Every finding on record at Aperion Care Burbank

Based on observation, interview and record review, the facility failed to provide adequate supervision and interventions for a resident assessed as being at risk for falls. This failure affected one (R9) of three residents reviewed for falls. This failure resulted in harm with injury when R9 was found on the floor in his room and sustained an impacted distal radius fracture to right wrist and reverse obliquity IT fracture of right hip. R9 underwent a surgical procedure of insertion of intermedullary rod to proximal femur.Findings include:R9 is 97 years and has resided at the facility since 2023. Past medical history includes but is not limited to unspecified dementia, other lack of coordination, displaced oblique fracture of lower end of right radius, subsequent encounter for closed fracture with routine healing, other reduced mobility, history of falling, essential primary hypertension etc.On 7/7/2026 at 8:45AM R9 was observed in bed, awake with confusion, hard of hearing but using a hearing device. R9 was asked what happened the day he fell and injured himself and he said, I don't know what happened, I can't remember.Minimum Data Set (MDS) assessment dated [DATE] section c (cognition) documented a brief interview for memory (BIMS) score of 7, indicating that R9 is cognitively impaired. Section GG (functional) of the same assessment documented that R9 requires supervision or touching assistance for eating and partial/moderate assistance for oral hygiene, personal hygiene, and rolling left to right, substantial/maximal assistance for upper and lower body dressing, sit to lying and lying to sitting on side of bed, chair/bed -to-chair transfer, and dependent on staff for toilet transfer, tub/shower transfer, toilet hygiene and putting or taking off foot wear. R9 is dependent on manual wheelchair, requires supervision/touching assistance to wheel 50 feet with two turns, and dependent on staff to wheel 150 feet in the corridor or similar space.Nurse's note dated 5/5/2026 at 00:56:43 (12:56 AM) by V24 LPN (Licensed Practical Nurse) stated the following: Certified Nurse Assistant (CNA) was out in the hallway and heard door slam in R9's room. Writer went to investigate and found resident lying behind the door up against the wall. Slowly and carefully pulled Resident to lie straight on the floor. Body assessment revealed pain in the right wrist with abrasion and right hip pain. 98-90-18-136/64 95% RA (Vital Signs). (Tele-Health Company) called and due to unwitnessed fall with R9 taking Eliquis, to send to ER (Emergency Room) 911. Director of nursing (DON) notified, as well as R9's son.Hospital record dated 5/5/2026 documents in part: History of present illness (HPI), R9 is a [AGE] year-old male, PMHx (Past Medical History) of Dementia (A&O [Alert and Oriented] x1-2, wheelchair bound), Osteoporosis, Prior stable T12 vertebral burst fracture (no operative intervention), Prior PE (Pulmonary Embolism)on Eliquis (described as provoked in 2023, however on chronic DOAC [anticoagulants]), Prostate cancer (diagnosed 20 years ago) managed with hormonal therapy (completed), BPH (Benign Prostatic Hyperplasia), HTN (Hypertension), Chronic sensorineural hearing loss who presented to the ED on 5/4/26 following unwitnessed fall, on anticoagulation, at his nursing facility. admitted for fragility fractures of the R (right) distal radius, R Proximal femur. History obtained from patient and patient's son (POA-Power of Attorney) present in the room. Patient was in his usual state of health until the evening of 5/4/26, when he reportedly got up from his bed / wheelchair at his SNF (skilled nursing facility) to close his door, when he fell onto his R side. No staff were present in the room at the time to witness the event. However, it is likely R9 hit his head. R9 is a poor historian, baseline dementia. Patient does not remember falling. He reports he does not remember much but denies chest pain, dizziness before the fall. He denies any current abdominal pain, chest pain, SOB (shortness of breath), n/v/d (nausea/vomiting/diarrhea). Patients son reports the only medication he is currently on is the Eliquis. R9 at baseline uses a wheelchair due to a previous fall about two years ago. METs (Metabolic Equivalents of task)< 4 at baseline. He is nearly fully dependent on assistance/ devices to ambulate.Imaging: - XR R wrist/ R forearm (5/5) Comminuted minimally displaced fractures of the distal radius with impaction - XR R Hip-. (5/5) Linear oblique fracture across the right proximal femur with extension across the lower medial neck region, intertrochanteric region and proximal femoral shaftOn 7/7/2026 at 12:32PM, V2 (DON-Director of Nursing) said that resident's (R9) fall occurred on 3:00 to 11:00PM shift, resident's bed was close to the window, and he attempted to get up and walk to the door to close the door, resident can get up and make some steps, he should not be ambulating by himself without staff assistance. V2 said that R9 can transfer himself from bed to chair and chair to bed though he is not supposed to do so and V2 has seen him do that in the past. R9 was last seen in a wheelchair by the CNA, R9 then transferred himself to bed, got up from bed and walked to the door and fell. V2 affirmed that he had seen R9 self-transferring from bed to wheelchair but there was no intervention apart from R9 being redirected. Surveyor asked V2 if the redirection worked and he said no.Fall risk assessments dated 1/15/2026, 4/15/2026 and 5/8/2026 all indicated that R9 is at risk for falls. Fall care plan initiated 7/31/2023, revised 4/24/2026 documented that R9 is at risk for falls and injury related to falls. Goal: I will have interventions in place and reviewed as needed to address risk for falls and injury related to falls through next review. Interventions: provide visual cues to use call light for assistance, anticipate and meet the resident's needs, be sure resident's call light is within reach and encourage resident to use it for assistance as needed, bed height to be placed where my feet are flat on the floor, ensure the resident is wearing appropriate footwear. There are no interventions to address R9's confusion or attempt to ambulate independently.IDT fall committee note dated 5/5/2026 documented in part: Per nurse's note, C.N.A heard door slam in room. Resident observed to be lying behind the door and up against the wall. Resident was lying behind door blocking the door. Contributing factors: 6. impaired memory,7. confused, 4. gait imbalance,9. incontinent. Environmental factors: 17. There was already a safety intervention in place. Situational factors: 14. Ambulating without assist.2c. Contributing factors: Resident with dementia, alert with confusion, hard of hearing and requires assistance with ADLs, uses wheelchair for mobility and ambulation. Prior interventions and support provided: call light within reach, bed in low position. 7. Root cause of the fall determined by IDT: resident stated he went to close room door, resident noted with comorbidities that place resident at risk or fall. Due to resident impaired insight to current functional mobility secondary to ------------------------------------------------, resident made attempt to ambulate from one side of room to door which resulted in a fall with injury. Resident considered wheelchair bound and has been since admission.On 7/8/2026 around 3:30PM, V2 (DON) said for residents at high risk for falls, staff are supposed to do more rounds, if a resident refuses assistance it should be reported to the nurse. A confused resident who is at risk of falling with a tendency to get up, staff should not leave them by themselves. R9 probably should have had more supervision, and it should be in the care plan.7/7/2026 at 1:35PM, V35 (R1's POA) said that R9 cannot get up from bed without assistance and have not done so in years. Staff told him that there was too much noise in the hallway, resident got up and walked to the door to close the door, V35 said that is impossible because R9 is hard of hearing and could not hear the noise in the hallway without his hearing device. V35 said that facility then told him that someone put resident in bed and forgot to close the door.On 7/7/2026 at 1:55PM, V22 (Therapy manager) said that R9 has been currently in therapy since May 8th five times a week, they are training him to walk with assistance. Before the fall, resident received therapy and was able to stand and pivot, he is not supposed to walk by himself, can only transfer from chair to bed and bed to chair with assistance. On 7/8/2026 at 4:08PM, V22 said that R9 was trained on a walker the last time he was in therapy prior to the fall, but he was not discharged on a walker, resident was discharged on a wheelchair. V22 added that R9 is not supposed to walk by himself but for confused patients they can try to get up thinking that they can still walk. V22 added that residents who are confused and at risk of fall should not be left unsupervised in a wheelchair by themselves in the room.Physical therapy discharge, date of service 1/2/2026 -3/20/2026 documented that R9 was discharged with an assessment of supervision or touching assistance for chair/bed to chair transfer, sit to stand transfer, roll left to right and lying on side of bed. Ambulation: walk 10 feet- partial/moderate assistance. Walk 150 feet- not attempted due to medical condition or safety concern.On 7/8/2026 at 12:10PM V34 (R9's family member) said that her father (R9) has never walked in years or since he has been at this facility, there is no way he will get up by himself and walk all the way from the window to the door, she told the facility the same thing when they told her that was the cause of his fall.Timeline of incident provided by facility documented the following:8:30PM, R9 observed sitting in wheelchair in the doorway to his room.9:00PM -10:00PM - Staff in and out of room. (No description of R9's location or activity currently).10:06PM, Staff members leave room during final rounds of the shift (No description of R9's location or activity currently).10:08PM- Staff responded to sound of R9 falling and bumping into the door.Review of facility incident report did not indicate whether R9 was in bed or wheelchair prior to the fall according to staff statements and could not account for any staff who transferred resident from wheelchair to bed.Statement from V23 (Restorative C.N.A) documented that she saw R9 sitting in his wheelchair around 9:00PM, V23 was told that R9 refused to be transferred to bed. Statement from V24 (RN-Registered Nurse) stated that R9 was in bed around 8:30PM when she gave him medication, no sign of restlessness, V23 woke resident up to receive medication. Statement from V8 (C.N.A) indicated that R9 was in bed around 9:30PM and 9:45PM and refused to be changed. V8 saw resident in wheelchair in his room around 5:30PM, he was in bed after dinner, V8 did not assist him to bed. Another staff member who is on vacation and could not be interviewed documented that R9 was in his wheelchair around 8PM, then she heard the loud noise around 10:30PM while she was in another room.On 7/7/2026 at 3:03PM V23 (Restorative C.N.A) said that she recalls R9 and remembers the day he had a fall. V23 was busy with another resident when she was called to help get R9 up from the floor. V23 said that the last time she saw resident, he was sitting in a wheelchair in his room, another staff member told V23 that resident refused to be put to bed, resident is a two person assist but can be transferred by one person before the fall. V23 has never seen R9 trying to get up from his wheelchair.On 7/7/2026 at 2:11PM, V24 (RN) said that she recalls R9, she was in the room across from the resident when the certified nurse assistant (C.N.A) informed her that he heard the door slam and the resident was lying on the floor, half against the wall. Resident was pulled up, body assessment completed, R9 complained of pain to right hip and right wrist. V24 said that resident was in bed around 8:30PM when she last saw him, V24 said she cannot tell if resident can transfer by himself but she is of the opinion that resident needs help to transfer. V24 said that resident did not have any indication of restlessness of wanting to get up from bed, V24 has never seen resident trying to get up, he is compliant with care and has never refused any type of care with her.On 7/8/2026 at 3:45PM, V8 (C.N.A) said that he remembers the day R9 fell, it happened on evening shift, V8 was in another patient's room around 8:30PM and finished around 9:15PM, V8 opened the door to R9's room, the nurse was in the room and told him that resident fell. R9 was in bed early, after dinner between 7:00PM and 7:30PM, V8 stated that he did not transfer R9 to bed, resident can be transferred with one person before the fall because he can stand and pivot, V8 has not seen resident walking, cannot remember if resident is a fall risk or had any fall precautions.Fall prevention policy revised 12/17/2025 stated in part:Purpose: to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance programs will monitor the program to assure ongoing effectiveness.Standards:A fall risk assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines.Safety interventions will be implemented for each resident identified at risk.Fall safety interventions may include but are not limited to:The bed will be maintained in a position appropriate for resident transfers.Each resident will be screened by a specialist therapist at the time of admission, quarterly, after each fall, as appropriate, and with significant change in resident's mental and functional abilities.Residents who require staff assistance will not be left alone after being assisted to bathe, shower or toilet,

Based on observation, interview and record review, the facility failed to ensure food was served at temperatures that were palatable and attractive. This failure affected all 48 residents that consume food/beverages from the facility's kitchen. Findings include: Facility census (7/6/2026) documents 50 residents reside in the facility. 2 residents are NPO (nothing by mouth), therefore 48 residents consume food from the kitchen. Facility grievance log (1/1/2026-7/6/2026) documents nine concerns related to the facility's food and food preferences. R25's face sheet documents R78 is a [AGE] year-old resident with active diagnoses including acute cystitis, klebsiella pneumoniae, chronic obstructive pulmonary disease, congestive heart failure, anemia, muscle wasting and atrophy, neuromuscular dysfunction of bladder, and unspecified cerebral infarction. R25's minimum data set (6/16/2026) documents a brief interview of mental status (BIMS) summary score of 13, indicating R25 is cognitively intact. On 7/6/2026 at 10:30 AM, R25 explained the food here is s****. It's cold, it tastes bad. Yes, they (staff) know. It's s**** all the time. R24's face sheet documents R24 is a [AGE] year old resident with active diagnoses including acute and chronic respiratory failure with hypoxia, intervertebral disk degeneration, hemiplegia/hemiparesis following cerebrovascular disease affecting the left side, peripheral vascular disease, combined systolic and diastolic heart failure, and osteoarthritis.R24's minimum data set documents a brief interview of mental status (BIMS) summary score of 11, indicating R24 has cognitive impairment.On 7/6/2026 at 10:30 AM, R24 stated the food's not great, not up to my (R24's) standards. It's not what I am used to, doesn't have any seasoning. It often comes to my room cold. It's just not good. Facility weekly menu (approved 3/2/2026) documents the lunch served on 7/7/2026 was ranch baked chicken, potato wedges, buttered carrots, margarine, mixed fruit dump cake and a beverage. On 7/7/2026 at 12:22 PM, observed V31 (Cook) prepare a test tray for the survey team from the steam table in the kitchen. V31 plated a portion of carrots and potatoes. The potatoes appeared to be chunks of cut up potatoes with skin on and lacked seasoning. V31 weighed the chicken, placed it on the plate, and placed a dinner roll on the plate. The margarine, cake, and beverage were not provided with the test tray. V9 (Dietary Manager) affirmed the thermometer was properly calibrated and tested the temperatures of the food on the test tray. Initial temperatures of the food on the test tray were chicken: 123 F potatoes: 91 F and carrots 102 F. Observed steam table was turned on to the high setting, however minimal steam was observed billowing from the steam table. Surveyor placed hand approximately one inch over the water in the steam table, which felt mildly warm. V31 and V9 affirmed the steam table was operational. The plate was covered and added to the tray cart. On 7/6/2026 at 12:33 PM, the final lunch tray was passed to the residents. The temperature of the food on the test tray at point of service was chicken: 105 F, carrots: 91 F, and potatoes were 88 F. Temperatures were confirmed with V9 (Dietary Manager). Test tray was consumed; the carrots were lukewarm, the potatoes were cold and unseasoned, lacking any flavor. V9 affirmed food should be served at a palatable temperature when served to residents. On 7/7/2026 at 12:25 PM, V2 (Director of Nursing) explained food palatability is important so residents will want to eat the food and consume adequate nutrition. On 7/7/2026 at 12:30 PM, V5 (Nurse Practitioner) affirmed V5 has heard complaints from the residents about the facility's food. V5 recalled the complaints were related to food being unseasoned or not serving food from resident's ethnicities, such as Hispanic or African American. V5 explained in African American cultures, they typically have more seasoning in the food. Facility policy titled Menu Planning and Requirements (2020) documents menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served. Planned menus take into consideration cultural backgrounds and food habits of residents.

Based on record review and interview, the facility failed to develop and implement a comprehensive, written Quality Assurance and Performance Improvement (QAPI) plan, failed to include documentation demonstrating the evaluation of the effectiveness of corrective actions or performance improvement activities, and failed to document a process/protocol for conducting systematic Root Cause Analyses (RCA). These failures have the potential to affect all 50 residents residing in the facility.On July 8, 2026, at 1:00 PM, review of the facility's QAPI Plan-Aperion Care Burbank dated Reviewed 1-5-26 QAPI Plan lacks explicit sections for evaluation of the effectiveness of corrective actions or performance improvement activities and systematic root cause analysis. On July 9, 2026, at 9:00 AM, review of the facility's Quality Binder documents in part, monitoring data collection related to low air loss mattresses not set to the proper weight setting and actions taken including restorative aide will cross reference PCC weight report with residents on low air loss mattresses and labeled weight that is on the air mattress box. This wound/pressure ulcer project started on 7/11/2025 and is an ongoing project with weekly monitoring. However, there was no data or information related to establishment of baseline data and tracking and trending of collected data from July 11, 2025 to current to determine if the facility's interventions were successful and if the goal of zero facility acquired wounds are being met. V1 (Administrator) stated the Performance Improvement Project (PIPs) for 2026 is Falls. The project was identified on 12/17/2025 with a due date of 2/4/2026. The Root Cause or Trends/Review of Data documents 6 Falls total (2 on the night shift, 2 during day shift, and 1 on evening shift). There was no evidence of a root cause analysis performed. Interview with V1 (Administrator) and V4 (Social Services) on July 9, 2026 at 10:35 AM regarding the tracking and trending of required QAPI data, analysis and synthesis of the data to inform interventions, and measuring the effectiveness of actions taken to improve quality of care and services. V1 (Administrator) stated we have a spreadsheet that includes that information. V1 provided a spreadsheet with a 5/29/2026 update. The spreadsheet documents in part header columns titled, Regulation/Focus Area, Findings, Actions Taken, Person Responsible, Follow-up/Support Person, Due date, Audit Tool, Goal/Metrics, To Do., Root Cause or Trends/Review of Data. For Wounds/Pressure Injury, the information under Root Cause or Trends/Review of Data show documentation of 1 Facility Acquired in April. V1 (Administrator) and V4 (Social Services Director) affirmed the root cause analyses which include asking the five why's were not performed for the Wound/Pressure Injury Project and the Falls project. V1 (Administrator) affirmed the QAPI plan lacked a documented process for tracking and trending of required QAPI data, systematic root cause analysis, and evaluation of the effectiveness of corrective actions or performance improvement activitiesOn July 9, 2026, at 1:40 PM, the facility provided printouts of monthly Wound Activity Report from January 1, 2026 to current that summarizes wound assessments for patients with active wounds and a report comparing Facility Acquired vs. Present on admission for the past 3 months which includes a graph displaying quarterly data. There was no evidence of analysis or synthesis of the wound activity report to inform whether actions/interventions were impacting residents positively or negatively. V1 also provided screenshots bar graphs of data showing Falls per 1000 Resident Days, Number of Residents with Facility Acquired Pressure Injuries per 1000 Resident Days, Number of NEW Facility Acquired Pressure Injuries per 1000 Resident Days, Number of Residents admitted to the Hospital per 1000 Resident Days, and Number of Antibiotic Starts per 1000 Resident days. The information on the horizontal axis and vertical axis was not readable and there was no evidence of analysis and synthesis of the monthly wound data from January - June 30, 2026 data. V1 affirmed there was no analysis and synthesis of the data nor evaluation of the effectiveness of corrective actions or performance improvement activities implemented.Review of facility policy titled, Quality Assurance Performance Improvement Program (QAPI) review dated 10/24/22 documents in a part All Performance Improvement Projects (PIPs) are a type of corrective action that generally involves a team making a concentrated effort over time to improve a systematic review. It often requires a systematic investigation, such as a Root Cause Analysis (RCA) to identify underlying causes or factors which have contributed to, or caused the problem. Interventions are designed to address the underlying causes. Once each intervention is implemented, the team closely monitors results to determine if changes are yielding the expected improvement or if the interventions should be revised. The facility did not implement its policy for conducting root cause analysis for two projects (wound/pressure injury project that started on July 11, 2025 and the falls project that started on December 17, 2025; both projects were still ongoing at the time of survey).

