Every finding on record at Ambassador Nursing & Rehab Center

Based on observation, interview and record review, facility failed to dispense accurate controlled substance pain medication in accordance with standards of professional practice for one resident (R7) out of 7 residents reviewed for medication administration in a sample of 35 residents.Findings IncludeR7's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Paraplegia, pressure ulcer of sacral region, stage 4, fatty liver, hypothyroidism, chronic pain due to trauma, major depressive disorder.Care plan (dated 08/01/2026) documents that R7 is at increased risk for alteration in pain/discomfort or has current pain related to: Pressure wounds to the sacral areaMinimum Data Set Section (MDS) section C (dated [DATE]) documents that R7's Brief Interview for Mental Status (BIMS) score is 15, indicating that R7's cognition is intact.The Illinois Department of Public Health surveyors were conducting an annual re-certification and licensure survey in the facility. On 08/18/2026 at 10:33AM, surveyor conducted an interview with R7. R7 stated, It was an agency nurse, V11 (Nurse), I think. She was our nurse that day and she came into my room at about 12:15 AM on 08/09/2026. She asked me if I wanted my pain medication. I didn't know that V11 was still here. She worked a double shift on 08/08/2026. She worked the 7AM shift and the 3PM to 11PM shift. I didn't have anything scheduled at that time. I said yes, and she left to the nursing station to get the medication. She took about 2 minutes to come back with the pain medication, Oxycodone, which I take PRN (As Needed) every 8 hours. V25 (licensed practical nurse) was here, and she was on duty for the 11PM to 7AM shift. V25 is a regular night shift nurse. She came back, handed me the medication, and took off. I grabbed the medication that V25 placed on the table, I looked, and I noticed the difference in the medication. The 2 pills that V25 gave me looked fatter than the Oxycodone pills I take. From my pill to whatever she gave me, it was fatter. I have been taking Oxycodone medicine for 1.5 years and I am familiar with what it looks like. My medicine is white and whatever she gave me was also white. She did not watch me take it. Our regular nurses watch us take the medicine. At 3PM, I asked her for pain medication, and she brought it to me without a problem. After, I took the medication at 3PM, I felt sleepy. My medication does not do that to me normally. I saw her again at 9PM, to give me my scheduled medication. She asked me if I wanted her to bring the Oxycodone medication at 11, when it's due again, and I said no. She returned again at 12:15AM, asking if I wanted the medication. She came in and placed the medicine on the table and she left. That's when I noticed that whatever she put on my table was not my medication because it was thicker. Once I noticed that the medicine was not mine, I pulled the call light to speak to my 3rd shift nurse, V25. V25 came to my room, and I told her that the other nurse gave me this medication. V25 noticed that this was not my Oxycodone medication. V25 left the medication on my table. V25 came back with V11 and my Oxycodone bingo card, to compare the medication that was given to me with the Oxycodone in the bingo card. V11 and V25 verified that it was not my medication in the cup. Then they took the medicine back from me, and they went to the nursing station. One minute later, the agency nurse, V11, came to my room. She started apologizing and coming up with excuses that she had a long day and had a fall. She was telling me what was going on during the shift, and it did not have anything to do with me. To me it was like she was nervous. V25 came in and brought me my Oxycodone medications for pain. The agency nurse could not account for my pain medicine that she pulled from my bingo card. V25 brought the bingo card and popped the pain medicine from the bingo card in front of me. Then the agency nurse said to me to have a good night, and she left. Next day the administration came up and spoke to me about what happened. On 08/19/2026 at 9:47AM, V3 (assistant director of nursing) stated, I am familiar with R7 and that he takes PRN Oxycodone. R7 expressed that his medications did not look the same according to him. I was on call that weekend. I had social services interview him and I came to see him. R7 said that it did not seem like it was an accurate medication. It was an agency nurse, V11. First, I asked V11, and V11 said that she gave the medication to the patient. R7 was alleging that he received something different in the cup. I placed V11 on a do not come back list. I in serviced the nurses. She pulled the medication from the bingo card. I don't recall what time this occurred. According to him, R7 said that he took the medication. I remember V25 (licensed practical nurse) was called into his room. I spoke to her. V25 said that R7 made a statement that the medication was different. V25 was not able to verify it because R7 took the medication. When R7 voices concerns, he could be a little particular. Agency nurses could be a trigger for him. We try to have regular nurses scheduled on R7's side, because he voices concerns with agency nurses. The allegation was not able to be confirmed, but I still did in-services with the nurse and V11 will not come back to the building. The nurses have to watch the residents take the medication; that's the proper way. R7 has a history of false allegations and history of substance abuse. R7 has made allegations against staff in the past which were false. R7 is care planned for it. On 08/20/2026 at 12:10PM, V3 stated, When disposing of a controlled substance, it has to be wasted by 2 nurses. This is the standard practice. When there is a discrepancy with a controlled substance, the narcotic should be wasted with a nurse colleague. The nurses should notify management (Director of Nursing, Assistant Director of Nursing) right away when a narcotic discrepancy occurs. On 08/20/2026 at 9:14AM, V25 (licensed practical nurse) stated, I recall the event on 08/09/2025 pertaining to R7. I was starting my shift and receiving report from V11 (agency nurse), when a certified nursing assistant informed us that R7 wants his pain medications. V11 told me that she would give R7 his Oxycodone because she promised him that she would give him his pain medications before she went home. V11 went to the nursing cart and pulled R7's Oxycodone from R7's bingo card and then she went to R7's room to give him his medications. I was by the nursing station and V11 told me that R7 wanted to see me. I went to his room and R7 told me that his Oxycodone pain medications that were given to him by V11 were not his medication. R7 said that he does not feel comfortable taking it. R7 was holding the medication in the medication cup. I told him that I was not sure, and I took the medication from him to the nursing station to verify the medication. I took out R7's bingo card for his Oxycodone medication and I verified the medication with the agency nurse, V11. I verified the medication in the cup, and it was different than what's in the bingo card. V11 took the cup of the incorrect medication and went to R7's room. I don't know what happened when V11 went to the room to speak to R7. R7 called again and asked me for his pain medication. I don't know what V11 did with the incorrect medication that was in the cup, but she signed wasted on the narcotic ledger. I did not waste the medications with V11. I just signed for the medications that I took to give to R7. I signed out the correct Oxycodone after the incident. When I verified the medication, it was not the correct Oxycodone that was in R7's bingo card. V11 was not off duty yet, she was working on an incident that she had earlier in the day. V11 did not finish giving me report yet, and R7 was asking for his pain medication. V11 said she would go and give it, and then after V11 gave R7 the medication, V11 told me that R7 was requesting to speak to me. When narcotics are wasted, you can't waste the medication without another nurse verifying. The next day, I calledV3 (assistant director of nursing) to notify her of what happened. Controlled Drug Disposition Form indicated that V11 (agency nurse) dispensed Oxycodone 5mg (2 tablets) to R7 on 08/08/2026 at 3:30PM (with 24 tablets remaining in the bingo card) and on 08/08/2026 at 11:57PM (with 22 tablets remaining in the bingo card). The narcotic ledge indicated that the Oxycodone dispensed to R7 at 11:57PM was crossed out and documented as wasted by V11. The narcotic ledger indicated that V25 (licensed practical nurse) dispensed the Oxycodone medication to R7 at 08/09/2026 at 12:22AM (with 20 tablets remaining in the bingo card). Concern Form (dated 08/09/2026) states: Resident (R7) stated to nurse on duty that she was giving him the wrong medication. Resident refused to take the medication. Nursing-In Service (dated 08/10/2026) documents that nurses were educated on the following topics: Medication Administration & Wound Care Compliance; The purpose of this in-service is to reinforce nursing responsibilities related to safe medication administration, completion of ordered wound treatments, proper documentation, and timely reporting of changes in resident condition. All nurses are responsible for ensuring that medications are administered safely, accurately, and according to the physician/provider's orders and facility policy. Follow the rights of medication administration, including the right resident, medication, dose, route, time and documentation. Guidelines for Controlled Substance Medications Policy (dated 07/30/2025) states in part: Controlled Substance Medication is defined as medications included in the Drug Enforcement Administration (DEA)classification as controlled substances and subject to special handling, storage, disposal and record keeping in the facility in accordance with federal and state laws and regulations. Any discrepancy is to be reported in writing and verbally to the appropriate supervisor and to the Director of Nursing/Assistant Director of Nursing. Controlled Substance Medications Policy (undated) states in part: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. The disposal of unused partial tablets and unused portions of single dose ampules must be destroyed and recorded in the presence of two licensed personnel.

Based on interview and record review, the facility failed to provide adequate supervision for two (R3, R4) of three residents with history of aggressive behaviors. The facility failed to ensure that R4, who required one-to-one supervision due to prior resident-to-resident altercation, was adequately supervised, resulting in another resident-to-resident altercation.Findings Include:The facility's final incident reportable for R3 and R4 dated 5/24/26 sent to State Agency on 5/29/26 at 3:38 PM reads in part: [R4] stated they engaged in an argument with [R3], and that [R3] got frustrated and pushed [R4]. [R3] denied the allegation adamantly stating he didn't make any type of physical contact with [R4]. [R3] further stated that [R4] pushed a chair that made contact with [R3's] walker and he got upset about it but never pushed [R4]. [R4] and [R3] were very upset with each other, and they verbalized threats to staff after they were separated. [R4] and [R3] placed on one-on-one monitoring. MD [Medical Doctor] informed. MD ordered [R4] and [R3] to be sent out to hospital for psychiatric evaluation due to increased irritability. [R4] and [R3] are responsible for themselves. Residents on the floor were interviewed, and no resident witnessed the allegation. Staff on the floor were interviewed, and no staff witnessed the allegation. There are no witnesses to the allegation.R3's clinical records show an admission date of 3/12/26 with listed diagnoses not limited to alcohol abuse, cocaine abuse, and heart failure. R3's Minimum Data Set (MDS) dated [DATE] shows a BIMS (Brief Interview for Mental Status) of 15, which means R3 was cognitively intact and was able to make needs known. R3's comprehensive care plan reads in part: (Date Initiated: 04/04/2026) R3 displays behavioral symptoms related to: A difficult time adjusting to the life in the long-term facility. These behavioral symptoms are manifested by: verbal abuse/aggression. [R3] shouts and uses derogatory terms against staff. [R3] has inappropriate conversations with staff and others. [R3] I display conflictual, difficult behavior with other persons related to: A difficult time adjusting to life in the long-term care facility. Behavior symptoms are manifested by: Covert/open conflict with or repeated criticism of staff and others. Behavior symptoms are manifested by: Unprovoked expressions of anger towards staff & peer (e.g., may approach neutral party & become verbally abusive), Complaints/concerns about other residents., General intolerance & limited ability to deal with frustration. History of substance abuse., Poor or ineffective coping skills.R4's clinical records show an admission date of 5/28/25 with listed diagnoses not limited to heart failure, hyperlipidemia, and chronic kidney disease. R4's MDS dated [DATE] shows a BIMS of 15, which means R4 was cognitively intact and was able to make needs known. R4's comprehensive care plan reads in part: (Date Initiated: 4/14/26) R4 has history of aggressive, inappropriate behavior. R4 has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior. History includes conflicts/altercations with others, disrespectful, insulting, demeaning behavior, and verbal and physical aggression.R4's progress notes dated 5/24/26 at 7:20 AM documented by V22 (Licensed Practical Nurse/LPN) reads in part: [R4] alleged that another resident made contact with him. Full body assessment performed, and no new abnormalities were found. [R4] denies pain or discomfort. [R4] increasingly irritated, making threat to physically harm other residents, unable to redirect or follow directions. [R4] placed on one on one precautions. MD [Medical Doctor] notified. MD gave order to send [R4] to hospital for evaluation. [R4] responsible for self. V1 (Administrator) and V2 (Director of Nursing) aware.On 6/10/2026 at 11:19 AM, a phone interview was conducted with R4. R4 stated that on 5/24/2026 at approximately 7:00 AM, while in the dining room preparing tables for breakfast, R3 approached and struck him on the right side of his face. R4 stated he did not strike R3 in return and was later sent to the hospital for evaluation. R4 reported that he was assigned one-to-one supervision at the time of the incident due to a prior altercation with another resident; however, the assigned staff member was not present during the altercation. R4 stated, If the staff was there, he could have prevented R3 from hitting me, and reported that he did not know where the one-to-one staff member had gone. R4 further stated that R3 called him names and that nursing staff assessed him following the incident.On 6/9/26 at 10:53 AM, R6 stated he witnessed the incident that happened on 5/24/26 between R3 and R4. R6 stated that his room is located directly across from the first-floor dining room and that he was sitting in his wheelchair in his room, from where he could observe activity in the dining room. R6 reported seeing R4 approached R3 his roommate and strike him on the leg with a chair. R6 stated he also witnessed R3 punched R4 on the face. R6 stated that R3 was using a walker and was seated in the dining room at the time when R4 approached him. R6 stated there were no staff members monitoring residents in the dining room when the incident occurred. R6 reported that he saw R3 immediately left the dining room and informed V1 (Administrator) about the incident. R6 does not recall the exact time, but estimated the incident occurred between 7:00 AM to 9:00 AM.On 6/9/26 at 10:25 AM, V5 (Social Services) stated that on 5/24/26, she arrived at work at approximately 10:30 AM and was called by V1 (Administrator) to investigate an incident involving R3 and R4. V1 advised V5 that an incident had reportedly occurred around 7:00 AM. Upon arrival, V5 observed that R4 was on the second floor under staff supervision, while R3 was on the first floor. V5 stated she interviewed both residents. R3 reported that R4 had struck him with a chair that morning. R4 denied hitting R3 with a chair and instead alleged that R3 had assaulted him. R3 denied assaulting R4. V5 was not aware of any direct witnesses to the incident; however, R3 claimed that other individuals had witnessed it. The alleged incident reportedly occurred in the first-floor dining room. V5 stated that, to her knowledge, no staff members witnessed the incident and that no staff were present in the dining room supervising R3 and R4 at the time. V5 stated that R4 was supposed to be on one-to-one supervision, meaning staff were expected to monitor him continuously. V5 further stated that R4 had previously been involved in an incident with another resident (R6) that included a physical altercation. V5 stated R4 had demonstrated both verbal and physical aggressive behaviors. While V5 had not personally witnessed physical aggression by R4, she had heard him make threats to punch other residents. V5 explained that R4 had originally resided on the first floor but had been moved to the second floor following a previous incident. Despite the move, R4 frequently came to the first floor, that's why he was on one-on-one staff supervision. V5 stated that R3 had been making threats toward R4 and had stated that he had a demon inside him and that he had killed before. Although R3 did not directly state that he intended to kill R4, V5 considered his statements threatening toward other residents. As a result, R3 was sent to the hospital for psychiatric evaluation. R4 was also sent out for evaluation due to threats he had made about punching others. V5 also stated that while in V1's office, R3 became very angry and screamed that he would punch anyone who got in his way. V5 stated that for the safety of other residents, both R3 and R4 were supervised by staff whenever they were interacting with others in common areas.On 6/9/26 at 1:58 PM, V13 (Certified Nursing Assistant/CNA) stated that his shift was from 10:45 PM to 6:45 AM and that he remained with R4 throughout the night (5/23/26) and until after 7:00 AM (5/24/26), while waiting for the relieving staff member to arrive. V13 stated that he and R4 were in the first-floor dining room around 7:00 AM. V13 stated he left briefly to go to the nurses' station to obtain wipes and then returned to the dining room right away. V13 stated as he was coming out of the dining room to go to the nurses' station, V13 observed R3 entering the dining room by himself. When V13 returned after obtaining the wipes, he observed R4 and R3 arguing. V13 stated that he intervened immediately and separated the two residents. V13 reported that he did not hear either R3 or R4 used profanity and could not recall the specific statements exchanged between them. V13 recalled hearing R4 said something about R3 stepping on his foot. V13 stated that he did not observe any physical altercation and only witnessed the residents shouting at one another. According to V13, V12 (CNA) arrived shortly thereafter and assumed responsibility for the situation. V13 stated that he notified the nurse and reported the incident to V14 (Registered Nurse/RN). V13 could not recall who else was present in the dining room at the time of the incident. V13 stated that R4 was on one-to-one supervision due to a history of altercations with other residents and indicated that he had previously received reports regarding such incidents.O6/10/26 at 8:49 AM, a phone interview conducted with V14 (RN). V14 stated regarding the incident involving R3 and R4 on 5/24/26, V14 recalled that it occurred around 7:00 AM that V13 informed her that an incident was occurring in the dining room. After hearing a commotion, V14 and V13 proceeded to the dining room, where several residents were present. V14 stated that she did not personally witness any physical contact between R3 and R4 and only became aware of the alleged hitting through information provided by witnesses. Upon entering the dining room, V14 observed that R3 was uncooperative and moving around the dining room. V14 perceived that R3 appeared to be anticipating another incident or attempting to provoke R4. R3 repeatedly entered and exited the dining room and was not responsive to redirection despite multiple CNAs attempting to monitor and redirect R3. V14 stated R4 was seated in the dining room eating breakfast and R3 repeatedly stopped near R4's table and appeared to be expecting a confrontation. V14 stated that R3's behavior appeared provocative toward R4. V14 stated that she further observed that R3 would look at R4 in a threatening manner and continued to move throughout the dining room despite staff efforts to redirect him. V14 described R3 as aggressive and difficult to control. V14 stated that staff were actively attempting to prevent the two residents from coming into close contact and to prevent either resident from harming the other. V14 stated that R4 also called R3 derogatory names like Pu**y and making cat-like sounds. V14 stated R3 was observed cursing and yelling at R4. V14 could not recall the exact words exchanged between R3 and R4 and did not recall hearing any statements regarding physical harm to R3. V14 stated that her attention was focused on the interaction between R3 and R4 and, therefore, she could not recall who else was present in the dining room. V14 stated before the end of her shift, the situation had de-escalated, and both residents were placed on one-to-one supervision. V14 reported the incident immediately to V1 (Administrator), V5 (Social Services), and V2 (Director of Nursing). V14 stated R3 did not report being struck by R4. V14 conducted a full-body assessment of R3 and did not observe any signs or symptoms of physical assault, including redness, bruising, or bleeding. V14 stated that R3 was not on one-to-one supervision at the time of the incident. V14 stated she did not know who was assigned to supervise R4 when the incident occurred or how the incident happened. V14 stated that R4 was supposed to be monitored and supervised by staff on a 24-hour basis. V14 reported that whenever R3 and R4 encountered one another, they would frequently tease and provoke each other. V14 described R3 as a difficult resident who often did not respond to redirection. V14 stated interactions between the two residents consistently created a tense environment. For that reason, V14 believed R3 should not have been permitted to be in close proximity to R4. V14 stated that when R4 was in the first-floor dining room for meals, R3 should not have been present in the dining room at the same time. V14 further stated that R3 and R4 had histories of aggressive behavior toward staff and other residents.On 6/10/26 at 10:01 AM, a phone interview was conducted with V1 (Administrator) regarding R3 and R4's incident on 5/24/26. V1 stated that staff found R3 and R4 arguing in the dining room and threatening one another. Staff intervened and separated R3 and R4. V1 stated that during the altercation, R3 and R4 stated that they did not like each other and made verbal threats face-to-face. V1 stated that during the one-on-one counseling, R3 stated that he was going to kill R4. The physician was contacted and provided an order to send R3 for a psychiatric evaluation. R3 was also observed cursing and threatening staff while using racial slurs. V1 stated that R4 also told staff that he was going to hit and kill both R3 and R6. Due to their threatening behaviors, R3 and R4 were sent to the hospital for evaluation. One resident had a diagnosis of schizophrenia, and the other had a diagnosis of bipolar disorder. V 1 stated R3 and R4 had histories of aggression toward staff and other residents. V1 stated that the R3 and R4 had a history of confrontations with other individuals in the facility and had made threats to kill someone. V1 stated, R4 was supposed to be on one-to-one supervision. However, it was not reported to V1 that R4 had picked up a chair and struck R3. Staff did not witness any physical altercation, and no one reported witnessing R3 being struck by R4 with a chair or walker. V1 stated that both residents had care plans and had a history of making allegations against one another. V1 stated that the reason R4 was on one-to-one supervision was due to a prior physical altercation with R6 in May, for which the facility had previously received a citation. V1 stated that R3's dislike of R4 was influenced by stories provided by R6. V1 further stated that the altercation may have been prevented if the residents had not been in close proximity to one another. Due to their history, R3 and R4 were not supposed to be in the same room at the same time.On 6/10/24 at 10:20 AM, V22 (Licensed Practical Nurse/LPN) stated that the incident between R3 and R4 occurred early in the morning. V22 was informed that R4 had been involved in a verbal altercation with R3. After the incident, R4 approached V22 and appeared angry. V22 stated R4 was on one-to-one supervision at the time. R4 expressed that other residents were not treating him well and stated that if someone punched him, he would punch them back. V22 stated R4 further indicated that he would hit someone in retaliation. V22 described R4's anger as uncontrollable and stated that he was resistant to redirection. R4 reportedly wanted to return to the first floor to fight and could not be redirected from that behavior. Due to his behaviors, R4 was sent to a psychiatric hospital for evaluation and treatment. V22 stated she assessed R4 and he had no injuries or no signs and symptoms of hitting. V22 explained that one-to-one supervision requires a designated staff member to remain with the resident at all times. V22 stated the supervising staff member should not be separated from the resident, even briefly. V22 stated that if R4 had not been left alone by staff, the altercation with another resident may have been prevented.On 6/10/26 at 2:09 PM, V2 (Director of Nursing) stated that residents residing in the facility have the right to remain safe. V2 stated residents involved in behavioral incidents may be placed on one-to-one supervision depending on the circumstances. V2 stated that one-to-one supervision requires the assigned staff member to remain with the resident at all times, 24 hours per day, until the supervision is discontinued or the resident is discharged from the facility. V2 stated that R4 was on one-to-one supervision due to a history of altercations with another resident. The supervision was intended to remain in place until alternative placement could be found for R4. V2 stated that R4 had a history of aggressive behavior toward other residents and had made verbal threats against them. For the safety of other residents, the facility maintained R4 on one-to-one supervision. R3 was not on one-to-one supervision. V2 stated that staff informed her of an incident involving R3 and R4, although she could not recall which staff member provided the information. V2 was informed that R3 and R4 had been yelling and cursing at each other in the first-floor dining room and were subsequently separated. V2 stated that nurses assessed both residents and completed full body assessments. No injuries were noted, and there were no signs or symptoms indicative of a physical assault. V2 stated that both R3 and R4 were transferred to a psychiatric hospital for evaluation due to unpredictable aggressive behaviors toward other residents and staff. V2 reported that no information was received from R6 indicating that R4 had struck R3 or vice versa.Surveyor was unable to contact R3. On 6/10/26 at 1:24 PM, contacted V29 (R3's Family Member) and stated that R3 is currently in the hospital and does not have his direct contact information.Surveyor requested video footage of the R3 and R4's incident on 5/24/26 in the dining room, but V1 and V2 stated there were no video footage recorded since the cameras were not functioning.The facility's policy titled, Your Rights and Protections as a Nursing Home Resident (undated) reads in part: You have the right to be treated with respect, and be free from abuse and neglect.

The facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects two (R1, R2) residents out of four residents reviewed for abuse. Findings include: On 05/09/2026 at 9:55AM, V3 (Licensed Practical Nurse/LPN) states she was the nurse assigned to care for R1 yesterday and had heard there was an altercation that took place between R1 and R2. V3 states she was called down to speak to V1 (Administrator) in the office. V3 states she assessed R1 and did not see any bruises and R1 denied having any pain. V3 states she called R1's doctor and received orders to send R1 to the hospital for evaluation. V3 states the incident occurred at approximately 2:30PM and she called the ambulance at approximately 4:30PM. V3 states R1 was placed on 1:1 monitoring until the ambulance arrived. V3 states her shift was supposed to end at 3:00PM so she left after calling the ambulance. V3 states she has never seen R1 be physically aggressive with anyone in the facility. R1's progress note dated 05/08/2026 at 4:28PM written by V3 (LPN) documents, R1 alleged that another resident made contact with him. Head to toe assessment completed. No new abnormalities noted. Dr. notified. Dr. ordered R1 to be sent to hospital ER for evaluation. Order noted and carried out. R1 is responsible for self. Administrator and DON aware. On 05/09/2026 at 10:03AM, R1 states he was assaulted yesterday by R2 and R2 punched him in the face. R1 states he was located on the first floor by the elevators and R2 called him an ***hole so R1 called R2 a p***y. R1 states R2 started verbally assaulting him some more and then said, you want to go outside? R1 states R2 stood up from his wheelchair and punched him in the face so R1 defended himself by blocking R2's hits and then R1 hit R2 in the head. R1 states he hit R2 in the head because R2 punched him in the face first. R1 states he called the police and filed a police report against R2. R1 states although R2 hit him in the face, he does not have any injuries. On 05/09/2026 at 10:19AM, V5 (Social Services Coordinator states there was an incident yesterday involving R1 and R2 and both residents were claiming the other one hit the other first. V5 states the facility is not sure who made contact first. On 05/09/2026 at 10:21AM, R2 states on 05/08/2026, he was located on the first floor in front of the elevator waiting for the elevator. R2 states that's when R1 came down the hall and bumped R2 with his rollator walker. R2 states he told R1 can't you see I'm here in front of you? R2 states R1 then called him Superman and a p***y. R2 states after R1 called him a p***y R2 states that's when I knocked him out. R2 states he is not a woman and do not have women body parts so R1 should not be calling him a p***y. R2 then changes his story and states R1 swung on him first and he blocked R1 and then that's when he punched R1 in the face and knocked R1 out. R2 states R1 always comes down to the first floor and walks past his room and R1 should not be down on the first floor. R2 states R1 lied to V1 (Administrator) about what happened and R1 called the police on him and filed a police report. R2 states another resident (identified as R3) was a witness to the altercation between R1 and R2. On 05/09/2026 at 10:48AM, V6 (Registered Nurse/RN) states R1 and R2 were former roommates and had a disagreement sometime last year and R1 was moved to the second floor of the facility. V6 states R2 remained on the first floor of the facility. V6 states R2 has a history of turning other residents against R1. V6 states R2 makes false allegations against R1 and has even recruited R3 against R1. V6 states now R3 has turned against R1 and does not like him because of R2. V6 states she constantly hears R3 saying lots of negative things about R1. V6 states she has never heard R2 talk negatively about R2 or R3. V6 states R1 has an independent community pass and goes out into the community everyday and usually does not return to the facility until the evening. V6 states R1 may go to the first floor to play games or go to the vending machine. V6 states R1 is usually gone from the facility for most of the day. V6 states she has never seen R1 be aggressive with any of the other residents. R2's progress note dated 05/09/2026 at 11:30AM written by V6 documents R2 was transferred to ER for psych evaluation with petition on doctors order. R2 was picked up by 2 ambulance staff in stable condition, vitals within his baseline, no changes noted to skin and resident orientation was AOX3-4 at this time. On 05/09/2026 at 11:02AM, R3 approached surveyor and stated he was a witness to the altercation between R1 and R2 on 05/08/2026 and that R2 was innocent. R3 states he was located next to the first-floor elevator sitting down on his rollator walker and saw R1 use his rollator walker to cut R2 off at the elevators. R3 states R1 pushed his walker in front of R2's wheelchair. R3 states R2 asked R1 why would you do that? and R1 said shut up you p***y. R3 states R1 kept calling R2 a p***y. R3 states R1 has been picking on R2. R3 states V7 (RN) then came over and stood in between R1 and R2 and told R1 to go up to his room on the second floor. R3 states R1 rode the elevator up but never got off but came back down to the first floor and when the elevator opened R1 flipped R2 off with his middle finger. R3 states no one witnessed this happen because R1 was on the elevator at the time. R3 states R1 then rode the elevator down to the basement but did not get off and came back up to the first floor. R3 states when the elevator doors opened, R1 then pushed his rollator walker into R2. R3 states that's when R2 jumped up from his wheelchair and punched R1 in the face. R3 states R1 then began hitting R2 back but R2 was blocking R1's punches. R3 then changes his story and states R2 only punched R1 because R1 pushed his rollator walker into R2 and R1 tried to hit R2 first.On 05/09/2026 at 12:16PM, V7 (Registered Nurse/RN) states she was the nurse assigned to care for R2 yesterday and she was located at the first-floor nurses' station when she saw there was a crowd waiting for the elevator. V7 states she then heard R1 and R2's voices so she went around from the nurses' station and saw that R1 and R2 were already separated. V7 states that R2 told her that R1 hit R2 first and R1 also told V7 that R2 was the person who hit R1 first. V7 states she did not witness either resident hit each other. V7 states she then called V3 (LPN), who was assigned to care for R1 to inform her of the incident. V7 states she then took R2 inside of his room to assess him. V7 states upon performing a full-body assessment, she did not see any bruising on R2 and R2 did not complain of pain. V7 states she then saw V1 (Administrator), V2 (Director of Nursing/DON), and social services come out of the office, and they interviewed a lot of people. V7 states after assessing R2, R2 was placed on 1:1 monitoring. V7 states she called R2's doctor to inform him of the incident. V7 states the doctor gave her orders to send R2 to the hospital for evaluation. R2's progress note dated 05/08/2026 at 2:30PM written by V7 (RN) documents R2 alleged that another resident made contact with him. Full body assessment completed and no new abnormalities found. There are no injuries MD and family notified. Administrator and DON aware. On 05/09/2026 at 1:37PM, V1 (Administrator) states he does not have video footage of the incident that occurred between R1 and R2 by the first-floor elevators on 05/08/2026. On 05/09/2026 at 3:25PM, V1 states R1 and R2 are former roommates and R2 has a history of making unfounded allegations regarding R1. V1 states there was a time when R2 told him that R1 had just passed by R2's room. V1 states he then reviewed the camera footage with R2 and did not see R1 on the camera. V1 states R2 insisted and was pointing at the camera saying he's right there. V1 states he informed R2 that R1 was not on the camera and even called the social worker in the office to verify. V1 states R2 seems to have a negative fixation on R1. V1 states he told R2 that this was not normal and that R2 needed to be evaluated. V1 states R2 then left his office while denying that he needed to be evaluated. V1 states after the incident yesterday, the facility received an order to send R2 to the hospital to be evaluated. V1 states R2 was sent out to the hospital for psychiatric evaluation today. V1 states he has had a conversation with R1 and R2 about the rules of the facility and possibly transferring them to another facility for safety reasons. Facility Reported Incident dated 05/08/2026 documents that the facility reported allegations of abuse for R1 to the state agency.Police report dated 05/08/2026 #JK-246935 Beat/Unit 1711 for R1 and R2 documents a report of simple battery. Facility policy dated 01/2019, titled Abuse Prevention Program documents in part, This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents.Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Facility policy dated 11/28/2017 titled Policy on Resident Rights, Respect & Dignity documents in part, The resident has the right. to be free from verbal, sexual, physical and mental abuse.

