Every finding on record at Arc at Normal

Based on observations, interview and record review, the facility failed to implement proper infection control practices to prevent cross contamination, for three of four (R1, R4 and R5) residents, reviewed for infection control, in a sample of 12. Findings include:1.On 7/8/2026 at 9:50 AM, V4, Wound Nurse/Infection Preventionist (IP), picked up bandages and dressing supplies from the top of the treatment cart, carried them into R4's room and laid them on a towel. V4 then performed hand hygiene and donned gloves. V4 uncovered R4, rolled R4 onto R4's right side, and removed the old dressing from R4's left distal medial buttock, that was dated 7/7/2026. V14 performed hand hygiene and donned gloves. V14 picked up the package of silver collagen off of the towel that the supplies were laying on, then opened a package of silver collagen, opened the box and took out the tube of stock (multiple resident use) medicated honey, took the cap off of the medication, applied the medication to the silver collagen, and with the same gloved hands applied it to R4's wound to R4's left buttock. V14 then performed hand hygiene and donned another pair of gloves and picked up the non-bordered foam dressing from the towel and opened it with V14's gloved hands, removed it and applied it to R4's wound. V4 then picked up the bordered foam dressing package from the towel and opened the package with V4's gloved hands and applied it to R4's wounds all without the benefit of hand hygiene and glove changes after opening packages.R4's Care Plan, dated 6/25/2026, documented, Follow universal precautions.2.On 7/8/2026 10:30 AM, V4, Wound Care Nurse/IP performed hand hygiene and donned gloves. V4 removed R5's blankets and pressure relieving boots. On R5's left heel, there was a dressing dated 7/7/2026, and V4 removed it with the same gloved hands that V4 removed R5's blankets with. V4 then performed hand hygiene, donned a new pair of gloves. V4 then took a medication cup of bleach solution and a gauze pad and cleansed area. Then V4 performed hand hygiene and donned another pair of gloves, opened the box of stock (multiple resident use) medicated honey, took the cap off the container, applied it to the foam boarded dressing and applied it to R5's left heel without benefit of hand hygiene. V4 then performed wound care to R5's right heel. V4, Wound Care Nurse/IP performed hand hygiene and donned gloves, removed the right boot, removed wound dressing that was dated 7/7/2026 without benefit of hand hygiene or glove changes. They performed hand hygiene and donned another pair of gloves, took the tube of stock medicated honey, took the cap off of the container, applied it to the foam boarded dressing and applied it to R5's right heel without the benefit of hand hygiene or glove changes.R5's Care Plan, dated 1/16/2026, documented, Administer treatments as ordered and monitor for effectiveness.3.On 7/8/2026 at 1:30 PM, V4, Wound Nurse/IP, performed hand hygiene and donned gloves, with their gloved hands, they opened the stock medicated honey box, removed tube, and took the cap off of the tube and with the same gloved hands, they took a pair of scissors, off the table, cut the calcium alginate to fit R1's wound, and applied the stock medicated honey to it. With the same gloved hands, they opened the package of non-bordered foam pad and applied all of it to R1's open wound. With the same gloved hands, they opened the package of boarded foam pad and applied it to the wound all without benefit of hand hygiene.R1's Care Plan, dated 6/9/2026, documented, Treatment as ordered.On 7/9/2026 at 2:30 PM, V4, Wound Nurse/Infection Preventionist stated that the medicated honey was a stock medication and it is used for multiple residents on the hallway. V4 stated that they should not use the same gloved hands to open packages and apply medications to the dressings and then use the same gloves to apply the treatment onto a resident.The Facility's policy, Dressing Change- (Clean/Non-Sterile), dated 12/2025, documented, 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. It continues, 13. Apply clean gloves.14. Clean area/wound with solution specified in treatment order. 15. Observe wound for response to treatment and any signs/symptoms of infection. 16. Apply prescribed ointment and/or dressing per doctor order. Follow manufacture's recommendations for application of dressing/ointments/cremes/moisturizers, etc. It continues, 22. Sanitize bandage scissors after each use before returning to pocket or cart.

Based on observation, interview and record review, the facility failed to provide food that was palatable and appetizing for two of three (R2 and R5) residents, reviewed for Dietary Services, in a sample list of 12. Findings include: 1.) On 7/07/2026 at 11:09 AM, R2 stated that the food is terrible, and R2 no longer eats it. R2 stated R2 hasn't eaten it in months. R2 stated that it was always cold when R2 ate it; they prepare the food and let the trays sit there for hours before serving. R2 stated they offer no alternate menu, you get what you get. R2 continued to state that when you ask about ordering a cheeseburger or another alternative staff say they don't do that anymore.R2's Minimum Data Set (MDS), dated [DATE], documented that R2 was cognitively intact. 2.) On 7/7/2026 at 10:12AM, R5 stated that the food is cold all the time, tastes horrible, bland and has no flavor. R5's MDS, dated [DATE], documented that R5's cognition was mildly impaired.The facility's Dining Manager, (Corporate) Menu (Spring/Summer) 26, dated 3/3/2026 documented, Wednesday (Day 18), Lunch: Hamburger Stroganoff, Buttered Peas, Watermelon and Beverage.The Facility's Meal Replacement Options, undated, documented what options there are if one wants a substitute. It also documented, Subject to Availability, these items may be served in place of your meal.Resident Council Meeting minutes, dated 4/8/2026, documented, 9. Cold food and warm milk. Cold food in the dining room.Resident Council Meeting minutes, dated 5/4/2026, documented, 9. Dietary: Cold food.The facility's Concern/Compliment Form, dated 4/15/2026, documented, Still getting cold food, and ice cream being melted. The Concern form continued, Summary of Pertinent findings: Substantiated. The Concern form then documents, Trays may be sitting before being passed on halls. The Concern form then documents, Getting food out of kitchen on hot plates as quickly as possible. Ice creams we are trying to send separately.The facility's Concern/Compliment Form, dated 4/15/2026, documented, Vegetables being cooked to long and are mushy. Fries not being cooked all the way and being floppy. The Concern form continues, Summary of Pertinent Findings: Substantiated. The Concern form then documents, Some vegetables don't hold up well through service. The Concern documents, Trying new products/menu/cooking /holding procedures. The facility's Concern/Compliment Form, dated 5/5/2026 documented, Cold food. The Concern form continues to document, Summary of Pertinent Findings: Substantiated. The Concern form then documents, Hall tray served late. The Concern form continues to document, Corrective Actions Taken. Offered resident to join us in the dining room to ensure hot food and more prompt service.On 7/8/2026 at 11:45 AM, V29, Dietary Manager, stated that they try their best to get the food out to the residents to keep it hot but that they have no control over how soon the (Certified Nurse Assistants) CNA's would pass the hall trays to the residents. V29 stated that V29 has had no complaints about the flavor of the food coming out of the kitchen and the only people who complain about cold food are the residents who eat in their room. V29 stated that most of the residents follow a liberalized diet and that they offer salt, pepper and sugar packets. V29 stated that the menus are on a rotation and are set by the corporation.On 7/8/2026 at 12:16 PM, a test tray with hamburger stroganoff, noodles and peas was tasted and all lacked flavor, was bland in taste and was not appealing on the plate.The Facility's Policy, Food Preparation: Taste-Testing, dated 05/2026, documented, 4. Food items will not be served unless palatable and pleasing to the eye.

Based on interview and record review, the facility failed to prevent a pressure ulcer from developing by failing to implement pressure relieving interventions for one (R2) resident and failed to complete pressure ulcer treatments as ordered for two (R2, R3) residents reviewed for pressure ulcers in the sample list of 14. This failure resulted in R2 developing a Deep Tissue Injury to the Right Heel.Findings include:1) R2's Care Plan (undated) documents R2's diagnosis of History of Ischemic Attack (TIA), Cerebral Infarction, Type 2 Diabetes Mellitus, Difficulty Walking, Communication Deficit, Reduced Mobility and Protein-Calorie Malnutrition. This Care Plan further documents R2's admission date of 3/27/2026.R2's Minimum Data Set (MDS) dated [DATE] documents R2 had moderate cognitive impairment.R2's Care Plan dated 3/27/2026 documents R2 was at risk for a skin impairment related to decrease mobility, post Cerebrovascular Accident (CVA), Left side weakness and incontinence.R2's Care Plan dated 5/4/2026 documents R2 had an actual skin impairment of pressure area: blister on Left Plantar Heel. R2's Weekly Skin Observation dated 5/4/2026 documents R2 had a new skin concern; type of skin concern was blister located to Left Heel, grey in color reddened area around the wound. Treatments include apply skin prep twice a day (BID), apply pressure relieving boots at all times until healed.R2's Weekly Skin Observation dated 5/16/2026 documents R2 had a new skin concern; type of skin concern was blister-open with drainage located to Right Heel-open blister- 4.5 x 4.5 centimeter (cm) with opaque colored drainage. Treatments include cleanse with wound cleanser and applied Antibiotic Ointment (TAO) and foam dressing.On 6/18/2026 at 12:12 p.m., V22 Wound Care Provider confirmed R2's wounds to Left and Right heel were Deep Tissue Injuries (DTIs). V22 stated the order for pressure relieving boots to be applied to both heels was given when V22 saw R2 at the facility on 5/19/2026. V22 stated some interventions such as an air loss mattress could have been put in place given R2's condition. V22 confirmed there was no order for an air loss mattress prior to R2's right heel wound and V22 was going to give an order but R2 was already sent out to the hospital on 5/24/2026.On 6/22/2026 at 7:18 a.m., V28 Certified Nurse Assistant (CNA) stated the only time V28 saw the pressure relieving boots applied to R2's left and right heels was after R2 developed the wounds to both feet. V28 stated the usual interventions to prevent pressure wounds would be turning and repositioning at least every two hours, frequent checks especially if residents were heavily incontinent or had impaired mobility, floating the heels or applying boots to the heels, and good hygiene.On 6/22/2026 at 7:10 a.m., V9 Licensed Practical Nurse stated V9 observed the pressure relieving boots applied to R2's feet only after R2 already developed the wound to the other foot. V9 stated some of the interventions that can be implemented to prevent developing pressure ulcers were applying skin prep to the area, turn and repositioning at least every two hours, good hygiene, close monitoring such as frequent skin checks and an air loss mattress. V9 confirmed V9 did not apply skin prep to the right heel prior to development of the wound. V9 stated there was no other treatment V9 applied to the right heel other than the treatment after R2 developed the new wound to right heel. On 6/22/2026 at 11:19 a.m., V4 Wound Nurse confirmed the wounds to R2's left and right heels were Deep Tissue Injuries (DTIs). V4 confirmed both DTIs were facility acquired pressure wounds. V4 confirmed the wound to the left heel was developed first which was on 5/4/2026 and the right heel developed later on 5/16/2026. V4 stated there was an order to apply a pressure relieving boot to the left heel after the wound was developed but not on the right heel because there was nothing on the right heel to treat. V4 confirmed R2 has impaired mobility related to history of stroke. V4 stated R2 liked to press both R2's heels on the mattress when R2 was in bed or R2 pressed heels on the floor when R2 was up in the wheelchair. V4 stated there should be some preventative measures for residents with impaired mobility to prevent development of pressure ulcers. V4 stated there were no interventions in place for R2's right heel because there was nothing there.On 6/22/2026 at 12:22 p.m., V2 Director of Nursing (DON) stated V2 does not know what the facility did different after R2 developed the pressure wound to the Left Heel to prevent the skin break down to R2's Right Heel. V2 stated V2 would need to check with V4 Wound Nurse.On 6/22/2026 at 2:30 p.m., V30 Licensed Practical Nurse (LPN) stated V30 did not apply any treatment or interventions to R2's right heel other than after the right heel already developed an opened wound.On 6/22/2026 at 2:45 p.m., V32 Regional Nurse Consultant stated there were interventions in place for the wound to the left heel but there were no interventions in place to the right heel prior to the development of the pressure wound because there was nothing on the right heel.The facility's Pressure Ulcer Prevention Policy dated 12/2025 documents several guidelines to prevent and treat pressure sores/pressure injuries. Some of the Guidelines: 5. Turn dependent residents approximately every two hours or as needed and position resident with pillow or pads protecting bony prominence as indicated, 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc.(etcetera) may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 or one or more Stage 3 or Stage 4 wounds. 11. Use positioning devices or pillows, rolled blanket, etc. to reduce pressure and friction/shearing from heels, toes, and malleoli as indicated.2) R2's Care Plan (undated) documents R2's diagnoses including History of Ischemic Attack (TIA), Cerebral Infarction, Type 2 Diabetes Mellitus, Difficulty Walking, Communication Deficit, Reduced Mobility, and Protein-Calorie Malnutrition. This Care Plan further documents R2's admission date of 3/27/2026.R2's Minimum Data Set (MDS) dated [DATE] documents R2 had moderate cognitive impairment.R2's Care Plan dated 3/27/2026 documents R2 was at risk for a skin impairment related to decrease mobility, post Cerebrovascular Accident (CVA), Left side weakness and incontinence.R2's Care Plan dated 5/4/2026 documents R2 had an actual skin impairment of pressure area: blister on Left Plantar Heel.R2's Physician's order dated 5/19/2026 documents an order for treatment to the Left Heel Deep Tissue Injury (DTI): Cleanse with diluted bleach solution, apply medicinal honey to the wound and cover with non-border foam dressing; wrap with rolled gauze and apply pressure boots at all times, every evening shift for wound.R2's Treatment Administration Record (TAR) dated 5/1/2026 - 5/31/2026 documents a physician's order with a start date 5/13/2026 for treatment to Left Heel (plantar) Blister: cleanse with wound cleanser, apply Antibiotic Ointment and cover with a Foam Dressing and place pressure boot at all times, every evening shift and as needed for wound healing.R2's Treatment Administration Record (TAR) dated 5/1/2026 - 5/31/2026 documents a physician's order with a start date 5/08/2026 for treatment to left heel (plantar): cleanse with wound cleanser and cover with Foam Dressing and place pressure boot at all times every evening shift for wound healing.R2's Physician's Order dated 5/19/2026 documents an order for treatment to Right Heel Deep Tissue Injury (DTI): Cleanse with diluted bleach solution, apply medicinal honey to the wound and cover with non-border foam dressing; wrap with rolled gauze and apply pressure boots at all times, every evening shift and AS NEEDED for Wound Management.R2's Treatment Administration Record (TAR) dated 5/1/2026 - 5/31/2026 documents ordered treatments to the Left Heel Deep Tissue Injury (DTI) were not signed off as completed on 5/11/2026, 5/15/2026, 5/17/2026, 5/18/2026 and 5/22/2026.R2's Treatment Administration Record (TAR) dated 5/1/2026 - 5/31/2026 documents treatments to Right Heel Deep Tissue Injury (DTI) was not signed off as completed on 5/22/2026.On 6/22/2026 at 2:30 p.m., V30 Licensed Practical Nurse (LPN) stated V30 came to work on the evening of 5/24/2026 and observed R2 sitting at the lounge area and noticed R2's dressings to both feet were saturated with drainage. V30 stated V30 applied the dressing to both R2's heels when V30 last worked on the evening of 5/23/2026. V30 stated V30 was not sure how often the treatments were supposed to be done but there should be an as needed (PRN) order for the treatments.3) R3's undated Care Plan documents R3's diagnoses including Cerebrovascular Disease, History of Ischemic Attach (TIA), Cerebral Infarction, Weakness, Hemiplegia affecting Right Dominant Side, Type 2 Diabetes Mellitus, Pressure Ulcer to Left Heel and Pressure Ulcer to Right Heel. This Care Plan further documents an admission date of 11/26/2025.R3's Minimum Data Set (MDS) dated [DATE] documents R3 had moderate cognitive impairment.R3's Care Plan dated 1/16/2026 documents R3 had an unstageable pressure ulcer to the Right Heel and stage 4 pressure ulcer on the Left Heel development related to immobility. This Care Plan further documents an intervention to administer treatments as ordered and monitor for effectiveness.R3's Treatment Administration Record (TAR) dated 5/1/2026 - 5/31/2026 documents a physician order with a start date of 3/4/2026 for a treatment to Cleanse left heel with NS (normal saline) apply betadine and leave open to air (OTA) after application-Daily and as needed (PRN) everyday shift for wound care.R3's Treatment Administration Record (TAR) dated 6/1/2026 - 6/30/2026 documents a physician order with start date 6/12/2026 for a treatment to Cleanse DTI (Deep Tissue Injury) to bilateral heels with wound cleanser, apply medicinal honey to DTI's cover with Foam Dressing. Leave pressure boots in place at all times every day and evening shift for wound healing.R3's Treatment Administration Record (TAR) dated 5/1/2026 - 5/31/2026 documents the treatments to the left heel were not signed off as completed on 5/5/2026, 5/19/2026, 5/20/2026, 5/21/2026 and 5/22/2026.R3's Treatment Administration Record (TAR) dated 6/1/2026 - 6/30/2026 documents treatments to the bilateral heels were not signed off as completed on 6/15/2026 and 6/18/2026.On 6/22/2026 at 11:08 a.m., V29 Licensed Practical Nurse (LPN) stated the way to know if the wound treatment was done was by checking on the TAR. V29 stated nurses should follow the treatment order on the TAR and then sign off the orders on the TAR after providing the wound treatment to document the completion of the treatment.On 6/22/2026 at 11:19 a.m., V4 Wound Nurse stated the way to know if the wound treatments were being done was by checking the TAR. V4 stated V4 expects the nurses to follow the orders based on the TAR and nurses should sign off on the TAR after providing treatment.On 6/22/2026 at 12:22 p.m., V2 Director of Nursing stated V2 expects the nurses to follow physician's orders for wound treatments and sign off on the TAR after providing wound care to document the treatment was provided.On 6/22/2026 at 1:00 p.m., V21 Licensed Practical Nurse (LPN) stated treatments should be signed off on the TAR to document that the treatment was administered.Facility's Medication Administration Policy dated 01/2026 documents Medication must be administered in accordance with a physician's order, for example the right resident, right medication, right dose, right route, and right time. This Policy further documents documentation of medication administration is recorded on the Medication Administration Record (MAR) or Treatment Record and includes the date, time, and initials of the licensed nurse or CMA (Certified Medical Assistant) who administered the medication.

Based on interview and record review, the facility failed to develop and implement a focus care plan for one (R2) of three residents reviewed for care plans in a total sample of 14.Findings include:R2's Care Plan (undated) documents R2's diagnosis of History of Ischemic Attack (TIA), Cerebral Infarction, Type 2 Diabetes Mellitus, Difficulty Walking, Communication Deficit, Reduced Mobility and Protein-Calorie Malnutrition. This Care Plan further documents R2's admission date of 3/27/2026.R2's Minimum Data Set (MDS) dated [DATE] documents R2 had moderate cognitive impairment.R2's Care Plan dated 3/27/2026 documents R2 was at risk for a skin impairment related to decrease mobility, post Cerebrovascular Accident (CVA), Left side weakness and incontinence.R2's Weekly Skin Observation dated 5/16/2026 documents R2 had a new skin concern; type of skin concern was blister-open with drainage located to Right Heel-open blister- 4.5 x 4.5 centimeter (cm) with opaque colored drainage. Treatments include cleanse with wound cleanser and applied Triple Antibiotic Ointment (TAO) and foam dressing.R2's Physician's Order dated 5/19/2026 documents an order for treatment to Right Heel Deep Tissue Injury (DTI): Cleanse with Dakins, apply medi honey to wound and cover with non-border foam dressing; wrap with Kerlex and apply pressure boots at all times. every evening shift for Wound Management.On 6/22/2026 at 11:11 a.m., V36 Certified Nursing Assistant (CNA) stated V36 refers to Point of Care (POC) or Kardex for interventions if V36 was not familiar with the resident caring for.On 6/22/2026 at 11:13 a.m., V37 Certified Nurse Assistant (CNA) stated V37 refers to POC if needing to look for interventions such as if the resident needs to wear boots, float heels or if they are heavy incontinent and needing frequent incontinence check. V37 stated V37 also refers to the nurses at times and V37 knows nurses will look at the care plan.On 6/22/2026 V9 Licensed Practical Nurse (LPN) stated V9 would refer to the Care Plan to verify resident's plan of care or if V9 was not familiar with the cares or treatment of the resident V9 was taking care of. V9 stated care plan are expected to be up to date with interventions for the staff to refer to. On 6/22/2026 at 12:22 pm., V2 Director of Nursing (DON) stated after the nurses notify the physician about skin issues, the physician will give some orders, and the nurses will process the orders to be implemented. V2 stated after the orders get processed, the resident's individual care plan should be updated with the new interventions.On 6/22/2026 at 11:19 a.m., V4 Wound Nurse stated if the facility developed an intervention, then the goals and interventions should be entered into the resident's individual Care Plan right away to be updated with the new interventions. V4 stated as a wound nurse, V4 enters the intervention for wounds directly into the resident's individual care plan. V4 confirmed staff may refer to POC or Kardex and care plan for interventions. V4 confirmed there was no care plan developed for R2's wounds to Right Heel after it was developed on 5/16/2026.

Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe ambient temperature for one (R1) of eight residents reviewed for physical environment. Findings:On 6/11/26 at 4:32 p.m., R1 was observed sitting on her bed with a fan directed toward her while receiving oxygen at 3 liters per minute via nasal cannula. R1 stated her room had been really hot earlier and that the heat made it more difficult for her to breathe. R1 reported her breathing improved only after the fans were turned on and stated that heat and humidity had worsened her respiratory symptoms over the past several days.R1's MDS dated [DATE] documents that R1 is cognitively intact. This MDS also documents that R1 has multiple respiratory diagnoses including Cardiorespiratory condition, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Chronic Lung Disease, Chronic Respiratory Failure with Hypoxia, and Respiratory Failure with Hypercapnia.R1's Care Plan dated 4/8/26 documents that R1 has an altered respiratory status/difficulty breathing related to COPD. This Care Plan documents that R1 is on continuous oxygen therapy related to ineffective gas exchange.On 6/11/26 at 2:20 p.m., V6, Housekeeper/Laundry Aide stated the facility has been pretty hot, primarily in the lobby area over the past few days. On 6/11/26 at 2:07 p.m., V5 (Housekeeper) stated it had been hot on the East Hall over the past 3 to 4 weeks. V5 stated she believed the air-conditioning on the East Hall had been broken down recently and was unsure if parts were pending repair or replacement. V5 stated, can't you feel the difference between the resident rooms and the hallway? She further stated residents had complained, particularly those with breathing difficulties, but was unable to identify specific residents who had voiced concerns regarding room temperatures.On 6/11/26, between 3:41 p.m. and 4:59 p.m., continuous observations were conducted with V3 (Maintenance Director), during which environmental temperature and humidity readings were obtained throughout resident care areas. Temperatures ranged from 75.7 F to 79.9 F, with the highest humidity reading of 65.8% recorded in Zone 7. Temperature and humidity readings were obtained in multiple resident rooms on all hallways and at both ends of the East and [NAME] Halls.On 6/11/26 at 2:25 p.m., V8 (CNA) stated the facility had been really warm, particularly in the television room, over the past several weeks. V8 stated that both residents and staff had complained about the heat in the building. Although V8 could not identify specific residents who had complained, she stated she had heard several complaints regarding the building temperature over the past couple of weeks.On 6/11/26 at 5:22 p.m., V9, Registered Nurse (RN) stated she had heard numerous resident complaints over the past several weeks regarding the temperature in the facility. V9 stated residents had specifically complained that the lounge area was hot and uncomfortable.On 6/11/26 at 6:24 p.m., V10, Licensed Practical Nurse (LPN) that several residents throughout the facility had complained of being hot over the past two to three weeks. V10 further stated that during the most recent weekend, both staff and residents complained that the facility was extremely hot and stated she thought it felt like it was 100 degrees.On 6/11/26 at 3:31 p.m., V3 (Maintenance Director) stated he had been monitoring temperatures throughout the facility daily, including weekends. V3 reported the highest temperature reading he observed was 83 F in a resident room the previous week (exact date unknown). V3 stated a portable air conditioning unit was immediately placed in the room, which resolved the issue. V3 further stated that rising outdoor temperatures over the past several weeks had resulted in noticeably warmer temperatures inside the facility. According to V3, the facility's HVAC contractor identified issues with the air conditioning system on 6/10/26, including a non-functioning condenser. V3 stated he was awaiting a repair quote and that additional repairs were needed to motor, fans, and compressors associated with the cooling system. V3 stated he anticipated the facility's air conditioning system would be fully operational within approximately two weeks.On 6/11/26 at 4:37 p.m., V1, Administrator stated the facility had been warmer than normal over the past several weeks and that the HVAC contractor had evaluated the air conditioning system on 6/10/26. V1 stated she was informed that significant repairs were needed and that corporate approval would be required due to the cost of the repairs. V1 further stated that corporate policy required quotes from at least two HVAC companies before repairs could proceed. V1 confirmed the facility was still awaiting the first repair quote and that a second HVAC assessment would need to be scheduled before repairs could be authorized and completed.

