Every finding on record at Aperion Care Wilmington

Based on observation, interview, and record review, the facility failed to prevent residents from developing facility acquired pressure ulcers. The facility also failed to provide the necessary treatments and services to promote healing and prevent infection. These failures affected 3 of 3 residents (R1, R3, R5) reviewed for facility acquired pressure ulcers in the sample of 7. R1 obtained a stage 3 pressure ulcer to the coccyx that required surgical debridement at the hospital and IV (intravenous) antibiotics. R3 and R5 also developed facility acquired stage 3 pressure ulcers. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included left femur fracture status post-surgical ORIF (open reduction internal fixation), right hemiplegia and hemiparesis, and stage 3 kidney disease. R1's MDS (Minimum Data Set) dated July 13, 2026, showed R1 was dependent on staff for bed mobility.R1's progress note on admission showed R1 has a surgical incision to her left outer leg. All other skin observations showed R1's skin was intact.R1's weekly skin observation sheet showed R1 has a stage 3 pressure ulcer to her coccyx, DTI (deep tissue injury) to her right and left buttocks, and DTI to her right and left heels.R1's Wound Care Physician note dated July 23, 2026, showed R1 had five wounds acquired since admission.Site 1: stage 3 coccyx wound that measured 6 cm/centimeters x 4.5 cm x depth is unmeasurable due to presence of nonviable tissue and necrosis. (length x width x depth) Surface area was 27 cm.Site 2: unstageable DTI to left buttock that measured 5 cm x 2.5 cm x unmeasurable depth, surface area 12.50 cm.Site 3: unstageable DTI to right buttock that measured 5 cm x 2.5 cm x unmeasurable depth, surface area 12.50 cm.Site 4: Unstageable DTI to left heel that measured 0.5 cm x 0.6 cm x unmeasurable depth, surface size 0.30 cm.Site 5: Unstageable DTI to right heel that measured 0.6 cm x 0.6 cm x unmeasurable depth, surface size 0.36 cm.The wound care physician note dated July 23, 2026, showed recommendations for a multivitamin daily, Vitamin C 500 mg (milligrams) twice a day, zinc ointment 20% to be applied every shift for 30 days to the left buttock, zinc sulfate 220 mg daily for 14 days to right heel, and a protein supplement. None of these were scheduled on R1's EMAR (electronic medication administration record). Another recommendation included pressure-off-loading boots. Could not find these boots, and these were not added as interventions to be used to prevent worsening of current DTIs.On August 11, 2026, R1 was sent to the ER (Emergency Room) due to R1 being disoriented and unable to say her name. R1's family member confirmed this was R1's baseline due to a stroke she had years ago. ER records showed while in the ER, R1 was negative for a stroke, but there was concern with her coccyx pressure ulcer. Consult was placed for a wound care evaluation, and it was determined that R1 required a surgical procedure to treat the wound. On August 12, 2026, R1 had a surgical debridement, and cultures were taken from the wound bed. The Physician Brief History/Operation Findings showed R1 had a stage 4 sacral wound to the bone with necrotic tissue.R1's wound care progress note dated August 13, 2026, showed R1 requires staff assistance for turning and repositioning. R1 has a 2.0 cm x 2.5 cm wound to her left heel, stage 5 sacral coccygeal wound measuring 5.5 cm x 7.5 cm x 5.5 cm and bone was palpable, right gluteal region wound unstageable 2.5 cm x 3.0 c x 0.1 cm, and left gluteal region wound 1.0 cm x 0.6 cm.R1's wound cultures came back positive for Escherichia Coli and ESBL (Extended Spectrum Beta-Lactamase). R1 started on two IV (intravenous) antibiotics. To be given for 30 days.R1 was discharged from the hospital and went home with home health care. R1 did not return to the facility.2. R3's EMR showed R3 was originally admitted to the facility on [DATE], with diagnoses that included type 2 diabetes with diabetic chronic kidney disease, chronic atrial fibrillation, and chronic obstructive pulmonary disease.R3's MDS (Minimum Data Set) showed that R3's cognition was intact, he needs substantial to maximal assistance to roll left to right and he is frequently incontinent of urine and bowel.On August 25, 2026, R3's plan showed R3 has a stage 3 pressure ulcer to their coccyx, unstageable DTI of the left lateral shin, and diabetic ulcer to the right heel related to immobility. with Interventions including monitor dressing every shift and as needed to ensure it is intact and adhering. Report loose dressing to treatment nurse. Administer medications as ordered. The resident requires wedge while in bed and pressure relieving device while up in chair to reduce pressure on coccyx and offloading boots for ankles while in bed. R3's care plan also showed R3 is incontinent of bowel and bladder. with interventions including check and change every 2 hours and PRN. Provide peri care after each episode. Apply house barrier cream after each episode as ordered. On August 24, 2026, at 12:50 pm, R3 was in his room in his bed lying on his back. There was no wedge under R3. R3 was alert and oriented. R3 said that no one had changed his brief or had turned him today. R3's brief was saturated with urine.On August 24, 2026, at 1:09 pm, V4 (Certified Nursing Assistant/CNA) said he changed R3 around 9 or 10 this morning. V3 (Wound Nurse) provided wound care to R3's right heel. Staff did not provide incontinence care for R3 after finding his brief saturated.On August 24, 2026, at 2:31 pm R3 was observed again on his back, and no wedge under him. R3 said that no one had come in since wound care to change his brief or to turn him. V5 (CNA) was R3's CNA now and said that she had not checked R3's brief or turned him since she started her shift at 2:00 pm. R3's brief was checked and it was found saturated. V5 did not change the resident at that time. V5 placed the covers back over R3 and left the room. On August 25, 2026, at 1:57 pm, R3 was in bed lying on his back, with no wedge under him. R3 denied anyone repositioning that day. V4 (CNA) and V15 (Registered Nurse/RN) checked R3's brief. The brief had bright red blood inside and there was stool on R3's right and left buttocks. R3's scrotum was red and R3's right and left gluteal folds had open areas. The staff did not provide incontinence care at this time for R3.On August 25, 2026, at 3:47 pm, V3 (Wound Nurse) did a skin check on R3. The skin on R3's inner thighs were red and excoriated. R3's lower back was red and there was dry stool on R3's right and left buttocks. V3 said that the wounds to R3's gluteal folds are facility acquired, stage 2 wounds. V3 did not measure the wounds.On August 26, 2026, at 10:11 am, R3 was on his back with no wedge under him. R3 said that no one had changed his brief or turned him today. V14 (CNA) said that she had not had a chance to check R3's brief since she had started working at 6:00 AM. V14 said that she was too busy helping other residents. V3's brief was found saturated and R3's groin and inner thighs were red. V17 (Licensed Practical Nurse/LPN) measured R3's wound to his gluteal folds. R3's right gluteal fold open area measured 9.0 centimeters long. R3's left gluteal fold open area measured 10.5 centimeters long. V14 provided peri-care to R3 but did not apply barrier cream to R3's skin before applying a new brief.On August 27, 2026, at 9:06 am, R3 was in bed lying on his back and there was no wedge under R3. R3 said that no one had changed him or turned him. V4 (CNA) was present at that time and said that he was R3's CNA for the day and he had not checked him since he started at 6:00 am. On August 27, 2026, at 11:37 am R3 was on his back, the wedge was on the head of R3's bedframe. V11 (Wound Doctor) said that she believed that the open skin to R3's gluteal folds was caused by his brief, and she recommended that his brief remained open.R3's Wound care note dated July 23, 2026, showed: Site 3 pressure wound to coccyx full thickness size 1.7 cm x 1 cm x 0.2 cm with surface area 1.70 cm.Site 4 unstageable DTI left lower lateral shin, 3 cm x 1 cm x not measurable depth, surface size 3.00 cm.Site 5 diabetic wound right heel wound size 1.5 cm x 1.5 cm x not measurable depth, surface size 2.25 cm.Site 6 left heel 1cm x1 cm x not measurable depth, surface size 1.00 cm.R3's August 20, 2026, Physician Evaluation and Management Summary showed:Site 5 right heel 2 x 1.6 x 0.2 cm surface size 3.00 (wound increased in size)Wound progress: not at goalDressing Treatment Plan Primary Dressings - Alginate calcium applied three times per week and as needed if saturated, soiled or dislodged for 30 days. Leptospermum honey Applied three times per week as needed if saturated, soiled or dislodged for 30 days. Secondary Dressing - Gauze Island with Border Apply three times per week as needed, if saturated, soiled or dislodged for 30 days.R3's August ETAR (Electronic Treatment Administration Record) showed:Left Lower Lateral Shin: Cleanse with wound cleanser, pat dry, apply skin prep, . every day shift every Mon, Wed, Thu for wound care. The records showed that no treatment was given on 8/20/26.Right Heel: Cleanse with wound cleanser, pat dry, apply skin prep, cover with border gauze dressing every day shift every Mon, Wed, Thu for wound care. The record showed that no treatment was given on 8/12/26 and 8/20/26.Apply house barrier cream to groin and buttock every shift for redness.Coccyx: Cleanse with wound cleanser, pat dry, apply calcium alginate to wound and cover with border gauze dressing every day shift every Mon, Wed, Thu for wound care. Left Heel: Cleanse with wound cleanser, pat dry, apply skin prep. every day shift every Mon, Wed, Thu for wound care. The record showed that no treatment was given on 8/12/26 and 8/20/26. 3. R5's EMR showed R5 was admitted to the facility on [DATE]. R5's diagnosis includes Parkinson's disease and chronic diastolic (Congestive) heart failure.R5's MDS showed that R5's cognition was intact and R5 was dependent on staff to roll left to right.R5's care plan dated August 14, 2026, showed, R5 has limited range of motion in bilateral upper/lower extremities related to Parkinson's disease. R5 requires assistance with bed mobility. R5 has bladder/bowel incontinence related to Parkinson's disease with intervention including apply barrier cream after each incontinent episode. Check and change every 2 hours and as needed, provide peri care after each incontinent episode. A potential for impairment to skin integrity related to decreased mobility, with interventions including protective skin barrier cream as ordered.R5's POS (Physician Order Set) dated June 9, 2026, showed, Wedge Pillow: resident to use wedge pillow when in bed to reduce pressure and bruise every shift for prevention.R5's progress note dated August 13, 2026 at 2:45 pm, wound was assessed in the sacral area, small area with bleeding, cleansed with appropriate wound cleanser, and applied ointment (Skin Protectant) covered with protective dressing per protocol. R5 remains bedbound, with pressure- relief measures in place and ongoing monitoring of skin integrity. Wound Nurse notified for plan care.R5's wound care note dated August 20, 2026, showed R5 had a Stage 3 pressure wound to Sacrum full thickness size 1.5 cm x 0.5 cm x 0.2 cm with surface area 0.75 cm. Recommendations: reposition per facility protocol off-load wound. Treatment plan dressing collagen sheet 3 times a week and as needed if saturated, soiled or dislodged. Hydrocolloid sheet 3 times a week and as needed, if saturated, soiled, or dislodged.R5's July ETARS showed: Apply house barrier to sacral area daily and as needed. The records showed that the treatment was not done on July 4, 6, 7, 12, 13, 19, 25 and 26. R5's August ETARS showed: Apply house barrier to sacral area daily and as needed. The records showed that the treatment was not done on August 2, 9,11,14,15, 20, and 25. On August 24, 2026, at 1:10 pm, R5 was in his bed lying on his back with no wedge. R5 said that no one had changed his brief or turned him. V3 (Wound Nurse) and V4 (CNA) were present. R5's brief was found saturated with urine. R5's body was stiff and he was unable to turn himself. R5's had a dressing to his sacrum, and the distal edge of the dressing was not attached to R5's skin and there was feces on the dressing. V3 provided wound care to R5's sacrum and after she completed wound care V4 reapplied the soiled brief.On August 24, 2026, at 2:38 pm R5 was found on his back and there was no wedge under R5. R5 said that no one had come to change his brief or reposition him since he had wound care provided. R5 said that he is unable to turn himself. V5 (CNA) said that she had not checked R5 since she got there. R5's brief was found saturated.On August 25, 2026 at 2:02 pm R5 was found on his back with no wedge under him and R5 said that no one had repositioned him on this day.On 8/26/26 at 10:39 am, R5 was on his back with no wedge under his back. R5 said that no one had changed his brief or repositioned him on this day. V14 (CNA) said that this was the 1st time today that she checked R5. V14 said that R5 was assigned to her for the day. V14 checked R5's brief and said yes, it was saturated. R5's scrotum was found with redness. R5's dressing to his sacrum was not attached to his skin on the distal side of the dressing. V14 provided incontinence care for R5, and she wiped stool from R5's rectum towards R5's unattached open dressing. After V14 was done providing incontinence care, V14 did not apply barrier cream to R5's skin.On August 27, 2026, at 9:12 am, R5 was in bed on his back. R5 said that no one had repositioned him or changed his brief today. V4 (CNA) said that he was R5 CNA for the day and he hadn't had a chance to check R5 yet. At 11:52 am R5 was found on his back and the skin under R5's dressing was found with redness.On August 27, 2026, at 12:59 pm, V2 (Director of Nursing) said that R1 was admitted to the facility without any pressure ulcers. V2 said that R1 acquired all her pressure ulcers at the facility. V2 said that R1's pressure ulcers were all avoidable. V2 said that the staff could have repositioned R1 from her back to one side of her body avoiding her surgical side. V2 said that all R3's wounds were acquired. V2 said that the 2 wounds that were found on August 15, 2026, were acquired and avoidable. V2 said that she put a wedge in R3 room on August 26, 2026, so the staff would use it for R3. V2 said that R5's wound was acquired and avoidable. V2 said that when briefs are not changed when they are soiled or saturated, it causes pressure ulcers and hinders the healing process. V2 said that it is the facility's expectations that wedges are used, residents are being repositioned every 2 hours, and briefs are changed every 2 hours or as needed. V2 said that it is the facility's expectation that the nurses carry out all orders. V2 said that not caring out orders can hinder the healing process. V2 said that it is the facility's expectation that the nurses carry out the wound doctors' recommendations as ordered. V2 said that the facility's wound doctors' recommendations do not require any approval from any other doctor.On 8/27/26 at 9:25 am, V3 (Wound Nurse/Registered Nurse) said that R1's five wounds were acquired and avoidable if the facility had provided care as expected. V3 said that when R1 was discharged her wounds had increased in size. V3 said that R3's stage 2 pressure wound to his right and left gluteal folds were acquired and avoidable. V3 said that R5's stage 3 pressure wound to his sacrum was a facility acquired and avoidable wound. V3 said that if incontinence care is not being done when they are soiled timely and residents are not being repositioned, wedges are not being used, and doctors' orders and treatments are not being done, it will cause pressure ulcers and keep wounds from healing. V3 said that when the wound doctor makes a recommendation the order is to be put in. V3 said that the recommendations do not need to be approved by the facility's physicians.

Based on observation, interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This applies to 4 residents (R1, R2, R3 and R4) reviewed for abuse in a sample of 5. Findings include:1. On 07/01/26 at 12:03 PM, R1 stated he got into an altercation with R2. R1 stated he was attempting to pass R2 in the hallway when he accidently bumped into him. R1 stated he attempted to apologize when R2 hit him. R1 stated he then grabbed R2 by his collar and R2 bit his right thumb on the knuckle. R1 stated he got antibiotics for the bite, but his thumb still hurt. R1 stated the staff broke them up but he did not recall their names. R1's right thumb appeared slightly reddened and swollen. On 07/01/26 at 12:10 PM, R2 stated he did not recall getting into an altercation with anyone. On 07/01/26 at 12:29 PM, V3 (Registered Nurse/Assistant Director of Nursing) stated while she was providing care to another resident, she heard a commotion from the hallway. V3 stated she came out to find R1 and R2 fighting. V3 stated she and CNAs (Certified Nursing Assistants) separated R1 and R2. V3 stated she did not recall who the CNAs were. V3 stated R1 had a bite injury to his right thumb and R2 had a scratch on his ear. V3 stated she provided care for R1 and R2's injuries and obtained an order for antibiotics for R1's bite injury. On 07/01/26 at 1:03 PM, V4 (CNA) stated she was working on 06/13/2026 when R1 and R2 got into an altercation. V4 stated she heard screaming and came running to see R1 grabbing R2's collar and R2 biting R1's thumb. V4 stated R1's right thumb had teeth marks and was bleeding. V4 stated he separated R1 and R2 then returned to his unit when other staff arrived. A progress note written by V3 on 06/13/2026 at 11:26 PM for R1 documents altercation between R1 and R2 and R1's bite injury. V3's 06/13/2026 at 11:54 PM progress note for R2 documents the altercation R1 and R2 and R2's left neck and left ear abrasions. The facility's Facility Reported Incidents for R1 and R2's 6/13/2026 altercation showed .R1 then shook his finger at [R2] and [R1] then closed his teeth on [R1's] right thumb . 2. On 7/1/26 at 11:35 AM, R3 said she had an altercation with R4 when R4 came into R3's room. R3 said R4 first hit her on her back and then R3 hit R4 upside the head. R3 said she stays in her room because she doesn't want R4 hitting her. On 7/1/26 at 1:10 PM V10 (Registered Nurse/RN) said she was working on 6/13/26 when the reported altercation took place between R3 and R4. V10 said one resident scratching another resident is physical abuse. On 7/1/26 at 2:49 PM, V1 (Administrator) said V3 (Assistant Director of Nursing) called her on 6/13/26 and told her about R3 and R4's altercation. V1 said one resident scratching and/or biting another resident is physical abuse. V1 said V10 told her V12 (CNA) pulled R4 out of R3's room after the altercation occurred. On 7/1/26 at 1:20 PM, V2 (Director of Nursing/DON) said V1 notified her on 6/13/26 that R4 wheeled herself into R3's room, a CNA saw and pulled R4 out of R3's room, and R3 got upset and went after R4 in the hallway and scratched her. V2's (DON) progress note dated 6/13/26 at 8:00 PM states she was made aware by the nurse on duty that R4 had a scratch on her right cheek from another resident (R3). V13's (Social Service Director) follow-up behavior note written on 6/15/26 at 1:05 PM states he provided follow-up to resident altercation on 6/13/26. V13 states per staff, R4 wandered into R3's bedroom, which upset R3, who then swatted at R4 to get her out of her personal space, scratching R4 on the cheek. R4's Face Sheet shows the following diagnoses: Alzheimer's disease and dementia. R4's MDS (Minimum Data Set) dated 4/8/26 shows she is rarely/never understood and she has a memory problem. R4's Care Plan last revised 4/8/26 states she is at heightened risk for abuse/neglect related to Alzheimer's disease and dementia. R4 exhibits impaired cognition and communication and has a history of wandering behaviors. The Facility Reported Incidents final report sent on 6/19/26 at 2:37 PM states on 6/13/26, R4 and R3 had an altercation, and listed the event as an accident/incident. R3 was upset because she believed R4 entered her room without permission. R3 then reached out to R4 in the hallway and scratched her. R4 and R3 were assessed for injuries and it was noted R4 sustained a scratch to her right cheek. The facility's policy titled, Abuse and Retaliation Prevention and Reporting-Illinois effective 1/8/26 states, Policy: This facility affirms the right of our residents to be free from abuse.In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse.Definitions.Abuse: Abuse means any physical or mental injury.inflicted upon a resident other than by accidental means.Abuse is the willful infliction of injury.with resulting physical harm.The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment .

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse. This applies to 4 residents (R1, R2, R3, R4) reviewed for abuse investigations in a sample of 5 residents.The findings include: 1.The facility's final Facility Reported Incidents for R3 and R4's physical abuse altercation listed the event as an accident/incident rather than resident abuse. The form showed an altercation was alleged and R4 sustained a scratch on her right cheek that required first aid. The form showed Upon investigation, [R3] was upset.[R4] reached out to [R3] in the hallway encountering her causing a small scratch. No conclusion was included on the form to show if abuse/assault did or did not occur. On 7/1/26 at 9:45AM, V1 (Administrator) was asked for her complete investigation file of the Facility Reported Incident from 6/13/26 between R3 and R4. V1 provided the initial and final reports that were sent to the state surveying agency and was unable to provide any additional evidence such as interviews with staff witnesses or documentation or observations of R4 after the abuse. On 7/1/26 at 2:49 PM, V1 said she is the Abuse Coordinator, and she was notified of the altercation between R3 and R4 by V3 (Assistant Director of Nursing/ADON) via phone on 6/13/26. V1 said R3 and R4 were not V3's residents on that day and V3 told V1 that she did not observe their altercation but heard R3 scratched R4. V1 said R3 and R4's nurse at the time of the altercation was V10 (Registered Nurse/RN). V1 said she did not interview R3 or R4. V1 said she did not go to see R4 or observe the scratch on her cheek. V1 said she only interviewed V3 (ADON) and V10 (RN) regarding the incident and both nurses told her they did not observe the altercation. V1 said V10 told her she thought V12 (Certified Nursing Assistant/CNA) was the staff member who pulled R4 out of R3's room. V1 said she did not attempt to interview V12 because she got information from V3 and V10 (who both told her they did not witness the altercation). V1 said she did not have any documentation showing she conducted any staff interviews regarding the altercation. V1 said witness statements and interviews should be documented to complete a thorough investigation. On 7/1/26 at 1:52 PM, V10 (RN) said V1 never interviewed her regarding R3 and R4's altercation. V10 said when there is an altercation between residents, the bedside nurse should document it in a progress note. On 7/1/26 at 2:36 PM, R4's EHR/Electronic Health Record was reviewed and did not show any documentation of her scratch assessment/appearance or treatment orders or any documentation that the abuse with injury occurred. 2.On 07/01/26 at 09:45 AM, documentation for the investigation of R1 and R2's physical altercation was requested from V1 (Administrator) and V2 (Director of Nursing/DON). V2 provided the initial and final reports submitted to the state surveying agency along with the face sheets for R1 and R2. V2 stated the documents that were provided was the complete investigation. No investigation conclusion was included on the final report. On 07/01/26 at 11:27 AM, V1 (Administrator) stated when the final report had been submitted to the state surveying agency that all of her investigation, including interviews, had been completed. Documentation of the investigation was requested from V1. V1 stated she was just about to type it up. V1 stated she had handwritten her interviews for the investigation. The handwritten investigation documentation was requested from V1. V1 was unable to provide her handwritten documentation for her investigation into the altercation between R1 and R2. On 07/01/26 at 12:03 PM, R1 stated he discussed the incident with staff present at the time of the incident on 06/13/2026. R1 stated he did not discuss the incident with any other facility staff. On 7/01/26 at 12:10 PM, R2 was unable to recall having an altercation with anyone. On 07/01/26 at 12:29 PM, V3 (ADON) stated she had informed the Administrator of the altercation between R1 and R2. V3 stated CNAs were present at the time of the altercation, but she could not recall any of the names of the CNAs present during the abuse. On 07/01/26 at 1:03 PM, V4 (CNA) stated she was present during the altercation between R1 and R2 and no one interviewed her about it, including the Administrator. On 07/01/26 at 1:23 PM, V5 (CNA) stated he informed V3 about what he witnessed between R1 and R2 at the time of the incident, but he did not talk to the Administrator or anyone else about the incident. On 07/01/26 at 2:58 PM, V1 stated she is the abuse coordinator, and she submitted the initial and final reportable to the state surveying agency regarding the altercation between R1 and R2 on 06/13/2026. V1 stated she interviewed R1 about the incident but R2 refused to talk to her. V1 stated she also interviewed V10 (RN) and V3 (ADON). V1 stated she did not interview any CNAs because V3 (ADON) informed her no CNAs were present during the altercation between R1 and R2. V1 stated documentation of interview/witness statements is a part of the investigation, but she had none to provide. A progress note written by V3 (ADON) on 06/13/2026 at 11:26 PM for R1 showed the altercation between R1 and R2 and included the presence of CNA staff, and V3's 06/13/2026 note from 11:54 PM for R2 included the presence of CNA staff during the altercation. The facility's 1/8/2026 Abuse and Retaliation Prevention and Reporting policy showed the facility will implement .systems to promptly and aggressively investigate all reports and allegations of abuse. Under VII. Internal Investigation the policy showed 1. All incidents will be documented, whether or not abuse.mistreatment.occurred, was alleged, or suspected. 2. Any incident or allegation involving abuse.will result in an investigation. The policy continued 4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Regarding the final investigation report, the policy showed .The final investigation report shall contain the following.Conclusion of the investigation based on known facts.

