Every finding on record at Aperion Care Oak Lawn

Based on interview and record review, the facility failed to protect a resident's right to be free from physical and verbal abuse from staff. These failures affected one (R4) of three residents reviewed for abuse. These failures resulted in R4 suffering mental anguish and physical pain when a staff yelled at him for pulling his call light, and another staff forcefully yanked R4's shoulder to turn him around while providing care. R4 said that he was afraid for his life when the same staff that he requested not to care for him returned to his room a day or two later and R4 told her she was not supposed to be in his room.Findings include: R4 was admitted to the facility on [DATE], face sheet listed the following past medical history in part: Chronic inflammatory demyelinating polyneuritis, primary osteoarthritis, type 2 diabetes, disorder of unspecified muscle, other lack of coordination, Paraplegia, muscle wasting, urinary tract infection, anemia, presence of urogenital implant, etc.On 8/24/2026 at 11:25AM, R4 was observed in his room, awake and alert. R4 stated that he has concern with staff being unprofessional and abusive. Surveyor asked R4 what he meant and he said that one day he pulled his call light because he was wet and needed to be changed. V16 (Certified Nursing Assistant/CNA) came in and R4 told her that he needed to be changed. V16 said she will come back. R4 waited for about an hour and the CNA did not come back, R4 pulled his call light again and the nurse, (V25 Licensed Practical Nurse/LPN) walked into the room and yelled at him, saying, why are you pulling your call light. R4 told the nurse that he needed to be changed and the nurse left. V16 came back into the room and was visibly upset and very rough while providing care to him. R4 said that when he turned towards the wall so staff can clean his back area, V16 just yanked him on the shoulder to turn him the other way and that was very painful R4. R4 said that he reported the incident to the social worker (V10) and requested that V16 not to care for him anymore. R4 said V16 came back to his room the following day or two and resident told her that she was not supposed to take care of him and she should leave his room. V16 asked him why. R4 said he was afraid that the staff may do something to him.Minimum Data set (MDS) assessment dated [DATE] section C (cognitive patterns) scored R4 with a brief interview for mental status (BIMS) score of 13, indicating that R4 is cognitively intact. Functional status (section gg) of the same assessment documented that R4 requires substantial/maximal assistance with toileting hygiene, shower/bath, toilet/tub transfer, chair/bed-chair transfer and sit to lying.On 8/24/2026, surveyor requested facility concern/grievance log for the past six months and reportable since January 2026. There was no concern log or reportable relating to the staff being rude and rough during care for R4.On 8/24/2026 at 2:50PM, V10 (Social Service Director) said that she is familiar with R4, and affirmed that R4 reported the incident of nurse (V25 LPN) being rude and CNA (V16) being upset and rough during care to her. V10 completed a concern form, reported to nursing and instructed the CNA be removed from resident care. V10 said that V16 was not supposed to go back to resident's room a day or two later, and it is never acceptable to be rude to a resident or rough with a resident while providing care.On 8/24/2026 at 3:10PM V11 (MDS/Licensed Practical Nurse) said that it was reported to her that R4 complained of staff being rude, the timeliness of answering his call light, and that staff was rough while providing care to R4. V11 reported to upper management. She did not speak to the staff or residents, but resident's liaison may have spoken to him. V11 added that she thinks she completed a concern form, not sure if upper management spoke to any staff. Surveyor asked V11 if it's okay for staff to be rude to resident or be rough during care and she said, I know where you are going with this, could be abuse but did not seem so to her.On 8/25/2026 at 9:02AM, V14 (Customer Service Liaison) said that she is the assigned angel for R4. He reported to her that the nurse (V25 LPN) came in and yelled at him when he pulled his light and that the nurse was being aggressive. When the CNA (V16) came to provide care, she was rough and turned resident aggressively. V14 reported the incident to the DON (Director of Nursing) and administrator because it was a sign of abuse. V14 added that abuse can be verbal, physical, theft, etc. V14 said that if a nurse is being rude to a resident, it could be considered verbal abuse and it is never okay to be rough with a resident while providing care.On 8/24/2026 at 4:07PM, V1 (Administrator) was asked about the concern logs supposedly completed by V10 (Social Service Director) and V11 (MDS/Licensed Practical Nurse) for R4. V1 said, I don't know, let me check my office. V1 later returned with a concern form that was not among the ones presented upon entrance dated 8/13/2026 (Thursday), signed by V14 (Customer Service Liaison) who documented in part that R4 felt the nurse was rude and that the CNA rushed with care which resulted in care being rough. Follow up action documented that V14 spoke to the nurse in question about customer service while answering call light and that the CNA no longer works at the facility. V1 initially said that he was not aware of any allegation of abuse from R4, later V1 admitted that he was aware of the concern reported by R4, it came up in the morning meeting the following day, they mentioned that the nurse was sharp and rude, the resident felt that the CNA was a little rough while providing care. V1 said he is the abuse coordinator. Abuse can be verbal, physical, mental, etc. V1 said he did not speak to the resident. He became aware of the incident the morning of 8/14/2026, V1 have other qualified staff who can handle such situation. If a resident reported that staff was rough during care and did not want to work with that staff anymore, then the staff will be removed from caring for the resident. V1 said that his job is to investigate if there is viable report of abuse. In this case, V1 does not think that resident reported an allegation of abuse but added that he is initiating an investigation for R4.Facility reported incident (initial) dated 8/24/2026 presented by V1 (Administrator) documented in part: It was reported to the administrator that R4 stated that a nurse yelled at him and a CNA provided rough ADL care. R4 had reported to staff on 8/14/2026 that nurse was rude and CNA was rough due to rushing care, however on 8/24/2026 stated that nurse yelled at him while answering call light.Review of personal file for V16 (CNA) did not show any documentation that she no longer works at the facility. Review of nursing staff schedule shows that V16 was assigned to R4 on the 11pm to 7Am shift on 8/13/2026 and V25 was assigned nurse. Further review of the schedule showed that V16 worked in the same unit on 8/15/2026, different unit on 8/16/2026 and was assigned to the resident on 8/17/2026. V25 worked on the same shift on 8/13/2026, 8/14/2026, and 8/17/2026.On 8/25/2026 at 3:33PM, V1 (Administrator) said that V16 is still employed by the facility. V1 does not believe in over the phone termination. V16 is not scheduled to work till 8/26/2026 and V1 will speak to her then. V1 said that V16 worked last on 8/21/2026 but did not work with R4, the reason for the termination will be the rough handling and the fact that R4 was not happy with the care provided.On 8/26/2026 at 1:11PM, V25 (LPN) said that she is familiar with R4, V25 works mostly night shift R4 is usually quite in his room, V25 has never had any interaction with R4 or yelled at him. V25 said that someone spoke to her about customer service last week or the week before she was made aware that R4 reported that the CNA was rough with care and that the nurse told R4 that she has to do her job. V25 said she was assigned to R4 on 8/13/2026 but whatever resident reported never happened.On 8/26/206 at 1:19PM, surveyor called V16 (CNA), someone who said was her sister answered the phone and said that V16 was not available, message left with the sister to call surveyor or the facility. At 2:15PM, attempted to reach V16 again but no one answered the phone.On 8/27/2026 at 9:46AM, V1 said that he is on the phone with V16 right now, but she is walking into an orientation, will call V1 back on her break. At 2:31PM, V1 said that V16 never called him back, V1 tried to call her but she did not pick up.On 8/27/2026 at 1:00PM, V33 (Medical Director) said that she was not aware of the abuse allegations going on at the facility, she was just informed by the administrator today. V33 said that it is her expectation that any allegation of abuse be taken seriously and for the facility to follow its abuse policy and procedure. Abuse prevention policy revised 3/28/2026 states 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.Definitions: Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.Protection of residents:Employees of this facility who have been accused of abuse, neglect, exploitation, retaliation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator, and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident's property is unsubstantiated.

Based on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of resident property and/or exploitation. This failure affected one resident (R6) of three residents reviewed for abuse. R6 lost 5 rings at the facility, one of which she said belonged to her grandmother and a family heirloom that she was intending to pass on to another family member. R6 also had some unauthorized charges to her credit card, facility has been aware of both incidents since March 2026, and nothing has been done. Applying a reasonable person concept, R6 suffered emotional and mental anguish as a result of losing her money and her grandmother's ring. R1was tearful when interviewed.Findings include:R6 has been at the facility since 1/17/2026, face sheet listed the following past medical history in part: Type 2 diabetes mellitus with other skin complications, moderate persistent asthma, other acute and sub-acute respiratory symptoms, epilepsy, unspecified, not intractable with status epilepticus, muscle wasting and atrophy, major depressive disorder, etc.Minimum Data Set (MDS) assessment dated [DATE] score R6 with a brief interview for mental status score of 14, indicating that resident is cognitively intact. Functional status (section gg) of the same assessment documented that R6 requires substantial/maximal assistance form staff for shower/bath, lower and upper dressing, dependent on toilet hygiene and putting off footwear and partial/moderate assistance for personal hygiene.On 8/24/2026 at 11:57AM, R6 said that she had a credit card, called to get the balance and it went from $1700.00 to 35 cents, there were several charges to her account, one was a television purchased from (Name of Store) for $500.00, $200.00 and $300.00 charges at a sports store, both purchases were one in March or April. R6 said that she called the police, and they told her that they may never find who made the purchases. R6 became emotional and told the surveyor that she does not want to get anyone in trouble. R6 said in April, she had a seizure at the facility during which staff assisted her with removing her clothing, staff also removed five rings from her fingers including her grandmother's ring. R6 said that staff were supposed to put the rings in a pink box and place them in her closet, couple of days later, her sister visited and R6 asked her sister to get the box for her and the box of rings were gone. R6 reported to the Administrator, they did not believe her, and she was told that she may have lost the rings somewhere else. R6 said that she was sure the rings were on her fingers before she had a seizure, R6 said that she can deal with 4 of the rings but the most painful is her grandmother's ring that has been in the family for a long time, that ring was from the 1900 and will probably be worth about $6000.00. R6 said that she was planning to pass the ring over to another family member, but now the ring is gone.On 8/24/2026, surveyor requested facility concern/grievance log for the past six months and reportable since January 2026. There was no concern log or reportable relating to misappropriation of property for R6.Facility reported incident dated 3/24/2026 (initial) obtained from the regional office documented the victim as R6, incident category, resident misappropriation of property/theft. Incident description: On 3/24/2026, it was reported to the administrator that R6 reported to staff purchases on her debit card that she didn't recognize, full report to follow.On 8/25/2026 at 10:35AM, surveyor presented this initial report to V1, and he said that he will go and check his office, V1 later presented an initial and final reportable for R6. Surveyor has confirmed with the regional office secretary that state surveying agency did not receive any final investigation for R6 and requested the fax cover for the final reportable. V1 said, I am just going to be honest, I never sent the final, I don't know what happened. V1 added that he is going to start an initial investigation for R6 for charges on her credit card, V1 has not heard anything about resident's missing rings, V1 will go and speak to R6 to figure out what is exactly missing.On 8/25/2026 at 9:02AM, V14 (Customer Service Liaison) said that she went to R6 who reported that there are some charges in her credit card that she is not aware of, V14 asked R6 if she gave her card to her sister and she said that her sister has access to her credit card. V14 said she went back to R6 couple of days later and she told her not to worry about it. V14 said that R6 reported this in March or April, V14 called the bank and they confirmed that there was a charge of $200.00 and $300.00 made online. V14 is not aware of any police report that resident said she made. V14 did not do anything else because resident told her it was okay. R6 did not mention anything to her about missing rings.Surveyor requested inventory of personal items for R6, but inventory list was not provided by facility.On 8/25/2026 at 11:24AM, V10 (Social Service Director) said that she could not find any inventory of items for R6 in the binder. V10 said that when a resident is missing a personal item, it will be reported in the concern log, if it is a clothing item housekeeping will help look for it, staff will help look for the item, if the item is not found, it will be reported to the administrator. V10 said that R6 reported that she was missing some rings sometime in March or April and they were never found. V10 mentioned it in the morning meeting and was told it had been addressed.On 8/25/2026 at 11:58AM, V1 acknowledged that he heard about the missing rings in March, it came up in the morning meeting, resident said she needs help finding her rings, usually a lot of different people will check when a resident is missing an item, he did not hear anything else about it. V1 said that missing items could be stolen, misplaced or down in the laundry. V1 does not speak to all residents when they are missing a sock, staff usually try to find the item. If a resident feels like their stuff is stolen, then it becomes theft, V1 said he delegates staff to follow up, there is no regulation that states that the administrator will be the person to follow up on missing items.On 8/25/2026 at 9:56AM, V15 (R6's POA) said that she is aware of the unauthorized charges to resident's credit card sometime in March and is aware of the missing rings. R6 said it was supposed to be in a pink box; she had it at one time but did not have them anymore.On 8/25/2026 at 10:17AM, V2 (Director of Nursing/DON) said that she is aware of R6's missing money and rings, she knew about the money for a while. But was made aware of the rings yesterday. V2 did not speak to R6 about the missing items.On 8/27/2026 at 1:00PM, V33 (Medical Director) said that she is not aware of the abuse allegations going on at the facility, she was just informed by the administrator today. V33 said that it is her expectation that any allegation of abuse be taken seriously and for the facility to follow its abuse policy ad procedure. V33 added that the case of resident's missing money and rings should have been investigated, resident's safety and well-being should be taken seriously.Facility Policy:Personal property and missing item policy revised 12/14/2018 documented in part: The facility recognizes and respects the resident's ability to keep personal belongings within reason during their stay at the facility.Upon admission, the resident, and/or representative shall be informed of the process of informing facility when high value items such as cash, jewelry, electronics etc. are brought in or removed from the facility and options available for safekeeping large sums of cash or other valuables.Report missing items directly to the Social Service Department or appropriate charge nurse or manager. If necessary, the resident, visitor, or employee shall fill out a Concern Report. These forms should be available at the reception desk or at each nursing station on each floor.The concern report shall be sent to the administrator or designee by the receptionist or appropriate charge nurse, if after 8:00PM.A search will be conducted in an attempt to locate the missing item and verify if the missing item was in the facility. If the item is not located, the administrator will be notified immediately.The administrator or designee will conduct an investigation. If theft or misappropriation is suspected, the administrator will report to the state agency according to reporting guidelines. When appropriate, police are contacted.The administrator or designee shall notify the appropriate individual(s) on the status of investigation within 5 business days and follow grievance/concern guidelines to determine if the appropriate individual is satisfied with corrective action or outcome. Abuse prevention policy revised 3/28/2026 states 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.Definitions: Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent (42 CFR 483.5).

Based on interview and record review, the facility failed to implement and follow its Abuse Prevention Policy and Procedures by failing to protect a resident (R4) from physical and verbal abuse, failed to protect a resident from misappropriation of property (R6), and failed to take immediate actions to ensure resident's safety. These failures resulted in psychological harm for R4 who feared for his life when a staff he accused of physically abusing him came back to his room a day or two later, and R6 who lost a family heirloom that she intended to pass on to another family member.Findings include:1.) R4 was admitted to the facility on [DATE], face sheet listed the following past medical history in part: Chronic inflammatory demyelinating polyneuritis, primary osteoarthritis, type 2 diabetes, disorder of unspecified muscle, other lack of coordination, Paraplegia, muscle wasting, urinary tract infection, anemia, presence of urogenital implant, etc.Minimum Data set (MDS) assessment dated [DATE] section C (cognitive patterns) scored R4 with a brief interview for mental status (BIMS) score of 13, indicating that R4 is cognitively intact. Functional status (section gg) of the same assessment documented that R4 requires substantial/maximal assistance with toileting hygiene, shower/bath, toilet/tub transfer, chair/bed-chair transfer and sit to lying.On 8/24/2026 at 11:25AM, R4 was observed in his room, awake and alert. R4 stated that he has concern with staff being unprofessional and abusive. Surveyor asked R4 what he meant and he said that one day he pulled his call light because he was wet and needed to be changed. V16 (Certified Nursing Assistant/CNA) came in and R4 told her that he needed to be changed. V16 said she will come back. R4 waited for about an hour and the CNA did not come back, R4 pulled his call light again and the nurse, (V25 Licensed Practical Nurse/LPN) walked into the room and yelled at him, saying, why are you pulling your call light. R4 told the nurse that he needed to be changed and the nurse left. V16 came back into the room and was visibly upset and very rough while providing care to him. R4 said that when he turned towards the wall so staff can clean his back area, V16 just yanked him on the shoulder to turn him the other way and that was very painful R4. R4 said that he reported the incident to the social worker (V10) and requested that V16 not to care for him anymore. R4 said V16 came back to his room the following day or two and resident told her that she was not supposed to take care of him and she should leave his room. V16 asked him why. R4 said he was afraid that the staff may do something to him.On 8/24/2026, surveyor requested facility concern/grievance log for the past six months and reportable since January 2026. There was no concern log or reportable relating to the staff being rude and rough during care for R4, or any documentation of missing items for R6.On 8/24/2026 at 2:50PM V10 (Social Service Director) and at 3:10 PM V11 (MDS/LPN) affirmed they were aware of the incident between R4 and the 2 staff members. On 8/24/2026 at 4:07PM, V1(Administrator) was asked about the concern logs supposedly completed by V10 and V11 for R4. V1 said, I don't know, let me check my office. V1 later returned with a concern form that was not among the ones presented upon entrance dated 8/13/2026 (Thursday), signed by V14 (Customer Service Liaison) who documented in part that R4 felt the nurse was rude and that the CNA rushed with care which resulted in care being rough. Follow up action documented that V14 spoke to the nurse in question about customer service while answering call light and that the CNA no longer works at the facility. V1 said that his job is to investigate if there is viable report of abuse. In this case, V1 does not think that resident reported an allegation of abuse but added that he is initiating an investigation for R4.On 8/25/2026 at 9:02 AM V14 (Customer Service Liaison) stated that she spoke to R4 who reported the same incident to her.Review of personal file for V16 (CNA) did not show any documentation that she no longer works at the facility. Review of nursing staff schedule shows that V16 was assigned to R4 on the 11pm to 7Am shift on 8/13/2026 and V25 (LPN) was assigned nurse. Further review of the schedule showed that V16 worked in the same unit on 8/15/2026, different unit on 8/16/2026 and was assigned to the resident on 8/17/2026. V25 worked on the same shift on 8/13/2026, 8/14/2026, and 8/17/2026. 2.) R6 has been at the facility since 1/17/2026, face sheet listed the following past medical history in part: Type 2 diabetes mellitus with other skin complications, moderate persistent asthma, other acute and sub-acute respiratory symptoms, epilepsy, unspecified, not intractable with status epilepticus, muscle wasting and atrophy, major depressive disorder, etc.Minimum Data Set (MDS) assessment dated [DATE] score R6 with a brief interview for mental status score of 14, indicating that resident is cognitively intact. Functional status (section gg) of the same assessment documented that R6 requires substantial/maximal assistance form staff for shower/bath, lower and upper dressing, dependent for toilet hygiene and putting off footwear and partial/moderate assistance for personal hygiene.On 8/24/2026 at 11:57AM, R6 said that she had a credit card, called to get the balance and it went from $1700.00 to 35 cents. There were several charges to her account, one was television purchased from (Name of Store) for $500.00, $200.00 and $300.00 charges at a sports store, both purchases were one in March or April. R6 said that she called the police, and they told her that they may never find who made the purchases. R6 became emotional and told the surveyor that she does not want to get anyone in trouble. R6 said in April, she had a seizure at the facility during which staff assisted her with removing her clothing, staff also removed five rings from her fingers including her grandmother's ring. R6 said that staff were supposed to put the rings in a pink box and place them in her closet, couple of days later, her sister visited and R6 asked her sister to get the box for her and the box of rings was gone. R6 reported to the administrator, they did not believe her, and she was told that she may have lost the rings somewhere else. R6 said that she was sure the rings were in her fingers before she had a seizure. R6 said that she can deal with 4 of the rings but the most painful is her grandmother's ring that has been in the family for a long time, that ring was from the 1900 and will probably be worth about $6000.00. R6 said that she was planning to pass the ring over to another family member, but now the ring is gone.Facility reported incident dated 3/24/2026 (initial) obtained from the regional office documented the victim as R6, incident category, resident misappropriation of property/theft. Incident description: On 3/24/2026, it was reported to the administrator that R6 reported to staff purchases on her debit card that she didn't recognize, full report to follow.On 8/25/2026 at 10:35AM, surveyor presented this initial report to V1, and he said that he will go and check his office, V1 later presented an initial and final reportable for R6. Surveyor has confirmed with the regional office secretary that the state surveying agency did not receive any final investigation for R6 and requested the fax cover for the final reportable. V1 said, I am just going to be honest, I never sent the final, I don't know what happened. V1 added that he is going to start an initial investigation for R6 for charges on her credit card. V1 has not heard anything about resident's missing rings. V1 will go and speak to R6 to figure out what is exactly missing.On 8/25/2026 at 9:02AM with V14 (Customer Service Liaison) and at 11:24AM with V10 (Social Service Director), both staff members affirmed that R6 reported some unauthorized charges to her card and some missing rings back in March or April of 2026.On 8/25/2026 at 11:58AM, V1 acknowledged that he heard about the missing rings in March, it came up in the morning meeting, resident said she needs help finding her rings, usually a lot of different people will check when a resident is missing an item, he did not hear anything else about it. V1 said that missing items could be stolen, misplaced or down in the laundry. V1 stated V1 does not speak to all residents when they are missing a sock, staff usually try to find the item. If a resident feels like their stuff is stolen, then it becomes theft, V1 said he delegates staff to follow up, there is no regulation that states that the administrator will be the person to follow up on missing items. V1 added that he is going to initiate an investigation into R6's unauthorized charges and her missing rings.Facility Policy:Review of abuse prevention policy revised 3/28/2026 states 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.Definitions: Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent (42 CFR 483.5).Protection of residents:Employees of this facility who have been accused of abuse, neglect, exploitation, retaliation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator, and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident's property is unsubstantiated.VII. Internal Investigation1. All incidents will be documented, whether or not abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property occurred, was alleged, or suspected.2. Any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation.4. Investigation procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed.The administrator or person designated to act as administrator in the administrator's absence will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The administrator or designee is also responsible for informing the residents or their representative of the results of the investigation and of any corrective action taken.

Based on observation, interview, and record review the facility failed to ensure that individual medication for one resident (R2) was locked safely in the medication cart when not in view of the licensed nurse, failed to lock nursing supply room that contained medications, and failed to ensure one resident (R2) medication was not left at bedside. These failures affected R2 reviewed for medication administration and storage and has the potential to affect all 127-residents residing at the facility.Findings include: 1.) On 08/24/26 at 10:51am, V2 (Director of Nursing/DON) stated that OTC (Over the counter medications) medications are kept in the basement in the nursing supply room. V2 stated that the facility has a system where if the nurse needs any medication they know to come to the south wing nurse who has the key to the room. V2 stated that the south wing nurse is the only nurse besides the person in charge of the nursing supplies who has the key. At 10:53am, V2 asked V4 (Licensed Practical Nurse/LPN) for the nursing supply room key. At 11:01am, upon getting to the nursing supply room, the door to the room was observed unlocked. V2 twisted the nursing supply room doorknob, and it opened without using a key. When asked why the door was unlocked, V2 stated, I don't know why but most of the OTC medication was stored in the black metal cabinet. The surveyor showed V2 the medications stored on the top of the black metal cabinet and there were four full bottles of 1000 pills of ibuprofen, two bottles of iron pill vitamins, three nicotine patches boxes, feeding tube, feeding pump, syringes, and IV (Intravenous) tubing. V2 stated no medication supplies should be stored in a room without locking it. I can see what you mean, and I will have to talk with the staff about this. V2 stated, This does not look right. After using the key that V4 gave V2 the cabinet cannot be opened, showing that the black cabinet has no key available at the time of observation.On 8/24/26 at 11:04am, V4 was called to try and open the cabinet door and stated I thought I had the key.On 8/24/26 at 11:06am V2 stated that she would make sure they find the key. V4 stated that V12 (Escort/Resident Care Assistant) might have taken the key with her on an escort duty with a resident for appointment consultation.On 08/24/26 at 11:52am, V7 (Registered Nurse/RN) stated that the nursing supply room is always open, unlocked with no staff. V7 stated in part that the MOD (Manager on Duty) is supposed to have the key but not always. During the same interview when asked about medication been left at bedside, V7 stated that no medication should be left on the bedside without an order (referring to physician order) and making sure the resident is able to self-medicate.On 08/24/26 at 1:42pm, V12 (Escort/Resident Care Assistant) stated that she was out with a resident but V13 (CNA/Central Supply /Transportation) is the staff in charge. I don't have the key to the nursing supply room. When the surveyor asked whether the nursing supply room should be locked. V12 acknowledged that the door should be locked. The surveyor then asked why it should be locked. V12 stated that someone might go into the room and take supplies out. V12 stated I have never had access to the key to the supply room. V13 hands over the supplies to me like the linens and I pass on to the floor.On 08/25/26 at 9:22am, V13 (CNA/Central Supply /Transportation) stated her job description includes passing (referring to taking OTC medications to the licensed staff nurses) and putting away supplies in the nurse's closet and medication room on the floors. The surveyor asked about locks on the nursing supply room. V13 stated in part that the room is supposed to be locked all the time. V13 stated that she has the keys to the black cabinet. When asked about who else has access to the key, V13 stated that I keep the keys at the reception desk. The surveyor asked whether medications are allowed to be stored on top of the cabinet in an unlocked room. V13 stated No, the room must be locked and now I am working on removing them (referring to medications) because someone can walk in and take them. V13 explained that she worked last Saturday and the door has been broken since then. The surveyor asked about when V13 was aware the door had no functioning lock. V13 stated that since Last week and I let V1 (Administrator) know about it. At 9:32am, the surveyor asked whether V13 is nurse and V13 stated that she is not a nurse I am not a nurse, but I am a CNA. V13 stated the key to the black cabinet is kept with V1 (Administrator).On 08/26/26 at 4:19pm, V1 (Administrator) stated that they just can't find the key which is supposed to be given to the south wing nurse, and it was with the receptionist (V34). V1 acknowledged that V34 is not a nurse. V1 then stated that yes, I know we (facility) did not meet the regulations on that one. V1 said I am not a nurse, but I know medication storage cabinet or medication room key should be kept by a licensed nurse.2.) R2's admission record showed documents that R2 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Metabolic encephalopathy, chronic edema, type 2 diabetes mellitus with diabetic polyneuropathy, dementia in other diseases classified elsewhere, unspecified severity with mood disturbances, non-pressure chronic ulcer of unspecified part of right lower leg with other specified severity and lack of coordination.R2's MDS (Minimum Data Set) documents R2 BIMS coded as 14 indicating that cognitively is cognitively intact.On 08/24/2026 at 11:14am, R2 observed in bed with multiple medication pills noted in the medication cup on the bedside table. R2 stated those are my morning medications, and I am going to take them, the nurse left it for me this morning and I will take it later.On 08/24/2026 at 11:16am V3 (Wound Care Director) was called to R2's room and was asked about the facility protocol on medication pass whether it is appropriate to leave medications at resident bed side. V3 stated it is not appropriate.On 08/24/2026 at 11:20am, V5 (LPN) who is the direct medication nurse for R2 stated I gave (R2) his medicines and he took it. The surveyor asked about the nursing professional standard on medication administration and about the facility policy. V5 stated we must make sure the resident swallows the medication before leaving the room and documents in MAR (Medication Administration Record) after they (residents) have taken the medication. The surveyor asked if R2 was on the self-Administration program. V5 stated No. When asked whether there is a physician order for R2 to keep his medication at bedside. V5 stated No order for that. V3, who was present at the time, stated in part that I (V3) checked that too there is no order for it and we will have to do in-service for the nurses not to leave medications at bedside without orders. V5 could not provide any facility assessment for self-administration and physician order for medication to be left at bedside.On 08/24/26 at 11:48am, V2 (DON) was made aware of the surveyor observation regarding R2's medications being left at bedside. V2 was asked her expectations of her nurses during medication pass and the facility medication administration policy on leaving medication at resident bedside. V2 stated that medication is not to be left at the bedside without orders, and the nurses are supposed to make sure the resident swallows the pills before leaving the room and chart (referring to MAR documentation). On 08/26/26 at 4:19pm, V1 (Administrator) stated I cannot tell you why the nurse will do that (referring to R2's medication being left at bedside). Facility policy presented titled Storage of Medications with revision date 08/2020 documents that medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Listed procedures include but are not limited to only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms and medication supplies are locked when they are not attended by people with authorized access.Facility Self-Administration of Medications with revision date 08/2020 documents that in order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (Or equivalent) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. listed includes but not limited to bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of residents who self-administer.The facility Administration procedures for all medications dated 08/2020 documented that listed procedures include but not limited to security indicated that all medication storage areas are always locked unless in use and under the direct observation of the medication nurse/aide.

Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one of six residents (R1) reviewed for call light. Findings include:R1's admission Record documents that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Parkinson's disease without Dyskinesia without mention of fluctuations, type 2 diabetes mellitus with diabetic neuropathy unspecified, chronic obstructive pulmonary disease unspecified, psoriasis vulgaris, and age- related osteoporosis without current pathological fracture.R1's MDS (Minimum Data Set) dated June 30, 2026, section C -cognitive pattern BIMS summary scored 14 indicating that R1 is cognitively intact.R1's physician order showed order for R1 to have incontinent care, off-loading offered and provided to residents (R1) every two hours. R1's ADL care plan under interventions documents to encourage residents (R1) to use bell/call for assistance.R1's care plan focuses bowel/bladder incontinence r/t (related to) physical functioning, physical limitations with revision date 07/15/2026, interventions listed include but not limited to ensure call light is within reach and answer promptly.On 08/24/26 at 11:59am, R1 was observed in bed with wheelchair at bedside and noted with blackish particles including the sit cushion. R1 stated he was wet and has not been changed since last night and wanted the surveyor to change him. When the surveyor asked R1 to use his call light to call the staff, R1 stated he could not find the call light. Surveyor observed that the call light was not within reach of R1.On 08/24/26 at 12:02pm, when this was brought to V8's (Certified Nursing Assistant) attention and was asked about the facility policy on call light placement. V8 stated that the call light should always be placed within the resident's reach.On 08/24/26 at 12:06pm, V7 (Registered Nurse) was asked about the facility's policy on call light placement. V7 stated that call light is supposed to be placed within resident reach. V7 stated that R1 can use the call light.Facility policy on Call Light with revision date 2/2/18 documents that the purpose of the policy is to respond to residents' requests and needs in a timely and courteous manner.

Based on interview and record review, the facility failed to report an allegation of verbal and physical abuse from staff for one resident (R4) and an allegation of misappropriation of resident's property for another resident (R6). These failures affected two residents (R4 and R6) reviewed for reporting of alleged abuse and misappropriation of property.Findings include: 1.) R4 was admitted to the facility on [DATE], face sheet listed the following past medical history in part: Chronic inflammatory demyelinating polyneuritis, primary osteoarthritis, type 2 diabetes, disorder of unspecified muscle, other lack of coordination, Paraplegia, muscle wasting, urinary tract infection, anemia, presence of urogenital implant, etc.Minimum Data set (MDS) assessment dated [DATE] section C (cognitive patterns) scored R4 with a brief interview for mental status (BIMS) score of 13, indicating that R4 is cognitively intact. Functional status (section gg) of the same assessment documented that R4 requires substantial/maximal assistance with toileting hygiene, shower/bath, toilet/tub transfer, chair/bed-chair transfer and sit to lying.On 8/24/2026 at 11:25AM, R4 was observed in his room, awake and alert. R4 stated that he has concern with staff being unprofessional and abusive. Surveyor asked R4 what he meant and he said he reported to the social worker (V10) that the nurse (V25) yelled at him for pulling his call light and V16 (Certified Nursing Assistant/CNA) was rough while providing care. R4 requested the CNA not to care for R4 anymore. On 8/24/2026 at 2:50PM, V10 (Social Service Director) said that she is familiar with R4 who reported that he had an interaction with 2 staff members not too long ago. R4 stated that he pulled his call light to be changed, the CNA came in and told him that she will be back. R4 waited for a while and pulled the call light again, the nurse then came and yelled at him, asking why he was pulling his light. R4 reported that nurse was rude, and when the CNA came back to provide care, she was upset and was rough during care.On 8/25/2026 at 9:02AM, V14 (Customer Service Liaison) said that R4 pulled his call light, and the nurse (V25) came in and yelled at the resident, R4 reported that the nurse was being aggressive. When the CNA came back to provide care she turned resident aggressively. V14 reported the incident to the (Director of Nursing/DON) and Administrator because it was a sign of abuse.2.) R6 has been at the facility since 1/17/2026, face sheet listed the following past medical history in part: Type 2 diabetes mellitus with other skin complications, moderate persistent asthma, other acute and sub-acute respiratory symptoms, epilepsy, unspecified, not intractable with status epilepticus, muscle wasting and atrophy, major depressive disorder, etc.Minimum Data Set (MDS) assessment dated [DATE] score R6 with a brief interview for mental status score of 14, indicating that resident is cognitively intact. Functional status (section gg) of the same assessment documented that R6 requires substantial/maximal assistance form staff for shower/bath, lower and upper dressing, dependent on toilet hygiene and putting off footwear and partial/moderate assistance for personal hygiene.On 8/24/2026 at 11:57AM, R6 said that she had a credit card, called to get the balance and it went from $1700.00 to 35 cents, there were several charges to her account, one was a television purchased from (Name of Store) for $500.00, $200.00 and $300.00 charges at a sports store, both purchases were one in March or April. R6 said that she called the police, and they told her that they may never find who made the purchases. R6 became emotional and told the surveyor that she does not want to get anyone in trouble. R6 said in April, she had a seizure at the facility during which staff assisted her with removing her clothing, staff also removed five rings from her fingers including her grandmother's ring. R6 said that staff were supposed to put the rings in a pink box and place them in her closet, couple of days later, her sister visited and R6 asked her sister to get the box for her and the box of rings were gone. R6 reported to the Administrator, they did not believe her, and she was told that she may have lost the rings somewhere else. R6 said that she was sure the rings were on her fingers before she had a seizure, R6 said that she can deal with 4 of the rings but the most painful is her grandmother's ring that has been in the family for a long time, that ring was from the 1900 and will probably be worth about $6000.00. R6 said that she was planning to pass the ring over to another family member, but now the ring is gone. On 8/24/2026 at 2:50PM, V10 (Social Service Director) stated for R6, she was informed that the charges to her debit card have been resolved.On 8/25/2026 at 11:24AM, V10 said that R6 reported that she was missing some rings sometime in March or April and they were never found, V10 mentioned it in the morning meeting and was told it had been addressed. On 8/25/2026 at 9:02AM, V14 (Customer Service Liaison) said that she went to R6 who reported that there are some charges in her credit card that she was not aware of. R6 reported this in March or April 2026. V14 called the bank and they confirmed that there was a charge of $200.00 and $300.00 made online. V14 did not do anything else because resident told her it was okay but stated that V1 (Administrator) was made aware.On 8/24/2026, surveyor requested facility concern/grievance log for the past six months and reportable since January 2026, there was no concern log or reportable relating to the staff being rude and rough during care for R4, or any reports of misappropriation of property for R6.V1 (Administrator) could not provide any initial or final report for abuse allegation for R4 and could not provide a final investigation/reportable for an initial investigation for R6 dated 3/24/2026. On 8/25/2026 at 10:35AM, surveyor presented an initial report dated 3/24/2026 for R6, incident category was resident misappropriation of property/theft signed and submitted by V1 to the state surveying agency which V1 did not present when surveyor requested all reports from January to current. V1 said that he will go and check his office and later presented an initial and final reportable for R6. Surveyor has confirmed with the regional office secretary that the state surveying agency did not receive any final investigation for R6 and requested the fax cover for the final reportable. V1 said, I am just going to be honest, I never sent the final, I don't know what happened. V1 added that he is going to start an initial investigation for R4 for the staff yelling and rough handling, an investigation for R6 for charges on her credit card, have not heard anything about resident's missing rings, V1 will go and speak to R6 to figure out what is exactly missing.Facility Policy:Abuse prevention policy revised 3/28/2026 states 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.Definitions: Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent (42 CFR 483.5).VIII. External Reporting1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, retaliation, or misappropriation of resident property has been made, the administrator, or designee, shall notify the Department of Public Health's regional office immediately by telephone or fax. Public Health should be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported to the administrator and is being investigated. The report shall include the following information, if known at the time of the report:If there is a reasonable suspicion that a crime has been committed that results in serious bodily harm a report shall be made to local law enforcement and IDPH immediately. If there is a reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then report to local law enforcement as soon as possible, but within 24 hours of when the suspicion was formed.2. Five-day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The final investigation report shall contain the following: Name, age, diagnosis, and mental status of the resident allegedly abused, neglected, exploited, retaliated against, mistreated, or from whom property was misappropriated The original allegation (note day, time, location, specific allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence, and any noted injuries) A summary of facts determined during the process of the investigation, review of the medical record, and interview of witnesses Conclusion of the investigation based on known facts The police report, if applicable If the allegation is determined to be valid and the perpetrator is an employee, a separate sheet listing the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions, and current employment status (still working, suspended, or terminated).

Based on interview and record review, the facility failed to investigate an allegation of verbal and physical abuse from staff to one resident (R4) and an allegation of misappropriation of property for another resident (R6). These failures affected two (R4 and R6) of three residents reviewed for abuse.Findings include: Upon entrance on 8/24/2026, surveyor requested facility concern/grievance log for the past six months and reportable since January 2026, there was no concern log or reportable relating to the staff being rude and rough during care for R4, or any reports of misappropriation of property for R6.V1 (Administrator) could not provide any investigation or staff interviews for abuse allegation for R4 or an investigation for charges to R6 credit card initially reported on 3/24/2026 and her missing jewelry reported to several staff members.1.) R4 was admitted to the facility on [DATE], face sheet listed the following past medical history in part: Chronic inflammatory demyelinating polyneuritis, primary osteoarthritis, type 2 diabetes, disorder of unspecified muscle, other lack of coordination, Paraplegia, muscle wasting, urinary tract infection, anemia, presence of urogenital implant, etc. Minimum Data set (MDS) assessment dated [DATE] section C (cognitive patterns) scored R4 with a brief interview for mental status (BIMS) score of 13, indicating that R4 is cognitively intact. Functional status (section gg) of the same assessment documented that R4 requires substantial/maximal assistance with toileting hygiene, shower/bath, toilet/tub transfer, chair/bed-chair transfer and sit to lying. On 8/24/2026 at 11:25AM, R4 was observed in his room, awake and alert, and stated that he is doing okay. R4 stated that he has concern with staff being unprofessional and abusive. Surveyor asked R4 what he meant and he said he reported to the social worker (V10) that the nurse (V25) yelled at him for pulling his call light and V16 (Certified Nursing Assistant/CNA) was rough while providing care. R4 requested the CNA not to care for R4 anymore.2.) R6 has been at the facility since 1/17/2026, face sheet listed the following past medical history in part: Type 2 diabetes mellitus with other skin complications, moderate persistent asthma, other acute and sub-acute respiratory symptoms, epilepsy, unspecified, not intractable with status epilepticus, muscle wasting and atrophy, major depressive disorder, etc. Minimum Data Set (MDS) assessment dated [DATE] score R6 with a brief interview for mental status score of 14, indicating that resident is cognitively intact. Functional status (section gg) of the same assessment documented that R6 requires substantial/maximal assistance form staff for shower/bath, lower and upper dressing, dependent on toilet hygiene and putting off footwear and partial/moderate assistance for personal hygiene. On 8/24/2026 at 11:57AM, R6 said that she had a credit card, called to get the balance and it went from $1700.00 to 35 cents, there were several charges to her account, one was a television purchased from (Name of Store) for $500.00, $200.00 and $300.00 charges at a sports store, both purchases were one in March or April. R6 said that she called the police, and they told her that they may never find who made the purchases. R6 became emotional and told the surveyor that she does not want to get anyone in trouble. R6 said in April, she had a seizure at the facility during which staff assisted her with removing her clothing, staff also removed five rings from her fingers including her grandmother's ring. R6 said that staff were supposed to put the rings in a pink box and place them in her closet, couple of days later, her sister visited and R6 asked her sister to get the box for her and the box of rings were gone. R6 reported to the Administrator, they did not believe her, and she was told that she may have lost the rings somewhere else. R6 said that she was sure the rings were on her fingers before she had a seizure, R6 said that she can deal with 4 of the rings but the most painful is her grandmother's ring that has been in the family for a long time, that ring was from the 1900 and will probably be worth about $6000.00. R6 said that she was planning to pass the ring over to another family member, but now the ring is gone.On 8/24/2026 at 4:07PM, V1(Administrator) was asked about the concern logs supposedly completed by V10(Social Service Director) and V11 (Licensed Practical Nurse) for R4 and he said, I don't know, let me check my office. V1 later returned with a concern form that was not among the ones presented upon entrance dated 8/13/2026, signed by V14 (Customer Service Liaison) who documented in part that R4 felt the nurse was rude and that the CNA rushed with care which resulted to care being rough. Follow up action documented that V14 spoke to the nurse in question about customer service while answering call light and that the CNA no longer works at the facility. V1initially said that he was not aware of any allegation of abuse from R4, later V1 acknowledged that he was aware of the concern reported by R4, it came up in the morning meeting the following day, they mentioned that the nurse was sharp and rude, the resident felt that the CNA was a little rough while providing care. V1 said he is the abuse coordinator, an abuse can be verbal, physical, mental, etc. V1 said he did not speak to the resident, he became aware of the incident the morning of 8/14/2026, V1 said that he does not speak to any resident that is missing a sock, he have other qualified staff who can handle such situation. If a resident reported that staff was rough during care and did not want to work with that staff anymore, then the staff will be removed from caring for the resident. V1 said that his job is to investigate if there is viable report of abuse and added that he is initiating an investigation for R4 and R6 today.Facility Policy:Review of abuse prevention policy revised 3/28/2026 states 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.Definitions: Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.Protection of residents:Employees of this facility who have been accused of abuse, neglect, exploitation, retaliation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator, and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident's property is unsubstantiated.VII. Internal Investigation1. All incidents will be documented, whether or not abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property occurred, was alleged, or suspected.2. Any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation.4. Investigation procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked will be interviewed.The administrator or person designated to act as administrator in the administrator's absence will review the report. The administrator or designee is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The administrator or designee is also responsible for informing the residents or their representative of the results of the investigation and of any corrective action taken.

Based on observation, interview and record review the facility failed to ensure that one of three residents (R1) in the sample who was dependent on staff assistance for ADLs (Activities of Daily living) received incontinent care in a timely manner. Findings include:R1's admission Record documents that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Parkinson's disease without Dyskinesia without mention of fluctuations, type 2 diabetes mellitus with diabetic neuropathy unspecified, chronic obstructive pulmonary disease unspecified, psoriasis vulgaris, and age-related osteoporosis without current pathological fracture.R1's MDS (Minimum Data Set) dated June 30, 2026, section C -cognitive pattern BIMS (brief interview for mental status score) summary scored 14 indicating that R1 is cognitively intact.R1's physician order showed order for R1 to have incontinent care, off-loading offered. and provided to residents (R1) every two hours. R1's care plan focuses bowel/bladder incontinence r/t (related to) physical functioning, physical limitations with revision date 07/15/2026, interventions listed include but not limited to ensure call light is within reach and answer promptly.On 08/24/26 at 11:59am, R1 was observed in bed with wheelchair at bedside and noted with blackish particles including the sit cushion. R1 stated he was wet and has not been changed since last night (wanting the surveyor to change him). Surveyor asked R1 to use his call light to call the staff, but R1 stated he could not find it. R1 stated that he had asked for help, and they (staff) said they were coming but had not come back.On 08/24/26 at 12:01pm, the surveyor asked V8 (Certified Nursing Assistant/CNA) who was assigned to R1 about the last time she checked on R1 for incontinent care. V8 stated, Not yet today, he was last changed last night. The surveyor then asked how often V8 make rounds. V8 stated that I am supposed to check at least every two hours, but I was busy with other residents since I came (resume duty) at 7am today. V8 turned R1 while in bed and R1 was observed wearing incontinent pad. R1's incontinent pad and bed linens were wet.On 08/24/26 at 12:06pm, V7 (Registered Nurse/RN) who is the charge nurse for R1 stated when she went into R1's room, he complained of not been changed since last night. V7 stated I let (V8) know about it, but I guess she has been busy with other residents. The surveyor asked V7 if V8 had reported that R1 refused care today. V7 stated that V8 has not reported that R1 refused care today.On 08/25/26 at 10:23am, during interview with V3 (Wound Care Director) was interviewed about the professional standard regarding physician orders and the responsibility of nurses. V3 stated that it should be followed unless resident refuses. The surveyor then asks what can happen to a resident if the physician orders like repositioning every two hours and incontinent care every two hours is not followed. V3 stated that it can have a negative effect on the resident skin, the resident can have skin break down.08/25/26 at 11:38am, V2 (Director of Nurse's) stated that physician orders must be followed, incontinent must be done B&B (Bowel and Bladder). V2 stated that if the physician order is not followed that can cause increased risk in skin alteration.The facility policy titled Incontinent Care presented with revision date 4/20/21 documented that the purpose of the policy is to prevent excoriation and skin breakdown, discomfort and maintain dignity.

Based on the interview and record review, the facility failed to protect the resident's right to be free from misappropriation of resident property by having the resident's bank card stolen by a facility staff member and used without authorization. This applies to 1 of 3 residents (R1) reviewed for misappropriation/exploitation in a sample of 5.The findings include:R1 was admitted on [DATE] with diagnosis of diabetes mellitus, enterocolitis due to clostridium difficile, congestive heart failure, hyperlipidemia, ischemic cardiomyopathy, muscle wasting, hypertension and Gastro-Esophageal Reflux Disease. R1 has mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R1 was discharged from the facility on 3/7/26.Facility Reported Incident submitted to the department by the facility documents date of occurrence 3/4/26 for R1. Resident misappropriation of property/theft was marked on the form. Incident description documents On 3/4/26 it was reported to the Administrator that the daughter of (R1) reported that her mother's debit card was missing. On 5/23/26 at 12:20 PM, V1 (Administrator/Abuse Coordinator) stated, R1's daughter reported to me that her mother's debit card had been used unauthorizedly. The card was used across the mall, and I walked into the mall to see the image of the person who used R1's card. It was a one-time $30 charge, but they couldn't show me the image. The incident was already reported to the police, and two days later, the police stopped by our facility and showed images of our employee using R1's card unauthorized, and she was arrested on the spot. Residents have the right to be free from misappropriation of their property.A review of the facility presented Abuse Prevention and Reporting policy, revised on 10/24/222, document: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents.

Based on interview and record review, the facility failed to ensure appropriate notification was provided for a room change for one (R3) resident of three residents reviewed for resident rights. Findings include:R3 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction (Stroke), Seizures, Chronic Kidney Disease, Dementia, and Gastrostomy (surgically created opening between the abdominal wall and stomach for a feeding tube) Status.R3's comprehensive assessment section C cognitive patterns document staff was unable to examine due to R3's memory problem Dementia and being rarely/never understood.On 04/13/2026 at 10:44 AM, V4 (Family Member) said, My mom went to the hospital a week ago and when she came back yesterday, they never told me about changing her room. When I got here, they just packed all her stuff and put it in another room without even telling me.On 04/15/2026 at 12:45 PM, V2 (Director of Nursing) was inquired of informing R3 or her representative of a room change. V2 said, R3 went to the hospital on 4/8/26 for altered mental status. She was admitted for a bleed on the brain. I'm not sure who tells them about a room change, I'd have to check the policy. It's not nursing, social service usually does that.On 04/15/2026 at 1:54 PM, V2 said, We don't have a policy for room change notification.On 04/15/2026 at 2:07 PM, V19 (Social Service Director) was inquired of room change notification. V19 said, I'm not 100% sure if that's my responsibility. I just started last week and I'm still training. My assistant is on vacation.On 04/15/2026 at 2:14 PM, V1 (Administrator) was inquired about room change notification. V1 said, Any facility staff that does the room change should notify the resident or representative. If it's the resident they just go and talk to them. If it's the representative they could do it by phone or in person, it may depend on the reason for the room change. From my knowledge we don't have a policy on room change notification. We should be contacting whoever is the legal representative. It doesn't have to be documented. V1 was inquired about how it would be known if anyone was contacted regarding the room change. V1 said, It can be documented.R3's progress notes from 04/08/2026 document her being lethargic and sent to the hospital for further evaluation. R3 was admitted to the hospital for a bleed on the brain and remained hospitalized for 4 days. There is no documentation of R3, her state guardian or V4 (Family Member) and power of attorney for care being notified of a room change. R3 was transferred back to the facility on [DATE] to a different room. V1 (Administrator) did not provide a policy for review during the investigation upon request.

Based on observation, interview, and record review, the facility failed to follow their policy by failing to ensure appropriate hand hygiene was performed during incontinence care for one (R3) resident of three residents reviewed for improper nursing care related to infection control.Findings include:R3 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction (Stroke), Seizures, Chronic Kidney Disease, Dementia, and Gastrostomy (surgically created opening between the abdominal wall and stomach for a feeding tube) Status.R3's comprehensive assessment section C cognitive patterns document staff was unable to examine due to R3's memory problem Dementia and being rarely/never understood.On 04/13/2026 at 12:25 PM, V6 (Certified Nurse Assistant/CNA) was asked to check if R3 was incontinent. V6 checked R3's disposable brief and said, She has loose stool and she's wet. R3's brief is soiled with urine and feces. V6 cleaned R3's perineal area and buttocks. V6 proceeded to put a clean fitted sheet and pad on the mattress and a clean disposable brief on R3, then adjusted the air loss mattress machine at the end of the bed while wearing the soiled gloves. V6 then took off her gloves, threw them into the garbage can and put on a clean pair of gloves. V6 didn't perform hand hygiene with soap and water or use hand sanitizer while in the room before putting on clean gloves.On 04/13/2026 at 12:40 PM, V6 was inquired of R3's incontinence care. V6 said, I changed her last at 7 this morning and checked her before lunch and she was dry. I should've changed my gloves after changing her (R3). It's for infection control because it could spread germs.On 04/13/2026 at 2:23 PM, V6 (CNA) entered R3's room to check R3. R3's care was observed. V6 opened R3's incontinence brief and said, She's (R3) wet again. This surveyor observed R3 soiled with urine. V6 cleaned R3's perineal area, removed the gloves and threw them into the garbage. V6 put on a new clean pair of gloves without performing hand hygiene. V6 didn't wash her hands with soap and water or use hand sanitizer before putting on the clean pair of gloves. V6 put the clean disposable brief on to R3.On 04/13/2026 at 2:28 PM, V6 was inquired of her care. V6 said, I should wash my hands or use hand sanitizer to keep from spreading germs, I'm sorry I forgot.On 04/15/2026 at 12:45 PM, V2 (Director of Nursing) was inquired of hand hygiene during incontinence care. V2 said, CNA should perform hand hygiene after changing gloves. It could be soiled, and it should be changed going from dirty to clean. It's infection control.PolicyThe revised 07/30/24 Hand Hygiene/Hand washing policy states in part:Definition: Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel).Guidelines: Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for cleaning your hands in the healthcare setting. Soap and water are recommended for cleaning visibly dirty hands.Examples of when to perform hand hygiene (Either Alcohol Based Hand Sanitizer or Handwashing): After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin. or wound dressings. If hands will be moving from a contaminated body site to a clean body site during patient care. After glove removal.

Based on observation, interview and record review, the facility failed to follow their storage of medication policy by having opened, used, expired medication for four of four residents (R87, R19, R105 and R95) reviewed for medication storage. Findings include: On [DATE] at 9:52am, during a medication cart audit with V6 (Nurse), R87's Insulin Glargine Kwik Pen listed the open date of [DATE] and expiration date of [DATE] written on it. R19's Insulin Aspart Kwik Pen listed the open date of [DATE] and expiration date of [DATE] written on it.V6 said, R87's and R19's insulin were opened, used and expired. V6 said, insulin is good for twenty-eight to thirty days after opening. V6 said, R87's and R19's insulin were expired. Expired medication should not be on the medication cart.R87 was diagnosed with type two Diabetes Mellitus. R87's physician order sheet documents: Insulin Glargine Kwik Pen. Status: Discontinued. R19 was diagnosed with type two Diabetes Mellitus. R19's physician order sheet documents active orders as of [DATE]: Insulin Aspart Injection Solution: Inject per sliding scale.On [DATE] at 10:02am, during a medication cart audit with V7 (Nurse), R105's insulin lispro listed the opened date of [DATE] and expiration date of [DATE] written on it. R95's Xalatan Ophthalmic Solution listed an opened dated [DATE] and expiration date of [DATE] written on it. V7 said, R105's eye drops are open, used and expired. V7 said, expired medication should not be on the medication care.R105 was diagnosed with type two Diabetes Mellitus. R105 's physician order sheet documents:Insulin Lispro Solution. Status: Discontinued. R95's physician order dated [DATE] Xalatan Ophthalmic Solution instill in right eye in the morning.Storage of Medications Policy no date: All expired medication will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Certain medication or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, once opened require an expiration date shorter than the manufactures' expiration date to insure medication purity and potency.