Based on interview and record review the facility failed to ensure residents were free from physical abuse for two (R3 and R4) of three residents reviewed for abuse in a total sample of 17 residents.Findings include:R4's Care Plan printed on 5/14/2026 documents an admission date of 01/16/2024. The Care Plan Documents R4 with the following diagnoses Anxiety, Dementia with Mood Disturbances, Hypothyroidism, Gastro-Esophageal Reflux Disease, Hypertension, Supraventricular Tachycardia, Vitamin D Deficiency, Alzheimer's Disease with Late Onset, and Major Depressive Disorder. The Care Plan further documents R4 wanders the unit aimlessly and may attempt to exit seek or pace the unit. R4's Care Plan dated 1/21/2025 documents potential for aggressive behavior related to Dementia. R4 may become combative with cares and attempt to kick, hit, push, grab, or bite others with interventions to observe R4's location and change in aggression level. Provide diversion when in common areas.R4's Care Plan dated 3/5/2026 documents R4 has potential to be physically aggressive due to Dementia; R4 may hit, kick, push or scratch others.R4's Care plan dated 12/20/2025 documents a focus on R4's wandering behavior with interventions to distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book.R4's Minimum Data Set (MDS) dated [DATE] documents R4 has severe cognitive impairment.R4's Incident Note dated 4/5/2026 documents Employee reported an alleged physical altercation between two residents. Residents immediately separated. POA's, MD, police and ombudsmen notified of alleged physical altercation.On 5/14/2026 at 12:25 p.m., R4 was up in Broda chair in the common area. R4 attempted to interview but was not able to comprehend the questions.R3's Care Plan printed on 5/14/2026 documents an admission date of 08/23/2024. The Care Plan documents R3's diagnoses as Hypo-Osmolality and Hyponatremia, Metabolic Encephalopathy, Polydipsia, Atrioventricular Block, Depression, History of [NAME] Thrombosis and Embolism, Blood and Blood-Forming Organs Disorders Involving the Immune Mechanism, Mild Cognitive Impairment, Sarcoidosis of Lung, Parkinson's Disease, Dementia, Psychotic Disturbances, Mood Disturbances, Anxiety, Sleep Apnea, Neurocognitive Disorder with Lewy Bodies, Parkinsonism.R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact.R3's Incident Note dated 4/5/2026 documents Employee reported an alleged physical altercation between two residents. Residents immediately separated. POA's, MD, police and ombudsmen notified of alleged physical altercation.On 5/14/2026 at 9:58 a.m., R3 was sitting in R3's chair in R3's room. R3 stated R4 wandered in R3's room one day and R4 grabbed the TV remote, R3 took the remote back from R4 and R4 hit R3 in the face. R3 stated that R3 hit R4 back to R4's face.On 5/14/2026 at 11:54 a.m., V4 Licensed Practical Nurse (LPN) stated V4 was on duty on 4/5/2026 and responded to R3's room after V4 heard R3 yelled. V4 stated R4 informed V4 that R4 wandered to R3's room and took R3's television (TV) remote control. R3 stated R3 took the TV remote back from R4, and R4 hit R3 to R3's face. R3 stated that R3 hit R4 back.On 5/14/2026 at 11:59 a.m., V5 Certified Nurse Assistant (CNA) stated V5 was on duty on 4/5/2026. V5 stated V5 heard R3 yelling get out of my room, don't hit me in the face again! V5 stated when V5 went to check on R3, R4 was coming out from R3's room. V5 stated R3 told V5 that R4 hit R3 in R3's face. V5 stated R4 was self-ambulatory at the time of the incident and R4 is known to wander around the unit.On 5/14/2026 at 12:17 p.m., V1 Administrator stated during V1's investigation, R3 told V1 that R4 wandered to R3's room and grabbed R3's remote. R3 took the remote back and R4 hit R3. R3 told V1 that R3 hit R4 back. V1 stated R3 and R4 hitting each other was a form of abuse and should have been prevented.Facility's Abuse Prevention and Reporting dated March 2026 documents This facility affirms the right of residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility 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 good and services by staff and mistreatment of residents. This will be done by:Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment.Identifying occurrences and patterns of potential mistreatment.

Based on observation, interview and record review, the facility failed to transfer residents according to the care plan and facility policy for four of six residents (R2, R4, R7 and R8), reviewed for accidents, in a sample of 15. Findings include:1.R2's Physician Order Sheets, dated 3/2026, document diagnoses of Type 2 Diabetes Mellitus and Congestive Heart Failure. R2's Minimum Data Set (MDS), dated [DATE], documents R2's cognition is severely impaired and R2 requires partial to moderate assistance for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).R2's Care Plan, dated 7/24/2025, documents, TRANSFER: The resident requires walker and gait belt and (#1) assist to transfer between surfaces.On 3/24/2026 at 2:12 PM, V5, Certified Nurse Assistant (CNA), transferred R2 from his wheelchair to his bed without using a gait belt by pulling up under R2's arm and by pulling up on R2's waistband on his pants. 2.R4's Physician's Order Sheet, dated 3/2026, documents a diagnosis of Parkinson's Disease without Dyskinesia.R4's MDS, dated [DATE], document R4's cognition is severely impaired and R4 requires substantial to maximum assistance for toilet transfer: The ability to get on and off a toilet or commode.R4's Care Plan, dated 7/30/2025, documents, TRANSFER: The resident requires gait belt and walker or sit to stand and (#1) assist to transfer between surfaces.On 3/24/2026 at 11:15 AM, V4, CNA, transferred R4 to the toilet without using a gait belt or a walker. Upon transferring R4 back to her wheelchair from the toilet, V4 did not use a gait belt or a walker and V4 used V4's right hand to guide R4's right hip and V4's left hand to pull the wheelchair up behind R4 for R4 to sit in.3. R7's Physician's Order Sheet, dated 3/2026, documents diagnoses of Dementia and Cerebral Infarction.R7's MDS, dated [DATE], documents R7 has severe cognitive impairment and R7 requires partial to moderate assistance for chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair) and substantial to maximum assistance for toilet transfer: the ability to get on and off a toilet or commode.R7's Care Plan, dated 11/17/2025, documents, TRANSFER: The resident requires gait belt, sit to stand, and (#1) assist to transfer between surfaces.On 3/24/2026 at 1:10 PM, V5, CNA, without use of a gait belt, lifted up underneath R7's bilateral axillae to lift her off of the bed and into her high back wheelchair. V5 then took R7 into her bathroom, had R7 grab the handrail while V5 lifted underneath R7's right arm to help her transfer from her high back wheelchair onto the toilet. Once R7 was done using the toilet, V5 did not apply a gait belt, had R7 grab the handrail with her left hand and V5, lifted up under R7's right axilla and assisted R7 to stand and sit in her high back wheelchair. V5 then took R7 over to her bed, did not lock R7's wheelchair, and did not place a gait belt on R7. R7 grabbed the assist rail on her bed, with her right hand, and V5 grabbed underneath R7's left axilla and started to assist her with standing up and R7's high back wheelchair rolled away causing R7 to sit on the very edge of her bed almost falling to the ground. After several attempts, V5 was able to place R7's legs and feet on her bed. 4. R8's Physician Order Sheet, dated 3/2026, documents a diagnosis of Alzheimer's Disease.R8's MDS, dated [DATE], documents R8 has severe cognitive impairment and R8 requires substantial to maximal assistance with toilet transfer: the ability to get on and off a toilet or commode.R8's Care Plan, dated 7/1/2024, documents, TRANSFER: The resident requires gait belt and w(with)/walker and (1) assist to transfer between surfaces.On 3/24/2026 at 1:30 PM, V6, CNA, transferred R8 from the wheelchair to the toilet without the use of a gait belt and using her pants to pull her up. Once R8 was finished using the toilet, V6 did not place a gait belt on R8, and she pulled up under R8's arm to assist R8 with standing and pulled up R8's pants. She then held onto R8's pants with one hand and pulled R8's wheelchair over and underneath her.On 3/24/2026 at 2:15 pm, V5, CNA, stated, facility staff normally use a gait belt, and gait belts are kept in rooms or supply closets.On 3/30/2026 at 10:45 AM, V10, CNA, stated that gait belts are used for transferring residents in and out of their wheelchairs.On 3/30/2026 at 10:46 AM, V11, CNA, stated that gait belts are used for transferring residents.On 3/30/2026 at 10:46 AM, V12, CNA, stated that gait belts are used for transferring residents.The facility's policy, Transfers- Manual Gait Belt and Mechanical Lifts, dated 12/2025, documents, Use of gait belt for all physical assist transfers is mandatory.

Based upon observation, interview, and record review, the facility failed to protect residents from abuse for seven (R3, R4, R5, R6, R9, R12, and R14) of eleven residents reviewed on a sample list of 17 residents.R3's undated Care Plan documents R3's diagnosis of Hyperlipidemia, Major Depressive Disorder, Alzheimer's Disease with Early Onset, Unspecified Glaucoma, Essential (Primary) Hypertension, Unspecified Protein-Calorie Malnutrition, Anxiety Disorder, and Dementia in Other Diseases Classified Elsewhere, Mild, With Other Behavioral Disturbance. Care Plan also documents R3 at high risk for abuse. R4's undated Care Plan documents R4's diagnosis as Age-Related Osteoporosis without Current Pathological Fracture, Alzheimer's Disease with Late Onset, Hyperlipidemia, Localized Edema(R60.0), Chronic Kidney Disease, Displaced Fracture of Second Cervical Vertebra, Fracture of Nasal Bones, Major Depressive Disorder, Essential (Primary) Hypertension, Unspecified Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Chronic Kidney Disease, Stage 3a, and Unspecified Protein-Calorie Malnutrition.R5's undated Care Plan documents an admission date of 12/05/2024 with the following diagnosis: Non-St Elevation Myocardial Infarction, Encounter for Palliative Care, Weakness, Acute on Chronic Systolic (Congestive) Heart Failure, and Hyperlipidemia. R6's undated Care Plan documents R6 is cognitively intact and has increased risk for abuse. R9's undated Care Plan documents R9 is at moderate risk for abuse due to a Dementia diagnosis and R9 is moderately cognitively impaired.R12's undated Care Plan documents R12 has impaired cognitive function, is at a high risk for abuse, trauma informed care, and impaired visual function.R14's undated Care Plan documents R14 can be physically and verbally aggressive. Facility Abuse Prevention and Reporting Policy dated 11/2016 documents physical abuse as the infliction of injury that occurs other than by accidental means, verbal abuse as the use of oral, written, or gestured communication or sounds to residents within hearing distance regardless of age, ability to comprehend or disability such as yelling or hovering over residents, deprivation or threatening of deprivation of goods, harassing, mocking, insulting, or ridiculing. Documents exploitation as taking advantage of a resident for personal gain through use of manipulation, intimidation, threats or coercion, and neglect as the failure to provide goods and services necessary to avoid physical harm, pain, or mental anguish.Facility File dated 1/9/26 documents R3 threw water on R14 and R14 hit R3 on R3's arm.Facility File dated 12/8/25 documents V4 Assistant Dietary Manager was slamming doors on R6 and R9 stating I'm the boss! This file documents on 12/15/25 V4 was terminated for disorderly behavior and misconduct after the allegation was substantiated.Facility file dated 12/11/25 documents R3 burst into bathroom while V15 Certified Nursing Assistant (CNA) was providing care for R4. R3 smacked R4 on buttock two times.Facility file dated 12/7/25 documents R6 stated to R5 to stop calling R6 names or R5 would get R6. R6 proceeded to kick R5 in the shin.Facility file dated 12/11/25 documents V5 CNA received a verbal warning on 12/15/25 for cutting R12's hair without permission and that V5 must obtain consent next time prior to cutting a resident's hair. V5 was in-serviced on resident grooming. V5 is not a licensed cosmetologist or barber. This file documents that V14, R12's guardian, gave consent to cut R12's hair.On 1/22/26 at 10:15AM, R12 was sitting in a recliner in the common room watching television. R12 was well groomed. No visible signs of bruising noted. R12 stated they cut my hair, and I didn't want them to, they did a bad job.On 1/22/26 at 10:30AM, V30 Licensed Practical Nurse (LPN) stated the facility has a cosmetologist that comes every Wednesday. V30 stated that V30 was instructed by V2 Regional Director to call all Power of Attorneys (POAs) and obtain consent for haircuts by staff as needed. V30 LPN stated V30 then called all POA's and documented it in residents' charts. R12's Progress Notes dated 12/11/25 at 3:47 PM documents V14, R12's guardian, gave consent for haircut written by V30 LPN.On 1/22/26 at 10:43 AM, V13 CNA stated that V5 CNA and herself gave R12 a shower and after the shower they were combing through R12's hair when knots were found in R12's hair. At that time V5 CNA cut the bottom of R12's hair to remove the knots. V13 denied holding R12 down to cut R12's hair.Attempts to contact V5 were unsuccessful.On 1/22/26 at 11:00AM, V14, R12's guardian, stated that V14 was notified of the incident on 12/11/25. V14 did not give consent prior to the incident. V14 stated she was told by V17 LPN that V17 was a former beautician, and V17 cuts other residents' hair. V14 was unaware that V5 CNA was person who cut R12's hair. V14 stated V14 was never told of the option of a licensed cosmetologist coming to the facility. V14 stated that if R12 was traumatized, R12 would absolutely remember the incident and could give an accurate description of the incident. V14 also stated V14 was not notified of R12's bruises when they found. V17 LPN's professional license documents no cosmetology or barber license within the State of Illinois.R12's admission Contract dated 1/3/25 documents R12 has the right to refuse services unless court ordered.R12's undated Care Plan documents impaired cognitive function, high risk for abuse, trauma informed care, and impaired visual function.R12's Skin Sheet dated 12/11/25 documents new bruise to back of left hand.R12's Skin Sheet dated 12/7/25 documents bruising to bilateral hands.

Based upon observation, interview, and record review the facility failed to care for a resident in a manner that promotes maintenance or enhancement of his or her quality of life for one (R5) of three residents reviewed for quality of care out of a sample list of 17 residents.Findings:R5's undated Care Plan documents an admission date of 12/05/2024 with the following diagnosis: Non-St Elevation Myocardial Infarction, Encounter for Palliative Care, Weakness, Acute on Chronic Systolic (Congestive) Heart Failure, and Hyperlipidemia. This Care Plan also documents R5 requires assistance from one staff member for dressing.R5's Minimal Data Set (MDS) dated [DATE] documents R5 with a Brief Assessment of Mental Status (BIMS) score of eight indicating moderate cognitive impairment. R5's admission Packet dated 12/05/2/025 documents:1. The right to live in an environment that promotes and supports each resident's dignity,individuality, independence, self-determination, privacy, and choice and to be treated withconsideration and respect.2. The right to respect for bodily privacy and dignity at all times, especially during care andTreatment.On 1/20/2026 at 1:06 PM, R5 observed lying in R5's bed with only an ill-fitting adult brief, one flat sheet available for resident to cover self, and R5 was visible from open entry doorway leading into R5's room.On 1/20/2026 at 1:06 PM, R5 stated R5 has been waiting to get pants put on since 7:00 AM.On 1/20/2026 at 2:54 PM, R5 was lying in bed with a sheet half covering body. Door to R5's room open. R5 was dressed in an adult brief only. No clothing on.On 1/21/2026 at 2:15 PM, R5 stated the staff do not like me because I can be an a****** (expletive). I experience long wait times for help with getting dressed a couple of times a week.On 1/22/2026 at 1:45 PM, V3 Director of Nursing (DON) stated that a resident request for care should not exceed a wait time of more than one hour and dignity should always be considered.Facility Policy Resident Rights dated 08/2017 documents the facility must provide services to keep resident's physical and mental health, at their highest practical levels.

Based upon interview and record review, the facility failed to prevent a resident from misappropriation by staff for one (R13) of three residents reviewed on a sample list of 17 residents.Facility file dated 12/11/25 documents V6 Certified Nursing Assistant (CNA), transported R13 to R13's home which was 30 miles away from the facility to get clothing for R13. R13 gave $50.00 to V6 for compensation. V6 informed the nurse after returning to the facility. V6 was terminated for exploitation of a resident. V6 placed R13 in V6's personal car. V6 had no training from the facility related to transportation of a resident. R13 did not have permission to leave the facility. R13's Progress Notes do not document R13 out of facility at any time.R13's Minimum Data Set (MDS) section C dated 12/3/25 documents R13 has no cognitive impairments.R13's MDS section GG dated 12/2/25 documents R13 ambulates with a wheelchair and requires maximum assist from staff for transfers.R13's undated Care Plan documents R13 has hemiplegia related to a stroke and is at increased risk for falls.R13's Physician Order Sheet (POS) documents no order to leave the facility.On 2/2/26, R13 stated that on 12/11/25 V6 took R13 home to get clothes. V6 was off duty and R13 had told staff several times R13 was planning to go home. R13 stated R13 was gone from facility from 7:30AM to 11:30AM. Facility Abuse Prevention and Reporting Policy dated 11/2016 documents physical abuse as the infliction of injury that occurs other than by accidental means, verbal abuse as the use of oral, written, or gestured communication or sounds to residents within hearing distance regardless of age, ability to comprehend or disability such as yelling or hovering over residents, deprivation or threatening of deprivation of goods, harassing, mocking, insulting, or ridiculing. Documents exploitation as taking advantage of a resident for personal gain through use of manipulation, intimidation, threats or coercion, and neglect as the failure to provide goods and services necessary to avoid physical harm, pain, or mental anguish. Facility Transportation for Residents Policy dated 11/2012 documents all personnel must be trained prior to transporting residents. Facility Incidents and Accidents Policy dated 4/2019 documents a report will be completed for residents leaving the premises without authorization, and documentation in nurse's notes is to include a description of the event and 72-hour documentation must be completed.

Based upon interview and record review the facility failed to develop and implement a baseline care plan for one (R1) of three residents reviewed for quality of care out of a sample list of 17 residents.R1's care plan documents an admission date to the facility as 12/24/2025 with the following diagnosis: Wedge Compression Fracture of Fourth Thoracic Vertebra, Subsequent Encounter for Fracture with Routine Healing (S22.040d), and Unspecified Fracture of Fourth Thoracic Vertebra.R1's care plan documents a focus assessment was initiated on 12/24/2025 regarding R1 having an Activity of Daily Living (ADL) deficit with no goals nor interventions documented.On 02/03/2025 at 10:30 AM, V10 Minimal Data Set (MDS)/Care Plan Coordinator stated R1's care plan did not document goals nor interventions for the multiple focus areas withing R1's care plan. V10 stated care plans are considered comprehensive given there are appropriate goals and interventions in place.The facility's Comprehensive care plan policy dated 11/2012 documents: the interdisciplinary team should attempt to schedule an initial meeting with the resident and/or resident representative within five days of admission to review the baseline plan of care.

Based upon interview and record review, the facility failed to assess and control a resident's pain for one (R2) of three residents reviewed on a sample list of 17 residents.R2's face sheet dated 1/15/26 documents R2 was admitted to the facility on [DATE] and expired 12/29/25. R2's undated Care Plan documents R2's medical diagnosis to include Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance, Unspecified Convulsions, Atrioventricular Block, First Degree, Essential (Primary) Hypertension(I10), Peripheral Vascular Disease, Unspecified, Spinal Stenosis, Lumbosacral Region, Unspecified Osteoarthritis, Unspecified Site, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia, Unspecified, Restless Legs Syndrome, Polyneuropathy, Unspecified, Unspecified Protein-Calorie Malnutrition, Acidosis, Unspecified, Edema, Unspecified, Gastro-Esophageal Reflux Disease without Esophagitis, Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Aftercare Following Joint Replacement Surgery, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Other Specified Disorders of Muscle, Dysphagia, Oral Phase, Other Abnormalities of Gait And Mobility, Other Lack of Coordination, Urinary Tract Infection.R2's undated Care Plan documents dementia, moderate risk for abuse, Activities of Daily Living (ADL's) self-care deficit, incontinent of bladder, elopement risk with wander guard present, behavior issues of agitation, anxiety, restlessness, aggression (verbal and physical), and resistant to care, unspecified convulsions and restless leg syndrome, antipsychotic and Parkinson medications, hip fracture, and seizure disorder.Facility investigation file dated 12/27/25 documents R17 stated R17 could hear R2 yelling in pain but no one listens to her. V20 Certified Nursing Assistant (CNA), stated on 12/25/25 R2 was in a lot of pain. V21 CNA stated that on 12/25/25 R2 had bruising on R2's left chest and was in a lot of pain and V21 reported this to V23 Licensed Practical Nurse (LPN). V22 LPN stated on 12/25/25 noted bruising to left chest but was unaware V22 had to report that to anyone. V23 LPN, stated on 12/25/25 at 6:00PM, V21 CNA reported R2 had bruising and was in a lot of pain, V23 stated V23 did not assess the bruises, gave pain medication, and did not notify anyone. V24 CNA, stated on 12/25/25, R2 was hollering in pain. V25 LPN stated that on 12/22 and 12/23/25, R2 was spitting out food, stopped feeding himself, had a low-grade temperature, left leg contracture, and had increase in pain. V25 did not notify anyone of changes. On 12/27/25 V26 CNA reported R2's bruises to V27 LPN. V27 LPN reported to the Abuse Coordinator, and V3 Director of Nursing as well as the physician and V27 obtained orders for an Xray and hospice care.R2's December Medication Administration Record (MAR) documents R2 started receiving pain medication regularly on 12/22/25. No Physician notification was documented. This MAR also documents R2's rate of pain as follows: On 12/24/25 at 1:34AM R2 rated pain at six out of ten with 10 being the highest level of pain. On 12/24/25 at 12:21PM rated pain at eight out of ten, on 12/24/25 at 8:30PM rated pain at eight out of ten, on 12/25/25 at 1:17 AM eight out of ten, on 12/25/25 at 8:38 AM seven out of ten, on 12/25/25 at 7:32 PM six out of ten, on 12/26/25 at 10:39 AM eight out of ten, on 12/26/25 at 12:09 PM eight out of ten, on 12/26/25 at 4:17 PM five out of ten, on 12/27/25 at 10:28 AM eight out of ten, on 12/27/25 at 11:59 AM nine out of ten, on 12/28/25 at 8:14 AM six out of ten, and on 12/28/25 at 2:39 PM nine out of ten.R2's Progress Notes do not document physician notification of R2's increased pain prior to 12/27/25.On 1/22/26 at 1:45PM, V3 Director of Nursing (DON), stated the medical doctor should be notified of a change in pain, and waiting five days for notification is a delay in care. V3 stated that the bruising was first noticed on 12/22/25 for R2 however no notification was made until 12/27/25. V3 stated that R2 had a fall on 12/7/25 and could have caused the bruising to R2's chest. V3 stated that Interdisciplinary Team (IDT) discussed R2's fall, however, the fall was not considered when the bruising was noticed.Facility Pain Management Program policy dated 11/2012 documents the facility is to notify the Medical Doctor of a change in condition. Also documents nursing to assess and reassess pain control measures for effectiveness.

