Every finding on record at Aperion Care Forest Park

Based on observation, interview, and record review, the facility failed to ensure the nurse administering the medications observed the resident while taking the medications, failed to ensure medications were administered one hour after the scheduled time, and failed to document medication administration after administering medications to the residents. These failures affected 6 (R5, R6, R7, R8, R9, and R10) residents reviewed for medication administration in the total sample of 13 residents.Findings include:R5's admission Record documented that this resident's diagnoses include but are not limited to spinal stenosis, hemiplegia (paralysis) and hemiparesis (muscle weakness), and osteoarthritis.R5's (05/11/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating the resident's mental status as moderately impaired.R5's (Schedule Date: 06/06/2026-06/06/2026) Medication Administration Audit Report documented that R5's 8am, 9am, and 10am medication administration time were more than one hour after the scheduled time except for Magnesium Gluconate. Of note, V5 documented time for the medication administration were between 4:57pm - 5:48pm.On 06/06/2026 at 10:29am, V5 (Licensed Practice Nurse) informed this surveyor he would be dispensing R5's medications. V5 was looking at the EHR (electronic health record) screen. On 06/06/2026 at 10:36am, V5 began preparing R5's medications.On 06/06/2026 at 10:57am, V5 brought R5's medications and blood pressure machine inside R5's room, placed the cup containing R5's medications on R5's side table, obtained R5's blood pressure and heart rate, and informed R5 to take her medications. R5 took one tablet and swallowed the tablet. On 06/06/2026 at 11:05am, R5 requested V5 to take her blood sugar. V5 left the room and brought the glucometer with him and checked R5's blood sugar. V5 left the room again, R5 started taking the medications one at a time without V5 present.On 06/06/2026 at 11:09am, outside of R5's room, this surveyor inquired V5 if he was going to observe R5 take the medications, V5 stated she (R5) said she wanted to take a rest. This surveyor and V5 went in the room and observed R5 took the last medication. R5 stated she did not say she wanted to take a rest.On 06/06/2026 at 11:20am, there were 16 residents on EHR (electronic health record) screen that remained on red. V5 stated he already passed their (R6, R7, R8, R9, and R10) medications but he had not documented them yet. And he just completed passing (R5)'s and still needed to pass medications to other residents. V5 stated he was supposed to document right after he gave the medications.On 06/06/2026 at 1:09pm, V2 (Director of Nursing) stated the expectation is to administer the medications one hour before and one hour after the scheduled time; the nurse should stay and watch the resident take the medications, to make sure the resident swallowed and tolerated taking the medication and is not choking; and medication administration should be documented right after the nurse administered the medications because that is the standard of practice. R6's admission Record documented that this resident's diagnoses include but are not limited to Type 2 Diabetes Mellitus, osteoarthritis, and schizophrenia.R6's (04/09/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03.: Indicating the resident's mental status as severely impaired. R6's (Schedule Date: 06/06/2026-06/06/2026) Medication Administration Audit Report documented that R6's 8am, 9am, and 10am medication administration time were more than one hour after the scheduled time. Of note, V5 documented time for the medication administration were between 4:25pm - 5:12pm. The 10:00am treatment administration was documented at 5:29pm.R7's admission Record documented that this resident's diagnoses include but are not limited Type 2 Diabetes Mellitus, hypertension, and adult failure to thrive. R7's (04/22/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating the resident's mental status as severely impaired. R7's (Schedule Date: 06/06/2026-06/06/2026) Medication Administration Audit Report documented that R7's 9am medication administration time was more than one hour after the scheduled time. Of note, V5 documented time for the medication administration was at 5:08pm. R8's admission Record documented that this resident's diagnoses include but are not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness), Type 2 Diabetes Mellitus, and dysphagia. R8 (05/21/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 05. Indicating the resident's mental status as severely impaired. R8's (Schedule Date: 06/06/2026-06/06/2026) Medication Administration Audit Report documented that R8's 8am and 9am medication administration time were more than one hour after the scheduled time. Of note, V5 documented time for the medication administration were between 5:14pm - 5:49pm.R9's admission Record documented that this resident's diagnoses include but are not limited to Parkinson's disease, dementia, and Type 2 Diabetes Mellitus. R9's (04/24/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 07. Indicating the resident's mental status as severely impaired. R9's (Schedule Date: 06/06/2026-06/06/2026) Medication Administration Audit Report documented that R9's 8am and 9am medication administration time were more than one hour after the scheduled time. Of note, V5 documented time for the medication administration were between 5:11pm - 6:00pm.R10'S admission Record documented that this resident's diagnoses include but are not limited hypertensive heart disease, COPD (Chronic Obstructive Pulmonary Disease), and schizophrenia. R10's (05/08/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating the resident's mental status as moderately impaired. R10's (Schedule Date: 06/06/2026-06/06/2026) Medication Administration Audit Report documented that R10's 8am, 9am, and 10am medication administration time were more than one hour after the scheduled time. Of note, V5 documented time for the medication administration were between 5:10pm - 6:10pm.The (undated) Medication Administration General Guidelines documented, in part Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures. Preparation. 6. Five rights - right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. Administration. 10. Medications are administered within one hour before or after scheduled time. 16. The resident is always observed after administration to ensure that the dose was completely ingested. Refusal of medication. 1. Residents may actively refuse medications. Refusal may also be through cheeking or pocketing of pills in the mouth. To detect this, the nurse should observe the resident takes and swallows the medication.

Based on observation, interview, and record review, the facility failed to ensure staff do not leave the resident's EHR (electronic health record) open when unattended. This failure affected 1 (R3) resident reviewed for confidentiality of record in the total sample of 13 residents. Findings include:R3's admission Record documented that this resident's diagnoses include but are not limited to COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure with hypoxia, and Type 2 Diabetes Mellitus.R3's (04/08/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 09. Indicating the resident's mental status as moderately impaired.On 06/06/2026 at 9:16am V5 (Licensed Practice Nurse) dispensed R3's medications.On 06/06/2026 at 9:38am, V5 left the EHR screen on, and visible, with R3's information accessible/viewable on the screen. V5 entered R3's room with R3's medications and took R3's vital signs. V5 left the medications at R3's bedside and went out of the room.On 06/06/2026 at 9:40am, V5 stated he left the EHR screen on, with R3's personal health information visible because he knew he was going to come back to the medication cart anyway.On 06/06/2026 at 1:15pm, V2 (Director Of Nursing) stated the EHR of the resident has resident's information and should not be left open unattended. V2 stated the expectation is after preparing the medications, close the screen and lock the med cart before going inside the resident's room to pass the medications. V2 stated leaving the EHR open is a HIPAA (Health Insurance Portability and Accountability Act) violation.The (undated) Medication Administration General Guidelines document, in part Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures. Preparation. 14. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. In addition, privacy is maintained at all times for all resident information by closing the MAR book when not in use.The (undated) Electronic Health Record documented, in part Purpose. To stablish the means by which this facility (i) allows only authorized users make entries into electronic health records and identifies the date and author of every entry; (ii) safeguards the confidentiality of patients records. Confidentiality. Users are required to maintain the confidentiality of electronic patient health records.

Based on observation, interview, and record review, the facility failed to ensure medications were disposed of where resident could not accessed them. This failure affected 1 (R12) resident reviewed for hazard and supervision in the total sample of 13 residents. Findings include:On 06/06/2026 at 1:28pm, V2 (Director Of Nursing) stated the 4th floor is a long term memory care unit. It is the facility's locked unit. On 06/07/2026 at 11:37am, R12 was observed propelling herself towards the nurses' station. On 06/07/2026 at 11:38am, R12 was rummaging through the garbage can. V15 (Licensed Practice Nurse) redirected R12 to stop what she was doing. Inquiring about what just transpired, V15 stated she (R12) was touching the garbage, and she (V15) stopped her right away and she (R12) was saying clean, clean. V15 stated she has a behavior of organizing whatever is in front of her. On 06/06/2026 at 9:56am, R12 was propelling herself on the hallway where V5 (Licensed Practice Nurse) was passing medications. On 6/06/2026 at 10:29am, during the medication administration observation with V5 (Licensed Practice Nurse), there were 2 blue capsules and 2 white tablets in a med cup in the trash can attached to 4th floor medication cart 3. On 06/06/2026 at 10:36am, V5 started dispensing R5's medications. On 06/06/2026 at 10:57am, V5 brought R5's medications inside R5's room. On 06/06/2026 at 11:09am, while both V5 and this surveyor were inside R5's room, observed R12 outside of the room, propelling herself towards the trash can that was attached to medication Cart 3. This surveyor informed V5 that R12 was getting close to the trash can. V5 and this surveyor went out of R5's room. On 06/06/2026 at 11:10am, V5 checked the trash can per surveyor's request and stated there were 2 blue pills and 2 white pills in the trash can. V5 stated R13 refused his medications, and he (V5) disposed of the medications in the trash can. V5 stated the expectation is to throw them where residents could not access the medications. V5 disposed the medications in the sharp container attached in medication cart 3 just above the trash can. On 06/06/2026 at 1:19pm, V2 (Director of Nursing) stated the nurse is expected to dispose of the medications where the resident cannot access them for safety because they are not to take medications that are not prescribed to them. V2 stated if a resident refused the medications, these could be disposed of in the sharp container that is attached to the med cart for safety.On 06/06/2026 at 3:30pm, V2 (Director of Nursing) presented this surveyor with The Medication Administration General Guidelines and read the guideline An adequate supply of disposable containers and equipment is maintained on the medication card for the administration of medications. Disposable containers are never reused. V2 stated each med cart has container where the staff could dispose of medications that were refused by the residents for safety.R12's admission Record documented that this resident's diagnoses include but are not limited to dementia, Alzheimer's Disease, hypertension, and schizophrenia. R12's (04/27/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating the resident's mental status as severely impaired. The (undated) Medication Administration General Guidelines document, in part Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures. Preparation 5. An adequate supply of disposable containers and equipment is maintained on the medication card for the administration of medications. Disposable containers are never reused. The (10/24/2022) Medication/Narcotic Destruction documented, in part 6. Non-controlled medications may be placed in the Drug Buster container or may be placed in a container with an undesirable material such as cat litter or used coffee grounds or in a sharps container.

Based on observation, interview, and record review, the facility failed to ensure staff don and doff gloves appropriately in an effort to prevent the cross contamination. This failure affects 1 (R5) resident reviewed for infection control during medication administration in the total sample of 13 residents. Findings include:R3's admission Record documents diagnoses including COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure with hypoxia, and Type 2 Diabetes Mellitus.R3's (04/08/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 09. Indicating the resident's mental status as moderately impaired.R3's (Active Order as Of: 06/07/2026) Order Summary Report documented, in part Oxygen at 2-4 LPM (liters per minute) via nasal cannula continuous every shift. Active 04/14/2026.R5's admission Record documented that this resident's diagnoses including spinal stenosis, hemiplegia (paralysis) and hemiparesis (muscle weakness), and osteoarthritis.R5's (05/11/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating the resident's mental status as moderately impaired.On 06/06/2026 at 10:50am, during the medication administration observation with V5 (Licensed Practice Nurse) dispensed R5's medications in a med cup. R3 was seated on a wheelchair, propelling herself towards V5 and asked V5 if he could attach the nasal cannula to the oxygen tank located behind her wheelchair. V5 donned gloves, touched R3's nasal cannula tubing and touched the oxygen tank located behind R3's wheelchair, removed the oxygen tank and placed it close to the medication cart, touched R5's medication cup and placed the med cup inside the medication cart. This surveyor inquired if he was supposed to change his gloves before touching R5's med cup after he touched R3's nasal cannula tubing and oxygen tank. V5 responded that he did not touch (R5)'s medications, he only touched the medication cup. On 06/06/2026 at 1:31pm, V2 (Director Of Nursing) stated the expectation is to change gloves between residents to prevent cross contamination. V2 stated if he was wearing gloves and touched a surface, the nurse cannot touch another surface with the same gloves; he should have sanitized his hands after touching R3's oxygen tubing and oxygen tank and before touching her (R5) med cup to prevent cross contamination.The (undated) Medication Administration General Guidelines document, in part Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures. Preparation. 2. Hand washing and hand sanitation: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: C) after coming into direct contact with the resident. 4. Hand sanitation is done with an approved sanitizer: a) between hand washing, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface).The (undated) Glove Use - Nursing documented, in part Purpose: To Establish tasks, procedures, and required use of sterile and non-sterile gloves by nursing personnel. The facility will provide gloves of appropriate quality and size for nursing personnel and use appropriate type of gloves based on medical or surgical aseptic technique in accordance with universal/standard precautions and transmission based precautions. Nonsterile gloves shall be worn for procedures involving contact with mucous membranes or for other resident care. 5. Gloves used for contact shall be removed and discarded after contact with each person, fluid item, or surface.

Based on observation and interview, the facility failed to provide care and maintain hygiene for resident's nails for two of three residents (R3 and R8) reviewed for ADL care.Findings include:On 5/19/26 at 12:30PM, R3 had long, dirty fingernails, R3 said he would like is fingernails to be cleaned. On 5/19/26 at 12:33PM, V11 (Certified Nurse Aide) said that she does nail care every two weeks only when the facility is staffed with two certified nurse aides on each hallway. V11 said she has not performed any nail care for R3. On 5/19/26 at 12:39PM, V2 (Director of Nursing) said that nail care should be performed as needed and when nails are visibly dirty. On 5/20/26 at 11:35AM, R8 with long, dirty fingernails, exposed incontinence brief, and exposed gastrostomy tube. R8 said he would like staff to clean and cut fingernails, but staff does not do it.On 5/20/25 at 11:35AM, V17 (Certified Nurse Aide) said he is assigned to R8, and said they do not provide any nail care for residents.On 5/20/26 at 11:39AM, V2 made aware of above findings and said that her expectations are for staff to provide nail care/grooming/dressing to residents that need it, and it is part of the certified nurse aide duties as part of ADL (Activities of Daily Living) care. Facility Policy on Activities of Daily Living (ADLs)Dressing - obtaining putting on fastening (buttons, snaps, zippers, Velcro laces) and taking off all items of clothing and putting on and removing braces and artificial braces, socks and shoes, accessories (belt, jewelry, scarf tying, and knotting a tie.Grooming. Maintaining personal hygiene, including planning the task and gathering supplies, Combing and or styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and or application of deodorant or powder.

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered by the physician for one of three residents (R7) reviewed for medication administration. Findings include:On 5/20/26 at 11:30AM, Observed V13 (Registered Nurse), passing morning medications due at 9:00AM. On 5/20/26 at 11:30 AM, V13 said he was still passing morning medications due at 9:00AM, because he was behind, said R7 has not received his insulin yet. On 5/20/26 at 11:32AM, R7 said that he had not received his insulin due at 9:00AM, R7 said he has been waiting, and no nurse has come to give him any medications, R7 said he has to wait long periods all the time to receive medication. On 5/20/26 at 11:39AM, V2 (Director of Nursing) made aware of above findings and said medications due at 9:00AM are to be given one hour before and one hour after the administration time, V2 said insulin should be administered following physician orders. On 5/21/26 at 10:47AM, V2 said that as a nursing standard if insulin is missed or given at a different time other than the physician order, physician should be notified. V2 said the physician was not notified on 5/20/26. V2 said facility has no Insulin policy, they follow Medication Administration Policy.An order summary report indicates that R7 has a physician order for Admelog SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro), Inject 14 units subcutaneously two times a day for Diabetes Mellitus at Breakfast (8AM) and Lunch (12PM). Check Blood Sugar prior to meals and ensure patient eats before giving insulin. Medication Administration Record for May 2026 indicates on 5/20/26 Admelog SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro), Inject 14 units subcutaneously two times a day was administered at 11:58AM. A Care Plan Report for R7 documents R7 has potential for complications related to Diabetes Mellitus, use of hypoglycemic medication. Intervention includes: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Facility Policy for Medication Administration General GuidelinesPolicy:Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personal authorized to administer medications to so only after they have been properly orientated to the facilities medication distribution system (Procurement., storage, handling and administration).Procedures:6. FIVE RIGHTS- Right resident, right drug, right dose, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. Administration:2. Medications are Administered in accordance with written orders of the prescriber.4. Medications are administered without unnecessary interruptions.10. Are administered within one hour before or after scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, Routine medications are administered according to the established medication administration scheduled for the facility. Documentation (including electronic)6. If a dose of regularly scheduled medication is withheld, refused, not available, or given any time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time or a starter dose of antibiotic is needed), The space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses of vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response.7. If an electronic MAR system is used, specific procedures required for a resident identification, identifying medication to a specific times, and documentation of administration refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the systems user manual. These procedures should be followed and may differ slightly from the procedures from using paper MARs. Electronic systems also describe procedures for secure access, maintaining privacy for resident information, and for electronic signatures. Maintenance and support procedures for these systems are described in the system user manuals. Procedures will vary between the various electronic systems available.

Based on observation, interview and record review, the facility failed to ensure essential equipment Mechanical lift is in working condition, by not inspecting a Mechanical lift on the 3rd floor with exposed inner cords from charging cord. This has the potential to affect all residents residing on the 3rd floor. Findings include:On 5/19/26 at 12:15PM, observed mechanical lift on the 3rd floor with exposed black and red cords from grey cord charger hanging. On 5/19/26 at 12:16PM, V15 (Registered Nurse) said that she is not sure if machine works, but if the cords are exposed like that it should not be used because it can be unsafe. On 5/19/26 at 12:39PM, V2 (Director of Nursing) said that if machines have exposed cord, it should be reported to maintenance department and removed from the floor for safety precautions. On 5/21/26 at 10:10AM, V4 (Maintenance Director) said that the mechanical lift machine should be removed from floor and reported to maintenance if there is a concern, V4 said that the outer grey cord protects the inner cords for safe operating. Review of Maintenance log for 3rd floor Work Orders indicate no reports of mechanical lift repair. Facility Policy on Transfers-Manual Gait belt and Mechanical Lifts-revised 1-19-18Purpose: In order to protect the safety and well-being of the staff and residents and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents.Responsibility:Licensed nurse. CNA. Restorative and therapy. Guidelines:4. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure the equipment remains in good working order.

Based on observation, interview and record review, the facility failed to ensure the resident's room environment was in good repair related to ceiling tiles not being replaced upon falling for two of two residents (R1, R2) reviewed for environment.Findings include: On 5/19/2026 at 11:50am This surveyor observed R1 and R2 room, with six ceiling tiles missing.On 5/19/2026 at 11:53am, R1 said my sister said they have not replaced the ceiling tiles they've been down for a while.On 5/19/2026 at 11:58am, R2 said the ceiling tiles have been missing for over a month water was coming down also.On 5/21/2026 at 9:40am V4 (Maintenance Supervisor) said I don't know how long the ceiling tiles have been down in R1 and R2 room, I was waiting for the roof to be repaired I will replace the tiles today.On 5/21/2026 at 2:00pm V1(Administrator) said the roof had to be replaced, now the tiles can be put in.A resident information sheet indicates R1 has severe glaucoma, blind, non-ambulatory, morbid obesity, history of falling, major depressive disorder.A resident information sheet indicates that R2 has a history of congestive heart failure, spinal stenosis, and anxiety.Facility Policy: Facility unable to present a policy.

Based on observations, interviews, and record reviews, the facility failed to provide a comfortable and homelike environment, failed to have a readily available and adequate supply of clean bed and bath linens for residents to perform daily hygiene, bathing, or showers, failed to provide adequate lighting in resident rooms, and failed to ensure a mattress was provided on the bed frame and the bed was made with linen and a pillow for a resident that transferred into a room. This failure affected four residents (R38, R43, R94, and R158) out of a sample of 67 residents and has the potential to affect all 199 residents residing at the facility reviewed for a clean and comfortable homelike environment. Findings include: Facility census, dated 2/23/26, documents 199 residents residing at the facility. R38's face sheet documents diagnoses that include but are not limited to paraplegia, chronic pain, urinary tract infection, and bacterial infections R38's BIMS (brief interview for [NAME] status) score, dated 12/04/25, is 14 which indicates R38 is cognitively intact. R38's physician order, dated 1/07/26, documents, in part, Coccyx: Cleanse with wound cleanser, pat dry with gauze, apply Medi honey and dry dressing, every day shift for wound care and as needed for wound care. On 2/23/26 at 11:00am, R38 said, I don't know what's going on, but there's no rags or towels anymore here (facility). I have to wait to get my dressings changed because the nurses say that they (facility nurses) have to wait for more clean towels and rags to clean me up first before they (facility nurses) can change my dressings. Sometime they (facility staff) bring in stained rags or cut up rags. I'm like you (facility staff) ain't cleaning me with that (stained or cut up rags). Those (stained or cut up rags) look like they're (stained or cut up rags) used to clean toilets or furniture. I want to get out of bed but have to wait because they (facility) don't have rags and towels to clean me up. Man, I'm sorry, it (not having clean washcloths and towels) just makes me mad. On 2/24/26 at 11:31am, a review of the entire facility's washcloths and bath towel was done with V19 (Housekeeping Supervisor/Laundry Supervisor). During observation of the facility's laundry department with V19 (Housekeeping Supervisor/Laundry Supervisor), 15 clean towels and 6 clean washcloths, as well as 4 sheared/cut towels (in pile with clean washcloths) were observed. V19 said, These (4 sheared/cut towels) aren't supposed to be with the clean rags. We (facility) cut the old towels and use them for dust rags. Surveyor inquired where the rest of the clean washcloths and bath towels are located in the laundry department. V19 replied, That's it down here (laundry department). There are carts on the floor with clean washcloths and bath towels. Surveyor inquired again where the rest of the clean washcloths and bath towels are located in the laundry department. V19 replied, There's (clean wash cloths and bath towels) more on the floors, but not down here (laundry department). We (facility) started doing our own laundry in January (1/2026), before the laundry was outsourced. I think we have enough (clean bath towels and wash cloths) for the residents but we're (staff) just not getting washcloths and towels fast enough up to the floors. On 2/24/26 at 11:36am, surveyor requested to see all linen carts and/or storage rooms that would have clean washcloths and bath towels for resident use for the entire facility. Upon observation of the second floor linen carts, with V19 (Housekeeping Supervisor/Laundry Supervisor), the following was observed: Two linen carts on the second floor A-side were observed. The first linen carts had no clean washcloths and no clean bath towels. The second linen cart had 8 clean bath towels and 11 clean washcloths. Two linen carts on the second floor B-side were observed. The first linen cart had 9 clean washcloths and 9 clean bath towels. The second linen cart had 7 clean bath towels and 8 clean washcloths. Surveyor asked V19 if there were any more linen carts or storage rooms on the second floor with clean washcloths and bath towels, and V19 replied, No. That's it. On 2/24/26 at 11:49am, upon observation of the third floor linen carts, with V19 (Housekeeping Supervisor/Laundry Supervisor), the following was observed: Two linen carts on the third floor A-side were observed. The first linen cart had no clean washcloths and no clean bath towels. The second linen cart also had no clean washcloths and no clean bath towels. V19 said, Oh boy. This isn't good. Three linen carts on the third floor B-side were observed. The first linen cart had 7 clean bath towels and 4 clean washcloths. The second linen cart had 7 clean bath towels and 6 clean washcloths. The third linen cart had 5 clean bath towels and 5 clean washcloths. Surveyor asked V19 if there were any more linen carts or storage rooms on the third floor with clean washcloths and bath towels, and V19 replied, No. On 2/24/26 at 11:56am, upon observation of the fourth floor linen carts, with V19 (Housekeeping Supervisor/Laundry Supervisor), the following was observed: Two linen carts on the fourth floor A-side were observed. The first linen cart had no clean washcloths and no clean bath towels. The second linen cart also had no clean washcloths and no clean bath towels. Two linen carts on the fourth floor B-side were observed. The first linen cart had no clean washcloths and no clean bath towels. The second linen cart also had no clean washcloths and no clean bath towels. Surveyor asked V19 if there were any more linen carts or storage rooms on the fourth floor with clean washcloths and bath towels, and V19 replied, No. We (facility) do not have a total inventory of how many washcloths and bath towels are here (facility). Like I said before, we (facility) just started this past January (1/2026) doing the laundry here (facility). It's a work in progress. R43's face sheet documents diagnoses that include but are not limited to psoriasis, psoriatic arthritis mutilans, and morbid obesity. R43's BIMS (brief interview for [NAME] status) score, dated 1/21/26, is 15 which indicates R43 is cognitively intact. R43's physician order, dated 1/19/26, documents, in part, Desitin External Paste 40 % (Zinc Oxide (Topical): Apply to underarms, and groin topically one time a day for dry skin/rash. R43's physician order, dated 1/19/26, documents, in part, Clotrimazole External Cream 1 % (Clotrimazole (Topical): Apply to underarms, and groin topically one time a day for dry skin/rash. R43's physician order, dated 12/15/21, documents, in part, Calcipotriene Cream 0.005 %: Apply to affected areas topically every 12 hours as needed for psoriasis. On 02/24/2026 at 1:21pm, R43 stated his concern was the facility did not have enough washcloths since facility changed laundry services. R43 stated he needed washcloths to clean his armpit, abdominal folds and groin so he could apply his medication 3 times daily at 6:00am, 2:00pm, and 10:00pm and to clean his armpit, abdominal folds and groin area so he could apply his Desitin cream at 11:00pm. R43 stated 2 to 3 weeks ago during the night shift, he observed (V44 - CNA) cut a diaper into pieces so she could use it to clean the residents. When asked how R43 felt about not having enough wash cloths, R43 replied, I gotta do what I gotta do. Record review of facility's Grievance Binder, shows R43's Concern/Compliment Form, dated 12/15/25, that documents, in part, Resident (R43) had no face cloth this morning. On 2/24/26 at 1:30pm, V33 (Director of Purchasing/Corporate) said, I was told you have a concern with the PAR (Periodic Automatic Replenishment) with the towels and washcloths. I think we (facility) have enough for the residents. On 2/24/26 at 3:12pm, V2 (Director of Nursing/DON) said, I think there's enough washcloths and bath towel for the residents. I just think that the staff are throwing them out. There should be, at minimum, three wash cloths and 3 towels for each resident. Record review of facility documents titled, Purchase Order, documents the following purchases: 12/4/25: 83 washcloths and 50 bath towels; 1/20/26: 15 bath towels; 1/28/26: 30 bath towels and 50 washcloths; and 2/12/26: 50 washcloths. Total purchased: 183 washcloths and 95 bath towels. Record review of facility document titled, (Name of Facility) Morning Meeting Minutes, dated 2/12/2026, documents in part, Getting low on washcloth. Record review of facility document titled, (Name of Facility) Morning Meeting Minutes, dated 2/24/2026, documents in part, Other issues: Need more linen. R158 is [AGE] years of age. Current diagnoses include but are not limited to Pleural Condition (Left Pleural Effusion), History of Falling, Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Hypertension, End Stage Renal Disease with Dependence on Renal Dialysis, Congestive Heart Failure, Dependence on Supplemental Oxygen. R158 was admitted to the facility on [DATE] per the census report from the hospital. R158's comprehensive assessment section C Cognitive Patterns dated 02/05/2026 documents a brief interview for mental status score of 10 which indicates R158 has moderate issues with thinking and memory. On 02/24/2026 at 10:30 AM, Resident #158 said, They moved me up here from downstairs after breakfast. They told me they didn't have to tell me anything. I've been up since 4AM and I want to lay down. They didn't have a mattress on the bed. A lady had to bring a mattress for the bed. They still haven't made my bed yet. They said they were going to get sheets but never came back. I'm tired and I want to go to sleep! R158's bed has a fitted sheet that appears to have brown stains. There is no flat sheet, blanket, or pillows on the bed. There is a covered linen cart in the hall but there are no bed linens on the cart at this time. On 02/24/2026 10:33 AM, V20, Registered Nurse (RN) was inquired of R158. V20 RN said, I didn't even know she was in the room. My CNA came and told me she was in the room. I had to go find some oxygen for her. I didn't even get any report. On 02/24/2026 10:35 AM, V25, Nurse Manager was inquired of R158's move from second floor. V25 said, I wasn't aware of it, I'm the manager for the third floor but I can try to help. R158 told V25 she was moved to the current room after breakfast and there wasn't a mattress on the bed. A lady brought in a mattress. They still haven't made my bed. On 2/24/26 at 11:16 AM, V3, Assistant Director of Nursing (ADON) said, I didn't know about her being transferred or anything with her roommate, but I can go find out what happened. V3 went to R158's room with this surveyor and observed R158'S bed with only a fitted sheet. R158 told V3 what happened when she was transferred to the room. On 02/24/2026 at 12:00 PM, V5, Social Service Director's (SSD) progress note documents R158's transfer was effective at 9:17 AM but was created at 11:41 AM after this surveyor questioned V3 ADON regarding R158's room transfer in which V3 was unaware of. On 2/24/26 at 12:31 PM, V3 came to the conference room to speak with this surveyor. V3 said, V5 told me she told her (R158) about moving and she was ok with it. V3 was asked if she spoke with R158. V3 said, No, I haven't but I know she has some dementia. Review of R158's admission contract indicates she signed her own contract on 01/26/2026. R158's comprehensive assessment documents she only has moderate issues with thinking and memory. On 02/24/2026 at 1:31 PM, V5 was inquired of R158's transfer. V5 SSD said, The CNAs made me aware (R158) wasn't appropriate for the floor. I was made aware she (R158) was being resistant to being moved. The CNA asked me to come tell her why she was being moved. I assisted her upstairs to the room. There wasn't a mattress on the bed, so I went back down and brought the mattress off her bed upstairs. It was two CNAs that helped me. I can't remember their names. Normally I work with guest services to make sure the move was smooth, but I don't normally work with moves, they needed my assistance. I'm not sure who her nurse was. I didn't speak to her nurse. My plan was to document it sometime today. On 02/24/2026 at 1:44 PM, V31, Certified Nurse Assistant (CNA) was inquired of R158's transfer. V31 said, R158 is a one person assist to transfer. She has a wheelchair. She is a check and change (incontinent). I was told to transfer her by V5 SSD to 4th floor after breakfast. Two other CNAs helped me. We packed all her stuff and took it upstairs. I transferred her in the wheelchair. I didn't tell V5 that she (R158) didn't want to move upstairs because I didn't know anything. She (R158) just asked why she was being moved out the room. I went to get V5 because she (R158) had a question, but she didn't refuse to go. V5 was at the nurse's station, I told her and V5 said she'd go talk to her (R158). When I took her (R158) up to the room there wasn't a mattress on the bed, so I told V5. When I went back to my floor, I told V25 LPN (Licensed Practical Nurse). On 02/24/2026 at 1:55 PM, V25, Licensed Practical Nurse (LPN) was inquired of R158's transfer. V25 LPN said, R158 is alert with some confusion, and she has dementia. She can transfer but needs assistance. She has a wheelchair. When the CNA's moved her, they just told me she was moving. I don't know who told me she was moving. I'm prn (as needed), but I've been here a year. I took the meds up there. I gave her morning meds before I took them. I don't know the nurse's name, but it was around 10 or 10:30 I went up there and gave report. I don't know who's responsible for making sure the room was ready. I didn't go into her (R158) room upstairs. On 02/24/2026 at 2PM, V32, Nurse Supervisor 2nd Floor was inquired of R158's transfer. V32 said, I was just coming in when it was happening, so I don't know about it. On 02/24/2026 at 2:38 PM, V20, RN was inquired of R158's transfer. V20 said, Why was R158 moved up here? After she was up here V25 LPN just came and brought her meds and said she was alert, oriented and cooperative. He never said why she was being moved or anything else. I wasn't even told she has dialysis. On 02/24/2026 at 2:51 PM, R158's bed is made up with a flat sheet, a pillow and blanket. R158 is sitting in her wheelchair next to the bed sorting through her belongings. R158's belongings are on the bed in a bag. There is a rolling walker at the foot of her bed. R158 said, They finally made my bed. My husband's here, he's in the washroom and he's gonna help me put my things away. That's his walker. It took the facility from 10AM to 2PM after R158 was transferred into her new room to have her bed fully made with complete bed linen. On 02/25/2026 at 2:45 PM, V2, Director of Nursing (DON) was inquired of R158. V2 said, I believe the social worker said she was moving. It was more based on her diagnosis due to dementia. I can't remember if she ever tried to leave or had any behaviors. The room was supposed to be set up with the bed made. V25 LPN (Licensed Practical Nurse) should have given report with all the resident's information. He (V25) has been here over a year, and he works full time. On 2/23/2026 at 11:01 AM, observed R94 resting in bed with V28 (R94's Family Member) at the bedside. R94's section room did not have a overbed or reading light. V28 explained, the facility has no linen here, I have been trying to get (R94) a blanket for hours now. He deserves and wants a blanket when sleeping. V28 also stated, I don't understand why (R49)'s roommate has an overbed light and (R49) doesn't. We had to bring on from home. (R49's) roommate has cabinetry, overbed lights, etc. I don't understand why we can't have that too. On 2/23/2026 at 11:09 AM, observed the 2nd floor linen room. There was no linen on any of the shelves. Surveyor requested if there were any blankets in the linen closet or on the unit. V27, Housekeeper and V26, Certified Nursing Assistant (CNA) checked the linen room and affirmed there were no blankets available for the residents on the second floor. V26 stated, this happens often, not having enough linen. On 2/23/2026 at 11:11 AM, V21, LPN stated, We are frequently run out of linen for the residents, it's like three times a week. We call down to laundry to get more, and hopefully it comes up. On 2/23/2026 at 11:18 AM, V8, Maintenance Director observed R94's room and confirmed that there was not an overbed light for R94. V8 explained, These rooms used to all be single occupancy rooms, but when COVID hit, they were remade back into 2 person rooms. They are licensed for 2 beds; we just never remodeled the second side. Record review of Illinois Long-Term Care Ombudsman Program Resident's rights booklet, dated 11/18, states in part that the facility must be safe, clean, comfortable, and homelike. The residents should receive the services and/or items included in the plan of care. Record review of facility policy titled, Resident Rights, dated 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Record review of facility job description titled, Certified Nursing Assistant, dated 5/02/17, documents, in part, The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Provide assistance in personal hygiene by giving bedpans, urinals, baths, backrubs, shampoos, and shaves; assisting with travel to the bathroom; helping with showers and baths. Provide for resident comfort by utilizing resources and materials; answering call lights and requests; reporting observations of the residents to the nursing supervisor. Record review of facility job description titled, Laundry Aide, dated 3/23/17, documents, in part, The primary purpose of your job position is to perform the day-to-day Laundry Department functions, to assure that quality laundry services are provided on a daily basis, to safeguard d the health, safety and welfare of all residents of the facility, and to assure the facility laundry is maintained in a clean, safe and sanitary manner, in accordance with the facility's established policies and procedures, applicable laws and regulations and the directions of your supervisors, who include the Laundry Supervisor, Administrator, Assistant Administrator, and other members of the facility's management to whom such persons report, in order to assure that the highest level of laundry services for the facility's residents is maintained at all times. As a Laundry Aide, you are delegated the authority, responsibility, and accountability necessary for carrying out your assigned duties. Record review of facility job description titled, Administrator, dated 5/02/17, documents, in part, The Administrator directs the day to day functions of the facility in accordance with current federal and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times.

Based on observations, interview and record review, the facility failed to ensure one (R57) resident oxygen tank was secured to prevent a hazard. This failure has the potential to affect all 58 residents that reside on the 2nd floor of the facility. Findings include: Facility census for 2/23/2026 documents that 58 residents reside within the second floor. R57's face sheet documents in part the following diagnoses: chronic obstructive pulmonary disease, diastolic heart failure, benign neoplasm of left adrenal gland. R57's physician orders (11/5/2025) document a current order for oxygen to be delivered at 2L per minute. On 2/23/2026 at 11:18 AM, observed R57 resting in bed, receiving oxygen via nasal cannula. An unsecured oxygen tank was between the closet and R7's room door. V8 (Maintenance Director) confirmed the observation. V8 stated that the oxygen tank should have been in a holster secured. V8 stated that unsecured oxygen tanks can be a hazard. On 2/25/2026 at 3:45 PM, V2 (Director of Nursing) affirmed that oxygen cylinders should be secured in holsters to prevent damage to the oxygen tank. Facility policy for Oxygen Therapy E-Cylinder Use (undated) documents in part, Purpose, To provide for safe, appropriate set-up and utilization of Oxygen E-cylinders .7. Obtain the E-cylinder oxygen tank and place on transport cart, if not already .

Based on observation, interview, and record review, the facility failed to ensure the Shift Change Accountability Record for Controlled Substances was signed by the outgoing nurse, failed to ensure the refrigerator for controlled substance was locked, failed to sign out controlled medication when given, failed to have two nurses count the controlled medications during shift change and failed to ensure that two nurses were present during wasting of a narcotic medication. These failures affected five residents (R22, R59, R63, R199 and R212) and have the potential to affect all the residents on the second-floor 3rd set and all the residents on the 4th floor Team 1. Findings include: The (02/23/2026) facility Midnight census report documented that there were 58 residents on the second floor. The (02/23/2026) 4th floor 7am- 3pm Daily assignment sheet documented that V17 (Registered Nurse) was assigned to residents in rooms 434 – 409; total of 25 residents including bed hold. On 02/23/2026 at 1:40pm, during the medication storage and labeling task with V17 of the 4th floor team 1 medication cart-controlled box, R199's bottle of liquid Ativan was not in the controlled box. V17 stated they keep the bottle in the refrigerator located in the medication storage room. On 02/23/2026 at 1:46pm, inside the 4th floor medication storage room, the small refrigerator was not locked. V17 took out R199's Lorazepam bottle inside the small refrigerator, showed to this surveyor, and stated they keep controlled medication inside the small refrigerator, and it should be locked so no one can take the controlled medication from the refrigerator. On 02/23/2026 at 1:47pm, review of the 4th floor Team 1 Shift Change Accountability Record for Controlled Substances revealed a missing signature on day 13, 1st shift, column 'off'. This was pointed out to V17. V17 stated it is part of the endorsement between incoming and outgoing nurses to count the controlled substance and to sign after counting the controlled substance. If not signed it means the controlled substance was not properly endorsed. On 02/24/2026 at 3:6pm, V2 (Director of Nursing) stated all controlled medications should be stored in double lock system. It is expected the door of the medication storage room is locked and the small refrigerator inside the medication storage room is also locked for safety reasons; so unlicensed personnel would not have access to controlled medications. On 02/24/2026 at 3:48pm, V2 stated the outgoing and incoming nurses during shift change are expected to count the controlled medications and both are expected to sign after counting the controlled medications to verify the count is correct. R199's (Active Order as of: 02/25/2026) documented, in part Diagnoses: (include but are not limited to) dementia, severe protein malnutrition, and encounter for palliative care. R199's (01/14/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 02. Indicating R199's mental status as severely impaired. Section O. Special Treatment, Procedures, and Programs. K1. Hospice Care. B. while a resident. R199's (08/28/25) Hospice Doctor's Order documented, in part Lorazepam 2mg/ml oral concentrate. Administer 0.25ml PO every 2 hours as needed for restlessness/agitation. The 4th floor Team 1 Shift Change Accountability Record for Controlled Substances revealed a missing signature on day 13, 1st shift, column 'off'. On 2/22/2026, at 12:35PM, Reviewed narcotic count for 3rd set medication cart on the second floor with V21 (LPN) and noted that Hydrocodone 10-325mg for R212 showed 24 tablets in the count sheet, but medication on hand was 17 tablets. V21 said that the count on the sheet was documented wrong by the nurses because it went from 21 back to 26 instead of 20, the DON have to do some education with them. On 02/24/2026 around 9:45AM, checked the team 1 medication cart on the 3rd floor with V34 (LPN) and noted that the count for R59's hydrocodone 7.5-325mg was documented as 18 on the count sheet, tablets on hand was 17. Surveyor presented this observation to V34 who said that the night nurse probably gave one to the resident at 6:00AM because he got one at 2AM. V34 was asked if they counted the narcotics at shift change and she said no, the other nurse was in a hurry. 02/24/2026 9:50 AM, checked the middle medication cart on the third floor with V35 (RN), and noted the following: Oxycodone 10mg tablets for R184 have 27 tablets on hand but the narcotic sheet showed 29 tablets. V35 said that she gave one to the resident this morning but had not signed it out and she wasted one. Surveyor asked V35 who wasted the medication with her, and she said, I did it alone, I was the only person at that time. Lacosamide 200mg tablet for R22 showed 16 tablets on hand, and the narcotic count sheet showed 17tablets. Diazepam 5mg tablet for R63 was documented as one left in the sheet count but has none at hand. V35 said that she gave both medications this morning but did not sign them out. On 2/25/2026 at 11:00AM, V2 (DON) said that nurses are supposed to do narcotic count at shift change, wasting of any narcotic should be done by two nurses always. Narcotic /controlled substances procedure (undated) provided by V2 (DON) states I part: Counting at change of shift, failure to count narcotics according to procedures below is grounds for disciplinary action including and up to termination. General guidelines: 1. Always participate in the counting of the controlled substances at the beginning and ending of your shift. Never say, go ahead without me and I will sign later. Never leave it to someone else's discretion when you are the one on duty. If you do not observe the medications, you sign as being present, you may be implicated if the medications are later missing. Medication /Narcotic destruction policy revised 10/24/2022 documented in part: 2. Non controlled and schedule V controlled medications must be destroyed by two (2) licensed nurses or one (1) licensed nurse and pharmacist. 7. the person witnessing the distribution/disposal of drugs must date and sign the drug disposition record. The (undated) Storage of Medications policy and procedure documented, in part 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. Temperatures. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. The (11/26/17) Narcotic/Controlled Substances – Counting documented, in part Purpose: 1. To count controlled substances with a partner and to verify the accuracy of the log sheets. General Guidelines: 1. Always participate in the counting of the controlled substances at the beginning and ending of your shift. General Procedure for Counting Controlled Substances. 16. Sign name, time and date of completed count.

Based on observation, interview and record review, the facility failed to ensure that staff properly date opened insulin and eye drops, failed to remove medications for discharged residents and completed medications from the medication cart, failed to refrigerate medications with refrigerate sticker and failed to maintain the refrigerator temperature below 40 degrees. This failure affected (R21, R51, R57, R71, R93, R128, R148, R183, R198 and R212) and has the potential to affect all residents on the second and fourth floor.Findings include: On [DATE] at 1:35pm, during the medication storage task with V17 (Registered Nurse) of the 4th floor Team 1 cart observed: R21's Erythromycin eye ointment was labeled start [DATE] x 10 days. R128's opened vial of Artificial Tears has no open and end dates. R183's opened vial of Olopatadine 0.2% Ophthalmic drop has no open and end dates. On [DATE] at 1:38pm, V17 stated the open vials of eye drops should have open and end date so nurses would know when to dispose them of and the eye ointment should be discarded when completed for safety reasons, so staff will not administer it to the resident. On [DATE] at 1:51pm during the medication Storage Task with V18 (Registered Nurse) of the 4th floor Team 3 medication cart observed R148's open vial of Dorzolamide 2% ophthalmic drops has no open and end dates. On [DATE] at 3:49pm, V2 (Director of Nursing) stated the expectation is to label the multidose medications with the open and end dates. The purpose of labeling is to be able to recognize when to dispose of medications to prevent from administering medications after the end date. On [DATE] at 3:51pm, V2 stated for safety reasons, once the medication is completed, it is expected of the nurse to dispose of the completed medication so the nurse will not mistakenly administer the medication. R21's (Active Order as Of: [DATE]) Order Summary Report documented, in part Diagnoses: (include but are not limited to) hypertension, cataract, and hemiplegia (paralysis) and hemiparesis (muscle weakness). R21's (02/2026) Medication Administration Record documented, in part Erythromycin Ophthalmic Ointment 5 MG/GM (Erythromycin (Ophth)) Instill 1 centimeter in both eyes two times a day for conjunctivitis for 10 Days -Start Date- [DATE] 1800. R128's (Active Order as Of: [DATE]) Order Summary Report documented, in part Diagnoses: (include but are not limited to) heart failure, Type 2 Diabetes Mellitus, and hypertension. Of note, no Active order for Artificial Tears. R148's ([DATE]) Order Summary Report documented, in part Diagnoses: (include but are not limited to) strabismus, Type 2 Diabetes Mellitus, and hypertension. Order Summary. Dorzolamide HCl Ophthalmic Solution 2 % (Dorzolamide HCl) Instill 1 drop in both eyes two times a day for OPHTHALMIC AGENTS. Active [DATE]. R183's (Active Order as Of: [DATE]) Order Summary Report documented, in part Diagnoses: (include but are not limited to) disorder of the cornea, quadriplegia, and intestinal obstruction. Order Summary: Olopatadine HCl Ophthalmic Solution 0.2 % (Olopatadine HCl) Instill 1 drop in both eyes in the morning for Allergies. Active: [DATE]. On [DATE] 12:35PM, reviewed the 3rd set medication cart on the second floor with V21 (LPN) and observed the following: R57 have the following medications that were open with no open date or expiration date. Incuse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 inhalation by mouth one time a day for SOB. Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 6 unit subcutaneously at bedtime for diabetes type 2. Trulicity Subcutaneous Solution Auto-injector 0.75 MG/0.5ML (Dulaglutide)Inject 0.75 mg subcutaneously one time a day every Fri for ANTIDIABETICS R212, there was Epoetin Alfa Solution 10000 UNIT/ML Inject 1 ml subcutaneously one time a day every Mon, Wed, Fri for HEMATOPOIETIC AGENTS. The medication was not open and had a sticker that stated to refrigerate. V21 said that she does not know why that medication is in the cart, it is supposed to be given dialysis. R51's Insulin Glargine Solution 100 UNIT/ML Inject 20 unit subcutaneously one time a day for diabetes, was open with no open or expiration dates. R71's Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously three times a day for ANTIDIABETICS, open, no open or expiration dates. There was one multi dose vial of Lantus that is dated [DATE], no expiration dated. R198's Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT (Umeclidinium-Vilanterol) 1 puff inhale orally one time a day for ANTIASTHMATIC AND BRONCHODILATOR AGENTS and Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG/3ML (Albuterol Sulfate)3 ml inhale orally every 24 hours as needed for ANTIASTHMATIC AND BRONCHODILATOR AGENTS both were open with no open dates. For a resident discharged [DATE], valganciclovir HCl Oral Tablet 450 MG (Valganciclovir HCl) Give 1 tablet by mouth two times a day for Prophylaxis related to kidney transplant was still in the medication cart. There were 2 eye drops Latanoprost 0.005% and Ipatratum 6.9% that were in the cart, open with no open dates. V21 stated that the resident has been discharged , she does not know why the medications are still in the cart. V21 added that she is not aware that the opened medications should be dated, the experience is eye opening for her. Reviewed the medication storage room on the second floor with V21 and noted 1 pack of hemorrhoidal suppository in the refrigerator that expired [DATE]. The refrigerator on the second-floor medication room was filled with medication, both inside and on the door, the thermoset inside was reading 50 degrees. On [DATE] at 11:00AM, V2 (DON) said that medications in the cart are supposed to be dated with an open date, insulins should have an open date and discard date. Medications with a refrigerate sticker should be in the refrigerator. Medications for discharged residents should be returned to pharmacy if residents do not take it with them. V2 added that the refrigerator used to store medications should be read 32 to 40 degrees. Storage of medication policy (policy # 4.1 undated) states in part: medications and biologicals are stored safely, securely and properly following manufacture's recommendations or those of supplier. The medication supply is accessible -------------------------------------------------------, or staff members lawfully authorized to administer medications. Procedures: 5 Except for those requiring refrigeration or freezing, medications intended for internal use are stored in the medication cart or other designated area. Temperature: 3. Medications requiring refrigeration are kept in the refrigerator at temperature between 2 degrees centigrade (36 degrees Fahrenheit) and 8 degrees centigrade (46 degrees Fahrenheit). Expiration dating (beyond use dating) 3. Certain medications or packaged types such as IV solutions multiple use injectable vials, ophthalmic, nitroglycerin tablets once opened require an expiration date shorter than the manufacture's expiration date to ensure medication purity and potency. 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and enter the date opened.