Based on observation, interview, and record review, the facility failed to follow its food service and sanitation policies by not ensuring milk was maintained at a temperature of at least 45 degrees Fahrenheit during meal service, failing to discard outdated bread observed with a green substance, failing to ensure the sanitizing solution was maintained at the appropriate concentration, and failing to use clean water when cleaning food carts. This deficient practice had the potential to affect all 118 residents who receive food prepared by the facility kitchen. Findings include:On 1/13/2026 at 10:29a.m. during the tour of the kitchen, there was no hand soap for hand washing, hand sanitizer was requested, V18 (Dietary Supervisor) did not present any hand sanitizer. V26 (Dietary Staff) said he informed someone from housekeeping at 9:30am that the hand soap was out, V26 said he do not know the name of the male staff that he informed. V18 said there should be hand soap available for hand washing at all times. V25 (Dietary staff) was observed cleaning the food carts with a white towel, placing the towel in the red bucket then removing the towel to continue cleaning the carts. V18 identified the bucket to be the sanitizing bucket. The bucket was filled with dirty water dark in color. The bucket was tested with the quaternary ammonium strip, the strip read 100 ppm, V18 said the concentration should be at least 200 ppm for sanitizing. During observation of dry food storage, assisted by V18, there was flying insects observed in the dry food storage room, observed by V18 (landing on white gallon stored metal on shelf). There were 2 large packages of dinner rolls with best used by date of 1/9/2026 observed with green substance one them, they were stored on the bread rack with the non-expired bread. There was a large package of hamburger buns observed with a black flying insect inside the bag of hamburger buns. V18 said the dinner rolls was expired and should have been thrown away, V18 observed the flying insect in the bag and removed it. V18 said she keep the dented cans on a shelf with non-dented cans, V18 said the staff would know not to use the dented cans by asking her first before using the canned foods.1/13/26 12:23pm during lunch services the milk was observed to be stored in a black tub/container, there were no ice noted in the tub, V26 (Dietary staff) was asked to touch the milk to feel for coldness, V26 said the milk was not cool, surveyor touched the milk, it was no cool to touch. V26 said there was no ice in the black tub to keep the milk cool. V26 said the practice is to place the milk in the freezer before serving it for lunch. V18 was summoned to complete a temperature on the milk, the milk was observed to be at 60 degrees Fahrenheit, V18 said the milk should be maintained at 40 degrees Fahrenheit, V18 walked away, V18 did not remove the milk at that time. V1 (Administrator) was summoned to inform him of the observation. The facility does have residents with feeding tubes that does not eat food served from the facility kitchen. Facility policy and procedures titled storage labeling and dating denotes products inventory must be labeled, dated rotated and discarded properly according to federal and guidelines. Items that have exceeded the manufactures expiration date or UB (use by) date should be discarded.Facility policy titled cold storage areas denotes in-part cold food and beverages should be stored under safe and sanitary conditions.Facility policy for storing-food storage denotes in-part food should be stored and prepared in a clean, safe, sanitary manner that complies with state and federal guidelines. Purpose to minimize contamination and bacteria. There should be separate area designated area for damaged food items to be returned to vender for credit. Dented cans should be returned to the vendor upon delivery or stored in a separate area until picked up by the vendor.Facility policy food and beverage temperature control denotes food temperature are maintained during serving times. Purpose to ensure residents receive safe food served at acceptable temperatures. Temperature food log denotes cold holding reference for milk is less than 45 degrees Fahrenheit.

Based on interview and record review the facility failed to follow their care plan policy and ensure that the care plan accurately reflects the resident advance directives to not be resuscitated, and failed to obtain a physician order and document R111's code status in her electronic medical record this affects two of three residents (R46 and R111) reviewed for advanced directives. Findings Include:1.R46's physician order sheet dated [DATE] denotes do not resuscitate. R46's Illinois Department of Public Health uniform practitioner order for life sustaining treatment (POLST) form dated [DATE] denotes no CPR: do not resuscitate (DNAR), signed by R46's agent under power of attorney and provider. R46's face sheet denotes R46 has a guardian the name is the same as the noted on the POLST form. R46's care plan for advanced directive, initiated date of [DATE], revision on [DATE] denotes I am a full code, attempt resuscitation CPR, including intubation and mechanical ventilation. Honor choice of resident and family surrogate, legal guardian or POA- dated [DATE]. Perform CPR if and when the resident stops breathing- dated [DATE]. Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and time frames to meet a resident medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. On [DATE] at 11:35am V23 (Care Plan Coordinator) said care plans should be updated quarterly and when there's a change. V23 said the care plan for advance directives should be updates as soon as the resident or power of attorney make changes from full code to Do not resuscitate. Facility comprehensive care plan policy effective date [DATE] denotes in-part to develop a comprehensive care plan that directs the care team and incorporate the residents goals preference and services that are to be furnished to attain the residents highest practicable physical, mental and psychosocial well-being. Advance Directive Policy dated [DATE] documents: To ensure that all residents and/or resident representative and informed concerning the right to accept or refuse medical or surgical treatment, at the resident's option, formulate an advance directive. A written physician's order is required in response to the resident's Advanced Directive(s) Physician's orders shall be specific and address each Advance Directive. 2.R111's face sheet under advance directive was blank. No code status was documented. R111's physician order sheet, active orders as of [DATE] did not document a code status. On [DATE] at 1:25pm, V2 (Director of Nursing) said, a resident's code status must be visible on the face sheet and in miscellaneous. V2 said, the resident's code status must be documented in two places in the resident's electronic record.

Based on interview and record review the facility failed to protect a resident from a resident-to-resident physical assault when R120 pushed R106 to the floor. This affected two (R106, R120) of four residents reviewed for physical abuse. Findings Include: R120's Minimum Data Set/MDS date 12/22/25 shows BIMS score of 15.On 1/13/26 at 11:52am R120 observed alert to person, place, time and situation. R120 said a male resident came to his room looking her his roommate (R34). R120 said he told the resident that he could not come in the room. R120 said he got out his bed and pushed the resident down to the floor. R120 said the resident was standing at the doorway when he pushed the resident to the floor. R120 said he don't know who the male resident was that he pushed to the floor. R120 said his roommate cannot have other residents visit him and that the residents can visit R34 in the dining room.R34 identified R106 as the resident that was pushed down by R120.On 1/13/2026 at 12:08pm R106 was observed sitting on his rollator near nurse station. R106 was alert to person, place and situation. R106 said he was up pretty late last night. He went to smoke. He went to sit in the dining room and he may have gone for another smoke break. R106 explained he was in the dinging room watching video on his phone, during that time, R34 asked him if he (R106) could help him with his phone. R106 said he told R34, yes. R106 said R34 left the dining room maybe to get his phone. R106 said he was waiting in the dining room for R34, R106 explained when R34 did not return, he went to R34's room to see if he was okay and still needed his help with the cell phone. R106 said R120 pushed him to the floor. R106 said he was in the hallway and not inside the room. R106 said R120 was telling him that he could not come inside the room when he (R120) approached him (R106) and pushed him. R106 said he fell onto the floor on his back. R106 said the nurse picked him up from the floor. R106 said he just returned from the hospital. R106 said he wanted to press charges against R120 for pushing him down. R106 said he's tired of being pushed around by other residents. R106 explained there was an incident where a resident threw coffee on him and when he defended himself, he was told that only R106 was on camera. R106 said he went to the hospital to get checked out because his back was hurting. R106 said he feels safe in the facility, but he does want to press charges. R106 said he did not hit R120. R106 was agreeable that surveyor inform the administrator (V1). On 1/13/26 at 1:48pm V1 (Administrator) said he was made aware today around 5:30am by the Nurse that R106 fell after being pushed by R120. V1 said he doesn't recall who the Nurse was that informed him. V1 said R120 has a right to his privacy. V1 was made aware that R120 stated that R106 was coming to visit R34 and not R120, and that R120 also stated that R34 could not have visitors in his room, and that R34 has to visit with residents in the dining room. V1 explained that R106 shouldn't be visiting residents in early morning hours. V1 said his expectation is that R120 notify the Nurse if he's having issues with residents and not push other residents to the floor. V1 said at this time he has not reported the is incident to the department he was waiting for R106 to return from the hospital and now that R106 has returned, and R106 said he wants to make a police report, he will now report this incident to the state surveying agency. V1 said he has not reviewed the video surveillance to determine what happened during that incident. V1 said he has 5 days to complete his investigation. On 1/15/26 at 3:36pm request was made to V1 to review the facility video surveillance, V1 said No. V1 said R120 admitted to pushing R106 to the floor when R106 was standing in the doorway of his room, R106 fell to the floor in the hallway. V1 demonstrated where R106 landed on the floor outside of room XXX.On 1/15/26 at 1:27pm V28 (Licensed Practical Nurse/LPN) said she was made aware by another Nurse that R106 was pushed on the floor by R120. V28 said she assessed R106 and R106 complained of pain to his back. V28 said R106 was assisted off the floor using a mechanical lift. V28 said she notified the administrator, the family and the physician. V28 said she was given orders to send R106 to the hospital for evaluation because R106 complained that his entire body hurt. V28 said she offered R106 pain medication but R106 was focused on wanting to press charges on R120 for pushing him down. V28 said R106 continuously made the statement that he wanted to press charges on R120.R106's emergency room records dated 01/13/2026 denotes chief complaint patient presents with a fall. [AGE] year-old male with past medical history of seizures, hypertension, COPD, schizophrenia coming in today for evaluation of back pain after he was pushed by another resident of his nursing home and fell onto his back. He states that he has pain all the way from his neck down into his feet. He denies any numbness, weakness, tingling anywhere in his body. He denies any saddle anesthesia, urinary retention, bowel incontinence, bowel retention. R106 after visit summary shows diagnosis of acute midline thoracic pain.Facility abuse policy dated 11/28/16 denotes in-part this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or including anguish to a resident. The resident right for people living in the long-term care facility denotes You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.

Based on interviews and record reviews, the facility failed to follow its abuse prevention policy and prevent and protect a resident from staff to resident misappropriation of resident property. This failure affected one resident (R38) out of three reviewed for theft in a sample of 50. In September 2025 R38's credit card was taken by a staff member, and purchases/cash advances were made without R38's permission. Findings include:On 1/14/26 at 9:50 AM, R38 stated that R38 was admitted to this facility August 2025. R38 stated that R38 gave her credit card to V14 (Business Office Manager) for V14 to process a payment to this facility. R38 stated that V14 returned credit card to R38 and placed card and receipt on R38's over the bed table. R38 stated that she is bedridden and does not leave her room. R38 stated that later when she went to put credit card back in her zippered pouch, R38 could not find credit card. R38 stated that she notified V14 that she could not find her card. R38 stated that she does not recall if she was checking her bank account or if the bank notified her, but there was an alert on her account for unusual activity. R38 stated that there were two charges, one to a florist for $500.00 and one was cash withdrawal from a bank for $800.00 plus a $2.50 service fee for transaction. R38 stated that R38 was told to freeze her card so no further purchases could be made. R38 stated that a couple of days later the police came to the facility to get her statement; afterwards the police gave her a card with the case number on it. R38 stated that she informed the police who she thought it could be that took her card. R38 stated that V20 (Certified Nursing Assistant/CNA) was inquiring about how R38 picks her lucky numbers. R38 told V20 that she chooses birth dates or other occasions. R38 stated that R38's family member has access to R38's bank account but R38 has the card. R38 stated that the bank did reimburse her for the two charges. R38 stated that she feels unnerved by this event. R38 stated that she has been robbed before in the community, but to think this could happen in a nursing home in which she should be safe is scary.R38's BIMS (brief interview of mental status) score, dated 8/8/25, notes R38's score is 15 out of 15. R38 is able to make needs known.R38's abuse/neglect screening, dated 8/5/25, notes R38 is at moderate risk for abuse.On 1/14/25 at 10:25 AM, V14 (Business Office Manager) stated that when R38 informed her that her credit card was missing, V14 reported it to V1 (Administrator). V14 stated that the police were notified, and a report was made. V14 stated that the incident occurred in September 2025. V14 stated that she assumes it was a staff member because R38 doesn't go anywhere.On 1/14/26 at 10:48am, V1 (Administrator) stated that V4 (Resident Liaison) would be the person who would know more information regarding R38's missing credit card. V1 stated that R38's credit card was missing, R38's POA (Power of Attorney) had it. V1 stated that R38 was concerned about the charges to her bank account. V1 stated that R38 called her bank, there were two charges not familiar to R38. V1 stated that V4 was on phone with R38 and the bank and knows more about these charges. V1 stated that the bank reimbursed R38 for the charges. V1 stated that no reportable was made for this event.On 1/14/26 at 10:53 AM, V4 (Resident Liaison/Staffing Coordinator) stated that she reported to V15 (Social Services Director) that R38's credit card was missing. V4 stated that she called R38's bank with R38 on 10/10/25. V4 stated that the bank informed them that the bank would investigate the pending charges on R38's card and reimburse R38 if the charges were determined to be fraudulent. V4 stated that she does not know why a reportable was not completed for this event.On 1/14/26 at 11:14 AM, V15 (Social Services Director) stated that she was asked to see R38 regarding missing credit card. V15 stated that V4 had done some of the investigation so she had V4 also present during meeting with R38. V15 stated that R38's POA had the credit card. V15 stated that by the time she followed up with R38, the bank had already reimbursed her. V15 stated that she did not speak with R38's POA to confirm she had R38's credit card.On 1/15/26 at 1:41 PM, V27 (CNA) stated that she worked with V20 (CNA) but does not recall any details regarding the event involving R38.R38's police report, dated 10/1/2025 at 5:06 PM, notes the police officer spoke with V1 (Administrator) via telephone. V1 advised that he believed V20 (CNA) assigned to R38's room the day R38's card had been used at an ATM, was responsible. V1 stated to the police officer that V20 had been assigned to another resident who had his debit card stolen. V20 had been talking to another staff member about how he had a scam system going on at the facility. Contact was made with R38's POA, who related she was aware of the incident, but did not know all the details. Bank statement for R38 was sent to the police department. R38's POA notified police officer that R38 had received her money back from the fraudulent transactions, besides the $2.50 fee from the ATM.Abuse prevention and reporting policy, revised 10/24/2022, notes this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. Misappropriation of a resident's property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on interviews and record reviews, this facility failed to follow its abuse prevention policy and report an allegation of staff to resident theft to the State Surveying Agency within the required timeframe. This affects one resident (R38) out of three residents reviewed for reporting theft in a sample of 50. Findings include:On 1/14/26 at 9:50 AM, R38 stated that R38 was admitted to this facility August 2025. R38 stated that R38 gave her credit card to V14 (Business Office Manager) for V14 to process a payment to this facility. R38 stated that V14 returned credit card to R38 and placed card and receipt on R38's over the bed table. R38 stated that she is bedridden and does not leave her room. R38 stated that later when she went to put credit card back in her zippered pouch, R38 could not find credit card. R38 stated that she notified V14 that she could not find her card. R38 stated that she does not recall if she was checking her bank account or if the bank notified her, but there was an alert on her account for unusual activity. R38 stated that there were two charges, one to a florist for $500.00 and one was cash withdrawal from a bank for $800.00 plus a $2.50 service fee for transaction. R38 stated that R38 was told to freeze her card so no further purchases could be made. R38 stated that a couple of days later the police came to the facility to get her statement; afterwards the police gave her a card with the case number on it. R38 stated that she informed the police who she thought it could be that took her card. R38 stated that V20 (Certified Nursing Assistant/CNA) was inquiring about how R38 picks her lucky numbers. R38 told V20 that she chooses birth dates or other occasions. R38 stated that R38's family member has access to R38's bank account but R38 has the card. R38 stated that the bank did reimburse her for the two charges. R38 stated that she feels unnerved by this event. R38 stated that she has been robbed before in the community, but to think this could happen in a nursing home in which she should be safe is scary.R38's BIMS (brief interview of mental status) score, dated 8/8/25, notes R38's score is 15 out of 15. R38 is able to make needs known.R38's abuse/neglect screening, dated 8/5/25, notes R38 is at moderate risk for abuse.On 1/14/25 at 10:25 AM, V14 (Business Office Manager) stated that when R38 informed her that her credit card was missing, V14 reported it to V1 (Administrator). V14 stated that the police were notified, and a report was made. V14 stated that the incident occurred in September 2025. V14 stated that she assumes it was a staff member because R38 doesn't go anywhere.On 1/14/26 at 10:48am, V1 (Administrator) stated that V4 (Resident Liaison) would be the person who would know more information regarding R38's missing credit card. V1 stated that R38's credit card was missing, R38's POA (Power of Attorney) had it. V1 stated that R38 was concerned about the charges to her bank account. V1 stated that R38 called her bank, there were two charges not familiar to R38. V1 stated that V4 was on phone with R38 and the bank and knows more about these charges. V1 stated that the bank reimbursed R38 for the charges. V1 stated that no reportable was made for this event.On 1/14/26 at 10:53 AM, V4 (Resident Liaison/Staffing Coordinator) stated that she reported to V15 (Social Services Director) that R38's credit card was missing. V4 stated that she called R38's bank with R38 on 10/10/25. V4 stated that the bank informed them that the bank would investigate the pending charges on R38's card and reimburse R38 if the charges were determined to be fraudulent. V4 stated that she does not know why a reportable was not completed for this event.On 1/14/26 at 11:14 AM, V15 (Social Services Director) stated that she was asked to see R38 regarding missing credit card. V15 stated that V4 had done some of the investigation so she had V4 also present during meeting with R38. V15 stated that R38's POA had the credit card. V15 stated that by the time she followed up with R38, the bank had already reimbursed her. V15 stated that she did not speak with R38's POA to confirm she had R38's credit card.R38's police report, dated 10/1/2025 at 5:06 PM, notes the police officer spoke with V1 (Administrator) via telephone. V1 advised that he believed V20 (CNA) assigned to R38's room the day R38's card had been used at an ATM, was responsible. V1 stated to the police officer that V20 had been assigned to another resident who had his debit card stolen. V20 had been talking to another staff member about how he had a scam system going on at the facility. Contact was made with R38's POA, who related she was aware of the incident, but did not know all the details. Bank statement for R38 was sent to the police department. R38's POA notified police officer that R38 had received her money back from the fraudulent transactions, besides the $2.50 fee from the ATM. Abuse prevention and reporting policy, revised 10/24/2022, notes this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediate. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health 's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. The term immediately as it is used in this policy in relation to reporting misappropriation of resident property, and suspicion of a crime shall be defined as, following management of the immediate risk to the resident or residents, including the administration of necessary medical attention, and establishing the safety of the resident or residents involved or not later than two hours after forming the suspicion. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health

Based on interview and record review, this facility failed to follow its abuse prevention policy and conduct a thorough investigation, prevent further theft from occurring, and take appropriate corrective action for an allegation of theft involving one resident (R38) out of three residents reviewed for abuse prevention in a sample of 50. Findings include:On 1/14/26 at 9:50 AM, R38 stated that R38 was admitted to this facility August 2025. R38 stated that R38 gave her credit card to V14 (Business Office Manager) for V14 to process a payment to this facility. R38 stated that V14 returned credit card to R38 and placed card and receipt on R38's over the bed table. R38 stated that she is bedridden and does not leave her room. R38 stated that later when she went to put credit card back in her zippered pouch, R38 could not find credit card. R38 stated that she notified V14 that she could not find her card. R38 stated that she does not recall if she was checking her bank account or if the bank notified her, but there was an alert on her account for unusual activity. R38 stated that there were two charges, one to a florist for $500.00 and one was cash withdrawal from a bank for $800.00 plus a $2.50 service fee for transaction. R38 stated that R38 was told to freeze her card so no further purchases could be made. R38 stated that a couple of days later the police came to the facility to get her statement; afterwards the police gave her a card with the case number on it. R38 stated that she informed the police who she thought it could be that took her card. R38 stated that V20 (Certified Nursing Assistant/CNA) was inquiring about how R38 picks her lucky numbers. R38 told V20 that she chooses birth dates or other occasions. R38 stated that R38's family member has access to R38's bank account but R38 has the card. R38 stated that the bank did reimburse her for the two charges. R38 stated that she feels unnerved by this event. R38 stated that she has been robbed before in the community, but to think this could happen in a nursing home in which she should be safe is scary.R38's BIMS (brief interview of mental status) score, dated 8/8/25, notes R38's score is 15 out of 15. R38 is able to make needs known.R38's abuse/neglect screening, dated 8/5/25, notes R38 is at moderate risk for abuse.On 1/14/25 at 10:25 AM, V14 (Business Office Manager) stated that when R38 informed her that her credit card was missing, V14 reported it to V1 (Administrator). V14 stated that the police were notified, and a report was made. V14 stated that the incident occurred in September 2025. V14 stated that she assumes it was a staff member because R38 doesn't go anywhere.On 1/14/26 at 10:48am, V1 (Administrator) stated that V4 (Resident Liaison) would be the person who would know more information regarding R38's missing credit card. V1 stated that R38's credit card was missing, R38's POA (Power of Attorney) had it. V1 stated that R38 was concerned about the charges to her bank account. V1 stated that R38 called her bank, there were two charges not familiar to R38. V1 stated that V4 was on phone with R38 and the bank and knows more about these charges. V1 stated that the bank reimbursed R38 for the charges. V1 stated that no reportable was made for this event.On 1/14/26 at 10:53 AM, V4 (Resident Liaison/Staffing Coordinator) stated that she reported to V15 (Social Services Director) that R38's credit card was missing. V4 stated that she called R38's bank with R38 on 10/10/25. V4 stated that the bank informed them that the bank would investigate the pending charges on R38's card and reimburse R38 if the charges were determined to be fraudulent. V4 stated that she does not know why a reportable was not completed for this event.On 1/14/26 at 11:14 AM, V15 (Social Services Director) stated that she was asked to see R38 regarding missing credit card. V15 stated that V4 had done some of the investigation so she had V4 also present during meeting with R38. V15 stated that R38's POA had the credit card. V15 stated that by the time she followed up with R38, the bank had already reimbursed her. V15 stated that she did not speak with R38's POA to confirm she had R38's credit card. R38's police report, dated 10/1/2025 at 5:06 PM, notes the police officer spoke with V1 (Administrator) via telephone. V1 advised that he believed V20 (CNA) assigned to R38's room the day R38's card had been used at an ATM, was responsible. V1 stated to the police officer that V20 had been assigned to another resident who had his debit card stolen. V20 had been talking to another staff member about how he had a scam system going on at the facility. Contact was made with R38's POA, who related she was aware of the incident, but did not know all the details. Bank statement for R38 was sent to the police department. R38's POA notified police officer that R38 had received her money back from the fraudulent transactions, besides the $2.50 fee from the ATM. The facility was unable to present any documentation that a investigation was initiated, witness statements were obtained, R38 interviewed, or alleged perpetrator, V20, was interviewed regarding this event. Abuse prevention and reporting policy, revised 10/24/2022, notes this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.

Based on interview and record review the facility failed to follow their practice to ensure that the Minimum Data Set assessment is accurately coded for four of four residents (R2, R46, R106, R116) reviewed for accuracy of MDS assessments. Findings include: 1. On 1/14/25 at 3:24pm V2 (Director of Nursing) said R46 was assess for hospice service and was not eligible for hospice services. V2 said R46 has never received hospice care while a resident at the facility. R46's Minimum Data Set/MDS section O for special services K1 for hospice dated 11/20/25 and 9/22/2025 shows X for hospice care performed while a resident at this facility. On 1/15/26 at 2:12pm, V21 (MDS Coordinator) said staff should ensure to code the MDS accurately to reflect the care for R46. 2. On 1/14/26 at 3:29pm, V16 (Restorative Nurse) said R116 is currently receiving restorative programing services 15 minutes a day, daily for range of motion to upper and lower extremity and bed mobility. Review of R116's MDS dated [DATE] section O for Restorative Nursing Programs for passive range of motion zero is documented for number of days for restoratives services performed. On 1/15/26 at 2:12pm V21 (MDS Coordinator) said staff should ensure to code the MDS accurately to reflect the care for R116. 3. R106's face sheet shows diagnosis of bipolar disorder, major depression disorder, schizoaffective disorder and anxiety disorder. R106's annual MDS assessment dated [DATE] section A1500 for Preadmission Screening and Resident Review (PASRR) no is documented for Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On 1/15/26 at 2:12pm V21 (MDS Coordinator) said staff should ensure to code the MDS accurately to reflect the care for R106. 4. R2 who was admitted on [DATE] with a diagnosis of type II diabetes, chronic pain, anxiety disorder, vascular dementia, and schizoaffective disorder. R2's MDS section dated 10/17/25 documents under restorative programs a score of 0 which indicates none. R2's restorative task dated 10/30/24 documents: R2 has limited range of motion. Under description it documents Nursing rehab/restorative documents: R2 will participate in assisted range of motion flexion and extension, adduction and abduction to Bilateral upper and lower extremities. On 1/16/25 at 10:00AM, V16 (Restorative Nurse) said R2 has been receiving restoratives services since 2024. V16 said she recently started doing restorative section of MDS but did not complete R2's MDS assessment in October. V16 said R2 should have been coded for restorative services on October MDS because she was receiving services and is unsure why she was not coded accurately.

Based on interview and record review, the facility failed to follow their incontinence care policy by not providing incontinence care for over two hours for a resident as requiring substantial/maximal assistance with incontinent care. This affects one of three residents (R124) reviewed for incontinence care. Findings include:R124's Minimal data set dated [DATE] section C (cognitive patterns) document a score of eleven which indicate moderate cognitive impairment. Section GG dated 11/8/25 documents: R124 requires substantial/maximal assistance with toileting (helper does more than half the effort. Helper lifts or holds truck or limbs and provides more that half the effort.) Section H (bowel and bladder) dated 10/29/25 urinary continence document always incontinent. On 1/13/26 at 1:13pm, R124 was observed on the sit to stand device with the back of his jogging pants wet. R124 had a strong smell of urine. R124's wheelchair cushion was observed wet. V10 (Certified Nursing Assistant/CNA) said, R124 was soiled and saturated with urine. V10 said, she was not R124's assigned CNA she was taking R124 to be showered. V13 (R124's Medical Power of Attorney) said, R124 is always left wet. Staff does not provide care.On 1/13/26 at 1:32pm, R124 said, he was last changed at 2:00am. V10 removed R124's adult brief. R124 brief was observed completely saturated with liquid consisted with urine and liquid dripping from R124's left hip.On 1/13/26 at 1:34pm, V9 (CNA) said, she was R124's assigned CNA. V9 said, she last provided incontinence care for R124 between 9am and 10am. V9 said, residents should be checked and changed every two hours and as needed.Incontinence Care Policy dated 11/28/12 documents: Incontinent resident will be checked periodically in accordance with the assessed incontinent episode or every two hours and provided perineal and genital care after each episode.

Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse by another resident for 1 of 3 residents reviewed for abuse. This failure resulted in R2 being sent out to the local hospital and sustaining a human bite to the right forearm and required treatment of antibiotics. This deficiency is past non-compliance that occurred from 5/17/2025 to 5/22/2025. Findings include: Incident report submitted to the state surveying agency for the incident of 5/17/25 in part states the incident occurred in the facility dining room at around 6:30am on 5/17/25. R5 is non-verbal with a low BIMS score. R5 stood up from his wheelchair, lost his balance and fell to the floor in a seated position. R2 was sitting at a table next to where R5 was sitting. R5 was not aware that R2's arm was stretched out along the edge of the table, so instead of grabbing on to the table, R5 grabbed on to R2's forearm to get off the floor. R2 was startled when R2 felt someone touching her arm and immediately attempted to move her arm away. In the process, R2's arm raised up and pressed against R2's mouth. R5 reacted by biting R2's arm. R2 was escorted to nurse's station and evaluated. MD (medical doctor) was notified, and orders were given to send R2 to the nearby hospital for precautionary evaluation. R5 was escorted to R5's room and placed on one-to-one monitoring. R5's MD was notified, and orders were given to transfer to hospital for psychiatric evaluation. R2 returned from hospital after being evaluated and receiving treatment for bruising to the right forearm. R5 was re-admitted to the facility after following psychiatric evaluation and treatment. R5 has been placed on temporary one-to-one monitoring to ensure his safety and the safety of residents within the facility. R5 has an admission record dated 5/27/2025 indicates that R5 has a diagnosis of delusional disorders, dysphasia, and schizophrenia, restlessness and agitation, delusional disorder, other genetic related intellectual disability, and autistic disorder. An order summary report indicates that R5 was transferred to the local hospital on 5/17/2025, a care plan revision on 4/15/2025 that indicates R5 has exhibited physical abuse to other staff and resident's related to poor impulse control. R2's Discharge summary dated [DATE] from local hospital states in part being seen and evaluated for human bite. Take antibiotics as directed. Augmentin 875-125mg (milligram) 1 tablet administered. R2's progress note dated 5/30/25 signed by V2 (Director of Nursing/DON) states IDT (interdisciplinary team) note. Attendees present: DON, Admin (Administrator), SS (Social Service), Wound Care. Summary of IDT meeting: Resident involved in resident-to-resident altercation resulting in bite to right forearm. Area cleaned, dried, and covered with DCD (dry clean dressing). MD contacted and informed of incident; order received for ER (emergency room) transfer. Family made aware. Resident returned to facility from ER, tetanus shot received abt (antibiotic) therapy initiated for 7 days. Wound care consult performed, treatment orders received and carried out. Resident pain will be managed by MD orders. Care plan reviewed and updated. On 5/27/2025 at 10:30am V1(Administrator) said it was reported by the housekeeper that was in the dining area at the time, that R5 stood up by the two tables, then fell between the tables. Upon getting up from the floor R5 tried to grab the table and grabbed R2's arm. R2 tried to pull away and R5 bit R2's arm. R5 was immediately separated from R 2. R5 was sent to the local hospital. On 5/27/2025 at 12:30pm R2 said that she was sitting in the dining area table in the early morning before breakfast and R5 was also sitting at the table next to her. He fell between the two tables, upon trying to get himself off the floor he grabbed my arm. I tried to pull away and that's when R5 bit my arm. I don't think he knew it was my arm. The housekeeper moved my wheelchair immediately. On 5/27/2025 at 12:40pm R3 said she was sitting two tables away from R2 and R5 who were both at other tables. R5 was throwing a slipper at another resident. R5 fell out his chair next to R2's table. While trying to get himself off the floor, R2's arm was in front of him. R5 tried to pull himself up by the table in turn he grabbed her arm, and when R2 tried to move her arm R5 bit her on the arm. He did it quickly. On 5/27/2025 at 1:10pm V8 (House Keeping) said she heard someone yelling and when she went into the dining area R5 was getting off the floor. I did not see R5 bite anyone. On 5/27/2025 at 1:15p V9 (Housekeeping) said I was in the dining area when R5 fell to the floor between two tables. R2 was at the table next to R5. He lost his balance fell to the floor between the two tables. Upon getting off the floor, he grabbed R2's arm. R2 tried to pull away, that's when he bit R2 on the arm. He did it so quick. I immediately called for help and moved R2 away from the table to safety. On 5/27/2025 at 2:40pm V10 (Wound Care Nurse) said I observed R2's right forearm on Monday morning. This occurred over the weekend. I classified it as penetrating trauma to the right arm. It was an open area pink and red full thickness 4.30 cm (centimeter) x 4.40 cm x 0.20cm no signs of infection to the area. Antibiotics were ordered. On 5/30/2025 at 1:30pm V2 (Director of Nursing/DON) said that R2 was bitten by R5. R5 apparently had fallen to the floor and while trying to get himself off the floor he grabbed R2's arm. R2 pulled away and he bit her arm. R5 was immediately transferred to the local hospital and remains out. R2 sustained a bite area to the right forearm 4.30 cm x 4.40 cm x 0.20cm bright pink or red drainage was noted at the time. Facility Policy: Abuse Prevention and reporting-Illinois Revisions, Reporting of crimes 11-20-17, 5-24-18, 1-22-19, 10-24-22. Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Identifying occurrences and patterns of potential mistreatment. Resident-to-Resident abuse (Any Type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident-to Resident altercation that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations. Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abuse another resident shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take steps necessary to ensure the safety of residents including but not limited to the separation of the residents. Prior to the survey date of 5/30/25, the facility had taken the following action to correct the noncompliance: 1.R2 and R5 assessed by nursing, MD informed, orders received for transfer for evaluation on 5/17/25. 2.Psychosocial Assessment completed on R2 and R5 on 5/17/25 and 5/22/25. 3.Updated Abuse and neglect screening completed on R2 and R5 on 5/17/25 and 5/22/25. 4.Families made aware of incident on 5/17/25. 5.House wide audit performed to identify residents with behaviors by Social Services on 5/19/25. 6.Facility wide audit of current residents abuse/neglect screening were reviewed and updated as needed by Social Services on 5/20/25. 7.QA Audit tool will be conducted on 5 residents a week for 4 weeks then 3 times a week for 5 months or as needed to monitor that the facility is in compliance with current resident being assessed for abuse/neglect, care plans updated, interventions are in place and residents are supervised by staff. 8. In-serviced all staff on Abuse Prevention and Reporting Policy including resident to resident altercations and supervision from date 5/17-5/18/2025. 9.In-service from date 5/17/2025 Abuse Supervision, emergency QAPI/Abuse prevention & Supervision policy revised, and care plan update. 10. Implementation of the dining room monitoring schedule for the 11pm to 7am shift. 11. Abuse Prevention and Reporting policy review by IDT with no changes made on 5/17/25. 12. Care plan of R2 and R5 updated on 5/18/25 and 5/22/25. 13. Ad hoc QAPI meeting was held to review event and action plan. Reviewed with medical director on 5/17/25.

Based on interview and record review, the facility failed to ensure a resident was free from accident hazards, by not using the mechanical lift for a dependent resident transfer for 1 (R1) of 3 residents. This failure resulted in R1 sustaining a non-displaced oblique fracture through the lateral plateau of the right tibia and fibula. R1 was transferred to the local hospital and underwent a surgical procedure on 5/15/2025. This deficiency is past non-compliance that occurred from 5/13/2025 to 5/15/2025. Findings include: On 5/27/2025 at 1:30pm V3 (Certified Nursing Assistant/CNA) said that R1 requested to have incontinence care. V3 took R1 to the room, proceeded to retrieve the mechanical lift. R1 said no I can stand and pivot. V3 said I ask her twice and she continued to refuse the mechanical lift and insisted on the stand and pivot transfer which I had transferred R1 several times using this method. V3 said after she did the stand and pivot transfer into the bed, she completed incontinence care on R1, which R1 then complained about right leg pain she proceeded to inform the nurse that R1 wanted pain medication. V3 said I know which transfer method to use by reading the care card on the back of the closet door or in the plan of care. R1 is obese and I should have informed the nurse that she was refusing care and ask for assistance from a co-worker, I realize now that it was not a safe transfer. On 5/27/2025 at 1:50pm V7 (CNA) said R1 will ask you to use the stand and pivot transfer and I inform her that I must follow what's on her care card. She is okay with the mechanical transfer. I do not transfer a resident without checking the care card or the plan of care in the computer. I will inform the charge nurse that the resident does not want to use the transfer method recommended on their care card. On 5/27/2025 at 2:30pm V2 (Director of Nursing/DON) said I expect all certified nursing assistants to have safety awareness and use the method of transfer on the resident's care card or in the plan of care if a resident refuses, the CNA should inform myself or the nurse of that refusal so that we can contact therapy to assist in a transfer. On 5/27/2025 at 2:45pm V1 (Administrator) said R1 refused her usual method of transfer, V3 transferred her by a stand and pivot motion and should not have done that transfer. The employee has been in-serviced and now understands a proper safe transfer. An admission record indicates that R1 has a diagnosis of right knee pain, unilateral primary osteoarthritis of the right knee, morbid (severe) obesity due to excess calories, and pain in the left knee. An order summary dated 5/27/2025 indicates R1 had an order for (brand name) external gel 4% to left and right knee and bilateral shoulders. A care plan intervention dated 4/17/2024 to transfer, using a mechanical lift with 2 staff for transfer. A progress note dated 5/13/2025 that R1 was admitted to the local hospital for a non-displaced oblique fracture through the lateral plateau. A report to the state surveying agency dated 5/13/2025 states that R1 had a new onset of swelling, discoloration and complained of pain to the right ankle and emergency room transfer and X-ray scan of the right ankle was ordered with a hospital diagnosis of non-displaced oblique fracture through the lateral plateau tibia and fibula. An x-ray scan dated 5/14/2025 result of right knee and right tib-fib there is a non-displaced oblique fracture through the lateral plateau. The final report the facility submitted to the state surveying agency dated 5/21/2025 states the resident underwent surgery on 5/15/2025. Facility Policy: Transfers-Manual Gait Belt and Mechanical Lifts, Effective date 11-28-12, Revised 1-19-18. Purpose: In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use Mechanical Lifting devices for the lifting and movement of Resident. Responsibility: Licensed Nurse, C.N.A, Restorative, Therapy Guidelines: 1. Mechanical lifting devices shall be used by any resident needing a two person assist, to who cannot be transferred comfortably and /or safely or normal transfer technique. 2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices annually and as needed. Refer to Manufacturer's Guide for proper instructions for use of equipment for transfer and weighing. 6. Residents transferring and lifting needs shall be documented in care plans and reviewed via care plan time frame and as needed. Prior to the survey date of 5/30/25, the facility had taken the following action to correct the noncompliance: 1. On 5/14/25 an in-service for nurses and CNAs was conducted on transfers, gait belt use at all times, and to use 2-person assistance for mechanical lifts. 2. QA nursing observation from 5/14-5/29/2025 on 5 residents a week to ensure the facility is in compliance with transfers. 3. On 5/14/25 the transfer policy was reviewed by the interdisciplinary team with no changes. 4. A house wide audit was performed to monitor compliance with transfers. 5. On 5/14/25 an Ad hoc QAPI meeting was held to review the event and action plan. Reviewed with the medical director. Policy review was discussed.

Based on observation, interview, and record review, the facility failed to follow their policy for nail care by failing to observe the condition of R2's toenails during weekly skin assessments and bathing, failed to document observations, and failed to provide podiatry services for one (R2) of three residents reviewed for foot care. This failure resulted R2 developing Onychomycosis, toe pain, toenail dystrophy with Onycholysis, subungual debris, and painful elongated toenails. Findings include: R2's current diagnoses include but are not limited to Peripheral Vascular Disease, Alzheimer's Disease, Hypertension, and chronic kidney disease. R2 was admitted to the facility on [DATE]. R2's care plan dated 3/14/2025 states in part: R2 is an older adult who scores low on the BIMS cognitive assessment and is noted to have impaired cognitive function, poor memory recall, and poor safety and environmental awareness that impact level of alertness, decision making tasks, and ability to complete tasks independently r/t dementia. I am at risk for alteration in skin integrity. Risk factors: use of anti-coagulant, h/o skin impairments, incontinence, decrease mobility, requires assist with ADLs (activities of daily living). Intervention: observe skin daily with ADL care and report changes to the nurse. 4/12/2019. I have an arterial/ischemic ulcer of the Left Lower Leg r/t Peripheral Arterial Disease, Vascular Insufficiency. Inspect the feet daily, especially between the toes. Report changes to the nurse. 3/14/2025. On 5/12/25 at 10:37 AM, V4 (Certified Nursing Assistant/CNA) assisted with removing R2's socks to observe her bilateral toenails. R2's bilateral toenails appear to have been cut recently. There is no redness, drainage, discoloration, or odor noted. R2 was inquired of her toenails. R2 said, I don't remember when the doctor came for my feet. On 5/12/25 at 12:12 PM, R2 is up in her wheelchair. She appears to be clean, well-groomed, and appropriately dressed. She is wearing socks and shoes. She is self-propelling her wheelchair. On 5/12/25 at 1:36 PM, V11 (Social Service Director/SSD) was inquired of R2's foot care by podiatry. V11 said, Residents are seen every other month and they service one side of the building. It's split every month. I get (electronic fax) documentation when the podiatrist is coming, and it lists what sides of the building he will see. The podiatrist has a list of residents when he comes to the building. We email or call the podiatry office to put residents on the list to be seen. R2 was recently seen last week. The nurse gave me report that the family requested for her to see podiatry. R2's nurse called the podiatrist to see her. She's been here longer than I've worked here. I think she's been seen every 60 days. There is no documentation of a nurse speaking with V18 (Family Member) in R2's progress notes. V2 (Director of Nursing/DON) provided the concern form she completed on 5/4/2025 regarding V18's (Family Member) concern about toenail care and discoloration of toenails. R2's podiatry care was requested for review from January 2024 to current. V11 (SSD) to provide the facility podiatry list from January 2025 to current. Upon review, R2 is not listed as being seen by the podiatrist. On 5/12/25 at 2:16 PM, V13 (Licensed Practical Nurse/LPN) was inquired of R2's foot care. V13 said, R2 got her nails clipped last week. I helped the podiatrist. I lifted her feet. She didn't complain of pain to me. No problems after it. V13 reviewed R2's medication administration record. She hasn't had any concerns with the medicine for her toes. She's been getting it at night. On 5/13/25 at 9:43 AM, V15 (LPN) was inquired of R2's foot care. V15 said, I wasn't here when her family came. It was reported to me her family had concerns with her foot care. I relayed the message to social service. I put in a request for her to be seen by the podiatrist. R2 didn't have issues with her feet prior to the request that I was aware of. On 5/13/25 at 10:31 AM, V16 (Wound Care Nurse/LPN) was inquired of R2's foot care. V16 said, V2 (DON) told me in morning meeting to see R2 and I put in a note. R2 hadn't complained to me prior to that day. I tried to call the family, but no one responded. V2 asked me to look at her feet and document what I saw. Her toenails were overgrown, hard, yellow in color, and thickened. It happens with age. There haven't been any concerns with her medicine. V11 (Social Service) contacted her podiatrist, and he came in the next day. On 5/13/25 at 11:44 AM, V2 (DON) was inquired of R2's foot care. V2 said, Prior to this visit the family or R2 didn't have concerns. I found out on 5/5/25 because there was a grievance from the family. I asked social service to see how soon we could get the podiatrist out to see her. I called the POA to let him know. I asked V16 (Wound Care/LPN) to see R2. On 5/6/25 V17 (Nurse Practitioner) assessed her. V16 ordered a topical medication to be applied at bedtime for six months. She deferred the oral medication due to possible liver damage. POA was notified as well as other family member. V11 (SSD) handles the podiatrist, I'm not sure how often they come in. I haven't seen the POA, or family come in since R2's been treated by the podiatrist. I'll check for the follow up documentation from the podiatrist. On 5/13/25 at 12:21 PM, V1 (Administrator) was inquired of R2's foot care provided by the podiatrist. V1 said, I spoke with the podiatrist's office, and they don't have any notes after July 2024 for R2. They forgot her off their list. They generate their own list from (electronic medical record) when they come in. R2 was last seen by the podiatrist on 5/9/2024 and 7/13/2024. She had not been seen for 9 months until R2's family requested for toenail care. R2's shower sheets were reviewed from January to April 2025. There is no documentation on the condition of her toenails. R2's shower days are every Wednesday and Saturday. V2 (DON) was to provide her May 2025 shower sheets for review. V2 provided R2's shower sheets with skin checks for review. The 5/6/25 sheet documents R2's family requested her to be seen for her toenails. On 5/14/25 at 9:00 AM, V2 was inquired of the resident skin assessments. V2 said, The nurses do weekly skin assessments, it should be head to toe. They check for any skin alterations. They should document it and do a follow up if needed. For R2 they should put in a podiatry consult and notify all appropriate parties. The CNAs (Certified Nurse Assistant) do showers weekly, document it on the shower sheet and notify the nurse of any skin alterations. Review of R2's weekly nursing skin assessment scheduled every day shift on Wednesday for skin integrity monitoring from January 2025 through April 2025 documents some assessments were completed, but there was no documentation of her toenail overgrowth and fungus presence. There were also multiple dates not documented as being performed. R2's progress notes on 5/5/25 by V17 (Nurse Practitioner) document R2's history of PVD (Peripheral Vascular Disease). Review of R2's progress notes state in part: On 5/6/26 at 10:25 AM, V16 (Wound Care/LPN) assessed R2's toenails as being overgrown, needing cutting, thick and yellow in color. Recommended to see podiatry. On 5/6/25 at 12:11 PM, V16 called V18 (Family Member) and left a message. On 5/6/25 at 1:03 PM, V19 (Podiatrist) scheduled to visit R2. On 5/6/25 at 1:06 PM, V17 (NP) prescribed Ciclopirox External Solution 8 % (Ciclopirox) Apply to toenails bilaterally topically at bedtime for Onychomycosis (a nail fungus causing thickened, brittle, crumbly, or ragged toenails) for 6 Months. Apply evenly over the entire nail plate and 5 mm (millimeters) of surrounding skin. Daily applications should be made over the previous coat and removed with alcohol every 7 days. This cycle should be repeated throughout the duration of treatment. On 5/6/26, time undocumented, V19 (Podiatrist) assessed R2 stating in part: Right and Left toenails: Nail dystrophy (thickened, discolored or deformed), discolored nails with Onycholysis (detachment of the nail from the nail bed), subungual (beneath the nail) debris, and painful elongated toenails. Impression: Onychomycosis (a nail fungus causing thickened, brittle, crumbly, or ragged toenails). Associated diagnosis: Toe pain. Plan: Toenail Debridement with findings. Note: R2 was seen as an emergency visit. Seen with RN (Registered Nurse) and V11 (SSD). After visit, POA (Power of Attorney) was called with V11 and informed of treatment. Risks to the liver from oral antibiotics were reviewed with POA. Patient primary physician prescribed Ciclopirox to be applied daily to toenails. Will continue to monitor and see patient again in 9 weeks. The facility assessment dated [DATE] states in part: indicate if you may accept residents with or your residents may develop the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Category: Heart/Circulatory System: Peripheral Vascular Disease. Staff competencies necessary to provide the level and types of care needed for the resident population: hygiene & bathing (oral care, nail care, shaving, grooming etc.) Targeted audience: Licensed nurses and nurse aides. Staffing and Personnel: total number needed: contracted services- podiatrist (1). The 1/25/2018 Nail Care Policy states in part: 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length, uneven edges, hypertrophied nails (abnormal thickening of the nail plate on the feet or hands). 6. Podiatry services may be required for residents with PVD (Peripheral Vascular Disease). 10. Document provision of care and pertinent observations.

Based on interviews and record reviews, the facility failed to prevent one resident who was identified as moderate risk for skin breakdown and is totally dependent on staff for all ADLs (activities of daily living), from developing three facility-acquired pressure ulcers. The facility also failed to provide the necessary care and services upon admission to promote healing of a left hip stage 2 pressure ulcer. This affected one of three residents (R1) reviewed for pressure sore. This failure resulted in R1 developing three facility-acquired pressure ulcers (unstageable wounds) including the coccyx area, right hip, and right lateral foot. R1's stage 2 wound to the left hip deteriorated to an unstageable wound. Findings include: R1's medical record notes R1 was admitted on [DATE] with diagnoses including, but not limited to, quadriplegia cervical spine, C1-4, complete, colostomy, neuromuscular dysfunction of bladder - indwelling catheter, left hip stage 2 pressure ulcer, history of osteomyelitis of pelvis, and history of pressure ulcer on buttocks. R1 transferred to hospital on 7/12/24 and did not return to the facility. On 9/23/24 at 11:50 AM, V4 (Wound Care Nurse) stated that V4 assesses all residents' skin on admission, re-admission, and if any skin issues arise. V4 stated that she assesses the wound, notifies physician, V5 (Wound Care Nurse Practitioner/NP), implements preventative measures such as air mattress, barrier cream, offloading - with heel boots or pillows, and notifies family. V4 stated that if the resident has wound(s), V4 does weekly skin assessments until wound(s) healed/resolved. V4 stated that if a resident's wound deteriorates, V4 will notify V5. V4 stated that when a new wound is identified, she documents wound measurements and tissue type. There is no documentation found in R1's medical record noting a weekly skin observation was completed on 6/30/24. There is also no documentation found in R1's weekly skin assessments that were completed noting other nursing measures not involving medications were documented in the weekly wound assessment per this facility's skin assessment and monitoring policy. On 9/23/24 at 1:25 PM, V5 (NP) stated that V5 ordered CRP (C-reactive protein - the liver releases this protein into the bloodstream in response to inflammation) level on 6/26/24 due to R1 developing a new wound. V5 stated that an elevated CRP level could be due to acute infection going on anywhere in the body, not just in a wound. V5 was informed R1's CRP level collected on 6/26/24 and resulted on 6/27/24 was 80.26 (normal range is 0-5). V5 was not aware of this result. On 9/23/24 at 2:00 PM, V2 (Director of Nursing/DON) stated that R1 was noncompliant turning and offloading heels. V2 presented a physician/nurse practitioner acquired wounds unavoidibility form, dated 7/3/24, noting R1's facility-acquired pressure ulcers to coccyx, right lateral foot, and right hip were unavoidable due to R1's noncompliance with pressure ulcer prevention program. This form was not signed or dated by V3 (Attending Physician) or V5 (Wound Care Nurse Practitioner). This form was also not part of R1's medical record prior to being informed of concern with R1's wound care treatments. There is no documentation found in R1's medical record, dated 5/24 - 6/19, noting R1 was noncompliant with turning or offloading heels. There is no documentation found noting R1's POA (power of attorney) was notified of R1's noncompliance. On 6/20/24, a care plan was initiated noting R1 is noncompliant/resistive to wound care treatments and turning/repositioning. R1's POS (physician order sheet), dated 5/24/24, notes an order for left hip wound treatment, cleanse with normal saline, pat dry, apply calcium, cover with dry dressing every Monday, Wednesday, Friday, and as needed. There is no physician order for wound care treatments for R1's right lateral foot wound, that was identified on 6/26/24, or R1's right hip wound, that was identified on 7/3/24, in R1's medical record until 7/11/24. R1's TARs (treatment administration records), dated May, June, and July 2024, does not have any documentation that R1's left hip dressing was changed on 5/27, 5/29, 5/31, 6/3, 6/7, 6/12, 6/14, and 6/17. There is no documentation found in R1's medical record noting R1 refused any wound care treatments. V4 documented R1 refused treatment on 6/5 after V4 provided wound care treatment and R1 tolerated it well. R1's functional ability assessment, dated 5/27/24, notes R1 is dependent for all ADLs. R1's pre-admission hospital record, dated 5/24/24, noted R1's upper extremities and lower extremities are flaccid. R1 has sensation to upper extremities but no sensation to lower extremities. R1's coccyx facility-acquired pressure ulcer was identified on 6/19/24. On 7/10/24, this wound measured 1.5cm (centimeters) x 0.5cm x 0.2cm, wound 100% pink or red non-granulating tissue, peri wound macerated (a softening and breaking down of skin resulting from prolonged exposure to moisture). On 6/19/24, R1's initial wound assessment noted wound measured 1.2cm x 0.3cm 0.2cm, 100% pink or red non-granulating tissue. This wound deteriorated as evidenced by increase in size. R1's right hip unstageable pressure ulcer, facility-acquired, was identified on 7/3/24. On 7/10/24, this wound measured 3cm x 1.8cm, wound 50% pale pink non-granulating tissue and 50% slough (yellow) loosely adherent tissue, peri wound macerated. On 7/3/24, R1's initial wound assessment noted wound measured 3.5cm x 2cm, 50% pale pink non-granulating tissue and 50% slough. This wound was unchanged. R1's right lateral foot unstageable pressure ulcer, facility-acquired, was identified on 6/26/24. On 7/10/24, this wound measured 8cm x 5cm, wound 50% pink or red non-granulating tissue and 50% necrotic (dead) soft adherent tissue, peri wound normal. On 6/26/24, R1's initial assessment noted wound measured 8cm x 6cm x 0.2cm. This wound was classified as a partial thickness wound due to abrasion. This wound deteriorated as evidenced by development of necrotic tissue. R1's left hip stage 2 pressure ulcer, present on admission on 5/24/24 deteriorated to an unstageable wound. On 7/10/24, this wound measured 6cm x 4cm, 60% pale pink non-granulating tissue and 40% necrotic soft adherent tissue, peri wound macerated. On 5/24/24, R1's initial wound assessment noted wound measured 0.8cm x 0.5cm x 0.1cm, 50% pale pink or red tissue and 50% pale pink non-granulating tissue. This wound deteriorated as evidenced by its increase in size and development of necrotic tissue. On 9/23/24 at 1:25 PM this surveyor requested V4 provide all of V4's (Wound Care Nurse) wound assessments for R1. V1 (Administrator) presented wound assessment details report for R1's left hip wound for 5/24/24 only; coccyx wound for 6/19/24, 6/28, 7/3, and 7/10; and right lateral foot and right hip wounds for 7/3/24 only. On 9/23/24 at 2:00 PM, this surveyor requested V2 (DON) provide all of V5's (Wound Care NP) wound care assessments for R1. V2 presented visit reports for 5/29/24, 6/19, 6/26, 7/3, and 7/10. V5's notes were not found in R1's medical record. There are no visit notes provided for 6/5 and 6/12. This facility's skin condition assessment and monitoring, pressure and non-pressure wounds, policy, revised 6/8/2018, notes pressure ulcers will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure skin conditions are identified by licensed nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA (certified nurse aide). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. The initial observation of the ulcer will be described in the nursing progress notes. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. These changes include, but are not limited to, new onset of purulent drainage, new onset of odor, significant increase in wound measurements, and onset of new ulcers. Physician ordered treatments shall be initiated by the staff on the TAR (treatment administration record) after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nursing progress notes.