Based upon interview and record review, the facility failed to protect one resident (R3) of four residents reviewed for physical abuse in a sample list of six residents. R2's Progress Note dated 9/6/25 documents a Psychosocial assessment was reviewed for R2. The assessment completed related to Physical Altercation - Resident to Resident. Behavioral diagnosis include: Unspecified Dementia, Moderate, Without Behavioral Disturbance; Psychotic Disturbance, Mood Disturbance, And Anxiety; Dysphagia, Oral Phase; Alzheimer's Disease With Early Onset, Dementia In Other Diseases Classified Elsewhere, Moderate, With Agitation; Unspecified Fracture Of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing; Fracture Of Unspecified Part Of Neck Of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing; Lumbago With Sciatica, Right Side, and Benign Prostatic Hyperplasia With Lower Urinary Tract Symptoms.R2's undated Care Plan documents R2 has aggressive behaviors related to dementia, resistive to care; physical aggression related to dementia; impaired cognitive function, at risk for falls, and moderate risk for abuse.R2's Progress Note dated 9/4/25 documents R2 is agitated and aggressive at this time. R2 is constantly getting up and down from wheelchair, R2 is cussing at staff and swinging at staff. Yelling at staff to stop bothering him and leave him alone. R2 is being rude and shouting in the lounge.R2's Progress Note dated 9/4/25 documents V3 reported a physical altercation. MD, POA, ombudsman, and local police department notified of the allegation. Investigation initiated.Police Report dated 9/4/25 documents Facility reported physical altercation between R2 and R3. R3's Social Service Progress note dated 9/6/25 documents R3's Psychosocial Assessment completed related to Physical Altercation - Resident to Resident. Behavioral diagnosis includes: Type 2 Diabetes Mellitus With Diabetic Polyneuropathy, Pan Lobular Emphysema, Major Depressive Disorder, Single Episode, Unspecified, Polyneuropathy, Dementia In Other Diseases Classified Elsewhere, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Other Disorders Of Phosphorus Metabolism, Restless Legs Syndrome, Obstructive Sleep Apnea, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety.R3's undated care plan documents R3 is at risk for abuse related to cognition, has Impaired Cognitive Function with Hallucinations, Aggressive Behavior including throwing liquids, and Behavioral issues related to Dementia.R3's progress note dated 9/4/25 documents V3 LPN reported a physical altercation. MD, POA, ombudsman, and local police department notified of the allegation. Investigation initiated.On 11/18/25 at 10:45AM, V1 and V2 provided behavior tracking with personalized interventions for R2. Documents R2's behaviors and interventions that were utilized and response to interventions. R2's interventions match Care Plan interventions and show staff knowledge of appropriate interventions to match R2's behaviors. Behavior tracking does not document R2 was removed from area causing agitation.Observations were conducted on 11/17/25 and 11/18/25 between the hours of 8:30 AM and 4:00 PM.On 11/17/25 at 9:35AM, R2 sitting in wheelchair in unit lounge. Old brown crescent shaped bruise approximately 1 inch by 1/4 inch noted to right upper cheek bone directly under glasses frame. No other visible abnormalities noted. R2's room noted to have fall mat on floor next to low bed. Call light within reach. Toilet riser noted and stable. Floor free of debris and obstacles to bathroom and to door entrance.On 11/17/25 at 9:55AM, R3 was in R3s room walking independently. R3s room was cluttered, but R3 stated this is how R3 keeps her things.General observations during survey include: R2 was observed multiple times in common areas and interactions with others including staff and residents.Interviews include V1 Administrator, V2 Director of Nursing (DON), V3 Licensed Practical Nurse (LPN), V7 LPN, V8 R2 Family Member, V11 Admin in Training (AIT), R2, R3, and R5.At 9:40AM on 11/17/25, R2 stated that everyone treats him well at the facility. R2 has no issues with any staff nor residents. R2 stated he has not had any altercations with any residents nor arguments.On 11/17/25 at 9:45AM, V3 Licensed Practical Nurse (LPN) stated that on 9/4/25, V3 heard R3's elevated voice in the lounge area while V3 was passing medications down the hall. V3 heard R3 state R3 was going to throw R3s hot chocolate on R2 and R2 responded you better not. At that point, V3 stated V3 witnessed R3 throw the liquid from R3s cup toward R2 and R2 placed both hands, in a choking motion and made contact with R3's neck, V3 stated they were immediately separated, R3 was moved to another wing in the facility. On 11/17/25 at 9:55AM, R3 stated R3 had an incident with another resident on the stairs by the kitchen. R3 stated resident is a hot head and you never know when he's going to blow his top. R3 stated the other resident (R2) was trying to come into R3s room and R3 told him that it was a girls room and that if he didn't back up, she'd throw the pot of water on him. R3 stated the other resident advanced on the stairs and she threw the water at him, and it startled him. R3 stated that other resident was in his wheelchair on the stairs. R3 stated no one hurt her and was very clear she had no injury and there was no intent to harm. On 11/18/25 at 9:45 AM, V7 LPN stated that R2's behaviors have been ongoing since admission. R2 usually starts with exit seeking and gets more and more agitated when R2 can't find a way out. R2's behaviors are predictable in how they present but not what triggers the behaviors. R2 usually has an increase in behaviors the evening and overnight.On 11/18/25 at 10:45AM, V1 stated R2 needs to be in a specialized Alzheimer's unit but there is not one available to him on his VA benefits as a wheelchair bound patient.

Based on interview, and record review, the facility failed to implement and revise a comprehensive care plan to address falls for two (R1, R3) of three residents reviewed for falls in a sample list of four.Findings Include:Fall Policy dated 10/2024 documents the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy documents the care plan addresses each fall, Interventions are changed with each fall, as appropriate.1.On 09/19/25, R1's record review of undated care plan documents an admission date of 08/15/25 with diagnosis Fracture of Left Calcaneus, Type 1 Diabetes Mellitus with Other Skin Ulcer, Fracture of Shaft of Right Tibia, Closed Fracture with Nonunion, and Muscle Wasting and Atrophy. The same care plan documents: R1 is at risk for falls related to the fracture to right shoulder Date Initiated: 08/16/2025 Revision on: 08/18/2025. R1 will have decreased risk of falls by next review date. Date Initiated: 08/16/2025 Revision on: 09/10/2025 Target Date: 11/27/2025. Anticipate and meet the resident's needs. Date Initiated: 08/18/2025. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 08/18/2025. Environmental rounds to ensure the resident is in the middle of bed to help prevent accidental exits from bed. Date Initiated: 08/17/2025. Sent to Emergency Department (ED) Date Initiated: 08/15/2025.On 09/19/25, R1's record review of Minimum Data Set (MDS) completed on 09/15/25 documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R1 is cognitively intact. The same MDS documents R1 is dependent on a total body mechanical lift for transfers.On 09/19/25, R1's record review of progress note dated 9/12/2025 at 6:35am V9 Nurse, documented R1 sustained a fall on 09/12/2025 at 5:15AM. Documents the incident occurred outside on the driveway and R1, who is alert and oriented to time, person, place and situation, attempted to pull straps of the total body mechanical lift sling out from her front right wheel and slipped off the wheelchair.On 09/19/25, R1's record review of progress note dated 9/12/2025 at 09:59am, V3 Director of Nursing, documents the Interdisciplinary Team (IDT) met to discuss the fall. R1 was outside waiting for the van to take R1 to dialysis and she called the west desk at approximately 05:15AM and asked this writer for help removing the straps of lift sling from R1's wheels of R1's power wheelchair. The same progress note documents the root cause: resident slipped out of the chair pulling the lift sling out from under her. Intervention: educate resident regarding asking for assistance with Sling placement. This intervention was not documented as completed.On 09/19/25, R1's record review of Comprehensive Incident Fall assessment dated [DATE] at 06:13AM completed by V9 documents under section C number four (4) list new intervention initiated immediately to prevent further falls documents to tuck straps to sling under resident. This intervention was not transcribed to the care plan.On 09/21/25 at 11:30AM, V1 Administrator, confirmed R1's care plan had not been revised/updated with new intervention.2. On 09/19/25, R3's record review of undated care plan documents an admission date of 10/06/2023 with diagnosis Vascular Dementia, Unspecified Severity, with Other Behavioral Disturbance, Presence of Other Specified Functional Implants, REM Sleep Behavior Disorder, Visual Hallucinations, Dementia, Unspecified Severity, with Agitation, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, History of Falling, Acute Kidney Failure, and Major Depressive Disorder. The same care plan documents: R3 is at risk for fall related to weakness and needs assist with mobility. History of falls. Date Initiated: 10/09/2023 Revision on: 01/10/2025. R3 will reduce his risk of injuries from falls by the next review date. Date Initiated: 10/07/2023 Revision on: 07/31/2025 Target Date: 11/27/2025. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 10/09/2023. Encourage resident to be in common area during mealtimes Date Initiated: 05/15/2024. Encourage resident to lay down when visibly tired Date Initiated: 03/24/2025. Ensure all supplies are within reach when providing cares Date Initiated: 02/14/2025. Environmental rounding to ensure resident is positioned in the middle of the bed. Date Initiated: 03/11/2025. R3 has stated verbally R3 prefers to sit/lay on the floor directly, and at times will move himself to the floor. Date Initiated: 05/21/2024 Revision on: 05/21/2024. Offer alternate seating when patient is visibly tired or restless Date Initiated: 09/04/2025. Offer resident fluids and snack after early a.m. get up Date Initiated: 06/24/2024. Offer to adjust positioning of chair when resident visibly tired as he allows Date Initiated: 01/10/2025. Place floor mat on the floor next to bed. Date Initiated: 10/13/2023 Revision on: 10/24/2023 Place snacks in easily accessible area Date Initiated: 03/31/2025On 09/19/25, R3's record review of Minimum Data Set completed on 9/2/25 documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates R3 is cognitively intact.On 09/19/25, R3's record review of progress note dated 9/6/2025 at 06:14am documents V9 was on hall three middle way and turned to push the medication cart and observed R3 crawling in the hallway to the common area fully clothed with one slipper sock on.On 09/19/25, R3's record review documents a progress note entered by V3 Director of Nursing, dated 9/8/2025 at 10:09am stating that the Interdisciplinary Team (IDT) met to discuss the fall. Root cause: resident purposefully placed self on floor to crawl. Intervention: resident care planned to crawl on floor. when desired.On 09/21/25 at 11:30am, V1 Administrator, confirmed R3's care plan had not been revised/updated with new intervention.

Based on interview and record review the facility failed to initiate resident centered interventions to prevent falls for one resident (R1) of three residents reviewed for falls in a sample list of four residents. This failure resulted in R1 falling from the wheelchair.Findings Include:Fall Policy dated 10/2024 documents that the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy documents the Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. The same policy also documents Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan.On 09/19/25, R1's record review of undated care plan documents an admission date of 08/15/25 with diagnosis Fracture of Left Calcaneus, Type 1 Diabetes Mellitus with Other Skin Ulcer, Fracture of Shaft of Right Tibia, Closed Fracture with Nonunion, and Muscle Wasting and Atrophy. The same care plan documents: R1 is at risk for falls related to the right shoulder Date Initiated: 08/16/2025 Revision on: 08/18/2025. R1 will have decreased risk of falls by next review date. Date Initiated: 08/16/2025 Revision on: 09/10/2025 Target Date: 11/27/2025. Anticipate and meet the resident's needs. Date Initiated: 08/18/2025. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 08/18/2025. Environmental rounds to ensure resident is in the middle of the bed to help prevent accidental exits from bed. Date Initiated: 08/17/2025. Sent to Emergency Department (ED) Date Initiated: 08/15/2025.On 09/19/25, R1's record review of Minimum Data Set (MDS) completed on 9/15/25 documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R1 is cognitively intact. The same MDS documents R1 is dependent on a total body mechanical lift for transfers.On 09/19/25, R1's record review of progress note dated 9/12/2025 at 6:35am V9 Nurse, documented R1 sustained a fall on 09/12/2025 5:15AM. Documents the incident occurred outside on driveway and R1, who is alert and oriented to time, person, place and situation, attempted to pull straps of the total body mechanical lift sling out from her front right wheel and slipped off the wheelchair.On 09/19/25, R1's record review of progress note dated 9/12/2025 at 09:59am, V3 Director of Nursing, documents the Interdisciplinary Team (IDT) met to discuss the fall. R1 was outside waiting for van to take R1 to dialysis. R1 called the west desk at approximately 05:15am and asked this writer for help removing the straps of lift sling from R1's wheels of R1's power wheelchair. The same progress note documents the root cause: resident slipped out of the chair pulling the lift sling out from under her. Intervention: educate resident regarding asking for assistance with sling placement. This intervention was not documented as completed.On 09/19/25, R1's record review of Comprehensive Incident Fall assessment dated [DATE] at 06:13am completed by V9 documents under section C number four (4) lists new interventions initiated immediately to prevent further falls. Documents to tuck straps of sling under resident. This intervention was not transcribed to the care plan.On 9/19/25 at 12:26pm, R1 stated on 09/12/25 R1 was rolling in R1's power wheelchair outside to wait on the van to take R1 to dialysis when the strap of the total body lift sling became tangled into the front wheel of the wheelchair and pulled the lift sling forward pulling R1's body forward. When R1 leaned forward R1 slid forward from the wheelchair to the ground. R1 further stated the seat belt on the wheelchair is broken and unable to be fastened. R1 stated R1 is unsure of the date the seatbelt broke but was it broke after admission to the facility. R1 stated nursing staff are aware the seat belt is broken. On 9/19/25 at 12:59pm, V9 stated R1 called V9 from R1's cell phone indicating R1 needed help with the straps of the lift sling as they were caught under the wheel of the wheelchair. V9 stated V9 delivered the coffee V9 had and then proceeded outside to R1's location and R1 was sitting on the ground. V9 stated R1 stated R1 fell from the wheelchair due to the straps of the sling being under the wheels of the power chair. V9 stated R1 was assessed and gotten off the ground and returned to the wheelchair and the straps were then tucked under R1 to prevent further incidents. V9 stated R1 should be care planned to have the straps of the lift sling tucked under R1 to prevent further incidents.On 09/21/2025 at 08:54am, V4 Maintenance Director, stated V4 was unaware of the broken seatbelt on R1's wheelchair. V4 stated staff use the TELS computer program (maintenance request platform) to request service/repair orders for equipment needing repair.On 09/21/2025 at 09:43am, R1 stated that R1 wears the seatbelt at all times when R1 is in the wheelchair and had the seatbelt been working it would have been worn and R1 would not have fallen from the wheelchair.On 09/21/2025 at 11:03am, V1 Administrator, confirmed R1 fell from the wheelchair on 09/12/25 and the care plan did not have proper interventions to prevent a fall from the wheelchair. On 09/21/2025 at 11:33am, V11 (R1s Family), confirmed the seatbelt on R1's wheelchair was functioning upon admission and broke during R1's stay. V11 confirmed R1 wears the seatbelt to prevent falls from the wheelchair.

Based on interview and record review the facility repeatedly failed to ensure residents' right to be free from physical abuse of R8 by R9, R5 by R4, R12 by R11, and R13 by R9. R5, R8, R12 and R13, are four of 20 residents reviewed for abuse on the sample list of 25. Findings include:1.) R8's Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status (BIMS) score of six, out of a possible 15, indicating severe cognitive impairment . R8's same MDS documents R8 has had no delusions or hallucinations, and no behaviors directed towards self or others.R9's MDS dated [DATE] documents the following: R9's BIMS score of three out of a possible 15, indicating severe cognitive impairment. R9's same MDS documents R9 has had no delusions or hallucinations, and no behaviors directed towards self or others.The Facility Reported Incident (FRI) of 7/5/25/2601647 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 7/5/25 at 8:20 AM, (V4, Certified Nursing Assistant/CNA) was pushing (R25)'s wheelchair down the hall. (R8) was in (R8)'s wheelchair in the middle of the hall. (V4, CNA) went to move (R8) to the side, and while (V4, CNA) was moving (R8), (R9) approached (R8), and made contact with (R8)'s face.The facility Illinois Department of Public Health Initial dated 7/5/25, and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 7/10/25 documents the following conclusion:1. Based on the results of the investigation, the facility has found the following: a. Resident (R8) was seated in (R8's) wheelchair in the [NAME] unit hallway. b. Resident (R9) was observed walking by Resident (R8) and made contact with the left side of (R8's) face. c. Resident (R8) stated she was not upset by the alleged occurrence. (R8's interview was conducted 7/7/25, two days after the physical abuse occurred. R8's BIMs score documented above indicates R8 has severe cognitive impairment)d. Resident (R9) does not recall the alleged occurrence. (R9's interview was conducted 7/7/25, two days after the physical abuse occurred. R9's BIM's score documented above indicates R9 also has severe cognitive impairment).On 9/5/25 at 9:30 am V4 CNA stated V4 was the CNA that witnessed R9 hit R8 in the face. V4, CNA stated (R9) smacked (R8) in the face, hurting her eye. I (V4, CNA) immediately separated them and reported to the (V1, Administrator/Abuse Prevention Coordinator. (R9) was a one-on-one (individual staff supervision) the rest of the day. (R8)'s face was not red but her eye was, probably because she was rubbing it. I could tell it hurt but she couldn't verbalize that. I told the nurse (unidentified) right away. We monitored her the rest of the day for any signs of injury. It did not seem to bother her later. Her face never got red. The nurse did a skin assessment on both (R9) and (R8). (R9) never even realized what he did, I guess. It was deliberate and for no reason. (R8) did not provoke him (R9) in any way. He just walked right up to her, and slapped her. On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R8 and R9 abuse allegation investigation documented above and confirmed R9 intentionally slapped R8 in the face.2.) R4s Minimum Data Set (MDS) dated [DATE] documents the following: R4's Brief Interview of Mental Status (BIMS) score of three out of a possible 15, indicating severe cognitive impairment.The same MDS documents R4 has had no delusions or hallucinations, and no behavior directed towards self or others, during the seven day lookback period.R5's MDS dated [DATE] documents R5's BIMS score of 14 out of a possible 15, indicating no cognitive impairment.R5's same MDS documents R5 has had no delusions or hallucinations, and has had no behaviors directed towards self or others during the seven day lookback period.The Facility Reported Incident (FRI) of 8/17/25/2601814 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 8/17/25 R2 was sitting in front of the menu board making it difficult for residents to exit the dining room. (R5) told (R4) to move out of the way and then (R4) swatted at (R5) making contact with (R5's) arm.The facility's Illinois Department of Public Health Initial Report dated 8/17/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 8/21/25 documents the following conclusion: 1. Based on the results of the investigation, the facility has found the following: a. Resident (R4) was observed sitting in front of the menu board after the Sunday afternoon church service. b. Resident (R5) believed (R4) was blocking the hallway and told her (R4) to move. c. Resident (R4) reached out and made contact with (R5's) arm in response to being told to move.On 9/02/25 at 2:50 pm V10, Social Service Designee/Dementia Unit stated V10 completed the psychosocial assessments on R4 and R5 after the resident-to-resident altercation. V10 stated on 8/17/25, R4 had hit R5 with a book.On 9/5/25 at 11:07 am (R5) stated (R4) is always out to get me. She is always making snide remarks and thinks people are talking about her. I just stay clear of her. The day we were coming out of church, I was talking to (V26, R20's Family Member). (R4) was stopped in front of us. I told (V26) to tell her (R4) to get out of our way. (R4) backed her wheelchair up. She (R4) raised her arm up and swung so fast, I couldn't block her. She (R4) hit me (R5) across the chest and my arm with her bible. It was a black, heavy book. (V28, Activity Assistant) immediately moved (R4) out of the way and went down the hall. I was fine physically. It only hurt a minute. It did not stay red long. She isn't that strong, just mean.(chest and arm). I was just (expletive) it happened is all. I (R5) stay clear of her (R4) as much as possible. I have not had anything like that happen again.On 9/5/25 at 10:58 am V28, Activity Assistant stated I was talking to a(unidentified family member) right after the church activity. I heard (R5) say to (R4) 'Do not hit me'. I turned around immediately and could see (R4's) pull back her hand real fast. I went over immediately and separated them. I did not actually see her hit (R5). (R5) said she did, though. (R5) said she asked (R4) to move because she was blocking the residents trying to leave the activity. I could see (R4) was holding up traffic coming out of church service. I took (R4) to the nurse's station for close observation. I told (V29, Licensed Practical Nurse) the nurse. She called the Administrator ( V1, Abuse Prevention Coordinator) and went to do a did skin check on (R5). I know (R20)'s (V26, Family Member) was pushing (R20's) wheelchair and saw the altercation too. (R5) is alert and oriented. She can tell you exactly what happened. (R4) is mostly confused. She can carry on a conversation but as far as recollecting anything, I am sure she can't. (R4) has a lot of paranoia. She often tells other people, including (R5) to quit talking about her. Other than brief remarks, I have never seen either of them get physical. That day was a first, and I believe (R4) did hit (R5).On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R4 and R5 abuse allegation investigation documented above and confirmed R4 intentional hit R5 with a book.3.) R11's Minimum data Set (MDS) dated [DATE] documents R11's Brief Interview of Mental Status (BIMS) score as 00 (Zero) out of 15, indicating severe cognitive impairment.R11's same MDS documents the following: R11 has had no hallucinated or delusions.The same MDS documents R11 has had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 4-6 days of seven the look back period, R11 has had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred 4-6 days of seven the look back period, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred 4-6 days of seven the look back period.R11 same MDS R11 has had behaviors of 'rejecting evaluation or care' that occurred 4-6 days of seven the look back period and has had behavior of wandering that occurred 4-6 days of seven the look back period.R12's MDS dated [DATE] documents R12's BIMS score as 04 (four) out of a possible 15, indicating severe cognitive impairment.R12's same MDS documents: R12 has had no delusions or hallucinations and has had no physical behaviors, .R12 same MDS documents R12 has had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred one to three days in the lookback period of 7 days, and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred 4-6 days in the lookback period of seven days.The Facility Reported Incident (FRI) of 7/02/25/2601326 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 7/2/25 (R12) attempted to help (R11) with (R12's) Bingo card. (R11) then pushed (R12's) hands away from the Bingo card and then (R11) made contact with (R12's) forehead with the Bingo card.The facility's Illinois Department of Public Health Initial Report dated 7/02/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 7/07/25 documents the following conclusion:1. Based on the results of the investigation, the facility has found the following: a. Residents (R12) and (R11) were seated side by side during the Bingo activity. b. Resident (R11) was observed moving Resident (R12's) hands from her Bingo card and then made contact (R12's) head using the Bingo card. c. Resident (R12) does not recall the alleged occurrence. d. Resident (R11) does not recall the alleged occurrence.On 9/3/25 at 12:00 pm V21, Activity Assistant / Legacy Dementia Unit stated V21 was present and observed (R11) haul off and hit (R12) in the head with the bingo card. It was deliberate. He (R12) is always trying to help other residents with something. (R11) can get agitated with a flip a switch. We are careful with making sure she is not setting to close to anyone. That day during Bingo, (R12) went over to (R11). He invaded her space, and she let him know, she didn't' not want his help. It was a second or two later she (R11) hit him (R12) in the head. It was not an accident by any stretch of the imagination. It stunned (R12) but did not leave a mark. I was right there, and could not prevent the altercation. Knowing (R11), I was immediately going to separate them to prevent it. I just was not fast enough. I separated them right after the fact. I told the nurse what happened and was present when she called ( V1, Administrator/ Abuse Prevention Coordinator).On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R11 and R12's abuse allegation investigation documented above and confirmed R11 intentional hit R12 on the head with a bingo card. 4.) R9's Minimum data Set ( MDS) dated [DATE] documents the following: R9's Brief Interview of Mental Status (BIMS) score of three of a possible 15, indicating severe cognitive impairment. R9's same MDS documents R9 has had no delusions, hallucinations or behaviors directed towards self or others.R13's MDS dated [DATE] document R13's BIMS score of nine out of a possible 15, indicating moderate cognitive impairment.R13's same MDS documents R13 has had no hallucinations, no delusions no behaviors of any type, during the seven day look back period.The Facility Reported Incident (FRI) of 6/18/25/2594972 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 6/18/25 (R9) tossed a fork on the floor. (R13) then propelled self (herself) over to retrieve the fork from the floor. (R9) told (R13) to go away and get out of there. (R9) then reached out and made contact with (R13's) arm.The facility's Illinois Department of Public Health Initial Report dated 6/18/25 and corresponding Final Abuse Investigation Report, Resident to Resident Physical dated 6/24/25 documents the following conclusion: 1. Based on the results of the investigation, the facility has found the following: a. Resident (R9) was observed tossing a fork on the floor. b. Resident (R13) was observed retrieving the fork from the floor and telling Resident (R9) to go away'' and get out of here. c. Resident (R9) was then observed reaching out and contacting Resident (R13) arm. d. Resident (R13) does not recall the alleged occurrence. e. Resident (R9) does not recall the alleged occurrence. On 9/5/25 at 10:45 m V27, Certified Nursing Assistant (CNA) stated It was a couple months ago. I witnessed (R9) throw a fork on the floor. (R13) wheeled her wheelchair over to picked it up. (R9) grabbed her wrist. She screamed and said it hurt at the time. After a few minutes, she had forgotten about it . The nurse (unidentified) did a skin assessment and there was nothing there. It was on a weekend or second shift. We separated the residents. We reported immediately, after we made sure the residents were safe. We told (V2, Director of Nursing/DON) because (V1, Administrator/Abuse prevention Coordinator) was not here. The (V2,DON) reported to (V1,Administrator/Abuse Prevention Coordinator). (R9) was anxious before and after that. We did a one on one with him the rest of the shift.On 9/5/25 at 12:05 pm V1, Administrator/Abuse prevention Coordinator reviewed R9 and R13's abuse allegation investigation documented above and confirmed R9 intentional made contact with R13's arm.The facility policy Abuse prevention and Reporting-Illinois dated 09/2024 documents the following: Guidelines:This facility affirms the right of our residents to be free from abuse, neglect, exploitation,misappropriation of property, deprivation of goods and services by staff or mistreatment. This facilitytherefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment ofresidents. In order to do so, the facility has attempted to establish a resident sensitive and residentsecure environment. The purpose of this policy is to assure that the facility is doing all that is within itscontrol to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivationof goods and services by staff and mistreatment of residents.The same policy documents:Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. 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. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her each, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. 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 same policy documents: Resident-to-Resident Abuse (any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. Not all resident-to resident altercations result in abuse. For example, infrequent arguments or disagreements that occur during the course of normal social interactions (e.g., dinner table discussions) would not necessarily constitute abuse but should be investigated to make this determination. 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 interview and record review, the facility failed to accurately encode minimum data sets for antipsychotic medications and falls, and failed to complete the correct minimum data set for a discharged resident. These failures affect two residents (R6 and R1) out of thirteen reviewed for minimum data sets on a sample list of 25.Findings include: 1. R6's Physician Order Sheet dated [DATE] documents R6 has a physician order to receive the antipsychotic medication Quetiapine in a dose of 100 milligrams daily, an order initiated on [DATE], the day of R6's admission to the facility. R6's Medication Administration Record dated for [DATE] documents R6 received this antipsychotic medication as ordered. R6's admission Minimum Data Set, dated [DATE] section N0450 documents R6 did not receive antipsychotic medications since admission to the facility. This section, when coded as affirmative, serves as a prompt for further questions about required dosage reduction attempts On [DATE] at 3:40 PM, V16, Minimum Data Set Coordinator, stated she was aware R6 takes Quetiapine and must have been in a hurry to make a mistake coding the wrong section at the bottom of the page for R6. V16 further stated she would need to submit a correction for R6's Minimum Data Set. 2. R6's Nursing Progress Note dated [DATE] at 9:30 PM documents R6 was found on the floor of her own room at 9:00 PM stating she had fallen off of the bed, hit her shoulder, was complaining of right shoulder pain, and stating needed to go to the hospital. This note further documents R6 left the facility with emergency medical technicians to go to the hospital at 9:22 PM. R6's Nursing Progress Note dated [DATE] at 2:58 AM documents R6 had returned to the facility from the hospital with a diagnosis of a right humerus fracture which was immobilized. R6's Care Plan for a focus area of ADL (activities of daily living) self-care deficit dated as initiated [DATE] documents R6's right shoulder fracture as a contributing factor. The facility's Fall Investigation Report dated as initiated [DATE] with an initial report to IDPH [DATE] and final report dated [DATE], includes R6's Nursing Progress Notes from [DATE] and [DATE], R6's Care Plan revisions, and x-ray reports documenting a displaced fractured right humerus. R6's admission Minimum Data Set, dated [DATE] section J1800 and J1900 documents R6 had experienced 1 fall with an injury that was not a major injury since her admission to the facility. Section J1900 clarifies injuries not considered major include skin tears, abrasions and bruises, while major injuries include fractures. On [DATE] at 3:40 PM, V16, Minimum Data Set Coordinator, stated when she coded the section for R6's falls she had obtained her information from the facility's risk management section of the electronic medical records which listed R6's injuries as swelling and edema and had no further revisions. V16 clarified she was aware R6 went to the hospital but missed the part about a fracture. V16 further stated she had missed a lot of things on the Minimum Data Set for R6 and would need to submit a correction. 3. R1's Minimum Data Set, dated [DATE] for Death in Facility documents R1 expired on [DATE] in the facility. R1's State of Illinois Certificate of Death certified [DATE] documents R1 expired [DATE] at 9:40 PM at (local hospital). On [DATE] at 11:58 AM and 1:10 PM, V16, Minimum Data Set Coordinator, stated R1 was discharged to the hospital but was never admitted to the hospital and so R1 was still considered to be a resident of the facility when he expired, and that was why V16 completed a 'Death in Facility' assessment. At 1:40 PM, V16 referenced the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual dated from [DATE] (current Minimum Data Set manual) which documents (page 31) The Death in Facility assessment must be encoded when a resident dies in the facility or while on a leave of absence. This same manual (page 35) defines a leave of absence to include, IF the resident was in a hospital for observation for less than 24 hours, AND the hospital does not admit the resident. This same manual (page 32) documents a Discharge Minimum Data Set must be completed If a resident has a hospital observation period for greater than 24 hours, regardless if the hospital admits the resident. R1's Nursing Progress Note dated [DATE] documents R1 was sent to the emergency room at 12:45 PM on this date. At 2:50 PM on this same date, R6's Nursing Progress Note documents a facility nurse received an update from the hospital that R1 was pending an admission to an ICU (intensive care unit) bed. On [DATE] at 1:40 PM, V16 agreed from 12:45 PM on [DATE] until 9:40 PM on [DATE] was something like 32 hours, more than the 24 hours referenced in the Minimum Data Set manual. V16 stated the appropriate Minimum Data Set to complete for R1 would have been a Discharge with Return Anticipated and she would need to submit a corrected Minimum Data Set for R1.

