased supervision for the victim will occur. Room od staffing changes will occur if needed to protect resident from alleged perpetrator. Emotional support and counseling will be provided.

Based on interviews and record review, the facility failed to ensure appropriate monitoring and supervision to a resident with known fall risk and impaired safety awareness to prevent accident hazards for 1 (R1) of 3 residents reviewed for supervision needs in the sample of 3.Findings include:R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Difficulty in Walking; Unspecified Cataract; Hyperlipidemia; Personal History of Other Malignant Neoplasm Of Skin; Hypothyroidism; Nontraumatic Subdural Hemorrhage; History of Falling; Cerebral Edema; Essential (Primary) Hypertension; Attention-Deficit Hyperactivity Disorder; and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has no BIMS (Brief Interview of Mental Status) score, short-term and long-term memory problems. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, R1 requires substantial/maximal assistance with toilet transfers. Absent is documented fall plan to show R1's fall prevention interventions. On 2/17/2026 at 12:37 PM Per record review, R1 hospitalized on [DATE] with not return to the facility.On 2/17/2026 at 1:08 PM V4 (Licensed Practical Nurse) said, R1 was admitted to the facility for only brief time, less than 24 hours. R1 was blind, alert x 3, and able to carry a conversation. On 1/31/2026 on day shift (7:00 AM - 3:00 PM), we had clinical students in the facility following our CNAs (Certified Nurse Assistants). R1 was assigned to V5 (Certified Nurse Assistant) that day. I was told that R1 was placed in the bathroom by clinical student. R1 was urinating on the floor, so the student left to get help to clean the mess, and by the time they came back, R1 was on the floor. It appeared that R1 slipped on the wet floor. R1's head was leaning against the wall. I was called, among other staff, to get R1 off the floor. At the time of my assessment, R1 did not have any visible injuries. I notified the doctor, let the doctor know that R1's fall was unwitnessed and R1 was on anticoagulants, so R1 was sent to the hospital. After R1 went out to the hospital, V6 (Family Member) said R1 will not be coming back to the facility. R1 was diagnosed with subdural hemorrhage. R1 was at high risk for falls. The only fall prevention intervention that I remember was that R1 had a bed alarm. Upon admission to the facility, V6 (Family Member) made us aware that R1 requires constant monitoring due to blindness. R1 was complaisant, wasn't trying to get out of bed or anything.On 2/18/2026 at 11:07 AM V5 (Certified Nurse Assistant) said, I was assigned to R1 on 1/31/2026 7:00 AM - 3:00 PM. I remember that R1 was blind, alert but a little confused. A clinical student and I took R1 to the bathroom early in the day. R1 was peeing on the floor. I tried to redirect him, but R1 insisted he knew what he was doing. R1 was somehow difficult to redirect. We finished cleaning R1 up, getting him dressed, put R1 back in the wheelchair, and left the room. During lunch time, we were passing food trays. R1 needed feeding assistance. I asked the clinical student to assist R1 with feeding. From my understanding, R1 requested to go to the bathroom during lunch meal. The clinical student came out to grab me to let me know that R1 was attempting to get up, and when I came into the room, R1 was already on the bathroom floor. There was a puddle of urine on the floor. I called for help, we got R1 off the floor with a gait belt and sheet and put him back into bed. R1 seemed fine, he kept saying he was fine. In the morning report, I was told that R1 is blind and needs assistance with feeding, I also figured he is a fall risk. R1 had bed alarm. R1 was transferred from bed to chair and bathroom with a gait belt. R1 wasn't great at following directions, very stubborn. On 2/18/2026 at 11:44 AM V2 (Director of Nursing) said, R1 was admitted to the facility on [DATE] and stayed here less than 24 hours. After getting a referral packet, we knew R1 was a high risk for fall. When there is a high-risk resident coming into the facility, we apply bed and chair alarm, we also try to place residents near the nursing station. R1 was placed in the furthest room from the nursing station because we didn't have available room near the nursing station, but we were anticipating room close to the nursing station to become available, so this was not a permanent room placement. R1's fall was investigated by V8 (Fall Coordinator). Clinical students cannot provide accurate monitoring and supervision for residents. Proximate supervision means that facility staff should be physically present with clinical students while providing direct patient care. We didn't report R1's fall. We report fractures or active hemorrhage. Based on R1's record, he had ongoing issues related to brain procedures and prior subdural hemorrhage as well. Based on the hospital record, we determined that we were not sure if this was an acute hemorrhage and after consulting with our former administrator, who's no longer here, we decided not to report this incident. Per record review, progress note dated 1/31/2026 written by V4 (Licensed Practical Nurse) reads in part, Vital Signs: BP 120/87 P 97 R 18 O2 97.0% RA T 98.3. Around 12:10 pm, CNA notified NOD that (R1) is on the ground. NOD went to assess resident and observed him sitting on the bathroom floor with his head against the door. Vitals were obtained. (R1) denies pain or discomfort. No visible injuries noted. Resident stated, I was coming out of the bathroom, but I slipped and fell. Resident was assisted back to his wheelchair by 3 CNA. MD paged and gave an order to send a resident to (local) Hospital ER for further eval. (V2) DON notified. (V6) made aware. 911 called. Around 12:35pm, (R1) transferred to (local) Hospital ER. Per record review, R1's Fall Risk Evaluation performed on 1/30/2026 scores him at 6, indicating low risk for fall.Per record review, R1's hospital record dated 1/31/2026 shows Stable appearance of a 7 mm subdural hemorrhage along the parieto-occipital convexity. In the setting of recent trauma, CT cannot definitely distinguish between a density that reflects a superimposed hyperacute/acute hemorrhage (subarachnoid or subdural), which cannot be entirely excluded.The facility Student Facility Responsibility policy (no date) reads in part, Patient Care. While at the Facility, students and faculty are not to replace the Facility staff and are not rendering service except as identified for educational value and delineated in the jointly planned educational experiences. Any such direct contact between a student and a patient shall be under the proximate supervision of a member of the staff of the Facility.

Based on interview and record review, the facility failed to ensure that 1 of 3 residents (R1) was treated with dignity and respect during care interactions and administrative care plan meetings reviewed for dignity from the sample of 3. R1 is a [AGE] year-old with diagnoses including but not limited to Meniere's Disease, PTSD, and Acute Metabolic Acidosis.R1's MDS dated [DATE] section C for cognition shows R1 with a BIMS (Brief Interview for Mental Status) of 15 demonstrating cognitively intact. On 01/09/2026, R1 reported that V14 LPN slammed medications onto her table and said a profanity while giving her her medications. The resident subsequently overheard the nurse refer to her as a f***ing problem.During a care plan meeting, the Administrator (V1) allegedly threatened R1 and her husband with eviction and being banned from the facility if they continued to voice grievances, stating the facility is not a hotel.On 1/14/26 at 11:00 AM R1 was seated up in bed on the telephone with (husband) and surveyors asked to speak with the resident. Resident appeared alert, oriented to self, time, and place, and situation and said that last Friday night V14 (LPN) the nurse slammed medications down on her bedside table and said Shut the f*** up. Here's your f***ing medication then preceded to walk out and she overheard the nurse and CNA talking and heard her say, That bitch is a f***ing problem. Started with resident pulling the call light and it took about 10 min for someone to come and then the CNA a tall black man (later identified as V16 CNA) came in didn't talk and just cowered over her and she requested him to assist her to get to her bedside commode. Resident said that the CNA said nothing, didn't instruct her or guide her on what to do, and just stood there and extended his arm. V16 didn't use his gait belt and said that she was afraid she would fall but the CNA didn't do anything and when she sat on the commode she asked him to stay nearby but instead left the room. She asked him to get the nurse because she had pain in her stomach and had gas pain and chest hurt. she asked for tums and for Tylenol. This is when the nurse was very mad, and slammed the pills down (R1 demonstrates how she slammed the pills that were in the cup) and started using profanity. R1 went on to say that they had a care plan meeting in her room with the administrator (V10 , DON, V2, therapy V11 and Restorative nurse V9 and she thinks the wound nurse. R1 said the administrator said that this is not a hotel and threatened her and her husband that she would be thrown out and banned from the place if her husband kept screaming at the staff and if she did the same. Resident denies screaming at the staff but is frustrated that she does not get baths as requested due to her illness and requires baths daily. (a sign on wall from management says she is to receive baths daily). Says that it frustrates her that they claim she refuses therapy but that she refused once because she is claustrophobic and has to go into the elevator to go to basement to receive therapy. R1 said they just discontinued her therapy and said that they were not given any notice from insurance saying she could no longer receive any therapy but only restorative. on 1/14/26 at 1:45 PM V14 LPN, said that she attended to R1's call light and that she was screaming and screaming so she could get some antacid medication which she gave the resident but that the resident kept screaming and was offered a Tylenol. V14 denied saying anything to the resident and indicated she did not use profanity towards the resident. Surveyor asked if she was upset with the resident, V14 said, I was not upset with her. She (R1) has anxiety and PTSD. On 1/14/26 at 2:30 PM, V16 CNA said that the resident R1 and asked him to come in to the room to assist her to get on the commode which he obliged doing. V16 went on to say he witnessed the nurse V14 being rude to the resident but that the resident was screaming for medications and kept screaming even after being given the medications but believed that the nurse was lacking in professionalism by being rude to the resident. When asked specifically what he heard the nurse saying, V16 could not recall the exact words but just said it was rude and harsh. On 1/14/26 at 2:45 PM, V1 administrator affirmed he was in the care plan meeting with the resident and husband but denied threatening either of them for eviction nor said anything derogatory to the resident pertaining to her appearance. V1 did however comment on the resident's food choices because of his own personal experiences with diabetes. V1 added that there may have been a comment pertaining to the facility not being a hotel because the husband and resident had unrealistic expectations of the facility. As a recap: On 01/09/2026, R1 reported that a nurse displayed a lack of professional customer service by using inappropriate language and slamming medication cups onto the bedside table during a routine medication pass.During a care plan meeting on 01/15/2026, the facility administration failed to maintain a supportive environment by making insensitive remarks regarding the resident's medical diagnosis and physical appearance. Specifically, the Administrator V1 suggested the resident's health condition was a direct result of personal habits, which the resident found demeaning.A staff member failed to provide proper guidance or verbal instruction to R1 during a transfer to a bedside commode and left the resident unattended against her expressed preference for a staff presence.These failures left R1 feeling frustrated and disrespected by staff, undermining the facility's responsibility to provide care in a manner that maintains or enhances each resident's dignity and individuality.

Based on observation, interview, and record review the facility failed to obtain order for usage of oxygen, ensure oxygen tubing are label on date when it was changed, and oxygen humidifier water bottle are not emptied. This deficiency affects all four residents (R3, R9, R85 and R96) in the sample of 20 reviewed for Oxygen management. Findings include: 1.On 12/2/25 at 12:10PM, Observed R9 lying in bed with oxygen via nasal cannula at 3 LPM (liters per minutes) with V17 LPN (Licensed Practical Nurse). Observed oxygen tubing not dated and tangled around the bedside rail. V17 said oxygen tubing should be free from tangled and kinks. The oxygen tubing should also be dated when it was changed weekly. R9 is admitted on [DATE] with diagnosis listed in part but no limited to Chronic Obstructive Pulmonary Disease (COPD), Pleural effusion, Palliative care. Active physician order sheet indicated Oxygen continuous (2-3) liters per minute (LPM) via nasal cannula every shift. Check humidifier water level every shift and as needed. Comprehensive care plan indicated that she is on oxygen therapy related to ineffective gas exchange, Respiratory illness, and mild COPD.2.On 12/2/25 on 12:15PM, Observed R96 lying in bed with family members at bedside. She has oxygen via nasal cannula at 3LPM, the tubing is not dated. V17 LPN said that oxygen tubing should be dated. R96 is admitted on [DATE] with diagnosis listed in part but no limited to Cerebral infarction due to occlusion or stenosis of left middle cerebral artery. Active physician order sheet indicated oxygen at 3LPM via nasal cannula for spO2 below 90% every shift for shortness of breath. No care plan formulated for usage of oxygen. 3.On 12/2/25 at 12:20PM, Observed R85 lying in bed with oxygen via nasal cannula at 3LPM with emptied humidifier bottle and oxygen tubing not dated. V17 LPN said that oxygen tubing should be dated, and humidifier bottle water should be check and replaced when emptied. R85 is admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis, muscle wasting and atrophy, Active physician order sheet indicated: continuous oxygen at 2LPM per nasal cannula. Comprehensive care plan indicated she is on oxygen therapy related to ineffective gas exchange, respiratory illness interstitial pulmonary disease. Intervention: Give oxygen as ordered by the physician4.On 12/2/25 at 12:27PM, Observed R3 lying in bed with oxygen via nasal cannula a 2.5 LPM with tubing not dated. V17 LPN said that oxygen tubing should be dated. R3 is admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis, paroxysmal atrial fibrillation. Active physician order sheet did not have order for oxygen usage. Comprehensive care plan did indicate plan for oxygen usage. On 12/3/25 at 9:42AM, Informed V2 DON (Director of Nursing) of above concerns with R3, R9, R85 and R96. V2 said that oxygen tubing should be dated when it was changed, and humidifier water bottle should be check and replaced as needed.On 12/4/25 at 1:22PM, Reviewed R3's medical records with V30 Nursing Consultant. V30 said that resident using oxygen should have physician order and should be care planned.Facility's policy on Oxygen Therapy and administration revised 7/2/25 indicated: Purpose: To assure adequate oxygenation to all spontaneous breathingNote: b.1. Oxygen rounds include checking the humidifier bottle has at least an inch of water. c. Oxygen setups should be changed every seven days and as needed if heavy soiling is present. Facility's policy on Physician orders revised on 7/3/25 indicated: Policy statement: it is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POC.

Based on observation, interview, and record review the facility failed to ensure resident medications were appropriately stored. This deficiency has to potential to affect all 5 residents (R7, R32, R49, R60, R74) reviewed for medication storage in a sample of 20.Findings Include:On 12/2/25 at 11:30AM, Observed V7 Wound Care Nurse (WCN), V21 Wound Tech, and V22 CNA (Certified Nurse Assistant) performed wound care to R7. Observed the following medications at bedside: Ketoconazole 2% cream, Zinc Oxide 4%, Triamcinolone 0.1% ointment and Mupirocin ointment 2%. V7 WCN that treatment medications should not be allowed at bedside unless ordered by physician but R7 requested his medications at bedside. She said that R7's son also brought medications from home. R7 said that he has the CNA apply those medications after incontinence to his buttocks. V7 added that R7's son also applied the medications when he comes to visit. On 12/3/25 at 9:24AM, Informed V2 DON (Director of Nursing) of above concerns. V2 said that resident cannot keep treatment medications at bedside without physician orders. On 12/4/25 at 1:29PM, Reviewed R7's medical records with V2 DON. R7 was admitted on [DATE] with diagnosis listed din part but not limited to Psoriatic arthropathy, Type 2 Diabetes Mellitus, Contracture left knee, anxiety disorder, adjustment disorder with depression. Dementia. Active physician orders indicated: Mupirocin external cream 2% apply to drain site topically every day shift for wound care. Apply to drain site and covered with bordered gauze. Triamcinolone Acetonide external cream 0.1% apply to buttocks, back and thighs topically every day shift for wound care. Triamcinolone Acetonide external cream 0.1% apply to upper back topically as needed for it the dressing is compromised daily as needed PRN). Triamcinolone Acetonide external cream 0.1% apply to upper back topically for wound care. Cleanse with NS (Normal Saline). Pat dry. Appy triamcinolone and leave open to air daily and PRN. Informed V7 that R7 does not have order for the following medications: Ketoconazole 2% cream and Zinc oxide 4%. V2 DON said that those medications were brought by V23 family member. R7's comprehensive care plan indicated: He exhibits the symptoms of resisting care which is refusing to follow doctor's orders and guidance promoting optimal health specifically complying with daily wound care and wound care treatments. The resident often dismisses health diagnosis and believes the approach to treatments is more beneficial that what is recommended by the health care professionals. He is at high risk for pressure sore development based on Braden scale score of 13 and related to arthropathic psoriasis, seborrheic dermatitis. R7 is not care planned that he wants to keep his medication at bedside. Facility's policy on medication Storage, Labeling and Disposal revised 7/2/25 indicated: Procedures: 4. Medications will be secured in locked storage area. Facility's policy on Physician orders revised 7/3/25 indicated: Policy statement: it is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the physician order sheet. Procedures: 2. All medications administered to the resident/patient must be ordered in writing by the patient's attending physician. 3. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures as approved by the medical director. On 12/2/2025 at 11:07 AM, third floor refrigerator medication room observed with R32, R49, R60, R74 medications stored inside the refrigerator with a broken thermometer. Refrigerator daily monitoring log for November and December was incomplete and observed an expired medication inside the refrigerator for one resident (R49) with the label Konvomep (also known as Omeprazole) 2-84 mg/ml, date opened 8/28/2025, expired 9/27/2025. V16 (Registered Nurse) said he was not aware the thermometer was broken, and refrigerator daily log is completed by night shift nurse. V16 returned the expired medication in the refrigerator. On 12/3/2025 at 9:21 AM, V2 (Director of Nursing) stated broken refrigerator thermometer should be reported to maintenance right away so a replacement can be obtained, refrigerator daily monitoring log should be checked, and form filled out daily, and no expired medication will be kept in the medication refrigerator. Expired medication should be removed and discarded. Policy and Procedure Policy Title: Storage of Medications, no revision Policy: Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 7. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from pharmacy if current order exists. Temperature 3. Medications requiring refrigeration are kept in refrigerator at temperatures between 2 C (36 F) and 8 C (46 F) with a thermometer to allow temperature monitoring. 5. The facility should maintain a temperature log in the storage area to record temperatures at least once a day. Expiration Dating (Beyond – use dating) 8. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview, and record review the facility failed to ensure that call light is placed within reach of resident who can use it all times. This deficiency affects one (R7) of three residents in the sample of 20 reviewed for Resident's accommodation of needs. Findings include: On 12/2/25 at 10:46AM, Observed R7 lying in bed. He is alert and oriented x3, able to verbalize his needs. Observed R7 has difficulty trying to reach for his call light that is tangled between the bed siderail and mattress. He has limited mobility on upper extremities. He said that he is trying to reach to for his call light to call for his nurse or CNA (Certified Nurse Assistant). Surveyor called for nursing staff assigned to R7. On 12/2/25 at 10:50AM, Showed observation made to V19 RN (Registered Nurse). V19 said that she gave R7's medication this morning and forgot to make sure that his call light is accessible to him. V19 removed the call light tangled between the siderail mattress by lifting the mattress.On 12/2/25 at 1:30PM, Informed V2 DON (Director of Nursing) of above observation. V2 said that resident's call light should be within reach and accessible to them. Facility's policy on Call light revised on 6/30/25 indicated: Procedure: 5. Be sure call lights are placed within reach of residents who are able to use it at all times.