Based on observation, interview and record review, the facility failed to sanitize mechanical lift equipment between resident use and failed to handle soiled linen in a manner that prevents contamination. These failures affected two (R17, R18) residents that utilize the mechanical lift and have the potential to affect all 50 residents that reside in the facility. Findings include: R17's Face sheet documents in part that R17 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, aphasia, chronic kidney disease stage 2, type 2 diabetes, hypertension, stage 3 pressure ulcer, and osteoarthritis. R17's Minimum Data Set (MDS) on 6/24/2026 documents in part that R17's Brief Interview for Mental Status (BIMS) score is 12, indicating that R17 is cognitively intact, and that R17 is dependent on staff for dressing and toileting while needing substantial assistance for bathing. R17's Care Plan includes in part that R17 requires enhanced barrier precautions related to chronic wounds (skin impairment to sacrum). R18's Face sheet documents in part that R18 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include type 2 diabetes, spinal stenosis, atherosclerosis, benign prostatic hyperplasia, pressure ulcers, and neuromuscular dysfunction of bladder. R18's Minimum Data Set (MDS) on 4/15/2026 documents in part that R18's Brief Interview for Mental Status (BIMS) score is 10, indicating that R18 has moderate cognitive impairment, and that R18 is dependent on staff for bathing, toileting, and dressing. R18's Care Plan includes in part that R18 requires enhanced barrier precautions related to indwelling urinary catheter (suprapubic catheter). On 7/6/2026 at 10:55AM, Certified Nursing Assistants (CNAs) were observed transferring R17 from the bed to her wheelchair via a sit-to-stand device. No sanitation was performed following the transfer of this resident on Enhanced barrier precautions due to a wound. Surveyor then followed the sit-to-stand to the bathing room, where V20 (Certified Nursing Assistant/CNA) proceeded to use the sit to stand device for R18, as she assisted him into standing position to perform incontinence care. R18 was also on enhanced barrier precautions. V20 (CNA) confirmed that she did not sanitize the sling between residents. On 7/8/2026 at 12:30PM, V2 (Director of Nursing/DON) stated, I believe each resident that uses the sit to stand has their own sling. When asked what the risk of residents on Enhanced Barrier Precautions (EBP) is sharing equipment without sanitizing between residents, V2 (DON) stated it creates an increased risk of infection. On 7/8/2026 at 1:20PM, Surveyor observed the sit-to-stand in the common conference room with a sling draped over the handle. Surveyor asked if that sling belongs to a particular resident. V27, Certified Nursing Assistant (CNA) replied, No we have 3 slings of different sizes. They (the slings) are utilized for multiple residents. V27 (CNA) also stated, We never sanitize the sit to stand slings, they go to laundry at the end of the day to be washed. On 7/8/2026 at 1:57PM, V18, Certified Nursing Assistant (CNA) stated, We (facility) send the slings (for the sit-to-stand) to laundry at the end of each day, regardless if they appear soiled. They (the slings) are not cleaned between residents. On 7/8/2026 at 2:10PM, V18 reiterated that the sit-to-stand slings are used for multiple residents. The slings are not cleaned between residents, but the actual machine should be cleaned between residents. We (CNAs) wipe them down with the cleansing wipes. Census (7/6/2026) documents 50 residents reside in the facility. On 7/6/2026 at 10:45 AM, completed tour of the laundry areas with V43 (Laundry Aide). Observed V43 open the soiled linen chute and several sheets, fitted sheets, soiled socks, and pieces of a disposable incontinence brief were in the chute. V43 affirmed that linen should be bagged when sent down the chute to prevent contaminating the chute. Observed visibly soiled/dirty towels and rags draped across the detergent barrels across from the chute. V43 confirmed this observation and affirmed the linen was soiled. Observed a blanket behind the washer that was visibly soiled with dirt and unidentifiable pink stains. V43 confirmed the observation and explained there was a leak behind the washer around a week ago and the linen there was to collect water from the leak. On 7/9/2026 at 2:45 PM, V1 (Administrator) affirmed the facility staff should be following the linen handling policy. V1 explained the purpose of bagging soiled linen to prevent the linen from contaminating other areas of the facility. Facility policy Cleaning & Sanitizing – Wheelchairs and Other Medical Equipment (1/25/2018) documents in part Devices/equipment used for more than one resident shall be cleaned between each resident. Facility policy titled Linen Handling- Laundry Department (revised 1/11/2018) documents the purpose of the policy is to ensure proper handling, storage, processing, and transport of all linen and laundry in accordance with accepted national standards in order to produce hygienically clean laundry to prevent the spread of infection to the extent possible. Guidelines include taking every effort to ensure soiled articles do not come into contact with floor, uniforms, furniture or other areas deemed clean and soiled linen shall be bagged by nursing personnel.

Based on observation, interview, record review, the facility failed to develop a smoking policy that meets state law requirements for the Smoke Free Illinois Act, failed to secure resident's (R41) smoking materials, and failed to reinforce/follow the staff smoking policy regarding safe disposal of cigarette butts. These failures affected one (R41) of three residents that smoke in the facility and has the potential to affect all 50 residents that reside in the facility. Findings include:Facility census (7/6/2026) documents 50 residents reside in the facility.Facility smoking list (undated) documents 3 residents smoke in the facility, one of which is R41. R41's Face sheet documents in part that R41 is a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses include fracture of tuberosity of right calcaneus, chronic atrial fibrillation, chronic kidney disease, chronic diastolic heart failure, aortic stenosis, gout, and chronic obstructive pulmonary disease.R41's Minimum Data Set (MDS) on 4/13/2026 documents in part that R41's Brief Interview for Mental Status (BIMS) score is 11, indicating that R41 has moderate cognitive impairment, and that R41 is dependent on staff for bathing and toileting, and needing moderate to substantial assistance for dressing.R41's Care Plan does Not include Smoking (prior to start of survey), despite R41 being on the facility smoker list.On 7/6/2026 at 11:33AM, Surveyor observed R41 sitting in his wheelchair in the hallway near the door to his room. There was a plastic bag containing a lighter and two loose cigarettes tucked between his thigh and his wheelchair. R41 stated I'm going to smoke after lunch. The nurses let me out to the smoking area.On 7/6/2026 at 11:35AM, V4 (Social Services Director) was alerted to the smoking materials in R41's wheelchair. V4 denied knowing that R41 is a smoker (despite R41 being on the facility smoking list). V4 (Social Services Director) promptly secured the smoking materials and stated she would follow up with R41 to complete the smoking contract. On 7/7/2026 at 1:10PM, V42 (Activities Director) escorted two residents out to the smoking patio to smoke. R41 rolled his wheelchair up to the patio table to the area closest to the door, back facing the building. R41 proceeded to smoke two cigarettes and disposed each lit cigarette butt onto the ground under his wheelchair. There was no redirection by V42 (Activities Director) despite the other residents telling R41 to use the provided cigarette receptacle attached to the walls.On 7/7/2026 at 3:01PM, V38 (Maintenance Director) measured the distance from the threshold of the patio door to where R41 was observed smoking in his wheelchair using a measuring tape. The distance was approximately 9 feet. V38 (Maintenance Director) affirmed that there were at minimum 5 scattered cigarette butts on the ground between the entrance to the door and the patio furniture set where the smokers sit. On 7/7/2026 at 3:30 PM, V1 (Administrator) affirmed residents should be smoking at least 15 feet away from the facility, and that the patio table and chairs (where one resident was sitting and R41's wheelchair was stationed) were less than the required 15 feet from the entrance.Facility policy Smoking Safety (10/24/2022) documents in part that Residents will be instructed, educated, and counseled about their inappropriate behavior such as littering with cigarette butts, dropping ashes at will, not making an effort to use the ashtray, etc. Also, per policy, Ensure residents are at least 10 feet away from the building and door when smoking.Record review of (410 ILCS 82/) Smoke Free Illinois Act (enacted 1/1/2028, revised 1/1/2024) documents in part, .Smoking in public places, places of employment, and governmental vehicles prohibited. No person shall smoke in a public place or in any place of employment or within 15 feet of any entrance to a public place or place of employment .

Based on observation, interview and record review, the facility failed to designate an infection preventionist that had completed specialized training in infection prevention and control. This failure has the potential to affect all 50 residents that reside in the facility. Findings include: Facility census (7/6/2026) documents 50 residents reside in the facility. On 7/6/2026 at 9:42 AM, the entrance conference was conducted and V2 (Director of Nursing) affirmed V2 is the designated infection preventionist (IP) for the facility. Requested documentation of the IP's primary professional training and evidence of completion of specialized training in infection prevention and control. Requested documentation was not given to the survey team prior to the exit of the survey. On 7/7/2026 at 11:11 AM, V2 (Director of Nursing) explained V2 had not completed specialized training in infection control that meets the regulatory requirement. V2 affirmed V2 was using CDC's iTRAIN nursing home infection preventionist modules but still had modules left to complete. V2 affirmed specialized training is a requirement of the infection preventionist. V2 explained the facility had recently hired a wound care nurse that was going to be the designated infection preventionist but that the nurse had not completed specialized training yet. On 7/9/2026 at 2:45 PM, V1 (Administrator) affirmed V1 is V2's supervisor. V1 did not know V2 did not complete the infection control modules for specialized training in infection control. V1 stated, I just assumed (V2) had them (completed) as the DON (Director of Nursing). Facility job description titled Infection Preventionist (4/14/2022) documents the infection preventionist shall be qualified through education, training, experience or certification or a combination of such qualifications within 30 days of hire or placement into the role. The training should include at least 19 hours in the following areas: principles of standard precautions, principles of transmission-based precautions, prevention of healthcare associated infections, hand hygiene, environmental cleaning, sterilization, disinfection, and asepsis, environment of care and water management, employee/occupational health, surveillance and epidemiological investigations, and antimicrobial stewardship.

Based on observation, interview, and record review the facility failed to follow facility policy, failed to discard expired drugs for one resident (R20), failed to write open dates for resident-specific medications for 13 residents (R3, R20, R25, R34, R35, R36, R41, R50, R51, R53, R55, R57, R58), failed to administer or discard loose and unidentified medications in the medication cart, and failed to write open dates on multidose house stock. This failure has the potential to place residents at risk of receiving expired and/or outdated medications or not receiving prescribed medications. This failure has the potential to affect all fifty residents residing in the facility. Findings:On 7/6/2026 at 2:37 V11 (Registered Nurse) and surveyor reviewed the contents of medication cart/west side. The following medications were found with no documented open dates:R3 had Dorzolamide 2% eye drops in the refrigerator with no open date. V11 confirmed that the drug was open and no open date was documented.R20 had open Breyna in the medication cart with no open date. V11 confirmed that the drug was open and no open date was documented.R20 had Atorvastatin 40 mg multidose bottle in the medication cart from an outside pharmacy with a 3/10/2026 expiration date. V11 confirmed that the expiration date of 3/10/2026.R20 had Metoprolol ER 25 mg multidose bottle in the medication cart from an outside pharmacy dated 2/12/2025 and with no expiration date. V11 confirmed no expiration date.R20 had Furosemide 40 mg multidose bottle in the medication cart from an outside pharmacy dated 9/1/2025 and with no expiration date. V11 confirmed no expiration date.R25 had opened Trelegy in the medication cart with no open date. V11 confirmed that the drug was open and no open date was documented.R34 had open Fluticasone Propionate inhaler in the medication cart with no open date. V11 confirmed that the drug was open and no open date was documented.R34 had open Fluticasone Propionate inhaler in the medication cart with a 3/8/2026 open date and not in a plastic bag. V11 confirmed that the drug was open.R34 had open Fluticasone Propionate inhaler in the medication care with no open date. V11 confirmed that the drug was open and no open date was documented.R35 had open Konvomep 2-84 mg/ml in the refrigerator with an expiration date of 6/11/2026. V11 confirmed that the drug was open and expired.R36 had opened Fluticasone Propionate inhaler in the medication cart with a 4/29/2026 open date and not in a plastic bag. V11 confirmed that the drug was open and not in a plastic bag.R41 had open Serevent Diskus in the medication cart with no open date and not in a plastic bag. V11 confirmed that the drug was open with no open date and not in a plastic bag.R50 had open Ventolin inhaler in the medication cart with no open date. V11 confirmed that the drug was open with no open date and no open date was documented.R50 had open Trelegy in the medication cart with no open date and not in a plastic bag. V11 confirmed that the drug was open and not in a plastic bag.R57 had open Gentamycin eye drops in the medication cart with no open date and not in a plastic bag. V11 confirmed that the drug was open with no open date and was not in a plastic bag.R58 had Fluticasone nasal spray in the medication cart with no open date and not in a plastic bag. V11 confirmed that the drug was open with no open date and not in a plastic bag.Three bottles of Acetaminophen 325 mg house stock/multidose bottles were open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Two bottles of Aspirin 81 mg house stock/multidose bottle were open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Two bottles of Calcium Carbonate house stock/multidose bottle were open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Calcium with Vitamin D 600 mg/10 mcg house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Clearlax house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Docusate Sodium 250 mg house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Three bottles of Ferrous Sulfate house stock/multidose bottle were open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottles.Gerikot/Senokot 8.6 mg house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Ibuprofen 200 mg house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Three bottles of Loratadine 10 mg house stock/multidose bottles were open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottles.Melatonin 5 mg Gerikot/Senokot 8.6 mg house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Vitamin B12 500 meq house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Vitamin C 500 mg house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Vitamin D3 10,000 international units (IU) house stock/multidose bottle was open in the medication cart with no open date on the bottle. V11 confirmed that the drug was open with no open date on the bottle.Omeprazole house stock/multidose bottle was open in the medication cart with no open date on the bottle and no expiration date on the bottle. V2 and V11 confirmed that the drug was open with no open date and no expiration date on the bottle.A loose pill was found in the medication cart. V11 stated V11 did not know what the drug was or who the drug was for. V11 discarded the pill.On 7/6/2026 at 2:49 V11 (Registered Nurse) stated each of the multidose medications should have an open date placed on the drug, bottle or bag once the drug is open. All inhalers, nasal spray and eye drops are supposed to be in a plastic bag. V11 stated it is important to date the medications when they are open to conserve the potency of the medicine. Once open, the drug is supposed to be good for thirty to sixty days depending on what it is. V11 stated it is important to put multidose inhalers, nasal sprays and eye drops in a plastic bag once they are opened and before they are put back into the medication cart as an infection control practice.On 7/6/2026 at 3:07 PM V2 (Director of Nursing) confirmed that there was no open dates on the bottles or bags of the above referenced drugs. V2 also confirmed that there was no open date or expiration date on the Omeprazole multidose house stock bottle. V2 stated all multidose bottles, inhalers, eye drops and nasal sprays should have an open date written on them the day they are opened. V2 stated eye drops are good for thirty days once the bottle is opened. V2 stated inhalers are good for sixty days once the bottle is open. Inhalers, nasal spray and eye drops should be in a plastic bag to prevent infection. V2 stated placing the open date on multidose medications as a matter of policy and a best practice.On 7/6/2026 at 11:25 V2 (Director of Nursing) was asked to clarify the facility policy. V2 stated multidose bottles are expected to have an open date on the bottle or packaging. Multidose house stock bottles are good for sixty days once they are opened. All resident-specific multidose medications such as inhalers, nasal spray and eye drops should be stored in a plastic bag in the medication cart.On 7/6/2026 at 12:13 PM V16 (Quality Assurance Pharmacist) stated house stock multidose bottles must have an open date. They have to label the bottles with an open date. V16 stated some medications have a shortened expiration date once it is opened so the open date is important. Nurses would have to read the package insert for each medication to know if the nurse should refer to the expiration date on the bottle or if the medication has a shortened expiration date once opened. V16 stated the pharmacy has a list of medications with a shortened use by date, but it is not all-inclusive. It is best practice to store resident-specific multidose inhalers, and nasal sprays in a plastic bag before placing the medication back in the medication cart.On 7/8/2026 at 9:25 AM V11 (Registered Nurse) stated twenty-seven residents receive medications from the west side medication cart today.On 7/9/2026 at 10:28 AM V6 (Licensed Practical Nurse) and surveyor reviewed the east medication cart which serves 24 residents today. Pyridostigmine Bromide for R51 was open with no open date on the multidose bottle.Amlodipine-valsartan 10 mg/320 mg two tablets were found in the medication cart for R53. There was no expiration date on the bottle. V5 confirmed that there was no medication expiration date on the label.A bottle of Enulose for R55 was found in the medication cart with no open date. V6 (Licensed Practical Nurse) stated it was clearly open. The bottle looks old. V6 confirmed that the drug was open with no open date on the bottle.On 7/9/2026 at 10:40 AM V11 (Registered Nurse) reviewed the west medication cart which V11 stated serves 26 residents today. Two Loperamide Hydrochloride 2 milligram tablets were found with no resident name attached to the drug and an expiration date of 10/2025. Five loose pills and one loose pink capsule were observed in the bottom drawer of the medication cart. V11 stated V11 did not know what resident the drugs were intended for. V11 stated the risk of finding loose pills and capsules is that a drug could accidentally be given to the wrong resident or a resident did not get prescribed medication.On 7/9/2026 at 11 AM V10 (Regional [NAME] President of Operations) observed loose medications in the west medication cart and stated those are missed medications. V10 stated the potential harm depends on what the drug is for, but we don't know what the drug is or who the drug was intended for. V10 asked V11 if V11 knew the drug name or the intended resident recipients and V11 stated no. V10 also observed the expired Loperamide Hydrochloride tablets (two) and house stock and resident-specific medications that were not dated. V10 stated we need to go through these medication carts now.Facility policy titled Administration Procedures for All Medications revised 8/2020 stated medications will be administered in a safe and effective manner. Check the expiration date on the package/container before administering any medication. When opening a multi-dose container, place the date on the container.Facility policy titled Storage of Medications revised 8/2020 stated medications and biologics are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and record the date opened and the date of expiration. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of the amount remaining.