Based on interview and record review the facility failed repeatedly to maintain complete and accurate medical records for two of 14 residents (R2 and R14) reviewed for accuracy of medical records on the sample list of 25.Findings include: 1.) R2's Physician Order Sheet dated 9/1/25 documents the following diagnosis and medication order: Ativan (name brand), ( antianxiety- Lorazepam) Oral Tablet 0.5 MG (Milligrams), Give 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety/agitation related to Anxiety Disorder, Unspecified for 14 months (inaccurate duration, exceeds the 14 day limit for prn anti-anxiety medication). Start date 07/29/25, end date of 9/26/26 (two-thousand twenty-six). R2 ‘s Consent dated 7/29/25, is incomplete, as it does not document the duration of time for Lorazepam 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety. R2's (Private Company) Psychiatry Note dated 8/22/25 documents the following: Type of Visit: Follow-up Visit :Chief Complaint: Per staff, patient exhibits agitation, aggression, and behavioral changes. The same (Private Company) Psychiatry Note documents the following a current medication list with no changes to the physician ordered Ativan ordered 7/29/25. R2's current medication list documents the same error in the duration of Ativan prn which exceeds the 14 days. The note documents R2's Ativan PRN (as needed ) order as follows: Lorazepam 0.5 mg PO q (every) 8 hrs (hours) PRN X (times )14 days, end dated 9/29/26 (two-thousand twenty-six). The documented Ativan order has the correct 14 day duration, but also documents inaccurately, the end date which is incongruent with the end date of a 14 month duration. R2's electronic Medication Administration Record (MAR) dated 9/1/25- 9/30/25 continued unrevised, with the same 7/29/25 Ativan PRN order that should have been replaced or discontinued on 8/11/25, after the 14-day required limit. R2's MAR dated 8/1/25 – 8/31/25 documents R2 was administered one dose of Ativan 0.5 mg on 8/29/25, (18 days after R2's Ativan was due to be revised or discontinued on 8/11/15). On 9/3/25 at 2:35 pm V2, Director of Nursing (DON) confirmed R2's electronic medical records. V2, DON stated R2's Physician Ordered for Ativan 'was a transcription error and should have been caught before the order went unrevised for the additional 23 days. V2 then clarified the order should not have exceeded 14 days. The documented 14 months was triggered in error. This error resulted in the wrong duration of 14 months documented throughout R2's chart ( included above) and R2's Ativan 0.5 mg dose being administered on 8/29/25, when the Ativan should have been discontinued or revised on 8/11/25. The facility policy “ Psychotropic Medication- Gradual Dosage Reduction” dated 04/2025 documents the following: “Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected: condition as per current standards of practice and are-prescribed at the lowest therapeutic dose to treat such conditions. The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/ problems, goals and approaches as it relates to the use of psychotropic drug use.” The same policy Psychotropic Medication- Gradual Dosage Reduction document: PRN (as needed) Psychotropics: “PRN hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication. The duration of use should not extend beyond 6 (six) months unless re-evaluated by the attending physician or prescribing practitioner and clinical rationale is provided.” 2. R14's Hospital Progress Notes dated for 8/9/25 through 8/25/25 documents R14 had experienced a urinary tract infection from the multi-drug resistant bacteria Klebsiella. These progress notes document R14 was simultaneously experiencing sepsis and a bacterial infection of his left knee hardware, all treated with the intravenous antibiotics Cefepime and Ceftriaxone. R14's Hospital Discharge Orders dated 6/26/25 document R14 was to continue the intravenous antibiotic Ceftriaxone daily beginning on 8/27/25, the day after R14's return to the facility as R14 had received a dose for 8/26/25 at the hospital. R14's Medication Administration Record dated for August 2025 does not document administration of Ceftriaxone to R14 on 8/27/25, 8/28/25, and 8/29/25. This lack of administration was noted as blank spaces where the administering nurse should place their initials when the medication was administered. On 9/3/25 at 9:40 AM, V2, Director of Nursing, stated he was the administering nurse as the intravenous medications are administered by a Registered Nurse. V2 stated he did administer the intravenous antibiotic and did not go into R14's record to document the administration. R14's Medication Administration Record dated for September 2025 did not document the administration of R14's intravenous antibiotic Ceftriaxone for 9/3/25, leaving R14's antibiotic administrations undocumented for a total of 4 out of 7 days between 8/27/25 through 9/3/25. On 9/5/25 at 1:45 PM, V2 again stated he had administered R14's intravenous antibiotic on 9/3/25 and had not gone into R14's record to document the administration.

Based on interview and record review, the facility failed to protect two residents' (R1, R10) from physical abuse for two of eight residents reviewed for physical abuse in a sample list if 15. Findings Include: Facility Abuse Prevention and Reporting policy effective 09/2024, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The policy documents as part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. The same policy documents on page two the definition of Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (21 0 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial wellbeing. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR Interpretive Guidelines). 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. (42 CFR 483.5). An example of a deliberate (willful') action would be a cognitively impaired resident who strikes out at a resident within his/her reach. On 06/24/25 R10's care plan review documents R10's admission to the facility on 6/14/2023 with the following diagnoses: Atherosclerotic heart disease of native coronary artery without angina pectoris, and unspecified lack of expected normal physiological development in childhood. On 06/24/2025 R11's care plan documents R11's admission to the facility on [DATE] with the following diagnoses: Vascular dementia, severe, with agitation, Autistic disorders and Dysphagia. On 06/24/2025 at 1:00 pm R10 stated on an unknown date that R11 struck R10 on the top of right-hand causing pain and redness and that staff applied an ice pack to the area to alleviate the pain. On 06/25/2025 at 11:55 am V3 (Activity Director) stated V3 was in her office in the activity room, when V3 heard yelling out and came out of the office noting R10 and R11 were very close together and R10 was trying to get up. V3 stated V3 did not see R11 strike R10, but R10 stated he was struck by R11. On 06/24/25 at 09:15 am V1 (administrator) confirmed on 06-17-2025 the facility submitted a final report documenting R11 struck R10 with a hand on the hand on 06/13/25. On 06/24/2025 at 09:15 am V1 provided a police report dated 06/13/25 documenting the Normal Police department had been notified of an aggravated battery incident at the facility. On 06/25/2025 at 1:55 pm V1 provided a written witness statement from V3 documenting that upon exiting the office in the activity room, V3 witnessed R10 and R11 waving their arms around. Example 2 On 06/18/25 R1's care plan review documents R1's admission to the facility on [DATE] with the following diagnoses: Unspecified dementia, severe, with other behavioral disturbance, and major depressive disorder. On 06/18/25 R2's care plan review documents R2's admission to the facility on 9/25/2024 with the following diagnoses: Dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance, Cognitive communication deficit, and Dysphagia. On 6/18/25 V5 (Assistant Director of Nursing) provided witness statements documenting V4 witnessed R1 walked over and stood near R2. R2 then reached out and scratched R1 with her (R2) fingernails. V4 stated that R1 did not provoke R2. On 06-13-2025 V1 (Administrator) provided a final summary of events to the department documenting V4 witnessed R2 scratching R1 in the hand.

Based on interview and record review, the facility failed to obtain medical evaluation and treatment following a resident's fall. This failure resulted in R2 experiencing aches, sharp pains, and a significant decline in cognitive, continence, and ambulatory status. R2 was one of three residents reviewed for accidents on a sample list of three. Findings include: R2's Census Detail dated [DATE] documents R2 was admitted to the facility [DATE], hospitalized from [DATE] through [DATE], re-admitted to the facility [DATE], and expired [DATE]. R2's Medical Diagnoses List dated [DATE] documents R2 had health conditions upon her admission including Malnutrition, History of Transient Cerebral Ischemia, and Chronic Kidney Disease. This same Diagnoses List documents, after R2's re-admission on [DATE], R2's diagnoses included a Displaced Right Femoral Neck Fracture, and Acute Respiratory Failure. R2's Nursing Progress Notes dated [DATE] document R2 experienced a fall in her room while ambulating with her walker and began complaining of new onset of pain R2 described initially as an ache. R2's Nurses Notes dated [DATE] and [DATE] document R2 had subsequent pain complaints described as sharp, and with numerical rating of 2 and 3. On [DATE] at 11:55 AM, V5, Licensed Practical Nurse, stated she had taken care of R2 after the fall, that R2 was alert and was telling staff about her pain. V5 additionally stated she had noted R2 was having right hip pain and was also walking funny on [DATE] and [DATE]. V5 then stated R2 was also experiencing a new onset of increased confusion on [DATE]. V5 concluded by stating she did not notify R2's physician until [DATE] when the physician ordered x-rays for R2. On [DATE] at 2:33 PM, V10, Certified Nursing Assistant, stated that on the weekend of [DATE] and [DATE], R2 was lying in bed moaning, complaining of pain, and sleeping a lot. V10 further stated R2 was incontinent of bowel and bladder, which was a change for R2 since prior to the fall R2 could take herself to the bathroom, and was complaining of increased pain in her right hip when V10 was turning and positioning R2 to change R2's soiled depends and linens. R2's Radiology Report dated [DATE] documents R2 experienced a displaced right femoral neck fracture. R2's Hospital History and Physical dated [DATE] documents R2's abnormal laboratory values mimicking a heart attack and low oxygen levels were the result of R2's fall and the increased physical bodily oxygen demands resulting in a low oxygen level. This History and Physical documents R2 received a computed tomography of the right hip and R2's fracture was described as an impacted fracture displaced superiorly (broken smaller pieces around the fracture and the lower portion of the broken bone was moved upwards). This History and Physical documents R2 was to be placed as non-weight bearing status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 had a Brief Interview for Mental Status (BIMS) score of 12, rating R2 as cognitively intact. This MDS documents R2 had no limitations in range of motion in any of her four extremities, only required set up assistance to accomplish daily living activities such as eating, toileting, ambulation over 150 feet with a walker, upper and lower body dressing, donning footwear, and personal hygiene. R2's MDS dated [DATE] documents R2 had a BIMS score of 1, rating R2 as severely cognitively impaired. This MDS documents R2 had an impairment in range of motion of one lower extremity, and was dependent upon staff to accomplish all daily living activities. There was no evaluation of R2 ambulatory status in this MDS due to R2 being placed as non-weight bearing status.

Based on interview and record review, the facility failed to manage new onset pain for a resident after a fall. This failure resulted in R2 experiencing aches, sharp pains, low oxygen levels, and a significant change in cognitive status. R2 was one of three residents reviewed for accidents on a sample list of three. Findings include: R2's Nursing Notes dated 4/12/25 at 3:25 AM, documents R2 experienced a fall in her room while ambulating with her walker. A subsequent note at 3:27 AM documents R2 was complaining of an achy pain with a numerical value of 2 or 3 out of 10 which was a new onset for R2. R2's Nurses Note dated 4/13/25 at 5:59 PM, documents R2 was complaining of increased sharp pain of her right hip. R2's Medication Administration Record dated for April 2025 documents from 4/1/25 through 4/12/25 day shift, R2 had rated her pain each and every shift as zero. This Record documents on 4/12/25, 4/13/25, and 4/14/25, R2 was rating her pain at 4. R2's Medication Administration Record and Treatment Administration Records dated for April 2025 documents no administration of any type of pain medication nor treatment from the time of R2's fall on 4/12/25 through the time of R2 being sent to the emergency room on 4/14/25. R2's Physician Order Sheet dated 6/13/25 documents none of R2's pain medication orders were initiated prior to 4/18/25 when R2 returned from her hospital admission after R2's fall and fracture on 4/12/25. On 6/12/25 at 11:55 AM, V5, Licensed Practical Nurse, stated she had taken care of R2 after the fall on 4/12/25. V5 stated R2 was alert and was telling staff about her pain. V5 further stated she had noted that R2 was having right hip pain and was walking funny on 4/12/25 and 4/13/25. V5 then stated R2 was also experiencing increased confusion on 4/13/25. V5 concluded by stating she had not notified R2's physician of the increased pain and confusion until 4/14/25 when R2's physician ordered the x-rays and subsequent transfer to the emergency room. On 6/12/25 at 2:33 PM, V10, Certified Nursing Assistant, stated she had provided care for R2 on 4/12/25 and 4/13/25. V10 further stated R2 was lying in bed all weekend moaning and complaining of pain. V10 stated R2 was usually continent of bowel and bladder, and able to take herself to the bathroom walking with a walker. V10 concluded by stating that R2 was incontinent that weekend and was making increased complaints of pain when V10 was turning and repositioning R2 to clean R2's soiled briefs and linens. R2's Radiology Report dated 4/14/25 documents R2 experienced a displaced fracture of the right femoral neck as a result of her fall on 4/12/25. R2's Nurses Notes dated 4/14/25 at 2:18 PM document R2 was sent to the emergency room for further evaluation. R2's Hospital History and Physical dated 4/18/25 documents R2 was admitted to the hospital for pain management, abnormal laboratory values, and surgical orthopedic consult. R2's hospital computed tomography scan dated from 4/14/25 documents R2's right femur fracture was impacted (lots of small pieces of bone) and displaced superiorly (upwards). This History and Physical documents R2's abnormal laboratory values were mimicking of a heart attack and were caused by R2's fall, pain, and increased bodily oxygen demands creating ischemia (lack of blood flow). R2's Minimum Data Set (MDS) dated [DATE] documents R2 had a Brief Interview for Mental Status (BIMS) score of 12, rating R2 as cognitively intact. R2's MDS dated [DATE] documents R2 had a BIMS score of 1, rating R2 as severely cognitively impaired.

Based on interview and record review the facility failed to follow physician orders for one (R1) of three residents reviewed for physician orders from a total sample list of 103 residents. This failure resulted in R1 being hospitalized with high ammonia levels that could have resulted in permanent harm. Findings include: R1's undated diagnosis sheet includes the following diagnoses: unspecified convulsions, alcohol dependence with alcohol-induced persisting dementia, fracture of right acetabulum, fracture of rib, malnutrition, fracture of anterior wall of right acetabulum, traumatic subarachnoid hemorrhage with loss of consciousness, and diabetes. The facility provided admission/discharge report documents that R1 was admitted to the facility on [DATE]. R1's hospital discharge orders dated 2/21/25 document medications to be continued including: Lactulose 10 gram/15 milliliter (ML) oral solution. Take 30 ML by mouth three times daily. R1's physician orders for February 2025 do not include an order for Lactulose. R1's February 2025 Medication Administration Record does not document that Lactulose was administered. R1's progress notes document on 2/22/25 that R1's mental status is alert and oriented to person, place, time, and situation. R1's progress notes document on 2/23/25 that R1's family member was concerned because R1 was not responding appropriately/like himself and seems extremely weak. R1 was unable to hold his head up and confusion was noted. R1's family member requested that R1 be sent to the emergency department for evaluation and treatment. R1's hospital records dated 2/23/25-3/3/25 document that R1 was admitted to the hospital with Hepatic Encephalopathy with hyperammonemia secondary to not receiving Lactulose at the facility. While hospitalized , R1 received Lactulose in various amounts to bring the ammonia level down with the result of improving mentation. On admission to the hospital on 2/23/25, R1's ammonia level was documented as 116 with significant confusion and decreased to 82 on 3/1/25 with lactulose administration resulting in improved mentation and the recommendation to continue lactulose for ammonia management. On 5/19/25 at 10:30AM, V3 RN (Registered Nurse) stated that she recalled having a conversation with R1's family member regarding not providing R1 Lactulose in the facility and that it was missed because of a system issue with the way that they look at discharge records and that they didn't look at the paper discharge records for R1. The staff are supposed to look at the paper discharge that comes with the resident, as well as the electronic discharge paperwork. On 5/19/25 at 1:10PM, V8 Nurse Practitioner stated that it was her expectation that the facility completed medication reconciliation with the discharge paperwork that comes with the resident from the hospital as soon as the resident arrives at the facility to ensure that nothing has changed. On 5/19/25 at 1:16PM, V7 Discharging Medical Doctor stated that R1 was mentally altered from the ammonia and it could have resulted in a coma. The family and patient told me that (R1) had not received his Lactulose in the facility and this certainly could have permanently harmed him.

Based on observation, interview, and record review the facility failed to complete quarterly fall risk assessments and implement fall interventions and fall prevention measures for three of four residents (R10, R79, R96) reviewed for falls on the sample list of 36. These failures resulted in R79, who is cognitively impaired, falling from a high bed onto the tile floor. R79 was seen in the emergency room and kept for an overnight hospitalization related to the subarachnoid hemorrhage R79 sustained from the fall. Findings Include: The facility's Fall Prevention Program dated October 2024 documents the program's purpose is to assure the safety of all residents in the facility and is to include measures which determine the individual needs of each resident by assessing the risk of falls, implementing appropriate interventions to provide necessary supervision, and using assistive devices as necessary. A Fall Risk Assessment should be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions should be implemented for each resident identified at risk. The bed should be maintained in a position appropriate for resident transfers. 1. R79's Medical Diagnoses List dated February 2025 documents R79 is diagnosed with Vascular Dementia, Psychotic Disturbance, Anxiety, Alzheimer's Disease, Need for Assistance with Personal Care, Morbid Obesity, Unsteadiness on Feet, Abnormalities of Gait and Mobility, Lack of Coordination, Cognitive Communication Deficit. R79's Physician Order Sheet dated February 2025 documents R79 was prescribed an anti-platelet medication in of March 2024. R79's Minimum Data Set, dated dated dated [DATE] documents R79 is severely cognitively impaired and requires staff assistance for transfers, bed mobility, and activities of daily living. R79's Care Plan dated 10/11/24 documents R79 is at risk for falls related to confusion and gait/balance problems. V29's Licensed Practical Nurse (LPN) Progress Note dated 1/31/2025 documents R79 was found on the floor beside her bed at approximately 11:15 PM. R79 was observed with a pool of blood underneath her head. R79's bed was clearly in the up position with the head up in Semi Fowler's position and the lower part bent at the knee area. R79 rated her pain as a 7/10 in her head. Emergency Medical Services were notified and R79 was discharged to the hospital. The cause of the fall was the bed was not in the lowest position. R79 has cognitive limitations due to dementia and immobility. On 2/20/25 at 1:40 PM R79 was sitting in her wheelchair in the television room. R79 had a half dollar sized raised hematoma on the left side of her forehead. R79 also had fading bruises under both eyes and a red fading bruise on the left side of neck. R79 was only alert to person and place. On 2/20/25 at 1:30 PM R79's bed frame was an older bed frame with an air mattress on top. There is an old half metal side rail on the right side of the bed frame. The bed frame, when lowered all of the way, was still about a foot off of the ground. On 2/20/25 at 1:08 PM V27 Certified Nurses Assistant (CNA) stated she put R79 to bed around 9:00 PM on 1/31/25. V27 stated on 1/31/25 R79 had gotten a new air mattress and a new bed frame that was an older model frame. V27 stated she believed part of the reason R79 rolled out of the bed was because of the new air mattress. V27 stated R79 could roll by herself in bed and was confused and needs the assistance of a staff and sit to stand mechanical lift for transfers. Confusion. V27 stated she thought she put the bed in the lowest position after she laid R79 down. However when V27 found R79 on the floor, V27 realized she had not put the bed all the way to the lowest position. On 2/20/25 at 3:29 PM V29 LPN stated the head of R79's bed was up at a 45 degree angle and the bed was also bent at the knees. V29 stated he asked V27 why the bed was like that and she stated so R79 could watch television. V29 also stated R79's bed was not at its lowest position. V29 stated the beds of confused residents should always be at the lowest position but R79's bed was about a foot and a half or two feet off the floor. R79 had blood on her head and on the floor. V29 confirmed R79 has poor safety awareness and would not be aware of where the edge of the bed was if she attempted to turn in bed. V29 also confirmed R79 was in a new air mattress and new bed frame that day for the first time. V29 stated he feels the cause of R79's fall on 1/31/25 was likely R79 trying to adjust herself in bed, then falling head first from the bed due to elevated angle of the head of the bed. V29 confirmed R79's injury risk increased due to the elevated height of the bed at the time of the fall. On 2/21/25 at 9:30 AM V2 Director of Nurses (DON) confirmed there was no quarterly fall risk assessment completed for R79. V2 stated R79 is currently a fall risk and confirmed R79 was a fall risk prior to her fall on 1/31/25 due to her impaired cognition, poor safety awareness, ability to turn and move in bed, and inability to safely transfer on her own. V2 confirmed when R79 was transferred to bed, V27 CNA should have ensured R79's bed was lowered as low as possible and the head of the bed is not elevated. V2 also confirmed on 1/31/25, when R79 fell out of bed and sustained a subarachnoid hemorrhage, R79's bed was not placed in the lowest position and the head of the bed was elevated, increasing R79's risk of injury when she moved in bed and fell out of bed onto the tile floor below. 31642 2. R10's Minimum Data Set (MDS) dated [DATE] documents the following: R10's Brief Interview of Mental Status score of two (2) out of a possible 15, indicating severe cognitive impairment. The same MDS documents R10 had two or more, falls since the last quarterly assessment. R10's Care Plan dated 12/30/24 documents the following: Focus: (R10) is at risk for falls r/t (related /to) dementia, morbid obesity, muscle wasting and difficulty walking. HX (history) of hip FX's (fracture). Interventions include: Apply (name brand non-skid material) on top and under w/chair (wheelchair) cushion. Date Initiated: 07/05/2024. On 2/20/25 at 2:10 PM R10 was seated in his wheelchair bedside. V33, Certified Occupational Therapy Assistant (COTA) and an unidentified Certified Nursing Assistant assisted R10 to a standing position from R10's wheelchair. V30 and V31 (R10's Family Members) entered R10's room as R10 was being assisted. R10 had non-skid material under, but not on the top of his wheelchair cushion. V33, COTA confirmed R10 had no non-skid material on top as his wheelchair cushion. V30 and V31 also noticed R10 did not have the non-skid material on the top of his wheelchair cushion. V30 and V31 both stated the facility is good about notifying them of R10's falls and has notified them R10 has had falls from his wheelchair. On 2/20/25 at 2:50 PM V30 Assistant Director of Nursing reviewed R10's medical record and confirmed R10 is to have non-skid material above and below R10's wheelchair to prevent R10 from sliding out if his wheelchair. 52228 3. R96 was admitted to the facility on [DATE] with diagnoses including Neurocognitive Disorder with Lewy Bodies, Dementia with behavior disturbances and Hallucinations. R96's Quarterly Comprehensive assessment dated [DATE] documents R96 has severe cognitive impairment and history of falls. R96's Care Plan Dated 10/21/25 documents R96 is at risk for falls related to dementia and cognitive disorder. This same record documents the following fall intervention: [name brand non-skid material] in wheelchair. On 2/19/25 at 2:10 PM, R96's highback wheelchair did not have non-skid material. On 2/19/25 at 2:11 PM, V18 (Certified Nursing Assistant) confirmed R96's highback wheelchair did not have non-skid material in place.