Based on observation, interview and record review the facility failed to ensure a resident was out of bed when requested for 1 of 4 residents (R18) in a sample of 20 reviewed for self-determination. Findings include:On 12/2/2025 at 11:15am R18 said I ask every day to be placed in my wheelchair and the certified nursing assistants say they will and never return until later, I have not been out of the bed since my therapy was discontinued a couple of weeks ago at least 2 to three, I would like to get out of bed.On 12/2/2025 at 11:20am V24(Certified Nursing Assistant-CNA) said I assist R18 out of bed when she had therapy, it's been weeks since I have assisted her to her wheelchair, I don't think she is in therapy anymore.On 12/2/2025 at 11:25am V26(Licensed Practical Nurse-LPN) said R18 should be out of bed as requested by the resident or they are on a schedule for being up in the chair.On 12/3/2025 at 1:00pm V27(Rehab Director) said R18 does not have any bed restrictions she can be out of the bed as requested by the resident or a schedule she PROM-passive range of motion to all extremities.On 12/3/2025 at 10:30am V2(Director of Nursing-DON) said all residents should be out of bed as per a schedule, therapy or by the resident request no-one should be in bed because therapy was completed.A admission record indicates that R18 has a diagnosis of hemiplegia and hemiparesis and a history of falling, an order review report as of 4/22/2025 R18 nursing rehab transfer to manual wheelchair via full body lift 2-3 staff for safety , a care plan dated 1/25/2025 transfer via mechanical aid, lift sling, 2 staff for transfers, a occupational therapy Discharge summary dated [DATE]-[DATE] highest practical level achieved. Facility Policy: Statement of Resident RightsNo resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the state of Illinois, or constitution of the United States solely on account of his or her status as a resident of the community, nor shall a resident forfeit any of the following rights.(F) Self Determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs(f), (I) through (11) of this section.2. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident, including the right to exercise free choice in selecting activities, schedules and daily routines.

Based on observation, interview and record review the facility failed to ensure an indwelling urinary catheter was placed below the waist for 1 resident's (R77) and failed to follow physician order for indwelling catheter size usage and failed to empty the urinary drainage bag every shift and as needed for 1 resident (R7) of 4 reviewed for urinary catheter in a sample of 20. Findings include:On 12/2/25 at 11:30AM, Observed V7 Wound Care Nurse (WCN), V21 Wound Tech, and V22 CNA (Certified Nurse Assistant) performed wound care to R7. Observed urinary catheter tubing with sediments draining to dark yellow orange colored urine. V22 CNA emptied the urinary drainage bag using urinal. Urinary output obtained 1000ml. V22 said that the urinary bag was empty when she came at7:00AM. V22 said that R7 pee a lot. V7 WCN checked R7's indwelling urinary catheter size and said that he is on Fr 18 with 5cc balloon. On 12/2/25 at 1:28PM, Informed V2 DON (Director of Nursing) of above observation. V2 said that R7 cannot have a urinary out of 1000 ml from 7:00am to 11:30am. The night shift did not empty the urinary drainage bag after their shift ends. V2 said that she will provide in-service with her staff regarding urinary catheter management. On 12/4/25 at 10:52AM, Surveyor and V3 ADON (Assistant DON) checked R7's indwelling urinary catheter size of Fr 18 with 5 cc balloon. Reviewed R7's medical records with V3 ADON. R7 is admitted is admitted on [DATE] with diagnosis listed din part but not limited to Retention of urine, Functional quadriplegia, Benign Prostatic Hypertrophy (BPH)Obstructive and reflux uropathy, calculus of kidney. Active physician order sheet indicated: Indwelling catheter type (Foley) catheter size (18 Fr), (10cc) balloon, reason for use: BPH related to obstructive and reflux uropathy. Catheter care every shift. Change indwelling catheter drainage bag. Informed V3 that R7 has indwelling catheter size of Fr 18 with 5 cc balloon but the order is Fr 18 with 10cc balloon. V3 said that they should be following physician order for indwelling urinary catheter usage. Facility's policy on Physician orders revised 7/3/25 indicated: Policy statement: it is the policy of this facility to secure that all resident/patient medications, treatment and plan of care must be in accordance with the licensed physician's order. The facility shall ensure to follow physician orders as it is written in the POS. Facility's policy on Urinary catheter care revised 7/3/25 indicated: Purpose: to prevent catheter-associated urinary tract infections. General guidelines: a. Observed the resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly, report it to the physician or supervisor. Maintain an accurate record of the resident's daily output, per facility policy and procedureInfection Control:2. c. Empty the drainage bag regularly using a separate, clean collection container for each resident. d. Empty the collection bag at least every 8 hours. On 12/2/2025 at 11:10am this writer observed R77 in bed with her indwelling urinary catheter drainage bag attached to the upper bed railing above her waist. On 12/2/2025 at 11:45am this writer and V26(Licensed Practical Nurse) observed R77 urinary catheter drainage bag above the waistline. On 12/2/2025 at 11:48am V26 said R77 indwelling catheter drainage bag should be placed below her waist to prevent back flow and a possible urinary tract infection, V26 then placed R77 urinary catheter drainage bag below her waist. On 12/3/2025 at 10:30am V2(Director of Nursing-DON) said all indwelling catheter drainage bag should be placed below the waist to prevent urinary tract infections and backflow of urine into the bladder. An admission record for R77 indicates a diagnosis of quadriplegia, an order review report dated 12/4/2025 for an indwelling size FR16/10ml balloon for neurogenic bladder and functional quadriplegia and chronic multiple wounds, a care plan dated 4/15/2025 intervention please position catheter bag and tubing below the level of the bladder. Facility Policy: Indwelling Catheter revised/reviewed 6/30/2025 Policy Statement It is the facility's policy to ensure that no resident will have indwelling catheter, unless condition shows that there is a medical reason to justify the use of the indwelling catheter. Procedures 7. Indwelling catheter bag will always be positioned below the bladder region to prevent backflow if the foley bag has no anti-backflow valve.

Number of residents sampled:1Number of residents cited:1Based on observation, interview, and record review the facility failed to ensure enteral (tube) feeding management was implemented with medication administration affecting 1 of 1 (R85) resident reviewed for enteral feeding management in a sample of 20.Findings Include:On 12/3/2025 at 8:15 AM, V19 (Registered Nurse) administered one medication via enteral tube for R19 without checking tube feeding (TF) placement prior to administration. V19 stated she did not check for placement, but TF should be checked for placement prior to medication administration using pH strip or by aspiration. TF site was covered with clean dry dressing; there was no other placement confirmation identified. TF bottle was hanging and infusing at 50ml/hr, container did not have a visible start time. V19 said she cannot assume as to when feeding was started, there should be a start time of infusion. V19 reset the tube feeding machine to zero after medication administration. V19 flushed tube feeding with 60ml of tap (sink) water before medication administration and 90ml of water after one medication administration. V19 stated she gives extra flushing to R85 because she does not drink water.On 12/3/2025 at 9:21 AM, V2 (Director of Nursing) stated nurse should check tube feeding placement before medication administration. Tube feeding container should have name, rate, and start time of infusion. Tube feeding should be flushed according to physician order and policy.Review of Order Summary Report indicate start date of 8/13/2025, read Enteral Feed Order every shift Enteral feeding - Tube type: (G tube). Jevity 1.2, Rate: (50 ml/hr). start at 3pm and infuse for 21 hours or until 1050ml is reached per day. Flush Gtube 150 ml q 6hr.Policy and ProcedureTitle: Enteral Tube Feeding Care, Revised 6/30/25Procedure:3. Check that feeding bag is properly labeled to include: c. Date and time feeding was started.Title: Medication Pass, Revised 7/2/25Procedures:1. G-Tube Medications:c. Check placement of G-tube by checking if the marker of the actual enteral tube is still located at the G-tube insertion site.d. The nurse will aspirate the gastric content and confirm the pH of the aspirated material.e. Flush GT with at least 15 to 30mL of water before and after administering medications.

Based on observation, interview, and record review the facility failed to use appropriate infection control practices during medication administration. The facility also failed to obtain an order for EBP (Enhanced barrier precaution), place signage and set up for resident with surgical drainage tube on left inner thigh. This deficiency affects two (R89 and R96) in the sample of 20 reviewed for Infection Control Program. Findings include: On 12/2/25 on 12:15PM, Observed R96 lying in bed with family members at bedside. No EBP ( Enhanced Barrier Precaution) signage posted and no set up outside her room. R96 is admitted on [DATE] with diagnosis listed in part but no limited to Cerebral infarction due to occlusion or stenosis of left middle cerebral artery. Active physician order sheet indicated Empty right side groin JP (Jackson Pratt) drain every shift for right groin hematoma. Monitor JP drain site every shift ordered 12/3/25. No ordered for EBP (Enhanced barrier precaution). On 12/4/25 at 10:44AM, Rounds made with V3 Infection Preventionist to R96. Still observed no EBP signage posted and no set up outside her room. Informed V3 that R96 has JP drain on her right surgical incision inner thigh. V3 said that R96 should have an order for EBP due to surgical drainage. R96 should have EBP signage posted and set up outside her door. Facility's policy on Enhanced Barrier Precaution (EBP) revised 9/16/25 indicated: Policy: The facility will use EBP to reduce transmission of multi-drug-resistant organism in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high contact resident care activities for residents known to be colonized or infected with MDROs as well as residents with wounds and or indwelling medical devices. Procedure: 1. EBP will be used for any resident in the facility: *Has indwelling medical devices regardless of XDRO colonization status.7. An EBP sign should be posted on the doors of each resident on EBP On 12/2/2025 at 9:40 AM during medication pass observation V15 (Licensed Practical Nurse) prepared a medication Magnesium 100mg as ordered by physician for R89. Magnesium Oxide was not available at 100mg but a house stock Magnesium Oxide 400mg tablet was available. V15 proceeded with dispensing the 400mg, cut it into four parts, retrieved one-fourth of the medication and returned the remaining three-fourths in the original bottle of Magnesium Oxide (400mg) while touching medication with her bare hands and without performing hand hygiene throughout the process. V15 stated the remaining portion of the tablet should not be thrown away and should be returned in the original bottle container because that is what she read in the book at nursing school. On 12/3/2025 at 9:21 AM V2 (Director of Nursing) stated medication should not be touched using bare hands and once dispensed and split into four, remaining unused medication should be discarded and not returned into original bottle for infection control purposes. On 12/4/2025 at 9:20AM V2 stated facility does not have policy and procedure specific to handling medications, but as standard of practice, medications should not be handled with bare hands because of infection control. Review of R89 Order Summary read, start date of 11/16/2025 Magnesium Oral Tablet 100 MG. Give 1 tablet by mouth one time a day for supplement for 30 Days.

Based on observation, interview, and record review the facility failed to ensure to update facility's daily nurse staffing information form posted at the front desk. This failure has the potential to affect 92 residents receiving care in the facility. Findings include: On 12/2/25 at 9:24AM, Observed daily nurse staffing form posted at the front desk indicated date of 11/24/25. V14 Receptionist said that she got busy due to holiday and forgot to update it. She said that she is responsible for updating the nursing daily posting when she comes to work at 8am. On 12/2/25 at 1:28PM, Informed V1 Administrator of above observation. He said that the daily 24-hour nurse staffing form should be updated and posted on daily basis. V1 said that they don't have policy on daily nurse staffing posting. Facility unable to provide policy.

Based on interview and record review, the facility failed to follow their policy in alerting a resident's responsible party of a change in condition for weight loss and new identified wound. This affected one resident (R1) of three residents reviewed for notification of change in condition. Findings include:On 7/16/25 at 12:00PM, V1 (Administrator), said that about one hour before R1 was discharged V5 (Wound Care Nurse) was notified about the new wound identified on R1. When V5 went to see R1 the resident was discharged , did not notify the Physician because the resident had already left the facility.On 7/16/25 at 12:15PM, V2 (Director of Nursing), said if a new wound was observed on the resident, then nurse will notify MD (Medical Doctor) to obtain treatment orders and notify family. V2 said she was made aware of the new wound identified on R1 by V3 (Registered Nurse). V2 said that for weight loss identification the facility will notify Nurse Practitioner, and registered dietitian will be notified. V2 said that family was not notified of changes in weight and the responsible party was not made aware of wound identified prior to discharge. On 7/16/25 at 2:05PM, V3(Registered Nurse) said that he was the nurse who discharged R1 on 7/14/25, R1 had a new wound, said it was about 2cm (centimeters) by 2cm, no discharge and covered the wound with a dressing. V3 said he did not notify the Physician or Nurse Practitioner.R1 is admitted on [DATE] with diagnosis listed in part but not limited to Parkinsonism, difficulty in walking, unspecified lack of coordination, anemia, other specified anxiety disorder, insomnia, vertigo of central origin, spinal stenosis, retention of urine, multiple fractures of ribs. admission Braden Assessment on 6/24/25- Braden/skin assessment indicated R1 is at high risk for developing pressure ulcers/skin impairments. Physician order summary report indicates may use pressure relieving device when indicated, skin-apply house stock topical moisturizer, pressure reducing chair cushion to wheelchair, turning and repositioning at regular intervals, Weights upon admission/readmission x4 weeks, then monthly. Care plan for Impaired mobility function related to weakness, unsteady gait, impaired physical function, neuropathic pain poor safety awareness-. At risk for alteration in nutritional status related to alcohol use disorder- monitor for signs and symptoms of dehydration and weight loss. High Risk for pressure sore development, based on Braden score of 17 and related to diagnosis- apply pressure relieving cushion to the wheelchair, Registered dietician recommendations as needed, skin check every shift. Pay special attention to bony prominences. Assess skin during bed bath/shower and routine care. Facility Policy on Notification for Change of Condition- revised 7/2/25.Policy StatementThe facility will promote care to residents and provide notification of resident change in condition status. Procedures1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the residents legal representative or an interested family member when there is:b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).Facility Policy on Weights-revised 7/3/25.Policy Statement It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician. For a resident who is on dialysis, the resident's dry weight will also be obtained monthly. Procedures 1. During the 1st week of the month, the restorative staff or designee will weigh each resident to fulfill the monthly weight requirement. For the dialysis residents, their dry weights will be obtained on the first week of the month immediately after the residents come back from their dialysis. 2. The monthly weights will be reflected on the resident's individual chart. 3. The significant weight changes (monthly (5%), quarterly (7.5%), and every 6 months (10%) will be assessed and addressed by the IDT which includes but not limited to the Dietician, Physician, Medical Specialist, Speech Therapist, Nutritionist, and Nurses.

Based on interview and record review the facility failed to assess newly identified wound. The facility also failed to notify physician and obtain wound care treatment. This deficiency affects one (R1) of two residents reviewed for Wound/Pressure Ulcer Prevention and management. Findings include:On 7/16/25 at 11:50 AM, V4 (Social Service Director) said if a new wound is identified then we notify our wound care nurse, then she will evaluate and decide if the resident will be able to go home and home health is notified as well.On 7/16/25 at 12:00PM, V1 (Administrator), said that about one hour before R1 was discharged V5 (Wound Care Nurse) was notified about the new wound identified on R1. When V5 went to see R1 the resident was discharged , didn't not notify the Physician because the resident had already left the facility.On 7/16/25 at 12:15PM, V2 (Director of Nursing), said if a new wound was observed on the resident, then nurse will notify MD (Medical Doctor) to obtain treatment orders and notify family. V2 said she was made aware of the new wound identified on R1 by V3 (Registered Nurse).On 7/16/25 at 12:30PM, V6 (Nurse Practitioner) said she was not aware of any new wounds found on R1 early in the morning before discharge, R1 did not complain of any pain or any signs of distress. V6 said she is unaware of the possibilities of R1 developing sepsis and dehydration after discharge.On 7/16/25 at 12:45 PM, V5 (Wound Care Nurse) said she was notified that R1 had a wound to lower back an hour before discharge and did not assess the resident, no measurements were taken. The MD and family were not notified. V5 said that R1 had already been discharged . On 7/16/25 at 2:05PM, V3 (Registered Nurse) said that he was the nurse who discharged R1 on 7/14/25. R1 had a new wound, and it was about 2cm (centimeters) by 2cm with no discharge. He covered the wound with a dressing. V3 said he did not notify the Physician or Nurse Practitioner and did not notify the family. On 7/17/25 at 11:00AM, V7 (Certified Nurse Aide) said she was taking care of R1 getting him changed before he was going home. V7 observed a blister to the lower back. V7 said it was small and black in color not open and informed V3.R1 is admitted on [DATE] with diagnosis listed in part but not limited to Parkinsonism, difficulty in walking, unspecified lack of coordination, anemia, other specified anxiety disorder, insomnia, vertigo of central origin, spinal stenosis, retention of urine, multiple fractures of ribs. admission Braden Assessment on 6/24/25- Braden/skin assessment indicated R1 is at high risk for developing pressure ulcers/skin impairments. Physician order summary report indicates may use pressure relieving device when indicated, skin-apply house stock topical moisturizer, pressure reducing chair cushion to wheelchair, turning and repositioning at regular intervals, Weights upon admission/readmission x4 weeks, then monthly. Care plan for Impaired mobility function related to weakness, unsteady gait, impaired physical function, neuropathic pain poor safety awareness-. At risk for alteration in nutritional status related to alcohol use disorder- monitor for signs and symptoms of dehydration and weight loss. High Risk for pressure sore development, based on Braden score of 17 and related to diagnosis- apply pressure relieving cushion to the wheelchair, Registered dietician recommendations as needed, skin check every shift. Pay special attention to bony prominences. Assess skin during bed bath/shower and routine care. Facility Policy on Wound Care Guidelines- revised 1/24/24OVERVIEW OF THE PROGRAM: This facility adheres to the Federal and State regulatory requirements for wound care management and the care guidelines for wound care established by the National Pressure Injury Advisory Panel. The goal of this care guidelines is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in the facility. The purpose of the prevention recommendations is to guide evidence-based care to prevent development of pressure injuries, and the purpose of the treatment focused recommendations is to provide evidence-based guidance on the most effective strategies to promote pressure injury/ulcer healing. PROCEDURES: 1. Timely identification of residents assessed to be at risk for skin breakdown. a. The Braden Scale must be completed by a licensed nurse on admission/re-admission and weekly for the first 4 weeks of admission/re-admission in the facility. A re-assessment shall be completed monthly, and as often as needed if there's a significant change in status of MDS. b. The scores from the Braden Scale and Clinical Evaluation should be interpreted/ calculated to determine level of risk: Low Risk High Risk c. Each risk factor and potential cause(s) identified should be reviewed individually and addressed into the resident's care plan. d. Facility shall develop a plan of care and implement intervention according to the resident's Braden Scale and Clinical Evaluation or identified individual risk factors. 10. Pressure Injuries Treatment a. Initiate wound care treatment upon identification of the wound with physician's order. b. Develop a care plan with appropriate interventions. c. Timely referral to the facility's Wound Care Specialist for all pressure injuries and/ or wounds.

