Every finding on record at Aperion Care Elgin

Based on observation, interview, and record review, the facility failed to monitor and assure safe smoking activities and utilize essential equipment per manufacturer's instructions. This applies to 6 of 6 residents (R1, R2, R19, R24, R85, R98) reviewed for accidents and supervision in a sample of 21. The findings include: 1. On 05/26/26 at 10:46 AM, R19's dresser tabletop contained four black cases with cigarettes and a clear plastic cup with four cigarettes in it. On 05/27/26 at 9:18 AM, R19 was on the supervised smoking patio with one activity staff and other residents and was observed to have ash dropped on his clothes and small holes in his shirt and pants. R19 said the holes were from the ash as his pants were made from nylon and burned easily. R19 then threw his cigarette butt against the wall of the building and then dusted the ash off his shirt and pants. At 05/28/26 at 11:44 AM, R19 was unsupervised at the front of the facility, and he had ash on his shirt, his pants, and on his wheelchair seat. R19 was not aware there was ash all over him. R19 was wearing a different pair of pants with holes in them. On 05/28/26 at 2:02 PM, V5 (Social Services Assistant) said smoking assessments were done quarterly. V5 said residents were not supposed to throw cigarette butts on the ground or against the wall of the building as it was not the proper way to dispose of cigarettes. V5 said it could cause a fire if it was not thrown in the appropriate place. V5 said if a resident was dropping ash on their clothes, they should wear a smoking apron as ash could cause holes and burn the residents. V5 said if these behaviors were present, she would educate the residents and then redo the smoking assessment to see if they were still deemed an independent smoker. V5 said smoking materials should be placed in a nightstand or dresser drawer so no one else can reach it. On 05/28/26 at 2:10 PM, V6 (Social Services Director) said independent smokers needed to show they could conduct themselves in a way to prove they were independent smokers. V6 said residents were to put out the cigarettes in the designated areas. V6 said she would educate them based on their smoking behavior and usually, education was enough to keep the independent smokers independent. V6 said if the team saw ash on the residents' clothes, they would redo the smoking assessment and provide a smoking apron to make sure the residents were safe to prevent the ash burning holes in the residents' clothes. R19's face sheet showed he was admitted to the facility with diagnoses including osteoarthritis, chronic obstructive pulmonary disease, asthma, abnormalities of gait and mobility, unsteadiness on feet, lack of coordination, polyarthritis, major depressive disorder, weakness, and suicidal ideations. R19's MDS (Minimum Data Set) dated 05/15/26 showed R19 was cognitively intact. R19's Care Plan dated 05/14/24 showed R19 was an independent smoker with a goal showing [R19] will not suffer injury from unsafe smoking practices through the review date with interventions including to observe clothing and skin for signs of cigarette burns. 2. On 5/26/26 at 12:20 PM a lighter and pipe were observed on R85's bedside table. R85 was not in his room at this time. R85's Smoking Safety Risk assessment dated [DATE] only shows he uses cigarettes and lighter, it does not show he also smokes a pipe. Assessment says IDT/Care Plan recommendations: 2. All smoking materials will be kept locked in facility designated area. On 5/28/26 at 4:04 PM, V2 (DON/Director of Nursing) said smoking materials should never be left out on a resident bedside table unsupervised, because it poses a risk to all residents. V2 said if someone gets a hold of the smoking materials who is not safe to have them, there is a risk for harm or fire in the facility. The facility's policy titled, Smoking Safety last revised 10/24/22 states, Purpose: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor.Safe Measures:.The facility has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety and security reasons. 3. On 05/26/2026 at 10:37 AM, R24's bed electrical cord was plugged into a power strip. R24 stated the power strip was already in the room when she came to the facility. The Manufactures instruction for R24's bed warning states power cord must be plugged into appropriate wall outlet ensuring it can be unplugged easily in case of an emergency. To avoid risk of electric shock this equipment must only be connected to supply mains with protection earth. 4. On 05/26/2026 at 10:54 AM, R1 had two vape devices on her over bed table. On 05/27/2026 at 12:45 PM, R1 stated she no longer goes outside or gets out of bed, so the staff allow her to use her vape device in her room. R1 stated the staff allow her to keep her vape devices because she told them it is her personal property. On 05/27/2026 at 1:49 PM, V19 Activity Aide stated she does the smoking activity with the residents. V19 stated She tried to encourage R1 to go outside to vape. V19 stated R1 should not use the vaping device in her room. V20 Activity Aide stated the smoking materials are kept in an office for residents that require assistance. V 20 Activity Aide stated she did not know what the hazards are for vaping but R1 should not be vaping in her room or holding her own device in her room. On 05/27/2026 at 3:22 PM, V5 Social Services Assistant stated R1's vape devices were recently brought to her, she had not previously held them. R1's smoking safety risk assessment electronically signed by V5 Social Services Assistant on 05/13/2026 states R1 uses an electronic smoking device, receives oxygen and requires supervision while smoking. All R1's smoking materials will be kept locked in facility designated area. 5. On 05/26/2026 at 11:34 AM, R 98's oxygen concentrator set at 1.5 liters by nasal cannula was plugged into a regular power strip. The manufactures instructions for the oxygen concentrators warning- improper use of the power cord and plugs can cause burn, fire or other electrical shock hazards. Ensure the main power cord is fully inserted into the concentrator and the power cord plug is completely inserted into a fully functioning AC (Alternating Current) wall outlet. Failure to do so may cause an electrical safety hazard. 6. On 05/26/2026 at 12:59 PM, R2's tube feeding pump was plugged into a power strip. On 05/27/2026 at 3:17 PM, V10 RN (Registered Nurse) stated when she disconnected R6 from her tube feeding the feeding pump was connected to the power strip. The pump is always connected to the same power strip. On 05/28/2026 at 10:51 AM, R2's tube feeding infused at 68 milliliters per hour and plugged into a regular power strip. The manufacture instructions for R2's feeding pump state to plug the power cord into a 115V (Volt) AC (Alternating Current) 60 Hz ([NAME]) three wire grounded outlet. On 05/27/2026 at 2:54 PM, V21 Maintenance Director stated resident medical equipment can be plugged into power strips if they are hospital grade. V21 stated R24's bed was plugged into a regular power strip not a hospital grade power strip, but it didn't matter for hospital beds were plugged into a regular outlet. After viewing the oxygen concentrator for R98 and the feeding pump for R2, V21 stated the devices were not plugged into a hospital grade power strip.

Based on observation, interview, and record review, the facility failed to safely store all resident medications.This applies to 5 residents (R67, R1, R17, R22, and R89) reviewed for medication storage in a sample of 21 residents. Findings include: 1. On 5/26/26 at 11:16 AM, a 12 fluid ounce bottle of bismuth subsalicylate was seen on R67's nightstand table. The cap of the bottle noted to be crooked, not fastened correctly or properly sealed. Medication noted to be about 7/8ths of the way empty. R67 was not in his room when observation made. On 5/27/26 at 11:14 AM, the bottle of bismuth subsalicylate was again noted on R67's nightstand with the cap not fastened properly. On 05/28/26 at 4:04 PM, V2 (DON/Director of Nursing) said any medications stored at a resident's bedside need to be locked up for safe medication storage. V2 said all medications are to be locked up and stored securely for the safety of all residents in the facility, because any resident can walk into R67's room and ingest the medication when it is not safe for them to do so. The facility's undated policy titled, Storage of Medications states, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures:. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 2. On 05/26/2026 at 10:54 AM, a 3-ounce bottle of antifungal miconazole 2& powder was on R1's extra overbed table against the wall. 3. On 05/26/2026 at 11:13 AM, Lidocaine Viscus 2% 100ml bottle dated March 2025 with approximately a quarter amount of medication remaining was on shelf next to R17's bed. R17 stated she uses for sore on her tongue. R17 stated she got the sores from biting her tongue when she gets nervous. R17 stated a nurse left it for her to use when she needs it. R17 stated she doesn't track when she uses it. On 05/27/2026 at 12:59 PM, V8 LPN (Licensed Practical Nurse) assigned to R2 and R17 stated she did not have any residents assessed to store medications at the bedside. 4. On 05/26/26 at 11:30 AM, R22's dresser drawer had hydrocortisone acetate 1% cream in it. R22's face sheet showed she was admitted to the facility with diagnoses including multiple sclerosis, asthma, type 2 diabetes mellitus, epilepsy, obstructive sleep apnea, gout, pain, hepatomegaly, and edema. R22's POS (Physician Order Sheet) dated 05/28/26 did not show an order for hydrocortisone acetate 1% cream or to store medications at the bedside. The facility was unable to provide an assessment which showed R22 was assessed to self-administer or store medications at the bedside. 5. On 05/26/26 at 11:41 AM, R89's bedside dresser contained a Chloraseptic sore throat fast acting bottle spray which contained phenol 1.6%. R89 was not in her room. R89's face sheet showed she was admitted to the facility with diagnoses including peritonitis, cerebral infarction, schizoaffective disorder, unsteadiness on feet, cognitive communication deficit, hypertension, acute respiratory failure, and intestinal obstruction. R89's POS dated 05/28/26 did not show an order for Chloraseptic sore throat fast acting bottle spray or to store medications at the bedside. The facility was unable to provide an assessment which showed R22 was assessed to self-administer or store medications at the bedside. On 05/28/26 at 11:23 AM, V23 (RN/Registered Nurse) said she was the nurse caring for residents in R22 and R89's hallway, and none of the residents should have medications at their bedside. On 05/28/26 at 11:27 AM, V8 (LPN/Licensed Practical Nurse) said none of the residents in the B hallway were allowed to keep their medications at the bedside. V8 said the staff need to ask the doctor and do an assessment to see if the residents are qualified to store medications at bedside. V8 said once cleared, the medications needed to be stored and locked away in case another resident came in and took the medicine. V8 said if a resident was allowed to store medication at the bedside, there should be an order in their medical record. On 05/28/26 at 11:31 AM, V7 (RN) said if a resident wanted to store medications at their bedside, they would need to ask the doctor and do an assessment to validate they were alert and oriented and knew why the medication was taken and to properly take the medication. V7 said the medications also needed to be stored in a locked drawer as residents who wandered and were not alert or oriented could go into the room and take the medications.

Based on observation, interview, and record review, the facility failed to provide an environment that promoted dignity in a resident common area. This applies to 2 of 21 residents (R5 and R86) reviewed for dignity in the sample of 21. The findings include: R5's Face Sheet showed R5 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and chronic kidney disease. R5's MDS (Minimum Data Set) dated 4/8/2026 showed R5 is cognitively intact and requires set-up and clean-up assistance for eating. R86's Face Sheet showed R86 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, depression, and generalized anxiety disorder. R86's MDS (Minimum Data Set) dated 4/21/2026 showed R86 is cognitively intact and requires supervision or touching assistance during meals. On 5/26/2026 at 12:12 PM, observations in the main dining room showed a gray garbage receptacle positioned among resident dining tables. A sign affixed to the front of the receptacle read, DIRTY BIB CONTAINER. A second sign on the top of the receptacle read, BIBS & TOWELS - NO GARBAGE. The receptacle was in plain view of residents, visitors, and staff. R5 and R86 were present in the dining room and were observed wearing blue clothing protectors during the meal service. On 5/26/2026 at 12:02 PM, V13 (Behavioral Aide) referred to R5 as the resident over there with the blue bib when discussing R5. On 5/27/2026 at 12:18 PM, observations in the main dining room again showed the gray receptacle labeled DIRTY BIB CONTAINER positioned among resident dining tables and visible to residents, visitors, and staff. On 5/28/2026 at 12:25 PM, observations in the main dining room again showed the gray receptacle labeled DIRTY BIB CONTAINER positioned among resident dining tables and visible to residents, visitors, and staff. On 5/28/2026 at 12:33 PM, R5 was sitting in the dining area as dietary staff were cleaning up. R5 stated, I keep telling them [staff] to call it a clothing protector, while pointing to her chest, adding, but they don't listen. R5 stated she did not like the term bib and described the term as derogatory. R5 stated the container labeled DIRTY BIB CONTAINER is always present in the dining room and visible to residents and visitors. R5 stated she did not like the label or the placement of the container in the dining room. On 5/28/2026 at 12:43 PM, R86 was sitting in her room organizing her belongings. R86 pointed toward her chest and stated staff refer to clothing protectors as bibs. R86 stated the term bib is used for babies. R86 further stated the container labeled DIRTY BIB CONTAINER is always present in the dining room and visible to everyone, including visitors. On 5/28/2026 at 12:35 PM, V12 (Dietary Aide) stated the gray receptacle in the dining room was used for collection of used clothing protectors. V12 stated staff commonly referred to the items as bibs and stated the CNAs (Certified Nursing Assistants) were responsible for placing them on residents during meals. On 5/28/2026 at 12:53 PM, V18 (Certified Nursing Assistant) stated the correct terminology is clothing protector. On 5/28/2026 at 1:43 PM, V2 (Director of Nursing) stated residents are expected to be treated with dignity and respect. V2 stated the preferred terminology is clothing protector. V2 stated she routinely reminds staff to use the term clothing protector when referring to resident dining apparel. V2 further stated the term bib may be viewed as demeaning. The facility policy titled, Dignity, with a review date of 4/23/2018, stated the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The policy further stated the facility aims to enhance residents' self-esteem and self-worth. The policy also indicated labels should be inconspicuous and respect the resident's dignity.

Based on observation, interview, and record review, the facility failed to provide feeding assistance to a dependent resident with a history of weight loss. This applies to 1 resident (R25) reviewed for feeding assistance in a sample of 21 residents. Findings include:On 5/26/26 at 12:21 PM, R25 was observed lying in bed with his lunch tray set up in front of him on the overbed table. Both of his hands appeared to be partially closed with his fingers in a flexed position. When asked, R25 said he did not know if he was able to feed himself. R25 was noted to have a towel lying on his chest with apple sauce on it that fell off his spoon. R25 had regular silverware and a regular plate, no adaptive equipment, and was having difficulty scooping the food from his plate and making it to his mouth. He had a pureed diet with mashed potatoes, apple sauce, pureed peas and carrots, pureed meatballs and gravy, and an ice cream magic cup. R25 was asked again if he gets help with eating his meals or if he always feeds himself and he seemed confused by the question. No staff were present to provide supervision or feeding assistance.On 5/27/26 at 12:19 PM, R25 was again observed lying in bed, with his tray set up in front of him, attempting to feed himself lunch. R25 was grasping the spoon in his left hand- with his fingers in a constant gently flexed position. R25 did not have a regular grasp on the spoon, but was able to hold it in his left hand and attempt to scoop the pureed items from his plate. R25's right arm/hand did not appear to be functional at all, as he did not move it while attempting to feed himself. His feeding coordination was slow and not completely accurate, as he continued to spill some magic cup ice cream onto his chest. R25's lunch tray consisted of a magic cup, lemon pudding, pureed turkey casserole, pureed zucchini, and pureed noodles. R25 had managed to take 3 small spoonfuls from the top of the magic cup and bring them to his mouth with his left hand. From 12:21 PM- 12:23 PM, R25 was observed trying to take a singular scoop of the magic cup, but he was unsuccessful as he did not have functionality of his right hand to hold the cup in place while scooping with his left hand. R25 then verbalized problema to surveyor and said he would like staff assistance with eating.On 5/27/26 at 12:24 PM, V14 (CNA/Certified Nurse Assistant) was seen down on the opposite hallway and was told R25 was asking for feeding assistance. V14 said R25 usually eats by himself. V14 then assisted R25 to eat the rest of his magic cup (about 80% of cup), 1 bite of turkey casserole, 1 bite of pureed pasta, and 3 bites of pureed zucchini. R25 then drank some of his glass of nectar thick water and nectar thick juice, which he was able to grasp in his left hand and drink without assistance.On 5/28/26 at 12:25 PM, V15 (CNA) said R25 used to be a set up for meals, but ever since he became a pureed diet 2-3 months ago, he needs to be fed or he won't eat. V15 said R25 has a good appetite, he just needs assistance with eating.R25's Face Sheet shows the following diagnoses: quadriplegia, disorders of muscle, need for assistance with personal care, psychotic disorder with delusions, and lack of coordination.R25's POS (Physician Order Sheet) shows he was downgraded to pureed diet on 2/20/26.R25's last Dietary Quarterly Review assessment dated [DATE] states plan of care reviewed and R25 requires limited assistance with eating.R25's Weights and Vitals Summary shows the following:Weight on 2/4/26- 171.8 lbsWeight on 4/2/26- 158.4 lbsWeight on 5/4/26- 142.2 lbs- a significant weight loss of 17.23% weight loss over 3 months.R25's Point of Care Response History (Task-GG- Eating) shows from 5/4/26 through 5/28/26, he was only assisted with eating for 10 of the 71 meals he was served in the facility.On 5/28/26 at 12:45 PM, V16 (OT/Occupational Therapist) said R25 was last seen by OT from 5/7/26-5/13/26. V16 said upon R25's discharge from OT services, on 5/13/26, R25 was completely dependent on staff for eating. V16 said there is a concern for choking and low nutritional intake if R25 was left alone and unsupervised to eat on his own after being assessed as dependent with feeding.R25's OT Evaluation & Plan of Treatment dated 5/7/26 shows his baseline status for eating as of that date was dependent. Documentation states R25 was recently hospitalized due to generalized weakness and lethargy. He presents with deficits in sitting tolerance/balance, impaired grasp, right arm contracture, decreased coordination, activity tolerance, strength, and functional reach. R25's OT Discharge summary dated [DATE] shows functional skills assessment for eating is dependent and his left and right grip strength was poor.On 5/28/26 at 12:54 PM, V8 (LPN/Licensed Practical Nurse) said she was taking care of R25 and is familiar with him. V8 said most of the time R25 feeds himself, but if he is eating in his room he needs to be supervised in case of a choking incident and to monitor his eating. V8 said she did not know R25 had any weight loss, because restorative deals with weights and weight loss.On 5/28/26 at 1:06 PM, V11 (Restorative Nurse) said feeding ability is determined by watching the resident eat to see if they are able to pick up the utensils and feed themselves. V11 said at a minimum R25 needs to be supervised throughout each meal because he is on a mechanically altered diet. V11 said it is a concern if a resident is dropping food on themselves while eating and they are unable to use spoon to scoop from magic cup. V11 said it's even more important to supervise R25 while eating because of his history of weight loss. V11 said she was not aware R25 was discharged from OT on 5/13/26 as dependent for eating.On 5/28/26 at 1:59 PM, V17 (Registered Dietician) said she completed an assessment for R25 on 5/5/26 when she added magic cup three times a day, but she has never watched him eat. V17 said it is encouraged that residents on mechanically altered diets be supervised at meals and if a resident needs assistance with meals, the tray should not be brought into their room and set-up and left there. V17 said she did not know R25 was dependent for eating when he was discharged from OT on 5/13/26 and she expects to be notified of any change in condition.R25's Care Plan last revised 3/2/25 shows he usually requires partial moderate assistance for eating. The facility's policy titled, Meal Time Observation for Food Acceptance & Food Replacement copyrighted 2020 states, Guideline: Residents will be observed during meal times to monitor acceptance and intake of food and beverage items.Procedure:.2. The staff will ensure that residents consuming meals in locations outside of the dining room, such as day rooms, resident rooms, or private dining rooms are monitored appropriately as needed. 3. Nursing staff will be readily available during meal times for all dining locations and will assist in monitoring residents for adequate intake and any signs and symptoms of chewing or swallowing problems during meal times.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders, including the prescribed dosage. There were 25 opportunities with 2 errors, resulting in an 8% medication error rate. This applies to 2 of 4 residents (R74 and R84) observed during the medication pass.The findings include: R74's Face Sheet showed diagnoses including chronic obstructive pulmonary disease, hypertension, and diabetes mellitus. R74's POS (Physician Order Sheet) and MAR (Medication Administration Record) showed an order for Acetaminophen Oral Tablet 325 mg (milligrams) - Give 325 mg [1 tablet] by mouth every 6 hours as needed for pain. On 5/27/2026 at 9:17 AM, V10 (RN-Registered Nurse) stated R74 requested pain medication for chronic generalized pain. V10 stated she would administer Tylenol (Acetaminophen) because R74 had an order for it. V10 was observed administering two Acetaminophen tablets from a bottle labeled Acetaminophen 325 mg. V10 stated the total dose administered was 650 mg. R84's Face Sheet showed diagnoses including hyperlipidemia, major depressive disorder, and rheumatoid arthritis. R84's POS and MAR showed the following orders: Metformin HCl Oral Tablet 500 mg - Give 1 tablet by mouth in the morning for diabetes mellitus. Metformin HCl Oral Tablet 1000 mg - Give 1 tablet by mouth in the evening for diabetes mellitus. On 5/27/2026 at 9:33 AM, V10 (RN) was observed preparing and administering medications to R84. V10 was observed administering one Metformin 1000 mg tablet. V10 reviewed the medication bingo card, which showed Metformin 1000 mg - 1 tablet by mouth in the evening. V10 confirmed this was the medication administered to R84. On 5/27/2026 at 1:53 PM, V2 (DON-Director of Nursing) stated medications are expected to be administered in accordance with physician orders and nurses are expected to verify the correct medication and dose prior to administration. V2 stated nurses are expected to follow the five rights of medication administration, including the right resident, right medication, right dose, right route, and right time. V2 stated medication administration discrepancies may result in unintended or adverse effects. The facility policy titled, Medication Administration General Guidelines, Policy 7.2, stated medications are to be administered as prescribed. The policy further states staff are to follow the five rights of medication administration, including the right resident, right medication, right dose, right route, and right time. The policy states the five rights are to be triple checked prior to medication administration. The policy also states the MAR should always be utilized during medication administration.

Based on interview and record review, the facility failed to ensure the resident attended infectious disease (ID) follow-up appointments, documenting and notify the attending the ID specialist of the missed appointment, resident refusal of care and the resident's discharge from the facility. This applies to 1 of 3 (R6) residents reviewed for care regarding active infections. The findings include:Review of the Electronic Medical Record (EMR) showed that R6, a [AGE] year-old resident, was admitted to the facility from the hospital on September 5, 2025. R6's multiple diagnoses included non-traumatic spinal cord injury, acute paraplegia, surgical site infection, sepsis, lumbar radiculitis, diabetic amyotrophy, diabetes mellitus type 2, and multilevel lumbar spinal stenosis.Hospital records dated September 5, 2025, documented that R6 had undergone extensive lumbar spinal surgery on July 31, 2025. His postoperative course was complicated on August 8, 2025, by fever, severe sepsis, and a postoperative lumbar infection. R6 was under the care of an ID specialist and prescribed Unasyn 3 g IV every six hours via PICC line, with a treatment end date of September 24, 2025. Hospital documentation indicated that the ID specialist required a follow-up appointment in approximately three weeks, due September 23, 2025.The Physician Order Sheet (POS) for September 2025 confirmed the order for Unasyn 3 g IV every six hours via PICC line.Progress notes dated September 8, 2025, documented that the ID office contacted the facility and provided R6's follow-up appointment dates for September 19 and September 30, 2025. Record review showed no documentation that R6 went to his appointment for the September 19,2025. Progress notes dated September 25, 2025, indicated that R6 was discharged home. The EMR contained no documentation that: -R6 attended the scheduled ID appointment on September 19, 2025, or had refused the appointment, or the ID specialist was notified of the missed appointment or the discharge to ensure continuity of infection treatment.On November 28, 2025, at 1:15 p.m., V3 (Licensed Practical Nurse) stated that R6 had refused the September 19 ID appointment. However, there was no record of refusal in the EMR, nor evidence of notification to the ID specialist to modify treatment or reschedule follow-up.On November 30, 2025, at 11:00 a.m., V2 (Director of Nursing) stated that facility's practice requires staff to notify the ID specialist when a resident refuses a scheduled follow-up appointment, as the specialist may need to adjust antibiotic therapy or provide an earlier appointment. No such notification occurred.

