Every finding on record at Arcadia Care Watseka

Based on observation, interview, and record review, the facility failed to identify and report increased arm pain and new swelling, failed to ensure pain medication was available, failed to administer pain medication as ordered, and failed to obtain x-rays timely for one (R1) of three residents reviewed for hospice care in the sample list of 14 residents. These failures resulted in a delay in treating R1's pain resulting in increased pain and R1 refusing to get out of bed. Findings include: The facility's Pain Management Program, dated December 2025, documents the following: Residents descriptions regarding the quality, duration, and location of pain will be used to evaluate pain and identify any changes. Physical signs such as grimacing and body posturing/guarding will be used to identify pain. A care plan will be developed and implemented based on assessment, pain rating, and pain-relieving interventions, and will be reviewed and updated each time pain management is found to be ineffective. Document assessments of pain and response to pain management and notify the physician when pain is not relieved by comfort measures or medications. The facility's Physician-Family Notification-Change in Condition policy, dated December 2025, documents the facility will consult with the resident's physician or designee and the resident's representative when there is an accident which results in injury, a significant change or deterioration in condition or a need to significantly alter treatment. On 8/11/26 at 11:23 AM, V4 and V20, Certified Nursing Assistants (CNAs), provided R1's incontinence cares and turned R1 side to side in bed.R1's Minimum Data Set, dated [DATE], documents R1 has severe cognitive impairment and is dependent on staff for assistance with dressing, bed mobility and transfers. R1 received scheduled pain medication, no PRN (as needed) pain medications were given and R1 had no reports of pain during the five-day review period. R1's Care Plan, dated 1/22/26, documents R1 is at risk for pain related to Cholecystitis and Chronic Kidney Disease and includes interventions to administer pain medication as ordered. R1's Care Plan dated 1/29/26 documents R1 receives hospice care and includes an intervention to notify the physician and hospice if pain or discomfort is not alleviated by current medication or treatment. R1's Care Plan documents R1's diagnoses include Moderate Intellectual Disabilities, and this Care Plan does not include R1 has chronic pain or location of pain. R1's Hospice Notes document the following: On 6/27/26, R1 complained of right arm and shoulder pain that hurt all night. On 7/2/26, R1 had right shoulder pain and paralysis on the right side. On 7/8/26, R1 received a bath due to pain and restlessness, R1 was uncomfortable, and no comfort medications were available. R1 continued to complain of right arm pain on 7/11/26, Morphine was administered, and x-rays were not completed yet. On 7/15/26, R1 complained of right side and chest pain, Morphine was increased to 0.5 ml every two hours as needed, and a dose was given at this time. R1's Physician's Order, dated 7/10/26 at 7:51 PM, documents chest and right shoulder x-ray STAT (immediately). R1's Radiology Results Report with examination date of 7/12/26 at 3:00 AM and report time of 9:12 PM documents questionable nondisplaced right lateral 8th rib fracture, Osteopenia, and degenerative changes. R1's Radiology Results Report with examination date of 7/12/26 at 3:00 AM documents degenerative changes of right shoulder with no acute fracture. R1's July 2026 Medication Administration Record (MAR) documents the following: Between 7/1/26 and 7/9/26, Tylenol 650 milligrams (mg) was the only PRN (as needed) pain medication administered, given two times during this time frame, once on 7/1/26 at 6:03 AM for pain rated 2 on 1-10 scale and once on 7/9/26 at 1:15 PM for pain rated 6. R1 had an active order, dated 1/28/26, for Morphine Sulfate 100 mg per (5) five milliliters (mg/ml) give 0.25 ml by mouth every two hours as needed for moderate pain, but this medication was not administered until 7/10/26 at 9:22 PM for pain rated 4. This order was not discontinued until 8/4/26, and five additional doses were given between 7/11/26 and 7/13/26, with pain rated 9 on 7/13/26. On 7/11/26, Morphine Sulfate dose was increased to 0.5 ml by mouth every two hours as needed, with one dose given on 7/13/26 and 7/15/26. Lidocaine patch application daily to right ribs was added on 7/14/26 and Morphine was increased to 0.75 ml twice daily on 7/15/26. Methocarbamol 1000 mg give 1500 mg four times daily for rib pain for three days was added on 7/14/26, but no doses were administered. R1's Morphine Sulfate 100 mg/5 ml Controlled Substance Proof of Use with start date of 7/10/26 documents five doses of 0.25 ml were given after 7/11/26 when the order was increased to 0.5 ml every two hours PRN. R1's Nursing Notes document the following:On 7/8/26 at 3:57 AM, R1 complained of right shoulder pain (no documented administration of pain medication or pain rating).On 7/9/2026 at 4:25 AM, R1 had a change in condition and hospice sitter arrived. R1 was confused and restless and Tylenol was given at bedtime due to R1's inability to verbalize pain, with slightly effective results. Hospice Certified Nursing Assistant (CNA) was notified there was no Ativan or Morphine Sulfate on hand for R1. The CNA updated hospice nurse who would be in today to assess R1 and have the pharmacy deliver R1's medication.On 7/10/2026 at 7:17 AM, a CNA reported R1 was complaining of right arm/shoulder pain. R1 was assessed and R1's shoulder area was mildly swollen and R1 reported R1 had fallen but unable to recall when this fall occurred. PRN Morphine was given, hospice nurse was notified, hospice entered orders to be implemented which was relayed to the oncoming shift and to continue to monitor for pain, swelling and change in condition. (There is no documentation V18, R1's guardian, was notified.)On 7/11/2026 at 3:47 AM, Hospice nurse gave orders to increase Morphine and x-ray of right rib and shoulder asap (as soon as possible) due to sudden onset of pain.On 7/11/26 at 4:13 PM, R1 refused to get out of bed this shift due to shoulder pain. Morphine 0.25 ml instead of the ordered 0.5 ml was given three times on 7/11/26.On 7/11/26 at 10:30 PM and 10:59 PM, R1 reported to hospice R1 had fallen out of bed but was unable to say when this happened. R1's roommate (R7) was asked if R1 fell out of bed, R7 said yes but did not know when this happened. R7 was asked how R1 fell and R7 pointed to R7's right side. R1 had vocal complaints of pain and facial expressions of pain over the past five days. On 7/14/26 and 7/15/26, R1's Methocarbamol was not available to give. On 7/15/26 at 5:37 PM, R1 was transferred to the local hospital per V18's (R1's) Guardians request. On 8/10/26 at 9:48 AM, V6, Hospice Registered Nurse (RN), stated: The day R1 reported falling out of bed R1 complained of R1's right arm hurting and wouldn't get out of bed, which was unusual for R1. Hospice ordered STAT x-rays, which weren't completed until a couple days later while R1 continued to stay in bed due to pain. There were concerns that R1's PRN Morphine was not administered as ordered, it was increased and then later changed to scheduled. On 8/10/26 at 10:10 AM, V18, R1's Guardian, stated the facility did not initially report R1's arm pain and alleged fall to V18, and V18 was unaware of R1's pain and alleged fall until reported by hospice. On 8/10/26 at 1:15 PM, V5, Hospice CNA, stated: R1 started having pain when turning in bed, indicating something was wrong as that was unlike R1. R1 complained of right arm pain to both V5 and V6 on 7/13/26 and R1 reported R1 had fallen out of bed, but the facility denied that happened. R1 requires a full mechanical lift for transfers and would not be able to transfer R1's self off the floor without staff assistance. On 8/11/26 at 9:06 AM, V11, Agency Licensed Practical Nurse (LPN), stated V11 did not do any assessment of R1's right arm when R1 reported pain since R1 is on hospice and V11 notified R1's hospice nurse that day (7/9/26). On 8/11/26 at 9:21 AM, V13, RN, stated: R1 was in a lot of pain on the night of 7/8/26, R1 had declined, R1 looked bad, R1 wasn't feeling well, and V13 RN notified hospice that there was no Morphine available for R1. It had been passed on in report R1 had significant right arm pain reported that day or the day prior and R1 needed pain medication. R1 was R1's usual self when V13, RN, last cared for R1 on 7/5/26 and 7/6/26. R1 had prior right arm pain but nothing too significant with occasional Tylenol given. This was a significant change for R1. V13, RN, did not notify V18 of R1's pain or change of condition since V13 believed the prior shift had reported this. On 8/11/26 at 9:42 AM, V12, Licensed Practical Nurse (LPN), stated: R1's rib pain came out of the blue as R1 had never complained of pain before. V12 and V6 questioned whether R1 had a fall that went unreported, as R1 and R7 both reported R1 had fallen out of bed. V12 did not think R1's pain was resolved, and hospice was working on getting R1's Morphine scheduled once the possible fractures were identified, as the Morphine was PRN prior to that. On 8/11/26 at 2:49 PM, V14, LPN, stated: R1 had prior complaints of right arm pain but thought R1's increased pain was odd since R1 has limited movement and does not self-propel R1's wheelchair. V14 gave R1 Tylenol because R1 did not have hospice medications ordered the night V16, CNA, reported R1's arm pain. It is possible that V14 did not document this administration on R1's MAR. R1 was guarded and flinched while attempting right arm range of motion. V14 later found out about R1's possible rib fracture and thought R1 meant rib pain when reporting right arm pain. V14 reported R1's pain to the oncoming nurse but did not contact hospice or V18. On 8/11/26 at 3:24 PM, V16, CNA, stated: V16 worked on 7/6/26-7/8/26 and R1 always complained of R1's right arm hurting but started complaining of it more around that time, which was reported to both V13, RN, and V14, LPN. R1's pain affected R1 during turning and changing in bed, R1 would complain of pain if R1's arm was moved too much and required stabilization to limit movement while dressing R1. On 8/11/26 at 3:37 PM, V19, Agency LPN, stated: R1 refused to get out of bed that day (7/10/26) due to right arm pain and Morphine was administered. R1 told V19 that R1 had a recent fall but was unable to give specifics. V19 contacted hospice but did not notify V18 as V19 left that for hospice to do. On 8/11/26 at 10:52 AM, V2, Director of Nursing, stated R1's chest x-ray showed questionable rib fracture, but R1's hospital Computed Tomography (CT) did not indicate any fractures. V2 confirmed R1's chest x-ray was completed on 7/12/26 (over 24 hours after initially ordered by hospice). At 12:40 PM, V2 reviewed R1's hospice notes, morphine orders, Medication Administration Record (MAR), and Morphine Controlled Substance form and confirmed discrepancies in doses administered after R1's Morphine was increased to 0.5 ml. V2 confirmed the prior order for 0.25ml should have been discontinued when it was increased. V2 confirmed R1's first dose of Morphine was given on 7/10/26 after R1's Morphine was delivered, and confirmed Methocarbamol was not given. V2 stated V2 does not like to have hospice deliver Morphine until it is being used. V2 stated V2 had issues with hospice not reporting pain and communicating orders to the floor nurses. V2 stated hospice, R1's physician, and V18 should have been notified when R1's shoulder pain was first identified. At 4:25 PM, V2 stated the nurse (V19) should have reported R1's report of alleged fall immediately to V18 at the time it was reported and documented in a nursing note or incident report. On 8/12/26 at 2:10 PM, V21, Crisis Nurse Consultant, stated R1's x-rays were completed within 24-48 hours, which would be an acceptable time frame since R1's x-ray orders were not STAT.

Based on observation, interview, and record review, the facility failed to obtain a urinalysis and cultures timely and as ordered, and report results for three (R1, R3, R8) of four residents reviewed for Urinary Tract Infections (UTIs) in the sample list of 14 residents. This failure resulted in R1 experiencing continued symptoms, delayed treatment, and hospitalization for UTI. The facility also failed to change a urinary catheter as ordered and provide hygienic urinary catheter and perineal cares for two (R3, R8) of four residents reviewed for UTI in the sample list of 14 residents. Findings include:1.) R1's Minimum Data Set (MDS), dated [DATE], documents R1 has severe cognitive impairment, R1 is dependent on staff for toileting hygiene, and R1 has a urinary catheter. R1's Care Plan, dated as revised/resolved 7/11/26, documents R1 is at risk for infection related to urinary catheter use and to notify the physician of any signs of infection or changes in condition. R1's Physician's Order, dated 7/7/26, documents an order for a urine culture scheduled for 7/9/26. R1's undated temperature log documents R1's temperature was between 99.0- and 99.3-degrees Fahrenheit (F) on 7/10/26-7/12/26. R1's Hospice Note, dated 7/8/26, documents: R1 was lethargic, difficult to arouse, complained of stomach pain and had a scant amount of urine in the urinary catheter bag. A urine culture was ordered, and V15, Assistant Director of Nursing (ADON), was notified.R1's Nursing Notes document the following: V17, Nurse Practitioner (NP), evaluated R1 for bloody urine on 7/8/26. R1 had urinary catheter change the night prior which may have caused insertion site trauma; and to monitor urine output and color. V17, NP, re-evaluated R1 on 7/9/26 and noted urine culture pending to assess for UTI. On 7/9/2026 at 4:25 AM, R1 had gross hematuria (bloody urine) in R1's urinary catheter bag and little urine output, less than 100 milliliters. R1 was restless and did not drink much that shift. On 7/10/2026 at 1:38 AM, an unidentified Certified Nursing Assistant (CNA) reported R1 was unresponsive, upon entering R1's room R1 spoke and complained of being cold. R1's air conditioner was set to 65 F and was adjusted. R1's catheter was draining amber colored urine and R1's catheter was removed. On 7/10/2026 at 10:01 AM, R1 had increased confusion/disorientation. R1 attempted but was unable to urinate and hospice was notified. On 7/11/2026 at 3:47 AM, R1 was incontinent of urine three times with moderate amount this shift and continued to complain of some pain with urination. On 7/13/26 and 7/14/26, V17, NP, re-evaluated R1 and notes low grade fever last week and urine culture is pending to assess for UTI. On 7/15/26 at 5:37 PM, R1 was transferred to the local hospital per V18's (R1's Guardian) request.R1's nursing notes do not document a urine sample was collected or attempts were made. R1's Hospital Notes, dated 7/15/26, document R1's long term care facility reported R1's urinary catheter was removed yesterday and R1 had progressive decline over last two to three days. R1's urinalysis was positive for blood, nitrites, and leukocytes (indicative of infection). R1 was given intravenous antibiotics and was admitted to the hospital for UTI and Acute Pyelonephritis (kidney infection). On 8/10/26 at 9:48 AM, V6, Hospice Registered Nurse (RN), stated R1's urinary catheter was draining amber colored and blood-tinged urine; a urinalysis was ordered by hospice, but the facility never followed through with this and R1 ended up being hospitalized for a UTI. On 8/10/26 at 1:15 PM, V5, Hospice CNA, stated on 7/8/26 R1 had a fever, chills, UTI symptoms, with bloody urine and was very confused. V5 stated V6, Hospice RN, visited that day, R1's catheter was removed, and the facility was supposed to collect a urine sample, but hospice never received any results until after R1 was hospitalized . On 8/11/26 at 9:21 AM, V13, RN, stated R1 had little urinary catheter output and thought hospice had discontinued the urinalysis order or the sample was already obtained, so V13, RN, did not attempt to obtain a urine sample. V13, RN, stated V13 does not always see when orders are entered for urinalysis or cultures and attempts to obtain urine collection are documented in the nursing notes. On 8/11/26 at 2:49 PM, V14, Licensed Practical Nurse (LPN), stated R1's urinary catheter was changed due to complaints of pain, R1's urine looked gunky and hospice gave the ok to leave the catheter out once it was removed. V14, LPN, did not recall if a urine sample was collected. On 8/11/26 at 3:37 PM, V19, Agency LPN, did not recall any information regarding R1's urine characteristics, symptoms, or if a urine sample was collected. On 8/11/26 at 10:25 AM, V2, Director of Nursing (DON), stated hospice was notified of R1's blood-tinged urine and we were to collect a urine sample for urinalysis. On 8/12/26 at 8:31 AM, V2, DON, stated there was no documentation that R1's urinalysis and culture was completed and V2 even checked with the laboratory. 2.) R3's Minimum Data Set (MDS), dated [DATE], documents R3 has severe cognitive impairment, is dependent on staff for toileting hygiene, is incontinent of bowel and has a urinary catheter. R3's Care Plan revised 7/6/26 documents R3 has a urinary catheter and intervention to change the catheter as ordered. R3's Physician's Order, dated 3/11/26 and discontinued date 8/11/26, documents to change R3's urinary catheter every 30 days and as needed. There is no documentation in R3's Electronic Medical Record (EMR) that R3's urinary catheter was changed in July or August 2026. R3's Hospice Note, dated 7/16/26, documents R3 has a urinary catheter changed every 30 days, urine is often cloudy with thick, white sediment. R3 has had a couple UTIs during this period with antibiotic treatment. R3's Hospice Order, dated 7/20/26, documents orders for urinalysis and culture with sensitivity if indicated. R3's Nursing Notes document: On 7/20/26, hospice was notified R3's urine was amber colored, and a urine culture was ordered. On 7/21/26, R3's urine contained sediment. R3's urine is noted as amber colored through 8/4/26 with declining, poor oral intake. R3's Urinalysis and Culture, collected 7/21/26 and reported 7/24/26, documents positive for nitrites, leukocytes and few bacteria; and greater than 100,000 colony forming units/milliliter (cfu/ml) of mixed pathogens, probable contamination, and to contact the laboratory. There is no documentation in R3's EMR that these results were followed up with the laboratory, hospice, or physician; or that another urine sample was collected. On 8/11/26 at 1:47 PM, V20 and V4, Certified Nursing Assistants/CNAs, entered R3's room and provided urinary catheter care, with V15, Assistant Director of Nursing (ADON), present. V20, CNA, used a washcloth to cleanse R3's urinary catheter tubing starting further away from R3's body and moving upwards towards R3's urinary meatus/catheter insertion site. At 2:15 PM, V20, CNA, confirmed V20 cleansed R3's urinary catheter tubing in upwards motion towards insertion site. V15, ADON, stated urinary catheter tubing should be cleansed in downward motion moving away from the insertion site. V15, ADON, confirmed this is to prevent introducing bacteria. On 8/11/26 at 10:41 AM, V2, DON, confirmed R3's urine culture was contaminated. V2, DON, stated V2 will have to see if there is documentation of communication with hospice or physician regarding this or if another culture was done. At 1:19 PM, V2, DON, confirmed R3 had no additional urine tests after 7/21/26 or documentation of communication with hospice or physician regarding the contaminated specimen, which should have been done. On 8/12/26 at 8:01 AM, V2, DON, stated V2 was unable to find documentation that R3's catheter was changed in the last couple months and V2 had also checked with hospice. 3.) R8's MDS, dated [DATE], documents R8 has severe cognitive impairment and is dependent on staff for toileting hygiene. R8's active Care Plan documents an intervention, dated 6/4/26, R8 is incontinent of bowel and bladder and requires one staff assist for toileting assistance. R8's Urology Note, dated 7/6/26, documents R8 has history of UTIs and a prophylactic antibiotic, Keflex 250 milligrams (mg) daily was prescribed. R8's Physician's Order, dated 7/20/26, documents urine culture scheduled for 7/23/26. R8's Urine Culture collected on 7/29/26, resulted on 8/6/26, and print date 8/12/26, documents greater than 100,000 cfu/ml of Enterococcus Faecalis (indicating infection), and Keflex is not listed on the sensitivity report. Macrobid is listed as an appropriate antibiotic with the organism being sensitive to this medication.There is no documentation in R8's EMR that a urine sample was collected or attempts made prior to 7/29/26. As of 8/11/26, R8's EMR did not include documentation the results of R8's urine culture were obtained and reported to a provider. R8's Nursing Note, dated 8/12/26 at 1:24 PM, documents physician was notified of R8's urine culture results and new orders received for Macrobid 100 mg twice daily for 10 days. On 8/10/26 at 11:34 AM, V20, CNA, entered R8's room, R8 removed R8's soiled incontinence brief which was wet with a moderate amount of dark urine. R8 walked to the bathroom while V20 stayed in R8's room and did not provide assistance with R8's toileting. R8 walked back to R8's wheelchair where V20, CNA, assisted R8 with applying a clean brief but did not offer or provide perineal cleansing prior to assisting R8 with dressing. V20, CNA, stated V20 is not aware of R8 having any recent UTIs. V20 stated R8 wipes R8's self when using the toilet. On 8/11/26 at 4:25 PM, V2, DON, stated if the MDS is coded as dependent on staff for toileting hygiene then staff should provide perineal cleansing with incontinence/toileting. V2, DON, confirmed staff should provide R8's perineal cleansing due to incontinence and history of UTIs. On 8/12/26 at 11:10 AM, V2, DON, stated V2 confirmed R8's urine specimen was not sent until 7/29/26 and thought this was due to a prior urine sample collected that was not sent to the laboratory in time. V2, DON, stated staff should document in the nursing notes when urine samples are collected or attempts made. V2, DON, stated the laboratory had R8's name wrong on the urine culture and V2 obtained the results today. At 1:15 PM, V2, DON, stated V2 was unable to find documentation that a urine sample was collected or attempts made prior to 7/29/26 and did not find documentation R8's physician was notified of the results which V2 will follow up with today. At 1:35 PM, V2, DON, stated V2 received orders for Macrobid for R8. The facility's undated Perineal Care Competency documents for catheter care, gently wipe four inches of the catheter from meatus outward and to cleanse urethral area and labia in downward strokes moving outwards to thighs as part of perineal cleansing. The facility's Urinary Catheter Care policy, dated December 2025, documents to record dates of catheter insertion and changes in the nursing notes and treatment administration record.

Based on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for one (R1) of three residents reviewed for injuries in the sample list of 14 residents. Findings include:The facility's Abuse Prevention and Reporting policy, dated March 2026, documents injuries of unknown source criteria is when the source of the injury was not observed by any person or explained by the resident and the injury is suspicious because of the extent of the injury, location of the injury or the number of injuries observed at once or over time. On 8/10/26 at 8:12 AM, R1 was in R1's room in a reclining geriatric chair with a full mechanical lift sling between R1 and the chair. On 8/11/26 at 11:23 AM, V4 and V20, Certified Nursing Assistants (CNAs), provided R1's incontinence care and turned R1 side to side in bed. R1's Minimum Data Set (MDS), dated [DATE], documents R1 has severe cognitive impairment, R1 is dependent on staff for assistance with dressing, bed mobility and transfers, and had no falls since the last assessment. R1's Hospice Notes document R1 complained of right arm pain on 6/27/26 and 7/2/26. R1's Nursing Notes document complaints of right shoulder pain beginning on 7/8/26 and continued through 7/11/26 when R1 refused to get out of bed due to pain and Morphine was given. On 7/10/2026 at 7:17 AM, a CNA reported R1 complained of right arm/shoulder pain. R1 was assessed and R1's shoulder area was mildly swollen. R1 reported R1 had fallen but unable to recall when this fall occurred. On 7/11/26 at 10:30 PM and 10:59 PM, R1 reported to hospice R1 had fallen out of bed but was unable to say when this happened. R1's roommate (R7) was asked if R1 fell out of bed. R7 said yes but did not know when this happened. R7 was asked how R1 fell and R7 pointed to R7's right side. R1 had vocal complaints of pain and facial expressions of pain over the past five days. R1's Radiology Results Report with examination date of 7/12/26 at 3:00 AM and report time of 9:12 PM documents questionable nondisplaced right lateral 8th rib fracture, Osteopenia, and degenerative changes.There is no documentation in R1's electronic medical record that R1 had a fall or incident in late June or early July 2026. The facility's Report to State Agency Regional Office, dated 7/17/26, completed by V2, Director of Nursing (DON), documents on 7/12/26, R1's roommate, R7, reported R1 had fallen out of bed. R1's x-ray completed on 7/12/26 revealed a non-displaced fracture of the right lateral eighth rib. An investigation was conducted and based on the findings it was determined that R1, who requires a full mechanical lift for transfers, sustained an unwitnessed fall from bed.The facility's investigative file for R1's injury/unwitnessed fall only contained four staff interviews, all nurses, and no interviews with CNAs. These interviews review R1's pain and if signs of injury but do not identify if R1 had any incidents or falls to cause R1's increased pain and possible rib fracture other than R7 reported R1 allegedly fell out of bed on an unidentified date within days prior, not weeks/months. R7's Brief Interview for Mental Status, dated 7/29/26, documents R7 has moderate cognitive impairment.On 8/10/26 at 1:15 PM, V5, Hospice CNA, stated: R1 started having pain when turning in bed, indicating something was wrong as that was unlike R1. R1 complained of right arm pain and R1 reported R1 had fallen out of bed, but the facility denied that happened. R1 requires a full mechanical lift for transfers and would not be able to transfer R1's self off the floor without staff assistance.On 8/11/26 at 9:21 AM, V13, Registered Nurse (RN), stated: R1 was in a lot of pain, complaining of right arm on the night of 7/8/26. R1 was R1's usual self and had no complaints when V13, RN, last cared for R1 on 7/5/26 and 7/6/26, and V13, RN, was off work on 7/7/26. R1 did not fall when V13, RN, worked. R7 reported R1 had fallen but R1 never reported a fall to V13. On 8/11/26 at 9:42 AM, V12, Licensed Practical Nurse (LPN), stated: V12, LPN, and hospice questioned whether R1 had a fall that went unreported. V12, LPN, spoke with R1 and R7 who said R1 fell out of bed, allegedly two to three days prior. V12, LPN, spoke with staff and no one knew anything about a fall involving R1.On 8/11/26 at 2:49 PM, V14, LPN, stated: R1 had prior complaints of right arm pain but thought R1's increased pain was odd since R1 has limited movement and does not self-propel R1's wheelchair. R1 was guarded and flinched while attempting right arm range of motion. V14, LPN, later found out about R1's possible rib fracture and thought R1 meant rib pain when reporting right arm pain. No one had reported to V14, LPN, that R1 had a fall and V14 does not believe R1 fell as R1 does not move or squirm around a lot in bed. V14, LPN, speculates that something might have happened during a full mechanical lift transfer where R1 may have been scrunched up. V14, LPN, had not observed any concerns with R1's transfers, this is just speculation.On 8/11/26 at 12:40 PM, V2, DON, stated V2 did the investigation for R1's injury of unknown origin. V2 DON confirmed only nurses were interviewed for the investigation. V2, DON, stated it was determined R1 had an unwitnessed fall, no staff confirmed R1 had a fall, V2 just went by what R1 and R7 reported. V2, DON, stated V2 interviewed staff who worked two to three days prior to 7/11/26. V2, DON, confirmed V2 did not interview any CNAs to determine if R1 had a fall or any incidents that went unreported, and confirmed the facility uses agency nurses and CNAs.

Based on observation, interview, and record review, the facility failed to administer physician ordered nutritional supplements for one (R1) of three residents reviewed for weight loss in the sample list of 14 residents. Findings include:R1's Minimum Data Set, dated [DATE], documents R1 has severe cognitive impairment and R1 requires supervision/touch assistance of staff for eating. R1's Care Plan, dated 3/6/26, documents R1 has an expected significant weight loss due to disease process and is under hospice care. This Care Plan includes an intervention to administer nutritional supplements as ordered. R1's ongoing weight log documents R1's weight as follows:2/1/26 107.5 pounds (lbs.)4/7/26 109.3 lbs. 5/1/26 105.8 lbs.6/1/26 102.3 lbs.7/5/26 99.2 lbs.7/27/26 97.0 lbs.8/1/26 95.0 lbs. (11.63% loss in six months)8/5/26 96.4 lbs. R1's August 2026 Medication Administration Record (MAR) documents to give nutritional shake daily with breakfast for weight management and protein-calorie malnutrition. This order was implemented on 7/23/26 and is signed out by the nurses as given daily. On 8/10/26 at 12:52 PM, R1 was eating lunch in the dining room. V3, Certified Nursing Assistant (CNA), stated R1 receives a frozen nutritional supplement at meals and dietary staff serve the nutritional supplements and shakes with the meal trays. V4, CNA, stated R1 only gets a frozen nutritional supplement, no other supplements at meals, and R1 did not have a nutritional shake with breakfast.On 8/11/26 at 8:10 AM, R1 was eating breakfast in the dining room. R1's meal did not include a nutritional shake. At 8:40 AM, V4, CNA, had assisted R1 with breakfast and R1 was finished eating. R1's meal did not include a nutritional shake and R1's meal ticket did not list any nutritional shakes or supplements with breakfast, confirmed with V4 CNA.On 8/11/26 at 8:42 AM, V22, Dietary Manager (DM), stated nursing communicates new orders for nutritional supplements to the dietary department during the morning management meetings. V22, DM, stated dietary staff are notified and it is listed on the meal tickets, which is what dietary staff refer to when serving nutritional supplements. V22, DM, stated nutritional shakes are served by dietary staff with the meal tray. On 8/11/26 at 10:52 AM, V2, Director of Nursing, stated the nutritional shake was ordered for R1's weight loss. V2 confirmed the nutritional shake was ordered on 7/23/26 and to be given with breakfast. V2 stated dietary staff serve the nutritional shakes.

Based on observation, interview, and record review, the facility failed to have sufficient nurse staffing resulting in delayed medication administration for two (R1, R2) of five residents reviewed for sufficient staffing in the sample list of 14 residents. Findings include:The facility's Facility Assessment Tool, dated as updated 6/19/26, documents the 6:00 AM-6:00 PM shift is staffed with one Registered Nurse (RN) and two Licensed Practical Nurses (LPNs). The facility's Nursing Daily Schedule, dated 8/10/26, documents two of the three scheduled nurses called off, replaced with V2, Director of Nursing (DON), and V15, Assistant DON (ADON). On 8/10/26 between 7:50 AM-8:08 AM, there was no nurse on the dementia unit. V23, LPN, was the only other nurse working in the facility besides V2, DON. On 8/10/26 at 7:57 AM, V2, DON, was passing medications from the medication cart on the 400 hall. At 8:07 AM, V2 stated there are currently only two nurses working, the third nurse is on the way. V2 stated there were two call offs this morning.On 8/10/26 at 1:29 PM, V2, DON, stated V2 has to notify the physician that some medications were given late today. At 1:37 PM, V2 was still passing medications. V2 prepared R1's medications including Lactobacillus, Alprazolam 0.5 milligrams (mg), Artificial Tears, Fluticasone nasal spray, Omeprazole 20 mg, Senna 8.6 mg, Fiber 625 mg, Baclofen 10 mg, Citalopram 20 mg, Eliquis 2.5 mg, and Metoprolol 25 mg. The Electronic Medication Administration Record (EMAR) listed these medications in red, indicating late or past due administration. V2, DON, stated these were R1's morning medications and V2 notified V17, Nurse Practitioner, who gave permission to give the medications late and doses omitted if scheduled more than daily. R1's August 2026 Medication Administration Record (MAR) documents these medications are scheduled to be given lib b (liberalized breakfast) with additional doses of Fluticasone, Metoprolol, and Eliquis scheduled at lib d (liberalized dinner), and Baclofen scheduled at lib l (liberalized lunch) and lib d. This MAR with print date 8/10/26 at 12:05 PM does not document these medications were given yet. 2.) On 8/10/26 at 1:37 PM, V2, DON, stated R2 is the only diabetic resident on V2's assigned hall. V2 stated R2 has orders for sliding scale insulin three times daily and V2 has not gotten to R2 yet today. On 8/10/26 at 2:01 PM, R2 approached V2, DON, while V2 was preparing R4's medications. R2 asked V2 when R2 was going to receive R2's medications and R2 said R2 had not received any medications yet today. V2 stated V2 was going to have to notify the physician regarding R2's insulin. On 8/10/26 at 2:14 PM, V2, DON, prepared and administered R2's medications including Ferrous Sulfate 325 mg, vitamins, Baclofen 10 mg, Spironolactone 25 mg, and Tizanidine 2 mg. The EMAR listed these medications in red, as well as R2's insulin. V2 checked R2's blood glucose level, which was 532. At 2:26 PM, V2 called V24, Physician, reported V2 was behind with medication administration due to a nurse calling off, and reported R2's blood glucose level. V2 received orders to administer Insulin Aspart 50 units and recheck R2's blood glucose in an hour. R2's August 2026 MAR documents these medications were scheduled at lib b. This MAR documents Tizanidine is scheduled at lib b and lib d; Baclofen is scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM; and additional dose of Tizanidine at lib d; and Insulin Aspart per sliding scale at 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM. On 8/11/26 at 7:55 AM, V2, DON, stated V2 arrived to work yesterday around 7:00 AM and night shift had not stayed over to assist with medication administration. On 8/10/26 at 3:36 PM, V15, ADON, stated V15 was called in to work the floor and cover the dementia unit due to a call off 8/10/26. On 8/11/26 at 11:23 AM, V15 confirmed V15 arrived to work around 8:00 AM yesterday. The facility's Medication Administration Policy, dated January 2026, documents medications must be administered according to the physician's order, including the right time. The facility's Liberalized Medication Administration policy, dated December 2025, documents medications ordered for specific times will be given as such and lists the lib b times as 6:00AM-11:00AM, lib l as 12:00PM-3:00PM, and lib d as 4:00PM-7:00PM.

Based on observation, interview, and record review, the facility failed to administer medications timely resulting in missed doses of insulin for one (R2) of five residents reviewed for staffing in the sample list of 14 residents. Findings include:The facility's Medication Administration Policy, dated January 2026, documents medications must be administered according to the physician's order, including the right time. On 8/10/26 at 7:57 AM, V2, Director of Nursing (DON), was passing medications from the medication cart on the 400 hall. At 8:07 AM, V2 stated there are currently only two nurses working, the third nurse is on the way. V2 stated there were two call offs this morning.On 8/10/26 at 1:29 PM, V2, DON, stated V2 has to notify the physician that some medications were given late today. At 1:37 PM, V2 stated R2 is the only diabetic resident on V2's assigned hall. V2 stated R2 has orders for sliding scale insulin three times daily and V2 has not gotten to R2 yet today. On 8/10/26 at 2:01 PM, R2 approached V2, DON, while V2 was preparing R4's medications. R2 asked V2 when R2 was going to receive R2's medications as R2 had not received any medications yet today. V2 stated V2 was going to have to notify the physician regarding R2's insulin. On 8/10/26 at 2:14 PM, V2, DON, prepared R2's medications and the Electronic Medication Administration Record (EMAR) listed R2's medications in red (indicating late or past due), including R2's insulin. V2 checked R2's blood glucose level, which was 532. At 2:26 PM, V2 called V24, Physician, reported V2 was behind with medication administration due to a nurse calling off, and reported R2's blood glucose level. V2 received orders to administer Insulin Aspart 50 units and recheck R2's blood glucose in an hour. R2's August 2026 Medication Administration Record (MAR) documents Insulin Aspart 100 units per milliliter per sliding scale based on blood glucose checks ranging 150-500 scheduled at 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM, with the highest blood glucose as 499 and 20 units as the amount to administer for blood glucose of 500. This MAR does not document R2's morning and noon blood glucose checks or insulin administration on 8/10/26. This MAR lists R2's blood glucose of 523 with Insulin Aspart 50 units administered on 8/10/26 at 2:32 PM. R2's Nursing Note, dated 8/10/26 at 2:28 PM, documents V24 notified R2 missed breakfast and lunch insulin and received orders to administer 50 units.

