Every finding on record at Aperion Care Lakeshore

Based on observation, interview, and record review, the facility failed to ensure residents have access to their personal clothing and belongings. This failure affects one (R1) resident out of four residents reviewed for resident rights. Findings include: On 08/01/2026 at 10:13AM, V3 (R1's Family Member) states R1's missing items has been an on-going issue for a while. V3 states she tried to resolve this with management, and they agreed to replace R1's things but the facility has been giving her the run around. V3 states on Friday 06/19/2026, she purchased and dropped off the following items for R1: 1 package of multiple-colored socks (brown, green, cream, and black), 1 new black hoodie, 1 tan skull cap, 1 striped red and black pajama pants set, 1 gray t-shirt. V3 states she handed the items directly to V1 (Administrator). V3 states V1 told her he would give R1's items to a Certified Nursing Assistant/CNA to make sure they would label and write R1's name on the inside of all the items. V3 states she purchased these items for R1 for the upcoming Fathers' Day holiday. V3 states she charged these items on her credit card for R1 and left the price tags on the items. V3 states on Fathers' Day (06/21/2026), she visited R1 in the facility and saw R1 had on the same socks and pants from when she last visited R1. V3 states this is how she knew that R1's items that she dropped off had never made it to R1 for his use. V3 states she inquired to V1 about the whereabouts of R1's items that she had given V1. V3 states V1 said the CNA told V1 R1 used some of the items. V3 states V1 told her that R1's items must be in the dirty clothes pile. V3 states she told V1 it was impossible for R1's items to all be in the dirty clothes and R1's items were missing. V3 states R1 has problems with always being cold so she buys R1 hoodies to cover his arms and head. V3 states R1 also loves to sleep in his socks and pajama pants because he is always cold. V3 states she left a comforter in the facility for R1 to use to keep him warm. V3 states this comforter was creamed colored on one side and had reddish stripes on the other side. V3 states she also brought a coat to the facility for R1, and it was blue and cream colored. V3 states R1 had his coat for this past winter but all of a sudden, R1's coat came up missing also. V3 states it's not fair for her to have to keep replacing R1's items. V3 states V1 told her that he would replace the items V3 purchased for R1. V3 states after V1 told her this, V1 assured her she would not have any problems with being reimbursed and V3 believed V1. V3 states V1 agreed to resolve this matter and is not sure why it's taking so long for her to be reimbursed. V3 states she has called the facility several times and she is constantly being put on hold and not speaking with anyone. V3 states R1 is physical and mentally incapacitated and V3 don't want to play these games with the facility. On 08/01/2026 at 12:45PM, R1 observed sitting up in his bed in high fowler's position eating his lunch meal. R1is noted with confusion and is alert and oriented to person only, surveyor unable to interview R1. R1 is noted to be the only resident living in his assigned room. Surveyor observes a handwritten note on R1's closet, dated 06/23/2026 and signed by V3 (R1's Family Member). V3's signed note documents, New: 1 Black hoodie, 1 Plaid PJ, 1 [NAME] cap, 4 pair of socks (white, brown, black, green). (R1's) Father's Day gift, please return his laundry to his room, thanks, V3.R1's MDS/Minimum Data Set, dated [DATE], documents R1 has a BIMS/Brief Interview for Mental Status of 10/15, indicating R1 is cognitively impaired.On 08/01/2026 at 12:52PM, V7 (Certified Nursing Assistant/CNA) now located inside of R1's room and states she is the CNA responsible for caring for R1 today. V7 is made aware of V3's handwritten note placed on R1's closet. V7 states she does not know anything about the note or missing clothing items for R1. R1 was made aware of the need to search his room for his missing clothing items. V7 donned gloves and searched R1's closet, 2 dresser drawers, and 1 nightstand drawer for R1's missing clothing items. On 08/01/2026 at 12:58PM, during the search of R1's room with V7, R1 yells out, They stole a lot of my stuff. R1 was unable to give surveyor further details. Upon completing a search of R1's room, V7 was unable to find R1's missing items inside of his room.On 08/01/2026 at 1:00PM, V4 (Licensed Practical Nurse/LPN) stated she is the nurse responsible for caring for R1 today. V4 is made aware of V3's handwritten note placed on R1's closet. V4 also stated she does not know anything about the note or missing clothing items for R1.Record review of R1's electronic health record/EHR performed on 08/01/2026 at 2:40PM does not show R1's clothing items were inventoried in the facility.On 08/01/2026 at 3:02PM, V11 (Assistant Administrator) states there is a storage room in the basement of the facility that is used to store residents' belongings. V11 states there are no other storage rooms used for storing residents' belongings in the facility.On 08/01/2026 at 3:24PM, V10 (Maintenance) performs a tour of the basement storage room and laundry room. V10 does not locate R1's missing clothing items. V10 states he is not aware of any missing clothing items for R1.On 08/02/2026 at 8:52AM, V1 (Administrator) stated he spoke with V3 (R1's Family Member) this morning and told her he would replace R1's missing clothing items. V1 stated sometime before Father's Day this year, V3 dropped off some clothing items for R1 and gave them to V1. V1 states he gave R1's clothing items to the Activity Director so they could be labeled with R1's name and placed inside of R1's room. V1 stated V3 informed him of the following missing items for R1: some PJs/pajamas, hoodies, socks, and a hat. V1 stated he currently does not know the whereabouts of R1's missing clothing items that were handed to him by V3. V1 stated he will have his new Housekeeping Director search for the missing items again. V1 stated he will also be ordering from an online retail store to purchase new items for R1 to replace R1's missing items. V1 stated he was never made aware of R1's missing clothing items prior to today and this is the first time V1 is hearing of this. V1 stated he does not recall having a conversation with V3 and telling V3 he will replace R1's missing items. V1 stated when a residents' family member brings in items for the residents, the items should be given to a staff member. V1 states the staff member should ensure the residents' items are labeled with their name and then inventoried in the facility. V1 stated an inventory sheet should then be filled out and scanned into the resident's EHR/electronic health record and filed under the miscellaneous tab. On 08/02/2026 at 9:05AM, V1 was made aware of surveyor's previous record review of R1's inventory sheet in his EHR and surveyor's inability to locate an inventory sheet for R1. An inventory of R1's belongings in the facility was then requested from V1.On 08/02/2026 at approximately 9:50AM, V1 (Administrator) provides surveyor with a grievance form for R1's missing belongings, dated 08/02/2026.On 08/02/2026 at 12:59PM, V9 (Housekeeping Director) stated she was first made aware of R1's missing clothing items today by V1 (Administrator). V9 stated she started conducting a search of the storage room for R1's missing items but has not yet located R1's missing items. V9 stated if a resident's clothing items are brought into the facility and are not inventoried or labeled and are sent down to the laundry room, it would be harder to return the items to the correct resident/owner. V9 stated when the laundry room receives clothing items that are not labeled, they store them in the facility's storage room in the basement until someone claims them. V9 stated she is still searching for R1's missing items and will not be done searching until approximately tomorrow.An inventory of R1's belongings in the facility was not provided to surveyor during this survey.Grievance/concern logs, dated 05/20/2026 to 07/23/2026, were reviewed and documents other residents in the facility made concerns regarding missing personal belongings.R1's care plan documents, (R1) requires assistance with dressing upper and lower body r/t limited mobility, muscle weakness. I will be able to dress with donning and doffing with clothes with extensive assistance for 15 min a daily X 6-7days/ daily through the review date. Assist resident to choose clothing.Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents You have the right to keep and wear your own clothing. You may keep and use your own property.Facility policy, dated 08/23/2017, titled Resident Rights documents, Notice of resident rights will be provided upon admission to the facility. These rights include the residents' right to: Retain and use personal possessions to the maximum extent that space and safety permit.Facility policy, dated 12/13/2018, titled Personal Property and Missing Items documents, The facility recognizes and respects the residents ability to keep personal belongings within reason during their stay at the facility. High value items shall be documented on the inventory sheet when the facility is notified of items brought in or removed from the facility by the resident, representative or visitors. Clothing items should be labeled with the resident's name using adhesive labels/laundry tape (preferred) or permanent marker. Report missing items.the resident, visitor, or employee shall fill out a Concern Report. After receiving the report of the missing item, the facility will proceed to address the issue(s) brought to their attention.

Based on observation, interview, and record review, the facility failed to follow planned menus and diet extensions. These failures have the potential to affect all 243 residents receiving food prepared in the facility's kitchen. Findings include: On 05/19/26 at 11:00 AM, V22 (Cook) stated he prepared the food for lunch. V22 stated the portion size to be served are listed on the recipe and the diet spreadsheets. V22 stated today the baked fish portion size is 3-ounces for regular and mechanical soft diets and everyone is receiving pudding for dessert. V22 stated the serving size for the pudding is a #8 scoop size for all diets except the diabetic diets which receive #16 scoop size instead of the #8 scoop size.On 05/19/26 at 11:42 AM, observed lunch tray line in progress. Observed V24 (Dietary Aide) putting one piece of fish on resident trays receiving regular texture diets. Per visual observation, the portion of the fish was very small and did not appear to be a 3-ounce portion.On 05/19/26 at 11:47 AM, surveyor asked V24 to select a piece of fish from the tray line and put it on a plate. Surveyor then requested V4 (Dietary Manager) to weigh the piece of fish.On 05/19/26 at 11:49 AM, using an industrial food scale which was covered in plastic wrap and tarred to zero, V4 put the piece of fish on the scale. V4 looked at the reading on the scale and stated the fish weighed 1.5-ounces.On 05/19/26 at 11:50 AM, surveyor requested for V22 to select and weigh the largest piece of fish on visual appearance from a pan of cooked fish for the tray line. V22 selected the largest piece of fish from the pan and placed the fish on the scale after tarring it to zero. V4 looked at the reading on the scale and stated that piece of fish weighed 2-ounces.On 05/19/26 at 11:51 AM, V4, Food Service Manager, stated the portion size should be 3-ounce and the fish is purchased frozen as a 3-ounce fillet portion. V4 stated some of the volume of food is lost during the cooking process. V4 estimates approximately one ounce is lost during the cooking process. V4 stated therefore to get a 3-ounce final serving portion of fish they should be buying 4-5-ounce portions of fish.On 05/19/26 at 12:27 PM, during meal round observations, R5 stated she would have liked a bigger portion of fish. R5 said, I only got one piece; it was small today. R5 stated she would have liked more of it.On 05/19/26 at 12:33 PM, observed R1 lying in his bed with his finished meal tray on his bedside table. R1 consumed 100% fish. Observed small bowl on R1's tray with a plastic lid on it. R1 stated the fish portion was too small. R1 stated the portions are usually small. R1 told the surveyor to take a look at the pudding in the bowl, it looks like one spoon of pudding. R1 asked, Shouldn't there be more pudding in there? Surveyor removed the plastic lid from the small bowl and looked at the portion of pudding inside. The portion size of the pudding did appear very small. R1 said it would be okay for the surveyor to take R1's bowl of pudding because he was not going to eat it anyway. On 05/19/26 at 12:47 PM, R6 stated the portions used to be bigger, but now the kitchen does not give the residents enough food. R6 stated the portion of fish served to him today was too small and there should have been more of the fish on his plate. On 05/19/26 at 12:57 PM, observed staff deliver R23's lunch tray to her. R23 removed the lid from her plate of food and said the fish portion looks a little small to her. R23 stated she wished the portion was bigger and that she would eat more if it was served to her.On 05/19/26 at 1:05 pm, V22 checked the recipe and diet spreadsheet and stated the portion size for pudding is #8-scoop for all diets except the diabetic diets who receive #16-scoop.On 05/19/26 at 1:07 PM, using R1's pudding served to him, V22 scooped out the pudding from the serving bowl and put it into an empty #16-scoop. The pudding did not fill the #16-scoop. The #16-scoop was filled 3/4 of the way with pudding.On 05/19/26 at 1:08 PM, V4 viewed the #16-scoop with pudding in it and stated it is filled 3/4 of the way and it should be filled all the way and level at least for the residents on diabetic diets. V4 stated the other residents should have received 1/2 cup of pudding using a #8 scoop.On 05/19/26 at 1:10 PM, V25 (Dietary Aide) stated he is the one who portioned out the pudding for everyone for the lunch meal. V25 stated he used the yellow handled scoop to portion out pudding for all the residents. V25 looked at the #16-scoop and stated the yellow scoop he used was smaller than the #16-scoop. V25 stated everyone received the same portion using the yellow scoop. V25 stated no one told him which utensil to use to portion out the pudding. V25 stated he used the smaller portion because he would rather not use too big of a scoop so that he does not run out of food. V25 stated he wanted to make sure everyone got some of the pudding.On 05/19/26 at 1:13 PM, V4 stated the yellow handled scoop V25 used to portion out the pudding was the #20 scoop. V4 looked at a chart posted on the wall and stated the #20 scoop provides a little less than 2 ounces.On 05/20/26 at 11:50 AM, lunch tray line started and observed V25 serving the ham. V25 stated V23 (Cook) told V25 to put three to four of the 1/2 slices of ham on each plate and that he is putting four 1/2 slices of ham on each resident's plate of food.On 05/20/26 at 12:14 PM, surveyor asked V25 to remove the ham he had portioned onto a resident plate and put it on a separate plate.On 05/20/26 at 12:15 PM, surveyor asked V51 (Cook) to weigh the ham provided by V25 using a food scale.On 05/20/26 at12:16 PM, observed V51 put a piece of plastic on the food scale, tarre it to zero and then add the ham provided by V25 from the tray line. There were four 1/2 slices of ham on the scale. V51 looked at the scale measurement and stated the ham weighs 2.2 ounces. V51 stated the ham portion being served should be 3 ounces. V51 stated she will add one more piece of ham and asked the tray line to give her another piece of ham.On 05/20/26 at 12:18 PM, V51 added an additional 1/2 slice of ham to the ham already on the scale. Surveyor looked at the scale which read 2.5-ounces. V51 stated this is still not enough ham. V51 stated she needs to add another piece of ham.On 05/20/26 at 12:19 PM, V51 asked for another piece of ham from the tray line and added an additional 1/2 slice of ham to the ham already on the scale. V51 and surveyor viewed the scale. V51 stated the six 1/2 slices of ham weighed 3.1 ounces. V51 stated the tray line should be serving six 1/2 slices of ham to serve 3 ounces of ham and that the four 1/2 slices of ham was not enough.On 05/20/26 at 12:20 PM, V51 stated it is important for the residents to get the right amount of protein, and the kitchen should be serving the portion listed on the recipe and spreadsheet. V51 stated she was never told to weigh the sliced meat or protein to figure out how much to give for a portion on the tray line. V51 stated but after seeing the difference in what was being served on the tray line today and what that portion weighed on the scale compared to what should have been given, she will do that from now on.On 05/20/26 at 12:31 PM, V4 stated the most accurate way to determine portion sizes for meat is by using the scale and that is what the cook should be doing before the tray line starts so they can tell the staff how much food to serve to the residents. V4 stated yesterday the cook should have weighed out the fish after cooking before the tray line started because you cannot tell by looking at something how much it weighs. V4 stated if the cook had weighed out the fish portions they would have seen that one piece of fish was not going to provide 3-ounces of protein and they could have adjusted the portions accordingly to make sure the residents received 3 ounces of fish.On 05/20/26 at 1:36 PM, V50 (Certified Nursing Assistant) stated she does notice that when she is passing out the trays some of the portions do look smaller than they should be.On 05/21/26 at 10:11 AM, V28 (Certified Nursing Assistant) stated residents do complain about the portions being too small and that the food is not enough for them. V28 stated she sees that the portions are too small. V28 said, That is all the time. It is not enough food for them.On 05/21/26 at 10:21 AM, V53 (Licensed Practical Nurse) stated the portion sizes in her opinion do look small for certain residents.On 05/21/26 at 10:28 AM, V54 (Certified Nursing Assistant) stated she does not think the residents are served enough food. V54 stated the portion sizes are too small. V54 said, They give too little of a portion. It is not enough for a grown person. V54 stated the residents complain to the staff that they are not being given enough food, and they will scavenger for more food on the leftover trays on the food carts.On 05/21/26 at 11:30 AM, via telephone interview, V55 (Registered Dietitian) stated the kitchen should be following the menus and diet spreadsheets to ensure proper portion sizes are given so the residents are getting adequate calories and protein. V55 stated the potential problem with the kitchen giving portion sizes that are too small is it could lead to weight loss and skin breakdown. V55 stated fish, chicken, and meat lose volume as part of the cooking process, and the best way for the kitchen staff to determine how much 3-ounces is would be for them to weigh the protein item on a scale. V55 stated no one can tell how many ounces something is by just eyeballing the item. V55 stated if the fish only weighed 1.5 ounces the staff should have increased the portion to two. V55 stated the residents should have been served 3-ounces of ham if that is what the recipe and diet spreadsheets called for. V55 stated a #8 scoop portion is equivalent to 1/2 cup, a #16 scoop serving is equivalent to 1/4 cup and #20 scoop portion is equivalent to three Tablespoons. V55 stated residents receiving three Tablespoons of pudding instead of 1/2 cup is not a lot and this would affect the overall calorie intake of the meal by not providing enough calories. V55 stated the kitchen wants to ensure the residents are receiving adequate amount of calories and protein and that is why the staff should be following the spreadsheets.Facility provided document titled, Diet Roster - By Diet dated 05/20/26 listing residents with their diet orders. The report indicates there are four residents who receive nothing by mouth (NPO).Kitchen policy titled Standardized Recipes undated documents in part, standardized recipes should be available and followed by kitchen staff to produce high quality, flavorful, and consistent products. Each recipe should include but not limited to serving size - this is the single required portion of the final product served and equipment and utensils to use - listing of cooking and serving tools to produce and serve the food item.Kitchen policy titled Portion Control undated which documents in part, portion size is determined by the nutritional needs of the residents, federal and state regulations that specify the food groups, and portion sizes that must be served according to the facility menu. Use standardized recipes based on facility census and cycle menus. Serve portions according to the menu spreadsheet. Use scoops, spoodles, ladles, and scales to serve proper menu portions on the tray line. Weight or measure ingredients. Weighing is the most accurate. Use standard measuring equipment. Level off ingredients.Kitchen policy titled Menus undated which documents in part, menus are planned in advance and are followed as written to meet the nutritional needs of the residents and menus are served as written unless changed due to an unpopular items on the menu, an item could not be procured, or in the event of a special meal.Facility provided copy of Diet Spreadsheet Week 4, Tuesday Week 24 dated 03/02/26 which documents in part for lunch meal for regular diets to receive 3-ounces baked fish and for regular, mechanical soft/ground and pureed diets to receive #8 scoop of pudding and for LCS (Low Concentrated Sweets) diet to receive #16 scoop pudding.Kitchen recipe titled Baked Fish lists portion size as 3-ounces and instructions include but not limited to serve 3-ounces of fish per portion.Kitchen recipe titled Banana Pudding list portion size as #8 scoop and instructions include but not limited to portion #8 scoop pudding into dessert dishes.Facility provided copy of Diet Spreadsheet Week 4, Wednesday Week 25 dated 03/02/26 which documents in part for lunch meal for regular diets to receive 3-ounces baked ham.Kitchen recipe titled Baked Ham list portion size as 3-ounces and instruction include but not limited to weight slices randomly to maintain 3-ounce portion control.Facility provided document titled Conversions and Measurements which documents in part, #8 scoop measure 1/2 cup, #16 scoop measure 1/4 cup, #20 scoop measure three Tablespoons.

Based on observation, interview, and record review, the facility failed to provide effective pest control for nine [R2, R15, R16, R17, R18, R19, R20, R21, R23] residents in a sample of 23. These failures have the potential to affect all 247 residents residing in the facility. Findings Include: Pest Control Invoice documents indicate the following:10/23/25-Exterminator sprayed for German Roaches and bed bugs on the third floor. 11/12/25- sprayed on second floor for German Roaches and in laundry rooms, pantry, kitchen, locker room, and basement. Fourth floor room was sprayed for bed bugs.Rodent traps were placed on the first, second, third, fourth nursing floors and basement. 12/23/25,12/29/25, 1/5/26, 1/16/26, 2/18/26, sprayed fourth floor for bed beds and German Roaches, nursing stations for bed bug activity, also nursing station chairs. 4/16/26 to 5/22/265 German Roaches and mice were treated: dining rooms, nursing stations, pantries, kitchen, laundry area, and several fourth-floor rooms. On 5/19/26 at 10:19AM, R1 stated, I been having mice in my room since December 2025. I still see roaches as well. The mice live in my dresser drawls (sic). Every day I clean out the mice droppings. When I pull out my clothes the mice dropping fall out all over the floor and in the bottom of my drawl (sic). R1 pulled out her dresser drawer and a shirt. R1 stated, Look at all the mice droppings all over my personal items. [V17, Maintenance] placed a mouse trap in the corner of my room, but the mouse traps are not helping at all. The mice jump in and out my garbage can, because the garbage cans stay full of garbage. The garbage is not emptied daily, the floors are not swept and mopped daily, most of the time it's every three days. Both the room garbage cans are running over and then my roommate, and I started placing garbage in the bathroom garbage can and that one started to run over as well. Look at the garbage can, it's not lunch time, but there are two days of lunch food in the garbage cans. The garbage has not been emptied over two days. All these spots on my floor have been there for days, the floors are very sticky under my shoes. There are roaches in my room as well. I see a couple of roaches every day. I been killing them with my shoes (sic). On 5/19/26 at 10:25AM, V17 [Maintenance], V8 [Licensed Practical Nurse], V18 [Housekeeping/Floor Tech], V20 [Housekeeper Director] and surveyor observed R1's dresser drawer with black small pellets covering R1's clothing, books, papers, and bottom of the dress drawer. Also observed several piles of black small pellets in the corners in R1's room. On 5/19/26 at 10:28AM, V8 [Licensed Practical Nurse] stated, Oh my goodness, those are mice droppings on her clothes, personal items and in bottom of R1's dresser drawers. I will get housekeeping to clean up the mice droppings, certified nurse assistant to take all her clothes to laundry for cleaning, and maintenance for mice traps. I have not seen any mice, I work the day shift, but I have saw mice droppings in the facility. On 5/19/26 at 10:40 AM, V20 [Housekeeping Director] stated, I will have a housekeeper come and clean out the dresser drawers, floors and bathroom. I see the mouse droppings on R1's clothing items and personal items. The black small pellets are mice droppings in the room corners. Observed many small black pellets along the base of the wall. On 5/19/26 at 11:00 AM, V17 [Maintenance Director] stated, We been having a problem with mice for three months. V1 [Administrator] will call out the exterminator. Roaches have been on-going, but the exterminator comes every two weeks. The roaches are better. Lately I get more complaints about mice. On 5/19/26 at 11:10 AM, R23 stated, There are mice living in the wall of my room. Look under at the head of the bed, there's a hole and the mice come in and out all the time. I place the yellow small basin in front of the hole with soap and water to poison the mice. The maintenance man puts down glue traps but that has not work for months, since March. I been asking V1 [Administrator] and maintenance to fix the hole in my wall, for months but it has not been fixed. On 5/19/26 at 11:18AM, V1 [Administrator] and surveyor observed a hole in the wall at the head of the bed in R23's room. V1 stated, This is my first time knowing about the hole. I will have [V17] fix the hole now. I will call out the exterminators about the mice in here. On 5/19/25 at 11:30 AM, R16 stated, I have mice living under my dresser and in my clothes. The mice and roaches have been here for over two months. I complain to [V1], but the mice glue traps are not working. The roaches just won't go away. Look by the wall and you will see mice droppings. Surveyor observed R16's floor had colored sticky spots on the floor. On 5/19/26 at 11:43 AM, R15 stated, I have mice running around in here all night. I try to kill them with my shoes. On 5/19/26 at 12:10 PM, R17 stated, I have mice running around all night. On 5/20/26 at 12:25 PM, observed R18's room with three glue pads in the corners in the room. V21 [Housekeeper] stated, I have not seen any mice, but I clean up and see mice droppings in [R18's] room and other rooms. I float from floor to floor. It is hard to keep up with the cleaning moving from floor to floor. V21 and surveyor observed small black pellets near the base board floor. V21 stated, Those are mice droppings. On 5/20/26 at 12:44 PM, R19 and R20 [Roommates] both said they saw mice running across the floor. On 5/19/26 at 1:24PM, R21 stated, I have bugs in my room for about a month. I have red bite marks on my body. The bugs leave black dots all over my sheets in the morning, I think they are bed bugs. V1 [Administrator] said the facility did not have bed bugs, but it is something biting me up only at night. On 5/19/26 at 1:30PM, V1 [Administrator] stated to R21 and surveyor, I will call the exterminator to check out [R21's] room. Meanwhile I will move [R21] and his roommate to another room. On 5/21/26 at 2:40PM, V1 [Administrator] stated, The facility had a roach problem off and on. The exterminator comes out every two weeks and as needed. We stitched out pest control company. One contract ended in February, and the other one picked back up in April. Staff and residents have reported sightings of mice, and the exterminator comes out and lay down glue traps and bait. R2, R15, R16 and R23 reside on the fourth floor. R17 and R18 reside on the third floor. R19 and R20 reside on the second floor. R21 reside on the first floor. Policy:Pest Control dated 11/28/12All building openings shall be tight-fitting and free of breaks.The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents.Garbage and trash shall be stored in areas separate from those used for preparation and storage of food.Garbage and trash shall be promptly removed.

Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable home-like environment for nine [R2, R15, R16, R17, R18, R19, R20, R21, R23] residents in a sample of 23. Findings Include:During the survey dates of 5/19/26-5/21/26, general observations of the facility were completed. Environment throughout the facility surveyor's shoes were sticking to the floors, due to sticky substances on the floors in spots. The facility hallways were not clean with visible small shreds of papers noted on the floors. Walking down the hallways noted residents' garbage cans were full of clutter and food contains covering the bedside tables and window seals. On 5/19/26 at 10:19AM, R1 stated, I been having mice (sic) in my room since December 2025. I still see roaches as well. The mice live in my dresser drawls (sic). Every day I clean out the mice droppings. When I pull out my clothes the mice dropping fall out all over the floor and in the bottom of my drawl (sic). R1 pulled out her dresser drawl and a shirt. R1 stated, Look at all the mice droppings all over my personal items. [V17 Maintenance] placed a mouse trap in the corner of my room, but the mouse traps are not helping at all. The mice jump in and out my garbage can, because the garbage cans stay full of garbage. The garbage is not emptied daily, the floors are not swept and mopped daily, most of the time it's every three days. Both the room garbage cans are running over and then my roommate, and I started placing garbage in the bathroom garbage can and that one started to run over as well. Look at the garbage can, it's not lunch time, but there are two days of lunch food in the garbage cans. The garbage has not been emptied over two days. All these spots on my floor have been there for days; the floors are very sticky under my shoes. There are roaches in my room as well. I see a couple of roaches every day. I been killing them with my shoes (sic). On 5/19/26 at 10:25AM, V17 [Maintenance], V8 [Licensed Practical Nurse], V18 [Housekeeping/Floor Tech], V20 [Housekeeper Director] and surveyor observed R1's dresser drawer with black small pellets covering R1's clothing, books, papers, and bottom of the dress drawers. Also observed several piles of black small pellets in the corners in R1's room. Observed both room garbage cans and bathroom garbage cans were completed full of food garbage containers stack up going up the wall and garbage on the floor surround the garbage can areas. Observed seven stains, spills, spots in different colors all over the floor. On 5/19/26 at 10:28AM, V8 [Licensed Practical Nurse] stated, Oh my goodness, those are mice droppings on her clothes, personal items and in bottom of R1's dresser drawers. I will get housekeeping to clean up the mice droppings, certified nurse assistant to take all her clothes to laundry for cleaning, and maintenance for mice traps. I have not seen any mice, I work day shift, but I have saw mice droppings in the facility. On 5/19/26 at 10:40 AM, V20 [Housekeeping Director] stated, I will have a housekeeper come and clean out the dresser drawers, floors and bathroom. I see the mouse droppings on (R1's) clothing items and personal items. The black small pellets are mice droppings in the room corners. The garbage cans are running over with trash. The garbage should be emptied by housekeeping twice a day. I don't know if (R1's) garbage was emptied or not. There are two housekeepers on each floor and two floor technicians for day shift 6AM to 2:30 PM, a total of eleven housekeeps. There are two housekeepers in the facility from 2PM to 10PM, to empty garbage, clean up spills, they clean where needed. Observed many small black pallets along the base of the wall. On 5/19/26 at 11:00 AM, V17 [Maintenance Director] stated, We been having a problem with mice for three months. V1 [Administrator] will call out the exterminator. If the resident rooms are not cleaned, garbage is not emptied, floors not swept or mopped, it could potentially keep the mice around. Roaches have been on-going, but the exterminator comes every two weeks. The roaches are better. Lately I get more complaints about mice. On 5/19/26 at 11:10 AM, R23 stated, There are mice living in the wall of my room. Look under at the head of the bed, there's a hole and the mice come in and out all the time. I place the yellow small basin in front of the hole with soap and water to poison the mice. The maintenance man puts down glue traps but that has not work for months, since March. I have to keep my own room clean. I clean my floors with old shirts, because housekeeping does not sweep and mop. I have to take out my own garbage, if did not, the mice will take over my room. Every blue moon ill gets a housekeeper to come in a clean-up my room. I been asking V1 [Administrator] and maintenance to fix the hole in in wall, for months but it has not been fixed. On 5/19/26 at 11:18AM, V1 [Administrator] and surveyor observed a hole in the wall at the head of the bed in R23's room. V1 stated, This is my first time knowing about the hole. I will have [V17] fix the hole now. I will call out the exterminators about the mice in here. On 5/19/25 at 11:30 AM, R16 stated, I have mice living under my dresser and in my clothes. The mice and roaches have been here for over two months. I complain to [V1], but the mice glue traps are not working. The roaches just won't go away. Look by wall and you will see mice droppings. The housekeepers come around at times. They all do something different. Some just empty the garbage but won't sweep nor mop the floor. The garbage is not emptied every day. Look at my garbage. Surveyor observed R16's garbage full and running over the top of the garbage can. R16's floor had colored sticky spots on the floor. On 5/19/26 at 11:43 AM, R15 stated, I have mice running around in here all night. I try to kill them with my shoes. Housekeeping come in here a few times a week. My room is never cleaned daily. On 5/19/26 at 12:10 PM, R17 stated, I have mice running around all night. The housekeeper does not clean my bathroom. It is my room and bathroom that will need to be cleaned. My toilet is so gross full of stains and dirty. Surveyor observed yellow and brown colored stains on the side of the toilet that runs to the floor next to the toilet. The bathroom garbage can was full of garbage, papers, and food containers. On 5/20/26 at 12:25 PM, observed R18's room with three glue pads in the corners in the room. V21 [Housekeeper] stated, I have not seen any mice, but I clean up and see mice droppings in R18 and other rooms. I float from floor to floor. It is hard to keep up with the cleaning moving from floor to floor. V21 and surveyor observed small black pallets near the base board floor. V21 stated, Those are mice droppings. On 5/20/26 at 12:44 PM, R19 and R20 [Roommates] both said they saw mice running across the floor. Housekeeping services are not here every day. On 5/19/26 at 1:24PM, R21 stated, I have had bugs in my room for about a month. I have red bite marks on my body. The bugs leave black dots all over my sheets in the morning. I think they are bed bugs. [V1, Administrator] said the facility did have bed bugs, but it is something biting me up only at night. Houskeeper does not clean my room, that's a joke. Maybe twice a week. I take out my own garbage to try and keep the mice out of here. On 5/19/26 at 1:30PM, V1 [Administrator] stated to R21 and surveyor, I will call the exterminator to check out R21's room. Meanwhile I will move R21 and his roommate to another room. On 5/21/26 at 2:40PM, V1 [Administrator] stated, The facility had a roach problem off and on. The exterminator comes out every two weeks and as needed. We stitched out pest control company. One contract ended in February, and the other one picked back up in April. Staff and residents have reported sightings of mice, and the exterminator comes out and lay down glue traps and bait. Housekeeping needs to keep the resident's room clean if not it could potentially keep the mice and roaches around. R2, R15, R16 and R23 reside on the fourth floor. R17 and R18 reside on the third floor. R19 and R20 reside on the second floor. R21 reside on the first floor. Policy: Housekeeping Cleaning PolicyTo establish a schedule to ensure the building is maintained in a clean manner. Pest Control dated 11/28/12All building openings shall be tight-fitting and free of breaks.The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents.Garbage and trash shall be stored in areas separate from those used for preparation and storage of food.Garbage and trash shall be promptly removed.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care in a timely manner for 4 (R1, R10, R11, R13) of 7 residents reviewed for ADL care. Findings include: 1.R1's admission Record documents in part paralysis and weakness of the left non-dominant side following a stroke, other muscle disorders, and history of falling. R1's 4/04/2026 MDS (Minimum Data Set) assessment documents moderate cognitive impairment. R1 is dependent on staff with toileting hygiene, lower body dressing, personal hygiene, and rolling left and right. R1 is always incontinent of urine and frequently incontinent of bowels. R1's Care Plan Report documents R1 has an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit (revised 3/30/2026). Intervention reads R1 is dependent on staff for personal and toilet hygiene (revised 12/17/2025). R1's care plan also reads R1 has a potential for impairment to skin integrity (revised 10/26/2023). Interventions include keeping skin clean and dry (initiated 7/14/2023). R1's care plan also reads R1 has bladder and bowel incontinence (revised 7/26/2023). Interventions include checking and changing R1 every 2-3 hours and as needed (initiated 7/26/2023). On 5/19/2026 at 10:58 AM, R1 was oriented to person, place, time, and situation. R1 stated overnight CNAs (Certified Nurse Aide) failed to change R1's incontinence product on 4/27/2026 and 4/28/2026. R1 stated there were additional recent nights where staff failed to change R1 during the entire 8-hour shift but could not recall those dates. During the interview, surveyor observed R1's fingernails long with dark brown sediments under some fingernails. R1 stated asking staff to cut them. R1 stated staff will say they will do it later in the day but forget to come back to do it. R1 stated because R1's fingernails are so long, R1 must be careful not to scratch self specifically when eyes are itchy. On 5/19/2026 at 12:11 PM, V9 (Nurse) stated R1 did complain before about not being changed overnight. R1 would say that the staff would answer the call light and say they would change R1 later, but staff would not return. On 5/19/2026 at 12:13 PM, V10 (CNA) stated R1 complained two weeks ago that night shift didn't change R1's incontinence product. On 5/20/2026 at 7:42 AM, V35 (Nurse) stated assigned to R1 today. V35 stated was not aware R1's nails were long. V35 stated if the resident is not diabetic, then a CNA can cut the resident's fingernails. R1's admission Record did not list diagnosis of diabetes. On 5/20/2026 at 7:49 AM, V36 (CNA) stated V36 came onto morning shift (7AM) and finding R1 not changed about two weeks ago. R1 complained the overnight staff didn't change R1 because the CNA couldn't find extra help to change R1. Regarding nail care, V36 stated if the resident doesn't have diabetes or any other condition/issues that prevent CNAs from cutting them, then V36 will cut resident's fingernails. V36 stated will try to keep residents' nails maintained in a way where the residents can function with them. V36 stated being assigned to R1 this shift and will look at R1's nails. On 5/20/2026 at 11:53 AM, R1's fingernails remained long. R1 stated a CNA came in the morning and told R1 that they will do nail care after lunch. On 5/21/2026 at 9:45 AM, R1's fingernails remained long. R1 stated staff didn't cut them yesterday and said they'd do it today instead. R1 stated staff have not said when they will do it. 2.On 5/19/2026 at 12:22 PM, V11 (CNA) stated sometimes coming onto shift in the morning and finding residents not cleaned overnight. V11 stated R13 is one of the residents that has complained about it. V11 has started the morning shift and found R13 real wet and R13's incontinence brief very soiled. V11 stated the bed was soaked and saturated. V11 stated the stains on the linen were dark and you can just tell they didn't clean [R13] all night. On 5/19/2026 at 12:26 PM, R13 was alert and oriented to person, place, date, and situation. R13 stated night CNAs do not change R13's incontinence product right away. R13 stated having to wait hours until getting the CNA's attention. R13 stated most of the time the night CNAs will only change R13 once during the shift. R13 lays soaked in bed until the CNA changes R13 around 5:00 AM. R13's 3/24/2026 MDS assessment documents R13 is cognitively intact. R13 is dependent on staff for toileting and personal hygiene. R13 is always incontinent with urine and frequently incontinent with bowels. R13's Care Plan Report documents R13 has limited mobility to bilateral upper and lower extremities (revised 5/17/2022). R13 is at risk for impaired skin integrity (revised 3/26/2026). Interventions include keeping R13's skin clean and well lubricated, monitoring for moisture, and providing skin care per facility guidelines (all initiated on 3/26/2026). R13's Care Plan Report also documents R13 has an ADL and functional ability for self-care and mobility deficit (revised 7/21/2024). R13 is totally dependent on staff for toilet use (revised 12/29/2025). R13 is incontinent of bladder and bowel related to impaired mobility (revised 6/27/2024). Interventions include checking and changing R13 three times every shift and as required for incontinence (revised 3/15/2022). On 5/19/2026 at 12:33 PM, V12 (CNA) stated finding R13 soaked at the start of morning shift one time with R13 complaining about the night CNA not changing R13. On 5/19/2026 at 1:11 PM, V27 (CNA) stated sometimes picking up morning shifts. V27 stated multiple incidents of finding residents soaked like no one checked on them the whole night. V27 stated the residents' beds were completely soaked and discolored needing complete linen changes. On 5/19/2026 at 1:26 PM, V29 (CNA) stated coming onto morning shift a few times and finding multiple residents wet. V29 stated, You can tell they've been wet all night like even up to the mattress. If it was just the diaper it would be recent, but I would find the whole bed and linen soaked and wet. 3.On 5/19/2026 at 11:44 AM, R25 (President of Resident Council), R10 (Vice President of Resident Council) and R11 stated residents have complained about having a hard time finding the night CNAs during Resident Council. R10 and R11 stated they have also had trouble finding a night CNA that is available to help. R10 stated waiting 1-2 hours before getting a hold of the night CNA. R10's 5/8/2026 MDS assessment documents R10 is cognitively intact. R10 requires supervision or touching assistance with toileting and personal hygiene. R11's 5/12/2026 MDS assessment documents R11 is cognitively intact. R11 requires substantial/maximal assistance with toileting and supervision or touching assistance with personal hygiene. Facility's Resident Council Minutes from 3/26/2026 and 4/30/2026 document concerns of CNA to do more rounds at night. On 5/21/2026 at 12:03 PM, V3 (Director of Nursing) stated was not aware of any complaints regarding incontinence care during night shift. V3 was also not aware of R1's nail concerns. V3 reviewed R1's electronic medical record. V3 stated V3 doesn't see any reason why staff have not cut R1's fingernails. Facility's Call Light policy (last revised 2/2/2018) documents: Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. Facility's Incontinence Care policy (last revised 4/20/2021) documents: Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident 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. Facility's Nail Care policy (last revised 1/25/2018) documents: Observe condition of resident anils during each time of bathing. Note cleanliness, length uneven edges, hypertrophied nails.