Based on observation, interview and record review, the facility failed to develop and implement interventions to prevent a resident from sustaining a serious fall related injury for one of three residents (R7) in the sample of thirteen. This failure resulted in R7 sustaining a subarachnoid bleed (brain bleed) after falling.Findings include:Final Incident Report (11.6.2025) documents, in part: At approximately 5:00 AM, resident was noted sitting on the floor in the hallway. Resident noted with an open area to the back of his head.Resident was immediately assessed by NOD (Nurse on Duty). First aid was provided. Resident sent to emergency room for evaluation. Resident admitted with Subarachnoid hemorrhage and two staples to the back of head. Physician and family notified. Investigation initiated.The facility completed its investigation through medical review and interviews. Based on facility review the resident fell backwards suddenly and sustained injury to the back of head. The resident remains in the hospital with a diagnosis of Subarachnoid hemorrhage and two staples to the back of head. Resident BIMS (Brief Interview of Mental Status) is 10. Prior to ambulating resident removed helmet and was non-compliant with safety interventions. R7's medical record (Face Sheet) documents R7 is a [AGE] year-old with diagnoses including but not limited to: Disease of spinal cord, Ataxia, Schizophrenia, Epilepsy. Extrapyramidal and movement disorder, Abnormalities of gait and mobility and restlessness and agitation. R7's MDS documents R7's BIMS (Brief Interview for Mental Status) score of 10 or moderately cognitively impaired. On 12.5.2025, at 11:21 AM via telephone, V12 (RN-Registered Nurse) said, I was on the floor when R7 fell. I didn't witness the fall; I saw him on the floor. He was getting agitated; he didn't want to be touched. He was in bed when I last checked on him. To be safe, his helmet should be on all the time. What would be safe for him would be to do 1:1 (supervision). He was 1:1 and had a sitter for a long time when he was first admitted . He gets out of bed constantly. He's currently not 1:1 and doesn't have a sitter. He did not have a sitter at the time of the fall. He was in a different room when he fell; that's maybe ten rooms from the nurse's station. That's too far. When he came back from the hospital, he was put in a room by the nurse's station. You can see into the room from the nurse's station, but you might not be able to get to him in time if he stands up.On 12.5.2025 at 2:00 PM, V2 (Director of Nursing) said, R7 was admitted with TBI (Traumatic Brain Injury). He was more bedridden when first admitted . I think he's walking with a walker. They called me around 5:00 AM. Staff told me he was walking in the hallway and fell. He didn't have his helmet on. My intervention was to move him closer to the nurse's station so that we could monitor him. Its better. The nurses can watch him from the nurse's station while doing their charting. We reeducate him when he's non-compliant with interventions. He's not alert so he doesn't really comprehend, it's probably not effective. He came with helmet from the hospital, I don' know that anyone has tried a new helmet.On 12.5.2025, at 3:28 PM, V15 (Restorative Nurse) either me or V20 (MDS Coordinator) would do fall care plans. I can't recall if I did the fall care plan for R7, but I know that he has one. I don't know when he came, but he hasn't been here so long. I don't know when exactly the sitter discontinued, but I think it was less than two months. I don't know why the sitter was discontinued. CNAs were assigned as sitters for the resident. I can't recall if he had any falls while he had a sitter. The helmet we implemented because he had a fall, but he's non-compliant. The staff monitor him (CNAs, nurses). We do rounds, try to keep him up in the dining room. I'm going to say we round on him like every hour. We encourage to keep the helmet on, he has a low BIMS score. Sometimes he understands, sometimes he doesn't.V20 was not available for interview.On 12.5.2025, at 4:20 PM, V18 (CNA-Certified Nursing Assistant) said R7's current room is across from the nurse's station. V18 said, R7's previous room was at the end of the hallway. You couldn't see it from the nurse's station unless you got up and looked down the hallway.On 12.5.2025, at 4:28 PM, R7 awake, alert, sitting in wheelchair in dining room. R7's wearing his helmet, strap not secured, helmet on backwards. V16 (CNA-Certified Nursing Assistant) sitting next to resident. V16 said, I tried to put his helmet on, but he won't let me. R7 said, my helmet is okay.On 12.5.2025, at 4:34 PM, V17 (RN-Registered Nurse), took R7's helmet off, turned it around, then placed back on resident's head.On 11.3.2025 at 4:12 AM, R7's Nurses Note documents, in part: Resident noted on the floor by hallway. He has a behavior of repeatedly getting out of bed despite education. He has bleeding minimal back of head but refused assessment refuse further assessment. Patient agitated. 911 was called. 911 transferred to (local hospital).On 11.3.2025 R7's hospital record documents, in part: The patient was brought in by the ambulance for a fall this morning. He admits to photophobia, frontal headache. CT Head without contrast, Impression: 1. Bilateral anterior frontal lobe subarachnoid hemorrhage. 2. Small right convexity and left parafalcine subdural hematomas measuring up to 4mm.On 11.3.2025-12.5.2025 R7's Progress notes do not document when 1:1 sitter was discontinued or why.R7's falls care plan initiated 7.17.2025, revised 7.25.2025 does not list close monitoring as an intervention.

Based on interview and record review, the facility failed to ensure that a resident remain free from abuse for one of four residents (R2) reviewed for abuse in the sample of 13.Findings include:R2's medical record (face sheet) documents R2 is a [AGE] year-old admitted to the facility with diagnoses including but not limited to: Specified disorders of brain, Cardiomegaly, Electrocution, and Seizures. R2's MDS (Minimum Data Set) documents a BIMS (Brief Interview for Mental Status) score of 15 or cognitively intact.R3's medical record (face sheet) documents R3 is a [AGE] year-old admitted to the facility with diagnoses including but not limited to: Atherosclerotic heart disease of native coronary artery without angina pectoris, Hypertensive heart and chronic kidney disease without heart failure, Chronic kidney disease, and Hyperlipidemia. R3's MDS (Minimum Data Set) was not completed.Final Incident Report (10.29.2025) documents in part, (R3) alleging (R2) made contact with (R2) and noted redness to lower lip. (R3) no longer in facility. Body assessment performed on (R2) and noted with redness to left lower lip.On 10.24.2025, R2's statement documents: Resident alleged roommate struck him in the mouth after asking him to not slam door. Resident stated he asked roommate to not slam door in a calm tone.On 12.4.2025, at 3:47 PM, V1 said, R'2s and R3's incident was not substantiated. There were no witnesses (staff or residents).R2 and R3 were not available for interview.On 10.24.2025, V19's statement documents: I didn't witness the allegation. (R2) told me (R3) made contact with him. (R2) denied any pain or discomfort, and he had a little redness to lower lip.On 10.24.2025, at 3:24 PM, R2's Nursing Progress Note documents in part, Resident 1 allegedly made contact with another resident 2 and noted with redness to left lower lip.On 10.24.2025, at 2:30 AM, R3's Nursing Progress Note documents in part, resident came out from his room walking around the floor then went back to his room. After a few minutes he came to nurse's station stating that he got into argumentation (argument) with co-roommates and does (not) want to stay in that room this time.Abuse Prevention Program (revised 3.1.2021) documents, in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.For the purpose of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or any punishment with resulting harm or pain or mental anguish or deprivation by an individual.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.4. Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

Based on interviews and record review, the facility failed to report an allegation of resident abuse within two hours of notification. This failure affected one resident (R1) reviewed for Reporting of Alleged Violation. Findings include:R1 is [AGE] year old with diagnosis including but not limited to: spinal stenosis, morbid obesity, other abnormalities of gait and mobility, low back pain and heart failure.R2 is [AGE] year old with diagnosis including but not limited to: depression, insomnia, aphasia, hypertensive heart disease without heart failure and facial weakness.On 9/10/25 at 10:30 am, V2 (DON) stated the following, We transferred R1 to a sister facility because he alleged that R2 hurt his arm. The incident was unwitnessed and occurred on 7/29/25. V25 (MDS Nurse) was the MOD (Manager on Duty) on that day and completed an incident report of the incident between R1 and R2. R1 had an in-house X-ray done because he complained of pain to his arm, but there were no injuries noted via X-ray and no redness. All abuse allegations are handled by V1, however in his absence I am able to send an abuse incident to IDPH. All alleged abuse incidents must be reported within 2 hours of the incident.On 9/10/25 at 10:45 am, V25 (MDS Nurse) stated the following, R1 had stated that he was in an altercation with R2 a little after 7:00 am. I was the MOD that morning, which is why I completed an incident report. The information was given directly from R1 since the incident was unwitnessed. The Administrator was notified by me immediately via telephone. I always notify the Administrator about any allegations regarding abuse immediately.On 9/10/25 at 10:56 am, V1 (Administrator) stated the following, With abuse allegations, we are to report abuse within two hours of the incident. Abuse can be physical, verbal, mental, financial, seclusion and more. Abuse can also be resident to resident, staff to resident, family member to resident, etc. All allegations are reported to me immediately.Facility Census Report dated 9/8/25 documents a total of 172 current residents.Facility Incident Report dated 7/29/25 at 7:36 am documents, R1 alleged that another resident (R2) made contact with him while he was in bed.Facility email transmittal dated 7/29/25 documents, IDPH Incident Report involving R1 was reported at 10:22 am.Facility policy titled Abuse Prevention Program documents, this report (abuse report) should be made immediately, but no longer than two hours after the allegation is made.

Based on interview and record review, the facility failed to administer a resident's (R1) scheduled medication for neuropathic pain and failed to document physician notification of a resident (R1) missing scheduled doses of the neuropathic pain medication when reviewed for quality of care/treatment in the sample of 3 residents (R1, R2 and R3). This failure resulted in R1 experiencing increased neuropathic pain to bilateral lower extremities for 3 days and causing R1 to not consistently sleep for 2 nights due to increased nerve pain.Findings Include: On 8/20/2025 at 1:26 pm, V4 (LPN) stated that if a medication has not been received from the pharmacy, the nurse should call V2 (Director of Nursing), and the V2 will request that the nurse tell the pharmacy the medication is needed stat. On 8/20/2025 at 3:17 pm, V7 (Assistant Director of Nursing) stated that because staff is at the facility to assist the residents, the nurses know when a resident's multidose blister card gets low, and the nurse should be calling the doctor for a refill. V7 stated that nurses should follow up with the pharmacy first; if a new script is needed, the nurse should inform the doctor. V7 stated that if the doctor is not reachable, the nurse should call the nurse practitioner. V7 stated that if the nurse practitioner is not reachable, the nurse must contact the medical director. V7 stated that if the doctor has not contacted the nurse back the end of the nurse's shift, the next shift nurse should follow up by reaching out to the doctor again for the medication order. R1's Care Plan (initiated on 11/7/2023, revised on 8/5/2025) documents, in part, a focus of R1 is at increased risk for alteration in pain/discomfort related to paraplegia due to history of a gun shoot wound and interventions of administer analgesic medication as ordered per plan of care and assess physical as well as, psychosomatic reasons for the pain. Recognize that psychosomatic pain may cause physical distress. R1's Care Plan (initiated 11/7/2023, revised 6/25/2025) documents, in part, a focus of R1 demonstrating physical and emotional impairment secondary to neurological damage caused by neuropathy and spinal cord injury. Facility's policy titled Medication Administration undated documents, in part, Purpose: To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration. Policy: Unless otherwise specified by the physician, medications will be administered within 60 minutes before or after the facility's dosing schedule, except before or after meal orders and non-routine time ordered medications. Facility's policy titled Ordering Medications dated May 2024 documents, in part, that Refill requests can be faxed the pharmacy's main fax number, sent via EHR (Electronic Health Record) system, reordered via (electronic link format), and/or left on the pharmacy refill voicemail. Refill requests should be sent in 72 hours prior to the last dose. Facility's policy titled Guidelines For Pain Management undated documents, Purpose: It is the intent of the facility to promote resident independency, comfort, and to preserve resident dignity in an ongoing effort to promote the highest level of quality for their lives. One aspect of this commitment is to maintain an effective pain management plant to provide residents the means to receive necessary comfort, exercise greater independence, and therefore enhance their overall welfare and well-being. This policy also documents, in part, that with chronic pain, many residents may have conditions which cause them to experience chronic pain; principles of treating chronic pain include pain medication is usually more successful for attaining pain relief if given routinely, not PRN. The resident's plan of care must be specific for each resident related to their pain and the management plan in place for pain relief and comfort which include interventions of any ordered medications. Lastly, this policy documents, PAIN is 'whatever the experiencing person says it is, existing whenever the experiencing person says it does. Facility's Job Descriptions for Registered Nurse (RN) and Licensed Practical Nurse (LPN) (both undated) document, in part, that for the nursing responsibility for drug administration, RN's and LPN's ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the resident and reports needs to the Nurse Supervisor, and orders prescribed medications, supplies and equipment as necessary, and in accordance with established policies. Findings Include: R1's admission Record documents, in part, diagnoses of paraplegia, polyneuropathy, chronic pain syndrome, hyperlipidemia, neuromuscular dysfunction of bladder, insomnia, acquired absence of kidney, puncture wound of abdomen, assault by other firearm discharge, need for assistance with personal care, resistance to multiple antibiotics, dependence on wheelchair, and constipation. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact. On 8/20/2025 at 1:34 PM, R1 observed propelling self with R1's arms while in R1's manual wheelchair. R1 stated that R1 has paraplegia and neuropathy with R1 experiencing pain up and down my (R1's) legs but it's primarily in my left knee, right thigh and right foot. R1 stated, The pain is burning, tightness and sharp. It's like a shooting pain. It's real bad when it's in my foot and shoots up my leg. It's a lot of pain. R1 stated that R1 uses a massager to help with this neuropathic pain since it's on and off all day; however, the massager doesn't make the pain go away, just slows down the hurting. R1 stated that R1 has scheduled medication for the neuropathy pain which is Pregabalin 200 milligrams (mg) three times a day. R1 stated that R1 does have an order for Hydrocodone/Acetaminophen, but Hydrocodone doesn't help with my neuropathy pain if I am not getting my scheduled Pregabalin. R1 stated that R1 received 2 doses of Hydrocodone/Acetaminophen over this past weekend (8/15/2025 to 8/17/2025) when the facility did not administer R1's Pregabalin, but it (Hydrocodone/Acetaminophen) didn't work. R1 stated, I couldn't sleep all Saturday (8/16/2025) and Sunday (8/17/2025) nights. I stayed up all night with shooting pain. I couldn't go to sleep. I finally felt relief when I got it (Pregabalin) on Monday (8/18). R1 stated that on Wednesday, 8/13/2025, around 7:00 AM, R1 near V4 (Licensed Practical Nurse, LPN) and V9 (LPN) hearing V9 saying to V4 that they put in another order because I only have 2 days left of my medication, the Pregabalin. R1 stated that the Pregabalin must not have been reordered because R1 took the last dose of Pregabalin on 8/15/2025 at 1:00 PM. R1 stated that V14 (LPN) administered R1's Baclofen on 8/15/2025 at 9:00 PM, but not dose of Pregabalin 200 mg. R1 stated that on the night of 8/15/2025, R1 had severe nerve pain and asked for a Hydrocodone 5/325 mg PRN (whenever needed) dose. R1 stated that R1 did not received any of the three doses of Pregabalin 200 mg on Saturday (8/16/2025) and Sunday (8/17/2025). R1 stated, I couldn't take it. Every time I tried to move, the pain really hurt, and it continued. It didn't slow down. R1 stated that on 8/18/25, R1 did not receive the 9:00 AM or 1:00 PM doses of the Pregabalin 200 mg, and R1 finally received the Pregabalin 200 mg on Monday evening dose on 8/18/2025 (scheduled at 9:00 PM). R1's Medication Administration Record (MAR), dated August 2025, documents, in part, a medication order of Pregabalin 100 mg capsules, Give 200 mg by mouth three times a day for Neuropathy, with scheduled times of 9:00 AM, 1:00 PM, and 9:00 PM. The following documentation for R1's Pregabalin 200 mg is noted:8/16/2025 for 9:00 AM, 1:00 PM AND 9:00 PM: V8 (LPN, Former Employee) documents a pharmacy code of 9 which indicates Other / See Nurse Notes.8/17/2025 for 9:00 AM and 1:00 PM: V4 (LPN) documents a pharmacy code of 9 which indicates Other / See Nurse Notes.8/17/2025 for 9:00 PM: V5 (Registered Nurse, RN) documents a pharmacy code of 9 which indicates Other / See Nurse Notes.8/18/2025 for 9:00 AM and 1:00 PM: V4 (LPN) documents a pharmacy code of 9 which indicates Other / See Nurse Notes. R1's eMAR Progress Notes document, in part, the following correlating documentation for R1's Pregabalin 200 mg from the August 2025 eMAR:8/16/2025: No eMAR Medication Administration Nurses Notes from V8 (LPN, Former Employee) for Pregabalin 200 mg scheduled 9:00 AM, 1:00 PM AND 9:00 PM.8/17/2025 at 9:24 AM: V4 (LPN) documents an eMAR Medication Administration Nurses Note for Pregabalin of Awaiting pharmacy delivery. There is no eMAR Medication Administration Nurses Note from V4 for the Pregabalin 200 mg scheduled at 1:00 PM.8/17/2025 at 10:37 PM: V5 (RN) documents an eMAR Medication Administration Nurses Note for Pregabalin of Awaiting pharmacy delivery.8/18/2025 at 9:19 AM and 2:42 PM, V4 (LPN) documents eMAR Medication Administration Nurses Notes for Pregabalin of Awaiting pharmacy delivery for the Pregabalin 200 mg scheduled doses of 9:00 AM and 1:00 PM. R1's eMAR, dated August 2025, documents, in part, a medication order of Hydrocodone-Acetaminophen 5-325 mg, Give 1 tablet by mouth every 8 hours as needed (PRN) for pain. The documentation for R1's Hydrocodone-Acetaminophen 5-325 mg PRN is documented, in part, as follows:8/15/2025 at 11:01 PM: V14 (LPN) documents administration with R1's pain scale as 3 on a 0 to 10.8/17/2025 at 8:00 AM: V4 (LPN) documents administration with R1's pain scale as 5 on a 0 to 10. On 8/20/2025 at 2:33 PM, V4 (LPN) stated that on 8/13/2025, V9 (LPN) informed V4 to follow up with trying to get a new prescription for R1's Pregabalin 200 mg due to the low amount of capsules remaining for R1. V4 stated that when the pharmacy multidose blister pack (which stores each Pregabalin capsule in numbered blister pouches on a card) is around 8 to 10 capsules remaining, V4 will start the process of obtaining replacement medications, so the resident does not run out of Pregabalin. V4 stated that V4 called the doctor's office for V11 (Attending Physician) and left a message for the need for R1's new Pregabalin prescription with unknown office staff. V4 stated that on Friday, 8/15/2025, R1's Pregabalin supply (amount of capsules remaining in the controlled substance box) was due to be used completely on 8/15/2025, and when V4 called the pharmacy, V4 was informed that there was no prescription for Pregabalin 200 mg to send the new supply. V4 stated that on 8/17/2025, when V4 started V4's day shift, R1 was complaining of pain, and V4 medicated R1 with Hydrocodone-Acetaminophen 5-325 mg PRN. V4 stated that on 8/17/2025, R1's Pregabalin 200 mg capsules were not present in the facility, and R1 did not receive the scheduled 9:00 AM and 1:00 PM doses on V4's shift. V4 stated that on 8/17/2025, V4 stated that V4 phoned V10 and the physical medicine doctor about R1 not having the Pregabalin in the facility. When asked if V4 documented these physician notifications, V4 stated that V4 only made an eMAR note. V4 stated that on 8/18/2025, R1 still did not have the Pregabalin in the facility to administer to R1 at 9:00 AM and 1:00 PM. V4 stated that V4 phoned the pharmacy at the end of V4's shift on 8/18/2025, and V4 was informed that the Pregabalin for R1 was being delivered on 8/18/2025. On 8/21/2025 at 2:02 PM, V14 (LPN) stated that V14 was the evening shift (3-11PM) for R1 on 8/15/2025. V14 stated that V14 had received in nursing report from V4 (LPN) that they were expecting the Pregabalin from pharmacy. V14 stated that V14 either called R1's primary doctor (V11) or the on-call doctor's service to obtain more Pregabalin for R1 but couldn't remember exactly which one, and V14 did not receive a return doctor's phone call. V14 stated that V14 did not document the doctor phone call on 8/15/2025. V14 stated that for R1's Pregabalin 200 mg scheduled dose on 8/15/2025 at 9:00 PM, R1 had the last dose given which was 1 capsule. When informed that R1's Pregabalin order was for Pregabalin 100 mg and to give 2 capsules for the 200 mg dose, V14 stated that V14 is pretty sure that the one Pregabalin capsule was a 200 mg dose. V14 stated that R1 complained of pain to R1's legs around 11:00 PM on 8/15/2025, and V14 medicated R1 with a Hydrocodone-Acetaminophen 5-325 mg PRN dose. On 8/20/2025 at 6:11 PM, V8 (LPN, Former Employee) stated that V8's last day of employment at the facility was 8/16/2025. V8 stated that R1 is alert, oriented, needs ADL help due to paraplegia and has pain in R1's legs which radiates down R1's legs. V8 stated that on 8/16/2025, V8 was R1's nurse for the day and evening shifts (7 AM to 11 PM). V8 stated that R1's Pregabalin 200 mg capsules were not in the controlled substance box in the medication cart. V8 stated that on 8/16/2025, V8 called the pharmacy, and they said that they needed a prescription for the Pregabalin. When asked if V8 notified R1's doctor about R1 not receiving R1's scheduled 9 AM/1PM/9PM doses on 8/16/2025, V8 stated that V8 could not remember if V8 called a doctor; if V8 spoke over the phone or via text for a doctor; or if V8 left a voicemail message for a doctor about R1's missing Pregabalin doses. When asked if V8 documents when V8 notifies a doctor of a resident missing a scheduled pain medication, V8 said that V8 would put a note in the electronic health record (EHR) generated from the eMAR. (Review of R1's eMAR Medication Administration Nurses Notes for Pregabalin documentation on 8/16/2025 shows no eMAR Medication Administration Nurses Notes on 8/16/2025). On 8/20/2025 at 2:44 PM, V5 (RN) stated that on 8/17/2025, V5 worked the evening shift (3-11PM) and was R1's nurse. V5 stated that V5 did not administer R1's scheduled 9:00 PM dose of Pregabalin 200 mg due to the medication not available in the facility to administer. V5 stated that on 8/17/2025, V4 had reported in nursing report to V5 that V4 had already called the pharmacy and doctor about R1's Pregabalin. V5 stated that V5 did not make a call to R1's doctors about R1 missing R1's scheduled 9:00 PM dose of Pregabalin. On 8/20/2025 at 3:17 PM, V7 (Assistant Director of Nursing, ADON) stated that when V7 returned back to work on Monday, 8/18/25, V7 was informed by the Resident Council President that R1 wanted to speak to V7. V7 stated that V7 immediately went to see R1 who informed V7 that R1 did not have or receive Pregabalin over the weekend (8/16//2025 to 8/17/2025) and no doses of Pregabalin as of their conversation on 8/18/2025. V7 stated that Pregabalin is used specifically for neurological pain and is a controlled substance (requiring a prescription). V7 stated that Hydrocodone/Acetaminophen is a narcotic medication for generalized pain and also requires a prescription. V8 stated that from the clinical standpoint, (Pregabalin) is more effective for neurological pain. V7 stated that it's the nurse's job description and is the expectation that if a medication is not available in the facility to be administered, the nurse must call the doctor to notify the doctor. V7 stated that controlled substances that need a prescription, the nurse is expected to not wait until the medication runs out to call the doctor or call the pharmacy. V7 stated that it's the nurse's responsibility to continue to call the doctor or nurse practitioner if the nurse does not receive a timely response from the initial call placed. V8 stated, It's not acceptable to leave a message with doctor on an answering service and not follow up. V7 stated that there has to be effective communication for continuity of care. V7 stated that there used to be an on-site nurse practitioner (V12) in the facility every Monday through Friday from 9:00 AM to 4:00 PM who would write the prescription refills for a resident's controlled substance medication that was due to be empty (zero remaining) over the weekend; therefore, there would be no lapse in medication coverage. V7 stated that V12 stopped working in the facility within the past 1 to 2 weeks while V7 was off of work. V7 stated that the if the nurse does not receive a return call back from a doctor or nurse practitioner, the nurse should call the medical director of the facility, V13. V7 stated that with R1 not receiving the scheduled Pregabalin three times a day for 2 and 1/2 days, R1 would be in excruciating pain, discomfort and stress and this would affect R1's mood, where R1 would not be a happy client. On 8/20/25 at 4:19 PM, V2 (DON) stated that Pregabalin is a controlled substance that requires a prescription from the doctor for pharmacy to refill this medication. V2 stated that nurses are expected to notify a resident's physician or nurse practitioner for renewal of Pregabalin prior to the medication being completely administered (zero capsules remaining). V2 stated that V12 (Former Nurse Practitioner) stopped working in the facility 2 weeks ago, and nurses are expected to follow up with the primary doctors/nurse practitioners for medication refills. V2 stated that V15 (Nurse Practitioner) is now managing some residents, including R1, for pain management needs. When asked about V2 being notified or was V2 aware of R1's Pregabalin not being administered as scheduled, V2 stated that V2 worked 4 hours in the facility on 8/15/2025 and was not answering or taking work phone calls over the weekend (8/16-8/17/2025) adding, I (V2) was [NAME] (missing in action). V2 stated that when a nurse goes to administer a medication to a resident and the medication is not available in the facility, the nurse will document a pharmacy code of 9 and will document the reason why the medication was not administered. V2 stated that the nurse is to notify the doctor also of the resident missing a scheduled medication as ordered by the doctor. V2 stated, They (nurses) should be documenting the doctor when they notify them (doctors). On 8/21/2025 at 12:50 PM, V15 (Nurse Practitioner) stated that V15 is the physical medicine nurse practitioner seeing several residents, including R1, in the facility for pain management and evaluates frequency needs for narcotic medications. V15 stated that V15 visited R1 on 8/18/25 and that R1 has paraplegia. V15 stated that R1 has used Hydrocodone-Acetaminophen sparingly (1 to 2 times) and that nurses verified this as well. V15 stated that R1 is on scheduled medications for R1's pain, such as Pregabalin, and Pregabalin has an indicated use for neuropathic or polyneuropathy pain. V15 stated that narcotics, like Hydrocodone-Acetaminophen, that are not needed long-term, should be weaned off, especially if the resident's pain is controlled by other medications. When asked the potential of R1 not receiving scheduled Pregabalin as ordered, what are potential risks that R1 can experience, and V15 stated that R1's pain would increase and not be controlled. When asked how many days can a resident be without pain, or experiencing pain, when the resident is not receiving their scheduled doses of Pregabalin, V15 stated that V15 cannot give an exact time frame, but Pregabalin is a medication that needs to build up in the system, and we don't want a lapse in giving this medication in my professional opinion.

F725Based on observation, interview and record review, the facility failed to ensure sufficient staff to administer medications as ordered by physician and attend to resident's needs or care in a timely manner. These failures could potentially affect all residents residing in the facility. The findings include:On 8/5/25 At 10:50AM Observed R34 up and about, ambulatory with steady gait, alert and oriented x 3, verbally responsive. Stated medication does not come on time depending on the nurse. R34 said on 8/2/25 (Saturday) there was only 1 nurse working and the nurse on her side came late around 12noon. She said she got her morning medications around 12noon, and it is supposed to be given around 9am. Stated medications were given late because of short staff. MDS (Minimum Data Set) dated 6/5/2025 showed R34's cognition was intact. R34's physician order sheet (POS) and medication audit report dated 8/6/25 documented medications not limited to Furosemide, Magnesium, Thiamine, Cyanocobalamin, Folic Acid, Aspirin, Potassium Chloride, Divalproex, Gabapentin, Amlodipine, Metoprolol scheduled on 8/2/25 with physician ordered time at 9AM were administered at 11:34AM, 11:39AM and 11:40AM. R34's care plan dated 5/30/25 showed interventions not limited to Administer medication per physician order. On 8/5/25 at 11:26AM R46 observed sitting on wheelchair, alert and oriented x 3, verbally responsive, very upset stated that he did not get his 9am medications yet. He said he has been having pain on right leg and scored pain as 8/10. R46 said he does not need PRN (as needed) pain medication if he gets his scheduled medications around 9am. Stated he has been residing in the facility for almost 5 years and at times, his medications are given late depending on the nurse working and at times short of staff. R46 said he has been waiting for his medications for couple of hours and no staff came. On 8/5/25 At 11:33AM Observed V18 (Licensed Practical Nurse / LPN) prepared medications and prepared the following medications: Cephalexin 500mg 1 capsule, Diclofenac 50mg 1 tablet, Eliquis 5mg 1 tablet, Lisinopril 10mg 1 tablet, Metoprolol 50mg 1tablet, Magnesium oxide 400mg 1 tablet, Furosemide 40mg 1 tablet, Fish oil 1 capsule, Folic acid 1 tablet. MDS dated [DATE] showed R46's cognition was intact. R46's POS and MAR (Medication Administration record dated 8/5/25 showed medications not limited to Cephalexin, Diclofenac, Eliquis, Lisinopril, Metoprolol, Magnesium oxide, Furosemide, Fish oil, Folic acid with physician ordered time at 9AM. On 8/06/2025 10:08 AM Surveyor conducted resident council meeting attended by 6 residents including R77 and R156 and stated on 8/2/25 their medications were given late due to short of staff. They waited for 2-3 hours to get their scheduled medications. R77 said if medication is given late there is shorter time gap for the next dose of medication. R156 stated he had witnessed that his roommates have been calling for help to be changed and needed to wait for more than an hour.R77's physician order sheet (POS) and medication audit report dated 8/6/25 documented medications not limited to Furosemide, Spironolactone, Zinc oxide, Fluticasone, Jardiance, Methocarbamol, Spiriva inhaler, Allopurinol, Metformin, Gabapentin, Amlodipine scheduled on 8/2/25 with physician ordered time at 9AM were administered at 12:37PM. R77's care plan dated 5/29/25 showed intervention not limited to Administer medication as ordered. MDS dated [DATE] showed R77's was cognitively intact. R156's physician order sheet (POS) and medication audit report dated 8/6/25 documented medications not limited to Pregabalin, Vitamin C, Multivitamin, Lidocaine, Baclofen, Docusate Sodium, Polyethylene Glycol scheduled on 8/2/25 with physician ordered time at 9AM were administered at 11:29AM and 11:30AM. R156's care plan dated 11/7/23 showed intervention not limited to Administer medication as ordered.MDS dated [DATE] showed R156's cognition was intact.On 8/7/25 at 10:55am Observed R70 resting in bed, alert and oriented x 3, verbally responsive. Stated there are times that he needed to wait for at least an hour to be changed. He said at one point he waited for 3hours to be changed, and he missed his therapy session because he was late to go down. R70 said care is not done in a timely manner because of short staffing. MDS dated [DATE] showed R70's cognition was intact. He needed Partial / moderate assistance with toileting and personal hygiene, shower / bathe self, upper and lower body dressing. MDS showed R70 was Occasionally incontinent of bowel and bladder.At 8/7/25 at 11:01AM Observed R163 resting in bed on moderate high back rest, alert and oriented x 3, verbally responsive. Stated most of the time, has been calling for help but nobody would respond to call light to attend to his needs in a timely manner. Stated he needed to wait at least an hour to an hour and half to be changed due to short of staff. MDS dated [DATE] showed R163's cognition was intact. He needed Partial / moderate assistance with oral hygiene; Dependent with toileting hygiene, shower / bathe self, lower body dressing, chair / bed transfer; Substantial / maximal assistance with upper body dressing and personal hygiene. MDS showed R163 was always incontinent of bowel and bladder. On 8/7/25 at 11:49AM V2 (Director of Nursing / DON) stated nurses are expected to administer Medications to residents according to physician order. Should follow 5R's (right route, right resident, right time, right frequency, right dose) in giving medications. V2 said nurses should give meds 60minutes before and after physician ordered time. She said If the order time is at 9am, nurse is expected to give medication between 8am to 10am. If medication was given at 11:30am, it is considered late and not following physician ordered time. V2 said if blood pressure, blood sugar, pain medication was not given according to physician ordered time could potentially affect blood pressure, blood sugar or aggravate pain. V2 said she makes sure that there is always sufficient staff to meet resident's needs or care in a timely manner.Facility's census dated 8/5/25 showed 172 residents. Facility's LPN's and RN's job description (undated) showed in part: Prepares and administers medications as ordered by the physician. Facility's medication administration policy (undated) showed in part: To ensure that resident medications are administered in a timely manner. Unless otherwise specified by the physician, medications will be administered within 60minutes before and after the facility's dosing schedule. Licensed professional nurses administer medications according to times documented on the medication administration record. Medication administration pass may begin sixty minutes before the scheduled times of administration but may not exceed to sixty minutes after the scheduled times of administration. Facility's call light use policy (undated) showed in part: To respond promptly to resident's call for assistance. Facility's staffing policy dated 1/2021 showed in part: Adjust staff schedules to support resident care and provide ADLs.