Based on observations, interviews and record reviews, the facility failed to check and document the temperatures of residents' personal refrigerators daily in an effort to prevent food borne illness. This failure affected four (R24, R92, R181, and R205) residents reviewed for personal food storage in the total sample of 67 residents.Findings include:On 02/23/2026 at 10:55am, R92's (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates: 2/2, 2/7, 2/8, 2/13 - 2/22. V15 (3rd Floor Unit Manager/Licensed Practice Nurse) checked the refrigerator and stated there were food items inside the refrigerator. V15 stated housekeeping was in charge of checking the refrigerator.On 02/23/2026 at 11:27am, R181 (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates: 2/7, 2/8, 2/13 - 2/16, and on 2/21. R181 stated he kept his food and drinks inside the refrigerator. On 02/23/2026 at 11:32am, R24's (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates: 2/2, 2/7, 2/8, 2/13, 2/14, 2/15, 2/16, 2/21, 2/22. V15 stated there were missing entries on the temperature log. V15 checked R24's small refrigerator and stated there were food items inside the refrigerator.On 02/23/2026 at 12:06pm, R205's (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates: 2/2 - 2/22. R205 stated he kept his leftover food items inside his refrigerator. On 02/25/2026 at 12:54pm, V19 (Housekeeping and Laundry Supervisor) stated the Housekeeping Department was in charge of checking and monitoring the temperature of the personal refrigerator daily to make sure there were no old food items in the refrigerator and if the temperature was within the range, so, food would not get spoiled because facility did not want the residents to eat the food and get sick from food poisoning. R24's (Active Order as Of: 02/25/2026) Order Summary Report documented, in part Diagnoses: (include but are not limited to) Crohn's disease, weight loss, and major depressive disorder.R24's (01/22/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R24's mental status as cognitively intact. R24's (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates: 2/2, 2/7, 2/8, 2/13, 2/14, 2/15, 2/16, 2/21, 2/22.R92's (Active Order as Of: 02/25/2026) Order Summary Report documented, in part Diagnoses: (include but are not limited to) hemiplegia (paralysis) and hemiparesis (muscle weakness), intestinal obstructions, and dementia.R92's (11/25/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating R92's mental status as moderately impaired. R92's (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates:2/2, 2/7, 2/8, 2/13 - 2/22.R181's (Active Order as Of: 02/25/2026) Order Summary Report documented, in part Diagnoses: (include but are not limited to) obesity, Type 2 Diabetes Mellitus, and hypertension. R181's (01/05/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R181's mental status as cognitively intact. R181 (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates: 2/7, 2/8, 2/16 - 2/16, 2/21.R205's (Active Order as Of: 02/25/2026) Order Summary Report documented, in part diarrhea, Type 2 Diabetes Mellitus, and chronic kidney disease. R205's (01/28/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R205's mental status as cognitively intact.R205's (02/2026) Refrigerator/Freezer Temperature Log has missing entries on dates: 2/2 - 2/22.The (undated) Refrigerator in Resident Rooms documented, in part Guideline: In keeping with the home-like environment for residents, some residents will request to have a refrigerator in the room. Residents and/or responsible party that request to have a refrigerator in the room will be counseled on food safety guidelines. Resident and/or responsible party will agree to allow periodic safety checks by staff and allow staff to discard outdated food per safety guidelines. Procedure: 2. Each refrigerator shall have a temperature log with daily entry. 3. The housekeeper will enter the temperature once daily.

Based on interview and record review, the facility failed to follow its abuse policy by failing to report an alleged violation involving a resident-to-resident verbal/mental abuse. This failure affected one (R7) of two residents reviewed for abuse in a total sample of 67.Findings include:R7 reported that she was being harassed by another resident as documented in a progress note dated 2/16/2026 at 23:36:35 by V47 (LPN), Patient complained of being harassed by another patient. Patient asked to be pushed by wheelchair to her room. Patient informed me that she heard that the other patients might attack her if she is seen in the dayroom tomorrow. Patient was in her room when R16 came to her room and started to bother her. I asked R16 to leave and he continued to harass her. Patient was crying and called for her family members to come. Called nursing supervisor of the current situation. Family members came and it was intense for several moments. Eventually, the patient family members dispersed and left. It was further reported for the police to come if there was any further involvement.R7 is [AGE] years old, and the face sheet listed the following past medical history: blindness to left eye, essential primary hypertension, diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema bilateral, hyperlipidemia, history of falling, type 2 diabetes with other circulatory complications, etc.On 2/23/2026 at 11:32AM, R7 said that R16 has been messing with her, she reported to staff, and nothing is being done. R16 will come to her room, harassing her and telling her that he will get some people to come and beat her up. R7 said that R16 messes with her wig when she puts it on.On 02/24/2026 at 9:16AM, R16 said he recalls an altercation with R7, R16 said he told R7 to stop messing with people and leave them alone. R16 said to the surveyor, I know what R7 told you, she said that I threated her, but I did not threaten her. R16 added that he made it clear to R7 and her sister that if R7 put her hands on him first, he will do the same.On 2/24/2026 at 2:28PM V48 (Family member) said that her sister (R7) keeps getting into an altercation with R16, R7 had an issue with another resident, R16 went to R7's room to confront her. V48 said that R7 called her crying, V48 came to the facility with other family members and spoke to management. R7's other sister called the facility and spoke to a CNA (V45) and spoke to a nurse. R16 went to R7's room and pushed her door open, told R7 that she better not come to the dining room, or he will f her up.On 2/24/2026 at 11:13AM, surveyor requested for the investigation and reportable for R7 and R16 from V1 (Administrator) who said that he is the abuse coordinator, V1 said that he did not have any investigation or reportable for R7 and R16 because it was not abuse. V1 was asked if he conducted any investigation to determine if abuse occurred or did not occur and he said, no, the staff statements is my investigation.On 2/24/2026 at 3:07PM, V18 (RN) said that she was called to the third floor that a resident's family member was on the floor. V18 was informed that R7 called her family and said that R16 came to her room and threatened her. V18 told the family members the facility is going to investigate due to R7 stating that R16 threatened her. V18 called the DON and the administrator, not sure if anyone reported the incident, the administrator is the abuse coordinator, V18 did not witness what happened.On 2/25/2026 at 2:56PM V45 (CNA) said that she was present on the day R7 and R16 had an altercation, but she did not witness what happened. V45 was at the nursing station, she answered the phone, and it was R7's family member who was very upset, stating that R16 said something to R7. Several attempts were made by the surveyor to speak to V47 (LPN) but was unsuccessful.Abuse prevention and reporting revised 10/24/2022 states in part under guidelines: the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, ---------------------------------------------------------------------------------------------------------In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to, ------------------------------------------------------------- and mistreatment of residents.Definitions: Mental and verbal abuse. Mental abuse is the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.Verbal abuse may be considered 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.Examples of mental and verbal abuse include, but are not limited to harassing a resident, mocking, insulting, ridiculing, yelling or hovering over a resident with the intent to intimidate, threatening residents, etc.Resident-resident abuse (any type).A resident -to-resident altercation should be reviewed as a potential of abuse. Not all resident-resident altercations result in abuse, for example infrequent arguments or disagreements that occur during the course of normal social interactions (e.g. dinner table discussions) would not necessarily constitute abuse but should be investigated to make this determination.Internal reporting requirements and identification of allegation.Any allegation of abuse or any incident that results in bodily injury will be reported to the department of public health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on interview and record review, the facility failed to follow its abuse policy by failing to initiate and thoroughly investigate an allegation of resident-to-resident verbal/mental abuse. This failure affected one (R7) of two residents reviewed for abuse in a total sample of 67. Findings include:R7 is [AGE] years old, and the face sheet listed the following past medical history: blindness to left eye, essential primary hypertension, diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema bilateral, hyperlipidemia, history of falling, type 2 diabetes with other circulatory complications, etc.On 2/23/2026 at 11:32AM, R7 was observed in the dining room, awake and alert and stated that R16 has been messing with her, she reported to staff, and nothing is being done. R16 will come to her room, harassing her and telling her that he will get some people to come and beat her up. R7 said that R16 messes with her wig when she puts it on.Progress noted dated 2/16/2026 at 23:36:35 by V47 (LPN) documented the following: Patient complained of being harassed by another patient. Patient asked to be pushed by wheelchair to her room. Patient informed me that she heard that the other patients might attack her if she is seen in the dayroom tomorrow. Patient was in her room when R16 came to her room and started to bother her. I asked R16 to leave and he continued to harass her. Patient was crying and called for her family members to come. Called nursing supervisor of the current situation. Family members came and it was intense for several moments. Eventually, the patient family members dispersed and left. It was further reported for the police to come if there was any further involvement. On 02/24/2026 at 9:16AM, R16 said he recalls an altercation with R7, R16 said he told R7 to stop messing with people and leave them alone, she got mad and started cursing R16 out. R16 cursed R7 back, he never went into her room but was in the doorway, a CNA was present and told both to stop. R16 said to the surveyor, I know what R7 told you, she said that I threated her, but I did not threaten her. R16 added that he made it clear to R7 and her sister that if R7 put her hands on him first, he will do the same. R16 said that the altercation started with other residents on the floor, he expected someone to put them side by side and get the truth of what happened. On 2/24/2026 at 2:28PM V48 (Family member) said that her sister (R7) keeps getting into an altercation with R16, R7 had an issue with another resident, R16 went to R7's room to confront her. V48 said that R7 called her crying, V48 came to the facility with other family members and spoke to management. R7's other sister called the facility and spoke to a CNA (V45) and spoke to a nurse. R16 went to R7's room and pushed her door open, told R7 that she better not come to the dining room, or he will f her up.On 2/24/2026 at 3:07PM, V18 (RN) said that she was called to the third floor that a resident's family member was on the floor. V18 was informed that R7 called her family. said that R16 came to her room and threatened her. V18 told the family members the facility is going to investigate due to R7 stating that R16 threatened her. V18 called the DON and the administrator, not sure if anyone investigated the incident, the administrator is the abuse coordinator, V18 did not witness what happened.On 2/25/2026 at 2:56PM V45 (CNA) said that she was present on the day R7 and R16 had an altercation, but she did not witness what happened. V45 was at the nursing station, she answered the phone, and it was R7's family member who was very upset, stating that R16 said something to R7.Several attempts were made by surveyor to speak to V47 (LPN) but was unsuccessful.On 2/24/2026 at 11:13AM, surveyor requested for the investigation for R7 and R16 from V1 (Administrator) who said that he is the abuse coordinator, he did not do any investigation for R7 and R16 because it was not an abuse. V1 said that R16 told him that R7 was being rude to a staff, R16 intervened and told R7 to stop, she became rude to R16. V1 said that the supervisor on duty (V18) spoke to both residents, V1 also spoke to the CNA (V45) and no one reported any abuse. V1 added that not every disagreement is an abuse, verbal abuse is if someone says something like watch out, I am going to get you. V1 said to the surveyor, from what you are saying, I am going to initiate an investigation.There is no documentation that anyone spoke to R7 or R16 regarding the incident, V1 only documented speaking to R7 about moving her to another floor.Abuse prevention and reporting revised 10/24/2022 states in part under guidelines: the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, ---------------------------------------------------------------------------------------------------------In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to, ------------------------------------------------------------- and mistreatment of residents.Definitions: Mental and verbal abuse. Mental abuse is the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.Verbal abuse may be considered 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.Examples of mental and verbal abuse include, but are not limited to harassing a resident, mocking, insulting, ridiculing, yelling or hovering over a resident with the intent to intimidate, threatening residents, etc.Resident-resident abuse (any type).A resident -to-resident altercation should be reviewed as a potential of abuse. Not all resident-resident altercations result in abuse, for example infrequent arguments or disagreements that occur during the course of normal social interactions (e.g. dinner table discussions) would not necessarily constitute abuse but should be investigated to make this determination.Internal investigation: all incidents will be documented, whether or not abuse neglect, exploitation, mistreatment misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation.

Based on interview and record review, the facility failed to obtain from an outside resource routine and emergency dental services. This failure affected one (R210) resident reviewed for dental services in the total sample of 67 residents. Findings include:R210's census list documented that R210 was admitted at the facility on 10/26/2020 and was discharged on 1/28/2026. R210's (01/05/2026 - 02/28/2026) order Recap Report documented that R1's diagnoses include but are not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness), cerebral infarction, and COPD (Chronic Obstructive Pulmonary Disease). R210's (01/16/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R210's mental status as cognitively intact. The (02/24/2026) email correspondence with V5 (Social Services Director) documented, in part Subject: (R210) Notes. Kindly include any dental notes. The (02/24/2026) email correspondence between National Preventive solutions and V36 (Social Services Assistant) documented, in part The most recent notes we have for (R210) are from 2024. (V49 - Dentist National Preventive Solutions) saw (R210) for an exam and wrote a referral for her to have extractions. (R210) is not enrolled in our dental program so she may not be added to the list to be seen regularly unless we receive a request from the facility or family. I would be happy to send you the forms from 2024 or add her to be seen during the next visit, if needed. R210's (04/01/2024) Dental Consult National Preventive Solutions documented, in part Treatment Type: Exam. Referral extract 14, 3, 8, 9.R210's (04/01/2024) Patient Referral Form documented, in part Reason For Referral: Extract #8, 9, 3, 14. Of note, no additional dental services note received from facility including extraction of teeth # 8, 9, 3, and 14.On 02/26/2026 at 12:42pm, V50 (Clinical Support National Preventive Solutions) stated she (R210) was never enrolled in the dental program. (V49) saw her on 04/01/2024 and they never heard anything after April 01, 2024. V50 stated he (V49) did the exam and made a recommendation for teeth extraction of #3, 8, 9 and 14. The facility should take the referral to an outside dental office. It is the facility's responsibility to schedule. V50 stated for Medicaid residents they were usually seen by their dentist 3-4 x a year and by their dental hygienist 8 times a year. The program is paid for by Medicaid. On 02/24/2026 at 10:09am, V5 (Social Services Director) stated she (R210) was on medicaid and she should be scheduled to see a dentist and an ophthalmologist at least once every year. She can get a pair of glasses and can have dental cleaning once a year and as needed if she needed more attention. Nursing would let the Social Services know if she needed to be seen and she would put her on the list and she would send an email out for eye and dental appointment. On 02/25/2026 at 9:44am, V2 (Director Of Nursing) stated dental services should be provided to the resident at least yearly. If the dental service was last provided in 2024, it means she (R210) was not provided dental service the whole year of 2025. On 02/25/2026 at 1:38pm, V43 (Assistant Administrator) stated the facility did not have Dental services policy and procedure as it relates to frequency of providing the services. Requested V43 to send an email as to the facility expectation. The (undated) Dental Visits documented, in part Based on Centers for Medicare and Medicaid Services (CMS) regulations, nursing home facilities are required to ensure residents have access to dental services, but there is no rigid, universally mandated, specific timeframe (such as every 6mnths) for a dentist to physically see a resident. Residents will be seen on an as needed basis. Authored by V1 (Administrator). The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must provide services to keep your physical and mental health at their highest practicable levels.

Based on observations, interviews, and records review, the facility failed to post Enhanced Barrier Precaution (EBP) signage for a resident requiring EBP and failed to ensure staff don gown and gloves when providing Activities of Daily Living (ADL) Care. These failures affected one (R75) resident reviewed for infection control in the total sample of 67 residents. Findings include:On 02/23/2026 at 10:57am, there was a Personal Protective Equipment (PPE) bin inside R75's room. No EBP sign posted by the door. Inside the room, R75 was lying on low air loss mattress set at 280lbs. This surveyor requested V14 (Certified Nursing Assistant) to check if R75 was wet. V14 donned gloves and turned R75 on her side. R75 was noted with border foam dressing on the sacrum and white dressing just above the sacrum; R75's incontinence brief was moderately soiled. V14 stated she would change her (R75) incontinence brief. V14 left the room and returned with incontinence brief. V14 donned gloves and proceeded with changing R75's incontinence brief. While V14 was changing R75, this surveyor noted an EBP sign posted on the wall, above R75 head of the bed.On 02/23/2026 at 11:06am outside of R75's room, V15 (3rd Floor Unit Manager/Licensed Practical Nurse) stated she (R75) did not have an active wound; she was on dialysis and has a dialysis port on her left clavicle. She should be on EBP (Enhanced Barrier Precautions) and there should be an EBP sign visible so when staff was assisting her with ADL (Activities of Daily Living) care, they would know what PPE (personal protective equipment) to wear. Staff should be donning gown and gloves to prevent infection. As this surveyor was interviewing V15, V14 came out of the room and this surveyor inquired if she donned gown when she changed R75's incontinence briefs. V14 stated she did not need to wear a gown because she just change her incontinence briefs. Surveyor informed V14 that R75 was on EBP. V14 stated there was no sign by the door which indicated she was on EBP. This surveyor informed V14 there was a sign above R75's head of bed. V14 stated it would make more sense if the sign was by the resident's door so she would know right away she had to wear gloves and gown before she changed her incontinence briefs.On 02/24/2026 at 3:45pm, V2 (Director of Nursing) stated staff who had to do ADL care to a resident on EBP is expected to don gown and gloves to prevent infection. The (undated) List of Residents on EBP include R75 with clinical indication of presence of an indwelling access device (Renal Dialysis). R75's (02/25/2026) Order Summary Report documented, in part Diagnoses: (include but are not limited to) dependence on renal dialysis, hypertension, and complication of vascular prosthetic device, implant and graft. Order Summary: Enhanced Barrier Precautions due to the following diagnoses: ESRD, Dependence on Renal Dialysis. Active 07/29/2024. R75's (01/30/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R75's mental status as cognitively Intact. Section I - Active Diagnoses: Dependence on Renal Dialysis. R75's (11/11/2025) care plan documented, in part Focus: Enhanced Barrier Precautions r/t (related to) Central Line. Goal: EBP will be maintained. Interventions: Gown and glove(s) during high contact resident care activities (such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use, wound care (any chronic skin opening).The (03/20/2024) Facility Provided document titled Center for Clinical Standards and Quality/Quality, safety & Oversight Group documented, in part Subject: Enhanced Barrier Precautions in Nursing Home. The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. GUIDANCE: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Changing briefs or assisting with toileting. (highlighted) Facilities have discretion on how to communicate to staff which residents require the use of EBP. CMS supports facilities in using creative (e.g., subtle) ways to alert staff when EBP use is necessary to help maintain a home-like environment, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.

Based on observation, interview, and record review, the facility failed to ensure call light devices were placed within residents' reach. This failure affected two (R6 and R7) residents reviewed for call light devices in the total sample of seven residents.Findings include:R6's admission Record documented that R6's diagnoses (include but not limited to) pulmonary embolism, Type 2 Diabetes Mellitus, and COPD (Chronic Obstructive Pulmonary Disease). R6's (12/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R6's mental status as moderately impaired. Section GG0130. C. Toileting hygiene, E. Shower/bathe self, F. Upper body dressing. G. Lower body dressing, H. putting on/taking off footwear: 2 - Substantial / maximal assistance. R6's (12/16/2025) care plan documented, in part Focus: I am at risk for falls and injury related to falls Risk factors: Requires assistance with ADL's, possible medication side effects, incontinence, Neuropathy, H/O (history of) Falls. Goal: I will have interventions in place and reviewed as needed to address risk for falls and injury related to falls. Interventions: Ensure a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. Ensure The resident's call light is within reach and encourage the resident to use it for assistance as needed.R7's admission Record documented that R7's diagnoses (include but not limited to) hypertension, Type 2 Diabetes Mellitus, and osteoarthritis. R7's (12/02/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 09. Indicating R7's mental status as moderately impaired. Section GG. 0130. Toileting hygiene and shower/bathe self: 03 - Partial/moderate assistance. R7's (12/09/2025) care plan documented, in part Focus: I am at risk for falls and injury related to falls. Risk factors: Requires assistance with ADL's, possible medication side effects, Dementia, CVA, OA (osteoarthritis). Goals: I will have interventions in place and reviewed as needed to address risk for falls and injury related to falls. Interventions: Ensure a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light and personal items within reach. Ensure The resident's call light is within reach and encourage the resident to use it for assistance as needed.On 02/04/2026 at 11:01am, surveyor requested a copy of floor's list of residents on high risk for falls. Review of the list indicated R6's was on falling leaf program with intervention to educate on calling for assistance prior to transfer.On 02/04/2026 at 11:05am, this surveyor and V17 (Certified Nursing Assistant) went inside R6's and R7's room. Both R6 and R7 were lying on bed. Inquiring about his call device, (R6) stated he did not know where his call device was. V17 (Certified Nursing Assistant) checked for R6 call light and stated both (R6 and R7) call lights were on the floor, not within their reach. V17 stated their call lights should be within their reach so they could call for assistance when they needed assistance. On 02/04/2026 at 3:42pm, V2 (Director of Nursing) stated call device should be within reach of a resident, in case the resident needed to call the attention of staff. The purpose of ensuring the call light is within reach is to prevent falls. It is part of fall intervention. So, resident who needed assistance would not do things on their own. The (undated) Certified Nursing Assistant Job Description documented, in part The Certified Nursing Assistant is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and responsibilities. Provide for resident comfort by utilizing resources and materials; answering call lights and requests. The (2/2/18) Call Light documented, in part To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. All residents with the ability to use a call device have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. The (11/21/17) Fall Prevention Program documented, in part Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Fall/safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the Fall Prevention Program. At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times.

Based on interview and record review, the facility failed to update a resident's care plan after each fall. This failure affects one (R5) resident reviewed for care plan in the total sample of 7 residents.Findings include:R5's admission Record documented that R5's diagnoses (include but not limited to) hypertension, alcohol dependence, and osteoarthritis. R5's (01/14/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 08. Indicating R5's mental status as moderately impaired.R5's (11/01/2025 - 12/31/2025) Progress notes documented that R5 had unwitnessed falls on 11/04/2025, 11/05/2025, 11/27/2025, 11/30/2025, 12/05/2025, and on 12/07/2025.R5's (01/21/2026) care plan documented, in part Focus: I am at risk for falls and injury related to falls. Risk factors: Requires assistance with ADL's, possible medication side effects, Chronic pain, OA. Goals: I will have interventions in place and reviewed as needed to address risk for fall and injury related to fall. 11/27/2025 Encourage the resident to rest during periods of fatigue. 11/4/2025 Obtain labs. Resident educated on asking staff for help and the importance of using call light and proper bed positioning. 11/5/2025 Encourage the resident to rest during times of fatigue. 12/5/2025 Labs to rule out UTI (urinary tract infection) and referred to therapy.12/7/2025 Labs to rule out high ammonia levels. Of note, care plan was not updated when R5 had a fall incident on 11/30/2025. On 02/05/2026 at 11:24am, V18 (MDS Coordinator/LPN) stated with each fall, the care plan should be updated; to treat each fall needing a new intervention; to investigate to get to the root cause of the fall. The purpose of updating the careplan is to try to prevent resident from falling; if the intervention does not work, try new intervention. On 02/05/2026 at 11:32am, this surveyor showed V18 R5's care plan and R5 falls incidents and stated she (R5) fell on [DATE] and her care plan was not updated for the fall on 11/30/2025. The expectation is to update the care plan with each fall. On 02/05/2026 at 12:14pm, V12 (Restorative Director) stated care plan is updated annually, quarterly, and with any change in condition. If the fall happens on a Sunday, the care plan shall be updated the next day, Monday. The purpose of updating the care plan is to see what is working and what is not working. On 02/05/2026 at 12:28pm, this surveyor showed V12 R5's care plan and R5 fall incidents and stated she fell on [DATE] and care plan was not updated for the fall on 11/30/2025. V12 stated the care plan should be updated with the fall incident on 11/30/2025. On 02/05/2026 at 1:15pm, V2 (Director Of Nursing) stated careplan should be updated with each fall incident. IDT (Inter Departmental Team) should come up with new intervention. The purpose of updating the careplan is to see if the new intervention will work. The care plan should be updated with new intervention when she had a fall incident on 11/30/2025. The (1/4/19) Restorative Nursing Program documented, in part Purpose: to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. The (11/21/17) Fall Prevention Program documented, in part Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The Fall Prevention Program includes the following components: Care plan incorporates: Identification of all risk/issue. Addresses each fall. Interventions are changed with each fall, as appropriate.

Based on interviews and record reviews, the facility failed to implement their abuse prohibition policy by failing to conduct a thorough investigation for an injury of unknown origin. This failure affects one of three residents (R1) reviewed for injuries of unknown origin. As a result, R1 was noted with swelling to the right lower forearm and grimacing in pain and was transported to the local hospital and R1 was found to have sustained a right comminuted distal radial fracture with displacement, a comminuted and impacted distal ulnar fracture with displacement, and a hematoma to the right side of the head.Findings includes:R1's hospital record, dated 9/22/25, notes R1 was brought in by EMS (emergency medical services) crew. Per EMS report, R1 had fall yesterday. This morning R1 had images which showed distal radius and ulna fracture. R1 states that she remembers falling yesterday. On physical exam by emergency room physician, a small hematoma was noted to R1's right lateral head; swelling noted to right wrist with obvious deformity. The emergency room diagnoses: fall and closed fracture of distal ends of right radius and ulna. The hospital's orthopedic surgeon was consulted and noted unclear, unwitnessed mechanism of injury given R1 is bedbound and has been for the last 3-4 years. Also noted is an injury to R1's head, deformity to wrist with dorsal prominence, and moderate swelling around wrist. R1's fracture was closed reduced and right arm placed in a splint.R1's hospital x-rays, dated 9/22/25, shows mildly comminuted (severe break where the bone shatters into three or more pieces, often from high-impact trauma, car accident or fall) fracture of the distal radial diaphysis with 1/4 shaft width radial displacement of the distal fracture fragment; mildly comminuted and impacted fracture of the distal ulnar metaphysis with 1/4 shaft width ulnar displacement of the distal fracture fragment; partially imaged osteoarthritis in knuckles and finger joints; and regional soft tissue swelling.There is no documentation found in R1's hospital record noting right arm injury due to pathological fracture.The facility's investigation into this incident only has statements from V3 RN (registered nurse), V4 RA (restorative aide), and V5 CNA (certified nursing assistant.) The facility did not present any further statements from other staff that worked on R1's nursing unit the days preceding the incident. The facility's investigation, dated 9/22/25, notes R1's right arm injury was due to a pathological fracture. The facility is unable to present any hospital documentation noting R1 had osteoporosis in right arm.On 1/8/26 at 9:45 AM, V1 (administrator) stated that R1 injured right arm when R1 hit arm on side rail. V1 stated that an investigation was done regarding this incident. V1 stated that all the nurses and CNAs (certified nurse aides) on R1's nursing unit were interviewed; all denied R1 falling.On 1/8/26 at 10:55 AM, V2 DON (director of nursing) stated she was present in facility at the time of R1's injury on 9/22/25. V2 stated that she was notified by staff and immediately went to R1's room to assess R1. V2 stated that R1 was not able to state what happened. V2 stated that she interviewed R1's roommates and was informed by one of them that R1 was rolling top sheet up and arm hit side rail. V2 stated that due to R1's comorbidities V2 believed right arm fracture was pathological. V2 stated that V2 called the hospital and asked if injury and R1's comorbidities could fracture be pathological fracture. V2 is unable to state the name of person and his/her job title that she spoke with at hospital. When questioned regarding the hematoma (a localized collection of blood outside of blood vessels, usually caused by injury or trauma) to R1's right lateral head noted on R1's hospital records on 9/22, V2 responded R1 did not have a hematoma, R1 has a dry flaky scalp.On 1/8/26 at 11:04 AM, V3 RN (registered nurse) stated that R1 only gets out of bed on dialysis days; Tuesdays, Thursdays, and Saturdays. V3 stated that R1 transfers via a mechanical lift device. V3 stated that R1 is very dependent on staff for ADLs (activities of daily living). V3 stated that V3 obtained R1's vital signs at beginning of day shift, R1's right arm was normal appearing. V3 stated that R1 received medications at 9:00 AM and R1's right arm was still normal appearing. V3 stated that V4 (restorative aide) informed V3 at 12:30 PM that R1 did not eat well for lunch and R1's arm was swollen. V3 stated that she assessed R1; R1's right wrist area was swollen and R1 was unable to move fingers. V3 stated that V3 does not recall if R1 was sent out for x-rays or x-rays were done in facility.On 1/8/26 at 11:25 AM, V4 RA (restorative aide) stated that when V4 walked past R1's doorway observed R1 was not eating. V4 entered R1's room to assist R1 with meal. V4 stated that he noticed R1 was grimacing. V4 stated that V4 attempted to give R1 fork to eat and observed R1's right wrist was swollen. V4 stated that V4 informed R1's nurse. V4 stated that R1 requires extensive assistance with repositioning. V4 stated that R1 gets up for dialysis via a mechanical lift device.On 1/8/26 at 11:55 AM, V5 CNA stated that he was feeding R1's roommate on 9/22/25 when R1 informed V4 that she was in pain. V5 does not recall any further details.R1's MDS (minimum data set), dated 8/27/25, section GG notes R1 requires extensive assistance with turning side to side in bed and is dependent on staff for all transfers.R1's abuse risk assessment, dated 8/27/25, notes R1 is at low risk for abuse. R1's abuse risk assessment completed post injury, dated 9/26/25, notes R1 is at moderate risk for abuse.The facility's abuse prevention and reporting policy, revised 10/24/22, notes, in part, an injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. The final investigation report shall contain the following: conclusion of the investigation based on known facts.

Based on observations, interviews and record review, the facility failed to ensure adequate supervision and proper use of assistive devices for one wheelchair dependent resident (R1) of three residents reviewed, resulting in an injury requiring urgent transport to the hospital for an acute comminuted femur fracture.This past non-compliance occurred from 07/29/2025 to 08/05/2025.Findings include: R1 is a [AGE] year-old resident of the facility with a Brief Interview for Mental Status (BIMS) score of 12, and with pertinent medical diagnosis including but not limited to Displaced Comminuted Fracture of Shaft of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Age-Related Osteoporosis; Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease; End Stage Renal Disease; and Dependence on Renal Dialysis. On 08/11/2025 at 1:04 PM, upon request, R1 agreed to speak with this Surveyor in her room. R1's room was dark; the television was on, so R1 turned it off; a wheelchair was located on the right side of R1's bed; one attachable wheelchair footrest was noted on the seat of the wheelchair; and the room appeared clutter-free. R1 said that most of the time, the pain level from her right leg, post-surgery, was a ten out of ten, but, on occasion, it went down to five. R1 said she didn't remember the date, but about two weeks ago, at about 1:00 or 2:00 PM, V4 (CNA) wheeled her outside of her room, while on her wheelchair, in order to take her to get her hair done at the facility's hair salon. R1 said that as V4 was pushing her in the hallway, her right foot rolled under her wheelchair, she hollered, then V4 ran back to her room to get a footrest, fastened it to the wheelchair, and placed her right foot on it. R1 said her knee was hurting so bad. R1 said V4 then wheeled her to her hair appointment; and when she was done, she was wheeled back to her room. On 08/12/2025 at 11:50 AM, R1 reiterated to this Surveyor that on 07/29/2025, V4 was wheeling her on her wheelchair towards the hair salon, and that she had no footrests on either side of the wheelchair at the time she was being pushed down the hallway. R1 said that after her right foot rolled under her wheelchair, V4 went inside her room, got a footrest for her, fastened it to her wheelchair, placed her right foot on it, and wheeled her to her hair appointment. On 08/11/2025 at 11:17 AM, V12 (Family Member) told this Surveyor that about two weeks ago, on a Tuesday, at about 5:50 PM, R1 called her from the long-term care facility, and said V4 rolled her right leg under her wheelchair while she was taking her to the beauty shop, and her wheelchair did not have a leg brace to support her leg. V12 said that R1 told her that, after V4 realized R1's right leg had been rolled under the wheelchair, she put a leg brace on the wheelchair and put R1's right foot on it. V12 said that the hospital doctor told her R1's right leg had been fractured in two places. On 08/14/2025 at 9:29 AM, V4 told this Surveyor that on 07/29/2025, R1's right foot came off her wheelchair's leg rest while she was wheeling her about halfway down the hallway to the hair salon for an appointment. V4 said she did not know how it happened, only that it (R1's right foot) slipped off. V4 said she never looked at R1's feet or legs while she was pushing her wheelchair from behind. V4 said that when she went to the front of the wheelchair after R1 hollered, ow, my leg, R1's leg was under the wheelchair, but she did not know how far it had gone under. In a progress note from 07/29/2025 at 6:28 PM, V13 (RN) stated in part that R1 verbalized pain on her right knee and said that it was during transfer when she went down to the salon this morning. In a progress note from 07/30/2025 at 9:00 AM, V14 (APN) stated in part that R1 presented with very bad knee pain and ten out of ten severity for one to two days. In a progress note from 08/01/2025 at 11:34 AM, V15 (NP) stated in part that R1 complained of pain to her right leg, which was not improving with medication, and the pain had been there since her foot dragged under the wheelchair while she was going for an appointment. On 08/12/2025 at 12:32 PM, V6 (APN, Orthopedic Surgery) told one of the Surveyors that she remembered R1 and her injury while at the hospital; and she believed it would have been unlikely that R1's right foot would have gotten caught underneath the wheelchair if the footrests and her feet were put on properly (if they were put on at all). On 08/12/2025 at 12:40 PM, V5 (Restorative Nurse) told this Surveyor that she assessed residents to determine if they were able to move on wheelchairs unassisted, and in R1's case, she was unable to wheel herself, independently, and needed substantial dependent assistance with locomotion. V5 said she had approved two footrests for R1's wheelchair and had instructed nurses and CNA's to ensure they were attached to R1's wheelchair whenever she was going to any destination. V5 said R1 had minimal strength in her legs, her core strength was weak, she was unable to hold her legs up for a long period of time, and believed that it would always be a safe measure to put both footrests on her wheelchair for long distances, like going to the hair salon. V5 said that due to R1's poor functional abilities in her lower extremities, if she was not positioned well while the CNA was transporting her, there could be a problem; so, the staff should make sure that there was proper resident positioning prior to pushing R1. V5 reiterated that, due to R1's weak lower extremities, it was most important that her feet and body be positioned properly. R1's MDS, section GG, dated 07/18/2025, stated in part that R1 was wheelchair dependent, and, thus, unable to wheel herself fifty feet unassisted. On 08/12/2025 at 2:38 PM, V1 (Administrator) told this Surveyor that the administration did not have a facility policy that addressed the proper supervision and use of wheelchairs on 07/29/2025, when R1's right leg injury happened. V1 said they looked for one but could not find it. V1 also said that no video footage of R1's wheelchair incident on 07/29/2025 existed because it had been erased after seven days, and no one reviewed the footage while it was available because there was a lot of footage to go over in order to locate it. R1's x-ray report, dated 08/01/2025, stated in part that R1 suffered an acute comminuted distal femur fracture and an 11mm lateral displacement with distal fragments. A hospital progress note dated 08/06/2025 at 2:25 PM from V6 stated in part that R1 presented to the hospital with a closed right distal supracondylar femur fracture after getting right leg caught under wheelchair while someone was pushing her.R1's hospital summary report dated 08/06/2025 described R1's operative procedure as closed reduction and intramedullar nailing right distal femur on 8/5.The facility provided documentation to the Survey team on 08/12/2025 that outlined steps the facility began taking on 08/02/2025 to address the acceptable supervision for and proper use of assistive devices, such as a wheelchair, after R1's incident.Prior to the survey date of 08/11/2025 the facility had taken the following actions to correct the noncompliance:conducted an in-service training on the following topics:Proper Placement of Feet on FootrestsEmphasis on correct use of footrestsImportance of proper foot positioning during wheelchair useFall Prevention StrategiesIndividualized interventions and supervision tailored to resident needsReinforcement of fall prevention protocolsSafe Handling and Use of WheelchairsCompetencies and training completed for all nursing staffFocused on proper wheelchair use and resident safety during transfers and transportOn-going monitoring by facility administration

Based on interview and record review, the facility failed to ensure a resident's safety while providing incontinence care. This failure affects one of three residents (R2) reviewed for falls in a total sample of six residents. This failure resulted in R2 sustaining left leg fracture to the tibia and right leg fracture to the femur, requiring hospitalization. The past non-compliance occurred from 05/5/2025 to 05/13/2025. Findings include: R2 is a [AGE] year-old female. R2's diagnoses are but not limited to end stage renal disease, chronic pulmonary edema, chronic respiratory failure, dependence on renal dialysis, major depressive disorder, stroke, heart failure, adult failure to thrive, traumatic subdural hemorrhage, and dependence on supplemental oxygen. R2's BIMS (Brief Interview for Mental Status) dated 5/01/2025, notes R2 is alert. R2's MDS (Minimal Data Set) Section GG dated 4/03/2025, notes R2 is dependent with toileting. R2 requires substantial to maximal assistant to roll left and right in the bed. R2's care plan notes R2 is at risk for falls. Interventions include observe and report unsafe conditions and situations. Staff is to ensure proper positioning. Lying to sitting on the side of bed is dependent. Progress note dated 5/5/2025, notes R2 had a witnessed fall on 05/05/2025, at 5:00 PM. The aide informed the nurse that the resident slid down from her bed during a brief change. R2 landed on the floor on her knees. R2 was assessed for pain, injury, wound, and possible fracture -- none noted. R2 had bilateral leg pain. R2 said she fell as she rolled over during a briefs change. Progress note dated 05/07/2025, notes R2 was admitted to the local hospital for left fibula fracture. On 5/17/2025, at 11:54 AM, R6 stated, R2 was in the mechanical lift. The side rail had to be up for her to roll out of bed because she cannot move. The aide that handled her is rough. It was one aide. I was told it was supposed to be two aides. She did not go get any help right away when R2 fell. That aide was standing there in a state of shock. R2 kept saying she was on her knees. R2 landed on her knees. The aide left the resident by herself to go get help instead of calling for help. It was a man aide that came and picked R2 up and put R2 in the bed. R2 was crying out telling the aide please be patient with me. They did not take x-rays until the next day. They did not send R2 out right away either. This place needs to be shut down. R2 laid in bed with those fractures all night. R2 was begging for help. I never heard the aide say anything to the resident. I was told by a person who works here that R2 is in the hospital with broken bones. That aide is too rough, and I told the nurse about it. I want to remain confidential. I feel sad I could not help her that night. On 5/17/2025, at 3:10 PM, V2 (MDS Nurse) stated, R2 is dependent for transfers. This means the staff needs to assist her totally or they might use a mechanical lift. On 5/17/2025, at 4:02 PM, V5 (Fall Coordinator) stated, R2 is more dependent with transfers. She is not able to ambulate. She is a mechanical lift for transfers. I reviewed this incident. From my understanding, it happened during toileting hygiene when the aide was trying to clean her. R2 fell out of the bed; she rolled out of bed. With transfers, R2 requires two people. With mobility, R2 requires maximum assistance with one aide. She can slightly roll over while the aide is changing her. I spoke with the nurse not the aide. The nurse stated she was informed that during toileting hygiene, R2 rolled out of bed and landed on her knees. The root cause of R2's fall was weakness, limited mobility related to functional ability deficits, and degeneration of the joints. R2 stated she rolled out of the bed and could not catch herself. The resident did not say anything else to me. On 5/18/2025, at 9:30 AM, V6 (Assistant Director of Nursing) stated, the nurse told me that she was notified by the aide that during ADL (Activities of Daily Living) care, R2 rolled towards the aide. The aide was not transferring R2 but was just doing regular ADL care. R2 was not able to keep her balance. She rolled and landed on her knees. X-rays were done and she was sent to the hospital. At the hospital, she had fractures to both legs. On 5/18/2025, at 10:00 AM, V8 (Certified Nursing Assistant) stated, R2 is a two person assist with the mechanical lift, or if she needs to be pulled up in bed. When staff is changing her in bed, staff is supposed to put up the bed rail and clean her. R2 can assist you with rolling and holding onto the bar while cleaning her. If staff forget to put the railing up while cleaning her, she is going to fall. The rail must be up because she has poor truck control. I do not see R2 letting staff clean her up without the rail being up or a second assistant being there in front of her. She will say, I'm scared or ask you to go to get some assistance? R2 is very verbal. She will tell staff what she needs, what to do or need to do. I heard about the incident, but I was not there. The aide that was helping told me that she was cleaning R2. When the aide turned R2 over to clean her, R2's head was hanging off the bed. The aide told R2 I got you. R2 said something about her legs. The aide stated she lowered R2 gently to the floor. It took four people to get R2 off the floor. The aide should have the rail up or had a second assistant. Some people just do not listen. If she did not know she could have asked another aide or looked in the POC. There is a care plan book to look in for information as well. On 5/18/2025, at 10:11 AM, V9 (Certified Nursing Assistant) stated, R2 has good bed mobility. She can grab the rail, and she can hold on. She is pretty good about that. She must have the railing to hold on to prevent her from failing. She will tell you make sure the rail is down. Her legs are not good. If there is no railing her legs may slide out. The railing must be up to prevent her from failing out of bed. I do not know what the situation was with that aide. I have worked with that aide, and she was new. I remember talking about the mechanical lift and having two people. If the railing was not up, she should have made sure both were up. Having the railings up is for safety. I was one of the people that helped to get R2 off the floor. On 5/18/2025, at 11:10 AM, V12 (Certified Nursing Assistant) stated, yes, I remember what happened that day. Me and the nurse just got R2 from dialysis and put her to bed. The nurse stepped out and I begin to change R2 on her left side towards the door. I rolled her and her feet began to slide off the bed. As her feet where sliding, I began to push her back into the bed. She kept saying my legs are sore. I stated I needed to go get help because she was sliding out of the bed. She was holding the pole. I yelled for assistance. I had to put her down because she was sliding out of the bed, and she would not allow me to push her out of the bed. I was pushing her legs. The bed was on the floor. She did not fall. It took four of us to put her back in the bed. She did not fall, but I had to lower her down to her knees. She is not good at moving, staff must do all the work. I have only been in the facility for three weeks. Both bed railings were not up. Only the one railing towards us was up. I was never told information if she was a two person or one person. It looks like she required two people assistance. On 5/18/2025, at 11:50 AM, V13 (Registered Nurse) stated, I was the nurse that was on duty. After R2 came from dialysis, we transferred her to the bed with the mechanical lift. We positioned her for comfort. I went to pass medication. The aide called me and told me R2 had a fall. I checked her vitals, and they were normal. R2 had chronic knee pain. She stated the pain was the same. I notified the nurse practitioner (NP). The NP asked me to order bilateral hip and knee x-rays. I ordered them. I informed the relative. I notified the DON. The resident stated when the aide was changing her, she rolled over out of the bed when she turned on her side. The aides must put the railing up for her to hold on. When she turns, she can hold on to turn her upper body. The railing helps with safety and mobility. On 5/18/2025, at 1:06 PM, V23 (Director of Nursing) stated, I was informed about R2's fall. I do not recall when I was informed, but I was informed. She had slipped from the bed during ADL care. The aide assisted her to the floor. The aide stated she was performing peri-care and she felt the resident coming close to her. She tried to reposition the resident, and it was not happening. She assisted the resident to the floor. The resident is alert. I did not get a chance to interview her before she went to the hospital. The IDT (Interdisplinary) team reviews all the falls, the fall risk assessments, description of the falls, factors, root causes analysis and IDT interventions. I expect staff for dependent residents to look at bed mobility, transfers, and ADL care. If they do not know what type of assistance a resident requires, I expect them to ask other nurses or aides. On 5/19/2025, at 10:26 AM, V25 (Nurse Practitioner) stated, I am aware of the patient. They did inform me about the assisted fall. I had treated her for medical problems. Yes, it is possible for the resident to fall out of bed and sustain fractures. Being an elderly frail resident she is an increased risk for fractures. Facility policy titled Fall Prevention Program, dated 11/21/2017, notes to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. Direct care staff will be oriented and trained in the Fall Prevention Program. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. Prior to the survey date of 05/19/2025, facility had taken the following action to correct the noncompliance: 1. R1 new fall assessment completed with new interventions and are plan updated. 2. Nursing staff in-serviced on fall policy and interventions from 05/06/2025 to 5/09/2025. Nurses and aides in-serviced on high-risk residents, frequent monitoring and supervision. 3. Aides and nurses in-serviced on proper bed mobility and positioning. 4. Facility wide assessment has been done to identify all residents that are at risk for fall new interventions put in place. The binder was updated, and care plans were updated. Audits will be conducted daily to ensure fall risks are completed and interventions are in place. After any fall occurs for six months and discussed in daily meetings. 5. Nurses in-serviced on completing new fall risk assessments after fall interventions are updated and care plan is updated. The director of nursing and the nurse consultant will audit each new fall with record review and observation to ensure compliance weekly for six months.

Based on observations, interviews, and record reviews, the facility failed to follow its physician orders policy and hypoglycemia guidelines and administer emergency medication to treat a resident exhibiting signs and symptoms of severe hypoglycemia (low blood sugar level) for one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. On 2/21/25, R1 was nonresponsive and with a blood sugar level of 29; no treatment initiated prior to EMS (emergency medical services) 911 arrived and transported R1 to the hospital emergently. The immediate jeopardy began on 2/21/25 when R1 was found unresponsive and with a blood glucose level of 29. V1 and V2 were notified of the immediate jeopardy on 03/13/2025 at 9:35 AM. The surveyor confirmed by onsite observations, interviews, and record reviews that the immediacy was removed on 3/13/2025, but remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 3/2/25 at 7:49 PM, V7 LPN (licensed practical nurse) stated that V7 does recall R1. V7 stated that V7 was about to leave facility at end of shift on 2/21/25 when the CNA (certified nurse aide) told her that R1 did not look right. V7 went to R1's room and checked R1's blood sugar and it was low. V7 stated that R1 was non-responsive. V7 stated that V7 was alone on nursing unit as the rest of the evening shift staff left. V7 stated that another nurse came to assist her, but does not recall the nurse's name. V7 stated that V7 last saw R1 during evening medication pass. V7 stated that R1 did not have any oral diabetic medications and R1 was not receiving insulin. When questioned if V7 administered any medication to R1 to treat low blood sugar, V7 did not respond. V13 CNA (agency certified nurse aide) worked 3:00 PM - 11:00 PM shift on 2/21/25. V13 was unavailable for interview during this survey. On 3/3/25 at 11:34 AM, V8 ADON (assistant director of nursing) stated that staff are expected to try nursing interventions, call NP (nurse practitioner) on call and follow the orders given. V8 stated that if the resident is alert, give hard candy or a packet of sugar. V8 stated that if the resident is not alert, there is glucose in the crash cart and emergency kit. V8 stated that there is a crash cart and emergency kit located at the nurses' station on each nursing unit. V8 stated that V12 (nursing supervisor) works 10:00 PM until 6:00 AM and should have been called to assist V7 with R1. On 3/3/25 at 11:40 AM, this surveyor and V8 ADON checked emergency box located in medication room on R1's nursing unit. The kit contained two doses of baqsimi (nasal glucagon) nasal spray for treatment of severe hypoglycemia. V8 stated that when a medication is used from emergency kit, the nurse documents on the sign out sheet, so medication can be replaced. V8 stated that on 2/21/25 baqsimi medication was not removed from the emergency kit. On 3/3/25 at 11:50 AM, V8 ADON stated that V8 reviewed R1's progress notes. V8 stated that V7 documented R1's blood sugar was 29, notified V10 NP, and sent R1 out via EMS (emergency medical services) 911. V8 stated that staff are expected to know what is in the emergency kit. V8 stated that after reviewing the policy, V7 LPN did not give R1 anything to treat hypoglycemia. On 3/3/25 at 12:20 PM, V12 (nursing supervisor) stated that V12 worked on 2/21/25. V12 stated that V12 did not receive any calls for a resident with low blood sugar. V12 stated that V12 heard about this event a few days later when staff were talking about it. V12 stated that if V12 had been made aware V12 would have instructed V7 to administer baqsimi nasal spray from the emergency kit and would have gone to R1's bedside to assist. On 3/3/25 at 12:46 PM, V10 NP (nurse practitioner) stated that V10 was not notified by nursing that R1's blood sugar was 29 and R1 was nonresponsive. V10 stated that if a resident has a blood sugar of 29 and is nonresponsive, V10 would expect the nurse to administer medication to treat hypoglycemia while waiting for EMS 911. On 3/3/25 at 1:05 PM, V14 (EMS paramedic) stated that when V14 arrived at R1's bedside V14 and crew were informed that the night shift nurse was making rounds and found R1 nonresponsive. V14 stated that the crew was informed that the evening shift nurse had already left facility. V14 stated that the crew quickly got R1 in to the ambulance to start treatment while in route to the hospital. V14 stated that the crew was informed that no treatment was initiated by the nurse prior to their arrival. V14 stated that the crew checked R1's continuous blood glucose system receiver. V14 stated that R1's blood sugar bottomed out at 7:30 PM and remained that way until their arrival at 11:34 PM. R1's hospital discharge instructions, dated [DATE], notes insulin 70/30, administer 20 units subcutaneously daily in the morning. R1's POS (physician order sheet), dated 2/18/25, notes continuous blood glucose system sensor and receiver. It also notes an order for insulin 70/30 suspension pen-injector, inject 20 units subcutaneously one time a day for high blood sugar. R1's POS, dated 2/19/25 at 00:50 AM, notes an order for insulin 70/30 suspension pen-injector, inject 20 unit intramuscularly three times a day for high blood sugar. V15 LPN (licensed practical nurse) created the order changing R1's insulin from subcutaneous to intramuscular and from daily to three times daily. V15 was unavailable for interview during this survey. R1's medical record, dated 2/19/25, V10 NP noted R1's hospital stay notable for hypoglycemia from poor oral intake. R1's diabetes is stable. Blood sugar level 115 this morning. On insulin 70/30 daily, order blood sugar testing before meals and at bedtime. Baqsimi nasal spray as needed. On 2/21/25 at 11:47 PM, V8 LPN noted CNA (certified nurse aide) notified V8 of R1 not being responsive. V8 observed R1 unresponsive. V8 than obtained vital signs, and blood sugar, pulse 60 beats/minute, respirations 20/minute, oxygen saturation level 90% on room air, and blood sugar 29. R1 transferred to the hospital via stretcher. On 2/22, R1 has been admitted for Hypoglycemia. R1's EMS (emergency medical services) run sheet, dated 2/21/2025, notes EMS crew was dispatched to the facility at 11:27 PM for a resident with a diabetic problem. The crew arrived at R1's bedside at 11:34 PM. Upon arrival R1 was in the room with a CNA, unresponsive, diaphoretic, with a GCS (glascow coma score) of 3. The CNA advised the crew that R1 had low blood sugar. V7 LPN just checked it, but I don't know what it is. R1's continuous blood glucose system receiver just says 'LOW'. The crew looked at R1's continuous blood glucose system receiver and the trends it showed was: blood glucose at a normal level around 3:00 PM with it dropping to LOW around 3:30 PM and continuously being at LOW until the crew's arrival at 11:34 PM. R1 was loaded on to the stretcher and brought down to the ambulance. R1's vital signs were taken, and all were within normal limits with the exception of her blood glucose level which was at 31. Two intravenous catheter insertion attempts were made, one in each forearm but were unsuccessful. IO (intraosseous) equipment was set up, the hospital was called to clear the IO insertion. An IO was established in R1's left tibia. R1 was administered dextrose 10% at a keep open rate. R1's oxygen saturation level was starting to decrease in route. A nasal cannula was placed on R1 and oxygen was delivered at 4 liters. R1's hospital record, dated 2/22/25, was unavailable for review during this survey. R1's care plan, dated 2/19/25, notes R1 is an insulin dependent diabetic. Interventions include, but not limited to, diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. The facility's physician orders-entering and processing policy, revised 1/31/2024, notes if the medication is needed immediately, it will be removed from the emergency drug kit. All appropriate paperwork will be filled out when a drug is removed from the emergency drug kit. The facility's hypoglycemia guidelines, undated, notes contact physician if blood sugar is below 60. Take vital signs. Repeat finger stick in 15 minutes after intervention. If unable to swallow notify the physician and prepare glucagon from the emergency drug kit for administration as ordered. Document findings, interventions, and physician contact in resident's clinical record. The Immediate Jeopardy that began on 02.21.25 was removed on 03.13.25 when the facility took to remove the Immediacy. Removal Plan: Action Steps Responsible Person(s) Target Date: Change of condition assessment done as soon as change Nurse managers Ongoing is noticed to monitor condition Daily clinical meeting IDT Ongoing Nursing Huddle/CNA DON/ADON Ongoing Change of condition NP / Dr notified Admin/DON/Nurses Ongoing All department Heads to read 24-hour report daily before DON/ADON Ongoing Morning meeting at 9:30am Guardian Angel rounds and sheets to be completed daily DON/ADON Ongoing and turned into and reviewed daily at standdown, don't just report issues, correct as you go. New insulin orders will be discussed daily in morning meeting Weekly insulin Orders checked and verified orders for the last week Nursing 3/4/2025 Nurses including agency inserviced on verifying with repeat DON 3/5/2025 back to NP/physicians when taking orders. All nurses not already inserved they will be inserviced prior to next scheduled shift. Nurses including agency inserviced on following Dr orders DON 3/5/2025 Completed 3/13/25 for agency staff and the five rights of medication and Hypoglycemia protocol (see policy) All nurses not already inserved they will be inserviced prior to next scheduled shift. Facility wide audit completed for residents on Insulin to ensure correct DON /RNC 3/4/2025 orders in place and orders for hypoglycemic treatment Emergency QAPI completed with Medical Director Admin/DON/Medical Director 3/13/2025 Orders written for residents on insulin to monitor for signs DON/RNC 3/13/25 and symptoms of hypoglycemia Facility policy reviewed and revised to include emergency CCO 3/13/25 response and directions for use of baqsimi Pharmacy consultant to review all insulin orders monthly during On going monthly facility visits for 6 months to verify that dose is appropriate Red emergency drug kits will be checked weekly to verify all DON / ADON On going medications are available.