Based on interview and record review, the facility failed to develop and revise care plans and failed to ensure the resident/their representative was offered to participate in the development of the individualized care plan. These failures affected five residents (R5, R22, R37, R41, R52) reviewed for care planning. Findings include: R41's Face sheet documents in part that R41 is a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses include fracture of tuberosity of right calcaneus, chronic atrial fibrillation, chronic kidney disease, chronic diastolic heart failure, aortic stenosis, gout, and chronic obstructive pulmonary disease. R41's Minimum Data Set (MDS) on 4/13/2026 documents in part that R41's Brief Interview for Mental Status (BIMS) score is 11, indicating that R41 has moderate cognitive impairment, and that R41 is dependent on staff for bathing and toileting, and needing moderate to substantial assistance for dressing. R41's Care Plan does Not include Smoking (prior to start of survey), despite R41 being on the facility smoker list. Smokers List provided to Surveyors on 7/6/2026 included 3 residents, one of which is R41. R22's Face sheet documents in part that R22 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, chronic kidney disease, gastrostomy tube, falls, and hypertension. R22's Minimum Data Set (MDS) on 6/25/2026 documents in part that R22's Staff Assessment for Mental Status score is 3, indicating that R22 has severe cognitive impairment, and that R22 is dependent on staff for all activities of daily living. R22's Order Summary Report includes in part: Monitor Heart Monitor and check battery percentage every shift. (6/22/2026) R22's Care Plan (as of 7/7/2026) does Not include any information on how to monitor R22's heart monitor, how to care for the monitor, nor the physician managing the data from the heart monitor following transmission of data. On 7/6/2026 at 9:42AM, Surveyor noted that resident had a cardiac monitor attached to an adhesive layer on his chest. V11 (Registered Nurse) was unsure of where the results are going or the necessary care for the device, stating only we (facility) need to keep an eye on the battery and keep the cell phone at bedside plugged in. On 7/8/2026 at 02:30PM, V2 (Director of Nursing/DON) stated he (V2) is not sure about R22's heart monitor and unsure why it (the heart monitor) is not in the care plans. No updated care plan was provided to the surveyor by the end of the survey to indicate what care/frequency the adhesive for the heart monitor is to be changed or with which physician the facility is collaborating with regarding the cardiac monitoring. R5's Face sheet documents in part that R5 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage, traumatic brain injury, seizures, aphasia, gastrostomy, and ileostomy. R5's Minimum Data Set (MDS) on 5/26/2026 documents in part that R5's Staff Assessment for Mental Status score is 3, indicating that R5 has severe cognitive impairment, and that R5 is dependent on staff for all activities of daily living. R5's Order Summary Report includes in part: low air loss mattress TID (3 times a day) and PRN three times a day for Wound prevention check setting and inflation. (5/23/2026) On 7/8/2026 at 12:30PM, V33 (Wound Nurse/Licensed Practical Nurse/LPN) acknowledged that R5 has orders and care plans for low air loss mattress for prevention, however I (V33 – Wound LPN) neglected to discontinue the order or update the care plans when he (R5) no longer qualified for the special mattress. Braden score has been consistent at 13 (Moderate Risk) with no change in risk noted in last 3 Braden assessments. Most recent Braden on 6/11/2026 was documented as a 10, indicating high risk, showing increased risk from prior assessments. R52's Face sheet documents in part that R52 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include atrioventricular block, osteoarthritis, vascular dementia, peripheral vascular disease, chronic systolic heart failure, major depressive disorder, anxiety, and history of falls. R52's Minimum Data Set (MDS) on 5/20/2026 documents in part that R52's Brief Interview for Mental Status (BIMS) score is 5, indicating that R52 has severe cognitive impairment, and that R52 is dependent on staff for dressing and toileting, and needing substantial/maximal assistance for bathing. R52's Care Plan includes in part 6/18/26 Skin impairments to: Left Heel, Left Buttock, Date Initiated: 05/19/2026, Revision on: 06/18/2026 however there are no new interventions care planned following the discovery of the left heel wound. Interventions are: Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 05/19/2026, Pressure reducing mattress on bed. Pressure relieving chair cushion. Date Initiated: 05/19/2026, Provide diet as ordered and monitor Nutritional status and dietary needs. Date Initiated: 05/19/2026. Order Summary Report includes in part: low air loss mattress every day shift. (Ordered 6/18/2026) Facility policy Comprehensive Care Plan (11/17/2017) documents in part that the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. R37's face sheet documents R37 is a [AGE] year-old resident with diagnoses including: osteomyelitis of vertebrae, other specified sepsis, stage IV pressure ulcer to the lower back, basal cell carcinoma, wedge compression fracture of the vertebrae, and protein-calorie malnutrition. R37's minimum data set documents a brief interview of mental status (BIMS) summary score of 10, indicating R37 has cognitive impairment. On 7/6/2026 at 10:29 AM, R37 was observed resting in bed with V45 (Family Member) at the bedside. V45 stated R37 only speaks/understands limited English and is confused at baseline, so V45 is at the facility daily to help with care provided. V45 had questions about R37's plan of care. V45 denied that V45 or R37 had ever been invited to participate in the development R37's plan of care or participated in care plan meetings. V45 stated V45 would love to attend something like that, so everyone can be on the same page. On 7/6/2026 at 10:52 AM, V25 (Registered Nurse (RN) Assessment Coordinator) stated she was the RN care plan coordinator for the facility. V25 affirmed residents and their representatives have the right to participate in the development of the comprehensive plan of care. V25 explained when residents first admit to the facility, social services meet with the residents/representatives. V25 denied that V25 or other members of the IDT meet with the residents/representatives on admission, it is only social services. V25 explained after a resident has been admitted for three months, V25 will schedule a care plan meeting. V25 denied a care plan meeting is held with the initial development of the comprehensive care plan, only after 3 months. V25 denied physicians or other providers are invited or participate in the development of the comprehensive care plan. V25 could not recall if a care plan meeting was held since R37 was admitted to the facility. V25 reviewed R37's electronic health record and affirmed there was no documentation that affirmed a care plan meeting was with R37 and/or their representative. V25 stated the facility should have conducted a care plan meeting for R37 and their representative. On 7/6/2026 at 11:19 AM, V4 (Social Services Director) affirmed V4 is responsible for setting up initial care plan meetings and V25 sets up care plan meetings afterward. V4 recalled a few staff members individually spoke with R37 and V45 around admission but did not recall if R37 had a care plan meeting since admission. V4 stated the facility documents in the electronic health record if a resident is invited and when care plan meetings were conducted. V4 explained the purpose of the care plan is to identify what care is being provided and revise any treatment approaches as necessary. R37's electronic health record did not document R37, or their representatives, were invited in the development of the comprehensive care plan. No further information was provided that indicates the interdisciplinary team met with R37 and offered the opportunity for R37/V45 to participate in the development of R37's plan of care prior to the exit of the survey. Facility policy titled Comprehensive Care Plan (revised 11/17/2017) documents the facility will develop and implement a comprehensive and person-centered care plan for each resident, consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment and must be prepared by an interdisciplinary team that includes, but is not limited to, the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food/nutrition staff, and to the extent practicable the resident and the resident's representative. An explanation should be included in a resident's medical record if the participation of the resident and their representative is determined not practicable for the development of the resident's care plan. The resident and/or their representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone, or video conference (if available) at least quarterly.

Based on interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency within the required time reporting requirements. This failure affected one resident (R3) in a sample of 42 residents. Findings include: R3's face sheet documents R3 is a [AGE] year-old resident with the following active diagnoses: hemiplegia and hemiparesis of the right dominant side, chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, other seizures, congestive heart failure, aphasia, bipolar disorder, and major depressive disorder. R3's care plan documents R3 has a behavior problem, can be verbally aggressive and resistive to cares, and makes false allegations about facility staff. Concern/complement form (6/2/2026) documents V44 (R3's family member) emailed a concern regarding the care R3 received during incontinence care. R3 was interviewed, and no other concerns were identified, and V44 was satisfied of the outcome of the grievance. Email from V44 (6/2/2026) attached to the grievance documents after speaking to (R3), (R3) said he never refuses to be changed and that the certified nursing assistant (CNA) (unnamed) is really rough with (R3). He has asked the CNA but they refused to give their name. (R3) is feeling uncomfortable with getting changed because of the way (R3) is being treated. I would like to have a meeting about this situation because he should be comfortable while he is in the facility. V1's (Administrator) statement attached to the grievance documents on 6/3/2026, V1 met privately with R3 to discuss concerns brought forward by the resident's family regarding incontinence care and interactions with staff. R3 stated he does not refuse incontinence care and expressed a preference to maintain R3's morning routine. R3 and V1 identified a plan of care to better meet his preferences including being checked and changed prior to lunch, dinner, activities and as needed throughout the day. V1 met with R3's family following the interview and provided updates regarding the resident's preferences. V1 documents, the concern was investigated, resident preferences were reviewed and interventions were implemented to promote resident choice, dignity, and satisfaction with care. On 7/7/2026 at 3:07 PM, V1 (Administrator) confirmed V1 is the abuse prevention coordinator. V1 affirmed a resident being handled roughly by a certified nursing assistant is an allegation of physical abuse. V1 stated allegations of abuse must be reported to the state survey agency immediately. Concern form and email (6/2/2026) reviewed with V1 and V1 recalled the incident. V1 explained V1 spoke with the resident and the resident denied it happened, so V1 did not report it. During V1's investigation, V1 determined R3 was having a behavior and wanting to go home, so R3 fabricated the allegation. V1 explained R3 had a long history of making false allegations of staff not providing adequate care. Facility abuse prevention and reporting policy (revised 3/18/2026) documents residents have the right to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. When an allegation of abuse, exploitation, neglect, mistreatment, retaliation, or misappropriation of resident property has been made, the administrator or designee shall notify the state survey agency regional office by telephone or fax. The state survey agency shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been made to the administrator and is being investigated.

Based on observation, interview and record review the facility failed to protect the residents' right to be treated with dignity and respect in a manner that promotes dignity, failed to protect the resident's right to refuse treatment, failed to follow the resident's care plan to ensure dignity was maintained and agitation was addressed/redirected with dignity. These failures affected two residents (R11, R19) in a sample of 41 residents. Findings include: R11's face sheet documents in part R11 is a [AGE] year-old resident with diagnoses including: stage IV (4) chronic kidney disease (severe), metabolic encephalopathy, anxiety, dementia, and history cerebrovascular accident (stroke). R11's minimum data set (5/29/2026) documents a brief interview of mental status summary score of 04, indicating R11 has severe cognitive impairment. R11 is dependent on staff for activities of daily living, has impairment on both sides of R11's upper body, and impairment on one side of R11's lower body. On 7/6/2026 at 11:40 AM, observed R11 resting in bed with respirations even and unlabored. R11 was unable to be interviewed due to cognitive impairment. Concern/compliment form (6/1/2026) documents V26 (Family Member) reported to V2 (Director of Nursing) R11 has been in pain during transfers and ADL (Activities of Daily Living) cares. On 5/30/2026, the certified nursing assistants were having personal conversations while completing ADL care and not paying attention. It sounded like R11 was in pain during bed mobility and ADL care. V26 did not feel the certified nursing assistants were abusive in any way but had poor bedside manner. V27's (Certified Nursing Assistant) witness statement (6/1/2026) documents on 5/30/2026 around 11:30 AM, V27, V28 (Certified Nursing Assistant) and V29 (Certified Nursing Assistant), was providing ADL care to R11 with V26 (Family Member) present in the room. While caring for R11, V27, V28 and V29 were engaging on conversation about what their lunch would be for their break. R11 complained of pain when turning and always complains of pain while turning. V26 asked V27, V28, and V29 to keep their conversations focused on R11 so they stopped their side conversation. V28's (Certified Nursing Assistant) witness statement (6/2/2026) documents staff were discussing what they were going to have for lunch. V26 (Family Member) communicated V26 was uncomfortable with the situation. The staff immediately apologized and stopped the conversation. V29's (Certified Nursing Assistant) witness statement (5/30/2026) documents on 5/30/2026, V28 and V29 assisted V27 with care for R11 as R11 has limited mobility and needs assistance turning. V26 (Family Member) was present in the room and requested that we (staff) be gentle. During the brief and linen change, R11 said R11 was in pain, so we used extra caution when positioning clean linen under R11. At one point, V27, V28, and V29 were having a conversation about food/lunch. V26 requested that we not discuss that. We immediately apologized, ended the conversation, and focused on patient care. On 07/08/2026 10:28 AM, reviewed concern/compliment form (6/1/2026) with V2 (Director of Nursing). V2 recalled the incident and confirmed V26 made management aware of the concern. V2 confirmed during care, the staff (V27, V28, and V29) were talking about what they were going to get for lunch. V2 explained the expectation is during care staff are supposed to focus on caring for the residents and not having personal conversations while performing ADL care. V2 affirmed staff apologized and they (V27, V28, and V29) were in-serviced on customer service. Surveyor requested documentation of the in-servicing completed. Documentation was not provided prior to the exit of the survey. V2 stated V2 goes around and talks to residents to see how the care is but never completed all staff in-servicing or developed any quality assurance audits to monitor compliance for other potential residents that may be affected. On 7/8/2026 at 1:55 PM, V27 (Certified Nursing Assistant) recalled the complaint from V26 (Family Member). V27 recalled on 5/20/2026, V27 wasn't normally assigned to care for R11. R11's family member (V27) was in the room and asked if we wanted V27 to leave. We said we didn't mind. V27 recalled performing incontinence care with V28 and V29 and R11 was in pain during turning. As we were finishing up his incontinent care, V28 and V29 had come back from their lunch, and we were talking about where they went for lunch in front of R11 and V26. V26 asked us to stop talking about that in front of R11 so we stopped. Surveyor inquired if V27 received education or in-servicing after the incident. V27 stated, They (management) made me sign a paper that said I wouldn't talk about personal things in front of residents, if that counts. R19's admission record documents R19 is an [AGE] year-old resident with active diagnoses including unspecified dementia with other behavioral disturbance, chronic kidney disease, protein-calorie malnutrition, type 2 diabetes with neuropathy, chronic gout, osteoarthritis, pressure ulcer of the left hip, contracture of left elbow. R19's minimum data set (5/14/2026) documents a brief interview of mental status (BIMS) summary score of 99, indicating R19 was unable to complete the interview. R19 has severe cognitive impairment making decisions regarding tasks of daily life. R19 is dependent on staff for activities of daily living, including transferring. On 07/08/2026 1:21 PM, observed V27 (Certified Nursing Assistant) pushing R19 down the hallway into R19's room. R19 was visibly confused and distraught asking non-sensible questions to V27 as V27 pushed R19 down the hallway. V27 did not reply to any of R19's questions or address R19 in any way but continued to push R19 into his room. V27 began to speak to V30 (Housekeeper) in Spanish. V27 and V30 casually conversed back and forth in front of R19, who was still confused. On 7/8/2026 at 1:25 PM, observed V27 (Certified Nursing Assistant) and V17 (Certified Nursing Assistant) prepare to transfer R19 via mechanical sling lift. V17 and V27 did not explain the procedure to R19, and R19 was yelling out, asking what they were doing to her. R19 yelled, I don't know what you're doing to me, stop, I don't even know who I am!. R19 refused for them to perform ADL care. V17 and V27 did not respond or acknowledge the request and continued performing ADL care. V17 quickly pulled R19's legs up and placed them on the wheeled recliner. R19 yelled out in pain. V17 and V27 did not acknowledge R19 yelling out in pain or communicate with R19 after she was yelling. V17 and V27 laid the back of the recliner down and R19 asked V17 and V27, what are you doing to me?! Stop it!. V17 and V27 did not acknowledge or respond to R19. V17 and V27 pulled R19 up in the recliner using the sling under R19 without telling R19 staff were pulling R19 up. R19 screamed in pain and asked why they were doing that to R19. V17 stated, we are getting you up. V17 and V19 did not acknowledge R19 yelling in pain. V17 and V27 began to connect the sling to the mechanical lift. R19 said No, stop that, I don't want to go there. V17 told R19 we're putting you in bed and did not explain the process of how they were putting R19 in bed. R19 grabbed the bar of the lift where the sling connects to the lift. V27 said, No, don't do that. Let go of that. V27 began peeling (extending) R19's fingers from the lift without telling R19 what V27 was doing to prevent R19 from grabbing the bar. V17 began operating the mechanical lift and placed R19 in bed. R19 yelled in pain when R19 was placed on the bed. R19's care plan (revised 5/21/2026) identifies R19 has outbursts of repetitive, inappropriate vulgar language, gets easily agitated, throws items/utensils and can be difficult to direct at times. Interventions to meet this identified encouraging activities to provide diversions/distractions (6/26/2025), Redirect inappropriate behaviors by offering alternative activities, providing positive reinforcement for desired behaviors, and using distraction techniques (6/21/2025), Redirect resident when behaviors are present (12/5/2023), Reorient and cue resident as needed (12/5/2023), use clear, concise, and calm communication when interacting with the resident (6/21/25), Encourage and allow open expression of feelings and reinforce appropriate expression of feelings (6/21/2025), Provide opportunities for positive interaction/attention by stopping and talking with resident when passing in hallways, etc. (6/21/2026), Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. (12/26/2024), Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation (12/26/2024), Leave resident alone and re-approach later as needed. (3/13/2024). On 7/8/2026 at 1:48 PM, V27 affirmed R19 is confused at baseline and staff try to calm R19 and let her be. Interventions V17 and V27 have found to help comfort R19 when agitated is singing, like singing happy birthday or having activities redirect her. V17 affirmed V17 was checking and making sure R19's legs were in alignment when she was yelling out. V17 explained that R19 yelling out is R19's baseline and she will frequently mistake staff for her daughter and begin to curse out staff. V27 affirmed residents have the right to refuse care, V17 added, always. Surveyor inquired why care was not stopped when R19 was refusing care. V17 explained, I care for (R19) like every day I'm here. I'm used to her behaviors. As long as I know she is in a good position and I'm not hurting her, I continue (performing ADL cares). V17 and V27 affirmed non-verbal signs of pain include exclamations of pain, moaning, crying, or pulling away. V17 stated you can tell when R19 is in pain because R19 will rub an area, she will touch that part of the body and will tend to moan more. V17 and V27 affirmed a dignity standard is to explain procedures to residents while completing them, even when they have cognitive impairment/dementia. V17 stated, I don't really know if (R19) can understand (instructions). V27 stated the reason why V27 and V17 didn't sing or provide other comfort measures during the transfer is because We only have one shot with singing happy birthday, and we need to save the happy birthday for when we do peri care (incontinence care). V27 affirmed when R19 gets agitated, staff will try to redirect R19 by talking to R19. V17 recalled R19 likes it when staff talk to her and compliment her by saying things like you look so pretty! (positive reinforcement). On 7/8/2026 at 2:40 PM, V2 (Director of Nursing) confirmed V2 expects residents to be treated with dignity and respect. V2 affirmed residents have the right to refuse care. V2 affirmed staff should be guiding residents and telling them what they are doing as they perform care. V2 expects staff to follow the resident's care plan. V2 confirmed R19 is familiar with R19 and her care needs. V2 explained R2 is alert and oriented sometimes to self and has frequent outbursts and behaviors towards the staff. V2 recalled R19 is redirectable if staff have conversations with R19 during an outburst. V2 denied ever seeing R2 in pain but recalled staff saying R2 rubbed an injury in the past when she was in pain. V2 affirmed R19 saying she was hurting while being transferred and yelling is an indicator of pain. V2 explained a reasonable person would feel agitated, angry or upset if they are not treated with dignity or if care continued after they said to stop. On 7/9/2026 at 1:10 PM, V5 (Nurse Practitioner) affirmed V5 is R19's primary care provider. V5 confirmed V5 is actively treating R19 for pain related to gout, which affects V5's knees. V5 recalled R19 has dementia and behaviors, and regularly screams at staff, usually with a fixation upon her daughter and being agitated towards her daughter. These behaviors manifest as yelling and screaming profanities or threatening staff. V5 affirmed R19 yelling out in a response to repositioning is abnormal and not R19's baseline. V5 explained that R19 will work with staff if they are very polite, respectful, and talking through things. R19 responds best when you call her things like Ms. (NAME) instead of just her name. Illinois long-term care ombudsman program's document titled, RESIDENTS' RIGHTS for People in Long-Term Care Facilities (Revised 11/2018) documents Your rights to dignity and respect . your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life . Your rights to participate in your own care .You should receive the services and/or items included in the plan of care . You have the right to request, refuse, and/or discontinue any treatment. If you refuse treatment, your facility must tell you what may happen because of your refusal and tell you of other possible treatments . Facility policy titled, Resident Rights (1/4/2019) To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Aresident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