Based on observation, interview, and record review, the facility failed to protect the residents' rights to be free from verbal and physical abuse by a resident who frequently demonstrated verbal and physical abuse to others in the facility. This applies to 4 of 6 residents (R20, R37, R93, R145) reviewed for abuse in the sample of 33. A reasonable person would feel targeted, paranoid, and not safe based on R133's behaviors and physical abuse to other residents. The findings include: 1.R145's Face sheet shows that R145 has multiple psychiatric diagnoses including schizophrenia and generalized anxiety. Minimum Data Sheet (MDS) March 10, 2026, shows R145 is alert and oriented. R145's Abuse/Neglect Screening dated June 1, 2026, shows he was at risk for abuse. R145's incident report dated March 12, 2026, shows R145 had an altercation with R133. On June 1, 2026, at 11:33 AM, R145 was walking in the hallway when R133, who was in his wheelchair, came up behind R145 and suddenly struck R145 in the middle of his lower back with his left fist without provocation. R145 did not react and just kept on walking. R145 stated maybe R133 just wanted him to get out of the way. R145 continued to walk while mumbling to himself. At 4:09 PM, R145 was resting in bed, when he was informed that R133 left the unit, R145 finally spoke about R133's behavior towards him. R145 stated that R133 always bothers him. R145 also said R133 talks badly about him and struck him on his back earlier.On June 3, 2026, at 1:47 PM, V1 (Administrator) stated R133 was the instigator during the altercation with R145. While R145 was standing, R133 was yelling and waving his arms towards R145 while repeatedly approaching R145 with his wheelchair. R145 pushed R133 while he was sitting in his wheelchair to get out of his way. 2. R37's Face sheet shows that R37 has multiple diagnoses including anxiety disorder and unspecified dementia. MDS dated [DATE], shows R37 is alert and oriented. R37's Abuse/Neglect screening dated April 27, 2026, shows he was at risk for abuse.Incident reports dated March 25, 2026, April 25, 2026, and May 18, 2026, showed R37 and R133 had altercations.On June 1, 2026, at 4:13 PM, R37 was resting in bed, he was alert and oriented. R37 stated that R133 started bothering him without reason. R133 was an a**h*l* who ran his wheelchair over his foot and kicked him in the legs. They had altercations 3 different times, and R133 was doing it on purpose. R37 said he reported it to the social worker, but they were not doing anything about it. R37 stated that he was not the only resident that was targeted by R133, He is a bully. On June 2, 2026, at 1:18 PM, V2 (Director of Nursing/DON) stated R133 has been abusing his privileges. R133 has had multiple altercations with R37. In one of their altercations, R133 cut in line in front of R37 during smoking time. While propelling his wheelchair he bumped into R37 and kicked him to get him out of the way. R37 fell on the ground. On June 2, 2026, at 3:26 PM, V25 (Social Services Director) stated in one of R133's and R37's altercations, they were in the dining room, R133 rolled his wheelchair over R37's foot, but V25 was not sure if it was accidental or intentional. R37 and R133 continued to have altercations, so they asked R37 if he wanted to move to another unit and he gladly accepted. On June 3, 2026, at 2:07 PM, V1 (Administrator) stated R37, and R133 have had multiple altercations with one another. Every single event was instigated by R133. The first time they had an altercation was on March 25, 2026, R133 was sitting in his wheelchair and was blocking the entrance door of the dining room. When R37 wanted to enter, R133 refused to move, which blocked R37 from entering. So R37 pushed R133's wheelchair out of the way. R133 intentionally threw himself on the floor, there was no injury sustained. The next one was on April 25, 2026, both were in line for cigarettes, R133 accused R37 of looking at him, then R133 struck R37 in the leg. R37's legs were x-rayed; there was no injury noted. The third one was on May 18, 2026, R133 was backing out his wheelchair when R37 came behind the wheelchair and R133 accidentally rolled the wheel over R37's feet. R37 was sent to the hospital for further evaluation, there was no injury noted. After the third incident, R37 was moved out of the locked BHU (Behavioral Health Unit).On June 3, 2026, at 2:21 PM, V17 (Certified Nursing Assistant/CNA) stated R37 and R133 had an altercation on May 18, 2026, during lunch time. R133 believes that he was given a job by the facility owner to help staff pick up used meal trays. R133 went to the dining room to help. R133 took R35's tray from the table without consent. R35 yelled at him.R37 yelled at R133 as well for taking R35's tray. V17 (CNA) heard the commotion, and she saw R133 holding R35's tray. R37 was following R133 and was yelling at him at the same time. When V17 asked what was going on, R37 said that R133 ran his wheelchair over his foot. R37 was gesturing like he was about to hit R133. V17 immediately intervened and separated them. R133 was redirected and went back to his room. R37 was sent to the hospital via 911, for further evaluation. 3. R93's Face sheet shows that R93 has multiple psychiatric including anxiety disorder, brief psychotic disorder, and schizophrenia. R93's MDS dated [DATE], shows he is alert and oriented. R93's Abuse/Neglect screening dated May 6, 2026, shows he was at high risk for abuse.The facility's incident report dated January 23, 2026, shows that R133 and R93 had a resident-to-resident altercation. They were immediately separated and assessed for injury. No injury noted upon head-to-toe assessments. On June 1, 2026, at 4:37 PM, R93 was resting in bed. R93 said he and R133 had an altercation before but that was in the past. On June 3, 2026, at 1:58 PM, V1 (Administrator) stated R133's and R93's altercation happened when R133 blocked the doorway of the dining room, which prevented R93 from entering the dining room. R93 moved R133's wheelchair out of the way, and R133 threw himself on the floor, pretending that he was pushed by R93. 4. R20's Face sheet shows that R20 has multiple diagnoses including anxiety disorder, and Alzheimer's disease. MDS dated [DATE], shows R20 is alert and oriented. Abuse/Neglect Screening dated April 16, 2026, showed R20 is at risk for abuse.On June 1, 2026, at 4:30 PM, R20 was in bed, he was alert and oriented. R20 stated that a few months ago (he was unable to recall exact date of when it happened) R133 called him insulting names and even ran his wheelchair over his right foot. According to R20, R133 was constantly bothering him, and he (R20) reported it to the staff. R20 also said he was not afraid of R133, but he was just irritated towards him because he used to constantly harass him. R133's face sheet shows R133 is [AGE] years old with multiple medical diagnoses including delusional disorders, and paranoid schizophrenia. Minimum Data Set (MDS) dated [DATE], shows R133 is cognitively impaired.R133's Abuse/Neglect Screening dated March 25, 2026, showed R133 is at high risk for abuse. This same screening showed R133 exhibits poor space boundaries and provoking/antagonizing behavior with peers. R133 has history of false accusations related to psychosis.The facility's resident to resident altercations/incident report from January to June 2026, showed R133 had multiple altercations with different residents.R133's Behavior/Progress Notes from January 2026 to present showed multiple antagonistic and delusional behaviors towards peers, entering other residents' rooms without permission, exhibiting poor boundaries, and argumentative behaviors towards staff and peers.R133's care plan with revision date of May 21, 2026, showed, R133 has a behavior problem. R133 makes grandiose/persecutory complaints about staff, peers, and other unknown individuals to staff and others (e.g. State Regulatory Agency, and Ombudsman office) related to persistent delusional ideation. R133 often denies or minimizes these reports later when follow-up is provided. The incident reports made by R133, are often vague in nature and are made by R133 hours or days after the incident allegedly occurred. R133 tends to call 911 to make inaccurate reports. R133 also regularly exhibits antagonistic, verbally and physically aggressive behavior toward staff and peers related to delusional thoughts, poor impulse control, delusional disorders, and paranoid schizophrenia. R133 would approach peers and make taunting sounds while they are talking, make inflammatory comments (e.g. that the resident is having sexual relations with his/her family members, that they are demons, R133 was in a Chinese prison etc.) and will respond to staff redirection with yelling/hitting doors. R133 tends to threaten staff related to paranoia. On June 2, 2026, at 2:15 PM V1(Administrator) stated R133 frequently gets involved in verbal and/or physical altercations. R133 is very delusional sometimes he is a priest, a rabbi, or a [NAME]. R133 says random things, believes that staff and other residents make anti-sematic statements towards him. R133 also states that the other residents were following him and giving him the evil eye. R133 verbalized that the medication is ungodly and antisemitic, and he didn't want to take any Chinese pills. The staff are doing 15 minutes check on him; room changes have been necessary in the past to separate him from the people whom he thinks were giving him an evil eye. R133 is non-compliant with medications, and he takes medications selectively. R133 will pick and choose whichever medication he wants to take depending upon his mood and who is giving him the medications. On June 2, 2026, at 1:50 PM, V2 (Director of Nursing) stated they try to redirect all their residents when displaying behaviors. They have to be careful with R133. They redirect him, but the problem with R133 is that he does not take redirections very well, he constantly calls the police and the state for everything. R133 was non-compliant with medications which was a big problem in curving his behavior and the facility cannot force him to take is medications. R133 does not allow doctors or nurse practitioners to interview or examine him. R133 has made false claims against nurses, CNAs, and other residents. R133's mindset is I'm not leaving, they are. R133 has the potential to demonstrate harm towards others. V2 said we have tried to send him out to the hospital for psychiatric evaluation and treatment; however, when the EMTs (Emergency Medical Technicians) would come to take him, he would adamantly refuse to go. The EMTs would tell our staff that they cannot force someone to go to the hospital. R133 would fight with the EMTs, and so they would just leave him here. R133 is always the instigator. If he is having issues with a resident, we move that resident away as a means to stop the altercation, but once the resident is removed from that situation, R133 will pick another resident to target. R133 intimidates people. They had a meeting with his physician, and the physician suggested that the best thing they could do would be to send R133 to a group home or an assisted living facility, but no one would accept him because of his behavior. Once in a great while he will pick a nurse that he likes, and he might take his medications but that's a rarity. The state guardian was notified of his behavior, however, the state guardian said, if R133 was happy here, she does not see any reason to move him. V2 added, R133 has been abusing his privileges.On June 2, 2026, 1:37 PM, V42 (Social Service) stated R133's behavior was mostly related to his psychosis, he has a lot of delusional beliefs. R133 antagonized peers, he would go up to them and accused them of having sex with their mothers. Most of the staff who work in this unit were aware of R133's behavior. Facility has care plans and assessments for his behaviors. They attempted to do a lot of counseling, but he does not respond to most staff. Interventions they had in place to prevent some of these altercations were to pay him a little extra attention, keep a closer eye on him, especially during meals and smoke times, frequent monitoring, and the presence of staff inside the unit. Ideally there should be someone within line of sight of the residents. R133 has been non-compliant with medications. R133 only took Salt tablets and Tylenol in the past years that he has been here. R133 refused to meet with psychiatric nurse practitioner nor the psychiatrist. On June 2, 2026, at 3:26 PM, V25 (Social Services Director) stated R133 has been on increased monitoring, which means heightened awareness of the staff whenever R133 was out of the room and in proximity with other residents especially when he is in milieu. This was a way to provide redirections when R133 begins to exhibit antagonistic behavior and for safety of the other residents. They also attempted to counsel R133. R133 has been very resistant to all the treatment plans, including medications, and appointments with a psychiatrist. They offered counselling and anger management groups, but he consistently refuses. They had regular care plan meetings which he refused to attend to. R133 was sent to psychiatric hospital before, and they just send him back because he refused to cooperate with treatment plan. They attempted to manage R133 the best way they could, but he is a very difficult person. They have tried significant referrals to other facilities, but they were not successful.On June 2, 2026, at 12:51 PM, V43 (Housekeeping) stated R133 likes to instigate fights with other residents and new staff. R133 likes to be called [NAME] and if not called like that, he gets upset. R133 has been wandering and entering other residents' rooms without permission. Other residents had been complaining about him. V43 had personally heard residents screaming at R133 to get out of their rooms and V43 informed the social services about it. This was an everyday occurrence with R133. There are certain residents that he will try to intimidate or yell at. V43 also said, R133 would scream out loud at certain residents, R133 would say He likes to have sex with his mother! R33 would do that to R20 and R145. R145 does not bother anyone, he just mumbles to himself. R133 gets into altercation with regards to the meal trays, he would enter bedrooms and grab people's tray without consent which upsets other residents. On June 3, 2026, at 2:21 PM, V17 (CNA) stated R133 picks and chooses different people to bully, he likes to bully R20, R145, R93, and R163. R93 doesn't like to wear a belt, and his pants would slip down which bothers R133, and R163 who was cognitively impaired and talks constantly to herself also bothers R133. R133 bullied selective people. The residents are not afraid of R133 they just felt irritated towards him due to his behavior. The staff who work in BHU, including the administration, were all aware of R133's antagonistic, aggressive, and bullying behavior towards specific residents. V1, V25, and V42 all identified that R133 was non-compliant with treatment plan, and they stated that one of their interventions was to increase the monitoring of this resident. On June 1, 2026, at 11:33 AM, when R133 struck R145, there were no staff present in the hallway. They attempted to send R133 to the hospital after he struck R145, but R133 refused and the EMT paramedics left. However, facility called an ambulance again and the second set of EMT staff were firmer towards R133, so they were able to bring R133 to the hospital.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment by failing to ensure resident rooms were free from offensive odors, sticky or soiled flooring, pests, and unsanitary conditions, and by failing to ensure resident bathrooms contained clean, functional toilets. This applies to 6 of 9 residents (R6, R47, R62, R80, R117, R132) reviewed for homelike environmental concerns in a sample of 33. The findings include: 1.On June 1, 2026, at 11:37 AM, in R6's room, there was an unknown, brown-colored substance on the bathroom floor tile, at the base of the toilet, and surrounding the base of the toilet. An unknown liquid was observed around the base of the toilet on the bathroom floor.On June 2, 2026, at 9:24 AM, R6 was sitting in his wheelchair in his room. The floor was sticky. A foul odor was present in the bathroom. A brown-colored substance was observed around the base of the toilet, an unknown liquid was around the base of the toilet, and on the floor. Multiple flying insects were observed throughout the room and around the bathroom area. R6 stated, The toilet is broken and they never fix it. I need a new one. 2. On June 2, 2026, at 9:07 AM, R117 was lying in bed watching television. A foul odor was present in the room. The floor near the bed was sticky and contained food debris. In the bathroom there was a brown-colored substance around the base of the toilet and on the floor.3. On June 3, 2026, at 10:25 AM, R132 and R47 said their toilet was not working so they use the bathroom in another resident's room across the hall. R132 said they were told by V1 (Administrator) to use the bathroom in the shower room down the hall. R47 said the shower room is too far to make it to sometimes.4. On June 3, 2026, at 10:27 AM, R80 was lying in bed watching tv (television) and said the bathroom has been out of order for a long time. R80 said he uses the bathroom across the hall in another resident's room or in the shower room. R80 said the shower room is too far to make it to sometimes.On June 3, 2026, at 9:13 AM, V9 (Housekeeping Director) said the housekeeping staff will start by cleaning the bathroom. V9 said they spray cleaner on all the surfaces of the bathroom and then wipe down the bathroom using a separate for each area. They start with a wipe for the mirror, then sink, toilet, and a different wipe for grab bars. V9 said the housekeepers sweep and mop the bathroom floor. V9 said all rags get discarded. V9 said the housekeepers start at bed closest to the window and move back towards the door. V9 said housekeepers will empty trash and spray all surface areas in the room with neutral cleaner. V9 said if a foul odor is noted, the housekeeper will try and locate the source. V9 said if the smell is from a spill, the nursing staff will clean up the spill and housekeeping will clean and sanitize the area. If the foul odor smell is still detected V9 said the housekeeper will use a urine remover spray to treat the area. V9 said if she is notified by staff that the floors in the resident's rooms are sticky, she will instruct the housekeeper to do a deep clean. Housekeeping will post signs and advise nursing staff and residents that the room will be unavailable for use during that time. V9 said she keeps pest control logs outside of her office. V9 said the staff should document the date, room number and resident or staff member who observed pest. V9 said the facility is sprayed twice a month and as needed for pest.On June 2, 2026, at 9:29 AM, V8 (Maintenance Director) said the brown substance around the bottom of the toilet and on the floor are water spots in the rooms of R6, R62 and R117. V8 said the toilet for R6 is leaking and needs repair. V8 when residents have water damage on the floor and the toilet is leaking, he will have to put in a work order and get it fixed. On June 3, 2026, at 10:06 AM, V8 (Maintenance Director) said as far he is aware the bathroom for R47, R132 and R80 has been out of order for over two weeks. V8 said the timeframe for repair depends on the severity of the situations. V8 said time frame for repairing the toilet depends on the amount of work that needs to be done, when the work order was put in, and the cost must be considered.On June 3, 2026, at 10:15 AM, V1 (Administrator) said she meet with R47, R80 and R132 about the toilet to let them know the toilet needs to be repaired. V1 said the repairs needed in the bathroom are extensive and needed to have a quote and approval before repair. V1 said the prior maintenance director began work on the bathroom on March 24, 2026. The bathroom has been out of order since that time. V1 said residents have been instructed to use the shower room bathroom which is down the hall from their rooms. V1 said she received a quote for repair on May 1, 2026, but has not started work yet.The facility provided their policy titled, Housekeeping Services Policy that shows the purpose is to ensure that the facility, equipment, furnishing and resident rooms are maintained in a sanitary manner; to provide a comfortable environment, and to prevent the development and transmission of infection. It is the policy of the facility to maintain a clean, odor free, comfortable and orderly environment in all health care and public areas, which meets the sanitation needs of the facility and residents right for a safe, clean, comfortable homelike environment. Guidelines show the department shall routinely clean the environment of care using accepted practices, to keep the facility free from offensive odors, dirt and hazards. Environment showed housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior environment.The facility provide policy titled, Maintenance Policy shows the purpose is to ensure that the building interior and exterior grounds, and equipment are maintained in a safe and operable manner. It is the policy of the facility to provide a safe, accessible, effective and efficient environment of care that is consistent with its mission, services and law and regulations. Policy guidelines showed 3. The maintenance director will monitor and contract services for pest control on a regular and as needed basis and assure the building is kept free of any possible infestations of rodents or insects.7. Plumbing fixtures and piping shall function properly and maintained in good repair.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with nail care, dressing, personal hygiene, and toileting. This applies to 5 of 6 residents (R13, R14, R66, R106 and R109) reviewed for ADLs (Activities of Daily Living) in the sample of 33.The findings include: 1. R13's Face Sheet listed the following diagnoses: Parkinson's disease without dyskinesia and without mention of fluctuations. R13's quarterly MDS (Minimum Data Set) dated April 7, 2026, showed that the resident was moderately impaired with cognition. The same MDS showed that R13 had functional limitation in ROM (range of motion) to both sides of his upper and lower extremities and required total assistance from the staff with personal hygiene. On June 1, 2026, at 11:22 AM, R13 was in bed, alert and oriented. R13 had accumulation of long facial hair. R13's fingernails were long; some were jagged and some had black substances under the nails. R13 stated that he wanted to be shaven, and he wanted his fingernails trimmed and cleaned. On June 2, 2026, at 9:15 AM, R13 was in bed, alert and oriented. R13 had accumulation of long facial hair. R13's fingernails were long; some were jagged and some had black substances under the nails. R13 stated in the presence of V3 (Registered Nurse/Wound Care Nurse) and V4 (Certified Nursing Assistant/CNA) that he wanted to be shaven, and he wanted his fingernails trimmed and cleaned. According to V4, R13 cannot shave and cannot trim and clean his nails on his own because the resident required total assistance from the staff with regard to his personal hygiene. R13's care plan initiated on May 29, 2026, showed that the resident was at risk for functional self-care performance deficit related to Parkinson's disease. The same care plan showed multiple interventions including R13's dependence with regards to personal hygiene. 2. R14's Face Sheet listed the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease) with exacerbation and type 2 diabetes mellitus with diabetic chronic kidney disease. R14's annual MDS dated [DATE], showed that the residents were cognitively intact. The same MDS showed that R14 had functional limitation in ROM to both sides of his upper and lower extremities and required maximum assistance from the staff with personal hygiene. On June 1, 2026, at 11:09 AM, R14 was in bed, alert and oriented. R14 had accumulation of long facial hair and the resident's fingernails were long with black substances under the nails. R14 stated, I would love to be shaven. R14 also stated I see my fingernails are very long, I do not know why my fingernails are dirty. R14 added that he wanted to have his fingernails trimmed and cleaned. On June 2, 2026, at 10:03 AM, R14 was in bed, alert and oriented. R14 had accumulation of long facial hair and the resident's fingernails were long with black substances under the nails. In the presence of V2 (Director of Nursing), R14 stated that he wanted to be shaven, and he wanted his fingernails to be trimmed and cleaned because he cannot do it on his own. V2 acknowledged that R14 needed to be shaven, and the resident's fingernails needed to be trimmed and cleaned by the nursing staff. R14's care plan initiated on May 21, 2026, showed that the resident has a potential for a functional self-care performance deficit. The same care plan showed multiple interventions including maximum assistance with personal hygiene. 3. R106's Face Sheet listed the following diagnoses: adult failure to thrive, paraplegia and personal history of traumatic brain injury. R106's quarterly MDS dated [DATE], showed that the resident was cognitively impaired. The same MDS showed that R106 had functional limitation in ROM to both sides of his upper and lower extremities and required total assistance from the staff with upper body dressing and personal hygiene. On June 1, 2026, at 11:21 AM, R106 was sitting in his reclining wheelchair inside his room. R106 was confused. The resident had accumulation of long facial hair, and his black shirt had food debris on the chest area. On June 2, 2026, at 9:12 AM, R106 was sitting in his reclining wheelchair inside his room. R106 was confused. The resident had accumulation of long facial hair. In the presence of V3 and V4, R106 stated that he wanted to be shaven. According to V4, R106 cannot shave himself and the resident required total assistance from the staff with all his ADLs including personal hygiene. R106's active care plan initiated on March 25, 2026, showed that the resident has potential for functional self-care performance deficit related to paraplegia and multiple contractures. The same care plan showed multiple interventions including total dependence on the staff with personal hygiene and dressing. On June 3, 2026, at 9:35 AM, V2 (Director of Nursing) stated that the nursing staff are expected to provide assistance to residents requiring help with personal hygiene and grooming, including shaving, nail care and dressing to maintain and ensure residents cleanliness, proper hygiene and grooming. 4. R109's Face Sheet listed the following diagnoses: Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms and dementia. Minimum Data Set (MDS) dated [DATE], showed R109 required assistance with ADL(Activity of Daily Living) care. On June 1, 2026, at 12:15 PM, V16 (CNA) assisted R109 to the toilet. R109 was heavily saturated with urine which overflowed from his incontinence brief to his pants and incontinence pad. V16 stated R109 was last changed between 8 to 9 that morning. On June 1, 2026, at 10:51 AM, V17 (CNA) stated R109 is alert but forgetful, he has dementia. Although he can clean himself, R109 is incontinent, he requires reminder, prompting, guidance from staff to do the toileting. 5. R66's Face Sheet listed the following diagnoses: with multiple diagnoses including adult failure to thrive, anorexia, dysphagia, major depressive disorder, orthostatic hypotension, dementia, psychosis, abnormal weight loss, celiac disease, anxiety, history of fractures, protein calorie malnutrition. R66 was admitted to the facility on [DATE]. R66's minimum data set (MDS) dated [DATE] showed R66 is cognitively impaired and requires maximal assistance from staff to complete activities of daily living (ADLs). On June 03, 2026, at 8:47 AM, R66 was sitting in the dining room during breakfast with soiled pants that contained a large brown spot in front. There was a foul odor noted when standing near R66. There were several staff members feeding other residents and entering and exiting the dining area during this time. V29 (CNA) said that she was going to go find R66's CNA. R66's CNA (V27) was assisting another resident at the time. R66 was left to sit in soiled clothing until V27 was done assisting another resident. On June 03, 2026, at 9:34 AM, V30 (CNA) said that any CNA can assist in toileting residents. The facility's Incontinence Care Policy with revision date of April 20, 2021, showed the purpose of this policy is to prevent excoriation and skin breakdown, discomfort, and maintain dignity. This same policy showed guidelines; Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every 2 hours and provided perineal and genital care after each episode.

Based on interview and record review, the facility failed to provide an effective system of transportation to ensure residents received timely and necessary medical care and services. This failure applies to 6 of 7 residents (R18, R37, R49, R118, R154, and R164) reviewed for quality of care. The findings include:1.R37's face sheet shows R65 was admitted to the facility on [DATE], with diagnoses that included lumbar radiculopathy (pinched spinal nerve) and low back pain. On June 02, 2026, at 2:10 PM, R37 said he has had pain in his back for years and sees a special doctor for his pain. R37 also said he has pain in his shoulders and neck. R37 said prior to being admitted to the facility he would see his pain specialist regularly nearly every month and has only seen the pain physician once since he's been admitted to the facility. R37 said the ride share company or some other transportation service cancelled his transportation for his appointment with the pain physician approximately a week ago. R37's POS (Physician Order Set) dated October 21, and December 18, 2025, showed R37 was referred to pain management for chronic back pain. R37's progress notes show his appointment scheduled for May 28, 2026, with the pain physician for pain management was cancelled due to insurance transportation. 2. R118's face sheet shows R118 was admitted to the facility on [DATE], and on May 1, 2026, for fractured great toe. On June 02, 2026, at 2:23 PM, R118 said three appointments were made for her to see the physician about her broken toe and they were all cancelled. R118 said she broke her toe when she fell out of her wheelchair while trying to self-propel down the hall in her wheelchair. R118's progress notes show her appointments scheduled for May 12, May 20, and May 27, 2026, to be seen by the orthopedist were cancelled due to insurance transportation availability, inappropriate insurance transportation vehicle, and no availability of ambulance transportation. 3. R154's face sheet shows that R154 is was admitted to the facility on [DATE], with diagnoses that included stage 3 chronic kidney disease, obstructive and reflux uropathy (urinary tract obstruction), and hydronephrosis (kidney swelling due to disrupted urine flow). On June 02, 2026, at 2:20 PM, R154 said he needed to see the urologist for kidney issues, which he usually seen regularly. R154 said his urology appointments were cancelled three times because transportation didn't show up. R154's POS showed there were orders written on September 25, 2025, and again on May 27, 2026, for R154 to see the urologist. R154's progress notes show his appointments scheduled for May 14, May 21, and May 27, 2026, were cancelled due to insurance transportation not showing up. 4. R164's face sheet shows R164 has been complaining of a toothache and difficulty chewing. On June 02, 2026, at 2:20 PM, R164 said he was supposed to be picked up between 8:00 and 9:00 AM for a 10:30 AM dental appointment last Wednesday and transportation never showed up. R164 said this appointment was scheduled 6 months ago. R164 said he was scheduled to see the dentist for cavities, and he is currently on painkillers and antibiotics for his tooth pain and infection. The facility used to have a van for transportation but no longer has one. R164 said he no longer trusts the transportation to make it to his appointments. R164's POS shows on May 4, 2026, there was referral for dental follow up appointment related to toothache and difficulty chewing; and on June 1, 2026, a referral to the dentist for a tooth abscess. R164's progress note shows his appointment scheduled for May 28, 2026, was cancelled due to insurance transportation. R164's dental provider notice dated May 27, 2026, shows their records indicated he either missed and appointment, arrived late to an appointment, or gave less than 72 hours' notice of cancellation and any further missed appointments, cancellations without 72 hours notification, or late arrivals, may result in discontinuation of your treatment. 5. R49's EMR (electronic medical record) showed that R49 was admitted to the facility with diagnoses that included spondylosis, cardiomegaly, other low back pain, social phobia, post-traumatic stress disorder, pain in left ankle and joints of left foot, cervicalgia, dorsalgia, and auditory hallucinations. R49's quarterly Minimum Data Set, dated [DATE], showed that R49 was cognitively intact. On June 1, 2026, at 11:36 AM, R49 stated it has been challenging to get to follow up appointments since the van has been broken. R49 stated he has missed appointments with V37 (Pain Specialist) and V38 (Psychiatrist). R49 progress notes written by V18 (Medical Scheduler) showed that on February 26, 2026, and May 21, 2026, R49 missed appointments with V37 (Pain Specialist) due to insurance transportation not showing up and the appointments were cancelled. R49 progress notes written by V18 also showed that on March 13, and May 13, 2026, R49 missed appointments with V38 (Psychiatrist) and the appointments were cancelled. 6. R18 electronic medical record showed R18 was admitted to the facility with diagnoses that included chest pain, chronic pulmonary embolism, other low back pain, other intervertebral disc displacement, lumbosacral region, and major depression. R18's quarterly Minimum Data Set, dated [DATE], showed that R18 was cognitively intact. R18's POS (Physician Order Set) shows R18 has the following physician order: Pain clinic referral for chronic back pain dated December 12, 2025.The facility's scheduled appointment list showed that R18 had an appointment with V41 (Pain Specialist) on February 19, 2026, and March 23, 2026. On June 4, 2026, at 2:00 PM, V18 stated R18 missed those two appointments due to transportation not sowing up. R18's progress notes written by V18, dated February 19, 2026, and March 23, 2026, showed the same.On June 3, 2026, at 2:30 PM, V18 stated that she arranges transportation for all residents to go to their physician appointments. V18 stated that resident appointments are made through/by their insurance company unless the resident has straight Medicaid. V18 stated after the appointment is made she will check the day before and an hour before the appointment to see if the appointment has been picked up by transportation company. If the appointment was not picked up or if the transportation company does not show up, V18 stated that she will cancel the appointment. V18 stated she will only order alternative transportation if the resident has missed three or more appointments and if the resident really needs to see the doctor. V18 stated, as she shrugged her shoulders, that she doesn't know why she waits till after a resident has had three missed appointments before she schedules alternative transportation. V18 then stated, I know they [doctors' appointments] are important. I would want to go to my appointments. V18 stated she did not get any direction to wait for 3 missed appointments before obtaining alternate transportation.On June 06, 2026, at 8:27 AM, V2 (Director of Nursing) said getting residents to their scheduled appointments is difficult because available transportation is based on their insurance and transportation companies have not been showing up to transport the residents. V2 said insurance companies require a few days' notice to schedule transportation, and they provide a list of transportation options they will cover. V2 said V18 (Medical Scheduler) can call families for assistance with transporting residents to their appointments when transportation companies don't show up, but families are busy and don't have time. V2 said when transportation doesn't show up the residents generally miss the appointment, and we must cancel the appointment and reschedule. V2 said if the residents really need to be seen by their provider, and we cannot get transportation, they will be sent to the hospital. V2 said if R118 must miss a second scheduled appointment with the orthopedist it's probably in R118's best interest to be sent to the hospital. V1 (Administrator) said if R118 misses a second scheduled appointment with the orthopedist she would contact the physician and await instructions or plan to send R118 to the hospital and the same would be done for R164 for his dental appointment. V2 said R154 should have been sent to the emergency room after the second missed appointment with the urologist so they could remove his specific type of foley. V2 said R37 has had chronic back pain for years. V2 said there is a specific ride share company and that is another option that can be used for appointment transportation; however, sometimes they don't show up either. V2 said although the ride shares companies sometimes don't always show, there should be an attempt to use them. The facility's policy for transportation for residents shows: The facility will maintain a current list of transportation arrangements and services in order to promptly transfer residents. Designated personnel shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility.

Based on observation, interview, and record review, the facility failed to ensure an accurate count of controlled substances was consistent with their documentation on the medication sign out sheet. This applies to 9 of 9 residents (R10, R13, R18, R57, R94, R105, R122, R130, R143) reviewed for controlled medications in the sample of 33. The findings include:On June 3, 2026, from 8:58 AM through 9:55 AM, controlled medications count was conducted with V7, V12, and V14 (All License Practical Nurses/LPN), and V13 (Assistant Director of Nursing/ADON). The following were observed:1. R122's Lorazepam 0.5 milligrams (mg) tablet actual count showed there were 7 tablets remaining in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 8 tablets left. 2. R57's Lorazepam 0.5 mg tablet actual count showed there were 24 tablets in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 25 tablets left. 3. R105' s Clonazepam 0.5 mg tablet actual count showed there were 9 tablets in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 10 tablets left. 4. R94's Lorazepam 0.5 mg tablet actual count showed there were 15 tablets in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 16 tablets left. 5. R18's Tramadol HCL 50 mg tablet actual count showed there were 8 tablets remaining in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 9 tablets left. 6. R13's Alprazolam 0.5 mg tablet actual count showed there were 20 tablets remaining in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 21 tablets left. 7. R143's Lorazepam 1 mg tablet actual count showed there were 12 tablets remaining in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 13 tablets left. 8. R10's Lorazepam 0.5 mg tablet actual count showed there were 21 tablets remaining in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 22 tablets left. 9. R130's Lorazepam 0.5 mg tablet actual count showed there were 20 tablets remaining in the blister pack, however, the controlled drug receipt/record/disposition form or log documented that there were 21 tablets left. Copy of the controlled log of R10, R13, R18, R57, R94, R105, R122, R130, R143 was requested to V7, V12, V13, and V14. Copies were provided but upon review, of R18, R57, R94, R105, R122, R130, R143 controlled logs were all signed.On June 4, 2026, at 10:09 AM, V13 (ADON) was asked why the controlled log had signatures of staff documented on the missing tablet, V13 said she was told that the nurses can sign. On June 4, 2026, 10:10 AM, V40 (Wound Care Nurse Consultant) stated she told the nurses to go ahead and sign before they gave copy of the Controlled Drug Receipt/Record/Disposition Form to state representative. On June 3, 2026, at 3:57 PM, V2 (Director of Nursing/DON) stated there is nothing written in their policy and procedure of when the staff nurse should sign out a controlled substance from the controlled log/record form. But the expectation is that the staff nurse should sign it out from the log the moment the staff removed the controlled medication from its container for accurate accounting of the narcotic medications.

