Every finding on record at Arcadia Care Morton

Based on observation, interview, and record review, the facility failed to ensure that sufficient nursing staff were available to meet residents' needs in a timely manner and did not respond promptly to call lights. The facility also failed to implement and maintain an effective staffing policy that ensured adequate staffing levels to meet residents' care needs. These failures had the potential to affect all 77 residents reviewed for sufficient staffing.Findings Include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 8/10/26 and signed by V1 (Administrator in Training), documents that 77 residents reside within the facility.The facility assessment tool dated 01/2026 through 01/2027 documents, Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The requirement for the facility assessment may be found in Appendix 1. The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care of staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Using a competency-based approach focuses on ensuring that each resident is provided with care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the facility assessment is for the facility to evaluate its resident population and identify resources needed to provide the necessary person-centered care and services the residents require. Staffing plan: Refer to Facility Assessment Addendum and CMS (Centers for Medicare and Medicaid Services) Minimum Staffing Rule.The facility's Call Light policy dated 1/2026 documents, Purpose: to respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 1. All residents who have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonably accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to the resident's room to respond to the call system and promptly cancel the call light when the room is entered. 4. Requests shall be responded to in a courteous and professional manner.The facility's Dignity policy dated 1/2026 documents, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth.The facility's Resident Rights policy dated 12/2025 documents, Purpose: to promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems, and condition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Notice of resident rights will be provided upon admission to the facility. These rights include the resident's rights to voice grievances and have the facility respond to those grievances.The facility resident council meetings dated 8/6/26, 5/7/26, 4/2/26, 3/5/26, 2/5/26, 1/1/26, 12/4/25, 11/6/25, 10/2/25, 9/4/25, and 8/7/25 included complaints of staffing, call lights, and customer service for nursing staff.On 5/5/2026, R25's Concern/Compliment Form documents, (R25) and roommate have problems with call lights regarding incontinence care.On 5/7/2026, R64's Concern/Complaint Form documents, On 5/4/26, she (R64) was put to bed wet.On 5/20/2026, R64's Concern/Complaint Form documents, (R64) stated night shift CNAs (Certified Nurse Assistants) did not check her on rounds. Stated her call light was activated for a pillow, and she had to sleep without a pillow.On 7/2/2026, R63's Concern/Complaint Form documents, (R63's) sister (R64) states staff often forget to give (R63) a call light and bed controller.On 7/2/2026, R72's Concern/Complaint Form documents, (R72) stated 2nd shift staff place call light and bed control out of reach.On 8/9/26 at 9:05 AM, R82 was sitting in her room in a wheelchair. R82 stated, There are not enough nurses, and I have been getting my medications late. Everyone is rushed here and does not have time to listen to me.On 8/9/2026 at 9:43 AM, R44 stated she feels that a lot of the time it takes staff awhile to answer her call light. R44 stated CNAs will complain they are short staffed.On 8/9/2026 at 9:45 AM, R66 stated staff are busy all the time and complain to R66 that they (CNA's) are short staffed when coming in to do R66's cares, when it takes them a long time to answer his call light.On 8/9/2026 at 10:00 AM, R1 was in his wheelchair in the hallway close to his doorway. R1 stated staff always take a long time to answer call lights. R1 stated, CNAs will not empty my urinal; it forces me to fill up an empty cup with my urine so that I can use my urinal.On 8/9/26 from 9:35 AM through 11:00 AM, R75 was lying in bed on his right side. R75 was non-verbal. R75's upper and lower extremities were noted to be contracted. Both arms were maintained in a flexed position, with the elbows bent toward the body. Both hands and fingers were contracted inward, with the fingers flexed toward the palms. R75's legs were also contracted, with both knees maintained in a bent/flexed position and the lower extremities drawn toward R75's body. R75 remained in this contracted position throughout the observation and had no positioning devices, splints, palm protectors, or other supportive devices in place. R75's right leg was positioned directly on top of his left foot pressure ulcer and left shin pressure ulcer. The dressings covering R75's left shin pressure ulcer and left hip pressure ulcer were dated 8/7/26 and were saturated with blood-tinged drainage. A blood-tinged dressing was lying on top of R75's mattress. R75's right great toe wound was uncovered and had no dressing in place. R75's left leg was positioned directly on top of the right great toe wound. No pressure-relieving pillows, devices, or other off-loading interventions were observed between R75's knees/legs, under his elbows or legs, or beneath his heels. R75's fingernails were greater than one-half inch in length and had brown debris underneath the nails. R75 had a full beard and mustache. R75's adult incontinence brief was full of feces that were leaking out at the openings by his legs. Feces were observed on R75's pillow, and a baseball-sized area of blood-tinged drainage was observed on the left side of his incontinence bed pad. Thick, brownish sputum was observed extending from R75's mouth down onto his chest. No activities were offered to R75 during this time.On 8/9/26 from 11:15 AM through 2:00 PM, R75 remained lying in bed on his right side. R75 was non-verbal. R75's upper and lower extremities were noted to be contracted. Both arms were maintained in a flexed position, with the elbows bent toward the body. Both hands and fingers were contracted inward, with the fingers flexed toward the palms. R75's legs were also contracted, with both knees maintained in a bent/flexed position and the lower extremities drawn toward R75's body. R75 remained in this contracted position throughout the observation and had no positioning devices, splints, palm protectors, or other supportive devices in place except for a pressure-relieving boot on his right foot. R75's right leg was positioned directly on top of his left foot pressure ulcer and left shin pressure ulcer. R75's left leg was positioned directly on top of the right great toe wound. No pressure-relieving pillows, devices, or other off-loading interventions were observed between R75's knees/legs, under his elbows or legs, or beneath his heels. No activities were offered to R75 during this time.On 8/9/26 at 9:00 AM V5/LPN (Licensed Practical Nurse) stated they were left with two nurses today, due to another nurse calling in. V5 stated, Two nurses are not enough for this entire building and management refuses to come in and help on the weekends. They tell us they meet the state minimum guidelines for staffing even with two nurses. There is so much for us to do to be able to adequately take care of these residents. This has been an ongoing issue.On 8/9/26 at 9:25 AM V7/LPN stated a nurse had called in, which left only two nurses to cover the entire building. V7 reported only having one nurse on each side of the building makes it nearly impossible to get medications out on time, finish wound care, and take care of the resident's needs, especially on the weekend when there are no department managers or receptionists to help out. V7 noted the facility had changed the medications to liberalized to keep the medications from being late (pushing the acceptable window to 6:00 AM to 11:00 AM) for morning medications, which still does not help when you are passing medications all day. V7 stated, Two nurses are entirely not enough, and management does not come in to help on the weekend.On 8/9/26 at 9:49 AM R85 stated her biggest concern is the facility not having enough staff to get to them timely and that a lot of times her call light is on for 40 minutes or so during the nights when she wants to get changed after being incontinent. R85 stated, I get severe anxiety over it. I lay here forever until someone comes to change me or helps me.On 8/9/26 at 11:10 AM V6 (CNA/Certified Nursing Assistant) verified R75's fingernails were long and dirty and R75 needed to be shaved. V6 verified R75 had dried feces on his pillowcase and a bloody drainage on his incontinence bed pad. V6 verified R75 had no pressure relieving pillows, devices, or other off-loading interventions between his knees/legs, under his elbows or legs, or beneath his heels. V6 stated, (R75) is never gotten out of bed. I do not even know if (R75) had a wheelchair that we can get him up in. I am one of the only CNAs that tries to take care of (R75). (R75) only gets attention whenever he has a (bowel movement). Otherwise (R75) just lies in the bed with no attention and does not get turned and re-positioned. We need more staff as we very rarely have enough.On 8/9/26 at 11:15 AM V5 (LPN) stated, (R75) is pretty much just existent. (R75) does not get turned and re-positioned. No one does anything for (R75). (R75) just lays in bed with his television on. No one ever gets (R75) out of bed, and I do not see (R75) get any activities. I have seen times where (R75's) wound treatments have not been done for two to three days. (R75) has not had any pressure relieving boots or elbow protectors on in at least six months. (R75) is getting way more wounds and his wounds are getting worse due to the neglect of (R75's) cares. I have never seen anyone do range of motion with (R75). It is very stressful here to try and get everything done for the residents with two nurses only. It is impossible.On 8/10/26 at 9:10 AM V10 (LPN/Licensed Practical Nurse) stated, (R75) is always in bed. I have never seen (R75) gotten up into a chair except for when sent to the hospital. When there are only two nurses working on day shift it is impossible to get everything done.On 8/10/26 at 9:50 AM V9 (Advanced Practice Wound Nurse) stated, I assess (R75's) wounds weekly. (R75) has terrible wounds and some have worsened. Just last week I had to debride four of (R75) wounds. At times the facility looks like a ghost town with not enough staff. (R75) looks like he is Just there. There have been a few times that I have come in, and the wound dressings were not done as ordered.On 8/10/2026 at 1:00 PM, V15 (Certified Nurse Assistant/CNA) stated staffing is always short; it is hard to get resident cares completed some days lately.On 8/10/2026 at 1:10 PM, V16 (CNA) stated some days she can get tasks done but not to the extend residents deserve. Staffing is always short.On 8/10/2026 at 1:15 PM, V17 (CNA) stated staffing is always short, people call in, and no one replaces the staff who call in most of the time. This prevents us from getting showers done, resident care, and any other tasks we are responsible for.On 8/10/2026 at 10:47 AM, V25 (Ombudsman) stated that when she comes into the facility on her regular visits or if a resident calls her, the facility is always short staffed. V25 stated that one weekend she came in, the facility only had one CNA (Certified Nurse Assistant) working when there were supposed to be five CNAs working. V25 said she often sees short staffing; residents complain about short staffing all the time, long call light wait times, and long waits for their cares.On 8/10/2026 at 3:00 PM, V1 (Administrator in Training) stated she has heard about resident complaints regarding short staffing from resident council meetings or grievances submitted. V1 stated she has been told call lights are taking too long to be answered and that CNAs enter resident rooms to answer call lights and tell residents they are short-staffed, explaining that this is why the call lights were not answered in a timely manner or why they cannot provide showers. V1 stated she bases her staffing on the state staffing minimum guidelines and does not consider adjusting staffing for resident acuity needs.

Based on interview, and record review, the facility failed to provide pressure ulcer care as ordered for three of three residents (R5, R6, and R7) reviewed for pressure ulcers in a sample of seven. Findings include: The facility's Skin Condition Assessment and Monitoring-Pressure and Non-Pressure policy, reviewed 07/2026, documents that this policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented. This form also documents that physician-ordered treatments shall be initiated by the staff on the electronic Treatment Administration Record after each administration. 1.R5's current TAR, Treatment Administration Record, documents to cleanse the left hip with wound cleanser, pat dry, apply Medi honey, and cover with a border foam daily and PRN (as needed). This treatment is not signed out as being completed on 7/7/26, 7/8/26, 7/9/26, 7/11/26, and 7/12/26. R5's current TAR documents to apply a debriding ointment to R5's left hip daily for the left hip wound. This treatment is not signed out as being completed on 7/16/26. 2. R6's current TAR documents to cleanse the left heel with wound cleanser, pat dry, apply skin prep to the surrounding skin, apply Medi-honey to the wound, and cover with collagen and a bordered foam every day shift. This form shows that R6's wound care was not signed out as being completed on 7/3/26 and 7/7/26. R6's current TAR documents to cleanse the left outer ankle with wound cleanser, pat dry, apply Medi-Honey collagen sheet, and place in a sock and protective boot. This treatment is not signed out as being completed on 7/3/26, 7/7/26, 7/8/26, and 7/14/26. 3. R7's current TAR documents to cleanse R7's left buttock with wound cleanser, pat dry, apply skin prep to the surrounding tissue, Medihoney and collagen to the wound bed, cover with a bordered foam every day shift. This form is not signed out as being completed on 7/7/26, 7/8/26, 7/9/26, 7/11/26, and 7/16/26. On 7/22/26 at 11:30am, V2, Director of Nursing, verified that R5, R6, and R7's wound care was not signed out as being completed. V2 stated that if it is not charted, it didn't happen. On 7/22/26 at 2:00pm, V1, Administrator, also verified that R5, R6, and R7's wound care was not signed out as being completed as ordered. V1 also stated that if it is not documented, then it did not happen.

Based on interview and record review, the facility failed to maintain a full-time qualified Director of Nursing. This failure has the potential to affect all 79 residents residing in the facility. Findings include: The Facility Assessment, dated 1/6/26, documents that one Director of Nursing will be staffed. This form documents the final rule regarding Nursing Services, see Code of Federal Regulations section 483.35 for details. Centers for Medicare and Medicaid Services Code of Federal Regulations Section 483.35 documents that facilities must designate a full-time RN as the Director of Nursing and utilize RN services for at least 8 consecutive hours a day, 7 days a week (with specific waivers/exemptions allowable in certain rural areas). On 6/22/26 at 10:30am, V1, Administrator, stated that there is no Director of Nursing at this time. On 6/23/26 at 10:00am, R6, Resident Council President, stated that it seems like care has gone downhill since there has not been a Director of Nursing. The facility's Census Report, dated 6/22/26, documents that 79 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to answer and follow up with call lights in a timely manner for three of three residents (R3, R4, and R5) in a sample of six. Findings include: The facility's Call Light policy, effective 01/2026, documents to respond to residents' requests and needs in a timely and courteous manner. This form documents to listen to residents' requests. Do not make him or her feel that you are too busy to help. Respond to request. If item is not available, or request is questionable, get assistance from charge nurse. Return to the resident with a prompt reply. On 6/22/26 at 12:45pm, R4's call light was activated. At 1:00pm R4's call light was answered, and R4 was told that she would be right back to help her with her toileting needs. At 1:10pm, R4 stated that she needed to be changed because she was incontinent of stool. R4 stated that she was told they would be right back to assist her, but they still have not come back. At 1:20pm, R4 reactivated her call light because she was not assisted with her toileting needs. R4's call light was answered at 1:25pm and assistance was provided. On 6/22/26 R3 activated her call light at 12:50pm. At 1:10pm R3's call light remained on. R3 stated that she had her call light on about a half hour ago, which was answered, and she was told by the staff that she did not have time to put R3 on the bedpan and left the room. R3 stated that she needed to have a bowel movement. R3 was becoming more anxious and agitated the longer she waited. At 1:25pm V5, Licensed Practical Nurse, was summoned to R3's room. V5 stated that call lights are to be answered as soon as possible, and 40 minutes is too long for the call light to be on. R5's Concern/Compliment form, dated 4/16/26, documents that there is a lack of follow-through time after answering call lights. R5 documented that it was over a half an hour after her call light was answered. R5's Concern/Compliment from, dated 5/20/26, documents that her call light was activated for a pillow, and she had to sleep without a pillow. The facility's Resident Council Minutes, dated 6/4/26, documents that call light response is an issue on third shift. On 6/23/26 at 10:00m R6, Resident Council President, stated that there have been complaints concerning call lights not being answered in a timely manner, the last couple of months in Council meetings. R6 stated that there were also complaints about follow-up after call lights were answered. R6 stated that staff will say they will be right back, but never come back. On 6/23/26 at 2:00pm, V1, Administrator, stated that call lights are to be answered as soon as possible. V1 also stated that follow-up is to be as soon as possible, too.

Based on observation, interview, and record review, the facility failed to implement isolation precautions for one of three residents (R1) reviewed for infection control in a sample of six. Findings include: The facility's Infection Precaution Guidelines, effective 01/2026, documents that it is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. This form also documents Contact Precautions: in addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident care items. This form documents that the above epidemiologically important organisms include (multidrug-resistant organisms) such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), other highly transmissible infections such as Clostridium difficile and herpes, etc. R1's current Physician Order Sheet documents for R1 to take Sulfamethoxazole-Trimethoprim 800-160mg (milligrams) tablet by mouth twice daily MRSA of the throat. On 6/22/26 at 11:30am, R1 did not have an isolation sign posted on her door, nor was there Personal Protective Equipment (PPE) available. R1 stated that staff wear gloves during care, but no other PPE. On 6/23/26 at 11:45am R1 did not have an isolation sign or PPE available. On 6/23/26 at 11:45am, V9, Registered Nurse, stated that she was unsure as to what isolation R1 should be on, but verified that R1 did have MRSA of the mouth and was positive for C-diff (Clostridioides Difficile). V9 stated that it is the Director of Nursing or Infection Preventionist's responsibility to post the signs for isolation. V9 stated that there is neither a DON nor an Infection Preventionist employed at this facility. V9 verified that R1 did not have an isolation sign posted, nor had PPE readily available for use. On 6/24/26 at 2:00pm, V1, Administrator, verified that R1 should have had a sign placed on her door indicating that she was in contact isolation. V1 stated that V3, Corporate Infection Preventionist, is covering infection control, but is only at the facility three days a week.

Based on observation, interview, and record review the facility failed to ensure that sufficient staff was available to meet the needs of residents. This failure has the potential to affect all 77 residents currently residing at the facility. Findings include:The facility's Census Report dated 5/1 /26 documents 77 residents reside within the facility.The Facility Assessment, dated 1/6/26, documents General Care: Activities of Daily Living- Bathing, Showers, Oral/Denture Care, Dressing, Eating, Support with Needs Related to Hearing/Vision/Sensory Impairments; supporting resident independence in doing as much of these activities by himself/herself. Bowel and Bladder- Bowel/Bladder Toileting Programs, Incontinence Prevention and Care, Intermittent or Indwelling or Other Urinary Catheter, Ostomy, Responding to Requests for Assistance to the bathroom/toilet promptly in order to maintain continence and promote dignity. Staffing Plan: Staff: Direct Care Staff- Refer to Facility Assessment Addendum and CMS (Centers for Medicaid and Medicare Services) Minimum Staffing Rule.The Illinois Long-Term Care Ombudsman Program Residents' Rights Booklet, dated 11/2018, documents Your rights to dignity and respect: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.The facility's Resident Council Minutes, dated 3/5/26, documents New Business: 2. Nursing: Residents say showers are improving. Customer service is still an issue. Call light response time is an issue at times. The facility's Resident Council Minutes, dated 4/2/26, documents New Business: 10. Nursing: Showers are becoming an issue, staffing concerns, cell phone usage, and customer service concerns were discussed.The facility's Water Pass-Hydration Policy, dated 12/2025, documents Purpose: To provide fresh drinking water to residents in a clean and sanitary manner to meet hydration needs. Guidelines: Fresh cold ice water will be provided to each resident a minimum of three times each day, unless contraindicated.The facility's Call Light Policy, dated 1/2026, documents Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered.Resident Council's Concern/Compliment Form, dated 2/5/26, documents Third shift only changed resident one time during the night.R8's Concern/Compliment Form, dated 2/17/26, documents Third shift on 2/17/26 did not change R8 all night. This same Concern Form documents an (unknown) CNA (Certified Nursing Assistant) came in the room and walked out, not returning to change R8. Resident Council's Concern/Complement Form, dated 3/5/26, documents Nurse staffing, nurse and CNAs are not stable, still using agency often. This same form documents Summary of Pertinent Findings: Continue to hire staff. Staff are being held accountable, so they are leaving.R9's Concern/Compliment Form, dated 3/2/26, documents This evening an (Unknown) third shift CNA took over an hour to answer call light and change me.R12's Concern/Complement Form, dated 3/4/26, documents (R12) voiced concerns during 3/4/26 on angel rounds regarding call light times from the previous weekend.R12's Concern/Compliment Form, dated 3/30/26, documents (R12) states that on 3/27/26 that she was not changed at all during night shift. This same Concern Form documents Summary of Pertinent Findings: Substantiated. Staffing concerns were reported and confirmed by V2/Director of Nursing. Corrective Action Taken: V1/Administrator and V2/Director of Nursing working on staffing together before new scheduler starts on 4/6/26.R11's Concern/Compliment Form, dated 4/24/25 documents (R11) states last night she was on her call light for more than thirty minutes before someone came and helped.The facility's Daily Assignment Sheet for Nursing and CNAs dated 3/27/26 one Agency CNA (V8), one Agency Nurse (V7), and one Facility LPN (Licensed Practical Nurse) (V9) worked 10 pm- 6am. The facility's Daily Staffing Calculator dated 3/27/26 documents Resident Census 72.On 5/2/26 at 9:51 AM, R7 stated he had staffing concerns involving a specific night shift featuring only one CNA and two nurses (on 3/27/26). R10 stated no one was answering call lights and there was no CNA on his side of the building to help him or any resident. R7 stated, It seems as though second and third shifts are short a lot of time or they have agency CNA's who don't do their job. No one even came in and rounded the night of 3/27/26. On 5/2/26 at 10:00 AM, V4/RN (Registered Nurse) stated, I came into work the morning of 3/28/26 and V7/Agency LPN (Licensed Practical Nurse) reported that she was the only staff member on her side of the building during the entire night. V7 told me there was one Agency CNA (V8) and one nurse (V9/LPN). When I started my shift that morning, a lot of residents were upset because they had not been provided with incontinent care all night.On 5/2/26 at 12:13 PM V6/LPN stated, It can be challenging on third shift, especially with staffing inconsistencies and a lot of times ice water doesn't get passed. While we are typically scheduled for four CNAs and two nurses, we are often short-staffed. This shortage, combined with varying staff performance, leads to longer call light wait times and less frequent checks for incontinence and general care. On 5/3/26 at 9:05 AM R8 reported persistent delays in call light response times, particularly during the night shift, where she has waited over an hour for assistance recently. R8 stated that staff members have attributed these delays to being short-staffed. On 5/3/26 at 9:15 AM R12 stated my hygiene needs are not being met; specifically, on the third shift, I am often only changed once due to delayed response times. Staff state it is due to staffing shortages or agency staff just not doing their jobs. On 5/3/26 at 9:45 AM, R2 reported that her call light often goes unanswered for extended periods. As a result, [NAME] frequently performs self-transfers to use the bathroom independently. On 5/3/26 at 11:04 AM V11/LPN stated A lot of times ice water won't get passed on third shift because after the kitchen closes before 10:00 PM we can't get in the kitchen to get ice anymore, therefore third shift can't pass fresh ice water. We need more staffing because of agency. Agency staff often don't know what to do. It's just like a body filling the opening and not taking care of the residents timely. On 5/3/26 at 11:41 AM R11 stated the facility is always having staffing issues which causes her to have to wait longer on her call light and not get changed timely. R11 stated, I have recently had to wait over a 1/2 hour to an hour to get changed after being incontinent.On 5/3/26 at 12:27 PM, V8/Agency CNA stated, On 3/27/26 when I arrived at work all the CNAs were already gone. After around forty-five minutes, (V9/LPN) realized there was only one CNA for the entire building for third shift. (V9) called on-call to let them know of the shortage, but no one ever came in. I only stayed on one side of the building attempting to do incontinent rounds on the residents. That was on B side. If I had time I went to the other side and answered a few call lights but was unable to change anyone on A side. The Agency Nurse (V7) didn't want to do any incontinence cares because she was Agency as well and was having to complete her nursing duties. We should not have worked that short on night shift.On 5/8/26 at 11:56 AM, V1/Administrator verified that the night shift on 3/27/26, was understaffed with only two nurses and one CNA who worked. V1 stated, I was not notified by (V2/Director of Nursing) staff was working that short until two days later (3/30/26). I should have been notified immediately. V1 acknowledged the safety risks of the shortage, noting, That is not enough staff on third shift to take care of all the residents we have, ensuring rounds are being done and call lights are being answered timely. While V1 admitted that staffing has been an ongoing issue for the past three months despite using agency fill-ins, they noted that the facility is currently doing a lot of hiring in hopes of having full staff again.

Based on observation, interview, and record review the facility failed to ensure fresh ice water is passed to residents three times per day per facility policy. This failure has the potential to affect all 77 residents residing within the facility. Findings include:The facility's Census Report dated 5/1/26 documents 77 residents reside within the facility.The facility's Water Pass-Hydration Policy, dated 12/2025, documents Purpose: To provide fresh drinking water to residents in a clean and sanitary manner to meet hydration needs. Guidelines: Fresh cold ice water will be provided to each resident a minimum of three times each day, unless contraindicated.R10's Concern/Compliment Form, dated 2/5/26, documents Nature of Concern/Compliment: (R10) told me sometime after 4:00 AM (R10) had asked for ice water. (R10) was told by two unknown CNA's (Certified Nursing Assistants) that between the hours of 4:00 AM - 6:00 AM they can't do that.On 5/2/26 at 9:45 AM, R2 had a cup of warm water sitting on R2's bedside table. R2 stated the staff occasionally pass fresh ice water on second shift and rarely on third shift. R2 stated she usually has to request fresh ice water which sometimes takes the staff a long time to bring when she does request it. R2 stated she would like fresh ice water passed to her every shift.On 5/3/26 at 9:15 AM, R12's water cup was sitting on R12's bedside table empty. R12 stated fresh ice water does not get passed three times a day. R12 stated, We are lucky if ice water gets passed one time a day. I would like it to be passed three times a day.On 5/3/26 at 11:25AM, R10 stated he prefers just ice in his cup, but the staff does not come around and offer it at least three times a day. R10 stated, Third shift will say they don't have access to the ice at times.On 5/2/26 at 12:13 PM, V6/LPN (Licensed Practical Nurse) stated she works third shift as a nurse and it can be challenging, especially with staffing inconsistencies and a lot of times ice water doesn't get passed.On 5/3/26 at 9:25 AM, V7/Agency LPN reported critical staffing shortages during her 6:00 PM to 6:00 AM shift on 3/27/26. According to V7, no CNAs were on her side for third shift. V7 stated that the lack of personnel made it impossible to complete essential tasks, including rounding on residents, changing them, and providing ice water.On 5/3/26 at 11:04 AM V11/LPN stated, A lot of times ice water won't get passed on third shift because after the kitchen closes before 10:00 PM we can't get in the kitchen to get ice anymore, therefore third shift can't pass fresh ice water.On 5/6/26 at 11:49 AM, V13/CNA stated that fresh ice water isn't getting passed a lot of times on second shift due to staffing and working with Agency CNA's most of the time.On 5/8/26 at 11:46 AM V2/Director of Nursing stated ice water should be passed every shift.

Based on interview and record review, the facility failed to ensure residents were free from physical and verbal abuse for three of four residents (R3, R4, and R6) reviewed for abuse in a sample of 12. Findings include:The facility's Abuse Prevention and Reporting-Illinois Policy, dated 3/2026, documents Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive in resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Definitions: Abuse: Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than b y accidental means (210 ILCS (Illinois Compiled Statues) 44/1-103). 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 (Code of Federal Regulations) 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 well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 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). Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means, and that requires medical attention (77 Illinois Administrative Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines.) Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines.) R3 and R4's Final Five-Day Reported Incident to Illinois Department of Public Health, dated 3/20/26, documents on 3/14/26 V3/Activity Aide heard yelling in the dining room. V3 entered the dining room to see R9 yelling at R4. R4 appeared upset with coffee on herself and the table. R4 reported to V3 that R3 had hit her. R8 and R9 both stated they had witnessed R4 throw coffee on R3, when R3 was trying to assist another resident in the dining room, which resulted in R3 slapping R4. Both R3 and R4 were immediately separated. R3's Abuse Allegation Interview, dated 3/14/26, documents I think I slapped a woman (identified as R4) open handed in the face. (R4) came and threw a drink on me. It got my orange shirt all wet and I had to change it. R4's Abuse Allegation Interview, dated 3/17/26, documents I was minding my own business in the dining room. This big man (R3) came up and slapped me several times for nothing. R3's MDS (Minimum Data Set) Assessment, dated 3/20/26, documents R3 is moderately cognitively impaired, requires supervision with most ADLs (Activities of Daily Living), had physical and verbal behaviors directed at others, and put others at significant risk for injury. R3's Care Plan documents R3 has potential to be verbally aggressive related to history of behaviors related to psychosis. This same Care Plan documents R3 has the potential to be physically aggressive related to history of related behaviors and psychosis such as spitting, throwing medications and water when agitated. R3's Progress Note, dated 3/20/26, documents IDT (Interdisciplinary Team) reviewed resident to resident altercation between (R3) and (R4) physical abuse. Root cause of allegation determined to be medication compliance along with increased stimuli. R4's MDS, dated [DATE], documents R4 is moderately cognitively impaired, requires partial/moderate assistance with most ADLs, and had no behaviors directed at others. R4's Care Plan documents R4 is/has potential to be verbally and physically aggressive related to anger, depression, poor impulse control related to metabolic encephalopathy, which includes throwing water on her peers. On 5/2/26 at 9:30 AM, R4 stated she remembers a big man (identified as R3) slapping her across the face in the dining room. [NAME] stated, I don't even know what I did to get slapped. On 5/2/26 AT 3:33 PM, V3/Activity Aide stated, A few months ago I was preparing to take my break when I heard loud yelling coming from the dining room. Upon entering the dining area, I observed two residents, (R3) and (R4), yelling at each other. I observed coffee had been spilled on (R4) and her table. (R4) immediately reported to me that (R3) had slapped her in the face twice. I observed visible finger marks on the left side of (R4's) face, consistent with her report. (R3) admitted to me that he had slapped (R4) because (R4) made him mad. On 5/3/26 at 8:55 AM, R9 reported witnessing a physical and verbal altercation that occurred in the dining room a few months prior involving R3 and R4. R9 reported that R4 was antagonizing R3 by intentionally blocking R3's path as R3 attempted to push another resident through the dining room. R9 stated, (R4) told (R3) to go on and that's when (R3) become upset. (R3) then slapped (R4) in the face with his hand and yelled shut up b***h. On 5/3/26 at 9:05 AM, R8 reported witnessing a physical altercation in the dining room occurring months prior. R8 reported, R4 threw a cup at R3, prompting R3 to slap R4 open handedly in the face. On 5/3/26 at 9:30 AM R3 states he slapped a female resident (identified as R4) in the face in the dining room a few months ago because R4 had threw a drink on R3. 2. R5 and R6's Final Five-Day Reported Incident to Illinois Department of Public Health, dated 2/27/16, documents On 2/23/26 (V6/LPN/Licensed Practical Nurse) heard yelling while walking down the hallway. (V6) entered (R5 and R6's) room and saw (R6) tussling with (R5) over items belonging to (R6). (R6) stated she was trying to find a clean pair of socks when (R5) went off on (R6) and started throwing things and hitting (R6) and (V6). V6/LPN's Witness Statement, dated 2/23/26, documents I was walking down the hall and heard yelling in (R5) and (R6's) room. Upon entering the room, I saw (R6) and (R5) tussling over items belonging to (R6). I pulled (R5) away while in her chair, whiling pulling (R5) back she started to physically hit (R5) in the arm approximately three times. R5's MDS dated , 3/27/26, documents R5 has short-term and long-term memory problems. On 5/2/26 at 12:13 PM V6/LPN stated, I recently witnessed a resident-to-resident altercation between (R5) and (R6). While passing (R5 and R6's) room, I saw (R5) attempting to take (R6's) belongings. When (R6) tried to reclaim (R6's) items, (R5) started hitting (R6) on the arm multiple times. When I was intervening to remove (R6) from the situation (R5) began hitting me. On 5/3/26 at 9:37 AM R6 reported that a few months ago, upon returning to her room from a hospital stay, R6 began looking for a pair of clean socks. R6 stated, My roommate, (R5), falsely accused me of stealing her socks. (R5) began hitting me in the face, arms, and upper body. A staff member (identified as V6/LPN) came into the room to help me and (R5) began hitting her as well.