Based on observation, interview and record review the facility failed to follow their policy and procedure for recording resident refrigerator temperatures for one of one (R11) resident reviewed for personal resident refrigerator.Findings include:R11's Face sheet documents in part that R11 is a [AGE] year-old male who was initially admitted to the facility on [DATE]. Diagnoses include in part chronic kidney disease, type 2 diabetes, vascular dementia, dysphagia, protein calorie malnutrition, chronic obstructive pulmonary disease, seizures, and hemiplegia/hemiparesis following cerebral infarction. R11's Minimum Data Set (MDS) on 5/29/2026 documents in part that R11's Brief Interview for Mental Status (BIMS) score is 4, indicating that R11 has severe cognitive impairment, and that R11 is dependent on staff for bathing, toileting, and dressing, and partial/moderate assistance for eating. On 7/6/2026 at 9:35AM, Refrigerator Temperature Log for June 2026 (Identifies R11's Name and Room Number but did not list month/year) was hanging on the side of R11's refrigerator, and showed it was initiated on June 11th. There was no documentation on June 12th, June 13th, June 14th, or June 15th (4 days not logged). All temperatures/dates are initialed by V7 (Admissions Director) except for the 11th and 29th. Refrigerator Temperature Log for July 2026 for R11 has documentation of temperature for July 1st through July 7th, and were documented with initials of V7 (Admissions Director). This record was obtained on 7/7/2026, and was not hanging on the refrigerator at initial observation on 7/6/2026 at 9:35AM.On 7/6/2026 at 11:23AM, V7 (Admissions Director) stated, I'm waiting for the paper for July so I can hang it on the fridge. I (V7) am responsible for obtaining the temperatures each day, and to make sure it is 40 degrees or lower. If it is higher, then maintenance is notified. When asked about the missing days on the June schedule (June 12th-June15th), and V7 affirmed she was off those days. After reviewing the time card for V7 (Admissions Director), Surveyor noted that V7 (Admissions Director) documented temperatures for R11's personal refrigerator on the following days that she (V7) did not work onsite at facility: June 20th, June 21st, June 27th, June 28th, July 4th, and July 5th. Facility policy Refrigerators in Resident Rooms (DiningRD.com Guideline & Procedure Manual 2020) documents in part Each refrigerator shall have a temperature log with daily entry and The housekeeper will enter the temperature once daily.

Based on observation, interview and record review, the facility failed to ensure that a dependent resident received adequate dental services, failed to properly store resident's dentures and failed to promptly refer a resident with lost dentures for dental services. These failures affected one (R9) of one resident reviewed for dental services.Findings include:R9 is 97 years and has resided at the facility since 2023. Past medical history includes but is not limited to displaced oblique fracture of lower end of right radius, subsequent encounter for closed fracture with routine healing, unspecified severe protein calorie malnutrition, vitamin D deficiency, other reduced mobility, other lack of coordination, history of falling, etc.Minimum Data Set (MDS) assessment dated [DATE] section c (cognition) documented a brief interview for memory (BIMS) score of 7, indicating that R9 is cognitively impaired. Section GG (functional) of the same assessment documented that R9 requires supervision or touching assistance for eating and partial/moderate assistance for oral and personal hygiene.On 7/6/2026 at 11:30AM R9 was observed eating lunch in the dining room, R9 was observed eating by himself, no staff was assisting R9 with lunch and he was noted to be eating with no teeth.On 7/6/2026 at12:20PM, surveyor asked V11 (assigned nurse for the resident) if the resident uses dentures and she said yes. Surveyor and V11 went back to the dining room, V11 checked resident's mouth and affirmed that he does not have the upper or lower dentures. V11 and surveyor went to resident's room, V11 checked the drawers in resident's nightstand and said, I don't see it, I will check with the family because they sometimes take it home, I will call the family and check with them.Active physician order dated 6/17/2026 documented the following: diet mechanical soft texture, thin consistency, recommend diet modification no bread, 1:1 assistance.Activities of daily living (ADL) care plan initiated 3/25/2024 documented in part; I have ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day related to dementia. Interventions include oral hygiene: Brush teeth, rinse dentures, clean gums with toothette, rinse mouth with wash. My usual performance is partial.On 7/6/2026 at 2:55PM, V11 said that she called the family they will be at the facility tomorrow, V11 did not ask them about the dentures.On 7/7/226 at 12:18PM, V18 (CNA) said that she assisted R9 with breakfast, but was not sure if he had any dentures. V18 said that she is not even aware that R9 had dentures and has never seen him with one.On 7/7/2026 at 1:35PM, V35 (R1's POA-Power of Attorney) was at the facility and said that someone called him twice yesterday inquiring if the family have resident's dentures, V35 told them that he has no need for it, he checked with his sisters, and they do not have it.7/7/2026 at 12:38PM, V4 (Social service director) presented a concern form for resident's dentures and said that she was just notified that the dentures are missing, no one knows for how long, but facility will replace it.Dental services and loss or damage of dentures policy dated 11/28/2017 stated in part: Guidelines: The facility will, if necessary or requested by the resident, assist with scheduling appointments for dental services, arranging for transportation to and from the dental services location and promptly refer residents with lost or damaged dentures for dental services. Prompt referral means, within reason, as soon as the dentures are lost or damaged. Referral does not mean that the resident must see the dentist at the time but does mean that an appointment (referral) is made, or that the facility is aggressively working at replacing dentures.

Based on observation, interview and record review, the facility failed to follow its policy and procedures and failed to follow physician orders for two of two (R5, R22) residents reviewed for enteral feedings. Findings include: R5's Face sheet documents in part that R5 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage, traumatic brain injury, seizures, aphasia, gastrostomy, and ileostomy.R5's Minimum Data Set (MDS) on 5/26/2026 documents in part that R5's Staff Assessment for Mental Status score is 3, indicating that R5 has severe cognitive impairment, and that R5 is dependent on staff for all activities of daily living.R5's Order Summary Report includes in part: Enteral Feed Order every shift related to GASTROSTOMY STATUS (Z93.1) Administer via enteral feeding pump: run Jevity 1.2 at 75ml (milliliter)/hour x20hrs; Total Volume 1500ml. Start 10am Stop 6am (6/6/2026) and Enteral Feed Order as needed [Enteral] CLOSED system container - Change feeding administration set with each new bottle; label the formula container, syringe and administration set with resident's name, date, time, and nurse's initials. (5/22/2026)On 7/7/2026 at 1:00PM, No feedings were hanging for R5 despite order to start feedings at 10am. V13 (Licensed Practical Nurse - Restorative) stated, I'm delayed today, was helping another surveyor. I will hang his feedings soon.On 7/7/2026 at 3:05PM, feedings were hanging, only 45ml (milliliters) infused (rate 75ml per hour). There was no date/time of administration listed on the bottle).R22's Face sheet documents in part that R22 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, chronic kidney disease, gastrostomy tube, falls, and hypertension.R22's Minimum Data Set (MDS) on 6/25/2026 documents in part that R22's Staff Assessment for Mental Status score is 3, indicating that R22 has severe cognitive impairment, and that R22 is dependent on staff for all activities of daily living.R22's Order Summary Report includes in part: Enteral Feed Order every shift Continuous Enteral Feeding: Formula: Jevity1.2; Rate: 80; Start at 10:00am time and stop at 6:00am, Flush with water: Amount: 350 every 4. Tube Type: PEG tube; Monitor Every Shift.On 7/7/2026 at 01:00PM, Surveyor noted that R22's feeding was hanging, but there was no label with required information to notate the rate or when the feedings were hung. Volume infused indicated 1327 milliliters had been infused despite an ordered 10am start time. V13 (Restorative Licensed Practical Nurse) acknowledged that she (V13) did not clear the volume infused when starting the feedings today. V13 (Restorative Licensed Practical Nurse) also confirmed that the feedings should be labeled with date, time, rate, and name of formula.On 7/8/2026 at 9:52AM, Surveyor noted that R22 had approximately 900ml (milliliters) of tube feeding hanging in an open system feeding bag. V11 (Registered Nurse/RN) confirmed that a 1000ml bottle was utilized to initiate the feedings and that the rate is 80ml per hour. With this calculation, the tube feedings were set up for 12.5 hours of continuous feedings (without factoring in if the feedings were paused for patient care. When surveyor asked V11 (RN) about the limit for feedings in a bag, V11 (RN) stated I'm not sure, I'll need to check into that.On 7/8/2026 at 11:13AM, V36 (Dietician) stated that it is the preference that residents are receiving feedings from a closed system bottle, but I'm (V36) unsure on the specifics of the process of administering the feedings and how long they are hanging in a closed system versus an open system, will defer to nursing on that.On 7/8/2026 at 2:00PM, V10 (Regional [NAME] President of Operations) affirmed that it is not preferred to use the open systems for tube feeding because it reduces the hang time allowed for the feedings. In an open system, there should not be more than 10-12 hours of feeding at a time in the bag. V10 acknowledged that there was a limit in an open system in order to prevent illness from an extended hang time.Facility policy Gastrostomy Tube - Feeding and Care (8/3/2020) documents in part that nurse should label container with resident's name, flow rate, date, and time. Also, while Formulas in a closed system can safely hang 24-48 hours, open system (formula decanted from original container to feeding reservoir) should only hang ready to use formulas 8-12 hours. ( Reconstituted formula or formula with modular components up to 4 hours.)

Based on interview and record review, the facility failed to obtain resident weights per provider order. This failure affected one resident (R24) in a sample of 42 residents. Findings include: R23's face sheet documents R23 is a [AGE] year-old year old resident with active diagnoses including: acute and chronic respiratory failure with hypoxia, intervertebral disc degeneration, chronic combined systolic and diastolic (congestive) heart failure, and muscle wasting/atrophy. R23's physician orders documents an active order (4/8/2026) to obtain weights weekly for congestive heart failure. R23's weight log documents weights were obtained on 4/7/2026, 4/20/2026, 4/27/2026, 5/1/2026, 5/4/2026, 6/10/2026, 7/2/2026, and 7/6/2026. No other weight values were given to the survey team prior to the exit of the survey. R23's progress notes did not document reason why weights were not obtained as ordered. On 7/8/2026 at 11:14 AM, V38 (Registered Dietician) affirmed V38 is the dietician for the facility and monitors resident weights. V38 confirmed there was an order for weights to be obtained weekly. V38 reviewed R23's electronic health record and affirmed the only weights obtained were on 4/20/2026, 4/27/2026, 5/1/2026, 5/4/2026, 6/10/2026, 7/2/2026, and 7/6/2026 after the order was given for weekly weights. V38 explained the increased weight monitoring was due to R23's diagnosis of heart failure to monitor for shifts in fluid status, and review with other symptoms like shortness of breath and edema. Residents with heart failure may have fluid shifts and frequent changes to weights based on the treatment of heart failure. V38 explained V38 uses weights to determine causes of weight loss, such as attributing the weight loss to dietary issues or heart related fluid shifts. On 7/8/2026 at 12:05 PM, V2 (Director of Nursing) affirmed the facility should be following physician orders. V2 was not aware R23's weights were not being obtained as ordered. V2 affirmed V2 would speak to other managers and figure out why the weights were not taken or put into the electronic health record. No further rationale was given to the survey team from V2 or other staff why the weights were not obtained or entered into the electronic health record prior to the exit of the survey. On 7/8/2026 at 12:15 PM, V5 (Nurse Practitioner) stated V5 expects facility to follow orders from providers. V5 explained the purpose of weekly weights is to monitor for increased weight gain which is symptomatic of worsening heart failure. V5 affirmed V5 put in the order and was not sure why the weights were not documented in the clinical record. V5 stated, that (weights) should be in the clinical record. Facility policy titled Weight Assessment and Intervention (2020) documents weights are monitored monthly or more often as recommended by the interdisciplinary care team. Nursing staff will be recorded monthly or as indicated by the interdisciplinary care team. Residents on fluid management programs will have weights monitored at frequency determined necessary to monitor changes in fluid status. Weights shall be recorded in the individual resident's health record.