Based on the observation, interview, and record review the facility failed to label and date medications as they were opened to determine expiration dates. This applies to 11 of 11 residents (R1, R28, R30, R66, R75, R93, R94, R122, R137, R157, R166) reviewed for medication storage in the sample of 33.The findings include: On June3, 2026, from 8:58 AM to 9:40 AM medication carts inspection was conducted with V12, V14, and V15 (All License Practical Nurse/LPN). The following were observed:1.R157's Insulin Lispro was opened on April 20, 2026. Label showed to discard 28 days later, after it was opened. The pharmacy audit assistance form showed that this medication should be discarded 28 days after it was opened.2.R166's Humalog Kwik Pen was opened and not dated. The pharmacy audit assistance form showed that this medication should be discarded 28 days after it was opened. 3.R30's Novolog Flex Pen has label that showed it was opened on April 27, 2026. Label showed discard 28 days after opening. The pharmacy audit assistance form showed that this medication should be discarded 28 days after it was opened.R30's Fluticasone/Vilanterol (Breo Elipta) INH 200-25 was opened on April 15, 2026. The pharmacy audit assistance form showed that this medication should be 42 days after it was opened. 4. R22's Insulin Lispro was opened and not dated. The pharmacy audit assistance form showed that this medication should be discarded 28 days after it was opened. 5.R1's Azelastine HCl Ophthalmic solution was opened and not dated. The pharmacy audit assistance form showed that this medication should be discarded 90 days after it was first used. 6.R94's Fluticasone Propionate Diskus 10/50 mcg inhaler was opened and not dated. The pharmacy audit assistance form showed that this medication should be discarded 6 weeks after it was opened. 7. R73's Advair Diskus was opened and not dated. The pharmacy audit assistance form showed that this medication should be discarded 30 days after it was opened. no opening date. 8. R93's Treshiba (Decludec) pen was open and not dated. The pharmacy audit assistance form showed that this medication should be discarded 56 days after it was opened.9. R28's Novolog and Lantus Flex Pen was open and not dated. The pharmacy audit assistance form showed that these medications should be discarded 28 days after they were opened.10. R137's Lantus and Lispro were open and not dated. The pharmacy audit assistance form showed that this medication should be discarded 28 days after it was opened. 11. R75's Advair Diskus was open and not dated. The pharmacy audit assistance form showed that this medication should be discarded 30 days after it was opened.

Based on observation, interview and record review, the facility failed to ensure staff adhered to infection control practices, including hand hygiene and appropriate use of gloves during provision of care. This failure applies to 7 residents (R13, R36, R62, R66, R109, R124, R143,) reviewed for infection control in a sample of 33. The findings include: 1. R124's Face sheet showed R124 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, hypertension, major depressive disorder, parkinsonism, hearing loss, cognitive communication deficit, anxiety, dementia and hyperlipidemia. R124's minimum data set (MDS) dated [DATE], showed R124 has severe cognitive impairment. R124 requires moderate to maximal assistance for to complete activities of daily living. On June 01, 2026, at 11:05 AM, V3 (Wound Care Nurse) entered R124's room to provide wound care to R124's right heel. V3 applied gloves without performing hand hygiene. V3 started to remove dressing from R124's heel when V3 realized all supplies had not been gathered. The removed dressing was lying on the floor next to R124's right heel. With the same gloves V3 reached into her pocket with gloved hand and handed wound cart keys to V27 (Certified Nursing Assistant/CNA) to retrieve needed items. V27 returned to R124's room and handed items and keys to V3. V3 placed keys back into her pocket. V3 removed gloves and applied new gloves without hand hygiene. V3 cleansed R124's wound with wound cleanser and then applied a new dressing using the same soiled gloves. V3 then removed gloves and did not perform hand hygiene after care. 2. R66' s Face sheet showed R66 was admitted to the facility on [DATE], with multiple diagnoses including adult failure to thrive, anorexia, dysphagia, major depressive disorder, orthostatic hypotension, dementia, psychosis, abnormal weight loss, celiac disease, anxiety, history of fractures, protein calorie malnutrition. R66's minimum data set (MDS) dated [DATE] showed R66 is cognitively impaired and requires a wheelchair for mobility. R66 requires maximal assistance from staff to complete activities of daily living (ADLs). On June 01, 2026, at 11:43 AM, V26 (CNA) and V27 (CNA) were providing incontinence care on R66 following a bowel movement. V27 applied gloves without performing hand hygiene. R66's perineal area and buttocks were red. V26 continued to clean R66. With the same soiled gloves V27 applied a new brief on R66. V3 (Wound Care Nurse) entered the room and applied gloves to look at a new skin tear on R66's left leg. Following the assessment V3 removed gloves without applying hand hygiene and went to the wound cart to obtain supplies. V3 applied new gloves and cleansed and covered R66's skin tear using the same gloves. V27 continued to get R66 dressed using the same soiled gloves. V27 and V3 removed gloves after completion of care and did not perform hand hygiene. On June 03, 2026, at 9:07 AM, V27 took R66 from the dining room to the bedroom to perform incontinence care. V27 had brown stains seeping through the front of her pants and there was a foul odor noted. V27 assisted R66 into the bed and threw a dirty towel that was on R66 onto the floor. The chair pad was wet. V27 then went into the bathroom to wet towels with warm water. V27 returned to the room and draped the wet towels on the footboard of the bed and the resident's dresser. V27 removed R66's shoes and placed them on the wet pad in R66's wheelchair. V27 applied gloves and touched R66's light switch, curtains, and bedroom remote. Using the same gloves removed R66's brief and threw it into a trash bin without a liner. V27 used wet towels that were draped on the footboard to clean R66's perineal area and buttock. V27 removed soiled gloves and noticed that there were no additional bags in the room. V27 placed soiled gloves at the foot of R66's bed. V27 applied new gloves without performing hand hygiene and applied lotion to R66's buttocks. V27 removed soiled gloves and applied new gloves without hand hygiene. V27 placed a clean brief underneath R66 and covered R66 with a blanket. V27 removed gloves and exited room and returned with bags for soiled laundry and gloves. V27 applied gloves and placed soiled gloves that were placed on the bed inside of one bag and soiled linen into another bag. V27 removed trash and linen from room and then removed gloves. V27 did not perform hand hygiene after resident care. On June 03, 2026, at 9:27AM, V27 said that hands are to be washed after every glove change and that she had forgotten to do so. On June 03, 2026, at 9:31AM, V29 (CNA) said that when performing incontinence care on women, the CNA should wipe from front to back. V29 said that hand hygiene should be performed as often as possible. On June 03, 2026, at 9:34 AM, V30 (CNA) said that hand hygiene should be performed before and after handling each resident and after finalizing care. V30 said that when cleaning the perineal area staff should wipe from front to back. 3. R36's Face sheet showed she was admitted to facility on September 15, 2025, with diagnosis of Emphysema, Type II Diabetes, Hypertension, Anxiety, chronic kidney disease, Bipolar, Malignant Neoplasm of breast, weakness, left hip pain. R36's quarterly MDS dated [DATE], showed she is cognitively intact and has functional limitations in range of motion; showed impairment in lower limbs requiring total assistance from staff with toileting, dressing and bathing and the use of mechanical device for transfers. 4. R143's Face sheet showed he was admitted to the facility on [DATE], with the diagnosis of Toxic Encephalopathy, contracture of muscle, abnormal posture, adult failure to thrive, anxiety, Dysphagia, major depressive disorder, post-traumatic stress disorder, attention deficit disorder. R143's quarterly MDS dated [DATE], showed his cognition as severely impaired and has functional limitation in range of motion; showed impairment in upper and lower limbs requiring total assistance from staff with toileting, dressing, eating, and bathing and uses mechanical devices for transfers and mobility. On June 2, 2026, at 11:13 AM V4 (CNA) and V20 (CNA) were assisting R36 with care using a mechanical lift. V4 removed her gloves after using the mechanical lift without performing hand hygiene. V4 proceeded down the west hallway with the mechanical lift, pausing to touch and adjust R143's head pillow on his wheelchair with both bare hands and proceeded to push the mechanical lift down the hallway without performing hand hygiene. On June 2, 2026, at 11:19 AM, V20 (CNA) was performing patient care with R36 when she discarded her gloves, adjusted R36's clothing while she was sitting in her wheelchair, adjusted items on R36's bedside table and exited the room without performing hand hygiene. V20 proceeded across the hallway and entered another resident's room without performing hand hygiene. On June 26, 2026, at 11:41 AM, V2 (Director of Nursing/DON) stated staff had received training on handwashing and peri care a month ago. She stated the handwashing procedure; if staff can't get to soap and water then they should use hand sanitizer for a full 20 seconds. V2 stated the staff must take their gloves off before they leave a resident's room when providing care. She stated the staff should use hand sanitizer. V2 stated the staff should not touch any residents, without washing their hands or using hand sanitizers first. On June 2, 2026 at 11:48 AM V10 (Registered Nurse/RN) stated staff should wash hands when they are dirty and use hand sanitizer when there is patient contact. On June 2, 2026, at 12:49 PM, V19 (Infection Preventionist/IP) stated the staff should be washing hands and or using hand sanitizer before and after gloving hands. They should be washing their hands if they are visibly dirty. V19 Stated staff should be performing hand hygiene before and after patient contact. On June 2, 2026, at 11:15 AM signage posted on the wall showing How to Handwash? Wash Hands When Visibly Soiled! Otherwise, Use Handrub was observed on the residents' west corridor. 5. On June 1, 2026, at 12:15 PM, V16 (CNA) assisted R109 to the toilet who was heavily saturated with urine. V16 removed dirty incontinence brief, she opened cabinet to get clean incontinence brief and clothes, assisted R109 to change brief and put new set of clothes, picked soiled clothes and soiled brief. V16 left the room carrying soiled items without hand hygiene. V16 changed her gloves in between tasks but did not perform any hand hygiene all throughput the provision of care. 6. R13 had multiple diagnoses including Parkinson's disease without dyskinesia and without mention of fluctuations, based on the face sheet. R13's quarterly MDS (Minimum Data set) dated April 7, 2026 showed that the resident was moderately impaired with cognition. The same MDS showed that R13 had functional limitation in ROM (Range Of Motion) to both sides of his upper and lower extremities and required total assistance from the staff with toileting hygiene. On June 2, 2026 at 9:15 AM, V4 (CNA) with the assistance of V3 (RN/Wound Care Nurse) provided incontinence care to R13. R13's disposable brief was wet with urine. With her gloved hands, V4 cleaned R13's perineal area, then proceeded to apply a new disposable brief to the resident, put on a clean gown, covered R13 with a clean sheet and blanket and held the resident's bed remote to adjust the resident's bed while using the same soiled gloves that she (V4) used to clean the resident. On June 3, 2026 at 9:26 AM, V2 (Director of Nursing) stated that during resident care, the nursing staff are expected to remove their used/soiled gloves, perform hand hygiene such as hand washing or use of alcohol rub, apply a new pair of gloves then proceed to perform the clean task. According to V2, V4 (CNA) should have removed her used gloves after providing incontinence care to R13, used an alcohol rub for hand hygiene, then apply a new pair of gloves before performing the clean task of applying new brief and clean gown, covering the resident with a clean sheet and blanket and before handling equipment such as bed remote, to prevent cross contamination and to maintain infection control. 7. R62's EMR (Electronic Medical Record) showed R62 was admitted to the facility on [DATE], with multiple diagnosis non-pressure chronic ulcer of unspecified part of the lower right leg, dementia, skin transplant. The MDS (Minimum Data Set) showed R62 is cognitively impaired and requires staff assistance with ADLs (activities of daily living). R62's care plan, dated May 20, 2026, showed R62 required enhanced barrier precautions related to chronic wounds. Care plan continued to show gown and glove during high contact resident care, wound care and maintain enhanced barrier precautions for the duration of their stay OR until resolution of the wound. On June 2, 2026, at 11:23 AM, V3 (RN/Wound Care) wearing the required PPE (Personal Protective Equipment) gown, entered the room of R62 carrying wound care supplies. V3 placed wound care supplies on the unclean surface of R62's television stand. V3 applied gloves without first performing hand hygiene and removed R62's socks. V3 placed gauze and a sterile bordered gauze package on the unclean surface of R62's bed. V3 removed the soiled bordered gauze dressing from R62's right lower leg wound and placed the soiled dressing on the resident's bed. V3 did not remove gloves or perform hand hygiene after handling the soiled dressing. V3 obtained wound cleanser and gauze, cleansed the wound, and wiped the wound using gauze that had been placed on the R62's bed. V3 placed the used gauze on the resident's bed. V3 did not remove gloves or perform hand hygiene. V3 opened a sterile bordered gauze package, dated it with a pen from her pocket, and placed the opened dressing on the R62's bed. V3 removed her gloves and placed them on the resident's bed. V3 applied a new pair of gloves without performing hand hygiene. V3 applied Urea External Cream 20% to the resident's skin and rubbed the cream into the skin with gloved hands. V3 removed the gloves and placed them on the resident's bed. V3 applied a new pair of gloves and applied the bordered gauze dressing. On June 2, 2026, at 2:40 PM, V2 (DON) said the nurse before providing wound care should gather supplies don PPE (personal protective equipment) and complete hand hygiene before entering the room. V2 said when the nurse removes the soiled dressing it should be placed in a garbage can. V2 said nurses should change soiled gloves before moving from dirty to clean. V2 said the nurse should use new gauze to clean each wound to prevent cross contamination. V2 said it is her expectation for nurses to follow physician orders and infection control practices. On June 04, 2026, at 9:24 AM V2 (DON) said that the purpose of enhanced barrier precautions (EBP) is to provide a barrier between staff and residents who have wounds, catheters, g-tubes, and infections such as extended spectrum beta lactamase (ESBL). EBP signs are posted to alert residents, staff, and visitors about the precautions that need to be taken before entering the room. It is the expectation that staff follow the EBP policy and don personal protective equipment. V2 said that staff are informed to adhere to the EBP policy when entering room to provide care for the residents. The facility's policy titled Dressing Change-(Clean/Non-Sterile) dated January 9, 2018, guidelines showed 3. Bring supplies into resident's room. Individual resident supplies may be placed on the overbed table after it has been disinfected and/or a protective barrier placed on the table (clean towel, plastic bag, small choux, foam tray, etc.) .5. Place plastic trash bag within easy reach of worksite.6. Wash hands. 7. Prepare/ open any necessary supplies and place on top of clean barrier.8. Apply gloves. In the event that personal contamination is anticipated, personal protective equipment, such as a gown or mask should be worn.10. Remove soiled dressing and place in plastic trash bag. 11. Remove soiled gloves and place in plastic trash bag. The facility policy titled Hand Hygiene/Handwashing dated July 30, 2024, showed hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Perform hand hygiene when hands are visibly dirty, after known or suspected exposure to patient's infectious diarrhea, at room entry, before performing an aseptic task, before and after having direct contact with patients' intact skin, if hands will be moving from a contaminated body site to clean- body site during patient care, after glove removal. The facility policy titled Enhanced Barrier Precautions dated May 7, 2024, showed the purpose to reduce the risk of transmitting multidrug- resistant organisms (MDRO). Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission. multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated when performing high-contact resident care activities dressing, bathing/showing, transferring, providing hygiene, changing briefs or assisting with toileting, device care and wound care.

Based on observation, interview, and record review, the facility failed to ensure staff implemented safe transfer techniques by utilizing a gait belt and locking the wheelchair during a resident transfer. This applies to 1 resident (R66) reviewed for safe transfers in a sample of 33. The findings include:R66's Face sheet showed R66 was admitted to the facility on [DATE], with multiple diagnoses including adult failure to thrive, anorexia, dysphagia, major depressive disorder, orthostatic hypotension, dementia, psychosis, abnormal weight loss, celiac disease, anxiety, history of fractures, protein calorie malnutrition.R66's minimum data set (MDS) dated [DATE] showed R66 is cognitively impaired and requires a wheelchair for mobility. R66 requires maximal assistance from staff to complete activities of daily living (ADLs).R66's current care plan showed R66 requires assistance with transfers related to failure to thrive, orthostatic hypotension, and dementia. R66's interventions included assessing for pain, properly locking brakes on wheelchair, and providing cues for safety and techniques.On June 03, 2026, at 9:07 AM, R66 was taken to her bedroom by V26 (Certified Nursing Assistant/CNA) to assist with dressing and incontinence care. V26 pulled R66's wheelchair up towards the side of the bed. V26 lifted R66 from the wheelchair using R66's left arm and placed her onto the bed. V26's gait belt was around V26's waist. R66's wheelchair was not locked during the transfer. V26 rolled R66's wheelchair to the front of R66 closet.On June 03, 2026, at 9:31 AM, V29 (CNA) said that gait belts are to be used anytime a resident is transferred and that wheelchairs should be locked prior to transferring residents.On June 03, 2026, at 4:27 PM, V32 (CNA) said that all residents should be transferred with a gait belt unless the resident is using a mechanical lift. V32 said that before lifting a resident the staff should ensure that the wheelchair is locked and in place.On June 04, 2026, at 9:24 AM, V2 (Director of Nursing) said that staff should be using gait belts to transfer residents. V2 said that when transferring from the wheelchair, staff should ensure that the wheelchair is locked before moving the resident.The facility's policy Transfers-Manual Gait Belt and Mechanical Lifts purpose: In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. The guidelines show 5.) The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: 1= 1 person transfer with gait belt, 2=2 person transfer with gait belt. 9.) Use of gait belt for all physical assist transfers is mandatory.The facility's policy Activities of Daily Living (ADLs) showed Transfers (Standing Pivot): Lock brakes prior to starting the transfer, apply gait belt per policy, position resident to assist with further transfer (lean forward, come to edge of chair), place hands correctly (DO NOT hold under the aims), provide cues to resident to let them know what you are doing, have them count with you, assist resident to stand, using appropriate body mechanics, pivot resident to the chair or bed, then lower slowly asking them to reach back for the chair, once they are in the chair, make sure they are positioned safely and comfortably.

Based on observation, interview, and record review, the facility failed to follow physician order and principles of medication administration. In addition, the facility failed to ensure that uncrushable medication was not crushed. There were 27 medication opportunities with 4 medication errors resulting in 14.8% error rate. This applies to 2 of the 3 residents (R9 and R26) reviewed for medication pass in the sample of 33. The findings include: 1. Face sheet showed R9 is a resident who has gastrostomy tube (g-tube). R9 is NPO (Nothing by mouth) according to V2 (Director of Nursing/DON) on June 4, 2026, at 11:48 AM.On June 2, 2026, at 9:35 AM, V11 (Nurse) administered multiple medications to R9 including Midodrine, and hyoscyamine sulfate. Using a medication syringe V11 aspirated the Midodrine medication from the medicine cup. As V11 was removing the air from the syringe prior to the administration, he pulled some crushed chunks of Midodrine from the syringe and there were also a lot of residual Midodrine left inside the wall and bottom part of the medicine cup. V11 did not ensure to administer the full dose of the midodrine to R9. In addition, V11 crushed the hyoscyamine sulfate sublingual tablet and mixed it with water, then he aspirated it with a medication syringe and squirted it directly to R9's mouth who is supposed to be NPO. On June 2, 2026, at 3:34 PM, V11 (Nurse) stated he always administers medications to R9 the same way he administered all R9's medications this morning. 2. On June 2, 2026, at 10:45 AM, V10 (Nurse) administered multiple medications to R26 including Ferrous Sulfate 325 mg tablet. R26's Medication Administration Record (MAR) dated June 2026, showed that R26 does not have an order for Ferrous Sulfate. In addition, the MAR showed R26 is supposed to receive Folic Acid 1 mg. V10 did not give this medication, however, she signed this Folic Acid as given. On June 3, 2026, at 4:28 PM, V10 confirmed that she gave the Ferrous Sulfate and that she did not give the Folic Acid. On June 2, 2026, at 12:17 PM, V5 (Registered Pharmacist) stated Hyoscyamine SO4 sublingual tablet is designed to be dissolved for rapid absorption. If it is crushed and mixed with water, it will alter the delivery system and affect the absorption in the tongue. It would not give the rapid absorption that is expected. On June 2, 2026, at 1:58 PM, V2 (Director of Nursing) stated that when nursing staff are administering medications, they are supposed to follow the principles or 5 rights of medication administration which are the right medication, dose, patient, route, time. Medications are administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system and in the facility. The facility has sufficient staff, and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures: 5 rights- right resident, right drug, right dose, right route, and right time, applied for each medication, being administered.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. This applies to 1 resident (R2) reviewed for abuse in a sample of 3 residents. The findings include:On 4/29/26 at 10:49 AM, R2 said R1 attacked him. R2 said R1 kicked him in his left knee and R3 witnessed it. R2 said he wants to press charges against R1, but up front they are acting like nothing even happened. R2 said the police never interviewed him about the incident.On 4/29/26 at 10:59 AM, R3 said she witnessed the altercation between R1 and R2. R3 said R1 got aggressive with R2 and started grabbing R2's legs to try to push him down. R3 said when R2 didn't fall, R1 kicked R2 in his left knee and then R2 fell and landed on his left hip.On 4/29/26 at 11:07 AM, R1 said he kicked R2.On 4/29/26 at 1:25 PM, R2 said when R1 kicked him, it knocked him off his feet. R2 said he fell on his left hip and has continued to have pain in his hip since R1 knocked him down. R2 rates his hip pain as a 5/10 on a 0-10 scale. R2 said he has pain when he walks and when he lays on his back and it feels like a bruise to his left butt area.On 4/29/26 at 1:39 PM, V7 (LPN) said R1 kicking R2 is a reportable incident and that was why she reported it to V1 (Administrator) immediately. V7 said R1 called 911 after the incident, not a staff member. V7 said if a resident requests an ambulance or to go to the hospital, that is their right and it should be honored.On 4/29/26 at 2:05 PM, V8 (Certified Nursing Assistant/CNA) said he witnessed the altercation between R1 and R2 on 4/25/26. V8 said right before the 4PM smoke break, residents were lining up to go outside to smoke. V8 said R2 was standing in line and R1 aggressively grabbed R2's leg and started shaking it to try to get R2 to fall, but when R2 stayed upright, R1 kicked R2 in his left leg and R2 fell. V8 said R1 kicking R2 was physical abuse.On 4/29/26 at 2:34 PM, V9 (CNA) said she saw R1 trying to push R2 out of the way in line, and when R2 didn't budge, R1 kicked R2's left leg and R2 fell. V9 said after R2 fell she saw him with his left hand on his left knee, and he kept asking to call the police and the ambulance. V9 said she helped R2 stand up and walked him to the couch in the nearby lounge to sit down. V9 said V7 (Licensed Practical Nurse/LPN) was then notified of the incident and came to assess R2. V9 said R1 kicking R2 was physical abuse.On 4/30/26 at 11:12 AM, V1(Administrator) said she is aware R1 kicked R2 and R2 fell. V1 said V7 (LPN) completed an assessment of R2 after the incident. V1 said R1 called 911 for himself, the facility did not call the police or an ambulance for R2, the victim. V1 said she is aware R2 had an Xray ordered of his hip because of hip pain. V1 said she did not report the incident to the state surveying agency after R1 kicked R2.On 4/30/26 at 12:45PM, V2 (Director of Nursing) said one resident kicking another resident is physical abuse, the incident should be reported to the state surveying agency, and the police should be called.On 4/30/26 at 12:57 PM, V3 (Assistant Director of Nursing) said R1 kicking R2 is physical abuse as it was deliberate contact. V3 said after physical abuse occurs in the facility, the police should be called by facility staff, and an ambulance should be called if the resident requests.R2's Behavior Note documented on 4/25/26 at 9:08 PM by V7 states she was informed by CNA that the residents were standing in line waiting to go out to smoke. R1 rolled up in his wheelchair stood up and kicked R2 in his leg for no reason and it was witnessed by residents and staff. Administrator in facility and talked with resident about what happened. R2's Nurses Note documented on 4/28/26 at 10:31AM by Restorative RN (Registered Nurse) states R2 voicing complaint of left hip pain. Restorative Nurse documented notifying the Nurse Practitioner who then ordered a hip Xray. R2's POS (Physician Order Sheet) shows order dated 4/28/26 for left hip with pelvis 3 view Xray.R1's Care Plan last revised 9/11/25 states R1 regularly exhibits antagonistic, verbally, and physically aggressive behavior toward staff and peers related to delusional thoughts, poor impulse control, delusional disorders, and paranoid schizophrenia.The facility's policy effective 1/8/26 titled Abuse and Retaliation Prevention and Reporting-Illinois states, Policy: This facility affirms the right of our residents to be free from abuse.Definitions: The following definitions are based on federal and state laws, regulations, and interpretive guidelines. Abuse: Abuse means any physical or mental injury.inflicted upon a resident other than by accidental means.Abuse is the willful infliction of injury.with resulting physical harm, pain, or mental anguish to a resident.The term willful in the definition of abuse means the individual must have acted deliberately; not that the individual must have intended to inflict injury or harm.Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means, and that requires medical attention.Physical abuse includes hitting, slapping, pinching, kicking.

Based on interview and record review, the facility failed to report a resident to resident abuse allegation to the state surveying agency and to the police. This applies to 2 of 2 residents (R1,R2) reviewed for abuse in a sample of 3 residents.The findings include:On 4/29/26 at 10:49 AM, R2 said R1 attacked him. R2 said R1 kicked him in his left knee and R3 witnessed it.On 4/29/26 at 10:59 AM, R3 said she witnessed the altercation between R1 and R2. R3 said R1 got aggressive with R2 and started grabbing R2's legs to try to push him down. R3 said when R2 didn't fall, R1 kicked R2 in his left knee and then R2 fell and landed on his left hip.On 4/29/26 at 11:07 AM, R1 said he kicked R2.On 4/29/26 at 1:39 PM, V7 (Licensed Practical Nurse/LPN) said R1 kicking R2 is a reportable incident and that was why she reported it to V1 (Administrator) immediately.On 4/29/26 at 2:05 PM, V8 (Certified Nursing Assistant/CNA) said he witnessed on 4/25/26 R1 aggressively grabbing R2's leg and shaking it to try to get R2 to fall, but when R2 stayed upright, R1 kicked R2 in his left leg and R2 fell. V8 said R1 kicking R2 was physical abuse.On 4/29/26 at 2:34 PM, V9 (CNA) said she saw R1 trying to push R2 out of the way in line, and when R2 didn't budge, R1 kicked R2's left leg and R2 fell. V9 said V7 (LPN) was then notified of the incident and came to assess R2. V9 said R1 kicking R2 was physical abuse.On 4/30/25 at 11:12 AM, V1(Administrator) said she is aware R1 kicked R2 and R2 fell. V1 said V7 (LPN) completed an assessment of R2 after the incident. V1 said R1 called 911 for himself, the facility did not call the police or an ambulance for R2, the victim. V1 said she is aware R2 had an Xray ordered of his hip because of hip pain. V1 said R1 kicking R2 was not reported to the state surveying agency.On 4/30/26 at 12:45PM, V2 (Director of Nursing) said one resident kicking another resident is physical abuse, the incident should be reported to the state surveying agency.On 4/30/26 at 12:57 PM, V3 (Assistant Director of Nursing) said R1 kicking R2 is physical abuse as it was deliberate contact.The facility's policy effective 1/8/26 titled Abuse and Retaliation Prevention and Reporting-Illinois states, Policy: This facility affirms the right of our residents to be free from abuse.Definitions: The following definitions are based on federal and state laws, regulations, and interpretive guidelines. Abuse: Abuse means any physical or mental injury.inflicted upon a resident other than by accidental means.Abuse is the willful infliction of injury.with resulting physical harm, pain, or mental anguish to a resident.The term willful in the definition of abuse means the individual must have acted deliberately; not that the individual must have intended to inflict injury or harm.Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means, and that requires medical attention.Physical abuse includes hitting, slapping, pinching, kicking.Procedures:. V. Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation, or suspicion of potential abuse.they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator.Upon learning of the report, the administrator.shall initiate an incident investigation. Any allegation of abuse.or any incident that results in.injury will be reported to the Illinois Department of Public Health Immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on observation and interview, the facility failed to ensure residents have a safe, functional, sanitary, and comfortable restroom environment. This applies to 18 of 18 residents (R3, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24) reviewed for restroom environment in sample of 24.The findings include:On March 12, 2026, at 1:32 PM, V3 (Environmental Manager) said that some residents have shared restrooms, while others have private rooms. She said each housekeeper has assigned residents' restrooms and bedrooms to clean daily. V3 said the day shift housekeepers clean the residents' bedrooms and bathrooms, including the toilets, sinks, soap, and paper towel dispensers daily. V3 said the housekeepers clean the residents' dining rooms after mealtimes, three times a day.On March 12, 2026, at 1:44 PM, the shared bedroom restroom for R3, R20, R21, R22, R23, and R24 was inspected in the presence of V3. There were toilet papers on the restroom floor, and the floor also had scattered black, stained footprints. There was a blue cloth bed pad with large brown stains at the front of the toilet base on the floor. V3 said the cloth bed pad was probably placed to soak the leakage from the base of the toilet. There was a black-and-white plunger on the floor next to the toilet. V3 said the plunger looks filthy and dirty. V3 said the toilet had been leaking, and it was brought up in the facility's team meeting.On March 12, 2026, at 1:48 PM, the shared bedroom restroom for R8, R9, R10, R11, R12, and R13 was inspected in the presence of V3. The bathroom's sink had large areas of stale brown stains and toothpaste build-up. The floor had several scattered black stains. V3 said the floor needs to be swept and mopped. The toilet seat was chipped in scattered areas, and the porcelain inside the toilet bowl had large areas of black buildup. A plunger was placed on the floor next to the toilet. V3 said the staff used the plungers to unclog the toilet, and they are not clean or hygienic. On March 12, 2026, at 2:30 PM, R9 said the housekeeping staff comes to clean the bathroom every three days. R9 said the black build-up stains in the toilet have been there ever since she could remember, and she said, I hate it, and that the chipped toilet is not hygienic, considering that she shares the restroom with five other residents. R9 said the toilet gets clogged at least once a day, and the residents always let the staff know each time it gets clogged. V3 said she knew about the toilet leakage because it had been brought up in the facility's team meeting a couple of times. V3 said she had previously notified V6 (Maintenance Director).On March 12, 2026, at 2:44 PM, R10 said the housekeeping staff comes to clean the bathroom maybe once a week. R10 said the black buildup stains in the toilet have always been there since she has been there, ever since she can remember, and she does not like toilets being dirty or the toilet seat being chipped. V10 said the facility staff is aware of the toilet seat being chipped.On March 13, 2026, at 2:30 PM, R8 said that the facility staff comes to clean the bathroom three times a week, but the bathroom is always dirty. R8 said she does not like using dirty restrooms, and she sometimes goes to the bathroom in the shower down the hall because her restroom would be dirty. On March 12, 2026, at 1:54 PM, the shared bedroom restroom for R14, R15, R16, R17, R18, and R19 was inspected in the presence of V3. There was a blue cloth bed pad with large brown stains at the front of the toilet base on the floor. There was also a large area on the restroom floor with black stains and peeling tiles beneath the cloth bed pad. On March 12, 2026, at 1:56 PM, R14 said the tiled toilet floor had black stains for a long time and that he had told the facility staff. V14 said the bed pad cloth is always there to cover up the unpleasant sight of the floor.On March 12, 2026, at 1:58 PM, R16 said the restroom floor had been with black stains for a very long time, and he had told the staff at the facility.On March 12, 2026, at 2:00 PM, R18 said the toilet sometimes leaks, and he is sure someone at the facility knows because it has been happening for a long time.On March 12, 2026, at 2:42 PM, V6 (Maintenance) said the black-stained tile on the shared restroom floor for R14, R15, R16, R17, R18, and R19 was from moisture, such as urine. V6 said he notified me about two months ago that the restroom floor tiles next to the toilet needed to be replaced, and it is still on his work-to-do list. V6 said the toilet seat for R8, R9, R10, R11, R12, and R13 needed to be replaced, and he was unaware. V6 also said the black buildup in the toilet was dirty and needed cleaning.On March 14, 2026, at 3:00 PM, V2 (Director of Nursing) said he had heard concerns about some residents' toilets getting clogged. V2 said the plungers are unsanitary and should not be left in residents' restrooms. The facility's undated Housekeeping Cleaning Schedule policy showed, Purpose: To establish a schedule which ensures the building and equipment is maintained in a clean and sanitary manner. All items may be cleaned more frequently, if necessary. 1. Daily: a. Toilet, lavatory .

