Every finding on record at Aperion Care Midlothian

Based on observation, interview and record review, the facility failed to protect a resident's right to be free from physical abuse by a staff member. This failure affected one (R1) of three residents reviewed for abuse. R1 sustained redness and bruising on his left eye after he was hit by staff while providing care.Findings include:R1 is 77 years and have resided at the facility since 2023, face sheet listed the following past medical history: Benign neoplasm of cerebral meninges, chronic embolism and thrombosis of left popliteal vein, atherosclerotic heart disease of native coronary artery without angina pectoris, other seizures, hypertensive heart disease without heart failure, major depressive disorder, dementia in other diseases classified elsewhere, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Alzheimer's disease unspecified, essential primary hypertension, etc.Review of R1's quarterly Minimum Data Set (MDS) dated [DATE] revealed under section C - cognitive patterns R1 has a brief interview for mental status (BIMS) score of 3 indicating memory problem, section GG-functional status indicates R1 requires supervision/touching assistance from staff for eating but dependent on staff for all other activities of daily living (ADL) needs. R1's face sheet however indicated that R1 is responsible for himself and makes his own decisions.On 6/16/2025 at 9:50AM, R1 was in bed, awake and alert with some confusion, and stated he is doing okay. surveyor noted dark purplish bruising around resident's left eye and asked him what happened to his eye. R1 said, Staff hit me. Surveyor asked resident how and when the incident happened. R1 said yesterday in the hallway, resident could not give details of what he was doing in the hallway before the incident or what happened after. On 6/17/2026 between10:30AM and 12:35PM, R5 and R6 (R1's roommates) stated that they were in the room the day R1 had an altercation with V4. R5 stated that he could not see through the privacy curtain, but he heard an argument and what sounded like someone was being struck. R6 said that he observed V4 hit R1 with a shampoo bottle in his arm and leg.Facility reported incidents dated 6/12/2026 documented in part: On 6/12/2026, R1 reported that that he felt the care provided to him this morning shift was inconsistent with the facility standards, R1 stated that staff bumped him during Activities of Daily Living (ADL) care. R1 was assured of his safety, CNA was suspended, nursing staff performed a skin check on R1 with superficial scratch under left eye noted, MD was notified, responsible parties notified, village police notified.Police report dated 6/12/2026 documented in part: To facility for a battery complaint. Upon arrival, I met with V1 the Administrator who relayed that at approximately 1130 hours on today' s date, an employee and a patient were in a physical altercation. V1 relayed that the individuals involved were V4 (the employee) and R1 (patient). V1 relayed that V4 said that R1 was grabbing her by the shirt refusing to let go because he did not know who she was. V1 relayed that V4 said that she was getting worried that R1 was going to hit her, so she struck him to get him to release his grip from her shirt. Prior to my arrival, V1 sent V4 home for the day. V1 also relayed that R1 has a history of being combative with staff during his time at the facility. I spoke with R1 who relayed not verbatim, that he was lying in bed when V4 entered the room and stated that the hospital is not fair. R1 relayed that he told V4 that he would hit her. When I asked R1 why he would say that R1 relayed that he did not remember. R1 relayed that he believed V4 struck him in the left eye approximately 4 times. R1 relayed that he usually does not contact police and does not want to press charges against V4.Care plan initiated 9/27/2023 documented in part: I have potential to be physically aggressive towards staff during care related to poor impulse control. Interventions include assess and address contributing sensory deficits, explain to the resident the importance of care to assist in eliminating. If the resident refuses, allow it at the time and try again within the next hour. Get more familiar staff to assist.Fire department report dated 6/12/2026 documented in part: Unit 2732 was dispatched to facility for reported assault, Chief Complaint: Assault. [AGE] year-old male with a medical history of hypertension, seizures, and Parkinson's disease, and no known allergies, was involved in an incident of suspected abuse at a nursing home. The patient reports being assaulted, with the event occurring at approximately 12:10 on June 12, 2026, and lasting for about.10 minutes. The mechanism of injury is described as blunt trauma. Patients report no pain, with a pain scale of 0, primary impression is an eye injury.On 6/17/2026 at 9:29AM, V10 (Police officer) said that he responded to a call for battery, thought a resident made the call, but it was one of the employees that called. V10 interviewed the resident (R1) and witnesses, R1 showed signs of bruising on his left eye. V10 asked R1 what happened, and he said that he was lying in bed when staff (V4) entered the room, staff said that the hospital is not fair, R1 told staff that he would hit her, staff in turn hit R1. V10 asked R1 how many times staff hit him, and he said about 4 times. V10 spoke to V1 who said that R1 has a history of being combative, the facility has a policy of sending involved staff in an abuse case home immediately. V10 spoke to two other residents, the one close to R1 said that he could not see anything through the privacy curtain, he heard arguments and could hear someone being hit with punches. Fellow officer spoke to another resident in the room who said that he saw R1 hitting staff, then staff grabbed something and hit R1 with the object in his arms and legs, the resident could not see much because staff was standing between him and R1. V10 also spoke to V4 over the phone and she said that she entered R1's room and announced herself, told R1 that she was going to be his CNA, V4 saw R1's leg hanging out of the bed and went to help him, R1 hit her and she told him not to do it again. V4 went to help R1 again and he grabbed her shirt, V4 tried to free herself and ran out of the room, never admitted to hitting R1. V10 said that R1 did not want to press charges and refused to be transported to the hospital. V10 added that paramedics gave R1 an ice pack, R1's left eye was red and discolored but not necessarily swollen. The incident happened between 11:30AM and 12:00PM. V10 returned to the facility around 5:15PM and took pictures of R1's eye which has some bruising at this point.On 6/17/2026 at 2:17PM V11 (Firefighter/Paramedics) said that on 6/12/2026 they received a call for an injured person, upon arrival at the facility, they realized that it was a confrontation between one of the residents and a staff. The resident stated that the staff (CNA) struck him multiple times in the face area, resident was assessed, his vital signs were okay, resident refused transportation to the hospital, he sustained a slight bruising and discoloration. V11 described the injury as 3 out of 10 bruises but stated that it was consistent with someone being hit in the face area. R1 denied any pain but was mostly emotionally distressed, maybe from calling 911. V11 did not speak to other residents in the room but stated that the police officer spoke to the roommates and from what V11 overheard, their account of the event was consistent with what R1 reported, that he was struck by the staff.On 6/16/2026 at 12:52PM, V7 (Attending physician) said that he was notified of the incident, facility called him and said that there was a physical altercation, R1 was struck by a CNA, R1 sustained a minor scratch, there was no loss of consciousness, V7 did not order anything just routine neuro checks.On 6/16/2026 at 11:05AM, V4 certified nurse assistant (CNA) said that she went into R1's room to address him and let him know that she is his CNA, and resident told her that he doesn't know her and told her to get out of the room. V4 noticed resident's leg hanging out of the bed and wanted to help him, but he kicked her. V4 then went to get the remote control from resident's bed, and he grabbed her shirt and was screaming obscenities at her. V4 said he grabbed resident's hands, broke free and ran out of the room to tell the nurse who told her that she would swap resident with another CNA. Surveyor asked V4 if she called for help all the time resident was holding her and she said no, she just ran out of the room after she broke off from his hold. V4 said that she did not get a chance to swap resident because she was sent home. The incident happened between 11:00 AM and 11:40AM. She left the building around 12:00PM. V4 said that she did not hit the resident, he was sitting at the side of the bed, maybe his hand bumped him.On 6/16/2026 at 10:48AM, V1 (Administrator) said that he was called to the front lobby by staff, when she got there, V4 (CNA) was there and the assistant director of nursing (ADON) told V1 that R1 reported to his nurse and the nurse reported to the ADON that V4 struck him. V1 spoke to the resident who stated that staff hit him, could not give specific description but mentioned that the staff has glasses and V4 was the only CNA on duty with glasses and she was assigned to R1 that day. V1 spoke to V4 who told her that R1's leg was hanging off the bed, V4 went to assist resident, and he kicked her and looked like he would get out of bed. V4 went to get the remote control for the bed and R1 grabbed her on her shirt and was pulling her down, V4 was trying to release herself from resident, maybe resident's hand hit his eye. V1 said that the police gave resident a cold pack and resident was holding it over his eye, resident's eye was red but not swollen. V1 added that R1 has never accused any staff of hitting him.On 6/16/2026 at 11:58AM, V6 (LPN) said that around 11:30AM on 6/12/2026, she was walking down the hallway and V4 said that she needed help with R1, V6 went into the room and R1 was saying, I don't want her, pointing to V4, she struck me. V6 told V4 to go to the lobby and got another staff member to help her with R1. V6 said that R1 was not scared, he just didn't want V4, V6 have worked with R1 a couple of times, he will yell out once in a while and is picky when it comes to staff taking care of him. V6 has not witnessed R1 hit any staff, Abuse policy revised 3/18/2026 documented in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident-secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents.

Based on observation, interview, and record review, the facility failed to make water available for residents in between meals to maintain residents' hydration and failed to make water pitchers available for residents. These failures affected five residents R2, R9, R10, R11, and R12, reviewed for water availability in between meals.On 5/11/26 between 11:45am and 12pm, during observation of residents on the units with V14(CNA/Certified nurse assistant), and later with 15(CNA), and V16(LPN/Licensed Practical Nurse Supervisor), several residents including R2, R9, R10, R11, and R12, were observed without water or water pitchers at the bedside. Other residents were observed with empty water pitchers. The Surveyor asked V14(CNA/Certified nurse assistant) why residents did not have any water pitchers or water available at their bedside to drink when needed before lunch is served. V14 responded that all residents get water on their trays during mealtimes. V14 later said that residents should be given water in the pitchers daily. V14 stated she was not sure if new water pitchers are available in the storage.On 5/11/26 between 11:45am, V2 (Director of Nursing) Stated that all residents with orders for thin liquids should have water available at the bedside except if they are on fluid restriction. V2 later presented the list of 4 residents on Nectar Thick liquids, 2 residents on Honey thick liquids, and 3 residents on Fluid Restriction. R2, R9, R10, R11, and R12 were not on these lists.Physician Order Sheet records for these five residents dated as follows showed that they have orders for Fluid Consistency to be Thin Liquids: R2 - 12/5/2022; R9 - 1/25/2023; R10 - 4/8/2024; R11 - 9/1/2021; R12 - 12/4/2019.Nutrition Care Plans for these 5 residents also state that diets orders should be followed.Facility's policy on water pass hydration with latest revision dates 11/28/2012 fits in part: to provide water to residents in a clean and sanitary manner to meet hydration needs. Procedure states to perform hand hygiene and scoop ice into a picture or Styrofoam cup and fill with tap water to cover the ice and fill the cup or pitcher.

Based on observation, interview, and record review, the facility failed to ensure that residents' bed frames have functioning manual lift mechanism to raise or lower the bed and failed to ensure that a resident's electric bed was in good repair. These failures affected five residents, R3, R4, R5, R6, and R7, reviewed for functional beds that was in good repair.Findings include:On 5/11/26 between 11:15am and 12:00pm, during observation of residents on the units with V14(CNA/Certified nurse assistant), and later with V15(CNA), the following were observed: With V14, R7's electric bed frame control was not functioning; V14 looked under the mattress and found the electric cord and tried to connect it to the bed frame, but the bed still did not work. V14 stated that she(V14) would notify Maintenance staff. With V15, several other bed frames with manual crank handles including the bed frames for R3, R4, R5, and R6 were observed to not work properly. V15 stated that if the crank handle cannot lift the bed, then staff must bend too much to help residents who need assistance.On 5/11/26 at 1:45pm, V3(Maintenance Director) Interviewed regarding the non-functional bed frames. V3 stated that if nursing staff notified him of the non-functioning bed frame like they did for some bed frames, that he (V3) repaired some of the bed frames. V3 added that some of the bed frames' crank handles have rusted ends, and he tried his best to repair them. V3 showed this surveyor the oil spray bottle that he uses to make the crank handles that were stiff so work properly. V3 later presented a list of records of Maintenance issues that he(V3) fixed every day. V3 said he would go and fix the bed frames.On 5/12/26 at 11am, V1(Administrator) stated that since the facility Started to admit more residents that require more care, that the facility has started purchasing more electric beds that will not have problems with crank handles, and that the facility will continue to replace the old bed frames with new beds.Facility's document titled Job description for Maintenance Director states in part: Ensure that supplies and equipment are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the administrator. Make periodic rounds to check equipment and to ensure that necessary equipment is available and working properly. Monitor maintenance procedures to ensure that supplies are used in an efficient manner to avoid waste.

Based on observation, interview, and record review, the facility failed to follow the medical patient rights act which requires staff members to wear a visible name badge that discloses the employee's first name, licensure status, if any, and staff position of the person examining or treating the patient or resident. This has the potential to affect all 43 residents residing on Unit 1 at the facility.Findings include:Facility census dated 11/14/2025 documents 43 residents residing on Unit 1 at the facility.R1's face sheet documents diagnoses that include but are not limited to depression, acute kidney failure, type 2 diabetes, and chronic obstructive pulmonary disease.R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact.On 11/14/2025 at 12:27pm, R1 said, No, there are very few staff that wear ID badges. It's a problem. I (R1) didn't even know who the guy was trying to get me to sign consents. I (R1) want to know who I (R1) am talking to and who is caring for me. How do I (R1) know if it's not just someone off the street. Am I (R1) just supposed to believe the person coming in my room that they are staff here? I (R1) don't want to be taken advantage of.R3's face sheet documents diagnoses that include but are not limited to asthma, diabetes and congestive heart failure.R3's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R3 is cognitively intact.On 11/14/2025 at 12:33pm, R3 said, That's a joke. The staff hardly ever have ID badges on. Sometimes, they (staff) slap a sticker on their shirt with their name. I (R3) know most of them though. When there's a new face, I'm (R3) like who is this? Don't touch me if you can't prove who you are. It would be nice if they (staff) wore badges.R4's face sheet documents diagnoses that include but are not limited to diabetes, chronic kidney disease, and anxiety disorder.R4's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R4 is cognitively intact.On 11/14/2025 at 12:38pm, R4 said, No, most staff don't wear ID badges. I (R4) know most of them (staff). The staff is good. I (R4) don't want to get any of them in trouble.On 11/14/2025 at 11:12am, during tour of the facility with V2 (Director of Nursing/DON), V3 (Licensed Practical Nurse/LPN) was observed with an ID badge that was not visibly displaying V3's name and staff position. V3 said, Oh, it's here. Let me fix it. V2 proceeded to take apart V3's ID badge so V3's name and staff position was visible.On 11/14/2025 at 11:15am, during tour of the facility with V2 (Director of Nursing/DON), V4 (Certified Nursing Assistant/CNA) was observed without an ID badge, V4 said, It's (ID badge) getting made. I (V4) lost it about a week ago.On 11/14/2025 at 11:26am, during tour of the facility with V2 (Director of Nursing/DON), V6 (Restorative Aide) was observed without an ID badge. V6 said, I've (V6) never had a real badge. I've (V6) been here like a year.On 11/14/25 at 11:28am, during tour of the facility with V2 (Director of Nursing/DON), V5 (Certified Nursing Assistant/CNA) was observed without an ID badge. V5 said, I (V5) wasn't given a badge. Been here about 3 months.Facility's daily schedule, dated 11/14/2025, documents the follow: V3 (Licensed Practical Nurse/LPN) assigned to Unit 1; V4 (Certified Nursing Assistant/CNA) assigned to Unit 1; V6 (Restorative Aide) assigned to Unit 1; and V5 (Certified Nursing Assistant/CNA) assigned to Unit 1.V2's (Director of Nursing/DON) e-mail, dated 1/14/2025 at 2:50pm, documents the hire dates for the following employees: V3 (Licensed Practical Nurse/LPN) hire date of 11/3/2025; V4 (Certified Nursing Assistant/CNA) hire date of 12/2/2024; V5 (Certified Nursing Assistant/CNA) hire date 7/31/2025; and V6 (Restorative Aide) hire date 1/11/2024. On 11/14/2025 at 11:30am, V9 (RN/Registered Nurse/Regional [NAME] President of Operations) said that it's preferred for staff to wear ID badges. V9 stated that it doesn't take a minute to obtain the employees' ID badges. V9 said that V9 is unaware if there is a policy on employees wearing ID badges, but V9 will check to see if there is a policy.On 11/14/2025 at 2:53pm, V2 (Director of Nursing/DON) said I (V2) was told there is no policy for employee ID badges. No one could find it. I (V2) know that the students that come here have ID badges. All employees should have ID badges so the residents can identify who is caring for them. We (facility) do have different colored scrubs to differentiate between different job positions. V2 stated that the facility has stickers to put the required information on if an employee does not have a badge. V2 affirmed that employees should wear ID badges when working.Record review of The Public Health (410 ILCS 50/) Medical Patient Rights Act, Sec. 6. Identification badges, documents, in part, A health care facility that provides treatment or care to a patient in this State shall require each employee of or volunteer for the facility, including a student, who examines or treats a patient or resident of the facility to wear an identification badge that readily discloses the first name, licensure status, if any, and staff position of the person examining or treating the patient or resident. (Source: P.A. 98-243, eff. 1-1-14; 98-890, eff. 1-1-15; 99-180, eff. 7-29-15.)Record review of the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based upon observation, interview, and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for 36 of 40 dependent residents (R2, -R6, R10, R12, R18, R20, R21, R28, R29, R32, R33, R34, R36, R38 - R40, R44, R51, R54, R56 - R59, R61, R67, R68, R74, R75, R80 - R82, R85, R96) in the sample reviewed for staffing. Findings include:The (7/20/25) facility census includes 87 residents. On 7/21/25 at 10:23am, long facial hair was observed on R6's face and his toenails were notably thick and long. Surveyor inquired if R6 prefers to be shaved R6 stated Yeah, I'm supposed to have shaves every day. On 7/21/25 at 10:26am, surveyor inquired about the appearance of R6's toenails V8 (LPN/Licensed Practical Nurse) responded I (V8) see long toenails, he (R6) could go for a good clipping. Surveyor inquired about R6's long facial hair V8 replied Do you (R6) wear a beard? R6 responded No, I never have one. Concerns were also identified with R6's LALM (Low Air Loss Mattress) on the incorrect setting (incorrect weight) while in use. On 7/21/25 at 10:58am, concerns were identified with R2's LALM on the incorrect settings (incorrect weight, static mode) while in use. On 7/21/25 at 11:07am, R56 stated the care of the workers (facility staff) close to shift change its ridiculous they (staff) rush you while going through their duties and affirmed he has concerns with ADL (Activities of Daily Living) care provided by the facility. On 7/21/25 at 11:16am, R4's nails were long with black debris beneath them. Surveyor inquired if R4 can cut and/or clean his own nails R4 stated No [R4's diagnoses include hemiplegia and hemiparesis]. Concerns were identified with R4's LALM on the incorrect setting (incorrect weight) while in use. R4's (infusing) IVPB (Intravenous Piggyback) label stated 250/83ml/hr (milliliters per hour) however the rate was set on 250ml/hr. Surveyor inquired what rate R4's IVPB rate was set on V11 (RN/Registered Nurse) inspected R4's dial-a -flow and stated 250 however the rate was supposed to be 83ml/hr. R4's indwelling urinary catheter contained cranberry colored urine. Surveyor inquired about the appearance of R4's urine V11 responded It's red. I (V11) see like dark red so there's blood. Surveyor inquired why there was blood in R4's urine V11 replied He has like this blood tinge urine, sometimes its lighter. He (R4) takes Eliquis and Plavix. When I talked with the Nurse Practitioner, she (Nurse Practitioner) said it could be from tension or the blood thinners. Surveyor inquired if R4's catheter was secured to his leg to prevent tension and/or trauma V11 stated No. Surveyor inspected R4's indwelling urinary catheter and there was notable tension noted due to bag placement and failing to secure the tubing to resident's leg. On 7/21/25 at 11:33pm, R67's bilateral hands and right arm were contracted however restorative devices were not in use. Surveyor inquired if R67 was able to move his right arm R67 was unable to do so. Surveyor inquired if R67 could open his right hand, minimal movement was noted. Surveyor inquired if R67 receives restorative therapy R67 stated I have MS (Multiple Sclerosis) my feet used to be like normal but because they never stretched my feet they got bent. The left foot is really curved. Even though they say they have therapy, no they don't. They just chit chat, they don't do nothing, they keep making excuses and it doesn't get done. R67's left foot was internally rotated and notably deformed. On 7/21/15 at 11:50am, surveyor inquired if R67 requires restorative devices V12 (Restorative Aide) stated No ma am, not that I know. He (R67) just have the heel protectors. Surveyor inquired about required restorative devices/splints for R67's hands V12 responded No ma am, he don't have any of those on his hands. Surveyor inquired if R67 receives PROM (Passive Range of Motion) due to inability to move the right hand and/or arm V12 replied I (V12) was doing the PROM on his right side (10 reps) and he (R67) would help me with the left side twice a day, that's on the days that they (facility) didn't send me (V12) out on the escorting, and that was discontinued. On 7/21/25 at 11:55am, surveyor inquired about concerns in the facility R44 stated My leg is so so. Surveyor inquired if R44 could move his lower extremities, R44 had difficulty lifting his left foot and was unable to lift the right. R44's (July 2025) documentation survey report includes AROM (Active Range of Motion) which states resident will be able to complete 15 repetitions of AROM flexion extension exercises to all extremities daily [PROM/Passive Range of Motion was excluded]. R44's (4/11/25) functional assessment affirms range of motion impairment (on 1 lower extremity). On 7/22/25, surveyor observed the facility's 9am medication administration and there were 6 medication errors out of 25 opportunities, resulting in a 24% medication error rate [excluding late medication administration - subsequently identified]. Three of four residents (R12, R80, R96) in the medication administration sample were affected.On 7/22/25 at 10:00am, five (5) of V8's (LPN) assigned residents (R32, R36, R38, R58, R74) were highlighted red on the EMAR (Electronic Medication Administration Record). Surveyor inquired what red highlighted residents indicates on the EMAR V8 stated Red means that I'm behind in my time. Surveyor inquired if all assigned resident medications (scheduled for 9am) were administered today V8 responded I'm behind and affirmed that the red highlighted residents did not receive their medications yet. Surveyor inquired about the regulatory requirement for medication administration V8 replied It's a 2-hour window a hour before and a hour after the scheduled time. Surveyor inquired how many residents V8 is currently assigned to V8 stated 22.On 7/22/25 at 10:08am, nineteen (19) of V11's (RN) assigned residents (R2, R4, R18, R20, R21, R28, R29, R33, R39, R40, R44, R51, R54, R56, R57, R59, R61, R67, R82) were highlighted red on the EMAR. Surveyor inquired why residents were highlighted red on the EMAR V11 stated Because of the timeframe and affirmed the highlighted residents had not yet received their 9am medications. Surveyor inquired how many residents V11 is currently assigned to V11 responded 32.On 7/22/25 at 10:15am, eight (8) of V20's (LPN) assigned residents (R3, R5, R10, R34, R68, R75, R81, R85) were highlighted red on the EMAR. Surveyor inquired what red highlighted residents indicates on the EMAR V20 stated It means that I'm late. Surveyor inquired if all assigned residents received their 9am medications V20 responded No. Surveyor inquired how many residents V20 is assigned to V20 replied 32. On 7/22/25 at 12:04pm, V11 was observed passing 9 am medications (2 hours after the required administration time). Surveyor affirmed with V11 that eight (8) of the assigned residents (R2, R21, R33, R56, R57, R59, R67, R82) had not yet received their medications.On 7/23/25 at 10:13am, surveyor inquired about the facility restorative staff V21 (Restorative Aide) stated We have 2 restorative aides and there's a restorative nurse. The restorative nurse has been off for a couple of months. Surveyor inquired about the facility restorative program V21 responded It's Monday through Friday for each resident basically on every unit. I'm assigned to unit 1 and (V12/Restorative Aide) is on unit 2. Survey inquired about R44's restorative care V21 replied From his (R44) waist down is paralyzed, we (staff) basically exercise the limbs 15 minutes a day. Surveyor inquired where restorative care is documented V21 stated It's in the POC's (electronic plan of care). Surveyor inquired about concerns with R44's (July 2025) restorative documentation V21 reviewed the documentation and responded I (V21) see there's nothing right there on the 1st, the 8th, the 11th, and 12th its missing, it wasn't documented in the POC. Surveyor inquired how frequent V21 gets pulled from restorative care - to work the floor as a CNA V21 replied On a 30-day basis, it could be 10 or 15 of those days. V21 reviewed the July 2025 schedules and stated, I was pulled on the floor July 7th and 8th. Surveyor inquired about R67's restorative care V21 stated He (R67) gets exercises on his arms and legs for 15 minutes every day. Surveyor inquired about R67's (July 2025) restorative documentation V21 reviewed the documentation and responded He's missing for this month the 5th, 7th, 8th, 11th, 12th, and 13th and affirmed the entries were blank.On 7/22/25 at 3:52pm, V1 (Administrator) affirmed that the facility does not have a staffing policy therefore staffing is based on The acuity of the residents and the population, the actual number of them (residents).