Based on interviews and record reviews, the facility failed to prevent the verbal/mental abuse of a resident. This applies to 1 of 3 (R1) reviewed for abuse in a sample of 17. The findings include:On 9/15/25 at 12:30 PM, R1 stated V4 (CNA- Certified Nursing Assistant) and V5 (CNA) were harassing him at the facility. R1 alleged V4 called him Honey Bunn7 and came into his room uninvited in a threatening manner making threatening comments such as her father purchased her a gun and telling R1 he had not better be talking about V4. R1 stated one day V4 was standing in the hall and pointed to R1 and began a hoola dance. R1 stated he reported the harassment to V1 (Administrator) and V1 prohibited V4 and V5 from working near the unit on which R1 was residing. R1 stated on 9/13/25, R1 left his room to warm up food and saw V4 and V5 at the nursing stating in his hall. R1 stated he told his nurse that V4 and V5 were not to be near his hall and to call V1 to confirm they needed to leave. R1 stated he began recording the episode on his phone. At 12:32 PM R1 played the video he recorded on the phone which showed R1 continuously telling the nurse on his hall that the two staff were not supposed to be present in the back of the building near his hall, that V1 gave the two staff a stern warning, that they would not receive any more warnings, and to call V1 and confirm the information. The video showed as R1 repeatedly told the nurse the staff were not to be on his unit, V4 and V5 remained near R1 and eventually the floor nurse began to move the staff toward the front of the building. The video showed the floor nurse on the phone walking behind V4 and V5 and the staff were walking toward the front of the building. At 6 minutes and 6 seconds of the recording s the staff walked away from R1, a female voice off camera stated, That's what he is. A little bitch! R1 immediately replied, Oh I'm a little bitch, huh? Thank you! R1 stated he previously showed V1 the video and V1 was going to address the behavior with the staff. Facility Email, dated 9/14/25, shows R1 told V1 on 9/13/25 V4 was on his wing in spite of V1 telling V4 that she was only work in another part of the building. The email shows R1 brought his concern to the attention of the nurse on duty. The email shows R1 recorded the interactions and V4 stated to R1, You are just a little bitch. On 9/15/25, V4 denied calling R1 any names and stated R1 was harassing V4 for some time including following her around the building and calling her a bitch and racial slurs. V4 stated on 9/13/25, she arrived at the facility and went to the back to look for her assignment. V4 stated she did not call R1 a bitch but that she was on the phone with her dad and told her dad R1 called V4 a bitch. V4 stated R1 then followed V4 and V5 to the front of the building and continued to harass them. On 9/15/25 at 11:33 PM, V5 stated she did not hear V4 swear at R1. V5 stated she was taking her break and performing charting at the back nursing station when she saw R1. V5 stated V4 was also at the back nursing station putting her personal belongings down. V5 stated she did not say anything to R1 and R1 did not say anything to V4 or V5. On 9/15/25 at 10:00 AM, V1 (Administrator) stated he received an email from R1 alleging V4 and V5 were present in the back of the building near R1 and V4 swore at R1. V1 stated V4 and V5 were previously instructed to remain in the front of the building because of conflicts between R1 and V4 and V5. On 9/15/25 at 1:39 PM, V6 (Registered Nurse) stated she was on duty 9/13/25 when R1 came out of his room and told her V4 and V5 should not be working on his unit. V6 stated I needed to speak with administration which she did and administration told V6 the staff needed to move to the front of the building. V6 stated V4 and V5 moved away from the unit in 5 to 10 minutes of R1 initially stating they should not be on his unit. When asked if V6 felt the staff were lingering at the nursing station after they were told they should not be there, V6 stated, Yeah, a little bit but not that much. On 9/15/25, V7 (CAN) stated on 9/13/25 R1 was telling the nurse in the hall that V4 and V5 could not be in the back of the building, and they were warned not to be in the back. V6 stated the nurse told the staff they needed to go to the front hall nursing station and there was much talking back and forth and one of the nurses was trying to calm it down. V7 stated V4 and V5 stayed at the back hall nursing station 10-20 minutes before they went to the front of the building. Nursing note written by V6 (Registered Nurse) and effective 9/13/25, showed The nurse was passing the medication; the resident come to the nurse and was complaining about staff CNA. He wants the CNA out of the unit. The CNA and the resident were arguing each other. Facility email, dated 9/7/25, shows R1 expressed concern to V1 that V4 walked into his room in a threatening way without his permission. Facility email, dated 9/5/25, shows R1 expressed concern to V1 that V4 entered his room in a threatening way, allegedly called R1 Honey bunny, and R1 requested that V4 not be anywhere near him in the future. Facility email by V8 (Human Resources), dated 9/16/25, shows the facility outcome of investigation proves that R1 violated the facility's abuse policy. The email shows the violation of the policy leads to automatic termination. Concern/complaint forms, dated 8/23/25, show R1 had concerns regarding staff attentiveness. The form shows the staff were assigned to a different unit. Final Abuse Investigation, submitted 9/16/25, shows, Profanity was used in the environment shared between [V4] and R1, however the intention was unclear. Employee is not longer employed at facility for customer service purposes. Facility document Abuse Prevention and Reporting - Illinois, revised 10/24/22, shows, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The document shows, Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. On 9/15/25 at 12:30 PM, R1 stated V4 (CAN- Certified Nursing Assistant) and V5 (CAN) were harassing him at the facility. R1 alleged V4 called him Honey Bunn7 and came into his room uninvited in a threatening manner making threatening comments such as her father purchased her a gun and telling R1 he had not better be talking about V4. R1 stated one day V4 was standing in the hall and pointed to R1 and began a hoola dance. R1 stated he reported the harassment to V1 (Administrator) and V1 prohibited V4 and V5 from working near the unit on which R1 was residing. R1 stated on 9/13/25, V4 R1 left his room to warm up food and saw V4 and V5 at the nursing stating in his hall. R1 stated he told his nurse that V4 and V5 were not to be near his hall and to call V1 to confirm they needed to leave. R1 stated he began recording the episode on his phone. At 12:32 PM R1 played the video he recorded on the phone which showed R1 continuously telling the nurse on his hall that the two staff were not supposed to be present in the back of the building near his hall, that V1 gave the two staff a [NAME] warning, that they would not receive any more warnings, and to call V1 and confirm the information. The video showed as R1 repeatedly told the nurse the staff were not to be on his unit, V4 and V5 remained near R1 and eventually the floor nurse began to move the staff toward the front of the building. The video showed the floor nurse on the phone walking behind V4 and V5 and the staff were walking toward the front of the building. At 6 minutes and 6 seconds of the recording s the staff walked away from R1, a female voice off camera stated, That's what he is. A little bitch! R1 immediately replied, Oh I'm a little bitch, huh? Thank you! R1 stated he previously showed V1 the video and V1 was going to address the behavior with the staff. Facility Email, dated 9/14/25, shows R1 told V1 on 9/13/25 V4 was on his wing in spite of V1 telling V4 that she was only work in another part of the building. The email shows R1 brought his concern to the attention of the nurse on duty. The email shows R1 recorded the interactions and V4 stated to R1, You are just a little bitch. On 9/15/25, V4 denied calling R1 any names and stated R1 was harassing V4 for some time including following her around the building and calling her a bitch and racial slurs. V4 stated on 9/13/25, she arrived at the facility and went to the back to look for her assignment. V4 stated she did not call R1 a bitch but that she was on the phone with her dad and told her dad R1 called V4 a bitch. V4 stated R1 then followed V4 and V5 to the front of the building and continued to harass them. On 9/15/25 at 11:33 PM, V5 stated she did not hear V4 swear at R1. V5 stated she was taking her break and performing charting at the back nursing station when she saw R1. V5 stated V4 was also at the back nursing station putting her personal belongings down. V5 stated she did not say anything to R1 and R1 did not say anything to V4 or V5. On 9/15/25 at 10:00 AM, V1 (Administrator) stated he received an email from R1 alleging V4 and V5 were present in the back of the building near R1 and V4 swore at R1. V1 stated V4 and V5 were previously instructed to remain in the front of the building because of conflicts between R1 and V4 and V5. On 9/15/25 at 1:39 PM, V6 (Registered Nurse) stated she was on duty 9/13/25 when R1 came out of his room and told her V4 and V5 should not be working on his unit. V6 stated I needed to speak with administration which she did and administration told V6 the staff needed to move to the front of the building. V6 stated V4 and V5 moved away from the unit in 5 to 10 minutes of R1 initially stating they should not be on his unit. When asked if V6 felt the staff were lingering at the nursing station after they were told they should not be there, V6 stated, Yeah, a little bit but not that much. On 9/15/25, V7 (CAN) stated on 9/13/25 R1 was telling the nurse in the hall that V4 and V5 could not be in the back of the building, and they were warned not to be in the back. V6 stated the nurse told the staff they needed to go to the front hall nursing station and there was much talking back and forth and one of the nurses was trying to calm it down. V7 stated V4 and V5 stayed at the back hall nursing station 10-20 minutes before they went to the front of the building. Nursing note written by V6 (Registered Nurse) and effective 9/13/25, showed The nurse was passing the medication; the resident come to the nurse and was complaining about staff CNA. He wants the CNA out of the unit. The CNA and the resident were arguing each other. Facility email, dated 9/7/25, shows R1 expressed concern to V1 that V4 walked into his room in a threatening way without his permission. Facility email, dated 9/5/25, shows R1 expressed concern to V1 that V4 entered his room in a threatening way, allegedly called R1 Honey bunny, and R1 requested that V4 not be anywhere near him in the future. Facility email by V8 (Human Resources), dated 9/16/25, shows the facility outcome of investigation proves that R1 violated the facility's abuse policy. The email shows the violation of the policy leads to automatic termination. Concern/complaint forms, dated 8/23/25, show R1 had concerns regarding staff attentiveness. The form shows the staff were assigned to a different unit. Final Abuse Investigation, submitted 9/16/25, shows, Profanity was used in the environment shared between [V4] and R1, however the intention was unclear. Employee is not longer employed at facility for customer service purposes. Facility document Abuse Prevention and Reporting - Illinois, revised 10/24/22, shows, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The document shows, Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability.

Based on observation, interview and record review, the facility failed to follow sanitary practices in the facility kitchen and during meal service in the dining room. This applies to all 84 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated April 21, 2025 showed that the facility census was 86 residents. Facility provided information that two residents are NPO (nothing by mouth) status. On April 21, 2025 at 09:19 AM, the initial tour of facility kitchen was done in presence of V3 (Dietary Manager). V5 (Dietary Aide) was washing dishes at a low temperature dish machine. On request, V5 ran a test strip through the dish machine and the tip turned from white to orange showing 200 ppm (parts per million) per instructions for chlorine test strip guidance on the dispenser bottle. When asked, V5 stated that he did not test the dish machine earlier with test strips and that the sanitizer range should be 100-200 ppm. Guidance for chlorine test strips posted on the wall showed the ppm should range between 50-100 ppm. Facility was requested for policy guidance for chlorine test strips. On April 22, 2025 at 12:20 PM, V3 stated that V5 misspoke and that the chlorine should be 50-100 ppm as posted on guidance poster near the dish machine. V3 stated that the dish machine servicing contractor was notified that morning as the test strips continued to show 200 ppm. V3 added that the dish machine service representative came in that morning and replaced something in the dish machine and stated that they will be back. V3 added that the facility has two different kind of chlorine test strips from two dish service companies and the current dish service contractor told him that it is okay to use both test strips. On April 22, 2025 at 3:43 PM, V1 (Administrator) stated that the dish machine servicing company is coming back to the facility later this evening to install a part into the dish machine as the cycle (to turn off water) would not stop running. On April 23, 2025 at 1:50 PM, V12 (Dish machine Service Representative) stated that he replaced two contactors as one of them was sticky and the other one looked old. V2 stated that the contactors are control components that turn the wash or rinse pump on. V12 stated that if he does not change the contactors, the machine will not work well and only intermittently. V12 also added that he does not know what test strips that the facility was using to test the chlorine sanitizer and that they should use the test strips that turns from white to light purple (registering between 50-100 ppm). Customer Service Report dated April 22, 2025 for dish machine included that two bad (single pole) contactors were replaced. Facility policy and procedure titled Dishwashing: Machine Operation included as follows: Guideline: The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Procedure: 2. Check the dishwashing machine before first use. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. 4. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Manufacturer's chlorine sanitizer test procedure showed as follows: Remove a 1.5 inch strip of clean, dry test paper from container below. At the end of the rinse cycle, dip strip of test paper into the final rinse water from the dish machine. Chlorine papers are dip, blot and read at once. Immediately compare test paper strip to the color chart on the test strip dispenser. Test range must be in the range shown below: test paper reading 50-100 ppm. 2. On April 21, 2025 at 12:27 PM, room meal service was observed in the D-wing of the facility. The resident meal trays were placed on free standing cart in the D-wing with uncovered juice and water cups. These room trays were platted in the main dining room (located in another area) from the steam table and placed on the cart. This cart was then wheeled to the unit and meal trays passed out to the residents in their room by staff. Visitors, staff, and residents were seen in transit in hallway where the cart with meal trays were stationed. When V6 (Social Service Designee) who was assisting in passing room trays, was asked why the juices and water are not covered, V6 responded that she doesn't know why and that she works in social services. R30, R44, R56, R80, and R385 received room trays with the juice and water uncovered. Facility policy and procedure titled 'In-Room Dinning for Infection Control (2020) included as follows: Guideline: In order to control the spread of infectious disease, it may be necessary to implement in-room dining operations. Procedure: 3. All foods should be covered during transport. 3. On April 22, 2025 at 12:23 PM, V4 (Cook), was platting food at the steam table and noted to have her gloves soiled and dripping with pureed Brussels sprouts and gravy. V4 proceeded to take a hamburger bun from a plastic bag with the same gloves and added a slice of hamburger patty with tongs on one side of the bun and added lettuce and tomato on top with the same soiled gloves. This meal was prepared for R50 who had placed an order for a substitute meal. V3, who was in the vicinity, and V4 were notified of the unsanitary practices. Facility menu for Week 1 Tuesday lunch meal included oven roasted turkey with gravy and Brussels sprouts.

Based on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to follow their policies for handling soiled laundry, contact isolation, hand hygiene during provisions of care, and cleaning medical devices between residents. This applies to all 86 residents residing in the facility. The findings include: The facility's Long-term Care Application for Medicare and Medicaid dated April 21, 2025, showed the facility's census was 86 residents. 1. On April 22, 2025, at 4:00 PM, V10 (Maintenance Director) said for the facility's Water Management Plan for Legionella, V10 does not do anything because there is no risk for Legionella in the facility. V10 said there is one eye wash station in the facility, in the kitchen, and V10 activates the eye wash station once a month. V10 demonstrated activating the eye wash station, V10 turned the eye wash station on, the water pushed the eye wash covers off, and V10 immediately turned off the eye wash station water. V10 said once a week V10 obtains water temperatures in five resident rooms and the shower rooms. V10 said he does not obtain any other water temperatures in the facility. V10 said he does not document the hot water tanks temperature. On April 23, 2025, at 1:20 PM, V1 (Administrator) said the facility does not have documentation to show V10 was monitoring water temperatures prior to April 16, 2025. On April 23, 2025, at 2:20 PM, V16 (Regional Consultant) said V10 should be following the facility's Water Management Plan for Legionella and documenting the control measure monitoring. The facility's policy titled Water Management Program Guidelines revised on March 24, 2025, showed, Purpose: To identify and reduce the risk of Legionella and other opportunistic pathogens growth and spread in the facility water system. Guidelines The facility shall develop and implement a facility water management program plan to identify potential hazards and reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water system in accordance with current recommendations from ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) standard 514: .Control Measures- Determine locations where control measures shall be applied and maintained to stay within established control limits. Monitoring/Corrective Actions- Establish procedures for monitoring whether control measures are operating within established limits and if not, take corrective actions. Confirmation- Establish procedures to confirm the following: program is being implemented as designed- verification; Program controls the hazardous conditions throughout the building water systems- validation. Documentation- Establish documentation and communication procedures for all activities of the program . Environmental Services shall be responsible for monitoring the identified areas of risk per and implementing corrective action as indicated and established by the water management program/plan. The facility will perform an assessment of their water system to identify risk areas and determine corrective actions to be taken when control measures are identified to be outside of the parameters established by the facility . Examples of internal factors that increase the risk of Legionella growth: .Water temperature fluctuations: Provide conditions where Legionella grows best (77 degrees Fahrenheit to 113 degrees Fahrenheit); Legionella can still grow outside this range. Many things can cause the hot water temperature to drop into the range where Legionella can grow, including low settings on water heaters, heat loss as water travels through long popes away from the heat source, mixing cold and hot water within the plumbing system, heat transfer (when cold and hot water pipes are too close together), or heat loss due to water stagnation. In hot weather, cold water in pipes can heat up into this range . The facility's Water System Assessment for Legionella Risk dated January 3, 2025, showed .2. Cold Water Distribution: Eyewash stations- List all locations: Kitchen and Utility Room . Comments: Any areas of risk identified such as potential stagnation, dead legs, etc.? If yes please describe below: Eye was stations: Potential stagnation due to infrequent use. Intervention: flush weekly for five minutes . Heating: Water Heaters- List location of each water heater: East boiler room and [NAME] boiler room . Potential risk for improper temperature settings. Intervention: Temperature settings of water heater and/or storage tank (if applicable) will be checked weekly and logged to confirm temperature is set between 140 to 160 degrees Fahrenheit . Hazard Analysis: .Processing Step: 2. Hot Water Tank Heater and/or Hot Water Storage, Mixing Valve. Potential Hazard: Potential growth of microorganisms in heating system. Scalding potential if temperatures are greater than 100 degrees Fahrenheit at the fixture. Risk: Yes. Risk Basis: High Risk: There is potential for microbiological growth at the heating step. This is reduced at temperatures greater than 124 degrees Fahrenheit. Elevated temperature targets also present a noticeable scalding hazard. There factors provide further reason why maintenance of the target temperatures are an essential control measure. Control Measures: 1. Adjust temperature to provide further microbiological control and prevent scalding . Processing Step: 6. Emergency Eye Wash Stations. Potential Hazard: Potential growth of microorganisms which could be propagated and transmitted via cold water distribution piping system and aerosolized. Risk: Yes. Risk Basis Medium Risk: The Emergency Eye Wash and Showers are usually classified as medium risk due to the rarity of their use and the specific situation when they are used. Control Measures: 1. Weekly testing, flushing and cleaning of Emergency Eye Washes . Control Limits and Monitoring: Processing Step: Hot Water Heater and Storage: Domestic Hot Water Tanks, Kitchen Hot Water Tank. Critical Control Limit: Water Heater/Storage Tank set to not less than 140 degrees Fahrenheit (recommended 140 to 160 degrees Fahrenheit. Monitoring: Verify temperature settings of water heater(s)/storage tanks. Frequency: Weekly . Processing Step: Cold Water Distribution: Check disinfectant level (chlorine or chloramine), temperature, and pH (potential of Hydrogen). Critical Control Limit: Potable Water: Cold Water temperature less than 68 degrees Fahrenheit; Residual chlorine of chloramine 0.2 to 0.4 ppm (parts per million); pH 6.5 to 8.5. Monitoring: Check cold water critical control limit in at least three locations: sample a point closest to entry point of water into the facility and at least two fixtures located in areas of the facility most distal from water entry point. Frequency: Weekly. Limit Deviation Corrective Action Suggestion: Contact municipal water department . Processing Step: Plumbed Eye Wash Stations. Critical Control Limit: Preventative maintenance, flushing and cleaning. Monitoring Flush all plumbed eye was stations for five minutes and clean nozzles and equipment. Frequency: Weekly . The facility does not have documentation to show Control Measures were being monitored as shown in the Water Management Plan for Legionella. 2. On April 23, 2025, at 1:24 PM, during a tour of the facility's laundry with V1 and V15 (Housekeeping), V15 said she receives the facility's soiled laundry through a laundry chute and brings the bags of soiled laundry to the washing machine. V15 said when she loads the soiled laundry into the washing machine, V15 wears gloves. V15 continued to say she does not wear a gown or apron when handling the soiled laundry. No apron or gown was observed in the laundry room. On April 23, 2025, at 1:51 PM, V1 said V15 should be wearing an apron when handling soiled laundry. The facility's policy titled Linen Handling- Laundry Department revised on January 11, 2018, showed Purpose: To ensure the proper handling, storage, processing, and transport of all linens and laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible. Guidelines: The facility staff should handle all used laundry as potentially contaminated and use standard precautions (i.e., gloves) . 6. Laundry personnel shall wear aprons and utility or non-sterile gloves when handling linens soiled with blood or body fluids . 36567 3. R53's had multiple diagnoses on face sheet including sepsis, unspecified organism, urinary tract infection, site not specified, flaccid hemiplegia affecting left nondominant side, unsteadiness on feet, unspecified abnormalities of gait and mobility, cellulitis of right lower limb, need for assistance with personal care. R53's quarterly MDS (minimum data set) dated March 31, 2025 showed that R53 was cognitively intact and was frequently incontinent of urine. R53's POS (physician order summary) showed Macrobid Oral Capsule 100 mg (milligram), Give 100 mg by mouth two times a day for UTI (urinary tract infection) for 7 Days (start date April 21, 2025 5:00 PM). R53's POS also showed Contact Isolation for ESBL (extended spectrum beta-lactamases) in urine until resolved (start date April 21, 2025). On April 22, 2025 at 9:30 AM, R53 was lying in bed and stated that he ate breakfast in the dining room and plans to go for therapy in the therapy room. R53's door had a posting for contact isolation. On April 22, 2025 at 9:58 AM, R53 was seen self controlling his motorized wheelchair to the reception desk where he placed an order for his lunch with V17 (Receptionist). On April 22, 2025 at 10:30 AM, R53 was seated at a table with R29 and R41 in the main dining room and was drinking coffee. R4, R6, R25, R44, and R386 were also seated in close proximity to R53. R53 remained in the dining room to participate in bingo during activities. On April 22, 2025 at 10:36 AM, V2 (Director of Nursing) stated that R53 is on contact isolation for ESBL urine and as long as it is contained, he can go outside his room. V2 stated that R53 uses the urinal by himself. On April 23, 2025 at 9:18 AM, R53 was in his motorized wheelchair and was seen entering the therapy room by touching the door handle and opening the door. Within a few minutes, R385 was seen coming into the therapy room by touching the same door handle. R80, who was already in the therapy room riding the bicycle, also touched the same door handle when she left the therapy room. Both R80 and R385 were ambulatory and R80 used a walker. R53 was participating in therapy with V9 (Physical Therapy) and was handling common weights and a walker that were used by other residents. V9 was seen touching R53's back and walker during therapy. V9 was not wearing gloves and gown. On April 23, at 9:22 AM, V2, who had come to the vicinity, was asked if R53 is allowed to participate in therapy in a common room with other residents and whether V9 should be wearing any gloves or gown. V2 stated that as long as V9 washes hands in between patients, V9 does not have to wear any gowns or gloves. V2 stated They (V9) are not touching the source. On April 23, 2025 at 9:50 PM, V9 stated that she did not know that R53 was on contact isolation. When asked how she knows whether a resident is on contact isolation or not, V9 stated that normally she gets the residents for therapy from their room and will see the signage of contact precautions on the door. V9 stated that R53 brought himself into therapy so she was unaware that he was on contact precautions. V9 stated that therapy is done in the resident's room for residents with contact precautions and wearing gown and gloves. R53's care plan initiated on April 21, 2025 showed that R53 is on antibiotic therapy related to ESBL in urine. Interventions for the same included contact isolation for ESBL in urine until resolved. Facility's infection precaution policy and procedure revised on May 15, 2023, shows as follows: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. The 2007 Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions will be utilized in this facility with some modifications Transmission-based precautions: 3. Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. In some instances, residents colonized with these organisms may also require Contact Precautions, for example, when a draining wound cannot be contained, when a resident exhibits noncompliant behaviors with stool or other body fluids, or when a resident has very poor perianal hygiene, etc.[etcetera] . Points to remember: -Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one of person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment -In general, contact precautions are not required in the LTC [long term care] setting for MDRO's [multi drug resistant organism] if the source of the infection can be contained or if the infection is colonized. Examples include wounds infections where the drainage is contained by dressings, urinary infections that are contained by a catheter that does not leak, infections of the blood stream, etc. -All faucets and handles are considered to be contaminated, as are sinks and hoppers. -Gather all equipment and supplies needed before going into the room. Only take needed supplies into the room. When possible dedicate the use of noncritical resident-care equipment to a single resident or cohort of residents infected or colonized with the pathogen requiring precautions. When use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident . 43389 4. On April 21 2025 at 10:41 AM, R3 stated to the nurse-on-duty she needed to be changed because she had been having diarrhea since last night. R3 stated her medication was making her sick. After the nurse left the room, R3 vomited into the garbage can and onto the floor. V13 (CNA/Certified Nursing Assistant) came into the room with an incontinence brief and wipes to assist R3 with incontinence care. V13 put on gloves and helped R3 onto her back and cleaned her from the front to the back with wet wipes. V13 then helped R3 onto her right side and cleaned the stool she had on her bottom. V13 then removed his gloves and without performing hand hygiene started going through R3's personal drawers looking for barrier cream. R3 stated I don't have any cream. V13 left the room without performing hand hygiene and went into the clean utility room to get some barrier cream. V13 came back with the barrier cream, he went into the bathroom and washed his hands with soap and water. He put on gloves, and started to place barrier cream on R3's buttocks. While V13 was applying the white barrier cream. R3 stated, I'm going again. Loose stool began to pour out of R3. V13 started cleaning R3 and then stopped, V13 then took off his gloves, and put on new gloves. V13 did not perform hand hygiene. V13 waited and then started cleaning R3 once she had finished having a bowel movement. Once R3 was clean, V13 took the gloves off and put on new gloves without performing hand hygiene. V13 applied barrier cream to R3's buttocks. V13 removed his gloves and put on new gloves without performing hand hygiene. V13 helped R3 onto her left side by holding R3's torso and buttocks to the side while he pulled the right side of the incontinent brief around to R3's right side. After V13 finished cleaning R3 up, V13 started cleaning the vomit off of the floor next to R3's bed. V13 stated he needed to get some disinfectant for the floor. V13 removed the gloves he had just cleaned the vomit with and opened R3's door without performing hand hygiene. V13 then went down the hall to the housekeeper's cart and grabbed a can of disinfectant. V13 then put on a pair of new gloves, again without performing hand hygiene. V13 sprayed the disinfectant on the floor and wiped it up. V13 grabbed the garbage bag that had the soiled incontinence brief in it and put it on the floor next to R3's room door and went out of the room and rolled the linen cart down the hall to R3's room. V13 removed his gloves and donned new gloves without performing hand hygiene and put the dirty linens in the linen cart. R3 took the gloves off, and without performing hand hygiene, grabbed R3's wheelchair and put it closer to her bedside. V13 put some additional linens in the linen cart then took the trash he had by the entry, left the room with it, and threw it away in the hallway trash cart. On April 23, 2025 at 2:00 PM, V2 (Director of Nursing) stated staff should wash hands before providing care, after providing care, after removing gloves, and before touching other surfaces. V2 stated staff should perform hand hygiene to prevent transmission of infection. The facility's Hand hygiene/handwashing policy revised July 30, 2024 showed the following; when to perform hand hygiene: at room entry, before exiting the room, before and after having direct contact with a patient's intact skin, after contact with blood, body fluids, or excretions, mucous membranes, non-intact skin or wound dressings, after contact with inanimate objects in the immediate vicinity of the patient, if hands will be moving from a contaminated-body site to a clean-body site during patient care, and after glove removal. 15845 5. On April 22, 2025, at 8:33 A.M., V7 (Licensed Practical Nurse) retrieved a blood pressure monitoring device from the top of the medication cart and brought it into R48's room to check R48's blood pressure. Upon completing the blood pressure check, V7 returned the device to the top of the medication cart and proceeded to retrieve multiple medications from the cart for administration. At this time, the blood pressure device remained on top of the cart, posing a risk of cross-contamination with medication cards and other supplies being used for medication administration. V7 failed to disinfect the blood pressure device both prior to and following its use. Additionally, V7 did not perform hand hygiene after assessing R48's blood pressure and before preparing or administering medications. V7 continued with the medication pass to other residents without disinfecting the blood pressure device. Review of the Physician Order Sheet (POS) for April 2025 indicated a medical order dated March 31, 2025, specifying that R48 is on Enhanced Barrier Precautions (EBP) due to the presence of a peritoneal dialysis catheter. R48 was also receiving intravenous antibiotics for treatment of leukocytosis. The care plan dated April 1, 2025, reaffirmed that EBP measures must be maintained for R48. 6. On April 22, 2025, at 9:00 A.M., V8 (Registered Nurse) utilized a blood pressure monitoring device to check the blood pressure of R20. Following the assessment, V8 returned the device to the top of the medication cart and retrieved multiple medications from the cart, while the device remained on the cart, risking cross contamination of the medication cards and supplies. V8 did not disinfect the blood pressure device before or after use and continued the medication administration process without cleaning the equipment. V8 subsequently used the same contaminated blood pressure device to assess the blood pressure of R6 without performing any disinfection in between uses. Review of the Electronic Medical Record (EMR) for R20, an [AGE] year-old resident, showed diagnoses including cellulitis of the left lower limb, pruritus, edema, and urinary tract infection (UTI). The EMR for R6 documented diagnoses including emphysema, asthma, dysuria, disorders of skin and subcutaneous tissue, spontaneous ecchymoses, dementia, and bipolar disorder. On April 22, 2025 at 11:26 A.M., V2 (Director of Nursing) stated that facility protocol requires blood pressure monitoring devices to be disinfected with bleach wipes between uses on different residents, regardless of whether residents are under Enhanced Barrier Precautions or Standard Precautions. Review of the facility's Infection Control Policy dated November 28, 2012, states: Handwashing/hand hygiene is the single most important precaution to prevent contamination of infection from one person to another. Wash hands before and after each resident contact and contact with resident belongings and equipment . When use of common medical equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident.

Based on observation, interview, and record review, the facility failed to provide assistance to residents requiring moderate assistance with grooming. This applies to 1 of 5 residents (R75) reviewed for ADLs (Activities of Daily Living) in the sample of 18. The findings include: R75's EMR (Electronic Medical Record) showed R75 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, weakness, and pseudobulbar affect (condition that causes inappropriate laughing or crying). R75's MDS (Minimum Data Set) date January 21, 2025, showed R75 had moderate impaired cognition and required moderate staff assistance for grooming. R75's care plan showed R75 had an ADL self-care/mobility performance deficit that may fluctuate with activity throughout the day related to fatigue, multiple sclerosis, and a need for assistance with personal care. On April 21, 2025, at 10:14 AM, R75 said she cannot remember when she had her last shower but thought is was at least a week ago. R75 said she needs to be shaved. R75 had whiskers that were approximately 1/4 on chin, and also had whiskers above her upper outer lip on both sides. R75 said she is not allowed to have a razor and would like to be shaved but no one has offered. Her hair was stringy and matted to her head. On April 22, 2025, at 11:26 AM, R75 said she thinks her shower day is on Mondays but did not get one yesterday. R75 said she did not refuse, no one offered. On April 23, 2025, at 8:36 AM, R75 was lying in her bed, her hair was stringy and matted to her head. Whiskers are still on her chin and upper lateral lip. Her face was very shiny, R75 said no one has assisted her with oral care, shaving, or washing her face and hands. At 11:05 AM, R75's appearance was the same as earlier. R75 said no one has offered to shower her or help her get cleaned up. On April 23, 2025, at 12:05 PM, V2 (DON/Director of Nursing) said when it is not a resident's shower day, the expectation is that the CNAs (Certified Nursing Assistants) provide grooming care which includes oral care, washing face and hands, getting dressed, and incontinence care/toileting. On shower days, they provide showers, nail care, shaving, oral care, and comb hair. R75 refuses showers frequently. V2 was asked to provide documentation of refusals and provided one shower sheet dated April 3, 2025, that showed R75 refused a shower but had a bed bath instead. There were no other refusals documented. On April 23, 2025, at 1:18 PM, V14 (CNA) said on shower days she will wash the resident's hair unless they refuse to get hair wet, wash their body, apply lotion or Vaseline, check toenails, notify social services to put resident on list to see podiatrist list, get resident dressed, and get resident up out of bed or back to bed if they refuse to stay up. V14 said she showered R75 on Monday afternoon. Facility provided their revised policy dates January 31, 2018, titled Shower and Tub Bath. The policy showed the purpose was to ensure resident's cleanliness to maintain proper hygiene and dignity .Equipment: . shampoo . Facility provided undated policy titled, Shaving Male and Female Residents. The policy showed the Purpose: To provide cleanliness, comfort, and improved morale . Important Information on Frequency and Method of Shaving 1. male residents will be assessed for daily shaving .2. Female residents will be asked regarding preference to give consent for the method of removing facial hair such as clipping with scissors, electric razor or safety razor, and information added to the plan of care. 3. Female residents will be assessed weekly, and assistance provided in accordance with the resident's preference.