Based on interviews and record review, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include:On March 13, 2026, at 3:00 PM, R2 was walking around at his bedside and the doorway of his room. R2 said he got into a fight with his roommate (R1) in the dining room on March 12, 2026. R2 said, he got in my face, and I pushed him. R2 said when he pushed R1, R1 fell out of his wheelchair and was able to get up on his own. On March 13, 2026, at 3:15 PM, R1 was in the day room in his wheelchair. R1 said he was in the dining room on March 12, 2026, around 7:00 AM, when R2 approached him and started yelling at him, and suddenly pushed him out of his wheelchair. R1 said it happened so fast, and there was another resident in the dining room, but he did not remember the resident. R1 said there were no staff present in the dining room with them, and no staff saw what happened. R1 said he felt bad that someone attacked him at his place of residence. R1 said he asked the nurse to call the police, but the nurse refused. R1 also said he did not know the name of the nurse working on the unit on March 12, 2026. R1 said he did not sustain any injury at the time of the incident and denied having any pain. R1 had on short pants, and short sleeves on, no injury or bruising was noted on the resident. R1 said he reported the incident to V1 (Administrator) on March 12, 2026, around 11:00 AM that R2 pushed him out of his wheelchair. On March 13, 2026, at 4:11 PM, V18 (Social Services Director) said he was notified by V1 (Administrator) via text message around 6:50 AM on March 12, 2026, on his way to work that R1 had an altercation with R2. V18 said he and V1 both viewed the camera footage on March 12, 2026, in the morning. V18 said the footage showed R1 approaching R2 in the dining room and R2 yelled and pushed R1 to get away from him. V18 said part of the view where R1 was positioned was blocked off, and he did not see whether R1 fell out of his wheelchair. V18's progress notes for R1 from 10:11 AM on March 12, 2026 showed, Following breakfast services this morning, resident approached peer [R2] in [Unit] dining room, began to yell and wave his arms at peer while repeatedly approaching his wheelchair. Per peer, resident grasped him by the arm during the interaction; writer and administrator attempted to view the interaction via [Unit] dining room safety cameras, though the view was partially blocked and we were unable to verify this. Peer [R2] became agitated in response to the resident's behavior, began to argue with peers and pushed peer away from him. Both residents left the area after that. On March 14, 2026, at 10:35 AM, the video camera footage was reviewed without audio. The video showed R2 pacing in the dining room and R5 (identified by V1 while viewing the footage) walking into the dining room. R5 was seen walking towards R1 and speaking with him. R5 walked back to a table. R2 continued to pace back and forth in the dining room and within approximately one minute, R2 was seen talking to R1 in a threatening manner, with R2's upper body moving towards R1 repeatedly. Immediately after, R2 forcefully pushed R1 by reaching out with two flat hands toward R1. The camera view on R1 was partially blocked and did not show whether R1 fell out of his wheelchair. V1 said the push was forceful and that it was an abuse of R1. On March 14, 2026, at 1:08 PM, R5 was in her room, sitting on the bed. R5 was confused and could not answer questions about what happened between R1 and R2 in the dining room on March 12, 2026. On March 14, 2026, at 12:28 PM, V9 (Nurse) said that on the morning of March 12, R1 propelled his wheelchair down the hallway and said to her, he hit me, he hit me. V9 said she followed R1 to his room and asked R1 to explain what happened, and R1 repeated, he hit me. V9 said she asked R1 where he was hit, but R1 couldn't specify. V9 said she assessed R1 for injuries; there were none, and R1 denied pain. V9 said R1 did not ask her to call the police. V9 said she calmed R1 down, went to talk to R2, and saw R2 pacing in the dining room. V9 said she asked R2 what happened, and R2 told V9, He got in my face, and I pushed him out of my face. V9 said R2 gestured and held both of his hands out flat-handed to show that he pushed R1 out of his space. V9 also said she assessed R2 for injuries and found none. V9 said once a resident says they pushed another resident, it is an abuse allegation, and it has to be reported immediately, whether it's a behavior issue or not and she reported it to V1. R1's Electronic Medical Record (EMR) showed R1's diagnoses include paranoid schizophrenia and delusional disorder. R1's abuse care plan initiated on September 11, 2024, showed that R1 was at a heightened risk (moderate) for abuse due to psychiatric issues (paranoid schizophrenia, delusional disorder). The care plan interventions included observe resident when the company of peers. Observe resident in care area situation. Ensure safety if feeling unsafe. Report any verbalization of abuse or neglect to administrator immediately. The facility's January 8, 2026, Abuse and Retaliation Prevention and Reporting Policy showed Policy: This facility affirms the right of our residents to be free from abuse. or mistreatment. This facility therefore prohibits abuse. and mistreatment of residents. The policy further showed Definitions . Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to report an accurate allegation of abuse to the state surveying agency in a timely manner. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include:On March 13, 2026 at 3:00 PM, R2 was walking around at his bedside and the doorway of his room. R2 said he got into a fight with his roommate (R1) in the dining room on March 12, 2026. R2 said, he got in my face, and I pushed him. R2 said he pushed R1, and R1 fell out of his wheelchair and was able to get up on his own. On March 13, 2026, at 3:15 PM, R1 was in the day room in his wheelchair. R1 said he was in the dining room on March 12, 2026, around 7:00 AM, when R2 approached him and started yelling at him, and suddenly pushed him out of his wheelchair. R1 said it happened so fast, and there was another resident in the dining room, but he did not remember the resident. R1 said there were no staff present in the dining room with them, and no staff saw what happened. R1 said he felt bad that someone attacked him at his place of residence. R1 said he asked the nurse to call the police, but the nurse refused. R1 also said he did not know the name of the nurse working on the unit on March 12, 2026. R1 said he reported the incident to V1 (Administrator) on March 12, 2026, around 11:00 AM that R2 pushed him out of his wheelchair. On March 13, 2026, at 4:11 PM, V18 (Social Service Director) said he was notified by V1 (Administrator) via text message around 6:50 AM on March 12, 2026, on his way to work, that R1 had an altercation with R2. V18 said he and V1 both viewed the camera footage on March 12, 2026, in the morning. V18 said he met with R1 and R2, and he documented a behavioral progress note in R1's EMR after viewing the camera footage with V1. V18 said they saw in the camera footage that R1 was approaching R2 in the dining room and R2 yelled and pushed R1 to get away from him. V18 said part of the view where R1 was positioned was blocked off, and he did not see whether R1 fell out of his wheelchair. R1's behavioral progress note documented by V18 at 10:11 AM on March 12, 2026 showed, Following breakfast services this morning, resident approached peer [R2] in [Unit] dining room, began to yell and wave his arms at peer while repeatedly approaching his wheelchair. Per peer, resident grasped him by the arm during the interaction; writer and administrator attempted to view the interaction via [Unit] dining room safety cameras, though the view was partially blocked and we were unable to verify this. Peer [R2] became agitated in response to the resident's behavior, began to argue with peers and pushed peer away from him. Both residents left the area after that. On March 14, 2026, at 10:35 AM, V1 said V9 (Nurse) had called to notify her regarding R1 and R2's incident at approximately 6:40 AM on March 12. V1 said she also notified V18 (Social Service Director) at approximately 6:40 AM the same day, and asked V18 to find out what had happened between R1 and R2. On March 14, 2026, at 12:28 PM, V9 (Nurse) said that on March 12, R1 propelled his wheelchair down the hallway and said to her, he hit me, he hit me. V9 said she followed R1 to his room and asked R1 to explain what happened, and R1 repeated, he hit me. V9 said she asked R1 where he was hit, but R1 couldn't specify. V9 said she assessed R1 for injuries; there were none, and R1 denied pain. V9 said R1 did not ask her to call the police. V9 said she calmed R1 down, went to talk to R2, and saw R2 pacing in the dining room. V9 said she asked R2 what happened, and R2 told V9, He got in my face, and I pushed him out of my face. V9 said R2 held both of his hands out flat-handed to show that he pushed R1 out of his space. V9 also said she assessed R2 for injuries and found none. V9 said she called V1 (Administrator) at approximately 6:45 AM on March 12, 2026, to inform her that R1 alleged R2 had hit R1. V9 said she had to notify V1 the moment R2 told her he pushed R1 because it was an abuse allegation. V9 said per the facility's protocol, once a resident says they pushed another resident, it is an abuse allegation and it has to be reported immediately, whether it's a behavior issue or not. On March 14, 2026, at 3:00 PM, V2 (Director of Nursing/DON) said she was notified via text message at approximately 6:36 AM on March 12, 2026, by V1 that an incident had occurred between R1 and R2. V2 said the text message read from V1 stated, allegedly [R2] pushed [R1] in the dining room because [R1] was yelling at him. V2 said she was not part of the investigation, but she believed the incident was investigated by V1 and V18. V2 said V1 is responsible for completing the facility's abuse investigations and reporting to (state surveying agency), and she is responsible for completing the fall investigations. V2 said she would complete the abuse investigations if V1 were not available. V2 said if she were investigating the alleged incident between R1 and R2, she would document it in the behavioral progress note and send an initial report to (state surveying agency) immediately. On March 14, 2026, at 3:31 PM, V1 and V2 viewed the unit dining room safety camera footage. After viewing the part where R2 pushed R1, V2 said, he shoved him. V2 said that it should have been reported to (state surveying agency). On March 14, 2026, at 3:34 PM, V1 said she did not send an initial abuse allegation notification to (state surveying agency) and she did not notify the police and she should have. V1 said per the facility's policy, the timeline for notifying (state surveying agency) regarding an abuse allegation, such as a resident pushing another resident, is within two hours of the time of occurrence. The Facility Reported Incidents form that V1 sent to (state surveying agency) on March 13, 2024, showed the incident occurrence as abuse and that the occurrence date was March 13, 2026, not March 12. The document description alleged, On March 13, 2026, [R1] and [R2] alleged that they both had a resident-to-resident behavior to an (state surveying agency) Surveyor. They were immediately separated and assessed for injuries, pain, and emotional distress . The facility's January 8, 2026 Abuse and Retaliation Prevention and Reporting Policy showed, Any allegation of abuse, retaliation, or any incident that results in serious bodily injury will be reported to the (state surveying agency) immediately, but not more than two hours after the the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours .

Based on interview and record review, the facility failed to follow their policy and investigate an allegation of resident-to-resident physical abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include:On March 13, 2026, at 3:00 PM, R2 was walking around at his bedside and the doorway of his room. R2 said he got into a fight with his roommate (R1) in the dining room on March 12, 2026. R2 said, he got in my face, and I pushed him. R2 said he pushed R1, and R1 fell out of his wheelchair and was able to get up on his own. On March 13, 2026, at 3:15 PM, R1 was in the day room in his wheelchair. R1 said he was in the dining room on March 12, 2026, around 7:00 AM, when R2 approached him and started yelling at him, and suddenly pushed him out of his wheelchair. R1 said it happened so fast, and there was another resident in the dining room, but he did not remember the resident. R1 said there were no staff present in the dining room with them, and no staff saw what happened. R1 said he felt bad that someone attacked him at his place of residence. R1 said he asked the nurse to call the police, but the nurse refused. R1 also said he did not know the name of the nurse working on the unit on March 12, 2026. R1 said he reported the incident to V1 (Administrator) on March 12, 2026, around 11:00 AM that R2 pushed him out of his wheelchair. On March 13, 2026, at 3:50 PM, V1 (Administrator) said she was unaware that R2 had pushed R1. On March 13, 2026, at 4:11 PM, V18 (Social Service Director) said he was notified by V1 via text message around 6:50 AM on March 12, 2026, on his way to work that R1 had an altercation with R2. V18 said he and V1 both viewed the camera footage on March 12, 2026, in the morning. V18 said he met with R1 and R2, and he documented a behavioral progress note in R1's EMR after viewing the camera footage with V1. V18 said they saw in the camera footage that R1 was approaching R2 in the dining room and R2 yelled and pushed R1 to get away from him. V18 said part of the view where R1 was positioned was blocked off, and he did not see whether R1 fell out of his wheelchair. V18 provided a copy of R1's behavioral progress note documented at 10:11 AM on March 12, 2026. The behavioral progress note showed, Following breakfast services this morning, resident approached peer [R2] in [Unit] dining room, began to yell and wave his arms at peer while repeatedly approaching his wheelchair. Per peer, resident grasped him by the arm during the interaction; writer and administrator attempted to view the interaction via [unit] dining room safety cameras, though the view was partially blocked and we were unable to verify this. Peer [R2] became agitated in response to the resident's behavior, began to argue with peers and pushed peer away from him. Both residents left the area after that. On March 14, 2026, at 10:14 AM, V1 said she now remembered going to see R1 at approximately 9:00 AM on March 12, 2026, after being notified by V9 (Nurse) that R1 was upset. V1 said she spoke with R1 in his room, and R1 told her he was upset because his roommate, R2, did not flush the toilet. V1 said that was all she knew about the incident involving R1 on March 12, 2026. V1 said she was unaware that R1 had been attacked by R2, as R1 alleged. V1 said she did not complete a grievance report for R1. V1 said she did not complete an investigation of an abuse allegation because there was only a behavioral event between R1 and R2 on March 12, 2026. V1 said she initiated an abuse investigation at approximately 4:00 PM on March 13, 2026 (during the Survey and 33 hours after the incident) after being notified by the (state surveying agency) surveyor that R1 told her he was pushed out of the wheelchair by R2. On March 14, 2026, at 10:35 AM, the video camera footage was reviewed without audio. The video showed R2 pacing in the dining room and R5 (identified by V1 while viewing the footage) walking into the dining room. R5 was seen walking towards R1 and speaking with him. R5 walked back to a table. R2 continued to pace back and forth in the dining room and within approximately one minute, R2 was seen talking to R1 in a threatening manner, with R2's upper body moving towards R1 repeatedly. Immediately after, R2 forcefully pushed R1 by reaching out with two flat hands toward R1. The camera view on R1 was partially blocked and did not show whether R1 fell out of his wheelchair. V1 said the push was forceful and that it was an abuse of R1. On March 14, 2026, at 12:28 PM, V9 (Nurse) said that on March 12, R1 propelled his wheelchair down the hallway and said to her, he hit me, he hit me. V9 said she followed R1 to his room and asked R1 to explain what happened, and R1 repeated, he hit me. V9 said she asked R1 where he was hit, but R1 couldn't specify. V9 said she assessed R1 for injuries; there were none, and R1 denied pain. V9 said R1 did not ask her to call the police. V9 said she calmed R1 down, went to talk to R2, and saw R2 pacing in the dining room. V9 said she asked R2 what happened, and R2 told V9, He got in my face, and I pushed him out of my face. V9 said R2 held both of his hands out flat-handed to show that he pushed R1 out of his space. V9 also said she assessed R2 for injuries and found none. V9 said she called V1 (Administrator) at approximately 6:45 AM on March 12, 2026, to inform her that R1 alleged R2 had hit R1. V9 said she had to notify V1 the moment R2 told her he pushed R1 because it was an abuse allegation. V9 said per the facility's protocol, once a resident says they pushed another resident, it is an abuse allegation and it has to be reported immediately, whether it's a behavior issue or not. On March 14, 2026, at 3:00 PM, V2 (Director of Nursing/DON) said she was notified via text message from V1 around 6:36 AM on March 12, 2026, that an incident had occurred between R1 and R2. V2 said the text message read from V1 stated, allegedly [R2] pushed [R1] in the dining room because [R1] was yelling at him. V2 said she was not part of the investigation, but she believed the incident was investigated by V1 and V18. V2 said V1 is responsible for completing the facility's abuse investigations and reporting to (state surveying agency), and she is responsible for completing the fall investigations. V2 said she would complete the abuse investigations if V1 were not available. On March 14, 2026, at 3:34 PM, V1 said V1 said she should have begun an investigation on March 12, 2026. V1 said she began investigating R1's allegation at approximately 4:00 PM on March 13, 2026. The facility's January 8, 2026, Abuse and Retaliation Prevention and Reporting Policy showed, Policy: The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse.and mistreatment of residents. VII. Internal Investigation 1. All incidents will be documented, whether or not abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property occurred, was alleged, or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation.

Based on interview and record review, the facility failed to notify law enforcement and the state surveying agency of the attempted diversion of narcotic medications. This applies to 2 of 2 residents (R7 and R8) reviewed for control of narcotic medications.The findings include: On 02/13/26 at 11:15 AM, V3 (Registered Nurse/RN) stated on 08/09/25 he left two bingo cards of Norco, one for R7 and one for R8 on top of the cabinet in the medication room. V3 stated he took a break and when he returned from break, the medications were not where he placed them. V3 stated only him and V4 (RN) had keys to the medication room. V3 stated he searched the medication room and found both of the bingo cards inside of V4's unzipped shoulder bag. V3 stated he contacted V2 (Director of Nursing/DON) and informed her of the situation. V3 stated V2 and V1 (Administrator) immediately came to the unit. On 02/14/26 at 1:44 PM, V2 stated on 08/09/25, she received a call from V3. V3 stated he had placed two narcotic medications (Norco) on the counter in the medication room that were due to be wasted. V2 stated V3 took his break, and when he returned, the medications were not where he put them. V2 stated V4 had two bingo cards with Norco for two separate residents in her personal bag. V2 stated the bingo cards were visible and wrapped with the narcotic sheets still attached to them. V2 stated she removed the medications from V4's personal bag. V2 stated V4 admitted that she put the narcotics in her bag. V2 stated V4 stated she was addicted to drugs and just had gotten out of rehab one or two months prior. On 02/23/26 at 3:18 PM, V1 stated the narcotic medications found in V4's personal bag belonged to R7 and R8. V1 stated the police were not called due to the narcotic medications not leaving the facility, the medication count was accurate, and no residents missed any medications. V1 stated the police would only be called if there was a discrepancy with the drug count or the resident not being able to get their medications. V1 stated V4 was not reported to state licensing agency or the state surveying agency for the same reason. R7 was admitted to the facility on [DATE] with multiple diagnoses which included major depressive disorder, bipolar, anxiety, osteoarthritis, cervicalgia, and left-hand contracture per R7's Face Sheet. R7's Order Sheets for 07/01/25 through 08/30/25 showed a discontinued order for Norco Tablet 10-325 mg, give one tablet every 12 hours as needed for pain, start date 07/11/25. The same orders showed another discontinued order for Norco Tablet 10-325 mg, give one tablet every 8 hours as needed for pain, start date 08/09/25. R8 was admitted to the facility on [DATE] with multiple diagnoses which included acquired absence of right leg below knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes per R8's Face Sheet. R8's Order Sheets for August 2025 showed an order for Norco Tablet 5-325 mg (milligrams) give one tablet by mouth every 12 hours as needed for severe pain (7-10 on pain scale), for 5 days. The same orders showed the medication was ordered and started on 08/01/25 and ended on 08/06/25. The facility's Discrepancies, Loss, and/or Diversion of Medications Policy, revised 08/2020, showed, All discrepancies, suspected loss, and/or diversion of medications, irrespective of drug type or class, are immediately investigated and a report filed. Procedures: Immediately upon discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing (DON), and consultant pharmacist are notified and an investigation conducted. The DON leads the investigation. 5. Appropriate agencies required by state regulation will be notified. Robbery: Immediately following the robbery: Notify the police

Based on interview and record review, the facility failed to securely store controlled substances in the medication room. This applies to 2 of 2 residents (R7 and R8) reviewed for medication storage.The findings include:On 02/13/26 at 11:15 AM, V3 (Registered Nurse/RN) stated on 08/09/25 he left two bingo cards of Norco, one for R7 and one for R8 on top of the cabinet in the medication room. V3 stated he took a break and when he returned from break, the medications were not where he placed them. V3 stated only him and V4 (RN) had keys to the medication room. V3 stated he searched the medication room and found both of the bingo cards inside of V4's unzipped shoulder bag. V3 stated he contacted V2 (Director of Nursing/DON) and informed her of the situation. V3 stated V2 and V1 (Administrator) immediately came to the unit. On 02/14/26 at 1:44 PM, V2 stated on 08/09/25, she received a call from V3. V3 stated he had placed two narcotic medications (Norco) on the counter in the medication room that were due to be wasted. V2 stated V3 took his break, and when he returned, the medications were not where he put them. V2 stated V4 had two bingo cards with Norco for two separate residents in her personal bag. V2 stated the bingo cards were visible and wrapped with the narcotic sheets still attached to them. V2 stated she removed the medications from V4's personal bag. V2 stated when narcotic medications are in the medication room, they should be double locked. On 02/23/26 at 3:18 PM, V1 stated the narcotic medications found in V4's personal bag belonged to R7 and R8. On 02/23/26 at 3:41 PM, V12 (Assistant Director of Nursing) stated narcotic medications stored in the medication room should have been double locked and not stored on the cabinet. V12 stated the medications should have been placed back in the narcotic drawer in the medication cart, and locked. R7 was admitted to the facility on [DATE] with multiple diagnoses which included major depressive disorder, bipolar, anxiety, osteoarthritis, cervicalgia, and left-hand contracture per R7's Face Sheet. R7's Order Sheets for 07/01/25 through 08/30/25 showed a discontinued order for Norco Tablet 10-325 mg, give one tablet every 12 hours as needed for pain, start date 07/11/25. The same orders showed another discontinued order for Norco Tablet 10-325 mg, give one tablet every 8 hours as needed for pain, start date 08/09/25. R8 was admitted to the facility on [DATE] with multiple diagnoses which included acquired absence of right leg below knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes per R8's Face Sheet. R8's Order Sheets for August 2025 showed an order for Norco Tablet 5-325 mg (milligrams) give one tablet by mouth every 12 hours as needed for sever pain (7-10 on pain scale), for 5 days. The same orders showed the medication was ordered and started on 08/01/25 and ended on 08/06/25. The facility's Storage of Medications Policy showed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