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that IV (Intravenous) medication was labeled properly, failed to ensure that medication rooms are locked, failed to ensure that medication refrigerators are maintained within the required range, and failed to store refrigerated medications at required temperatures. These failures have the potential to affect 87 residents. Findings include: The (7/20/25) facility census includes 87 residents. On 7/21/25 at 11:16am, an IVPB (Intravenous Piggyback) was infusing through R4's IV (Intravenous) access however the residents name was not on the bag. Vitamin C, B complex, B7, zinc, and amino blend were listed (on the IVPB label) with check boxes next to each supplement however none of the boxes were checked. On 7/21/25 at 11:19am, surveyor inquired if any of the listed medications were checked on R4's IVPB V11 (RN/Registered Nurse) inspected the IVPB and responded, No checks. Surveyor inquired if staff know what's in R4's IVPB if nothing was checked V11 replied We don't and affirmed that she did not hang R4's IVPB.The July 2025 (unit 1) medication room refrigerator temperature log affirms freezer Ice was documented on 7/1, 7/2, 7/3, 7/4, 7/6, 7/7, 7/8, 7/12, 7/13, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22 and 7/23. On 7/23/25 at 11:11am, surveyor inspected the (unit 1) medication room with V20 (Licensed Practical Nurse). Several residents' medications (including Insulin, Ativan solution) were observed (on top of) a refrigerator labeled food. Surveyor inquired why the resident medications (that require refrigeration) were on top of the refrigerator V20 stated They're (pharmacy staff) switching out the refrigerator now, it just happened 10 minutes ago. Pharmacy is delivering one now. A melting piece of ice was observed in a clear locked box (containing Ativan solution) and a thermometer was hanging from the box, surveyor requested the current temperature on that thermometer V20 responded It's 79 degrees. Surveyor inspected the thermometer and affirmed it was 79F (Fahrenheit) therefore out of required range.On 7/23/25 at 11:19am, surveyor relayed concerns regarding the unrefrigerated medications observed on unit 1 (which require refrigeration). V1 (Administrator) stated Well just re-order everything then instructed V20 to contact the pharmacy and request replacement medications for each resident. On 7/23/25 at 11:30am, V23 (RN) entered the (unit 2) medication room (which was unlocked and unsupervised by authorized Nursing staff). Surveyor inquired why the (unit 2) medication room was unlocked V23 affirmed she was unsure. The medication refrigerator temperature was 67F and a buildup of ice was on the freezer (roughly 3 inches thick). Surveyor inquired what the (unit 2) medication refrigerator temperature should be V23 stated It should be under 70. The July 2025 (unit 2) medication room refrigerator temperature log affirms freezer Ice was documented on 7/9, 7/10, 7/18, 7/20, 7/21, 7/22, and the 7/23 temperature entry was blank. On 7/23/25 at 11:36am, (6 minutes later) surveyor relayed concerns regarding medication storage on unit 2. V2 (Director of Nursing) approached the (unit 2) medication room (as requested) and stated the The door is ajar. The (unit 2) medication room was (again) unsupervised by authorized Nursing staff. Surveyor inquired what range the medication refrigerator temperature should be maintained at V2 responded I (V2) refer to this (referencing the temperature log) its 36 to 46 degrees (Fahrenheit). Surveyor inquired about the current temperature in (unit 2) medication refrigerator V2 replied Looks like it's about 68 so it's warm. Surveyor inquired about concerns with the (unit 2) medication refrigerator freezer V2 stated The freezer needs to be defrosted. Surveyor inquired what's currently in the (unit 2) medication refrigerator V2 removed each item and affirmed that insulins, olanzepine solution, haldol decanoate, zepbound, latanopoprost, and aplisol were found. Surveyor inquired what V2 plans to do with the (unit 2) refrigerated medications V2 stated I'll have to re-order them and get them replaced since the refrigerator was warm. Surveyor inquired about the July 2025 (unit 2) medication room refrigerator log V2 reviewed the log and affirmed that freezer Ice was documented several times. The (undated) storage of medications policy states medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36F and 46F with a thermometer to allow temperature monitoring.

Based on observation, interview and record review, the facility failed to ensure that the outside dumpster was closed. These failures have the potential to affect all 87 residents residing at the facility.Findings include:Facility census, dated 7/21/2025, documents 87 residents residing at the facility.On 7/21/2025 at 9:39am, the outside facility dumpster was observed with V6 (Dietary Manager). The dumpster was observed opened at the outside facility dumpster area, with a swarm of flies flying inside and outside the dumpster. When asked about the opened dumpster, V6 replied, It (dumpster) should be kept closed to stop rodents and bugs. Housekeeping be dumping stuff too. Look at all those flies.On 7/22/2025 at 9:57am, the outside facility dumpster was observed with V22 (Housekeeping Director/Head of Laundry). The dumpster was observed opened at the outside facility dumpster area, with a swarm of flies flying inside and outside the dumpster. When asked about the opened dumpster, V22 replied, Yeah, the dumpster should be kept closed at all times. Gotta keep it closed to keep the smell and the flies down. Housekeeping and Dietary us this dumpster.Facility policy titled, Pest Control, revised date 9/01/2022, documents, in part, 1. The Environmental Services Director will be responsible for coordinating the facility pest control. 16. Outside dumpsters shall be of sufficient size that the lid can be tightly closed. 17. The dumpster shall be kept clean and maintained in good repair, and a lid shall be kept closed.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Facility job description titled, Housekeeper, date created 3/23/2017, documents, in part, Summary: The primary purpose of the Housekeeper is. assure that our facility is maintained in a clean, safe, and comfortable manner.

Based on observation, interview, and record review, the facility failed to conduct hand hygiene prior to passing meal trays , and before providing meal time assistance. This affected 4 residents (R12, R22, R72 and R76) reviewed for hand hygiene in the sample of 40 residents. Findings include:On 7/21/25 at 12:54pm, surveyor observed V13 (certified nursing assistant/CNA) perform hand hygiene and wash her (V13) hands, retrieve a meal tray from the food cart, walk to the table R22 was sitting at, and serve R22 the meal tray. While serving R22 the meal tray, V13 was observed touching R22 while arranging the meal tray for R22. V13 then walked back to the food cart, did not perform hand hygiene, retrieved another meal tray from the food cart, walked to the table R72 was sitting at and served R72 the meal tray. After serving R72 the meal tray, V13 went back to the food cart, did not perform hand hygiene, retrieved another meal tray from the food cart, walked to the table R76 was sitting at and served R76 the meal tray. V13 then walked back to the food cart, did not perform hand hygiene, retrieved another meal tray from the food cart, walked to the table R12 was sitting at and served R12 the meal tray. On 7/21/25 at 1:03pm, V21 (Restorative Aide) was observed taking residents' meal trays who had finished eating and placing the, in the food cart to be taken back to the kitchen for cleaning. After placing a dirty meal tray in the food cart, V21 did not perform hand hygiene and was observed to go to the table R22 was sitting at and asked R22 Are you done eating? R22's meal tray was observed with approximately 80% of the food not eaten. V21 was then observed to pick up R22's spoon and assist R22 with eating is (R22) meal. On 7/21/2025 at 1:15pm, V13 said, You (staff) do not have to wear gloves while passing trays. You (staff) clean your hands before passing meal trays and when you (staff) are done passing meal trays to all the residents. On 7/21/2025 at 1:26pm, V2 (Director of Nursing/DON/Infection Preventionist/IP) said, Hand hygiene is done while passing trays to prevent transferring bacteria to other residents.Facility policy titled, Hand Hygiene/Handwashing, revised date 7/30/2024, documents, in part, Definition: Hand Hygiene means cleaning your hands by either using (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 hang hygiene (either alcohol based hand sanitizer or handwashing): before and after having direct contact with a patient's intact skin. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.Facility policy titled, Infection Prevention and Control Program, effective date 11/28/2012; revision date 11/28/2017; reviewed/approved by: IDT (interdisciplinary team) no date, documents, in part, Purpose: To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. 1. The facility has established an Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and health care workers. 2, The Infection Control Program meets the guidelines of the U.S. Department of Health and Human Services' Centers for Disease Control and Prevention, HCFS, The Occupational Health and Safety Administration, local, state, and federal rules. 14. All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections. 15. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to implement care plan interventions, and/or failed to ensure that ADL (Activities of Daily Living) care was provided to four of forty dependent residents (R3, R4, R6, R59) in the sample. Findings include: R6 is [AGE] years old with diagnoses which include arthritis and lack of coordination. R6's (6/18/25) BIMS (Brief Interview Mental Status) determined a score of 4 (severe impairment). R6's (6/18/25) functional assessment affirms resident is dependent on staff for personal hygiene. R6's (6/17/25) ADL care plan includes self-care performance deficit, personal hygiene – my usual performance is dependent. On 7/21/25 at 10:23am, long facial hair was observed on R6's face and his toenails were notably thick and long. Surveyor inquired if R6 prefers to be shaved R6 responded Yeah, I'm supposed to have shaves every day. On 7/21/25 at 10:26am, surveyor inquired about the appearance of R6's toenails V8 (Licensed Practical Nurse) replied I (V8) see long toenails, he (R6) could go for a good clipping. Surveyor inquired about R6's long facial hair V8 responded Do you (R6) wear a beard? R6 replied No, I never have one. R4's diagnoses include hemiplegia and hemiparesis following cerebral infarction. R4's (6/22/25) BIMS determined a score of 9 (moderate impairment). R4's (5/2/25) functional assessment affirms resident requires substantial/maximal assistance with personal hygiene. R4's (1/28/25) ADL care plan includes self-care performance deficit, monitor residents' abilities for ADLS and assist resident as needed. On 7/21/25 at 11:16am, R4's nails were long with black debris beneath them. Surveyor inquired if R4 can cut and/or clean his own nails R4 stated No. The (11/28/12) activities of daily living policy includes grooming: maintaining personal hygiene (shaving, nail care). On 7/21/25 at 10:19am, surveyor observed R3 lying on her right side with long fingernails on both hands and brown substances underneath the nail beds, and brown substances imbedded all along the sides of all 10 fingernails. When asked about R3's fingernails, R3 replied, Of course I (R3) want my nails cut. I (R3) ask all the time. They (nails) are filthy. I (R3) need help. R3's Face Sheet, documents medical diagnoses that include but are not limited to Parkinson's disease, general arthritis, rheumatoid arthritis, and depressive disorder. R3's BIMS (Brief Interview for Mental Status) Summary Score: 15, dated 4/23/25, suggests R3 is cognitively intact. R3's MDS (Minimum Data Set) section GG Functional Abilities, dated 5/16/25, documents, in part, Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene): Partial/Moderate Assistance. R3's Care plan, revised date 6/26/25, documents, in part, I (R3) require assistance with ADLS (activities of daily living) due to generalized weakness related to Dx. of Anemia Osteoarthritis Old Myocardial Infarction Rheumatoid Arthritis r/t (related to), with interventions that document, in part, Provide 1-person extensive assistance for bathing. Upon review of R3's care plan, there is no documentation that R3 refuses nailcare. On 7/23/25 at 3:13pm, V2 (Director of Nursing/DON/Infection Preventionist/IP) said, I (V2) expect nails to be trimmed and cleaned. Nail care is done with every shower for sure or can be on a as needed basis also. Facility policy titled, Nail Care, revised date 1/25/18, documents, in part, . 1. Observe condition of resident nails during each time of bathing. Not cleanliness, length uneven edges, hypertrophied nails. 4. After bathing, use orange stick, and clean debris from around and under finger and toenails. 5. Trim toenails carefully in a straight fashion and fingernails in an oval fashion avoiding tissue after bathing or when needed. R59 is [AGE] years old admitted to the facility on [DATE], past medical history includes: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acquired absence of other left toes, type 2 diabetes with diabetic neuropathy, acquired absence of right leg below knee, cardiomegaly, weakness, major depressive disorder, etc. 07/22/2025 9:38AM, R59 was observed in his room awake and alert and was noted with lots of facial hair, dry scaly rashes on his face and very long fingernails with brownish substances underneath. Surveyor also noted a large matrass on the floor beside the resident with lots of brownish stains. 07/23/2025 11:30AM, R59 was observed again in his room still with lots of facial hair, some whitish rashes were noted on resident's face and resident was asked if he would like to be shaved and he said yes. 59 said that he cannot shave himself, he needs staff assistance and some of them will do it and others do not. R59 was noted with long fingernails with brownish materials underneath, R59 said that he would like his fingernails trimmed but no one does it. R59 said that he requires staff assistance for activities of daily living, he had a stroke and cannot move his right side. Care plan initiated 9/20/2024 and revised 2/20/2025 states that R59 has an ADL care self-performance deficit related to disease process, interventions indicated that R59 is dependent on staff for all ADL care. On 7/23/2025 at 3:16PM, V2 (DON) said that the expectation is for resident's nails to be cleaned and trimmed when providing activities of daily living (ADL) care. V2 added that some residents will refuse but the C.N.A is supposed to report any refusal to the nurse who will document it in resident's medical record. Refusal of ADL care should also be care planned.

Based upon observation, interview, and record review the facility failed to ensure that (R4's) IVPB (Intravenous Piggyback) was infusing at the correct rate and failed to ensure that prescribed medications were administered within regulatory requirements for 32 of 40 residents (R2, R3, R4, R5, R10, R18, R20, R21, R28, R29, R32, R33, R34, R36, R38, R39, R40, R44, R51, R54, R56, R57, R58, R59, R61, R67, R68, R74, R75, R81, R82, R85) in the sample. These failures have the potential to affect 87 residents.Findings include: On 7/21/25 at 11:16am, a 250 milliliter IVPB (Intravenous Piggyback) was infusing through R4's IV (Intravenous) access. R4's IVPB label stated 250/83ml/hr (milliliters per hour) however the rate was set on 250ml/hr. On 7/21/25 at 11:19am, surveyor inquired what rate R4's IVPB rate was set on V11 (Registered Nurse) inspected R4's dial-a -flow and stated 250 however the rate was supposed to be 83ml/hr. The (7/20/25) facility census includes 87 residents. On 7/22/25 at 10:00am, five (5) of V8's (LPN/Licensed Practical Nurse) assigned residents (R32, R36, R38, R58, R74) were highlighted red on the EMAR (Electronic Medication Administration Record). Surveyor inquired what red highlighted residents indicates on the EMAR V8 stated Red means that I'm behind in my time. Surveyor inquired if all assigned resident medications (scheduled for 9am) were administered today V8 responded I'm behind and affirmed that the red highlighted residents did not receive their medications yet. Surveyor inquired about the regulatory requirement for medication administration V8 replied It's a 2-hour window a hour before and a hour after the scheduled time. On 7/22/25 at 10:08am, nineteen (19) of V11's (Registered Nurse) assigned residents (R2, R4, R18, R20, R21, R28, R29, R33, R39, R40, R44, R51, R54, R56, R57, R59, R61, R67, R82) were highlighted red on the EMAR. Surveyor inquired why residents were highlighted red on the EMAR V11 stated Because of the timeframe and affirmed that the highlighted residents has not yet received their 9am medications. Surveyor inquired about the regulatory requirement for medication administration V11 responded It's usually an hour before and a hour after the scheduled time. On 7/22/25 at 10:15am, eight (8) of V20's (LPN) assigned residents (R3, R5, R10, R34, R68, R75, R81, R85) were highlighted red on the EMAR. Surveyor inquired what red highlighted residents indicates on the EMAR V20 stated It means that I'm late. Surveyor inquired if all assigned residents received their 9am medications V20 responded No. Surveyor inquired how many residents V20 is assigned to V20 stated 32. On 7/22/25 at 12:04pm, V11 was observed passing 9 am medications (2 hours after the required administration time). Surveyor affirmed with V11 that eight (8) of the assigned residents (R2, R21, R33, R56, R57, R59, R67, R82) had not yet received their medications.The (undated) medication administration policy states medications are administered in accordance with written orders of the prescriber. Medications are administered within 1 hour before or after scheduled time unless otherwise specified by the prescriber.

