Every finding on record at Aperion Care Wesley

Based on interview and record review, the facility failed to ensure an allegation of suspected physical abuse of one resident (R7) by another resident (R6) of three residents reviewed was reported to Illinois Department of Public Health (IDPH) in a sample of seven. Findings include:R7's current face sheet documents R7's medical diagnosis to include but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate. MDS Minimum Data Set) section C-Cognitive Patterns dated 07/15/2026 document R7's Brief Interview for Mental Status as 8/15 indicating R7 has moderate cognitive impairment. MDS section GG-Functional Abilities document R7 is dependent on staff for ADL (Activities of Daily Living) care.R6's current face sheet documents R6's medical conditions to include but not limited to unspecified dementia, unspecified severity, with agitation, hypertensive heart disease with heart failure, myocardial infarction type 2. (MDS Minimum Data Set) section C-Cognitive Patterns dated [DATE], document R6's Brief Interview for Mental Status as 5/15 indicating R6 has severe cognitive disability. MDS section GG- Functional Abilities documents R6 requires Setup or clean-up assistance/Supervision or touching assistance with ADL (Activities of Daly living) care.R6's hospital records dated 8/8/2026 documents R6 was evaluated in the ED (Emergency Department) after being struck in the forehead by a cane. Reason for visit is listed as battery. Diagnosis: Assault by blunt trauma.On 08/15/2025 at 1:49PM, V1(Administrator) stated R6 and R7's discharge paperwork from recent hospital visit of 8/8/2026 was not yet linked in both residents' medical records. V1 stated when residents come back to the facility from a hospital visit or admission nursing is supposed to review the discharge paperwork immediately. V1 stated he was notified on 08/08/2026 when R6 and R7 were sent to the hospital. He was told R6, R7 bumped into each other. Staff did not mention abuse to him or that R6 had hit R7 with his walking cane. V1 stated nursing staff should have notified him that hospital discharge paperwork for R7 documented R7 was hit with a cane by another resident. V1 would have started investigations of abuse. Abuse allegations should be sent to Illinois Department of Public Health (IDPH) within 2 hours. The facility is the residents' home, and they should be provided with a safe environment. Residents should be supervised to prevent abuse. If a resident is abused, they can be scared, there can be injuries, and resident can be affected emotionally from the abuse.On 08/16/2026 at 5:42PM V10 (Assistant Director of Nursing -ADON/RN) said R6 and R7's discharge records dated 8.8.2026 were in the residents' unit buried in clutter. They had not been scanned into their medical records. They had not been reviewed. If I had seen in the discharge paperwork documenting R7's the admitting diagnosis was for battery, I would have reported it right away to V1(Administrator) who is the abuse coordinator so that investigations can start right away. Staff should notify V1 of any suspicion or allegation of abuse so that he can start investigations. This is their home. They should feel safe here. Residents should be supervised to prevent resident abuse.On 08/16/2026 at 2:01PM, V2 (Director of Nursing-DON) stated if there was any concern from the hospital that they suspected abuse I wound notify V1. We did not get R6 or R7's discharge paperwork.Policy titled Nursing dated 1/16/26 documents:-Any accident or incident will be addressed, documented, investigated and reported according to facility policy and applicable requirements.

Based on observations, interviews and records review, the facility failed to ensure one (R7) of three residents in a sample of seven reviewed remained free from physical abuse when R7 was struck by another resident (R6) who has known history of aggressive behaviors. This failure resulted in R7 sustaining some bruising and mental anguish. Findings include:R7's current face sheet documents R7's medical diagnosis to include but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate. MDS Minimum Data Set) section C-Cognitive Patterns dated 07/15/2026 document R7's Brief Interview for Mental Status as 8/15 indicating R7 has moderate cognitive impairment. MDS section GG-Functional Abilities document R7 is dependent on staff for ADL (Activities of Daily Living) care.R6's current face sheet documents R6's medical conditions to include but not limited to unspecified dementia, unspecified severity, with agitation, hypertensive heart disease with heart failure, myocardial infarction type 2. (MDS Minimum Data Set) section C-Cognitive Patterns dated [DATE], document R6's Brief Interview for Mental Status as 5/15 indicating R6 has severe cognitive disability. MDS section GG- Functional Abilities documents R6 requires Setup or clean-up assistance/Supervision or touching assistance with ADL (Activities of Daly living) care.On 08/15/2026 at 11;26AM, R7 was observed sitting in the dining room with peers coloring. R7 was observed with a faint black skin discoloration on the right side of the forehead. R7 stated she was on her wheelchair when a girl tripped her, and she fell. R7 could not provide further information.On 08/15/2026 at 11:43AM, R6 was observed trying to get out of the building. R6 pushed the emergency exit door. The alarm went off. Staff tried to get R6 to let go of the door. R6 tried to hit staff with his cane, cursing at staff. R6 stated he wanted to go home and continued to threaten staff attempting to hit them with his cane.R6's hospital records dated 8/8/2026 documents R6 was evaluated in the ED (Emergency Department) after being struck in the forehead by a cane. Reason for visit is listed as battery. Diagnosis: Assault by blunt trauma.On 08/15/2026 at 1:26PM, V2 (Director of Nursing-DON) stated she was notified on 08/08/2026 R7 had bumped into another resident (Cannot remember which resident) and that R7 had bumped into the medication cart on the hallway on her right-side forehead. R7 had bruising on the forehead. V5 got orders to send R7 to the nearby emergency room evaluation due to R7 being on aspirin. CT scan was negative. V2 stated she was not notified about R7 being hit by another resident with a cane.On 08/15/2025 at 1:49PM, V1 (Administrator) stated R6 and R7's discharge paperwork from recent hospital visit of 8/8/2026 was not yet linked in both residents' medical records. V1 stated when residents come back to the facility from a hospital visit or admission nursing is supposed to review the discharge paperwork immediately. V1 stated he was notified on 08/08/2026 when R6 and R7 were sent to the hospital. He was told R6, R7 bumped into each other. Staff did not mention abuse to him or that R6 had hit R7 with his walking cane. V1 stated nursing staff should have notified him that hospital discharge paperwork for R7 documented R7 was hit with a cane by another resident. V1 would have started investigations of abuse. Abuse allegations should be sent to Illinois Department of Public Health (IDPH) within 2 hours. The facility is the residents' home, and they should be provided with a safe environment. Residents should be supervised to prevent abuse. If a resident is abused, they can be scared, there can be injuries, and resident can be affected emotionally from the abuse. On 08/16/2026 at 2:01PM, V2 (Director of Nursing-DON) stated if there was any concern from the hospital that they suspected abuse I wound notify V1. We did not get R6 or R7's discharge paperwork.On 08/16/2026 at 10:58 AM V6 (Nurse Practitioner) via phone stated she was not in the facility when the incident between R6 and R7 happened. V6 stated her progress note dated 08/10/2026 that documents R7 was hit by R6 with a cane was based on what staff (No name provided) at the facility told her and her review of hospital records. V6 stated the facility knows what happened. They are the ones who sent R6 to the hospital. Staff should do frequent rounding and monitoring of residents. Provide activities and keep residents in a safe area. Residents should be kept safe. The facility should educate the staff on importance of frequent rounding and monitoring residents to prevent resident to altercations and accidents.On 08/16/2026 2026 at 12:56PM, V19 (Licensed Practical Nurse-LPN) stated she has worked with R6 and R7. R7 can get very angry and agitated if another resident is yelling. R7 can shout to that resident to shut up. R6 always states he does not want to be here. Always pushing doors to get out of the unit. R6 has tried to hit other residents with his cane when he gets upset. R6 has been sent out to the hospital several times for being unable to control his behavior. He can be dangerous to other residents.Progress notes dated 8/10/2026 by V6 (Nurse practitioner) document R7 was as sent out to ER (Emergency department) for evaluation due to another resident hitting her head with his cane. CT (Computerized Tomography) scan of the head was negative.On 08/16/2026 at 1:21PM V3 (Registered Nurse-RN) stated R6 was agitated yesterday trying to leave the facility. R6 was trying to hit everyone with his cane because he was upset and agitated for not being able to leave the facility. R6 is always trying to leave the facility. Today he tried to go to the elevator to get out of the building. R6 and R7 reside in a dementia unit. Residents should not be hitting each other.On 08/16/2026 at 5:42PM V10 (Assistant Director of Nursing -ADON/RN) said R6 and R7's discharge records dated 8.8.2026 were in the residents' unit buried in clutter. They had not been scanned into their medical records. They had not been reviewed. If I had seen in the discharge paperwork documenting R7's the admitting diagnosis was for battery, I would have reported it right away to V1(Administrator) who is the abuse coordinator so that investigations can start right away. Staff should notify V1 of any suspicion or allegation of abuse so that he can start investigations. This is their home. They should feel safe here. Residents should be supervised to prevent resident abuse.V5, (Licensed Practical Nurse-LPN), V7, V8 (Certified Nursing Assistants -CNAs) who took care of R6 and R7 on 08.08.2026 could not be reached during this survey.Abuse Prevention and reporting -Illinois policy dated 11/28/16 documents:- This facility affirms the right of our residents to be free from abuse.- Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.-Abuse is the willful infliction of injury.-Physical Abuse is the infliction of injury on a resident that occurs other than byaccidental means and that requires medical attention.-Physical abuse includes hitting, slapping, pinching, kicking, and controlling behaviorthrough corporal punishment.

Based on observation, interview and record review, the facility failed to separately launder personal resident items and facility laundry. This failure has the potential to affect all 75 residents that reside in the facility.Findings include:On 06/15/26 at 1:14pm V6 (Housekeeper) observed folding basket of laundry containing facility sheets and towels, and resident personal clothing.On 06/15/26 at 1:14pm V6 (Housekeeper) stated that the facility always washes resident personal belonging with facility's shared linen items. V6 stated that it is okay to mix the resident's personal clothing with facility shared linen.On 06/15/26 at 1:30pm V7 (Maintenance Director) stated that the resident's personal items should be washed separate from the facility's sheets and towels. V7 stated that washing all the items together is an infection control concern.On 06/16/26 at 1:02pm observed washing machine with personal resident items and facility shared laundry items. On 06/16/26 at 1:02pm V9 (Laundry Aide) stated that all the items observed in the washing machine came from one resident's room. V9 stated that the items in the washing machine are a mix of resident personal belongings and facility shared items. V9 stated that personal items and facility shared items should not be laundered together.Facility's policy titled Infection Prevention and Control Program dated 11/28/27 documents in part, Purpose: To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Guidelines: 1. The facility has established an Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and health care workers. 14. All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections. 15. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments.Facility's policy titled Linen Handling-Laundry Department dated 01/11/18 documents in part, Purpose: To ensure the proper handling, storage, processing, and transport of all linens and laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible. Guidelines: The facility staff should handle all used laundry as potentially contaminated and use standard precautions. 7. Laundry personnel shall sort the linen and personal laundry into separate hampers for washing.

Based on observation, interview and record review, the facility failed to provide the residents with bath linen that is in good condition. This failure affected all 75 residents that reside in the facility.Findings include:On 06/15/26 at 12:00pm observed one 4th floor linen cart empty with no linen and one 4th floor linen cart with 1 small towel, 1 gown, 1 pillow case and multiple cut pieces of a bath blanket. Observed one half empty bag of soiled linen in soiled linen bin and no available line in the linen closet.On 06/15/26 at 12:07pm V3 (Housekeeper) stated that the facility does not always have linen available. V3 stated that the CNA's (Certified Nursing Assistants) have to go find linen.On 06/15/26 at 12:16pm V4 (Licensed Practical Nurse/LPN) stated that the facility doesn't really have linen. V4 stated that they are always told that linen has been ordered. V4 stated that sometimes they don't have linen for the whole shift or until the shift is almost over.On 06/15/26 at 12:32pm observed 3rd floor with two empty linen carts, no soiled linen in the soiled linen container and no available linen in the linen closet.On 06/15/26 at 12:53pm V5 (CNA) stated that sometimes the staff have to cut up sheets and blankets to wash the residents. V5 stated that there have been times that she has not received linen the whole shift. V5 stated that the facility provides wipes but the wipes are not enough to wash the residents whole body.V5 stated that she has had to leave the residents bed without a sheet because there was no sheets available to make the beds.On 06/15/26 at 1:14pm observed V6 (Housekeeper) in laundry room folding linen. V6 stated that there is definitely not enough linen in the facility. Linen count done with V6 that included 14 fitted sheets, 3 bath blankets, 2 large towels and 2 washcloths. V6 stated that the majority of the linen is still on the nursing units. On 06/15/26 at 1:30pm V7 (Maintenance Director) stated that he orders a large amount of line every month. V7 stated that he doesn't know what the staff does with the linen and he believes that they must be throwing the line away. V7 stated that it takes time to wash the linen, but it goes to the floors as soon as it is done.On 06/16/26 at 1:02pm V9 (Laundry Aide) stated that she gets complaints from the staff that there is not enough linen, but she gives them what she has. V9 stated that she tells the facility to order more linen but what is ordered is never enough.On 06/22/26 at 2:03pm V2 (Assistant Director of Nursing/ADON) stated that there is a lack of linen but the problem is the staff hide the linen. V2 stated that linen is ordered but staff hide linen or throw linen in the garbage. V2 stated that there is still a gap in linen. V2 stated that cutting up blankets to wash residents is not acceptable. V2 stated that sometimes staff inform him that they don't have line and V2 goes to find linen in other resident's rooms. V2 stated that staff should not have to search for towels, they should be readily available. V2 stated that not having linen available could hinder care to the residents.V2 stated that staff are improvising to wash residents up and they should not have to.