Based on interview and record review, the facility failed to prevent residents from experiencing neglect inflicted by a Certified Nursing Assistant. This failure applied to two (R3, R4) of three residents reviewed for abuse and neglect and resulted in R3 and R4 being knowingly left in soiled incontinence briefs for multiple hours by staff. R3 reported that R3 was having severe discomfort due to incontinence causing R3's skin to burn in sites of open skin areas. R4 stated he felt unappreciated, like a stepchild and left in the corner. Findings include: R3 is [AGE] years old and admitted to the facility 8/24/23 with diagnoses that include osteoarthritis, morbid obesity, and chronic respiratory failure. According to the minimum data assessment of 8/5/24, R3 is dependent on staff for activities of daily living including toileting. On 9/12/24 at 1:15pm R3 was observed to be alert and coherent sitting in bed and described an incident that occurred with a CNA (Certified Nursing Assistant) on 9/1/24. During this interview, R3 said the CNA (V4) failed to answer requests for assistance when R3 activated the call light which prompted R3 to call the front desk from R3's cell phone. R3 said that R3 waited longer and shared this complaint to a family member who also called the facility to ask for assistance on behalf of R3. R3 reported that R3 was having severe discomfort due to incontinence causing R3's skin to burn in sites of open skin areas. R3 said that V4 finally came into the room after 5pm, which is two hours from the start of the evening shift and when V4 came into the room to render care, V4 was confrontational, rude, and rough with care. R3 said, after this interaction, V4 did not return to the room to provide care to R3 or R3's roommate for the entirety of the 3-11 shift. R3 said they called out into the hall to ask for care to be given to R4 (roommate), and R3's calls were ignored. R3 said R3 overheard V4 in the hallway passing the room saying, 'I guess they are going to sit there [in excrement]- I ain't going back in that room'. R3 said that is when R3 called the manager on call. R4 is the roommate of R3 and according to Minimum data assessment, is cognitively intact, totally dependent on staff for all activities of daily living and is incontinent of bowel and bladder. On 9/12/24 at 1:50pm, R4 said that R4 witnessed the interaction between R3 and V4 from R4's bed. R4 said after V4 left the room, V4 did not come back into the room and R4 did not receive any incontinence care the entirety of the 3-11pm shift. R4 stated he felt unappreciated, like a stepchild and left in the corner. Point of Care documentation was reviewed for 9/1/24 and meaning no staff documented providing incontinence care to R3 or R4 during the 3-11pm shift. On 9/12/24 at 4:04pm V6 (Wound Care Coordinator) said on 9/2/24, V6 received a complaint from R3 via the on-call clinical phone. V6 said that when R3 was explaining the interaction that happened with V4 the previous evening, R3 mentioned that R3 felt neglected. V6 said as soon as V6 ended the call with R3, V6 reported the concern to the Administrator in Training (V2) who was in the facility at the time. On 9/16/24 at 10:31am V2 (Administrator in Training) said that V2 was notified of R3's complaint and went to speak with R3 at the bedside. V2 said V2 did not speak with R4 or any other residents to ensure other residents were not feeling or experiencing neglect. V2 said V2 relayed R3's interview and information to V1 (Administrator), and V2 was instructed to complete a concern grievance form for R3. The grievance form dated 9/1/24 lists the nature of the concern as: conduct and care of staff. The grievance did not elaborate on the concern, nor was there a progress note available to review in the health record. Corrective Actions were taken with V4 on 9/3/24, and included: Inservice of staff member, not assigned to same resident, staff member suspended for poor customer service and lack of response time in providing patient care. On 9/16/24 at 10:20am, V1 (Administrator) said V1 received a call from V2 on 9/2/24 regarding the incident with R3 and V4 that occurred on 9/1/24. V1 said V4 was suspended 9/2/24 for substantiated concerns of poor customer service. V1 said that it was not relayed that an allegation of neglect was a concern, and therefore did not investigate. V4 (CNA) was not available to be interviewed during this investigation. Facility Abuse prevention and Reporting Policy, revised 10/24/22 states in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment .This will be done by: Identifying concerns of resident' allegation of deprivation of goods and services by staff; Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment and misappropriation of property; Filing accurate and timely investigative reports. The policy goes on to define Neglect: Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish. Neglect means a facility's treatment, psychiatric rehabilitation, person al care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident including deprivation of goods and services by staff. Neglect may be the result of a pattern of failures or the result of one or more failures involving one resident and one staff person. Facility Employee handbook updated 1/23 states in part; under Violations of Conduct Standards That Constitute Grounds for Immediate Dismissal- Negligent or willful acts of conduct detrimental to customer service or [facility] operations. Conduct Toward Residents- All employees have an ethical and professional responsibility to support and promote the highest standards of conduct. It is the policy of [the facility] to comply with all applicable federal, state and local laws and regulations. Every employee will voluntarily assume the obligations of self-discipline, honor and integrity as set forth by [the facility]. We will not accept conduct which limits, restricts or interferes with our ability to respond to the needs of [the facility's] residents or vendors. [The facility] has a zero-tolerance policy for abuse and neglect. The abuse, neglect, or other mistreatment of residents in the facility is unlawful and prohibited. It is always imperative that every employee commit to maintaining the dignity of each resident.

Failures at this level required more than one deficient practice statements. I. Based on interview and record review, the facility failed to monitor and supervise a resident with cognitive impairment, identified as high fall risk with a history of falls and decreased safety awareness. This affected one of three residents (R4) reviewed for falls and supervision. This failure resulted in R4 having two unwitnessed falls which resulted in a small subdural hematoma and a hematoma to right side of forehead. R4's diagnosis includes Vascular Dementia and Altered Mental Status. Brief interview for mental status dated 4/11/24 documents a score of five which indicates severe cognitive impairment. Fall risk assessment dated [DATE] documents: at risk for falls. Care plan dated 2/9/24 documents: R4 had an activity of daily living (ADL) self-care/mobility performance (functional abilities) deficits that may fluctuate with activity throughout the day related to activity intolerance, impaired balance, limited mobility/range of motion, shortness of breath and impaired cognition. Interventions documents: R4 requires substantial/maximal assistance with chair/bed to chair transfer, lying to sitting on side of bed and toilet transfer. Fall occurrence dated 11/16/23 documents: R4 had an unwitnessed fall in resident's room. Upon rounding staff, observed R4 lying on the floor on her right side next to her bed and wheelchair. R4 statement documents: she was trying to get into her wheelchair and her legs got weak, she fell to the floor and hit her head. New injury: hematoma to right side of forehead (bleeding under the skin). On 6/7/24 at 11:03AM, R7 (R4's roommate) who was assessed to be alerted and oriented to person, place, and time, said R4 went to the bathroom without staff assistance and fell . R7 said, she asked R4 to wait for staff but R4 did not. R4 is forgetful. On 6/7/24 at 12:23PM, V5 (Nurse) said, R4 needs assistance with transfers. R4 has episodes of confusion and requires reminders. On 6/7/24 at 12:48PM, V6 (Nurse) said, R4 was able to make her needs known. R4 required one-person physical assist with transfers and ambulation. R4 is forgetful and needs reminders. On 6/7/24 at 1:42PM, V2 (Director of Nursing/DON) said, R4 self-transferred from bed to wheelchair. R4 went to the bathroom. R4 loss her balance. R4 fell on to the floor. R4 required assistance with toileting. R4 will attempt to toilet self. R4 has intermittent confusion. On 6/12/24 at 11:15AM, R4 who was assessed to be alert to name and situation, said she went to the bathroom by herself, fell and hit her head. R4 could not recall what she hit her head on. R4 was apologetic and said, she was sorry she could not remember. R4 said, she forgets a lot. R4 was asked if she could use the call light, R4 replied, no she forgets. R4 said, she can call 911 but doesn't have a phone. On 6/12/24 at 12:55PM, V34 (Director of Rehab) said, R4's cognition is not consistent. R4 can follow step by step instructions when given prompts. R4 requires redirections. R4 was on physical therapy before she fell . R4's care plan initiated on 09/16/2019 documents: At risk for falls and injury related to falls. Risk factors: requires assistance with ADLs, possible medications side effects, urinary incontinence, weakness, impaired cognition, not used to being dependent to staff. Intervention: assess for altered cognition, decline in safety awareness, assist with ADL's. Anticipate and meet the resident's needs, assist with toileting upon awakening, before and after meals, during rounds, before bedtime as needed (PRN), ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Physical therapy evaluation and plan of treatment dated 3/7/2024 documents: R4 readmitted and presents with a continued functional decline in all areas of mobility placing R4 at risk for further decline and a high risk for falls. Precaution: history of falls. Indoor Mobility (ambulation): needed some help. Functional cognition: needed some help, has patient fallen in past year: yes, does patient feel unsteady when walking: yes, does patient worry about falling: yes, reason for therapy: R4 presents with balance deficits, decreased safety awareness, safety awareness deficits, strength impairments and tremors. Assessment summary: follows one -step directions usually with prompts/cues. Diagnosis: lack of coordination and unsteadiness on feet. Nursing note dated 3/30/2024 documents: Called doctor about R4's unwitnessed fall. No new orders. Provide schedules toileting assistance. Call light in reach. Nurse Practitioner note dated 4/1/2024 documents: per nurse on duty. Dementia: alert and orient times 1-2: forgetful. History of fall. Fall/safety precaution: 1:1 transfer assistance. Urge R4 to call for assistance when transferring. Fall IDT (Intra Disciplinary Team) note dated 4/1/24 documents: R4 was transferring from the toilet to the wheelchair, while reaching (for) the wheelchair to sit (down) she slid down, she denies hitting her head. IDT fall committee meeting note dated 4/1/24 documents: root cause-attempting to transfer without assistance. New interventions and/or changes suggested by the IDT at this time: continue to encourage to ask for assistance. Hospital paperwork dated 4/2/2024 documents: R4 was seen for confusion as well as falls. R4 also had a CT of head which showed a small subdural hematoma (pool of blood between the brain and it outermost covering.) Fall prevention program dated 11/28/12 documents: to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. 39340 II. Based on interview and record review, the facility failed to monitor and prevent one resident with a diagnosis of Alzheimer's disease with a history of exit seeking behaviors and wandering from eloping from the facility. This affected one of three residents (R1) reviewed for supervision. This failure resulted in R1 exiting the facility unauthorized and being found outside by emergency services a mile away from the facility in a yard confused with only a t-shirt and shorts in the month of January. Findings Include: R1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, type II diabetes, chronic obstructive pulmonary disease, hypertension, heart disease, post-traumatic stress disorder, delirium, delusional disorders, and cocaine use. Resident brief interview for mental status sated 1/19/24 documents a score of 2/15 which indicates severe cognitive impairment. R1's referral paperwork dated 1/15/24 documents: Sitter discontinued 1/10/24. Patient at doorway when approached room today. Easily redirected. Per nurse wandered x1 last night. Patient requires 24/7 supervision for safety precautions. R1's initial elopement risk dated 1/16/24 documents: at risk for elopement and should be placed on the elopement risk protocol. R1's social service progress note dated 1/17/24 documents: social service spoke to Nurse Practitioner while visiting resident. Stated recommends for resident to be in a locked Alzheimer unit due to inability to redirect resident. R1's physician progress notes dated 1/22/24 documents under history: Resident with vascular dementia, post-traumatic stress disorder, delusional disorder, and previous cocaine use. He has been very delusional, confused, and aggressive. He is attempting to elope to meet his girlfriend and engage in previous activities. R1's police report dated 1/29/24 call received at 12:22PM from local citizen for well-being check. Address documented on the police report and where R1 was located is approximately one mile from nursing facility. (According to goggle maps, approximately a 25-minute walk from the facility) Under notes: Male in t-shirt and shorts sitting by garage/seems lost. Cold exposure. Subject transferred to local hospital. R1's ambulance report dated 1/29/24 documents under impression: confusion/delirium; under complaint Patient confused and slow to answer questions; under mental status; Patient is alert but slow at answering questions, patient unable to tell crew address, president, time or what he is doing outside in the cold. Under narrative: dispatched to above location for the male patient who seems confused. On arrival crew found patient standing outside with bystanders at his side. Bystanders stated they found this man wandering their yard and have no clue who he is. Bystanders stated patient looks like he's freezing and unsure how long he has been outside. Crew asked patient what was going on. Patient was alert but slow at answering questions. Patient could not give crew his home address or phone number and had no idea how he got to his location. Patient stated he left his house and just started walking and ended up here. Patient had no complaints besides being cold and just looking to go back home but patient could not tell crew or police his address. Patient had no phone or wallet to call family or get further information. R1's hospital record dated 1/24/24 at 1:05PM documents under chief complainant: Altered mental status. Patient was found outside in a t-shirt and shorts and unable to identify himself. Patient is confused and unable to provide any history. Resident physician spoke with nursing home who reported that they have been looking for patient. Under history: Patient was brought in by emergency medical services when found wondering in someone's yard. Patient eloped today and was unable to be stopped by staff. According to Accuweather (weather application), weather in Oak Lawn on 1/29/24 was a low of 31 degrees and high of 40 degrees. On 6/7/24 at 12:28PM, V6 (Nurse) who was identified as the nurse assigned to R1 on 1/29/24 at time of elopement. V6 said that was her first time working with R1. V6 said she wasn't familiar with R1, and staff reported R1 was combative, but they did not report he was at risk for elopement. V6 said R1 was with her most of morning following her as she did her morning medication pass between [PHONE NUMBER]AM. V6 said she last observed R1 sitting at the nursing station but unable to recall what time that occurred. V6 said she noticed R1 was gone right before lunch. V6 said she asked the staff and walked the facility and was unable to find the resident. V6 said she called the code and staff began looking for R1. V6 said she did recall hearing any alarms at time of incident. On 6/11/24 at 9:24AM, V13 (Social service director) was asked about her documentation on 1/17/24 in relation to R1 needed a locked unit. V13 said the facility is not considered a locked unit but the all the doors have alarms. V13 said they were attempting to find R1 another facility. V13 was asked what interventions were in place for R1 being at risk for elopement. V13 said making sure staff is aware R1 has a bracelet in place to trigger alarm doors upon attempting to exit. V13 was unaware of monitoring or rounding on the resident and said that would be a nursing intervention. V13 was unable to provide any documentation of the monitoring of R1's location, wandering behavior, and attempts diversional interventions in behavior log. On 6/11/24 at 10:41AM, V2 (DON) said R1 was asked about interventions R1 had in place for being on elopement risk prior to elopement. V2 said R1 had a bracelet in place to trigger alarm doors upon attempting to exit. V2 said she was unaware of the interventions (monitoring location every 15/30/60 and documenting wander behavior and identify patterns of wandering) and would not be the responsibility of nursing staff to document that information and unsure who would be responsible. V2 unable to provide any documentation of monitoring location, wandering behavior or patterns of wandering. On 6/11/24 at 11:58am, V25 (Front Desk) said V6 (nurse) called a code pink and reported R1 was missing. V25 said she received a call from local hospital if the facility was missing any residents and gave R1's description which matched and reported he would be returning to the facility. V25 said she did not hear any alarm day of elopement and said there is no system that alerts her when any door alarms. V25 said you cannot hear all the door alarms from each exit door. On 6/11/24 at 9:54AM, V10 (Certified Nursing Assistant/CNA) who was working on 1/29/24, said she did not hear any alarms that day. On 6/11/24 at 1:17pm, V27 (CNA) said staff told her R1 was missing around lunch time. V27 said she does not recall hearing any alarms. V27 said sometimes it's hard to hear the door alarms if you are in a room or another hallway. On 6/7/24 at 1:19PM, V8 (Maintenance Director) reviewed door check list tool log and said doors are checked daily. V8 was unable to locate the door checklist for the week of January 28th- January 31st. V8 said the northwest door by the oxygen room has a device that alarms when a resident wearing a bracelet is close to the doors attempting to exit. The door also has an alarm that is activated when the door is pushed with a 15 second delay prior to the door opening. The second door that leads outside does not have any alarm. On 6/11/24 5:05PM, V8 said there were no changes to the door after R1's elopement. R1's care plan for elopement documents: R1 deemed to be at risk for elopement as evidence by assessment and reassessment elopement review of risk/wanderer, unable to find what I am seeking, pacing, or roaming repeatedly. Responds poorly to staff redirection, impaired cognition. Risk factors Alzheimer's disease, delusion, on wander guard date initiated 1/23/24 revision 3/8/24. Disguise exits, cover door knobs and tape floor distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; identify patterns of wandering, intervene as appropriate; monitor for fatigue; monitor location every 15/30/60 min (no time was documented) document wandering behavior and attempts diversional interventions in behavior log; wander alert right wrist initiated on 1/23/24 revised 3/8/24. Facility code pink policy reviewed 11/25/18 documents under should an employee discover that a resident is missing from the facility, they should: report missing person to nursing supervisor; review orders to determine if resident out on pass; alert staff by announcing code pink; inform staff the name and picture of resident that is missing if available; make a thorough search of the building and premises; notify administrator and director of nursing immediately if resident not found after search; administrator and director of nursing will evaluate the situation develop a plan of action based on individual resident; the following steps should occur: Nurse should notify the attending physician; notify resident legal guardian; notify the police department; provide search team with resident information; increase search by more extensive search of surrounding area, remain in contact with hospitals; complete incident report and notify the state agency according to reporting guidelines, document appropriate notifications in the medical record. Facility elopement device policy revised 9-13-19 documents: The elopement alert exit door device will be inspected for proper working daily by maintenance and manger on duty.

Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for fall prevention by not ensuring that interventions were in place per the resident's plan of care for a resident at risk for falls and they failed to ensure that a resident who is at risk for falls due to wandering and impaired safety awareness was adequately monitored to prevent injury. These failures applied to two (R24 and R95) of three residents reviewed for falls and resulted in R24 obtaining a lumbar spine fracture while receiving care and R95 not receiving adequate supervision to determine the cause of superficial skin tears and bruising. Findings include: 1.) R24 was admitted to the facility on [DATE] with past medical history of multiple sclerosis, acute respiratory failure with hypoxia, other lack of coordination, metabolic encephalopathy, flaccid hemiplegia affecting left non dominant side, foot drop left and right foot, etc. On 10/10/23 at 11:00AM, R24 was observed in his room lying on his back, noted to be on isolation with an isolation cart outside the door and a contact isolation sign on the door. R24 is on isolation for C-diff per staff. R24 was observed lying in bed in the same position from 11:00AM to 1:00PM, his bed remained high and not down to the floor, no floor mats noted on either side of the bed. On 10/11/2023 at 11:10AM, resident was observed again in his room lying on his back, bed was high, no floor mats were noted on either side of the bed. Surveyor asked resident why he went to the hospital the last time and he said that he fell while he was being changed by the certified nursing assistant (CNA), resident is still on contact isolation for C-diff. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive pattern) score R24 with a BIMs score of 15, indicating that resident is alert and oriented. Section G (functional status) of the same assessment documented that resident requires extensive to total assistance with one to two staff physical assist for all ADL needs. Fall risk assessment dated [DATE] scored R24 as being at risk for falls with a score of 11. Fall care plan initiated 2/24/2023 stated that resident is at risk for falls related to generalized weakness, intake of antidepressant medication, left upper extremity and bilateral lower extremity no mobility, right upper weakness. Goal, resident will not sustain serious injury through the review date. Interventions include bed height to be placed where my feet are flat on the floor, fall mats, be sure resident's call light is within reach, etc. Hospital record dated 7/14/2023 states in part: male with past medical history of MS with left sided hemiplegia, bedbound at baseline presents for evaluation of fall from bed at his nursing home. Patient stated that he had a fall from his bed while being changed at the nursing home he landed on his back, he was told he has been having a lot of diarrheas the past few days. CT lumbar spine without contrast revealed a right L2 transverse process fracture. Discharge instructions of the same hospital record states you presented to the hospital after falling out of bed, imaging of the lumbar spine showed a right L2 transverse process fracture which is a fracture in your lumbar spine. On 10/12/2023 at 12:13PM, V20 (LPN) said that she was the nurse assigned to R24 the day he had a fall, the CNA notified her that resident was on the floor, she went into the room and resident was in there with the CNA. V20 assessed resident and said that resident was not looking good to her, she called the ambulance and sent resident to the hospital. V20 said that the CNA told her that the resident was on the floor, she is not sure what happened before the fall, resident was on isolation for C-Diff at that time. V20 added that R24 is a fall risk and some of his interventions include bed to the lowest position, floor mats and call light within reach. On 10/11/2023 at 3:35PM, V2 (Director of Nursing/DON) said that R24 went to the hospital after his fall. V2 interviewed resident after he came back from the hospital and he said that he fell while he was in the process of getting care, he rolled over and rolled out of bed, he was trying to assist the CNA. V2 said that she did not interview the CNA during the fall investigation because she resigned. She spoke to the nurse but cannot recall what she said. Surveyor presented a facility reported incident for R24 dated 7/14/2023, stating that the resident had an unwitnessed fall. V2 said, Oh, I don't know anymore, I must have mixed them up. Fall prevention policy revised 11/21/2017 states its purpose as to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each residents assessing the risk of falls and implementation of appropriate interventions to provide necessary supervisions and assistive devices are utilized, as necessary. Quality assurance program will monitor the program to assure ongoing effectiveness. Under standards, the policy states in part that a fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions will be implemented for each resident identified at risk. 40718 2.) R95's diagnoses include a history of Dementia with Behavioral Disturbance, Bipolar Disorder, Generalized Anxiety Disorder, and Ataxia. R95 was admitted to the facility on [DATE]. On 10/10/2023 at 11:45 AM observed R95 sitting on her bed with a large round dark bluish colored bruise on her right arm and large, long dark scabs on her left arm. The facility's Fall Log Report from 04/02/2023 - 10/10/2023 documents R95 had unwitnessed falls 09/13/23 at 12:00AM and 10/04/2023 at 6:54 PM. R95's progress note dated 09/13/2023 12:00 AM documents R95 had an un-witnessed fall 09/13/2023 at 12:00 AM. On initial rounds at the resident's room, nurse on duty saw R95 was sleeping on the floor shirtless with blanket as her pillow. R95 was unable to give description. Neurological checks initiated. R95 is alert and disoriented per usual baseline. Intervention includes safety checks. R95's current care plan documents she is at risk for falls related to wandering, impaired safety awareness, and medication side effects, with interventions including anticipate and meet the resident's needs; follow facility fall protocol. R95's current care plan documents she is at risk for elopement and wandering per family history, with a history of eloping from their home, R95 seeks exits when she is confused or will often pick up items that do not belong to her; and R95 likes to sit near windows/doors even when not exit seeking with interventions including distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. R95's current care plan initiated 04/25/2022 documents she has a potential for impairment to skin integrity related to requiring assistance with activities of daily living at times, and impaired thought processing with interventions including assess/record changes in skin status; follow facility protocols for treatment of injury; report pertinent changes in skin status to physician. R95's current care plan initiated 02/22/2023 documents she has multiple bruises on bilateral arms with interventions including report bruising to nurse/physician and was revised on 10/12/2023 during the annual survey to include intervention of offering (brand name of elastic thread fabric) to arms/leg for injury prevention. R95's current care plan originally reviewed by surveyor 10/11/2023 did not include information of newly identified bruises or skin tears as of October 2023 and was revised by facility 10/12/2023 during the annual survey. On 10/11/23 at 03:06 PM V2 (Director of Nursing) stated she isn't sure where the superficial skin tears on R95's left arm came from. V2 stated a week or two ago V22 (Admissions Director) reported to her that she saw R95 in the hallway bleeding. V2 stated she cleaned the area on R95's arm and wrapped it up. V2 stated R95's skin is thin and fragile so it is vulnerable to injury and if she bumps against something her skin could tear. V2 stated she was not aware of a bruise on R95's right arm and is not sure where the bruise on her arm came from however R95 moves around a lot and wanders so it could have come from anywhere. On 10/11/23 at 03:30 PM V2 (Director of Nursing) stated she is not sure where the large bruise on R95's arm came from. V2 stated R95's bruise looks like it's healing, and a skin assessment would be done when identified and the injury of unknown source would be documented and monitored. V2 stated when the skin tear was originally observed on R95's left arm she forgot to chart the observation in R95's medical records. V2 asked how she could investigate where R95's bruise and skin tears originated from since she has dementia and it's not like R95 can tell her how it happened or can pinpoint when she did it. R95's medical records did not include documentation of identification of or monitoring of a skin tear or bruise within the last 30 days prior to the start of the annual survey 10/10/2023. R95's progress note dated 10/12/2023 08:03 AM documents she has a history of bruises due to previous falls and ambulating without assistance, according to therapy she can get fatigued and this is when she has had her previous falls and bumps into walls or doorways; R95 had a fall 10/04 and with continue ambulation she bruise, healed skin tear is most likely from fall and bumping a non-vulnerable exposed area on wall/door frame, care plan updated. On 10/12/23 at 01:30 PM V2 (Director of Nursing) stated R95's skin is being monitored consistently however the nursing staff failed to document it. V2 stated R95 is being monitored frequently by all staff in all care areas. V2 stated it's possible R95 sustained her bruise and the skin tears prior to staff being able to get to her in time. V2 could not provide an explanation as to how staff were unaware of how exactly R95 developed her bruise and skin tears although she is reportedly being constantly monitored. The facility's Fall Prevention Policy reviewed 10/12/2023 states: Purpose is to assure the safety of all residents in the facility when possible. The program will include implementation of appropriate interventions to provide necessary supervision. Safety interventions will be implemented for each resident identified at risk. Fall/safety interventions may include but are not limited to: The bed will be maintained in a position appropriate for resident's transfers. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care. The facility's Skin Condition Assessment & Monitoring of Pressure and Non-Pressure Policy reviewed 10/12/2023 states: The purpose is to establish guidelines for assessing, monitoring and documenting the presence non-pressure skin conditions. On the skin's surface, bruises undergo progressive changes before they fade: 2-5 days - Blue. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity.