Based on interviews and record reviews, the facility failed to follow professional standards of nursing care and clarify with the physician the frequency and route of administration of insulin 70/30 prior to administering the medication. This failure affected one resident (R1) out of three reviewed for significant medication errors in a sample of 4. Prior to admission, 20 units of insulin 70/30 was administer to R1 subcutaneously once a day. The order was changed on 2/19/25 at 00:50 AM to insulin 70/30, administer 20 units intramuscularly three times a day. This resulted in R1 having severe hypoglycemia with a blood sugar level of 29 and being nonresponsive for unknown length of time. The immediate jeopardy began on 2/21/25 when R1 was found unresponsive and with a blood glucose level of 29. V1 and V2 were notified of the immediate jeopardy on 03/13/2025 at 9:35 AM. The surveyor confirmed by onsite observations, interviews, and record reviews that the immediacy was removed on 3/13/25, but remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 3/3/25 at 5:00 PM, V10 NP (nurse practitioner) stated that R1 had an order for insulin 70/30 subcutaneous daily. V10 was not made aware that R1's insulin was changed to three times a day. V10 stated that V10 would not have changed R1's insulin to be given three times daily. V10 stated that insulin should not be administered intramuscularly. V10 stated that insulin should be administered within 30 minutes of when blood sugar is checked. V10 stated that insulin 70/30 is an intermediate-acting insulin and should not be given two doses close together. On 3/4/25 at 9:13 AM, V8 ADON (assistant director of nursing) stated that the nurse is expected to review discharge paperwork sent with new admission from the hospital. V8 stated that if there is a question regarding any physician order, the nurse is expected to clarify the order prior to implementing it. When questioned why insulin administration was changed from subcutaneous to intramuscular, V8 stated that V8 will have to look into this. When questioned reason insulin 70/30 was changed from daily to three times a day, V8 stated that she will have to look into this as well. V8 stated that the nurse is expected to know when insulin peaks and duration of its action. R1's POS (physician order sheet), dated 2/18/25, notes an order for novolin 70/30 insulin, administer 20 units subcutaneously once a day. On 2/19/25 at 00:50 AM, the insulin order was changed to 20 units intramuscularly three times a day. V15 LPN (licensed practical nurse) created the order changing R1's insulin from subcutaneous to intramuscular and from daily to three times daily. V15 was unavailable for interview during this survey. R1's MAR (medication administration record), dated February 2025, notes six nurses administered insulin 70/30 intramuscularly. R1 received a total of 9 doses intramuscularly. It also notes on 2/21/25 the 9:00 AM scheduled dose of novolin 70/30 insulin was administered at 11:31 AM by V11 LPN (licensed practical nurse) and the 12:00 PM scheduled dose was administered at 12:19 PM by V11. R1's EMS (emergency medical services) run sheet, dated 2/21/2025, notes EMS crew was dispatched to the facility at 11:27 PM for a resident with a diabetic problem. The crew arrived at R1's bedside at 11:34 PM. Upon arrival R1 was in the room with a CNA, unresponsive, diaphoretic, with a GCS (glascow coma score) of 3. The CNA advised the crew that R1 had low blood sugar. V7 LPN just checked it, but I don't know what it is. R1's continuous blood glucose system receiver just says 'LOW'. The crew looked at R1's continuous blood glucose system receiver and the trends it showed was: blood glucose at a normal level around 3:00 PM with it dropping to LOW around 3:30 PM and continuously being at LOW until the crew's arrival at 11:34 PM. R1 was loaded on to the stretcher and brought down to the ambulance. R1's vital signs were taken, and all were within normal limits with the exception of her blood glucose level which was at 31. Two intravenous catheter insertion attempts were made, one in each forearm but were unsuccessful. IO (intraosseous) equipment was set up, the hospital was called to clear the IO insertion. An IO was established in R1's left tibia. R1 was administered dextrose 10% at a keep open rate. R1's oxygen saturation level was starting to decrease in route. A nasal cannula was placed on R1 and oxygen was delivered at 4 liters. Per the National Library of Medicine, insulin is absorbed faster after intramuscular injection compared to subcutaneous injection. Intramuscular injections should be avoided as they increase the risk of hypoglycemia. Per the FDA (Food and Drug Administration), novolin insulin 70/30 is an intermediate-acting insulin. The effects of Novolin 70/30 start working 30 minutes after injection. The greatest blood sugar lowering effect is between 2 and 12 hours after the injection. This blood sugar lowering may last up to 24 hours. Symptoms of hypoglycemia may include, but not limited to: sweating, confusion, shakiness. Severe hypoglycemia can cause unconsciousness, seizures, and death. The Centers for Medicare & Medicaid Services requires nurses to verify specific information prior to the administration of medication to avoid errors, referred to as verifying the rights of medication administration. These rights of medication administration are the vital last safety check by nurses to prevent errors in the chain of medication administration that includes the prescribing provider, the pharmacist, the nurse, and the patient. The nurse ensures the route of administration is appropriate for the specific medication and also for the patient. Some medications can only be given safely via one route. Nurses must administer medications via the route indicated in the order. If a nurse discovers an error in the order or believes the route is unsafe for a particular patient, the route must be clarified with the prescribing provider before administration. The Immediate Jeopardy that began on 02.21.25 was removed on 03.13.25 when the facility took to remove the Immediacy. Removal Plan: Change of condition assessment done as soon as change is noticed to monitor condition Nurse managers Ongoing Daily clinical meeting IDT Ongoing Nursing Huddle/CNA DON/ADON Ongoing Change of condition NP / Dr notified Admin/DON/Nurses Ongoing Action Steps Responsible Person(s) Target Date: All department Heads to read 24-hour report daily before Morning meeting at 9:30am DON/ADON Ongoing Guardian Angel rounds and sheets to be completed daily and turned into and reviewed daily at standdown, don't just report issues, correct as you go. DON/ADON Ongoing New insulin orders will be discussed daily in morning meeting Weekly insulin Orders checked and verified orders for the last week Nursing 3/4/2025 Nurses including agency inserviced on verifying with repeat back to NP/physicians when taking orders. All nurses not already inserved they will be inserviced prior to next scheduled shift. DON 3/5/2025 Nurses including agency inserviced on following Dr orders and the five rights of DON 3/5/2025 Completed 3/13/25 for agency staff medication and Hypoglycemia protocol (see policy) All nurses not already inserved they will be inserviced prior to next scheduled shift. Facility wide audit completed for residents on Insulin to ensure correct orders in DON 3/4/25 place and orders for hypoglycemic treatment. Emergency QAPI completed with Medical Director Admin/DON/Medical Director 3/13/25 Orders written for residents on insulin to monitor for signs and symptoms of DON/RNC 3/13/25 hypoglycemia Facility policy reviewed and revised to include emergency response and CCO 3/13/25 directions for use of baqsimi Pharmacy consultant to review all insulin orders monthly during monthly On going facility visits for 6 months to verify that dose is appropriate Red emergency drug kits will be checked weekly to verify all medications are available. DON / ADON On going

Based on observations, interviews, and record reviews, the facility failed to follow its physician - family notification - change in condition policy and notify the attending physician/nurse practitioner of a resident having severe hypoglycemia and obtain emergent treatment orders. This failure affected one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. On 2/21/25, R1 was nonresponsive and with a blood sugar level of 29; no treatment initiated prior to EMS (emergency medical services) 911 arrived and transported R1 to the hospital emergently. Findings include: On 3/2/25 at 7:49 PM, V7 LPN (licensed practical nurse) stated that V7 does recall R1. V7 stated that V7 was about to leave facility at end of shift on 2/21/25 when the CNA (certified nurse aide) told her that R1 did not look right. V7 went to R1's room and checked R1's blood sugar and it was low. V7 stated that R1 was non-responsive. V7 stated that V7 was alone on nursing unit as the rest of the evening shift staff left. V7 stated that another nurse came to assist her, but does not recall the nurse's name. V7 stated that V7 last saw R1 during evening medication pass. V7 stated that R1 did not have any oral diabetic medications and R1 was not receiving insulin. When questioned if V7 administered any medication to R1 to treat low blood sugar, V7 did not respond. On 3/3/25 at 11:34 AM, V8 ADON (assistant director of nursing) stated that staff are expected to try nursing interventions, call NP (nurse practitioner) on call and follow the orders given. V8 stated that if the resident is alert, give hard candy or a packet of sugar. V8 stated that if the resident is not alert, there is glucose in the crash cart and emergency kit. V8 stated that there is a crash cart and emergency kit located at the nurses' station on each nursing unit. V8 stated that V12 (nursing supervisor) works 10:00 PM until 6:00 AM and should have been called to assist V7 with R1. On 3/3/25 at 11:40 AM, this surveyor and V8 ADON checked emergency box located in medication room on R1's nursing unit. The kit contained two doses of baqsimi (nasal glucagon) nasal spray for treatment of severe hypoglycemia. V8 stated that when a medication is used from emergency kit, the nurse documents on the sign out sheet, so medication can be replaced. V8 stated that on 2/21/25 baqsimi medication was not removed from the emergency kit. On 3/3/25 at 11:50 AM, V8 ADON stated that V8 reviewed R1's progress notes. V8 stated that V7 documented R1's blood sugar was 29, notified V10 NP, and sent R1 out via EMS (emergency medical services) 911. V8 stated that staff are expected to know what is in the emergency kit. V8 stated that after reviewing the policy, V7 LPN did not give R1 anything to treat hypoglycemia. On 3/3/25 at 12:20 PM, V12 (nursing supervisor) stated that V12 worked on 2/21/25. V12 stated that V12 did not receive any calls for a resident with low blood sugar. V12 stated that V12 heard about this event a few days later when staff were talking about it. V12 stated that if V12 had been made aware V12 would have instructed V7 to administer baqsimi nasal spray from the emergency kit and would have gone to R1's bedside to assist. On 3/3/25 at 12:46 PM, V10 NP (nurse practitioner) stated that V10 was not notified by nursing that R1's blood sugar was 29 and R1 was nonresponsive. V10 stated that if a resident has a blood sugar of 29 and is nonresponsive, V10 would expect the nurse to administer medication to treat hypoglycemia while waiting for EMS 911. On 3/3/25 at 1:05 PM, V14 (EMS paramedic) stated that when V14 arrived at R1's bedside V14 and crew were informed that the night shift nurse was making rounds and found R1 nonresponsive. V14 stated that the crew was informed that the evening shift nurse had already left facility. V14 stated that the crew quickly got R1 in to the ambulance to start treatment while in route to the hospital. V14 stated that the crew was informed that no treatment was initiated by the nurse prior to their arrival. V14 stated that the crew checked R1's continuous blood glucose system receiver. V14 stated that R1's blood sugar bottomed out at 7:30 PM and remained that way until their arrival at 11:34 PM. R1's EMS (emergency medical services) run sheet, dated 2/21/2025, notes EMS crew was dispatched to the facility at 11:27 PM for a resident with a diabetic problem. The crew arrived at R1's bedside at 11:34 PM. Upon arrival R1 was in the room with a CNA, unresponsive, diaphoretic, with a GCS (glascow coma score) of 3. The CNA advised the crew that R1 had low blood sugar. V7 LPN just checked it, but I don't know what it is. R1's continuous blood glucose system receiver just says 'LOW'. The crew looked at R1's continuous blood glucose system receiver and the trends it showed was: blood glucose at a normal level around 3:00 PM with it dropping to LOW around 3:30 PM and continuously being at LOW until the crew's arrival at 11:34 PM. R1 was loaded on to the stretcher and brought down to the ambulance. R1's vital signs were taken, and all were within normal limits with the exception of her blood glucose level which was at 31. Two intravenous catheter insertion attempts were made, one in each forearm but were unsuccessful. IO (intraosseous) equipment was set up, the hospital was called to clear the IO insertion. An IO was established in R1's left tibia. R1 was administered dextrose 10% at a keep open rate. R1's oxygen saturation level was starting to decrease in route. A nasal cannula was placed on R1 and oxygen was delivered at 4 liters. The facility's physician orders-entering and processing policy, revised 1/31/2028, notes if the medication is needed immediately, it will be removed from the emergency drug kit. All appropriate paperwork will be filled out when a drug is removed from the emergency drug kit. The facility's physician - family notification - change in condition policy, revised 11/13/2018, notes the facility will consult with the resident's physician or NP when there is a significant change in the resident's physical, mental, and psychosocial status (deterioration in health, life threatening condition). The facility's hypoglycemia guidelines, undated, notes contact physician if blood sugar is below 60. Take vital signs. Repeat finger stick in 15 minutes after intervention. If unable to swallow notify the physician and prepare glucagon from the emergency drug kit for administration as ordered. Document findings, interventions, and physician contact in resident's clinical record.

Based on interviews and record reviews, the facility to provide quality care and services in accordance with professional standards of practice for blood sugar monitoring, insulin administration, recognizing the signs and symptoms of hypoglycemia, and implementing interventions to treat hypoglycemia for one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. This failure resulted in R1 receiving intermediate-acting insulin on 2/21/25 at 11:31 AM and 12:19 PM leading to severe hypoglycemia with a blood sugar level of 29. Findings include: On 3/2/25 at 7:49 PM, V7 LPN (licensed practical nurse) stated that V7 does recall R1. V7 stated that V7 was about to leave facility at end of shift on 2/21/25 when the CNA (certified nurse aide) told her that R1 did not look right. V7 went to R1's room and checked R1's blood sugar and it was low. V7 stated that R1 was non-responsive. V7 stated that V7 was alone on nursing unit as the rest of the evening shift staff left. V7 stated that another nurse came to assist her, but does not recall the nurse's name. V7 stated that V7 last saw R1 during evening medication pass. V7 stated that R1 did not have any oral diabetic medications and R1 was not receiving insulin. When questioned if V7 administered any medication to R1 to treat low blood sugar, V7 did not respond. V13 CNA (agency certified nurse aide) worked 3:00 PM - 11:00 PM shift on 2/21/25. V13 was unavailable for interview during this survey. On 3/3/25 at 5:00 PM, V10 NP (nurse practitioner) stated that R1 had an order for insulin 70/30 subcutaneous daily. V10 was not made aware that R1's insulin was changed to three times a day. V10 stated that V10 would not have changed R1's insulin to be given three times daily. V10 stated that insulin should not be administered intramuscularly. V10 stated that insulin should be administered within 30 minutes of when blood sugar is checked. V10 stated that insulin 70/30 is an intermediate-acting insulin and should not be given two doses close together. On 3/3/25 at 1:05 PM, V14 (EMS paramedic) stated that when V14 arrived at R1's bedside V14 and crew were informed that the night shift nurse was making rounds and found R1 nonresponsive. V14 stated that the crew was informed that the evening shift nurse had already left facility. V14 stated that the crew quickly got R1 in to the ambulance to start treatment while in route to the hospital. V14 stated that the crew was informed that no treatment was initiated by the nurse prior to their arrival. V14 stated that the crew checked R1's continuous blood glucose system receiver. V14 stated that R1's blood sugar bottomed out at 7:30 PM and remained that way until their arrival at 11:34 PM. On 3/4/25 at 9:13 AM, V8 ADON (assistant director of nursing) stated that the nurse is expected to review discharge paperwork sent with new admission from the hospital. V8 stated that if there is a question regarding any physician order, the nurse is expected to clarify the order prior to implementing it. When questioned why insulin administration was changed from subcutaneous to intramuscular, V8 stated that V8 will have to look into this. When questioned reason insulin 70/30 was changed from daily to three times a day, V8 stated that she will have to look into this as well. V8 stated that the nurse is expected to know when insulin peaks and duration of its action. R1's POS (physician order sheet), dated 2/18/25, notes an order for novolin 70/30 insulin, administer 20 units subcutaneously once a day. On 2/19/25 at 00:50 AM, the insulin order was changed to 20 units intramuscularly three times a day. V15 LPN (licensed practical nurse) created the order changing R1's insulin from subcutaneous to intramuscular and from daily to three times daily. V15 was unavailable for interview during this survey. R1's MAR (medication administration record), dated February 2025, notes six nurses administered insulin 70/30 intramuscularly. R1 received a total of 9 doses intramuscularly. It also notes on 2/21/25 the 9:00 AM scheduled dose of novolin 70/30 insulin was administered at 11:31 AM by V11 LPN (licensed practical nurse) and the 12:00 PM scheduled dose was administered at 12:19 PM by V11. R1's EMS (emergency medical services) run sheet, dated 2/21/2025, notes EMS crew was dispatched to the facility at 11:27 PM for a resident with a diabetic problem. The crew arrived at R1's bedside at 11:34 PM. Upon arrival R1 was in the room with a CNA, unresponsive, diaphoretic, with a GCS (glascow coma score) of 3. The CNA advised the crew that R1 had low blood sugar. V7 LPN just checked it, but I don't know what it is. R1's continuous blood glucose system receiver just says 'LOW'. The crew looked at R1's continuous blood glucose system receiver and the trends it showed was: blood glucose at a normal level around 3:00 PM with it dropping to LOW around 3:30 PM and continuously being at LOW until the crew's arrival at 11:34 PM. R1 was loaded on to the stretcher and brought down to the ambulance. R1's vital signs were taken, and all were within normal limits with the exception of her blood glucose level which was at 31. Two intravenous catheter insertion attempts were made, one in each forearm but were unsuccessful. IO (intraosseous) equipment was set up, the hospital was called to clear the IO insertion. An IO was established in R1's left tibia. R1 was administered dextrose 10% at a keep open rate. R1's oxygen saturation level was starting to decrease in route. A nasal cannula was placed on R1 and oxygen was delivered at 4 liters. R1's hospital record, dated 2/22/25, was unavailable for review during this survey. The facility's hypoglycemia guidelines, undated, notes contact physician if blood sugar is below 60. Take vital signs. Repeat finger stick in 15 minutes after intervention. If unable to swallow notify the physician and prepare glucagon from the emergency drug kit for administration as ordered. Document findings, interventions, and physician contact in resident's clinical record. Per the National Library of Medicine, insulin is absorbed faster after intramuscular injection compared to subcutaneous injection. Intramuscular injections should be avoided as they increase the risk of hypoglycemia. Per the FDA (Food and Drug Administration), novolin insulin 70/30 is an intermediate-acting insulin. The effects of Novolin 70/30 start working 30 minutes after injection. The greatest blood sugar lowering effect is between 2 and 12 hours after the injection. This blood sugar lowering may last up to 24 hours. Symptoms of hypoglycemia may include, but not limited to: sweating, confusion, shakiness. Severe hypoglycemia can cause unconsciousness, seizures, and death. The Centers for Medicare & Medicaid Services requires nurses to verify specific information prior to the administration of medication to avoid errors, referred to as verifying the rights of medication administration. These rights of medication administration are the vital last safety check by nurses to prevent errors in the chain of medication administration that includes the prescribing provider, the pharmacist, the nurse, and the patient. The nurse ensures the route of administration is appropriate for the specific medication and also for the patient. Some medications can only be given safely via one route. Nurses must administer medications via the route indicated in the order. If a nurse discovers an error in the order or believes the route is unsafe for a particular patient, the route must be clarified with the prescribing provider before administration.

Based on interview and record review, the facility failed to protect residents from resident to resident physical abuse. This failure affects four of four residents (R1, R2, R3 R4) reviewed for abuse. This failure resulted in R1 getting feces thrown in R1's eye and on R1's body. This physical abuse caused R1 to feel upset, disgusted, abused, and scared R4 would throw more and R4 would try to attack R1. Findings include: 1.) R1 is an [AGE] year-old resident admitted to facility on 2/17/2024 with medical diagnoses including but not limited to: major depressive disorder, moderate protein-calorie malnutrition, adult failure to thrive and age-related osteoporosis. R1 has a Brief Interview for Mental Status (BIMS) score of 9/15 dated 10/30/2024 which suggests moderate cognitive impairment. Minimum data set (MDS) section GG dated 10/30/2024, R1 requires substantial/maximal assistance for shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. R1 is dependent on staff for toileting hygiene. R1 needs partial/moderate assistance for oral hygiene. R1 needs supervision or touching assistance for eating. R1 reported an allegation of abuse on 11/19/2024 that had allegedly happened on 11/17/2024 to the State Survey Agency. On 11/25/2024, at 09:33 AM, R1 stated, regarding another resident throwing feces/urine at me this happened in R1's old room. R4 was my old roommate. They moved me after that. R4 uses a colostomy bag. Feces got in my eye. The facility did not send me to the doctor. My linens were all a mess, and I was hollering, and the nurse came to my room. The nurse V5 LPN (Licensed Practical Nurse) helped clean me up. The social worker came in and asked me what happened I am not sure if the other resident (R4) is still here. I did have eye drops put in my eyes after that which helped. I do not have any other problems other than my complaint. On 11/25/2024, at 12:31 PM, R1 stated it made me feel awful and scared when R4 threw feces on me. We shared food and stuff before this. I feel safe to stay here now. I don't believe they will allow anyone to come in here and abuse me again. On 11/26/2024, at 11:05 AM, R1 stated I felt just terrible and awful when R4 threw feces at me. It felt disgusting to have feces all over me. It got in my eye and all over my body. I was scared that R4 might throw more or reach over and try to attack me. I called my son right after the nurse (V5) cleaned me up to tell him because I was so upset. My son got upset too. It felt like something was under my eyelid. That was an uneasy feeling. On 11/25/2024, at 12:23 PM, surveyor asked R4 if she got in an altercation with R1 last week. R4 stated, I am a nice person I did not try to throw anything on R1 I have nervous hands. I am a nice person. R1 don't like me. I'm going to stay in this room. I like it here. I am a nice person; I didn't try to do that. R1's Progress note dated 11/17/2024 documents: Late Entry: Narrative: V5 informed by certified nursing assistant that resident roommate bodily fluids made contact with her. V5 immediately intervened, R1 sitting on the own separate bed, close curtains to make sure remain separation. Full head to toe body assessment made and no injuries noted. ADL care performed on R1. V5 remain with resident until certified nursing assistant came and took resident to shower room. R4 progress note dated 11/18/2024 documents in part: Note Text: Resident's behavior/mood noted at times. Resident's behavior noted as was physically aggressive. Other resident specific behaviors not noted above: Bodily fluids making contact to roommate (R1) Reportable initial transmission dated 11/25/2024 for this incident that occurred on 11/17/2024 reviewed. On 11/27/2024, at 12:43 PM, V30 (CNA) stated, regarding the incident that involved R1 and R4 about a week ago, I went down the hall and when I got to that room R4 was upset about not eating her lunch as it ended up on the floor. Both R1 and R4 were arguing back and forth on how the lunch got on the floor. I went to get her a sandwich, cookies and potato chips. She was thankful for that and R1 and R4 were calm. I went to check on R1 and R4 about an hour later. R4 asked if I could help her empty her colostomy bag. R4 said, I can do it, but her hand was shaking really bad. I put two towels under her breast like R4 asked and R4 pushed the bowel movement out of her colostomy bag into the gradual container. I cleaned the gradual. R4 asked me for the gradual container back so she could empty colostomy later. Both residents were calm when I left the room. Later, I was passing down the hall with my dirty linen cart and R1 and R4's room light was on. R1 stated, R4 got bowel movement on me. I had already done rounds on that room. I went in the room to see what R1 needed and seen bowel movement on R1's arm. R4's gradual container to empty R4's colostomy was laying on R1's arm. R1 was starting to make a phone call. R1 was upset and I went and told the nurse. On 11/25/2024, at 1:34 PM V6 (Social Worker) stated, I was notified of the incident with R4 throwing feces at R1 on Monday when I returned. That incident happened on a Sunday from my understanding. I asked how the situation escalated. R1 and R4 had already been separated in different rooms. I interviewed each resident to see what went on. R4 did not have much to say except being upset that she could not discharge home. R4's mom can no longer care for her. R4 stated she had been under some stress over this and kind of reacted. R1 explained R4 was having an episode and R1 was asking if R4 was ok. R4 started calling R1 names and everything escalated from there. R1 said she got feces in her eye and mouth and R1 was screaming. The nurse (V5) and certified nursing assistant got her into the shower chair and went to clean her up and separated R1 and R4 immediately. I have been doing well being checks on R1 and R4 since that incident. On 11/25/2024, at 09:56 AM, V5 Licensed Practical Nurse (LPN) stated I am aware of an incident of R4 throwing feces at R1. It happened last week Sunday (11/17/2024). R4 is still here and on this floor. When I came in that morning, I was informed by certified nursing assistant that R4 threw feces on R1. That happened before I got here. I went straight to that room. Both R1 and R4 were in their bed. I cleaned R1 up and stayed with her until certified nursing assistant came and got her up to go to shower. R1 had already notified her son. I did notify V3 (Director of Nursing). R1 said some feces splashed in her eye so I rinsed them out. V31 (Nurse Practitioner) came later in the week to see her. No new orders. R4 is now in a room by herself. That was the only time R4 ever did something like that. On 11/26/24, at 11:27 AM, V3 Director of Nursing (DON) stated, regarding the situation with R1 and R4, I do recall this was on a Sunday (11/17/2024). The nurse sent me a message that R1 had feces on her. I asked what happened and R1 stated it came from R4 direction. The nurse would get assistance to clean her up. I asked how both residents were. Nurse stated, they were both ok. I told her to ask R4 if she knew how the feces got on R1. R4 initially said, I don't know. I did delegate to nurse to notify family and physicians. I don't recall hearing about R4's family. I do know the nurse got ahold of R1's son. I was made aware there were no injuries. When they cleaned up R1 the staff removed her from the room while we investigated what had happened. I was not made aware that R1 stated she got feces in her eye. I was made aware she had feces in her hair and on left shoulder. Monday morning comes and it is thoroughly investigated, and administration got involved. Monday it was found out that R4 threw feces at R1. R4 did tell a staff member on Monday that her cousins made her do it. R4's cousins were not in the facility at this time. This would be considered abuse. V1 (Administrator) is the abuse coordinator. I did report this to V1 on Sunday (11/17/2024). I do not know when this was reported to the state survey agency. My expectation of staff regarding any type of abuse is to notify V1 the administrator immediately. On 11/25/24, at 2:16 PM, V2 (Assistant Administrator) stated, regarding R1 and R4 incident where R4 threw feces at R1, R4 was sent out by involuntary petition to a local hospital. The hospital held her for a period of time. This incident was not reported to the state because we did not have all the details until Monday morning when we investigated. The incident happened on a Sunday (11/17/2024). This incident as of 11/25/2024 still has not been reported to the state survey agency. On 11/25/2024, at 11:47 AM, V1 (Administrator) stated, we investigated the incident with R4 throwing feces at R1. We did a full investigation. I will bring the whole binder on it. We did not report it right away as we were not aware of the feces hit the resident. This should be reported. We were made aware last Monday (11/18/24) that feces did hit the resident We did put in an action plan and a removal plan in place and did education for full house. We did abuse/neglect screenings on everyone. The resident (R4) that threw feces is still in the facility. R4 had never done anything like this. R4 has an unrealistic view of discharge and was going through some things. We put R4 in a private room. I do not think R1 went out to hospital. I know she was assessed. This should have been reported to the state survey agency once we found out feces hit R1. The staff handled it well. R1 was cleaned up. In this situation the staff handled the situation well even though we were not 100 percent knowledgeable of extent of the incident. I will bring you the whole binder for this investigation. R1 Care plan dated 4/8/24 documents: Focus: ABUSE | NEGLECT | EXPLOITATION | TRAUMA I am an adult living with chronic health conditions, challenges, and comorbidities. Based on the comprehensive facility assessment conducted, there is benefit from placement in a skilled care setting and stability has been demonstrated throughout the admission screening process. Denies having been the perpetrator and/or recipient of mistreatment, abuse, neglect, and/or exploitation. It is determined that symptomatological factors exist that require monitoring. Goals: I will be cared for in a safe manner and verbalize to staff any incidences of abuse or neglect through review date. Interventions: Conduct appropriate screening to determine any history of maltreatment including abuse, neglect, living through trauma or surviving combat/violence. Reach and communicate to the resident that their safety, security and dignified care are the priority. o Ensure safety if feeling unsafe. [certified nursing assistant (CNA), registered nurse (RN), LPN] o Focus on PERSON-CENTERED CARE. Follow person-centered care models affording the resident as much initiative, control and self-determination as possible. Remind the individual that person-centered care or person-first care is a treatment model based upon honesty, sharing valid concerns, integrity and being forthright with care partners. o Observe resident in care situations. [LPN,RN] o Observe resident when in company of peers. [CNA] o Provide reassurance when negative feelings occur. [CNA,LPN] o Recognize that the resident is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless. Work with the resident to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making. o Report any verbalization of abuse or neglect to administrator immediately. [certified nursing assistant (CNA)] 2.) R2 is an [AGE] year-old resident admitted to facility on 08/07/2024 with medical diagnoses including but not limited to: moderate protein-calorie malnutrition, diabetes mellitus type 2, dementia severe without behavioral disturbance, and adult failure to thrive. R2 has a Brief Interview for Mental Status (BIMS) score of 6/15 dated 10/01/2024 which suggests severe cognitive impairment. According to minimum data set (MDS) section GG dated 10/01/2024, R2 requires partial/moderate assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. R2 needs supervision or touching assistance for eating and oral hygiene. R2 Care plan dated 10/3/2024 documents: Focus: ABUSE | NEGLECT | EXPLOITATION | TRAUMA I am an adult living with chronic health conditions, challenges, and comorbidities. MODERATE Based on the comprehensive facility assessment conducted, there is benefit from placement in a skilled care setting and stability has been demonstrated throughout the admission screening process. Denies having been the perpetrator and/or recipient of mistreatment, abuse, neglect, and/or exploitation. It is determined that symptomatological factors exist that require monitoring. Goals: I will be treated with respect, sensitivity, dignity, and feel safe while I live here in the facility Interventions: Conduct appropriate screening to determine any history of maltreatment including abuse, neglect, living through trauma or surviving combat/violence. Reach and communicate to the resident that their safety, security and dignified care are the priority. Focus on PERSON-CENTERED CARE. Follow person-centered care models affording the resident as much initiative, control and self-determination as possible. Remind the individual that person-centered care or person-first care is a treatment model based upon honesty, sharing valid concerns, integrity and being forthright with care partners. Recognize that the resident is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless. Work with the resident to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making [social worker (SW)] R2 Progress note dated 10/2/24 documents in part: Note Text: Resident's behavior/mood noted at This shift. Resident's behavior noted as none noted. Other resident specific behaviors not noted above: Behavior triggers: Other resident becoming physically aggressive toward them. R3 Progress note dated 10/2/2024 documents: Note Text: Resident's behavior/mood noted at This shift. Resident's behavior noted as was physically aggressive. On 11/25/2024, at 10:04 AM, R2 stated, I have not gotten in a fight with anyone. No one has hit me. I have not hit anyone. I do not know anyone by that name. I have not had any problems with anyone that I know of. If I need help, I will use call light, but I don't need help right now. I have not had any injuries. The staff comes to help me to the restroom. I like it here. I don't have any issues here. I am not neglected. I broke my glasses; I have to talk to my daughter when she comes maybe tomorrow. They come and take care of my hip. Resident sitting up in wheelchair watching television. Resident is clean and well groomed. Resident is thin. No foul odors noted. On 11/25/2024, at 10:24 AM, R3 stated, I have not gotten in a fight with anyone here. I have not hit anyone, and no one has hit me. No physical abuse or neglect has happened. Staff comes to help me when I hit the call light. I have not had any falls or hurt myself. Resident in bed resting. Resident clean and well groomed. No foul odors noted. R2/R3 Investigation 10/2/24 notes in investigation packet document: R3 - He tried to hit me, but he did not hit me. I did not hit him. I am not happy about the lights being on and the tv being too loud. R2 - He lightly slapped me on the left side/cheek of my face. I did not hit him back. Family notified. Immediately seperated. Room change R3. Statement from V7 Registered Nurse (RN) in investigation packet for incident on 10/2/2024 between R2 and R3 documents: I was informed by a V8 (CNA) that R3 and R2 was arguing about the television. R3 stated that he wants to sleep but R2 won't turn off the lights and doesn't want to lessen the volume of the television. We immediately separated the R2 and R3 and did room change. R3 stated that he slapped R2 because R2 didn't listen to R3. body assessment done, no injuries. Vital signs checked, within normal limits. Both residents didn't complain of pain. (DON), management, (NP) and family notified. Statement from V8 (CNA) in investigation packet for incident on 10/2/2024 between R3 and R2 documents: I heard R2 and R3 yelling at each other about the lights being on and the TV being too loud. R3 wanted R2 to turn his TV down and turn the lights off. I heard R2 say that if R3 hits him again he will hit him back. I separated the residents and informed the nurse who then reached out to the (DON) and administrator. On 11/26/24, at 11:27 AM, V3 Director of Nursing (DON) stated, regarding R2 and R3, I know we separated the residents due to a disagreement over TV volume. R2 and R3 were having a disagreement and R2 stated, R3 became physical with him. That is why we initiated separation. Staff did not witness the physical altercation. During investigation it was found to be that R3 slapped/hit R2 on his cheek. I was called on this incident and I notified V1 (Administrator) but my nurse (V7) also notified the abuse coordinator. R3 got sent out for a psychiatric evaluation and returned within 24 hours. I do not recall if R2 was sent out to the hospital. Normally we send the aggressor to the hospital in a situation like this and assess the other resident to see if there is a need to be sent out to hospital. R2 did not have any injuries upon assessment. Family was notified for both R2 and R3. I did not speak to families, but the nurse (V7) did as it is part of our protocol. On 11/25/24, at 2:16 PM, V2 (Assistant Administrator) stated regarding R2/R3 incident R2 stated he was hit by resident R3, and it made slight contact with his cheek. We did not send out R2 because during the investigation it seemed like the aggressor would have been R3. Our investigation results were that R2 was hit by R3. R3 denied allegations. On 11/26/24, at 09:40 AM, V1 (Administrator) stated, regarding R2 and R3 staff overheard the argument and got the nurse (V7) and separated the R2 and R3. R3 hit R2 so we sent R3 out for psychiatric evaluation. R3 came back stable. We put them in separate rooms. This was the first time R3 had hit anyone. It is hard to gauge intensity, but from what we could tell it was minor but there was contact. On 11/25/2024, at 2:23 PM, V7 RN (Registered Nurse) stated, regarding R2 and R3, I remember V8 (CNA) told me that they were arguing because R3 he wanted to sleep around that time, and he wanted to turn off the lights but R2 wanted to watch TV and leave the lights on. V8 went in because they were arguing, and she heard loud voices. As far as I remember it was just a verbal altercation. When I went in there, I immediately separated R2 and R3 to prevent further incident. I informed V3 (DON) right away and V1 (Administrator). I told them that we could change the room of the one resident. R3 was more aggressive. When I got in the room, they were both in the middle of the room. R2 was sitting in w/c watching the TV. R3 was telling R2 to lessen the volume of the TV because R3 couldn't sleep. I do not think it had progressed to anyone putting hands on the other. On 11/26/2024, at 2:11 PM V8 (CNA) stated, I do recall the incident between R2 and R3. I was next door from their room and was doing my care for the resident there. I heard R2 and R3 talking back and forth. At first, I thought it was the television. It was getting louder. Then I stopped what I was doing and went next door to See what was going on. R2 and R3 were talking at the same time. R2 and R3 were arguing about the television. R2 said, R3 hit him on his face. He told this to me. I did not tell anyone other than my nurse (V7). I talked to R3 and guided him out of the room. R2 was in his bed. I then told the V7 (nurse) when I was in the hallway talking to R3. I don't remember exactly. V7 may have been at the nurse's station because R2 and R3's room was right by the nurses station. V7 talked to R2 and R3 and we decided to change rooms. I did not hear or witness any hits or slaps or sounds like that. Our abuse coordinator is V1 the administrator. This is an allegation of abuse. Our policy states we are to report any abuse to the administrator(V1). I did not call the V1 because I had reported it to the V7 (registered nurse) so I thought V7 would do it. It didn't dawn on me to report it. I remember V7 texting V1 (administrator) at that time. The last time we had an abuse in-service was last week sometime. V2 (Assistant Administrator) is the one that did the in-service and he did go over that we are all to report to V1 (administrator). I am just used to the nurse reporting it. On 11/26/2024, at 12:16 PM, V9 (Social Worker) stated, regarding R3 and R2, I was made aware there was a situation over the TV being too loud. I was told by staff that nobody seen it, but R2 told me that R3 hit him on the cheek. I assessed both residents and followed up with both residents. I moved R3 to a room with a resident that he can better cohabitate with. I gave R2 another roommate that fits well with him. R2 had also told V8 (CNA) that he was hit by R3. Our abuse coordinator I think is V3 (DON). Typically, we go through the DON as well as V22 (Social Worker Director). I was not there when it happened. I did not report to the abuse coordinator. I usually report to my director and my director usually reports to the abuse coordinator from what I know. I know we had abuse training recently; I do not know the exact date but it was about a couple weeks ago. Abuse Prevention and Reporting - Illinois Policy dated 11/28/2016 and with last review dated of 12/17/2021 documents (in part): Guidelines: 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 purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property: Resident-to-Resident Abuse (Any type): Resident -to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations. Internal Reporting Requirements and Identification of Allegations: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. External Reporting Initial Reporting of Allegations: When any allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. Five-day Final Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Based on interview and record review, the facility failed to have a written policy to address the response to an opioid overdose and failed to ensure that staff were trained and competent in monitoring of a resident after administration of Narcan medication. The facility also failed to follow recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration) for the administration and monitoring of a resident assessed to be at risk for substance abuse and who received Narcan medication for a suspected overdose. This failure affects one of one (R11) resident reviewed for overdose treatment. These failures resulted in R11 not being monitored in accordance with SAMHSA recommendations after receiving Narcan while in the facility for a suspected overdose. The Immediate Jeopardy began on [DATE] when R11 was administered Narcan for suspected overdose while in the facility and staff failed to provide continuous monitoring for potential recurrence of signs and symptoms of opioid toxicity for at least 4 hours after being administered Narcan. V1 (Administrator) was notified on [DATE] at 1:59PM of the Immediate Jeopardy. The immediacy was removed on [DATE] but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R11 is a [AGE] year-old female originally admitted to the facility on [DATE]. R11's medical diagnoses include Schizoaffective Disorder, Bipolar Type, Blindness One Eye, Anxiety Disorder, Personal History of Traumatic Brain Injury, Tobacco Use, Bipolar Disorder, Current episode depressed, Severe w/out, psychotic features, Cannabis abuse, Drug Induced Subacute Dyskinesia, and hyperlipidemia. R11's MDS (Minimum Data Set) assessment dated [DATE], documents that R11 has a BIMS (Brief Interview of Mental Status) score of 09 (moderate cognitive impairment) and uses a wheelchair. R11's Abuse/Neglect Screening effective date [DATE] documents that R11 is at moderate risk for abuse/neglect, with a risk measure score of 3 - Screening indicators include: (yes) Factors that increase the resident's vulnerability (e.g., confusion, disorientation, poor insight/poor judgement, history of being exploited, etc .); (yes) history of substance abuse; (yes) diagnosis of depression and/or history of depressive illness. R11's current care plans document the following: - Abuse focus (initiated [DATE]) documents that R11 is observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect or further trauma; given R11's poor and compromised health/mental health status, cognitive issues, physical decline and need for 24-hour care, the interdisciplinary team (IDT) recognizes that I am considered a vulnerable adult. - Supervised access to the community (initiated [DATE]). - History of substance abuse focus (cocaine, marijuana) (initiated [DATE]) related to rigid personality traits and ineffective coping and at risk for further episodes of illicit substance abuse as well as adverse side effects/complications that may result from it. - History of persistent substance use/abuse and resultant medical complications from this harmful behavior. I am now living in a skilled facility at a younger age. I have used: marijuana, tobacco, and cocaine (initiated [DATE]); intervention includes restricted independent pass privileges and requires supervision when accessing the community; there are no noted updates or revisions to R11's care plan after this incident on [DATE] until [DATE]. - Impaired cognition focus (initiated [DATE]) documents that R11 has impaired cognition/thought process related to diagnosis of mental illness and traumatic brain injury. Symptoms are manifested by poor temporal orientation & difficulty with recall. R11 Nurse Progress Note(s) written by V32 Licensed Practical Nurse (LPN) document: - [DATE] 22:03 Note Text: At around 9PM, resident observed sleeping on wheelchair in front of resident's room, resident was hard to arouse, VS (vital signs) are normal BP (blood pressure): ,d+[DATE] P (pulse): 78, o2 (Oxygen Saturation): 95% RA (room air), responded to chest rubs, Narcan (Opiate Antagonist) administered r/t (related to) unknown substance intoxication. Resident responded to stimuli after Narcan administration. Resident stated she is fine. NP (Nurse Practitioner) (V33). Awaiting for response. - [DATE] 22:23 Note Text: No new orders from (V33 - Nurse Practitioner). R11 was interviewed on [DATE] at approximately 6:30PM. R11 was asked if she remembered getting Narcan last month and she said that she had no memory of that event. R11 said the administrator told her about it but she didn't believe it ever happened because she had no memory of it. Surveyor asked if she ever remember getting a nasal spray (medication) and R11 said no, I don't remember that ever. Surveyor asked R11 if she ever took any illicit substances like opioids or marijuana and R11 denied any drug use and added that she only smokes cigarettes. Surveyor asked if she ever gets cigarettes from people outside and R11 said yes, she does and it's possible that someone put something in her cigarette without her permission. Surveyor asked if she remembered being very sleepy in the hall and hard to arouse. R11 denied any recollection of such event. R11 was asked if she is normally a heavy sleeper and difficult to wake up and she said she is a heavy sleeper but will usually wake up easily if someone tries to wake her up. R11 could not provide any other details or information about the incident on [DATE]. On [DATE] at 4:44PM V32 (LPN) said, R11 is alert and knows what's going on. She goes down to smoke independently. She can transfer and eat independently and would say that she needs limited assistance. (On [DATE]) I remember that day, when I came back from break the other nurse working told me that R11 was difficult to arouse. She was in the hallway in her wheelchair. Vitals were within normal limits. I did a chest rub and she said it hurt. She had pinpoint pupils. I asked staff where she had been and they said her usual, outside. I used my judgement and administered Narcan. I gave her one dose and she became more responsive to stimuli .She looked high that night, but I've never seen that behavior with her. I asked her but she denied taking anything. I was checking on her all through that time. After 40 minutes she was back to herself. She then got annoyed and told me to remove the ice I had put behind her neck. We (other staff and I) stayed in the room for 15 minutes and then I went back and forth finishing med pass. I waited more than an hour and then I let her be. Her vitals and respiratory rate were fine. I notified the administrator and nurse practitioner, who gave no new orders, but the administrator told me to do the urine screen. The urine screen was not done during my shift because R11 said she didn't have to urinate, so I endorsed it to the next nurse. I don't know if they did the test. I didn't call 911 because she responded .I don't remember if the nurse practitioner told me to monitor her, but I would do it regardless because she is under my care .I guess I would monitor for at least an hour. There were no new orders and no restrictions afterwards. What I do now (on my own) is that I watch her when she comes up from smoking. I did get training on administering Narcan. They said only send the resident out if they are unresponsive; give another dose, if they wake up good, if not, then call 911. If they don't respond after two doses, call 911, doctor, administrator, and family. V32 said, I pulled the Narcan from the convenience box. I don't remember if I put it in her chart, but I should have put it in as a one-time order. Review of staffing for [DATE] documented that V23 (RN) was the oncoming nurse, after V32's shift. [DATE] at 10:40PM V23 Registered Nurse (RN) said, the (previous) nurse endorsed to me about the incident and she told me what happened with R11; she told me to monitor the resident's vitals. During my shift, the resident had good vitals and she asked me to give her some water. In the morning she asked me for an Ensure. I checked her vitals when I first arrived, then I came back about 30 minutes later and checked her again. She was responding. I asked her to press the call light if she needed anything and she agreed. I checked on her around 2am and she told me not to wake her again until the morning. I think it was around 4am when I was back in her room, and she told me she was okay. It's normal for her to fall asleep in the wheelchair and then I usually wake her up to tell her to sleep in her bed. Usually, she is in the morning in the bed. It usually takes her one to two minutes before she wakes up. The evening nurse had endorsed to me to do the drug test, but I was not able to do it during my shift. First, the kit was not in the nursing station or med room, and I didn't know where it was. I think it was somewhere in the office, so we had to wait for someone to arrive, so I just endorsed it to the oncoming morning nurse. I had training during orientation on how to respond to overdose. Procedure is to spray it in the nostril and if they are not responding then we call 911. After you give it, you wait ,d+[DATE] minutes and then call 911. I would give another dose while I am waiting for 911. If the person responds, then you monitor them closely. You have to check on them every 30 minutes until they come back to their normal self. If the person responds, then you don't have to send them to the hospital. This was new to me, and she never has this behavior. [DATE] at 5:37PM V33 (Nurse Practitioner) said, I don't recall the incident with R11. There's no general protocol; we go based off the nurse's judgement. If they take opioids for chronic pain and there is a change in status, then we would treat giving Narcan to see if that would improve the situation or not. I would have them sent to the hospital for the evaluation but again it depends on the nurse's assessment. Let's say you give the medicine, and the patient improves, then we also based the facility's judgment as well. If it is a medical emergency, then we would send to the hospital. I do recommend the rapid drug test if we suspect the patient is using something that they are not supposed too. Surveyor presented information provided from V1 (Administrator), that after administering Narcan, facility staff should do a rapid drug urine screen and send the resident to the hospital if the screen comes back positive but if the test comes back negative, they don't have to transfer resident to the hospital; surveyor then asked V33 if this seemed like a reasonable practice to follow. V33 said, assuming the patient is stable after getting Narcan and improves, I would say that that is reasonable to follow that protocol. I don't recall the nurse contacting me at all for the results. I may have ordered drug test (for R11). I have seen R11 and followed up with her in person after the incident and there should be Progress Notes. There are no specific guidelines that I follow. Monitoring is just nursing 101 for any clinical issue - any acute mental status change. You always monitor after applying treatment. There's nothing specific that I know that the facility does for suspected overdose. I am not aware of any protocol that the facility follows. [DATE] at 5:43PM, V36 (RN) was asked about facility protocol for administering and monitoring residents after being administered Narcan for suspected overdose. V36 said, call 911 five minutes after giving one dose, then give a second dose if resident doesn't respond after 15 minutes. Constantly stimulate and assess the resident. If the resident [NAME] up, then reassess, take vitals, call the doctor. If the doctor gives orders to send the resident to the hospital, then we will transfer them. If they do not give orders to transfer to the hospital, then we would just monitor them in the facility for 72 hours; taking vitals once a shift. If the doctor orders it, then we will do a drug test. [DATE] at 4:33PM V14 Director of Nursing (DON) was interviewed about the incident with R11 on [DATE]. V14 said, when a resident needs Narcan, we administer it, notify the physician, and wait for further orders. We may or may not send them out at the discretion of the provider. I would like to be notified so that we can investigate further as to what happened. It's a case-by-case basis on whether we do the rapid drug test or not, depending on the provider. It's all at the providers discretion. We do monitor as a standard given - for no specific amount of time, just monitor closely and make sure they're at their baseline. I was not the DON at that time, and I am not familiar with the situation. Surveyor asked if there is a written policy or protocol to follow after administering Narcan and V14 said, it's standard practice as a nurse to notify the provider for any change of condition. [DATE] at 6:05PM V1 (Administrator) said, there is no specific monitoring (after overdose) because my nurses are not trained for that. They call me and I make the call; I take the decision making out of their hands at that point. If the rapid drug test comes back positive, they're going to the hospital. That's why we have them do the rapid drug test and if it comes back positive, they go out. The nurse did call me (for R11), and I told her to do the drug test. It was done and came back negative, so she didn't get sent out. Surveyor asked when and who completed the rapid drug test since it was not documented and both nurses that worked with R11 immediately after the incident confirmed that they did not conduct the drug test and V1 said, I will find out who did the drug test. Surveyor then asked if the drug test should be part of R11's medical record and V1 said, yes, I suppose the drug test should be part of the medical record. I ask R11 all the time to do a drug test for me and she agrees because she hangs out with the boys; some guys that live next door and they hang out by the side of the building. I don't know if I assume guilt by association. She always comes back negative. Reviewed R11's EMR (electronic medical record); there is no documentation that R11 was closely monitored after administration of Narcan; there is only one set of vitals documented in progress notes for [DATE] (during incident) and respiratory rate is not documented; no other vitals noted to be taken on [DATE] or [DATE]. Review of R11's MAR (medication administration record) does not show that R11 was administered any opioid type of medication or that R11 was administered Narcan on [DATE]. Review of physician orders does not include any orders or results of drug screen for R11. [DATE] at 4:27PM V37 (Pharmacist) was asked if they provide the facility with any instructions on monitoring after administration of Narcan and V37 said, We don't include the package insert or anything when we dispense it. The facility will have a specific policy. We only send it if they ask. I can provide the manufacturer insert. Review of Narcan Nasal Spray Package Insert (manufacturer) includes the following: - Risk of Cardiovascular (CV) Effects: .Monitor these patients closely in an appropriate healthcare setting after use of naloxone hydrochloride. - WARNINGS AND PRECAUTIONS - Risk of Recurrent Respiratory and Central Nervous System Depression, The duration of action of most opioids may exceed that of NARCAN Nasal Spray resulting in a return of respiratory and/or central nervous system depression after an initial improvement in symptoms. Therefore, it is necessary to seek emergency medical assistance immediately after administration of the first dose of NARCAN Nasal Spray and to keep the patient under continued surveillance. Administer additional doses of NARCAN Nasal Spray if the patient is not adequately responding or responds and then relapses back into respiratory depression, as necessary [see Dosage and Administration (2.2)]. Additional supportive and/or resuscitative measures may be helpful while awaiting emergency medical assistance. - Precipitation of Severe Opioid Withdrawal - The use of NARCAN Nasal Spray in patients who are opioid-dependent may precipitate opioid withdrawal characterized by the following signs and symptoms: body aches, diarrhea, tachycardia, fever, runny nose, sneezing, piloerection, sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, abdominal cramps, weakness, and increased blood pressure .Abrupt postoperative reversal of opioid depression after using naloxone hydrochloride may result in nausea, vomiting, sweating, tremulousness, tachycardia, hypotension, hypertension, seizures, ventricular tachycardia and fibrillation, pulmonary edema, and cardiac arrest. - Administration Instructions . Monitor patients and re-administer NARCAN Nasal Spray using a new NARCAN Nasal Spray every 2 to 3 minutes, if the patient is not responding or responds and then relapses back into respiratory depression . Surveyor asked facility administration for written policy to address overdose several times throughout the course of this survey, and none was provided. Surveyor was provided with Narcan Instructions for Use (manufacturer) and with Physician-Family Notification-Change in Condition Policy; neither of which specified a protocol for the treatment/monitoring of overdose. On [DATE] at 2:45PM surveyor was provided facility Substance Use Disorder Guidelines (Reviewed: [DATE]) - it is to be noted that review of policy did not include specific written policy to address overdose. This concern was shared with facility administration at this time. SAMHSA Opioid Overdose Prevention Toolkit - Five Essential Steps for First Responders document includes: Step 5: Monitor The Person's Response . All people should be monitored for recurrence of signs and symptoms of opioid toxicity for at least 4 hours from the last dose of naloxone or discontinuation of the naloxone infusion. People who have overdosed on long-acting opioids should have more prolonged monitoring. [2,5,6] Most people respond by returning to spontaneous breathing. The response generally occurs within 2 to 3 minutes of naloxone administration. (Continue resuscitation while waiting for the naloxone to take effect.) [2,5] Because naloxone has a relatively short duration of effect, overdose symptoms may return. [2,5,6] Therefore, it is essential to get the person to an emergency department or other source of medical care as quickly as possible, even if the person revives after the initial dose of naloxone and seems to feel better. CMS State Operations Manual under F689 Interpretive Guidelines, documents the following for skilled nursing facilities: According to the Substance Abuse and Mental Health Administration (SAMHSA), opioid overdose deaths can be prevented by administering naloxone, a medication approved by the Food and Drug Administration to reverse the effects of opioids. The United States Surgeon General has recommended that naloxone be kept on hand where there is a risk for an opioid overdose. Facilities should have a written policy to address opioid overdoses. The SAMHSA website houses a number of resources related to opioid management including this document intended for prescribers which addresses appropriate prescribing, monitoring for adverse effects, and treating overdoses: SAMHSA Opioid Overdose Prevention Toolkit: Information for Prescribers, https://www.samhsa.gov/resource/ebp/opioid-overdose-prevention-toolkit. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. On [DATE] the survey team verified by observation, interview, and record review, that the facility implemented the following to remove the immediacy. Removal Plan: 1. R11 has been reassessed and shows no signs of active substance use. DON and ADON, Initiated Date [DATE], Completion Date [DATE] 2. R11's care plan reviewed. Administrator, Initiated Date [DATE], Completion Date [DATE] 3. All residents with a history of substance abuse have been reviewed by the Interdisciplinary Team (IDT) for care plans and interventions. Minimum Data Set (MDS) and Social Services, Initiated Date [DATE], Completion Date [DATE] 4. The facility has updated the substance use disorder policy to include post-Narcan administration monitoring, response to overdose, and when to indicate transfer. Chief Nursing Officer, Initiated Date [DATE], Completion Date [DATE] 5. Nurses are being retrained and competencied on how to respond to emergencies related to substance use including administration and monitoring after giving Naloxone, administering Cardiopulmonary Resuscitation (CPR) when appropriate, and hospital transfer as soon as possible before the start of their next shift. Nurses on vacation or Family Medical Leave (FMLA) will be inserviced and competencied before returning to work. New Nurses will be inserviced and competencied during New Employee Orientation, prior to working directly with residents. Agency Nurses will be provided inservice material in their Orientation Packet that they receive prior to their first scheduled shift at Aperion Care Forest Park. ADON and DON, Initiated Date [DATE], Completed date [DATE] and Ongoing 6. A Quality Assurance Performance Improvement (QAPI) meeting was held with the medical director to discuss the incident with R11, policy updates, and follow up. Administrator, Initiated Date [DATE], Completion Date [DATE] 7. During the monthly Quality Assurance (QA) Meeting, IDT will review ongoing training of nurses, review competencies and review any incidents of Narcan medication administration. QAPI Team, Initiated Date [DATE], Ongoing monthly until [DATE] 8. The facility will monitor the next 5 uses of Narcan, up until [DATE] to ensure staff follow the updated facility policy on substance use. DON and ADON, Initiated Date [DATE], Ongoing up until 5 Narcan uses or [DATE]. 9. The facility will randomly competency 3 nurses a week for the next 12 weeks to ensure they are aware of the proper protocol for Narcan administration and substance use. Competencies will be added to Annual Nursing Competencies. DON and ADON, Initiated Date [DATE], Completion Date [DATE] and Ongoing