Based on observations, interview and record review, the facility failed to prevent one cognitively impaired resident (R1) with Dementia and a history of elopement risk and stating he wants to go home from exiting thru a facility door into the community. This failure affected 1 of 3 residents reviewed for safety. As a result, R1's whereabouts were unknown for approximately 5 hours until R1 was located wandering approximately 10 miles from the facility.R1's medical diagnoses include but are not limited to dementia, hypertensive heart disease, myocardial infarction, chronic diastolic heart failure. R1 was admitted to the facility 10/15/25. R1's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 10, indicating R1's cognition is moderately impaired.R1's progress noted dated 04/04/26 documents in part, Standing by elevator to go downstairs.R1's progress note dated 04/05/26 documents in part, Resident noted absent from unit. Observed on 4th floor during day shift prior to shift change; report given and care endorsed. Per report, resident exited facility approximately 3:10pm. At approximately 4:30-5:30, resident noted not present. 911 notified per protocol.R1's risk management form dated 04/05/26 documents in part, During evening medication pass NOD (nurse on duty) made rounds and resident was not in dining room or room. NOD initiated a code pink and conducted a head count and floor and facility search. NOD asked assigned CNA (Certified Nursing Assistant) when was the resident seen last? CNA responded that she thought he was in activities. A second statement that R1 was last seen at 3:30PM.R1's Elopement Risk and Community Survival Skills assessment dated [DATE] documents in part, 4. Behavioral Observations: c. Becomes agitated, confused and/or disoriented? yes. Recommendations: Elopement risk decision. The resident presently appears to be: 1. At risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. Rational for decisions: Has hx (history) of exit seeking behavior, at times attempts to wander off floor. Resident is at risk for elopement. Wander guard in place.On 6/15/26 at 12:40PM R1 asked surveyor are you here to take me out of here? R1 said I want to go back to my family and they won't let me go. R1 said ain't no police take me to the hospital. These people here caught me and brought me back here. R1 said I used to live on the southside of the city. They told me that I have to stay here and I can't leave. I have a bracelet on my arm, they tell me that I be trying to run away or something. R1 said when I ran out of here, I got on the bus, I'm over 65 so I got a bus pass. I don't know why they won't let me go home, I don't have a disease and I won't contaminate anybody.On 06/15/26 at 12:16pm V4 (Licensed Practical Nurse/LPN) stated that R1 has always been exit seeking since R1's admission. V4 stated that R1 needs constant redirection. V4 stated that she has not reported V4's elopement attempts to R1's physician because R1's physicians are already aware of R1's behaviors.V4 said there is the alarm by the back elevator, when it goes off, we can't hear that well. On 06/16/26 at 12:10pm The surveyor observed numbers written on the keypads located along the doors.V7 (Maintenance Director) stated that the numbers on top of the keypads were the codes for the keypads. V7 stated that he guesses that the residents can put the right code into the keypad. V7 stated that the exit doors when pushed have a 15 second delay before the doors will open. V7 stated that before R1's elopement, the exit door alarms could not be heard if no one was nearby. V7 stated that some wander guards are working properly, and some are not. V7 stated that the facility is continuing to work and fix the wander guards. V7 said the wander guard system is still being worked on (today) and per the contracted company will be fully functioning in approximately 2 weeks. On 06/15/26 at 12:53pm V5 (Certified Nursing Assistant/CNA) stated that sometimes the elevator doors open and there is no one on the elevator. V5 stated that when the elevators doors open and there is no one on it, the staff have to stop the residents from getting on the elevator.On 06/16/26 at 10:47am V8 (Licensed Practical Nurse) stated that she did not see R1 at the beginning of her shift that started on 4/5/26 at 3pm. V8 stated that it is not normal for her to not see R1 at the beginning of her shift, but due to an altercation with other residents, V8 did not see R1. V8 stated that it was R1's normal behavior to try and get on the elevator, he wants to go home, and would sometimes become aggressive. V8 said R1 is at high risk for elopement. V8 said it has been reported to her by other staff that R1 has gotten off the floor and to keep an eye on him. V8 stated that she noticed R1 was not in R1's original location for dinner time and began looking for R1. V8 stated that while looking for R1, V8 noticed a door on the first floor was slightly open, which leads to the street. V8 stated that she ran out of the open door onto the street and began looking for R1 and asking people if they had seen R1. V8 stated that when she could not locate R1, V8 called the police and made a police report. V8 stated that R1 was found by the police on the south side and taken to the hospital for an evaluation. V8 stated that R1 had gotten off the unit multiple times before R1 eloped. V8 stated that when R1 was found and returned to the facility that R1 stated that R1 will leave again.On 06/17/26 at 12:31pm V11 (Restorative Nurse) stated that R1 goes in and out of being confused. V11 stated that R1 is not safe to be outside by himself. V11 stated that R1 has been confused since R1's admission. V11 stated that there have been times that she has had to redirect R1 back to R1's floor on the locked unit.On 06/18/26 at 2:24pm V12 (Certified Nursing Assistant/CNA) stated that sometimes the elevators open by itself and if staff are not watching the residents, the residents will try to get on the elevator. V12 stated that she has observed residents attempting to push numbers on the keypad and has to redirect the resident.On 06/22/26 at 9:54am V20 (Social Service Director) stated that elopement risk assessments are done on admission and quarterly. V20 stated that exit seeking behaviors are residents trying to get to the ground floor by themselves, trying to go to the stairwell and a resident verbalizing they are trying to leave. V20 stated that although R1's quarterly assessment wasn't due on 02/23/26, she did an audit and determined R1 was no longer an elopement risk and R1's wander guard bracelet was removed. V20 stated that R1 was not exit seeking and stable for months before R1's wander guard was removed on 02/23/26. Surveyor asked V20 if R1's elopement risk assessment dated [DATE] was incorrect, V20 stated that the assessment dated [DATE] was not an incorrect assessment. V20 stated that staff are aware to notify her if a resident is exit seeking. V20 stated she was never notified by staff that R1 was having exit seeking prior to R1's elopement from the facility.On 06/22/26 at 2:03pm V2 (Assistant Director of Nursing) stated that R1 was already an elopement risk before R1 eloped from the facility. V2 said I know R1 eloped previously but he was not a super at risk person for elopement. V2 said if a resident is attempting to get on the elevator or the stairs and saying they want to go home then they are super at risk for elopement. V2 stated that he is unsure of how R1 was able to get off the locked unit; R1 has Dementia, but V2 said I believe R1 left the unit via the elevator. V2 stated that sometimes the elevator opens and residents take the opportunity to get on the elevator if no one is paying attention. V2 stated that it is possible that R1 could have put the code in the keypad since the code was written on the keypad. V2 stated that having the numbers written on the keypad poses a risk for residents to get off the unit. V2 stated that rounds should be made at least every 2 hours. V2 stated that R1 was gone for more than 2 hours before the staff discovered that R1 was missing; rounds were not made within that 2 hours to check on him. V2 stated that R1 could have gotten injured being out in the community alone and riding the train by himself.On 06/22/26 at 3:19pm V1 (Administrator) stated that he was informed via phone that R1 had eloped from the building. V1 said according to the nurse the exit alarm was sounding. V1 stated that after viewing the facility's cameras, it was discovered that R1 exited the facility through the door on the 1st floor. V1 stated that it was daylight outside when R1 exited the facility. V1 stated that when he arrived at the facility, it was already dark and R1 was still missing. V1 stated that in search of R1, V1 went to 2 local hospitals and 1 local grocery store. V1 stated that while searching the area for R1, V1 received a phone call from the police stating that R1 was found at the train station on the south side. V1 stated that he requested for police to take R1 to the local hospital for evaluation. V1 stated that he was informed by the nurse that the first-floor alarm was sounding and the exit door was found slightly open. V1 stated that 1st floor door alarm at the time of R1's elopement could only be heard locally in the area of the door. V1 stated that it is probably not a good idea for the codes to be on top of the keypads. V1 stated that the codes on top of the keypads unlock the units, and someone could go down the stairs or out the door. V1 stated that the wander guard system is being upgraded and is ongoing.On 6/22/26 at 1:35PM V21, Operations Manager, said some of the wander guards were not responding to the old code so we had to switch them out. The maintenance guy did his rounds and informed us that the code/s were not working.R1's emergency room record dated 4/5/26 at 9:11PM (over 5 hours since last seen) notes presents after being found by police department wandering. Has history of Dementia. Facility requested medical evaluation before returning to facility. Plan to return to the facility. R1's Psychiatry Note dated 2/20/26 [in part] describes R1 engaging but appears mildly irritable, and pt appears confused with irrelevant or tangential responses consistent with cognitive impairment. Pt reports participating in various activities during the day and coming to the dining room but is unable to elaborate further due to impaired recall and limited insight. Insight and Judgment are poor. R1's Elopement Risk and Community Survival Skills assessment dated [DATE] documents in part, 4. Behavioral Observations: c. Becomes agitated, confused and/or disoriented? no. g. Resident can safely maneuver in community and is without debilitating physical impairment making resident unsafe. no. Recommendations: Elopement risk decision. The resident presently appears to be: 1. Not at risk to elope at this time and placement on the Elopement Risk Protocol is not indicated. d. Rational for decisions: Although resident has a hx of attempting to leave the floor unsupervised he no longer presents with this behavior. Wander guard removed on 02/23/26R1's document titled Progress Note - Chronic Care Management dated 02/19/26 documents in part, Cognition: Patient has Severe Impairment cognitive status. Assessment/Plan: Progressive, exit-seeking, impulsive, frequent agitation and care rejection. Wander guard, behavioral strategies. involve social work/family; monitor for safety.R1's psychiatry note dated 02/20/26 documents in part, Staff report pt (patient) has recently appeared more anxious, agitated, and restless, and at times becomes verbally aggressive toward staff and is not easily redirectable which represents a change from baseline.R1's document titled Progress Note - Chronic Care Management dated 03/03/26 documents in part, Assessment/Plan:. At risk for elopement. R1's progress note dated 04/13/26 documents in part, Resident observed standing near elevator and stairwell area, attempting to access other floors and exit facility. He stated, I want to go home.R1's care plan initiated on 10/20/25 includes interventions for fall risk, impaired cognition, and elopement risk. Intervention includes placing wander guard on R1's wrist.Facility's policy titled Elopement Device reviewed 02/27/26 documents in part, Purpose: To establish procedures for ensuring personal elopement devices are used in accordance with identified risk, physician orders an to ensure the security system is inspected to identify malfunctions should they occur. Policy: It is the policy of this facility to use elopement alert systems and devices when an assessment has identified the risk of elopement. Procedure: 1. Elopement alert devices will be used as a interventional tool to prevent resident elopements.Facility's policy titled Code Pink - Missing Resident /Elopement reviewed 02/27/26 documents in part, Guideline: 1. All personnel are responsible for reporting a cognately resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. 2. Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or she should:. Notify the attending physician of the resident's attempt to leave the facility. Complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions as indicated. (1) Examples of interventions may include but are not limited to: (a) Wander guard bracelet. (b) Increased monitoring such as 15 minute visual checks, 1:1 supervision.

Based on observation, interview and record review, the facility failed to promote proper staff/resident/representative communication by not ensuring all facility staff wear identification. This failure has the potential to affect all 72 residents that reside in the facilityFindings include:5/19/26, surveyor observed multiple staff members not wearing name tags or name tags being worn below the waist.5/19/26 at 11:40 AM, V14 (Therapy) stated their name tag was on their jacket downstairs. V14 stated they should be wearing a name tag.5/19/26 at 11:43 AM, V15 (Activity Aide) stated they forgot their name tag at home. V15 stated they should be wearing a name tag so residents and family can identify them.5/19/26 at 11:45 AM, V16 (Licensed Practical Nurse) was observed wearing their name tag below the waist. V16 stated they were not sure where to wear the name tag, but the name tag should be visible.5/19/26 at 11:46 AM, V18 (Certified Nursing Assistant) stated they have been at the facility for a month. V18 stated the facility never gave them a name tag. V18 stated they believe they should wear a name tag, so they are not mistaken for a resident.5/19/26 at 12:11 PM, V17 (Activity Aide) was observed wearing their name tag below the waist. V17 stated they were not told where to wear the name tag.5/19/26 at 12:12 PM, V19 (Certified Nursing Assistant) stated they have been at the facility for five days. V19 stated the facility had not given them a name tag. V19 stated they should be wearing a name tag so everyone can identify them.5/20/26 at 10:27 AM, V4 (Licensed Practical Nurse) stated we are supposed to wear name tags. The name tag identifies who I am and my position. The name tags should be worn where they can be visible.5/20/26 at 11:50 AM, V13 (Social Service Director) stated staff are supposed to wear name tags whenever they are on shift so residents and family can identify them.5/20/26 at 12:39 PM, V1 (Administrator) stated staff are supposed to be wearing name tags to be identified. The name tags should be worn in the shoulder area. Facility Employee Handbook, 1/2023, reads in part: Name Badge: All employees are issued name badges at the time of hire. Name badges must always be worn while on duty and should be worn in the shoulder area.