Based on interview, and record review the facility failed to protect a resident's (R2) right to be free from sexual abuse by another resident (R1), resulting in psychosocial harm of R2. R1 and R2 are two of seven residents reviewed for abuse in the sample list of seven. Findings include: The facility's Final Abuse Investigation Report dated 6/21/24 documents the following: On 6/18/24 at approximately 10:00 AM V3 Licensed Practical Nurse (LPN) witnessed R1 and R2 sitting beside each other in the [NAME] living area. V3 witnessed R1's hand on R2's chest, V3 immediately separated R1 and R2, and R1 was taken to R1's room. R1 and R2 were interviewed and had no recollection of the incident. R1's ongoing Diagnoses List includes Dementia with behavioral disturbance, restlessness, agitation, and Pseudobulbar Affect (inappropriate/involuntary laughter or crying). R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 12, the high end of moderate cognitive impairment, and R1 uses a wheelchair for mobility. R1's Care Plan dated 2/17/24 documents R1 likes to watch pornography and may express/display sexual advances towards staff. R1's Nursing Note dated 6/18/2024 at 10:10 AM documents resident (R1) was witnessed touching another resident's (R2) breast while in a common area, residents were separated by this nurse (V3) and management alerted. R2's ongoing Diagnoses List includes Aphasia (difficulty speaking) and Alzheimer's Disease. R2's MDS dated [DATE] documents R2 does not speak, is rarely/never understood, and rarely/never understands others. R2's MDS documents R2 has short and long term memory impairment, is dependent on staff for mobility/transfers, and does not recall current season, room location, staff names/faces, or that she is in a nursing home. R2's Psychosocial assessment dated [DATE] documents R2 has no recollection of the event with R1. On 6/27/24 at 9:23 AM V3 LPN stated V3 witnessed R1's/R2's incident (6/18/24) which happened mid-morning. V3 stated R2 was sitting in a wheelchair in the lounge area and R1 was in a wheelchair next to R2. V3 stated R1 had R1's hand down the top of R2's blouse. V3 stated V3 asked R1 what R1 was doing, R1 put R1's hand down further into R2's blouse and grabbed R2's breast. V3 stated V3 separated R1 and R2, and R1 took himself back to R1's room. V3 stated R1 knew what R1 was doing and knew it (touching R2's breast) was wrong. V3 stated R2 was not aware of what was happening and did not respond to being touched by R1. V3 confirmed R2 has severe cognitive impairment and does not have the ability to consent to intimate touching. On 6/27/24 at 12:31 PM V22 (R2's Family) stated V1 Administrator recently contacted V22 to report R2 was sitting in the day room and a male resident put his hand down R2's shirt and fondled R2. V22 was asked how R2 would have felt or responded to this situation if R2 did not have cognitive impairement. V22 stated R2 would have been aghast and mortified, R2 probably would have pushed him (R1) away, and R2 would have felt afraid. The facility's Abuse Prevention and Reporting-Illinois policy dated as revised October 2022 documents the following: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Sexual abuse includes unwanted intimate touching of any kind, including the breasts and perineal areas. Nonconsensual sexual contact includes when the resident appears to want the contact to occur, but lacks the cognitive ability to consent.

Based on observation, interview, and record review the facility failed to ensure a resident's PICC (Peripherally Inserted Central Catheter) infusion line and IV (Intravenous) pump were patent (open and not blocked) and infusing a physician ordered IV antibiotic 24/7 (24 hours a day/seven days a week) for one of two residents (R1) reviewed for PICC lines in the sample of three. These failures resulted in the facility failing to administer R1's physician ordered continuous IV (Intravenous) antibiotic as ordered for the treatment of R1's Sepsis and Epidural Abscess (infection of the spine or skull), R1 experiencing numerous occasions of mental anguish, and R1 experiencing an unwanted visit to the emergency room (ER) room to gain vascular access. Findings include: The facility's Facility Assessment Tool dated 08/2022 through 10/2023 documents, Purpose: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. (The facility) reviews all referrals. The summary of diagnosis listed below are considered for admission to our facility. We accept residents with a variety of diseases, conditions, physical and cognitive disabilities, or combination of conditions that require complete medical care and management. Diagnosis Summary: Infectious Diseases. Special Treatments: IV Medications. The facility's Resident Care Policy and Procedure Central Venous Access Device and Midline Catheter Care and Management dated 06/2017 documents, Central Venous Access Devices (CVAD), including PICC (Peripherally Inserted Central Catheters), as well as midline catheters will be routinely monitored and cared for following established procedures and guidelines. Licensed practical nurses may monitor central venous access devices and midline catheters for complications. Only registered nurses may change dressings, access ports, change needless connectors, connect administration sets, flush and lock central venous access device lines and midline catheters, perform blood draws for the device, and remove non-tunneled PICC's, CVAD's, and midline catheters. R1's Admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact. R1's Hospital Discharge Summary dated 10-20-23 documents, You (R1) were here for infection of your neck that was treated with surgery and antibiotics. You were treated with antibiotics and need to be on antibiotics until 12-4-23. Principal Discharge Diagnoses: Sepsis and Epidural Abscess. Discharge on IV Nafcillin by PICC placement. R1's Hospital Discharge Transfer Order dated 10-20-23 documents, Nafcillin (Penicillin Antibiotic) 12 grams in 0.9% (percent) 880 ml (milliliters) infusion, infuse 12 grams IV (Intravenous) every 24 hours. R1's Active Order Summary Report documents the following orders: Nafcillin Sodium Intravenous Solution Reconstituted (Nafcillin Sodium) use 12 grams intravenously in the evening related to Extradural and Subdural Abscess. 12 grams in 0.9 % (percent) NaCL (Sodium Chloride) 880 ml (milliliters) to be run over 24 hours. Flush each lumen of PICC line with five ml of normal saline before and after infusion at bedtime. Order date: 10-20-23. R1's Care Plan dated 10-21-23 documents, (R1) has a peripheral midline PICC line to right arm due to Sepsis. Nursing to maintain midline/PICC line per orders. R1's Nursing Note dated 10-27-23 at 1:40 AM and signed by V4 (Agency LPN/Licensed Practical Nurse) documents, IV pump beeping stating air in line. No RN present to maintain line. DON (Director of Nursing/V2) and on-call manager notified of IV pump being shut off due to no RN in building. R1's Nursing Note dated 10-29-23 at 2:17 AM and signed by V7 (Agency LPN) documents, (R1) in bed resting at this time. (R1) has a PICC line and has fluids that should be running, but due to the line having air in it and there is not an RN on staff, (R1) was informed that she could wait till (until) morning or she would be sent to the hospital. (R1) requested to be sent to the ER and this nurse informed on-call and (V2). R1's Emergency Department Notes dated 10-29-23 at 3:53 AM document, Chief complaint: Vascular Access Problem. (R1) is currently living a (nursing home) for septic arthritis that (R1) was diagnosed with approximately one month ago. (R1) sent by nursing home staff due to her PICC not working properly in order for her to receive her nightly medication through her PICC line. (R1) is currently at the facility to receive 24-hour IV antibiotic therapy for septic arthritis. Per (R1) she has not received her antibiotics routinely as scheduled. Call (nursing home) and spoke with nurse (V7/Agency LPN) who advised that (R1) was sent into the emergency department for administration of her antibiotics infusion because he was advised by the nurse manager to do so because there is not a registered nurse in the building. LPN (s) are not allowed to administer medications through PICC line. An RN not on staff until day shift today. R1's Nursing Note dated 11-1-23 at 2:22 AM and signed by V7 (Agency LPN) documents R1's IV PICC line was not running and was displaying air in line. On 11-10-23 at 9:45 AM R1 was sitting in her bed with Nafcillin 12 GM in 0.9 % Normal Saline infusing at 42 ml/hour through a PICC line in the right upper arm. R1 was crying with visible tears and stated, When a RN isn't here, and my machine (IV pump) acts up the staff shut my machine off. I have gone without my antibiotic seven nights now. Two nights I went without it (IV antibiotic) for seven hours. I have had to be sent to theER on e night just to get the IV restarted. I should not have to be sent out of the facility in the middle of the night just to get my IV fixed and turned back on. I spent over a month in the hospital before coming to this facility. I was very sick, and I have an infection in my blood stream that was caused by an infection in my spine. I do not want to go without my antibiotics and have a set-back. I am afraid I will die without it (antibiotic). I called (V3/Infectious Disease RN) and told her I am afraid, and the facility is not giving me my antibiotic at night. Please help me. On 11-10-23 at 10:00 AM V2 (Director of Nursing) stated, I know (R1) has had air in her IV line and her pump was beeping a couple times on third shift. There was no RN on-site to manage it, so I told the nurses to send her to the ER. We do not have RNs in this building 24/7 (24 hours a day/seven days a week). The IDT (Inter-Disciplinary Team) reviews new admissions together and we knew when we admitted (R1) that she had a PICC line with antibiotics 24/7. On 11-10-23 at 10:35 AM V4 (Agency LPN/Licensed Practical Nurse) stated I was working third shift on 10-27-23 and taking care of (R1). At 1:38 AM that night (R1's) IV pump started to malfunction. (R1) gets a continuous antibiotic through a PICC line. There was no RN on duty to fix the pump and there was air in the line of the tubing. I called (V2/Director of Nursing) to see what I should do. (V2) instructed me to shut off (R1's) pump and wait for a RN in the morning to turn the antibiotic back on. (R1) did not get her antibiotic until after 7:00 AM when V8 (RN) came in and hooked it back up. The entire time (R1's) pump was off, (R1) was crying and afraid she was going to die. R1's mother (V6) even called me and was screaming at me. I was so upset that I quit, and I am not going back to the facility because I do not feel comfortable with taking care of a PICC line without an RN in the building. On 11-10-23 at 10:45 AM V8 (RN) stated, (On 10-27-23) I came in around 7:00 AM and cleared the air out of (R1's) tubing and hooked her IV back up. (R1's) IV antibiotics had been shut off that night because there was no RN working. I have had to turn (R1's) pump on twice when I have gotten here in the morning. On 11-10-23 at 10:50 AM V6 (R1's Mother) stated, (R1) has been really scared living at that facility because there have been multiple nights that her IV pump has been shut off and she has not gotten her antibiotic. (R1) is a very sick girl and has to have antibiotics continuously. (R1) has an infection of her spine. I have spoken to staff multiple times about this issue. I am trying to get (R1) moved to a facility closer to me that has RN's available to manage her IV. On 11-10-23 at 3:55 PM V3 (Infectious Disease RN) stated, I got a call from (R1) a week or more ago. (R1) was crying and telling me she was not getting her antibiotics because there was no RN in the building to manage her PICC line. (R1) told me there were seven nights she has not received her antibiotic. The facility admitted (R1) knowing she needed antibiotics through the PICC line 24 hours a day every day for at least two months. The facility should have made sure there was a RN there to administer and manage (R1's) PICC line and antibiotics. (R1) is septic and has an infection of the spine. (R1) is very ill and has to have her antibiotics around the clock. I have tried to call (V2) for over a week to talk to her about (R1) not getting her antibiotics. (V2) never returned my calls until yesterday. This clinic and V5 (Infectious Disease Physician) should have been notified every time (R1) did not get her antibiotics so we could have monitored (R1's) labs (laboratories) closer and developed a plan. (V5) and this clinic were never notified when (R1) missed her antibiotic. (R1) had to notify us herself. On 11-11-23 at 3:03 PM V7 (Agency LPN) stated, There have been numerous nights that (R1's) IV pump has been beeping and (R1) had air in her IV line. There was no RN in the building, so I have called (V2) and (V2) instructed me to send (R1) to the ER (emergency room ). (R1) was crying and did not want to go to the ER just to get her IV to work. The second time the paramedics came in and fixed the air in the line, but about an hour after they left the pump started to beep again. I turned the pump off and an RN did not come in to turn in back on until day shift, which was around four hours later, so (R1) did not receive her IV antibiotics. There have been numerous nights (R1's) pump does not work and (R1) does not get her antibiotics and I have had to turn it off. (R1) cries and is afraid she is going to die whenever I have to turn the pump off.

Based on observation, interview and record review, the facility failed to communicate a resident's fall risk and safety needs to prevent a fall, thoroughly investigate a fall, care plan resident's fall risk and implement post fall interventions for three of three residents (R1, R2, R3) reviewed for falls on the sample list of three. This failure resulted in R1 falling after getting up and ambulating independently, and sustaining a severe intracranial hemorrhage that resulted in R1's death. Findings Include: The facility Fall Assessment and Management Policy [DATE] documents it is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. The potential for falls will be care planned when appropriate, based on the results of the Fall Risk Assessment. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factor of the resident. Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. After a fall, a licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regards to future intervention, and resident specific risk factors. The resident and family will be involved in the care planning process whenever possible. 1.) R1's Fall Risk assessment dated [DATE] documents R1 is at moderate risk for falls. R1's Care Plan dated [DATE] documents R1 is at risk for falls related to having a recent fall history and significant decline physically. The only fall prevention intervention documented at this time is to make sure the call light is within reach. R1's Progress Notes dated [DATE] document R1 was admitted to the facility on [DATE] at 6:30 pm via ambulance. These notes also document R1's family informed V3 Agency LPN about R1's safety needs: R1 is a high fall risk with frequent intermittent confusion and requested R1 not take the ordered Eliquis (blood thinner) due to R1's frequent falls and prolonged bleeding. V1 stated V11 provided most day to day care for R1 and requested that R1 be toileted at 1:00 am and 4:00 am. R1's Progress Notes dated [DATE] documents R1 was found face down on the floor, behind the door, by CNA. R1 was confused prior to the fall and now was not able to tell nurse his name. R1 was noted to have blood coming from R1's head and a large hematoma to the right eye and forehead. 911 was called and R1 was sent to the Hospital. R1's Hospital History and Physical dated [DATE] documents R1 presented to the ED (Emergency Department) following an unwitnessed ground level fall. According to the chart review, upon EMS (Emergency Medical Services) arrival, R1 was noted to be with decreased LOC (Level of Consciousness) and noted with obvious head injury near R1's right eye. Additionally, in route to the ED, R1 was noted to be hypoxic for which R1 was placed on a non-rebreather mask with 100% FiO2 (Fraction of Inspired Oxygen). While in the ED, R1's LOC continued to decline with a Glasgow Coma Scale rating of 1 meaning no response. R1's preliminary CT (Computed Tomography) imaging of the brain showed concerns for intracranial bleed. R1's CT scan dated [DATE] documents R1 has an Acute 1.6 cm (centimeter) Intraparenchymal Hemorrhage involving the left parietal paraventricular white matter and extending to the left basal ganglia with a large amount of blood spilling into the body of the left lateral ventricle as well as body of right lateral ventricle. R1 also has an extensive right periorbital hematoma. R1's Hospital Discharge Summary dated [DATE] by V8 Physician documents - R1 was admitted to the hospital with an extensive ICH (Intracranial Hemorrhage) after sustaining a ground level fall while on Eliquis. R1's prognosis was poor and R1 was not expected to survive. R1 expired later in the day. Cause of Death: Intracranial Hemorrhage with anticoagulant use for AFib (Atrial Fibrillation). On [DATE] at 11:01, V3 Agency LPN (Licensed Practical Nurse) stated R1 was confused but pleasant at time of R1's admission. R1's family was very concerned about R1's decline and R1's falling. Prior to admission, R1 resided at home with V11 and V11 was R1's primary caregiver. V11 requested R1 be toileted at 1 am and 4 am because that is what R1 was used to because that is when V11 got R1 up to toilet when at home. V3 stated V3 passed that information on to the oncoming nurse and also charted the information because even though (R1) was not cognitively with it, his body would still wake up and he would want to toilet because that is what he was used to. On [DATE] at 11:13 am, V11 stated V11 had requested R1 be toileted at 1 am and 4 am due to that being the schedule that R1 was used to at home for the past couple of weeks. V11 also stated R1 ambulated very slowly and needed assistance with stabilization due to R1's unsteady balance. On [DATE] at 11:25 am, V10 CNA stated V10 had assisted V12 LPN with toileting R1 around 9 or 10 pm using a gait belt and walker due to R1 being unsteady. V10 then stated the next time V10 had any interaction with R1 was at midnight but that R1 was asleep so R1 was not toileted at that time, then about 1:15 am, V5 CNA yelled out for help so V10 responded and saw R1 lying face down on the floor, behind the door, bleeding from R1's head, so V10 went to get the nurse. V10 stated V10 was not given any information on R1, including when or how R1 toileted. On [DATE] at 11:42 am, V12 Agency LPN stated R1 was very confused upon admission to the facility, a very high fall risk because R1 really didn't understand R1's own mobility limitations and kept trying to get up independently and kept losing R1's balance. V12 stated V12 and V10 had toileted R1 before 10:00 pm, then put R1 to bed for the night. V12 stated V12 went to another unit at 11:00 pm but later in the night, came back to the unit to assist V4 Agency LPN, due to R1 falling. V12 stated prior to R1's family leaving for the night, V11 asked how often we (facility staff) check on residents and V12 told V11 that residents are checked on every 2 hours and toileted at those times. V11 was asking due to R1's confusion and trying to get up so V12 told V11 due to R1's confusion, V12 would have the CNA's check on R1 every hour to see if R1 needed anything and V11 was okay with that. V12 stated that V3, who admitted R1, never reported to V12 that R1 needed to get up at 1:00 am and 4:00 am. On [DATE] at 11:55 am, V4 Agency LPN stated V4 was not given report by V3 or V12 upon arriving for V4's night shift, therefore was not given any information regarding R1's fall risk or specific needs for toileting during the night. V4 stated an unidentified nurse did tell V4 that R1 had a lot of confusion, decreased safety awareness, and that R1 required one assist for toileting. V4 then stated around 1:15 am on [DATE], R1 fell . V4 explained staff had to log roll R1 to get R1 moved to see R1's injuries, due to being facedown behind the door. V4 stated R1 had a large hematoma to R1's forehead and eye. V4 explained R1 had a history with bleeding, had blood coming from the hematoma and was not responding at all so, R1 was sent to the hospital. V4 stated R1 was rounded on every two hours. V4 stated staff didn't tell V4 that R1 needed checked on more frequently. On [DATE] at 12:15 pm, V2 DON (Director of Nursing) stated the facility tries to mimic the residents home routine, so if R1 was used to being toileted at 1:00 am and 4:00 am, we {facility} would try to do that and that information should have been passed on from one shift to the other, and care planned however the facility has 24 hours to get the baseline care plan together because sometimes we aren't able to talk with families and gather that information until the next day. 2) R3's Fall Risk assessment dated [DATE] documents R3 is a moderate fall risk. R3's care plan dated [DATE] does not document R3's fall risk or any fall prevention interventions. R3's MDS (Minimum Data Set) dated [DATE] documents R3 is alert and oriented and requires limited assistance of one staff for bed mobility, transfers, and ambulation. R3's Progress Notes dated [DATE] documents R3 self reported a fall. Upon assessment, no bruises were noted however R3 did complain of pain to the left chest. R3 was sent to the hospital for evaluation and fractures noted. R3's Hospital CT (Computerized Tomography) of Chest dated [DATE] documents findings of acute fractures of the left 5th, 6th and 7th ribs. On [DATE], V2 DON (Director of Nursing) confirmed R3's care plan does not include R3's fall risk, any fall prevention interventions, or post fall interventions. 35510 3. R2's Fall Risk assessment dated [DATE] documents R2 is a high risk for falling. R2's Care Plans document R2 is at risk for falls related a diagnosis of Dementia with Behaviors, poor safety awareness and impulsiveness and a history of falls. These Care Plans document interventions including to ensure R2's wheelchair is near R2's bed when patient in bed, encourage/assist res to position self in middle of bed as allows before leaving room after cares provided, anti-skid strips applied to floor at R2's bedside and to provide low bed with floor mat. R2's Fall Investigation documents R2 had a fall on [DATE] at 8:45pm. This investigation does not document if R2's call light was in place prior to the fall. R2's Follow-up Report documents the Interdisciplinary Team met and reviewed resident observed on the floor and root cause of self transferring but no investigation in to why R2 was self-transferring with an intervention to offer toileting when R2 is restless. There is no documentation in the investigation that R2 was restless prior to the fall or in R2's Progress Notes on [DATE]. R2's Progress Notes do not document details surrounding R2's fall on [DATE]. R2's Fall Investigation documents R2 had a fall on [DATE] at 1:50am. This fall investigation documents R2 was sent to the hospital after this fall and R2 had a laceration to the right and left forehead. This investigation documents assigned CNA reported R2 was on the floor in R2's room. R2 observed screaming and lying on R2's left side between the bed and floor mat with bleeding to R2's head. There is no documentation of if the call light was in reach. This investigation documents V15, CNA stated R2 was toileted around 1:30am, but there is no documentation of investigation of how R2 was positioned in the bed after toileting, prior to staff leaving R2's room. This investigation documents the root cause of R2's fall on [DATE] at 1:50am that R2 rolled out of bed with no documented investigation in to why R2 rolled out of bed, with an intervention to encourage/assist R2 to position self in the middle of bed as allows before leaving the room. R2's Fall Investigation documents R2 had a fall on [DATE] at 10:50pm. This investigation documents V16, CNA reported to V17, LPN that R2 was on the floor and R2 was visually observed on the floor when V17 entered R2's room. This investigation documents R2's statement of what happened as, I don't know, my feet slipped from under me. The Fall Details Report documents V16 found R2 sitting upright on the mat on the floor facing the foot of the bed. This report documents not applicable (N/A) for Footwear and does not document if R2's call light was within reach when last observed. This investigation documents the root cause of R2's fall on [DATE] at 9:15pm as self transferring but does not document investigation in to why R2 was self transferring. This investigation documents an interview with V19, Agency CNA reported that R2 had one sock on and one shoe on but does not document which foot the sock and which foot the shoe was on or the location of the second sock and second shoe. R2's Fall Investigation dated [DATE] 6:36pm documents R2 had a fall on [DATE] at 6:36pm. This investigation documents V6, Registered Nurse (RN) and V9, Certified Nursing Assistant (CNA) who was sitting nearby heard R2 fall and call out. V6 and V9 responded to R2 and found R2 on R2's left side on the floor beside R2's bed. R2 was facing R2's wheelchair with head touching the wheelchair and R2's head was bleeding. This report does not document if R2's call light was within reach. V9's witness statement in the investigation documents R2 had shoes on but the Fall Details report in the investigation documents R2 only had socks on. V9's statement also documents R2 was curled up when V6 and V9 first observed R2 on the floor. The Falls Details Report documents R2's position when found as lying on right side, next to bed, with head touching wheelchair but the investigation notes document R2 was on R2's left side. There is no documentation as to if R2's wheelchair was placed near the bed prior to the fall or if a fall mat was in place. There is no documentation in this investigation to the wheelchair being assessed for potential issues with jagged edges/missing components as R2 received lacerations to R2's head from the wheelchair. On [DATE] at 12:30pm, R2's room was observed. There were no non-skid strips on the floor next to R2's bed. On [DATE] at 2:20pm, R2 was laying in R2's bed. R2's call light was on the floor next to R2's bed and R2's wheelchair was in the middle of R2's room, not in close proximity to R2's bed. At 2:30pm, V13, Licensed Practical Nurse (LPN)/Unit Coordinator stated R2's bed used to be positioned differently and that the facility moved the positioning of the bed and the non-skid strips were still in the old location. V13 stated V13 would have the facility place the non-skid strips where they needed to be due to the beds new position. When mentioning call light and wheelchair placement, V13 moved the wheelchair to be close to R2's bed as R2's wheelchair is supposed to be next to the bed and attached R2's call light to R2's bed within reach of R2. On [DATE] at 10:20am, V2, Director of Nursing (DON) stated V2 related R2's fall to toileting and R2 had been incontinent. V2 stated V2 speculated restless due to R2 stating R2 wanted to milk the cows, but stated there are no interviews or documentation in R2's medical records documenting R2 had been restless prior to the fall. V2 stated the nurses are supposed to be documenting details of falls in the residents medical record/progress notes and have been educated multiple times to do so. V2 stated V2 don't know if R2 moved the fall mat on [DATE] or if the floor mat was not pushed all the way next to the bed. V2 stated V2 does not usually chart about call light in reach as it is supposed to be in reach anyway. V2 stated V2 did not ask about R2's positioning in bed upon return from the bathroom/toileting on [DATE]. V2 stated V2 cannot change what nurses place in the investigation and that nurses should make sure information they document is accurate. V2 stated V2 was unsure of why not applicable (N/A) was documented for Footwear but the V19 provided details as above for R2's fall that occurred on [DATE]. V2 stated V2 don't know if an evaluation of the wheelchair was completed after R2's fall when R2 received lacerations from hitting R2's head on the wheelchair but does not remember one being done.