Based on observation, interview, and record review, the facility failed to provide a safe environment by not adequately assessing, monitoring or supervising residents at risk for falls for 4 of 5 (R1, R3, R4, R5) reviewed for falls; and failed to follow their fall prevention program by not ensuring fall interventions were securely in place for a resident (R1) with a history of and risk for falls. These failures resulted in R1 falling and being hospitalized for laceration to the left ear; R3 falling and being hospitalized for laceration to the left eyebrow; R4 falling and being hospitalized for right femur fracture with surgical repair; and R5 falling and being hospitalized for left femur fracture. Findings include: (R1) 1. On 05/24/2024 at 11:40 AM, R1 said he had a fall incident a few months ago in March. R1 added that after taking his nighttime medication, he sat on the side of his bed and had went out. R1 then said he awoke approximately ten minutes later and was on the floor next to his bed and he was bleeding from his left ear. He said the nurse who came to check him out, sent him to the hospital where he received stitches to his left ear and stayed at the hospital for a few days. On 05/24/2024 at 12:00 PM, reviewed fall leaf program binder located at nursing station on the third floor. R1 was not listed on undated fall leaf program residents. R1 was listed on undated fall intervention log that indicated R1 should have non-skid strips to the floor at bedside to improve traction/prevent slipping and call for assistance. (Non-skid strips were not observed in place during interview with R1 on 05/24/2024 at 11:40 AM or during room observation at 4:01 PM.) On 05/24/2024 at 1:14 PM, V8 (Licensed Practical Nurse) said on day of R1's fall incident, R6 (R1's roommate) went to the doorway around 10:00 PM and said that R1 was on the floor. Upon entering R1's room, V8 saw R1 on the floor with blood coming from his left ear. V8 (LPN) added that R1 is on seizure precautions, is a frequent faller, and seemed confused after the fall. V8 then said that she had previously discussed R1's frequent falls with previous Director of Nursing. On 05/24/2024 at 2:17 PM, V6 (LPN/Restorative Nurse) said R1 takes seizure medications that make him sleepy, so his meds were adjusted a few months ago because R1 was sedated at times. V6 added that R1 had previous falls on 02/24/24 and 03/09/2023. At 02:26 PM, V6 reviewed fall leaf program residents then indicated that R1 was mistakenly not included but will be added due to his history of falls, medical diagnosis, seizure precautions and seizure medications. V6 then said R1 has current fall interventions in place to: call don't fall and non-skid strips to floor near bedside and non-skid footwear. R1's face sheet indicated resident recently admitted to facility on 01/09/2024 and has a past medical history not limited to: hemiplegia and hemiparalysis following cerebral infarction affecting left non-dominate side, seizures, abnormalities of gait and mobility, lack of coordination, weakness, age-related physical debility, unspecified escherichia coli, bipolar disorder, insomnia, and tremors. R1's Fall Risk assessment dated [DATE] indicated R1 is at risk for falls. R1's care plan with last completion date of 04/09/2024 reads in part: risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, possible medication side effects, seizure disorder, tremors, cerebrovascular accident with left hemiplegia (date initiated 12/30/2023). R1's hospital paperwork dated 03/02/2024 indicated resident was treated by V10 (emergency room MD) for laceration to the left earlobe status post unwitnessed fall encounter at facility. R1's facility reported final incident report dated 03/08/2024 indicated R1 had a fall incident on 03/02/2024 in his room and sustained a laceration to his left ear. R1 was emergently transferred to local hospital where he received five stitches to the open area on his left ear. Report also indicated R1 requires supervision to limited assistance with activities of daily living (ADL's), transfers and toileting. (R3) 2. On 05/24/2024 at 12:11 PM, observed V5 (Certified Nursing Assistant) pushing R3 in his wheelchair out of his room. Observed dressing to R3's left outer eye, resident alert to self. V5 said R3 had an injury to his left eye from his fall a few weeks ago. On 05/24/2024 at 2:42 PM, V6 (LPN/Restorative Nurse) said regarding R3's last fall on 05/06/2024, he was observed sitting on the toilet seat with a facial wound and was sent out to a local hospital for a laceration to his left brow. V6 added that R3 has dementia and should be closely monitored by staff. R3's FRI (facility reported incident) final report dated 05/14/2024 indicated resident was observed sitting on the toilet by staff with a bleeding open wound to his left eyebrow on 05/06/2024. R3 self-reported falling to the floor while ambulating to the bathroom, stood himself up from the floor then continued to ambulate himself to the bathroom. R3 was emergently transferred to a local hospital where he received six sutures to the laceration above his left eyebrow. R3's hospital paperwork dated 05/06/2024 indicated that R3 was treated emergently by V11 (Doctor of Osteopathic Medicine) post fall for facial lacerations and received stitches. R3's Fall Risk assessment dated [DATE] indicated R3 is at risk for falls. R3's face sheet indicated resident admitted to facility on 04/01/2024 and has a past medical history not limited to: epilepsy, dementia, generalized osteoarthritis, abnormal posture, lack of coordination, history of falling, syncope and collapse, and insomnia. R3's active physician orders showed order to clean left eyebrow with normal saline, pat dry, apply triple antibiotic ointment then cover with dry dressing daily and as needed (active date 05/09/2024); send resident to [hospital] for further evaluation related to fall and left eyebrow laceration per family request (active date of 05/06/2024). R3's care plan with last completion date of 4/17/2024 reads in part: at risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, possible medication side effects, incontinence, Seizure disorder, syncope, dementia, history of falls, spinal stenosis, osteoarthritis (date initiated 02/17/2023). (R4) 3. R4's face sheet indicated resident admitted to facility on 12/30/2021 and has a past medical history not limited to: abnormalities of gait and mobility, hemiplegia and hemiparalysis following cerebral infarction affecting right dominate side, fatigue, abnormal posture, lack of coordination, right femur fracture, history of falling, vascular dementia, seizures, insomnia, hypertension, and repeated falls. R4's facility reported final incident report dated 02/28/2024 indicated resident had a fall incident while staff was present on 02/27/2024. R4 stood to adjust himself, slipped and fell the complained of right hip pain. Report also indicated that R4 requires assistance with ADL's, transfers and toileting. Fall incident report indicated R4 was transferred into a wheelchair post fall, taken to his room and transferred back to bed. Upon further assessment of range of motion, R4 complained of right hip pain and was then sent out emergently for x-ray of right hip. R4's hospital records dated 2/28/2024 through 03/04/2024 and discharge summary signed by V12 (Medical Doctor) on 03/04/2024 both indicated resident was treated for a right femur fracture post fall in the shower at facility that required surgical repair on 02/28/2024. R4's fall risk assessment dated [DATE] indicated resident is at risk for falls. R4's care plan with last completion date of 03/14/2024 reads in part: at risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, possible medication side effects, cerebrovascular accident with right side weakness, frequent falls, seizure disorder, low back pain, incontinence, abnormal gait/mobility, lack of coordination, abnormal posture, fatigue. readmitted to the facility status post-acute hospital stay 03/04/24 (date initiated 12/31/2021, revision on 03/14/2024). On 05/26/2024 at 4:33 PM, V13 (Certified Nursing Assistant) indicated that after she showered R4, she left the resident unattended to retrieve an incontinence brief from the next shower stall when R4 had a fall incident and complained of right hip pain. V13 (CNA) then indicated that she put him in his chair and took him to the room then went to inform the nurse. (R5) 4. R5's face sheet indicated resident initially admitted to facility on 03/28/2024 with last admitted [DATE] and has a past medical history not limited to: hemiplegia and hemiparalysis following cerebral infarction affecting left non-dominate side, left femur fracture, end stage heart failure and renal disease, presence of left artificial hip joint, seizures and history of falling. R5's care plan with last completion date of 04/09/2024 reads in part: at risk for falls and injury related to falls. Risk factors: requires assistance with ADL's, incontinence, possible medication side effects, left hemiparalysis, history of falls, seizure disorder, abnormal gait/mobility, unsteadiness, on feet, lack of coordination (date initiated 04/02/2024, revision on 04/08/2024). R5's hospital record/note dated 05/06/2024 by V19 (Internal Medicine Resident) and V20 (Medical Doctor) indicated R5 presented with left femoral fracture post fall at the facility. R5's facility reported final incident report dated 05/07/2024 indicated that resident had a fall incident while ambulating self to the bathroom on 05/02/2024 at 12:20 AM. R5 was emergently sent out to a local hospital for further evaluation and was diagnosed with a mild left femur fracture. R5's fall risk assessment dated [DATE] indicated R5 is at risk for falls and had a recent admission in March for falls. On 05/24/2024 at 11:00 AM, R5 was observed near second floor nurse's station. Resident alert to self and not interviewable at this time. Reviewed fall leaf binder located at nurse's station that indicated R5 is in the program. On 05/25/2024 at 11:30 AM, V6 (Restorative Nurse/LPN) presented nursing in-service dated 05/24-05/25 with topics of fall prevention/falling leaf program. On 05/26/2024 at 3:25 PM, V18 (Licensed Practical Nurse) said she was called to room by V15 (Certified Nursing Assistant) who said R5 was on the floor. Upon her assessment, she noted R5 laying on his side with a bed pad under his head. V18 added that R5 was favoring his left shoulder, he said it was bothering him. She and two other staff members stood resident up and put him into the bed. She completed assessment and noted no range of motion limitations to lower legs. She notified all parties including physician, x-ray was ordered, which she added x-ray of left hip due to fall a few weeks prior in which left side was x-rayed as well. V18 (LPN) added that R5 couldn't tell her how he fell , but he had a history of falls and dementia. R5 transferred into a dialysis chair shortly after incident and was given acetaminophen prior to be transported to dialysis for restlessness with dialysis. When R5 returned from dialysis, V18 (LPN) said she was no longer on duty but was told that R5 was x-rayed between noon and 1:00 PM that day and was found to have a femur fracture. On 05/26/2024 at 3:34 PM, when asked for timeline of R5's post fall evaluation and treatment, V1 (Administrator) said the following: facility called for stat x-ray at 1:17 AM on 05/02/2024, x-ray technician arrived at 11:49 AM and x-rays were completed at 1:30 PM. Resident was not complaining of pain and vitals were stable so 911 wasn't necessary and we were told ambulance would be arriving shortly. It came at 4:15 PM then left 20 minutes later. I feel that my staff addressed the fall in a timely manner. Sending resident to dialysis at the time wasn't the wrong call because the resident was not stating pain or discomfort. Staff did make two follow up calls and were told tech was in route. Resident was stable and not in pain so waiting on x-ray tech made sense. Fall Prevention Program policy last revised 11/21/2017 reads in part: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The fall prevention program includes the following components: Methods to identify risk factors, methods to identify residents at risk, care plan incorporates but not limited to the identification of all risk/issue and preventative measures. Safety interventions will be implemented for each resident identified at risk. Fall/Safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the fall prevention program. Nursing personnel will be informed of residents who are at risk for falling. The fall risk interventions will be identified on the care plan.

Based on interview and record review, the facility failed to protect a resident (R2) of 4 residents in the sample (R1, R2, R4 and R5) from physical abuse inflicted by his roommate (R3). This failure caused R2 to be struck with a metal rod multiple times to the face resulting in an emergent transfer to the hospital for treatment of his injuries. Findings include: R2 is an [AGE] year old with significant cognitive impairment and diagnoses including dementia, stage 3 chronic kidney disease and otsteoarthritis. R3 is an [AGE] year old with significant cognitive impairment and diagnoses including dementia, hemiplegia and hemiparesis, and aphasia following cerebral infarction. On 4/6/24 at approximately 4:10 AM, R2 was lying awake in bed and was suddenly physically assaulted by his roommate (R3) with a metal rod taken from the closet. R3 used this metal rod to strike R2 multiple times in the face with no apparent provocation. On 5/10/24 at 11:10 AM, V11 (CNA Certied Nurses Aide) stated, I heard screaming when I was in the hallway and went and saw (R3) standing over (R2's) bed and hitting the man. R3 was hitting R2 in the head area as he was sitting in bed. I immediately went to the guy with the pole and tried to calm him. I was successful in calming him down but when the man (R2) tried to get up, R3 said that he was going to hit him again. I called another CNA (V12) and I told her to got some towels to stop the bleeding from R2's head. We both got V10 (Agency LPN Licensed Practical Nurse) , who I think was an agency nurse who came and took over to help with R2's bleeding. I really don't know this man R3 but I know that R2 is a nice guy and that he gets up in the middle of the night and walks around and that's probably what might have got R3 going. On 5/10/24 at 12:10 PM, V1(administrator) stated, V2 (assistant administrator) did most of the investigation as I was off that week. The facility contacted me on that day 4/6/24 to let me know that (R3) had hit his roommate (R2) with a piece of metal in the face and the CNA (V11) was documenting in the hallway close to the room at the time and heard yelling and went in to the room saw R3 standing over R2 who was lying in bed at the time. Staff reported that V11 pulled R3 pulled away from (R2.) V12 CNA entered the room and grabbed a towel to apply first aide on the resident and the other CNA V11 was calming R3 down. The nurse V10 came in and assessed and provided first aide to R2; and R3 was escorted out to the room and he was allegedly calm and did not continue to be aggressive and taken to the dining room to be monitored 1:1. 911 was called and R2 was transported to the ER and R3 was sent to a psychiatric hospital. I was told in the hospital that the family of R2 did not want the resident to come back. I saw R2 in theER on [DATE] and spoke with ER staff who said he had stitches on right eye and were admitting him for observation. R2 had facial contusions and laceration. one above right eye was stitched up across the eyebrow. As for R3, he was diagnosed with a psychotic episode in the hospital. R3 was experiencing a psychotic episode which led to the resident walking over to R2 and struck the resident multiple times across his face and head. Surveyor asked who provided this information pertaining to R3, V1 indicated that it was the psychiatric hospital staff but did not specificity as to which staff person. On 5/10/24 at 12:15 PM, V2 (assistant administrator) stated, It was reported to me by my administrator what occurred and I did the actual investigation of the incident involving (R2) and (R3). I spoke with (V11/CNA) and she notified me that she heard screaming coming from R2 and R3's room and saw (R3) with a metal object in hand and hit (R2). She mentioned she called for assistance from (V12/CNA) and arrived to help her and that R3 reportedly took the metal pole from the closet rod away from R3. They then called for the nurse V10 to provide first aide and assured everyone was separated and called an ambulance around 4:20 AM. R3 was given 1:1 in the common area in the nursing station. Both CNA's were providing 1:1 to R3 in the nursing station until the police arrived. The police and fire arrived at around 4:30 AM and then R2 was sent to hospital for treatment and we issued an involuntary notice petition for R3 and sent to the psychiatric hospital. It was not reported to me R3 was having a psychotic episode and that the resident just got physically aggressive. There were no occurrences between the two residents and it seemed that it came out of the blue and no antecedent to it all. We couldn't pinpoint any factor in my investigation. Efforts to reach V10 LPN and V12 CNA three times were left with unanswered calls. V1 (administrator) tried to facilitate the efforts and explained that both staff were currently working in alternative facilities at the time. Facility's internal investigation showed an interview with V10 (Agency LPN) which reads, At approximately 4:20 AM, writer was notified of room needing assistance. upon enteringroom patient in bed 2 (R2) was siting at bedside bleeding profusely from face. Assessed patient and applied pressure to bleeding. 911 called and vitals recorded. Nursing assistant stated the patient in bed 3(R3) hit paitent in bed 2 (R2) with metal object. Metal object was confiscated. The aggressor (R3) stated he will hit him again and needs to die. Patient removed from room, while waiting for ambulance. Facility's internal investigation showed interview with V12 (CNA) which reads, At about 4:30 AM, V11 (CNA) called for help. I quickly got up and hurried over to room and helped redirect the resident who hit the resident with the piece of metal. I called the nurse from the hall and told her to call the ambulance. I then took the metal object from the resident. Facility abuse policy and procedures titled Abuse Prevention and Reporting reads in part, The 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. The policy and procedures however did not specifically address the management and/ or handling related to resident-to- resident abuse. Hospital records dated 4/26/24 reads in part, 82yo M with PMH of dementia, DM, HTN, HLD, who is admitted to trauma service after being assaulted at nursing home. Medicine consulted for co-management of chronic medical conditions. Pt unable to provide much history to me - somewhat limited by facial swelling and appears to be confused, trying to get out of restraints/bed. Spoke to son who also was unable to provide much history or medication list. PMH:Patient seen and examined with resident staff; their full history and physical is pending. Patient presented as a trauma level 2, from scene; I was present in the ED soon after patient arrival. 82 yo male, status post assault by roommate at nursing facility, struck by pole. Denies Loss of consciousness. Primary survey with airway intact, bilateral breath sounds, palpable pulses equal pupils. Secondary survey with multiple facial lacerationss and swelling. Labs and imaging reviewed. Hgb 11.5 CT head, c-spine, face pendingA/P: s/p assault, facial lacs and likely fractures- OMFS consulted - if requires admission, will admit to Trauma.

Based on interview and record review the facility failed to prevent the overdose of illicit drugs at the facility for 5 of 12 residents (R1, R2, R3, R12, and R9) reviewed for substance abuse on the sample list of 13. This failure resulted in an immediate jeopardy. The immediate jeopardy began on [DATE] at 11:23 PM when R1 and R2 who were roommates, were both found unresponsive. R2 required CPR, Narcan, and emergency services. R1 required Narcan and emergency services. On [DATE] at 1:15 PM, R3 was found unresponsive and required Narcan and emergency services. On [DATE] at 4:02 PM, R12 required Cardiopulmonary Resuscitation (CPR), Narcan, and emergency services and again on [DATE] at 1:30 PM, R12 required Narcan and emergency services. All incidents were related to the use of illegal substances. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:55 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE] at 2:45 PM but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. 1. R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include paraplegia, Diabetes Mellitus, morbid obesity, chronic pain syndrome, overactive bladder, hyperglycemia, and nicotine dependence. On [DATE] an additional diagnoses was added to R1's record of Poisoning by other opioids, accidental (unintentional). R1's facility assessment dated [DATE] showed he has no cognitive impairment and requires extensive assistance from staff for most cares. R1's care plan initiated [DATE] showed, I have a history of opioid abuse. At risk for withdrawal symptoms. I will be free of withdrawal symptoms and be kept comfortable as possibly by next review date. Interventions: Call light within reach while in room. Monitor for safety. Notify MD (medical doctor) of changes as needed. Observe effectiveness of medications. Psych consult as needed. R1's [DATE] Nurses Note entered at 11:23 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs (Emergency Medical Technicians) arrived and resident was taken to [acute care hospital] . R1's [DATE] Nurses Note entered at 2:15 AM showed, Spoke to ER (emergency room ) Nurse of [acute care hospital] resident admitted with Dx (diagnosis) Opioid Overdose. R1's acute care hospital documents from [DATE] through [DATE] showed, . Chief Complaint: Overdose . History of Present Illness: . presents to ED (Emergency Department) via EMS (Emergency Medical Services) from [long term care facility] due to overdose. Per EMS SNF (skilled nursing facility) staff found patient and his roommate unresponsive. Unknown down time. EMS gave 10 mg Narcan with some response . On arrival to the ED patient was minimally responsive with pinpoint pupils, requiring bagging. Patient was given 2 mg (milligrams) intranasal Narcan followed by 4 mg IV (intravenous) Narcan. Patient became more responsive, answering some questions and following some commands. At that time, patient denied taking anything, denied alcohol use, denied intentional overdose. Then stopped answering questions. Patient's roommate reportedly responded to Narcan as well . During interview patient stated he did not remember coming to the hospital or remember what happened prior to coming to the hospital . Urine Drug Screen pending . Results of urine drug screen requested and not received. R1's [DATE] Nurse Practitioner Note showed, . Patient was brought to the ED for unresponsiveness and was admitted for opioid overdose. Was treated and transferred back to [long term care facility] on [DATE] where he resides as a long term care patient . R1's [DATE] Social Service Note showed, Writer spoke to resident to explain that he will be on restriction for 30 days due to previous behavior. Resident was receptive to information. Writer will continue to follow up as needed. R1's [DATE] Social Service Note entered at 2:31 PM by V39 (Social Services Director) showed, Writer spoke to resident who presents to be alert and oriented x 3 and can make his needs known. Writer informed resident he would be placed on a temporary restriction for 30 days due to incident that occurred. Resident was receptive to information stating he does not go out anyway . R1's [DATE] Abuse/Neglect Screening showed R1 to have no history of substance abuse. (20 days after hospitalization for substance abuse overdose) R1's [DATE] Social Service Note showed, Writer met with resident who presents to be alert and oriented x 3. Gave Fentanyl information to resident with known substance use. The information talks about Fentanyl and what it can be found in because of resident substance use history. Resident respectfully declined receiving the information on Fentanyl. Writer will continue to follow up. On [DATE] at 4:13 PM, V6 RN (Registered Nurse) said, We sent out [R1] and [R2]. I was on break and they called me. By the time I was there all nurses were already in the room doing interventions . They found [R2] unresponsive, they started performing CPR (cardiopulmonary resuscitation) and gave Narcan . they were just unresponsive. We did not know why they were unresponsive. Technically Narcan would be for overdose . I can't remember. I don't know how they got the drugs or what they were. I think after that incident they made new rules to check and monitor some people that would usually have something like that. I don't know of any drug use that occurs between the residents . On [DATE] at 10:11 AM, V37 (Restorative Aide) said R1 has had residents from other room overdose in his room. V37 said he has seen R1 with wads of money and flashing it around. V37 said the problem is residents are allowed by Administration to come and go as they please. 2. R2's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include vitamin B12 deficiency anemia, alcohol abuse, polyneuropathy, hypertension, acute post hemorrhagic anemia, and chest pain. On [DATE] diagnoses were added to R2's record including cocaine abuse, cannabis abuse, and poisoning by other opioids, accidental (unintentional). R2's facility assessment dated [DATE] showed he has no cognitive impairment and requires supervision for most cares. R2's [DATE] Physician Order Sheet showed an order started [DATE] for Narcan Nasal Liquid 4 MG . 1 application in nostril as needed for overdose . R2's care plan initiated [DATE] showed, I have a history of drug abuse . I will not show signs and symptoms of distress related to no drug use . Interventions: Allow resident to voice feelings of frustration related to situation, no alcohol use, etc. Encourage resident drink lots of fluids and rest when needed. Give reassurance, redirection, allow resident to vent, offer snack, drink, walk, to call and speak to family etc. R2's [DATE] Nurses Note entered at 9:16 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs arrived and resident was taken to [acute care hospital] . R2's acute care hospital documents from his admission [DATE] through ,d+[DATE] showed, . Chief complaint: Drug Problem, Patient was found unresponsive at nursing home. Patient denies drug or ETOH (alcohol), and patient responded to 2 mg of Narcan . male with medical history as noted below who presents with vomiting brown vomitus . unresponsive episode at home at nursing home after drinking. Denied opioid use but did respond to Narcan given by ems. States last drink at 5:00 PM. Drinks heavily and regularly . Patient is currently residing at a nursing home . Upon my evaluation, patient provides additional history. He had experienced 2 episodes of bright red blood per rectum at around 5 PM. Thereafter he had some shots of vodka and ,d+[DATE] can of natural ice beer. He also smoked a joint. Then he went and took a nap and woke up diaphoretic as he was being transported to our facility via EMS. Upon arrival to our ER he had 2 episodes of nausea and vomiting . He adds that he drinks couple of beers once a week; no history of withdrawals; did have an episode of passing out when he had smoked a joint previously and was dehydrated as it was hot outside . Urine Drug Screen: . cocaine metabolite: detected; . Marijuana/THC (tetrahydrocannabinol): Detected . R2's [DATE] Nurses Note entered at 6:47 PM showed, Resident arrived back to the facility from [acute care hospital] alert and stable. R2's [DATE] Social Services Note showed, Writer spoke to resident to explain that he will be on restriction for 30 days due to previous behavior. Resident was receptive to information. Writer will continue to follow up as needed. R2's [DATE] Elopement Risk & Community Survival Skills Assessment showed R2 was assessed for supervised pass in the community only. On [DATE] at 12:40 PM, V36 LPN (Licensed Practical Nurse) said, We did a code for [R2], got him stabilized, took vitals and probably gave him Narcan . We know to consider Narcan is the resident is unresponsive to pain. The resident's usually have friends that alert us if they have been using substances that day . specifically [R2] we monitor. Friends say he is out smoking and don't know what he was smoking . 3. R3's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include peripheral vascular disease, chronic obstructive pulmonary disease, paraplegia, stage 4 pressure ulcer of sacral region, acquired absence of left and right leg above knee, stage 4 pressure ulcer of left hip, osteoarthritis, hyperlipidemia, major depressive disorder, myelitis, chronic kidney disease, and colostomy. R3's facility assessment dated [DATE] showed R3 has no cognitive impairment and required extensive to total assist from staff for most cares. R3's care plan initiated [DATE] showed, Resident presents with behavior concerns as evidenced by abusing drugs in the facility . Resident will decrease behaviors throughout next review . Encourage resident to participate in facility activities, Staff to complete room search to confiscate any drugs. R3's care plan initiated [DATE] showed, .have a history of substance use/abuse related to mental illness and maladaptive coping . I will not show signs and symptoms of distress related to no drug use . Implement increasingly restrictive interventions in an effort to help me break my addictive cycle including supervision while I am in the community, restricting independent pass privileges, and implementation of money guidance and budget controls to reduce/prevent access to substances . [DATE]: Make sure that I am aware of rules prohibiting use of alcohol, illicit substances, and intoxication . R3's [DATE] at 1:15 PM progress note showed, It was reported to writer that patient was found incoherent out on the patio and may have used an outside controlled substance. Writer went to speak with the patient, patient was responsive but still appeared to be 'out of it'. Patient was given a cool towel and was put in bed. Writer reported incident to doctor. R3's [DATE] at 1:22 PM progress note showed, Writer spoke to [Nurse Practitioner] and was instructed to give resident Narcan. Narcan was administered at approximately 1:40 PM . R3's [DATE] Order Administration Note entered at 1:24 PM showed, Writer did not administer due to OD (overdose) ordeal. This note did not indicate what medication was not administered. R3's [DATE] at 7:43 PM progress note showed, Resident was sent out to [acute care hospital] via lifeline ambulance for further evaluation related to incident which transpired on AM (morning) shift . R3's [DATE] Nurses Note entered at 10:39 PM showed, Resident returned from [acute care hospital] via stretcher with NNO (no new orders) in a stable condition . R3's [DATE] Acute Hospital Documents showed he arrived at the ED at approximately 5:44 PM. These same documents showed, Diagnoses: Fever in adult, Urinary tract infection . heroin abuse . Patient arrived via EMS (emergency medical services) from [long term care facility] after receiving two rounds of Narcan at noon from a drug overdose . At noon he was found unresponsive on the facility patio. After receiving 2nd round of Narcan he was awake and alert. Patient was then transported back to his room Patient initially denied any illicit drug use but states he did receive his Norco and gabapentin at 6AM and 8 AM. After later questioning patient endorsed having $20 worth of heroin around noon. R3's [DATE] Nursing Note entered at 3:19 PM showed, Spoke with resident regarding drug use, resident reports he has a history of heroin use and that he got the heroin in the city while out on pass on Thursday prior to the weekend - he reports he did not take any until Sunday, and he snorted it Sunday around noon. Resident did report that he would be accepting of seeking help for substance abuse, resident informed he is not allowed to leave facility at this time unsupervised that due to substance abuse he needs supervision while out of the facility, he was accepting of this. Asked resident if we could search his person and room, he was agreeable- found bag of powdered substance with a white paper rolled into shape of joint filled with substance in fanny pack. Resident admitted it was heroin . R3's [DATE] Nurse Practitioner Note showed, . On ,d+[DATE] he was found to be incoherent, lethargic, with suspicion of using illicit substance; was given Narcan at facility then transferred to ER for evaluation; where he admitted to using heroin . R3's [DATE] Nurses Note showed, TORB (telephone order read back) MD transfer to [acute care hospital] for evaluation and detoxification . R3's [DATE] Social Service Note entered at 4:01 PM by V5 (Social Services Assistant) showed, Writer spoke to resident to explain that he will be on restriction for 30 days due to previous behavior resident was receptive to the information. Writer will continue to follow up as needed. R3's [DATE] Nurse Practitioner Note showed, . (Referencing R3's [DATE] incident) He was found to be incoherent, lethargic; with suspicion of using illicit substance; was given Narcan at facility then transferred to the ER (emergency room ) for evaluation; where he admitted to using heroin; he went back and was admitted for detox; now back here for further care . Assessment/Plan: . AMS (altered mental status) due to heroin use - resolved . Has Narcan in the event. Social Service is following the incident . R3's [DATE] Social Services Note entered by V5 at 12:30 PM showed, Writer was notified by staff that resident went out on pass during 30 day restriction. Writer will follow up when resident returns. R3's [DATE] Social Service Note entered by V5 (Social Service Assistant) showed, Writer spoke to resident who presents to be alert and oriented x 3 and can make his needs known. Writer spoke to resident to explain that 30 day restriction was not up yet due to previous behavior . The facility's resident sign in and sign out log showed R3 signed himself out of the facility on [DATE] at 12:20 PM and returned to the facility at 3:40 PM. Additionally, R3 was signed out of the facility on [DATE] at 11:17 AM, [DATE] at 11:25 AM, [DATE] at 11:26 AM, [DATE] at 11:53 AM, [DATE] at 10:17 AM, [DATE] at 2:44 PM, [DATE] at 10:51 AM, and [DATE] at 10:27 AM. R3's [DATE] Nurses Note showed, Resident currently out in community. No distress or discomfort noted upon departure. R3's Social Services Note dated [DATE] entered at 3:41 PM by V5 (Social Services Assistant) showed, Writer was instructed to do a random search in resident room. Writer spoke to resident who presents to be alert and oriented x 3 and can make his needs known and consented to the search. Resident was noted with some white powder substance in his possession. An order to discontinue the patient from going outside was given per Social Service. Resident was told that he could no longer go outside, resident stated that he is grown and he will go outside when he wants to. Staff will continue to redirect and follow up as needed. R3's [DATE] Elopement Risk & Community Survival Skills Assessment completed by V39 Social Services Director (This assessment was not signed as completed until [DATE].) showed R3 to not have a history of illicit drugs while in the community for the previous 3 months. This same assessment showed R3 to require supervision when out in the community on pass. R3's [DATE] Nurse Practitioner Note showed, . Recent AMS (altered mental status) due to heroin use - resolved. Had detox at hospital. Has Narcan in the event. Advised on avoidance of illicit substances . R3's [DATE] nursing note entered at 11:18 PM showed, Obtained clean catch urine sample for drug test. R3's [DATE] Social Service Note showed, Write met with resident who presents to be alert and oriented x 3, gave Fentanyl information to resident with known substance use . 4. R12's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type 2 Diabetes Mellitus without complications, Chronic Obstructive Pulmonary Disease, gastrostomy, heart failure, schizoaffective disorder, dysphagia, hypertension, major depressive disorder, hyperlipidemia, and tobacco use. R12's [DATE] facility assessment dated [DATE] showed he is mildly cognitively impaired and required extensive assistance from staff for most cares. This same assessment showed R12 requires supervision of 1 staff member for locomotion off the unit. R12's current Physician Order Sheet showed an order dated [DATE] for Naloxone HCl (Hydrochloride) 4 mg . as needed. R12's [DATE] nursing note entered at 11:14 AM by V3 DON (Director of Nursing) showed, Writer received report from social service staff that resident was noted with some white powder substance in his possession. Staff immediately took substance and gave substance to the administrator. Staff instructed to notify provider and ask is drug toxicity is needed. R12's [DATE] Elopement Risk & Community Survival Skills Assessment completed by V5 (Social Service Assistant at 3:31 PM (6 hours after a white substance was found in R12's room that was believed to be an illegal substance.) showed R12 to have no history of self-harm, alcohol, and/or illicit drugs while in the community and is able to avoid persons who constitute a bad influence, and is able to practice 'harm reduction' strategies and verbalizes to ability and has no recent violations in the last 30 days of adhering to pass privilege policies including adhering to local laws. This assessment showed, Resident appears to be capable of outside independent and or supervised pass privileges . R12's [DATE] nursing note entered at 3:46 PM by V7 LPN (Licensed Practical Nurse) showed Around 9:30 AM social service staff reported to this writer that they found a small bag with marijuana in it. Social staff stated they returned it to the administrator. This writer called the on call NP to make aware. Order to discontinue patient from going outside was given per Social Service. Resident was told that he could no longer go outside, resident stated that he is grown that he will go outside when he want to. R12's [DATE] Social Service Note entered at 4:34 PM by V5 (Social Services Assistant) showed, Writer received report at 8:15 AM from Restorative staff that while resident was sleeping there was some white powder substance at bed side. Writer immediately took substance and gave substance to the administrator. Writer notify family and nursing provider and ask if drug toxicity is needed. Writer will continue to follow up. R12's [DATE] Nurse Practitioner Visit Note showed, . Nurse reported he was very sleepy . Nurse reported to me he was very sleepy yesterday, found some white substances next to him with suspect cannabis. He woke up without incident and continues to be his usual self today . Assessment/Plan: Somnolence due to unknown substance, likely cannabis-resolved . Spoke with him today, he denies using any substances, stated that it was nothing, Advised on avoiding illicit substances due to adverse reactions . asked if we can check his urine to rule out other causes; he does not want, Monitor for now . R12's [DATE] Nurse Practitioner Visit Note showed, . Previously seen for lethargy/somnolence, found some white substances next to him with suspect cannabis . Assessment/Plan: . Somnolence due to unknown substance - resolved . previously denied using illicit substances and did not want his urine checked . Order Narcan PRN (as needed) in the event. Monitor . R12's [DATE] nursing note entered at 4:02 PM showed, Resident roommate alerted writer resident was not responding, upon assessment, resident noted sitting up in wheelchair in bathroom, alert, non-verbal . pupils dilated, breathing was shallow, resident was lowered to floor and CPR was initiated, 911 called, will continue to monitor. (blood pressure) ,d+[DATE], (pulse) 62, (respirations) 12 . R12's [DATE] acute care hospital records showed, . Brought in by [emergency medical services], was found down on the floor by NH (nursing home) staff. Was given unknown amount of Narcan by NH staff. Arrives alert and oriented x 4, reports taking Heroin today. Spo2 (oxygen saturation) found to be 88% on RA (room air) . Patient presents for overdose from snorting heroin. Resident at [long term care facility] for last 9 months. Responded and awakened after Narcan . ED (Emergency Department) Diagnosis and Impressions: 1. Accidental overdose of heroin . R12's [DATE] nursing note entered at 5:15 PM showed, Resident status post emergency care, resident was given CPR (cardiopulmonary resuscitation) after he was noted unresponsive, resident was transferred to [acute care hospital] via 911 . R12's [DATE] Social Service Note entered at 11:15 AM by V5 (Social Services Assistant) showed, Write did a wellbeing check on resident this morning. Resident stated that he is fine. Writer asked do you feel safe in the environment, resident stated yes. Writer explain to resident I will be doing a room search, resident gave me permission to do the room search. Writer did not find anything in resident's room. Writer expressed that he is NOT allowed any visitors at this time or access to the community. Writer will continue to follow up as needed. R12's care plan initiated [DATE] showed, Community Access Supervised require the support, care, and services of a long-term care facility and has been determine by community access assessment to be able to access the community with supervision . I am on supervised access to the community. Obtain a physician's order for outside pass privilege. Inform me of any restrictions placed by my physician . R12's [DATE] Elopement Risk & Community Survival Skills Assessment completed by V39 (Social Service Director) at 4:35 PM (This assessment was not signed as completed until [DATE]. (6 days after R12 experienced a second overdose requiring emergency medical services.) showed R12 to have no history of self-harm, alcohol, and/or illicit drugs while in the community and is able to avoid persons who constitute a bad influence, and is able to practice 'harm reduction' strategies and verbalizes to ability and has no recent violations in the last 30 days of adhering to pass privilege policies including adhering to local laws. This assessment noted The resident appears to be capable of outside supervised pass privileges only . R12's [DATE] Nursing Note entered by V7 LPN at 2:37 PM showed, Resident is alert and oriented to self. Around 1:30 PM in front of the nurses station resident observed staring at the ceiling, blank stare, eyes and pupil dilated. Resident did not respond to touch or sound. Resident assisted back to his room, resident continue to stare at the ceiling, appear to be under the influence of unknown substance. Narcan 4 mg administered via nostril. Resident started to respond to sound and touch two minutes after the administration of Narcan. Drug screen done which also showed resident was positive . MD (doctor) called new order to send resident out to hospital for evaluation . R12's [DATE] Acute Care Hospital documentation showed, . Chief Complaint: Overdose, Patient overdosed on heroin, found unresponsive by staff. Given Narcan at 1:30 PM. EMS (Emergency Medical Services) just called to patient NH for transport . Patient overdosed on heroin, found unresponsive by staff. Given Narcan at 1:30 PM . Nursing home staff reports that the patient was reported found in an unresponsive state sitting in his wheelchair. No evidence of trauma or paraphernalia noted when found. Patient was given 4 mg intranasal Narcan with appropriate response. Sent to the emergency department afterwards for evaluation. Urine drug screen performed afterward showing positive opiates. Patient reports . was snorted from a friend who gave it to him . Does not know if it was laced with other medications. R12's [DATE] Incident Note entered by V3 DON (Director of Nursing) at 10:30 AM showed, . Resident noted with change of mental status. Lethargic. Slow to arouse. Resident appeared to be under the influence of an illegal substance. Narcan given. Root Cause of the incident: Resident ingested an illegal substance. R12's [DATE] Social Service Note entered by V5 (Social Services Assistant) at 12:46 PM showed, Writer met with resident for a well-being checkup. Resident presented in a pleasant mood. Writer asked resident did they have any questions of concerns. Resident stated he did not. Writer asked resident does he feel safe in his environment. Resident stated yes Writer encouraged resident to seek staff assistance when needed. Resident was receptive to information. Care plans have been updated. Staff will continue to follow up as needed. R12's [DATE] nursing note entered at 2:47 PM showed, Patient refused to give urine sample and to straight cath during AM shift. Will endorse to next shift nurse. R12's care plan initiated [DATE] (15 days after R12's second overdose incident) showed, Substance Abuse, Implement increasingly restrictive interventions in an effort to help me break my addictive cycle including supervision while I am in the community, restricted independent pass privileges and implementation of money guidance and budget controls to reduce/prevent access to substances . R12's [DATE] Social Service Note entered at 4:24 PM by V5 (Social Services Assistant) showed, Writer was instructed to do a random room search in resident room. Writer spoke to resident who presents to be alert and oriented x 3 and can make his needs known and consented to the search. Nothing was found during room search. Writer and staff will continue to redirect resident and follow up as needed. R12's [DATE] Psychiatric Nurse Practitioner Note showed, . Patient did admit to taking illegal substance, I know I shouldn't have done that. It will never happen again. My family got angry at me. R12's [DATE] Social Service Note entered at 4:09 PM by V5 (Social Services Assistant) showed, Writer met with resident who presents to be alert and oriented x 3, gave Fentanyl information to resident with known substance abuse. The information talks about Fentanyl and what it can be found in because of resident substance abuse history. On [DATE] at 11:14 AM, V37 (Restorative Aide) said he was notified by someone in housekeeping that R12 had a small baggie of a white substance on his table. V37 said he notified V5 (Social Services Aide) about the baggie and she handled the situation after that. On [DATE] at 10:50 AM, V7 LPN (Licensed Practical Nurse) said he had to administer Narcan to R12. V7 said R12 was sitting in his motorized wheelchair in front of the nurse's station starting off. V7 said R12 did not respond to touch and his pupils were dilated. V7 said when R12 did not respond to a sternal rub he knew it was time for Narcan. V7 said he considered Narcan because R12 was one of the residents who had been out smoking. V7 said R12 responded to Narcan and he knows his urine drug screen was positive. V7 said sometimes when the residents are out smoking they have symptoms of potentially overdosing. V7 said when they smell marijuana room checks are done by social services. The DON (Director of Nursing) and Administrator gave us a protocol that even if residents respond to Narcan we are having to send them to the ER. V7 said he has been lucky and has never had to give more than one dose of Narcan for the patient to respond. V7 said they treat the resident like a change of condition, bring them back to revival, take vitals, make notifications, and send them to the hospital. 5. R9's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include paraplegia, atherosclerotic heart disease, neuromuscular dysfunction, polyneuropathy, cerebral infarction, and acute kidney failure. R9's facility assessment dated [DATE] showed he has mild cognitive impairment and was dependent with all cares. R9's care plan initiated [DATE] which showed, Substance Abuse, I have a history of substance use/abuse/chemical dependency (marijuana and cocaine) related to rigid personality traits and ineffective coping. Despite education/support to assist with sobriety, I do not exhibit self-awareness and motivation to change .Interventions: Implement increasingly restrictive interventions in an effort to help me break my addictive cycle including supervision while I am in the community, restricted independent pass privileges and implementation of money guidance and budget controls to reduce/prevent access to substances. Meet with my interdisciplinary team to discuss the extent of my illness. Refer to the psychiatrist and clinical psychologist, as indicated. My physician my write an order restricting my outside pass privileges. Provide information related to treatment services/programs. Assist with referral process, as consented to. Provide me with a psychiatric and psychological evaluation, supportive mental health intervention, and treatment recommendations. R9's [DATE] Physician Order Sheet printed [DATE] showed no orders for Naloxone. R9's [DATE] eMAR (electronic Medication Administration Record) showed no Naloxone on order or administered. R9's [DATE] eMAR showed an order started on [DATE] for Naloxone HCl Liquid 4 mg as needed. The Naloxone order was discontinued on [DATE]. This MAR showed no doses of Naloxone given. R9's [DATE] MAR did show on [DATE] and [DATE] Drug Panel 9 Test one time only for suspected OD (overdose). R9's Social Services Assessment for Abuse and Neglect dated [DATE], [DATE] and [DATE] completed by V5 (Social Services Assistant) showed R9 was assessed as having no history of substance abuse. On ,d+[DATE] 23 at 8:00 PM, V43 LPN (Licensed Practical Nurse) entered a nursing progress note which showed, Resident noted in lobby lethargic and somewhat unresponsive but responds minimally when name is called. Resident suspected to be under the influence of some substance after visiting with other residents. Resident was in a motorized wheelchair which had to be operated by staff in order to get resident back to his room. Sternal rub was done and resident was given Narcan 4 mg in left nostril. After approximately 2 minutes resident began to look around. Supervisor on duty (V18 LPN) made aware, writer was instructed to call 911. 911 was called, resident was put back to bed via (mechanical lift) lift . On [DATE] at 1:29 PM, V5 (Social Services Assistant) completed a social service note for R9 which showed, . No history of substance abuse noted . Yes current use of smoking products. Cannot determine hazardous behavior with smoking products . On [DATE] at 12:39 AM,