Failures at this level required more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from sexual abuse by another resident, failed to identify repeated sexual predatory behaviors and implement interventions to address these behaviors for R9, resulting in psychosocial harm of R10 and R11, who voiced expressions of fear of R9, and resulted in R9 sexually abusing R5 and R15, for six (R5, R9, R10, R11, R15) of 14 residents reviewed for abuse in the sample list 20. These failures also put other residents in the facility at risk for psychosocial impact, including not limited to emotional harm, loss of dignity, and feeling afraid, as well as being at risk for further abuse from R9. The Immediate Jeopardy began on 6/11/26, when R9 was witnessed with R9's hand up underneath R5's shirt and R5 was not wearing a bra. V1, Administrator In Training, and V3, Regional Administrator, were notified of the Immediate Jeopardy on 7/1/26 at 10:53 AM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 7/7/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. B. Based on interview and record review, the facility failed to protect a resident's (R5) right to be free from sexual abuse by R4 and failed to protect a resident's (R2) right to be free from sexual exploitation and mental abuse by an employee (V32, Certified Nursing Assistant). R2 and R5 are two of 14 residents reviewed for abuse in a sample list of 20. These failures resulted in psychosocial harm of R5 and R2. A reasonable person would have feelings of fear and humiliation as a result of the abuse. Findings include: A. The facility's Abuse Prevention and Reporting policy, revised March 2026, documents the facility affirms the residents' right to be free from abuse and therefor prohibits abuse and mistreatment of residents. This policy documents abuse prevention measures including identifying, reporting, investigating occurrences and patterns of potential mistreatment and abuse. The Sexual Capacity to Consent Determination policy, dated January 2026, documents the following: Residents without the capacity to consent to sexual activity may not engage in sexual activity. The Interdisciplinary Team will assess and determine a resident's ability to consent to the sexual activity whenever there is an allegation of resident sexual abuse or other warranted situations. Sexual abuse is any non-consensual sexual contact with a resident, including unwanted intimate touching especially of breasts and perineal areas. The facility's Behavioral Health Services Program, dated March 2025, documents the purpose of the program is to establish a system to identify behaviors and implement appropriate interventions and individualized care plans to ensure each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. this policy documents to follow person-centered interventions as care planned, notify family and physician for changes in condition, administer medications as ordered, and monitor/document response to interventions. This policy documents if behaviors do not subside or pose a threat to themselves or others, implement one to one monitoring. This policy documents behaviors and interventions will be reviewed during the facility's daily or weekly clinical meetings. On 6/29/26 between 8:22 AM and 9:00 AM, during intermittent observations, there were no resident rooms with stop sign banners across doorways. R9 walked independently about the dementia hall and approached surveyor multiple times within personal space and R9 prompted to shake R9's hand. On 6/29/26 at 1:02 PM, R9 stated R9 has close friends in the facility but does not have any girlfriends. R9 stated R9 has not had anyone close like that since R9's wife passed away. R9 denied touching any female residents and was unable to provide any details regarding R9's behaviors. On 6/30/26 at 8:05 AM, R9 walked independently and wandered the dementia unit hall. R9 approached surveyor and R9 prompted to shake R9's hand. R9 attempted to remove a stop sign banner from R11's room doorway to enter and V4, Licensed Practical Nurse, redirected R9 away from R11's room. R11 was lying in bed at this time. R10's doorway contained the same banner barrier as R11's. V4, Licensed Practical Nurse (LPN), stated the banners were put up yesterday afternoon. On 6/30/26 at 8:08 AM, R10 stated R10 has had problems with another resident coming into R10's room, and R10 identified R9 by R9's name. R10 stated R10 tells R9 to get out of R10's room and R9 will just stand there, and R9 also goes into R10's friend's room (R11) located across the hall. R10 stated, He (R9) scares me. At this time, R10 approached R9's doorway. R10 pointed and identified R9 by name and R9 was the man R10 was referring to. On 6/30/26 at 8:18 AM, R11 did not recall any men coming into R11's room. The facility's Clinical and Order Alerts Listing Report, dated 6/1/26-6/29/26, documents:On 6/10/26 at 11:23 AM, R9 is getting more touching with female staff and residents if they don't shake R9's hand and R9 will grab shoulders and arms. At 11:25 AM, R9 is going into female resident rooms while staff is providing cares, enters while residents are getting dressed/undressed or using the bathroom.On 6/11/26 at 10:27 AM, R9 is entering female resident rooms while staff is providing cares. At 10:28 AM, R9 is watching other residents get dressed/undressed and when using the bathroom. At 10:29 AM, R9 is getting upset when female staff and residents won't shake R9's hand right away and will grab onto their shoulders and/or arm. On 6/24/26 at 5:32 PM, R9 has been going into female bathrooms while in use, redirected but R9 goes right back. R9 follows females into their rooms and refuses to leave when asked. R9's Minimum Data Set (MDS), dated [DATE], documents R9 is [AGE] years old, has severe cognitive impairment and requires supervision/touch assistance with transfers and walking. R9 had physical behaviors directed towards others 1-3 days, other behavioral symptoms not directed towards others 4-6 days, and wandering 4-6 days during the one-week review period. This MDS documents these behaviors do not significantly intrude on the privacy or activity of others. R9's Care Plan, dated 4/9/26, documents R9 wanders into other resident rooms with no new interventions to address this behavior since 2/19/25. R9's care plan does not address any sexual behaviors or behaviors directed towards female residents or interventions to address these behaviors. R9's diagnoses include Unspecified Dementia with Behavioral Disturbances. R9's active behavior tracking does not identify sexual behaviors or predatory behaviors directed towards female residents as R9's targeted behaviors. R9's Nursing Notes document the following: On 12/11/2025 at 10:37 PM R9 had to be redirected out of other resident rooms and will not stop going into them. An unidentified Certified Nursing Assistant (CNA) had to sit in the hallway to keep R9 from going into resident rooms who are sleeping. On 12/12/26 at 10:53 PM R9 had to be redirected out of other resident rooms numerous times while CNA was providing care/showers on another resident. R9 also attempted to lay another resident down in bed. R9 was educated R9 is not allowed to assist other residents and R9 laughed. On 12/29/2025 at 10:57 PM R9 continues to try to lay other residents in bed and R9 was educated. On 2/10/2026 at 11:39 PM R9 continues to go into other resident rooms and R9 attempted to get an unidentified female resident out of her bed after waking her up. R9 was redirected to the television room but then had to be redirected again after entering another resident room. On 4/16/2026 at 10:08 PM R9 was told numerous times to stay out of female resident rooms, R9 continued to go into the rooms waking residents up and attempting to assist a female resident into her wheelchair. R9 opened another female's door after this resident asked R9 to leave her alone, R9 was educated but laughs in your face and continues to do what R9 wants. R9's Progress Note, dated 5/27/26, recorded by V33, Nurse Practitioner, documents R9 as stable with no new behavioral concerns. There is no documentation that R9's intrusive and predatory sexual behaviors were reported to V33 or V18, Physician. R9's Progress Notes recorded by V34, Psychiatry NP, document the following: On 4/28/26 R9 continued to be restless wandering in and out of resident rooms and will touch residents' hands while they are sleeping. R9 was easily redirected but only effective for short duration. An additional dose of Lorazepam (antianxiety) was prescribed in the morning and to continue the scheduled evening dose. On 5/12/26 no medication adjustments were made. On 6/9/26 R9 paces the hallways and enters female resident rooms, and no medication adjustments were made. The facility's abuse log dated January-June 2026 does not document any allegations involving R9. R5's Census documents R5 admitted on [DATE] and discharged on 6/26/26. R5's MDS, dated [DATE], documents R5 has severe cognitive impairment and a diagnosis of Unspecified Dementia with Behavioral Disturbances. R5 wandered daily during the one-week review period. R10's MDS, dated [DATE], documents R10 has moderate cognitive impairment and a diagnosis of Dementia. R10's Care Plan, dated 6/1/26, documents trauma informed care R10 experienced a traumatic event/circumstances of sexual assault when R10 was younger and R10 is at low risk of abuse/neglect per screening. Interventions include to provide a safe and secure environment and emotional support and evaluate interventions. R11's MDS, dated [DATE], documents R11 has moderate cognitive impairment and a diagnosis of Alzheimer's Disease. R11's Nursing Note, dated 4/16/2026 at 10:22 PM, documents R11 was upset that male resident would not leave R11 alone, R11 pacing in hallway then went to lay in bed and male resident opened R11's door, R11 came out and began pacing again and told male resident to stop bothering R11 but male resident continued until CNA and nurse intervened and went to lay down in his bed. R15's Census documents R15 admitted on [DATE] and expired on 5/28/26. R15's MDS, dated [DATE], documents R15 had severe cognitive impairment and required substantial maximal staff assistance for transfers and bed mobility. R15's Care Plan, dated 6/1/26, documents R15 at high risk for abuse/neglect per screening. On 6/29/26 at 11:44 AM, V8, Certified Nursing Assistant/CNA, stated the following: V8 and V17 have reported R9's behaviors of going into female resident rooms R10 and R11, watching them undress and go to the bathroom, and R10 has expressed fear of R9. R9 sneaks in and watches staff when providing cares. Management, including V2, Director of Nursing/DON just tells us not to chart like that and to redirect R9. R9 has not been put on one to one or increased monitoring. Around 4-5:00 PM on 6/11/26, V8 found R5 and R9 in R9's room with the door shut. R9 had his hand up underneath R5's shirt and R5 was not wearing a bra. R5 was pretty confused and unable to consent to this. R5 was crying at the time of the incident; R5 cries only when R5 is upset about something. V8 removed R5 from R9's room. V24, Social Services called and asked V8 about the incident later that week. V8 stated these behaviors have been reported to the nurses as well as V1, Administrator in Training, and V3, Regional Administrator. V8 considered these behaviors as abuse. On 6/30/26 at 8:30 AM, V16, CNA, stated the following: V16 has worked in the facility since October and was told R9 had tried to undress R15, sometime prior to V16's employment. R9 likes to be physical with women, rubs staff's backs, and is persistent. R9 has to be watched closely at all times because R9 would try to get R15 out of bed. R10 has come to V16 to report R9 was in R10's bathroom and R11 has reported R9 standing over R11's bed watching R11. R10 will sit in the television room and has told V16 that R10 is uncomfortable with R9 being here and R10 wishes R9 wasn't here. R11 has yelled at R9 a few times to get R9 to leave R11 alone. R9 only goes into female resident rooms. These behaviors make V16 feel uncomfortable and management is aware of R9's behaviors. When staff try to chart these behaviors, management tells staff not to chart that way, or not to use certain words that make R9 sound like a predator. On 6/30/26 at 1:00 PM, V17, CNA, stated the following: R9 has a particular fascination with female residents, especially R10 and R11, including watching R11 and following R11 into the bathroom; and R10 has said R10 is afraid of R9 as R10 has woke up and found R9 standing over R10's bed and R9 has followed R10 into the bathroom. R9 waits to see if staff are watching and then enters these rooms when staff aren't looking and R9 does not do anything when staff are watching. Staff try to redirect R9, and V1 and V2 are aware of these behaviors. All the staff on the memory care unit know about R9's behaviors and talk about it. R9 has consistently had these behaviors since R9 admitted to the unit. Stop sign banners were supposed to be put across resident room doorways a long time ago but that hasn't happened yet. V17 doesn't think it is right that these female residents should have to put up with R9's predatory behaviors. R9 seems more alert than the other residents on the unit, and V17 heard that R9 was found with R9's hand up a female resident's shirt. It is frustrating that no one has listened to the staff regarding R9's behaviors and V17 has worried about this. The CNAs just try to watch R9 closely. V24, Social Services Director, was aware of R9's behaviors as V24 even came to the unit to watch R9 about a month ago. On 6/30/26 at 3:33 PM, V19, Licensed Practical Nurse/LPN, stated R9 goes specifically into female resident rooms even when staff are providing cares. V19 confirmed R9 has been caught watching female residents undress and toilet. V19 stated R9 used to go into R15's room all the time, R9 is touchy/feely, and would rub R15's upper arm and back, once near R15's breasts, which was reported to the former Administrator, V66, and former DON, who said they would investigate it. V19 stated V19 documented this in a nursing note and was unable to recall when this occurred. V19 stated V2 and V3 were also aware of these behaviors. V19 stated staff just try to keep an eye on R9 or have R9 sit in the television room or dining room, but R9 has not had one to one supervision or 15-minute checks in place. V19 stated R9 goes into R11's room and V19 had to get R9 out because R9 thought it was funny even though R11 was begging R9 to leave R11 alone. V19 stated R11 told V19 that R11 is afraid of R9, but due to R11's short term memory loss, R11 forgets this within 15 minutes. On 6/29/26 at 1:05 PM, V24, Social Services Director, stated R9 wanders the hall and into resident rooms. R9 likes to take care of the ladies, as R9 used to take care of R9's mother. V24 was unaware of R9 touching other residents besides handshakes and was unaware of R9 going into female resident rooms watching them undress or toilet. V24 stated V24 was not aware R9 had R9's hand underneath R5's shirt and that is something that would need to be immediately reported to the Administrator. On 6/29/26 at 3:12 PM, V2, DON, stated R9 wanders all around the unit and wants to shake hands. V2 stated V2 just found out today about R9's behaviors, as V2 was not aware R9 was watching female residents undress and use the toilet, or that R9 had his hand up R5's shirt. V2 stated this should have been care planned and medication reviewed as follow up to these behaviors/allegations. On 6/30/26 at 10:12 AM, V2 stated R9's behaviors should have been reported to nursing, R9's physician, and psychiatry. V2 stated V24, Social Services Director, should be reviewing the dashboard alerts and discussing behaviors as part of the interdisciplinary team meetings, as V2 does not review those alerts. V2 stated behavior tracking should be targeted with more specific behaviors, which is documented in the tasks section of the resident's electronic medical record. On 6/29/26 at 2:08 PM, V1 and V3 both stated nothing had been reported to them about R9's behaviors of watching female resident undress and toilet or touching female residents inappropriately. V1 and V3 stated the allegation of R9 having his hand up R5's shirt was reported today by V24. At 3:45 PM, V3 provided the facility's Sexuality Capacity to Consent Determination policy. V3 stated an assessment for capacity to consent is only completed when a resident desires to have a sexual relationship with another resident, not when it involves Dementia and resident to resident allegations. V3 stated in this case, neither R4 nor R5 have the ability to consent to sexual activity. On 7/1/26 at 8:56 AM, V3, Regional Administrator, stated R9 admitted to the facility from the hospital after being found riding a bicycle around town wandering and confused after R9's mother passed away. V3 stated R9 was the caregiver for R9's mother and R15 resembled R9's mother. V3 stated V66 (Former Administrator) was the facility's Administrator a year ago. V3 was not aware of any prior abuse allegations involving R9 and V3 will check the abuse allegation files. At 9:04 AM, V3 stated there was only one allegation involving R9, which was staff to resident verbal abuse regarding food. On 6/30/26 at 10:20 AM, V20, MDS/Care Plan Coordinator, confirmed R9's care plan does not address R9's behaviors directed towards female residents including watching them undress or toilet and touching them inappropriately. V20 stated V20 was not made aware of R9's behaviors until yesterday. On 6/30/26 at 11:35 AM, V18, Physician, stated V18 believes V18 was notified during rounds of R9's behaviors of going into female resident rooms watching them undress/toilet, but V18 was not aware of R9 touching residents. V18 stated V18 does not manage this and would have deferred to psychiatry services as they handle that. On 7/1/26 at 8:58 AM, V33, NP, stated V33 was not aware of R9's behaviors. On 7/1/26 at 11:36 AM, V34, Psychiatry NP, stated V34 is in the facility every other week and R9's behaviors included going into other resident rooms to take care of them, and more recently, going into female resident rooms and grabbing onto them which was scaring these residents. V34 stated these behaviors were reported to V34 about a month or two ago. V34 described R9 as being unaware of what R9 is doing due to Dementia. V34 was unaware of R9's behaviors of watching female residents undress or using the bathroom. V34 stated these behaviors would be considered sexual inhibition secondary to Dementia and V34 questions if R9 has underlying developmental disability which may also be contributing. V34 stated V34 last evaluated R9 on 6/9/26 and V34 had last made adjustments in R9's medications on 4/28/26. V34 stated if V34 was notified of R9's sexual inhibitions, V34 would have consulted with the psychiatrist and increased Seroquel (antipsychotic) and Lexapro (antidepressant). V34 stated the facility should implement interventions such as placing signs on the door and increasing supervision and frequency of monitoring to watch R9 and redirect R9 away from female resident rooms. On 6/30/26 at 9:56 AM, V22 (R5's Power of Attorney) stated R5 was only at the facility a few weeks for therapy, R5 has Dementia with short term memory loss and poor recall and R5 is mostly nonverbal. V22 stated R5 would not be able to consent to being touched or able to indicate no. R5 was probably not even aware of the situation or that it happened. On 6/30/26 at 9:56 AM, V22 (R5's Power of Attorney) stated R5 was at the facility only for a couple weeks to receive therapy. R5 has Dementia with short term memory loss and poor recall and R5 is mostly nonverbal. V22 stated R5 wouldn't be able to consent to being touched or be able to indicate no and R5 probably wasn't even aware of the situation. V22 stated if R5 did not have Dementia, R5 used to be feisty and would have fought the resident off. The Immediate Jeopardy that began on 6/11/26 was removed on 7/7/26 when the facility took the following actions to remove the immediacy: 1. On 7/1/26, R9 was placed on continuous one-to-one supervision while awake (and additional supervision during sleeping hours as clinically indicated) until a comprehensive interdisciplinary assessment determined appropriate long-term interventions. Completed by V2, DON. 2. On 7/2/26, V2 notified R9's physician and responsible party were immediately notified of the behavioral concerns and protective interventions. 3. V24, SSD, requested a psychiatric consultation and behavioral health evaluation for R9 on an urgent basis on 6/30/26. V34, Psychiatry NP, evaluated R9's sexually inappropriate behaviors and adjusted R9's medications on 7/2/26. 4. V24 completed psychosocial assessments, provided emotional support, and updated care plans with protective interventions for R10 and R11 on 7/2/26. V2 notified R10's and R11's physicians on 7/2/26. V20 MDS/Care Plan Coordinator completed Skin Assessments for R10 and R11 on 7/1/26. 5. On 7/6/26, V24 completed a facility wide review of behavior tracking to identify residents exhibiting sexually inappropriate, sexually intrusive, aggressive, or predatory behaviors and each identified resident had an interdisciplinary behavioral assessment to determine risk to other residents and care plans were updated with interventions to include individualized supervision, monitoring, environmental controls, behavioral interventions, and staff response expectations. 6. On 7/1/26 V2, V20 and V49, Assistant DON, completed head to toe assessments for all residents with Brief Interview for Mental Status (BIMs) score of less than 11. 7. Residents with a BIMs score of 11 or greater were interviewed by V1 and V24 regarding abuse to include sexual abuse. Completed on 7/6/26. 8. V24 interviewed resident family members for all residents with a BIMS of 11 and below were interviewed regarding abuse and safety on 7/1/26. 9. On 7/2/26, V24 completed abuse and neglect screenings for all residents with BIMs of less than 11 and updated their care plans with abuse risk level, and supervision and protective measures on 7/6/26. 10. On 7/1/26, the interdisciplinary team (IDT) consisting of V1, V2, V24, and V49 were in-serviced by V3 to conduct daily review of all behavioral incidents at the morning clinical meeting to ensure timely intervention, implementation of resident-specific protective measures, timely investigation, physician notification, care plan updates, abuse policy implementation, identification of sexual abuse and repeated sexual predatory behaviors. V3 and V24 confirmed this daily review was not completed until 7/6/26. 11. On 7/1/26 V1 and V3 initiated staff education on the abuse policy with focus to: Prevention of resident-to-resident abuse. Recognition of sexually inappropriate and predatory behaviors. Immediate intervention requirements. Mandatory reporting requirements. Documentation expectations. Resident supervision responsibilities. Individualized behavioral interventions. Staff members and contracted agency staff who were not present during the initial education will receive the training before working next shift provided by V1, V2 or designee for facility staff in person or by phone until 100% completion is obtained. Education will be provided to contracted agency for completion prior to the provider assigning shift. V1 verified staff were allowed to work between 7/1/26 and 7/6/26 without receiving this training, however as of 7/7/26 no additional staff worked without receipt of the training and V1 verified education will be ongoing for all agency staff prior to working. 12. V24 or designee will conduct rounds five times per week for 12 weeks on various shifts for all residents identified with sexually inappropriate or aggressive behaviors to verify required supervision and interventions are being implemented. V24 initiated these audits on 7/2/26. 13. V3, V65 Regional Nurse Consultant or designee will complete audits five times per week for 12 weeks then as determined by the Quality Assurance and Performance Improvement Committee to ensure continued compliance. These audits were initiated by V1 on 7/2/26. 14. V1 or designee will interview five residents per week for 12 weeks to ensure residents feel safe and have no abuse concerns. These audits were initiated by V1 on 7/2/26. 15. V1 or designee will use an audit tool related to Abuse/Abuse Reporting/Investigating and interview five staff members per week for 12 weeks to ensure staff know reporting requirements. V1 initiated these audits on 7/1/26 but did not complete the audit tool until 7/6/26. 16. The facility held a Quality Assurance meeting and reviewed the components of F600 immediate jeopardy on 7/1/26 with V67 [NAME] President of Clinical Services, V61 Chief Nursing Officer, V18 Medical Director, V3 Regional Administrator/Director of Operations, V68 Director of Social Services and Activities, V1 Administrator in Training, V2, V24, and V49. B1) The facility's Abuse Prevention and Reporting policy, revised March 2026, documents the facility affirms the residents' right to be free from abuse and therefor prohibits abuse and mistreatment of residents. This policy documents sexual abuse includes sexual harassment, sexual coercion, sexual assault, including non-consensual or non-competent to consent to sexual activity; mental abuse includes humiliation, harassment, threats of punishment or deprivation; and exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. This policy documents it is strictly prohibited for staff to photograph or record residents or their private space for other than medical or facility purposes, including sending recordings through multimedia messaging or social media, and this will be considered an allegation of abuse. The facility's Final Abuse Investigation Report, dated 6/24/26, documents the following: V1, Administrator in Training, was notified of an allegation of sexual abuse of R5 by R4 on 6/17/26 at approximately 7:10AM. The Certified Nursing Assistant (CNA V7) stated V7 briefly stepped away from the dining room and upon returning V7 observed R4 seated in a wheelchair with R4's hand inside the front waistband of R5's pants who was standing. R5's Census documents R5 admitted on [DATE] and discharged on 6/26/26. R5's Minimum Data Set (MDS), dated [DATE], documents R5 has severe cognitive impairment and a diagnosis of Unspecified Dementia with Behavioral Disturbances. R5 wandered daily during the one-week review period. R4's MDS, dated [DATE], documents R4 has severe cognitive impairment. R4's Care Plan, dated 12/1/25, documents R4 has Alzheimer's disease and has behaviors of saying inappropriate things and being verbally aggressive to staff. R4's Psychiatry Progress Notes, dated 4/28/26 and 5/12/26, document R4 has sexually inappropriate behaviors. R4's Psychiatry Progress note, dated 6/9/26, documents staff reported concerns that R4 is making more sexual remarks and attempting to touch female staff during care. On 6/29/26 at 8:41 AM, V7, CNA, stated V7 witnessed the incident between R4 and R5 about a week ago, it was in the dining room just before breakfast. V7 went into the dining room to get trays and caught R4 with his hand down inside R5's pants and incontinence brief with palm up. R4 was seated and R5 was standing next to R4. R5 had no reaction and did not seem aware of what was going on. R4 is very hands on and likes to grab at staff and make sexual remarks. There was no other staff present in the dining room when this incident occurred. On 6/29/26 at 10:36 AM, V28, Registered Nurse, stated V7 reported to V28 that R4 and R5 were in the dining room and R4 had his hand down R5's pants. V28 stated V28 did a full assessment for R5, who was unable to communicate that anything had happened. V28 described R4 as alert/oriented to person, place and occasionally time, R4 knows right from wrong and is able to follow commands. V28 stated R4 is more cognitively intact and R5 does not have the capacity to consent to sexual activity/touch. V28 stated R4 has been verbally sexually inappropriate towards staff but not towards residents prior to this incident. On 6/30/26 at 9:56 AM, V22 (R5's Power of Attorney) stated it was reported that a few weeks ago a male resident (R4) was found with his hand inside R5's pants. V22 stated R5 has Dementia with short term memory loss and poor recall and R5 is mostly nonverbal. V22 stated R5 wouldn't be able to consent to being touched or be able to indicate no and R5 probably wasn't even aware of the situation. V22 stated if R5 did not have Dementia, R5 used to be feisty and would have fought the resident off. B2) The facility's abuse investigation, initially reported on 5/3/2026 at 4:09 PM, and the final investigation report submitted on 5/7/2026 at 4:08 PM documented an allegation that V32, Certified Nurse Aide (CNA), conducted a video call showing R2 during resident care. On 7/1/2026 at 9:31 AM, V31, Certified Nurse's Aide (CNA), stated that while assisting V32 with providing incontinent care to R2, V32 entered R2's room carrying a personal cellular phone. V31 stated V32 propped the phone against a stereo on the dresser and observed that the phone was engaged in a video call. During the provision of incontinent care, R2's back and buttocks were exposed and visible to the phone. V31 stated V32 told V31 that a friend wanted to become a CNA, and V32 showed the friend what the job was like. On 7/1/2026 at 1:16 PM, V37, R2's guardian, V37 stated R2 would not have wanted someone outside of R2's care to see R2's back and buttocks and that, prior to R2's cognitive decline, R2 was able to communicate R2's wishes. V37 stated the incident was unprofessional and unethical. On 7/1/2026 at 12:55 PM, V3, Regional Administrator, stated V31 reported observing V32 place her phone on a stereo in R2's room. V3 stated the facility expectation is that personal cell phones are not used in resident care areas.

Based on observation, interview, and record review, the facility failed to ensure a resident (R1) was free from physical restraints applied for staff convenience; failed to assess for the use of physical restraints; failed to identify the specific medical symptoms justifying the use of a physical restraint; failed to notify the resident's representative; and failed to obtain a physician's order for physical restraints for one (R1) of three residents reviewed for restraints in the sample of 20. These failures put R1 at risk for psychosocial impact that includes but is not limited to emotional harm, dehumanization, pain, loss of dignity, self-respect, feeling of imprisonment, increased agitation and restlessness and at risk for serious physical injury. The Immediate Jeopardy began on 6/11/26 at approximately 5:30 PM, when R1 was found sitting in the nurse's station in R1's wheelchair with a bed sheet that was rolled linear across R1's torso and tied behind R1's wheelchair, out of R1's reach, restricting R1 from getting out of R1's wheelchair. R1 also had on two hospital gowns, one frontward and one backward, which were tied behind R1 and restricted R1 from moving R1's arms as R1's arms were not through the sleeves. R1 was agitated as R1 tried to get his arms free. V1, Administrator in Training, and V3, Regional Administrator, were notified of the Immediate Jeopardy on 7/1/26. at 10:08 AM, the surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 7/7/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:The facility's Restraints policy, revised May 2018, documents the following: Physical Restraints are any manual method, device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement to normal access to one's body. Examples of restraints include vests or arm restraints the resident cannot easily remove and also may include tucking in or using fasteners to hold a sheet/fabric/clothing tightly which restricts a resident's movement, placing a resident in a chair that prevents a resident from rising. Residents with restraints shall have a physician's order, initial and quarterly assessments, and less restrictive interventions implemented prior to restraint use. The facility prohibits the use of restraints for discipline or convenience, and limits restraint use for management of medical symptoms that warrant the use of restraints. The facility's Abuse Prevention and Reporting policy, revised March 2026, documents abuse preventative measures includes assuring physical restraints are used sparingly and properly. R1's Minimum Data Set, dated [DATE], documents R1 has severe cognitive impairment, behaviors not directed towards others noted 4 to 6 days out of the 7 day review period, R1 did not use any physical restraints, and R1 required dependence on staff for transfers. R1's Care Plan does not identify any physical restraint use or interventions. R1's active Care Plan documents the following: R1 has Alzheimer's Disease, Anxiety Disorder, and transfers with one to two staff assist and gait belt. R1 can be agitated, physically aggressive towards staff and removes R1's clothing. R1 is at risk for falls and has poor safety awareness. Interventions include increased supervision when in common areas due to impulsiveness. The facility's Final Abuse Investigative Report, dated 6/16/26, documents the following: On 6/11/26 a staff to resident (R1) abuse allegation was reported. An unidentified Certified Nursing Assistant (CNA) was interviewed and reported being asked to watch R1 because R1 kept trying to get up from R1's chair, R1 was agitated and weak, and R1 could not stand up but kept trying. This CNA noticed a sheet tucked around R1 and the wheelchair, and two CNAs took R1 to be laid down in bed. The facility concluded based on staff interviews R1 experienced episodes of agitation and staff responded appropriately by providing one to one supervision until R1 could be laid down. The alleged abuse incident report, dated 6/11/26 for R1's abuse allegation, documents staff notified V3, Regional Administrator, that R1 had a sheet secured around R1's waist and wheelchair. This report does not document V30, R1's Power of Attorney, was notified of this allegation. This report documents a nurse statement, dated 6/11/26, as having two admissions who weren't doing well, R1 was weak and kept trying to get up, the nurse was next to R1 the entire time and asked a CNA to watch R1 so the nurse could take a break. The nurse securely tucked a sheet around R1's waist and chair. This report documents a CNA statement, dated 6/11/26, as being called by the nurse to sit with R1, and it took a few minutes for the CNAs to finish helping another resident. The CNAs walked into the room and found R1 tied to a chair and the other CNA said nice illegal restraint to the nurse. The nurse responded it was going to be undone when the nurse was done with her work, and the nurse wasn't going to keep R1 tied there. The CNAs untied R1 from the chair and assisted R1 to bed. The nurse also had R1 double gowned restricting R1 from using R1's hands as R1 normally does. Another CNA interview, dated 6/15/26, documents the same description as the 6/11/26 CNA interview, and mentions the nurse had her legs over R1's legs. The Corrective Action Form, dated 6/15/26, documents a verbal warning was given to V4, Licensed Practical Nurse (LPN), for misconduct regarding an incident on 6/11/26 at 4:20 PM that occurred on the facility's dementia unit/hall. This form documents it was reported that V4 failed to follow employee conduct in accordance with the facility's handbook and failed to follow safety policies, rules, or practices. R1's electronic medical record (EMR) does not document a physician's order for restraints prior to 6/29/26, an assessment for physical restraint use, medical symptoms justifying restraint use or alternative less restrictive measures implemented prior to restraint use. R1's electronic medical record does not document V30 was notified regarding restraint use to obtain consent for use or notified of the staff to resident abuse allegation on 6/11/26. R1's Physician Order, with created date of 6/29/26, documents an order for a soft restraint, release every hour and at meals with start date 6/12/26. This order was entered by V4, LPN, and documents V18, Physician, as the prescriber. R1's Physician Order, created 6/29/26 by V2, Director of Nursing, documents an order for a soft restraint, release every hour and at meals, with start date 6/11/26. This order documents V18 as the prescriber. These orders do not specify what device is used as the soft restraint. On 6/29/26 at 1:13 PM, R1 was self-propelling his wheelchair down the dementia unit hallway. R1 stood from his wheelchair and took a few steps. V5, CNA, instructed and assisted R1 to sit back down in the wheelchair. Attempts were made to interview R1 who was confused and did not respond to questions. On 6/29/26 at 11:10 AM, V4, LPN, was working on the dementia unit where R1 resides. V4 stated prior to R1's recent fall (6/5/26), R1 was impulsive with transfers and walking, R1 has weak and unsteady gait, and requires staff to walk with R1. V4 stated staff have to almost be right there to catch R1, R1 is still impulsive with transfers requiring close supervision and monitoring, and V4 feels like R1 needs a (lap cushion that loops through wheelchair arm rests). At 12:12 PM, V4 stated V4 did not have R1 tied up, V4 had a sheet across R1's lap that was tucked in at the side of R1's wheelchair, not tied, which was to help R1 feel the comfort of the blanket rather than trying to stand. V4 stated R1 had only one hospital gown on that was applied and tied normally. On 6/29/26 at 11:29 AM, V5, CNA, stated on 6/11/26, R1 returned from the hospital and at approximately 5:30 PM, V4 came out of the dementia unit nurses' station asking V5 and V8 CNA to watch R1 so V4 could take a break. V5 stated R1 was found sitting in a wheelchair with a sheet rolled linear across R1's torso and tied behind R1's wheelchair, out of R1's reach preventing R1 from getting out of the wheelchair. V5 stated R1 also had two hospital gowns on, one frontward and one backward, which were tied keeping R1's arms down and restricting movement as R1's arms were not through the sleeves. V5 was unsure how long R1 had been like that as V4 had been in the nurse's station with R1 with the door closed for about 30 minutes prior. V5 and V8 immediately removed the restraints and assisted R1 to bed and reported this to V1, Administrator in Training, at approximately 6:00 PM. On 6/29/26 at 11:44 AM, V8, CNA, described R1 as being restrained by V4 in the same way as described by V5. V8 stated V8 was unsure how long R1 had been restrained as V4 had been with R1 in the nurses' station with the door closed for 30 minutes prior. V8 stated V8 told V4 this was an illegal restraint, V8 considered this abuse and reported this immediately to V1 and then V3, Regional Administrator. V8 stated R1 was pretty annoyed and agitated as R1 was trying to get his hands free. V8 stated prior to this, V4 was sitting with her foot on R1's lap preventing R1 from standing and V4 has done this a few times before. On 6/29/26 at 2:08 PM, V3 stated R1 returned from the hospital during mealtime, R1 was not doing well, he was a mover and wanderer, and staff were trying to keep R1 busy so the staff could pass meal trays. V3 stated V3 was told V4 had a sheet draped across R1's lap, V8 reported the sheet was tied but V4 reported it wasn't. V3 stated whether the sheet was tied or not, R1 was in the restraint for less than two hours. V3 stated V3 would refer to the facility's restraint policy, but there should be a physician's order, skin checks, and that it is used appropriately. V3 stated there should be an assessment for restraints documented in the assessments section of the resident's EMR. V3 stated and V3 completed the initial report and handed the allegation over for V1 to complete the investigation. V1 stated V1 spoke to V4 who had two admissions that weren't doing well, V4 asked the CNAs to watch R1 so V4 could take a break, and V4 tucked a sheet around R1's waist and wheelchair. V1 stated V4 denied having the sheet tied or R1 double gowned. V1 stated V1 spoke to V8 and V5 who reported finding R1 tied to his wheelchair and double gowned by V4 so that R1 couldn't use R1's hands. V3 stated a physical restraint was in place as ordered so abuse was not substantiated. On 6/29/26 at 3:12 PM, V2, Director of Nursing, stated V2 was working the floor the day of R1's allegation and V2 was not involved in the investigation of this incident. V2 stated R1 had no prior order or assessments for restraints. On 6/30/26 at 10:12 AM, V2 stated restraints need consents from both the physician and the resident's family, which would be documented in the nursing notes. V2 stated the physician's order should specify the type of restraint used and confirmed it would not be acceptable or appropriate to use a sheet or hospital gown as a restraint. On 6/30/26 at 9:05 AM, V30 stated R1 has had several falls and requires assistance of two staff for walking. V30 stated the hospital had R1 in restraints but no one at the facility had contacted V30 about using restraints. V30 stated V30 was not aware of the allegation that a nurse had tied a sheet to R1's wheelchair or gowns used to restrict R1's movement. V30 stated if that happened it would have made R1 agitated. On 6/30/26 at 11:35 AM, V18, Physician, stated V18 was not made aware of R1's restraints until after the incident. V18 stated V18 had not given any orders to use restraints for R1 and would only order physical restraints if a resident were violent, otherwise V18 gives referral for psychiatry services to address behavioral needs. V18 stated the facility should be following its restraint policy and use the appropriate restraint devices which should be outlined in the policy. V18 stated restraints used in this manner (as described per R1's allegation) could cause increased confusion, agitation and risk for injury. The Immediate Jeopardy that began on 6/11/26 was removed on 7/7/26 when the facility took the following actions to remove the immediacy:R1's alleged restraint was removed on 6/11/26 by V5 and V8. On 7/2/26, V2 completed a Restraint Evaluation for R1. V1 and V3 interviewed V4, V5, and V8 on 6/11/26 and 6/15/26. R1 was assessed for physical/psychosocial effects by V49, Assistant Director of Nursing, on 6/11/26. R1's pain was assessed on 6/11/26 by V2. V18, R1's physician, was notified on 6/11/26 by V3. V30, R1's Power of Attorney, was notified on 7/6/26 by V3. On 7/1/26 V20 MDS/Care Plan Coordinator updated R1's care plan with individualized interventions to address R1's behaviors.V1 suspended V4 on 6/11/26 pending the investigation. V4 was given a verbal warning and education on the facility's restraint and abuse policy on 6/15/26 by V1 and V3. All residents currently in-house had completed skin assessments and observation for restraint use completed by V2, V20, and V49, Assistant Director of Nursing on 7/1/26. Family members of residents with Brief Interview for Mental Status score of 11 and below for all residents in-house were interviewed regarding abuse on 7/1/26 by V24 Social Services and V54 Medical Records.V24 completed abuse/neglect risk screening for all in-house residents on 7/1/26 and care plans were updated on 7/6/26. V1 and V3 initiated abuse and restraint in-service/education for all staff on 7/1/26. Staff members and contracted agency staff who were not present during the initial education will receive the training before working next shift provided by V1, V2 or designee for facility staff in person or by phone until 100% completion is obtained. Education will be provided to contracted agency for completion prior to the provider assigning shift. V1 verified staff were allowed to work between 7/1/26 and 7/6/26 without receiving this training, however as of 7/7/26 no additional staff worked without receipt of the training and V1 verified education will be ongoing for all agency staff prior to working. V1 verified staff who had not received this training worked between 7/1/26 and 7/6/26. Additional training was provided on 7/6/26 and as of 7/7/26 no additional staff worked without receipt of the training. V1 verified education will be ongoing for all agency staff prior to working. Facility Administrator or Designee will interview 5 residents per week for 12 weeks to ensure residents feel safe and have no concerns with abuse. These audits were initiated by V1 on 7/2/26. V1 or designee will use an audit tool related to Abuse/Abuse Reporting/Investigating and interview five staff members per week for 12 weeks to ensure staff know reporting requirements. V1 initiated these audits on 7/1/26 but did not complete the audit tool until 7/6/26. The facility held a Quality Assurance meeting and reviewed the components of F604 immediate jeopardy on 7/1/26 with V67 [NAME] President of Clinical Services, V61,Chief Nursing Officer, V18, Medical Director, V3, Regional Administrator/Director of Operations, V68, Director of Social Services and Activities, V1, Administrator in Training, V2, V24, and V49.