Based on interview and record review, the facility failed to follow their policy to quarterly assess a resident's nutritional status. This applies to 1 of 4 residents (R63) reviewed for nutrition in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R63 was admitted to the facility on [DATE], with multiple diagnoses including polyosteoarthritis, legal blindness, vitamin D deficiency, chronic gastritis, and nicotine dependence. R63's MDS (Minimum Data Set) dated April 8, 2025, showed R63 was cognitively intact. R63's nutrition care plan dated November 3, 2023, showed I have a nutritional problem or potential nutritional problem secondary to HIV (Human Immunodeficiency Virus), cannabis dependence, legally blind, vitamin D deficiency, hypertension, history or COVID-19, and medications which may affect appetite and/or weight. The care plan continued to show a goal revised on October 21, 2024, I will maintain stable weight plus/minus 5% (percent) through next review. On April 21, 2025, at 9:46 AM, R63 said he is blind. R63 said he thinks he has been losing weight. On April 21, 2025, at 12:13 PM, R63 was sitting in the dining room eating lunch. R63 was eating unassisted and was dropping food onto his lap, on the table, and on his meal tray. R63 was not assisted by facility staff. R63 got up from the lunch table and left the dining room. R63's Weights and Vitals Summary dated April 23, 2025, showed the following weights for R63: On November 5, 2024, 151.8 pounds; On December 3, 2024, 151.4 pounds; On January 2, 2025, 148.8 pounds; On February 3, 2024, 146.3 pounds; On March 1, 2025, 144 pounds and; On April 3, 2025, 140.8 pounds. On April 23, 2025, at 1:14 PM, V3 (Dietary Manager) said he performs quarterly nutrition assessments on residents who are not being seen by the dietitian. V3 continued to say he documents his assessments in the EMR. The EMR showed V3 documented a nutrition assessment for R63 on October 29, 2024. As of April 23, 2025, at 1:00 PM, the EMR does not show R63 had a nutrition assessment since October 29, 2024. On April 23, 2025, at 1:18 PM, V2 (DON/Director of Nursing) said V11 (Dietitian) does not evaluate a resident unless the resident has a significant weight loss. V2 continued to say V11 told V2 she did not need to see R63 because he did not have significant weight loss. On April 23, 2025, at 2:51 PM, V2 said R63's nutrition assessment by V3 was on October 29, 2024, and R63's last nutritional assessment by V11 was on August 1, 2024. On April 23, 2025, at 3:24 PM, V1 (Administrator) said residents should have a nutritional assessment completed at least quarterly. The facility's policy titled Routine Nutritional Documentation and assessment dated 2020, showed Guideline: After admission the resident is assessed and monitored in accordance with the MDS schedule and evaluation of need determined at admission. High-Risk residents at admission are placed on the high-risk roster and followed as indicated. Residents at nutritional risk or with current nutritional concerns are referred to the Registered Dietician for a comprehensive nutritional assessment. The MDS schedule will screen for nutritional triggers which may indicated a nutritional problem or opportunity for improvement. Nutrition screening may also be used to monitor for nutritional risk. Ongoing comprehensive nutritional assessments are updated as needed by the Registered Dietitian for residents screened or trigger on the MDS with nutritional concerns. Some communities choose to complete a baseline nutritional assessment on each resident annually. Procedure: 1. The MDS schedule is used to define the time frame for documentation. The Dining Service Manager is responsible for observing the resident at meal times, reviewing the MDS, completing section K of the MDS, and signing the MDS . 3. Progress notes will be used by the Dining Services Manager and Registered Dietitian as needed to record observations, progress towards nutritional goals, and incidental information related to the nutritional care of the resident. A progress note will be entered into the health record by the Dining Services Manager in accordance with the MDS schedule, no [NAME] than quarterly. In circumstances where the resident is being followed by the Registered Dietitian due to a nutritional risk, the quarterly note by the Dining Services Manager may be deemed unnecessary. 4. The care plan will be updated as changes are made to individualized nutritional interventions and reviewed at least quarterly.

Based on observation, interview, and record review, the facility failed to monitor and care for a midline peripheral intravenous catheter. This applies to 1 of 1 residents (R48) reviewed for intravenous catheters in the sample of 18. The findings include: R48's electronic medical record showed R48 was admitted to the facility on [DATE] with diagnoses that included stable burst fracture of second lumbar vertebra, subsequent encounter for fracture with routine healing, dependence on renal dialysis, gait abnormalities, and need for assistance with personal care. On April 21, 2025 at 10:10 AM, R48 stated that she is receiving intravenous antibiotics. R48 showed the surveyor, her right arm intravenous catheter which had a transparent dressing that was dated April 14, 2025. Underneath R48's transparent dressing, there was a gauze dressing which was stained with dried blood and was covering the insertion site. On April 21, 2025 at 1:24 PM with V2 (Director of Nursing/DON), observed R48 right upper arm intravenous catheter and V2 confirmed that there was a gauze dressing underneath the transparent dressing that had dried blood on it and was covering the insertion site. R48 had the following order dated April 6, 2025: Insertion of midline catheter. Sent for imaging on April 6, 2025 at 10:01 AM. R48's progress note dated April 6, 2025 showed the following: A vascular nurse was in the facility at approximately 8 PM to open vascular access to right midline catheter. R48's medication administration record showed administrations of Ceftriaxone Sodium (Antibiotic) Reconstituted 1 Gram for 6 days starting on April 6, 2025 through April 11, 2025. On April 23, at 2:00 PM, V2 stated when central or midline intravenous catheters are placed, she expects the nurses to check for signs and symptoms of infection and bleeding every shift. V2 stated nurses are supposed to chart their assessments in the resident's progress notes. V2 stated that from the moment the midline is inserted, there should be monitoring every shift for infection, redness and warmth, bleeding, and swelling and the nurses should also be monitoring every shift the circumference of the resident's arm where the catheter line is inserted. V2 stated she expects the nurse to change midline intravenous dressing after the first 24 hours of insertion. V2 stated with a gauze dressing, the dressing should be changed every 2 days. V2 stated she believes R48 midline catheter was inserted on April 6, 2025, therefore R48's dressing should have been changed on April 8, 2025, as needed, and weekly. As of April 23, 2025 at 11:15 AM, the facility did not have a care plan for the care of R48's midline intravenous line. There was also no documentation to show that the circumference of the R48's right arm was being measured. Prior to April 20, 2025 there was no documentation in the MAR (Medication Administration Record) or the TAR (Treatment Administration Record) that the midline intravenous line was being flushed or monitored every shift. The facility's Intravenous Access Line Maintenance Protocol policy dated February 7, 2020 showed the following: Site Maintenance: Transparent dressing changes should be done on admission or 24 hours post insertion, then weekly and as needed. Measure upper arm circumference and exterior catheter length with each dressing change and as needed. Gauze dressing changes should only be used if patients are sensitive to clear transparent dressings and must be changed every 2 days.

Based on interview and record review, the facility failed to report a suspicion of a crime to law enforcement and the survey agency in a timely manner in accordance to the facility policy. This applies to 1 of 3 (R1) residents reviewed for incidents in sample of 5. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], and discharged from the facility on March 29, 2025. R1 had multiple diagnosis including cachexia, severe protein -calorie malnutrition, dysphagia oropharyngeal phase, unsteadiness on feet, and cognitive communication disorder, adult failure to thrive, and cognitive communication deficit. R1's MDS (Minimum Data Set) dated March 5, 2025, showed R1 was severely cognitive impaired, and required assistance for ADLs including partial assistance with eating, substantial assistance with oral hygiene, bed mobility, and upper body dressing, and dependent on staff assistance for toileting, bathing, lower body dressing and transfer. On March 30, 2025, at 10:13 AM, V1 (Administrator) stated there had been a firearm in a purse in the facility on March 12 or 13th, 2025. V1 explained V4 (R1's daughter) called the facility and spoke to V6 (RN) and stated she had left her purse in R1's room after her visit and did not realize it until she got home. V1 stated V6 took the purse to V5 (Social Services Director). V5 took the purse to V1's office and locked it in a drawer of the desk and locked the door to V1's office. V1 stated V4 had stated she was unable to come back to the facility that day. V1 stated he locked the purse in the basement office in the facility safe after talking to V4. V1 stated he did not contact law enforcement, nor report to IDPH (Illinois Department of Public Health) that there was a firearm in the facility, in violation of the facility sign on the door for no firearms allowed in violation of the Illinois Concealed Carry Firearms Act. V1 stated V4 came to the facility to pick up her purse the next day. V1 stated he received a text message on March 13, 2025, at 4:36 PM from V5 (Social Services Director) informing him of the purse that had a firearm inside it. V1 stated he was not in the facility at that time and returned to the facility around 7:30 PM to lock the purse inside the safe. On March 30, 2025, at 12:11 PM, V1 provided a copy of initial report to IDPH, dated March 30, 2025, and called the local police department (incident 25-2003) after surveyor inquired if there was a report made to law enforcement or IDPH. On March 30, 2025, at 1:16 PM, V4 stated she visits R1 daily but does not always remember to sign in and out of the visitor log. V4 stated she was visiting on March 13, 2025, and left in a hurry by ride share car because the driver will not wait longer than 3 minutes. V4 stated she had a concealed carry firearms license and did have a firearm in her purse when she entered the facility. V4 could not remember the time she left the facility or even the time that she arrived at the facility that day, but did state as soon as she arrived home, she called the facility and talked to a nurse to explain the purse needed to be locked away for safety. On March 31, 2025, at 2:50 PM, V6 (RN) stated she was assigned to R1 on the evening shift of March 13, 2025, and received a call from V4 at 4:16 PM according to the caller ID on the telephone. V6 stated V4 told her she left her purse at R1's bedside and just realized it when she arrived home and immediately called the facility. V6 stated V4 said the purse needed to be locked in a safe because it contained a firearm. V6 stated she went to retrieve the purse from R1's room and brought the purse to V5 who was the manager in the facility at the time. V6 stated the purse was black, medium sized, was closed and she did not look inside the purse. V6 stated she did not think to call local law enforcement because she had a manager in the facility, and she would leave that decision to management. On March 30, 2025, at 10:56 AM, V5 (Social Services Director) stated she was in the facility on March 13, 2025, around 4:30 PM when V6 brought her a purse. V6 told her V4 had called and informed her that there was a firearm in the purse and V5 stated she contacted V1 by text. V5 stated she did not call local law enforcement because she was not instructed to do so. V5 stated she took the purse. Locked it in a desk drawer and locked the office and made the key to the office unavailable by putting the key in the freezer of the refrigerator in V1's office and locked the door. R1 was in the hospital during this investigation and unable to be interviewed. R2 (R1's roommate) stated she had no knowledge of a purse being left in their room and neither R1 or R2 would have been capable of picking up the purse due to immobility. V3 (Nurse Consultant) provided a document titled Resident Rights and Responsibilities that was signed by V4 on March 4, 2025, on behalf of R1. The document showed 14. Residents are prohibited from keeping any weapons in their possession, i.e. gun, knife, razor blade, stick, etc. that may cause bodily injury. The Illinois Concealed Carry Firearm Act, 430 ILCS 66/1 showed Concealed firearm means a loaded or unloaded handgun carried on or about a person completely or mostly concealed from the view of the public. 430 ILCS 66/65 showed Prohibited areas (a) A licensee under this act shall not knowingly carry a firearm on or into: (7) Any building, real property, and parking area under the control of a public or private hospital or hospital affiliate, mental health facility or nursing home. 430 ILCS 66/70 showed A licensee in violation (e) Except as otherwise provided, a licensee in violation of this Act shall be guilty of a class B misdemeanor. The facility's policy titled Abuse Prevention and Reporting-Illinois, Reporting of Crimes revision October 24, 2022, showed External Reporting .Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities (i.e. telephoning 911) in the following situations .When there is a reasonable suspicion that a crime has been committed in the facility by a person other than a resident. and If there is a reasonable suspicion that a crime has been committed and does not involve serious bodily injury then a report to local law enforcement and Department of Public Health as soon as possible but within 24 hours of when the suspicion was formed.

Based on interview and record review the facility failed to investigate an incident of a suspicion of a crime in accordance with their policy. This applies to 1 of 3 (R1) residents reviewed for incidents in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], and discharged from the facility on March 29, 2025. R1 had multiple diagnosis including cachexia, severe protein -calorie malnutrition, dysphagia oropharyngeal phase, unsteadiness on feet, and cognitive communication disorder, adult failure to thrive, and cognitive communication deficit. R1's MDS (Minimum Data Set) dated March 5, 2025, showed R1 was severely cognitive impaired, and required assistance for ADLs including partial assistance with eating, substantial assistance with oral hygiene, bed mobility, and upper body dressing, and dependent on staff assistance for toileting, bathing, lower body dressing and transfer. On March 30, 2025, at 10:13 AM, V1 (Administrator) stated there had been a firearm in a purse in the facility on March 12 or 13th, 2025. V1 stated he did not have an investigation for the incident nor any documentation regarding the occurrence. V1 stated V4 (R1's daughter) called the facility when she realized she forgot her purse in the facility at R1's bedside. V1 stated he did not report the occurrence at the time to either law enforcement or Department of Public Health because he thought V4 had no malicious intent. V1 stated he was notified by V5 (Social Services Director) by text that V4's purse was found and V5 locked the purse in V1's desk and locked V1's office door. V1 stated he later came to the facility the same day around 7:30 PM and locked the purse in the basement of the facility in a safe and directed staff not to open the safe. V1 stated V4 came and retrieved her purse from the facility the next day. On March 30, 2025, at 12:11, V1 provided an initial incident to IDPH (Illinois Department of Public Health) dated March 30, 2025, and contacted law enforcement on March 30, 2025, for the occurrence of March 13, 2025. V1 stated he did not have a policy regarding what to do with a firearm discovered in the facility but followed Illinois State Police guidelines. During this investigation, V1 did not provide documentation of the State Police guidelines for firearm safety. There was a sign on the front door of the facility that showed firearms were banned from the facility. V1 did not provide an investigation, timeline of events, interviews held, or preventative measures taken for the occurrence of a firearm being left in a purse at R1's bedside, as requested during this investigation. The Illinois Concealed Carry Firearm Act, 430 ILCS 66/65 showed that a licensee was prohibited from knowingly entering a nursing home with a firearm on or about their person. The facility's policy titled Abuse Prevention and Reporting-Illinois, Reporting of Crimes revision October 24, 2022, showed The facility affirms the right of our residents to be free from abuse, neglect . and mistreatment of residents .In order to do so the facility has attempted to establish a resident sensitive and resident secure environment . Internal Investigation .All incidents will be documented .Investigation Procedures: The appointed investigator will at a minimum attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, .The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and any corrective action taken to the Department of Public Health within 5 working days of the reported incident.

Based on interview and record review, the facility failed to hold care plan conferences with residents and their representatives and failed to invite residents and their representatives to participate in the care planning process. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for administration in the sample of 6. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55 AM, R1 was sitting on the edge of his bed eating his lunch. R1 was not able to answer questions regarding care plan meetings due to his cognitive status. Facility documentation shows R1's MDS assessments were completed on June 22, 2024, September 22, 2024, and December 23, 2024. Facility documentation shows a multidisciplinary care plan meeting was held with R1 and V5 (POA-Power of Attorney for R1) on July 9, 2024 and September 23, 2024. The facility does not have documentation to show a care plan meeting has been held with R1, R1's family member, and the IDT (Interdisciplinary Team) since September 23, 2024. 2. The EMR shows R2 was admitted to the facility on [DATE]. The EMR continues to show R2 was transferred to the local hospital on January 2, 2025 for a surgical procedure and returned to the facility on [DATE]. R2 was transitioned to hospice care on January 28, 2025. R2 has multiple diagnoses including malignant neoplasm of the border of the tongue, abnormal gait, lack of coordination, cognitive communication deficit, dysphagia, alcohol abuse, convulsions, alcoholic hepatitis without ascites, celiac disease, depressive episodes, and malignancy of the colon. R2's MDS dated [DATE] shows R2 is cognitively intact. The facility did not attempt to provide eating assistance to R2 due to her medical condition, and she requires supervision for all other ADLs. R2 is always continent of bowel and bladder. Facility documentation shows R2's MDS assessments were completed on September 3, 2024, October 25, 2024, January 24, 2025, and February 7, 2025. Facility documentation shows a care plan conference was held on September 10, 2024. The facility does not have documentation to show another care plan meeting has been held for R2 since September 10, 2024. 3. The EMR shows R3 was admitted to the facility on [DATE]. R3 was transferred to the local hospital on June 2, 2024, and returned to the facility on [DATE]. R3 has multiple diagnoses including, polyosteoarthritis, diabetes, abnormal gait, lack of coordination, dysphagia, skin cancer, heart failure, psychosis, delusional disorders, major depressive disorder, OCD (Obsessive Compulsive Disorder), hoarding disorder, and generalized anxiety. R3's MDS dated [DATE] shows R3 is cognitively intact, requires supervision with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with toilet hygiene, showering, bed mobility, and transfers between surfaces, and is dependent on facility staff for dressing. Facility documentation shows R3's MDS assessments were completed on June 13, 2024, July 23, 2024, August 27, 2024, September 16, 2024, October 25, 2024, January 22, 2025, and February 27, 2025. Facility documentation shows a care plan conference was held on December 11, 2018, and on November 18, 2024. The facility does not have documentation to show any other care plan meetings have been held for R3. 4. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including, adjustment disorder, hypertensive heart and chronic kidney disease with heart failure, atrial fibrillation, emphysema, and dependence on supplemental oxygen. Facility documentation shows R4's MDS assessments were completed on September 13, and December 2, 2024. Facility documentation shows an initial care plan meeting was held on September 16, 2024. The facility does not have documentation to show a care plan meeting was held with R4, R4's family member, and the IDT (Interdisciplinary Team) since September 16, 2024. 5. The EMR shows R5 was admitted to the facility on [DATE] with multiple diagnoses including, major depressive disorder, asthma, abnormal gait and mobility, lack of coordination, suicidal ideations, obstructive sleep apnea, lymphedema, and hypertension. Facility documentation shows R5's MDS assessments were completed on May 18, 2024, August 15, 2024, November 15, 2024, and December 18, 2024. Facility documentation shows an initial care plan meeting was held on May 28, 2024. The facility does not have documentation to show a care plan meeting was held with R5, R5's family member, and the IDT since May 28, 2024. 6. The EMR shows R6 was admitted to the facility on [DATE] with multiple diagnoses including, dementia, abnormal gait, cognitive communication deficit, depression, and history of cerebral infarction. Facility documentation shows R6's MDS assessments were completed on March 3, 2024, March 10, 2024, June 7, 2024, September 7, 2024, and December 8, 2024. Facility documentation shows an initial care plan meeting was held on March 12, 2024. The facility does not have documentation to show a care plan meeting was held with R6, R6's family member, and the IDT since March 12, 2024. On March 4, 2025 at 2:22 PM, V2 (DON-Director of Nursing) said the facility does not have a care plan coordinator and no staff member has been assigned to ensure care plans are taking place. V2 continued to say care plan meetings should be held with the IDT, the resident, and the family members after each MDS review which is quarterly, or if there is a significant change with the resident. V2 said the facility is not currently holding care plan meetings quarterly or following significant changes with residents. On March 4, 2025 at 10:15 AM, V1 (Administrator) said the facility does not have a policy regarding care plan meetings. V1 also said the facility does not have a care plan coordinator at this time. V1 provided a copy of the facility's undated admission contract, entitled IL Admission Packet. The facility's Admission Packet shows, Family and Resident Participation in Care Plan Conferences: This facility conducts care planning conferences at regular intervals in order to develop the interdisciplinary approach to the care that is delivered. Members of each professional discipline attend care planning meetings and every aspect of care is addressed at these meetings. Care plan meetings are utilized to discuss any changes in condition or developments related to the Resident's well-being. This facility encourages the participation of both Residents and families in the care planning process. In fact, participation by the Resident and family is considered to be vital to the staff understanding the needs of the Resident and family. At a designated time prior to the care planning conference, both the Resident and family/authorized representative will be informed of the time and place of this scheduled meeting.

Based on interview and record review, the facility failed to schedule neuropsychological testing for a resident as ordered by the neurology physician. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55 AM, R1 was sitting on the edge of his bed, eating his lunch. R1 was not able to answer questions due to his cognitive status. On July 15, 2024 at 10:00 AM, V10 (Neurologist) documented R1 was seen in his office to address R1's partial symptomatic epilepsy with complex partial seizures. V10's discharge instructions show multiple orders, including, Neuropsychological testing referral. As of March 4, 2025, the facility does not have documentation to show the neuropsychological testing appointment was made for R1 or that R1 was seen by a neuropsychologist. On November 25, 2024, V10 (Neurologist) documented R1 was seen in his office. V10's documentation shows R1 Not oriented to month or year. Unable to name things like phone, keyboard, mouse. Can name glasses and watch. Repeats phrase. V10 continued to document, [R1's] presentation and findings are consistent with a diagnosis of left parieto-occipital lobe epilepsy. Plan: Neuropsychological testing ordered previously. The following tests were ordered: None this visit, all ordered previously. On March 4, 2025 at 12:03 PM, V8 (Psychological NP-Nurse Practitioner) said she has been working with R1 for about six months. V8 said, A neuropsychological examination cannot be done by me. It is a completely different assessment. Not every psychologist can do that type of testing. It requires a neuropsychologist who is trained in that. With that type of testing, we can get a better picture of what is going on in the brain and it helps us to plan the resident's care. On March 4, 2025 at 10:02 AM, V2 (DON-Director of Nursing) said, [V10] (Neurologist) ordered neuropsychological testing. We did not make that appointment. The facility's policy entitled Physician Orders - Entering and Processing revised 1-31-18 shows, Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders (a prescriber is noted as physician, nurse practitioner, and a physician's assistant). Guidelines: 5. Following a physician visit, a licensed nurse will check for any orders that require confirmation under Clinical orders pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed.

Based on interview and record review, the facility failed to schedule an ophthalmology appointment for a resident as ordered by the neurologist. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55 AM, R1 was sitting on the edge of his bed, eating his lunch. R1 was not able to answer questions due to his cognitive status. On July 15, 2024 at 10:00 AM, V10 (Neurologist) documented R1 was seen in his office to address R1's partial symptomatic epilepsy with complex partial seizures. V10's discharge instructions show multiple orders, including, Ophthalmology referral. As of March 4, 2025, the facility does not have documentation to show the ophthalmology appointment was made for R1 or that R1 was seen by an ophthalmologist. On November 25, 2024, V10 (Neurologist) documented R1 was seen in his office. V10's documentation shows R1 Not oriented to month or year. Unable to name things like phone, keyboard, mouse. Can name glasses and watch. Repeats phrase. V10 continued to document, [R1's] presentation and findings are consistent with a diagnosis of left parieto-occipital lobe epilepsy. Plan: Visual impairment - referral to neuro-ophthalmology placed previously. The following tests were ordered: None this visit, all ordered previously. On March 4, 2025 at 10:02 AM, V2 (DON-Director of Nursing) said, [V10] (Neurologist) ordered an ophthalmology referral. We did not make that appointment. The facility's policy entitled Physician Orders - Entering and Processing revised 1-31-18 shows, Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders (a prescriber is noted as physician, nurse practitioner, and a physician's assistant). Guidelines: 5. Following a physician visit, a licensed nurse will check for any orders that require confirmation under Clinical orders pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed.

Based on interview and record review, the facility failed to ensure a resident received an MRI (Magnetic Resonance Imaging) as ordered by the neurologist. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55 AM, R1 was sitting on the edge of his bed, eating his lunch. R1 was not able to answer questions regarding his MRI due to his cognitive status. On July 15, 2024 at 10:00 AM, V10 (Neurologist) documented R1 was seen in his office to address R1's partial symptomatic epilepsy with complex partial seizures. V10's discharge instructions show multiple orders, including, MRI Brain Epilepsy with and without contrast. Schedule this appointment to take place on or around July 15, 2024. The facility does not have documentation to show the MRI was scheduled for R1 as ordered by V10 (Neurologist). On November 25, 2024, V10 (Neurologist) documented R1 was seen in his office. V10's documentation shows R1 Not oriented to month or year. Unable to name things like phone, keyboard, mouse. Can name glasses and watch. Repeats phrase. V10 continued to document, [R1's] presentation and findings are consistent with a diagnosis of left parieto-occipital lobe epilepsy. Plan: MRI Brain epilepsy with/without contrast ordered previously.The following tests have been ordered MRI Epilepsy protocol (call [phone number] to set this up). On March 4, 2025 at 10:02 AM, V2 (DON-Director of Nursing) said, [V10] (Neurologist) ordered an MRI for [R1] on July 15, 2024. The MRI was supposed to be completed before his next visit on November 25, 2024. That was never done. When [R1] returned to the [V10] office on November 25, 2024 and the MRI was not completed, [V10] ordered it himself, and we finally got the MRI done on December 30, 2024. The facility's policy entitled Physician Orders - Entering and Processing revised 1-31-18 shows, Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders (a prescriber is noted as physician, nurse practitioner, and a physician's assistant). Guidelines: 5. Following a physician visit, a licensed nurse will check for any orders that require confirmation under Clinical orders pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed.

Based on interview and record review, the facility failed to ensure transportation arrangements were made for a resident with a scheduled physician follow-up appointment. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55 AM, R1 was sitting on the edge of his bed, eating his lunch. R1 was not able to answer questions due to his cognitive status. On November 25, 2024, V10 (Neurologist) documented R1 was seen in his office. V10's documentation shows R1 Not oriented to month or year. Unable to name things like phone, keyboard, mouse. Can name glasses and watch. Repeats phrase. V10 continued to document, Future appointments: March 17, 2025 11:00 AM - V10 (Neurology). On March 4, 2025 at 10:34 AM, V1 (Administrator) presented the facility's Transportation Log. The Transportation Log showed residents with appointments for the period of March 3, 2024 to March 26, 2025. The Transportation Log did not show R1's scheduled appointment for March 17, 2025 at 11:00 AM to see V10 (Neurologist), or that transportation had been set up for R1 to attend the appointment. On March 4, 2025 at 2:47 PM, V6 (Transportation Coordinator) said, It is the nurse's job to set up the appointments. Then the nurse for each resident fills out a piece of paper to tell me the resident has an appointment and then I set up the transportation. [R1] was not on the transportation list because I did not set up transportation for an appointment on March 17, 2025. I was not aware he needed transportation. If the resident is not on the transportation list, the resident will miss the appointment because no transportation was set up for the resident.