Based on interviews and record reviews, the facility failed to notify the physician in a timely manner of a change in condition of one (R74) resident out of three residents reviewed for change in condition in a total sample of twenty. This failure resulted in R74 requiring hospitalization with diagnosis of stroke. Findings Include:R74's Minimum Data Set (MDS) dated [DATE] noted she was cognitively impaired. R74's Electronic Medical Record (EMR) noted she was initially admitted to the facility on [DATE]. She was [AGE] years old with diagnoses not limited to personal history of transient ischemic attack, cerebral infarction due to embolism of right middle cerebral artery, Alzheimer's disease, paroxysmal atrial fibrillation, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and unspecified dementia. On 03/03/26 at 11:49 AM, via telephone V19 (R74's Family Member) stated that she was the principal care giver for R74 for so many years. On 9/19/25 she visited R74 during the morning shift, V24 (Licensed Practical Nurse/LPN), V25 (Certified Nursing Assistant/CNA) and V50 (Registered Nurse Hospice) were on duty. V18 (Family Member) also came to visit R74 in the facility around evening time, and because he is an eye Surgeon, he was able to immediately recognize the sign of stroke when he saw R74. On 03/03/26 at 12:45 PM, V25 (CNA) stated that she has been in the facility for thirteen years, she works 6:30am-2:30 pm shift, and she is familiar with R74. On 09/19/25, she observed that R74's face was shifted to the right, she was not talking, so she notified V24 (LPN).On 03/03/26 at 1:25 PM, via telephone, V24 (LPN) stated that she has been in the facility for eighteen years, she works 7am-3pm shift on the fourth floor, and she is familiar with R74. On 09/19/25 towards the end of the morning shift, she observed that she was not talking, eyes closed, she checked her vitals, she called the hospice. After she called, V50 (Registered Nurse/RN Hospice) came with V19 at the bed side. V24 stated that she left because R74 was on hospice, and it is the policy of the facility to notify the physician and family when there is any change in condition. On 03/03/26 at 2:05 PM, via telephone V16 (R74's Physician) stated that on 9/19/25, no staff member told her about R74's facial drooping to the right which is a sign of stroke, until V18 spoke with her and she sent R74 to the hospital. She also stated that if V24 or V28 (LPNs) had notified her, she would have sent R74 to the hospital immediately because the initial ninety-minute observation window is very important. On 03/03/26 at 3:48 PM, via telephone V18 (R74's Family Member) stated that on 09/19/25, he came all the way from O'Hare airport to visit R74 in the facility after dinner, and he observed that R74 had suffered stroke because her face was deviated to the right, but V28 (LPN) on duty had not contacted V16 immediately about the change in R74's condition. He requested that V28 call V16 right away so he can speak with V16. He spoke with V16, and she told him that no one reported R74's change in condition to her, so after he spoke with her, she gave order to send R74 to the hospital for evaluation, and she was admitted with diagnosis of stroke.On 03/04/26 at 4:05 PM, via telephone V28 (LPN) stated that she has been in the facility for about twenty years, she works 3pm-11pm shift, full time on the 4th floor. On 9/19/25, she worked 3pm-11pm shift with R74, the outgoing V24 (LPN) endorsed to her that R74 was not doing good, but she did not ask if she notified V16 because R74 was on hospice. V28 also stated that upon her initial rounds around 3:30 PM, she saw R74's mouth deviated to the right, and when she was feeding her with boost drink around dinner time at 5:00 pm with V19 at bedside. V28 stated she did not call V16 at that time, until when V18 came around 7:00 pm, he requested to speak with V16, then she called V16, and she gave order to send R74 to the hospital for immediate evaluation. V28 stated that she should have notified V16 immediately for further instruction after she observed the facial shifting or drooping because that was a change in condition, and she also stated that shifting of her face to the right is a sign of stroke, but she did not notify the physician because R74 was under hospice care. On 03/05/26 at 9:54 AM, V24 (LPN) stated that she did not observe R74's facial deviation to the right, and she did not tell V28 that she saw R74's mouth deviated to the right during 7am-3pm shift. She also stated that she did not call V16 (R74's Physician), and she would have informed V16 if she observed facial drooping because that was a change in condition which should be reported to V16 immediately. An attempt was made to contact V50, but V1 (Vice President Operation) stated that V50 is no longer working for the Hospice company.On 03/05/26 at 10:19 AM, V2 (Director of Nursing/DON) stated that she has been in this facility for two years. She also stated that it is her expectation that nurses will notify the physician with any change in condition to prevent delays in care. R74 was on hospice, the hospice doctor was notified and made aware of the change in condition, but it was not documented.On 03/05/26 at 11:33 AM, via telephone V31 (R74' Hospice Physician) stated that on 09/19/25, a female hospice nurse )he cannot remember her name), called him around the morning shift (7am-3pm shift) that R74 had weaknesses. He cannot remember the side of the body, and he was not given the details of the change in condition as face shifting/facial drooping to the right side. He would have called V18 before sending her to the hospital, and the delay in care could have contributed to her sustaining stroke. He also stated that R74 was on hospice for comfort care, and he did not know that R74's Physician Orders for Life Sustaining Treatment/POLST form has the option for selective treatment which includes hospitalization. Documents reviewed for this investigation are not limited to the following:R74's Face Sheet, Minimum Data Set (MDS), Physician Order Sheet/POS, Medication Administration Record/MAR, and Care Plan. R74's electronic medical record (EMR) Progress notes dated 9/19/25, noted that V28 notified V16 after V18 request.F74's POLST dated 10/27/22 documents in part: Selective treatment, transfer to hospital, if indicated.R74's Hospital record dated 9/20/25-9/24/25 document in part: Stroke due to embolism of right middle cerebral artery.Physician-Family Notification-Change in Condition policy dated 11/13/18 documents in part; To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner.

Based on interview and record review, the facility failed to maintain record of Covid-19 vaccine status of two staff (V8 and V15) reviewed for COVID-19 immunization. This failure could potentially affect all residents residing in the facility. The findings include: On 3/3/36 at 10:58AM V15 (CNA / Certified Nursing Assistant) stated she has been working in the facility for 2 months and she is up to date with immunization including COVID-19. On 3/3/36 at 11:02AM V8 (LPN / Licensed Practical Nurse) stated she has been working in the facility for almost 10 months. Stated she received Flu vaccine in December 2025. V8 stated she received COVID-19 vaccine last year. V8 stated her Immunization record was provided to the facility.On 3/4/26 at 2:29 PM V4 (IP / Infection Preventionist Nurse, ADON / Assistant Director of Nursing) stated all staff are screened for Covid vaccine. He stated COVID-19 vaccine is not mandatory, but it is recommended. V4 stated staff complete covid-19 vaccination consent - declination form upon hire. Reviewed V8 (LPN) covid-19 vaccination consent - declination form dated 5/6/25 with V4 and stated V8 consented to receive Covid-19 vaccine. V4 stated he checked ICARE (Illinois Comprehensive Automated Immunization Registry Exchange) system for vaccination records and showed V8 is due for COVID-19 vaccine in 2025. V4 stated there is no Covid-19 vaccination status in V8's file. He stated V15's covid-19 vaccination consent - declination form dated 1/6/26 showed V4 declined to receive Covid-19 vaccine due to vaccine was received from another facility. He stated there is no Covid-19 vaccination status in V15's file. He checked ICARE system and showed V15 is due to receive COVID-19 vaccine in 2025. On 3/5/26 At 10:57AM V2 (DON / Director of Nursing) stated she has been working in the facility for 6 years and transitioned as DON 2 years ago. V2 stated COVID vaccine for staff is recommended but not mandatory. She stated vaccination status of all staff should be in record or documented. V2 stated COVID-19 vaccine is recommended to be given yearly. She said if staff are not up to date with Covid-19 could possibly cause an outbreak of Covid -19 as they are at risk of getting COVID-19 easily. V2 said V8 (Licensed Practical Nurse / LPN) usually is working on the 3rd floor. On 3/5/26 At 11:25AM V4 (/ IP Nurse, ADON) stated COVID -19 vaccination for staff is recommended but not mandatory. He stated staff are educated regarding COVID-19 vaccine. V4 stated staff vaccine status should be obtained and maintained in their record. He stated HR (Human Resource) is handling the record for staff vaccination status. V4 stated upon hire, staff should have vaccination record or vaccine history updated as appropriate. He stated Staff is supposed to get their COVID-19 vaccine in their own pharmacy. V4 stated if staff is not up to date with Covid-19 vaccine, they could easily catch the virus that could lead to outbreak. He further stated that staff have no sufficient immunity because vaccination was not up to date. On 3/5/26 at 11:36AM V45 (Director of Human Resource) stated he has been working in the facility for over 2 years. He stated vaccination record of staff are updated annually for flu and Covid-19. V45 stated staff vaccination status including COVID-19 should be kept / maintained in their file. Reviewed V8 and V15 employee's file, no COVID-19 vaccine record in their file. He stated V8 and V15 thought they emailed / provided their vaccine status, but they never did. V45 stated he just got the record after surveyor asked for it. He stated both employees (V8 and V15) were not up to date with COVID-19 vaccine. On 3/5/26 at 1:50PM V48 (CNA Supervisor, CNA Scheduler) stated she is responsible for CNAs scheduling. She stated V15 (CNA) is rotating or working on all floors 2nd, 3rd and 4th floor.V8's employee covid-19 vaccination consent - declination form dated 5/6/25 shows in part: V8 consented to receive the current COVID-19 vaccine.V8's vaccination record card provided on 3/5/26 after surveyor's request and shows in part: COVID-19 vaccine was given on 2/11/22. V15's employee Covid-19 vaccination consent - declination form dated 1/6/26 shows in part: V15 declined COVID-19 due to V15 received the vaccine from another facility. V15's vaccination record card provided on 3/5/26 after surveyor's request and shows in part: COVID-19 vaccine was given on 1/21/22.Facility provided employee's record and shows: V8 (LPN) date of hire was on 5/7/25. V15 (CNA) date of hire was on 1/7/26. Facility's census report dated 3/3/26 shows: 72 residents.Facility's COVID-19 vaccination guidelines - residents and employees dated 12/9/24 shows in part: to minimize the risk of residents acquiring, transmitting, or experiencing complications from COVID-19. The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following: The COVID-19 vaccine status of staff and related information. If a staff member is not eligible for COVID-19 vaccination because of previous immunization at another location or outside of the facility, the facility should request vaccination documentation from the staff member to confirm vaccination status.

Based on observations, interviews, and record reviews, the facility failed a.) to ensure food items were properly labeled and dated, b.) to discard expired food based on food quality and use by date guidelines. These failures have the potential to affect all 71 residents receiving food prepared in the facility's kitchen. Findings include:On 03/03/26 at 9:27AM, V10 (Dining Manager) stated all items should be labeled with a delivery date, an open date and use by date. V10 stated items are discarded on or before the use by date. Manufacturer guidelines for dates and storage are followed. V10 stated different foods have different shelf life depending on what the food item is. V10 pointed to papers posted on the wall near the walk-in refrigerator. V10 stated that is a list which lists the different use by dates depending on what the food item is. The document is titled, Use by Guidelines. V10 stated items are discarded on or before the use by date. V10 stated it is important for food items to be properly labeled with an open and use by date, so the staff knows when to throw out the food.On 03/03/26 at 9:37 AM, observed in walk-in refrigerator number two the following items:An opened case of fresh oranges dated with delivery date 02/10/26. Observed inside the box three oranges that were very soft and mushy instead of firm and two oranges had patches of white, fuzzy growth on the surface of the peel. V10 looked at the white, fuzzy growth on the orange peel and said, I think that's mold. V10 picked up one of the oranges and his thumb pushed easily through the damp, softened area of the orange peel. V10 stated he will have to throw the oranges out because they have gone bad and cannot be served to the residents.An opened box of fresh cucumbers dated with a delivery date 02/10/26. Observed inside the box four cucumbers that had some areas of white discoloration on the surface of the cucumber skin and very soft patches instead of being hard and firm.V10 stated since the quality of the cucumbers has deteriorated he would not serve them to the residents and they need to be thrown in the garbage. V10 stated they should have been thrown out before now.On 03/03/26 at 9:54 AM, observed the following item in the prep cook area:Large opened plastic container of peanut butter dated with an open date of 02/19/26. There was no use by date written on the label. V10 stated there should be a use by date on the label so the staff knows when to discard it.Opened plastic 11-ounce container of Ground Thyme dated with delivery date 03/06/24. Manufacturer had printed on label best by date 01/01/26. V10 stated the spice should have been discarded on or before 01/01/26 per the manufacturer guidelines.On 03/04/26 at 2:41 PM, V32 (Director of Regional Dietitian Consultant) stated a box of fresh oranges and cucumbers dated 02/10/26 should have been discarded before this week. V32 stated signs that the produce was deteriorating would be bruising, or mushy texture instead of the items hard and firm. V32 stated the potential problem of keeping food that has deteriorated/spoiled in the refrigerator is it could potentially be served to a resident and that has the potential to cause food borne illness. V32 stated manufacturer use by dates or best by dates should be followed to prevent potential food born illness.On 03/03/26, facility provided list of diet orders for all residents in the facility. The diet order list indicates there is one resident receiving nothing by mouth (NPO).Facility provided policy titled Storage Periods, Use-By Guidelines undated which documents in part, food should be stored properly and used within the appropriate time period to ensure safe and high-quality food is served and the Use-By Guidelines-Posted should be sued to determine a use by date when labeling opened or unopened food that must be used within a certain time frame. Foods with a manufacturer's use-by date should still require an opened-on date once the item is opened. Expired food items should be disposed of.Facility provided copy of Use-By Guidelines-Posted undated which documents in part,Produce (fresh fruits and vegetables) use by date - check daily for freshnessPeanut Butter use by date - 3 monthsSpices (opened) - one year or product expiration date, whichever comes firstFacility provided policy titled, Food Storage undated which documents in part, food should be stored and prepared in a clean safe sanitary manner that complies with state and federal guidelines to minimize contamination and bacteria. Food should be labeled and dated to monitor food safety. Food or beverage items that have exceeded the manufacturer's expiration date or use by date or which are opened and are past their expiration date, should be discarded. Food items that do not have a manufacturer's expiration date should be labeled with contents and dated with a received and use by date. Any food that is suspected of being contaminated or obviously contaminated should be discarded immediately.