Based on interview and record review, the facility failed to complete a discharge minimum data set (MDS) within required timeframes. This failure affected one resident (R59) in a sample of 42 residents reviewed. Findings include: R59's face sheet documents R59 was admitted to the facility on [DATE] and discharged from the facility on 3/2/2026. R59's payor source prior to discharge was Medicaid. R59's electronic health record does not document that a discharge MDS was completed within 14 days of R59's discharge. On 7/07/2026 at 3:38 PM V25 (MDS Nurse, Registered Nurse Assessment Coordinator) affirmed V25 is responsible for MDS coordination in the facility. V25 reviewed R59's electronic health record and affirmed R59 discharged from the facility on 3/2/2026 and R59's payor source was Medicaid prior to discharge. V25 confirmed a discharge MDS was not completed for R59's discharge. V25 stated, I don't know how we missed that. V25 affirmed the facility uses the resident assessment instrument (RAI) to complete MDS. V25 affirmed the resident assessment instrument requires a discharge MDS to be completed with 14 days of the assessment reference date (date of discharge). V25 affirmed the Minimum Data Set is used to determine Medicaid reimbursement. CMS' Resident Assessment Instrument (RAI) 3.0 Manual (10/2025) documents OBRA required non-comprehensive assessments include: Discharge Assessment - Return not Anticipated Discharge Assessment - Return Anticipated 09. Discharge Assessment-Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). Consists of demographic, administrative, and clinical items.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to implement care plan interventions, and failed to ensure that call lights were accessible for two of 42 residents (R31, R34) in the sample reviewed for accommodation of needs.Findings include:R34's Face sheet documents in part that R34 is a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, vascular dementia, and cerebral palsy. R34's Minimum Data Set (MDS) on 6/17/2026 documents in part that R34's Brief Interview for Mental Status (BIMS) score is 7, indicating that R34 has severe cognitive impairment, and that R34 is dependent on staff for bathing and toileting while needing substantial assistance for dressing. R34's Care Plan documents that R34 is at risk for falls and injuries related to falls; Interventions include in part a working and reachable call light and personal items in reach.On 7/7/2026 at 3:13PM, R34 was sitting at bedside in his wheelchair. When asked where his call button was, he (R34) replied I don't know. V40 (Restorative Certified Nursing Assistant) confirmed the call light was out of reach and located it behind the bedside table. V40 affirmed that the call light needs to be in reach of the resident.R31's Face sheet documents in part that R31 is an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include unspecified dementia, chronic atrial fibrillation, aortic stenosis, chronic kidney disease, hypertension, and major depressive disorder.R31's Minimum Data Set (MDS) on 6/5/2026 documents in part that R31's Brief Interview for Mental Status (BIMS) score is 3, indicating that R31 has severe cognitive impairment, and that R31 requires substantial/maximum assistance from staff for bathing and toileting while needing supervision/touch assistance for dressing.R31's Care Plan documents that R31 is at risk for falls and injury related to falls; Interventions include in part Ensure.a working and reachable call light and personal items in reach and Ensure the resident's call light is within reach and encourage the resident to use it for assistance when needed.On 7/6/2026 at 12:39PM, R31's call light was seen on the floor towards the head of the bed. V37 (Certified Nursing assistant/CNA) affirmed call light was on the ground out of reach and stated, She doesn't really use a call light, she can get up and move around.On 7/8/2026 at 9:25AM, R31's call light was noted to be on the floor out of reach. V37 (Certified Nursing Assistant/CNA) confirmed that the call light is on the floor behind the headboard. Per V37 (CNA), R31 moves a lot in the bed so it ends up on the floor. When asked if there is anything to prevent having the call light out of reach, V37 replied Yes, we can clip it to the bed or to the curtain next to her bed. She does not have a clip on her call light.On 7/8/2026 at 12:30PM, V2 (Director of Nursing/DON) reiterated, Call lights are to be reachable. If the resident drops it or is moving about in bed, there are clips to hold it within reach of the resident.Facility policy Call Light (2/2/2018) documents in part that All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on interviews and record review, the facility failed to ensure all food served to residents was procured from approved or satisfactory sources. This has the potential to affect all residents receiving meals from the facility kitchen. On 04/02/2026 at 11:17 AM, V3 (Food Service Director) said she had been working at the facility since August 2025 and was in charge of ordering the facility's food. V3 said if a food shortage ever happened, she would go to the store and buy what was needed with the Administrator's card, then provide the Administrator with a receipt of the purchased items. V3 said she co-owned a food pantry with her husband and, occasionally, would take canned goods, like green beans or fruit mix from her personal pantry to the facility's kitchen for use in the resident's meal preparation. V3 said she took canned goods from her personal pantry to the facility's kitchen because she was running low of the food items and did not want to go to the store to buy them. V3 said she had taken maybe two or three cases containing twenty-four little green bean cans to the facility's kitchen, probably twice, since she started working at the facility in August 2025, and had prepared them as part of resident meals and served it to them. V3 said the facility had contracted food providers that supplied the kitchen with food for residents. V3 said she did not create any delivery invoice for the food items she took to the facility kitchen from her personal pantry because she never thought of that. V3 said she did not remember exactly the last time she prepared and served a meal with food from her personal pantry to the facility's residents, but believed she had done so, maybe a week ago. V3 said she did not tell V1 (Administrator) she took cans from her personal pantry to the facility's kitchen and now felt like she did something wrong.On 04/02/2026 at 1:42 PM, V1 (Administrator) said V3 had just told him she had taken food from her personal pantry for use in the facility kitchen. V1 said that (using unauthorized food items) was not our practice; adding, we use the food from our food providers.On 04/06/2026 at 9:50 AM, V1 said he did not have a policy and procedure for kitchen food procurement.The facility four-week cycle menus, dated 03/02/2026, had green beans scheduled to be served during lunch on Sunday (day 1); Friday (day 6); Saturday (day 21); and Wednesday (day 25).An In-Service of Dietary Manager document, dated, 04/03/2026, and provided by V1, stated, The Dietary Manager will review with Administration and Consultation for guidance regarding food products from outside sources being stored and served to the residents. The Dietary Manager will not bring food from personally owned food pantry to serve to the residents.A document provided by V3 contained a list of four contracted facility food providers. V3's personal food pantry was not on the list.

Based on interview and record review, the facility failed to follow their facility assessment tool of having specified number of staff needed to care for their resident based on the resident population and their needs. This failure has the potential to affect all 53 residents at the facility.Findings include:On 7/7/2025, the census provided was 53 residents. Review of facility assessment tool (undated) indicated under staffing plan that based on resident population and their needs, the total number of licensed nurses per shift will be 2 on day, evening, and night shifts. The total number of Certified Nurse Assistants (CNAs) will be as follows: day shift 4-5, evening shift 3-4, and night shift.Facility PBJ staffing report (CASPER report 17050) for fiscal year quarter 2, 2025, January to March 31, 2025, triggered excessively low weekend staffing.On 07/08/25 at 11:18 AM, V15 (Staffing Coordinator) said she basically schedules 4 CNAs and 2 nurses for the morning and afternoon shift (7AM to 3PM, and 3:00PM to 11:00PM), then 3 CNAs and 2 nurses for the night shift (11:00PM to 7:00AM). V15 said she schedules the same number of staff on weekdays and weekends; call off is high on weekends, but V15 tries to call the staff beforehand to make sure they will work their shift. If there is a last-minute call off, the facility will use agency. Reviewed the weekend schedules and staff timeclock for four weekends in the month of June 2025 with V15 and noted the following: The facility was short on Sunday June 1, for CNAs on 3pm to 11Pm and 11PM to 7AM shift, short 1 CNA on 6/7 and 6/8 for the same shifts, short of CNAs on 6/14 and 6/15/2025 on the same shifts, short 1 CNA on 11 pm to 7Am shift on 6/21/2025 and short 1 CNA for 4 hours on 6/22/2025, 3pm to 11pm shifts.Surveyor presented these shortages to V15, who said that she will try to see if there are time clocks for agency staff somewhere, because they do not clock in with the facility.Requested for any staffing policy from facility, but V1 (Administrator) could not provide one.

Based on observation, interview, and record review, the facility failed to ensure the red sanitizing bucket with the cleaning rags contained the correct amount of chemical sanitizer (Quaternary Ammonia) to clean food preparation surfaces, and failed to ensure the food preparation surfaces are free of potentially contaminated objects. These failures have the potential to affect all 50 residents that receive oral diets from the facility's kitchen. Findings Include:On 7/7/25, V1(Administrator) presented the facility census as 53. 3 residents are NPO(nothing by mouth).On 7/7/25 at 10:45am, during observation of the kitchen with V4 (Dietary Manager), the following were observed:*The red sanitizing bucket containing the cleaning rags in the prep area was observed by the surveyor, and V4 stated that the sanitizing chemical is quat. The solution in the red bucket with rags was tested by V4, holding it for over 10 seconds, and the color did not change. V4 dipped the test strip into the sanitizing solution 2 more times, each time holding it for over 10 seconds, and the test strips still did not change color. V4 stated the color should change to show at least 200 ppm (parts per million). V4 stated the red bucket should contain the correct amount of chemical sanitizer (Quaternary Ammonia).*Staff's car keys observed on the food preparation table beside disposable plates and spoons, across from the stove area; V4 stated, This should not be there. V4 proceeded to remove the keys.*Staff's bottled water that was half full of water, and an opened breakfast/cereal cup was observed on the food preparation counter to the right side of the staff's car keys. V4 stated the food belongs to the cook (V10), and he would remind V10 to not put personal foods on the prep table.V4 was asked who was responsible for making the sanitizing solution, V4 stated the [NAME] and the Dietary Aide both do it.On 7/8/25 at 12:05pm, V1 presented a Facility Policy titled On Tray Dietary Policies and Procedures. This undated policy states in #9: Service area wiping clothes are clean and dry or placed in a chemical sanitizing solution with the appropriate concentration.This policy also states under Buckets, Red and Green: To ensure food safety. #4 states: Use a test strip to check the PPM (parts per million) of the sanitizing solution before use and record at least before preparing every meal (three times a day) and log accordingly. For quat sanitizer, follow the manufacturers recommendation (test strip 200- 400 PPM).

Based on observation, interview, and record review, the facility failed to ensure nsulin medications were labeled with an open and expiration date, and failed to remove expired medications from the medication cart. This affects 3 of 9 residents (R25, R8, and R155) reviewed for medication label and storage in total sample of 30 residents, and has the potential to affect all residents receiving house stock medications.Findings include: On 7/7/25 at 11:01am, the [NAME] medication cart showed the following:*Guaifenesin 400mg tablets, manufacture expiration date of June 2025.*R25's Lorazepam 0.5mg, 18 tablets remain in bingo card. Manufacture expiration date of 05/07/2025. V13 verified she counted the narcotics that morning.*R8's first Humalog insulin pen, opened. There was no open date, and no expiration date noted. V13 said the medication is in use. V13 said the medication should have open and expiration date.*R8's second Humalog insulin pen, opened. There was no open date, and no expiration date noted. V13 verified the insulin pen is in use for R8, and the medication should have open and expiration date.*R155's Lantus insulin pen, opened. There was no open date or expiration date noted. V13 verified the insulin pen is in use for R155. On 7/8/25 at 7:30am, V2 (Director of Nursing) said insulins should be labeled with open and expiration date, and expiration medications should not be on the medication cart. During a follow up interview, V2 said she has to verify when insulin medications expire. Facility policy Storage of Medications date 9/2016, last revision date 8/2020, denotes expiration dating (beyond use date) certain medications or package types such as IV solutions multiple dose injectable vials ophthalmic, nitroglycerin tablets and blood sugar testing solutions and strips require an expiration date shorter than the manufacturers expiration date once opened to ensure medication purity and potency. Outdated contaminated or deteriorated medication and those in containers that are cracked soil or without secure closures are immediately removed from inventory disposed of according to seizures and medication disposal and reordered from the pharmacy if a current order exists.

Based on observation, interview, and record review, the facility failed to implement safety measures with Activities of Daily Living (ADL) as indicated in resident plan of care. This failure resulted in R1 sustaining a laceration on the left leg during transfer from wheelchair to bed with 6x4x2 measurements and being transferred to the local hospital for sutures. This failure also resulted in R2 sustaining intraparenchymal hematoma and transferred to local hospital. Findings Include: 1. R1's medical record documents: admitted [DATE]. Diagnosis Information include Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Radiculopathy, Lumbar Region, Need for Assistance with Personal Care, Subsequent Encounter for Fracture Without Routine Healing. R1's Care Plan Report read Focus: R1 have an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day. Interventions: Chair/bed to chair transfer: R1 usual performance is dependent x 2, revision date 11/15/2024. R1 use a mechanical lift for transfer assist, Revision date 3/28/2025. R1's Minimum Datat Set/MDS Section GG, date 3/20/2025, indicates R1's Chair/bed-to-chair transfer as dependent defined as assistance of 2 or more helpers is required for resident to complete the activity. Facility Restorative General Information, dated 3/1/2025, indicates R1's Assist Status of X2, Sit/Stand. Facility Reported Incident, Final Report reads: On March 26th, 2025, while being transferred by CNA, (R1's) left leg bumped against the lever of the halo of her bed. A head to toe assessment was completed and noted with an open area on the left lateral lower leg area. Area cleansed thoroughly and dressing was applied; no LOC (level of consciousness) was noted and ROM (range of motion) remains at baseline. An order was received from MD (Medical Doctor) to send resident to ER (emergency room ) for further evaluation. Resident returned from ER with sutures in place. Based on the investigation it was determined that (R1's) open area to her left lateral lower leg was due to her leg bumping into the lever of the halo on her bed during transfer. (R1's) bed, including the halo, was changed immediately and resident expressed feeling safe without further concerns. Minimum pain noted and managed with medications. (R1) continues to reside in the facility. Care plans were reviewed and updated by IDT (Interdisciplinary Team). MD and family made aware. R1's Hospital Record Discharge Instruction, dated 3/26/2025, reads: (R1) was seen today for a laceration to left leg. Laceration details: location: L lower leg: Length (cm): 6Depth (mm): 2. Hospital was able to repair the laceration. Repair method: Sutures. Suture technique: Simple interrupted. Number of sutures: 10 On 5/29/2025 at 10:15AM, R1 was in bed. V8 (Certified Nursing Assistant/CNA) was providing morning care. R1 stated on 3/26/2025, she was transferred from wheelchair to bed by one CNA using stand-pivot method. R1 stated on transfer, her left leg hit the bed and she sustained laceration to the leg. R1 stated she went to hospital and received ten sutures to her left leg. On 5/29/2025 at 11:57AM, V3 (Certified Nursing Assistant) said on 3/26/2025, she transferred R1 by stand-pivot from wheelchair to bed by herself, with no assistance from other staff. V3 said R1 was a one-person assist with gait belt use. V3 said there is a book/binder at the nurse's station used by staff to identify the transfer assistance of each resident. V3 said they are to look at this binder at the beginning of the shift to identify resident transfer assistance. On 5/29/2025 at 1:47PM, V6 (License Practical Nurse) said R1's transfer assistance has always been a 2- person assist, with sit-to stand or mechanical lift. V6 said on 3/26/2025, she sent R1 out to hospital after sustaining a laceration to the leg. V6 said R1 returned to facility with sutures to her left leg. This past noncompliance occurred from 3/26/2025 through 3/27/2025. Prior to the survey date of 5/29/2025, the facility had taken the following actions to correct the noncompliance: 1. On 3/27/2025, the facility Compliance Assurance Committee developed a plan of correction for the 3/26/2025 R1's improper transfer. 2. On 3/27/2025 V3 (Certified Nursing Assistant) received an education in- service, Topic: Transfer/Hoyer lift given by V1 (Administrator) and V11 (MDS Coordinator). On 3/27/2025 V3 was given written corrective action notice regarding improper transfer by V1. 3. On 3/27/2025, all facility staff (Nursing Management, Nurses and Certified Nursing Assistant/CNAs) were in-serviced on Topic: Transfers/Hoyer lift by V1 and V11 4. There are no subsequent improper transfer determined by Quality Assurance Tool from 3/28/2025, 4/1, 4/8, 4/15, 4/22, 4/29, 5/5, 5/13, 5/20, and 5/27/2025 2. R2's medical record reads: admitted : 11/20/2023. Diagnosis Information include Moderate Protein-Calorie Malnutrition, Moderate Intellectual Disabilities, Unspecified Lack of Coordination, Need for Assistance with Personal Care, History of Falling. R2's Care Plan Report reads Focus: R2 have an ADL self-care/ mobility performance deficit r/t Impaired balance, S/P (status post) R (right) Knee Patella tendon repair. Needs assistance or dependent in: Eating, Bed mobility, Transfer, Personal hygiene, Dressing, Toileting hygiene, Bathing. Interventions: Bed mobility: dependent, Revision date 11/28/2023. Focus: R2 require assistance with bed mobility r/t weakness. Interventions: Providing assist of 1-2 staff as needed, Revision date 4/25/2025. Focus: R2 at risk for falls and injury related to falls. I have history of fall. Interventions: All essential/ personal items placed closer to bed and within resident's reach, Revision date 2/19/2024. R2's MDS Section GG, date 4/21/2025, indicates R2 need substantial/maximal assistance with rolling left to right from lying on back on the bed. Facility Reported Incident, Final Report reads: On April 26, 2025, (R2) was successfully transferred into bed by a certified nursing assistant (CNA), who then proceeded to provide incontinence care. Upon completion of incontinent care, the resident was positioned safely and centered in bed. Shortly thereafter, the resident was observed on the floor. The CNA immediately notified the assigned nurse, who conducted a prompt head-to-toe and neurological assessment. No loss of consciousness was observed. The attending physician was notified and ordered the resident to be transferred via 911 to the nearest emergency department for further evaluation. The resident's Power of Attorney was also notified. (R2) was admitted to (hospital), where he was diagnosed with an intraparenchymal hematoma. Based on the CNA's interview, it was revealed that the resident appeared to turn over to reach for his stuffed Christmas bear and family photograph and slid out of bed, as these items are known to provide comfort. The resident's care plan will be reviewed and updated by the Interdisciplinary Team (IDT) upon his return to the facility. On 5/29/2025 at 12:14PM, V4 (Certified Nursing Assistant/CNA) said she was the assigned CNA to R2 when he fell out of bed on 4/26/2025. V4 said she raised the bed after transferring R2, and proceeded to provide incontinence care to R2. V4 said she turned away from R2 for a split second when R2 fell . V4 said she believes R2 hit his face on the fall. On 5/29/2025 at 1:28PM, V5 (Registered Nurse) said she was called an informed by V4 that R2 fell from the bed. V5 said R2 was on the floor and laying on his back. V5 said on assessment, R2 had redness on the left side of his face near the eye. V5 said she called 911 and R2 was transferred to local hospital. On 5/29/2025 at 12:46PM, V2 (Director of Nursing) said R1's transfer assistance has always been 2-person assist with sit-to- stand. R1 is now care planned for use of mechanical lift transfer from bed to chair (wheelchair), and chair to bed with 2-person assist. V2 said staff should position the bed mid-level during care to avoid too much bending for back safety. Staff should have all needed supplies within reach and should not lose sight of resident whereabouts. V2 stated these incidents would have been avoided if staff followed the care plan. On 5/29/2025 at 2:09PM, V7 (Restorative Nurse) said resident transfer assistance is recorded in the Restorative binder available at nurse station, and can also be seen in the resident electronic record. V7 also said staff should not transfer residents by themselves if transfer care plan indicates 2-person assist. This past noncompliance occurred from 4/26/2025 through 4/30/2025. Prior to the survey date of 5/29/2025, the facility had taken the following actions to correct the noncompliance: 1. On 4/30/2025, the facility Compliance Assurance Committee developed a plan of correction for the 4/26/2025 R2's fall incident. 2. On 4/29/2025 V4 (Certified Nursing Assistant) received an education in-service, Topic: Fall Prevention and Transferring given by V2 (Director of Nursing) along with handouts, Title: The 4P's of reducing the Risk of Falls. 3. On 4/29/2025, all facility staff received an education in-service, Topic: Fall Prevention and Transferring given by V2 (Director of Nursing) along with handouts, Title: The 4P's of reducing the Risk of Falls. 4. There are no subsequent fall incident related to bed mobility determined by Quality Assurance Tool from 4/30/2025, 5/1, 5/2, 5/5, 5/6, 5/7, 5/8, 5/9, 5/12, 5/13, 5/14,5/15, 5/16, 5/19, 5/20, 5/21, 5/22, 5/23, and 5/27/2025. Observation of transfers, bed mobility, and fall prevention protocol was completed on this survey, with no other concerns identified. Policy and Procedure: Title: Transfers- Manual Gait Belt and Mechanical Lifts, Revision date 1/19/2018 Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents. Guidelines: 5. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: 0= Independent 1= 1 person transfer (25% or less assistance from the caregiver) with gait belt 2= 2 person transfer with gait belt (ONLY when use of mechanical lift is not possible) SS= Sit to Stand Lift with 2 caregivers H= Mechanical Lift (Hoyer) with 2 caregivers Title: Fall Prevention Program, Revision 11/21/2017 Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Standards: Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions. Fall/safety interventions may include but are not limited to: The resident's personal possessions will be maintained within reach when possible. Residents who require staff assistance will not be left alone after being assisted.