Based on observation, interview, and record review the facility failed to ensure emergency sized tracheostomy tubes for a resident (R1) who required tracheostomy care were available. This failure resulted in R1 experiencing acute respiratory distress and requiring an emergency hospitalization for acute respiratory failure. R1 had to be connected to mechanical ventilation for emergency respiratory support. The facility also failed to ensure licensed nurses were trained on how to change tracheostomy tubes and to dispose of expired tracheostomy inner cannulas. This applies to 1 of 3 residents (R1) reviewed for respiratory care. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including nontraumatic subarachnoid hemorrhage from an intracranial artery, ruptured aneurysm, acute respiratory failure with hypoxia, tracheostomy, obstructive sleep apnea, and hypertension. R1's EMR showed he was transferred to the hospital on [DATE] and was not readmitted . On [DATE] at 3:15 PM, V3 (Licensed Practical Nurse/LPN) said R1 was transferred to the hospital in the morning for acute respiratory distress. V3 said R1 was admitted with tracheostomy with a size 6 cuffed trach tube and was receiving supplement oxygen of 6 L (liters) via a trach collar with humified 28% of FiO2 (fraction of inspired oxygen). V3 was asked to assess R1's beside respiratory supplies. There was a box of size 6DIC inner disposable cannulas containing 10 cannulas with an expiration date of [DATE]. V3 said tracheostomy equipment should be checked and disposed of when expired. V3 was unable to locate any emergency tracheostomy exchange kits for R1. V3 said residents with tracheostomies required emergency tracheostomy exchange tube kits with an obturator (tracheostomy stoma insertion [NAME]) for emergency situations at the bedside. V3 said he was R1's nurse on [DATE] when his entire trach tube had decannulated (expelled out). V3 said he was unsuccessful when he attempted to reinsert a new trach tube for R1. V3 said R1 was then transferred to the hospital and returned the same day with a new trach tube. On [DATE] at 8:10 AM, V4 (Registered Nurse/RN) said she was R1's overnight nurse on [DATE]. V4 said that around 11:25 PM R1 was having low oxygen levels. V4 said she administered a nebulizer treatment and then attempted to suction R1 but was unsuccessful. V4 said R1 continued to have low oxygen levels. V4 said she then attempted to change R1's inner trach cannula but had resistance when she attempted to insert a new inner cannula. V4 said she was not trained in changing entire tracheostomy tubes. V4 said she then contacted R1's physician and received an order to transfer R1 to the hospital. V4 said the emergency paramedics arrived at 11:55 PM and requested for R1's emergency tracheostomy supplies. V4 said she provided V7 (Emergency Paramedic) with a size 7 tracheostomy exchange tube kit without an obturator because that was the only kit she had available at the bedside. V4 said R1 was then transferred to the hospital and admitted for acute hypoxemic respiratory failure. On [DATE] at 8:35 AM, V7 (Emergency Paramedic) said that when the emergency response team arrived at the facility R1's oxygen levels were worsening. V7 said they attempted to ventilate and suction R1 but were also met with resistance. V7 said the protocol for when resistance is met with patients with tracheostomies is to change the entire trach tube. V7 said he asked V4 if she had attempted to change R1's trach tube, V4 responded no because she was not trained to change entire trach tubes. V7 said V4 then provided him with a new trach tube kit. V7 said the kit contained an uncuffed trach tube without an obturator. V7 said R1's trach tube was changed and then R1 was ventilated with a bag valve mask and transferred to the hospital. On [DATE] at 11:40 AM, V10 (Respiratory Therapist Manager) said her company provided the facility with as-needed external respiratory consulting services including tracheostomy care. V10 said residents with tracheostomies required specific emergency equipment at bedside including trach tube kits with the same type of trach tube and an obturator. V10 said the kits should include one of the same size and a downsized one. V10 said tracheotomy equipment should be checked routinely to ensure safe trach care is being provided. V10 continued to say licensed nurses could change trach tubes if there was a doctor's order and if they were trained appropriately. On [DATE] at 11:20 AM, V11 (Pulmonary Nurse Practitioner/NP) said she expected the facility staff to ensure all appropriate emergency tracheostomy equipment and supplies are maintained and kept at bedside according to the facility's policy to ensure safe tracheostomy care could be provided for residents with tracheostomies. On [DATE] at 1:30 PM, V2 (Director of Nursing/DON) said she confirmed that when R1 returned on [DATE] with a new trach tube, it was replaced with a size 4. V2 said the facility expects nursing staff to ensure that residents with a tracheostomy have the required emergency tracheostomy supplies at bedsides, including tracheostomy kits with a trach tube of the same size and a downsized tube, and an obturator. V2 said she also expects licensed nurses to follow the facility's tracheostomy policies to ensure they can respond safely to emergencies. V2 continued to say that she expects nurses to be able to change entire trach tubes monthly as ordered and during emergencies. R1's tracheostomy care plan initiated on [DATE] had multiple interventions including TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. R1's progress note dated [DATE] said O2 sat checked: 86%, Pulse: 75, RR: 20. Suctioning done but resistance noted. Nebulization done. At 11:25 PM, Resident is breathing with O2 sat: 86%, but still unable to advance suction catheter. Notified PCP and called 911. At 11:55 PM, EMS came and assessed the resident. At 12:05 AM, EMT notified the nurse/writer that they will try to change the trach in the facility. R1's Emergency Response report dated [DATE], said Nurse stated she tried to pass a suction tube down the patient's trach, but could not. Crew asked if the nurse had tried changing the trach and the nurse stated she was not authorized to change the trach .Crew asked nurse for a new trach tube and was given one. Crew attempted to ventilate with a bag valve mask and were met with resistance, not able to ventilate. Crew attempted to suction and met with resistance unable to suction. Patient's SpO2 reading was falling .Once tube was prepped, patient's tracheostomy was removed and replaced with new. Crew was now able to ventilate with a bag valve mask . R1's hospital note dated [DATE] said R1 was admitted for acute on chronic hypoxic respiratory failure. The note said EMS attempted to change the inner cannula, but they did not have the proper equipment; however after the clogged inner cannula was removed his SpO2 improved .Upon arrival to the ED he presented with stable and appropriate vitals but he quickly became hypotensive and hypoxic. His trach was connected to mechanical ventilation. R1's hospital note dated [DATE] said R1 was treated for a trach misplacement. The note said he came with a 6 french ET tube. However, there was some resistance on arrival, he had minimal blood. Here, a 4 french trach was placed and XR confirmed placement. R1's Order Summary Report dated [DATE] showed orders for Trach: Licensed nurse may re-insert trach tube, as needed for dislodgment and Trach: Change Trach tube every day shift every 1 month(s). The facility's Admission Data Form: Tracheostomy Patient said the equipment needed included one same size trach and one downsized trach at the bedside at all times. The facility's Tracheostomy Care policy dated [DATE] did not indicate if licensed nurses were responsible for reinserting entire trach tubes nor did it provide instructions on how to perform the procedure. The policy states Emergency Care: If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat maybe used to maintain opening. If necessary, suction the resident through the opening. Physician generally responsible for reinserting new tube.

Based on interview and record review, the facility failed to ensure a resident with substance use disorder was safe for independent community access after being hit by a car the previous day while out in the community. This failure resulted in R2 being found on the side of the road by a bystander and requiring hospitalization . Hospital records show R2 had fractures of the left fourth through 12th ribs, and an elevated blood alcohol level. This applies to 1 of 3 residents (R2) reviewed for accidents in the sample of 6. The Immediate Jeopardy began on March 24, 2024 at 9:14 AM when R2 signed out of the facility without being assessed to be safe for independent community access after presenting to the nurse with alcohol on his breath, and after being hit by a car the previous day while out on community pass. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on April 17, 2024 at 10:28 AM. The facility presented an abatement plan to remove the immediacy on April 17, 2024 at 1:51 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on April 17, 2024 at 3:56 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on April 17, 2024 at 6:03 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on April 18, 2024 at 9:07 AM, and the survey team accepted the abatement plan on April 18, 2024 at 10:14 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on April 18, 2024 at 10:14 AM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, mild osteopenia of the right lower leg, low back pain, chronic pain syndrome, multiple rib fractures of the left side, alcohol use, repeated falls, and multiple wedge compression fractures of the spine. R2's MDS (Minimum Data Set) dated March 15, 2024 shows R2 is cognitively intact and requires supervision for all ADLs (Activities of Daily Living). R2 is always continent of bowel and bladder. On April 15, 2024 at 9:51 AM, V3 (LPN) said, When [R2] came back to the facility on [DATE], he smelled like he was drinking. He did not come to me and tell me he was hit by a car. He told the therapist, who came to me. I notified [V4] (Physician). We called the paramedics, and [R2] signed a paper to refuse to go with them. He would not let us do X-rays either. They came and he refused. I worked a double shift on March 23, and was in the building from 7:00 AM to 11:30 PM. I returned the next day at 7:00 AM and was assigned to care for [R2] again. He came to me to get his medications before 9:00 AM, and he smelled of alcohol. He said he was going to leave the facility and go out in the community. It is not my call to keep him in the facility. At that time, I did not notify anyone. I did not call [V4] (Physician) to notify him [R2] wanted to go out or to check if it was okay since he was hit by a car the day before. I did not complete a community access assessment to determine if he was able to go out into the community without supervision. Later, I received a call from the hospital, and they told me they had [R2]. He was picked up from the street by emergency response. On April 15, 2024 at 10:44 AM, V5 (Police Officer) said, The driver of a vehicle hit [R2] on March 23, 2024, while he was in the crosswalk, approximately one half mile from the facility. The driver was making a turn at the stop sign and [R2] happened to be in her blind spot, and she hit him in his wheelchair. He was bleeding from his forehead. He fell out of the wheelchair onto the ground, and someone helped him get back into his wheelchair and sit until the fire department came. The street he was on is one of our busier streets. It is a four-lane road with a turn lane. We tried to get him to go to the hospital, but he refused. On April 15, 2024 at 12:17 PM, V4 (Physician) said, [R2] drinks every day. He went out on Saturday (March 23, 2024) and he was hit by a car. [V3] (LPN) must have assessed him to be safe in the community before he went out on Sunday (March 24, 2024). [R2] doesn't follow the rules. He still insists to go out. It was a possibility that he could have had supervision while out in the community on Sunday (March 24, 2024) but I was not contacted regarding that. I don't think he likes being supervised. V4 continued to say he was not contacted by V3 (LPN) for an order for R2's independent community pass on March 24, 2024. On April 15, 2024 at 12:34 PM, V1 (Administrator) reviewed R2's care plan that was in place on March 23, and 24, 2024. V1 reviewed R2's care plan interventions which show that the resident is aware of the rules and regulations associated with accessing to the community and that the resident understands that access to the community is a privilege which may be revoked at any time due to engaging in prohibited activities and/or behaviors. V1 also reviewed the care plan intervention which shows to obtain a physician's order for outside pass privilege and inform if there have been any restrictions to the resident's community access placed by the physician. After reviewing R2's care plan, V1 said, I don't know the rules and regulations associated with accessing the community. I do not know what the prohibited activities are. V1 continued to say the facility does not have a list of rules or regulations for residents with independent community access. On April 11, 2024 at 12:00 PM, R2 was self-propelling his wheelchair down the hallway towards his room. R2 had noticeable bruising around his right eye and faded bruising across the bridge of his nose and across his forehead. R2 had a scab on the top of his left hand. R2 said the hand injury and bruising were caused by injuries he sustained while out on pass in the community on March 23, 2024. R2 said he was out in the community in his wheelchair on March 23, 2024, when he was hit by a car. The car hit his wheelchair, causing his wheelchair to tip over. R2 said bystanders stopped and helped him get off the ground and back into his wheelchair before the police and paramedics arrived. On April 11, 2024 at 12:00 PM, R2 said he could not recall the events of March 24, 2024 that led to his hospitalization from [DATE] to April 2, 2024. On April 11, 2024 at 12:21 PM, V8 (NP) said, Anyone who is under the influence of alcohol or intoxicated cannot make decisions to be safe. On April 11, 2024 at 1:00 PM, V6 (SSD-Social Service Director) said, [R2] does not understand the consequences of his actions because he has been drinking his whole life. The Illinois Traffic Crash Report number 2024-00017709 shows R2 was struck by an automobile in a four-lane street on March 23, 2024 at 9:15 AM. V13 (Vehicle Driver) failed to yield the right of way to R2 in a crosswalk and struck R2. The facility's resident sign out sheet dated March 24, 2024 shows R2 signed himself out of the facility at 9:14 AM. Local fire department documentation dated March 24, 2024 shows EMS (Emergency Medical Services) was notified on March 24, 2024 at 1:27 PM and had contact with R2 on March 24, 2024 at 1:32 PM. The EMS provider documented: [EMS Crew] dispatched for male with back pain from being struck by a vehicle 2 days ago. Upon arrival on scene [Local Police] stated that they were called for a check on the wellbeing. [Local Police] stated that patient wheelchair had gone off the sidewalk and he was already assisted back to the sidewalk by a passerby. [Local Police] stated that patient had refused any need for [Police] or EMS. Police stayed on scene to see if [R2] could make it back to [the Facility]. Police stated they called for EMS as patient was unable to navigate broken wheelchair back to [the Facility]. Patient stated that he had no medical complaints and refused to be seen at the hospital. EMS offered to get him back to [the Facility] via courtesy ambulance ride. Patient initially refused and then agreed as his wheelchair was broken. When EMS brought cot to patient, he complained of back pain from the accident. EMS advised that if he was still in pain to be seen at the ER. Patient kept refusing ER transport. After a few minutes of assisting patient to cot, patient agreed to be transported to [local hospital] ER due to his back pain as long as we brought his broken wheelchair with. BLS (Basic Life Support) assessment and care provided On March 25, 2024 at 3:28 AM, V7 (Hospital NP-Nurse Practitioner) documented R2 Presented to the emergency department at [local hospital] on March 24, 2024 after bystanders found him on the side of the road inside of his wheelchair unable to get up and called 911.Patient is very poor historian and was unable to recall the events that took place for him being on the side of the road.A chest CT revealed fractures of the left fourth through 12th ribs. There is also bibasilar atelectasis predominantly in the left lower lobe with mild left effusion and hemarthrosis (bleeding) but no evidence of pneumothorax. He was seen the following morning on the medical unit. He was tremulous in upper and lower extremities. His speech was slurred. He had evidence of intoxication and possible early withdrawals of alcohol which is a chronic issue for him. He had multiple hospitalization s regarding injuries associated with alcoholism.On March 23, 2024 he was in his wheelchair when he was struck on his right side apparently by a driver who was using her phone at the time. He was knocked out of the wheelchair, landed on his left side which is where the injuries are present. Police were called to the scene, and he refused transport against medical advice and was given an incident report at that time with the exchange of driver information. R2's blood alcohol level, collected at the local hospital on March 24, 2024 at 4:15 PM shows, Abnormal: 337 mg/dl (milligrams/deciliter). The report shows the normal/flag reference level is less than 10 mg/dl. On March 24, 2024 at 1:19 PM, V3 (LPN) documented: Resident alert and oriented, signed out the facility this AM at approximately 0914 (9:14 AM). [R2] was encouraged to be cautious while out of the facility since he was involved in an accident just yesterday to what [R2] responded in aggressive manner using profane language. He was noticed to have alcohol breath at the time. At approximately 1420 (2:20 PM) received a call from [local hospital] to notify of [R2] been brought to the ER by [local] paramedics as per ER nurse. [R2] was reported to be sleeping on the grass on the side of the street then found by [local police department] who contacted emergency staff and transported [R2] to the emergency room as reported by ER nurse. [R2] appears alcohol intoxicated on arrival to ER. PCP and POA made aware. On March 23, 2024 at 3:35 PM, V3 (LPN-Licensed Practical Nurse) documented: Resident alert and oriented reported to have been involved on an accident where he was hit by a car at a near intersection, resident refused to provide any information to this writer but states to therapist,, I was hit by a car while I was crossing the street. PCP (Primary Care Physician) and administration informed of the occurrence. MD gave order to send [R2] to the ER for evaluation and treatment. [Ambulance Company] was contacted to transport resident to nearest ER. EMTs (Emergency Medical Technicians) arrived at approximately 3:25 PM but resident refused to be transported at the time and signed a refusal of care form provided by ambulance service. PCP and POA (Power of Attorney) made aware of incident and refusal of care by [R2]. He was up in his wheelchair. He complains of discomfort to left side rib cage. No skin discoloration or any swelling noted to area. The facility does not have documentation to show R2 has a physician's order to consume alcohol. The facility does not have documentation to show R2 was reassessed to be safe in the community without supervision on March 24, 2024, after being hit by a car on March 23, 2024. The facility's Elopement Risk and Community Survival Skills Assessment shows nine community survival skills assessment questions with yes or no answers. The assessment continues to show: Community Survival Skills - If one or more is marked NO then resident is at risk in community and a supervised pass is indicated. R2's quarterly Elopement Risk and Community Survival Skills Assessment, completed by V12 (ADON-Assistant Director of Nursing) on January 26, 2024 shows two of the nine community survival skill questions were answered no. Based on the Elopement Risk and Community Survival Skills Assessment completed on January 26, 2024, R2 did not meet the criteria for independent pass privileges. V12 (ADON) selected, Appears to be capable of outside independent pass privileges at this time. A care plan for outside pass privileges including risk factors for non-compliance for adhering to pass policies and parameters is indicated. The facility does not have documentation to show why R2 received independent pass privileges when he did not meet the criteria for independent pass privileges. The facility does not have documentation to show R2 had another Elopement Risk and Community Survival Skills Assessment completed between January 26, 2024 and March 24, 2024. As of March 24, 2024, the facility did not have documentation to show R2 had a physician's order to leave the facility without supervision. On March 3, 2024 at 5:20 PM, V9 (RN-Registered Nurse) documented, Resident's behavior/mood noted at this shift. Resident's behavior noted as was socially inappropriate.Resident was observed to have alcohol in his possession which rolled out from his jacket, and he appears to be drunk . On January 30, 2024 at 11:00 PM, V3 (LPN) documented, Resident continues to be noted to have strong alcohol breath this evening. He was noticed to be loud while speaking to peers, residents, and staff. On January 25, 2024 at 10:41 AM, V3 (LPN) documented, Resident was witnessed to have alcohol breath and behaving erratically, using profane language towards staff. On January 24, 2024 at 4:09 PM, V10 (RN) documented, Resident alert and oriented, appears intoxicated at this time. Resident has a strong smell of alcohol. Resident asking for alcohol test but this resident knows how to make the result of alcohol test negative. Alcohol serum was ordered STAT by PCP, narcotic medications discontinued. On January 24, 2024 at 3:42 PM, V3 (LPN) documented, Resident alert and oriented was noticed to be verbally aggressive and disruptive after he was made aware PRN (as needed) Norco can't be administered due to apparent alcohol intoxication. [R2] appears to have strong alcohol breath and was noticed to have erratic movements and slurred speech while interacting with staff, very argumentative when questioned as to whatever he is been drinking or not. Verbal education provided in regards of opioids and alcohol interaction to what [R2] responded on a very offensive way towards staff providing education. PCP made aware of behavior and suspects alcohol intoxication. MD gave an order for alcohol serum tomorrow and d/c (discontinue) order for PRN Norco. [R2] had an encounter with MD in which PCP made [R2] known of Norco been d/c. On January 24, 2024 at 2:00 PM, V4 (Physician) documented, Plan: Alcohol intoxication. He claims he does not drink. Last time tricked on alcohol saliva test. Will do blood test. Now he is refusing blood test. On January 23, 2024 at 1:09 PM, V3 (LPN) documented, Resident alert and oriented appears to be argumentative with staff and peer. Resident is demanding to have PRN Norco, but unable to state the origin of his pain. [R2] was made aware his last administration was less than 6 hours ago and he must wait until his next scheduled time, but he will be able to get PRN Tylenol or ibuprofen. [R2] was also noticed to have strong alcohol smell during assessment, but resident denied having drank alcohol. This nurse provided verbal education in regards of risks of mixing opioids and alcohol to what [R2] responded on an aggressive manner, using profane language. PCP made aware of behavior. On January 22, 2024 at 7:15 PM, V3 (LPN) documented, Resident was noticed to have strong alcohol breath, with slurred speech and loud voice, he was noticed to be argumental with peer residents and staff. Resident approached this nurse to request PRN Norco. This nurse verbally educated [R2] on risks of taking opioid medications while alcohol intoxicated, to which [R2] replied, My doctor knows and its okay just give it to me. [R2] was made aware of order been written to hold medication if suspected to be intoxicated. [R2] became angry and started using foul language towards staff. On January 18, 2024 at 11:59 AM, V3 (LPN) documented, Resident was noticed to have alcohol breath, slurred speech, and also appears argumental with peer residents and staff. On January 18, 2024 at 7:30 PM, V9 (RN) documented, Resident appears to be intoxicated, smells like alcohol with slurry speech and talking loudly in the hallway. Insisting to get his Norco pill. Explained to him that writer is unable to give medication for his own safety. Displayed an angry attitude and verbalized, I will call [V4] (Physician), I want to get out of this place. On January 8, 2024 at 11:30 PM, V3 (LPN) documented, Resident was noticed to have alcohol breath and slurred speech. No medication due at this time. On January 3, 2024 at 2:57 PM, V3 (LPN) documented, Resident was noticed to be highly alcohol intoxicated, strong alcohol breath during lunch meal. [R2] was encouraged to stop drinking as is unsafe and he has history of injuries related to alcohol intoxication. Resident denied feeling intoxicated and left the site. On January 3, 2024 at 6:57 PM, V10 (RN) documented, Resident noted to be alcohol intoxicated and has strong alcohol breath before dinner time. Female CNA approached writer that the resident tried to grab her in the dining room. Staff CNA redirected the resident and went away, encouraged to stop drinking as is unsafe and he has history of injuries related to alcohol intoxication. Resident denied feeling intoxicated and got agitated and left. On January 2, 2024 at 11:24 PM, V3 (LPN) documented, Resident was noticed to have strong alcohol breath and acting oddly using profane language to address staff, slurred speech, PCP made aware. R2's care plan for community access, initiated on August 23, 2023, and in effect on March 23 and 24, 2024 shows: Community Access - Independent. Goals: [R2] will be agreeable to access the community under facility policy governing community pass privileges, through next review. Interventions initiated August 23, 2023 show: Explain that receiving and maintaining an on-going pass privilege will be contingent upon compliance with my care/treatment plan. Make sure that I am aware of the rules and regulations associated with accessing to the community and that I understand that access to the community is a privilege which may be revoked at any time due to engaging in prohibited activities and/or behaviors. Obtain a physician's order for outside pass privilege and inform if there have been any restrictions to my community access placed by my physician. The facility's policy entitled Community Pass Guidelines, revised 11-17-17 shows: Purpose: To define the facility and the resident's responsibility when a resident leaves the facility with the consent of the facility. Guidelines: The resident has the right to community access with the consent of the facility and the residents' cooperation with the standards described within. If the resident refuses to adhere to the standards, he or she may be restricted from independent pass privileges. 1. A Community Skills Assessment will be completed by Social Services upon Admission, Quarterly, or as appropriate with changes in cognitive or functional ability. If appropriate, the resident will be given independent community access. 2. The Resident/Representative will be provided with medications and instructions for the duration of the visit. 3. Residents returning from passes that are suspected to be under the influence of alcohol, or illegal drugs will agree to drug testing and/or treatment programming. 4. Residents returning from passes that have resulted in injuries caused by falls, or bruising of unknown origin may have the Overnight Community Passes restricted until the facility reassess the resident's safety in the community. The Immediate Jeopardy that began on March 24, 2024 was removed on April 18, 2024 at 9:07 AM when the facility took the following actions to remove the immediacy: All staff were in-serviced on community pass/Substance abuse policy and signs and symptoms of alcohol and substance abuse. Training included reporting suspected alcohol or substance to the direct supervisor, DON (Director of Nursing), NP, and MD. The in-service was validated with a quiz. Staff that are on FMLA (Family Medical Leave Act) or vacation will receive the in-service prior to returning to work. Any agency staff will receive education prior to start of shift. New hires will receive education during orientation prior to starting on the floor. House-wide community access assessments have been reassessed. Residents with independent access will have corresponding physician orders and corresponding care plan. R2 has been reassessed for community access, and R2's care plan was updated. A new community access will be completed after a resident has a fall or incident in the community. The reassessment will be conducted as soon as the resident returns to the facility. The DON will monitor falls and risk management for compliance. Residents with independent community access have been educated on community access and substance abuse. A QA (Quality Assurance) tool has been implemented to ensure residents have appropriate community access, physician orders, and care plan interventions. The QA tool will be completed five times a week for 1 month, and then weekly for six months. An emergency QAPI (Quality Assurance Performance Improvement) plan was implemented. Any IDT (Interdisciplinary Team) member unavailable will be called via telephone. All staff have had comprehensive community access quiz. Any staff on FMLA or vacation will complete the quiz prior to returning to work. Any agency staff will complete prior to starting their shift. [The facility] out on pass privileges is based on an individual resident-centered care. Any restrictions for a resident that has out on pass privileges is assessed, and care planned on individual needs.

Based on interview and record review, the facility failed to ensure a resident was safely transferred by using a mechanical lift and two staff assistance to prevent injuries. As a result, R1 sustained an acute distal femur fracture and was admitted to the hospital. This applies to 1 of 3 residents (R1) reviewed for safe transfers in the sample of 7 Findings include: On 02/10/2023 at 10:30 AM and 3:30 PM, V2 (Director of Nursing/DON) said R1 uses a mechanical lift with two staff assistance and on 02/08/2023 around 9:00 AM V6 (Certified Nursing Assistant/CNA/Hospice) transferred R1 from wheelchair to shower chair without using a mechanical lift and asking for help. V2 said after the shower, when V6 got R1 back to her room, V6 noticed swelling in R1's knee and reported it to V3 (Registered Nurse/RN). V2 said R1 complained of pain upon assessment and x-ray was taken per the physician's order. R1 had a distal femur fracture per radiology report and was transferred to the hospital for further evaluation. V2 said the hospice provider creates a binder for each resident, and hospice staff is expected to use the binder and sign in and out in the visitation log, which is kept in the binder. On 02/10/2023 at 3:40 PM, V8 (R1's Physician and Medical Director) said a nurse from the facility reported to him that R1 was fine with no new problems and complained of pain after the transfer. V8 said that V6 (CNA) should have used the mechanical lift with two staff assistance to transfer R1. V8 said, The fracture must have happened during the transfer. A review of the face sheet showed that R1 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses including gout, dementia, cerebral atherosclerosis, type 2 diabetes, chronic obstructive pulmonary disease, and an encounter for palliative care. R1's Minimum Data Set, dated dated dated [DATE] showed R1's cognitive abilities were severely impaired, and R1 required a mechanical lift with extensive two assists for transfer. A review of the care plan dated 06/18/2022 and the current care plan showed R1 required a mechanical lift and two staff assistance for transfer. The radiology report dated 02/08/2023 showed R1 had an acute distal femur fracture. R1's care profile in the hospice binder was highlighted for transfer mechanical with two staff assistance under special instructions. The visitation log showed in and out signatures of other hospice staff and was missing V6's signatures. The facility phone investigation report with V6 witnessed by V10 (RN Case Manager-Hospice) showed R1 was calm with no complaints of pain or discomfort and no noticeable swelling upon undressing R1 before the shower. V6 stated in the report, I have been caring for R1 for a long time, and she transfers by herself. On 02/10/2023 at 12:10 PM and 12:28 PM during interview, V4 (CNA) and V3 (RN) said they were assigned to R1 on 12/08/2023. V4 (CNA) arrived to work around 6:00 AM, and R1 was in a wheelchair sitting in the dining room. V4 said after R1's breakfast, she wheeled R1 to her room, and V4 did not notice any distress or no complaint from R1. V3 (RN) said that R1 did not complain of any pain and was not in distress when she made her rounds at 8:00AM. V3 said V6 (CNA) notified her (V3) that R1 had some swelling and asked her to assess R1. V3 said she assessed R1 and R1 told her Dolor meaning pain in Spanish, and R1 had swelling in her right knee. V3 said she notified R1's physician, applied cold compresses, and administered pain medication. V3 said R1 had an acute distal femur fracture after a stat x-ray. V3 and V4 said R1 requires mechanical lift with two staff assist for transfer, and V6 did not call them for assistance. V3 said she was not aware that V6 transferred R1 by herself. On 02/10/2023 at 3:07 PM V6 (CNA) was interviewed in the presence of V9 (Hospice Executive Director/Hospice RN Case Manager). V6 said she was taking care of R1 for a month, twice a week by herself and never used the mechanical lift since she was unaware that R1 needed the mechanical lift and two assistances. V6 said she never knew the facility had a hospice binder for R1. A facility's Transfers - Manual Gait Belt and Mechanical Lift policy included: PURPOSE: To protect staff and residents' safety and wellbeing and promote quality care, this facility will use a mechanical lift for lifting and movements of residents. GUIDELINES: Mechanical lifting devices shall be used for any residents needing two staff assistance or who cannot transfer comfortably and/or safely by normal transfer technique.