Based on observation, interview and record review, the facility failed to ensure residents receive nutritionally adequate meals by not following planned menus to provide at least five fruits and vegetables and 16 ounces of milk per day. These failures have the potential to affect all 71 residents receiving food prepared in the facility's kitchen. Findings Include: On 03/03/26 at 9:31AM, observed cases of milk cartons in the kitchen walk-in refrigerator. V10 (Dining Manager) stated milk is available to the residents at breakfast and dinner for those who request milk.On 03/04/26 at 11:45 AM, V12 (Cook) stated beverages are sent up on a beverage cart to the unit prior to the start of each meal. V12 stated the juice served at meals including breakfast, lunch and dinner is a juice drink that the staff prepares using a powdered mix.On 03/05/26 at 7:50 AM, observed on the 3rd floor a beverage cart containing two large pitchers of pink colored drink, a metal container with six cartons of milk inside covered with ice, coffee/tea and applesauce.On 03/05/26 at 7:55 AM, V38 (Certified Nursing Assistant) stated there are approximately 25 residents living on the 3rd floor and one beverage cart gets delivered to the unit prior to the trays coming up from the kitchen. V38 stated the staff gives out the beverages on the unit with meal trays. V38 stated most of the residents receive the drink from the pitcher but there are a few residents who receive plastic containers of orange juice on their trays (the orange juice is put on by the kitchen staff downstairs before the trays are delivered to the unit). V38 stated the milk is put on the resident trays by the staff on the unit if the residents request milk. V38 observed the metal container with the six cartons of milk inside. V38 stated if they run out of milk, they call down to the kitchen for more.On 03/05/26 at 7:57 AM, R45 overheard the conversation the surveyor was having with V38 and stated she (R45) has never received orange juice, and she has been living in the facility for over 1.5 years. R45 stated that no one ever gave her the option to receive orange juice. R45 stated she only receives the pink punch they deliver to the unit and that is not juice. R45 stated she wishes she was given real orange juice because she would like that, and it would be better for her to drink.On 03/05/26 at 8:02 AM, V39 (Dietary Aide) stated she was the one who prepared the pink punch sent up to the units on the beverage cart for breakfast today. V39 stated this is the same punch she always makes for breakfast, lunch and dinner. V39 showed surveyor the powdered mix packet labeled Fruit Punch Drink Mix and stated this is what she uses to make the punch for all meals. V39 stated there are only six to seven residents in the entire facility who do not like the fruit punch, so she gives them individual containers of orange juice when they are available. V39 stated today there are only two (4-ounce) containers of orange juice left over and there are no more containers in the freezer. V39 stated not all the residents receive cartons of milk at breakfast or dinner (they do not give out milk on resident's individual trays). V39 stated she sends up eight cartons per floor in a metal container filled with ice for the staff to give out to residents who request milk with their meals.On 03/05/26 at 12:54 PM, V32 (Director of Regional Dietitian Consultant) stated on the menu when it lists Assorted Juice at breakfast the kitchen should be serving real juice, not powdered fruit drink. V32 stated the powdered fruit drink is okay to serve for the evening snack as listed on the menus as Fruit Drink.On 03/05/26 at 12:57 PM, V47 (Director of Nutrition Service for Contracted Menu Company) stated via telephone interview that she signs off on all the menus as a state licensed Registered Dietitian to confirm that the menus meet the nutritional requirements and regulations for the state. V47 stated she uses the Administrative Code from the Department of Public Health Section 300.2050 Meal Planning and there is a regulation to provide a good source of Vit C daily (60 mg of Vit C), at least five fruits and vegetables servings daily and at least 16 ounces of milk to residents daily and if the menus were followed this is what the residents would be receiving. V47 stated the menu is nutritional adequate if they are followed as planned and specified. V47 stated assorted juice is listed on the menus to be provided at breakfast every day and the assorted juice needs to be 100% fruit juice. V47 stated the facility should be providing orange juice in the morning every day to meet 100% Vitamin C requirements and Vitamin C is important for immunity and wound healing. V47 stated the kitchen should not be providing fruit drink at breakfast in place of the orange juice because the fruit drink is not 100% real juice. V47 stated five fruits and vegetables should be served daily and the orange juice which should be served in the morning is counted as one fruit serving. V47 stated Fruit Punch Drink does not count as a fruit serving because it is not real juice. V47 stated it is important for the residents to receive at least five fruits and vegetables per day to ensure residents are receiving adequate Vitamin C, micronutrients and fiber. V47 went over the cycle menu dated 03/03/26, 03/04/26, 03/05/26, 03/06/26, 03/07/26 and pointed out that because the facility is not providing orange juice as 100% real juice at breakfast the residents are receiving four servings of fruits and vegetables instead of the required five servings. V47 stated the soup served on 03/04/26 does not count as a vegetable serving because there is no guarantee there is a 1/2 cup vegetables in each serving of the soup. V47 stated on 03/05/26 even though there are some extra vegetables in the turkey pot pie and marinara sauce they would not add up to 1/2 cup and therefore cannot be counted as a full serving. V47 stated residents should be served 16 ounces of milk per day and that is why it is listed on the menu to be served as 8 ounces at breakfast and dinner. V47 stated this is regulation to meet calcium needs and milk is also fortified with Vit D. V47 stated if a resident does not like milk they could be provided with cottage cheese, yogurt, ice cream as a calcium equivalent but this would need to be individualized by the Registered Dietitian covering the facility. V47 stated milk should be provided to every resident not only upon request. On 03/03/26, facility provided list of diet orders for all residents in the facility. The diet order list indicates there is one resident receiving nothing by mouth (NPO).Per R45's electronic health record (EHR) she admitted to the facility on [DATE] and is on a regular diet with cut-up meat and double portions vegetables with lunch and dinner per her request. Based on R45's MDS (Minimum Safety Set) dated 12/26/25 R45 is cognitively intact. Week At A Glance Week 1-4 lists Assorted Juice everyday for breakfast and milk at breakfast and dinner every day.Diet Spreadsheet Week 3 lists 6-ounces Assorted Juice at breakfast and 8-ounces milk at breakfast and dinner.Administrative Code Section 300.2050 Meal Planning documents in part, each resident shall be served food to meet the resident's needs and to meet physician orders. The facility shall use this section to plan menus and purchase food in accordance with the following Recommended Dietary Allowances of the Food & Nutrition Board of the National Research Council, National Academy of Sciences. Milk and Milk Products Group: 16 ounces of more of Grade A whole or low fat pasteurized milk where milk is used for fluid consumption. Vegetable and Fruit Group: Five or more servings of fruit or vegetables.Facility provided policy titled, Guidelines in Menu Planning undated which documents in part all menus meet the Centers of Medicare & Medicaid Services health requirements. Menu planning includes but not limited to five servings of fruit and vegetables per day and two cups of milk.Facility provided policy titled Menus undated which documents in part, menus are planned in advanced and followed as written to meet the nutritional needs of the resident and a Registered Dietitian licensed in the state signs and approves the menus and menus are served as written unless changed due to an unpopular item on the item, an item could not be procured, or in the event of a special meal.

Based on observations, interviews, and record reviews, the facility failed to follow their policies by not securely storing their medications, disposing of expired medications, and ensuring residents don't receive expired medications for two out of two medication carts and one out of one medication storage rooms reviewed for medication storage.Findings include: On 3/03/2026 at 9:53 AM, surveyors reviewed the fourth-floor medication cart with V9 (Nurse). V9 stated the medication cart contained medications for 27 residents. In the third drawer, there was an orange, oval pill marked with 152 and an open/crushed capsule at the bottom of the drawer not in their original packaging. At 10:05 AM, during narcotic drawer review, R63's blister packet for Clonazepam 0.5mg (milligram) had a broken seal for pill slot #7. A medication was in the slot but the seal was broken. V9 stated will give the packet to V2 (Director of Nursing) to address what to do with it. At 10:09 AM, during narcotics review in the refrigerator, R41 had a Morphine solution of 20mg/ml (milliliter) that expired 8/22/2025. V9 stated per R41's corresponding Individual Controlled Substance Record, R41 last received the medication on 12/19/2025. R41 also had a bottle of Lorazepam 2mg/ml that expired 8/20/2025. V9 stated per R41's corresponding Individual Controlled Substance Record, R41 last received the medication on 1/05/2026. On 3/03/2026 at 10:22 AM, surveyors reviewed the third-floor medication cart with V8 (Nurse). V8 stated the medication cart contained medications for 25 residents. There was an orange, round pill not in its original packaging in the second drawer. In the fourth drawer, there were two bottles of R48's Acetaminophen 500mg tablets. The pharmacy dispensed one bottle on 12/23/2024 and the other on 3/24/2025. Both bottles did not have expiration dates. V8 did not know if the pills were expired or when the pills will expire. V8 stated R48 no longer takes the pills because R48 now takes the medication in liquid form. In the same drawer, there was also a packet of Loperamide 2mg that expired 2/2026. At 10:34 AM, during narcotics review in the refrigerator, R48 had a bottle of Morphine 20mg/ml that expired 2/03/2026. On 3/03/2026 at 2:31 PM, surveyors reviewed the first-floor medication closet with V2 (Director of Nursing). There was a bottle of Melatonin 1mg that expired 2/2026. V2 stated all nurses are responsible for keeping their carts clean, secure, and orderly. V2 stated the night nurses are responsible for going over all the medications in the cart to remove expired medications. V2 stated V2 goes over the medication rooms monthly. On 3/04/2026 at 8:18 AM, V26 (Nurse) prepared medications for R76. At 8:26 AM, V26 left medication cart unlocked at the nurses' station and went into R76's room to administer medications to R76. Medication cart was not visible from the room. V26 did not return to medication cart until 8:36 AM. Facility's undated Storage of Medications policy documents in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacy at the time of dispensing. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. Facility's undated Medication Administration General Guidelines policy documents in part: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observation, interview and record review, the facility failed to follow mechanical soft/ground diet menu/spreadsheets. This failure has the potential to affect all 16 residents receiving mechanical soft diets prepared in the facility kitchen.Findings Include: On 03/03/26 at 12:22 PM, observed R21's lunch tray on nightstand on the side of R21's bed (out of his reach). R21 received ground chicken with gravy, mashed potato, regular cut corn, one slice of bread cut in half on main plate and a separate covered bowl containing a fruit crisp. R21's meal ticket read Mechanical Soft Ground Meat texture, thin liquids and listed for the following items to be served: Ground Breaded Chicken Thighs with Gravy, Mashed Potatoes & Gravy, Creamed Corn, Soft Bread/Margarine, Soft Chopped Pear Crisp, Beverage.On 03/03/26 at 12:27 PM, observed V13 (Certified Nursing Assistant) preparing to feed R21. V13 looked at the plate of R21's food and looked at R21's meal ticket. V13 stated R21 should been given creamed corn not regular corn. V13 said, I'm not going to give that (pointing to the regular corn) to him because I don't want him to choke. V13 stated if the kitchen had given R21 creamed corn she would have fed that to R21 because creamed corn is small cut up pieces of corn in a gravy, so it is easier to chew/swallow. V13 said, the regular corn is too much of a risk for him (R21), that is why I am not going to give it to him.On 03/03/26 during lunch round observations observed other residents in addition to R21 (R50, R51, R61, R75) on mechanical soft diets receive regular cut corn instead of creamed corn as printed on their individual meal tickets.On 03/03/26 at 12:45 PM, V12 (Cook) stated he was the cook who prepared the food for the lunch meal ticket. V12 stated he gave the ground diets the same cut corn that he served to the regular diets. V12 stated he checks the menu and spreadsheets to see what food he needs to prepare for the upcoming meal. V12 stated the ground diets should have been served creamed corn. V12 stated the kitchen was out of cans of creamed corn and that is why he gave the ground diets the regular corn. V12 stated it was his responsibility to serve the items listed on the spreadsheet. V12 stated the potential problem with giving the ground diets regular corn is the regular corn could make them choke.On 03/03/26 at 12:51 PM, V10 (Dining Manager) stated it is his responsibility to make sure the food needed for the meal is ordered and available for the cook to prepare. V10 stated he did not see creamed corn on his production/inventory sheets and that is why he did not order the creamed corn.On 03/04/26 at 2:21 PM, V32 (Director of Regional Dietitian Consultant) stated mechanical soft consistency should be ground, soft, bite sizes pieces. V32 stated the mechanical soft and ground diets are the same thing. V32 stated some of the reasons residents require a mechanical soft or ground diet is if they have poor or missing dentition or dysphagia (chewing/swallowing problems). V32 stated all diet orders are confirmed by the doctor or nurse practitioner. V32 stated the information in the residents' EHR regarding diet gets integrated into the kitchen tray card system and this information then gets printed on the residents' meal tickets. V32 stated the meal tickets list the resident's diet order and lists the menu items to be served to the resident on that meal. V32 stated all the food items listed to be served on the meal ticket are based on the menus/spreadsheets for the diet consistency based on the resident's diet order. V32 stated the food items are listed on the meal tickets so the kitchen staff knows what food items to serve the resident and in the correct form (regular or ground or pureed). V32 stated the kitchen staff should be providing the food listed on the meal ticket. Surveyor showed V32 a copy of a R21, R50, R51, R61, R75's meal tickets from 03/03/25. V32 looked over the meal tickets and stated the residents should have received ground chicken, mashed potatoes, creamed corn, bread and pear crisp. V32 stated per the spreadsheet and meal tickets the mechanical soft/ground diets should have received creamed corn, not regular cut corn. V32 stated it is important for the spreadsheets and meal tickets to be followed to ensure the residents can tolerate the food being provided. V32 stated it could be a safety concern if residents on mechanical soft/ground diets were provided regular cut corn instead of the creamed corn because there is the potential risk of choking and/or aspirating.On 03/03/26, facility provided list of diet orders for all residents in the facility. The diet order list indicates there are 16 residents receiving mechanical soft diets.Diet Spreadsheet Day 17 - Tuesday documents in part for mechanical soft ground meat to serve creamed corn at lunch.Facility provided policy titled, Meal Identification, Resident Meal Card dated 2020 which documents in part, Resident tray cards shall be utilized by Dining Services staff to identify and provide accurate meal service for the individual while honoring their dining needs and preferences.Facility provided policy titled Menus undated which documents in part, menus are planned in advanced and followed as written to meet the nutritional needs of the resident.Facility provided policy titled Diet Summary Dental Soft (Mechanical Soft) Diet - This consistency modified diet is for individuals with limited or difficulty chewing regular textured foods. Foods should be moist and fork tender. Eliminates very hard, sticky, crunch or hard to chew foods.Facility provided policy titled, Textured Diets - Guidelines for Mechanical Soft Ground Meat which documents in part, recommended under vegetables to give creamed corn and to avoid whole kernel corn (except in mixed vegetables).