Based on interview and record review, the facility failed to ensure administration operationalizes and oversees facility's policies and procedures regarding substance abuse to ensure the safety of residents with a history of substance abuse. This failure resulted in a delayed response to the facility's substance abuse issue and resulted in 5 residents (R1, R2, R3, R9, and R12) overdosing on illegal substances and requiring Narcan administration, emergency services, and in some cases CPR. The findings include: The facility's records show the first episode of an overdose on illegal substances at the facility occurred on [DATE] and continued to occur through [DATE]. R1's [DATE] Nurses Note entered at 11:23 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs arrived and resident was taken to [acute care hospital] . R2's [DATE] Nurses Note entered at 9:16 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs arrived and resident was taken to [acute care hospital] . R3's [DATE] at 1:15 PM progress note showed, It was reported to writer that patient was found incoherent out on the patio and may have used an outside controlled substance . R3's [DATE] Acute Hospital Documents showed he arrived at the ED at approximately 5:44 PM. These same documents showed, Diagnoses: heroin abuse . R12's [DATE] acute care hospital records showed, . Brought in by [emergency medical services], was found down on the floor by NH (nursing home) staff . reports taking Heroin today. Patient presents for overdose from snorting heroin . Diagnosis and Impressions: 1. Accidental overdose of heroin . R9's [DATE] Nurses Note entered at 12:39 AM showed, Resident assisted to bed x 3 person . resident became responsive after 2 Narcan administration. Resident stated I'm okay. Urine collected, positive for opioid substance . The incidents for R1, R2, R3, R9, or R12's were not reported the local law enforcement or the State Survey Agency. A complete list of residents who experienced an overdose and required Narcan was requested repeatedly and not received throughout this survey. Social Services Assessments were reviewed and were not completed accurately regarding resident drug abuse history to compile an accurate list of residents at risk. On [DATE] at 12:03 PM, V32 CNA (Certified Nursing Assistant) said, I don't know but sometimes the hallways smell like weed . On [DATE] at 11:14 AM, V37 (Restorative Aide) said, There are drugs everywhere, a lot of residents have them. They always smell of marijuana. One day a paralyzed resident was in his bed smoking a joint. Someone had to give that to him. V37 said he saw a resident in a motorized wheelchair drop a bag of marijuana off his lap onto the floor. V37 said he just rolled his wheelchair over it to hide it and another resident picked it up and gave it back to him. V37 said there are a lot of residents that go out in front of the building to smoke and he sees cars pull up to them and get out, they will only be there a couple minutes then leave. I haven't seen a transaction but it's odd. I've reported to the administrator. The nurses have started carrying Narcan in their pocket. On [DATE] at 12:40 PM, V36 LPN (Licensed Practical Nurse) said, We did a code for [R2], got him stabilized, took vitals and probably gave him Narcan . We know to consider Narcan if the resident is unresponsive to pain. The resident's usually have friends that alert us if they have been using substances that day . specifically [R2] we monitor. Friends say he is out smoking and don't know what he was smoking . On [DATE] at 10:50 AM, V7 LPN said he was present when R12 overdosed. V7 said when R12 was not responding to a sternal rub and his pupils were dilated he knew it was time for Narcan. V7 said sometimes when residents are out smoking they have symptoms of potential overdose. V7 said room checks are initiated when they smell marijuana. On [DATE] at 12:14 PM, V41 (Medical Director) said, I was made aware of the issue of overdosing in the facility several weeks into the situation. It was actually brought to my attention by one of my Nurse Practitioners that they had used Narcan on some of our residents. I called the Administrator and he said they were working on it through education . He said they traced it back to just one resident and he was transferred out. I would think the police would have been involved too . Of course I would have expected to have been notified right away. I would have been able to help with the situation, reach out to an addict team, Notify (State Survey Agency), Treat medically whoever was in need, and ensure the regulatory stuff would have been followed through. This is a bizarre situation that looks like someone is bringing drugs in . On [DATE] at 12:44 PM, V1 (Administrator) said, At first we didn't know we had a Fentanyl problem. I thought maybe they were nervous and everyone that was 'out of it' (unresponsive) so they were just giving them Narcan too. When we looked into it and [R12] was positive for cocaine I started looking at Fentanyl. That's when I got a test kit, not a urine test kit. It was a substance test kit. I got the substances to test from a room search. If you go online, it won't let you buy the Fentanyl test kits because of weird political or probably money reasons. In Illinois you can't buy Fentanyl test kits but at 333 State St, in downtown Chicago they have a box on the 3rd floor in the Chicago Department of Public Health office where you can take as many Fentanyl test strips and Narcan as you want. They are there for the drug users who don't want to die from Fentanyl so they can test their own product. I've reached out and I'm getting 500 Fentanyl test strips that I can distribute to other facilities and family members. I said we gotta get ahead of this, so we put an action plan together for people who even smoke a little pot and become unresponsive. I know weight wise it's good to put it (Fentanyl) in heroin but why put it in marijuana. The drug dealers who are cutting the marijuana, the heroin, or the cocaine are using the same surfaces, it's a cross contamination issue. Two people told me that, one was a coordinator we were talking to about NA (Narcotics Anonymous) meetings for our facility and also Dr. Google (Internet search engine). When we were using Narcan like nobody's business, we assessed all residents for a history of substance abuse and updated a list. (List was requested repeatedly and not received until [DATE] upon exit.) One of the people were non-responsive on the patio but our staff monitor that, but that's one set of eyes. If they wheel somebody to the elevator and back that's not a problem they don't have to necessarily be out there. So we set up a camera. We did do training on nurses for drug overdose and responding and Narcan usage . We did start to do some searches of bags and personal things, nothing super harsh because we know if someone wants to sneak something in they can. We initiated random room searches. Those are documented in the resident's records. No checklist. We did a resident council meeting . I told them if they are smoking pot and they are feeling 'out of it' they should let the nurses know because it could be Fentanyl . we have a new company that will be working with our active substance users to look at other underlying mental health issues such as anxiety and depression that could be contributing to their substance use . We did also reach out to [a local company] and they are willing to come in and meet with the residents to discuss overdosing. They are a harm reduction group. They will go over the signs of OD and what they should do (at the time of this survey there was no evidence this had been completed) . [R12] is going to NA meetings because he is somebody that when he is out in the community he goes immediately to get cocaine, like a moth to a flame . Something I still don't know is where the Fentanyl was coming from. Too many different people in and out of the facility. They had to have been getting it from someone. We talked to everybody, I looked at probably 30 hours of video checking to see if staff were going in and out of rooms more frequently . Just because you have community access and are found with drugs on you it doesn't mean that you are sharing. We haven't used Narcan in months (last documented Narcan usage found in resident sample was [DATE].) That's good considering how often we were using it . I tested the drugs myself. [R3] was actually honest about it. Until we Narcan' d him, we didn't even know he had a heroin issue. He told us he was using heroin every day. Now all of a sudden he is out (unresponsive). So when we tested it and found it had Fentanyl in it, he was really upset about it. He said he would get on the bus and go back into the neighborhood or somewhere to get it but that doesn't mean he is being honest. I believe we actually looked at who had a substance abuse history between nursing consultants and our social services team. They did the assessments. (A document was provided by the Administrator with some steps taken by the facility, all undated, all marked 'completed'.) It shows 'completed' but it was varying dates. At one point we sat down and said 'We are outgunned here.' After that multiple Narcan usages. I would say the education started in September. At first we were like 'hmm [R2] just got really drunk or someone overdosed on something they were taking. Maybe it's an isolated incident.' The two residents would have been isolated verses widespread. Then in September is when we realized we had a pattern. It was shocking to me because [R2] is no newbie when it comes to using substances so how in the world are they overdosing. Especially [R3] too. We were absolutely playing defense. Narcan was being given and the resident perked up and they (the nurses) were like 'oh he is good' and let them just go back to their rooms. I flushed the drugs. I did not call the police. I did not report to (State Survey Agency). I don't know what the reasoning would be to report it. We look at harm. (This surveyor asked V1 if he considered a resident overdosing on illegal drugs, requiring CPR (cardiopulmonary resuscitation), emergency services, and in some cases a hospital stay an 'unusual event' that would require reporting and be considered harm?) I guess I'll take your input on that. We were actually expecting IDPH to come out earlier because a lot residents were freaking out I figured someone would call in. We were well expecting you guys. The reality is Fentanyl is a problem. I'm still trying to figure out how this would be reportable. This is uncharted territory and I guarantee you we did some things wrong here. There hasn't been any more Narcan use 'knock on wood' but we are putting things into place where residents are educated and are smarter now. We were going to bring drug sniffing dogs in, not the police though because the police don't want to do it. I called the Chicago police (not the local police department) to see if they take their dogs in to facilities and they said 'If a resident has a bag of heroin and he is in a wheelchair with no legs, we don't want to be on the news 'perp walking' them out of the facility. It's bad PR (Public Relations). The facility's job description titled Administrator created [DATE] showed, Summary: The Administrator directs the day to day functions of the facility in accordance with current federal and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures . Review and check competence of workforce and make necessary adjustments/corrections as required or that may become necessary . Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas .Ensure that all facility personnel, residents, and visitors follow established safety regulations to include fire protection/prevention, smoking regulations, infection control, etc. Review accident/incident reports (e.g. falls, injuries, or an unknown source, abuse, etc Monitor to determine the effectiveness of the facility's risk management program .

Based on interview and record review, the facility failed to supervise and provide minimum assistance to prevent falls for 2 of 3 residents (R1 and R2) reviewed for falls in a total sample of 11. This failure resulted in R1 suffering from a right tentorial subdural hemorrhage, and R2 suffering from acute fractures of the posterolateral and lateral 5th-9th ribs, left pneumothorax and slight left lung contusion. Finding include. 1. On 5/30/23 at 2:00pm, V8 (RN) stated that she was informed by R2 at the end of her shift that he fell in the bathroom. V8 stated that R2 can walk to the bathroom with one assist. V8 stated that R2 requested to be changed and she sent V36 to go and change R2. V8 stated that she witnessed V36 go into R2's room and was informed by V36 that R2 has been changed. V8 stated that R2 needs were addressed during her shift, and he did not complain or have any concerns during her shift. On 6/1/23 at 2:00pm, V36 (CNA) stated I checked on R2 in his room during rounds and he was dry. He did not tell me he had fallen in the bathroom. V36 stated she checked the second time during rounds after 2pm and R2 had a bowel movement so she changed R2. V36 stated that, the third time she gave him water and R2 did not mention anything about a fall. V36 stated that she had witnessed R2 walk to the bathroom and walk out of the bathroom in the past; V36 stated I have seen him sitting at his bed side by himself and standing. V36 stated that she is not sure of R2's fall status. He would put his call light on for assistance. V36 stated that residents will have a fall band if at risk for falls and all fall risk residents are assisted in the wheelchair if they need to go to the bathroom. On 5/30/23 at 2:30 pm, V9 (2nd Floor Supervisor) stated that she was informed by the outgoing nurse that R2 fell on his side in his room. V9 stated that an x-ray of his ribs was done and R2 was sent to the hospital once x-ray results came back positive. V9 stated that R2 did not inform anybody he needed assistance with toileting. He can walk to the bathroom by himself. On 6/1/23 at 11:15 am, V24 PT (Physical Therapy Assistance) stated that R2 needs a minimum of one assist with bed mobility, turning side to side, sitting at the bedside. V23 (Physical Therapist) and V24 both stated that R2 did not receive a physical therapy evaluation and did not provide a reason. R24 stated that R2 was referred to OT (Occupational Therapy) on 2/27/23 but was picked up by PT on 5/23/23. He is receiving bed mobility from PT due to max assist. On 6/1/23 at 3:15pm, V2 (DON) stated that a fall assessment is done on all residents and the fall interventions are documented in the care plan. V2 stated that a leaf is placed on the resident's door to identify high risk residents. Physician order dated 2/27/23 reads; Physical Therapy (PT) Evaluation and Treatment as Indicated. Fall risk assessment dated [DATE] reads; Score:13 Category: At Risk for Falls. Facility's standing order set reads, PT eval and treat as indicated. Facility's fall incidents show; R2 fell on [DATE] and 5/10/23. Facility's document reads; Report to IDPH (Illinois Department of Public Health) [NAME] Office. Initial 5/10/23 and Final 5/10/23. Physician order dated 5/23/2023 reads; Therapy: PT Evaluation and Treatment 3-5 x/week x 41 days, to address ther-ex, ther-ac, neuromuscular re-education, gait training, w/c management, manual therapy. Minimum Data Set Section G. Functional Status reads; I-Toilet use: Self Performance 3 (Extensive assistance) and Support 2 (One-person physical assist). Care plan initiated 2/27/23, reads I am at risk for falls and injury related to falls. PT and OT to evaluate and treat as indicated. 2/28/23 reads; Assist with toileting upon awakening, before and after meals, during rounds, before bedtime PRN. 5/15/23 reads; PT, OT (Occupational Therapy) and RT (Raspatory Therapy) to evaluate upon return from the hospital. Radiology Results Report dated 5/10/23 reads, Impression: (1) Acute facture of posterolateral and lateral left 5-9 ribs, including comminuted segmental fracture of the 6th, 7th, and 8th ribs. (2) 30% or so left pneumothorax and slight left lung contusion. Hospital report dated 5/11/23 reads; Current Admission Orders: Diagnosis; Traumatic pneumothorax, initial encounter. Facility's policy titled; Fall Prevention Program; Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk falls and implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary . Standards: . Safety interventions will be implemented for each resident identified at risk. . Residents who require staff assistance will not be left alone after being assisted to bath, shower, or toilet. 2. On 05/30/2023 at 2:30PM, R1 stated that she remembers she was being assisted by CNA to the bathroom while walking with her walker when she slipped and fell backwards. On 05/31/23 at 2:50PM, V35 (Agency Certified Nursing Assistant) said while she was assisting R1 with walking to the bathroom with her walker, R1 asked her to adjust the toilet raiser before entering the bathroom, and while she was doing that, R1 suddenly fell backwards. On 06/01/23 at 11:45AM, V24 (Physical Therapy Assistant - PTA) and V25 (Physical Therapy - PT) said that at the time of the fall, R1 needed minimal assistance with rollator, which means staff has to physically hold her while walking. V25 said that he knows R1 because he has worked with her and R1 has the tendency of falling when no one is holding her because she leans backwards, and her hips are very unstable. V24 also clarified that their software does not allow putting in minimal assist so they put partial/moderate assist which could mean minimal to moderate assist. On 06/01/2023 at 1:18PM, V39 (PTA) said that around the time of R1's fall, he was just coming back from leave. He said that during that time, R1 needed minimal help with everything like transfers, and ambulation with rollator. He also mentioned that he told R1 that he felt R1 was not ready for the rollator use yet because she becomes really tired. He described that R1 manifests shakiness when she gets tired. He also said that during the treatment, he was just grabbing the gait belt that was on her because she was becoming really shaky. He also mentioned that minimum assist means constantly touching the resident to give them the 25% of help they need. On 06/02/2023 at 10:30AM, V39 stated that R1's therapy performance fluctuates but the safest assistance she needed is minimum assist by 1 person. R1's face sheet order summary report dated 6/2/2023 indicated admission of 05/23/2023 and diagnoses including repeated falls, presence of right artificial knee joint, presence of right artificial hip joint, dependence on renal dialysis, malignant neoplasm of left kidney, except renal pelvis, malignant neoplasm of colon, hypotension, fracture of coccyx, end stage renal disease, other low back pain, unsteadiness on feet, abnormal posture, other abnormalities of gait and mobility, and other lack of coordination. R1's fall risk assessment dated [DATE] indicated at risk for falls, and gait/balance problem while standing and walking. Skilled evaluation dated 4/27/2023 indicated unsteady gait, poor balance, use of manual wheelchair, and safety concerns. Documentation survey report for April 2023 indicated walking in the room did not occur for 4/24/2023 - 4/26/2023 and 4/28/2023, and extensive assistance with one-person physical assist on 4/27/2023. PT Treatment Encounter Note dated 4/28/2023 indicated R1 was instructed with gait training using rollator with min A x 1 (minimal assist by 1 person) on level surface for x (for) 40 feet each and unsteady gait pattern. PT Discharge Summary for dates of service 3/7/2023 to 4/28/2023 indicated functional skill on ambulation as partial/moderate assistance. Care plan revised 5/24/2023 indicated R1 is at risk for falls and injury related to falls, and risk factors include lack of coordination, abnormal posture and abnormal gait/mobility. Hospital admission record dated 4/29/2023 indicated Neuro ICU H&P (Neurology Intensive Care Unit History and Physical) Note chief concern of R SDH (right subdural hemorrhage), and CT Head without IV (intravenous) contrast final result dated 4/29/2023 indicated findings of stable known right tentorial leaflet subdural hemorrhage, and impression of stable known right tentorial subdural hemorrhage. PT provided a document entitled Suggested Terminology for Objective Data that indicated the following: Minimal (Contact) Assistance - Patient requires small amount of help to accomplish activity; patient requires no more help than touching and expends 75% or more of the effort. Patient is able to assume all of his body weight, but requires guidance for initiation, balance, and/or stability during the activity. Moderate Assistance - Patient requires more help than touching; expends half (50%) or more (up to 75%) of the effort. Patient is able to assume part of his body weight in initiating and performing activity. Facility Policy: Title: Fall Prevention Program: Revisions: 11/21/2017 Purpose: To assure safety of all residents in the facility, when possible. Fall/safety interventions may include but are not limited to: Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Monitor gait, balance, and fatigue with ambulation if applicable.

Based on interview and record review the facility failed to implement their Coronavirus (Covid-19) testing policy to prevent or reduce the spread of Covid-19 on the third floor nursing unit. This failure affected 25 of 45 (R16, R18 - R36, and R38- R43) residents reviewed for outbreak testing, and prevention of the spread of Covid-19. This failure resulted in V55 (nursing aide) testing positive on 3.29.23 the facility failed to follow their policy and test the residents who received direct care from V55 (R16, R19 - R36). The failure resulted in R19- R21 testing positive 13 days later. R18 displaying signs and symptoms of Covid-19 on 4.6.23, the facility failed to immediately isolate and test R18 allowing R18 to go out to the dentist. R18 tested positive on 4.7.23, and R38-R43 all on the same unit testing positive for Covid-19 on 4.10.23and 4.11.23. V46 (nurse) and V47 (cna) provide direct care for R18 and tested Covid positive six days later. The Immediate Jeopardy that began on 03.29.23 was removed on 04.28.23. V1 administrator was notified of the Immediate Jeopardy on 04.27.23 at 12:14pm The immediacy was removed on 04/28/23, but the deficiency remains at a level 2 harm, until the facility can do an evaluation of the effectiveness of the interventions implemented. Findings Include: V55 - On 4/20/23 at 3:31pm, V55 (certified nurse aide, C.N.A) said, I tested positive for Covid-19 on 3/29/23. I had body aches and a temperature of 100.4 F. The last scheduled day I worked was 3/28/23. I worked with R16, R19 - R36. On 4/21/23 at 12:46pm V18 (Assistant Director of Nursing A.D.O.N.) said, we do not have the first or the second test for R19 -R21. We follow our Covid-19 policy. On 5/2/23 at 10:45am, V1 (Administrator) there was no changes to the current policy after the Immediate Jeopardy. There was an execution issue on following the current policy that led to Immediate Jeopardy. Staff did not follow the policy. Assignment sheet dated 3/26/23 and 3/28/23 documents V55 had (R16, R19 - R36). Covid-19 staff line list dated 3/29/23 documents: V55 was covid positive with headache and cold-like systems. Last day worked 3/28/23. Facility acquired. No rapid point of care testing report was completed on 3/29/23 and 4/1/23 for (R16, R19-R36). Rapid point of care test report dated 4/10/23 documents: R19-R21 tested positive on 4/10/23. Facility Covid testing- Residents and staff revised 10-21-22 documents under testing of staff and residents: testing trigger a newly identified covid positive staff or resident that can identify close contacts. Under staff: test all staff, regardless of vaccination status, that had a higher risk of exposure with a covid 19 positive individual. Under residents: Test all residents regardless of vaccination status that had close contact with a covid-19 positive individual. Under testing trigger: newly identified covid-19 positive staff or resident in the facility that is unable to identify close contacts; under staff- test all staff regardless of vaccination status, facility wide or at a group level if staff assigned to a specific location where the new case occurred (e.g unit, floor or specific area of the facility), Under residents- test all residents, regardless of vaccination status, facility wide or at a group level (e.g unit, floor or other specific area of the facility). Initial outbreak testing: Test #1 immediately (but not earlier than 24 hour after the exposure), Test 2: if the test was negative, test again 48 hours after the first negative test and Test 3: if the second test was negative, again 48 hours after the second negative test. R18 - Nursing note dated 4/6/23 at 07:05AM (7:05AM) documents: R18 observed with loose cough and not expectorating. No complaint of (c/o) pain. Skin warm/dry (w/d) to touch, Temp. 100.0F. Tylenol 1000mg given. Endorsed to 7-3 nurse to follow up (F/U). On 4/18/23 at 3:27pm, V46 (nurse) said, I did not test or isolate R18. I would not test R18 for twenty four hours nor would I isolate R18. We don't isolate unless a resident has Covid. I treated the symptoms. Nursing note dated 4/6/23 documents: R18 returned from appointment with new orders from Endodontist. Nursing note dated 4/7/23 at 16:11 (4:11PM) documents: Writer observed resident with cough and slight fever of 99.5F, Tylenol and cough medicine given for comfort per NP orders. Rapid covid test performed with positive results. On 4/21/23 at 11:40am, V18 (A.D.O.N.) said, R18 should have been tested when R18 displayed symptoms. V2 (D.O.N.) said, Covid symptoms are loss of taste or smell, sore throat, cough, fever or loose bowels. On 5/2/23 at 10:45am, V1 (Administrator) there was no changes to the current policy after the Immediate Jeopardy. There was an execution issue on following the current policy that led to Immediate Jeopardy. Staff did not follow the policy. Rapid point of care test report dated 4/7/23 documents: R18 was Covid-19 positive. Covid-19 staff line list dated 4/11/23 documents: V47 was covid positive with cough, fever, body aches, sore throat and cold like symptoms. Last day worked 4/9/23. Facility acquired. Assignment sheet dated 4/9/23 documents: V47 worked with R18 on 4/9/23. Covid-19 staff line list dated 4/11/23 documents: V47 (cna) was covid positive with headache and sore throat. Last day worked 4/11/23. Facility acquired. Rapid point of care test report dated 4/10/23 documents: R39-43 tested positive on 4/10/23. R38 tested positive on 4/11/23. Facility Covid testing- Residents and staff revised 10-21-22 documents under testing of symptomatic individuals: Anyone with even mild symptoms of covid-19 regardless of vaccination status should receive a viral test for covid-19 as soon as possible. According to the centers for Medicare and Medicaid services QSO-20-38-NH revised 09/23/22 documents: Residents who have signs or symptoms of COVID-19, regardless of vaccination status, must be tested as soon as possible. While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions (TBP) in accordance with CDC guidance. Once test results are obtained, the facility must take the appropriate actions based on the results. On 05/02/23 the surveyor verified by observations, record review and interview that the facility implemented the following to remove the immediacy. The facility failed to implement their COVID 19 testing policy to prevent or reduce the spread of COVID 19 on the third floor nursing unit ACTION TAKEN: ACTION TAKEN COMPLETION DATE 1. R18 had a COVID test completed on 4/7. He was placed on isolation at that time. 4/7/23 2. R38-R43 were placed on isolation at the time of their positive test. 4/11/23 3. All staff will be educated on Covid 19 Symptoms, reporting, testing and quarantine of symptomatic Residents and staff (Attachment A- Education Handout & Post-Test). Staff on vacation or FMLA will be in-serviced before returning to work by the Director of Nursing . New hires will be in-serviced before beginning work by the Director of Nursing. Staff's knowledge base will be evaluated per their post-test. If staff does not have sufficient knowledge, they will be re-educated and knowledge base will be re-evaluated via the post test. 4/28/23 and ongoing 4.The facility will implement and utilize the COVID-19 Test Tracking Tool (Attachment B-COVID-19 Test Tracking Tool) to ensure that all residents and staff identified are tested according to the testing method used after an outbreak (Contact Trace vs Broad Based vs Facility Wide). 4/27/23 5. The Administrator or designee will audit testing of staff and residents following an outbreak until outbreak is resolved. The audit will be completed at the end of each testing period. The findings of the audit tools will be reviewed in the QA meeting. If the Administrator is not available, the Administrator will appoint the designee to review with QA Committee. 4/27/23 and ongoing 6. The DON or designee will review progress notes at least 5 times per week to ensure any residents identified with symptoms are quarantined and tested upon identification of symptoms according to the guidelines. The audit will continue x 6 months. The findings of the audit tools will be reviewed in the QA meeting. If the Administrator is not available, the Administrator will appoint the designee to review with QA Committee. 4/27/23 7. The DON and ADON or designee will be inserviced on following CMS/CDC guidelines for contact tracing to ensure all staff/residents were properly identified and confirmed through investigation 4/27/23 8.The Administrator or designee will review and verify contact tracing accuracy to ensure if follows CMS/CDC guidelines with each outbreak initiated. The findings of the audit tools will be reviewed in the QA meeting. If the Administrator is not available, the Administrator will appoint the designee to review with QA Committee. 4/27/23

Based on interview and record review, the facility failed to manage one residents with type one diabetes by failing to get a continuous blood glucose monitoring device and not following physician orders for Lantus. This affected 1 of 3 residents (R3) reviewed for diabetes. This failure resulted in R3 being hospitalized for diabetic ketoacidosis Findings include: R3 was admitted to the facility on [DATE] with a diagnosis of type I diabetes and gastroparesis. R3's physician progress note dated 2/21/23 documents: Patient states blood sugar this morning was 55. Requesting a continuous blood glucose device to avoid finger sticks. Ordered from pharmacy. Patient states asymptomatic this morning. R3 physician order sheet dated 2/21/23 documents: order for continuous blood glucose system sensor. R3's medication administration record for February 2023 under Dexcom documents: 9 which indicates other /see nursing note on 2/21/23, 2/22/23, 2/24/23 and 2/25/23. R3's progress note documents continuous glucose device placed on 3/21/23. On 4/14/23 12:55PM, R3 who was alert and oriented at time of interview said she requested for continuous blood glucose monitoring device because she had one prior to entering the facility. R3 said she was unsure that she could get the device and when she went out on pass back home she got her equipment and brought it back to the facility. R3 said she knows how to change and monitor device and that the blood glucose reading will alert to her phone if too high or low. R3 said she placed it on 3/21/23. On 4/14/23 at 3:53Pm, V18(ADON) said physician's orders are expected to be followed. V18 said facility was trying to get R3's glucose device from pharmacy but there was an issue wih the insurance. V18 presented email communication with the pharmacy dated 3/22/23. There were no other communications presented. On 4/14/23 at 3:10PM, V67(pharmacy) said pharmacy has continuous blood glucose equipment and device but as part of facility contract, the facility would have needed to call and request for item to be sent. There are certain items and medications that default to profile only and will only be sent if specifically requested. V67 said she was unable to access that far back in the system to see if there were any requests made. R3's medication administration record for February 2023 under insulin lantus : inject 34 unit subcutaneously at bedtime. On 2/20/23, 2/21/23 and 2/23/23 documents: 15. 15 indicates no insulin needed. On 2/25/23 documents 3: 3 absent from home. R3'a blood glucose on 2/20/23 at 21:35 78, 2/21/23 at 22:08 95, 2/23/23 at 21:22 95. There were no documented blood glucose readings for R3 from 2/25/23 at 11:22am was 320 until 2/26/23 at 7:42Am documents: 400. R3's progress note dated 2/25/23 at 10:45: Resident complains of emesis 6-7 times, medication given but not effective, was not able to tolerate her breakfast, latest vitals are blood pressure-115/57, pulse-119, respirations 24, temperature 98.2 Blood sugar 309 mg/dl. Referred to MD, advised to be sent to local hospital, called ambulance for transportation eta given is after 1 hour. R3's local hospital record dated 2/25/23 documents under chief complaint: nauseas and vomiting due to hyperglycemia. Last blood glucose reading documented at 19:08 at 166. There was no documentation of any insulin given during hospital stay. R3's progress note dated 2/25/23 at 23:40 documents: Resident returned to the facility from local hospital in stable condition via stretcher by two EMTs, no signs of distress observed, vitals WNL, no new order given, will continue to monitor. The next progress note was dated 2/26/23 at 23:15 which documents: Writer placed a call to hospital for a follow up and was made aware that the resident was still being evaluated, endorsed to night shift nurse to follow. On 2/27/223 at 23:01 documents: resident admitted for diabetic ketoacidosis. On 4/19/23 at 11:22AM, V18(ADON) said blood sugar should be assessed at time of readmission. On 4/21/23 at 1:41PM, V63(MD) said staff should call to verify if medication like Lantus should be held. V63 said unsure parameters for lantus and if or when it should be held, just base it on the patient at time of administration and staff should call him to make decision. On 4/21/23 at 4:54PM, V59(Nurse) said a low blood sugar would be less then 100 and we would call the doctor if we held any insulin. V59 was unable to recall R3. R3's 911 report dated 2/26/23 documents: call received at 8:29AM, at patient 8:36AM. Under narrative documents: dispatched for breathing problems. R3 was found alert and confused breathing quickly while sitting in bed. Per staff, R3 was seen yesterday for vomiting and returned last night. This morning, staff noted that R3 breathing quickly. R3 was placed on oxygen by nursing staff. Staff reported patient blood glucose reading was high. Assessment of R3 note tachypnea, warm skin and disorientation. Vital signs heart rate 140, blood pressure 108/68, pulse ox 97 %, respirations 36, and glucose was high. R3's hospital record dated 2/26/23 documents under diagnosis: Type I diabetes with ketoacidosis without coma. Upon arrival glucose above 600. R3's after visit summary from V62(MD) documents: always administer lantus to patient. Not administering basal insulin will result in diabetic ketoacidosis.

Based on interview and record review, the facility failed to monitor and supervise the common dining area and failed to follow the Minimum data set for transfers. This affected 2 of 3 residents (R8, R10) reviewed for falls and supervsion. This failure resulted in R8 having an unwitnessed fall sustaining a laceration requiring 4 sutures. Findings include: 1. R8 - R8 was admitted to the facility on [DATE] with a diagnosis of hemiplegia affecting left side, history of falling, anxiety disorder and abnormalities of gait and mobility. R8's brief interview for mental status dated 1/17/23 documents a score of 12/15 which indicates moderately impaired. R8's Minimum Data Set, dated dated dated [DATE] under functional status documents: Transfer- how resident moves between surfaces including to or from bed, chair, wheelchair, standing position(excludes bath/toilet) documents a score of 3 under self-performance which indicates extensive assistance- resident involved in the activity, staff provide weight bearing support; under support documents a score of 3 which indicates two person assist. Under balance from surface-to-surface transfer (bed to chair or wheelchair) documents a score of 2- not steady only able to stabilize with staff assistance. R8 fall risk assessment dated [DATE] documents: at risk for falls. R8 incident report dated 1/11/23 at 19:05 documents: resident had unwitnessed fall in the dining room. Observed lying on the floor on his side, has lacerated wound and bleeding to left eyebrow. Under resident description: I was trying to get up from wheel chair but I lost my balance. R8's hospital record dated 1/11/23 documents: patient had unwitnessed fall, Patient was found in dining room on the floor by staff. Laceration noted to left eyebrow. Under procedure documents: 3.5 cm laceration to left eyebrow. Suture repair was done with derma bond and close approximation of wounds. On 4/5/23 at 4:24PM, V7(Nurse) said R8 fell on [DATE] and she was alerted by another resident that R8 was on the floor. V7 said she was unable to recall if there were any staff in the dining room at the time of fall but dining room is monitored by staff when residents are present. On 4/8/23 at 4:35PM, V8(CNA) said staff monitor dining room area when residents are present. Each staff is assigned every 30 minutes to monitor residents. On 4/14/23 at 3:53PM, V18(ADON) said common dining rooms are monitored by staff when residents are present. V18 said he is unable to recall if any staff were present in the dining room at the time of R8's fall. V18 said that R8 only requires one to one monitoring if presenting with exit seeking behavior. On 4/14/23 at 3:40PM, V43(CNA) said staff are monitoring the dining room when residents are present. V43 said he was not assigned to the dining room at time of R8's incident but assisted the nurse with transferring R8 back to wheelchair. R8's incident report dated 1/24/23 documents: Resident had witnessed fall in his room, the Certified nursing assistant was preparing the residents bed and instructed to stay still on his wheelchair when suddenly fell to the floor as he was trying to stand from his wheelchair, the resident struck his head in the floor. Under resident description: resident stated he did not know what happened. Under action taken: put pressure to stop bleeding on the lacerated wound. R8 final report dated 2/1/23 documents under occurrence: Resident had a witnessed fall when he suddenly stood up from his wheelchair as the CNA was preparing to transfer him from his wheelchair to his bed at bedtime. Resident stated that he did not know why he self-transferred without waiting for assistance. R8's hospital record dated 1/24/23 documents: witnessed fall from wheelchair. Patient stood up and lost balance, falling forward into floor, laceration to left eyebrow. 3 cm jagged scar above left mid and lateral eyebrow from last time. Has new depth wound 4cm medial to this with bleeding, depth to muscle. Under procedures documents: laceration repair 4 cm laceration was repaired using 4 x 4.0 nylon suture. On 4/8/23 at 4:35PM, V8(CNA) said she was assisting R8 to go to bed. R8 was in his wheelchair next to the bed when he suddenly got up and fell hitting his head in the floor, while she was fixing the bed. V8 said no one else was in the room with her at time of incident. R8's plan of care date initiated 1/12/22 documents chair to bed transfer 1 assist, may require 2 person assist. R8's care plan initiated on 5/3/22 revised 2/6/23 documents: I am wanderer related to exit seeking. Impaired safety awareness. Interventions: one to one with staff. R8 is at risk for falls and injuries related to falls. Risk factors: requires assistance with activities of daily living, possible medication side effects, incontinence, stroke, dementia, history of falls. Low back pain, lack of coordination, abnormal gait and posture initiated on 1/11/22 and revised on 2/3/23; interventions dated 1/13/22: assess for altered cognition, decline in safety awareness, assess for pain; physical therapy and occupational therapy to evaluate and treat, orient to environment, observe, report unsafe conditions, interventions dated 1/13/23 therapy to evaluate upon readmission, continue to educate resident to ask for staff assistance, monitor for syncope, assess for pain. 2. R10 - R10 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, abnormalities of gait and mobility, lack of coordination, type II diabetes, arthritis, and pain in left leg. R10 brief interview for mental status score dated 1/3/23 documents a score of 15/15 which indicates cognitively intact. R10s Minimum Data Set, dated dated dated [DATE] under functional status documents: Transfer- how resident moves between surfaces including to or from bed, chair, wheelchair, standing position(excludes bath/toilet) documents a score of 3 under self-performance which indicates extensive assistance- resident involved in the activity, staff provide weight bearing support; under support documents a score of 3 which indicates two person assist. Under balance from surface-to-surface transfer (bed to chair or wheelchair) documents a score of 2- not steady only able to stabilize without staff assistance. On 4/6/23 at 11:30AM, R10 who was alert and oriented at time of interview, said staff transferred her without hoyer lift and she fell . R10 said a female staff was going to transfer her to her wheelchair by herself. R10 said she told the staff she needs a hoyer lift but staff did not listen and said they could transfer R10 to the chair by themselves. R10 said she ended up on the floor in pain and was sent to the hospital. R10 said she did not have any serious injuries from fall. On 4/11/23 at 12:18PM, V18(ADON) said they are unable to identify the staff member that was assisting R10 during transfer at time of fall. R10's fall risk dated 1/3/20 documents at risk for falls. R10s incident report dated 2/24/23 documents: Writer was notified by staff after transferring resident to wheelchair her feet started sliding and she slid down; resident description documents: after transferring to my chair I started sliding down. Under mental status documents oriented to place, time , person and situation. R10's physical therapy discharge summary dated 12/31/22 documents: Transfer dependent. Under recommendations: transferring to wheelchair using hoyer.

Based on interview and record review, the facility failed to ensure a resident drank fluid to stay hydrated. This affected 1 of 3 (R4) residents reviewed for hydration. This failure resulted in R4 being hospitalized and treated for hydration with a 1500ml bolus of fluid. Findings include: R4 had the diagnosis of Dementia, hemiplegia and hemiparesis and dysphagia and a lack of coordination. Minimal data set dated [DATE] documents; R4 requires extensive assistance with one person physical assist with eating. R4's laboratory results dated [DATE] documents BUN 127 (Critical) Reference range 7-28mg/dL. On 4/19/23 at 10:43, V75 (Certified Nurse Assistant, C.N.A.) said, I did not measure the amount fluid I gave R4. I was instructed to put the amount of fluid the pitcher held. Point of care charting dated February 20/21, 2023 documents: No fluid was given for the day and evening shift. 400 ml was given on the night shift for 2/20/23 and 200ml was given on the night shift on 2/21/23. Emergency Department notes dated 2/21/22 - Chief complaint lab abnormalities. BUN high. R4 had a blood urea nitrogen (BUN) was 127. R4's mouth: mucous membranes dry. R4 endorsed not feeling well Fluids were given for dehydration. Sodium chloride 500milliters (mL) and Lactated ringers 1000 Ml *fluid bolus* was infused. Water Pass- Hydration dated 11/28/12 documents: To provide fresh drinking water to residents in a clan and sanitary manner to meet hydration needs.

Based on observation, interview, and record review, the facility failed to identify that an air mattress power cord was damaged while in use (the cord was frayed with exposed wires). After a loss of power in resident room, facility staff proceeded to plug in the damaged cord into another outlet across the room, where the power proceeded to go out a second time after a visitor stepped on the cord that was going across the room floor and experienced electrical shock. The facility failure to identify that the damaged cord was continuing to be used had the immediate potential to affect two (R25 and R26) residents residing in the room, putting them at risk of fire hazard/injury. (R26) is ambulatory and at risk for injury. The Immediate Jeopardy began on 2/7/23. V1 (Administrator) was notified on 2/14/23 at 11am of the Immediate Jeopardy. The facility presented a removal plan on 2/14/23 at 3:57pm. The plan was accepted, and on 2/15/23 the surveyor conducted onsite record reviews and interviews to confirm the removal plan was implemented. V1 (Administrator) was informed that the Immediate Jeopardy was removed on 2/15/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: R25 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included Morbid obesity, Pressure Ulcer of left heel Stage 3, Major Depressive Disorder, Hypertension and Anxiety Disorder. According to MDS (Minimum Data Set) assessment dated [DATE], R25 requires Extensive physical assistance for bed mobility and transfers. R26 is a [AGE] year old woman admitted to the facility 1/20/23 with diagnoses that include, Immune Thrombocytopenic Purpura, Unsteadiness on Feet and Hypokalemia. R26's medical records were reviewed. MDS dated [DATE] notes that R26 ambulates with supervision without the use of ambulatory devices. According to progress notes dated 2/7/23, R26 was out at appointment during the day shift. R25 and R26 share a room. On 2/7/23 at 11:43AM Surveyor entered R25 and 26's shared room and observed an electrical cord extending from R25's bed to an outlet across the room. R25 was lying in bed on an air mattress and was wearing a nasal cannula via an oxygen concentrator. Once surveyor identified self as an IDPH worker, R25 frantically began speaking about events that occurred just prior to the surveyor entering the room. R25 said, I am very upset! The power went out in my room and was out for an hour, until finally the wound care nurse came in. He had to call maintenance and tell them that I was on an air mattress for my wounds and that it was a medical emergency. While the CNA (Certified Nursing Assistant) was giving me a bed bath, the power went out suddenly. The TV's shut off, the concentrator went out, and the mattress went out. It happened between 10am to 11am. The CNA told the nurse who came in and gave me some medicine. Later, the wound care nurse came in and told maintenance. The power was re-set, and everything came back on. They never moved me off of the bed at all. The mattress is hurting me because it isn't inflated all of the way and it is hurting my back. I wear the oxygen as needed. While still in R25's room at approximately 12:00PM, surveyor was completing interview with R25 and accidentally stepped back on an electrical cord powering R25's air mattress. Immediately, there was a flash of light, small puff of smoke, and surveyor received an electric shock to the body. R25 was lying in bed and power loss was observed to the oxygen concentrator, the television, and the air mattress, which began to deflate. After R25 verbalized she was unharmed, surveyor noted that the electrical cord on the floor had wires that were exposed. Shortly after, V15 CNA entered the room, saying it was because the call light activated outside the room. V15 went to deactivate the call light on the wall in between the beds and said that the light wasn't on in the room but was on outside the room. R25 notified V15 that the power went out again and V15 went to get the nurse. Surveyor went to R26's bed, pressed the remote buttons to move the bed and assessed that there was no power. R26's cords were plugged up behind the bed. At 12:04PM, V49 RN came into the room with V15 saying that V15 CNA notified her of the power outage. R25 informed V49 that the power went out again and mentioned the electrical cord. V49 picked up the cord close to the bed and surveyor informed V49 to be careful and that it had caused a shock. V49 viewed the cord and verbally identified wires were exposed, and hesitantly unplugged from the wall outlet. At 12:05PM V15 CNA said, I was here when the power went out earlier. I told the receptionist and a nurse about it and I didn't follow up to know what happened because I was in another resident's room. V49 RN said, another nurse on the floor let me know about the power outage because I was caring for another resident. By the time I came in to give R25's medication, the power was not out. I saw that the air mattress was back on and I didn't bother with it. We are going to get her up now, so that we can change the mattress and the pump. R25 and V15 prepared to get R25 up, and R25 attempted to sit on the side of the bed to get in the wheelchair but requested to V15 that they get the mechanical lift. At 12:12PM V49 RN said, I am the assigned nurse for R25 today. I knew the power was back on in the room because maintenance came to tell me that it was. At 12:30PM V23 Maintenance Director was asked how often he made rounds to resident rooms and he said, I walk through the units every day and I fix things if a request is made. I get stopped in the hall and am notified verbally, by text message, or by the maintenance request logs. I have one other person working as my assistant. I review the logs daily. V23 was asked about the power outage in R25 and R26's room and V23 said, somehow the power tripped in the room and the breaker went off. I flipped the breaker, and I went into the room and checked for frayed cords. I checked the blow up mattress and TV cords and they were okay. I don't know what caused the issue because I'm not an electrician. The pump was plugged into the outlet by the foot (across the room); No, it was not plugged into the outlets by the headboard behind the bed. The issue has since been resolved because the power came back on. I wouldn't expect for the power to go out twice, if it continued, I would call the electrician. We have already switched the mattress pump out for R25. We do check cords to see if they are damaged and it would be my responsibility to make sure of that. At 2:45PM R25 was observed in room, on a different bed and mattress. At 2:51PM V48 RN was asked about their knowledge of the power outage in R25's room and said, the wound care nurse told me there was no electricity on R25's side. When I went in, I unplugged the cord from the outlet behind the bed, thinking that the outlet was not working and plugged it in across the room. The power was back on, and I called maintenance right away, who told me that it was a short circuit and he had to go to the fuse box to get it working. I didn't notice anything wrong with the electrical cord. At 2:56PM V49 RN was interviewed again and said, after the second power outage, maintenance came to remove the pump and the air mattress. When I was in the room at that time, I saw there were naked wires on the electrical cord and the mattress was deflated so the CNA and I put R25 to the chair, they came and replaced it and we waited for it to inflate. On 2/15/23 at 2:14PM V2 Assistant Administrator said, we don't have any monthly resident room inspection results or inspection schedules available to be reviewed. The facility provided a policy titled Preventive Maintenance and Inspections undated, which stated in part; Preventative maintenance is the care and servicing by personnel for the purpose of maintaining fixture, equipment and facilities in a satisfactory operating condition by providing for systematic inspection, detection, and correction of incipient failures either before they occur or before they develop into major defects. Maintenance includes tests, measurements, adjustment, and part replacements that are performed specifically to prevent faults from occurring; Each resident room will be inspected and documented monthly. Facility provided user manual for air mattress and pump (undated) which states in part; Warning- to reduce the risk of burns, electrocution, fire or injury to persons: 5. Never operate this product if it has a damaged cord or plug, If it is not working properly, if it has been dropped or damaged, or dropped into water. Return the product to a service center for examination and repair. 12. Connect this product to a properly grounded outlet only. Grounding Instructions: Danger- Improper use of the grounding plug can result in a risk of electric shock. If repair or replacement of the cord or plug is necessary, do not connect the grounding wire to either flat blade terminal. The wire with insulation having an outer surface that is green with or without yellow stripes is the grounding wire. Note- If the repair or replacement of the cord is necessary, please contact a qualified electrician or serviceman. To reduce the risk of electric shock, do not modify the cord or plug in any way. Check with a qualified electrician or serviceman if the grounding instructions are not completely understood, or if in doubt as to whether the product is properly grounded. United States Department of Labor - (OSHA) Occupational Safety and Health Administration webpage discussing Electrical - Hazards / Flexible Cords, reads: A flexible cord may be damaged by door or window edges, by staples and fastenings, by abrasion from adjacent materials, or simply by aging. If the electrical conductors become exposed, there is a danger of shocks, burns, or fire. On 2/15/23, the surveyor verified by observations, interviews, and record review that the facility implemented the following to remove the immediacy: 1. Device in question (Air Mattress Pump) was removed from the room immediately following the occurrence. Initiated and Completion Date 2/7/23 2. Preventive Maintenance Policy has been reviewed and revised 2/14/23. Completion Date 2/14/23 3. Staff will be in-serviced by Administrator or designee on recognizing damaged cords, to report them and to remove from power source, and replace with a properly working unit. After the completion date all prn, part time, agency, contract and on leave staff will be re-educated prior to next scheduled shift. Maintenance will be notified of any/all devices that are not properly working. Initiated on 2/14/23 and Completion Date 2/15/23 4. Maintenance will be in-serviced on the preventive maintenance policy by Aperion Care Regional [NAME] President of Operations. Completion Date 2/14/23 5. A facility wide search will be conducted for all air mattresses to ensure all cords attached to the pump are intact with no deficiency's (ex: no cuts, frayed wires, exposed wires) by Maintenance Supervisor or designee. Initiated and Completion Date 2/14/23 6. Facility reviewed its orientation process and verified that all Maintenance Employees will be trained on Preventive Maintenance by the facility Administrator. The orientation program was developed by corporate legal and compliance officer. No Maintenance staff will be allowed to work without preventive maintenance training. Initiated and Completion Date 2/14/23 7. The Facility Maintenance Supervisor will conduct Daily or when in use Audits to ensure that air mattresses are intact with no deficiency per the Preventive Maintenance Policy. Initiated on 2/14/23 and Completion Date Ongoing 8. The Facility Administrator will collect the Daily or when in use audits from the facility Maintenance supervisor to ensure that all air mattresses are intact with no deficiency. QA tool titled Daily/When In Use Preventive Maintenance on Hospital Bed reviewed. Initiated on 2/14/23 and Completion Date Ongoing 46344 2. Based on interview and record review, the facility failed to have fall interventions in place per the resident's plan of care by not ensuring that bed rails were in place for resident use to aid in repositioning and they failed to ensure that bed and side table were locked to prevent them from sliding. This failure applied to one (R15) of one resident reviewed for bed rails and resulted in R15 falling out of bed and sustaining a laceration to the right eyebrow and continuing to experience pain related to the injury of the left shoulder since the fall. Findings include: R15 is an [AGE] year old male who was originally admitted to the facility on [DATE] and still resides in the facility. R15 has multiple diagnoses including but not limited to the following: hemiplegia, CHF, type II DM, prostate cancer, AFib, HTN, depression, abnormalities of gait and mobility, unsteadiness on feet, intestinal obstruction, hyperlipidemia, anxiety, anemia, and GERD. On 1/30/23 at 12:40 PM, R15 was interviewed regarding the falls he had in the facility. At this time it was observed that two quarter side rails were in place on R15's bed. R15 said he has had two falls while at the facility. R15 said his most recent fall was on 12/28/22, he was reaching for something on his bed side table on the left side of his bed. The bed side table rolled away and he fell off the bed. R15 said, the bed side drawer was open and I hit my head on the side table drawer. I attempted to grab on to something but there was nothing there to grab hold of. R15 demonstrated how he uses the side rails for bed mobility and to assist with transferring. R15 says since this fall he has had pain in his left shoulder and at this time rates his pain 8/10. At night time, his pain will get as bad as a 9-10 and it prevents him from sleeping. R15 said that on 12/16/22 he had another fall where he slid out of the bed. R15 said he was attempting to reposition himself in bed when the bed slid out from underneath him due to the bed not being locked. Review of R15's medical record includes Emergency Department Provider Note, which states in part but not limited to the following: Patient endorses head and neck pain following fall. Patient reports headache and lower back pain. Patient states when he hit the floor he had right-sided head bleeding. Review of systems: Skin: abrasion right side of head. On 2/1/23 at 11:00 AM, V17 (Licensed Practical Nurse) was interviewed regarding R15's fall on 12/28/22. V17 said I was the nurse on duty during R15's fall on 12/28/22. V17 said, I was notified by a staff member that R15 was on the floor. When I went in R15's room he said that he was sitting on the side of his bed, he reached for an item on his bedside table, and the bedside table rolled away. He slid down the bed and hit his head. There was no side rail on the left side of his bed because he had stated that he attempted to grab onto something to stop his fall and there was nothing there. Side Rail assessment dated [DATE] states in part but not limited to the following: Benefits of bed rail use: increased bed mobility, increased transfer ability, increased independence for self-care during rehabilitation; Least restrictive rail device that is appropriate for this resident: quarter rail: right, quarter rail: left R15's care plan with initiation date of 10/25/2022 states in part but not limited to the following: Focus: I have been assessed to need bedrails: quarter rail-right, quarter rail-left. Goal: I will benefit from side rails and have increased bed mobility, no adverse outcomes, safe transfers, independent turn and reposition. Focus: I am at risk for falls and injury related to falls. Goal: I will have interventions in place and reviewed as needed to address risk for falls and injury related to falls through next review. Interventions: Assist with ADLs as needed. Anticipate and meet the resident's needs. Ensure a safe environment with personal items within reach. Ensure the bed is in lowest position with wheels locked. 2/1/23 at 2:26 PM, V37 (Restorative Nurse) was interviewed regarding R15's fall on 12/28/22. V37 said, I am responsible for completing the side rail assessments. From there, if a resident is appropriate for side rails, I let maintenance know and they install them. Side rails are used to help with positioning, transfers, and to provide stability. At 3:00 PM, V23 (Maintenance Director) was interviewed regarding side rails. V23 said when a side rail needs to be installed on a resident's bed, restorative will notify me. This is typically done by word of mouth. We do not keep any logs or records when a side rail needs to be installed. At 3:10 PM, V34 (Certified Nursing Assistant) said side rails are used to help prevent the residents from falling. Side Rails/Bed Rails policy with revision date of 10/24/2022 states in part but not limited to the following: Purpose: To ensure the appropriate, safe and correct installation, use, and maintenance of bed rails. Fall Prevention Program policy with revision date of 11/21/27 states in part but not limited to the following: Purpose: To assure the safety of all residents in the facility, when possible. Fall/safety interventions may include but are not limited to: The bed locks will be checked to assure they are in the locked position at all times. The resident's personal possessions will be maintained within reach when possible. These items include tissues, water, drinking glass, and phone.