Based on observations, interviews, and record reviews, the facility failed to discard out-dated food items, store food items away from cleaning solution, and ensure food items were distributed and served to residents under sanitary conditions. This has the potential to affect 168 residents that receive nutrition from the kitchen. Surveyor 40061's findings include: On 8/05/2025 at 9:18 AM, surveyor conducted an initial kitchen tour with V7 (Dietary Manager). In the dry storage room, there was an opened box of powdered non-dairy creamer packets. One of the labels in the box documented in part to best use by 6/22/2025. V7 stated there was no expiration date on the box. V7 did not know if powdered creamer expired and stated it was better to toss it since V7 did not know if the product was still good. At 9:29 AM, during the initial kitchen tour, there was a large box of bananas on the bottom shelf in one of the prep stations in the back of the kitchen. Next to the box was a sanitation bucket. V7 stated there was cleaning solution in the bucket. On 8/06/2025 at 2:10 PM, V7 provided 'Diet Tally' of all residents in the facility. Four residents do not receive nutrition by mouth (no prepared food from the kitchen). Facility's 'Food Storage (Dry, Refrigerated and Frozen)' policy documents in part that food shall not be stored where chemicals are stored. All out-dated goods will be discarded the day after expiration. -- -- -- -- -- The findings include: On 8/5/25 At 12:32PM Dining observation conducted on 2nd floor dining room. Observed V20 (Certified Nursing Assistant / CNA), V21 (CNA), V22 (RESTORATIVE AIDE/CNA), V23 (CNA) passing / distributing lunch trays from the dining room to residents' rooms with mandarin oranges in dessert bowl and juice in plastic cup not covered and exposed to contaminants. On 8/7/25 at 10:06AM V7 (Dietary Manager) and V8 (Regional Director of Operations for Archway management) stated they are contracted in the facility. V8 said staff in the unit should bring meal cart outside of resident's rooms to distribute or pass meal tray, so all food items are covered and not exposed to contaminants. V7 and V8 said if staff is passing meal trays from the dining room to resident's rooms, all food items such as mandarin oranges in dessert bowl or juice in cup should be covered for infection control to prevent contamination. On 8/7/25 at 11:49AM V2 (Director of Nursing / DON) said staff is expected to distribute or pass meal trays in sanitary condition, all food items should be covered and not exposed to contaminants for infection control to prevent contamination.

Based on observation, interview and record review, the facility failed to ensure wheelchair armrest was not worn out or wabbly for 1 resident (R101) and failed to ensure call light were within reach and in good working order for four residents (R7, R17, R51, R98) reviewed for reasonable accommodation of needs out of a sample of 35. The findings include: R101's admission record showed initial admit date on 7/15/2009 with diagnoses not limited to Epilepsy, Unspecified asthma, Hypertensive heart disease, Pain in unspecified joint, Benign prostatic hyperplasia, Pain in left ankle and joints of left foot, Personal history of traumatic brain injury. MDS (Minimum Data Set) dated 7/11/2025 showed R101's cognition was intact. He needed set up or clean up assistance with eating; Supervision or touching assistance with chair / bed and toilet transfer. MDS showed R101 uses wheelchair and received restorative nursing programs for active range of motion (AROM), splint or brace assistance and transfer 7 days in a week. On 8/05/2025 at 10:57AM Observed R101 sitting on the side of the bed, alert and oriented x 3, verbally responsive. Stated his wheelchair armrest is broken and told staff about it but never took care of it. R101 said he needed a new wheelchair because it is falling apart, so it was taped. Observed wheelchair armrests (right and left) were worn out and wabbly with blue tape around it. On 8/6/25 At 12:39PM V29 (MAINTENANCE DIRECTOR) stated he has been rounding and checking resident's wheelchair and equipment on daily basis. He said did not happen to see tape on R101's wheelchair armrest. V29 said when an equipment or device is taped or broken it is not good and not safe to use it should be taking care of right away. On 8/6/25 At 2:25PM V43 (RESTORATIVE NURSE, LPN) – has been working in the facility for 3 years. She said R101 is using an electric wheelchair and is on restorative NURSING program for AROM upper and lower extremities. V43 said Restorative aide is seeing R101 5 days a week. She said no report received regarding R101's wheelchair broken or falling apart but she said R101 mentioned that he needed a new wheelchair. V43 said If resident's wheelchair is broken it is not safe to use. On 8/6/25 At 3:10pm V43 said she saw R101's wheelchair armrest (right and left) was worn out, wabbly and there was tape on both sides. On 8/7/25 at 11:49AM V2 (Director of Nursing / DON) said equipment like wheelchair use by resident should be functioning or working properly, not worn out, or damage for resident's safety. Findings Include: R51's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. R51 Physician Order Sheet (POS) dated 8/5/25 shows an active diagnosis of multiple sclerosis, repeated fall, other muscle spasm, ataxic, asthma, migraine intractable, syncope and collapse. On 8/5/25 at 10:55 AM, R51 received in bed, call light not visible, stated that he has been in this facility for six months, and he has no call light since. He also stated that, because he has no call light, he would not be able to call for help to receive care as needed. On 8/6/25 at 9:06 AM, R51 received in bed, call light not within reach, stated no one care to listen to him. V25 (Certified Nursing Assistant/CNA) entered R51's room to pull the call light string from the floor underneath R51's roommate dresser and she attached the call light to R51's bed sheet. She stated because the call light is not within reach, R51 could fall when trying to reach for the call light under the dresser. On 8/7/25 at 11:12 AM, V2(Director of Nursing/DON) stated that she has been in the facility for three months and she expects that all residents will have call light attached within reach to alert staff for help as needed, and for safety. V18 (Licensed Practical Nurse/LPN), and V21 (CNA) Both stated that staff should make sure the call lights are within reach of the residents at all times. Facility policy titled Call Light, Use of dated 1/1/20, documents in part: Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. R7 has diagnosis not limited to Need for Assistance with Personal Care, Hypertensive Heart Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Dysphagia, Myocardial Infarction, Cognitive Communication Deficit, Atherosclerotic Heart Disease, Chronic Embolism and Thrombosis, Vascular Dementia, Major Depressive Disorder, Convulsions, Gastrostomy, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Anoxic Brain Damage, Acute Kidney Failure, Acidosis and Acute Respiratory Failure with Hypoxia. R7'S MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 99 indicating resident is rarely/never understood. R7's Care Plan document in part: Focus: R7 is at Risk for Falls as evidenced by the following risk factors and potential contributing Diagnosis: Anoxic brain damage, CVA (Cerebral Vascular Accident). Interventions: Place my call light within reach and encourage me to use it for assistance as needed. Focus: Side Rails: I could benefit from use of Non-Restrictive Side Rail(s) or devices to improve, and/or maintain my functional bed mobility independence and promote healthy skin integrity. The use of the devices will enable me to become more self-sufficient in positioning and turning while in bed, enable my participation sitting up in bed and lastly to enable me to assist with my transfer in and out of my bed. Grab Bar(s) (Halo), General Weakness with impaired strength and endurance, CVA with Hemiparesis or Hemiplegia, Impaired Cognition, Impaired Communication. Interventions: Place my call light within reach and encourage me to use it for assistance as needed. On 08/05/25 at 12:39 PM R7 was observed lying in bed. R7's call light was observed positioned on the floor near the left side of the headboard out of R7's reach. V41 (Certified Nurse Assistant) entered R7's room. Surveyor asked R7 the location of R7's call light. V41 responded on the floor. V31 proceeded to the head of R7's bed, picked up the call light cord and attached it to R7's pillow. On 08/07/25 at 12:25 PM V2 (Director of Nursing) stated The call light should be placed on the side, attached to the gown or clothes depending on the individual. The call light should be within reach, in case the resident need something or need to go to the bathroom. It is for safety. On 08/07/25 at 04:53 PM V1 (Administrator) provided a document titled Education Record dated 08/05/25 Call Light Policy. Findings include: On 08/05/25 at 11:14 AM, observed R17 and R98 residing in the same room with R98 in the first bed position and R17 in the 3rd bed position. On 08/05/2025 at 11:15 AM, observed R98 lying in bed. There was no call light within R98's reach. Observed call light switch located on the wall however there was no string or cord attached to the switch. R98 stated when he needs help from the staff he uses his call light. R98 said, the call light is right here and he grabbed onto the string attached to the over the bed light switch and pulled it continually which turned the over the bed light on and off. R98 stated he just needs to wait now for one of the staff to come. On 08/05/25 at 11:18 AM, observed R17 lying in bed. R17's bed was in the lowest position with a floor mat next to his bed. R17's call light not within reach. Upon further observation there was no string attached to R17's call light switch on the wall near his bed. On 08/05/25 at 11:18 AM, V11 (Registered Nurse Trainee) stated he does not see R17's or R98's call light. V11 said, I'm trying to find them. They are both missing the string which attaches to the call light switch on the wall. V11 stated there should be a string attached to the switch on the wall so that R17 and R98 can activate their call lights by pulling on the string. V11 stated the problem with V17 and R98 not having access to their call light is when they are in distress or need something they cannot alert the staff. On 08/05/25 at 11:22 AM, observed V12 (Certified Nursing Assistant) attaching a string to the call light switch on the wall. V12 stated she is attaching a string to R17 and R98's call light so they can have use of the call light because the string was missing. V12 stated someone should have noticed and replaced the string. V12 stated the extra string is kept at the nursing station. V12 stated all the residents should have access to a call light in case something happens, and they need the staff. V12 stated after giving care to a resident she always makes sure the resident's call light is within their reach. V12 stated this is important because most of the residents including R17 and R98 are at fall risk and the staff does not want them to try to get up on their own. On 08/07/25 at 9:50 AM, V2 (Director of Nursing) stated all residents should have access to a call light and call lights should be within their reach. V2 stated having call lights within the resident's reach and in working order is important in case they need assistance from the staff so they can alert the staff that they need help or assistance. V2 stated not having access to a call light is also a safety concern because if a resident needs to go to the bathroom and they are not able to contact the staff they may try to get up by themselves which could potentially risk a fall. R17 has diagnosis which includes but not limited to Gout, Inflammatory Disorders of Scrotum, Anxiety Disorder, Unspecified Psychosis, Unspecified Severe Protein Calorie Malnutrition, Age-Related Osteoporosis, Wedge Compression Fracture of First Lumbar Vertebra, Sophronia, Abnormalities of Gait Immobility, Unspecified Dementia, Dysphasia, Adult Failure to Thrive, Unspecified Hearing Loss. R17's MDS (Minimum Data Set) dated 07/21/25 documents in part, partial/moderate assistance for toileting hygiene and mobility including transfers. R17's fall care plan documents in part R17 is at risk for falls with goal for R17 to have a safe environment and intervention includes but not limited to place my call light within reach and encourage (R17) to use it for assistance as needed. R98 has diagnosis which includes but not limited to Myasthenia Gravis, Hypertensive Heart Disease, Type 2 Diabetes Mellitus, Schizophrenia, Shortness of Breath, Long Term Use of Anticoagulants (Current), Long Term Use of Insulin (Current), Long Term Use of Oral Hypoglycemic Drugs (Current), Pain in Left Hip. R98's MDS dated [DATE] documents in part, BIMS (Brief Interview for Mental Status) score indicating moderate cognitive impairment and requires partial/moderate assistance with toileting hygiene and supervision/touching assistance with chair/bed to chair transfer. R98's fall care plan documents in part, R98 is at risk for falls as evidenced by the following risk factors including decreased strength and endurance, episodes of incontinence of bowel and bladder, respiratory disorders with increased risk for shortness of breath. R98's fall care plan goal includes but not limited to R98 will have a safe environment and intervention includes but not limited to place (R98) call light within reach and encourage (R98) to use it for assistance as needed. Facility provided policy titled Resident Rights undated which documents in part as a resident of this facility, you have the right to a dignified existence and the facility will protect and promote your rights as designated below: the facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. Facility provided policy titled, Call Light, Use of dated 01/01/20 which documents in part to assure call system is in proper working order and when providing care to residents be sure to position the call light conveniently for the resident to use and be sure all call lights are placed on the bed at all times, never on the floor or bedside stand.

F695Based on observations, interviews, and record reviews, the facility failed to: (A) Maintain proper storage of oxygen nasal cannula tubing for 3 (R39, R52, and R107). (C) Ensure nebulizer tubing and mask were changed for 1 (R62) resident.These failures affected four (R39, R52, R62, and R107) out of four residents reviewed for respiratory care in a sample of 35.Findings Include: R39's Minimum Data Set (MDS) dated [DATE], Brief Interview Score indicates he is cognitively impaired. R39 Physician Order Sheet (POS) dated 8/5/25 shows an active diagnosis which are not limited to: chronic obstructive pulmonary disease, dependence on supplemental oxygen, other fatigue, and acute respiratory failure with hypoxia. R39 has an active order for oxygen at 2 Liters per minute/lpm, via nasal cannula every shift for Shortness of Breath (SOB)R52's MDS dated [DATE], Brief Interview Score (14) indicates she is cognitively intact. R52's POS dated 8/7/25 shows an active diagnosis of chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, unspecified asthma with status asthmaticus, and respiratory failure with hypercapnia. R52 has an active order for oxygen at 2-3 lpm, per nasal cannula as needed related for hypoxia. R62's MDS dated [DATE], Brief Interview Score (05) indicates she is cognitively impaired. R62 POS dated 8/5/25 shows an active diagnosis of cardiac murmur, asthma and cough. R62 has an active order for ipratropium-albuterol inhalation solution0.5-2.5, 1 vial inhale orally every six hours as needed for wheezing. R62's medication Administration Record/MAR shows nebulizer treatment was given on 8/5/25 at 6am.R107's MDS dated [DATE], Brief Interview Score (14) indicates she is cognitively intact. R107 POS dated 8/5/25 shows an active diagnosis of chronic obstructive pulmonary disease (COPD), transient cerebral ischemic attack, and epilepsy R107 has an active order for oxygen at 2-3 lpm, per nasal cannula as needed for SOB.On 8/5/25 at 10:06 AM, surveyor and V17 (Registered Nurse/RN) entered R62's room, observed nebulizer tubing/mask not changed. She stated that tubing should be changed every weekly on Sundays to prevent infection, but the last time the tubing/mask was changed was 7/21/25. On 8/5/25 at 11:18 AM, R39 received up in bed, his portable oxygen nasal cannula tubing was hanging on his wheelchair when not in use. V10 (Registered Nurse/RN) stated that the nasal cannula should be stored in a bag when not in use.On 8/5/25 at 11:23 AM, R107 observed in bedroom, up in her wheelchair, stated she has been in the facility for ten years, she has no bag for her oxygen tubing, and she has used her oxygen today. Oxygen nasal cannula tubing hanging on the oxygen concentrator tank, not in a plastic bag when not in use. On 8/6/25 at 10:08 AM, V28 (Licensed Practical Nurse/LPN) stated the nasal cannula should be kept in a bag when not in use.On 8/6/25 at 9:53 AM, surveyor and V28 entered R52's room, observed oxygen nasal cannula tubing hanging on the oxygen concentrator tank. V25 stated that the oxygen nasal cannula tubing, should be stored in a bag when not in use to prevent germs which can cause respiratory infection, and she will discard the tubing now.On 8/7/25 at 11:12 AM, V2 (Director of Nursing/DON) stated she expects that the nebulizer tubing/mask will be changed every Sunday, and oxygen nasal cannula tubing will be kept in a plastic bag when not in use to prevent infection.Facility policy titled Oxygen Administration documents in part: Tubing, humidifier bottles and filters will be changed, cleaned and maintained no less than weekly and as needed (PRN).The facility could not provide any policy on storage of oxygen nasal cannula tubing when not in use.

F755Based on observation, interview and record review, the facility failed to follow their policies and procedures to ensure resident received their medications according to the physician's order for 6 (R25, R34, R46, R77, R107 and R156) residents reviewed for medication administration in a sample of 35.The findings include: R34’s admission record showed admit date on 5/29/2025 with diagnoses not limited to Other seizures, Hypertensive heart disease without heart failure, Polyneuropathy, Depression, Idiopathic peripheral, Autonomic neuropathy. MDS (Minimum Data Set) dated 6/5/2025 showed R34’s cognition was intact. R46’s admission record showed admit date on 4/3/2020 with diagnoses not limited to Unilateral primary osteoarthritis right hip, Chronic obstructive pulmonary disease, Chronic pulmonary edema, Heart failure, Paroxysmal atrial fibrillation, Unspecified atrial flutter, Hypertensive heart disease with heart failure, Type 2 diabetes mellitus, Venous insufficiency (chronic) (peripheral), Iron deficiency anemia, Hyperlipidemia. MDS dated [DATE] showed R46’s cognition was intact. R77’s admission record showed admit date on 5/26/2021 with diagnoses not limited to Chronic obstructive pulmonary disease, Acute and chronic respiratory failure with hypercapnia, Chronic obstructive pulmonary disease with (acute) exacerbation, Chronic diastolic (congestive) heart failure, Hypertensive heart disease with heart failure , Venous insufficiency (chronic) (peripheral), Type 2 diabetes mellitus, Other unilateral secondary osteoarthritis of hip, Gout. MDS dated [DATE] showed R77’s was cognitively intact. R156’s admission record showed admit date on 12/21/2023 with diagnoses not limited to Paraplegia, Hyperlipidemia, Neuromuscular dysfunction of bladder, Polyneuropathy, Acquired absence of kidney. MDS dated [DATE] showed R156’s cognition was intact. On 8/5/25 At 10:50AM Observed R34 up and about, ambulatory with steady gait, alert and oriented x 3, verbally responsive. Stated medication does not come on time depending on the nurse. R34 said on 8/2/25 (Saturday) there was only 1 nurse working and the nurse on her side came late around 12noon. She said she got her morning medications around 12noon, and it is supposed to be given around 9am. Stated medications were given late because of short staff. R34’s physician order sheet (POS) and medication audit report dated 8/6/25 documented medications not limited to Furosemide, Magnesium, Thiamine, Cyanocobalamin, Folic Acid, Aspirin, Potassium Chloride, Divalproex, Gabapentin, Amlodipine, Metoprolol scheduled on 8/2/25 with physician ordered time at 9AM were administered at 11:34AM, 11:39AM and 11:40AM. R34’s care plan dated 5/30/25 showed interventions not limited to Administer medication per physician order. On 8/5/25 at 11:26AM R46 observed sitting on wheelchair, alert and oriented x 3, verbally responsive, very upset stated that he did not get his 9am medications yet. He said he has been having pain on right leg and scored pain as 8/10. R46 said he does not need PRN (as needed) pain medication if he gets his scheduled medications around 9am. Stated he has been residing in the facility for almost 5 years and at times, his medications are given late depending on the nurse working. R46 said he has been waiting for his medications for couple of hours and no staff came. On 8/5/25 At 11:28AM Surveyor asked V18 (Licensed Practical Nurse / LPN) regarding R46 scheduled medications and stated she came in late around 10am today, it was V2 (DON) and V15 (LPN) covered her assignment with V11 (RN orientee) and prepared R46’s medications. She said V11 attempted to give medications to R46 but did not take it stating there were medications missing. V18 attempted to administer previously prepared medications to R46 and said could not see his blood thinner medication which is pink and oval shape and did not see the Glucosamine. On 8/5/25 At 11:33AM V18 discarded previously prepared medications and prepared the following medications: Cephalexin 500mg 1 capsule, Diclofenac 50mg 1 tablet, Eliquis 5mg 1 tablet, Lisinopril 10mg 1 tablet, Metoprolol 50mg 1tablet, Magnesium oxide 400mg 1 tablet, Furosemide 40mg 1 tablet, Fish oil 1 capsule, Folic acid 1 tablet. V18 said Glucosamine tablet was not available. She said she will order it to the pharmacy. V18 administer prepared medications and R46 said “where is my Glucosamine?” V18 responded it was not available and was ordered already. R46 took prepared medications by mouth. R46’s POS and MAR (Medication Administration record dated 8/5/25 showed medications not limited to Cephalexin, Diclofenac, Eliquis, Lisinopril, Metoprolol, Magnesium oxide, Furosemide, Fish oil, Folic acid with physician ordered time at 9AM. On 8/06/2025 10:08 AM Surveyor conducted resident council meeting attended by 6 residents including R77 and R156 and stated on 8/2/25 their medications were given late. They waited for 2-3 hours to get their scheduled medications. R77 said if medication is given late there is shorter time gap for the next dose of medication. R77’s physician order sheet (POS) and medication audit report dated 8/6/25 documented medications not limited to Furosemide, Spironolactone, Zinc oxide, Fluticasone, Jardiance, Methocarbamol, Spiriva inhaler, Allopurinol, Metformin, Gabapentin, Amlodipine scheduled on 8/2/25 with physician ordered time at 9AM were administered at 12:37PM. R77’s care plan dated 5/29/25 showed intervention not limited to Administer medication as ordered. R156’s physician order sheet (POS) and medication audit report dated 8/6/25 documented medications not limited to Pregabalin, Vitamin C, Multivitamin, Lidocaine, Baclofen, Docusate Sodium, Polyethylene Glycol scheduled on 8/2/25 with physician ordered time at 9AM were administered at 11:29AM and 11:30AM. R156’s care plan dated 11/7/23 showed intervention not limited to Administer medication as ordered. On 8/7/25 at 11:49AM V2 (Director of Nursing / DON) stated nurses are expected to administer Medications to residents according to physician order. Should follow 5R’s (right route, right resident, right time, right frequency, right dose) in giving medications. V2 said nurses should give meds 60minutes before and after physician ordered time. She said If the order time is at 9am, nurse is expected to give medication between 8am to 10am. If medication was given at 11:30am, it is considered late and not following physician ordered time. V2 said if blood pressure, blood sugar, pain medication was not given according to physician ordered time could potentially affect blood pressure, blood sugar or aggravate pain. Facility’s LPN’s and RN’s job description (undated) showed in part: Prepares and administers medications as ordered by the physician. Facility’s medication administration policy (undated) showed in part: To ensure that resident medications are administered in a timely manner. Unless otherwise specified by the physician, medications will be administered within 60minutes before and after the facility’s dosing schedule. Licensed professional nurses administer medications according to times documented on the medication administration record. Medication administration pass may begin sixty minutes before the scheduled times of administration but may not exceed to sixty minutes after the scheduled times of administration. Findings Include: R25’s Minimum Data Set (MDS) dated [DATE] shows he is cognitively intact. R25's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: end stage renal disease, dependence on renal dialysis, other age-related cataract, unspecified atrial fibrillation, type2 diabetes mellitus with foot ulcer, dry eye syndrome, anemia, and hypertensive heart disease without heart failure. R107’s Minimum Data Set (MDS) dated [DATE] shows she is cognitively intact. R107's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: anemia in chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, chronic obstructive pulmonary disease, and epilepsy. On 8/5/25 at 10:35 AM, R25 in bed, stated that he has been in the facility for about eight months. He does not receive his scheduled medication at times and sometimes he received his medication late, and he did not receive some of his medications last Saturday 8/2/25. On 8/5/25 at 11:23 AM, R107 up in wheelchair, stated that she has been in the facility for ten years, she receives her medication late at times, and she did not receive most of her medications on Saturday 8/2/25. On 8/7/25 at 10:03 AM, V44 (Registered Nurse/RN) stated that she has been in the facility since 2016, Medication Administration Record (MAR) should be signed once the medication is given, and if MAR is not signed, then the medication is not given. She worked 3pm-11pm shift on 8/2/25 with R25 without signing the MAR. On 8/7/25 at 10:18 AM, V42 (Licensed Practical Nurse/LPN) stated that she has been in the facility for twenty-seven years, and she worked 7am-3pm shift on 8/2/25 with R107. Nurses should administer medication as ordered by the physician, sign the MAR, and if MAR is not signed, the medication is not given, and that will affect the resident’ well-being. On 8/7/25 at 11:12 AM, V2 (Director of Nursing/DON) stated that she has been in the facility for three months, it is her expectation that nurses will administer medication has scheduled by the physician, and sign MAR. When medications are not administered to resident as ordered it could lead to increase sickness and distress. She ensures that nurses sign the MAR once the medication is given, and no resident reported to her that medication was not administered as scheduled. Documents reviewed for this complaint are not limited to the following. R25’s Medication Administration Record (MAR) shows that fourteen medications were not signed/administered to him on 8/2/25 during the 3pm-11pm shift. R107’s MAR shows that fifteen medications were not signed/administered to her on 8/2/25 during 7pm-3pm shift. R25, and R107’s Face Sheet, POS, MAR, and Section C of MDS. Policy and Procedure titled, “Medication Administration” documents in part: Medication administration record (MAR) will be signed after for each medication administered to the resident. Resident Council Meeting Minutes from 6/24/24 to 7/29/25. Grievance/Concern Forms from 8/2/24 to 12/12/24, and 5/1/25 to 8/4/25.