Based on interview and record review the facility failed to develop a plan of care to reduce or prevent the risk of falling with interventions to include supervision and monitoring for 2 of 3 residents (R1, R2) reviewed for fall prevention. This failure resulted in R2 having an unwitnessed fall sustaining a closed non-displaced right femoral neck fracture, and R1 rolling from bed and sustaining a right femur fracture. The findings include: R2 R2 had the diagnosis of dementia with behavior disturbance, anxiety, and hypertension. Hospital paperwork dated 1/10/22 documents: R2 is below baseline level requiring increased physical assist for transfers and mobility. Physical Therapy Treatment dated 1/6/22 documents: R2 requires extensive hand-on for functional transfers. R2 remains confused, unable to follow commands consistently. R2 was unable to take steps or ambulate at this time. R2 demonstrate flexed forward posture with decrease balance and posterior lean with fatigue. R2's mobility remains limited due to decreased cognition/safety awareness/confusion, generalized decondition, decrease balance and activity tolerance. Suggested support at discharge: physical assist, close contact for safety and constant supervision. On 2/22/22 at 2:12pm, V12 (Therapy Director) said, we didn't evaluate R2. I briefly reviewed R2's hospital package. R2 was fall risk. Close contact and constant supervision mean R2 needs someone with R2 with him at all times for any transfers. On 2/22/22 at 2:37pm, V3 (Nurse) said, when R2 arrived, R2 was placed in bed and instructed to use call light with understanding. R2 had a fall within thirty minutes of arrival. R2 was discharge to the hospital. I did not receive in report that R2 was a fall risk, nor did I read R2's entire hospital package. On 2/23/22 at 11:40am V2 (DON) said, R2 was in the facility for 15-20 min before R2 was found on the floor. I can't remember R2 ambulation status. I determined, R2 was a fall risk based on reading the hospital paper after R2's fall. I expect the nurse to read the hospital paper on admission and to put in necessary intervention to prevent falls. On 2/23/22 at 2:41pm, V21 (CNA) said, I helped transfer R2 to the bed off the stretcher with the EMTs. R2 was alert to self. I got R2 situated, told R2 if R2 need anything to use the call light. It was no way to determine if R2 knew how to use a call light. That would take more than an hour to determine that. I walked away, heard something, turned around, R2 was on the floor at the foot of the bed. It seemed like R2, took a couple steps, and fell . Progress noted dated 1/13/21 documents: Resident is alert to self. Fall event dated 1/13/22 documents: R2 was sitting on R2's buttock with back against the wall supported by the palms of R2's hands. R2 complained of right hip pain. R2 stated, I don't know what happened. Fall event dated 1/13/22 documents: R2 was disoriented but with normal limits, predisposing physiological factor: gait imbalance, functional loss, forgets to use call light, resident was standing, predisposing situation factor: ambulation with assist. Hospital paperwork dated 1/13/22 documents: R2 has dementia, does not know where R2 is, recall falling, date, year or time. R2 had an unwitnessed fall in R2's room resulting in a closed nondisplaced right femoral neck fracture. R1 R1 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)], assault by shotgun, hypertension, and vascular dementia without behavioral disturbances. R1's brief interview for mental status score dated 11/21/21 documents a score 15/15 is which indicates cognitively intact. R1's progress note dated 10/27/21 documents: R1 was observed in the floor by staff. Resident said, I was sleeping and rolled to the floor, but I am not hurt. R1's Fall IDT note dated 10/30/21 documents under root cause of fall: Resident ID alert and oriented x4, resident can self-transfer to electric chair, requires assistance x1 for ADL (activities of daily living) care. Resident stated R1 was sleeping and rolled out of bed. Non-pitting [CONDITION(S)] notes to left ankle. Resident later complaints of increased pain to left lower extremity. Interventions: Physical therapy to screen, education on bed mobility and x-ray of left lower extremity R1s fall care plan revised on 10/27/21 documents: R1 is at risk for falls and injury related to falls. Interventions dated 11/15/20: assess for altered cognition; assess for pain. Provide pain interventions as appropriate; assess for side effects of medications; assist with ADL's. Anticipate and meet the resident needs; assist with toileting; follow fall policy. Intervention dated: 10/27/21 documents head to toe assessment completed. Range of motion intact. Physical therapy to screen. Educated proper positioning in bed and body mechanics. X-ray bilateral lower extremities. On 2/22/22 at 2:56pm, V12 (Therapy Director) said she was unable to locate any recent dates of service or screening for therapy for R1. R1's progress note dated 1/24/22 at 5:56pm: Resident complaints of pain and crackling sound to right knee upon lifting leg. No swelling noted at this time. Pain medication given. V19 (MD) notified. Orders given for x-ray of right leg. Order called in to local radiology services. Radiology services will be out throughout the night. R1's progress note dated 1/25/22 at 9:35am documents: Resident stated to writer (V2) that R1 had a fall in R1's room, the evening of 1/24. Resident reported that R1 was sleeping and attempted to roll over in bed and rolled too far. Resident stated that R1 got self off the floor, back into bed, and transferred self in to R1's wheelchair. Resident, then went to nursing station to report complaints of pain. Head to toe assessment performed, ROM performed, all extremities moved within normal limits, with a complaint of pain to right knee. Resident rates the pain 10/10. NP contacted and informed resident compliant. Order received for x-ray of right hip, femur, tibia, and fibula. Order placed with local company. R1 radiology results reported dated 1/25/22 at 10:46am documents under right femur: Grossly displaced distal femoral fracture. Under impression: acute fracture. R1's facility report to IDPH documents under final report: Resident is alert and oriented times 4, requires stand by assist for transfers. Resident informed staff on 1/25/22 at approximately 9:00 am, that R1 had an unwitnessed fall the evening of 1/24/22 in R1's room. Resident stated while R1 was sleeping R1 rolled over and out of bed. Resident informed staff that R1 got self off the floor, back into bed, then into wheelchair. (Resident is unable to get self off the floor independently.) After getting back into the wheelchair resident went to the nursing station, with complaints of pain to right knee. Resident stated R1 attempted to cross R1's leg and heard a pop. R1's fall risk assessment dated [DATE] documents resident is at risk for falls. R1's hospital record dated 1/ 25/22 documents: Resident reports last night R1 was experiencing neuropathic pain in the right thigh and angled self near the edge of the bed and slept on R1's left side to alleviate R1's pain. This morning R1 woke up on the ground with pain to right lower extremity. R1 is unsure of how R1 fell to the ground but believes R1 fell off the bed. Patient notes that trauma was focused over right lower extremity and denies hitting R1's head or losing consciousness. Patient was able to pull self off the ground, back up into bed. X-ray femur dated 1/25/22 documents acute spiral fracture of the distal right femur. Facility policy titled Fall Prevention Program revised 11-21-17 documents: Under purpose: To assure the safety of all the residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Each resident will be screened by a specialist therapist at the time of admission, quarterly, after each fall, as appropriate, and with significant change in the resident's mental and functional abilities.

Based on interview and record review, the facility failed to follow their pain policy by not reassessing and documenting a new onset of pain, administrating and documenting pain medication for one (R1) of three resident reviewed for pain management. This failure resulted in ineffective pain management for R1. R1 said R1experienced pain 10/10 for over 3.5 hour after rolling from the bed and sustaining a right femur fracture. The findings include: R1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's brief interview for mental status score dated 11/21/21 documents a score 15/15 is which indicates cognitively intact. R1's progress note dated 1/24/22 at 5:56pm: Resident complaints of pain and crackling sound to right knee upon lifting leg. No swelling noted at this time. Pain medication given. V19 (MD) notified. R1's progress note dated 1/25/22 at 9:35am documents: Resident stated to writer (V2 Director of Nurses/DON) that R1 had a fall in R1's room, the evening of 1/24. Resident reported that R1 was sleeping and attempted to roll over in bed and rolled too far. Resident stated that R1 got self off the floor, back into bed, and transferred self in to R1's wheelchair. Resident, then went to nursing station to report complaints of pain. Head to toe assessment performed, ROM performed, all extremities moved within normal limits, with a complaint of pain to right knee. Resident rates the pain 10/10. NP (Nurse Practitioner) contacted and informed resident compliant. Order received for x-ray of right hip, femur, tibia, and fibula. Order placed with local x-ray company. R1's hospital record dated 1/25/22 documents: Resident reports last night R1 was experiencing neuropathic pain in the right thigh and angled self near the edge of the bed and slept on R1's left side to alleviate R1's pain. This morning R1 woke up on the ground with pain to right lower extremity. R1 is unsure of how R1 fell to the ground but believes R1 fell off the bed. Patient notes that trauma was focused over right lower extremity and denies head or losing consciousness. Patient was able to pull self off the ground, back up into bed. Patient had imaging done at nursing home that confirmed fracture. Patient is unable to detail where the fracture was. R1 received Tylenol but continues to rate the pain as a 10/10. X-ray Femur dated 1/25/22 documents acute spiral fracture of the distal right femur On 2/25/22 at 12:09pm, R1 who was alert and oriented at time of interview, said R1 was experiencing neuropathic pain prior to bed and eventually fell asleep. R1 said R1 rolled off R1's bed and heard a crack when R1 hit the floor. R1 said R1 was able to get self back in bed and pulled R1's call light. Two staff answered the light and R1 informed them that R1 fell but R1 reported the staff did not believe R1. R1 said the nurse gave R1 Tylenol at that time and R1 did not receive any other pain medications after that until R1 was at the hospital. R1 said R1 had pain for almost 2 days and R1's pain was 10/10. R1 said R1 did not want to the return to the facility after the way they treated R1. On 2/25/22 at 11:34am, V2(DON) said R1 reported that R1 had fallen and was experiencing pain to R1's right leg. V2 said when she attempted to do range of motion to right leg, R1 yelled out in pain and V2 stopped assessment. V2 said she observed swelling to the right upper leg and informed V20(Nurse Practitioner). V2 said she informed V30 (Nurse). V2 said she did not administrator any pain medication. V2 said she would expect the nurse to assess the pain. Document the pain assessment, document medication given and if it was effective. V2 said she did not see that documentation in R1's medical record. On 2/24/22 at 3:31pm, V30(Nurse) said R1 will usually request Tylenol in the morning, but she is unclear if she gave R1 Tylenol on 1/25/22. V30 said R1 denied any pain or discomfort during her shift. V30 said pain would be documented in R1's progress notes. R1's progress notes does not document any pain or follow up assessments between fall note 1/24/22 at 6:56pm through 1/25/22 at 9:35am. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility policy titled: Pain Management Program reviewed 4/1/21 documents: It is the goal of the facility to facilitate resident independence. Promote resident comfort. Preserve and enhance resident dignity and facilities life involvement. The pain management program includes documentation of pain assessment and monitoring; Pain medication shall be appropriate for the population served; medications for the control or relief of anxiety related to pain. Pain assessment protocol will be initiated under any of the following situations: a change in the resident's condition occurs to require pain medications; Resident receives routine pain medication or pain not controlled. Documentation of assessment and the resident response to the pain management plan will be made with each assessment

Based on observation, interview, and record review the facility failed to implement an individualized plan of care for pressure ulcers and the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was subsequently sent to the hospital for a wound infection. Findings Include: 1. R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/22/22 at 12:49pm V1 (Wound Care Coordinator) stated on 12/27/21 she was on duty and when she went to conduct wound care for R1. The dressing to R1's lower left leg was dated for 12/23/21. V1 said the dressing had a brownish substance on it and the dressing was loose with the 4x4 boarder gauze was coming off (edges lifting up). When she removed the dressing R1 had maggots in the anterior leg wound. V1 said there were a lot of maggots, more that she could count. V1 said she cleaned the wound and applied a new dressing to the lower leg. She notified the V5 (Nurse Practitioner), and orders were given to send R1 to local hospital for wound evaluation and debridement. V1 said she asked V2 (Nurse) to come and look at the wound so that she could be aware of the wound status. V2 was R1's nurse at that time. V1 said V2 refused to make an observation of the wound, stating No I'm not going to look at that. V1 said R1 often moved around in the bed, maybe the dressing came loose. V1 said R1 has scheduled orders for wound treatment and also PRN (as needed) orders for wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 said the dressing should be change as ordered or as needed. V1 said she notified V7 (R1's POA) that R1 wound was getting worst but she did not notify V7 that R1's wound had maggots because she did not want V7 to get scared. V1 said R1 had 3 wounds to left lower extremity. She does the wound treatments Monday through Fridays if she's scheduled to work, otherwise the nurse that assigned to care for the resident supposed to complete the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 said on 12/23/21 she completed wound rounds with V4 (Wound Care Physician), and the (name brand) treatment was initiated to R1's left leg anterior wound. On 1/22/22 at 1:29pm V2 (Nurse) said she does not document anything that she does not see for herself. V2 said she informed R1's family that R1's wound was observed with maggots. V2 said she does not remember what she mentioned to the family and does not know what she mentioned to the hospital nurse when she gave report. When asked if she looked at the wound so that she could document what she reported to the hospital nurse and R1's family V2 did not give respond. On 1/22/22 at 2:47pm V4 (Wound Care Physician) said he was not informed that R1 was observed to have maggots in R1's wound. V4 said that is a horrible horrible thing. V4 said R1 has orders for wound care every two days and the treatment is honey. The honey treatment may attract insects and therefore it's important that the wound dressing is intact and not loose. V4 said if R1 wound dressing became loose insect can get under the dressing and lay maggots. V4 said R1 had a [CONDITION(S)] infection in R1's wound but it was the wound treatment that attracted the insects to the wound. V4 said orders should be implemented when he writes them. If the facility is going to do treatment dressing as they desire, they should inform him. He would ask them why and inform them that the dressing should be changed every two days. V4 said the wound treatment dressing should be completed as ordered and the treatment dressing should be changed if the dressing comes loose. V4 said he saw R1 on 12/30/21 and no one mentioned anything about R1 having maggots in R1's wound. On 1/23/22 at 3:07pm V5 (Nurse Practitioner) said she was notified by V1 on 12/27/21 regarding R1 having maggots in R1's leg wound. V5 said she was not there, and she did not see them. When V1 contact her V1 was very concerned about R1's wound. V5 said she gave orders to send R1 to local hospital for wound evaluation and debridement. V5 said she saw R1 the next day on 12/28/21. V5 said the wound physician should have been made aware of the concern of the maggots in R1's wound. It is her expectation that the orders be communicated to the hospital as given. V5 said she does not know if the hospital debrided R1's wound. R1's progress note completed by V5 (Nurse Practitioner) shows in-part, patient is a poor historian due to cognitive/psychiatric impairment, chief complaint/reason for this visit: infected wound, AMS (altered Mental Status), Falls, HPI Relating to this Visit, being seen today per nursing request for infected wounds. Wound nurse report resident wound declining 2/2 current infection and multiple comorbidities. Nurse report presence of foreign object in wounds (maggots) upon dressing change with noted foul smelling drainage with greenish discharge. Nurse also report wounds recently cultured 2/2 drainage and odor, with noted results positive for pseudomonas and [CONDITION(S)]. Nurse report resident seen and followed by ID. Per nursing resident not at R1's baseline mentation, denies fever, chills, cough, loss of appetite or body aches. Recently treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Per nursing PCP made aware of resident current lab results and change in baseline mentation with order to transfer to ER for further evaluation and treatment. Noted in bed alert, in NAD. Informed of plan of care. POA phoned per nursing report to inform of impending transfer for medical evaluation and treatment. Denies CP, SOB, Palpitation, Fatigue, Blurred Vision or H/A. No s/s of respiratory distress, no SOB, JVD, use of accessory muscles for breathing. Dressing intact to wounds. PMHx significant for: [CONDITION(S)], Dementia, [CONDITION(S)], [CONDITION(S)], CHF, [CONDITION(S)], PVD, [CONDITION(S)], [CONDITION(S)], COVID 19. R1's plan of care dated 10/22/21 shows in part I (R1) have pressure ulcers, pressure ulcer will show signs of healing and remain free from infection through review date. Interventions are to administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Low Air Loss Mattress in use. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. R1's POS with start date 11/17/21 shows left lower leg anterior wound: cleanse with NSS (normal saline), apply (name brand treatment), cover with dry dressing, change daily and PRN, left lat (lateral) Leg: cleanse with NSS, pat dry, apply Santyl, and cover with dry dressing daily, one time a day for wound care, start date 11/08/21, left lower leg posterior wound: cleanse with NSS (normal saline), Pat dry, apply [MEDICATION(S)], cover with dry dressing, change daily and PRN start date 11/17/21, and left ankle cleanse with NSS, pat dry, apply Santyl, cover with dry dressing daily, start date 11/08/21. R1's TAR (Treatment Administration record) dated for December 2021 does not show treatment documentation for left lower leg anterior wound. On 1/23/22 at 1:50pm V1 said the documentation for left lower leg is for the left lower leg anterior wound. V1 said somehow the documentation may have been changed but she's certain that the documentation is for the left leg anterior wound. R1's TAR for December 2021 shows left lower leg cleanse with NSS, pat dry, apply (name brand treatment) and cover with gauze and ABD pads, wrap with kerlix daily, documentation show the first sign off for this treatment was 12/30/21. R1's wound assessment and plan dated 12/23/21 completed by V4 shows in-part R1's name, discussed care and course of treatment and obtained general consent to evaluate and treat, active/initial phase of treatment, wound location left anterior lower leg, pressure injury, healing, date of onset 10/08/21, measurement 8cm length x 5.5 cm width x 0.2 cm depth, wound bed 100% granulation, peri wound-within limits, exudate- moderate, signs and symptoms of infection-none, treatment- every 2 days medical honey gel-cleanse wound with normal saline or sterile water, apply to wound bed, cover with dry dressing and as instructed, wound slightly improving, treatment change to medical honey, follow up as scheduled, wound risk factors paranoid [CONDITION(S)], type 2 diabetes mellitus, hypertension, acute post hemorrhagic [CONDITION(S)], peripheral vascular disease. R1's emergency department records dated 12/27/21 at 3:51pm shows in-part patient (R1) a/ox4 (alert and orient) to ED from Aperion care NH for c/o left lower leg wound. Patient states that NH RN (Registered Nurse) patient was sent because (R1) has maggots in (R1's) vagina. Patient also states LLE (lower left Extremity) wounds needs to be cleaned. Patient denies any other complaints at this time. Chief complaint, patient presents with wound check-LLE wounds, and medical problems re-evaluation. Past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . No report of fever chills, nausea, vomiting. No shortness of breath, chest pain, abdominal pain. Patient reports (R1) was told there was magnet in (R1's) sacral wound that was removed from the nurse. Patient unsure when left lower extremity wound became worst. Patient reports (R1's) doctor sent (R1) in for evaluation. Comments: left lower extremity: anterior wound with granulation tissue, distal medial wound with purulent drainage, [CONDITION(S)] up towards the knee, warmth to the lower extremity, 1 plus pitting [CONDITION(S)]. Two pinpoint areas unstageable pressure wounds, no surrounding [CONDITION(S)] or drainage noted. Review of R1's emergency room records, there is no documentation that shows R1 was sent for wound debridement and wound evaluation of anterior left leg wound as ordered by V5. There is no report documented from the facility nurse that R1 was sent to the hospital for wound debridement and evaluation of the anterior left leg wound. On 1/22/22 at 2:28p.m V3 (Manager on Duty) said wound treatment should be administered as ordered, V3 said documentation should be accurate and complete. V3 said orders should be carried out when they are received or as soon as possible that day. V3 said if it's not documented then it's not done. 2. On 1/22/22 at 11:13am R2 was observed resting on low air loss mattress. R2's skin was observed with assistance from V10 (Certified Nurse Assistant/CNA) and V9 (agency CNA). R2 was observed to have a dressing to the right foot dated 1/21/22. The dressing was soiled with a large brownish red stain. R2 had a dressing to the left foot dated 01/17/2022. R2 had a dressing to the sacrum, no date noted. R2 did not have a treatment dressing to the right gluteal fold wound. The wound was observed to be pink in color. R2 did not have a treatment dressing to the left hip. The wound was observed to be pink in color. R2 [CONDITION(S)] tie was observed soiled with yellow substance. The date was observed to be 1/17/22. On 1/23/22 at 11:41am R2 was observed for wound care. V1 administered wound care with assist from V8 (wound tech) R2 had the same soiled dressing to the right lower leg dated 1/21/22. V1 removed the dressing and implemented wound care. The wound was observed to be pink in color. R2's left foot was observed to be intact. V1 said the dressing is for preventive measures and she changes that left foot every 3 days. R2's wound to the sacrum was soiled in feces. V1 removed the dressing and administered wound care to sacrum. R2's sacrum wound was large and pink in color. V1 cleansed the wound to R2's left hip, applied wound treatment and a clean dry dressing. The wound to R2's left hip was pink in color. V1 cleansed the wound to R2's right gluteal fold, applied wound treatment, and a dry dressing. The wound to R2's right gluteal fold was observed to be pink in color. R2 was observed with the same soiled yellow [CONDITION(S)] tie, date was observed to be 1/17/22. R2's POS dated shows in-part Right Gluteal Fold: cleanse with NSS, Pat Dry, apply Santyl and cover with gauze and dry dressing M-W-F and PRN, one time a day every Mon, Wed, Fri for wound care AND as needed for wound care. Right Ankle: cleanse with NSS, pat dry, apply (brand name dressing), and cover with gauze, ABD, and wrap with (brand name wrap) every M-W-F and PRN, one time a day every Mon, Wed, and Fri for wound care AND as needed for wound care. Left Hip: Cleanse with NSS, Pat dry, pack with collagen and cover with gauze and dry dressing every M-W-F and PRN, one time a day every Mon, Wed, Fri for wound care AND as needed for wound care. Sacrum: Cleanse with NSS, Pat Dry, pack with collagen and cover with gauze and dry dressing every M-W-F and Prn Until Healed, one time a day every Mon, Wed, Fri for wound care AND as needed for wound care. Change [CONDITION(S)] tie daily, every day shift and as needed. Review of R2's December TAR, there were no documentation for wound care treatment PRN for R1's left hip, right ankle, right gluteal fold, or sacrum. Review of R2's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/23/21 at 2:24pm V11 (Nurse) said she changed the [CONDITION(S)] tie for R2 on 1/23/22, 1/22/22, and 1/21/22. When informed that the date on the [CONDITION(S)] tie shows 1/17/22, V11 then said the night nurse changed the [CONDITION(S)] tie and she signs off on it. Then V11 said she does not have time to change the [CONDITION(S)] tie. She only has time to suction R2 if needed because she is so busy. She has 19 residents on the Covid unit and 12 to 13 residents that are not on the Covid unit. On 1/23/22 at 3:00pm V12 (Director of Nursing) said the facility needs 5 nurses for the 7am to 3pm shift. V12 said there is 4 nurses on duty today and there were 4 nurses scheduled yesterday. V12 said the facility can function with 4 nurses. When V12 was informed of V11 concern of having 19 residents on the Covid unit that require constant monitoring because they can change at any moment and not being able to change the [CONDITION(S)] collar as ordered, V12 said she has seen V11 work and that V11 can get it done. V12 said the facility needs 10 CNAs for the 7:00am to 3:00pm shift. The facility has 8 but had 2 call offs. V12 said she does not know who orientated the agency CNAs on the level of care the residents need but they should ask the unit nurse if they have concerns. R2 plan of care dated 9/15/21 shows I (R2) have pressure ulcers to my right lateral ankle, left hip, right buttock, right gluteal fold r/t impaired mobility. Management of Pressure Ulcer, Prevention of Future Pressure Ulcers, Wound Will Show Signs of Improvement, Educate Resident/Representative on importance of keeping skin clean and moisturized, Evaluate skin for areas of blanching or redness, Evaluate ulcer characteristics, Keep skin clean and well lubricated, low air loss mattress, Monitor bony prominences for redness, Monitor nutritional status, Notify family of new onset finding, Notify provider if no signs of improvement on current wound regimen, offloading device, Provide skin care per facility guidelines and PRN as needed, Provide wound care per treatment order, Weekly wound assessment, including LxWxD (length x width x depth), type of tissue present, drainage, odor. S/S of infection noted or decline to wound status, call MD and all other appropriate parties. Facility policy Titled Comprehensive Care Plans dated 11/28/2012 with last revision date of 11/17/17 shows in-part to develop a comprehensive care plan that directs the care team and incorporate the resident's goals, preference and services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. The facility will develop and implement a comprehensive person-centered care plan for each resident, consist with the resident rights that includes measurable objectives and timeframes to meet a resident medical, nursing and mental psychosocial needs that are identified in the comprehensive assessment. Facility policy Titled Skin Condition Assessment and monitoring- pressure and non-pressure dated 11/28/12 with last revision date 6/8/2018 shows in part the 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, wound assessment/measurement-number 7. Shows physician ordered treatments shall be initiated by staff on the electronic treatment administration Record after each administration. Other nursing measure not involving medications shall be documented in weekly wound assessment or nursing note. Facility policy Titled Physician Orders-Entering and processing dated 08/22/2017 with revision date of 01/31/2018 shows in-part purpose- to provide general guidelines when receiving, entering, and confirming physician or prescribers' orders. (A prescriber is noted as physician, nurse practitioner, and physician assistant.) Number 6 -verbal and telephone orders will be documented as such in the electronic medical record. Facility Policy Titled Pressure Ulcer Prevention dated 11/28/2012 with revision date of 01/15/2018, shows in-part to prevent and treat pressure sores/ pressure injury. Number 1- maintain clean/ dry skin during daily hygiene measures.

Based on observation, interview, and record review the facility failed to have effective interventions in place to prevent a resident dependent on staff for care and at risk for skin breakdown from developing a pressure ulcer. The facility also failed to update interventions and the plan of care as needed to prevent worsening of a facility acquired pressure ulcer. This failure affected one (R2) of four residents reviewed for pressure ulcers and resulted in R2 developing a stage 4 pressure ulcer subsequently requiring hospitalization with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R2 was admitted to the facility on [DATE]. R2's past medical history includes but not limited to Arthropathy unspecified, Essential primary hypertension, other lack of coordination, local infection of the skin and subcutaneous tissue, Non-pressure chronic ulcer of buttock, Adult failure to thrive, Dementia, Dysphagia oral phase, [CONDITION(S)], etc. R2 was transferred to the hospital on 8/16/2021 and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital medical record from 8/16/21 includes: Review of systems documented stage 4 pressure ulcer to sacrum, foul odor, necrosis, and black liquid oozing from wound, unable to visualize edge of wound bed. Clinical data documents that R2 has an extensive pressure ulcer to the sacrum with necrotic appearing drainage; CT reveals [CONDITION(S)] to decub (decubitus ulcer); case discussed with physician for possible surgical evaluation in regard to debridement. Per facility admission notes, R2 is totally dependent on staff for transfers and requires 2-person physical assist; requires extensive assistance with eating with 1-person physical assist; requires extensive assistance with toileting 1-person physical assist; requires extensive assistance with dressing 1-person assist; and is totally dependent with personal hygiene, requiring 1-person physical assist. Facility admission progress note for R2 dated 2/7/2021 documents that there were no skin or wound concerns. 2/17/2021 wound care documentation includes skin concern observed, right buttock redness. 2/22/2021 wound care documentation includes new skin concern, skin stripping on right buttock, treatment obtained. Care plan dated 2/06/2021 and revised 3/29/2021 includes a focus on potential for impairment in skin integrity related to mobility and incontinence with interventions including administer/monitor effectiveness of medications as ordered and follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] There were no documented interventions or updates to R2's plan of care after 3/29/2021 to address the continued care and management of her pressure ulcer. Facility documented wound assessments has wound classification as skin stripping, facility acquired from 2/7/2021 to 6/25/2021. Wound assessment and plan wound physician documented the same wound as skin tear, full thickness with fat layer exposed, wound measurement 7 cm (centimeter) in length X 9 cm width X UTD (unable to determine) cm Depth. 7/2/2021 facility wound assessment documented wound as skin stripping, type trauma, facility acquired. Physician wound assessment dated [DATE] documented the same wound as pressure injury, stage 4, full thickness exposed underlying structure. 8/31/2021 at 2:01PM, V4 Wound Care Nurse said that she took over wound care at the end of June and that on 6/23/2021 during dressing change, she noted a stage 4 pressure ulcer to the resident's sacrum with signs and symptoms of infection like a foul odor and heavy off-white drainage but (R2) did not have a temperature (fever). 8/31/2021 at 2:26PM, V3 Assistant Director of Nurses (ADON) stated that she used to be on the floor as the wound care nurse. R2's wound was not over a bony prominence at first; that's why it was categorized as a skin stripping. V3 was presented with some of the wound assessment she did on R2 and she said, I don't know how I categorized that as skin stripping, I am not even sure how my name appeared on that assessment. 8/31/2021 at 3:09PM, V10 MDS (Minimum Data Set) Coordinator said that she is familiar with R2 and that (R2) was at risk for alteration in skin integrity upon admission. (R2) eventually developed a pressure ulcer. She added that residents who were admitted with or who develop a pressure ulcer at the facility should have a care plan with interventions for the management of the pressure ulcer. Facility document titled, Pressure Ulcer Prevention (revision date 1/15/18) states its purpose as to prevent and treat pressure sores/pressure injury. Under the guidelines, the policy states to inspect skin several times daily during bathing, and repositioning measures .