Based on observation, interview, and record review the facility failed to ensure resident care areas were maintained in a clean, safe, and homelike condition by failing to ensure resident's rooms were clean, failing to adequately clean resident's care equipment after use and stored in a clean condition, and failing to keep resident's room furniture free of damage. These failures apply to six of six residents (R5, R10, R60, R62, R81, and R88) reviewed for environment. Findings include: R5 is an [AGE] year-old female with a diagnoses history of Dementia, Parkinson's Disease, Schizophrenia, Age Related Osteoporosis, and History of Falling who was admitted to the facility 06/29/2020. R10 is an [AGE] year-old female with a diagnoses history of Dementia, Parkinson's Disease, and Epilepsy who was admitted to the facility 10/08/2023. R60 is a [AGE] year-old female with a diagnoses history of Dementia, Inner Ear Disorder of Both Ears, and a History of Falling who was admitted to the facility 09/01/2021. R62 is an [AGE] year-old male with a diagnoses history of Dementia, Spinal Fusion, Paralysis of a Single Limb, Heart Failure, and History of Falling who was admitted to the facility 03/26/2020. R81 is a [AGE] year-old male with a diagnoses history of Impaired Brain Function, Severe Muscle Tissue Breakdown, History of Falling, and Need for Assistance with Personal Care who was admitted to the facility 01/16/2023. R88 is an [AGE] year-old male with a diagnoses history of Parkinson's Disease, Heart Failure, and Need for Assistance with Personal Care who was admitted to the facility 12/13/2024. On 02/03/25 at 10:35 AM, there was a PPE (Personal Protective Equipment) bin outside a resident's room on the first-floor hallway soiled with dust, and medical equipment in the hall near the bin soiled with multiple droppings. On 02/03/25 at 10:50 AM, V2 (Director of Nursing/DON) stated the medical equipment sitting in the hall near the PPE bin is a bladder scan machine that is not being used and it should be covered. V2 covered the soiled bladder scan machine with plastic without cleaning it. On 02/03/25 at 10:52 AM, R81's room wall had a cord hanging out of it and nothing hooked up to the cord and his clothes cabinet had a missing drawer, multiple broken drawer handles, and had dust buildup. R81 stated he has reported the condition of his clothes cabinet and staff also see it but nothing has been done. On 02/03/25 at 11:02 AM, R88 was lying in his bed with his oxygen cannula on and his oxygen machine was seen with a heavy amount of dust. On 02/03/25 at 11:05 AM, multiple PPE bins were outside of residents rooms on the 1st floor hallway with a heavy buildup of dust and some residue stains. On 02/03/25 at 11:44 AM, R5's bed railings on both sides were heavily soiled with a brownish red substance, a pillow had a heavily stained personalized pillow case sitting beneath her feet near the foot of her bed, her bedside drawers and vents had a heavy presence of dust and particles, her blinds had a heavy amount of dust, her head board had spots/stains, her bedside table was soiled with substances and dusty, a toothbrush was sitting on top of it with a dark buildup in the bristles, a remote control was sitting on top of it with a residue in between the dials, and her room garbage can was without a bag and had heavy buildup in the bottom. On 02/03/25 at 11:52 AM, R10's tube feeding equipment was attached to her and operating, heavily soiled with substances. Her oxygen cannula on her face and her oxygen machine was seen with a heavy buildup of dust and particles, blind's near her bed had a heavy buildup of dust, the nightstand drawers were left open with several care items sticking out of it, her bed rails were soiled with residue, the footboard pressure relieving machine was seen with a buildup, and her head board and walls behind her had spots and stains. R60's night stand had a heavy amount of dust and residue, and her bed frame underneath the head of her bed had a heavy buildup and trash. R10 and R60's room floor was seen with trash and their shared bathroom with soiled surfaces. On 02/03/25 at 11:59 AM, R62 was in his room lying in his bed, R62's bathroom garbage bin was soiled with a substance running down the side, his room floors were dirty and had trash on them. His bathroom sink had a significantly heavy calcified buildup around the faucet. On 02/04/2025 from 11:50 AM - 12:11 PM, V2 (DON) stated all resident's PPE bins should be kept clean and also their care equipment even when not in use. V2 stated if housekeeping staff are cleaning daily there shouldn't be any visible stains or dust left behind on care equipment or in their rooms. V2 made observations with surveyor of R5's room; surveyor observed R5's room to be in the same unclean condition as observed by surveyor on 02/03/2025 at 11:44 AM and V2 also confirmed these observations. When asked by surveyor if R5's room should be in the observed unclean condition V2 stated housekeeping comes in and cleans daily and confirmed that R5's room and furnishings are not clean and should be. V2 stated R5's pillowcase should have been cleaned in the laundry. V2 made observations with surveyor of R10 and R60's room; surveyor observed R10 and R60's room to be in the same unclean condition as observed by surveyor on 02/03/2025 at 11:52 AM and V2 also confirmed these observations. When asked by surveyor if R10 and R60's room should be in the observed unclean condition V2 stated oxygen equipment should not be found with dust and substances, care items should be placed inside the drawer when not in use, and all of R10 and R60's room furnishings and equipment should be maintained in a clean condition. V2 confirmed that residents rely on staff to keep their rooms in clean condition. V2 made observations with surveyor of R81's room and surveyor observed R81's room to be in the same condition as observed by surveyor on 02/03/2025 at 10:52 AM. V2 also confirmed these observations. V2 confirmed and agreed that staff enter the resident's rooms daily and if they observed R81's furniture damaged they should have addressed it and should have had the cord removed from his wall. V2 stated housekeeping and maintenance are responsible for room cleaning and maintenance. On 02/05/25 at 11:55 AM V2 (DON) stated R62 does use his bathroom and is dependent on staff for showers. V2 stated housekeeping staff are responsible for keeping R62's room clean including cleaning the floors and removing trash. V2 stated R62's bathroom faucet should be cleaned by housekeeping and there shouldn't be any heavy build up around the faucet. The facility's General Housekeeping Policy received 02/04/2025 states: The facility will ensure that the facility and resident rooms will be clean, and sanitary through housekeeping services. The housekeeping staff will clean and sanitize the resident rooms and bathrooms daily. The facility's Medical Care Equipment, Instruments and Health IT Devices Infection Control Plan Policy received 02/04/2025 states: It is the policy of this facility to prevent infection and create/maintain a safe environment for the residents, through proper cleaning and sanitizing of medical care equipment, instruments and or other related health devices. After equipment is properly cleaned, it may be stored in a clean bag and labeled Ready For Use and shall be moved to a clean storage location.

Based on interview and record review, the facility failed to provide effective fall interventions and adequate supervision for a resident while smoking. This failure applied to one (R21) of one resident reviewed for falls. Findings include: R21 is a [AGE] year old male who was originally admitted to the facility on [DATE] and continues to reside in the facility. R21 has multiple diagnoses including but not limited to the following: dysarthia, lack of coordination, abnormalities of gait and mobility, history of falling, and vertebra fracture. On 2/4/26 at 1:20PM, observed a smoking break and spoke with V19 (Activity Aide). It is to be noted that there were 7 residents present (5 in wheelchairs and 2 with walkers) smoking with 2 staff members supervising. V19 said I was present on 1/11/2025 when R21 fell outside while smoking. I was aware he fell on [DATE] outside while smoking but I was not present during this fall. R21 is in a wheelchair and has a habit of picking things up off the ground. V19 said I did not see R21 fall on 1/11/2025 but it is my understanding that he was in his wheelchair and reached down to grab his cigar. R21 fell out of his wheelchair and his face was on the concrete. I am not trained to transfer residents or evaluate them after a fall. I had to call nursing personnel and leave him in this position until someone came to assist. V19 said we should have as many staff supervising as we have residents in wheelchairs. It is difficult to push them outside, light their smoking material, and ensure they are being adequately supervised. On 2/5/25 at 10:59AM, V17 (Restorative Nurse/Fall Coordinator) said R21 admitted to us due to a mechanical fall at home. R21 was at risk for falls upon admission and requires assistance with his ADLs (activities of daily living). On 12/4/2024 at 9:00AM, R21 fell outside while smoking because he was trying to reach for his cigar that he had dropped on the ground. I provided him with a grab reacher to help assist R21 in grabbing things on the ground. However, R21 only uses this grab reacher in his room. V17 said on 1/11/25 at 4:00PM, R21 had another fall while outside smoking. He had dropped his cigar again and fell out of his wheelchair attempting to pick it up. He did not have his grab reacher with him at this time. V17 said I would have expected the staff to assist him when he dropped his cigar. It would not be appropriate for R21 to use his grab reacher to pick up his cigar, the staff should be providing him with assistance or a new cigar. V17 requires supervision when smoking. On 2/5/25 at 11:42AM, V18 (Vice President of Operations) said my expectation would be that the staff are physically watching and monitoring residents for safety when they are smoking. R21's smoking assessment dated [DATE] states in part but not limited to the following: R21 requires assistance with smoking due to impaired cognition and requires a wheelchair for mobility. Resident is not considered a safe smoker and requires smoking management and supervision consistent with facility policy. Facility policy titled Smoking with revised date of 8/19/2024 states in part but not limited to the following: It is the facility's policy to monitor and assess residents that smoke to promote smoking in a safe manner. Those who are assessed as unsafe smoking will be provided supervision during smoking. Facility policy titled Fall Occurrence with revised date of 7/26/2024 states in part but not limited to the following: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Based on interviews and records review, the facility failed to follow their policy to ensure a resident was free from abuse by one staff member being physically abusive toward one resident (R1), out of seven residents reviewed. This failure resulted in R1 experiencing emotional trauma. Findings include: R1's current face sheet documents R1 is an [AGE] year-old individual initially admitted to the facility on [DATE], with medical diagnosis that include but not limited to: displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R1's MDS (Minimum Data Set) section C documents R1's Brief Interview for Mental Status (BIMS) dated August 19, 2024, as 9/15, indicating R1 has moderate cognitive impairment. R1's MDS section GG-Functional Abilities documents R1 requires Partial/moderate assistance eating, Upper body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, Chair/bed-to-chair transfer. R1 requires partial to moderate assistance with Toilet transfer, and section GG further documents R1 needs Substantial/maximal assistance with Oral hygiene, Toileting hygiene, Shower/bathe self, Lower body dressing. On 09/08/2024 at 9:30 AM, V4 (Licensed Practical Nurse-LPN) who speaks Spanish and works with R1, interpreted for surveyor what R1 was saying in Spanish. R1 was observed in her room lying in bed awake, with R1's wheelchair next to R1's bed. R1 was alert and oriented to person, place, and situation and stated a female staff member with dark skin and regular height V3 (Certified Nursing Assistant), forcefully pushed R1 on R1's wheelchair and was hitting R1 when R1 tried to get up from her wheelchair. R1 stated this happened in the hallway next to R1's bathroom. R1 stated V3 held R1 by R1's shoulders and was pushing R1 down forcefully into the wheelchair and hitting R1. R1 stated she asked God why V3 was hitting R1 and R1 had not done anything wrong to V3. R1 was observed to be sad when talking about what happened to her and stated if R1 had strength, she would hit V3 back and pulled V3's hair, but because R1 does not have strength to hit V3, R1 prayed to God to help and protect R1. R1 started crying and stated her parents never hit her, and R1 did not know why V3 was rough towards R1 and hitting R1 on the shoulders. R1 stated she was screaming for help, but no one came to R1's rescue. R1 stated she is always afraid now, so R1 tries to look for good people in the facility to protect R1, and R1 will never forget V3 hit her. R1 further stated she was afraid of retaliation for speaking about what happened to her and R1 stated she did not want to talk about it anymore because it made R1 sad. On 09/08/2024 at 11:52 am, V6 (Activity Aide) stated she was in the dining room on the second floor opening her computer and was sitting down under the TV and V6 could see R1's bathroom from where V6 was sitting. V6 stated V6 observed R1 seated on the toilet then R1 got up and V3 was outside R1's bath. V6 stated she observed V3 push R1 back on to the toilet roughly and R1 fell on the toilet sideways. V6 stated R1 was screaming and crying and speaking Spanish stating Why are you doing this to me. I did not do anything to you. V6 stated when R1 screamed, nobody went to see what was going on. V6 stated she understood what R1 was saying because V6 speaks Spanish. V6 stated V3 was not startled by R1 and as soon R1 got up from the toilet, V3 pushed R1 back to the toilet. V6 stated the bathroom door was open when R1 was using the bathroom and V3 was right there with R1 looking at R1 as R1 was using the bathroom. V6 stated R1 was screaming and crying after being pushed by V3, then V3 assisted R1 to the wheelchair, got her dressed and brought R1 to the dining room. V6 stated V6 spoke to R1 and R1 was crying and told V6 that R1 does not know why V3 treats R1 like that because R1 did not do anything bad to V3. V6 stated pushing a resident roughly is a form of abuse. V6 stated before V6 left the facility for the day at about 5:30pm she reported to V8 (Licensed Practical Nurse-LPN) what V6 had witnessed because V8 was the nurse on duty for R1. On 09/08/2024 at 4:36pm V2 (Director of Nursing) and surveyor toured R1's floor and observed that sitting in the dining room near the TV, R1's bathroom is visible. V2 stated if a person is sitting in the dining room near the TV, the person can observe R1's bathroom directly. On 09/08/2024 at 11:10am, V3 (Certified Nursing Assistant -CNA) stated via phone that on Saturday 08/10/2024, V3 stated around 2:10pm, V3 was taking her break in the dining room and V8 come to the dining room and told V3 to watch R1 because R1 is a high fall risk, and R1 was trying to get out of the wheelchair. V3 stated she rushed to R1 and told R1 to sit down because R1 was almost falling. V3 stated she did not push R1 and just put her hand on R1's shoulders to seat her down. V3 stated R1 got agitated and started crying and stated V3 put her hands on R1's shoulders and asked R1 to sit down forcefully. On 09/08/2024 at 12:42pm, V8 (Licensed Practical Nurse-LPN) stated via phone that on 08/10/2024, V8 did not observe anything between R1 and V3 and it was V6 (Activities Aide) who reported to V8 that R1 wanted to use the washroom and V6 witnessed V3 being aggressive while V3 was transferring R1 from the wheelchair to the toilet. V8 stated V6 did not tell V8 right away about the incident, and V6 when to the front desk and called V8 after the shift was over and V3 had already gone home. V8 stated V6 told her this happened right before the first shift was over, therefore V8 was not able to ask V3 what happened. V8 stated they called V2 to inform V2 what was reported by V6 to V8, and then V1 called V8 to ask V8 what had happened. V8 stated she told V1 (Administrator) that V8 did not witness anything and that it was V6 who told V8 that V6 had witnessed V3 being aggressive with R1 during bathroom care. V8 stated she has heard V3 speak loud to R1 because of language barrier because R1 is Spanish speaking and is not fluent in English and V3 speaks broken English. On 09/08/2023 at 1:55pm, V9 (Social Services Director) stated she knows there was an incident report done regarding allegation of V3 and abuse on 08/10/2024, with R1. V9 stated that V3 was being unkind and rude to R1 while assisting R1 to the toilet. V9 stated after the abuse allegation, she V9 did not complete any assessments for R1. V9 stated she spoke to R1 based on report and offered R1 general emotional support, but V9 did not ask R1 what happened because V9 did not want to open the wounds of what happened with R1. V9 stated V9 did not discuss, investigate, or offer R1 support related to the incident. V9 stated she did not document any interactions between V9 and R1 regarding the abuse allegation because V9 interactions with R1 are ongoing. On 09/09/2024, V9 stated via email that R1's most recent BIMS (Brief Interview for Mental Status) scored a 09/15, which suggests R1 has moderately impaired cognition. On 09/08/2024 at 2:37pm, V2 (Director of Nursing -DON) stated on 08/10/2024, V8 (LPN) was the nurse on duty on R1's side of the unit and V8 called V2 stating that V6 (Activities Aide) had told V8 that V3 (CNA) had pushed R1 on the wheelchair in the dining room after R1 stood up. V2 stated V8 stated R1 was ok, V8 had notified V1(Administrator/Abuse Coordinator), and R1's physician and R1's family. V2 stated she spoke with R1 on 08/12/2024 when V2 come back to work and R1 was crying stating staff, staff. V2 stated interpreter services by phone was not working well on that day, so V2 did not understand R1 well. V2 stated there are nursing staff who can speak Spanish and can interpret for V2 what R1 was saying, but V2 did not use any of the staff to complete investigations. V2 stated she did not document anything regarding R1's abuse allegation investigations because she (V2) did not do a complete follow up with R1 about what happened. V2 stated V3 was suspended the same day on 08/10/2024, and V3 resigned on 8/16/2024. V2 stated R1's care plan was not updated after the incident/abuse allegation of 08/10/2024. V2 stated If it's not documented, it is not done. V2 stated no one; nurses, Social Services documented the abuse allegation by R1 on 8/10/2024 or any assessments completed after the allegation. V2 stated R1 should not be left alone in the bathroom because R1 is a high fall risk, and CNAs are supposed to bring all supplies to the bathroom when they take R1 to the bathroom. On 09/08/2024 at 3:31pm, V1(Administrator) stated he received a call on 8/10/2024 from V8 (LPN) around 5:00pm stating that on 08/10/2024, V8 told V1 that V6 heard R1 and V3 being loud in the bathroom and when R1 stood up, V3 told R1 to sit down in a loud voice because V3 was scared R1 was going to fall, and R1 shouted no. V1 stated V1 then called V6 to follow up and V6 repeated the same story V8 had told V1, and that V3 put V3's hands on R1's shoulders to steady R1. V1 stated R1 told V1 that R1 does not like V3 because V3 was hard and mean to R1. V1 stated R3 was suspended immediately and then R1 resigned because she did not like being suspended. On 09/08/2024 at 4:00pm, V10 (Social Services Designee), V10 stated she interviewed R1 on 08/12/2024 using the interpreter services regarding the allegation of abuse by V3 on 08/10/2024. V10 stated R1 was upset when telling V10 what V3 did to R1. V10 stated R1 said V3 yelled at R1 because R1 was standing off the toilet, and V3 put her hands on R1's shoulders firmly. V10 stated yelling to residents is not allowed and it's against their rights and staff cannot yell at residents especially when the resident is trying to go to the bathroom. V10 stated she did not document the conversation with R1 and stated she was supposed to document to show that the conversation/assessments she (V10) had with R1 happened. V10 stated she has seen R1 in the dining room or in hallways but V10 has not gone back to ask R1 how R1 feels about the alleged abuse. R1's care plan dated 07/08/2024 documents R1 is incontinent of bladder and bowel. Abuse policy titled 07/12/2024 documents: -It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely thorough investigations of abuse. -Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. -Types of abuse and examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and rough handling.