Based on observation, interview, and record review the facility failed to practice appropriate infection prevention and control measures by staff not wearing appropriate Personal Protective Equipment (PPE) while providing care to a resident (R167) on Enhanced Barrier Precautions (EBP) and failed to ensure that a resident (R177) with wounds was on Enhanced Barrier Precautions (EBP). These failures have the potential to affect R177 and all 62 residents residing on the 3rd floor. Infection Control Findings include: R177's 'admission Record' documents in part diagnosis information of acquired absence of left leg below knee, encounter for orthopedic aftercare following surgical amputation, and encounter for change or removal of surgical wound dressing. R177 admitted to the facility on [DATE]. R177's 'Order Summary Report' documents in part Enhanced Barrier Precautions for Wounds every shift. The order date and start date is 08/03/2025. On 8/05/2025 at 10:50 AM, R177 was in bed and had dressing to left below knee amputation. R177 stated new left below knee amputation surgical site and other wounds to right lower extremity that requires wound care from the facility. There was no Enhanced Barrier Precaution signage in R177's door or personal protective equipment. Facility did not put signage until the following day. Findings include: On 08/05/25 at 11:47 AM, observed V13 (Certified Nursing Assistant) performing incontinence care for R167. V13 was wearing a face mask and gloves. V13 was not wearing a gown. Observed adequate supply of PPE including gowns, gloves, masks hanging on the outside of R167's door next to signage for Enhanced Barrier Precautions. On 08/05/25 at 11:51 AM, V13 stated she was changing R167's incontinence brief because he was wet. V13 stated she has been working at the facility for approximately two months. V13 stated she sometimes wears a gown, but she always wears gloves and a mask. V13 stated she wears a gown if there is a sign on the resident's door for isolation. V13 went with surveyor to observe the EBP sign outside R167's door. V13 then stated based on that sign she should wear a gown. On 08/05/25 at 11:59 AM, V14 (Registered Nurse) stated staff are required to wear gloves, gown and mask when providing direct care to residents with any touch contact if the resident is on EPB. V14 stated the purpose of the staff wearing appropriate PPE is to contain infections and stop the spread of infection. V14 stated if a staff is changing a resident without wearing a gown there is the potential that urine and/or stool from the resident could get on the staff's clothing which could potentially spread to another resident. V14 stated that is why a gown should be worn over the staff's clothing. V14 stated R167 has wounds on his legs which have dressings on them which is why he is on EBP. V14 stated anyone coming in direct contact with R167 when giving care should be wearing mask, gloves, and gown. On 08/06/25 at 12:30 PM, V4 (Infection Control Preventionist/Licensed Practical Nurse) stated anyone on any kind of isolation should have signage posted outside the room to alert anyone going into the room what PPE should be worn and the type of precautions needed depending on the type of care being given. V4 stated the purpose of Enhanced Barrier Precautions are to help prevent the spread of infection in the facility. V4 stated EBP are used for residents with any type of openings from medical devises and for residents with wounds. V4 stated if a staff is going to have any direct contact with the resident on EBP with potential exposure to bodily fluids the staff are required to wear a gown and gloves. V4 stated it is important to have the EBP sign posted outside the room, so the staff/visitor is alerted to what they need to wear and do before entering the room. V4 stated if the sign is missing the staff and/or visitor will not know they should be performing hand hygiene before entering and upon exiting the room and/or wear gown and gloves during high contact resident care activities. V4 stated if the staff does not wear gown and gloves when providing incontinent care and changing a resident's incontinent brief, changing their clothing or when changing linens there is a potential risk of spreading infection. V4 stated it is her and/or nursing responsibility for posting the EBP signage outside the resident's door. On 08/06/25 at 12:40 PM, V4 stated R177 is on EBP for his wound and he was admitted to the facility over the weekend. V4 stated she got an order for EBP on Tuesday, 08/05/25 and put up the EBP signage 08/05/25. V4 stated R177 was admitted to the facility with the wound and therefore the EBP signage should have been posted outside his door on the day he was admitted to the facility. V4 stated the potential problem with the EBP sign not being posted on R177's door upon admission is that the staff did not know they should be following EBP guidelines and may not have been wearing a gown and gloves during direct contact with the resident until the EBP signage went up yesterday which could potentially lead to the spread of infection. On 08/07/25 at 11:40 AM, V27 (Wound Care Director/Registered Nurse) stated R167 has an open wound to his right ankle which was identified on 06/30/25 and a skin tear to his lower leg which is an opened wound. V27 stated R167 should be on EBP because he has opened wounds and that she wears a gown and gloves when treating R167's wounds. V27 stated anyone providing direct care that is not wearing a gown could potentially contaminate his wound which is an infection control concern. On 08/07/25 at 9:52 AM, V2 (Director of Nursing) stated if a resident is on EBP there should be signage outside the door to alert staff, so they are reminded to do hand hygiene before and after entering the room and to wear a gown and gloves when providing contact care activities such as changing bed linens and when providing incontinence care. V2 stated wearing appropriate PPE is important to keep the residents and the staff safe and decrease the spread of infection in the facility. V2 stated the potential problem with the staff not wearing a gown and gloves when giving care to a resident on EBP is that bodily fluids can get on the staff's uniform which can potentially cause the spread of infection. V2 stated the facility wants to make sure the staff are not walking around spreading anything. V2 stated on the units the Certified Nursing Assistants (CNAs) have designated assigned rooms however they are responsible for answering all call lights on the unit for all the residents and assist other CNA with providing care as needed. R167's diagnosis included but not limited to Anthropopathic Psoriasis, Hypertensive Heart Disease, Wernicke's Encephalopathy, Anxiety Disorder, Seizures, Alcoholic Cirrhosis of Liver Without Ascites, Unspecified Protein Calorie Malnutrition, Iron Deficiency Anemia, Alcohol Dependence Withdrawal, Unsteadiness on Feet, Lack of Coordination, Repeated Falls, Weakness, Abnormal Weight Loss, Depression, Disorder of Adult Personality and Behavior, Need For Assistance With Personal Care, Altered Mental Status. R167's Order Summary Report dated 08/07/25 documents in part Enhanced Barrier Precautions every shift with order date 08/05/25 and right anterior foot cleanse with normal saline solution, pat dry, paint with betadine, bordered dressing order date 06/20/25 and apply Gentamicin Sulfate External Ointment to right ankle topically every day shift for wound care. Cleanse with normal saline solution, pat dry, apply santyl/gentamicin calcium alginate, gentle foam or kerlix ordered date 06/30/25. R167's infection control care plan documents in part that facility did not include a focus for EBP until 08/05/25. It documents in part, R167 is on Enhanced Barrier Precaution for wounds and skin openings requiring a dressing with intervention to all right follow Enhanced Precaution guidelines when providing care and coming in direct contact with potentially infected material or devices that put blank (R167) at risk. Direct care activities include dressing, bathing showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting and incontinence care. Facility provided policy titled, Guidelines for Enhanced Barrier Precautions (EBP) which documents in part, Enhanced Barrier Precautions are defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of MDROs (Multidrug-Resistant Organisms) in the form of blood or body fluids onto the hands and/or clothing of the rendering caregiver. Residents who are at high risk for acquiring or spreading MDROs include residents with wounds regardless of MDRO status. Examples of high contact resident care activities at which time EBP is to be practiced are: providing hygiene (Activities of Daily Living), changing linens, changing briefs/assisting with toileting. Ensure that proper signage is posted on the resident's room door instructing those who plan to enter the room to check first at the Nurses' Station for education/instruction. Facility provided copy of Enhanced Barrier Precaution sign from the U.S. Department of Health and Human Services Center for Disease Control and Prevention which documents in part, providers and staff must also wear gloves and a gown for the following high-contact resident care activities which include but are not limited to wound care: any skin opening requiring a dressing.

F554Based on observations, interviews, and record reviews the facility failed to: 1. Obtain a physician order to keep medication at bed side for two (R107, and R126).2. Determine if self-administration of medication was appropriate for one (R107) out of two residents observed with medications at bed side table in a sample of 35. Findings Include:R107's Minimum Data Set/ MDS dated [DATE], Brief Interview Score (14) indicates she is cognitively intact. R107's Physician Order Sheet (POS) with active orders as of 8/5/25 shows Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for shortness of breath. R126's Minimum Data Set/ MDS dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. R126's Physician Order Sheet (POS) with active orders as of 8/5/25 shows Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT 2 puff inhale orally every 6 hours as needed for shortness of breath. On 8/5/25 at 11:23 AM, Surveyor entered R107 and R126's room, observed two dispenser containing Ventolin HFA inhalation aerosol solution at bed side tables. Both stated they have been having the dispensers at the bed side for over a month, and they have used the inhaler today. On 8/6/25 at 10:08 AM, surveyor and V28 (Licensed Practical Nurse/LPN) entered R107 and R126's room and observed Ventolin inhalation dispenser at R107, and R126's bed side table. V28 identified the medications as Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT Albuterol Sulfate Inhaler, stated that medication should not be left at the bed side table to prevent misuse or overuse. She also stated that there should be a physician order to keep inhaler at bed side, to self-administer, and an assessment to determine if the resident could self-administer safely. On 8/7/25 at 11:12 AM, V2 (Director of Nursing/DON) stated that for any resident to keep medication at bed side for self-administration, there should be a physician order, and medication self-administration safety assessment to prevent overdose and other resident taking the medication. R107's clinical records had no documentation to show a self-administration of medication assessment was completed, and physician order for self-administration to keep medication at bed side was found.R126's clinical records had no documentation/physician order for self-administration or to keep medication at bed side was found.The facility policy titled, Self-Administration of medications by residents dated 3/2023; documents in part: A physician order is obtained to self-administer medications if the above storage and skill assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the MAR.

Number of residents sampled: 172Number of residents cited: 3 Based on observations, interviews, and record reviews, the facility failed to ensure a homelike environment for three residents (R42, R88, R172) out of a total sample of 172 residents in the facility.Findings include: On 8/05/2025 at approximately 10:20 AM, R172 stated facility is slow to fix broken furniture and fixtures. R172 stated ceiling panel by the window has been missing for weeks. There was some type of leak from the ceiling and someone from maintenance took the panel out and never finished fixing it. When surveyor entered bedroom, surveyor observed the missing ceiling panel by R172's foot of the bed. Piping exposed and there were multiple towels and linen on the floor under the ceiling panel. On 8/05/2025 at 10:36 AM, R42 (roommate) stated the ceiling panel fell off and there was some water leak. R42 stated it's been this way for weeks. R42 stated the facility isn't doing anything to fix it or put it back. R42 also pointed to the cabinet in front of the bed. The left side panel and left cabinet door are missing. R42 stated the left side belonged to R88 (roommate). R42 stated the cabinet door fell off days ago and the facility hasn't fixed it. On 8/05/2025 at 3:39 PM, V31 (Housekeeping) stated R42 reported the broken cabinet previously but could not recall how long it's been broken. On 8/05/2025 at 3:43 PM, R42 stated cabinet has been broken for at least a week. On 8/06/2025 at 9:33 AM, the ceiling panel remained missing and there were towels on the floor. R88 stated has been in the room for a week now and the cabinet panel and door were broken when R88 moved in. R88 stated the maintenance and upkeep of the building could be a lot better. On 8/06/2025 at 12:31 PM, V29 (Maintenance Director) provided survey team with facility's work orders from 2/01/2025 through 8/06/2025. No mention of the ceiling panel or R88's cabinet. V29 stated was not aware of R88's cabinet until V1 (Administrator) notified V29 on 8/05/2025 late afternoon. V29 stated went into the room this morning and already fixed it. When asked about the ceiling panel, V29 did not know about the issue. V29 stated I hadn't noticed that it was gone. V29 stated staff have access to electronic reporting system and are supposed to put in any work order requests through there. Maintenance department will then review the work orders each morning to review which issues need priority. V29 stated maintenance team are also supposed to conduct daily inspections. On 8/06/2025 at 1:53 PM, V39 (Maintenance Assistant) and V29 stated they didn't know about the missing ceiling tile until surveyor informed them. Neither could provide information as to why the ceiling tile was missing or for how long. Facility's undated Resident Rights policy documents in part: The facility must care for you in a manner and environment that enhances or promotes your quality of life. The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services. The facility will provide you with private closet space as space permits. Facility's 'Preventative Maintenance Program' documents in part: Buildings and grounds are to be inspected daily. As areas needing repair or attention are identified, they should be dealt with immediately. If that is not possible, the issue and the area and/or resident room number should be recorded for proper follow up.

Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews the facility failed to submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for R10 and failed to refer R10 to the appropriate state-designated authority for a Level II PASRR evaluation and determination after a significant change for one out of a total sample of 35 residents. Findings include: On 8/05/2025 at 11:14 AM, R10 was sitting in bed staring at room curtain. Surveyor attempted to interview R10 but R10 was quiet and mostly to self with a flat affect. During other random observations, R10 was on the first floor dining room or walking in the hallway. R10 kept mostly to self with flat affect. On 8/05/2025 at approximately 11:30 AM, V17 (Nurse) stated that R10 is alert and oriented to person and place. V17 stated R10 used to be more alert but has considerably slowed down. V17 stated R10 is quieter, keeps to self and requires more encouragement and queuing now. On 8/05/2025 at 3:45 PM, R10 was sitting in a chair in R101's room. While R101 spoke with surveyor, R10 sat in a chair by the door. R10 was quiet with flat affect. Surveyor attempted to include R10 in conversation but R10 remained quiet. When R101 asked what was wrong, R10 did not answer. R101 continued to ask what was wrong and after a few minutes, tears formed in R10's eyes. R10 remained quiet and did not verbalize feelings. R10's 8/09/2023 'Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome' documents in part a determination of No Level II Required - No [Severe Mental Illness]/[Intellectual Disability]/[Related Condition]. The assessment did not include mental health diagnosis, behaviors and symptoms, or mental health medications. V54 (Office Manager) attested on [DATE] that R10's Level I was complete and accurate of information. R10's 'admission Record,' however, documents in part diagnoses including but not limited to schizoaffective disorder, bipolar type (onset 5/29/2018), post-traumatic stress disorder (onset 5/29/2018), anxiety disorder (onset 5/29/2018), bipolar disorder (onset 12/02/2018), homicidal ideations (onset 12/02/2018), auditory hallucinations (onset 12/02/2018), and mild intellectual disabilities (onset 5/29/2018). R10's 'Order Audit Report' also documents in part that R10 was on Haloperidol (antipsychotic) from 12/31/2022 through 2/20/2025 and Seroquel (antipsychotic) from 12/31/2022 through 11/30/2024. R10's current 'Order Summary Report' documents in part that R10 is taking Risperdal for psychosis, Seroquel for schizoaffective disorder-bipolar type, and trazadone for insomnia. R10 is also taking non-psychiatric medications such as Hydroxyzine for anxiety disorder and Carbamazepine for behavior disturbances (off-label use). On 8/07/2025 at 2:25 PM, V54 (Office Manager) stated signing R10's 8/09/2023 Level I PASRR but did not do the assessment. V54 stated someone else did it but could not recall who. V54 stated [V54] is not clinical in practice. V54 stated when facility is short staffed in Social Services and Admissions Department, facility asks V54 to help sign and submit the PASRRs. V54 stated not knowing what [V54] was signing. 'Level I Attestation and Signature' statement documents in part: By checking this box, I attest that I have reviewed all information contained herein and that I take responsibility for the completeness and accuracy of information reported throughout this submission. I attest that I am a health care professional working in a clinical capacity for this provider. I understand that approved submitters include clinical professionals such as nurses, [Licensed Practical Nurses], social workers (with a [Bachelor of Science] degree or higher), physicians, or home health agency clinical staff. Social service staff are not required to be licensed to submit information. I understand that administrative staff are not permitted to submit clinical information to [company name].I understand that Illinois PASRR considers knowingly submitting inaccurate, incomplete or misleading Level I information to be Medicaid fraud, and I have completed this form to the best of my knowledge. On 8/07/2025 at 11:33 AM, V48 (Social Service Director) stated the staff in charge of Admissions is supposed to oversee residents' PASRRs but there hasn't been a consistent Admissions person. V48 stated V52 (current Admissions) has been with facility for a week and is still learning. V48 is assisting with PASRRs but has not had a chance to review R10's PASRR. V48 stated it is important to have accurate PASRR assessments to ensure that the facility is appropriate for the residents and that the residents receive the services that they need. Further review of R10's MDS (Minimum Data Set) assessments document in part a significant change MDS dated [DATE]. On 8/07/2025 at 12:36 PM, V47 (MDS Nurse) stated R10's 7/06/2024 Significant Change MDS was due to R10 slowing down mentally and being more withdrawn. V47 stated R10 required more assistance with activities of daily living. On 8/07/2025 at 1:03 PM, V48 stated facility should have referred R10 to the appropriate state-designated authority for a Level II PASARR (Pre-admission Screening and Resident Review) evaluation and determination. Facility's 'Pre-admission Screening and Resident Review (PASRR)' policy documents in part: It is the Policy of this facility to Comply with Federal, State and the appointed screening agency, [Company Name], in standards addressing the PASRR assessment/screening process. Review the PASRR document to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his /her maximum level of well-being.

Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow-up and refer a resident with mental illness (R78) to the appropriate state-designated authority for a Level II PASRR (Pre-admission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 residents. Findings include: R78's 'admission Record' documents in part an initial admission date of 6/02/2025. Diagnosis information includes schizoaffective disorder, bipolar disorder, insomnia, and depression. R78's 'Clinical Physician Orders' include orders for Ziprasidone Hydrochloride for schizophrenia, Trazadone for insomnia, and Amitriptyline Hydrochloride for depression. R78's 5/31/2025 'Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome' documents in part a determination of Refer for Level II Onsite. Requested R78's Level II PASRR multiple times from V1 (Administrator), V2 (Director of Nursing), V33 (Social Service Coordinator), V36 (Nurse Consultant) and V48 (Social Service Director) throughout the course of the survey. On 8/06/2025 at 2:33 PM, V33 stated do not recall if R78 had a Level II assessment. On 8/07/2025 at 11:33 AM, V48 provided survey with a new PASRR Level I for R78 dated 8/07/2025. It also documents in part a determination of Refer for Level II Onsite. V48 does not think R78 ever received a Level II assessment. V48 stated the staff in charge of Admissions is supposed to follow-up with the PASRRs but there hasn't been a consistent Admissions person. V48 stated V52 (current Admissions) has been with facility for a week and is still learning. V48 is assisting with PASRRs but has not contacted the state-designated authority to do the assessment until date of the survey. Facility's 'Pre-admission Screening and Resident Review (PASRR)' policy documents in part: It is the Policy of this facility to: 1. Comply with Federal, State and the appointed screening agency, [Company Name], in standards addressing the PASRR assessment/screening process. 2. Request full and complete PASRR materials (Level 1 and 2) for each referral source prior to or soon following admission. 3. Review the PASRR document to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being.

Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow physician orders and perform daily wound care for R177 and failed to ensure accurate Treatment Administration Records (TAR) for R177 for one out of a total sample of 35 residents.Findings include: R177's 'admission Record' documents in part diagnosis information of acquired absence of left leg below knee, encounter for orthopedic aftercare following surgical amputation, encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus, and type 2 diabetes mellitus. R177's 'Care Plan Report' documents in part a focus that R177 has an amputation of left below knee amputation (BKA). Interventions include to do dressing change per doctor's order. R177's 'Order Summary Report' documents in part wound care orders for left below knee amputation site. Staff are to cleanse with normal saline solution, pat dry, apply nonadherent dressing pad, loose gauze bandage, and compression/elastic bandage every day shift and as needed for wound care. The order date and start date is 8/02/2025. On 8/05/2025 at 10:50 AM, R177 stated new left below knee amputee. admitted to the facility on Friday (8/01/2025) for wound care and other skilled services. R177 stated the nurses did not change the dressing to the site over the weekend. R177 was concerned stating that being a diabetic makes it difficult for wounds to heal and wanted wounds taken care of as ordered. R177 stated facility didn't do wound care to left BKA until Monday (8/04/2025). R177's 'Treatment Administration Record (TAR)' documents in part that V26 (Wound Care Nurse) checked off wound care administered to left below knee amputation site on Saturday (8/02/2025). It has no charting for 8/03/2025 wound care to left below knee amputation site. On 8/05/2025 at 3:09 PM, V26 stated [V26] did not do R177's BKA wound care on Saturday despite what R177's TAR reads. V26 stated R177 said the BKA dressing was supposed to be changed every other day. Since R177 admitted from the hospital on Friday night, V26 did not do the dressing change Saturday. Surveyor asked if V26 verified R177's wound care orders with the hospital or R177's admitting physician. V26 stated no. Surveyor went over R177's current wound care orders with V26. V26 stated V27 (Wound Care Coordinator) placed the orders in. On 8/05/2025 at 3:26 PM, V27 stated that staff called V27 on 8/02/2025 about R177's wounds. V27 audited R177's chart remotely from home and did not see any initial/admitting wound care orders. V27 coordinated with the physician and placed the wound care orders. V27 stated V26 was supposed to do the wound dressing on Saturday as ordered. V27 also stated that V15 (Wound Care Nurse) was scheduled to do R177's wound care on Sunday but is not sure why V15 did not do it. Facility's 'Physician Orders-(Following Physician Orders)' policy documents in part: It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. Facility's 'Wound Cleansing and Dressings' policy documents in part: It is the policy of this facility to cleanse all wounds to clear exudates, bacterial contamination, and debris from the wound bed. Optimal wound healing cannot proceed until inflammation producing substances are removed from the wound bed. Wound cleansing is completed as indicated in the physician's order by licensed nurse. It is the policy of this facility to perform wound dressing changes as ordered by the physician using clean technique on all chronic or contaminated wounds. Apply new dressing after cleansing the wound per physician order.

Based on observation, interview and record review the facility failed ensure hazardous items were stored securely for one R12 resident reviewed for safety in a sample of 35.Findings Include:R12 has diagnosis not limited to Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Psychotic Disturbance, Dependence on Wheelchair, Disorder of Adult Personality and Behavior, Mood [Affective] Disorder, Cerebral Ischemia, Paranoid Personality Disorder and Altered Mental Status. R12's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 99 indicating resident is rarely/never understood. Section GG - Functional Abilities document in part: Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving (Dependent) Helper does all of the effort. R12's Care Plan Document in part: Dressing/Grooming: Focus: I have a Self-Care Deficit with impaired Dressing and Grooming abilities and I would benefit from participation in a Dressing/Grooming Restorative Nursing Program as evidenced by the following risk factors and potential contributing Diagnosis: General Weakness and/or fatigue, Impaired Strength and Endurance, Requires Limited Assist with Grooming. The Restorative Aides and/or Certified Nursing Assistant will provide my established Dressing and Grooming assistance per the goal for my Dressing and Grooming Restorative Program 6-7 days weekly. Focus: ADL'S (Activities of Daily Living): I have a Self-Care Deficit and I require assistance with ADLs to maintain the highest possible level of functioning.On 08/05/25 at 11:51 AM R12 Two disposable razors were observed in two of three plastic cups located on R12's overbed table. R12 said I usually shave myself; I have disposables. I had three disposable razors and theses are only two razors that I used. They gave the razors to me to be used. It is a disposable razor, and I need to shave. No one has ever done it, I shave myself.On 08/07/25 at 11:40 V36 (Regional Nurse Consultant) stated I don't think we have a shaving assessment for R12. Restorative may have an assessment for R12.On 08/07/25 at 12:25 PM V2 (Director of Nursing) stated disposable razors, are kept in the storage room. We have the certified nurse assistant of restorative aide assist the resident with shaving and we throw the disposable razors out afterwards. The disposable razors get dull and can cause cuts and scrapes. The residents should be assessed if they can use the razor. I have restorative on each floor they or the certified nurse assistant shave shaves the residents. I am not sure if R12 has a shaving assessment, I will have to look to see what his assessment is. If the disposable razors are left at the bedside, R12 could try to use the razors and cut himself.On 08/07/25 at 12:35 PM V36 (Regional Nurse Consultant) stated they did reassess R12 on the MDS (Minimum Data Set) Section GG (Functional Abilities). R12 is able to shave himself if he has a mirror. We don't have a shaving assessment for R12. R12 should not have razors at the bedside from a safety standpoint.On 08/07/25 at 01:00 PM V43 (licensed Practical Nurse/Restorative Nurse) stated there are no assessments for shaving. We provide the equipment and supervise when the residents are shaving. The razors are thrown in the sharp's container. I never assessed R12 myself and R12 is able to move the upper extremity. We will have to assess if R12 can shave himself. I am not aware if the residents can have the razors at the bedside. R12's certified nurse assistant should supervise him. The residents should not have razors at the bedside unless approved by the doctor or they have an order. If razors are left at the bedside there is a potential that R12 can cut himself.On 08/07/25 at 01:12 PM V43 (licensed Practical Nurse/Restorative Nurse) stated I removed the two razors and social service is educating R12.On 08/07/25 at 04:53 PM V1 (Administrator) provided a document titled Education Record dated 08/05/25 Razor Disposal Policy.Policy:Titled Guidelines for Handling Contaminated Sharps dated 08/18/23 document in part: Purpose: As part of the facility's Infection Prevention and Control Program -it is the intent of the facility to ensure that sharps -defined as objects that can penetrate a worker's skin, such as needles, razor blades or other potentially infectious materials. Contaminated Sharps: Prompt Disposal: Contaminated sharps must be disposed of in a sharp's container - immediately or as soon as feasible after use.

Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow provider orders and provide radiology services to one resident (R78) out of a total sample of 35 residents.Findings include: On 8/05/2025 at 11:20 AM, R78 stated experiencing coughing spells sometime last month. A provider evaluated R78 and ordered a chest x-ray. R78 stated facility never did it. R78's 7/14/2025 11:15 AM progress note by V32 (Nurse Practitioner) documents in part that R78 complained of chronic cough. As part of treatment plan, V32 ordered a chest x-ray. R78's ‘Order Audit Report' documents in part that V30 (Nurse) entered the two-view chest x-ray on 7/16/2025 (two days later) at 4:47 PM on behalf of V32. On 08/06/2025 at approximately 9:30 AM, V1 (Administrator) informed surveyor that there was no chest x-ray results for R78. On 08/06/2025 at 12:22 PM, V34 (Nurse) stated the nurse practitioners or doctors will communicate to the nurses if there are new orders. The providers will put the orders in the computer unless it's a verbal or telephone order. The nurses will then have to acknowledge and confirm the order in the electronic medical record. V34 stated if the nurse doesn't see the order then they can call the provider and verify whether they still want the order. V35 (Nurse) also stated that they can follow-up with V2 (Director of Nursing) or V3 (Assistant Director of Nursing) to help verify the order. On 8/06/2025 at 3:26 PM, V30 (Nurse) stated following up with V32 (Nurse Practitioner) regarding the chest x-ray on 7/16/2025. Per V30, V32 gave a verbal order to another nurse on 7/14/2025. V30 stated the nurse should have entered it in the electronic medical record but must have forgotten to do it. V32 instructed V30 to continue with the order for chest x-ray for cough and shortness of breath so V30 entered it in the computer. V30 stated calling the contracted radiology company twice to do the chest x-ray but they never did it during V30's shift so V30 endorsed it to the oncoming shift to follow-up. R78's progress note dated 7/18/2025 at 5:30 AM documents in part that R78 continued to complain of cough and was still due for the chest x-ray. R78 called emergency services for hospital evaluation. Facility's ‘Guidelines for Diagnostic Services' documents in part: It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. The facility will provide or obtain radiology and other diagnostic services to meet the needs of its residents.