Based on observation, interview, and record review the facility failed to ensure a resident was free from chemical restraints, failed to implement and document individualized non-pharmacological interventions prior to psychotropic medication administration, and failed to administer medications according to physician's orders for one of three residents (R1) reviewed for unnecessary medications in the sample list of 20. This failure resulted in R1 sustaining a fall resulting in an acute subdural hematoma.Findings include:On 6/30/26 at 1:06 PM, R1 was lying in bed on R1's right side. The bed was in the lowest position, and a fall mat was positioned next to the bed.R1's admission Record, dated 2/20/26, documents R1 has diagnoses that include, but are not limited to Alzheimer's Disease, Generalized Anxiety Disorder, Mood Disorder, and Repeated Falls.R1's Minimum Data Set, dated [DATE], documents R1 is severely cognitively impaired.On 6/30/26 at 1:17 PM, V16, Certified Nursing Assistant (CNA), stated R1 rummages, attempts to fix items on the wall, and wanders into other residents' rooms. V16 reported when R1 first arrived at the facility, R1 was hostile toward staff due to frustration with a loss of independence. V16 stated R1 did not rest during the day and had no consistent sleep pattern, describing R1 as very active.On 6/30/26 at 1:20 PM, V5, CNA, stated R1's behavior varied depending on the situation. V5 reported R1 frequently attempted to get up and down, describing R1 as a busy body who was always on the go and could be redirected. V5 stated R1 did not have a sleep pattern. V5 also stated aggression toward others had not been personally observed, but V5 had heard that R1 had hit staff within the past few months.On 7/1/26 at 12:27 PM, V17, CNA, stated V17 had never seen any behaviors from R1 that were out of the ordinary. V17 reported R1 wanders frequently and attempts to stand up often, which V17 described as confusion rather than a behavioral concern. V17 stated when R1 was first admitted , R1 would kick and say rude things to staff, but R1 appeared to acclimate over time. V17 stated offering a snack or an activity usually occupied R1 and that R1 enjoyed having R1's back scratched.On 7/1/26 at 1:59 PM, V24, Social Services Director (SSD), stated R1 is impulsive. V24 reported R1 likes to tinker and fix things and attempts to stand up repeatedly despite weakness related to health concerns. When R1 was ambulatory, R1 would walk and roam the hallway. V24 reported when R1 was first admitted , R1 would sometimes disrobe and attempt to remove clothing, such as pants. V24 stated R1 can become agitated during care and may appear irritated or on edge when staff are providing care. V24 stated R1 has never been a harm to themself or others.On 7/1/26 at 4:29 PM, V19, Licensed Practical Nurse (LPN), stated upon R1's admission, the resident displayed significant behavioral concerns. R1 would hit and attempt to bite staff, wander throughout the unit, and try to fix items in the environment. According to V19, attempts to redirect R1 often resulted in biting, kicking, or spitting at staff. V19 reported R1 did not have any sleep supportive medications upon admission and demonstrated an extremely irregular sleep pattern, sometimes remaining awake for 48 to 72 hours, followed by sleeping for an entire day. V19 stated a tramadol order was eventually initiated and believed it was helpful, suspecting R1 was experiencing unexpressed pain. V19 stated R1's behaviors typically improved after tramadol administration. V19 further reported based on V19's experience, Lorazepam is not effective for elderly residents with dementia and R1's behaviors appeared to worsen when Lorazepam was administered.R1's Encounter Note, dated 5/12/26, documents R1 had increased agitation, physical combativeness, exit-seeking behaviors, and sleep disturbance. Staff reported R1 was up all night and restless. It further documents R1 appeared drowsy and asleep at the time of the encounter. This encounter note goes on to document, to address the current instability and history of six falls since admission, an as needed (PRN) dose of Lorazepam (anti anxiety) 0.25 milligrams (mg) was added to R1's scheduled BID (twice a day) regimen and the dose of Divalproex (anti convulsant used for manic phases) previously lowered, will be re-increased for mood stabilization. This note also documents R1 is again receiving two antipsychotic medications after the restart of Quetiapine (anti psychotic) that medication will be marked for gradual dose reduction (GDR) while continuing Risperidone (anti psychotic) 1 mg BID for verbal and physical aggression.R1's Encounter Note, dated 5/14/26, documents a staff member called contracted psychological services because R1 had not been sleeping at night. It further documents that the staff member attempted to create a calm environment to reduce stimulation and R1's agitation did not respond, so Trazodone 25mg nightly was started. R1's Electronic Medical Record did not document any Physician's orders for Trazodone 25mg.R1's Physician Order Note, dated 5/14/26 at 3:06 PM, documents an order for Trazodone 50mg with directions to give one tablet by mouth at bedtime for sleep deprivation. This order was entered by V4, LPN.R1's Physician's Order Note, dated 5/18/26 at 4:30 PM, documents an order for Lorazepam 1mg with directions to give 1mg at bedtime for Insomnia. This order was entered by V4, LPN.On 7/1/26 at 12:06 PM, V4, LPN, reported R1 used to be more violent toward staff at night but had not demonstrated violent behaviors in several months. Regarding the trazodone order, dated 5/14/26 that V4 entered, V4 stated night shift staff might have asked V4 to reach out for medication to help R1 sleep. V4 stated V4 probably contacted psychological services but likely did not document the communication. Regarding the Lorazepam 1mg order, dated 5/18/26 that V4 entered, V4 could not recall who V4 received the order from or the circumstances surrounding the need for the order.On 7/2/26 at 8:59 AM, V18 (Medical Director) stated contracted psychiatry services manage medications for R1. V18 cannot recall or confirm whether R1's order for Trazodone 50mg and Lorazepam 1mg was issued by V18. V18 stated all psychotropic medication management is referred to contracted psychiatry services.On 7/6/26 at 1:33 PM, V2 stated no laboratory tests were obtained prior to R1's hospitalization on 6/5/26 to evaluate for potential underlying medical conditions that may have contributed to R1's behaviors.On 7/8/26 at 9:48 AM, V2, Director of Nursing (DON), stated the order for 25mg of Trazodone was never entered in R1's order. V2 stated R1's order for Trazodone 50mg entered on 5/14/26 by V4, LPN, was a transcription error.R1's Encounter Note by the contracted psychiatry services, dated 5/28/26, documents R1 continued to exhibit nighttime behavioral problems, including persistent behavioral disturbances and significant drowsiness. It also documents during the encounter, R1 was observed at bedside, sound asleep, was very drowsy upon awakening, and had difficulty remaining awake. This note documents staff and chart review indicate continued aggressive behaviors, labile mood symptoms, increased agitation, physical combativeness, exit seeking behaviors, and sleep disturbances. This note goes on to document the primary care provider also recently adjusted Lorazepam from 0.25 mg twice daily to 1 mg at bedtime and increased trazodone to 50 mg at bedtime. It also documents R1's POA (Power of Attorney) requested all bedtime medications be administered at 6:00 PM to help address sundowning behaviors and to avoid awakening R1 after falling asleep for nighttime administration. It also documents a new order for PRN Lorazepam 0.5mg.R1's Medication Audit Report, dated 6/1/26, documents a physician order for Lorazepam 0.5 milligrams (mg) stating to take 1 tablet by mouth every 6 hours as need for agitation for 14 days and do not give within 6 hours of bedtime dose. It also documents R1 received 1mg of Lorazepam at 4:48 PM and then received an as needed dose of lorazepam 0.5mg at 6:57 PM.R1's Medication Administration Note, dated 6/1/26 at 6:57 PM, documents Lorazepam 0.5mg was given because R1 restless, agitated, and no longer receives a nighttime dose of Lorazepam. It does not document any nonpharmacological interventions attempted prior to the administration of this medication.R1's Medication Audit Report, dated 6/4/26, documents a physician order for Lorazepam 0.5 milligrams (mg) stating to take 1 tablet by mouth every 6 hours as needed for agitation for 14 days and do not give within 6 hours of bedtime dose. It also documents R1 received 1mg of Lorazepam at 5:15p.m. and then received an as needed dose of lorazepam 0.5mg at 6:54 PM by V12, LPN.R1's Medication Administration Note, dated 6/4/26 at 6:54 PM., documents Lorazepam 0.5mg was given because R1 was anxious. It does not document any nonpharmacological interventions attempted prior to the administration of this medication.R1's Medication Audit Report, dated 6/5/26, documents a physician order for Lorazepam 0.5mg stating to take 1 tablet by mouth every 6 hours as needed for agitation for 14 days and do not give within 6 hours of bedtime dose. It also documents R1 received 1mg of Lorazepam at 4:56 PM and then received an as needed dose of lorazepam 0.5mg at 6:30 PM by V12, LPN.R1's Medication Administration Note, dated 6/5/26 at 6:30 PM, documents Lorazepam 0.5mg was given because R1 was anxious. It does not document any nonpharmacological interventions attempted prior to the administration of this medication.R1's Nursing Note, dated 6/5/26 at 10:05 PM, documents R1 was found on the floor by a CNA during rounds. R1 was lying on the floor with R1's head on the floor mat. R1 was bleeding on R1's left forearm. No new head injuries were observed at this time, however, old scrapes and existing bandages, to the right arm and top of scalp were noted. R1 was sent to the local hospital for further evaluation and treatment.R1's Emergency Department Physician Report, dated 6/5/26, documents R1 presented with scattered bruising across the face and scalp. R1 was subsequently transferred to a larger hospital for management of a subacute subdural hemorrhage.R1's General Medicine Discharge summary, dated [DATE], documents R1 had a known chronic subdural hematoma with a small acute component. R1 was admitted to the neurological intensive care unit for monitoring and remained clinically stable throughout the hospitalization. The geriatrics team evaluated R1 for Delirium in the context of Advanced Dementia. Due to concern for possible paradoxical agitation, they recommended that the facility slowly taper R1's benzodiazepines.On 7/1/26 at 10:38 AM, V69, Pharmacist, reviewed R1's medications administered on 6/5/26 at 4:59 PM (Depakote 375 mg, mirtazapine 7.5 mg, lorazepam 1 mg, trazodone 50 mg, and risperidone 1 mg). V69 stated there are potential drug interactions among these medications. V69 reported trazodone and mirtazapine may increase the risk of serotonin syndrome, central nervous system (CNS) depression, or drowsiness. V69 further stated lorazepam and trazodone may also contribute to CNS depression and drowsiness, and the combination of Depakote and lorazepam may further increase CNS depressant effects. V69 stated that individuals may experience varying levels of CNS depression depending on their tolerability to this medication regimen. While discussing the additional PRN lorazepam 0.5 mg dose administered to R1 at 6:34 PM, V69 stated R1's PRN lorazepam order includes a specific instruction not to administer it within six hours of R1's evening lorazepam dose. V69 added this instruction was likely included by the provider out of concern for R1's safety.On 7/1/26 at 1:16 PM, V12, LPN, stated R1 used to be very active and would attempt to get up and walk independently, but R1 was very unsteady, so staff would walk with R1. V12 stated R1 is still anxious at times but is now primarily in a wheelchair and less mobile. V12 reported R1 has exhibited behaviors such as crawling on the floor and pinching R1's skin. V12 did not report any additional behaviors and stated the CNAs would be more familiar with R1's behavioral patterns, as V12's interactions with R1 are brief and primarily related to medication administration. V12 stated V12 has had no issues with R1 taking R1's medications. V12 reported when R1 exhibited behaviors, staff would typically redirect R1, and at one point, R1's scheduled Lorazepam and as needed dose helped soothe R1 and made R1 tired. V12 only recalls portions of R1's fall on 6/5/26. V12 stated V12 was working on another hall when a CNA informed V12 that R1 had been found on the floor. The fall was unwitnessed. When V12 assessed R1, V12 observed bleeding on R1's left arm. V12 notified the physician, and R1 was sent to the hospital. R1's vital signs were stable at the time of transfer. V12 stated V12 does not recall any additional details. V12 cannot recall why V12 administered R1's as need Lorazepam so closely to R1's evening dose of Lorazepam.On 7/1/26 at 3:07 PM, V2, Director of Nursing/DON, stated n long term care, staff are expected to chart by exception. V2 stated nursing staff are expected to document the specific behaviors observed rather than simply using a behavior descriptor. Documentation should clearly describe the signs and symptoms exhibited. When a medication is ordered for a specific behavior, the medication should only be administered when the resident is demonstrating that behavior. A re evaluation is expected to be completed one hour after administration. V2 also stated staff should document any non pharmacological interventions attempted in conjunction with medication administration. V2 stated R1 is impulsive with decreased safety awareness related to impaired cognition and does not demonstrate an understanding of safety risks. V2 reported when R1 was first admitted , R1 would hit staff and did not tolerate being touched during care. On 7/6/26 at 11:50 AM, V2 stated V2 could not provide behavior documentation to support R1's psychotropic medication changes.On 7/2/26 at 9:12 AM., V38, Physician, stated recalling R1's hospitalization. V38 reported R1 had a chronic subdural hematoma with a mild acute component. The acute portion represented a new bleed; however, it remained stable on multiple assessments, which is why no intervention was required. V38 stated being unable to determine the exact cause of the acute component but noted R1 is at very high risk for falls and had multiple bruises consistent with a history of prior falls. Based on clinical assessment, V38 stated the fall that occurred on 6/5/26 was the most likely cause of the new acute component of the bleed.On 7/2/26 at 11:48 AM, V34, Psychiatry Nurse Practitioner, stated when V34 began seeing R1 in March of 2026, staff reported R1 was physically and verbally aggressive and impulsive with self transferring. V34 stated when rounding, R1 was usually asleep, but staff consistently reported R1's behaviors occurred at night, followed by sleeping during the day. V34 stated not knowing why the primary care provider initiated Trazodone and Lorazepam, noting that increasing Lorazepam from 0.25 mg twice daily to 1 mg every evening represented a significant dosage change. V34 stated R1's medications were moved to the evening based on R1's Power of Attorney concerns that R1 was not sleeping. The previous schedule required staff to wake R1 a few hours after falling asleep to administer additional doses, which raised concern R1 might awaken fully and then remain awake through the night. V34 stated an order was given for the PRN Ativan not to be administered due to concern for oversedation, particularly given R1's fall risk. V34 stated being unaware that PRN Ativan was administered earlier than ordered on 6/1, 6/4, and 6/5. V34 stated staff could have contacted the after hours provider for approval but reported having no documentation that such communication occurred.On 7/2/26 at 12:30 PM, V2, DON, stated nurses are expected to receive, document, and follow physician orders accurately. R1's administration of scheduled and as needed Lorazepam on 6/1/26, 6/4/26, and 6/5/26 reviewed by V2. V2 stated these were medication errors and staff were not following the physician orders. V2 would be concerned with the administration of the as needed Lorazepam so closely to the scheduled Lorazepam because R1 is a fall risk.The facility's Behavioral Health Services Program policy, revised January of 2023, documents when inappropriate or distressed behaviors occur, interventions should be implemented by utilizing the least restrictive or least intrusive measures first, and evaluating the effectiveness of these interventions before utilizing more restrictive or intrusive interventions.The facility's Abuse Prevention and Reporting - Illinois policy, revised March of 2026, documents the facility should assure that chemical restraints are not used.

Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy by failing to ensure employee background checks were completed upon hire. This failure has the potential to affect 62 residents in the facility. Findings include:The facility's Abuse Prevention and Reporting policy, revised March 2026, documents abuse prevention measures include conducting pre-employment screening of employees. This policy documents the facility will check the Illinois Health Care Worker Registry for abuse and neglect, fingerprint results, and the sex offender website links on the registry for any new employees prior to starting work. On 6/29/26 at 11:10 AM and on 6/30/26 at 8:05 AM, V4, Licensed Practical Nurse, was working on the dementia unit/hallway of the facility. On 6/29/26 at 1:52 PM, V42, Human Resources (HR), provided V4's employee file which did not contain background checks and listed V4's hire date as 12/1/24. V42 confirmed V4's hire dated as 12/1/24 and confirmed V4 did not have background checks completed. V42 stated V42 took over as HR on 12/15/24 and background checks are to be completed for all employees prior to hire. On 7/7/26 at 8:15 AM, V2, Director of Nursing, stated the nurses do not have set assigned hallways and are expected to answer call lights for any/all residents (confirming nurses have the potential to interact with all residents in the facility). The facility's June 2026 Nursing Daily Schedules document V4 worked in the facility on the 300 and 400 hallways. The facility's Midnight Census Report dated 6/29/26 documents 62 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to have a full-time qualified social worker. This failure has the potential to affect all 62 residents in the facility. Findings include: The Facility Assessment, revised 6/19/26, documents Social Services is included in the facility's resources/staffing needed to provide competent support and care of its residents. This assessment documents resident care/services include care of residents with cognitive impairment, mental health diagnoses, and behaviors. V24, Social Services Director (SSD), was working in the facility 6/29/26-7/2/26. On 7/2/26 at 9:25 AM, V24 stated V24 is the facility's SSD. V24 stated V24 is currently enrolled in courses to obtain a bachelor's degree as V24 does not meet the qualifications for a Social Worker for facility's with over 120 beds. V24 stated V68 (Regional SSD) has a degree and meets the qualifications but is only in the facility a couple times per month, not full time. The facility's Illinois Department of Public Health License, Permit, Certification, Registration issued 12/1/25 and expiring on 11/30/26 documents the facility has 123 licensed beds. The facility's Midnight Census Report, dated 6/29/26, documents a census of 62 residents.

Based on interview and record review, the facility failed to implement a Performance Improvement Plan (PIP) for identified problems with abuse, behavior monitoring, and falls. This failure has the potential to affect all 62 residents in the facility.Findings include:Record Review: Review of the facility's QAPI (Quality Assurance Performance Improvement) Binder revealed no Performance Improvement Projects (PIPs) had been completed for abuse or falls. Documentation for April, May, and June identified behaviors, abuse, and falls as ongoing areas of risk. There was no evidence that PIPs had been initiated or implemented to address these quality concerns.On 7/2/26 at 11:50 AM, V42, Regional Manager of Dietary, revealed that QAPI meetings included discussion of weekly weights, hospice residents with weight loss, infection prevention, wounds, falls, behavior logs, and monthly weight reports. V42 stated the Administrator, Director of Nursing (DON), Social Services, Dietary Manager, Minimum Data Set Coordinator, and Infection Prevention/Wound staff participated in the meetings and the Medical Director participated by telephone.On 7/2/26 at 11:53 AM, V1, Administrator, revealed that QAPI meetings had been held May 2026 and continued into June 2026. V1 stated the meetings included the Administrator, DON, Business Office Manager (BOM), and Assistant Director of Nursing (ADON). V1 stated reports were sent to the Medical Director by email and the information was reviewed; concerns were discussed during morning meetings. V1 further stated the consultant pharmacy and psychiatric consultant were not involved in the QAPI meetings and only completed medication reviews. V1 also confirmed no Performance Improvement Projects (PIPs) had been completed for approximately one year on behaviors, falls, or abuse.On 7/2/26 at 12:15 PM, V24, Social Services Director, revealed behaviors and grievances were discussed in morning meetings and during the QAPI meetings held monthly and provided to the Administrator for review. V24 stated there has been no Performance Improvement Projects (PIPs) in place for behaviors or abuse.The facility's Midnight Census Report, dated 6/29/26, documents a census of 62 residents.

Based on observation, interview, and record review, the facility failed to timely report an allegation of abuse to the Administrator and report abuse allegations to the State Survey Agency for six (R2, R5, R9, R10, R11, R15) of 14 residents reviewed for abuse in the sample list of 20. Findings include: 1.) The following resident to resident sexual abuse allegations were identified through staff (V8, V16, V17, Certified Nursing Assistants (CNA), and V19, Licensed Practical Nurse) and resident (R10) interviews conducted on 6/29/26 and 6/30/26 between 8:00 AM and 3:33 PM: R9 has predatory behaviors including going into female resident rooms R10 and R11, watching them undress and go to the bathroom, and R10 and R11 have expressed fear of R9. R9 rubbed R15's back and near R15's breasts, R9 attempted to get R15 out of bed and undressed which was reported to the former Administrator, V66. Around 4-5:00 PM on 6/11/26 V8 found R5 and R9 in R9's room with the door shut, R9 had his hand up underneath R5's shirt and R5 was not wearing a bra. These residents all resided on the Dementia unit. These behaviors and incidents were reported to management and administration throughout the last year. R10 stated R10 has had problems with another resident coming into R10's room and R10 identified R9 by R9's name and when R9 approached R10's doorway. R10 stated R10 tells R9 to get out of R10's room and R9 will just stand there, and R9 also goes into R10's friend's room (R11) located across the hall. R10 stated (R9) scares me (R10). The facility's Clinical and Order Alerts Listing Report dated 6/1/26-6/29/26 documents:On 6/10/26 at 11:23 AM, R9 is getting more touching with female staff and residents if they don't shake R9's hand and R9 will grab shoulders and arms. At 11:25 AM, R9 is going into female resident rooms while staff is providing cares, enters while residents are getting dressed/undressed or using the bathroom.On 6/11/26 at 10:27 AM, R9 is entering female resident rooms while staff are providing cares. At 10:28 AM, R9 is watching other residents get dressed/undressed and when using the bathroom. At 10:29 AM, R9 is getting upset when female staff and residents won't shake R9's hand right away and will grab onto their shoulders and/or arm. On 6/24/26 at 5:32 PM, R9 has been going into female bathrooms while in use, redirected but R9 goes right back. R9 follows females into their rooms and refuses to leave when asked. The facility's abuse log dated January-June 2026 does not include allegations involving R9 and there is no documentation the above allegations were reported to the state survey agency. On 6/29/26 at 2:08 PM, V1, Administrator In Training, and V3, Regional Administrator, stated nothing had been reported to them about R9's behaviors of watching female residents undress and toilet or touching female residents inappropriately. V1 and V3 stated the allegation of R9 having his hand up R5's shirt was reported today by V24, Social Services Director. V1 and V3 confirmed abuse allegations are to be reported to administration and the State Survey Agency. On 7/1/26 at 8:56 AM, V3 stated V66 (Former Administrator) was the facility's Administrator a year ago. V3 was not aware of any prior abuse allegations involving R9 and V3 will check the abuse allegation files. At 9:04 AM, V3 confirmed there were no abuse allegation files involving R9, besides an allegation of staff to resident verbal abuse regarding food. 2. The facility's abuse investigation, initially reported on 5/3/2026 at 4:09 PM, and the final investigation report submitted on 5/7/2026 at 4:08 PM, documented an allegation that V32, Certified Nurse Aide (CNA), conducted a video call showing R2 during resident care. On 7/1/2026 at 9:31 AM, V31, Certified Nurse Aide (CNA), stated V31 observed V32 conduct a video call during R2's care and V31 reported it a few hours later. On 7/1/2026 at 12:55 PM, V3, Regional Administrator, stated the facility expects abuse allegations to be reported immediately upon becoming aware of the allegation. The facility policy titled Abuse Prevention and Reporting – Illinois, last approved March 2026, directed employees to immediately report any incident, allegation, or suspicion of abuse, neglect, retaliation, exploitation, mistreatment, or misappropriation of resident property to the Administrator or an immediate supervisor, who must then immediately notify the Administrator. The state agency will be notified of abuse allegations and notified of the findings of the abuse investigation.

Based on observation, interview, and record review, the facility failed to thoroughly document and thoroughly investigate abuse allegations, and implement appropriate corrective measures for seven (R1, R4, R5, R9, R10, R11, R15) of 14 residents reviewed for abuse in the sample list of 20. Findings include:The facility's Abuse Prevention and Reporting policy, revised March 2026, documents all abuse allegations will be documented and investigated, and at a minimum will include attempts to interview the person who reported the incident, anyone likely to have knowledge of the incident and the resident, and residents who the accused employee has regularly provided care for and staff who has regularly worked with the accused. 1.) On 6/29/26 at 11:10 AM and on 6/30/26 at 8:05 AM, V4, Licensed Practical Nurse, was working on the dementia unit/hallway of the facility. This unit contained a video surveillance camera located at the entrance of the hallway facing the exit door at the opposite end of the hall. The facility's Final Abuse Investigative Report, dated 6/16/26, documents on 6/11/26 a staff to resident (R1) abuse allegation was reported. An unidentified Certified Nursing Assistant (CNA) was interviewed and reported being asked to watch R1 because R1 kept trying to get up from R1's chair, R1 was agitated and weak, and R1 could not stand up but kept trying. This CNA noticed a sheet tucked around R1 and the wheelchair, and two CNAs took R1 to be laid down in bed. The facility concluded based on staff interviews R1 experienced episodes of agitation and staff responded appropriately by providing one to one supervision until R1 could be laid down. The alleged abuse incident report, dated 6/11/26 for R1's abuse allegation, documents staff notified V3, Regional Administrator, that R1 had a sheet secured around R1's waist and wheelchair. This report documents a nurse (unidentified) statement dated 6/11/26 as having two admissions who weren't doing well, R1 was weak and kept trying to get up, the nurse was next to R1 the entire time and asked a CNA to watch R1 so the nurse could take a break. The nurse securely tucked a sheet around R1's waist and chair. The nurse also had R1 double gowned restricting R1 from using R1's hands as R1 normally does. This report documents unidentified CNA statements, dated 6/11/26 and 6/15/26, as being called by the nurse to sit with R1 and CNAs walked into the room and found R1 tied to a chair referred to as an illegal restraint. The nurse responded it was going to be undone when the nurse was done with her work, and the nurse wasn't going to keep R1 tied there. The above abuse investigation and report do not identify the names of the staff involved or the staff interviewed. There is no documentation the facility reviewed video surveillance or interviewed any residents regarding the alleged perpetrator (V4 Licensed Practical Nurse). The Corrective Action Form, dated 6/15/26, documents a verbal warning was given to V4, LPN, for misconduct regarding an incident on 6/11/26 at 4:20 PM that occurred on the facility's dementia unit/hall. R1's Minimum Data Set, dated [DATE], documents R1 has severe cognitive impairment, R1 did not use any physical restraints, and R1 required dependence on staff for transfers. R1's electronic medical record (EMR) does not document a physician's order for restraints prior to 6/29/26, an assessment for physical restraint use, medical symptoms justifying restraint use or alternative less restrictive measures implemented prior to restraint use. R1's Interdisciplinary Team Note, dated 6/16/2026 at 2:11 PM, documents following the investigation of the allegation on 6/11/26, the facility determined R1 experienced agitation and staff responded appropriately with one-to-one care and supervision until R1 could be laid down. R1's skin and pain assessment found no new skin alterations and R1's care plan was reviewed and updated as appropriate to ensure R1's psychosocial needs are met. The facility's June 2026 Nursing Daily Schedules document V4 worked in the facility on the 300 and 400 hallways. These schedules document V4 worked on R1's hallway (the Dementia unit) 6:00AM-6:00 PM shift on 6/11/26 and resumed working this unit as of 6/16/26. On 6/29/26 at 11:29 AM, V5, CNA, stated on 6/11/26 at approximately 5:30 PM, V4 came out of the dementia unit nurses' station asking V5 and V8 CNA to watch R1 so V4 could take a break. V5 stated R1 was found sitting in a wheelchair with a sheet rolled linear across R1's torso and tied behind R1's wheelchair, out of R1's reach preventing R1 from getting out of the wheelchair. V5 stated R1 also had two hospital gowns on, one frontward and one backward, which were tied keeping R1's arms down and restricting movement as R1's arms were not through the sleeves. V5 was unsure how long R1 had been like that as V4 had been in the nurse's station with R1 with the door closed for about 30 minutes prior. On 6/29/26 at 11:44 AM, V8 confirmed V8 witnessed R1 restrained by V4 with the same descriptions as V5 stated. V8 stated prior to this V4 was sitting with her foot on R1's lap preventing R1 from standing and V4 has done this a few times before. On 6/29/26 at 2:08 PM, V3 stated R1 returned from the hospital during mealtime, R1 was not doing well, he was a mover and wanderer, and staff were trying to keep R1 busy so the staff could pass meal trays. V3 stated V3 was told V4 had a sheet draped across R1's lap, V8 reported the sheet was tied but V4 reported it wasn't. V3 stated V3 completed the initial report and handed the allegation over for V1 to complete the investigation. V1 stated V1 spoke to V4 who asked the CNAs to watch R1 so V4 could take a break, and V4 tucked a sheet around R1's waist and wheelchair. V1 stated V4 denied having the sheet tied or R1 double gowned. V1 stated V1 spoke to V8 and V5 who reported finding R1 tied to R1's wheelchair and double gowned by V4 restricting R1's hand movement. V1 stated additional CNA's were interviewed and no residents were interviewed since the incident occurred on the facility's Dementia unit. V1 confirmed the facility's investigation does not identify or include the staff involved, the staff interviewed, review of video surveillance or resident interviews. V1 and V3 stated a physical restraint was in place as ordered so abuse was not substantiated, V4 was given a verbal warning and allowed to return to work. V3 confirmed the facility's surveillance cameras are functioning. V3 stated these cameras are not reviewed for abuse investigations as that is not facility policy. On 7/1/26 at 5:15 PM, the facility's active video surveillance screens were viewed with V3 on the computer in the front office. The dementia hall video was clear and able to see residents and staff moving about. The entire hallway was visible besides a small portion that was partially obstructed by a decorative banner that was hanging in front of the camera on the hallway. R1's room doorway located across from the nurse's station and hallway were visible. This was confirmed with V3. On 7/2/26 at 10:13 AM, V3 stated the facility's video surveillance maintains footage for a 72 hour period. 2.) The facility's Final Abuse Investigation Report, dated 6/24/26, documents the following: V1 was notified of an allegation of sexual abuse of R5 by R4 (who reside on the Dementia unit) on 6/17/26 at approximately 7:10AM. The Certified Nursing Assistant (CNA V7) stated that V7 briefly stepped away from the dining room and upon returning V7 observed R4 seated in a wheelchair with R4's hand inside the front waistband of R5's pants who was standing. The facility's investigative file for this allegation does not document the names of staff interviewed and only contains interviews with two staff, a nurse and CNA. The investigation does not include any other staff or resident interviews or that video surveillance was reviewed. The following additional resident to resident sexual abuse allegations were identified through staff (V8 CNA, V16 CNA, V17 CNA, and V19 Licensed Practical Nurse) and resident (R10) interviews conducted on 6/29/26 and 6/30/26 between 8:00 AM and 3:33 PM: R9 has predatory behaviors including going into female resident rooms R10 and R11, watching them undress and go to the bathroom, and R10 and R11 have expressed fear of R9. R11 have expressed fear of R9. R9 rubbed R15's back and near R15's breasts, R9 attempted to get R15 out of bed and undressed which was reported to the former Administrator, V66. Around 4-5:00 PM on 6/11/26 V8 found R5 and R9 in R9's room with the door shut, R9 had his hand up underneath R5's shirt and R5 was not wearing a bra. R10 stated R10 has had problems with another resident coming into R10's room and R10 identified R9 by R9's name. R10 stated R10 tells R9 to get out of R10's room and R9 will just stand there, and R9 also goes into R10's friend's room (R11) located across the hall. R10 stated (R9) scares me (R10). At this time R10 approached R9's doorway. R10 pointed and identified R9 by name and R9 was the man R10 was referring to. R10's MDS, dated [DATE], documents R10 has moderate cognitive impairment. The facility's abuse log dated January-June 2026 do not include any allegations involving R9. On 7/1/26 at 5:15 PM, the facility's active video surveillance screens were viewed with V3 on the computer in the front office, including a full view of the Dementia unit's dining room. On 6/29/26 at 2:08 PM, V1 confirmed V1 completed the investigation for this allegation and the investigation did not identify staff names who were interviewed. V1 stated V1 interviewed V7, CNA, and V28, Registered Nurse. V1 confirmed no other staff or residents were interviewed and video surveillance was not reviewed for this abuse investigation. V1 and V3 both stated nothing had been reported to them about R9's behaviors of watching female resident undress and toilet or touching female residents inappropriately. V1 and V3 stated the allegation of R9 having his hand up R5's shirt was reported today by V24. On 7/1/26 at 8:56 AM, V3 stated V66 (Former Administrator) was the facility's administrator a year ago. V3 was not aware of any prior abuse allegations involving R9 and V3 will check the abuse allegation files. At 9:04 AM, V3 confirmed there were no abuse investigations involving R9, besides an allegation of staff to resident verbal abuse regarding food.

Based on interview and record review, the facility failed to provide and document urinary catheter care for one of three residents (R13) reviewed for catheter care on the sample list of 20. Findings Include:The facility's Urinary Catheter Care policy, dated December 2025, documents in order to reduce the risk of or prevent infections in residents with indwelling catheters, urinary catheter care should be performed and documented on the Treatment Administration Record (TAR) at least daily. R13's Care Plan, dated 6/18/26, documents R16 has an indwelling urinary catheter related to Obstructive and Reflex Uropathy. R13's Treatment Administration Record for June 2026 does not document any urinary catheter care completed. On 7/6/26 at 4:30 PM, V49, Assistant Director of Nurses (ADON), confirmed R13 has a urinary catheter has had some recent urinary tract infections. Staff should be providing catheter care every shift. Catheter care should be documented on the TAR daily. On 7/7/26 at 2:30 PM, V2, Director of Nurses, confirmed R13 has a urinary catheter and catheter care should be completed at least daily and charted on the TAR in R13's medical record.

Based on observation, interview, and record review, the facility failed to complete thorough fall investigations following falls for two (R7, R1) residents and did not implement fall interventions for two (R7, R13) out of three residents reviewed for falls on a sample list of 20 residents. The Facility's Fall Prevention Program policy, revised May of 2022, documents safety interventions will be implemented for each resident identified as being at risk for falls. It further documents, all assigned nursing personnel are responsible for ensuring ongoing precautions are put into place and consistently maintained. 1. An Incidents by Incident Type Report, dated 6/29/26, documents R7 had unwitnessed falls on 4/10/26, 4/20/26, 4/25/26, 4/26/26, 5/17/26, and a witnessed fall on 4/26/26. R7's Minimum Data Set (MDS), dated [DATE], documents R7 is moderately cognitively impaired. R7's Care Plan documents R7 is at risk for falls and has an intervention, dated 4/26/26, for the Medical Director to review medications related to increase falls. R7's Fall Follow Up Note, dated 4/27/26, documents the Interdisciplinary Team met and discussed R7's fall on 4/26/26. It also documents as an intervention to prevent further falls that the Medical Director will be notified of R7's increased fall risk and a medication review will be requested. R7's Unwitnessed Fall Risk Management, dated 4/26/26 at 2:45 a.m. does not document any statements from staff documenting when R7 was last seen prior to the fall. On 6/29/26 at 10:12 AM, R7 was observed seated in a wheelchair in the resident room watching television. The room was tidy and the bed was made. R7 appeared well groomed and was wearing hat. Anti rollback devices were present on the wheelchair, and the call light was within reach. R7 stated R7 can recall falling a couple of times within the past month or two but was unable to recall the details of the falls or any injuries associated with them. On 6/30/26 at 9:20 AM, V14, Licensed Practical Nurse, could not recall R7's fall on 4/26/26. On 7/2/26 at 10:57 AM, V39, Certified Nurse's Aide, was contacted in regard to R7's fall on 4/26/26 at 2:47AM. V39 stated V39 no longer works at the facility and directed surveyor to call someone else and ended the call. On 6/30/26 at 10:19 AM, V2, Director for Nursing (DON), stated the investigations for R7's falls were still being put together as V2 was unaware that falls that were not reportable to the State Agency should be investigated. V2 stated staff should be collecting witness statements at the time of a resident's fall and entering them into the Risk Management. On 7/7/26 at 11:50 AM, V2, DON, stated the Medical Director would have been faxed to review R7's medications. V2 stated V2 reached out to the Medical Directors office but confirmed V2 does not have any documentation that R7's medications were reviewed after R7's falls on 4/26/26. On 6/30/26 at 10:35 AM, V2, DON, stated every fall investigation should have witness statements from any staff present at the time of the fall. V2 stated the witness statements would indicate when a resident was last seen by staff. V2 confirmed there are no witness statements for R7's fall on 4/26/26 at 2:45a.m. 2. An Incidents by Incident Type Report, dated 6/29/26, documents R1 had unwitnessed falls on 4/9/26, 4/11/26, and 6/5/26. R1's Unwitnessed Fall Risk Management, dated 4/9/26 at 6:13 AM, does not document statements from staff regarding the last time R1 was seen or checked on prior to the fall. R1's Unwitnessed Fall Risk Management, dated 4/11/26 at 12:15 PM, does not document statements from staff regarding the last time R1 was seen or checked on prior to the fall. On 6/30/26 at 10:35 AM, V2, DON, stated every fall investigation should have witness statements from any staff present at the time of the fall. V2 stated the witness statements would indicate when a resident was last seen by staff. On 7/2/26 at 9:51 AM, V2, DON, stated there are no statements for R1's falls on 4/9/26 and 4/11/26. 3. R13's Incident Note, dated 5/30/26, documents R13 sustained a fall at 4:50 PM. R13 was found on the floor next to R13's bed. R13 was unable to say how it happened. R13 was not injured. R13's Fall Follow-up Note, dated 6/1/26, documents R13's fall was reviewed, and it was determined R13 slid out of bed. A raised edge mattress was implemented as a new fall-related intervention. On 7/2/26 at 2:00 PM, R13's bed had an air mattress but no raised edge mattress in place. On 7/7/26 at 2:00 PM, V2, Director of Nurses, confirmed R13's raised edge mattress was never ordered or put into place after R13's fall on 5/30/26.