Based upon observation, interview, and record review the facility failed to ensure that residents are assessed properly for restorative care needs, failed to ensure that residents are assessed properly for restorative device needs, failed to ensure that required restorative care was provided to (R44, R67) as directed and failed to provide restorative devices to two of 40 residents (R59, R67) in the sample.Findings include: R67's diagnoses include MS (Multiple Sclerosis). R67's (July 2025) documentation survey report includes PROM (Passive Range of Motion) exercises 10 reps to all extremities 2 times daily however several entries were noted to be blank. The facility list of residents with orthotics or splints (excludes) R67's name. On 7/21/25 at 11:33pm, R67's bilateral hands and right arm were contracted however restorative devices were not in use. Surveyor inquired if R67 was able to move his right arm R67 was unable to do so. Surveyor inquired if R67 could open his right hand, minimal movement was noted. Surveyor inquired if R67 receives restorative therapy R67 stated I have MS my feet used to be like normal but because they never stretched my feet they got bent. The left foot is really curved. Even though they say they have therapy, no they don't. They just chit chat, they don't do nothing, they keep making excuses and it doesn't get done. R67's left foot was internally rotated and notably deformed. At 11:50am, V12 (Restorative Aide) entered R67's room, surveyor inquired if R67 requires restorative devices V12 stated No ma am, not that I know. He (R67) just have the heel protectors. Surveyor inquired about required restorative devices/splints for R67's hands V12 responded No ma am, he don't have any of those on his hands. Surveyor inquired if R67 receives PROM due to inability to move the right hand and/or arm V12 replied I was doing the PROM on his right side (10 reps) and he would help me with the left side twice a day, that's on the days that they (facility) didn't send me out on the escorting, and that was discontinued. The (July 21, 2025) restorative intervention/task schedule report with required nursing rehab/restorative care (excludes) R67's name. R44's diagnoses include dementia and osteoarthritis of hip. On 7/21/25 at 11:55am, R44 was seated in a wheelchair. Surveyor inquired about concerns in the facility R44 stated My leg is so so. Surveyor inquired if R44 could lift either leg from the foot pedal. R44 had difficulty lifting his left foot and was unable to lift the right. Surveyor inquired if R44 receives restorative therapy V11 (Registered Nurse) stated, I'm not 100% sure who's on their (restorative staff) list. The July 21, 2025, restorative intervention/task schedule report with required nursing rehab/restorative care (excludes) R44's name. R44's (July 2025) documentation survey report includes AROM (Active Range of Motion) resident will be able to complete 15 repetitions of AROM flexion extension exercises to all extremities daily. [PROM was excluded]. On 7/22/25 at 2:32pm, V1 (Administrator) affirmed the facility employs (1) restorative nurse and (2) restorative aides. On 7/23/25 at 10:13am, surveyor inquired about the facility restorative staff V21 (Restorative Aide) stated We have 2 restorative aides and there's a restorative nurse. The restorative nurse has been off for a couple of months. Surveyor inquired about the facility restorative program V21 responded It's Monday through Friday for each resident basically on every unit. I'm assigned to unit 1 and (V12/Restorative Aide) is on unit 2. Survey inquired about R44's restorative care V21 replied From his (R44) waist down is paralyzed, we (staff) basically exercise the limbs 15 minutes a day. Surveyor inquired where restorative care is documented V21 stated It's in the POC's (electronic plan of care). Surveyor inquired about concerns with R44's (July 2025) restorative documentation V21 reviewed the documentation and responded I (V21) see there's nothing right there on the 1st, the 8th, the 11th, and 12th its missing, it wasn't documented in the POC. Surveyor inquired how frequent V21 gets pulled from restorative care - to work the floor as a CNA V21 replied On a 30-day basis, it could be 10 or 15 of those days. V21 reviewed the July 2025 schedules and stated, I was pulled on the floor July 7th and 8th. Surveyor inquired about R67's restorative care V21 stated He (R67) gets exercises on his arms and legs for 15 minutes every day. Surveyor inquired about R67's (July 2025) restorative documentation V21 reviewed the documentation and responded He's missing for this month the 5th, 7th, 8th, 11th, 12th, and 13th and affirmed the entries were blank. The (undated) passive range of motion policy states residents will be assessed for their need of passive range of motion per the functional limitation range of motion assessment. If the resident is recommended for a PROM program, trained nursing staff will provide the range of motion exercises. PROM is provided by the staff will no assist from the resident. 07/22/2025 9:38AM, R59 was observed in his room awake and alert and was complaining of pain, stated that he had a stroke and cannot move his right side. R59 was noted with contracture to his right hand but did not have any device or splint. 07/23/2025 11:30AM, R59 was observed again in his room, R59 said that he was supposed to wear a splint on his right hand, but staff put it on him sometimes. Surveyor asked R59 where his splint is, and he said that it should be in his top drawer. At 11:45AM, V14 (LPN) walked into the room and said that she is the assigned nurse for the resident. surveyor asked her to see if she can locate resident's splint, she looked in all 3 drawers and could not find it. V14 said that she could not find it but maybe it was lost when the resident moved, she will search the room further. R59 has an active physician order for right hand splint every shift to prevent contraction. Care plan dated 11/15/2024 states that R59 requires the use of splint related to decrease range of motion. Goal: Resident will tolerate wearing right hand splint daily. Interventions: assess daily for skin breakdown, report to the nurse if sign of skin breakdown, staff applies right hand splint daily. On 7/23/2025 at 3:16PM, V2 (DON) said that staff fond resident's splint in the closet after surveyor left the room. V2 was asked if the splint was supposed to be in the closet and she said, not during wearing time.

Based on interview and record review, the facility failed to refer residents with possible serious mental disorders for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This failure affects 2 residents (R5 and R79) reviewed for pre-admission screening in the sample list of 54 residents.Findings include: R79 is [AGE] years old admitted to the facility on [DATE], medical history includes hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, type 2 diabetes, essential primary hypertension, neuralgia, and neuritis unspecified, major depressive disorder severe without psychotic features, schizoaffective disorder bipolar type, etc. 07/22/2025 12:00 PM, R79 was observed in her room in bed, awake and alert and stated that she is doing okay. Resident said that she gets out of bed three times a week, will like to have more activities but does not want to get up more than three times. Per record review, R79 has diagnoses of major depressive disorder and schizoaffective disorder bipolar type. There is no evidence that R79 received PASARR level 1 or 11 screening while at the facility. 07/23/2025 at 9:30AM, requested PASARR information for R79 from the DON and none was provided. 07/23/2025 1:46 PM, V2 (DON) said that they do not have any PASARR for R79, they are going to submit a request today. R5's face sheet documents, in part, initial admission date 9/12/2016; admission reentry 12/06/2016. R5's face sheet documents R106's diagnoses that include but are not limited to schizophrenia (date diagnosed 12/04/2019) and schizoaffective disorder (date diagnosed 8/07/24). R5's care plan, revised date 10/12/2021, documents, in part, I (R5) use psychotropic medications (Abilify) r/t (related to) Disease process (schizophrenia). Review of R5's OBRA (Omnibus Budget Reconciliation Act) (-I Initial Screen, dated 9/08/2016, documents, in part, Based upon all information and data available to me for this person there is reasonable basis for suspecting DD (Developmental Disability) or MI (Mental Illness): No. On 7/22/25 at 1:20pm, V1 (Administrator) stated that R5's MDS (Minimum Data Set) did not have the correct information, so the MDS did not flag to have a PASARR II (Preadmission Screening and Annual Resident Review) done. V1 affirmed that schizophrenia and schizoaffective disorder require a level 2 PASARR, which could possibly approve R5 for special services. On 7/23/25, V1 (Administrator) provided R5's Notice of PASRR Level I Screen Outcome, dated 7/22/2025, that documents, in part, PASRR Level I Determination: Refer to Level II Onsite. Facility policy titled, Preadmission Screening and Annual Resident Review (PASARR), review/revised date 11/17/2017, documents, in part, Guidelines: It is the policy to screen all potential admissions on an individual basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based upon the Level 1 screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the level II screen. Objective PSASRR Policy: The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon significant change for those individuals identified. Procedure f. Coordination of Care. iv. The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change is status assessment to the State PASARR representative.

Based on interview and record review, the facility failed to have a pain management care plan with resident's goals and preferences for two residents who receive pain medications (R20 and R59) reviewed for care planning in a sample of 54 residents.Findings include:R59 is [AGE] years old admitted to the facility on [DATE], past medical history includes: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acquired absence of other left toes, type 2 diabetes with diabetic neuropathy, acquired absence of right leg below knee, cardiomegaly, weakness, major depressive disorder, etc.07/22/2025 9:38 AM, R59 was observed in his room, awake and alert and stated that he is waiting for someone to change him. R59 added that the nurses ran out of his Norco, he received one tablet yesterday and they told him that was the last one. R59 added that he is in pain right now and rated his pain as 8 on a 1 to 10 scale. R59 said that he can get Tylenol, but it does not help with his pain, he had a stroke and cannot move his right side, does not want to sit up due to his pain. Review of active physician order for R59 shows an order for pain assessment Q shift, every shift.R59 also have the following orders: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug*. Give 5 mg by mouth every 6 hours as needed for Pain. Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for Pain. Lidocaine Pain Relief 4 % Patch Apply to right shoulder topically every 12 hours for Pain.Review of resident's care plan did not show any care plan with measurable goals and interventions to manage resident's pain.R20 is [AGE] years old admitted to the facility on [DATE], past medical history includes but not limited to major depressive disorder, type 2 diabetes with hyperglycemia, unspecified psychosis not due to substance or known physiological condition, hyperlipidemia unspecified, hypotension, etc.07/22/2025 9:28AM, R20 was observed in his room, awake and alert and stated that he is doing okay, R20 said that he has pain sometimes and gets medication when he needs it.07/23/2025 10:00 AM Per record review, R20 receives medication for pain, physician order dated 7/23/2025 stated to assess pain every shift. R20 has an active order for Ibuprofen Oral Tablet 400 MG (Ibuprofen) Give 1 tablet by mouth every 8 hours as needed for mild pain.R20 does not have any care plan for pain management.On 07/23/2025 at3:16 PM, V2 (DON) said that residents who are on pain management should have a care plan in place for it. The purpose of the care plan is to make sure that resident's pain is being managed effectively, ensure that there is a goal in place to help track resident's pain level and re-evaluate the effectiveness of every treatment. V2 added that the MDS nurse have been off for a week or two now, but she will follow up with whoever is covering.Comprehensive care plan policy revised 11/17/2017 states its purpose as to develop a comprehensive are plan that directs the care team and incorporates resident's goals, preferences and services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psycho-social wellbeing.Under guidelines, the policy states in part that the facility will develop and implement a person-centered care plan for each resident, consistent with resident's rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based upon observation, interview, and record review the facility failed to ensure they (facility) have a LALM (Low Air Loss Mattress) policy, failed to ensure that staff are aware of required LALM settings, failed to ensure that LALM settings were correct, and/or failed to ensure that the LALM was used correctly for three of 40 residents (R2, R4, R6) in the sample. Findings include:R6's diagnoses include pressure ulcer of left heel.On 7/21/25 at 10:23am, R6 was lying top of a LALM (Low Air Loss Mattress) wearing an incontinence brief, a flat sheet and thick pad were also beneath him. R6's mattress was set on 210 pounds however he (R6) appeared to be thin. Surveyor inquired about R6's weight V8 (LPN/Licensed Practical Nurse) stated I would put it at about 160. Surveyor inquired what setting R6's mattress is currently on V8 responded 210. [R6's 7/6/25 weight was 120.6 pounds - roughly 90 less than the LALM setting]. Surveyor inquired what's allowed on a LALM (while in use) V8 replied It's supposed to be just a pad, and we can have a sheet. R2's diagnoses include pressure ulcer of left buttock, unstageable.On 7/21/25 at 10:58am, MASD (Moisture Associated Skin Damage) was present on R2's left buttock. R2 was lying atop of a LALM set at 280 pounds and static mode (firm setting). Surveyor inquired about R2's current LALM settings V9 (LPN) stated, It's 280, on static. Surveyor inquired if V9 if knows what static mode indicates V9 responded I don't. Surveyor inquired if R2 appeared to weigh 280 pounds R56 (roommate) replied Absolutely not! V9 affirmed he (R2) did not. [R2's 7/6/25 weight was 179.2 pounds - roughly 100 pounds less than the LALM setting]. R4's diagnoses include pressure ulcer of left lower back (stage 3). On 7/21/25 at 11:16am, surveyor inquired if R4 has any wounds V11 (Registered Nurse) stated He does however resident refused an assessment. R4 was lying atop of a LALM with the setting on 350 pounds however he did not appear to weigh that much. [R4's 7/6/25 weight was 217 pounds - roughly 130 pounds less than the LALM setting].On 7/22/25 at 3:54pm, V1 (Administrator) stated We do not have a policy for the low air loss mattresses, we (facility) base everything on the manufacturer's guidelines. Surveyor inquired what's allowed on a LALM (while in use) V1 responded A flat sheet with a disposable brief or a flat sheet with a pad.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to re-order prescribed medications, and failed to ensure that prescribed medications were available for one of four residents (R12) reviewed for medication administration. Findings include: R12's (July 2025) POS (Physician Order Sheets) include Citalopram20mg (milligrams) daily, Mirtazapine 7.5mg daily, and Oxybutynin Chloride ER (Extended Release) 5mg daily (scheduled for 9am administration). On 7/22 at 8:34am, while dispensing R12's prescribed (9am) medications V20 (LPN/Licensed Practical Nurse) affirmed that 3 medications (Citalopram, Mirtazapine, Oxybutynin) were unavailable. Surveyor inquired about R12's unavailable medications V20 stated I don't have it. Surveyor inquired if R12's unavailable medications were reordered V20 reviewed R12's EMAR (Electronic Medication Administration Record) and affirmed the record states On 7/19/25 The pharmacy has indicated that the order has been rejected. Patient status is leave of absence for each of R12's unavailable medications. V20 advised that the facility has additional medications available in the (electronic medication storage) and V2 (Director of Nursing) was searching for R12's unavailable medications. On 7/22/25 at 9:01am, surveyor inquired if Citalopram, Mirtazapine, or Oxybutynin were found in the facility electronic medication storage (for R12) V2 stated I (V2) looked up all the meds and they're not here. Surveyor requested a list of medications contained in the facility electronic medication storage V2 affirmed I don't have one. The (9/2018) ordering and receiving non-controlled medications policy states medications are received from the pharmacy on a timely basis. Refills are written on a medication reorder form or by peeling the reorder tab from the prescription label and placing it on the appropriate area on the medication reorder form provided by the pharmacy for that purpose or requested via the facility's EHR system and ordered as follows: at least 3 days in advance, to ensure adequate supply is on hand.

Based upon observation, interview, and record review the facility failed to implement required care plan interventions and failed to provide a urinary catheter leg strap to prevent tension/trauma for one of 40 residents (R4) in the sample reviewed indwelling urinary catheters.Findings include:R4's diagnoses include hydronephrosis with renal and ureteral calculous obstruction.R4's (5/2/25) physician orders include indwelling urinary catheter care every shift.R4's (5/2/25) indwelling urinary catheter care plan states the following intervention: monitor for blood-tinged urine. On 7/21/25 at 11:16am, R4's indwelling urinary catheter contained cranberry colored urine. Surveyor inquired about the appearance of R4's urine V11 (Registered Nurse) responded It's red. I (V11) see like dark red so there's blood. Surveyor inquired why there was blood in R4's urine V11 replied He has like this blood tinge urine, sometimes its lighter. He (R4) takes Eliquis and Plavix. When I talked with the Nurse Practitioner, she (Nurse Practitioner) said it could be from tension or the blood thinners. Surveyor inquired if R4's catheter was secured to his leg to prevent tension and/or trauma V11 stated No. Surveyor inspected R4's indwelling urinary catheter and there was notable tension noted due to bag placement and failing to secure the tubing to resident's leg. The urinary catheter care policy (revised 2/14/19) states indwelling catheters may be secured to prevent trauma and tension.

Based upon observation, interview, and record review the facility failed to follow physician orders, failed to ensure that enteral feed orders include required total volume with start/stop times, and failed to ensure that one of 40 residents (R6) in the sample received prescribed enteral nutrition. Findings include:R6's Physician Orders include (6/13/25) Diet: nothing by mouth. (6/27/25) Enteral feed orders: Jevity 1.5cal at 45ml (milliliters) per hour for 20 hours (total volume and start/stop times are excluded). R6's (July 2025) Medication Administration Record affirms enteral feed orders include (1:00pm) start time however a stop time is excluded. On 7/21/25 at 10:26am, surveyor inquired about R6's gastrostomy tube feeding (Jevity 1.5 cal) hung at 1pm, 7/20 @ 45 ml/hr (hour) per container (which was not infusing). V8 (Licensed Practical Nurse) stated It goes back up at 1pm, I (V8) discontinue it at 9am. Surveyor inquired how much tube feeding was left in R6's Jevity (1,000ml) container V8 replied about 350 therefore R6 received only 650ml. [45ml infused over 20 hours = 900ml and the Jevity container was 1,000ml therefore R6 did not receive 250ml of required enteral feeding]. On 7/23/25 at 3:17pm, surveyor inquired about requirements for tube feeding orders V2 (Director of Nursing) stated The amount, the formula you're using and for how long the hours. Surveyor inquired if R6's tube feeding rate is 45ml/hr infused over 20 hours how many milliliters should be infused? V2 responded 900. R6's weights are as follows: (6/13/25) 125.8 pounds and (7/6/25) 120.6 pounds therefore -4.13% weight loss (within roughly 3 weeks).The (11/28/12) gastrostomy tube feeding policy states prescribed formula volume is given continuously over 16-24 hours. Licensed nurse will review physician's order for type of formula, concentration, rate of flow, and method of administration. Label container with resident's name, flow rate, date, and time.

Based on observations, interviews, and record reviews, the facility failed to ensure the oxygen humidifier was changed weekly and failed to label with date the nasal canula and failed to contain respiratory equipment for a resident. This affected one of forty (R7) residents reviewed for Respiratory care. Findings include: On 7/21/2025 at 10:28am, R7's nasal cannula oxygen tubing that was not currently in use, was observed not labeled and hanging over the oxygen concentrator not contained. R7's oxygen humidifier was dated 7/7/25 (14 days earlier). R7's CPAP (continuous positive airway pressure) mask was observed not contained laying on top of R7's white storage bin.On 7/21/25 at 1:09pm, R7 said, I've (R7) been here a couple years. Yes, I (R7) use oxygen. I'm (R7) not sure when and if the nurses change my oxygen equipment.R7's diagnoses includes but are not limited to asthma, sleep apnea, acute and chronic respiratory failure, and pneumonia. R7's BIMS (Brief Interview for Mental Status) Summary Score: 15, dated 3/20/25, suggests R7 is cognitively intact.R7's Order Summary Report, dated 7/22/25, documents in part, Rinse CPAP/BiPAP water reservoir, dry thoroughly, and refill with distilled or sterile water before use daily; Oxygen Equipment Management--change out, date & label all tubing/bags/set ups .clean filter and wipe down machine; Oxygen at 2lpm as needed. Maintain Saturations above 90%. R7's Care Plan, date revised 12/20/21, documents, in part, I (R7) have altered respiratory status/difficulty breathing r/t Sleep Apnea, Obesity, OSA (obstructive sleep apnea) with interventions that documents, in part, OXYGEN SETTINGS: O2 as ordered per MD (medical doctor). Check 02 (oxygen) sat every shift for sob (shortness of breath). R7's Care Plan, date revised 5/24/24, documents, in part, I (R7) use a C-pap/bi-pap machine while sleeping r/t (related to) sleep apnea.On 7/23/25 at 3:13pm, V2 (Director of Nursing/DON/Infection Preventionist/IP) said, We (staff) put the oxygen mask and tubing in a bag when the resident isn't using it. On Sunday we change out tubing (oxygen). Every 7 days we change tubing (oxygen) and humidifiers. Biggest thing for changing the oxygen equipment is we (staff) use water and avoid Legionnaires and diminish likelihood of infection and help breath better at night and decrease the microorganisms. Facility policy titled, Oxygen and Respiratory Equipment - Changing/Cleaning, reviewed/revised date 1/17/2019, documents, in part, Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: . 2. Nasal Cannula a. Nasal cannulas are to be changed once a week and PRN (as needed). B. Whenever possible, residents using a portable oxygen tank, will be switched to a room oxygen concentrator while in their room. c. A clean plastic bag with a zip loc or draw string, etc. will be provided to store the cannula when not in use. It will be dated with the date the tubing was changed. 4. Oxygen Humidifiers: a. Oxygen humidifiers should be changed weekly or as needed and will be dated when changed.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that prescribed medications were available, and failed to ensure that extended-release medications were not crushed therefore failed to maintain a medication error rate below 5%. There were 6 medication errors out of 25 opportunities, resulting in a 24% medication error rate. Three of four residents (R12, R80, R96) in the medication administration sample were affected. Findings include:R12's (July 2025) POS (Physician Order Sheets) include but not limited to Citalopram20mg (milligrams) daily, Mirtazapine 7.5mg daily, and Oxybutynin Chloride ER (Extended Release) 5mg daily (scheduled for 9am administration). On 7/22 at 8:34am, while dispensing R12's prescribed (9am) medications V20 (LPN/Licensed Practical Nurse) affirmed that 3 medications (Citalopram, Mirtazapine, Oxybutynin) were unavailable. Surveyor inquired about R12's unavailable medications V20 stated I don't have it. V20 advised that the facility has additional medications available in the (electronic medication storage) and V2 (Director of Nursing) was searching for R12's unavailable medications. On 7/22/25 at 9:01am, surveyor inquired if Citalopram, Mirtazapine, or Oxybutynin were found in the facility electronic medication storage (for R12) V2 stated I (V2) looked up all the meds and they're not here. R96's POS includes Lisinopril 10mg, give 40 mg in the morning (start date 7/12/25).On 7/22/25 at 9:08am, V11 (LPN) dispensed R96's prescribed medications (scheduled for 9am administration) and affirmed she was prepared to administer them however only (1) tablet of Lisinopril (10mg) was dispensed. Surveyor inquired about R96's Lisinopril orders V11 accessed the EMAR and stated, Give 40 milligrams, we need more pills. Surveyor inquired how many Lisinopril tablets should have been dispensed V11 responded 4. On 7/22/25 at 9:20am, V11 (Registered Nurse) dispensed R80's Oxybutynin Chloride ER (Extended Release) tablet and crushed it prior to administration. Surveyor inquired what the ER indicates on R80's Oxybutynin Chloride orders V11 stated Extended release. Surveyor inquired if staff are allowed to crush extended-release medications V11 responded I don't think so. The (undated) medication administration policy includes the 5 rights: right resident, right drug, right dose, right route, and right time. Triple check of these 5 rights is recommended. 1) when the medication is selected, 2) when the dose is removed from the container, and 3) just after the dose is prepared and the medication is put away. Label, container, and contents are compared against the MAR (Medication Administration Record) by reviewing the 5 rights. The dose is removed from the container and verified against the label and the MAR by reviewing the 5 rights. Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 rights.

Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure residents were free from a significant medication error. This affected three of four residents (R12, R80, R96) reviewed for medication.Findings include:R12's (July 2025) POS (Physician Order Sheets) include but not limited to Citalopram (Antidepressant) scheduled for 9am administration, Mirtazapine (Antidepressant) scheduled for 9am administration, and Oxybutynin Chloride (Antispasmodic) scheduled for 9am administration. On 7/22 at 8:34am, while dispensing R12's prescribed (9am) medications V20 (LPN/Licensed Practical Nurse) affirmed that 3 medications (Citalopram, Mirtazapine, Oxybutynin) were unavailable. V20 advised that the facility has additional medications available in the (electronic medication storage) and V2 (Director of Nursing) was searching for R12's unavailable medications. On 7/22/25 at 9:01am, surveyor inquired if Citalopram, Mirtazapine, or Oxybutynin were found in the facility electronic medication storage (for R12) V2 stated I (V2) looked up all the meds and they're not here. R96's (July 2025) POS states Lisinopril (Antihypertensive) 10mg, give 40 mg in the morning (scheduled for 9am administration).On 7/22/25 at 9:08am, V11 (LPN) dispensed R96's prescribed (9am) medications and affirmed she was prepared to administer them however only (1) tablet of Lisinopril (10mg) was dispensed. Surveyor inquired about R96's Lisinopril orders V11 accessed the EMAR and stated, Give 40 milligrams, we need more pills. Surveyor inquired how many Lisinopril tablets should have been dispensed V11 responded 4. On 7/22/25 at 9:20am, V11 (Registered Nurse) dispensed R80's Oxybutynin Chloride ER (Extended Release) tablet and crushed it prior to administration. Surveyor inquired what the ER indicates on R80's Oxybutynin Chloride orders V11 stated Extended release. Surveyor inquired if staff are allowed to crush extended-release medications V11 responded I don't think so. The (undated) medication administration policy includes the 5 rights: right resident, right drug, right dose, right route, and right time. Triple check of these 5 rights is recommended.

Based on interview and record review, the facility failed to have a treatment order in place and failed to perform dressing changes to the sacral wound for seven days. This affected one of three residents (R1) reviewed for wound care in a total sample of six. This failure resulted in the sacral wound deteriorating by becoming larger in size, and R1 being diagnosed with osteomyelitis of the sacral wound after being hospitalized for an elevated white blood cell count indicating an infection. Findings Include: R1 is an [AGE] year old with the following diagnosis: adult failure to thrive, dementia, cerebral infarction, type 2 diabetes, stage 4 pressure ulcer of the sacral region, pressure induced deep tissue damage of the left and right heel, stage 3 pressure ulcer of the right upper back, and osteomyelitis of the sacral region. The Admission Hospital Records dated 1/17/24 document R1 had a skin and wound consult for a DTI (deep tissue injury) to the right anterior ear that measured 3 cm x 1 cm, a DTI to the right clavicle that measures 0.5 cm x 1 cm, a DTI to the right chin that measured 0.5 cm x 1 cm, a DTI to the left heel that measured 3 cm x 4.7 cm, a DTI to the right heel that measured 3 cm x 5 cm, and a sacrococcyx stage 2 that was partial thickness skin loss that measured 4 cm x 0.5 cm x 0.1 cm. The Admission Observation dated 1/17/24 documents R1 was admitted from the hospital with a pressure ulcer to the coccyx, right buttocks, abscess to the right ear, pressure injury to the right heel and left. A Nursing note dated 1/17/24 documents R1 arrived to the facility from the hospital. Skin issues were noted on the coccyx, right buttocks, right and left heel, right clavicle, and right ear. The physician and the DON were made aware of the admission. The Physician Order Sheet documents an order for an unstageable DTI to the sacrum was to be cleansed with wound cleanser, then apply alginate calcium, then cover with border once a day for wound care. This order was placed on 1/24/24. There is only an order for zinc barrier cream to be applied to the coccyx area once a day in the evening. The order for the zinc barrier cream was not started until 1/21/24. The Treatment Administration Record (TAR) dated 01/2024 documents there is no dressing change order for the sacral wound until 1/25/24. The zinc barrier application once daily was started on 1/21/24. A Lab Result note dated 2/10/24 documents a white blood cell count of 20.7 uL (4.5-11 uL), CRP of 126.2 mg/dL (normal is less than 0.3 mg/dL), and an ESR of 55 mm/hr (normal is 0-15 mm/hr). The physician was notified and ordered to send R1 to the hospital. The physician was unsure of the source of infection. R1 does have a sacral wound. The Hospital Records dated 2/11/24 document R1 presented to the hospital for abnormal labs. R1 was sent for an evaluation of an elevated white blood cell count of 21,000. R1 denied any symptoms. The chest x-ray was negative, the blood cultures had no growth, and the urinalysis was without a urinary tract infection. R1 was reporting pain in the back. R1 was noted with a stage 4 sacral ulcer with a foul odor. The increased white blood cells are likely secondary to the sacral wound/osteomyelitis. Wound care was consulted. An Infectious Disease note from the hospital dated 2/14/24 documents R1 had an infected sacral decubitus ulcer. Plan is to continue IV antibiotics monitor the white blood cell count. A General Surgery note from the hospital dated 2/14/24 documents the sacral ulcer is a stage 4 with undermining and extends to the bone. The sacral wound measures 5 cm x 3 cm. A General Surgery note from the hospital dated 2/19/24 documents R1 underwent a debridement of the sacral wound and a bone biopsy. R1 was noted to have a necrotic wound to the sacrum with that extended down to the bone. During the debridement, the physician was able to get down to the bone layer and the bone appeared to be infected with a necrotic coccyx that was loose as well as severely eroded. The area of debridement measured 11 cm x 10 cm. After being stabilized, R1 returned to the facility on [DATE]. A Nursing note dated 2/24/24 documents R1 returned to the facility from the hospital. Wounds were observed on the right ear, right upper back, sacrum, and both heels. Infection Charting date 3/12/24 documents R1 is receiving three different kinds of IV antibiotics for a wound infection. A Nursing note dated 3/14/24 documents the nurse practitioner ordered R1 be sent out to the hospital for evaluation. R1 had increased respiratory rate of 22 (normal is 12-16) and is now wearing 1 L of oxygen nasal cannula. The oxygen saturation are 96%. Blood pressure slightly low at 95/53. The Death Certificate dated 3/20/24 documents the cause of death as pneumonia and osteomyelitis. On 4/12/24 at 2:03PM, V3 (Wound Nurse/Floor Nurse) stated R1 admitted to the facility with an open wound to the right ear, deep tissue injury to bilateral heels, and a wound to the sacrum. V3 was not able to recall the stage of the sacral wound upon admission. V3 was also unable to recall why R1 went to the hospital on 2/10/24. V3 reported osteomyelitis is an infection that starts in the wound and enters into the bone. V3 denied being aware of R1 having any signs or symptoms of infection in the sacral wound. V3 stated signs of infection would be increased drainage, foul odor, or a change to the drainage. V3 reported the physician should be notified immediately of changes to the wound. V3 stated the best way to prevent infection in a wound is to perform the dressing changes to keep the wound clean. On 4/12/24 at 3:09PM, V6 (Nurse) stated V6 admitted R1 to the facility and R1 had wounds to the ear, sacrum, and bilateral heels. V6 was not able to remember what the stage of the sacral wound was on admission but admitted the wound was an open wound. V6 reported that when a resident is admitted the physician must be called to see what orders are going to be continued form the hospital and if any new orders will be put in place. V6 was not able to recall what was ordered for the wound on the night of admission. V6 stated if an order was not put in place on the shift a resident was admitted then it should be put in place the next shift. V6 reported the importance of an order for dressing changes is to make sure the wound is being treated and assessed. V6 also admitted to being the nurse that sent R1 out to the hospital on 2/10/24. V6 stated R1 had an elevation of white blood cell count and the physician was concerned for an infection so R1 was sent to the hospital. V6 denied R1's sacral wound having any signs or symptoms of infection the day R1 went to the hospital. V6 reported signs and symptoms of infection are foul odor, increase in pain, and purulent drainage. V6 stated R1 was diagnosed at the hospital with a wound infection. On 4/12/24 at 3:29PM, V7 (Nurse) stated V7 was aware R1 had an infection to the wound but V7 was unaware of what kind. V7 reported signs of infection are changes in vital signs, changes in drainage of the wound, and foul odor. On 4/12/24 at 3:42PM, V2 (DON) stated R1 was admitted with bilateral heel DTIs and a sacral wound. V2 believed the sacral wound was a DTI as well because they were not able to see what was underneath the wound. V2 reported in 02/2024, R1 went out to the hospital for elevated white blood cell count and the facility was not able to identify a source of the infection. V2 denied R1 having any signs of symptoms of infection but stated the sacral wound ended up being the source of infection and was diagnosed with osteomyelitis. V2 reported once R1 returned from the hospital, R1's white blood cell count never returned to normal and remained elevated. V2 stated osteomyelitis is an infection of the bone that has migrate from another part of the body that had an infection. On 4/15/24 at 11:07AM, V9 (Wound Physician) stated R1 was admitted to the facility with the same wounds R1 was discharged from the facility with. V9 was unable to name all the wounds. V9 reported R1 was sent to the hospital in 02/2024 for elevated white blood cell count, CRP, and ESR along with a concern for osteomyelitis. V9 stated V9 was unable to remember the exact conversation but V2 reached out to V9 with concerns with the sacral wound so that prompted laboratory testing. V9 was unable to give a timeline on when a resident begins to show symptoms of osteomyelitis because every resident is different. V9 stated R1 developed necrotic tissue to the sacral wound and due to the necrotic tissue, they were unable to see if there was any infection underneath the wound. V9 denied being aware of R1 having any signs or symptoms of infection to the sacral wound. V9 reported this time of infection develops in the wound first and then moves to the bone. V9 stated if no dressing order is in place from the hospital then staff should reach out to V9 or another physician for an order. V9 denied being aware that no dressing changes were in place for one week for R1. V9 reported if dressing changes aren't being done then the wound could develop an infection due to not being clean. V9 stated zinc barrier cream is not a treatment for a wound because it will assists in keeping moisture off the skin but will not clean a wound. On 4/15/24 at 1:16PM, V2 stated the admitting nurse is responsible for getting orders from the physician once a resident is in the facility. V2 reported any care that is provided to a resident needs to have an order put into the computer system and agreed that all wound care and dressing changes requires an order. V2 stated the nurse is responsible for observing any changes to the skin and reporting them to the physician. V2 reported if a resident discharges from the hospital without any orders for wound care then the wound needs to be discussed with the physician so an order can be put in the computer. V2 stated an order for a dressing change needs to be put into place no later than 24 hours after the wound was found. V2 reported there is no reason a wound should not have any dressing change orders in place for one week. V2 stated an order needs to be put into place as soon as possible so care can be provided. V2 reported if no order was put in place then there is no way to guarantee dressing changes were being performed. V2 stated an infection can develop if the dressing changes are not done. V2 reported R1 having no order for the sacral wound should have been brought to V2's or the physician's attention sooner than one week. Per the National Pressure Injury Advisory Panel (https://npiap.com/general/custom.asp?page=PressureInjuryStages) the definition of a stage 2 pressure ulcer is, partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). In conclusion, a stage 2 pressure ulcer is an open wound. The Wound Assessment Details Report dated 1/19/24 documents a wound to the coccyx that is a stage two that measures 4 cm x 5 cm x 0.2 cm. There are no signs of infection documented. The Wound Physician notes dated 1/23/24 documents R1 has an unstageable DTI to the sacrum that measures 8 cm x 5.1 cm x 0.1 cm. The wound is 70% granulation tissue and 30% skin. The plan is to apply calcium alginate once daily for 30 days. The Wound Assessment Details Report dated 1/25/24 documents a wound to the coccyx that is a stage two that measures 4 cm x 5 cm x 0.2 cm. This wound is considered stable at this time. It is documented that treatment in place. The Wound Assessment Details Report dated 1/30/24 documents a stage two to the coccyx that measures 8.3 cm x 6 cm x 0.1 cm. No signs of infection or documented. This wound is considered deteriorated due to an increase in size. The Wound Physician note dated 1/30/24 documents an unstageable DTI to the sacrum measures 8.3 cm x 6 cm x 0.1 cm. The wound is now 50% necrotic tissue, 30% granulation tissue, and 20% skin. The wound progress is documented as exacerbated due to nutritional compromise. The Wound Assessment Details Report dated 2/6/24 documents a wound to the coccyx that measures 10.5 cm x 7 cm by unknown. This is now classified as a stage four and was debrided on this day. The wound is considered deteriorating due to an increase in size. There are no signs of infection documented. The Wound Physician note dated 2/6/24 documents the stage four pressure wound to the sacrum measures 10.5 cm x 7.3 cm x 0.1 cm. The wound is 70% necrotic tissue, 10% granulation tissue, and 20% skin. The wound was debrided on this day to remove necrotic tissue and establish the margins of viable tissue. The wound is considered exacerbated due to generalized decline of the patient. There are no signs and symptoms of infection documented at this time. The Wound Physician note dated 2/27/24 documents the stage four to the sacrum measures 11.4 cm 9.2 cm x 3.7 cm. The necrotic tissue is 20%, the granulation tissue is 25%, and viable tissue (bone) is 55%. This wound is considered exacerbated due to the osteomyelitis with debridement in the OR. The Braden Observation 1/24/24 documents score of 17 indicating at risk for developing pressure ulcers due to being occasionally moist, chairbound, having slightly limited mobility, and a potential problem with friction and shearing. The Infection Charting dated 2/27/24 documents R1 has an infection to the sacral wound and is receiving two different kinds of IV antibiotics. The Care Plan that is not dated documents R1 has a potential for impairment to skin integrity related to impaired mobility and incontinence. R1 has a pressure ulcer on the coccyx/buttocks upon admission and bilateral DTIs on the heels that were present upon admission. An intervention documented is to treat per physician order. The policy titled, Pressure Ulcer Prevention, dated 1/15/18 documents, Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: .2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. The policy titled, Admission of Residents, that is not dated documents, .Procedure: .8. Conduct head to toe nursing assessment of body systems, parts, and surfaces, identifying functional status, abilities, needs, or problems. This is to be used as baseline for the plan of care and obtaining comprehensive physician orders. 14. Moisture barrier may be applied by CNA as needed to intact skin and may be kept at the bedside. The policy titled, Skin Condition Assessment and Monitoring - Pressure and Non-Pressure, dated 6/8/18 documents, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure, injuries, and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: . Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment .Caregivers are responsible for promptly notifying the charge nurse of skin breakdown .Wound Assessment/Measurement: .3 . Dressings will be checked daily for placement, clean list, and signs and symptoms of infection.

Based on interviews and record reviews, the facility failed to safely transfer using the mechanical lift. This affected one of three residents (R1) reviewed for safety during transfers. This failure resulted in R1 being transferred to the local hospital and treated for an acute, displaced, and comminuted fracture of right distal femur with impaction. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, stroke with hemiplegia (paralysis) affecting left non-dominant side, dementia, bilateral partial foot amputations, and weakness. On 3/16/24 at 3:10 PM, V2 DON (director of nursing) stated that V2 does not know how R1 fractured R1's right femur. V2 stated that V2 was informed R1 complained of pain and x-rays were ordered and showed right femur fracture. V2 stated that V2 asked staff what happened but the staff stick together and cover for each other and would not tell her anything. On 3/16 at 12:10 PM, V3 (nurse) stated that when V3 came in to work on the morning of 12/15/23, R1 complained of pain. V3 stated that V3 completed an assessment, called R1's physician, and received an order for x-rays of R1's right hip and knee. V3 stated that R1 is alert and oriented x 3, R1 is able to make needs known. V3 stated that R1 requires only one person to assist with transfers. V3 stated that R1 cannot walk or take any steps. V3 denied witnessing R1 standing up bearing weight. When questioned about R1's functional assessment noting R1 was dependent on staff for all transfers and required the use of a mechanical lift device, V3 responded R1 was a one person assist with transfers. V3 denied R1 had any contractures in bilateral hands. V3 denied R1 had any residual weakness due to R1's history of stroke with hemiplegia of left non-dominant side. On 3/20/24 at 12:01 PM, V3 (nurse) stated that the nurse completes and prints two copies of the transfer to hospital form (one for the hospital staff and one for the paramedics). V3 stated that the nurse is expected to sign this form to verify the information being provided is truthful. V3 stated that V3 completed and signed the transfer form for R1 on 12/15/23. When questioned what V3 documented as the reason for R1's transfer, V3 did not respond. When informed that the copy of the transfer form the hospital received on 12/15/23 notes reason for transfer was fall, V3 responded that V3 doesn't know about that. When questioned if V3 falsified the documentation on R1's transfer form, V3 denied documenting any false information on R1's transfer form. On 3/16 at 2:35 PM, V7 CNA stated that R1 was alert and oriented x 3, R1 was able to communicate with staff and make needs known. V7 stated that R1 transfers from bed to chair with two staff. V7 stated that R1 was not able to walk or take any steps. V7 stated that R1 was not able to assist with the transfers, R1 just held onto staff as R1 was manually lifted under her arms. On 3/18 at 1:55pm, V10 (restorative nurse) stated that the restorative programs a resident participates in is determined according to his/her abilities, and his/her potential. V10 stated that R1 was not appropriate for the restorative transfer program. V10 stated that R1 had partial amputation of both feet, bilateral lower extremity weakness, and contractures. V10 stated that R1 was appropriate for PROM (passive range of motion) and bed mobility program. V10 stated that R1 was dependent for transfers and required two person assist and a mechanical lift device for all transfers. V10 stated that staff are in-serviced once a month and as needed on proper transfer techniques. V10 stated that V10 would not consider it safe to transfer R1 any other way than with a mechanical lift device. V10 stated that V10 is responsible for initiating, reviewing, and revising each resident's care plan related to transfers. V10 stated that V10 reviews care plans quarterly and updates as needed. V10 stated that R1's care plan was current for transferring via mechanical lift device. On 3/18/24 at 2:20pm, V1 (administrator) stated that R1 was afraid of heights. V1 stated that R1 should have a care plan regarding refusal to use hoyer lift. V1 stated that R1's care plan is 103 pages and she has not reviewed it all yet. V1 was unable to provide this surveyor with care plan or documentation in R1's medical record noting fear of heights and refusal to use mechanical lift device. On 3/18/24 at 3:50 PM, V12 CNA (certified nurse aide) stated that R1 was alert and oriented x 3, able to make needs known. V12 stated that both of R1's hands were slightly contracted. V12 stated that R1 was unable to bear weight or walk. V12 stated that R1 was dependent for transfers from bed to wheelchair. V12 stated that when V12 was assigned to provide care for R1, V12 would transfer R1 from bed to wheelchair with another CNA by manually lifting R1 up under R1's arms. On 3/21/24 at 12:27pm, V2 DON stated that the purpose of the resident's care plan is to provide proper care and to know about each individual's needs. V2 stated that the care plan is important to review to ensure the focus, interventions, and goals reflects the resident's current status. V2 stated that there should be no false information in the resident's medical record. V2 stated that R1 was afraid of heights and would not use the mechanical lift device. There is no care plan or any documentation found in R1's medical record noting R1 refused to use mechanical lift device. R1's care plan, initiated 10/20/2020, notes R1 is totally dependent with transfers related to generalized weakness. Interventions include, but not limited to, transfer from bed to chair with two persons using the mechanical lift device, using safe technique and verbal cues. R1's functional ability assessment, dated 12/8/2023, notes R1 requires substantial/maximal assistance with bed mobility (the ability to roll from lying on back to left and right side); sit to stand not attempted due to medical condition or safety concerns; chair/bed-to-chair transfer, R1 is dependent on staff; walking or taking one step not attempted due to medical condition or safety concerns. Restorative assessment, dated 12/5/2023, notes R1 with paralysis/paresis of right upper extremity, left upper extremity, right lower extremity, and left lower extremity. R1 has existing contracture or limited ROM (range of motion). R1's ROM of right shoulder is 75% of normal, right elbow is 75% of normal, left elbow is 75% of normal, right wrist/hand/fingers is 50% of normal, left wrist/hand/fingers is 50% of normal, right hip/knee/ankle is 50% of normal, and left hip/knee/ankle is 50% of normal. The facility's transfer - mechanical lift policy, revised 1/19/2018, notes mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations, manual lifting is not permitted. The transferring needs of residents will be assessed on an ongoing basis. Assessment of the resident's transferring needs shall include: mobility status, weight bearing ability, and cognitive status.