Based on observation, interview, and record review, the facility failed to protect a cognitively impaired resident who is at risk for abuse (R1) from being physically and emotionally abused by another resident (R2). The facility also failed to develop interventions to address the potential for abuse for two of three residents (R1, R2) reviewed for abuse in a sample of 4. This failure resulted in R2 physically slapping R1 on the face, scratching R1's upper body, and biting R1's hand, which caused R1 to experience emotional distress. Findings include: Final facility incident report documented the following: On 04/20/2025, R1 and his roommate R2 had an alleged resident to resident behavior and were immediately separated and assessed for injuries. Both residents have Dementia. Upon assessment for injuries, none were noted to R2. R1 was noted with superficial scratches to face and right earlobe, and left knee, a discoloration to the upper lip and left had middle finger, which have all healed. R1 was moved to another room. R1 has poor impulse control and lacks social boundaries related to Dementia . 1. R1's face sheet indicated resident admitted to facility on 08/28/2023 and has a past medical history not limited to major depressive disorder, dementia, obsessive-compulsive disorder, anxiety, Alzheimer's Disease, and psychosis. Review of Minimum Data Set Section C - Cognitive Patterns dated 02/13/2025 showed R1 has severe cognitive impairment. R1's care plan last reviewed on 02/17/2025 documented a history of sexual abuse as a child and physical and emotional abuse during childhood/adolescence; at risk for abuse/neglect related to dementia, confusion, depression, history of abuse, passive personality/minimally communicative, often wander in peers' bedrooms which can be startling/upsetting to peers; 01/28/25-was bitten by peer after wandering into his room (last revised on 02/28/2025); an elopement risk/wanderer related to confusion, disorientation, dementia .often enter peers' bedrooms due to confusion, disorientation; do not exhibit disruptive behavior when entering peers' bedrooms, though my presence is often startling to peers .; have impaired cognitive function as evidenced by confusion, disorientation, impaired memory, inattention, care rejection related to dementia, unspecified psychosis, Wernicke's Encephalopathy, mild cognitive impairment. Review of nurses note dated 04/20/2025 at 10:01 AM reads in part, resident was noted on the floor together with the other resident. Upon assessment, the following observations noted: scrape on the right cheek and a scratch on the left cheek, a rounded mark was noticeable on his left hand around the middle finger, a scrape on the left earlobe, a purplish discoloration on the upper lip, and a small scrape on left knee . Review of behavior note dated 04/20/2025 at 12:00 PM reads in part, per staff report, nursing staff was alerted of incident in resident's bedroom by peer; when nurse arrived, she reportedly observed the resident on the floor with one of his roommates [R2]; the resident's finger (R1) was reportedly in [R2's] mouth. Per nursing report, it was unclear what had instigated the incident, though the resident has a pattern of wandering into peers' rooms related to confusion which may startle or upset peers . R1's abuse/trauma screening dated 04/21/2025 indicated that resident is at high risk for the likelihood of abuse/trauma occurring. On 05/02/2025 at 10:40 AM, R1 was ambulating in the hallway throughout the locked unit. R1 was not interviewable. 2. R2's face sheet indicated resident admitted to facility on 03/03/2025 and has a past medical history not limited to Parkinson's Disease, Dementia, cerebrovascular accident, major depressive disorder, and anxiety disorder. Review of Minimum Data Set Section C - Cognitive Patterns dated 03/10/2025 showed R2 has severe cognitive impairment. R2's aggressive behavior assessment dated [DATE] indicted that resident has a history or recent episode of aggressive/agitated behavior and/or non-compliance with medications, treatment, regimen, resisting care and a history of agitation/aggressive behavior at previous [skilled nursing facility]. R2's care plan last reviewed on 03/17/2025 documented have the potential for aggressive behavior, per history, related to Dementia, may yell at staff or make loud vocalizations during care provision related to confusion (initiated 03/03/2025); have a behavior problem related to Dementia, occasionally will make hypersexualized comments and may touch staff inappropriately during activities of daily living (ADL) care provisions; am resistive to care (shower/ADL care refusal) related to Dementia and depression (last revised on 04/21/2025). R2's behavior note dated 04/20/2025 at 11:30 AM reads in part, per staff report, nursing staff was alerted of incident in resident's bedroom by peer; when nurse arrived, she reportedly observed the resident on the floor with one of his roommates [R1]; peer's finger was reportedly in the resident's (R2) mouth. Per nursing report, it was unclear what had instigated the incident, though [R1] has a pattern of wandering into peers' personal space related to confusion which may startle or upset peer . R2's active physician orders as of 05/02/2025 revealed orders for haloperidol lactate concentrate 2 milligram/milliliter (MG/ML) give 0.5 mg by mouth every 6 hours as needed for agitation, start on 04/18/2025; hydroxyzine hcl oral Tablet 50 MG by mouth in the evening for agitation, start on 04/04/2025; lorazepam oral tablet 0.5 MG give 1 tablet by mouth every 6 hours as needed for Anxiety, start on 04/18/2025. On 05/02/2025 at 10:45 AM, R2 was observed in locked unit activity room seated at a table. Regarding incident, R2 said he was in his room and fell . R2 added that nothing happened with my roommate, then added that he did not get into a fist fight with anyone or touch anyone. R2 indicated that he feels safe at the facility. On 05/02/2025 at 12:18 PM, V5 (Certified Nursing Assistant/CNA) indicated at time of incident, she was off the locked unit assisting with a resident transfer, and when she returned to the unit, a resident told her that, two people are on the floor. When V5 entered the room, she saw R1 and R2 lying on the floor and R2 had R1's right ring and middle fingers in his (R2) mouth and was biting down on them. V5 said she called out for help then ran towards R1 and R2. V5 added that when she attempted to separate the residents, R2 had let go of R1's hand but then slapped him (R1) on his left cheek with an opened hand. V5 (CNA) added that R1 was crying and was trying to push R2 away from him and that R1 looked scared. V5 indicated that R1 and R2 were roommates at the time of incident and R1 walks over to R2's side of the room to stare out the window, stares at R2, then R1 walks away. V5 then said after they were separated, the nurse (V7) came in and she took R1 into the shower room with V6 (CNA). V5 said she saw R1 had a scratch mark behind his ear that was bleeding, a light scratch to his chest, a scrape to his left knee, and a bite mark on his right hand. V5 said R1 was still crying at this time and looked upset. V5 also said that R2 had gotten angry at R1 that morning before breakfast because R1 had walked near R2 to look out the window in the dining room. V5 said that R2 stood up and started yelling at [R1] and R2 was trying to get to R1 who was just standing there and staring at him (R2). On 05/02/2025 at 01:22 PM, attempted to call V7 (Registered Nurse) regarding the incident with R1 & R2. No answer, and a detailed message was left. V7 did not return call upon exiting complaint survey. On 05/02/2025 at 01:29 PM, V6 (CNA) said regarding incident with R1 & R2, she heard V5 (CNA) yelling for help saying R1 and R2 were, fighting are the floor. V6 said when she entered the room, she saw R1 and R2 both on the floor and she saw R2 smack R1 on the face prior to being separated by staff and R2 was saying that R1 deserved it and R2 was laughing at R1. V6 added that R1 was crying, and she could see bite marks to his fingers, his ear was bleeding, and visible redness to R1's back. V6 added that it looked as if R2 had pushed R1 down to the floor because R1 had hand marks to his shoulders. V6 said that R2 would always be mean to R1, would try to kick [R1] out of the room and that R2 always seems to be saying stuff to [R1]. V6 indicated that R1 and R2 kind of have a history then said that R2 was the aggressor during this incident and R1 was the victim. V6 said after R1 and R2 were separated, she and V5 (CNA) took R1 to the shower room. R1 was still very emotional at this time. On 05/02/2025 at 1:51 PM, V1 (Administrator) said regarding the findings from her investigation, R1 and R2 were both on the ground, and staff were unable to determine if both residents fell . V1 added that R2 was upset at R1 for looking at him but could not determine who the aggressor was. V1 (Administrator) added that she was not made aware of the incident that occurred in the dining between R1 and R2 on the morning of incident. Abuse policy last reviewed 10/24/2022 reads in part: this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by .establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, identifying occurrences and patterns of mistreatment .Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 4. This failure resulted in R1 being bitten by R2, causing bleeding, hospital transfer, and antibiotic therapy for injury. The findings include: R2 is a [AGE] year-old male admitted with moderate cognitive impairment as per the MDS dated [DATE]. R2 was admitted with an admitting diagnosis including anxiety, dementia with behavior disturbance, cognitive communication deficit, and schizophrenia. R1's diagnosis includes moderately impaired cognition, as per the Minimum Data Set (MDS) dated [DATE]. R1 had an admitting diagnosis, including alcohol-induced persisting dementia, anxiety, depression, and Alzheimer's disease. 1/28/25 3:21 PM nurses note for R1 from V3 (Agency Licensed Practical Nurse/LPN) documents in part 930am Resident noted large bite mark on left arm. CNA (Certified Nursing Assistant) report a resident on unit caused the bite mark. This patient was very aggressive going into patient's room on unit. Open closed door ambulate(s) really fast around other patient on unit. DON/ADON (Director of Nursing/Assistant Director of Nursing) made aware visit patient/unit. Treatment nurse here rendering care for bite on left arm. Patient was sent to hospital for cares to bite mark. POA (Power of Attorney) was called notified of incident. Left facility at 10:44 AM for (local hospital). R1's Order Summary Report dated 2/11/25 documents an order dated 1/28/25 Send to ER for further evaluation. Another order dated 1/28/25 Cleanse left forearm bite mark daily with NSS (normal saline solution) and keep area to air dry until healed. Continue treatment of Amoxicillin-Pot Clavulanate tablet 875-125 mg. Give 1 tablet by mouth every 12 hours for bacterial infection for 7 days. Order dated 1/30/25 Monitor injury to left forearm q (every) shift report any s/s (signs and symptoms) of infection to physician every shift for wound care. On 2/11/25 at 9:50 AM, R1 was observed wandering and coming out of another resident room. On 2/11/25 at 9:50 AM, V10 (R1's certified nursing assistant/CNA) pulled up R1's arm sleeves and showed two-bit marks on both forearms one inch apart, along with a one-centimeter-round scab with bite marks. On 2/11/25 at 9:40 AM, V10 stated that V10 works with R1 almost every day, but I wasn't working on 1/28/25 when R2 bit R1. R1 is nonverbal and cannot understand a lot. He has early-onset frontal lobe dementia and wanders to other residents' rooms. Both R1 and R2 reside in a locked dementia unit. According to V10, on 1/28/24, when R1 entered R2's room for the first time, R2 bit R1 on his left wrist. R1 was not bleeding from the injury. V10 than added that R1 returned to R2's room again about 10 minutes later and tried to move R2's wheelchair. R2 got upset, and a bit on both R1's forearms caused bleeding from the left forearm. R1 was sent out to the hospital, and he returned with oral antibiotics. V10 added that R1 must be monitored as, he wanders around to keep him safe. On 2/11/25 at 10:00 AM, V5 (Certified Nursing Assistant/CNA) stated, I was in the nurse's station when the incident happened when R1 entered R2's room. We heard shouting from R2 to R1. There was no staff in the resident's room, and nobody witnessed the incident. R2 bit R1 two times 5 minutes apart. For the first time, R2 bit on R1's lateral side of his left hand. When R1 came out of R2's room, we noticed no bite on his left wrist. Then, R1 was bleeding a decent amount the second time and turned into purple discoloration with the bite site. R1 was assigned to V6 (CNA) as V7 (CNA) called off. I believe V6 is suspended, and I don't know why. On 2/11/25 at 11:20 AM, V13 (Restorative Aide/CNA) stated, I heard commotions between R1 and R2, and R1 had a bit mark on his left wrist from the first bit and was bleeding, but not that much. When R2 bit on R1 a second time after 30 minutes, I went into the hallway and saw R1 was bleeding from the left arm. R1 always wanders around and is hard to redirect. Somebody must monitor the hallway to see the dementia resident's activities and prevent them from going to other resident rooms/isolation rooms. On 2/11/25 at 11:35 AM, V6 (CNA) stated, I was assigned to another group of residents. R1 was assigned to V12 (CNA), and R1 is a resident who wanders around and triggers other residents to get upset. On 2/11/25 at 10:15 AM, V4 (CNA) stated, I heard about the issue between R1 and R2 on 1/28/25. R1 wanders to R2's room, and R2 gets irritated by R1, and R2 gets on R1's arm and bites him. I was in the hallway just outside of the dementia unit. R2's room was very close to the nurse's station, and we could hear when R2 was shouting and screaming at R1. I went to the dementia hall and checked on R1, and he was bleeding. On 2/11/25 at 11:20 AM, V2 (Director of Nursing/DON) stated, We were short by one CNA on the dementia unit on 1/28/25 due to call off (V7). V7's residents were not assigned to any specific CNA. The other four CNAs were supposed to chip in to cover for V7's residents, including R1. R1 was bit two times by R2. The first bit wasn't as bad as the second bite. The second bite was bleeding. Somebody must have followed him to redirect him to prevent injury from other residents entering their room. He has the right to be free from abuse/harm. On 2/11/25 at 11:35 AM, V6 (CNA) added, Almost a month ago, when R1 entered R3's room and lay on R3's bed, R3 got upset, put his hands on R1's neck, and threw him to the door. They are not doing anything to prevent R1's trigger to other residents. On 2/11/25 at 12:40 PM, V3 (Agency Licensed Practical Nurse/LPN) stated, I didn't witness the incident. V12 said that R1 went to R2's room, and R2 bit on R1's forearms. R1 always goes to other resident's room. R1 needs to be closely monitored to make him safe. There were a lot of conversations regarding who should take care of the resident group, including R1, as the originally assigned CNA (V7) called off. Overall, all the CNAs are responsible for monitoring the residents in the dementia unit. On 2/11/25 at 3:21 PM, V16 (Nurse Practitioner) stated, It was reported to me that R1 was bit by another resident (R2). The injury was assessed, and we sent him to the hospital for further evaluation, and he returned with an oral antibiotic. There was blood on his left forearm. To keep him safe in the unit, they should closely monitor and redirect him when he attempts to enter another resident's room. On 2/11/25 at 3:35 PM, V1 (Administrator) stated, I know residents have the right to be free from harm. We had a call-off on 1/28/25 and were short by one CNA. R1 is a resident who wanders to other residents' rooms and needs to be monitored. On 2/14/25 at 10:00 AM, V17 (Staffing Scheduler/CNA Supervisor) stated, Since V7 called off on 1/28/25, we split her residents among the other four CNAs in the dementia unit. V6 was assigned to care for R1. She (V6) refused to care for R1, so we suspended her for not caring for R1. Behavior Management Team Review Meeting Note dated 11/4/24 document: R3 became agitated when R1 entered his room and lay on his bed. R3 attempted to maneuver R1 to the bedroom door, and R1 tripped and fell over. R3 is a [AGE] year-old male admitted with moderate cognitive impairment as per the MDS dated [DATE]. R3 was admitted with an admitting diagnosis, including anxiety, hallucination, dementia, depression, and schizophrenia. Behavior Management Team Review Meeting Note dated 12/22/24 documented that R1 had entered R4's bedroom, and residents were observed pushing each other. Behavior Management Team Review Meeting Note dated 12/29/24 documented that R4 struck R1 on his chest and arms. The facility presented the Abuse Prevention and Reporting Guidelines document: The facility affirms the right of the resident to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment.

Based on observation, interview, and record review the facility failed to ensure food was stored, distributed, and served to residents in a manner to prevent food contamination. The facility failed to have a system in place for sanitizing dishware and food service equipment during the renovations of the kitchen. This failure resulted in the local health department revoking the facility's permit to prepare food on site and resulted in an Immediate Jeopardy. This has the potential to affect all 161 residents that consume food from the facility. Finding include: The Immediate Jeopardy began on August 26, 2024, when the facility's kitchen was closed for floor repair and food preparation continued in the facility without the ability to maintain safe food temperatures and sanitize food service equipment and dishware. As a result, the local health department revoked the facility's permit to prepare food on August 27, 2024. On August 28, 2024, the facility was still attempting to prepare puree and mechanically altered food onsite from catered food items and use plastic food trays and other dietary service equipment without a means of sanitation. V1(Administrator), V3(Dietitian Consultant), V4 (Corporate Consultant) and V5 (Nursing Consultant) were notified of the Immediate Jeopardy on August 28, 2024, at 4:30PM. The facility submitted a removal plan on August 29, 2024, at 10:00AM, that was returned for modification and the plan was accepted at 2:20PM. The immediacy was confirmed as removed by observations, interviews, and record reviews. Although the immediacy was removed on August 29, 2024, the facility remains out of compliance at a Level II because additional time is needed to evaluate the implementation and effectiveness of the plan. The facility's census sheet dated August 28, 2024, documents a facility census of 165 residents. V8 (Assistant Director of Nursing) stated on August 28, 2024, that 4 residents were NPO (nothing by mouth). The facility diet list that the facility has 11 residents on puree diets and 30 residents on mechanical soft diets. R3 to R13 are listed as residents receiving puree textured diets. The local County Health Department documented on August 27, 2024, a suspension to operate (food service operations) related to, inadequate refrigeration and ongoing construction project. V6 (Director of Environmental Services from the local County Health Department) stated during phone interview on August 27, 2024, that food service operation needed to close due to inability to maintain food temperatures and lack of hand washing sinks for dietary employees. V6 stated that the rented refrigeration unit was not holding temperatures. The facility's incident report submitted to the department August 27, 2024, that charted, The facility was inspected by the local food health department that food temperatures were not holding in the temporary refrigerated container. The facility enacted our emergency crisis management plan. The facility's kitchen was observed on August 28, 2024, at 10:30AM to be closed and nonfunctional. Construction workers were noted in the kitchen removing floor tiles. Dietary equipment food service carts, food trays, wash bins and dishware were noted being stored in the hallway near the kitchen and door leading to the parking lot. This area did not have a hand sink or means for staff to perform hand washing. V2 (Dietary Manager) and V1 (Administrator) stated during interviews of August 28, 2024, that the facility needed to close the kitchen for removal and repair of the floor. Both V1 and V2 confirmed that the kitchen was closed, and work began on August 26, 2024, at 8:30AM. The facility rented three 20-foot storage containers, one of which was a refrigerated unit. These storage containers were located outside the building near the kitchen in the parking lot. This area did not contain any handwashing stations for staff. The area surrounding the refrigerator unit outside was observed with puddles of free-standing water from the previous night rainfall. V2 then added that prior to the local health department shutting down the kitchen, staff was attempting to prepare food in other areas of the facility and 20-foot storage containers. V2 confirmed that temperatures in the refrigerated storage container were high secondary to the warm weather conditions and need to open the door. V2 stated that he had only a few days' notice prior to the work starting in the kitchen and did not have a plan for this project. V2 continued to add that the facility had numerous issues with the refrigerated container and needed to obtain a generator to provide power. V1 also stated a brief notice about the kitchen closure and that corporate had discussed this project but specific plans were not developed. On August 28, 2024, the residents were still being served breakfast at 10:00AM until 10:30AM. R1 was observed without the super cereal (high protein/calorie hot cereal) on his tray. R1's diet is listed in the medical record as no added salt with super cereal supplement for breakfast. R8 was observed with puree eggs, bread, and hash browns on his tray. R8's diet order is listed in the medical record as regular puree diet with nectar thick liquids and house supplement 2.0 three times a day. Residents were being served the meal in take out type containers with milk in disposable Styrofoam cups. V2(Dietary Manager) was asked about the meal and stated that the meal was catered due to the kitchen closure. V2 was asked about the food temperatures and stated, I have them in my head, I have not had time to write them down. V2 was interviewed about preparation of puree food items and stated that the staff was using the blender in the sub kitchen and then cleaning it. This sink was a single hand washing type of sink with one compartment. Space for air drying cleaned items was not noted in place. Later during the tour of the rented food storage containers, V2 stated that the facility was going to use plastic food trays for lunch meal service. V2 then added that the dietary staff would use the sinks in the activity room to clean used food trays and other dietary service equipment and dishware. The two sinks in the activity room were observed to be household type sinks measuring 12 inches by 12 inches that would not allow the food trays or larger pots/pans to be totally submerged for sanitation. Again, space for air drying items was not noted in this area. The only available hand wash sink for food service employees was noted in the service kitchen. This service kitchen is in another area of building and not near the back door entry and outdoor rented food storage containers. This consisted of a large steam table and small hand wash sink. The other hand wash sink located in the main dining area was disconnected and nonfunctional since it was connected to the main kitchen. V7 (Cook) was observed on August 28, 2024, attempting to prepare the puree dinner rolls for the evening meal. V7 was using the food processor in the sub kitchenette with only the single hand sink to provide for cleaning and sanitizing. V7 stated he would clean the food processor in this sink. This same sink would be used for hand hygiene. V6 (Director of Environmental Services from the local County Health Department) was interviewed by phone on August 28, 2024, at 12:52PM and stated that the facility was told, no food preparation on site and that the facility could, plate the catered food. V6 confirmed that additional processing of food for puree diets should not happen on site secondary to lack of hand washing stations and ability to safely clean and sanitize dishware. V6 stated the facility was advised to use all disposable items. The facility's policy for Monitoring Food Temperatures for Meal Services, dated 2020 documents: Prior to serving a meal food temperature will be taken and documented for all hot and cold foods to ensure proper serving temperature. The temperature for each food item will be recorded on the Food Temperature Log. Foods that require a corrective action (such as reheating) will have the new temperature recorded with a notation of the corrective action interventions. The FDA documents in the Food Code of 2022 that, Food employees shall keep their hand hands and exposed portions of their arms clean. Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. Food employees shall clean their hands and exposed portions of their arms as specified. Immediately before engaging in food preparation including working with exposed food, clean equipment, and utensils. Food service employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation. The FDA Code of 2022 also documents that Equipment food-contact surfaces and utensils shall be clean to sight and touch. The code continues to add that when cleaning food contact surfaces and equipment the item must be submersed in the solution between 7 to 30 seconds depending upon the solution for sanitation and then air-dried. The facility submitted the following plan to remove the immediacy: 1. Facility will utilize a local organization's kitchen in [NAME] to prepare mechanical and puree diets for residents that are on puree or mechanically altered diets to have their food safely prepared. This will be managed by the Dietary Director/Designee. Facility spoke with V6 (Director of Environmental Services from the local County Health Department) and V6 approved the facilities use of the local organization's kitchen to be used in the interim. 2. The facility anticipates a completion date of 9/4/24 to have the Local County Health Department come in and inspect the facilities project and approve food service operations. 3. Facility has 1 handwashing sink in each serving room; a total of 1 of operational handwashing sinks since there are two serving rooms in the facility. In addition, the facility will obtain 2 portable hand washing stations to ensure that dietary staff is able to perform appropriate hand washing process. The portables were on site on 8/29/2024. 4. The facility will obtain disposable foil pans. For Utensils, 3 containers will be provided to rinse, wash and sanitize to ensure a method for sanitizing food service equipment and service items between meals to prevent food borne illnesses. This will be on site at local organization's kitchen in [NAME]. Once sanitized the equipment will be transported back to the facility. A delivery was made this morning for additional disposable supplies and the facility can obtain more as needed during this project. Facility will utilize test strips to ensure proper Ph for sanitation. This will be managed by the Dietary Director/Designee and monitored by the facility Administrator. 5. The facility is only storing milk products in the cooler located in the dining room. The cooler temperature is being monitored to maintain at safe temperatures during holding. A log for temperatures will be maintained by the Dietary Director/Designee and is being checked every shift. The facility will continue to cater food for the residents until the project has been completed. Administrator will maintain documentation of temperatures. 6. The facility is having food delivered from vendor in insulated bags via private vehicle to the facility. Food is then transferred back and forth to local organization's kitchen in [NAME] via private vehicle in insulated bags. The facility has developed a temperature tool to monitor and document temperatures of food - pick up time and temps, after transfer time and temps. 7. Prior to start of shift, the Dietary Director/Designee will monitor food temperatures and document temperature on the newly developed log. The Administrator will monitor and maintain these logs daily during the kitchen closure and make immediate corrective action if not complete. 8. An emergency QA meeting has been conducted with facility medical director and IDT team to review the incident and action plan. The facility has reviewed the policies and procedures and has developed and amendment on how the facility will monitor temperatures during this interim. The QA team will also refer this incident for review of emergency action plan for any changes.

Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from abuse. This failure resulted in R2 being physically abused by V5 (Certified Nursing Assistant/CNA) on 11/2/23; R2 complaining of leg pain and limping on 11/5/23; a new order for morphine sulfate every six hours for pain being placed on 11/6/23; and R2 using a wheelchair for leg pain relief. The findings include: The Immediate Jeopardy began on 11/2/23 at 9:00 PM when V3 (CNA) and V4 (CNA) witnessed V5 (CNA) physically abusing R2 during nighttime cares. V1 (Administrator) was informed of the Immediate Jeopardy on 11/17/23 at 1:03 PM. The surveyors confirmed by observation, interview, and record review, that the immediacy was removed on 11/20/23, however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R2's Admission Record, printed by the facility on 11/16/23, showed she had diagnoses including severe dementia, senile degeneration of brain, adult failure to thrive, and weakness. R2's 8/14/23 facility assessment showed R2 had severe cognitive impairment, with hallucinations and delusions. The assessment showed R2 had behaviors of rejection of care and required extensive staff assistance for dressing, toileting, and personal hygiene. R2's care plan initiated on 5/3/23 showed she is resistive to care and will regularly refuse ADL (activities of daily living)/hygiene tasks such as showering, changing soiled clothes and linens related to dementia. The care plan showed R2 may become aggressive/ combative during care related to confusion. Interventions in place included: Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. Identify and document resident's triggers for resisting care. If resident resists with ADLs, reassure resident, leave, and return 5-10 minutes later and try again. R2's care plan initiated on 5/6/22 showed she was receiving hospice services related to a diagnosis of failure to thrive and dementia. R2's care plan initiated on 3/5/23 showed she was at risk for abuse and neglect related to cognitive impairment, depression, and dysfunctional behavior (combative behavior, care resistance) related to dementia and senile degeneration of brain. On 11/16/23 at 11:22 AM, V3 (CNA) said she worked a double shift on 11/2/23 from 6:00 AM-10:00 PM. V3 said about 9:00 PM that night she was assisting V4 (CNA) with changing R2's clothes and providing nighttime care. V3 said she asked V4 about using the cream (topical antianxiety cream) for R2 that calms her down before changing. V3 said V4 declined using the cream. V3 said her and V4 took off R2's shirt and R2 was grabbing onto her clothes when they were taking them off. V3 said R2 was not being combative. V3 said V5 was in the room at the time, charting on a computer and V4 asked V5 to help with R2. V3 said V5 grabbed R2's hair and started punching R2 in the chest. V3 said V5 hit R2 in the chest at least 6 times, maybe as much as 12 times. V3 said V5 then kicked R2 in the leg. V3 said her and V4 told V5 to stop several times. V3 said she (V3) backed away and V4 got in between R2 and V5 to block them. V3 said it all happened so fast. V3 said one of the times V5 hit R2 close to the neck and she heard R2 gasp for air. V3 said the incident started in the bathroom doorway and ended up in the corner of the bathroom. V3 said she did not see R2 do anything to make V5 do that. V3 said R2 was not combative prior to V5 hitting her. V3 said of course R2 was combative after V5 started hitting her. V3 said she did not report the incident until the next morning because she was afraid of retaliation. On 11/16/23 at 11:58 AM, V4 (CNA) said he worked on 11/2/23 from 4:00 PM-10:00 PM. V4 said he was the CNA assigned to R2 on 11/2/23. V4 said R2 was being a handful so he asked V3 to help him. V4 said he asked V5 to help and hold R2's hands. V4 said he did not know if V5 pulled R2's hair because he was trying to pull R2's pants up. V4 said when he stood up, both V5 and R2's hands were swinging, and he could not tell who was hitting who. V4 said he had to stand between R2 and V5 to make sure no physical contact continued, because they were both hitting each other. V4 said he can get R2 to calm down and de-escalate by playing music. V4 said he did not report the incident. V4 said he was baffled by the situation and did not know what to do. V4 said he had never seen V5 act like that with any other resident. On 11/17/23 at 9:51 AM, V9 (Registered Nurse/RN) said V3 reported to her before 7:00 AM on 11/3/23, that she (V3), V4 and V5 were changing R2's clothes on the PM shift on 11/2/23 and V5 started punching R2's chest and pulling R2's hair. V9 said V3 told her that at one point during the incident V5 hit R2 by the throat and R2 gasped for air. V9 said V3 told her that V5 kicked R2's leg. V9 said V3 told her that V5 started hitting R2 in R2's room and continued into R2's bathroom. V9 said she assessed R2 after V3 reported the allegation to her. V9 said as she was palpating R2's upper chest area, R2 said Some people can be nasty. V9 said she asked R2 if anyone hit her, R2 hesitated, then said no. V9 said she thinks it was Sunday (11/5/23) that staff noticed R2 limping. V9 said R2 was assessed and when her leg was squeezed, she would move her leg and had pain. V9 said Hospice was updated, X-rays were completed and were negative. V9 said she thinks R2's leg pain was a result of the incident on 11/2/23. V9 said the gel was discontinued and morphine was ordered for the pain. V9 said R2 uses the wheelchair for comfort, to reduce her leg pain. V9 said R2 did not use the wheelchair prior to the incident on 11/2/23. On 11/17/23 at 2:03 PM, V5 (CNA) said V4 and V3 were taking care of R2 on 11/2/23. V5 said V4 asked her to help with R2. V5 said she went over to help them and R2 hauled off and kicked her (V5) in her knee. V5 denied hitting or kicking R2. V5 said she put her arm out and put her hand on R2's forehead, on her hairline, to stop R2 from kicking her. V5 said V4 got between them and took R2 out of the bathroom. On 11/17/23 at 10:32 AM, V7 (CNA) said R2 could be calmed down by having the nurse apply the cream, by playing music, telling R2 a story, listening to her, leaving her alone and approach later. On 11/17/23 at 10:55 AM, V8 (CNA) said R2 could be calmed down by music and with the cream that calms her down. On 11/16/23 at 1:57 PM, V1 (Administrator) said R2 tends to be aggressive with care. V1 said she was notified of a potential situation related to V5 being aggressive towards R2. V1 said she investigated the allegation. V1 said V3 told her that she did not see everything, but she thought she saw V5 kick R2. V1 said V5 denied this. V1 said when she took V4's statement, he said that R2 kicked V5, and V5 pushed R2 away from her, then R2 lunged at V5. V1 said V4 said when R2 lunged out, V5 reflexively responded and made contact with R2's chest. V1 said V4 told him that he stepped between them to separate them. V1 said V5 said she did not strike out but put her hand on top of R2's head to calm her. V1 was asked why V5 was terminated, yet the allegation was not substantiated by the facility. V1 said she terminated V5 because there was inappropriate behavior, but not abusive behavior. V5 should be trained enough to know to walk away from a combative resident. V1 said that was not the correct way to handle the situation. V1 said something physical happened, but it was a reflex reaction, and a physical response was not an appropriate response. V1 said while interviewing V4 he did not tell her that he witnessed V5 hitting R2, and she (V1) can only go by what she is told during the interviews. On 11/16/23, R2 was observed in her room on the dementia unit, lying in a low bed at 10:32 AM. R2 was not able to be interviewed. R2 was also observed sitting in a wheelchair in the dining/activity room holding a stuffed animal on 11/16/23 at 2:00 PM. R2 was confused and not able to be interviewed. The facility's Preliminary 24-hour Abuse Investigation Report, dated 11/3/23, showed an allegation of physical abuse to R2 by an employee was reported on 11/3/23 at 6:37 AM. The report showed V5 was removed from the schedule and suspended pending the investigation. R2's doctor, the police, R2's guardian, and the Ombudsman were all notified. The facility's timecard document from October 23-11/5/23 showed V5's last date and time of work at the facility was 11/2/23 at 10:00 PM. R2's Progress note dated 11/5/23 showed Writer was informed by the CNA that the resident is limping on her right leg .Resident was grimacing when the posterior side of the leg was touched. R2's Order Recap Report, printed by the facility on 11/17/23, showed a new order on 11/6/23 for morphine sulfate solution 20 mg (milligrams) per ml (milliliter). Give 0.25 ml by mouth every 6 hours as needed for pain. The report also showed an order placed on 11/6/23 for X-ray of right hip, right femur, right knee, right tibia, right fibula, right ankle, right foot, right toes STAT for pain and limping. The X-ray results dated 11/7/23 showed no fractures or dislocations to any of these areas. V5's employee file was reviewed. The 11/6/23 facility document titled Human Resources Notice of Corrective Action showed R2 was terminated on 11/6/23 due to inappropriate physical behavior towards a resident on 11/2/23. The facility's policy and procedure titled Abuse Prevention and Reporting-Illinois, with a revision date of 10/24/22 showed This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents .Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention .Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment . The immediate jeopardy that began on 11/2/23 was removed on 11/20/23 when the facility took the following actions to remove the immediacy: On 11/20/23, the staff were re-educated on Abuse and Abuse reporting by the Administrator and a risk management training agency. All abuse assessments were reviewed, and care plans were updated as appropriate on 11/20/23 by Social Services. All residents, as appropriate, received in-servicing by Social Services on 11/20/23 regarding abuse and neglect and reporting procedures. Employees (V5 and V4) were terminated on 11/6/23 by the Administrator and HR (Human Resources). The Abuse and Neglect Policy was reviewed on 11/17/23 by the Administrator and the Medical Director. On 11/17/23, the Medical Director reviewed and approved the Abatement Plan. Beginning 11/20/23 and ongoing, Abuse Assessments and care plans shall be randomly audited by the Psychiatric Rehabilitator Services Director monthly x 6 months to assure residents at risk for abuse are identified and care plans are updated accordingly. Results of audits will be reviewed monthly by the QAPI (Quality Assurance and Performance Improvement) committee.