Based on observation, interviews and record reviews, the facility failed to follow their abuse policy and procedure in preventing and protecting residents from verbal and physical abuse. This failure affected seven (R5, R6, R9, R10, R12, R18, and R20) of eleven residents reviewed for abuse. This failure resulted in R5 being hit with a cane by R6 and sustaining a laceration on the left side of head and closed fracture of the distal left ulnar shaft requiring surgical repair; R9 was hit by a staff member and sustained a hematoma to the forehead and was sent to the hospital for further evaluation; R10 was struck by another resident with a motorized wheelchair and sustained a scratch and swelling to his right foot; R12 was cursed out, accused of stealing personal belongings, and was struck on the hand and foot causing an abrasion; and R18 experienced abuse by a staff member who poured hot and cold water on R18, while pushing him around while in his shower chair. Findings include: R5 is a [AGE] year old, male, admitted in the facility on 07/11/2022 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Schizoaffective Disorder, Bipolar type; Major Depressive Disorder, Recurrent, Unspecified and Anxiety Disorder, Unspecified. According to MDS (Minimum Data Set) dated 01/01/2023, R5 has BIMS (brief interview for mental status) of 13, which means little to no impairment in cognition. Incident report dated 01/12/23 documented that R6 struck R5 with his cane on his left arm and left side of his head. R5 stated his roommate hit him with his cane on his head and arm. R5 stated his roommate's (R6) table was in his way and when he moved it that R6 got up and hit him with his cane. On 01/30/2023 at 1:54 PM, R5 was in his room, lying in bed, with soft cast on left hand covered with a bandage. R5 is alert and oriented, was asked on what happened to his hand. R5 stated he does not remember what happened. R5 was also asked if he had any incident with another resident that he was hit with a cane. R5 stated that there was none. Per R5's progress notes dated 01/12/23, time stamped 8:36 PM, documented: R5 touches roommate's (R6) table ending up things on the floor. Roommate (R6) got upset and had exchange words and roommate (R6) hit him with a cane on the left side of his head and left arm. On 01/31/23 at 3:47 PM, V30 (Licensed Practical Nurse, LPN/Supervisor) was interviewed regarding R5 and incident on 01/12/23. V30 stated, A couple of weeks ago, I was called to the floor, went to their (R5 and R6) room. They were roommates. It was reported that they had a physical altercation. R5 was in the washroom washing his hands and was asked on what happened. He (R5) showed me a cut on the forehead and bruise on his left arm. He said R6 hit him with a cane. I asked why, he said that he tried to get the remote control on the table to turn down the TV. I cleaned his forehead because of the cut and asked if he has any pain. He denied any pain, dried the cut and applied antibiotic. I moved him to another room. I went to R6, asked what happened. He (R6) admitted that he hit R5 with his cane because he (R5) moved his table and everything went to the floor. Then I told him (R6) that if he had issues with another resident to call nurse or call for help. For R6, it was the first time. For R5, he always complained about his roommate's television volume. Progress notes dated 01/14/23 recorded that R5 was experiencing left lower arm pain, X-ray to left arm was taken. X-ray result dated 01/15/23 documented: X ray left radius/ulna, AP (anterior posterior) and lateral Impression: Minimally comminuted acute fracture of the distal left ulnar shaft. Progress notes dated 01/16/23 documented that R5 was sent to the hospital and was admitted with diagnosis of fracture. Hospital records dated 01/15/23 recorded: Diagnoses: Assault, Closed fracture of upper end of left arm. Admission History and Physical also recorded: Chief Complaint: Left elbow pain HPI (History of Present illness) - [AGE] years old, male (R5) with Stage 4 lung cancer with metastasis to cervical spine s/p (status post) chemo (in remission), and epilepsy who presented to the ED (emergency department) after injury sustained at NH (nursing home). Patient (R5) was hit with a cane by co-resident at NH, resulting in head and ulnar injury. He presented to the ED two days later. In ED, hemodynamically stable, breathing well on room air, afebrile, CT (computed tomography) head with no acute intracranial abnormality. Imaging notable for left distal ulnar diaphyseal fracture, ortho team was consulted and requested preop clearance prior to surgical intervention. Orthopedic Surgery Date of Service: 01/16/23 - Procedure Performed: Open reduction internal fixation of the left distal ulnar shaft fracture On 01/31/23 at 12:01 PM, V10 (Social Services Director) was asked regarding R5 and R6 incident on 01/12/23. V10 replied, I learned about the incident the night after it happened. That he (R5) was touching his (R6) personal belongings, and he (R6) just hit him (R5) with his (R6) cane. They were separated. They are both alert and oriented. R5 has a behavior of touching peer's belongings. It was addressed prior to the incident, it was care planned. We just need to encourage him (R5) to engage in activities and encourage him (R5) not touch peer's belongings. R5's care plan on Behavior problem with touching my peer's belongings was only initiated on 01/13/23. There was no other care plan created prior to 01/12/23 related to any of R5's behavior. V6 (Patient Relations) was interviewed on 01/31/23 at 9:02 AM regarding R5 and R6. V6 verbalized, They were roommates before. They shared the same model of television (TV). They both have the same remote. R5 grabbed R6's remote by mistake. I don't remember, maybe two weeks ago, they paged me. I went to the room. R6 said his TV remote was not working thinking R5 had his remote. I went to R5 and asked if he had his (R6) remote and was told he (R5) does not watch TV. I told him that there used to be two remotes and now there was one but not working. R5 said he had put it in his bag, his remote and R6's remote. So he (R5) gave me the little duffel bag, I found both remotes. So I told him (R5) if he could give back his (R6) remote and he said yes, that was it. I left the room. Throughout the whole thing, he (R6) stayed on his side and so was R5). It was morning shift when this happened. R5 actually was not on good terms with his former roommates because he (R5) said that TV was loud, so we gave him a room change. Again, he (R5) had an issue with TV being loud, so he (R5) was moved again, with R6. Next day, they had the remote issues. I resolved the remote issue and there was no problem afterwards. I don't have any documentation for this remote issue. Per census report, R5 was moved to R6's room on 01/10/23. Therefore, the incident with R6 related to TV remote happened on 01/11/23. On 01/30/23 at 1:42 PM, R6 was asked regarding incident with R5. R6 stated, I did hit him, I don't know his name. One day, he took my TV remote and put it in his drawer. V6 knew, he helped me get back my remote. Then, all of a sudden, he knocked my table and we argued. He was trying to reach something from his bag, thought he is going to get something, so I took my cane and hit his left arm and hand. According to progress notes dated 01/12/23 at 12:02 PM, R6 notified V17 (LPN) of concerns with roommate (R5) touching his belongings when he steps out of the room. V17 mentioned during interview on 01/31/23 at 2:20 PM, On 01/12/23, R6 notified me that when he steps out of his room, R5 touched his belongings. I mentioned it to V1 (Administrator), V3 (Director of Nursing) and Social Services. I talked to R5 and R6 and notify management. It was during morning shift that he (R6) told me about him (R5) touching his belongings. On 02/01/23 at 9:22 AM, V2 (Assistant Administrator) was interviewed regarding abuse investigation and incident between R5 and R6. V2 replied, I am not the Abuse Coordinator, V1 (Administrator) is. I do the majority of the investigation together with team V1, V3 (Director Of Nursing) and V4 (Assistant Director Of Nursing) to get statements. Regarding R5 and R6 incident, it occurred on 01/12/23. It was reported that R6 hit R5 with his cane on his left arm and left side of his head. They were separated immediately. R6 was moved to another room. they were both assessed for injuries. He (R6) does not have any injuries. R5 had a cut on the left side of his head and fracture on the left ulnar. He (R5) was sent out to the hospital. Xray was taken due to him (R5) complaining of pain on the left hand. R6 was sent out to the hospital for psychiatric evaluation. Not to my knowledge that there were prior incidents that happened between the two. R6 was triggered by R5 because he (R5) reached for his (R6) cane that is why he (R6) struck him (R5) with his cane. He (R6) was sitting in his chair when R5 moved his (R6) side table, verbal altercation occurred and R5 attempted to grab his (R6) cane but he (R6) struck him with the cane. The verbal altercation issue was he (R5) wanted to turn down the volume of his (R6) TV. To my knowledge, that was the first time it happened to both of them. Not to my knowledge that there were prior reports or issues regarding TV remote on both residents. On 02/01/23 at 11:58 AM, V3 was asked if regarding R5 and R6. V3 verbalized, Prior to 01/12/23 incident, I was not aware of any issues going on between them. I am not aware of any behavior issues on R5 and R6. On 02/01/23 at 2:40 PM, V4 was also interviewed regarding R5 and R6, stated, I was not aware of any issues going on between them or any behavior concerns for the two residents.' V1 was interviewed on 02/01/23 at 12:21 PM regarding abuse and incident between R5 and R6. V1 verbalized, I am the Abuse Coordinator, I investigate allegations on abuse and follow our policy and procedures regarding abuse prevention. All staff, including all CNAs (Certified Nurse Assistants), nurses, patient relations, management, dietary, everyone is trained throughout the year on abuse. Regarding R5 and R6, the incident happened on 01/12/23. V2 and myself did the investigation. It was reported that R6 struck R5 with his cane. R5 had mild pain on the left hand, fracture to his left ulnar and cut to his left side of head. We believed it was caused by being struck by R6's cane. I talked to him (R6), said he was sitting in his wheelchair and he (R5) pushed over the end table. He (R6) asked him (R5) why he did that. R5 said it was on his (R5) side. He (R5) also said what R6 is going to do with his (R6) cane. R5 attempted to grab the cane and that is when he (R6) struck him with the cane. I am not aware of any incidents or any issue going on between these two residents prior to the 01/12/23 incident. With what happened to these residents is considered physical abuse. There was no documentation regarding incidents on 01/11/23 regarding TV remote. There was a documentation on 01/12/23 during morning shift when R6 reported his concern on R5 touching his belongings, but it was not addressed. On 02/01/23 at 1:10 PM, V31 (Nurse Practitioner) was asked regarding R5 and R6. V31 stated, I was informed about their physical altercation, don't remember when. That R6 got mad at R5 for invading his space, he (R6) hit him (R5) with his (R6) cane, on R5's left side of head, left arm, left thigh, left side. I don't think R6 got hurt but R5 had a cut on his head, and fracture of the left arm. The cause of the fracture was the cane because he (R6) hit him (R5). R5 said he was moving his (R6) table and thought he (R5) was in his (R6) space. R5 does not have any behaviors, never heard anything like that. He is awake and alert majority of the time and has some forgetfulness, occasional confusion and he has seizure disorder and cancer. No behavior. No problems whatsoever. R6 is a long-term patient, known to be aggressive. He had a roommate prior to R5. The roommate was R10. He (R6) got mad because I was told that he (R10) was touching his stuff and got angry and pushed him, shoved him with his motorized wheelchair. R10 is very, very confused but never been in any physical altercation. As far as I knew, it was addressed. There are a lot of things going on in the floor that staff are not telling me about. I would assume staff on the floor knew their behaviors. R6's Physician Progress note dated 12/08/2022 recorded: Discussed with patient (R6) argument patient had with roommate (R10). R6 states he just made him get away from his belongings. That the other patient kept trying to take his things. He is not normally aggressive. R6's Behavior/Mood Charting assessment dated [DATE] documented he was verbally and physically aggressive, behavior triggers include others entering their personal space (getting too close) or their room; other resident yelling, cursing or verbal aggression directed at them. Mood exhibited included repeated verbalizations, displayed anger with self/others, agitated/easily upset. There was no care plan initiated addressing R6's aggressive behavior upon further review of R6's medical records. On 02/01/23 at 4:40 PM, V38 (Psychiatrist) was interviewed regarding R5. V38 stated, I have been seeing R5 since July 2022. He came from the hospital, Psychiatric Unit. He has Schizophrenia, lung cancer. On 01/25/23, I saw him. He is alert, oriented to place, cognitively declined, unable to make decision, little bit withdrawn and has a flat affect. I don't think he has unusual behavior. I was informed that he was assaulted by another resident. I come to the facility every week. He is usually in his room, sits on his bed, try to sleep at night because he sleeps during the day. I don't think he (R5) would be aggressive, not likely. If another resident is verbally aggressive, I don't think he (R5) will react violently. Approaches or interventions that could help him (R5) be prevented from abuse are to reinforce him (R5) to come out and ask for help if having problems or issues with roommates since he has Dementia and might not remember what to do at times; if placing or moving him (R5) to another room, consider who the roommates would be. Whether his roommate has any unusual behavior towards other residents. His roommates should be assessed and observe for any aggressive behavior. V1 also mentioned, Any precipitating behaviors of resident in terms of acting out verbally, physically should be reported to Social Services and addressed it by notifying the doctor, initiating care plans and assess interventions for effectiveness. 40920 2. R9 is a [AGE] year-old female who was admitted to the facility on [DATE] with past medical history including, but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia, pneumonia due to coronavirus disease, unspecified lack of coordination, dysphagia oropharyngeal phase, hematuria, anxiety disorder, aphasia, etc. 1/29/2023 1:00PM, R9 was observed in her room in bed sleeping and unable to awaken to her name. Room was noted to be cluttered, bed not on low position, no floor mats noted on both sides of the bed, resident had half bed rails on both sides of the bed. No call light was noted by resident or within reach. 1/29/2022 at 2:35PM, R9 was observed in her room, awake, but unable to answer any questions. Resident's call light was still not within reach and still tied under the mattress. Observed a high back wheelchair at the bedside, with urinary catheter, noted in a privacy bag and half side rails were noted on both sides of the bed and lowered. Facility abuse risk assessment dated [DATE] coded resident with a score of 0, indicating low risk for abuse. Facility reportable dated 12/12/2022 documented that R9 was allegedly abused by a staff member identified as V29 (C.N.A) investigation was initiated and will continue. The same reportable stated that resident was interviewed about the incident and she shook her head yes and gestured her hand to her forehead and whispered, the C.N.A, the one that changes me. The document states under actions for other residents who could be affected that staff member is suspended until investigation is completed. The investigation was signed as completed on 12/16/2022. 1/31/2023 at 1:49PM V1 (Administrator) said that the allegation between R9 and V29 (C.N.A) was unfounded, R9 had a bump on her head but the source is undetermined. V1 said he is not sure of resident's need, but she is probably dependent on staff, he is not sure if V29 has been named in another allegation, she was the assigned C.N.A for R9 on the day of the incident, she may have been called back to work before the other incident. Surveyor asked V1 if staff on suspension could be called back before the investigation is over and he said, sometimes you can call them back, it is done on a case-by-case basis. V1 said that V29 no longer work at the facility, she was terminated for breaking rule #7 of the union code. Surveyor pointed out to V1 that the rule #7 was documented as abusing a resident or another staff, so was V29 terminated based on this, he said Yes. V1 added that there is no proof that V29 abused resident, but she was terminated anyway. V1 was asked if it is the facility practice to terminate staff without proof and he said that it is determined on a case-by-case basis. 1/31/2023 at 2:54PM, V8 (Social Services) said that she is aware of the incident involving R9 and a staff, she was informed that the C.N.A supposedly hit the resident, she was shadowing her supervisor (Social Service Director) at that time and helped her with completing the incident report. V8 added that her supervisor spoke to the resident, she was not present and not sure what the resident said. 1/31/2023 at 3:07PM, V10 (Social Service Director) said that the C.N.A involved in the abuse allegation no longer works at the facility, the resident shook her head yes when she was asked about the incident, and she showed how the incident occurred by winging her hand to her head. V10 stated that herself, the nurse practitioner, and the administrator interviewed resident and she confirmed that the incident happened. V10 said that resident had a bruise to her forehead, she spoke to the daughter who was very upset, and said that she was filing a police report due to the incident. 2/2/2023 at 1:13PM, V41 (Wound Care Nurse), said that he went to do an admission assessment with R9's roommate when R9 motioned him to her bed, she was pointing to her head, she asked her if she have a headache and resident said no, he asked her if she was hit she nodded yes, V41 asked R9 by your nurse and she nodded her head no, he then asked by your C.N.A and she nodded yes. V41 said he then reported to the nurse supervisor who told him to report to the administrator (V1). 2/2/2023 at 2:45PM, V42 (Nurse Practitioner) said that she is familiar with R9, her daughter showed V42 a video of what happened that she recorded in the emergency room , the resident nodded yes when she was asked if she was hit by staff. V42 stated that she saw the resident, did not notice any physical evidence, resident is aphasic and does not have a clear speech, she can only nod yes or no. V42 said that yes when herself, the administrator and another staff went to see her, the abuse was founded, the staff no longer work at the facility because that is unacceptable. 3. R18 is a [AGE] year-old male who has resided at the facility since 9/30/2022 with medical history including, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, major depressive disorder, lack of coordination, essential primary hypertension, muscle weakness, etc. On 1/30/2023 at 12:45PM, R18 was observed in his room in his motorized wheelchair, awake, alert and oriented and stated that he is doing okay. R18 stated that he recalls having an issue with a staff member, she was angry with him because he had a bowel movement. The staff kept on pouring hot water and cold water on him and pushing him around while in his shower chair. R18 said that he reported the issue to staff and called the police, a police report was done. Facility reportable dated 12/14/2022 documented that the same staff member V29 (C.N.A) was involved in another abuse investigation with R18. R18 alleged that V29 was being rough with him while assisting him with ADL care. Police report (#) documented on the reportable. Further review of the reportable indicated that the C.N.A (V29) was interviewed on 12/14/22 during the investigation. This investigation was concluded on 12/19/2022. 40718 4. R10 is an [AGE] year-old male with a diagnoses history of Dementia, Major Depressive Disorder, Hearing Loss, Epilepsy, History of Falling, and Spinal Stenosis who was originally admitted to the facility on [DATE]. R10's progress note dated 12/6/2022 documents: Around 9PM while V7 (Licensed Practical Nurse) was walking along the hallway, he witnessed two residents up against each other's wheelchair in their room. V7 called the floor staff to separate the two. Assessed both residents for injuries. R6 denies any pain, however when the writer assessed R10, he observed that his right foot has a minor scratch on the dorsal section. Resident was moved temporarily to another room. The family member was notified and explained the situation. R10's Physician progress note dated 12/07/2022 documents: he was seen for right foot pain; Patient was recently struck by another patient in his motorized wheelchair. Patients right foot mildly swollen but no bruising or malformation seen. Will obtain X-rays to verify no fracture or dislocation. Encouraged patient to use analgesic if he feels he needs it; assessment and plan for x-rays of right foot 3 views. R10's Current Care plan initiated 08/26/22 documents he is at risk for abuse/neglect related to Dementia, history of physical abuse with interventions initiated 08/26/22 including observe resident in care situations; Observe resident when in company of peers. R10's care plan initiated 08/17/2022 documents he has cognitive impairment and experiences disorientation to time and has problems with recall/periods of confusion, which is related to a diagnosis of dementia with interventions including: provide me with orientation/grounding information (verbal, description) information throughout the day to help me increase my comfort level and awareness of my environment. On 02/01/2023 from 9:41 AM - 09:43 AM R6 stated in December while he and R10 were both ambulating in their wheelchairs in opposite directions, R10 observed R6 reach for hismcane and stated what are you about to do with that stick? R6 stated R10 then grabbed R6's wheelchair remote control and pulled it. R6 stated he then began pushing R10 out of the room so he can get staff to come and remove R10. R6 stated V7 (Licensed Practical Nurse) had observed him and R10 during this time when their wheelchairs were in contact with each other and had another staff remove R10. R6's Physician Progress note dated 12/08/2022 documents Discussed with patient argument patient had with roommate. R6 states he just made him get away from his belongings. That the other patient kept trying to take his things. He is not normally aggressive. R6's Behavior/Mood Charting assessment dated [DATE] documents he was verbally and physically aggressive, behavior triggers include others entering their personal space (getting too close) or their room; other resident yelling, cursing or verbal aggression directed at them. Mood exhibited included repeated verbalizations, displayed anger with self/others, agitated/easily upset. Location of occurrence was resident's room. Physician and family notified. On 01/31/2023 from 09:19 AM - 09:25 AM V6 (Patient Relations) stated R10 and R6 shared a room and R10 was in bed one. V6 stated R6 was irritated with R10 constantly calling out for the nurse so R10 was moved out of the room. V6 stated R6 has been in the facility for [AGE] years and has been in his current room the entire time so he feels he has seniority. V6 stated R6 was moved from his room January 12 due to an altercation with another resident. On 01/31/2023 from 10:23 AM - 10:35 AM V7 (Licensed Practical Nurse) stated he found R6 and R10's wheelchair were in contact while facing each other and overheard R10 saying back off, back off. V7 stated he immediately informed V32 (Charge Nurse/Registered Nurse). V7 stated he stayed with R6 and R10 and continued to observe them then V32 came immediately to separate them. V7 stated he advised V32 to immediately remove R10 because he has some confusion and will move around and try to go in the bathroom on his own, so he was moved two doors down to another room. V7 stated R10 doesn't use the call light and will have bowel incontinence and spread feces on floor and walls. V7 stated R10 does go in other residents rooms and bathrooms. V7 stated if he was in charge of making room changes, he would not put someone who is confused or could go in other people's belongings or touching other people's items with a resident who is alert and oriented and independent. V7 stated R6 is very neat and independent. V7 stated R10 does not generally get agitated. On 01/31/2023 from 2:01 PM - 2:17 PM V1 (Administrator) stated it was documented in the medical records that there was an incident with R6 and R10 where one rolled over the other one's foot. V1 stated it was reported that V7 (Licensed Practical Nurse) passed by the room observed R6 and R10's wheelchairs together and one of the resident's foot was rolled over and that resident was sent to the hospital. V1 stated he was not given any additional details about the incident and that's all that he was told. V1 stated if more information was provided, he may possibly have looked further into it. V1 stated if something indicated that an allegation of abuse occurred then an abuse investigation would have been initiated. V1 stated indicators of abuse would include someone reporting a deliberate hit or comment. V1 stated based on the information reported by V7 to the surveyor about this incident there could possibly be a need to determine if R10's foot was ran over intentionally or unintentionally however there were no details to indicate to investigate further at the time. V1 stated once an investigation is initiated it would then be reported to the state. V1 stated if willful intent occurs care plans would be updated, room changes may occur, a resident may be sent out for evaluation, a psychosocial/emotional well-being report and an abuse assessment would be completed, and 72 charting for nursing and social services regarding the incident would be conducted. V1 stated staff need to report an allegation immediately once they feel an allegation is made. On 02/01/2023 at 09:52 AM V39 (Certified Nurse's Assistant) stated she has worked at the facility for seven months. V39 stated R10 becomes confused when leaving the dining area while looking for his room. V39 stated R10 does attempt to use the bathroom by himself and cannot use the bathroom by himself. V39 stated when R10 attempts to use the bathroom by himself he may make a mess and spread his excrements around the bathroom. V39 stated at times, typically in the morning R10 will be extra alert or excited and will attempt to go to the bathroom by himself. V39 stated if she observed R10 in this state she will take him out of his room or have him near her. On 02/01/2023 from 12:33 PM - 12:51 PM V1 (Administrator) stated if R6 pushed R10 out of the room during their incident on 12/06/2022 it was willful and if R6's foot was hurt in the process that would be willful. 5. R12 is a [AGE] year-old female with a diagnoses history of Morbid Obesity due to Excess Calories, Type 2 Diabetes Mellitus, and Recurrent Major Depressive Disorder who was originally admitted to the facility 7/8/2015. R20 is a [AGE] year-old female with a diagnoses history of Schizoaffective Disorder Depressive Type, Vascular Dementia, and Human Immune Deficiency Virus who was admitted to the facility 06/13/2022. On 01/30/2023 from 11:38 AM - 11:46 AM R12 stated in the last room she was in her roommate scratched her and the social worker was informed. R12 stated her roommate was prone to that type of behavior and she asked the facility why they didn't just place her roommate in a room by herself. R12 stated she had two scratches on her hand as a result of the incident. R12 stated her roommate was aiming to scratch her legs and when the nurse saw this she instructed her roommate to leave her alone. R12 stated her roommate called her a profane name, told her to shut up, and told her she wished she was dead. On 02/01/2023 from 10:53 AM - 10:56 AM R12 stated when she shared a room with R20, R20 was always cursing at her and calling her names. R12 stated this did upset her and hurt her feelings. R12 stated she was scared R20 might do something to her in her sleep. R12 stated she expressed these concerns to the Certified Nursing Assistant's but they would always say that R20 won't do anything to her. Abuse Investigation Report dated 01/12/2023 documents: on 01/10/2023 after a comment was made by R12 about R20 being loud, R20 began using profanity at R12 and reached for R12; V21 (Licensed Practical Nurse) was present during the incident and grabbed R20's wheelchair to pull her away from R12. V21 observed redness on R12's foot; R12 reported that when R20 was escorted into the room by V21 she made a statement about R20 being loud leading to a verbal disagreement and during this incident R20 reached over and grazed R12's foot; R17 was present during the incident reported that she heard R20 cursing and going back and forth verbally and R20 has these outburst often; Care plans were updated, and residents 72 hour checks were initiated. Statements attached to abuse investigation report dated 01/12/2023 documents: V21 (Licensed Practical Nurse) reported on 01/10/2023 R20 became upset about a statement that R12 made that Here comes R20 she's so loud, and yelled to R12 shut up (profane word)!; R12 told R20 you need to stop cursing at me.; R20 continued to curse at R12 calling her a profane word and stating to R12 you need to stop stealing my stuff you ugly (profane word).; R20 then turned around from her wheelchair and attempted to reach R12's foot and was pulled away and removed from the room; when R12 was assessed there was redness noted on her right foot but no scratch was seen. R12 reported that when R20 was in her wheelchair she turned around and attempted to grab her foot and when she pulled her foot away R20 told her to get the (profane word) out of her room; when R20 reached and scratched her foot/hand that's when the nurse pulled her away R20 never liked me. R17 Reported she heard R20 cursing and cursed R12 out real bad and told her to stay out of it before she puts me out, R20 also used profanity at R17, R20 curses at everyone. R12's Progress note dated 1/10/2023 documents: Resident was seen having a verbal disagreement with her roommate concerning the inappropriate behavior she expresses such as cursing out loud and accusing her of stealing her personal belongings. Roommate was up in her room in her wheelchair receiving her medication via feeding tube when roommate reached out to resident s foot and scratched her. Roommate was then removed and re-educated. Resident requested a room change. Social Services made aware. Resident was transferred from to another room oriented to new room belongings in place and medication in cart. R12's Physician Progress note dated 1/11/2023 documents: Patient also upset because she had an altercation with one of her room mates. They ended up moving her to a different room and not all of her possessions are with her yet. R12's progress note dated 1/12/2023 created by V21 (Licensed Practical Nurse) documents: This writer followed up with resident regarding behavior on 1/10 no injury[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide timely incontinence care for residents known to require staff assistance with toileting. This failure affected six of six residents (R11, R12, R14, R22, R24, R25) reviewed for incontinence care and resulted in three residents ( R12, R14 and R24) developing multiple urinary tract infections while in the facility. Findings include: 1. R11 is a [AGE] year old male admitted to the facility 12/27/2019 with diagnoses that include Paraplegia, Morbid obesity and Pressure Ulcer Stage III. Review of R11's medical record MDS (Minimum Data Set) dated 2/3/23 indicates that he is cognitively intact and requires extensive two person physical assistance with toileting as he is always incontinent of bowel and has an indwelling urinary catheter. On 01/30/2023 from 11:59 AM - 12:10 PM R11 stated he has to call down to the nurse's station to get staff to respond to the call light. R11 stated he begs the staff to change him. 2. R12 is a [AGE] year old female admitted to the facility 11/5/2015 with diagnoses that include Arthritis, Morbid obesity, and Urinary Tract Infections. MDS dated [DATE] indicates that R11 is cognitively intact and requires one person physical staff assistance with toileting due to urinary and bowel incontinence. On 01/30/2023 from 11:38 AM - 11:46 AM R12 stated it takes staff hours to answer her call light and there was a couple of times that she wasn't provided with incontinence care timely. R12 stated the excuse staff gives is that they are short of staff. On 01/30/2023 from 11:34 AM - 11:48 AM R12 stated she rang the call light at 8:15 AM because she had urinated and needed to be changed and urinated again at 10 AM. R12 stated at 11:15 AM she notified V6 (Patient Relations) she needed to be changed because no one had responded to her call light and her bed and adult brief were soaked with urine. R12 stated V6 then sent a CNA (Certified Nursing Assistant) to assist her and the CNA told her she wasn't assigned to her but did provide her with incontinence care. Medical Record reviewed for R12. Urinalysis collected 12/1/22, resulted with positive culture results on 12/6/22 and indicated Escherichia coli and Proteus mirabilis bacteria present. Progress notes dated 12/7/22 written by V31 Nurse Practitioner stated that R12 was diagnosed with a UTI (urinary tract infection) and placed orders for antibiotic Ciprofloxacin 250mg every 12 hours for 3 days. Medication Administration Record dated 12/7/22 indicated that R12 received antibiotic Ciprofloxacin 250mg every 12 hours for 3 days for infection. 3. R14 is a [AGE] year old woman admitted to the facility with diagnoses which included Chron's Disease, Heart failure, Polyneuropathy and Anxiety Disorder. According to MDS (Minimum Data Set Assessment) dated 1/5/23 indicates that R14 is incontinent of bowel and bladder functioning and requires extensive two person staff assistance with toileting. On 1/30/23 at 1:00PM, R14 was observed in bed, alert and oriented. R14 said, I usually have to wait a long time to be changed. I have Chron's Disease and have diarrhea frequently sometimes and since I can't get up to the toilet I go in my brief. Sometimes the staff gets mad at me because I have diarrhea but I can't help my body. I haven't been changed since this morning and need to be changed now. I keep getting Urinary Tract Infections because I'm sitting in my stool. At 1:20PM V27 CNA came into the room and removed R14's lunch tray. V27 did not provide incontinence care for R14. During observations on the unit, it was noted that R14 had not received any incontinence care between 1:00PM and 2:45PM. At 2:00PM V21 LPN Unit Manager was seen collecting R14's belongings. V21 said, R14 has a urinary tract infection that requires isolation because it is highly transmissible and may be resistant to some antibiotics. We are moving her room temporarily. She was complaining of symptoms over the weekend and the final results for the culture came back today, positive for E. Coli bacteria with ESBL (extended spectrum of beta lactamase). Urine culture collected 12/6/22 resulted on 12/9/22 and was positive for E. Coli bacteria. Physician orders dated were placed for treatment. On 12/29/22, a follow up culture was obtained via urinary catheter and was negative for bacteria. Urine culture reported 1/28/23 noted that sample was collected on 1/26/23 and was positive for Escherichia coli (E. Coli) bacteria of greater than 100,000 colonies. 4. R22 is an [AGE] year old female admitted to the facility 10/6/22 with diagnoses that included Dementia, Osteoporosis, and Major Depressive Disorder. According to MDS (Minimum Data Set Assessment) dated 12/19/22 R22 is incontinent of bowel and bladder function and requires extensive staff assistance with toileting and hygiene. On 1/30/23 at 2:33PM, R22 was observed lying in bed, on a low air loss mattress with a strong smell of urine. At 2:43PM, V27 CNA (Certified Nursing Assistant) was observed sitting at the nurse's station on the phone. Surveyor asked to check R22 for incontinence care and at 2:45PM V27 and surveyor went to R22's room. When V27 removed the top covers, R22 was observed in a heavily saturated brief. V27 was observed wiping the front genital area and buttocks and placed a new brief. Surveyor asked V27 the proper way of cleaning female genitals while providing incontinence care and V27 cleaned between the legs and labia, after prompted by surveyor. V27 finished providing care and placed a new brief without changing gloves or performing hand hygiene. Surveyor noticed large dark yellow rings on the bed pad. V27 said it could be urine but it's not wet. I haven't changed the bed pad today; it was put there by the night shift. I last checked her this morning. Care plan dated 10/7/22, revised 1/8/23 states that R22 has the potential for complications related to incontinence, with a past medical history of UTI (urinary tract infection). Interventions include that the CNA should wash, rinse and dry perineum; change clothing as needed after incontinence episodes. Assist with toileting before and after meals, upon rising in the AM and before bed at night and as needed. On 2/1/23 at 11:10AM V3 DON (Director of Nursing) said, CNA's should document that they provided incontinence care for every occurrence in the Point of Care section of the chart. Delays in receiving incontinence care may lead to poor results in customer service, skin breakdown and poor hygiene. I can tell if an incontinent resident has not been changed for an extended period of time based on a heavily soiled brief or if they told me. R14 has Chron's Disease and should be changed more frequently because she has frequent stools. I would not expect her to have to wait in a soiled brief for over an hour because a delay in changing could contribute to developing UTIs (urinary tract infection). At 12:59PM V31 NP (Nurse Practitioner) said R14 has been treated for several UTIs while in the facility. Poor incontinence care could be the cause of frequent UTIs. I ordered a urinalysis because she complained to me of painful urination. UTIs can occur with residents who are incontinent because stool has E. Coli and can get in to the urinary hole if the resident is sitting for any time. 5. R24 is a [AGE] year old woman admitted to the facility 12/30/22 with diagnoses that include, Spinal Stenosis, Morbid obesity, Abnormalities of gait and mobility and Urinary Tract Infection. MDS dated [DATE] indicates that R24 has full cognition and requires extensive one person staff assistance with toileting as she is frequently incontinent of bowel and bladder functions. R24's medical record was reviewed. On 1/30/2023, Physicians Order Sheet included an order for urinalysis with a reflex culture. The specimen was collected 1/31/23 and resulted 2/3/2023 and contained E. Coli bacteria. On 2/1/23, an order was placed for antibiotic Ciprofloxacin 250mg by mouth every 12 hours for UTI for 7 days. Care Plan for incontinence initiated 1/2/23 stated R24 had a past medical history of UTI. UTI care plan initiated 2/1/23 included interventions that state Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. 6. R25 is a [AGE] year old female admitted to the facility 1/20/23 with diagnoses that included Morbid obesity, Pressure Ulcer of left heel Stage 3, Major Depressive Disorder, Hypertension and Anxiety Disorder. According to MDS (Minimum Data Set) dated 1/25/23, R25 requires Extensive physical assistance for toileting and hygiene and is incontinent of bowel and bladder function. On 2/7/23 at 11:45AM R25 said, On Saturday 2/4/23, it was about 1:15PM when I had a bowel movement and called for help. I was waiting for about 30 minutes or so, and then I called down to the front desk using my cell phone to get some assistance. At about 2pm someone came in but brought the wrong size brief. Shift change is at 3pm. They never came back. Someone on the second shift changed me at 3:50PM. Facility Policy titled Incontinence Care revised 4/20/21 states in part; Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode. 4. Wash the labia first then groin areas; In the female, separate labia wash with strokes from top downward each side separately with a clean cloth or clean area of the cloth. Keep labia separated with one hand. 9. Change gloves and perform hand hygiene; 10. Apply clean incontinence brief or incontinence pad. 46344 Based on observation, interview, and record review, the facility failed to follow professional standards of catheter care by not emptying the bedside urinary catheter bag for a resident, putting them at risk of urine backing up into the bladder. This failure applied to one (R23) of one resident reviewed for catheter care. Findings include: R23 is a [AGE] year old male who was admitted to the facility 9/3/21 with diagnoses that include Spinal Stenosis, Vascular Dementia, and urine retention. On 1/30/23 at 2:08PM, V25 RN (Registered Nurse) was observed in the hallway outside the room of one resident, R23, with a new urinal in hand and preparing medications. At 2:10PM V25 said, I asked the CNA to empty R23's urinary drainage bag hours ago when I saw it was pretty full. She still hasn't done it and now it is about to burst open. When going into the room with V25, Surveyor noted that the urinary bag was so full that it was tightly expanded, and urine was backed up into the tubing. R23 said, I can feel when the bag is full because it starts pulling and it is uncomfortable. I asked the CNA to empty it earlier because it hasn't been emptied since last shift- about 6AM. I put on my call light, and they came in to turn it off and told me they would be back. They came to give me lunch and removed my tray but didn't empty the bag. Surveyor observed urinary bag to have approximately 2500ml of urine. V25 RN was seen filling up the urinal fully, twice, and then a third time. V25 said, I wasn't really paying attention to the amount because I had to empty it three times, as you saw, but I think it was about 2300ml. At 2:20PM V26 CNA (Certified Nursing Assistant) was observed at the nursing station with a personal bag of food, using a personal cell phone and speaking with coworkers. V26 said I haven't changed R23's urinary bag this shift. I have been in the room several times today. The nurse asked me to empty it earlier but I got busy. I haven't washed him up or cleaned his bed today. I'm about to help with a transfer and then I leave at 3PM.

Based on interview and record review, the facility failed to provide an individualized, resident-centered, plan of care and interventions to address significant weight loss for a resident with a history of weight loss and failure to thrive. This failure affected one (R13) of three residents reviewed for nutrition services and resulted in R13 having an unintended weight loss of over 40 pounds in a period of approximately two months. Findings include: R13 is a [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction, Adult Failure to Thrive and Vascular Dementia. MDS (Minimum Data Set Assessment) dated 10/26/22 indicated that R13 was cognitively intact and required one person staff supervision with eating. During her stay, R13 lost a total of 43.4 lbs from the date of admission to discharge which calculates to 26.67% percent weight loss. R12 was transferred to the hospital 12/19/22 for evaluation of failure to thrive. On 1/31/23 V51 (Family Member) said, the facility called to inform me that R13 was losing weight, and there was a point where I asked for gastric tube consult because she had one in the past that was effective. Two weeks went by, and she was still losing weight. The next thing they are telling me, is they ordered a palliative care consult that we never discussed. They finally told me they would do the consult and sent her out. On 2/1/23 at 11:10AM, V3 DON (Director of Nursing) said, I believe R13 was determined to have a diagnosis of failure to thrive due to weight loss and poor eating habits. Nursing staff should have been documenting the amount of food that was eaten with each meal. We followed dietary recommendations and reached out to the family. Unfortunately, since the recommendations were not successful, the team sought hospice or palliative care. The Nurse Practitioner would have made the decision to place a consult for hospice or palliative care. I don't recall if there was ever a GI consultation to place a gastric tube. On 2/7/23 at 11:40AM V31 Nurse Practitioner said, I was aware of R13's weight loss and was often refusing the foods and shakes (house supplements) due to psych issues. I remember talking to R13 and the family about increasing portions to double during mealtimes. R13 needed encouragement during meals, but the facility doesn't have enough staff to sit there for a 1:1 feed and watch her eat. I think I asked R13 about a gastric tube but I don't know if it is documented. I usually would document that sort of consult. Later R13's daughter asked about a g-tube consult and I placed the order. On 2/7/23 at 2:24PM V44 Physician said, I was aware of R13's significant weight loss and the interventions we placed were not effective. I tried to speak with her, and she was very depressed. Surveyor asked V44 about the rationale for increasing portions and frequency of house supplements when the medical team was aware that R13 was already not accepting prior orders and V44 said that they weren't sure. V44 was asked if a gastric tube consult would have been appropriate after it was determined that R13 lost 20.8 lbs over 28 days (from 10/22/22-11/19/22) and at what point would it have been appropriate to seek higher level of care for R13 when it was documented that the interventions in place for nutrition status were not effective? In response, V44 abruptly ended the interview without answering the last questions asked. R13's medical record was reviewed from 10/21/22 to 12/19/22. Admission progress note 10/21/22 said R13's admitting diagnosis included failure to thrive. Physician Order Sheet dated 10/30/22 included order to give house supplement 3 times daily. October Documentation Survey Report indicates meal intake was not reported 7 times, and R13 ate 17 out of 24 meals reported. Physician Order Sheet dated 11/21/22 added additional nutrition supplements. In November 2022, Documentation Survey Report indicated that meal intake was not reported 26 times and R13 ate 50% or less of 46 out of 73 meals reported. December Medication administration Record indicated that R13 regularly refused all nutritional supplements including house shakes and on 12/12/22, nutritional shakes were increased in frequency from 3 times to 4 times daily. On December 2022 Documentation Survey Report indicated meal intake was not reported for 21 of 54 meals, 19 meals were refused and only 5 meals were reported to have been eaten over 50%. Weight results from admission to discharge were recorded as follows (in lbs): 10/22/2022 162.8 11/6/2022 162.5 11/17/2022 144.5 11/19/2022 142.0 11/25/2022 137.5 12/8/2022 127.0 12/19/2022 119.4 Facility Policy titled Physician-Family Notification-Change in Condition revised 11/13/18 states in part; The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment; A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on the at resident before). (D) A decision to transfer or discharge the resident from the facility.