Based on interview and record review, the facility failed to provide the 2 persons assistance while turning one dependent resident (R1) in bed. This failure affected one resident of three reviewed for accidents. This failure resulted in R1 falling to the floor and sustaining a frontal hematoma and laceration requiring glue to close. The findings include: R1 has diagnoses of Paraplegia, Complete, Dementia, Major Depressive Disorder, Mononeuropathy of Bilateral Lower Limbs, Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction, Contracture, and Immobility Syndrome (Paraplegic). Progress Note, dated 2/15/24, documents R1 is a 2 person assist with bed mobility. R1's MDS (Minimum Data Set), dated 8/7/24, notes a BIMS (Brief Interview for Mental Status) score of 3, impaired. R1 is noted to have no physical or verbal behavioral symptoms. R1 is noted to have Functional Limitation in Range of Motion to her lower extremity on both sides. Section GG notes R1 is dependent on staff for toileting hygiene, sit to lying or lying to sitting on side of the bed and transfers. R1 requires substantial/maximal assistance with the helper does more than half the effort for rolling left to right. R1 had 0 falls since the prior assessment. R1's fall risk assessment score is 14, dated 8/5/24. R1's Restorative Observations, dated 8/5/24, notes right and left lower extremity paralysis/paresis. Existing contracture or limited range of motion. R1's care plan designates requires assistance with bed mobility related to weakness. Intervention include provide assist of 1-2 staff as needed. R1's Fall Initial, dated 10/24/24, noted R1 noted on floor by CNA (Certified Nursing Assistant) upon during rounds. Unwitnessed fall, precipitating and contributing factors: R1 confused, forgets to use call light and incontinent. New injuries observed raised area/ swelling/discoloration noted to right forehead. 911 called. R1's IDT Fall Committee Meeting Note: resident was observed on the floor and stated she wanted to reposition herself and rolled over to the floor. Review of V4 incident statement documents R1 observed on the floor. 911 called and transported resident to hospital for evaluation. V8's statement, as I was doing rounds at about 4:00 AM I walked into (R1's) room to do a safety check and (R1) was on the floor. (R1) stated she rolled out of bed and hit her head. Both statements are dated 10/24/24. No statement from V13 was provided. Fire Department record, dated 10/24/24, documents, dispatched for the fall victim. Upon arrival crew located the patient laying supine on the floor. Alert and oriented times three. Patient's nurse stated the patient was being changed and cleaned in bed when she was rolled out. Patient hit her head on the floor when she fell . Staff had already performed general wound care to the patient's forehead. Patient's history and meds was obtained from staff on scene. Call received at 3:43AM and ambulance on scene at 3:50AM. Hospital records, dated 10/24/24, presents with mechanical fall out of bed, (R1) states nurses were changing her diaper and rolled her over and she kept rolling and fell to the ground. (R1) head strike with frontal hematoma. Additionally pain in knee with a hematoma just below the right knee. Contracture and external rotation of right hip. Pain in right knee with hematoma over right tibial tuberosity. Mental status: Alert and oriented to person, place, and time. Neurological: positive for headaches. Imaging results for bilateral hips, pelvis, knees, right tibia and femur listed as results pending. Emergency Department Course: 10/24/24 agreeable to return to nursing home after irrigation and skin glue repair of laceration. On 11/19/24 at 10:01AM, R1 was observed in bed with a bump on the right side of her forehead, scabbed over in the center, pink skin, and dry without drainage. R1 was asleep. On 11/19/24 at 11:45AM, V4 said, The CNA (Certified Nursing Assistant) called me to the room. I went to the resident room; after assessing (R1), I called 911 because the physician told me to send her to the hospital. At baseline, (R1) is alert and oriented x 2, and she is very responsive and has periods of confusion. (R1) is a 2 person assist for transfers and she typically sleeps throughout the night. (R1) had been checked not long before the fall. Whatever I wrote is what happened. V4 said she didn't remember more than what was written. On 11/19/24 at 1:57PM, V8, CNA, said, I don't know who (R1) is. I don't remember someone falling and getting a goose egg or large bump on their head. I have had people fall but I don't know their names. Some people are 2 person assists because they are combative. On 11/20/24 at 12:54PM, V13, CNA, said, On 10/24/24, there was only 2 CNAs that night. V13 I was coming to east hall (opposite R1 hall) and the nurse called me and said they had a fall. I went in the room and (R1) was on the floor next to the bed. V13 said she was trying to change her diaper and she fell . The surveyor who is she? V13 said V8 by name. V13 said, (V8) told me she was trying to change (R1's) diaper in bed. I did not help in turning or changing R1 before the fall, I was on the East hall. They called 911 and I came back to my hall. On 11/20/24 at 11:50AM, R1 was in bed alert and oriented place and self, confused about time. The surveyor asked R1 what happened to her head? R1 she had a raised area, size and shape of an egg, with a scab in the center. R1 said her head and ankle hurt. R1 said, You should have seen it before; it was bigger and ugly. The girl was turning me and was pushing me, and I kept saying stop, you're going to push me out. The girl kept pushing, and next thing I knew, I fell to the floor. V15, Director of Nursing, was brought to the room, and R1 repeated the incident that the girl pushed her out of bed. R1 said, It hurt my shoulder and my head. R1 was on air mattress. R1's right leg was contracted, with knee bent, and foot towards R1's torso. R1's left leg extended out in front of her. On 11/19/24 at 12:11PM V5, CNA, said, (R1) needs 2 persons to turn her. (R1) can't help with positioning and is heavy, and 2 people are needed to turn her. We don't have a rail for (R1). I have not seen R1 kick, fidget, or try to get of the bed. (R1's) cognition goes in and out; she does get confused. On 11/19/24 at 12:49PM V7, CNA, said, (R1) is 2 persons assist for cares. (R1) never tries to get up or out of bed. (R1) can't roll out of the bed, and she can't help to turn. (R1) is cooperative. (R1) had a fall; when I came back to work R1's face was swollen, all on the right side was swollen. (R1) said they were trying to roll her over and she fell . (R1) told me that. It can be possibly true. (R1) can't sit up in the bed and she can't stand or doesn't try to walk. On 11/20/24 at 10:25AM, V11, MDS (Minimum Data Set) Nurse, said, When the fall was discussed with the team, we were told the fire department picked (R1) off the floor after the fall. Per the documentation, (R1) rolled off the bed. At 10:43AM, V11 presented Functional Ability assessment, dated 8/7/24. V11 said, (R1's) bed mobility is dependent. (R1) needs 2 person assistance. In the facility when someone is dependent, we use 2 people or more. (R1) has no behaviors that would mean she needs 2 persons for assistance. For turning and repositioning in bed, (R1) needs 2 people. (R1) has no strength in arms and legs. (R1) does not have the strength to turn herself in bed. I have no idea how she rolled out of bed. When they talked about the fall, I wondered too. Vased on our assessment, (R1) is dependent and can't roll herself. The binder at the nurses' station tells how many people can help. The staff gets trained to use 2 people. The staff is told if they use 2 people for the transfer, then they need to use 2 for bed mobility and changing briefs. On 11/20/24 at 11:07AM, V10, Restorative Nurse, said, Anyone with a fall risk score below a 9 are at risk. (R1) was not part of the falling leaf program when she fell , and she is not now. Based on assessments, (R1) needs extensive assistance with care; she needs a lot of help. (R1) cannot get up, she can assist with slight movement, but staff would need to do the turning. (R1) can be between 1 to 2 person assist with bed mobility, it depends on staff. I can do (R1) by myself. It is in the kardex in computer chart; you can see how much staff (R1) needs for care. V10 read from Kardex and documented BED MOBILITY with assistance. V10 said, There is no direction if she needs 1 or 2 person, it depends on the person. Observation record will show if she has contractures. (R1) was not able to walk before the fall. I went over the fall. (R1) is on a bed mobility restorative program. The program says (R1) will practice repositioning in bed, and she does not use rails for program. On 11/20/24 at 12:03PM, V12, Restorative Aid, said, For (R1's) bed mobility, I go in and I turn her side to side, with another person at all times. I move her contracted leg as much as she can bear. (R1's) right leg is contracted and her left leg she does not bend. The CNA and I are doing all the work to turn her, she is dependent on staff. I have never seen her turn or try to roll. In all the time I have worked with (R1), she has never tried to roll or initiate the roll in bed. On 11/20/24 at 12:28PM, V15, Director of Nursing, said, I started last week. Paraplegia affects the ability to use legs. Facility fall prevention program, dated 11/21/2017, states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program includes the following components: use and implementation of professional standards of practice. Care plan incorporates: Preventative measures. Safety interventions will be implemented for each resident identified at risk. Direct care staff will be oriented and trained in the Fall Prevention Program. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or chair and provide care as assigned in accordance with the plan of care.

Based on interview and record review, the facility failed to prevent a fall by providing a two person assist with bed mobility during ADL (Activity of Daily Living) care. This affected one of three (R2) residents reviewed for safety during direct care. This resulted in rolling of the bed during direct care and sustaining a head injury requiring 9 sutures. Findings include: Facility final report to the department, dated 9/19/24, denotes thorough investigation completed, including staff and resident interviews. On 9/13/2024 resident was observed on the floor in his room. Head to toe assessment completed. Minimal bleeding noted to right forehead. First aid rendered, and pressure applied to area. Neuro checks initiated and completed. NO change in LOC (level of consciousness). ROM (range of motion) at baseline. Resident denied pain. MD (Medical Doctor) gave orders to send resident to ER (emergency room ). Staff Interviews revealed staff was present at the time of the fall. Based on the investigation, the root cause of the fall was resident stated he was attempting to reposition himself in his bed, lost his balance, rolled over the side of the bed onto the edge of the floor mat. Staff could not reach him in time to break the fall. Resident returned from ER with sutures to the right forehead. CT (Computed Tomography) scans negative. Care plans were reviewed and updated. Facility incident report, dated 9/13/2024 for witness fall, location (room #) room, The CNA (Certified Nursing Assistant) verbalized that she was doing ADL (Activities of Daily Living) care in the morning, the resident abruptly turned on his side, lost his balance and rolled over. The CNA tried to grab the resident but was unsuccessful and the resident landed at the edge of the floormat. The resident verbalized that he rolled over and landed at the edge of the floor mat. Physical assessment done, vital signs taken and are all within normal limits, wound dressing done. Pain medication administered. Sent to (hospital name) for further evaluation. Injury type: face. Oriented to place, person, and situation. Predisposing environmental factors- there was already a safety intervention in place. Predisposing physiological factors- gait imbalance. R2 hospital records, dated 9/13/24, denotes chief complaint-fall, physical exam- 4 cm (centimeters) laceration overlying his forehead, simple. clinical impression head injury, forehead laceration. Laceration repair- location: forehead, length: 4 cm, number of sutures: 9 sutures. R2 MDS (Minimum Data Set), dated 07/29/24, denotes in section GG for functional abilities and goals denotes roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed, 02 is noted, 02 substantial/maximal assistance- helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 9/19/24 at 10:59am, R2 was observed alert to person, place, time, and situation, R2 observed sitting in a high back wheelchair. R2 said he was being washed up in bed, the girl told him to roll over, and he rolled too far and fell out of bed. R2 said he hit his head on the floor. R2 said it was one girl that was washing him up at the bedside. R2 observed with 2-inch laceration to the forehead with multiple sutures in place. R2 had purplish discoloration around the right eye and purplish discoloration under the left eye. R2 said he feels safe at the facility. On 9/19/24 at 11:37am, V1 (CNA-Certified Nursing Aide) said, I was giving (R2) a bed bath, I was washing (R2's) back, (R2) was laying on his left side, his back was facing me. (R2) turned a little more and fell out of bed. The air in the air mattress was increased on my side, and that contributed to pushing (R2) out of the bed. V1 said she did bring R2 closer to her before the turn, and R2 had room on the side of the bed for the turn. V1 said, The air in the air mattress always does that. V1 admitted to putting the air mattress on static mode when providing R2 care. V1 said, (R2) fell on the floor, he landed on the floor mat, but his head landed on the corner of the floor mat. V1 said she observed blood on R2's forehead. V1 said she went and got the nurse right away. V1 said she was on the opposite side of where R2 fell , and she could not catch R2 before he fell . V1 said R2 was not resisting to care. V1 said R2 is one assist with turning, repositioning, and bed mobility. V1 said the plan for R2 is to move his bed to the wall. V1 admitted the current plan of 2-persons assist with bed mobility for R2. V1 admitted the current plan of 2-person assist with turning and repositioning R2. On 9/19/24 at 1:50pm, V2 (Director of Nursing) said the facility does not put the air mattress on static mode during care / ADL care. V2 said after R2's fall, the facility plan is to use two people for turning and repositioning all residents that use an air mattress, regardless of body weight, V2 said this is for safety, it will prevent resident from rolling out of bed. On 9/19/24 at 2:42pm V4 (Restorative aide) said R2 need substantial to max assist with bed mobility, tuning from side to side. V4 said R2 needs two-person assist with bed mobility. V4 said R2 required two-persons assist prior to the fall. V4 said R2 sometimes does not want two people assisting him. On 9/20/24 at 10:13am V6 (Physical therapy manager) said R2 has weakness on his left side. R2 can roll to his left side but he will not stay in that position too long. V6 said she was not there when the fall occurred, she knows sometimes those air mattresses are slippery. R2's most current plan of care was presented by V2. R2's plan of care does not address the use of 2 person assist with bed mobility, does not address the use of two person assist with turning and repositioning while in use of air mattress. The operator's manual for R2's bed denotes, in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or position. The static mode will help ensure the patient does not bottom out when in a sitting position. Facility policy titled Fall prevention program, last revision date 11/21/2027, denotes to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Guidelines: methods to identify risk factors, methods to identify residents at risk, assessments time frames, use and implementation of professional standards of practice, communication with direct care staff. Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Facility Comprehensive care plan policy, with revision date of 11/17/17, denotes to develop a comprehensive care plan that directs the care team and incorporate the residents' goals, preference, and services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to identify, assess, and implement interventions in preventing the development of pressure ulcer for one (R19) of three residents in the sample of 37 reviewed for pressure ulcer. This failure resulted in R19 developing an unstageable pressure ulcer on the sacral area. Findings include: R19 is an [AGE] year old, female, initially admitted in the facility on 06/14/22, with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side; Parkinson's Disease without Dyskinesia, Without Mention of Fluctuations; and Neurocognitive Disorder with Lewy Bodies. R19's MDS (Minimum Data Set), dated 07/02/24, recorded: Section C, BIMS (Brief Interview for Mental Status) score of 99, which means R19 was unable to complete the interview; and Section M0150 Risk of Pressure Ulcers/Injuries - R19 is at risk of developing pressure ulcers/injuries. R19's Care plan on potential for alteration in nutrition, dated 09/06/23, documented: Intervention - Assess for changes in elimination, changes in skin integrity (04/02/24). Braden Observation, dated 01/03/24, documented a score of 16.0, which means R19 is at risk for development of pressure ulcers. Weekly Skin Observation, dated 08/05/24, documented R19 had intact skin. Her progress notes, dated 08/05/24, also documented intact skin. R19's shower sheets, dated July 2024, recorded normal skin. Shower sheet, dated 08/06/24, documented an open area on R19's sacrum. There was no documentation in the progress notes/wound notes, dated 08/06/24, addressing R19's open area on the sacrum. R19's Wound Assessment Details, dated 08/09/24, recorded an Unstageable Facility Acquired Pressure Ulcer on the sacrum with measurements: 2.7cm length x 2.4 width x depth unknown. R19's POS (Physician Order Sheet), dated 08/09/24, documented: Cleanse sacrum with wound cleanser then apply calcium alginate with silver then cover with foam dressing daily and PRN (when needed) one time a day for wound. On 08/12/24 at 11:40 AM, R19 was observed in the dining room attending activities. She was sitting in her wheelchair. R19 was awakeand alert, but did not respond when greeted. On 8/12/2024 at 1:10 PM, V24 (Wound Care Nurse) was observed performing wound care on R19. R19 was in bed, on a low air loss mattress, turned to left side, with a pressure ulcer on the sacral area. The sacral pressure ulcer had 30% slough, 70% granulation tissue, with clean wound edges. There was no discharge noted on the wound. Current measurements were taken as 2.7 cm (centimeters) x 2.4 cm. According to V24, R19's sacral wound is an unstageable pressure ulcer, facility acquired. V24 added, She had an old pressure ulcer healed on the sacrum, it reopened. She is nutritionally compromised and also incontinent. On 08/14/24 at 11:05 AM, V23 (Wound Nurse Practitioner) stated, I was contacted a week ago regarding sacral wound; it is a facility acquired. The last time I saw her was last January 2024, she had a wound on the sacrum and was healed. It reopened 08/09/24 as Unstageable. I was first notified on 08/09/24, and I gave orders for calcium alginate. Facility has to follow its skin protocol. With fragile scar tissue, it can open in a matter of hours. On 08/14/24 at 11:10 AM, V24, Wound Care Nurse, stated, I am not here every day. When I came back on 08/09/24, I was informed that she has a wound on the sacrum. When I assessed it, it was Unstageable. I notified (V23) right away. If I am not here, nurses should notify Director of Nursing (DON), and she notifies (V23). On 08/14/24 at 11:15 AM, V6 (Registered Nurse, RN) stated, The CNAs (Certified Nurse Assistants) usually check residents' skin during shower and incontinence care. If there are any skin issues per CNA, I do the assessment myself and I tell DON. I also sent a message to the Wound Care Nurse. On 08/14/24 at 11:55 AM, V20, Certified Nursing Assistant/CNA stated skin assessments on residents are done during morning care and changing. If skin issues are noted, the CNAs notify the nurse on duty. On 08/14/24 at 12:23 PM, V2, Director of Nursing, stated, (V24) is the Wound Care Nurse, and she is not here every day. She works Mondays, Wednesdays, Fridays, and PRN (as needed). Floor nurses do wound care. The nurses and CNAs do the skin assessment. CNAs assess skin during ADL (activities of daily living) care. If there are skin issues, CNAs notify nurses. Nurses will do the assessment, and if there are open areas or redness, the nurse will call the Primary Physician and ask for orders or treatment orders. On (R19), the wound on the sacrum was identified by (V24) on 08/09/24 as Unstageable. I was not here that time. They just told me over the phone that she (R19) had an open area on the sacrum. I told (V24) to do the assessment and implement interventions and notify (V23). In the shower sheet, on 08/06/24, there was an open area. I believe (V22, CNA) reported it to the nurse. The nurse will document under wound observation note. Staff has to assess the body of residents on a daily basis. If they found any redness, they have to inform the nurse, and the nurse will check/assess and inform the doctor and put all the necessary interventions. There is a weekly skin assessment completed by treatment nurse. CNAs do the skin assessment and it is recorded on a daily basis via plan of care. The nurse who identified the skin issue will do the first treatment. V2 was asked to present documentation from the plan of care, dated 08/06/24, relative to R19's open area to the sacrum, but nothing was presented during the course of this survey. On 08/14/24 at 1:34 PM, V25 (Medical Director) stated, If a resident is not mobile, they have to move the resident every two hours or so, feed resident properly; change resident on time; and if there are skin issues, contact wound care team immediately. Facility's Policy titled, Pressure Ulcer Prevention, dated 1/15/18, documented the following: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin.