Based on observation, interview and record review, the facility failed to identify an infectious outbreak, implement measures to prevent the spread of this infectious outbreak, and failed to have an infection control program in place to monitor and track infectious diseases at the facility. This failure has the potential to affect all 166 residents residing at the facility. The Facility Data Sheet dated 8/29/2023 documents 166 residents reside at the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/11/2023 at 12:37 PM after R1 tested positive for scabies and the facility failed to implement measures to prevent the spread. The Immediate Jeopardy was identified on 9/7/23. V1 (Administrator) was notified of the Immediate Jeopardy on 9/7/23 at 9am. The surveyor confirmed by observation, record review and interview that the immediacy was removed on 9/12/2023, non-compliance remains at a Severity Level Two due to the need to evaluate the implementation of policies and procedures, audits, and quality assurance monitoring. Findings include: The Scabies Outbreak Report documents on 8/24/2023 R7-R41 were identified with rashes that were treated with Permethrin (medicated cream used to treat scabies) beginning 8/25/2023. On 9/1/2023 at 9:21 AM V5 (County Infectious Disease Investigator) stated the facility has been in continuous outbreak status for scabies since 5/11/2023 and the facility just reported a large number of new cases in the past week for which she provided the facility with recommendations in an email on 8/25/2023 to treat the outbreak. On 8/29/2023 at 9:30 AM V1 (Administrator) stated the corporate office reported to her there was an outbreak of rashes at the facility. V2 stated a whole house sweep was completed on 8/23/2023 and the facility identified several residents with rashes. V1 stated V6 (Medical Director) was at the facility to assess the rash outbreak on 8/24/2023 and provided orders to treat the rashes as suspected scabies. V1 confirmed staff were also identified with suspicious rashes. 1. On 9/1/2023 at 11:29 AM, V2 (Director of Nursing) stated R1 tested positive for scabies on 5/11/2023 and the facility policy is for roommates to be treated and isolated in the effected room and if there is an adjoining bathroom, the residents in that room are also treated and isolated. V2 confirmed R1's room had an adjoining bathroom so the residents in the adjoining room were also to be treated. R1's scabies scraping lab report, resulted 5/11/2023, shows R1 positive for scabies. R1's Physician Progress Note, dated 5/5/2023, documents R1 with a scattered red itchy red rash noted from head to toe of his body. R1's Order Recap Report dated 5/1-6/30/2023 does not document R1 being placed in contact isolation. R1- R3's Census List Report dated 9/5/2023 shows R1 residing in the same room as R2 and R3. Census List Report dated 9/5/2023 shows R4 and R5 residing in the adjoining room with a shared bathroom. R2-R5's Order Recap Report dated 5/1-6/30/2023 does not show R2-R5 receiving prophylactic treatment or being placed in isolation. 2. On 8/29/2023 12:39 PM, R7 stated he was hospitalized Father's Day weekend for pain in his foot and during this hospitalization he was diagnosed and treated for scabies. R7 stated he had a rash for approximately 2 months before being hospitalized in June. R7 further stated he was treated again a few days ago and his rash is now gone. R7's scabies scraping lab reports, dated 5/10/2023 and 6/1/2023, shows R7 negative for scabies. R7's Order Recap Report dated 5/1-6/30/2023 documents R7 with orders on 5/26/2023 for Mupirocin twice per day and Doxycycline for 5 days for a rash and Impetigo. R7's Physician Progress Notes dated 5/5/2023 documents R7 with an itchy rash to right upper and bilateral lower extremities. R7's Progress Note dated 6/1/2023 documents R7 with a rash to his arms, abdomen, and legs. R7's Physician Progress Note dated 6/7/2023 documents R7 with a rash to his body and a diagnosis of impetigo was made. R7's Progress Notes dated 6/18/2023 shows R7 sent to the hospital and admitted with a diagnosis of cellulitis. R7's Physician Note dated 6/23/2023 shows R7 diagnosed for scabies during his hospital admission. The Scabies Outbreak Report documents R7 with a rash to his arms, legs, and abdomen, identified on 8/24/2023, and treated for scabies on 8/25/2023. R7's Brief Interview of Mental Status (BIMS) report dated 7/21/2023 documents R7 as cognitively intact. 3. On 8/29/2023 at 12:25 PM R6 stated approximately a month ago he was treated for a rash and itching. R6's Order Recap Report dated 6/1-9/5/2023 shows R6 with orders dated 6/30/2023 for Diphenhydramine for 3 days to treat a rash, and Hydrocortisone 6/30-8/10/2023. R6's Practitioner Visit Note dated 6/30/2023 documents R6 with a rash and itching. R6's Order Recap Report dated 6/1-9/5/2023 shows R6 treated for scabies on 7/28/2023 and 8/5/2023. The Scabies Outbreak Report documents R6 with a rash to his arms, legs, and abdomen, identified and diagnosed as scabies on 7/27/2023 per a positive skin scraping. R6's BIMS report dated 8/22/2023 documents R6 as cognitively intact. 4. On 8/31/2023 at 11:10 AM R11 had scratches and scabs to both her upper arms. On 9/5/2023 at 9:50 AM a skin assessment completed with V7 showed R11's rash improving. R11's Order Recap Report dated 6/1-9/5/2023 documents R10 with orders on 6/12/2023 for Clotrimazole External Cream to her left-hand rash for 10 days, 6/14 and 21/2023 for Promethean Cream, 6/17/2023 with Doxycycline Monohydrate for a skin infection, and Clotrimazole External Cream for a rash 6/22-7/6/2023. R11's Initial Wound Evaluation and Summary Report dated 6/14/2023 documents R11's rash diagnosed as scabies and a reassessment on 6/21/2023 shows R11's rash as resolving. R11's scabies scraping lab report, dated 6/14/2023, shows R11 negative for scabies. On 8/31/2023 at 11 AM V7 stated she noted R11 would screaming out frequently during the day when she had the rash on her hands which is not her usual behavior. On 9/5/2023 at 3:05 PM V23 (Wound Physician) stated she does not usually see residents for skin rashes but did assess R11 as a favor. V23 stated she was suspicious the rash could be scabies and her protocol are if is suspicious, she treats. 5. On 8/31/2023 at 10:50 AM R8 stated, It (rash) is starting to go away. They are finally treating me right. Not sure what they treated me with before. R8 stated the rash is all over and lifted his shirt showing a visible rash to his arms and chest-multiple areas of this rash showed healing scratches and scabbed lesions. R8 stated, I had it a long time .I have been suffering for a long time. I scratch and bleed, I am up all night, and I was not getting any relief. On 9/5/2023 at 9:25 AM a skin assessment completed with V7 showed R8's rash resolving. R8 stated, he is feeling a lot better. R8's Physician Progress Notes dated 4/28, 5/8, 5/16, 6/6, and 8/3/2023 document R8 with itching and rashes to his body. R8's Order Recap Report dated 6/1-9/5/2023 documents R8 with orders 6/2/2023 for Triamcinolone Acetonide External Cream twice a day through 8/3/2023 for itching and Hydroxyzine at bedtime for itching (order continues). R8's scabies scraping lab report, dated 4/10/2023, shows R8 negative for scabies. 9/6/2023 6:59 AM V24 (Night Nurse) stated he was not sleeping well because of the itching from his rash but after the Hydroxyzine was ordered that did help. Since he was treated with Promethean he is improving. R8's BIMS dated 7/4/2023 documents R8 as cognitively intact. 6. On 8/31/2023 at 10:56 AM R9 stated, I have been scratching the (heck) out of them. R9 stated he has been scratching at his itchy rash for a couple of months, and since a cream was applied a few days ago it is now going away. R9 exposed his arms which had a resolving red rash and scratches to both his arms. On 9/5/2023 at 9:30 AM a skin assessment completed with V7 showed R9's rash resolving. R9 stated, his rash is much better. R9's Order Recap Report dated 6/1-9/5/2023 documents R9 with an ongoing order dated 6/23/2023 for Triamcinolone Acetonide External Cream for itching twice daily. R9's Weekly Skin Observation Notes dated 7/5/2023 documents R9 with healing scabs to shoulder from scratching, 8/9/2023 with a rash to back and chest and scabs to lower extremities. R9's Physician Progress Notes dated 8/1, 18 and 21/2023 document R9 with a rash to his body. R9's scabies scraping lab report, dated 7/31/2023, shows R9 negative for scabies. R9's BIMS dated 8/5/2023 documents R9 with moderate cognitive impairments. 7. On 8/31/2023 at 11:13 AM R12 was noted with scratches and a rash to his abdomen, entire right arm and from his left elbow up toward his shoulder. R12 was scratching at these areas stating he itches. On 9/5/2023 at 9:40 AM a skin assessment completed with V7 showed R12's rash was resolving but he was continuing to itch. R12's Order Recap Report dated 6/1-9/5/2023 documents R12 with orders dated 6/30/2023 for Hydrocortisone Cream to abdomen, chest, and left trunk for 10 days and Diphenhydramine for 3 days for itching, 7/18/2023 for Hydrocortisone Cream to abdomen, chest, and left truck for 10 days for itching. Another order on 8/2/2023 documents Hydrocortisone to abdomen, chest, arms for severe itching and rashes related to restlessness and agitation. An order 8/18/2023 documents R11 to receive Diphenhydramine at bedtime and Loratadine every morning for a rash. R12's Progress Notes dated 6/30-8/23/2023 do not document any assessments of R12's rash. 9/6/2023 6:59 AM V24 (Night Nurse) stated R12 had the worst time sleeping because of itching, .I felt sorry for him. He would be up at night unable to sleep because of the scratching . V24 stated he is much better and sleeping again. R12's BIMS dated 8/8/2023 documents R9 as severely cognitive impaired. 8. On 8/29/2023 at 12:21 PM R10 laid in bed scratching at her arms which had scabbed scratches in various stages of healing and open bleeding wounds up and down both of her upper arms and chest. On 9/5/2023 at 9:45 AM a skin assessment completed with V7 showed R10's rash to her arms almost gone and the rash to the chest improving. R10's Order Recap Report dated 7/1-9/5/2023 documents R10 with orders dated 7/22/2023 for Alclometasone Dipropionate External Cream for 7 days and Claritin daily (current order) for a rash, 8/18/2023 for Diphenhydramine and Loratadine for 5 days for a rash and 8/23/2023 for Alclometasone Dipropionate Cream for 7 days for a rash. R10's Progress Notes dated 7/22-8/23/2023 do not document assessments of R10's rash. 9. R29's Order Recap Report dated 6/1-9/5/2023 documents R29 with a current order dated 6/20/2023 for DermaCerin External Cream twice a day for itching to left abdominal area. R29's Progress Notes dated 6/20/2023 documents R29 with complaints of itching and a rash to her trunk. A note dated 7/10/2023 documents R29 with a rash and complaints of itching with no new orders. 10. R36's Order Recap Report dated 7/1-9/5/2023 documents R36 with orders dated 7/22/203 for Triamcinolone Acetonide External Cream for 7 days to a rash to his right underarm and face, and 8/8/2023 for Cephalexin Oral Capsule and Mupirocin (antibiotics) for 7 days for a rash. R36's Physician Progress Notes dated 7/12/2023 document R36 with a rash and on 8/7/2023 with itching and rash to his bilateral arms. 11. R35's Order Recap Report dated 7/1-9/5/2023 documents R35 with an order dated 7/22/2023 for Hydrocortisone to bilateral leg rash twice a day for 7 days. R35's Progress Notes dated 7/22-8/23/2023 do not document any assessments of R35's rash. 12. On 8/31/2023 at 10:05 AM R15 stated she had a rash to her arms and legs with itching for about a month. On 8/31/2023 at 10:10 AM R14 stated he had a rash to his legs with itching for about over a month. Both these residents reside in the behavior health area at the facility. On 8/31/2023 at 10:05 AM R20 stated he had a rash to his entire body with itching for about a month. R20 residents on the main resident living area. On 9/1/2023 at 12:54 PM, V7 (Nurse) stated rashes were consistently present after being identified for R9, R10, R12, and R35 and intermittent for R21 and R36. V7 stated if the resident ran out of their ordered treatment cream, she would place the resident on the physician list for renewal. V7 further stated, if she still had some treatment cream left, she would apply it as needed when the nursing assistants reported the rash or itching and confirmed she was applying these treatments, even if the order was not currently in place. On 8/29/2023 11:03 AM V2 (Director of Nursing) stated the facility noted rashes in the building the 2nd week of July and did a sweep through the building between 7/11-13/2023, with the main focus on the dementia area. V2 confirmed direct care staff also reported rashes but continued working. On 8/29/2023 at 10:20 AM V3 (Acting Infection Control Preventionist) stated she started employment at the facility on 8/22/2023, on 8/23/2023 an in-service was completed with staff to ensure rashes were identified and reported; we in-service staff because the rashes were prevalent and noticeable. On 8/24/2023 she was notified by employees that they had rashes that they reported have been present anywhere from 10 days to 3 months. 8/29/202 11:19 AM V7 (Nurse) confirmed she is the nurse on the dementia area and is working on this date providing direct care to residents. V7 was wearing short sleeve shirt and had a rash visible to her arms, stating she also has the same rash behind her knees, abdomen, and feet for approximately 1- 2 months. V7 stated she reported this rash to V8 (Wound Care Nurse) at the time she noticed it. V7 stated after V6 (Medical Director) came and assessed the residents on 8/24/2023, V4 (Quality Assurance Nurse) instructed staff to apply Promethean cream, but she has not because the cream was not available on 8/24/2023, on 8/25/2023 she was off, there was nobody present at the facility on 8/26-27/2023 to issue her the Promethean cream and still has not yet received it as of the time of this interview. V7 stated the facility did not tell her she could not work with her rash and has worked 8/26, 27, and 29/2023 without being treated. V7 stated she primarily works on the dementia area and first noted R11 with a rash approximately 2 months prior and reported R10 currently has the worst rash. V7 further stated R11, R29 and R35 have been placed on the physician list for a few weeks related to their rashes which are not resolving. On 8/29/2023 at 11:51 V10 (Nursing Assistant) confirmed she is primarily assigned to the dementia area and is working on this date providing direct care to residents. V10 was wearing short sleeve shirt and had a rash visible to her arms stating she also had the same rash to her legs and abdomen. V10 stated her primary assignment is the dementia area and she has not been treated because they told her they were out of Promethean and needed to order more; V10 was off 8/25-28/2023. V10 stated she reported her rash to a nurse a while back but does not remember who. V10 stated there was a facility meeting approximately 8 weeks ago with V2 and V4 and during this meeting the staff were asked to put up hand if they had a rash which multiple staff did. V10 stated some residents have had a rash for 2-3 months and some have creams ordered which are being applied by nurses. V10 stated she has reported and observed rashes to R8, R9 and R41. On 8/29/2023 at 12:10 PM V9 (Nursing Assistant) confirmed she is a nursing assistant assigned to work on the dementia area and is providing direct care to residents on this date. V9 had on a short sleeved and had a visible rash to her hands but stated she also has a rash to her stomach, feet, and back for approximately 2 months. V9 stated she treated herself 3 weeks ago with a bottle of Promethean provided by V8 (Former Wound Nurse) in the past but has not received treatment since. V9 stated she has reported these rashes multiple times to multiple people, including V2, V4 and the regular floor nurses. V9 stated she has never been taken off work. V9 stated the first resident she noted with a rash was R8 about 3 months ago, then after that she saw R11. On 8/31/2023 at 11:20 AM V9 stated she worked 8/30/2023 until approximately 8:30 AM when they sent her home instructing her to treat her rash and report back to work 8/31/2023. V9 said she on occasion will work on other units in the facility. On 8/29/2023 11:30 AM V11 (Nursing Assistant) confirmed she is a nursing assistant assigned to work on the dementia area and is providing direct care to residents on this date. V11 was wearing short sleeves and had a visible rash to her arms, and reported she also has the rash to her wrists, stomach, and underarms. V11 stated R9 and R41, who reside in the same bedroom, had rashes approximately 1 month after her return from medical leave. V11 stated she reported the resident rashes which was reported to V7 who would apply treatments, but the rashes were not resolving. V11 stated on 8/22/2023 she noted rashes to R9, R36, R40 and R12 while providing care. V11 stated she told V4 on 8/24/2023 that she had a rash, and he did not remove her from directly providing care to the residents but offered her to see the company workers compensation nurse. V11 stated she treated herself with Promethean cream she purchased herself on 8/25/2023 after working her shift. On 9/5/2023 12:37 PM V1 confirmed V11 returned from medical leave on 9/5/2023. On 8/30/2023 at 1:10 PM V14 (Nursing Assistant) stated she primarily works in the dementia area and routinely takes care of R8, R11, R29, and R10 who all have had rashes for the past 2 months. V14 stated she will occasionally work on other units in the facility. V14 had a rash visible to her arms and stated she is providing direct care to residents on the dementia area on this date. V14 stated she has reported her ongoing rash to V1, V2, V4, V7, V8, and V15 (Wound Care Nurse). V14 stated, V15 scraped her for scabies in June and it came back negative and gave her Promethean cream. V14 stated she also worked 8/28/2023 and has not treated or been removed from resident contact. On 8/29/2023 at 12:23 PM V12 (Nursing Assistant) stated she has been employed at the facility for 3 weeks. V12 stated she worked 8/24, 8/25, and 8/28/2023 and was first treated after work on 8/28/2023 after she went to the emergency room . V12 stated she reported her rash to her stomach, arms, and chest to the nurses and V4 last week when first noted it and was not told to remain off work. On 8/31/2023 at 11:00 AM V28 (Agency Nursing Assistant) stated he is agency and works at other facilities, only working at this facility a several days per month. V28 stated when he works, he is scheduled in all the different areas within the facility. V28 showed a visible rash to both his forearms stating it stared on 8/28/2023. He stated when he arrived to work on 8/29/2023 he was sent home and has since been treated. On 8/29/2023 at 1:07 PM V13 (Nursing Assistant) stated she started at the facility on August 1, 2023, and trained and worked throughout the facility. V13 stated she has a rash for a week and a half and received treatment outside of the facility on 8/24/2023. V13 stated when she started there were multiple residents in the facility with rashes, but she can only remember, R9 and R12 had rashes while she cared for them. The Daily Staffing Schedules show on 8/22/2023 V13 worked the main residential unit, 8/25 and 28/2023 working the dementia unit and 8/29/2023 working the regular unit but escorted a R36 to an appointment in the community. On 9/1/2023 at 1:55 PM V25 (Restorative Nursing Assistant) stated she had a rash which she did not report to the facility and treated herself on 8/21/2023 with Promethean cream the facility provided her last year. V25 stated her rash resolved after she treated herself. V25 confirmed she provides care to residents throughout the facility. On 8/31/2023 at 11:35 AM V20 (Human Resources) stated a couple of months ago there was a staff meeting and some staff, including V10 and V14, reported they had rashes. An in-service sheet dated 7/14/2023 document V10 and V14 attended this meeting. On 8/31/2023 at 11:48 AM V2 (Director of Nurses) stated she has been employed at the facility since October 2022. V2 stated she did not notify or involve V6 (Medical Director) of the outbreak of employee and resident rashes until their corporate office contacted the facility. V2 stated she was unaware a negative skin scraping did not necessarily indicate a resident did not have a scabies infestation. V2 stated she has an ongoing argument with wound care nurses as to who should track and monitor rashes, stating the wound care nurses state they do not track or monitor rashes. V2 stated currently there is no specific facility protocol to track and monitor rashes but the nurses and herself are responsible for tracking, monitoring, and reporting these rashes. V2 confirmed there was no facility infection control surveillance being completed at the facility prior to June 2023 to monitor resident infections and outbreaks, except for Covid, and no employee tracking at all. V2 stated the employees did report itching and rashes in July and the staff affected were instructed to go through their dermatologist or they were informed they could see the facility workers compensation nurse. No employees were removed from direct resident care. V2 stated she had no direction, and she was doing the best she could. V2 stated she has since become aware V8 had provided some employees with cream to treat scabies while he was employed at the facility. The Employee Rash Survey provided 9/6/2023 at 9:04 AM additionally documents V26-34 (Nursing Assistants) and V35 (Nurse) with rashes. The Monthly Infection Log was provided on 8/31/2023 for the months June-August 2023 for residents. No rashes which were identified between June-August were present on these logs and no logs were provided for employees. The facilities Daily Staffing Schedules showed on 8/25/2023 V11, V12 and V14 worked at the facility, on 8/26 and 27/2023 V7 worked on 8/28/2023 V7, V12, and V14 worked, and on 8/29/2023 V7, V9, V10 and V14 worked. The Daily Staffing Schedules show V34 (Nursing Assistant) worked the main residential unit on 8/23/2023, the dementia area on 8/25 and 8/28/2023; V33 (Nursing Assistant) worked the behavior health unit on 8/22 and 8/24/2023 and the dementia area on 8/26-27/2023. On 9/1/2023 1:29 PM V6 (Medical Director) stated he was at the facility to assess the residents last week. V6 stated the rashes he saw appeared to be an infectious rash and he is treating those rashes as suspicious for scabies. V6 stated the big picture is to prevent this from happening again and he has discussed protocol going forward so an outbreak at this level can be prevented in the future. V6 stated he was not aware of the number of resident and employee rashes further stating he does expect the facility to let him know, follow the protocol, and monitor and report to the physicians as they should. V6 stated employees with rashes need to be assessed to determine if it is infectious and removed from work if infectious to prevent spreading. V6 confirmed scabies is worse at night and if the scraping is negative, it does not rule out scabies as the cause of the rash. V6 confirmed delay in treatment can cause spread of the rash and residents experiencing symptoms, but each resident needs to be assessed and evaluated individually. On 9/5/2023 at 11:56 AM V21 (Local Health Department Epidemiologist) stated any new onset rash that appears to be spreading or affecting more than one resident should be suspected as possibly contagious and investigated to determine the diagnosis and medically investigated to determine if it is infectious. Until the rash can be ruled out as not infectious, residents should be isolated, and employees should not provide direct care. V21 stated the County Health Department expects the facility to follow Center for Disease Control (CDC) guidelines, monitor their infectious diseases at the facilities, report their outbreaks, and follow protocols to prevent outbreaks. V21 stated failure to contain the spread is up to the facility to monitor and work with their Medical Director to determine the cause of the rash, establish a treatment plan, and implement of measures to prevent the spread. V21 confirmed if a scraping resulted as negative that does not mean the resident does not have scabies, stating it is up to the facility and the Medical Director to diagnose and treat accordingly. V21 confirmed if treated for scabies and symptoms resolve, the rash is likely from scabies, particularly if there have been recent exposures. V21 confirmed, if an affected person is treated and the rash resolves, and then re-occurs, there is likelihood they were re-exposed again and re-infected. V21 stated untreated scabies can lead to further spread within the facility, in the community and to the family of employees. V21 stated if a person with scabies goes untreated, they will continue with symptoms, including an itching rash, often more prevalent at night, and potential infection of the wounds from scratching. V21 stated, it is negligent for the facilities not to take the proper care to prevent the spread and to follow CDC guidelines and lack of surveillance and delay of treatment causes ongoing transmittal and spread. Email correspondence dated 8/24/2023 at 4 PM between V1 and V5 includes direction from V5 that all residents and employees (symptomatic and asymptomatic) should be treated on the same day. This email includes an attached document titled, Management of Scabies in Illinois Healthcare and Residential Facilities. This document includes guidance including, healthcare workers should immediately report any signs of infestation to themselves or residents to the infection control practitioner and should have process in place to identify and controlling a scabies outbreak. Signs and symptoms include rash to the skin which may vary greatly in appearance according to pre-existing skin conditions and the site, and secondary bacterial infections may develop because of intense scratching caused by the mites. The Scabies Control policy dated 2/15/2018 documents scabies is a highly communicable disease of the skin caused by the itch mite. The purpose is to eliminate and treated irritated skin areas and prevent the spread of infection. Signs include intense itching and eruptions of burrows which is transmitted by physical contact. The physician is to be notified promptly upon identification and the physician will provide an examination. Treatment for residents infected or being considered for prophylactic treatment will be provided and all affected individuals will be completed at the same time. Contact isolation will be initiated until after initial treatment. The Infection Surveillance, Tracking and Reporting policy dated 2/14/2018 documents the purpose is to identify, monitor, track and report infections and monitor adherence to infection control practices. Infection tracking includes but is not limited to completing infection tracking logs for all residents with an infection, monitor for trends by unit/location, clusters of the same infection, outbreaks and employee illnesses, track resident and staff outbreaks and complete outbreak line-listing report/investigation. The Immediate Jeopardy that began on 5/11/2023 was removed on 9/12/2023 when the facility took the following actions to remove the immediacy: 1. House wide skin checks of residents was completed by nursing staff on 8/23/23. Residents identified with skin rashes were given treatment of Permethrin cream 5% and placed on contact precautions until treatment was completed by nurses. All residents identified with skin rashes received second treatments by nursing staff. Exposed residents (asymptomatic) were educated and treated prophylactically with Permethrin cream 5% and placed on contact precautions until treatment was completed by nursing staff. 2. All staff were checked and or interviewed for any signs and symptoms of any skin rashes by Nursing staff. All staff were provided with Permethrin cream 5% and completed treatment overseen by Infection Preventionist. 3. All staff were in-serviced regarding guidance on Infection Control: Identification of outbreaks and implementation of measures to prevent the spread once outbreak occurs, education of general communicable diseases, contact precautions, and prevention of transmission of any communicable disease and prevent further spread. Any new employees, agency staff and any staff on vacation shall receive in-service prior to working on the unit. 4. Skin checks to be completed for all new resident admissions upon arrival at the facility and will be performed by nursing staff to be monitored by Infection Preventionist (IP). 5. New hire staff will complete a self-skin assessment questionnaire during first day of orientation. 6. Facility has implemented an infection surveillance procedure to monitor and track outbreaks for both residents and employee infection and identify outbreaks. 7. Call off log will be monitored by IP and Administrator daily to identify staff with potential infectious illness. Any staff identified with a rash will not be able to return to work without proper medical clearance to be monitored by Human Resources and IP. 8. Resident and employee skin checks will continue weekly until outbreak ends. 9. Audits will be conducted weekly to ensure that skin checks are completed to be overseen by IP and Administrator. 10. Any new occurrences of rash will be assessed by nurse, findings will be reported to Director of Nursing, or IP, proper notification to family and proper physician notification, in house skin assessment by MD/NP for appropriate treatments and interventions. 11. Currently new hired IP to complete CDC infection control training. 12. Emergency Quality Assurance Performance Improvement (QAPI) with Medical Director was done and action plan will be reviewed monthly during QAPI meeting thereafter overseen by Administrator and IP nurse.

Based on observation, interview and record review, the facility failed to implement infection control policies and procedures for the isolation of roommates of Covid-19 positive residents to prevent the spread of infection. This failure has the potential to affect 37 residents (R1-R3, R5, R9-R41) in the secured behavior unit who were not Covid positive. The Census Sheet provided on 6/23/22 showed that R1-R5, and R9-R41 all reside in the secured behavior unit. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 6/19/2022 at approximately 3PM after R7 tested positive for Covid-19 and the facility started moving residents to different rooms. The Immediate Jeopardy was identified on 6/28/2022 at 10:00 AM. Although the immediacy was removed on 6/30/2022, non-compliance remains at a Severity Level Two due to the need to evaluate the implementation of policies and procedures, audits, and quality assurance monitoring. The findings include: R7's 6/19/22 Progress Notes from 1:47 PM showed a positive rapid Covid-19 result with R7 exhibiting Covid-19 symptoms. On 6/23/2022 at 11:05 AM, V3 (Infection Preventionist) stated the facility is in outbreak status, and that the first resident who tested positive was R7 on 6/19/22 (four days earlier). V3 stated R7 was left in his original room in the secured dementia unit, and R7's roommates (R4 and R6) were moved from the secured dementia unit and placed into separate rooms in the secured behavioral unit. V3 continued, stating more residents tested positive on 6/20/2022, 6/21/2022 and 6/22/2022, and that more room moves were made. At the time of the survey, the facility had 33 confirmed resident and staff cases of Covid-19. V3 also explained that the facility's isolation policies include using red zone isolation for residents who are positive for Covid-19, and yellow zone isolation for residents who have been exposed to a person who tested positive for Covid-19. V3 stated yellow zone residents would not have symptoms of Covid-19, and they still test negative. V3 stated the facility does not cohort residents who have been exposed to Covid-19 (yellow zone residents) with residents who have not been exposed to Covid-19. On 6/27/22 at 10:20 AM, V3 stated that R6 became symptomatic and tested positive for Covid-19 on 6/22/2022 (three days after his exposure to R7, and after living with R3 and R5 for those three days). V3 stated R6 moved back into the red zone with R7, his former roommate. On 6/23/2022 at 2:30 PM, the secured behavior unit had a total of two rooms marked with signs indicating yellow zone isolation. The two rooms housed R1-R5. None of the other 11 rooms in the secured behavioral unit were designated as yellow or red zones of isolation. On 6/27/22 at 11:20 AM, R5 (the former roommate of the now Covid-positive R6) wandered the secured behavioral unit hall with his mask below his nose. At 11:50 AM, R5 was in the hall again with his mask below his nose, carrying his trash down the hallway. On 6/27/2022 at 10:20 AM, V3 stated when R7 tested positive on 6/19/2022, R7's two roommates (R4 and R6) were each moved into two other separate shared bedrooms. V3 stated that R4 was moved into a room with R1 and R2, and R6 moved into a room with R3 and R5; however, V3 also stated that R1, R2, R3 and R5 had no prior known exposure to Covid-19. V3 confirmed R4 and R6 should not have been placed in rooms with R1, R2, R3 and R5. On 6/27/2022 at 1:24 PM, V1 (Administrator) stated the facility notified her via phone of R7's positive Covid-19 result on 6/19/2022 around 3 PM. V1 stated the room moves occurred between 3-7 PM. V1 stated three facility staff who were on call were involved in the room moves on 6/19/2022. V1 stated .Bottom line is- a poor decision was made. On 6/28/2022 at 4:32 PM V7 (Medical Director) stated he expects the facility to comply with facility policies and the Center for Disease Control (CDC) guidelines for Covid-19, including placement of residents who had close contact with residents who tested positive for Covid-19. V7 confirmed that residents not exposed to Covid-19 are placed at increased risk of contracting it when they are incorrectly housed together in rooms with residents who have been exposed to Covid-19. The facility policy, Infection Control- Interim policy addressing healthcare crisis related to Human Corona Virus dated 8/13/2021 documents roommates of residents with Covid-19 should be considered exposed and potentially infected and placed under transmission-based precautions (yellow zone isolation). If possible, roommates should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for a total of 14 days after their last exposure. The potentially exposed roommate should remain in a single room under transmission-based precautions and continue to be monitored closely for the development of symptoms. The facility's Resident Vaccine Matrix showed R4 received his second Covid-19 vaccination on 9/21/2021 and did not receive any boosters. The Resident Vaccine matrix showed R5 received his second Covid-19 vaccination on 7/21/2021 and did not receive any boosters. The Center for Disease Control's Interim Infection Prevention and Control Recommendations to Prevent Covid-19 Spread in Nursing Homes, last updated 3/29/2021, shows residents who had close contact with someone infected with Covid-19 and are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with Covid-19 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. The Immediate Jeopardy that began on 6/19/2022 was removed on 6/30/2022 when the facility took the following actions to remove the immediacy: 1. All staff were in-serviced on Center for Disease Control (CDC) guidance for infection control, co-horting of residents, donning and doffing of Personal Protective Equipment (PPE), hand-washing and Covid policies and procedures. Staff on vacation or leave will be in-serviced before returning to work by the Infection Preventionist (IP). 2. The exposed residents were placed on quarantine under transmission-based precautions, increased monitoring/screening every shift for signs and symptoms of covid and ongoing outbreak testing, notifications, etc. 3. New hires will be trained on CDC guidance for infection control, co-horting of residents, timing for transmission based precautions and screening requirements before starting by the IP. 4. The Director of Nursing/Administrator/Infection Preventionist will review line listing and room assignments in morning meeting daily to ensure co-horting is appropriate and follows CDC guidance. 5. The IP shall be responsible for making all Covid-19 related decisions and approving all room changes. Staff were educated to notify the IP prior to making any room changes regarding those affected by COVID. The IP shall train the Minimum Data Set Coordinator, on making such decisions in her absence. 6. Quality Assurance Performance Improvement (QAPI) review with Medical Director to review infection control concerns, root cause and plan of action. The action plan will be reviewed monthly at QAPI meeting. 7. Daily rounds are to be conducted by the IP to ensure compliance with proper PPE by residents and staff. 8. Any future changes to infection control policies and procedures shall include approval and review from the Medical Director. In the absence of the Medical Director, the company Infection Control physician shall be included.