Based on observation, interview, and record review, the facility failed to ensure proper Personal Protective Equipment (PPE) was worn by staff when providing high contact resident care activities to a resident (R1) on Enhanced Barrier Precaution (EBP). This failure has the potential to affect all 26 residents residing on the fourth-floor unit. Findings Include:On 3/3/26 at 11:51 AM, an enhanced barrier precautions signage was noted posted on R1's door that reads in part: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting. At that time, R1 was observed lying in bed without a blanket, exposing a visibly soiled brief.On 3/3/26 at 11:59 AM, the surveyor observed V49 (Certified Nursing Assistant) providing incontinence care to R1 without wearing an isolation gown. V49 stated she is typically assigned to approximately 10-11 residents on the fourth floor but also assists with answering call lights and attending to the needs of other residents throughout the floor.On 3/3/26 at 2:28 PM, V4 (Infection Prevention Nurse) stated the facility's protocol for Enhanced Barrier Precautions applies to residents with chronic wounds, gastrostomy tubes, indwelling catheters, and other devices that create openings in the body. V4 stated staff are required to wear gowns and gloves during high-contact care activities, including incontinence care (changing briefs and bed baths), tube feedings, emptying indwelling catheters, transferring residents, changing linens, and accessing central lines. V4 further stated the purpose of Enhanced Barrier Precautions is to prevent the spread of infection and reduce the risk of transmitting communicable organisms. Some residents placed on EBP may be colonized with bacteria or infections. V4 stated staff must wear appropriate personal protective equipment (PPE) to protect themselves and prevent transmission of microorganisms to other residents. V4 stated failure to use proper PPE may result in staff transmitting bacteria between residents, which could lead to illness. Residents in long-term care facilities often have compromised immune systems and multiple comorbidities, placing them at higher risk for infection. V4 also stated that appropriate signage should be posted on the resident's door to alert staff and visitors regarding required PPE. V4 stated R1 was placed on Enhanced Barrier Precautions due to chronic wounds, which present a potential entry point for microorganisms.R1's Minimum Data Set assessment dated [DATE] shows R1 has severe impairment with cognition and is totally dependent with staff's assistance on toileting. R1's comprehensive care plan shows R1 is on enhanced barrier precaution related to chronic wounds with one intervention that reads in part: gown and glove during high contact resident care activities (such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs) (date initiated 1/12/26).The facility's Enhanced Barrier Precautions policy dated 5/7/24 reads in part: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities, especially when care is being bundled: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any chronic skin opening requiring a dressing.The facility's residents' roster printed on 3/3/26 shows 26 total residents residing on the fourth floor.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I re-assessment was completed upon expiration for two (R5, R51) out of six residents reviewed for PASRR compliance in a total sample of 20 residents.Findings include:R5's electronic health records (EHR) indicate R5 was initially admitted to the facility on [DATE], discharged from the facility from 07/25/25 and re-admitted to the facility on [DATE]. Diagnosis includes but not limited to Bipolar Disorder.R5's Order Summary Report dated 03/03/26 includes but not limited to Lamictal tablet 200 mg- give one tablet by mouth one time a day for depression; Amitriptyline HCl Oral Tablet 50 mg - give one tablet by mouth at bedtime for depression; Lurasidone HCl Oral Tablet 40 mg - give two tablet(s) by mouth in the evening for psych condition with dinner.R5's MDS (Minimum Data Set) dated 12/19/26 documents in part, active Psychiatric/Mood Disorder diagnoses include but not limited to Bipolar Disorder, Post Traumatic Stress Syndrome (PTSD). R5's Notice of PASRR Level I Screen Outcome dated 11/10/25 documents in part, PASRR Level I Determination: Exempted Hospital Discharge. Number of Approved Days: 30 days. Suspected or confirmed PASRR Condition(s): (MH) Mental Health Disability.R5's PASRR Outcome Explanation dated 11/10/25 documented in part, your Level I screen shows you have evidence of serious mental illness or intellectual/developmental disability (IDD). Further PASRR evaluation is not required because you meet criteria for an exempted hospital discharge. This means you may stay up to thirty (30) days in a Medicaid-certified nursing facility without further PASRR evaluation. If you or your care provider thinks you need to stay longer than thirty (30) days, a nursing facility staff member must submit a new Level I screen to Maximus. This must be completed by or before the 30th day after your admission to the nursing facility.R51's electronic health records (EHR) indicate R51 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Depression, Schizophrenia, Social Phobia, Bipolar Disorder.R51's Order Summary Report dated 03/03/26 includes but not limited to Olanzapine 20 mg - give one tablet by mouth at bedtime related to Schizophrenia, Bipolar Disorder; Olanzapine 5 mg - give one table by mouth at bedtime; Fluoxetine HCl Oral Capsule 20 mg - give two capsule(s) by mouth one time a day for antidepressant.R51's MDS (Minimum Data Set) dated 02/06/26 documents in part, R51's active Psychiatric/Mood Disorder diagnoses include but not limited to Depression, Bipolar Disorder.R51's Notice of PASRR Level I Screen Outcome dated 10/28/25 documents in part, PASRR Level I Determination: Convalescence Categorical. Number of Approved Days: 60 daysSuspected or confirmed PASRR Condition(s): (MH) Mental Health Disability.R51's PASRR Outcome Explanation dated 10/28/25 documented in part, Your PASRR Level I screening is complete. Your Level I screen shows you may have a serious mental illness or intellectual/developmental disability (IDD). You meet criteria for Convalescent Care, and you may stay for up to 60 calendar days in nursing facility without further PASRR assessment as long as you also require the level of services provided by a nursing facility and if you need to stay longer than the approved number of days the nursing facility must submit a new PASRR screen request to Maximus, 7-10 days before the time approval expires.On 03/04/26 at 11:17 AM, V3 (Social Service Director) stated the purpose of PASRR is to determine if the nursing home facility is an appropriate environment and if the resident with severe mental illness requires any special services. V3 stated her involvement in PASRR is when a resident is already in the building and a new PASRR is needed because their initial PASRR was approved short term. V3 stated it is important for residents initially admitted with short term approval to get re-screened within the stated time frame to see if their needs change and to confirm the nursing home continues to be an appropriate placement for them. V3 stated R5's PASRR was done 11/10/25 and R5 was approved for 30 days. V3 stated R5 admitted [DATE] (there was a delay in admission from the hospital). V3 stated R5's PASRR was still only approved for 30 days so R5's PASRR should have been re-done on or before 01/10/26. V3 stated R51 was admitted [DATE]. R51's PASRR Level I completed 10/28/25 indicated that he was approved for 60 days. V3 stated R51 should have had a PASRR re-evaluation completed by the end of December 2025. V3 stated both R5 and R51's PASRR re-screenings are overdue.Facility provided document titled, Preadmission Screening and Annual Resident Review (PASARR) dated 10/27/25 which documents in part, the objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting.

Based on interview and record reviews, the facility failed to complete the admission Minimum Data Set (MDS) assessments using the Centers for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument (RAI) process within the regulatory timeframes for one (R57) of six residents reviewed for resident assessment in a sample of 20.Findings include:On 3/04/26 at 3:00 PM, record review of R57's electronic health record (EHR) revealed that R57 was admitted to the facility on [DATE]. R57's admission MDS assessment with assessment reference date (ARD) of 02/09/26 was completed on 02/19/26; locked and accepted on 02/23/26.On 03/05/26 at 8:50 AM, V40 (MDS Coordinator) stated she is the MDS Coordinator at a sister facility. V40 stated the previous MDS Coordinator left two weeks ago, and the facility has hired a new MDS Coordinator but V40 is onsite to help train the new MDS Coordinator and to make sure everything is up to date and submitted on time. V40 stated the facility follows the CMS RAI (Resident Assessment Instrument) manual October 2025 which provides instructions/guidelines on how to code the different sections of the MDS and the timeframes for submission. V40 stated that from the day of admission the facility has 14 days to complete the resident's admission MDS. V40 stated if a resident gets admitted on [DATE] then that would be day one and 02/18/26 would be the 14th day which means the MDS assessment should be completed by 02/18/26. V40 stated if the MDS was completed on 02/19/26 then that would be late. V40 stated It is important to submit the MDS on time because the facility wants to make sure they have a good baseline of the resident, and they want to do that in a timely manner.Facility provided copy of CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1, October 2025, Chapter 2 manual page 17 titled RAI OBRA-required Assessment Summary which indicates in part that admission (Comprehensive) MDS assessment's completion date is no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days).

Based on interviews and record reviews, the facility failed to ensure accuracy of MDS (Minimum Data Set) assessment for one (R57) of six residents reviewed for resident assessment in a total sample of 20.Findings include:R57 was admitted to the facility on [DATE] with diagnosis that included Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Hyperlipidemia, Major Depressive Disorder, Glaucoma, Essential (Primary) Hypertension.R57's admission MDS (Minimum Data Set) assessment dated [DATE] Section N - Medications indicates in part, there were four days that insulin injections were received during the last 7 days or since admission/entry if less than 7 days.R57's Order Summary Report with order date range from 02/05/26 to 02/09/26 does not contain an order for insulin injections.R57's electronic medication administration record (MAR) dated from 02/01/26 to 02/28/26 does not contain an administration of insulin injections.On 03/05/26 at 8:36 AM, V40 (MDS Coordinator) stated she is the MDS Coordinator at a sister facility. V40 stated the previous MDS Coordinator left two weeks ago, and the facility has hired a new MDS Coordinator but V40 is onsite to help train the new MDS Coordinator and to make sure everything is up to date and submitted on time. V40 stated the facility follows the RAI (Resident Assessment Instrument) manual October 2025 which provides instructions/guidelines on how to code the different sections of the MDS including section N on how to code insulin. V40 stated section N addresses if the resident has received insulin while being in the facility and to determine if the resident has received insulin during the look back period the MDS Coordinator reviews the resident's MAR and counts the number of days insulin injection was received. V40 looked at R57's February 2026 MAR and stated she did not see any administration of insulin injections. V40 reviewed R57's MDS dated [DATE] section N and stated R57 was coded for having received insulin infections for four days. V40 stated It looks like it was an error because the resident had received blood thinner injections for four days, not insulin injections. V40 stated R57's admission MDS dated [DATE] is not an accurate assessment and it needs to be modified to reflect the medications R57 had received. V40 stated she does not want R57's MDS assessment to show that the facility was giving insulin when the facility did not administer any insulin injections to R57. V40 stated it is important for the MDS to accurately reflect the resident because the plan of care is based on the MDS assessment.Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, October 2025, Section N0350: Insulin documents in part: Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.

Based on interviews and record reviews, the facility failed to have an individualized comprehensive care plan for two (R10, and R74) residents out of a total sample of twenty residents. Findings Include: R74's Minimum Data Set (MDS) dated [DATE] noted she was cognitively impaired. R74's Electronic Medical Record (EMR) noted she was initially admitted to the facility on [DATE]. She was [AGE] years old with diagnoses not limited to personal history of transient ischemic attack, cerebral infarction due to embolism of right middle cerebral artery, Alzheimer's disease, paroxysmal atrial fibrillation, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and unspecified dementia. Physician Order Sheet dated 9/4/25 hospice consult. On 03/05/26 at 10:19 AM, V2 (Director of Nursing/DON) stated that she has been in this facility for two years, and comprehensive resident-centered care plan is important to ensure that residents receive specific care tailored to specific medical conditions. R74 should have a comprehensive person-centered care plan tailored to her hospice care to ensure collaboration between the hospice team and that the facility staff ensure her wishes for the end of life are respected and met. She also stated that R74 should have a care plan for her hospice care so that identified interventions are reviewed and implemented. V2 reviewed R74's comprehensive care plan with no documentation of hospice. R74's electronic medical record (EMR) noted R74's had no care plan for hospice care. Comprehensive Care Plan Policy dated 11/17/17, documents read in part: The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights. R10's admission Record documents in part a diagnosis of vascular dementia. R10's admission date to the facility was 11/17/2025. R10's 11/28/2025 MDS (Minimum Data Set) assessment documents in part that R10's cognition is severely impaired. It also documents in part that R10 had wandering behavior that occurred 4 to 6 days during the assessment period. R10's November 2025 progress notes document in part multiple incidents of staff finding R10 in the stairwells, near exits, or on different units (11/17/2025, 11/23/2025, 11/24/2025, 11/25/2025, and 11/29/2025). Progress notes document in part wandering and exit-seeking behavior. R10's 11/21/2025 Elopement Risk & Community Survival Skills Assessment documents in part that R10 is at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. Rational for decision: [R10] is exit seeking and is at risk for elopement. R10's 2/25/2026 Elopement Risk & Community Survival Skills Assessment documents in part that R10 is at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. It reads although R10 is stable at this time, R10 has a recent history of exit seeking behavior. On 3/03/2026 at 2:14 PM, R10 was oriented to self and city but disoriented to date or situation. R10 could not provide medical history or reason for being at the facility. R10 wore a wander alarm bracelet to the left wrist. R10 ambulated independently. On 3/05/2026 at 8:46 AM, V8 (Nurse) stated when R10 admitted to the facility, R10 wanted to go home. V8 stated R10 wandered and tried to exit the facility. On 3/05/2026 at 8:53 AM, V33 (Certified Nurse Aide Supervisor) stated R10 had behaviors of trying to go out the doors and trying to find a way out to go home. V33 stated R10 is now more involved in activities with less behaviors but remains an elopement risk. R10's current Care Plan Report did not contain focuses for R10's wandering behaviors or elopement risk. On 3/05/2026 at 9:38 AM, V40 (MDS Coordinator) reviewed R10's current comprehensive care plan with surveyor. V40 stated did not see a focus for wandering or elopement risk. On 3/05/2026 at 9:49 AM, V3 (Social Service Director) stated facility's electronic medical record resolved or cancelled out R10's wander/elopement risk care plan. V3 stated [V3] had to reactivate the care plan for it to be active. Facility's history record for R10's wander/elopement risk care plan documents in part that V3 resolved it on 1/05/2026. V3 did not reinstate it until 3/05/2026 (date of survey). Facility's Comprehensive Care Plan policy (last revised 11/17/17) documents in part: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observations, interviews, and record reviews, the facility failed to obtain a written order, assessment, or care plan for a family member (V41) to administer medications to a resident (R50) and failed to supervise R50's medication administrations for one resident out of a total sample of 20 residents.Findings include: R50's admission Record documents in part diagnoses of subarachnoid hemorrhage, subdural hemorrhage, and dysphagia (difficulty swallowing). R50's Care Plan Report documents in part that R50 is unable to consume regular consistency foods and requires a mechanically altered diet related to difficulty swallowing and chewing (initiated 3/26/2025). On 3/04/2026 at 8:04 AM, V26 (Nurse) prepared R50's medications which included Keppra oral solution, omeprazole, metoprolol, and famotidine. Keppra oral solution was in one medicine cup. The omeprazole, metoprolol, and famotidine were crushed and mixed with apples sauce in a separate medicine cup. At 8:08 AM, V26 went to R50's room and placed the medicine cups on top of the bedside drawer. V26 stated V41 (R50's family member) likes to administer the medications. V26 stated the doctor is aware of it. V41 stated [V41] usually administers the medications after R50 eats breakfast. V26 left the room and continued to prepare and administer medications to other residents including R76. At 8:34 AM, R50 was eating breakfast. The medicine cups were on top of the bedside drawer. V41 stated [V41] will give it to R50 when [R50] is done eating. On 3/04/2026 at 10:47 AM, surveyor reviewed R50's Order Summary Report, assessments, and progress notes (from November 2025 to time of survey), and care plan. No order for V41 to administer R50's medications. No assessment for self/family administration. No provider progress note reads that family is allowed to administer medications. No care plan for family to administer medications. On 3/04/2026 at 11:38 AM, V2 (Director of Nursing) stated [V2] did not recall a doctor's order to allow family members to administer R50's medications. V2 stated the nurse is supposed to administer the medication. V2 stated V2 will verify if V41 is allowed to administer medications. Surveyor requested documentation that they assessed V41 to be safe to administer medications to R50, informed the physician, obtained order, and requested policies/procedures related to self/family administration for medications. On 3/04/2026 at 12:30 PM, V26 stated when V26 received orientation, other nurses informed V26 that it was okay to allow V41 to administer it. V26 stated V30 (Nurse Practitioner) and possibly V42 (R50's Physician) are aware of it. On 3/04/2026 at 12:36 PM, V30 stated staff did not inform [V30]. V30 stated [V30] was not aware that family were administering the medications to R50. On 3/04/2026 at 1:12 PM, V2 stated V2 did not find an order or documentation that V42 was notified or is aware that R50's family is administering the medications. V2 stated [V2] left a message for V42 and was waiting for a response. At approximately 2:20 PM, V2 stated V42 was aware that V41 wanted to administer the medication and will put order into electronic medical record (at time of survey). On 3/05/2026 at approximately 8:55 AM, V41 was at R50's bedside. There were two medicine cups on top of the bedside drawer. One had a clear liquid, and one had applesauce with mixed powder in it. R50's nurse was not in the room. V41 stated the nurse left them for V41 to administer. V41 stated V1 did not know the names of the medications in the cups. V41 then began to administer the medications. On 3/05/2026 at 10:53 AM, V2 stated nurses are not supposed to leave medications at bedside. V2 stated V41 is allowed to administer the medications to R50 but the nurse is supposed to supervise and make sure R50 takes them. Facility's undated Oral Medication Administration policy documents in part: Administer medication and remain with resident while medication is swallowed. Caution with residents who have difficulty with swallowing. Do not leave medications at bedside. Facility's undated Medication Administration General Guidelines policy documents in part: Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. The resident is always observed after administration to ensure that the dose was completely ingested. On 3/04/2026 at 2:33 PM, V1 (Regional [NAME] President of Operations) wrote (via email) that they did not have additional policies/procedures for self-administration or family administering medications.