Based on observation, interview, and record review, the facility failed to label opened foods in the refrigerator, freezer, and cooler with an open, use by, and expiration date. This failure has the potential to affect all residents in the facility. Findings Include:On 3/2/2026 at 9:34 am, surveyors observed large ice cream bucket dated 10/20/2025, and the freezer thermometer is 0 degrees. Pickles in the refrigerator have a received date for 1/29/26 and no open or expiration date, and refrigerator has a temperature tracking log with last temperature logged as 36 degrees. Nine (9) salads on a plastic plate covered in clear plastic wrap were observed in the refrigerator without use by date or expiration dates in the refrigerator by the ice machine. The refrigerator temperature was 36 degrees Fahrenheit. Observed six (6) bowls of cereal on a tray in the dry storage room without open or use by/expiration dates. On 3/2/2026 at 9:36 am, V4 (Dietary Supervisor) stated foods are labeled with open and expiration dates to make sure the kitchen is not serving expired foods, and the staff utilizes first in and first out using the dates with the closest expiration date to the current date. V4 stated residents can get sick with diarrhea and vomiting which can compromise a resident's immune system and can even lead to death.V5 (Dietary Aide) was seen walking around going in and out of the refrigerators and freezer with a black marker. On 3/2/2026 at 9:52 am, V5 (Dietary Aide) stated she was labeling the lemonade she prepared this morning. V5 stated she prepared the salads this morning, wrapped the salads with plastic, and placed them in the refrigerator. V5 stated everyone is responsible for labeling food with open and expiration dates. V4 and V5 verified a tray containing 9 salads had no use by or expiration dates. V5 stated residents can get sick from expired food. Facility Policy titled On Tray Dietary Policies and Procedures undated documents: All food not in original containers should be labeled, dated, and stored in NSF approved containers and Food should be labeled and dated to monitor food safety.

Based on observation, interview, and record review, the facility failed to ensure the narcotic accountability sheets were completed per facility protocol for two floors of four floors reviewed for medication storage and labelling. Findings include: On 3/4/26 at 9:50am, V34 (LPN-Licensed Practical Nurse) assisted with checking a medication cart on the 2nd floor. A narcotic accountability sheet titled, Shift Change Controlled Substance Inventory Count Sheet was in a 2 South red binder in the narcotic drawer. V34 explained that each date has three entries for day shift, evening shift and night shift and is signed by the oncoming nurse and the nurse going off shift. There was an inventory sheet, dated 3/1 and 3/2. No year is written on the sheet but V34 confirmed it is the current sheet used to count the narcotics. On the sheet, the same initials are written in the following boxes: 3/1 on nurse, 3/1 off nurse, 3/1 on nurse, 3/2 off nurse. V34 stated these initials were for 3/1 evening shift and 3/1 night shift. V34 pointed to the initials and stated the nurse worked a double shift. The four consecutive boxes were signed by V35 (RN-Registered Nurse). V34 stated, That's how it's done if we work a double. We sign out all (four) boxes.Another narcotic inventory sheet documented V35 signed in four consecutive boxes for 3/3 day shift in the on nurse/off nurse signature box and 3/3 evening shift on nurse/off nurse signature box. V34 indicated V35 did another double shift. On 3/4/26 at 10:32am, V35 assisted with checking a medication cart on the 1st floor. A narcotic accountability sheet titled, Shift Change Controlled Substance Inventory Count Sheet was in a 1 North red binder in the narcotic drawer. V35 confirmed a nurse did not initial in the off-shift signature box for 3/2 day shift. V35 was identified as the nurse that signed the narcotic sheets that were on the 2nd floor. V35 confirmed that 2nd floor is the floor that she is normally scheduled on. At 10:36am, V35 was asked why an inventory sheet on the 2nd floor had V35's initials in four consecutive boxes. V35 stated that 2nd floor is normally where V35 works. V35 stated, If I do a double (shift), I take responsibility for the whole 16 hour shift. So, I count by myself. I sign in the on shift and off shift box. I take the responsibility. I put (my initials) in all boxes because I count at the beginning and end of shift.A facility document titled, Daily Schedule confirmed V35 was scheduled on 3/1/26 for evening shift and night shift. V35 was also scheduled on 3/3/26 for day shift and evening shift. On 3/4/26 at 11:32am, V3 (DON-Director of Nursing) stated, Our policy is that even if you do a double shift, you count with a second person. You need that second person to validate that count is correct. Nurses should not count by themselves. Supervisor is the back up person that can count with the nurses. V3 indicated all nurses on staff will be educated on the narcotic accountability protocol. The facility narcotic sheet titled, Shift Change Controlled Substance Inventory Count Sheet documents: 1. Nurse coming on to shift must verify count of all controlled substances with nursing coming off shift OR any time the medication cart keys are exchanged.A facility policy, with a revision date 11/26/17, and titled, Narcotic/Controlled Substances - Counting, documents: Purpose: 1. To count controlled substances with a partner and to verify the accuracy of the log sheets. General Procedure for Counting Controlled Substances: 3. Have a partner to assist in count. 16. Sign name, time and date of completed count.

Based on observation, interview, and record review, the facility failed to ensure the main entree for a pureed meal was the correct consistency. This failure had the potential to affect nine (R50, R90, R116, R150, R196, R200, R219, R274, R276) residents of nine residents reviewed for pureed diets in a sample of 72 residents. Findings include: On 3/2/26, V4 (Dietary Supervisor) provided a list of residents that receive pureed meals. R50, R90, R116, R150, R196, R200, R219, R274, R276 were listed. On 3/3/26 at 9:25am, V32 (Cook) started preparing the pureed meal. The facility menu documented the main entree for the pureed meal was Pureed Breaded Chicken. V32 indicated nine residents receive pureed meals. V32 placed 15 breaded chicken cutlets into the food processor with chicken broth. At 9:28am, V32 started pureeing the chicken but stopped when the food processor made a sharp noise. V32 stated, It's too much chicken. It's having a hard time. V32 poured more chicken broth into the blender. At 9:32am, four minutes later, V32 stopped the food processor and provided plastic spoons for a taste test and a consistency check. The consistency was not smooth, and pieces of chicken were visible. The texture was gritty with pieces of chicken, and the taste was dry. At 9:35am, V32 transferred the pureed chicken to a silver container, wrapped it and placed it in the oven. V32 indicated it was ready for service. At 9:40am, V4 (Dietary Supervisor) performed a taste test of the pureed chicken and confirmed the texture was not smooth. V4 confirmed when a food item is placed in the warmer it is ready to be served. V4 had to provide instructions for V32 to process the pureed chicken longer. On 3/4/26 at 1:30pm, V4 stated, It is important to make sure pureed foods are blended well because you do not want a choking hazard. If not, it could lead to swallowing issues that could lead to death. It also makes it more edible for them, especially for the ones that cannot chew, for easier swallowing. It should just go down the throat easily. We do not want the food getting stuck.A facility policy, dated 2020 and titled, Pureed Food Preparation, documents: 6) Pureed foods will be the consistency of applesauce or smooth, mashed potatoes.

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed during dining for 4 residents (R152, R179, R214, R256) on the 4th floor, failed to ensure proper Doffing of PPE (Personal Protective Equipment) for one resident (R223), and failure to follow Droplet Precautions for one resident (R274) on the 3rd floor. This failure has the potential to affect all residents residing on the 3rd and 4th floors.Findings include: 1.R274 has a diagnosis of but not limited to Cerebral Infarction, Asthma, Type 2 Diabetes Mellitus, Covid-19 (2/24/2026), and Pneumonia. R274 has a Brief Interview of Mental Status score of 07, indicating severe cognition impairment. R274's face sheet documents a diagnosis of Covid-19 Present at admission with an onset date of 2/24/2026. R274's Order Summary Report dated 3/04/2026 documents Droplet Precautions for Covid every shift until 3/03/2026. R274's care plan focus: Covid-19 dated 2/27/2026 documents, Follow Facility Protocol for Covid-19 Screening/Precautions. Strict Isolation -Droplet & Contact for Covid-19 positive. On 3/02/2026 at 11:16am, R274's room had a Droplet Precaution sign with no PPE bin in the hallway near the room. PPE bin was inside of R274's room. On 3/02/2026 at 11:17am, V7 (Licensed Practical Nurse-LPN) stated, I believe (R274) is on droplet precautions due to having Covid-19 and she should be off isolation tomorrow. The PPE bin should be outside of the room and PPE should be donned outside of the room. On 3/02/2026 at 1:06pm, V15 (LPN) stated, We should done PPE in the doorway prior to entering the resident's room. On 3/04/2026 at 12:16pm, V3 (Director of Nursing) stated, For a resident who is on Droplet precautions, the PPE bin should be on the outside of the room, and PPE should be donned prior to entering the resident's room to prevent the spread of microorganisms throughout the facility. Droplet signage states, Everyone Must: make sure their eyes, nose, and mouth are fully covered before room entry. Infection Control-Interim Covid-19 policy, with a revision date of 7/24/2023, documents, For residents who are known or suspected of having Covid-19 HCP (Health care Provider) must wear an N95 respirator, eye protection, gown and gloves when entering the room. Job description, dated 5/02/2017, titled Registered and Licensed Practical Nurse, documents, monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies. Job description, dated 5/02/2017, titled Certified Nursing Assistant, documents, Adhere to professional standards, company policies and procedures, and all federal, state and local requirements. 2.On 3/4/26 at 9:55am, V33 (CNA-Certified Nurse Assistant) was in a 2nd floor hallway outside of R223's room in a white jumpsuit and gloves. V33 then walked across the hallway and entered a shower room. V33 exited the shower room and walked back into R223's room. At 9:57am, V33 exited R223's room still in the same personal protective equipment (PPE). On 3/4/26 at 9:59am, R223 was sitting in a wheelchair in the 2nd floor common hallway directly outside the shower room. V33 indicated they just transferred R223 to the wheelchair to bring R233 to the shower room. V33 stated \they just found out R223 had lice and needed a shower. At 9:59am, V33 stated, I'm wearing this for my safety. We have to give (R223) a shower. (R233) has lice. V33 was asked if PPE was to be worn in a common hallway. V33 stated, No, I'm not supposed to wear it in the hallway. I should have taken it off. At 10:16am, V34 (LPN – Licensed Practical Nurse) stated, (V33) needs to remove gown in room and get another one. It should not be worn in hallway. On 3/4/26 at 2:37pm, V3 (DON – Director of Nursing) stated, The protocol is to take off PPE before you leave room so you don't take anything out of the room and contaminate others. On 3/4/26, V3 (DON), V33 (CNA) and V34 (LPN) confirmed V223 had lice. However, when R223's Progress Notes were submitted on 3/5/26, they documented the opposite. On 3/4/26 at 12:21pm, R223's Progress Notes read, NOD (Nurse on Duty) observed a gray lice on resident bed, performed a head to toe assessment head check nothing noted. A facility policy, with a revision date of 5/15/23, and titled, Infection Precaution Guidelines, documents: All personal protective equipment (disposable isolation gowns, mask, gloves, etc.) should be used once and discarded in either the trash or used linen receptacle before you leave the room. 3.On 3/2/2026 at 12:27 pm, V12 (Certified Nurse Assistant-(CNA) was seen removing a tray for the meal cart and walking to R256's room. V12 exited R256's room and no hand sanitizer was used before removing the next tray. V12 removed R179's tray from the cart and walked down the hallway opened a swing door with her hand and walked to the other side of the unit. V12 was observed exiting the swing door again touching it with her bare hands without using hand sanitizer, returning to the side of the hallway where R179's room was with tray in her (V12's) hands and walking to the dining room placing the tray in front of V179. No hand sanitizer was used. V12 removed another tray from the cart, walked down the hallway and placed it on R152's bedside table. V12 exited the room without using hand sanitizer and removed R214's tray from the meal cart, walked the tray down the hallway to R214's room and placed it on his bedside table. No hand sanitizer was used upon returning to the cart. On 3/2/2026 at 12:34 pm, V12 (Certified Nurse Assistant) stated she washes her hands with soap and water, dries her hands, applies hand sanitizer, and then passes all the trays to the residents. V12 stated the reason she does not use hand sanitizer during meal tray pass is because she is taking the tray to the resident and not anyone else. V12 stated the purpose of hand washing and hand sanitizer during meal tray pass is to prevent a resident from getting sick. On 3/2/2026 at 12:39 pm, V13 (Certified Nurse Assistant) stated she washes her hands with soap and water before passing meal trays and uses hand sanitizer between each passing of a meal tray to a resident. V13 stated the purpose of using hand sanitizer is to prevent the spread of germs that can potentially make a resident sick. Facility's Policy titled Hand Hygiene/Handwashing, dated 11/28/2012 revised on 7/30/2024, documents, hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water, antiseptic hand wash, or antiseptic hand rub, (i.e. alcohol-based hand sanitizer including foam or gel). Examples of when to perform hand hygiene (either alcohol-based hand sanitizer or handwashing): -At room entry -Before exiting room -After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

Based on observation, interview, and record review, the facility failed to ensure privacy curtains were in place and failed to ensure a privacy curtain fully covered a resident's space. This deficient practice affected six residents (R132, R172, R183, R231, R255, R260) reviewed for privacy in a total sample of 72 residents. Findings Include: 1.R255 is [AGE] years old. R255's diagnosis includes but are not limited to atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, hyperlipidemia, essential hypertension, malignant neoplasm of rectosigmoid junction, and gastrointestinal hemorrhage, unspecified. R255's Brief Interview for Mental Status (BIMS), dated 02/11/2026, documents R255 has a BIMS score of 12, which indicates R255 has some moderate cognitive impairment. On 03/02/2026 at 11:20am, R255 was seen coming out of the bathroom in his room and sitting on his bed. No privacy curtain observed hanging from the ceiling to cover around R255's bed. R255 has one roommate in a room with three beds. R255 stated, I did not notice that I did not have a curtain around my bed. On 03/04/2026 at 12:06pm V27(Housekeeping Director) stated, The housekeeping staff are responsible for making sure each resident has a privacy curtain hanging in their room. The purpose of the privacy curtain is to provide privacy for the residents while they are in their room. I took the privacy curtain down to wash, and I did not put the privacy curtain back up. On 03/04/2026 at 10:54am V3(DON/Director of Nursing) stated the housekeeping staff is responsible for ensuring privacy curtains are hanging and that the privacy curtain extends around the resident's bed. The purpose of the privacy curtain is to provide privacy for the resident. On 03/04/2026 at 12:15pm, V13(LPN/Licensed Practical Nurse) stated the housekeeping staff places the privacy curtain up in the residents' rooms. The purpose of the privacy curtain being up and available is to provide dignity and privacy for the residents. 2.On 3/3/26, during initial tour of floors 3 and 4, the following was noted: At 11:51am, V17 (CNA-Certified Nurse Assistant) was providing incontinence care for R183, and the privacy curtain was not long enough to encompass R183's private space. V17 confirmed the privacy curtain was not long enough. 3.R172 and R231 share a room. There was no privacy curtain in place to separate the two living spaces. At 12:10pm, R231 stated, I wish that we had a curtain. Sometimes, you just need a little one on one time. Even the people from the hallway can see me when the door is open. I'm a pretty private person. 4.R132 and R260 share a room. There was no privacy curtain in place to separate the two living spaces. At 12:25pm, R132 expressed that R260 requires a lot of attention. R132 confirmed staff have to come in and provide personal care in R260's bed. R132 stated, Sometimes, I have to leave the room or just not look. R132 stated it does not bother him to the point of switching rooms but expressed that a curtain would be nice. On 3/3/26 at 10:30am, V37 (LPN-Licensed Practical Assistant) stated, (R260) requires incontinence care all the time and receives it in the bed. (R260) cannot do anything on his own. The absence of a privacy curtain for R132, R172, R231, R255 and R260 was noted on 3/2/26, 3/3/26 and 3/4/26. On 3/4/26 at 10:09am, V28 (RN-Registered Nurse) confirmed R132, R172, R231 and R260 did not have a privacy curtain in place. V28 stated, The importance of the privacy curtain is if patient receiving personal care, need to have it. Each resident should have their own private space. They took them to wash it and there's no replacement. On 3/4/26 at 11:56am, V27 (Housekeeping Director) stated, Short curtains or no curtain are because they are getting washed. I try to wash them every other week. I put them on rotation. 24 hours to put the privacy curtains back up. It was explained the absence of privacy curtains was for the last three days, 3/2/26 to 3/4/26. V27 indicated there are no back up or replacement privacy curtains in the facility. V27 confirmed while the privacy curtains were being washed, the residents had no curtain in place. On 3/4/26 at 1:00pm, V1 (Administrator) stated the facility does not have a policy for Privacy. V1 stated, It is in the Resident rights packet that is given on admission. A document, with a revision date of 11/18, and titled, Residents' Rights for People in Long term Care Facilities documents: Your rights to privacy and confidentiality: You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.

Based on observation, interview, and record review, the facility failed to provide a dignified experience when performing incontinence care and failed to ensure a resident's confidential information was not displayed for two residents (R183, R255) reviewed for dignity in a total sample of 72 residents.Findings include: 1.R183's Face Sheet documents the following Medical Diagnoses: Unsteadiness on Feet, and Other Abnormalities of Gait and Mobility. R183's ADL (Activities of Daily Living) Care Plan documents R183's ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day. R183's Minimum Data Set, dated [DATE], documents: Section C-Cognitive Patterns: total score of 15 out of 15 which indicates R183 is Cognitively Intact without any Inattention, Disorganized Thinking and Altered Level of Consciousness. Section GG – Functional Abilities documents R183 requires substantial to maximal assistance for toileting hygiene, lower body dressing and personal hygiene. R183 also requires substantial to maximal assistance for mobility. Rolling left to right in bed requires partial/moderate assistance. On 3/2/26 at 11:51am, V17 (CNA-Certified Nurse Assistant) was providing incontinence care for R183, and the privacy curtain was not long enough to encompass R183's private space and provide visual privacy. R183 was turned onto the right side and R183's backside was visually exposed. V17 attempted to pull the privacy curtain around R183's private space but was unable to fully cover the area. V17 stated, The curtain is too short. It does not go around the bed. On 3/3/26 at 10:18m, R183 stated, I wear a diaper and they do have to change me. I cannot get up by myself to go to the bathroom. They try to close the curtain around my bed, but it doesn't go all the way around. It does bother me that I don't get the privacy for my body. If they cannot close it all the way, then they close the door. But both of my roommates do walk around, and other workers come in sometimes too. Most of the times they do not close the curtain. On 3/4/26 at 11:56am, V27 (Housekeeping Director) stated the facility does not have back up or replacement curtains. On 3/4/26 at 1:00pm, V1 (Administrator) stated the facility does not have a policy for Privacy. V1 stated, It is in the Resident rights packet that is given on admission. A document, with a revision date of 11/18 and titled, Residents' Rights for People in Long term Care Facilities, documents: Your rights to privacy and confidentiality: You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care. A facility policy, with a revision date of 1/16/18 and titled Incontinence Care, documents: Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Procedure: 1. Explain procedure to resident and bring equipment to bedside. Provide privacy. Rationale/Amplification: Obtain second staff member, if needed. Avoid unnecessary exposure. A facility policy, with a revision date of 4/23/18 and titled, Dignity, documents: Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. 2.R255 is a [AGE] year-old individual with a BIMS (Brief Interview for Mental Status) score of 12, indicating R255 has moderate cognitive impairment. BIMS dated 02/11/2026. On 03/02/2026 at 11:33am, R255 was observed walking down the fourth-floor hallway. R255 was observed with a white wristband on his right wrist. R255 stated, I went to the hospital days ago. Nobody has asked me if I wanted to take this wristband off. On 03/02/2026 at 11:35am, observed what was written on the wristband: R255's name, date of birth , gender (M)(male), age, and medical record number. On 03/04/2026 at 12:15pm, V13(LPN/Licensed Practical Nurse) stated, (R255) still has this white hospital wristband on his right wrist. I don't know off the top of my head when (R255) came back from the hospital. V13 observed R255's wristband and stated the following information is listed on the wrist band, R255's name, date of birth , age, sex, medical record number and the date of 01/31/2026. If I can see all this information listed about (R255), anybody can see this information about (R255). In my professional nursing opinion, this is a violation of (R255's) privacy. On 03/04/2026 at 10:55am, V3(DON/Director of Nursing) stated, When a resident returns from the hospital and the resident has on a wristband from the hospital which contains the resident's personal information, the wristband should be removed when the resident returns to this facility. The wristband should be removed to protect the resident's privacy. The nurse is responsible for removing the resident's wristband from the hospital. R255's hospital after visit summary documents R255 was admitted to the hospital on [DATE] and discharged from the hospital on [DATE].

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) to one resident (R46). This failure affected one resident out of sample size of 72.Findings include:R46 has a diagnosis is Hemiplegia and Hemiparesis, Disorders of Muscle, Hypertension, History of Falling, and Vitamin D Deficiency.R46 has a Brief Interview of Mental Status score of 10, indicating moderate cognition impairment.R46's Minimum Data Set Section GG, dated 01/02/2026, documents, Toileting hygiene: the ability to maintain perineal hygiene indicates 01: Dependent-Helper does ALL of the effort.R46's Task for Toileting Hygiene for 3/03 documents a time of 12:14am. There is no time listed for the 7:00am-3:00pm shift for toileting hygiene.R46's care plan focus, dated 7/26/2023, documents, I have bladder and bowel incontinence related to impair mobility: Check and change Q2-3H (every 2-3 hours) and PRN (As needed).On 3/03/2026 at 10:55am, R46 stated he had not been changed since 8:30pm on 3/02/2026.On 3/03/2026 at 11:08am, R46's incontinence brief had a dark yellow liquid substance in the front and back of the brief.On 3/03/3036 at 11:09am, V7 (Licensed Practical Nurse-LPN) said, No, it does not look like (R46's) incontinence brief has been changed this shift, and the brief appears to be filled with urine (yellowish liquid substance).On 3/03/2026 at 11:12am, V38 (Certified Nursing Assistant) stated residents are checked every two hours or more frequently for incontinence care. V38 stated R46 is not in her set but R46 should have been changed at least once this shift and more often if necessary. On 3/04/2026 at 12:16pm, V3 (Director of Nursing) stated residents should be changed at least twice a shift, once at the beginning and once at the end of the shift and more frequently if necessary.Policy titled Incontinence Care, with a revised date of 1/16/2018, documents, to prevent excoriation and skin breakdown, discomfort and maintain dignity and incontinent resident will be checked periodically in accordance with the assessed with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode.Job description, dated 5/02/2017, titled Certified Nursing Assistant documents, provide assistance in personal hygiene and adhere to professional standards, company polices and procedures, and all federal, state and local requirements.

Based on observation, interview, and record review, the facility failed to label and date oxygen equipment (tubing and humidifier bottle) and failed to contain suction tubing. These failures affected one resident (R59) reviewed for oxygen in a total sample of 72 residents.Findings include:R59's diagnosis includes but is not limited to paraplegia, tracheotomy, cerebral infarction, iron deficiency, hypoglycemia, anemia, and venous thrombosis and embolism.R59's Brief Interview of Mental Status (BIMS) score is 13. R59 is cognitively intact.R59's Physician Order Sheet (POS), dated 2/13/26, documents, Trach: Change out date and label trach tubing weekly. Every night shifts every Sunday.R59's care plan, dated 10/28/26, documents: Focus: Risk for ineffective airway clearance. Intervention: Perform nasotracheal/oropharyngeal suctioning as appropriate to maintain airway. Provide oxygen as indicated by resident conditions and or provider order. Suction as needed. Utilize humidity (humidified oxygen or humidifier). Focus: I have a tracheostomy r/t impaired breathing mechanics. Interventions: suction as necessary.On 3/2/26 at 10:50 am, R59 was lying in bed receiving oxygen through the trach collar at 5 liters. R59 was pointing at his trach collar, then the humidifier bottle, shaking his head no. The humidifier bottle was almost empty and not dated. The trach collar was not dated. A suction machine was sitting on the nightstand with the suction tubing hanging down touching the side of the nightstand, not contained and not dated. On 3/2/26 at 11:00 am, V9, Licensed Practical Nurse (LPN), stated, The humidifier bottle and trach tubing should have been dated when it was hung. The humidifier bottle should have been replaced. I will get another one. The suction tubing should not be hanging. It should be contained and labeled with a date because of infection control. I am not sure how often the tubing should be changed, I think weekly. On 3/3/26 at 10:30 am, R59's humidifier bottle was noted to be empty. V7, LPN, stated, The humidifier bottle should have been replaced last night. I will get another one.On 3/4/26 at 2:02 pm, V3, Director of Nursing (DON), stated that oxygen tubing's are changed weekly on Sundays and should be dated when it is changed. Suction and oxygen tubing's should be contained and dated if not in use because it can get dirty and to prevent microorganisms. Facility issued document titled, Oxygen Therapy undated, documents, General Guidelines: Check the water level in the humidifier bottle often. If it is near or below the refill line, pour out any remaining water and refill it with sterile or distilled water.Facility's job description titled License Practical Nurse documents: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. Such supervision must be in accordance with current federal state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality of care is always maintained. Essential Duties and Responsibilities: Monitor your assisted personal to ensure that they are following established safety regulations in the use of equipment and supplies.

Based on observation, interview, and record review, the facility failed to ensure the residents' personal refrigerator temperature logs were monitored. This failure affected three residents (R59, R167, and R197), reviewed for personal refrigerators in a sample of 72 residents. Findings include:R59's diagnosis includes but is not limited to paraplegia, tracheotomy, cerebral infarction, iron deficiency, hypoglycemia, anemia, and venous thrombosis and embolism.R167's diagnosis includes but is not limited to Chronic Obstructive Pulmonary Disease (COPD), Glaucoma, benign prostatic hyperplasia, gastritis, and arthritis.R197's diagnosis includes but is not limited to fracture of shaft of left femur, chronic kidney disease, quadriplegia, disorders of muscle, multiple sclerosis, hyperlipidemia, hypertensive heart disease, and obstructive reflux uropathy.On 3/2/26, R59, R167 and R197's personal refrigerator temperature log sheet had multiple days of missing temperature checks in February 2026. The month of March R197 had a missing temperature check on 3/3/26. On 3/4/26 at 10:36 am, V36, Housekeeper, stated housekeeping is supposed to check the resident's refrigerator daily, to make sure it's clean, the temperature is at a safe range, and no old or spoiled foods are in it.On 3/4/26 at 12:00 pm, V27, Houskeeper Director, stated the housekeeping department checks the resident's personal refrigerators daily. The refrigerators are checked daily to make sure there are no spoiled foods in the refrigerators. On 3/4/26 at 2:02 pm, V3, Director of Nursing (DON), stated the resident's refrigerator should be checked daily by the housekeeping department to make sure the temperature is at a safe level. If it is to low, the food can spoil.Facility's policy titled, Refrigerators in Resident Rooms documents: Procedure: 2. Each refrigerator shall have a temperature log with daily entry. 3. The housekeeper will enter the temperature once daily. 6. All food will be monitored when daily temperature check is performed.Facility's job description titled Housekeeper documents: Summary: The primary purpose of the Housekeeper is performed the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility and as may be directed by the Administered, and /or the Director of Environment Services, to assure that our facility is maintained in a clean, safe, and comfortable manner.