Based on observation, interview and record review the Facility failed to employee a full-time Director of Nursing. This failure has the potential to affect all 78 Residents residing in the Facility.Findings include:The Facility Assessment Tool, dated 1/6/26, documents: V9 (Former Director of Nursing/DON) as the Director of Nursing; a Director of Nursing to provide resources needed to provide competent support and care for Resident population every day and during emergencies; and the Administrator identifies team members including the Director of Nursing.The Resident Census Roster, dated 3/6/26, documents 78 Residents residing in the Facility.V2's Professional Regulation License Lookup, printed 3/8/26, documents V2's active Licensed Practical Nursing status as active on 1/26/25.V9's Employee File, printed 3/9/26, documents a start date of 12/22/25 and a termination date of 1/26/26.The Facility Director of Nursing Job Description, dated 7/2023, requires a Registered Nurse with a current encumbered state license and must direct the overall operation of the Nursing Department in accordance with current State and Federal standard guidelines.On 3/8/26, V1 (Administrator) could not provide a Director of Nursing license. V1 stated, We do require a full-time Director of Nursing for our Facility. We have not had a full-time Director of Nursing since 1/26/26. I had to terminate (V9) Former Director of Nursing, We do not have a Registered Nurse as a Director of Nursing, (V2) is our Assistant Director Nursing and has been acting as our DON, even though (V2) is only a Licensed Practical Nurse.

Based on observation, interview and record review the Facility failed to use Enhanced Barrier Precautions while providing indwelling urinary catheter care for one of three Residents (R7) reviewed for indwelling urinary catheter care. This failure has the potential to affect 22 additional Residents residing in the Facility (R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R20, R31, R32, R44, R34) and failed to maintain a sanitary homelike environment for two of eight Residents (R11 and R12) reviewed for physical environment in a sample of 34.Findings include:1.The Facility Infection Surveillance, Tracking and QA (Quality Assurance) Policy, dated 12/2025, documents: identify, monitor, track and report infections and monitor adherence to infection control practice; direct observations and adherence to hand hygiene and proper use of PPE (Personal Protective Equipment), monitor the availability of PPE; monitor to ensure that proper precautions are initiated as appropriate; reporting of outbreaks or reportable infections to the Local and State Health Department as required.The Facility Licensed Nursing Home Administrator Job Description, dated 7/2023, documents to direct the day-to-day functions of the Facility in accordance with current Federal and local standards, guidelines and regulations that govern nursing facilities to ensure the highest degree of quality of care can be provided to Residents.The Facility Resident Census Roster documents R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R20, R31, R32, R44, R34 residing on A Wing Hallway (room [ROOM NUMBER] through 25).R7's Physician Order Sheet/POS, dated 3/9/26, documents R7's diagnoses including Urogenital Implants, Benign Prostatic Hyperplasia with lower urinary tract symptom impairments and Retention of Urine. R7's current Care Plan documents: enhanced Barrier Precautions related to indwelling urinary catheter; and gown and glove during high contact Resident care activities such as providing hygiene or device care/use.On 3/9/26 at 9:48 am, V12 (Licensed Practical Nurse/LPN) entered R7's room and performed indwelling suprapubic urinary catheter care. V12 did not wear a gown or mask during the indwelling suprapubic urinary catheter care.V12 stated, I am assigned to this entire Hallway (A Wing- room [ROOM NUMBER] through 25). V12 verified that V12 did not wear a gown or mask during R7's indwelling urinary catheter care.On 3/9/26 at 10:30 am, V1 (Administrator) stated, Our nurses should always wear a gown, gloves and mask when providing catheter care. They should know that EBP (Enhanced Barrier Precautions) is required.2.The Facility Infection Surveillance, Tracking and QA (Quality Assurance) Policy, dated 12/2025, documents: identify, monitor, track and report infections and monitor adherence to infection control practice.The Facility Licensed Nursing Home Administrator Job Description, dated 7/2023, documents: directs the day-to-day functions of the Facility in accordance with current Federal and local standards, guidelines and regulations that govern nursing facilities to assure the highest degree of quality of care can be provided to Residents; and ensure that the Facility is maintained in a clean and safe manner for Resident comfort.The Facility Housekeeper Job Description, dated 7/2023, documents: directs the day-to-day functions of the Facility in accordance with current Federal , State and local standards, guidelines and regulations governing our Facility; and ensure work/cleaning schedules are followed; coordinate daily housekeeping services with nursing services and perform routine cleaning assignments in Resident living areas; clean floors; and discard waste/trash in proper containers.On 3/7/26 at 10:32 am, in room [ROOM NUMBER], a soiled (wet) incontinence brief, approximately eight-inch area of brown matter on a white bath towel, soiled (wet) maroon sweatpants, soiled (wet) brown sweatshirt and yellow non-skid socks were laying on the floor in front of R11's and R12's commode. On 3/7/26 at 1:09 pm, in room [ROOM NUMBER], a soiled (wet) incontinence brief, approximately eight-inch area of brown matter on a white bath towel, soiled (wet) maroon sweatpants, soiled (wet) brown sweatshirt and yellow non-skid socks were laying on the floor in front of R11's and R12's commode. On 3/8/26 at 8:15 am, in room [ROOM NUMBER], a clear bag contained soiled maroon sweatpants, soiled brown sweatshirt and yellow non-skid socks were laying on the floor in front of R11's and R12's sink.On 3/9/26 at 10:30 am, V1 (Administrator) stated, The soiled clothing and towel, and dirty incontinence brief are unacceptable to remain on the bathroom floor that long.

Based on interview and record review the facility failed to provide showers at least weekly for residents and failed to provide incontinence cares forcing residents to sit in their own urine and feces for long periods of time for five out of six residents (R5, R7, R8, R12, and R13) reviewed for quality of care in the sample of 21. This failure resulted in R5, R7, and R13 experiencing pain/discomfort and developing psychosocial harm leaving them to feel degraded, angry, and helpless. Findings Include:The Resident Rights policy revised 08/2017 documents Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's rights to: Exercise his or her rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facilities rules, as long as those rules do not violate a regulatory requirement.The Certified Nursing Assistant Job Description revised 07/2023 documents Job Summary: The primary purpose of a Certified Nursing Assistant is to provide residents of the facility in your nursing unit with nursing and care under the supervision of a Charge Nurse, and to safeguard the health, safety, and welfare of all residents of the facility, in accordance with the facility's established policies and procedures and applicable laws and regulations, and directions your supervisor, who includes the Administrator, Director of Nursing, Assistant Director of Nursing, House Supervisor, Charge Nurse, Rehabilitation Director or other members of the facility's management to whom such persons report, in order to assure that the highest degree of quality care is maintained at all times. As a Certified Nursing Assistant, you are delegated the administrative authority, responsibility, accountability necessary for carrying out your assigned duties. Essential Duties and Responsibilities: Carry out assignments for resident care including (but not limited to): bathing, dressing, grooming, shaving, feeding, restorative nursing procedures and retraining. Keep resident's bed, dresser, bathroom, and general living area clean and tidy. Answer call lights promptly. Put resident's clothing away properly. Wash, clean, and dry all incontinent residents. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty.The Incontinent Care policy revised 4/2021 documents Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.The Concern/Compliment Forms document the following concerns: On 10/2/25 Resident Council complained Showers are still a concern on all shifts. On 10/23/25 Resident Council complained Showers are still an issue on first and second shifts. On 12/2/25 R17 complained that she has only had one shower since she has been at the facility and would like another one. On 12/4/25 Resident Council complained Showers are improving but residents state they have to ask several times to get complete. On 12/2/25 R18 complained that she prefers a shower and is given a bed bath. R18 has to Nag staff to get a shower.Resident Council Meeting Minutes for October, November, and December 2025 were reviewed with the following concerns. The 10/2/25 Minutes document Showers are still a concern. The 11/6/25 Minutes document concerns with showers. The 12/4/25 Minutes document Grievances were written for showers. Resident Council Meeting Minutes dated 1/1/26 documents Nursing: Call lights not being answered in a timely manner, showers are still a concern.1. R5's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R5's BIMS (brief interview for mental status) score was 15 meaning cognition intact. Section GG (functional abilities) documents R5 requires partial/moderate assistance for toileting.On 1/5/26 at 3:38 PM, R5 stated that earlier that day R5 went to the bathroom and removed her wet disposable brief and turned the bathroom call light on for someone to bring her another one. R5 sat on the toilet for 35 minutes, and no one came. R5 stated that her buttocks were hurting from sitting on the toilet. R5 finally put her wet disposable brief back on, shut off the bathroom call light and left the bathroom. When R5 got back to her call light in her room R5 turned it on. R5 was not sure how long it was before staff came in, but they (staff) shut the light off and said they were going to take R5 to the shower. R5 stated that she had the wet disposable brief on from about 8:45 AM until 10:30 AM when staff took her to the shower. R5 also stated that she is supposed to have help when going to the bathroom, but she does it by herself because there is not enough staff. R5 stated it makes her feel helpless and angry that she does not get cared for properly. Sitting in a wet disposable brief is uncomfortable and causes burning. I deserve better.2. R7's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R7's BIMS (brief interview for mental status) score was 15 meaning cognition intact. R7's MDS/Minimum Data Set Section GG (functional abilities) dated 12/22/2025 documents R7 is dependent with toileting cares, and dependent with rolling left to right.On 12/29/2025 at 2:43 PM, R7 stated that there are not enough staff to answer call lights or give showers. R7 stated that she had been administered MiraLAX (a liquid laxative). R7 was unable to recall the exact date the medication was given. R7 stated that she subsequently had a bowel movement and activated her call light to notify staff. According to R7, staff did not respond promptly, and R7 was required to remain soiled for more than 90 minutes. R7 further stated that after staff assisted with cleaning her, the bed linens were not changed. R7 expressed anger and distress regarding the incident, stating that the experience made her feel degraded and that her dignity was compromised. R7 reported that she filed a grievance regarding this incident but stated that no corrective action was taken.On 1/2/26 at 11:10 AM R7 stated that last week R7 asked for a shower and was given a quick bed bath because R7 is a mechanical lift, and it takes two staff to get R7 to the shower. R7 stated then on Tuesday 12/30/25 R7 had to wait two and a half hours to be changed. An agency CNA was working the night shift and said that she had a hernia so she could not lift to change R7 and R7 had to wait until the day shift came in to be changed. R7 stated It is degrading. I have no dignity whatsoever. I have been at the facility for two years and I deserve better treatment.3. R8's MDS Section C (cognitive patterns) dated 11/19/2025 documents R8's BIMS (brief interview for mental status) score was 10 meaning moderately impaired. R8's MDS Section GG dated 11/19/2025 documents R8 is partial/moderate assistance with toileting cares, and partial/moderate assistance with rolling left to right, sit to lying, and toilet transferring.On 12/29/2025 at 11:20 AM, R8 was in her room, lying on her right side underneath her covers, R8 was asleep and not interviewable. R5/R8's Roommate stated this morning (12/29/25) R8 had told R5 that she (R8) was wet. R5 put the call light on at 6:14 AM for R8 and it was not answered until 6:56 AM. During that time R8 was soiled in her own urine the entire time.4. R12's MDS Section C (cognitive patterns) dated 11/20/2025 documents R12's BIMS (brief interview for mental status) score was 15 meaning cognition intact. R12's MDS Section GG dated 11/20/2025 documents R12 is dependent for toileting and showers. R12 is always incontinent of urine and has an ostomy.On 12/30/2025 at 1:07 PM, R12 reported that her (family member) typically visits daily and assists R12 with showers, changing R12's disposable brief, and managing R12's ostomy bag. R12 stated that staff rely on her (family member) to perform these tasks, despite it not being his responsibility. R12 further stated that when her (family member) does not visit, staff attempt to provide R12 with a bed bath instead of a shower, and R12 must repeatedly request staff to provide her scheduled shower.5. R13's MDS Section C (cognitive patterns) dated 12/15/2025 documents R13's BIMs (brief interview for mental status) score was 15, meaning cognitively intact. R13's MDS Section GG dated 12/15/2025 documents R13 is dependent on toileting cares, and substantial/maximal assistance for rolling left to right.On 12/30/2025 at 1:25 PM, R13 reported that on 12/29/2025 R13 waited all morning and afternoon for assistance with changing her soiled and wet (disposable brief). R13 stated that a staff member initially began to assist R13 but then left and did not return. R13 reported that both her (disposable brief) and bed linens were soiled. According to R13, the staff member stated there were no clean sheets available and left to locate some but did not return. R13 was visibly upset, tearful, and angry stating This made me feel terrible, I kept wondering am I going to live the rest of my life like this? Will I always be this mistreated?On 12/30/2025 at 2:20 PM, V16/Certified Nurse Assistant stated she worked on 12/29/2025 and it was after 3:00 PM when R13 voiced she had been asking for someone to change her all day. V16 stated R13 was covered in R13's urine all over R13's back up to R13's neck and down to R13's feet. V16 stated R13's disposable brief was saturated, and the smell of urine was very strong. V16 stated R13 was reddened everywhere the urine touched R13's skin and V16 Felt horrible for R13.On 12/30/2025 at 2:00 PM, V14/Certified Nurse Assistant V14 stated all staff are having to choose what resident cares to complete. V14 also stated when agency staff are called, they do not come into the shift until a few hours after the shift has started and that also slows down resident cares.On 12/31/2025 at 9:30 AM, V21/Certified Nurse Assistant stated staffing is becoming an issue, V21 stated the facility has not evaluated the resident load compared to the staff and that the last DON (Director of Nursing) was the only management staff who truly helped on the floor caring for residents and evaluated the true resident load or needs. V21 stated it is hard to care for residents when CNAs are required to do all the resident cares and dietary tasks during mealtimes. V21 also stated that CNAs are required to serve room trays, pick up room trays, serve in the dining room, and feed residents, all while trying to find time to chart and care for residents. V21 stated residents are suffering because CNA staff are not able to care for residents properly.On 12/31/2025 at 9:50 AM, V1/Administrator stated she was not aware that residents were sitting in their own urine and feces for long periods of time and that is not acceptable. V1 also confirmed CNAs are required to help with dietary tasks. V1 confirmed staff are over worked and V1 Does not know what to do about it.On 1/2/25 at 9:36 AM, V20/Ombudsman stated I got a call from (R7) recently and (R7) was very upset. (R7) was raising her voice saying her call light was on and staff were not coming. (R7) said that she had sat in feces for 90 minutes with her call light on and no one answered it. V20 also stated that there are a lot of complaints about call lights from residents that say the call lights are not answered or staff will come in and turn the light off saying they will be back, and they do not return.

Based on observation, interview, and record review, the facility failed to provide enough food at meals for all residents to receive the meal listed on the menu, provide enough food to allow staff to cook residents the assigned menu, and answer call lights timely for eight of eight residents reviewed for dietary needs and call lights (R5, R6, R7, R8, R12, R13, R14, and R15) in a sample of 21. This failure has the potential to affect all 83 residents who reside at the facility. Findings Include: The facility's Midnight Census Report dated 12/29/2025 documents 83 residents reside at the facility.The Resident Rights policy revised 08/2017 documents Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's rights to: Exercise his or her rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facilities rules, as long as those rules do not violate a regulatory requirement.The Call Light policy revised 01/2022 documents Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered.The [NAME] Job Description dated 05/2017 documents Summary: The [NAME] is responsible for food preparation in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with our established policies and procedures, and as may be directed by the Dietitian and/or Director of Food Services, to assure that quality food service is provided at all times. Essential Duties and Responsibilities: Review menus prior to preparation of food. Ensure that all food service procedures are followed in accordance with established policies.The Dietary Aide Job Description revised 07/2023 documents Summary: The Dietary Aide is responsible for aiding all food functions as directed/instructed and in accordance with established food policies and procedures. Essential Duties and Responsibilities: Review, prepare & (and) serve meals in accordance with planned menus with standardized recipes & special diet orders.The Certified Nursing Assistant Job Description revised 07/2023 documents Job Summary: The primary purpose of a Certified Nursing Assistant is to provide residents of the facility in your nursing unit with nursing and care under the supervision of a Charge Nurse, and to safeguard the health, safety, and welfare of all residents of the facility, in accordance with the facility's established policies and procedures and applicable laws and regulations, and directions your supervisor, who includes the Administrator, Director of Nursing, Assistant Director of Nursing, House Supervisor, Charge Nurse, Rehabilitation Director or other members of the facility's management to whom such persons report, in order to assure that the highest degree of quality care is maintained at all times. As a Certified Nursing Assistant, you are delegated the administrative authority, responsibility, accountability necessary for carrying out your assigned duties. Essential Duties and Responsibilities: Carry out assignments for resident care including (but not limited to): bathing, dressing, grooming, shaving, feeding, restorative nursing procedures and retraining. Answer call lights promptly. Wash, clean, and dry all incontinent residents. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. The Concern/Compliment Forms document the following concerns: On 10/2/25 Resident Council complained Call lights not being answered in a timely manner. On 10/23/25 R16 complained Long call light times. On 10/30/25 R16 complained Concerns about the dietary menu. On 11/6/25 Resident Council complained Call lights are not being answered in a timely manner.Resident Council Meeting Minutes for October, November, and December 2025 were reviewed with the following concerns. The 10/2/25 Minutes document Call lights not being answered in a timely manner. The 11/6/25 Minutes document that V31/Prior Director of Nursing was invited to the meeting to discuss nursing concerns that included call lights. The 12/4/25 Minutes document Grievances were written for call lights. Resident Council Meeting Minutes dated 1/1/26 documents Nursing: Call lights Not being answered in a timely manner, showers are still a concern. Dietary: All trays are getting late again, no milk on trays for cold cereal this morning. Residents feel that PB (Peanut Butter) & (and) J (Jelly) and grilled cheese are not good alternatives for meals.On 12/30/2025 at 12:00 PM, the Lunch Menu documented Beef and Bean Chili, Cornbread, and Snickerdoodle Blonde Bars. On the trays chocolate pudding was being served instead of the Snickerdoodle Blonde Bars. V7/Cook stated residents are having chocolate pudding because the facility is out of eggs needed to make the Snickerdoodle Blonde Bars.1. R5's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R5's BIMS (brief interview for mental status) score was 15 meaning cognition intact.On 1/5/26 at 3:38 PM, R5 stated that earlier that day R5 went to the bathroom and removed her wet disposable brief and turned the bathroom call light on for someone to bring her another one. R5 sat on the toilet for 35 minutes, and no one came. R5 stated that her buttocks were hurting from sitting on the toilet. R5 finally put her wet disposable brief back on, shut off the bathroom call light and left the bathroom. When R5 got back to her call light in her room R5 turned it on. R5 was not sure how long it was before staff came in, but they (staff) shut the light off and said they were going to take R5 to the shower. R5 stated that she had the wet disposable brief on from about 8:45 AM until 10:30 AM when staff took her to the shower. R5 also stated that she is supposed to have help when going to the bathroom, but she does it by herself because there is not enough staff. R5 also stated that the kitchen runs out of food and R5 does not get served what the other residents are having. It does not matter what the menu says the kitchen serves what they have.2. R6's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R6's BIMS (brief interview for mental status) score was 14 meaning cognition intact.On 12/31/25 at 9:48 AM, R6 stated that call lights can be answered in two minutes to two hours depending on the day. There is not enough staff especially on evening shift.3. R7's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R7's BIMS (brief interview for mental status) score was 15 meaning cognition intact.On 12/29/2025 at 2:43 PM, R7 stated staff typically take a long time to answer her call light. R7 also stated that the meal portions get small when the kitchen starts running out of food and R7 does not always get what is on the menu. On 12/29/2025 at 2:46 PM, this surveyor was in R7's room talking to R7. R7 turned on her call light for assistance. No staff came to answer R7's call light until 3:10 PM. R7 stated this call light wait time is a normal occurrence. 4.R8's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R8's BIMS (brief interview for mental status) score was 10 meaning mild cognitive impairment.On 12/29/2025 at 11:20 AM, R8 was in her room, lying on her right side underneath her covers, R8 was asleep and not interviewable. R5/R8's Roommate stated this morning (12/29/25) R8 had told R5 that she (R8) was wet. R5 put R5's call light on at 6:14 AM for R8 and it was not answered until 6:56 AM. During that time R8 was soiled in her own urine the entire time.5. R12's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R12's BIMS (brief interview for mental status) score was 15 meaning cognition intact.On 12/30/2025 at 1:07 PM, R12 stated she never gets a menu, so she does not know what is being served at each meal. R12 stated it used to be on the facilities daily paper that is passed out to each resident but even when the menu was posted, the menu was never followed. R12 had a large plastic three shelve storage unit in her room that had various food items such as beef stew, tamales, soda, etc. (etcetera). R12 stated when she uses her call light that it will usually take a while and sometimes it can take a couple of hours. R12 stated her (family member) typically comes in daily and will help with R12's showers, or helps change R12's disposable brief, or R12's ostomy bag. R12 stated the staff depend on her (family member) to do these tasks for R12 due to the staff saying they are short staffed.6. R13's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R13's BIMS (brief interview for mental status) score was 15 meaning cognition intact.On 12/30/2025 at 1:25 PM, R13 stated the facility does not serve enough food during meals. R13 stated she keeps snacks, so she does not go hungry. On R13's bedside table was a basket full of various food items. R13 stated she has long call light wait times when she needs staff assistance.7. R14's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R14's BIMS (brief interview for mental status) score was 12 meaning mild cognitive impairment.On 12/30/2025 at 1:05 PM, R14 stated that the kitchen runs out of food all the time. R14 also stated he does not depend on staff to help him, he is independent, but that his roommate does depend on staff. R14 stated he has witnessed staff taking at least an hour to answer a call light for his roommate.8. R15's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R15's BIMS (brief interview for mental status) score was 99 meaning severely cognitively impaired.On 12/30/2025 at 12:15 PM, V18/R15's Family Member stated R15 is not interviewable. V18 stated staff are short a lot. V18 stated he will put R15 on the toilet while he is at the facility visiting R15 because staff will not answer R15's call light fast enough. V18 stated staff will wait a long time to come in sometimes because staff know V18 helps R15. V18 said staff expect V18 to toilet R15. V18 stated it is frustrating that the facility is short on staffing. On 12/30/25 at 12:40 PM, V9/Certified Nursing Assistant/CNA stated that staffing is short and there is not enough staff to answer the call lights as soon as they should be answered.On 12/30/25 at 12:49 PM, V10/CNA stated, Being short on food has been a problem for a while. Especially for the residents that want to eat in their room. There is not enough of what is on the menu and these residents will get whatever can be found. Several of the residents have bought their own cereal to have available when the kitchen is out of food. Mornings there will not be any juice and when the kitchen runs out of eggs or sausage the resident will only get toast. Especially rooms 20 to 29 do not get what is on the menu because there is not enough food for all residents. R5, R12, R13, and R14 are some of the residents that buy food to have available when the facility runs out. On 12/30/25 at 12:57 PM, V11/CNA stated that running out of food for the residents is a huge issue. V11 also stated I have gone to get the resident a Peanut Butter and Jelly Sandwich because they did not get much food.On 12/31/2025 at 9:50 AM, V1/Administrator stated that residents should not have to wait more than ten to 15 minutes for the call light to be answered. V1 stated if staff are not busy and a call light is going off and they do not answer it, that is not acceptable. V1 stated that the kitchen should have the ingredients needed to follow the menu and be able to provide the same meal to all residents for all meals.On 12/31/2025 at 10:00 AM during a joint interview with V22/CNA and V23/CNA while they were working on B Hall, they both stated that staffing is always short, staffing is never correct on the daily staffing sheets and that A Hall never has enough staff to help with how heavy the resident cares have become. Both also stated they never have time to get all the resident cares completed or are always behind due to them having to help dietary staff by delivering the hall trays and serving the meals and drinks in the dining room. On 1/2/25 at 9:36 AM, V20/Ombudsman stated that there are a lot of complaints about call lights from residents that say the call lights are not answered or staff will come in and turn the light off saying they will be back, and they do not return. On 1/3/25 at 2:47 PM, V30/Registered Nurse stated that there has been several days the facility ran out of the main menu items and deserts. A day or two before Christmas for breakfast the residents only got a small bowl of cereal and toast. V30 stated that she heard the reason they ran out of food was because the person ordering the food said there was a budget to follow.On 1/5/26 at 1:40 PM, V12/Previous Dietary Manager stated It is absolutely correct meals are not followed and they (the facility) do run out of food. I would send the order in for what I needed and then when it was reviewed by someone from corporate the order would be lowered. When enough food is not delivered you have to make substitutions, so residents get fed. V12 also stated I reported to the company compliance that we were running out of food, and I got written up. It was retaliation for making the call. I left the room got my things and said Merry F****** Christmas to you. You should be ashamed how you treat these residents, and I walked out.On 1/7/26 at 10:05 AM, V33/Registered Dietician stated that she was not told that the facility was not following the menu and not serving the same meals to all residents because the facility ran out of food. V33 stated that V12/Prior Dietary Manager was not good at keeping V33 informed of dietary issues. The menus are not set up in house and they should be followed. V33 also stated that substituting toast to replace sausage or eggs is not ok if that is what is occurring. V33 stated that she does not know why the facility would have run out of eggs so they could not make the Snickerdoodle Blonde Bar.On 1/7/26 at 2:07 PM, V34/Regional Dietary Manager stated that she has only been in her position for a month. V34 has heard complaints of the facility running out of food due to V12/Previous Dietary Manager was not ordering the correct amount of food.

Based on observation, interview, and record review the facility failed to ensure all resident rooms were cleaned daily and trash was taken out daily for three of three residents (R2, R5, and R7) reviewed for housekeeping in the sample of 21. These failures have the potential to affect all 83 residents who reside in the facility. Findings Include: The facility's Midnight Census Report dated 12/29/2025 documents 83 residents reside at the facility.The Housekeeper Job Description revised 07/2023 documents Summary: The primary purpose of the Housekeeper is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. Essential Duties and Responsibilities: Ensure that work/cleaning schedules are followed as closely as practical. Clean, wash, sanitize, and/or polish fixtures, ledges, room heating/cooling units, bathroom fixtures etc.(etcetera). Clean floors including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting etc. Discard waste/trash into proper containers and reline receptacle with plastic liner. Performs other duties as assigned.Resident Council Meeting Minutes dated 12/4/25, documents Grievances were written for soiled items in rooms. Resident Council Meeting Minutes dated 1/1/26 documents Laundry/Housekeeping: Resident's state when housekeepers are off work their rooms do not get cleaned.The Laundry and Housekeeping Schedule dated 12/15/25 to 1/6/25 documents there was one Housekeeping/Laundry Staff scheduled for days and none for 4:00 PM -12:00 AM on 12/20 and 12/21/25. There were two Housekeeping/Laundry Staff scheduled for days and none for 4:00 PM-12:00 AM on 12/17/25. There were two Housekeeping/Laundry Staff scheduled for days and one for 4:00 PM -12:00 AM on 12/16, 12/18, 12/27, and 12/28/25.1. R2's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R2's BIMS (brief interview for mental status) score was 15 meaning cognition intact.On 12/31/25 at 9:34 AM R2 stated that his room did not get cleaned on 12/30/25 but he would have liked it to be cleaned. R2 also stated that when V3/Housekeeper is off his room does not get cleaned. V4/Housekeeper Manager is supposed to cover for V3 but does not clean the rooms.On 1/2/2025 at 1:35 PM, R2 stated My room was not cleaned again today.2. R5's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R5's BIMS (brief interview for mental status) score was 15 meaning cognition intact.On 12/29/2025 at 11:15 AM, R5 stated her room does not get cleaned daily. R5 stated her trash is only taken out when she asks staff.On 1/5/26 at 3:38 PM, R5 stated that her room had not been cleaned since 12/30/25 and she was having to Mash the garbage down in her wastebasket. R5 also stated This morning there was water on the floor in the bathroom and I took my t-shirt to mop it up so I wouldn't fall.On 1/5/26 at 3:38 PM, R5's room had a strong odor of urine. R5's wastebasket sitting next to R5's wheelchair was full of trash. The bathroom wastebasket was full of soiled disposable briefs.On 1/6/26 at 11:05 AM, R5 was sitting in therapy and stated, My room still hasn't been cleaned. R5 stated that when she went to the bathroom this morning (1/6/26) there was something that looked like tea spilled on the floor next to R8's bed. R5 stated I decided I wasn't cleaning it up this time.On 1/6/26 at 11:15 AM, R8/R5's Roommate was lying in bed. There was a large brown dried sticky stain on R8's floor next to R8's bed. There was a soiled disposable brief in the bathroom wastebasket. The rest of the floor in the room and bathroom had not been swept or mopped. R8 stated that no one had cleaned the room.3. R7's MDS/Minimum Data Set, dated [DATE] Section C (cognitive patterns) documents R7's BIMS (brief interview for mental status) score was 15 meaning cognition intact.On 12/29/2025 at 2:43 PM, R7 stated she is lucky if housekeeping comes in to sweep and mop the floors. R7 stated her room is not cleaned daily, and her trash is not taken out daily.On 12/29/2025 at 11:25 AM, V3/Housekeeper stated if she is gone the daily cleaning does not get done in all the rooms.On 12/31/25 at 9:38 AM, V14/Certified Nursing Assistant stated that housekeeping did not clean the rooms on A Hall on 12/30/25.On 12/31/25 at 9:40 AM, V3/Housekeeper stated that she was off on 12/30/25 and no one cleaned the resident rooms on 12/30/25.On 12/31/25 at 11:58 AM V4/Housekeeping/Laundry Manager stated that when staff have a day off she fills in. V4 was asked who cleaned A Hall on 12/30/25. V4 stated that she did. When V4 was told that residents and staff had said the rooms on A Hall were not cleaned on 12/30/25 V4 said Hmm and then mumbled something about laundry. On 12/31/2025 at 1:00 PM, V1/Administrator confirmed resident rooms should be cleaned daily with the floors being swept/mopped and trash should be taken out daily or when the trash can is full.On 1/3/25 at 2:47 PM, V30/Registered Nurse stated that there was not a housekeeper for A side of the building and none of the residents' rooms were cleaned. On 1/5/26 at 12:40 PM, V1 stated the same staff are cross trained to do laundry and housekeeping. There should be at least three housekeeping/laundry staff on days with one doing laundry, the other two doing housekeeping, and one housekeeper/laundry staff that works 4:00 PM to 12:00 AM.