Based on observation, interview, and record review, the facility failed to assess and implement interventions to prevent significant weight loss of a resident. This failure resulted in R54 sustaining a significant weight loss of 23 pounds (14.94 percent) over 6 weeks. This applies to 1 of 2 (R54) residents reviewed for weight loss in a total sample of 19 residents. The findings include: R54's EMR (Electronic Medical Record) showed R54 was admitted to the facility from a acute care hospital on July 7, 2022 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R54's MDS (Minimum Data Set) dated July 14, 2022, showed R54's cognition was severely impaired and required limited assistance of facility staff for eating. R54's nutrition care plan, initiated on July 7, 2022, showed R54 had a nutritional problem or a potential nutritional problem secondary to congestive heart failure, heart disease, constipation, [CONDITION(S)], depression, uncontrolled type 2 diabetes mellitus, gastroesophageal reflux disease, 3 strokes, [CONDITION(S)], hypertension, left facial droop, dysphagia (difficulty swallowing), history of [CONDITION(S)], medications which may affect weight/appetite, and nutrition diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R54's nutritional goals initiated on July 13, 2022, included maintaining a stable weight and remaining free of signs and symptoms of dehydration, through the next review. R54's interventions included encouraging oral intake of meals, snacks, and fluids, inviting the resident to activities that promote additional intake, monitor weight as ordered, provide nutritional supplement as ordered, and provide and serve diet as ordered, as well as monitoring the intake and recording every meal. The care plan did not show any additional interventions added from July 14, 2022 through August 31, 2022. On August 29, 2022, at 11:25 AM, R54 was lying in bed in a hospital gown. R54 appeared thin. On August 30, 2022, at 12:49 PM, R54 was sitting in his wheelchair in his room eating lunch without the assistance of facility staff. R54's clothes appeared to be loose fitting. R54's right hand was shaking, and food was falling off his plate, and onto the floor. On August 31, 2022, at 11:19 AM, R54 said, I did lose a lot of weight. It's hard to eat this food because I don't like the food. R54's EMR showed R54 had the following weights: On July 7, 2022, 154 pounds; On August 16, 2022, 131 pounds; On August 26, 2022, 139.8 pounds; On August 31, 2022, 139 pounds. The Nutrition Progress Note dated August 19, 2022, at 1:17 PM, by V5 (Dietician) showed R54's current body weight was 131 pounds, indicating a 14.9 percent weight loss in a month. Reweigh requested. Nursing, DON, and administrator notified. Dietitian to follow as needed. The facility does not have documentation to show R54 was weighed from July 8, 2022, through August 15, 2022. The facility does not have documentation to show a reweigh was obtained within 72 hours of the significant weight loss identified on August 16, 2022. The facility does not have documentation to show R54 was reweighed the day after the weight was obtained on August 16, 2022, which showed a significant weight loss. The facility does not have documentation to show the doctor or nurse practitioner was notified of the significant weight loss. On August 31, 2022, at 12:02 PM, V5 (Dietician) said, When a reweigh is requested, it should be completed within 48 hours. R54 did have a significant weight loss. I did not add any interventions after his significant weight loss was identified in August. On August 31, 2022, at 12:46 PM, V11 (NP/Nurse Practitioner) said, I was first notified of the weight loss on August 31, 2022, and I ordered labs. I should have been notified of the significant weight loss within 24 hours. If I was notified sooner, I would have ordered labs earlier and consulted with psychiatry about [R54]'s weight loss to potentially start another antidepressant as an appetite stimulant. On August 31, 2022, at 09:10 AM, V2 (DON/Director of Nursing) said, Residents are weighed monthly during the first week of the month. If there is a discrepancy in a resident's weight, we need to reweigh them. The dietician will email me if a resident needs to be reweighed and I will notify the nurse. The nurse notifies the doctor or nurse practitioner of significant weight loss. On August 31, 2022, at 01:13 PM, V2 said, A CNA (Certified Nurse Assistant) weighed the resident on August 26, 2022 but did not chart or report to anybody until today. The CNA should have notified and charted the weight immediately. The weight was charted today as a late entry. The Initial Nutrition assessment dated [DATE], at 10:05 AM, by V5 (Dietician) showed a nutritional risk score of 15, indicating R54 is at a high nutritional risk. The assessment continued to show a 7.9 percent weight loss over one month. Differences in scales (in-house versus hospital), prior limited access to food, recent hospitalization , history of [CONDITION(S)], and current suspected inadequate oral intake may cause/contribute to weight changes. The assessment continued to show the following weight history for R54 from the hospital referral document: On June 15, 2022, 158.4 pounds; On June 14, 2022, 159.5 pounds; On June 13, 2022, 162.8 pounds; On June 12, 2022, 159.5 pounds; On June 11, 2022, 160.6 pounds; On June 9, 2022, 159.5 pounds; On June 8, 2022, 165 pounds; On June 7, 2022, 167.2 pounds; On June 6, 2022, 162.8 pounds. On June 5, 2022, 163.9 pounds; On June 4, 2022, 163.9 pounds; On June 3, 2022, 160.6 pounds; On June 1, 2022, 168.3 pounds; On May 31, 2022, 164.8 pounds. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . V11's note did not show R54 had weight loss. The facility does not have documentation to show R54 had [CONDITION(S)] for the period of his admission on July 7, 2022 to August 31, 2022. R54's July and August 2022 MAR (Medication Administration Record) did not show R54 had received a diuretic. The facility policy titled Weights revised on October 17, 2019, showed, Guidelines: .2. Residents identified at nutritional risk may be weighed weekly or bi-weekly as per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Re-weight should be obtained if there is a difference of five pounds or greater (loss or gain) since previous recorded weight. 4. Re-weight should be taken as soon as possible after an unanticipated weight change is noted and prior to calling the physician. (Usually within 72 hours). 5. Efforts should be made to obtain all weights and re-weighs by the 10th of each month. 6. Undesired or unanticipated weight gains/loss of five percent in 30 days, 7.5 percent in three months, or 10 percent in six months shall be reported to the physician, dietician and/or dietary manager as appropriate. The facility provided manual titled Guideline and Procedure Manual for Long Term Care Foodservice 2020 Edition, showed: Weight Assessment and Intervention: Guideline: Weights are monitored monthly or more often as recommended by the interdisciplinary care team. The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Weight data will be used as one step in determining if changes to the nutritional plan of care are needed to prevent or slow unintentional weight loss within the limits of the resident's clinical condition. Policy information is based on 2017 Centers for Medicare and Medicaid Services (CMS) Guidelines State Operations Manual Appendix PP- F692. Procedure: 1. Nursing staff will record the resident weight the day they move in, the next day, and once a week for four weeks thereafter to establish a base weight and stability of weights. If no weight concerns are noted, the resident's weight will be recorded monthly thereafter or as indicated by the interdisciplinary care team . 4. Any weight change of five percent or more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, registered dietitian, dining services manager, or other members of the interdisciplinary team within 24 hours. Verbal notification must be confirmed in writing. The facility policy titled Physician-Family Notification- Change in Condition revised on November 13, 2018, showed, (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).

Based on observation, interview and record review, the facility failed to investigate and report to the State survey agency an allegation of staff to resident abuse immediately. The facility failed to ensure that the resident was not exposed to further abuse while the investigation was in progress and the facility failed to have evidence that all allegations of abuse are investigated. This applies to one of four residents (R4) reviewed for abuse in the sample of four. This has the potential to affect all of the 82 residents currently residing in the facility per the facility data sheet. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begun on 6-19-14 when R4 reported to E4 (Occupational Therapist) an allegation of abuse. E2 (Director of Nursing) was informed of the Immediate Jeopardy on 7-8-14 at 2:00pm and the acting administrator (E10) was informed of the Immediate Jeopardy on 7-8-14 at 2:30pm. While the Immediacy was removed on 7-9-14 at 4:00pm, the facility remains out of compliance at a level 2 due to need to evaluate the effectiveness of corrective measures put in place, the need to complete the in-servicing plan, and to monitor and evaluate the effectiveness of the abuse prevention program. The findings include: According to the Admission Record form, R4 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. On 7/1/14 at 12:20 PM in the main dining room, R4 said she informed staff of sexual harassment from E1 (Administrator). On 7/1/14 at 3:00 PM, E2 (Director of Nursing/DON) was asked about the allegation of sexual harassment. E2 said she was not informed of this allegation and no investigation was done. E2 said E1 is the abuse coordinator. On 7/2/14 at 1:50 PM, E4 (Occupational Therapy Assistant/OT) said that in mid-June 2014 in mid-week, he was doing therapy and saw E1 on the exercise bicycle in the therapy room. E4 said R4 was next to the bicycle and heard E1 and R4 singing. E4 said that on the following day, R4 told E4 that E1 said something sexual to her. R4 reported that E1 told her, "Do you know what you need, you need a good screw." E4 said he did not hear the conversation between E1 and R4 because he was providing therapy to another resident. E4 said E5 (Physical Therapy Assistant/PT) was also in the room. E4 said he reported this allegation verbally to E2 (DON) and E7 (Care Plan Coordinator) on the same day that R4 made the allegation. On 7/2/14 at 2:00 PM, E5 (PT) said she saw E1 on the bike doing exercise and R4 was in her wheelchair in the therapy room beside E1, and heard both of them singing. E5 said this struck her as looking out of ordinary. E5 said she did not hear the conversation between them as she was doing paperwork. E5 said she remembered R4 leaving the room in a huff. E5 said that on the following day, E4 told her of R4's sexual allegation towards E1. E5 said she remembers that R4 was very quiet but appeared disturbed on the day R4 made the report to E4. E5 said E1's behavior had changed in the past 6-8 weeks trying to push residents beyond their abilities and was shouting profanities during a staff meeting. On 7/2/14 at 2:20 PM, E6 (Social Service Director) said R4 did not report to her the sexual allegation. E6 said that on 7/1/14, she discussed with E2 and E3 (Psychosocial Rehab Coordinator) the allegation. E6 said she was informed during the discussion that E4 reported that E1 asked her, "Do you know what you need, and you need to sing." E1 also asked R4 "when was the last time she got layed." E6 said she reported the allegation to the Ombudsman. E6 said E1's behavior has changed in the past two weeks and had become verbally abusive towards staff. E6 said she would like the resident and staff to be treated with dignity. On 7/2/14 at 1:20 PM, E2 said that she brought to E7's (Care Plan Coordinator) attention the sexual allegation as written report and E7 gave the letter to E1. On 7/3/14 at 2:35 PM, E2 said no letter was given to her regarding sexual allegation. E2 said she saw E1 sitting on the exercise bicycle but cannot recall the date. On 7/2/14 at 1:25 PM, E7 (Care Plan Coordinator) said she heard rumors about E1 and R4. E7 said R4 gave her a letter on 6/30/14 complaining about a nurse but did not report sexual allegation. E7 said she gave the original letter to E1 and a copy to E2. On 7/2/14 at 12:50 PM, R4 said, E1 was on the exercise bike and asked her if she walked yet and if she used the manual wheelchair. E1 asked, "Do you sing? Well then sing for me." R4 said she sang Puff the Magic Dragon. E1 then said, "Do you know what you need, a good screw. How long has it been?" R4 in turn asked E1, "How long has it been for you?" E1 responded, "Oh a couple of days." R4 said the conversation made her "feel like in the past, that she was bad and had a dirty feeling because of history of sexual abuse." R4 said she reported this incident to E5. R4 said that on 7/1/14, E3 (Psychosocial Rehab Coordinator) and E6 interviewed her regarding the incident. R4 said that on 7/1/14 E1 went to her room and told her, "How dare she report him to State." On 7/2/14 at 2:50 PM during interview with R2 in their room, R4 said she was in the bathroom sitting on the toilet with her pants down to her ankles when he asked her this. R4 said this happened on 6/18/14. R4's Psychiatric Evaluation on 3/25/14 of mental status showed R4 is oriented times 4 to time, place, person, and situation. R4's BIMS (Brief Interview for Mental Status) on assessment reference date of 5/18/14 and 6/17/14 both showed summary score of 15 interpreted as cognitively intact. R4's MDS (Minimum Data Set) quarterly assessment on 6/17/14 was coded 0 (behavior not exhibited). Z3 (Nurse Practitioner) stated during phone interview of 7-10-14 at 1:10pm that R4 is alert and orientated times four with no dementia and no memory loss. On 7/2/14 at 2:50 PM, R2 (R4's roommate) said that on 7/1/14 at approximately 4:30 PM, E1 knocked on their door. R2 told E1 not to come in because R4 was in the bathroom. R2 said E1 still walked in the room. R2 said R4 was sitting on the toilet with the door open. E1 stood behind R4's bedside table aligned with the doorway of the bathroom. E1 peered in at R4 sitting on the toilet and asked, "Where are my headphones?" "How did you have the nerve to report me? It didn't happen." R2 said E1 then took the box for the headphones on top of the TV and left the room. R2's admission MDS on 6/16/14 showed a BIMS score of 15 interpreted as cognitively intact. The Social Services Admission Note on 6/9/14 showed R2 is alert and oriented times 3 and able verbalize self needs known. On 7/9/14 at 12:50 PM, R4 said that on the same day that she gave a letter to E2 and E7 regarding her complaint about a nurse, she also gave a letter to them about her allegation of sexual harassment from E1. R4 said both E2 and E7 said they cannot find the letter regarding her allegation on E1 and only had the letter about the nurse. R4 said that on 7/1/14 when E1 came to her room, E1 took the connector to the television and headset. R4 said the headset was just hooked up a couple of hours prior to E1 taking it back, R4 said she now gave back the headset to staff since she cannot use it without the connector. R4 said she has not discussed with the facility staff her history of sexual abuse because it gives her "creepy feelings" and just want to "put it away." On 7/2/14 in the morning, E2 was asked if investigation was started regarding the allegation. E2 said R4 was interviewed and that the investigation was ongoing and E2 said E1 has been placed on administrative leave on 7/2/14. The start of the investigation was not until 7-1-14, several weeks after R4 had initially reported the allegations. The allegation was neither promptly reported or investigated by the facility. On 7/2/14 at 10:00 AM, E1 was still at the facility. E1 explained his goals for the residents in the facility. E1 said he heard of the allegation made by R4 and denied the allegation. E1 asked if he needed to be suspended. During this interview, E1 received a call and said he had been suspended. E1 was not physically removed from the facility until 7-2-14 and continued to have contact with the residents. The facility policy titled, "Abuse Prevention Program Facility Procedures" requires, "Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator, or an immediate supervisor who must then report it to the administrator."..."If mistreatment has occurred, the resident's representative and the Department of Public Health shall be informed as soon as possible within 24 hours. Through observations, interviews and record review the survey team confirmed that the facility took the following steps to remove the immediacy: 1. E1 was removed from resident contact on 7-2 and remains on administrative leave. An acting administrator was appointed to take over the duties. 2. The facility submitted an addendum to the abuse policy to cover abuse allegations when the administrator cannot coordinate the abuse investigation. In the absence of the administrator, the role will be performed by E10 (owner/licensed administrator) or another member of the ownership team or Director of Nursing. This was approved by the medical director and acting administrator, E10. 3. The facility policy was revised to include staff responsibility to report any and all abuse allegations to their supervisor, directly to the administrator, Director of Nursing, and or abuse coordinator. This was approved by the medical director and acting administrator. 4. The facility policy was revised to include that any management team or ownership team who informed of the abuse allegation shall follow the same procedure as the administrator or abuse coordinator as per policy. The individual being informed of the abuse allegation shall advise the administrator, DON, or Abuse coordinator immediately. This was approved by the medical director and acting administrator. 5. Staff will be provided training on the abuse policy and the revised policy. Staff not on duty 7-8 and 7-9 will be trained on the abuse policy prior to working on the unit. 6. Additional training of abuse policy and procedure will be scheduled quarterly and when it is necessary starting July 8, 2014. All new staff will be provided training on abuse as part of new orientation process. 7. The QA committee will review all abuse allegations at the monthly meeting along with any corrective action plans. 8. The DON and Social Service Director will continue to make daily rounds, talk to residents about feelings and how residents can report abuse. 9. The facility held an emergency QA meeting on July 9, 2014. The medical director was not able to attend, however the information presented during the meeting was presented to the medical director. 10. The guardian angel program was presented at the QA meeting 7-9-14 and will be used as a tool to reach every single resident. Completion date: July 9, 2014 and ongoing.

Based on observation, interview and record review, the facility failed to follow their abuse prevention policy by not reporting and investigating an abuse allegation immediately and failed to immediately remove the accused from contact with the resident involved in the investigation. This resulted in the facility failing to investigate all allegations of abuse reported by R4 and failing to remove the suspected staff from contact with R4 and all other residents in the facility. This has the potential to affect all of the 82 residents currently residing in the facility. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begun on 6-19-14 when R4 reported to E4 (Occupational Therapist Assistant) an allegation of abuse. E2 (Director of Nursing) was informed of the Immediate Jeopardy on 7-8-14 at 2:00pm and the acting administrator (E10) was informed of the Immediate Jeopardy on 7-8-14 at 2:30pm. While the Immediacy was removed on 7-9-14 at 4:00pm, the facility remains out of compliance at a level 2 due to need to evaluate the effectiveness of corrective measures put in place, the need to complete the in-servicing plan, and to monitor and evaluate the effectiveness of the abuse prevention program. The findings include: According to the Admission Record form, R4 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. On 7/1/14 at 12:20 PM in the main dining room, R4 said she informed staff of sexual harassment from E1 (Administrator). On 7/1/14 at 3:00 PM, E2 (Director of Nursing/DON) was asked about the allegation of sexual harassment. E2 said she was not informed of this allegation and no investigation was done. E2 said E1 is the abuse coordinator. On 7/2/14 at 1:50 PM, E4 (Occupational Therapy Assistant/OT) said that in mid June 2014 in mid-week, R4 told him that E1 said something sexual to her. E4 said he reported this allegation verbally to E2 (DON) and E7 (Care Plan Coordinator) on the same day that R4 made the allegation. On 7/2/14 at 2:00 PM, E5 (Physical Therapy Assistant/PT) said E4 told her of R4's sexual allegation towards E1 the day after the incident occurred. On 7/2/14 at 2:20 PM, E6 (Social Service Director) said she heard the sexual allegation on 7/1/14 and discussed it with E2 (DON) and E3 (Psychosocial Rehab Director). E6 said she reported the allegation to the Ombudsman. On 7/2/14 at 1:25 PM, E7 (Care Plan Coordinator) said she heard rumors about E1 and R4. On 7/2/14 at 12:50 PM, R4 said she reported the sexual allegation to E4 the day after it happened on 6/18/14. No documentation was found regarding the allegation and staff members who were interviewed could not provide written documentation as evidence that the facility's abuse policy was followed. On 7/2/14 in the morning, E2 was asked if investigation was started regarding the allegation. E2 said R4 was interviewed and that the investigation was ongoing. E2 said E1 has been placed on administrative leave on 7/2/14. The witness statement form showed that R4 was interviewed on 7/1/14. It documented that R4 reported that E1 asked R4, "You know what you need," to which R4 replied, "What a good screw?" E1 replied, "Yes, how long has it been?" R4 said, "I don't know, how long has it been for you?" E1 replied, "About 2 days." On 7/2/14 at 10:00 AM, E1 was still at the facility. E1 explained his goals for the residents in the facility. E1 said he heard of the allegation made by R4 and denied the allegation. E1 asked if he needed to be suspended. During this interview, E1 received a call and said he had been suspended. The facility policy titled, "Abuse Prevention Program Facility Procedures" requires, "Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator, or an immediate supervisor who must then report it to the administrator."..."Employees of this facility who have been accused of abuse, neglect or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee." Through observations, interviews and record review the survey team confirmed that the facility took the following steps to remove the immediacy: 1. E1 was removed from resident contact on 7-2 and remains on administrative leave. An acting administrator was appointed to take over the duties. 2. The facility submitted an addendum to the abuse policy to cover abuse allegations when the administrator cannot coordinate the abuse investigation. In the absence of the administrator, the role will be performed by E10 (owner/licensed administrator) or another member of the ownership team or Director of Nursing. This was approved by the medical director and acting administrator, E10. 3. The facility policy was revised to include staff responsibility to report any and all abuse allegations to their supervisor, directly to the administrator, Director of Nursing, and or abuse coordinator. This was approved by the medical director and acting administrator. 4. The facility policy was revised to include that any management team or ownership team who informed of the abuse allegation shall follow the same procedure as the administrator or abuse coordinator as per policy. The individual being informed of the abuse allegation shall advise the administrator, DON, or Abuse coordinator immediately. This was approved by the medical director and acting administrator. 5. Staff will be provided training on the abuse policy and the revised policy. Staff not on duty 7-8 and 7-9 will be trained on the abuse policy prior to working on the unit. 6. Additional training of abuse policy and procedure will be scheduled quarterly and when it is necessary starting July 8, 2014. All new staff will be provided training on abuse as part of new orientation process. 7. The QA committee will review all abuse allegations at the monthly meeting along with any corrective action plans. 8. The DON and Social Service Director will continue to make daily rounds, talk to residents about feelings and how residents can report abuse. 9. The facility held an emergency QA meeting on July 9, 2014. The medical director was not able to attend, however the information presented during the meeting was presented to the medical director. 10. The guardian angel program was presented at the QA meeting 7-9-14 and will be used as a tool to reach every single resident. Completion date: July 9, 2014 and ongoing.

Based on interviews and record review, the facility failed to keep one resident safe from abuse and failed to follow their abuse prevention policy by not reporting and investigating an abuse allegation immediately and failed to immediately remove the accused from contact with the resident involved in the investigation. This resulted in R4 having continued exposure to accused staff member for fourteen days after an allegation was made by R4. This applies to one resident of four (R4) reviewed for abuse. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begun on 6-19-14 when R4 reported to E4 (Occupational Therapist Assistant) an allegation of abuse. E2 (Director of Nursing) was informed of the Immediate Jeopardy on 7-8-14 at 2:00pm and the acting administrator (E10) was informed of the Immediate Jeopardy on 7-8-14 at 2:30pm. While the Immediacy was removed on 7-9-14 at 4:00pm, the facility remains out of compliance at a level 2 due to need to evaluate the effectiveness of corrective measures put in place, the need to complete the in-servicing plan, and to monitor and evaluate the effectiveness of the abuse prevention program. The findings include: According to the Admission Record form, R4 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. On 7/1/14 at 12:20 PM in the main dining room, R4 said she informed staff of sexual harassment from E1 (Administrator). On 7/1/14 at 3:00 PM, E2 (Director of Nursing/DON) was asked about the allegation of sexual harassment. E2 said she was not informed of this allegation and no investigation was done. E2 said E1 is the abuse coordinator. On 7/2/14 at 1:50 PM, E4 (Occupational Therapy Assistant/OT) said that in mid June 2014 in mid-week, R4 told him that E1 said something sexual to her. E4 said he reported this allegation verbally to E2 (DON) and E7 (Care Plan Coordinator) on the same day that R4 made the allegation. On 7/2/14 at 2:00 PM, E5 (Physical Therapy Assistant/PT) said E4 told her of R4's sexual allegation towards E1 the day after the incident occurred. On 7/2/14 at 2:20 PM, E6 (Social Service Director) said she heard the sexual allegation on 7/1/14 and discussed it with E2 (DON) and E3 (Psychosocial Rehab Director). E6 said she reported the allegation to the Ombudsman. On 7/2/14 at 1:25 PM, E7 (Care Plan Coordinator) said she heard rumors about E1 and R4. On 7/2/14 at 12:50 PM, R4 said she reported the sexual allegation to E4 the day after it happened on 6/18/14. No documentation was found regarding the allegation and staff members who were interviewed could not provide written documentation as evidence that the facility's abuse policy was followed. On 7/2/14 in the morning, E2 was asked if investigation was started regarding the allegation. E2 said R4 was interviewed and that the investigation was ongoing. E2 said E1 has been placed on administrative leave on 7/2/14. On 7/2/14 at 1:20 PM, E2 said that she brought to E7's (Care Plan Coordinator) attention the sexual allegation as written report and E7 gave the letter to E1. On 7/3/14 at 2:35 PM, E2 said no letter was given to her regarding sexual allegation. E2 said she saw E1 sitting on the exercise bicycle but cannot recall the date. On 7/2/14 at 1:25 PM, E7 (Care Plan Coordinator) said she heard rumors about E1 and R4. E7 said R4 gave her a letter on 6/30/14 complaining about a nurse but did not report sexual allegation. E7 said she gave the original letter to E1 and a copy to E2. On 7/2/14 at 12:50 PM, R4 said, E1 was on the exercise bike and asked her if she walked yet and if she used the manual wheelchair. E1 asked, "Do you sing? Well then sing for me." R4 said she sang Puff the Magic Dragon. E1 then said, "Do you know what you need, a good screw. How long has it been?" R4 in turn asked E1, "How long has it been for you?" E1 responded, "Oh a couple of days." R4 said the conversation made her "feel like in the past, that she was bad and had a dirty feeling because of history of sexual abuse." R4 said she reported this incident to E5. R4 said that on 7/1/14, E3 (Psychosocial Rehab Coordinator) and E6 interviewed her regarding the incident. R4 said that on 7/1/14 E1 went to her room and told her, "How dare she report him to State." On 7/2/14 at 2:50 PM during interview with R2 in their room, R4 said she was in the bathroom sitting on the toilet with her pants down to her ankles when he asked her this. R4 said this happened on 6/18/14. On 7/9/14 at 12:50 PM, R4 said that on the same day that she gave a letter to E2 and E7 regarding her complaint about a nurse, she also gave a letter to them about her allegation of sexual harassment from E1. R4 said both E2 and E7 said they cannot find the letter regarding her allegation on E1 and only had the letter about the nurse. R4 said that on 7/1/14 when E1 came to her room, E1 took the connector to the television and headset. R4 said the headset was just hooked up a couple of hours prior to E1 taking it back, R4 said she now gave back the headset to staff since she cannot use it without the connector. R4 said she has not discussed with the facility staff her history of sexual abuse because it gives her "creepy feelings" and just want to "put it away." On 7/2/14 at 2:50 PM, R2 (R4's roommate) said that on 7/1/14 at approximately 4:30 PM, E1 knocked on their door. R2 told E1 not to come in because R4 was in the bathroom. R2 said E1 still walked in the room. R2 said R4 was sitting on the toilet with the door open. E1 stood behind R4's bedside table aligned with the doorway of the bathroom. E1 peered in at R4 sitting on the toilet and asked, "Where are my headphones?" "How did you have the nerve to report me? It didn't happen." R2 said E1 then took the box for the headphones on top of the TV and left the room. R4's Psychiatric Evaluation on 3/25/14 of mental status showed R4 is oriented times 4 to time, place, person, and situation. R4's BIMS (Brief Interview for Mental Status) on assessment reference date of 5/18/14 and 6/17/14 both showed summary score of 15 interpreted as cognitively intact. R4's MDS (Minimum Data Set) quarterly assessment on 6/17/14 was coded 0 (behavior not exhibited). Z3 (Nurse Practitioner) stated during phone interview of 7-10-14 at 1:10pm that R4 is alert and orientated times four with no dementia and no memory loss. On 7/2/14 in the morning, E2 was asked if investigation was started regarding the allegation. E2 said R4 was interviewed and that the investigation was ongoing and E2 said E1 has been placed on administrative leave on 7/2/14. The start of the investigation was not until 7-1-14, several weeks after R4 had initially reported the allegations. The allegation was neither promptly reported or investigated by the facility. On 7/2/14 at 12:50 PM, R4 said she reported the sexual allegation to E4 the day after it happened on 6/18/14 and yet E1 was not removed from contact with R4 or other residents until July 2, 2014, 14 days after the alleged abuse occurred. On 7/2/14 at 10:00 AM, E1 was still at the facility and was observed in the facility by the survey team. E1 said he heard of the allegation made by R4 and denied the allegation. E1 asked if he needed to be suspended. During this interview, E1 received a call and said he had been suspended and then left the facility. The facility policy titled, "Abuse Prevention Program Facility Procedures" requires, "Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator, or an immediate supervisor who must then report it to the administrator."..."Employees of this facility who have been accused of abuse, neglect or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee." Through observations, interviews and record review the survey team confirmed that the facility took the following steps to remove the immediacy: 1. E1 was removed from resident contact on 7-2 and remains on administrative leave. An acting administrator was appointed to take over the duties. 2. The facility submitted an addendum to the abuse policy to cover abuse allegations when the administrator cannot coordinate the abuse investigation. In the absence of the administrator, the role will be performed by E10 (owner/licensed administrator) or another member of the ownership team or Director of Nursing. This was approved by the medical director and acting administrator, E10. 3. The facility policy was revised to include staff responsibility to report any and all abuse allegations to their supervisor, directly to the administrator, Director of Nursing, and or abuse coordinator. This was approved by the medical director and acting administrator. 4. The facility policy was revised to include that any management team or ownership team who informed of the abuse allegation shall follow the same procedure as the administrator or abuse coordinator as per policy. The individual being informed of the abuse allegation shall advise the administrator, DON, or Abuse coordinator immediately. This was approved by the medical director and acting administrator. 5. Staff will be provided training on the abuse policy and the revised policy. Staff not on duty 7-8 and 7-9 will be trained on the abuse policy prior to working on the unit. 6. Additional training of abuse policy and procedure will be scheduled quarterly and when it is necessary starting July 8, 2014. All new staff will be provided training on abuse as part of new orientation process. 7. The QA committee will review all abuse allegations at the monthly meeting along with any corrective action plans. 8. The DON and Social Service Director will continue to make daily rounds, talk to residents about feelings and how residents can report abuse. 9. The facility held an emergency QA meeting on July 9, 2014. The medical director was not able to attend, however the information presented during the meeting was presented to the medical director. 10. The guardian angel program was presented at the QA meeting 7-9-14 and will be used as a tool to reach every single resident. Completion date: July 9, 2014 and ongoing.