Based on interview and record review, the facility failed to provide supervision to prevent elopement for one [R1] out of four [R1, R4, R5, R6] residents reviewed for elopement. This failure resulted in R1 eloping through the front entrance three times including on 10/12/26 sustaining open areas to both feet, and on 2/6/26 sustaining a fall with a close head injury and left lower lip laceration requiring sutures. Findings Include:This was identified as an Immediate Jeopardy which began on 10/12/25.On 2/27/26 at 1:52 pm, the administrator was notified of the Immediate Jeopardy. On 02/28/26 at 3:54PM, the facility abatement plan was approved.The Immediate Jeopardy was removed on 3/1/26. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. R1 was admitted on [DATE] with medical diagnosis of schizophrenia, depression, anxiety, lack of coordination, abnormalities of gait and mobility, obesity, and essential hypertension. R1's Minimum Data Set [MDS] Brief Interview Mental Status Score indicates R1 is cognitively intact. R1's progress nurse note, dated 4/23/25, at 11:00PM, documents R1 was seeking to exist the facility, tried to leave the building but staff was able to re-direct back to facility. On 2/24/26 at 8:20AM, V7 [R1's Family Member] stated, (R1) has eloped from the facility too many times. The last two elopements (R1) sustained injuries. When (R1) was on the locked unit, he was not able to elope. In January, (R1) went to the hospital and returned to an unlocked unit. At that time, (R1) eloped and sustained a head injury, lost some teeth, and a deep cut to his mouth that required sutures. The last elopement, I literally begged the hospital not to send (R1) back to that facility, I was afraid for (R1's) safety. 1.R1's Social Service Note, dated 6/21/25 6:45 PM, documents R1 left the facility without permission, staff redirected the resident back into the facility. Elopement care plan was created, elopement assessment updated. R1's 6/21/25 Elopement Risk/Community Survival Skills Assessment: documents R1 is at risk of eloping and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. R1's Care plan: documentsR1 is an elopement risk related to exit seeking. Intervention: Intervene as appropriate. Date initiated: 6/21/25. On 2/26/25 at 10:40AM, V3 [Social Service Director] stated, An Elopement Risk/Community Survival Skills Assessment are completed upon admission, quarterly, any medical/behavior significant change, any elopements or attempt to elope. On 4/23/25, (R1) did leave out the front door, but staff were with (R1) and re-directed (R1) back to the facility. I did not complete an Elopement Risk/Community Survival Skills Assessment and did not update the care plan, because I thought it was a minor incident. On 6/21/25, (R1) left out the front lobby door, and staff went outside directly after (R1) and re-directed (R1) back into the facility. I completed (R1's) Elopement Risk/Community Survival Skills Assessment, and (R1) was now an elopement risk, and (R1's) care plan was updated. On 6/25/25, a (electronic monitoring device) was placed on (R1). I went to (V1, Administrator) to receive the (electronic monitoring device). The nurse and I went together and placed the device on (R1), and he did not refuse the device. It is the nurse's responsibility to place the (electronic monitoring device) to monitor placement and functionality. Unless I am told by nursing staff, I assume the (electronic monitoring device) is still in place. If a resident goes to the hospital, it is not my responsibility to ensure the (electronic monitoring device) was still in place; nursing is responsible. (R1) was admitted to the fourth floor. After 4/23/25 and 6/21/25, (R1) remained on the fourth floor. On the fourth floor all residents can leave on the elevator at free will, there's no keypad nor any code required to exit the fourth floor. R1's Elopement Risk and Community Survival Skills Assessment, dated 6/23/25, indicated R1 was not at risk to elope, the Elopement Risk Protocol is not indicated. Completed by V21 [Social Worker]. R1's Elopement Risk and Community Survival Skills Assessment, dated 9/25/25, indicated R1 was not at risk to elope, the Elopement Risk Protocol is not indicated. Completed by V21 [Social Worker]. On 2/26/26 at 10:58 AM, V21 [Social Worker] stated, An Elopement Risk/Community Survival Skills Assessment are completed upon admission, quarterly, any medical/behavior significant change, any elopements or attempt to elope. I do not remember why I completed another Elopement Risk/Community Survival Skills Assessment. I don't know why I indicated (R1) was not an elopement risk two days after (R1) eloped. That was a clinical error. I do not remember the reason why I completed another Elopement Risk/Community Survival Skills Assessment for (R1) on 9/25/25. I indicated (R1) was not an elopement risk, again, it was a clinical error. On 2/24/26 at 3:25 PM, V1 [Administrator] stated, On 6/21/25 was the first time (R1) left the facility with staff present. (R1) was re-directed back into the facility and placed one to one from 6/21/25 to 6/27/25, and (R1's) (electronic monitoring device) was placed on 6/25/25. (R1) remained on the fourth floor. The fourth floor is not a locked unit. There is no code needed for elevator use. (R1's) elopement dated 6/21/25, the police were not called, there was no incident report completed, and I did not report the incident to IDPH (Illinois Department of Public Health), because there was no injury to (R1). R1's Social Service Progress, dated 09/28/2025 at 7:45PM, documented R1 attempted exit seeking behavior, redirected aggrieved to PRN, placed on 1:1 monitoring, care plan and assessments reviewed. On 2/26/25 at 10:40AM, V3 [Social Service Director] stated, (R1) was noted with exit seeking behaviors on 9/28/25. The nurse gave (R1) medication to assist with agitation. There were no Elopement Risk and Community Survival Skills Assessment complete. (R1's) care plan was not updated for 9/28/25. (R1) remained on the fourth floor, which is not a secure nursing floor. 2.R1's Social Service Note, dated 10/12/2025 at 1:45PM, documents, (R1) left the facility unauthorized. Staff conducted immediate searches in the community. 911 was called and filed was reported. Staff will continue to follow up. Care plans and assessments updated. R1's Social Service Note, dated 10/12/2025 at 5:52PM, documents it was reported that R1 took himself to the hospital because he was hearing voices. Will follow up as needed. R1's Nurse Note, dated 10/12/2025 at 6:05PM, authored by V18, Licensed Practical Nurse, documents, About 5:45PM, I received call from the nurse at hospital saying that (R1) checked himself into the hospital saying that he was hearing voices and fax medication and face sheet, administrator, on call supervisor, DON (Director of Nursing) and supervisor on duty notified. R1's Nurse Notes, dated 10/12/2025 at 8:32PM, authored by V18, Licensed Practical Nurse, documents, (R1) is back to facility per stretcher by ambulance, alert, oriented and verbally responsive upon skin assessment noted with an open area on the sole of both feet, area cleaned and apply dry dressing, physician notified and endorsed to monitor, (R1) remain 1:1 monitoring, Administrator and DON [ Director of Nursing] made aware. R1's Elopement Risk and Community Survival Skills Assessment, dated 10/12/25, documents R1 is at risk of eloping and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. R1's Care plan, updated on 10/29/25, documents Social Service Director will refer R1 to Activity Department as well as one-to-one psychotherapy. When R1 returns, R1 will be placed on one to one or every thirty minutes for 24-hours or until further notice. R1's Hospital documents, dated 10/12/25, indicates the following:Time of service: 5:25 PM.Upon R1's arrival he explained he left the nursing home today because he was hearing voices and came straight to the hospital. I hear voices like the devil.R1 was drowsy, appeared sedated.Emergency note: R1 states he lives at the nursing facility and provided the name. Phoned nursing facility and spoke to V18 [R1's Licensed Practical Nurse]. V18 stated that R1 tried to elope earlier but was stopped and given Haldol 5mg orally around 12:23PM, but she [V18] could not locate R1 a few hours later. R1's Skin Report, dated, 10/13/25, documents R1 has open areas to the sole of both feet. R1's physician orders document: (electronic monitoring device)-Check Placement/Functionality q shift (every shift), start 6/25/26 and end 10/31/25. On 2/25/26 at 1:49 PM, V18 [Licensed Practical Nurse] stated, On 10/12/25, I worked a double shift on the fourth floor, 7AM to 3PM and 3PM to 11PM. I was (R1's) nurse. I was not aware that (R1) was an elopement risk. All the residents on the fourth floor are able to go on the elevator as they please. Earlier that morning (R1) tried to leave out the front door, but he was stopped by staff, and I was notified. I do not remember who notified me. I re-directed (R1) to come back to the fourth floor. (R1) was agitated. I gave him Haldol 5mg, and I continued to work. I did not report his exit seeking because (R1) did not get out of the facility. I kept close watch on (R1) the best I could, I had to take care of other residents. Around 1:00PM, I could not locate (R1). (V12, Weekend Nurse Supervisor) and I went outside looking for (R1), but we did not see (R1). I went back to the fourth floor and continued to work. Later around 5:45PM, I received a phone call from the hospital nurse saying that (R1) checked himself into the hospital saying that he was hearing voices. I notified the administrator, on call supervisor, and DON. (R1) returned back to the facility around 8:30 PM, per body assessment, noted (R1) with new open areas on the bottom of his feet. (R1) absolutely had a (electronic monitoring device) on his arm. A (electronic monitoring device) helps prevent a resident from eloping.R1's medication administration record documents on 10/11/25, 10/12/25, 10/13/25, 10/14/25, and 10/15 'N' (No). R1's physician order read: (electronic monitoring device) placement and functionality every shift for monitoring. Start date of 6/25/25. V18 stated, The initials documented for 10/11/25, 10/12/25, 10/13/25, 10/14/25, and 10/15 that documented 'N' were mine. I documented 'N' for No. There was no (electronic monitoring device) in place on (R1). Now I remember (R1) did not have a (electronic monitoring device) in place. After I noted (R1) did not have a (electronic monitoring device) in place, I did not report the findings to anyone. I don't remember why I did not report (R1's) (electronic monitoring device) was not in place to administration or nursing supervisor. After (R1) eloped on 10/12/25, I still did not report to nursing administration or supervisor that R1's (electronic monitoring device) still was not in place. On 2/27/26 at 3:55 PM, V12 [Weekend Nurse Supervisor] stated, On 10/12/25, around 12:30PM, (V18, Licensed Practical Nurse) made me aware she could not locate (R1). (V18) and I searched for the facility and outside. Code pink was called. (R1) was not located. The police were notified. I did not receive a police report, I did not collect nor document the police officer badge number, and I did not request the police report number. I did not document the incident in (R1's) chart; his nurse documented. I did not know how (R1) got out the front doors. I do not remember. I do not know if (R1) had a (electronic monitoring device), I cannot remember. On 2/28/25 at 11:56AM, V1 [Administrator] stated, On 10/12/25, (R1) left the facility and took himself to the hospital. (R1) was placed one-to-one for a week, and (R1) was moved to the third-floor, locked memory care unit. (R1's) (electronic monitoring device) has always been in place since 6/25/25.I completed a past non-compliance for 10/12/25 incident. The failure was identified: (R1) exited the front door.Actions: (R1) was assessed for injuries, none was noted. Family and MD (Medical Director) were made aware. New order received from MD. Resident was placed on one-to-one supervision for a week. A Quality Assurance [QA] tool has been implemented to monitor compliance of door alarms and to monitor residents displaying new signs of elopement behavior. Administrator or designee will conduct daily audits of five residents a week for two months, then two residents a week for four months or as needed to monitor for compliance. All Resident's and care plan updated, all resident's elopement assessment has been updated. All exit doors were checked and found in compliance with functionality. Facility has implemented daily door checks of the exit doors. All staff have been in serviced on elopement policy and procedure. QAPI (Quality Assurance Performance Improvement) meeting was held to review events and action plan. Reviewed with medical director. Agency staff will be educated before the start of their first shift. Code pink drills have been conducted on all three shifts. With the past non-compliance in place (R1) eloped out the facility on 2/6/25 because he got on the elevator, and the front desk staff buzzed (R1) out the facility.V1 failed to identify R1 had an order to monitor the (electronic monitoring device) placement and functionality every shift and staff were documenting as no post his elopement. V1 also failed to recognize R1 had injury to his feet. 3.R1's progress notes, dated 02/06/2026 at 1:10PM, authored by V16, Licensed Practical Nurse, documents, (R1) was seen around 7am this morning during rounds by the elevator. When asked where he was going to, he stated he was heading to the vending machine to get a coke. Later, when I attempted to administer his medications, I noticed the resident was missing. I contacted the receptionist to page him to his room but was still unable to locate (R1). I checked the first floor and other areas but (R1) could not be found. Social services and DON [Director of Nursing, V2] were notified, and all necessary steps were taken. (R1) was later found at the hospital, Nurse practitioner and family (V7) made aware. R1's Social Service Note, dated 02/06/2026 at 1:28PM, documents R1 left facility. family notified. Care plan and assessment reviewed and updated; IDT made aware; will continue to follow up as needed. R1's Elopement Risk/Community Survival Skills Assessment, dated 2/6/26, documents R1 is at risk of eloping and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. R1's care plan was reviewed. The care plan was not updated related to 2/6/26 elopement. R1's Hospital documents, dated 2/6/26, indicate:R1 said he was running and tripped and fell and struck his mouth and face.CT (Computed tomography) Maxillofacial - Chipped tooth at the left maxillary medial incisor. Missing right mandibular medial incisor tooth.Repaired lower lip laceration with sutures. On 2/25/25 at 1:05 PM, V16 [Licensed Practical Nurse] stated, I was (R1's) nurse on 2/6/26, on the third floor south unit. At the start of my shift at 7:00 AM, I saw (R1) standing at the elevator waiting for its arrival. I asked (R1) where he was going. (R1) said he was going down to the first-floor vending machine for a soda. (R1) knew the elevator code; I saw him place in the code numerous times. Since (R1) has been on the third floor south unit, he always goes down to the first floor to get snacks and soda out the vending machines and comes back to the floor. Around 9:30AM, I was looking for (R1) to administer his morning medications, but I could not locate (R1). Then I called the receptionist and asked her to overhead page (R1) back to his room. After a while (R1) did not return, I went to the first floor, and I did not see (R1). I notified (V1, Administrator) that (R1) could not be located. Staff and I went outside and did not see (R1). I did not work with (R1) until (R1) was re-admitted to the third floor south unit on 1/16/26. I did not know (R1) was an elopement risk resident. There is no list of elopement risk residents at the nursing station. (R1) did not have a (electronic monitoring device) since he was on this unit. There was no physician order to check for (electronic monitoring device) placement. I have never seen any (electronic monitoring device) on (R1's) wrist or ankles. There was no way for me to know (R1) was an elopement risk resident. On the third floor south unit, we have an elevator that requires a code to retrieve the elevator. The majority of the third floor south unit residents know the elevator code including (R1). The code was in place for the third floor north residents that live on the locked secure unit. Just in case the resident from the third floor north locked unit gets out, they would not be able to leave the third floor, because they don't know the code to the elevator. The code to the elevator was not kept from the third floor south residents. Later, around 10:45 AM, (V1, Administrator) told me (R1) was located at the hospital. On 2/25/25 at 1:05 PM, V17, Registered Nurse, stated, The residents and (R1) on 3South unit knew the code to the elevator. The code was put in place for the 3North residents. On 2/24/26 at 8:15 AM, V6 [Former Receptionist] stated, On 2/6/26 the start of my shift 7AM, I was at the front desk getting organized with staff standing around blocking my view. A man stood at the front door, looked like a staff member, so I pressed the door release button for the front door to open, and (R1) walked out, not knowing he was a resident. Around 9:30 AM, (V16, Licensed Practical Nurse) asked me to overhead page for (R1), because she could not find him. (R1's) name was not familiar. Later, around 10:30AM, the hospital called the facility. I heard (R1) had fallen and hit his head while lost outside. (V1) called me in his office, and he showed me the video surveillance. The time (R1) left the facility was 7:04 AM on the video. (V1) said it was all my fault, and (R1) got hurt because of me. Then (V1) fired me. (R1) was not on the elopement risk list, neither was his picture. (V3, Social Service Director) asked if the (electronic monitoring device) alarm sounded. I told them the alarm did not sound. (R1) did not have a (electronic monitoring device) in place. If (R1) had had on a (electronic monitoring device), the front door alarm would have sounded. (V1) blamed me for the whole incident and did not hold the nursing staff accountable for (R1's) elopement. There are a lot of staff that look like residents and it's hard to tell the difference. There was no way for me to know that (R1) was an elopement risk resident. On 2/27/26, V6 phoned surveyor and stated, (V14, Certified Nurse Assistant/Nurse Scheduler) called me and told me to tell the state surveyor that (R1) left the facility at 8:45AM not 7:04AM. I will not lie to the state surveyor. I saw the video, and (R1) left out the front door at 7:04AM. I do not want to be harassed to tell the state surveyor lies. On 2/27/26 at 1:15 PM, V19 [Licensed Practical Nurse] stated, (R1) was an elopement risk resident that was on this unit 3North. This is a secure locked unit. There is no elevator access to this unit. To get on or off this until you must place in a code which is the same as the elevator code. None of the residents on this unit knows the code. (R1) was on this secure unit from 10/15/26 to 1/8/26. During that time frame, (R1) did not have any elopements. (R1) went to the hospital due to behaviors on 1/8/26 and was re-admitted back to the facility on 3South unit. That unit is on the same floor, but it is not a secure lock unit. There is a keypad on the elevator, that's extra security for the 3North residents just in case they leave the secure locked unit. On 2/28/26 at 11:17AM, V13 [Maintenance Director] stated, I been working here for five years. The (electronic monitoring device) alarm is only on the front lobby door. If a resident with a (electronic monitoring device) in place and come within five feet of the front door, the alarm will sound and stay on until front desk staff enters the code. The (electronic monitoring device) alarm system is checked every day by the maintenance staff. The alarm system has been functioning properly. From 10/1/25 to present day 2/28/26, the alarm has been working. On 2/27/26 at 4:00 PM, V2 [Director of Nursing] stated, I have been the Director of Nursing since November 2025. I don't have prior information regarding (R1's) elopements. The facility has one secure unit, 3North. On 2/6/25, during my investigation, (V16, Licensed Practical Nurse), the nurse that worked with (R1) when he eloped on 2/6/26, told me she did not know that (R1) was an elopement risk resident. (V16) said (R1) knew the third-floor elevator code and saw (R1) place in the code. Other residents knew the code as well. I have seen residents put in the elevator code on the third floor. On (R1's) medication administration record for October 2025, (V18, Licensed Practical Nurse) documented 'N' for (electronic monitoring device) placement and functionality, means the (electronic monitoring device) was not in place. N means NO. If a nurse notes a (electronic monitoring device) is not in place, and there is an order for the (electronic monitoring device), the nurse was to contact the Administrator, Director of Nursing or Nurse Manager to receive a (electronic monitoring device) to place on the resident immediately. The purpose of the (electronic monitoring device) is to prevent elopement. (R1) eloped on 2/6/25 because (V16) did not know he was an elopement risk resident. (R1) had eloped in the past, (R1) knew the code to the elevator, (R1) did not have his (electronic monitoring device) on, the receptionist was not paying attention, and just buzzed (R1) right out the door. It is nursing staff responsible to ensure the orders are placed in the medication administration record to check for (electronic monitoring device) placement every shift and functionality. Upon admission or re-admission, it is the whole team to work together to ensure the elopement resident (electronic monitoring device) is back on. (R1) was on the secured locked unit from 10/15/25 until 1/8/26, with no elopement incidents. Upon (R1's) re-admission, (R1) was placed on the 3South unit. It was not my decision to move (R1) off the secure locked unit. When (R1) was sent to the hospital on 1/8/26, I was under the impression that (R1) would not be returning to the facility. Upon (R1's) re-admission, the (electronic monitoring device) was not placed on (R1), I do not know why. If (R1's) (electronic monitoring device) was placed on (R1) upon re-admission, if the receptionist (V6) and (V16) knew who the elopement residents were, and if (R1) did not know the code to the elevator, (R1's) elopement may have been potentially prevented on 2/6/26. On 3/1/26 at 11:00 AM, V20 [R1's Physician] stated, 'I take care of a lot of residents it hard to remember all of them. I reviewed (R1's) chart prior to this interview. I don't remember if I was made aware of (R1's) elopements. The chart documented I was made aware, so I was made aware. I do not recall if (R1) had a (electronic monitoring device) in place. I don't know why the (electronic monitoring device) order dated 6/25/25 was discontinued on 10/31/25 and not reordered. There must have been a good reason why, but I do not remember. I do not see any reason documented in (R1's) medical record. According to (R1's) medical chart, he sustained bilateral foot injuries on 10/12/25. On 2/6/26, I don't know if (R1) had injuries. On 2/28/26 at 1:35 PM V1 [Administrator] stated, (R1) did not have any elopements from 10/15/25 to 1/8/26. (R1) was residing on 3North secure unit. (R1's) room was across from the nursing station. On 1/8/26, (R1) was admitted to the hospital. Upon (R1's) return back to the facility on 1/16/26, (R1) was in a room on the 3South unit. That unit is secure; the elevator has a key code in order to get on the elevator. (R1) got on the elevator with someone and went to the first floor and the front desk staff buzzed (R1) out the door. I moved (R1) off the locked unit because he was young and needed a better quality of life. I completed a past non-compliance for 2/6/26 incident. The failure was identified: (R1) exited the front door.Actions: (R1) was assessed for injuries, none was noted. Family and MD were made aware. New order received from MD. Resident was placed on one-to-one supervision for a week. A Quality Assurance [QA] tool has been implemented to monitor compliance of door alarms and to monitor residents displaying new signs of elopement behavior. Administrator or designee will conduct daily audits of five residents a week for two months, then two residents a week for four months or as needed to monitor for compliance. All Resident's and care plan updated, all resident's elopement assessment has been updated. All exit doors were checked and found in compliance with functionality. Facility has implemented daily door checks of the exit doors. All staff have been in service on elopement policy and procedure. QAPI meeting was held to review events and action plan. Reviewed with medical director. Agency staff will be educated before the start of their first shift. Code pink drills have been conducted on all three shifts. Based on interviews and record reviews, the past noncompliance dated 10/12/26, the facility failed to recognize, and correct the noncompliance related to R1's elopement on 10/12/26 and failed to prevent R1's elopement on 2/6/26 due to the following:Staff do not know who the elopement risk residents were. V6 [Former Receptionist] and V16 [Licensed Practical Nurse] did not know R1 was elopement risk. V16 allowed R1 to leave the third floor unsupervised. V6 allowed R1 to leave out the front door. V21 [Social Service] completed R1's elopement assessments and documented R1 was not an elopement risk.Nursing staff did not ensure R1's wander guard was in place and checked every shift.Elopement residents knew the elevator code.R1's care plan was not updated per all exit seeking behaviors.The facility did not review and update Elopement Risk binder for nursing stations and front desk. Facility's Elopement Device policy, dated 8/23/2017, documents:Elopement alert devices will be used as an intervention tool to prevent resident elopements.At the time of application, the approved form is kept at the front desk.The wander guard device will be inspected by nursing personnel once each day by inspecting the location of the device on the arm or leg. Placing the transmitter tester near the anklet or bracelet to test the battery for proper working order.The functionality of the device on resident will be checked daily by social services and manger on duty. Facility's Code Pink-Missing Resident/Elopement policy, dated 11/15/2017, documents:All personnel are responsible for reporting a cognitively resident attempting to leave the premises to charge nurses soon as practical.Should an employee discover that a resident is missing from facility, he or she should:Immediately report to charge nurse or supervisorReview Physician order to see if resident have an authorized pass to leaveAlert staff announcing code pinkInform staff of the name of missing resident and a pictureNotification administrator, Director of Nursing immediatelyNurse should notify the physician, resident's family, responsible party.Notify police, file a missing report.Remain in contact with hospitals, nursing facilities, and family members.Complete incident report and notify state agency according to reporting guidelines.Document notations in the medical record.Upon return to facility:Examine resident for injuriesContact physician, responsible partyComplete incident reportDocument finds in medical recordReview Resident's out on passComplete a new Elopement Risk Assessment and update plan of careReview and update Elopement Risk binder. The immediate Jeopardy that began on 10/12/25 and was removed on 3/1/26 when the facility took the following actions to remove the immediacy: 1. All residents in the facility have been reassessed for elopement risk. The facility will monitor elopement risk assessments to ensure residents have not had a change in status to warrant a reassessment. Monitoring will be completed by Social Service Director with oversight by Administrator. A new QA tool will be put in place to monitor 10 residents a week x 12 weeks to ensure assessments are accurate. 2.All resident care plans have been reviewed with revisions made as needed. Care plans will be reviewed with each change to the elopement assessment. A new QA tool has been put in place to monitor 10 residents per week x 12 weeks to ensure compliance3.The elopement binder at the front desk and on the units has been reviewed and updated to assure that all residents that are elopement risk with wander guard are on the list including and new admissions and/or re-admissions. It will be reviewed weekly and updated with changes of resident status to ensure it is accurate.4.All staff have been newly retrained on elopement including code pink procedure, signs of elopement, elopement policy, and how to identify a resident at risk for elopement in the facility. Education has been completed by social service, administration, and nursing leadership. Any staff on FMLA or vacation will be retrained prior returning to work. The facility does not use agency for staffing.5. The facility has conducted a code pink drill on all shifts to monitor staff response and identify opportunities for additional training. Code pink drills will continue weekly x 12 weeks. This was completed by the facility administrator and the maintenance director on three shifts (1st, 2nd, and 3rd shift) - 02/27/26 and during the early morning hours on 02/28/26.6. An ad hoc QAPI meeting has been conducted with the medical director to discuss the elopement events and facility follow up7. The elopement policy has been reviewed with no required changes by the IDT team8. The facility has updated the key code to the elevators by a contracted vendor with a new key pad installed. The staff that work on the unit are to know the key code to the elevators and the staff are not to disclose the key code to residents. The code for the elevators will be changed once a month and staff will be reminded weekly not to tell the code to the residents. 9. 9. The facility has conducted a house wide audit of residents who utilize wander guard. Residents who utilize wander guard have a new corresponding order to check them each shift on the MAR and a new additional reminder on the special instruction tab on the electronic medical record. A new functionality log has been implemented to monitor function. The log will be kept on the 3rd floor nursing station and the DON and/or nursing designee will be monitoring to assure compliance.

Based on observation, interview, and record review, the facility failed to maintain environment free of bedbugs for residents reviewed for a safe and comfortable environment. These failures affected 7 residents that were exposed to bed bugs and has the potential to affect 74 residents living on the same floor.Findings include: On 12/17/2025 at 1:54 PM, R4 was seen in her room with R5. R4 spoke more Bangladesh, less English. R4 would start with a few words of English, then would continue with Bangladesh. R5 was able to express her thoughts clearly within topic during conversation. R5 stated she transferred into another room last month because this room she currently occupies was infested with bed bugs. R5 stated she was bitten by bed bugs scratching her arms. R5 stated people came to fumigate the room due to bed bugs. On the same floor, at the door, a tape was seen with Do Not Enter written with R6's, R7's, and R8's names written as occupants in the room. V10 (Registered Nurse) was asked about the room. V10 stated she does not know why there was a tape with Do Not Enter on the door. V10 paged V5 (Maintenance Director). V5 went to the floor and denied any knowledge of the tape on the door. V7 (Scheduler/Former Housekeeping Director) introduced herself as former housekeeper and went inside the room with writer and V5. The room was without residents and was crowded with multiple plastic bags and clutter. Per V7, it is the Housekeeping Director, not Maintenance Director, that is in-charge of bed bug problems. V5 and V7 went to the basement where V8's (Housekeeping Director) office was located. V8 was found inside laundry room; denied any knowledge of bed bug issue or treatment in the facility. V8 (Assistant Administrator) was asked about bed bug concerns. V8 said V11 (Pest Control Company) will come on Monday to address bed bugs concern in room identified with bed bugs. Per resident's census history, R6, R7, and R8 used to occupy the room that was seen full of plastic bags and clutter on top of the bed and floor. The room looked more like a storeroom than a bedroom. On 12/17/2025 at 2:24 PM, R6 stated she was transferred to her current room because she was bitten by bed bugs and the problem of bed bugs has been going on for weeks. R7 stated that she was relocated because her roommate was bitten by bedbugs that is the reason that she was transferred to her current room. R8 was seen on the same floor but different room. R8 stated that she was transferred into her current room [ROOM NUMBER] to 7 days ago because of bedbugs. R8 stated that she must kill bedbugs on the curtains and on her bed. Room that has R9 and R10's names also have a tape with (Do Not Enter) written on it. On 12/19/2025 at 10:35 AM, V1 stated the room that was found to have full of plastic bags and clutter needs to be decluttered and currently was in the process of decluttering. The same room was not yet treated for bedbugs because it needs to be empty of personal belongings. V1 stated he always listens to residents 100%. When residents state that they were bitten by bedbugs he takes it 100%. V1 stated they found only 2 live bedbugs; when pest control reports document dead bedbugs, it means there are bedbugs in the facility. V1 stated V6, Housekeeping Director, is also the Environment Service Director and should be aware of the bedbug situation in the facility. V1 stated he understands residents are uncomfortable when bitten by bedbugs, and it is inconvenient when they are not able to access their personal belongings because of bedbugs. Per V11 (Pest Control Company) service report, dated 12/11/2025, the room that was seen full of plastic bags and clutter needs to be treated for bed bugs. Per report, dead bedbugs and live bedbugs were seen. Rooms that were occupied by residents R3, R4, R5, R5, R7, R8, R9 and R10, were included on pest control report related to bedbugs. Change of rooms related to bedbugs' concern: R4 and R5 were relocated on 09/10/2025.R6, R7 and R8 were relocated on 12/11/2025. R9 and R10 were relocated on 12/10/2025. Pest Control Policy dated 09/01/2022:The Environmental Services Director will be responsible for coordinating the facility pest control. The pest control program will be conducted on a regular and as needed basis. Employees are instructed to promptly report all observation of pests to their department heads. The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects and rodents.

Based on interview and record review, the facility failed to prevent and protect residents from physical abuse. This failure affected one (R3) out of three residents reviewed for abuse. This failure resulted in R2 sustaining a closed fracture of orbital wall.Findings include:R3's admission record shows admission date on 12/31/24, with diagnoses not limited to Chronic Kidney Disease, Hypo-Osmolality and Hyponatremia, Hypokalemia, Osteoarthritis, Hypertension, Other Abnormalities of Gait and Mobility, Fracture of Other Specified Skull and Facial Bones, Left Side, Initial Encounter for Closed Fracture (added 09/14/25). R3's MDS (Minimum Data Set), dated 06/26/25, reveals R3 is cognitively intact and requires supervision or touching assistance for mobility. R3 has a care plan initiated on 01/03/25 stating he is at risk for abuse/neglect and will be cared for in a safe manner. R6's admission record shows admission date on 06/27/25, with diagnoses not limited to Psychotic Disorder with Delusions due to Unknown Physiological Condition, Unspecified Dementia with Other Behavioral Disturbance, Alcohol Dependence with Withdrawal, Bipolar Disorder, Anxiety Disorder. R6's MDS, dated [DATE], indicates R6's cognition is moderately impaired and R6 has adequate vision. R6's Admission/re-admission Observation Assessment, dated 09/08/25, documents R6 requires supervision or touch assistance with mobility and R6's Activities of Daily Living care plan indicates R6 requires supervision with mobility. R6 has a care plan in place for verbal aggression initiated on 08/12/25 which documents, (R6) has the potential to be verbally/physically aggressive/threatening staff and others related to ineffective coping skills, mental/emotional illness, and poor impulse control. R6 has a care plan for diagnosis and history of severe mental illness as manifested by delusions-paranoia.R6's electronic health records reveal R6 was hospitalized from [DATE] to 08/15/25 due to verbally threatening facility staff by saying, I will beat your ass. Bit** ass nig**. R6's admitting hospital diagnosis for this hospitalization was aggressive behavior. R6 was also hospitalized from [DATE] to 09/01/25 due to increased agitation and odd behavior of defacing facility property with gang signs and attempting to smoke in his room. R6's admitting hospital diagnosis for this hospitalization was for acute psychosis. R6 was also hospitalized from [DATE] to 09/08/25. On 09/02/25, R6 was threatening to hurt staff inside and outside the facility and searching for staff with an object in his hand saying he was going to hit the staff with it. R6's hospital admitting diagnosis for this hospitalization was aggressive behavior. R6 readmitted to the facility on [DATE]. On 09/08/25 at 11:45 AM, R3 was in the lounge sitting in a chair. R3 had black and blue marks under R3's right eye and right eye was bloodshot. R3's response to questions was garbled, with R3 mumbling in a low voice which was difficult to understand. R3 provided responded to questions with short responses. R3 stated he does not remember what happened to his eye. R3 indicates he did not fall and was not pushed. When asked if R3 remember R6, R3 said, maybe. R3 stated R6 did not bump into him or push him. When asked if anyone punched R3, he said, I'm not sure. On 09/18/25 at 8:20 AM, V36 (Housekeeper) stated via an interpreter, V29 (Food Service Director), on 09/09/25, V36 was cleaning a resident's room on the 4th floor when she heard a thud sound, so she went to see what was going on. V36 stated when she went to the 4-North Lounge, she saw R3 lying on his back on the floor and R6 was on top of R3. V36 stated she ran to get help. On 09/16/25 at 2:39 PM, V19 (Social Service Director) stated he was doing rounds on the 4th floor on 09/09/25 and while in the 4-North Lounge, he saw R6 walk into the dayroom aggressively. V19 remembers R3 was the only resident in the lounge at that time. V19 stated R6 was angry and walking quickly. V19 stated at that time, R3 in the process of getting up from his chair, and V19 saw R6 aggressively bump into R3 causing R3 to fall to the ground. V19 stated he asked R6 what was going on and R6 told V19, I'm mad, man. I'm mad. I'm pissed off and I don't want to talk. I'm pissed off. I'm pissed off. V19 stated R6 was not specifically going after R3, it is just that R3 was in the wrong place at the wrong time. V19 stated R6 was angry about something leading up to this, but he does not know what happened. V19 stated the goal is to always protect the residents to keep them safe and free from abuse. V19 stated R6 did make physical contact with R3, which is considered abuse.On 9/17/25 at 12:45 PM, V19 reenacted what he saw on 09/09/25 in the 4-North Lounge with the surveyor acting as R3 and V19 acting as R6. V19 stated it looked as if R3 was in the process of getting up from a chair when R6 made physical contact with R3. V19 acting as R6 charged head on directly toward surveyor as surveyor was attempting to get up from a chair. V19 demonstrated how the front of R6's right shoulder area made contact with R3's face. V19 stated this is what caused R3 to fall, but he not sure if R3 fell backwards or forward. V19 stated R6 was mad and there was some type of trigger that caused R6's anger, but he does not know what it was. V19 stated it was R6's anger that led to R6 willfully and aggressively hit R3 with force. On 09/16/25 at 1:20 pm, V13 (Certified Nursing Assistant) stated the incident happened in the 4-North Lounge right before lunch time on 09/09/25. V13 stated usually R3 sits in the 4-Southwest Lounge, but on that day when staff tried to get R3 to eat in the 4-Southwest Lounge, R3 wanted to go to the 4-North Lounge. V13 stated R3 was the only resident in the 4-North Lounge that she knows of, because all the other residents were in the 4-Southwest Lounge waiting for the lunch trays to arrive and be passed out. V13 stated when the incident occurred, she was sitting at the 4th floor nursing station with some of the other staff because they were waiting for the lunch trays to arrive. V13 stated this was around 12:00-12:30 PM. V13 stated one of the housekeepers was yelling fall, fall so they all got up and ran to the 4-North Lounge. V13 stated when she entered the 4-North Lounge, she saw R3 on the floor and could see that he was trying to get up. R6 was walking out of the 4-North Lounge, and she asked R6 what happened and R6 said to V13, I don't know what happened, he (R3) just fell on the floor.On 09/17/25 at 11:10 AM, V2 (Director of Nursing) stated on 09/09/25, he was called to go up to the unit, and R3 and R6 were already separated by the time V2 arrived on the unit. V2 stated he first went to check on R3 who was in his room with his nurse. V2 stated R3 had an abrasion under his eye with mild swelling. V2 stated R3 appeared calm but irritated and restless. V2 stated R3's doctor was notified and gave order to transfer him to the hospital. V2 stated when he saw R6 he was alert, agitated, irritable. V2 stated R6 said he bumped into R3. V2 stated he does not remember if R6 said it was intentional. V2 stated we think it was an accident because R6 was agitated and aggressively walking and bumped into R3. V2 stated he does not know why R6 was agitated and R6 could be unpredictable and demonstrate aggressive behaviors abruptly; they just happen, there is not necessarily a trigger. On 09/17/25 at 3:33 PM, V1 (Administrator) stated he is the Abuse Coordinator for the facility. V1 stated the goal is to keep the resident's safe and free from abuse. V1 stated it is the resident's rights to be free from abuse while they are residing in the facility and that all residents are at risk for abuse, and it is everyone's responsibility to prevent abuse. V1 stated on 09/09/25, R6 walked into the room aggressively and quickly made contact with R3. V1 stated R3 fell straight backwards. V1 stated maybe when R3 fell, he made contact with the floor and that is how R3 injured his eye. V1 stated R3 was sent to the hospital and diagnosed with a fractured eye socket. V1 stated this injury was caused by contact with R6 and he does not know what R6's state of mind was when he made contact with R3. V1 stated it was an observed fall and R6 bumped into him, it was not willful intent, so therefore it was not abuse. V1 stated he does not think R6 had intent to harm R3; R6 happened to aggressively bump into R3 and that caused the injury to R3. V1 stated there is no video footage of the incident because the facility cameras have not been working for a while. V1 stated the facility did an immediate discharge for R6 because of the other incidences he was involved in and because R6 he made contact with a resident. V1 stated he did not want to take a chance R6 could do something like that again. On 09/18/25 at 10:52 AM, V34 (Nurse Practitioner) stated R3 sustained a fall due to an unintentional interaction with another resident and this fall is what caused R3's injury. V34 stated R3 was sent out to the hospital and was diagnosed with an orbital wall fracture of the right eye. V34 stated R3's eye area would have had to come in contact with something to cause the injury, but no one knows what that was because no one witnessed the fall. R3's Nurse's Note titled Fall-Initial Occurrence, dated 09/09/25, documented, resident had a witnessed fall on 09/09/25 12:30 PM in the 4-North Lounge. Resident was watching television in 4-North Lounge, then another resident who was agitated and walking fast toward the 4-North Lounge bumped into this resident resulting him losing his balance and fell on the floor. Witnessed fall, observed to have struck head. An abrasion under the eyes. Send to hospital for further evaluation per doctor's order.R3's hospital records, dated 09/09/25, documented, some concern from nursing staff, as well as myself, with lack of description of mechanism of injury. Nursing facility (name of facility) was called twice but was uncertain as to why patient had blood from his nose. After workup patient with orbital fractures and significant periorbital ecchymosis and periorbital swelling. As a mandated reporter, filed report through the Illinois Department of Public Health, for possible elder abuse. R3's Emergency Department Physical Exam comments documents ecchymosis to inferior aspect of right eye. Raccoon sign on the left eye. Blood from right nare. Contusion and ecchymosis overlying left forehead.R3's hospital records, dated 09/09/25, Quantitative Computed Tomography (CT) completed 09/09/25 impression right medial orbital and likely inferior orbital wall fractures. R6's Petition for Involuntary/Judicial Admission, dated 09/09/25, documents, resident presents with increased agitation and responding to internal stimuli resulting in psychomotor whereby resident was walking very fast towards 4-North Dining Room and bumped into other resident. Also, resident was verbally confrontational with staff, placed on 1:1 monitoring; unable to be redirected, refused a PRN (as needed), may pose as a threat to himself and others. R6's Nursing Progress Note, dated 09/10/25, documents resident is admitted to hospital with diagnosis: aggression. Facility's final incident report submitted to Illinois Department of Health on 09/16/25 listed R3 as the victim and R6 as the perpetrator. Incident category listed as Resident Abuse. Facility final incident report documents in part, based on the investigation that included interviews with staff and residents R6 was agitated and was walking swiftly into the 4-Floor Lounge when he accidentally bumped into R3, resulting with R3 losing his balance and falling to the floor.Facility provided document titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities dated 11/2018 which documents your rights to safety: you must not be abused, neglected, or exploited by anyone financially, physically, verbally, mentally or sexually. Facility provided policy titled Abuse Prevention and Reporting - Illinois reviewed 04/13/22 which documents the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on record review and interview, the facility failed to follow their abuse policy for two residents (R1, R2,) out of five residents reviewed abuse. This failure resulted in staff not intervening in a timely manner, thus allowing R2 to hit R1 in the face, causing an injury to R1's right eye and nose.Findings include:R1's 8/26/2025 22:54 Nurses Note Narrative states: An agitated resident went into resident room and made contact with her. Resident was immediately separated from her and secure her safety. Complete assessment performed, provided first aid interventions and called 911. NP (Nurse Practitioner) notified. Family notified. Administrator, DON (Director of Nursing) and ADON (Assistant Director of Nursing) notified. Offered pain medication. BP (blood pressure)-146/70 P (pulse)-80 R (respirations)18 T (temperature)-97.5 Sat (oxygen saturation)-96% room air. Neuro (neurology checks) initiated.R1's 8/27/2025 05:41 Nurses Note Narrative states: Resident admitted at Hospital. Diagnosis: Retrobulbar Hematoma.R1's hospital records document: past medical history CVA (Cerebral Vascular Accident), COPD (Chronic Obstructive Pulmonary Disease), T2DM (type 2 Diabetes Mellitus), HTN (hypertension), hemiplegia. The patient presents emergency department for above complaint, report, nursing home staff witnessed another resident enter patient's room and assault her. Never fell out of bed. Hematoma noted on imaging after an unwitnessed assault at her extended care facility. The patient Physical Exam Vitals reviewed. Head: Comments: Facial trauma with R (right) eyelid edema and laceration Nose with abrasion. Underwent lateral canthotomy secondary to retrobulbar hematoma and increased eye pressures, Ophthalmology evaluation: Assault; Laceration of right canaliculus, initial encounter.R2's care plan documents potential to be physically or verbally aggressive towards staff related to anger. Poor impulse control and mental illness reviewed 3/27/25. Reviewed 5/7/25 R2 was aggressive with staff, punched a staff member in the face. Reviewed 8/12/25 R2 was throwing objects and spat on Social Service Director.R2's 8/26/2025 19:00 Nurses Note Narrative states: The resident was noted a little anxious, was redirected back to his room. The writer told the CNA (Certified Nursing Assistant) to accompany her to the resident room in order to give him his PRN (as needed) medication for his anxiety, which he took. Social worker was notified, and he came to the floor to see the resident. Resident was calm afterwards and stayed in his room while staff continued to do their other tasks.R2's Nurses 8/26/2025 20:00 Note Narrative states: Resident was noted coming out from his room agitated and running on the hallway and ended into another resident's room (residents initials) and made contact with her. He was taken away by staff immediately and placed on 1:1. Complete assessment performed on resident. Maintained 1:1 supervision on resident. Police called and took the resident to (name) Hospital. NP and Dr (doctor) notified. Resident mother notified via (phone number). Administrator, DON and ADON notified.R2's 8/26/2025 20:29 SOCIAL SERVICE Note Text states: Resident is exhibiting physical aggression to staff and peers, refused PRN. Poses as a danger to himself and others, placed on 1:1. Police transferred resident to Hospital.On 9/2/25 at 10:15 am, V6 (Licensed Practical Nurse) stated she was in another resident room across from R1's room. V6 stated as she was coming out of that room, V6 saw R2 standing in R1's room next to her bed. V6 stated immediately went into R1's room and saw R2 standing next to her bed. V6 stated R2 raised his hand while he was standing over R1 and V6 grabbed his hand before he could strike R1. V6 stated saw R1 lying in her bed and noticed her right eye was bleeding. V6 immediately called for help and asked R2 what happened, but he did not reply. V6 stated R2 can talk, but that day he refused to talk. V6 stated on normal days, R2 can talk and make his needs known. V6 stated gave R1 first aide, called 911 and the doctor. V6 stated the paramedics came and took R1 to the hospital. V6 stated had taken care both residents and that was the first time they had an altercation.On 9/2/25 at 1:30 pm, V10 (Doctor) stated she was called by the nurse taking care of R1 and told by the nurse R1 was assaulted by another resident. V10 stated according to the hospital records, R1 sustained trauma to her right eye from the other resident assaulting her. V10 stated the assault caused bleeding behind R1's right eye. V10 stated it is too early to say if R1 will have any vision changes. V10 stated R1 is still at the hospital being treated and evaluated for trauma to her right eye. On 9/3/25 at 12:20 pm, V4 (Certified Nurse Aide) stated he was assigned to R1 that evening. V4 stated after dinner, V4 had given R1 hygiene care, gave her roommates water, then left the room. V4 stated a little while later, V4 was giving another resident care when V6 called for help. V4 stated V4 went towards the noise and saw V6 stopping R2 from hitting R1 in the face. V4 stated they intervened and escorted R2 from R1's room. V20 stated saw R1 had been injured in the face from R2. V4 stated V4 was assigned to stay with R2 until the police came to the unit.On 9/2/25 at 11:20 am, V11 (Licensed Practical Nurse) stated after dinner, R2 was pacing and acting anxious. V11 stated she gave R2 a pill that was ordered to be given as needed for anxiety. V11 stated after R2 was given the anti-anxiety pill, he went to his room. V11 stated a little while later, V11 was sitting at the nurse station charting, when suddenly V11 heard a loud scream coming from R1's room. V11 stated ran towards R1s' room. V11 saw V6 and another staff member in there. V11 stated when entering the room, they were escorting R2 out of R1's room. V11 stated V11 saw R1 lying on her bed bleeding from the right side of her face. V11 stated R1 is bedbound and needs assistance getting out of bed. V11 stated R1 does not talk much at all, mostly nonverbal. V11 stated R2 can talk and make his needs known, but is confused at times. On 9/2/25 at 11:45 am, V9 (Social Worker Director) stated for the most part R2 is pleasant but does have a psych diagnosis. V9 stated R2 can talk to you when he wants to talk to you. V9 stated prior to the incident, R2 was agitated, and the nurse had given him some medicine to calm him down. V9 stated he was called to R1's room by the nurse and they were escorting R2 out of her room. V9 stated noted at that time R2 was responding internal stimuli, not sure if he was delusional or having a hallucination. V9 stated they placed R2 on 1:1 supervision until the police and paramedics arrives. V9 stated R2 was taken to the hospital for agitation. On 9/3/25 at 11:36 am, R7 (R1's Roommate) was sitting up in wheelchair. R7 stated she has been in the facility for twelve years. On the day of the incident, she had just woken up to see R2 over R1, and he was touching R1's face. R7 also stated she called for help; a lot of staff came to take R2 away, and the ambulance came to pick up R1.Facility's abuse policy documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriate of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and sensitive and resident secure environment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Based on interview and record review, the facility failed to follow their policy to ensure one resident (R6) was free from abuse. This failure affects 1 resident (R6) reviewed for abuse.Findings include: According to R6 face sheet provided by facility, R6 has diagnoses that include but not limited to moderate protein-calorie malnutrition, autistic disorder, bipolar disorder, anxiety disorder, and chronic obstructive pulmonary disease with (acute) exacerbation. R6's MDS (Minimum Data Set), dated 7/17/2025, indicates R6 has a BIMS (Brief Interview for Mental Status) score of 8, indicating moderately impaired cognition. According to R9 face sheet provided by facility, R9 has diagnoses that include but not limited to autistic disorder, Tourette's disorder, epileptic seizures, schizoaffective disorder, generalized anxiety, major depressive disorder, Asperger's syndrome, violent behavior. R9's MDS, dated [DATE], indicates R9 has a BIMS score of 11, indicating moderately impaired cognition. According to R9's Aggressive Behavior Assessment, dated 5/7/2025, comment section, on 5/7/25 R9 was physically and verbally aggressive with staff, punched a staff member in the face, slammed doors, banged on facility property. Facility Reported Incident, incident date 6/26/25, documents: In the early morning hours of 6/26/25 resident R9 woke up and stood up in the middle of the night and walked towards the bathroom. Resident's roommate R6 was startled and got up out of bed quickly. While R9 was trying to go around R6, R9 became agitated, and his shoulder made contact with R6. Resident R9 was sent out for a psychiatric evaluation. R6 refused to go to the hospital for a medical evaluation. 8/13/25 at 1:30 PM, V1 (Administrator) stated, I am the Abuse Coordinator. Some types of abuse are physical, verbal, mental, misappropriation of funds/property, sexual, neglect. All staff are in-serviced on abuse. Within the last three months, the entire building has been in-serviced on abuse. When abuse is witnessed, staff have to immediately report to the Abuse Coordinator. For resident-to-resident abuse, staff separate the residents, they are put on one-to-one, staff do a room change, we notify family, physician, police, IDPH (Illinois Department of Public Health). We hospitalize as needed, investigate, and conduct interviews (staff and residents), conclude investigation and act accordingly, notify IDPH of final conclusion. For the incident involving (R6) and (R9), (R9) woke up to go to the bathroom. (R6) got startled and got out of bed quickly. (R9) got startled and agitated and (R9's) shoulder made contact with (R6). Staff heard something coming from the room and went to the room. Staff did not witness anything. (R9) was relocated to a different room. (R9) bumped into (R6) in the middle of the night when going to the bathroom. On 8/14/25 at 3:10 PM, V22 (Certified Nursing Assistant) stated V22 just started working in the facility, part-time, overnights. The nurse told me there was a fight between the two residents (R6 and R9) and there would be a room change. I did not hear or witness anything. I accompanied the resident to the new room. I don't remember the name of the resident I accompanied. The resident did not say anything about what happened. On 8/15/25 at 10:16 AM, V23 (Licensed Practical Nurse) stated, (V33, Certified Nursing Assistant) notified me that (R6) was getting up from bed. (V33) was in the hallway and saw (R6) coming towards the door. I asked (R6) 'what is the problem'. (R9) was getting up from bed to go to the bathroom. (R6) was thinking (R9) was coming to (R6), so (R6) stood up from the bed, and (R9) thought (R6) was coming for (R9). They each thought the other was coming for them. (R9's) arms were swinging and bumped (R6). (R6) told me (R9) touched (R6) on the shoulder and in the face. (R9) told me that (R9) was trying to maneuver around (R6) to go to the toilet. I assessed both of them, separated them, and put them on one-to-one. Because (R6) stated (R6) was touched in the face, the Medical Doctor ordered for (R6) to be sent to the hospital for evaluation. (R6) refused. We called the police. They came. (R6) refused to go to the hospital. (R9) was not sent to the hospital. I observed drainage from (R6's) eyes. R6's Nurses progress note, dated 6/26/25 at 07:27, reads: Resident had altercation with roommate. Writer observed resident bleeding from left eye. Resident stated roommate choked resident on the neck. The writer cleaned the resident's bleeding with normal saline and moved resident to another room. Psych doctor was notified and ordered resident's transfer to hospital for medical evaluation and send roommate to hospital for psych evaluation. Paramedics came to pick up resident, but resident refused to go to hospital. Police was called (sic) and came to talk to resident, but resident also refused. Police acknowledged they will come back whenever the resident change mind (sic). Currently resident is sleeping, no bleeding at this time and we will continue to monitor. Nurses progress note, dated 6/26/25 at 16:15, reads: Concerned of resident having difficulty opening eyes with mild drainage, mild swelling and bruising on left eye likely due to prior incident.R9's Behavior progress note, dated 6/26/2025 at 03:59, reads: The resident was petitioned to the hospital for a psychiatric evaluation following an altercation with roommate. During the investigation resident was swinging at both roommate and staff. Resident denied to have (sic) any issue with roommate. Resident refused PRN (as needed) medication and couldn't be redirected, indicating resident posed a danger to self and others. Due to unpredictable behavior, a psych evaluation would be beneficial. Paramedics picked up the resident at 3:45 am. Resident was alert with no injury and denied pain or discomfort at the time. Facility policy Abuse Prevention and Reporting-Illinois, 10/24/22, documents: 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. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to provide adequate supervision to prevent a fall of a resident (R1), who was assessed at risk for fall and has a history of falls. These failures affect 1 resident in a sample of 4 residents reviewed for falls. As a result, R1 fell and sustained a head injury with a laceration, requiring R1 to be sent to the hospital. R1 received sutures to close the laceration. Findings include: R1's face sheet documents, R1 was admitted to the facility on [DATE]. R1's face sheet documents diagnoses that include but are not limited to repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. R1's care plan, revised date 10/27/22, documents, I (R1) am at risk for falls r/t (related to) convulsion, dementia, anxiety and MDD (major depressive disorder) with interventions that document, in part, Ensure resident wearing non-skid footwear . Frequent rounding to ensure resident is wearing nonskid socks . R1's care plan, date initiated 5/6/23, documents, WANDERING/ELOPEMENT: (R1) has been observed to be disoriented to place, have impaired safety awareness, wander aimlessly throughout the facility, and have a history of attempting to exit the facility without supervision r/t dementia. It has been determined by the outcome of the elopement assessment that the resident is included in the elopement prevention program. R1's care plan, revised date 7/9/24, documents, I (R1) have an ADL (activities of daily living) and functional ability for self-care and mobility performance/deficit r/t (related to) dementia, schizophrenia, anxiety disorder, MDD (major depressive disorder), and convulsion with interventions that document, in part, BED MOBILITY: The resident requires supervision from staff for repositioning and turning in bed . TRANSFER: The resident requires partial assistance from staff to move between surfaces . R1's care plan, revised date 8/25/24, documents, I (R1) require assistance with walking r/t (related to): dementia. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 00, which indicates R1's cognition is severely impaired. R1's Minimum Data Set (MDS) section GG, dated 2/06/25, documents R1 requires partial/moderate assistance for sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed; partial/moderate assistance chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair); and partial/moderate assistance for ambulating 10 feet. R1's FALL- INITIAL OCCURRENCE NOTE, dated 10/29/24, documents, . Unwitnessed Fall . This writer was at the Nurses station charting when a sound of something falling was heard. Room was checked with CNA (certified nursing assistant) and observed resident kneeling down trying to get back up. This writer asked resident to remain seated to be assessed, resident was non-compliant and got back up by himself. R1's FALL- INITIAL OCCURRENCE NOTE, dated 11/11/24, documents, . Witnessed Fall . reported that resident stood up from the chair and lost balance and fell on his buttocks without hitting his head. R1's FALL- INITIAL OCCURRENCE NOTE, dated 4/7/25, documents, . Unwitnessed Fall . Resident walked out of his room with blood noted on the left eyebrow . Unable to give statement due to been delirious. R1's Order Summary Report, order date 4/7/25, documents, Send resident to (Name of Hospital) Hospital for medical evaluation due to unwitnessed fall. R1's Order Summary Report, ordered date 4/17/25, documents, Wound Left eyebrow, suture site, cleanse with antimicrobial wound cleanser apply bacitracin and LOTA (leave open to air) everyday shift for wound care for 7 Days. R1's progress note, dated 4/7/2025 at 7:15am, V7 (Registered Nurse/RN), documents, Resident had an unwitnessed fall 04/07/2025 5:45 AM. Location of Fall: Resident room. Resident walked out of his room with blood noted on the left eyebrow on 04/07/2025 5:45 AM . Assessment: Unwitnessed fall . New injury observed. Laceration to the left eyebrow . R1's progress note, dated 4/7/2025 2:50pm, V9 (Licensed Practical Nurse/LPN), documents, Resident was received at 7:05 AM with endorsement of awaiting ambulance to be sent to (hospital) ER (emergency room ) for evaluation post fall. Resident transported to (hospital) by . ambulance at 8:10am. Follow Up call made at 1: 30pm and resident was still under evaluation. Another call made at 3:05pm and resident is awaiting discharge. (Hospital) ER will call for report . Will endorse for next shift to follow up return. R1's progress note, dated 4/7/2025 5:31pm, V10 (Licensed Practical Nurse/LPN), documents, The resident is brought back to the facility by two paramedics from (Hospital)on a stretcher. He presents with a left eyebrow laceration, sutured with three stitches, opened to air without s/s (signs and symptoms) of infection noted . On 4/20/25 at 10:45am, R1 was sitting on the side of R1's bed, swaying back and forth, appearing as if R1 was attempting to stand up. R1 was barefoot, with a pair of red nonskid footwear/socks under R1's bed. Surveyor introduced self and R1 replied, Can you help me? I'm trying to get up. Surveyor inquired about R1's call light that was attached to R1's bottom sheet of R1's bed, and R1 replied, My call light for the nurse is over there (R1 pointed to the towards the door of R1's bedroom). Surveyor pointed to R1's call light that was next to R1, and was attached to R1's bottom sheet of R1's bed, and R1 replied, What's that string for? R1 was oriented only to person. When asked about R1's fall that occurred on 4/7/25, R1 replied, I didn't fall. What do you mean? On 4/21/25 at 10:51am, V6 (Licensed Practical Nurse/LPN) said, (R1) is a fall risk. There is a sticker of a leaf by his name by his bedroom door that indicates he's a fall risk. I do not know anything about his recent fall. For fall risk residents, the bed is in the low position, call light within reach. And for (R1), (R1) is by the nurse's station so the CNAs (Certified Nursing Assistants) can watch him. And plus, we (staff) do frequent rounds. When asked if the pair of red non-skid socks under R1's bed should be on R1, V6 replied, Yeah. They (nonskid socks) are to prevent falls, but he kicks them off. When asked if there is staff at the nurse's station at all times monitoring R1, V6 replied, Well . not all the time, but most of the time. On 4/22/25 at 9:51am, V7 (Registered Nurse/RN) said, I know him. I had him that day (4/7/25 fall). I am also the supervisor. At 5:30, I was doing rounds, and a CNA said she found a resident on the floor. (R1) had a cut on forehead that was bleeding. I gave him first aid, cleaned it, and applied gauze. I called the physician. I called the ambulance and ambulance picked him up before I left there. Later, I saw that he got stitches to the laceration. (R1) can walk. He goes to the bathroom by himself sometimes. He's a dementia resident. Gait is not steady. That's why they put a diaper on him, so he won't get up. Bed is always lower, lowest setting. Yes, he is supposed to have nonskid socks on. I'm not sure if he had his skid socks on. The nonskid socks help if resident gets up, if there was water on the floor, they are not gonna (sic) fall. I'm not sure if he had his nonskid socks on cause (sic) he was in bed with cover on during my shift. On 4/22/25 at 10:31am, V10 (Licensed Practical Nurse/LPN) said, I've been here 4 months. Yes, I work with (R1) sometimes .I mean once in a while. On April 7th, I had (R1). He came back from the hospital and was stable. He was okay. There wasn't anything different about him other than the left eyebrow. He had a cut there because he fell . I can't remember what the hospital did. He did have sutures. Since I've been here, he walks but with an unsteady gait and kinda (sic) zig zags when he walks . Most times. He can walk on his own. His bed is always in lowest position, call light by side, rounds every 2 hours, and (R1's) room is opposite nurse's station so eyes are always on him. He should have nonskid footwear all the time because he is impulsive, and he has some shoes too. No other falls that I am aware of. On 4/22/25 at 10:48am, V2 (Assistant Director of Nursing/ADON) said, Yes, in a general, I'm familiar with (R1). Since I've been here, he's ambulated with some assistance from staff. If a fall assessment was completed incorrectly, I don't know if anything extra would have been done. Yes, I expect fall assessments to be completed accurately. not sure if he had a fall plan. Restorative would know. It (Fall Assessments) might trigger a care plan for someone to be at risk for falls. I know what happened with his most recent fall (4/7/25 fall), but I wasn't here. I believe the fall took place in (R1's) room. He came out of the room, had a cut to one of the eyebrows, and was sent to the hospital. The hospital didn't admit (R1), just placed sutures and he came back. Fall requiring sutures is an injury that needs to be reported to you (IDPH). I didn't see him, so I don't know if it hurt him. I'd have to look at his chart to see if fall precautions were in place. On 4/22/25 at 12:08pm, V12 (Medical Director) said, A fall with sutures can cause harm to the resident. It is an injury. That is the harm, he got sutures, so that has harm. On 4/22/25 at 1:44 pm, V14 (MDS Coordinator/Licensed Practical Nurse (Prior Restorative Nurse) said, Yes, know (R1). He is ambulatory, but there were days when we had to sit him in the wheelchair. He would refuse to get up and walk. He has dementia. When he is ambulatory, (R1) would walk on his own. His gait is not steady. I mean he would be wobbly sometimes when walking, sit in his wheelchair sometimes, and other days he would be walking on his own fine. We weren't encouraging him to walk on his own, but were kinda (sic) redirecting him. Interventions in place to prevent (R1) from falling was nonskid socks, but I'm not familiar with other interventions. For the 4/7 fall: evaluate for assistive device was the recommendation. (R1) never used an assistive device prior to his falls. He wasn't as unsteady, and we (facility) didn't want to take away his independence. Restorative couldn't get him to use a walker. No 1:1 for supervision interventions. Yes, (R1's) Fall Risk Assessment on 2/12/25 was not accurately completed. I'm not sure if it (accurately completing R1's 2/12/25 Fall Assessment) would have changed anything. On 4/23/25 at 10:42am, V9 (Licensed Practical Nurse/LPN) said, Yes, he's my patient. A little bit about (R1) is that he walks around with redirection, and with no assistance, other than cuing and observing with constat monitoring. (R1's) gait is unsteady. His room is across the nurse's station because he is a fall risk patient. We (staff) check him (R1) every 15 minutes throw a side-eye and look at (R1) from the nurse's station. He always has non-skid socks on. He sleeps with them (non-skid socks). (R1) always has to have them (non-skid socks) on even when sleeping. (R1) will not wear shoes. On 4/7, the nurse before endorsed to me that (R1) fell and he called hospital, and the ambulance is on its way. I continued monitoring (R1) until the ambulance picked him up. He did not return for me. On 4/23/25 at 11:50 am, V17 (Physical Therapy Director) said, Yes, we (Physical Therapy) evaluated him last week for Physical Therapy. (R1) was evaluated for an assistive device but (R1) is not suitable for an assistive device. (R1) is partial monitor assistance for bed mobility and staff assistance while ambulating. On 4/23/25 at 12:43pm, V20 (Director of Nursing/DON) said, Yes, staff should implement interventions in care plan. Supervise him when walking. Complicated residents like him like the inability to call for help, his impulsiveness. They (residents) have the tendency to fall again. There are certain residents that need increased supervision. Very impulsive . Doesn't call for staff. It's part of the supervision issue that already in place. We (facility) cannot do 1:1. There's a lot of dementia patients and a lot of redirection. Staff are doing their best. During daytime they (residents) have a lot of activities to involve and engage in. Facility policy titled, Fall Prevention Program, revised date 11/21/17, documents, 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 . 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; Preventative measures. Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines; A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident; Safety interventions will be implemented for each resident identified at risk; The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained; Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions; The Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. In addition, Director of Nursing is responsible for informing the Administrator of program analysis. Fall/safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the Fall Prevention Program; Footwear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid. Facility policy titled, Resident Rights, reviewed 1/4/19, documents, 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. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability . Facility presented pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life . Your facility must provide equal access to quality care regardless of diagnosis . You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually . Your facility must be safe, clean, comfortable, and homelike . You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices . You should receive the services and/or items included in the plan of care .