Based on interview, and record review the facility failed to protect one resident (R6) from physical abuse. This failure affected 1 of 3 residents reviewed for physical abuse and caused R6 to be sent to local hospital and R6 sustaining a comminuted left intertrochanteric fracture requiring R6 to have open reduction internal fixation of the left hip fracture. Findings include: R6 has a diagnosis which include but are not limited to: Repeated falls, Alzheimer's disease, lack of coordination, abnormalities of gait and mobility, weakness, dementia, ataxic gait, unsteadiness on feet, and insomnia. R6 has a Brief Interview for Mental Status (BIMS) dated 07/10/25 with no score and indicates that R6 has memory impairments.R7 has a diagnosis which includes but are not limited to: cocaine abuse, disorientation, other disorders of the brain, cerebral infarction, cerebral ischemia, and anxiety.R7 has a Brief Interview for Mental Status (BIMS) dated 04/30/25 with a score of 6 and indicates that R6 has memory impairments. During this survey R6 was able to answer surveyor questions appropriately.The facility Initial Reportable Incident to the state agency dated 07/13/25 at 9:40 am, documents, in part: R7 allegedly made contact with R6. R6 and R7 immediately separated. Body assessment completed on R7, no injuries or pain. R6 sent to local hospital for an evaluation. Hospital reported R6 sustained left hip fracture due to fall. Physician and family notified. Police was contacted and notified. R7 was placed on one-to-one period. investigation initiated. R6's local hospital record dated 07/14/25 documents, in part: Interval Events: Plan for open reduction internal fixation left hip fracture . Imaging/Other Studies: CT (Computed Tomography) without contrast, left: Results: 07/14/25: Impression: 1: Comminuted left intertrochanteric fracture.On 07/15/25 at 11:30 am, Surveyors observed V23 (Licensed Practical Nurse, LPN) (R6 and R7's nurse on 07/13/25) leave the facility via 911 emergency due to V23 not feeling well. On 07/15/25 at 1:07 pm, V12 (R6's Family Member) stated that on 07/13/25 V12 received a phone call from V23 (LPN) stating that V23 turned away from R6 for one second and R6 was pushed by R7 onto the floor. V12 also explained that V23 informed V12 that R6 was going to the local hospital for an evaluation. V12 stated that the local hospital informed V12 that R6 sustained a left hip fracture. V12 then explained that on 07/14/25 V12 came to the facility and informed V1 (Administrator) at facility that V12 filed a police report number JJ333620 regarding R7 pushing R6 onto the floor causing R6 to sustain a left hip fracture. On 07/16/25 at 9:31 am, V1 (Administrator) informed surveyors that V23 was a admitted to the local hospital. Surveyor was not able to interview V23 for this investigation. On 07/16/25 at 9:52 am, R7 stated that a few days ago R7 was standing at the elevator when R6 kept approaching R7. R7 stated that R7 told R6 Get the F*** away from me and pushed R6 away from R7. R7 explained that R6 landed on the floor after R7 pushed R6. R7 then stated, I didn't throw her down. I pushed her. R7 then reiterated that R7 kept yelling at R6 Stay away from me and that R6 didn't. On 07/16/25 at 10:23 am, V22 (Certified Nursing Assistant, CNA) denied that V22 was assigned to R6 or R7 on 07/13/25 and does not know where V25 (CNA) and V26 (CNA) (who were assigned to R6 and R7) were located on the unit during the time of R6 and R7's incident. V22 explained that V22 believes that V25 and V26 were down the hallway gathering their belongings to leave for the day. V22 further explained that V22 was at the nurse's station on 07/13/25 during the time of the incident with R6 and R7. V22 then stated that V22 recalls R6 standing in front of R7 at the nurse's station, elevator area when R7 was telling R6 to get out of her (R7's) face. V22 further explained that R6 kept walking into R7's face when R7 turned around and put her (R7's) hand out in front of R6 making contact with R6's chest causing R6 to fall onto the floor. V22 further explained that V22 was behind the nurse's station when the incident occurred and was gathering her belongings to go home. V22 then explained that by the time she came from around the nurse's station to R6 and R7, R6 was already on the floor. V22 also explained that V23 (Licensed Practical Nurse, LPN) R6 and R7's assigned nurse was down the third-floor unit hallway still passing medications and that V24 (Registered Nurse, RN) was sitting at the nurse's station charting. V22 explained that V22 and V23 (LPN) assisted R6 off the floor. On 07/17/25 at 9:34 am V24 (Registered Nurse, RN) stated that on 07/13/25 around 6:45 am, V24 was at the nurses station charting and not paying attention to R6 and R7 at the third-floor unit elevator area in front of the nurses station. V24 explained that V22 (CNA) was informed V24 that R6 sustained a fall at the nurses station in front of the elevator. V24 stated that although V24 was at the nurses station with R6 when R6 sustained a fall, V24 denies witnessing or hearing R6 sustained a fall or hear any conversation between R6 and R7. V24 explained that V24 was not the assigned nurse for R7 or R6 and did not assist with R6's fall on 07/13/25. V24 stated that R6 is a resident that ambulates with unsteady gait and requires assistance from staff supervision. V24 explained if a resident who ambulates requires staff supervision to ambulate is not supervised, the resident can sustain a fall, elope, or encounter an argument with another resident. V24 then explained that it is important to monitor and supervise residents who walk with an unsteady gait that are high risk for falls because the resident may need assistance from staff to prevent the resident from falling. On 07/17/25 at 9:48 am V25 (CNA) stated that on 07/13/25 when R6 sustained a fall, V25 was assigned to R6, got R6 dressed around 4:30 am and R6 began walking throughout the unit. V25 explained that R6 is a resident who requires supervision from staff when she walks to prevent R6 from falling. V25 further explained that V25 is instructed to walk with R6 when she is up walking because R6 is a high risk for falls. V25 then explained that during the time of R6's fall on 07/13/25, V25 did not witness R6's fall at the nurse's station in front of the elevator and that V25 was at the nurse's station packing V25 belongings (cell phone and cell phone charger) preparing to go home. V25 explained that V25 heard a sound and observed R6 laying on the floor in front of the elevator at the nurses station and R7 standing next to R6. V25 also explained that R6's nurse was down the third-floor unit hallway preparing her cart/medications when V25 called for R6's nurse after R6 sustained a fall on 07/13/25. V25 explained that V25 and V23 (LPN) assisted R6 off the floor. V25 denies seeing R7 push R6 on 07/13/25 or recalls anything R7 said to R6 on 07/13/25.On 07/17/25 at 10:00 am, V26 (CNA) stated that V26 did not witness R6 fall on 07/13/25. V26 explained that it was the end of V26's shift around 6:45 am and V26 was at the nurses station charting waiting for the next shift of staff to arrive on the unit. V26 stated that V26 was not assigned to R6 or R7 on 07/13/25 during the time of R6 fall incident. V26 explained that V22 (CNA) informed V26 that R7 pushed R6. V26 also stated that V26 heard V23 (LPN) stating to R7 Why did you do that to R6. V26 further explained that V23 (LPN), V25 (CNA), and V22 (CNA) (who were assigned to R6 and R7) addressed the incident between R6 and R7 on 07/13/25 and that V26 went home. V26 also stated that V26 is familiar and has cared for R6 in the past. V26 stated that R6 ambulates and requires supervision from staff when walking to prevent R6 from falling.On 07/17/25 at 10:35 am, V28 (On Call Physician) (R6 physician on 07/13/25) stated that on 7/13/25 V28 received a call from the facility that staff witnessed R6 falling backwards onto R6's back area and complained of facial grimaces. V28 explained that staff informed V28 that R6 was a resident who walked with an unsteady gait and was roaming the nurses station area when R6 fell. V28 stated that residents who ambulate with and unsteady gait should be placed in a fall supervision program and supervised by staff at all times when walking to avoid the resident from falling and sustaining an injury. V28 further explained that V28 gave orders for R6 to be sent out to the local hospital for an evaluation to rule out fractures. V28 then stated that V28 was informed that R6 sustained a hip fracture due to R6 fall on 07/13/25. When V28 was asked regarding R7's aggressive behaviors, V28 explained that when staff called V28 at the time of R6's fall on 07/13/25, staff at the facility did not inform V28 regarding R7 being involved with R6's fall on 07/13/25 until right before the surveyor spoke with V28 on 07/17/25. V28 stated, If I was made aware that there was a fight, I would have ordered interventions to address R7's behaviors such as possibly ordering a mood stabilizer, placing R7 on one-to-one monitoring, and sending R7 out to the local hospital for a psychiatric evaluation. On 07/17/25 11:25 am, V2 (Director of Nursing, DON) stated that R6 is an alert, not oriented resident, who wanders throughout the unit, is high risk for falls, has had multiple fall incidents in the past and requires supervision from staff when walking. V2 explained that residents who are high risk for falls can sustain a fall if the resident is not supervised when ambulating and require staff supervision when walking to keep the resident safe. V2 stated that fall interventions in place for R6 include staff placing R6 in a wheelchair after R6 has been ambulating the unit for a while and making sure R6 is hydrated. V2 stated that V2 was not present in the facility during the time of R6 and R7's incident on 07/13/25. V2 stated that V2 was informed by staff that R7 was allegedly seen extending R7's left arm towards R6 during the time of R6's fall on 07/13/25 and that V2 was still investigating the cause of R6's fall on 07/13/25. V2 then explained that V2 instructed staff to call R6's physician regarding R6's fall incident and that R6 physician gave orders to send R6 out on 07/13/25 to the local hospital and was diagnosed with left hip fracture. When V2 was asked regarding the physicians orders/response to R7's behaviors V2 stated that V28 should have been made aware of R7's aggressive behaviors and that V2 was still conducting V2's investigation with R6 and R7's incident on 07/13/25.On 07/17/25 12:32 pm, V1 (Administrator) stated that V1 is the facility abuse coordinator. V1 explained that staff should report abuse immediately to V1 and that V1 reports allegations of abuse to the local state agency within two hours. V1 explained that on 07/13/25 V1 reported an alleged abuse regarding R6 and R7 that V1 labeled allegation of contact. V1 then explained that if a resident pushes another resident that it is considered physical abuse. V1 further explained that if physical abuse occurs in the facility the facility must protect the alleged victim and remove the alleged perpetrator. V1 stated that the facility must address and report abuse to the local state agency to assure the safety of the residents. V1 stated that V1 was still conducting V1's investigation regarding R6 and R7 on 07/13/25.R7 progress note dated 07/13/25 authored by V6 (Licensed Practical Nurse, LPN) documents in part: R7 placed on 1:1 (one-to-one) monitoring.The facility's document dated 03/26/25 through 07/16/25 and titled Incident by Incident Type show that R6 sustained a fall on 07/13/25 at the facility. R6's progress notes dated 07/13/25 at 7:59 am authored by V23 (Licensed Practical Nurse, LPN) documents in part: Writer standing at nurses station providing care to another resident and upon turning around writer heard another resident stating don't come near me and when writer turned around resident had her arm extended and resident walked into her arm and stumbled back losing balance falling on her buttocks.R6's care plan dated 06/30/25 documents in part R6 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming. R6 has problems understanding the immediate environment. Symptoms are manifested by: Attempting to leave the facility with a responsible escort (elopement). Pacing roaming or wandering in and out of peers' room. Goal: The resident will respond to staff redirection to re-direct attention from a potentially problematic situation (such as elopement or entering a peers' s room) when any difficult behavior occurs. Interventions: Staff will encourage R6 to sit and take breaks. ADL's (Activities of Daily Living): R6 has a Self-Care Deficit and R6 require assistance with ADLs to maintain the highest possible level of functioning . Interventions: Ambulation: I usually require supervision and set-up support for Walking (Verbal Cures and set-up assistance): Locomotion on Unit I usually require supervision and set-up support for Locomotion on Unit: Provide frequent rest periods as indicated . Falls: R6 is at risk for falls as evidence by the following risk factors and potential contributing diagnosis: Dementia, Alzheimer's Disease: Interventions: 05/27 increase supervision, provide structured supervision discussed with therapy continued skilled Therapy: Provide me with activities that minimize the potential for falls while providing diversion and distractions.The facility's document dated 01/2019 and titled Abuse Prevention Program documents, in part: Policy it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and crime against a resident in the facility. The following procedure shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a third party . If you suspect abuse: separate the alleged perpetrator and assure all residents safety . for the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: 1. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm . 4. Physical Abuse: hitting, slapping, pinching, kicking, etcetera it also includes controlling behavior through corporal punishment.

Based on interview, and record review, the facility failed to provide adequate supervision for a resident (R6) at risk for falls and failed to ensure that a resident (R6) at risk for falls does not have repeated falls. These failures affected 1 of 3 residents, reviewed for falls and fall prevention interventions, caused R6 to be sent to local hospital and R6 sustaining a comminuted left intertrochanteric fracture requiring R6 to have open reduction internal fixation of the left hip fracture.Findings include:R6 has a diagnosis which include but are not limited to: Repeated falls, Alzheimer's disease, lack of coordination, abnormalities of gait and mobility, weakness, dementia, ataxic gait, unsteadiness on feet, and insomnia. R6 has a Brief Interview for Mental Status (BIMS) dated 07/10/25 with no score and indicates that R6 has memory impairments.R6 [NAME] Data Set (MDS) dated [DATE] shows that R6 requires supervision or touching assistance for walking. The facility's document dated 03/26/25 through 07/16/25 and titled Incident by Incident Type show that R6 sustained falls on 05/08/25, 05/20/25, 05/25/25, 05/27/25 and 07/13/25 at the facility.R6 Fall Risk Reviews dated 07/13/25, 06/09/25, 05/27/25, 05/26/25, indicate that R6 is high risk for falls.R6's local hospital record dated 07/14/25 documents, in part: Imaging/Other Studies: CT (Computed Tomography) without contrast, left: Results: 07/14/25: Impression: 1: Comminuted left intertrochanteric fracture.On 07/17/25 at 9:34 am V24 (Registered Nurse, RN) stated that on 07/13/25 around 6:45 am, V24 was at the nurse's station charting and not paying attention to R6 when V24 was informed by V22 (Certified Nursing Assistant, CNA) that R6 sustained a fall at the nurse's station near the elevator. V24 denies witnessing or hearing R6 fall when R6 sustained a fall. V24 stated that although V24 was at the nurse's station with R6 when R6 sustained a fall, V24 was not the assigned nurse for R6 and did not assist with R6's fall on 07/13/25. V24 stated that R6 is a resident that ambulates with unsteady gait and requires assistance from staff supervision when ambulating. V24 explained if a resident who ambulates requires staff supervision is not supervised the resident can sustain a fall, elope, or encounter an argument with another resident. V24 then explained that it is important to monitor residents who walk with an unsteady gait because the resident may need assistance from staff to prevent the resident from falling. On 07/17/25 at 9:48 am V25 (Certified Nurse's Assistant/CNA) stated that on 07/13/25 when R6 sustained a fall, V25 was assigned to R6 and got R6 dressed around 4:30 am and R6 began walking throughout the unit. V25 explained that R6 is a resident who requires supervision from staff when she walks. V25 further explained that V25 is instructed to walk with R6 when she is up walking because R6 is a high risk for falls. V25 explained that during the time of R6's fall on 07/13/25 V25 did not witness R6 fall at the nurse's station near the elevator and that V25 was at the nurse's station packing V25's belongings (cell phone and cell phone charger) preparing to go home. V25 explained that V25 heard a sound and observed R6 laying on the floor in front of the elevator at the nurse's station and R7 standing next to R6. V25 also explained that V23 (Licensed Practical Nurse/LPN) (R6's nurse) was down the third-floor unit hallway preparing her cart/medications when V25 called for V23 to assist after R6's fall. V25 explained that V25 and V23 (Licensed Practical Nurse, LPN) assisted R6 off the floor. On 07/17/25 at 10:00 am, V26 (CNA) stated that V26 did not witness R6 fall on 07/13/25. V26 explained that it was the end of V26's shift and V26 was at the nurse's station charting waiting for the next shift staff to arrive. V26 stated that V26 was not assigned to R6 or R7 on 07/13/25 during the time of R6's fall incident. V26 explained that V22 (CNA) informed V26 that R7 pushed R6. V26 also stated that V26 heard V23 (LPN) stating to R7 Why did you do that to R6. V26 explained that the V23 (LPN), V25, and V22 (who were assigned to R6 and R7) addressed the situation. V26 stated that V26 is familiar and has cared for R6 in the past. V26 stated that R6 ambulates and requires supervision when walking to prevent R6 from falling.On 07/17/25 at 10:35 am V28 (On Call Physician) (R6 physician on 07/13/25, R6 last fall) stated that on 7/13/25 V28 received a call from the facility that staff witness R6 falling backwards onto R6's back area and complained of facial grimaces. V28 explained that staff informed V28 that R6 was a resident who walked with an unsteady gait and was roaming the nurses station area when R6 fell. V28 stated that residents who ambulate with and unsteady gait should be placed in a fall supervision program and supervised by staff at all times when walking to avoid the resident from falling and sustaining an injury. V28 also stated that V28 was informed that R6 ‘s evaluation at the local hospital showed that R6 sustained a hip fracture due to R6 fall on 07/13/25.On 07/17/25 11:25 am, V2 (Director of Nursing, DON) stated that R6 is an alert not alert resident, who wanders throughout the unit, is high risk for falls, has had multiple fall incidents in the past and requires supervision from staff when walking. V2 explained that residents who are high risk for falls can sustain a fall if the resident is not supervised when ambulating and require staff supervision when walking to keep the resident safe. V2 stated that fall interventions in place for R6 include staff placing R6 in a wheelchair after R6 has been ambulating the unit for a while and making sure R6 is hydrated. The facility's undated policy titled Incident/Accidents/Falls documents, in part: Policy: It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management . The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated, and resolved. The facility will create a data base related to incidents/accidents as part of the QAPI (Quality Assurance Performance Improvement) process to enable trending and tracking. This information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible.

Based on interview and record review, the facility failed to follow their policy to ensure residents were free from abuse by one staff member being physically abusive towards two residents ( R104, R119) out of five residents reviewed for abuse in a sample of 28. This failure resulted in the residents experiencing emotional trauma/fear and anxiety. Findings include: 1. According to R119's facesheet printed 7/11/24, R119 is [AGE] years old with diagnoses that include but are not limited to unilateral primary osteoarthritis, right and left knee; venous insufficiency; need for assistance with personal care. According to R119's MDS (Minimum Data Set), 6/3/24, R119 has a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition. R119's care plan initiated 2/13/24 reads in part: R119 is an adult living with chronic health conditions and comorbidities that include orthopedic aftercare, unsteadiness on feet, gait and mobility issues, anxiety; that requires the support, services and structure of this care setting to maintain stability and highest practicable level of functioning. Facility Reported Incidents, 7/10/24, reads in part: Resident (R119) alleges that employee (V11/Certified Nursing Assistant-CNA)) displayed inappropriate behavior. V11 Employee Disciplinary Action Form, 7/10/24, reads in part: Suspended pending investigation. On 7/10/24 at 1:30 PM, R120 (husband of and roommate of R119) said R119 was in bed and he (R120) was in the wheelchair near his bed. R120 said, V11 came into the room looking mean. V11 had a mad face. R120 said, R119 and I felt vulnerable and we could see V11 was not in a good mood. V11 let the head of the bed up to take off R119's gown. R119 was reaching behind untying the gown. V11 was standing with hand on hip looking at R119. R119 was taking time because she had eyeglasses on. R119 was not able to untie the gown and was pulling the gown over her head when V11 said, you're not going fast enough. V11 then grabbed the gown and yanked it off R119's head. R119 said to V11, watch it you're going to break my glasses. R120 stated he said to V11 be careful. Then V11 said to R119 I can't break your glasses. After V11 yanked the gown over R119's head R119's eyeglasses were skew on R119's nose. V11 threw the gown in R119's face. By the look on R119's face, R119 was distressed by what happened. R120 said, It made me feel scared of V11. I'm in a wheelchair and V11 is big and solid. I felt like I failed as a fiance because I was not able to protect R119. I was worried about V11 hitting R119 and me. R119 said, I was full of stress, and it made me distressed. R120 said V11 was the kind of person you never knew what kind of mood V11 would be in. R119 would ask the morning shift who would be R119's CNA for the evening. Knowing V11 would be the CNA made R119 nervous because V11 was frequently rough with R119. R119 said I'm nervous when I have V11 because I don't know what's going to happen. R120 said R120 and R119 did not report to the facility because V11 had been rough in the past and we would just not let V11 back in the room. I would go to the head nurse and request someone else. 2. According to R104's facesheet printed 7/11/24, R104 is [AGE] years old and have diagnoses that include but are not limited to atrial fibrillation, morbid (severe) obesity due to excess calories, atherosclerotic heart disease of native coronary artery, hypertensive heart disease with heart failure, need for assistance with personal care. According to R104 MDS, 5/22/24, R104 has a BIMS score of 14, indicating intact cognition. R104's care plan initiated 7/11/24 reads in part: R104 is an adult living with chronic health conditions and comorbidities that requires the support, services and structure of this care setting to maintain stability and highest practicable level of functioning. Facility Reported Incidents, 7/10/24, reads in part: R1 (now R104) alleged that the employee (V11) displayed inappropriate behavior a few months ago. V11 Employee Disciplinary Action Form, 7/10/24, reads in part: Suspended pending investigation. 7/10/24 at 2:06 PM, R104 said V11 was changing me and wanted to move my legs toward the center of the bed. V11 grabbed my legs to aggressively and twisted my left leg. I yelled ouch and V11 backed off. In general, V11 is rough. It's annoying. I did not report because I didn't consider it to be serious. I did mention it in casual conversation with another CNA (R104 did not want to give the name of the CNA). 7/11/24 at 1:06 PM, V24 (Registered Nurse) stated I have worked with V11 before. I have not had a problem with V11. 7/11/24 at 4:55 PM, V29 (Licensed Practical Nurse) stated I have worked with V11. I have not had complaints about V11. 7/11/24 at 5:17 PM, V30 (Certified Nursing Assistant) stated I have worked with V11 before. V11 does V11's job. On 7/11/24 at 6:30 PM, V2 (Director of Nursing) said, I am head of the team while the administrator is on vacation. The facility does abuse training, upon hire and as needed. Every employee gets abuse training. The Administrator is the Abuse Coordinator. If there is an allegation of abuse, investigation starts right away. First goal is to keep the resident safe. Report to the Abuse Coordinator. Do a head-to-toe assessment, assess distress, notify physician, and family. If staff is involved the staff is suspended immediately pending investigation. V11 was suspended right away after being notified of the allegations. V11 was suspended for the allegations of abuse by three different residents, involving three different situations. The facility reported all incidences to State Agency and facility investigated allegations. Psychological, emotional, physical, sexual, verbal, involuntary seclusion, neglect, exploitation, financial, misappropriation of resident property, injury of unknow origin are forms of abuse. V11's natural personality is to be strong, V11 is not friendly and bubbly. V11 should be thoroughly educated on customer service when taking care of patients. Throwing a gown at a resident, pushing a resident down, twisting a resident's leg, telling a resident they are useless and will die soon is abuse. 7/12/24 at 10:28 AM and 1:20 PM attempted to call V11 (CNA) there was no answer, unable to leave message due to mail box full and cannot except messages at this time. 7/12/24 at 11:30 AM, contacted V2 (DON) to contact V11 for phone interview but did not receive a response or call from V11. Facility Abuse Prevention Program, 3/1/21, documents in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview and record review the facility failed to document timely skin assessments upon readmission, failed to ensure that skin assessments were accurate, failed to provide timely incontinence care to prevent MASD (Moisture Associated Skin Damage), and failed to ensure that a wound was offloaded to prevent further decline for one of four residents (R2) reviewed for pressure ulcers. R2 sustained MASD, right buttock skin shearing and a (stage 3) sacrum pressure ulcer - with necrotic tissue (at the facility) which required surgical debridement. The facility also failed to document timely skin assessments upon readmission and failed to ensure that treatment orders were obtained and/or administered to R1 on readmission. On [DATE], R1 sustained an (unstageable) sacrum pressure ulcer which was 100% necrotic with purulent/odorous drainage. Findings include: 1. R2's diagnoses include dementia, type 2 diabetes mellitus, pressure ulcer right heel, and urinary incontinence. R2's ([DATE]) BIMS (Brief Interview Mental Status) determined a score of 1 (severe impairment). R2's ([DATE]) functional assessment affirms maximal assistance is required for toilet hygiene. R2's ([DATE]) care plan states resident is at increased risk for alteration in skin integrity related to impaired cognition, diabetes and comorbidities. Skin will be checked during routine care on a daily basis. R2's body check sheets were documented (,d+[DATE]) nothing is marked on the body however on ,d+[DATE] redness is documented and the right buttock is circled. R2's POS (Physician Order Sheets) include ([DATE]) Zinc Oxide Ointment 10%, apply to buttock every day and evening shift. Indications for use: incontinent moisture association skin damage. R2's ([DATE]) weekly skin check states does resident have loss of skin integrity? No. [MASD was identified the day prior]. R2's ([DATE]) wound evaluation includes sacrum MASD. Length 13.0 x 10.0 x 0.0cm (centimeters). Exudate: serous. Amount: small/minimal. Tissue Type: Granulation 100%. Wound Color: Pink, Red. Wound Margins: Undefined. Surrounding Tissue: Color changes: reddish skin tone, maceration. However, R2's ([DATE]) Physician Orders (obtained the same day) affirm Medihoney and Calcium Alginate were ordered for pressure ulcer of sacral region (stage 3). R2's ([DATE]) physician wound assessment states resident sustained a skin injury (skin tear/shearing) on buttock. Recommend that patient limit chair time (not to exceed 1 hour at a time). Sacrum wound 30% thick adhered devitalized necrotic tissue. A curette was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed. On [DATE] at approximately 11:52am, surveyor inquired about R2's cognitive status. V5 (Licensed Practical Nurse) stated, She's confused. Surveyor inquired if R2 has any pressure ulcers. V5 responded, She has sacral area. On [DATE] at 2:07pm, R2 was observed sitting in a wheelchair. Surveyor inquired if R2 has any wounds. V7 (Certified Nursing Assistant) stated, She has wounds right here on her bone and pointed to her sacrum. V7 removed R2's incontinence brief (as requested) which was dry however (2) 4x4 inch dressings on R2's sacrum and right buttock were noted to be completely saturated with serosanguinous drainage (observed through the dressing). V8 (Wound Care Coordinator) subsequently removed R2's dressings (as requested) a large skin integrity impairment was observed on R2's sacrum and right buttock (which appeared sheared). Surveyor inquired about R2's wounds. V8 stated, She got MAS (Moisture Associated Skin), she came back like this from the hospital when she left (facility) it was redness [R2's treatment orders - for MASD were received by the facility [DATE], 2 days prior to [DATE] hospital transfer]. Surveyor inquired why R2 was up in a chair sitting on her buttock/sacrum which causes pressure. V8 replied, She can be up like to 2 hours. R2's progress notes include ([DATE]) 6:58pm, readmitting resident from hospital [Skin assessment is excluded]. ([DATE]) 11:46am (roughly 17 hours after admission) open skin on sacral area measuring 13.0 x 10.0 x 0.0cm (centimeters). On [DATE] at 2:40pm, surveyor inquired what causes MASD. V12 (Medical Director) stated, If someone doesn't change the diaper often enough, usually it's from urine. Surveyor inquired if MASD is unilateral. V12 responded, Usually it would be on both sides. Surveyor inquired how a resident develops a skin integrity impairment on only one buttock. V12 replied, It's like a pressure ulcer, she's not getting up and not getting repositioned often enough. 2. On [DATE], IDPH (Illinois Department of Public Health) received allegations that R1 was sent to the emergency room and found to have severe infected wounds on the spine (to the bone) and heels. R1 expired [DATE] (per complainant). R1's diagnoses include but not limited to dementia, peripheral vascular disease, severe protein-calorie malnutrition, and unstageable sacrum pressure ulcer. R1's ([DATE]) BIMS (Brief Interview Mental Status) affirms resident is rarely/never understood. Cognitive skills for daily decision making are severely impaired. R1's ([DATE]) functional assessment affirms (2 persons) physical assist is required for bed mobility and toilet use. On [DATE] at 2:20pm, surveyor inquired about R1's functional status. V8 (Wound Care Coordinator) stated, I believe he (R1) was bed bound. Surveyor inquired about R1's current location. V8 responded, He (R1) passed and affirmed he expired. Surveyor inquired about R1's wounds V8 replied He (R1) acquired wounds at the hospital, he came back with a wound on the sacrum. Surveyor inquired what the facility implemented for R1's wounds V8 stated After the assessment, I call the doctor, get orders, and put him on the list to be seen by the doctor. Surveyor inquired if R1 was compliant with treatments V8 responded As far as wound care, yes. Surveyor requested R1's (initial) wound assessments and (most current) wound assessments during this survey. The census affirms R1 was readmitted (from the hospital) on [DATE]. R1's ([DATE]) initial wound assessment includes (right heel) pressure injury (unstageable), identified [DATE]. (Sacrum) pressure injury (unstageable), identified [DATE]. Exudate: serous. Odor: not present. [R1's assessments were documented 4 days after readmission]. The census affirms R1 was also readmitted (from the hospital) on [DATE]. R1's ([DATE]) Treatment Administration Record affirms from [DATE]-[DATE] (4 days) treatment orders and/or administration are excluded. R1's ([DATE]) wound assessment includes (right heel) pressure injury (unstageable). (Sacrum) pressure injury (unstageable). Exudate: seropurulent. Odor: foul. 100% necrotic. [Purulent/odorous exudate affirms R1's sacrum wound was likely infected}. The ([DATE]) guidelines for prevention/treatment of pressure injuries states immobility can play a large role in the causing pressure injuries. Tissue closest to the bone may be the first tissue to undergo changes related to pressure. PU/PIs are usually located over a bony prominence, such as the sacrum. Turn and reposition resident who are at risk for pressure injury often unless contraindicated. At least every 2 hours is recommended. Shearing occurs when layers of skin rub against each other when the skin remains stationary, and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. If upon any assessment an actual pressure ulcer/pressure injury is found immediate steps will be taken to ensure that notifications to the physician are made. Also, to ensure that a treatment is in place as well as any appropriate interventions related to area(s). Both urine and feces contain substances that may irritate the epidermis and make the skin more vulnerable to break-down and moisture related skin damage. Irritation and maceration resulting from prolonged exposure to urine and feces may hasten skin breakdown, and moisture may make skin more susceptible to damage from friction and shear during positioning. The first signs of infection may be a delay in healing and an increase in exudate. Signs may include the following: changes in the characteristics of any exudate. Abnormal odor.

Based upon observation, interview and record review the facility failed to ensure that staff are aware of how to transfer residents (from chair to bed) safely, failed to implement fall prevention interventions, and failed to provide supervision for one of three residents (R2) reviewed for falls. These failures resulted in R2 sustaining a fall (10/29/23) and forehead laceration which required suture repair. Findings include: The fall log affirms that R2 fell on [DATE], 10/20/23, and 10/29/23. R2's diagnoses include dementia, restlessness, and agitation. R2's (10/3/23) BIMS (Brief Interview Mental Status) determined a score of 1 (severe impairment). R2's (10/3/23) functional assessment affirms moderate assistance is required for sit to stand and chair/bed to chair transfer. R2's care plan states (9/27/23) Resident is at risk for falls as evidenced by cognitive impairment, decreased strength and endurance. Interventions: If resident is awake upon rounds offer to assist resident up to wheelchair and bring to Nurse's station. Resident will join morning and afternoon activities. Intervention: I would like staff to provide me transfer devices as applicable. (10/31/23) Resident has an alteration in skin on her left side of forehead. Laceration with three sutures. R2's (10/29/23) incident report states resident noted sitting on her wheelchair by the nurse's station awake and alert. During afternoon medication pass saw her walking and about to fall but it happened too fast for intervention. Resident noted with skin alteration to left side of forehead. Predisposing factors: confused, impaired memory, decreased strength and endurance. Resident is confused as per baseline. Uses a wheelchair with x1 staff assist for locomotion. R2's (10/29/23) initial FRI (Facility Reported Incident) states resident noted laying on the floor on her left side. 911 was called for immediate transfer. Resident received 3 sutures. On 11/16/23 at 11:11am, surveyor inquired about R2's (10/29/23) fall. V9 (CNA/Certified Nursing Assistant) stated, I was at the nurse's station in my POC (electronic medical records) by the time I raised my head and heard somebody say hey stop it she (R2) went down, she was on the floor. Surveyor inquired about R2's fall prevention interventions. V9 responded, We did do one on one some days, but that day we put her at the nurse's station so we can see her, but we couldn't get there that fast. On 11/16/23 at 11:24am, surveyor inquired about R2's (10/29/23) fall. V10 (LPN/Licensed Practical Nurse) stated, because she is a fall risk, we put her at the nurse's station so we can monitor. While I was talking to the nurse practitioner on the phone (behind nurse station), she (R2) stood up and took like 2 or 3 steps, but I couldn't get there on time to intervene. We (staff) tried to stop the bleeding and called 911 immediately. She (R2) hit her head on the floor. On the left side she (R2) had a cut on her head, a laceration I would say. Surveyor inquired about R2's fall prevention interventions. V10 responded, what I know so far is we put her (R2) by the Nurse station to observe from time to time. On 11/14/23 at 1:43am, R2 (and 4 other residents) were observed (unsupervised) in the dining room. V3 (Activities) subsequently entered the dining room, surveyor inquired why the residents were unsupervised in the dining room. V3 stated, We start at 2:00pm, so I have to prepare. On 11/14/23 at approximately 1:47pm, V4 (LPN/Licensed Practical Nurse) entered the dining room. Surveyor inquired why R2 was left unattended - in the dining room. V4 stated, I have to check with one of the Nurses. Surveyor inquired about R2's fall prevention interventions. V4 responded, She (R2) needs to be monitored. On 11/14/23 at approximately 1:52pm, surveyor inquired about R2's cognitive and functional status. V5 (LPN) stated, She's confused. She (R2) used to walk like 2 months ago but after the fall incident she stopped walking. Surveyor inquired about R2's fall prevention interventions. V5 responded, The bed should be in the lowest position, call light within reach and we put her by the Nurse station so we can watch. Surveyor inquired about R2's current location. V5 stated, She's in the dining room now. On 11/14/23 at 2:07pm, V6 (CNA) attempted to transfer R2 from the wheelchair to the bed (by herself) however R2 was unable to stand therefore assistance was requested. V6 and V7 (CNA) subsequently transferred R2 to the bed without a gait belt. R2 was unable to plant her feet on the ground and/or stand during transfer therefore V6 grabbed the back of R2's pants to prevent her from falling. V7 was noted to be wearing a gait belt around her (V7) waist. Surveyor inquired why R2 was transferred without a gait belt. V7 stated, Usually she could walk, and I wasn't at a good angle to use it. On 11/16/23 at 2:40pm, surveyor inquired about potential harm to a resident that falls from a standing position and hits their head. V12 (Medical Director) stated, They can get a subdural hematoma. The (undated) transfer belts/gait belts policy states a gait belt is used as indicated for safety by the person qualified to transfer the resident. The resident is transferred by grasping the secured gait belt to provide stability and balance during movement. The (undated) incidents/accidents/falls policy states the facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated, and resolved.