Based on interviews and record reviews, the facility failed to follow their identified offender policy by not complying with state regulations in performing criminal background checks within 24 hours of the admission of a new resident and failed to schedule a fingerprint-based criminal history record inquiry with 72 hours of receiving the initial criminal background results for 4 (R8, R12, R35, R67) of 5 residents reviewed for identified offenders. This failure has the potential to affect the safety and well-being of all 89 residents that currently reside in the facility. Findings include: Per facility census dated [DATE], total in-house census is 89 residents. Per interviews with V17 (Social Services Director) and V18 (Social Services Designee) on [DATE], there are 5 identified offenders who currently reside at the facility. Per record review, the admitted s, criminal background checks including local and national sex offender registries and fingerprinting for 4 (R67, R35, R8, and R12) of 5 identified offenders revealed the following: R8's admission record indicated resident admitted to the facility on [DATE]. R8's initial criminal history inquiry was conducted on [DATE]. R8 consented to fingerprinting on [DATE] and was fingerprinted on [DATE]. R8's sex offender check was conducted on [DATE]. R8's identified offender care plan was initiated on [DATE]. On [DATE] at 3:00 PM, V18 (Social Services Designee) said when she started the process to have R8 fingerprinted on [DATE], she discovered that his initial criminal background results were expired so a new search was completed on [DATE]. R12's admission record indicated resident admitted to the facility on [DATE]. R8's criminal history inquiry was conducted on [DATE]. No fingerprint documentation was provided for R12. R12's sex offender check was attempted on [DATE] but was incomplete; resident birthdate and results were not listed. No identified offender care plan was found on file. R35's admission record indicated resident admitted to the facility on [DATE]. R35's criminal history inquiry was conducted on [DATE] and repeated on [DATE]. R8 consented to and was also fingerprinted on [DATE]. R35's sex offender check was attempted on [DATE] with no results, system was down. The facility made no other search attempts or provided evidence for the check at a later date. R35's identified offender care plan was initiated on [DATE]. R67's admission record indicated resident admitted to the facility on [DATE]. R67's criminal history inquiry was conducted on [DATE] and issued on [DATE]. R67 consented to fingerprinting on [DATE] and was fingerprinted on [DATE]. R67's sex offender check was attempted on [DATE] with no results listed, system was down. No other evidence of search attempts were provided at a later time. R67's identified offender care plan was initiated on [DATE]. R8, R12, R35, and R67 were all previously convicted with criminal offenses. On [DATE], interviews with V17 (Social Services Director) and V18 (Social Services Designee) from 02:26 PM through 03:13 PM revealed that identified offender reviews for new residents upon admission were delayed due to the lack of an admissions director so the facility performed an audit towards end of year in 2023 to initiate these reviews. V17 then said the criminal history information response process (CHIRP) should be done within 24 hours of admission, and she believed fingerprinting should be completed within 30 days if applicable. On [DATE] at 3:30 PM, V1 (Administrator) said that around [DATE], the facility identified that uniform conviction information act (UCIA) checks were not being conducted by the previous admission director. As a result, the admission director was terminated, and the facility then conducted an audit and conducted the UCIA background checks and completed this audit by January of 2024. Identified Offender Policy last revised [DATE] reads as follows: Policy Statement: The facility will comply with the state regulations in addressing residents who are identified offenders. Procedures: 1. The facility shall review the results of the criminal history background checks immediately upon receipt of these checks. 2. The facility shall be responsible for taking all steps necessary to ensure the safety of residents while the results of a name-based background check is pending, while the Identified Offender Report and Recommendation is pending. 3. If the results of a resident's criminal history background check reveal that the resident is an identified offender the facility will: a. Immediately notify the Department of State Police that the resident is an identified offender. b. Within 72 hours, arrange for a fingerprint-based criminal history record inquiry to be requested on the identified offender resident. 4. All name-based and fingerprint-based criminal history record inquires shall be submitted to the Department of State Police electronically in the form and manner prescribed by the Department of State Police. 5. If the identified offender is on probation, parole, or mandatory supervised release, the facility shall contact the resident's probation or parole officer, acknowledge the terms of release, update contact information with the probation or parole office, and maintain updated contact information in the resident's record. The record must also include the resident's criminal history record. 6. A written notice confirming whether identified offenders are residing in the facility shall be posted prominently in the facility. It should include a statement indicating that information regarding sex offenders may be obtained from Illinois State Police website (www.isp.state.il.us) and information regarding persons serving terms of parole or mandatory supervised release may be obtained from the Illinois Department of Corrections website (www.idoc.state.il.us). 7. For current residents who are identified offenders, the facility shall review the security measures listed in the Identified Offender Report and Recommendation provided by the Department of the State Police. 8. The facility shall incorporate the Identified Offender Report and Recommendation into the identified offender's care plan. 9. If the identified offender is a convicted or registered sex offender or if the Identified Offender Report and Recommendation prepared pursuant to Section ,d+[DATE].6(a) of the Act reveals that the identified offender poses a significant risk of harm to others within the facility, the offender shall be required to have his or her own room within the facility. 10. The facility shall evaluate care plans at least quarterly for identified offenders for appropriateness and effectiveness of the portions specific to the identified offense and shall document such review. The facility shall modify the care plan, if necessary, in response to this evaluation. The facility remains responsible for continuously evaluating the identified offender and for making any changes in the care plan that are necessary to ensure the safety of residents. 11. Incident reports shall be submitted to the IDPH Division of Long-Term Car Field Operations in the Department's Office of Health Care Regulation in compliance with Section 300.690 of this Part. The facility shall review its placement determination of identified offenders based on incident reports involving the identified offender. In incident reports involving identified offenders, the facility shall identify whether the incident involves substance abuse, aggressive behavior, or inappropriate sexual behavior, as well as any other behavior or activity that would be reasonably likely to cause harm to the identified offender or others. If the facility cannot protect the other residents from misconduct by the identified offender, then the facility shall transfer or discharge the identified offender in accordance with Section 300.3300 of this Part. 12. The facility shall notify the appropriate local law enforcement agency, the Illinois Prisoner Review Board, or the Department of Corrections of the incident and whether it involved substance abuse, aggressive behavior, or inappropriate sexual behavior that would necessitate relocation of that resident.

Based on interview and record review, the facility staff failed to recognize a resident was experiencing an opioid overdose and failed to administer Narcan (opioid reversal agent) for a resident with a known history of substance abuse who was currently on opioid pain medication as well as Methadone; the facility failed to have protocols in place were in accordance with recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration). This failure applied to one (R3) of one resident reviewed for overdose and resulted in R3 being emergently transferred to local hospital due to being found unresponsive and requiring administration of opioid reversal agent (Narcan). The Immediate Jeopardy began on [DATE] when R3 overdosed while in the facility and V7 (RN) failed to identify R3 was experiencing an overdose and failed to administer opioid overdose reversal agent. V2 (Director of Nursing) and V22 (Regional Director of Clinical Services) were notified on [DATE] at 11:50AM of the Immediate Jeopardy. V21 (Vice President of Operations) was also called on phone conference at time the Immediate Jeopardy was called. The immediacy was removed on [DATE] but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3 is a [AGE] year-old female with history of COPD, substance use disorder, hypertension, failure to thrive, and aphasia. R3 was admitted to the facility on [DATE] and discharged to home on [DATE]. R3 was admitted to the facility on [DATE] after a brief hospital stay, where R3 was admitted for adult failure to thrive. Hospital discharge paperwork includes information related to safe opioid use and includes there is a potential for serious increased sedation and life-threatening respiratory depression when taking an opioid pain product at the same time as a benzodiazepine (such as Xanax, Ativan, Klonopin, etc.). Review of R3's nursing progress notes document the following: [DATE] 15:43 Health Status Note Note Text: At 2:20pm resident came back from ER via ambulance on stretcher assisted by 2 staff. A/Ox3, responsive and verbalized feeling nauseated. Vitals checked B/P,d+[DATE], P64, R 18, T97.6F O2 sat 89%-91% RA denies difficulty breathing. At 2:27pm NOD called ER to get discharge report and per operator no nurse available to take the call. At 3:20pm NOD f/up called ER and per nurse (name) resident was given Narcan at 12:50pm d/t Opioid overdose with no discharge instructions. At 3:38 pm NOD notified V23 (Primary Physician) of discharge Dx and made aware that resident current orders for Norco and Methadone and asked for parameter orders for B/P and P and Oxygen at ,d+[DATE]L per NC PRN for SOB. At 3:30pm (son) made aware that resident returned to facility and notified of current condition. On [DATE] at 1:58PM, V7 (RN) confirmed she was the nurse on duty when R3 had the overdose on [DATE]. Surveyor asked V7 what symptoms R3 was exhibiting when she assessed R3. V7 said R3 was unresponsive, cold, clammy, and sweaty. V7 said she does take vitals before giving Methadone and would not have given it if the patient was showing any symptoms like low blood pressure, respiratory rate, or oxygen saturation below baseline. V7 was asked if V7 received any training or in-service related to use of Methadone. V7 stated, Not really, we just follow the protocol from the Methadone clinic. V7 said (overdose) did not cross her mind because R3 took Methadone regularly and if the resident had a history of opioid overdose, then maybe it would have clicked in her mind. V7 added R3's son would visit often and sometimes V7 would hear them argue. Review of Pre-hospital Care Report Summary (ambulance run sheet) documents: Call Received: 12:13:38 On Scene: 12:18:36 Patient Contact: 12:20:13 Left Scene: 12:33:53 At Destination: 12:37:28 Transfer of Care: 12:40:42 Flowchart documents patient's breathing is slow and shallow; capillary refill is delayed, skin temperature is cool and diaphoretic; unresponsive; Vitals at 12:23:13 BP ,d+[DATE] Pulse 64 Respirations 2, Effort: shallow; SPO2: 96 with )2 > 3 LPM. Narrative History Text: UOA pt found lying in bed unresponsive. Staff says pt was last seen normal approx. 20 minutes prior to our arrival. Pt is cool and diaphoretic and is having agonal respirations approx. twice per minute and has a weak carotid pulse. Pt has a valid DNR but specifies to use comfort measures only. No change to pt status through duration of the call. Pt moved to MICU. (hospital) contacted without orders. Pt transported without incident. (hospital) contacted without orders. Hospital Encounter Summary includes the following documentation: Reason for Visit - Altered Mental Status Description - Opioid overdose, accidental or unintentional, initial encounter (HCC) (Primary Dx) Vitals Taken: Blood Pressure ,d+[DATE], Pulse 88, Respiratory Rate 18, Oxygen Saturation 100% on NRB (non re-breather mask) at 15L, adequate oxygenation. Patient presenting to the emergency department with complaint of altered mental status. Patient was noted to be unresponsive in her nursing home and agonal breathing with her last known well 30 minutes prior to arrival. She is noted to be DNR/DNI with comfort care measures. Patient's glucose was in the 90s. She was agonal breathing on arrival. Methadone and Norco noted to be in her med list so 2mg Narcan given to the patient without symptomatic improvement. Attempted to contact patient's son but unable to so a message was left on his phone answering for his machine. Administered Medications [DATE] 12:50PM CDT naloxone (Narcan) 2MG/2ML injection given. ED Course / Re-exam . 1347 Patient continues to be alert and responsive. Possible Narcan working and patient is now alert. Discharge Rx: New Prescriptions Naloxone HCL (Narcan) 4MG/0.1ML LIQD Call 911 - Administer single spray in one nostril upon signs of opioid overdose - may repeat in alternating nostril after ,d+[DATE] minutes if no response - if repeat is needed, a new container must be used. R3's care plans were noted that there was no physician order or care plan interventions for R3 related to history or risk substance abuse disorder or opioid reversal medication at the time of admission or prior to overdose incident on [DATE]. [DATE] at 1:51PM V2 (DON) said staff were in-serviced on using overdose signs and symptoms and use of Narcan (initiated on) [DATE] or 23 and then the Narcan was delivered from the Pharmacy on [DATE]. V2 said, We did the in-service in June because of the change from the pharmacy to corporate and pharmacy changed to nasal and to be incorporated into the crash cart. So, starting at time, we started keeping it on the crash cart rather than for the individual. We have pharmacy general meds on the 2nd floor, like a house stock. When (R3) was initially sent to the hospital I know the nurse didn't think she was having an overdose. Her Methadone is standard, and the Norco is PRN (as needed), so the nurse didn't think it was an overdose. The nurse was thinking it was more sepsis or something cardiac. At the time of the overdose, we did have Narcan in the convenience box. Surveyor asked why R3 did not have orders for any opioid reversal agents at the time of overdose per their policy dated [DATE]. V2 said, I know that's on our policy, but we followed what came on the discharge summary from (hospital). We do relay that information to the doctor and the NP (nurse practitioner). Pharmacy delivery manifest documents delivery for R3 on [DATE] at 6:35AM of Naloxone 4MG/0.1ML NASAL SPRAY, Quantity 2. V24 (Pharmacy Representative) on [DATE] interviewed from 4:25PM - 4:49PM. V24 confirmed pharmacy sent the Naloxone to the facility for R3 on [DATE] at approximately 6:35AM according to manifest. V24 attempted to pull facility transaction report and stated there was nothing on the report because there was no pull for the residents in this building, indicating Naloxone provided by pharmacy had not been used or needed to be replaced due to being used for any resident. It is to be noted the Naloxone for R3 was sent eight days after R3's overdose incident. On [DATE] at 11:47AM, V2 said, We did not do an investigation to try to determine the cause of the overdose. V22 (Regional Director of Clinical Services) added, It seemed like her (R3) meds, so we don't know how it happened. Social Services did a room search and didn't find anything. I don't believe the son visited that day and he had visited I think, two days prior. The nurse didn't think of anything related to opioid overdose because she was looking at her medical issues. The nurse thought it was something cardiac related. Surveyor asked how facility could determine if R3 had used illicit drugs versus nurse error without an investigation or review of Controlled Substance logs (Narcotic Count sheet) for R3. V2 did not respond. During this investigation, facility failed to provide documentation a complete and thorough investigation related to overdose for R3 was conducted. Facility was asked to provide documentation of controlled substance count sheet for R3 during her stay at the facility but it was not provided. There was no documentation of room search in R3's medical record or per interviews with social service staff. R3's physician orders were reviewed and include (but not limited to): Methadone HCL Oral Tablet 10 MG (Methadone HCL) Give 1 tablet by mouth one time a day for pain - Order Date [DATE], Start Date [DATE]. Norco Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain - Order Date [DATE], Start Date [DATE]. Review of R3's MAR (Medication Administration Record) documents on [DATE], R3 was given all medications as ordered and vitals taken during mediation administration were within R3's baseline (BP documented on MAR at 0900 is ,d+[DATE]). There is no documentation of PRN (as needed) Norco being administered on [DATE]. [DATE] at 12:07PM V25 (CAP/Methadone Clinic Representative) stated he could neither confirm nor deny any specifics related to R3 because the patient has not signed a release but can answer general questions. Surveyor asked V25 what is the likelihood of an overdose for patient who has been on the same dose of Methadone for several years? V25 said, It is very unlikely. I would only say if they were taking illicit drugs paired with their methadone then overdose would become more likely. If combined with [NAME] or unprescribed suboxone or any other type of opioid or opiate, then there is a higher chance. Patients can be prescribed Norco while being on Methadone, but the doctor must be aware they are being prescribed Methadone and we have a letter from the doctor being aware. Otherwise, then anything shows up (in urine sample) shows up as illicit. We do check urine monthly and the urine results come back in a week. If urine sample comes back dirty then we keep in mind if they are asking for increase, etc. The only thing we would punish them for would be they would have less available on hand. While in a nursing home, they can pick it up or a worker for the site will come with an ID badge and lock box and they can pick it up for them. [DATE] at 12:18PM V22 (Regional Director of Clinical Services) was asked why there was no care plan related to R3's substance abuse risk or use of Naloxone per their Naloxone Clinical Guidelines policy. V22 responded the policy was created on [DATE]th, but it wasn't started until the in-services were done. So, guideline didn't take effect until it was completed - [DATE]rd. Prior to this we didn't have a policy. V22 then affirmed they accepted a resident (R3) with a history of substance abuse and on Methadone without having a plan in place if R3 was to overdose. [DATE] at 1:47PM, V23 (Medical Director) stated overdoses can happen with use of illegal drugs. V23 said, Maybe we can add random drug tests. There's no way they can overdose on prescribed narcotics because they are giving specific dose. Those doses are all within the recommended doses and they are within the recommended guidelines. On a regular patient with a regular prescription the chance of overdose is zero. Surveyor asked if there is there a concern a resident getting opioids on a regular basis can overdose? V23 said, Everything is documented in the eMAR (electronic medication administration record), so the chance of duplicating a dose is very rare. When this (overdose) happened to her (R3), they (facility) did notify me the patient was sent out. I think no one knew. It looks like someone might have given her something or she took something illicit. I think the nurse thought it was more of a cardiac issue. I have been the medical director there for [AGE] years and this is the first time something like this happens. The nurses have been there for a long time and can recognize when the patients are inebriated or something. Proactively, I think we will institute in-service for the nurses on recognizing the signs and symptoms of overdose and when to administer the Narcan. Facility provided documented titled, Naloxone Clinical Guidelines, dated [DATE], which reads: I. Purpose: Upon a physician's medication order per resident or facility standing order, naloxone may be administered by a licensed nurse or authorized staff to resident as indicated for the complete or partial reversal of suspected opioid-induced respiratory depression and/or unresponsiveness and/or possible respiratory/ cardiac arrest. Naloxone (Narcan(R), Evzio) is a prescription medication can block or reverse the effects of an opioid overdose. Prompt and timely Administration of naloxone can save the life of someone overdosing on opioids, including heroine or prescription medicines like OxyContin(R) or Percocet(R). II. Procedures: 1. Facility will assess a resident on admission who is at risk for opioid abuse or overdose. o Person with recent inpatient hospitalization for suspected opioid use and overdose o Person with diagnosis of opioid use disorder o Person with history of opioid use or dependence, or diagnosed substance use disorder o Person with current prescribed opioid orders o Person with current prescribed opioid and benzodiazepine orders o Past opioid use and justice involved resident o Current or recent registrant of a methadone maintenance program, or a detox program o Visitor: Friends and family members of the above who may visit the resident and provide illicit or prescription opioids o Resident who frequently attempts to elope or leave the facility premises with current prescribed opioid or history of opioid dependence 2. Obtain Standing Order for Naloxone Use and Indication for at risk resident. Standing Order for Use of Naloxone for Resident o Indication: Unresponsiveness and/or difficulty breathing due to suspected opioid-induced respiratory depression. o Exclusions, if known: Comfort care plan, hospice, or end-of-life care; known allergy to naloxone. o Order: Naloxone nasal spray (4mg) or available supply and dosage form, repeat dose in 2 to 3 minutes for unresponsiveness or difficulty breathing (e.g., RR < 8 cycles/min), until individual is breathing (respiratory rate greater than 10). Initiate emergency medical response protocol (call 911) and transfer the individual to the hospital emergency department. Notify the attending physician and/ or appropriate medical practitioner. 3. Signs of Symptoms of Opioid Overdose o Slowed/ dyspnea (RR < 8cycles/min); irregular, or no breathing o Skin, nails turn blue o Extreme sleepiness o Unresponsive to sternal rub or when shaken o Pinpoint pupils o Low 02 Saturation (e.g., <85%) 4. Standardized Procedure for Naloxone Administration 1. Confirm signs and symptoms of potential opioid overdose (see item #3) 2. Call [DATE] and administer naloxone as follows (select dispensed dosage form). Start CPR as indicated. A. Single-Step Intranasal Naloxone: ( 2mg/0.1ml or 4mg/0.1 ml) o Peel back the package to remove the device o Hold the device with your thumb on the bottom of the plunger and 2 fingers on the nozzle o Place and hold the tip of the nozzle in either nostril until your fingers touch the bottom of the patient's nose o Press the plunger firmly to release the dose into the patient's nose o Repeat if there is no response after ,d+[DATE] minutes B. Auto-Injector Naloxone: (0.4mg/0.4ml) o Pull auto-injector from outer case and pull off red safety guard o Place the black end of the auto-injector against the outer thigh, through clothing if needed, press firmly and hold in place for 5 seconds. Repeat if there is no response after ,d+[DATE] minutes. C. Naloxone HCl injection vial 0.4mg/ml (requires a syringe for administration) Naloxone Hydrochloride Injection 0.4 mg/ml 11. o Inspect the solution for injection for any particulate matter or discoloration before use. o Remove cap from vial and clean with alcohol swab. Remove cap from needle of syringe. o Withdraw 1mL (0.4mg) from vial. o A deep intramuscular administration may be used and injected into a large muscle such as the thigh or deltoid muscle or if the subcutaneous route is selected, inject beneath the skin or an initial dose of 0.4 mg (1ml) of Naloxone hydrochloride may be administered intravenously as a push injection. o Response to naloxone may be slower with an intramuscular or subcutaneous injection. o Do not leave the resident and continue to monitor response to the medication. o Start supportive or resuscitative measures until emergency medical assistance arrives. o If the desired degree of counteraction and improvement in respiratory functions are not obtained, repeat the injection at two-to-three-minute intervals. o If no response is observed after a total of 10 mg of Naloxone hydrochloride has been administered, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned References: National Library of Medicine 2013; [NAME] Manual in Nursing 2015; IDPH.illinois.gov.opioids 2010; IPRO [NAME]-QIO Resource Library ,d+[DATE] CMS State Operations Manual requires the following for skilled nursing facilities: According to the Substance Abuse and Mental Health Administration (SAMHSA), opioid overdose deaths can be prevented by administering naloxone, a medication approved by the Food and Drug Administration to reverse the effects of opioids. The United States Surgeon General has recommended naloxone be kept on hand where there is a risk for an opioid overdose. Facilities should have a written policy to address opioid overdoses. The SAMHSA website houses a number of resources related to opioid management including this document intended for prescribers which addresses appropriate prescribing, monitoring for adverse effects, and treating overdoses: SAMHSA Opioid Overdose Prevention Toolkit: Information for Prescribers, https://www.samhsa.gov/resource/ebp/opioid-overdose-prevention-toolkit. The Immediate Jeopardy began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. On [DATE] the survey team verified by observations, interviews, and record review the facility implemented the following to remove the immediacy. The facility abatement plan includes the following: 1) R3 is no longer a resident of this facility and was discharged to the community in stable condition as planned on [DATE]. 2) Nurse on duty for R3 was educated on [DATE] on Naloxone Clinical Guidelines and has been re-educated 1:1 by DON and/or designee on [DATE] regarding Naloxone Clinical Guidelines but not limited to the facility's Naloxone clinical guidelines and identifying signs and symptoms of overdose in residents with a substance use disorders and medication pass policy and procedure with an emphasis on narcotic administration and monitoring adverse reactions. 3) Naloxone spray is available in all crash carts in the facility. Implementation started on [DATE] and is ongoing. 4) On [DATE] all nurses were re-educated on but not limited to the facility's Naloxone clinical guidelines and identifying signs and symptoms of overdose in residents with a substance use disorders this education is ongoing as of [DATE]. 5) Current residents with substance use disorders (10 total) were identified on [DATE] and updated on an ongoing basis. Updated again on [DATE] and this list is available to staff at each nurse's station and reception desk. Staff are being re-educated on the location of this list on [DATE]. 6) Current 10 residents with substance use disorders were assessed on [DATE] to ensure there are no active signs or symptoms of overdose. 7) On [DATE], All other residents receiving narcotic medications were identified, total of 22 residents, and will be monitored daily for any signs and symptoms of overdose. 8) All nurses are being re-educated on but not limited to the medication pass policy and procedure with an emphasis on narcotic administration and monitoring adverse reactions on [DATE] and will be ongoing. 9) Staff are being re-educated on but not limited to the facility's Naloxone clinical guidelines and identifying signs and symptoms of overdose in residents with a substance use disorder on [DATE]. This will continue for any newly hired staff or PRN staff. 10) Monitoring for residents with substance use disorders was implemented on or around [DATE]th, 2023, any residents with a substance use disorder goes out on pass or has a visitor is monitored every hour thereafter for the first 24 hours for any signs and symptoms of overdose. This is ongoing. 11) Quality assurance audit will be conducted daily by the DON and/or designee to ensure staff are identifying any signs or symptoms of overdose timely and administering Narcan timely when indicated. This will start on [DATE] and continue for the first month. All identified trends will be reviewed by the monthly QAPI committee, and a plan will be discussed and implemented until resolution. 12) The incident and abatement plan will be discussed and reviewed with the facility medical director on [DATE] at 3pm. 13) Emergency QAPI meeting will be conducted on [DATE] at 3:30pm.