Based on observation, interview and record review, the facility failed to implement preventative measures and follow physician's orders for pressure ulcer treatment to prevent new wounds from developing and promote healing of existing wounds, failed to notify the physician of resident refusal of preventative measures, failed to provide wound and incontinence care to prevent infection of wounds, and failed to reassess and update the treatment plan for changes in wounds and when new wounds were noted for two (R2 and R1) out of 3 residents reviewed for pressure ulcers from a total sample of 18. This failure resulted in R2 developing an unstageable pressure ulcer on the right heel and R1 developing an unstageable infected pressure ulcer on the coccyx/sacrum. E2 (Director of Nursing) and E3 (MDS -Minimum Data Set-Nurse) were informed of the Immediate Jeopardy on 3-11-14 at 4:30pm, in the facility's conference room. E1 (Administrator) was notified at 7:30pm on 3-11-14. The Immediate Jeopardy began on 2/19/2014 when R2 developed and unstageable pressure ulcer on the right heel. Immediacy was removed on 3/12/2014 at 6:00pm. The facility remains out of compliance at a level 2 due to need to evaluate the effectiveness of corrective measures put in place, the need to complete the in-servicing plan, and to monitor and evaluate the effectiveness of the wound and skin program changes. The findings include: 1) The face sheet admission record showed that R2 was originally admitted to the facility on [DATE]. The POS (Physician Order Sheet) dated 3/2014 showed R2's [DIAGNOSES REDACTED]. The " Infectious Disease and Wound Specialist " progress notes dated 3/14/2013 showed that R2 was assessed with [REDACTED]. The progress notes also showed that R2's right heel wound had healed on 8/16/2012. The left ischium wound measurements were 0.3 cm for length, 0.4 for width, and 1.9 cm for depth. The plan was to protect right heel with heel suspension orthotic boot and to lubricate the skin. The Braden Scale pressure sore skin assessment dated [DATE] showed that R2 was a high risk for pressure ulcer. The " Wound Care Specialist Evaluation " dated 2/20/2014 showed that R2 has the following pressure ulcers with interventions and assessment as follows: - A stage 4 pressure ulcer of the left ischium. The ulcer was described with light serous exudate and measurements were 0.2 cm. in length; 0.8 cm. in width; 1.2 cm. in depth; undermining at 1.1 cm. at 7 o ' clock. - An Unstageable pressure ulcer described as necrotic on the right heel. The pressure ulcer measurements were 0.4 cm in length; 0.3 cm. in width; and a not measurable depth. The right heel unstageable pressure ulcer was acquired at the facility on 2/19/2014. - The Plan Intervention for the pressure ulcers were pressure reduction in chair and in bed and float heels to off load pressure. - R2 was assessed as oriented times 3 (person, place and situation) with mood and affect to be calm and cooperative. The POS (Physician order Sheet) dated 3/2014 showed treatment orders dated 2/20/2014 as follows: 1) " Cleanse left ischium stage 4 with normal saline, apply [MEDICATION NAME] Alginate dressing then cover with dry dressing and change daily (scheduled for 11:00P.M.-7 A.M. shift) and as needed. " 2) " Paint right heel with [MEDICATION NAME] then cover with dry dressing daily (scheduled for 11P.M.-7:00 A.M. shift) and change as needed. " On 3/10/2014 at 3:00 P.M., 3:15 P.M., 4:30 P.M., 5:05 P.M. and 5:30 P.M., R2 was lying on his left side facing window. R2 remained on the same position during these observations. Upon prompting, E6 (Wound Treatment Nurse), E31 (Licensed Practical Nurse) and E27(Nurse Aid) assisted to do skin check for R2 at 5:30 P.M. R2 was without heel suspension or a heel protector to off-load pressure from the heels. E27 and E31 stated they were not aware that R2 was supposed to have heel suspension boots or heel protector. R2 was also noted with a disposable brief and an incontinent cloth pad and a sheet on a low air low mattress. R2 was urine soaked. The absorbent padding from the brief had turned into a gel like consistency due to heavy saturation of urine. It was also noted that the urine had leaked through the brief onto the incontinent cloth pad. Redness and excoriation to the scrotal area was also noted. R2 was observed with soft stool smeared throughout the rectal /buttocks, scrotal and groin area. There was no dressing on the left ischium pressure ulcer. There was also stool around the opening of the pressure ulcer on left ischium. E27 (Nurse Aid) stated that there was no dressing in placed on R2' s left ischium pressure ulcer when E27 changed R2's incontinent brief at 2:00pm and at 4:00 P.M. E27 stated that she had informed an unidentified staff at 2:00 P.M. when E27 found out that there was no dressing on the left ischium pressure ulcer. E27 also added that she should have increased the frequency of changing R2's incontinent brief to keep him clean and dry. E31, (the nurse in charge of R2 from day and evening shift of 3/10/2014) had stated that he was not aware that R2 ' s dressing was off. E6 stated that she does not do the daily dressing change and only does the dressing change once a week to evaluate the existing and new wounds. After the incontinence care, E6 with assistance from E31 and E27 had proceeded with pressure ulcer dressing change. During this observation, the unstageable pressure ulcer on the right heel had a dry dressing with a label date of " 3/7 " (this was 2 days prior to date of observation on 3-10). Observation of wound care indicated that infection control was not maintained. Cross contamination from dirty to clean and clean to dirty was noted. E6 had prepared the wound supplies onto the treatment tray and failed to observed possible cross contamination during the preparation. E6 had also used same gloves to open multiple single pack of dressing supplies and the application of these supplies for pressure ulcer treatment. E27 also had failed to wash hands after removal of soiled gloves and prior to donning new pair when she provided the incontinence care prior to dressing change. R2 was not maintained to be clean and dry from bowel and bladder incontinence to prevent cross contamination and development of wound infection. The TAR (Treatment Administration Record) dated 3/2014 documented that the treatment for [REDACTED]. The right heel treatment was also not signed as given on 3/9/2014, but was signed on 3/8/2014. This was contradictory to the observation made on 3/10/2014 that the right heel dressing had a date labeled 3/7/2014 as the last dressing changed. On 3/13/2014 at 11:30 A.M., E33 (Licensed Practical Nurse- the nurse assigned on 3/8 and 3/9/2014 for 11 P.M.-7 A.M. shift) stated during interview that she does not remember if she changed the dressing on the left ischium on 3/9/2014. However, E33 had stated that it is the facility's practice and policy to sign the TAR when treatment was given. E33 also added that she did not change R2's right heel pressure ulcer dressing on 3/8 and 3/9/2014. E33 also added that though, she had signed the TAR on 3/8/2014 that the right heel dressing was changed, E33 stated that she made a mistake and thought that she was signing the left ischium dressing. This was an indication that physician orders for treatment of [REDACTED]. R2 right heel dressing was not changed for 2 days and left ischium dressing was not changed for 1 day. On 3/10/2014 at 10:15 A.M. and at 12:45 P.M., R2 was seated in his wheelchair that has a foam cushion. R2 was also noted to be wearing shoes while up in a chair. On 3/11/2014 at 9:30 A.M. and at 11:30 A.M., R2 was observed sitting in his wheelchair with the same foam cushion. Again R2 was wearing shoes that were in contact with his heels. R2 stated that it was his preference to be up at 5:00 A.M. daily, but staff put him back to bed after lunch around 1 to 2:00 P.M. R2 also added that he just sits in his wheelchair for duration of 8-9 hours. R2 also added that staff does not lift him up from his wheelchair while he was seated. This was an 8-9 hours prolonged sitting with a resident who is a high risk of pressure ulcer and had an existing stage 4 pressure ulcer on the ischium area without pressure relief. On 3/11/2014 at 1:30 P.M., R2 was in bed. R2 was not wearing a heel suspension nor were his heels off loaded from pressure. E23 (Licensed practical Nurse) and E32 (Nurse Aid) was in R2's room and stated that they were not aware that R2's heels was supposed to have his heels offloaded nor was aware of the heel suspension. E32 added that R2 was not being reposition while seated in his wheelchair because R2 uses a mechanical lift for transfer. On 3/11/2014 at 12:30 P.M., Z1 (Wound physician specialist) during interview stated that R2 should be turned and repositioned at a minimum of at least every 2 hours to off load pressure from the identified pressure ulcers and other parts of bony prominence. Z1 also added that prolonged sitting was not appropriate for R2 and that an air or gel cushion was the appropriate pressure relieving device for seat cushion. Z1 also added that R2's pressure dressing should have been intact at all times and change as ordered, otherwise infection could happen. Z1 also added that R2 should be off from pressure on his heels and therefore shoes was not recommended but instead a heel protector and heel suspension while in bed was appropriate measures. The " Wound Care Specialist Evaluation " dated 3/13/2014, (a note from Z1) showed that R2 was calm and cooperative. The notes showed that it was reiterated to R2 the importance of limited sitting but R2 refuses. It was also noted that R2 was only up this time that the foam cushion was changed to gel cushion for R2 to use while seated in his wheelchair. The most recent care plan available dated 7/5/2013 and revised 2/24/2014 showed that R2 has an actual impairment to skin integrity with chronic stage 4 pressure ulcer on the left ischium. It was also indicated that R2 refused to see Z1 on 1/3/2014. The care plan interventions included the following: -keep skin clean and dry -skin check daily - float heels while in bed, use heel protectors when in bed - turn and reposition every 2 hours and as needed -administer treatments as ordered The care plan interventions were not followed as above. Furthermore, the care plan showed no interventions with regards to R2's prolong sitting and R2's refusal to see Z1 on 1/3/2014. There was no assessment to determine possible causes of the refusal. Z1's documentation on the " Wound Care Specialist Evaluation " dated 12/12/2013, 1/9/2014, 1/23/2014, 2/6/2014, 2/20/2014 2/27/2014 showed that R2 was " calm and cooperative. " The " Daily Skin Assessment /Wound Status" for February 6, 2014 to February 27, 2014 did not identify R2's right heel unstageable pressure ulcer. This ulcer was never identified on the daily skin assessment form, however a treatment order was in place as of 2-20-14. Z1 had documented on 2/20/2014 that R2 had a facility acquired unstageable pressure ulcer on the right heel on 2/19/2014. The documentation on the " Daily Skin Assessment " had failed to identify and monitor R2's development of new pressure ulcer that had progressed to an unstageable. R2's MDS (Minimum Data Set) dated 3/14/2013 and 2/7/2014 documents that R2 was without negative behavior, mood disturbances or signs and symptoms of [MEDICAL CONDITION]. R2 was also assessed with [REDACTED]. 2. R1 is a [AGE] year old individual that was readmitted to facility on 03/04/13 after hospitalization related to placement of feeding g- tube due to resident declined nutritional status and refusing to eat. While at hospital [MEDICAL CONDITION] Resistant Staphylococcus Aurous (MRSA) was identified in R1's wounds and R1 was started on intravenous antibiotic therapy treatment and continued at the facility. According to re-admission orders [REDACTED]. R1 is receiving nutrition through newly placed [DEVICE] feeding tube. Hospital records for R1 on 2-21-14 document that R1 was admitted on [DATE] from the facility with open wounds of both heels measuring 2 centimeters by 2 centimeters with depth to the subcutaneous tissue. R1 was also noted with an open wound at the left lateral malleolus and sacrum. The heel wound was noted to be draining pus and later noted to be positive for infection. Hospital record documents under history, " The patient was found to have several decubiti, the most significant which appears to be that of the left heel that looks to be grossly infected as evidenced by gross purulence being expressed. " Wound cultures from the hospital dated 2-22-14 indicate that R1's wounds on the sacrum and heels were positive [MEDICAL CONDITION]. On 03/11/14 from 12:40pm to 1:05pm. a phone interview was conducted with Z1 (Wound Care Doctor). Z1 stated she had been working with R1's pressure ulcers on the feet on and off since October of last year. Z1 stated that R1 had recently been in hospital and had pressure ulcer on coccyx debrided and was noted to have [MEDICAL CONDITION] Resistant Staphylococcus Aurous and [DIAGNOSES REDACTED] in sacral pressure ulcer and started on intravenous antibiotic therapy for this at hospital which was continued at facility. Z1 stated that special low air loss mattress was ordered to help healing process because it redistributes weight and helps relieve pressure, specifically to pressure on sacral area. Z1 stated that resident wearing and adult incontinent brief could negatively affect healing process to sacral area because it would keep moisture and soiling to stay against skin causing irritation and friction. R1 stated that multiple layers on low air loss mattress could affect effectiveness because it decreased the benefits of the redistribution or air flow to sacral area. Z1 stated that with the low air loss mattress would be more effective if it only had thin draw sheet between resident and fitted sheet on mattress. Z1 stated that if soiling such as urine or feces was on dressing and or wound for extended periods could cause increased issues with infection because it could contaminate area. Z1 stated dressing should be change immediately after any visibly soiling and extra care should be taken to ensure feces doesn ' t contaminate area. Z1 stated she would expect facility to notify her or the primary care physician if resident was refusing treatments and she had only been made aware of R1 refusal of treatment on 03/10/14 by E6 (wound care nurse). Z1 stated that for best practice with turning and repositioning resident to help wound healing for pressure ulcer on sacral area that resident should be turned and repositioned at least every two hours and should be more side to side and only occasionally place on back. Z1 stated that pillows could be used to be position resident from side to side but should use as few as possible and should be place above buttock to ensure no extra pressure on pressure sore on sacral area. Z1 stated example of turning and repositioning of left side, right side, middle, left side, right side, middle. Z1 stated that R1 should have pressure relieving boots on in bed and when up to help relieve pressure to pressure ulcers on heels and foot and could also float feet off bed by putting pillow under legs. Z1 stated that if resident had on foot protectors in bed should not have feet pressed against foot board as this could increase pressure and feet should not be placed on top of foot board as this would increase pressure to area. Z1 stated that she felt pressure areas could possibly be healed and at very least remain stable. On 03/10/14 at 10:25 am, R1 was in room lying on back, had thick blue incontinence pad between low air loss mattress and resident and had on pressure relieving boots on but R1 was noted to have slid down in bed and feet were pressed against foot board. On 3/10/14 at 2:24 pm, R1 was in room receiving [MEDICAL TREATMENT] with E7 ([MEDICAL TREATMENT] nurse) and E15 (certified nurse's aide/[MEDICAL TREATMENT] technician) present in room. R1 was again noted to be on his back with thick blue incontinent pad between resident and low air loss mattress as well as sweat pants. R1 had on foot protectors but was slid down in bed and both feet were pressed against footboard. E15 stated R1 wears an adult incontinent brief while in bed. E7 or E15 made no attempt to reposition resident off back or slide up in bed to relieve pressure from footboard. On 03/10/14 at 3:45 pm, R1 was in room, in bed lying on back had on sweat pants as well as thick blue incontinence pad between resident and low air loss mattress. R1 had on foot protector but feet/heels were lying on top of footboard. On 03/11/14 at 6:50am to 8:25 am wound care was observed. E6 (wound care nurse) performed treatment and was assisted by E19 (Certified Nurse's Assistant). Upon entering room R1 had heel protectors on but, feet were lying over foot board of bed. R1 was on low air loss mattress with upper part of body positioned to the right side with pillow underneath lower back and buttock. R1 had on sweat pants, adult incontinent brief and thick blue incontinent pad between him and low air loss mattress. During wound care E6 was noted to contaminate treatments to all areas on both feet by wiping same open area with same side of 4x4 gauze multiple times. E6 was observed to open the 4x4 gauze that came from the treatment cart, open these with gloved hands then use same gloved hands to clean wound areas thereby contaminating the wound. E6 did this with all wound areas. On multiple occasions E6 touch bedding, resident and residents clothing with gloved hands then touched area being used as her designated clean field and entire tray used for supplies of treatment, thereby contaminating entire clean dressing field. E6 also cut and placed packing for sacral area by cutting into ribbons and placing on tray that E6 had contaminated with ungloved hands and soiled gloves. When E6 went to do the treatment for [REDACTED]. E6 cleaned area and had to wipe area several times, used approximately half a box of cleaning wipes due to dried feces on and around dressing and anus. E6 or E19 were unable to tell when last time resident had been checked for incontinence. After soiled dressing was removed R1 noted to have feces in and around edge of bed of pressure area, thereby causing contaminations and area and increasing possible issues with infection. E6 again contaminated wound on coccyx by using same side of the 4x4 gauze. E6 used the same side of the gauze to wipe same area four times on same side of gauze. When E6 put on adherent wound covering pad and dressing tape was observed to have wrinkles along bottom of wound area which can cause pressure and allow open areas for feces to enter wound if incontinent. When E6 finished treatment R1 was positioned to right side and staff put on adult incontinence brief, thick blue incontinence pad and sweat pants between resident and low air loss mattress. E19 stated that since R1's return from the hospital he is total care and requires two people assist for most all activities of daily living. On 3/11/14 at 10:45, R1 was in bed had pillow under lower back and buttock, thick blue incontinent pad and sweat pants between pressure area on coccyx and low air loss mattress and feet were in protective boots but pushed against end of foot board. On 03/11/14 at 4:30pm, R1 was noted to be in room in bed. E20 (certified nurse aid) entered room and stated he had just been in to turn resident. E20 stated that since R1's return from hospital he is total care and requires two assist for most activities of daily living. E20 stated that before the last hospitalization he could help with some of his activities of daily living. E20 stated R1 was incontinent of bowel and bladder but not with bladder very often due to [MEDICAL TREATMENT]. R1 was turned toward left side with one pillow under back and another pillow under buttock. E20 stated that R1 had on adult incontinent briefs, sweat pants and thick blue incontinent pad on bed and that was how they usually changed him and kept him in bed. E20 indicated that R1 was turned and repositioned every two hours and schedule was right side, middle, left side, middle, right side, middle. On 3/12/14 at 8:20 am, R1 was in room, in bed receiving [MEDICAL TREATMENT]. E7 ([MEDICAL TREATMENT] nurse) was present. R1 had pillow under right buttock and E7 stated that was to relieve pressure on bottom. R1 also had thick blue incontinence pad between him and low air loss mattress. On 03/12/14 at 8:45, E3 (Nurse) and E18 (CNA-Certified Nurse aid) and E19 (CNA) went to check on R1. E19 stated that R1 was to be turned every two hours and was to be right side, middle, left side, middle, right side, middle. E19 confirmed this turning schedule. E19 stated they had turned and repositioned resident around 7:00am. Upon entering room, R1 was noted to have thick blue incontinent pad, adult incontinent brief and pillow under right buttock. E3 verified that R1 should not have all the padding between bottom and low air loss mattress and pillow should be placed above buttock area under lower back. R1 was repositioned on back by staff. At 9:00am all staff exited R1's room at no time did staff check incontinent brief for soiling and staff also did not ask R1 if he was incontinent and needed changing. According to R1's TAR (Treatment Administration Record) for month of March 2013, that was initiated on 3/4/14 with R1's readmission to the facility, indicates that on 03/09/14 and 03/10/14 that R1's treatment was not done due to resident refusal. On 03/08/14 there is no signature or initial to indicate ordered treatment was done for R1 on that day. No documentation could be found in R1's chart to indicate wound care doctor or primary care physician was notified of R1's treatment not being done on 3/8/14 or refusal on 03/09/14. TAR also indicates that on 3/8/14 daily skin check was not done and on 03/09/14 daily skin check was not done due to refusal. R1 was first noted with the unstageable pressure ulcer to the sacrum/coccyx on 2-11-14 by E6. E6 noted the wound as follows: " measures of 3.8cm x 3.5cm x 0.1cm wound bed with slough, some granulation noted, edges are attached, margins are uneven with moderate drainage. " Z1 however documented in the wound notes of 2-20-14 that this same area was, " (due to necrosis) of coccyx that is related to pressure and less than one day old " . Z1 went on to indicate that this area was acquired in the hospital, however R1 was out less than 24 hours for treatment for [REDACTED]. The facility was asked several times to produce the treatment records for February of 2014 and but none was provided during the survey. A treatment order was noted for 2-18-14 for R1 as follows: " Coccyx, cleanse with Normal Saline, pat dry, apply foam dressing, skin prep surrounding tissue, apply border gauze. Change daily." R1 was then sent to the hospital on 2-21-14 and at that time the coccyx/sacrum was positive [MEDICAL CONDITION] infection and required a debridement, which was performed secondary to infection. According to R1's TAR for January 2014, under heel protectors to be worn at all times while in bed there and off load bilateral feel while in bed is no indication this was done on the 6-2 shift on the 1/08/14, 01/09/14, 01/10/14, 01/18/14, 01/19/14, 01/30/14, on 2-10 shift on the 1/25/14, 01/26/14, on the 10-6 shift on the 1/29/14, 1/30/14, 1/31/14. The TAR Under these has hand writen to chart if non-compliant and no corresponding charting could be found regarding refusal. Under skin checks daily (10-6) on 01/29/14 & 01/30/14) there is no indication these were done. According to the treatments areas for the left heel and right heel, there is no indication theses were done on 1/28/14, 1/29/14, 1/30/14, or 01/31/14. Facility was unable to provide TAR for R1 for February 2014 when requested. Facility also unable to provide documentation regarding refusal of care for the dates noted above when requested. Through observation, interview and record review, the survey team confirmed that the facility took the following steps to remove the immediacy of the situation: 1) R1 and R2 have been reassessed for skin breakdown by the facility wound care nurse and the DON. Both R1 and R2's plan of care have been reviewed and updated and revised as required to address each resident's skin breakdown. The revised care plans address additional interventions including the use of a low air low mattress and other pressure relieving devices as appropriate. Effective date: 3-12 and ongoing. 2) Nursing staff that care for R1 and R2 have been in serviced on the following: The wound: ? Facility wound care policy ? Proper wound care techniques ? Revised care plans for each resident ? Required documentation that must be maintained in order to document wound care treatment ? Required reporting related to wound care to the md and the facility DON ? The turning schedules for R1 and R2 that are posted in the bathroom or above their beds. ? Bowel and bladder program for each resident including checking each resident in at least every two hours or more often as needed ? Infection control techniques in connection with wound care and steps to ensure that there is no cross contamination ? Steps to take in the event that either the resident refuses wound care treatment including the need for social services to meet with the resident and document those meetings on an ongoing basis to counsel the residents on the effect of refusal of care. The physician will also be notified of refusal of care and this will be documented. This should be tailored for which of these residents has refused wound care to address that specifically and to state that the counseling is ongoing for that resident, is being documented, and that the resident ' s doctor has been contacted and the contact has been documented. Effective date: 3-12-14 and ongoing 3) The DON has been in serviced on the requirement that she will on a daily basis examine each of these residents to ensure that each resident is properly positioned, that required reliving devices are in use and appropriately placed. The resident's dressing is proper and documented and that the resident is clean and dry. The DON will also on an ongoing daily basis audit each resident's chart to ensure that required documentation for wound care is present and properly completed. Effective date: 3-12-14 4) Identification of other residents having the potential to develop pressure ulcers will have the following steps to assure that the deficient practice does not occur. ? The facility has identified each resident who is at risk for skin breakdown. The care plan for each such resident will be identified as high, medium or low risk for skin breakdown. Depending upon level of risk, the care plan will identify interventions and approaches for each resident that will address the prevention and or care of the skin breakdown. ? Each such resident has been assessed for skin breakdown. ? The care plan for each such resident has been reviewed and revised as needed to ensure that it addresses each resident ' s assessment and contains interventions and approaches that address each resident ' s condition and sets forth an approach that is designed to prevent skin breakdown or care for skin breakdown that has occurred. ? The facility has reviewed the pressure reliving devices that have been ordered for each resident and evaluated whether those pressure relieving devices are appropriate or whether additional devices are required. The DON and charge nurse have been in serviced on the requirement that presence and proper use of pressure relieving devices will be monitored by them during their rounds daily. -The facility has verified that the doctor for each resident has been fully appraised of the resident's condition including any refusal of care and the communication with each doctor has been reflected in the resident ' s chart -The facility has reviewed each resident's response to wound care and has provided education to the resident as needed concerning the resident's wound care. This will be continued on an ongoing basis. -Facility nursing staff including the DON have been in serviced on the following facility wound care policies: -Facility infection control policies -Proper wound care techniques -The care plan for each resident at risk for skin breakdown including care plan revision. -Required documentation that must be maintained -Required reporting to the wound physician -Documentation for wound care refusal -Turning schedules for each resident -Bowel and bladder program for each resident -Infection control techniques Effective Date: 3-12-14 5) The facility has identified each resident who is at risk for skin breakdown. The care plan for each resident reflects the interventions and has been updated. 3-12-14 and ongoing 6) Quality Assurance: An emergency QA meeting has been scheduled for 3-18/14 with the medical director. Effective Date: 3-18-14 and ongoing 7) The Quality Assurance audits will include: ? Audits of charts at least on a weekly basis to ensure that wound documentation is in place. ? Each resident's care plan will be reviewed at least on a monthly basis or more often as needed to ensure that each care plan correctly reflects each resident ' s condition. This will be done by the Care Plan Coordinator and DON. ? Each resident is properly positioned by audits ? Each resident has proper devices ? Each resident is clean and dry ? Observations during care for infection control and techniques ? Turning schedules are posted and resident is positioned correctly Effective date: 3-13-14 and on going