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers; failed to ensure a resident's wound dressing is intact as ordered by the physician; and failed to complete skin assessments accurately. This failure caused 1 resident (R2) to develop a 25x10 cm unstageable pressure ulcer to the sacrum and sustain severe pain (7/10). This failure affects 1 resident (R2) in a sample of 4 residents reviewed for pressure ulcers. Findings Include: R2's Face sheet, dated 4/21/2025, documents a diagnosis of but is not limited to Failure to thrive, Dysphagia, Major Depressive Disorder. Review of R2's Weekly Skin Assessments documents, on 3/12/2025 R2's skin was intact with no concerns. On 3/19/25, documents an unstageable pressure ulcer to R2's coccyx. On 3/24/2025, R2's skin was assessed and documented skin was intact with no concerns (incongruent with current unhealed pressure ulcer). No weekly skin observation was completed in R2's electronic health record since 3/24/25. Record review of document titled, Facility Acquired Worsening Wound Investigation Report, dated 3/19/24, documents R2 had predisposing risk factors including hypertension, anemia, poor appetite, bowel incontinence, and urinary incontinence. 27 other risk factors were not noted, including malnutrition. At the time the wound was developed turning and repositioning, and preventative skin products were in place. 11 other potential interventions were not noted. The document also indicates the wound was unavoidable based on: Resident advanced disease process, but also unavoidable due to, goals of care review, review of clinical record, collaboration with PCP, visual examination of the wound, discussion with wound care nurse R2's physician orders document an active order (4/10/2025) for Wound: Coccyx: cleanse with Dakin's, apply silver calcium alginate cover with foam dressing daily every shift for wound care. R2's wound summary (4/21/25) documents an unstageable pressure ulcer was first assessed on R2's coccyx on 3/17/2025 with dimensions of 25 cm x 10 cm, and was last assessed on 4/17/2025 as unstageable. On 4/21/2025 at 11:14 am, R2 stated R2 has a pressure ulcer to R2's bottom (sacrum). R2 explained the pressure ulcer was caused, from my diaper. R2 affirmed the pain from the pressure ulcer is about 7/10. On 4/21/2025 at 11:28am, V18 (Wound Care Nurse, Licensed Practical nurse) stated V18 was unsure when R2's sacral pressure ulcer was discovered. V18 stated when the ulcer was discovered, the pressure ulcer was unstageable. On 4/21/2025 at 11:36 am, R2's sacral wound was observed and appeared open, reddened, with wound edges intact. No dressing was noted covering the wound. V18 affirmed there should be a dressing on R2's pressure ulcer. On 4/21/2025 at 12:45pm, R2's sacrum was observed, and no dressing was noted on the wound. V18 stated the purpose of dressing changes is to help heal the wound and for infection control measures. V18 stated when staff notice the dressing is not present on a wound, the staff member should notify the nurse or wound care nurse to reapply the dressing. On 4/22/25 at 11:10 am, V11 (Wound Care Coordinator) stated V11 was notified R2 had a wound to her coccyx on 3/17/2025 that measured 25x10 cm. V11 stated R2's wound to the coccyx was unstageable due to slough being present when the wound was first assessed. V11 stated the nurses do conduct skin checks weekly. V11 affirmed V11 was assessed on 3/12/24 with skin intact. V11 stated V13 (Nurse Practitioner) was notified of the wound and V13 was involved in determining that the pressure ulcer is unavoidable. On 4/22/2025 at 12:21 pm, V13 (Nurse Practitioner) affirmed V13 is the primary care provider for R2. V13 affirmed pressure ulcers are usually preventable, and caused by prolonged pressure to bony areas. V13 explained R2's pressure ulcer was caused by poor oral intake. V13 recalled R2 used to be up walking around the facility, then had a change in condition and became weaker, developing malnutrition. V13 stated R2's pressure ulcer couldn't have developed in a week. On 4/23/25 at 10:53 am, V9 (Licensed Practical Nurse) stated V9 is familiar with R2. V9 recalled assessing R2's skin on 3/12/2025 while R2 was receiving continent care, and affirmed R2's skin was intact. V9 stated the wound was later discovered over the weekend, and V9 was not sure which nurse discovered the wound. V9 stated pressure ulcers can be caused by incontinence, poor hydration/nutrition, friction/sheering, incontinence and prolonged pressure to an area. V9 affirmed R2 was incontinent, had poor nutrition, and was bedbound because whenever we (staff) put (R2) in the wheelchair, she would slide down. V9 stated the facility expectation is that resident's skin is assessed weekly by the nurse. V9 stated V9 was unsure why no weekly skin observation was completed for R2 since 3/24/25. V9 stated V9 has not been assigned to care for R2 since before 3/24/25. On 4/23/2025 at 12:50 pm, V20 (Director of Nursing) stated the expectation is that a weekly skin assessment is completed on every resident weekly by the nurses. V20 stated, I don't know why the last weekly skin assessment was completed on 3/24/2025. Every shift the CNA (Certified Nursing Assistant) is to report any skin changes to the nurse or the wound care nurse. This wound didn't develop in one shift, but probably over 24 hours. V20 verified the weekly skin Assessment completed on 3/24/25 that the skin is intact. V20 affirmed the weekly skin assessment on 3/24/25 is incorrect, and should document a coccyx wound with a description of the wound. V20 stated pressure ulcers are caused by pressure to bony prominences. V20 stated, It is possible an unstageable pressure ulcer measuring at 25x10 cm, if we consider other things. V20 affirmed the form titled Facility Acquired/Worsening Wound Investigation Report that the form doesn't quite make sense, and needs to be revised. Part of this form needs to be reviewed more. V20 affirmed malnutrition is not checked on the unavoidable wound care assessment. V20 affirmed every nurse should be able to apply a temporary dressing if the dressing is removed during continent care. On 4/23/24 at 2:03 PM, V21 (Wound Care Physician) affirmed V21 is the Wound Care physician for R2. V21 believed R2's wound was primarily caused by malnutrition, incontinence, and immobility. V21stated a resident could have developed an unstageable pressure ulcer in an 8-hour shift if the resident was lying on a hard surface without proper pressure relief, like a deflated mattress. It only takes a few hours for damage to occur in vulnerable areas in these situations. Facilities Pressure Ulcer Policy with a revision date of 1/15/2018 documents: Purpose: To prevent and treat pressure sores/ pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin. 3. Change bed linen per schedule and whenever soiled with urine, feces or other material. 4. Keep bottom sheet dry and tightly stretched and free of wrinkles. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. 6. Employ active and passive range of motion exercises to improve circulation as indicated (in accordance with physician order and plan of care) 7. Whenever possible, encourage resident to change position at regular intervals as able to promote circulation. Wheelchair residents may be instructed to shift weight from one buttock to the other. 8. If redness does not disappear within 30 minutes the turning schedule may be shortened to 1 hour. 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds.

Based on interview and record review, the facility failed to ensure ongoing precautions were put into place and consistently maintained, and failed to ensure residents were in a safe position, for 1 residents (R2) of 3 residents reviewed for safety. These failures resulted in R2 falling out the bed, sustaining a right femur fracture. Findings include, R2's clinical record indicates: R2 is a sixty-seven-year-old admitted with the following medical diagnosis of severe morbid obesity, bilateral primary osteoarthritis of knee, fracture of right femur, major depressive disorder, post-traumatic disorder, anxiety disorder, overactive bladder, and unsteadiness on feet, embolism of lower extremity. R2's Minimum Data Set (MDS) Brief Interview Mental Status score= 15, indicating R2 is cognitively intact. R2's MDS section GG indicates R2 is total dependent for ADL incontinence care and personal hygiene assistance. R2 requires maximum assistance with bed mobility. R2's Care plan indicates in part: 4/1/22, R2 at risk for falls related to osteoarthritis of knee. Interventions: Be sure R2 is centered in bed when sleeping. Check and change R2 three times per shift for incontinence, toileting before and after meals, upon rising in the morning and before bed at night. (8/24/22). 10/5/21, R2's bed height to be placed where R2's feet are flat on the floor. 2/22/22, be sure R2's call light is in reach. R2 needs prompt response to all requests for assistance. 8/3/2021, R2 has limited mobility in bilateral lower extremities related limited mobility, osteoarthritis in both knees. 7/21/24, R2 has an ADL and functional ability for self-care and mobility deficit related to osteoarthritis of knee. Interventions: R2 requires extensive assistance by staff to turn and reposition in bed. 1/25/24, R2 is totally dependent on staff for toilet use. 2/20/25, R2 has a right hip fracture. R2's fall history: 9/3/21 R2 observed sitting on the floor; R2 was trying to transfer self. 10/4/21 R2 observed on bathroom floor; slipped while trying to sit on toilet seat. 11/2/21 while staff answering call light, observed R2 sitting on the floor trying to transfer from wheelchair to the bed. 10/4/23 observed R2 on floor next to bed; R2 said she was dreaming and fell to the floor. Intervention: ensure resident centered in bed while sleeping. 1/31/25 1040 am resident was observed sliding out of bed but before staff could get to R2 she fell out of bed. R2's Hospital Discharge Instructions, dated 2/15/25, indicated: Diagnosis: Femur Fracture. Diagnostic Radiology report, dated 2/14/25: Acute mildly displaced fracture of the medial femoral metaphysis. On 3/13/25 at 10:00 AM, R2 stated, On 1/31/25, day shift (V5, Certified Nurse Assistant) came to assist me, because I was soiled with bowel movement and urine. The last time I was changed was 4AM. (V5) assisted me to turn on to my right side, and I grabbed my side grab bar to hold on. I told (V5) I could not turn any further because I was the edge of the bed. (V5) was trying to remove the linen from under me, and she pushed me forward while doing so. Then my left leg flopped over the bed mattress, and I kept going. I ended up somehow in a sitting position between my bed and the wall, underneath the window. (V5) ran out to get assistance. (V4, Assistant Director of Nursing), (V6, Restorative Nurse/Licensure), and a few Certified Nurse Assistants. (V4) asked me what happened, and I explained to her how I feel out the bed, due to the fact I told (V5) to stop, and she kept pushing me over. I did not slide out the bed trying to reposition myself; that is not true. After I fell I was not in pain, just sore. (V13, Licensed Practical Nurse) was my nurse and called an ambulance for me. When the ambulance arrived, I refused to go to the hospital because I was not in pain at this time. The pain slowly increased over time to horrible pain, then I was sent to the emergency room . I learned my femur bone was broken. This would have never happened, if (V5) stopped pushing me over when I told her to stop. On 3/12/25, at 11:00 AM, V5, Certified Nurse Assistant, stated, Start of my shift, I made rounds and (R2) was sleeping in twisted position near the edge of the right side of her bed. I did not check to see if she needed incontinence care because she was sleeping, and I did not move her to the center of the bed because I did not want to wake her up. I took (R2) her breakfast tray, but she was still sleeping. Later around 10:20AM, I was making rounds picking up the breakfast trays, and observed (R2's) leg hanging out of the bed, between the bed and the wall. By the time I reached (R2), she had fallen off the bed onto the floor in a sitting up position between the bed and wall. I called out for assistance. (V13, R2's nurse/Licensed Practical Nurse/LPN), (V4) and other nurses and Certified Nurse Assistants came to assist. (R2's) nurse, (V13), and (V4, Assistant Director of Nursing) assessed (R2). (V6, Restorative Nurse), another Certified Nurse Assistant, and I assisted (R2) off the floor using a mechanical lift into bed. Once (R2) was in bed, (V6) and I provided incontinence care to (R2); she had a bowel movement. During ADL care, (R2) did not complain of pain or have any signs of distress. Once the ambulance came, (R2) refused to go get checked out. Around a week or so later, (V4, Assistant Director of Nursing) told me not to work with (R2) anymore, because (R2) told (V11, Insurance Case Manager) that I pushed her off the bed. (V4) suspended me pending investigation. I did not push (R2) off the bed onto the floor. I saw her hanging off the bed but could not reach her in time. I returned to work a few days later. Upon the start of my shift, I should have repositioned (R2) in the center of the bed and checked to see if she needed to be cleaned up, maybe she wouldn't have fallen. I did not want to wake her up. On 3/13/25 at 2:00 PM, V13, Licensed Practical Nurse, stated, I was (R2's) nurse the day she slid out the bed. (V5, Certified Nurse Assistant) called out for help I entered (R2's) room and noted (R2) on the floor between the bed and wall. (R2) told me that she was trying to reposition herself and slid off the bed. During (R2's) body assessment, (R2) denied pain. The physician gave an order for (R2) to be evaluated at the hospital, but (R2) refused to go. On 3/12/25 at 2:18 PM, V6, Restorative Nurse\Licensed Practical Nurse, stated, (R2) is alert and oriented x3. (R2's) bed mobility I maximal assist; (R2) requires one staff to assist. For ADL care, (R2) needs total assistance from staff, and mechanical lift for transfers. (R2) has two side handles to assist with repositioning. On 1/31/25, I heard (V5) yell out for assistance. I walked in (R2's) room and observed (R2) in a sitting up position on the floor between the bed and wall. (R2) said that she slipped of the bed, I do not know the details. After (R2) was assessed, (V5) and I used the mechanical lift to transfer (R2) off the back into bed. (R2) had a large amount of bowel movement on her. I assisted (V5) in providing incontinence care. During ADL care, (R2) did not complain of pain. (R2) has fallen five times since her admission. (R2's) fall interventions are to ensure (R2) is centered in the bed while sleeping, check resident three times per shift for incontinence. If (V5) noted (R2) sleeping on the edge of the bed and did not assist and reposition her to the center of bed, (R2's) fall was avoidable. On 2/15/25, (R2) reported an increase in pain in her right leg area and (R2) agreed to go receive an evaluation and (R2) was diagnosed with right femur fracture. On 3/13/25 at 3:04 PM, V4, Assistant Director of Nursing, stated, On 1/31/25, I went into (R2's) room to provide assistance with the fall. (R2) said she slid out of bed, while trying to move over off the edge of the bed. (R2) was assessed on the floor, no compliant of pain or distress noted. (R2's) physician gave order to send (R2) to hospital for further investigation. (R2) had an incontinent episode and was cleaned up. Once the ambulance arrived, (R2) refused to go, she said there was not pain and did not want to go. (R2) requested that (V5) no longer takes care of her. I did not ask (R2) why she felt that way about (V5). I made sure (V5) did not provide any care for (R2). On 2/15/25, (R2) reported an increase in pain in her right leg area and (R2) agreed to receive an evaluation, and (R2) was diagnosed with right femur fracture. On 2/19/25, the Administrator received a phone call from (V11, Insurance Case Manager) and she said that (R2) reported she was pushed off the bed by (V5, Certified Nurse Assistant). (V1) and I both went to interview (R2) about her fall incident on 1/31/25. (R2) explained to (V1) and I, that she slid off the bed. I did not ask (R2) if (V5) had pushed her off the bed; I do not know why I did not ask her. (V5) was suspended. (V1) completed the IDPH (Illinois Department of Public Health) reportable and investigation. I was not made aware of the abuse allegation until 2/19/25. If (V5) observed (R2) early in her shift laying twisted on the edge of the bed, then (V5) should have followed (R2's) care plan and assisted (R2) in the center of the bed. (R2's) care plan also states for staff to provide ADL incontinent care three times per shift. If (V5) would have repositioned (R2) in the center in bed and provided ADL care, potentially (R2) would not have fallen off the bed. On 3/12/25 at 4:25 PM, V1, Administrator, stated, I was made aware of (R2's) fall with fracture and reported the incident to IDPH. I also made an addendum on 2/19/25, when I received a phone call from (V11, R2's Insurance Case Manager). I spoke with (R2), and she explained she slipped out of bed trying to reposition herself off the edge of the bed. During our interview, (R2) did not mention (V5) pushed her off the bed. (V5) was suspended and investigation was completed. The abuse allegation of the fall was not substantiated after interviewing other residents and nursing staff. I was not made aware of the abuse allegation until 2/19/25. Policy documents in part: Fall Prevention Program dated 11/28/12. To assure the safety of all residents in the facility. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions. Use and implement of professional standards of practice. Care plan incorporates identification of all risk, address each fall. Preventative measures, interventions are changed with each fall. Assigned certified nurse assistant are responsible for initiating safety precautions. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. The resident will be checked approximately every two hours or as according to the care plan, to assure they are in a safe position.

Based on interview and record review, the facility failed to have fall interventions in place to prevent a resident from serious injury. This failure affects one (R1) of three residents reviewed for falls in a total sample of four residents. The failure resulted in R1 sustaining two cervical (neck) fractures and be subjected to excruciating pain while awaiting surgery to fix the injuries. Findings include: R1 is a [AGE] year-old male. R1's diagnoses are, but not limited to: displaced fracture of first cervical vertebra, displaced fracture of second cervical vertebra, anterior displaced dens fracture, Parkinson's disease, dementia, schizoaffective disorder bipolar type, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, cognitive communication deficit, and high blood pressure. R1's BIMS (Brief Interview for Mental Status), dated 1/10/2025, notes R1 is alert. R1's care plan notes R1 requires the use of a neck brace due to fracture of the first and second cervical vertebrae. R1 has had a fall due to Parkinson's disease, dementia, abnormal gait and mobility, anxiety disorder, and a history of falls. R1 is at risk for falls. R1 has had an actual fall due to Parkinson's disease, dementia, abnormal gait and mobility, anxiety disorder, and history of falls. R1's care plan goals are not sustaining serious injury through the review date, provide (sticky pad to prevent resident from sliding out from the wheelchair) to the wheelchair, and re-educate R1 to lock the wheelchair before sitting down or when stationary. R1 fall risk assessments, dated 11/22/2024, 12/09/2024, and 12/19/2024, note R1 has had 1-4 falls in the past three months, is chair bound, requires the use of assistive devices, and takes medications such as antiseizure, narcotics, psychotropics and/or sedatives/hypnotics. Facility final report, dated 12/23/2024, notes R1 is alert, able to verbalize his needs, uses a wheelchair as primary locomotion but forgetful, impulsive and needs persistent redirection/education for safety awareness. On 12/19/2024, a loud noise was heard and R1 was observed on the floor. R1 reported he was attempting to pick up something off the floor and he fell forward. R1 had a small skin cut on his forehead. R1 was sent to the hospital and admitted with cervical fracture now pending surgical procedure per hospital nurse. Currently, R1 wears a neck brace around the clock. Nurse's note, dated 12/19/2024, notes, around 12:00 PM, this writer heard a noise coming from (R1's) room. Writer immediately went to (R1's) room; (R1) calling for help. When in the room, the writer observed (R1) lying on his left side facing the room's door, and blood coming from his forehead. A head-to-toe assessment was done. (R1) was observed with laceration about 3 centimeters long and 0.5 centimeters deep. (R1) complained of a headache and a pain level of 8/10, on the pain scale. At 5:22 PM, writer called local hospital emergency department and spoke to hospital staff. (R1) was be admitted with the diagnoses of cervical spine fracture. Fall Occurrence Report, dated 12/19/2024, notes R1 had an un-witnessed fall on 12/19/2024 in his room. R1 was lying on his left side, facing the door, and bleeding from his forehead. R1 stated, While sitting on my wheelchair, I was trying to pick up something from the floor. I lost my balance, fell to the floor, and hit my head on the door. Cervical Spine X-ray, dated 12/20/2024, notes R1 has an acute transverse fracture through the base of the dens type II. Acute type II odontoid fracture with mild posterior displacement of odontoid process. There is a communicated fracture of C1 with fractures involving the anterior arch and the posterior arches bilaterally. IDT (Interdisplinary Team) Note, dated 12/23/2024, notes R1 was asked what he was trying to do prior to fall. R1 stated he was sitting in his wheelchair and tried to pick up something on the floor. R1 lost control of his upper trunk fell face forward. On 1/25/2025, at 9:40 AM, R1 was lying flat in bed. R1 had a C-collar (medical device used to support and immobilize a person's neck). On 1/25/2025, at 9:42 AM, R1 stated, I do not know what happened. I have a lot of pain in my neck. I do not remember if I could walk around. I can get out of bed by myself, but they do not want me to. I can get up and go to the bathroom by myself, but they do not let me. On 1/25/2025, at 9:48 AM, V2 (Certified Nursing Assistant) stated, (R1) is alert and oriented. I must help him go to the bathroom. I always must tell him to push the call light if he needs something. But he is not compliant. He wants to get up and do things by himself, but he cannot. He has always been this way. He cannot walk by himself. I was here when he had the fall. I was with another resident helping them change. I came out of the room. I heard my name. It was a nurse that called me. We went there but there was someone in the room. Everyone came up. It was a fall. It was (V10, Certified Nursing Assistant). He was the first one in the room. When I got there, care was already being rendered. On 1/25/2025, at 9:55 AM, V3 (Licensed Practical Nurse) stated, I was (R1's) nurse the day he fell . I sent him out. I was at the nurse's station. It was almost at the end of my shift. I heard a noise. It sounded like a big thump. I ran with (V11, Nurse). The bathroom door was blocking us from entering. (R1) stated he was alright. He stated he was trying to get something from the closet, and he fell forward out of the wheelchair. It looks like he got up from the wheelchair. He cannot walk by himself, and he is wheelchair bound. He shakes a lot possibly due to his Parkinson's. (V11) called for help. I asked (R1) if he could push backwards so I could get in. I got in the room and assessed him. He was bleeding from the forehead. He was at his baseline. He denied hitting his head. I sent him out because he could have hit his head. He was alert and oriented and just complained of pain from his head. On 1/25/2025, at 1:08 PM, V10 stated, I was the Restorative Aide that day. After I finished my round, I started my charting. I heard one of the nurses yelling. The door was halfway open. I was slim enough to rescue (R1). I opened the door so staff could get in. I saw the resident on his side on the floor. He was bleeding a little. To my knowledge he was not complaining of anything. The wheelchair was close to him, but it was not locked. He can lock and unlock himself. He had shoes on, and his bed was low. He does not always fall. He is cautious. He does a lot of things by himself. He cannot walk by himself. He uses his wheelchair to move around. On 1/26/2025, at 10:12 AM, V12 (Fall Coordinator/Nurse) stated, Before the 12/19/2024 fall, he was a high risk for falls due to his fall risk assessments. The fall on 12/19/2024, resulted in first and the second cervical fractures. The interventions in place before this fall was call light in reach to use when needed, remind him of his center of gravity when reaching for things on the floor, educate to call staff for assistance, dycem to the wheelchair, and re-educate to lock his wheelchair when he is stationary. (Wheelchair pad) is a sticky mat that helps the residents not to slip out of the wheelchair. He is alert enough to understand the education pertaining to locking his wheelchair. I believe he is alert and oriented. The root cause of this fall is he was picking up an item on the floor. He lost his balance and fell forward. The resident was able to verbalize this. The new interventions in place were to provide him with a reacher and grabber. The nurse on the floor told me the (wheelchair pad) was in place. (V3) stated it was in place. I cannot find in my documentation if his wheelchair was locked. If the wheelchair was not locked and he fell forward, this could contribute to his injuries. On 1/26/2025, at 11:30 AM, V3 stated, I saw the wheelchair locked and I saw the (wheelchair pad). It is a pad, and it attaches. Staff put it in the wheelchair. It is used for support for him not to slide. Per his statement he got up to get something and he was far from his call light. On 1/26/2025, at 12:25 PM, V13 (Medical Physician) stated, I am his physician. I was notified of his fall. I was aware of his significant injuries. I think he hit his forehead, and it caused a fracture. A forehead injury can cause a fracture. Review of R1's medical record and fall documents do not note if R1's wheelchair was locked to prevent R1 from falling out of his wheelchair. 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.