Based on observation, interview and record review, the facility failed to protect and prevent the physical assault of one (R2) of three residents reviewed for physical assault. This failure resulted in R3 punching and kicking R2; R2 required treatment at local hospital. Findings include: Facility's final incident report (06/20/2022) documents, under Brief Description of Incident: Was reported to Administrator that resident (R3) made physical contact with (R2). R2's medical record (Face Sheet) documents R2 is a [AGE] year-old, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set of 04/12/2022) documents R2 is cognitively intact and has no behaviors. 07/06/2022 at 1:13 PM, R2 said, on Father's Day, 06/19/2022, R3 came up behind R2, picked up a chair and said: I'm going to hit you. R3 put the chair down then punched me right here (pointing to right eye). R2 said both black eyes are a result of being punched by R3. R2 also said they had to go to the Emergency Department and received sutures as a result of the assault by R3. Old bruising was noted below both of R2's eyes and the nose appeared bruised. R3 said a Smoking Monitor witnessed the incident. I'm supposed to be safe here. Writer asked R2 if they felt safe in the facility, R2 said no. R2 said a Smoking Monitor witnessed the incident. 06/19/2022, R2's Emergency Department discharge instructions document in part: Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Physical Assault -Closed head injury -Laceration of left eyebrow -Rib contusion, left R2's Hospital discharge instructions: -Continue to use ice on the face and ribs -Wound check in 2 days, suture removal in 5 days On 07/06/2022 4:03 PM, V7 (Smoking Monitor) said they were present during the altercation involving R2 and R3. V7 said, This is how it started. R3 was already drunk, yes R3 was really, really drunk. It was time for them to go out to smoke. R2 was sitting in the break room with us (space near the smoking patio). R3's girlfriend, R4, was in the break room too. R2 walked by, touched R4 lightly on the shoulder and said, 'Hey R4.' R3 heard R2 talk to R4. R3 said, 'Don't you speak to my f****** girlfriend. You don't you speak or touch my girlfriend R3 followed R2 and said: 'I'll whoop you're a**.' R3 picked up a chair, that's when I grabbed the chair and said R3 don't you hit R2 with that chair, you could hurt R2. R3 went towards R2 and started throwing punches and making contact. R2 fell to the floor and R3 was kicking R2. R2 had two black eyes, R2's nose was bleeding; there was a cut to side of R2's right eye. It took a lot of us to pull R3 off R2. V7 described R3 as big, muscular, and strong. 07/06/2022 at 4:26 PM, V8 (Smoking Monitor) said, I was working the day of the incident between R3 and R2. R3 turned around and started to hit R2. We (V7 and I) tried to stop R3. R3 was drunk. R3 carried the chair to hit R2. R3 wanted to kill that guy (R2). R3 was kicking R2 while R2 was down on the floor. R3 was the aggressor; R2 didn't do anything. R2 said: R3, you are my friend, you can't do this. R3's alcohol urine test (collected 06/19/2022, received 06/20/2022, reported 06/22/2022) documents R3's alcohol urine level as 143.2 mg/dl; reference range: 0.0-10.0. Level is flagged as critical result.

Based on observation, interview and record review, the facility failed to follow their policy to prevent and monitor a resident that acquired in the facility an initially assessed stage III pressure ulcer and failed to document in treatment administration record that, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1 acquiring a facility acquired stage III pressure ulcer upon discovery. Findings Include: On 06/28/2022 at 10:58 AM, surveyor observed R2's sacral wound. Wound dressing was not dated. Wound had a large area with 3 parts, raw and has slough on the upper part of the wound with moderate amount of serosanguinous drainage. On 06/28/2022 at 11:00 AM, V3 (Registered Nurse) stated that to prevent worsening of a wound, the nurses are expected to turn and reposition the residents, use barrier cream, empty R2's ostomy bag frequently because his stool is liquid so it can leak, give him supplemental nutrition and encourage him to eat lunch to gain wait. When she (V3) found the wound on R2, she submitted an incident report for the wound nurse to check on R2. When R2 was admitted , he had a slight redness discoloration on his coccyx area. V3 stated she submitted the incident for the wound nurse on 6/1/2022. On 06/28/2022 at 11:27 AM, V4 (Wound Doctor) stated that on 06/07/2022 R2's wound had a measurement of 8cm width, 10 cm length. The sacral wound was staged as unstageable. V4 stated R2 refused treatment. I was going to do a physical debridement but R2 refused. V4 stated, On 06/14/2022, we started a chemical debridement. There was barely any improvement from that. On 06/14/2022 R2's sacral wound was staged as Stage III. There was no improvement of the wound. On 06/28/2022 at 12:34 PM, V8 (Wound Nurse/Licensed Practical Nurse) stated that R2's wound was discovered on 6/2/2022. V8 stated that the wound was staged at a Stage III. Currently the wound has not improved and stayed the same from discovery. The dressing is ordered to be changed daily. V8 stated that Santyl is the treatment medication used on the wound for R2. V3 stated that during initial assessment upon admission, R2 had a discoloration that had opened up later. V8 stated that R2's Stage III pressure ulcer was acquired in the facility. There is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The expectation for nurses at the facility is to follow physician orders. V8 stated that she usually is the one who completes the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident's treatment administration record is not documented, that means the treatment was not done. Director of Nursing and Associate Director of Nursing are doing the inventory of appropriate treatments progress. [MEDICATION(S)] is the generic name for Santyl. V8 stated that she worked 6/21/2022 and 6/25/2022 and is not sure why R2's treatment administration record is not signed. On 06/28/2022 at 1:00 PM, V6 (Director of Nursing) stated she won't be able to verify that treatment was done. She stated that the nurse should know that when the wound nurse is not available, they are expected to do the wound treatments. V6 stated that she assigned nurses for the weekend when the wound care nurse is not around, so they should do the treatments. She stated that when treatment administration record is not signed, that means the nurses did not do the treatment. V6 also stated, As a nurse, Stage III pressure ulcer does not happen overnight. V6 stated she doesn't know why the wound was discovered as a stage III. Lastly V6 stated that R2's sacral wound was a facility acquired Stage III when discovered. R2's Facesheet documents in part: admitted - 5/5/2022. R2's weekly skin check (6/2/2022) documents in part: Resident does have loss of skin integrity. Resident has a new loss of skin integrity. R2's Weekly Wound Evaluation (6/2/2022) documents in part: Stage III is when there is full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling. Site: Coccyx, Type: Pressure injury: In-house acquired, Pressure ulcer stage: Stage III. Length: 10.0 cm, Width: 9.0 cm, Depth: 0.1 cm. Serosanguineous drainage. 50% Slough, Surrounding tissue: [CONDITION(S)]. R2's Weekly Wound Evaluation (6/8/2022) documents in part: Site: Coccyx, Type: Pressure injury: In-house acquired, Pressure ulcer stage: Unstageable. Length: 10.0 cm, Width: 9.0 cm. Serosanguineous drainage. 50% Slough, 30% Necrotic. Surrounding tissue: [CONDITION(S)]. R2's Weekly Wound Evaluation (6/14/2022) documents in part: Site: Coccyx, Type: Pressure injury: In-house acquired, Pressure ulcer stage: Unstageable. Length: 10.0 cm, Width: 9.0 cm. Serosanguineous drainage. Surrounding tissue: [CONDITION(S)]. R2's Care Plan (6/23/2022) documents in part: The resident has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues. Sacrum. Scrotum, Right heel, left heel. left calf, left ischium. Precautions for prevention of Pressure Ulcers will be completed: good peri care and drying of the skin, Apply protective barrier cream, Reposition resident frequently. When in bed/chair/geri chair and/or W/C, Off load heels PRN, CNA shower and skin observations to be reported to nurse for any unusual findings or changes in the resident's skin integrity. Administer Wound Care (Treatments) per MD orders (See POS/TAR for current orders). Weekly measurements and documentation. R2's Active Orders on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Clean with Normal Saline, apply Santyl (Collagenases) to sacrum, scrotum topically everyday shift for wound care related to pressure ulcer of right buttock and cover with dry dressing. R2's Treatment Administration Record for June 2022 documents in part: [MEDICATION(S)] Ointment 250 UNIT/GM, apply to coccyx topically everyday shift for wound care related to pressure ulcer of right buttocks. Clean with NSS, apply Santyl ([MEDICATION(S)]) and cover with dry dressing -Start Date- 06/02/2022. No signed documentation for Sunday June 5th, 2022. R2's Treatment Administration Record for June 2022 documents in part: [MEDICATION(S)] Ointment 250 UNIT/GM, apply to coccyx topically everyday shift for wound care related to pressure ulcer of right buttocks. Clean with NSS apply Santyl ([MEDICATION(S)]) and cover with dry dressing -Start Date- 06/07/2022. No signed documentation of treatment administration of sacrum on Sunday June 12th, 2022, Monday June 13th, 2022, Sunday June 19th, 2022, Monday June 20th, 2022, Sunday June 26th, 2022, and Monday June 27th, 2022. R2's Wound Evaluation and Management Summary signed by V4 (Wound Doctor) on 6/7/2022 documents in part: Unstageable (Due to Necrosis) Sacrum full thickness. Etiology: Pressure. Wound size (L x W x D): 8 cm x 10cm x Not measurable cm. Treatment: Santyl with gauze dressing complete once daily. R2's Wound Evaluation and Management Summary signed by V4 (wound Doctor) on 6/14/2022 documents in part: Stage 3 Pressure Wound Sacrum Full Thickness. Etiology: Pressure. Wound size (L x W x D): 8 cm x 10cm x Not measurable cm. Treatment: Santyl with gauze dressing complete once daily. Facility's Pressure Injury Prevention Policy (05/2017) documents in part: It is the policy of this facility to implement measures to protect the resident's skin integrity and prevent skin breakdown whenever possible. The purpose of this policy is to establish and provide consistent measures for the prevention of pressure injuries based upon the assessment of pressure injury risk. This facility will implement interventions based upon the results of the risk assessment. Facility's Preventative Skin Care policy documents in part: It is the intent of the facility that the facility provide preventative skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well groomed and free from pressure sores.

Based on interview and record review the facility failed to safely transfer 1 of 4 (R9) residents in accordance with the residents' individualized care plan. This failure resulted in R9 suffering a traumatic Left lateral femoral condyle fracture. Findings Include: R9 has diagnosis not limited to Major Depressive Disorder, [CONDITION(S)], Anxiety Disorder, Reduced Mobility, Need for Assistance with Personal Care, History of Falling, Spinal Stenosis, Cervical Region, [CONDITION(S)], Lack of Coordination, Unsteadiness on Feet, Cervical Disc Displacement, High Cervical Region and Muscle Weakness. R9's MDS (Minimum Data Set) BIMS (Brief Interview For Mental Status) score is 13 indicating intact cognitive response. On 12/15/21 at 11:55 AM V16 (Certified Nurse Assistant) stated there was a time my coworker called me to help in room 314 with R9 and I went there to help to care for R9. V20 (Certified Nurse Assistant), V6 (Certified Nurse Assistant) and I (V16) went there to transfer R9 from the wheelchair to the bed. R9 was in the wheelchair and asked us to help her (R9) to bed because she (R9) could not sit there any longer. V20 (Certified Nurse Assistant) said to R9 hold onto my V16 neck. The bed was level, R9's feet did not rest on the floor, I lifted R9 and R9 held me on my neck. I was a little close to R9 then I turned and put R9 on the bed. There is a sign behind the bed of every resident that shows how to transfer the resident, but that sign was not there. V20 (Certified Nurse Assistant) was explaining to R9 how we can do the transfer and V6 (Certified Nurse Assistant) put R9's feet on the bed. When R9 sat on the bed that is when the assistance from V6 (Certified Nurse Assistant) and V20 (Certified Nurse Assistant) was available to me. The facility policy is to put how to transfer the resident behind every bed. The other place to find the transfer information is in the care plan. The next day I was called and told not to come to work. V20 (Certified Nurse Assistant) and I were suspended. I was not aware R9's leg was fractured. They told me the complaint from R9 was R9 said her (R9) leg was broken. I received the transfer of the resident in-service. On 12/15/21 at 12:43 PM R9 stated, V6 (Certified Nurse Assistant), V20 (Certified Nurse Assistant) and V16 (Certified Nurse Assistant) came to transfer me to the bed. V16 (Certified Nurse Assistant) was not my (Certified Nurse Assistant). V20 (Certified Nurse Assistant) had V16 (Certified Nurse Assistant) come in here and said if I (R9) don't let V16 (Certified Nurse Assistant) pick me (R9) up you (R9) are not going to get out of the chair. V20 said V16 (Certified Nurse Assistant) is going to pick you (R9) up and V16 (Certified Nurse Assistant) has been doing this a long time. When I (R9) let V16 (Certified Nurse Assistant) pick me up out of the wheelchair my legs did not clear the bed and my left leg twisted. My knee went back and started swelling. It was painful and I said you are hurting my knee. V16 (Certified Nurse Assistant) was transferring me (R9) by himself without a gait belt. The other Certified Nurse Assistants were not trying to help V16 and V16 could have dropped me. I have a fear of people messing with me now. I went to the hospital on 05/20/21 and was told my left knee was fractured. They have been putting a pain patch on my knee. On 12/16/21 at 8:58 AM V21 (Restorative Director) stated R9 was a two person assist where R9 could stand and pivot. R9 has never been less than a 2 person assist with transfers. R9 was assessed as a two person assist because R9 was weak and R9's balance was unsteady. If a person is assessed as a two person assist and is not transferred as a two person assist there is a possibility for a fall or possible injury. On 12/16/21 at 09:14 AM V22 (Rehab Aide) stated, R9 could stand on the right leg. On 05/17/21 when the therapist and I transferred R9 from the bed to the wheelchair R9 did not have any complaints of pain. R9 was a two person transfer. On 12/16/21 at 09:26 AM V23 (Physical Therapy Assistant) stated, when I saw R9, R9 assist was to stand with minimum to moderate assist for sit to stand and transfers. R9 could do partial weight bearing. I told R9 don't use the left lower extremity to pivot because R9 was having a little pain in the ankle. R9 was a two person assist for transfers. If R9 is a two person assist for transfers and is not transferred with a two person assist R9 might fall, or both the resident and staff can get injured. On 12/16/21 at 10:10 AM V2 (Director of Nursing) stated R9 went to the emergency roiagnom on [DATE] and came right back. The pain to R9 left knee was new for R9. R9 has issues with bones and [CONDITION(S)]. Based on review of the admitting diagnosis R9 did not have a fracture when admitted . The day of the incident I asked the staff if when R9 was taken to therapy was R9 having any pain. According to what the staff said R9 did not complain of any pain to her (R9) knee. After R9 was transferred from the wheelchair to the bed R9 started complaining of pain to her (R9) left knee. Something probably happened during the transfer from the wheelchair to the bed. If a resident is a two person assist for transfers and is not transferred with two assist there is a potential for a fall or injury. On 12/16/21 at 10:58 AM V21 (Restorative Director) stated, the initial care plan indicate R9 required assistance for transfers and mobility. R9 was a two person stand and pivot. On 12/16/21 at 11:50 AM V24 (Licensed Practical Nurse) stated, what R9 would say was V16 (Certified Nurse Assistant) broke her (R9) left knee in the process of transfer R9 from the wheelchair to the bed. R9 had no complaints of pain to the left knee prior to R9 saying V16 (Certified Nurse Assistant) broke her (R9) knee. On 12/16/21 at 12:02 PM V20 (Certified Nurse Assistant) stated, we explained how we were going to transfer R9. We lifted R9 legs up on bed. V6 (Certified Nurse Assistant) was on the other side of the bed to pull R9 over. R9 was requesting to get in the bed because she (R9) said she (R9) had been sitting up for over 2 hours. On 12/16/21 at 12:19 PM V29 (Physical Therapist) stated, R9 is dependent with a two person assist for transfers to kind of like carry R9 with more than 90% help to transfer. If R9 is not transferred with a two person assist R9 could potentially fall or be injured. The two person transfer lessens the risk for a fall or injury. On 12/16/21 at 12:26 PM V25 (Licensed Practical Nurse) stated, R9 complained of having pain to the left knee and R9 went for x-rays and to the hospital. On 12/16/21 at 12:55 PM V6 (Certified Nurse Assistant) stated, R9 was my resident on 05/17/21. When I came in R9 said she (R9) wanted to go to bed. R9 is a two assist for transfers. R9 started telling me that V16 (Certified Nurse Assistant) broke her (R9) leg. V16 (Certified Nurse Assistant) lifted R9 out of the wheelchair. V16 (Certified Nurse Assistant) put his arms under R9 arms, counted 1-2-3, transferred R9 to the bed then we assisted with positioning R9 in the bed. On 12/16/21 at 01:07 PM V28 (Nurse Practitioner) stated, the facility said R9 was complaining of pain to the left lower extremity. There are a lot of factors but the short answer, technically the Certified Nurse Assistant should have their gait belt on. There is a potential for a fall or injury depending on how the transfer was done. If R9's leg gets twisted there is a potential for injury. On 12/16/21 at 01:23 PM surveyor spoke with receptionist at V35 (Attending Physician) office. Receptionist stated V35 was in a meeting. Contact information left with no return call. MDS (Minimum Data Set) Section G - Functional Status document in part B. Transfer 3. Extensive Assistance, 3. Two + person physical assist. E. Surface-to-Surface transfer (transfer between bed and chair or wheelchair) 2. Not steady, only able to stabilize with staff assist. Transfer and Bed Mobility/Limited Lift review dated 02/10/21 document R9 Transfer Ability: Extensive assistance, 2+ person Physical Assist. Fall Risk Care Plan initiated 02/17/21 document's in part resident is at risk for fall r/t (Related to) requires ADL (Activities of Daily Living) assistance for transfer and mobility. Assist with bathing, dressing and transfers. Transfer Needs Care plan dated 02/17/21 document's in part Total Dependence (Full staff support) 2 person assist. Transfer Needs Care plan updated 03/30/21 document's in part Extensive Assist High (more than 25% weight bearing assistance) 2 = can be used for stand/pivot. 2 person assist. Interdisciplinary Plan of Care document's in part R9 is at risk for compression fractures r/t (Related to) [CONDITION(S)]. Maintain good support during transfers. R9 is at risk for painful joints, brittle bones and limited mobility, flexion and contracture r/t (related to) [CONDITION(S)]. SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 05/20/21 document in part Pain Location Left knee. Transfers Totally Dependent, High Fall Risk. SBAR (Situation, Background, Assessment and Recommendation) Communication Form and Progress Note dated 05/20/21 document's in part 2. Functional Status Evaluation (compared to baseline; decreased mobility. Appearance: Crying for pain on L (left) Knee, 10/10 10 being the most painful. L (Left) knee swollen and warm to touch. Request to be sent to the hospital. Hospital record dated 05/20/21 document's you injured your left leg when moving from your wheelchair to your bed. Injury: Left lateral femoral condyle fracture. Diagnoses Left Foot Pain, Left Knee Pain, unspecified Chronicity, Left ankle pain, unspecified Chronicity and Acute Pain to Left Knee. Imaging Tests: MRI (Magnetic Resonance Imaging) of Knee and X-ray of Knee. Chief Complaints: Leg Pain (Left), Lower Extremity [CONDITION(S)] (Left). Left Lower Extremity Swelling: Knee, Tenderness: Knee; Ankle. History of Present Illness OA ([CONDITION(S)]), poor mobility who presents w (with)/left knee swelling/pain, Left ankle pain. In Service dated 05/31/21 Tilted Resident Rights and How to Transfer a Resident with R16 and R20 in attendance. Policy: Titled Policy and Procedure Mechanical Lift Transfer (Full Size/Hoyer Type Lift) undated document in part Purpose: To assure that all residents that are assessed to require extensive assistance high (with minimal to no ability to bear weight of bilateral lower extremities) and/or total assistance in transfer are transferred safely with no injury to resident or care handler. Titled Incidents/Accidents/Falls undated document in part Policy: The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved. Procedure: If a resident is involved in an incident/accident an immediate assessment of the resident will be completed by a nurse. Titled Resident Handling Policy Limited Lift signed 05/24/21 by V16 document in part Gait belt usage is mandatory for all resident handling.

Based on interview and record review, the facility failed to ensure that staff protected a resident that was assessed for increased vulnerability for three residents (R45, R54, R91) in the sample of 72 reviewed for abuse. This failure resulted in R91's physical assault on R45 and R54 which required transfer to the hospital for R45 for an injury of contusion of right shoulder and required emergent transfer to the hospital for R54 for laceration to the right eyebrow measuring one centimeter (cm) in length and four cm in depth that required two sutures. Findings include: R91's Admission Record documents, in part, that R91 is a [AGE] year-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R91's Trauma Screening, dated 9/17/21, documents, in part, that R91 has factors that increase (R91's) vulnerability ( . confusion, disorientation, poor insight/poor judgement, poor communication skills . frailty/weakness). However, in this same screening, R91 is assessed as having history or presence of dysfunctional behavior (e. g. [for example], provoking, aggressive, manipulative, derogatory, disrespectful . and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. R91's MDS, dated [DATE], documented that the staff assessment for mental status was conducted for R91 and that R91 has short- and long-term memory problems with cognitive skills for daily decision making as modified independence. R91's Care Plan, dated 9/16/21, which was presented to this surveyor on 11/10/21 by V22 (Social Services Director, SSD), after V2 (Director of Nursing, DON) had provided R91's requested complete care plan, documents, in part: (R91) displays conflictual, difficult behavior with other persons related to: Poor or ineffective coping skills and general intolerance and limited ability to deal with frustration. Behavior symptoms are manifested by: Complaints/concerns about other residents and physical contact with staff. Approaches: Teach and remind (R91) to communicate (R91's) feelings, including anger and frustration through means other than hitting, touching. On 9/16/21 at 3:51 pm, V21 (Licensed Practical Nurse, LPN) documented, in part, in R91's incident note, Writer noted (R91) in the hallway making physical contact towards (R45, R54) with a cane. Census documents for the date of 9/16/21 indicated that R45 and R91 were roommates with R54 residing in the next neighboring room. On 11/8/21 at 1:18 pm, V16 (RN) stated that on 9/16/21, during her morning medication pass, V16 was in the hallway and stated, I (V16) am the witness. V16 stated that she (V16) observed R45 and R54 outside of R45's room where R91 hit R45 and R54 with R91's black cane. V16 stated that she (V16) witnessed in the hallway R91 hit R45 in the back of the head. V16 stated that V16 called out for help, and as she (V16) was getting to (R91), (R91) was swinging to hit (R54) again. V16 stated, (R45) ran away and was trying to shield himself. V16 then stated that at this time, R54 was observed in the hallway, facing the wall and holding onto the safety rail attached to the hallway wall with hands, and that R91 hit R54 from behind with R91's cane. V16 stated that V16 didn't notice that R54 was bleeding from the face until R54 turned around from facing the wall. V16 stated staff helped (R54) into a chair (in the hallway) because (R54) couldn't walk and was so weak. V16 stated that R45, R54 and R91 were separated, sent to hospitals and that staff didn't know what happened between these three residents prior to observing them in the hallway. When asked about R91's previous behaviors, V16 stated, I (V16) don't know (R91) that much. (R91) was on another floor. (R91) relatively new to second floor when this happened. On 11/08/21 at 3:17 pm, V21 (LPN) stated that on 9/16/21, she (V21) was at the second-floor nurse's station when V21 heard V16 shout so I (V21) ran. V21 stated, I (V21) saw (R91) striking (R45). I (V21) saw (R91's) cane go up and strike at (R45). V21 stated that staff separated R91 from R45, and As we (staff) backed out (R91) away from (R45), I (V21) saw (R91's) arm with cane swing and connected with (R54). V21 also stated that R54 was standing in the hallway, facing the wall, and holding onto the safety bar. R45's Admission Record documents, in part, that R45 is [AGE] years old with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's Trauma Screening, dated 3/9/21, documents, in part, that R45 has factors that increase (R45's) vulnerability ( . confusion, disorientation, poor insight/poor judgement, poor communication skills . frailty/weakness) and that R45 has no history or presence of dysfunctional behavior (e. g. [for example], provoking, aggressive, manipulative, derogatory, disrespectful . and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. R45's Minimum Data Set (MDS), dated [DATE], documented that R45's Brief Interview for Mental Status (BIMS) was not performed due to R45 is rarely/never understood and that R45 has short- and long-term memory problems with cognitive skills for daily decision making as moderately impaired. R45's Care Plan, dated 6/11/20, documents, in part: (R45) demonstrates cognitive impairment related to unspecified symptoms and signs involving cognitive functions and awareness. Symptoms are manifested by: Impaired decision making, poor logic, and poor ability to understand cause and effect. Approaches: Assess suspected transient causal factors. On 9/16/21 at 8:55 am, V16 (Registered Nurse, RN) documented, in part, in R45's incident note, Writer noted (R45) walking in the hallway and (R91) making physical contact towards (R45) with a cane on the head twice . On assessment, slight redness noted to right upper posterior head. R45's emergency department records, dated 9/16/21, document, in part, that R45's reason for hospital visit is hit by a cane at NH (nursing home). R45's emergency department discharge instructions, dated 9/16/21, document, in part, that R45 had contusion of right shoulder and that a contusion is a bruise that appears on your skin after an injury. R54's Admission Record documents, in part, that R54 is [AGE] years old with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R54's Trauma Screening, dated 8/16/21, documents, in part, that R54 has factors that increase (R54's) vulnerability ( . confusion, disorientation, poor insight/poor judgement, poor communication skills . frailty/weakness) and that R54 has no history or presence of dysfunctional behavior (e. g. [for example], provoking, aggressive, manipulative, derogatory, disrespectful . and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. R54's MDS, dated [DATE], documented that R54's BIMS score is a 6 which indicates severe cognitive impairment. R54's Care Plan, dated 9/16/21, documents, in part: (R54) demonstrates cognitive impairment related to: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches: Offer and lend (R54) wise judgement/guidance. On 9/16/21 at 2:35 pm, V16 (Registered Nurse, RN) documented, in part, in R54's incident note, (R54) standing in front of (R54's) room by the door holding on the rail when (R91) make(s) physical contact towards (R54). Residents were immediately separated. (R54) being assess, noted above right eyebrow with laceration measuring 0.7 x 1.0 x 0.5 (centimeters) with medium amount of blood. Noted (R54) slow to respond . Called 911. (R54) reported with translator that (R91) hit (R54). R54's emergency hospital records, dated 9/16/21, document that with interpreting assistance by hospital staff, R54 stated that approximately 1 hours prior to arrival (R54) was struck in the head by a cane of a fell ow nursing home resident. (R54) also seems to endorse being struck in the back at some point with the same walking cane during the altercation and that R54's right eyebrow laceration, length 1 cm, depth 4 cm was repaired and closed with 3 sutures. In facility document, titled Initial Report and dated 9/20/21, faxed timely to the state agency, V2 (DON) documented that the physical altercation of R45, R54 and R91 occurred on 9/16/21 at 9:30 am. V2 documented, in part, Nurse on duty reported that (R91) and (R45) and (R54) were involved in a physical altercation while in the unit hallway. On 11/9/21 at 9:38 am, V22 (Social Services Director, SSD) stated that V22 was not in the facility on 9/16/21. V22 stated that monitoring and keeping (residents) closer to nurse's station are interventions for supervising residents, and nursing and social services staff are responsible for monitoring resident behaviors. On 11/10/21 at 9:33 am, V22 (SSD) stated that there is no specific time frame for rounds for monitoring residents and that nurses will report back to him (V22) with any resident behaviors. V22 stated that V22 will assess a resident's vulnerability, as indicated in the trauma screening document, in the facility during quarterly evaluations, and whenever there is a physical altercation incident between residents, nurses will screen residents' mental and physical conditions. On 11/9/21 at 3:28 pm, V2 (DON) was shown in R45 and R54's electronic medical records that there was no trauma screening performed on or after 9/16/21 (date of physical assault from R91) for R45 and R54. V2 stated, That should have been done. On 11/10/21 at 3:15 pm, V33 (Attending Physician) stated that she (V33) has recently saw R54 in person and uses a translator to communicate with R54. V33 stated, (R54) is a vulnerable resident. When V33 was asked about any long-term care resident suffering physical harm, like R54's incident of being struck by R91, V33 stated, No physical harm should happen, and residents are to be frequently monitored. When V33 was asked about residents having the right to not have any abuse or harm, not even one time like R54, V33 stated, That's right. Staff need to monitor behaviors if there's more than normal confusion. When V33 was asked if staff are expected to prevent physical harm from resident to resident, V33 stated, Of course. Staff need to give medications and do rounds more. Facility document, titled Final Report and dated 9/20/21, that was faxed to the state agency documented, in part, the conclusion from the incident between R45, R54 and R91 on 9/16/21 at 9:30 am: Conclusion: An investigation was completed which determined that (R91) made physical contact with (R45) and (R54). According to staff who were present at the time of the incident, (R54) entered room of (R91) and (R45) which agitated (R91). On 11/9/21, V2 (DON) was asked for the facility's resident rights policy, and V2 provided this surveyor with a document, titled Residents' Rights for People in Long Term Care Facilities and dated November 2018, which documents, in part: . Your rights to safety: You must not be abused, neglected or exploited by anyone . physically . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Facility policy, titled Abuse Prevention Program and dated January 2019, documented, in part: Policy: It is the policy of this facility to prohibit and prevent resident abuse . in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse . of a resident . Procedure: If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions . VII. Prevention: The facility desires to prevent abuse . against a resident by establishing a resident-sensitive and resident-secure environment . As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse . or who have needs and behaviors that might lead to conflict . Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Abuse and Crime Reporting: Policy: . 4. Physical abuse: Hitting.