Based on interview and record review, the facility failed to have a comprehensive care plan upon admission that included effective interventions to address history and risk of substance abuse for a resident with a history of substance use disorder. This failure applied to one (R3) of four residents reviewed for comprehensive care plans and resulted in R3 having an overdose while in the facility with no related interventions in place; the facility subsequently failed to update R3's plan of care to include interventions for when substance use is suspected or identified upon R3's return to the facility after being hospitalized for overdose. Findings include: R3 is a [AGE] year-old female with history of COPD, substance use disorder, hypertension, failure to thrive, and aphasia. R3 was admitted to the facility on [DATE] and discharged to home on [DATE]. Prior to being admitted into the facility, R3 was discharged from local hospital, where she was admitted on [DATE] for adult failure to thrive, requiring extensive assistance with ADL's (activities of daily living) and rehabilitation to build strength. Hospital reports medical history of cognitive dysfunction, COPD, hypertension, right hemiplegia, and polysubstance abuse, opioid use disorder, depression, and PTSD. Pre-Admission, hospital orders include Methadone 10mg oral daily and Hydrocodone-Acetaminophen (Norco) one tablet oral every 4 hours as needed. Barriers for discharge include abuse/neglect concerns: possible financial abuse. Assessment and Plan: (include) Polysubstance abuse: follows at Center for Addiction Problems (CAP - address/phone number provided) - remotely was on methadone 80mg QD (daily). Dose was checked during last admit ,d+[DATE] w/CAP (phone number) and currently on 10mg. - continued home methadone 10mg QD (daily). Hospital discharge paperwork includes information related to safe opioid use and includes there is a potential for serious increased sedation and life-threatening respiratory depression when taking an opioid pain product at the same time as a benzodiazepine (such as Xanax, Ativan, Klonopin, etc.). Review of R3's nursing progress notes document the following: [DATE] 15:43 Health Status Note Note Text: At 2:20pm resident came back from ER via ambulance on stretcher assisted by 2 staff. A/Ox3, responsive and verbalized feeling nauseated. Vitals checked B/P,d+[DATE], P64, R 18, T97.6F O2 sat 89%-91% RA denies difficulty breathing. At 2:27pm NOD called ER to get discharge report and per operator no nurse available to take the call. At 3:20pm NOD f/up called ER and per nurse (name) resident was given Narcan at 12:50pm d/t Opioid overdose with no discharge instructions. At 3:38 pm NOD notified V23 (Primary Physician) of discharge Dx and made aware that resident current orders for Norco and Methadone and asked for parameter orders for B/P and P and Oxygen at ,d+[DATE]L per NC PRN for SOB. At 3:30pm (son) made aware that resident returned to facility and notified of current condition. R3's care plan includes the following: R3 has been determined by community access assessment to be able to access the community with supervision. Date Initiated: [DATE]. Intervention (includes): I am on supervised access to the community. R3 is receiving Methadone/Norco for pain. Date Initiated: [DATE]. Interventions (include): For respiratory depression: Monitor respirator rate, depth and effort after administration of pain medications. Monitor for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress, sedation, urinary retention. Observer for adverse reactions with every interaction with the resident. Behavioral Symptoms - Narcotic Seeking R3 has a history of substance abuse and chemical dependency and engages in medication seeking behaviors. R3 demands medications be provided to her outside of physician prescription and prior to the time medications are scheduled to be provided to her and makes demands that personnel assist her with obtaining illegal substances. R3 and her son demand to be provided high dosages of medication and then claim that she receives too much medication. When blood pressure is low and the physician orders medications held, R3 and her son demanded that methadone/medications be provided to R3 anyway. R3 is receiving psychological services and participating in substance mitigation programming to address addictions, substance use/abuse, and healthy/productive coping strategies. Date Initiated: [DATE]. Interventions are included in the plan of care with date initiated [DATE]. R3's physician orders upon admission to the facility include Methadone and Norco; both are opioid medications. Physician Orders include: Methadone HCL Oral Tablet 10 MG (Methadone HCL) Give 1 tablet by mouth one time a day for pain - Order Date [DATE], Start Date [DATE]. Norco Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain - Order Date [DATE], Start Date [DATE]. It is to be noted that there was no physician order or care plan interventions for R3 related to history or risk substance abuse disorder or opioid reversal medication at the time of admission. On [DATE] at 1:58PM, V7 (RN) confirmed she was the nurse on duty when R3 had the overdose on [DATE]. Surveyor asked V7 what symptoms R3 was exhibiting when she assessed R3. V7 said R3 was unresponsive, cold, clammy, and sweaty. V7 said (overdose) did not cross her mind because R3 took Methadone regularly and if the resident had a history of opioid overdose, then maybe it would have clicked in her mind. V7 added R3's son would visit often and sometimes V7 would hear them argue. On [DATE] at 4PM, V1 (Administrator) stated he believed R3 was a drug addict, and he suspected her son was bringing her drugs. Surveyor asked what made V1 think R3's son was bringing her drugs and V1 responded her behavior would change, like she was disconnected when he was here. Surveyor asked what if anything the facility did to act on this suspicion? V1 responded nothing was ever confirmed but if it was, it would have been something social work would have been involved with but V1 didn't think anything was ever confirmed. [DATE] at 4:12PM, V10 (Social Services Director) was asked if she was ever made aware of any concern R3's son was providing R3 with illicit drugs. V10 responded, it was never brought to her attention as a concern. V10 added she was aware R3 had a history of drug use. [DATE] at 4:19PM V11 (Social Service Designee) stated she facilitates care between the facility and CAP (methadone clinic) and is responsible for care planning residents for substance abuse and the Methadone use. It is to be noted there was no physician order or care plan interventions for R3 for any substance abuse disorder or opioid reversal medication at the time of admission. R3's care plan was updated on [DATE] to reflect Behavioral Symptoms - Narcotic Seeking, with Date Initiated: [DATE]. Interventions are included in the plan of care with date initiated [DATE]. On [DATE] at 2:03PM, V11 (Social Service Designee) was asked what changed on [DATE] when R3 had an addition to the care plan related to narcotic seeking behaviors. V11 responded, On this particular day I got a report one of the CNA's went to the nurse and told the nurse the resident (R3) asked her for some type of illicit drug. She (R3) had never done this before. This was a really big surprise to me because she (R3) was always very proud of her sobriety. She (R3) said she's been sober for years, ever since she went to rehab. After the overdose in June, I did talk to her (R3) because she didn't feel well and was wondering what happened. We focused on her blood pressure was maybe low. Surveyor asked V11 if she talked to R3 about the overdose after it happened and if she questioned R3 about taking any illicit substances. V11 responded she did not. V11 said, I did not ask her any questions. (i.e . did you take something, etc.). I did not feel comfortable asking her those questions. That's why I had the psychotherapist come with me; because she had a good rapport with her. It didn't cross my mind she n(R3) had possibly taken anything. [DATE] at 12:18PM V22 (Regional Director of Clinical Services) was asked why there was no care plan related to R3's substance abuse risk or use of Naloxone per their Naloxone Clinical Guidelines policy. V22 responded the policy was created on [DATE]th, but it wasn't started until the in-services were done. So, guideline didn't take effect until it was completed - [DATE]rd. Prior to this we didn't have a policy. V22 then affirmed they accepted a resident (R3) with a history of substance abuse and on Methadone without having a plan in place if R3 was to overdose. [DATE] at 1:47PM, V23 (Medical Director) stated, When this (overdose) happened to her (R3), they (facility) did notify me the patient was sent out. I think no one knew. It looks like someone might have given her something or she took something illicit. I think the nurse thought it was more of a cardiac issue. I have been the medical director there for [AGE] years and this is the first time something like this happens. The nurses have been there for a long time and can recognize when the patients are inebriated or something. Proactively, I think we will institute in-service for the nurses on recognizing the signs and symptoms of overdose and when to administer the Narcan. Facility provided documented titled, Naloxone Clinical Guidelines, dated [DATE], which reads: I. Purpose: Upon a physician's medication order per resident or facility standing order, naloxone may be administered by a licensed nurse or authorized staff to resident as indicated for the complete or partial reversal of suspected opioid-induced respiratory depression and/or unresponsiveness and/or possible respiratory/ cardiac arrest. Naloxone (Narcan(R), Evzio) is a prescription medication can block or reverse the effects of an opioid overdose. Prompt and timely Administration of naloxone can save the life of someone overdosing on opioids, including heroine or prescription medicines like OxyContin(R) or Percocet(R). II. Procedures: 1. Facility will assess a resident on admission who is at risk for opioid abuse or overdose. o Person with recent inpatient hospitalization for suspected opioid use and overdose o Person with diagnosis of opioid use disorder o Person with history of opioid use or dependence, or diagnosed substance use disorder o Person with current prescribed opioid orders o Person with current prescribed opioid and benzodiazepine orders o Past opioid use and justice involved resident o Current or recent registrant of a methadone maintenance program, or a detox program o Visitor: Friends and family members of the above who may visit the resident and provide illicit or prescription opioids o Resident who frequently attempts to elope or leave the facility premises with current prescribed opioid or history of opioid dependence 2. Obtain Standing Order for Naloxone Use and Indication for at risk resident. Standing Order for Use of Naloxone for Resident o Indication: Unresponsiveness and/or difficulty breathing due to suspected opioid-induced respiratory depression. o Exclusions, if known: Comfort care plan, hospice, or end-of-life care; known allergy to naloxone. o Order: Naloxone nasal spray (4mg) or available supply and dosage form, repeat dose in 2 to 3 minutes for unresponsiveness or difficulty breathing (e.g., RR < 8 cycles/min), until individual is breathing (respiratory rate greater than 10). Initiate emergency medical response protocol (call 911) and transfer the individual to the hospital emergency department. Notify the attending physician and/ or appropriate medical practitioner. 3. Signs of Symptoms of Opioid Overdose o Slowed/ dyspnea (RR < 8cycles/min); irregular, or no breathing o Skin, nails turn blue o Extreme sleepiness o Unresponsive to sternal rub or when shaken o Pinpoint pupils o Low 02 Saturation (e.g., <85%) 4. Standardized Procedure for Naloxone Administration 1. Confirm signs and symptoms of potential opioid overdose (see item #3) 2. Call [DATE] and administer naloxone as follows (select dispensed dosage form). Start CPR as indicated. A. Single-Step Intranasal Naloxone: ( 2mg/0.1ml or 4mg/0.1 ml) o Peel back the package to remove the device o Hold the device with your thumb on the bottom of the plunger and 2 fingers on the nozzle o Place and hold the tip of the nozzle in either nostril until your fingers touch the bottom of the patient's nose o Press the plunger firmly to release the dose into the patient's nose o Repeat if there is no response after ,d+[DATE] minutes B. Auto-Injector Naloxone: (0.4mg/0.4ml) or Pull auto-injector from outer case and pull off red safety guard o Place the black end of the auto-injector against the outer thigh, through clothing if needed, press firmly and hold in place for 5 seconds Repeat if there is no response after ,d+[DATE] minutes. C. Naloxone HCl injection vial 0.4mg/ml (requires a syringe for administration) Naloxone Hydrochloride Injection 0.4 mg/ml 11. o Inspect the solution for injection for any particulate matter or discoloration before use. o Remove cap from vial and clean with alcohol swab. Remove cap from needle of syringe. o Withdraw 1mL (0.4mg) from vial. o A deep intramuscular administration may be used and injected into a large muscle such as the thigh or deltoid muscle or if the subcutaneous route is selected, inject beneath the skin or an initial dose of 0.4 mg (1ml) of Naloxone hydrochloride may be administered intravenously as a push injection. o Response to naloxone may be slower with an intramuscular or subcutaneous injection. o Do not leave the resident and continue to monitor response to the medication. o Start supportive or resuscitative measures until emergency medical assistance arrives. o If the desired degree of counteraction and improvement in respiratory functions are not obtained, repeat the injection at two-to-three-minute intervals. o If no response is observed after a total of 10 mg of Naloxone hydrochloride has been administered, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned References: National Library of Medicine 2013; [NAME] Manual in Nursing 2015; IDPH.illinois.gov.opioids 2010; IPRO [NAME]-QIO Resource Library ,d+[DATE].