Based on observation, interview, and record review, the facility failed to ensure physician-ordered compression stockings were applied for 1 (R63) out of 1 resident to reduce lower extremities swelling in a final sample of 20 reviewed for quality of care. Findings Include:On 3/4/26 at 11:39 AM, R63 observed in the dining room sitting in a geriatric chair and noted with bilateral legs and feet swollen. R63 was not wearing any compression stockings.On 3/4/26 at 11:48 AM, Surveyor asked V49 (Certified Nursing Assistant/CNA) and V24 (Licensed Practical Nurse/LPN) to assist R63 back in her room. V24 confirmed R63's both legs and feet are swollen. V24 stated R63 has an order for compression stockings (TED hose) to be applied when R63 is assisted out of bed in the morning, typically around 6:00 AM, and removed at bedtime. V24 stated R63 was already up in the chair when she came on shift around 7:00 AM and was not informed R63 is not wearing her TED hose. V24 stated, This is the first time I'm seeing this. It's an oversight. V49 and V24 looked for the TED hose in R63's room but none were found.On 3/4/26 at 12:13 PM, V24 stated, They said [R63] refused her TED hose this morning. When asked if the refusal had been reported to [V24], V24 stated it had not been reported.On 3/4/26 at 12:27 PM, V2 (Director of Nursing) stated TED hose are to be applied according to the physician's order, typically on in the morning and off at a specified time. V2 stated residents are asked to wear them and if a resident refuses, staff should report to the nurse in charge and document the refusal. Repeated refusals should be care planned and reported to the physician and Social Services Director (SSD).On 3/4/26 at 2:25 PM, V4 (Infection Prevention Nurse/Assistant Director of Nursing) stated R63's TED hose order is to be applied at 6:00 AM and off at 6:00 PM for R63's both legs swelling.Review of R63's Order Summary Report with active orders as of 3/4/26 read in part: Apply TED hose to both lower extremities in the morning for swelling of both legs and remove per schedule (Order date 2/23/26). R63's Minimum Data Set, dated [DATE] shows R63 has severe cognitive impairment and needs substantial/maximal assistance from staff with lower body dressing. R63's comprehensive care plan does not show R63 has refusals with her TED hose.The facility's Anti-Embolism - Elastic Stockings policy (undated) reads in part: To promote venous return from lower extremities. To provide support for lower extremities. Stocking should be removed at least daily for skin care, circulatory check and reapplication. Stockings shall be removed in accordance with physician orders.

Based on observation, interview, and record review, the facility failed to ensure correct settings of air loss mattress for one (R4) resident with facility acquired unstageable pressure ulcer reviewed in a sample of 20. The findings include:R4's admission record / face sheet shows initial admit date on 1/17/26 with diagnoses not limited to Muscle wasting and atrophy, Other abnormalities of gait and mobility, Other lack of coordination, Anemia, Essential (primary) hypertension, Unspecified dementia, Chronic embolism and thrombosis, Peripheral vascular disease, Unilateral primary osteoarthritis left knee, Hyperlipidemia, Hypertensive heart disease with heart failure, Chronic systolic (congestive) heart failure, Chronic gout, Spinal stenosis. On 3/3/26 at 10:44AM Observed R4 lying on air loss mattress in bed, display setting shows 130 lbs., alternating, with signal red light indicating failure and beeping intermittently. On 3/4/26 At 11:26AM V29 (Wound Care Coordinator, LPN / Licensed Practical Nurse) stated she has been working in the facility for 2 years and transitioned as wound care coordinator 2 weeks ago. She stated R4 with unstageable pressure ulcer in the sacrum area. Wound care observation conducted with V29 assisted by V48 (CNA / Certified Nursing Assistant Supervisor, CNA Scheduler). Observed R4 lying on air loss mattress display setting shows 130 lbs. with signal red light indicating failure and beeping intermittently. Observed sacral wound with dressing in placed, V29 removed wound dressing and observed open wound about the size of tennis ball on sacral area. Wound bed appears beefy red with scattered yellowish slough about 20%. Observed V29 cleansed wound with Dakin's solution then she applied Santyl ointment to wound. V29 applied soaked gauze with Dakin's solution to wound bed and covered with foam dressing. Reviewed R4's EHR (Electronic Health Record) with V29 and stated R4 has facility acquired unstageable pressure ulcer on sacral area, identified on 9/17/25. Stated R4 was last seen by wound care specialist on 2/26/26. Wound Measurement: 7.0 x 9.0 x 4.0cm. V29 stated sacral wound is improving with no signs and symptoms of wound infection. She stated R4 is using Air loss mattress to keep pressure off the wound. V29 stated that air loss mattress setting should be correct according to resident's weight and operating / working properly. She stated Resident's weight should be correctly set on the mattress. V29 stated if resident's weight is 160lbs, the setting should be around 160lbs range. V29 said if air loss mattress setting is not correct, there could be a loss of air, could not work properly and could affect the wound healing. She stated air loss mattress setting should be checked every day. V29 stated if there is an indication of air loss mattress failure, it could mean that air loss mattress is not working properly, and wound could get worse or delay wound healing. On 3/5/26 At 10:57AM V2 (Director of Nursing / DON) stated 6 years working in the facility and transitioned as DON 2 years ago. V2 stated use of Air loss mattress, staff are expected that it should match on the range of resident's weight, should be fully inflated, no warning signal, functioning properly. She stated if air loss mattress is not in a correct setting, it defeats its purpose, could affect / delay wound healing. V2 stated Air loss mattress is used to reduce pressure on all bony areas of the resident. R4's EHR shows weight as follows: On 3/1/2026 = 161.4lbs. On 2/1/26 = 162.0lbs. MDS (Minimum Data Set) dated 1/20/26 shows R4's cognition was severely impaired. MDS shows 1 unstageable pressure ulcer that was not present on admission or reentry.R4's POS (Physician Order Sheet) dated 3/4/36 shows order not limited to: Low air loss mattress for wound management. Treatment: Sacrum- cleanse with Dakin's solution, apply Santyl then lightly packed with 1/4 strength Dakin's moist gauze, cover with Bordered foam daily and as needed. R4's Wound assessment dated [DATE] shows in part: Facility acquired unstageable pressure ulcer on Sacrum. Measurement: 7 x 9 x 4 cm.R4's wound MD notes dated 2/26/26 show in part: Sacral Stage IV pressure ulcer. Wound measurement 6.6 x 7 x 2.3cm. Wound progress: No change.Care plan dated 1/26/26 shows in part: R4 has an actual and potential for impairment to skin integrity related to skin fragility related to age, impaired mobility, impaired circulation, bowel and bladder incontinence, presence of scar tissue, history of wounds and comorbidities. Check air mattress if functioning properly every shift and PRN. Facility's Alternating pressure and low air loss mattress user manual (undated) shows in part: Low pressure, or system failure indicators allow the user to be aware of any air pressure changes, or system malfunctions. Weight settings range from less than 250lbs to 1,000lbs and can be used to adjust the pressure of the inflated cells based on the patient's weight.Facility's pressure injury prevention policy dated 2/18/26 shows in part: Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds.

Based on observations, interviews, and record reviews, the facility failed to ensure foot care was provided for 1 resident (R1) and failed to assist the resident in making appointments with a qualified person to receive appropriate foot care, demonstrating inadequate care. This failure resulted in R1 suffering physical harm stating symptoms of unbearable foot pain and also suffering psychosocial harm stating feelings of depression, irritability and difficulty sleeping. Findings include: On 1/13/25 at 10:27am, surveyor observed R1 displaying facial grimacing and when surveyor inquired about the facial grimacing, R1 replied, It's my feet. Look at my feet. The pain is unbearable sometimes. I am so depressed and mad. The pain makes it impossible to sleep. Surveyor observed R1's feet, which were red, very dry, and scaly. R1's toenails were long, and discolored. A maroon colored substance was observed between the 1st and 2nd toe and the 4th and 5th toe on R1's right foot. A brown substance was observed between the 1st and 2nd toe on R1's left foot. Surveyor asked when the last time R1 received nail care and R1 replied, I went to the podiatrist once. The staff will not touch my nails because they said I have to see podiatry. It was years ago since I seen the podiatrist. My fingernails and hair aren't any better. My hair is all matted. R1's Face Sheet, documents medical diagnosis that include but are not limited to type 2 diabetes mellitus; other abnormalities of gait and mobility; cerebral infarction; dislocation of internal left hip prosthesis; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; need for assistance with personal care; dysphagia, oropharyngeal phase; gastro-esophageal reflux disease without esophagitis; gastrostomy status; and dysphagia following cerebral infarction. R1's BIMS (Brief Interview for Mental Status) Summary Score: 10, dated 10/11/24, suggests moderate cognitive impairment. R1's Care Plan, revised date 4/24/24, documents, in part, (R1) has Diabetes Mellitus, with interventions, Check all of body for breaks in skin and treat promptly as ordered by doctor. R1's Care plan, revised date 5/22/24, documents, in part, (R1) has an ADL (activities of daily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Activity Intolerance, Fatigue, Limited Mobility, abnormal gait, Dysphagia, weakness, CVA (cerebral vascular accident) with residual hemiplegia, with interventions that document, in part, Toilet hygiene-My usual performance is Dependent; Shower/Bathe self: (R1) take a shower/bath/bath at sink/bed bath my usual performance is dependent. R1's Order Summary Report, dated 1/14/25, documents, in part, Order date 9/16/25 Podiatry consult for toenail trimming. On 1/13/25 at 11:02am, while surveyor and V3 (Registered Nurse/RN) were in R1's room, V3 said, I'm not sure when (R1) went to the podiatrist last. Yes, they (toenails) are overgrown. Let me check when her next appointment is. On 1/15/25 at 11:06am, V17 (Social Services Director) said, I schedule the residents for the podiatry clinic. I don't know when (R1) was last seen by podiatry. I contacted the podiatry office and they said that she (R1) was last seen in 2017. She is now set up to go January 30th (1/30/25). I cannot find any other records. Facility presented document from the podiatry office, undated, that documents, in part, (R1) (11/15/1951) was seen in March 2017 . Our office has received a request to reinstate (R1) for podiatry services. She has been added to the visit list and scheduled to be seen . 1/30/25 when (Podiatrist) is next on the building. On 1/15/25 at 1:18pm, V23 (Medical Director) said, I know of her (R1), but I am not her attending. My colleague is her attending and would know more but and I can try to answer your questions. When asked about R1's feet care and podiatry V23 replied, I am not aware of any issues with her (R1). V23 stated that Diabetes can cause poor circulation in the feet and pain. V23 said that she will try to reach R1's attending physician and have R1's attending physician call this surveyor. R1's attending physician never called this surveyor. Evidence shows that R1 has Type 2 Diabetes Mellitus which poses a risk to foot health. R1 has an active order for a Podiatry consult that was ordered on 9/16/25 and the facility was not able to provide evidence that R1 has seen the podiatrist recently. The facility was only able to provide documentation that R1 saw the podiatrist in March of 2017 (almost 8 years ago). Facility policy titled, Activities of Daily Living (ADLS), undated, documents, in part, Bathing: Washing and drying the body (excluding back and shampooing hair), including full body sponge bath, planning the task, and gathering supplies, and transfer into and out of tub/shower. Grooming: Maintaining personal hygiene, including planning the task and gathering supplies, combing and/or styling hair, face, and hands, brushing teeth, shaving, or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and/or application of deodorant or powder. Facility policy titled, Nail Care, revised date 1/25/18, 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length uneven edges, hypertrophied nails. 4. After bathing, use orange stick, and clean debris from around and under finger and toenails. 5. Trim toenails carefully in a straight fashion and fingernails in an oval fashion avoiding tissue after bathing or when needed. Be sure nails are soft before trimming. Additional soaking in warm soapy water may be necessary to soften nails. 10. Document provision of care and pertinent observations. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