Based on interviews and record reviews, the facility failed to prevent resident to resident sexual assault of inappropriate touching. This affected 3 of 4 (R5, R16, and R26) residents reviewed for abuse. This failure resulted in the residents expressing that they felt unsafe, uncomfortable, nervous, and shame. Findings include: The facility's incident report dated 8/12/2022 documents the following: On 8/12/22 at approximately 4 PM R5 stated that R6 touched her inappropriately. She prefers not to be touched in anyway. R6 Behavior Care Plan documents the following: R6 has a behavior problem with attempting to touch my peers inappropriately. Date initiated 6/22/2022. There are 2 interventions in this care plan both are dated 6/22/2022. 1) Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. 2) Anticipate and meet the resident's needs. On 9/27/22 at 12:05 PM R5 states on 8/12/2022 that R6 had a weird look in his eyes when he called her to come to him in the hallway. R5 states when she came, R6 reached out and touched her private area. R5 states, I will never forget the look in his eyes. He looked at me in a strange way, as she stairs off as if reliving the incident. She said she told the administrator. R5 states she also told her son and daughter and she didn't feel right being at the facility so her children came and got her. R5 states, I still don't feel right. I feel like I'm unsafe here, but I have to stay because I am getting assisted living. R5 states that when R6 touched her private area it made her feel uncomfortable. On 9/27/22 at 1:20 PM V1 (Administrator/Abuse Coordinator) states that R5 told him that R6 said come here and that he could not hear her. V1 states that R5 said that R6 reached out and touched R5's private are. V1 states that he viewed the video of the 8/12/2022 incident with R5 and R6 and he saw R6 touch R5 in that area. V1 states R5 pulled back and walks backwards, then she turns around and leaves R6 there in the hallway V1 states he was not aware of any history of inappropriate touching by R6. V1 states during his interview with R6, I told him he touched someone and he was just in denial. On 9/28/2022 at 9:31 AM V12 (staffing coordinator) states she works at the facility as the activity director. V12 states on 8/16/2022 R6 was reaching for her grandmother and said he wanted to grab her grandmother's breast but used a different lewd word. On 9/28/2022 at 9:39 AM R15 stated: R6 said he wanted to touch her breast. R15 stated He was grabbing at me and I moved. I thought he was a pervert, He made me nervous. R6 nurse progress note dated 8/16/2022 by V30 (RN), documents the following: It was reported to this writer that RT made lewd, suggestive comments to fell ow resident R15 while both were in the third floor dining room. At the time, R15 was accompanied by her granddaughter V12, who was present and witnessed the entire incident. V12 reported that R6 also attempted to touch her breasts. On 9/28/22 at 2:50 PM R16 states that just a little while ago R6 rolled over to her side and rubbed her arm. He made me uncomfortable and nervous. He scared me when he came up to me. That's scary because that's perverted. He doesn't need to be around women. On 9/28/22 at 2:57 PM surveyor asked R26 if R6 had touched her and she said: Yes. Surveyor asked R26 where R6 touched R26 and R26 looked distressed. She lifted her right arm and pointed to her left breast and chest area. Surveyor asked, How did that make you feel when he did that. R26 states, shame. R6's progress note by V30 (RN) dated 9/28/2022 at 2:50 PM documents the following: it was reported to this writer this male resident had two separate incidents of touching 2 different female residents, all within the space of 15 minutes, in the dining area. The first incident took place at 2:00 PM in the dining area. RN separated male resident from first female resident whom he reportedly touched. RN had a detailed conversation with male resident, attempting to redirect him. Male resident appeared to understand and abide by RN's attempt at redirection.V30 (RN) separated male resident, and left him sitting at a table by himself. Within 15 minutes, this writer heard female screams coming from the dining area. RN responded to the dinging area, and noted male resident sitting very close to a second different female. Second female resident noted that male resident was attempting to grope her. RN once again attempted to redirect Male resident by verbal exhortation. RN took patient to his room and placed him in bed. On 9/28/2022 at 11:05 Am V30 (RN) states R6 is alert times 2. V30 stated he has gotten reports of R6's inappropriate touching. V30 stated: 1 week ago I had to talk to him. V30 stated: He asked R6 what happened and R6 just looks like he doesn't know what's going on and gives a weird look. I documented it in the chart. V30 states, R6 grabbed the breast of V36 (CNA) a couple days ago. V30 states he redirected R6 and asked the CNA to be careful. V30 states R6 says inappropriate stuff and when you ask him he doesn't say anything. He just gives a weird look. I talk to him and try to redirect him. I can't think of anything else we are doing to prevent R6's behavior. He has a Psychiatric doctor evaluation. R6's progress note by V30 dated 9/25/2022 documents R6 grabbed at CNA's Breast in the resident's room. R6's progress note by V45 (Psych Doctor). It was reported by CNA of grabbing her breasts on Sunday and Nurse Practitioner also. Both are females. On 9/30/22 at 1:05 PM V45 states this situation with R6 is a serious matter and something needs to be done because R6 is assaulting women. On 9/28/2022 at 10:30 AM V14 (CNA) states R6 stays in the bed. V14 states R6 is touchy, feely. V14 states. He tries to grope you and residents. V6 states, no one told her that R6 does that initially. She learned it by working with him. V14 states, about a month ago they told her to keep R6 in the Geri-chair, because other-wise he goes around and tries to touch people. The facility's Abuse Prevention and reporting policy documents the following: Guidelines: the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on interviews and record reviews, this facility failed to follow their Skin Condition Assessment and Monitoring of Pressure and Non-Pressure policy to include not identifying a right heel deep tissue injury, and not initiating wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected 1 of 3 residents (R3) reviewed for pressure sore prevention and treatment. This failure resulted in R3 having wound debridement in a local hospital. Findings Include: R3 admitted in the facility on 5/29/22 and on admission skin integrity admission documentation, R3 was noted to have stage 3 sacral area, with no measurement, and right iliac crest open area. Reviewed wound rounds documentation dated 6/7/22 reads in part: type as pressure, classification stage as ulceration and with clinical stage as unstageable with scant/serosanguinous with a measurement of 9.5cm x 10cm x unknown (Length X Width x Depth). R3 was seen by wound doctor on 6/4/22. Documented that R3 has a large sacral wounds and left heel deep tissue injury (DTI). Noted with preventative measure in place for dressing changes, debridement as needed and off-loading heel boots. Reviewed Treatment Administration Record (TAR) for the month of May 2022, and there is no noted treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] pressure injury and Left Heel DTI. Reviewed TAR for the month of June 2022. Sacral wound treatment started on 6/2/22 for santyl ointment and on 6/5/22 additional treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] There were no noted treatment prior to the date of 6/2/22. R3 was admitted in the facility on 5/29/22. On 9/28/22 at 2pm, interviewed V20 (Wound Nurse) and V20 stated R3 was admitted on [DATE] with a sacrum pressure ulcer. Usually the admitting nurse will not put the treatment. The practice in this facility is for wound nurse to see and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If admitted , admitting nurse is instructed to just cover with dressing until wound care evaluates the resident. I received the order on 5/31/22, I documented the order was obtained. I probably forgot to enter the order. We are supposed to enter the orders as soon as the order was given to me or nurses, we are supposed to put the order immediately in the resident's chart. If the order is not entered in the POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/29/22 at 230pm, interviewed V48 (Wound Doctor) stated The wounds present on admission were DTI on left heel and sacrum pressure injury. I saw the resident 4-5 days after the admitted . I recommended initial debridement to local hospital and then plan to get consent to do follow up debridement as needed in the facility. I ordered [MEDICATION(S)] ointment at the date of my visit. I only saw R3 one time. R3 was sent out to the hospital on my second schedule visit, so I was not able to see R3 at the time. The Left heel DTI was intact, and heel protector was ordered to prevent developing an open site on Left heel. My expectation for the nursing facility is to follow the hospital wound treatment, get an order from attending physician. I will then see the resident and change the treatment as needed. Hospital record (hospitalization on [DATE]) reviewed and documented: Date of Service 6/10/22 reads in part: Sacral 12cm x 14cm, unstageable pressure injury with base entirely covered in fluctuant necrotic tissue, serosanguinous drainage seen at superior edge of the wound with palpation. strong malodor. Peeling necrotic tissue surround fluctuant necrotic tissue. Right Lateral Ankle deep tissue pressure injury on the lateral malleolus with a this ling extending up the leg 10cm x 2cm, Left Lateral Heel/Ankle deep tissue pressure injury 10cm x 4cm. General Surgery consulted given sacral decub which appear to be infected. Starting broad spectrum antibiotic will debride at bedside. May requires further debridement 6/11/22 at 0950.Large sacral wound necrotic and malodorous. Will obtain surgical evaluation, likely the source of infection, NPO for debridement at bedside. Went to OR (operating room) 6/11/22 for debridement. status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure complicated by bleeding site and packed and bleeding slowed. There is no right heel DTI documented during the facility stay of R3. Skin Condition Assessment and Monitoring Pressure and Non-Pressure with a revision date of 6/8/18, reads in part: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin condition and assuring interventions are implemented. Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by the license nurse and documented in the residents' clinical record. Physician ordered treatment shall be initiated by the staff on electronic (TAR) after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurse's notes.

Based on interview and record review, the facility failed to follow their nutritional monitoring policy by not monitoring a resident's nutritional intake at each meal to detect potential nutritional problems for 1 of 3 (R3) reviewed for weight loss. This failure resulted in (R3) having a significant unplanned weight greater than 10% in one month. Findings include: R3 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan dated 12/12/21 documents: R3 had a potential for altered nutrition. Intervention dated 3/22/21: determine food dislike, monitor weights, observe for changes in oral intake/appetite, note for significant changes. Nutrition Progress note dated 11/11/21: R3's meal intake remains variable. No recommendation. Nutrition Progress note dated 12/28/21: R3 had significant weight loss: 9.3% x 3 months. R3' weight dated 1/6/22 documents: 12/15/21 - 161.5 pounds/lbs., 11/2/21 - 183.5 lbs., 10/1/21 - 187.5 lbs. On 1/6/22 at 3:11pm, V15 (ADON) said, R1 had declining health and wasn't eating. On 1/7/22 at 1:06pm V15 (ADON) said, we conduct a daily meeting to review weights. If there is a weight loss, we would notify the MD and dietitian immediately. Restorative weighs resident and compares weights for any loss or needed re-weighs so any weight loss can be addressed. R3's weight loss was not planned. On 1/7/22 at 1:42pm, V16 (CNA) said, R3 wasn't eating. I notice R3's weight loss around Thanksgiving. R3 looked thin and his face was shriveled up. R3 was independent with eating, did not like the facility food and did not report any swallowing difficulties. I told the V18 (Nurse). On 1/7/22 at 2:12pm, V17 (Restorative nurse) said, restorative aide will tell the floor nurse about any weight loss so the doctor can be notified. I will inform V2 (DON), V15 (ADON) and V45 (Dietitian) of any weight loss so we can implement interventions and update the doctor. I don't have any correspondence for R3's weight loss recorded on 12/15/21 to V45. On 1/11/22 at 11:29am, V18 (nurse) said, I gave R3 medication. R3 did not have any swallowing issues. I don't recall anyone reporting R3's losing weight. On 1/11/22 at 11:50 am, V30 (nurse practitioner) said, I am notified if a resident has a 5-8% weight loss. I was notified late on 12/27/21 or on 12/28/21 of R3's weight loss. I saw R3 on 12/28/21, R3 reported having a hard time swallowing. I was debating making R3 nothing by mouth and start intravenous fluids. I ordered labs which indicated R3 was dehydrated. I should have been updated prior to 12/27/21 or 12/28/21 of R3's weight loss. I would have been able to assess R3 for swallowing problem sooner, ordered speech to evaluation and treat. R3 had a hypotensive episode. R3 was discharged to the hospital (on 12/29/21). On 1/14/21 at 7:34am, V45 (dietitian) said, R3 had a significant weight loss of 12% x 6 weeks. Weights are monitored weekly at a minimal. R3 needed to be assessed medically. I was notified of R3's weight loss on 12/28/21. R3 was on a general diet and did not have any swallowing difficulty until he became weak and was discharged to the hospital (on 12/29/21). R3 ate 50-75% for most meals and 76-100% for a few meals. On 1/25/22 at 4:14pm, V8 (nurse) said, [MEDICATION(S)] levels are taken to see if a resident is eating, and it can indicate malnutrition. Lab result dated 12/13/21 documents: [MEDICATION(S)] 2.7gm/dL (ref. range 3.2 -5.0) low. Lab result dated 12/28/21 documents: [MEDICATION(S)] 2.8gm/Dl (ref. range 3.2 -5.0) low. Low [MEDICATION(S)] may indicate malnutrition. Nutrition amount report dated 12/15/21, 12/16/21 and 12/23/21 documents: R3 ate 51%-75% for 2 of 3 meals. Nutrition amount report dated 12/20/21: R3 ate 76%-100% for 2 of 3 meals Nutrition amount report dated 12/22/21: R3 ate 76%-100% for 1 of 3 meals. Nutrition amount report dated 12/22/21, 12/26/21 and 12/27/21 documents: R3 ate 51%-75% for 1 of 3 meals. Nutrition amount report dated 12/17/21-12/19/21, 12/21/21, 12/24/21 and 12/25/21. No documentation for 3 of 3 meals. Weight change note dated 12/27/21 documents: R3 observed with significant weight loss. Family noted that R3 prefers boiled eggs and fruit for breakfast. R3 consumed 100% of dinner. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 appeared to have difficulty swallowing. R3 ate a small portion of breakfast sausage. Lung sounds very course. R3 appears mildly confused with difficulty coughing. Questionable aspiration pneumonia. Speech therapy to see tomorrow. Nursing note dated 12/29/21 documents: R3's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital paperwork dated 12/29/21 documents: R3 was alert, cachectic (physical wasting with loss of weight). R3 had not been eating much. R3 did not like the food. R3's [CONDITION(S)] was secondary to poor intake and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interviews and record review the facility failed to notify the physician of critical laboratory results immediately after receipt from the outpatient lab for 1 of 3 (R15) residents reviewed for acute change in condition. This failure resulted in a approximately a 30 hour delay in notification of critical abnormal lab results, R15 having an acute change in condition being transported to the local hospital for evaluation and being admitted for hyperosmolar hyperglycemic syndrome, dehydration and acute kidney failure. Findings include: R15: Review of R15's medical record notes R15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/22/2021 at 12:30pm, V31 NP (nurse practitioner) stated that laboratory results will pop up in the resident's electronic medical record to be reviewed. V31 stated that V31 would expect the nurse to call nurse practitioner/physician with critical laboratory values immediately upon receiving results. V31 stated that V31 was not made aware of any critical laboratory values for R15. On 10/22/2021 at 1:50pm, V12 LPN (licensed practical nurse) stated that critical laboratory test results are telephoned to the nurse by the outside laboratory service. V12 stated that the physician/nurse practitioner should be notified of all critical results immediately. V12 denied receiving any critical laboratory test results for R15. On 11/9/21 at 1:30pm, V2 DON (director of nursing) stated that blood glucose (sugar) results are documented in the resident's MAR (medication administration record). V2 stated that the vital sign section of the resident's electronic medical record pulls the blood glucose results from the MAR and also notes the time the results were obtained. V2 stated that staff do not document blood glucose results directly into this section. V2 stated that blood glucose testing should be performed before the resident begins to eat meal. V2 stated that the physician should be notified for blood glucose results greater than 400. Review of R15's laboratory test results, dated 10/12/21 at 3:06pm, notes a critical sodium level was called with readback to V12 LPN by the outside laboratory service. R15's critical sodium level was 167 (normal range is 136-147). Review of R15's laboratory test results, dated 10/12/21 at 1:34pm, notes R15 with white blood cells 15.56 (normal range is 4.8-10.8), neutrophils 12.84 (normal range is 1.4-6.8), elevated neutrophils indicate infection; blood glucose level 402 (normal range is 70-110; BUN (blood urea [MEDICATION(S)]) 55 (normal range is 8-28); creatinine 2.53 (normal range is 0.4-1.6). BUN and creatinine levels monitor how well kidneys are functioning. Review of R15's progress notes, dated 10/13/21 at 6:42pm, notes V3 ADON, V3 spoke with nurse practitioner regarding R15's laboratory test results, V3 received order to transfer R15 to the hospital emergency room for evaluation of acute kidney injury and uncontrolled blood glucose. Review of R15's hospital record, dated 10/13/2021, notes R15 presented to the emergency room with altered mental status, low blood pressure secondary to dehydration, acute kidney injury, elevated sodium level, elevated potassium level, and HHS (hyperosmolar hyperglycemic syndrome - a serious complication of diabetes, occurs when a person's blood sugar levels are too high for a long period, leading to severe dehydration). Per EMS (emergency medical services), this facility called because R15 had low blood pressure, high blood sugar, making incomprehensible sounds, and has altered mental status. Per nurse at this facility, R15 has been displaying increased altered mental status for the past few days, was sleeping all day, was difficult to arouse today, and would not eat dinner today. R15 visibly winces to pain with palpation of left lower abdomen. CT (computed tomography) scan of R15's abdomen noted moderate fecal burden in rectum. In the emergency room , R15's initial blood sugar level performed at R15's bedside was greater than 600 (normal range is 70-110). Laboratory testing blood sugar was 796. R15's sodium level was 157 (normal range is 136-147). Review of R15's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's blood glucose results documented in R15's MAR (medication administration record), dated October 2021, notes: On 10/4/21 at 6:00am, there are no results documented. On 10/4 at 11:00am, R15's blood glucose 318. On 10/4 at 4:00pm, 'NA' is documented as R15's blood glucose result. On 10/7 at 4:00pm, blood glucose documented as 138. On 10/7 at 9:00pm, blood glucose documented as 214. On 10/8 at 11:00am, 4:00pm, and 9:00pm there are no results documented. On 10/9 at 11:00am, blood glucose documented as 204. On 10/10 at 9:00pm, there are no results documented. Review of the vital sign documentation section of R15's medical record, October 2021, notes the exact time the bedside blood glucose testing was performed/documented. In addition to the missing documentation in R15's MAR, noted above, it also notes R15's blood glucose level was not monitored/documented on 10/10 at 6:00am or 9:00pm; 10/12 at 6:00am; or 10/13 at 11:00am. Review of R15's blood glucose results in the vital sign section of R15's medical record notes : On 10/4/21 at 12:05pm, R15's blood glucose result is noted to be 314 and 318. On 10/4 at 6:28pm, blood glucose result is 434. On 10/7 at 5:01pm, blood glucose result is noted to be 138 and 400. On 10/7 at 10:18pm, blood glucose result is noted to be 214 and 350. On 10/9 at 3:04pm, blood glucose result is noted to be 356 and 204. There is no documentation found in R15's medical record noting R15 received fast acting insulin on 10/4 at 6:00am or 4:00pm; 10/8 at 11:00am, 4:00pm, 9:00pm; 10/10 at 9:00pm; 10/13 at 11:00am or 4:00pm. There is no documentation found in R15's medical record noting reason for discrepancy in blood glucose results, interventions implemented to verify results, or physician notification of blood glucose level greater than 400.

Based on observations, interviews, and record reviews, this facility failed to implement interventions to prevent the development of facility acquired pressure ulcers for 3 residents (R15, R19, and R21) out of 5 residents reviewed for being at risk for skin breakdown in a sample of 22. This failure resulted in R19 being admitted to the hospital with worsening sacral pressure ulcer, [CONDITION(S)] (bone infection) of sacral wound and developing [CONDITION(S)]. Findings include: 1. R19: On 11/9/21 at 9:30am, R19 is observed to be frail, weak. R19 was observed lying supine in bed on a regular mattress. R19's feet were observed to be pressed against foot board. On 11/9/21 at 9:30am, R19 stated that since admission on 8/23/21, R19 was not getting turned/repositioned routinely by staff. R19 asked if R19 could have an air mattress placed on R19's bed. On 11/9/21 at 11:36am, V11 (maintenance director) stated that V11 is notified when a resident needs a specialty mattress from V2 DON (director of nursing), V3 ADON (assistant director of nursing), or wound care nurse. V11 stated that this facility has some specialty mattresses on hand, housekeeping cleans and sanitizes them before putting in storage. V11 stated that V11 received a list yesterday, 11/8/21 at 2:31pm, for a specialty mattress for R19's bed. V11 stated that V11 leaves at 4:00pm and did not have time to place R19's mattress yesterday; V11 stated that V11 is in process of doing it now. V11 stated that sometimes staff will alert V11 ahead of time if resident is being readmitted ; if resident had specialty mattress before hospitalization , V11 will put one on before resident returns. V11stated that V11 does not recall being made aware R19 was returning to this facility prior to R19's re-admission on 11/5/21. On 11/9/21 at 1:30pm, V2 DON (director of nursing) stated that a specialty mattress should be placed on the resident's bed prior to the resident being readmitted to this facility. V2 stated that maintenance staff provide the specialty mattresses. V2 denied being informed R19 was re-admitting to this facility on 11/5/21. Review of R19's medical record notes R19 was admitted to this facility on 8/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19's admission assessment, dated 8/23/21, does not note any alterations in skin integrity. Review of R19's wound assessment, dated 8/24/21, notes a pressure injury to left dorsal foot, measuring 7cm (centimeters) x 2cm, 100% necrotic (dead) tissue. R19's right heel with an unstageable pressure injury, measuring 4cm x 3.5cm, 100% necrotic tissue. Review of R19's wound care physician note, dated 9/7/2021, notes R19 with a stage 3 sacral pressure ulcer, measuring 5cm x 7cm, 20% intact skin, 50% granulation tissue, 20% necrotic tissue, and 10% slough (yellow non-adherent tissue). Left heel deep tissue injury, measuring 4cm x 5cm, 100% deep maroon. Right heel deep tissue injury, measuring 1.5cm x 2cm, 100% deep maroon. Review of R19's wound care physician note, dated 9/11/21, notes R19 with a new wound: an unstageable pressure ulcer to right ankle anterior crease, measuring 2.5cm x 5cm x 0.1cm, 25% granulation tissue and 75% necrotic tissue. Review of R19's wound care physician note, dated 9/14/21, notes R19 with a new wound: a right lateral foot deep tissue injury, measuring 2cm x 1cm, 100% deep maroon. Review of R19's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation found in R19's medical record noting R19 had a consultation with a surgeon regarding sacral pressure ulcer. Review of R19's hospital record, dated 10/25/21, notes R19 was admitted to the hospital with worsening sacral pressure ulcer and developing [CONDITION(S)]. X-ray results of R19's right foot with [CONDITION(S)] (infection of the bone) involving the lateral base of the fifth metatarsal. MRI (magnetic resonance imaging) of R19's pelvis notes sacral [CONDITION(S)] and a presacral abscess measuring 8.7cm x 1.9cm x 2.6cm. During hospitalization , R19's abscess was drained and a PICC (peripheral intravenous central catheter) line was placed for long term antibiotics to treat R19's [CONDITION(S)]. There is no documentation found in R19's medical record noting weekly skin observation assessments were performed since R19's admission to this facility. 2 R15: On 11/3/2021 at 9:55am, this surveyor observed V47 (wound care nurse) perform wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When V47 removed R15's sacral dressing, dressing was observed to be non-occlusive and covered on both sides with bowel movement. R15's bowel movement was observed in the wound bed. Review of R15's medical records notes R15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's Braden score, dated 8/2/21, notes R15 is at risk for skin breakdown. Review of R15's progress notes, dated 10/13/2021, V13 LPN (licensed practical nurse) noted R15 has a small opening on the sacral area, family, nurse practitioner, and V3 ADON (assistant director of nursing) notified. On 11/8/21, R15's unstageable sacral pressure ulcer, measured 8cm x 13cm x 1.5cm, with undermining 2.5cm 9 o'clock to 3 o'clock, 15% red tissue and 85% slough (yellow non-adherent tissue). Review of R15's medical record notes R15's last documented weekly skin observation assessment was on 4/28/2021. 3. R21: Review of R21's medical record notes R21 was admitted to this facility on 10/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R21's admission assessment, dated 10/29/21, notes R21's skin without any skin breakdown noted. Review of R21's Braden score, dated 10/30/21, notes R21 is at moderate risk for skin breakdown. Review of R21's wound note, dated 10/30/21, notes R21 with a stage 3 sacral pressure ulcer, 50% pink or red, 50% necrotic (dead), measuring 7cm x 2cm x 0.2cm. Review of R21's pre-admission hospital record does not note R21 with any alterations in skin integrity except for surgical incision to abdomen. On 10/26/21, R21's white blood cell count was 5.5 (normal range is 4.2-11). Review of R21's hospital record, dated 11/2/21, notes R21 presented to the emergency room with low blood pressure requiring intravenous fluids and intravenous medications to stabilize blood pressure. R21's white blood cell count was 15.5. Review of this facility's pressure injury and skin condition assessment policy, revised 1/17/2018, notes a skin condition assessment and pressure ulcer risk assessment (Braden score) will be completed at the time of admission/re-admission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by the licensed nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be reported promptly to the charge nurse who will perform the detailed assessment. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. The licensed nurse is responsible for notifying the attending physician, director of nursing, and legal representative of any suspected wound infection. The attending physician will be notified within 7-14 days of the resident's lack of response to treatment. Review of this facility's pressure ulcer prevention policy, revised 1/15/2018, notes to inspect the skin several times daily during bathing, hygiene, and repositioning measures. Turn dependent resident every two hours or as needed and position resident with pillow or pads protecting bony prominences. Specialty mattresses are used for residents who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds.

Based on interviews and record reviews, this facility failed to promptly relay critical laboratory results to the physician for three residents (R15, R16, and R17) out of three residents reviewed for abnormal laboratory results in a sample of 22. Findings include: On 10/22/2021 at 12:30pm, V31 NP stated that laboratory results will pop up in resident's electronic medical record to be reviewed. V31 stated that V31 would expect the nurse to call nurse practitioner/physician with critical laboratory values. V31 stated that V31 was not made aware of any critical laboratory values for R15. V31 stated that V31 is familiar with R17. V31 stated that V31 would expect the nurse to notify of critical creatinine value, if value is trending upward would expect the nurse to also notify nephrologist so any changes with [CONDITION(S)] treatment could be addressed immediately. V31 stated that it is important to monitor a resident's potassium level because potassium can affect the heart, a high potassium level, can give resident a potassium reducing medication and repeat the potassium level. V31 stated that if potassium level is critically low at 2.7, would give order to administer a potassium supplement and send resident to hospital. V31 stated that resident would need a workup on heart done. 1. R15: On 10/22/2021 at 1:50pm, V12 LPN (licensed practical nurse) stated that critical laboratory test results are telephoned to the nurse by the outside laboratory service. V12 stated that the physician/nurse practitioner should be notified of all critical results immediately. V12 denied receiving any critical laboratory test results for R15. Review of R15's medical record notes diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's laboratory test results, dated 10/12/21 at 3:06pm, notes critical sodium level was called with readback to V12 LPN by the outside laboratory service. R15's critical sodium level was 167 (normal range is 136-147). Review of R15's laboratory test results, dated 10/12/21 at 1:34pm, notes R15 with white blood cells 15.56 (normal range is 4.8-10.8), neutrophils 12.84 (normal range is 1.4-6.8), elevated neutrophils indicate infection; blood glucose level 402 (normal range is 70-110; BUN (blood urea [MEDICATION(S)])55 (normal range is 8-28); creatinine 2.53 (normal range is 0.4-1.6). BUN and creatinine levels monitor how well kidneys are functioning. Review of R15's progress notes, dated 10/13/21 at 6:42pm, notes V3 ADON, V3 spoke with nurse practitioner regarding R15's laboratory test results, V3 received order to transfer R15 to the hospital emergency room for evaluation. Review of R15's medical record, dated 10/12, notes V12 LPN was the nurse assigned to provide care for R15 for the day (7:00am-3:30pm) shift. The U.S. National Library of Medicine ([MEDICATION(S)] plus) notes DKA is a life-threatening problem that affects people with diabetes. DKA happens when the signal from insulin in the body is so low that: glucose (blood sugar) can't go into the cells to be used as a fuel source, the liver makes a huge amount of blood sugar, and fat is broken down too rapidly for the body to process. Fat is broken down into ketones. Ketones are normally used by the muscles and the heart. When ketones are produced quickly and build up in the blood, they can be toxic by making the blood acidic. This condition is known as acidosis. 2. R16: On 10/22/21 at 1:55pm, V10 LPN stated that the nurse is expected to check laboratory results every shift. V10 stated that the results are called to the physician/nurse practitioner. V10 stated that with critically high or low results, the physician is notified immediately. V10 stated that the nurse documents in the resident's progress notes when the physician is notified. V10 stated that V10 does not recall receiving any critical laboratory test results called to V10 on 10/20/21. On 11/3/2021 at 12:00pm, V20 NP (nurse practitioner) stated that laboratory results are electronically transmitted to the resident's medical record by the outside laboratory service. V20 stated that V20 will review the lab results. V20 stated that V20 would expect the nurse to call V20 with all critical laboratory results. V20 stated that potassium is an electrolyte in the body that helps the heart function. V20 stated that V20 does not recall reviewing R16's laboratory test results on 10/20/21. Review of R16's laboratory test results, dated 10/20/2021 at 1:15pm, notes critical potassium level was called with readback to V10 LPN by the outside laboratory service. R16's critical potassium level was 2.7 (normal range is 3.7-5.1). Review of R16's medical record notes R16's laboratory test results were noted as reviewed. There is no documentation of any treatment ordered or initiated upon review of this critical potassium level. 3. R17: Review of R17's laboratory test results, dated 10/20/21 at 1:17pm, notes critical creatinine level was called with readback to V10 LPN by the outside laboratory service. R17's critical creatinine level was 13.35 (normal range is 0.4-1.6). Review of R16's medical record notes R16's laboratory test results were noted as reviewed. There is no documentation of any treatment ordered or initiated upon review of this critical creatinine level. Review of this facility's physician notification of laboratory results policy, revised 3/14/2018, notes the nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician/nurse practitioner. All critical laboratory values will be reported to the physician promptly. Abnormal laboratory value parameters include, but not limited to: white blood cell count greater than 12 or potassium less than 3 shall be reported. The licensed nurse is responsible for documenting the notification of results in the clinical record.

Based on observation, interview, and record review, the facility failed to put preventive measures in place for a resident at risk for falls. This failure affected one of one resident (R4) reviewed for falls and resulted in R4 fracturing his left tibia as a result of fall. Findings include: R4 is an [AGE] year-old male admitted into the facility 06/26/2021 with diagnosis of Dementia Hypertension, Congestive heart failure, [CONDITION(S)]. On 08/23/2021 at 5:00pm R4 fell and sustained a fracture to his left tibia. On 08/30 2021 at 11:25, observation of R4 in bed with no fall precaution in place. Bed is not in the lowest position no floor mats noted. On 8/30/2021 at 9:19am, observation of R4 in bed with no side rails on R4's bed. R4 is asleep currently with his head leaning against a cabinet that's next to his bed. No fall precautions in place. R4's bed not in the lowest position and there are no floor mats in place. On 08/31/2021 at 1:00pm, V3 (ADON - Assistant Director of Nursing) stated side rail assessments are done at admission and quarterly and as needed. On 08/31/2021 at 3:19pm, V26 (Licensed Practical nurse - LPN) stated I had did my rounds and was getting report. The CNAs was about to transfer R4 into the bed because he had just came back from [CONDITION(S)]. By the time I walked down to round again and I heard some grunting noise coming from R4's room. When I got to the R4's room, the left side rails was up and R4 was laying on the floor on his left side with his foot jammed into the rail (bed frame). I tried to lift the bed up but it would not move so I went to go get help from 2 CNAs. We still could not get him out so I went got the other nurse to help me. The bed would not go up so she told me to go get an extension cord from the fourth floor. I don't why she told me to go get the extension cord because the bed was working. By the time I made it back with the cord they had already had him up. I'm not sure how they got him up. I assumed I had to get the extension cord to help get the bed up but the bed was working it just wouldn't move. On 08/31/2021 at 3:19 while conducting an interview with V26 (LPN), V26 showed surveyor R4's foot was on the bottom of the bed in a small space in the bed frame. On 09/1/2021 at 10:57 am, V2 (DON - Director of Nursing) stated, From the report, R4 was found on floor with his foot in the rail. I don't remember what side. His foot was in the bed frame in one of the spaces. He has same bed. When we came in on the next day it (the bed) was working. The plug is at the head of the bed .to the end of the bed .he has the same mattress. On 09/1/2021, V27 (Maintenance Director) stated, We replace the motors, the remote controls the foot boards and headboards. We do the mattress gap test quarterly. We check by taking a tape measure and measure the gap between the mattress and the headboard and foot board. we check to make sure there is not a gap more than 4 and a half inches. I was on vacation the last week and a half and did not get any report about R4's bed not working. He must have been on the floor if it (R4's leg) was under here (bottom of the bed frame). On 09/1/2021 at 11:34am, V28 (Maintenance Assistant) stated, I was here but did not get any work order for R4's bed not working. The cable is plugged in the wall behind the bed. On 09/1/2021 at 2:32pm V3 ADON stated, In order to prevent this from happening again we removed the side rails from the beds. We ordered (PT/OT) physical therapy and occupational therapy and encourage R4 to use the call light for assistance. We still educate to use the call light even if they don't understand how to use the call light. Nothing was put in place to keep this from happening again because this was an isolated incident, and it was not an error in equipment or nothing like that. On 09/01/2021 at 3:20pm V18 (Restorative Nurse) stated she was on vacation when R4 fell . V18 stated I didn't look at the report yet. (V3 ADON) is the head of the team. He (V3) did it (created fall report) while I was off. I would have put interventions in place for low bed, floor mats, add him to the falling leaf program and add him to the fall list. Record review of R4 progress note shows on 08/23/2021 R4 was observed on the floor on his left side with his left ankle under the rail and his left heel in between the rail. Record review of R4 progress notes does not show fall precautions were put in place for R4 post fall. Record review of R4 care plan does not show preventive measures in place to prevent further injury to R4. Facility failed to provide requested fall policy.

Based on observation, interview and record review the facility failed to develop interventions to promote a safe environment for a resident (R1) with cognitive deficits, wandering behaviors and the behavior of sitting on top of furniture. This is based on 1 (R1) of 3 residents reviewed for safety and fall prevention. This failure resulted R1 sitting on a dresser and then falling forward onto her head. R1 was observed with swelling to the head. R1 subsequently was sent to local hospital and diagnosed with a fall at nursing home, closed head injury, large frontal scalp hematoma, and non-displaced neck fracture. Findings include: R1 is a [AGE] year old female, R1 plan of care shows R1 has diagnosis of hypertension, [CONDITION(S)], unspecified other frontal-temporal dementia, unspecified signs and symptoms involving cognitive functions and awareness, dementia with other disease classified elsewhere with behavioral disturbance, other Alzheimer's disease, history of falling, unspecified [CONDITION(S)] not due to substance or known physiological condition, contusion of right eyelid and periocular area, [CONDITION(S)] of unspecified orbit, unspecified displaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing and Alzheimer's disease unspecified. R1 facility incident report dated 4/1/2021 at 2:16pm shows unwitnessed incident in resident room completed by V8 (Nurse). Incident note states Resident (R1) falls from the nightstand in the room next door. Resident was told not to sit there, but resident still sitting there. Resident was noted to be on the floor by CNA assigned, resident was asked if she was okay, and the resident stated yes, but my head hurt. Resident was asked what happened, resident said that she fell out from the nightstand, upon head-to-toe assessment, resident is noted with a big inflammation on her front head, resident was asked if she has pain on the scale 0 to 10, resident said yes, but she did not grade it she just said pain on her head, resident was assisted to her room and bed for facility transfer order. Incident note dated 4/1/2021 at 2:16pm notes injuries observed at time of incident was hematoma to forehead. Mental status is orientated to person, place, and situation. No injuries reported post incident. Predisposing environmental factors, none box is checked. Predisposing physiological factors, none box is checked. Predisposing situation factors, none box is checked. Witness statements dated 4/1/2021 from V4 (LPN Licensed Practice Nurse), V5 (CNA Certified Nursing Assistant) and V8 (Nurse) show the same statement as follows Resident (R1) falls from nightstand in the next-door room. Resident was told not to sit there, but resident still sitting there. Resident was noted on the floor by CNA assigned, resident was asked if she was okay, and the resident stated yes but my head hurt. Resident was asked what happened, resident said that she fell out from the nightstand, upon head-to-toe assessment, resident is noted with a big inflammation on her front head. Resident was asked if she has pain on the scale 0 to 10, resident said yes, but she did not grade it she just said pain on her head, resident was assisted to her room and bed for facility transfer orders. Witness statement from V6 (Housekeeping staff) dated 4/1/21 shows that V6 observed resident (R1) suddenly fall forward as she was trying to reach for something. She stated that she observed resident sitting on nightstand. On 04/01/2021 2:16 PM resident statement: Resident stated that she fell out from a nightstand where she was seated. Incident report dated 4/1/21 at 2:16pm states that the DON, POA, and Physician were all notified of the incident at on 4/1/21. Assessment noted on 4/1/2021 at 2:16 pm included the following: Vital Signs: BP 169/89 - Lying, left arm at 15:14 Temp 98.1 at 15:15 Temporal Artery pulse 77, regular at 15:15 Respiration 18 at 15:15 Pain level 0 at 12:53 O2 98% on room air at 15:15 Assessment: Unwitnessed fall, neurological checks initiated. Alert and oriented to time, person, place, and situation. No changes in range of motion from normal baseline. New injury observed. Resident is noted with a big inflammation on her front head. Actions/ Interventions: Resident (R1) was assisted back to her room and bed, vital was taken, ice package was given, neuro checks continue, head to toe assessment is done, 911 is called, MD, ADON, DON, and family member are made aware, resident is kept sitting up until ambulance comes. Intervention: Resident is told not to sit on nightstands, resident is monitored every 5 minutes. R1 progress note titled fall IDT states root cause of fall: Resident has cognitive deficits due to cognitive deficits secondary to dementia and Alzheimer's. Resident was sitting on the dresser as she was attempting to reach for an item. R1 progress notes dated 4/1/21 at 10:15p.m shows, writer called hospital for update on resident status post fall. Nurse on duty, stated resident has been admitted for C7 fracture with possibility of surgery. A surgical consult will be held in the AM at for definite plan. If no surgery is done, resident may possibly return to facility tomorrow 4/2/21, as stated by NOD (Nurse on Duty). Power of Attorney aware. R1 emergency department records dated 4/1/21 shows admitting diagnosis fall at nursing home, closed head injury, large frontal scalp hematoma, dementia with behavioral disturbance and non-displaced C7 lamina fracture. On 4/15/21 at 10:04a.m R1 was observed walking down the hallway, then entering her room. V3 (Nurse) followed. R1 was observed with purple discoloration to the right side of her face, neck, and mouth area. R1 had large swelling to right side of her head extending down to her face. During an attempt to interview R1, she observed to be alert to name. When asked how she got the discoloration to her face, R1 replied Oh no not again!. R1 then proceeded to move things around on her bed. R1 continued saying random words. On 4/15/21 at 10:08a.m, V3 (Nurse) said she was the nurse assigned to R1 today (4/15/21). V3 said R1 sustain the bruising and swelling to the head from a fall. V3 said R1 fell from a chest dresser in another resident's room. V3 said R1 would always go to that room and sit on the dresser. V3 said the staff would have to constantly redirect R1 because R1 has dementia and R1 does not remember what you tell her. V3 said R1 had been going in that room and sitting on the dresser for awhile. On 4/15/21 at 10:56a.m V5 (CNA) said R1 has been going into another resident's room and sits on the dresser. V5 said she needs to constantly tell R1 to get down when she sees R1 on the dresser. V5 said she did not witness the fall on 4/1/21. V5 said R1 had been going into that room and sitting on the dresser for about 2 weeks prior to R1 falling from that dresser. V5 said she did not inform anyone that R1 had been sitting on the dresser. V5 told R1 she should not be sitting on the dresser because she could fall and hurt herself. V5 stated R1 is elderly and most elderly people are weak. V5 said R1 does not remember what you tell her because R1 has dementia and therefore R1 always must be redirected. On 4/15/21 at 11:20a.m V4 (Nurse) said on 4/1/21 he saw R1 in another resident's room sitting on the dresser. V4 said he redirected R1 down and took R1 back to her room and put R1 in the bed so that R1 could go to sleep. V4 said about 10 minutes later, he was sitting at the nurse's station when he heard a loud boom sound. He immediately got up and went toward the sound. V4 said he observed R1 on the floor and getting up. V4 said as he approached R1 he observed some swelling to R1's head. V4 said he did an assessment and took R1 to her room. There he noticed that the swelling to R1 head was very soft. V4 said an ice pack was given to R1 and her vital signs were assessed. V4 said it had only been 10 minutes between the time he took R1 to her room and R1 returning to another room then falling from the dresser. V4 said he did not inform anyone that he saw R1 sitting on that dresser prior to the fall. V4 said R1 should not be on the dresser because she could fall from the dresser just as she did. V4 said he does not know how long R1 had been going in that room and sitting on that dresser but that R1 goes into that room often to visit with her friend. V4 did say he has heard the aides tell R1 to get off the dresser in the past but he does not know when that was. On 4/15/21 at 11:32a.m V6 (Housekeeper) said on 4/1/21 she was standing near the elevator, when she saw R1 sitting on the dresser in the room across from the elevator. V6 said she saw R1 fall forward, face first onto the floor. V6 said a loud sound was made when R1 hit the floor. V6 said she saw the nurse go to the room where R1 had just fallen. V6 said she did not see R1 reach for anything prior to falling. V6 said she has seen R1 sitting on that dresser in the previously, however she could not remember the date. V6 said she did not notify anyone that R1 was sitting on the dresser prior to the fall. On 4/16/21 at 10:56a.m V8 (Nurse) said R1 fell from the dresser but she did not witness it. V8 said R1 always sits on that dresser and staff must redirect her but she continues to sit on the dresser. V8 said she does not remember if V4 informed her that R1 was sitting on the dresser prior to R1 falling on 4/1/21. V8 said R1 should not be sitting on the dresser because she could fall and hurt herself. V8 said R1 forgets what you tell her within 5 minutes and R1 must be reminded constantly. V8 said if she was informed, she would have kept and eye on R1. Meaning when she saw R1 sitting on the dresser, she redirected R1 back to her room. On 4/23/21 at 12:03p.m V8 said she completed the incident report for R1. She said she filled it out very quickly and therefor missed some information on the report. V8 said the incident did not happen in R1's room but it happened in another room. R1 was not orientated to place and situation. R1 did not lose consciousness after the fall on 4/1/21. R1 was ambulatory. Furniture was a predisposing environmental factor in the incident. Impaired memory was a predisposing physiological factor in the incident. On 4/16/21 at 11:16a.m V2 (ADON-Assistant Director of Nursing) said he conducts fall investigations for the facility. V2 said he was informed that R1 fell from the dresser on 4/1/21. V2 said when he arrived on the unit staff had taken R1 to her room and R1 was in the bed. V2 said he was not aware that R1 was going into another room and sitting on the dresser. V2 said when R1 fell it was the first time he had heard of R1 going in that room and sitting on the dresser. V2 said it is not safe for resident to be sitting on the dresser because they could fall. V2 said he should have been made aware so that he could have implemented interventions for R1. V2 said if he would have known he would have removed the dresser from the room. V2 said prior to the fall R1's fall score was 10 which represents a high risk for falls. V2 said R1's fall risk score is now 11. R1 remains a high risk for falls. R1's fall risk assessment dated [DATE] shows a score of 10 (high risk). R1's MDS dated [DATE] shows R1 has diagnosis of other frontotemporal dementia, unspecified symptoms and signs with cognitive functions and awareness, Alzheimer's, non-Alzheimer's dementia and [CONDITION(S)] (other than schizophrenia). R1 care plan dated 4/10/2019 with revision date of 4/15/21 states (R1) has impaired cognitive functioning or impaired thought processes related to dementia. Focus points on the care plan state Due to my cognition I sit on furniture (i.e. nightstands). Some of the Interventions points on the care plan state Administer medications as ordered. Monitor/document for side effects and effectiveness.; Ask yes/no questions to determine the resident's needs.; Upon observance of resident sitting on furniture i.e. nightstand. Staff will redirect the resident to a chair. Date Initiated: 04/05/2021 Revision on: 04/15/2021. The intervention of redirecting R1 when observed sitting on a nightstand was not initiated until 4/5/21. V5 said she observed R1 sitting on the dresser 2 weeks prior to R1 falling on 4/1/21. Additional care plan for R1 dated 3/26/2019 with revision date of 4/21/21 shows R1 is at risk for falls and injury related to falls. Risk factors include Major cognitive disorder, Dementia caused by behavioral abnormalities, possible medication side effects, incontinence, H/O (History of) falls, and Alzheimer's. It further states R1 will have interventions in place and reviewed as needed to address risk for fall and injury related to fall through next review.

Based on interview and record review, the facility failed to keep a resident free from abuse as a result of a physical altercation between two residents, (R1 and R2). This failure resulted in R1 being emergently transferred to local hospital, where he was diagnosed with a left [CONDITION(S)]. Findings include: R1 is an [AGE] year old resident of the facility whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 is a [AGE] year old resident of the facility whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3/30/21 1:20 PM R2 stated, I was telling him (R1) that he kept urinating on the floor in the bathroom. He then got out of his bed and grabbed me. We fell and we were tussling on the floor. He got up and sat on the garbage can. He told them that I was aggressive with him. That was on Friday. At this time, R5 also said, I heard the two of them (R1, R2) fighting okay .I didn't see anything! 3/30/21 at 1:40PM, R1 stated The man in the next bed (R2), came up to me; he was talking and saying that I urinated on the floor. I ask him how could he know that I was urinating on the floor if he didn't see me? He grabbed me by my collar and hit me here and here. (R1 pointed to his chin and forehead). We fell to the floor and then I got up. 4/1/21 1:00 PM V17 (CNA-Certified Nursing Assistant) said, a little after 8:00 am (R2) came to the nursing station and said, come get this man, he urinated all over the floor. We separated them (R1 and R2). R1 was set up in the hall to eat his breakfast. Later R1 went back in the room. At some time he told his family that he had been punched. (V6, LPN-Licensed Practical Nurse) came in to work and R1 told V6 that he had been hit. We kept them separated and then R1 was moved to another room. 3/31/21 1:36 PM V7 (LPN-Licensed Practical Nurse) said, about 8:00 am when R2 came to the nursing station. He said that R1 urinated on the floor and we needed to come and get him. R1 was standing by the bathroom, he said R2 pushed him. I took R1 to the nursing station, R2 denied pushing him. We kept them separated and I told the staff to keep them separated. 3/31/21 12:47 PM V6, LPN said, I came in at 10:15am or so on my off day (3/26/21). As far as I know the incident happened about 8:25-8:30am. R1 was in the room with V2. When I came in R1 was sitting in his chair. He said, thank God you are here. He reported an altercation with R2. R1 said that R2 asked me about urine. R1 said, he hit me on my forehead, chin and lip. I lost my balance and fell on my tailbone and knee. R1 was holding his left hip. I checked him for bruises and gave him two (acetaminophen). I called (V5-Family Member). I went and told the doctor that he (R1) needed x-rays. A progress note on 3/26/21 reads that R1 was assessed for injuries. R1 said that he fell on his left tail bone and knee. He complained of pain on the left tail bone and knee. An x-ray was ordered. A progress note dated 3/26/21 5:19 PM reads that the x-ray findings presented an acute transcervical fracture of the proximal femur. R1 was sent to the hospital on 3/26/21. A discharge note from the hospital dated 3/29/21 reads that R1 was brought to the emergency department and was found to have a left [CONDITION(S)]. He went to OR (operating room) on 3/27/21 for left THA (total hip arthroplasty). A Policy titled Abuse Prevention and Reporting-Illinois reads, Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on observations, interviews, and record reviews, the facility allowed use of bedrails without appropriate assessment and possible risk for entrapment for one resident (R1). This affected one resident (R1) of three residents reviewed for falls. As a result, R1 suffered a rib fracture while in the bed attempting to hold on to or brace himself while falling from the bed. Findings include: R1's [DIAGNOSES REDACTED]. R1 was prescribed Calcium [MEDICATION NAME] with Vitamin D for [MEDICAL CONDITION] from 8/16/19-8/21/19. On 9/24/19 at 2:17PM, R1 was observed in bed with bilateral assist rails in the up position. On 9/25/19 at 11:00AM, R1 was in bed with bilateral rails in up position. On 9/24 and 9/25/2019, R1 was observed in bed, with the head of the bed elevated approximately 30 degrees, and bilateral rails in the up position. Rails were placed in the center of the bed and were about 1/3 of the bed length. R1 is unable to answer questions, but oriented to name for surveyor. R1 responds with one or two words. R1's Progress Notes, dated 9/14/19, denotes R1 complained of pain to his left side and back during assessment following the fall. R1 was sent to the hospital for evaluation. The hospital's After Visit Summary, provided by the facility, denotes [DIAGNOSES REDACTED]. Further hospital records, obtained by IDPH, denote closed fracture of one rib, sixth, on left side and post traumatic minimally displaced posterior left sixth rib fracture. Staff members were interviewed about the fall incident and the use of the railing attached to R1's bed as follows: On 10/9/19 at 1:30PM, the left side rail of R1's bed that he was in on 9/14/19, has a side rail with a length of 26 1/2 inches. The distance from the top of the headboard to the nearest point on the side rail is 291/2 inches. The opening when the bed is in about 45 degree position is 5 1/2 inches. There is no gap in the area from the rail to the mattress. The side rail opens by pressing a knob located at the base where the rail attaches to the bed. Once knob is pressed, the side rail flips up towards the headboard. The side rail is attached to the bed frame by a clasp that screws and tightens onto the bed frame. On 9/24/19 at 2:34PM, V12, Certified Nursing Assistant (CNA), said when she entered R1's room on 9/14/19, she saw him sliding onto the floor from the top of the bed, between the bed rail and the head board. V12 said it looked like R1 slid into this position. V12 said she called for help and assisted R1 to the floor. On 9/24/19 at 11:37AM, V4, Nurse, by phone interview, said on 9/14/19 she had finished walking rounds and about ten minutes later, the CNA (V12) said R1 was on the floor. When V4 entered R1's room, she saw him hanging from the side rail and most of his body was being supported by the side rail. R1 was sliding out of the bed from the opening at the head of the bed, and the top of the left side rail. R1 complained of headache and back pain, so he was sent to the hospital for an evaluation. V4 said R1 returned from his evaluation the same shift and the hospital said, he had a fractured rib from hanging from the side rails. On 9/25/19 at 10:32AM, V3, Admissions Nurse, said on 9/14/19, R1 slid out of his bed. V3 said he did not witness the fall. V3 was told when the CNA (V12) entered the room, R1 was about to land on the floor so she assisted him to the ground. V3 said R1 was diagnosed with [REDACTED]. V3 said he does not know how R1 got the rib fracture. V3 said the assist rail did not do a god job of assisting with R1's bed mobility or re-positioning, but did stop a fall. On 9/25/19 at 11:00AM, with V3 present, the surveyor asked R1 to raise his right leg, then his left leg. R1 was unable to purposefully move legs; only a visible twitch to his legs observed. On 9/25/19 at 1:52PM, V19, Nurse, said on 9/14/19, he saw R1 sliding out of the bed; the rails were up. R1 was going towards his left side, his head was between the head board and the rail. I have not seen him roll before. He did not assist us putting him on the floor. R1 was not in a reasonable position to get in out of bed. I did not see him holding the rail, but he was up against the rail. R1 can't control his legs because they are weak. On 9/26/19 at 9:33AM, V20, Director of Rehab, said R1 was on caseload for physical and occupational therapy from 8/6/19-8/26/19. V20 said R1 can move his upper extremities, but against gravity he only shows muscle twitching. R1's right arm is stronger than his left, but he can't move his arms in an upward motion or lift them. R1 has limited range of motion in his hands and fingers. He might be able to grab the rail with his right hand. R1 is unable to move his left leg and his right leg is weak. R1 is dependent on staff to reposition him in bed. V20 said R1 would probably not be able to stop himself if he was rolling in the bed. R1 requires moderate assist with 2 persons for bed mobility. On 8/26/19, day of therapy discharge, R1 notes read he is not able to turn himself and needs a second person to complete the turn safely. On 9/26/19 at 10:08AM V21(CNA) said R1 can't participate in any of his cares. He tries to move but can't. Once turned with assist he will try to grab for the rail. V21 said she has seen R1 sliding in the bed and requires to be repositioned. V21 said when the head of the bed is elevated, he will slide. V21 said she places pillows around him to keep him in position. On 9/26/19, V27 (Nurse Practitioner) said R1 has dementia and has very weak extremities. His left arm is weaker than the right. V27 said R1 was not previously considered a high fall risk. V27 said she doesn't think he has the strength to stop himself from sliding. V27 said R1 has a [DIAGNOSES REDACTED]. The only other causes of a rib fracture would be related to spontaneous events from [MEDICAL CONDITION], which R1 does not have. R1 does have [MEDICAL CONDITION]. On 8/5/19, R1's Side Rail Assessment denotes no side rails are attached to the resident's bed. There was not a more current Assessment completed on or before 9/14/19. On 8/12/19, a Functional Status Assessment for bed mobility was completed, denoting R1 requires extensive assist with staff providing weight bearing support. The same assessment denotes R1 has impairment on one side of upper and lower extremities. Review of R1's care plan denotes limited range of motion to upper and lower extremities. Care plan denotes R1 is cognitively impaired related to dementia. On 9/24/19, V6, Nurse, said the Side Rail Assessment should be completed before side rails are used. V6 said she can't think of any resident she is assigned to that does not use rails. On 9/24/19 at 2:54PM, V13, Restorative Nurse, said she does not discuss the risk of side rail use with resident's family or representatives. V13 said the initial Side Rail Assessment is done by the admitting nurse. V13 does the Assessment quarterly. The purpose of Side Rail Assessment is to see if the rails are still appropriate for the resident to use. On 9/26/19, V13, Restorative Nurse, said there is no documentation that any other interventions were attempted for R1 before the rails were applied to the bed. V13 said she did not know when the rails were placed on R1's bed. V13 said the Hospice service may have provided a new bed with rails. V13 said the side rail assessment does ask what other interventions have been attempted. V24, Assistant Administrator, said R1's bed is not a Hospice delivered bed and is the facility's bed. The facility policy denotes bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one quarter, or one eight lengths. Examples of bed rails include: side rails, bed side rails, safety rails, grab bars, and assist rails. The same policy denotes the facility shall ensure that prior to the installation of bed rails, the facility has attempted to use alternatives.