Based on observation, interview and record review, the facility failed to ensure that a low air loss mattress was functionally operating and failed to set the low air loss mattress at the appropriate resident weight and pressure settings which affected one (R129) of two residents reviewed for pressure ulcers in a sample of 72. These failures caused R129's stage 4 sacral pressure ulcer to decline and increase in size. Findings include: R129 is a [AGE] year-old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R129's Minimum Data Set (MDS), dated [DATE], documented that R129's Brief Interview for Mental Status (BIMS) was not performed due to R129 is rarely/never understood and that R129 has short- and long-term memory problems with cognitive skills for daily decision making as moderately impaired. R129's same MDS documents that R129 requires two persons physical assist due to total dependence for bed mobility, transfer, dressing, toilet use, bathing and personal hygiene, and R129's skin and ulcer/injury treatments include a pressure reducing device for the bed. On 11/08/21 11:45 am, R129 was observed in bed on a low air loss (LAL) mattress system. The LAL mattress pump at the foot of the bed was observed with the weight dial set at approximately 220 pounds with the arrow pointing midway between the 200- and 250-pound markers. The static button indicator light was on with a yellow light lit next to the static button. R129 was observed with a [CONDITION(S)], not actively moving any extremities and not responsive to this surveyor's questions. On 11/8/21 at 1:55 pm, this surveyor phoned V42 (R129's Power of Attorney, POA) and inquired about R129's care in the facility. V42 stated that she (V42) recently had concerns about R129's sacral pressure ulcer worsening, and after requesting to see R129's sacral wound, V42 wanted R129 sent to the hospital. V42 stated that R129 stayed two weeks in the hospital and had to have a surgery to debride the sacral wound. On 10/15/21 at 2:22 pm, V37 (Licensed Practical Nurse, LPN) documented, in part, (V42, Power of Attorney, POA) came to visit (R129) at 1 pm and requested evaluation at hospital for non-healing sacral wound. Wound care done by (V24, Wound Care Coordinator) this am. (V42) spoke with (V24). Nurse practitioner aware of (V42's) request with order to send (R129) to (hospital) emergency room . R129's census documents that R129 was hospitalized from 10/15/21 to 10/31/21. On 11/9/21 at 11:52 am, R129 was observed in bed on the same LAL mattress system. The LAL mattress pump at the foot of the bed was observed with the weight dial at the same setting of approximately 220 pounds, and the static button indicator light was on with a yellow light lit next to the static button. On 11/9/21 at 11:55 am, V37 (LPN) was called into R129's room by this surveyor to review R129's LAL mattress pump settings. Both V37 and this surveyor viewed the LAL pump setting together for R129 with the weight of 220 pounds, and the static button indicator light on with a yellow light. When V37 was asked about the static mode button being on, V37 stated, I (V37) really don't know what static mode is. V37 then pressed the static mode button off, and the yellow indicator light went off. V37 stated that she (V37) checks to make sure all of the light indicators are on on the LAL pumps and will review the LAL mattress settings on her (V37) rounds at least three times a shift. V37 stated that CNA's (certified nursing assistants) and wound care nurses will check the LAL mattress settings too. R129's monthly weight report from May to November 2021 documents R129's weight range of 112.4 pounds to 121.6 pounds which is significantly lower than the observed weight setting on R129's LAL mattress pump. On 11/9/21 at 3:30 pm, V24 (Wound Care Coordinator) and this surveyor reviewed R129's LAL pump settings together, and both observed the weight dial setting adjusted to approximately 180 pounds with the arrow midway in between 150-to-200-pound markings. V24 stated that when the LAL mattress is set up, housekeeping or maintenance personnel are responsible for setting the weight on the LAL pump according to the resident's actual weight. V24 stated that floor nurses are responsible for checking the LAL pump settings. When this surveyor asked V24 about the yellow light indicator next to the static button, V24 stated, I (V24) am not sure what that means. This surveyor asked what the static mode is used for on a LAL mattress, and V24 stated, I (V24) am not sure. When asked about the static mode button yellow indicator light being lit up, V24 stated, The light is always on. I (V24) don't know about the static mode. V24 stated that if there was low pressure in the LAL mattress, then the low-pressure indicator light would turn red and make a beeping sound. When asked if there have been any recent concerns with R129's air loss mattress malfunctioning, V24 stated, Yes. It was alarming and blinking with the red light lit up. We were trying to figure out where the air loss was coming from. I (V24) removed the tubing connection from pump, and there wasn't much air coming from the tube. I (V24) put my hand over the connection from the pump, and the pump was not giving out enough air (to keep mattress inflated). I (V24) reported it to V3 (QA/Infection Prevention Nurse). V24 stated that he (V24) expects the nursing staff to turn and reposition resident every two hours and to maintain a LAL mattress. On 11/10/21 at 9:23 am, V24 provided this surveyor with the manufacturer guidelines for R129's LAL mattress and stated that he (V24) read the guidelines. V24 stated that R129's LAL will promote weight distribution, and that when the static mode is on, this disconnects the alternating pressure from going inside the mattress. R129's Order Summary Report documents active orders as of 11/9/21 which include low air loss mattress. R129's Care Plan, dated 10/14/21, documents, in part that R129 has alteration in skin integrity and is at risk for additional skin issues related to: Dementia/Alzheimer's, Incontinence, Decreased Mobility, Comorbidities, Stage IV sacrum. Interventions: 4. Pressure reducing/relieving mattress as needed, low air loss. On 9/29/21 at 1:23 pm, V35 (Wound Physician) documented in the wound evaluation and management summary that R129's stage 4 sacral pressure wound size (L, length, by W, width, by D, depth): 3 x 2 x 1 cm (centimeters), surface area: 6.00 cm squared, granulation tissue: 85 % (percent). On 10/5/21 at 1:31 pm, V35 documented in the wound evaluation and management summary that R129's stage 4 sacral pressure wound size (L x W x D): 4.4 x 5.2 x 1 cm, surface area: 22.88 cm squared, thick adherent devitalized necrotic tissue: 50 %. Additional wound detail: Per nursing report, there was an issue with air loss mattress which further exacerbated the wound. R129's facility provided hospital records (from hospital stay 10/15/21 to 10/31/21) were reviewed and documented that R129 was sent from the facility on 10/15/21 due to sacral wound worsening and that R129 had a surgical debridement 10/21/21: Sharp excisional debridement of stage IV sacral decubitus ulcer 12 x 7 x 3 cm including skin, subcutaneous tissue and bone. On 11/10/21 at 10:18 am, V28 (Wound Care Nurse) stated that R129's pressure ulcer interventions for the sacral wound included the LAL mattress. V28 stated that it (LAL mattress) is the first intervention to help in terms of healing a wound and helps with relieving pressure off wound. If a resident is dependent on ADL's (activities of daily living), even staying 2 hours in one position can trigger a skin alteration. V28 was asked about how a LAL mattress is set up, and V28 stated, (It's) based on the weight of the resident. We (nurses) check the weights in (electronic medical record) and turn the knob to the weight of resident. V28 stated that the resident's current weight needs to correlate on the LAL pump setting, and If the weight setting is too high, and the resident is not heavy enough for that weight setting, then it would be a hard mattress. Then the intervention might not be appropriate. Weight setting is there for a reason to set up directly to the resident's weight. On 11/10/21 at 1:44 pm, V2 (DON) stated that the purpose for using a LAL mattress is for wound healing and prevention and to decrease or prevent moisture on the skin. V2 stated that the settings of LAL mattresses are done by the wound care nurse and floor nurses and that the floor nurses will check settings every shift to make sure the settings are correct. When V2 was asked what kind of settings should be used for a LAL mattress, V2 stated, I (V2) am not sure. Housekeeping staff will put in the settings when they set up the LAL mattress. Housekeepers will ask the nurse for the weight, and housekeeper will set up LAL mattress with weight of the patient. On 11/10/21 at 2:44 pm, V30 (Housekeeping Director) stated that V30 is responsible for setting up the LAL mattress and putting the weight setting on the LAL pump. V30 stated, Nurses or wound care nurse gives me (V30) the weight. I (V30) put whatever they (nurses) tell me (V30). Then I (V30) turn the dial to the weight. V30 stated that she (V30) will check the LAL mattress if she (V30) gets a report of any malfunctioning. When asked if she (V30) responded to any report of R129's LAL mattress malfunctioning, V30 stated that she (V30) did respond to check R129's LAL pump because the lights were not working. On 11/10/21 at 2:56 pm, V40 (Housekeeper) stated that she (V40) recalled replacing R129's malfunction LAL mattress. On 11/10/21 at 12:45 pm, V35 (Wound Physician) stated that she (V35) is treating R129 for the sacral pressure wound and sees R129 weekly. V35 stated that she (V35) performs weekly measurements of R129's sacral wound and recently have been updating R129's family with a video call during the weekly measurements and assessments she (V35) performs. When V35 was asked about her (V35) documentation on 10/5/21 about R129's deterioration in the sacral wound from nursing report of an issue with the LAL mattress, V35 stated, I (V35) was notified on my (V35) exam that day. Nurse (V24) said that day or the day before (R129's LAL was not working correctly). I (V35) noticed it. From what I (V35) could see, it felt like the mattress was not inflated even when raised up the pressure. V35 stated that the purpose of a LAL mattress is to directly off load the wound to provide circulation floor to the wound. V35 stated that someone with a high skin moisture level, like R129, could cause a delay in wound healing. But the benefit of having a LAL mattress outweighs (R129's) risk factors. Facility provided undated manufacturer's guideline, titled 8 inches Alternating Pressure Mattress Replacement System with Low Air Loss, User Manual, documents, in part: Introduction: Pressure injuries are defined as localized injuries of the skin and/or underlying tissue over a bony prominence as a result of pressure or pressure in combination with shear. Support surfaces or specialized mattress systems are used . to prevent and treat pressure injuries. The (8 inches Alternating Pressure Mattress Replacement System with Low Air Loss) is intended for: 1) Pressure redistribution for individuals with but not limited to the following conditions: At risk or present pressure injuries . Product Features: . 2) Therapy control unit: Analog system. This analog control unit includes an easy to use pressure dial that is adjustable to the patient's weight . Static button is available to discontinue alternation therapy . Product Function: . Analog Pressure Dial: Adjust the dial to correspond to the patients' appropriate weight setting . Static Pressure Button: Press the static pressure button to discontinue alternating therapy . Operation: . Step 4: The control unit is preset in alternating mode and its cycle time is set at 10 minutes/60Hz ([NAME]). Press the Static button to set it in static mode, and the Static indicator will come on. The static mode will begin within 5 minutes. Press the Static button again to switch back to alternating mode. Undated facility policy, titled Preventative Skin Care, documents, in part: Guideline: It is the intent of the facility that the facility provide preventative skin care . and free from pressure sores. All residents will be provided a preventative pressure reducing mattress. Equipment: . 3. Air mattress . Procedure: . 5. Air mattresses . may be used on those residents identified as being high risk for potential breakdown.

Based on observation, interview and record review, the facility failed to monitor a cognitively impaired resident with known exit seeking behavior; failed to develop, update and implement individualized care plan interventions; failed to implement their Policy and Procedure Regarding Missing Residents and Elopement by failing to complete elopement risk assessments as per policy for one of three residents (R1) reviewed for incidents and accidents. These failures resulted in R1 leaving the third floor, gaining access to and falling from the facility's elevated smoking patio (six feet, four inches from ledge of deck to ground below) and sustaining a fractured foot. Findings include: R1 is a [AGE] year old readmitted to the facility on [DATE] with diagnoses including but not limited to Dementia with Behavioral Disturbances, [CONDITION(S)], Unspecified Mood (Affective) Disorder, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms; Anxiety Disorder, and Restlessness and Agitation. R1's Annual MDS (Minimum Data Set) of 08/10/2020 shows the following: Resident's cognition is moderately impaired; demonstrates behavioral symptoms not directed towards others that place R1 at risk for physical illness or injury and wandering that places R1 at significant risk of getting to a potentially dangerous place. Elopement Risk Review of 02/21/2020: Resident doesn't have a history of elopement, however resident has started exit seeking. She will be placed on elopement protocol program and monitored for relocation. She removes (electronic monitoring device). Score: 16 Elopement Risk Review of 08/11/2020: On (electronic monitoring device), room assigned near the nursing station to monitor resident from leaving the floor. Score: 24. On 12/10/2020 at 10:40 AM, V3 (ADON-Assistant Director of Nursing) said, (regarding Elopement Risk Review scores)I don't fill them out so I don't know. They then said, if it's less than 10 it's low risk, greater than 10 high risk for elopement. When you complete the assessment in (electronic medical record) the computer generates a score. No additional information regarding range of scores was provided. Facility's Incident Report Final submitted 08/15/20 for incident of 08/11/2020 notes, This AM resident went out through the alarmed door and exited the patio by sliding down the side of the patio wall landing on (R1's) feet then buttocks. Resident was sent to the hospital post fall, returned with a fracture of the left foot calcaneus (broken heel bone) and fractures of the second through fourth proximal metatarsals (broken bones of foot) with a splint in place. On 11/29/2020 at 1:30 PM, surveyor toured the facility's elevated smoking patio with V9 (Maintenance Director). V9 measured the distance from patio ledge to ground below. The distance on the north side is 74 inches. On 12/02/2020 at 3:19 PM and 12/11/2020 at 1:39 PM, V2 (DON-Director of Nursing) said, I looked at the tape after the incident. I saw the elevator door open, someone got off and (R1) got on. I don't know if it was a resident or staff member that got off (the elevator) or if the person was male or female. I would like to think that if it were a staff member they would have redirected her. She did not have a sitter until she came back from the hospital. She is now on the 1st Floor (across from Nurses' Station) and has a sitter 24/7. She was moved from the 2nd Floor to the 3rd Floor when it (2nd Floor) became a Covid Unit. At the time of the incident, she probably did have a wander guard. I can't be sure. Social Service did not tell me it had been discontinued. On 12/08/2020 at 2:25 PM, V23 (CNA-Certified Nursing Assistant) said, I heard the alarm and the overhead announcement, Patio door open please check. I went to check, I thought it was a smoker trying to get out to the patio to smoke. I didn't see anyone in the Dining Room. I approached the door. I saw R1 on the other side of the rail. I saw her jump from the patio ledge to the ground below. She landed on her feet. She still tried to run. I called a Code 99 (Elopement). On 12/03/2020 at 1:58 PM and 12/12/2020 at 11:28 AM, V21 (CNA) said, R1 was trying to leave that night. She was up all night, pacing. One time she made it into the stairwell and got down a flight of stairs between the 2nd and 3rd floors. Each time she tried to leave the unit it was by stairwell. The nurse (V16) knew about it (attempts to leave unit). I went to follow her (R1), I could see V16 coming towards me to help me get R1. -She (V16) just told me that I had to watch her because she was trying to leave. I would re-direct her when she tried to leave. Sometimes she had a sitter. She didn't that night. I don't know if she had one scheduled (for that shift when incident occurred). Clearly she needed one. When everyone was in the room with that resident there wasn't anyone to watch her. There aren't enough CNAs. On 12/03/2020 at 1:23 PM, V20 (CNA) said, I don't really know how she got to the patio door. She's usually supposed to have a sitter. She didn't have one that night. If there's no sitter, you (staff) have to take the place of the sitter. It's a problem when you have to care for other patients. V21 (CNA) and V22 (CNA) took her away from the elevator (during the shift). I saw her not so long before the code (Code 99-Elopement) was called, standing in the doorway of her room. I don't know if she had a (electronic monitoring device). On 12/03/2020 at 12:44 PM, V19 (RN-Registered Nurse) said, We suspect she got off the floor on the elevator. When we start our rounds, it's difficult to maintain close monitoring. We have to pass meds, turn and reposition residents. I don't know what happened. If someone was there (at Nurses' Station) we could have stopped her. I took care of her when she was on the 2nd Floor. She was very anxious, pacing. She tried too many times to get off the unit using the elevator. On 12/03/2020 at 12:07 PM V16 (RN-Registered Nurse) said, she was the nurse assigned to resident at time of incident. I heard one of the staff paging the code from the desk (3rd Floor Nurses Station). I was in a room helping staff (CNAs V21 and V22) with a resident. I went down to the first floor. When I got down to the first floor, I saw other staff wheeling (in wheel chair) R1 back into the building. Prior to the incident she would just walk back and forth on the unit. She never tried to leave by elevator or stairwell. I never heard of any elopement behavior. Some interventions that were in place at the time of the incident were redirection, close monitoring. She did not have a (electronic monitoring device) at the time of the incident. On 12/12/2020 at 2:05, V16 said, when asked for clarification, Maybe you should ask the DON about it (the incident), she's the one that investigated it. I don't remember that anymore, I only remember what's in the incident report. That night she didn't need a sitter. She was sleeping most of the night. It was roughly between five and six is what I remember (when code was paged). We're usually passing our meds around that time. I overheard that when she was on the 2nd Floor she needed a sitter. I was thinking about why she was moved from the 2nd Floor to the 3rd Floor. It was because of Covid. The 3rd Floor has a higher acuity level than the 2nd Floor. The 2nd Floor is the behavior floor. On 12/02/2020 at 4:08 PM, V17 (Former Social Service Aide) said, R1 had an (electronic monitoring device). She had a history of taking it off. She paced by the elevator a lot, trying to elope. When asked by this writer if resident ever got off the unit, V17 replied, Plenty of times. She got out of the building a few times. Twice she got to the bottom of the ramp outside (in front of facility's main entrance). We were able to bring her back inside. She got off the unit three times down to the 1st Floor. On 12/03/20 at 3:58 PM and 12/12/2020 at 10:20 AM, V24 (R1's Family Member) said, She is a flight risk. She's always running, trying to escape from the unit. She wants to be with her family. She was able to go down the elevator from the 3rd Floor to the 1st Floor through the door on the smoking patio and jumped over the railing. A staff member actually saw her jump off the patio. I got a call from the nurse (V16) around 8:30 AM (day of incident) and was told that she fell while trying to elope two times; she injured her foot but was otherwise okay. She did try to leave the facility before the incident. Sometimes the nurses called me. They would say, she tried to get on the elevator but we stopped her. She had a sitter off and on as far back as 2018. Some days she was okay and didn't need one. Progress Notes as follows, document multiple attempts made by R1 to leave the unit. PRN (as needed) medications are given for behavior. No documentation is found noting notification of Psychiatrist. -02/24/2020, 4:05 PM: Pt agitated walking around trying to leave facility unable to redirect. Pt needs constant redirection and monitoring (electronic monitoring device) in place. Needs constant monitoring place on 1:1. -02/25/2020 7:17 AM: At 11:45 PM resident came to Nurses' Station. Walked back and forth. Is anxious. Wants staff to take off her (electronic monitoring device). Needs constant redirection. -05/31/2020, 2:29 PM: Resident very agitated, voicing wanting to leave and running without direction on unit, and attempting to leave via elevator or stairs. [MEDICATION(S)] IM as ordered. Resident became calmer and stopped ranting. -06/09/2020, 10:10 AM: Suddenly became agitated, trying to open stairway door. Unable to re-direct. -06/11/2020, 3:23 PM: Resident was observed running in the hallway trying to go down the stairwell. She was pacing the floor. This is baseline. 1:1 counseling and provided a sitter for her room. Resident responding to internal stimuli AEB (as evidenced by) talking to herself. -06/13/2020, 10:30 AM: Very anxious, restless, trying to open stairway, door unable to redirect. -06/19/2020, 3:21 AM: Res confused, became agitated, trying to use stairway to go out, unable to redirect. -07/15/2020, 10:40 AM: Attempts to get in elevator on occasion. -07/27/2020, 9:30 AM: Res became agitated, trying to use stairway to go down, unable to redirect. On 11.29.2020, the facility presented a pre-filled care plan for wandering, pacing or roaming dated 08/10/2020 (annual care plan). 12/03/2020 at 4:49 PM V18 (SSD-Social Service Director) said when resident's annual review is completed, a new care plan is made, old care plans are removed and filed in Medical Records. No previous care plans related to R1's wandering, pacing, or roaming behavior addressing R1's previous attempts to leave the unit were provided after multiple requests. On 12/11/2020 at 10:32 AM, V25 (Medical Records) said, These are her (R1's) old care plans. 43 care plans from 06.2017 -05.2019 were noted. No care plans were found in R1's medical record (Hard Copy); no wandering, pacing, or roaming were in Medical Records On 12/03/2020 at 4:49 PM and 12/09/2020 at 4:22 PM, V18 (SSD) said, She paces a lot and is an elopement risk. To my knowledge she never got out of the facility before the incident (08/11/2020). She was on the 2nd Floor and transferred to the 3rd Floor. She never tried to get off the 2nd Floor, she did get off the 3rd Floor. She was trying to get to the 2nd Floor because that was her home. Prior to the incident, I don't believe she had a sitter because she wasn't an elopement risk like that, she never tried to run. She had a wander guard but she cut it off. So we put it on her ankle. The last time I saw her was in October, she didn't have a (electronic monitoring device) at that time but she did have an (electronic monitoring device) at the time of the incident (08.11.2020). Social Service is responsible for initiating/updating the care plan. It should be updated after each incident, quarterly and annually. Interventions could include 1:1 monitoring/sitter, electronic monitoring device)/check for placement of (electronic monitoring device), redirection. Typically I try to get to elopement risk assessments within 72 hours of admission. They are done annually, quarterly, and with a significant change (any improvement or decline of physical or mental health). It really surprised us, we never saw her do anything like that (leave unit). This writer informed V18 that there is documentation in R1's medical record (Progress Notes, Elopement Risk Review) and staff statements regarding R1's known exit seeking behavior prior to the incident. V18 said, I was never told she had exit seeking behavior. It would have made a difference (with interventions). We would have monitored her more closely, maybe a sitter before the incident. I think we should have monitored her more closely. Policy and Procedure Regarding Missing Residents and Elopement (undated) notes: -Policy Statement-It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All residents assessed to be at risk of elopement will have this issue addressed in their plan of care. Procedure for the Prevention of Missing Residents 1. All residents shall be assessed for behaviors that place them at risk of elopement utilizing an elopement risk assessment upon admission, quarterly, annually and upon significant change of condition. An assessment dated [DATE], was completed 34 days after R1 was readmitted on [DATE]; no admission or quarterly assessments were found. On 12/10/2020 at 2:40 PM, V3 (ADON) said, (regarding Policy and Procedure Regarding Missing Residents and Elopement) if that's all you have that's the only policy and procedure we have in place. I can reach out to the DON and my nurse consultant to see if there is an Elopement Program Protocol or any other elopement protocol. No additional documentation was provided.

Based on observation, interview and record review the facility failed to provide Restorative Nursing Care for three residents (R1, R10 and R6) of 3 reviewed for Restorative Services. This failure resulted in the decline of function for R1, R10 and R6. Findings Include: R1 was [AGE] years old readmitted to facility on 10/1/2018. His mental status was intact and he had multiple [DIAGNOSES REDACTED]. R1 was screened and evaluated for Physical therapy on 8/10/2020 for evaluation of weakness. He was discharged on [DATE] from Physical Therapy. When R1 was discharged from physical therapy on 8/20/20, R1 was able to ambulate up to 100 feet with a rolling walker and Stand By Assist(SBA) according to Physical Therapist notes. Referral from Physical Therapy to Restorative Nursing was done on 8/21/2020. The recommendations for R1 documented Range of Motion to extremities and restorative ambulation for 100 feet or as tolerated with SBA using a rolling walker. The activity was not transferred on the restorative program and according to V15(Restorative Nurse) she may have overlooked it. She had no assessment for R1 in terms of Restorative services On 9/8/2020 at 10:00AM, R1 was in electric wheelchair in the hallway. He was alert and oriented x3. He said he had a stroke and only received physical therapy three times since January 2020. He said he did not receive any restorative therapy either. According to him he cannot stand up now as his legs were weak. He attempted to stand but could not. On 9/8/2020 at 11:56AM, V1(Director of Nursing/DON) said R1 was on restorative nursing. On 9/8/2020 at 1:10PM, V10(Restorative Aide) said R1 was not on Restorative Nursing for Ambulation. She said they performed Range of Motion for R1. She said the last time she performed exercises for R1 was a week ago when she weighed him. At that time, she noted his legs were very weak. She said she forgot to report to the therapy director. On 9/8/2020 at 12:15PM, V15 (Restorative Nurse) said she may have overlooked the ambulation order and if a resident did not get the treatment as prescribed, chances are that they will decline in their functional status. On 9/9/2020 at 10:10AM, V21(Nurse Practitioner) said it was the expectation that a restorative program was to avoid decline in residents' function. Facility's undated policy on Restorative note, Once the residents had been assessed and has been determined to require at least 2 restorative programs, the licensed nurse must complete the HFS functional Endurance. Surveyor:(NAME) Erica During an interview on 9/9/20 at 10:20AM V10, Restorative CNA, said I do restoratives for the first floor. V10 said R10's restorative programs include transfers and active range of motion (AROM). V10 said R10 can transfer with a gait belt and assist but she has been refusing to let anyone get her up. During an interview on 9/9/20 at 10:45AM V16, Restorative Nurse, said the goal of restorative programs is to prevent contractures, deconditioning, and to keep residents at the level they are at rather than have a decline in function. V16 said R10 requires extensive assistance with transfers and she does not require a machine or lift. V16 said R10 does not get out of bed often, but she used to get up before COVID. V16 reviewed R10's restorative documentation related to R10's restorative transfer program and said the aids are probably not doing the restorative programs correctly. During an interview on 9/11/20 at 10:10AM V26, Nurse Practitioner, said the purpose of a restorative program is to restore functional status. The expectation from a restorative program is for a resident not to decline. During an interview on 9/11/20 at 10:24AM V16 said R10 is a mechanical lift. V16 said if a resident requires a mechanical lift for transfers then they should not be on a transfer program, because they would be at risk for a fall. V16 said R10 could fall if she is transferred without a mechanical lift because she has general weakness. Record Review on 9/10/20 of R10's Task for Nursing Rehab date initiated 1/24/19 states Transfers Resident will participate safely in transferring from bed to chair / wheelchair with EXTENSIVE x 1 assist as tolerated to improve level of function. Record review on 9/10/20 of R10's Restorative Programs indicates on 9/9/20 at 9:03 she received Transfer program for 15 minutes. The Restorative Programs Log is dated 8/10/20 thru 9/9/20. Every day has a least 15 minutes documented of Transfer program. Record review done on 9/10/20 of R10's Comprehensive Restorative Nursing Review effective date 8/11/20 Bed Mobility Program and Transfer Program are checked. Record review done on 9/10/20 of R10's Comprehensive Restorative Nursing Review effective date 8/11/20. Section G. Quarterly Nursing Program Evaluation AROM and AAROM have no note written. Transfer Restorative Nursing Program describe the resident's progress: address progress, maintenance or regression. List the goal and describe how the resident is meeting the goal. This section has the same verbiage from the task: Resident will participate safely in transferring from bed to chair / wheelchair with EXTENSIVE x 1 assist as tolerated to improve level of function. No description of R10's progress towards the programs goal. The assessment does not address any refusals to participate in the restorative programs. Record review on 9/10/20 of R10's care plan for Restorative Programs dated 8/11/20 includes a Restorative Program for Transfers. Problem states resident is unable to transfer independently and requires assist of TOTAL X2 ASSIST. R10's Comprehensive Restorative Nursing Review effective date 8/11/20 states the resident will transfer per the program with EXTENSIVE x 1 assist. Record review on 9/10/20 of R10's care plan for Transfer Needs dated 8/11/20 states the resident has been assessed for their transfer needs and continues to require the following support: Mechanical lift. Observations on 9/8/20 of R6 at 11:21AM; 11:49AM; and 12:15AM in bed without hand rolls or devices in her hands. Observations on 9/9/20 of R6 at 9:48AM in bed without hand rolls or devices in her hands. Observation on 9/9/20 at 10:00AM of R6 receiving morning cares by V23, Certified Nursing Assistant. R6 bilateral hands were closed in fits and kept near her body along her hip region. R6 kept her arms straight not bent. V23 was able to open R6's hands slightly to wash them. No hand roll or device was in R6's hand at the start of care. V23 said she completed care on R6, just finishing her hair. No device or hand roll was placed in R6's hands. Observations on 9/9/20 of R6 at 11:59AM R6 in bed without hand rolls or devices in her hands. During an interview on 9/9/20 at 10:20AM V10, Restorative Aide, said R6 is on active assisted range of motion (AAROM), but she is more of a passive assisted range of motion (PROM) because she can't move her extremities without help. V10 said R6 can' t participate in the dressing and grooming restorative program. V10 said R6 can't participate in the Bed Mobility program. V10 said R6 used to have hand rolls in her hands, but she does not anymore. V10 said she is the restorative for R6's floor. During an interview on 9/9/20 at 10:45AM V16, Restorative Nurse, said R6 was using hand rolls in the past. V16 said the purpose of the hand rolls is to prevent her from digging her fingers into her palm. V16 said R6 should have hand rolls in her hand and they are to only be removed when doing hand hygiene. V16 said R6 had carrots device in her hands, before. V16 said in the 8/7/20 assessment R6 had no contractures and full range of motion to all extremities with assistance. During an interview on 9/9/20 at 12:40PM V16 said after assessing R6 today she has severe loss in function to her extremities. R6 has a fixed contracture on her shoulder. The restorative programs for ROM were not successful and R6 has declined in range of motion. Record review on 9/10/20 of R6's Restorative Nursing Review dated 8/7/20 completed by V16 states on page 3: does the resident currently use Splint/Brace? Answer is Yes. The type and location states: palm protectors on both hands at all times. Page 8 states resident has no contractures on all her joints. No further limitation on Range of Motion. Splint or Brace assistance Restorative Nursing Program has no note. Record review on 9/10/20 of R6's Restorative Nursing Review dated 8/7/20 completed by V16 states R6 has mild loss / 75% of Norm. to left and right wrist and fingers (flexion and extension) and left and right shoulders. Record review on 9/10/20 of R6's Restorative Nursing Review dated 9/9/20 completed by V16 states moderate loss /50% of norm to left and right wrist and fingers. Left and right shoulders state fixed/ no joint mobility. The facility's undated Procedure for facility Restorative Nursing Programming goals to assist a resident in reaching or maintaining his/her highest level of functioning are resident specific, realistic, measurable, and correspond to identified resident rights.