Based on interview and record review the facility failed to prevent and protect a resident with a diagnosis of dementia from physical and verbal abuse by facility staff. This affected one of three residents (R2) reviewed for abuse. This failure resulted in R2 being yanked and tugged by V4 (certified nursing aide) and V4 telling R2, I'm not doing this with you, you're getting on my f****** nerves. Using the reasonable person concept may have resulted in R2 being fearful and displaying anxiety around facility staff. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy, pneumonia, atrial fibrillation, shock, difficulty walking, dysphagia, anemia, unspecified dementia without behavioral disturbances, delirium, restlessness and agitation. R2's brief interview for mental status documents a score of 0 which indicates resident is never/rarely understood. On 1/9/24 at 12:08 PM, V9 (CNA) said she was assisting R2 back to her room from the dining room with V8 (CNA) and V4 (CNA). R2 has dementia and did not want to get out of the chair. V4 said to R2 No, you're going to bed. V9 said, V4 (CNA) began to forcefully yank R2's clothing off. V9 said V4 told R2, I'm not doing this with you, you're getting on my f****** nerves! V9 said V4 (CNA) was treating R2, like a ragdoll. V9 said V4 transferred R2 in the bed by giving her a bear hug and flung her on the bed. On 1/9/24 at 11:49 AM, V8 (Certified nursing assistant, CNA) said R2 was refusing and yelling and pushing at V4 (CNA). V8 said R2 told V4, You are not going to do me like that. V8 said V4 stopped for a minute to collect herself but then continued to take off R2's shirt as R2 was resisting. V8 said V4 was pulling and tugging on R2. V8 said V4 (CNA) picked R2 up by grabbing R2's upper arms and threw R2 into the bed. R2 was still refusing when V4 provided incontinence care. V8 said it was abusive and if that was her family member, she would not want them treated in that way. On 1/9/24 at 1:28 PM, R3 (R2's roommate) who was alert and oriented at time of interview said one staff (V4) will say things to R2 like, Oh my God and You're the hardest one I have to put to bed. R2 is always telling her to Wait a minute. R3 said V4 is the only staff that seems to have a problem with R2. R3 said no other staff have that problem when they are in the room with R2. R3 said V4 moves too fast and does not have patience with R2. Facility reportable undated documents: V9 (CNA) was asked to explain what she had witnessed on 1/5/24. V9 stated she witnessed V4 transfer R2 in the bed. V9 began to describe how the R2 was being handled by V4, stating that V4 placed her arms around R2 almost forcefully to put R2 in the bed. V9 was asked if she could come for further interview for her statement. V9 agreed, but resigned later that day. Facility abuse prevention and reporting policy dated 11/28/16 documents: The facility affirms the right of residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Abuse means any physical or mental injury inflicted in a resident other than by accidental means. Abuse is the willful infliction of injury, intimidation or punishment with resulting pain harm or mental anguish to the resident. Physical abuse is the infliction of injury that occurs other than by accidental means and requires medical attention. physical abuse includes hitting, slapping and controlling behavior through corporal punishment. Verbal abuse may be considered to be a type of mental abuse. Examples include but not limited to: mocking, insulting, ridiculing, yelling or hovering over a resident with the intent to intimidate.

Based on interviews and record reviews, the facility failed to prevent or determine how an injury of unknown origin occurred for 1 of 3 residents (R1) reviewed in a total sample of five. This failure resulted in R1 being found with swelling to the right hand and having a fracture to the right middle finger. Findings Include: R1 is a [AGE] year old with the following diagnosis: osteoporosis, vitamin D deficiency, Alzheimer's disease, and lung cancer. R1 admitted to the facility on [DATE]. A Nursing note dated 1/29/23 documents swelling was noted to the back of the right palm of the hand. An order was obtained for an x-ray of the affected area. A Nursing noted 1/30/23 documents the radiology company is currently in the facility this morning to do an x-ray of the right hand related to swelling. R1 is moving around in no distress. R1 has no facial grimacing noted. X-ray results show that there is an acute nondisplaced fracture of the third metacarpal. The physician was notified, and the order was given to send R1 to the hospital for evaluation and treatment. The X-ray Report dated 1/30/23 documents the x-ray of the right hand shows an acute and non-displaced fracture of the third metacarpal. The Resident Abuse Investigation Form dated 1/30/23 documents V4 (CNA) noted R1's right hand was swollen. The nurse was notified. An x-ray was ordered. X-ray results indicated an acute and nondisplaced fracture of the third metacarpal of the right hand. R1's unable to verbalize any information about the hand to staff. R1 was sent to the hospital for an evaluation. After thorough interviews with staff and other residents, no one has witnessed anyone being rough, nor observed anybody trying to inflict physical harm on R1. R1 has a diagnosis of osteoporosis, degenerative joint disease, and malignant neoplasm of the lungs. Per conversation with the physicians, because of the bone condition, R1 can be vulnerable to injuries. R1 was observed with R1's hands tucked under R1's buttocks which appears R1's sitting on R1's hands and rocks back-and-forth at times. R1 was also observed placing R1's hands in between R1's legs and crossing one like over the other and rocking back-and-forth while seated. R1 is also observed pulling at R1's own hands at times during care and may have caused trauma when those forceful movements were done. Pain management is in place. R1 will have a follow up appointment with ortho. The care plan was updated accordingly. The Hospital Records dated 1/30/23 documents R1 presented to the emergency room for evaluation of a finger injury. Per nursing home staff, R1 was found to have a right third finger fracture yesterday. Nursing home staff noted swelling to the hand so the physicians sent R1 to the emergency department for an evaluation. R1 would not open the right hand for examination. The x-ray of the right hand shows an oblique fracture of the mid third metacarpal and is noted without displacement. Degenerative joint disease and osteopenia are seen. R1 was discharged from the hospital with a diagnosis of closed fracture of the right hand. On 2/16/23 at 1:59PM, R1 was sitting in a wheel chair at a table near the wall in the dining room. R1 did not answer any questions during the interview. R1 was not able to state R1's name. The top of R1's right hand was swollen near the index and middle finger. R1 was noted putting R1's right hand in between R1's legs while they were crossed. R1's movement of the right arm is purposeful but slow moving with not much force. Staff did not redirect the behavior of R1 putting R1's hand in between R1's legs. On 2/16/23 at 2:14PM, V3 (Nurse) stated the last time I worked with R1 was the Thursday before R1 had swelling. R1 had no issues with R1's hand then. R1 sits on both of R1's hands and puts them in between R1's legs. R1 will cross R1's legs with R1's hands in between them. R1 is alert to self only. You cannot have a conversation with R1. R1 was not able to say what happened. R1 does have a diagnosis of osteoporosis. We have not done anything for the behavior with R1's hands. R1 has dementia and is not going to remember not to do it. We don't know how this could have occurred other than the behavior of putting R1's hands between R1 legs or under R1's butt. On 2/16/23 at 2:25PM, V4 stated hat morning I was passing juice during breakfast. R1 reached up for the cup, and R1's hand looks swollen. It was R1's right hand. It was swollen by the thumb and index finger. R1 couldn't tell us what happened. R1 can only answer yes or no questions because R1 is confused. R1 has a tendency to hold R1's hands between R1's legs or under R1's behind. R1 is still doing that behavior of sitting on R1's hands and putting it in between R1's legs. No we don't redirect R1. No we have not been told to do something different for R1 when R1 does that. On 2/16/23 at 2:47PM, V5 (Former Nurse) stated V4 told me on 1/29 that R1's right hand was swollen on the top. I went over to look at it and it was swollen, but R1 had no complaints when I did my assessment. I called the doctor and got an order for an x-ray. The next day they found that R1 did have a fracture. Nobody can tell what caused the swelling. R 1 was not able to say what happened because R1 cannot communicate. R1 is confused. Sometimes when R1 will put R1's hands under R1's butt, or in between R1's legs and crosses the legs. We don't stop her from doing that behavior. R1 still does it since we noticed the swelling. R1 goes into whatever position R1 wants and we cannot stop R1. R1's bones are more fragile with osteoporosis so fractures can happen easier. On 2/16/23 at 3:06PM, V6 (CNA) stated The last time I worked with R1 before they noticed the hand was swollen, was on 1/28 on the 3 to 11 shift. I had no issues with R1 that evening. Nothing happened. R1 does have a behavior of playing with her brief. R1's bones are just brittle from being old so we just treat R1 carefully. No one has any idea how this happened. On 2/16/23 at 3:54PM, V7 (CNA) stated I first noticed R1's hand was swollen on Sunday morning when I was getting R1 up. It was R1's right hand. R1 was in her wheelchair and I was bringing R1 out of R1's room and I noticed it. I told the nurse, and V8 (Nurse) tried to look at it, but R1 refused to let him see it. R1 kept hiding the hand. Nothing happened that would've caused R1's hand to swell. I just check on the residents during the night to see if they're breathing. I did not look at R1's hand. I did not notice any swelling during the night. No one knows how this happened. On 2/16/23 at 4:04PM, V1 (Administrator) stated I was told Monday that R1 was getting an x-ray for swelling in R1's hand. It ended up coming back positive for a fracture. We tried looking at it but R1 doesn't let you touch R1's hands. I started talking with everyone and they all said nothing happened. The CNA (V7) was the first one who noticed the swelling. V6 said V6 got R1 up and brought R1 out to the dining room like V6 always does. I was asking them care questions and if R1 has any behaviors. A couple different staff members told me R1 takes R1's hand and puts in between R1's legs then crosses the legs over and rocks back and forth. They also told me R1 will put R1's hands under her bottom and sit on them. Since she her dementia is so bad R1 couldn't tell me what happened. We couldn't find anything else that happened that we saw besides R1 repetitive movements R1 has. On 2/16/23 at 4:17PM, V8 (Nurse) stated the CNA told me in the morning that R1's hand was swollen. It was at the very end of my shift so I told the next nurse what was going on. Nothing happened that night. If R1 has osteoporosis then that makes your bones weaker. You need to be more careful with these residents. On 2/17/23 at 2:54PM, V9 (Medical Director) stated a nondisplaced fracture is a crack in the bone. There's no separation of the bone and the bone is still in place where it should be. There is just a crack somewhere in the bone. These fractures occur because of some kind of trauma. I'm not very familiar with what exactly are R1's diagnosis but the osteoporosis can severely weaken the bones, so simple movements could have caused this fracture. I've never seen R1 have this behavior; if the staff is saying that R1 has this behavior then yes something like that could have caused this. This is all hearsay because we can't exactly say what happened because she's not able to tell us. The Care Plan with no documented date documents R1 is an adult with impaired cognitive function, has poor self in environmental awareness, and has significant difficulty understanding information presented insignificant, difficulty being able to respond to such communications appropriately. Given this, provide R1 cueing, prompts, and reminders to maintain safety and autonomy is required related to neurocognitive disorder. The Care Plan with no date documents R1 is at risk for bone fractures related to osteoporosis. The interventions are listed as follows: encourage consumption of 50 - 75% of diet, handle gently when assisting with mobility, labs/diagnostics as ordered with results reported to the doctor, and monitor for pain/redness/swelling. There was no new interventions added after the fracture on 1/30/23. The Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score cannot be documented because R1 is rarely/never understood. Section G of the MDS documents R1 needs extensive assist or is total dependent on all activities. These activities require a 1 to 2 person assist. Section I of the MDS documents R1 does have a diagnosis of osteoporosis. The policy titled, Abuse Prevention and Reporting- Illinois, dated 10/24/22 documents Injuries of unknown source: For resident injuries, not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. Any injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; end of the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injuries located in the area, not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries overtime.

Based on interview and record review, this facility failed to follow their post fall policy by not properly assessing and perform range of motion after an unwitnessed fall for 1 of 1 (R3) residents reviewed for post fall assessments. This failure resulted in R3 having documented behaviors of restllessness/lethargy, compalints of leg pain upon movement and being assessed to have a left leg fracture that went unidentified for nine days. Findings include: R3 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal data section C (cognitive skill for daily decision making) dated 8/18/21 documents R3 is severely impaired. Fall occurrence dated 7/29/21 documents: R3 had an unwitnessed fall. Management incident investigation form dated 7/30/21 documents: R3 has decrease attention span and exhibiting behaviors such as restlessness/lethargy. Nursing note dated 7/30/21: R3 was sitting in wheelchair with a restless condition, nurse to nurse report given, R3 was restless before going to bed during the evening shift. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 states, she has pain to left hip that radiates down her leg whenever she is moved or with palpations. R3 had a recent fall with pain to left hip. Concerns for fracture vs dislocation. R3 had an inward rotation and [CONDITION(S)] of leg prompting need for x-ray. X-ray results dated 8/6/21 reported on 8/7/21 documents: Acute left femoral neck fracture. On 9/14/21 at 2:36pm, V2 (DON) said, it is my expectation for my nursing staff to do a full body assessment with all falls and discharge/readmission. R3's fracture could have been identified sooner with a full body assessment. The nurse should have completed a body assessment, due to R3's restlessness and pain. R3's fracture was missed. On 9/14/21 at 5:09pm, V11 (nurse), said, I was given report by the night nurse that R3 fell and was restless on 7/29/21. R3 sitting in her wheel chair close to the table in a bent position with her right hand over her stomach on her right thigh. R3 was in pain. R3 was leaning over as if she had a stomach ache. I did not do a body assessment, R3 was screaming and would not allow anyone to touch her which was not normal. On 9/14/21 at 4:14pm, V7 (Nurse Practitioner) said, staff reported R3 was complaining of pain since the fall on 7/29/21. There was nothing to review from the hospital visit on 7/30/21. R3 was sitting in the wheelchair, I could tell R3 was trying to relieve the pain by attempting loading off her weight. I assessed R3 in the wheelchair with clothes on. R3's leg was inward/internally rotated. I ordered an X-ray which documented a fracture. Change in condition evaluation dated 8/7/21 documents: R3's medical doctor was notified, R3 was discharged to the hospital for acute left femoral neck fracture. Hospital paperwork dated 8/7/21 documents: R3 had deformity to left hip. Musculoskeletal: left lower extremity shortened, decreased range of motion due to pain in the hip joint. R3 had a left femoral neck fracture. Hospital operative report dated 8/10/21 documents: R3 had a left intramedullary nailing of intertrochanteric femur fracture. Post Fall Policy dated 11/28/12 documents: Observed or unobserved, licensed nurse should assess immediately, observe positioning and overall condition, assess for fractures.

Based on interview and record review, the facility failed to follow their pain management program by not assessing the cause or source pain, or notifying the physician of the new onset of pain post fall incident for 1 of 1 residents reviewed for pain management. This failure resulted in R3 having complaints of leg pain, abnormal baseline behaviors after a fall incident where R3 was assessed to have an unidentified left leg fracture for nine days Findings include: R3 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal data section C (cognitive skill for daily decision making) dated 8/18/21 documents R3 is severely impaired. Fall occurrence dated 7/29/21 documents: R3 had an unwitnessed fall. No change in range of motion from baseline, no injuries observed. Fall risk assessment dated [DATE] documents: Intermittent confusion, chair bound and no [CONDITION(S)]. Management incident investigation form dated 7/30/21 documents: R3 has a history of fall, identify as a fall risk, had a decrease attention span and exhibiting behaviors such as restlessness/lethargy. Nursing note dated 7/30/21: R3 was sitting in wheelchair noted in a restless condition, report given, that R3 was restless before going to bed during the evening shift. R3 was transferred to the hospital. 72 hour follow-up charting dated 8/1-21 documents: New onset of pain. Medication administered for pain. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Per staff R3 complained of pain to left leg whenever moved. R3 states, she has pain to left hip that radiates down her leg whenever she is moved or with palpations. R3 is able to sleep through night, pain subsides with immobility. R3 does not take anything for pain. R3 had a recent fall with pain to left hip. No x-ray to review from hospitalization on [DATE]. Concerns for fracture vs dislocation. R3 had an inward rotation and [CONDITION(S)] of leg prompting need for x-ray. X-ray results dated 8/6/21 reported 8/7/21 documents: Acute left femoral neck fracture. On 9/10/21 at 2:49pm, V1 (administrator) said, R3 had an unwitnessed fall and sustained a fracture hip. On 9/14/21 at 2:22pm, V8 (nurse) said, I helped put R3 in the geri-chair on 8/5/21. R3 looked like she was pain. R3's face was frowned and grimaced. On 9/14/21 at 2:36pm, V2 (DON) said, the nurse should have completed a body assessment, due to R3's restlessness and pain. R3's fracture was missed. On 9/14/21 at 4:14pm, V7 (Nurse Practitioner) said, staff reported R3 was complaining of pain since the fall. I could tell R3 was trying to relieve the pain by loading off her weight. I assessed R3 in the wheelchair with clothes on. R3's leg was inward/internally rotated. I ordered an X-ray. Nursing staff should have communicated with NP/MD that R3 was in pain. I did know R3 was in pain until I asked. Getting in the wheel chair would have aggravated R3's leg causing pain. On 9/14/21 at 4:39pm, V9 (can) said, it was reported on 8/2/21 that, R3 was having one of those days when she didn't want to be bothered. On 9/14/21 at 5:09pm, V11 (nurse), said, I was given report by the night nurse that R3 fell and was restless on 7/29/21. R3 sitting in her wheel chair close to the table in a bent position with her right hand over her stomach on her right thigh. R3 was in pain. R3 was leaning over as if she had a stomach ache. I did not do a body assessment, R3 was screaming and would not allow anyone to touch her which was not normal behavior/baseline. I did not give R3 any pain medication before she was discharge to the hospital. On 9/15/21 at 10:38am, V2 (DON) said, grimacing, restlessness, no wanting to move, tensing up are all non-verbal indicators of pain. R3 yelling out was baseline but yelling with movement could be contributed to pain. Once we got the x-ray result that reported R3 had a fracture, we could have got a one-time stat does for pain management. Looking back acetaminophen was not enough pain management for a resident with a fracture. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital paperwork dated 8/7/21 documents: R3 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 was given [MEDICATION(S)] in the emergency room and [MEDICATION(S)] by the emergency medical service. R3 had deformity to left hip. Musculoskeletal left lower extremity shortened. R3 had a left femoral neck fracture. Pain Management Program policy dated 11/28/12 documents: To establish a program which can effectively manage pain in order to removed adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance, promote physiological and psychological wellness. When a resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign change and changes in behavior/mood will be used to determine the present of pain.