Based on observation, interview, and record review, the facility failed to provide appropriate and sufficient services to ensure comprehensive bladder function assessment was completed and comprehensive care plan was developed for 2 (R39 and R145) residents reviewed for indwelling urinary catheter, and failed to address R52's urinalysis results in a sample of 35. This resulted in R52 experiencing burning with urination, which was left untreated. The findings include: 1. R52's Progress note, dated 4/19/2024 at 12 PM, by V40 (Nurse Practitioner) was reviewed. The progress note stated R52 complained of dysuria. R52 reported burning upon urination. Repeat urinalysis was ordered. R52 completed oral antibiotics recently. On 4/30/2024 at 9:31 AM, review of the electronic medical record included an order for Nitrofurantoin Macrocrystal Oral Capsule 100 MG, which was ordered on 4/9/2024 and discontinued 4/16/2024. On 4/30/2024 at 1 PM, review of the urinalysis collected 4/20/2024 at 7:40 PM and resulted on 4/22/2024 at 11:39 AM, was positive for a small amount of blood, cloudy clarity, the presence of calcium oxalate crystals, moderate leukocytes, nitrate was present, WBC clumps were present, there was trace protein, many bacteria and white blood cells greater than 100. On 05/01/24 at 10:03 AM, V15 (Licensed Practical Nurse/LPN) was interviewed. Laboratory result reporting expectations to provider were discussed. V15 (LPN) stated the nurse receives laboratory results and notifies the provider in the moment. V15 (LPN) entered the electronic health record and V15 (LPN) reviewed the urinalysis collected on 4/20/2024 and results on 4/22/2024. V15 (LPN) stated the expectation is the nurse notify the Nurse Practitioner of the results. V15 (LPN) reviewed the electronic health record and could not locate provider notification of the urinalysis results. V15 (LPN) contacted V3 (Director of Nursing/DON). V3 (DON) stated the process when laboratory results are received, is the floor nurse contacts the provider, notifies the provider of the results, and enters that notification in the electronic health record. V25 (Wound Nurse) was brought into the discussion by V3 (DON), because V3 (DON) stated that she was new. V25 (Wound Nurse) reviewed the electronic health record and stated notification of urinalysis results to the provider was not documented if it occurred. R52's progress note, dated 5/1/2024 at 10:45 AM, entered by V25 (Wound Nurse). It stated: Relayed labs to NP/PPHR new order for repeat UA and urine culture. Notified nurse on duty to collect urine. On 5/2/2023 at 10:00 AM, R52 stated she has burning when she urinates for the past few weeks. R52 stated she was on antibiotics, but the burning came back. R52 stated they took another urine sample today. On 5/02/24 at 10:05 AM, V38 (LPN) attempted to reach V39 (Nurse Practitioner) by phone. V38 (LPN) stated V39 (Nurse Practitioner) will be at the facility around 10:30 or 11 AM. V38 (LPN) stated she does not know if there is another way to reach the Nurse Practitioner. On 05/02/24 at 12:33 PM, surveyor attempted unsuccessfully to reach V39 (Nurse Practitioner) by phone. V1 (Administrator) stated V1 (Administrator) was trying to reach V39 (Nurse Practitioner), and has asked the facility's front desk to let surveyor know when V39 (Nurse Practitioner) arrives. On 05/02/24 at 2:08 PM, V1 (Administrator) stated V39 (Nurse Practitioner) is not coming to the facility today. V1 (Administrator) stated he is trying to get hold of V39 (Nurse Practitioner) by phone so that surveyor can speak to V39 (Nurse Practitioner). V1 (Administrator) stated there is no one that covers for V39 (Nurse Practitioner) when she is not available. On 5/3/2024 at 10:10 AM V1 (Administrator) provided a copy of a document titled: Laboratory: 4/22/2024 11:39 Urinalysis. It documented Reviewed by V39 (Nurse Practitioner) on 4/22/2024 at 12:23. On 5/3/224 at 11:49 AM, V39 (Nurse Practitioner) was interviewed with V1 (Administrator) present. V39 (Nurse Practitioner) stated she was waiting on the culture and sensitivity results after she reviewed the urinalysis on 4/22/2024 before any action was taken on the urinalysis results. V1 (Administrator) reviewed the medical orders. V39 (Nurse Practitioner) and V1 (Administrator) confirmed no urine culture and sensitive was ordered until 5/2/2023, when V25 (Wound Nurse) contacted the nurse practitioner. V39 (Nurse Practitioner) stated, I see what you are seeing. It was not that I wasn't seeing her, but it was an oversight that the culture and sensitivity wasn't ordered. V39 (Nurse Practitioner) stated, The quality of care fell through because there were two different providers involved. Review of policy titled Physician-Family Notification - Change in Condition, dated 10/1/2015 and updated 11/17/2017 and 11/13/2018, stated: Purpose: to ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient and effective manner. 2. R145's health record documented admitted on 11/13/2020, with diagnoses not limited to Chronic ischemic heart disease, Transient cerebral ischemic attack, Hyperlipidemia, Heart disease, Retention of urine, Unspecified open wound of right forearm, Major depressive disorder, Bipolar disorder, Unspecified atrial fibrillation, Elevated prostate specific antigen, Personal history of covid-19, Insomnia, and Acute ischemic heart disease. Minimum Data Set (MDS), dated [DATE], showed R145's cognition was intact. He needed supervision or touching assistance with oral, toileting and personal hygiene, upper and lower body dressing, chair/bed and toilet transfer; Partial/moderate assistance with shower/bathe self. MDS indicated R145 was continent of bowel and bladder. Bladder function assessment, dated 3/6/24, showed R145 had no catheter. On 4/30/24 at 11:01 AM, R145 was very agitated, screaming/yelling, showing his leg bag with yellow colored urine, and stating remove this (pointing to his urinary bag). I don't need this, I can pee to the bathroom in a very loud voice. On 5/1/24 at 1:28 PM, V3 (Director of Nursing / DON) said, For a resident with indwelling urinary catheter, a bladder function assessment should be done upon admission/readmission, quarterly, and as needed. Assessment is done to know the appropriate care or needs of the resident, justification of indwelling urinary catheter use, as resident will be put at risk for infection. Care plan should be developed as well for urinary catheter use. Care plan is like a road map of needs of the resident to identify the concern and problem, put interventions appropriate for the resident, a plan of treatment based on the needs of the resident. Reviewed R145's electronic health record, no bladder function assessment completed, and no care plan found for urinary catheter use. Facility's policy for bowel and bladder assessment dated [DATE] documented in part: - A bowel and bladder assessment will be completed by a licensed nurse: Admission, quarterly and with significant resident changes,and as needed. - The resident's plan of care will be developed to address the issue(s), goals and appropriate interventions for elimination program, using an interdisciplinary team approach. 44103 3. On 4/30/24 at 11:33 AM, R39 was resting in bed alert and able to verbalize needs. R39 was noted with an indwelling urinary catheter. On 5/01/24 at 9:52 AM, R39 was noted still with an indwelling urinary catheter. R39 stated it was inserted to help with R39's wound healing. R39's Minimum Data Set (MDS), dated [DATE], shows R39 is cognitively intact. R39's physician orders with active orders as of 4/30/24 shows an order of: Foley Catheter: 18 French 30 ML Balloon to Gravity Drainage. To promote wound healing. R39's electronic health records do not show a comprehensive bladder function assessment was completed related to the use of indwelling urinary catheter. R39's comprehensive care plan does not address the use of the indwelling urinary catheter. On 5/01/24 at 2:58 PM, V32 (MDS/Care Plan Coordinator) stated all services provided to the residents should be addressed in the care plan for the staff to know what to do for the residents based on the care plan interventions. V32 stated the use of indwelling urinary catheter should be addressed in the resident's care plan. The facility's policy titled; Comprehensive Care Plan, dated 11/17/17, documents: The facility will develop and implement a comprehensive person-centered care plan for each resident and must describe the services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being. 50057

Based on interview and record review, the facility: failed to re-assess the hydration needs of a resident in a timely manner after hospitalization for Hypernatremia; failed to follow up on the abnormally high blood levels of sodium; and failed to follow the Dietician's recommendation to increase gastrostomy tube feeding water flush for a resident with hypernatremia and dehydration. These failures affected one resident (R1) who was recently hospitalized for Hypernatremia/Dehydration. As a result, R1 was re-hospitalized within a month of the previous hospitalization and diagnosed with Hypernatremia again and Fecal Impaction. Findings include: R1's face sheet and progress notes show R1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which include but are not limited to: Cerebral Palsy, Gastrostomy, and Dysphagia. R1 is on NPO (Nothing by mouth) status and receives all nutrition and hydration by G-Tube. These records also show R1 was hospitalized for Hypernatremia/Dehydration due to water deficit on 3/26/23 through 3/29/23, and again on 4/29/23 through 5/7/23. R1 was readmitted with Hypernatremia and Fecal Impaction. R1's MDS (Minimum Data Set), dated 2/9/23 and 4/29/23, both show R1 is severely cognitively impaired, without any BIMS (Basic Interview for Mental Status) score listed. After R1 was hospitalized for high blood levels of sodium from 3/26/23 through 3/29/23, R1's blood levels of sodium in mEq/L (milliequivalents per liter) as shown in the laboratory results reviewed were as follows: 4/6/23 -151mEq/L (Normal Range is 131-145); No record that a physician or Nurse Practitioner was notified. 4/20/23 - 150 mEq/L; No record that a physician or Nurse Practitioner was notified. 4/25/23 - 153 mEq/L; No record that a physician or Nurse Practitioner was notified. 4/28/23 - 158 mEq/L - V6(LPN) notified Nurse Practitioner (NP) the next day(4/29/23). NP ordered to send R1 to the hospital for Hypernatremia. R1's Care plan, dated 5/11/22, states R1 is at risk for dehydration related to G-Tube feeding. Intervention states to evaluate the diet and refer to the Dietician. Intervention, dated 9/7/21, states R1 is dependent on Tube Feeding and water flushes and to provide Tube Feeding as ordered. Another intervention states in part to monitor for constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. R1's hospital records, dated 03/26/2023, written by V14 (emergency room - ED Physician) states in part: Reason For Consultation: Hypernatremia [AGE] year-old Nursing home (NH) resident admitted for evaluation of dyspnea. Per ED notes, sent from NH due to desaturations. Labs on admission were significant for: Na (Sodium)-162 mEq/L . Under Assessment/Plan, V14 (Hospital ER Physician) wrote in part: Hypernatremia-Dehydration due to water deficit ~ 5-5.7L. R1's Hospital Records, dated 4/29/23, documents R1's admitting diagnoses includes Hypernatremia and Fecal Impaction. On 5/7/23, V15(Hospital Physician) wrote, under Detailed hospitalization Summary, R1 has recurrent episodes of Hypernatremia. V15 documented there should be a bowel regimen to prevent constipation. Page 18 of the Hospital Records: On 4/29/23, V17(Hospital Physician), under Assessment /Plan, documented in part: Hypernatremia . Free water deficit of around 4 liters, likely caused by inadequate water with tube feedings. This note also states R1's vomiting was resolved, and R1 was severely dehydrated with fecal impaction on admission. X-Ray of the abdomen, dated 5/2/23, also shows fecal impaction. Page 58 states in part: Problem List - Emesis (Vomiting), Dark Stool, Fecal Impaction (now resolved). On admission, patient was found to have a physical impaction, (now disimpacted) and severe hypernatremia. Page 65 states in part: Diagnosis (Nutrition): New Nutrition Diagnosis: Inadequate enteral nutrition infusion related to infusion volume not reached or schedule for infusion interrupted. Inadequate enteral nutrition volume compared to estimated requirements and evidence of dehydration. Page 53 states in part: Under Initial Nutrition Assessment written by V27(Hospital Dietitian) on 5/1/23 at 10:03am, states in part: SNF (Skilled Nursing Facility) scans with Cyclic feeds of Glucerna 1.5 at 65 ml/hour with no referenced volume target, stop or start time. Page 37 states in part: Under Assessment and Plan, states that R1 was severely dehydrated with fecal impaction on admission. For the first hospitalization , R1's progress notes, dated 3/26/23 at 11:25 AM, written by V5(LPN/Licensed Practical Nurse) states: Called hospital; The resident was admitted for hypernatremia. For the second hospitalization , R1's progress notes, dated 4/29/23 at 3:18 PM, written by V6 (LPN) states R1 was sent to the hospital for Hypernatremia. On 4/29/23 at 7:34 PM, V21(LPN) documented in part: Ambulance notified facility that resident was diverted to (another) hospital due to tachycardia. Resident will be admitted with diagnosis of hypernatremia. On 5/9/23 at 2:50 PM, V13 (Dietician) was interviewed regarding R1's hospitalization on [DATE] through 3/29/23, and the diagnoses of Hypernatremia, and what the facility did to increase R1's hydration status to prevent another hospitalization . V13 stated R1 has orders for 250 ml(milliliters) of water flush every 6 hours. V13 added, But I'm not there and I don't know how much the nurses give. V13's attention was drawn to R1's order, dated 4/27/23 and 4/29/23,(about a month after the hospitalization of 3/26/23 and diagnosis of Hypernatremia); this order is the same feeding rate and 250 ml water flush, with no schedule and no total volume (Glucerna 1.5 65ml/hr(hour) x 15 hours). V13 responded she(V13) was not aware of the first hospitalization (3/26/23 through 3/29/23) until around April 26, (a month after). V13 added, When I saw the hypernatremia around April 26th, I increased the water flush from 250ml QID (4 times a day) to 300ml QID (not reflected on the current POS dated 5/7/23). Inquired from V13 why the POS (Physician Order Sheets) and Medication Administration Record (MAR) for March, April, and May 2023 do not state the total volume of formula R1 was supposed to receive, and there is no scheduled time for the G-Tube feeding for R1. V13 responded R1 should get a total volume of 900 ml for 15 hours. V13 was asked for the schedule for the 15 hours, and V13 stated the nurses will determine the schedule. Dietician Recommendation, dated 4/26/23, under Progress Notes/Plan, states in part: Increase water flush to 300ml QID 2/2 hypernatremia. However, this recommendation was not followed and R1's POS dated 4/27/23 and 5/7/23 for water flush still reads Flush Tubing with 250 ml water every 6 hours. Dietician Recommendation dated 2/18/23, 2/27/23, and 3/17/23, under Nutrition Progress Notes/Plan, states in part: Tube Feeding Glucerna 1.5 65ml/hr x 15hrs with 300ml water flush QID (4 times a day). However, R1's POS did not reflect this change. R1's Physician Order Listing Report shows R1 was getting only 250 ml water flush instead of 300 ml water flush recommended by the Dietician on the above listed dates. Current POS, dated 5/7/23, states Flush Tubing with 250 ml water every 6 hours. On 5/10/23 at 2:32 PM, V24 (Facility's Medical Director/R1's Physician) was interviewed regarding R1's hospitalization s in March and April 2023, and the hospital diagnoses of Hypernatremia, Dehydration, and Fecal Impaction, since R1 depends on staff to get hydrated through the G-Tube. V24 stated some patients can have insensible water loss, and it could also be due to not getting enough fluids, but the tests done in the hospital will determine the cause of the dehydration/hypernatremia for the patient. V24 was also asked about how physician orders are written for G-Tube feeding for residents. V24 responded when the Dietician writes the G-Tube feeding recommendations, the physician order will be entered in the system. On 5/15/23 at 9:12 AM, V2(Director of Nursing) was asked about how the Dietician gets notified about the need for nutrition/hydration re-assessment of a resident who was hospitalized for dehydration and returns to the facility, to prevent another hospitalization from the same hydration issues. V2 stated, Usually, the Dietician will get a phone call. Inquired from V2 about who was responsible for making the phone call to notify the Dietician. V2 responded, I will get back to you on that. V2 was also asked about why some residents on G-Tube feeding have the total volume and scheduled time of feeding specified in the physician orders, and other residents don't. V2 responded, It depends on which nurse puts in the order. Facility's policy on Assessment of Residents, dated 11/28/12 with latest revision date 4/18/22, states, under purpose To gather comprehensive information as a basis for identifying president problems and needs and developing or revising an individual plan of care. Other assessment monitoring shall be initiated and recorded on facility approved forms or in conjunction with the resident's clinical condition, assessed needs, and planned interventions. These assessments are to be performed at the time of admission when the resident's past or current history indicates the need/problem is present and/or as observed or deemed necessary. Examples include but are not limited to: Upon Admission, As indicated. #b states: Dehydration Risk Assessment: To determine risk for dehydration based on clinical diagnosis, oral intake, medications and cognition. Assessment to be completed within the first 14 days in conjunction with the MDS (Minimum Data Set) process. Facility's policy on gastrostomy tube feeding and care, dated 11/28/2012 with latest revision on 8/3/20, states: To provide nutrients, fluids, and medications as per physician orders to residents requiring feeding through an artificial opening into the stomach. Cyclic - prescribed amount of formula volume is given over a specific period of time that is usually less than 24 hours (8-20 hours). Continuous - prescribed formula volume is given continuously over 16 to 24 hours. Facility's policy on Hydration Monitoring Protocol, dated 2020, states, under Guidelines, Residents at risk for dehydration will be identified using the care assessment areas for dehydration, and fluid maintenance or other appropriate quality indicators. Determining residents at risk for dehydration is completed with collaboration between the dining services manager, registered dietitian, and nursing staff. Under Procedure, this policy states: Resident's fluid needs shall be determined according to Registered Dietitian Recommendation. #3 states: The Nutrition Assessment and all progress notes shall reflect factors that put the resident at risk for dehydration as well as interventions to reduce risk factors and ensure adequate fluid intake.

Based on observation, interview, and record review, the facility failed to (a) ensure resident safety by allowing two residents(R4 and R5) to go out on a community pass without a medical provider authorization/order, (b) ensure safe return of one resident(R4) from a community pass that was unauthorized by medical provider. These failures resulted in R4 and R5 sustaining serious injuries requiring hospitalization and treatment. Findings Include: 1. R4's Brief Interview for Mental Status (BIMS), dated May 24, 2022, documents R4's BIMS (Brief Interview for Mental Status as 13/15. R4's Activities of Daily Living (ADL) Assistance, dated May 25, 2022, documents R4 as requiring extensive assistance with transfer and bed mobility, and R4 needs limited assistance with walking. Current POS(Physician Order Sheet) documents: R4 is an [AGE] year-old female admitted to the facility on [DATE]. R4 is [AGE] year-old female with diagnosis not limited to: Alzheimer's disease, unspecified, Chronic Obstructive Pulmonary Disease with (Acute) exacerbation, [CONDITION(S)], Current episode mixed, Mild, anxiety Disorder, unspecified, Disorder, unspecified [CONDITION(S)] not due to a substance, or known physiological condition, unspecified hearing loss, bilateral. On 10/19/2022, staff allowed R4 to go out on a community pass, and R4 was returned to the facility at 9:30pm by Chicago Police. On 10/30/22 Social Worker(V6) provided R4 another community pass. R4's progress notes by V6 (SSD/Social Services Director), dated 10/20/2022 at 11:40, document R4's community pass was restricted for 14 days after R4 went on a community pass on 10/19/2022 and was brought back to the facility via [MEDICATION(S)] (Chicago Police Department). R4's SS-Community Survival Skills Assessment, dated 10/13/2022 and 10/20/2022, completed by V6 document R4 has the ability to adhere to pass privilege policies, e.g., respecting time parameters and curfews Social Services progress notes documents, (R4) left facility on a restricted community pass (four hours only pass) on 10/30/2022. (R4) has failed to return the facility to date. On 11/16/2022, 10:30am, V1(Administrator) said based on the admitting diagnosis from the hospital, a resident is placed on dementia unit and an Interdisciplinary team-IDT does resident assessments. V1 said a resident pass privilege is based on Social Services assessments and based on assessment, a resident's pass level is determined. V1 said documentation on resident assessments and residents progress notes should be completed on time. On 11/16/2022 at 10:42am, V6(Social Services Director) said when a resident is admitted to the facility, the resident is coded red, which means the resident is restricted on observation for 14 days, and during this time, the resident cannot leave the facility on a community pass. V6 said after the resident is monitored for 14 days for behavior, medication compliance, cognition and if there were no issues with resident, the resident can then be given a yellow pass, which means the resident can leave the facility on a community pass for up to four hours. V6 stated if the resident displays good conduct for a month when the resident is on yellow, then they go to green, which means resident can leave the facility for up to ten hours. V6 said, If the resident is on red, they can still go out on a pass with an escort who is a family member and on file, or with a staff member. On 11/16/2022 at 10:42am, V6 said, (R4) did not exhibit and behavioral problems and was fine and was not aggressive and took her(R4) medication. (R4) went out on a pass on the 10/19/2022, and (R4) was brought back by the police the same day because (R4) ran out of money and (R4) flagged down the police who escorted resident back to the facility. V6 stated she spoke to R4 who said R4 had run out of money, and told the police to bring R4 back. V6 stated R4 provided the name of the facility to the police and R4 was brought back to the facility. V6 stated she completed another community assessment on R4 on 10/20/2022, and R4 was a yellow. V6 said V6 congratulated R4 for calling the police, and since R4 was able to use the police to get back to the facility, V6 gave R4 a yellow pass, even though R4 had used all of her money in the community and was not able to get back to the facility. V6 stated, a yellow coded pass means the resident can be out only for 4 hours. On 11/16/2022 at 10:42am, V6 stated she did not consider the previous time R4 was gone for more than 4 hours from the facility, and R4 did not have money to get back to the facility. V6 said, I did not know what time specifically (R4) had come back to the facility. We only look for the residents after 8pm, if they go on a pass and don't come back. I don't know when (R4) left the faciity on a community pass, and I think (R4) came back after 7pm. (R4) was brought back to facility by the police. On 11/16/22 at 10:55am, V10(PCP/Primary Care Provider) said, When (R4) left the faciity on [DATE], I did not know where (R4) was until 10 days later. V10 stated R4 was not supposed to leave the unit, but R4 was able to get out of the facility. V10 indicated she (V10) was not consulted by staff, and did not write an order for R4 community pass. Subsequently, R4 sustained a left jaw and nasal fracture, two aching wrists and R4 has unsteady gait per medical records from community hospital. R4's medical records from community ED(Emergency Department), dated 11/09/2022, document: R4 sustained a left jaw and nasal fracture, two aching wrists and R4 has unsteady gait per medical records from community hospital. On 11/16/2022 11:36am, V1(Administrator) said, When residents go out, the residents sign out by receptionist, and sign back in upon entry. If a resident did not come back to the facility, the receptionist would notify Social Services staff that the resident does not come back.After staff is notified, the staff should notify the resident's physician, family member, Director of Nursing and the Administrator ,and possibly the police will be notified. On 11/16/2022 11:36am,V1 stated she started working at the facility on 11/10/2022. V1 stated she met with the previous Administrator, who told V1 that R4 was in a hospital, and at the hospital, R4 had told hospital staff R4 had left Against Medical Advice-AMA. Per surveyor documentation review, there is no evidence R4 left facility AMA. V1 stated if a resident does not come back at the time their pass privileges they should return, the facility should start looking for the resident, the facility should follow facility policies. V1 stated resident community pass privileges should have a physician order. V1 said Our goal is to keep residents safe. On 11/16/2022 at 12:11pm, V2(Director of Nursing -DON) said R4 was going out to the community on a pass and comes back. V2 said Social Services do community assessments and assign residents pass privileges depending on the assessment. V2 said that on 10/19/2022, R4 went out on a pass to the community. V2 said V2 does not know what time R4 left the facility, but R4 come back to the facility at 9:32pm, brought back by the police. V2 said If a resident is gone out on a pass for longer than the pass privilege allows, Nursing staff is supposed to call V2 or V1 (Administrator), and notify resident family who is the emergency contact number, and then call police. V2 said, I have no idea how long (R4) was supposed to go out on a pass for. V2 said R4 came back within R4 time frame to come back, but V2 does not know what time R4 left, and what time R4 was supposed to come back to the facility. V2 said that the pass privilege / facility policy determines who is safe to go into the community safely on a pass, and who needs an escort to be safe going out into the community. V2 said there are residents who don't get pass privileges because they are not safe to go to the community alone, or without an escort. On 11/16/2022 at 1:40pm, V12(Nurse) said on 10/19/2022 when V12 started her evening shift of 3-11pm, she did not see R4 in the unit. V12 said V12 did not know exactly what time she called the receptionist to ask about R4's whereabouts. V12 stated she was told R4 was out on a community pass. V12 said, This was after 6pm. V12 stated she documented at 9:28pm that R4 was brought in by police. On 11/16/2022 at 2:29pm, V6(Social Services) stated she does not know the whereabouts of R4, and does not know if R4 is at the hospital. Progress note(written by V6) on 10/20/22 at 11:40am, documents: (R4) was on a restricted pass. V6 said, The progress note should not be in (R4's) progress notes, it should have been error-ed out. On 11/16/2022 at 2:29pm, V6 said V6 makes discretionary decisions on resident's community pass privileges. V6 said Yes, a doctor order is needed for a community pass. V6 was unable to show a doctor's order in R4's physician order sheet for R4's community pass. V6 said V6 should follow facility policies. On 11/16/2022 at 2:45pm, V14(Family member of R4) said, I don't know where (R4) is. The Social Worker from a hospital called me last week and told me (R4) is in the hospital and the Social Worker is trying to place (R4) somewhere else, but I don't know where the Social Worker was calling me from. V14 said the police had put out a missing person flier, and that is how the hospital knew R4 is was a missing person. The Social Worker from the hospital called V14 to let V14 know R4 was at the hospital. V14 said, I don't know where (R4) is and I have not seen (R4) since (R4) left the facility. On 11/16/2022 at 2:55pm, surveyor called V10(Nurse Practitioner) regarding R4. V10 said, (R4) plays a very good game and (R4) is good at masking (R4's) delusions, but after talking to (R4) for a while, you would know (R4) is very delusional. (R4) is very confused at times and has strange beliefs. V10 said, (R4) said (R4) can have (R4's) teeth made out of (R4's) hip bone, by getting (R4's) hip bone and mashing it to make teeth, which shows (R4) has very poor insight. V10 stated because R4 has dementia, R4 is at brisk for serious harm if R4 is not supervised. R4 was on the 3rd floor, which is for dementia residents, and even though R4 is not on the complete locked unit on the 3rd floor, R4 was still in the dementia unit for safety. V10 said, When (R4) left the faciity on [DATE], I did not know where (R4) was until 10 days later. R4 was not supposed to leave the unit, but R4 was able to get out of the facility. V10 said review of the video system at the facility showed R4 left the faciity on [DATE] at 9:00 am. V10 said V10 got the information on when R4 left from the Social Worker (V6) and the previous Administrator. V10 said R4 should never have left the faciity on [DATE] because recently, on 10/19/2022, R4 left the faciity on a restricted community pass and R4 got confused while out in the community and police had to bring R4 back to the facility. On 11/16/2022 at 2:55pm, V10 said, After (R4) did not return to the facility on [DATE], facility made a police report. On 11/9/2022, (R4) was reported to have been taken at a nearby hospital by EMS (Emergency Medical Services) on 11/ 2. (R4) was domiciled when EMS found (R4), and (R4) has been domiciled since (R4) left the facility. V10 said per hospital records, R4 fell and broke R4's Maxillary bone and sprained bilateral wrists. V10 said R4 was also very dehydrated when R4 was taken to the emergency department of a nearby hospital after R4 was found sleeping on a bus stop bench. On 11/16/2022 at 4:06PM, V26(Licensed Practical Nurse-LPN) said, (R4) would go out on a community pass about 3 times a week and (R4) would come back between 7-8pm, and if (R4) was not in at this time, that is when a supervisor would be notified. V26 said V26 did not know how many hours R4 was supposed to be out in the community as long as R4 come back between 7-8pm. Review of physician orders do not document Community pass privileges for R4. 2. POS(Physician Order Sheet) dated 9/05/22, documents R5 is [AGE] year-old male, with Diagnosis not limited to: [CONDITION(S)] Disease, Type II DM, Dementia-unspecified), lack of coordination, abnormal gait and mobility, [CONDITION(S)] and [CONDITION(S)]) was allowed to go out on community pass without community skills assessment and without doctor's order. According to resident's (R5) medical records, R5 fell while out on a pass and sustained fracture of right pubis and fracture of right femur. R5's Brief Interview for Mental Status (BIMS), dated 9/16/22, documents: R5 has a BIMS score of 13/15, and R5's Activities of Daily Living (ADL) Assistance, dated 9/22/22, documents R5 needs extensive assistance with ADLs. R5's SS/Social Services-Community Survival Skills Assessment, dated 10/12/2022, document R5 is not eligible for community pass at this time. No previous Community Assessment Pass is documented. Elopement /Authorized leave assessment, dated 10/12/2022, is on file for R5. Review of Physician Orders do not document Community pass privileges for R5. On 11/15/2022 at 12:33pm, R5 was observed in R5's room speaking to R5's roommate. R5 was laying in bed with R5's wheelchair nearby. R5 said R5 can walk a little distance without wheelchair. R5 said on 9/15/2022, R5 went with R5's brother to the gas station near the facility to buy chips. R5 said R5's wheelchair got caught on something and R5 fell and broke R5 hip, leg, and R5 had to be transported to the hospital where R5 said R5 had surgery. R5 said before R5's fall on 8/15/2022, R5 used to go to the beach during the summer, and R5 said at that time, R5 was never restricted from going out to the facility. On 11/15/2022at 12:46pm, V10 (Nurse Practitioner) said R5 went out to a nearby gas station, and while there, fell and landed on right side and broke the head femur head, superior and inferior acetabular (socket of the ball-and-socket hip joint). V10 said R5 has slight dementia and should not have been out there by himself (R5). V10 said R5 was assessed by Social Services. V10 said Social Services assess residents for pass privileges. V10 said R5 should have had an escort when R5 left the building on a pass so that if anything was to happen to R5, the escort could have helped R5, because R5 does not have the ability to correct the problem. V10 said R5 thinks R5 has more capabilities to take care of R5 than R5 has. V10 said if R5 had an escort the day R5 fell , the fall could have absolutely been prevented. V10 said, I have seen (R5) go out by himself after the fall. On 11/15/2022 at 1:08pm, V11 (Licensed Nurse Practitioner-LPN), said R5's cognition is a 3, meaning R5 is oriented to person, place and time, but sometimes R5 can be confused. V11 said R5 knows how to ask for help. V11 said R5 should not have been going out by himself because R5 has [CONDITION(S)] disease and should have an escort to keep R5 safe when R5 is out and about. V11 said an escort while R5 is out and about in the community can help R5 maneuver R5's wheelchair. V11 said R5 is a fall risk because of R5's medical diagnosis and should have an escort to keep R5 safe when R5 is going on the ramp in and out of the facility without staff supervision. Facility Policy titled Community Pass Guidelines, dated 11/28/2022, documents -The resident has the right to community access with the consent of the facility, physician's orders and the residents' cooperation with the standards described -Decisions regarding pass privileges, including, independent privileges or being accompanied by a responsible individual are determined by physician orders and social services assessments

Based on interview and record review, the facility failed to address the refusal of life sustaining treatment for one resident (R1) documented as having cognitive impairment; and failed to communicate with residents' family regarding decline in the condition of the resident. These failures resulted in R1 having a delay in surgical treatment, and R1 developing [CONDITION(S)]. Findings include: R1's medical record showed R1 was initially admitted to the facility on [DATE]. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's plan of care presented for cognition focus, initiated 10/17, and with revision date 11/05/2021, identified R1 as an adult with impaired cognitive function, that has poor self and environmental awareness. R1 scored 12 out of 15 on BIMS (Brief Interview for Mental Status), and has difficulty in understanding information presented. Listed intervention includes, but not limited to, communicate with me, my family and clinical team about my care needs. R1's Advance Directive Status plan of care, presented initiated 8/04/2021 with revision date 11/05/2021, listed R1 as a Full Code, and interventions to this focus includes, but not limited to, R1 receiving continuing education about options to address life sustaining care throughout R1's stay at the facility, if R1 remained coherent and able to understand the information. R1's plan of care documented R1 had wounds on bilateral heels and pressure ulcer coccyx. The goal of care is the pressure ulcer will show signs of healing and remain free from infection through reviewed date listed as 8/17/2022. R1's plan of care documented R1 as having a venous /stasis ulcer of the left heel, right heel, and a new pressure ulcer coccyx. The goal of care is to have no symptoms of infection through the reviewed date and target date listed as 8/17/2022. R1's vascular consultation document from, dated 6/23/22, documents in part: (R1) has Pressure ulcer of right heel was unstageable. History from the facility was that (R1) was non-ambulatory for a long period of time. (R1) is indeed non-ambulatory, (R1) should have an above-knee amputation on the right (referring to right leg). Review of R1's wound consultation notes, dated 6/28/22, showed R1 had 75% gangrene of the right heel and debridement was done. Documentation on 7/12/22 also showed gangrene at 75% with severe necrotic odor. R1's hospital record (7/20/22 admission) showed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure performed listed includes, but not limited to, Right above knee amputation (8/15/22), Perma-Cath placement with informed consent obtained through V26 (family). Review of R1's electronic chart progress notes did not show any documentation R1's refusal of life sustaining surgical intervention was addressed by a psychotherapist or a psychiatrist. The facility was unable to present any documentation that addressed R1 understanding of the severity of the situation. R1's medical record present did not show any documentation R1's refusal of life sustaining surgical intervention was clearly explained to R1's understanding. The facility did not show any documentation the facility followed up with or seek any psychotherapy and psychiatrist consultation to address the root cause of R1 refusal. No family member was informed, and no guardian was consulted. On 8/11/22 at 2:54 pm, V27, PRSC (Psychiatrist Rehabilitation Services Coordinator) was interviewed regarding communicating with R1 in making decision to adhere to treatment plan of amputation of the right leg. V27 stated, in part, The nursing department wants the Social Service Department to speak to (R1) about the issue. V27 stated she did, and R1 said, R1 will get back to them on whether (R1) wants the surgery done. V27 stated, (R1) did not get back to them (referring to Social Services Department). On 8/15/22 at 11:58 am, V23 (Wound Care Physician) stated R1 has a right heel diabetic wound. V23 stated R1 has gangrene of the right heel. V23 stated the wound was being treated with [MEDICATION(S)] soak. When asked whether R1 was sent out for consultation, V23 stated R1 was sent out for consultation, and the plan was to amputate. V23 stated (V23) last saw R1 on 7/12/22. V23 stated he did not order any antibiotics because 75% of the leg was with black gangrene tissue and had a mild odor. V23 stated, (R1's) leg cannot be saved so there was no point in ordering any antibiotics. On 8/17/22 at 12:58 pm,V16, PRSD (Psychiatrist Rehabilitation Services Director), stated, We (referring to the facility Social Services Department) offer counseling to the resident just to educate them of the importance of compliance with medical procedures and treatment. We reach out to the family of the resident, and if the resident still refuses, there is nothing we can do at that time. The resident is given time to digest the information and will be re-approached. When the surveyor asked V16 about cases where the prognosis of the resident is poor with possibility of death, V16 stated, If, for example, there is a severe reason for why this medical treatment or procedure is needed then (the facility) will involve the psychotherapist to step in. The surveyor asked V16 whether R1 was referred to the psychotherapist or psychiatrist to inquire about R1's refusal of life sustaining procedure to amputate the infected leg. V16 stated R1 was referred to the psychotherapist. V16 was asked to present documentation of the psychotherapist addressing this issue with R1. V16 was unable to produce any documentation to support his statement. On 8/16/22 at 11:44 am, V24, NP (Nurse Practitioner) for V25 (Primary Physician), stated (R1) has multiple co-morbidities and was being treated by in-house wound care team. (R1) was sent out for possible vascular consultation. When the surveyor asked whether V24 physically assessed R1's wound, V24 stated, I (V24) defer to the wound care team when they tell me the wound is stable. The surveyor then asked whether V24 was aware R1 has gangrene on his right leg. V24 stated she was told the wound was in a stable condition, and V24's wound documentation about R1's wound refer to the wound as being stable. When the surveyor asked about R1's refusal of life sustaining surgical intervention, and V24 was asked whether R1 would have benefit from psychotherapy or psychiatrist consultation, V24 stated, (R1) is alert able to make decisions by self and I (V24) don't know how to answer that. On 8/17/22 at 4:15 pm, V23 (Wound care Physician) was asked whether V23 was aware R1 was refusing the surgical procedure. V23 stated, I'm not aware (R1) was refusing the amputation. V23 stated, in part, I (V23) have known (R1) a long time. I've had good relationship with (R1) for over four years. (R1) needs the amputation; that's what (R1) needs. It is a lifesaving procedure for (R1) and if the patient (referring to R1) cannot understand, they (referring to the facility) need someone else to make the decision, unless (R1) is on a DNR (Do Not Resuscitate) status. They (Facility) can call the family or appoint a guardian. V23 stated, The resident has the right to refuse, if the patient is of a clear mind, but (R1) might die; the resident needs to know the consequences. The resident (R1) may need a more professional intervention and opinion. On 8/22/22 at 3:55 pm, V25 (Primary Physician) stated, (R1) was non-decisional, unable to make medical decisions. (R1) was not in any condition to understand what was going on. V25 stated due to [CONDITION(S)], R1 was not clear, non-decisional, and was unable to consent to surgery. The consent was signed by the POA (Power of Attorney). V25 stated, Typically, the POA or surrogate will be the decision maker in this case. (R1) was in the hospital last time (referring to admission of 7/20/22) for severe [CONDITION(S)], arterial insufficiency of the right leg with gangrene. (R1) requires [CONDITION(S)] and blood transfusion, requires amputation of the right above the knee, and has [CONDITION(S)] that is related to prolonged illness, [CONDITION(S)] related to [CONDITION(S)], and [CONDITION(S)]. (R1) had [CONDITION(S)] at this admission. (R1 was sent and admitted to the hospital on 7/20/22, amputation was performed during the same hospital stay on 8/15/22) The facility Job Description for Social Services Director documented , The purpose of the Social Service Director is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of the facility's social service department in accordance with federal, state and local standards, guidelines and regulations, to assure that medically related emotional and social needs of the residents, families. The facility Psychiatric Rehabilitation Service Coordinator (PSRC) Job Description documented the primary purpose of the job description is to implement the programs of the Social Services Department, to assure that the medically related emotional and social needs of the resident are met/maintained on as individual basis, to safeguard the health, safety and welfare of all manner in accordance with facility's established policies and procedures applicable laws and regulations and the directions of your supervisors, who include the PRSD, Administrator and/or other members of the community's management to whom such persons report, in order to assure that the highest level of social services for the community's residents is maintained at all times. As a PRSC, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Based on observation, interview, and record review, the facility failed to correctly enter a phone physician order, resulting in the improper wound treatment being utilized; failed to report abnormal findings to the physician; and failed to ensure wound treatments were provided as ordered for one of three residents (R2) reviewed for wounds. These failures resulted in R2 developing an infection in R2's left foot wound leading to [CONDITION(S)] and requiring hospitalization . Findings include: R2's BIMS (Brief Interview for Mental Status), dated 6/27/22, determined R2 had a score of 14, indicating R2 is cognitively intact. R2's Admission Record documents R2's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Treatment Administration Record documents that Santyl Ointment 250 unit/gm (gram) should be applied topically to the left foot every other day, with a start date of 4/20/22, and a discontinue date of 5/17/22. Within those dates, there were 7 missing documentations for the Santyl administration. R2's left bunion treatment order is documented as QOD (Every other day), with a D/C (discontinue) date of 4/14/22. From April 1st, until the D/C date, there were 5 missing treatment documentations. R2's left plantar foot wound treatment order documented as QOD, with a D/C date of 4/19/22, shows 6 missing treatment documentations from April 1st until the D/C date. R2's left plantar foot wound order documented as QOD, with a start date of 4/20/22 until 5/17/22, shows 6 missing treatment documentations for that time period. R2's 5/12/22 Wound Assessment Details charted by V23 (RN/Former ADON/Assistant Director of Nursing) documents, in part, Exudate: Amount - Moderate, Type - Purulent. R2's 6/29/22 ED (Emergency Department) physician note documented by V30 (MD/Medical Doctor) documents, in part, History of Present Illness .presents to ED from nursing home for an infection of left foot wound .there is a focal point of purulent discharge .Medical decision making: Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Medication Review Report, with an order start date of 7/12/22, documents, Wound: Left Plantar Foot: Clean with NSS (normal saline) and pat dry, apply DermaCol (collagen matrix dressing) and Cal (calcium) alginate on the wound bed. Cover it with ABD pad, Kerlix (woven gauze bandage) and tape. QOD (every other day) or as needed; Communication type: Phone. R2's 7/12/22 Wound Care consultation noted, documented by V24 (Wound Specialist/Advanced Practice Nurse), documents, in part, Topical Application: DermaCol Ag (collagen matrix dressing with silver) plus CalAlginate (calcium alginate). On 7/12/22 at 12:01 PM, the surveyor observed V15 (LPN/Licensed Practical Nurse/Wound Care Nurse) prepare a collagen matrix dressing, calcium alginate dressing, ABD (abdominal) pad, woven gauze bandage, tape, and a saline flush. V15 stated the wound care specialist who comes every other Tuesday, was just here and changed the dressing order to what was prepared. On 7/12/22 at 3:22 PM, the surveyor inquired why on R2's Treatment Administration record from April to June there are many empty boxes. V15 stated, I'm not sure, but maybe means that nobody charted. V15 agreed if it is not charted, then one cannot be sure if the treatment was done. On 7/13/22 at 1:00 PM, when the surveyor inquired if V23 notified the physician of the purulent exudate on R2's foot on 5/12/22, V23 stated she (V23) doesn't remember if she (V23) notified the physician at that time, but added That would warrant notifying the physician. On 7/13/22 at 3:35 PM, the surveyor inquired who puts in the order when the wound specialist makes a new recommendation to the wound treatment? V15 stated, I do. The surveyor pointed out the current wound treatment order and V24's consultation note. V15 stated she (V15) used the (advanced wound care) dressing with silver during R2's dressing change on 7/12, but just put the order in incorrectly. On 7/13/22 at 2:11 PM, V24 (Wound Specialist/APN) stated purulent drainage is pus, which indicates the presence of bacteria. V24 added he (V24) would expect to be notified of that type of drainage. V24 stated he (V24) does not recall being notified R2 had purulent drainage. V24 added if a wound dressing is not changed as ordered, that can lead to Extra fluid collection, exudate and eventually of course it can become infected. The surveyor inquired if an infection in the foot wound can lead to [CONDITION(S)]. V24 replied, Yes, especially a patient with diabetes. V24 explained an infected foot wound can lead to [CONDITION(S)] very easily due to poor skin resistance to bacteria penetration in diabetic patients. The Wound Nurse Job Description, dated 3/23/17, documents, in part, Summary: The Wound Nurse is responsible for providing primary skin care to residents under the medical direction and supervisor of the residents' attending physician, the Director of Nursing, or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders. Essential Duties and Responsibilities include but are not limited to Examine the resident and his/her records and charts and discriminate between normal and abnormal findings, in order to recognize when to refer the resident to a physician for evaluation, supervision or directions; identify, manage, and treat specific skin disorders . foot problems such as corns and callouses, decubitus ulcers, bacterial, parasitic and [CONDITION(S)] skin infections. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) job descriptions, dated 5/02/17, documents in part, The RN/LPN is responsible for providing direct nursing care to the residents .to ensure that the highest degree of quality care is maintained at all times. Essential duties and responsibilities include but are not limited to Receive and transcribe telephone orders from physicians and record on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician Orders-Entering and Processing policy, dated 8/22/17, documents, in part, Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders (a prescriber is noted as a physician, nurse practitioner, and a physician's assistant). Guidelines .3. Notify the resident's physician (if not the prescribing physician), for verification if applicable. The Foot Care policy, undated, documents, in part, Purpose: to provide comfort and prevent infection of the feet. Procedure .9. Document time, date, treatment and include pertinent observations and description of feet.