Based on observation, interview, and record review the facility failed to have enough staff to answer call lights, provide showers, provide incontinent care, clean residents' rooms daily, and prevent falls. The facility also failed to accurately report the number of staff that worked on the daily staffing report and failed to update the Facility Assessment Tool with the number of staff needed. This has the potential to affect all 83 residents residing in the facility.Findings include:The facility's Midnight Census Report dated 12/29/2025 documents 83 residents reside at the facility.The Facility Assessment Tool for 08/2025 through 08/2026 documents Requirement: Nursing facilities will conduct, document, and annually review a facility wide assessment, which includes both their resident population and the resources the facility needs to carry for their residents. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. 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 intent of this facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. The Facility Assessment documents the facility should staff seven Certified Nursing Assistants/CNAs on days and evenings for 87-92 residents and three CNAs on Nights for a census under 86. (There is no guidance if the census is higher than 86 on nights.) It also documents Disclaimer: Use of this tool is an example and does not ensure regulatory compliance. Dated 7/1/24. The Staffing Calculator and Scheduling -User Guide (not dated) documents This guide provides clear instructions for administrators to use the Daily Staffing Calculator and Apploi Scheduler to ensure compliance with Illinois licensure minimum staffing requirements. Other Direct Care Staff - Therapists Direct resident care only; include resident-specific charting. Activity Staff Only direct resident engagement. (not planning/office time) Compliance Tips Count only direct resident care + (and) resident-specific charting.The Detailed Census Report for 12/1-12/31/25 documents a census of 86 residents daily on 12/26 and 12/27/25, 87-91 residents daily for the rest of the month.The Daily Staffing Calculator-Illinois Licensure Minimums (detailed) Report documents - Certified Nursing/CNA Hours as follows: 12/4/25-17 worked (18 needed), 12/5-16 worked (18 needed), 12/6-20 worked (22 needed), 12/7-20 worked (22 needed), 12/8-17 worked (18 needed), 12/13-21 worked (22 needed), 12/14-21 worked (22 needed), 12/22-17 worked (18 needed), 12/23-17 worked (18 needed), 12/26-16 worked (18 needed), 12/27-21 worked (22 needed), 12/28-21 worked (22 needed), and 12/31/25-17 worked (18 needed).The Daily Assignments Sheets dated 12/3 and 12/23/25 (picked at random) document that in addition to the nursing staff scheduled that on Wednesday 12/3/25 V1/Administrator/Registered Nurse/RN worked the floor 7:00 AM-9:00 AM, V41/MDS/Minimum Data Set Coordinator/RN worked the floor 8:00 AM-12:00 PM, and V29/Previous Director of Nursing worked the floor 12:00 PM-6:00 PM. On 12/23/25 V1 and V41 both worked the floor from 7:00 AM to 4:00 PM.The Daily Staffing Calculator-Illinois Licensure Minimums (Detailed) Reports dated 12/3 and 12/23/25 (picked at random) were reviewed for accuracy of the documented hours. On 12/3/25 there were 30 Therapists Hours documented (actual was 22.15 hours per V26/Therapy Director) and Activity Staff 22 hours were documented (actual was 16.5 hours per V40/Activity Director). On 12/23/25 there were 24 Therapists hours documented (actual was 20.03 hours per V26) and Activity Staff 24 hours were documented (actual was 15.45 hours per V40).The Labor Log by Therapist for 12/3/25 documents 28.27 hours. V26/Therapy Director hand wrote the treatment hours totaled 22.15 hours. The Labor Log by Therapist for 12/23/25 documents 25.13 hours. V26 hand wrote the treatment hours totaled 20.03 hours. The Laundry and Housekeeping Schedule dated 12/15/25 to 1/6/25 documents there was one Housekeeping/Laundry Staff scheduled for days and none for 4:00 PM -12:00 AM on 12/20 and 12/21/25. There were two Housekeeping/Laundry Staff scheduled for days and none for 4:00 PM-12:00 AM on 12/17/25. There were two Housekeeping/Laundry Staff scheduled for days and one for 4:00 PM -12:00 AM on 12/16, 12/18, 12/27, and 12/28/25.The Incident/Accident Log printed 12/29/25 documents that R19 was admitted to the facility on [DATE]. R19 had a fall on 11/28 and 12/4/25 at the Nurses Station. R19 fell on 12/13 and 12/15/25 in the Assisted Dining Room/ADR. (There was a fall on 12/3/25 in the ADR for R19 that was not documented)The Concern/Compliment Forms document the following concerns: On 10/2/25 Resident Council complained Call lights not being answered in a timely manner. Resident Council also complained Showers are still a concern on all shifts. On 10/23/25 R16 complained Long call light times. On 10/30/25 R16 complained Concerns about the dietary menu. On 11/6/25 Resident Council complained Call lights are not being answered in a timely manner. Resident Council also complained Showers are still an issue on first and second shifts. On 12/2/25 R17 complained that she has only had one shower since she has been at the facility and would like another one. On 12/4/25 Resident Council complained Showers are improving but residents state they have to ask several times to get complete. On 12/2/25 R18 complained that she prefers a shower and is given a bed bath. R18 has to Nag staff to get a shower.Resident Council Meeting Minutes for October, November, and December 2025 were reviewed with the following concerns: 10/2/25 Call lights not being answered in a timely manner. Showers are still a concern. 11/6/25 concerns with call lights and showers. 12/4/25 Grievances were written for cell phones, showers, soiled items in rooms, and call lights. Resident Council Meeting Minutes dated 1/1/26 documents that Nursing: Call lights are not being answered in a timely manner, showers are still a concern and when housekeepers are off work their rooms do not get cleaned.On 12/29/2025 at 2:43 PM, R7 stated that there are not enough staff to answer call lights or give showers. R7 stated that she had been administered MiraLAX (a liquid laxative). R7 was unable to recall the exact date the medication was given. R7 stated that she subsequently had a bowel movement and activated her call light to notify staff. According to R7, staff did not respond promptly, and R7 was required to remain soiled for more than 90 minutes. R7 further stated that after staff assisted with cleaning her, the bed linens were not changed. R7 expressed anger and distress regarding the incident, stating that the experience made her feel degraded and that her dignity was compromised. R7 reported that she filed a grievance regarding this incident but stated that no corrective action was taken.On 12/30/2025 at 12:15 PM, V18 (R15's Family Member) stated that when he visits R15's he has to put R15 on the toilet due to the call light not being answered timely and a lack of staff. On 12/30/25 at 12:49 PM, V10/CNA stated that staffing is often short. Especially on the night shifts. They do not have enough staff to get the residents up and dressed in the mornings. V10 stated that on 12/23/25 they had V10 on the daily but not on the main schedule so V10 did not show up for work. V10 got a call V10 needed to come to work. V10 called V11/CNA to see how short the facility was and V11 said that he was the only one on his unit and he needed help. V10 stated that she went in and worked about four hours to help. V10 stated It is a daily occurrence that we get here and there is not enough staff. There is no one here at 6:00 AM to address that. It has happened two to three times in one week that it is just me and one other CNA in the building. We get here at 6:00 AM and go from one end of the hall to the other and do the best we can. Along with doing the resident care we have to stop care to feed in the assisted dining room. V10 also stated It is not ok to leave residents in the ADR unattended. We have been told not to do it, but we have to because there is not enough staff.On 12/30/2025 at 1:07 PM, R12 stated when she uses her call light that it will usually take a while and sometimes it can take a couple of hours. R12 stated her family member typically comes in daily and will help with R12's showers, or helps to change R12's disposable brief, or her ostomy bag. R12 stated the staff here depend on her family member to do these tasks for R12 due to the staff saying they are short staffed.On 12/30/2025 at 1:05 PM, R14 was in his room, in his wheelchair, dressed. R14 voiced he does not depend on staff to help him, he is independent, but that his roommate does depend on staff. R14 stated he has witness staff taking at least an hour to answer a call light for his roommate.On 12/30/2025 at 1:25 PM, R13 stated she has long call light wait times when she needs staff assistance.On 12/31/25 at 9:48 AM, R6 stated that call lights can be answered in two minutes to two hours depending on the day. There is not enough staff especially on evening shift.On 12/31/2025 at 10:00 AM in a joint interview, V22/Certified Nurse Assistants/CNA and V23/CNA were working on B Hall and stated staffing is always short, staffing is never correct on the daily staffing sheets and that A Hall never has enough staff to help with how heavy the resident cares have become. V22 and V23 both stated they never have time to get all the resident cares completed or are always behind due to the demand to help dietary staff and resident cares.On 1/2/25 at 9:36 AM, V20/Ombudsman stated that there is a bad issue with the facility being short of CNAs. There are a lot of agency staff working so the facility may have the number of staff that they say are needed so it looks good on paper, but it is not. I got a call from (R7) recently and (R7) was very upset. (R7) was raising her voice saying her call light was on and staff were not coming. (R7) said that she had sat in feces for 90 minutes with her call light on and no one answered it. V20 also stated that there are a lot of complaints about call lights from residents that say the call lights are not answered or staff will come in and turn the light off saying they will be back, and they do not return. On 1/2/26 at 11:10 AM R7 stated that last week R7 asked for a shower and was given a quick bed bath because R7 is a mechanical lift, and it takes two staff to get R7 to the shower. R7 stated then on Tuesday 12/30/25 R7 had to wait two and a half hours to be changed. An agency CNA was working the night shift and said that she had a hernia so she could not lift to change R7 and R7 had to wait until the day shift came in to be changed. R7 stated It is degrading. I have no dignity whatsoever. I have been at the facility for two years and I deserve better treatment.On 1/2/26 at 11:55 AM, V1Administrator stated that staffing is a struggle. Several days a week V1 will work the floor from 7 AM to 11 AM then have the Director of Nursing or V41/MDS/Minimum Data Set Coordinator work the floor the rest of the day. There have been times V1 has had to work the floor all day. V1 stated that the facility needs to hire three nurses for 12-hour shifts, one full time day nurse, one part time day nurse, and one part time night nurse. The Certified Nursing Assistants/CNAs work 8(eight)-hour shifts and there needs to be seven CNAs hired, one full time for days, three full time for evenings, two part time evenings, and one part time nights. Until they get the positions filled the facility has had to use a lot of agency staff. There have been problems with the agency staff not taking care of the residents like facility staff do. V1 has had complaints about agency staff being on their phone, not answering call lights, and not providing the care the residents should get. V1 stated I have to do finagling to get the staffing numbers I need. On 1/3/25 at 2:47 PM, V30/RN stated that there are times the staffing is very poor. Evening shift needs more CNAs because there are not many regular staff and agency is used to fill in. The agency staff are not familiar with the residents and are not as efficient as staff that know the residents. There was a day that at 6:00 AM there were only two CNAs in the building and there should have been 8.On 1/3/26 at 3:04 PM, V31/CNA stated that she usually works the night shift and when she comes in there are not enough staff working evenings. Most of the staff on evenings are agency staff and they do not get everything done that needs to get done. The facility needs more reliable CNAs. V31 also stated that she thinks residents are having falls because there is not enough staff. On 1/5/25 at 11:00 AM, V11/CNA stated that lack of staff is an issue and that is one of the reasons V11 recently resigned. On 12/23/25 at 6:00 AM there were only two CNAs to start the shift and there should have been seven. V11 stated It's not just one day this happened it happens often. When we ask for help it may be hours before we get it. There are cares that can't be done. I am one person and can only do so much. V11 also stated There is supposed to be staff in the Assisted Dining Room at all times but that's not possible.On 1/6/26 at 10:55 AM, R12 was sitting in therapy in her wheelchair. R12 stated that there is not enough staff. I can't get them to get me up. They won't get me up twice a day like they are supposed to because they say they are too busy. If they do get me up, I'm left sitting in my wheelchair all day. I want to go home and I'm not gonna get there if they don't get me up. On 1/6/26 at 2:25 PM, V35/Regional Nurse Consultant stated that R19 had an unwitnessed fall in the ADR on 12/3/25. V35 also stated that R19 also had falls on 11/28, 12/4, 12/13, and 12/15/25. On 1/6/26 at 2:47 PM, V1/Administrator stated that the CNAs work 7.5 (seven and a half) hours, and the nurses work 12 hours. Since IDPH (Illinois Department of Public Health) last cited the facility for staffing the facility determined their needs to be a minimum of 18 CNAs Monday to Friday and 22 CNAs for Saturday and Sunday. V1 also stated that the Facility Assessment was not updated and does not show the accurate number of CNAs needed daily to provide the care the residents need. When V1 was shown that two of the random sampled reported daily staffing numbers (12/3 and 12/23/25) were not accurate for the Therapy Hours and Activity Hours V1 stated that she gets the numbers daily from V26/Therapy Director and V40/Activity Director and was not aware they were not accurate. V1 also stated that she will need to start getting the accurate numbers from V26 and V40.

Based on interview and record review the facility failed to prevent falls, investigate one fall, notify the Physician and Residents Representative of two falls, and failed to put interventions in place for two falls for one resident (R19) of five residents reviewed for accidents in the sample of 21. Findings include:The Fall Prevention Program revised 05/2022 documents Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The Fall Prevention Program includes the following components: Use an implementation of professional standards of practice. Immediate change in interventions that were successful. Notification of physician, family/legal representative. Documentation requirements. Care plan incorporates: Identification of all risk/issues. Addresses each fall. Interventions are changed with each fall, as appropriate. Standards: Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determined possible safety interventions. Fall/safety interventions may be included but are not limited to: Call lights are answered promptly. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. In addition to the use of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk: The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the residents' risk factors and the plan of care.The Incident and Accident policy revised 5/2022 documents Policy: The incident/accident report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident to resident altercations. Procedure: An incident is defined as any happening, not consistent with the routine operation of the facility, that does not result in bodily or property damage. An accident is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/accident report will be completed for: 6. All unexpected events occur that cause or pretend to a resident or employee. 1. An incident/accident report is to be completed by a RN/Registered Nurse or LPN/Licensed Practical Nurse and is to include: a. Date and time of an incident/accident. B. Full written statement and possible causes of incident physical assessment, injuries noted, vital signs, treatment, education of appropriate.R19's computerized Medical Record documents that R19 admitted to the facility on [DATE] with diagnoses which included Athetoid Cerebral Palsy, Anxiety, and Developmental Disorder of Speech and Language. R19's MDS (Minimum Data Set) assessment dated [DATE] documents Section C (Cognitive Patterns) a BIMS (Brief Interview for Mental Status) of 99, indicating (severely impaired cognition). Section GG (Functional Ability) documents R19 is dependent on staff for eating, all activities of daily living, transfers, and requires partial assist for bed mobility. R19's Care Plan documents R19 is at risk for falls r/t (related to) immobilization and decreased cognition.R19's Nursing Note dated 11/28/25 at 2:58 PM, documents Therapy was walking down the hall towards the nurses' station when she saw (R19) lean forward in the wheelchair and fall out of the chair and hit her head on the sharps container and the nurses cart.R19's Nursing Note dated 12/4/25 at 6:02 PM, documents (R19's) sustained a fall on 12/04/2025 5:05 PM. The incident occurred in the nurse station. Resident is alert and disoriented per usual baseline.An e(electronic)-mail written by V20/Ombudsman to V1/Administrator dated 12/11/25 at 10:19 AM, documents Good Morning (V1/Administrator). What was the outcome of (R7) stating that the residents were left in the ADR (Assisted Dining Room) alone and that (R19) fell while in the ADR alone . (R19) fell, hitting her head on (R7's) chair.R19's Witnessed Fall Report dated 12/13/25 at 6:15 PM, documents that R19 fell in the (Assisted) Dining Room. The CNA (Certified Nursing Assistant) called the nurse about the witnessed fall of (R19). The CNA said they witnessed (R19) slide out of the chair to the floor. There is no notification documented that the physician or resident's representative were notified of the fall. R19's Nursing Note dated 12/15/25 at 11:17 AM, documents: (R19) sustained a fall on 12/15/2025 8:50 AM. The incident occurred in the ADR (Assisted Dining Room).An e-mail written by V1/Administrator to V20/Ombudsman dated 12/19/25 at 2:00 PM, documents that V29/Prior Director of Nursing/DON was doing the investigation on R19's suspected fall on 12/3/25 in the ADR and V29's last day was unexpectedly yesterday. V1 will have to find the information and will get it to V20 shortly.The Incident/Accident Log printed 12/29/25 documents that R19 was admitted to the facility on [DATE]. R19 had a fall on 11/28 and 12/4/25 at the Nurses Station. R19 fell on 12/13 and 12/15/25 in the Assisted Dining Room/ADR. (There was a fall on 12/3/25 in the ADR for R19 that was not documented)V21's Witness Statement signed by V21/CNA dated 1/6/2026 documents I was working on 12/3/2025. At approximately 5-5:30 PM I heard a resident yell from the assisted dining room. When I entered the dining room (R19) was on the floor tipped back in her chair. I then yelled for a nurse and (V37/Licensed Practical Nurse/LPN) and (V38/LPN) entered.V37's Witness Statement signed by V37/LPN dated 1/6/2026 documents, I was assigned to B wing on 12/3/2025. At approximately 5-5:30 (PM) prior to dinner I heard (V21/CNA) yell for help from the assisted dining room. When I entered the dining room I observed (R19) lying on the floor on her back with her wheelchair under her.V38's Witness Statement signed by V38/LPN dated 1/6/2026 documents, On 12/3/2025 I was assigned to A wing. The Certified Nursing Assistant (V21) yelled for help. I entered the dining room and observed (R19) lying on the floor. We got (R19) back up into her chair. I assessed (R19's) head to ensure no injuries, no injuries were noted.On 1/2/25 at 9:36 AM, V20/Ombudsman stated that R7 told V20 on 12/4/25 that a resident (that was [AGE] years old that could not talk or do anything for herself, later identified as R19) fell in the assisted dining room and there was no staff in there to help. R7 kept yelling until staff finally came to help. V20 asked V1/Administrator about R19's 12/3/25 fall on 12/4/25 because V20 was worried if there were no staff in the ADR with the residents because that is not safe. V1 said she was not aware of the fall and would have V29/Prior DON look into it. V20 stated I still have not heard back about (R19's) fall. I sent an email to (V1) to follow up on the fall and I still have not got an answer about what happened.On 1/2/26 at 11:10 AM R7 stated that there was a resident (R7 did not know the residents name but described her as [AGE] years old that could not talk. The resident was later identified as R19) that fell backwards in her wheelchair while in the Assisted Dining Room hitting R7. R7 stated There is supposed to be staff in the dining room to help us. When (R19) fell I was yelling for help for (R19). (R20) was going to try to help but I was afraid that (R20) would fall and get hurt so I told (R20) not to try to lift (R19). Staff finally came to get (R19) off the floor. On 1/3/26 at 2:34 PM, V39/R19's Family Representative stated that R19 was admitted to the facility on [DATE] and was notified of R19 falling three times. V39 stated she would have liked to know if R19 had other falls. Staff told V39 that R19 fell because they (staff) could not use a seat belt to keep R19 in the wheelchair. V39 stated If they would put (R19) on the floor on a mat (R19) would be happy playing with her toys.On 1/3/25 at 2:47 PM, V30/Registered Nurse/RN stated There should be someone in the assisted dining room all the time with the residents. It is not safe for them (residents) to be unattended.On 1/6/26 at 2:25 PM, V35/Regional Nurse Consultant stated that she had started the investigation today (1/6/26) to find out if R19 had a fall on 12/3/25. Staff confirmed that R19 did have an unwitnessed fall in the Assisted Dining Room on 12/3/25. The nurse (V38/LPN) did not do an Incident Report, make a Nursing Note, or do any notifications to the physician or R19's Representative, and no interventions were put in place for the fall on 12/3/25 in the ADR. V35 also stated that R19 also had a fall on 11/28, 12/4, 12/13, 12/15 and there was no intervention put in place for the fall on 12/15/25.

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions/EBP or perform hand hygiene during indwelling urinary catheter care for 1 resident (R9) of 3 residents reviewed for catheter care in the sample of 21. Finding include:The Urinary Catheter Care policy revised 09/2020 documents Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines: 1. Disposable one-time use gloves shall be worn when emptying urinary drainage bags and when performing perineal care. 2. Hand hygiene shall be performed before and after touching any part of the urinary catheter drainage system.The Enhanced Barrier Precautions policy revised 12/2025 documents Statement of Purpose: Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Personnel: Personal providing direct care. Personal Protective Equipment: Gown and gloves. Policy: EBP may be considered and implemented for: Wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains, AV (arteriovenous) fistulas, etc. (etcetera). Personal Protective Equipment- Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: Dressing, Bathing/Showering, Providing Hygiene, Changing Linens, Incontinent Care, Medical Device Care, Wound Care.The Certified Nursing Assistant Job Description revised 07/2023 documents Job Summary: The primary purpose of a Certified Nursing Assistant is to provide residents of the facility in your nursing unit with nursing and care under the supervision of a Charge Nurse, and to safeguard the health, safety, and welfare of all residents of the facility, in accordance with the facility's established policies and procedures and applicable laws and regulations, and directions your supervisor, who includes the Administrator, Director of Nursing, Assistant Director of Nursing, House Supervisor, Charge Nurse, Rehabilitation Director or other members of the facility's management to whom such persons report, in order to assure that the highest degree of quality care is maintained at all times. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. Assure that established infection control and standard precaution practices are maintained when performing nursing procedures.R9's computerized Medical Record documents that R9 is an [AGE] year-old that admitted to the facility on [DATE] with diagnoses which included Dementia, Cognitive Communication Deficit, Retention of Urine, Obstructive and Reflux Uropathy, and Urinary Tract Infection.R9's Physician's orders, printed 12/31/25, document an order for Enhanced Barrier Precautions related to an indwelling urinary catheter and indwelling urinary catheter care every shift and as needed. Order date 8/30/24.R9's Care Plan documents Enhanced Barrier Precautions r/t (related to) indwelling catheter. Date Initiated 8/30/24. Intervention Educate staff/resident/family on enhanced precautions as needed. Gown and glove during high contact resident care activities (such as dressing, bathing, showering, changing briefs, assisting with toileting or wound care). The same Care Plan also documents Risk of infection and recurrent infections related to nutritional deficit and hydration deficit as evidenced by poor oral intake, dehydration, and weakened immune function. Date initiated 11/4/25. Interventions Ensure proper hygiene practices to prevent infection, such as hand washing, wound care, and maintaining a clean environment. Date initiated 11/4/25.On 12/31/25 at 10:03 AM, R9 was lying in bed watching television. V11/Certified Nursing Assistant/CNA entered R9's room to provide indwelling urinary catheter care. V11 applied gloves without washing his hands and did not put on a gown. V25/CNA came in the room to talk to R9's roommate. V11 asked V25 if V25 would help reposition R9 in bed so V11 could do catheter care. V25 assisted repositioning R9 and did not wear gloves or a gown. V11 then filled the washbasin with water and put several washcloths in the water. V11 used a washcloth to clean R9's penis. V11 then took another washcloth out of the washbasin and cleaned R9's scrotum. V11 then took another washcloth out of the washbasin and cleaned the catheter tubing and catheter bag. V11 then changed his gloves for the first time since starting care but did not wash his hands. V11 then pulled up and adjusted R9's pants.On 12/31/25 at 10:14 AM, V11/CNA was asked if a gown was required when doing catheter care. V11 stated that a gown was not required for catheter care. On 12/31/25 at 2:35 PM, V1/Administrator stated that when a resident is in Enhanced Barrier Precautions a gown and gloves should be worn for all high contact resident care, and this included indwelling urinary catheter care. V1 also stated that hands should be washed when entering a resident's room before putting on gloves and hands should be washed after each time gloves are removed. V1 also stated that gloves should be changed after touching anything dirty.

Based on record review and interview, the facility failed to document all complaints and/or concerns voiced in resident council meeting. This failure has the potential to affect all 82 residents that currently reside in the facility.Findings Include:The Facility's Resident Council policy dated 02/2025 documents The purpose of the Resident Council is to allow the residents the opportunity to express their thoughts and ideas in a safe and confidential manor. Additionally, the council serves to promote improvement and control concerning the quality of life at the facility.The Facility's Grievances policy dated 09/2017 documents The purpose is to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnish, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. Grievances maybe filed orally (meaning spoken), in writing, or anonymously. Every effort shall be made to resolve all grievance in a timely manner, usually within 5 business days. On 11/20/25 R4 stated she had concerns that she did not receive the right medicine. She stated that she counts the number of pills she takes and sometimes it is not right. When I say something to the nurses, they get very crabby about it, so I just take them. But I really don't think I get the pills I should. I have talked to a lot of the staff about it. I have brought it up in resident council multiples times and I asked (V5/Activity Director) one time to actually check, and she came back and said she did, I do not think she did. I am pretty worried about medicine. Resident Council from September to November 2025 do not document any complaints or concerns about R4 or anyone else getting the right medicines. On 11/21/25 R7, R8 and R9 who are frequently on the attendance list for Resident Council confirm that they have heard other residents complain about their medications. On 11/21/25 at 1:00 PM V6 (Ombudsman) stated I come to this Resident Council Meeting every month. I have heard residents complain about not getting the right medications, getting them late or not getting them at all. All of that has been voiced multiple times in the past three months for sure. On 11/21/25 at 2:00 PM V5 (Activity Director) confirmed that all concerns voiced during Resident Council Meeting minutes should be treated like a grievance, with a written form for investigating and tracking the complaint to its conclusion. At the beginning of the conversation V5 denied ever hearing any residents complain about not getting the right number of medications, getting medications late or not getting medications at all. However, V5 stated that when that happens, I just go ask the nurse. V5 stated she couldn't remember specifics of any one resident complaining or what it was about, but she does remember checking with nurses when residents do complain. V5 confirmed that she did not document via a grievance form any time she might have been asked about medications and did not inform the Director of Nursing or the Administrator.On 11/21/25 at 2:30 PM V1 (Administrator) stated that her expectation is that all concerns that are voiced during Resident Council have a grievance form so the appropriate Manager can investigate and improve whatever the situation is. The managers can't fix problems they do not know about, it is very important that all concerns are recorded and documented. The Facility Census Listing dated 11/20/25 documents 82 residents currently reside in the facility

Based on interview and record review, the facility failed to ensure sufficient nursing staff were available to meet the needs of residents. This failure has the potential to affect all 85 residents residing in the facility.Findings include:The facility's Call Light policy revised 1/2022 documents resident call lights will be answered in a timely manner. All staff should assist in answering call lights. Nursing Staff members shall go into the resident's room to respond to call system and promptly cancel the call light when the room is entered. Bathroom lights should be viewed as emergencies and immediate attention will be given. Requests shall be responded to in a professional and courteous manner. The Facility Assessment (reviewed 8/16/2024) documents the following: Staffing Plan: The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs.The facility's Resident Roster dated 8/18/25 documents 85 residents reside in the facility. On 8/18/25 at 2:34 PM V3(Ombudsman) stated it was mentioned in resident council on 8/7/25 that it was taking staff long periods of time to answer residents call lights and to be taken to the bathroom. On 8/19/25 at 1:55 PM V17 (Activity Director) stated she is responsible for resident council and typing the resident council concerns. V17 stated, I have not been documenting the concerns voiced in resident council on the resident council minutes. I was instructed not to from past administration. Usually if residents voice concerns, I go to the department head responsible for the department they are complaining about and let them know the concerns. Nothing gets documented. I believe it was brought up in the last resident council meeting that call lights have not been answered timely.On 8/19/25 at 11:40 AM, V12 (Licensed Practical Nurse) stated staffing is an issue because staff call in often. V12 stated when staff call in for their shift, we must make do with the staff we have which causes longer wait times for the residents. On 8/19/25 at 11:46 AM, V13 (Licensed Practical Nurse) stated staffing is an issue at the facility and Certified Nursing Assistants (CNAs) are understaffed. Residents will often complain that their call lights are not being answered timely because we don't have enough staff. On 8/19/25 at 11:56 AM, V14 (Certified Nursing Assistant) stated residents often experience long wait times and staff struggle to respond promptly due to limited coverage.On 8/19/25 at 12:40 PM, V19 (Certified Nursing Assistant) stated that the facility is often not clean, and the staff often work short which makes for longer wait times for residents. V19 stated the residents will complain often that they are not getting the help they need. On 8/18/25 at 9:18 AM R1 states from 2pm-10pm he has had to wait 3 hours before when he had turned on his call light. R1 stated, I hate sitting in my poop waiting for someone to change me. The staff rarely get to my call light timely on nights. I wait at least 30 minutes every night sometimes more for my call light to be answered. They don't have enough staff.On 8/19/25 at 1:45 PM, R3 stated his call light is frequently ignored, with wait times exceeding one hour, and expressed concern about insufficient staffing.The facility Concern Form dated 8/7/25 documents R8 expressed in Resident Council that R8 is having issues with her call light being answered in a timely manner, and staff state that R8 needs to wait. This form further documents R8 has had to wait for two hours for toileting assistance. On 8/20/25 at 12:35 PM, R8 stated that she often waits a long time for toileting assistance. R8 stated she requires a mechanical lift to be transferred to the toilet and staff will tell R8 that it takes too long to toilet her, so R8 often urinates and poops in her adult brief. R8 stated she has had to wait for hours in a soiled adult brief for staff to come and change her. The facility's Daily Assignment Sheet dated 8/9/25 documents the total Nursing Staff hours were 190 hours for the day. V21 (Regional Director of Operations) documented on Daily Assignment Sheet the facility was short 33 Nursing hours for 8/9/25 based on Facility Assessment staffing calculations. The facility's Daily Assignment Sheet dated 8/10/25 documents the total Nursing Staff hours were 185 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 38.5 Nursing hours for 8/10/25 based on Facility Assessment staffing calculations. The facility's Daily Assignment Sheet dated 8/16/25 documents the total Nursing Staff hours were 176.9 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 47.1 Nursing hours for 8/16/25 based on Facility Assessment staffing calculations. The facility's Daily Assignment Sheet dated 8/17/25 documents the total Nursing Staff hours were 177.5 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 41.5 Nursing hours for 8/17/25 based on Facility Assessment staffing calculations. On 8/20/25 at 11:56 AM, V21 (Regional Director of Operations) confirmed staffing shortages on the above dates based on minimum staffing calculations.