Based on observation, interview and record review, the facility failed to ensure three of four residents (R1, R4, R5) were not subjected to physical and verbal abuse from another resident (R3) who were reviewed for abuse on the sample list of six. This failure resulted in R1 becoming fearful of R1's safety while at the facility because of R3's physically attacking R1 when R1 is bedbound and unable to defend R1's self. Findings Include: The facility Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media dated 3/15/18 documents the following: All residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse means the infliction of injury on a resident that occurs, other than by accidental means and the required (whether or not given) medical attention. Physical abuse may include, but is not limited to such acts as: hitting, slapping, kicking, hair pulling and pinching. Verbal abuse means the use by an employee or agent or oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. 1.) On 5/15/23 at 10:10 am, R1's room door had two stop signs adhered on it. R1 was lying in bed and stated R1 has been attacked by R3 who has dementia, while here at the facility. R1 explained R3 used to come into R1's room quiet a bit and when R1 would ask R3 what R3's name is and what R3 wanted, R3 would say Oh, you know who I am, then several months back, R3 came in and started hitting R1. R1 stated R1 reported it and it was already investigated by the facility and IDPH (Illinois Department of Public Health). R1 stated R1 hadn't had any other problems with R3 until a couple of weeks ago. At this point, R1 started to cry and explained, R3 wheeled R3's self into R1's room again and when R1 told R3 to leave, after activating the call light, R3 started pinching R1's right leg, to the point R3 broke the skin. R1 stated R1 tried pushing R3 away and kicking at R3 but that leg doesn't work right, I (R1) have a spacer in that knee and I'm not able to bend it or really even move it, Im pretty much bed bound. R1 stated staff responded to the call light and R1's yells for help and got R3 out of R1's room and R3 hasn't been back since. R1 started to cry again and stated, R1 don't feel safe in the facility with (R3) also being at the facility and close to me (R1) {R3 residents right across the hall from R1}, I'm scare of what (R3) will do next. R1 went on to say, R3 has already attached R1 twice and R1 can't defend R1's self so now R1 has a spray bottle, pointing to a green spray bottle sitting on the over bed table and stated if R3 comes back in here and staff don't respond quickly, R1 can spray R3 with it to try and get R3 to go away; and if that doesn't work, I (R1) have an extending fly swatter that I can use to try it and shoo (R3) away with. R1 explained R1 doesn't want to have to use them but that is the only way R1 can defend R1's self. R1 also stated the one time that R1 has come out of R1's room since the attach was for a care plan meeting and on R1's way back to R1's room, R1 noticed R3 sitting next to the nurses stated. R1 explained, I (R1) started to panic when I (R1) seen (R3). I (R1) tried going quickly past (R3) and even turned my head so (R3) didn't see my face. I (R1) didn't want (R3) to follow me back to my room. R1's MDS (Minimum Data Set) dated 4/15/23 documents R1 is alert and oriented. R3's MDS dated [DATE] documents R3 has severely impaired cognition. The facility's final abuse investigation between R1 and R3 dated 4/25/23 documents R1 stated R3 came into R1's room and requested to be covered up with a blanket and began pinching R1's leg. R1 stated R1 asked R3 to stop and then put on R1's call light. V15 CNA (Certified Nursing Assistant) responded to R1's call light after hearing R1 yelling and removed R3 from the room. At the time V15 responded, R3 was not doing anything but R1 stated R1 was pinched by R3. R3 does not recall the incident due to R3's diagnoses. The facility believes the allegation is substantiated. On 5/15/23 at 1:16 pm, V1 Administrator confirmed R1 has been in an abusive situation while at the facility, more than once, but thinks R1 is confused and that the first situation was not with R1. 2.) The facility's final Abuse Investigation dated 5/7/23 between R3 and R4 documents V17 Housekeeping/Laundry Supervisor witnessed R3 hitting R4 closed fisted with the bottom of R3's hand on R4's arm. When V17 asked R3 what are you doing, R3 then grabbed R4's arms. V18 CNA (Certified Nursing Assistant) also witnessed R3 grabbing R4's arm. Upon completion of the investigation, the facility believes the incident did occur as a result of R3's diagnoses. R3's ongoing Diagnoses List documents R3 has Unspecified Psychosis, Dementia with Behaviors, and Delusional Disorder. R3's MDS (Minimum Data Set) dated 4/5/23 documents R3 has severely impaired cognition. R4's MDS dated [DATE] documents R4 has severely impaired cognition. On 5/16/23 at 9:09 am, V17 stated V17 was coming upstairs from laundry and walked into the east wing lounge area. V17 witnessed R3 hitting R4. V17 stated V17 looked around to see if there was any staff around and there wasn't, so V17 went up to R3 and talked to R3 and rubbed R3's hand trying to calm R3 down and at that time, R3 stopped hitting R4's arm but then tightly grabbed R4's arm. At that point, an unidentified staff member came around the corner, so V17 asked the unidentified staff to take R3 away from R4. The two residents were separated and V17 asked R4 if R4 was okay and R4 replied, yeah, (R3) better be glad that (R3) is a lady. R3 was still irate and trying to grab and hit everyone in R3's reach. On 5/16/23 at 1:15 pm, V1 Administrator stated V1 watched video surveillance of the alleged abuse and the video showed R3 was sitting behind R4 in the lobby area. R3 rolled up to R4, R3 said something, you could see R3's mouth moving but not able to hear anything and then R4 said something back to R3. R4 looked upset and after R4 responded, R3 grabbed R4's arm and started pinching at R4. R3's hand was holding onto R4's arm and then pinching R4's torso area. Then I seen R4 moving R4's arm trying to get it away from R3 and trying to push R3 away. That went on for about 20 seconds then V17 and V18 came into the lobby area and they both separated R3 and R4. V18 moved R3 closer to the nurses station, and V17 was talking to R4. R3 was still upset, and reaching out trying to pinch a staff member that was walking by. Confirmed physical abuse occurred. 3.) On 5/15/23 at 9:50 am, R5 was sitting up in a recliner in R5's room and stated a couple of weeks ago, R5 was asleep in R5's wheelchair in R5's room, with R5's back facing the door when R5 was awoken by someone hitting R5 upside the back of the head and cussing at R5. R5 stated, R5 don't know who it was because they were behind R5 but R5 yelled out, why did you just hit me and several people came to R5's room. R5 reported staff said said it was a female resident, they told me her name but I don't remember who it was but they got her out of here. R5 stated, I (R5) don't know why they {facility} are making such a big deal about it, but then again, I guess people can't just go around and hit others. I (R5) just don't understand why she was cussing at me, I don't cuss so I don't appreciate her cussing at me. R5's Final Abuse Investigation dated 5/3/23 documents R5 reports that R3 smacked the back of R5's head. R5 has a BIMS (Brief Interview for Mental Status) score of 15 {indicating R5 is alert and oriented} and stated that R3 who has a BIMS of 4 {indicating severe cognitive impairments} came into R5's room while R5 was resting in R5's wheelchair and smacked R5 on the back of the head. During medication pass around 2100, V10 RN (Registered Nurse) went into R5's room and saw R3 in R5's room. V10 removed R3 and during that time, R5 reported that R3 smacked R5 on the back of R5's head. The facility believes the incident did occur as a result of R3's diagnoses. On 5/15/23 at 1:02 pm, V1 Administrator confirmed R3 verbally and physically abused R5.

The failures at this level require more than one deficiency statement. A.) Based on record review and interview the facility failed to supervise a resident with suicidal ideation, failed to implement the facility suicide watch policy and failed to initiate care plan interventions after R1 verbalized intentions of killing R1's self. Theses failures resulted in R1 continuing to experience thoughts of self harm and then attempting to strangle R1's self with call light and bed control cords. These failures affect one (R1) of five residents reviewed for accidents in a sample list of 31 residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/20/22 when R1 made suicidal comments which indicated a plan to use the call light cord to harm himself and the facility did not remove the call light cord nor initiate new Care Plan interventions. V1 Administrator was notified of the Immediate Jeopardy on 1/31/23 at 4:11 PM. The surveyor confirmed by record review, observation and interview that the Immediate Jeopardy was removed on 2/2/23, but noncompliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: a. R1's Nurse Progress Note dated 1/3/23 at 11:34 PM documents Found (R1) in his bed with two call lights and bed control cords wrapped around (R1's) neck. R1's Nurse Progress Note dated 1/4/23 at 7:00 AM documents R1 was sent to the emergency room for psychiatric evaluation. R1's undated Face Sheet documents R1 admitted to facility on 10/6/22 with medical diagnoses of Surgical Aftercare following Surgery on the Nervous System, Spinal Stenosis, Muscle Weakness, Muscle Wasting and Atrophy, Malignant Neoplasm of the Prostate, Rheumatoid Arthritis, Major Depressive Disorder and Anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, transfers, dressing, and toileting, supervision with eating, and limited assistance of one person for personal hygiene. R1's current Care Plan does not document a focus area, goal nor interventions for risk of abuse. R1's Care Plan documents a focus area of 'Risk for harm to self or others' dated 10/7/23. R1's Care Plan does not document any added interventions from 10/7/22-1/4/23. R1's Nurse Progress Note dated 12/20/22 at 10:55 AM documents (R1) was making suicidal comments, was crying. (R1) wanted to hurt himself with the call button cord. (V18) Licensed Practical Nurse (LPN) went to (R1's) room to check on (R1). (R1) stated 'December was supposed to be my month of healing, my sister canceled my trip to Michigan, the beginning of the year was filled with sadness, loneliness'. (R1) stated 'I am working in therapy, and nothing is working'. (V18) asked (R1) if wanted to hurt himself. (R1) responded 'I feel hopelessness. There is nothing for me here.' R1's Nurse Progress Note dated 12/27/22 at 9:20 PM documents (R1) was really tearful and sad all day. During medication pass (R1) refused medications. (R1) stated 'I do not want my medication, food or water. I am just going to let mother nature take its course with this body'. Encouraged to think positive. (R1) refused and stated, 'just wants to die and wanted to be left alone.' R1's Nurse Progress Note dated 12/30/22 at 8:52 AM documents (V31) (R1's family) called in relation to new referral to see in-house psychiatrist. Questions and concerns addressed. R1's Nurse Progress Note dated 1/2/23 at 7:15 AM documents (R1) lying in bed crying. Stating that this is no quality of life. (R1) stated that he was tired of just taking drugs and not feeling normal. Non-pharmacological interventions: distraction and conversation. Summary: (R1) was wanting to not take medication anymore due to feeling out of sorts. R1's Nurse Progress Note dated 1/3/23 at 11:34 PM documents Found (R1) in his bed with two call lights and bed control cords wrapped around (R1's) neck. (R1) stated this is where all of his problems started, that this is where they will all end. (R1) unhappy about his medical diagnoses, the amount of medication he is taking, not being able to go to his own home, being denied going to his sister's for Christmas. Non-pharmacological interventions: Conversation and distraction. Summary: (R1) made aware of why cords were removed at this time. (R1) does not wish to be sent out to the hospital but also does not have any hope of living at this time. R1's Nurse Progress Note dated 1/4/23 at 7:00 AM documents Spoke with (V1) Administrator and (V1) stated to call the doctor about (R1's) current mood state. Once off the phone with (V1), called the on-call Physician. On call Physician called back and stated (R1) needed to be sent to emergency room for psychiatric evaluation. Family was notified and is ok with sending (R1) out. R1's Nurse Progress Note dated 1/11/23 at 12:33 PM documents (R1) told staff that he did not see any point in living anymore. (R1) states he would like to stop eating and just close his eyes and go to sleep and not wake up. (R1) has one on one in room at this time. R1's Nurse Progress Note dated 1/11/23 at 5:43 PM documents (R1) stated he'd rather die than take those things (medications) that allow us to control him. Summary: (R1) continues to verbalize suicidal thoughts and thoughts of death. R1's Nurse Progress Note dated 1/16/23 at 9:35 AM documents Sent a referral packet to Psychiatric Service on 1/11/23. (R1) was approved and is on the list for counseling services. R1's Electronic Medical Record (EMR) does not document R1 was placed on suicide watch per facility policy and does not document notification to V40 Physician of R1's statements on 12/27/22 and 1/2/23. On 1/27/23 at 11:45 AM V28 Certified Nurse Aide (CNA) stated I am (R1's) CNA today. (R1) is not on any kind of 15-minute checks or continuous observations. Nobody has been watching (R1). I have seen (R1) a couple of times this morning. (R1) has either been in his room or roaming around facility in wheelchair. I think (R1) is in the dining room now. I will have to check. On 1/26/23 at 1:35 PM R1 stated I have had Depression for many years. I have taken medicine for it for many years. I have gotten to the point lately where I just do not want to live anymore. The medicine does not seem to help. I thought December would be better, but I feel worse now than ever. They (staff) told me now I have Parkinson's Disease. Sometimes I just feel like there is no hope. On 1/26/23 at 12:25 PM V2 Director of Nurses (DON) stated (V20) Licensed Practical Nurse (LPN) should have sent (R1) out to the emergency room as soon as she was aware (R1) attempted suicide. Instead of calling the doctor and Power of Attorney (POA), (V20) called (V21) Dementia Coordinator who was the nurse manager on call that night. (V21) instructed (V20) to monitor (R1). I would have sent (R1) directly to the emergency room for evaluation. On 1/27/23 at 1:00 PM V22 Registered Nurse (RN)/Assistant Director of Nurses (ADON) stated I came into work on 1/4/23 and saw the cords sitting on the nurses desk so I asked (V20) what was going on. (V20) told me that (R1) had tried to commit suicide earlier in her shift and she was told by (V21) to remove the cords from (R1's) room so she did. When (V20) told me that I immediately told (V21) to call (R1's) physician, Power of Attorney (POA) and facility Administrator. I told (V21) 'I need you to call right now' and (V21) started making phone calls. We (staff) sent (R1) out to the emergency room for evaluation. On 1/26/23 at 1:30 PM V21 Dementia Coordinator/Nurse Manager stated I was on call the night (R1) attempted suicide. (V20) LPN called me and told me the staff had found (R1) laying in (R1's) bed with all the cords wrapped around (R1's) neck. (V20) told me (R1) was ok so I told (V20) to keep a close eye on (R1) by increasing visual checks. I did not tell (V20) to place (R1) on continuous monitoring or send to the emergency room . I did not notify (V1) Administrator, (V2) Director of Nurses or anyone else. I just told (V20) to make sure nothing was in reach. I should have had (V20) send (R1) out immediately and make all the notifications. (V2) DON brought all the managers together in the conference room on 1/4/23 and inserviced us on what to do when a resident attempts suicide and the suicide watch protocol. On 1/26/23 at 1:45 PM V24 Social Service Assistant (SSA) stated R1 was referred for therapy for Depression after the 1/3/23 attempted suicide. V24 stated We (facility) do have (V25) Licensed Clinical Social Worker come out to facility. (V25) has been coming to facility for over a year to visit with residents. After (R1) attempted suicide we (staff) started doing one to one visits with (R1). (R1) was first seen by (V25) on 1/13/23. (R1) did not see any other therapists or psychiatrists prior to (R1) attempting suicide. We (staff) knew (R1) was depressed because he would cry, refuse medications and make statements about how lonely and sad he was. We (staff) should have gotten (R1) help sooner. On 1/27/23 at 2:45 PM V2 Director of Nurses (DON) stated (R1) does have a history of Depression. (R1) has made comments indicating or stating (R1) wants to kill himself. We (staff) did not respond as we should have. We (staff) should have not given (R1) his call light after he said he wanted to use it to harm himself. We (staff) should have tracked and monitored (R1's) behaviors. We (staff) should have updated (R1's) Care Plan on 12/20/22 after (R1) made the comment that he wanted to use the call light to kill himself. We (staff) should have gotten (R1) a referral for psychiatric services sooner than we did. We (staff) should have placed (R1) on suicide watch after each statement of (R1) wanting to harm himself. The suicide watch policy was completely disregarded. We (facility) have failed (R1) in many ways. We are in the process of fixing those problems but they should have never happened in the first place. The facility policy titled 'Suicidal/Violent Residents' revised 11/01/05 documents Policy: This facility offers initial management stabilization and transfers when needed, to residents with psychiatric emergencies. A psychiatric emergency is an urgent, serious disturbance of behavior, affect, or thought that makes the resident unable to cope with life and/or personal relationships. Psychiatric emergencies may include, but are not limited to overactive, violent or suicidal residents. Verbalization of wishes to die, I wish I was dead, and other remarks or actions leading staff to believe the resident is suicidal will automatically trigger a suicide watch. This will require Physician and Power of Attorney (POA) notification and a every 30-minute charting sequence to be initiated. This will be reevaluated every 12 hours until Physician discontinues such a requirement. Procedure: 6. Facility supervisor in charge will notify (V2) Director of Nurses (DON)/(V1) Administrator. They will instruct the nurse to notify psychiatric hospital to prepare the resident for immediate psychiatric consultation and hospitalization . The Immediate Jeopardy that began on 12/20/22 was removed on 2/2/23 when the facility took the following actions to remove the immediacy. 1. R1 was assessed by V51 Social Service Director (SSD) on 1/31. V51 confirmed on 2/2/23 R1 was assessed on 1/31/23. 2. V2 Director of Nurses (DON) confirmed R1's environmental round was completed on 1/31/23 by DON, V22 Assistant Director of Nurses (ADON), V1 Administrator, and V55 Maintenance Supervisor. 3. V2 DON confirmed V40 Physician and V31 (R1's) Power of Attorney (POA) were notified of increased 15 minutes checks on 1/31/23. 4. V2 DON confirmed a schedule was created and staff were assigned to 15 min checks schedule created on 1/31/23. V2 verified 15 minute checks were documented as starting on 1/31/23 at 6:45 PM. 5. V52 Minimum Data Set Coordinator verified R1's care plan was updated on 2/1/23 by V52. 6. V1 Administrator confirmed the Interdisciplinary Team (IDT) met on 2/2/23 to review care plans for all residents. 7. V51 Social Service Director confirmed an audit of all resident psychosocial assessments was completed and referrals were made as necessary on 2/2/23. 8. V51 confirmed the facility will continue to have ongoing weekly audits for residents with mental health diagnoses or psychotropic medications. V51 confirmed facility started the audits on 1/31/23 and will continue weekly on Thursdays for four weeks. 9. V59 Clinical Educator confirmed V59 completed inservice training for the IDT for proper process for monitoring and documenting behaviors on 2/2/23. 10. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on depressive symptoms on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 11. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on signs of suicidal behavior on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 12. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on behavior tracking on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 13. V58 Regional Nurse Consultant confirmed all staff present in the facility had been inserviced on reporting procedures and enhanced monitoring on 1/31/23. V58 confirmed all staff not present in the facility would be inserviced prior to clocking in for their next shift. 14. V59 Clinical educator and V22 ADON confirmed all audits of residents on psychotropic medications and behavior tracking were completed on 1/31/23. 15. V1 Administrator confirmed the Quality Assurance (QA) team will audit for residents with increased depressive signs and symptoms, new admissions for behavioral care plans and interventions, and behavior weekly for four weeks and that the first audit has been completed. 31642 B. Based on record review, observation and interview the facility failed to ensure a resident was properly positioned in a wheelchair and failed to correctly implement a fall intervention for one of five residents (R10) reviewed for accidents on the sample list of 31. Findings include: b.) R10's Face Sheet dated on admission 2/18/2020 documents the following diagnoses: Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, and Osteoporosis Without Current Pathological Fracture. R10's Minimum Data Set (MDS)dated 11/3/22 documents R10 is severely cognitively impaired, totally dependant on two staff for transfers and requires extensive assistance with mobility on unit. R10's Fall incident report investigation, dated 1/4/23 documents the following: Witness statement of what happened written by (V53 Certified Nurses Aide) entered by (V22, Assistant Director of Nursing/ADON) on 1/6/23. While attempting to reposition resident (R10), resident leaned back sliding forward in (the) chair, and staff member lowered resident to the floor. The same report documents: Conclusion, IDT (Interdisciplinary Team) met and reviewed, resident (R10) observed on the floor ROOT CAUSE' slid to the edge of the chair while CNA (V53) was pushing her (R10) back to her room, CNA lowered her (R10) to the ground. 'INTERVENTION' (non-skid material) in wheelchair. The same report documents: Root Cause, Due to resident action or internal factor. On 2/2/23 at 4:10 pm V53, stated I (V53) was the CNA that assisted (R10) the day (1/4/23) she (R10) fell out of the wheel chair. V53 stated the following: It basically happened after lunch. I wasn't the CNA that fed (R10), or cared for (R10), I (V53) was just helping out. I (V53) saw her (R10) awake, out in the lounge on West hall. I (V53) could see she had slid down in her wheelchair, some. Her (R10's) shoulders were low and up against the wheel chair back. Her (R10) butt must have been closer to the front edge of the seat, than I thought. (R10) was covered in a blanket. Basically, I (V53) could not see how far she (R10) was scooted forward. Basically, I (V53) should have checked (to see how far forward R10 had scooted in the wheel chair). Basically, I started to push (R10's) wheelchair down to her room. (R10) had scooted more, so I hurried to get her back in her (R10's) room. I (V53) was only about one room from hers. I pushed (R10's) wheelchair really fast into her room. I needed to catch her before she fell out (of the wheelchair). I grabbed the back of her waistband and (R10's) shoulder started to lean back farther. By then I was basically at the side of her (R10's) wheelchair. I pushed the wheelchair backwards, out of the way. Basically, (R10) slid the rest of the way to the floor, basically down my leg. (R10) did not have a wheelchair chair cushion in her wheelchair that I saw. It (wheelchair cushion) may have slide out of the wheelchair with her (R10). (R10) does not stand. Her (R10's) cushion may have been under her on the floor, I don't know for sure. I just know it was not in her chair. I went to get (V22, ADON). She (V22, ADON) basically, came and took care of her (R10). On 2/2/23 at 2:40 pm R10 was laying in a low bed with scoop mattress. R10 was pleasantly confused. R10's wheelchair had a 12 inch by 12 inch piece of non-skid material on top of the wheel chair slick, polyester covered cushion. The wheel chair, cushion sat directly on the vinyl wheel chair seat. The wheelchair cushion slid easily front to back and did not have non-skid material. V16, CNA confirmed the non-skid material on the top of the wheel chair cushion and stated I don't know why that (non-skid) is on top instead of under the cushion. It does not stop the cushion from slipping right off the wheel chair. On 2/2/23 at 2:47 pm V22, Assistant Director of Nursing (ADON) assessed R10's wheelchair and stated I don't know a lot about this. I can see this cushion slides all over the place. That doesn't work. The (non-skid material) should be under the cushion I'd say. Or maybe both on top and below the cushion, because R10 does scoot down in her wheel chair.