Based on interviews and record reviews, the facility failed to follow their Fall Prevention Program by (a) not orienting a resident to use the nurse call device when assistance is needed, (b) not identifying risk for falls and implement appropriate fall interventions for a resident who is at risk for falls, and (c) not providing supervision to the washroom to prevent a resident from falling for 1 (R44) of 2 residents reviewed for fall incidents in a sample of 34. These failures resulted in R44 having a fall incident while using the washroom unassisted which resulted in numerous fractures. Findings Include: R44's Hospital records (2/28/22), emergency room Documentation documents in part, [AGE] year-old female from nursing home with mechanical fall with bimalleolar fracture to the left ankle. Discussed with orthopedic surgery plan to take patient to surgery today for ORIF. History and Physical Reports read in part, R44 admitted from skilled nursing facility with trimalleolar fracture status post-surgery. CT left ankle without contrast impression: trimalleolar fracture with moderate displacement and moderate comminution, complex mildly displaced intra-articular fractures base of third and fourth metatarsals, nondisplaced base of second metatarsal fracture, nondisplaced intra-articular fracture base of first metatarsal, and severe soft tissue swelling. X-ray of pelvis impression: bimalleolar fracture with minimal medial widening of the mortise. X-ray of left tibia/fibula impression: bimalleolar fracture with minimal medial widening of the mortise. On 5/03/22 at 12:17 PM, R44 was sitting on a wheelchair alert and able to verbalize needs. Surveyor noted R44's left foot swollen. R44 stated, I fell on ,d+[DATE] in the bathroom. I broke my bones on my left leg. I had a broken ankle. They took me to surgery. The cast was removed Friday. I was by myself. I was getting up from the toilet and I tripped. The nurse came and got me up on the wheelchair. R44's facility record reviewed. R44's initial admission in the facility was 11/18/2021. Facility's fall-initial occurence note - V2 with an effective date of 2/28/22 at 11:00 AM shows R44 was found on the floor of the washroom lying on her (R44) right side. V25 (Licensed Practical Nurse) assessed R44 with swollen left ankle with pain, and received an order to send R44 to the local hospital. Resident statement: I finished using the washroom and want to come out and fell and hurt my ankle. On 5/4/22 at 12:12 PM, an interview conducted with V2 (Director of Nursing). V2 stated he (V2) is in charge of fall prevention program. V2 stated that the fall assessments are completed for residents upon admission, and fall precautions should be added as interventions in the fall care plan. V2 stated that the purpose of the fall care plan is to specify and let the staff know what type of care the resident needs. V2 stated that the fall care plan should be initiated and fall precautions should be implemented upon admission of the resident. V2 stated that fall interventions are implemented based on the condition of the resident such as history of falling, assistance needed with activities of daily living (ADL), and limitations with mobility. V2 stated all residents residing in the facility are considered at risk for falls, and staff has to make sure that all residents receive the assistance they need. Surveyor reviewed with V2 R44's minimum data set (MDS) assessments in R44's electronic health record (EHR). R44's Admission MDS with assessment reference date (ARD) of 11/25/21 shows R44 requires supervision with setup help from the staff for toileting, bed mobility, transfer, walk in room, and dressing. R44's Quarterly MDS with ARD 1/21/22 shows R44 requires supervision one staff physical assist for toileting, bed mobility, transfer, walk in room, and dressing. Surveyor and V2 checked R44's EHR for a quarterly fall risk assessment but none was found. V2 stated that if R44 requires supervision assistance with ADLs, R44 is at risk for falling. V2 stated a fall risk assessment should have been completed. V2 stated that staff should be assisting R44 to the washroom at all times. V2 stated that staff should not leave R44 in the washroom alone. Surveyor and V2 also reviewed R44's comprehensive care plan from the day of R44's admission on 11/18/21 through the day of R44's fall on 2/28/22. V2 confirmed that R44 did not have a fall care plan in place, and did not have any fall interventions in place. V2 stated that if R44 had no fall care plan that means fall precautions to prevent R44 from falling were not implemented. V2 stated fall interventions that should have been implemented to prevent R44 from falling are frequent monitoring of R44 if R44 needs to go to the bathroom and provide assistance, toileting program, and rounding at least every 2 hours. V2 stated that moving forward fall assessments are done and fall care plans are initiated for all residents. R44's EHR indicates R44 has diagnoses listed not limited to nondisplaced transverse fracture of shaft of right fibula, initial encounter for closed fracture , [CONDITION(S)], unspecified, type 2 diabetes mellitus , complications, [CONDITION(S)], Ccurrent episode mixed, mild, [CONDITION(S)] with behavioral disturbances, long term (current) use of insulin, and psychotic disorder with delusions due to known physiological condition. R44's MDS with ARD of 1/21/22 shows R44 is cognitively intact. R44's physician order sheet (POS) shows R44 has ordered high risk medications which includes, [MEDICATION(S)] Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject 10 unit subcutaneously at bedtime, Insulin [MEDICATION(S)] Solution 100 UNIT/ML Inject 3 unit subcutaneously three times a day, [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth at bedtime, [MEDICATION(S)] Solution 40 MG/0.4ML ([MEDICATION(S)]) Inject 40 mg subcutaneously in the morning, [MEDICATION(S)] Tablet 0.5 MG Give 1 tablet by mouth two times a day. On 5/4/22 at 12:59 PM, surveyor observed R44 resting in bed alert and verbally responsive. Able to verbalize needs. Surveyor asked R44 if staff assistance is being provided every time R44 needs to go to the bathroom. R44 stated, I go with my wheelchair. I wheel my wheelchair to the bathroom. I have a good right leg. I can stand with my right leg and go use the toilet. Surveyor also asked R44 if assistance was provided whenever R44 needed to go to the toilet before her (R44) fall in February. R44 stated, Before I fell I was able to walk just like you. I was able to go on my own. Surveyor asked R44 if staff provided her (R44) education on asking for help when needed especially when she (R44) needs to go to the bathroom. R44 answered, No. Nobody educated me to call if I need help going to the bathroom. I call the staff for something else like my food tray but not going to the bathroom. Surveyor asked R44 if staff educated R44 on using the call light to call for help. R44 answered, No. I ask my roommate to call for help. I didn't know I have a call light. At 1:03 PM, an interview conducted with V12 (Registered Nurse). V12 stated that before R44's fall on 2/28/22, R44 was able to do all her (R44) ADLs by herself (R44). V12 stated that R44 never calls for help. V12 stated R44 would go to the washroom by herself with no staff assistance. V12 stated that R44 was independent and still wants to be. At 1:09 PM, an interview conducted with V18 (Certified Nursing Assistant (CNA). V18 stated she (V18) is R44's regular CNA. V18 stated before R44 fell , R44 walked independently. V18 stated R44 was going to the washroom on her own. V18 stated that R44 was independent and prefers to do her everything on her (R44) own. On 5/5/22 at 12:15 PM, reviewed R44's EHR and could not find any documentation that R44 was educated on the use of the call light when assistance is needed. At 12:21 PM, an interview conducted with V6 (Wound Care Nurse/Assistant Director of Nursing). V6 stated call light education provided to the residents are documented in the progress notes. Surveyor requested from V6 to provide copy of documentation that education was provided to R44 on the use of the call light prior R44's fall on 2/28/22. At 12:51 PM, V6 came back to this surveyor and stated that there is no documentation found in R44's clinical record indicating that education was provided on the use of call light. Reviewed facility's policy titled, Fall Prevention Program revised on 11/21/17 reads in part: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determines 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 Use and implementation of professional standards of practice Immediate change in interventions that were successful Care plan incorporates: - Identification of all risk/issue - Addresses each fall - Interventions are changed with each fall, as appropriate - Preventative measures Standards: A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Fall/safety interventions may include but are not limited to: 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. The location of the placement will be verbalized for those residents with visual deficits. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. 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. The resident will be reminded as needed to call for assistance before attempting to ambulate.

Based on observation, interview and record review, the facility failed to perform a comprehensive skin assessment, failed to implement preventative interventions to prevent the development of a pressure ulcer, and failed to provide treatments for a facility acquired pressure ulcer. This failure resulted in R2 developing a bone infection from an open infected area in the sacrum (bottom of the spine) that required hospitalization . This failure affects 1 of 3 residents (R2) reviewed for pressure ulcers in a total sample of 7 residents. Findings include: R2's Face Sheet documents resident is a [AGE] year-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/22/2021 at 2:05pm and 4:31pm, this surveyor attempted to contact V12 (Certified Nursing Assistant/CNA) who was the CNA on duty and assigned to R2's care on 10/04/2021 when R2's sacral wound was first identified. During the investigation surveyor did not receive a call back from V12. On 11/20/2021 at 2:32pm V2 (Registered Nurse) stated, R2 was my patient that I work with regularly, but currently R2 is in the hospital. R2 was sent out because R2's wound was getting worse. R2's wound was on the sacrum. R2 was bed bound and required a lot of assistance. R2 came to the 3rd floor when the second floor was shut down in September. I do skin assessments only when the certified nursing assistant notices a problem with a resident's skin; that's when the CNA will call me and that's when I do a skin assessment. I did not do any skin assessments for R2 because the CNA did not notify me of R2 having any skin problems. R2 is bed bound so R2 gets bed baths. If the CNAs notice anything new on the skin, then they call me to come and look at it. I am required to do a weekly skin assessment on the residents. R2 was sent out November 9, 2021 to the hospital because V10 (Wound Nurse Practitioner) was worried that R2 might have [CONDITION(S)]. On October 29, 2021 the wound looked the same; it didn't get any worse, but it wasn't getting any better. I don't assess wounds, the wound nurse deals with the wounds. On November 9, 2021, R2 was exhibiting behaviors of screaming and R2's behavior was off. On November 9, 2021 V10 (Wound Nurse Practitioner) was here doing wound rounds and said that R2's wound was getting worse. V10 sent R2 out to the hospital because V10 was suspecting that R2's wound were infected. I did not assess R2's skin because prior to the discovery of the wound, which was on October 4, 2021, nobody notified me that R2 had a skin alteration. R2's hospital admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/20/2021 at 4:09pm, V1 (Director of Nursing) stated, R2 had a sacral and gluteal wound. Those wounds formed at the facility. I believe in early October the resident developed wounds. To my knowledge, R2 was turned and repositioned every two hours. Two of the smaller wounds healed, but I believe the sacral wound deteriorated. R2 was sent to the hospital on November 9, 2021, because we noticed R2's wound was not improving. R2 was admitted to the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Every week I speak to V15, who is R2's doctor and medical director, and R2's doctor told me that R2 has [CONDITION(S)]. On 11/22/2021 at 1:28pm V1 (Director of Nursing) stated, Skin assessments are done upon admission and wound care follows up. Skin assessments are done quarterly and upon admission. The nurses are only supposed to do skin assessments when there is a problem area identified by the CNA. The CNAs will look at the skin during a shower, and if there is a problem, the CNA will let the nurse know, and the nurse will notify the wound nurse. Nurses are required to do skin assessments upon admission and quarterly and when there is a problem area identified by the CNA. A nurse working the floor is supposed to do weekly skin assessments for the residents who are assigned for a skin assessment during that shift. I don't recall doing a skin assessment on R2. Sometimes when the nurses are busy, I will help with skin assessments. I did not do a skin assessment on R2. I signed off on R2's skin assessments for the date of October 1, 2021, but I never actually looked at R2's buttocks and sacral area. On October 1, 2021, when I signed off on the weekly skin assessment, I never looked at R2's buttocks, I just did not do it. By signing off on the weekly skin assessment, it means that I did a full skin inspection on R2, however, I did not assess R2's buttocks and sacral area so I failed to do a complete skin assessment for this resident. On 11/21/2021 at 10:50am V8 (Wound Nurse) stated, R2 is currently in the hospital. R2 has a wound on the sacrum which developed at the facility. When I started working as a wound nurse on 25th of October, R2 had the sacral wound. When I started treating R2's wounds, I heard that the wound was new, and it started at our facility. On October 25, when I first saw R2's wounds, I noticed that R2's wound was not able to be staged because there was a lot of sloth there. I was doing wound treatments for R2 daily and as needed. When the CNA was trying to reposition R2, R2 was hitting and noncompliant. When I was doing wound care, I needed assistance because R2 was a bit combative. R2's wound was bad, and as I did the treatment, the wound was not getting better. I know that we sent R2 to the hospital because the wound was not getting better, in fact R2's wound was getting worse. I know that V10 (Wound Nurse Practitioner) was worried that R2's wound was infected and V10 was worried that R2's infection might have spread to the bone. R2 was sent to the hospital on November 9, 2021 and it was confirmed in the hospital that R2 did develop [CONDITION(S)] because of the wound. On 11/21/2021 at 11:10am V9 (Wound Nurse) stated, I am doing R2's wound treatment. I first learned of R2's wound on October 4, 2021, when (V13) the Assistant Director of Nursing (ADON) came to me and told me about R2's wound. V13 notified me that V13 discovered a wound on R2's sacral area. V13 (ADON) accompanied me to R2's room and we looked at R2's wound together. V13 was working the floor that day because a nurse who was scheduled to work the 3rd floor called off and that's how R2's wound was discovered. When I initially went to see R2's wound with V13 on October 4th, I saw R2 had a wound that was opened and it had sloth, and it was hard to stage R2's sacral wound because it was open, and it was covered with sloth so it was difficult to determine what was underneath it. Basically, what happened is that the wound was there, and nobody reported it, and nobody was treating R2's sacral wound until V13 (ADON) saw the wound and notified me. Basically, whoever was caring for R2 was covering up the wound and not letting anyone know that it was there. When I saw the wound on October 4, 2021, R2's wound was already an opened full-blown wound. Since we discovered it, the wound got bigger and we were caring for it, but it got bigger. R2 is very close to me; I really love R2, so when I learned of this wound it was heartbreaking to me. I cannot believe that someone was covering up the wound. I will say that R2's skin assessment was not done by the nursing staff during showers; that is why the wound on the sacrum developed into stage 4. The problem is that the nurses are not doing skin assessments when residents are having showers. The nurse will assess the resident's skin when the CNA will notify the nurse of a skin issue. The nurse is also required to do a skin assessment once a week. We used to have the shower sheets, now we do the shin assessments in the computer. Now they only do shower sheets when they notice a skin alteration. When I saw R2's wound on October 4, 2021, the wound on the sacrum was open and deep, so R2's wound was there for a while and nobody reported it. On 11/21/2021 at 11:35am V10 (Wound Nurse Practitioner) stated, R2 has a stage 4 sacral wound. After I did the wound debridement, the wound is now a stage 4. On November 9, 2021, R2 was sent to the hospital. I first saw R2's wound on October 5th. On October 5th, when I first saw R2's sacral wound, it was unstageable due to the amount of sloth. R2 had 3 wounds when I saw R2 on October 5th. R2 had a sacral wound unstageable, left gluteal unstageable and right gluteal stage 2. I did blood work and urine culture and I started antibiotics on October 6th. I also ordered a urinary catheter to be placed to help with wound healing. On October 12th, the left gluteal wound became a stage 3. On October 19, 2021, the sacral wound was debrided and became a stage 4. About 75% of necrotic sloth was removed from the sacral wound on October 19th. On November 2, 2021, the left and the right gluteal wounds closed, and the sacral wound was the only wound that was left opened, but it was not improving. On November 9th the sacral wound was the only open wound, and I discussed the care with V15 (R2's primary care doctor). I discussed the plan with R2's primary doctor and the plan was to place a g-tube because of nutrition issues, and we had a plan to do a bone biopsy for R2 to rule out [CONDITION(S)] and blood work. R2 was sent out to the hospital on November 9, 2021, because R2's sacral wound looked worse, and R2 was refusing blood work and refusing everything so we sent R2 out. We could not assess the level of malnutrition if R2 was refusing blood work. We also sent R2 out because there was a possibility of an infected wound. It's hard to determine when it started but the sacral wound on October 5, 2021 was not able to be staged but it was open for a while before I first assessed it on October 5, 2021. When R2 was sent to the hospital on 11/09/2021, I was suspecting that R2's wound was infected, and that the infection spread to the bone. On 11/22/2021 at 10:43am V13 (ADON) stated, On October 4, 2021, I was working on the floor that day; a nurse called off and I filled in. R2 said that R2's bottom hurts. On October 4, 2021 at 2:30pm, as R2 reported that R2's butt hurts, we turned R2 over and I looked at R2's buttocks. I saw an open area on R2's sacrum, and it looked like it needed attention immediately. The wound looked like it was circular, and it was on R2's sacrum. R2's wound appeared to have sloth and I was not able to stage it. R2 is bed bound and R2 was getting care that day by V12 (CNA), but the CNA did not report to me R2 had a wound. R2 reported pain at the buttocks area, and that is how I discovered R2's sacral wound. V12 (CNA) did not tell me anything about the wound all day. When I asked V12 (CNA), who was working that day with R2, if V12 has seen this wound, V12 said 'yes'. V12 stated, 'I saw the wound and applied some barrier cream on the wound.' I asked V12 if the regular nurse that works the 3rd floor knew about this wound. I (V13) don't remember what V12 said. Nothing was done to address R2's wounds and when I first saw R2's sacral wound, it was completely open and not covered by a dressing. On October 4, 2021 at 2:33pm I (V13) asked V9 (Wound Nurse) to come and look at R2's wounds immediately, because R2's wound looked like it needed immediate attention. When V9 (wound nurse) came to assess R2's wounds, V9 stated that R2's wounds look horrible and that the wounds don't look good. R2's wounds could have been avoided. If the CNA or the nurses would have reported R2's wounds sooner, when they first developed, R2 wound not have developed a stage 4 wound and it would not have gotten infected. If the staff reported R2's wounds sooner, than R2 would not have developed such a huge wound. The policy in this facility is that when a resident is receiving a shower or a bed bath, the nurse should go in there and assess the resident's skin. So, with every bed bath or a shower, the nurse should be assessing the resident's skin. The nurses are required to do a general skin observation once per week called a UDA (User-Defined Assessment). The UDA assessment that nurses do is a skin assessment that is supposed to be done once a week. The nurses are consistently supposed to do resident skin assessment. It is obvious that the nurses who were caring for R2 were not assessing R2's skin. The facility policy is that nurses are supposed to assess the resident's skin with every bed bath or shower, but clearly that is not being done and that is why R2's wound was not discovered earlier. The problem is that the nurses are not doing the skin assessments as they are required to. Every resident receives two showers a week, so the nurses are supposed to assess resident's skin with the showers and once a week as part of the UDA assessment. On 11/22/2021 at 12:11pm, V11 (Administrator) stated, The policy here at the facility is that with showers the CNAs are supposed to report any kind of skin breakdown to the nurse. The nurses are required to assess the resident's skin weekly. When a resident is showered, the nurse is required to do a skin assessment only if the resident reports an issue. The nurse is required to do a weekly skin assessment. There was a situation where the wound nurse practitioner sent out R2 to rule out [CONDITION(S)]. The wound nurse practitioner was worried that R2's wound was already infected, which it was, and the infection spread to the bone. On 11/22/2021 at 4:04pm, V15 (medical director/R2's doctor) stated, R2 has [CONDITION(S)]. It was confirmed at the hospital that R2 does [CONDITION(S)] which happened because of the wound. I learned of R2's wound when R2 was admitted to the hospital while I was on vacation. The wound could have been avoided if the staff addressed and treated the wound sooner. R2's sacral wound would not have developed into a stage 4. It is difficult to assess wounds when you first look at them because you don't know what's happening underneath the skin, but if the facility assessed and treated the wound sooner, R2 would not have developed [CONDITION(S)]. R2 does have [CONDITION(S)], R2 does have an infection in the bone; it was confirmed during R2's hospitalization . General Skin Observation (dated 10/01/2021 at 10:01am) authored by V1 (Director of Nursing) documents that R2's weekly skin observation was completed, skin is warm, dry, and within normal limits. Shower & Tub Bath Policy (dated 01/31/2018) states that C.N.A must call for a nurse to report and reddened areas, skin discoloration or breakdown. Complete Bed Bath Policy (dated 01/31/2018) states that C.N.A must call for a nurse to report and reddened areas, skin discoloration or breakdown. Progress Note (dated 10/05/2021 at 11:00am) authored by V10 (Wound Care Nurse Practitioner) documents R2 was examined for follow up w lab review shows [CONDITION(S)], and for sacral and buttock wounds. Followed by wound care team inhouse with recommendation for {urinary} catheter. On PO antibiotics to promote wound healing. Progress Note (dated 11/09/2021 at 11:59am) documents R2's sacral wound is worsening and there is a concern for [CONDITION(S)], but pt. is non-compliant with lab testing, severe decreased appetite. Pt might need to go to hospital for evaluation. Wound Consultation Note (dated 10/05/2021) documents R2's wound measurements: Sacral wound 2.2Lx2Wx0.3D; left gluteal 3Lx5Wx0.3D; Right gluteal 4Lx7Wx0.1D. emergency room CT of Abdomen and Pelvis (dated 11/09/2021) documents R2 has a large left sided sacral decubitus pubis ulcer extends to the underlying bone with apparent destruction of the distal coccyx. Findings are concerning for [CONDITION(S)]. emergency room report MDM/ED course (dated 11/09/2021) documents R2 is a [AGE] year old from nursing home with [CONDITION(S)] and [CONDITION(S)] without fever. Found to have [CONDITION(S)] of the sacrum as well as possible bilateral lower lobe pneumonia.