Based on observation, interview, and record review the facility failed to implement adequate housekeeping services to keep the facility clean and free of odors. These failures have the potential to affect all 85 residents residing within the facility. Findings include:The facility's Daily Census form, dated 8/18/25, indicates that 85 residents are currently residing in the facility.The facility's Housekeeper policy revised 7/2023 documents the primary purpose of the housekeeper is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. Ensure that work/cleaning schedules are followed as closely as practical. Clean floors including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting etcetera.The facility's Housekeeping Supervisor Job Description revised 7/2023 documents the primary purpose of the Housekeeper Supervisor is to perform the day to day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. Ensure that work/cleaning schedules are followed as closely as practical. Coordinate daily housekeeping services with nursing services when performing routine cleaning assignments in resident living and/or residential areas. Clean floors including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting etc.The facility's A Hall and B Halls daily cleaning list, provided by V7/Housekeeping Supervisor, documents, Mop floors in your section. This list does not include sweeping floors.The facility's Laundry and Housekeeping Schedule dated 7/28/25 through 8/24/25, documents two housekeepers and one laundry aide worked on 8/15/25 and 8/16/25, one housekeeper and one laundry aide worked 8/17/25, and two housekeepers and one laundry aide worked 8/17/25.On 8/18/25 from 9:25 AM through 9:31 AM a tour was conducted of A-Hall. room [ROOM NUMBER]'s floor was sticky with scattered debris through the room. A large sticky red spill was observed by the bed against the wall. room [ROOM NUMBER]'s floor had small stains throughout the floor with a large brown sticky stain observed underneath the bed and another large yellowing-brown stain slightly underneath the side table. Scattered debris was observed throughout the entire room. room [ROOM NUMBER] had a bright red sticky stain observed by the bed, with crumbs and debris scattered throughout the entire floor. room [ROOM NUMBER] had thick black marks on the floor in between the bathroom and the bed. The entire floor was sticky with old spill stains throughout the floor. room [ROOM NUMBER]'s floor was scattered in debris and was sticky throughout the entire room. A Hall (Short) was observed to have small sticky brown spots down the hallway with scattered debris, and multiple stains. A Hall (Long) was observed to have multiple stains down the hallway.On 8/18/25 at 2:07 PM V7/Housekeeping Supervisor confirmed at this time room [ROOM NUMBER]'s floor remained sticky with scattered debris, room [ROOM NUMBER]'s floor had small stains throughout the floor with a large brown sticky stain remaining underneath the bed and another large-yellowish brown stain slightly underneath the side table, room [ROOM NUMBER]'s floor remained scattered with crumbs, debris, and a red stain by the bed, room [ROOM NUMBER] had thick black marks on the floor and the floor remained sticky, room [ROOM NUMBER] remained sicky with scattered debris throughout room, and A Hall (long and short) remained with scattered stains. V7 stated, This past weekend we only had one housekeeper and one laundry aide for the entire building. I was here on Saturday, but we can't get everything done. Every other weekend is like that. On the weekend with one housekeeper, they will typically clean the dining room out from breakfast and lunch, clean the nurse's station, take out the trash from the rooms, clean the bathrooms, and do spot checks. During the week we typically schedule one laundry aide and two housekeepers, as well as me. One housekeeper will take A hall and one will take B hall. I assist with doing the small dining room, offices, and running the floor machine throughout the facility. We had a call in today, so we had one laundry, one housekeeper, and then me. I did spot checks today on B hall but couldn't get to everything. I still have a little more to do in some of the rooms.On 8/18/25 at 9:18 AM R1 stated housekeeping misses his room a lot for cleaning and states he does not believe housekeeping did much to his room over the weekend.On 8/18/25 at 2:14 PM R8 stated, My trash has not been taken out of my room since last Friday and no one has cleaned my room since then. They are always short on housekeepers, and I get tired of my room not getting cleaned. I tell them all the time and then no one comes back to speak to me about it. I don't like when my room gets that dirty.On 8/19/25 at 1:45 PM, R3 was sitting on his bed in his room. R3's room had a very strong urine odor. R3 stated housekeeping often does not come in and clean his room because they do not have enough help.On 8/19/25 at 11:46 AM V13/LPN (Licensed Practical Nurse) stated housekeeping is terrible and they do not do the job correct.On 8/19/25 at 11:56 AM, V14/CNA (Certified Nursing Assistant) stated the facility is dirty and they only have one housekeeper on each side of the facility per day and they cannot get to it all.On 8/19/25 at 12:40 PM V19/CNA stated that the facility is often not clean and stated there is only one housekeeper that cleans one time a day and is not able to get all the cleaning done. On 8/19/25 at 12:11 PM V15/Human Resource Director provided the hours worked per department for housekeeping and laundry for the dates 8/15, 8/16, 8/17, and 8/18/25. On 8/15/25 there were a total of 22 hours worked in housekeeping and laundry, 8/16/25 a total of 23 hours worked in housekeeping and laundry, 8/17/25 a total of 15 hours worked in housekeeping and laundry, and 8/18/25 a total of 23 hours worked in housekeeping and laundry. V15 stated at this time they use the calculation of 0.45 x (times) the census to determine how many housekeeping/laundry/and maintenance staff to schedule. V15 verified at this time 37.8 hours per day should have been staffed for 8/15, 8/16, 8/17, and 8/18 and were not.On 8/19/25 at 1:55 PM V1/Administrator in Training stated We (the facility) have 37.8 hours per day for housekeeping/laundry/maintenance. We currently are not meeting that.

Based on interview and record review the facility failed to promptly provide medical care for a resident promptly after a decline in condition for one of five residents (R2) reviewed for change in condition in a sample of nine. Findings include:The facility's Hospice Services, dated 10/2024, documents Guidelines: the facility shall honor the advance directives and care alternatives residents may desire when terminally ill and to afford residents with care that allows for dignity and comfort during the end stage of their lives. 2. The resident's advanced directives will be honored in all aspects of Hospice services. 9. Facility licensed personnel will be responsible to notify the Hospice Service Coordinator in the event of a change in the Hospice residence condition and prior to transfer of resident to another facility including an acute hospital.R2's admission Record, dated [DATE], documents R2 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Presence of Cardiac Pacemaker, Major Depressive Disorder, and Alzheimer's Disease. R2's current Census record documents R2 admitted to hospice on [DATE]. R2's IDPH (Illinois Department of Public Health) Uniform POLST (Practitioner Order for Life-Sustaining Treatment) form revised [DATE] documents R2 is a full code and to attempt CPR (Cardiopulmonary Resuscitation). This further documents R2 selected full treatment with primary goal of attempting to prevent cardiac arrest by using all indicated treatments. Utilize intubation, mechanical ventilation, and all other treatments as indicted. R2's Progress Note, dated [DATE] at 5:15 AM and signed by V22/Agency LPN (Licensed Practical Nurse), documents (R2) exhibiting [NAME] strokes breathing pattern. BP (Blood Pressure) 63/54, R (Respirations) 22, SPO2 (Saturation of Peripheral Oxygen) 84% (percent) on 2 L (liters) oxygen via NC (nasal cannula) continuous. Temperature 98.3. P (Pulse) 144. Generalized mottling noted. (Hospice) contacted. Spoke with (V23/Hospice Registered Nurse/RN) updated on (R2's) condition and signs and symptoms. (R2) remains full code at this time. (Hospice) is contacting appointed guardian on call phone number for clarification. (R2) continues medications for comfort. Hygienic cares performed and positioned for comfort.R2's Client Coordination Note, dated [DATE] at 5:22 AM and signed by V23/Hospice RN) documents V23 received a call from the facility that R2 had a change in condition with an elevated heart rate of 140 that was weak, R2's blood pressure was 60/30, and oxygen saturation reading was 84% despite oxygen therapy. V23 further documents she made facility aware that R2 remains a Full Code at this time and that V5/R2's Guardian did not feel that R2's medical record contained enough documentation to change R2's code status the last time they spoke. V23 made facility aware she would make some calls for guidance and call the facility back with updates. R2's Client Coordination Note, dated [DATE] at 5:50 AM and signed by V23/Hospice RN, documents V23 contacted V24/R2's on call Guardian and received guidance that nothing can be done to change R2's Code Status until the following day. V24 advised V23 that the facility should follow protocol for a resident with a declining condition that is a Full Code. V23 documents that V23 contacted the facility with this guidance and was told V23 would receive a call back after facility determines what they are required to do. R2‘s Progress Note, dated [DATE] at 6:04 AM and signed by V22/Agency LPN, documents Received return call from (V23/Hospice RN) with (Hospice.) Made aware (Hospice) spoke with on call guardian and made aware No attorney available over the weekend. (R2) to remain full code until further notice. (V23) scheduled (Hospice) visit with (R2) today. (R2) remains resting quietly with eyes closed. Comfort medications continue. Will continue to monitor.R2's Client Coordination Note, dated [DATE] at 8:05 AM and signed by V23/Hospice RN, documents that after multiple attempts to contact the facility nurse V23 spoke to V11/LPN who stated the nurse from the previous shift did not pass along R2's condition change or that V11 was to follow up with V23. This note further documents that V23 made V11 aware that R2 is a Full Code and R2's code status could not be changed until the following day, V23 requested that V11 contact V1/Administrator in Training (Prior Director of Nursing) for guidance as they should follow R2's current code status. V23 documents that V11 stated she would contact V1 and then call V23 back with an update. R2's Client Coordination Note, dated [DATE] at 10:00 AM and signed by V23/Hospice RN, documents V23 called the facility back and spoke with V11 who stated she has a call out to V1 and if she has not heard anything by the time V11 is done passing medications for the morning V11 will call again. V11 stated she will call V23 if she hears anything.R2's Progress Note, dated [DATE] at 5:22 PM and signed by V10/LPN documents This nurse spoke with (V23/Hospice RN) and contacted (V1/Administrator in Training) for approval to send (R2) to the emergency room. This nurse wasn't able to obtain a BP and (R2) had a low oxygen saturation. (R2) remained on 3 L of O2 (oxygen) until EMT (Emergency Medical Technicians) arrived. (R2) was sent to the emergency room via emergency medical transport. (V23) was made aware (R2) had been sent and stated to this nurse she (V23) would contact the guardian and keep the facility updated on (R2's) status.R2's Client Coordination Note, dated [DATE] at 11:15 AM and signed by V23/Hospice RN, documents V23 received a call from V11 who stated that R2 was being sent to the local hospital by ambulance.On [DATE] at 3:24 PM V5/R2's Guardian stated, The facility should have sent (R2) to the hospital right away if he was actively dying. I was never able to sign the DNR (Do Not Resuscitate) based on the information provided from the (Hospice) company prior to (R2) having to go to the hospital. I was upset when I found out the facility waited approximately five and a half hours before they sent (R2) out to the hospital since (R2) was still a Full Code. On [DATE] at 4:15 PM V23/Hospice RN stated, I thought it was an extreme amount of time to wait to send (R2) to the hospital on [DATE] since he was a full code. The facility contacted me at approximately 5:20 AM and stated (R2) was actively dying. I advised the facility to treat (R2) as they would with any resident who was a full code. The nurse that contacted me stated she was going to get ahold of the charge nurse before sending (R2) out to the hospital to see what they wanted to do. I never heard anything back from that nurse, so I called the facility back around 6:00 AM and spoke to the nurse again and let them know what (V24/R2's On Call Guardian) had stated. That nurse stated they were still waiting to speak to the charge nurse because they felt like since he was on hospice they shouldn't send him to the emergency room. I then called back around 8:00 AM and spoke to a different nurse on duty. I then explained again I would advise them to send (R2) out to emergency room. They stated they could hardly get a BP on (R2) and that (R2) had begun to mottle. The staff nurse continually told me they were going to wait for the charge nurse to let them know what to do. I let the facility know that would be on them, that (R2) is a full code and should be treated as such. Around 11:00 AM the facility called me and stated they were transferring (R2) to the hospital.On [DATE] at 12:27 PM V10/LPN stated I was not aware of (R2's) condition until (V23/Hospice RN) called the facility. I spoke to (V23) around 8:00 AM regarding the status of (R2). I told (V23) I would have to notify (V1/Administrator in Training) to see if they wanted me to send (R2) out to the hospital, since that is our facility's protocol. We (facility staff) have been told we have to let management know before sending someone out to the hospital to ensure it is ok since (R2) was hospice. I assessed (R2) and could hardly get a BP reading and you could tell (R2) was actively dying. I didn't know what to do since (R2) was on hospice, but still a full code. I believe I messaged (V1) around 8:30 AM because she was off that day. I did not hear back from (V1) until approximately 10:30 AM to send (R2) to the hospital. I did not get (R2) sent to the (local hospital) until around 11:00 AM. Between 8:00 AM and 10:30 AM (V23) kept calling to see where we were with sending (R2) out to the hospital because (V23) stated we should be sending (R2) since (R2) is still a full code. I kept telling (V23) I was waiting to hear back from (V1) to see what to do. To be honest I am a brand-new nurse and wasn't sure what to do. I did not document the time correctly in the progress notes. I accidently put 5:22 PM but it was technically around 11:00 AM when I sent (R2) out to the hospital.On [DATE] at 2:37 PM V1/Administrator in Training stated she was the prior Director of Nursing when R2 was sent out to the hospital on [DATE]. V1 stated, If any resident, including residents on hospice, are a full code and are actively dying staff should notify the physician and send the resident out to the hospital immediately. There is no rule at the facility that staff must get a hold of the Director of Nursing first. (R2) should have been sent out immediately when (R2) was experiencing a change in condition and was actively dying. V1 verified five and a half hours was too long to wait to send R2 out to the hospital on [DATE].

Based on interview and record review, the facility failed to prevent abuse for one resident (R2) of three residents reviewed for abuse in a sample of 15. This failure resulted in R2 being sent to the hospital diagnosed with an orbital fracture and suffering psychosocial harm that any reasonable person would after being abused. This past non-compliance, which involved R2, occurred from 3/09/23 to 3/14/23. This failure resulted in an Immediate Jeopardy. Prior to the survey date of 3/29/2024, the facility had taken the following actions to correct the non-compliance: 1) Immediate actions taken for those residents identified: On 3/9/24, R2 was assessed and sent to the hospital. On 3/11/24, R2's Abuse screening and Care Plan were reviewed and updated accordingly. On 3/9/24 R1 was assessed and placed on a 1:1 until he was sent to the hospital. On 3/9/24 when R1 returned from the hospital R1 was placed on a 1:1 and remains on 1:1. On 3/11/24 R1's Abuse screening and Care Plan were reviewed and updated accordingly. 2) Measures put into place/System changes: On 3/11/24 the Interdisciplinary Team reviewed the Facility's Abuse Prevention Policy with no changes needed at this time. On 3/13/24 V16 (Assistant Director of Nursing) reeducated all staff on the Facility Abuse Prevention Policy. On 3/12/24 the Interdisciplinary Team reviewed and updated all residents current abuse screenings. On 3/13/24 A Quality Assurance and Performance Improvement meeting was held with V12 (Medical Director) to discuss alleged allegation and facility comprehensive follow up. V1 (Administrator), V2 (Director of Nursing), V12 (Medical Director), and V16 (Assistant Director of Nursing) were in attendance. On 3/14/24 the Interdisciplinary Team reviewed and discussed Medical Records of referrals prior to admitting to ensure resident safety and well-being of residents with Dementia. On 3/14/24 the Interdisciplinary Team reviewed and discussed any New Admission's Abuse Screenings and Psychosocial Screenings to ensure resident safety and well-being of residents with Dementia. On 3/13/24 V16 (Assistant Director of Nursing), interviewed all residents to ensure they feel safe and report no similar occurrences. Findings Include: The Abuse Prevention and Reporting policy dated 11/28/16, documents The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used and this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The Final Abuse Investigation Report sent to (the State Agency) dated 3/9/24, documents that R2 a [AGE] year-old female was physically abused by R1. On 3/9/24, at 1:38 PM, (R1) came out of his room in his wheelchair to use the phone at the nurses station. (R2) was sitting at the nurse's station also. After hanging the phone up (R1) rolled his wheelchair backwards. (R2) moved her chair backward to get out of (R1's) way. When (R1) got turned around (R1) noticed (R2) sitting in her wheelchair. (R1) then moved toward (R2) ultimately making contact. Staff immediately ran to separate the two residents. (R1) then fell out of his wheelchair onto the floor. R2 had an abrasion to the bridge of her nose. On 3/29/24 at 2:40 PM, the video was observed of the incident between R1 and R2. R2 was sitting in the hall near the nurse's desk. R1 wheeled past R2 and went to the nurse's desk to use the phone. When R1 hung the phone up he was backing up in his wheelchair. R2 was backing up to move out of R1's way. R1 turned his wheelchair around and looked like R1 was going to go past R2. Suddenly R1 raised his fist towards R2. R2 put her hands up in front of her face. Quickly R1 grabbed R2's shirt with his left hand at her right shoulder so R2 could not move away from R1. R1 leaned forward in his wheelchair, fully extended his right arm hitting R2 in the face at full force with his fist. R1 hit R2 several times with at least a couple of the hits connecting with R2's face. R1 was trying to stand from his wheelchair as he was hitting R2 and R1 fell to the floor. When R1 fell to the floor R2's wheelchair rolled back and R2's face was out of camera view. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, Unspecified Severity, with Agitation, Paranoid Schizophrenia, Schizoaffective Disorder, Bipolar Type, Mixed Hyperlipidemia, Type 2 Diabetes Mellitus without Complications, Other Specified Chronic Obstructive Pulmonary Disease, Other Abnormalities of Gait and Mobility, Hemiplegia and Hemiparesis following Non Traumatic Intracerebral Hemorrhage Affecting Left Non Dominant Side, and Dysphagia, Oral Phase. R1's MDS (Minimum Data Set) dated 2/23/24 documents a BIMS (Brief Interview for Mental Status) Score of 4/15, indicating (severe impairment). R2's Face Sheet documents R2 was admitted to the facility on [DATE] with a diagnosis of Dementia in Other Diseases Classified Elsewhere, Moderate, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Familial Hypercholesterolemia, Other Lack of Coordination, Repeated Falls, Essential (Primary) Hypertension, Other Symptoms and Signs Involving the Musculoskeletal System, and Unilateral Primary Osteoarthritis, Right Knee R2's MDS (Minimum Data Set) dated 2/21/24 documents a BIMS (Brief Interview for Mental Status) could not be conducted due to resident is rarely/never understood. R2's primary language is Vietnamese. R2 has Long Term and Short Term Memory Problems. R2's Care Plan documents that R2 has impaired communication: R/T (related to) a language barrier. Date Initiated: 1/29/2021. R2 has an orbital fracture putting her at risk to experience Pain or related discomfort. Date Initiated: 3/11/2024. On 3/29/24 at 1:03 PM, V1 (Administrator) stated that she got a call from V2 (Director of Nursing) that there was an incident between R1 and R2. V1 got on her phone to watch the video of what happened. V1 stated It was disturbing. R1 came out of his room and went to the nurse's station to use the phone. R2 was sitting behind R1 in her wheelchair. R1 started to back up so R2 was backing up also. R1 then turned around and hit R2. The first punch went to R2's face. R2 blocked the second punch, and third punch was in the face also. I have never seen anything like it. R1 fell out of his wheelchair on the third punch. V10 (Agency Licensed Practical Nurse) jumped over R1 to get to R2. The staff got an ice pack and was trying to keep R2 calm. The police were called and 911 was called to take R2 to the hospital. On 3/29/24 at 11:44 AM, V4 (Laundry Assistant) stated that she was going down the hall and saw R1 going towards R2. R1 reached out to grab R2's wheelchair and hit R2 in the face. R1 hit R2 at least twice. R2 does not speak English. It was so fast R2 did not have time to protect herself. R2's glasses pushed into her nose and put a cut on the bridge of her nose. On 3/29/24 at 12:00 PM, V5 (Certified Nursing Assistant) stated that R1 was on the phone at the nurse's station and R2 was behind R1 so she could use the phone next. V5 went into another resident's room and heard a loud commotion in the hall. V5 came out and R1 was on the floor and V6 (CNA) had a towel holding on R2's face. R2 wears safety glasses and sustained cuts on R2's face. On 3/29/24 at 12:16 PM, V6 (Certified Nursing Assistant) stated that she was coming down the hall and heard R2 screaming and saw R1 raised up in his chair with his fist raised towards R2. R1 had already hit R2 and R1 kept hitting R2, R1 only stopped because he fell out of his wheelchair. R1 did not say why he hit R2. R2 does not speak English and did nothing to provoke R1 to hit her. On 3/29/24 at 2:01 PM, V9 (R2's Power of Attorney) (in broken English) stated that a guy punched R2 in the face and R2 got a fracture. On 3/29/24 at 3:04 PM, V10 (agency Licensed Practical Nurse) stated that she was charting and R1 and R2 were both close to the nurse's station. V10 walked to the med room and as V10 was coming back out R1 was attacking R2. R1 was hitting R2 in the face with his fist. R1 fell while he was hitting R2. V4 (Laundry Assistant) was close by R2 and V4 got in front of R2 to protect R2. R2 was pointing at R1, tears were coming from her eyes, and blood was coming from R2's nose. R2 was shocked and afraid. R2 was bleeding from a laceration that R1 caused. When V10 questioned R1, R1 said I didn't do that (R2) did it to herself. The B**** deserved it. On 3/29/24 at 12:27 PM, R1 was asked if he has ever hit anyone at the facility. R1 stated Some Vietnamese woman (R1 laughed). I hit her in the head. R1 was asked why he hit R2, and he stated that R2 talked to him bad in the war. (Unable to confirm if R1 was in the war.) R1's Behavior Note dated 3/9/24 at 4:45 PM, documents that R1 was sitting at the nurse's station with R2. The nurse got up to put a cup of water in the Med room and came back out and witnessed R1 attacking R2. R1 was able to strike R2 with his fist several times before staff members got to both residents. R1 had to be pulled off R2 physically by staff. R2 who was attacked was bleeding from the base of her nose and left hand. R2 was sent out to the hospital for medical attention. A Nurse questioned R1 and ask why he attacked R2. R1 denied doing anything. R1 also stated that R2 did it to herself. R1 was asked again by the nurse why he punched R2 in the face and R1 stated that R2 deserved it. R2's an A*****. R1 also expressed to a Certified Nursing Assistant that he did not like R2's kind because he went to war with them. R1 made a phone call to a family member and expressed to them that he just hit a Korean in the face. A Police report was filed and R1 was sent out to the hospital for a psych evaluation. R2's Emergency Department Nurses Note dated 3/9/24 at 2:34 PM documents that R2 arrived at the Emergency Department by Emergency Medical Services from (the facility) due to being assaulted just prior to arrival by another resident. R2 has abrasions on her face and bilateral hands. Staff reports no other reported injuries, no fall, no loss of consciousness. Patient is Vietnamese speaking only -video interpreter used for assessments. R2's Emergency Department Provider Notes dated 3/9/24 at 3:00 PM documents Chief Complaint -Assault Victim. Vietnamese interpreter used throughout visit. R2 is a [AGE] year-old female with past medical history of Hypertension, Hypercholesterolemia, Neurocognitive Disorder, presenting to the emergency department complaining of assault. R2 comes from a (facility), was struck multiple times by another resident with a closed fist in the center of R2's face. R2 was wearing glasses that got pushed into the bridge of her nose causing a superficial laceration. R2 denies any loss of consciousness or fall. R2 was able to lift her hands and block most of the other punches. Endorses pain to the bridge of her nose. R2's Computed Tomography/CT Facial Bone Scan dated 3/9/24 at 4:08 PM, documents [AGE] year-old status post blunt facial trauma. Bones: Acute moderately displaced fracture of the right medial orbital wall, which is depressed into the adjacent ethmoid air cells. Soft tissue: Mild stranding/thickening of the bilateral preseptal soft tissue. Impression: 1. Displaced fracture of the right medial orbital wall. A portion of the abutting right medial rectus muscle extends into the fracture defect. Correlate with ophthalmologic examination to exclude extraocular muscle entrapment. 2. Mild bilateral preseptal stranding/thickening which may suggest post traumatic contusion. Clinical Impressions, Right Orbital Fracture - Assault. R2's Emergency Department Discharge Summary dated 3/9/24 at 6:04 PM documents to expect swelling around the eyes in the next few days, the swelling will die down. An orbital fracture is a break in the orbit or eye socket, which is the bony structure that protects the eye. This fracture usually causes swelling and pain, and it may affect vision. R2's Nursing Notes dated 3/9/24 at 11:26 PM, documents that R2 arrived back at the facility from the hospital at 7:00 PM with a diagnosis of a right orbital fracture. R2's Nursing Note dated 3/11/24 at 12:43 AM, documents that R2 is alert an unable to verbally express her needs due to a language barrier. There are no verbal or nonverbal signs of pain or discomfort. Adhesive strips are intact to the bridge of R2's nose, light bruising around right orbital area, and a small bruise to top of R2's forehead from previous incident. R2's Nursing Note dated 3/11/24 at 11:58 AM, documents that a call was place to an eye care center for R2 to be seen regarding a fracture. R2's 72 hour Follow Up assessment dated [DATE] at 3:48 PM, documents a laceration and hematoma following a resident-to-resident altercation. R2's Eye Appointment Follow Up dated 3/12/24 at 10:05 AM, documents Diagnosis orbital fracture, initial encounter for closed fracture. Comments This does not appear to be an orbital fracture, but if it is, the bones are in place. This can heal on its own. In time, this will heal, and the cheek pain will lessen. Order for Maxitrol for right eye four times a day. R2's Nursing Note dated 3/13/24 at 12:23 AM, documents that R1 is alert to self with confusion per baseline, and communication is difficult due to R2 not speaking English. R2 has discoloration around her nose, right/left orbital areas, small discoloration spot on top of R2's forehead and bruising to the top of R2's left hand from an incident a few days ago. R1's Physician Psychiatry Progress Note dated 3/21/24 at 9:44 AM, documents that R1 was seen due to physical aggressive behaviors. R1 is a male with a history of Paranoid Schizophrenia and Major Depressive Disorder. R1 is being seen at the request of staff for physically aggressive behaviors. Staff report that R1 struck R2. R1 states, (R2) got in my space and wouldn't let me use the phone so I punched the B****. R1 does not express remorse today, stating (R2) deserved it.