Based on observations, interviews and record reviews, this facility failed to follow its code blue policy and procedure for one resident (R1) found unresponsive after consuming a meal in a sample of 6 residents requiring increased monitoring with meals in a sample of 20. Findings include: Review of the medical record notes that R1's [DIAGNOSES REDACTED]. On [DATE] at 12:45pm, this surveyor noted that there is a crash cart with a full oxygen tank on each nursing unit. The crash cart is located directly across the nurses' station on the unit R1 resided and Z5 worked. An ambu bag is located on top of the crash cart. During interview on [DATE] at 10:40m, Z5 RN (registered nurse) stated that she worked 11:00pm to 7:30am shift at this facility. Z5 stated that she provided care for R1 on the night of [DATE] and that R1 was in wheelchair and awake most of the night at the nurses' station. Z5 stated that R1 went to bed at 2:00am but was up 45 minutes later. Z5 stated that at 5:00am, she checked R1's vital signs, blood pressure ,[DATE], heart rate 82, respirations 18, and temperature 98.4. R1's blood sugar was 149. Z5 stated that R1 needed to go to the bathroom. The CNA (certified nurse aide) took R1 to the bathroom; shortly thereafter R1 was found unresponsive in the bathroom. Z5 stated that R1 did not have a heartbeat or respirations. Z5 denied calling a code blue to get additional nursing assistance. Z5 called EMS (emergency medical services) 911. Z5 stated that she did not initiate CPR (cardiopulmonary resuscitation) because it was quicker to call 911 and she needed to print paperwork for R1's transfer to hospital. Z5 stated that R1 was eating a peanut butter and jelly sandwich while being toileted. Z5 stated that E11 CNA noticed something in R1's mouth, but Z5 did not check R1's mouth. Z5 stated that she did not know where the oxygen tank and supplies were located. During interview on [DATE] at 7:10am, E10 CNA stated that she got R1 ready for [MEDICAL TREATMENT] on [DATE] at 5:00am. E10 stated that R1 was sitting in wheelchair in hallway near exit door awaiting transportation for [MEDICAL TREATMENT]. R1 self propelled wheelchair into bathroom. E10 stated that transportation arrived for R1 about 5:20am so E10 and E11 went to the bathroom to get R1. E10 stated that they found R1 slumped over in wheelchair. E10 stated that she does not recall seeing any food in R1's mouth. E10 stated that the resident's nurse gives the resident a sack lunch to have while at [MEDICAL TREATMENT]. E10 denies seeing R1 eat the sandwich. During interview on [DATE] at 9:00am, E11 CNA stated that R1 was awake most of the night, restless. E11 stated that R1 was sitting in hallway near exit door awaiting transportation to [MEDICAL TREATMENT]. E11 stated that R1 informed her that R1 needed to use the bathroom. E11 stated that after 5 minutes she checked on R1 and found R1 slumped over in wheelchair. E11 called out R1's name but got no response. E11 stated that she got Z5 (RN). E11 stated that Z5 called 911. E11 stated that she noticed something in R1's mouth, with her finger swiped out food. E11 and E10 moved R1 and wheelchair out of bathroom. E11 stated that EMS arrived, transferred R1 from wheelchair to cart and initiated CPR. E11 stated that she saw Z5 give R1 the sack lunch and place beside R1 in wheelchair but that she did not witness R1 eating the sandwich. Review of R1's POS (physician order [REDACTED]. Review of the EMS (emergency medical services) report dated [DATE] notes the following: 5:19am, call received 5:22am arrived at scene 5:23am, R1 in wheelchair, chief complaint: unresponsive, not breathing. treatment prior to arrival: none. First assessment: unresponsive, lung sounds absent, pupils unresponsive, asystole (heartbeat absent). R1 immediately transferred to stretcher and CPR initiated. Review of the emergency room report, dated [DATE] notes the following: R1 was found unresponsive, EMS arrived, ACLS (advanced cardiac life support) protocols were followed, R1 intubated prior to arrival. Upon arrival to hospital, R1's endotracheal tube became dislodged. After removing copious thick peanut butter secretions, an endotracheal tube was re-inserted and CPR continued. R1 expired at 6:06am. R1's medical record was reviewed. There is no narrative documentation of the event that occurred on [DATE] Review of this facility's code blue policy, dated ,[DATE], notes in part: the nurse establishes unresponsiveness; calls a code blue; all licensed nurses will respond; call 911; CPR started by the first person on scene; CPR will be alternated between the nursing staff until the ambulance arrives; crash will be brought to scene; connect oxygen to ambu bag; start intravenous access; suction as needed; notify physician, administrator, and family; and descriptive charting noting what happened, date/time, vital signs, and how the resident was found at the time the code blue was called, what was done (CPR, oxygen, intravenous fluids, etc), notification of physician - outcome/response, 911 called, name of family member notified - relationship, condition of resident/vital signs at time of transfer, and where transferred to, by whom, and what ambulance.

Based on interview and record review, the facility failed to implement the fall prevention interventions documented on the fall prevention plan of care for one resident (R1) of three high risk fall residents all reviewed for fall prevention. This failure resulted in R1 sustaining trauma to head and neck which required surgical cervical laminectomy/ fusion (cervical disc excision and stabilization of spinal column) and sutures to head. Findings include: The admission data sheet for R1 documents the date for readmitted to facility on 1/13/16 with the following Diagnoses: [REDACTED]. R1's cognition was severely impaired based on latest Brief Interview for Mental Status (BIMS) dated 1/26/16. Minimum Data Set (MDS) Section G dated 1/26/16, denotes that R1 required extensive assistance with 1 person to safely move in bed. Fall Risk Assessments done on 1/13/16, 1/26/16, 4/6/16 denote R1 is At Risk for Falls. Review of care plan revised on 3/28/16 denotes; Resident at risk for falls due to impaired cognition, poor safety awareness and episodes of restlessness related to Alzheimer's. Interventions include: Floor mat at bedside dated 1/18/16. Place resident in the fall prevention program, provide resident with low bed (1/18/16). Re-direct resident to not attempt to stand unassisted. On 4/15/16 at 1:00pm, E2(Director of Nursing) provided R1's Incident Report dated 4/6/16. E2 also provided initial and final investigation sent to Illinois Department of Public Health (IDPH) for 4/6/16 fall. On 4/19/16 at 2:45pm, E2 stated, E5(Certified Nursing Assistant,CNA) was taking care of R1 at the time of the fall on 4/6/16. The day shift nurse, E4(Licensed Practical Nurse,LPN) notified me of R1's fall on 4/6/16 when I arrived at work about 8:30am that day. I interviewed E5 the next day on 4/7/16 who stated that she washed R1 and put his clothes on. The low bed was raised up. She did not put the bed in the lowest position after morning care and did not leave the floor mat in place before she left the room. I called the community hospital R1 was admitted to on 4/7/16 and spoke to a nurse who stated that R1 had trauma to the neck from the fall and sutures to the right temporal lobe. I followed up again on 4/13/16 with the hospital and they told me the same thing. I interviewed other staff involved and have statements from the investigation Facilities incident Investigation form by E3(CNA) dated 4/6/16 at 7:10 am denotes; Resident rolled out of bed onto the floor secondary to severe cognitive awareness. Send R1 out to the hospital for evaluation. Review of signed and dated written statement by E3 on 4/6/16 denotes; I was doing rounds at 7:10am and walked in R1's room. I found R1 on the floor with mat on the side of him and his bed in the highest position. I went and got the nurse and another CNA to help with assisting the patient. On 4/20/16 at 9:00am, E3 stated, I was doing my rounds about 7:10am, when I observed R1 on the floor. The floor mat was lying next to him on the floor (not under him). The bed was in the highest position and R1 had blood on his head and blood clots on the floor. Review of E5's signed statement dated 4/7/16 denotes; I was on my way out of the door, at 6:35am on 4/6/16, and notice the nurse and two other CNA's in R1's room. I then observed R1 on the floor with a gash on his head and blood. The bed was not in the lowest position and the floor mats were not in place. Patient known to roll out of bed. On 4/20/16 at 11:43am, E5 stated, I was giving care to R1 on 4/6/16 and changed his diaper and cleaned him up. The bed was at waist height. I finished giving care and I gathered all my things and left the room. I forgot to put the bed down in the lowest position. I pushed the floor mat back in front of the bed. He rolls a lot in bed. Review of Physician order [REDACTED]. status [REDACTED]. Review of E4's nursing progress noted dated 4/6/16 at 7:10am denotes; Resident observed on floor on side of bed next to floor mat. Laceration observed to lateral aspect of forehead near temporal lobe. Observed with active bleeding. First Aide required and administered, pressure dressing applied. 1:1 observation until paramedics arrived. Doctor and wife notified. On 4/20/16 at 9:04am, E4 stated, I was coming on shift and saw staff in R1's room, I observed R1 bleeding in the temporal area and applied a pressure dressing. Review of E6(LPN) progress noted dated 4/6/16 at 11:47pm denotes; R1 was transferred to a local community hospital emergency room (ER), but was later transferred to another community hospital. R1 was admitted to the hospital with [REDACTED]. Review of medical records from local ER denote; 1 centimeter(cm) laceration above right eyebrow, given sutures. Cervical collar placed. Computed tomography (CT) of spine suggest atlantoxial subluxation and could represent post traumatic subluxation. Neurosurgeon needs to consult but not in house at current ER. R1 was transferred to another community hospital for neurosurgeon consults on 4/6/16. Review of medical records from community hospital that R1 was transferred to on 4/6/16 and admitted denotes; R1 arrived with a Cervical collar from other ER. A cervical spine scan done at local emergency room R1 was originally sent to, showed acute posttraumatic subluxation and a consult to neurosurgeon was ordered. R1 admitted to hospital with [DIAGNOSES REDACTED]. Review of Z2 (Trauma Nurse Practitioner, Joan Kelly) on 4/13/16 at 9:06am denotes; R1 is scheduled for Operating Room(OR) with Z3(Neurosurgeon) on 4/14/16 for cervical laminectomy/cervical fusion. Review of Z3's operative report dated 4/14/16 denotes; admitting [DIAGNOSES REDACTED]. Procedure: Cervical Laminectomy/fusion. On 4/22/16 at 11:22am, Z4 (Attending Medical Doctor) stated, I know I ordered a low bed and floor mats for the patient to prevent injury from falls. He then had trauma to his neck a few days later from a fall.

Based on interviews, and record review, the facility's psycho-social service staff failed to provide care planning with interventions for residents in the facility with behavioral problems. The psycho-social staff failed to develop a comprehensive treatment plan with interventions for dealing with medication compliance, reassessment for safe smoking practices, and to address physical and verbal aggression for 1 of 1 (R13) residents from the sample of 18 reviewed for psych-social services. The facility failed to provide a safe and hazard free environment for residents in the facility. These failures resulted in R13 setting a mattress on fire in the facility. These failures had the potential to affect all 86 residents in the facility. These failures resulted in an Immediate Jeopardy which was determined to have started on 6/24/12 when the facility failed to reassess R13 for supervised smoking. E1 (administrator) and E2 (director of nursing) was notified of the Immediate Jeopardy on 7/27/12 at 1:40 PM. While the Immediate Jeopardy was removed on 7/31/12 at 5:30 PM, the facility remains out of compliance at severity level 2 because the facility has yet to train all shifts in regards to safe smoking practice for residents and has yet to reassess all residents for safe smoking practices. The new assessment tool and plans of care has yet to be fully implemented and the facility's evaluation of the effectiveness of the new plan of care has yet to be conducted. Findings include: The physician's orders [REDACTED]. Hospital records that were sent to the facility when R13 was admitted , noted that R13 had been in several other facilities which resulted in many hospitalization s due to R13's physical and verbal aggressive behaviorals. The hospital discharge report further stated that R13 had thrown a chair at a television set in the facility's day room, that R13 was observed making verbal threats towards the staff and peers, and had been refusing to take any prescribed medications since his admission to the other facility. R13 was also observed to be expressing paranoid delusional thoughts, and threatening to harm other peers, stating "I will kill somebody." The most recent MDS (minimum data set) dated 5/29/12 that was completed after R13 had been admitted to the facility documented that R13 had some difficulty remembering the date, and year, and had a cognitive summary score of 8 out of. 15. R13 had hallucinations, delusions, verbal behavioral symptoms directed toward others (threatening, screaming, cursing at others). . A review of the facility's MAR (medication administration report) documented that R13 had been refusing to take any medications that had been prescribed by the physician since R13 had been admitted to the facility on [DATE]. The initial psychosocial of 5/18/12 documents that R13 a [AGE] year old male was admitted with [DIAGNOSES REDACTED]. R13 was ambulatory, alert and oriented x 3. R13 previously resided at another facility where R13 was referred for a psychiatric evaluation due to R13 destroying that facility's property. R13 busted a television set. The note further noted that R13 has fair cognition/hygiene, displays a guarded mood, was euphoric, consistently laughing, even when it is inappropriate to do so. R13 was counseled on safe sex practices, community safety, community pass policy, substance abuse policy, call light system, residents rights and smoking policy. On 6/4/12 R13 was counseled by social service on taking his medications. The PRSC (professional rehab service coordinator) documents that R13 was counseled on 6/6/12 concerning R13's aggressive behavior towards the nursing staff. There was no documentation indicating that a plan or interventions had been put into place addressing R13's noncompliance with taking medications or to address R13's aggressive behaviors. Nor was a suggestion documented to have R13 attend any group sessions or receive 1:1 counseling on a regular basis. The PRSC note dated 6/4/12 and 6/6/12 documents that R13 had to receive 1:1 counseling due to verbal aggressive behavior towards the nursing staff. R13 was refusing to have blood work done, called the phlebotomist a "vampire". As an intervention, R13 was advised to attend onsite skills training group 3 times a week to increase social, coping, and symptoms management skills. The note documented that social service would provide 1:1 counseling as appropriate to increase compliance with medical care. No plan or frequency for the 1:1 counseling was documented by the PRSC. The facility's skills training attendance log for 6/15/12 thru 7/3/12 was reviewed. The logs failed to document that R13 had ever attended the group sessions. A incident report and a nursing progress note dated 6/16/12 at 7:30 AM, documents that R13 was involved in a physical altercation with R30 at breakfast. R13 attempted to bully R30 by stating that R30 was sitting in R13's seat. R13 was observed to throw his breakfast tray and hit R30 in the top of the head. Attempts by nursing to redirect R13 failed. R13 became agitated and yelled profanities at R30. The police was called who took R13 out for a walk, was allowed to return to the facility. On return to the facility nursing documents that R13 continued to display aggressive behavior, using profanity and calling the staff names. The physician was notified and orders for R13 to be sent to the hospital for a psychiatric evaluation were given. E22 (nurse aide) stated on 7/26/12 at 2:45 PM, that after the police had left the facility R13 was walking around yelling that someone was going to get hurt. On 6/16/12 at 12:24 PM R13 was engaged in a verbal altercation with R30 which escalated into a physical altercation. The PRSC documented that R13's was not easily redirected and that R13 continued to attempt to hit R30. R13 was sent to the hospital for a psychiatric evaluation. R13 returned to the facility from the hospital on [DATE] refusing the nurses physical assessment and medications. There was no documentation in the record indicating that R13's plan of care had been updated by the psycho-social staff to include interventions to encourage R13 to take his medications and comply with medical care. The last PRSC note documentation dated 7/5/12 (after R13 was sent to the hospital on [DATE]) noted that R13 was involved in a physical altercation with R10. The note further documents that R13 was counseled on the rules of the facility, and medication compliance. R13 remained agitated. Facility policy titled Facility Smoking Safety Policy documents that smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan of care. The following behaviors and/or conditions will jeopardize and cause revocation of the person's independent privileges: 1. Smoking in any non-designated area, such as resident rooms, bathrooms, hallways, elevators, stairways and/or smoke-free courtyard. Consequences of non-compliance 1. Residents will be instructed, educated and counseled abut their inappropriate behavior...Documentation will be entered in the record accordingly. 2. Further incidents of non-compliance may result in loss of independent privileges which means smoking materials will be turned over to a designated staff member, held in a secure location and the resident will only be allowed to smoke when supervised. The smoking safety risk assessment completed by the PRSC dated 6/9/12 documents that R13 was safe and independent smoker and did not require supervision. R9 stated on 7/27/12 at 2:45 PM that on 6/24/12 around 3:00 AM in the morning R9 was awaken with the smell of smoke in the bathroom shared with the next room. R9 stated that when he opened the bathroom door R9 observed R13 sitting on the toilet smoking a cigarette. R13 was observed to drop the cigarette in the toilet. R9 further stated that he told R13 that smoking was not allowed in the bathrooms, R13 stood up and began yelling profanities at R9. R13 attempted to hit R9. R13 also stated that the nursing call light was pulled and a nurse aide came into the room and observed the ashes on the floor and in the sink. R9 stated that the charge nurse nor administrator did not attempt to interview R9 concerning the event. E22 (nurse aide) stated that she entered the shared bathroom of R9 and R13, the smell of smoke and ashes were observed on the bathroom floor. E22 further stated that the incident was reported to the nurse. E2 (director of nursing ) stated on 7/27/12 at 11:15 AM, that the nurse in charge should have attempted to take R13's cigarettes and lighter and reported the above incident to the PRSC who should have addressed and reassessed R13's smoking privileges. E1 (administrator) on 7/27/12 at 12:10 PM stated that the above incident was brought to her attention. E1 further stated that when R13 was approached, R13 denied smoking in the bathroom. E1 also stated that R13 was counseled by the PRSC. There was no documentation in the clinical record indicating that R13 had been counseled by the PRSC or that R13's smoking privileges had been reassessed and that R13 was placed on the supervised smoking list. E12 (PRSC) stated on 7/26/12 at 11:00 AM, that she was aware that R13 had been smoking in the bathroom. R13's room was searched but R13's smoking was not reassessed for needing supervision. There was no documentation in the nursing notes, incident report or the concerns log concerning the above occurrence R13's initial plan of care dated 5/17/12 failed to include goals and interventions to address R13 noncompliance with taking prescribed medications, or R13's aggressive behaviors. The PRSC updated plan of care dated 5/25/12 included interventions of providing incentives for R13 to compliant with care; 6/21/12 to attend symptoms management group at least 2 times per week. The plan of care failed to include the types of incentive interventions to be used, or that R13 smoking privileges should be reevaluated. An incident report dated 6/30/12 at 11:15 PM, documents that R13 was involved in an altercation on the smoking patio with R31. E8 documented in the progress notes that on 6/30/12 R13 hit R31 with a broomstick. The police were called. R13 demanded that the police arrest R31. When the police refused, telling R13 that he started the altercation, R13 became verbally abusive using profanity toward the police. The police took R13 out side for a walk but R13 was allowed to returned to the facility and his room. R13 remained agitated, verbally aggressive using profanity toward the staff. R13 refused all medications. At 11:30 PM R13 continued to be agitated pacing back and forth on the unit, laughing and using profanity stating "I'm going to hurt somebody. I'm going to kill a ----". At 11:45 PM, R13 came from his room and sat in the dining room. At 12:00 AM E8 (nurse) noted that an alarm sounded, black smoke from R13's room filled the area, and the water fire sprinklers became active. The fire department was called. The police was again called and R13 was removed from the facility. The facility submitted the following plan: 1. The facility has identified all residents who present non-compliance with medications. 2. The facility has identified all residents with risk of aggressive behaviors. 3. The MD has been notified of refusals for all residents identified with medication non-compliance. 4. The individualized care plan has been implemented or updated for all identified residents with aggression and/or non-compliance with medications. 5. A protocol for the management of medication non-compliance has been developed by the facility ' s Psychiatric Medical Director. 6. The facility has reviewed and updated the Behavior Management policy for agitated residents. 7. All nursing staff was in-serviced on medication management and implementing appropriate interventions to address medication refusals. All new nursing personnel will be in-serviced prior to starting work in facility. 8. Facility personnel have been in-serviced on the prevention and management of resident aggression / resident to resident altercations, including medication management and timely removal of the aggressor from the facility. All new personnel and employees on vacation/scheduled time off will be in-serviced prior to start and/or return to work. 9. Social Services personnel will be in-serviced on implementing and documenting progressive interventions in the resident plan of care, assessments and progress notes. 10. All new residents will be thoroughly screened prior to admission. All residents will be assessed for risk behaviors upon admission, based upon known history and presented behaviors, with care plans developed in accordance with assessed needs. 11. Nursing personnel will immediately report any medication refusals to the DON / designee. 12. Facility personnel will immediately report any aggressive behaviors to the Administrator / designee. 13. The DON / designee will track medication refusals to ensure appropriate follow-up. 14. Administrator / designee will randomly audit documentation for residents with aggressive behaviors to ensure follow-up. 15. Findings will be reviewed during monthly QA meetings for next 3months or as long as deemed necessary by the QA Committee.