Based on observation, interview and record review the facility failed to implement adequate supervision and specific interventions for 2 (R76, R147) of 4 of residents who were identified as a high fall risk in a sample of 24. R76 had an unwitnessed fall that resulted in a right femoral fracture. Findings include: On 2/7/2023 at 10:30am R147 was observed in bed with the call light hanging off the side of the bed. On 2/7/2023 at 10:35am V21(Licensed Practical Nurse-LPN) said that R147 is a high fall risk and had a fall on 2/6/2023 without an injury. On 2/8/2023 at 12:00pm V2 (Director of Nursing-DON) said that R147 is a fall risk and should have the call light within reach. An Order Review Report documents a Fall Precaution order for 1/17/2023. An order dated 2/7/2023 to send to local hospital for evaluation status post fall to rule out head injury. A Fall Risk Evaluation dated 1/17/2023 with a score of 3.0. On 2/6/2023 a Fall Risk Evaluation score of 26 which 8 or above indicates high risk for falls. A care plan with an intervention to keep call light in reach. On 2/9/2023 at 12:30pm R76 was observed with bed raised up high off the floor. On 2/9/2023 at 12:35pm V21 said R76 is a high fall risk, and the bed should be lowest to the floor. V21 said R76 had a fall on 12/24/2022 that resulted in her having a right femoral fracture. On 2/9/2023 1:30pm V2 said that R76 is a high fall risk, and all interventions should be in place to prevent further injury. An Order Review Report dated 2/8/2023 indicates that R76 has a diagnosis of a History of Falls. An Order Review Report dated 2/8/2023 that indicates R76 has an order dated on 12/29/2022 for Fall Precautions weakness and history of falls. A care plan that indicates R76 has a right femur fracture related to a fall and a focus of Modify environment as needed to meet current needs, non-slip surface for bath/shower, bed lowest position with wheels locked. Floors that are even and free form spills, clutter, adequate, glare-free light. A care plan for Activity of Daily living-ADL self-care Performance Deficit and Impaired Mobility, stroke, limited mobility and impaired balance, a focus of toilet use -staff to provide prompt peri-care every shift and as needed. A Radiology Results Report dated 12/24/2022. that indicates R76 has an Acute distal, femoral acute fracture A hospital visit on 12/25/2022 that indicates R76 has a Nondisplaced oblique fracture of shaft of right femur, initial encounter for closed fracture. A fall risk evaluation dated 11/21/2022 that indicates a fall risk of 5.0 low risk. A fall risk evaluation dated 12/8/2022 of 5.0 low risk. A fall risk evaluation dated 12/9/2022 of 11.0 no injury. A fall risk evaluation dated 12/22/2022 of 17.0 high risk for falls with injury. A fall risk evaluation dated 4.0 with injury from 12/24/2022. A fall incident report dated 12/25/2022, fall occurred on 12/24/2022 unwitnessed fall with pain to right leg and injury. A post fall investigation dated 12/22/22 unwitnessed fall with injury. Facility Policy: Revised 12/5/2022, Fall Prevention Program Guidelines. Policy Statement: Fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence-based prevention interventions. 2. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. 3. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 7. a. Place call device within reach always and respond to call light promptly. b. The bed shall be always in the locked position and maintained in a position appropriate for resident transfers.

Based on observation, interview and record review, the facility neglected to follow their policies for neglect, significant change in condition and fall incident. These failures contributed to a resident (R1), experiencing a delay in medical treatment and sustained multiple falls. R1 was hospitalized on [DATE] with altered mental status, new onset of [CONDITION(S)], and a newly diagnosed right lower lobe nodule. This applies to 1 of 3 residents (R1) reviewed for neglect. The findings include: The EMR (Electronic Medical Record) shows that R1, a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews were held with the staff who were on duty on 2/11/2022-2/12/2022, from 11:00 P.M. through 7:00 A.M. shift and were in charge of R1's care: -V5 (Nurse), was interviewed on 2/19/2022 at 10:13 A.M. V5 said (R1) did not have a fall when I worked that shift. She was just wandering around, redirected as needed, I let her wander so she can get tired, and when she gets tired, then she will be redirected to bed. V5 said that she did not assess R1 for the wandering behavior. -V7 (CNA/ Certified Nurse Assistant) was interviewed on 2/19/2022 at 7:28 A.M. V7 said that R1 was pacing, wandering all night through and did not sleep at all. V7 also said that R1 cannot be redirected, very agitated, very weak, gait was very unsteady and had fallen at least at minimum of 6 times that night shift. V7 also added that R1 tried to escape the facility by trying to get to the elevator, stairway and the glass window. V7 also said that she saw V5 just sat at the nursing station and did not stand up at all to check (R1). I am not a nurse, but definitely something was going on and a huge change for (R1), but (V5) did not check her, she might need medication or just send her out to the hospital since she was very weak, has COVID, very unsteady gait and walking with head leaning down almost hitting wall or counter. She definitely needed something that night. We, together with (V8 and V9) informed (V1, Adminstrator,V2, Director of Nursing and V10, Human Resource that day of 2/12/2022 that (V5) did not do his job as a nurse to check (R1's) needs and felt (V5) had neglected (R1). V7 also added that this was definitely a significant changed of R1's medical and mental status that night shift, she was different from her baseline. -V8 (CNA) was interviewed on 2/19/2022 at 1:54 P.M. V8 said that R1 was trying to elope that night, tried to jump off from the window, escape from the stairways and the elevator. V8 added that all the alarms were on and loud, but V5 was just sitting at the nursing station, and reacted like he just woke up, did not get up and did not say anything how to handle R1. V8 also said that R1 fell at least 10 times that night and that R1 had wandered through residents' rooms even if R1 was positive for COVID. V8 added that V5 neglected to check (R1) and that R's needed medical attention due to change in physical, mental and behavior status. V8 also said that R1's gait was so unsafe and that R1 had walked that night with gait that was very unsteady, bumping the walls and counters because R1's head and upper torso were on a leaned forward positioned. She was very weak but cannot be redirected to rest. -V9 (CNA), interviewed on 2/19/2022 at 5:17 P.M., V9 said that (V5) did not take care of (R1's) needs, did not check her at all, just let her fall and let her wander around, we tried to take care of her, but just (R1) was unmanageable. -V7, V8, V9 all said just check the camera what (V5) did that night, all we know is that he just sat down and neglected (R1's) care and needs and he did not check (R1). We informed this situation to (V1, Administrator, V2, Director of Nursing and V10 Human Resource on 2/12/2022. -V6 (Nurse for 2/12/2022 morning shift) was interviewed on 2/19/2022 at 10:58 A.M. V6 said that R1 has significant change in mental and physical condition that started the night shift of 2/11/2022. V6 also said that R1 was bumping the medication carts, cannot be redirected and was very weak. V6 added that she sent R1 to the hospital on 2/12/2022 at 11:00 A.M due to significant change in medical status. V6 added that V5 did not inform her that R1 had multiple falls that night shift. On 2/19/2022 at 3:52 P.M., V1 said that the facility's camera was not functioning, so it did not record what happened that night shift of 2/11-12/2022. V1 also said that V7, V8 and V9 did not report an allegation of neglect for R1. V1 said that all they said was all childish fight and an allegation of discrimination. V1 also said that their statements (V7, V8 and V9) did not show allegation of neglect but an allegation of discrimination. V1 further said that it is the facility's policy to report allegation of neglect to the administrator immediately and that V7, V8 and V9 have failed to report. On 2/19/2022 at 4:00 P.M., V2 said that it was expected for V5 to have checked and assessed R1 to determine immediate medical treatment when R1 had an acute change of condition on the night of 2/11-2/12/2022. On 2/18/2022 at 10:45 A.M., R1 was observed lying in bed. R1 was confused and was a poor historian. R1 was observed with large bruise on the left side of face and around the left eye. R1 was also noted with large bruise and swollen left lower leg The nurse's notes dated 2/12/2022 at 7:34 A.M. documented by V5 (Nurse) shows that (R1) was up all night walking in and out of other residents' room. Refused to go to sleep. Patient is confused. Redirected by staff as needed. Further review of the nurse's notes dated 2/12/2022 at 12:39 P.M., documented by V6 (Nurse) shows that At about 11:00 am, (R1) continue to be confused and disoriented, wandering to other resident rooms, and resisting redirection. At 11:20 am, (R1's Attending Physician) was notified of resident behavior and ordered to send resident to hospital. R1 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Medical Provider Notes dated 2/12/2022 shows, (R1) was sent to the hospital on 2/12/22 s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Labs in ED (Emergency Department) showed new [CONDITION(S)] and +COVID-19.CT (Computerized Tomography) of the chest and A/P (anterior/posterior) showed (R) lower lobe nodule with recommendations to have a CT chest f/u in 3 months. Patient was evaluated by psychiatrist and determined that patient is on the optimal medication regimen for her [CONDITION(S)] overlying [CONDITION(S)].Patient will need 24/7 supervision and assistance for her safety and ADLs (Activities of Daily Living). Patient seen and examined in room Patient noted to have a bruise underneath (R) eye. Patient also noted to have [CONDITION(S)] and bruise to RLE (right lower extremities). PMH (past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy for abuse/neglect with a revision date of 1/17/2022 shows that the facility should provide professional care and services in a manner that is free from any type of abuse . including neglect. Type of abuse: .Neglect- failure to provide necessary care adequate care (medical and psychological). Neglect is the failure to care for a person in a manner which would avoid him/her pain, or the failure to react to a situation which may be harmful. Staff maybe aware of should have been of the situation that resident require but fails to provide that care and service. All allegations of abuse or suspicions of abuse/neglect should be reported to the administrator immediately. The facility's policy for significant change in medical status dated 7/28/2021 shows to provide care immediately to residents who were noted with significant change in medical condition. The facility's policy for fall with a revision date of 7/28/2021 shows that facility should ensure that residents are assessed for risk for falls and interventions are put in place .4. An incident report will be completed by the nurse each time a resident fall. 5. The nurse initiate and start interventions to address falls in the unit.

Based on observation, interview and record review the facility failed to assess a resident for a significant change of condition, report this change to the physician and oncoming nursing staff. This failure resulted in R1 experiencing a delay in treatment and sustaining multiple falls and requiring hospitalization . This applies to 1 of 3 residents (R1) reviewed for change of condition. The findings include: The EMR (Electronic Medical Record) shows that R1, a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's notes dated 2/12/2022 at 7:34 A.M. documented by V5 (Nurse) shows that (R1) was up all night walking in and out of other residents' room. Refused to go to sleep. Patient is confused. Redirected by staff as needed. Further review of the nurses' notes dated 2/12/2022 at 12:39 P.M., documented by V6 (Nurse) shows that At about 11:00 am, (R1) continue to be confusion and disoriented, wandering to other resident rooms, and resisting redirection. At 11:20 am, (R1's Attending Physician) was notified of resident behavior and ordered to send resident to hospital. R1 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Notes dated 2/16/2022 shows At about 12:50 PM, (R1), readmitted , from hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Provider Notes dated 2/12/2022 shows, (R1) was sent to the hospital on 2/12/22 s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Labs in ED (Emergency Department) showed new [CONDITION(S)] and +COVID-19.CT (Computerized Tomography) of the chest and A/P (anterior/posterior) showed (R) lower lobe nodule with recommendations to have a CT chest f/u in 3 months. Patient was evaluated by psychiatrist and determined that patient is on the optimal medication regimen for her [CONDITION(S)] overlying [CONDITION(S)].Patient will need 24/7 supervision and assistance for her safety and ADLs (Activities of Daily Living). Patient seen and examined in room Patient noted to have a bruise underneath (R) eye. Patient also noted to have [CONDITION(S)] and bruise to RLE (right lower extremities). PMH (past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews were held with the staff who were on duty on 2/11/2022-2/12/2022, from 11:00 P.M. through 7:00 A.M. shift and were in charge of R1's care: V5 (Nurse), was interviewed on 2/19/2022 at 10:13 A.M. V5 said (R1) did not have a fall when I worked that shift. She was just wandering around, redirected as needed, I let her wander so she can get tired, and when she gets tired, then she will be redirected to bed. V5 said that he did not assess R1 for the wandering behavior. V7 (CNA/ Certified Nurse Assistant) was interviewed on 2/19/2022 at 7:28 A.M. V7 said that R1 was pacing, wandering all night through and did not sleep at all. V7 also said that R1 cannot be redirected, very agitated, very weak, gait was very unsteady and had fallen at least at minimum of 6 times that night shift. V7 also added that R1 tried to escape the facility by trying to get to the elevator, stairway and the glass window. V7 also said that she saw V5 just sat at the nursing station and did not stand up at all to check (R1). I am not a nurse, but definitely something was going on and a huge change for (R1), but (V5) did not check her, she might need medication or just send her out to the hospital since she was very weak, has COVID, very unsteady gait and walking with head leaning down almost hitting wall or counter. She definitely needed something that night. We, together with (V8 and V9) informed (V1, Administrator, V2, Director of Nursing and V10 (Human Resource) that day of 2/12/2022 that (V5) did not do his job as a nurse to check (R1's) needs and felt (V5) had neglected (R1). V7 also added that this was definitely a significant changed of R1's medical and mental status that night shift, she was different from her baseline. V8 (CNA) was interviewed on 2/19/2022 at 1:54 P.M. V8 said that R1 was trying to elope that night, tried to jump off from the window, escape from the stairways and the elevator. V8 added that all the alarms were all on and loud, but V5 was just sitting at the nursing station, and reacted like he just woke up, did not get up and did not say anything how to handle R1. V8 also said that R1 fell at least 10 times that night and that R1 had wandered through residents' rooms even if R1 was positive for COVID. V8 added that V5 neglected to check (R1) and that R1 needs for medical attention due to change in physical, mental and behavior status. V8 also said that R1's gait was so unsafe and that R1 had walked that night with gait that was very unsteady, bumping the walls and counters because R1's head and upper torso were on a leaned forward positioned. She was very weak but cannot be redirected to rest. V9 (CNA), interviewed on 2/19/2022 at 5:17 P.M., V9 said that (V5) did not take care of (R1's) needs, did not check her at all, just let her fall and let her wander around, we tried to take care of her, but just unmanageable. V7, V8, V9 all said, just check the camera what (V5) did that night, all we know is that he just sat down and neglected (R1's) care and needs and he did not check (R1). V6 (Nurse for 2/12/2022 morning shift) was interviewed on 2/19/2022 at 10:58 A.M. V6 said that R1 has significant change in mental and physical condition that started the night shift. V6 also said that R1 was bumping the medication carts, cannot be redirected and was very weak. V6 added, that R1was sent to the hospital on 2/12/2022 at 11:00 A.M due to significant change in medical status. V6 added that she did not receive a report from V5 that R1 had multiple falls that night shift. The EHR shows no documentation how R1 was that night shift of 2/11-12/2022. There was no assessment regarding R1's acute change in medical and psychological condition to determine correct treatment. On 2/19/2022 at 4:00 P.M., V2 said that it was expected for V5 to have checked and assessed R1 to determine immediate medical treatment. On 2/18/2022 at 10:45 A.M., R1 was observed lying in bed. R1 was confused and poor historian. R1 was observed with large bruise on the left side of face and around the left eye. R1 was also noted with large bruise and swollen left lower leg. The facility's policy for significant change in medical status dated 7/28/2021 shows to provide care immediately to residents who were noted with significant change in medical condition.