Based on observation, interview, and record review, the facility failed to consistently implement wound prevention interventions and complete weekly skin/wound assessments for one of three residents (R16) reviewed for pressure ulcers on the sample list of 20 residents.Findings Include:The facility's Pressure Ulcer Prevention policy, dated December 2025, documents the policy's purpose is to prevent and treat pressure injuries. Staff are to use positioning devices, pads, pillows, etc. to reduce pressure from heels and toes as indicated.The facility's Pressure Injury and Skin Condition Assessment policy, dated December 2025, documents each pressure ulcer will be assessed and measured at least every seven days by a licensed nurse and documented in the resident's clinical record. A wound assessment for each identified open area will be completed and will include site location, size, stage of wound, odor, drainage, description, and date and initials of individual performing the assessment.R16's Care Plan, dated 6/23/26, documents R16 is diagnosed with Impaired Mobility, Heart Failure, Failure to Thrive, and Incontinence which place R16 at risk for skin impairment. R16 has actual pressure wounds. Staff are to minimize pressure over bony prominencesOn 7/2/26 at 2:00 PM, R16's bilateral pressure relieving booties were in R16's wheelchair under blankets. R16 was in R16's bed lying down.On 7/2/26 at 2:35 PM, V50, Hospice Registered Nurse, confirmed R16 requires the use of bilateral pressure relieving booties to assist with wound prevention and healing. V50 confirmed when staff arrived, R16's booties were in R16's wheelchair covered with blankets and not on R16's feet as R16 lay in bed. V50 confirmed this is an important wound intervention because of R16's contractures and inability to move R16's feet and legs much on her own. V50 confirmed R16 has pressure wounds on both of R16's feet/ankles.On 7/6/26 at 4:30 PM, V49, Wound Nurse/Assistant Director of Nurses, confirmed R16 has wounds on both of R16's feet and ankles and due to R16's bilateral leg contractures. R16's feet and ankles often rub together and R16 cannot move them well on R16's own to relieve pressure. V49 confirmed R16 requires the use of pressure relieving booties on both feet to help relieve pressure or wound formation or deterioration. V49 confirmed the booties are not always kept on R16 as they should be. V49 confirmed weekly skin/wound assessments are not always completed for R16 and multiple assessments in the last couple months were left incomplete.On 7/7/26 at 2:00 PM, V2, Director of Nurses, confirmed R16 is on Hospice services, does not have a great appetite, has had recent weight loss, has wounds, is nutritionally at risk, and requires consistent interventions to prevent further skin breakdown and wound deterioration. V2 also confirmed R16's skin/wounds should be assessed thoroughly by the facility at least weekly and that documentation should be available in R16's medical record.

Based on observation, interview, and record review the facility failed to ensure post fall monitoring was completed timely and reflected ongoing assessment for one (R,6) of three residents reviewed for falls on a sample list of 20 residents.Findings include:On 6/29/26 at 10:55 AM, R6 was sitting in a wheelchair and eating chips in their room. R6 recalled the fall that occurred on 5/8/26. While describing the incident, R6 leaned forward in the wheelchair and pointed to the left foot, then to the space between the front and back wheelchair wheels. When asked for clarification, R6 nodded yes to indicate the left foot became caught between the wheelchair wheels, causing a forward fall. R6 lifted sweatpants to show bruising on both knees and pointed to the right hand, which was in a brace. R6 confirmed with a nod that these were the areas injured during the fall and again nodded yes when asked if healing was occurring and if R6 was feeling better.An Incidents by Incident Type Report, dated 6/29/26, documents a witnessed fall on 5/8/26.R6's Minimum Data Set, dated [DATE], documents R6 is moderately cognitively impaired.R6's 72 hour Occurrence Follow Up Charting (R6's post fall monitoring and assessments) for 5/8/26 at 10:56 PM, 5/9/26 at 9:56 AM, 5/9/26 at 4:56 PM, 5/10/26 at 11:57 AM, and 5/10/26 at 7:57 PM documents identical, verbatim documentation in each assessment entry and all entries were signed on 5/13/26.On 6/29/26 at 3:45 PM, V2, Director of Nursing, stated that 72 hour follow up charting is expected to be completed by each shift after a fall. V2 confirmed R6 did not have all required 72 hour follow up documentation completed correctly and noted that most entries were opened and completed on 5/13/26, which V2 stated is not the facility expectation.On 7/7/26 at 11:49 AM, V65, Regional Nurse Consultant, stated the facility does not have a policy addressing neurological checks or post fall assessments.

Based on observation, interview, and record review, the facility failed to provide assistance with eating for one of three residents (R16) reviewed for Activities of Daily Living on the sample list of 20. Findings Include: R16's Care Plan, dated 3/24/26, documents R16 is diagnosed with Activity Intolerance, Alzheimer's Disease, Dementia, Fatigue and has an Activity of Daily Living self-care performance deficit that requires one staff to assist with eating. R16 has a risk for weight loss and is under Hospice Care. R16 requires meal intake monitoring and has a goal to eat 50 percent or more of R16's meals. On 7/6/26 at 4:55 PM, R16 was sitting in R16's wheelchair in the television room by R16's self. R16 had a sandwich on R16's lap which R16 was tearing up into pieces but not eating. The sandwich had been torn apart but R16 was not eating it. On 7/7/26 at 9:00 AM, R16's breakfast tray was on R16's overbed table, untouched. R16 denied eating breakfast. At 10:00 AM, facility staff had still not come in to assist R16 with eating. On 7/6/26 at 2:35 PM, V50, Hospice Registered Nurse, stated R16 requires staff assistance with eating. R16 will eat if staff take the time to feed R16 and continue to offer foods R16 likes. R16 enjoys soda pop and pudding. V50 stated facility staff need to take the time to feed R16. On 7/7/26 at 2:00 PM, V2, Director of Nurses, confirmed R16 is on Hospice services, does not have a great appetite, has weight loss, has wounds, is nutritionally at risk, and requires staff assistance with eating. Staff are to attempt to assist R16 with every meal. Staff should not be leaving R16 with food in R16's lap and should be providing queuing, encouragement, and assistance.

Based on observation, interview and record review the facility failed to maintain resident equipment in a safe operable condition, failed to replace/repair equipment in disrepair after resident fall with injury and failed to implement new interventions post fall and an accident. These failures affected two of three residents (R2 and R3) reviewed for resident injury/injury of unknown origin on the sample list of seven.Findings include:1.) R2's current diagnoses sheet documents the following: Hemiplegia, Unspecified, Affecting Left Nondominant Side; Cerebral Infarction Due to Embolism of Right Vertebral Artery; and Generalized Muscle Weakness.R2's Minimum Data Set (MDS), dated [DATE], documents the following: R2's Brief Interview of Mental Status score was 15 out of a possible 15, indicating R2 has no cognitive impairment. The same MDS documents R2 is dependent on staff to roll left and right, defined as the ability to roll from lying on the back to the left and right side and return to lying on the back in bed, and is dependent on staff for chair/bed-to-chair transfers.R2's Care Plan, updated 4/10/26, documents R2 may be predisposed to develop skin impairment. The intervention following the bruise and skin tears on 4/7/26 is documented as follows: Resident's (R2's) right arm should be elevated on a pillow.R2's Weekly Skin Observation, dated 4/07/26 at 2:49 p.m., documents: Note Text: Resident's weekly skin status. Type of skin concern: Bruising, skin tear. Located to Other (specify) - Left forearm, scattered bruising and skin tears. Treatments include cleanse, pat dry, triple antibiotic ointment, and dry dressing daily until healed. Resident does not complain of pain. No new skin concern or change in skin condition that required MD notification. MD (unidentified physician) was notified of new condition. Family (V19, Power of Attorney) was notified of new condition. New orders received: Care plan reviewed.There was an associated picture taken of R2's left forearm bruise and skin tears. The picture displayed a large, very dark bruise. Measurements were to be determined by a measuring tape laid beside the skin tears and bruise; however, the measuring tape was not legible in the picture.R2's Nursing Note, dated 4/10/26 at 1:47 p.m., documents the first measurement of R2's left forearm injury, written by V6, Licensed Practical Nurse: Note Text: Changed dressing to left forearm. Cleansed with N.S. (normal saline), patted dry, applied TAO (triple antibiotic ointment), covered with a border foam dressing. New bruising/hematoma noted to same arm (length 6.5 cm x width 5 cm), center of the bruise is raised approximately 0.5 cm to 1 cm.R2's Nursing Note, dated 4/10/2026 at 2:25 p.m., documents the following: Note Text: IDT (Interdisciplinary Team) met. Resident (R2) does not have full sensation to the left arm due to past stroke. If the arm is not supported, then the arm will hang or fall. Bruising/skin tear noted to left forearm. Full range of motion without pain. Resident was in a geriatric recliner-type wheeled chair when arm fell and hit side of chair. MD (unidentified), POA (V19, Power of Attorney) notified. Intervention: Arm to be propped on pillow while in chair to prevent hanging. Care plan reviewed and updated.On 4/28/26 at 11:50 a.m., R2 was seated in a partially reclined geriatric wheeled chair in the dining room. R2 had a full-body mechanical lift sling under his body and above the chair seat. R2's left arm was flaccid. R2's left arm was resting on the armrest of the chair at an angle, with his hand on his left abdomen. R2 did not have a pillow to support his left arm, as later identified on R2's care plan.R2 had a large faded purple and green bruise on his left forearm. The faded bruise spanned approximately four inches in length by three inches in width. At the center of the faded bruise was a quarter-sized raised area protruding approximately one-quarter inch. Distal to the bruise on R2's left forearm were three scabbed areas with new scarring surrounding each scab. The scab closest to the bruise was approximately quarter-sized; below that was a nickel-sized scab; below that was a dime-sized scab.When this surveyor asked R2 what happened to his arm, R2 stated: I did not even know anything happened to my arm until I was going to get a shower a couple weeks ago. One of the CNAs saw it and told the nurse. They checked it out, and I got the shower. In the shower it was painful, a stinging type of pain. I had a stroke and have no feeling in this arm, usually. I guess you would say it is paralyzed. I guess it was some kind of nerve pain when the water hit my arm in the shower. The nurses have been great at cleaning it every day and putting new bandages on it. Today is the first day it has gone uncovered. The nurse looked at it, cleaned it, and said we are leaving it open to heal faster. It is looking good now. At first it was all messed up. The sores have healed, and the bruise was real dark and big. It is not 100 percent healed yet, but is getting there. One of the nurses used a piece of material down in the seat of my chair. I was told it covered the open metal gears that scraped my arm. That material should protect my arm so this does not happen again. I can't move my arm, feel pain, or see very well. I did not know my arm had fallen. I will be reminding the CNAs to wait and make sure my arm is not tucked down in the gears before they push the back of the chair up when I need to sit instead of lay back.On 4/28/26 at 11:55 a.m., V7, Certified Nursing Assistant (CNA), approached R2's partially reclined geriatric wheeled chair. V7 stated: I was the one that reported R2's bruise to the nurse. I know how it happened. I went to give him a shower and saw it. It lines up with this metal next to the armrest. The seat vinyl does not cover the metal like it is supposed to.V7 removed a piece of pool-noodle-like foam material from below the armrest adjacent to the geriatric wheeled chair vinyl seat. The foam material measured approximately four inches long and covered a metal hinge. The metal hinge attached the seat of R2's wheeled chair to the back of the chair. The metal was fully exposed. The vinyl seat material did not cover the metal hinge connection.V7 stated: This stuff was put on the metal to prevent R2 from scraping his arm. You can see how it lines up exactly with R2's bruised area.R2 then stated: It had to have happened when they got me up in the chair that day. V7 stated the incident occurred a couple weeks ago. R2 agreed. Neither V7 nor R2 could recall the date, later documented as 4/7/26.On 4/28/26 at 12:15 p.m., V6, Licensed Practical Nurse (LPN), stated: R2 had a huge bruise on his left arm and skin tears. It made no sense because he had a stroke and does not even move his left arm. I do not know who initially reported the injury or who investigated it. He was not sure when I talked to him what had happened. He is totally dependent on staff. He said he could feel pain when they showered him, but other than that he had no sensation in his left arm. I have done the treatments when I worked and completed measurements. The hematoma was really big and swollen. It was dark purple all around the skin tear. It has faded a ton. What you see now has really faded. You can line his arm up with the geri chair and see the bare metal piece of the chair lines up with his injury. It is supposed to be under the vinyl seat. He is a big man. I think his weight stretches the vinyl material and causes the metal gear to be exposed. The vinyl pulls from the side of the chair. It was obvious a staff member had to have let his arm hang down and caught his arm in the hinges of the geri chair. They had to have pushed the back of the chair to an upright position. Someone put a piece of foam on the exposed metal to prevent it from happening again.On 4/28/26 at 2:25 p.m., R2 was lying in bed. V18, Certified Nursing Assistant (CNA), looked at R2's geriatric wheeled chair sitting outside R2's bedroom door. V18 stated: I am sure his arm got caught inside the chair when someone pushed the back of the chair up. You can tell when he is laid back in the chair his arm drops down that way. I was not here when it happened. I just know he can't control his arm, so we have to protect it for him.V18 confirmed that R2 did not have a pillow supporting his left arm when he was transferred from the chair to bed. V18 stated: This is the first I heard that he is supposed to have a pillow under his arm. It makes sense for sure. I have worked a lot since he got hurt, and nobody said anything about a pillow. I will find one when I get him up later today.On 4/28/26 at 2:35 p.m., in a second interview, V7, Certified Nursing Assistant (CNA), stated: I had no idea R2 was supposed to have his arm propped on a pillow. I would have thought someone would have said something. I guess we have access to the care plans, but we don't have time to look at every resident's care plan. We are supposed to get new information on all care when it changes. He got the skin tear and bruise weeks ago. We should have been told. I have worked multiple shifts since it happened. I didn't know, or I would have done it. I will have to find one. I may have to fold a bath blanket to rest his arm on. We don't have a lot of extra pillows.On 4/28/26 at 3:10 p.m., V2, Director of Nursing, stated R2's injuries were the result of an environmental hazard. V2 also stated: I have a specialty pillow in mind for R2's arm to rest on. I am not sure why the pillow was not implemented. The care plan was updated. The intervention should have been passed on in report.2.) R3's Initial admission Assessment, dated 04/01/26, documents R3 had no falls prior to admission and no skin impairment.R3's diagnoses sheet on admission, dated 04/01/26, documents the following: Dizziness and Giddiness, Essential Hypertension, Dorsalgia (spinal pain), Unspecified, Need for Assistance, and Altered Mental Status.R3's Minimum Data Set (MDS), dated [DATE], documents the following: R3's Brief Interview of Mental Status score was 12 out of a possible 15, indicating R3 has moderate cognitive impairment.R3's Care Plan, updated 4/06/26, documents the following: R3 is at risk for skin impairment. I will maintain or develop clean and intact skin by the review date. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc., to MD (Physician).R3's same Care Plan documents R3 is at risk for falls. Resident will have decreased risk of falls by next review date. Anticipate and meet the resident's needs. Rearranged room related to resident's preference. Date Initiated: 04/06/2026 (post-fall as documented below).R3's Comprehensive Incident/Fall Assessment, dated 4/5/26, documents: (R3) had an unwitnessed fall on 04/05/2026 at 08:00 which resulted in a skin tear that measured: right forearm 3.5 cm (presumed length) x 5.5 cm (presumed width).R3's Incident Follow Up, dated 04/6/2026 at 10:29 a.m., documents the following: Late Entry: Note Text: IDT (Interdisciplinary Team) met and discussed incident. Resident sustained unwitnessed fall in her room, skin tear noted to right forearm, ROM WNL (Range of Motion Within Normal Limits) per her baseline. Resident was observed on the floor on her left side, next to bedside. Resident was wearing nonskid footwear, floor was dry and free from debris. Root cause - lightheadedness, dizziness, narrow pathway to nightstand. Intervention: Check orthostatic blood pressure, rearrange room. Care plan reviewed and updated.On 4/28/26 at 12:05 p.m., R3 was ambulating with a front-wheeled walker. R3 had a large bandage on her right forearm. The bandage measured approximately four inches long by three inches wide. R3 stated she cut her arm on the sharp edges of the footboard of her bed when she fell a few weeks ago.R3 then showed this surveyor the foot of the bed. There was a plastic-like, gnawed, sharp-edged laminate area on the left edge of R3's footboard. The damaged laminate area measured approximately seven inches. The foot of the bed was approximately twelve inches from the outside wall. The same outside wall had an air conditioner/heater installed that protruded approximately the same distance. The middle of R3's mattress was pushed up against the air conditioner/heater.R3 stated: Maybe you can get that guy in here that said he would fix this. I would like a new bed. I told them that when I moved in here (4/1/26, prior to the 4/5/26 fall). I don't like my bed up against this heater. One of the nurses said I have to have my bed here. I would like my recliner in here too. I was told when that lady (unidentified roommate) moved out of here, there would be room. She has been gone several days. I have mentioned my bed to every nurse that comes to my room. Can you resolve this? The Lord knows I have tried. I am only going to be here until I get stronger. Then I am going back home.On 4/28/26 at 12:15 p.m., V6, Licensed Practical Nurse (LPN), stated: I don't know about her fall. I was not here. I heard she had an unwitnessed fall a few weeks ago. I have done treatments on her right arm skin tear. She told me several times that the foot of the bed caused the skin tear. I was not here, and I don't know who investigated the fall.V6 then walked to R3's room and confirmed the left footboard panel had sharp, jagged, laminate plastic-like edges extending approximately seven inches long by one inch wide. V6 stated she had never checked the footboard but was aware a few weeks ago that the Maintenance Department was supposed to look at R3's bed.V6 stated: It is easy to see how R3's bed caused the skin tear now that I see this jagged plastic. V6 rubbed the edge of the seven-inch damaged area of the footboard. V6 also confirmed that R3's bed was against the air conditioner, leaving an approximately twelve-inch path where R3 presumably walked. V6 stated: This is where she said she fell. V6 pointed to the floor and the foot of R3's bed.On 4/28/26 at 2:50 p.m., V2, Director of Nursing (DON), reviewed R3's incident report and confirmed V2 completed R3's fall investigation. V2 then walked to R3's room. R3 was seated on the side of her bed. V2 asked R3 if she could look at the footboard of the bed.R3 stated: I wish you would. There was a guy that looked at it a day or two after I got here (4/1/26 admission). He said he would be back to fix my bed. He never came back. I have mentioned it at least a dozen times to the nursing staff. I also have told anyone that would listen. I don't want my bed up against this radiator thing on my wall. I can't walk past it. I feel there is no room there. That is the side of the bed I am used to getting out of to go to the bathroom. Go ahead and look at the sharp edges on that (pointing to footboard). Run your hand down the edge. That is terribly sharp.V2 leaned down and confirmed the jagged plastic with sharp edges on the footboard of R3's bed. V2 then told R3 she would get the room rearranged to R3's liking and get her a different bed. R3 responded: Can I hold you to that, since you're a manager?V2 left R3's room and told this surveyor the intervention for R3's fall was to rearrange R3's room to create a safe path for R3 to walk. V2 stated: I am not sure why that did not happen. Maintenance was aware R3's bed needed moved away from the wall.V2 also stated she did not evaluate the footboard of R3's bed when she assessed the room during her fall investigation. V2 stated the rough edges of the footboard were the most likely cause of R3's skin tear, as well as the path being too narrow for R3 to safely walk.On 4/29/26 at 1:55 p.m., V1, Regional Administrator, stated: We have a meeting every morning. She had not been here very long when she fell. She brought her request to us about her bed. We discussed the need for a different bed for R3 in morning meeting. V16, Maintenance Director, is off right now and is not available. He was in the daily meeting when R3's bed was discussed. We were aware R3's bed was in disrepair. I checked yesterday and could not find the work order in our system. We have a Regional Maintenance Director (V17) that would have addressed R3's bed had the work order been entered in our system, as it should have been.The facility policy, Fall Prevention Program, revised 01/2026, documents the following safety guidance: 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 as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness.The same policy documents: Identification of all risks/issues Addresses each fall Interventions are changed with each fall, as appropriate Preventative measuresThe same policy documents: Fall/safety interventions may include but are not limited to: The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards. Lighting will be appropriate for the time of day and in accordance with the resident's desire and the plan of care. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provided care as assigned in accordance with the plan of care.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse and verbal abuse for three (R26, R24, R61) of four residents reviewed for abuse in a sample list of 35. Findings Include: The facility's Abuse Prevention and Reporting Policy dated September 2024 documents the facility affirms the right of the residents to be free from abuse. Physical Abuse is the infliction of injury on a resident that occurs other then by accidental means. Examples of physical abuse include hitting, slapping, and kicking. Verbal abuse may be considered a type of mental abuse and includes the use of oral communication to residents within hearing distance. Examples include harassing a resident, mocking, insulting, yelling at, and threatening residents. A resident to resident altercation should be reviewed as a potential situation of abuse. This policy also documents employees are required to report any incident, allegation or suspicion of potential abuse to the administrator immediately. 1. R26's Medical Diagnoses List dated March 2025 documents R26 is diagnosed with Bipolar Disorder, borderline Personality Disorder, and Dementia Moderate with Agitation. R26' Minimum Data Set, dated dated dated [DATE] documents R26 has a moderate cognitive impairment. R26's Aggressive Behavior assessment dated [DATE] documents R26 has a general awareness and capability of understanding his behavior, has been verbally and physically aggressive with other residents and has a trigger of loud noises. R26's Care Plan dated 2/19/25 documents R26 has a behavior problem of verbal and physical aggressions towards staff and peers. R26 also has the potential to be physically aggressive related to poor impulse control. 2. R61's Medical Diagnoses List dated March 2025 documents R61 is diagnosed with Major Depression Disorder and Chronic Ulcers of the Lower Extremities. R61's Minimum Data Set, dated dated dated [DATE] documents R61 is cognitively intact. R61's Care Plan dated 12/27/24 documents R61 is at a high risk for abuse/neglect. R61's Progress Note dated 12/20/24 documents R61 stated that she was yelled at and slapped in the face by R26 when he was trying to get by her coming from the dining room. V11 Certified Nurses Assistant (CNA) witnessed this altercation. The Final Abuse Investigation Report dated 12/30/24 documents on 12/20/24 R26 got in R61's face and started yelling and then hit her in her face. On 3/24/25 at 2:00 PM R61 stated R26 is often very moody and yells and curses at others. R61 stated in December 2024 R26 was sitting in the middle of the dining room path and there was a traffic jam when she asked R26 to move forward and out of the way. As she passed around his wheelchair she accidentally hit the wheel of his chair with her chair and he yelled and reached out tried to kick her and hit her. He ended up slapping her across her face. R61 stated she was stunned and it stung a bit. R61 stated staff stepped in-between them and took her to her room. R26 stated she avoids R26 at all costs. R26 stated she doesn't want to pass by R26 and he would knock her teeth down her throat. R61 stated, R26 is very aggressive towards others and just the other day R61 told R26 to chill out when he was going back and forth with another resident and he told R61 to shut the f*** up b**** (expletives). On 3/24/25 at 2:32 PM V11 (CNA) stated she observed the altercation between R26 and R61. There was a wheelchair jam trying to get out of the dining room. R26 was yelling at R61 to move and she said she was doing the best she could. As they passed each other R26 kept trying to kick R61 and R26 slapped R61 across the face. V11 stated she then got in between the residents and blocked his feet and hands from hitting her again. V11 stated she was concerned that R26 would kick R61's legs and she has fragile wounds on her legs. V11 stated she got R61 out of the dining room. V11 stated there have been many occasions that R26 gets into arguments or altercations with other residents- both verbally and physically. R26 also curses at residents and tries to hit others if he is agitated. 3. R24's Medical Diagnoses List dated March 2025 documents R24 is diagnosed with Generalized anxiety and Major Depressive Disorder. R24's Minimum Data Set, dated dated dated [DATE] documents R24 is cognitively intact. On 3/22/25 at 11:02 AM R24 stated a male resident (R26) punched her in the arm about a month ago as she passed him in the dining area. R24 stated R26 was stopped in his wheelchair and was in the way of others passing. R24 passed around R26 in her wheelchair and R26 reached out and punched her in the arm. R24 stated R26 punched her pretty hard and he then started yelling/cursing at her. R24 stated R26 is often verbally and physically abusive to other residents. R26 wheels around the facility and will tell other residents to shut the f*** (expletive) up and calls people b**** (expletive). The Final Abuse Investigation Report dated 2/13/25 documents on 2/6/25 R24 reported R26 hit her in her arm when she asked him to move out of the way. On 3/24/25 at 2:10 PM V21 Licensed Practical Nurse (LPN) stated she did not witness R24 getting slapped by R26 but she did come over when she heard the commotion and saw R24 was visibly upset and crying. R24 stated she was passing by R26 and he punched her in the arm. On 3/24/25 at 4:00 PM V1 Administrator confirmed R26 has behavior issues and gets agitated easily. V1 confirmed residents need to feel safe in their home and some interventions need to be put in place in order to keep residents safe from R26's verbal and physical outbursts. V1 confirmed these incidents of slapping, punching, and verbally attacking residents with foul aggressive language could be considered abusive.

Based on observation, interview, and record review the facility failed to use proper equipment to transport a resident (R1) resulting in R1 sustaining an impacted tibia fracture and associated proximal fibula fracture. The facility also failed to follow its incident/accident policy by failing to report a serious injury to the state survey agency and thoroughly investigate an injury to determine the root cause and develop interventions for one (R1) of three residents reviewed for accidents in the sample list of seven. Findings include: On 12/3/24 at 1:56 PM R1 stated on 10/20/24 R1 had a left leg tibia/fibula fracture caused while V9 Certified Nursing Assistant (CNA) was pushing R1 in a shower chair down the hallway, R1 started to slip and attempted to push herself back up and R1's left toe/foot caught on the rug in the hallway. R1 screamed ow and thought it was broken. R1 stated x-rays were not taken for two to three days. R1 stated R1 was seen by V15 Orthopedic Physician on 11/6/24, who told R1 that R1's leg could not be casted as it would worsen R1's foot drop and require amputation, so the bones were left to fuse. On 12/4/24 at 9:24 AM the shower chair was viewed with V7 CNA. The chair was made of plastic piping and had four small caster wheels, and it did not include foot pedals or foot/leg support. R1's Diagnosis List documents R1 has a diagnosis of Multiple Sclerosis and is wheelchair bound. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is cognitively intact, has impaired range of motion to both legs, uses a wheelchair for mobility, and is dependent on staff for transfers. R1's Nursing Note dated 10/21/2024 at 12:35 AM documents R1 received a shower and complained of ankle and knee pain, physician notified and orders received for x-ray. The Incident Investigation Form dated 10/21/24 at 12:30 AM, recorded by V9 CNA, documents V9 was pushing R1 in a shower chair down the hallway after R1's shower when R1's left foot was low to the ground and struck the edge of the carpet rug in front of the patio door. This form documents R1 screamed ow and V9 backed up to assist in moving R1's foot, R1 was brought to her room and the nurse was notified. The Incident Investigation Form dated 10/21/24 at 12:30 AM, recorded by V17 CNA, documents V17 witnessed V9 pushing R1 in a shower chair, R1 yelled ow and R1's toe was stuck underneath the carpet. R1's left ankle x-ray dated 10/21/24 documents a questionable hairline fracture of the anterior aspect of the left distal tibial metaphysis and recommends additional radiographs for further evaluation. R1's left ankle x-ray dated 10/22/24 documents R1 has diffuse Osteopenia (decreased bone mineral density) and a subacute nondisplaced fracture of the distal end of the left tibia. R1's Progress Note dated 11/6/24, recorded by V15, documents R1's chief complaint as I (R1) slipped, caught the rug, and it rebroke my (R1's) ankle and hyperextended my (R1's) knee. This note documents based on x-rays completed on 11/6/24 R1 had an impacted left distal tibia fracture with an associated proximal fibula fracture; and R1 is nonambulatory/bed-bound and has contractures to both ankles. This note documents due to R1's significant contractures V15 did not recommend casting and recommended to repeat x-rays of the left leg to ensure that there are no changes in alignment. R1's Care Plan with revised date 12/3/24 does not document R1's injury. There is no documentation that the facility reported R1's incident and fracture to the state survey agency or conducted a thorough investigation to identify root cause and develop/implement interventions to address the incident. On 12/3/24 at 3:32 PM V17 CNA stated V17 witnessed V9 CNA pushing R1 in a shower chair down the hall, R1's toe stubbed against the rug in front of the patio door and R1 yelled Ow. V17 stated R1 was transferred to bed and complained of left shin and ankle pain which was reported to the nurse. V17 stated a lot of times residents' feet brush against the floor when staff use the shower chair to transport residents. V17 stated the staff use the shower chair to transport because there is not enough room in the shower room for the full mechanical lift and R1 uses the mechanical lift for transfers. On 12/4/24 at 9:35 AM V17 described the shower chair used for R1, and it was not a reclining back shower chair and did not have foot rest/support. V17 stated R1's incident happened on 10/20/24 around 10:00 PM. On 12/3/24 at 4:16 PM V1 Administrator stated V1 did not report R1's injury since she did not become aware of the fracture until about a week after the incident happened. V1 confirmed R1's injury should have been reported to the state survey agency and the facility should have investigated the injury/incident. V1 stated V1 obtained staff statements regarding the incident, and staff were educated to slow down when transporting residents in a shower chair and ensure the resident's feet are off of the floor. V1 stated V1 was told by staff that R1's toe got caught on the rug while staff were pushing R1 in the shower chair down the hallway. On 12/4/24 at 9:10 AM V2 Director or Nursing stated V2 updates the care plans and confirmed R1's care plan does not address R1's injury. V2 stated V2 did not investigate R1's injury/incident and stated V2 thought it was acceptable for staff to use shower chairs to transport residents. On 12/4/24 at 1:31 PM V16 (R1's Physician) stated V16 ordered R1's x-rays, V16 saw R1 on 10/31/24 and R1 reported R1's foot got caught and hyperextended her leg while coming back from the shower. V16 confirmed R1's fractures would be consistent with an injury caused from stubbing her toe/foot on the carpet while being transported in a shower chair. V16 stated it would have been safer to use a wheelchair to transfer between locations rather than a shower chair since there is no foot support or pedals, which a wheelchair has. The Owner's Manual for (shower chair), provided by the facility on 12/4/24, dated November 2018 documents This device is NOT intended to be used as a transfer bench or device. The facility's Incident and Accidents policy dated October 2024 documents an incident/accident report will be completed for all serious accidents/incidents of residents and unexpected events that cause actual or potential harm to a resident and will include the date/time of the incident/accident, written statements, possible cause of incident, physical assessment, injuries, vital signs, treatment, and notification of appropriate parties. This policy documents to report actual injuries to the state survey agency within 24 hours of the occurrence and submit a narrative summary of the incident within five working days.