Based on interview and record reviews, the facility failed to follow its policy on preventing falls and implementation of fall risk interventions to reduce or prevent the risk of falling for one (R7) of five residents reviewed for fall prevention. This failure resulted in R7 falling from bed, then being sent to the hospital for evaluation where R7 was diagnosed with [REDACTED]. Findings include: R7 is an [AGE] year old. female, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to R7's MDS (Minimum Data Set) dated 4/10/18, she (R7) has short and long-term memory problems. Per MDS also, R7 does not have bed alarm. Fall risk review dated 4/10/18, 4/16/18, 6/3/18 and 6/8/18 all documented that R7 had been determined to be high risk for falls. R7's Physician order [REDACTED].>7/17/2015: Bed sensor alarm while in bed 7/17/2015: Bed sensor alarm while in bed, and low bed/floor mats. R7's care plan on fall dated 10/10/17 documented the following interventions: Gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future recurrence. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all request for assistance. Anticipate and meet needs. Complete fall risk assessment per facility protocol. R7's care plan on fall also documented the following interventions: 4/16/18: sent to hospital emergency for evaluation. No updated interventions was made on 4/16/18. 6/3/18: fall mats bilaterally. R7's progress notes dated 4/16/18 documented: had a fall incident and was found on the floor turned on her left side. Denied any pain, able to move extremities, no apparent injury noted. Was sent to the hospital for evaluation. Hospital records dated 4/16/18 Discharge Summary indicated that R7 came to the hospital with Primary [DIAGNOSES REDACTED]. X-rays were done as follows: CT (Computerized Tomography) cervical spine and CT brain without contrast both revealed negative results. R1 came back into the facility on the same day. R7's progress notes dated 6/3/18 documented: R7 lying on the right side of her bed. No apparent injuries were noted, able to move all extremities within normal limits. Was sent to the hospital for evaluation. Ambulance report dated 6/3/18 documented: Called to (name of facility) for an [AGE] years old female for a fall. Upon arrival, nurse reports at 11:45 AM the patient was found lying right lateral recumbent on the floor next to her bed apparently having a fall. Trauma assessment reveals bruising on the right upper extremity. Hospital records dated 6/3/18 indicated that R7 presented to the emergency department (ED) due to an unwitnessed fall in the nursing facility. The ED notes also revealed that during general examination of R7's extremities, tenderness was appreciated with palpation over left elbow, shoulder and clavicle. ED notes also documented that R7 had bruising noted to the right forearm, moving all extremities. Diagnostic work-ups as follows: Head CT ; Cervical spine CT; RAD ([MEDICAL CONDITION] dose) Shoulder and RAD elbow, left were all done and all tests indicated no fracture or dislocation noted. There were no diagnostic or x-rays done on R7's lower extremities per hospital records. R7 was readmitted back into the facility on [DATE]. R7's progress notes dated 6/10/18 documented: V15 (RN) was alerted that R7 was observed with a bruise. V15 went to see R7 which she performed assessment and noted a discoloration on R7's lateral aspect of left thigh. V14 was notified and ordered to send R7 to the hospital for further evaluation. Hospital records dated 6/10/18 on Clinician History of Present Illness Summary stated that R7 was brought due to a chief complaint of left posterior thigh ecchymosis noted by the nursing facility today. Radiology reports as follows: 6/10/18: Femur 2 or more views left; History: Left leg pain status [REDACTED]. 6/11/18: CT Lower extremity left without contrast; History: Left leg fracture; Impression: Impacted distal femoral metaphyseal fracture without intra-articular extension of the fracture line. On 11/15/18 at 2:55 PM, V11 (Licensed Practical Nurse, LPN) was interviewed regarding R7's fall incident last 4/16/18. V11 stated, I was going upstairs from a break and I heard her (R7) from the door asking for help so I went to her (R7) room. She (R7) was on the floor, side of the bed, lying on her (R7) left side asking for help. At first, she (R7) denied any pain, when we turned her, I was with a nurses' aide, don't remember the aide's name, she (R7) complained of back pain. There were no visible injuries and she (R7) can still move her (R7) extremities except the contracted right knee. We put her (R7) on the bed, she (R7) was moaning in native language. I asked her (R7) and said back pain. I gave her (R7) PRN (when needed) pain , I notified V14's office and was told to send out R7 to the hospital for evaluation. She (R7) doesn't know how to use call light and doesn't talk at all. I don't remember if there's any bed alarms at that time, otherwise it will go off. I didn't hear any sound at that time, we just monitor her closely. On 11/15/18 at 3:14 PM, V12 (LPN) was asked regarding R7's fall incident last 6/3/18. V12 stated, V16 (CNA) came to me and told me that R7 was on the floor on the side of the bed. What I remember was I saw her (R7) lying on her side, on the floor. We both took the lift and brought her (R7) back to bed. I did a full body assessment - no redness on parts of the body, able to move her (R7) extremities without any indication of pain. She (R7) was confused, not so verbal and unable to relate to me what happened with the fall. I called V18 (Physician) and ordered to send her (R7) to the hospital. I always remind CNAs to always make sure that her (R7) bed is lowered and fall mats in placed. I don't remember if she had a bed alarm. On 11/19/18 at 12:05 PM, V15 (RN) was asked regarding R7's bruise noticed last 6/10/18. V15 stated, I worked 7-3 shift. Afternoon shift came, it was V17 (CNA) who changed her (R7) incontinent brief and noticed a bruise and told me. I went to her (R7) room and saw a bruise on the lateral aspect of her (R7) left thigh. So I called V14 and explained the situation and ordered to send her (R7) to the hospital. When I went to her (R7) room, she (R7) is not that verbal, unable to verbalize any pain. Bed is in low position. I don't remember if there were siderails up that time, I don't remember if fall mats were there. She (R7) is not high risk for falls because she (R7) has never fallen on my shift. I don't remember any chair/bed alarms because she has not fallen on my shift and she (R7) doesn't need any alarms. I was not informed that she (R7) is a fall risk. I didn't look into her care plan to find out if she needs interventions for fall prevention because there's not any condition that made me review her (R7) care plans. On 11/19/18 at 12:50 PM, V17 (CNA) was asked regarding R7's bruise. V17 stated, I was the one who noticed the bruise on her (R7) left thigh. I was doing patient care when I went to change her (R7) and noticed the bruise on her left thigh. I reported it to V15. She (R7) doesn't talk that much. That time when I noticed the bruise, she (R7) wasn't moving, bed was low, fall mats were there. I don't remember if she has a bed alarm. I don't think she has an alarm in bed because she doesn't need it. She (R7) was bedbound. Yes, 100% there was no alarm on her (R7) bed, not that I remember. I have never known her (R7) to fall. She (R7) is not a fall risk at all. V16 was also interviewed regarding R7's fall incidents and verbalized does not remember the fall incidents anymore. On 11/20/18 at 10:30 AM, V2 was asked regarding falls. V2 stated, There is a Falling Star Program which the Restorative Department is the one running the program. I oversee this program. When a patient comes in, the restorative department assessed the resident and if they are high risk for falls they will be evaluated and if they are needed to be in the program. If a resident had a fall incident, it automatically include that resident in the falling star program. If a resident had a fall incident, the IDT (interdisciplinary team) consisting of Social Services, Nursing, Administration, Restorative, Activities do a morning meeting but other than that, we meet every week to talk about fall interventions. The Restorative Department is responsible for notifying the nurses and CNAs with regards to fall interventions, regardless if resident had not fallen on their shift, that resident is still considered to be high risk and fall interventions need to be implemented. We have bed pad alarm and chair alarms as part of the interventions in preventing falls. For residents who are bed bound, bed pad alarm is to be used. On 11/20/18 at 12:02 PM, V19 (LPN/Restorative) was asked regarding R7 and the Falling Star Program. V19 stated, This is the program for the facility for falls. When someone had a fall, IDT meet and go over interventions to be taken into place. We place a falling star sign next to their names by the door in their rooms so staff would know if they are high risk for falls. I don't remember R7 as high risk because she was bed bound. I cannot recall when we placed her on the falling star program. V19 continued, In preventing falls and future falls, we need to place fall mats, bolsters, place resident in a room close to nurses' station, if resident is confused and doesn't know how to use call light - an alarm is to be placed depending on the team's decision and doctor's orders. On 11/21/18 at 10:40 AM, V30 (Medical Director) was interviewed regarding falls and fractures. V30 stated, If a resident had fallen and there were no complaints of pain or any bruising at the time of fall, then a week later complained of pain or a bruise had developed and x-ray can confirmed fracture. The hurting, bruise and swelling may not show up at the time of fall but it developed over time and may not show up like in an oblique fracture. V30 was asked on expectations on staff regarding interventions in preventing falls. V30 further stated, The goal is no fall incidents as much as possible. Fall precautions should take in place both for low and high risk individuals. The use of bed and chair alarms, supervision, lowered beds and fall/floor mats should be part of the interventions in preventing falls. We cannot confine the residents all the time so we also need to provide mobility and exercises. For bed bound and confused residents who are excited to get out of bed, bed alarms should be placed since they don't follow instructions and fall/floor mats should be in placed at all times. Facility's policy titled Policy and Procedure Falling Star Program revised date 05/2012 documented in part: Purpose: To evaluate a resident for the potential risk of falling and plan appropriate measures and interventions to reduce or eliminate those risks. Policy: 5. A Plan of Care will be initiated utilizing fall prevention strategies to reduce or eliminate each resident's fall risk. 6. Every fall incident will be reviewed by the IDT Committee to determine whether fall interventions are appropriate. 8. Upon fall incident the following procedure will be completed: The resident's care plan will be updated with new interventions for any identified risk factor that was identified. If the resident had not previously been placed in the Falling Star Program, the resident will be assessed for the program. Safety movement devices will be used as an integral tool to prevent unassisted ambulation and to prevent/reduce resident falls. All alarms and sound monitors will be installed according to manufacturer recommendations. Facility's policy titled Incidents/Accidents/Falls, undated, stated in part: Procedure: 15. Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place.

Based on observation, interview and record review, the facility failed to provide physician-ordered pain medications prior to performing wound care for 1 of 13 residents (R95) reviewed for pain from a sample of 28 residents. This failure caused R95 to endure excruciating pain during wound care procedures for a facility-acquired stage-4 pressure sores. Findings include: Per facility face sheet dated 7/25/18, R95 is an [AGE] year old resident with [DIAGNOSES REDACTED]. R95's BIM (Brief Interview for Mental Status) score was unable to be recorded on the latest MDS (minimum data set) dated 6/16/18 as it shows severe cognitive impairment. On 7/24/18 at 9:30 AM V5 (Wound Care nurse) and V6 (Certified Nurses Aide) were prepared to conduct wound care on R95 who was in a supine position with head of bed at 45 degrees. Resident was turned to her right side by V6(C.N.A) and R95 was audibly moaning and groaning with a grimacing facial expression. V5 and V6 did not ask R95 if she was okay and proceeded as V5 peeled off the sacral dressing as R95's moaning grew louder. The exposed wound revealed a softball sized wound with purplish darkened edges. Asked to describe the wound, V5 stated, It's a stage 4 pressure injury of the sacrum. She's been on hospice for six months but she got this wound in the facility. It last measured 4.5 X 7.5 X 0.4 centimeters deep has undermining from 12:00 to 12:00 and tunneling between 9:00 and 10:00. She has about 30 percent slough which has decreased to 25 percent slough wound edges are unattached. She also has a DTI (Deep Tissue Injury) on her left toe. Hospice comes about once a week every Monday. It's really a non healing wound. The size has increased and there's more tunneling. I pack it with [MEDICATION NAME] gauze and cover it with foam dressing. At the end of treatment a wedge cushion was placed on resident's left side at 9:54 am. V5 proceeded to show wound of left big toe and placed [MEDICATION NAME] to left open toe area. Asked if R95 is in pain, V5 stated, She's like that. She got something at 6 AM. Asked about a gauze covering the left upper ankle area V5 stated, Its just a foam cover to protect her foot. she doesn't have a wound there. Asked if it can be seen, V5 removed the gauze cover to reveal a wound and again R95 moaned aloud but continued on with the procedure. V5 stated, It looks like the dressing was not effective so I have to measure it and document this new wound. It measures 0.5 cm x 0.3 x no depth. It's non-blancheable redness located on left foot upper dorsal foot. I use a protective dressing to put over it. At 10:01 AM after the completion of the wound treatments, V5 (Wound care nurse) asked her CNA (V6) to go out and ask the floor nurse if she can be given anything in between (meaning pain medications). Asked what they should do when a resident shows signs and symptoms of pain, V5 stated, I was told she got something at 6:00 AM. I asked V6 to ask the nurse to get an order. Asked again what she would do if R95 was exhibiting signs and symptoms of pain, V5 repeated, I was told she got something at 6:00. R95's Physician order [REDACTED]. Give 2 tablets by mouth every 6 hours as needed for elevated temperature but not specific to wound care. There were no other physician orders [REDACTED]. Further review of R95's MAR (Medication Administration Records) for (MONTH) (YEAR) and (MONTH) do not show any type of pain medication given to R1 prior to wound care. Review of R95's current care plans do not address pain related to pressure sore treatments. 7/25/18 interview at 11:00 AM with V2 (Director of Nursing) states, I expect that the nurses treat pain and manage pain for every resident experiencing pain. Depending on the resident condition as each is individual, nurses should evaluate and treat pain as they see it. If their current pain regime isn't working, it should be re evaluated and obtain needed pain medications from the doctor. 7/25/18 interview at 3:00 PM with V11(Physician) states, I'm the hospice doctor on the purple team where we see a group of patients but I am familiar with ( R95). Our goal is supporting the family, managing end of life issues, and yes pain management is one of those as our objective is to keep the resident comfortable and pain free. I recommend that before wound care they (staff) pre-medicate any resident at least one hour prior to conducting any wound care. There are a couple of options staff can do if the patient is experiencing pain during wound care and one of them would be (and depending on how far along they are with the wound care) either finish the wound care if almost done or give more pain medication if it is within the timeframe the nurses can give more. If she was already exhibiting signs and symptoms of pain then I would not have started the procedure at all. Stage 3 or 4 pressure ulcers are very painful. I believe she should have had the [MEDICATION NAME] 5 mg upon admission to hospice as that is a standing order for all our patients and I see as I have her chart in front of me that that should be part of her medications the staff should have been providing. Review of facility medication administration records for (MONTH) and (MONTH) of (YEAR) do not show any pain medications administered prior to the wound care procedure conducted on 7/25/18. Facility's undated policy titled, Management of Pain states, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: promptly and accurately assessing and diagnosing pain; encouraging residents to self report pain; aggressively assessing pain in nonverbal and cognitively impaired residents; Monitoring treatment efficacy and side effects; Monitoring and minimizing anticipated pain when possible; Using non-pharmacological and complimentary and alternative medicine when appropriate. Nursing observation is an important part of the pain assessment, especially in the non verbal resident. Nursing will observe behaviors that may indicate pain in the nonverbal or cognitively impaired resident. Pain may be indicated when there are changes in the following: facial expressions, vocal behaviors, body movements, routines, mental status. Abstract literature from Ostomy Wound Management dated 2009 states in part, Pain is an ever-present problem in patients with pressure ulcers. The literature established that 1) pressure ulcers cause pain; 2) pain assessment was typically found to be self-reported using different versions of the McGill Pain Questionnaire, Faces Rating Scale, or Visual Analog Scale; 3) pain assessment instruments should be appropriate to patient cognitive level and medical challenges; 4) in some cases, topic medications can ease pain and although information on systemic medication is limited, pain medications have been found to negatively affect appetite; and 5) wound treatment is painful, pain on nutrition, and pressure ulcer pain considerations for special groups (e.g., children, end-of life patients, and bariatric patients.) The NPAP (National Pressure Ulcer Advisory Panel) presents this white paper as the current scientific knowledge base on the topic. Pain is an ever-present problem in patients with pressure ulcers. As a protective physiologic mechanism, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Irrespective of a patient's age or health status, pressure ulcer pain needs to be assessed and treated because it has widespread physical and psychosocial implications for the patient, family and clinician. Pathophysiology of Pressure Ulcer Pain: Pressure ulcer pain may be caused by tissue trauma from sustained loads, inflammation, damaged nerve endings, infection, dressing changes, debridement, operative procedures, and other treatments. The skin has more sensory nerves than any other body organ. As the pressure ulcer cellular damage expands, chemicals are released that irritate nociceptive nerve terminals. Nociceptive pain is an appropriate physiological response to a painful stimulus and involves acute or chronic inflammation.

Based on observation, interview and record review, the facility failed to ensure policies and procedures for aspiration precautions and meal services were followed. The facility failed to adequately supervise residents on aspiration precautions that affected three of three residents (R1, R2 and R3) reviewed for supervision in a sample of nine. The facility also failed to identify a resident choking in the dining room, which resulted in R1 dying due to asphyxia and choking from a food bolus. Findings include:R1's nurse progress note by E5 (Licensed Practical Nurse/LPN) reads in part: Late Entry[DATE] (3:53PM) Type: Incident note - 12pm - Res (resident) in dining room, having lunch, in stable condition, no Resp (respiratory) distress noted. 12:30pm - Reported by CNA (Certified Nursing Assistant) to check Res, went to dining room immediately with team 1 nurse and observed Res unresponsive, head was slumped to side, skin cool and pale, one arm was on the table, one arm was down, carotid artery pulse palpable but very weak, unable to take BP (blood pressure), no breath sounds noted, code blue called. Rechecked VS (vital signs), unable to obtain pulse at this time, CPR (cardiopulmonary resuscitation) initiated, 911 called, MD (medical doctor) notified, called brother but no answer, left voice message. 12:40pm - Chicago Fire Dept (department) arrived. 1:10pm- skin turned pink, started breathing, peripheral pulses palpable. 1:20pm - Sent to (local) ER (emergency room ) (4:20pm)- Receive phone call from (local hospital), Res passed away at ER and nurses are trying to talk to brother. The fire department's report reads in part: [DATE]:Time dispatched - 12:36pm1st on scene -12:38pmPatient contact - 12:40pmAmbulance arrival: 12:50pmPt (patient) found lying in 3rd floor dining room, CPR in progress, in care of RN (registered nurse) staff. According to staff, Pt was eating a large piece of sausage which he aspirated. Upon transition of care, CPR was maintained, monitor pads applied, and attempted to ventilate Pt. Pt airway was opened and (forceps) were used to remove several pieces of large sausage from the Pt upper airway and lower airway (beyond the vocal cords). Incident type- person unconscious not breathingCause - Foreign bodyComplaint - UnresponsiveAmbulance called to location to find unresponsive [AGE] year old male on the floor with CPR being performed by (Local Fire Department) truck. Per Truck, patient was eating his lunch in the nursing home and began to choke on food. When truck arrived patient was pulseless and apneic. Truck was able to remove a large amount of the airway obstruction. Patient was in asystole upon arrival. CPR continued and ALS (advanced life support) cardiac arrest protocols initiated. R1's Hospital records reads in part:Emergency Physician Evaluation - [DATE] - Patient is a [AGE] year-old male brought in by EMS (emergency medical services) from the nursing home in full cardiopulmonary arrest. According to EMS they got a call for a person unresponsive and not breathing. When he arrived they found the patient cyanotic with the staff doing chest compressions. EMS attempted to intubate him and found several large pieces of sausage blocking his airway which they removed with (forceps). R1's Certificate of Death Worksheet reads in part: date of death : [DATE]Cause of death: a. Asphyxia b. Choking on food bolusDescribe how injury occurred: Choked on food bolus On [DATE] at 3:24pm, E3 (Certified Nursing Assistant/CNA) stated in part, during lunch time, she was in the dining room observing residents. (E4/CNA) was feeding (R4) and when (E4) was done, (E4) said she was going to leave to check if anyone else needed assistance with feeding. E3 stated she said ok, then she stayed in the dining room. (E1/Administrator) came in with a guest (Z1/Administrator in Training) and there were still trays on the table. E3 stated she asked (E1) to watch the residents while she was going to get the food cart to get the rest of the trays that were left in the dining room. E3 stated that (R1) did not have a tray and did not have any food. E3 stated she got the food cart, picked up the trays and told (E1) that she was going to push the trays and cart back to the elevator. E3 stated when she was pushing the cart, that's when all of this happened. (E1) came out the dining room and said (R1) needed help. E3 said she and (E5/Licensed Practical Nurse/LPN) ran in the dining room. E3 said that (E1) called the nurse and (Z1) was trying to help. (R1) was in distress and needed help. (E5) was sweeping (R1's) mouth. E3 stated she assisted by clearing the tables and helping (R1) to the floor and then wheeled other residents away in the hallway and doesn't know what else happened. E3 stated that she doesn't remember (R1) with any food in the mouth and was not choking. On [DATE] at 10:16am, E1 stated in part that (E3) and (E6/CNA) took trays out of the table and were putting them in the carts when he found (R1) unresponsive. E1 stated he left (Z1/Administrator in Training) with (R1) and ran to the nurse's station and called (E5) for help. E1 stated that was no food and there was no tray by (R1). E1 stated that (E3) told him that (E3) was going to put trays in the carts and that's when he stayed in the dining room to introduce (Z1) to the residents. E1 stated that there were no CNA's or nurses at the dining room at the time (R1) was found unresponsive and that he is not clinical. (R1) looked like (R1) was sleeping. E1 stated that (E5) was the first one present in the dining room and code blue was initiated. E1 stated that (R1) left with a pulse and died at the hospital due to cardiac arrest and that this information was from the hospital and (R1's) attending physician (Z2). On [DATE] at 10:06am, Z1 stated that on that day (,[DATE]), she was touring with (E1) at the dining room and (E1) went over to (R1) who appeared to be unresponsive. (E1) said, sir, sir and ran and got some help. Z1 stated she was left in the room, and tried rubbing (R1's) shoulder, but (R1) was not responsive. Staff came within less than 10 seconds. Z1 stated she did not do the Heimlich maneuver or CPR. Z1 stated she has no clue if (R1) was choking because she is not clinical and just knew that (R1) was not responsive. There were no other staff except for (E1) when (R1) was found unresponsive. On [DATE] at 12:39pm, E5 (LPN) and E8 (LPN) were interviewed. E5 stated in part that her and (E8) were at the nurse's station. E5 stated that (E3) called her, so she and (E8) went to the dining room and found (R1) blue, with face/chin down to the chest, head down and not responding. (R1) was pale and skin was cold. E5 stated that she tried to wake up (R1), tried to clean (R1's) mouth because she saw food in (R1's) mouth, on the table, and on the floor. E8 stated that, (R1) is a big guy, so she held (R1's) head while (E5) was sweeping (R1's) mouth until all the food was out. (R1) was still unresponsive, called code blue. E5 stated this happened about 12:30pm when (E3) was around there and other CNA's were feeding, cleaning tables and helping other residents. While (R1) was still in the chair, (E7/Assistant Director of Nursing) tried doing the Heimlich (maneuver) but was not successful. (R1) was assisted to the floor. Everyone came in to help, tried CPR and called 911. On [DATE] at 11:58am, E6 (CNA) stated in part that she was assigned to (R1) that day and (R1) was not at risk for choking. E6 stated that only one cart of trays came up. (R1) ate lunch from the first cart. (R1) was done eating, but there were still other residents eating because the other two carts filled with trays came in later. E6 stated she picked up (R1's) tray, and (R1) said he was finished. E6 stated that there was another CNA in the dining room, so she left to go feed another resident. E6 stated while she was feeding, she heard the code blue and ran to the dining room. On [DATE] at 12:39pm, E11 (CNA) stated in part that she was not in the dining room during lunch time the day the incident occurred. E11 stated that her resident was adamant that she give the resident a shower so that is what she was doing at the time. On [DATE] at 3:08pm, E4 (CNA) stated in part that (R1) was not at risk for choking or had aspiration precautions that she knew of. E4 stated that they have to monitor all residents. E4 stated that she went downstairs to bring the carts filled with trays and that's when she heard the code blue. E4 also stated that during lunch, residents were eating polish sausage, vegetables and bread. E2 (Director of Nursing) provided an interview written statement by E12 (CNA) reads in part: [DATE] When the tray came up, I passed the tray and gave him his tray. He was in a playful mode and I sat his tray in front of him. There were 3 staff members in the dining room during lunch passing trays. I went and fed a resident after passing out trays and left other staff members in there. After I was done feeding my residents I went back and helped to pick up trays and I noticed the resident sitting up in his chair watching TV (television) with no distress; I did not notice any chewing movements and he was calm looking towards the TV as usual. After we finished picking tray I went down and heard a code blue. On [DATE] at 1:39pm, E2 stated in part that she faxed an initial report to IDPH (Illinois Department of Public Health) on [DATE] before 3pm even though the fax sheet says 1900 (7PM) that CPR initiated, 911 called. MD (Medical Doctor) notified and ordered to send resident to ER for further evaluation. Notifications made. E2 stated that she responded to the code blue, when she got there, (R1) was being transferred to the floor from the chair. E2 stated she guided and did CPR, they suctioned food particles that looked like meat and mixed vegetables out of (R1's) mouth. The paramedics asked if (R1) was eating, but (R1) said (R1) was done eating. (R1) was on a regular diet, no aspiration precautions. Staff are to observe residents in the dining room, monitor those who gets fed, and make sure if any type of concern occurs that someone is there to address or call appropriate person. E1 stated that no one saw (R1) choke and no one said (R1) was doing the universal sign that (R1) was in distress. (R1's) last speech evaluation was in 2014. Any resident on aspiration precautions, have to make sure, at least can be seen at all times when they are eating. Staff are to visualize what person is doing and must be in sight. Staff should know who they are supposed to look at for those at risk of choking, those who are not eating, those who need cueing, repositioning to upright position, and be mindful and careful, provide comfort and support. E1 also stated that she sent the final report to IDPH on [DATE] at 6:07pm that reads resident who is alert and oriented .was noted unresponsive. E1 said she spoke with the physician who stated with co-morbidities, (R1) had a cardiac arrest. E1 stated that she did not mention to (Z2) that (R1) had food in (R1's) mouth. On [DATE] at 12:37pm, E7 (Assistant Director of Nursing) stated in part that she heard a code blue called, (R1) was in the dining room, unresponsive, CPR initiated. E7 stated she did not do the Heimlich maneuver. E7 stated in part that she didn't think (R1) was on aspiration precautions. E7 stated that for those on aspiration precautions, staff are to monitor them, supervise during meals, make sure no signs of aspiration. The expectations are for staff to continuously monitor, supervise and usually someone is in the dining room doing this. If patient refuses to go to the dining room, then staff need to monitor by staying close by and provide supervision where staff can see the patient. If someone is choking, nurses are to perform the Heimlich maneuver and try to help that patient. Patient's usually give a universal sign of choking. On [DATE] at 2:05pm, Z2 (Attending Physician) stated in part that they called her and the nurse said (R1) was unresponsive and called 911. Z2 stated that she received a fax from the hospital saying that (R1) had a cardiac pulmonary arrest. Z2 stated that her office cannot find the fax. Z2 stated that (R1) was diabetic, hypertensive and had MS (multiple sclerosis). (R1) may have had history of dysphagia, but she did not know of any recent problems. (R1) may be on aspiration precautions, and that should be done for all residents in a nursing home. Z2 stated that she was shocked when the staff said (R1) was unresponsive. Z2 stated that staff did not tell her anything about any food found in (R1's) mouth. If staff did tell her, then (R1) could have aspirated. If there was food, they would see (R1)choking on food and staff could have performed the Heimlich maneuver. Z2 stated that those on aspiration precautions, staff are to watch them eat, encourage to eat slowly, and not very fast. On [DATE] at:-11:24am, R5 stated in part that he was in his room and (R1) was eating in the dining room. (R1) either had a heart attack or was eating too much. (R1) is deceased . -11:30am, R6 stated in part that (R1) was his roommate and (R1) died . (R1) was in the dining room during lunch and staff told him that (R1) was eating and choked. -12:25pm, R7 stated in part that she was eating in the dining room and (R8) was eating by (R1). R7 stated (R1) was at the table behind her and someone said (R1) was turning blue. Multiple other residents were interviewed and stated they did not witness anything in the dining room. R1's [DATE] Physician Medication Review Report reads in part:[DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] shows that R1 needs supervision and one person physical assist for eating. R1's Interdisciplinary Plan of Care reads in part: [DATE]-Concern - The Resident's Nutritional Status is/may be potentially compromised, and is / may be at risk for weight loss r/t (related to) Dx (diagnoses) and order for therapeutic diet.Interventions: Aspiration precautions[DATE] - Needs/Problem - Impaired swallowing related to Dysphagia Goals - Will have no choking episodes with eatingWill have no s/s (signs and symptoms) of aspiration - [DATE] On [DATE] at:-11:47am, R2 was eating lunch in R2's room near the back wall, with no staff present. R2 was not visible from the nurse's station and hallway. During continuous observation until 11:57am, there were no staff members watching R2. At this time, E8 (LPN) followed the surveyor in R2's room. E8 asked R2 if R2 needed anything. R2 had consumed 75% of the meal. E8 left the room. -11:59am, R3 was sliding down in bed, the head of the bed not at a 90 degree angle (approximately 45 degrees), with the over the bed table in front of R3. R3 was eating lunch in the room with no staff present, feeding self without utensils. -12:05pm- R2 was still in the room, drinking soup, with no staff watching R2. -12:06pm - E11 walked out of R3's room and said in part that (R3) was not done eating yet, she just checked and (R3) still eating. R3 was not repositioned and was not sitting upright in a 90 degree angle. -12:08pm- R2 was still in room, slight cough while drinking milk with no staff watching R2. -12:12pm- R3 was in the same position, using fingers and hand to finish eating beans, and then drank the juice from the fruit cup. During continuous observation until 12:21pm, E11 walked in to pick up R3's tray. E11 stated in part that (R3) gets out of bed for meals on Mondays, Wednesdays and Fridays. Today is Tuesday, so (R3) stays in bed. -5:22pm - dinner arrived. R2 and R3 were in the dining room. R3 was facing towards the window (north) and R2 was at the same table facing east. Staff were passing out trays. -5:29pm, E9 (Restorative CNA) was the only staff member present in the dining room, with R3's back facing towards E9's view. -5:48pm, E12 (CNA) walked in the dining room stated in part that there's usually one CNA who does not have feeders, so today it would be her in charge of watching the dining room. The surveyor asked E12 why she was not at the dining room monitoring residents during dinner. E12 responded, I was passing out trays.From 5:30pm - 5:50pm, there were four times when there were no staff members present while 15 residents were eating in the dining room, and no staff members were looking in at neither 4 doors of the dining room. E9 was feeding R4, but repeatedly left the dining room. While E9 was feeding R4, E9 was sitting at the south end of the room, where there was a wall obstructing her view of R2 and R3. At 5:50pm, there was no one in the dining room. R3 was drinking milk and R2 finished dinner. R2 asked the surveyor, can you help me get out of here? The facility's Diet Type Report dated [DATE] reads in part:R2 - NAS/NCS, mech (mechanical)/soft, thin liquids, Additional directions: Aspiration precautionR3 - NAS, mechanical soft, thin liquids, additional directions - 1:1 supervisionR2's MDS with ARD of [DATE] shows that R2 needs supervision and one person physical assist for eating. R2's Comprehensive and Interdisciplinary Plan of Care does not address aspiration precaution interventions and goals as ordered by the physician. R2's Physician Medication Review Report dated [DATE] reads in part: Diet Order Summary - Aspiration precaution R3's Physician Medication Review Report dated [DATE] reads in part: Diagnoses: [REDACTED].R3's Interdisciplinary Plan of Care of Nutrition reads in part:[DATE]:Interventions - Position resident for meals uprightReminders to clear food in cheeksSupervision/cues/encouragementNeeds/Problem - At risk for aspiration R/t (related to) Hx (history) of aspiration PNA (pneumonia)Approaches - 3. Assess for coughing or clearing of the throat after a swallow6. Position resident in upright position for meals9. Allow ample time for swallowing On [DATE] at 11:06am, Z3 (Speech Therapist) stated in part that (R1, R2 and R3) have dysphagia and on aspiration precautions. Any resident on aspiration precautions should eat in the dining room with supervision. Staff should be looking for any signs of having difficulty swallowing, to make sure residents are taking small bites and small sips, and not eating too fast. If any resident is seen coughing during meals, then she is called to evaluate the patient because coughing is an overt sign that something might be going on. On [DATE] at 10:35am, E1 (Administrator) stated in part that there should always be at least one to two staff members assigned to supervise the dining room whose role is to only supervise and not do other tasks such as pass out trays or feed residents.The facility's policy and procedure titled, Aspiration Precautions dated [DATE] reads in part: Aspiration is a common problem among the residents who have difficulty swallowing or dysphagia. Aspiration mean food or fluids that should go into the stomach go into the lungs instead. When such material goes into the lungs it can cause Aspiration Pneumonia. Aspiration Pneumonia can worsen quickly if not properly identified and treated. It is important for signs of aspiration be identified. Procedure:2. After an assessment of the aspiration is completed a plan of care is developed to minimize the risk of aspiration. 3. Residents that have been assessed to be a risk of aspiration will be monitored on a regular basis. The facility's policy and procedure titled, Meal Service dated [DATE] reads in part: It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs including meal service and assistance with eating. 8. Residents will be monitored for appropriate positioning, diet consumed, food preferences and feeding assistance . 0.