Based on interview and record review, the facility failed to provide adequate supervision to prevent a fall. This applies to 1 of 3 residents (R1) reviewed for falls with injuries in a sample of 3. This failure resulted in R1 incurring a nasal bone and right orbital fracture. Findings include: R1's 3/8/2022 Social Service Progress Note documents R1 admitted to the facility on [DATE] from a hospitalization due to worsening mood and increased agitation. R1's diagnoses include dementia with behaviors and [CONDITION(S)]. This note further documents R1 as oriented to person only and with impaired memory and judgement. R1's Fall Initial Occurrence Note dated 3/9/2022 at 1:45 PM documents R1 as trying to get up from the reclining wheelchair and falling forward hitting her right eye. This report documents R1 with a bump on her forehead and a bruise to her right eye. R1 was sent to the hospital for evaluation and treatment. On 5/10/2022 at 2:29 PM V5 (Former Nurse) stated R1 had been trying to get out of R1 wheelchair all day. V5 stated she and the staff were trying to redirect R1 but it was not working and she required supervision to prevent her from falling out of the chair. V5 stated she left for her lunch break and at that time R1 was in the dining room with staff. V5 stated she instructed the staff to supervise R1 before she left. V5 stated when she returned she was notified R1 had an unwitnessed fall in the hallway and was not in the presence of staff at the time of the fall as instructed by V5. On 5/10/2022 at 3:26 PM V11 (Nursing Assistant) stated she was assigned as R1's Nursing Assistant on 3/9/2022 when R1 fell . V11 stated R1 was a huge fall risk. V11 stated she put R1 to bed but she was trying to get up so V11 placed R1 in her reclining wheelchair in the hallway so she could be supervised closely. V11 stated she was rounding and in another residents room when another resident yelled out. V11 stated she came out of the room and found R1 on the floor. Per V11 R1 had climbed out of her reclining wheelchair and was laying face down on the floor trying to roll onto her back and the chair was pushed over. V11 stated she required 1:1 supervision and she was doing rounds and was unable to supervise her as she required. 5/11/2022 12:02 PM V13 (Nurse Practitioner) confirmed R1's injury was preventable. V13 stated if V5 instructed staff to supervise R1 and they did not provide that supervision the fall and subsequent injuries could have been prevented. R1's hospital Cat Scan 3/9/2022 of the Facial Bones Bones documents R1 with nasal bone and right orbital fractures. The facility policy Fall Prevention Program dated 11/21/2017 documents the purpose of the policy is to assure the safety of all residents. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. This policy further documents it is the responsibility of all assigned nursing personnel to ensure precautions are put in place and consistently maintained.

Based on observation, interview and record review the facility failed to assess a resident with gastrostomy tube (g-tube) for appropriateness of feeding based on the nutritional needs and failed to re-assess a resident who was losing weight. This failure resulted in R135 having significant weight loss of 11 pounds in 20 days on g-tube feeding. This applies to 2 of 5 residents (R84, R135) reviewed for weight loss in the sample of 32. The findings include: 1. Face sheet showed that R135 is [AGE] years-old with multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/08/21 at 12:58 PM, V18 (Certified Nursing Assistant/CNA) attempted to feed (pleasure feeding) R135 during lunch time. R135 refused to eat, however she (R135) drank the whole cup of iced tea. R135 was noted to have an ongoing g-tube feeding of [MEDICATION(S)] 1.5 at 45 ml/hr (milliliter per hour). On 11/09/21 at 10:19 AM, V19 and V20 (Both Restorative Aid) weighed R135 and she was 118.2 lbs. On 11/09/21 at 10:21 AM, V18 (CNA) stated that prior to hospitalization (9/27/21), R135 had poor appetite. V18 had never seen her eat more than 25%. R135 does eat and drink. R135 went to the hospital because she was found with her mouth foaming and altered mental status. V18 felt that because R135 was not eating drinking she was already malnourished and dehydrated. R135's weight monitoring log showed: 9/21/2021-155.8 lbs., 10/20/2021-129.2 lbs., 10/22/2021-130.0 lbs., 10/28/2021-123.6 lbs., 11/4/2021-120.8 lbs., 11/9/2021-118.2 lbs. From 10/20/21 (129.2 lbs.) to 11/9/21 (118.2 lbs.), R135 a weight loss of 8.5% (11 lbs.) in 20 days. On 11/10/21 at 11:55AM, V11 (RD) stated that R135 went to the hospital (9/27/21) and came back on 10/13/21. Facility staff did not notify her (V11) that R135 had a newly inserted g-tube and was receiving g-tube feeding. V11 said that staff are supposed to notify her (V11) within 24 to 72 hours if a resident gets readmitted with newly inserted g-tube. In addition, V11 said that staff must notify her if a resident needed nutritional assessment, and about residents who are having significant weight changes especially a sudden weight loss, the staff should not wait until V11's next visit to the facility. Had she (V11) been notified, V11 would have increased R135's tube feeding to 50 ml/hr. V11 would also recommend additional 150 ml flush four times a day on top of what R135 was receiving. V11 would also recommend weekly weights, monitor lab work, add health shake, whole milk or sugar cereal for her pleasure feeding and this would have prevented R135's further weight loss. V11 stated she was not aware of R135's g-tube status until the state agency staff inquired about R135's weight and nutritional status. On 11/10/21 at 10:25 AM, V22 (R135's physician) stated he is not familiar with R135's condition but he had seen her on 10/14/21. V12 added that he works part time in the facility and would expect that they would follow facility's protocol (policy and procedure) with regards to weight loss and nutritional assessment. On 11/10/21 at 1:35 PM, V22 continued to say that he expects that the registered dietitian would recommend appropriate g-tube feeding and/or appropriate supplement to meet R135's need. V22 checked R135's record and said that the last time R135 was assessed by primary physician's group was on 10/13/21 and was just seen today by V23 (NP). The significant weight loss could have been prevented if R135 was monitored closely. R135's care plan showed: R135 requires tube feeding related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . with 250ml water flush every 6 hours and Pleasure feeding mechanical soft diet (10/14/21). Goal: R135 will maintain adequate nutritional and hydration status as evidence by stable weight, no sign and symptoms of malnutrition or dehydration through next review date 01/22. Intervention: V11 (RD) to evaluate quarterly and as needed (PRN). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. Review of R135's record (Care Plan) showed, g-tube was inserted on 10/5/21. Upon re-admission to facility, R135's physician ordered [MEDICATION(S)] 1.5, at 45ml/hr. with 250ml water flush every 6 hours was to be administered. Despite having pleasure feeding during mealtime, R135 continued to refuse the food. V11 (Dietician) was not informed of R135's newly inserted g-tube, and the need for hydration and nutritional evaluation for the appropriateness of the ordered g-tube feeding to ensure that R135 was receiving adequate nutrition and hydration. V23 (NP) was aware of the g-tube feeding and pleasure feeding but was not aware that R135 was not eating and continued to lose weight despite the g-tube feeding. The facility monitored R135's weight, however, there was no evidence of documentation to show that R135's significant weight loss was being addressed. 2. Face sheet documents that R84 is [AGE] years-old with multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/08/21 at 9:20 AM, V17 (CNA) was feeding R84 pureed breakfast. R84 appears to have poor appetite, only nibbled at her food. On 11/09/21 at 12:37 PM, V17 stated that R84 used to have a good appetite but since last month (sometime in October), R84 started showing a decline in her appetite. R84 would eat the cream of wheat and would only nibble the side dishes (other food) in the tray. Sometime last week, R84's appetite deteriorated more. She has been eating less and less. R84's weight log documents: 6/10/2021-158.2 lbs., 7/2/2021-157.0 lbs., 8/6/2021-149.6 lbs., 9/8/2021-142.8 lbs., 10/5/2021-141.4 lbs., 11/2/2021-138.2 lbs. On 11/9/21 at 10:33 AM, V19 and V20 weighed R84, and R84 was 127.4 lbs. From 11/2/21 (138.2 lbs.) to 11/9/21 (127.4 lbs.) R84 had a significant weight loss of 7.8% (10.8 lbs. weight loss in one week). From 10/5/2021 (141.4 lbs.) to 11/9/21 (127.5 lbs.), R84 had a 9.9% weight loss in one month. On 11/10/21 at 10:50 AM, V23 (NP) stated she (V23) was not notified about R84 not eating and that R84 had significant weight loss. V23 further stated the facility should have notified her (V23) as soon as they found out about the significant weight loss and if she would been notified, she would have ordered laboratory works and she would have referred it to V11 (RD) for nutritional assessment and to ST (Speech Therapy) for swallow evaluation. The unplanned significant weight loss could have been prevented. On 11/10/21 at 12:02 PM, V11 sated if a resident is on a planned weight loss, and the resident is eating and losing weight, then this means that the treatment plan recommended to the resident is working. However, if a resident is on a planned weight loss and is losing weight because the resident is not eating well then there's a problem. V11 said that R84 is obese and was under a planned weight loss. V11 noted that R84 was having weight loss, however, V11 was not aware that R84 was not eating well lately. V11 was only notified of R84's poor appetite on 11/9/21 (after inquiry from state agency staff). V11's assessment of a resident's food intake relies on the nutritional value of the food that was consumed rather than the amount of the food that was offered to the resident. If V11 was notified of R84's poor appetite, V11 would have recommended medication the would enhance appetite, nutritional supplements, super cereal, calorie count, weekly weight monitoring, she (V11) would call R84's family to get added information about what R84 likes to eat, and would update care plan related to nutrition. These could have prevented R84's significant weight loss. There was no evidence of documentation in R84's clinical record to show that R84's significant weight loss and poor appetite was being addressed despite staff being aware of R84's declining appetite.

Based on observation, interview and record review the facility failed to transport a resident in a wheelchair in a safe manner; utilizing durable medical equipment to prevent an injury. As a result R2 sustained a tibia fracture requiring the use of a long hard cast to the left leg. This applies to 1(R2) of 3 residents reviewed for accident/incident/injuries. The Findings Include: R1's Face Sheet says R1 is 288 pounds and has the following pertinent diagnosis: Non- displaced fracture of the tibia shaft, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] of the left hip, lumbago with sciatica on the left side and spinal stenosis. On 4/14/2021 at 10:21AM, R2 was laying in bed, obese with a hard long cast to the left leg. R2 said she has left hip and left leg issues. R2 said on 3/30/2021, V8(Auxiliary Technician) was pushing me from an outside visit with family to inside of the building. R2 said there were no leg rest on her wheelchair. My left leg got caught under the wheelchair causing a tibia fracture. V7(Family) was present and saw what happened. R2 said V8 is not a certified nursing assistant. After V7(Family of R2) told V8 to stop, V7 stopped, but my leg was already underneath the chair. R2 said she could not respond because was yelling in pain. Then V7 turned me around and pushed me backwards into the building and to my room. V7 placed me by the bed and exited without notifying the nurse. After sitting in pain I looked outside the door and saw V5(Nurse), told her what happened and received an x- ray. My leg rest were lost due to all the moving(changing rooms) because of the pandemic. If I would have had my leg rest on the wheelchair, my leg would not be broken. On 4/14/2021 at 1:17PM, V5(Nurse) said she could not remember the time but R2 saw her outside of the room passing medication and complained of foot pain. V5 said when she looked at R2's foot there was no difference but her left knee cap had a sloping mark. V5 said R2 told me her leg got caught underneath the wheelchair as V7 was pushing her. V5 said she called V10(Medical Doctor/ Director) and an x- ray was ordered. V5 said, R2 has a tibia fracture from the accident. On 4/14/2021 at 2PM, V7(Family of R2) said it happened on 3/30/2021 at 11:50AM. V7 said she yelled at V8 to stop because R2 was yelping and screaming in pain as he rolled over her leg. V7 said her wheelchair did not have any leg rest on it. V7 said at 1PM, she called the facility and discovered that R2 was not treated until 1 PM. V7 said if R2 had wheelchair leg rests on her wheelchair her leg would not be broken. On 4/14/2021 at 2:10PM, V8(Auxiliary Technician) said he was pushing R2 back to her room from an outside visit and her foot got caught underneath the wheelchair.V8 said he told R2 to hold her up legs while he pushed her. V8 confirmed V7 was present and there was no leg rest on the wheelchair. V8 confirmed after it happened he pushed R2 backwards to her room. On 4/15/2021 at 9:09 AM, R2 was again in bed with a long hard leg cast on the left leg. R2 said V8 did not ask her to raise her legs as he pushed her. R2 said I could not have raised my legs, I have left hip and left leg issues, constant swelling in both legs and I need a hip replacment. R2 said she has to be pushed by someone and she does not remember who pushed her outside for the visit, it was not V8. R2 said V8 pushed her for the first time the day he got her leg caught underneath the wheelchair. Restorative Care Plan dated 4/3/2021 says Wheelchair to have leg rests on when being pushed by staff. On 4/16/2021 at 8:17AM,V1(Administrator) said V8 is a male with a small frame and it was probably difficult for him to propel R2 who is obese. V1 said R2 did not have leg rest on because she propels herself and leg rest are not indicated for self propelling residents. When asked why was V8 pushing a resident who propels herself, V1 responded I can not answer that. On 4/15/2021 at 5PM, V10(Medical Doctor/Director) said he does not get involved in analysis on the cause or prevention of injuries. V10 said he has 1000's of patients and does not remember R2's medical history, I am a doctor and I prescribe treatment. On 5/16/2021 V12(Medical Doctor) said he has no knowledge of how R2 injured her leg. X- Ray Report dated 3/30/2021 says, Left Acute spiral distal tibia fracture.

Based on interviews and record reviews, the facility failed to assess and intervene when 1 resident (R1) with a history of constipation had no documented bowel movement for a period of 5 days. The facility also failed to consistently and accurately track continent residents bowel movements by failing to ensure that staff were knowledgeable about the tracking program. These failures resulted in 1 resident, (R1) becoming severely impacted, sustaining a perforated rectum and requiring emergent resection of the colon and an [CONDITION(S)]. These failures affected 1 of 5 residents reviewed for bowel elimination/tracking. Findings include: R1's admission face sheet reflects that R1 is [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) of 2/16/21 reflects a BIMS (Brief Interview for Mental Status) of 14 R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .S. (bedtime). PRN (as needed medication orders) included Milk of Magnesia 30 ml (milliliters) daily as needed for constipation, R1's regular medications included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's diet at that time was LCS (low concentrated sweets), regular texture, regular consistency. R1's care plan with a last reviewed date of 2/18/21 reflects that R1 has a potential for constipation related to having hard stools and the use of [CONDITION(S)] medication. The date initiated for this particular focus area is 10/25/18 with a revision date of 2/17/21. Interventions include to follow facility bowel protocol for bowel management; to monitor medications for side effects of constipation; to keep the physician informed of any problems and monitor/document/report prn (as needed)to nurse-signs and symptoms of complications related to constipation. This care plan also reflects an ADL (Activities of Daily Living) self-care performance deficit related to his psychiatric diagnoses, and notes that R1 is continent of bowel and bladder. This focus area was revised 2/17/21 with a target date of 6/29/21. Under toilet use, the care plan intervention documents supervision. Because of his mental health issues, R1 resided in the behavioral health unit of the facility. Nursing note from 3/7/21 timed at 11:00 AM reflects that R1 put on his call light and complained of chest pain. At that time, he was noted to have a moderate amount of bright red blood in the toilet and in the bed with him, which was coming from his rectum. R1's physician was contacted and R1 was sent to the hospital for evaluation. Hospital records reflect a complicated course for R1. emergency room records dated 3/7/21 reflects that R1 presented with rectal bleeding and a 5 day history of abdominal pain. (there was no mention of where this information was obtained). R1 was found to have a tender abdomen and chest x-ray showed probable free air. A Cat Scan revealed free abdominal air and R1 was taken for emergency exploratory surgery. It was felt that R1 was most likely septic from a perforated [MEDICATION(S)]. Operative report from 3/7/21 notes the following procedures done: exploratory laparotomy; rectosigmoid resection; removal of multiple large hard balls of stool in the peritoneal cavity and the pelvis; drainage of pelvic abscess; end [CONDITION(S)]; Hartman's procedure and peritoneal lavage. Upon entering of the abdominal cavity, the following was found: the whole belly was filled with purulent fluid .multiple very hard, large balls of stool lying in the pelvis .there were very large holes in the distal sigmoid colon and the mid rectum .this is obviously related to severe constipation and this has eroded through the colon being ongoing for a few days. There is complete necrosis of the rectum with abscesses and foul smelling drainage. at least 10 balls were removed . the rectum . is completely perforated almost circumferentially from the stool, . the whole colon was filled with rock hard stool. Ideally he would need a subtotal colectomy and [CONDITION(S)] but he is very ill and septic .would add another several hours to the procedure .abdominal cavity irrigated .abscesses in the pelvis were drained and necrotic tissues were debrided. may have to go back in and do re-exploratory laparotomy and remove whole of colon but will try medical management to get whole of colon cleaned out with (bowel prep medication), laxatives and [MEDICATION(S)] rocks of stool noted throughout the [MEDICATION(S)] colon, throughout the descending colon, splenic flexure and even the right colon .removing all would have taken too much time . On 3/8/21, R1 again was taken for emergency exploratory laparotomy to place a wound vacuum. 3rd Operative Report (not dated, possibly 3/11/21, dictated date) reflects procedures done were exploratory laparotomy; removal of wound vac; subtotal colectomy; [CONDITION(S)].the whole of the large bowel had rock hard stool, all the way from cecum to [CONDITION(S)] .[CONDITION(S)] never put out any stool despite bowel prep .not possible to clean this colon .best option is subtotal colectomy .it was a massive colon filled with rock hard stool, probably over 10 pounds . Hospital discharge summary reflects R1 was discharged on [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Acute left upper extremity DVT (deepvein [CONDITION(S)]) Septic shock due to peritonitis perforated rectum status post [MEDICAL RECORD OR PHYSICIAN ORDER] dysphagia [CONDITION(S)] possible pneumomediastinum Pelvic abscess persistent fever diabetes; hypothyroidism; [CONDITION(S)] R1 was readmitted to the facility on [DATE]. On 3/29/21 at 10:25 AM V2 (ADON) stated that prior to R1 being discharged to the hospital, R1 was alert to name, place and time but he needed reminders or cueing for hygiene. He was able to self-toilet and feed himself. He was usually cooperative and walked independently. His behaviors included yelling and punching things like walls. He was usually reliable when staff spoke to him, His current status is that he is alert to his name and he knows where he is. He remains in bed and uses his call light for assistance. He is incontinent of bladder and has an [CONDITION(S)] which staff take care of. He is able to use a urinal. He has gotten stronger and more alert since admission and can move both arms, He is able to speak, and sometimes he makes sense, but other times does not. V2 stated that the facility does track BMs (bowel movements) and continent residents are questioned about their BMs. It should be happening on every shift and as needed, and the information gets recorded in their electronic charting system. Typically it is CNAs (Certified Nursing Aids) that do this tracking but nurses are able to do it also. If there is any reason to not trust what a resident is telling them, they can tell the residents that staff want to see their BMs once they have had one. If a resident hasn't had a BM for a couple of days, the nurse should assess them, which would include evaluating their abdomen, by listening to bowel sounds and palpation of the abdomen, The nurse should also check to see if they have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If they don't, the nurse can check the facility's standing orders and give them something. On 3/30/21 at 12:35 PM V8 (CNA) stated that continent residents are to be asked daily about their BMs. If there is no BM for 48 -72 hours, they are to let the nurse know so the resident can be given something to help them. In the bowel tracking program, there are multiple columns, two labeled continent and incontinent. Her understanding is that continent just means they are aware of when they have to have a BM and can control it. She does not use the continent column to indicate when a resident has had a BM. If there is documentation of a BM, there should be further documentation of description, such as amount and consistency. After reviewing R1's bowel tracking from 2/28/21 through 3/7/21. V8 stated that she only saw evidence of BMs for R1 on 1 day, 3/1/21. V8 noted multiple checks under the not applicable column for R1 but could not say what that means, because everyone goes to the bathroom, There is a specific column for ostomies so this column would not be marked for that. On 3/30/21 at 12:10 PM, V7 (Restorative CNA) stated R1 had good days and bad days, and at times was delusional, and he couldn't stay focused at those times. V7 stated that although she is a restorative CNA she does work the floor at times and is familiar with R1 and the bowel tracking program. She asks the resident if they have had a BM and charts it. Some residents self-toilet and they take them at their word. R1 would generally answer questions. According to V7, when the Bowel and Bladder section opens up on the computer, the first question they are to answer is if the resident is continent or incontinent. Her understanding is that if she marks continent, it means the resident has had a BM. Further questions to be answered include questions on amount and consistency. Bowel tracking is to be done once a shift. She has been told that residents should not go longer than 72 hours without a BM. She reviewed bowel tracking for R1 from 2/28/21-3/7/21. She noted there were many checks under the column titled Not Applicable but she could not explain what that column meant or what it should be used for. On 3/30/21 at 11:10 AM, V 6 (CNA) stated she has worked on the behavioral unit for several months and is familiar with R1. With regards to BM tracking, they don't usually see the residents BMs. Many of the residents tell them when they have had a BM. She also asks about it during rounds and documents it in the computer. Some residents are good about telling you but if they're not she at least documents continent or incontinent, because she knows that about the residents. V6 stated she doesn't know what the not applicable column is used for. She doesn't ask about amount and consistency because they usually won't tell her. She was not told to chart continent in place of a BM. When she checks no BM she gets that from the resident. R1 is usually responsive and answers questions although he can have bad days. V6 stated she cared for R1 on the day he was discharged to the hospital. He only complained of chest pain, and she noted blood in the toilet and the bed She told the nurse right away. The nurse checked him and sent him to the hospital. Bowel tracking record for R1 from 2/28/21 and 3/7/21 only reflects documentation of R1 having 2 small bowel movements on 3/1/21, described as soft. There are no documented bowel movements for R1 after 3/1/21. Under the column titled no bowel movement, there are at least one check per day, and sometimes more, indicating no BMs for 3/3/21, 3/4/21. 3/5/21 and 3/6/21 There are no progress notes indicating any assessment of R1's abdomen, There is no indication that bowel sounds were checked or R1's abdomen was palpated. There are no notes indicating R1's physician or nurse practitioner were called. R1's March MAR (Medication Administration Record) reflects no prn doses of Milk of Magnesia were given. : Facility policy titled Bowel Elimination Protocol states 'residents who have had no BM for 48 hours will be observed for signs and symptoms of constipation which may include but is not limited to bowel sounds, abdominal distention, watery stool, nausea/vomiting, etc. and review of record. If signs and symptoms of constipation are presMS acent, may offer non-pharmacological interventions such as prune juice, natural [MEDICATION(S)] or encourage increased fluids. Residents who have had no BM for 72 hours will be considered for pharmacological intervention of increased non-pharmacological interventions. If resident continues to have no BM after additional interventions, notify MD for further instructions. On 3/29/21 between 1:30 PM and 1:45 PM, R2 - R5 were interviewed. R2 stated that the facility staff ask him about his BMs off and on. R3 stated they don't ask me. R4 stated staff haven't asked him about his BMs recently; they used to but not anymore. R5 stated staff used to ask about BMs, but not anymore. R2-R4 have BIMS scores of 15 for cognition; and R5 has a BIMS score of 13 on most recent MDS. On 3/30/21 at 1:50 PM, V9 (Nurse Practitioner)stated that she saw R1 for a telehealth visit at the end of February and he had no complaints, although he is not always reliable due to delusions and hallucinations. Typically a person with such a large impaction would be having abdominal pain and possibly nausea and vomiting. Psychiatric medications can cause constipation She typically won't let a resident go more than 4 days without a BM before she orders something for them. On 3:30 PM at 2:45 PM V10 (Nurse Practitioner for V13-MD for R1) stated she saw R1 for 2 telehealth video visits, one the end of February and one after his re-admission, On the first call, he answered questions with yes/no answers, He appeared anxious but expressed no concerns at that time She specifically asks about diarrhea or constipation and he denied both. With the amount of impaction he had, she would expect someone to have nausea/vomiting, loss of appetite, abdominal distention and probable pain with palpation of the abdomen. Their abdomen might be very hard or it might be tender. Psychiatric medications can be constipating. It is important to track BMs and there should be some intervention after 72 hours with no BM. R1's perforated bowel with resultant surgeries and peritonitis are the direct result of his impaction; impactions are preventable with good bowel management. Despite multiple attempts, V13 (R1's facility MD) did not return calls and could therefore not be interviewed. V14, R1's surgeon was away from his office and could not be reached for interview.

Based on observation, record review, and interview the facility failed to rapidly cool, hot potentially hazardous (CS - Time/temperature controlled for safety), food to a safe internal temperature of 41 degrees Fahrenheit (F) or below within the maximum permitted six hours to prevent food borne illness. This failure resulted in the facility preparing to serve unsafe food without recognizing the potential for food borne illness to all 161 residents. This failure resulted in an Immediate Jeopardy. The improperly cooled turkey roasts was observed being prepared for meal service. An Immediate Jeopardy was identified. The Immediate Jeopardy began when the facility dietary staff failed to recognize the need for rapid cooling of hot potentially hazardous foods intended for later service to residents on 6/22/2019 at 2:30 PM. Such food was permitted to remain under conditions favorable for bacterial growth and potentially food borne illness if consumed by residents. On 6-25-19 at 3:07 P.M., V1, Administrator was notified of the Immediate Jeopardy situation. While the immediacy was removed on 6-23-19, the facility remains out of compliance at a severity level 2, while the facility is in the process of training and retraining staff on the facility's policy and procedure for rapidly cooling potentially hazardous foods after preparation. Findings include: According to the menu for the noon meal on 6-23-19, Oven Roasted Turkey was the planned protein source for all residents. On 6-23-19 at 9:10 A.M., V6, Day Cook was preparing the turkey roast, by slicing the roast into serving size for the noon meal. V6 stated that four, eight to ten pound turkey roasts were cooked on 6-22-19. The roasts were netted made up from both white and dark meat. V6 stated that V6 pulled the two pans of turkey roasts from the walk in refrigerator at 9:05 A.M. At 9:10 A.M. the internal temperature of one of the turkey roasts was 45 degrees Fahrenheit (F). The temperature was taken with the surveyor's thermometer. The surveyor's thermometer recorded 32 degrees F. during a field point test that indicates the thermometer was accurate. V6 verified the internal temperature of the roasts was 45 degrees F. and the ice point test. temperature was 32 degrees F. recorded by the surveyor's thermometer. V6 stated that he did not see any documented evidence that the turkey roasts were monitored to ensure that the roasts were rapidly cooled. V6 stated the roasts were tightly covered with aluminum foil when V6 got the roasts out of the walk in refrigerator. V6 stated the cooking broth was removed from the pan. V6 stated on 6-23-19 9:20 A.M., the turkey roasts planned serve to resident. V7, Dietary Aide stated on 6-24-19 at 10:05 A.M., V7 place the four raw turkey roasts in the oven at 8:00 A.M. on 6-22-19. V7 checked the temperature of the roast and the temperature of the roasts were 178 degrees F. V7 stated V7 pulled the roasts out of oven at 2:00 P.M. and covered the roasts and placed them in walk in refrigerator at around 2:30 P.M. V7 stated that the roast were not cut in smaller pieces or loosely covered. V7 stated V7 did not follow the facility's Cooling Food - Two Stage Process policy. The turkey roasts were in the temperature range between 178 degrees F. and 45 degrees F. for approximately 19 hours. On 6-23-19 9:55 A.M., V5, Dietary Manager stated that the facility has a temperature and time log to record the rapid cooling of hot potentially hazardous food. V5 checked the log and the last entry was 6-1-19. V5 stated the time and temperature should be completed according to the facility's policy The facility's undated policy Cooling Food - Two Stage Process, was reviewed. The policy states potentially hazardous cooked foods will be cooled properly to prevent food borne illness. The procedure in stage I states Cool foods from 135 degrees F. to 70 degrees F. within two (2) hours.' In Stage II Cool foods from 70 degrees to 41 degrees F within 4 hours. The policy further offers methods and procedures to facilitate rapid cooling including Food will be cooled in pans less that 4 deep (preferably 2 deep), Cut large items such as roasts, into quarters, and Food will be covered loosely, to allow heat to escape. The Resident Census and Conditions of Residents form completed 6-24-18 specifies that 161 residents reside in the facility. This also documents residents with pressure ulcers, receiving hospice care, on [MEDICAL TREATMENT], and receiving respiratory treatments. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The turkey roasts were discarded by V5 at 12:20 P.M. on 6-23-19. No residents were served turkey roasts that had been not properly cooled down. Cool logs set in place immediately, education provided. Completed 6-23-19. 2. Dietary Manager in-serviced dietary staff on the policy and procedure in properly cooling food with a 2-stage process on 6-23-19, completed by 6-26-19 prior to staff working. Registered Dietitian to provide additional upon next visit. Completed 6-26-19. 3. Proper cooling logs will be audited by the Administrator, the Dietary Manager or designee daily for 2 weeks then 2 times a week for 3 months. Observation will be discussed with the QUA committee on 8-8-19, and concerns will be discussed among the members for 6 months or as needed.