Based on observation, interview, and record review, the facility failed to provide adequate supervision during a facility fire as directed by the facility's policy for a known wandering resident with Dementia, failed to ensure staff were aware of the exit doors being unlocked when the fire alarm sounded and their responsibility to monitor wandering, confused residents during an emergency, and failed to keep the Wandering Resident binders updated, completed, and accessible for two (R2 and R9) of three residents reviewed for Elopement risk in a sample of 10. These failures resulted in a cognitively impaired resident (R2) with a known history of wandering, who required supervision or touch assistance by staff for locomotion and walking, exiting the facility without staff knowledge for approximately twenty minutes, being found after ambulating approximately 400 feet, crossing a one lane, low traffic, side street after midnight in the dark, going door to door at an apartment complex. The street in front of the facility approximately 400 feet from the apartment complex where R2 was located is a two lane street with moderate activity of traffic and a 35 mph (mile per hour) speed limit. These failures resulted in an Immediate Jeopardy. The immediate Jeopardy began February 9th, 2024, when the facility failed to provide R2 with adequate supervision and failed to ensure staff were monitoring wandering residents and/or exit doors during a facility fire emergency. R2 exited the facility at 12:32am unattended without staff knowledge and was found approximately 20 minutes later after ambulating approximately 400 feet, crossing a one lane, low traffic, side street, going door to door at an apartment complex. The street in front of the facility approximately 400 feet from the apartment complex where R2 was located is a two lane street with moderate activity of traffic and a 35 mph (mile per hour) speed limit On 2/22/24 at 10:59am V1 Administrator was notified of the Immediate Jeopardy. Findings include: A. The facility's Emergency Operations Plan-Fire Alarm/Detection System policy, dated 11/1/17, documents Purpose: Code Reference: Facilities shall have and maintain a plan for the protection of all persons in the event of fire, or other emergency, which would require either relocation or evacuation. This policy also states: Code Reference: For nursing homes/hospice facilities, the proper protection of residents requires the prompt and effective response of health care staff. The basic response required of staff includes removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of residents. This policy goes on to state 3. Emergency Incident Command. 6. Assign supervision of those residents requiring special attention or services, such as wandering, confused, non-alert, or intellectually disabled residents. On 2/14/24, at 1:00pm, R2 is lying in bed awake, talking insensibly. V6 Agency Certified Nursing Assistant/CNA is seated in the room with R2. On 2/14/24, at 1:05pm, V6 CNA stated the following: I am her one on one. I am an agency CNA. I heard that during the fire (R2) got out and was over at the apartments inside someone's apartment for about 45 minutes. I think she heard the alarm, and it was her natural instinct to get out. I did not work that day but worked the day after. She is not really a wanderer. She walks back and forth out in the hallways but had never tried to leave before that I know of. She would stop at the exit doors and look out. She will push on the bar, but when it alarms, she'll step back. On 2/14/24, at 2:15pm, V4 Environmental Services Director stated that the exit doors automatically unlock when the fire alarms go off. R2's Elopement Risk Assessment, dated 1/25/24, documents R2 has a diagnosis of Dementia, has the physical ability to leave the building, spends time on the first floor or wanders between floors and units, is a risk to elope at this time and placement on the Elopement Risk Protocol is indicated. R2's Minimum Data Set/MDS assessment, dated 1/22/24, documents R2 is severely cognitively impaired, wanders, and requires supervision or touching assistance for ambulation. R2's Fall Risk Assessment, dated 2/8/24, documents R2 is disoriented x (times) three at all times, has balance problems while standing and walking, jerking or unstable when making turns, requires use of assistive device, and is at risk for falling. R2's current Care plan includes: R2 is an elopement risk/wanderer related to Dementia, ambulatory, and recent history of attempt to elope on 2/9/24 and additional comorbidities. R2 is an elopement risk/wanderer related to history of wandering off property at home prior to admission to facility, Dementia, ambulatory, and additional comorbidities. R2's Progress Note, dated 2/9/24 at 3:54am by V7 Licensed Practical Nurse/ LPN, documents: Resident was wandering and exit seeking during fire incident. Alarms and locks on doors were checked and intact during initial attempt to exit. Resident redirected away from door. When staff went to assist other resident's, staff eventually noticed resident was not in area. Staff began to look for resident. Management informed staff that resident was noted by police in residential apartment across the street. Resident assisted back to facility for cares, assessments, and monitoring. Full body assessment completed, and 15 minute checks initiated. All notifications were notified. On 2/15/24, at 1:55pm, this writer viewed the path out the exit door that R2 eloped from. The sidewalk has a slight downward slope and there is a high curb to step down into the side street. On 2/16/24, at 2:38pm and on 2/21/23 at 10:19am, V11 CNA stated the following about the night of the fire: I saw (R2) in another resident room, R2 got out of there and was redirected, but I didn't see (R2) try to get out. When the fire alarms sound the exit doors get disabled, I guess. (R2) moves very quickly. V11 continued to state that no one was assigned to monitor the wanderers. Our main thing to do when the fire happened was to get everybody out of their rooms. (R2) was in my group. (R2) is a wanderer so have to keep a close eye on her and pay attention. (R2) has pushed on exit doors before; she pushes on everything. The facility's Daily Assignment Sheet dated 2/8/24 documents the third shift nurse assigned to R2's (B) Hall was V7 Agency Licensed Practical Nurse/LPN; R2 was assigned to V10 and V11 CNA's group of residents. On 2/16/24, at 5:26pm, V7 Agency LPN, confirmed V7 was working on B Hall the night of the fire. V7 stated the following: V12 LPN was giving lots of orders and seemed to be taking charge. No one was assigned to watch the wanderers. (R2) wanders around the building. I noticed (R2) went to one of the exit doors. I didn't see her push it. I checked the door, and it was locked, and the fire alarms were sounding. Afterwards they said that eventually when it switches to the generator the doors unlock. V7 stated If it is a known thing that these (exit) doors unlocked then most definitely wanderers should be supervised. I don't think staff knew that. Not sure they have the staff for that though because they have a lot of elopement risk residents so doors should be watched. On 2/20/24, at 1:50pm, V1 Administrator confirmed the fire alarm sounded on 2/09/24 at 12:01am. This writer viewed the camera footage of R2 exiting the facility during the fire emergency with V1 Administrator. R2 was pacing the hall, going in/out of resident rooms, and standing by and looking out the exit door several times. At 12:32am R2 slipped out the exit door at the end of B hall. At 12:45am V11 CNA noticed R2 was missing. At 12:48am V1 announced to staff a resident was over at the apartment (per police notification). Staff took off running out the door including V1 Administrator and V11 CNA. At this time, V1 stated that a policeman came up to V1 in the front lobby area and informed V1 a resident was over at Apartment 10; the owners had called police. Police didn't know who the resident was. At 12:50am V1 came back in from outside the exit door then at 12:52am R2 was seen escorted back into facility at the B Hall exit door then placed in a wheelchair upon entrance. On 2/20/24, at 2:22pm, V12 LPN confirmed V12 worked on A Hall the night of the fire and stated the following: The nurse who was the Registered Nurse/RN was who was to be in charge. So (V21 RN) was in charge and they were reporting to (V21) what we were to do and (V21) was relaying it back to us. Not aware if anyone was put in charge of wanderers. They said afterwards that when the fire alarms go off the exit doors become unlocked. I did not know that before the fire, but it was only my second day. There could have been someone to monitor wanderers, but there is not a lot of staff at night to assign someone. There is an emergency plan at the nurses' station. I think it said that B wing nurse should be in charge, but not that someone should be in charge of the wanderers. On 2/20/24, at 2:47pm, V21 RN confirmed V21 was working on A Hall the night of the fire and is an Agency nurse. V21 stated the following: I was not specifically in charge for the emergency. From my understanding the fact that they had the Director of Nursing/DON (V2) there (V2) would have been in charge of everything. On 2/21/24, at 9:30am, V10 CNA stated the following regarding the night of the fire: I originally had (R2) in my group, but due to a call off I took a different group of residents. The exit doors unlock once the fire alarms go off, 15 seconds later. I suspected it beforehand but didn't know for sure until afterwards. No one was designated to watch the wanderers specifically. V10 stated that (R2) is confused and that it is unsafe for (R2) to be outside without supervision. On 2/21/24, at 11:13am, V2 Director of Nursing/DON stated the following: After I got here, I would have been considered the person taking charge. V2 confirmed (R2) is a wanderer. (R2) was in her room when I got here. (V7 LPN) and I got (R2) out of (R2's) room and (V7) took (R2) to the nurse's station. After that I don't think I saw (R2) again. No one was assigned to specific wandering residents. No one was assigned to watch exit doors, but they were in sight from nurse's station. (R2) did not have 1:1 during the fire. V2 is unaware that the facility's Emergency Operations Plan-Fire Alarm/Detection System policy documents that supervision is to be assigned to the wanderers during a facility fire emergency. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on 2/9//24, but noncompliance remains at Level Two because additional training is needed to evaluate the implementations and effectiveness of actions taken, due to concerns during observations when clearing the immediacy. Prior to the survey date, the facility took the following actions to correct the noncompliance. 1. On 2/9/24 R2 was immediately placed on 15 minute checks. R2's Elopement Risk Assessment and Care plan were reviewed and updated accordingly. 2. On 2/9/24 all staff were educated on the Facility's Elopement policy. 3. On 2/9/24 all staff were educated on the Facility's Code Pink Guidelines. 4. On 2/9/24 all staff were educated on the Facility's Code Red Guidelines. 5. On 2/9/24, all Resident's Elopement Assessments were reviewed and updated accordingly, and all Residents at Risk Plan of Cares were reviewed and updated accordingly based off the individual Elopement Assessment. 6. On 2/9/24 an Elopement drill was completed. B. R9's Elopement Risk Assessment, dated 1/13/24, documents R9 has dementia, physical ability to leave the building, spends time on the first floor or wanders between floors or units, frequently checks status of facility exits and/or stairways, verbalizes a serious/strong intent to leave the facility (pacing, packing belongings, etc.), at risk to elope and should be placed on the Elopement Risk Protocol. R9 is at high risk. On 2/16/24, at 11:48am, V15 and V16 CNAs were unable to locate the Wandering Resident binder at the A Hall nurse's station. On 2/16/24, at 11:50am, V17 LPN located the Wandering Resident binder in a cabinet drawer at the B Hall nurse's station. On 2/16/24, at 11:55am, V14 Social Service Director/SSD found the A Hall Wandering Resident binder in a cabinet drawer of the A Hall nurse's station hidden under a [NAME] of computer paper. On 2/16/24, at 11:56am V1 Administrator stated the Wandering Resident binders are not where they are supposed to be. They are to be left out and not moved. On 2/16/24, at 2:30pm, the Resident Wandering binders from A Hall, B Hall, and the front reception desk include a list of wanderers dated 1/22/24. These three binders' lists are not consistent with one another, contain residents who are no long wanderers and/or have been discharged , and are incomplete as they do not include R9. On 2/20/24, at 12:42pm, V14 SSD confirmed R9's Elopement Risk Assessment, dated 1/13/24, documents R9 is a high risk for elopement and is to be placed on the Elopement Risk protocol. V14 stated R9 should have been placed on the Elopement list on 1/13/24 and was not. V14 stated the wanderers should be on the list and have their facesheet and photo in each binder. V14 confirmed the current Wandering Resident list dated 1/22/24 is inaccurate. V14 confirmed that the 1/22/24 list in the binders were all different, but I fixed them. V14 stated But then yesterday when I came in the Wandering Resident binders were all different again. I found that they had been messed with. The B Hall binder was missing R2's information (no photo or face sheet), and another resident's information was also missing. The A hall binder was missing one resident. The B Hall binder was in a drawer today. The staff are to leave the Wandering Resident binders on the desk in full view, not in a drawer. On 2/20/24, at 1:15pm V2 Director of Nursing/DON stated they do not have an Elopement Risk protocol per say- it just means that wanderers will be monitored, care plans updated, and they will be placed on the Wandering Resident list in the binders. On 2/21/24, at 9:30am, V10 CNA stated, I don't believe anyone has shown them (Wandering Resident binders) to me if we do have them.

Based on observation, interview, and record review the facility failed to ensure physical abuse did not occur for one (R2) of ten residents reviewed for abuse in the sample of 25. These failures resulted in R1 hitting R2 in the right shoulder and punching R2 in the nose twice resulting in R2 bleeding from (R2's) nose and complaining of right shoulder pain. Findings include: The facility's Abuse Prevention and Reporting policy and procedure, revised 4/29/22, documents: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This policy defines: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The facility shall also contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations: . 2. Physical abuse involving physical injury inflicted on a resident by another resident except in situations where the behaviors is associated with dementia or developmental disability. The Abuse Investigation regarding R1 and R2, dated 12/17/23, documents Summary of investigators findings: Investigation findings noted the (R1) approached (R2) when (R2) wouldn't turn down his TV (television), after repeatedly asked to do so. (R1) made contact in attempt to get (R2's) attention to turn his TV down as his previous attempts to get his attention didn't work as the TV was so loud. Staff witnessed the incident and immediately removed (R1) from the room. (R2) was assessed with no redness or bruising noted. (R2) states he was fine and stated yes when asked if he feels safe in his environment. (R1) was moved into a different room. This investigation does not indicate law enforcement was notified. The Progress Note for R1, dated 12/17/23, written by V13 LPN/Licensed Practical Nurse, documents I walked past residents' room, noted (R1) standing over roommates wheelchair. Observed (R1) strike roommate with closed fist twice. I yelled to stop, when he stopped and said that roommate would not turn down tv. No injuries noted to (R1). He was then moved to another room. The quarterly MDS (Minimum Data Set) assessment for R1, dated 12/6/23, documents R1 with moderately impaired cognition with no behaviors. The current Care Plan for R1, documents (R1) is at risk for abuse/neglect and has the potential to be physically and verbally aggressive r/t (related to) Dementia. Interventions include When (R1) becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later and Observe (R1) when in company of peers. The Progress Note for R1, dated 12/17/23, written by V13 LPN, documents I observed (R2) in his room. (R1) was standing over (R2) and struck (R2) with closed fist in face two times. I yelled to stop. (R1) did stop, (R1) stated that (R2) would not turn down tv (television). (R1) was moved to another room. (R2) had bloody nose which was cleaned up. No other open areas noted, (R2) did complain of right shoulder pain. The quarterly MDS assessment for R2, dated 11/16/23, documents R2 with moderately impaired cognition without behaviors. The current Care Plan for R2, documents (R2) is at risk for abuse/neglect, has potential to be verbally aggressive r/t poor impulse control, prefers to keep to self, has limited range of motion in right upper and lower extremities related to CVA (stroke) resulting in hemiparesis (partial paralysis and weakness) and some left sided weakness, and has impaired communication. On 1/3/24, 1/4/24, and 1/5/24 between 8:20 am and 4:00 pm, R1 was sitting in a wheelchair and propelling himself in and out of his room, to and from the dining room and the television area independently. While sitting in the television area there were other residents in the vicinity at times with no staff present. No behaviors were noted. On 1/3/24, 1/4/24, and 1/5/24 between 9:38 am and 4:00 pm, R2 was sitting in a wheelchair or lying in bed in his room with no behaviors. On 1/4/24 at 8:20 am, R1 stated he has not had any problems with anyone at the facility. does not and has not had issues with any of the residents in the facility. When R1 was asked if he had any problems with his prior roommate R1 smiled and stated I don't know anything about that. I'm not a violent person at all. On 1/3/24 at 10:20 am, R2 stated he was watching television and R1 came up to him and punched (held up closed fist) him in the right shoulder and in the nose two times (held up two fingers) causing his nose to bleed and pain in his shoulder. R2 stated R1 was moved out of his room. On 1/3/23 V1 Administrator stated she is the Abuse Coordinator for the facility, and she was notified on 12/17/23 of an altercation between R1 and R2, R1 asking R2 to turn his television down and not doing it, and R1 hitting R2 in the nose causing his nose to bleed a little. V1 Administrator stated the residents were separated, R1 was moved to a different room and an investigation was completed. V1 stated she did not call the police or substantiate the resident-to-resident abuse allegation because R2 said he was fine, R1 apologized and doesn't remember anything, both residents are cognitively impaired and R1 did not intend to harm just to get R2's attention. On 1/4/24 at 9:08 am, V13 LPN/Licensed Practical Nurse stated she was walking past R1 and R2's room and saw that (R1) had (R2) backed up into a corner in their room and (R1) was standing in front of (R2). (R1) raised his closed fist and punched (R2) in the nose twice. V13 LPN stated she screamed out for R1 to stop and (R2) was bleeding from his nose. V13 LPN stated when she asked R1 why he was hitting R2, R1 was fumbling for words and making excuses and said He, He, I told him. V13 LPN stated she didn't see R1 hit R2's shoulder but R2 said R1 did and R2 was complaining of his right shoulder hurting and did not know why R1 hit him. V13 LPN stated evidently R1 was upset because he asked R2 to turn his television down and R2 did not do it. V13 LPN stated she cleaned R2 up and reported the altercation to R2's Physician, family and Administrator and moved R1 to another room on the other side of the facility. V13 LPN stated R1 will attempt to propel himself towards his old room and staff redirect him back to the other side of the facility. V13 LPN stated she believes that R1 Absolutely 100 percent knows what he is doing.

Based on observation, interview, and record review, the facility failed to implement infection control procedures of testing COVID-19 symptomatic staff members, perform contact tracing testing on staff and residents with direct exposure to the COVID-19 positive staff member and resident, and perform facility wide testing to prevent the potential spread of a highly contagious and potentially deadly disease to residents and staff. Direct care staff, while working with signs and symptoms of COVID-19 (headache, fatigue, and body aches) unnecessarily exposed residents to an infectious disease. These failures had the potential to affect all 77 residents residing within the facility. These failures resulted in R6 being hospitalized with the diagnosis of COVID-19 pneumonia. Findings include: The CDC (Centers for Disease Control and Prevention) COVID-19 Potential Exposure at Work, dated 9/23/22, documents, Following a higher-risk exposure, HCP (healthcare professionals) should: Have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The facility's Interim COVID-19 Testing Residents and Staff policy, dated 5/12/23, documents, Testing of Symptomatic Residents and Staff: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-1 as soon as possible. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular PCR) or a second negative antigen test taken 48 hours after their first negative test and maintain transmission-based precautions until results are confirmed. Staff with signs and symptoms of COVID-19 must be tested and are expected to be restricted from the facility pending the results of COVID-19 testing. Staff who do not test positive for COVID-19 but have symptoms should follow facility policies to determine when they can return to work. Resident close contact exposures-Testing & Quarantine: Close contact is defined as being within six feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection. These residents should still wear source control if able and should be tested as described below: Test #1 Immediately (but not earlier than 24 hours after the exposure). Test #2: If the 1st test was negative, test again 48 hours after the first negative test, and test #3: If the 2nd test was negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Following the the exposure, the asymptomatic healthcare profession should be tested as follows: Test #1 Immediately (but not earlier than 24 hours after the exposure). Test #2: If the 1st test was negative, test again 48 hours after the first negative test, and test #3: If the 2nd test was negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. A single new case of SARS-CoV-2 infection in any healthcare professionals or resident should be evaluated to determine if others in the facility could have been exposed by completing contact tracing investigation. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach. However, a broad-based (e.g., affected unit, floor, department or other specific area (s) of the facility or facility-wide testing approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and healthcare professionals identified as close contacts or on the affected unit (s) if using a broad-based approach, regardless of vaccination status. Initial outbreak testing is recommended: Immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. If additional cases are identified in in the initial outbreak testing and the facility has switched to the broad-based approach, testing should continue on affected unit (s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. Documentation of testing: For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. On 9/11/23 at 8:50 a.m., the facility's main entry door held a sign stating that the facility had COVID-19 positive cases within the facility. A 3rd shift facility Assignment sheet, dated 8/15/23, documents that V4 (CNA-Certified Nursing Assistant) worked 3rd shift with V30 (CNA) and V36 (LPN-Licensed Practical Nurse) on the facility's B wing. On 9/18/23 at 10:10 a.m., V4 stated that she called off work sick on 8/16/23 with COVID-19 like symptoms. V4 also stated, When I went to the ER (emergency room ) on 8/16/23, I had nausea, body aches, and a migraine. They (ER) didn't test me there. I notified the scheduler (V15) that evening that I wasn't coming in. I never once was asked to test after I called off on 8/16/23. On 9/14/23 at 11:10 a.m., V15 confirmed that she was aware that V4 called off on 8/16/23 for being sick. On 9/14/23 at 11:25 a.m., V14 (Human Resources) stated, I was aware that (V4) called off on 8/16/23, but I didn't know why. I think she gave me the ER note, but I didn't read it. V14 provided a hospital note, dated 8/17/23, that documents, (V4) was seen and treated in our emergency department on 8/17/23. V14 stated, I got this note, but I don't know why she was in the ER. The facility's COVID-19 Testing log, no date but provided by V1 (Administrator) on 9/13/23, has no documentation of V4 being COVID-19 tested following V4 calling off sick on 8/16/23. A 2nd shift facility Assignment sheet, dated 8/19/23, documents that V4 worked 2nd shift with V31 (Agency RN-Registered Nurse), V33 (Agency CNA), V34 (Agency CNA), and V35 (Agency CNA) on the facility's A wing. A 3rd shift facility assignment sheet, dated 8/19/23, documents that V4 worked with V3 (Nurse Supervisor LPN) and V11 (CNA) on the facility's A Wing. A 3rd shift facility assignment sheet, dated 8/20/23, documents that V4 worked with V23 (Agency Registered Nurse) and V11 on the facility's A Wing. The assignment sheet also documents that V3 worked until 10:00 p.m. on the A wing as well. On 9/13/23 at 2:15 p.m. V4 stated, I worked on 8/19/23 and still felt really sick. I was sick to my stomach, dizzy, runny nose, body aches, and just drained. It kept getting worse. So, when I came in on 8/20/23 at 10:00 p.m., (V3) was working so I told her I was still feeling sick, and my son was sick at home. It was around shift change so she told me she would leave some rapid tests out for me. I tested not once but twice, and the nurse (V23) was right there watching. She saw the positives as well. I took a picture and sent them to (V3) to let her know I was positive, and she sent me home. The next day, (V14 Human Resources) called and said I needed to come back to test. I was super sick and didn't have anyone to drive me in. So, I told her I wouldn't be able to come in. On 9/18/23 at 10:10 a.m., V4 stated, When I came back to work on 8/19/23, I was still having the headaches, nausea, and fatigue. I pushed through the symptoms to try and get my work done. The next night (8/20/23), the symptoms were real bad. I was so drained with fatigue and my body was hurting. I worked through my first set of rounds at 12:00 a.m. Then I tested myself. I notified V3 and sent her pictures of the positive test results at 12:59 a.m. After speaking to her and (V23), I went home. V4's Timecard, dated 9/14/23, documents that V4 worked on 8/19/23 from 8:42 p.m. to 6:00 a.m. and 8/20/23 from 10:09 p.m. to 1:18 a.m. On 9/13/23 at 2:45 p.m., V3 stated, That night (V4) told me that she was sick, and someone in her household was sick. So, she thought she should test. It was shift change, and I didn't have any tests. So, I sent her to the other hall to test. After I left, she contacted me and told me that she had tested positive. We agreed that she should go home, and I notified (V2 Director of Nursing) the following day. On 9/13/23 at 1:10 PM, V11 stated, I worked with (V4) on 8/19 and 8/20/23. On 8/19/23, (V4) was acting weird, and kind of avoiding us like she didn't feel good. On 8/20/23, (V3) was working when (V4) came in and said she wasn't feeling well. (V4) also said her son was sick at home as well. (V3) asked her if she thought she needed to test and (V4) agreed. However, (V3) never tested her because it was around shift change. (V23) ended up getting a test out for (V4) and (V4) tested herself. (V23) and the other nurse looked at the results which were positive and told (V4) she needed to go home since it was positive. (V4) worked for a while before she went home on 8/20/23. I worked with (V4) the whole weekend, but the facility has never tested me to this day. On 9/14/23 at 2:00 p.m., V23 stated, I gave (V4) the COVID-19 tests to take. She was pretty sick. I watched her swab herself, and I confirmed that they were both positive. I watched her take a picture of them and send them to (V3). After she told (V3) she was positive she went home. I generally work A-hall when I'm in the facility. I have not been tested at all by the facility since (V4) or (R3) tested positive, and I worked there after that. On 9/18/23 at 3:00 p.m., V31 stated, I was not aware that I was exposed to a staff member who was COVID-19 positive. I knew I had taken care of (R3) and (R16) prior to them testing positive, but not a staff member that I had worked with. I have never been tested by the facility, nor has my agency tested me. The facility's COVID-19 Testing log, no date but provided by V1 on 9/13/23, documents that resident COVID-19 testing was initiated on 8/22/23 for residents only residing on the A-Wing. The log has no documentation of contact tracing testing for those in direct contact of V4 while V4 was symptomatic beginning on 8/15/23 including, B wing residents, V11, V23, V30, V31, V33, V34, V35, and V36. The facility Resident COVID-19-line list, no date but provided on 9/11/23 by V1, documents that R3 tested positive for facility acquired COVID-19 on 8/22/23. R3's Nurses note, dated 8/22/23 at 5:30 p.m., document, Narrative: Resident tested COVID-19 positive and placed into contact and droplet isolation. Resident asymptomatic. A 1st shift facility assignment sheet, dated 8/21/23, documents that V24 (Agency LPN), V9 (CNA), V10 CNA, and V45 (CNA) were assigned to the facility's A-wing putting them in direct contact with R3. A 2nd shift facility assignment sheet, dated 8/21/23, documents that V24, V28 (CNA), V37 (CNA), and V40 (Agency CNA) were assigned to the facility's A-wing putting them in direct contact with R3. A 3rd shift facility assignment sheet, dated 8/21/23, documents that V41 (Agency LPN), and V42 (Agency CNA) were assigned to the facility's A-wing putting them in direct contact with R3. A 1st shift facility assignment sheet, dated 8/22/23, documents that V24, V38 (CNA), V10, and V43 (Agency CNA) were assigned to A-wing putting them in direct contact with R3. A 2nd shift facility assignment sheet, dated 8/22/23, documents that V24, V44 (Agency CNA), V39 (CNA), and V40 were assigned to A-wing putting them in direct contact with R3. The facility's COVID-19 Testing log, no date but provided by V1 on 9/13/23, documents that CNAs and nurses working with R3 on 8/22/23 2nd shift and 8/23/23 1st were the only staff members, with the exception of department heads, that were initially tested following R3's COVID-19 positive diagnosis. The log has no documentation of the direct exposure staff members (V9, V24, V28, V37, V39, V40, V43, V44) tested on ,d+[DATE] and 8/23/23 receiving the 2nd and 3rd testing in the sequence of contact tracing testing. There is also no documentation of V10, V38, V41, V42, or V45, who had direct contact/exposure with R3, receiving contact tracing testing. On 9/14/23 at 2:40 p.m., V24 stated, I worked with (R3) before right before the outbreak and after. I've never been tested until just last week. The facility's COVID-19 testing log, no date but provided by V1 on 9/13/23, documents that V24 was initially tested for COVID-19 on 8/23/23. The only other testing that V24 had received was on 9/8/23. The facility's Resident COVID-19-line listing, no date but provided by V1 on 9/11/23, documents that R6 tested positive for facility acquired COVID-19 on 8/24/23. R6's Nurses notes, dated 8/24/23 at 9:30 a.m., document, Resident tested COVID-19 positive. Resident remains asymptomatic. Resident moved from yellow zone quarantine to red zone isolation. R6's Alert note, dated 8/28/23 at 3:24 a.m., documents, The resident was sent out to hospital due to oxygen stats dropping. Went into the resident room around bedtime to give medications. The resident was halfway out of bed and did not look well. Resident vitals were checked, and results were blood pressure 166/85, pulse 70, respirations 24, temperature 96.7, sp02 (oxygen saturation) 70% (on room air). The resident was placed on oxygen at 4L (liters) stats increased to 97%. Doctor was notified of the situation and gave verbal orders to send residents out if stats dropped again. Resident stats were monitored throughout the shift up until 3 am. Resident stats dropped between 87-88% on 2L. wheezing was heard in both upper lungs along with rapid breathing. R6's Hospital Critical Care Admission History & Physical, dated 9/3/23, documents, R6 is sent over from nursing for increasing oxygen requirement. He had increased work of breathing in the ED (emergency department) was placed on BiPAP (bilevel positive airway pressure). Respiratory symptoms possibly secondary to COVID-19 pneumonia versus heart failure exacerbation. He tested COVID-19 Testing log, no date but provided by V1 on 9/13/23, documents that testing for all residents residing on the B wing was not initiated until 9/8/23. The facility's Absence/[NAME] Report, dated 8/27/23, documents that V28 called off on this date because she was not feeling well. The report also documents, Directed her to come to facility for COVID-19 test. The facility Absence/[NAME] Report, dated 8/30/23, documents that V28 called off at 1:00 p.m. for her shift that was to begin on that date at 2:00 p.m. because she was still not feeling well. The facility COVID-19 Testing log, no date provided on 9/13/23, documents that the only testing that V28 received was on 8/22/23, 9/8/23, and 9/12/23. The facility's Absence/[NAME] Reports, dated 8/28, 8/29, 8/30, and 9/1/23, all document that V29 (laundry aide) called off on those days for symptoms of cough, sore throat, chills, chest hurting, head hurting, no energy, and troubles breathing. The facility's COVID-19 Testing log, no date but provided by V1 on 9/13/23, documents that V29 was not tested until 9/8/23 and 9/12/23. On 9/18/23 at 9:55 a.m., V29 stated, I tested the first day I called in on 8/28/23 and it was negative. That was the only COVID-19 test I got until 9/8/23. I didn't have to test when I came back to work. The facility's Absence/[NAME] Report, dated 8/31/23, documents that V30 (CNA) called off on this date at 7:38 p.m. for her 10 p.m. shift because she was not feeling well. The facility's COVID-19 Testing log, no date but provided by V1 on 9/11/23, documents that V30 was not COVID-19 tested until 9/2/23. On 9/18/23 at 1:50 p.m., V32 (Agency CNA) stated, I'm agency and I normally work here at least three or four times a month. I've never been COVID-19 tested by this facility, and my agency doesn't test us either. On 9/14/23 at 1:15 p.m., V2 (Director of Nursing) stated, Infection Preventionist (IP) monitors the Employee Illness log. All managers take their own call offs then notify IP. If staff report being sick, they are rapid COVID-19 tested and sent home. If it's after hours, then the nurse who is working is responsible for swabbing the staff member. If that is negative, they are sent home and required to retest in 48 hours. A negative is needed at that time to return to work. We found out on Monday (8/21/23) that (V4) supposedly tested positive. (V4) reported that she self-swabbed. So, we don't accept that. We needed her to come in to confirm her results. Since we weren't able to confirm that she was positive we presumed, she was positive. That is why we initiated testing. I'm not aware of her calling off sick on 8/16/23. If she called off for COVID-19 related symptoms, then she should have been tested . We tested all of the residents on A-Wing and the staff that worked on that hall. The staff working (A-hall) 8/22/23 on 2nd shift were all tested . On 9/8/23 we initiated all residents and all staff to make sure we didn't get out of outbreak and had more positive. We didn't' have to do that, but we wanted to be safe. Once we got through day 1, day 3, and day 5, we went to twice a week testing. If agency staff are here during outbreak they should be being tested . V2 confirmed that V11, V31, V33, V34, and V35 have not had any COVID-19 testing completed. On 9/18/23 at 3:15 p.m., V1 (Administrator) stated, When agency staff call off, we don't know the reasoning of calling off. It is all scheduled through an application. If an agency staff member is calling off, we get notified of a cancellation, and that is it. We don't call the agency to find out the reason of calling off. So, we have no way of knowing if they are sick. We do not test our agency staff, nor do we require them to test before coming back to work after calling off. On 9/19/23 at 10:05 a.m., V2 stated, On 8/16/23, (V4) should have been tested for COVID-19, and not returned to work until she had two negatives with being symptomatic. (V4) should never have worked at all on 8/19 or 8/20 with being symptomatic, and we had not COVID-19 tested her. (V23) saw the two positive COVID-19 cards. We do not test agency staff on a regular basis. The agency staff would not be aware of exposure or positives until they actually came back to the building to work. I don't feel like agency is any different than visitors when it comes to exposing the residents. I don't know if they are sick when they call off, and they should be reporting to us if they are sick while they are working. No staff were day 1, day 3, or day 5 tested initially with the outbreak. The next testing date was 8/30/23. Staff that were working on A hall that day and department heads were tested . It doesn't appear all staff were tested . We initiated testing all staff on 9/7 & 9/8. There were some staff who were not tested because we cannot force them to come in on their day off. We were implementing Tuesday and Friday Testing. If the staff did not test on 9/7 or 9/8/23 we tried to capture them on their next shift. They shouldn't have worked if they didn't test. (R6) was hospitalized for COVID-19 pneumonia. Staff who are symptomatic have to be tested within 24 hours and then 48 hours later. After the 2nd negative, they can return to work at any point as long as they are free of a fever for over 24 hours and not requiring medication. If a staff member calls off symptomatic, we were directing them in to be tested . On 8/28/23, (V28) tested and was negative. She should have tested again in order to come back to work especially since she called off on 8/30/23. There's no documentation that she was tested again. (V29) should have been tested more than just the first time. He shouldn't have come back to work without that 2nd negative. I began testing all of the residents on 9/8/23 to ensure everyone was negative before coming out of the outbreak. On 9/19/23 at 11:15 a.m., V1 stated, If staff have any COVID-19 like symptoms they should be told they can't work, and they are to come into the facility to be tested within 24 hours or they can be tested at the doctors. Staff members are required to do that testing, and if it's negative, they test again 48 hours later. At this point if that test is negative and they have no symptoms, they can return to work. (V4) would have tested the initial testing on 8/17/23 and then again 48 hours later in order to come back to work both should be negative. With COVID-19 like symptoms we presume them COVID-19 positive until we get two negatives. On 8/19/23, (V4) shouldn't have even come in if she was still stick. When she came back that day, she should have let us know she was sick again in order to be tested . She should have called her supervisor and said she was sick, and she wouldn't have been allowed to work without testing. On 8/20/23, if she told (V3) she was sick, (V3) should have tested her right there and sent her home. Whether that test was negative or positive she would have been sent home since. (V4) should not have continued working that night. I heard that she had tested positive the following day (8/21/23), but I was being told there was no proof. We requested she come to the facility for us to test her, but she refused to come in. Since she refused to come in, we had to presume her positive. The testing should have started for the whole facility at that point. We must presume her positive back to 8/16/23 when her symptoms started. All the residents would have been affected since she worked B hall on 8/15/23 and A hall on 8/19 and 8/20/23. The staff members that she had direct contact with should have done the day 1, day 3, and day 5 contact tracing testing for sure. That should have occurred with all the residents as well. As far as I was aware, A hall and all of A hall staff were being tested , and B hall testing as well as the rest of the staff testing started on 9/8/23. From the beginning, I thought we should have just done facility wide testing to be on the safe side. I wasn't aware that all the staff, especially the contact traced staff weren't being tested . When (R3) tested positive, we should have looked back at least 24 hours and immediately tested all those staff members who took care of him. There's no excuse for that. With not testing correctly we are exposing the residents and other staff members to potentially getting COVID-19. On 9/19/23 at 2:35 p.m., V47 (Medical Director) stated, Symptomatic staff members should not be working while they are showing symptoms. These staff need to be tested in order to return to work. If a resident or a staff member tests positive, those who were directly exposed to that person should be tested immediately. I would prefer the whole building be tested regardless of if there is any resident or staff member who tests positive. The facility room roster, dated 9/11/23, documents that the facility consists of two wings (A & B) that make up the whole facility of resident rooms. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents form 672, dated 9/19/23 and signed by V2, documents that 77 residents reside in the facility.