I. Based on interviews and record reviews, the facility failed to report abnormal laboratory results to attending physician. This failure resulted in R1 having an acute respiratory change of condition with an oxygen saturation of 73% while wearing a non-rebreather mask. R1 was sent out to the local hospital after calling 911. R1 was admitted to the MICU with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 expired later that day with cardiogenic shock and septic shock documented as a cause of death II. Based on interview and record review the facility also failed to do blood sugar monitoring to residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice affects 3 of 4 residents (R5, R11, and R12) reviewed for blood sugar monitoring is a sample of 23. Findings Include: I. R1 admitted in the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility record reviewed and R1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Labs were as follow: BMP (Basic Metabolic Panel, test that provides information about the body's energy use, which is known as metabolism), BNP (Brain Natriuretic Peptide, test that measures levels of a protein called BNP that is heart made by heart and blood vessels. The test is an important tool for healthcare providers to diagnose heart failure quickly), EGFR (Estimated Glomerular Filtration Rate, test to measure level of kidney function), and CBC (Complete Blood Count, test used to evaluate overall health). Laboratory use by the facility provided documentation that they tried to reach the facility multiple times to report the blood test result and there were no answers. Laboratory documentation reads in part: Specimen collected at [DATE] at 21:53. Called facility multiple times, no response at 3:35am, 3:57am, 4:07am ([DATE]), result faxed to facility at 4:15am. Facility called at 10:55am ([DATE]), no answer. Progress Notes of R1's for [DATE] reviewed, R1's chart does not have any documentation that any nursing staff relayed result of this STAT blood test to R1's physician or nurse practitioner. STAT blood test (done on [DATE]) result are as follow: BNP: 56,516.0 (normal range 0.,d+[DATE].25 pg/ml) BMP: BUN 63 (normal range ,d+[DATE] mg/dL), and Creatinine 2.4 (normal range 0.,d+[DATE].4 mg/dL). EGFR: 27.8 (normal range 60.,d+[DATE].0 ml/min) CBC: Platelet count 109 (normal range ,d+[DATE] K/uL) R1's progress notes also shows another STAT blood draw and chest x-ray ordered on [DATE]. V13 was the nurse on duty on [DATE]. On [DATE] at 11:20am interviewed V13 (Nurse) and stated No one gave me of any endorsement regarding labs for R1. And I did not see anything in the communication, I always check beginning of my shift the communication. No one called me from the lab during my shift that day. I don't know anything about R1 labs result. If the lab had faxed it, then we will find the fax in the front computer by the south side nurse's station. If the out-going nurse communicated with me about pending lab result, I will follow up with the lab, but I did not receive any endorsement about R1's lab. As soon as we find out that there is an abnormal lab results, we supposed to call the physician right away. On [DATE] AT 11:10am, V12 (Nurse) stated With Lab result, if it is not critically high or critically low, we don't call the physician and we wait for the next day for the NP or the doctor to come and check their lab. We don't report if it is not critically high or low because of the time constraints. With the STAT lab result we call the physician no matter what the lab level result is. On [DATE] at 1:30pm, V9 (Nurse Practitioner) stated My expectation was for the nurses to inform me of lab result of any residents as soon as they see the result. I am expecting them to call me and relay the result for STAT order. Around the clock medication order is scheduled medication and must be given as ordered for frequency. If a chest x-ray suggested follow up with CT-Scan then I would give an order to do follow up with CT, and with R1 diagnosis, I would definitely suggest hospital evaluation, because the lungs are not getting good oxygenation. For BNP with high number of 56,000, the safest place for any resident is in the hospital. Resident would probably need to be on IV [MEDICATION(S)] or something. I would send resident immediately to the hospital with that level of BNP and R1's medical condition. R1's progress notes on [DATE] at 10:50am shows that R1 had a change in condition, saturating low 73%, placed on non-rebreather mask and on 12 liters of oxygen. R1 continued to have saturation of 73%. Nurse on duty was notified that R1 oxygen saturation dropped at 10:50am, and at 10:51am nurse seen the resident, resident continued to have low oxygen saturation and 911 was called at 10:59am. 911 arrived at 11:05am. R1 was transferred via 911 on [DATE] to a local hospital and expired in the hospital on [DATE]. Hospital record reviewed and reads in part: Chief of complaint, shortness of breath, visit diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1presenting from the nursing home for evaluation of [CONDITION(S)]. Respiratory: hypoxic on arrival, started on a non-rebreathing, difficult to obtain saturation. X-ray shows right sided pneumonia. R1 started to have thick secretions orally and was unable to tolerate. R1 was intubated. BNP elevated, will give gentle fluid bolus. R1 brought to MICU for suspected septic and likely cardiogenic shock. Hospital laboratory results reviewed and noted kidney function not in normal range: BUN 80 (normal range is ,d+[DATE] mg/dL) and Creatinine 3.2 (normal range 0.,d+[DATE].95 mg/dL). Death certificate record reviewed and reads in part: date of death [DATE]. Cause of death, Cardiogenic Shock, Septic Shock and Pneumonia. Facility policy for Physician Notification of Laboratory/Radiology/Diagnostic Results with an effective date of [DATE] reads in part: To assure physician ordered diagnostic test are performed and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. A nurse is responsible for monitoring the receipt of test result. Test result should be reported to the physician or other practitioner who ordered them. Guidelines for reporting: X-ray or other diagnostic tests reveal suspected findings which may requires immediate intervention including but not limited to pneumonia. Unless another parameter is ordered by physician BUN greater than 60. Licensed nurse is responsible for documenting the notification of result in the clinical record. Facility policy for Physician-Family Notification-Change in Condition with an effective date of [DATE] reads in part: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, effective manner. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. II. R5 R5 was admitted in the facility on [DATE] from a local hospital with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood sugar monitoring checked and R5 had only reading on [DATE] at 16:01, it reads as 240 mg/dL. R5 was admitted in the facility with diabetes oral medications, [MEDICATION(S)] 25mg daily (for diabetes) and [MEDICATION(S)] 1000mg twice a day (for diabetes). R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 R11 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's POS reviewed. R11 is with orders of insulin [MEDICATION(S)] solution inject 6 units subcutaneously before meal (for Diabetes), insulin [MEDICATION(S)] for sliding scale (Blood sugar parameter: ,d+[DATE] give 2 units, ,d+[DATE] give 4 units, ,d+[DATE] give 6 units, ,d+[DATE] give 8 units and ,d+[DATE] give 10 units) four times daily with meals and insulin [MEDICATION(S)] 30 units subcutaneously at bedtime (for Diabetes). R11's POS reviewed and shows blood glucose level monitoring is attached to the order of the insulin sliding scale four times daily with meals. The blood glucose monitoring is not being done before meals and R11 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 R12 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 admitted in the facility on [DATE]. R12's POS reviewed and shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no order for blood sugar monitoring. R12 only has two blood glucose reading since admission and those are on [DATE] at 6:52am (214 mg/dL) and on [DATE] at 12:03 pm (241 mg/dL). On [DATE] at 11:30am, V14 (Nurse) stated Blood sugar monitoring we do to monitor resident who are diabetic for [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (high blood sugar). It is not safe to give insulin if the blood sugar is not check. Always check the blood sugar before administering insulin. If there is no blood sugar monitoring and the resident is with insulin, we need to call the doctor and get a blood glucose monitoring order. On [DATE] at 1:30pm, V9 (Nurse Practitioner) stated We take a blood sugar level as the resident admitted in the facility. Depending on the medication, if insulin as sliding scale order, we should check blood sugar at least 4 times a day and to call provider if the result is greater than 400 and [CONDITION(S)] reading. With oral medication, we should check blood sugar level at least twice a day because if residents' blood sugar level is over controlled the blood sugar can go low. Blood sugar check is done to monitor if the residents' blood sugar level is responding to treatment. Short acting and long-acting insulin must be monitored for blood sugar level because what if the sugar is low, then the short acting insulin must not be given. On [DATE] at 11:00am, V2 (Director of Nursing) stated . If the insulin order is scheduled 2x per day, we will check the blood sugar twice a day. If they are on oral drugs, we do blood sugar check every morning before breakfast. Even with oral meds we would like to have a baseline blood sugar. We document the blood glucose check in the MAR. Blood sugar check frequency depends on the doctors order, the facility practice at a minimum of daily check if resident is on oral medication. V2 reported that the facility does not have any policy for blood glucose monitoring.

Based on interview and record review this facility failed to develop fall/safety prevention interventions to ensure the bed remained in the low position while occupied for 2 of 3 residents (R1 and R2) reviewed for fall prevention interventions. This failure resulted in R1 falling from the bed while in the highest position and being transported to the local hospital and treated for an opened, bleeding dehiscence wound to left above the knee amputation. Findings Include: R1 was admitted with the diagnosis of Dementia and Complete Left Traumatic Amputation at the Knee. R1's fall assessment dated [DATE] documents: fall risk due to intermittent confusion, chair bound medication use and diagnosis. On 4/20/2021 at 10:05am, V4 (nurse) said, R1 was a high fall risk due to R1's amputation. I'm not sure what fall intervention that was in place. R1 was sitting on the side of the bed. R1 did not want to lie down in bed. R1 was anxious about going home. R1 slid off the bed. R1 hit the floor with her stump. R1's stump opened up. I couldn't stop R1's stump from bleeding. I discharged R1 to the hospital. On 4/20/2021 at 10:56am, V5 (Nurse) said, R1 was alert with periods of confusion. R1 was high fall risk. R1 was non-complaint with everything. R1 tried to make unassisted transfer. I heard R1 fall. R1 was observed with an open the stump with some bleeding after the fall. On 4/20/2021 at 12:47pm, V8 (cna) said, R1 like to raise her bed up to the highest position. R1 kept raising the bed to the highest position the night she fell . When I entered, R1's room after the fall. R1's bed was highest position. On 4/20/21 at 1:20pm, V1 (DON) said, R1 would attempted to put her legs out the bed. R1 could raise the height of the bed. R1 had periods of confusion. R1 like to sit side of the bed. R1's care plan dated 3/9/21: R1 is at risk for falls due to impaired thought process and below knee amputation. Intervention: Call light in reach and bed height where feet touch the floor. R1 fall incident dated 3/21/21 documents: R1 had an unwitnessed fall from the bed. R1 was observed on the floor sitting upright. R1 had new injuries to left stump, staple loosen but in place, moderate amount of bleeding from stump, wrapped with towel to stop the bleeding. 911 called. R1 was transferred out to hospital. Predisposing Physiological/situation Factors: R1 had gait imbalance, left below the knee amputation and R1 was sitting. Emergency department diagnosis dated 3/21/2021 documents: R1 had a fall from bed with some bleeding: Diagnosis: Wound Dehiscence (wound separation were the edges no longer meet). R2's brief interview for mental status dated 3/18/21 documents a score of six with indicated servere cognitive impairment. R2's fall assessment date 2/8/21 documents: fall risk due to intermittent confusion, chair bound, medication use and diagnosis. On 4/16/2021 at 12:36pm, Surveyor observed, R2 in bed. R2's bed was in the highest position. R2 did not have a fall mat on the floor while in bed. On 4/16/2021 at 12:52pm, Surveyor observed, V2 (Director of Nursing/DON), lowering R2's bed. V2 said, we told R2 we have to keep the bed in the lowest position. On 4/16/2021 at 1:08pm, V2 (Director of Nursing) said, R2 is at high risk for fall with a history of falls. Intervention are put in place to prevent future falls. R2 bed was not in the lowest position nor was the fall mat in place. R2 is on the falling leaf program. The falling leaf program is for residents with a history of falls, had one fall in the facility and education was not appropriate. R2 should have had a fall mats in place and the bed should have been in the lowest position. R2 has a care card that will inform the staff of what intervention we put in place after a fall. R1 was a fall risk. R1's intervention was to keep the bed in the lowest position and call light within reach. R1's staple came loose on the amputation site/stump. R1 was discharge to the hospital due to the amputation site bleeding. On 4/16/2021 at 3:14pm, V9 (Administrator) said, R2's bed was up. V2 (Director of Nursing) corrected the problem. It is not a chronic issue. Staff use residents care cards for fall interventions. R2's fall incident dated 2/8/21 documents: R2 had an unwitnessed fall on 2/8/21. R2 was noted in side lying position beside bed. Predisposing Physiological Factors: Impaired memory, decline in cognitive skills and incontinent. Interventions: bed in the lowest position and fall mat while in bed. R2's care plan dated 2/8/21 documents: R2 is a risk for falls. R2's bed to be in the lowest position and floor mats in place when resident is in bed. R2's care card documents: R2 bed in the lowest position, floor mat when in bed. Fall Prevention Program dated 11/28/21: The program will include measures which determine the individual needs of each resident by assessing the risk of fall and implementation of appropriate interventions. Safety will be implemented for each resident identified at risk.

Based on interview and record review the facility failed to follow their Abuse Prevention Policy and failed to keep a resident safe from sexual abuse by a staff member for 1 of 3 residents (R5) reviewed for abuse in a total sample of 14. This failure resulted in R5 being assaulted during care causing the resident to receive counseling services to cope and treat recurring nightmares related to the sexual assault. Findings Include: The Incident Report dated 11/18/20 documents that R5 had informed staff of being sexually assaulted by V7 (CNA) during a bath. A full investigation was completed and IDPH and the Police were notified immediately. V7 admitted to assaulting the resident and was arrested at the facility. The Nurse's Notes dated 11/18/20 documents that a full body assessment was done on R5 and there were no injuries and no signs of trauma noted to the resident. The Social Service Notes dated 11/23 and 11/24/20 documents that R5 is receiving counseling services from a therapist. R5 has been given art supplies, a journal, and is being treated with music therapy. R5 has complaints of nightmares and also has 1:1 sessions to develop coping mechanisms. On 1/13/21 at 11:10am V1 (Administrator) stated The allegation of sexual assault was substantiated. V7 (CNA) was sticking fingers inside of R5 during a bath. This was done without the resident's consent and may have occurred a couple of times but R5 was unsure of the time frames. We investigated everything, we called the Police and V7 was arrested. We gave testimony to the Attorney General as well. V7 came in and admitted to assaulting R5. V7 was seen on the cameras taking R5 for a shower and was noted to be in the room for an hour. Our interviews of other staff revealed that showers with R5 usually takes about 30 minutes. All staff and all residents in the building were interviewed and there were no other concerns with abuse noted. IDPH was notified. On 1/13/21 at 1:05pm V6 (Social Service Director) stated R5 is receiving in house therapy and is being seen twice per month. R5 was also given art supplies for art therapy and journaling. R5 has 1:1 sessions with a staff member that is certified in sexual assault. R5 had some nightmares after the assault and was introduced to music and medications were prescribed to help manage the nightmares and trauma. The nightmares have decreased. R5 could not remember how many times the assault had taken place but did say it happened a few times. A definitive number was not given. R5 did wait a few days before telling me about the incident and reported feelings of being scared. I reassured the resident of the safety measures in place. On 1/13/21 at 1:10pm V2 (DON) stated I completed the body assessment. R5 had no signs of external trauma. We did complete sexual abuse in-servicing with all of the staff and talked about reporting behaviors immediately. V7 was arrested and charged. A criminal background check was done prior to V7 being hired and it came back clean. On 1/13/21 at 2:30pm R5 was observed sitting in the chair. R5 stated V7 was supposed to be putting me back in bed and V7 touched me inappropriately in my private area by putting fingers inside of me. This happened more than once. I did tell staff at one point and they handled it. I had to talk to the Police and that staff member was fired. I still have nightmares about what happened to me. I have to see a therapist to help with that. The Abuse Prevention Policy documents that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. Sexual abuse is the non-consensual sexual contact of any type with a resident. It includes unwanted intimate touching, all types of sexual assault of battery. Any forced, coerced or extorted sexual activity with a resident is considered to be sexual abuse. s

Based on interview and record review, the facility failed to treat an open lesion on a resident's sacral region for four days for one (R1) of three residents reviewed for wound care in a total sample of seven residents. This failure of resulted in the delay of treating for four days of an open lesion progressing to a stage III pressure ulcer Findings Include: R1 is a [AGE] year old with the following Diagnosis: [REDACTED]. R1 admitted to the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE] Section H documents R1 is frequently incontinent of urine and always incontinent of stool. Section M of the MDS dated [DATE] documents R1 is at risk for pressure ulcers with no interventions to prevent pressure ulcers in place. The Skilled Evaluation on 3/5/20 documents R1 has an open lesion to the sacral area. No documentation of any other staff notified about the new wound. The Skilled Evaluation on 3/6/20 documents R1 has a skin tear to the sacral area. No documentation of any other staff notified about the wound. The Skilled Evaluation on 3/9/20 documents no wounds noted on R1. The Wound Assessment Report dated 3/9/20 documents R1 has a sacral wound identified on 3/9/20 that is a stage 3 with measurements of 5 cm x 7.5 cm x 0.1 cm. A Nurse Note dated 3/10/20 documents R1 with an open area to the sacral region. The area was cleaned and dressed. On 7/23/20 at 11:58AM, V6 (LPN) stated, I don't remember R1 having any wounds. We do weekly skin assessments on the residents. I would let the DON and wound care know if I found one. On 7/23/20 at 1:35PM, V7 (Wound Care Coordinator) stated, R1 developed a pressure ulcer on the sacrum that was noted on the 9th. The wound was assessed to be a stage 3 pressure ulcer and the resident was placed on a low air loss mattress that same day. On 7/23/20 at 2:00PM, V7 stated, I saw her on 3/9. When I am notified about a wound, I normally see them that day unless they find it over the weekend then I see them first on Monday. I see a resident for just about every type of wound when I am notified. I know R1 had a skin tear or something on R1's thigh then they found that wound on R1's sacrum and I treated it the day I was told about it. Yes, R1 is high risk for pressure ulcers. We are notified through a risk management form the nurse fills out. I never had a notification any sooner than March 9th for R1's wound. If it was there sooner and they were documenting on it then I wasn't notified about it. The policy titled, Skin Condition Assessment & Monitoring- Pressure and Non-Pressure, dated 6/8/18 documents, Caregivers are responsible for promptly notifying the charge nurse of skin breakdown. At the earliest skin of a pressure injury or other skin problem, the resident, legal representative, and attending physician will the notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.

Based on observations, interviews, and record reviews, this facility failed to develop and implement appropriate measures to minimize the risk of falls for one resident (R3) out of 4 reviewed for risk for falls in a sample of 5. This failure resulted in R3 sustaining an upper arm fracture requiring hospitalization . Findings include: On 4/3/19 at 1:00pm, R3 is observed left side lying at the edge of the bed. There are bed bolsters on each side of R3's bed and a floor mat on the left side of bed. On 4/5 at 10:30am, R3 is observed left side lying at the edge of the bed. Throughout this survey, this surveyor did not observe R3 move any extremity. This surveyor did not observe any side rails on R3's bed. On 4/4/19 at 1:30pm, V7 LPN (licensed practical nurse) stated that after a fall, residents are assessed head to toe for any injuries. V7 stated that if the fall was unwitnessed, then neurological checks are initiated. On 4/5/19 at 10:30am, R3 stated that R3 does not know how R3 hurt left arm. On 4/5/19 at 11:00am, V6 CNA (certified nurse aide) stated that R3 does not move. V6 stated that residents that can move in bed have bed bolsters and floor mats. V6 stated that residents should be positioned in the middle of the bed to prevent a fall. On 4/9/19 at 10:30am, V3 ADON (assistant director of nursing) stated that R3 is not able to reposition self in bed. V3 stated that after R3's fall, floor mats were put in place. V3 stated that R3 tends to favor lying on left side. V3 stated that residents should be positioned in the center of the bed to prevent a fall occurring. On 4/9/19 at 3:20pm, V11 (attending physician) stated that R3 was not able to move extremities. V11 stated that in V11's opinion it is highly unlikely that R3 moved and fell out of bed. Review of the medical record notes R3 with [DIAGNOSES REDACTED]. On 3/16/19, R3 was readmitted with head injury and displaced fracture of left upper arm. Review of R3's BIMS (brief interview of mental status), dated 3/5/19, notes R3's score is 3 out of 15. Review of R3's fall risk assessment, dated 2/28/19, notes R3 is not at risk for falls. Review of R3's fall occurrence, dated 3/5/19, notes R3 was observed lying on the left side of bed on R3's left side. Facility investigation determined R3 rolled out of bed which resulted in a fall related injury. Review of R3's hospital medical record, dated 3/16/19, notes R3 was admitted to the hospital with [REDACTED]. Review of R3's falls care plan notes R3 is at risk for falls related to impaired mobility, weakness, dementia, stroke with right sided paralysis, and left hand contracture. Interventions identified include: encourage and educate R3 to use call light pad by using chin/cheek to press, frequent round check, and check/change for incontinence. After fall on 3/5/19, R3's care plan was updated to include hourly monitoring for placement in bed. Review of R3's bed mobility care plan, dated 2/22/18, notes R3 requires assistance with bed mobility due to immobility. Interventions identified include: bilateral half side rails, provide encouragement, and provide assistance as tolerated.

Based on observation, interview and record review facility failed to follow their resident care standards for one resident (R3) out of three residents by failing to monitor R3 vital signs resulting in R3 not getting better management of her vital signs. Findings Include: Facility's resident care standards denotes following standards are to be practiced by all nursing employees in the performance of direct and indirect care procedures for or with the resident, whether using equipment for technical procedures or when assisting residents to carry out self-care activities. These standards will not be repeated again in the individual procedures unless significance warrants repetition. Nursing care is planned and provided to: Timely medications and treatments. Timely initiate appropriate nursing interventions. Provide care to prevent complications of immobility, such as pressure ulcers and decline in activities of daily living. R3's care plan initiated [DATE] denotes with activity intolerance secondary to cardiac arrhythmia. Interventions medications as ordered and monitor for changes in ability to tolerate activities, increase in symptoms of arrhythmia, shortness of breath, dizziness, etc. and report to doctor. R3's physician progress notes [REDACTED]. Labs BUN 71, creatinine 1.3 and potassium 5. Assessment: Dehydration; plan start 0.9 normal saline one liter Monitor for bleeding, daily weights, discussed with nursing. R3's nurse note dated [DATE] written at 3:00pm denotes IV 0.9 running as ordered. Blood pressure ,[DATE], R20, pulse 96, remains alert and oriented no signs of distress. V7 (Assistant Director of Nursing) stated on [DATE] at 1:00 pm the nurse practitioner (NP) had just left but before she left gave an order for [REDACTED]. V7 stated during rounds the nurses should had at least once during their shift, taken R3 vital signs. R3's nurse note dated [DATE] written at 4:52 pm denotes blood pressure ,[DATE] Nurse practitioner notified. IV push [MEDICATION NAME] order discontinued and potassium on hold for two days. R3 to continue IV fluids. R3's medication sheet denotes potassium 20 meq held on [DATE]. R3's medication sheet denotes [MEDICATION NAME] 40 milligrams discontinued. Surveyor noted from facility camera video V5 arrived on the unit at 10:45 pm on [DATE] for the night shift did rounds and entered R3's room with no blood pressure cuff or stethoscope in her hand only a piece of paper at 10:51:33 pm and exit R3's room at 10:52:47 pm on [DATE]. Surveyor noted from facility camera video V5 doing rounds and enter R3's room with no blood pressure cuff or Stethoscope in her hand only a piece of paper at 12:18:15 am and exit at 12:18:44 am on [DATE]. Surveyor noted from facility camera video V5 doing rounds and enter R3's room empty handed with no blood pressure cuff or stethoscope on [DATE] at 2:47:11 am exit at 2:47:50 am run to medicine cart and retrieve blood pressure cuff stethoscope and call for help. Surveyor noted from facility camera video staff on [DATE] at 2:48:50 three nurses running with crash cart and oxygen to R3's room and another nurse on the phone. Surveyor noted from facility camera video on [DATE] paramedics coming on the unit at 3:03 am and going to R3's room. V6 (Certified Nurse Aide) stated on [DATE] at 2:30 pm started her shift on [DATE] at 10:30pm on [DATE]. V6 stated when V5 entered R3's room V6 was already cleaning R3 up because R3 had a bowel movement. V6 stated the only time V6 saw V5 go in R3's room was at that time. V6 stated while V6 was cleaning and changing R3, did not see V5 take R3's vitals/blood pressure. R3's nurse note dated [DATE] upon making rounds at 10:40 pm received R3 responsive with certified nurse aide providing care to R3, blood pressure ,[DATE], pulse 128. R3's nurse note dated [DATE] written at 4:43 am denotes at 12:55 am certified nurse aide went to R3's room to provide care because R3 had moved R3s bowels, vital signs taken blood pressure ,[DATE], pulse 124 Oxygen and breathing treatment at this time. R3's nurse note dated [DATE] written at 4:56 am denotes blood pressure ,[DATE] pulse 179, called for help other staff at bedside CPR was started while 911 called. R3's nurse note dated [DATE] written at 5:16 am denotes 911 arrived, tried to revive R3 to no avail, R3 confirmed expired. V1 (Director of Nursing) stated on [DATE] at 1:30 pm R3 at one point had low blood pressure (BP) and an order was given to start intravenous fluids and to monitor R3. V1 stated the pm shift documented during their shift that R3 blood pressure was stable. V1 stated the night shift came in and V5 did rounds and documented that R3s BP was low ,[DATE] and continued to monitor. V1 stated that V5 also documented later that R3s blood pressure was ,[DATE]. V1 stated they questioned V5s documentation after they reviewed the chart and V5 told them that the only time she manually checked R3's blood pressure was at the beginning of V5s shift. V1 stated V5 told them she got scared and panicked because that was the first time dealing with a CODE and falsified that she retook R3's blood pressure after it was only taken once. V1 stated suspended V5 and during the investigation V5 resigned and told them V5 was not coming back to work. V1 stated completed their investigation and concluded that V5 had falsified documentation based on the video and her statement. V1 stated that V5 should have taken R3's vital signs during her shift and since V5 falsified R3s records can't say she did that. V5s' signed statement denotes V5 arrived at work and began making rounds on residents assigned to her. Initial round on R3 was at 10:50 pm R3 was alert, responsive 0.9 IV infusing vital signs BP ,[DATE] and pulse 128. Doctor was not notified because previous shift had just initiated IV fluids for [MEDICAL CONDITION]. Documentation recorded in nurse notes at 12:55am was inaccurate. V5's employee report dated [DATE] denotes suspension pending investigation regarding Code Blue event on [DATE]. V8 (Doctor) stated on [DATE] at 3:30 pm V5 falsified records and can't tell if she really knew that she should have taken R3's vitals before she expired. V8 stated V5 should have been monitoring and acting according to the facility's protocol for taking R3's vitals since there was no specific order to take them and that she should have used her nursing judgement and taken R3's vitals at least once during her shift before R3 expired. V8 stated management problem cannot be proved as neglect because the nurse judgement at that time was lack of knowledge that V5 should have been monitoring R3's blood pressure, R3 was getting the intravenous fluids for abnormal labs. V8 stated if resident has low blood pressure it could cause [MEDICAL CONDITION]. V8 stated there are no written rules for monitoring and taking blood pressure but it is a clinical judgement of the nurse. V8 stated V5 should have called them when R3s BP was ,[DATE] and pulse 128 so it could have been managed at the hospital. V8 stated it is common sense of a good nurse to call the doctor. V8 stated if the nurse knew or believe the blood pressure was not okay and still did not make the phone call would have been neglect. V8 stated because V5 falsified the records can't say what V5 knew and didn't know only what V5 should have done. V8 stated that V5 acted more incompetent than negligent and believes V5 falsified V5s notes to cover up her mistakes. V8 stated if V5 knew or believe the blood pressure was not okay and still did not make the phone call would have been neglect. V8 stated can't say for sure that if the V5 had taken R3's vitals and called the ambulance that R3 would have not expired. V8 stated if V5 did take R3's vitals she should have called him and would have sent R3 to the hospital becuase they could have managed R3s situation better than the nursing home. V8 stated having low blood pressure can cause a resident with a history of chronic [MEDICAL CONDITION] to go into AFIB with is a harmful situation for the resident. R3's death certificate denotes dated of death [DATE] causes chronic [MEDICAL CONDITION] and Dementia.