Based on observation, interview and record review, the facility neglected to follow physician orders [REDACTED]. This deficient practice applies to two (R1 and R2) out of three residents sampled for pressure ulcers from a total sample of 18 that developed unstageable pressure ulcers in the facility. Findings include the following: 1) The face sheet admission record showed that R2 was originally admitted to the facility on [DATE]. The POS (Physician order [REDACTED]. The " Infectious Disease and Wound Specialist " progress notes dated 3/14/2013 showed that R2 was assessed with [REDACTED]. The progress notes also showed that R2's right heel wound had healed on 8/16/2012. The left ischium wound measurements were 0.3 cm for length, 0.4 for width, and 1.9 cm for depth. The plan was to protect right heel with heel suspension orthotic boot and to lubricate the skin. The Braden Scale pressure sore skin assessment dated [DATE] showed that R2 was a high risk for pressure ulcer. The " Wound Care Specialist Evaluation " dated 2/20/2014 showed that R2 has the following pressure ulcers with interventions and assessment as follows: - A stage 4 pressure ulcer of the left ischium. The ulcer was described with light serous exudate and measurements were 0.2 cm. in length; 0.8 cm. in width; 1.2 cm. in depth; undermining at 1.1 cm. at 7 o ' clock. - An Unstageable pressure ulcer described as necrotic on the right heel. The pressure ulcer measurements were 0.4 cm in length; 0.3 cm. in width; and a not measurable depth. The right heel unstageable pressure ulcer was acquired at the facility on 2/19/2014. - The Plan Intervention for the pressure ulcers were pressure reduction in chair and in bed and float heels to off load pressure. - R2 was assessed as oriented times 3 (person, place and situation) with mood and affect to be calm and cooperative. The POS (Physician order [REDACTED]. 1) " Cleanse left ischium stage 4 with normal saline, apply [MEDICATION NAME] Alginate dressing then cover with dry dressing and change daily (scheduled for 11:00P.M.-7 A.M. shift) and as needed. " 2) " Paint right heel with [MEDICATION NAME] then cover with dry dressing daily (scheduled for 11P.M.-7:00 A.M. shift) and change as needed. " On 3/10/2014 at 3:00 P.M., 3:15 P.M., 4:30 P.M., 5:05 P.M. and 5:30 P.M., R2 was lying on his left side facing window. R2 remained on the same position during these observations. Upon prompting, E6 (Wound Treatment Nurse), E31 (Licensed Practical Nurse) and E27(Nurse Aid) assisted to do skin check for R2 at 5:30 P.M. R2 was without heel suspension or a heel protector to off-load pressure from the heels. E27 and E31 stated they were not aware that R2 was supposed to have heel suspension boots or heel protector. R2 was also noted with a disposable brief and an incontinent cloth pad and a sheet on a low air low mattress. R2 was urine soaked. The absorbent padding from the brief had turned into a gel like consistency due to heavy saturation of urine. It was also noted that the urine had leaked through the brief onto the incontinent cloth pad. Redness and excoriation to the scrotal area was also noted. R2 was observed with soft stool smeared throughout the rectal /buttocks, scrotal and groin area. There was no dressing on the left ischium pressure ulcer. There was also stool around the opening of the pressure ulcer on left ischium. E27 (Nurse Aid) stated that there was no dressing in placed on R2' s left ischium pressure ulcer when E27 changed R2's incontinent brief at 2:00pm and at 4:00 P.M. E27 stated that she had informed an unidentified staff at 2:00 P.M. when E27 found out that there was no dressing on the left ischium pressure ulcer. E27 also added that she should have increased the frequency of changing R2's incontinent brief to keep him clean and dry. E31, (the nurse in charge of R2 from day and evening shift of 3/10/2014) during interview stated that he was not aware that R2's dressing was off. E6 stated that she does not do the daily dressing change and only does the dressing change once a week to evaluate the existing and new wounds. After the incontinence care, E6 with assistance from E31 and E27 had proceeded with pressure ulcer dressing change. During this observation, the unstageable pressure ulcer on the right heel had a dry dressing with a label date of " 3/7 " (this was 2 days prior to date of observation on 3-10). The TAR (Treatment Administration Record) dated 3/2014 documented that the treatment for [REDACTED]. The right heel treatment was also not signed as given on 3/9/2014, but was signed on 3/8/2014. This was contradictory to the observation made on 3/10/2014 that the right heel dressing had a date labeled 3/7/2014 as the last dressing changed. On 3/13/2014 at 11:30 A.M., E33 (Licensed Practical Nurse- the nurse assigned on 3/8 and 3/9/2014 for 11 P.M.-7 A.M. shift) during interview stated that she does not remember if she changed the dressing on the left ischium on 3/9/2014. However, E33 had stated that it is the facility's practice and policy to sign the TAR when treatment was given. E33 also added that she did not change R2's right heel pressure ulcer dressing on 3/8 and 3/9/2014. E33 also added that though, she had signed the TAR on 3/8/2014 that the right heel dressing was changed, E33 stated that she made a mistake and thought that she was signing the left ischium dressing. This was an indication that physician orders [REDACTED]. R2 right heel dressing was not changed for 2 days and left ischium dressing was not changed for 1 day. On 3/10/2014 at 10:15 A.M. and at 12:45 P.M., R2 was seated in his wheelchair that has a foam cushion. R2 was also noted to be wearing shoes while up in a chair. On 3/11/2014 at 9:30 A.M. and at 11:30 A.M., R2 was observed sitting in his wheelchair with the same foam cushion. Again R2 was wearing shoes that were in contact with his heels. On 3/11/2014 at 1:30 P.M., R2 was in bed. R2 was not wearing a heel suspension nor were his heels off loaded from pressure. E23 (Licensed practical Nurse) and E32 (Nurse Aid) was in R2's room and stated that they were not aware that R2's heels was supposed to have his heels offloaded nor was aware of the heel suspension. E32 added that R2 was not being reposition while seated in his wheelchair because R2 uses a mechanical lift for transfer. On 3/11/2014 at 12:30 P.M., Z1(Wound physician specialist) during interview stated that R2 should be turned and reposition at a minimum of at least every 2 hours to off load pressure from the identified pressure ulcers and other parts of bony prominence. Z1 also added that prolonged sitting was not appropriate for R2 and that an air or gel cushion was the appropriate pressure relieving device for seat cushion. Z1 also added that R2's pressure dressing should have been intact at all times and change as ordered, otherwise infection could happen. Z1 also added that R2 should be off from pressure on his heels and therefore shoes was not recommended but instead a heel protector and heel suspension while in bed was appropriate measures. The " Wound Care Specialist Evaluation " dated 3/13/2014, (a note from Z1) showed that R2 was calm and cooperative. The notes showed that it was reiterated to R2 the importance of limited sitting but R2 refuses. It was also noted that it was only up this time that the foam cushion was changed to gel cushion for R2 to use while seated in his wheelchair. The most recent care plan available dated 7/5/2013 and revised 2/24/2014 showed that R2 has an actual impairment to skin integrity with chronic stage 4 pressure ulcer on the left ischium. It was also indicated that R2 refused to see Z1 on 1/3/2014. The care plan interventions included the following: -keep skin clean and dry -skin check daily - float heels while in bed, use heel protectors when in bed - turn and reposition every 2 hours and as needed -administer treatments as ordered Z1's documentation on the " Wound Care Specialist Evaluation " dated 12/12/2013, 1/9/2014, 1/23/2014, 2/6/2014, 2/20/2014, and 2/27/2014 showed that R2 was "calm and cooperative." The " Daily Skin Assessment /Wound Status for February 6,2014 to February 27,2014 did not identify R2's right heel unstageable pressure ulcer. This ulcer was never identified on the daily skin assessment form, however a treatment order was in place as of 2-20-14. Z1 had documented on 2/20/2014 that R2 had a facility acquired unstageable pressure ulcer on the right heel on 2/19/2014. The documentation on the "Daily Skin Assessment " had failed to identify and monitor R2's development of new pressure ulcer that had progressed to an unstageable. 2. R1 is a [AGE] year old individual that was readmitted to facility on 03/04/13 after hospitalization related to placement of feeding g- tube due to resident declined nutritional status and refusing to eat. While at hospital [MEDICAL CONDITION] Resistant Staphylococcus Aurous (MRSA) was identified in R1's wounds and R1 was started on intravenous antibiotic therapy treatment which was continued at the facility. Hospital records for R1, of 2-21-14 document that R1 was admitted on [DATE] from the facility with open wounds of both heels measuring 2 centimeters by 2 centimeters with depth to the subcutaneous tissue. R1 was also noted with an open wound at the left lateral malleolus and sacrum. The heel wound was noted to be draining pus and later noted to be positive for infection. Hospital record documents under history, " The patient was found to have several decubiti, the most significant which appears to be that of the left heel that looks to be grossly infected as evidenced by gross purulence being expressed." Wound cultures from the hospital dated 2-22-14 indicate that R1's wounds on the sacrum and heels were positive [MEDICAL CONDITION]. On 03/11/14, from 12:40pm to 1:05pm, a phone interview was conducted with Z1 (Wound Care Doctor). Z1 stated she had been working with R1's pressure ulcers on feet on and off since October of last year. Z1 stated that R1 had recently been in hospital and had pressure on coccyx debrided and was noted to have [MEDICAL CONDITION] Resistant Staphylococcus Aurous and [DIAGNOSES REDACTED] in sacral pressure ulcer and started on intravenous antibiotic therapy for this at hospital which was continued at facility. Z1 stated that special low air loss mattress was ordered to help healing process because it redistributes weight and helps relieve pressure, specifically to pressure on sacral area. Z1 stated that resident wearing and adult incontinent brief could negatively affect healing process to sacral area because it would keep moisture and soiling to stay against skin causing irritation and friction. Z1 stated that multiple layers on low air loss mattress could affect effectiveness because it decreased the benefits of the redistribution or air flow to sacral area. Z1 stated that with the low air loss mattress would be more effective if it only had a thin draw sheet between resident and fitted sheet on the mattress. Z1 stated that if soiling such as urine or feces was on dressing and or wound for extended periods could cause increase issues with infection because it could contaminate area. Z1 stated dressing should be change immediately after any visibly soiling and extra care should be taken to ensure feces doesn't contaminate area. Z1 stated she would expect facility to notify her or primary care physician if resident was refusing treatments and she had only been made aware of R1 refusal of treatment on 03/10/14 by E6 (wound care nurse). Z1 stated that for best practice with turning and repositioning resident to help wound healing for pressure ulcer on sacral area that resident should be turned and repositioned at least every two hours and should be more side to side and only occasionally place on back. Z1 stated that pillows could be used to be position resident from side to side but should use as few as possible and should be place above buttock to ensure no extra pressure on pressure sore on sacral area. Z1 stated example of turning and repositioning of left side, right side, middle, left side, right side, middle. Z1 stated that R1 should have pressure relieving boots on in bed and when up to help relieve pressure to pressure ulcers on heels and foot and could also float feet off bed by putting pillow under legs. Z1 stated that if resident had on foot protectors in bed should not have feet pressed against foot board as this could increase pressure and feet should not be placed on top of foot board as this would increase pressure to area. Z1 stated that she felt pressure areas could possibly be healed and at very least remain stable. During several observations, R1 was noted to lying on the special mattress with several layers between R1 and the mattress. R1 was also noted during these observations to have slid down in bed with both feet pressing against the foot board, creating pressue. These observations were noted on 3-10-14 at 10:25am, 3-10-14 at 2:24pm, 3-10-14 at 4:45pm, 3-11-14 at 6:50am and 3-11-14 at 10:45am. On 3/12/14 at 8:20 am, R1 was in room, in bed receiving [MEDICAL TREATMENT]. E7 ([MEDICAL TREATMENT] nurse) was present. R1 had pillow under right buttock and E7 stated that was to relieve pressure on bottom. R1 also had thick blue incontinence pad between him and low air loss mattress. On 03/12/14 at 8:45, E3 (Nurse) and E18 (CNA-Certified Nurse aid) and E19 (CNA) went to check on R1. E19 stated that R1 was to be turned every two hours and was to be right side, middle, left side, middle, right side, middle. E19 confirmed this turning schedule. E19 stated they had turned and repositioned resident around 7:00am. Upon entering room R1 was noted to have thick blue incontinent pad, adult incontinent brief and pillow under right buttock. E3 verified that R1 should not have all the padding between bottom and low air loss mattress and pillow should be placed above buttock area under lower back. R1 was repositioned on back by staff. At 9:00am all staff exited R1's room at no time did staff check incontinent brief for soiling and staff also did not ask R1 if he was incontinent and needed changing. According to R1's TAR (Treatment Administration Record) for month of March 2013 that was initiated on 3/4/14 with readmission indicates that on 03/09/14 and 03/10/14 that R1's treatment was not done due to resident refusal. On 03/08/14 there is no signature or initial to indicate ordered treatment was done for R1 on that day. No documentation could be found in R1's chart to indicate wound care doctor or primary care physician was notified of R1's treatment not being done on 3/8/14 or refusal on 03/09/14. TAR also indicates that on 3/8/14 daily skin check was not done and on 03/09/14 daily skin check was not done due to refusal. R1 was first noted with the unstageable pressure ulcer to the sacrum/coccyx on 2-11-14 by E6. E6 noted the wound as follows: " measures of 3.8cm x 3.5cm x 0.1cm wound bed with slough, some granulation noted, edges are attached, margins are uneven with moderate drainage. " Z1 however documented in the wound notes of 2-20-14 that this same area was, " (due to necrosis) of coccyx that is related to pressure and less than one day old " . Z1 went on to indicate that this area was acquired in the hospital, however R1 was out less than 24 hours for treatment for [REDACTED]. The facility was asked several times to produce the treatment records for February of 2014 and none was provided during the survey. A treatment order was noted for 2-18-14 for R1 as follows: " Coccyx, cleanse with Normal Saline, pat dry, apply foam dressing, skin prep surrounding tissue, apply border gauze. Change daily. " R1 was then sent to the hospital on 2-21-14 and at that time the coccyx/sacrum was positive [MEDICAL CONDITION] infection and needed a debridement was performed secondary to infection. According to R1's TAR for January 2014, under heel protectors to be worn at all times while in bed there and off load bilateral feel while in bed is no indication this was done on the 6-2 shift on the 1/08/14, 01/09/14, 01/10/14, 01/18/14, 01/19/14, 01/30/14, on 2-10 shift on the 1/25/14, 01/26/14, on the 10-6 shift on the 1/29/14, 1/30/14, 1/31/14. The TAR Under these has hand writen to chart if non-compliant and no corresponding charting could be found regarding refusal. Under skin checks daily (10-6) on 01/29/14 & 01/30/14) there is no indication these were done. According to the treatments areas for the left heel and right heel, there is no indication theses were done on 1/28/14, 1/29/14, 1/30/14, or 01/31/14. Facility was unable to provide TAR for R1 for February 2014 when requested. Facility also unable to provide documentation regarding refusal of care for the dates noted above when requested.

Based on observation, record review and interview the facility failed to provide pain medication as scheduled and failed to document pain characteristics, for one resident (R2) reviewed for pain in the sample of five. These failures resulted in R2's pain levels not being controlled. Findings include: R2 has [DIAGNOSES REDACTED]. R2 is on hospice and has physician orders [REDACTED]. During interview on 1/28/2014 at 11:45 AM, R2 stated that the nursing staff does not give him his scheduled [MEDICATION NAME] on time which allows his pain levels to increase. R2 stated that he can take [MEDICATION NAME] as needed (prn) for break through pain, but it doesn't take away the pain; it only makes him sleepy. R2 stated that E6 (nurse) always gives his [MEDICATION NAME] late, sometimes 1 hour to 1 1/2 hours late and his pain gets worse. When R2 asks E6 to give him his [MEDICATION NAME] on time, E6 gets mad, but then the pain gets so bad that the [MEDICATION NAME] won't work. During the interview R2 was observed to occasionally grimace, grunt or hold his left side as if in pain. R2 stated that he has spoken to the hospice nurse about not getting his pain medication as scheduled and last night he received his [MEDICATION NAME] at 1:45 AM. R2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses do not describe the location and characteristic of R2's pain in nurses notes or on the MAR. On 1/28/14 at 1:15 PM, E4 (nurse) verbally assessed R2 as having lots of pain and denied knowledge of issues with R2's pain medications stating that he is on a schedule for the [MEDICATION NAME] and there had not been a problem to his knowledge. E4 received education from Z3 (Hospice Nurse) about chronic pain and medication and since then has no problem administering the prescribed medication. When interviewed 1/28/14 at 1:50 PM, Z1 (family) stated the same information as R2 regarding his not receiving his [MEDICATION NAME] at the ordered times and stated that E6 doesn't give R2 his [MEDICATION NAME] on time and yells at him for asking. Z1 stated that she had spoken to E2 (Director of Nurses) and nursing staff during the care plan meeting on 1/15/2014. On 1/28/14 at 2:20 PM, E6 denied the allegation and stated that he gives R2 his pain medication as scheduled and the prns when he asks; that R2 often doesn't look as if he's in pain and goes outside to smoke cigarettes. On 1/28/14 at 4:50 PM, E2 denied any knowledge of E6 not administering R2 his pain medication as ordered and of R2 not receiving his scheduled [MEDICATION NAME] as ordered and stated that she has not inserviced staff about hospice and narcotic administration; that she is waiting for the hospice staff to do so. On 1/29/14 at 12:55 PM, Z3 (nurse) stated that the hospice has experienced an ongoing problem with the facility giving R2 his scheduled pain medication on time; he isn't receiving the meds as he should be. He gets the medication late which allows the pain to get out of control, but the facility staff refuses to give the pain medications even though she has done lots of teaching with the staff regarding pain medication and chronic pain and end of life. The facility staff's response is that he doesn't look or act like he's in pain. Z3 continued on to say that she has tried to explain to staff that it doesn't mean that he's not in pain and R2 doesn't have a good quality of life unless his pain is under control. R2 has increased pain at night and gets more pain relief and is more alert with the [MEDICATION NAME], is more proactive with his care after the [MEDICATION NAME]. His increasing ascites makes him uncomfortable and in pain. As stated by Z3, R2 and Z1 have called her several times regarding his not receiving his [MEDICATION NAME] as scheduled because staff gives it late, especially E6. Z3 has spoken in depth with E2 who said that she would address the problem, but nothing has been done as of yet and Z3 met with the facility on 1/15/14 during R2's care plan conference and explained the issue with staff at that time also. Z3 stated that because of a lack of effectiveness when the [MEDICATION NAME] was to be given TID, today, 1/29/14, R2's [MEDICATION NAME] was increased to four times a day (every 6 hours) which will hopefully keep him more pain free. On 1/29/14 at 3:40 PM, Z7 (hospice nurse) also stated that she had been having an ongoing problem with the facility not giving R2 his medication for pain on time. Both R2 and his wife have called her several times about his not receiving his pain meds on time; the other night R2 called her at 2:00 AM to tell her that he hadn't received his [MEDICATION NAME] until 1:30-1:45 AM. Z7 stated that she's spoken to the nurses several times, but they say that he doesn't look like he's in pain and the hospice staff has told them that since pain is subjective, it doesn't mean that he's not in pain. "I've explained to them that his smoking may be a technique he uses to distract himself from his pain. Its very frustrating that the facility doesn't medicate him on time". Z7 continued on to say that as a result of his pain levels, R2's [MEDICATION NAME] has been increased to four times daily as of today and he'll receive it every 6 hours and hopefully be more pain free. The [MEDICATION NAME] was increased because of the lack of effectiveness when given three times daily and his not receiving it as scheduled. "Hopefully every 6 hours will keep him covered better". R2 had a discontinued physician's orders [REDACTED]. R2's current physician's orders [REDACTED]. The medication is signed as given at 11 PM on 1/22/14 and on each shift 1/23/14 through 1/28/14. On 1/29/14 the [MEDICATION NAME] was ordered to be increased to every six (6) hours.

Based on interview and record review, the facility failed to conduct a comprehensive assessment and follow physician orders [REDACTED]. This failure resulted to R2's delayed medical evaluation and treatment for [REDACTED]. This applies to one of four (R2) residents reviewed for declined in ADL (Activities of Daily Living), in the sample of seven. The finding includes: The POS (Physician order [REDACTED]. The two most current MDS (Minimum Data Set) dated 7/9/2013 and 9/25/2013 showed the following R2's assessments: -scored 15 for BIMS (Brief Interview For Mental Status) = cognitively intact - 3/3 = extensive assistance with two person physical assist 0/1= independent with eating with set up help only The nurse's notes dated 1/30/2013, 6/17/2013, 7/15/2013 and 10/13/2013 showed R2 was alert and oriented times three (person, place and time). R2 was also able to verbalized needs. The Nurse's Notes documentation also showed the following: -12/8/2013 at 1:15 P.M.; R2, after lunch was sleeping at the table. R2 did not open her eyes when staff tried to wake her up. The Director of Nursing (E1) was notified and attending physician (Z1) was paged. -12/8/2013 at 1:50 P.M.; Z1 replied and stated "Just keep (R2) monitor her closely." -12/8/2013 at 10:00 P.M.; R2 was awake and alert. -12/9/2013 at 5:00 A.M.; R2 with no complaint. -12/10/2013 for A.M. to 2 P.M. shift charting: R2 was alert and oriented x2. R2 was evaluated by Speech therapist. The diet was changed from regular consistency to pureed diet with thick liquids and Z1 was notified. R2 was also noted to be tired after breakfast. - 12/12/2013 at 8:15 A.M.; "(R2) was not alert, lethargic very sluggish, difficulty swallowing. Spoke to (Z1) related to change in LOC/mental status. Labs ordered, urinalysis, and chest xray ordered. Per (Z1), want to see results. " -12/13/2013 at 2:40 P.M., (R2) was sent to hospital due to change in LOC (level of consciousness). (R2) was alert and oriented at time of discharge to hospital at 10:00 A.M. The above documentation contained no evidence R2 was closely monitored as ordered by the physician. There was a lack of monitoring on 12/9/2013 for all day (6 A.M.- 2:00 P.M. shift; 2 P.M.- 10 P.M. and 10 P.M.- 6 A.M.) There was also a lack of monitoring and follow up on 12/12/2013 for 2 P.M.-10 P.M. and 10 P.M. to 6 A.M., even after R2 was noted with continued lethargy, decreased alertness, sluggishness and swallowing difficulty at 8:45 A.M. on same day. The next documentation was on 12/13/2013 at 2:40 P.M. when R2 was sent out to the hospital. Review of the Speech Therapist Notes dated 12/10/2013 showed the speech evaluation was not done "due to (R2's) extremely poor level of arousal after three attempts of evaluation." On 12/30/2013 at 11:55 A.M., E2 (Speech Language/Pathologist) stated R2 had a definite significant change in medical condition when seen on 12/10/2013 during an attempt for swallowing evaluation. E2 further stated that R2 remained unresponsive for three attempts of evaluation. E2 described R2 as follows and added the following steps were tried to wake or arouse R2: -eyes not fully open, was not able to eat due to being unresponsive - Mouth was open, hanging down, no movement of the lips and no reflexes when a glass was pushed to R2's lips - R2 did not response to tactile stimuli when a cold spoon was placed touching the lips and mouth - No verbal response, only moans for occasionally - R2 had remained unresponsive despite of repositioning R2 in bed to sit up for eating at a 90 degree angle. E2 further added this was not R2's baseline and this was definitely a significant change. E2 said a CNA (Certified Nurse Assistant) in which E2 cannot remember the name had told her R2 had been noted to for the past few days with a significant change in medical status. E2 also stated she had informed E1(Director of Nursing) regarding her observation of R2. On 12/31/2013 at 10:36 A.M., E3 (CNA) stated she saw E2 on 12/10/2013 during an attempt for swallow evaluation. E3 also stated R2 had a definite significant change in status and was not the same R2 anymore. E3 also added R2's significant change had been ongoing for few days already before 12/10/2013 until the day R2 was sent sent out to the hospital(12/13/2014). E3 described R2's significant changes as follows: - "(R2) had stopped talking and if she does, it does not make sense and was not coherent" - "(R2) was like in deep sleep and remained with no response even you scream her name or touch her with use of some force" - "(R2) was not eating lunch when saw on 12/10/2013 due to unresponsiveness" - "(R2) was not able to bear weight during transfer and had to totally lift her with 2 person assist" On 12/31/2013 at 10:19 A.M., E4(CNA; Rehab Aide; Activity Aide) stated during interview on (12/10/2013), R2 was "sleeping a lot, not responding, nods but will not talk back, tried to wake her up but would not response, eyes closed and slumped sideways while seated on her wheelchair." E4 also stated R2 was observed with the significant change few days before the hospitalization of 12/13/2013. On 12/31/2013 at 9:40 A.M., E5 (Licensed Practical Nurse) stated R2 was noted to be "more tired than usual. On 12/10/2013, (E2) informed me to update Z1 for diet change and (R2) looked very sleepy." E5 further stated he was more concern with R2 on 12/12/2013 because (R2) remained weak, lethargic and she did not come out of it. (R2) used to come out of it when she get sleepy or tired but not this time." On 12/31/2013 at 11:00 A.M., E6 (LPN, Licensed Practical Nurse) stated she had informed Z1 regarding R2's significant change on 12/12/2013. E6 also added that "whatever I charted on 12/12/2013 was what I told (Z1)." E6 also stated there R2 was not checked for neurological assessment and functional assessment. The nurses' notes dated 12/8/2013 to 12/13/2013 showed no evidence there was a thorough assessment that would have included a comprehensive neurological and functional status. The nurses' notes also did not reflect the observations made by E2, E3, E4 and E5. On 12/30/2013 at 11:05 A.M., Z1 stated she was notified regarding R2's lethargy. Z1 also added that she was she was not given a complete details of assessment that would have included a thorough neurological and functional status and therefore was not able to get the whole picture of what was going on with R2. Z1 further added she was not notified R2 had not improved and showed persistent decreased alertness. Z1 also added her treatment orders were based on the assessment and information that was relayed to her and if the assessments lack information, the order might not have been appropriate. Z1 also stated her expectation was to monitor R2 closely and consistently and if there was no improvement, she should have been notified with detailed and thorough assessment in order to be able to provide prompt appropriate treatment. Z1 said "it was the lack of complete assessment and information that was relayed to me that made me gave an order for [REDACTED]. The Emergency Department record dated 12/13/2013 at 2:22 P.M. showed R2 response only to painful stimuli. The History and Physical Hospital record dated 12/14/2013 entered by Z1 showed "(R2) has been having increasing lethargy with decreased responsiveness over the past few days. MRI (Magnetic Resonance Imaging) and CT (Computed Tomography) of the brain result showed a new stroke as well as subarachnoid hemorrhage." The Hospital Flow Sheet showed R2 was in the critical care unit from 12/13/2013 to 12/16/2013. R2 was assessed as "lethargic" on 12/13/2014; stuporous on 12/14/2013 and 12/15/2013 and comatose on 12/16/2013. The Hospital record dated 12/29/2013 showed R2 was sent out to a hospice center with medical [DIAGNOSES REDACTED]."

Based on interview and record review facility staff failed to perform safe transfers, failed to revise and implement care plan interventions to prevent recurrent unsafe transfers and failed to follow facility protocols to evaluate individual resident transfer/ ambulation abilities. This applies for two of three residents (R2 and R3), reviewed for falls in the sample of four residents. As a result: R2 sustained multiple unsafe assisted transfers in a 2 month period. R2 sustained a non-displaced fracture through the base of the left medial femoral condyle and frequent complaints of pain. The findings include; 1) R2 has [DIAGNOSES REDACTED]. R2's 8/27/13 Incident /Accident report includes; while being assisted with a stand - pivot transfer by E8 and E12 (certified nurse aides),from wheelchair to a shower chair, R2's legs gave out resulting in a fall incident. This incident report included a written statement by E12. E12 documented, that on 8/27/13 E8 requested E12 to assist with transferring R2. E12 states that prior to the transfer, E12 told E8, 3 separate times, that R2 is a mechanical lift transfer but E8 replied saying that she was not because she can stand." The statement included "as we lifted (R2), with a gait belt, (R2), began to squat down to the floor, saying she was falling." On 10/05/13 at 3:00PM, R2 stated during interview, "on 8/27/13, (E8) and another nurse aide attempted to transfer me from wheel chair to shower chair when my legs gave out and I fell . I told E8 prior to the fall that I could not stand and walk but E8 said "Yes you can." "I told them I was falling and I started to sink down to the floor. My knees buckled. E8 kept saying; yes you can, your not trying hard enough, just do it." R2 said "I started screaming in pain, saying lower me to the floor or get the (mechanical lift). Then I fell on my knees." R2 said "I have venous thrombosis and cellulitus in my lower extremities and had problems standing due to pain in my legs at the time of this fall incident." R2 also said "E8 got mad at me, saying I wasn't cooperating because I couldn't stand." R2 also said that since the 8/27/13 fall, she has frequent, daily pain in her left knee area since the 8/27/13 fall incident and her pain medication is not holding down the pain. On 10/05/13 at 3:45PM, E8 during interview stated that on 8/27/13, while being pivot transferred from wheel chair to a shower chair, R2 kept saying "my leg, my leg, let me fall. " E8 told R2 "I can't let you fall." R2 has been complaining of a lot of lower extremity pain for years. During this transfer R2's knees buckled and E12 and I lowered R2 to the floor. On 10/08/13 at 2:00PM, E12 stated; on 8/27/13, E8 was R2's nurse aide and asked E12 to help transfer R2. E12 told E8 that R2 was a mechanical lift transfer but E8 said "No she's not." E12 said, "I know (R2's), a (mechanical lift), transfer." R2' legs began to sway after she stood up and R2 kept saying "I'm falling, I'm falling." At this point E12 directed E8 to put R2 back in her chair but E8 refused and said "No, come on, lets keep on going." Just then, R2's knees bent and she started going down. E12 said "I couldn't lift her back up, so we lowered R2 to the floor." R2's care plan includes limited mobility related to weakness, transfer with mechanical lift with two or more assist when unable to tolerate pivot transfers. During 10/08/13 interview, E2 (DON) and E6 (careplan coordinator), stated, R2 has no restorative or therapy assessment of her transfer abilities or status prior to the 8/27/13 fall with fracture injury. R2's 8/27/13 nurses notes include: - 3:00PM, complaint of pain to lower extremities , especially the left one. Norco (pain medication), administered. - 3:30PM, R2 went to the director of nurses (DON), office and requested hospital evaluation of severe lower extremity pain. - 10:30PM admitted to hospital with [DIAGNOSES REDACTED]. R2's 8/31/13 readmission assessment and nurses notes document new [DIAGNOSES REDACTED]. R2's 9/01/13 through 10/05/13 Medication administration records (MAR), document almost daily administration of Norco (as needed (PRN), pain medication), for complaint of left leg pain. R2's 9/28 - 10/05/13 MAR's document Norco PRN administered 2 - 5 times per day for complaints of left leg pain. On 10/11/13 at 10:20AM, during a telephone interview, Z1 (R2's physician during 8/27 - 8/31/13 hospitalization ), stated R2 had no fall incidents while hospitalized ,[DATE] - 8/31/13. R2 sustained a distal femur fracture from a fall incident 8/27/13 at the nursing home. R2's 8/27/13 emergency room X-rays of the left ankle and left lower leg were negative for fractures because the Xrays were not taken of the fracture site (distal femur). R2 was admitted to the hospital with [REDACTED]. When R2 was started on physical and occupational therapy, R2 started having complaining of left leg pain while weight bearing. On 8/31/13, Z1 ordered an X-ray of R2's left femur and found a non-displaced distal femur fracture. Z1's 8/31/13, hospital progress note states, R2 has on-going left knee pain, worsening with physical therapy on 8/30/13. No new injuries since admission but fall occurred prior to hospital admission. 8/31/13 X-ray documented a non-displaced left distal femur fracture. Z2's 8/31/13 progress note documents, R2's 8/31/13 left knee X-ray shows a non-displaced medial tibial plateau fracture. Z2 documented; reviewed R2's 8/27/13 tibia, fibula and ankle X-ray's and it is difficult to ascertain any fracture site in these films. Z2's recommendation included follow-up with orthopedic in a few weeks for repeat X-ray of the left knee. R2's 8/11/13, 3:00AM nurses note, document a fall incident while being transferred in the facility. R2's 10/06/13, 7:19PM nurse aide "Interactions / Behaviors" documentation, states while transferring R2 in a mechanical lift, one of the lift straps came loose, causing the lift to tilt over to the side with R2 suspended in the air. Staff were able to get R2 back into bed, re-strap the sling to the lift and transfer R2 into her chair "safely." On 10/10/13 at 4:15PM, during a telephone interview, E2 (DON), stated facility has no incident report of R2's 8/11/13 fall or any nursing documentation of R2's 10/06/13 mechanical lift incident. E2 said, R2's 10/06/13 mechanical lift transfer incident was the result of improper hooking of the sling to the lift, not due to a mechanical problem. As of 10/05/13 R2's care plan was not updated with new interventions to prevent recurrence of transfer related incidents after the 8/11/13, 8/27/13 and 10/06/13 incidents. 2) R3's 8/10/2013 incident/accident report includes, at 12:00 pm E5 (CNA), "was transferring (R3) by herself without a gait belt. R3 had trouble with stand and pivot and E5 lowered him to the floor ... " R3's 5/18/2013, 8/10/2013 and 8/16/2013 fall risk evaluation documented R3 to be a high fall risk. R3's 5/10/13 care plan includes R3 is a high risk for falls, requires two assist with all transfers and ambulation. R3's transfer ability care plan problem includes; "resident will transfer with hands on assist of two with gait belt at every opportunity." R3's mobility showed decreased strength, coordination and endurance in lower extremities and to use a gait belt with two CNAs for mobility. On 10/8/2013 at 1:15 pm, during a telephone interview, E5 (CNA) stated, R3 usually stands with assist but verbalized he was afraid of falling. E5 asked therapy staff what was needed for R3's transfer's and was told to use a sit to stand device. E5 said that a doctor's order was needed before using a mechanical lift device. E5 attempted using the sit to stand device but R3 again voiced he was afraid he would fall. E5 then proceeded to stand pivot transfer R3 without any assistive device, by herself. E5 stated she held the waistband of R3's pants and R3 held her waist and as E5 began to stand resident from bed to chair R3 began slipping and R3 had to be lowered to the floor. R3's 7/22/2013 occupational therapy progress notes, under activities of daily living (ADL), documented ADL transfers with assistive device (AD). The facilities policy titled " Resident Handling " documented, " each resident is assessed upon admission and as needed but not less than quarterly to determine their ability to transfer and ambulate. Resident needs will be determined and classified as (A) one person assist. (B) Two person assist. (C) Mechanical assist or (D) Independent. This information will be communicated via the care plan and pocket worksheet. All direct caregivers are required to utilize safety (gait) belts for all transfer and ambulation unless medically contraindicated. " R2 and R3's care plans do not identify A, B, C, D assessment for transfers. The facilities policy, titled " Reporting of Resident Accidents/Incidents, " documented under " procedures " #5 states, "a descriptive summary of the accident/incident will be recorded in the resident's medical record by a licensed nurse witnessing or discovering the occurrence. " R3's 8/3/2013-8/12/2013 nursing progress notes did not show a post accident/incident nursing assessment related to the accident/incident of 8/10/2013.