Based on interview and record review V4 (Registered Nurse) failed to recognize verbal abuse as abuse, and failed to immediately report an allegation of verbal abuse to (V1/Administrator) for one resident (R1) reviewed in a sample of three. V4 also failed to protect R1 when V4 instructed the alleged perpetrator (V3/Certified Nursing Assistant) to assist R1 who made allegations of abuse with cares that evening. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7-26-23, the facility remains out of compliance at a severity Level II as the facility continues to have the Administrator/Designee complete random interviews of both staff and residents three times a week for 12 weeks to ensure there are no active Allegations of Abuse. The results of these interviews will be reviewed in Quality Assurance Meeting monthly for six months or until an average of 90 percent compliance or greater is achieved for three consecutive months. The Quality Assurance Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Findings include: The Abuse Prevention and Reporting policy dated 11/28/2016, documents Protection of Residents Employees of the facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately. The employees shall not be permitted to return to work until the result of the investigation has have been reviewed by the administrator and is determined that any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property is unsubstantiated. The Final Incident Report for R1 sent to the (State Agency) dated 6/28/23 documents that R1 has a diagnosis of Chronic Obstructive Pulmonary Disease, Encephalopathy, Weakness, Morbid Obesity, and Type 2 Diabetes. R1 has a Brief Interview for Mental Status (BIMs) of 13 (cognition intact). Occurrence: Allegation of alleged verbal abuse from (V3/Certified Nursing Assistant/CNA) to (R1) was reported. (V3) was suspended pending investigation. Injuries: No physical injury, (R1) asked that (V3) not be allowed back in his room for cares due to her being rude and cursing at him. Actions Taken: Investigation started, (V3) called for questioning and placed on suspension pending investigation. Investigation completed and (V3) was terminated due to verbal behavior towards (R1). Final Report Summary: After investigation was completed it was noted that (V3) spoke rudely to (R1), cursing at him in his room. This was heard by (V5/Certified Nursing Assistant) that was in (R1's) room to assist with cares. (V3) was terminated for violation of residence rights to safety, dignity, and respect. Along with violation of company policy # (number) 11- Engaging in discourteous or inappropriate behavior (foul language) towards a resident and # 30- Making any statement or engaging in any conduct that is obscene. On 7/21/23 at 3:45 PM, V2 (Director of Nursing) stated that she got a call around 9:30 PM on 6/27/23 from V4 (Registered Nurse) that V3 (Certified Nursing Assistant) was refusing to care for R1 due to his behaviors. V2 instructed V4 to write a statement and leave it in her mailbox. V2 did not instruct V4 to send V3 home. The morning of 6/28/23, V2 read V4's statement and realized V3 had abused R1 on 6/27/23. On 7/21/23 at 7:05 PM, V4 (Registered Nurse) stated that V5 (Certified Nursing Assistant) told her that there was a verbal altercation between V3 (Certified Nursing Assistant) and R1. V3 was cursing at R1. V3 was also refusing to provide care for R1. Around 9:30 PM, V4 called V2 to report that V3 refused to care for R1. V4 was told for her and V5 to write a statement and leave it in her mailbox. V4 does not remember if she told V2 about the abuse. V2 did not tell V4 to send V3 home so V3 stayed until the end of her shift at 10:00 PM. V4 considered what V3 did as abuse but did not send her home because it was not physical abuse. V4 told V3 she needed to calm down and could not curse at any residents. R1 needed to be changed and was an assist of two so V4 asked R1 if V3 could come and assist her with R1's care. At first R1 said No and V4 explained there were no other staff available, and he was an assist of two. R1 agreed for V3 to help V5 change R1. When V3 and V5 entered R1's room R1 refused to have V3 touch him and V3 left R1's room. I later asked (V3) whether she wants to be placed in a different group because the current one she was on she had issues with several residents. (V3) stated that it didn't matter because she was going to do the same thing if a resident was being rude to her. On 7/22/23 at 11:09 AM, V5 (Certified Nursing Assistant) stated that between 8:30 PM and 9:00 PM, V3 (Certified Nursing Assistant) asked her to help put R1 to bed. R1 asked why it took so long for him to be able to go to bed. V3 started cussing at R1 and calling him a B****. Then R1 started yelling back calling V3 names. V3 left the room with R1 wet and soiled. V5 immediately went to V4 (Registered Nurse) and told her what had happened. V4 called V2 (Director of Nursing) and V4 was told to write a statement. V5 did not hear the conversation between V4 and V2. V5 also stated It all happened so fast. I can't remember everything that was said. It was loud and hostile. I knew it was abuse and I was surprised when (V3) was not sent home. (V4) had tried to get (V3) to help her change (R1) but that didn't happen, so I helped change (R1). The Witness Statement signed by V4 (Registered Nurse) dated 6/27/23, documents Around 9:00 PM on Wednesday (6/27/23), (V5/Certified Nursing Assistant/CNA) approached me and informed me that (R1) needed care, and that (V3/CNA) assigned to take care of (R1) had refused to help him. (V5) informed me that (V3) got into a verbal altercation with (R1), (V3) had called (R1) a B****, said his mother is a B****, and a black A** S** of a B****. (V3) did this and stormed out of (R1's) room and told (R1) that he will have to put himself to bed and change his own (disposable brief) because (V3) was not going to deal with him anymore. Knowing that this had happened several times before with multiple residents while they were under (V3's) care. I decided to talk to (V3) and inform her that she cannot, under any circumstances address residence in this manner. I went to ask (R1) if he will allow (V3) to assist him while I helped (V3), and he adamantly refused; saying that (V3) had been very disrespectful and called him all sorts of names. I informed (R1) that (V3) will be coming back to the room to assist him because I only had two CNAs on the floor, and (V5) was assisting someone else, but I assured (R1) that I will be in the room to observe and assist. I approached (V3) and informed her that she will go back in (R1's) room and finish taking care of (R1), and that I will assist her. (V3) agreed but stated that If (R1) disrespects or calls me any names, or yells at me, I will yell right back, and I will leave and not help him. I told (V3) to calm down and to stop having verbal altercations with residents. I informed (V3) to not engage (R1) if he starts saying anything that (V3) thinks is rude or offensive. (V3) said that she cannot do that (keep quiet while a resident is disrespecting her). We went into (R1's) room and I explained to (R1) that myself and (V3) we're going to assist him get ready for bed because he needed to be cleaned up and changed in clothing. (R1) again refused to have (V3) touch him or help him in any way, stating that (V3) had been very rude to him and he didn't want her helping him in any way. At this point (V3) left the room. I ask (R1) to explain to me what had happened initially that triggered the whole incident. (R1) said that (V3) entered the room and very rudely said to (R1) So are you ready to go to bed or what. Because I'm not going to wait for you or come back here after I leave. This infuriated (R1) and their verbal exchange ensued. (V5) that was not assigned to (R1) ended up taking care of him. I later asked (V3) whether she wants to be placed in a different group because the current one she was on she had issues with several residents. (V3) stated that it didn't matter because she was going to do the same thing if a resident was being rude to her. The Witness Statement signed by V5 (Certified Nursing Assistant) dated 6/27/23 documents that V5 (Certified Nursing Assistant) was helping V3 (CNA) put R1 to bed. R1 had requested to go to bed before 7:00 PM and V3 refused so R1 had to wait. R1 asked why he was going to bed so late and after that, things happened fast. V3 started going off on R1. V3 said she would get to R1 when she felt like it and was cursing at R1. V3 called R1 a B**** and his family members a B****, black a**, etcetera. V3 knew R1 was soiled but did not change him. V3 was unprofessional by not providing care for him. On 7/22/23 at 10:16 AM, V2 (Director of Nursing) stated that had she been told by V4 (Registered Nurse) the extent of what had happened she would have instructed V4 to send R3 home and would have notified V1 (Administrator). V4 needs to be reeducated on abuse and the abuse policy. V4 should have sent V3 home. The Assignment Sheet Update dated 6/27/23 documents V3 certified nursing assistant, and V5 certified nursing assistant worked on the evening shift. V3 was assigned to rooms 19-29. (R1's room included). The Facility Time Keeping Sheet dated 7/21/23 at 1:29 PM, documents that V3 (Certified Nursing Assistant) worked on 6/27/23 from 2:07 PM - 10:04 PM. The Human Resources Notice of Corrective Action for V3 (certified Nursing Assistant) dated 6/30/2023, documents that on 6/27/23 V3 engaged in discourteous or inappropriate behavior (foul language) towards R1. Making statements or engaging in conduct that is obscene. The corrective action was to discharge V3. The Immediate Jeopardy began on 6/27/23, when the facility failed to recognize verbal abuse as abuse, failed to immediately report an allegation of verbal abuse to (V1/Administrator), and failed to protect R1 when V4 (Registered Nurse) instructed the alleged perpetrator (V3/Certified Nursing Assistant) to assist R1 who made allegations of abuse with cares that evening. V8 (Regional Nurse Coordinator) was notified of the Immediate Jeopardy on 7/25/23 at 1:29 PM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1) Immediate actions taken for those residents identified: (R1) has been assessed for Psychosocial needs related to alleged incident with no negative outcome noted. The facility will continue to provide needed care and services. R1 remains at baseline. Completed by V11 (Social Service Director). 2) Measures put into place/ System changes: All Staff have been educated on the Facility's Abuse Policy including identification of all types of Abuse, timely reporting of Abuse and protection of all residents, (removal of alleged perpetrator (s). If any staff are unable to be contacted, they will be taken off the schedule until Education can be provided. Completed by V8 (Regional Clinical Nurse) and V2 (Director of Nursing). 3) All Staff have been interviewed related to have they seen or witnessed any abuse including verbal and mental abuse. (Attachment C) Completed by V11 (Social Services Director) and V2 (Director of Nursing). 4) All Interviewable Residents have been interviewed related to have they seen or witnessed any abuse including verbal and mental abuse. Completed by V17 (Assistant Director of Nursing). 5) All residents have been assessed for signs, symptoms or reports of abuse. (Attachment E) Completed by V11 (Social Service Director).

Based on record review and interview, the facility failed to follow policy and procedure related to pressure ulcers and implement a turning an repositioning program for a resident at risk for pressure ulcer development, for one of three residents reviewed (R1), in a sample of 13. These failures resulted in R1, who is a paraplegic, developing a necrotic unstageable pressure ulcer on the coccyx causing R1 discomfort and requiring debridement. Findings include: The facility policy, titled, Pressure Ulcer Prevention (revised 1/15/18), documents, Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin. 3. Change bed linen per schedule and whenever soiled with urine, feces or other material. 4. Keep bottom sheet dry and tightly stretched and free of wrinkles. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. 6. Employ active and passive range of motion exercises to improve circulation as indicated. 7. Whenever possible, encourage resident to change position at regular intervals as able to promote circulation. Wheelchair residents may be instructed to shift weight from one buttock to the other. 8. If redness does not disappear within 30 minutes, the turning schedule may be shortened to 1 hour. 9. Pressure reducing mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. 10. Use pressure reducing pads in chairs to protect bony prominences for residents identified as Moderate/High/Severe risk. 11. Use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels, toes and malleoli as indicated. 12. Encourage resident to maintain proper nutrition and hydration, providing supplements and ordered and necessary assistance at mealtime as needed. 13. Offer snacks and fluids at regular intervals, as indicated unless contraindicated. 14. Moisture barrier may be applied by CNA (Certified Nursing Assistant) as needed to intact skin and may be kept at bedside. The facility policy, titled Skin Condition Assessment & Monitoring - Pressure and Non-Pressure (revised 6/18/18), documents, Purpose: To establish guidelines for assessing, monitoring and documenting the presences of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. The policy later documents, A wound assessment will be initiated and documented in the resident chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse. The policy advises staff are to, 1. Measure length vertically in relation to head to toe position. Measure width horizontally in relation to hip-to-hip. Measure depth straight down into the deepest part of the wound. *If the wound is necrotic and the base of the wound bed is not visible or tunneling, the stage cannot be measured and must be recorded as non-stageable with an undetermined depth. Lastly, the policy advises, 6. The resident's care plan will be revised as appropriate to reflect alteration of skin integrity, approaches and goals for care. The Electronic Medical Record documents R1 was admitted to the facility on [DATE] after becoming a recent paraplegic. On 5/18/22, a Braden Scale for pressure ulcer risk identified R1 as at Moderate Risk for experiencing skin breakdown. A Restorative Observation assessment, dated 5/20/22, documents R1 has paralysis/paresis of both lower extremities, is incontinent of urine and is, Totally dependent on staff for repositioning and turning in bed as necessary (specify frequency - with no frequency identified). A Minimum Data Set assessment, completed on 5/24/22, documents R1 has no cognitive impairment, requires the extensive assistance of two staff members for bed mobility/repositioning, has impaired functional range of motion in both upper and lower extremities, and is at risk for the development of pressure ulcers, but is without current skin impairment. R1's Plan of Care, initiated on 5/17/22, documents R1, has potential for impairment to skin (related to as needed) opioid, incontinence and decreased mobility (related to) [CONDITION(S)] and instruct staff to avoid shearing, fold back/remove wheelchair leg rest prior to transfer, keep skin clean and dry, use lotion on dry skin, and minimize pressure over bony prominences. According to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Weekly Skin Observation, dated 7/19/22, documents R1's skin as Skin intact, no concerns noted. A Skin Condition Report, dated 7/24/22, documents nursing staff identified on 7/23/22 a, Red purple area with a small slit down the middle on R1's Sacrum, and under, Care Plan the box next to, No change to Care Plan was checked. The 7/24/22 Skin Condition Report fails to document a proper wound assessment, as outlined in the Skin Condition Assessment & Monitoring policy, which should include measurements of the wound by the licensed nurse. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documented evidence that R1's Plan of Care was revised to include the development of a pressure ulcer/injury and new pressure relieving interventions were not implemented. An Initial Wound Evaluation & Management Summary, dated 7/25/22, documents V18 (Wound Physician) examined R1 and identified, Mild perianal [CONDITION(S)] and an Unstageable (due to necrosis) full thickness coccyx pressure wound, measuring 3 cm (centimeters) by 4 cm by an undetermined depth. R1's Initial Wound Evaluation & Management Summary documents, Evolving pressure injury. Thin, black necrosis debrided. Patient says he is going to be discharging home. He says he went a couple weeks without the condom catheter and he was soiled with urine frequently. On 8/02/22 at 9:22 am, R1 stated he had no skin issues when he first admitted to the facility for further rehabilitation. R1 stated, since his injury occurred, he has poor function of his arms and hands, with significant pain in hands and forearms. R1 stated he is not able to reposition himself well and needs assistance. R1 indicated if he is, having a good day, he is able to get himself onto his right or left side independently, but he can't hold that position without pillows to support his body, because his legs spasm and he will roll to his back. R1 stated during his stay at the facility, he was never on a routine turning and repositioning schedule. R1 stated staff relied on him to reposition himself, but no one would put pillows under his side so he could hold that position and he would roll back onto his back eventually. R1 stated that on 7/15/22, R1's bottom started hurting and he told staff (unknown). R1 stated staff still had not implemented a routine turning and repositioning program at that time to help him offload pressure from his back/bottom. According to R1, around that same time, the facility ran out of the condom catheters he used at night. R1 stated he was leaking urine constantly and his skin was always wet. R1 stated, since the pressure ulcer developed, he is experiencing pain in the area and his sleep is poor because of it. On 8/01/22 at 1:38 pm, V18 (Wound Physician) stated when he observed R1's coccyx wound on 7/25/22, the wound was, Likely a couple of weeks old, Deep Tissue Injury that was starting to necrose, due to pressure on the area. V18 stated that R1 should have been on a repositioning program prior to the wound developing, and recommended off loading pressure from his coccyx at that time. V18 also stated, R1 told him he went two weeks without his condom catheter and was left soiled and wet for prolonged periods of time. On 8/02/22 at 12:14 pm, V6 (Certified Nursing Assistant) stated R1 could not reposition himself, but, He wasn't repositioned much on third shift. V6 stated she would ask R1 if he was comfortable or if he needed turned, but R1 wasn't on a scheduled/routine turning program. V6 confirmed that R1 did have a condom catheter that he used at night when he was first admitted , but later he no longer had one and she was unsure of why, so he would just void in the bed or incontinence brief. On 8/02/22 at 12:47 pm, V8 (Certified Nursing Assistant) stated R1 could not reposition himself. V8 stated, throughout the night, they would check on him to ensure he was comfortable, but R1 was never on a repositioning schedule every two hours, as, They (Residents) need a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 also confirmed that R1 had a condom catheter a majority of the time at night, but there were times when they didn't use one so R1 would leak urine on himself. On 8/02/22 at 1:01 pm, V7 (Certified Nursing Assistant) stated she felt R1 could roll and reposition himself and confirmed that R1 was not on a routine turning and repositioning program. On 8/02/22 at 1:18 pm, V15 (Licensed Practical Nurse) stated R1's, Coccyx wound developed quick, but I'm not surprised because he laid in bed all day. V15 stated R1 could roll himself onto his side if using the side rail, but V15 was unsure if R1 could hold that position on his own. V15 stated R1 was not on a turning and repositioning program/schedule. On 8/02/22 at 3:12 pm, V3 (Wound/Restorative Registered Nurse) stated if nursing staff find that a resident has developed a pressure ulcer/injury, they are required to use the Skin Assessment form to describe the location, appearance and size of the wound. V3 stated nursing staff are supposed to include the wound measurement, but concluded that, some don't know how to measure the wounds. V3 stated the resident's plan of care is to be updated with new interventions to minimize the risk of further wounds from developing and promote wound healing. V3 stated, since R1 was identified as at Moderate Risk for pressure ulcer development at the time of his admission, he should have been on a turning and repositioning schedule of every two hours. V3 stated that R1 could turn himself using the side rail, but needed physical assistance of one staff member to push his hips over and secure a side lying position with pillows. V3 stated R1 did have a condom catheter that he was to use at night. V3 was unaware of any supply issues with the condom catheter and was uncertain as to why staff would not have been utilizing it at night so he could maintain dry skin.

Based on observation, interview and record review, the facility failed to ensure a resident's alternating flow mattress was not removed, the facility failed to ensure a wound treatment was in place as ordered by Physician for 2 of four residents (R4,R1) reviwed for wounds in a sample of four. This failure resulted in R4 developing an Unstageable Pressure Ulcer which required surgical debridement. Findings include: A Pressure Ulcer Prevention policy dated 1/15/18 gives as its purpose, To prevent and treat pressure sores/ pressure injury. This policy instructs, Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. 1. R4's Braden Scale for Predicting Pressure Sore Risk dated 11/14/22 documents R4 is at high risk for developing pressure ulcers because R4 responds only to painful stimuli and cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits R4's ability to feel pain or discomfort over one half of R4's body. In addition, this Braden Scale documents that although R4 has adequate nutrition, R4 is constantly moist; R4's ability to walk is severely limited or non-existent and cannot bear her own weight and/or must be assisted into the chair or wheelchair; R4 can only make occasional slight changes in body or extremity position but is unable to make frequent or significant changes independently. This pressure ulcer risk also documents R4 moves feebly or requires minimum assistance and during a move, R4's skin probably slides to some extent against the sheets, chair, restraints or other devices, and may occasionally slide down in the bed or chair. R4's Care Plan dated as initiated 3/18/21 documents that R4 has a higher potential for impairment to skin integrity. This same Care Plan's goal is for R4 not to develop alteration in skin integrity through the next review date of 4/25/22. This Care Plan documents the facility will maintain R4's skin integrity with interventions which includes to minimize pressure over bony prominences and to provide pressure relieving and pressure reducing devices including a pressure reducing mattress. R4's Weekly Skin Observation dated 2/4/22 documents that R4's skin is intact. R4's Weekly Skin Observation dated 2/11/22 documents R4 has some skin concerns but this observation form does not indicate what skin concerns were noted or what interventions were put into place. R4's Wound Specialist's Wound Evaluation & Management Summary Dated 2/14/22 documents R4 had developed an unstageable pressure ulcer due to necrosis on R4's right medial sacrum (just above the buttocks) which had developed at least one day before the evaluation. This same summary documents under the additional wound detail section that, (R4) is hospice care. When she transitioned to hospice, she went a few days without air mattress per nurse and that is when scar from MASD (moisture associated skin damage) wound opened. Appears consistent with pressure injury today. Was purple around it last week, consistent with DTI (Deep Tissue Injury) at that point. In addition, this wound summary documents R4 required surgical excisional debridement to remove necrotic (dead tissue) from within the wound. On 3/17/22 at 1:45p.m. V6 (Certified Nurse Aide/CNA) and V9 (CNA) transferred R4 from the wheelchair to the bed using a mechanical lift then removed R4's incontinence brief before turning R4 to the right side. V4 (Registered Nurse) entered R4's room then removed R4's right medial sacral pressure ulcer dressing. R4's wound was a round hole approximately the size of a dime just above R4's buttock on the right side. The wound appeared too narrow and too deep to visualize the wound bed. On 3/21/22 at 10:30a.m. and 3:13p.m. V3 (Wound Nurse) stated that R4 has an unstageable pressure ulcer to the sacrum which developed on or around 2/8/22. V3 stated she believed she entered a note into R4's chart after she assessed R4's wound and obtained treatment orders, however, V3 is unable to locate that note describing the wound. V3 stated that R4 has been at risk for the development of pressure ulcers and was using an alternating air flow mattress as a preventive measure until approximately 1/18/22 when R4 became a hospice recipient and R4's alternating air flow mattress was changed to another type of mattress. V3 stated that R4 had been evaluated by the Registered Dietitian for her nutritional risk, but since R4 was eating greater than 50 percent of her meals and was receiving additional protein through supplements and high protein foods, R4's diet was not a factor in R4's development of her pressure ulcer. V3 stated that when she investigated the root cause of the development of R4's pressure ulcer, she determined that R4's pressure ulcer was the result of removing R4's alternating air flow mattress for another mattress and because of R4's debility related to recently having COVID-19. V3 stated that she believes that when R4's Wound Specialist evaluates R4's wound again, he will reclassify R4's wound as a stage 4 pressure ulcer. A Facility Acquired/Worsening Wound Investigation Report dated 2/9/22 documents R4 developed a facility acquired unstageable pressure wound on 2/8/22 as a result of R4's alternating air flow mattress being removed and replaced by a different mattress after transitioning to Hospice care. This investigation further documents the facility's Registered Dietitian did not have any dietary recommendations for R4 as the pressure ulcer was not associated with R4's nutritional status. A Skin Condition Assessment & Monitoring-Pressure and Non-Pressure policy dated as revised 6/8/18 gives as its purpose, To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. This policy also states, Dressings which are applied to pressure ulcers, skin tears, wounds, [CONDITION(S)] or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. 2. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/17/22 at 11:02a.m. V4 (Registered Nurse) entered R1's room to examine R1's wound dressing. V4 stated that the only wounds and dressings R1 has is to her right and left heels. V4 stated she believes R1's heel wounds are now healed, and the dressings are being used as a protective measure. V4 proceeded to remove R1's right and left heel dressings and demonstrated that the skin around each heel was without wounds and intact. V4 did not inspect any other areas of R1's body to observe for wound dressings. On 3/17/22 at 1:32p.m. V6 (Certified Nurse Aide/CNA) and V9 (CNA) entered R1's room to provide incontinence care. V6 and V9 proceeded to remove R1's incontinence brief then assisted R1 to roll to the right side so V9 could wash R1's buttocks and perineal area. R1's buttocks was bright red with multiple superficial open areas. V6 pointed to a larger superficial wound approximately the size of a dime on R1's right buttock and stated that this wound was being treated with a dressing previously, but that no one had been applying that dressing for the last few days. On 3/21/22 at 10:00a.m. V3 (Wound Nurse) verified that R1's buttocks is reddened with multiple superficial open areas, and with one larger but superficial open area to the right buttock. V3 stated that R1 has physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated R1's wounds are caused from incontinence and are called Moisture Associated Skin Damage (MASD). V3 stated that because R1's right buttocks MASD is a little larger, R1's physician ordered a treatment and dressing to be applied three times per week and as needed. V3 stated that nurses are supposed to ensure R1's dressing is in place by assessing the dressing every day, then reapply the wound treatment and dressing during the scheduled dressing changes or in between times should the dressing come off.