Based on observation, interview and record review the facility failed to assess fall risk and implement fall interventions for 3 of 5 residents (R1, R8, R12) reviewed for falls in the sample of 12. This failure resulted in R1 falling out of bed and sustaining a right shoulder fracture requiring hospitalization . Findings include: 1). On 3/5/13 at 2:20pm, E11(Nurse Aide) stated that on 2/14/13 day shift, she was assigned to weigh patients. "I was going into (R1)'s room to weigh the roommate and saw (R1) on the floor. I didn't hear any alarms sounding and there weren't mats on the floor on either side of the bed." E11 stated "I told both the day and night nurse right away that morning that (R1) fell out of bed. When I returned to work I learned that (R1) went to the hospital because she broke her arm. That's when I told (E2)(Director of Nursing)." E11 stated that E12(Nurse Aide) came into the room, lifted R1 up under the arms and placed R1 back into bed before a nurse came to assess her. On 3/6/13 at 2:30pm, Z1 (Physician) stated "I didn't know about (R1)'s second fall." Z1 stated the staff called him on 2/14/13 because R1 was complaining of right arm pain. "(R1) had a fall the day before on 2/13/13, they never mentioned that (R1) fell on [DATE]. I understood the right arm pain was from the fall the day before." Z1 stated the bed alarm would have alerted the staff to check on R1 before she fell , and the floor mats could have cushioned her fall. "Because these interventions were not in place, that contributed to the fall and fracture. She would not have fallen if she was monitored. If she didn't fall, she would not have broken the arm." On 3/19/13 at 9:25am E14(Kitchen Staff) stated she witnessed R1's fall in the dining room on 2/13/13. "(R1) kept getting up from the wheelchair during lunch, the aide kept putting her back in the wheelchair. No one was directly around (R1) when she got up, started walking and fell . I called for help right away, we waited for the nurse to come, the nurse has to check the resident before moving them." E14 stated R1 did not have an alarm clipped to her clothing. "Some of the residents have the alarm that is attached to them, their clothing. (R1) did not have one on. There was no alarm sounding when she got up." Nurse Note 2/21/13 by E2(Director of Nursing) documents that he was made aware by E11 on 2/21/13 that R1 had fallen out of bed on 2/14/13 about 7:30am. Incident Report 2/22/13 documents that on 2/14/13 R1 was "noted laying on the floor next to bed at approximately 7:15am." Incident Investigation 2/21/13 of R1's fall on 2/14/13 documents E12 picked up R1 and put her back into bed. E13 (Nurse) came into the room to do an assessment, so E12 left the room. Nurse Note 2/14/13 9:22am documents R1's right arm was "bruised with a lot of pain, resident was screaming and hollering due to the increase of pain with movement." A call was made for a stat xray to right arm and shoulder areas. R1 was laid back in bed and given pain medication. Nurse Note 2/14/13 4:31pm documents R1 sustained a "right head humerus fracture." R1 was medicated for pain and an ambulance was called to transport R1 to the hospital. On 2/23/13 at 9:50am, E3(Assistant Director of Nursing) stated a Fall Risk Assessment is completed on admission, quarterly, and after each fall. E3 stated the primary nurse must complete the fall investigation after a resident falls, updates the care plan with new interventions to prevent further falls, and notifies the physician and family of the fall. The resident is not to be moved after the fall until assessed by the nurse. E3 stated it is not known why a fall risk assessment was not done, why the fall care plan was not updated after the fall on 2/14/13, or why the interventions were not followed. Xray Report 2/14/13 documents "findings suspicious for nondisplaced subcapital humeral head fracture." Fall Care Plan was initiated on 1/30/13 and lists interventions as "W/C (wheelchair) alarm", which was not in place on 2/13/13 according to E14's interview, and "bed alarm" and "floor mat", which were not in place on 2/14/13 according to E11's interview. The Fall Care Plan is not updated after the fall on 2/14/13. The last Fall Risk Assessment is dated 1/30/13 and scores R1 as high risk for falls. An intervention is for R1 to be on the Falls Prevention Program. A Fall Risk Assessment is not completed after the 2 falls on 2/13/13 and 2/14/13. The Fall Prevention Program includes the following components: notification of physician, family/legal representative; care plan incorporates addressing each fall, interventions are changed with every fall, as appropriate; preventative measures; Fall Risk Assessment will be performed after any fall incident; safety interventions will be implemented for each resident identified at risk. 2). On 2/23/13 at 10:45am, R12 was in bed, mats were not on the floor on either side of the bed. R12's Fall Care Plan includes an updated intervention on 2/8/13 for "floor mats in place to prevent injury for falls." Fall Incident Report 2/7/13 documents R12 slid out of bed and was found on the floor. The last Fall Risk Assessment completed on 12/26/12 scores R12 as a high risk for falls. There is no Fall Risk Assessment completed after the fall on 2/7/13. 3). Fall Incident Reports document the following: 12/1/12 R8 was observed on the floor, 12/13/12 R8 found on mat on right side of bed, and 12/22/12 R8 was found lying on stomach on the floor at the side of bed with safety mat covering him. On 3/5/13 at 11am and 2:45pm, R8 was in bed, mats were not on the floor and an alarm was not on the bed. Fall Care Plan for R8 documents interventions on 2/17/13 are "floor mat" "bed alarm" because R8 "does intentionally try to crawl out of bed onto mats."

Based on record review, staff/physician interviews, the facility neglected to provide care and services for 1 residents (R6) on anticoagulant therapy ensuring: 1) R6's physician was made aware of significant and abnormal lab value used for monitoring [MEDICATION NAME] levels [MEDICATION NAME] time and International Normalized Ratio (PT/INR) in a prompt time frame 2)continuous monitoring of resident (R6's) medical condition with abnormal PT/INR values for adverse effects of [MEDICATION NAME] 3)R6's physician/alternate or medical director was notified immediately of R6's onset of dark brown stools which required immediate medical intervention These failures resulted in R6 having a massive [MEDICAL CONDITION] (GI Bleed), causing cardiopulmonary arrest, brain death and subsequently taken off life support 3 days after transfer to hospital. These failures had the potential to effect all 18 residents in the facility identified on anticoagulant ([MEDICATION NAME]) therapy. An Immediate Jeopardy was identified on [DATE] and facility DON (E1) was notified. The Immediate Jeopardy was determined to have begun on [DATE] when facility received abnormal PT/INR results for R6 and did not call or follow-up on results faxed to the physician for verification of medical interventions needed to provide R6 with appropriate and timely care. The Immediate Jeopardy was removed on [DATE] but facility remains out of compliance at a severity level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. Findings include: R6 was readmitted to facility on [DATE] after hospitalization for 11 days due to infection of sacral wound. R6 has a history of Coronary Bypass Surgery, Diabetes Mellitus and Gastrointestinal Hemorrhage. R6 was alert and orientated but required assistance from staff for activities of daily living. R6's Computerized Physician order [REDACTED]. [DATE] [DATE] [DATE] [DATE] [DATE] Physician order [REDACTED]. Results were faxed to E3 (LPN) at 2:25 PM. PT results were 41.7 H (Reference range 11XXX,[DATE].6) and INR results were 3.4 H (Reference Range 0XXX,[DATE].0). Documentation on the lab report denotes the results were faxed to R6 physician on [DATE] by E3 1 day after receiving results. There is no further documentation on nurse notes or labs that any follow-up was made to R6's physician for further orders for [MEDICATION NAME]. E3 stated in phone interview on [DATE] that she had called the R6 physician's office with the PT/INR results and was told to fax the results. E3 stated she doesn't recall if she reported abnormal levels to oncoming shift. R6 continued to receive the 3 mg of [MEDICATION NAME] for the next 3 days. R6 was also on Aspirin 325 mg. The Geriatric Dosage Handbook including Clinical Recommendations and Monitoring Guidelines identifies [MEDICATION NAME]([MEDICATION NAME]) as a high alert medication denoting The Institute for Safe Medications Practices inlcudes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.Under Warnings/Precautions "concomitant use of aspirin increases [MEDICATION NAME] anticoagulant effect and may cause severe GI irritation." R6's care plan regarding use of anticoagulant therapy for recommends to avoid aspirin and aspirin containing medications. Observed for signs of active bleeding (nosebleeds, bleeding gum, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stolls, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis). Nurse notes from [DATE] through [DATE] have no documentation of R6 being monitored for any abnormal bleeding. Documentation on [DATE] at 6:32 am by E6 (LPN) denotes "R6 observed with dark brown stool, history of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] ulcers, vitals within normal range. Z1 (physician ) answering service called, awaiting for call back. Endorse to oncoming nurse to follow-up. ADL's performed by staff, resident kept clean. Blood glucose within normal limit." E6 stated in phone interview on [DATE] at 3:00 PM, staff were cleaning up R6, noticed dark brown stools, did not notice any direct bleeding. R6 was alert and not complaining of pain. I had concerns R6 had a history of [REDACTED]. Called Z1's answering service and told oncoming nurse of observations. Documentation on [DATE] at 9:14 AM by E5 denotes"Staff CNA called writer to R6 room due to R6 not responding. Upon entering room, writer noted resident to be unresponsive, diaphoretic, appeared to have mucous substance coming from mouth mucous substance removed. R6 blood sugar was 285, respirations 28, Saturation Pulse Oximeter (SPO) 86 with O2 on at 3 liters, Oxygen increased to 90, pulse 50, blood pressure ,[DATE], 911 called, report given to ER. Further documentation on [DATE] at 1:22 PM denotes "hospital ER called, informed R6 admission to hospital with [DIAGNOSES REDACTED]. E5 (LPN) stated in interview on [DATE], she had not been informed by E6 (night nurse) of R6's dark brown stools or a call was out for Z1. E5 stated she was passing meds down hallway when E8 (CNA) come to get her because R6 was not responding. E5 stated she had not passed meds yet to R6 so had not seen him. E5 stated she went into room and saw R5 unresponsive and diaphoretic, did sternal rub, responded with movement. E5 stated R6 was usually alert and orientated. E5 stated she checked vitals and called 911. E6 stated I thought it was R6's blood sugar or R6 had a [MEDICAL CONDITION]. E6 stated she had not noticed any bleeding, did not check diaper. E6 stated paramedics were there within few minutes. Facility 24 hour report dated [DATE] documents "R6 observed with brown stool. History of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] ulcer. Z1 paged, awaiting call back." There was no further documentation of monitoring R6 vitals or dark brown stools until R6 went out by 911 or if Z1 had responded to call on [DATE]. Review of Emergency Medical Service (EMS) Sheet denotes 911 was notified and arrived at scene at 8:42 AM. EMS notes denote upon arrival at 8:42 AM, R6 was in bed unresponsive, agonal breathing. R6 went into witnessed full arrest while attempting to obtain vitals. R6 was in asystole entire time treating R6. CPR was performed throughout patient contact. Emergency Record review denotes R6 arrived in ER at 9:00 AM in [MEDICAL CONDITION]. R6 was resuscitated and place on ventilator. R6 received 4 units of packed cells and 4 units of fresh frozen plasma, given Vitamin K 10 mg. R6's lab results of [DATE] were: [MEDICATION NAME]- 127, INRO 12.3, PTT-92, hemoglobin 3.4. R6 was declared brain dead and removed from life support on [DATE]. Z4 (ER attending) for R6 on [DATE] stated in phone interview on [DATE]," I recall R6 coming in by paramedics and saying "he's so pale is this guy must be sitting in a pool of blood." Z4 stated R6 was wrapped in blankets and sheets and when we uncovered R6 he had a large amount of blood from the rectum. Z4 also stated R6 was dead in full arrest when he came in, was resuscitated with fluids, [MEDICAL CONDITION] and medications. Z4 stated R6's [MEDICAL CONDITION] was related to blood loss because of GI bleed. R6 premlinary autopsy [DIAGNOSES REDACTED]. b)dilated cecum and colon with old blood consistent with recent GI bleed. R6 death certificate listed R6 cause of death as [MEDICAL CONDITION] due to GI Bleed. Z1 stated in phone interview on [DATE] that he had not known the facility had faxed the results of R6's PT/INR result of [DATE]. Z1 stated that if he was aware of the abnormal PT/INR he would of stopped the [MEDICATION NAME] and ordered another PT/INR. Z1 stated on [DATE] that because R6 had continued to receive the [MEDICATION NAME], it contributed to R6's [MEDICAL CONDITION]. Facility policy for Physician Notification of Laboratory Results includes: The guidelines were developed to ensure that : 1. All significant laboratory results are relayed to the physician in an appropriate and prompt manner. 2. Medical problems are communicated to the physician in a timely manner. Nurse responsibilities: 1. Notify the appropriate physician of all critical and alert laboratory results. This should be done via the telephone. 2. Provide the physician with relevant information regarding diagnoses, resident condition, and current medications and dosages. 3. Provide the physician with information regarding recent results. 4. Results which are neither critical nor alert in status should be faxed to the physician (or called at the physician 's request). 5. All physician contacts regarding laboratory results should be documented in the resident's record. 6. If the attending physician does not respond to critical and / or alert notifications the medical director should be contacted by telephone for direction. Facility GUIDELINES for PHYSICIAN NOTIFICATION FOR CHANGE IN CONDITION OVERVIEW INCLUDES: These guidelines were developed to ensure that: 1. All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and are to be documented in the medical record. 2. Medical care problems are communicated to the attending physician in a timely, concise, and thorough manner. NURSE RESPONSIBILITIES The nurse should not hesitate to contact the attending physician at any time for a problem which is his or her judgement requires immediate medical intervention. Should the physician not be available, the alternate physician should be contacted . If neither of these physicians are available, the Medical Director should be notified. The facility took the following actions to remove the Immediate Jeopardy. The facility will continue to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well being. -The nurses have been re-educated on Reporting Abnormal Labs to Physicians on [DATE] and 20. -The nurses have been re-educated on Reporting PT/INR Results Physicians on [DATE] and 20. -The orders and labs of all residents receiving [MEDICATION NAME] have been reviewed by the DON and ADON on [DATE]th. -Tracking logs for all [MEDICATION NAME] orders have been initiated by Nursing Management on [DATE]th and will continue on a permanent basis. -The LPN who failed to report the PT/INR has been disciplined. -The LPN who failed to report immediately assess the resident when coming on duty has been disciplined. -Nursing staff was educated on Neglect on [DATE]th (see attached) To ensure this practice is maintained: -All labs will be be delivered to the nursing office where they will be reviewed by DON/ADON before being distributed to the Nurse. On days when the ADON/DON are not present, the nursing supervisor on that day will review the lab results. -DON/ADON will follow-up and ensure Physician notification via phone on all abnormal labs especially PT/INR results. This began on [DATE]th and will be ongoing. -DON/ADON will maintain the [MEDICATION NAME] Tracking Forms. This began on [DATE]th and will be ongoing. -DON/ADON will educated all future nurses on this practice during the orientation period. The began with th orientation of a new nurse on April 20th and will continue as a part of the orientation for all new nurse. - A monthly report will be provide to the Quality Assurance Committee detailing: the number of residents on [MEDICATION NAME]: adherence to recommended follow-up; physician response to abnormal lab results; the number of instances and names of physician involved when contacting the medical director was required. This process will begin with the MAY QA meeting and continue for a minimum of six months or until substantial compliance is achieved. The reports will be present at the monthly QA meeting.

Based on record review, staff/physician interviews, the facility failed to provide care and services for 2 of 6 sampled residents (R4, R6) on anticoagulant therapy ensuring: 1) R6's physician was made aware of significant and abnormal lab value used for monitoring [MEDICATION NAME] levels [MEDICATION NAME] time and International Normalized Ratio (PT/INR) in a prompt time frame 2)continuous monitoring of resident (R6's) medical condition with abnormal PT/INR values for adverse effects of [MEDICATION NAME] 3)R6's physician/alternate or medical director was notified immediately of R6's onset of dark brown stools which required immediate medical intervention 4)a program in was place identifying and tracking residents identified on [MEDICATION NAME] therapy for PT/INR results for 1 of 18 residents (R4) and 1 closed record These failures resulted in R6 having a massive [MEDICAL CONDITION] (GI Bleed), causing cardiopulmonary arrest, brain death and subsequently taken off life support 3 days after transfer to hospital. These failures had the potential to effect all 18 residents in the facility identified on anticoagulant ([MEDICATION NAME]) therapy. An Immediate Jeopardy was identified on [DATE] and facility DON (E1) was notified. The Immediate Jeopardy was determined to have begun on [DATE] when facility received abnormal PT/INR results for R6 and did not call or follow-up on results faxed to the physician for verification of medical interventions needed to provide R6 with appropriate and timely care. The Immediate Jeopardy was removed on [DATE] but facility remains out of compliance at a severity level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. Findings include: R6 was readmitted to facility on [DATE] after hospitalization for 11 days due to infection of sacral wound. R6 has a history of Coronary Bypass Surgery, Diabetes Mellitus and Gastrointestinal Hemorrhage. R6 was alert and orientated but required assistance from staff for activities of daily living. R6's Computerized Physician order [REDACTED]. [DATE] [DATE] [DATE] [DATE] [DATE] Physician order [REDACTED]. Results were faxed to E3 (LPN) at 2:25 PM. PT results were 41.7 H (Reference range 11XXX,[DATE].6) and INR results were 3.4 H (Reference Range 0XXX,[DATE].0). Documentation on the lab report denotes the results were faxed to R6 physician on [DATE] by E3 1 day after receiving results. There is no further documentation on nurse notes or labs that any follow-up was made to R6's physician for further orders for [MEDICATION NAME]. E3 stated in phone interview on [DATE] that she had called the R6 physician's office with the PT/INR results and was told to fax the results. E3 stated she doesn't recall if reported abnormal levels to oncoming shift. R6 continued to receive the 3 mg of [MEDICATION NAME] for the next 3 days. R6 was also on Aspirin 325 mg.The Geriatric Dosage Handbook including Clinical Recommendations and Monitoring Guidelines identifies [MEDICATION NAME]([MEDICATION NAME]) as a high alert medication denoting The Institute for Safe Medications Practices inlcudes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.Under Warnings/Precautions "concomitant use of aspirin increases [MEDICATION NAME] anticoagulant effect and may cause severe GI irritation. R6's care plan regarding use of anticoagulant therapy for recommends to avoid aspirin and aspirin containing medications. Observed for signs of active bleeding (nosebleeds, bleeding gum, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stolls, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis). Nurse notes from [DATE] through [DATE] have no documentation of R6 being monitored for any abnormal bleeding. Documentation on [DATE] at 6:32 am by E6 (LPN) denotes "R6 observed with dark brown stool, history of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] ulcers, vitals within normal range. Z1 (physician ) answering service called, awaiting for call back. Endorse to oncoming nurse to follow-up. ADL's performed by staff, resident kept clean. Blood glucose within normal limit." E6 stated in phone interview on [DATE] at 3:00 PM, staff were cleaning up R6, noticed dark brown stools, did not notice any direct bleeding. R6 was alert and not complaining of pain. E6 stated "I had concerns R6 had a history of [REDACTED]." Called Z1's answering service and told oncoming nurse of observations. Documentation on [DATE] at 9:14 AM by E5 denotes 'Staff CNA called writer to R6 room due to R6 not responding. Upon entering room, writer noted resident to be unresponsive, diaphoretic, appeared to have mucous substance coming from mouth mucous substance removed. R6 blood sugar was 285, respirations 28, Saturation Pulse Oximeter (SPO) 86 with O2 on at 3 liters, Oxygen increased to 90, pulse 50, blood pressure ,[DATE], 911 called, report given to ER.' Further documentation on [DATE] at 1:22 PM denotes "hospital ER called, informed R6 admission to hospital with [DIAGNOSES REDACTED]. E5 (LPN) stated in interview on [DATE], she had not been informed by E6 (night nurse) of R6's dark brown stools or a call was out for Z1. E5 stated she was passing meds down hallway when E8 (CNA) come to get her because R6 was not responding. E5 stated she had not passed meds yet to R6 so had not seen him. E5 stated she went into room and saw R5 unresponsive and diaphoretic, did sternal rub, responded with movement. E5 stated R6 was usually alert and orientated. E5 stated she checked vitals and called 911. E6 stated I thought it was R6's blood sugar or R6 had a [MEDICAL CONDITION]. E6 stated she had not noticed any bleeding, did not check diaper. E6 stated paramedics were there within few minutes. Facility 24 hour report dated [DATE] documents "R6 observed with brown stool. History of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] ulcer. Z1 paged, awaiting call back." There was no further documentation of monitoring R6 vitals or dark brown stools until R6 went out by 911 or if Z1 had responded to call on [DATE]. Review of Emergency Medical Service (EMS) Sheet denotes 911 was notified and arrived at scene at 8:42 AM. EMS notes denote upon arrival at 8:42 AM, R6 was in bed unresponsive, agonal breathing. R6 went into witnessed full arrest while attempting to obtain vitals. R6 was in asystole entire time treating R6. CPR was performed throughout patient contact. Emergency Record review denotes R6 arrived in ER at 9:00 AM in [MEDICAL CONDITION]. R6 was resuscitated and place on ventilator. R6 received 4 units of packed cells and 4 units of fresh frozen plasma, given Vitamin K 10 mg. R6's lab results of [DATE] were: [MEDICATION NAME]- 127, INRO 12.3, PTT-92, hemoglobin 3.4. R6 was declared brain dead and removed from life support on [DATE]. Z4 (ER attending) for R6 on [DATE] stated in phone interview on [DATE]," I recall R6 coming in by paramedics and saying "he's so pale is this guy must be sitting in a pool of blood." Z4 stated R6 was wrapped in blankets and sheets and when we uncovered R6 he had a large amount of blood from the rectum." Z4 also stated R6 was dead in full arrest when he came in was resuscitated with fluids, [MEDICAL CONDITION] and medications. Z4 stated R6's [MEDICAL CONDITION] was related to blood loss because of GI bleed. R6 premlinary autopsy [DIAGNOSES REDACTED]. R6 death certificate listed R6 cause of death as [MEDICAL CONDITION] due to GI Bleed. Z1 stated in phone interview on [DATE] that he had not known the facility had faxed the results of R6's PT/INR result of [DATE]. Z1 stated that if he was aware of the abnormal PT/INR he would of stopped the [MEDICATION NAME] and ordered another PT/INR. Z1 stated on[DATE] that because R6 had continued to receive the [MEDICATION NAME], it contributed to R6's [MEDICAL CONDITION]. On [DATE], surveyor requested E1 (DON) the list of residents on anticoagulants. E1 presented a list of 18 residents identified on [MEDICATION NAME] faxed from the pharmacy on [DATE]. E1 was asked if there is any program of identifying and tracking residents on anticoagulants, E1 stated "not that I'm aware of." E1 was asked if the facility had a policy or procedure for residents on anticoagulant therapy, E1 presented a fax document from a sister facility dated [DATE] titled "Recommendation for Monitoring and Adjusting Doses for [MEDICATION NAME] ([MEDICATION NAME]) which discusses the variance of [MEDICATION NAME] dose and doseage recommendation of PT/INR results. Facility policy for Physician Notification of Laboratory Results includes: The guidelines were developed to ensure that : 1. All significant laboratory results are relayed to the physician in an appropriate and prompt manner. 2. Medical problems are communicated to the physician in a timely manner. Nurse responsibilities: 1. Notify the appropriate physician of all critical and alert laboratory results. This should be done via the telephone. 2. Provide the physician with relevant information regarding diagnoses, resident condition, and current medications and dosages. 3. Provide the physician with information regarding recent results. 4. Results which are neither critical nor alert in status should be faxed to the physician (or called at the physician 's request). 5. All physician contacts regarding laboratory results should be documented in the resident's record. 6. If the attending physician does not respond to critical and / or alert notifications the medical director should be contacted by telephone for direction. Facility GUIDELINES for PHYSICIAN NOTIFICATION FOR CHANGE IN CONDITION OVERVIEW INCLUDES: These guidelines were developed to ensure that: 1. All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and are to be documented in the medical record. 2. Medical care problems are communicated to the attending physician in a timely, concise, and thorough manner. NURSE RESPONSIBILITIES The nurse should not hesitate to contact the attending physician at any time for a problem which is his or her judgement requires immediate medical intervention. Should the physician not be available, the alternate physician should be contacted . If neither of these physicians are available, the Medical Director should be notified. 2.R4 [DIAGNOSES REDACTED]. R4's current POS denotes an order for [REDACTED]. Record review reveals the last PT/INR completed on R4 was [DATE] with results of Pro-time 36.2 INR 2.89. Pharmacy review form dated [DATE] denoted a recommendation from Z2 (pharmacist) for a monthly PT/INR on R4. Z2 stated in phone interview he had made a recommendation for a PT/INR for R4 but recommendation was never followed up on. R4's care plan dated [DATE] for complications related to anticoagulant therapy,approach includes "coordinate lab work." The facility took the following actions to remove the Immediate Jeopardy. The facility will continue to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well being. -The nurses have been re-educated on Reporting Abnormal Labs to Physicians on [DATE] and 20. -The nurses have been re-educated on Reporting PT/INR Results Physicians on [DATE] and 20. -The orders and labs of all residents receiving [MEDICATION NAME] have been reviewed by the DON and ADON on [DATE]th. -Tracking logs for all [MEDICATION NAME] orders have been initiated by Nursing Management on [DATE]th and will continue on a permanent basis. -The LPN who failed to report the PT/INR has been disciplined. -Nursing staff was educated on Neglect on [DATE]th (see attached) To ensure this practice is maintained: -All labs will be be delivered to the nursing office where they will be reviewed by DON/ADON before being distributed to the Nurse. On days when the ADON/DON are not present, the nursing supervisor on that day will review the lab results. -DON/ADON will follow-up and ensure Physician notification via phone on all abnormal labs especially PT/INR results. This began on [DATE]th and will be ongoing. -DON/ADON will maintain the [MEDICATION NAME] Tracking Forms. This began on [DATE]th and will be ongoing. -DON/ADON will educated all future nurses on this practice during the orientation period. The began with th orientation of a new nurse on April 20th and will continue as a part of the orientation for all new nurse. - A monthly report will be provide to the Quality Assurance Committee detailing: the number of residents on [MEDICATION NAME]: adherence to recommended follow-up; physician response to abnormal lab results; the number of instances and names of physician involved when contacting the medical director was required. This process will begin with the MAY QA meeting and continue for a minimum of six months or until substantial compliance is achieved. The reports will be present at the monthly QA meeting.