A. Based on observation interview, and record review the facility failed to develop a plan of care with interventions to monitor 1 of 18 residents (R13) reviewed for verbal and physical aggressive behaviors in the sample of 18. The facility also failed to follow their smoking policy and re-assess 1 of 3 residents R13 reviewed for unsafe smoking in the sample of 18. These failures resulted in R13 setting a mattress on fire in the facility. These failures resulted in an Immediate Jeopardy which was determined to have started on 6/24/12 when the facility failed to reassess R13 for supervised smoking. E1 (administrator) and E2 (director of nursing) was notified of the Immediate Jeopardy on 7/27/12 at 1:40 PM. While the Immediate Jeopardy was removed on 7/31/12 at 5:30 PM, the facility remains out of compliance at severity level 2 because the facility has yet to train on all shifts in regards to safe smoking practice for residents and has yet to reassess all residents for safe smoking practices. The new assessment tool and plans of care has yet to be fully implemented and the facility's evaluation of the effectiveness of the new plan of care has yet to be conducted. Findings include: R13 is a [AGE] year old male with [DIAGNOSES REDACTED]. R13's clinical record documents that R13 was admitted to the facility on [DATE] from the hospital. A review of R13's hospital records dated 5/16/12 documents that R13 was admitted to the acute care hospital from another facility for a psychological evaluation due to a display of physical and verbal aggressive behavior towards the staff and peers. The report stated that R13 had thrown a chair at the television in the facility's day room. The hospital report further stated that R13 was observed making verbal threats towards the staff and peers, refused to take any medications since being admitted . R13 was also observed to be expressing paranoid delusional thoughts, and harm to other peers, stating "I will kill somebody." E12 PRSC (professional rehab service coordinator) stated on 7/13/12 at 10:30 AM, that she was aware of R13's past behavior as documented in the hospital records. E12 further stated that since being admitted to the facility R13 had been refusing all medications, was verbally aggressive toward the staff and other peers. E12 stated that no interventions other 1:1 counseling had been planned to address R13's behaviors. A review of the facility's MAR (medication administration report) documented that R13 had been refusing to take any medications that had been prescribed by the physician since R13 had been admitted to the facility. The most recent MDS (minimum data set) dated 5/29/13 documented that R13 had some difficulty remembering the date, year, had hallucinations, delusions, verbal behavioral symptoms (threatening others, screaming, cursing) and had a cognitive summary score of 8 out of 15. The interim care plan dated 5/17/12 failed to have a plan of care with interventions to address R13's aggressive behavior and noncompliant with taking his prescribed medications. The smoking safety risk assessment completed by the PRSC dated 6/9/12 documents that R13 was safe and independent smoker and did not require supervision. Nursing documented that on the day of admission (5/17/12), R13 was refusing all medications stating "don't give me that dope", I don't want to take it. In addition, nursing documented that R13 was observed to be agitated and aggressive toward the staff and other residents on the unit. All attempts to calm and redirect R13 failed. Nursing documented that prn (as needed) medications were offered and refused by R13. A incident report and a nursing progress note dated 6/16/12 at 7:30 AM, documents that R13 was involved in an physical altercation with R30 at breakfast. R13 attempted to bully R30 by stating that R30 was sitting in R13's seat. R13 was observed to throw his breakfast tray and hit R30 in the top of the head. Attempts by nursing to redirect R13 failed. R13 became agitated and yelled profanities at R30. The police was called who took R13 out for a walk, was allowed to return to the facility. On return to the facility nursing documents that R13 continued to display aggressive behavior, using profanity and calling the staff names. The physician was notified and orders for R13 to be sent to the hospital for a psychiatric evaluation were given. R13 returned to the facility from the hospital on [DATE] refusing the nurses physical assessment and to taking any medications. There was no documentation in the record indicating that R13's plan of care had been updated by nursing or the psychosocial department to address or encourage R13 to take his medications and comply with medical care. R9 stated on 7/27/12 at 2:45 PM that on 6/24/12 around 3:00 AM in the morning R9 was awaken with the smell of smoke which was coming from the bathroom shared with the residents in the next room. R9 stated that when he opened the bathroom door R9 observed R13 sitting on the toilet smoking a cigarette. R13 was observed to drop the cigarette into the toilet. R9 further stated that he reminded R13 that smoking in the bathrooms was not allowed. R9 stated that R13 stood up and began yelling profanities at R9 and attempted to hit R9. R9 said that the nursing call light was pulled and a nurse aide came into the room and observed the ashes on the floor and in the sink. R9 stated that the neither the charge nurse nor administrator attempted to interview R9 concerning the incident. Facility policy titled Facility Smoking Safety Policy documents that smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan of care. The following behaviors and/or conditions will jeopardize and cause revocation of the person's independent privileges: 1. Smoking in any non-designated area, such as resident rooms, bathrooms, hallways, elevators, stairways and/or smoke-free courtyard. Consequences of non-compliance 1. Residents will be instructed, educated and counseled abut their inappropriate behavior...Documentation will be entered in the record accordingly. 2. Further incidents of non-compliance may result in loss of independent privileges which means smoking materials will be turned over to a designated staff member, held in a secure location and the resident will only be allowed to smoke when supervise E22 (nurse aide) stated that she entered the shared bathroom of R9 and R13, the smell of smoke and ashes were observed on the bathroom floor. E22 further stated that the incident was reported to the nurse. E1 (administrator) on 7/27/12 at 12:10 PM stated that the above incident was brought to her attention. E1 further stated that when R13 was approached, R13 denied smoking in the bathroom. E1 also stated that R13 was counseled by the PRSC. There was no documentation in the clinical record by the PRSC indicating that R13 had been counseled by or that R13's smoking privileges had been reassessed, or that R13 was placed on the supervised smoking list. E12 (PRSC) stated on 7/26/12 at 11:00 AM, that she was aware that R13 had been smoking in the bathroom. R13's room was searched for smoking materials but R13's safe smoking was not reassessed after R13's noncompliant's with the smoking policy. An incident report dated 6/30/12 at 11:15 PM, documents that R13 was involved in an altercation on the smoking patio with R31. E8 documented in the progress notes that on 6/30/12 R13 hit R31 with a broomstick. The police were called. R13 demanded that the police arrest R31. When the police refused, telling R13 that he started the altercation, R13 became verbally abusive using profanity toward the police. The police took R13 out side for a walk but R13 was allowed to returned to the facility and his room. R13 remained agitated, verbally aggressive using profanity toward the staff. R13 refused all medications. At 11:30 PM R13 continued to be agitated pacing back and forth on the unit, laughing and using profanity stating "I'm going to hurt somebody. I'm going to kill a ----". At 11:45 PM, R13 came from his room and sat in the dining room. At 12:00 AM E8 (nurse) noted that an alarm sounded, black smoke from R13's room filled the area, and the water fire sprinklers became active. The fire department was called. The police was again called and R13 was removed from the facility. Z4 (physician) stated on 7/27/12 at 1:00 PM that when R13 was making statement intending to harm the staff or other peers, R13 should have been sent to the hospital by the nursing staff for an psych evaluation. Z4 stated that when a resident is threatening violent against him or herself or the staff the police should be contacted and the resident should be sent out by calling 911. E22 (nurse aide) stated on 7/26/12 at 2:45 PM, that after the police had left the facility R13 was walking around yelling that someone was going to get hurt. E8 (nurse) stated on 7/26/3:00 PM that E22 did report that she did attempt to ask R13 for his cigarettes and lights but R13 refused to give them to E8. E8 also stated that this incident was reported to the PRSC the next day. E8 stated on 7/12/12 at 11:00 AM, that on 7/1/12 at 12:00 AM, black smoke was observed coming from R13's room. When the door to the room was opened, R13's bed was on fire. E8 (nurse) further stated that all residents had to be evacuated from the facility and the fire department was called. E8 further stated that R13 had been assessed to be a safe smoker and allowed to keep his own cigarettes and lighter. E2 (director of nursing ) stated on 7/27/12 at 11:15 AM, that the nurse in charge should have attempted to take R13's cigarettes and lighter and reported the above incident to the PRSC who should have addressed and reassessed R13's smoking privileges. E2 stated that since the fire no residents are allowed to have cigarette lights or matches. On 7/13/12 at 1:30 PM and 2:00 PM, R37 and R38 was observed by the surveyor returning to the facility from outside after smoking cigarettes and handing a cigarette light to E17 (receptionist). E17 stated at this time that independent residents are allowed to take their lights outside when they smoke and return the lighters to E17. E17 also stated that it was possible that not all independent smoker would remember to return the lighters to her. The facility submitted the following plan: 1. Alleged perpetrator was immediately removed by the local police on 7/1/12. Legal guardian was immediately informed. Attending physician was notified. 2. All residents in unit one were temporarily evacuated as directed by the fire department and were maintained in a temporary housing under facility staff supervision. No physical injuries were observed. Residents ' family representatives were informed about the event and the facility evacuation and temporary relocation. 3. Residents were returned to the facility after it was determined to be safe and acceptable by the Midlothian Fire Department and Health Inspector. 4. All resident rooms were inspected for smoking paraphernalia. All identified items have been confiscated. 5. The assessments and care plans for all residents who smoke have been reviewed and updated as needed. 6. All residents were observed for signs and symptoms of distress related to fire incident and encouraged to seek out staff in the event that they had questions and/or concerns. 7. The facility ' s smoking policy was revised to provide safekeeping of residents ' smoking paraphernalia. 8. The aggression risk assessments and care plans of all identified residents have been reviewed and updated as needed. 9. All new residents will be thoroughly screened prior to admission. All residents will be assessed for risk behaviors upon admission, based upon known history and presented behaviors, with care plans developed in accordance with assessed needs. 10. Facility staff were in-serviced on the following: a. Revised resident smoking policy and supervision of all smokers. b. Fire prevention and fire emergency management, including evacuation. c. Prevention and management of resident aggression / resident to resident altercations, including medication management and timely removal of the aggressor from the facility. All new personnel and employees on vacation/scheduled time off will be in-serviced prior to start and/or return to work. 11. Residents were reeducated on: a. Fire prevention and revised smoking policy, including the safekeeping of smoking paraphernalia. 12. Facility personnel will immediately report any unsafe smoking behavior, and/or aggressive behavior to the Administrator / designee. 13. All department heads and designees will monitor resident behaviors and check assigned areas for signs of smoking non-compliance during routine rounds and at random. 14. Administrator will ensure the completion of daily room rounds to check for smoking paraphernalia and ensure resident compliance and safety. 15. Administrator / designee will randomly audit documentation for residents with smoking and/or aggressive behaviors to ensure follow-up. 16. Findings will be reviewed during monthly QA meetings for the next 3 months or as long as deemed necessary by the QA Committee. B. Based on observation, interview and record review the facility failed to follow their plan of care and fall prevention policy to reduce the risk for falls for 2 of 2 residents both identified to be at high risk for falls,(R8, R18) both were reviewed for falls, in the sample of 18. The July 2012 Physician order [REDACTED]. R8 has a plan of care, dated 6/12/12, to reduce the risk of serious injuries related to falls. The interventions in the plan of care documents R8 is to utilize a bed alarm when in bed and a chair alarm when in a chair. The last fall risk observation documentation, dated 6/11/12, documents R8 is at a high risk for falls. The nursing progress notes document fall incidents on the following dates: 8/13/11, 9/4/11, 10/11/11, 1/24/12, 1/30/12, 4/8/12, 6/11/12, and 6/13/12. The facility's incident report documents fall incidents on 4/6/12 and 1/23/12. The facility's incident report documents a physical therapy evaluation was to be completed as an intervention to R8's fall 6/11/12. There is no documentation in the Clinical Record indicating this was completed. The facility did not provide the report when asked. On 7/12/12 at 9:45am, E2 (Director of Nurses) stated, "The physical therapist should be in today." On 7/10/12 at 9:35am, R8 was observed in bed with the bed alarm string attached to R8's clothing but the bed alarm box was laying next to R8, not secured to anything. The alarm would not sound if R8 attempted to get out of bed without assistance. On 7/10/12 at 12:55pm, R8 was observed sitting in a chair eating lunch. The chair alarm string was attached to R8's clothing but the chair alarm box was sitting in R8's sweatshirt hood. The box was not secured to anything and would not alarm if R8 attempted to get up without assistance. The alarm box fell out of R8's hood and sounded. At that time, E4 (nurse) reattached the chair alarm string to the box and placed the alarm box in the sweatshirt hood, again not secured to anything. The July 2012 Physician order [REDACTED]. R18 has a plan of care, dated 6/20/12, to reduce the risk of serious injury related to falls. Care plan interventions documents R18 is to utilize a chair alarm when in the chair. R18's fall risk assessment, dated 6/12/12, documents R18 is at a high risk for falls. The nursing progress notes document fall incidents on the following dates: 9/17/12, 10/22/12, 3/20/12, and 5/16/12. On 7/9/12 at 12:00 R18 was observed in the chair in the dining room with a chair alarm string attached to R18's clothing and the chair alarm box was sitting in the chair next to R18, not secured to anything. The alarm would not have sounded if R18 attempted to get up without assistance. On 7/12/12 at 8:25am, R18 was observed in a chair with a chair alarm string attached to R18's clothing and the chair alarm box sitting in the chair next to R18, not secured to anything. The alarm would not have sounded if R18 attempted to get up without assistance On 712/12 at 9:50am R18 was observed in a chair with a chair alarm string attached to R18's clothing and the chair alarm box sitting in the chair next to R18, not secured to anything. The alarm would not have sounded if R18 attempted to get up without assistance. E2 (Director of Nursing) was present during this observation and stated, "We probably need to get a chair alarm pad instead. It doesn't do any good if not attached." The Fall Prevention Program Policy documents safety interventions will be implemented for each resident identified at risk. The Director of Nursing or designee is responsible for monitoring the Fall Prevention Program, including purchase of additional equipment.

Based on record review and interview, the facility failed to assess, develop and implement a plan of care with interventions to prevent a fecal impaction for one of one resident (R2) reviewed for bowel management in a sample of 18. This failure resulted in R2 being treated at the hospital for fecal impaction. Findings include: R2's current diagnoses, per July 2012 Physician order [REDACTED]. The Physician order [REDACTED]. R2 receives nothing by mouth and receives Fibersource 70 milliliters per hours from 2pm until 10am daily. The nurses' note dated 3/6/12 document R2 was referred to the hospital for evaluation of coffee ground emesis. At the hospital, R2 was referred to Z3 ([MEDICATION NAME] consultant) on 3/6/12 by E13 (Facility Medical Director and Attending Hospital Physician) for an evaluation. Z3's report of consultation documents a history which includes "during the last admission, R2 did have a significant amount of impaction." Z3's consultation report documents an impression which includes "fecal impaction- patient does have a large amount of stool in his rectum. He needs some disimpaction and and then we will once again treat him with [MEDICATION NAME] and [MEDICATION NAME] through his gastrostomy tube. Z3 ordered manual disimpaction and [MEDICATION NAME] and [MEDICATION NAME] per the gastrostomy tube." R2 was readmitted back to the facility on [DATE] per nurses' note. The Clinical Record for March, April, and May 2012 lacks documentation of initiation of a bowel regimen interventions or monitoring to prevent further occurrences of fecal impaction. Nurses' note dated 6/9/12 documents R2 was sent to the hospital for evaluation of two incidents of coffee ground emesis. At the hospital, R2 was referred again to Z3 on 6/9/12. Z3's report of consultation documents R2 "has a history of recurrent fecal impactions. Despite that fact, R2 has been discharged back to the nursing home on [MEDICATION NAME] and stool softeners, I note he is not on any at this time. At this time of his admission, he is vomiting large amount of brownish fluid." Z3's consultation report documents the impression as "1. Recurrent fecal impaction- unfortunately there is nothing new for this particular problem. He needs manual disimpaction followed by soapsuds enemas and then finally large volumes of [MEDICATION NAME]. In the past he has responded well to this therapy. Hopefully, when he gets discharged back to the nursing home this time, they will continue him on [MEDICATION NAME] on a regular basis. 2. Nausea and vomiting- it is likely due to the impaction. I would note that he has been started on some [MEDICATION NAME]. We will certainly continue that medication while he is being treated for [REDACTED]. R2 was readmitted back to the facility on [DATE] per nurses' note. The Physician order [REDACTED]. of fecal impaction, and no plan of care to assess and monitor R2 for constipation and/or bowel movement frequencies. On 7/12/12 at 9:55am, E2 (Director of Nursing) stated when a resident returns from the hospital, the hospital records remain on the unit for 7 days then go to Medical Records. They are available for the physicians to review when the resident returns. The nurses also refer to them for the admission. Z3 follows R2 both here and at the hospital so Z3 is aware of R2's history and treatment during hospitalization s. On 7/12/12 at 10:00am, E4 (Nurse), stated "the hospital records are used by the nurses to re-admit the residents and then they are sent to Medical Records. If the physician requests the records I get them for the physician. I am not aware R2 has any history of constipation or fecal impactions." On 7/12/12 at 1:35pm, E13 stated "R2 did have fecal impactions in the hospital. Fecal impaction is an issue for R2. He has multiple co-morbidities. R2 is difficult to assess because he has mental [MEDICAL CONDITION] and doesn't speak. I am not sure why he wasn't started on a bowel regime or monitoring upon his return from the hospital in March." On 7/12/12 at 1:50pm, E2 stated "I wasn't aware of the hospital documentation of fecal impactions. R2 doesn't have a plan of care in place and he should. Residents with an impaction issue should have a care plan in place to monitor bowel movements." The facility's Bowel Elimination Management Policy documents "for residents with cognition deficits, the nurse aide is to note the occurrence, frequency and character of bowel movements and the results are to be given to the charge nurse for follow up. For residents who have had no bowel movement for 2 days (6 shifts) are to be offered 4 ounces of prune juice at supper or at bedtime. Residents who have had no bowel movement for 3 days (9 shifts) will be observed for the possibility of fecal impaction. If the assessment reveals suspected impaction, review the physicians orders for authorization to perform a rectal exam or notify the physician of assessment findings and request an order to perform a rectal examination to check for fecal impaction and treatment orders. The unit manager/charge nurse will monitor bowel elimination documentation at least weekly." There is no documentation in the Clinical Record by the nursing assistant or nurses of bowel movements, interventions or of any notification or follow-up by nursing staff regarding R2's bowel elimination on the following dates: 3/16/12, 3/21/12, 3/23/12, 3/29/12-4/1/12, 4/9/12-4/13/12, 4/16/12-4/20/12, 4/21/12, 4/22/12, 4/24/12, 4/25/12-4/27/12, 4/28/12, 5/2/12-5/4/12, 5/6/12-5/10/12, 5/13/12-5/14/12, 5/16/12-5/18/12, 5/19/12, 5/24/12-5/27/12, 5/29/12-5/30/12, 6/1/12-6/3/12, and 6/15/12 per the nurse and nurse aide entries..