Based on observation, interview, and record review, the failed to accurately assess a resident for a risk of elopement, develop an elopement plan of care for a moderately impaired resident at risk for elopement, provide adequate supervision to prevent a resident's elopements, inform/educate direct care staff of a resident's multiple elopements and elopement risks, and failed to notify the Physician and Administrator of a resident's elopement for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of Dementia, eloping from the facility on 8-25-21 around 11:30 PM, after sunset, proceeding to a two-lane interstate, and being found lying on a concrete barrier on an exit ramp between two lanes of traffic by the police, one mile away from the facility. R1 then eloped into the front parking lot of the facility the following morning (8-26-21 at 7:38 AM) after police returned R1 to the facility earlier that morning (8-26-21 at 2:10 AM). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8-31-21 the facility remains out of compliance at a severity level II as the facility continues to educate staff on elopement policies and procedures and wander guard (electronic monitoring bracelet) systems, perform elopement drills, monitor door alarm response times, and review elopement action plans as part of the facility's Quality Assurance and Performance Improvement program. Findings include: The facility's Code Pink: Missing Resident/Elopement policy dated 11-15-18 documents, All personnel are responsible for reporting a cognitively impaired resident attempting to leave the premises, or suspected of missing, to the charge nurse as soon as practicable. Upon return of the resident to the facility, the Director of Nursing or charge nurse should: 1. Examine the resident for injuries. 2. Contact the attending Physician and report finding and condition of the resident and obtain a Physician's order. 3. Notify the legal guardian/responsible party. 5. Notify the administrator. 7. Complete the incident report indicating when the resident returned and the condition of the resident. 8. Make appropriate entries into the resident's medical record. 10. Complete a new elopement risk assessment and updated plan of care appropriately. 11. Review and update the elopement risk binder. R1's Physician's Order Sheet dated 8-27-21 document R1 with diagnoses of Convulsions, [CONDITION(S)], Major Depressive Disorder, Hallucinations, Disorientation, [CONDITION(S)], [CONDITION(S)], Lack of Coordination, Cognitive Communication Deficit, Unsteadiness on Feet, Abnormalities of Gait and Mobility, [CONDITION(S)], Personal history of [CONDITION(S)], and Dementia with Behavioral Disturbance. These same orders document R1 requires 24-hour nursing care. These orders also document that R1 receives [MEDICATION(S)] for the diagnosis of [CONDITION(S)] with convulsion, [MEDICATION(S)] for the diagnosis of Dementia with Behavioral Disturbance, [MEDICATION(S)] for the diagnosis of [CONDITION(S)], [MEDICATION(S)] for the diagnosis of [CONDITION(S)], [MEDICATION(S)] for the diagnosis of [CONDITION(S)], [MEDICATION(S)] for the diagnosis of Dementia, and [MEDICATION(S)] for the diagnosis of [CONDITION(S)]. R1's History and Physical dated 3-1-21 documents, Active Problem: Acute [CONDITION(S)]/Dementia with behavioral disturbances/agitation. History of memory/cognitive deficits. According to (R1's) wife, it is significantly worsened. (R1) started having memory loss starting back in 2019. This was first noticed after (R1) crashed his truck and could not get details straight. Also, to be noted (R1) had a longstanding history of being physically abused as a child with memory issues most of his life due to this abuse. (R1) cannot tell me what hospital he is at. R1's Minimum Data Set assessment dated [DATE] documents R1 is cognitively moderately impaired and requires supervision of staff for locomotion on and off the unit and walking. R1's Physician Note dated 6-15-21 and signed by V16 (R1's Nurse Practitioner) documents, (R1) was seen today. Staff state that he keeps saying that he wants to go home. His wife did take him home for only four days, but he had a wrench threatening which scarred the grandchildren. He can have violent outbursts and is anxious. [MEDICATION(S)] was recently started for him for sleep. He keeps telling provider he wants to go home and is anxious and depressed due to this. He says if he is not discharged , he will leave through the window. He states he is not sleeping well due to the facility. Delusional material expressed: Wants to go home and cannot remember he cannot. Memory immediate: Appears impaired. Memory/Recent: Appears impaired. R1's Nurse's Note dated 6-8-21 at 6:11 AM documents, (R1's) wife called facility and informed this nurse that (R1) had called her several times in a span of a few minutes, and that (R1) was 'very agitated and threatening to either break out of facility or commit suicide'. When asked if he had any means to carry out this threat, wife denied this, but she did state that she is aware that he can possibly break out through the bedroom window. This nurse did go and assess (R1) after getting off the phone with his wife, and (R1) was resting in bed, denied any suicidal ideation, and stated that he did not plan on breaking out of facility. R1's Elopement/Unauthorized Leave Risk Review dated 7-23-21 and signed by V9 (Social Service Director) documents, Is there a history of wandering/elopement and/or does the resident verbalized a strong desire to leave? Yes. Signs of compromised decisional capacity and substantially impaired judgement and/or physical status limitations that would place the resident at risk in the community: Yes. Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan: No. Not at risk to elope at this time and placement on Elopement Risk Protocol is not indicated. R1's Comprehensive Care Plan dated 4-30-21 through 8-25-21 does not include a Care Plan with interventions to prevent R1 from eloping from the facility. R1's Police Event Report dated 8-26-21 at 12:28 AM and signed by V12 (Local County Police Deputy) documents, 12:28 AM Caller: (V11/Community Witness). Male (R1) lying on concrete barrier between turn lanes on ramp to Broadway from I (Interstate)-155 South bound. Wearing orange shirt and camouflage hat. First arrive 12:42 AM out with (R1) a quarter of mile from I-155 interstate. (R1) states, 'Out on foot checking corn'. A website Accuweather.com states the weather on 8-25-21 in [NAME], Illinois reached a high of 92 degrees Fahrenheit (F) and a low of 70 degrees F with scattered [NAME]. This same website states a sunset time of 7:44 PM. R1's Initial Report to the State Agency dated 8-26-21 at 12:03 PM and signed by V1 (Administrator) documents, Date of Occurrence: 8-26-21. Time of Occurrence 8:00 AM. Diagnosis: Unspecified Dementia and [CONDITION(S)]. Description of Occurrence: (R1) exited facility, was redirected, and came back to facility. (Local Police) department was present. Action Taken: Door codes changed, medications reviewed, and (R1) on checks. (V6/R1's Family Member) and (V7/R1's Physician) notified. R1's Social Service Note dated 8/26/2021 at 09:33 documents, (R1) exited facility this (morning) to return home. (R1) believes that his wife needs his assistance. (R1) was cooperative and re-entered facility with (Local Police) Department. Medications reviewed and resident on frequent checks. Restorative nurse and social services to contact (R1's) wife regarding returning to home. R1's Progress Notes dated 8-25-21 from 10:00 PM through 8-26-21 at 9:00 AM do not include any documentation of R1's multiple elopements that occurred after 10:30 PM on 8-25-21, and do not include documentation of V1 or V7 being notified of R1's elopements from the facility. On 8-27-21 at 9:35 AM, R1 walked to his room independently from the outside back of the building courtyard. R1 walked to his room and sat on the edge of his bed. R1 was dressed in construction clothing (work boots, jeans, and an orange long sleeve shirt) and was wearing a construction hat. R1 stated, I want to go home. I left out of here the other night through the window around 11:00 PM. I walked the highway towards my home. It was dark out. A police officer picked me up around 1:00 AM and took me to my home where my wife lives. It was hot out, but I survived. I think my wife is having an affair with her ex-boyfriend. If I find out I will beat her to death. I am twitching now. My step dad beat me all the time so I feel like if I go off, I will hurt somebody bad. My wife tells me I have to live here because I cannot remember things. I will find a way out of here. I will live homeless in the woods where nobody can find me. Somebody screwed down a chunk of wood in the window seal so that I cannot open the window. I will break the window out if I have to. On 8-27-21 at 11:30 AM V6 (R1's Family Member) stated while crying, On Wednesday night 8-25-21 (R1) left the facility unattended. (R1) had left me a message on my phone at 11:30 PM that he had left the facility and was walking home. I did not get the message until after 1:00 AM. On 8-26-21 around 1:00 AM a [NAME] County police deputy was knocking on my door and stated they had (R1) and dropped him off at my house. The deputy told me that (R1) was found lying on a concrete median on an off ramp on I (Interstate)-155 South. (R1) was drenched in sweat because the weather was very humid. It had also stormed that night. (R1) told me that he left out of the window at the facility and that he was not going back to the facility. (R1) said he would commit suicide first. I called the facility and V14 (CNA/Certified Nursing Assistant) answered the phone. I stated to (V14), 'Are you missing (R1) from your facility?' I heard (V14) drop the phone and I heard running. (V10/Registered Nurse) then got on the phone and stated, 'Is (R1) a resident here?' I stated back to (V10), 'What kind of question is that?' (V10) then said that I would have to bring (R1) back to the facility as there was no one available to pick (R1) up at my house. (V10) stated that she did not know (R1) was missing from the facility. I live in [NAME], Illinois which is 21 miles from the facility. I then called the [NAME] Sheriff's office and a deputy picked (R1) up from my house and took (R1) back to the facility. (R1) was admitted to that facility because he was becoming increasingly confused and was having major behaviors at home. (R1) was also having [CONDITION(S)] after [CONDITION(S)] which was causing (R1) to lose brain function. (R1) is not safe to leave the building without staff, especially at night. (R1) could get lost or fall. I should not have to worry about (R1). (R1) had falls at home, prior to his admission, and had fell backwards, ripping the top of his scalp off, which required sutures. I have told staff over and over that (R1) was threatening to leave the facility through the window. (R1) knew how to remove the window in his room. The facility should have made sure (R1) was safe. On 8-27-21 at 2:55 PM, V11 (Community Witness) stated, On 8-26-21 around 12:30 AM I was leaving [NAME] on south I-155. When I went on an exit ramp, I saw a male gentleman lying on a concrete median. It had been raining right before I saw him. The male looked unsafe, so I called the police to report this immediately. Where I saw this male, it was around two to three miles from (the facility). On 8-27-21 at 11:50 AM, V10 (RN) stated, On 8-26-21 around 1:00 AM I got a phone call from (V6) that (R1) was at her home. I was not aware that (R1) was gone out of the facility. The last time staff saw (R1) was around 10:00 or 10:20 PM on 8-25-21. (V6) told me that the police had brought (R1) to her house and (R1) was found on an interstate. I told (V6) to bring him back to the facility. Around 2:10 AM a [NAME] County police deputy brought (R1) back to the facility. I do not know how (R1) got out of the facility. No alarms were going off. I did not chart anything about this incident in (R1's) progress notes. I did not notify (V1/Administrator) or (V7/R1's Physician) about (R1) leaving the facility unattended. I notified the manager on call (V15/Licensed Practical Nurse/LPN) about the incident. (R1) kept telling me he was going to go home after the police brought him back to the facility. On 8-28-21 at 11:15 AM, V15 (LPN) stated, On 8-26-21 around 1:30 AM, (V10) called me and reported that (R1) had eloped from the facility and ended up at his wife's house. (V10) told me that the police brought (R1) back to the facility. I told (V10) to make sure (R1) is observed continuously. Later on that day, sometime after 8:00 AM, (R1) was found in the front of the building parking lot without staff presence. Staff should have been watching (R1) continuously, so I am not sure how (R1) got back outside without being noticed. That morning I texted (V1) and (V2/Director of Nursing) that (R1) had eloped. I am not sure if (V1) and (V2) thought my text was from (R1's) elopement in the morning. (V1) and (V2) must not have realized that (R1) had eloped earlier that morning (prior evening). On 8-27-21 at 11:05 AM, V9 (Social Service Director) stated, I came in yesterday and was told by (V15/LPN/Licensed Practical Nurse) that (R1) had left the facility. I spoke to his wife yesterday and she was very angry and stated that (R1) needs more supervision. I am not sure when (R1) left or how (R1) got out of the facility. All I know is that (R1) got out of the facility unattended and the police had to bring him back. I know in the past, (R1) would threaten to break windows and leave the facility. (R1) did not have an elopement Care Plan and interventions developed until yesterday (8-26-21) after (R1) had left the facility. (R1) needs supervision at all times due to confusion and would not be safe to leave the building unattended. On 8-27-21 at 12:00 PM, V1 (Administrator) stated, (R1) was found outside in the front parking lot by V13 (Therapist) yesterday (8-26-21) at 7:38 AM. The staff did not know that (R1) had gotten out of the facility unattended. I watched the security cameras and saw (R1) leave out the front door unattended at 7:36 AM. I was not aware of (R1) making statements about wanting to leave the facility through the window. I was not notified that (R1) had left the building unattended at night on 8-25-21 and was found on an interstate (on morning of 8-26-21). I also did not know that a police deputy had brought (R1) back to the facility. I definitely should have known that (R1) was making threats to leave the building and that (R1) left the building unattended. (R1) is not safe to leave the building without supervision. On 8-27-21 at 1:00 PM, V2 (Director of Nursing) stated, I know sometime in April 2021 (R1) had threatened to get out of his window to leave the facility. I was not aware that (R1) had eloped Wednesday night 8-25-21 and that the police brought him back. (V10) should have notified me immediately of this incident. (R1) has short term memory loss and would have been unsafe to walk home or leave the facility without staff assistance. (V8/Care Plan Coordinator) did not create or implement a Care Plan with interventions regarding (R1's) elopement attempts or regarding (R1) stating that he was going to leave the facility through the window. (V8) did not create an elopement care plan with interventions due to (R1's) elopement/unauthorized leave risk reviews indicating (R1) is not at risk for elopement. The elopement/unauthorized leave risk reviews dated 4-29-21 and 7-23-21 were not accurately coded and should have identified that (R1) is at risk for elopement. On 8-27-21 at 9:25 AM, V3 (CNA/Certified Nursing Assistant) stated, I work here four days a week. I know (R1) does not want to be here. (R1) always says he wants to go home. I am not aware of (R1) ever leaving the building unattended or eloping from the building. (R1) is not an elopement risk. (R1) walks independently. Whenever I do my rounds every two hours, I check on (R1). (R1) is not on any supervised checks that I am aware of. (R1) is confused and would be unsafe to leave the building alone. (R1) would not know where to go or what to do if he left the building. There is an interstate close by that would be very dangerous if (R1) walked on it. On 8-27-21 at 9:50 AM, V4 (Registered Nurse/RN) stated, I heard from other staff that (R1) eloped from the building a few days ago. I was not here when (R1) left the building. (R1) has short term confusion. (R1) is usually well mannered. I am not aware of (R1) needing any increased supervision and I do not know what door (R1) left out of. On 8-27-21 at 10:05 AM, V5 (CNA) stated, I have worked at the facility full time for around three years. I am the staff responsible for (R1) today. I am not aware of (R1) ever leaving the building unattended by staff. (R1) is not on frequent checks or anything. (R1) is confused and is not safe to leave the building without staff. There is too much traffic outside and (R1) gets confused easily. (R1) would not know where he was if he left. On 8-27-21 at 2:20 PM, V7 (R1's Physician) stated, (R1) is not safe to leave the facility without staff. (R1) is definitely not safe to walk outside at night without assistance. (R1) requires supervision of staff. The facility has not even informed me of (R1) elopements. The Immediate Jeopardy was identified on 8-29-21. The Immediate Jeopardy began on August 25, 2021 when R1 eloped from the facility and R1 was found lying on a concrete barrier on an exit ramp of an interstate after sunset. On 8-31-21 at 10:10 AM V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Staff were in-serviced/trained on elopement precautions and facility's policy and procedure for monitoring residents at risk for elopement on 8/31/21 by facility management. Staff on vacation or FMLA (Family Medical Leave Act) will be in serviced before returning to work by the Administrator/Director of Nursing, Nurse management, and HR (Human Resources). The Administration will monitor for ongoing compliance. 2. New hires will be trained on elopement precautions, Code Pink (Elopement- Missing Person) policy, and wander guard systems as part of their general orientation before starting by HR, Nurse management, or Social Services. 3. Social Service was in-serviced by Regional Vice President on proper elopement assessment and Care Plan initiation on 8/31/21. 4. Resident elopement assessments for all residents were reviewed and updated accordingly by the IDT (Interdisciplinary) team. Elopement Care Plans were reviewed and updated by the IDT team. 5. All staff were educated by ADON (Assistant Director of Nursing) on identifying residents at risk for elopement, and the policy and procedure for reporting to leadership to ensure proper interventions/care plans were initiated timely. Residents at risk for elopement were placed in red binders at each Nurse's station and the reception desk. 6. Social services assessed current residents for elopement precautions and ensured all at risk residents have updated Care Plans and interventions in place. 7. Code Pink (Elopement-missing person) drill was performed on 8/31/21 by Administration. 8. The back door was secured with an alarm on 8-25-21. 9. A QAPI (Quality Assurance and Performance Improvement) review with Medical Director to review elopement incident and plan of action. Action plan will be reviewed monthly at QAPI meeting. Medical Director approved of plan with no further recommendations. 10. Medical director notified of incident on 8/26/21 in the facility by the Administrator and reviewed the facility's immediate action plan. Medical Director agreed with immediate action plan. 11. Emergency Care Plan initiated, R1 placed on frequent checks, R1 engaged with activities and other staff, R1's window secured by maintenance to ensure safety of R1 and door codes were changed by maintenance.

lift Findings include: 1. R1's Facesheet documents R1 was admitted to the facility on [DATE]. This same facesheet also states R1 has a history of falls. R1's Physician order [REDACTED]. This same POS also states, (Mechanical) lift for all transfers. R1's Activity of Daily Living sheet (not dated) documents R1 requires the assistance of two plus persons for bed mobility and requires total dependence on staff for transfers. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. This same MDS also documents R1 requires extensive assistance for bed mobility. R1's Nurse's Notes on 1/16/18 at 9:00 P.M. states, Resident (R1) fell out of bed while CNA (Certified Nursing Assistant/V4) was providing care. Skin tear noted on left elbow. Resident complaining of pain 8/10 on hips and chest around ribs. Resident being transported to (local area hospital) for further evaluation . R1's Report of Incident form to the local state agency on 1/23/18 documents a final report summary, (V4) was providing evening cares on (R1). (V4) turned (R1) to (R1's) left side while in bed during cares, and (R1) began sliding out of bed away from (V4) . R1's XR (X-Ray) Hip 2 Views Unilateral Right at local area hospital on [DATE] at 12:51 A.M. documents an impression of Acute mildly displaced intertrochanteric [MEDICAL CONDITION] femur. R1's Discharge Summary from local area hospital documents R1 underwent Right Hip Gamma Nail Insertion on 1/18/18. On 3/6/18 at 3:00 P.M., V4 (CNA) stated, I was cleaning (R1) by myself I had someone help me (mechanically lift) (R1) from the wheelchair to the bed, but then the CNA left the room and I rolled (R1) to (R1's) left side by myself. Normally when we rolled (R1) side to side we would have two (staff members). We are supposed to roll a resident with two people when they are a (mechanical lift) If we are rolling a resident by ourselves, we should roll the resident towards us. (R1) was turned away from me. V4 also stated that no siderails were in use on R1's bed. On 3/6/18 at 4:10 P.M., V2 (Director of Nursing) stated, (R1) should have had two CNAs (Certified Nursing Assistants) when being rolled to (R1's) side in bed. (R1) was a (mechanical lift) transfer. All (mechanical lift transfers) are automatically two assist with cares regarding bed mobility and transfers. (R1) was also a left lower extremity [MEDICAL CONDITION], even more of a reason to have two (staff members). There were ten CNAs on the shift the night (R1) fell . There was no reason to have only used one CNA. The use of two CNAs could have prevented this fall .Even if the resident only requires one CNA for cares, the resident should always be turned toward the staff member, not away from them. (R1) was turned away from (V4). 2. R3's current care plan includes but is not limited to [DIAGNOSES REDACTED]. R3's Nurse's Notes on 1/1/18 at 6:58 P.M. states, This nurse was called to the DR (dining room) at approx. (approximately) 6:30 P.M. to observe resident sitting on the floor .See Fall Report for details . R3's Incident Investigation Worksheet on 1/1/2018 lists a fall intervention of tilt wheelchair. R3's Report of Incident form to the local state agency on 1/14/18 states (R3) age 80 had a fall on 1/13/18 at 6:10 P.M. (R3)was sent into the ER (emergency room ) for further evaluation and treatment. R3's Incident Investigation Worksheet on 1/13/2018 list a fall intervention of (anti-slip mat) to wheelchair. Throughout the days of 3/6/18 and 3/7/18, R3's wheelchair was not tilted and an anti-slip mat was not noted in the seat of R3's wheelchair. On 3/7/18 at 2:10 P.M., V2 (Director of Nursing) verified that there was not an anti-slip mat in R3's wheelchair and that the wheelchair was not tilted. V2 stated, There should be. On 3/7/18 at 2:20 P.M., V6 (Maintenance Director) stated I was never informed that (R3) needed a tilt wheelchair. I am the only one in the building who knows how to tilt the wheelchairs. The wheelchair (R3) is in currently does not tilt. (R3) would need a whole new wheelchair. Had I been notified, the wheelchair could have been changed out right away.

Based on record review and interview the facility failed to assess R2's nutritional risks and address risk factors for impaired nutritional status, failed to identify and implement nutritional interventions to maintain R2's nutritional status, and failed to the notify the physician and dietician of R2's nutritional risks and decrease appetite for one of three residents (R2) reviewed for weight loss in the sample of three. These failures resulted in R2 experiencing a significant weight loss, a decrease in R2's energy levels, and a decrease in participation of activities of daily living. The facility's Nutritional Intervention Procedure dated 08/2016 documents, The purpose of this procedure is the establish guidelines for the Charge Nurse and Registered Dietician when nutritional intervention is required and to assure the nutritional needs of the residents are met. The charge nurse, assigned licensed nurse, or certified nursing assistants shall evaluate and record in percentages the resident's nutritional intake on a nutritional intake record after each meal and after consumption of nourishments. Residents are considered to be at nutritional risk if they have any of the following conditions: Food consumption of less than 50% (percent). Significant or severe weight loss by time interval of 5% in one month or 7.5% in three months, development of skin breakdown, abnormal lab values (significant [MEDICAL CONDITION]'s, protein deficiencies, dehydration). Recent fracture or surgery. Problems and changes in the resident's nutritional status requiring nursing intervention include refusal of food and beverages for three meals, poor appetite or loss of appetite for three consecutive days, inability to feed self or need for assistance, change in eating location, unanticipated weight gain or loss. The Registered Dietician and physician will be notified when nutritional problems are observed and validated via monthly weights. Specialized rehabilitation services and the dietician may be contacted to assist staff in developing appropriate interventions as determined by the assessment findings. Residents with evidence of weight loss shall be placed on weekly weight measurements. The Registered Dietician is responsible for recommending nutritional interventions to meet the resident's identified needs and providing a written report of observations and recommendations for the resident's care to the Administrator and Director of Nursing. Teaching, diet instruction, and resident compliance shall be documented in the resident's medical record and in the resident's plan of care. The facility's Weights-Nutritional at Risk policy dated 03/2017 documents, Notify the physician, dietician, and responsible party of all significant weight loss or gain. The unit manager or designee will ensure the appropriate persons are notified of significant gain or loss. The dietician will notify the nutritional at risk committee of the weight change and implement interventions promptly. The nutritional at risk committee will develop a written plan of care and evaluate the effectiveness of the interventions at each nutritional at risk meeting weekly until weight is determined to be stable or nutritional risk is determined to be resolved. R2's Nursing Progress Notes dated 12-6-17 documents R2 was discharged to another facility. R2's 11-1-17 to 12-21-17 physician's orders [REDACTED]. The same POS documents R2's diet as a regular diet with double protein portions three times daily at meals. R2's Electronic Clinical Notes dated 9-21-17 and 9-27-17 document R2 walks to the dining room with a walker to all meals and has a good appetite. These same notes document R2 is social with staff and residents. R2's Hospital Patient Profile Report dated 11-1-17 documents R2 underwent a Cholecystectomy Laparoscopic (surgical removal of the gallbladder) to the right side and R2 underwent a hernia repair surgery on 9-20-17. R2's Weight Log dated 3-2-17 to 11-29-17 documents R2 had a significant weight loss from 10-4-17 of 216 pounds to 190 pounds on 11-29-17 (12% weight loss). R2's [MEDICATION NAME] Laboratory result dated 11-20-17 documents R2's [MEDICATION NAME] level was 3.3 gm/dl (grams per deciliter) which was below the normal reference range of 3.4 gm/dl to 4.8 gm/dl. R2's Nurse's Notes dated 11-25-17 at 11:00 a.m. documents, (R2) refused shower and refused to get up for breakfast. Appetite remains poor. R2's Clinical Notes dated 11-3-17 at 2:59 p.m. and electronically signed by V13 (Social Service Director/SSD) documents, (R2) has been having continued issues with lower strength and energy since returning from the hospital. (R2) is needing more assistance with staff in transfers and toileting. (R2) has been eating some meals in his room and in therapy. (R2) appears to have increased moods with less interest in doing things, appearing down, sleeping more in the day, having lower energy, and having less of an appetite. R2's Social Progress Note dated 12-1-17 and signed by V13 (SSD) documents, (R2) continues to have a decline in physical (condition). (R2) is noncompliant with cares, wants to be in bed all day, and eats meals in his room. (R2) becomes aggravated at staff when they encourage him to do cares, shower, or therapy. Some cognitive decline noted! Less conversation with staff like before. R2's Physician's Progress Note assessment dated [DATE] and signed by V16 (R2's Physician) is incomplete and does not include R2's weight loss, vital signs, decrease in R2's appetite, or decrease in R2's activities of daily living. R2's Care Plan dated 2-25-16 to present does not include R2's nutritional risks or interventions related to R2's decrease in appetite, R2's significant weight loss, or R2's decline in activities of daily living. R2's Clinical Record does not include documentation of V16 (R2's Physician) or V19 (Registered Dietician) being notified of R2's decrease in appetite, R2's significant weight loss of 12%, or R2's decline in activities of daily living. R2's Clinical Record does not include documentation, as required by the facility's policy, of R2's food intake percentages for the months of November and December, 2017. R2's Nutritional Progress Notes do not include a nutritional assessment since the significant weight loss of 12% on 11-29-17. On 2-6-18 at 10:30 a.m., V19 (Registered Dietician) stated, I was not notified of (R2's) weight loss from 216 pounds to 190 pounds (12% weight loss). I should have been notified of a weight loss of 5% within one month or 7.5% within three months. Had I known I would have assessed (R2's) appetite, asked the nurse if (R2) had any fluid issues such as [MEDICAL CONDITION], and added fortified foods three times daily with meals and possibly a medication pass substitute. I would have started weekly weights. Residents sometimes have a poor appetite after surgery. I should have been notified within 24 hours of a significant weight change and the physician should have been notified. I had wrote a progress note regarding (R2) on 11-27-17, but did not know (R2's) November weight at that time to accurately assess (R2's) nutritional status. On 2-6-18 at 9:45 a.m., V3 (Assistant Director of Nursing) stated, (R2) had a 12% weight loss from 10-4-17 to 11-29-17. The physician should have been notified. Dietary should discuss (R2's) weight loss with the dietician to see if we (the facility) need to make changes. The dietician and physician make decisions as to the cause of (R2's) weight loss and the interventions that need to be done at that time. The dietician and the physician were not notified of (R2's) weight loss. Usually we have a weekly weight meeting to discuss weight loss within a week of obtaining the monthly weights, but for some reason that meeting was not done. According to our (the facility) policy (R2) was at risk nutritionally due to having a significant weight loss, having a recent surgery, having the [DIAGNOSES REDACTED]. No assessment was done and it was not identified that (R2) was a nutritional risk. A care plan should have been developed regarding (R2's) weight loss and nutritional risks. (R2's) nutritional risks should have been recognized when (R2) had hernia and gallbladder removal surgery. I know (R2) quit eating and had a decline. We (the facility) cannot find any documentation of (R2's) food intakes for the months of November and December, 2017. On 2-6-18 at 10:00 a.m., V14 (Dietary Manager) stated, I know (R2) was re-weighed and (R2's) weight of 190 pounds on 11-29-17 was accurate. The day that (R2) had the weight loss I was responsible for calling the nursing department and dietician. (R2's) weight loss slipped through the cracks and I was not told about the weight loss until after (R2) was discharged . There is no nutritional assessment done by nursing. The only nutritional assessments done are completed by the dietician. (R2) had no nutritional assessment done by anyone after having a significant weight loss. No careplan was implemented regarding (R2's) nutritional risks, nutritional interventions, or (R2's) decreased appetite. On 2-5-18 at 2:00 p.m., V9 (R2's Family Member) stated, For a couple months before (R2) was discharged from the facility, (R2) was not going to the dining room for meals anymore and was losing a lot of weight. Every time our family would visit (R2) his meal tray would be in his room untouched. Staff would never help him eat. The facility was doing nothing to help (R2) and was letting him lay in his room all day. On 2-7-18 at 11:20 a.m., V16 (R2's Primary Physician) stated, One of the problems I have is when I go to the facility the resident's vitals, resident's weights, and resident's current problems are not documented or told to me so I can address them. When I am told a resident's weight, I am not told whether that weight is normal for that resident or if it is a weight loss or gain. I was not informed of (R2's) decline in activities of daily living, (R2's) decrease in energy, (R2's) significant weight loss, or (R2) staying in his room. Had I known I would have prescribed (R2) [MEDICATION NAME] to start with as an appetite stimulant and anti-depressant. I would have assessed (R2) and re-checked (R2's) labs (laboratories). An [MEDICATION NAME] level of 3.3 indicates (R2) was not eating enough.