Based on observation, interview and record review, the facility failed to monitor for and notify the physician of changes in weight and edema for a resident with chronic kidney disease, and failed to transcribe and complete laboratory testing as ordered for one of one residents (R27) reviewed for edema on the sample list of 46. This failure resulted in R27 having a 13 pound weight gain in one month with increased lower extremity edema which caused pain and a decrease in mobility. This failure also resulted in R27's kidney function deteriorating from a stage 2 to a stage 3B kidney failure. Findings Include: On 12/12/22 at 2:27 PM, R27 was sitting up in the wheelchair with edema to bilateral lower extremities. R27 stated R27's legs are sore due to being more swollen than normal and that R27's socks are cutting into R27's legs. On 12/13/22 at 2:19 PM, edema continues to bilateral lower extremities. On 12/13/22 at 3:12 PM, V17 RN (Registered Nurse) stated R27 has had edema of lower extremities for a couple of years and takes lasix due to kidney failure. V17 checked R27's legs, which were very taunt and shiny. R27 reported to V17 that R27's legs are more edematous than usual and V17 responded it could be due to R27's recent increased weight gain. At this time, V17 also stated R27 had just had laboratory tests completed and would make sure V23 Nephrologist had those results. R27's December 2022 Physician Orders document a diagnosis of Chronic Kidney Disease and localized edema with an order for 1500 ml (milliliter) per day fluid restriction and Lasix {Diuretic} 40 mg (milligrams) twice a day. There is also an order to send laboratory results to V23 however there are no active laboratory orders on the Physician Order Sheet. R27's Care Plan dated 7/6/22 documents R27 has Chronic Kidney Disease and uses diuretics and to monitor for weight gain, edema and monitor lab values. On 12/14/22 at 10:23 AM, R27's legs remain edematous and R27 again stated R27's legs are more sore than usual and that R27 has a hard time propelling R27's wheelchair with R27's feet anymore explaining, I (R27) can do it but it hurts and takes me longer {to get to where I'm going}. R27's ongoing vitals document on 10/1/22, R27 weighed 223.0 pound. On 11/4/22 R27 weighed 238.4 {a 15.4 pound weight gain in one month}, and 236 on 12/1/22. R27's Progress Notes from October - December 12, 2022 do not document any edema, or that the physician was notified of R27's weight gain. On 12/13/22 at 3:47 PM, V2 DON (Director of Nursing) with V8 Regional Nurse Consultant present stated the facility holds monthly weight meetings. At this time, V8 stated R27 flagged for a significant weight gain and explained with any weight gain/loss, the physician should be contacted to see if they want a change in treatment. V8 stated the nurses should have done a comprehensive assessment on R27 for the weight changes, which would have caught the increase in edema, and then updated the primary physician, as well as V23 Nephrologist. V8, after checking R27's progress notes, confirmed there is no documentation of R27's lower extremity edema or weight gain and that the physician was not made aware of R27's change in condition. R27's Laboratory tests dated 12/12/22 document a BUN (Blood Urea Nitrogen) level of 24 milligrams per deciliter(mg/dl) (normal is 9-20), Creatine 1.65 mg/dl (normal is 0.66-1.25), Albumin 3 (grams/deciliter) (normal is 3.5 - 5.0), and EGRF (Estimated Glomerular Filtration Rate) 39 (30-59 indicates stage 3 kidney disease). On 12/14/22 at 11:12 AM, V2 DON with V12 Unit Coordinator present stated V2 is trying to find out where the order for the laboratory tests that were completed on 12/12/22 came from. V2 provided a faxed physician order from V23 that was time stamped on 12/8/22. This order documents labs were ordered on 5/12/22 and expected to be completed on 11/12/22. V2 stated the facility didn't receive those orders until 12/8/22 when it was faxed over, that is why the laboratory tests were ran on 12/12/22. On 12/14/22 at 11:13 AM, V24 (V23's nurse) stated R27 was last seen on 5/12/22 by V23 and received orders at that time for laboratory tests to be completed at 1 month (June 2022), 3 months (August 2022) and 6 months (November 2022). V24 stated the 6 month test was to be due on 11/12/22 and it wasn't done, actually none of the labs were completed, that is why V24 re-faxed over the orders. V24 stated R27 has a follow up appointment on 12/22/22 that V23 needs those results for. V24 stated the last time R27 was seen by V23, R27 was in fluid overload. That is when (V23) put (R27) on the fluid restriction and (R27) was to continue the lasix 40 mg twice a day. V24 stated R27's visit Progress Notes and Orders were sent to the facility with R27 on 5/12/22. V24 stated their is no communication between the facility and V23 in R27's record but if R27 is having increased swelling and increased weight, V23 should have been notified. V23 would have increased R27's diuretics or added a second one like Torsemide, placed on daily weights and been doing increased laboratory tests to monitor R27's kidney function. V24 stated V24 still hasn't received the laboratory results from 12/12/22. On 12/14/22 at 2:25 PM, V2 DON with V1 Administrator present confirmed R27's May 2022 Progress Notes and Orders from R27's appointment with V23 are not in R27's medical record stating, I'm {V2} not sure where the orders went and why they weren't processed except for we {facility} have so much agency. I {V2} don't know what happened or what they {agency staff} did with the paperwork upon (R27's) return on 5/12/22. On 12/15/22 at 9:15 AM, V24 (V23's nurse) reviewed laboratory results from 12/12/22 and stated R27's EGFR went from a 61 in May 2022 to 39 in December 2022 explaining that shows that (R27) went from a Stage 2 to a Stage 3B kidney failure. V24 stated in April 2022 R27 was in the hospital with acute kidney failure due to his kidney's tanking but with hospitalization and changes in treatment, R27's kidney function had improved, that is why (V23) wanted labs at 1 month, 3 months and 6 months; to ensure (R27's) kidney function was stable. V24 stated had the labs been completed as ordered, V23 could have seen when R27's kidney function started to decline again and changed medications at that time. Everyone is different but with his history of kidney failure, and age, I (V24)really don't see (R27's) kidney functioning being able to improved at this time. Some people can remain at a stage 3B for years while others require dialysis in a short amount of time due to the continued decline. V24 also stated, because (R27) wasn't monitored like (R27) should have been, by not completing laboratory tests to ensure kidneys are/were stabilized and functioning as best they could, now (R27's) kidneys have gotten worse again.

Based on observation, interviews, and record review the facility failed to prevent a fall by failing to provide supervision, ensure a call light was within reach and failing to ensure a wheelchair cushion was not moveable for one (R59) of seven residents reviewed for falls on the sample list of 46. This failure resulted in R59 falling out of the wheelchair, hitting her head and sustaining a laceration which required emergency medical attention and 25 staples to close the laceration. 1. R59's emergency room report dated 12/12/22 documents R59 presents with complaints of a ground level fall and likely hit her head on the bed frame. This report documents R59 had a large flap laceration to the left mid/frontal scalp region. This report documents the laceration to the head was closed with 25 staples. On 12/12/22 at 2:15 PM, R59 was lying in bed. The top of R59's head had a large U shaped laceration which was closed with staples. R59's Nurse's note dated 12/12/2022 at 10:24 AM documents at 7:15 AM that, (R59) laying on floor on left side at the foot of roommate's bed. Writer noted a large laceration to left side of scalp. Resident was conscious and alert to self. (R59) stated she fell down but was unable to tell writer what she was doing or any other detail regarding the fall. This note documents R59 was sent to the emergency room . On 12/14/22 at 9:11 AM, V22 Certified Nurse's Assistant stated on 12/12/22 around breakfast she was pushing residents to the dining room. When she walked past R59's room she noticed she was lying on her back with her head between the footboard and the wall of R59's roommate's bed. V22 stated R59's was holding her head and was bleeding. V22 stated her wheelchair was at her feet. V22 stated her call light was not in reach. V22 stated R59 can not propel herself in the wheelchair like she could, but will try. V22 stated V22 is not sure who got her up in the chair but she should not be left in the room by herself because she needs supervised once she is up in her chair. On 12/14/22 at 11:15 AM, V12 Restorative Nurse stated R59 is at risk for falls due to having a couple falls in the past. V12 stated she investigated the 12/12/22 fall. V12 stated the cushion in R59's chair was not appropriate because it would slip and slide around when R59 was up in the chair. V12 stated R59 has poor posture combined with the cushion moving. V12 stated she feels the cushion contributed to R59's fall. V12 stated they replaced the cushion after her fall because it put her at greater risk for falling. V12 stated R59 had the cushion for awhile. R59's careplan with a revision date of 8/2/22 documents R59 is at risk for falls and includes an intervention to ensure call light is always within reach.

Based on record review and interview the facility failed to ensure R1 and R2 were not subjected to mental abuse by an employee. This failure resulted in staff refusing to assist R1 to the bathroom and instructing R1 to use her adult brief to urinate in, leaving R1 lying in a wet (incontinence brief). This staff treatment caused R1 to cry and feel like a baby. R1's ability to sleep was also impacted following this incident. R1 and R2 are two of three residents reviewed for abuse in the sample of three. Findings include: The facility's Resident Care policy and procedure regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media dated 3-15-18 documents, All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by an employee or agent. 1.) R1's Admission Record documents R1 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress Notes dated 9-29-22 document R1 was discharged home. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact with a BIMS (Brief Interview of Mental Status) score of 14, requires extensive assistance of two or more staff for transfers and toileting, and is occasionally incontinent of urine. R1's Care Plan dated 9-9-22 documents, Toilet use-extensive assist one-person physical assist. Transfer-extensive assist one-person physical assist with gait bet and walker. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 and R2's Final Report to Illinois Department of Public Health dated 9-23-22 and signed by V1 (Administrator) documents (regarding an incident of 9/17/22), Conclusion: (R1) stated (V11/Agency CNA/Certified Nursing Assistant) came into room after using the call light. (R1) told (V11) she had to use the bathroom. (V11) checked (R1) and (R1) was incontinent. (R1) stated (V11) said she was going to return to the room when (R1) was finished, but never returned. (V10/LPN/Licensed Practical Nurse) stated she saw (R1's) call light blinking and went to her room. (R1) was crying and stated (V11) told her to use her (adult brief) for the bathroom. (V10) assisted (R1) by changing her (adult brief). (V10) left the room and addressed (V11) about telling (R1) to use bathroom in (adult brief), which (V11) denied. Later during the night, (V11) saw (R1's) call light flashing. (V11) asked (V10) to come with her into (R1's) room. (V11) asked (R1) to tell (V10) what she told (V11). (R1) stated (V11) was giving her attitude during cares in her room. (R1) also stated (V11) had an attitude during cares as well. Upon completion of investigation, facility believes (V11) exhibited attitude that does not meet facility standards during cares with both residents (R1 and R2), however facility unable to substantiate the allegation of telling (R1) to use bathroom in (adult brief). (V11) no longer works for the facility. Agency notified. Physicians and Power of Attorneys notified of outcome of investigation. V10's (LPN) Investigation Form dated 9-20-22 and signed by V1 (Administrator) documents, I saw the call light going off for (R1's) room. I entered the room and (R1) was crying. (R1) told me that (V11/Agency CNA/Certified Nursing Assistant) told her to use the bathroom in her depend (adult brief). I assisted (R1) with changing her and I left the room. R1's Investigation Form dated 9-19-22 documents, (On 9-17-22), (V11) came in and the attitude that (V11) had was like I was bothering her. (R1) stated, I need to use the bathroom and get one of those diapers on. I turned over and (V11) said, Oh! You are incontinent. I am just going to come back when you are finished. Nurse (V10) came in and told me she would be right back, and the girl (V11) came in with the nurse (V10) and sat down in (the) chair and said, I want to hear what you are going to tell (V10) I said. (V11) did not change the wet pad under me. (V11) just pulled it up and left. I had to call for a pain pill and something to settle me down. On 9-30-22 at 10:35 AM R1 stated, (On 9-17-22) in the middle of the night, (V11) came into the room to answer my call light. I told (V11) I needed to get up to use the restroom. (V11) checked my diaper (adult brief) and said to me, You are already wet. I am not going to take you to the bathroom. Just go ahead and finish (being incontinent) in your diaper. I told (V11) I would at least like to use the bedpan. (V11) told me she did not have time for that and told me to finish in my diaper. (V11) was very rude. I was crying about it. I was so upset. I am used to being independent and wanted to go to the bathroom. (V11) acted like I was a baby. I told the nurse (V10) how (V11) was so rude to me and made me pee my diaper. I felt like (V11) was very abusive to me. I have never felt that way. I had to take a pain pill to calm down and get back to sleep. On 9-30-22 at 2:30 PM V10 (LPN) stated, I went into (R1's) room sometime around 3:00 AM or so (9-17-22). (R1) was crying and said (V11) has turned her over and told her she was already wet, so instead of taking her to the bathroom, (V11) told (R1) to wet her (adult brief). When I checked (R1) her (adult brief) was soaked. I changed her and cleaned her up. (R1) did ask me for a pain pill. On 9-30-22 at 11:15 AM V1 (Administrator) stated, I have notified the agency that (V11) is no longer allowed to work at this facility due to multiple resident complaints about her being rude. 2.) R2's Admission Record documents R2 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Notes dated 9-22-22 document R2 was discharged home. R2's MDS assessment dated [DATE] documents R2 is cognitively intact with a BIMS (Brief Interview of Mental Status) score of 14, requires limited assistance of one staff for transfers and toileting, and is always continent of urine. R2's Investigation Form Statement dated 9-19-22 documents, (V11) came in and placed walker and acted hateful about it. (V11) did not go to the bathroom with me and did not turn on my light. (R2) asked (V11) to put head of bed down and (V11) just gave attitude. (V11) wants to complain about not having enough help, staff did not show up, and they were shorthanded. (V11) just had a completely different attitude. (V11) told (R2), You just called me an hour ago. (V11) did not apologize. I almost dread the nights to come. It is like they do not want me to be here, and I really need them (staff) at night. On 10-1-22 at 2:45 PM R2 stated, (V11) was very rude. (V11) acted like I did not need help and acted like I was a liar. (V11) was very huffy and would tell me, I do not have time to keep helping you! (V11) does not need to be a CNA or need to take care of the elderly.

Based on observation, interview and record review the facility failed to provide adequate supervision for a high fall risk resident by failing to implement interventions for fall prevention for one of three residents (R1) reviewed reviewed for falls on the sample list of six residents. This failure resulted in R1 being left unattended by staff members in a dining room area, and then ambulating independently without a wheelchair or staff assistance into the hallway and falling. R1 sustained a fracture to the nasal bone, fracture to the nasal septum, and fracture to the left maxillary sinus requiring surgical intervention. Findings include: On 9/21/22 at 10:45 am R1 had swelling to bridge of R1's nose with an incision site present. R1's fall risk assessment dated [DATE] documents a fall risk score of 80, indicating high risk for falls. R1's care plan initiated on 8/15/2019, documents that, R1 is at risk for falls related to fall with nasal and facial fractures, R1 has impaired cognition, R1 has behaviors and may become resistive or combative, and R1 has a history of sitting self down on floor. The care plan documents interventions as: Offer assist to common area when up in wheelchair, (date initiated: 2/19/2021), and encourage to sit in common area for visual supervision when up in wheelchair (date initiated: 5/2/21). R1's Minimum Data Set assessment dated [DATE] documents Moving from seated to standing position: 2: Not steady, only able to stabilize with staff assistance. R1's medical record documents on 9/5/2022 at 4:10 PM by V3 Agency Licensed Practical Nurse, was called by dietary aid to help a resident. when came to area resident was lying on stomach hands on face blood all over face. lacerations to right upper brow, right lower eye and upper nose. R1's Fall occurrence report documents on 9-5-22 at 3:45 PM, Type: Fall, Location: Common Area, Activity: Ambulating. Care prior to fall: visually observed on 9/5/22 at 3:30 PM, Wheelchair not in use. The facility's investigation file documents, Final report: date of occurrence: 9-5-22 at 3:45 PM. Conclusion: R1 attempted to ambulate without wheelchair or staff assistance from dining room to store, in the main lobby area. While ambulating R1 fell on to the floor, R1 was attempting to purchase items from store with BINGO earnings although store was closed. R1 is an extensive assistance during locomotion and has a BIMS (brief interview of mental status score) of 3. Upon observation noted laceration to right upper brow, lower eye and upper nose. Transported to emergency room for evaluation and treatment, facility notified the next morning of fracture to nasal bone, nasal septum left maxillary sinus extending to left pterygoid plate and left pterygoid palatine fossa. Returned to facility on 9-7-22. Facility believes the cause of fall was due to attempting to ambulate independently to purchase an item form store without her wheelchair or staff assistance. On 9/21/22 at 11:04 AM V3 Agency LPN stated, on 9-5-22 I was notified by a dietary employee, something about blood and a resident, I went down to the dining room hallway area and (R1) was on the floor, lying on (R1's) belly, with (R1's) head lifted up holding (R1's) face with (R1's) hands, it was bleeding, I assessed (R1) and sent (R1) out to the emergency room . (R1) had shoes and socks on, I don't know where her wheelchair was at the time of the fall. (R1) is a fall risk, especially depending on her mood, some days (R1) will try to get up and walk on (R1's) own and other days (R1) just sits in the wheelchair, depending on (R1's) mood we don't leave (R1) alone, that day in report I was told (R1) was in one of (R1's) walking moods, so I knew to keep an eye on (R1's) behaviors. (R1) had went down to play bingo and fell . On 9/21/22 at 9:55 AM V4 Activity Assistant stated, bingo started around 2:30 PM on 9-5-22, (R1) was sitting at a middle table in the dining room playing and visiting with other residents. After bingo was over I was picking up the bingo cards and cleaning the tables, (V5 Activity Assistant) had left the dining room to take other residents back to their rooms, (R1) was sitting at the table visiting with (R6). I left to take another resident back to their room, I went to the bathroom and when I returned, no residents were in the dining room, I figured another staff member had taken (R1) back to (R1's) hallway. I went back to the office to chart, about 15 minutes later I heard someone scream, I went out into the hallway and was told that someone from dietary had found (R1) on the floor. I didn't know (R1) had been trying to get up and walk that day. Didn't even cross my mind (R1) would try to get up on her own. On 9/20/22 at 2:08 PM V5 Activity Assistant stated, on 9/5/22 we started bingo around 2:30 PM in the dining room, I had went down to the lounge area on (R1's) hallway, I pushed (R1) to the dining room, (R1) was sitting in at one of the middle dining room tables, bingo had ended around 3:15 PM, (R1) was sitting in the dining room in (R1's) wheelchair visiting with (R6). I left to take other residents back to their rooms. (V4) was still in the dining room, I came back from the bathroom and there was no more residents in the dining room, (V4) was not in there either, I went back out in the hallway and down to the office, I had a call to do with another resident, I did that. About 10 to 20 minutes later I saw the paramedics in the hallway by the dining room and other staff members, another staff member told me then that (R1) had fell . This was the first time I had seen (R1) come out to Bingo in a long time, (R1) sometimes comes to other events, (R1) doesn't propel her own chair to and from the activities, (R1) has to be pushed in (R1's) wheelchair. On 9/21/22 at 2:05 PM V2 Director of Nursing stated, on 9/5/22 (R1) was in the dining room playing bingo, chatting with other residents, bingo had ended, and was then observed on the floor in the hallway outside of the dining room between the bird cage and the glass cabinet purchasing store by a dietary staff member. The activity staff members (V4 and V5) said (R1) was sitting at the table in the dining room talking with another resident and they had started taking other residents back to their rooms. (R1) was then found on the floor. (R1) went to the emergency room , had facial and nasal fractures and had surgery on her nose. The root cause of (R1's) fall was self ambulating after activity to get a bingo prize from the store, we don't know If maybe (R1) seen something she wanted or what because (R1's) wheelchair was in the dining room, (R1) would have walked out of the dining room to the left towards the glass case store area, instead of going right, the direction of (R1's) room. There were no other residents or staff members in the area when the fall occurred. R1's hospital records, dated 9/5/22 document, CT of face: impression 1- multiple facial fractures, there is a commuted mildly depressed and left laterally deviated nasal bone fracture and comminuted nasal septal fracture. 2- fractures along the maxillary sinus walls inferolateral on the right side and far posterior on the left. This is probably extending through the left pterygoid plates and pterygoid palatine fossa area. 3- bilateral right greater than left maxillary sinus hemorrhage and fluid. Bilateral ethomoiditis. 4- soft tissue contusion and laceration overlying the nasal bone. Plastic Surgery Consultation note: 9-6-22, assessment- fractures of nasal bone, nasal septum, left maxillary sinus extending to left pterygoid plate and left pterygoid palatine fossa. Recommendations: plan for reduction next week, will need medical clearance. History and Physical Information- patient has been immobile since having COVID last year, sometimes tries to get up and walk as she did last night and had a ground level fall sustaining the above listed injuries. R1's hospital post procedure notes document, date of service 9-12-2022 Procedure: closed reduction nasal bone fracture repair. Procedure details: began by manual manipulation and reduction of nasal bones, I then used a butterknife to further reduce and set the nasal bones into position, the bones were very comminuted so perfect reduction was quite difficult. I then used a septal forcep to manipulate and bend the nasal septum into a better position. Nasal splints were then placed. The facility's policy, with a revision date of April 2019, titled Fall Assessment and Management Policy documents, It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Procedure: Fall risk planning and assessment: C- The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident.

Based on observation, interview and record review, the facility failed to document thorough investigations to determine the root cause of falls. The facility also failed to ensure residents were protected from injury and the potential for injury during transport. This failure affects two of three residents (R1, R2) reviewed for falls in the sample of five residents. This failure resulted in R1 falling forward from R1's wheelchair while being transported. R1 sustained a 2 centimeter laceration to R1's left forehead which required emergency room intervention. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires extensive assistance of one/limited assistance of one for mobility on and off unit. This MDS also documents R1 is cognitively intact. R1's fall investigation for R1's fall on 5/4/22 documents the following: The Final Report sent to the State Survey Agency on 5/10/22 at 4:18pm documents R1 had fallen out of the wheelchair while being transported by V3, Certified Nursing Assistant (CNA.) This report documents R1 had bleeding from the left side of R1's head and went to the emergency room and received three sutures above the left eye. This report also documents while being transferred in the wheelchair, R1's foot dropped onto the floor causing (R1) to fall forward from the wheelchair. Intervention is for R1 to have foot pedals on while being transported by staff in the facility. There is no documentation in this fall investigation as to why R1's foot dropped. There is no documentation that the wheelchair was evaluated after the fall. There is no documentation the use of leg rests/foot pedals in place/in use during the transport via wheelchair. R1 and V3's witness statements do not document the use of leg rests/foot pedals. R1's emergency room records dated 5/4/22 document R1 reported R1 was being pushed by a staff member at the facility and R1 put R1's foot down to rest on the pedals but there was not a pedal down and R1 fell out. These records document Computed Tomography (CT) of the brain results documenting R1 has a left frontal scalp subgaleal hematoma (bruise.) These records also document R1 had a 2 centimeter round laceration with avulsion of skin to R1's left forehead and bruising to R1's right knee and left shoulder. R1's Physician's Orders dated 4/29/22 document an order for Physical Therapy and Occupational Therapy to evaluate and treat. R1's Physical Therapy (PT) Evaluation dated 5/4/22 at 1:53pm documents the reason for the referral to PT is due to ongoing decline in function and increased need for caregiver assistance. This evaluation also documents R1 is very stiff in both lower extremities and trunk. On 5/16/22 at 1:45pm, R1 stated V3, Certified Nursing Assistant (CNA) was pushing R1's wheelchair (on 5/4/22) after R1 had went to the restroom. R1 stated R1's foot rests were not on R1's wheelchair or the pedals were not down. R1 stated R1 can only hold R1's feet up/legs up for so long before R1 needs to rest them. R1 stated R1 uses the foot pedals frequently to assist with R1's legs when they get tired and thought V3 had put the foot pedals down. R1 stated R1 had moved R1's legs/feet down to rest them on foot pedals, but the foot pedals were not down and that is when R1 fell forward out of the wheelchair. R1 stated R1 has to use the foot pedals due to weakness in both R1's legs. On 5/17/22 at 1:10pm, V1, Administrator stated R1 stated R1 was holding R1's feet up but R1's right leg dropped. V1 stated R1 did not say why the right leg dropped and V1 did not ask about potential reasons causing R1's leg to drop. V1 stated V1 did not think there were foot pedals on R1's wheelchair at the time of the fall. V1 stated R1 did not tell V1 anything about foot pedals not being there and V1 did not ask details about the wheelchair or why R1's leg dropped. V1 stated V1 did not take a look at R1's wheelchair after R1's fall from the wheelchair. 2. R2's Care Plans dated 12/30/21 document R2 requires physical assistance with gait belt and walker for ambulation. R2's Fall Investigations document as follows: On 3/16/22 at 5:45am, R2 fell in R2's room while ambulating. This note documents no injuries were noted. Bed was not in low position and nursing staff states that R2 will raise R2's bed to standard height on R2's own and self transfer. Intervention: remove fall mat as R2 will get in and out of bed per staff. R2 stated, (R2) slipped on that damn thing pointing to the fall mat next to R2's bed. This note documents R2 tripped on the floor mat attempting to self transfer. This note documents the root cause of the fall as mat in way of ambulation and intervention of non-skid strips on floor. There is no documentation in this investigation as to what R2 was attempting to do or why R2 got up on R2's own. There is no documentation as to which staff stated R2 raises R2's bed on R2's own. There is no documentation of multiple staff interviews. On 4/13/22 at 9:16am an unidentified CNA walked past R2's room and observed R2 laying on R2's left side on the floor holding R2's head in front of R2's chair. R2 was wearing shoes and a robe. R2 stated R2 was cold so R2 got up and went to bedroom to put a robe on. R2 stated R2 lost R2's balance and fell . Fall intervention- sign placed on walker that documents to remember to use R2's walker at all times. This note documents there were no witnesses. Conclusion: observed on the floor. Root Cause: didn't use R2's walker. Intervention: sign placed on walker to remind R2. There is no documentation as to R2's location prior to the fall. This investigation documents the walker was by the bedside table, but there is no documentation as to R2's location prior to the fall in relation to the walker. There is no documentation in to investigating why R2 was cold/temperature in R2's room. This investigation does not document additional witness statements from multiple staff who provided care for R2. On 5/17/22 at 2:30pm, V2, DON confirmed there were no additional witness statements related to R2's fall on 4/13/22. V2 stated the investigation does not document investigation in to multiple details of R2's fall. R2's Fall Investigation (5/7/22 at 1:35am per Progress Note) documents: The facility's final report to the State Survey Agency on 5/11/22 at 3:24pm documents R2 was assessed by staff and had bleeding to the left side of R2's head. This report documents R2's roommate (R4) stated R2 was standing near the foot of (R4's) bed, turned to (R2's) own bed, stumbled and fell on to the floor. R2 did not have R2's walker during ambulation. R2 was sent to the emergency room and found to have a left [CONDITION(S)]. There is no documentation as to where R2 was found on the floor or how R2 was positioned when R2 was found on the floor. There is no root cause of this fall documented. On 5/17/22 at 1:10pm, V1, Administrator stated V8, CNA stated R2's roommate (R4) called for help. V8 stated V8 did hourly checks on R2 and R2 was in the bed about an hour before when V8 peeked in on R2. R2's roommate had turned on the call light and that is when V8 found R2 on the floor. I don't recall staff mentioning if they had asked what R2 was trying to do or why R2 had gotten up on R2's own. The Root Cause: the only thing we got was he fell by R2's bed. Roommate did not say. V1 stated V1 did not ask about R2's walker location and R4 did not say what R2 was trying to do when R2 fell . The facility's Fall Assessment and Management Policy dated April 2019 documents the facility is to assess each resident's fall risk with each fall to help facilitate an interdisciplinary approach for care planning to appropriately monitor assess and ultimately reduce injury risk. The potential for falls will be care planned when appropriate based on the fall assessments. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident. Assessment parameters include a description of how the resident was observed and circumstances surrounding the fall.