Based on interview and record review the facility failed to asses and notify the physician of a change/decline from the normal baseline of 1 of 3 residents (R1) reviewed for quality of care and assessment. This failure resulted in R1 being emergently sent to the local hospital for evaluation and admitted and treated for [REDACTED]. [MEDICAL CONDITION], and increase in white blood cells), R1 was transferred to ICU and required intubation. Findings include: Record review on facility presented health status note by V3 (Assistant Director of Nursing - ADON) dated on [DATE] documented, R1 has shown a decline in three consecutive days via Significant Change Analysis Report for ambulation, transfer, toileting and hygiene. On [DATE] at 10:00 AM V3 (ADON) stated, R1 was functionally declining and was not on his base line. I didn't notified physician, instead I notified therapist to evaluate him. Record review on physician order [REDACTED]. decline. Record review on facility documentation doesn't indicate any follow up after R1's functional decline in [DATE] until his condition gets worse for hospitalization through 911 on [DATE]. Record review on facility presented health status note dated on [DATE] at 8:10 AM documents that R1 was sitting on the floor, lethargic having abnormal vitals: Temperature 97.2, Oxygen saturation 87 percent with 10 litter non-rebreather mask and a heart rate of 51. Facility called 911 and transferred R1 to the local hospital at around 8:00AM On [DATE] at 1:35 PM V9 ( attending physician) stated, I should be notified when there is change in condition with patient. It is part of their protocol. I wasn't notified on R1's change in condition in between [DATE] and [DATE] except [DATE] in AM. I am reviewing R1's hospital records, R1 has elevated White blood cell count, potassium, INR, and [MEDICATION NAME] level. So R1 was in real shock. On [DATE] at 1:00 PM V7 (emergency room Physician) stated, I know the patient's condition was very complicated when we received (R1) in the ER (emergency room ). (R1's) [MEDICATION NAME] and potassium levels were way elevated, (R1)was intubated upon arrival and had to give multiple bolus of intravenous (IV) fluids. We started treating (R1) with three IV antibiotics. There was not even any IV lines with patient. Record review on hospital record indicates that upon R1's arrival on [DATE] at 8:33 AM R1 had an elevated [MEDICATION NAME] level of 16, potassium level of 7.0, and white blood cell (Wbc) of 26.8. R1 was intubated, multiple bolus of intravenous fluids given and treated with three antibiotics. Record review on death certificate indicates that R1 was expired on [DATE]. Record review on facility's health status note documented on [DATE] that facility received a phone call from local hospital saying that R1 was expired at 12:37 AM. Record review on facility presented policy on notification for change of condition revised on [DATE] document: Policy Statement: The facility will provide care to residents and provide notification of resident change in status Procedures: 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: b. A significant change in the resident's physical, mental, or psychosocial status. Record review on facility presented policy on General Care revised on [DATE] document: Policy statement: It is the facility's policy to provide care for every residents to meet their needs Procedures: 3. Assessment shall be completed per facility policy; progress notes shall be put in by exception when assessments aren't appropriate or if additional information is needed. 4. During the resident stay at the facility, the resident will be monitored for changes .

Based on observation, interview and record review, the facility failed to ensure a wall mounted upholstered headboard was securely fastened to the wall in 1 of 3 residents (R1) reviewed for safe equipment in resident rooms.This failure resulted in the upholsterd headboard falling off the wall on to R1's head and face. R1 was sent to local hospital and was admitted and treated for [REDACTED]. Findings Include; R1 was a [AGE] year old resident with [DIAGNOSES REDACTED]. The Facility Incident Report dated 3/4/19 documents ; On 2/26/19 at 11:30 PM, nurse (V14) was making rounds, heard a sound coming from the resident's (R1 room.) Nurse noted that the decorative cushion frame that was attached to the wall had accidentally fallen on residents face. The nurse called for assistance and the frame was removed from the resident immediately. Complete assessment was done, slight redness noted initially on resident's face. Neurocheck was initiated. No grimacing noted. MD (Medical Doctor) was informed, x-ray of face ordered and done. X-ray result does not show any fracture. But by morning of 2/28/19 should be (2/27/18) resident left side of face had swollen. MD informed and ordered to send resident to the emergency room at hospital. Resident admitted with [DIAGNOSES REDACTED]. Progress Notes dated 2/27/19 document; at 7:45 AM R1 remains left side of face redden swelling. 11:14 AM V12 MD (Medical Doctor) notified of x-ray result, left eye result shows negative for fracture, and dislocation. MD was informed of swelling was not gone (going) down, left eye closed due to swelling. V12 MD order to send resident to local hospital ER (emergency room ) for evaluation. At 12:10 PM resident transported to hospital. DON (Director of Nursing) and family made aware. Progress notes dated 3/1/19 ; At 6:20 PM (R1 ) readmitted this [AGE] year old patient of V12 MD from hospital, brought to facility by ambulance per stretcher accompanied by 2 crew members. Resident is non-verbal and does not follow any instruction, generalized weakness,breathing with no labor, skin warm and dry, . readmitted with dx (diagnosis) of facial [MEDICAL CONDITION]. Resident's left side of face swelling, redness, and blisters. Resident started on [MEDICATION NAME] 100 mg (milligram) (antibiotic) by mouth two times a day for seven days. On 3/14/19 at 10:25 AM via telephone V14 LPN (Licensed Practical Nurse ) stated; The resident (R1) is always nonverbal. I was doing rounds around 11:00 PM. I saw R1 with a board covering her head, the board was sideways and covering R1's left face and head. I told the roommate to use call light for help. I called V15 , another nurse for help, and we removed the board. The board had round buttons on it, and it left blanches (white areas) on R1's face. I put ice on face (the). The blanches went away and the face became red, I don't remember if it was swollen. I texted the DON (Director of Nursing) around 12:28 AM. I texted the doctor (V12) around 6:00 AM when I saw a blister on her face. V12 MD (Medical Doctor) texted back to do facial x-rays. I did not speak to the doctor. I called the family around 7:00 AM before I left. I gave a report to the morning nurse about the x-rays My shift was over, and I left. On 3/14/19 at 9:45 AM via telephone V12 Medical Doctor and Primary Care Physician for R1 stated; R1 was a long term resident at this facility. The facial [MEDICAL CONDITION] and facial swelling was most likely caused by the incident involving the head board falling on her. She probably had a small skin cut which allowed bacteria in and caused the [MEDICAL CONDITION]. R1 went back to the hospital about a week later for shortness of breath. She was diagnosed with [REDACTED]. The family decided to put her in Hospice during this time. The facial [MEDICAL CONDITION] did not have anything to do with her death. On /3/12/19 at 1:30 PM V4 Nurse Consultant sated; R1 could not have removed the upholstered inset herself, R1 needed help with all ADL's (Activities of Daily Living). R1 required assistance to move in bed and get out of bed. R1's roommate also would not be able to remove the insert. She was bed bound. We have no idea how this happened. On 3/12/19 at 12:50 PM with V5 Director of Maintenance observed R1's former room where the decorative wall headboard fell on R1 . There is a wood frame on the wall behind the bed. The upholstered inset is missing. There are nine round areas approximately one inch across within the wood frame, that look like adhesive. There is a hole in the wall, approximately 3/4 of an inch across near the bottom of the wall, there is no stud (wood support) exposed. On 3/12/19 at 12:45 PM V5 Maintenance Director stated; the upholstered board that's on the wall behind the bed fell on R1. I went to R1's room the morning on 2/27 /19 at about 6:00 AM, it was leaning against the wall. There was one nail approximately 2 inches long still attached to the board. There were three nails on the floor behind the bed. It appeared to be attached originally with four nails and some type of adhesive on the back. The hole in the wall is where one of the bottom nails was. I don't check the wall insert boards per se. I do a general room check every two weeks, when I check the light bulbs. I rely on the housekeepers and nurses to tell me if there is a problem. I do not know how this happened. The insert should have fallen straight down. This is the first time this has happened. I checked all the rooms after this happened, and a couple of rooms had loose wall insert head boards, I fixed them with additional adhesive. There are 99 decorative wall inserts in the building. They are 3 feet 8 inches long and 3 feet 5 1/2 inches wide, they weigh 24.4 pounds. They were installed about [AGE] years ago by a contractor, I did not install them. The facility policy titled, Maintenance dated 2/20/17 documents; It is the facility policy to maintain equipment and the building. Procedure 1. All resident care equipment and the building environment will be maintained by the maintenance department.

Based on observation, interview, and record review, the facility failed to follow their pressure ulcer prevention policy and procedures by failing to prevent the development of new pressure ulcers for one (R79) of four residents reviewed for new or worsened pressure ulcers. This failure resulted in R79 developing avoidable stage IV pressure ulcers and emergent discharge to the hospital [MEDICAL CONDITION]. Findings include: At 9:30 AM during the initial tour, R79 was observed in bed in a supine position wearing an incontinence brief and lying atop a green colored incontinence pad. Under the incontinence pad was a white draw sheet and under the draw sheet was a folded up blanket under R79's buttocks. At 11:35 AM R79 was observed in the same supine position. V5 (LPN-Licensed Practical Nurse) stated, Yes I think (R79) got the pressure sores here. He was first here on the first floor and then moved to the second floor, now he's here. Asked what she does for R79's pressure sores, V5 stated, I don't do wound care, it's just the wound care nurse and she was already here early this morning. Asked again what she does to care for R79, V5 stated, He doesn't normally get up and I think the last time he was up was Saturday. He's on an air mattress. Facility face sheet dated 2/7/18 shows R79 as a [AGE] year old resident originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of facility pressure sore list submitted by V2 (Director of Nurses) on 2/5/18 shows R79 with two facility acquired pressure sores. On 2/6/18 at 9:30 AM during another resident's (R52) wound care observation, surveyor asked to demonstrate the electronic pressure alert monitoring system that was used on other residents including R79. V4 stated, these pads go on to the pressure points on high risk residents and when the sensor monitors increased pressure for a certain time, it rings at the nursing station so the nurses can tell the cna's (certified nurse's aides) to turn the patient. Asked if V79 was on this monitoring system, V4 stated Yes. Asked about the pressure alert monitoring system, V4 (Wound Care Nurse) stated, Well the problem here is that this is an expensive system but it's not used right because first, the roommates or the residents would complain that the alarm would go off right in the room and would say Time to turn me, time to turn me and wake up the resident or roommate so we had to turn off that function in the room. The other problem is that the only way the nurses know the alarm goes off is only when there's a nurse sitting at the nursing station but they're not always there. When they are there it's silenced right away and they don't check to see if the c.n.a. turned the resident. The other problem is that the residents need to be turned and cleaned up right away when they're wet or had a bowel movement. Asked if she discussed this with anyone, V4 stated, Oh I tell this to V9 (Infectious Disease/Wound Doctor) and he tells me the same thing. I told the administration and they're finally going to get rid of it after a year of using it. It's so expensive but it's not used right. I have to come in early in the morning just to check to see if residents have been changed and are clean and dry. I can't be here all the time. R79's Wound Assessment Details Report dated 10/23/17 shows MASD (Moisture-Assisted Skin Damage) to the right buttock; Classification: Incontinence; Source: Facility-acquired; Date identified: 10/23/17. (Date of admission: 9/20/17) Size in cm-centimeters: 4.50 cm. (length) x 4.00 cm. (width) x Unknown (deep). V4 comments on the same report writes, 10/23/17 12:52 PM: Patient develop unstageable ulcer on the right buttock. Instructed staff to keep turning and change diaper frequently. Will continue to monitor. Another report for R79 dated 12/11/17 shows Wound: Sacrum; Source: Facility-acquired; Date identified; 12/4/17; Clinical Stage: Deep Tissue Pressure Injury; Size: 6.50 cm. length x 4.50 cm width x 0.02 cm deep. Current plan and comments: 12/11/2017 01:58PM by V4: Weekly skin assessment done, ulcer became unstageable, instructed staff to turn and change diaper frequently. Will ask (V9-Infectious Disease/Wound Doctor) to reevaluate the ulcer. Will continue to follow. 2/6/18 Interview at 11:30 AM with V4 states, I assessed (R79) when he was first admitted and he was high risk and did not have any pressure ulcers. He acquired them while he was here. We discharged him yesterday (2/5/16) and we were told he was admitted to the hospital [MEDICAL CONDITION] more likely due to the wound. Asked if the hospital provided the facility with any other information, V4 stated, No they don't tell us much except the [DIAGNOSES REDACTED]. He was also being seen by V9. 2/7/18 Interview with V2 (Director of Nursing) at 3:00 PM states, We got rid of the turning and repositioning clocks last year because we had an issue with staff not following it on our last survey. Asked if they do anything else to ensure staff was prompted to turn and reposition residents, V2 stated, Well we don't do overhead announcements either. We got rid of that too. We have this electronic pressure alert monitor system that alerts us at the nursing station but I was told we are getting rid of it soon because it's expensive and staff doesn't really respond to the alarms because someone has to be sitting at the nursing station all the time for us to know its ringing. We do have the managers do regular rounds to ensure residents are turned and repositioned. On 2/8/18 at 12:00 PM interview with V9 (Infectious Disease/Wound Doctor), states, I don't know if (R79) acquired those wounds you're speaking of but I do know they got worse there (at the facility). (R79) is nutritionally compromised and he refused a feeding tube so that affects wound healing. He also likes to stay on his back and doesn't like to be turned side to side from what the facility tells me. He was discharged and admitted [MEDICAL CONDITION] but he was really discharged because we needed to debride his buttock wound which was already septic in the facility. He needs to given intravenous antibiotics which can only be treated in the hospital as that can be life-threatening. R79's Care Plans dated 12/21/17 states, The resident has a stage 4 right buttock and Stage 4 Sacrum; The resident's pressure ulcer will show signs of healing and remain free from infection; Interventions: The resident needs use of bed rails, trapeze bar, etc for resident to assist with turning; The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing; Facility policy and procedure dated February 20, 2017 titled Skin Care Treatment states, It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [REDACTED]. Procedures: Charge nurses must document in the nurses' notes and/or the Wound Report Form any skin breakdown upon assessment and identification. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. Refer any skin breakdown to the skin care coordinator for further review and management as indicated. Braden Scale or similar assessment to determine risk for pressure sore will be done upon admission or readmission. Residents who are not able to turn and reposition themselves will be turned and repositioned every 2 hours. Stage III and IV including decubiti/pressure ulcers may be referred to wound care specialist for further clinical and treatment consultation in accordance to facility protocol and standard of care.