Based on interview and record review the facility failed to implement practitioner ordered wound treatments, implement preventative skin barrier treatments, and provide weekly assessment and monitoring of post-surgical incisions and Moisture Associate Skin [MEDICAL CONDITION]. This applies to 1 of 3 residents (R2) reviewed for wound care in a sample of 12. This resulted in R2 developing extensive excoriated areas of skin which delayed surgical intervention to repair R2's left hip. Findings include: The hospital Transfer From dated (MONTH) 5, (YEAR) documents R2 transferred to the facility for continuation of intravenous antibiotics after surgery completed by V19 (Orthopedic Surgeon) on (MONTH) 30, (YEAR) to remove a left hip prosthesis and placement of antibiotic spacer for a infected hip joint. Hospital discharge instructions document R2 admitted to the hospital on (MONTH) 20, (YEAR) for abnormal laboratory values (low sodium). The hospital discharge instructions dated (MONTH) 23, (YEAR) documents under Treatment/Wound Care to see wound care sheet provided. The attached Wound Care Consult dated (MONTH) 23, (YEAR) documents R2 with a left hip full thickness surgical wound with 100% white necrotic tissue of uncertain depth and halted wound healing. The treatment Plan documents to cleanse left hip wound with normal saline, apply [MEDICATION NAME] gel and cover with dressing and if wound not improving to consider using Santyl ointment and contact the surgeon if any signs of infection noted or wound is not improving. On (MONTH) 21, (YEAR) at 9:10 am, V22 (Nurse) stated V22 completed a weekly skin assessment on (MONTH) 7, (YEAR) for R2 and R2 presented with opened reddened areas to the back of thigh and two wounds to the left hip which were 1-2 inches long, close together and which were not fully closed. V22 stated all of these wounds were not new on that date but V22 could not indicate when V22 first saw these wounds but it was at some point after R2 returned from the hospital on (MONTH) 23, (YEAR). R2's P[NAME] (Point of Care) Response history for skin observation (MONTH) 23-June 12, (YEAR) documents R2 with redness on (MONTH) 2, and 5, (YEAR) and open skin on (MONTH) 6, (YEAR). All of these entries document the skin condition as not new and the nurse as notified. This documentation indicated V10 (Nursing Assistant) completed the entries on (MONTH) 2, (YEAR). On (MONTH) 21, (YEAR) at 10:08am, V10 (Nursing Assistant) stated after R2 returned from the hospital in (MONTH) (YEAR), R2's posterior area of the thighs were red, with open areas and very excoriated. V10 stated R2 was frequently incontinent of urine and was able to let staff know if R2 needed changed so staff could assist. V10 stated if R2 needed to be changed during smoking times R2 would only let the staff change R2's incontinence brief but R2 wouldn't let them change R2's wet pants for another 15-30 minutes until after R2 finished smoking. V10 confirmed V10 completed the P[NAME] care documentation completed on (MONTH) 2, (YEAR) and the entries were accurately describing R2's skin condition as not new. The Skin Condition Report dated (MONTH) 6, (YEAR) and completed by V11 (Wound Nurse) documents R2 with new Moisture Associate Skin [MEDICAL CONDITION] (MASD) as follows: left and right posterior iliac crest, right and left buttock are documented as reddened and the right and left posterior thighs are documented as reddened with bleeding. R2's (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. In addition, [MEDICATION NAME] Cream to buttocks topically one time a day for MASD was initiated on (MONTH) 8, (YEAR) and Zinc Oxide skin barrier ointment after each incontinence episode for MASD was initiated on (MONTH) 7, (YEAR). There is no documented evidence skin barrier was being applied between (MONTH) 23, (YEAR) and (MONTH) 6, (YEAR). A Provider Order Information Report completed by V19 (Orthopedic Surgeon) on (MONTH) 8, (YEAR) documents daily wound care to buttocks, thigh and hip incisions, use Santyl to the hip incision. Will plan hip aspiration after wounds healed. A emergency room Physician Report dated (MONTH) 12, (YEAR) documents R2 sent for evaluation of an abnormal sodium level. The exam section documents .Skin: (R2) has reddened skin with some induration from (R2's) waist down to the bilateral thighs and buttocks and perineum. (R2) has scattered deeper breakdown in this area (R2) has 2 areas of the incision (surgical) that look superficially opened . The hospital Wound Care Progress Notes dated (MONTH) 13, (YEAR) documents R2 with two non-healing surgical wounds of the left lateral hip with a recommendation to use Santyl. R2 is also documented with a excoriation and redness to the left thigh measuring 14 centimeters (cm) X 9 cm X 0.1 cm, posterior upper left thigh measuring 3 cm X 4.5 cm X 0.1 cm, right posterior thigh measuring 11 cm X 0.6 cm X 0.2 cm, right buttock 3 cm X 1 cm X 0.1 cm, right buttock measuring 4.5 cm X 1.2 cm X 0 0.1 cm, right lateral buttock measuring 3 cm X 1 cm X 0.1 cm, right medial inner thigh measuring 1 cm X 2 cm X 0.1 cm, left inner thigh proximal measuring 1 cm X 0.6 cm X 0.1 cm, left distal thigh measuring 0.7 X 0.7 X 0.1, and right groin measuring 3.6 cm X 0.8 cm X 0.1 cm with treatments which include skin barrier ointment to these areas. The (MONTH) (YEAR) Weekly Wound Tracking Report documents R2 surgical wounds closed as of (MONTH) 21, (YEAR) and there is no further follow up of the surgical wounds on this report for R2. The (MONTH) (YEAR) Weekly Wound Tracking Report documents R2 with MASD on (MONTH) 6, (YEAR) and there is no other documentation of MASD or surgical wounds on this report for R2. There is no evidence in R2's electronic medical record weekly skin assessments and monitoring of MASD or the left hip surgical wounds between (MONTH) 23, (YEAR) and (MONTH) 6, (YEAR). On (MONTH) 21, (YEAR) at 1:44 pm, V2 (Director of Nursing) confirmed weekly skin assessments should be completed and the facility cannot provide them. On (MONTH) 21, (YEAR) at 10:45 am, V11 stated on (MONTH) 6, (YEAR) V11 was notified R2 had red areas and MASD to R2's posterior upper hip area extending to about 4 inches above R2's knees with a few open areas. V11 obtained orders to treat these areas. V11 stated V11 assessed R2 after hospitalization and R2 had some redness without open areas posteriorly and Zinc Oxide ointment was being used. V11 stated R2's hip incisions were closed but had fresh skin covering them. V11 stated R2 was on a lot of diuretics which caused R2 to frequently wet R2's self and also would rub the back of R2's thighs on the wheelchair. V11 stated V11 was not aware of the discharge recommendation to use [MEDICATION NAME] to the left hip surgical wounds and confirmed the order should have been implemented. V11 stated staff are to notify V11 of any changes in skin condition or open areas and confirmed weekly assessments of all wounds are to be completed. On (MONTH) 21, (YEAR) at 11:46 am, V19 stated the last appointment on (MONTH) 8, (YEAR) R2 had extensive redness and ulcers to the buttocks and thighs due to difficulty with moisture and keeping R2 dry. V19 stated R2's skin must be healed to move forward and replace R2's hip to prevent an infection and R2's surgery will be delayed until R2's wounds are healed. V19 stated V19 could not indicate if treatments were implemented if R2's wounds would have healed and stated a wound care practitioner would be the expert to answer that question. On (MONTH) 21, (YEAR) at 12:57 pm, V20 (Wound Care Practitioner) stated from a wound care standpoint it would be best practice to initiate R2's [MEDICATION NAME] as recommended on (MONTH) 23, (YEAR) due to the natural [MEDICATION NAME] and antibacterial qualities in [MEDICATION NAME]. V20 stated V20 could not say if it was initiated if the surgical incisions would have healed but V20 stated it would definitely have been beneficial and frequent assessments of these surgical incisions should be occurring to monitor healing. V20 stated R2's skin should have been kept dry and a protective skin barrier applied which does not require a physician order. V20 stated a skin barrier should have been implemented quickly and timely to prevent and treat R2's excoriated skin areas to prevent deterioration of the skin which can occur quickly when it gets moist. V20 stated if a skin barrier had been applied R2 being wet up to 30 minutes would likely not be harmful to R2's skin. R2's P[NAME] history for behavior symptoms (MONTH) 23-June 12, (YEAR) documents R2 with refusal of care one time on (MONTH) 1, (YEAR). The Minimum Data Set, dated dated dated (MONTH) 24, (YEAR) documents R2 as cognitively intact, a one person assist for toileting and frequently incontinent of urine. The policy Skin Condition Assessment and Monitoring- Pressure and Non-Pressure dated (MONTH) 8, (YEAR) documents weekly assessments are to be documented, each resident will be checked for skin breakdown daily and any changes will be promptly reported to the nurse who will perform an assessment. Also, physician ordered treatments shall be documented on the TAR.

Surveyor: Strother, Cheryle Based on interviews and record review the facility failed to: 1. Assess one resident (R1) who had a change in mental and physical condition after a recent readmission from the hospital, 2. Follow the facility's policy and procedure for charting on re-admissions; showing documentation every shift for 72 hours and evaluating vital signs and changes. 3. Document notification of physician and orders received. 4. Assess pain and current physical status prior to giving prn narcotics as ordered. This failure resulted in R 1 who was assessed as "groggy and lethargic", being found 5 hours later unresponsive with no pulse, no respirations-pronounced dead by the local paramedics at the facility. Preliminary coroner report done after autopsy documents that R1 died from combined drug intoxication. R1, with drug seeking behaviors as well as physical and psychiatric diagnosis, was noted to be on multiple drugs: antidepressants, antianxiety, antipsychotics, both narcotic and over the counter pain meds. Facility nursing staff continued to give narcotics prn to this resident even after noting significant changes in her condition and documenting that due to lethargy, her other scheduled drugs should be held. R1 was readmitted from hospital with new narcotic patch [MEDICATION NAME] - no assessment of breakthrough pain was done when R1 continued to ask for her previous prn pain meds even with new patch in place. R1 was [AGE] years old and died 48 hours after readmission. The multiple scheduled meds that R1 was on include:[MEDICATION NAME] XL 300mg. daily, [MEDICATION NAME] 0.5mg.daily, [MEDICATION NAME] 1mg., [MEDICATION NAME] XR 200mg daily, [MEDICATION NAME] 100mg. two times a day, [MEDICATION NAME] 2 mg. 4X daily, [MEDICATION NAME] 20mg. at bedtime, [MEDICATION NAME] 50mg. at bedtime Senna 8.6mg 2X daily, [MEDICATION NAME] Patch 50 mcg. #10 apply every 72 hours.,[MEDICATION NAME] 10 mg. one suppository rectally as needed (PRN) daily, Fleet enema rectally daily PRN, [MEDICATION NAME] 20 mg. vial IM 2X PRN, Miralex 17 GM. every AM, [MEDICATION NAME] 600 mg. tab. every 6 hours PRN, [MEDICATION NAME] 10 mg. every 6 hours PRN, [MEDICATION NAME] 4 mg. tab. every 6 hours PRN, [MEDICATION NAME] Plus Suspension 30 ml. 4X daily PRN, Immodium 2 mg. capsule every 4 hours PRN, [MEDICATION NAME] with [MEDICATION NAME] 100 mg./5ml.- take 10 ml. every 6 hours PRN, [MEDICATION NAME] 1 mg. tab. every 8 hours PRN, [MEDICATION NAME] 2 mg./2ml Injection ,[DATE] ml. IM every 8 hours PRN, [MEDICATION NAME] ,[DATE] mg ,[DATE] tabs every 6 hours PRN. The failure to monitor and respond to significant changes in condition and assess new medications and their effect led to an Immediate Jeopardy, which was identified on [DATE] at 1pm. The Administrator, E1 was notified on [DATE] at 1:05pm. The Immediate Jeopardy began on ,[DATE] when R1 expired and was removed on [DATE] when correction plan put in place. Findings include: R1 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing notes on [DATE] at 4:00pm document R1 complained of chest pain with numbness and tingling radiating through left shoulder and arm. R1 had one emesis (vomit); physician notified and orders received to send to hospital. R1 returned to the facility on [DATE] at 11:00pm according to the facility's 3-day assessment form. On [DATE] from 6am-2pm this form was blank. E9's (Nurse) nursing note dated [DATE] at 2:00pm documents "around 7:00am R1 noted to be in her room asleep." After waking up R1 she was "noted to be groggy so I held her 8:00am meds " ([MEDICATION NAME] 100 mg, [MEDICATION NAME] 2 mg. one tab and Senna 8.6 mg). Around 12:15pm writer went in to give R1 her noon meds not having assessed her since holding the drugs. "I called R1 by name and she did not respond. I went to her bed to arouse her. R1 was cool to touch and non responsive. I was unable to obtain a pulse. Code blue and 911 notified, cardio [MEDICAL CONDITION] resuscitations (CPR) was started. CPR continued and still unable to obtain pulse, 911 arrived and took over CPR. 911 stopped, CPR stopped and R 1 pronounced dead at 12:30pm. Coroner, family, Administrator (E1) and DON(E2) notified." -On [DATE] at 12:00pm, E9 confirmed that she was assigned to R1 the morning of [DATE]. Around 7:00am E9 said she went into R1's room to wake her, shook R1's shoulder but R1 appeared groggy- rolled over looked at her blankly, R1 just wanted to roll over. R1 did not argue with E9 about holding her morning medications. R1's usual behavior is to take all her medications when offered and has a history of requesting opioid prns on a daily basis. E9 stated she did not notify the physician or obtain a hold order for R1's morning medications. E9 also stated she did not notify anyone, including the charge nurse, or conduct a further assessment nor take vital signs. E9 said she did not see R1 from 7:00am until around 12:00pm when she went to give R1 her noon medications. E9 stated she went into R1's room to administer medications around noon and found R1 laying on her left side unresponsive, no pulse, cyanotic and cold. E9 then called a code and 911 was activated. R1 was pronounced dead by the paramedics in the facility. E9 said she resigned after this traumatic event. -E2(DON) stated on [DATE] at 2:00pm, "R1 returned from the hospital on [DATE] and was acting her normal. R1 was always complaining of abdominal pain but nothing was ever wrong. On [DATE] there was a telephone order to hold R1's 8:00am medication." During interview on [DATE] E2 confirmed to surveyor that the actual MD order to hold meds and notify the physician was done after the actual decision by nurse to withhold meds due to resident's physical condition and assessment. Review of the telephone order and physicians order set dated [DATE] does not indicate a time the telephone order was received or written and states "hold 8am meds." This telephone order was signed by E2. - On [DATE] at 11:40am, Z2 (R1's physician-facility Medical Director) stated, "I was notified on [DATE] that R1 was lethargic. I don't remember the time or any other specific information regarding R1's condition. I don't know who paged me to obtain the telephone order to hold R1's AM medications." The additional nursing assessment on blood pressure fluctuations and rising pulse was not related to the physician at this time in order for MD to make comprehensive follow up. Interview with Z2 on [DATE] at 10:30am, Z2 stated, "Someone from my group of six physicians saw R1 during her hospitalization on [DATE] through [DATE]. I did not see R1 at the hospital. I did not know or write the discharge orders for [MEDICATION NAME] or [MEDICATION NAME]. The facility nurse who calls to confirm the residents admission or readmission orders [REDACTED]. I did not approve R1's readmission orders -On [DATE] at 1:30pm, E7(CNA) confirmed that she was responsible for R1's care on [DATE] during the shift starting at 6:00am until 2:00pm. E7 said R1 was laying on her left side facing the window. At 7:30am E7 asked R1 if she was going to eat breakfast but R1 refused. E7 stated at 11:30am she went to R1's room, stood in the doorway asking if any of the residents in the room were going to eat lunch. E7 stated she did not observe R1 in the room. E7 said she had not seen R1 since 7:30 am nor did she obtain any vital signs for R1. -E10(Charge Nurse) confirmed on [DATE] at 11:30am that she was the charge nurse on duty ,[DATE] between 6:00am until 2:00pm. E10 said she was not aware of R1's change in mental and physical condition. E10 said E9 had not notified her that R1's AM medications were held or that E9 notified the physician due to R1 being "groggy/lethargic.". -E8(Nurse) confirmed on [DATE] at 2:30pm that on [DATE] she was R1's nurse from 2:00pm until 10:00pm. E8 said R1 seemed more tired than usual but took all of her medications including one [MEDICATION NAME] 50 mg. in order to help her sleep. Review of E8's nursing notes dated [DATE]-late entry for [DATE] 2:00pm-10:00pm: R1 alert and orientated; R1 requested PRN (as needed) medications (no time documented); [MEDICATION NAME] ,[DATE]mg. two tablets and [MEDICATION NAME] 4 mg. given. R1 was resting in bed most of the shift but came out at medication pass time; R1 stated she has been "groggy because the hospital put her on scheduled [MEDICATION NAME] and [MEDICATION NAME] IV and she just wants to sleep it off." Nurses notes do not document any symptoms of pain or distress other than R1 stating she had pain. There was no additional nursing interventions or assessment to alleviate or assess pain level especially after nursing documents that R1 remained sleepy, groggy and tired more than usual behavior. The narcotic was administered prn without additional assessment to include recent IV [MEDICATION NAME] given less than 48 hours prior and consideration that R1 still had on the [MEDICATION NAME] 50 mcg patch placed by the hospital on [DATE] at discharge. Review R1's resident admission 3-day assessment documents on [DATE] at 2:00pm-10:00pm (no specific time) the following: Blood pressure- ,[DATE], temperature- 97.6, pulse-88, respirations-20. On [DATE] at 10:00pm-6:00am (no specific time)- blood pressure- ,[DATE], temperature-afebrile, pulse 128, respirations- 18. There is no nursing assessment made at the time the second readings showed significant change. -E12 (nurse) confirmed through nursing notes and interview that on [DATE] from 10:00pm-6:00am she was R1's nurse. At 1:15am R1 came up to the nurses desk asking for her PRN medications. In no apparent distress. E12 also administered R1's PRN medications which included [MEDICATION NAME] ,[DATE] - two tablets, [MEDICATION NAME] 1 mg. and [MEDICATION NAME] 4 mg. No further assessment documented in the nursing notes indicating the necessity of the PRN medications, other modalities tried, attempt at assessment of pain in combination with multiple pain meds and drugs administered already, and evaluation of her previous grogginess Interview with E1(Administrator) and E2 (DON) both stated R1's blood pressures previously had variations, but in reviewing the available medical chart of R1, it shows R1 had only isolated incidents of low blood pressure There was no evidence that R1 previously ever experienced the combination of dropping Blood Pressure and rising pulse to 128 noted before death. -E5 (CNA) said on [DATE] at 12:45PM that on [DATE] she was R1's CNA from 2:00pm until 10:00pm. R1 appeared to be very drugged up, groggy, couldn't keep her eyes open, really out of it. R1 stayed in bed all day only came out for medications. -E6 (CNA) stated on [DATE] at 1:50pm that on [DATE] she was R1's CNA for the 6:00am until 2:00pm shift. R1 was sleepy, dopey and was not out of her room all day except for medications and meals. R1 never missed medication administration. E6 said approximately 10:30am or 11:00am R1's roommate received a telephone call and she went to get her. E6 said she did not talk or see R1 on [DATE] as alleged by the facility. -E4 (Nurse)said on [DATE] at 11:00am that on [DATE] she was R1's nurse from 6:00am until 2:00pm. E4 said R1 was up early asking for pain medication and then went back to bed. R1 refused breakfast and lunch. E4 said the CNA's obtain the vital signs and when residents return from the hospital nurses are to complete charting for 72 hours, including vital signs every shift. R1's pain medication request "seemed to be more about getting the pain med than about the pain itself." E4 said never was R1" so groggy that she would not give her her meds-that would mean something was really wrong with her. " -R3 (R1's roommate), alert and oriented, also a former RN was interviewed on [DATE] at 11:40am. R3 said that R1 never got up all morning on [DATE], not even to use the bathroom. She was" too doped up." " She didn't move all morning. When we went to bed (on [DATE]) R1 was too tired to talk to me. When E9 brought me my 11:00am medications I told E9 that R1 wasn't moving." E9 said "Oh, maybe R1 is catching up on her sleep." R3 stated that no assessment was done by the nurse at the time she expressed her concern. Review of the facility's incident report dated [DATE] shows R1 died in her sleep on [DATE]. R1 had been transferred to hospital on [DATE] for chest pain and returned to the facility on [DATE] at 11:00pm. On the day of R1's death in AM, R1 was allegedly sleeping as her usual behavior, observed and heard snoring by roommate and staff members up until about an hour prior to discovery. Facility's policy and procedure for charting criteria for new admissions and re-admits show to document every shift for 72 hours and vital signs. If you are notifying a physician you must chart what you told him/her and if orders were received. The facility took the following actions to remove the immediacy which puts the level of deficiency to level two in order to allow time to evaluate facility nursing response to the next significant change in condition and in order to evaluate that the facility informs the physician of patient condition and does the necesssary nursing assessment required until resident stabilized. Facility submitted: 1. Facility developed new procedure on admits and readmits on [DATE] 2. Facility developed new BP monitoring sheets on [DATE] 3. In service held [DATE] for all staff who are in the building and posted new policy for all staff to review. Rest of staff will be in serviced end of today and tomorrow. 4. QA will monitor and check for compliance ongoing. Administer and DON, ADON will be responsible.

Based on record review and interview the facility failed to monitor one resident (R1) for unnecessary drugs and excessive dosages who was receiving multiple [MEDICAL CONDITION] and narcotic medications. The facility also failed to develop a medication reduction plan of these medications and develop a comprehensive assessment of her ongoing physical and psychosocial needs and chronic prn drug usage. This failure led the Coroner to conclude that R1's immediate cause of death was a combined drug intoxication following autopsy and toxicology testing. Findings include: Review of facility [DIAGNOSES REDACTED]. The most recent Minimum (MDS) data set [DATE] indicated that R1 was completely independent for all activities of daily living and had no cognitive impairments. Review of a Pharmacy Consultation Report dated 9/1/10 states that R1 has experienced a recent fall and takes the following medications which may cause or contribute to the falls: [MEDICATION NAME] XL; [MEDICATION NAME]; Klonopin 2 mg; [MEDICATION NAME]; [MEDICATION NAME]; [MEDICATION NAME]; [MEDICATION NAME]; [MEDICATION NAME] and [MEDICATION NAME]. The report also stated that R1 has many behaviors and drug seeking tendencies. A recommendation is noted to the physician to document an assessment of the risk vs benefit. This report also recommends that the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. There was no documented followup or physician signature that this pharmacy consult was reviewed or that facility put in place a plan to determine drug usage and potential falls or facility addressed the issue of drug seeking and how to appraoch and assess this need. Review of MAR (medication administration record) dated for November 2010 shows R1 having the following medications ordered: -Budeprion XL 300mg q d (every day) -Risperdone .5mg q morning -Risperdone 1 mg every day -[MEDICATION NAME] XR 200 mg 1 tab every day -[MEDICATION NAME] 100mg 1 tab every day -[MEDICATION NAME] 2 mg twice q day -[MEDICATION NAME] 300 mg 1 tab q day -[MEDICATION NAME] 10/325 2 tabs every 6 hours prn x 2 weeks then resume [MEDICATION NAME] 10/325 2 tabs every 8 hours prn -Klonopin 2 mg 1 tab four times daily -[MEDICATION NAME] 20 mg 1 tab at HS -[MEDICATION NAME] 300mg po 1 tab @ HS (bedtime) -[MEDICATION NAME] 50mg po 1 tab at HS -Ducolax 10 mg suppository once daily as needed -[MEDICATION NAME] 20 mg vial every 12 hours as needed [MEDICATION NAME] 10 mg 3 times a day as needed [MEDICATION NAME] 600mg every 8 hours as needed [MEDICATION NAME] 30 ml 4 times a day as needed [MEDICATION NAME] 10 mg every 6 hours as needed [MEDICATION NAME] 25 mg caps every 6 hours as needed [MEDICATION NAME] 4 mg 1 tab every 6 hours as needed [MEDICATION NAME] 3 mg every 4 hours as needed, IM [MEDICATION NAME] 2 mg every 4 hours as needed [MEDICATION NAME] 1 mg every 4 hours as needed [MEDICATION NAME] 20mg bid x 5 days Senna 8.6 mg po BID [MEDICATION NAME] 10 mg po three times a day Review of a second Pharmacy Consultation Report dated 11/3/10 states that R1 takes [MEDICATION NAME] 2 mg by mouth four times daily scheduled AND [MEDICATION NAME] 1 mg by mouth every four hours as needed. The recommended maximum daily dose threshold for this medication when used to treat anxiety as outlined in F329 is: [MEDICATION NAME] ([MEDICATION NAME]) 2 mg and [MEDICATION NAME] (Klonopin) 1.5 mg. This consult report requested that the continued use of both these medications at this dose be reevaluated and that a risk versus benefit analysis be performed. Also, the interdisciplinary team was encouraged to ensure ongoing monitoring for potential adverse consequences and implementation and monitoring of resident-specific non-pharmacological interventions. R1's psychiatrist (Z3) documented on this pharmacy recommendation that R1 "continues to display out of control behavior which may require prn meds." It is unclear what out of control behaviors Z1 is referring to: E2 provided surveyor with monthly behavior tracking sheets that showed facility monitoring for anxiety only; E11 (PRSD) stated on 12/8/10 that there was "no need to track R1's behaviors as she did not display any behaviors other than appearing very sleepy." Other staff interviews on 12/8/10 included E5, 6 and 7 (nurses' aides), E4 and 8 (nurses) who all described R1 as being sleepy, tired, and spending most of her time in her room, exhibiting no problem behaviors other than drug seeking behavior. E1 (administrator) stated on 12/9/10 that the facility did not develop a gradual medication reduction plan of antipsychotic, antianxiety or antidepressants for R1 since her admission 7/22/10. E1 also stated that the physician was aware of the all the medications R1 was taking. E2 (Director of Nursing) stated that R1 is "a very sick and anxious person and requires the current doses being prescribed of the [MEDICAL CONDITION] and pain meds," but could not show on tracking that behaviors improved/worsened or were actually being managed by current doses given or that frequent grogginess was considered an effect of the multitude of drugs prescribed. R1 was admitted to the hospital on [DATE] for complaints of chest pain. Hospital reports from that admission show no cardiac abnormalities. The hospital applied a [MEDICATION NAME] 50mcg on 11/18/10 at approximately 8:00pm in addition to administering 1 mg of [MEDICATION NAME] intravenously. R1 was discharged back to the facility on [DATE] at 11:00pm. Nurses notes indicate R1 slept through the night. E10 (evening nurse on 11/19/10) stated on 12/8/10 that R1 seemed more tired than usual on 11/19/10 but took all of her meds. E5 (nurse's aide on 11/19 evening) stated on 12/8/10 that R1 was very drugged up and couldn't keep her eyes open. E5 said R1 seemed really out of it and stayed in bed that evening. No evidence MD notified or that new drug regime considered when administering all of the usual meds to resident. Review of MAR (medication administration record) shows that R1 received the following medications on 11/19/10: [MEDICATION NAME] at 7am and 5:15pm [MEDICATION NAME] 10/325 2 tabs at 7am, 1pm, 8pm [MEDICATION NAME] XL 300mg at 8am Risperdone 0.5mg at 8am [MEDICATION NAME] 2 mg at 8am, 12pm, 4pm, and 8pm Risperdone 1 mg at 8pm [MEDICATION NAME] XR 200mg at 8pm [MEDICATION NAME] 50mg at 8pm Review of MAR (medication administration record) shows that R1 received the following medications on 11/20/10: [MEDICATION NAME] 10/325 2 tabs 1:15am [MEDICATION NAME] 1 mg 1:15am [MEDICATION NAME] 4 mg 1:15am R1 was found unresponsive by facility staff on 11/20/10 at approximately 12:15pm and pronounced dead at the facility at 12:30pm. Interview with Z1 (County Coroner) stated on 12/9/10 that the immediate cause of death as stated on the Report of the Coroner's Forensic Pathologist to the Coroner and dated 12/6/10 is listed as a combined drug interaction because there were multiple drugs close to the overdose level. Z1 stated on 12/16/10 at 11:30pm that R1's death certificate will also list R1's cause of death as a combined drug interaction.