Based on observation, interview, and record review, the facility failed to ensure one dependent resident (R21) was safely transported in a wheelchair. This failure affected one (R21) of two residents reviewed for falls in a sample of 37. This failure resulted in R21 falling forward out of a wheelchair while being pushed by staff, hitting R21's head, and sustaining a contusion to right forehead, requiring transfer to a local hospital for emergent care. Findings include: R21 is an [AGE] year-old resident admitted to the facility on [DATE], with diagnoses including but not limited to generalized anxiety disorder, moderate intellectual disabilities, muscle wasting and atrophy, and history of falling. Minimum Data Set (MDS), dated [DATE], documents R21's Brief Interview for Mental Status (BIMS) score as 00, which indicates severe cognitive impairment. MDS, dated [DATE], also documents R21 is dependent on staff for wheelchair mobility and toileting hygiene; needs substantial/maximal assistance for oral hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear; needs partial/moderate assistance is needed for upper body dressing and personal hygiene; and needs supervision or touching assistance for eating. Fall risk assessments completed on R21 document the following: 11/20/2023 - Fall risk score =18; At risk for falls 02/19/2024 - Fall risk score = 14; At risk for falls 04/29/2024 - Fall risk score = 14; At risk for falls 07/12/2024 - Fall risk score = 16; At risk for falls 07/29/2024 - Fall risk score = 14; At risk for falls Care plan for R21, dated 11/21/2023, documents: Focus: I am at risk for falls and injury related to falls. I have history of fall. Risk factors: Requiring assistance with activities of daily living (ADL's), possible medication side effects, cataract, right leg cast in place. Goal: I will have interventions in place and reviewed as needed to address risk for falls and injury related to fall through next review. Interventions: All essential/personal items placed closer to bed and within resident's reach. Send to hospital for evaluation. Neurochecks as ordered. Bump to Forehead: assess for pain, provided pain interventions as appropriate. Assess for altered cognition, decline in safety awareness. Assess for side effects of medications. Assist with ADLs, anticipate and meet resident's needs. Assist with toileting upon awakening, before and after meals, during rounds and before bedtime. Progress note, dated 07/12/2024, documents: While (V31) Certified Nursing Assistant (CNA) was wheeling (R21) back to his room; (R21) abruptly became agitated and noted to slide his body down landing on the floor and bumping his head. Certified Nursing Assistant unable to prevent fall in a timely manner due to resident's abrupt agitated behavior. Upon staff interview of incident, (R21) stated, 'I wanted her (referring to V31) to wheel me faster back to my room.' (R21) assisted safely back to wheelchair. Vital signs taken. Body assessment completed with discoloration/redness noted to the right side of forehead. Pain assessment completed with no complaints of pain made. Range of motion assessed and within resident's baseline. Level of consciousness within resident's normal range. First aid rendered to affected site per medical doctor (MD) orders. Neuro checks initiated. (R21) assisted safely to bed. Activities of daily living (ADL) care rendered. Bed in lowest position with call light in reach. MD made aware and gave orders to send (R21) to hospital for further evaluation. MD orders carried out. (V32) Case worker made aware. Plan of care ongoing. Progress note, dated 07/12/2024, documents: (R21) is being transported via ambulance to hospital. Order summary with signed bed hold policy sent with (R21). Report called and given to emergency room nurse. MD made aware. (V32) made aware. All departments made aware. Local hospital emergency room note dated, 07/12/2024, reads: [AGE] year-old man with history of hypertension, hyperlipidemia, benign prostatic hypertrophy, failure to thrive, not on blood thinners here for evaluation of head injury. Patient coming from facility after falling out of wheelchair, hit head, sustained small contusion to right forehead. Fall initial occurrence note, dated 07/12/2024, documents description of occurrence: While CNA (V31) was wheeling resident back to his room; resident abruptly became agitated and noted to slide his body down landing on the floor and bumping his head. CNA (V31) unable to prevent fall in timely manner due to resident's abrupt agitated behavior. On 08/12/2024 at 10:04 AM, R21 was sitting at table in a wheelchair in the activity room. Bruise noted to forehead, purple in color, and slightly smaller than quarter sized. On 08/13/2024 at 9:54 AM, R21 was in a wheelchair in activity room. Bruise remained purple in color and remained slightly smaller than a quarter in size. On 08/13/24 at 10:07 AM, V6 (Registered Nurse) stated, The bruise on his forehead is from his fall last July. The bruise did not fade out. He has not had any falls since last one in July. He sometimes is a bit aggressive with movement, but not all the time. No aggressive attitude. Bruise has remained since fall last month. It was a little bigger, not much. When asked what interventions are in place to keep him safe, V6 stated he had fall mats and low bed in place. On 08/14/24 at 9:49 AM, (V2) Director of Nursing (DON), stated, The bruise on (R21's) forehead has been there since his fall on 07/12/2024. It doesn't heal. He keeps messing with his face. He has not had a fall since the one in July. On 08/14/24 at 3:39 PM V29, (Certified Nursing Assistant/CNA), stated, I have worked here about a month. I have worked with (R21). He is a fall risk. The interventions we have in place are place call light in reach, lower his bed, and floor mats. I can't think of anything else at the moment. He does not have any behaviors. I am not aware of any falls. On 08/14/24 at 12:43 PM, V27 (CNA stated, I have worked here 3-4 months. I have taken care of (R21) before. Sometimes he gets a little aggressive. Nothing too crazy. Sometimes when someone sits where (R21) wants to sit, he makes noises or will ball up his fists and shake them. I have not been here when he has had a fall. I know (R21) is a high fall risk. The interventions we have in place are that we get (R21) up so someone is watching him. Staff is always in the activity/dining room so we can watch (R21). I am not aware of any other interventions in place to keep him from falling. On 08/14/24 at 11:57 AM, (V2) Director of Nursing (DON), stated, (R21) is confused. He can't walk and does not want to go to another facility. He loves it here. He has a lot of pictures. He has behaviors sometimes. He is resistive with care or does not want to be put to bed. He sometimes become restless. He has had 2 falls. The first one he rolled over on his bed, and the last one, (V31) was wheeling (R21), and he became restless and leaned forward and ended up on the floor. We sent him out to the hospital. The family is very concerned about him. They want him to be sent out to hospital for any fall. He sustained bruising to the head. He hit is head when he hit the floor. Sometimes he is just restless once in a while. When he is in bed he just moves around once in a while. He sometimes looks for his pictures, and if they are on the floor, he will try to get them. CNAs know if his pictures on the floor, to pick up and give to him because he will look for it. When he gets restless like that, we give him time and talk to him. He started to move that time in the wheelchair, and he lost his balance in the chair. A lot of times he is in the dining area, and he is leaning on the table. We are careful with him because he is leaning a lot of time without a table in front of him. We have people all the time in the dining room to watch him. I tell them to always check on (R21). He is high risk for falls. Interventions when he is in bed his bed is in low, low position and we have a floor mat, and always redirect him. When he is restless, we give him space and redirect him. We listen to him. We tell him to always stay by the table. He is alert with confusion. He is total care. He is dependent with all ADLS. Eating is fine, but he is total assist for everything else. When a risk assessment is 14-18, that means high risk for falls. For (R21) is high risk. Care plan states he has poor safety awareness. He is not aware what he is doing. V2 was asked when V31 was pushing him did he have leg rests? V2 replied, I am not sure. (R21) was sent out to the hospital; we did not report because it was no injury. His hematoma to forehead is not serious so we did not report it When asked, what is your expectation for CNA's? How should they propel resident in wheelchair? V2 responded, They should make sure resident is safe and tell them what they are doing and make sure they are not moving. Yes, if he leans forward, the CNA will tell him to lean back. The expectation is for the CNA to transport safely, so the resident is safe and does not get harmed. V2 was sked, When he fell on [DATE], what intervention did you add to prevent further falls? V2 replied, We make sure to ask for assistance, and to stop pushing the chair. On 08/14/2024, investigation was provided, conducted by V2 regarding R21's fall on 07/12/2024. Investigation includes statement from V31 as follows: While I was wheeling resident back to his room; all of a sudden he became agitated and slide his body down landing on the floor and bumping his head. It happened so fast and I couldn't get to him fast enough. I then made sure he was safe and called for the nurse to see him. On 08/14/24 at 4:16 PM, V25, Medical Director, stated. I have been Medical Director since about 2015. I am not by the computer, but I can try to log in. I remember most of my patients, but do not remember everything. I am logging in now. I recall the name (for R21), but I want to be sure. I get calls on everything that happens. I am sure I was called regarding his fall. He has anxiety and dementia no other psych diagnoses. The psychiatrist would be better to ask that question. When asked what is the expectation MD has of staff regarding falls, he stated, Obviously they need to be assessed and sent to the hospital, and they will do evaluation and testing. When asked if this fall could have been prevented? V25 stated, Obviously they could have held them from falling forward. Did you ask the CNA? If I am on the street and see someone falling, I will try and prevent it. I think everyone will try to do that. I have not seen behaviors whenever I have seen him. Fall Prevention Program Policy, dated 11/28/12, states: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: The Fall Prevention Program includes the following components: Use and implementation of professional standards of practice. Standards: Safety interventions will be implemented for each resident identified at risk. Fall/safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the Fall Prevention Program Transfer conveyances shall be used to transfer residents in accordance with the plan of care.

Based on interview and record review, the facility failed to immediately transfer a resident to the emergency room after a fall that resulted in left hip pain and a fracture. This failure resulted in a surgical delay in treatment (more than 7 hour) for R5 who was experiencing left leg pain and had a fracture. The facility also failed to ensure a resident (R6) was not transferred from the floor after a fall and complaints of right upper leg pain prior to emergency medical services arriving. These failures apply to 2 of 4 residents (R5 and R6) reviewed for quality of care in the sample of 14. The findings include: 1. R5's Fall-Initial Occurrence Note, dated 12/29/23, shows R5 had a fall in the dining room at 1:46 PM and landed on the floor and her left side. R5's Progress Notes, dated 12/29/23 at 8:44 PM, shows, Left leg new onset of pain .MD (Medical Doctor) notified of new pain onset, new orders received. x-ray of left leg. R5's X-ray report shows a reported dated and time of 12/30/23 at 12:10 AM. The report shows R5 had an impacted intratrochanter fracture with varus deformity of the left hip. R5's Progress Notes, dated 12/30/23 at 7:30 AM, shows, Resident noted to have pain in left leg with grimaced face. MD made aware and ordered transfer out to hospital for evaluation. (more than 17 hours after R5's fall and 7 hours after receiving x-ray results showing a hip fracture) R5's Hospital Notes shows she had a left femur cephalomedullary nailing on 12/30/23. On 3/8/24 at 11:45 AM, V8 (Registered Nurse) said she did an assessment after R5 fell . V8 said R5 was not complaining of pain, but she also is not able to articulate very well if she is having pain. V8 said she called the physician and he ordered a STAT (Immediate) x-ray of her left leg to make sure there were no injuries. On 3/8/24 at 1:26 PM, V18 (Registered Nurse) said she works from 3:00 PM to 11:00 PM. V18 said on 12/29/23, it appeared R5 was having pain so she called the doctor and he ordered stat x-rays to be done. V18 said she was unsure if x-ray came during her shift. On 3/8/24 at 2:01 PM, V8, Registered Nurse, said when she came in on 12/30/23, she noticed R5 was in pain. R5 was grimacing. V8 said she looked up the x-ray results and it showed a fracture, so she called the physician and sent R5 out to the hospital. V8 said she is not sure when x-ray came, but the nurse should be looking for the results within three hours. V8 said sometimes the x-ray company calls to let the staff know of the results, but sometimes they just fax the report. V8 said it is the nurse's responsibility to follow up on any x-ray results. V8 said she is unsure why R5 was not sent out when the x-ray results were received. On 3/8/24 at 1:54 PM, V2 (Director of Nursing) said if a stat x-ray is ordered, the x-ray company will arrive within 3 hours and she thinks they have 4 hours to read the x-rays and send the report. V2 said typically the x-ray company calls if there is a fracture, but sometimes they just fax the report. V2 said she is not sure why it took so long for the nurse to review the report and send R5 out to the hospital. V2 said sometimes if a resident has had a fall and is having pain, they would not wait for x-ray results, they would just send the resident to the hospital for evaluation. The facility's Physician Notification of Laboratory/Radiology/Diagnostic Results Policy, revised on 3/14/18, shows, STAT or Same Day orders will be called to the laboratory service by the nurse who transcribes the order. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered them .x-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: Pneumonia, New fracture. 40798 2. R6's Admission Record, (dated 3/8/24), shows she was admitted to the facility on [DATE], with a fracture of her left upper arm. R6's diagnoses include, but are not limited to, Alzheimer's disease, repeated falls, and syncope with collapse. R6's Order Summary Report (dated 3/8/24) shows and order from 1/18/24 whereby R6 is to keep a shoulder immobilizer in place. R6's Care Plan initiated on 1/18/24 shows R6 had an open reduction internal fixation (ORIF) (surgical repair) of her left upper arm bone (humerus) and should keep her shoulder immobilizer in place. R6's Fall-Initial Occurrence Note, dated 1/28/24, shows R6 had an unwitnessed fall in her room at 8:30 AM and was found lying on the floor. R6 reported pain to her right upper leg at a level of 7 on a 0 to 10 pain scale. R6 was sent to the hospital for evaluation and treatment. R6's Nurse's Note, dated 1/28/24 at 8:10 AM, shows R6 was found on the floor near her bedside with complaints of right leg pain. R6 was given pain medication, assisted back to bed, then the physician was notified and R6 was sent to the Emergency Department for evaluation. R6's Progress Note, dated 1/28/24 at 3:00 PM, shows R6 was admitted to the hospital with a diagnosis of closed, non-displaced fracture of her right femur. On 3/8/24 at 11:29 AM, V8, Registered Nurse (RN), said she was summoned to R6's room after the CNA (Certified Nursing Assistant) found R6 on the floor (on 1/28/24). V8 said she did an assessment of R6, and R6 complained of right hip pain. R6 said she and four staff members rolled a blanket under R6 and used it to lift R6 to her to bed. V8 said she then contacted the physician and was given orders to send R6 to the hospital. V8 said she called 911 and R6 was taken to the hospital by ambulance. V8 said she later contacted the hospital for an update on R6, and was told R6 had a hip fracture and would need surgery. On 3/8/24 at 12:04 PM, V2, Director of Nursing/DON, said if a resident is found on the floor, the nurse needs to assess the resident and if there is hip pain, they need to leave them on the floor. V2 said when the ambulance, (EMS) emergency medical services arrives, they need to immobilize the resident and transfer them. V2 said staff should not move them because it could add insult to injury. V2 also said staff should never use a blanket to transfer a patient off the floor; it's not safe and they could drop the person. The facility's Transfers-Manual Gait Belt and Mechanical Lifts Policy (revised 1/19/18) shows, .manual lifting is not permitted.