Based on observation, interview, and record review the facility failed to implement safety measures, failed to provide adequate supervision and toileting assistance to prevent falls (R2, R5); and failed to develop and implement fall interventions and thoroughly complete fall investigations (R1, R2, R5). These failures affected 3 (R1, R2, and R5) of 3 residents reviewed for falls in the sample list of 14. These failures resulted in R2 and R5 sustaining falls with lacerations that required emergency room treatment of medical glue closure. Findings include: The facility's Fall Prevention policy dated 11/10/18 documents all staff must observe residents for safety and if residents who are high risk for falls are observed up assistance must be summoned/provided. This policy documents to conduct a fall huddle after the fall with the staff on duty to identify details of the event and appropriate interventions, and the nurse will document the circumstances of the fall and the new interventions. Falls will be reviewed during the morning Quality Assurance meetings and the resident's care plan will be updated with new interventions. This policy lists properly fitting clothing, frequent checks while in bed, and frequent toileting schedule as some of the fall prevention interventions. 1.) The facility's Final Report to IDPH (Illinois Department of Public Health) documents on 9/19/24 at 3:00 PM R2 was witnessed to trip on a mound of dirt on the grass patio area causing R2 to fall face first on the concrete. This report documents R2's fall likely occurred due to R2's Dementia diagnosis and the mounds of dirt caused by moles; and the post fall intervention is that the patio area will be frequently monitored to ensure mole mounds are taken care of right away. V16 Activity Aide Witness Statement dated 9/19/24 documents residents were outside on patio area, R2 walked off of the concrete area onto grass and tripped on a mound of dirt causing R2 to fall face first onto the concrete. R2's Assess Intervene and Monitor for Wellness form dated 9/19/24 at 3:58 PM documents R2 fell outside on the patio and R2 had skin tears to the left elbow and upper arm, an abrasion to the left elbow, and a facial laceration. R2's Emergency Department Notes dated 9/19/24 document R2 presented due to a fall while outside on the facility's patio and R2 had a laceration to the left cheek, an abrasion to left shoulder, and skin tear to the left elbow. R2's left cheek laceration required medical glue closure. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has severe cognitive impairment and requires supervision or touching assistance for transfers and walking. R2's Care Plan dated 9/26/24 documents R2 is at risk for falls related to cognitive impairment, R2 does not understand limits and R2 has poor safety awareness. This care plan includes an intervention dated 9/19/24 to level out dirt mounds on the patio and an intervention dated 9/26/24 to ensure R2 is wearing pants that fit properly. R2's Nursing Note dated 9/26/2024 at 3:22 PM documents R2 fell in another resident room after slipping on her pant legs that were too long, and R2 sustained a cut above her right eye from the clip on the call light cord. R2's Interdisciplinary Note dated 9/26/24 documents the root cause of the fall as R2's pants were too long and the new fall intervention was to ensure R2 wears pants that fit properly. There is no documentation that staff were interviewed regarding this fall to determine who found R2, when R2 was last observed prior to the fall, and what R2 was doing at that time. On 10/16/24 at 9:27 AM V16 Activity Aide stated V16 witnessed R2's fall on the patio, R2 was walking outside in the patio area, and the mole mounds are horrid out there.V16 stated we are constantly stomping them down and V16 told R2 to be careful. V16 stated R2 then tripped over a mole mound causing R2 to fall and hit R2's head on the pavement, which broke R2's glasses and caused a cut by R2's eye. V16 stated R2 was not wearing shoes at the time, since R2 is not use to wearing shoes. V2 stated all of the staff were aware of the mole mounds prior to the fall and we would try to stomp them down. V16 stated V16 doesn't believe the facility had a maintenance staff at that time. On 10/16/24 at 12:39 PM V3 Licensed Practical Nurse (LPN) stated V3 was R2's nurse on 9/26/25 and R2's fall was unwitnessed. V3 stated it was believed that R2 slipped on her pants that were too long and hung underneath R2's feet. V3 stated R2 cut her forehead on the call light cord clip during the fall. On 10/16/24 at 12:40 PM V5 Certified Nursing Assistant (CNA) stated R2 was found on the floor of another resident's room and R2 was wearing pants that were too long, which were removed from R2's closet after the fall. On 10/16/24 at 1:05 PM V1 Administrator in Training stated V1 would have set traps to address the mole issue if V1 had been notified, but no one had reported the mole issue to V1 until after V1 was investigating R2's fall on 9/19/24. On 10/17/24 at 9:00 AM V1 stated V1 had no documentation of staff interviews for R2's fall on 9/26/24. V1 stated V1 went to the unit for R2's fall and R2 was wearing an outfit that didn't belong to R2 as the pants were too long and the staff had tried rolling the pantlegs up. V1 stated R2 had slipped on her pants and V5 and V6 were the CNAs working R2's unit at the time. V1 stated V1 has told the staff that V1 needs written statements any time there is a resident fall, but the staff aren't always good about doing that. V1 stated the staff should document and describe any environmental factors and the resident's footwear at the time of the fall. V1 confirmed there should be documentation of information prior to a resident fall, such as when the resident was last toileted, when the resident was last checked on and the resident's activity at that time. 2.) On 10/16/24 at 8:00 AM R5 had facial bruising and swelling around he left eye and forehead. Attempts were made to interview R5, but R5's speech was unclear and R5 was unable to appropriately answer questions. At 8:07 AM R5 was walking in the hallway with a wheeled walker and assistance from V6 CNA. The facility's Final Report to IDPH documents R5 fell on [DATE] at 3:42 PM and was found sitting on the floor of the room next to R5's after leaving the bathroom. This report documents R5 went into the wrong room without R5's walker and had a laceration above R5's left eye, a bump on R5's forehead, and a skin tear to the left elbow. The facility documents the conclusion of R5's fall as R5 is known to get up without R5's walker at times and therapy evaluation and treatment as the post fall intervention. The facility's investigative file for R5's fall provided by V1 on 10/16/24, only included one written statement from staff, V8 CNA. V8's written statement dated 10/10/24 documents V8 was in the television room to prevent resident behaviors, V8 heard R5 yell and found R5 lying on the floor with blood on R5's face. There are no other documented interviews as part of R5's fall investigation to determine when R5 was last toileted or R5's activity when last observed prior to the fall. R5's Emergency Department Notes dated 10/10/24 document R5 presented for an unwitnessed fall with bleeding and contusion of the left forehead. R5 had a puncture wound near the hairline that measured four millimeters and a one centimeter laceration near the left eye brow that both required medical glue closure. R5's MDS dated [DATE] documents R5 has severe cognitive impairment and requires partial/moderate staff assistance for toileting hygiene and toileting transfers. Walking assistance is documented as not attempted for this assessment. R5's Care Plan with revised date 3/13/24 documents R5 performs Activities of Daily Living with setup help and verbal cues, and R5 walks independently with a walker and cues for locations as needed. This care plan documents an intervention dated 7/5/23 that R5 is independent with toileting with setup assistance, and has not been updated to reflect R5's toileting assistance as noted on R5's 9/16/24 MDS. R5's Care Plan with revised date 10/11/24 documents an intervention dated 10/10/24 for therapy to evaluate and treat. The facility's Daily Assignment Sheet dated 10/10/24 documents V8 as the only CNA working on the unit between 3:00 PM and 4:00 PM. On 10/16/24 at 8:20 AM V8 stated V8 was the only staff member on the unit when R5 had an unwitnessed fall on 10/10/24. V8 stated V8 was with other residents preventing behaviors when V8 heard R5 yell. V8 found R5 lying on the floor of R5's adjoining room, R5 was bleeding from R5's eyebrow, and R5 did not have R5's wheeled walker with R5. V8 stated V8 was aware that R5 was in the bathroom, but R5 would take herself to the bathroom and was independent with walking and using the wheeled walker. At 12:12 PM V8 stated on 10/10/24 at approximately 1:00 PM V8 toileted R5 and assisted R5 to bed, and R5's wheeled walker was within reach at that time. V8 stated V8 had passed by R5's room a few times prior to the fall and R5 was in bed asleep. On 10/16/24 at 9:42 AM V3 LPN stated V3 was R5's nurse and V8 was R5's CNA on 10/10/24. V3 stated R5 was in R5's bedroom and R5 has a history of getting up and walking by herself without her walker. V3 stated R5 left her walker outside of the bathroom door in R5's room, but R5 must have gotten confused and went into the adjoining room where R5 fell . V3 stated R5 had a cut and bump above her eye and was sent to the emergency room where medical glue was applied to close the cut. V3 confirmed V3 was not on R5's unit when R5 fell . V3 stated one CNA is not enough for R5's unit since the residents are always on the go and need assistance. On 10/16/24 at 11:44 AM V2 Director of Nursing stated V2 does not have any additional fall investigation documentation besides what is documented in the progress notes. At 4:44 PM V2 stated R5 usually gets out of bed, grabs R5's walker, and goes to the bathroom. V2 stated R5 is incontinent and the staff should prompt and assist R5 to toilet at least every two hours. V2 stated it is standard to have two CNAs assigned to the dementia unit and there are times recently that staff only worked partial shifts. V2 reviewed the 10/10/24 Daily Assignment Sheet and confirmed V8 was the only CNA on the unit between 3:00 PM and 4:00 PM. V2 stated V11 the Former Dementia Unit Director should have been on the unit at that time, but V11 had left the facility without notifying anyone. V2 stated We determined staffing as a factor for this fall, just didn't document that. On 10/17/24 at 9:00 AM V1 stated V1 had no other written statements for R5's 10/10/24 fall. V1 confirmed R5's fall investigation was not thorough and does not document staff statements were obtained from other staff that were assigned to R5's unit when R5 fell , and there was no documentation to determine when R5 was last toileted or observed prior to R5's fall. 31642 3.) R1's Diagnoses Sheet updated October 11, 2024 documents the following: Diffuse Traumatic Brain Injury With Loss of Consciousness Of Unspecified Duration, Subsequent Encounter, Mild Cognitive Impairment Uncertain or Unknown Etiology, Anxiety Disorder Unspecified, Unspecified Osteoarthritis Unspecified Site, Other Intervertebral Disc Degeneration Lumbar Region, Non-Surgical Orthopedic/Musculoskeletal, Essential (Primary)Hypertension, Long Term (Current) Use of Anticoagulatants, and Personal History of Pulmonary Embolism. R1's Physician Order Sheet dated 10/17/24 documents: Apixaban ( anticoagulant/blood thinner) Oral Tablet 2.5 milligrams, give one tablet by mouth two times a day. R1's Minimum Data Set, dated dated dated [DATE] documents R1 has a Brief Interview of Mental Status score of six out of a possible 15, indicating severe cognitive impairment. The same MDS documents R1 has had two or more falls, has no range of motion limitation of upper or lower extremities and is incontinent of bowel and bladder. R1's Fall Risk Evaluation dated 9/19/24 documents R1's fall risk score as 19. The same risk evaluation documents the following: Assess the resident status below. If the total score is 10 or greater, the resident should be considered HIGH. RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. The facility provided a fall log on 10/16/24, that documented R1 had falls 9/5/24, 9/12/24, 9/19/24, and 10/10/24. V1, Administrator confirmed an additional fall 10/15/24 had occurred that is not documented on the fall log. R1's Care Plan dated 10/10/24 documents the following: The resident review shows risk for falls. Risk Factors include: Behavior- impulsive without regard for safety, Deconditioning: 9.5.24-rolled out of bed, 9.12.24 Leisure room loss balance, 9.19.24 dining room. The same Care Plan documents the following fall interventions: 9.5.24-scoop mattress Date Initiated: 09/05/2024 9.12.24-medication review Date Initiated: 09/13/2024 9.19.24-placed on 15 min checks for 24 hrs (hours) Date Initiated: 09/20/2024 R1's same Care Plan dated 10/10/24 documents: Resident is usually able to to perform ADLs (activities of daily living) with max (maximum) hands on assist. Intervention: TOILET USE: The resident is totally dependent on two staff for toilet use. This care plan documents: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R1's same care plan does not document falls and fall interventions that occurred 10/10/24, 10/12/24 and 10/15/24. On 10/17/24 at 12:55 pm V2, Director of Nursing (DON) reviewed R1's fall investigations for 9/5/24, 9/12/24, 9/19/24, 10/10/24, 10/12/24 and 10/15/24. V2 confirmed R1 had falls on 10/10/24, 10/12/24 and 10/15/24 that did not include intervention related to R1's falls 10/10/24, 10/12/24 and 10/15/24. V2 stated (V24), Registered Nurse was hired to start next week as the designated Care Plan Coordinator, until then, all nurses are responsible for updating the care plan. V2 also confirmed R1s fall intervention documented for R1's 9/19/24 fall was to complete 15 minutes checks. V2 stated the 15 minutes checks were not completed by the Certified Nursing Assistants as they were supposed to be for that fall. V2 confirmed there were no interviews documented for R1's falls on 9/5/24, 9/19/24 and 10/10/24. V2 stated All investigations should include witness statements, if the fall was witnessed or not. It is necessary in order to determine what caused the fall and if there are any injuries that need continued assessments. I can't know what type of intervention to put in place unless the fall is thoroughly investigated. R1's A.I.M. (Assess Intervene Monitor) For Wellness-Event Record dated 10/15/2024 at 11:55 pm documents the following: Note Text: Event Details: (R1) appears to have experienced an alleged Intentional Change in Plane; Witnessed w/o (without) head involvement (confirmed in interviews head involvement could not be determined, see below). Event was first noted on 10/15/2024, 11:55 PM Evaluation of the resident and event occurred on or about 10/15/2024 11:55 PM. Just prior to/at the time of the event (R1) appears to have been lying in bed. (R1's) account of the event is resident has hx (history) of Dementia and unable to account incident. Witness to the event includes: (V20, Certified Nursing Assistant/CNA) see nurses note 10/15 23:55 (11:55 pm). Location of the event is: residents (R1) room. Description of the environment at the time of the event includes: clean, dry, well lit. Staff's immediate response is noted as the staff (V20, CNA)(attempted) lower resident to floor for safety. Body assessment completed. This type of event is believed to not have occurred previously (documented falls as noted above). See also A.I.M. For Wellness-Event Record for additional details. A- Assessment/Evaluation: BP (Blood Pressure) 155/89 -10/15/2024 23:58 Position: Lying l/arm P (Pulse) 97 - 10/15/2024 23:55 Pulse Type:Regular R (respirations) 18.0 - 10/14/2024 11:27 T (temp) 98.0- 10/15/2024 23:58 Route: Forehead (non-contact) BS (Blood Sugar) 174.0 - 10/15/2024 12:31 O2 (oxygen saturation) 96 % - 10/15/2024 23:57 Method: Room Air A Neurological Checklist does not appear to be warranted (confirmed in interview neurological assessment should have been conducted as it is unknown if R1 hit his head) at this time. Review of (R1's) medication reveals: The resident does not have any noted medication changes in the last week. The resident is not on Warafin. The resident does not take a direct thrombin inhibitor or platelet inhibitor (R1 does take Apixaban as noted above on POS). Resident is not on Hypoglycemic Medication/Insulin. Resident does not take Digoxin. Resident does receive antidepressant medication .The resident does not appear to have had any changes in psychotropic medication in the last 30 days. No changes observed in functional status within the last 3 days. Enabler in use include: No Change in cognition/decision making noted within last 3 days. Sensory enabler in use include: N/A No changes noted in behavior within the last 3 days. No change in lifestyle/routine noted the last 3 days includes. No changes noted in respiratory status in last 3 days. No changes in cardiovascular status noted within the last 3 days. No changes observed/noted within the last 3 days. GU (genitourinary) status not clinically applicable to the change in condition being reported. No changes in GU symptoms noted within the last 3 days. On 10/17/24 at 10:33 am V20, Certified Nursing Assistant (CNA) stated she worked 10/15/24 when R1 fell from bed. V20, CNA stated she raised R1's bed approximately three feet or a little more to change R1's incontinence brief in bed. V20 stated V26, CNA was also working the same hall. They split up to get rounds done for all the residents. V26, CNA was in another resident's room, while V20, was providing R1's care alone. V20 stated I (V20) did not know R1 required two people to change him. Often, we do have two CNA's to provide his (R1's) care. It is much easier and safer. V20 also stated R1 was laying on his side facing away from V20 as V20 provided posterior incontinence care. V20 asked R1 to stop rolling. R1 kept leaning and started to roll out of the bed. V20 grabbed his shirt and pants as best she could and tried to lower him to the floor, from the opposite side of the bed. V20 stated I did not actually see him land on the floor because I was on the opposite side of the bed. I was not able to hold on to him all the way down. V20 stated I did not hear a loud thump like he hit his head or anything. He was not complaining of anything but back pain. The nurse came in and so did (V26). We helped him up and got him back in bed. That is all he wanted to do. On 10/17/24 at 12:55 pm, during the same review of R1's fall investigations V2, DON/Director of Nursing, in review of R1's 10/15/24 fall investigation and care plan (noted below), V2, DON stated (V20) CNA should have had the second (V26) CNA assist to meet R1's toileting needs in bed. He is a slippery one. He can also be inappropriate grabbing the CNAs during care. A second CNA could have prevented the fall or most likely would have. On 10/17/24 at 1:45 pm V4, Licensed Practical Nurse stated V4 was the nurse when R1 fell [DATE]. V4 said she understood R1 had not hit his head when she had done a full physical assessment while R1 was on the floor. (R1) was trying to get up on his own from the floor and responded to me appropriately when I asked his to grip my fingers and move his legs. I completed his assessment in bed because he was getting up on his own. He had previous back pain I had given him Tylenol for within a half hour. When I assessed him for pain he only had the pain he always has. I took her at her word, that (V20) lowered him (R1) to the ground from his bed while (V20) was changing him. If he was supposed to have two people I would think the CNA's already knew that. Usually when I have worked the CNA's work together. V4 also stated R1 does turn on his call light. Sometimes she has seen him turn his call light on and yells help me, over and over until staff goes in to check on R1. On 10/17/24 at 11:55 am, V23, Housekeeper, was in R1's room cleaning. R1 was in the dining room. R1 had a scooped mattress on his low bed. R1's call light cord extended from the wall outlet to R1's bed. A red button to depress for activation was at the end of cord. The call light cord, button end was attached by a clip to R1's bed. The call light button was pushed, and did not activate the light outside his room or activate sound to direct staff to R1's room. V23, verified R1's call light was not functioning properly and stated she will get him a new one. On 10/17/24 at 12:00 pm R1 was seated in a chair in the dining room eating. R1 stated he does not remember anything about any falls, except The floor was cold when he fell out of bed. When asked how long he was on the floor he said he would have to guess, maybe 15 minutes. R1 stated I try to always use the call light, but sometimes forgets. On 10/17/24 at 12:05 pm V2, Director of Nursing stated All residents are to have a call light that works, especially resident with fall history.

Based on interview and record review the facility failed to protect a resident's (R2) right to be free from sexual abuse by another resident (R1). This failure resulted in R2, who is cognitively impaired, as a reasonable person that would not expect to be sexually abused in their own home or health care facility, causing them to feel fear, anxiety, and anger.The facility also failed to protect a resident's (R4) right to be free from physical abuse by another resident (R3) and protect a resident's (R6) right to be free from physical abuse by another resident (R4). These failures affected 5 (R1, R2, R3, R4, and R6) of 5 residents reviewed for abuse in a sample list of 14. Findings include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility's residents have the right to be free from abuse and dementia management is listed as one of the measures implemented to prevent abuse. This policy documents abuse is the willful infliction, a deliberate act, of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, pain or mental anguish. This policy documents non-consensual sexual contact of any type is sexual abuse. 1.) The facility's Final Report to IDPH (Illinois Department of Public Health) documents the following: On 10/9/24 at 6:30 PM V1 Administrator in Training was notified of an altercation between R1 and R2, and during the investigation it was identified that the altercation was actually inappropriate touching. Staff interviews determined R1 was sitting in the leisure room, R2 wandered into the room and sat beside R1, and R1 placed his hand on R2's right inner thigh and perineal area. R1 and R2 were immediately separated. V19 Unit Aide Witness Report dated 10/9/24 at 6:35 PM documents V19 witnessed R1's hand on R2's inner right thigh and R1 aggressively/firmly moved his fingers up and down R2's vaginal area on the outside of R2's clothing. V14 Certified Nursing Assistant (CNA) written statement dated 10/9/24 documents V19 witnessed R1 grab and rub R2's vaginal area. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment and has daily verbal, physical, and other behaviors during the review period. R1's Care Plan with revised date 10/11/24 documents R1 has sexually inappropriate behaviors towards staff and R1 was sexually inappropriate to a female resident. R2's MDS dated dated 8/5/24 documents R2 has a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. On 10/16/24 at 10:31 AM V14 CNA stated R2 sat next to R1 in the leisure room and V14 witnessed R2 stroke R1's vaginal area on the outside of R2's clothing. V14 stated R2 did not seem aware of R1's actions. On 10/16/24 at 10:55 AM V19 Unit Aide stated V19 was in the leisure room on the dementia unit with residents watching a movie. V19 stated R2 was sitting next to R1 and R1 firmly put his hand onto R2's inner thigh and moved his fingers aggressively along R2's vaginal area on the outside of R2's clothing. V19 stated R2 had a blank look on her face, R2 was confused, and R2 did not seem aware of R1's actions. V19 stated V19 immediately separated R1 from R2, and the incident was reported to V1 Administrator in Training. V19 stated R2 has previously made inappropriate sexual comments towards staff regarding their breasts and butt. On 10/16/24 between 11:20 AM and 11:22 AM V3 Licensed Practical Nurse and V12 Social Services Director/Dementia Unit Director stated R2 is confused, R2 does not recognize her family, and R2 does not have the cognitive ability to consent to sexual touching. On 10/26/24 at 12:58 PM V21 (R2's Family) was asked how R2 would have responded to the incident with R1 if R2 did not have cognitive impairment. V21 stated R2 would not like being touched by R1, and R2 would have been afraid of R1 since R2 does not know R1. On 10/16/24 at 1:27 PM V1 Administrator in Training stated the BIMS score is used to determine the resident's ability to consent to sexual activity, and a BIMS score of 13-15 indicates the resident is cognitively intact and able to consent. V1 stated the family and physician are also involved and the nurse educates the residents on safe sex practices. 2.) The facility's Final Report to IDPH documents on 2/28/24 at 3:45 PM R7 walked into R3 and R3 pushed R7 causing R7 to fall. The facility's Final Report to IDPH documents the following: On 10/13/2024 at 1:45 PM V1 Administrator in Training was notified of an altercation between R3 and R4. Staff heard scuffling in R4's room and witnessed R3 had R4 by the arm and would not let go. R3 is very territorial (per usual). This most likely occurred due to a recent room change that caused R3 and R4 to share a bathroom. R4 was moved to a different room. V7 CNA written statement dated 10/13/24 documents at approximately 1:45 PM V7 heard a loud noise, went to R4's room, and R4 opened the door trying to get away from R3 who had hold of R4's arm. This statement documents R3 and R4 were arguing, R4 got his arm free from R3, and then R3 swung at R4. R3's MDS dated [DATE] documents R3 has severe cognitive impairment, hallucinations, and daily verbal, physical, and other behaviors during the review period. R3 requires supervision or touching assistance for transfers and walking. R4's MDS dated [DATE] documents R4 has a severe cognitive impairment and requires supervision or touching assistance for walking. On 10/16/24 at 1:27 PM V1 stated R3 has a history of physical aggression towards other residents, and on 2/28/24 R7 walked into R3 and R3 pushed R7 down. On 10/16/24 at 1:56 PM V7 CNA stated V7 heard a noise like someone fell , V7 went to R4's room and witnessed R4 open the door trying to leave the room. V7 stated R3 had hold of the underside of R4's forearm and R4 was trying to lift his arm to get away from R3. V7 stated R3 and R4 were upset with each other and R3 attempted to swing and hit R4, but V7 was able to intervene and prevent additional contact. V7 stated V7 believed R3 used the bathroom, which adjoined with R4's room, and R3 entered into R4's room by mistake. V7 stated R4 is fine until someone messes with R4 or R4's belongings. 3.) The facility's IDPH Notification Form dated 10/15/24 documents an allegation of a resident to resident physical altercation between R4 and R6 that occurred on 10/15/24 at 5:15 PM. V15 Unit Aide's undated written statement documents on 10/15/24 between 5:10 PM and 5:20 PM R4 was eating and R6 was rubbing the table, R4 thought R6 was reaching for R4's food and smacked R6's hand against the table with R4's closed fist. This statement documents R4 was fully aware of R4's actions and R4 stated R4 acted because R4 thought R6 was trying to grab R4's food. R6's MDS dated [DATE] documents R6 has short term and long term memory impairment, transfers and walks with supervision or touching assistance, and has daily verbal, physical, and other behaviors during the review period. R6's Care Plan dated 6/6/23 documents R6 has behaviors that others may find disruptive and socially inappropriate which may cause others to seek reprisal against R6. This care plan documents R6 had altercations with other residents and goes into other resident rooms, and includes an intervention to intervene as needed as soon as R6's behavior is noted to ensure residents' safety. On 10/16/24 at 2:50 PM V15 Unit Aide stated last evening around 5:20 PM R6 was finished eating and R6 was rubbing the tables, which she likes to do. V15 stated R4 thought R6 was reaching for R4's food and R4 took his closed fist and smacked the back of R6's hand. V15 stated R4 acted intentionally, R4 later apologized and said that R4 acted because R4 thought R6 was going to take R4's food. V15 stated we try to keep R6 away from R4, because R6 likes to grab other residents' food.

Based on interview and record review the facility failed to ensure a resident (R1) was free from misappropriation of funds by an employee (V3 (Business Office Manager/BOM). This failure resulted in psychosocial harm for R1. R1 is one of four residents reviewed for misappropriation of property in the sample list of six. Findings include: The facility's Abuse Prevention Program dated 11/28/16 documents abuse includes misappropriation of resident property and exploitation, which includes unauthorized use of a resident's belongings or money. The facility's undated Resident Funds Policy and Procedure documents The facility will institute security measures to insure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include: signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight by the facility Administrator, and signed quarterly statements. The facility's Fax (Electronic Facsimile) Worksheet IDPH (Illinois Department of Public Health) Notification Form dated 9/13/24 documents on 9/13/24 at 11:00 PM V1 Administrator In Training was notified of an allegation of misappropriation of R1's property involving V3 and V4 Activity Aide. The facility's Final Report to IDPH for this incident documents the anonymous caller alleged V3 and V4 took $600 from R1's Trust Fund which was given to V5 (V3's and V4's Family Member) for car repairs. R1's Resident Trust Fund Transaction Log dated July 2024 documents on 7/30/24 Check #6633 was deducted for $200 in cash. This log does not document R1's signature authorizing this transaction, as prompted on the form, or what the cash was used for. The facility's Check #6633 dated 7/30/24 documents the check was made out to cash for an amount of $200. This check documents (R1's) cash on the memo line, and the check was signed by V1 and V3. V3's Notice of Termination dated 9/17/24 documents V3's employment was terminated due to failing to follow facility policy and procedure. R1's Minimum Data Set, dated dated dated dated 9/9/24 documents R1 has a Brief Interview for Mental Status score of 12, the higher end of moderate cognitive impairment. On 9/30/24 at 8:43 AM R1 stated the other day V1 talked to R1 about R1's Trust Fund, and V1 asked if R1 had given money to V3 or V4. R1 stated R1 never receives receipts for transactions or quarterly statements, so R1 did not notice any prior unknown transactions. R1 stated V1 reviewed R1's transactions with R1, and there was one cash transaction for an amount of $300 that R1 was unsure of. R1 stated R1 was told that V3 had been giving R1's money to V5 for car repairs, which R1 did not authorize. R1 stated this made R1 feel very insecure since R1's money is suppose to be kept safe by the facility. R1 stated R1 only receives $60 per month for disability and just recently received a large back payment. At 11:40 AM R1's Trust Fund records were reviewed with R1. R1 denied authorizing the check for $200 that was deducted from R1's account on 7/30/24. R1 stated that must have been the transaction that R1 was thinking of during R1's previous interview. On 9/30/24 at 9:36 AM V3 BOM stated a few months ago R1 had requested $500 in cash, but V3 was only able to give R1 $200. V3 stated if a resident requests cash for $200 or more, a check is written for that amount and the cash is given to the resident. V3 stated the resident has to sign the cash box log when V3 provides the cash. On 9/30/24 at 8:59 AM V1 Administrator In Training stated V3's employment was terminated for not following facility policy by not providing Resident Trust Fund receipts and statements to residents. At 9:50 AM V1 Administrator In Training stated on 9/13/24 at 11:00 PM the facility received an anonymous phone call alleging overhearing a phone conversation between V3 and V5 in which V3 stated V3 would get into big trouble and would need to take out money in installments. V1 stated the caller alleged that there were two checks for $600 taken from R1's Trust Fund, and V5 had been going to the facility to get the money. At 11:53 AM V1 reviewed R1's Trust Fund logs. V1 stated residents should be signing the logs next to each check written, including checks for cash withdrawals. V1 confirmed V1 and V3 signed the check for R1's $200 cash withdrawal, and confirmed there is no documentation of R1's authorization for this transaction to verify that this cash was given to R1.

Based on observation, interview, and record review the facility failed to effectively manage pain, routinely assess for pain, and timely implement pain medication orders for one (R45) of two residents reviewed for Hospice in the sample list of 36. This failure resulted in R45 experiencing uncontrolled pain as evidenced by grimacing, moaning, and yelling out. Findings include: The facility's Pain Prevention & Treatment policy dated 12/7/17 documents: It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, diagnosis that may anticipate pain. Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan. On 8/25/24 at 8:34 AM R45 was lying in bed moaning. V7, V9, and V10 Certified Nursing Assistants (CNA) entered R45's room. V9 stated R45 is on hospice and does that a lot, in regards to R45's moaning. V9 stated V9 will try to see what R45 needs. On 8/25/24 at 8:42 AM R45 had been repositioned. V4 Registered Nurse entered R45's room and R45 reported having back pain when V4 asked about R45's pain. On 8/25/24 at 4:15 PM V7, V9, V28 CNAs entered R45's room, provided urinary catheter care, and transferred R45 with a full mechanical lift from the bed into a reclining geriatric chair. During the catheter care R45 grabbed hold of the privacy curtain and moaned when staff turned and moved her. During the transfer R45 had facial grimacing and cried out ow, it hurts, hurry hurry. V7 and V9 were asked about R45's pain and moaning, and stated that was normal for R45. On 8/26/24 at 3:33 PM R45 was heard moaning from R45's room. V9 stated V9 will check on R45. R45's ongoing Diagnoses List documents R45 has Cirrhosis of the liver, Acute Kidney Injury, Hyperuricemia, and Esophageal Varices. R45's Minimum Data Set, dated dated dated [DATE] documents R45 has severe cognitive impairment, and during the last five days R45's pain was almost constant, frequently affected sleep, and almost constantly affected daily activities. R45 rated the worst intensity of pain as very severe, horrible during the last five days. There is no documentation that R45's pain is routinely assessed besides on admission and when PRN (as needed) pain medication is administered. R45's Care Plan dated 7/23/24 documents R45 is at risk for pain and documents interventions to anticipate need for pain relief and respond immediately to complaints of pain, monitor/document probably cause for pain episodes, remove/limit causes of pain when possible, monitor and report signs of pain to the nurse. This care plan does not document new interventions were developed/implemented to address R45's pain after 7/23/24. R45's July 2024 Medication Administration Record documents Percocet (narcotic pain medication) 5-325 milligrams (mg) one tablet twice daily for pain from 6/29-7/16/24, Fentanyl (narcotic) 12 micrograms (mcg) (incorrectly noted as 25 mcg) patch apply every 72 hours starting 7/17/24, Percocet 5-325 mg one tablet every 4 hours PRN from 6/29/24-8/15/24. 20 doses of PRN Percocet was given in July, and there were four times that R45's pain was rated 7-9 on a 1-10 scale between 7/10/24 and 7/16/24. R45's Hospice Physician Order Form dated 8/14/24 documents an order to discontinue Fentanyl 12 micrograms (mcg) and start Fentanyl 25 mcg patch apply every 72 hours. There is no documentation that this was implemented prior to 8/25/24 (11 days after the order). R45's August 2024 MAR documents Fentanyl 12 mcg patch was administered every 72 hours from 8/1-8/25/24, excluding 8/19/24 in which this entry documents to refer to R45's nursing notes. R45's nursing notes do not document why this medication was not administered. R45's August 2024 MAR documents Morphine Sulfate concentrate 20 mg/ml (milliliters) give 5 mg or 10 mg every hour PRN for pain initiated 8/15/24, Percocet 5-325 mg one tablet every 4 hours PRN discontinued 8/15/24. This MAR documents Tylenol 650 mg PRN was given on 8/20/24 at 10:20 AM for pain rated 9, and 15 doses of Morphine 10 mg and seven doses of Morphine 5 mg were given. R45's pain was rated 7-10 for 11 of the Morphine administrations, and 6 of these doses are documented as being ineffective in pain relief. There is no documentation that R45 refuses pain medication. R45's Controlled Substances Proof of Use dated 8/15/24-8/25/24 documents three Morphine Sulfate 0.5 ml (10 mg) administrations 8/24/24 at 8:00 PM, and 8/25/24 at 12:00 AM and 5:00 AM that are not documented on R45's MAR or nursing notes. There are no pre and post pain assessments documented for these administrations. On 8/25/24 at 10:48 AM V4 Registered Nurse (RN) stated R45 gets Fentanyl, Morphine, Tylenol and Ativan for pain, some of these medications are scheduled and some are given PRN. V4 stated we have been giving R45's PRN medications around the clock. V4 stated it was passed on in shift report today that R45 was uncomfortable and was up until 3:00 AM. At 11:36 AM V4 stated R45 had only one Fentanyl 12 mcg patch on this morning, which V4 removed and applied two patches. On 8/26/24 at 9:31 AM V14 Licensed Practical Nurse stated V14 was not sure why V14 did not administer R45's Fentanyl patch on 8/19/24, and possibly R45 refused the medication. On 8/26/24 at 12:00 PM V26 Hospice RN stated V26 consults with the nurses about R45's pain during each visit and the facility calls when R45 has increased pain. V26 confirmed the facility should call hospice if there are problems managing R45's pain. V26 stated V26 ordered Fentanyl 25 mcg from the hospice pharmacy on 8/18/24 and discovered during narcotic count on 8/20/24 that the facility still only had the 12 mcg patches. V26 confirmed not administering Fentanyl as ordered could contribute to R45 having increased pain. On 8/26/24 at 3:49 PM V21 LPN stated R45 was in a lot of pain on Saturday night (8/24/24), and R45 is usually in a lot of pain when R45 is laying down. V21 stated R45 rated R45's pain that night as a 10, we repositioned R45, V21 administered Haldol, Morphine, and Ativan and R45 slept for a few hours. V21 stated R45 woke up again moaning around 1:30-2:00 AM and then again at 6:00 AM. V21 stated Morphine does help relieve R45's pain and it helped that night. V21 stated if the medication administration is not documented on the MAR then it would be on the count sheets. V21 stated sometimes it doesn't show up on the MAR when V21 documents PRN medication administration. V21 stated R45 moans, yells out, and thrashes about when R45 has pain. On 8/25/24 at 3:42 PM V2 Director of Nursing (DON) stated pain should be documented in a progress note, pain should be assessed on an hourly basis for hospice residents, and hospice should be consulted for any uncontrolled pain. When asked about pain assessment documentation, V3 Assistant DON stated we chart by exception and pain scales are documented when PRN medications are given. V3 stated 12 mcg was ordered on 7/17/24 and V3 put an order in today to increase to 25 mcg and may apply two 12 mcg patches until the 25 mcg patches arrive. At 3:51 PM V2 reviewed R45's hospice binder and confirmed order to increase Fentanyl 25 mcg on 8/14/24. On 8/27/24 at 3:55 PM V2 stated hospice nurses give the facility their notes and order forms, and verbally tell the nurses of any new orders.

Based on interview and record review the facility failed to provide dialysis services to one (R15) of two residents reviewed for dialysis services from a total sample list of 36. This failure resulted in R15 being hospitalized for Hypervolemia. Findings include: On 8/27/24 at 1:10PM, R15 stated, I missed nearly two and a half months of dialysis because V11 Social Services Director didn't understand that I needed dialysis and didn't get a nurse involved. I ended up in the hospital really sick. I was doing dialysis three times a week before I came here. R15's undated census report documents that R15 was initially admitted to the facility on [DATE]. R15's undated diagnosis sheet documents that R15 was admitted with a diagnosis of kidney failure. R15's admission record dated 12/18/23 documents that R15 was admitted to the facility with a renal shunt for dialysis. R15's medical record documents that R15 was admitted to the hospital on 1/30/24 for Hypervolemia. R15's hospital discharge notes dated 2/6/24 document that R15 needs three times a week dialysis, to follow up with nephrology and to have a renal diet. On 8/27/24 at 2:30PM, V1 administrator stated , R15 was admitted urgently in December of 2023. The day of admission R15 was supposed to have dialysis; however the facility could not provide transportation on that date and after that I'm not sure what happened because (V11 Social Services Director) was handling it (dialysis appointments). On 8/27/24 at 2:45PM, V2 Director of Nursing said that nursing issues such as dialysis should be managed by nursing and that now they are being done so. On 8/27/24 at 1:50PM, V32 Dialysis Registered Nurse said that R15's first treatment at their facility was on 2/9/24 after she had been being dialyzed at the hospital. V32 said that R15 has kidney failure that requires dialysis three times a week and that the risks of not receiving dialysis three times a week could result in critical fluid overload including hospitalization .

Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affected three of five residents (R1, R2, R3) reviewed for abuse in the sample of nine. R1 pushed R2 who sustained skin tears to both elbows. R1 shoved R3 who fell into the wall, hit her head/back against the wall, then fell to the ground. R3 complained of back pain and was sent to the emergency room . Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse can include such things as hitting, slapping, pinching, and kicking. The Abuse Investigation Summary dated 4/24/24 documents on 4/24/24 at 6:15 PM R1 and R2 were involved in an incident of physical aggression. R1 and R2 were ambulating in the hallway. R1 stopped walking and as R2 walked past, R1 shoved R2 to the floor. R2 sustained skin tears to both elbows. The Abuse Investigation Summary dated 4/24/24 documents on 4/24/24 at 6:30 PM R1 and R3 were involved in an incident of physical aggression. R1 was standing in the hallway and R3 walked past him. As R3 walked past, R1 shoved R3. R3 stumbled but caught herself before falling to the ground. The Abuse Investigation Summary dated 4/26/24 documents on 4/26/24 at 1:30 PM R1 and R3 were involved in an incident of physical aggression. R1 was standing in the hallway and R3 walked past him and appeared to reach her hand out towards R1. As she did this, R1 shoved R3. R3 hit the wall behind her and fell to the ground. R1's Medical Diagnoses sheet dated May 2024 documents R1 is diagnosed with Alzheimer's Disease, Altered Mental Status, and Delusional Disorders. R1's Psychosocial Evaluation dated 3/9/24 documents R1 is uncooperative, wanders, paces, enters other resident's bedrooms uninvited, has delusions, is physically aggressive and abusive, violates the personal space of others and does not understand social limits. R1's Wandering/Elopement Evaluation dated 3/11/24 documents R1 is ambulatory and wanders. R1 also may become agitated when approaching others during wandering. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1 also has physical behavioral symptoms directed towards others (hitting, pushing, grabbing, kicking). R1's Care Plan dated 2/22/24 documents R1 is cognitively impaired and has the potential to be physically aggressive related to Dementia, Alzheimer's Disease, Pain, and Delusional Disorder. The same Care Plan documents R1 has a behavior problem with peers in his personal space related to Dementia. Staff are to intervene as necessary to protect the rights and safety of others. R2's Medical Diagnoses sheet dated May 2024 documents R2 is diagnosed with Dementia with Behaviors, Anxiety, and Insomnia. R2's Care Plan dated 3/11/24 documents R2 is cognitively impaired and wanders aimlessly with his head down. R2 has behaviors that others may find disruptive or socially inappropriate such as intruding into other's personal space. Other residents may seek reprisal against R2. R3's Medical Diagnoses sheet dated May 2024 documents R3 is diagnosed with Bipolar Disease, Alzheimer's Disease, Dementia, Hallucinations, Anxiety, Depression, and Wandering. R3's Care Plan dated 3/11/24 documents R3 is cognitively impaired and wanders. R3 has the potential to be verbally aggressive related to Depression and Cognitive Deficits. On 5/2/24 at 2:10 PM V1 Administrator confirmed R1 has a history of physical aggression towards staff and other residents. V1 confirmed R1 is ambulatory, wanders, and needs supervision. V1 confirmed R1, R2, and R3 are all cognitively impaired residents who reside on the facility's locked dementia unit. V1 stated during the abuse investigation for incidents on 4/24/24, R1 was visualized on video surveillance walking down the hall, stopping and then as R2 passed him in the hallway, R1 shoved him and R2 fell to the floor. V1 stated as staff were attending to R2, R1 was standing in the group of residents that started to congregate in the area. R3 then started to walk through the group of people surrounding R2 and R1 preceded to shove R3. R3 stumbled into the wall but did not fall to the ground. V1 confirmed facility staff should have removed R1 from the hallway after he shoved R2 and in not doing so they did nothing to protect other residents from becoming victims. V1 stated one staff should have attended to R2 and one staff should have removed R1 from the area and supervised him so he was not able to be aggressive with anyone else. V1 confirmed R2 sustained an abrasion to each elbow from the fall. After R2 was attended to, R1 was sent to the hospital for a psychiatric evaluation. The hospital performed diagnostic tests and found nothing acute. The hospital said R1 was not acting aggressive and sent R1 back to the facility the next morning on 4/25/24. V1 confirmed when R1 returned, the staff did not implement increased supervision or any other new intervention to ensure R1 would not be physically aggressive towards any other residents. R1 went about his business as usual. V1 Administrator confirmed the staff need to be able to keep residents safe from other resident's aggression. V1 also confirmed during the abuse investigation for the incident on 4/26/24, R1 was visualized on video surveillance again walking down the hallway. R1 stopped in the hallway and R3 passed R1 walking down the hallway. As R3 passed R1, she reached towards R1 and R1 shoved R3. R3 fell into the wall, hit her head/back against the wall, and fell to the ground. R3 complained of back pain and was sent to the emergency room but no acute injuries were found. R1 was again sent to the the hospital for a psychiatric evaluation and remains there at this time.