Based on observation, interview, and record review the facility failed to notify the physician of a resident's continued pain and constipation for one of five residents (R11) reviewed for pain in the sample of 15. This resulted in R11 failing to receive medical treatment to relieve constipation and severe abdominal pain. Findings include: The facility's Change in Condition or Status Notification policy dated 03/2016 documents, Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. A significant change of condition is a decline or improvement of the resident's status that will not normally resolve itself without intervention of staff or by implementing standard disease-related clinical interventions . The facility's Pain Assessment and Management policy dated 10/2010 documents, Report the following to the physician or practitioner; Significant changes in the level of the resident's pain and unrelieved pain despite care plan interventions. The facility's Bowel Protocol dated 01/2012 documents: M.O.M. (Milk of Magnesia)-30 cc (cubic centimeters) if no BM (bowel movement) x 3 days or three consecutive small BM's. May repeat x one in eight hours for constipation. [MEDICATION NAME] 10 mg (milligrams) suppository insert one suppository rectally if no results from M.O.M. May repeat x one in 24 hours for constipation. Fleets enema insert one rectally. If no results from [MEDICATION NAME] suppository. If no results call MD (Medical Doctor) for constipation. R11's Minimum Data Set assessment dated [DATE] documents R11's BIMS (Brief Interview for Mental Status) is a score of 15, indicating R11 is cognitively intact. R11's current Bowel Elimination Care Plan documents R11 is at risk for alteration in bowel elimination related to weakness, [MEDICAL CONDITION], opiate therapy, etc .This same care plan documents R11 will have a regular elimination pattern as evidenced by soft/formed bowel movement at least once every three days and report changed in bowel status to the resident's physician as needed. R11's physician's orders [REDACTED]. M.O.M. (Milk of Magnesia) 30 cc (cubic centimeters) if no BM (Bowel Movement) x three days or three consecutive small BM's may repeat x one in eight hours for the [DIAGNOSES REDACTED].O.M and repeat x one in 24 hours for the [DIAGNOSES REDACTED]. [MEDICATION NAME]/[MEDICATION NAME] 5 mg/ 325 mg ([MEDICATION NAME]) one tablet every six hours as needed for pain. R11's Abdomen KUB (Kidneys, Uterus, and Bladder) x-ray dated 1-16-17 documents reason: Constipation, Abdominal Distention, and Pain. This x-ray documents: Findings would support the clinical [DIAGNOSES REDACTED]. If problem worsens or persists contact our office. R11's BM Elimination Logs are incomplete or indicate R11 had no BM on 1-2-17 through 1-7-17, 1-12-17, 1-13-17, 1-15-17 to 1-17-17, or 1-19-17 to 1-22-17. R11's Pain Evaluation dated 1-22-17 and electronically signed by E24 (Licensed Practical Nurse/LPN), documents R11's acceptable level of pain is a 2 on a 1-10 (1 indicates no pain, 5 indicates moderate pain, and 10 indicates worst pain) scale. This same Pain Evaluation documents R11 has non-verbal sounds of pain (crying, whining, gasping, moaning, or groaning) and protective body movements or postures of pain (bracing, guarding, rubbing or massaging a body part/area, clutching, or holding a body part during movement) that are not described as instructed to complete on the pain assessment form. On 1-23-17 at 10:30 a.m., R11 complained of right sided abdominal pain and diarrhea. R11 was holding the right side of his abdomen and had facial grimacing. On 1-23-17 at 11:30 a.m., E7 (Certified Nursing Assistant/CNA) was performing incontinence care on R11 and transferring R11 from the bed to the wheelchair. During these cares R11 was holding the right side of his abdomen and was moaning in pain. On 1-24-17 at 9:23 a.m., R11 complained of pain to the right side of his abdomen at a 10 on a 1-10 pain scale. R11 was guarding the right side of his abdomen. On 1-24-17 at 9:20 a.m., R11 stated, I was given a suppository and milk of magnesia one time around the 16th of January, but nothing since. For the right sided pain they (facility staff) are only giving me pain medications The nurses say nothing is wrong with me. My stools are watery and loose. I am able to to pass small pieces of stool. My stool is normally formed and I am not having normal stools now. I have had this terrible pain for over two weeks. I wish they would do something for me. I am uncomfortable with my daily living because of the pain. On 1-26-17 at 10:45 a.m., R11 was lying on his right side. Rll was holding his right side with his hand and stated, I am having pain. I was asked by the nurse this a.m. if I wanted a pain pill. I don't want a pain pill. I want something for my bowels. On 1-23-17 at 11:50 a.m., E7 (CNA) stated, (R11) has been having pain to the right side. (R11's) stools have been liquidly which is not normal for him. On 1-23-17 at 1:30 p.m., E7 verified that she did not tell the nurse about (R11's) complaints of pain. (R11) stated, I thought they already new about the pain. On 1-24-17 at 11:50 a.m., E10 (CNA) stated, (R11) has been having complaints of right abdominal pain. It has been taking him longer than usual to have a bowel movement. On 1-24-27 at 1:40 p.m., E16 (CNA) stated, I take care of (R11) a couple times a week (R11) complains of pain to the right side of his abdomen. The right sided pain to the abdomen is new pain for him .The nurse gave him a pain pill . If the bowel movement logs are blank or marked as a zero for two days we (staff) should inform the nurse so they can give him something else . On 1-25-17 at 9:00 a.m., E1 (Administrator) stated, (Nurses) should have called the doctor when (R11's) pain was a '10' on a 1-10 scale and was only relieved to a '6', because according to his pain evaluation his acceptable level of pain is a '2'. On 1-26-17 at 10:40 a.m., E13 (Licensed Practical Nurse) stated, No one reported to me on Sunday (1-22-17) that (R11) had a hard BM. If it was reported I would have assessed him and listened to his bowel sounds. He said he had a blockage before. The physician's office should have been contacted that (R11's) problem persisted . R11's Clinical Notes from 1-17-17 to 1-23-17 do not include any documentation of Z3 (R11's Physician) being notified of R11's continued right abdominal pain or constipation. On 1-24-17 at 1:25 p.m., Z1 (Z3's Registered Nurse) stated, The last notification we have had regarding (R11) was on 1-17-17 regarding (R11's) KUB abdominal results. If suppository was not working they (facility staff) should have contacted us (physician's office staff) before now if he is still having pain. That is just good nursing care. I would want to know if the pain persisted. I have no record of them (facility staff) calling us (physician's office staff).

Based on observation, interview, and record review the facility failed to ensure a resident's bowel protocol was followed, and failed to assess and control a resident's pain for one of five residents(R11) reviewed for pain in the sample of 15. These failures resulted in R11 developing and experiencing unrelieved constipation resulting in continued unrelieved severe abdominal pain. Findings include: The facility's Pain Assessment and Management policy dated 10/2010 documents, The purpose of these guidelines are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and need that address the underlying causes of the pain. The pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain, and at least weekly in stable chronic pain .Possible behavioral signs of pain are verbal expressions such as groaning, crying, screaming, and facial expressions such as grimacing, frowning, clenching of the jaw, and guarding, rubbing, or favoring a particular part of the body. Identify the causes of pain such as .Constipation .Strategies that may be employed when establishing the medication regimen include .Reducing or preventing anticipated adverse consequences of medications (bowel regimen to preventing constipation related to opiod [MEDICATION NAME]). Implement the medication regimen as ordered, carefully the result of the interventions. The facility's Bowel Protocol dated 01/2012 documents: M.O.M. (Milk of Magnesia)-30 cc (cubic centimeters) if no BM (bowel movement) x 3 days or three consecutive small BM's. May repeat x one in eight hours for constipation. [MEDICATION NAME] 10 mg (milligrams) suppository insert one suppository rectally if no results from M.O.M. May repeat x one in 24 hours for constipation. Fleets enema insert one rectally. If no results form [MEDICATION NAME] suppository. If no results call MD (Medical Doctor) for constipation. R11's Minimum Data Set assessment dated [DATE] documents R11's BIMS (Brief Interview for Mental Status) is a score of 15, indicating R11 is cognitively intact. R11's physician's orders [REDACTED]. M.O.M. (Milk of Magnesia) 30 cc (cubic centimeters) if no BM (Bowel Movement) x three days or three consecutive small BM's may repeat x one in eight hours for the [DIAGNOSES REDACTED].O.M and repeat x one in 24 hours for the [DIAGNOSES REDACTED]. [MEDICATION NAME]/[MEDICATION NAME] 5 mg/ 325 mg ([MEDICATION NAME]) one tablet every six hours as needed for pain. R11's Abdomen KUB (Kidneys, Uterus, and Bladder) x-ray dated 1-16-17 documents reason: Constipation, Abdominal Distention, and Pain. This x-ray documents: Findings would support the clinical [DIAGNOSES REDACTED]. If problem worsens or persists contact our office. R11's Clinical Notes dated 1-16-17 document, (R11) is alert and oriented .(R11) complains of continuous pain to the right lower rib area. Pain not relieved by PRN medication regimen. Abdomen tender in the RUQ (right upper quadrant) .Resident states he has not had a bowel movement since before Thursday of last week (1-12-17). Suppository given as well as scheduled [MEDICATION NAME]. Waiting for result. Will re-evaluate. R11's Clinical Notes from 1-17-17 to 1-23-17 do not include any assessment of R11's bowel sounds, monitoring of R11 for bowel movements, or monitoring of R11 for right abdomen pain. R11's BM Elimination Logs are incomplete or indicate R11 had no BM on 1-2-17 through 1-7-17, 1-12-17, 1-13-17, 1-15-17 to 1-17-17, or 1-19-17 to 1-22-17. R11's PRN (As Needed) Medication Information Sheet dated 1-1-17 to 1-31-17, documents R11 has only received a [MEDICATION NAME] suppository on 1-16-17 at 8:30 a.m. for constipation, and the result after giving the suppository is incomplete. This same PRN Sheet documents R11 received [MEDICATION NAME] on 1-6-17, 1-11-17, 1-15-17, and 1-16-17 for complaints of pain, and on 1-15-17 the result after giving the [MEDICATION NAME] is incomplete. R11's PRN Medication Administration Information Sheets from 1-1-17 to 1-23-17 do not document R11 receiving a fleets enema or M.O.M. for constipation. R11's Controlled Substances Proof Of Use sheet dated 1-5-17 to 1-25-17, document R11 received [MEDICATION NAME] one tablet 22 different times within this time frame. R11's PRN Medication Information Log only documents four of the 22 times that R11 received [MEDICATION NAME]. The 18 of the 22 times that R11 received [MEDICATION NAME] is not documented on the PRN Medication Log with the reason for giving the [MEDICATION NAME] and the result after giving the [MEDICATION NAME]. R11's Medication Administration Record [REDACTED]. This same MAR indicated [REDACTED]. R11's current Pain Care Plan documents R11 will not experience any unmanaged pain through the next review goal date 1-31-17. This same Pain Care Plan documents R11 will be assessed and monitored for non-verbal indicators of pain (facial grimacing, moaning, clenched teeth, crying, whining, grasping, wincing, wrinkled forehead) and monitor and report to the nurse and signs and symptoms of pain or worsening of pain. R11's Pain Evaluation dated 1-22-17 and electronically signed by E24 (Licensed Practical Nurse/LPN), documents R11's acceptable level of pain is a 2 on a 1-10 (1 indicates no pain, 5 indicates moderate pain, and 10 indicates worst pain) scale. This same Pain Evaluation documents R11 has non-verbal sounds of pain (crying, whining, gasping, moaning, or groaning) and protective body movements or postures of pain (bracing, guarding, rubbing or massaging a body part/area, clutching, or holding a body part during movement) that are not described as instructed to complete on the pain assessment form. According to R11's Medical Record, R11 has had no other pain evaluations since 11-30-16. On 1-23-17 at 10:30 a.m., R11 complained of right sided abdominal pain and diarrhea. R11 was holding the right side of his abdomen and had facial grimacing. On 1-23-17 at 11:30 a.m., E7 (Certified Nursing Assistant/CNA) wiped loose stool from R11's buttock. E7 proceeded to roll R11 from side to side to finish peri cares. During these cares R11 was holding the right side of his abdomen and was moaning in pain. E7 finished R11's personal cares and then proceeded to transfer R11 from the bed to the wheelchair. During the transfer from the bed to the wheelchair, R11 was guarding the right side of his abdomen. On 1-24-17 at 9:23 a.m., R11 complained of pain to the right side of his abdomen at a 10 on a 1-10 pain scale. R11 was guarding the right side of his abdomen. On 1-24-17 at 9:20 a.m., R11 stated, I was given a suppository and milk of magnesia one time around the 16th of January, but nothing since. For the right sided pain they (facility staff) are only giving me pain medications The nurses say nothing is wrong with me. My stools are watery and loose. I am able to to pass small pieces of stool. My stool is normally formed and I am not having normal stools now. I have had this terrible pain for over two weeks. I wish they would do something for me. I am uncomfortable with my daily living because of the pain. On 1-26-17 at 10:45 a.m., R11 was lying on his right side. Rll was holding his right side with his hand and stated, I am having pain. I was asked by the nurse this a.m. if I wanted a pain pill. I don't want a pain pill. I want something for my bowels. On 1-23-17 at 11:50 a.m., E7 (CNA) stated, (R11) has been having pain to the right side. (R11's) stools have been liquidly which is not normal for him. On 1-23-17 at 1:30 p.m., E7 verified that she did not tell the nurse about (R11's) complaints of pain. (R11) stated, I thought they already new about the pain. On 1-24-17 at 9:40 a.m., E13 (Licensed Practical Nurse/LPN) stated, (R11's) back was hurting at a '10' on a 1-10 scale .I gave [MEDICATION NAME] one tablet for the pain .(R11) sometimes has the right sided pain .Sometimes (R11) gets constipation At the end of the week I got x-rays done for (R11's) right sided pain. I am not sure what the x-ray results were. On 1-25-17 at 8:30 a.m., E6 (Minimum Data Set Coordinator) stated, Pain assessments are done quarterly or with a change in condition or pain level. (R11's) last pain assessment done was 11-30-16. On 1-25-17 at 9:00 a.m., E1 (Administrator) stated, The staff(Nurses) should have recorded the result of giving [MEDICATION NAME] on 1-16-17. On 1-15-17 when (R11) was given [MEDICATION NAME], (R11's) result should have been documented .(Staff) should use the bowel protocol for bowel movements. If the nurses see the BM log is incomplete than they need to ask the cna's if the resident has had a BM. If not then they start the bowel protocol .They should have given him another suppository on 1-17-17 if (R11) did not have a BM .(Nurses) should have called the doctor when (R11's) pain was a '10' on a 1-10 scale and was only relieved to a '6', because according to his pain evaluation his acceptable level of pain is a '2'. The nurse should have described the non-verbal signs of pain and the protection of the body parts on the 1-24-17 pain evaluation and a pain evaluation should have been done when R11's pain was at a '10'. After (R11) had constipation the nurses should have documented and assessed (R11's) bowel sounds and monitored (R11) for BM's for several days to make sure (R11) was okay. On 1-25-17 at 10:00 a.m., E2 (Director of Nursing) stated, (R11's) BM logs are incomplete. If the logs were incomplete than they (facility staff) should watch the BM logs if the resident complains of not having a BM. I don't know when the nurses should have followed the bowel protocol because (R11's) record is incomplete. On 1-25-17 at 11:45 a.m., E2 (Director of Nursing) stated, There is no nursing assessment or monitoring of (R11's) from 1-16-17 to 1-24-17. They (facility staff) should follow the bowel protocol for monitoring and assessing after (R11's) x-ray showed constipation. On 1-24-17 at 11:50 a.m. E10 (CNA) stated, (R11) has been having complaints of right abdominal pain. It has been taking him longer than usual to have a bowel movement. On Sunday (1-22-17) it took (R11) longer than usual to have a bowel movement and it was a hard bowel movement. (R11's) bowel movements use to be softer. On 1-24-27 at 1:40 p.m., E16 (CNA) stated, I take care of (R11) a couple times a week (R11) complains of pain to the right side of his abdomen. The right sided pain to the abdomen is new pain for him .The nurse gave him a pain pill . If the bowel movement logs are blank or marked as a zero for two days we (staff) should inform the nurse so they can give him something else . On 1-26-17 at 10:40 a.m., E13 (Licensed Practical Nurse) stated, On 1-16-17 I gave (R11) a [MEDICATION NAME] for constipation. That is the day (R11) complained of rib pain. I have a [MEDICATION NAME] to try and relieve the pain. Sometimes he has back pain .(R11) said he had not had a BM since Thursday or Friday (1-12-17 or 1-13-17) of the prior week. I gave (R11) a suppository and he had a medium BM. (R11) still complained of pain to the abdomen so I got an order for [REDACTED]. If it was reported I would have assessed him and listened to his bowel sounds. He said he had a blockage before. The CNA's should be informing me after (R11) has not had a BM for two days, but some CNA's do not always work two day in a row so its is hard for us to know if they have had a BM. When we do assessments it is put in the clinical/nurse's notes .Everytime a PRN [MEDICATION NAME] was given it should have been charted with the result to whether it relieved the pain .The physician's office should have been contacted that (R11's) problem persisted . On 1-24-17 at 1:25 p.m., Z1 (Z3's Registered Nurse) stated, The last notification we have had regarding (R11) was on 1-17-17 regarding (R11's) KUB abdominal results. We gave orders to continue with laxatives and suppositories .If suppository was not working they (facility staff) should have contacted us (physician's office staff) before now if he is still having pain. That is just good nursing care. I would want to know if the pain persisted. I have no record of them (facility staff) calling us (physician's office staff). I would assess at least (R11's) bowel sounds daily after the constipation.

Based on interview and record review, the facility failed to ensure one of six residents (R3) reviewed with falls in a sample of six had the correct side rails on their bed per their plan of care. This failure resulted in R3 climbing over full side rails and fell sustaining a left femur and wrist fracture. Findings include: R3's nursing notes dated 2-3-12 at 3:15 pm state "Summoned to res (resident) room resident lying on the floor next to bed on her Lt. (left) side moderate amt (amount) of blood on floor. Res had been incontinent of BM (bowel movement) tried to climb out of bed towards bathroom and fell . Large hematoma Lt. side forehead and wrist injury complains of right shoulder pain and left hip pain which was noted to be swollen..." Nursing note dated 2-3-12 at 6:00 pm states R3 was admitted to the hospital with [REDACTED]. Facility's Accident/Incident Investigation dated 2-3-12 states "Resident was noted on the floor next to bed. BM in bed, alarm going off...Resident climbed out of bed and fell on to floor. Hematoma left side forehead left wrist injury left swollen hip." R3's POS (physician's orders [REDACTED]." R3's side rail assessment form dated 5-28-11 and last updated 1-16-12 states R3 is to have two half rails. At the top of this form is this statement "The use of bed rails as a restraint is prohibited unless they are necessary to treat a resident's medical symptom. If the bed rails are used for resident safety it is not considered a restraint." Items checked on R3's assessment were "alteration in safety awareness due to cognitive decline and history of falls." There is no documentation of how R3's side rails were being used to treat a medical condition or enabling R3. On 3-27-12 at 10:30 am, E5 (Social Service) stated on 2-3-12 she heard an alarm sounding and went to R3's room finding R3 on the floor next to her bed. E5 stated R3's side rail was up on the side of the bed where R3 had fallen. E5 said "it looks like (R3) climbed over the side rail." E5 indicated R3's bed had either 3/4 or full side rails at that time. On 3-27-12 at 11:35 am, E4 (Housekeeping Supervisor) stated the following: When R3 returned from a hospital stay on 2-1-12, R3 was moved to another room due to being in isolation. E4 did not move R3's bed to the new room but used the bed already in the room. The new bed in the new room had full side rails on the bed. E4 thought the long rails would be better and R3 would be safer with the full rails. On 3-27-12 at 11:15 am, E16 (Maintenance Supervisor) stated R3 had 3/4 side rails on the bed in the room used before 2-2-12 and full side rails were on the bed R3 was in when she fell on [DATE]. On 3-27-12 at 11:00 am, E2 stated she was working on 2-3-12 when R3 sustained a fall resulting in a left femur and wrist fracture. E2 stated R3 went over the side rail and landed on the floor. E2 stated both of R3's side rails were up at that time. E2 confirmed R3 had full side rails on her bed instead of half rails, climbed over the rails falling and sustaining a left femur and wrist fracture.

Based on observation, record review, and interview, the facility failed to reposition, failed to use gel cushion properly to provide pressure relief and failed to ensure the pressure ulcer dressing was intact and in place for four of eight residents (R1,R2,R4,R15) reviewed for pressure ulcers in the sample of 16. R1 developed a Stage III pressure ulcer after admission which has declined to Stage IV and developed another unstageable pressure ulcer. R2 developed multiple Stage III pressure ulcers in house. Findings include: The current physician's orders [REDACTED]. R1 has [DIAGNOSES REDACTED]. The current care plan dated 8/2/11 and updated 10/24/11 documents that R1 has some long/short term memory deficits. It also documents that R1 cries out often and has experienced [MEDICAL CONDITION] on occasion. Documented under Problem: Self care deficit, turning in bed R/T (related to) weakness and confusion. The Goal is: (R1) will maintain the ability to remain mobile in bed with extensive assist of two. This care plan identifies activities as a problem due to R1's confusion which places her at risk for skin break down due to her not moving much. Documented in this care plan under Problem: Pressure Sores: 8/2/11 Stage III to left heel not open. 10/9/11 Stage III to left heel Eschar has autolyticly debrided. 11/9/11, (R1) has multiple wounds. Stage III heel, skin tear to left posterior lower extremity and right anterior left extremity. Denuded skin under breasts. Stage III fissure under left and right side of Abdomen, Stage IV to left sacrum, Petechia to left upper arm and scattered rashy scabs to arms, legs and buttocks. On 9/27/11 Bruise to forehead- Hit with mechanical lift. On 10/1/11 skin tear to right elbow- unknown. On 12/19/11 at 9:30AM, R1 was in bed lying on her back. At 10:00 AM 11:00AM and 12:00 PM, R1 was still on her back in bed. At 1:00PM, 2:00PM and 3:00M, R1 was in bed on her back . According to pressure ulcer tracking records on 11/14/11, the Stage III pressure ulcer to the Sacrum measured 2.8 centimeters(cm) by 1.6cm by 0.2cm deep. On 12/20/11 at 10:30AM to 11:30 AM, E3 (Assistant Director of Nurses) and E13 (Treatment Nurse) did measurements and treatments to R1's skin tears and pressure ulcers. The Stage III pressure ulcer to left heel is heeled. The skin tears are all closed with scabs. The pressure ulcer on the sacrum is now Stage IV and measured 1.9cm by 1.6cm by 1.5cm. with undermining and tunneling present at average extent of 4.6 cm. Another unstageable pressure ulcer was identified on this date superior to sacral wound measuring 3.0cm by 3.2 cm by unknown depth. with bogginess and heavy amount of serosanguineous drainage, and odorous slough. E13 stated that this is a new pressure area that has developed since she measured last week. E13 stated that R1 spends most of the day in bed. During this dressing change, R1 called out and cried complaining of pain. E13 asked E11(Licensed Practical Nurse/ medication nurse) to administer pain medication while doing the treatment to the Sacral wounds. R1 continued to cry with pain during the treatment and afterward. R1 was sent to the hospital at 11:30 AM for intractable pain control and wound clinic referral. 2. R2's admission record documents R2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's physician orders [REDACTED]. On 12/20/11 at 9:15 a.m., 9:30 a.m., 9:30 a.m., and 10:00 a.m., R2 was sitting in a wheelchair in her room. At 10:10 a.m., E17 (Certified Nursing Aide) transferred R2 from the wheelchair to the toilet. R2 had a plastic covered alarm pad sitting on top of her gel cushion on the wheelchair seat. R2 had an open area on the coccyx area that was not covered with a dressing. E17 stated that there was no dressing found in R2's incontinence brief or slacks at this time nor when E17 got R2 up for breakfast around 6:45 a.m..on 12/20/11. E17 stated she was not aware that R2 even had a pressure sore. At 10:25 a.m. on 12/20/11, E11 (Licensed Practical Nurse) applied a dressing to R2's Stage III area on the coccyx and measured the area as 0.6 long x 0.5 wide x 0.1 centimeters deep. The Wound Assessment report dated 12/13/11 documents that the open area on R2's coccyx area measured 0.60 x 0.30 x 0.10. R2's care plan dated 10/25/11 documents R2 is occasionally incontinent of bowel and bladder, is at risk for skin breakdown, needs extensive assist with turning, repositioning, transferring, and dressing related to recent left [MEDICAL CONDITION]. The care plan also notes that R2 developed a new pressure sore on the left heel on 11/7/11 and developed a Stage III pressure ulcer on the coccyx on 12/13/11 (both while in the facility). 3. R4's care plan dated 10/12/11 documents R4 has confusion/memory problems related to Alzheimer disease, is unable to reposition or transfer herself, requires assist of two staff with transfers using a mechanical lift, is not ambulatory, is incontinent of bowel and bladder, and developed a pressure ulcer on 04/13/11 and on 12/16/11 while in the facility. R4's pressure ulcer scale dated 12/20/11 documents R4 is assessed as high risk for developing pressure ulcers. On 12/20/11 from 9:00 a.m. to 11:10 a.m., R4 was sitting in a wheelchair. An interview with E15 on 12/20/11 showed that R4 transferred from bed to wheelchair around 6:40 a.m. for breakfast and breakfast was served around 8:00 a.m.. At 11:10 a.m., R4 was transferred from her wheelchair to R4's bed in order for the treatment nurse (E13) to be able to check to see if R4 had a dressing in place on her coccyx and to measure the Stage II pressure ulcer. R4 was incontinent of bowel. Some of the bowel had seeped up under the lower part of the dressing covering the open area on the coccyx. E13 (Treatment Nurse) measured the open area as 2.5 centimeters long x 2.0 centimeters wide and with a 0.7 centimeters long x 0.5 centimeters wide x 0.0 deep reddened area surrounding the open area. There was heavy serous drainage that saturated the dressing covering the wound. Both sides of R4's buttocks were red and had indented area from the creases of the incontinence brief. A new order dated 12/20/11 documents E13 requested a new treatment for [REDACTED]. E13 stated on 12/21/11 at 11:30 a.m., that the size of the wound had not increased but that there was more serous drainage since the last assessment on 12/15/11. 4. R15's admission form documents R15 was admitted to the facility 11-13-11 with a deep tissue injury (DTI) to the right sacral area of the buttocks which developed into a stage IV pressure ulcer within 24 hours after admission. R15's Care Plan instructs staff to turn and reposition R15 every hour as an approach for pressure ulcer prevention and to promote wound healing. On 12-19-11 R15 was observed from 9:40 a.m. to 1:40 p.m. sitting in a wheelchair in R15's room. During this observation, R15 was not turned or repositioned by staff at any time nor did R15 reposition independently. E13 (Restorative Nurse) stated on 12-21-11 at 9:00 a.m. that all residents in the facility should be assisted by staff to turn and reposition every two hours and more frequently if they have a pressure ulcer.

Based on observation, interview and record review the facility failed to implement care plan interventions of personal body alarms and supervision during toileting for two of eight residents (R7, R15) reviewed for fall risk in the sample of 16. R7 fell , fractured her right humerus and sustained a subdural hematoma. Findings include: 1. R7's quarterly MDS (Minimum Data Set) dated 8/25/11 documented a BIMS (Brief Interview for Mental Status) score of 13, indicating cognitively intact. R7's ambulation score was coded a two (2) for assistance of one. R7's annual MDS dated [DATE] documents a BIMS score of 14; cognitively intact. R7's ambulation within resident's room was coded as an 8 meaning that the activity did not occur. R7's social progress note dated 11/14/11 documented no problems with communication and alert and oriented times three. R7's safety assessment tool dated 11/14/11 documented a score of 30 indicating the facility needed to implement fall precautions. R7's fall care plan dated 11/18/11 includes an intervention of a chair pad alarm to be placed in recliner. On 11/17/10 a problem of an unsteady shuffling gait and unable to ambulate independently was added. This same care plan includes an entry dated 3/19/11 which reads "Res (resident) got up out of recliner to get a piece of candy, lost balance and fell ." Nursing notes dated 12/2/11 document that "res (resident) continues to receive skilled PT (physical therapy) for strengthening, transfer training, ...and gait training....She can currently ambulate 25 ft (feet) with r.w. (roller walker) mod (moderate) assist in therapy..." On 12/3/11, R7's nursing notes document R7 was found on the floor in her room, under her sink, and lying on her left arm with a laceration above her right eye. R7 was moaning and yelling "it hurts it hurts". The right arm was noted to have instant swelling. R7 was sent to the emergency room . Observation sheet of witness or first employee on the scene reported by E12 (Certified Nursing Assistant) documents that on 12/3/11, R7 was found on the right face down, in her room at side of her bed, with personal body alarm not sounding. This form documents that resident said she was trying to go to the sink. R7's incident and accident investigation for the fall on 12/3/11 document R7 was face down on floor on top of her left arm under the sink. On 12/22/11 at 8:25 a.m. E12 (Certified Nursing Assistant) stated that while walking by R7's room she glanced in and saw R7's legs so she entered the room to find R7 lying on her stomach with her head turned to the right and a lot of blood so she ran to get E11 (Licensed practical Nurse). E12 stated that a body alarm was not sounding. On 12/20/11 st 4 p.m. E11(Licensed Practical Nurse) stated that on 12/3/11 it was reported by E12 (Certified Nursing Assistant) that R7 was on the floor. E11 assessed R7 and found her to be face down, left arm under her with blood on the right side of her face, complaining of right arm pain and a laceration above left eyebrow. E11 stated that R7 was alert and talking. E11 stated that R7 never walks by herself and an alarm was not sounding. E11 stated she could not remember if an alarm was on the bed or chair. Consultation report by Z6 (Consulting Hospital Physician) dated 12/03/2011 notes under History of Present Illness that "She (R7) was getting up out of a chair, she took 1 to 2 steps, and she fell , that is all she remembers, although she is unsure is she had loss of consciousness...she did bump her head." R7 was admitted to the hospital after the fall on 12/3/11 and did not return to the facility until 12/8/11. R7's twenty four hours nursing admission record dated 12/8/11 documented R7's physicial condition as poor, confused mental status and restless. R7's history and physical dated 12/3/11 documents R7 fell at the nursing home and had a brief loss of consciousness. A CT (computerized tomography which allows for a detailed image to be taken of the internal tissues of the body) was performed and demonstrated atrophied brain with a 1 by 6 centimeter thick large subdural hematoma and a left frontotemporal lesion. R7 also had a right humerus shaft fracture. R7's nurses notes on 12/9/11 documents R7 was placed on hospice. On 12/20/11 at 1:20 p.m., Z2 (R7's son) and Z3 (R7's daughter and power of attorney) stated R7 could not walk, was alert and sat in her recliner every day. On 12/19/11 at 9:30 a.m. during initial tour R7's door was closed and E3 (Assistant Director of Nursing) stated that R7 " was dying" . 2. Facility incident report documents that on 12-04-11 R15 sustained a fall while alone in the bathroom. The facility accident investigation report dated 12-4-11 indicates that R15 should not be left unsupervised while in the bathroom. On 12-19-11 during observation of R15 from 10:40 a.m. to 1:40 p.m., R15 was in her wheelchair, away from her call light, lethargic and difficult to keep aroused to answer questions or eat lunch. On 12-19-11 at 1:35 p.m. E22 (Certified Nurse Aide) stated that R15 had been more lethargic for the past month. On 12-19-11 at 1:40 p.m. E22 and E23 (Certified Nurse Aides) assisted R15 to transfer from the wheelchair into the bathroom and onto the toilet. E22 and E23 closed R15's bathroom door and both E22 and E23 left R15's room leaving R15 unattended and unsupervised in the bathroom. E26 (Minimum Data Set/Care Plan Coordinator) stated on 12/20/11 at 9:40 a.m. that the facility staff should not leave a resident at high risk for falling unattended in the bathroom and that that approach was recommended on the facility Accident Investigation Report after R15's fall on 12-04-11. B. Based on observation and record review, the facility failed to ensure that toxic chemicals and sharp items were kept in locked areas inaccessible to residents in a shower room on one of two residential wings. This failure had the potential to affect four cognitively impaired residents (R27 to R30) of 76 residents living in the facility. During the general tour of the facility with E25 (Maintenance Director) on 12/21/11 at 10:20 AM, a wall cabinet was unlocked inside the unlocked A wing shower room. The cabinet contained at least a dozen plastic disposable razors. Also a spray bottle of Rite Quat 256 Disinfectant, posting warnings of "Keep out of reach of children , Harmful if inhaled or absorbed through the skin," was hanging on a wall bracket nearby. A list prepared by E2 (Director of Nursing) of cognitively impaired, independently ambulatory residents living on A wing included R27, R28, R29 and R30. The Centers for Medicare and Medicaid Services (CMS) form # 672 completed by the facility indicated that the current resident census was 76.