Based on observation, interview, and record review, the facility failed to implement interventions in preventing the reopening of a healed pressure ulcer and worsening of an existing pressure ulcer for two (R18 and R29) of four residents in the sample of 27 reviewed for skin breakdown. This deficiency resulted in R18's healed pressure ulcer on the sacrum reopening and being identified as a facility acquired, Stage 3 wound. Findings include: 1. R18 is a [AGE] year-old, male, admitted in the facility on 07/24/23. with diagnosis of Multiple Sclerosis. According to Skin Wound Report. dated 07/24/23, he was admitted with Stage 2 pressure injury on the sacrum, measuring 1cm (centimeter) x 1cm x 0.1cm. R18's Care plan on pressure ulcer to sacrum related to immobility, dated 08/23/23, documented: Interventions: Avoid positioning the resident on sacrum; Encourage and assist with turning and repositioning at regular intervals as allowed and tolerated every shift and when requested for comfort; Facility follow policies/protocols for the prevention/treatment of skin breakdown. R18's NP (Nurse Practitioner) wound notes recorded the following: 08/30/23 - Integumentary: Wound status is healed. The wound is currently classified as a Category/Stage II wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 0cm length x 0cm width x 0cm depth. 09/20/23 - Integumentary: Wound status is open. The date acquired was 09/20/23. The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 7cm length x 8cm width x 0.2cm depth. There is a small amount of serosanguineous drainage noted. There is large granulation within the wound bed. There is a small amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance exhibited: scarring, maceration. R18's Wound Assessment Details Report, dated 10/18/23, documented: Sacral wound/Stage 3 pressure ulcer, date identified 09/20/23, facility acquired. Measurements: 3cm x 4cm x 0.10cm. On 10/22/23 at 10:00 AM, R18 was observed lying on his back, in bed, with head of bed slightly elevated, watching TV (television). R18 was asked if he has an active wound. R18 stated, I have a pressure ulcer in the lower back. At 12:10 PM, wound care was observed on R18. R18 has an indwelling urinary catheter and wears an incontinence brief. It was observed the brief was dry, but with scant amount of serosanguineous drainage. V4 (Registered Nurse, RN) stated during wound care, The discharge was coming from his sacral wound. Treatment is clean with soap and water and apply (ointment) and zinc, leave it open to air. It was noted R18's wound is open, with pinkish to reddish wound bed. It was also observed 10:00 AM to 12:10 PM, R18 was lying on his back in bed, watching TV. On 10/23/23, random observation every 15 to 30 minutes interval was conducted from 10:10 AM to 12:48 PM, which showed R18 was not repositioned, nor was his sacral wound offloaded. From 10:10 AM to 11:00 AM, R18 was observed in bed, lying on his back in a semi-sitting position. From 11:15 AM to 12:10 PM, he was observed in bed, lying on his back, with head of bed elevated to a 90 degree-angle. From 12:35 PM to 12:48 PM, he was lying on his back again in a semi-sitting position. At 1:50 PM, he was again observed lying on his back, in bed. R18 was asked if he is turned or repositioned while in bed. R18 stated, No, I am not turned. When I'm asleep, I sleep on my side. But when I am awake, no, they don't turn me. On 10/23/23 at 12:56 PM, V7 (Wound Care Nurse) stated, He is verbal; does not like to be in the wheelchair. He was admitted with Stage 2 pressure ulcer on the sacrum on 07/24/23, healed on 08/30/23. No hospitalization s since admission. It reopened on 09/20/23 as Stage 3, measuring 7cm x 8cm x 0.2cm. It reopened because he is noncompliant with repositioning. On 10/23/23 at 1:39 PM, V6 (Certified Nurse Assistant, CNA) stated, He cannot turn himself, but he is willing to be turned. He is compliant with turning, awake and asleep. We do turning and repositioning every two hours. V4, Registered Nurse/RN was also asked regarding R18 and repositioning. V4 mentioned, We do side turning every two hours. He is able and compliant. On 10/23/23 at 4:23 PM, V9, Wound Nurse Practitioner stated, His sacral wound was healed on 08/30/23. It reopened to Stage 3 on 9/20/23. I don't have anything documented for the opening. Scar tissues are very fragile for reopening. After a wound is healed, it is prone to reopen. To prevent sacral pressure ulcer from developing and worsening, in general - turning and repositioning per protocol, in general about 2-3 hours; nutrition; use of low air loss mattress. I expect staff for early identification of skin issues and implementation of preventative measures like use of low air loss mattress, following up of nutritional status, offloading, turning and repositioning. R18's NP Wound Notes, dated 10/25/23, recorded: Wound status is open. The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 6cm length x 9cm width x 0.1cm depth. There is a small amount of serosanguineous drainage noted. There is medium red, pink granulation within the wound bed. The periwound skin appearance exhibited: scarring, maceration, ecchymosis. 2. R29 is a [AGE] year old male, admitted in the facility on 07/13/23 with diagnoses of Hemiplegia, Unspecified Affecting Left Nondominant Side; Nontraumatic Acute Subdural Hemorrhage; Malignant Neoplasm of Prostate; Cerebral Infarction, Unspecified and Aphasia Following Cerebral Infarction. According to MDS (Minimum Data Set), dated 7/20/23, Section M, R29 was admitted with a Stage 3 pressure ulcer. R29's care plan, dated 09/06/23, regarding pressure ulcer on sacral buttocks documented: Interventions: Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent positioning; Follow facility policies/protocols for the prevention/treatment of skin breakdown; Minimize pressure over bony prominences R29's Skin Wound Report, dated 07/13/23, recorded: Stage 3 pressure injury on the sacrum, measurements of 1cm x 1cm x 0.1cm. R29's NP (Nurse Practitioner) notes documented the following: 07/26/23 - Integumentary: The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 2.5cm length x 2.5cm width x 0.1cm depth. 08/02/23 - Integumentary: The wound is currently classified as Unstageable/Unclassified wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 4cm length x 4.5cm width. There is large pink granulation within the wound bed. There is a small amount of necrotic tissue within the wound bed including eschar and adherent slough. 08/09/23 - Integumentary: The wound is currently classified as Unstageable/Unclassified wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 5cm length x 5cm width. There is a large amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance exhibited: scarring, maceration. On 10/23/23 at 12:56 PM, V7, Wound Care Nurse, stated, He is nonverbal; he is alert; he has a sacral ulcer, admitted with 07/19/23 his sacral wound increased in size to 2.5, he had multiple comorbidities, he had a history of head trauma. He had sepsis and infections; been in and out of the hospital. He also had prostate cancer. There were no recorded hospitalization s on R29 from 07/13/23 to 08/09/23 per census report. On 10/24/23 at 12:34 PM, V4 stated, He is turned every two hours. We put him in the reclining chair during daytime and stays there for about five to six hours. On 10/25/23 at 8:19 AM, V9, Wound Care Nurse Practittioner, was asked regarding length of time should a resident with sacral pressure ulcer can sit in the wheelchair or reclining chair. V9 stated, Residents who have pressure ulcers on the sacrum can be up and be put in wheelchair or reclining chair in two to four hours. Putting pressure on the sacrum will not allow blood flow. Blood flow facilitates wound healing. Facility's policy titled Skin Condition Assessment and Monitoring - Pressure and Non Pressure dated 6-8-18 stated in part but not limited to the following: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented.

Based on interview and record review, the facility failed to prevent or determine how an injury of unknown origin occurred. This affected one of three residents (R6) reviewed injury of unknown origin. This failure resulted in R6 sustaining an injury to the right knee receiving seven sutures at the local hospital. Findings Include: R6 is a [AGE] year old with the following diagnosis: chronic venous hypertension with ulcer of the left lower extremity, venous, insufficiency, chronic obstructive pulmonary disease, congestive heart failure, and Alzheimer's disease. R6's Care Plan, dated 8/23/23, documents R6 has a potential for impairment of skin integrity related to fragile skin, impaired mobility, and incontinence. The Change of Condition Evaluation, dated 8/27/23, documents R6 had a change in condition of a skin wound and this occurred in the afternoon. R6 had no changes in mental status observed. There were no other changes of condition documented besides a skin tear to the right knee. The Hospital Records, dated 8/27/23, documents R6 was sent to the hospital when staff noted a linear laceration to the right knee. R6 does not have any pain and does not recall how this occurred. Staff denied any falls or witnesses to the injury. R6 was alert and oriented times two. The laceration to the right knee was 2.5 cm horizontally. R6 received seven sutures to the right knee during a laceration repair. On 9/6/23 at 5:35PM, V9 (Wound Nurse Practitioner) stated the older a resident becomes the more fragile skin becomes. V9 endorsed if a resident has a disease related to lack of circulation then wounds can develop easier than residents who don't have circulation issues. V1 stated the facility should be monitoring residents as best as they can to prevent any wounds. On 9/7/23 at 1:48PM, V2 (Director of Nursing/DON) stated when V14 (CNA) got R6 in bed, a skin tear was found to R6's right knee. V2 endorsed R6 was not able to say what happened. V2 reported assuming R6 bumped R6's leg, but was not able to confidentially say how the wound occurred. V1 stated the skin tear was about one to two inches long. V2 reported R6 was sent the hospital because of the skin tear and increased confusion. Per the documentation, R6 did not have any changes in mental status. V2 stated seeing a blood stain on R6's pants once R6 was in bed but was not able to see the blood stain before due to R6 having dark pants. On 9/7/23 at 2:29PM, V14 stated V14 put R6 in the bed and started to undress R6. V14 endorsed when V14 pulled on R6's pants, a cut was found to the top of the right knee. V14 stated when V14 asked R6 what happened, R6 couldn't say. V14 denied any falls and denied R6 hitting any part of R6's body when getting into bed. On 9/8/23 at 12:42PM, V1 (Administrator) stated R6 was sent to the hospital after obtaining a new skin tear in the facility. When asked what an injury of unknown origin is, V1 replied, It's an injury that can't be explained how it happened by the resident or staff. V1 denied R6 being able to explain how the skin tear happened. The policy titled, Abuse, Neglect and Misappropriation of Resident Property, that has no date documents, .Purpose: This policy's purpose is to ensure that resident rights are protected by providing a method for investigation and reporting of allegations of mistreatment, neglect, abuse, including injuries of unknown source, unusual occurrences and misappropriation of resident property .Policy Interpretation and Implementation: . 8. The facility will ensure that all allegations of mistreatment, neglect or abuse, including injuries of unknown source, are reported immediately to the Administrator of the facility. The Administrator and/or other officials shall notify ISDH in accordance with ISDH Guidelines.

Based on observation, interview and record review, the facility failed to implement effective, specific interventions to minimize recurrent falls with injuries, and failed to review the effectiveness of the plan of care after each fall. This deficient pratice affected one of two residents (R1, R9) reviewed for falls in the sample of 13. The facility also failed to provide adequate supervision to prevent one of one resident (R9), in the sample of 13 from exiting the building and sustaining injuries with hospitalization . Findings include: R9 is a [AGE] year old male with [DIAGNOSES REDACTED]. During the four day survey, R9 was observed walking briskly with a shuffling gait through the corridors most of the time. R9 often walked towards the exit doors until redirected by staff. R9 is alert but confused. R9 has been care planned for his wandering and impaired sense of balance. R9's fall care plan lists the following approaches for fall prevention: 1.) Observe, record and report all unsafe conditions and situations, 2.) Monitor for orthostatic hypotension 3.) Monitor neuro status 4.) Encourage resident to ask for assistance 5.) Anticipate fall times 6.) Observe for functional decline due to psychotropic use 7.) Call light in reach 8.) Anticipate needs 9.) Check comfort level as needed These are generic approaches with no specific individualized interventions related to R9's fall risk areas. R9 had 3 falls and 3 documented near falls within a three month period. The falls occurred on the following dates: 3/19/11 at 11:25 AM, R9 was found lying on the floor mat beside his bed. R9 sustained a skin tear to his nose. The interventions documented were: 1.) Check the resident every two hours 2.) Scheduled toileting program 3.) Refer to Physical Therapy and Occupational therapy 4.) Low Bed 5.) Floor mats 6.) Behavior management program These interventions were documented on the incident report dated 3/19/11. The care plan for R9 lacked documentation of specific individualized interventions after the fall on 3/19/11. On 5/6/11 at 11:08 AM, R9 was ambulating in the dining room and tripped over his foot and fell . R9 sustained redness and bruising to the right eye. There was no revision to the care plan and no new interventions documented in R9's clinical record. On 5/27/11 at 1:45 PM, the facility's Falls Report noted that R9 was ambulating in the hallway, going to the exit door, lost his balance and fell . Interventions were listed on Incident Report: 1.) Bed in lowest position.(already in place) 2.) Floor mat (already ordered) Again, no new interventions specific to R9's falls were implemented or documented in R9's care plan. . On 7/15/11 at 9:10 AM, E3 (Nurse) stated that R9 exited the west door of the facility on 5/27/11 and fell on to his right side. R9 scraped his right hand, right forearm, right knee, right shin and had a laceration to the right eyebrow. E3 said, E9 (Restorative Aide) found R9 and she, E3 came soon after. E3 said, the exit door is alarmed and R9 often goes to the door and when the alarm sounds, staff know that he is attempting to leave the building. On 7/15/11 at 9:20 AM, E9 stated on the day of the fall, when she heard the exit door alarm go off, she immediately ran out of the office. E9 said R9 had left through the door tripped, fell (outside) and hit his head. R9 was admitted to the hospital with [REDACTED]. E9 (Restorative Aide) said that when she reached R9 on the ground, she sat R9 up and called the desk for help and E8 came out. When asked where the nursing staff was at that time, E9 stated, "They were in the dining room or the conference room." E9 also said, that it was the day of the resident picnic. E9 said, R9 has exited the door several times before but usually walked a short distance and turned back around and came back. E9 stated she was in her office when she heard the alarm sound on 5/27. Her office is located on the East wing of the building. R9 exited the door at the west end of the building. E9 stated that when she went to find R9, there were no other staff in sight at that time, which is why she had to use her phone to call for help. This lack of supervision and lack of updating of R9's plan of care for falls resulted in R9 exiting the building, falling and sustaining injuries with resultant hospitalization .

Based on record review and interview, the facility failed to assess pressure sore on a weekly basis, treat it immediately upon admisssion, refer deterioration to physician and dietician immediately, and send to the hospital 1 resident ( R3 ) in the sample of 12, for wound evaluation and treatment. As a result, R3's wound got bigger and infected, and R3 was sent to the hospital [MEDICAL CONDITION]. Findings include : R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per nurses notes and wound consultation notes dated 11/22/10, R3 was admitted to the facility with a stage II pressure ulcer on the coccyx measuring 0.8 x 0.3 cm . As of 11/29/10 wound progress notes, R3's sore remained the same. R3 was sent to the hospital for [MEDICAL CONDITION] on 12/2/10 and was readmitted back to the facility on [DATE]. According to R3's wound care notes dated 12/7/10, he came back to the facility with the coccygeal sore measured at 1.3 x 0.8. Although R3 was readmitted on [DATE], there was no assessment, referral, and treatment of [REDACTED]. Per R3's Physician order [REDACTED]. Although facility's Skin Condition and Pressure Ulcer Assessment Policy indicated that a weekly skin assessment will be done by a licensed nurse, R3's wound assessment is not on a weekly basis. Per R3's wound assessment on 12/15/10, R3's coccygeal sore was 2 x 2 cm in size stage II. Review of R3's record showed no weekly wound measurement until 9 days later when on 12/24/10, Z1 measured R3's sore. This Wound Care assessment dated [DATE] showed that at this time, R3's sore at the coccyx is now an Unstageable Necrosis, with excoriation, maceration, and odor. Z1 measured the sore at 12 x 15 x 0.2 cm with 30 % eschar, 20 % devitalized tissue, 30 % granulation tissue, and 20 % skin. Per Z1's notes, this wound had deteriorated because of infection, generalized decline of patient, and R3 being nutritionally compromised. There was indication in R3's record before 12/24/10, why this wound deterioration and increase in size was not referred by E4 ( Treatment Nurse ) to Z1, before 12/24/10. Z1 removed some of the necrotic tissues and ordered Santyl and [MEDICATION NAME] daily. Furthermore, per R3's POS dated 12/24/10, Z1 ordered also [MEDICATION NAME] and Pre [MEDICATION NAME] level. These lab tests were not ordered and done from the laboratory, and was verified by Z5 during lab result inquiry by phone on 4/14/11 at 2:22 PM. R3's [MEDICATION NAME] level was already low ( 3.3 ) on 11/25/10 ( normal 3.4 - 4.8 gm/dl.). Although there was deterioration of R3's wound per Wound Care assessment dated [DATE] and 12/31/10, there was no referral to the dietician during this period. R3's last dietary assessment was 12/15/11 in December 2010, when R3's wound did not deteriorate yet. During this time, the dietician also inaccurately noted that R3's sore was a stage III or IV per treatment nurse's notes. Treatment nurse notes indicated stage II ulcer. R3's next dietary assessment was done on 1/7/11, where the dietician indicated that nutritional wound approach was adequate to meet nutritional needs, as evidenced by skin healing per review of treatment nurse notes dated 1/7/11. 1/7/11 treatment nurse notes showed that contrary to what the dietician wrote, R3's wound had deteriorated. On 12/31/10, Z1 saw R3's wound again and it is still the same size as above, but that, the wound has deteriorated further due to infection and generalized decline of R3. Per R3's POS, Z1 ordered to transfer R3 to the hospital/ER for Surgical Evaluation and treatment of [REDACTED]. Review of R3's record however showed no indication that he was sent to the hospital as ordered. During 4/13/11 interview of E3 ( nurse ) at 3:52 PM, E3 said that Z1 ordered to send R3 to ER for debridement on 12/31/10. E3 continued that he called Christ hospital ER who said that they don't do debridement in ER. E3 said that after that, he called Z2 to inform him that Christ ER does not do wound debridement in ER. E3 added that Z2 then ordered to call Z4, to schedule an outside appointment. Per POS, on 1/3/11 after R3's appointment with Z4, Z4 ordered to schedule a wound debridement on 1/10/11. R3's White Blood Count ( WBC ) was already elevated as of 1/7/11, his hemoglobin was low at 9.9 gm/dl, and his [MEDICATION NAME] was low at 2.8 gm/dl. Per 4/14/11 interview with Z3 from Christ hospital ER, Z3 said that the hospital does not do wound debridement in ER, but if there is an order for [REDACTED]. Review of Z1's 12/31/10 order in the POS showed that it did not say to send R3 to ER for wound debridement . Z1's order was " for Surgical Evaluation and treatment of [REDACTED]. When Z2 was interview on 5/3/11 at 11:30 AM, Z2 verified that the reason why he told the nurse ( E3 ) to make an appointment with Z4 for R3, was because E3 told Z2 that ER would not take R3 for wound debridement. Z2 was aware that Z1 made an order to send R3 to the ER and had no issue with that. During 4/14/11 interview with Z1 at 11:15 AM, Z1 said that on 12/31/10, R3's wound was already infected but he did not [MEDICAL CONDITION] yet. Z1 said that the wound was necrotic and foul-smelling, and thus he ordered to send R3 out, for surgical evaluation and treatment of [REDACTED]. Z1 said that he even left Z2 a phone message, spoke with E2 ( Direct of Nursing ) about sending R3 out. Z1 said that R3 needed to go to the hospital that night of 12/31/10. Z1 continued that he was shocked when he found out one Friday after 12/31/10, that R3 was still at the facility. Z1 explained that his wound was bigger and still foul smelling. Finally, Z1 said that R3 became septic after that last time he saw him. Per nurses notes, on 1/10/11 at 8:30 AM, R3 was noted lethargic, slow to respond to verbal and tactile stimulation, with O2 saturation of 89 %. R3 was sent to hospital and was admitted . During 4/14/11 interview at 10:25 AM, Z8 said that R3 was admitted to the hospital with [REDACTED].