Based on observation, interview, and record review, the facility failed to monitor a cognitively impaired resident with known exit seeking behavior, for attempts to leave a nursing unit unescorted by staff, and check the functioning of a resident's electronic monitoring device daily according to the facility's policy. As a result, on 8/24/2019, R1, a cognitively impaired resident, left a monitored nursing unit by an elevator without staff being alerted, and left the building from an exit door, which was not alarmed at the time. A body matching R1's description was later found by local police in the river. This was identified as an Immediate Jeopardy situation that began on 08/24/2019 when R1 left the facility unnoticed and unattended by staff. V1 (Administrator) was informed of the Immediate Jeopardy on 09/11/2019 at 4:27 PM. The Immediate Jeopardy was removed on 09/13/2019. This deficient practice has the potential to affect R2, R4, R5, R6, R7, and R9, who were identified as elopement risks and reside on the same floor as R1. Findings include: On 8/30/2019 at 9:37 AM, the surveyor observed video footage of taped recording of R1 leaving the building on 8/24/2019. V1(Administrator), V2 (DON-Director of Nursing), V11 (ADON-Assistant Director of Nursing), V20 (Assistant Administrator), and V21 (Maintenance Director) were present at the time of the viewing. The surveyor saw resident at the service elevator, crossing hallway, and leaving facility via south exit door on 08/24/2019 at 9:26 AM. Housekeeping and Dietary staff are seen in video footage, however, they are not seen with R1. V1 (Administrator), on 08/30/2019 at 10:20 AM, describes the 4th floor as a monitored, semi-secure unit; semi-secure because all stairwell doors are alarmed but not locked, elevators (front and service) require a code to leave unit, and unit has elopement prevention system in place (sensors by front and service elevators). V1 said the exit door did not have an alarm at the time of the incident, and did not require a code to get out of the door. V1, on 09/10/2019 at 4:16 PM, said, We don't know how R1 got on service elevator; if staff were ignoring the alarm or if resident took off the electronic monitoring device. Observations were made on the 4th Floor on 08/29/2019 from 1:49 PM to 4:05 PM. All elevators are equipped with electronic monitoring sensors, and all require a code to bring the elevator to the floor. The electronic monitoring sensor was frequently alarming when no resident, who wears an electronic monitoring device, was near the sensor. V22 (Licensed Practical Nurse) on 08/29/2019 at 2:15 PM, said, It just goes off. It's a problem. They (management) know about it. It's been going on for some time. On 09/03/2019 at 2:20 PM with V12 (Housekeeping Supervisor), surveyor opened south exit door, setting off the alarm. V13 (Maintenance) responded to the alarm over two minutes later. V1 (Administrator), on 09/06/2019 at 3:38 PM, said staff should respond to alarm as soon as possible, I guess it would depend on the situation. While on the 4th floor, the surveyor also observed three elevators. All elevators have electronic monitoring sensors and keypads. Staff were observed using a code to bring the elevators to the 4th Floor. Observations were made on the 4th Floor on 09/05/2019 from 3:46 PM to 4:02 PM. R2 walked slowly past the front elevators. The sensors did not alarm until R2 turned around and walked past the sensor again. R3 walked past the front elevator without triggering the sensors. V8 (Social Service Director) at 3:51 PM, said R3's device didn't trigger the sensors because it was covered by R3's sock. R3's device was uncovered but did not activate the sensors. R4 walked past the front elevators and stood at the Nurses Station; the sensors did not alarm. At 4:02 PM the front elevators sensors alarmed. The code for R4's monitoring triggered the alarm, however, R4 was not near the elevators. At 4:08 PM, R5's monitoring device triggered the alarms; R5 was around the corner, approximately 20 feet away from the sensors. V21 (Maintenance Director) at 3:56 PM said he didn't know how close a resident had to be to the sensors in order for them to alarm, didn't know why there was a delay in the alarm sounding, or if there should be a delay. V8, at 4:07 PM, said that there should be no delay. V8 said on 08/30/2019 at 1:41 PM, residents' electronic monitoring devices were checked weekly prior to R1's elopement; now checked daily. V1 (Administrator) on 09/06/2019 at 3:38 PM, said he was not aware that the alarm kept going off; no log is kept of electronic monitoring devices codes that trigger the sensor. We don't monitor it. I guess someone could write it down. V27 (Vendor) on 09/09/2019 at 1:38 PM, said there should be no delay; the alarm should sound almost immediately; residents' electronic monitoring devices should be checked daily. Manufacturer's Installation Manual (Version 14, page 10) documents, The daily testing of electronic monitoring device and regular servicing of installed products is recommended to minimize problems detecting wanderers or general door security. Invoice of 09/06/2019 documents the 4th Floor electronic monitor device will be replaced because it's too sensitive; it goes off if resident is not by elevator. R1's face sheet documents R1 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) assessment, dated 07/24/2019, indicated the resident had moderate cognitive impairment. R1's hospital record Progress Note of 07/10/2019, documents, Per sitter/RN (Registered Nurse), he has been wandering out of his room and occasionally trying to leave the unit and Progress Note of 07/11/2019 documents, He was significantly agitated and trying to leave the floor. R1's facility's progress note of 07/18/2019 at 2:10 PM documents R1 was transferred from the 3rd floor to the 4th floor after R1 was noted at the Nurses Station on the 3rd Floor with a bag filled with his belongings, stating he was leaving to catch the bus. R1's Community Survival Skill Assessment, dated 07/24/2019, documents The resident does not appear to be capable of unsupervised outside pass privileges at this time. Resident needs supervision. R1's Elopement/Unauthorized Leave Risk Review, dated 07/24/2019, documents, At risk for elopement and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. R1's Care Plan titled, I am an elopement risk/wanderer r/t (related to) impaired safety awareness (initiated 07/27/2019, revised 08/26/2019) documents the following interventions: -Assess for fall risk, identify pattern of wandering, intervene as appropriate, monitor for fatigue and weight loss, Elopement Prevention Device #72. The care plan had no specific monitoring intervention beyond the electronic device. There is no interim care plan to address R1's wandering and exit seeking behavior. Facility's incident report of 09/04/2019 documents: Elopement with possible adverse outcome. Awaiting police information. Local police department missing person report narrative, with dates of 08/24/2019 to 09/04/2019, contained the following information: V15 (Detective-Local Police Department) was contacted 09/04/2019 by V16 (Detective-Neighboring Police Department) regarding R1. V16 related on (MONTH) 30, 2019 a body was located on the south branch of local river. The body was subsequently sent to Medical Examiner's Office where an identification was unable to be made. V16 reviewed a missing person flyer regarding R1 and noted the clothes that R1 was last seen wearing, matched the body that was located. V16 documented, the medical examiner's office reported due to the body being in the water anywhere from three days to three weeks physical identification could not be made. V16 reported the body was found to have dentures with R1's last name written on them. On 09/09/2019, both V16 (Detective) at 9:39 AM and V26 (Medical Examiner's Office) at 9:33 AM, confirmed the body retrieved from the local river had an electronic device attached to the leg. The facility's 4th floor direct care staff on duty the day of R1's elopement were interviewed about R1's elopement incident and plan of care for monitoring R1. V6 (Registered Nurse/RN) reported on 08/29/2019 at 11:13 AM and 09/10/2017 at 11:26 AM, I saw him (R1) that morning during initial rounds in his room, his elopement prevention device was on, and again in the dining room between 8:30 AM and 9:00 AM. I did notice him at approximately 9:30 AM getting onto the elevator. He said he wanted to go downstairs. I re-directed him to his room, he did go back to his room. I don't remember if his elopement prevention device triggered the alarm. I went on to do my medication pass then around 10:45 AM-11:00 AM, I went to check on him. He wasn't in his room or dining room, I called a Code Pink (code called when resident can't be found). V6 said she never received training about the electronic monitoring device system, elopement risk, and wasn't informed how frequently to check residents who are at risk for elopement prior to R1's elopement. V4 (Licensed Practical Nurse/LPN) on 08/30/2019 at 10:02 AM stated, I was passing medications out, V6 was getting ready to medicate him and she asked did I see (R1). I told her I saw him earlier. V6 already looked in his room. All staff on unit looked for him, but Code Pink called before 4th floor staff started to look for him. V5 (CNA-Certified Nursing Assistant) on 08/30/2019 at 10:37 AM reported, V6 (RN-Registered Nurse) asked me around 10:30 AM if I had seen R1. I last saw him between 8:30 AM-9:30 AM. I said he has an elopement prevention device on, and I'll start looking for him. I looked for him, I couldn't find him. I came across V6 again, she asked me if I found him I said no, she said ok I'm going to call a Code Pink. I came down to reception and told receptionist that I'm going to look for him outside. I drove east and west down the main road but didn't find him. V7 (CNA) was assigned to take care of R1 on the day R1's elopement. On 08/30/2019 at 12:36 PM and 09/10/2019 at 9:21 AM, V7 said, This was the first time I took care of him. I was told by another CNA that he had an elopement prevention device and we had to make sure he didn't get down stairwell or on elevator. He was in the dining room from 7:30 AM-9:45 AM. Then when I left the dining room, around 10:00 AM, he was at the elevator with nurse, I walked him to his room. V7 said she wasn't told how frequently she should check on R1. V7 defined frequently as every 30-45 minutes. I did not check on him from 10:00-11:00 AM. V7 said [MEDICAL TREATMENT] staff told her R1 was hanging around the service elevator that day. V7 said she did not receive any training about Code Pink, electronic monitoring device system, or elopement risk, and wasn't informed how frequently to check residents who are at risk for elopement prior to R1's elopement. V9 (CNA) on 08/30/2019 at 3:38 PM said, I stopped him from getting on the front elevator around 9:00 AM or 9:30 AM. I saw him go around the corner, I thought he was going to his room. His room was near the service elevator. The next time I heard anything was, I think, between 10:30 AM and 11:00 AM. They called a Code Pink and we all went to look for him. V10 (CNA) on 08/30/2019 at 4:20 PM and 09/10/2019 at 8:54 PM, said, I was in a resident's room when R1 got off the unit. He does wander, he wanders all the time. I've seen him get on the elevator, I've taken him off the elevator. We re-direct him to his room or Dining Room, if staff aren't paying attention to him he leaves; he will wander and try to find a way to get out. He needs 1:1 supervision. He shouldn't be re-directed to his room because no one can monitor (continuously) him in his room. It's better to re-direct him to the Dining Room, staff are always present. We're supposed to document in Point of Care every time a resident has a behavior. They didn't tell me how often to check on him. V8 (Social Service Director), 08/30/2019 at 1:41 PM and 09/10/2019 at 11:02 PM, said R1 was transferred to the 4th Floor due to behaviors including exit seeking and wandering. V8 said, I know when he was first admitted to the facility, he tried at least twice to leave, I know because they called his sister. R1 said he wanted to leave the facility and did try to leave while residing on the 3rd Floor. V8 said R1 wasn't appropriate for unsupervised community access due to poor decision making skills. V8 said interventions implemented included placing an electronic monitoring device on resident; moving him to the monitored unit. V8 said, When R1 was moved to 4th floor we felt it would be better for him to be at a smaller facility with a more secure unit because his behaviors (desire to leave facility, wandering, exit seeking); we felt he might be more appropriate for placement at a SMI (mental health) facility. We did talk to R1's family about placement at another facility because we thought it would be a better fit. V8 said, They monitor them (residents at risk for elopement) like very hour or so. To be honest, I would have to ask the nurse how often R1 should have been checked on for his whereabouts, it would be a nursing call, time frames for checks vary. I don't know if there is one (written monitoring policy), to be honest. I'll check with Nursing and get it for you as soon as possible, if it exists. V8 said, There is no written policy for frequency of monitoring residents at risk for elopement. Staff should check them hourly. We started documenting (on residents with electronic monitoring devices) after R1 eloped. V8 said there is no written Elopement Risk Protocol; protocol consists of placing an electronic monitoring device on resident, move resident to 4th Floor, care plan for elopement. V8 said she conducted in-services prior to R1 leaving facility that discussed elopement risk, electronic monitoring device system, and Code Pink (code called when resident can't be found). I explained there's a list of residents, who are elopement risks, at all Nurses Station and front desk, if they hear alarm go off they are to see which resident triggered system and check that resident is still on floor. V8 was unable to present sign in list for this in-service, We looked, we can't find it. The Facility's Elopement Device policy and procedure, effective 08/23/2017, revised 08/23/2109, included the following under procedure: 3. The elopement alert exit door device will be inspected for proper working daily. 4. The inspection and status of the test will be recorded on a facility-approved log. 6. The anklet or bracelet device will be inspected by nursing personnel once each day. R1's EMAR (Electronic Medication Administration Record), 08/2019 does not document electronic monitoring device was checked daily for placement prior to 08/24/2019, or on the day R1 eloped. R1's Order Recap Report (Physicians Order Sheet) documents an order to check electronic monitoring device placement with resident every shift for elopement risk, start date 08/24/2019. R2's, R4's, R5's, R6's, R7's and R9's 08/2019 EMARs and Physician order [REDACTED]. V7 (CNA), on 08/30/2019 at 8:30 AM said, I didn't check his (R1's) electronic monitoring device because he was up and dressed when I started my shift. The facility did the following to remove the immediacy, however, the facility remains out of compliance at a level two harm since additional time is needed to monitor the effectiveness of the in-service training: 1. Staff were in-serviced/trained by Social Service Director on elopement precautions and facility's policy and procedure for monitoring residents at risk for elopement on 8/24/2019 and 8/25/2019 by Staffing Coordinator. Training was initiated on 8/24/19 and will be ongoing. Staff on vacation or FMLA (Family and Medical Leave Act) will be in-serviced before returning to work by Social Services, Nurse management, and HR (Human Resources). Administration will monitor for compliance. 2. New hires will be trained on elopement precautions, code pink, and (electronic monitoring system) as part of their general orientation before starting by HR, Nurse management, or Social Services. 3. Nurses in-serviced on checking for (electronic monitoring device) every shift on 8/24/2019 and 8/25/2019 by Nurse manager. Training and monitoring will be ongoing and will be included in training upon hire by Nurse Management. QA (Quality Assurance) tool in place. 4. All (electronic monitoring devices) were checked for functionality on 8/24/19 by Social Services and Restorative Aid. This includes testing each (electronic monitoring device) with either the rest wand, or walking the resident near the (electronic monitoring) system to activate it. This is recorded on the daily (electronic monitoring system) functionality log. (Local Vendor-electronic monitoring system repair company) serviced the system on 8/27/19, 9/6/19, and 9/9/19. Administration will monitor weekly for 3 months and then monthly for 3 months for compliance. Logs and forms are kept at the front desk. 5. Maintenance program for checking functionality of devices reviewed and in place by 09/13/2019. 6. All door and elevators secured with an electronic monitoring system were checked for functionality by maintenance staff and are in working order as of 09/09/2019. Maintenance staff and Manager on Duty on the weekends will check for functionality by using the test wand near the secured doors and elevators. (Electronic monitoring system repair company) replaced (electronic monitoring system) sensors with new sensors on 09/06/2019, and 09/09/2019. QA tool in place and will be completed by maintenance staff and manager on duty. Log with forms is kept at the front desk. Administrator will oversee this for compliance. 7. Electronic monitoring system repair company will perform monthly inspections for 6 months to ensure proper functioning and quarterly thereafter. Electronic monitoring system repair company serviced the system on 8/27/19, 9/6/19, and 9/9/19. Maintenance responsible for scheduling and tracking the inspections. Work orders will be saved by maintenance. 8. Social Services assessed current residents for elopement precautions and ensured electronic monitoring devices were in place for residents at risk on 08/24/2019. Residents care plans were revised and updated by 09/13/2109. 9. Electronic monitoring device log will be reviewed by Administration or Manager on Duty to ensure daily inspections. This will be done weekly for 3 months and then monthly to ensure compliance. (Electronic monitoring system repair company) serviced the system on 8/27/19, 9/6/18\9, and 9/9/19. 10. Electronic monitoring device monitoring increased to daily monitoring including weekends and policy and procedure has been updated as of 08/24/2019. 11. Code Pink drill was performed on 8/25/19 by the Social Service Director and will be performed weekly for one month and monthly thereafter for 6 months by Social Services, Nurse management, and Administration. Staff will be re-inserviced on Code Pink and elopement if/when revisions are made and upon annual review of annual policy by Social Services, Nurse management, and Administration. New hires will be in-serviced on code pink during their general orientation. 12. Back door secured with an alarm, installed and operational on 8/27/19, and will be tested daily by Maintenance and Manager on Duty, by opening the door without the code to ensure that the alarm sounds. Staff response time will be recorded to ensure proper response time by Maintenance and/or Manager on Duty. QA tool in place and will be completed by Maintenance and Manager on Duty. Administrator will verify weekly for 3 months and then monthly for 3 months to ensure compliance. 13. QAPI (Quality Assurance and Performance Improvement) review on 09/13/2019 with Medical Director to review elopement incident and plan of action. Action plan will be reviewed monthly at QAPI meeting. Medical Director approved plan on 09/13/2019 with no further recommendations. 14. Medical Director notified of incident on 8/26/19 in the facility by the Administrator, and reviewed the facility's immediate action plan. He agreed with immediate action plan. On 09/12/2019 and 09/13/2019, the surveyor interviewed Nursing, Therapy and Maintenance staff and confirmed dates in-services were completed and knowledge of procedures; elevator and exit doors were checked and observed to be functioning; R2's, R4's, R5's R6's, R7's and R9's electronic monitoring devices were in place and functioning.

Based on interview and record review, the facility failed to follow the Physician's Orders for continuous suction of the [DEVICE], and failed to closely monitor a resident on anti-coagulants or blood thinning medications after the [DEVICE] was removed, for 1 resident (R1) reviewed for accommodation of needs in a total sample of 8. This failure resulted in R1 being found unresponsive, bleeding from the removal site. R1 was transported to the local hospital where R1 was unable to be resuscitated and expired. Findings Include: The Face Sheet documents that R1 was admitted to the facility on [DATE], after undergoing a left femoral popliteal bypass surgery, a vascular procedure that increases blood flow to the left foot due to [DIAGNOSES REDACTED]. The hospital records dated [DATE], documents that R1 had the left 4th and 5th toe amputated, and had a [DEVICE], or suctioning device, in place due to a non-healing wound opening up at the amputation site. The Skin Assessment on admission to the facility dated [DATE], documents that R1 had a stapled wound to the left groin, left lower leg, left inner ankle, and a non-healing wound to the left 4th and 5th toe amputation site, with moderate blood tinged drainage and a [DEVICE] in place. The Physician's order dated [DATE], documents the [DEVICE] should be on continuous suction and changed 3 times weekly. R1 is prescribed Aspirin 81mg and [MEDICATION NAME] 75mg daily. Both medications are used as anti-coagulants, or blood thinners, and may increase the risk of bleeding. The Nurse's Notes dated [DATE] at 3:40pm, documents R1's [DEVICE] was removed. The Nurse's Notes dated [DATE] at 4:35pm, documents R1 was found unresponsive and bleeding from the left foot wound, where the [DEVICE] was removed. The Paramedics were called, and cardiac [MEDICAL CONDITION] resuscitation (CPR) was initiated. The Ambulance Run Sheet dated [DATE] at 4:47pm, documents Paramedics were dispatched for a [MEDICAL CONDITION]. R1 was unresponsive in bed and was noted with approximately ,[DATE] liters of blood from the left foot wound where the [DEVICE] had been removed. R1 was transported to the local hospital for evaluation and treatment. The Hospital Records dated [DATE] at 5:05pm, document R1 was found in pool of blood at the facility with approximately 2 liters of blood loss from the wound to the left foot. Resident found unresponsive with no pulse. Asystole confirmed on the monitor. CPR continued with no change. Time of death called at 5:16pm. On [DATE] at 1:10pm, V8(Nurse) stated, I remember I was doing med pass and a staff member told me they had seen blood on the floor. I went in to assess the resident and R1 was unresponsive so we started CPR and called 911. The paramedics came and the resident was taken to the hospital. The [DEVICE] had been removed some time during the day. Residents' should be monitored for drainage and to make sure the wound is ok every 2 hours once a [DEVICE] is removed. R1 was fine that morning when I saw the resident, and I hadn't seen the resident since my morning rounds. It was a nice amount of fresh blood on the floor when I went in. On [DATE] at 1:35pm, V3 (ADON) stated, We do not have a [DEVICE] policy or protocol. Our wound nurses are trained on [DEVICE]. We have outside vendors that come in and in-service the staff for the [DEVICE] because we use different brands. I don't have any documentation to show what education has been done. The facility's practice for residents with [DEVICE] is to remove the device, and apply a dry dressing prior to a resident leaving the facility for an appointment. If a resident has an early morning appointment, the wound nurse would remove the [DEVICE] the evening before, because sometimes transportation comes before the wound nurses arrive. We do this so that we can keep track of the machine in case the resident is admitted to the hospital, because there have been times where we've sent residents out with the [DEVICE] and it was not returned to the facility. There's no policy on monitoring a resident after a [DEVICE] has been removed. The staff would monitor the resident every 2 hours unless there's something going on that requires more frequent monitoring. On [DATE] at 3:05pm, V11 (Wound Nurse) stated, The [DEVICE] was being removed due to R1 having a Doctor's appointment with the surgeon the next morning. I removed the [DEVICE] closer to the end of my shift around 3:00pm, so that the resident would be ready for the next day. Transportation for appointments can come early in the morning, and the wound team may not be here to remove the [DEVICE] at that time. Residents go to appointments without the [DEVICE] because sometimes the orders may change after the resident is assessed by the Doctor. I removed the [DEVICE] and put a dry dressing in place. The dressing was dry and intact when I left, and there was no active bleeding. We don't have a policy for frequent monitoring after a [DEVICE] has been removed. We would just monitor the resident every 2 hours unless there was something going on. On [DATE] at 10:40am, V7 (Physician) stated, [DEVICE] have a sponge that adheres to the wound. If there is good blood flow to the wound, bleeding can be caused by pulling off a layer of tissue on the wound once that sponge is removed. The resident had good blood flow to the wound because of the vascular surgery that had been done, so it is possible that the bleeding was caused from removing the wound vac. There were no complications noted after the surgery from my standpoint and no abnormal bleeding. I was unaware that the facility's practice was to remove the [DEVICE] the evening before a morning appointment. The [DEVICE] should be removed the morning of the appointment, or often residents come to the appointment with the [DEVICE] still in place, and I remove it here in the office and send them back to the facility with a dry dressing. On [DATE] at 1:40pm, V7 stated, The order was for continuous suction, and the expectation is that the resident receives the full benefit of the treatment by keeping the device in place up until the time of transport for the MD appointment. The facility should not have removed the device so that the resident receives the full benefit of the treatment. There is no information out there about how frequent to monitor a resident, but the resident should be monitored for signs of bleeding after removing the device so that pressure can be applied immediately to stop the bleeding. The [DEVICE] Operations Manual documents that the residents undergoing negative pressure wound therapy need frequent supervision. Residents' taking anti-coagulants require additional precautions or special care for the safe and effective use of the device. The Facility has no documentation of additional precautions in place for monitoring the resident.

Based on interview and record review, the facility failed to develop a nutrition and hydration plan to reduce/prevent the risk of an unplanned weight loss and dehydration, for 1 of 3 residents reviewed for weight loss and hydration. This failure resulted in R1 experiencing a 21.94% weight loss over 33 days. R1 had a change in condition, becoming lethargic, and was sent to the local hospital for evaluation. R1 was admitted and treated for [REDACTED]. Findings include: R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. R1 was acutely discharged to the hospital on [DATE] due to lethargy. 04/30/19 at 09:08 AM, V6, (Family Member), said On 04/13/19 or 04/14/19 my husband went to visit and R1 was sleeping during the day. On 4/16/19 I was called by the nurse practitioner about R1's weight of 88 pounds, down from 109 pounds on admission. They drew blood and R1 was dehydrated, malnourished, and sodium level was high. On 4/17/19, R1 was lethargic. R1 lost 20 pounds in a month and I was not informed. 05/01/19 at 12:43 PM, V4, (Dietician), said, We discussed R1's weight loss in a meeting on 4/17/19. Weight loss is a symptom of R1's illness. R1's symptoms are consistent with R1's acute illness that R1 went out with. Significant weight loss is 5% or more in 30 days. The facility notifies the doctor, nurse practitioner,or dietician of the weight loss. R1's weight loss did not trigger in the system because it was less than 30 days. I look at the intake report and I know how many calories were eaten based on the diet that they are on. 05/01/19 at 02:45 PM, V3, (Assistant Director of Nursing), said, If there is a change in the resident's weight we notify the doctor, dietician, and family member. Once the weight is entered, if there is a change in the resident's weight it triggers in our computer system right away. We then receive the weights and care plan. We have bi monthly meetings for weight loss. 05/01/19 at 03:10 PM, V15, (Certified Nursing Assistant), said, I provided R1's ADL (Activities of Daily Living) care and feeding. R1 could feed herself. R1 was picky; if the food touched, R1 would not eat it. I took care of R1 on day shift, and R1 received 2 meals during my shift. R1 would not let me feed her, or knock the spoon out of my hand at least 3 times a week. I would try to calm R1 down, then report it to the charge nurse. R1 had a very poor appetite. I did not weigh R1. 05/02/19 at 09:38 AM, V2, (Director of Nursing), said, I interviewed the CNA's (Certified Nursing Assistants) who said R1 is sometimes cooperative, eats slowly, and is a picky eater. R1 lost 5 pounds and we were trying to get R1 back on track. I told the nurse to document what R1 was doing and eating. R1 was not taking things in, and was declining. R1's weight loss did not trigger in the system. R1 was lethargic and not able to take anything oral. When they reported to me, everything was in the critical time on 4/16/19. The nurse should have been notified of the weight changes, decline, called the doctor, family member, and documented. It is important to report any changes in condition. There is a failure with communication. We have a weight meeting twice a month. 05/02/19 at 10:15 AM, V16, (Licensed Practical Nurse), said, The day before or the day R1 went out there was a decline in condition. I don't remember if anyone reported the weight loss. R1 had a poor appetite. They should notify the nurse practitioner or doctor. I was not aware of such a rapid weight loss. There was a failure in communication and documentation. 05/02/19 at 11:15 AM, V13, (Licensed Practical Nurse), said, I did not know R1 lost weight. Restorative does the weights and I think they let the Assistant Director of Nursing know if there is any change in the weight. If there is a change in condition, I should call the doctor and family to let them know. 05/02/19 at 12:07 PM, V18, (Licensed Practical Nurse), said, R1's plan of care was comfort measures, making sure R1 was clean, and pain relief. I consider eating a comfort measure. I was not aware R1 was not eating, or had weight loss. I would assess the resident and find out why they were not eating, then notify the doctor and family. 05/02/19 at 12:20 PM, V17, (Licensed Practical Nurse),said, I was R1's nurse the day R1 went to the hospital. R1 wasn't eating too well. I was told R1 had not eaten in a couple of days. If a resident has a poor appetite and weight loss, we contact the family, manager, doctor, and get doctor orders. 05/02/19 at 12:57 PM, V11, (Licensed Practical Nurse), said, I did not know that R1 had a decline in weight. To my knowledge, R1 was eating. The CNA's will let the nurse know if a resident is not eating, and the family, physician, and dietician will be notified. 05/02/19 at 01:21 PM, V19, (Certified Nurse Assistant), said, R1 was a total assist when on the 4th floor. R1 fed herself, and sometimes ate 75-100% of breakfast and lunch. R1 never refused meals. If you let R1 know what you were doing R1 was fine but would push you away if you did not. When R1 was transferred to the 2nd floor I don't know what happened. 05/02/19 at 01:32 PM, V20, (Nurse Practitioner), said, The first day that I was notified of R1's weight loss was the day before R1 went to the hospital on [DATE]. (Surveyor referred to progress note written by V20 on 04/09/19 indicating R1 had poor intake lately, weighed 107.6 pounds on 03/14/19 and 102.6 pounds on 03/27/19, if p.o. (By Mouth) intake does not pick up will consider adding [MEDICATION NAME]). V20 said, R1 had some weight loss. R1 was comfort care, nothing aggressive or invasive. R1 was doing well on the 4th floor. I was not notified of the next weight loss. I am assuming R1 not eating caused dehydration that led up to the hospitalization . IV fluids were given because R1 was lethargic and was not eating. R1 was not improving with IV hydration. Acute kidney injury was caused by the dehydration. 05/02/19 at 02:39 PM, V14, (Licensed Practical Nurse), said, On 04/16/19, the Nurse Practitioner came to the nurse's station and said R1 was not looking good. We started an IV (Intravenous) line and checked R1's vital signs. R1 only responded to pain. I informed the family. If there is a change in condition we are to call the doctor, get orders, notify the family, and do interventions here first. If we cannot maintain the resident they are sent out. I did not check the weight loss. 05/02/19 at 03:57 PM, V21, (Licensed Practical Nurse), said, R1 was on the second floor for comfort care including making R1 comfortable, feeding R1 if R1 wanted to be fed, changing diapers and alleviating pain. I attempted to feed R1 once, but R1 refused. We approached R1, and asked if R1 wanted to be fed, but R1 did not want to eat, and just took sips of water. Nothing was ever reported, and I was not aware of any weight loss. Record review: MDS (Minimum Data Set) dated 03/19/19, indicates R1 required Extensive assistance with eating with one person physical assist. Order Summary Report dated 05/01/19, Order summary General diet regular texture. Dietary Initial/Quarterly/Annual dated 03/13/19, indicates R1 weighed 109.4 pounds on 03/14/19, Appetite good and Eating assistance: supervision. Nutrition Assessment date 03/14/19, indicates R1 has inadequate p.o. (by mouth) intake, assistance with eating, weight status; no weight change, oral nutrition intake 26-75% with overall risk category > (greater than) 8 Points High Risk. Care Plan focus area indicates R1 needs assistance with Eating, have potential for altered Nutrition. Weight and Vitals Summary dated 05/01/19, indicates R1 weighed on 03/14/19 at 09:37 109.4 pounds, 03/14/19 at 14:49 107.6 pounds, 03/27/19 102.6 pounds, 04/11/19 88.8 pounds and 04/16/19 85.4 pounds. Percentage of meals eaten from 04/04/19 through 04/17/19, R1 ate 0-25% for 8 meals 26-50% for 3 meals, 51-75% for 4 meals, and 76-100% for 1 meal. Progress notes dated from 03/12/19 through 04/17/19, Nurse Practitioner states I was not made aware of R1 weight loss until 4/16/19. No documentation of weight loss notifications found in progress notes until R1's change in condition on 04/17/19. Record review of Hospital medical records dated 04/17/19, R1 has a [DIAGNOSES REDACTED]. R1 had a critical lab result (sodium 163). Policy: Titled Nutrition Intervention Program, not dated. Residents identified as needing additional nutrition interventions will be started on the NIP Program. 1. Significant weight loss at 1 month, 3 month, 6 months. 2. Significant change in food intake.

Based on interview and record review the facility failed to obtain new treatment orders after a change in the condition of a wound occurred for 1 resident (R1) of 6 residents reviewed for pressure sores in the sample of 25. This failure resulted in a 5 day delay for surgical intervention for R1. Findings Include: 1). According to the Face Sheet R1 was admitted on [DATE] for rehabilitation. The Face Sheet documents the following diagnosis; stroke, hypertension, asthma, pneumonia, urinary tract infection, and history of colonic malignancy. Nursing Progress Notes dated 6-30-2012 documents a facility acquired right heel unstageable wound. Nursing Progress Notes dated 7-3-2012 documents that R1 acquired an unstageable opened ulcer to the left buttock measuring 2.5 centimeters(cm) by 2.5 cm. Physician order [REDACTED]. Physician order [REDACTED]. These orders were given by the attending physician. Nursing Progress Notes dated 7-18-2012 documents that the left buttock wound worsened from 2.5 cm by 2.5 cm to 8.0 centimeters(cm) by 6.0 cm and the surrounding tissue was cyanotic(blue) and red with an odor. Physician order [REDACTED]. Given by the oncall attending physician. According to the Nursing Progress Notes dated 7-20-2012 R1 continued to breakdown and developed another opened area to the sacrum measuring 2.5 cm by 2.5 cm. On 11-7-2012 at 2:15 PM E7(Treatment Nurse) said that R1 was deteriorating quickly with pressure sores and that on 7-18-2012 the sacral sore was worse with an odor. E7 said that she called the doctor that was covering for the attending physician, described the wound and the doctor ordered an oral antibiotic ([MEDICATION NAME]), no change in treatment orders. E7 said that she could have called the wound doctor but did not because the wound doctor was coming in on 7-23-2012(5 days later) and the wound status could wait. On 11-7-2012 at 1:35Pm via telephone Z7 (wound care surgeon) said that the treatment nurse can call via telephone if it is her judgement to call. "I am a Board Certified Surgeon and I do not take sending residents out lightly. When I saw R1 on 7-23-2012, the wound had a odor, it was swollen the condition of the wound was too extensive for me to do bedside debridement, I immediately ordered for the resident to go out to the emergency room for surgical debridement. If I were called earlier with that description of the wound I would have sent the resident out for surgical debridement right away." On 11-7-2012 at 2:15PM, via telephone Z1 was the doctor who was covering for the attending around that time(7-18-2012). "The facility has a wound care surgeon who provides orders for residents with wounds that worsen. I ordered [MEDICATION NAME] on 7-18-2012 for R1, I do not make treatment orders for wounds, I am not a specialist, that is why the facility has a wound care surgeon. The wound care surgeon should have been called. I do not get involved with wounds except when I need to order an antibiotic." On 11-8-2012 at at 11:24 AM, E2(Director of Nursing) stated, "I probably would have called the wound care surgeon sooner." Pressure Ulcer and Skin Condition Assessment Policy undated states, "Weekly changes require physician and responsible party notification changes are a). new onset of purulent drainage, b). new onset of odor, c). [MEDICAL CONDITION], d). increased pain related to wound, e). significant increase in wound measurements and f). new onset of new ulcers." Wound Care Specialist Initial Evaluation dated 7-23-2012(5 days later) documents, " Left buttock pressure (10 cm by 7 cm)with unstageable necrosis for more than 7 days red with odor. Wound is too large for bedside debridement and high vascularity of the area, Needs to go to Operating room for debridement." Hospital Records dated 7-23-2012 documents that the wound on the buttock had a dirty base and was contaminated with fecal matter. Extensive necrosis with black center. R1 was placed on 3 antibiotics in the emergency department( [MEDICATION NAME], Aztreonam and [MEDICATION NAME]) and surgically debrided. R1 was transferred to another nursing home on 7-26-2012 on hospice because family declined any further surgical intervention.

Based on closed record review and interviews, the facility failed to follow its Abuse Prevention Program policy and conduct a thorough investigation for an incident of injury of unknown origin for 1 of 1 residents (R11) reviewed for injuries of unknown origin in a sample of 14. R11 sustained a Left Proximal Tibia and Fibula Fracture that was not found for days even though were aware an incident had occurred. Findings include: During a phone interview with Z2, family Member, on 9/9/11 at 8:50am, Z2 stated R11 informed her that on 8/1/11 R11 was sitting in a wheel chair in the activity room with her left leg around the leg of the table when a staff member pulled the wheelchair backward causing injury to R11 ' s leg. Z2 stated that R11 informed the staff that her leg was caught in the table and told staff " you are breaking my leg. " Z2 went on to say that R11 suffered a fractured left leg. R11 is a [AGE] year old resident whose Minimum Data Set ((MDS) dated [DATE] shows [DIAGNOSES REDACTED]. The MDS describes R11 as having no alterations in speech and hearing and is usually understood. Nurses notes dated 6/22/11 describes R11 as alert with confusion, participates in activities and socializes with peers. An Incident/Accident Notification report dated 8/1/11 with time of occurrence as 7:45am states Certified Nurses Aide (CNA) on duty observed swelling on resident's(R11) left leg, when she made her initial rounds and notified the nurse. Upon assessment by the nurse on duty, R11 was found with swelling below the left knee with reddish discoloration,warm to touch and with tenderness upon palpation. R11 ' s nurses notes dated 8/1/11 at 4:18pm states observation of left lower extremity swelling, bluish, pain with movement, and resident sent out to hospital for evaluation. E1 (Administrator) presented a Final Incident Investigation Report on 9/9/11 at 2:30pm completed by Z3 (former director of nursing), describing the discovery of the swollen leg by a certified nurses aide (CNA) occurring on 8/1/11 at 7:45am. The Report summarizes that R11 denied having an accident and denied inappropriate treatment, however, there was no investigative statement from R11. The Report also states that Z2 (family member) was interviewed and agreed that R11 would be able to recall if any incident had occurred. However, there was no statement from Z2.found. The Report also states that all nurses and CNA ' s that took care of R11 on 8/1/11 and several days prior were interviewed. Only three staff interviews were done. E10, Certified Nurses Aide,stated on 09-09-2011 at 11:40am that she was a witness to the initial discovery of the injury but was not interviewed during the investigation. E10 also said that all the staff on the 4th floor where R11 resided knew what had happened. E10 stated that R11 ' s leg was injured on a Wednesday (7/27/11) when activity staff was transferring R11 from the activity room to the bed room, and that she, E10, could not understand why nothing was done about it immediately. E10 was not able to identify the activity staff. E10 stated that the injury was not reported to the nursing staff until 8/1/11. E10 recalls that on 8/1/11 she was assisting E13 (CNA) with turning of R11 who was in bed, when R11 cried out complaining of pain in the left leg. E10 stated that R11, who is usually up in her wheelchair participating in activities on the unit, remained in bed from the day of the injury to the day the injury was reported. During a phone interview with Z3 on 9/10/11 at approximately 2:30pm, Z3 stated that she conducted the investigation. Z3 confirmed that she did not record the interview conducted with R11 nor Z2. Z3 also confirmed that the only staff interviewed were 2 CNA s and 1 nurse. Z3 was not aware that E10 was a witness to the discovery of the injury. Z3 was not aware that an injury had occurred to R11 while being transported by an activity staff on 7/27/11. Z3 ' s investigation conclusion states " The allegation of abuse or neglect cannot be substantiated due to lack of evidence and factual information. " The policy titled "Abuse Prevention Program Facility Policy" states in part...........The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: -identifying occurrences and patterns of potential mistreatment; -implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; and -filing accurate and timely investigative reports.

Based on observation, record review and interview the facility failed to implement care nd follow up on the prevention / care of pressure sores for 5 of 6 sampled residents ( R1, R2, R3, R5 and R8 ) reviewed for pressure sores out of a sample of 14 residents.. R1, R2, R3, R5 and R8 acquired pressure sores in the facility ( ranging from stage II to stage IV). There was also a delay in medical treatment and a delay in implementing preventive therapy to prevent the re-occurrence of these pressure sores. Findings include: The initial tour was conducted on 09-06-2011 with E1(Director of Nurses ) and E3(Treatment Nurse) accompaning surveyor. 1. R1 was observed on 9-6-11 at 1:00PM in her room in her bed. R1 is alert and oriented. Observations of R1's pressures sores on her left hip and sacral areas were redden, small amount of drainage and muscle tissue. R1 lower extremities were contracted and she was unable to move. R1's admission records reads, R1 is an [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of R1's pressure sore treatment log dated 9-2-11 reads, R1 has a stage IV pressure sore on her sacral area an acquired excoriation on her left hip. The dated it was acquired in the facility is stated as 5-10-11. The size of the excoriated area is 3cm x 4.5cm x 1.1. E3 (Treatment Nurse) stated," the left pressure sore started off as an excoriation a few months ago but then developed into a pressure sore." E3 had no comments as to why on the pressure sore log R1's left hip pressure sore is being continuously documented as excoriation instead of its existing status. Nursing notes dated 5-17-11 reads, open area left buttock (ischium) size is 7.2cm x 4.0cm x .4cm. The pressure sore tissue is 40% slough, 50% necrotic tissue and 10% reddened yellow and black tissue. Scant serosanguinous and the surrounding tissue is reddened and excoriation. This wound is unstageable and worsening. Review of the clinical records and the treatment log the first treatment of the left pressure sore was 5-17-11. E1(Director of Nursing) on 9-8-11 at 3:30PM did an extensive review of the records and also stated," R1 initial treatment was on 5-17-11. E1 stated," there are no further indications in the records that R1's left hip pressure sore was medically treated prior to 50% necrotic tissues and 40% slough." Review of R1's Minium (MDS) data set [DATE] (upon admission) notes R1 has one stage III pressures sores one her sacral area. E6 (MDS coordinator) stated on 9-8-11 at 12:30PM," she assess R1 and there was only one pressure sore on R1's body. E6 stated that R1 developed the second pressure sore later." Wound physician notes dates for 8-22-11 reads, R1 etiology of her left hip (ischium) wound is pressure. The stage of the pressure sores is a stage IV. The characteristic of R1's left hip pressure sores is: size, 3.5cm x 3.5cm x 1.3cm with drainage/exudate of serosanguinous. Wound physician notes dated 8-29-11 reads, etiology of her left hip is pressure. The stage is an IV, the size is 3cm x 4.5cm x 1.1cm with light drainage of serosanguinous. E1(Director of Nursing) stated on 9-8-11 at 4:00PM in the conference room, " R1 is being seen by a wound doctor but gave no response as to why 2 months later the wound doctor was notified instead of immediately after the wound was assess in May, 2011. E3(Treatment Nurse) stated on 9-8-11 at 1:00PM, R1 had another wound physician, we now have a different wound physician" E3 never obtained the previous wound physician's notes after several requests. Z1 (R1's Attending Physician) stated on 9-9-11 at 11:30AM, "R1 is a very difficult patient. Z1 stated, "I do not remember anyone from the facility telling him about R1's additional or second pressure sore, but R1 is currently being seen by a wound physician for care. Z1 gave no comments as to why the treatments were not done before it developed in a an unstageable pressure sore." 2. R2 was observed on 9-6-11 at 12:15PM in bed with her oxygen tubing on the floor. R2 was lying on a thick incontinence pad and had a plastic diaper on. Further observations of R2's, she had plastic diaper on and it was wet from urine. R2 had 2 open redden areas on her buttock and upper thigh. E3 stated on 9-6-11 at 12:15PM,"she did not know that R2 had pressure sores, no one told her about it. Review of R2's admission records reads R2 is an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R2's nursing notes dated 9-6-11 at 2:11PM reads, open area to sacrum and right posterior thigh. The size of both wounds are: .5 x .5 and reddened. R2's pressure sores are acquired in the facility with partial thickness loss of skin layers and they are both, a stage II pressure sores. Physician orders [REDACTED]. 3). R3 was observed in her room in her bed on 9-6-11 at 12:30PM. R3 was complaining about her buttock hurting and being wet. R3 was observed with many redden open small areas on both buttocks. E6( MDS coordinator) stated on 9-6-11 at 1:00PM stated," R3 is receiving ointment to prevent skin breakdown. Review of sR3's treatment records for the month of September, 2011 reads, barrier cream/protective ointment three times a day or as needed. For the month of September the 3:00PM to 11:00PM and the 11:00PM to 7:00AM shifts documentation for the cream on the treatment log was blank. 4). R8 was observed on 9-6-11 at 12:15PM in her room lying on an air mattress. R8 was lying in feces and urine. The thick incontinence pad had several dried brown urine rings on it. R8 has healed tissue on both of her buttock. R8 is unable to speak and express her needs. R8 E3( Treatment Nurse) stated on 9-6-11 at 12:30PM, "R8 should be kept clean and dry to prevent the re-opening of her stage II buttocks pressure sores. R8's admission records notes R8 is an [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of R8's treatment notes dated 3-24-11 reads the following," R8's stage II pressure sores has resolved/healed." E4 ( Certified Nurse's Aide) stated on 9-6-11 at 12:30PM, " how else are we to keep the bed/air mattress clean if we do not use an incontinence pad. We are not allowed to put any under garments on the residents while in bed at this facility." 5). R5 admission records notes the following," R5 is a [AGE] year old male admitted to the facility from 12-30-10 to 4-9-11. R12 had [DIAGNOSES REDACTED]." Physician orders [REDACTED]." Nursing notes dated 3-25-11 reads the following: lower right buttock 1.0cm x 1.5cm opening. Review of additional pressure sore treatment physician orders [REDACTED]. right lower buttock cleanse with normal saline then apply [MEDICATION NAME] every 3 days. Nursing notes dated 3-31-11 notes the size of R5's sacral pressure sore is: 3cm x 2.5cm x 1. Increased in size width and depth. Nursing notes dated 4-7-11 notes the size of R5's sacral pressure sore is: 3cm x 2.0cm x 1cm. Review of R5 treatment records (close record) notes R5 had no treatment records from 3-24-11 until 4-1-11. E1 and E2 confirmed that the facility could not find any treatment records for R5 for the treatment of [REDACTED]. The treatment records dated for April , 2011 notes R5 did not receive [MEDICATION NAME] every 3 days. The treatment was omitted for 4-3-11, given on 4-4-11 and that again on 4-6-11, on the second day. E1 and E2 had no comments as to why the records could not be found, Nor did they have any comments if R5 ever received the medical treatments for March, 2011 when there was an increase in size, width and depth of his sacral pressure sore.