Based on observation, interview and record review the facility failed to adequately supervise and maintain a safe environment for residents, thoroughly investigate a fall, and failed to include a focus area, goal and interventions for a resident. These failures affect three residents (R2, R4, R6) out of three residents reviewed for falls in a sample list of nine residents. R6 sustained a dislocated Right Fourth finger and Left Foot Contusion as a result of an unwitnessed fall when the resident was found with dresser on top of him. Findings Include: 1. R6's Electronic Medical Record (EMR) documents R6's medical diagnoses as Dislocated Right Fourth Finger, Contusion to Left Foot, Moderate Dementia with Agitation, Delusional Disorder, Dysthymic Disorder and history of Embolism and Thrombosis of Deep Veins of Left Lower Extremity. R6's Minimum Data Set (MDS) dated [DATE] documents R6 was severely cognitively impaired. This same MDS documents R6 requires supervision with toileting, dressing, personal hygiene, transfers, ambulation and maximum assistance with bathing. R6's Care Plan intervention dated 2/29/24 documents staff are to assist with ambulation and transfers. This same careplan documents an intervention dated 3/11/24 that instructs staff to cue, orient and supervise as needed. R6's Fall Risk Evaluation dated 4/13/24 documents R6 as a risk for falling. R6's Nurse Progress Note dated: -4/23/24 at 8:30 PM documents (R6) was found on the floor by (V17) Certified Nurse Aide (CNA) when she heard a loud noise coming from (R6's) room. (R6) was on the floor laying on right side with dresser on top of him. (V17) CNA removed the dresser and came for help. On entering room (R6) is sitting on his bottom with legs bent. On assessment area found to top of Left Foot where skin had been sheared and on further assessment area found to his Right ring finger, which is bent not aligned as it should be. -4/24/2024 at 1:53 AM documents (R6's) Unwitnessed event was first noted on 04/23/2024 8:30 PM. Just prior to/at the time of the event (R6) appears to have been in his room going through his dresser drawers. (V17) Certified Nurse Aide (CNA) working on unit had just walked by (R6's) room taking another resident to his room and (V17) saw (R6) at his dresser in the top drawer. (V17) CNA heard a loud noise from next door, went immediately to the room and found (R6) on the floor with dresser on top of him. Review of (R6's) pain parameters reveals (R6) rates pain level as 7. Non-verbal sounds of pain or crying at the time of the event. Facial expressions (e.g grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) at the time of the event. Protective body movements or grasping at body at the time of the event. New onset pain observed/reported. Pain location includes upper extremity limb pain. -4/24/2024 at 9:09 AM documents Interdisciplinary Team Meeting (IDT) Falls-Root Cause- (R6) fidgeting with dresser and fell . R6's Fall Investigation dated 4/23/24 documents R6 had an unwitnessed fall in his room at 8:30 PM on 4/23/24. This same fall investigation documents V17 Certified Nurse Aide (CNA) witnessed R6 in R6's room going through his dresser drawers prior to R6's fall. This investigation documents V17 did not assist R6 at that time. This same investigation documents V17 saw (R6) at his dresser in the top drawer. V17 heard R6 yelling out and found R6 on the floor with dresser on top of him. When moving dresser, a blanket was found under it which made in unbalanced. R6's Fall Investigation documents R6's Right Fourth finger and top of Left Foot were injured. V17's Fall Investigation statement dated 4/23/24 for R6's fall on 4/23/24 documents (V17) walked in (R6's) room and the lights were on and (R6) was between both beds with the large dresser on top of (R6). (V17) got the dresser off of him and notified the nurse immediately. R6's Hospital records dated 4/23/24 document (R6) was sent to the emergency department via ambulance service from facility for a report that (R6) had dresser fell on (R6's) Right Hand. (R6's) Right Hand is swollen and Right Fourth finger is angled over Right Fifth finger. Cold pack applied to Right Hand. Left Foot appears swollen as well. (R6's) Right Fourth Finger was reduced and placed finger in aluminum splint. (R6's) Right Fourth digit was anesthetized via digital block with subcutaneous injection of eight cc of 1% Lidocaine. This same hospital record documents R6's diagnosis for this hospital stay as Traumatic dislocation of joint of finger, Fall and Contusion of Left Foot. R6's X Ray results of Right Hand dated 4/23/24 documents Impression: Dislocation of the Fourth finger on Right Hand at the PIP (Proximal Interphalangeal) joint. R6's Final Incident Report to the State Agency dated 4/23/24 documents R6 was in his room 'fidgeting' with his dresser. Upon entering R6's room, R6 was noted to be on floor in between the bed with the dresser on top of him. Upon assessment of (R6), he was noted to have an abrasion to top of his Left Foot and Right Fourth finger was noted to be bent. R6 was sent to the emergency room where he was treated for an abrasion to top of Left Foot and dislocated Right Fourth finger. This same report documents Discharge Instructions from emergency room stated (R6's) Fourth Finger on Right Hand was dislocated, have reduced it back into place, wear splint on finger as needed for comfort and follow up with Orthopedic. R6's Final Report documents The facility believes that (R6) was rummaging through dresser, attempted to remove one of the drawers, causing dresser to tip over onto resident. On 5/2/24 at 3:32 PM R6 wandering in dining area tapping his fingers on dining room tables to music that was playing. No staff present in dining area. On 5/3/24 at 1:10 PM V4 Dementia Unit Director stated R6 has a history of rummaging in his dresser drawers. V4 stated R6 likes to remove the clothes from the drawers and refold them. V4 stated R6 'is very busy' and requires a lot of supervision. V4 stated R6 has no safety awareness and should be supervised more closely to help prevent falls. V4 stated If (V17) Certified Nurse Aide (CNA) had assisted R6 as she saw him rummaging in his drawers prior to his fall, then he probably would not have fallen that time. On 5/3/24 at 2:45 PM V1 Administrator stated R6's fall could have been prevented if the staff would have made sure R6's surroundings were safe. V1 Administrator stated she was unaware of R6's dresser having a blanket underneath it which caused it to be off balance. V1 stated If the staff would have just moved the blanket from out from under the dresser, (R6) probably would not have fallen and dislocated his finger. V1 stated the staff failed to make sure R6's dresser was stable which in turn caused R6 to fall and dislocate his finger. V1 Administrator stated R6 had advanced Dementia and cannot be expected to provide for his own safety. V1 stated The staff are supposed to do that and they did not. 2. R4's Electronic Medical Record (EMR) documents admitted to facility on 10/28/23 with medical diagnoses of Severe Dementia with Psychotic Disturbance, Thyrotoxicosis with Diffuse Goiter, Intestinal Obstruction, Intestinal Adhesions with Partial Obstruction, Alzheimer's Disease, Ascites, Repeated Falls, Weakness, Urinary Incontinence, Incontinence of Feces and Need for Assistance with Personal Care. R4's Minimum Data Set (MDS) dated [DATE] documents R4 was severely cognitively impaired. This same MDS documents R4 was dependent on staff for toileting, personal hygiene, bathing and maximum assistance for dressing. R4's Fall Risk assessment dated [DATE] documents R4 as a risk for falling. R4's Care Plan initiated on 10/31/23 does not include a focus area, goal nor interventions for R4's being at risk of falling until 11/7/23. R4's Electronic Medical Record (EMR) documents R4 was last observed at 1:41 AM on 11/5/23 prior to being found on floor at 7:05 AM on 11/5/23. R4's Nurse Progress Noted dated 11/5/23 at 7:50 AM documents At 7:05 AM (R4) was observed lying on the floor, noted with small amount of blood to her mouth/oral area and small amount of blood also noted on the floor next to her head. (R4's) Right bottom lip noted swollen, Right side of face noted red, bump to Right anterior scalp area, no visual laceration noted to head or anywhere else. (R4) was noted nonverbal, per attending (V7) Certified Nurse Aide (CNA) this is not her norm. R4's Fall Investigation dated 11/5/23 documents R4 had an unwitnessed fall in R4's room on 11/5/23. This same investigation documents time of R4's fall was 7:05 AM. This same investigation report documents R4 obtained an injury to the top of her scalp, level of consciousness was 'Stuporous' and mobility was 'ambulatory without assistance'. Root cause documented as self transfer. This same investigation documents (V3) (R4's) Power of Attorney (POA) stated (R4) fell a lot at home and that is one of the main reasons she was placed at facility. On 5/2/24 at 2:10 PM V7 Certified Nurse Aide (CNA) stated V7 was the CNA on duty assigned to R4 the morning (11/5/23) R4 had an unwitnessed fall in her room. V7 stated V7 was scheduled from 6:00 AM-6:00 PM. V7 stated V7 came in that day (11/5/23) and started at the opposite end of the hall getting people up. V7 stated I (V7) did not see (R4) that morning until I went in to get her up. The nurse was on another hall and the other CNA was with me. No one could have checked on (R4). The night shift had told us that (R4) had been up all night rummaging through drawers and being very busy. I thought (R4) was just sleeping since I hadn't seen her that morning. Once I got to (R4's) room, there was blood on the floor where she had a bloody lip. (R4) was wearing two pairs of pants and had put her head through the sleeve of her own shirt. I stayed with (R4) until the ambulance came and took her to the hospital. (R4) was trying to hold her head but I encouraged her not to do that since we (facility) didn't really know how bad she was hurt yet. (R4) moaned like she was in pain. On 5/3/24 at 1:15 PM V1 Administrator stated R4 fell on [DATE]. V1 stated the exact time of the fall unclear due to the last time R4 was checked on was 1:41 AM. V1 stated We (facility) have no way to show that (R4) was checked from 1:41 AM-7:05 AM when (R4) was found laying on the floor of her room. V1 confirmed there is no documentation of R4 being monitored or assisted with cares during that time frame. V1 stated (R4) could have been laying there for awhile. We (facility) know that (R4) was up and down all night. We (facility) know that (R4) was found at 7:05 AM. The staff should have been monitoring (R4) more closely, especially since she was up and about in the middle of the night already. (R4) ended up going to the hospital with a bloody fat lip that could have been prevented if our staff were watching her better. I am thankful (R4) wasn't hurt any worse. 3. R2's undated Medical Diagnosis List documents R2's medical diagnoses as Dementia, Insomnia and Anxiety. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring maximum assistance with toileting, dressing, personal hygiene and supervision with transfers and mobility. R2's Care Plan intervention dated 3/12/24 instructs staff to Assist (R2) with ambulation and transfers. This same care plan documents an intervention dated 3/11/24 for R2 to be supervised on a one to one continual basis when up and walking. R2's Nurse Progress Note dated 4/22/24 at 1:08 PM documents Staff was called to hall after being informed (R2) had a fall. (Facility was) Informed by (V18) visitor that (R2) walked into cart and fell to buttocks and did not hit his head. Assessed (R2) for injury and none noted. R2's Nurse Progress Note dated 4/22/4 at 1:11 PM documents Just prior to/at the time of the event (R2) appears to have been pacing. Location of the event: Hallway. Description of the environment: (R2) was walking up and down hall and housekeeping cart in the middle of the hall. Facility staff actions/interventions and response at the time of the event: Staff instructed to stay with (R2) at all times. R2's Fall investigation dated 4/22/24 documents (V18) Visitor saw (R2) walk into (housekeeping) cart, then fell to floor on buttocks. Root Cause: Clutter in hallway. On 5/2/24 at 3:35 PM R2 was walking in hall with V10 Unit Aide. V10 walking with R2 side by side or in front/back of R2 depending on space available. R2 walked into an unoccupied room with two beds, two dressers and an attached bathroom. R2 was walking in a narrow space about five feet long between a bed and wall up to bedside dresser in corner. There was not enough room for V10 to walk with R2 in that space, so V10 Unit Aide waited at the end of the bed and then when R2 walked out of the area, V10 would again walk with R2. V10 Unit Aide did not try to re-direct R2 out of that narrow space. R2 paced back and forth in that same space several times. R2 became unsteady twice during the time he was pacing back and forth in that same space. On 5/2/24 at 3:40 V10 Unit Aide stated V10 is assigned to 'constantly be with (R2)'. V10 stated R2 paces all day but at night will sleep through the night 'pretty well'. V10 stated V10 should stay directly with R2 at all times due to R2 falls frequently and has an unsteady gait. V10 Unit Aide stated V10 and R2 would not both 'fit' in the space between the bed and wall so V10 did not walk with R2 in that space. V10 Unit Aide stated I saw (R2) get a little wobbly and hoped he wouldn't fall again. I wouldn't have been able to help him. I should have tried to get (R2) to just walk somewhere else. On 5/3/24 at 1:05 PM V4 Dementia Unit Director stated R2 normally walks around the unit 'a lot' with his head down and eyes closed. V4 stated R2 was on a one to one continual observation when R2 fell on [DATE]. V4 stated (V12, Activity Aide) should have redirected R2 away from the housekeeping cart instead of 'just allowing (R2) to run into the housekeeping cart and fall because he was trying to maneuver around it'. V4 stated (R2) has no safety awareness and doesn't know what he is doing. The staff need to be paying closer attention to (R2) so he doesn't fall so much. We (facility) all know that (R2) falls and needs a lot of guidance. On 5/3/24 at 1:55 PM V12 Activity Aide stated V12 directly witnessed R2 walk into the housekeeping cart causing him to fall on 4/22/24. V12 stated I don't remember seeing anyone else with (R2). I was not the 'one to one' assigned to (R2) that day. I was walking out of the dining room because it was right after lunch so I was helping other residents get back to their rooms or other areas. (R2) was pacing and he walked right into the housekeeping cart. There were no staff directly next to (R2). That big yellow housekeeping cart was right in the middle of the hall in everyone's way. (R2) keeps his head down and eyes closed when he walks so he would not have even seen it. This is a Dementia unit. We (staff) have to keep the aisles and all the areas clear of fall hazards. Many of the residents do not have any awareness of their surroundings and could get hurt on something like that. On 5/3/24 at 2:40 PM V1 Administrator stated R2 fell on [DATE] due to a housekeeping cart sitting in the middle of the hallway. V1 stated the housekeeping cart should not be left in the middle of a resident hallway. V1 stated staff should have re-directed R2 away from the cart which would have avoided the fall to begin with. V1 stated R2 is unsteady on his feet at times. V1 stated R2 has been on continual observations when R2 is up and walking since 3/11/24. V1 stated There is no reason for (R2) to have fallen like that. The staff should have been watching more closely and redirected him prior to getting that close to the housekeeping cart. V1 stated R2's fall on 4/22/24 could have been avoided if the staff were paying closer attention to R2. The facility policy titled 'Fall Prevention' revised 11/10/18 documents Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an Assess/Intercommunicate/Manage (AIM) for Wellness form along with any new intervention deemed to be appropriate at the time. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up. Help must be summoned or assistance must be provide to the resident.

Based on observation, interview and record review, the facility failed to identify a resident's fall risk by inaccurately completing the admission fall risk assessment, develop an at risk for falls care plan and implement fall prevention interventions, provide appropriate supervision and assistance to prevent falls, investigate falls and implement appropriate post fall interventions for two of three residents (R1, R2) reviewed for falls on the sample list of three. This failure resulted in a newly admitted resident (R2) not being identified as a fall risk therefore not having any fall prevention interventions implemented. R2 experienced daily falls, including a fall on 1/26/24 in which R2 sustained a facial laceration requiring closure with adhesive glue and strips at the emergency room . Findings Include: 1. On 2/6/24 at 9:20 am, R2 was walking down hallway on the Dementia Unit, bent forward and leaning to the right, while holding onto the hand rail. R2 was repeatedly asking for help stating, I need help, I don't know where my kids are. R2 had a scabbed laceration above the left eye brow but was not able to state what happened. On 2/6/24 at 10:48 am, V2 AIT (Administrator in Training) stated R2 had a fall that was witness over the surveillance cameras by V16 BOM (Business Office Manager), which caused R2's eye laceration. V2 explained R2 was a fairly new admission at that point, coming from another facility with a history of falls. V2 also stated R2 had experienced multiple falls since being admitted to the facility. R2's ongoing Census documents R2 was admitted to the facility on [DATE]. R2's ongoing Diagnoses Listing documents the following diagnoses: Alzheimer's Disease, Vascular Dementia with Behavioral Disturbances, and Anxiety. R2's Admission assessment dated [DATE] documents R2 requires substantial/maximal assistance with moving from sitting to lying position and lying to sitting, partial/moderate assistance with moving from sitting to standing and for transfers, and has poor trunk control. R2's Fall Risk assessment dated ,d+[DATE]//24 and 1/25/24 documents R2 is not a fall risk however the one dated 1/30/24 documents R2 is a fall risk. R2's Progress Notes document the following: 1/24/24 at 3:42 pm - experienced a witnessed fall. R2 has a small bump on the head. 1/25/24 - experienced fall at approximately 6:40am. R2 was walking down the hallway, using the siderail with CNA (Certified Nursing Assistant) close by. R2's gait was unsteady and R2 was unable to keep balance and fell to floor. 1/26/24 - Staff reported witnessing R2 falling to the floor via video surveillance. Nurse and staff responded and noted R2 to be lying on the floor on R2's back with complaints of head pain and was noted to have a laceration with bleeding to above the left eye. 1/30/24 - observed R2 getting out of the recliner in the tv room, and when R2 stood up, R2 fell back on the foot rest and fell forward hitting R2's head on the left side above the eyebrow, where R2 had previously had steri-strips applied. The area had a small amount of blood, and pressure was applied with cold cloth, more steri-strips applied. R2's Risk Management Notes for the above falls document the following: 1/24/24 - CNA called nurse to hallway due to witnessing R2 fall on the floor. R2 bumped R2's head and also received a small skin tear to the left forearm. CNA stated R2 had an unsteady gait and was unable to keep R2's balance. R2 was not able to explain what happened. Education provided to R2 and CNA's to try and prevent falls. There is no post fall intervention documented as being implemented. 1/25/24 - R2 was walking down hallway with a CNA close by. R2's gait was unsteady and R2 was unable to keep balance and fell to the floor. There is no post fall intervention documented as being implemented. 1/26/24 - nurse called to hallway for a witnessed fall of R2. R2 was lying on R2's back on the inlet of the doorway in the hallway. Staff had witnessed R2 ambulating and became unsteady falling in the hallway/doorway via camera observations. R2 noted to have a laceration above the left eye, actively bleeding with open exposure of epithelial tissue. R2 was only able to state area of pain, not what had happened. R2 was sent to the hospital and the laceration to the left eye was repaired with glue and steri-strips. There is no post fall interventions documented as being implemented. 1/30/24 - R2 observed getting out of the recliner in TV room, when R2 stood up, R2 fell back on the foot rest and fell forward hitting R2's head on the left side above the eyebrow, where R2 had previously had steri-strips applied. The area had a small amount of blood, and pressure was applied with cold cloth, and more steri strips were applied. R2's medical record does not contain an at risk care plan for R2's fall risk upon admission. R2's Care Plan dated 1/29/24 {4 days after admission and after the first fall} documents R2 has had an actual fall with minor injury due to cognitive impairment. R2 does not understand limits, is unaware of safety needs, and has poor balance. This care plan includes interventions of: 15 minute checks for two weeks, pharmacy consult to evaluate medications, provide activities that promote exercise and strength building where possible, provide wheelchair when unsteady gait and PT (Physical Therapy) for strength and mobility. On 2/6/24 at 10:28 am, V2 stated that the fall care plan and interventions were completed on 1/29/24 explaining, after R2's first fall (1/24/24) therapy screened R2, after the second fall, V2 instructed staff to place R2 in a wheelchair due to weakness, after the third fall, pharmacy completed a medication review and after the 4th fall, R2 was placed on 15 minute checks. R2's PT Plan of Care dated 1/29/24 documents R2 presents to skilled PT after suffering 1-2 falls per day since R2 arrived at the facility {5 days prior}. R2 resides on the locked Alzheimer's unit and is currently using a wheelchair for mobility due to multiple falls. R2's PT notes dated 2/1/24 documents R2 requires support on the right side due to increased right side lean and wanting to reach out for wall rails. Fatigues quickly. On 2/6/24 from 9:20 am - 9:32 am, and 1:15 pm - 1:31 pm, R2 was wandering/walking the hall's unassisted, bent over forward and leaning to the right. R2's gait was unsteady. On 2/6/24 at 2:45 pm, V10 Agency LPN (Licensed Practical Nurse) stated R2 is suppose to have staff with R2 when ambulating, R2 is not to be ambulating independently. On 2/7/24 from 5:10 am - 5:45 am, R2 was wandering/walking the halls unassisted, bent over leaning forward and leaning to the right. R2's gait was unsteady. On two seperate occasions during this time, V12 CNA and V13 CNA walked past R2 and did not assist R2 with ambulation or redirect R2 to sit down and not ambulate independently. On 2/7/24 at 7:10 am, V15 CNA stated V15 was working on 1/25/24 when R2 fell . V15 explained R2 was not walking at the time, as the Risk Management Report documents but instead had been sitting in wheelchair and when R2 stood up, R2's foot hit the wheelchair wheel causing R2 to loose balance and fall. V15 stated V15 reported how the fall occurred to the nurse on duty. On 2/7/24 at 7:25 am, V10 confirmed V10 filled out the Risk Management Report for R2's fall on 1/2/524 and explained V15 had reported that R2 lost R2's balance and fell . V10 stated V10 does not recall V15 saying R2 had lost balance due to hitting R2's foot on the wheelchair wheel but V15 might have. V10 just assumed R2 had been walking and then lost balance due to R2's gait being unsteady. On 2/7/24 at 7:35 am, V2 stated no investigations for root cause R2's falls were completed and that V2 came up with the interventions based off what the nurses wrote on the Risk Management Reports. On 2/7/24 at 9:20 am, V2 confirmed R2's fall risk assessments dated 1/24/24 and 1/25/24 were not accurate as the medications that R2 takes, along with R2's known fall history would have made R2 a fall risk. V2 also confirmed R2 did not have a fall risk care plan implemented with fall prevention intervention implemented at the time of admission but should have. 2. On 2/6/24 at 9:40 am, R1 had a scabbed laceration over the right eyebrow, which was open to air. The entire right eye is surrounded with a purple bruise with a greenish colored bruise to the right cheek bone. R1's IDPH (Illinois Department of Public Health) Notification Form dated 1/27/24 documents R1 was found on the floor next to R1's bed, bleeding from R1's head. R1 had a facial laceration that was closed with adhesives while at the hospital. R1's MDS (Minimum Data Set) dated 11/1/23 documents R1 has severe cognitive impairments and requires set up assistance only for mobility. R1's Care Plan dated 1/29/23 documents R1 had a fall with minor injury with an intervention for pharmacy to conduct a medication review. On 2/6/24 at 1:44 pm, V2 AIT (Administrator in Training) stated V2 did not conduct an investigation into R1's fall. Stated the new intervention of pharmacy doing a medication audit was V2's idea as V2 is the one that decides what interventions to put into place since the facility does not have a DON (Director of Nursing). V2 confirmed the intervention was not an appropriate intervention due to R1 rolling out of bed and that a medication review would not assist in preventing R1 from rolling out of bed again or keep R1 safe if it did happened again. The facility Fall Prevention Policy dated 11/10/18 documents the facility will provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Upon admission, the resident's fall risk will be identified and appropriate interventions will be implemented for residents determined to be at high risk for falls. If resident's are high risk for falls and observed up or getting up, help must be summoned or assistance must be provided to the resident. If a fall occurs, immediately after the fall, a huddle will be conducted to help identify circumstances of the fall and the unit nurse will place new interventions and new interventions will be written on the care plan.