Based on interview and record review, the facility failed to supervise, monitor, and prevent three residents (R1, R9, and R10) with known substance abuse diagnoses from trafficking illicit drugs and alcohol in the facility. This resulted in R1's death due to substance abuse. The Immediate Jeopardy began on [DATE] when R1 expired. V24 (Administrator), V1 (Assistant administrator) and V3 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE]. The immediacy was removed on [DATE], however remains out of compliance at severity level two. The facility continues to educate all staff on the Alcohol Substance Abuse Policy, Community Access Privilege Program, Conduct Respect Policy, and Drug and Trafficking Policy as implemented by the facility. Findings include: R1 was a [AGE] year old male admitted to the facility on [DATE]. R1's diagnoses include but are not limited to: third degree [CONDITION(S)], alcohol dependence with withdrawal, cocaine abuse, cannabis use, psychoactive substance abuse, and anxiety disorder. R1 expired at a local hospital on [DATE]. R1's death certificate lists the cause of death as Combined Acetyl [MEDICATION(S)], [MEDICATION(S)], Desproronyl [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Heroin, and Oxycodone Toxicity. R1's Brief Interview for Mental Status (BIMS) dated [DATE] documents R1's cognition was intact. After multiple requested from V10 (Admissions Director), R1's criminal background check was never provided. Smoking evaluation dated [DATE] documents that R1 requires supervised and controlled smoking management. R9 is a [AGE] year old male admitted to the facility [DATE]. R9's diagnoses include but are not limited to: anxiety disorder, depression, and pain. R9 signed out against medical advice on [DATE]. R9's BIMS dated [DATE] documents that his cognition is intact. After multiple requests from V10, R9's criminal background check was never provided. R10 is a [AGE] year old male. R10's diagnoses include but are not limited to: alcohol abuse with intoxication, alcohol abuse, chronic pain syndrome, pain, and [CONDITION(S)] disorder. Review of R1's progress notes document the following incidents and behaviors: [DATE] resident has a criminal history related to possession of drugs and has been to jail for a couple of months due to possession of cocaine. Resident has a history of substance abuse with alcohol, marijuana, and cocaine being his drugs of choice. [DATE] resident was seen smoking marijuana in his room today. Social services met with the resident to follow up. Resident was educated on the facility's smoking policy and drug policy. Resident verbalized understanding to education provided. Social services performed a room search and confiscated items. Social services will continue to monitor the resident for behaviors. [DATE] receptionist reported to nursing supervisor that the resident was caught on camera smoking at the patio with two other residents with no supervision. Counseling done. V12 (Medical Director) was notified. [DATE] social services followed up with R1. Resident was reeducated on the facility's smoking policy and was encouraged to comply with policy. Resident stated understanding. A room search was performed. No smoking materials were found. Social services will continue to monitor resident for behaviors. [DATE] staff noted a strong smell of cigarette and marijuana outside of resident's room at 9:45 PM. Supervisor notified. Supervisor searched resident's room with R1 present. Supervisor confiscated two unopened bags of cigars, two used bags of cigars, one bag of cigar leaves, one lighter, and multiple small bags with left over marijuana leaves and unidentified substance. Education provided about facility smoking policy. Social services to follow up. [DATE] R1 was educated on the facility smoking policy and was encouraged to comply with care. A room search was performed and no smoking materials were found. Resident placed on one month patio restriction due to non-compliance with the smoking policy. Resident verbalized understanding. Social services will continue to monitor resident for behaviors. [DATE] at about 11:30AM IDPH (Illinois Department of Public Health) personnel went to interview R1. When she returned after interviewing R1, she stated it smells like marijuana in the room. Administration went to R1's room. A room search was conducted. Nothing was found. R1 admitted that he smokes marijuana on the patio. At 12:20PM, R1's room was searched per IDPH mention of smelling weed and cigarette smoke in R1's room. R1 agreed to search of belongings. R1 was educated that he cannot smoke or bring weed inside of the facility. R1 was educated about being on restriction and the risk of further violation of facility policies. 12:45PM V12 (Medical Director) stated that she would discuss this with V5 (Former Administrator) tomorrow since R1 admitted to doing drugs. No new orders given. [DATE] R1 was seen smoking marijuana in his room this morning. Smoking materials were confiscated by social services. R1 was educated again and expressed desire to transfer to another nursing home. Social services will monitor for behaviors. [DATE] staff confiscated needle and pills from R1's room yesterday. Social services met with R1 today to follow up. R1 denied having contraband in his room. Resident was reeducated again. Resident was offered psych services and declined. Social services will continue for behaviors. [DATE] R1 was found in his wheelchair in R9's room unresponsive. He had vomited a little liquid content. At 8:25 PM, chest compressions were initiated before 911 arrived and continued. R1 was taken to a local hospital by 911. R1 expired at 10:33PM. Review of R9's progress notes document the following incidents and behaviors: [DATE] resident does have a criminal history related to drug charges. Resident has not been in jail for many years. Resident has a history of substance abuse with heroin and cocaine being his drugs of choice. He was also educated on the patio guidelines. [DATE] writer informed nurse on duty that she smelled smoke. Resident noted sitting in his wheelchair in his room. R9's room smelled of smoke. R9 was asked if he smoked in his room. He said yes. R9 was reminded of the facility smoking policy and the dangers of smoking while oxygen is in use. R9 stated he would not do it again. R9 stated he did not have any more cigarettes. A lighter was taken and his room was searched. R9 placed on monitoring. [DATE] at 6:15PM R9 was requesting his pain pill. R9 went downstairs; after a few minutes, staff noted resident is having erratic behavior and brought the resident back to bed. Resident alert but having uncontrollable twitching of the body, trashing his arms, taking off his clothes and claimed that he feels something crawling on his body. Another physician saw R9 via telemedicine and R9 started crying uncontrollably; [MEDICATION(S)], an anxiety medication was given. At 8:50 PM, R9 was asleep but noted with a small plastic bag in the corner of his mouth filled with unknown substance but plastic still intact. At 10:35PM, R9 started twitching again and mumbling words. At 3:50 AM, R9 attempted to withhold medication with nurse present. Staff expressed to R9 that all medication must be taken in front of the nurse at all times. R9 stated understanding. R9's mood and behavior will continue to be monitored. [DATE] a nurse notified another nurse on the floor that R9 had been smoking in an empty room. R9 was reeducated and redirected to the room as stated by the nurse. R9 denies smoking in the room. Social services to follow up. [DATE] R9's urine analysis and blood tests were reviewed. According to the results, R9 tested positive for cocaine use. R9 expressed the test to be a false positive. R9 was educated and would not disclose where the drugs came from. No substance was found in R9's room. R9 agreed to substance abuse counseling. [DATE] R9 left the facility against medical advice. R9 could not be contacted during this investigation. Review of R10's progress notes document the following incidents and behaviors: [DATE] R10 very agitated. Noted R10 yelling and cursing at staff. Social worker noted resident with alcohol smell. R10 educated that if he continues behavior he will be sent out for psychiatric evaluation. [DATE] staff alerted that R10 maybe consuming alcohol. Resident is highly agitated and verbally aggressive. Resident smells of alcohol and refused to give a urine sample. R10 denies alcohol consumption. R10 was educated on how to behave appropriately in the community. Room search was completed with no findings. Due to suspicion of alcohol consumption and smelling of alcohol, R10 placed on two week community restriction. [DATE] social services met with resident to discuss noted aggression and signs of intoxication. At this time, resident appeared to be extremely agitated and combative. Resident denied any use of alcohol but continues to show signs and symptoms of use. In attempt to deescalate resident's aggression, resident appeared to have increased agitation. Social services met with the resident and was informed he will have community access restriction due to violating policy. He was also informed of the need to have an escort to access the community, as well as the need for substance abuse counseling. Resident understood but displayed agitation. [DATE] staff informed resident that keeping smoking materials is a safety hazard. A room check was performed, and no smoking materials were found. [DATE] resident was seen on the patio with his personal smoking materials on him during smoke break and refused to give activities his smoking materials. Social services met with resident. Resident seemed agitated. Resident refused to turn in his smoking materials and became verbally aggressive towards staff. [DATE] R10 stated he hates this place and he is going out for some real food, not this s**t. A pass was written for resident to go out for meal with resident returning back to the unit later in the evening around 9:00PM. At 9:30PM, resident was offered a breathing treatment and he became verbally aggressive with nurse on duty. Smell of alcohol noted on resident's breath. Resident educated on concerns of intoxication. [DATE] at 1:05PM, the building alarm sounded. The resident left the building and came back at 1:15PM. Staff searched his room and found a bottle of vodka liquor in his drawer. Resident's physician was notified for involuntary discharge. Awaiting response from his physician. [DATE] resident eloped from the facility yesterday for over an hour. Alcohol was found in resident's room. Resident was place on two week smoke restriction. [DATE] staff notified resident was smoking on the patio yesterday while on smoking restriction. Social services met with resident and encouraged him to comply. On [DATE] surveyor conducted interviews as follows: On [DATE] at 3:30PM, R2 stated, I witnessed a resident wheel over to the gas station and he met with his dealer. The police caught the dealer. The individual passed away. Whoever let him out had a lack of responsibility. There was a resident that is not here anymore, and someone handed drugs to the same resident. No staff was monitoring the patio when the drug deal occurred. I have seen other residents save their pain medication and switch it on the patio. There is so much that goes on here and it's not safe. On [DATE] at 3:40PM, R7 stated, R1 and I were roommates for six weeks. He had just turned 46 before he overdosed. We both had issues with substance abuse. I mind my own business. R1 went to a doctor's appointment and then he returned around 4:00PM. If anyone deserved pain pills, it was R1. He had [CONDITION(S)] on his leg. When R1 returned from the appointment, he laid on the bed and he was so depressed. He did not say a word, watch television or anything. At 6:30PM, R1 went to a party in R9's room downstairs. R8 told me that R1 was 'getting f****d up in R9's room.' You can be given [MEDICATION(S)] when you overdose on heroin. But if you overdose on cocaine, it's pretty much over. I had people coming up to my room trying to tell me different parts of the story. R1 died in an ambulance on the way to the hospital. R1 never did drugs in here. I would have told him to take it somewhere else. On [DATE] at 3:50PM, R5 stated, I have seen residents smoking pot. I know that a resident died from a [MEDICATION(S)] overdose that he got from another resident. I've seen alcohol that has been hidden in the ceiling tiles. I think the residents get alcohol from some of the staff. One of the workers still works here. I do not want to name any names. Tennis balls were thrown over the patio and a guy grabbed the ball and took it back into the facility. On [DATE] at 4:00PM R3 stated, R1 passed away. I have noticed residents nodding, like they are under the influence. The drug trafficking died down after R1 died . Everyone knows I'm clean. I do not know who brought the drugs in. On [DATE] at 4:05PM, R4 stated, I knew R1. I never saw him do drugs. I know that a tennis ball got thrown over the gate to a guy in a wheelchair. The tennis ball contained cocaine or heroin. R1 did whatever drug he got, and it was too much. V2 (Nursing Supervisor) tried to revive him. This was all over the nursing home. I cannot remember who told me about the tennis ball. There are staff that know about medication being hoarded by residents. I will not name any names. On [DATE] at 4:45PM, R8 stated, R9 killed R1 with drugs he got from his cousin to get his money. R9 dabbled with [MEDICATION(S)]. R1 used to carry a lot of money around and I never understood why. I was watching television and I saw R1 go into R9's room. This was after supper. R1 did not come out of the room for at least twenty minutes. I went to go check on R1. I know R1 had a drug problem. When I opened the door, R1 was slumped over in his wheelchair. R9 was slapping R1. I said, you killed R1. You overdosed him. R9 then said to me, 'Don't do this to me.' I notified the nurse immediately. I do not remember her name. R9 left the building and officers chased him down. When the police and V2 (Nursing Supervisor) were chasing him, R9 was discarding his drugs along the way. R9 was a wheelchair bound resident and could magically walk when he ran out of the building. He returned to the facility and signed AMA (Against Medical Advice) papers. Staff may not have known about R9 and his drugs. I believe that R9 talked R1 into buying a lethal dose of drugs. I know that R9's cousin smuggled drugs through tennis balls or through his food. On [DATE] at 1:00PM, V23 (Licensed Practical Nurse/LPN) stated, I was the nurse for R1. He was in my care for about one month before he was transferred. He spoke Spanish and I can speak Spanish. I could speak to him and understand what he was talking about. He had problem with pain due to surgery from his above the knee amputation. He would often get upset because he wanted an 'as needed' medication for pain. He wanted [MEDICATION(S)] and Oxycodone. I would tell him it's scheduled for every four hours. There was a couple of times he would try to hold it in his mouth, but I told him I need to see him swallow it and he would give the medication back to me. One time I smelled marijuana on him, and I verified this with another nurse. R1 said, 'Marijuana helps me better than [MEDICATION(S)] and oxycodone.' He was very difficult to manage. R1 was transferred to another unit after his return from the hospital. When R1 was transferred to the adjacent unit he was found smoking marijuana in his room one weekend. I was told that administration was informed. I know that alcohol has been found in R10's room before as well. On [DATE] at 1:47PM, V22 (Ombudsman) stated, I am not sure that V5 (Former Administrator) was even the administrator when these concerns were first brought to administration. I reported these concerns to V1 (Assistant Administrator) a week prior to the incident. I told her that there was rampant use of drugs and alcohol in the facility. I explained that the residents are concerned for their safety and well-being. There is alcohol being hid in the ceiling tiles. I was at the facility with the deputy ombudsman. I brought these concerns to administration. I told them that there is a resident, who wants to remain anonymous, who says that there is staff that buy residents alcohol to be their friends. The resident that told me this is a recovering alcoholic and does not need the temptation. There are drugs that are being brought into the facility. Administration has been very evasive. I was sending a lot of emails and they would bounce back to me. I believe that they were willfully interfering and ignoring me. The owner got involved and was very condescending about these serious issues in the facility. It's been long overdue. I have been reporting this to them since [DATE]. On [DATE], I was conducting on site visits. Almost every resident I talked to stated that it is a problem. Administration would not follow up with me. They would not give me information about R9. There is another resident I talked to. He would like to remain anonymous. He said that a housekeeper told him not to say anything, but there was a tennis ball with [MEDICATION(S)] coming out, laying on the floor next to R1 when he was found in R9's room. It is like administration does not want to do anything to help the residents. All of the residents I spoke to stated that they know drugs are being brought in from the outside. But they do not know who all of the players are. On [DATE] at 5:17PM, V2 (Nurse Supervisor) stated, R9 went out of the building without permission. He said he wants to leave the facility against medical advice. While the code was being performed on R1, an elopement call was announced. V16 (Nursing Supervisor) said half of the nurses need to continue the code and other half respond to elopement. Reception said R9 pushed the door and went out. I went out of building and ran after R9. He was headed west on the street. He stated that he wanted to leave. I explained to him that he had to sign some paperwork. He agreed to sign the paperwork. He dropped something in the grass. I asked him what he dropped, and he said forget about it. When he ran, I asked police to help us get him. A nurse escorted him back. I told the police that he dropped something outside. R9 was brought back and after looking for what he dropped, an empty plastic bag was found. On [DATE], at 11:19AM, V6 (Wound Nurse) stated, The state was here once and said there was a smell of weed. If he had something, he knew how to hide it. R1 had a wad of money. I asked him about the money. It has been a concern because we have been accepting more residents with substance abuse problems. Those are the residents that find ways to get things in the facility. The residents get crafty. They could put it in food or in tennis balls. It is hard to pinpoint trying to identify stuff. We have not had much training with residents who have substance abuse problems. The facility is accepting what they can get. Training could help staff to be prepared for residents like this. R1, R8, and R9 would be hanging out on the second floor. Residents are supposed to be closely monitored and watched if something is confiscated. On [DATE] at 1:30PM, V3 (Director of Nursing) stated, I do not recall any resident testing positive for an illicit substance through a urine test. If a resident does test positive, I would restrict community access, notify the doctor, and do room searches. An internal investigation would be done. I am not clear if that would be a reportable incident. Currently, there are residents in the building that have substance abuse problems. There are no incident reports for R1, R9, or R10. I do not see any documentation about [MEDICATION(S)] being offered. I do not recall doing in-services for substance abuse. No residents have doctor's orders to smoke weed in the facility. The importance of incidence reports is to help residents and the interdisciplinary team. On [DATE] at 1:54PM, V4 (Social Services Director) stated, Anyone with a history we always offer substance abuse counseling. We get a lot of refusals. Typically, we look for signs and symptoms of drug abuse. In-services used to be offered in person before COVID. After education and confiscation is counseling if offered. We talk to the residents. We have been informed to remove materials and complete an extensive room search each time. It is removed and education is done. The physician is always informed. If the urine sample comes back positive, more rounding should be completed. Involuntary petitions are done the moment when residents are a danger to themselves. I never found anything in R9's person. I cannot answer when I needed to send a resident out to protect residents. We stopped completing behavior contracts during COVID. It fell to the wayside. On [DATE] at 2:30PM, V8 (Social Worker) stated, From what I remember, there was marijuana, pills, and one needle in R1's room. The needle and pills were reported by nursing staff to V4 (Social Services Director) and myself. We confiscated the marijuana. It was a little bag. No other paraphernalia. The first time R1 refused to have us search. The next time the weed was found underneath his seat in his wheelchair. Nursing smelled marijuana. R1 admitted that he smoked marijuana and he did not see it as a problem. The room had an odor of weed. During smoke breaks, activity aides are supposed to be monitoring residents. They need to make sure residents do not have any contraband. I believe that residents get contraband because R1 did not leave the facility. I have not been training on drug paraphernalia. I would consider a needle drug paraphernalia. Honestly, I do not believe that R1 was being monitored since he was caught smoking weed on the patio. Staff is supposed to be monitoring the residents. We are supposed to have three social workers. It has been difficult to monitor residents with substance abuse problems. On [DATE] at 2:58PM, V9 (Nurse Practitioner) stated, I was aware that they had a history of substance abuse. I would refer to psych and/or pain specialist. I know R9 was referred to a specialist. I do not know of any policy on how to handle a resident with substance abuse problems. In my opinion, there should be a substance abuse program. Especially if they have a history of substance abuse. It is a big liability to admit residents with substance use problems. I do not think that they should be admitting residents without having a plan or protocol. The risk of drugs and other medications being taken together is [CONDITION(S)], [CONDITION(S)], falls. The combination is not good. R9's drug combination was not approved by be. R9 was requesting [MEDICATION(S)] with a [CONDITION(S)]. I do believe that R9 was drug seeking. I informed him that I could not give him any more pain medications. On [DATE] at 1:00PM, V11 (Registered Nurse) stated, I heard that R9 tried to pretend to take a pill. I do not know anything about R9's history. I knew that R1 had a history of addiction. I am not aware of any other protocols. I have not received any training on how to care for a resident with substance abuse problems. Any type of training is better than nothing. It seems like the past six months we have been receiving more residents with these backgrounds. On [DATE], at 1:08PM, V12 (Medical Director) stated, I am familiar with the incident with R1. It was part of his history that he had substance abuse issues. He wanted more narcotic medication. I am not sure about the protocol. I do not recall if I was notified if residents were ever using illicit substances. I completed the death certificate. The cause of death is listed as substance abuse. I do not recall being notified about the incidents that have been occurring in the facility. On [DATE] at 1:25PM, V13 (Nurse Practitioner) stated, I was the nurse practitioner for R1. I was aware of R1's substance abuse background and alcohol abuse. Usually they are referred to the psychiatrist. I did refer R1 to see a pain specialist. I do not recall the facility notifying me of any incidences or occurrences in the facility. I was not aware of the marijuana, needles, or pills. I am not familiar with the policies of the nursing home. On [DATE] at 2:36PM, V14 (Certified Nursing Assistant/CNA) stated, Residents came in and out of R9's room because he sells snacks and pop. I heard residents talking that R9 was selling drugs after R1 died . They would go into his room for snacks, but we really did not know what they were doing. I do not recall alerting administration. I did not tell anyone because I am not sure if it was going on. No one ever informed me about his history. I never saw any drug paraphernalia. He kept his door closed all the time. He was independent. Independent residents should be monitored. R1, R8, and R9 always hung out. R8 is a former alcoholic. On [DATE] at 3:19PM, V15 (LPN) stated, I do not remember being informed R1 had a history of substance abuse. There is supposed to be a staff member outside to monitor the residents when they go on the patio to smoke. V2 (Nursing Supervisor) and V16 (Nursing Supervisor) were the supervisors that confiscated the items from R1. They told me that they had found the drugs and locked it up for social services to talk to him about. This happened on the 4th floor. R9 liked his door closed. I do not know of receiving any in-services on residents that have substance abuse history. On [DATE] at 3:52PM, V2 and V16 stated, V15 (LPN) was passing 9:00PM medication outside of R1's room. There was a strong cigarette smell. There is a no smoking policy in the facility. She paged V2. V15 said the cigarette smell is coming from R1's room. I called V16 because I needed a witness. We called V17 (CNA) to go with us. When we went in the room, it did smell like cigarette smoke. The strong smell was in the bathroom. We asked R1 how he lit up his cigarette. The lighter is kept with the receptionist. I asked him where is lighter. R1 denied it. I told him that we have oxygen in the building. R1 said to go ahead and search. We started searching. R1 had big winter coat and I felt a lighter. I asked him how he got the lighter in his coat. He said he didn't know. He opened the seams and put the lighter in the open seem. He had more baggies. There were less than ten baggies. They had pink plastic and white powder was inside of them. There were more than five baggies. It was remnants of powder. Some have remnants of white powder and dry leaves. He had a lot of cash in his pockets very thick with twenty-dollar bills. We asked him what it was, and he said he did not know. V16 and I put the items in a plastic bag and put in the narcotic box. The next day I gave it to the social worker. We knew that R1 had a history of drug abuse. I do not remember if V12 was notified. V20 (Nurse), the morning supervisor, did not tell us what to do. The nurses know that they are supposed to be monitoring him. There was no directive on how to proceed. I am not sure if it was before or after. There have not been any in-services on how to deal with residents with substance abuse issues. I remember handing the baggies off to a social worker. I did not hear any gossip. No one ever said anything about R9 selling drugs. On [DATE] V4 (Social Services Director) stated, Typically if we confiscate contraband, we lock it up or throw it away to make sure that no one else gets it. We document it. I do not recall those items being handed to me. I do not remember those items being physically handed to me. It could have been an instance where they showed me, and I said throw it away. We never got the police involved. We throw it away and offer substance abuse monitoring and doing more rounding. When I went into R9's room, I never found anything. I did see a large box full of snacks. On [DATE] at 4:19PM, V17 (CNA) stated, I saw money; it was a lot of money. I did not count it. I saw a lighter. There were baggies. This happened on the 3rd floor. Sometimes I provided care to R1. I do not work with R9. On [DATE] at 6:19PM, V19 (Nurse) stated, I was in the middle of passing medication. R8 said he wanted to tell me something. R8 is a resident who resides on the same unit with R9. I explained to the CNA that I was passing medication. I asked her to go see what he needed. V14 was the CNA on duty. V18 (Nurse) was informed. V18 and R8 headed back towards R9's room. I asked V18 what was going on and she said nothing. That is when I proceeded to follow them. They were discussing something. When I went to the room with V18, it was hard to get in the doorway because R1's wheelchair was blocking it. V18 squeezed in first. I proceeded after her. When I saw R1, he was slumped over in his wheelchair. When I went to lift him up, there was some vomit on him, and I noticed his fingers were blue. V18 and R9 were discussing something. V18 started asking questions while I was attending to R1. I only heard a little bit of the conversation. R9 stated that R1 was sleeping. I did not see any drug paraphernalia. His bed was moved to the side and I did not see anything. A code blue was called. The rapid response team came. There are residents in the facility with substance abuse problems. The facility was unable to locate or find documentation pertaining to what happened to the confiscated materials and unidentified substances. The facility currently has twenty-six residents who have substance abuse problems and/or histories. There are no incident reports found pertaining to any of these events. There is no documentation that the police were ever contacted. R1's care plan interventions include: assess for safety and offer assistance; staff will do routine rounds to resident's room to make sure resident room is free of contraband; staff will encourage resident to attend psych therapy services; staff will educate and encourage resident to comply to facility drug policy. R9's care plan interventions include: record behaviors and monitor patterns of behavior; initiate non-pharmacological interventions for behaviors and monitor effectiveness; conduct a community safety skills evaluation as necessary to further assess the residents ability to negotiate safely outside of the nursing facility; assist the resident in locating an appropriate treatment provider and making the initial appointment; maintain on-going communication with the provider; place outside provider documentation in an accessible location; use a variety of approaches to gain the resident's confidence and increase motivation to engage in beneficial interventions; record behaviors and side effects; implement an appropriate safety plan; conduct a review of past behavior and evaluate potential for aggressive/inappropriate/high risk behavior; follow facility protocol addressing substance abuse; evaluate ability to control impulses. R10's care plan interventions include: assure the resident is in a safe environment; resident will attend substance abuse group counseling at least one to two times a week; reinforce facility rules and impose consequences as needed and appropriate; record behaviors and monitor patterns of behavior. The surveyor confirmed through observation, interview, and record review, that the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE], [DATE], [DATE], [DATE], and [DATE], all staff were in-serviced in person or by telephone by V24 (Administrator) and V3 (Director of Nursing). All staff were in-serviced on the facility's policy and procedures to prevent contraband, such as drugs and alcohol in the facility. Staff were also in-serviced about residents who have known substance abuse history must have their person/belongings searched whenever they are entering the facility. 2. On [DATE], all staff (nursing, reception, maintenance, dietary, social services, activities, interdisciplinary team, therapy[TRUNCATED]

Based on interview and record review, the facility failed to follow the plan of care for a resident by failing to provide an escort while outside for a resident identified as requiring supervision when out of the facility due to known fall risk. This failure resulted in one (R69) resident having a fall with an injury which required five sutures to the forehead. Findings Include: R69 was admitted to the facility on [DATE]. R69's [DIAGNOSES REDACTED]. R69's hospital records document he had a fall on 07/04/19 with a laceration. The facility's investigation report dated 07/04/19 documents: (R69) attempted to go down the facility's outside ramp without assistance and lost control which resulted in a fall with injury, was sent to the hospital and returned to the facility with 5 sutures; the conclusion of the root cause analysis for R69's fall incident 07/04/19 at 11:30AM was that he went out of the building without supervision. 11/06/19 01:39 PM V25 (Receptionist) stated, (R69) was sitting on the patio area in front of building by himself and went down the ramp in July. V25 further stated as she noticed him going down the ramp, she called a code and all staff available assisted. V25 stated, R69 lost control of chair while on ramp. After incident he was not allowed out without an escort. 11/06/19 01:17 PM V23 (Social Services Worker) stated, (R69) can go out with social services or CNAs, nursing, and/or activities. R69's community pass privilege assessment documents due to [DIAGNOSES REDACTED]. R69 has periods of confusion at times. For sake of safety we assessed him for use of an escort, as noted by R69 experiencing a fall when out by himself. R69's physician order [REDACTED]. R69's fall risk assessment dated [DATE] documents a high-risk score of 40 for falls. R69's fall care plan dated 03/26/19 documents R69 had a history of [REDACTED]. R69's current care plan effective, 03/07/18 to present, documents interventions including resident will utilize escort while in the community .related to compromised mental health status, neurological disorder, and compromised medical status. R69's current care plan, effective 05/29/18 to present, documents interventions including notify the nurse or social service departments of attempts to leave the building and resident will not leave the facility unescorted by a responsible person in the next 90 days. On 11/07/19 at 11:23 V26 (Nurse Practitioner) confirmed that (R69) received 5 stitches on the left side of his forehead due to injury obtained when he fell outside. V26 stated, (R69) is a fall risk and should be supervised if outside on his own .somebody should probably be with him. 11/07/19 11:58 AM V23 (Social Worker) stated, (R69) doesn't exhibit exit seeking behavior. The facility's fall management guidelines policy documents: Some risk factors or conditions that may predispose a patient to fall may include but are not limited to: musculoskeletal conditions, history of falls, unsteady gait, muscle weakness, stroke, age over [AGE] years, cognitive impairment, dementia.

Based on observation, interview and record review, the facility failed to follow its pain assessment policy by not ensuring a resident was assessed for pain at least each shift for acute pain. The facility also failed to follow its medication management policy by not providing scheduled pain medication to a resident. These failures affect one of three residents (R3) reviewed for pain in a total sample of 23. As a result, R3 was allowed to have a self-reported pain level of 30 on a 1-10 pain scale. Findings include: R3 is a [AGE] year old male admitted on [DATE] from a long-term care facility with [DIAGNOSES REDACTED]. R3's Physician order [REDACTED]. On 9/25/18 at 10:45am, R3 stated, I have not been given the [MEDICATION NAME] Extended Release for the last few days. I was told by the nurse they have not received the pain medication from Pharmacy because of problems between them and the Pharmacy. On a scale of 1-10, my pain level is at 30. I am constantly in pain due to my spinal stenosis from a car accident. The nurse gives me [MEDICATION NAME] when I ask for it. The [MEDICATION NAME] relieves my pain for only about three hours; I have to wait for another three hours to have another [MEDICATION NAME] because it is given every six hours. The nurse does not come in often to ask about my pain. I need the [MEDICATION NAME] Extended Release to be medicated on a constant level. On 9/25/18 at 12:05pm, V11 (LPN/Licensed Practical Nurse) stated, The resident has a medical condition that causes him pain. He is on [MEDICATION NAME] PRN (as needed) every 6 hours and on [MEDICATION NAME] ER. The policy is to ask him about his pain in the morning and check with him every two hours after that. When I came to work yesterday from being off a few days, I noticed there is no [MEDICATION NAME] ER left for the resident. I notified the Director of Nursing and followed up with Pharmacy. I was told by Pharmacy that they needed the script. I made the script and had the Nurse Practitioner sign it and faxed it to Pharmacy. On 9/26/18 at 12:10pm, R3 stated, I still have not received the [MEDICATION NAME] ER. This is the 4th time they ran out of it since February. During the last few days, the pain has affected me both physically and mentally. I have lost my appetite and feel edgy and [***] y; I don't like how I feel. This writer noted R3 becoming tearful while describing how the constant pain is affecting him. On 9/27/18 at 11: 45am, V3 (DON/Director of Nursing) stated, I was informed on the 24th by V11 about not having the [MEDICATION NAME] ER for the resident. The resident is prescribed to have the [MEDICATION NAME] ER twice a day, at 9am and 9pm. The extended release pain medication acts for an extended period of time. We normally received 60 tablets but because of insurance problems, we only received 14 tablets on 9/10/18. The nurse who signed off on the medication on the 10th should have contacted the supervisor or myself. We would have communicated with Pharmacy and the attending physician earlier. I believe the resident has experienced pain because he did not get the pain medication he needs. Before administering pain medication, the nurse must complete a pain assessment. Nurses should be checking every two hours and PRN for pain. On 9/27/18 on 1:30pm, R3 stated, I received the [MEDICATION NAME] ER last night around 9:30pm and this morning. I feel a lot better and have gained my appetite back. This writer noted R3 ate 100% of his lunch. A review of Resident Vital Sign Reports indicates pain assessment not completed on the following dates/shifts: 9/22/18 am shift, 9/22/18 pm shift, 9/23/18 am shift, 9/23/18 pm, 9/25/18 pm shift. A review of Controlled Substances Proof of Use records indicates R3 was not provided with the prescribed [MEDICATION NAME] on the following dates/times: 4/19 am, 4/19/18 pm, 5/15/18 pm, 5/16/18 am, 7/11/18 pm, 8/21/18 pm, 9//22 am, 9/22/18 pm, 9/23/18 am, 9/23/18 pm. 9/24/18 am, 9/24/18 pm, 9/25/18 am, 9/25/18 pm, 9/26/18 am. Care Plan report reads, Problems: (resident has alteration in comfort: pain r/t (related to) musculoskeletal impairment secondary to [DIAGNOSES REDACTED]. Goal Date: 10/30/18 . Interventions: Assess and Monitor for nonverbal indicators of pain . Administer and monitor for effectiveness and for possible side effects from medication . Pain Assessment and Management policy revised (MONTH) 2010 reads, General Guidelines: .6. Assess the resident's pain and consequences of pain at least each shift for acute pain. Medication Management Orders Management: Medication and Treatment Orders dated 3/17/2016 reads, Guideline: .Complete medication orders are obtained for medication(s) and/or treatment(s).

Based on observation, interview, and record review the facility failed to monitor and supervise two residents (R7, R8) to prevent the elopement of the resident. The facility failed to follow a resident's fall care plan and fall management policy by not frequently monitoring and evaluating one resident (R23) resulting in a hospitalization with fracture. The facility also failed to implement fall interventions to prevent one resident (R17) from frequently falling. These failures affect 4 (R7, R8, R23, R17) of 9 residents reviewed for accidents/incidents &supervision, in a sample of 23. These failures resulted in R23 sustaining a right femur fracture requiring hospitalization and treatment. Findings include: 1. R23 is a [AGE] year old male admitted to the facility on [DATE] from local acute care hospital with admission [DIAGNOSES REDACTED]. MDS (Minimum Data Set) dated [DATE] reads .Section C: Cognitive Patterns, Brief Interview for Mental Status (BIMS) .C0500. Summary Score: 05 (indicated cognitively impaired) .Section G. Functional Status: G0110. Activities of Daily Living (ADL) Assistance: .B. Transfer: 3 (Extensive Assistance)/2 (One person physical Assist), C. Walk in room: 2 (Limited Assistance)/2, D. Walk in Corridor:,[DATE] .G. Dressing: ,[DATE] .I. Toilet use: ,[DATE] .G0300. Balance During Transitions and Walking: 2 (Not steady, only able to stabilize with staff assistance) . Care Plan Report effective [DATE] - Present reads, Problems: Resident is at risk for falls: (resident had a fall on [DATE] . on [DATE] . Effective: [DATE] - Present .Interventions: .Monitor resident toileting patterns . Frequently check resident for toileting need . Care Plan Report effective [DATE] reads, Problems: The resident is disoriented to place and time .this resident has problems with decision making, insight, logic, calculation reason, planning and judgment. This problem is related to a [DIAGNOSES REDACTED].Provide reality based orientation information throughout the day to help the resident increase his/her comfort level and awareness of the environment . Care Plan Report effective [DATE] to present reads, Problems: Resident is at potential risk for exit seeking . Interventions: .Staff will monitor resident . A record review indicates the following: R23 was hospitalized from [DATE] - [DATE] as a result of an unwitnessed fall which occurred in the facility. R23 returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. Quality assurance review dated [DATE] reads, .Root-Cause Analysis: Resident wandering in his room . R3 was hospitalized from [DATE] - [DATE]. R23 returned to the facility on [DATE]. Hospital record dated [DATE] reads, .History and Physical Note: .Discussed with another RN (Registered Nurse) who was able to provide limited information per chart review - patient's nurse found him laying in bed grimacing and unable to respond to questions. He was unable to move his right leg. Significant deformity of right leg was noticed at the time. There is no documentation of a fall .Of note, patient recently had ORIF (Open Reduction Internal Fixation) of right leg on [DATE] after resulting in minimally displaced intertrochanteric [MEDICAL CONDITION] femur . He has presented to the ED (Emergency Department) several times with falls unwitnessed per NH - most recently on [DATE] with laceration to right forehead . In the ED, X-ray of right femur showed spiral fracture shaft of right femur with lateral displacement of distal fragment. CXR (Chest X-Ray) showed several acute left-sided rib fractures .orthopedic surgery was consulted with plan for ORIF of right femur this afternoon . MD (Medical Doctor) note dated [DATE] reads, .This patient has sustained a right hip periprosthetic midshaft femur fracture at the level below a previous cephalo-medullary short nail that was placed about two months ago. The patient is non-verbal and it is not clear how long he has had this fracture for. Certainly he has sustained serious life-threatening injury and has experienced substantial blood loss from the fracture .he is becoming hypothermic and will need blood . State Report faxed to state agency dated [DATE] reads, .Analysis/Conclusion: .After staff were questioned, it was determined that the resident had a previous right [MEDICAL CONDITION] which may have caused the right hip to be weakened in nature and not completely healed thus during routine care the right hip broke again . Quality Assurance Review dated [DATE] reads, .Root-Cause Analysis: .resident sometimes does attempt to walk with unsteady gait or sitting on the edge of the bed . On [DATE] at 10:30am, V3 (DON/Director of Nursing) stated, On [DATE] around 5:30am, the nurse noticed the resident going in/out of bed and put resident in a geriatric chair by the nursing station. At 6:30am, the resident was transferred back to bed, ADL (Activities Daily Living) provided and breakfast given. On [DATE] at about 11pm, the nurse noted the resident has a swollen right thigh. MD (Medical Doctor) and nurse supervisor were notified. The resident was transferred to the hospital on [DATE] and was discharged on ,[DATE]. The resident had a previous fracture on [DATE] from a fall and was hospitalized from [DATE] to [DATE]. My conclusion from my investigation is the resident's hip was re-fractured during routine care due to resident's [MEDICAL CONDITION] is not totally mended from the last fall. On [DATE] at 9:45am, V17 (R23's attending physician) stated, Based on the chest x-ray result of multiple acute rib fractures and right femur fracture, the resident might have had a fall in the facility. Normally routine care won't cause that kind of injury unless the resident is non-compliant and gets up suddenly during the delivery of routine care. Only a fall can cause that kind of injury. On [DATE] at 11:50am, this writer noted R23 in bed wearing only an incontinence brief. R23 is alert and oriented to self only. V23 (CNA/Certified Nursing Aide) stated, The resident removed his blanket every time I tried putting it on him. This writer requested V23 to make another attempt to place a blanket over R23. R23 did not resist and soon fell asleep. On [DATE] at 11:55am, V23 stated, The resident is a one-person assist in ADL care and in transferring and walking; his gait is not steady. He held onto his side rail when I changed him but he released his hand and allowed me to change him once I gently rubbed his hand and explained to him what I am doing. He was not fighting or trying to get up. On [DATE] at 12:25pm, V24 (CNA) stated, I took care of R23 on [DATE] from 3p -11p. I changed his incontinence brief twice with the help from another CNA. The resident was cooperative, not combative or trying to get up in the middle of the care. On [DATE] at 2:42pm, V3 stated, After reviewing the hospital record from ,[DATE] to ,[DATE], I agreed that the resident had a new fracture from the last incident. The resident has low safety awareness due to his dementia. Nursing staff keep residents under observation and watch for behaviors such as exiting bed and unsteady gait, but I have no tool of frequent monitoring. Fall Management Guidelines issued ,[DATE] reads, .Fall occurrence: .Frequent monitoring and evaluating of the resident is important to evaluate response to intervention and identification of any changes .these evaluation findings are recorded in the clinical record . 2. The facility presented fall log document that R17 had a fall happen on [DATE] with scratch, [DATE] with no apparent injury, and [DATE] with skin abrasion. Record review of facility fall log documents that R17 had unknown injury of bruise/skin tear documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review on care plan documents care plan was revised after each fall. On [DATE] at 9:50 AM V3 stated, The purpose of revising care plan after fall incident is to implement new interventions to prevent future falls. If the patient is falling again, that means interventions are not effective to prevent fall. On [DATE] at 1:15 PM, surveyor observed R17 moved to second floor and no floor mattress was in place at bedside as per fall care plan. On [DATE] at 10:10 AM, observed R17 with healing brown marks with right thigh and left small finger swollen. Record review on clinical record indicates that these injuries were recorded as self-inflicted. Record review on facility presented Fall Management Guidelines dated on ,[DATE] document: The resident's plan of care is revised to identify intervention/changes based on initial evaluation and possible cause of fall. Frequent monitoring and evaluation of the resident is important to evaluate response to interventions and identification of any changes. 3. R7's care plan, undated, documents that R7 has dementia and wandering behaviors. R7 is an elopement risk and the facility is to provide a wander guard. R7 has the physical and mental capability to find the way out of the facility, but evaluation indicates that R7 cannot thrive safely outside of the facility unescorted. Incident report dated [DATE] documents R7's elopement from the facility. Event description dated [DATE] documents that R7 (a resident with frequent wandering behavior, verbalizations of wanting to return home, and prior attempts to leave the facility unescorted) was sitting in the theater area on the first floor. The nurse on duty notified V27 (former facility receptionist) that R7 was at risk for elopement and not to let R7 come near the front door. V27 stated that R7 would not come near the front door if she was at the front desk. At 10:30PM, R7 was not able to be located in the facility. An elopement code was called. Staff began search internally and externally for R7. The physician, V1 (Executive Director), and state guardian were notified. A police report was filed. After review of the facility security video system, it was discovered that at 7:34PM, R7 left his room with a checkered coat and hat on. At 8:07PM, R7 exited the theater area and went to the patio. At 9:16PM, R7 climbed over the patio fence and took off walking down the street. It was determined that the patio exit was not armed with a wander guard transmitter. R7 returned to the facility and expired under hospice care [DATE]. Statement dated [DATE] notes that V27 stated, R7 went missing last night. I was notified by nursing staff that R7 had left the floor and I was not supposed to let him leave. I did not see R7 physically approach the desk area. To my knowledge, R7 was in the theater room and I never saw him approach the patio. On [DATE], at 10:49AM, V1 stated, R7 has behaviors before he eloped. If staff was out on the patio, R7 would not have eloped. On [DATE] at 11:34AM, V1 stated, If a wander guard system was by the patio door, R7 could have been monitored. There was no wander guard system in place. The facility relies on reception or staff to monitor residents. R7 had dementia. R7 stayed in the dining room and then sat on the patio for almost an hour or less. R7 then decided to jump over the fence. There is a camera on the patio that is monitored by the receptionist. V27 was given instruction that R27 was down in the dining room and he needed to be monitored. V27 said she did not see R7 go to the patio door. Residents can be physically and mentally harmed if/when they elope. Root cause analysis documents, undated, note that that nursing staff should not have allowed R7, who was an at-risk resident, to be left unsupervised. There was a lack of communication between staff as to where R7 went and if he had left the building. V27 should have not been left in charge of monitoring R7 due to the high activity at the reception desk. It was noted that the wander guard system is inconsistent in sensing the transponders. There was not a wander guard transmitter on the exit door of the patio. Staff did not follow the policy in regard to elopement search and procedures. There was a breakdown in communication and verification of residents, which caused the initial search procedures/codes to be delayed. The nurse assigned did not follow facility procedures to account for all of her residents at the start of the shift. Communication among staff about R7's location was not adequate. R7 was at high risk for elopement and should not be left in an environment that was not frequently monitored. Event description documentation dated [DATE] documents that at 8:40AM, R8 was not found in her room. A search was initiated. A code yellow was called. The physician was notified and staff initiated a community search with no findings. At 10:50PM, R8 returned to the facility. R8 was very confused during the interview, but was able to recall some of the elopement. On [DATE], AT 1:19PM, R8 stated, I do remember leaving the building for pizza. On [DATE] at 11:24AM, V28 (Maintenance) stated, I did not notice R8. R8's wander guard did not go off. I was talking with someone else at the receptionist desk. R8 went out with another resident who can leave the facility. I opened the door for that resident sometime in the afternoon. I did not notice that R8 had left. The wander guard was not working. I should have been more alert and should have made sure the wander guard was working. Care plan for R8, undated, documents that R8 is at increased risk for exit seeking. Community Pass Privilege assessment dated [DATE], documents that R8 is at risk for elopement. R8 experiences cognitive deficits that would make it necessary for R8 to use an escort in the community at all times. Exit Seeking Risk Screen, dated [DATE] notes that R8 has a [DIAGNOSES REDACTED]. Root cause analysis documents, undated, note that there was a lack of communication between staff as to where R8 went and if she had left the building. Reception should not have been left in charge of the monitoring of R8 due to the high activity at the reception desk. Staff did not follow the policy in regard to elopement search and procedures. There was a breakdown in communication and verification of residents, which caused the initial search procedures/code to be delayed. Communication among staff about R8's location was not adequate. Facility policy dated (MONTH) 2008, documents that staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If an employee observed a resident leaving the premises, he/should attempt to prevent the departure in a courteous manner.

Based on interview and record review, the facility failed to assess and identify a deep tissue injury and failed to follow their care plan interventions by not notifying Nurse or Physician of skin changes for 1 of 3 residents (R2) reviewed for pressure sore development. This failure resulted in one resident (R2) acquiring a deep tissue injury developing into a stage 4 pressure ulcer that became infected and required hospitalization . Findings Include: The medical record documents R2 as a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 was discharged to a local hospital on [DATE] and no longer resides at the facility. The first progress note addressing the sacrum wound for R2 is 9/1/17 by V5 RN (Registered Nurse) documents: Staff attention was called the resident's sacrum, when assessed no dressing was in place, staff cleaned the wound with NS (normal saline) dressing applied. Will continue to monitor. Endorse to the next shift to notify wound nurse. Progress Note for R2 dated 9/1/17 by V9 Wound Care LPN (Licensed Practical Nurse) documents: unstageable ulcer noted to sacrum/coccyx. Foul smell noted. Per MD (Medical Doctor) stat (immediate) wound culture, stat CBC (complete blood count ), cmp (comprehensive metabolic panel ), start IV ( intravenous) ABT (antibiotic therapy) Vanco ([MEDICATION NAME]) 1 gram x 1 dose, then [MEDICATION NAME] 3.37 gm Q8H (every 8 hours) X 10 days, 0.9 NS (normal saline) 100 cc (centimeter) per hour x 2 bags. Air mattress ordered and in place. Order Dakins solution moist gauze BID (twice a day). Education provided regarding the importance of turning and repositioning. Resident's family was notified of wound and new orders and gave verbal consent for orders. Family gave consent for PICC line (peripherally inserted central catheter) if needed. The Weekly Pressure Ulcer Evaluation report dated 9/1/18 for R2 documents suspected deep tissue injury sacrum/coccyx measurements length 7.00 cm (centimeter) by width 8.00 cm by depth 1.60 cm. On 4/17/18 at 11:00 AM V9 Wound Care LPN stated, 9/1/17 was the first time I saw the wound (R2's sacrum/coccyx). It had not been reported to the wound team. It looked bad and it smelled bad. I notified V13 PCP (Primary Care Physician ) at once and was given orders. The wound had to be there awhile. I remember the 11:00 PM to 7:00 AM Nurse reported to the 7:00 AM to 3:00 PM Nurse, who reported it to me. This wound was upsetting to me. The CNA (Certified Nursing Assistant) or Nurse should notify the wound care team immediately when there is a wound. On 4/17/18 at 3:00 PM V5 RN stated, R2's wound had an odor, slightly open. I only worked that day, I'm not a regular. I didn't see that patient (R2) before. On 4/17/18 at 10:30 AM V8 Wound Care Coordinator LPN stated, My understanding is the nurse and CNA didn't report the wound to the wound care team. I believe there was an investigation concerning R2's wound. I was not involved in the investigation. I don't know how a wound gets that big unnoticed. On 4/19/18 at 1:10 PM V1 Administrator stated, We did do an investigation concerning R2's pressure ulcer. We terminated a (V16) CNA (Certified Nursing Assistant ). V16 stated he/she saw a blister on R2's sacrum about two weeks before 9/1/17 and did not report it to anyone. V16 stated he/she didn't think it was anything. That is why V16 was terminated, because the skin condition was not reported. The CNAs have been instructed to report all skin changes to the Nurse. Progress Note dated 9/4/17 for R2 documents, relayed lab results to MD (Medical Doctor) with orders to send resident to hospital. laboratory results dated [DATE] for R2 document white blood cells 19.7 H (high) normal range 4.8-10.8. Wound Culture result dated 9/5/17 for R2 documents specimen sacral proteus mirabilis moderate growth, enterbacter cloacae light growth. On 4/18/18 at 11:15 AM V13 PCP stated, It's hard to believe an unstageable wound gets that big overnight. There had to be something there before, especially if it was infected. The wound may have been the cause of the acute kidney injury (dehydration); infection is usually the cause. I had heard there was an inquiry into this wound. Local hospital V17 admission medical records document on 9/4/17 R2 had a stage 4 sacral pressure ulcer. Laboratory creatinine (kidney function) value of 0.3 low, normal range 0.7 - 1.3. white blood count 14.54 high. The admitting [DIAGNOSES REDACTED]. R2's Care Plan dated 6/25/17 documents: R2 is at risk for impaired skin integrity related to incontinence of bowel and bladder. Interventions include: Report changes in skin status to physician. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing and daily care. The MD'S (Minimum Data Set) for R 2 dated 9/12/17 documents Section C Cognitive, decision Making as severely impaired. Section G Functional Status, bed mobility as total dependence with a two person assist, transfer as total dependence with a two person assist.