Based on interviews and record review, the facility failed to provide for pressure redistribution to prevent a resident's (R1) pressure injuries from developing out of 3 residents reviewed for pressure ulcers. This failure resulted in R1 developed avoidable bilateral buttock pressure injuries identified as facility acquired stage three pressure ulcer (left buttock) and unstageable pressure ulcer (right buttock). Findings include: R1's Face sheet documents that R1 is an [AGE] year-old male who has diagnoses is not limited to: Parkinson's disease without dyskinesia, dementia, chronic obstructive pulmonary disease, need for assistance with personal care, weakness. R1's admission Minimum Data Set (MDS) section M dated 01/29/2024 documents R1 is at risk for pressure ulcers and documents R1 does not have any pressure ulcers. R1's admission Minimum Data Set (MDS) section GG dated 01/29/2024 documents R1 needs extensive assistance for eating and bed mobility, and R1 is dependent on oral hygiene, toileting hygiene, shower, dressing, and transfers. R1's MDS/Minimum Data Set Section C dated 04/26/2024 shows R1 has a BIMS/Brief Interview for Mental Status score of 99, indicating that R1 was unable to complete the interview due to severe cognitive impairment. R1's Minimum Data Set (MDS) section M dated 04/26/2024 shows R1 has one stage 2 pressure ulcer and one unstageable pressure ulcer. R1's Minimum Data Set (MDS) section GG dated 04/26/2024 documents R1 needs extensive assistance for eating and bed mobility, and R1 is dependent on oral hygiene, toileting hygiene, shower, dressing, and transfers. R1's discharge Minimum Data Set (MDS) section GG dated 05/14/2024 documents R1 needs extensive assistance for eating and bed mobility, and R1 is dependent on oral hygiene, toileting hygiene, shower, dressing, and transfers. R1's discharge Minimum Data Set (MDS) section M dated 05/14/2024 shows R1 has one stage 3 pressure ulcer and one unstageable pressure ulcer. R1's doctor's progress note, 04/16/2024 4:35 PM, documents in part: buttocks are healed. left heel is better. 0.8 X 1.2 X 0.1 CM R1's weekly skin observation note, 04/17/2024 1:31 PM, documents in part: skin concerns observed: Right buttock - Resolved, Left heel - DTI (deep tissue injury), measures: 0.8 x 1.2 cm. Skin concerns observed are not new. R1's skin note, 04/21/2024 at 07:26 AM, documents in part: R1 was seen, and skin was examined. Measurements were taken, for the left buttock, 4.0 x 2.0 x 0.1 cm, for the right buttock it measures, 5.0 x 3.0 x 0.1 cm. The resident is currently using a LAL mattress and is currently on treatment for a DTI on his left heel. Staff were reminded regarding incontinence care and turning of residents. Also, referred to the Dietician for dietary management of the wound. R1's doctor's progress note, 04/23/2024 5:25 pm, documents in part: r. (right) buttocks has a black eschar. 5 x 3 x. 0.l (left) heel is larger. 2.5 x 3 cm. On 6/18/24 at 3:24 PM V4 (Registered Nurse/Treatment nurse) states that he began working as the treatment nurse in March 2024. V4 states that when there is documentation that a wound is healed, V4 states that it means it is already resolved, and V4 states it means the resident is discharged from wound care rounds. V4 states it is up to the doctor or NP (nurse practitioner) to determine appearance of a healed wound, but V4 states that for him, it means the skin is already intact. Surveyor questioned V4 what was the significance of R1's bilateral buttocks healed and four days later R1's bilateral buttocks noted with the following measurements (left buttock, 4.0 x 2.0 x 0.1 cm, and right buttock, 5.0 x 3.0 x 0.1 cm) per V4's documentation? V4 states that for four days, there was a bit of change, and V4 states that maybe the resident didn't receive wound care, V4 states maybe R1 was not turned as scheduled, maybe the resident's skin was not checked. V4 states maybe R1 was not eating enough nutrition, V4 states maybe if R1 stayed too long in bed. V4 states R1 was already being followed by wound care team and the prior wound care nurse. V4 states that he continued to follow R1 during the course, V4 states that wound care team were more focused on his sacrum wound and V4 states R1 would stay in the wheelchair per R1's wife request, so V4 states it was quite difficult to manage the wound. On 6/18/2024 at 2:10 PM V5 (Director of nursing/DON) states that in general wound preventative measures include turn and reposition as needed. V5 states that all residents are on weekly skin observations and V5 states that the overnight nurse is responsible to conduct these skin assessments. V5 states since this building just got acquired, V5 states that staff began the weekly observations in April 2024. On 6/18/2024 at 3:57 PM, V6 (Doctor of Medicine/Wound Clinician) states that he remembers R1. V6 states that it is hard to say if R1's wounds could have been preventative, V6 states it can be a contribution of nutrition and V6 worries that both wounds had deteriorated. V6 states more is going on with nutrition, diet, and V6 is not sure what the dietitian had for him. V6 states pressure can contribute to it. Surveyor informed V6 R1 is dependent on care. V6 states that both the heel and buttocks deteriorating can be due to pressure, nutrition, turn and reposition, and V6 states then the nurses must do more turning. V6 states that he agrees the wounds could have been prevented from opening to that measurement and appearance within four days. V6 states that his next note on April 30th, 2024, indicates the heel is larger and left buttock wound, and right buttock wound is the same measurement as previously. On 6/21/2024 at 1:13 PM V7 (Certified Nursing Assistant/CNA) states that R1 was a very sweet man to take care of. V7 states that R1 was total care. V7 states that when R1 would be able to be up in the wheelchair, R1 was able to feed himself. V7 states that when R1 was up in his wheelchair, R1's ability to feed self was way more successful than in bed. V7 stated for example, in the morning, because we didn't get him up until mid-morning, for lunch he was a feeder for only 10% of the time. For breakfast he was a feeder, like 90%. We would still sit with him and encourage him and open items up. We were still with him. V7 states that for the last week to a month R1 was in the facility, R1 wasn't eating as well. V7 states that she is the wound care assistant and was able to see his wounds once a week during wound care rounds. V7 states it was one moment of him sitting too long and it could have opened again. V7 states that R1 could not be sitting up in his wheelchair no longer than 3 hours. V7 states if R1 got up at 11am, V7 states R1 had to be back in bed by 1pm. V7 states staff would give report to each other, CNAs to CNAs. V7 states some people would say they had the hardest time with R1, and I just couldn't get him to turn over. V7 states these statements were from the newer CNAs. On 6/21/2024 at 3:00 PM V8 (Director Regional Dietitian Consultant) states that V8 conducted an assessment for R1 on May 8th, 2024, and on March 8th, 2024. V8 states that another dietitian conducted R1's assessment in April 2024. V8 states that R1 had a weight loss. V8 states there was intake improvement in May. V8 states that March intake was fair. V8 states that they base it on the nursing assistants' documentation and what they charted for residents' intake. V8 states if the CNAs charted that the resident ate ten times good and three times poor then it is fair intake. V8 states it depends on the individualized dietitian's clinical judgment. R1's wound assessment detail report dated 5/14/2024 documents in part, right buttock active, type- pressure ulceration, source- facility acquired, unstageable. R1's wound assessment detail report dated 5/14/2024 documents in part, left buttock active, type- pressure ulceration, source- facility acquired, stage three. R1's care plan dated 1/24/2024 documents in part: the resident will be free from injury through the review date. R1's physician order set documents in part: House Nutrition Supplement three times a day for nutrition support give 120ml TID (three times a day), Nutritional Treat one time a day - one cup of Yogurt (Family supplied), protein Sugar Free supplement one time a day 30 ml, nutritional shake two times a day supplement. R1's weight log documents the following: 01/23/2024 - 196.6 lbs (pounds), 1/28/2024- 195 lbs, 2/06/2024- 196 lbs, 03/01/2024- 196.3 lbs, 4/11/2024- 176.2 lbs, 04/30/2024- 176.2 lbs, 05/04/2024- 169.2 lbs. R1's weight documents R1's weight remained the same during the period R1's bilateral buttocks healed and R1's bilateral buttock wounds were noted. The facility's Policy, titled Skin Condition Assessment & Monitoring- Pressure and Non-Pressure dated 6-8-18, documents in part, the resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care. The facility's Policy, titled Pressure Ulcer Prevention dated 1/15/2018, documents in part, to prevent and treat pressure sores/pressure injury, turn dependent resident approximately every two hours or as needed, wheelchair residents may be instructed to shift weight from one buttock to the other.

Based on interview and record review, the facility failed to supervise dementia residents who are at high risk for falling, failed to ensure all residents are assessed for falls upon admission, failed to ensure safety precautions were in place to minimize the risk of injury and failed to follow their Fall Policy and Fall Risk Assessment Policy for 2 (R1, R2) of 3 residents reviewed for falls in the sample of 3 residents. These failures resulted in R1 sustaining a right [CONDITION(S)] requiring surgery and R2 sustaining a dislocation of the right hip prosthesis for a recent femur fracture which required surgery. The findings include: R1, a cognitively impaired, non-ambulatory, [AGE] year old female, was admitted over a year ago on 1/4/21 with a fractured femur that required surgery per face sheet. The Annual Minimum Data Set (MDS) dated [DATE], states R1 requires extensive assistance for her activities of daily living (ADLs). R1's cognition (Brief Interview Mental Score/BIMS) score is a 4 which indicates cognitive impairment. The surgery was a hip rodding in December 2021. R1 has been assessed as a high risk for falls on 1/4/22 and 10/5/21 with an unsteady gait. R1 has sustained many falls while in the facility per the care plan. R1 has had unwitnessed falls on 3/4/21 at 5 PM, 7/9/21 at 6 PM, 8/5/21 at 11:45 PM and 1/22/22 at 7:30 PM. R1's fall on 1/22/22 at 7:30 PM resulted in R1 fracturing her right femur and requiring Cephalomedullary fixation of the right femur. V6 (Registered Nurse/R.N.) and V7 (Certified Nurse Aide/C.N.A.) were the assigned staff members. R1's care plan interventions for falls were to ensure frequent monitoring and a low bed. On 3/9/22 at 11:17 AM, V7 stated on 1/22/22 R1 was complaining about sitting up all day and wanting to lay down so R1 was taken to her bed and laid down. V7 stated the bed was at its lowest position, not sure of the inches but low. V7 stated not to remember if there was a bed alarm but stated the corridor door is left open and the room is near the nurses' station. V7 stated there was no floor mattress or pad. V7 stated it was V6 who informed her that R1 was on the floor. V7 stated that R1 had to walk a few feet to reach the doorway which was unexpected because R1 was laid down 15 minutes earlier after being toileted. Attempts to contact V6 (R.N.) were unsuccessful. The facility's report on R1's fall of 1/22/22 at 7:30 PM documents R1 was found on the floor in hallway by her door. There were no witnesses, no alarms or floor mats. R1 did have a low bed but there is no measurement as to how low the bed was positioned. R1 sustained a skin tear to right elbow and right thigh and was sent to hospital where R1 had a Cephalomedullary fixation of the right femur. R1 returned to the facility on [DATE] per the MDS and nurses' note. The new intervention after this fall was to provide a chair/bed alarm but this intervention had been care planned since the 3/4/21 fall investigation and care plan. R2, a cognitively impaired, non-ambulatory, Spanish speaking, [AGE] year old male, was admitted on [DATE] with a metallic right hip prosthesis that was dislocated 2 times prior to entry to this facility; per R2's face sheet and admission MDS dated [DATE]. R2 required extensive assistance with ADLs. R2's BIMS is 8 per the admission MDS 1/13/22; but the 2nd admission MDS dated [DATE] (following surgery) documents a BIMS of 00 which indicates cognitive impairment. R2 sustained a fall in his room on 1/16/22 at 8 PM which resulted in R2 re-dislocating the hip prosthesis. V8 (R.N.) and V9 (Certified Nurse Aide/CNA) were assigned to R2. R2's care plan intervention for falls are to ensure frequent monitoring and a low bed. On 3/4/22 at 10:30 AM, V5 (4th Floor R.N.) stated the facility uses bed/chair alarms, floor mats and constant monitoring for residents at risk for falls. On 3/4/22 at 12:15 PM, V2 (Restorative R.N.) stated that the staff will round every hour for frequent monitoring and the fall risk residents are in rooms closer to the nurse's station. V2 stated due to R1's unsteady gait and the ability to take a few steps, a floor mattress would not be good in R1's room. V2 stated R2 came to this facility after R2 dislocated his hip prosthesis 2 times in another nursing home and surgery was put on hold while R2 received skilled therapy here. V2 stated that R2's bed was lowered to knee height approximately 16 inches from the floor because the bed height assisted in proper hip/knee alignment when exiting the bed. V2 stated after this 3rd dislocation of the prosthesis, surgery was performed as planned. On 3/4/22 at 2 PM,V2 (Restorative R.N.) stated R2 arrived with an immobilizer on his right leg due to sustaining a fall which required surgery at another nursing home prior to entry to this facility. Asked for R2's initial fall assessment, V2 stated it should be there. The initial 1/13/22 fall assessment was blank, and it was presented to V2. V2 had no response. The facility staff failed to provide an initial fall assessment for R2. On 3/9/22 at 10:40 AM, V8 (R.N.) stated R2 was a new resident, and this was the first time she worked with him. V8 stated R2 was very restless, moving around in the bed, would not use call light, spoke Spanish mostly and continuously removed his clothing and adult brief and threw them. V8 stated not to be aware of R2's cognition but stated when the C.N.A. would say English, English then R2 would respond in English. V8 stated R2 was unable to walk and had an immobilizer on his right leg. V8 stated not to recall any alarm on R2 when R2 was found on the floor in his room. V8 stated R2 was X-rayed, and the fracture was dislocated again. R2 was sent to hospital where surgery was done due to dislocating the metallic prosthesis in the right hip. On 3/9/22 at 11:52 AM, V9 (C.N.A.) stated R2 was always restless, agitated and removed his clothing and adult brief. V9 stated to recall a landing strip (a thin, rubberized mat) pad on the floor on R2's right side. V9 stated not to be aware that R2 was demented and that R2 kept saying wants to go outside for a walk. V9 stated she found R2 on the floor next to his bed. Review of the facility's R2 fall incident 1/16/22 documents that R2 is oriented to self only, sustained a mechanical fall with acute right femoral neck fracture, right hemi-arthroplasty dislocated 2 times since 1/7/22. R2's right leg was extended outward with immobilizer intact along with fecal matter smeared on his left hand, left thigh and smeared on bed sheets and pillow. Bed was positioned at knee height. After this fall, a personal alarm and floor mat were applied as fall interventions. The facility's policy labeled FALLS - CLINICAL PROTOCOL documents while many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or consequences of falling. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with physician whether these measures are still needed. The facility's policy labeled FALL RISK ASSESSMENT documents upon admission, the nursing staff and the physician will review a resident's record for a history of falls especially falls in the last 90 days and recurrent or periodic bouts of falling over time. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. Staff will evaluate functional and psychological factors that may increase fall risk, including mobility, excessive motor activity, cognition and activities of daily living. The staff and physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.