Based on interview and record review the facility failed to effectively manage and treat ongoing pain for two of three residents (R11, R35) reviewed for pain on the sample list of 25. These failures resulted in R11, on hospice, screaming out in severe pain throughout the night. Findings include: The Pain Prevention and Treatment policy dated 12/7/14 documents it is the facility's policy to assess for and reduce the incidence and severity of pain in order to enhance resident's quality of life. Pain is subjective and should be documented as perceived by the resident. R11's Medical Diagnoses list dated 10/12/23 documents Dementia with Agitation, Bipolar Disorder, Schizoaffective Disorder, Osteoarthritis, and Osteoporosis. R11's Physician Order Sheet dated October 2023 documents R11 is on Hospice and is prescribed Morphine Sulfate (narcotic analgesic) scheduled and as needed for discomfort. R11's Minimum Data Set, dated dated dated [DATE] documents R11 is severely cognitively impaired. R11's Care Plan dated 7/26/23 documents R11 suffers from chronic pain. Staff are to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Staff are to notify the physician if interventions are unsuccessful. R11's Care Plan also documents R11 is receiving Hospice Services and the goal is to remain as comfortable as possible. R11's Medication Administration Record dated October 2023 documents on the night of 10/7/23 through the morning of 10/8/23, R11 did not receive any of the 'as needed' doses of Morphine Sulfate. R11 received her last scheduled dose of Morphine Sulfate around 8:00 PM on 10/7/23. R35's Medical Diagnoses list dated 10/12/23 documents difficulty Walking, Muscle Weakness, and Bipolar Disorder. R35's Physician Order Sheet dated October 2023 documents R35 is prescribed Acetaminophen every eight hours as needed or Percocet (opioid analgesic) every four hours as needed for pain. R35's Care Plan dated 6/8/23 documents R35 suffers from chronic pain. Staff are to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. R35's Medication Administration Record dated October 2023 documents on the night of 10/7/23 through the morning of 10/8/23 R35 was given two doses of Percocet pain medication. On 10/11/23 at 2:00 PM R35 stated she had issues with the V10 LPN on the night of 10/7/23. R35 stated she is in almost constant pain and V10 was refusing to give her pain medication timely. R35 stated V10 was rude and told her she was not giving her pain medication and slammed the door when she left the room. R35 rated her pain as a 10/10 and stated the staff do not do enough to help her relieve her pain. R35 stated V10 LPN also just let R11 who was R35's roommate scream and yell in pain all night long. R35 stated R11 sounded so uncomfortable and was crying and it was horrible to listen to. On 10/12/23 at 1:00 PM V12 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23 both R11 and R35's pain was ignored by their assigned nurse V10 Licensed Practical Nurse (LPN). V12 stated R11 is on hospice, has impaired cognition, and will yell out when she is agitated or in pain. V12 stated on the night of 10/7/23, R11 was yelling out and when asked what was wrong, R11 stated she hurt and kept repeating that over and over. V12 stated R11 was crying and appeared to be in pain. V12 stated she reported this to V10 LPN and V10 snapped at V12 and said she was not going to give R11 anything for pain. V12 stated more than one staff member reported R11 being in pain to V10 but V10 would not administer R11's pain medication. V12 stated R11 was crying and yelling out in pain all throughout the night shift. V12 also stated R35 began to complain about severe pain in the early morning hours of 10/8/23. V12 stated she reported this to V10 LPN and V10 told her to mind her own business. V12 stated R35 repeatedly had on her call light complaining of pain. V12 stated R35 told her V10 LPN had entered her room to answer the call light and told her she was not getting anything for pain, shut off the light, and slammed the door. V12 stated R35 was visibly upset and in pain. On 10/12/23 at 1:46 PM V20 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23 V10 Licensed Practical Nurse (LPN) ignored R11 and R35's pain. V20 stated R11 was screaming in pain all throughout the night shift from about 9:00 PM through the end of the shift. V20 stated she told V10 LPN and other staff told her as well about R11's pain and R35's pain. V10 LPN did not address R11's pain and did not give her any pain medication. R11 cried and yelled out it hurts all throughout the night shift on 10/7/23. V20 stated R11 normally does not yell out and cry all night long and normally sleeps through the night. V20 stated R35 complained of pain in the early hours of 10/8/23 and V10 ignored her requests for something for pain. On 10/12/23 at 2:30 PM V13 Certified Nurses Assistant (CNA) stated on the night shift of 10/7/23, R11 cried in pain and yelled out for hours and V10 Licensed Practical Nurse did nothing for her (R11). V13 CNA stated R11 was yelling out and saying she hurt. V10 LPN was told by multiple staff and did nothing to help R11. V13 CNA stated R35 also stated she needed something for pain multiple times and V10 LPN was told and did nothing. V13 stated R35 told her V10 LPN had entered her room to answer the call light, R35 told her she needed pain medication, and V10 told her she was not getting anything for pain, shut off the light, and slammed the door. On 10/12/23 at 5:08 PM V11 Licensed Practical Nurse (LPN) stated she worked the night shift on 10/7/23. V11 stated R11 was in a lot of pain that night and was screaming out and crying and stating she hurt all throughout the night. V11 LPN stated she told V10 LPN about R11's pain. V11 stated V10 refused to give R11 any pain medication. V11 stated she told V10 if she didn't want to care for her residents properly then she could leave the facility. V10 refused to leave and refused to give R11 any pain medication. V11 LPN stated R35 was also complaining of pain and needs her prescribed pain medication every four hours. R35 was complaining of pain and rating it a 10/10. V11 stated R35 told her that V10 LPN was refusing to bring her pain medication and R35 was visibly upset and in pain. On 10/13/23 at 9:44 AM V10 Licensed Practical Nurse confirmed worked the night shift on 10/7/23 and was the assigned nurse for both R11 and R35. V10 confirmed she administered R11's scheduled Morphine Sulfate but did not give her any 'as needed' doses. V10 LPN confirmed staff members came to her concerning R11's pain but V10 did not feel like R11 was in that much pain. V10 LPN confirmed she did spend most of the shift on the dementia unit where the doors were shut and did not hear R11 yelling out or crying in pain. V10 LPN confirmed R11 and R35's room is not on the dementia unit. V10 LPN confirmed she was late a little late giving R35 her pain medication because she passed medications to the dementia unit first. V10 LPN confirmed if a resident is having pain, request pain medication, and/or has pain medication available to be given, the pain medication should be administered. On 10/13/23 at V30 Hospice Nurse stated R11 is alert to person, she's very confused and can express pain but can't say the location of her pain if asked. V30 stated R11 does have scheduled Morphine Sulfate for pain and 'as needed' Morphine Sulfate if needed for further discomfort. V30 stated if R11 or any patient for that matter is in pain and crying out, seems agitated, is crying or stating they are hurting, the nurse should give the prescribed pain medication that is available. V30 confirmed if R11 was exhibiting pain by yelling, crying, and stating she was hurting, V10 LPN should have administered the 'as needed' Morphine Sulfate. On 10/13/23 at 1:00 PM V2 Director of Nurses and V3 Director of Clinical Operations confirmed nurses should always address a resident's pain and discomfort by either giving pain medications or trying an alternative method of pain control. Both V2 and V3 both confirmed if those things are tried and the resident's pain is still not relieved, nursing staff should address uncontrolled pain with the resident's physician. Both V2 and V3 confirmed V10 LPN should have administered R11's 'as needed' pain medication when she was crying out in pain. Both V2 and V3 confirmed R35 is always complaining of pain and asks for her 'as needed' Percocet frequently.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to ensure staff were supervising residents, failed to ensure qualified staff were transferring residents, and failed to ensure bed wheels were locked to prevent accidents. The facility also failed to conduct fall investigations, develop and implement fall interventions, and complete neurological assessments after falls/accidents for three of five residents (R1, R3 and R4) reviewed for accidents in the sample list of ten residents. Failing to ensure trained/qualified staff were transferring R3 resulted in R3 falling from the wheelchair and suffering a head wound requiring seven staples. B. Based on interview and record review the facility failed to provide supervision to prevent a resident elopement for one of five residents (R10) reviewed for accidents in the sample of ten residents. Findings include: a. 1.) R3's undated medical diagnosis list documents medical diagnoses of Intellectual Disabilities, Muscle Weakness, Need for Assistance for Personal Care, Unsteadiness of Feet, Abnormalities of Gait and Mobility, Anxiety, Delusional Disorders and history of Right Femur Fracture. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as requiring limited assistance of one person for bed mobility and walking in room, and extensive assistance of two people for transfers, locomotion on and off unit, toileting and personal hygiene. R3's Physician Order Sheet (POS) dated June 1-30, 2023 documents a physician order dated 4/3/23 for Aspirin Enteric Coated (EC) 81 milligrams (mg) daily. R3's Fall Risk Evaluation dated 6/14/23 documents R3 as a high fall risk. R3's Medical Record documents R3 is on continual monitoring for history of falls. R3's Nurse Progress Note dated 6/14/23 at 8:06 PM documents (R3) was returning from bathroom in wheelchair when began to move impulsively and threw self out of wheelchair. Noted to have approximately two inch laceration over Right Eye. Area cleansed et dressing applied. R3's Hospital Discharge Summary dated 6/14/23 documents R3's chief complaint as 'fall, laceration' and discharge diagnosis as 'Laceration of Forehead'. This same report documents R3's scalp laceration was repaired. This same report documents [AGE] year old fell from (R3's) wheelchair at facility and hit his forehead sustaining laceration. (R3's) bleeding was stopped with pressure dressing. This same hospital report documents R3 received seven staples to Right Forehead just above Right Eye due to fall. R3's Final Incident Report to Illinois Department of Public Health dated 6/20/23 documents R3 fell in R3's room while being transferred from wheelchair to bed by (V24) Unit Aid on 6/14/23. (V24's) Unit Aid written witness statement documents I was assisting (R3) back into his room from the bathroom in his wheelchair. I put the wheelchair facing the chair I sit in and proceeded to walk from behind the wheelchair towards my chair. As I started to walk around (R3) used his feet to move the wheelchair forward, got his feet caught up and slid out of the chair and fell into his side dresser. I called for a Certified Nurse Aide (CNA) and a CNA and a Nurse assisted (R3) up onto (R3's) bed. R3's Nurse Progress Note dated 6/24/23 at 4:00 AM documents (R3) was found on floor of hallway. Emergency services called and (R3) transferred to emergency room . R3's Electronic Medical Record (EMR) does not document Neurological assessments completed for 72 hours or fall investigations after R3's 6/14/23 fall nor 6/24/23 fall. R3's Care Plan does not document new fall interventions after R3's 6/14/23 nor 6/24/23 falls. On 6/28/23 at 2:05 PM Observed R3 laying on covers in bed. Observed R3's Left Elbow to have a dark purple bruise approximately small orange sized, R3's Left mid Forearm to have a dark purple baseball sized bruise on outer side, and R3's top of Left Hand to have a baseball sized fading purple and gray bruise. Observed R3's Right Forehead just above Right Eyebrow to be bruised with [NAME] where staples had been removed earlier in day. On 6/29/23 at 11:50 AM (V9) Regional Director of Operations stated (R3) had a fall early morning of 6/24. The staff called me and said (V16) Unit Aide was supposed to be continuously monitoring (R3), (V16) fell asleep, (R3) got up and walked out into the hallway and fell . On 6/29/23 at 2:15 PM V1 Administrator stated R3 fell on [DATE] while being transferred by V24 Unit Aid. V1 stated Unit Aids are not trained to transfer, toilet or assist with feeding of residents. V1 stated (V24) Unit Aid should never have assisted (R3) with transferring. This led to (R3's) fall with a major injury. (R3) ended up with staples in his forehead. V1 stated V24 should have asked for help transferring R3. V1 Administrator stated Maybe this wouldn't have happened if (V24) would have asked for help. (V24) Unit Aid has already been educated on this. 2.) R4's undated Face Sheet documents medical diagnoses of Seizure Disorder, Schizoaffective Disorder and Depression. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, eating and personal hygiene, and extensive assistance of two people for toileting. R4's Nurse Progress Note dated 6/7/23 at 12:25 AM documents Facility staff actions/interventions and response at time of the event: (R4) was assessed area found to Right Forehead with a approximately one inch laceration and a half dollar sized bump. Follow up recommendations to manage the resident's condition and needs: to keep area to Forehead dry and clean, watch for any signs and/or symptoms of seizure due to head trauma R4's Nurse Progress Note dated 6/7/23 at 1:54 AM documents (R4) was pushing a chair and stumbled and hit head causing a small laceration to Right side of Forehead and a half dollar size bump. (R4) wound was cleansed and bandaged. Ambulance was called to transport to emergency room for treatment. Around 8:15 PM emergency room called to inform that (R4) was set to discharge. emergency room glued the laceration and are monitoring (R4). Update called for (R4) is sleeping at this time, wound to head has been glued, (R4) getting Intravenous fluids for hydration and (R4) had been given Haldol and Ativan due to increased anxiety. R4's Nurse Progress Note dated 6/18/23 at 8:07 AM documents (R4) was in dining area and staff stated (R4) fell on another resident's arm. (R4) balance is always unstable. R4's Nurse Progress Note dated 6/20/23 at 3:46 PM documents (R4) walked into wall per staff and observed blood to wall by bed. (R4) has open area to Right side of Forehead. First-aid rendered. Tylenol given for pain management. Ambulance called. R4's Nurse Progress Note dated 6/20/23 at 4:20 PM documents (R4) observed standing by wall in bedroom by staff . Observed blood coming from (R4's) head and noted blood stain on wall. First aid rendered. Ambulance called. Physician aware to send to emergency room for further evaluation. R4's Nurse Progress Note dated 6/21/23 at 7:30 AM documents At approximately 7:10 AM this morning (V12) Licensed Practical Nurse (LPN) was in hallway speaking with staff when (V12) saw staff run towards (R4's) room. (R4) was trying to get on floor (normal behavior). (R4's) head slid down the wall as (R4) was getting on the floor. Noted to have reopened wound on top of (R4's) head. Minimal bleeding noted. R4's Nurse Progress Note dated 6/21/23 at 2:21 PM documents (V12) LPN was informed by staff that (R4) hit the floor; witnessed; it was explained to (V12) that (R4) tripped over the wheelchair wheel of the chair (R4) was sitting in and hit (R4's) head; noted that (R4) reopened wound that had the steri strips; steri strips removed. R4's Electronic Medical Record (EMR) does not document a fall investigation nor neurological assessments after R4's 6/7/23 fall with head injury. This same EMR does not document Neurological Assessments after R4's head injuries on 6/20/23 and twice on 6/21/23. R4's Care Plan does not document any new fall interventions after 6/6/23. This same care plan documents an intervention to encourage R4 to not crawl on the floor. On 6/27/23 at 11:15 AM Observed R4 to bend down to a crawling position on hands and knees on the floor in the Dementia Unit hallway On 6/27/23 at 11:16 AM Observed V7 Certified Nurse Aide (CNA) observe R4 crawl on the floor of the Dementia Unit. V7 CNA did not encourage R4 to not crawl on the floor. On 6/28/23 at 12:00 PM Observed R4 bend down to a crawling position on hands and knees on the floor. V18 Dementia Unit Coordinator was standing by watching R4. V18 did not encourage R4 to not crawl on floor. On 6/29/23 at 9:00 AM Observed R4 bed down to a crawling position on hands and knees on the hallway floor with other residents within reach of R4. V19 and V20 Certified Nurse Aides (CNA) walked by R4 two times each without offering R4 assistance to stand up or not crawl on floor. On 6/27/23 at 11:20 AM V7 Certified Nurse Aide (CNA) stated (R4) likes to crawl around on the floor. (R4) used to be a carpenter so he thinks he is nailing boards to the floor. (R4) is careplanned for crawling on the floor. On 6/28/23 at 12:05 PM V18 Dementia Unit Coordinator stated R4 is careplanned to crawl on the floor. V18 stated (R4) crawls on the floor all the time. (R4) is always bumping his head all the time down there. On 6/29/23 at 9:03 AM V19 Certified Nurse Aide (CNA) stated as she was walking by R4 crawling on the floor (R4) does that all the time. (R4) bumps his head a lot. I don't know why they (facility) doesn't do something about that. On 6/29/23 at 9:05 AM V20 Certified Nurse Aide (CNA) stated I am agency. I don't know these residents at all. I don't know how to see their careplan. I just do what the other staff do. On 6/29/23 at 2:45 PM V1 Administrator stated (R4) crawls on the floor all the time. Every time I go back to the Dementia Unit, it seems like (R4) is crawling around on the floor. I thought (R4) was careplanned for that. I do know (R4) bumps his head a lot and also falls. The staff should add fall interventions with each new fall and implement the fall interventions to prevent a resident from falling the same way again. It is obvious that this isn't happening. I don't know if (R4's) major injury (head wound) could have been prevented but we can certainly reduce the risk of him falling or having these accidents that cause him head injuries. On 6/29/23 at 1:00 PM V3 Interim Director of Nurses (DON) stated I have been working with our staff to try to use the careplan. The staff can't use the careplan if there isn't one or if the resident careplan is not updated. (R4) should not be crawling on the floor. We (staff) know that (R4) has had multiple head injuries from crawling on the floor. This needs to stop. (R4) is really going to get hurt one of these times. (R4) already had sutures from a fall. We (facility) had two Certified Nurse Aides (CNA) that day (R4) fell and busted his head open. Both CNA's were agency and did not know the residents well. This facility does have a lot of agency staff. I think that is part of the problem. With every head injury or unwitnessed fall the staff should complete three days of Neurological Assessments. Staff did not do that in any of these times (R4) had falls or accidents. We (facility) also did not do a fall investigation. We (facility) really do have a lot of work to do. 3.) R1's Electronic Medical Record (EMR) documents R1 as severely cognitively impaired. R1's Fall Risk Assessment documents R1 as a fall risk. R1's Care Plan does not document a focus area, goal nor interventions for R1 being at risk of falls. R1's EMR documents R1 as requiring supervision with transfers, toileting and locomotion. R1's Nurse Progress Note dated 6/25/23 at 5:40 AM documents R1 was found sitting on floor next to R1's bed in R1's room early morning of 6/25/23. R1's EMR does not document a fall investigation initiated until 6/29/23. R1's Hospital Record dated 6/25/23 documents R1's discharge diagnosis as Contusion of Head. R1's Final Incident Report to Illinois Department of Public Health (IDPH) dated 6/29/23 documents R1 had a large Hematoma to Right Forehead noted at time of fall. This same report documents root cause (R1) attempted to get out of bed and bed was not locked and moved away from (R1) as she attempted to get up. On 6/27/23 at 11:10 AM Observed R1 with dark purple and black circular bruising all the way around both eyes. This same bruising also extended above (R1's) Right Eye to mid forehead. Observed R1 walking independently in the hall of the dementia unit. On 6/27/23 at 11:12 AM R1 stated You should see the other guy! As R1 making a fist with Right hand and punching palm of R1's Left hand. R1 stated R1 did not know how R1's face got bruised. R1 stated (expletive) like this doesn't happen every day. I don't know how it happened but it sure does hurt!. On 6/27/23 at 9:20 AM V18 Dementia Unit Coordinator stated They (staff) told me (R1) fell over the weekend and got those bruises on her face. I don't know how (R1) fell . No one told me that. I don't see any thing about falls on (R1's) careplan. The staff would not know what interventions were put into place if it is not listed on the careplan. We (facility) have a lot of agency staff so those staff especially need to be able to see the resident careplan. I haven't done any training's on this unit for fall preventions or reporting of injuries. They (facility) never told me to do that. On 6/29/23 at 10:20 AM V3 Interim Director of Nurses (DON) stated the facility did not do a fall investigation for R1's fall until 6/29/23. V3 stated We (facility) have been so busy with so many other things. I got it done today but truthfully I didn't start it until today either. The facility policy titled Fall Prevention revised 11/10/18 documents Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an Assess/Intercommunicate/Manage (AIM) for Wellness form along with any new intervention deemed to be appropriate at the time. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up. Help must be summoned or assistance must be provide to the resident. The facility policy titled Emergency Care Head Injury reviewed 12/22/17 documents residents should be evaluated for head injuries for a minimum period of 72 hours to determine any negative effects, and to allow for immediate treatment to minimize permanent damage. The following procedure focuses on proper assessment of residents who have sustained a head trauma. Secure the resident from further danger, assess the resident including vital signs, consciousness and neurological (neuro) status, immobilize resident's head and neck, assign staff to remain with resident, notify physician immediately. Ongoing assessment (vital signs and neurological checks) should take place as follows: initially and every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, every four hours for eight hours, every shift for the remainder of 72 hours. Assessments for the first 24 hours after injury shall be recorded on the Neurological/Head Trauma Assessment Form (Neuro Assessment Sheet). Additional documentation shall be recorded in the clinical record. Complete a Quality Care Tracking form and document all observations and occurrences. b. 1) R10's Undated Face Sheet documents medical diagnoses of Psychotic Disorder with Hallucinations due to known Physiological Conditions, Cerebral Vascular Accident (CVA), Flaccid Hemiplegia Affecting Unspecified Side, Hypertension, Diabetes Mellitus, Muscle Weakness, Difficulty in Walking and Major Depressive Disorder. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as moderately cognitively impaired. This same MDS documents R10 as requiring supervision for bed mobility, transfers, locomotion off unit, and eating, and assistance of one person for locomotion on unit, dressing, toileting and personal hygiene. R10's Careplan does not include an elopement focus area, goal nor interventions. R10's Electronic Medical Record (EMR) does not include an elopement risk after R10's elopement on 5/27/23. R10's Nurse Progress Note dated 5/27/23 at 10:12 AM documents Received a phone call that (R10) was leaving the facility and was going towards baseball park by self and that he got combative with staff and had verbal aggression. (R10) has been spoke to about leaving facility supervised with family. This writer called non-emergency police to help with (R10). Non-emergency police arrived and spoke to (R10) and staff helped (R10) go back into facility. R10's Nurse Progress Note dated 6/10/23 at 12:51 PM documents Received a call from facility that (R10) left without supervision, called the family and they had said (R10) will be coming to their house which is a few blocks away from facility and (R10) is having a home visit. R10's Nurse Progress Note dated 6/10/23 at 11:01 PM documents (R10) returned from family visit at (9:45 PM). (V27) (R10's) family member told staff that he fell in their driveway. (R10) stated he had A lot of beer and some fireball. (R10) has multiple wounds: two on Right Upper Forearm both skin tears. First 1.0 centimeters (cm) x.01cm, second 1.0 cm x .01cm cleansed and approximated steri-strips applied, (R10) has an open area to Right knee 2cm x 1.5cm cleansed and dry dressing applied, has open blister to both great toes on the Right .5cm x .2cm at the knuckle, on the Left great toe just below the nail .3cm x .2cm sure prep applied to both. R10's Nurse Progress Note dated 6/22/23 at 6:22 PM documents (R10) went outside this morning and was seen in both the front and back of the building. One on one was provide to ensure (R10) did not leave building. On 6/27/23 at 3:00 PM observed R10 using R10's Left hand and arm to propel self slowly in the wheelchair in the hallway. Observed R10's Right Foot on foot pedal and R10's Urinary Catheter tubing dragging floor underneath R10's wheelchair. On 6/29/23 at 10:45 AM V25 (R10's) Power of Attorney (POA) for Healthcare stated No one let me know (R10) was leaving without permission. (R10) needs to be supervised. (R10's) thinking was changed after he had his stroke. (R10) definitely should not be [NAME] himself around town. That is so dangerous. (R10) could get hit by a car or something. I am just picturing (R10) [NAME] himself down the road. How awful. I don't have any problem if (R10) wants to go visit his family in town but that place needs to keep a better eye on him and make sure he gets there and back safely. On 6/29/23 at 1:45 PM R10 stated I left two times (5/27,6/10). They (facility) didn't even know where I was. (V27) (R10's) family member had to call them (facility) and say I was at (V27's) house. It is easy to get out of here. I just roll out the front door. I just wait until the staff are busy and roll right on out. (V27) knew I was coming over. (V27) lives just down the road a couple of miles. I made it to (V27's) house ok both times before so I thought I could do it again. But, that last time they (facility) caught me. R10 stated If I can't get a ride to (V27's) house then I will just take myself there again. On 6/29/23 at 11:25 AM V26 Social Service Director (SSD) stated R10 has a diagnosis of a Psychotic Disorder and has been seeing behavioral health services through the facility. V26 stated R10 has had multiple angry outbursts due to his previous Cerebral Vascular Accident (CVA). V26 stated On 5/27/23 (R10) wheeled himself out of the facility and left the property. (V28) (R10's) family member called the facility to report that (V28) saw (R10) [NAME] himself down by the ball park a few blocks away. I called the non-emergency police. We (staff) and the police all went out looking for (R10). (R10) ended up at (V27) (R10's) family member's house. This is a couple of miles away from the facility. (R10) was intoxicated when he returned to facility later that night. Then again on 6/10/23 (R10) pretty much did the same thing. (R10) wheeled himself out of facility. (R10) wheeled himself across town again to (V27's) (R10's) family member's house. (V27) called the facility to let us (staff) know that (V27) would bring (R10) back after a family barbecue. (R10) was later returned to facility by (V27's) friend. When (R10) returned to facility he was intoxicated again. V26 SSD stated From what I understand the police found (R10) between a major retailer and the cemetery which is a little over two miles away. The police escorted (R10) the rest of the way to (V27's) house. When we (facility) went looking for (R10) we never did find him. The police found him. (R10) is not able to make sound decisions and should have been supervised more closely. On 6/29/23 at V29 Physician stated (R10) may belong in a different type of facility where they can manage his behaviors. (R10) should be more closely supervised due to (R10) eloping from facility twice before and attempted a third time. (R10) could get ran over by a car if he is [NAME] himself down the center of the highway. It sounds to me like (R10) has an alcohol addiction and uses very poor judgement. V29 stated the facility is responsible for R10's safety. V29 stated the facility should supervise R10 more closely. On 6/29/23 at 3:20 PM V1 Administrator stated After (R10) eloped from this facility on 5/27/23, we (facility) made a new rule that every resident regardless of their cognitive status had to be supervised when outside of the facility and on the property by staff or family. We (facility) did not put anything specifically in place for (R10). (R10) sits up in the dining room a lot which is by the front door. The exit doors are alarmed but (R10) is strong enough to push himself through the front doors. This should not have happened once, much less twice. The second time (R10) eloped on 6/10/23 our staff just simply weren't paying attention. (R10) could have gotten hurt so badly. A car could have not seen (R10) and ran into him. I don't even want to think about what all the bad consequences would be if (R10) was struck by a car as he was [NAME] himself down the middle of the highway. The facility policy titled Elopement Prevention Policy revised 10/06 documents the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and intervention for prevention will be established in the plan of care to minimize the risk for elopement. A licensed nurse will complete the Elopement Risk Assessment upon and/or within eight hours of admission to the facility. An interim plan of care for minimizing the risk for elopement will be initiated upon high risk determination. A facility staff member will take a photograph of the resident upon or within eight hours of admission. The photograph will be placed in the Medication Administration Record (MAR). Any resident assessed to be at high risk for elopement will have their photograph and basic identifying information placed in a special folder or binder to be maintained at the nurses station. The Interdisciplinary Team (IDT) will initiate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures will be included in each high risk resident's plan of care to minimize risk factors. Interventions of person door alarm devices and monitoring will be initiated as deemed necessary by the IDT and documented in the individual resident's plan of care. Any high risk resident will be promptly and courteously escorted back to the appropriate nursing unit, activity room, dining area or resident room when noted to be near an exit door. Revision of the Elopement Risk Assessment will be completed quarterly, after an isolated elopement attempt, monthly for resident who attempt elopement more than five times per week, upon a resident significant change in condition and as needed, determined by the IDT. The plan of care for minimizing elopement risks will be reviewed each time the Risk Assessment is completed with initials and dating of the care plan by any member of the IDT present for review. All employees will be educated within a reasonable timeframe of hire and throughout the year with elopement education on the location of the elopement file/binder and Elopement Prevention Policy.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to protect a resident's (R9) right to be free from physical and mental abuse by V24 Certified Nurse's Assistant (CNA) and V25 CNA. This failure resulted in V24 and V25 taking away R9's walker, hiding it from R9, pushing R9, striking R9 on the arm, and then hitting R9 forcefully in the face with a clothing protector, resulting in R9 having a catastrophic reaction in which R9 became combative with V24 and V25 and R9 being removed from the facility by emergency services and taken to the emergency room . B. Based on observation, interview, and record review the facility failed to protect resident's rights to be free of physical and verbal abuse by other residents by failing to supervise and implement behavioral interventions for wandering and physically aggressive behaviors for seven of seven residents (R2, R3, R6, R7, R8, R9 and R10) reviewed for abuse on the sample list of ten. These failures resulted in the repetitive physical abuse of R3 by R8, R9, and R10, and R3 being hit, punched, and pushed down. These failures also resulted in R6 physically attacking R7 by punching R7 in the head and pulling R7's hair, and then striking R2 on the arm. This failure has the potential to affect all 77 residents residing in the facility. These failures resulted in R3 being pushed to the ground by R8 and R3 sustaining a laceration to the back of the head which required emergency medical services and four staples to close the laceration. These failures also resulted in multiple occurrences of resident-to-resident physical abuse in which residents were hit, punched, and pushed down to the ground by other residents. These altercations could result in serious bodily injury and harm. These failures resulted in an immediate jeopardy. The Immediate Jeopardy began on 4/4/23 when the facility failed to supervise and implement behavioral interventions for wandering and physically aggressive behaviors after R3 was physically abused by R9. V2 Administrator in Training was notified of the Immediate Jeopardy on 6/9/23 at 3:42 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/12/23, but noncompliance remains at Level Two because the facility requires more time to evaluate the effectiveness of in service training and the Plan of Correction. Findings include: a. The facility's video footage dated 6/3/23 at 5:07 PM, shows R9 sitting at a table eating dinner. R9's back is to the camera and there is no sound to this video footage. R9 is moving her hand across the table and is appearing to clean up something off of the table. V24 Certified Nurse's Assistant (CNA) walks over to R9's table and starts to wipe off the table with a clothing protector. R9 starts to grab at the clothing protector and knocks it off onto the floor. V24 then grabs R9's right hand squeezing it and walks away to the other side of the room. R9 continues to clean up the table when V24 walks over with towels. R9 tries to grab at the towels and V24 starts grabbing and squeezing R9's hands. V25 (CNA) then walks up to table and R9 begins hitting V24 on V24's backside. V24 then grabs R9's hand again and took something out of R9's hands. V25 removes dishes that are in front of R9 and when walking away pushes R9's walker away from the side of R9's table. R9 then stands up and grabs the walker. R9 walks with the walker over to V24 and V24 pushes R9 back with both hands and walks away from R9. R9 then grabs some paper towels and walks back to table to sit down. V24 then approaches R9 and attempts to grab something away from R9 and walks away. V25 then removes a roll of toilet paper off of R9's walker. V25 then folds R9's walker up and puts it in a room attached to the dining room and stands directly in front of the door obstructing R9's ability to get into the room to the walker. R9 then stands up to find the walker. V25 is noted to be saying something to R9 and begins moving both hands in a swatting motion at R9 while blocking R9's ability to get to the walker. R9 then hits V25 on the shoulder. V25 then swings her arm and hit R9's left shoulder with her fist. A un-identified nurse attempts to intervene and V25 drops her cell phone on the floor and R9 hits V25's back with a clothing protector. V25 then takes the clothing protector off her back and with a very forceful motion swings the clothing protector into the air and strikes R9 in the face and chest with the clothing protector. R9 is then taken out of the room by the unknown nurse and V24. On 6/8/23 at 12:15 PM, V24 stated there was an incident with R9 on 6/3/23 in the dining room. V24 stated R9 was upset that other residents in the dining room had been given soda pop but not her. V24 stated that caused R9 to squeeze a cup of soda for another resident and spill it onto the table. V24 confirmed that V24 grabbed R9's hands and put up her hands to push R9 away from her. V24 stated after R9 hit V25 with the clothing protector. V24 and the un-identified nurse then helped R9 to her room. V24 stated she is new to the facility and was not trained for the Dementia unit and did not know R9's behavior plan of care. On 6/8/23 at 12:35 PM, V25 stated on 6/3/23 there was an incident with R9 in the dining room. V25 stated V24 was attempting to clean the dining room when R9 became combative. V25 stated she attempted to intervene and to get R9 to come out of the dining room. V25 stated after R9 hit her, V25 reached her arm out but didn't mean to hit R9 and then after R9 hit her with the clothing protector and she grabbed it and swung it and it hit R9 in the face. V25 stated V24 and an un-identified nurse had to make R9 go to her room and R9 continued to be physically aggressive and fighting the staff until the police showed up. V25 stated she is new to the facility and was not trained for the Dementia unit and did not know R9's behavior plan of care. R9's Discharge Instructions for emergency room visit on 6/3/23 provided by V21 Corporate Nurse document R9 was seen in the emergency room for agitation and aggressive behaviors related to Dementia. V24 and V25's employee file provided by V2 Administrator did not include training for Abuse Prevention. The facility's fax to the state agency written by V2 Administrator dated 6/3/23 at 8:01 PM documents, alleged physical altercation between staff and resident. On 6/7/23 at 11:16 AM, V2 Administrator in Training stated the incident on 6/3/23 happened around dinner time. V2 stated someone at the facility called and reported that a CNA had swung at a resident. V2 stated she went into the building and had V24 and V25 go home. V2 stated the police were already at the building. V2 stated the next day V2 reviewed the video footage and V2 confirmed that V25 hit R9. R9's careplan with a revision date of 5/4/23 documents R9 has the potential to be verbally aggressive due to Dementia. This care plan includes an intervention to walk away from R9 if R9's response to staff is aggressive. b. 1.) R3's care plan with a revision date of 10/7/22 documents R3 has a diagnosis of Dementia, wanders, and has a disregard for personal spaces. This care plan documents R3 as having severe cognitive impairment. On 6/7/23 at 10:54 AM, R3 was walking up and down the hallways and going up to staff, other residents, and visitors touching their arms, jewelry, and shirts. R3 was noted to have staples to the back of her head. R3's Incident note dated 4/4/2023 at 10:37 AM, written by V17 Licensed Practical Nurse documents, Writer made aware by staff resident was struck with a walker by (R9). Upon assessment, (R9) stated (R3) was in my room and (R9) wanted (R3) out. (R3) escorted from (R9's) room. R9's care plan dated 4/11/23 documents R9 has a diagnosis of Dementia and has the potential for verbal and physical behaviors. This care plan did not include a revision or update after the incident on 4/4/23. R3's Incident note dated 5/7/2023 at 7:30 PM written by V16 Licensed Practical Nurse (LPN) documents, (R3) was hit in the chest by (R10) and fell on to floor hitting her head. R10's careplan dated 4/11/23 documents R10 has a diagnosis of Dementia and has the potential to become physically aggressive with staff due to Anger, Depression, Dementia, and poor impulse control. This careplan does not include a revision after the 5/7/23 incident with R3 until 6/3/23. R8's Behavior Note dated 5/24/2023 at 6:06 PM, written by V19 LPN documents, (V19) was informed by staff that (R8) throat-punched one of the (R3) on the unit; (V3, Director of Nursing) notified. R8's Behavior Note dated 5/28/2023 at 1:17 PM written by V18 LPN documents, (R8) observed by staff to have pushed another (R3), (R8) is agitated and redirected to his room for monitoring. Hospital Records dated 5/28/23 document R3 received four staples to a head wound after R3 fell (was pushed down by R8) on 5/28/23. R8's care plan dated 5/3/23 documents R8 has a diagnosis of Dementia and poor impulse control and can become verbally aggressive to staff. This care plan does not include a revision after R8 throat punched R3 on 5/24/23 or after R8 pushed R3 to the ground on 5/28/23 until 6/8/23. On 6/7/23 at 10:48 AM, V19 Licensed Practical Nurse stated R8 doesn't like R3 because she walks around and is in other peoples' personal space and is touching others. V19 stated I don't remember who but on 5/24/23 a staff member told me that (R8) had throat punched (R3). V19 stated I text (V3 Director of Nursing) but she never responded back. No one told us of any new behavioral interventions for (R8) or what to do to prevent (R3) from getting into people's space. (R8) is aggressive to staff and his family also. I know there were medication changes after he pushed her down on 5/28/23 but I don't know anything else besides that. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated the facility's interdisciplinary team meets in the morning to go over incidents. V2 stated V2 did not know about the incidents occurring on 4/4/23, 4/11/23, or 5/24/23 until the incident occurring on 5/28/23 between R8 and R3. V2 stated the facility did not put in new behavioral intervention or increase supervision of R3. 2.) On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 has shown behaviors towards female residents and explained, R6 had physical contact and verbal outburst towards R7 and R2 both, just a few days apart from one another. V8 stated V8 was at the facility on both occasions. V8 stated, the first time was a week or two ago while V8 was sitting at the nurses station and R6 was sitting in R6's wheelchair in the hall across from the nurses station. V8 explained that R2 was trying to get by R6 but R6's foot was sticking out. R2 said excuse me, can you please move your foot {talking to R6} and the next thing V8 heard was R2 say Ouch, you didn't have to do that, V8 stated then V8 heard R6 say, you (expletive)! V8 stated V8 stood up and asked what happened and R2 reported that R6 had hit R2 on the hand. V8 stated R2 had no bruising or even redness but V8 immediately separated R2 and R6 and reported it to V9 RN (Registered Nurse), and gave a written statement. V8 explained a couple of days later, (V8) was across the hall from (R6's) room and (R7) was sitting outside of (R6's) room with (R7's) back to (R6's) door. Next thing (V8) knew, (V8) heard (R6) yelling I (R6) told you to stay the (expletive) away from me and then started hitting R7 in the back of the head and by R7's ear. V8 stated V8 immediately separated them both and reported the abuse. V8 explained in the past, R6 and R7 use to live next to each other and would constantly go after each other so the facility had to move them to separate halls. The facility provided an initial abuse investigation dated 5/26/23 documenting a resident to resident altercation that included witness statements for the abuse between R6 and R7 but the facility did not provide an initial abuse investigation involving R6 and R2. On 6/5/23 at 2:05 pm, R6 was outside smoking, then propelled R6's self back into the facility and sat across from nurses station. On 6/5/23 at 2:05 pm, AIT (Administrator in Training) stated V2 was the Abuse Coordinator and explained R6 and R7 have a history between them and situations like this have happened previously, before V2 started working at the facility in March 2023. V2 stated there was no abuse allegation between R6 and R2 that V2 is aware of. At this time, V3 DON (Director of Nursing) was present and stated that V3 was aware of R6 hitting R2 on the arm and getting verbally aggressive with R2 because it was reported to V3 but that the unidentified staff that reported it said they had already made V2 aware of it. On 6/6/23 at 9:05 am, V2 AIT stated V2 does indeed remember hearing about a physical abuse allegation between R6 and R2 but got the allegation confused and didn't realize that R6 had been involved in two separate abuse allegations, V2 thought the staff was talking about the abuse between R6 and R7. V2 stated the physical abuse between R6 and R2 happened on 5/27/23. R6's MDS (Minimum Data Set) dated 4/10/23 documents R6 is non-ambulatory but requires supervision only with locomotion. On 6/7/23 at 9:00 am, R6 was propelling R6's self throughout the facility in R6's wheelchair without supervision. R6's Progress Notes dated 5/31/23 by V26 Behavioral NP (Nurse Practitioner) document R6 has a diagnosis of Vascular Dementia secondary to multiple CVA's (Cerebrovascular Accident's) with Right Sided Hemiparesis, Neurogenic Bladder, Aphasia. History of Schizoaffective Bipolar with ongoing issues with verbal outbursts and making false allegations and threats towards his peers and staff. He will curse people out or threaten to kill them. or call state. R6 had required medications adjustments due to R6's behaviors and upon follow up, it was reported that R6 had another violent incident with a female peer (R7). R6 was not happy that R7 was near R6's doorway and grabbed R7 by the hair. R6 admitted to the incident but stated (R6) didn't care because (R6) didn't want (R7) near (R6). On 6/5/23 at 10:45 am, R7 was lying in bed. When asked questions regarding the abuse allegation between R6 and R7, R7 responded with LaLaLa. R7's Care Plan dated 2/20/23 documents R7 has impaired expressive communication related to CVA and can only speak a few words. R7's Progress Notes dated 5/31/23 by V26 document R7 has a diagnosis of Vascular Dementia secondary to CVA with Right sided Hemiparesis and new onset behaviors of agitating R7's peers. The Notes state that R7 likes pushing R7's self into peers' rooms and got R7's hair pulled for refusing to leave, over the weekend. The Notes state that R7 has been impulsive and will touch peer's or go up to them and chat la-la-la. On 6/7/23 at 9:10 am, R2 was lying in bed and stated a week or so ago, R2 was trying to propel R2's self down the hall to get R2's laundry from the laundry room and a overbearing man (R6) was sitting by the nurses station with (R6's) foot sticking out. R2 explained R2 asked R6 several times to please move R6's leg but R6 didn't so R2 tried to go by R6 and R6 hit R2 on the wrist. R2 stated It hurt bad but didn't leave a bruise. R2 stated staff was at the nurses desk and immediately came around to check what was going on and separated us. R2 stated R2 doesn't remember the exact date explaining, I'm 96 and my memory isn't what it use to be. The facility Abuse Prevention Program dated 11/28/16 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined. Abuse is the willful injection 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 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 in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never be able to see family again. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation. The Nurse's Midnight Census dated 6/4/23 documents there are 77 residents residing in the facility. The Immediate Jeopardy that began on 4/4/23 was removed on 6/12/23 when the facility took the following actions to remove the Immediacy. On 6/14/23 between 9:00AM and 3:00PM the surveyor confirmed through observation, interview, and record review that the facility took the following action to remove the immediate jeopardy: 1. V2 Administrator in Training and V6 Dementia Unit Coordinator were in-serviced on the Abuse prevention policy and procedures and behavioral health policy, by V10 Regional Director of Operations on 6/09/23. Verified by surveyor 6/14/23. 2. Staff were in-serviced on the Abuse prevention policy and procedures on 6/10/23 by V3 Director of Nurses. The surveyor confirmed staff providing resident care in the facility on 6/14/23 had received training and training will continue until all staff have been trained. 3. V3 and V29 Care Plan Coordinator implemented behavioral interventions for physically aggressive residents R6, R8, R9, and R10 on 6/10/23. Verified by surveyor 6/14/23. 4. R6 will be provided more 1:1 activities throughout the day by activity staff and V6 Dementia Unit Coordinator. Verified by surveyor 6/14/23. 5. R8's medication review was completed by pharmacy staff on 6/12/23. Social Service staff will continue to follow up with R8 weekly to encourage one to one activities. Verified by surveyor 6/14/23. 6. R9's behavioral healthcare will increase to once weekly and promote more 1:1 activities provided. Verified by surveyor 6/14/23. 7. R10's medication review, increase 1:1 music therapy with hospice continuing by Hospice. Verified by surveyor 6/14/23. 8. R3's care plan was reviewed and revised with updated interventions for wandering behaviors by V3 and V29 on 6/10/23. R3 will receive 1:1 care for 7 days and then the Interdisciplinary Team (IDT) will reevaluate trends and patterns and the need for 1:1 on 6/19/23. Verified by surveyor 6/14/23. 9. V2 and V3 in-serviced staff on interventions for physically aggressive behaviors, supervision of wandering residents, updating care plans, and behavior tracking on 6/12/23. Verified by surveyor 6/14/23. 10. R3, R6, R8, R9, and R10's care plans were reviewed and revised to meet the resident's care needs by V3 and V29. Completed on 6/12/23. Verified by surveyor 6/14/23 11. All residents at risk for abuse were assessed and care plan interventions put in place. Checked by V3 and V29 on 6/12/23. Verified by surveyor 6/14/23. 12. Behavior tracking with targeted behaviors for R3, R6, R8, R9, and R10 was reviewed and revised by V3 and V29 on 6/12/23. Verified by surveyor 6/14/23. 13. Training for current staff, agency staff and new staff will continue and remain ongoing to educate staff on how to handle challenging individuals and calming the agitated. All new staff will also be educated on abuse prevention policy and procedures. Started on 6/12/23 and continuing. An outside training company will provide additional training at the facility for all employees and agency staff the week of June 19, 2023. Verified by surveyor 6/14/23. Quality Assurance Activities to assure the alleged deficient practice will not recur include: 14. QAT (Quality Assurance Team) to review implementation and effectiveness of interventions put into place to prevent further abuse through the daily QA meeting every weekday morning for the next 2 weeks Verified by surveyor 6/14/23. 15. QAT to conduct random rounds/interviews to ensure staff are aware of how to handle physically aggressive behaviors and wandering residents twice a week for the next 2 weeks. Verified by surveyor 6/14/23. 16. In-service training by V2 on Abuse prevention policy and Behavioral health policy will continue monthly for the next 3 months and then annually after. Verified by surveyor 6/14/23. 17. All new employees/agency staff will be in-serviced on the abuse prevention policy and behavioral health policy by the V2, continuing for new employees/agency. Verified by surveyor 6/14/23.