Based on interview and record review the facility failed to implement an intervention for fall prevention as care planned for a resident, monitor and supervise a resident left alone in a room with a behavior of standing without assistance and have an element in place to reduce injury from an impact of a fall while a resident is sitting in a chair. This failure applies to 1 of 3 residents (R9) reviewed for falls, in a sample of 10. As a result, R9 fell from a chair while in a room unsupervised by a staff member. R9 sustained a laceration requiring sutures and an acute subdural hemorrhage. Findings include: An incident report entitled State Report dated [DATE] at 1:15pm stated, At around 1:15 pm, resident (R9) had a fall incident. According to initial reports resident has been requesting to be placed in chair instead of being in bed, and a few minutes while sitting, attempted to stand and fell , NOD (nurse on duty) noted a change in condition and mentation. Immediate action taken included sending R9 to a local hospital. The emergency department nursing assessment dated [DATE] documented for clinician history of present illness: Laceration is the result of impact from direct trauma. Laceration caused by fall [DATE]. Computerized tomography (CT) of brain at receiving hospital done on [DATE] at 7:48 pm notes, Comparison: CT brain performed at an outside institution [DATE] 4:54 pm. Findings: Relatively stable large, high density extra-axial collection consistent with acute subdural hemorrhage (new brain bleed). According to R9's hospital emergency department nursing transfer form entitled Patient Discharge Transition Record dated [DATE], R9 had a primary [DIAGNOSES REDACTED]. This document also documented R9 had a laceration. The laceration was described as an uncomplicated horizontal laceration located over the right side of forehead which is 1cm (centimeter) in length, and the skin closed with 3 sutures. According to the hospital's transfer consent form R9 was transferred to another hospital critical care unit (CCU) on [DATE] at 18:30 (6:30pm). R9's face sheet on admission to the facility lists the following [DIAGNOSES REDACTED]. Nursing note on admission to facility dated [DATE] at 12:36 am includes additional [DIAGNOSES REDACTED]. Facility nursing admission note of [DATE] documents a fall with subdural hematoma occurred on ,[DATE]. Additional documentation titled EP (electrophysiology physician) from post [DATE] fall on [DATE] indicates R9 suffered CVA (cerebral vascular accident) in ,[DATE] and has been having seizures from it. Original admitted to facility listed on face sheet is [DATE] with a date of birth of [DATE], making R9 [AGE] years old at the time of his death. R9 is at high risk for falls based on [DATE] fall risk assessment and has upper body ability to move based on fall out of bed of [DATE]. On [DATE] at 1:25 pm via telephone, E12(Assistant Director of Nursing) agreed [DATE] fall risk assessment score placed R9 at high risk for falling. Mobility section of risk evaluation and screening tool has section titled Rising from Chair notes an increase in key risk factor for fall if pushes up with arms. R9 had 2 falls based on nursing documentation and incident reports on [DATE] and [DATE] while in the facility. [DATE] nursing note at 6:55 am described an unwitnessed fall out of bed onto right side of bed. R9 explained reason for fall as, I fell when I tried to go to work. This fall did not result in any injuries. R9 has some ability to move as he was able to fall out of bed on [DATE] and fell on [DATE] while sitting in a chair. Neurological evaluation flow sheet of [DATE] at 1:15 pm notes R9's hand grasps as equal and Minimum data set completed [DATE] with an assessment date of [DATE] denoted R9 had cognitive impairment and needed physical assistance for bed mobility, transfer and walking. Z12 (Attending physician for R9) on [DATE] at 4:25 pm via telephone described R9 (whom he saw 3 times) as confused, screaming all the time, and unpredictable. Additional nursing notes previous to fall indicate R9 was confused and exhibiting agitated behavior. [DATE] 3:51 pm note indicates R9 constantly trying to get up and out of bed. Resident educated on the importance of not trying to get out of bed due to resident being unstable with standing. Resident continued to try to get out of bed [DATE] at 5:32 pm, At 3:00 pm resident noted physically aggressive and agitated pulling [DEVICE], LVAD (Left ventricular assist device) tube and trying to climb out of bed. [DATE] at 5:34 pm, At 3:00 pm resident noted physically aggressive and agitated screaming, yelling, pulling [DEVICE], LVAD tube and trying to climb out of bed. On [DATE] at 7:00 pm resident noted physically aggressive and agitated screaming, resisting patient care from CNA's, yelling pulling [DEVICE], LVAD and trying to climb out of bed. On [DATE] at 6:41 pm resident is alert and confused . [DATE] at 10:07 pm R9 is described as, alert, with bouts of confusion .on lo bed due to fall risk. [DATE] nursing note indicated R9 was sent out to hospital for replacement of Gastrostomy tube (feeding tube). E8 (Licensed Practical Nurse) who consistently worked dayshift of section where R9 resides stated on [DATE] at 11:26 am, worked with him (R9) full time On admission pretty antsy; trying to stand up majority of time from bed. Unsteady on feet. Unable to use call light for help. He didn't know where at or time. Would respond to name. No safety awareness. Told him please sit down; would continue to try and get up; stand up. Not daily, times when calm with eyes open. No way of knowing when he was going to try to get up. He was unpredictable and impulsive. Not redirectable. Day of R9 fall of [DATE], E8 continued her statement describing R9 as antsy, Unsteady on feet. Unable to use call light for help. He didn't know where at or time. Would respond to name. No safety awareness. Ativan would work off and on. Ativan didn't work day of fall and other times where it hasn't worked. Did not have chair alarm on (day of fall). Bed pads (yes). Chair, no pad on floor. Ativan would work off and on; and in room 209 right across from me (day of fall). Med cart there. I could turn around and see him. Preparing meds (medications) for patient. While in room reclining just sitting there. Reclined looking at t.v. He's calm He's unpredictable. He's sat in (type of) chair in room; been calm while watching t.v. He's also sat in (type of) chair, gotten agitated without warning. Took 60 seconds for him to fall. I walked away. E8 stated she was right outside of R9's room with her back turned when R9 fell . R9's fall care plan with goal date of [DATE] states problem of risk for falls R/T (related to) poor safety awareness, poor judgement of mobility limitations has interventions which include: Use fall risk screen to identify risk factors, Report falls to physician and responsible party, Remind resident and reinforce safety awareness. E8 stated R9 had no safety awareness and problem statement includes assessment of poor safety awareness. Intervention to remind resident and reinforce safety awareness in a resident with cognitive impairment and unpredictable behavior combined with chair alarm are measures in place for fall. Interventions also include observe for side effects of any drugs that can cause: gait disturbance, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness, change in mental status. Interventions for fall also include: provide bed/chair alarm as ordered [DATE], keep personal items within reach, Draw labs as per doctor's orders [DATE], Provide low bed [DATE], resident discharged to the hospital [DATE], and will reevaluate upon readmission [DATE]. Care plan for falls requires a chair alarm be in place which E8 in her signed statement reports was not in place day of fall. Level of supervision required is not addressed while in R9's care plan and there are no fall interventions listed to decrease the impact of a fall. At time of R9's fall he was on antipsychotic of Olanzapine 5 mg at bedtime and Lorazepam a benzodiazepine, 2mg intramuscular every 4 hours as needed. Medication administration record includes documentation of administration of Lorazepam on ,[DATE]. E8 stated on [DATE] at 11:26 am this was a mistake in charting which she would correct by late entry and that Ativan was given intramuscular on [DATE] (day of fall) at approximately 10:00 am. Requested fall policy and procedure. Facility presented handout titled, Fall Management Guidelines, as their procedure for management of falls. Under purpose of fall management document states, The falls management guidelines are an interdisciplinary process. They are designed to assist in the development of systems to provide individualized person centered care; to assist the resident in obtaining and/or maintaining their highest level of function and minimize the risk of falls and fall related injuries. Facility failed to address how they would minimize the risk of fall related injuries for R9 while in the chair given his history of falls and unpredictability and as per their policy. R9 expired on [DATE]. This was 11 days after the fall and being transferred to (2) additional acute hospitals. R9 death certificate dated [DATE] lists cause of death included : closed head injury and fall.

Based on observation, interview, and record review the facility failed to ensure that safety interventions were implemented involving transfers for 1 resident (R1) of 3 residents reviewed for transfers. This failure resulted in (R1) patient [DIAGNOSES REDACTED]. Findings Include: R1's care plan dated 3/6/14 indicate that R1 has limitation with range of motion, impaired standing balance and require 2 person assistance with transfer. Incident report dated 5/24/14 at 2:30pm, indicates that R1 was being transferred to the toilet by E10 (Certified Nursing assistant). The report continues to describe R1 being lowered to the floor twice by E10 during the attempted chair to toilet transfer. The report also states that R1 was placed in the chair by E10, and transferred into the bed by mechanical lift by E10 unassisted. Once in bed, R1 began to complain of pain in both arms upon movement. Z1(Doctor) was notified. Orders included X-Rays. Radiology report dated 5/24/14 at 7:40pm has the following impressions; 1. Anterior dislocation of the left shoulder. Recommend a follow-up X-ray examination after the dislocation has reduced to include a Grashey and/or transscapular view to re-evaluate for a fracture of the humeral head. 2. Anterior dislocation of the right shoulder. Recommend a follow-up X-ray examination to include a Grashey and transscapularviews after reduction of the right shoulder to completely exclude a fracture. On 6/10/14 at 10:05am E1 (Administrator) states that after the incident with R1,the Quality Assurance team initiated educating and training the staff on transfers Interview with E13 (Registered Nurse) on 6/12/14 at 11:30am, indicate that R1 was observed on the floor twice during the time when E10 CNA (Certified Nursing Assistant) was rendering incontinent care. E13 stated that the standing lifter used during this transfer should be used by two people during transfer of residents, and E10 didn't seek help prior to trying to transfer . On 6/11/14 at 10:45am Z1 (Physician) states, " R1 had dislocation of her shoulders; they told me it was from when they were trying to get R1 in bed. She didn't have any conditions that would contribute to a dislocation. She doesn't have a fracture, it's a dislocation. " Facility policy regarding proper transfers /mechanical lift transfers states in part -" Staff are to assist residents based on their individual needs assessment and that all mechanical transfers required at a minimum, 2 people.

Based on observation, interview and record review, the facility failed to administer [MEDICATION NAME]/[MEDICATION NAME] (a diuretic medication) ordered for an intravenous (IV) push according to the manufacturer's specification and as outlined in the state's nurse practice act for two supplemental residents (R31 and R32) and did not provide the correct doses of a subcutaneous medication administered to one of 30 sampled residents (R7). The facility allowed a non-qualified nursing staff to repeatedly administer an intravenous push medication ([MEDICATION NAME]) for R31 and failed to use calibrated equipment for monitoring R31 blood pressure. These failures put R31 a risk for serious side effects and adverse reactions from the improper administration of a strong diuretic. As a result, an Immediate Jeopardy was identified by the survey team on December 18, 2013. The Immediate Jeopardy was determined to have begun on December 17, 2013 at 10:00 am, when the facility failed to prevent a significant medication error from occurring for R31. On December 18, 2013 at 1:05 pm, E1(administrator), in the presence of E2 (Assistant Administrator) and Z4 (Nurse Consultant), was informed of the Immediate Jeopardy. On December 18, 2013 at 6:18 pm, while it was determined by the team that the immediacy was removed, the facility remains out of compliance at a Severity Level II. The facility needs to monitor and evaluate the effectiveness of the facility's staff education and revise policies and procedures. Findings include: 1. During the medication pass on December 17, 2013 at 10:00 am on the second floor, E15 (Licensed Practical Nurse/LPN) was administering medications to R31. E15 took R31's [MEDICATION NAME] vial labeled "[MEDICATION NAME] 10 mg/ml (milligram/millimeter) , 4 ml (40 mg) per IV Q 12 hours." E15 withdrew 4 ml of this medication via a syringe from the vial. E15 also withdrew 5 ml of saline solution via a syringe stating, "I don't have an order for [REDACTED]. At 10:05 am, E15 took R31's blood pressure before administration of the medications, and recorded a result of 128/62 mmHg. E15 stated that blood pressure should be taken before the administration of the medication to check if it is safe for the patient to have it. E15 flushed the intravenous access line with 5 ml of saline solution for 30 seconds. Then E15 administered a total of 4ml of [MEDICATION NAME] within 30 seconds and flushed the intravenous access with 5 ml after the medication for 30 seconds. The blood pressure machine used by E15 to take R31's blood pressure was not calibrated; the pointer on the dial of the machine was at 300. E3 (Assistant Director of Nursing/ADON) and Z4 (Nurse Consultant) did not respond when asked who and how often the facility check the medical equipment and did not provide any additional information about the subject. The facility failed to identify and ensure that the equipment is properly calibrated. -R31's December 2013 Physician order [REDACTED]. "12/4/13 : [MEDICATION NAME] 40 mg IV (4ml) every 12 hours" "12/17/13: Flush IV line with 5 ml saline before and after medication" R31's December 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On December 18, 2013 at 11:00 am, E15 confirmed that she had administered the medication as evidenced by E15's initials on the following dates: December 4, 5, 6, 9, 10, 11, 12, 14, 15, 16, 17,2013. R31's care plan which was updated on December 19, 2013 documents, "RN is responsible to administer IV medications per manufacturer's instructions. Monitor side effects." -On December 18, 2013 at 10:00 am on the second floor, E15 (Licensed Practical Nurse) stated that the intravenous push medication should be given slowly for 3 minutes. E15 confirmed that she has been administering the intravenous push medication for R31 for 2 weeks. E15 stated that LPNs are allowed to give the intravenous push medication if the Registered Nurse is present. On December 18, 2013 at 11:00 am on the second floor, E15 was preparing to administer R31's medications. E15 took R31's [MEDICATION NAME] vial labeled "[MEDICATION NAME] 10 mg/ml, 4 ml (40 mg) per IV Q 12 hours." E15 withdrew 4 ml of the medication via a syringe from the vial. E15 also withdrew 5 ml of saline solution via a syringe. E15 stated that R31's blood pressure was 128/65 mmHg. E15 used the same blood pressure machine that was not properly calibrated. E3 (ADON)was with E15 in R31's room during the administration of the intravenous push. E3 was looking at the watch and coaching E15 until 4ml of intravenous push medication was given completely for 5 minutes. E15 then flushed the intravenous access with 5 ml saline solution. On December 18, 2013 at 11:00 am on the second floor, E3 stated that the intravenous push medication should be given slowly for 5 minutes. E3 added that Licensed Practical Nurses are allowed to administer the intravenous push medication when they are physically supervised by a Registered Nurse (RN). At 11:15 am, E15 stated that "I did not call an RN yesterday because they are busy." At 1:20 pm, E27 (RN- Supervisor) also stated that RNs should be physically present when an LPN gives the intravenous medication; it is for RNs to supervise and make sure that the LPNs follow the guidelines. -The facility's policy on "Administering Medications by IV Push" documents under "Preparation: 3. The licensed nurse responsible for IV medications shall be knowledgeable of 1. Indications for use; b. appropriate routes of administration, doses and [MEDICATION NAME]; c. side effects; 4. A Registered Nurse may be supervised a Licensed Practical Nurse performs IV push." According to the Illinois Department of Financial and Professional Regulation memorandum entitled " Important Notice regarding the administration of IV Medications by LPNs " document that, " the administration of chemotherapeutic agents via intravenous routes, starting or adding blood or blood components, administration of medication via intravenous push and adding medication to existing intravenous infusions including [MEDICATION NAME] in [MEDICATION NAME] locks, is not allowed. " On 12-18-13 at 4:25pm, E45 Licensed Practical Nurse (LPN) during interview stated a Registered Nurse (RN) must supervise a (LPN) when giving intravenous push (IVP) medication. E45 stated the facility policy states it is okay for a LPN to give IVP medication. E45 stated LPN educational training states an LPN should not give IVP medication. E45 stated she has given IVP medication with RN supervision. On 12-18-13 at 4:35pm, E46 (LPN) stated IVP medication can be given by an LPN under RN supervision. E46 stated LPN educational training states IVP medication should always be given by an RN. On 12-18-13 at 4:40pm, E47 (LPN) stated IVP medication can be given by the LPN with RN supervision. E47 stated she has given IVP medication with RN supervision. -On December 18, 2013 at 3:00 pm, the manufacturer's medication insert for [MEDICATION NAME] was supplied by Z4 (Nurse Consultant) who stated that the document came from the pharmacy and "it should be given slowly for 1-2 minutes and not for 5 minutes." It documents that, " Dosage and Administration: [MEDICATION NAME] therapy with [MEDICATION NAME] injection, should be used only in patients unable to take oral medication or in emergency situations and should be replaced with oral therapy as soon as practical. The intravenous dose should be given slowly (1-2 minutes). The manufacturer's insert for [MEDICATION NAME] also documents that, "Cases of tinnitus and reversible or irreversible hearing impairment and [DIAGNOSES REDACTED] have been reported. Reports usually indicate that [MEDICATION NAME] toxicity is associated with rapid injection..." 2. On December 18, 2013 at 3:00 pm, E3 (ADON) stated that "I told you that only R31 has an IV push but R32 also has an intravenous medication push." R32's December 2013 Physician order [REDACTED]. "[MEDICATION NAME] (diuretic) 20 mg Intravenous every 8 hours" R32's December 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the facility's "Nursing Department Schedule" no Registered Nurse was physically present during the 11-7 shift on December 14, 2013. The facility has taken the following steps to remove the immediacy: R31 and R32 were assessed for any adverse side effects of the IV push [MEDICATION NAME]/[MEDICATION NAME] that was administered. The physicians of the resident were notified of the assessment, no adverse reactions or acute distress was noted. R31 and R32's interested party has been notified. On December 18, 2013, R32's 2pm dose of [MEDICATION NAME] was given by an RN and monitored for compliance. The facility's Nurses, RN's and LPN, across all shift, full time and part time have been or will be in serviced in person, via phone or by certified mail on the importance and means of following the policy and procedure for administering intravenous push medications. LPN's will not be administering IV push medications. Registered Nurses will only administer IV push medications, according to the nurse practice act. The facility's pharmacy will immediately notify the facility's DON, ADON and Nursing Consultant of any new orders for IV push medication, for monitoring of compliance. The facility has careful reviewed this area of investigation, has evaluated its existing systems and the competency of its staffs, and determined that compliance with this requirement may be achieved through appropriate instruction and monitoring The facility's Quality Assurance (QA) committee and/or designees will monitor the performance of the facility staff in this area. It will include (i) quality assurance review of records of residents receiving IV push medication; and (ii) quality assurance of resident care areas while residents are receiving IV push medications, under direct observation, to ensure all IV push medications are given per policy and procedure, daily for a week for each IV push administration, weekly for the remainder of the month and monthly thereafter for next 6 months, if necessary (ii) any appropriate disciplinary action against staff, or any additional instruction, deemed necessary based upon the monitoring. The facility's QA committee, headed by the Administrator, will determine whether any deficient practice is occurring when examining all collected data as outline above. 3. R7 is an [AGE] year old male admitted with [DIAGNOSES REDACTED]. R7's physician order [REDACTED]. R7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials. On 12/17/13 at 6:19 PM, E34 (Registered Nurse/Nurse Supervisor) presented a plastic bag with a pharmacy label attached that contained one open vial of [MEDICATION NAME] injection. E34 stated " We have been giving the patient 5000 units. " The pharmacy label contained the following documentation: R7's name, dispense date of 12/11/13, [MEDICATION NAME] sodium 5000 units/milliliter vial, and inject 1 milliliter (5000 units) subcutaneously every 12 hours. The facility's Medication Administration: General Procedures policy, with a 3/2012 revision date depicts the following: Medication Administration Procedure Section: 10. If the physician order [REDACTED]. R7's nurse notes from 12/11/13 to 12/19/13 did not contain any documentation regarding the facility staff notifying the physician of the fact that the 12/11/13 2nd [MEDICATION NAME] order for [MEDICATION NAME] 5000 units/milliliter, inject 0.5 milliliters every 12 hours could not be followed. The facility' s Subcutaneous Injections policy depicts the following in the preparation section: 1. Verify that there is a physician's medication order for this procedure. Verify the order for resident ' s name, drug name, dose, time, and route of administration. 3. On 12-18-13 at 4:25pm, E45 Licensed Practical Nurse (LPN) stated a Registered Nurse (RN) must supervise a (LPN) when giving intravenous push (IVP) medication. E45 stated the facility policy states it is okay for a LPN to give IVP medication. E45 stated LPN educational training states an LPN should not give IVP medication. E45 stated she has given IVP medication with RN supervision. On 12-18-13 at 4:35pm, E46 (LPN) stated IVP medication can be given by an LPN under RN supervision. E46 stated LPN educational training states IVP medication should always be given by an RN. On 12-18-13 at 4:40pm, E47 (LPN) stated IVP medication can be given by the LPN with RN supervision. E47 stated she has given IVP medication with RN supervision.

Based on observation, interview and record review, the facility failed to timely and accurately assess and treat the presence of pain for 2 of 6 residents (R1,R20) reviewed for pain and 1 resident (R44) in the supplemental sample. The facility failed to follow physician's orders [REDACTED]. The facility failed to follow their [MEDICAL TREATMENT] services agreement for 2 residents (R21, R23) out of 3 residents reviewed for [MEDICAL TREATMENT] in a sample of 30 by failing to coordinate care with the [MEDICAL TREATMENT] unit. Findings include: 1. R44 could be heard moaning and groaning from the hallway outside her room on 12/16/13 at approximately 1:30pm. Surveyor entered R44's room to find R44 sitting up in bed, complaining of back pain and thirst. R44 stated she gets back pains on a daily basis. The room was dark and R44 was tearful. R44 appeared thin and frail and stated that she has been trying to get staff attention but nobody has come into her room. R44's call light was not within her reach. When asked what she has done to get staff attention, R44 stated she has been hitting her plastic drinking cup on the bedside table. At approximately 1:33pm, E10 (Nurse) entered R44's room stating "your back is hurting? I'll be right back". Approximately 2 minutes later E10 returned and offered R44 a pill which R44 swallowed. When asked, E10 told surveyor that she gave R44 "a [MEDICATION NAME]". E10 then asked R44 several times how severe the pain is on a 1-10 scale. Each time R44 responded "it really hurts", not numerically rating her pain. Review of R44's physician's orders [REDACTED]. R44's pain flow sheet documentation dated 12/16/13, 12:30pm, shows a pain intensity of "8", however R44 did not give a numerical rating during the 1:30pm observation.. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" pain rating for that same hour that R44 was medicated. Also, the MAR indicated 7" intensity on that shift. Pain Flow Sheet shows consistently that movement is the aggravating factor for R44's pain. E10 presented a comprehensive pain assessment for R44 dated 12/18/13. There was no evidence of a comprehensive pain assessment having been done prior to this date. The assessment states R44 experiences sharp pain frequently and at no specific time of day. MAR for period 12/1/13 through 12/18/13 shows R44 was experiencing pain at "4" on 12/11/13 and at "6" on 12/13/13. There is no documentation of pain medications being administered on those two occasions. No evidence that pain characteristics was assessed. An undated Care Plan states nursing staff to assess R44's pain at regular intervals, noting predisposing factors. 2. R20 has a [DIAGNOSES REDACTED]. During the initial tour on 12/16/13 at approximately 9:45 am, R20 was observed in her room, in bed, alert, with bilateral hand contracture. R20 stated that she had a stroke 18 months prior, has limited movement in both hands and not able to raise her left leg. R20 went on to say that she hasn't had any exercises to her hands for more than one week. There were no positioning nor splinting devices in place. On 12/18/13 at approximately 1:45pm, R20 was sitting in the dining room with bilateral hand splints in place. R20 stated that the splints are causing pain in both hands. R20 stated she received pain medication earlier in the day when she told the nurse that she was in pain. R20 stated that the nurse did not assess her pain for severity nor returned to assess effectiveness of the medication. R20 described the current pain as excruciating at a "10" on the pain scale, and radiating into her thumbs. R20 stated that when she has splints in place, she receives pain medication at least 3 times daily and needs to be medicated more often than that because the pain is not usually controlled. At 2:10pm, E28 (Nurse) stated that she last gave R20 her prescribed pain medication at 10am. E28 stated that she did not assess the intensity of R20's pain and said that she gives the pain medication whenever R20 asks for it. E28 was made aware that R20 continues to complain of pain. At 2:45pm, E28 stated that she contacted R20's physician regarding R20's recurrent pain and received an order to administer pain medication every 4 hours instead of previous schedule of every 6 hours to achieve better pain control. R20's restorative assessment dated [DATE] states R20 complains of pain during passive range of motion exercises and refuses the application of splints at times due to pain. Facility's Pain Protocol dated October, 2010, states that pain is to be assessed when there is onset of new or worsening pain. This assessment is to include characteristics and severity of pain. The Protocol also states that the nurse will identify situations or interventions where an increase in pain may be anticipated such as wound care, ambulation, or repositioning. The Protocol also states that pain medications should be selected based on pertinent treatment guidelines. 3. On 12/17/13 at approximately 8:55am, R10 was observed in his room, sitting in an electrical chair with both lower extremities resting on the bed. R10's legs were observed to be grossly [MEDICAL CONDITION] bilaterally and exposed. R10's Care Plan dated 9/26/13 shows [DIAGNOSES REDACTED]. physician's orders [REDACTED]. R10 is on anticoagulant therapy. On 12/18/13 at approximately 10:55am, R10 was again observed sitting up in his room with no compression stockings on. Again at 2:45pm R10 was up in his chair with no compression stockings on. WebMD Medical Reference states that [MEDICAL CONDITION] is a blood clot in a deep vein. These clots are dangerous because they can break off and travel to the lungs causing a [MEDICAL CONDITION] embolism, a life threatening condition. The use of compression stockings is recommended to help reduce the pain and swelling associated with [MEDICAL CONDITION]. 6. R21's December 2013 Physicians Order Sheets document that R21 is diagnosed with [REDACTED]. It also documents that R21 has [MEDICAL TREATMENT] 3 times weekly on Tuesday, Thursday and Saturday. R21's medical record documented communication with the [MEDICAL TREATMENT] unit regarding R21's condition in the form "[MEDICAL TREATMENT] Coordination of Care" for the following dates for 2013: 8/20/13, 8/22/13,10/24/13, 11/7/13. On December 19, 2013 at 10:30 am, E25(Licensed Practical Nurse) stated during interview that the facility sends a "[MEDICAL TREATMENT] Coordination of Care" with the resident and all the forms are found in the resident's medical record. The facility's undated "SNF Outpatient [MEDICAL TREATMENT] Services Agreement" which was made with the local [MEDICAL TREATMENT] center documents that, "Collaboration of Care: Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. Documentation shall include, but not limited to, participation in care conferences, continual quality improvement program, annual review of infection control policies and procedures, and the signatures of tram members from both parties on a Short Term Care Plan and a Long Term Care Plan." 4. R1 is a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. On 12/18/13 at 9:52 AM, during pressure ulcer dressings to the left hip and sacrum, R1 moaned when E24 (Wound Care Nurse) removed the old dressings from R1's left hip and sacral wounds, R1 moaned again when E24 touched the sacral wound while cleansing the wound with a gauze pad soaked in a wound cleanser and R1 moaned a third time when E24 touched the left hip wound while cleansing the wound with a 0.9% normal saline soaked gauze pad. R1 said " ouch " and moaned a 4th time, when E24 wiped the wound cleanser off of the left hip wound. E11 (Wound Care Nurse) assisted E24 with the pressure ulcer dressing changes. On 12/18/13 at 9:58 AM, E11 asked R1 if the wounds hurt and R1 stated " yes " . On 12/18/13 at 9:59 AM, E11 asked R1 if she was in pain. R1 said that she had pain in her butt when it was touched. E24 continued the dressing change to R1' s sacral wound and R1 continued to moan throughout the rest of the dressing change as the sacral wound was touched. On 12/18/13 at 10:03 AM, after the dressing changes were completed, E24 asked R1 for her pain score. R1 said her pain score was an 8 out of 10. On 12/18/13 at 10:10 AM, R1 stated: " The staff come to change the pressure ulcer dressings once a day. " R1' s physician order [REDACTED]. Controlled Substance Disposition Record dated 11/11/13 indicates that R1 received one dose of the medication on 12/18/13 at 8:40 AM. R1' s physician order [REDACTED]. R1's care plan dated 10/13/13, for the sacral and left hip pressure ulcers documents: assess for discomfort/notify nursing staff for intervention as an approach. R1' s care plan dated 10/14/13, for pain documents: report resident complaints of pain to the nurse immediately. Observe signs/symptoms of pain. Report signs/symptoms of pain such as: persistent yelling or calling out; restlessness/agitation; crying/screaming/moaning. And listen to concerns and notify appropriate staff as approaches. E11 and E24 failed to reassess R1's pain before starting the pressure ulcer dressing changes. E24 asked R1 about her pain during the dressing changes, but did not initiate and implement any interventions to address R1's pain. E11 and E24 did not leave R1' s room to report any complaints of pain to R1' s assigned nurse during the dressing changes. The facility's Pain Clinical Protocol depicts the following: 4. the nursing staff will identify any situations or interventions where an increase in the resident ' s pain may be anticipated; for example, wound care, ambulation, or repositioning. 5. R23 is an [AGE] year old male admitted with [DIAGNOSES REDACTED]. R23's physician order [REDACTED]. On 12/16/13, the facility presented a copy of an unsigned nursing home [MEDICAL TREATMENT] transfer agreement between the facility and the local outpatient [MEDICAL TREATMENT] center, which was faxed to the facility from the local outpatient [MEDICAL TREATMENT] center on 12/16/13. The unsigned nursing home [MEDICAL TREATMENT] transfer agreement between the local outpatient [MEDICAL TREATMENT] center and the facility does not have any documented mutual obligations regarding the coordination of care and communication between the nursing facility and the local outpatient [MEDICAL TREATMENT] center. On 1/7/14 at 3:10 PM E1 during interview stated " The original contract with the facility and the local outpatient [MEDICAL TREATMENT] center required staff signatures is in the possession of the local outpatient [MEDICAL TREATMENT] center. The facility is only required to have a copy of the contract and the facility and outpatient [MEDICAL TREATMENT] center ' s required staff signatures are not required on the facility ' s copy. It is legal to have an unsigned copy of the outpatient [MEDICAL TREATMENT] contract in the facility. The contract is legal and binding. " On 1/7/14 at 2:15 PM, upon request, the facility failed to present credible evidence to show an enforceable [MEDICAL TREATMENT] contract between the facility and the local outpatient [MEDICAL TREATMENT] center. R23's [MEDICAL TREATMENT] coordination of care sheets dated 11/21/13, 11/23/13, 11/26/13, 12/5/13, 12/7/13, 12/12/13, 12/14/13, 12/17/13, and 12/19/13 did not contain documentation in the report from [MEDICAL TREATMENT] center section. The facility failed to present [MEDICAL TREATMENT] coordination of care sheets for R23 for 11/28/13 and 11/30/13 that contained documentation from the facility or local [MEDICAL TREATMENT] center. On 12/19/13 at 1:29 PM, E27 (Registered Nurse Supervisor) stated the following during interview: When the residents return from [MEDICAL TREATMENT] the nurses take their vital signs, check for medications that need to be given, feed the residents, and check the [MEDICAL TREATMENT] site for bleeding, infection, and function. The nurses check the [MEDICAL TREATMENT] documentation for new orders or labs. If a resident has issues at [MEDICAL TREATMENT] the [MEDICAL TREATMENT] center calls the staff nurse. The vital signs and dry weight are documented on the [MEDICAL TREATMENT] coordination of care sheet. If the information is not completed by the [MEDICAL TREATMENT] staff on the [MEDICAL TREATMENT] coordination of care sheets, the staff nurse should call the [MEDICAL TREATMENT] center to see if everything went ok at [MEDICAL TREATMENT]. We have to call and sometimes the [MEDICAL TREATMENT] center faxes the documentation to us. Nurses' notes from 11/21/13 to 12/19/13 did not contain any documentation regarding R23's post [MEDICAL TREATMENT] assessment on the days R23 received [MEDICAL TREATMENT] or phone calls from the facility staff to the [MEDICAL TREATMENT] center staff regarding the [MEDICAL TREATMENT] procedure. There was inconsistent documentation regarding the coordination of care and communication between the facility and local outpatient [MEDICAL TREATMENT] center. On 1/7/14 at 11:10 AM, E3 (Assistant Director of Nursing) stated: " The [MEDICAL TREATMENT] access care policy is the facility's only [MEDICAL TREATMENT] care policy. " The facility's [MEDICAL TREATMENT] Access Care policy with a October, 2010 revision date does not contain any information regarding the post [MEDICAL TREATMENT] care of a central catheter.

Based on interviews and record review the facility failed to assure that one resident (R1) of four sampled residents (R2-R4) remain free of physical restraints. This failure resulted in R1's lower legs and feet being wrapped together with bed sheets; restricting freedom of movement that resulted in pain and discomfort. R2-R4 had no concerns and was discharged to home from the facility after completing their short term rehabilitation program. Care Plan: R1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. R1 is alert and oriented to person, place and time. R1's individualized plan of care contains fall prevention interventions for the Certified Nursing Assistants (CNA)'s to carry out, including but not limited to : keeping the call light within reach, offer assistance as needed, report unsafe behavior, educate or remind the resident on the risk of fall, anticipate resident's need, assist with bed mobility, transfers or walking. November 12, 2013 at 10:00 am, R1 stated that the legs and feet were tied together with bed sheets and that another bed spread was wrapped around both legs from the knees to the ankles. R1 stated the legs and feet were hurting for hours and that R1 was not allowed to get out of bed. November 14, 2013 at 10:40 am, E3 (nurse) stated R1 was wrapped together with bed sheets where the ankles came together preventing R1 from getting out of bed. E3 stated E6 was told by her " that this form of restraint we don't do that " November 14, 2012 at 11:30 am, E4 (CNA) was asked by E3 nurses to go into R1's room and release the sheets wrapped around R1's legs. E4 stated the sheets was wrapped around the knees to the ankles of R1. Nursing Notes: November 1, 2013 at 5:30 am, E3 (nurse) was doing rounds and noticed that R1 was in bed lying down with both feet tied together by bed sheets. E3 asked E6 (CNA) who was assigned to R1. E6 stated she was the CNA assigned on a 1:1 to prevent falls for R1. E6 stated she wrapped R1 ' s legs and feet together. R1 sustained redness and greenish discoloration on the lateral right ankle. Incident Report: E6 was immediately removed from the 1:1 supervision of R1 and suspended pending investigation of the incident. E6 stated to E5 (Nursing Supervisor ) that she wrapped R1's legs and feet together with the bed sheets; because R1 repeatedly kept getting up out of bed and that E6 did not want R1 to fall. E6 was terminated from the facility as a result of using unapproved methods of physical restraints. Employee File: August 22, 2013, E6 cleared the Health Care Workers Registry, received a handbook/ training for Code of Conduct and Abuse. E6 signed the acknowledgement of receipt for employee handbook on abuse.

Based on observation, interview and record review, the facility failed to monitor for and implement preventive measures to prevent the development of new pressure ulcers for one resident (R2) in six residents at high risk for skin breakdown in the sample of 27 residents. Findings include: R2 is a [AGE] year old whose [DIAGNOSES REDACTED]. R2 is alert and oriented to person, place and time. R2 was admitted to the facility on [DATE] with infection to open wounds to both legs and otherwise intact skin. R2's care plan for 12/14/11 noted R2 to be at risk for skin breakdown on buttocks and other bony prominences. Interventions to prevent skin breakdown included: 1.) Apply moisture barrier to buttocks or moisturizer to dry skin. 2.) Apply lotion or moisturizer to dry skin. 3.) Inspect skin for early signs and symptoms of skin breakdown and report to nurses any redness, cracks, bruise, change in colors and temperature of skin areas. During the initial tour on 12/ 20/11 at 10:00 AM, R2 was awake in an oversized bed . R2's red and [MEDICAL CONDITION] legs were exposed to air as R2 lay on his back. R2 remained in the prone position when he was visited after lunch at 1:30 PM. Also, throughout the next two days, R2 was observed lying on his back only. Review of thePOS (Physician order [REDACTED]. The nurse's note for 12/07/11 at 12:07 notes open wounds on the buttocks area. The clinical record did not show follow up to this observation. On 12/21/11 at 2:00 PM, E5 (Nurse) was questioned about the wounds on the buttocks which she had noted. E5 stated that it was only excoriation and the area was being treated with a house stock skin barrier cream. When the area was viewed with E5and E6, CNA (Certified Nurses Aide) at 2:45 PM, the sacrum wound covered the whole sacrum with the middle area being black with necrotic tissue. Smaller wounds were noted on the lower left buttock, the upper left buttock and one to the right posterior thigh. E5, nurse stated, "That is fresh. It did not look like that when I saw it 2 days ago. I told the wound care nurse (E8) about the open areas on 12/07/11 and I got a doctor's order for the [MEDICATION NAME] dressing and asked E8 to follow up." E6, CNA stated that the area did not look that bad that morning. At 2:50 PM, E4, ADON (Acting Director of Nursing) viewed the wounds for the first time and stated that he would get the wound care nurse. At 3:00 PM on 12/21/11, E7, Wound Care Nurse came to observe R2's wounds. E7 stated that he was not the regular wound care nurse for R2. E7 said that the regular wound care nurse (E8) was busy. After viewing the wounds, E7 spoke with E8 on the phone then stated, "She said that site is new." When asked for the treatment orders for the wounds, E7 checked the treatment record and did not find a prescribed treatment for [REDACTED]. E8, wound Care Nurse arrived at 3:15 PM and stated that she did not report the wounds or document on them because the area was just shearing and excoriation. E8 stated, "I apply a skin barrier." E8 stated that she saw the area two days prior but did not notify the wound care doctor because R2 is a Hospice resident and, "Hospice has to give their approval for any referrals." E8 did a wound assessment and described the wounds as : 1.) Sacrum unsalable 9.4 x 15.0 cm 2.) Lower left buttock 1.8 x 3.1 cm 3.) Upper left buttock 1.7 x 2.3 cm 4.) Right posterior thigh 1.0 x 0.6 cm When E5, Nurse was asked for Hospice notes, they could not be found. R2 was admitted to Hospice on 12/02/11. On 12/22/11, E5 presented a Hospice note dated 12/21/11 which said the sacral sore had been pointed out to Hospice on 12/21/11. E5 also showed that wound treatment had been ordered for the four new wounds on 12/21/11. On 12/22/11 at 11:45 AM, Z4 MD stated that she was made aware of the wounds on 12/21/11 by the nurse and ordered a referral for R2 to the wound care specialist. The doctor mentioned that R2 was admitted with encrusted wounds to the legs. The doctor was reminded that there were four new wounds observed. The doctor repeated that R2 was being referred to the wound care specialist. On 12/23/11 at 10:10 AM, E15 stated that she had worked with R2 for about 10 days. E15 said that she bathes R2 every other day. E15 said that she has never seen the sacral wound because it was always covered with a large dressing. E15 said that the wound care nurse always provided the creams to apply to the other three wounds. At 10:40 AM, E8, wound care nurse arrived to change the dressings. After removing the dressings, E8 confirmed that the sacral wound and the left lower buttock wound had eschar caps. E8 stated that the treatment being applied now would loosen the cap in about one week and the wounds would then start healing better. E8 said that the wound care doctor would see R2 in six days.