Based on observations, interviews and record reviews, the facility failed to follow standard of practice when using a low air loss mattress, follow physician orders for wound care and failed to provide necessary care and services to prevent a sacral wound from reopening and prevent worsening of pressure ulcers for 2 (R1 and R2) out of 3 residents reviewed for pressure ulcers. This failure resulted in R1's sacral ulcer reopening and worsening of the sacral and buttocks ulcers which required hospitalization for debridement. Findings include: R1's face sheet reads an admitted [DATE]. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V3's (R1's Primary Physician) progress note dated 04/02/2021 06:04 PM reads R1 was severely deconditioned with worsening strength. V4's (Wound Physician) progress note dated 04/06/2021 11:54 PM reads R1 admitted to the facility with wounds to both buttocks stage 3. V14's (Physical Medicine and Rehabilitation Physician) progress note dated 04/19/2021 08:57 PM reads R1 is max assistance for toileting. V4's progress note dated 07/13/2021 11:50 AM reads R1's buttock pressure ulcers are larger and redder. Left buttocks wound measured 16.2 X 13 X 0.2 cm (centimeter) compared to the previous week's (07/06/2021) measurement of 8 X 4.5 X 0.2 cm. The right buttocks wound measured 10.7 X 7 X 0.2 cm compared to previous week's measurement of 10.2 X 7 X 0.2 cm. V15's progress note dated 07/15/2021 10:46 AM reads R1 remained max assistance for toileting. V4's progress note dated 07/20/2021 11:54 AM reads Long discussion about why [R1's] buttocks wounds are worse. [R1] uses a urinal and sometimes [R1] spills it because [R1] penis is retracted that gets [R1's] dressings wet. Last night [R1] slept soundly and wet [R1] during the night. Left buttock wound now measures 17.5 X 14 X 0.2 cm and right buttock wound measures 16 X 14 X 0.2 cm. V4's progress noted dated 08/03/2021 09:15 AM reads R1 now has a new sacral ulcer that is deep measured 5.5 X 1 X 3.2 cm. V4's progress noted dated 08/17/2021 09:28 PM reads R1's sacral ulcer is from a previous pilonidal surgery several years ago that took months to heal. Sacral ulcer is deep and slow to heal measured 4.5 X 1 X 3 cm. V4's progress noted dated 08/31/2021 04:11 PM reads sacral ulcer is deeper and goes to the bone measured 4 X 3 X 5.4 cm. V4's progress note dated 10/12/2021 10:51 PM reads [R1] buttocks wounds are all larger and more irritated. [R1] uses a urinal but it spills sometimes because of [R1's] obesity. Left buttocks measured 11 X 13 X 0.1 cm, right buttocks measured 15.5 X 9 X 0.1 cm, and sacral pilonidal wound measured 5.2 X 3.6 X 5.4 cm. V4's progress note dated 10/19/2021 12:01 PM reads Talked with [R1] because [R1] buttocks wounds are larger and [R1] has abrasions on [R1's] perineum. [R1] reminded me that [R1] uses a urinal and it often spills because of [R1's] obesity and positioning. Left buttocks measured 12.5 X 13.5 X 0.1 cm, right buttocks measured 15 x 16 x 0.1 cm, and sacral pilonidal ulcer measured 5 X 3.6 X 5.6 cm. V3's progress note dated 10/20/2021 06:26 PM reads R1's overall prognosis could be very poor with progression of [R1's] sacral wound, that can cause further complication including infection, [CONDITION(S)] (bone infection), and further deconditioning. V4's progress noted dated 10/26/2021 10:27 PM reads [R1's] wounds are all larger with necrotic eschar in the perineum, making both buttocks one large wound 32.5 X 21 X 0.2 cm. Sacrum with stool in the wound 8 X 7.1 X 6 cm. V3's last progress note dated 10/27/2021 05:45 PM reads R1 was transferred to the hospital for further treatment and debridement of R1's large necrotic ulcer. V3 wrote there was a high risk for [CONDITION(S)]. R1's Skin Care care plan dated 10/2021 reads R1 was incontinent of bowel and bladder. R1 needed extensive assist on bed mobility with more than two people assist. Skin care plan reads these were contributing factors to R1's skin issues. R1's comprehensive care plan does not include a care plan for R1's incontinence or bowel and bladder needs. On 12/21/2021 at 2:09 PM, V8 (CNA, Certified Nurse Assistant) stated when V8 would start working at 06:30 AM, V8 would frequently find R1 soaked. V8 stated V8 complained to V9 (Nurse) and they would have to change R1 right away. V8 stated they would find R1's diaper, clothes, linen and wound dressings soaked. V8 stated when they turned R1, R1's wound dressing would fall out because it was really soaked. V8 stated [V8] works full time doing eight hour shifts at the facility for almost seven years. V8 stated every morning when V8 came to work, R1 was soiled. V8 stated R1 would tell V8 that R1 would put on the call light during the night, and no one would come to clean R1. On 12/21/2021 at 2:26 PM, V5 (Wound Nurse) stated R1 was constantly wet, and the CNAs and staff needed to change R1 right away. V5 stated V5 informed staff to frequently check R1 for incontinence. Surveyor reviewed R1's comprehensive care plan with V5, who is also the MDS (Minimum Data Set) Nurse. V5 stated V5 does not read a care plan for R1's incontinence. On 12/21/2021 at 2:56 PM, V9 stated V8 would frequently complain that R1 was left soaked from the previous shift. V9 stated V9 mostly works 7 am shift from Sunday to Wednesday at the facility. V9 stated 3 out of the 4 days, V8 and V9 would always find R1 soaked. V9 stated they found the sacral and buttocks wound dressings soaked. V9 stated almost every day when V9 came to work early, V8 would complain right away that R1 was soaked. During a telephone conversation with V4 on 12/22/2021 at 10:29 AM, V4 stated constant moisture contributed to R1's pressure wounds getting worst. V4 stated R1 had a short penis and had difficulty using the urinal. V4 stated R1 would spill urine and it would wet the dressings, R1's sacrum, clothes and sheet. V4 stated it was a constant problem. V4 stated if staff changed R1 more frequently then R1 would do better but R1 refused. Surveyor interviewed multiple staff members including V5, V6 (Nurse), V7 (CNA), V8, V9 and V10 (CNA). No mention of R1 refusing incontinence care. Reviewed R1's comprehensive care plan. It does not read that R1 had noncompliant behaviors for toileting. During a telephone interview with V2 (Director of Nursing) on 12/22/2021 at 2:26 PM, V2 stated R1 was always incontinent. V2 stated the goal was to keep R1 dry at all times. Surveyor reviewed facility's policy titled Prevention of Pressure Ulcers last reviewed 01/2017. It reads Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap resident, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. Under Interventions and Preventative Measures: Residents with Risk Factors, it continues to read: 1. Risk Factor-Moisture . c. Provide clean, unwrinkled sheets d. Place resident on a minimum of a q (every) 2 hour check and change program e. Provide personal hygiene care/bath (teach staff to avoid leaving soap residue) to remove perspiration, bacteria and promote comfort. Frequency will be dictated both by facility routine and resident need. A resident who perspires profusely may need to receive more frequent care. f. Address causes of moisture if possible (e.g., bladder training, schedule toileting). It further reads: 6. Risk Factor - Bowel/Bladder Incontinence a. Check resident for incontinence at least q 2 hours and clean skin where soiled. b. Assess and treat urine leaks. R2 is a resident of the facility. R2's face sheet reads diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] ½ ABD PAD AND [MEDICATION(S)] FOR PROTECTION AND CUSHION. Order date is 03/29/2018. R2 also has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. - Apply SSD -Cover with gauze and ABD [abdominal] pad over -Secure with tape -Dress daily and PRN [as needed]. Order date 08/10/2021. R2 also has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/21/2021 at 10:50 AM, surveyor observed V5 and V7 perform wound care for R2. R2's lower extremities are contracted. R2 was lying on a low air loss mattress. Surveyor observed fitted sheet on the mattress, flat sheet folded twice over (4 layers of flat sheet) and two blue disposable pads underneath R2. R2 was also wearing an incontinence product. V7 turned R2 and V7 removed the incontinence product. R2 with stool and no dressing noted over sacrum. V5 stated V5 did not see a dressing on R2's sacral wound. V5 stated R2 should have a dressing over R2's sacral wound. V5 proceeded with wound care. V7 provided incontinence care and V5 finished the wound care at 11:10 AM. Did not observe V5 place REMEDY Z-GUARD cream as ordered. During a follow-up interview with V5 on 12/21/2021 at 2:56 PM, V5 stated REMEDY Z-GUARD cream is a barrier cream to protect against moisture. V5 stated staff are to place it after each incontinence episode for R2. V5 stated V5 forgot to apply the REMEDY Z-GUARD cream for R2. On 12/21/2021 at 3:58 PM, V2 provided surveyor with facility's low air loss bed manufacturer print outs. V2 stated that standard of practice is one flat sheet on a low air loss bed. V4 reiterated this during a telephone interview on 12/22/2021 at 11:23 AM. V4 also stated during the interview that staff should continue applying the REMEDY Z-GUARD cream for R2 because it is used to protect the peri wound from wetness and from stool.

Based on observation, interview and record review the facility failed to maintain the safety of 1 of 4 residents at risk for falls. The facility failed to ensure that R10 had proper equipment (foot rests) on her wheel chair and failed to ensure that staff were properly trained. R10 fell out of her wheel chair during return from an appointment. This failure resulted in R10 sustaining contusions and lacerations to her forehead and cheek. Findings Include: R10 is a [AGE] year old female resident with [DIAGNOSES REDACTED]. Interview with R10 on 2/24/11 at 11:15 am noted her in bed awake and alert with severe tremors to her bilateral upper and lower extremities. Tremors especially severe in arms and hands. R10 was pleasant, alert and oriented to person, place and time. R10 described an incident of falling out of her wheel chair on 10/7/10 as follows: "I had a doctors appointment and wanted ice cream afterwards, I know the neighborhood well and store is only a half block away. The transport van was not there after my appointment so the aide (E50) took me to the store. She (E50) made a fuss in the grocery store and kept saying "why do you want to buy just one thing". The manager of the store said to his employee, "maybe we should call someone" because she (E50) was getting loud and arguing with me. After we left I was in my wheelchair, I tend to lean to the right because of my Parkinson's. I kept telling her to push me back but she wouldn't listen. I felt like I was going to fall out of my wheel chair. I told her several times "push me back, push me back". We got down to the bar and grill and I fell out of my wheel chair. I think they need to instruct her (E50) on how to deal with people". Final Incident Investigation Report dated 10/7/10 written by E2, DON (Director of Nursing) documents the following: "During the investigation interviews, both employee (E50) and resident (R10) concur that foot rests had not been affixed to the wheel chair prior to the residents transport. It is likely the resident was not able to keep her feet sufficiently elevated off the ground during the period to/from the store and this contributed to the cause of her fall from the wheelchair. (E50) will receive disciplinary action regarding safe resident transfer". Investigation narrative documents that on 10/8/10 (E50) was interviewed by E1, Administrator and 3 other staff members: "(E50) was asked why (R10) did not have foot rests. She (E50) replied that (facility) does not use foot rests on wheel chairs. She was asked if she spoke with any of the staff before she left about the need for footrests. She (E50) indicated she did not". "(E50) was asked if she (R10) appeared to need physical assistance when she was leaning to the side. She indicated that (R10) attempted to scratch her and she could do nothing. She was asked if she had any scratch marks. She responded no." "(E50) then indicated (R10) did not act right and "old people" in America are rude and hard to work with". The last paragraph of the incident investigation report states, "The interview concluded and (E50) was informed that there were some serious concerns about her actions, her ability to ensure the safety of the resident and her decisions. She (E50) was placed on Administrative leave pending the outcome of the investigation". Interview with E1, Administrator on 2/24/11 at 11:55 am stated the following: "(E50) works for the home care division as a caregiver but helps out with transporting residents to and from appointments". E1 corroborated the information contained in the investigation report further adding that E50 had been disciplined for this incident. When asked if staff at the facility should have ensured that R10 had footrests on her wheelchair before she left for her appointment and instructed E50 on her basic care needs and assistance level, E1 replied "Yes". E1 states that E50 continues to work for the company but does not work with the nursing home division any more. E1 explained that as a result of this incident they have a new system in place. The facility developed an "Escort Information Checklist" to ensure that transporters are providing the necessary equipment while out for appointment to ensure resident safety. Fall risk assessment dated [DATE] documents a score of "11" for R10. Total score of 10 or above represents "HIGH RISK". MDS (Minimum Data Set) dated 11/18/10 documents a score of "0" for cognitive impairment indicating that R10 has no impairment in cognition or ability to make decisions. MDS also indicates that R10 has no long or short term memory impairment. emergency room report of local hospital dated 10/7/10 documents [DIAGNOSES REDACTED]. Nursing note dated 10/7/10 at 7:45 pm documents: "Resident returned from 11:30 appointment at 7:30pm. She returned with the left side of her forehead bandaged, and scratches on her left cheek". "According to the emergency room report [DIAGNOSES REDACTED]. Instructions are as follows: 1) Tylenol for pain 2) belt into wheel chair 3) follow up with own physician 4) Ice to area for 15 minutes 4 -5 times/day. Employee Disciplinary Report dated 10/13/10 for incident that occurred on 10/7/10 involving E50 and R10 documents: "On 10/7/10 (E50) assisted a resident to a Dr. appointment. Her failure to ensure the resident was transported in a safe manner resulted in the resident falling from the wheel chair and sustaining an injury. (E50) failed to ensure there were footrests on the chair, transported beyond the scope of the designated destination, allowed and participated in moving the resident prior to evaluation of emergency staff that were notified and failed to report the incident in a timely manner. These performance issues warrant a one day suspension. Safety training is required prior to (E50) providing care in an capacity. Any future performance issue will result in immediate termination".

Based on interview and record review, the facility failed to provide supervision for 1 (R3) of 3 sampled residents for falls. As a result of inadequate supervision R3 sustained a Right Femoral Neck Fracture and required surgical intervention. Findings include: History and Physical on admission documents, R3 was admitted to facility on 10/8/10 with intratrochanteric fracture of Left femur after a fall at home. On 11/21/10 R3 fell . Incident investigation report documents, "Resident (R3) sustained a fracture and had a right open reduction internal fixation on Tuesday, November 23." R3 is also diagnosed with [REDACTED]. R3 is dependent for assistance with all activities of daily living and requires supervision. On 12/15/10 at 2:25 pm, E2 (Licensed Practical Nurse) for R3 stated, "She's frequent Urinary Tract Infection. Urgency has alot. That's why put on hourly check." R3 Nurses notes dated 11/19/10 state, "Toilet every 1 hour." Care plan dated 12/9/10 documents "resident is at risk for fall or injury manifested by history of falls." E3 (Registered Nurse) was on duty when R3 fell on [DATE]. E3 (R.N) stated, "She (E4, Certified Nursing Assistant for R3) left R3 in dining room. E4 (C.N.A) went to Bush bathroom. She (E4, C.N.A) left (R3) in dining room without supervision without telling me. (R3) walked to bathroom and lost balance." Requested full investigation interviews from E6 (Administrator) regarding fall incident of 11/21/10 for R3. No interview of (E4, C.N.A for R3) was presented. E6 (Administrator) forwarded letter from (E5, Director of Human Resources) as documentation of explanation of R3 fall incident. . Letter dated 12/3/10 by Director of Human Resources (E5) documents, "Upon conclusion of a review and investigation around the incident of a resident who fell , it was discovered that you failed to follow the toileting schedule of a resident as well as falsified a time that you took the resident, you left your floor unauthorized and failed to follow proper procdedures in signing in and out of your time on and off the floor or advise your nurse."