Based on interview and record review the facility failed to 1) care plan and implement fall prevention interventions to address a cognitively impaired resident not seeking staff's assistance for toileting, and 2) respond quickly to a door alarm, provide monitoring and supervision to prevent a resident's elopement from the facility. This applies to one of three residents (R1) reviewed for falls and supervision in a sample of 9. As a result of the failure, R1 who had a history of [REDACTED]. R1 experienced a fall and sustained a right hip fracture which required a surgical procedure to repair. Findings include: 1. According to January 2016 POS (Physician order [REDACTED]. R1's December 4, 2015, MDS (Minimum Data Set) Comprehensive Assessment documented R1 was cognitively impaired and depended on staff member for physical assistance with activities of daily living R1's November 2015 through January 2016 Nurses' notes and incident reports included documentation as follows: -11/27/15: (R1) tried to get up and slipped hitting (R1's) butt -1/9/16: Heard the bed alarm sound and right away checked, found (R1) lying on left side on the floor; (R1) stated that (R1) is trying to walk and lost balance. -1/15/16 at 2:20 am: Heard the sound of the bed alarm and went inside the room. Observed (R1) sitting on the floor with legs extended beside (R1's) bed. (R1) stated, I slid on the floor and I'm not hurt. Able to ambulate and assisted to the washroom. -1/16/16 at 12:20 am: Answered call light from another room, passed by (R1's) washroom and observed (R1) lying on back on the floor with right knee flexed towards the left leg, with redness noted below and with complaints of pain when moving .transferred to (local hospital) accompanied by two paramedics at 1:35 am. According to the above, R1 had a total of 4 fall incidents during facility admission. Hospital Records documented, 1/16/16 X-ray of pelvis with Impression: Intertrochanteric fracture of the right femur. Fracture fragments are mildly displaced. The hospital's medical progress notes by the hospital physician on 1/17/2016 documented: R1 had a procedure in which a intramedullary rodding was done for repair of the closed intertrochanteric fracture of the right hip. R1's care plan documented the following : -Date initiated: 11/30/15 Focus: The Resident is at high risk for falls related to recent fall last month, impaired balance during transitions, gait problems such as unsteady gait even with mobility aid or personal assistance, impulsivity or poor safety awareness, cognitive impairment. Goal: The resident will be free of falls through the review date Interventions for R1 on 11/30/15: Be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Anticipate and meet the resident's needs. The resident uses (chair/bed) electronic alarm. Ensure the device is in place as needed. PT/OT (Physical therapy/Occupational therapy) consultation Provide resident with a safe environment. Move the patient close to the nurses' station. Monitor /document/report as needed to physician Maximize the resident's time out of bed Keep needed items, water etc, in reach Keep furniture in locked position Ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair -Interventions for R1's fall on 1/9/16: Reminded resident to ask assistance from staff for ambulation Encouraged to use assistive device for locomotion -Interventions for R1's fall on 1/15/16: Refer to maintenance director to check bed/mattress for any issues Ensure proper positioning on the center of the bed when sleeping to prevent sliding off Discontinue bed alarm During interviews with E8 (Registered Nurse), E14 and E15 (both Certified Nursing Assistants) conducted on 3/02/16 all reported, R1 used a wheelchair and did not use a walker Z2's (Nurse Practitioner) progress notes on 1/9/16 documented: Neurologic: A, O (Alert and oriented) 1 to 2, at baseline Problem: Episode of weakness According to E1 (Administrator) on March 3, 2016 at 12:00 pm, (Z2) diagnosed (R1) with Generalized muscle weakness which may have contributed to the fall There was no documentation on nurses' notes and on Documentation Survey report that assistance was provided for toileting, transfer and bed mobility prior to the fall on 1/15/16 According to a telephone interview with E8 (Registered Nurse) on March 2, 2016 at 11:42 am, R1 will get up to go use the bathroom, even without assistance. E8 stated that R1 was assisted to use the bathroom after the fall on 1/15/16. E8 stated that it was determined that R1 needed to use the bathroom at that time. E8 also stated that R1 uses a regular bed. There was no documentation on nurses' notes and documentation survey report that staff offered assistance to R1 on 1/16/16 prior to R1's fall. On February 28, 2016 at 5:00 pm, E6 (Licensed Practical Nurse) stated that R1 is alert and oriented to self and Z3 (R1's family) and would always ask where Z3 is. E6 stated that R1 exhibit some behaviors and at times confused and forgetful. E6 stated that R1 needs assistance for safety reasons. On March 1, 2016 at 11:00 am, E4 (Restorative Nurse) stated that R1 is alert and oriented 1 to 2 and was identified as at risk for falls. E4 stated that R1 had 4 fall incidents while in the facility. E4 stated that a toileting schedule was not put in place for R1 because R1 was identified as continent of bowel and bladder. E4 confirmed that R1 needs assistance with toileting and transfers, and that is it safer if R1 is assisted, and also confirmed that this was not in the fall care plan interventions. E4 stated that E4 planned to put R1 in a toileting schedule after R1 returns to the facility. On March 2, 2016 at 1:52 pm, Z1 (Physician) was interviewed via telephone. Z1 confirmed that R1 has periods of confusion. Z1 stated that R1 needed monitoring. Z1 stated that (Z1) had seen (R1) at a local hospital after R1 obtained a fracture after falling at the facility. On March 2, 2016 at 11:42 am, E8 was interviewed via telephone. E8 stated that R1 is alert and oriented to self. E8 stated that R1 does not remember my name. E8 stated that usually R1 would go to the bathroom per self. E8 stated that the last 2 fall incidents happened during E8's shift (11-7 shift). E8 stated that R1 would usually stand, move about in the room and use the washroom. E8 stated that R1 needs assistance with ADLs and needs assistance for safety. E8 stated that R1 can move about but needs assistance. E8 confirmed that R1 is not on any toileting schedules but needs assistance with going to the bathroom. E8 stated that I think the bed alarms are necessary, especially at night, so that we know that (R1) is trying to get up. They usually tell us if there is a change in the interventions, (R1) had a bed alarm. For R1's fall on 1/16/16, I just don't remember hearing the alarm or if I turned it off once I got there. On March 2, 2016 at 3:21 pm, E15 stated that R1 is alert to self and to person. E15 stated that R1 goes to the bathroom per self but it is safer for R1 to be assisted with transfers and toileting. On March 2, 2016 at 12:35 pm, E14 was interviewed. E14 stated that R1 is alert and oriented to wife and that R1 needs assistance with transfer and toileting. E14 added that R1 did not use a walker but used wheelchair when (R1) goes to the washroom by self. E14 stated that R1 can ambulate but for safety reasons, R1 needs assistance. The facility's undated policy on Fall Occurrence documents in part: It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. Those identified as high risk for falls will be provided interventions to prevent falls. 2. The facility's 12/31/15 incident report for R1 documented: E6 (Licensed Practical Nurse-LPN) was making rounds and noticed that (R1) was not in room; bathrooms were checked, dining room and other resident's rooms. (E6) also called first floor. Was in the process of looking for (R1) when (Z3 - R1's family) called and stated that (R1) called and that (R1's) at the gas station. (E6) sent (E14 - CNA) to get (R1) back to the facility. On February 28, 2016 at 5:00 pm, E6 stated that on 12/31/15 at around 8:15 pm, E6 was notified by E15 that E15 could not find R1. E6 stated that a facility-wide search was conducted. E6 stated that in the middle of the search, Z3 called the facility and stated that R1 was at the gas station and had called Z3. E6 stated E6 sent E14 to get R1 from the gas station and R1 was brought back to the facility at around 9:00 pm. E6 denied hearing exit door alarm going off during the time of the incident, there were too many sounds at that time. E6 stated that when E6 asked R1 why R1 went outside, R1 stated, I wanted to call (Z3). On March 2, 2016 at 3:21 pm E15 stated that E15 had seen R1 in the room at around 7:30 pm. E15 stated, When I went to (R1's) room, I didn't find (R1). I checked in the bathroom and every room. I told (E6) about it. I went to the 3rd floor and 1st floor and I even went and asked (E16- Receptionist). They told me that they didn't see R1. As soon as I came back, Z3 had called (E6) and was told that (R1) was at the gas station and then R1 returned to the facility. I asked (R1) why (R1) went out, (R1) said that (R1) was looking for (Z3) and also wanted to buy cigarettes. E15 stated that R1 had a monitoring device on the ankle but did not hear any alarms go off on the 2nd floor. On March 2, 2016 at 12:35 pm E14 stated, E14 was asked by E15 if E14 had seen R1. E14 stated that the last time E14 had seen R1 was during dinner time. E14 stated that they were asked to search the rooms for R1. E14 stated that when E6 received a call from Z3, E6 had instructed E14 to go to the gas station. E14 stated that R1 was inside the gas station talking to the clerk there and when asked why R1 went there, R1 told E14 that R1 wanted to call Z3. E4 stated that R1 had a monitoring device and did not hear any alarms go off on the second floor. E6, E14 and E15 stated that when a resident has a monitoring device and come near the elevator, the alarms get triggered; the elevators stop and open but won't close or move unless a staff member deactivates the alarm. E6, E14 and E15 also stated that if a resident with a monitoring device comes near a stairway exit door, the alarm also gets triggered. E6, E14 and E15 stated that they were not aware of any alarms that went off during those times. On March 2, 2016 at 4:00 pm, E16 (Receptionist) stated she did not hear the alarms on the front doors triggered. E16 stated that the alarms sound off when there is a resident with a monitoring device goes near the exit doors and that when the alarms sound, staff should check the exit areas for any residents who are at risk for elopement. On March 3, 2016 at 2:00 pm. E2 (Director of Nursing) stated that when E1 and E2 interviewed E18 (Registered Nurse) during the investigation, E18 stated she heard an alarm on one of the exit doors, looked to see if someone was outside and when E18 did not find anyone, E18 deactivated the alarm. On March 3, 2016 at 2:53 pm, E19 (Certified Nursing Assistant) E19 stated that on 12/31/15, E19 did not hear any alarms but stated that E19 thought that (E18) have heard and deactivated the alarm. E19 stated that when an exit door alarm is heard, staff looks to see on the first floor panel where the alarm is coming from and investigate whether there was a resident who went out or accidentally pushed the door. E19 stated that when it is clear, then the alarm can be deactivated. On March 3, 2016 at 2:57 pm, E18 stated that E18 had heard an alarm from an outside exit door. E18 stated, I had heard the alarm sound off from the exit door leading to the outside of the facility. I had looked around to see if anybody was there but I did not see anyone. Since no one had announced (from the other floors) that they were missing a resident, and seeing that there was no one in the area where the alarm came from, I had turned off the alarm .About 10-15 minutes later, I saw staff bring in (R1) from the outside. The facility's April 2013 policy on Missing residents and elopement document in part: Routine Procedures for the Prevention of Missing Residents and Elopements: -Close monitoring for elopement risk residents must be done on scheduled basis particularly at the beginning of each shift, during medication pass or at each meal and as often as necessary. The procedures for the response to missing residents and/or elopements shall be implemented for elopement risks residents who are not accounted for. -Facility personnel shall immediately respond to and determine the cause for the sounding of exit door alarms. If no reasons/causes can be identified, a specific missing resident alert code or announcement may be initiated as necessary.

Based on observation, interview and record review, the facility failed to properly assess and treat pain in one resident (R3) out of nine residents reviewed for pain in the sample of 19. As of a result of this failure, R3 suffered pain and decreased functional movement. Findings include: On 1/22/14 at 8:45 AM, R3 was observed during treatment of [REDACTED]. At 9:00 AM, R3 moaned when his right leg was lifted. R3 moaned two additional times during the cleaning and dressing of his right ankle ulcer. E5 (Wound Care Nurse) did not ask R3 if he was in pain or offer to pause the treatment. E5 stated that R3 "has gotten more stiff" and that she needs assistance to lift R3's leg to be sure it doesn't move too much while being treated. The Physician order [REDACTED]. On 1/23/14 at 9:00 AM, E26 (Restorative Aide) stated during interview that she provides daily passive range of motion (PROM)to R3, Monday through Friday and that certified nurse aids do weekend PROM. E26 states that R3 is guarded, as if he is in pain, but when asked if he is in pain R3 says he is not in pain. E26 stated sometimes R3 refuses PROM. On 1/23/14 at 9:20 AM, E4 (Restorative Nurse) stated she agrees R3 "appears guarded and pulls back if his extremities are moved." E4 stated E4's spouse said he's always done that". E4 stated she was not aware R3 ever refused ROM, had not considered pre-medicating R3 for pain prior to doing PROM and had not considered any other approaches to assuring the prevention of contractures. R3's Minimum Data Sets ((MDS) dated [DATE] and 11/22/13 indicate R3 was assessed as "severely impaired" in Section C1000 Cognitive Skills for Daily Decision Making". R8's care plan for range of motion dated 11/4/13 includes interventions to "monitor for signs and symptoms of pain and notify nurse", "medicate for pain as needed" and "provide rest periods". R3's care plan for pain dated 11/25/13 reads "Anticipate the resident's need for pain relief and respond immediately to any complaint of pain." "Identify and record previous pain history and management of that pain and impact on function. The care plan for pressure ulcers does not mention pain relief in the interventions, but states to "Turn/reposition resident at least every two hours while in bed per facility protocol. A "Comprehensive Pain Assessment" dated 8/29/13 indicates R3 has a "[DIAGNOSES REDACTED]. The assessment also reads " Has the resident undergone any painful procedures that would give you reason to believe he/she would be in pain" and was marked "yes - wound changes." The Monthly Physical Assessment Form, dated 11/13/13 (assessment date) and 12/13/13 (signature date) show the following: "1. Do you have now or experience any pain or discomfort - Yes 3. Intensity "unable to verbalize" B. "If individual is unable to rate pain, observe for the following indicators showing evidence of pain and circle all that apply. Moaning, crying" (were the items circled). 7. What increases the pain? Repositioning and wound care." R3's Physician order [REDACTED]. Medication Administration Records (MAR) for November and December 2013, and January 1-22, 2014 do not show any notations of [MEDICATION NAME] being administered. The MARs also show R3 was assessed as having no pain on any day on all three shifts. However, a sheet marked "Comfort Goal" shows one line of charting 1/19/14, 7-3 shift, showing a goal of 1-2 out of ten on the pain scale, had no entry in the column for pain rating, described the pain as "right arm, general, 30 minutes duration, aching and sharp, aggravated by movement, and treated with prn(as needed) med with relief." No charting was present in Nurses Notes from 11/2/13 to 1/19/14 regarding resident pain or treatment; one noted dated 12/4/13 at 2100 read "Patient resting in bed with no acute distress. No charting was present after 1/19/14 when the record was read and a copy obtained on 1/23/14. On 1/23/14 at 2:00 PM, Z8 (Physician) stated R3 "should be ranged daily; should be more often. He's reducible, but could become non-reducible and he's not a surgical candidate." Z8 stated she feels the contractures were avoidable. Z8 stated she has not been notified of Z8 having pain, but stated "There's no question he's in pain. He needs to have regular meds, perhaps [MEDICATION NAME] every 12 hours." Z8 expressed that R3 can't be properly ranged (range of motion) without pain relief. On 1/23/14 at 12:30 PM, E2 (Director of Nursing) stated "I would offer pain meds if he was guarding or grimacing during movement." E2 acknowledged that R3 could not effectively communicate pain verbally, but felt R3 should be given medication before movement.

Based on observation, interview and record review, the facility failed to properly assess and treat pain in one resident (R3) out of nine residents reviewed for pain in the sample of 19. As of a result of this failure, R3 suffered pain and decreased functional movement. Findings include: On 1/22/14 at 8:45 AM, R3 was observed during treatment of [REDACTED]. At 9:00 AM, R3 moaned when his right leg was lifted. R3 moaned two additional times during the cleaning and dressing of his right ankle ulcer. E5 (Wound Care Nurse) did not ask R3 if he was in pain or offer to pause the treatment. E5 stated that R3 "has gotten more stiff" and that she needs assistance to lift R3's leg to be sure it doesn't move too much while being treated. The Physician order [REDACTED]. On 1/23/14 at 9:00 AM, E26 (Restorative Aide) stated during interview that she provides daily passive range of motion (PROM)to R3, Monday through Friday and that certified nurse aids do weekend PROM. E26 states that R3 is guarded, as if he is in pain, but when asked if he is in pain R3 says he is not in pain. E26 stated sometimes R3 refuses PROM. On 1/23/14 at 9:20 AM, E4 (Restorative Nurse) stated she agrees R3 "appears guarded and pulls back if his extremities are moved." E4 stated E4's spouse said he's always done that". E4 stated she was not aware R3 ever refused ROM, had not considered pre-medicating R3 for pain prior to doing PROM and had not considered any other approaches to assuring the prevention of contractures. R3's Minimum Data Sets ((MDS) dated [DATE] and 11/22/13 indicate R3 was assessed as "severely impaired" in Section C1000 Cognitive Skills for Daily Decision Making". R8's care plan for range of motion dated 11/4/13 includes interventions to "monitor for signs and symptoms of pain and notify nurse", "medicate for pain as needed" and "provide rest periods". R3's care plan for pain dated 11/25/13 reads "Anticipate the resident's need for pain relief and respond immediately to any complaint of pain." "Identify and record previous pain history and management of that pain and impact on function. The care plan for pressure ulcers does not mention pain relief in the interventions, but states to "Turn/reposition resident at least every two hours while in bed per facility protocol. A "Comprehensive Pain Assessment" dated 8/29/13 indicates R3 has a "[DIAGNOSES REDACTED]. The assessment also reads " Has the resident undergone any painful procedures that would give you reason to believe he/she would be in pain" and was marked "yes - wound changes." The Monthly Physical Assessment Form, dated 11/13/13 (assessment date) and 12/13/13 (signature date) show the following: "1. Do you have now or experience any pain or discomfort - Yes 3. Intensity "unable to verbalize" B. "If individual is unable to rate pain, observe for the following indicators showing evidence of pain and circle all that apply. Moaning, crying" (were the items circled). 7. What increases the pain? Repositioning and wound care." R3's Physician order [REDACTED]. Medication Administration Records (MAR) for November and December 2013, and January 1-22, 2014 do not show any notations of [MEDICATION NAME] being administered. The MARs also show R3 was assessed as having no pain on any day on all three shifts. However, a sheet marked "Comfort Goal" shows one line of charting 1/19/14, 7-3 shift, showing a goal of 1-2 out of ten on the pain scale, had no entry in the column for pain rating, described the pain as "right arm, general, 30 minutes duration, aching and sharp, aggravated by movement, and treated with prn(as needed) med with relief." No charting was present in Nurses Notes from 11/2/13 to 1/19/14 regarding resident pain or treatment; one noted dated 12/4/13 at 2100 read "Patient resting in bed with no acute distress. No charting was present after 1/19/14 when the record was read and a copy obtained on 1/23/14. On 1/23/14 at 2:00 PM, Z8 (Physician) stated R3 "should be ranged daily; should be more often. He's reducible, but could become non-reducible and he's not a surgical candidate." Z8 stated she feels the contractures were avoidable. Z8 stated she has not been notified of Z8 having pain, but stated "There's no question he's in pain. He needs to have regular meds, perhaps [MEDICATION NAME] every 12 hours." Z8 expressed that R3 can't be properly ranged (range of motion) without pain relief. On 1/23/14 at 12:30 PM, E2 (Director of Nursing) stated "I would offer pain meds if he was guarding or grimacing during movement." E2 acknowledged that R3 could not effectively communicate pain verbally, but felt R3 should be given medication before movement.

This Requirement is not met as evidenced by: Based on observation, interview and record review, the facility failed to use proper equipment during transfer on 1 resident (R3) out of 4 residents reviewed for injury. This failure resulted to R1 sustaining a fracture of the right proximal fibula and a hairline fracture of the right proximal tibia. Findings include: Based on observation, interview and record review, the facility failed to use proper equipment during transfer on 1 resident (R3) out of 4 residents reviewed for injury. This failure resulted to R1 sustaining a fracture of the right proximal fibula and a hairline fracture of the right proximal tibia. Findings include: R3 has [DIAGNOSES REDACTED]. During 7/25/12 observation at 10:30AM, R3 was noted in a wheelchair with right sided weakness and is non-verbal. Per R3's incident report dated 7/14/12, at 10:45AM, while R3 was being transferred from a shower chair to the wheelchair, R3's right leg gave way and became limp. R3's report also indicated that a sit-to-stand lifter was used during this incident. On 7/25/12 at 10:35AM, E5 (Nurse) said that on 7/14/12. R3 ' s right knee was swollen right after she was transferred by E3 (CNA) using a sit-to-stand lifter. E5 added that she had seen staff use a mechanical lifter on R3, but never a sit-to-stand lifter. E5 said that she preferred the CNA ' s not to use the sit-to-stand lifter because R3 has right-sided weakness and her right hand could not hold on to the sit-to-stand lifter handle bar. E5 said that if she saw staff trying to transfer R3, she would have encouraged the use of the mechanical lifter instead. On 7/25/12 at 12:38PM, E4 (Restorative Nurse) said that R3 was assessed and is supposed to use a mechanical lifter, not a sit-to-stand lifter. E4 continued that it is because R3 needs extensive to total assistance with transfers, and is unable to bear weight on her right leg. E4 also said even prior to 7/14/12, the facility has a list indicating what type of lifter should be used for each resident. This list indicated that R3 needed a mechanical lifter not a sit-to-stand lifter. On 7/25/12 at 10:12 AM, E3 (CNA /Certified Nurse Aide) said that she used the sit-to-stand lifter on R3 before and no accident happened. E3 added that on 7/14/12, she used the sit-to-stand lifter again while she was putting her incontinence brief on and pulling on her pants with another CNA. E3 said that 2 to 3 minutes after R3 was on lifter, her leg gave way and thus R3 was placed back in the wheelchair again. E3 said she noted that R3 ' s right knee was swollen. E3 said that it was her fault because she should have used the mechanical lift not the sit-to-stand lifter. E3 said that otherwise, a picture of a sofa should have been in R3 ' s door if a sit-to-stand lifter is the appropriate device to be used for R3. R3 ' s care plan indicated that since 9/29/10, R3 had been using the mechanical lift during transfers, not sit-to-stand liter. R3 ' s 7/14/12 X-ray of the Right Knee indicated a fracture of the right proximal fibula and a hairline fracture of the right proximal tibia. R3 was sent out to the hospital and come back on 7/16/12 with a long leg circular cast.