Based on observations, record reviews and interviews the facility failed to provide supervision for 1 of 8 sampled residents, R2, who was a previous resident. R2 was allowed to re-enter the facility unsupervised and sexually assault R1. R2 had a history of [REDACTED]. This failure resulted in an Immediate Jeopardy. E2 (Administrator) was notified of the Immediate Jeopardy on July 21, 2011 at 10:36AM. The Immediate Jeopardy was determined to have begun July, 2011 at 11:15PM when R1 was sexually assaulted. Findings include: E4 (evening nurse) stated on 7-13-11 at 11:30AM , "I let (R2) back into the facility after leaving the facility against medical advice (AMA). (R2) was requesting a blanket because he was cold and needed to go to his room to get a blanket. This happened during the change of shift and we were in our nursing report. During the same time I was telling the night nurse that (R2) was barred from the building because of inappropriate sexual behaviors with (R1). Then (E6 -certified nurse aide) came to the nursing station and reported to the night nurse about the sexual act she witnessed between (R1) and (R2). I continued to finish my paper work to go home. The police came and the ambulance arrived and I just let the night nurses handle it. I did not go into the room to assess (R1) because the night nurses were caring for her." E4 also stated that during the evening shift; residents in the facility constantly come and go out the back door. "All of the residents know the code." E6 stated on 8-23-11 at 10:40AM, "I saw (R2) sitting in a chair by the door when we came into work that night. (E4) told me that the resident was not allowed in the building. E5 (night nurse) called E1(administrator). (E1) said to escort (R2) out of the building so we got him out of the building. On rounds at 11:30PM (R1's) call light went off and I saw (R2's) head between (R1's) thighs and (R2) was performing oral sex on (R1)." R2 was able to re-enter the facility after he was escorted out by E5 and E6 and enter R1's room undetected. Z2 (R8's Medical Physician) stated on 7-8-11 at 11:30AM, (R1) has severe anoxic brain damage and she is unable to speak or verbalize any of her needs. (R1) also needs extensive assistance with all aspects of physical concerns. Z2 stated (R1) would not have been able to call for help. Random interviews on 7-8-11 with E11(social service aide), E12(Rehab aide), E13 (staff nurse) and E14 (dietary aide) between the hours of 9:00AM to 12:00PM, all told surveyor that the facility's administration told every staff member not to allow R2 close to R1 because of inappropriate behaviors. All of them stated that this was well known in the facility. All of them stated they have seen R2 inappropriately touch R1 several times, they all said they have reported it several times. E10 (Housekeeping Supervisor) stated that she reported R2's behavior of sitting very close to R1 and rubbing her arm on 7-1-1 to administration. E3 (social service) stated on 7-8-11 at 4:00PM, "(R2's) physicians order on 7-1-11 were directly related to (R2's) feeding and playing with R1's hair and inappropriately touching her. (R2) had been told several times not to go near (R1). (R2) refused to obey these instructions knowing that (R1) cannot communicate that she is willing to accept sexual affection. (R2) left the facility and was instructed not to come back because of his inappropriate sexual behaviors toward (R1)." E3 also stated on 7-8-11 at 4:00PM that the staff had been complaining about R2's frequent inappropriate touching of R1. E3 stated that he witnessed this several times and counseled R2 several times but nothing else was put in place to protect R 1 or further address R2's behaviors. Z5 (Psychiatric Physician) stated on 8-23-11 at 10:00AM, "I gave orders to send R2 to get a psychiatric evaluation (7/1/11) because he was displaying behavior that the facility could not manage. These behaviors were touching a young girl inappropriately who could not defend herself ." E2 (Administrator) stated on 7-8-11 at 10:00AM, "everyone was told on 7-1-11 that (R2) is not allowed in the building because of his sexual gestures toward (R1)". E2 confirmed that no written formal instructions were given to the facility staff regarding R2. On 7-13-11 at 3:00PM, she said she was not aware that E4 allowed R2 back into the building. E2 stated that every staff member in the building was fully aware not to allow R2 back into the building; "this was no secret". E1(Director of Nursing) stated on 7-8-11 and again on 8-23-11 at 10:30AM, E1 stated that everyone in the building on the day shift and evening shift knew not to let R2 back in the building. R2 was not allowed back into the building because he left against medical advice (AMA) and because of his sexual behaviors toward R1. E17, E18 and E20 (Certified Nurse Aides) stated on 8-23-11 between 10:00AM and 11:00AM that they were not aware that R2 was barred from the building. All of these nurses were working the day R2 left AMA and none were informed by facility's administration that R2 was barred from the building. R2's social service notes 6-17-11 (late entry for the actual date of 6-13-11) dated 7-5-11, (a late entry for the actual date of 6-1-11) document that the resident was met with to discuss his continued attempts of being around another peer whom he was instructed to remain away from due to the other resident's inability to communicate. R2 was instructed that if he was non-compliant and not following staff direction, he would be sent out for psychiatric evaluation. There is no further documentation of any other interventions or monitoring done of R2 after the resident was counciled and the inappropriate behavior continued. R2 was allowed to sign out AMA on 7/1/11 and then allowed that evening to come back into the facility. The Immediate Jeopardy was removed on July 22, at 3:00PM. The facility still remains our of compliance at a Severity and Scope - Level 2. The facility needs to complete staff training and Nursing in - services, to evaluate the effectiveness of the revised policies/protocols/monitoring and assessments for /abuse - sexual assault and inappropriate behaviors. The facility took the following measures to remove the immediate jeopardy: 1). The Police were notified. 2). The former resident, R2 was removed from the facility. 3). The resident, R1 was sent to the hospital for evaluation. 4). The Director of Nursing came to the facility and made rounds to ensure all other residents in the facility were safe. 5). An Abuse investigations was initiated. 6). The facility door alarms were inspected and the codes were changed. 7). The facility was provided instructions on changing the door alarms codes. The codes to the door alarm will be changed monthly, or if the code is obtained by an unauthorized person. 8). resident in the facility were re-educated regarding the Door Alarms, Resident Safety and Visitor Policy with the facility including discharged residents. 9). New residents will be informed of the Policies during the Social Service Admission Process. 10). All staff were re-in-served regarding Door alarms, discharged residents, AMA, supervision and notification of the police. 11). In-services will be scheduled quarterly on door alarms, discharges, supervisions and notification of the police and for new employees. 12). Door alarms will be tested daily to ensure they are functions properly. 13). Maintenance Director will report to the Administrator, any malfunctions with door codes or alarms. 14). The results on the test of the door will be documented on a Quality Assurance Audit. 15). The results will be discussed in the monthly QA meetings. 16). These results will be supervised by the Administrator.

Based on observations, record reviews and interviews the facility failed to maintain a pressure relieving device for 1 of 2 residents (R8), reviewed for pressure sores in a sample of 8. These failures resulted in R8 acquiring multiple pressure sores that required hospital admission for antibiotic therapy and surgical intervention. The lack of nutritional intervention and resulting decline in R8's physical condition resulted in an Immediate Jeopardy. E2 (Administrator) was notified of the Immediate Jeopardy on July 21, 2011 at 10:36AM. The Immediate Jeopardy was determined to have begun May 1, 2011 at 3:00PM when R1 was admitted to the hospital for surgical debridement of necrotic tissue of multiple pressure sores and treatment for [REDACTED]. . Findings include: R8's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission skin assessment showed no skin breakdown. Physician notes dated 4-1-11 notes," transferred to hospital for evaluation of altered mental status and returned to the facility with no new orders." Nursing notes dated 4-6-11 at 11:34PM notes, "R8 has a very poor diet. R8 never eats full meals and rarely eats 1/3 of meals." Nursing notes dated 4-16-11, 4-17-11, 4-21-11, 4-25-11, 4-27-11 continue to state that the resident has a poor a appetite, refuses to swallow, and is eating less than 1/3 of meals. Wound care notes document the following: - 4-29-11 (R8) has a stage 2 acquired right hip pressure sores." - 5-19-11 acquired stage 3 to left knee and acquired stage 2 pressure sore to sacrum." - 5-27-11 acquired unstageable pressure sores to right medial leg, - 6-4-11 acquired unstageable to left hip along with unstageable acquired pressure sores to right and left heels." Dietician notes dated 4/7/11 show that a 2 week calorie count was ordered, her diet downgraded to puree and health shakes added. A recommendation for a gastrostomy tube placement was made if the oral intake did not improve. R8's yearly weight records for 2011 documents the following: February, 139 lb' s', March 137.8 lb's, April 134 lb' s', May (hospital weight) 115.8#'s. This is a 29 lb. unintentional weight loss within 4 months. Nursing notes dated 4-8-11 at 10:32PM ,"abscess to right scalp area". Nursing notes dated 4-29-11 notes" stage 2 acquired right hip pressure sore". Z7( R8's Attending Physician) on 7-12-11 at 3:00PM stated that R8's pressure sores and other co-morbidities ( dehydration, [MEDICAL CONDITION] and [MEDICAL CONDITION]) development are directly related to lack of food consumption/very poor appetite and poor nutrition. Z7 stated he sent R8 to the hospital. for the placement of a gastrostomy tube for R8 to increase her nutrition before any of the skin breakdown began. The hospital refused to place a gastrostomy tube because R8 had no family member or legal guardian to give consent for the surgery. Z7 stated it was the hospital's fault and not the facility's fault that she developed pressure sores. Z7 stated he sent R8 to the hospital and they did nothing; the hospital just sent her back to the facility. Z7 also stated that he discussed the nutritional needs of R8 ,(gastrostomy tube placement and legal guardian) with the Administrator. Z8 (Registered Dietician) on 7-21-11 at 2:30PM confirmed the recommendations of gastrostomy tube because of the decrease in oral intake. Z8 also stated that from 4-12-11 to 5-20-11 she did not assess or follow up on her own recommendations for R8's gastrostomy tube placement. Z8 stated," it was up to the physician." Z8 had no comments about the multiple pressure sores R8 developed between 4-12-11 to 5-20-11 the 29 lb weight loss or the medical problems related to lack of nutrition. Z8 stated that the next time she assessed R8 was May 20, 2011 after the placement of the gastrostomy tube. Social service notes dated 4-12-11 at 12:26PM ( a late entry for 4-11-11) notes," R8 deemed in need of guardianship due to not having any family or friends that could act as power of attorney with making healthcare decision. R8 is being referred for state guardianship." E3 (social service) stated on 7-8-11 at 3:30PM, that he found out about R8's medical condition and then began working on guardianship because R8 was declining. E3 had no comment as to why this was not done upon admission or before R8's physical decline started. E3 also stated that he told E2 (Administrator) about the need for guardianship. Review of hospital lab results dated 5-1-11 notes: sodium 163 (norm 136 to 145), chloride 128 (norm 98 to 107), BUN 52 (norm 7 to 18), [MEDICATION NAME] 2.2 (norm 3.4 to 5.0) , Hemoglobin 11 (normal 12 to 16). Hospital records dated 5-9-11 notes:"received a gastrostomy tube on 5-9-11." Hospital Discharge notes dated 5-11-11 notes: "renal consult was obtained for electrolyte imbalance, Patient was continued on intravenous hydration. Due the patient's failure to thrive, dehydration, [MEDICAL CONDITION] and a (Percutaneous [MEDICAL CONDITION] Gastrostomy) PEG was recommended and placed after consent was obtained from family. The PEG is functioning, intervenous fluids were weaned, patient became more alert." Z7 stated again on 7-20-11 at 1:30PM ," It is the hospital's fault because the hospital sent (R8) back to the facility and (R8) continued to decline and have skin breakdown. (Z7) stated I sent her to the hospital twice before the hospital would do something. (Z7) also stated ,"I am surprised R8 is still alive because of her low lab results, multiple pressure sores, not eating, hazards of immobility and the steady decline in her overall physical condition. Z7 stated that without eating for a length of time once the gastrostomy placement was done it was too late. Once the gastrostomy tube was inserted ( 4 weeks later) by the hospital it was too late, pressure sores had already developed, the damage was done". Z7 gave no reason as to why he did not inform Z9 (Medical Director) about R8's declining condition" Z9 stated on 7-20-11 2:30PM that the local hospital told him that R8 needs a gastrostomy tube because of multiple pressures sores and inability to eat. Z9 states that he assisted the facility in getting R8 a legal guardian. This process was done within 48 hours. Z9 stated if he would have known or been aware of the need for R8 to receive a medical treatment (gastrostomy tube placement) he would have intervened earlier. Z9 stated neither the facility or Z7 informed him of R8's declining medical condition. R8's dressing changes were observed on 7-9-11 at 9:30AM with E9. The right and left outer hips and sacrum were all Stage IV in size with copious drainage on the dressings. The Stage III pressure sores on each heel had [MEDICATION NAME] in place, and the lower leg had a Stage I pressure sore with a dressing in place. Observations of R8 on 7-8-11 at 10:00AM and on 7-12-11 from 9:30AM to 10:30AM, showed R8 was lying in bed on a deflated air mattress directly on the metal portion of the bed. E1, (Director of Nursing) and E9 (Treatment Nurse) on 7-8-11 at 4:00PM stated," they were not aware of the air mattress not working correctly. E9 stated she did not know the connections were not staying in place to keep air in the mattress. The Immediate Jeopardy was removed on July 21, at 3:00PM. The facility still remains out of compliance at a Severity and Scope - Level 2. The facility needs to allow time to complete staff training and Nursing in - services, and to evaluate the effectiveness of the revised policies/protocols/monitoring and assessments for pressure sores The facility took the following measures to remove the immediate jeopardy: 1). the resident is receiving treatment to pressure sores as ordered. 2). wounds and assessed weekly per treatment nurse and or charge nurse. 3). preventative measures continue to prevent further breakdown will be assess daily. 4). All resident have been assess for pressure sores by completing a skin assessment of each resident. 5). All residents will be assess upon admission to the facility. 6). All staff have been re-in-service regarding pressure sores preventions and care. 7). Care plans for residents with pressure sores have been revised, ,skin alteration noted for improvement or deterioration. 8). the physician will be notified for residents developing, having deterioration, non-healing wounds or signs and symptoms of infections with pressure sores. 9). Mechanical interventions for pressure sores will be monitored daily dure by nursing staff. 10). Maintenance Director will be notified of devices not functioning properly and the repair contractor will be called as needed. 11). Family and or legal representative will be notified for changes in would status. 12). Changes to the wounds will be reported upon discovery. 13). Social services will determine residents who have no family or legal representative and an application will be initiated. 14). The Director of Nursing will review the shower sheets daily, review reports for changes an development of new wounds. the Director of Nursing will monitor the Treatment Nurse's notification of the physician and notification of the family or legal representative. 15). Quality Assurance using a audit tool 3-5 times weekly will monitor the discovery, treatment, family/legal representative interaction. 16). the results of the audit will be discuss at the monthly quality Assurance meeting.

Based on record reviews and interviews the facility failed to protect and prevent the abuse of 1 of 8 sampled residents (R1) from a former resident (R2) who had a history of [REDACTED]. This failure resulted in an Immediate Jeopardy. E2 (Administrator) was notified of the Immediate Jeopardy on July 21, 2011 at 10:36AM. The Immediately Jeopardy was determined to have begun July 2, 2011 at 11:15PM when R1 was sexually assaulted. Findings Include: E4 (staff nurse) stated on 7-8-11 at 11:00AM "(R2) left the facility Against Medical Advice (AMA) on 7-1-11 at about 12:00PM. (R2) was not allowed back into the building because of his inability to follow instructions not to be near (R1). These instructions were not to touch her body, not to feed her, and not to sit by her. (R2) had options to go to the hospital or leave. (R2) left the facility. I was going to tell the night nurses about (R2's) behaviors and the facility's request that he go to the hospital or leave. I let (R2) in the building just to get a blanket because he said he was cold." E6, CNA (Certified Nurse Aide) on 7-8-11 at 2:00PM stated on 7-1-11 at about 11:15PM, she observed R2 with his head between R1's inner thighs. R2 was standing at the foot of the bed. R2 had slurred speech and had a strong smell of alcohol. E6 stated after she told R2 to stop, he raised his head and began to lick his lips. E6 stated that R1 was lying in the bed unable to make any sounds, nervous, shaking all over and had the call light in her hand squeezing it tightly. Z2 (R1's Attending Physician) stated on 7-8-11 at 11:00AM, "(R1) has severe [MEDICAL CONDITION] and she is unable to speak or verbalize any of her needs. (R1) also needs extensive assistance with all aspects of physical concerns. (R1) would not have been able to call for help." R1's assessments from 3/7/11 and care plan from 8/10/11 confirm that the resident was totally dependent upon staff for care and was non verbal. R2 's assessments and care plan dated 6/1/11 show that the resident is independent in all activities of daily living. R2 was admitted to the facility on [DATE]. Documentation from this date to discharge on 7/1/11 show episodes of R2 sitting close to R1, rubbing her arms, feeding the resident, playing with her hair and being found in her room. R2 was redirected each time, but the behaviors continued. E3 (Social Service Director) stated on 7-8-11 at 4:00PM that the staff had been complaining about R2's frequent inappropriate touching of R1. E3 stated that he witnessed this several times and counseled R2 several times. E3 stated nothing further was implemented to address or prevent this behavior from reoccurring. Z5 (Psychiatric Physician) stated on 8-23-11 at 10:00AM, "I gave orders to send (R2) to get a psychiatric evaluation because he was displaying behavior that the facility could not manage. These behaviors were touching a young girl inappropriately who could not defend herself ." emergency room records dated 7-2-11 at 12:00AM note the following: "The final [DIAGNOSES REDACTED]. A series of sexual transmitted test were done". Police report dated 7-1-11 at 11:25PM states that R2 was taken into custody outside the facility and detained while a investigation was done. The resident was arrested and charged with criminal sexual assault. The Immediate Jeopardy was removed on July 21, at 3:00PM. The facility still remains out of compliance at a Severity and Scope - Level 2 because of the need to allow for the facility to complete staff training and nursing in -services. The facility will also need to evaluate the effectiveness of the revised policies/protocols/monitoring and assessments for abuse/sexual assault and inappropriate behaviors. The facility took the following measures to remove the immediate jeopardy: 1). All staff were re- in -serviced on following the facility Abuse Protocols and procedures. 2). All of the residents in the facility have been re-educated on the Abuse Protocol prevention and reporting through a meeting with the residents. 3). An Abuse Investigation was conducted. 4). The final report was submitted to the Illinois Department of Public Health. 5). All employees have been re- in-serviced on the policy of Against Medical Advice (AMA). 6). All employees have been re - in-serviced on visitation policies of the facility. 7). The 2 nurses who failed to follow the facility's Abuse Policy and Procedures are no longer employed at the facility. 8). The Administrator/designee will conduct Abuse Investigation in accordance with the regulations. 9). The Administrator will review the employee in- services to ensure compliance. 10). Upon discovery of failure to follow the Abuse Policy and Procedures an investigation will ensue. 11). QA will be done/monitor by the Director of Nursing for abuse compliance Quartey. 12). QA the monitoring will be done 3-5 times per week.

Based on observations, record reviews and interviews the facility failed to seek a legal guardian for 1 of 8 sampled residents (R8) who was unable to make decisions for herself. As a result of the facility's inaction, the resident's medical condition deteriorated resulting in [MEDICAL CONDITION], dehydration, infection and [MEDICAL CONDITION]. Findings include: R8's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission social service notes for R8 dated 3-19-11 (a late entry for 3-4-11) document "Resident is a widow with no children. Resident has no listed family members. Resident is alert and oriented times 2." Nursing notes dated 4-6-11 at 11:34PM notes, "R8 has a very poor diet. R8 never eats full meals and rarely eats 1/3 of meals." Nursing notes dated 4-16-11, 4-17-11, 4-21-11, 4-25-11, 4-27-11 continue to state that the resident has a poor a appetite, refusing to swallow, and eating less than 1/3 of meals. Dietician notes dated 4/7/11 show that a 2 week calorie count was ordered, her diet downgraded and health shakes added. A recommendation for a gastrostomy tube placement was made if the oral intake did not improve. Nursing notes dated 4-8-11 at 10:32PM ,"abscess to right scalp area". Nursing notes dated 4-29-11 notes" stage 2 acquired right hip pressure sore". Social service notes dated 4-12-11 at 12:26PM (a late entry for 4-11-11) notes, "R8 deemed in need of guardianship due to not having any family or friends that could be used as power of attorney with making healthcare decisions. R8 is being referred for state guardianship." E3 (social service) stated on 7-8-11 at 3:30PM that he found out about R8's medical condition and then began working on a guardianship because R8 was declining. E3 had no comments as to why this process was not started when the resident was admitted prior to R8's physical decline. E3 also stated that he told E2 (Administrator) about the need for guardian. Z8 (R8's Attending Physician) stated on 7-8-11 at 4:00PM and 7-20-11 at 1:30PM, "The delay in treatment was due to no one available to sign for consent for the surgical procedure (gastrostomy tube placement) that needed to be done. "It was the local hospital who is responsible for the delay." Z8 stated that R8 was sent to the hospital twice within 30 days. The initial visit the hospital refused to place the gastrostomy tube because R8 had no one to sign. The hospital sent R8 back to the facility. Z8 also stated that the hospital notified the facility of the need to obtain a legal guardian so the surgical interventions could be done. R8 returned to the facility and continued to decline. Z8 also stated that he told the administrator that the facility needed to pursue a guardian for R8 before R8's medical decline. "R8's decline in medical condition is directly related to her inability to eat. Z8 stated that her body began to breakdown. The damage has already begun". E2 (Administrator) on 7-8-11 at 4:00PM stated that she found out about the need for R8 to have a legal guardian when the hospital called and requested that she, as the administrator should sign for the surgical procedure (gastrostomy tube placement) in April, 2011. E2 stated that administrators cannot sign for surgical procedures. E2 stated that she notified the court systems and "just had to wait until the court date that was assigned to R8". The court date that was assigned to R8 was May 6, 2011. Z9( Medical Director) stated on 7-21-11 at 1:30PM, that no one from the facility made him aware of R8's declining condition. The local hospital brought it to his attention and this is where he gave his assistance in getting R8 a legal guardian. Z9 stated that it took only 48 hours to obtain a legal guardian. R8 had the gastrostomy tube placed on 5-9-11. Hospital records indicate that R8 was admitted [DATE] with a [DIAGNOSES REDACTED]. Z14 (Temporary State Guardian) stated on 8-24-11 at 9:35AM, "My records indicate that the Administrator (E2) initiated,( R8's) state guardianship on May, 4, 2011. On May 6 an order from the courts were obtained and a consent for the surgery was received on May 9, 2011, the day of surgery." E2 did not initiate a state guardianship until 5-4-11. R8 began her medical decline on 4-7-11 (33 days prior). E2 also did not make the medical director (Z9) aware of the resident's declining condition, the need for guardianship to insert a gastrostomy tube, or the problems with the hospital not pursuing guardianship on R8's two previous admissions. Z8 did not contact Z9 and relate the problems regarding the resident's declining condition and the need for guardianship for the gastrostomy placement.