Based on record review, interview and observation the facility failed to assure pain medication was available for one resident (R12) who had been assessed as experiencing high levels of pain and failed to provide and utilize [MEDICAL CONDITION] pumps as ordered by the physician. This failure led to (a) R12 experiencing pain at a 7 (on a scale of 1-10) following therapy and while in [MEDICAL TREATMENT]. This is for one of 6 residents (R12) in the sample who has pain. Findings include: Review of admitting full Minimum Data Set ((MDS) dated [DATE] shows R12 is [AGE] years old, alert and oriented to all spheres with [DIAGNOSES REDACTED]. This MDS triggered Care Area Assessment to include Pain. The facility did not conduct an assessment to address his pain. On 2/21/12 E3 (nurse) entered R12's room to pass his midday medications at 11:10am. R12 asked E3 "What about the pain pill I requested over an hour ago?" E3 told R12 he does not have any pain meds available and he (R12) would have to wait until later tonight to get it, when pharmacy delivered it. R12 stated he is having a lot of pain after physical therapy, especially in his right hip. He cannot now go sit for four hours in [MEDICAL TREATMENT] without the pain medication, which he is scheduled for in 20 minutes. R12 also stated he has [MEDICAL CONDITION] and his lower extremities are very painful. Surveyor instructed E3 that R12 needed to receive pain medication prior to [MEDICAL TREATMENT]. E3 stated "It is quite a process and will take at least 20 minutes." E3 obtained the "contingency box" which she stated contained emergency medication but would have to get clearance from pharmacy by way of a combination to open the lock. This would be obtained once pharmacy received a script from the physician for the narcotic. At this point, E3 stated she had to leave the facility. E2 was notified of the situation and went into R12's room and said: "We talked about this the other day. There have been congressional hearings about the laws the DEA (drug enforcement agency ) passed regarding obtaining narcotics in nursing homes..." R12 interrupted E2 stating that he does not care about congressional hearings, "I shouldn't have to wait until you run out of my pain medication to reorder it and in the meantime, have to lie here in pain and then go sit for four hours, still with no relief. I've been here for two weeks now and you should know that this is how I manage my pain. Some days I take two pills and other days when I'm not in [MEDICAL TREATMENT], I take 1. What is so hard about that? I just can't be in that much pain while I'm sitting in [MEDICAL TREATMENT]." R12 told surveyor his pain was at least a 7 now. R12 received his pain medication at 11:50am, 1 hour and 40 minutes since he first requested it from E3 after returning from therapy. Review of R12's pain assessment dated [DATE] is not accurate or comprehensive. The location of R12's pain on this form states it is overall joint pain with no mention of hip or lower extremity pain (from the [MEDICAL CONDITION]) and the section on how it affects his daily activities is blank. It shows R12's pain is acute, internal and frequent, presently rated at a 7 (on a scale of 1-10) with it reaching an 8 at times. Additional information is not completed on the back of this form. There is a written comment stating "prefers a pain med prior to [MEDICAL TREATMENT] and will request." The pain care plan dated 2/4/12 is not being followed. The goal is for R12 to ask for pain med as needed and the approach is to give pain meds as ordered and to educate with early intervention of pain medication. Neither of these approaches are followed if the facility does not have the medication available when requested and the resident has to wait 1 1/2 hours for it to be obtained and administered. Review of R12's POS (physician order [REDACTED]." R12 was asked on 2/22/12 if he had the pumps somewhere in the room and R12 stated he did not and has not had any pumps since he was admitted on [DATE]. E2 confirmed on 2/23/12 R12 had not been using any [MEDICAL CONDITION] pumps and said R12's wife said she was going to bring in the pumps from home but has not yet.

Based on record review, interviews and observation the facility failed to accurately and comprehensively evaluate two residents who complained of pain, develop and implement plan of care to manage R 31 and R 25's existing pain, implement alternative interventions including non pharmacological to R 31 who verbalized additional (stomach) pain after taking the prescribed pain medication. This applies to two of five residents (R31 and R25) reviewed for pain management in the sample of 10. This failure led to R31 experiencing constant, unrelieved pain described as a 9 on a scale of 1-10 (10 as the worst). Findings include: (1) According to the medical record R31 is a [AGE] year old, alert and oriented , ambulatory female who was admitted to the facility on [DATE]. Her original admission was for short term therapy to regain her strength after her hospitalization . Her admitting diagnoses included hypokalemia and urinary tract infection. R31 also has no [DIAGNOSES REDACTED]. The form stipulates that R31 is expected to stay in the facility for 90 days or less. The facility's initial discharge plan noted R31 was admitted for respite care for a maximum of 1-2 months. On 05/03/12, R31 was observed in her room lying in bed at approximately 11:00 am. She was asked if she had any plans to live somewhere other than the facility. R31 replied she wouldn' t mind living somewhere else but she would need some help because of her back pain. R31 stated she is in pain all the time and rated the pain as a 9 on a scale of 1-10 (with 10 being the worst pain). R31 further stated the pain medication prescribed for her causes her so much stomach pain she just doesn't take it. R 31 stated the staff (nurses) were aware of this effect but offered no alternative treatment. R31 said she did take one pain pill yesterday (05/02/12) because she was desperate but she really paid for it later. R31 was asked if the nurses were aware of her pain and R31 stated that everyone knows about it. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The record reflected R31 is not receiving the [MEDICATION NAME] and she is being assessed on all 3 shifts as being pain free. The care plan was also reviewed and pain is not addressed in the plan. No other interventions were employed to relieve R31 ' s pain. E 5, RN (registered nurse) stated R31 sometimes complains of leg pain but she never wants to take anything for it, she will just change her mind and say " forget about it " . E5 also stated that the other day R31 asked for something less strong for pain but R31 can't take many pain meds because she has a lot of allergies [REDACTED]. R31's admission assessment completed on 08/13/12 noted that R31 has no pain and no [DIAGNOSES REDACTED]. E6 stated on 05/03/12 that R31 " doesn't have any pain, she has an order for [REDACTED]. Z1 stated on 05/03/12 at 1:15 PM, Z1 stated, "she has a chronic arthritis. I prescribed [MEDICATION NAME] initially because of her back pain and arthritis pain. She has a chronicarthritis problem. I got a call from the facility yesterday because she complained of pain. Today she's complaining of stomach ache. I expect the facility will tell me about my patients, I'm blinded of the level of information, so I need extra measures." Z 1 said he was unaware of R31's complaints of pain because he was never informed by the facility. Z1 also stated he saw R31 today (after discussion with the surveyor) and R31 did complain of back and joint pain. Z1 further stated because of her [MEDICAL CONDITION] and complaints of pain he will order x-rays to rule out possible compression fracture or other problems. (2) Review of May 2012 POS (physician order [REDACTED]. Review of History and Physical from an acute hospital stay in January 2012 states R25 also has a [DIAGNOSES REDACTED].. Interview and observation of R25 on 5/2/12 at 1:20pm found him lying in bed, alert and oriented to person and time. R25 stated he was experiencing pain in his lower extremities and in his back, rating it a 6 on a scale of 1- 10 and the pain is the reason he is lying down. R25's extremities were observed to be very [MEDICAL CONDITION] with compression stockings on. R25 said he has pain everyday but usually just deals with it. R25 does not always tell staff about his pain because it's just something he has to learn to live with. E4 (nurse's aide) stated on 5/3/12 at 11:05am R25 complains of pain off and on throughout the day, it depends on what the physical activity is that he's doing. E4 said R25 has pain when he's turning in bed or washing up for the day. E5 said his discomfort is probably one of the reasons R25 does not like to get up or go to therapy. Review of a fax dated 4/4/12 to R25's physician states R4 "wants stronger pain med for his legs and back pain. He has order for Tylenol 325 mg ii tabs q 6 hours. Please advise." E2 (director of nursing) was asked on 5/2 and 5/3/12 to provide any follow-up information to this request such as physician response or re-assessment of R25's pain and none was provided by end of survey 5/3/12. Review of MAR for the months of April and March 2012 that R25 was pain free for all but 7 of the 180 times it was rated (3 times a day)and received Tylenol 625 mg ten times in the same period. Review of pain assessment dated [DATE] is not comprehensive as it only identifies R25's pain as "all over" and does not evaluate what type of things relieve pain, what increases the pain or makes the pain worse. It is also incomplete as there are blank sections indicating how the pain has affected changes in daily activities. The pain care plan does not have measurable goals or evaluation of the interventions listed. One of the interventions is to use non-pharmacological interventions but no documentation was provided as to which of these approaches were after asking E5 (nurse).

Based on observation, record review and interview the facility failed to develop and implement individualized and specific interventions including the use of call lights to prevent residents from falling and wandering out of the facility. As a result: - R16 who has history of falling, sustained right distal radial fracture when she was found on the floor near her bath room. - R13 on 11/15/11 exhibited confusion and disorientation. On 11/16/11 at 2:00 pm R13's nurses notes indicated she returned to facility in a cab accompanied by the police. No one noticed when R13 wandered out of the facility. The facility did not determine the date, time, and how R13 left the facility. There was a potential danger for the health and safety of R13 when she left the facility. - On 2/1/12 R18's motorized chair tilted while he was seated in it and transported in the facility bus. R18 sustained hematoma on left leg medially below the knee; and his left shoulder had hematoma and abrasion. - R1 sustained a fracture to right humerus and laceration to the head; - R2 sustained a fracture to left femur of unknown origin. Findings include: 1. The facility documented an incident indicating R16. On 6/23/11 at 8:20 am she tripped on the wheel of her electric wheel chair when she was transferring herself from the wheel chair to her bed and fell on her right side. The incident investigation indicated [DIAGNOSES REDACTED]. Even though the investigation indicated interventions to include room near nurses station; this intervention was not added to R16's plan of care plan until 7/24/11. The only intervention that was added to R16's fall care plan on 6/23/11 was monitor her for medication side effects. The facility also documented an another incident on 7/23/11 at 9:00 pm staff noted R16 on floor of room near bath room with her back against edge of dresser; and it appears R16 attempted get to bath room without assistance and fell . R16 was admitted to the local Hospital with [DIAGNOSES REDACTED]. Again the incident investigation indicated morbid obesity, intermittent confusion, lower extremity wounds and recent loss of independence were the contributing factors for the fall. R16's 5/5/11 fall care plan interventions are generalized and not specific to her functional ability including her activities of daily living. R16's 4/23/11, 6/23/11 and 7/23/11 fall risk assessment noted she is at risk for falling. The risk factors included were history of falls, ambulation and elimination status was limited, gait and balance, medications and predisposing diseases. The facility did not evaluate these risk factors in developing care plan interventions, especially the assistance required in the area of activities of daily living since her last fall. 2. On 2/23/12 at 11:00 am R13 stated she called a cab and left the facility in the morning of 11/16/11. R13 said the cab driver called the police on her and brought her back to the facility, because she did not know where she was going and had no money to pay for the cab. R13 continued to say that she had difficulty with her medications. R13's 11/16/11 at 2:00 pm Nurse Notes noted she returned to the facility after the police had been notified by a cab driver, because she ran up the cab fare up to $50.00 and was delusional, confused in conversing with the cab driver. The police called the facility and confirmed R13 is a resident of the facility. R13 believed she lived somewhere else. The Nurses Notes also indicated the staff examination determined that she is delusional, disoriented and paranoid. The facility sent her for acute psychiatric hospitalization . The facility neither documented R13's wandering out of the facility on 11/16/11 as an unusual occurrence report nor conducted investigation. The facility did not determine when and how R13 left the facility or if the staff was negligent in monitoring her. The facility Director of Nurses confirmed this significant incident was not reported to the Department and had conducted no investigation. The facility has system for the residents to sign in and out of the facility by signing release of responsibility for therapeutic home visits. The sheet the facility had on record for R13's movement in and out of the facility was not consistent for the year 2011. There was no entry to reflect R13 leaving the facility on 11/16/11. This was confirmed by the facility Director of Nurses. On 11/15/11 R13's Psychiatry progress notes indicated she presented with new and intensified confusion. R13 was confused about recent events by asking for medication that were just given, confused to time and is talking about random past events. On 2/23/12 at 11:00 am over telephone the Physician Assistant (Z4) stated R13 did present with the confusion, but did not think R13 would leave the building. Z4 also stated the staff should have known R13's movements in and out of the facility. On 2/23/12 at 2:30 pm E14 the Psychiatric Rehabilitation Service Counselor (PRSC) stated R13 was not in right frame of mind when she left the building on 11/16/11, her medications needed adjustment, that is why the facility sent her for emergency psychiatric hospitalization . E14 also stated she needed to be supervised closely and should have known her leaving the building. The facility after the incident, conducted no assessment of R13's behavior of wandering out of the facility or developed any plan of care that guides the staff to monitor her. The facility failed to monitor R13 when she wandered out of the facility on 11/16/11. 3. On 2/1/12 at 1:50 pm it was noted in R18's Nurses Notes indicating he had an accident in side the facility bus during his transportation; he bumped his left leg below the knee medially. The area was swollen, painful to touch, bleeding was minimal. At the local hospital R18 received treatment for [REDACTED]. On 2/23/12 at 1:10 pm R18 who is alert and oriented stated that the bus driver did not know how to restrain his motorized chair with straps in the bus. As he was getting late for the doctor's appointment they proceeded to drive the bus without restraining his motorized chair. The driver took a sharp turn, which made R18's whellchair tip over and R18 got hit in several places on his body. On 2/23/12 at 3:30 pm E2, the Director of Nurses stated that when she got the call, she checked the chair in the bus and determined it was not easy to tilt the chair. E2 also stated the bus driver told her the chair was not strapped at R18's request. The facility did not conduct investigation of the incident to prevent such further occurrences. 4. Review of most recent full Minimum Data Set ((MDS) dated [DATE] shows that R1 is [AGE] years old and admitted to facility on 4/9/11 with [DIAGNOSES REDACTED]. The functional status section shows that R1 requires extensive physical assist for all mobility concerns including bed mobility. This MDS also shows that R1 is alert and oriented and speaks only Spanish. Review of Fall Risk assessment dated [DATE] and monthly thereafter, shows R1 is a high risk for falls and had a fall on 5/18/11. Review of incident report dated 10/11/11 states that R1 was helped to bed at 1:30pm by a nurse's aide who then went across the hall, heard a sound and found R1 lying on her stomach on the floor. Nurse's note dated 10/11/11 states R1 sustained a laceration to the right eyebrow and right upper arm. R1 was sent out to the ER and returned with a [DIAGNOSES REDACTED]. Z1 (R1's family member) stated on 2/23/12 at 2:30pm (with R1 present) that the "My mom came here for rehab and ends up fracturing her good arm. The stroke had made her left arm pretty useless and now she can't even feed herself because she broke her good arm." Z1 translated for R1 and stated that R1 had been attempting to reach the call cord that was out of her reach on 10/11/12 and rolled out of bed, falling on the floor. Z1 stated that R1 also sustained facial bruising and a cut to her eyebrow as a result of the fall. R1 did not have the (quarter) siderails that are in place now on her bed. Z1 said that R1 complains of pain to her back often and that is why R1 was shifting herself in the chair presently and requesting to lie down. Z1 asked R1 if the pain keeps her awake at night and R1 stated "Yes." Review of the facility investigation only states that R1 was placed in bed by the CNA and when the CNA left the room she heard a noise and returned to find R1 on the floor with injury. There is no statement obtained from the resident who is assessed as being alert and oriented as to how she fell out of bed. Interview with E2 (director of nursing ) on 2/24/12 at 10:45am stated that there had been no statements taken or any further investigation into this incident in an attempt to determine the cause of R1's falling out of bed. 5. Review of full MDS dated [DATE] shows that R2 is [AGE] years old, admitted to facility in November 2006 and has [DIAGNOSES REDACTED]. R2 is totally dependent on staff for all activities of daily living and does not ambulate. Care plan for falls dated 1/27/10 through 10/22/11 states "potential for trauma related to decreased strength, poor sitting balance, increased weakness in upper/lower extremities.(R2) is alert, oriented to her name only. Dependent for all ADL's. Oblivious to her safety needs. Assessed as high risk for falls. R2 will transfer safely with assist of two with hoyer lift." This was not achieved as R2 sustained an fracture to the femur of unknown origin sometime around 8/18/11. Observation of R2 on 2/22/12 at 2:10pm found her lying in bed. R2 was unable to answer simple questions but did maintain eye contact. Review of nurse's note dated 8/18/11 states R2's "left femur (thigh area) swollen, painful to touch, leg immobilized ... x-ray of leg ordered ... will continue to monitor." The next nursing entry is on 8/20/11 at 6pm, 2 days after observing the swollen and painful thigh, stating the xray shows a fracture to the left femur. It is unclear why there was a 2 day delay in diagnosing R2's fracture. There is no documentation indicating how staff delivered care to R2 during that time. E2 stated she did not know why there was a 2 day delay. E2 stated on 2/24/11 at 11:00am that "It looks like I didn't complete an investigation or report this to the state. I don't know what happened." The facility did not conduct staff interviews to assist in determining possible causes for this injury of unknown origin or to rule out the possibility of abuse. 6. E2 stated on 2/23/12 at 2:45pm that R5 was in a motor vehicle accident years ago leaving him a quadriplegia with traumatic brain injury. The current cognitive care plan originally dated 5/25/11 states R5 "doesn't appear to have recall after approximately five minutes. Seems to be forgetful of detailed information. Needs verbal cues to help provide a general framework for orientation." Another current care plan dated 5/25/11 states R5's assessment reveals a greater than normal risk for falls related to [DIAGNOSES REDACTED]. This care plan continues on stating that R5 was out of facility on Larkin Avenue on 7/1/11 at 2:00pm when he started sliding out of his wheelchair. He hit a pot hole the wheelchair tipped over. R5 complained of numbness to both wrists and left shoulder. X-rays ordered to rule out fractures. This same care plan contains an entry dated 9/21/11, 4pm, in which R4 was outside facility in his electric wheelchair, riding on the sidewalk. He hit a bumpy area on the ground and the wheelchair caused R5 to fall forward on the grass. Approaches listed on this fall care plan state "Lap belt on when up in wheelchair per resident's request and Advised resident to use the county transport when going out." These 2 approaches have not been implemented to assist in maintaining R5's safety when out of facility. When asked if R5 has been assessed for safety concerns when leaving the facility on his own in his electric wheelchair, E2 stated no, but it will be done shortly.

Based on interview and record review 1 of 1 resident (R3) was injured, while being transferred to an appointment in facility van by facility staff (E4) As evidenced by: On 10/5/11, at approximately 8:30 AM, R3 in a motorized wheel chair was placed in the facility's transportation van by E4 (CNA/driver). E4 on interview of E3 (Supervisor of Safety) and review of facility records and E4's employee files, was inserviced and trained for proper safety transportation of residents. E4 on request of R3 placed R3 in the van backwards, instead of forward as E3 and facility records indicated as being the proper and safe way for residents to ride. E3 did a return demonstration for Surveyor as to proper seating for residents while riding in the van. Facility incident and investigation form and interview of E2 confirm E4 placed R3 in a backwards position in her wheel chair while being transported. In addition to this wheel chair anchoring straps were not tightly fastened. While E4 was driving R3 in the van, E4 turned a corner and R3's wheel chair fell ("tipped") over and landed "against lift". E4 immediately returned to facility since being only two blocks away and nursing assessed R3 for injury. R3 received a skin tear to her left hand, bruising to her upper right chest area, bruising to right inner leg and had complaints of right shoulder, right upper back and right knee pain. Physician was notified and R3 was sent to the hospital. Hospital x-rays completed. R3 was found to have a fracture of the left seventh rib, with no pneumothorax.

Based on observation, interview and record review the facility failed to adequately supervise 1 resident to prevent a fall and failed to initiate appropriate interventions to prevent a future fall. This failure resulted in R12 falling and sustaining a hip fracture on 2/16/11. This is for 1 of 3 residents in the sample reviewed for falls. The findings include: R12 is an [AGE] year old resident with blindness who was admitted to the facility on [DATE] according to the Minimum Data Sets (MDS) and Care Assessment Areas (CAA's) dated 10/14/10. R12 was at risk for falls due to poor vision according to documentation in her care plan dated 10/20/10. Care plan interventions included keeping the environment free from obstacles. R12 was found on the floor in another resident's room on 11/27/10 at 3:30 PM according to nursing notes and incident/accident report dated 11/27/10. R12 was found with a television next to her according to the notes. R12 complained of pain to her sacrum and left foot. R12's care plan was updated 11/27/10 to include an intervention to check R12 frequently while in her room. R12 declined in her condition and was placed on hospice according to the significant change MDS dated [DATE]. R12 was assessed to require 1 person physical assist for ambulation in her room and in the corridor according to the MDS dated [DATE]. R12 was found on the floor in a hallway on 2/16/11 at 8:30 AM according to nursing notes. The fall was not witnessed and does not indicate which hallway the fall occurred according to the incident report dated 2/16/11. This was confirmed by E2 (Director of Nursing) on 4/28/11 at 1:30 PM. R12 complained of hip pain and was subsequently found to have a hip fracture according to the fall investigation tool and Xray report. All of the hallways (A,B,C,D) were observed cluttered with wheelchairs, mechanical lifts and/or adult recliner chairs on all days of the survey (4/25, 4/26, 4/27, 4/28). A wheelchair charger and long cord was observed on the floor outside of room D 2 on all days of the survey. On 4/28/11 at 11:55 AM E2 (Director of Nursing) stated that R12 would ambulate to other hallways and toward the front door when she was ambulatory. E2 said that R12 was resistant to care and would ambulate without assist. E2 confirmed that this behavior is not reflected in the MDS or the care plan and that no interventions were planned. On 4/27/11 12:15 PM Z4 (R12's Granddaughter) was interviewed by telephone. Z4 confirmed that R12 has been confined to a recliner chair and is no longer ambulating since her hip fracture occurred.

Based on observation, record review, and interview the facility failed to adequately assess 1 resident's change in condition who exhibited signs and symptoms of a TIA (Trans Ischemic Attack) and/[MEDICAL CONDITION]. As a result of this failure R3 had to wait approximately 3 hours before being sent to the hospital. This is for 1 resident in a sample of 3. (R3) The findings include: Review of R3's admission face sheet showed R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/17/10 at 11:40 a.m. R3 was observed sitting at a table in the facility's dining room with R4, R5, and R6. R3 was interviewed at this time. R3 stated, "On 9/3/10 at approximately 10:30 p.m. my speech became slurred. I couldn't drink water. I talked to E4 (RN) and she didn't say anything. She was going off duty. Then I talked to E3 and E5 (LPN's). I told them I think I had a stroke. They said you didn't have a stroke and they were laughing and saying you just go to your room. I told them something was wrong. They said you will be ok in the morning. They were laughing at me. I think I was acting like I was drunk or something. I went to my room and called my doctor's answering service. They couldn't understand me because I had slurred speech, so R4 had to talk to them for me. The doctor's service called back here and talked to the nurses, they said the doctor told them to watch me. I insisted on them sending me to the hospital. I got upset and was crying, then they finally sent me to the hospital. It took them over 2 hours to send me to the hospital." Interviews with R4, R5, and R6 on 9/17/10 noted all to say they were sitting in the dining room playing a board game on 9/3/10 at approximately 10:30 p.m. with R3. All stated R3 became motionless, then started with slurred, garbled speech. All stated that R3 attempted to drink some water but the water ran out of her mouth. R4, R5, and R6 stated R6 went to get E4 (RN) to examine R3 and stated E4 said nothing was wrong with R3. R6 then took R3 to E3 and E5 (LPN's). E3 and E5 told R3 to go to bed and was laughing at R3. R4, R5, and R6 were upset with E3's and E5's behavior. All stated, "They were laughing at R3 and R3 was having a stroke or TIA. They should not treat people that way." Interview with E4 on 9/17/10 at 2:40 p.m. noted E4 to say when she examined R3 she saw no signs of a TIA or a stroke. E4 stated R3 was speaking clearly. E4 admitted R3, R4, R5, and R6 told her R3 had just had slurred speech and was motionless for approximately 1 minute. E4 reported to E3 (nurse covering the unit until E5 arrived) that R3 was having a "behavior." Interview with E3 on 9/17/10 at 3:00 p.m. noted E3 to say, "R3 came to the nurses station and said she can't talk. R3 said, "I think I'm having a stroke. I'm not joking, it's true" She was stuttering, then talking straight, then stuttering again. She was trying to say a doctor's name and was saying Dr. Eck....Eck...Eck....and couldn't say the doctor's name. She started laughing and we (me and E5) started laughing. We told her to go to her room and we would monitor her. We went to her room and saw how she was talking and we sent her to the hospital." Nursing documentation showed on 9/3/10 at 11:20 a.m. when E5 asked R3 about her doctor, R3 had stuttering speech. R3 was instructed by E5 to go to her room. Nursing documentation also showed on 9/4/10 at 12:00 a.m. R3's doctor's answering service called the facility stating R3 had called wanting to speak to her doctor. The answering service was inquiring what was going on with R3. Nursing documentation showed on 9/4/10 at 1:00 a.m. R3 was crying, upset, and was afraid. R3 was finally sent to the hospital on [DATE] at 1:20 a.m. R3 was not sent to the hospital until approximately 3 hours after she complained of stroke signs and symptoms. Nursing documentation dated 9/4/10 at 6:00 a.m showed R3 was admitted to the hospital with [REDACTED]. Interviews and nursing documentation showed no thorough assessments were done on R3 to determine if she was having signs and symptoms of neurological problems. The facility's policy on assessing for neurological problems included assessing the resident for memory, paresthesia or paralysis, and speech patterns. Hospital history and physical documentation dated 9/4/10 showed assessment included "Left facial droop and slurred speech most likely due to stroke." Hospital data showed on 9/9/10 R3 was sent to the hospital again. History and physical documentation showed the assessment information as "Acute [MEDICAL CONDITION] ([MEDICAL CONDITION]) causing right sided weakness." R3 also complained of worsening slurred speech and difficulty talking and finding words. R3 returned to the facility after the first hospital visit on 9/6/10 with right facial drooping and slurred speech. R3 returned to the facility after the second hospitalization on [DATE] with slurred speech and right sided weakness. R3 had to receive physical and speech therapy. Interview with E2 (Director of Nurses) noted E2 to say, "E3 and E5 should have sent R3 out to the hospital right away when they noticed that she was stuttering and having bizarre behavior. That is some of the signs of a stroke. They should not have been laughing at her either. We don't treat our residents like that." Review of the facility's policy on Notification of Resident Change in Condition showed " The licensed nurse will immediately notify the attending physician when: there is a significant change in the resident's physical, mental, or psychosocial status." Review of R3's plan of care showed no problem or intervention to monitor for TIA's or [MEDICAL CONDITION]'s even though R3 had 2 recent hospitalization s for these problems.