Failures identified required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to safely transfer a resident resulting in the resident sliding toward the floor from the mechanical lift sling and being assisted to the floor by staff. The facility also failed to investigate falls to determine the root cause, failed to implement post fall interventions after multiple falls for three of three residents (R4, R5, R6) reviewed for falls in the sample of six. These failures resulted in R4's right arm humeral neck fracture with pain and R6's left [MEDICAL CONDITION]. B. Based on interview and record review, the facility failed to complete an investigation to determine a root cause and implement interventions for one of three residents (R1) reviewed for eating who experienced a choking incident in the sample of six. Findings include: The facility's Fall Assessment and Management Policy dated April 2019 documents the facility is to assess fall risk on admission, quarterly and with each fall to help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident. Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. A licensed nurse will immediately assess the resident and parameters after a fall including a description of how the resident was observed with circumstances surrounding the fall, unusual signs or symptoms, environmental factors (wet floor, uneven surfaces) and care plans will be updated. A.1. R4's Medical [DIAGNOSES REDACTED]. R4's Report to the State Survey Agency dated 1/22/2021 documents on this date at 7:00pm, V15 (Certified Nursing Assistant/CNA) was using the stand mechanical lift to transfer R4 from R4's wheelchair to R4's bed. R4 let go of the handles on the lift and dropped R4's arms. The lift sling began to slide up R4's back. V15 stopped the motion of the lift and balanced R4 on V15's knee and yelled for assistance. V16 (Licensed Practical Nurse/LPN) assisted V15 to lower R4 to the floor. This Report documents R4 did not have complaints at the time of the incident. There is no documentation that R4's range of motion was assessed after R4's fall. On 1/23/2021 and 1/24/2021, R4 began to complain of general aches and pains on both days. On 1/25/2021 R4 complained of right arm and shoulder pain while working with therapy. On 1/26/2021 an X-ray was completed with results documented as a humeral neck fracture of indeterminate age. R4's Physical Therapy (PT) Evaluation & Plan of Treatment notes document R4 had impaired range of motion due to right shoulder and right arm pain. These notes document R4's pain is constant to the right shoulder and has bruising. R4 is guarding the right shoulder and unable to stabilize a sitting balance with the right upper extremity. On 2/2/2021 at 4:20pm, V12 and V13 (Certified Nursing Assistants/CNAs) provided hygiene care to R4. R4 was wincing during assistance with bed mobility due to pain of the right shoulder per R4's statement. V12 stated R4 broke R4's right arm when R4 fell (on 1/22/2021). On 2/4/2021 at 11:00am, V20 (Physical Therapist/PT) stated V20 noted R4 guarding R4's right arm/shoulder, with extensive pain and bruising to the right upper arm on 1/25/2021 when V20 completed a therapy evaluation. V20 stated V21 (CNA) reported to V20 that day that R4 had been having the right arm pain. On 2/4/2021 at 12:00pm, V21 (CNA) stated V21 assisted R4 on 1/23/2021. V21 stated R4 was screaming because R4 was having right arm pain. V21 stated V21 reported R4 was screaming with right arm pain to V22 (Registered Nurse/RN). V21 stated V22 stated V22 would give R4 some pain reliever and if R4 was in that much pain V21 would have to get something stronger for pain relief. V21 stated she also reported R4 was having the right arm pain, guarding of the right arm and a bruise on the right arm to V20 (PT). On 2/3/2021 at 3:40pm, V2 (Director of Nursing/DON) stated V2 completed the investigation for when R4 was lowered to the ground after beginning to fall/slide out of the mechanical lift sling. V2 stated V15 (CNA) was transferring R4 by V15's self when R4 let go and began to slide/fall toward the floor. V2 stated R4 was weak from being sick with R4's recent COVID (human coronavirus) infection. V2 stated R4's right arm fracture probably happened when R4's arm was pushed up by the sling of the lift as R4 slid/fell toward the floor. V2 stated V16 (LPN) reported V16 had told V15 (CNA) to use the full mechanical lift on R4 because R4 was so weak from being so sick. V2 stated R4 had just transferred off the COVID positive unit after 10-12 days of being sick. V2 stated an employee (such as V15) would/should know when a resident is weaker. V2 stated the root cause of R4's fall on 1/22/2021 was weakness and not using the (full mechanical) lift as directed. V2 stated V15 should have followed the nurse's instructions and transferred R4 with the full mechanical lift. On 2/3/2021 at 4:05pm, V14 (Restorative Nurse) stated V14 printed R4's X-ray from the computer. V14 stated the X-ray company calls the facility with results in addition to faxing the report to the facility. R4's Occurrence Report dated 1/31/2021 documents R4 fell on [DATE] at 8:15am. This report documents R4 was lowered to the floor when R4 yelled help! as R4 was sliding out of wheelchair and assisted to the floor. There is no documentation of an investigation for this fall. There is no documentation of the root cause or post fall interventions implemented for this fall. On 2/3/2021 at 3:40pm, V2 (DON) stated the facility does not complete a full investigation for falls/incidents unless the incident is a reportable (to the State Survey Agency). V2 stated if the fall (report) makes sense, then we accept as is. V2 stated the floor nurses are to notify the resident's physician and family, investigate the fall and determine the root cause. V2 stated the floor nurses are also responsible for implementing post fall interventions and updating the resident's care plans after a fall. A.2. R5's Face Sheet dated 3/3/2021 documents [DIAGNOSES REDACTED]. R5's Progress Notes dated 12/1/2020 at 8:15am documents R5's nose was swollen, slightly bruised and scratched. R5 complained of generalized pain and was sent to the emergency room for evaluation due to fall with head injury. R5 was newly diagnosed with [REDACTED]. R5's Occurrence Report dated 12/1/2020 at 7:40am documents a staff member from R5's unit came up to east side and notified staff R5 was found on the floor. R5 was laying on R5's right side and had an abrasion on the center side of R5's nose. There is no documentation of name or witness statement of the staff who reported the fall. This report documents R5 is not independent for toileting. Care Prior to fall documents N/A (not applicable) for when R5 was last visually observed, toileted, given fluids, repositioned or medicated for pain or anxiety. Conclusion: R5 was incontinent of bowel and was trying to get away from the mess in (R5's) bed. R5 was sitting at the end of R5's bed and fell forward landing on R5's right side. This report documents the root cause was R5 had been incontinent, although there is no documentation of when R5 was last toileted or observed. There is no identified post fall intervention for this fall. This report documents R5 was sent to the emergency room for evaluation after assessment but does not describe what assessment revealed. R5's Progress Notes dated 12/1/2020 at 11:48am document the State Survey Agency was faxed to update about R5's fracture and V1 (Administrator) and V2 (DON) were notified. R5's Occurrence Report documents R5 was found on the floor on 12/20/2020 at 8:45am. This report documents R5 is always wanting to lie down and has been extra tired since R5 had COVID infection. R5 stated, I (R5) just want to lay down. This report documents R5 was found on the floor by V11 (CNA) but does not document a witness statement from V11. This report documents the root cause due to resident action or internal risk factors, but no specific reason/root cause. There are no documented post fall interventions for this fall. R5's Occurrence Report documents R5 was found on the floor on 1/29/2021 at 2:25pm. R5 was noted to have had a loose stool at the time of the fall. There is no documentation of an investigation as to the conclusion or root cause of this fall. There is no documentation of post fall interventions implemented after this fall. R5's Occurrence Report documents R5 was found on the floor next to the side of the bed on 1/29/2021 at 3:55pm and that R5 has had increased weakness since R5's [DIAGNOSES REDACTED]. There is no documentation as to a conclusion or root cause of this fall. There is no documentation of post fall interventions implemented after this fall. On 2/3/2021 at 3:40pm, V2 (DON) stated the facility does not complete a full investigation for falls/incidents unless the incident is a reportable (to the State Survey Agency). V2 stated the floor nurses are to notify the resident's physician and family, investigate the fall and determine the root cause. V2 stated the floor nurses are also responsible for implementing post fall interventions and updating the resident's care plans after a fall. A.3. R6's Face Sheet dated 2/3/2021 documents R6 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This sheet documents R6 was diagnosed with [REDACTED]. R6's Occurrence Report documents R6 had a fall on 1/11/2021 at 6:00am. This report documents R6 was attempting to sit on the toilet and missed, sliding to the floor. This report does not document which staff member found R6. There is no documentation as to R6's care and/or when R6 was last observed prior to the fall. There is no documentation as to what footwear R6 was wearing or environmental conditions at the time of the fall. There is no root cause identified for the fall. R6's Occurrence Report documents R6 was found sitting on the floor with R6's back against chair with legs extended in from of R6 on 1/13/2021 at 10:07am. R6 was noted to have a skin tear to the left elbow and bruise to the left lower back from this fall. There is no documentation of investigation as to R6's care and/or when R6 was last observed prior to the fall. There is no documentation as to what footwear R6 was wearing or environmental conditions at the time of the fall. There is no root cause identified for the fall. This report does not document post fall interventions to prevent future falls. R6's Occurrence Report documents R6 was found on the floor lying on R6's right side in front of R6's room on 1/21/2021 at 6:30pm. This report documents R6 reported trying to get up and R6 fell . R6 complained of left hip pain during the post fall assessment. There is no documentation R6's environment/floor was assessed in the report. This report does not document a conclusion, root cause or that post fall interventions were implemented to prevent future falls from occurring. R6's Report to the (State Survey Agency) dated 1/21/2021 documents R6 was found on the floor and complained of left hip pain. R6 does not remember to use R6's call light. This report documents an hour after the fall, R6 complained of left hip pain and R6 was sent to the emergency room . R6's X-ray performed at the emergency room revealed a left [MEDICAL CONDITION] and R6 was admitted to the hospital. R6's Care Plan will be re-evaluated upon return from the hospital and care plan will be adjusted to meet R6's needs. R6's Census dated 1/29/2021 documents R6 readmitted to the facility from the hospital. R6's Care Plans dated 2/1/2021 do not document post fall interventions from R6's fall resulting in left [MEDICAL CONDITION] on 1/21/2021. B. The facility's Adverse Event Policy dated 11/1/2017 documents the facility's adverse event monitoring will include identification, reporting, tracking, investigating, analyzing and using the data and information related to adverse events in the facility including developing activities to prevent adverse events. The facility must take and implement actions aimed at performance improvement. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 is cognitively intact. R1's Occurrence Report dated 1/20/2021 documents R1 was eating in R1's room. V3 (CNA) responded to R1's call light and found R1 slumped in chair and cyanotic. V3 noted R1's food tray in front of R1 and performed the [MEDICATION NAME] Maneuver on R1. After a couple of thrusts, (R1) coughed up a piece of meat. R1's color returned immediately and R1 began talking. There is no documentation of an interview with R1. There is no documentation of a root cause of the choking incident for R1. There are no evaluations documented from V9 (Dietary Manager), V10 (Registered Dietician/RD) or V11 (Speech Therapist). R1's Choking Investigation dated 1/25/2021 document R1 expelled a piece of meat that was approximately the size of a quarter. This investigation does not contain a statement from R1 as to why R1 felt like R1 choked. There is no documentation of evaluation of the meat product that had been served, interviews with additional resident's related to the beef stew that day, nor any evaluations by speech therapy or a Registered Dietician regarding the choking incident. On 2/1/2021 at 12:07pm, R1 stated R1 was eating lunch a couple weeks ago and there was beef stew. R1 stated R1 typically does not eat much meat, but thought it looked good and took a piece to try it. R1 stated, It was too big; I should have cut it smaller first, and R1 choked. R1 said it got stuck in R1' s throat and R1 pushed the call light and tried calling out for help but was unable to do so. R1 stated staff responded fast and Thank God, I thought I was a goner. R1 stated R1 has had no problems with eating, swallowing or symptoms of any problems in the past. R1 stated the meat in the beef stew was just too big. R1's Care Plans dated 1/26/2021 do not document updated interventions related to R1's choking incident on 1/20/2021.

Based on interview and record review the facility failed to identify or evaluate a thermal hazard and implement an intervention to prevent injury to one of three residents (R1) reviewed for resident injury in a sample of seven. This failure resulted in R1 sustaining second [MEDICAL CONDITION] the third, fourth and fifth fingers of the left hand. Findings include: R1's facility face sheet dated [DATE] documents a [DIAGNOSES REDACTED]. R1's Physician order [REDACTED]. R1's Medication Administration Record [REDACTED]. R1 also had a Physician order [REDACTED]. On [DATE] at 11:40AM, V16 (R1's Physician and Hospice Physician) stated (R1) would not have been moving around much on (R1's) own when (R1) was receiving the above mentioned medications at those times and doses. R1's progress note dated [DATE], 12:05PM documents (R1's) family was visiting and summoned staff to come to assist with changing (R1's) position in bed due to leaning toward the left side. While positioning (R1) it was noted that (R1's) arm was hanging down off the side of the bed toward the heater system (heat register). (R1's) arm was noted with redness and warm to touch, the area measured 5 centimeters (cm) by 3 cm. A cool towel was placed to the area. R1's progress note dated [DATE] at 7:36AM, documents When staff went to reposition (R1), (R1's) Left hand was noted to be hanging from the bed and laying on the wall heat register. R1 had second [MEDICAL CONDITION] the third (5cm in length); fourth (4.2 cm in leant); and fifth (5 cm in length) fingers of the left hand. The hospice nurse was notified. An order was received for [MEDICATION NAME] ointment to be applied to the areas every shift. On [DATE] at 12:59PM, V4 (Nurse) stated (R1's) left hand was laying on the heater unit on [DATE]. (R1) sustained second [MEDICAL CONDITION] the third, fourth and fifth fingers of the left hand. All three finger areas had broken blisters with no active bleeding. I found (R1) laying with (R1's ) hand on the heater unit next to (R1's) bed. The bed was push up next to the wall next to the heat register. I moved the bed slightly away from the wall at that time. (R1) was not able to move self about in bed at that time. (R1) was on hospice and receiving [MEDICATION NAME], Scapolomine, and [MEDICATION NAME]. I did not touch the heat register that day to see if it felt hot. On [DATE] V3, (Hospice Nurse) stated I did an assessment of (R1) on [DATE] in the morning and (R1) was not able to move (R1's) self in the bed. (R1) was actively dying. I did not look at (R1's)[MEDICAL CONDITION] the left hand that day since they were dressed and I did not want to cause (R1) any undue stress. On [DATE] and [DATE] V5 and V9 both Certified Nurse Aids (CNA's) as well as V14 (Nurse Unit Coordinator) and V18 (Assistant Director of Nursing) all concur that R1's bed remained positioned next to the wall heat register until the [DATE] incident causing the second [MEDICAL CONDITION] R1's left hand. They also concur that the heat registers are warm to touch not hot. They all also agree that R1 was not able to move self in bed on the last four or five days ([DATE] -[DATE]) before R1 expired. On [DATE] at 10:05 AM, V15 (Assistant Director of Nursing) stated (R1's) bed was sitting slightly away from the wall when I came into work about 6:30AM [DATE]. I positioned the night stand next to the wall and the bed next to the night stand to prevent the bed from being moved next to the wall. I was not aware that (R1) had another incident where (R1's) left arm had redness from the heat register on [DATE]. I felt the register that day and it felt slightly warm not hot to touch. On [DATE] at 12:30PM the digital thermometer hanging on the bed next to the heat register measured 91 degrees Fahrenheit. The Thermal Label tape placed on the heat register did not turn black. On [DATE] at 12:11PM, V19 (Maintenance Dirctor) stated The heat is hot water heat. I have been checking the heat registers regularly and none of them feel hot, just warm to touch.

Based on observation, interview and record review, the facility failed to utilize safety devices for three of nine residents sampled for falls (R15, R16 & R25), out of a total sample of 24. The facility failed to investigate and ensure an assistive device was functional (R15), failed to implement an assistive device to prevent falls (R16 & R15) and failed to transfer with the mechanical lift in a safe manner (R25). These failures resulted in R15 and R16 falling and receiving a fractured hip (R15) and an oblique fracture of the left femur (R16). The facility also failed to ensure that potentially hazardous chemicals were kept in locked areas that were not accessible to residents on two of three units. Findings include: 1. According to the facility admission form and the hospital History and Physical dated [DATE] , R15 was admitted to the facility on [DATE] after being in the hospital with a fractured right hip that R15 sustained at her home. R15's admission [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed R15 as moderately cognitively impaired, and required limited to extensive assistance for all ADLs (activities of daily living). R15 also required physical support with standing balance and was unsteady with sitting. Review of the fall assessments dated [DATE], [DATE], [DATE]/, and [DATE], show R15 to be at high risk for falls. Review of the Care Plan dated [DATE] found that the Care Plan has as the problem: "Resident at risk for falling due to recent hospitals stay for fall/hip fracture." One of the Interventions for falls is "Monitor for sounding safety alarms...answer promptly." The Care Plan also documents that R15 is to have padded hip protectors on at all times, which were ordered on [DATE]. Review of the Nurses Notes dated [DATE] at 9:40 p.m. E8, Certified Nurse Aide heard R15 crying from her room. Nurses Notes also documents, when the nurse came into the room and tried doing Range of Motion to R15's left leg, R15 complained of "excessive pain". R15 was sent to the hospital where she was admitted with a fractured left hip. On [DATE] at 11:05am, E8 said that when she entered R15's room, R15 was on the floor by her bed, the alarm was not sounding, and neither did R15 have on any padded hip protectors. E8 stated that she checked the bed alarm at that time and the alarm was functioning correctly, but had not been turned on when R15 had been put to bed. The incident report dated [DATE] documents the preventative measure being used at the time of the fall for alarm was "none". E8 and E11, Restorative Nurse, stated on [DATE] at 11:10am that the alarm should have been turned on when R15 was put to bed. There was no indication in the nurses notes, nor on the incident investigation form that the alarm had been checked or if it was functioning or not. This was only found when interview took place with E8 on [DATE], that it was not sounding and it had not been turned on. E11 confirmed and did not know why the status of the alarm had not been investigated at the time of the incident. The History and Physical from the hospital dated [DATE] documents that R15 sustained a Left femoral fracture and required an Intramedullary Nailing. R15 returned to the facility on [DATE] and expired on [DATE]. 2. The [DATE] physician's orders [REDACTED]. The MDS (Minimum Data Set) dated [DATE] states R16 has memory/cognitive problems, requires extensive assist with bed mobility, hygiene, toilet use and ambulation. The MDS states R16 requires limited assist with transfer and has poor standing balance. The facility fall assessment dated [DATE] states R16 is at high risk for falls. The Care Plan dated [DATE] states R16 fell while out of the facility fracturing her hip ([DATE]), ambulates with a walker with staff assist. The Care Plan identifies the following interventions: [DATE]: "Encourage resident to ask for assistance when has acute illness" [DATE]-"W/C(wheelchair) pad alarm." The facility Occurrence Report dated [DATE] at 5:00pm states, "......(R16) had fallen, they stated (R16) had come to the dining room with the mobility monitoring device attached and though the fall was unwitnessed there were 2 people supervising in the dining room. The entire (clip on alarm) was intact without shirt attachment present. No alarm sounding." The investigation conclusion states, "(R16) unaware of safety precautions has dementia.......Will use w/c alarm pad in place of (clip on alarm)......" The Nurse's Notes dated [DATE] at 7:00pm states, "....(R16) had apparently taken off alarm a stood for a brief period, then when going to sit back down missed the chair..." The Occurrence Report dated [DATE] at 12:28pm states R16 fell from the wheelchair to the floor in the lounge area. The report documents the alarm was "not sounding." The report states R16 was "able to move extremities without difficulty." The investigation conclusion states "........When (R16's) anxiety level is high she can be difficult to redirect.....also refuses medication.....has episodes of being withdrawn to room and wanting to find her parents...A low bed and curved mattress to be placed on bed to promote safety when in room." The conclusion does not address why R16's alarm was not sounding or what type of alarm was in use at the time of the fall. E3, LPN (Licensed Practical Nurse), stated on [DATE] at 12:55pm she found R16 lying on the floor in the lounge. E3 stated the clip on alarm was on the back of the wheelchair with the string still attached to the alarm box, "hanging over the chair." E3 stated the alarm did not sound because the unit was still "intact." E3 stated she thought after the fall (,[DATE]) they started using a sensor pad alarm. E4, Assistant Director of Nurse's, stated on [DATE] at 1:35pm a clip on alarm was used on [DATE] for R16 prior to the fall. E4 stated the clasp holding the alarm string to R16's clothing was "closed, like it had pulled off (R16's) shirt." E5, CNA (Certified Nurse Aide), stated on [DATE] at 10:05am that she thought R16 had a clip on alarm being used on [DATE]. The Nurse's Notes dated [DATE] at 7:15am state, "...noted (R16) c/o(complaint) weakness to LLE (left lower extremity) with transfers....ROM(range of motion) performed without difficulty...When asked if pain occurred (R16) touched thigh area above knee and moaned....." The Physical Therapy Discharge Summary dated from ,[DATE] to [DATE] states, "(R16) had fall on [DATE]. Difficulty participating since then. admitted to hospital [DATE]." The hospital Patient Report dated [DATE] states, "A total left hip replacement is noted. The orthopedic device is in anatomic position. An oblique fracture is noted involving the proximal femur. This crosses the distal aspect of the orthopedic device. The fracture appears acute." E7, Physical Therapist, stated on [DATE] at 9:35am therapy did do 55 minutes of exercise with R16 on the morning of [DATE]. E7 stated he was aware that R16 was having pain after the weekend. When asked if the exercises might have caused the fracture, E7 stated he thought a fall would cause the break, but not the exercises. E7 stated the most common problem in a hip replacement surgery is with dislocation. E7 stated usually a fracture in that bone (proximal femur) is caused by "trauma, then the exercises may cause pain but not a fracture." On [DATE] at 11:40am and 12:03pm R16 was in the reclining wheelchair without a sensor alarm in place. E16, CNA, stated on [DATE] at 11:30am that R16 is no longer using an alarm in the chair, only in the bed. On [DATE] at 8:10am R16 was in the dining room in the reclining wheelchair with a sensor alarm in place. E20, RN(Registered Nurse) stated on [DATE] at 8:10am that R16 is still using an alarm in the chair and bed. The Care Plan dated [DATE] states that R16 is to have a "wheelchair pad alarm" and bed alarm. 3. The [DATE] POS states R25 has [DIAGNOSES REDACTED]. The MDS dated [DATE] states R25 is totally dependent with transfers, eating, hygiene, bed mobility and toilet use. The facility fall assessment dated [DATE] states R25 is moderate risk for falls. The facility Occurrence Report dated [DATE] at 8:30am states, "2 CNAs were lifting (R25) in (mechanical lift) into his chair. The (mechanical lift) fell over as one CNA was positioning him into chair with the arm of the(lift) hitting (R25) in the forehead." The Nurse's Note dated [DATE] at 8:30am states R25 received a 2.5cm (centimeter) laceration on the forehead when the mechanical lift fell over hitting his head on the arm of the lift. The statement dated [DATE] written by E16 and E17, CNA's states, "...Applied lift sling, lifted (R25)-(mechanical lift) legs in closed position. (One) leg was through w/c, (left) leg in front of w/c....w/c locked, (R25) being lowered, (E16) pulling (R25) toward back of w/c.....to assist (R25) to seated position. (Lift positioned) at side of w/c. As (R25) lowered to w/c, (Mechanical Lift) began to lean toward (R25's) head. Hit his head......" E2, Director of Nurse's stated on [DATE] at 11:30am because R25 is so tall, the CNA's had the lift positioned on the side of the wheelchair, with one of the legs of the mechanical lift under/through the wheelchair and the other leg positioned outside of the front of the chair. E2 stated when the CNA's turned R25, lowered and pulled him straight in chair, the lift started to tip. E2 stated R25's head hit the metal arch of the lift. 4. During tour on [DATE] at 10:15am on the East Wing, the Maintenance Office door was unlocked and there were various chemicals stored inside this room. The bottles had precautionary labels to keep out of reach of children. On [DATE] at 11:15am the clean utility room door on east wing was unlocked and a bottle of glass cleaner spray was setting on the counter near the door. The precautionary label stated to keep out of reach of children. This door was still unlocked at 1:30pm, and 2:00pm. There were several residents seated in the lobby areas during the observations. Staff were observed going in and out of the clean utility room and it was not locked. On [DATE] at 2:20 pm the glass cleaner was still on the counter during the environmental review with Maintenance Director E9 and Housekeeping Director E18. E18 stated that the glass cleaner should not have been left out on the counter. On [DATE] at 9:10am an aerosol can of odor neutralizer spray was stored in the top drawer of a bedstand with isolation supplies in the corridor outside of R24's room. The label stated that the product contained acetone and isobutane. The product label had warning statements for flammability and to keep out of reach of children. Residents were observed on the corridor and could potentially gain access to the chemical. On [DATE] at 2:30 pm the beauty shop was observed unattended with the door open. There were two glass containers of comb disinfection solution on the counter. The beautician, E19 arrived a few minutes later stating that she had been in the bathroom. Maintenance Director E9 instructed E19 to pull the door closed to the shop if she had to leave the room unattended so that residents would not have access to the chemicals.