Based on observation, interview and record review, the facility failed to: develop and implement a care plan for a resident at high risk for skin breakdown, ensure proper nutrition and hydration via a jejunostomy feeding tube, ensure patency of the jejunostomy tube to prevent dehydration and promote wound healing, implement pressure relieving interventions, and completed pressure ulcer treatments as ordered for a resident. These failures affect one (R1) of three residents reviewed for pressure ulcers on the sample list of ten. These failures resulted in R1 becoming dehydrated and developing an infected stage III pressure ulcer requiring hospitalization for treatment. R1 also required surgery to replace a nonpatent enteral feeding tube. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/29/23 when the facility failed to develop and implement a care plan for a resident at high risk for skin breakdown, ensure proper nutrition and hydration via a jejunostomy feeding tube, ensure patency of the jejunostomy tube to prevent dehydration and promote wound healing, and implement pressure relieving interventions. On 6/7/23 at 2:00 pm, V2 AIT (Administrator in Training), V10 and V21 Corporate Nurses were notified of the Immediate Jeopardy situation. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 6/13/23 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: The facility Decubitus Care/Pressure Areas Policy dated January 2018 documents it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. A stage III pressure ulcer is described as broken skin, affecting full thickness and presents as a deep crater. Upon notification of skin breakdown, 4) notify the physician for treatment orders. 7) Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support. 8) When a pressure ulcer is identified, additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. The facility Enteral Feedings Policy dated April 2016 documents 3. each tube feeding order may contain the following information: formula name, method of administration, route (site of entry), rate of feeding, time of feeding, flush volume and times, and additives. 5. The dietitian shall be notified of each new admission or re-admission of tube-fed residents. The dietitian will provide a tube feeding assessment and any applicable recommendations to nursing staff at the facility within 72 hours of admission. Nursing staff will relay the dietitian's recommendations to the physician. 10. Physician order for pre-med and formula administration flushes will be sought. 11. A record of daily intake of the tube feeding and the flushes for the resident will be kept by the nursing department. 12. Placement of the tube will be confirmed via aspiration of residual. If unable to confirm placement via aspiration, air instillation method may be used. 23. Residents receiving a tube feeding shall have an appropriate care plan developed. R1's MDS (Minimum Data Set) dated 5/6/23 documents R1 was admitted to the facility on [DATE] with severe cognitive impairments, has slurred speech and is rarely able to make R1's self understood, has no skin impairments but is at risk for skin breakdown, requires extensive assist of two staff for bed mobility, has not transferred in the past seven days {out of bed}, and receives enteral tube feedings. R1 does not have a care plan for R1's risk of skin breakdown or for any pressure relieving interventions. On 6/6/23 at 10:32, V29 MDS/Care Plan Coordinator stated residents with feeding tubes and pressure ulcers should have that care planned. V29 confirmed R1 does not have a care plan for his enteral feedings, risk of skin breakdown or actual pressure ulcer explaining, with switching to computerized charts, I'm a little behind. R1's ongoing medical record Diagnosis List documents the following diagnoses: Traumatic Hemorrhage of the Right Cerebrum, Encephalopathy, Dysphagia, and Autism. R1's Hospital Discharge Orders/Facility Admission Orders dated 4/29/23 documents an order for an enteral tube feeding of Jevity 1.5 70 ml (milliliters) per hour for 14 hours. There were no free water flushes included on the hospital discharge orders, however there was a handwritten note that documents 350 ml QID (four times a day) next to the enteral feeding order. On 6/6/23 at 10:15 am, V10 Corporate Nurse stated V10 assumes that 350 ml QID is the flush order, but the nurses should have called to clarify that with V12 (R1's Physician). At this time, V10 also stated that R1 should have been assessed by V14 RD (Registered Dietitian) within 72 hours of admission. R1's medical record does not document V12 Physician was contacted to clarity R1's enteral feeding order or to obtain an order for free water flushes. The only nutritional assessment in R1's medical record is dated 6/4/23 {36 days after admission}. R1's Nutritional Assessment by V14 RD documents R1 has MASD (Moisture Associated Skin Damage) to the right and left inner buttocks and left lower buttock. Estimated nutritional needs are 1980 calories, 86 gm protein, and 1980 ml fluids. R1's increased needs estimated to maintain weights and promote wound healing. At this time, V14 suggests to increase tube feeding to Jevity 1.5 at 70 ml per hour for 16 hours. If tolerating after 48 hours, increase it to 18 hours. Again if tolerating after 48 hours, increase it to 20 hours feeding time and to decrease water flush to 350 ml water QID. On 6/6/23 at 10:46 am, V14 RD confirmed the 6/4/23 nutritional assessment for R1 was the first time V14 had assessed R1's nutritional needs. V14 explained, V14 comes to the facility on ce a month and when V14 was in the facility on 5/30/23, R1 was in the hospital, so R1 was not able to be assessed at that time. V14 stated, when a resident with a feeding tube is admitted to the facility, the facility should obtain a correct height and weight on the resident and notify V14 so an assessment can be completed to ensure the resident is receiving the required nutrition and hydration. V14 stated nobody at the facility reached out to V14 with that information or to alert V14 of having a resident (R1) with a feeding tube until V14 was in the facility on 5/30/23. V14 stated when R1 developed the pressure ulcers on 5/19/23, the facility should have alerted V14 of the change in condition so that additional recommendations could be made, but that didn't happen either. R1's Order Summary Report dated 6/5/23 documents an order dated 4/30/23 for an enteral feeding of 70 ml (milliliters) per hour one time a day for a diagnosis of Dysphagia, to start on 5/1/23 {2 days after admission}. There is no free water flush orders until 5/31/23 {32 days after admission}. The free water flushes are for 380 ml water QID (four times a day). This Order Summary documents a treatment order dated 5/19/23 to cleanse all wounds, apply Medihoney to the wound bed and apply hydrocolloid dressing and change three times a week on Monday, Wednesday and Friday and PRN (as needed) if the dressing is soiled or loose. R1's medical record does not document any intake monitoring for R1's enteral tube feeding or free water flushes to show how much nutrition and hydration R1 was receiving. R1's Progress Notes dated 5/19/23 documents R1 has a current skin issue including MASD (Moisture Associated Skin Damage) to three areas. R1's ongoing medical record Wound Measurements document R1 developed MASD to the Right inner buttock measuring 6.8 cm (centimeters) by 1.6 cm by 0.1 cm, left inner buttocks (lower) 2.3 cm by 1.0 cm by 0.1 cm, and left inner buttocks 5.3 cm by 0.9 cm by 0.1 cm. There is no documentation in R1's medical record including R1's May 2023 TAR (Treatment Administration Record) and Progress Notes that R1's wound treatment was completed as ordered. R1's Progress Notes dated 5/25/23 by V28 Agency LPN (Licensed Practical Nurse) documents {on 5/24/23} R1 appeared confused and drowsy and upon further assessment was found to be in delirious state with both hands raise to grab imaginary object, (R1) appear(s) drowsy but still respond to verbal command. (R1's) eyes are red with discharge. R1 was sent to the hospital for evaluation. R1's Hospital History and Physical dated 5/25/23 by V11 Hospital NP (Nurse Practitioner) documents R1 has resided at the nursing facility for one month and during this time has become dehydrated and developed a stage III pressure injury that was not present upon admission. Upon physical exam, R1 appears chronically ill and poorly nourished with a stage III pressure ulcer to the buttocks and coccyx with green drainage. R1 was noted to be septic and was admitted to the hospital with the following Diagnoses: Acute Sepsis related to Pressure Injury, Dehydration, Critical Hypernatremia, Electrolyte Imbalance, Lethargy, and Raised Serum Creatinine. R1's abnormal laboratory tests on 5/24/23, upon arrival to the hospital, were as follows: Sodium = 175 (normal is 135-145), BUN (Blood Urea Nitrogen) = 98 (normal is 8-25), Creatinine = 2.09 (normal is 0.7 - 1.5), BN/CR ( BUN/Creatinine ) = 46.89 (normal is 10-27), and WBC (White Blood Cell) Count = 13.5 (normal is 4.3 - 11). R1's Hospital Physician Notes dated 5/31/23 by V11 documents R1 was brought into the hospital from a local nursing home due to being severely dehydrated with a critical sodium level of 175. R1 has a J-tube (jejunostomy tube) for enteral tube feeding of Jevity 1.5 to run at a rate of 70 ml per hour from 2:00 pm - 4:00 am with a 380 ml water bolus along with water flushes between medications. J-tube was replaced while at the hospital. R1 was septic upon arrival mostly likely due to the sacral pressure ulcer. Acute Kidney Injury was due to pre-renal and dehydration. After fluids were given, R1's Creatinine levels returned to normal. R1's Hospital Discharge Instructions dated 5/31/23 document to ensure adequate water is given during flushing of tube and in between medications, R1 to have an air mattress, and Barrier Cream to bottom with foam dressing to open stage 3 pressure ulcer. On 6/6/23 at 11:05 am, V11 Hospital NP stated V11 is assuming R1 was not getting R1's feeding and/or water flushes explaining, there is no way that (R1) could have gotten so dehydrated if they (facility) were giving (R1) the ordered fluids. V1 stated R1's J-Tube was totally blocked off so and wondered how long it was blocked off, explaining that could have been why they were not giving fluids and/or feedings. V11 stated V11 had to have a surgeon come in and replace R1's J-tube. V11 also stated R1 had a nasty sacral pressure ulcer, that (R1) hadn't had the month prior. R1's eyes were sunken in and (R1) was very lethargic. I felt they had neglected (R1) by not giving (R1) these ordered fluids/feedings. V11 also stated, R1 not getting the proper nutrition, hydration, turned, cleaned up and bathed is what caused R1's pressure ulcer to develop and then become infected. R1 should not have developed that pressure ulcer. R1 probably had MRSA (Methicillin Resistant Staphylococcus Aureus) in the wound, based on the appearance of the wound with green drainage, that's why R1 was given IV (intravenous) Zosyn {Antibiotic}. V11 explained upon discharge, V11 ordered R1 to continue using the foam dressing to the pressure ulcers, as it will adhere to the wound and has a soft cushion to it. As of 6/5/23, R1's Physician Orders still document a treatment order of Medihoney and hydrocolloid to R1's pressure ulcers, not the foam dressing that was ordered at the time of hospital discharge on 5/31/23, or the order for an air mattress. These order now clarify the type of enteral tube feedings to be Jevity 1.5 but continues to order it at 70 ml per hour but does not document for how long, and also does not document flush orders or the recommendations of V14 from 6/4/23. On 6/5/23 at 11:30 am, R1 was lying on R1's back in bed, on a regular mattress. At 11:45 am, V3 DON (Director of Nursing), V9 RN (Registered Nurse) and V8 Agency CNA (Certified Nursing Assistant) entered R1's room to complete the ordered dressing changes. R1 was rolled to right side to reveal a foam dressing taped to left buttocks, which was not dated. V9 removed the dressing to reveal a 7.3 cm by 2.0 cm beefy red open area to the left buttocks with a full thickness,deeper area, in the middle of it measuring 1.5 cm by 1.7 by 0.2 cm. V9 cleansed the wound, applied Medihoney to the wound bed and then covered the wound with a hydrocolloid dressing. V3 confirmed the wound treatment that was originally on the wound was not what was showing as the active order on the physician order sheets but wasn't aware of the order for a foam dressing from the hospital. R1 was positioned on R1's back with a wedge slightly under R1's left hip. At 1:40 pm and 2:20 pm, R1 remained in the same position. At both times, R1 had dried BM (Bowel Movement) smeared down R1's legs and across the top of R1's right leg. On 6/5/23 at 2:25 pm, V10 stated there was no monitoring of R1's enteral nutritional and fluid intake because nobody put the order in to do so. V10 also stated R1 should have been getting feeding/flushes per the admission orders. On 6/6/23 at 8:58 am, 10:27 am, and 12:20 pm, R1 was sitting in a wheeled chair, reclined approximately 45 degrees, in the lounge across from the nurses station watching television. At 12:26 pm, V13 CNA stated V13 is assigned to R1 and that R1 was gotten up around 6:30 am {almost six hours prior} and placed in the chair. V13 stated V13 has not repositioned or toileted R1 since getting R1 up due to R1 being asleep every time V13 has checked on R1. The Immediate Jeopardy that began on 4/29/23 was removed on 6/13/23 when the facility took the following actions to remove the immediacy: 1. Changes made immediately following the reported incident, effective date 6/13/2023: 2. R1s order was changed and corrected as of 6/13/23 at 3:00PM to include enternal feeding type, how long the feeding is to run, and separate flush orders - completed on by V21, Regional Nurse 3. These orders are put in correctly and nurses will now have to sign off the flushes and feeding order - completed on 6/13/2023 - V21 Regional Nurse 4. Dietician updated notes are in assessments dated 6/4/2023 - Completed on 6/4/2023 by V14, Registered Dietitian 5. Intake tracking has been added to each shift for the nurses to fill in for both feedings and flushes - Completed and verified by V10 Regional Nurse 6/13/23 6. R1s care care plan has been updated to include skin break down on 6/13/2023 by V21 Regional Nurse and pressure relieving measures on 6/13/23 by V21. Care Plan is updated to include resident centered pressure relieving measures on 6/13/23 by V21, Regional Nurse. 7. R1s J tube now has orders now include for nurses to check J tube placement, J tube residual, and proper flushing completed by V21 Regional Nurse on 6/13/2023 8. R1 is on a pressure relieving mattress, is in a broda chair so he can be reclined and repositioned often, is frequent repositioning by staff Verified by S [NAME] Regional Nurse on 6/13/2023 9. R1s hospital discharge orders were double checked by 2 regional nurses to verify they are correct. Any incorrect orders were discontinued and entered correctly completed by V10 Regional Nurse and V21Regional Nurse on 6/13/2023 10. R1 will be assessed daily by nursing for skin assessments to assess for new wounds and monitor current wounds - completed by staff nurses daily, supplementary documentation added by V10 Regional Nurse on 6/13/2023 11. All residents have been assessed to check the braden scales and assure that daily or weekly skin checks are placed in the computer correctly - audit started by V21 Regional Nurse on 6/13/2023 and will be audited on an on going basis by V10, and V21, and eventually by the Director of Nursing once one is hired. 12. There are currently no other residents with a G tube or Jtube in the building 13. V10, and V21, and eventually by the Director of Nursing once one is hired will be monitoring all admissions and re admissions for G/J tubes to ensure proper orders are placed for 30 days starting 6/13/2023 14. Care policies for feeding tubes, skin breakdown have been reviewed do not show issues with identification, assessment, documentation, and process for notifications completed by V21, Regional Nurse on 6/13/2023 15. Clinical staff is being educated and trained on how to obtain accurate heights and weights with a return demonstration being performed starting on 6/7/2023 by V21 Regional Nurse to be completed by 6/13/2023 16. Nursing staff is being in serviced and educated on how transcribe physician orders for enternal feedings, flushes, wound care, and all physician orders in general by V21 Regional Nurse starting on 6/7/2023 to be completed by 6/13/2023 17. Nursing staff is being in serviced on how to monitor intakes for residents who are NPO and receive enternal feedings by V21 Regional Nurse starting on 6/7/2023 and completed by 6/13/2023 18. Nursing staff is being educated on how to care for G/J tubes for patency by V21, Regional Nurse starting on 6/7/2023 and completed by 6/13/2023 19. All mattresses in use at Watseka are pressure relieving mattresses unless the resident has a stage 2 or higher wound then they are placed on an air mattress. R1 was placed on a low air loss mattress as of 6/13/23 20. V10, V21 or the DON when one is hired will audit three times a week that all pressure ulcer treatments are completed as ordered starting 6/13/2023 for 3 weeks 21. V10 and V21, the regional team will ensure compliance by overseeing QA for the next 3 weeks then quarterly thereafter.

Based on observation, interview, and record review the facility failed to follow it's Abuse Prevention policy to prevent the physical, verbal, and mental abuse of residents by failing to orientate new employees regarding Dementia management and resident abuse, and by failing to investigate allegations of abuse and report allegations of abuse to the facility's Administrator, the State Agency, Adult Protective Services, and local law enforcement to prevent subsequent abuse. These failures affected seven of seven residents (R2, R3, R6, R7, R8, R9 and R10) reviewed for abuse on the sample list of ten and have the potential to affect all 77 residents residing in the facility. These failures resulted in multiple incidents of physical abuse to R3 and R3 sustaining a laceration to the back of the head requiring emergency medical services and staples to close the laceration. Findings include: The facility's Abuse Prevention Program policy with a revision date of 11/28/16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This policy documents that during orientation of new staff the facility will cover, Dementia management and resident abuse preventions; Including, How to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff. This policy documents, Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. This policy documents, Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation. This policy also documents, The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion), Otherwise, the report must be made not later than 24 hours after forming the suspicion. The Nurse's Midnight Census dated 6/4/23 documents there are 77 residents residing in the facility. 1. The facility's video footage dated 6/3/23 at 5:07 PM, shows V24 Certified Nurse's Assistant (CNA) grabbing and squeezing R9's hands and pushing R9 with both hands. This video also shows V25 CNA taking R9's walker and hiding it from R9, V25 striking R9 on the shoulder, and V25 grabbing a clothing protector and forcefully hitting R9 in the face and chest. On 6/8/23 at 12:15 PM, V24 stated she was hired at the facility about a month before the incident on 6/3/23. V24 stated she was not trained on Dementia management and resident abuse. On 6/8/23 at 12:35 PM, V25 stated she was hired at the facility about a month before the incident on 6/3/23. V25 stated she was not trained on Dementia management and resident abuse. V24 and V25's employee files provided by V2 Administrator in Training did not contain documentation that V24 and V25 were trained on Dementia management and resident abuse. 2. On 6/7/23 at 10:54 AM, R3 was noted to have staples to the back of her head. R3's Incident note dated 4/4/2023 at 10:37 AM, documents R9 struck R3 with her walker. R3's Incident note dated 5/7/2023 at 7:30 PM documents, R3 was hit in the chest by R10 and R3 fell on to floor hitting her head. R8's Behavior Note dated 5/24/2023 at 6:06 PM, documents R8 throat punched R3. R8's Behavior Note dated 5/28/2023 at 1:17 PM, documents R8 pushed R3 down. Hospital Records dated 5/28/23 document R3 received four staples to a head wound after R3 fell (was pushed down by R8) on 5/28/23. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated no one reported the physical abuse of R3 by R8, R9, and R10 that occurred on 4/4/23, 4/11/23, or 5/24/23 to her so the incidents were not investigated and the state agency, adult protective services, or local law enforcement were notified. V2 stated that after the incidents no new interventions were put into place to prevent further abuse. 34201 3.) On 6/7/23 at 9:00 am, R6 was propelling R6's self throughout the facility in R6's wheelchair without supervision. On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 had physical contact and verbal outburst towards R7 and R2 both, just a few days apart from one another. V8 stated R6 had hit R2 on the hand and called R2 a (expletive) when R2 was trying to get past R6 in the hallway. V8 also stated that R6 physically attacked R7 outside of R6's room and was hitting R7 in the back and side of R7's head and pulling R7's hair. The facility provided an initial abuse investigation dated 5/26/23 documenting a resident to resident altercation that included a few witness statements for the abuse between R6 and R7 but the facility did not provide any information regarding the abuse allegation involving R6 and R2. On 6/5/23 at 2:05 pm, V2 AIT (Administrator in Training) stated V2 was the Abuse Coordinator. V2 confirmed V2 only received a few witness statements regarding the abuse allegation between R6 and R7 and did not complete a thorough investigation. V2 stated R6 was educated on not hitting other residents then stated, R6 isn't with it though so education really isn't going to help that but it's something we {facility} still had to do. On 6/6/23 at 9:05 am, V2 AIT stated V2 remembers hearing about a physical abuse allegation between R6 and R2 but got the allegation confused and didn't realize that R6 had been involved in two separate abuse allegations, therefore V2 did not complete an investigation into the abuse allegation, implement any interventions to prevent further abuse, or report the incident to IDPH (Illinois Department of Public Health).

Based on observation, interview, and record review the facility failed to investigate allegations of physical abuse and prevent further abuse for seven of seven residents (R2, R3, R6, R7, R8, R9 and R10) reviewed for abuse on the sample list of ten. This failure resulted in multiple occurrences of physical abuse to R3 in which R3 sustained a laceration to the back of the head requiring emergency services and staples to close the laceration. This failure also has the potential to affect all 77 residents residing in the facility. Findings include: 1. On 6/7/23 at 10:54 AM, R3 was noted to have staples to the back of her head. R3's Incident note dated 4/4/23 at 10:37 AM, documents R9 struck R3 with a walker. R3's Incident note dated 5/7/23 at 7:30 PM, documents R10 hit R3 in the chest and R3 fell on to to floor hitting R3's head. R8's Behavior note dated 5/24/23 at 6:06 PM, documents R8 throat-punched R3 in the throat. R8's Behavior Note dated 5/28/23 at 1:17 PM, documents R8 pushed R3 down causing R3 to have a laceration to the back of the head. Hospital Records dated 5/28/23 document R3 received four staples to a head wound after R3 fell (was pushed down by R8) on 5/28/23. R3's care plan dated 12/14/22 does not document and changes to R3's plan of care. R8's care plan dated 5/3/23 does not document any changes to R8's plan of care. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated she did not know about the incidents involving R3 occurring on 4/4/23, 5/723, or 5/24/23. V2 stated these incidents were not investigated. V2 stated no changes were made to R3's plan of care after the incidents on 4/4/23, 5/7/23, 5/24/23, or 5/28/23. V2 stated no changes were made to R8's plan of care after the incident on 5/24/23. 34201 2.) On 6/7/23 at 9:00 am, R6 was propelling R6's self throughout the facility in R6's wheelchair without supervision. On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 has shown behaviors towards female residents and explained, R6 had physical contact and verbal outburst towards R7 and R2 both, just a few days apart from one another. V8 stated V8 was at the facility on both occasions. V8 stated, the first time was a week or two ago while V8 was sitting at the nurses station and R6 was sitting in R6's wheelchair in the hall across from the nurses station. V8 explained that R2 was trying to get by R6 but R6's foot was sticking out. R2 said excuse me, can you please move your foot {talking to R6} and the next thing V8 heard was R2 say Ouch, you didn't have to do that, then V8 heard R6 say, you (expletive)! V8 stated V8 stood up and asked what happened and R2 reported that R6 had hit R2 on the hand. V8 stated R2 had no bruising or even redness but V8 immediately separated R2 and R6 and reported it to V9 RN (Registered Nurse), and gave a written statement. V8 explained a couple of days later, (V8) was across the hall from (R6's) room and (R7) was sitting outside of (R6's) room with (R7's) back to (R6's) door. Next thing (V8) knew, (V8) heard (R6) yelling I (R6) told you to stay the (expletive) away from me and then started hitting R7 in the back of the head and by R7's ear. V8 stated V8 immediately separated them both and reported the abuse. V8 explained in the past, R6 and R7 use to live next to each other and would constantly go after each other so the facility had to move them to separate halls. The facility provided an initial abuse investigation dated 5/26/23 documenting a resident to resident altercation that included a few witness statements for the abuse between R6 and R7 but the facility did not provide any information regarding the abuse allegation involving R6 and R2. On 6/5/23 at 2:05 pm, AIT (Administrator in Training) stated V2 was the Abuse Coordinator. V2 confirmed V2 only received a few witness statements regarding the abuse allegation between R6 and R7 and did not complete a thorough investigation. V2 stated R6 was educated on not hitting other residents then stated, R6 isn't with it though so education really isn't going to help that but it's something we {facility} still had to do. On 6/6/23 at 9:05 am, V2 AIT stated V2 remembers hearing about a physical abuse allegation between R6 and R2 but got the allegation confused and didn't realize that R6 had been involved in two separate abuse allegations, therefore V2 did not complete an investigation into the abuse allegation nor implement any interventions to prevent further abuse. The Nurse's Midnight Census dated 6/4/23 documents there are 77 residents residing in the facility.

Based on observation, interview, and record review the facility failed to ensure the Administrator in Training, Director of Nursing, and the Unit Coordinator of the Dementia Unit received sufficient training to adequately manage the facility in a manner that maintained the physical and mental well-being of it's residents. These failures contributed to ongoing incidents of physical and mental abuse to residents diagnosed with Dementia. These failures affected seven of seven residents (R2, R3, R6, R7, R8, R9, and R10) reviewed for abuse on the sample list of ten and has the potential to affect all 77 residents residing in the facility. As a result of these failures, R3 was repetitively physically abused ultimately sustaining a laceration to the back of the head requiring emergency medical services and four staples to close the laceration. These failures also resulted in R9 having a catastrophic reaction after being subjected to physical and mental abuse by untrained staff. Findings include: 1. On 6/7/23 at 10:54 AM, R3 was walking up and down the hallways and going up to staff, other residents, and visitors touching their arms, jewelry, and shirts. R3 was noted to have staples to the back of her head. R3's nurse's notes dated 4/4/2023 at 10:37 AM, documents R9 struck R3 with her walker due to R3 wandering into R9's room. This note documents V3 Director of Nursing was notified. R3's Incident note dated 5/7/2023 at 7:30 PM documents, (R3) was hit in the chest by (R10) and fell on to floor hitting her head. R8's Behavior Note dated 5/24/2023 at 6:06 PM documents, R8 throat-punched R3 and V3 was notified. R8's Behavior Note dated 5/28/2023 at 1:17 PM documents, R8 pushed R3. On 6/7/23 at 10:23 AM, V2 Administrator in Training stated she doesn't know much about R8's admission into the facility. V1 stated V23 Former Dementia Care Coordinator left on 4/29/23. V2 stated the Interdisciplinary team were covering incidents and changes on the Dementia unit since then. V2 stated they have morning meetings in which they discuss what was going on in the facility. V2 stated V2 did not know about the incidents involving R3 occurring on 4/4/23, 4/11/23, or 5/24/23 until the incident occurring on 5/28/23 between R8 and R3. V2 stated the unit coordinator is responsible for the behavior programs. V2 stated no behavioral interventions were put into place after these incidents. On 6/7/23 at 10:37 AM, V3 stated she remembers getting a text about the incident on 5/24/23 and she told V19 to call V2 Administrator. V3 stated V3 doesn't remember talking about it in the morning meeting the next day. On 6/7/23 at 10:15 AM, V6 Dementia Unit Coordinator stated she took over five days ago. V6 stated she is not sure about the behavior tracking or behavior programs for the residents yet. On 6/7/23 at 10:48 AM, V19 Licensed Practical Nurse stated on 5/24/23 a staff member told me that R8 had throat punched R3. I text V3, Director of Nursing but she never responded back. V19 stated no one told us of any new behavioral interventions for R8 or what to do to prevent R3 from getting into people's personal space. On 6/7/23 at 10:54 AM, V20 Certified Nurse's Assistant stated R8 is physically aggressive and no one has told him about a behavioral plan for R8. The facility's video footage dated 6/3/23 at 5:07 PM, showed V24 Certified Nurse's Assistant (CNA) grabbing and squeezing R9's hands and pushing R9 with both hands. This video also showed V25 CNA taking R9's walker and hiding it from R9, V25 striking R9 on the shoulder, and the V25 grabbing a clothing protector and forcefully hitting R9 in the face and chest. On 6/8/23 at 12:15 PM, V24 Certified Nurse's Assistant stated the residents on the Dementia unit all wander and go into each others rooms and we go and tell and they ignore us and won't do anything about it. We don't want residents hurt. They never tell us new interventions and when we asked a corporate nurse what the protocol was when residents are combative and they said we don't have one. V24 stated they didn't train me at all and if you want me to be honest one day we (V24 and V25 CNA) showed up and V2 Director of Nursing just threw us back there with no training at all. V24 stated they usually only had one of us CNAs back there. V24 statede V24 also worked back there by herself for 16 hours with 16 to 17 Dementia residents. V24 stated there are 5 or 6 residents who walk and they wander into each others' rooms. There at least 8 residents who are aggressive back there. V24 stated when V24 reported it to the nurse (unknown nurse) there was nothing done and no new interventions were put into place. On 6/8/23 at 12:35 PM, V25 CNA stated she started at the facility on April 17th, 2023. V25 stated she ended up working on the Dementia unit and didn't get any abuse or Dementia training at the facility. V25 stated she wasn't aware of any behavior health programs or interventions for the residents. V25 stated the facility threw us (V24 and V25) to the wolves. V25 stated after they (V24 an V25) complained about other staff, the facility retaliated by scheduling them to work back there with no training or direction. V25 stated we didn't know anything about the residents. V25 stated another employee from an agency told them who was combative and other then that V25 had to create her own cheat sheet that would remind her who was incontinent and who needed assistance. V25 stated in regards to the incident with V9, everything was happening so fast and I didn't know what to do. V25 stated the nurse (unknown) was with agency and she didn't know what to do, I think that was her first day. On 6/5/23 at 9:00 AM, V2 Administrator in Training stated she applied for a temporary Administrator license but hasn't received it yet. V2 stated V1 Administrator is the actual Administrator but isn't in the facility. V2 stated he's(V1) only here once a week due to having a lot of buildings and being in the buildings that have a lot of concerns. V10 Corporate Nurse(Acting Administrator at another facility) who was present at this time, stated she was here doing training with V3 Director of Nursing even though she's(V3) been here awhile, there are a lot of nursing concerns here. 34201 2.) On 6/5/23 at 1:45 pm, V8 Agency CNA (Certified Nursing Assistant) stated R6 had physically attacked two separate residents R2 and R7, just a few days apart from each other. V8 explained R6 hit R2 on the arm when R2 was trying to pass R6 in the hallway and then hit R7 in the back and side of the head and pulled R7's hair. V8 stated V8 had reported both incidents to the nurse and Administration and gave a written witness statement. On 6/5/23 at 2:05 pm, V2 AIT (Administrator in Training) stated V2 was the Abuse Coordinator. V2 stated V2 only sent in an initial report to IDPH (Illinois Department of Public Health) on the incident between R6 and R7 and did not thoroughly investigate the incidents of abuse or really do anything other than gather a few witness statements regarding the incident between R6 and R7 because V2 didn't know what needed to be done. V2 explained V2 wasn't taught the right way how to handle doing reports and investigations. V2 stated V1 Administrator is the Regional Administrator, so V1 is over several facilities and has not been to this facility in a little over two weeks and the V2 did not call V1 for guidance of what to do.

Based on interview and record review the facility failed to promptly notify the physician of an acute change in condition, document changes in condition, and monitor/assess for changes in condition for two (R1, R7) of three residents reviewed for hospitalization in the sample list of 12. This failure resulted in R1's multiple hospital readmissions for fluid volume overload, pleural effusions, pulmonary edema, acute hypoxic respiratory failure and congestive heart failure. The facility also failed to monitor anticoagulant use for one (R7) of three residents reviewed for hospitalization s in the sample list of 12. Findings include: 1.) R1's Diagnoses List dated 5/24/23 documents R1 has type II Diabetes Mellitus with Chronic Kidney Disease. R1's Physician Order dated 3/22/23 documents R1 receives hemodialysis at a dialysis center three times weekly on Mondays, Wednesdays, and Fridays. R1's Brief Interview for Mental Status score dated 5/5/23 documents R1 is cognitively intact. R1's Care Plan dated 11/14/22 documents R1 has End Stage Renal Disease, is noncompliant with diet, and includes an intervention to weigh monthly and report weight changes to the physician and dietitian. This care plan documents R1 receives dialysis three times weekly and includes interventions to monitor for changes in condition including fluid status, cognition and activities of daily living needs, and report these changes to the dialysis center. This care plan documents R1 uses oxygen as needed for shortness of breath and includes interventions to monitor R1's oxygen saturation every shift and as needed, and notify the physician of concerns. R1's Nursing Note dated 4/16/2023 at 6:51 PM documents R1 refused all medications, had not ate all day, and stated R1 did not feel well. There is no documentation that V16 (R1's Physician) was notified. There are no documented monitoring/assessments of R1 between 4/16/23 and 4/17/23. There is no documentation that R1 was transferred to the hospital on 4/17/23 or the reason for the hospital transfer. R1's emergency room assessment dated [DATE] at 10:31 AM documents R1 complained of nausea, vomiting, shortness of breath for the past two days, and R1 has no cardiac history. R1's last dialysis was on 4/14/23, with dialysis scheduled for 4/17/23. This assessment documents R1 had similar symptoms and hospitalization with dialysis about a month ago. R1's lungs were diminished with wet crackles, oxygen saturation was 50% (normal is 95% or higher), blood pressure was 188/118, and pulse was 92. R1 weighed 165 pounds (lbs). R1's chest x-ray dated 4/17/23 documents R1 had changes that were suspicious for congestive heart failure with developing pulmonary edema and pleural effusions (fluid in the lungs). R1's emergency room Note dated 4/17/23 documents R1 was given intravenous Lasix (diuretic), placed on high flow oxygen, then placed on Bilevel positive airway pressure (BIPAP), and transferred to a higher level hospital. R1's Hospital Progress Note dated 4/21/23 documents R1 was transferred from an outside hospital for acute hypoxic respiratory failure, and nephrology was consulted for dialysis for fluid volume overload and hyperkalemia. R1's weight on 4/21/23 was 145 lbs and 6.4 ounces. There are no routine monitoring of R1's weights, blood pressure, and oxygen saturation in R1's medical record. R1's weight on 2/1/23 was 167 lbs, on 4/19/23 and 4/23/23 R1 weighed 159 lbs. There are no other documented weights in April and May 2023 or documented assessments/monitoring of R1 after 4/22/23 until 4/30/23. R1's Nursing Notes document the following: On 4/30/2023 at 6:03 PM oxygen was administered at 2 liters per minute due to R1's complaints of shortness of breath and coughing up phlegm. On 4/30/2023 at 6:37 PM R1 was R1's usual self earlier in the day, and now complained of shortness of breath. R1's blood pressure was 180/76, respirations were 26, and oxygen saturation was 94%. R1 had a cough with a clear amount of phlegm and a nebulizer treatment was administered. On 4/30/2023 at 7:41 PM R1 was sitting on the side of the bed and complained of feeling much worse. R1's blood pressure was 180/104, pulse was 98, Oxygen saturation was 94%. The physician was notified and R1 was transferred to the local hospital. R1's Hospital Discharge Summary dated 5/1/23 at 11:41 AM documents the following: R1 admitted to the hospital on 4/30/23 for complaints of shortness of breath. R1 reported having hemodialysis the day prior with 3.5 liters of fluid removed, and later that day R1 had sudden onset of shortness of breath and productive cough. R1's dialysis is scheduled three times weekly on Mondays, Wednesdays, and Fridays (indicating R1's last dialysis day was on 4/28/23.) R1's oxygen saturation was 65% on room air and R1 was placed on BIPAP. R1's chest x-ray showed volume overload with mild to moderate pleural effusions, pulmonary infiltrates, pulmonary edema, and congestive heart failure with mild cardiomegaly. R1 readmitted to the facility on [DATE] and there are no documented assessments/monitoring, or changes in condition between 5/5/23 and 5/15/23. R1's Nursing Note dated 5/15/23 at 3:17 PM documents R1's family member called and inquired how R1's condition was earlier in the day and if R1 went to dialysis. This family member reported that R1 had not felt good during the night. The nurse informed R1's family that R1's vital signs were obtained (these vital signs are not recorded in R1's medical record) and R1 was transferred to dialysis. R1 was transferred from dialysis to the local hospital and intensive care unit with diagnoses of hyperkalemia, shortness of breath, dialysis, and pulmonary edema. There are no documented assessments or monitoring of R1 after R1 returned to the facility on [DATE]. On 5/23/23 at 8:41 AM R1 stated R1 went from dialysis to the hospital on 5/15/23 for shortness of breath, nausea, coughing, dizziness and sweating. R1 stated the facility had sent R1 to dialysis with R1's symptoms to see if dialysis would improve R1's symptoms, but the dialysis center told R1 there was nothing they could do for R1 and sent R1 to the hospital. R1 stated R1 was in a wheelchair and was on oxygen when R1 was transferred to dialysis, and R1's symptoms began on the night before around 6:00 PM. R1 kept waking up during the night and reporting R1's symptoms to the nurses, and R1 was not sure if the nurses reported R1's symptoms to V16 Physician. R1 stated R1 was hospitalized for pneumonia. R1 stated R1's symptoms are always the same and usually begin about 1-2 days prior to R1 being transferred to the hospital. R12 (R1's room mate) stated about 3-4 weeks ago R12 had to contact emergency services to request R1 be transported to the emergency room . R1 stated R1 had kept asking the nurses to send R1 to the hospital, and they refused saying R1 only needed dialysis. On 5/24/23 at 8:24 AM R1 stated R1 went to the local hospital in April and had to be transported to a higher level hospital for treatment. R1's symptoms had started the night before, and R1 had requested to go to the emergency room . R1 stated V2 Director of Nursing told R1 that R1 needed dialysis and did not contact 911 as R1 had requested. On 5/24/23 at 8:14 AM V31 Dialysis Nurse stated on 5/15/23 R1 arrived at dialysis in a wheelchair and on oxygen, normally R1 is ambulatory and does not use oxygen. R1 complained of being short of breath, sweating, and abdominal pain that had started the night before and the facility nurses had not addressed R1's symptoms. V31 stated R1's health changes quickly and has a history of respiratory illness. V31 stated R1 was immediately transferred to the local hospital and admitted to the intensive care unit. V31 stated V31 spoke to V25 Licensed Practical Nurse on 5/15/23 who told V31 that R1 did not look good that morning. V31 stated R1 also reported that a few weeks prior R1 was experiencing similar symptoms and requested to go to the hospital, but R1 had to call 911 because the nurses would not. On 5/24/23 at 8:29 AM V33 Certified Nursing Assistant stated there was a day that R1 went to dialysis in a wheelchair and on oxygen, and R1 did not return to the facility that day. V33 stated normally R1 is able to walk and take care of R1's self, and only uses oxygen as needed typically at night. On 5/24/23 at 11:07 AM V2 Director of Nursing stated residents on dialysis should be weighed weekly and recorded in the electronic medical record. Vital signs, swelling in extremities, puffiness of the face, and assessing lung sounds are all part of monitoring/assessing for fluid overload. V2 stated we chart by exception and only when there are changes noted in the resident. V2 stated V2 would expect an assessment to be done and documented when a resident complains of not feeling well, and the physician should be notified. V2 stated vital signs are not always getting done. V2 stated R1 went in a wheelchair to dialysis on the morning of 5/15/23, and normally R1 is ambulatory and only uses oxygen after dialysis treatments when needed. V2 stated R1 does not always feel well on dialysis mornings. On an unidentified date V2 told R1 it was a scheduled dialysis day when R1 requested to go to the hospital for vomiting. V2 stated V2 had to assist with another resident, and R1 called 911. On 5/24/23 at 2:57 PM V16 Physician stated R1 is noncompliant with R1's orders and medications which contributes to R1's fluid volume overload, and R1 receives dialysis three times weekly. V16 stated the facility should be monitoring R1's weights at least weekly, and blood pressure daily. V16 expects the nurses to complete an assessment including vital signs and oxygen saturation when R1 has a change in condition including of shortness of breath, dizziness, or nausea/vomiting. V16 stated R1 can have a rapid increase in blood pressure, and the nurses should notify V16 of their assessment and R1's change in condition/symptoms. V16 stated V16 is unable to manage R1's fluid volume overload in the facility, and R1 requires hospitalization and additional dialysis to treat R1's fluid volume overload. V16 stated if the facility is not monitoring R1 for signs/symptoms of fluid volume overload, then R1 could go downhill fast or possibly die. V16 stated V16 should have been notified of R1's change in condition and symptoms and R1 should have been sent to the emergency roiagnom on [DATE]. R1 should not have been sent to dialysis in that condition. 2.) R7's Diagnoses List dated 5/24/23 documents R7 has End Stage Renal Disease, Kidney Failure, Atherosclerotic Heart Disease, Heart Failure, Type 2 Diabetes Mellitus, and history of myocardial infarction. R7's Care Plan revised 2/1/23 documents R7 receives dialysis three times weekly on Tuesdays, Thursdays, and Saturdays and includes interventions to monitor for changes and response to treatment, notify the dialysis center of changes in condition including fluid status, cognition, and activities of daily living needs. There are no routine assessments or monitoring of R7 and R7's vitals signs and weight documented in R7's medical record. R7's Nursing Notes document the following: On 5/14/2023 at 1:37 AM R7 had 3+ pitting edema to bilateral lower extremities, complaint of numbness/tingling to bilateral upper/lower extremities, blood pressure was 137/100, pulse was 104, oxygen saturation was 93%, respirations were 18, and blood glucose results were high. The physician was notified and R7 was transferred to the hospital. On 5/17/2023 at 4:06 PM R7 readmitted to the facility and reported that R7 had dialysis with 3 liters of fluid removed. There are no documented assessments after 5/17/23. On 5/22/23 at 1:13 PM R7 refused all morning medications and insulin. R7 complained of vomiting and diarrhea and requested to go to the emergency room . R7's face was puffy and abdomen was distended. R7 was transferred to the hospital by ambulance. There are no documented assessments/monitoring of R7 on 5/21/23 and prior to 5/22/23 at 1:13 PM or that R7's physician was notified of any change in condition prior to 5/22/23. R7's Hospital Note dated 5/14/23 at 8:33 AM documents R7 presented with weakness and abdominal pain that began over the last week with some nausea/vomiting, decreased urine output, fluid retention, weight gain, and abdominal distention. R7's pelvis computed Tomography showed anasarca (accumulation of fluid/swelling of the whole body), pleural effusion, abdominal ascites (fluid). On 5/23/23 at 1:11 PM V27 Certified Nursing Assistant stated on 5/21/23 R7 was overly tired and not out and about per R7's usual. V27 stated V27 served R7's supper tray then later that evening R7 went outside to smoke and V27 noticed R7's eyelids were swollen/puffy. V27 stated R7's ankles are always swollen, but R7 had no facial swelling prior. V27 stated V27 reported R7 feeling tired and R7's eyelid swelling to V30 Licensed Practical Nurse who said that V30 would assess R7. On 5/24/23 at 9:20 AM V26 Licensed Practical Nurse stated V26 reported to work on 5/22/23 at 10:00 AM and R7's face was puffy and abdomen was distended. V26 stated V26 last cared for R7 on 5/19/23 and R7 did not have facial swelling at that time. R7 complained of vomiting and diarrhea and was requesting to go to the hospital. It was passed on in report that R7 refused R7's morning medications. V26 stated R7 was transferred to the hospital around 11:00 AM. On 5/24/23 at 11:07 AM V2 Director of Nursing stated residents on dialysis are to be weighed weekly and recorded in the electronic medical record. Vital signs, swelling in extremities, puffiness of the face, and assessing lung sounds are all part of monitoring/assessing for fluid overload. V2 stated we chart by exception and only when there are changes noted in the resident. V2 stated V2 would expect an assessment to be done and documented when a resident complains of not feeling well, and the physician should be notified. V2 stated vital signs are not always getting done. V2 stated R7 was admitted to the hospital with fluid volume overload on 5/22/23. 3.) R7's Diagnoses List dated 5/24/23 documents R7 has a history of Transient Ischemic Attacks and Cerebrovascular Infarction. R7's April and May 2023 Medication Administration Records documents R7's Coumadin (anticoagulant) was increased from 5 milligrams (mg) daily to 7.5 mg daily on 4/6/23 and then decreased to 3.5 mg daily on 5/1/23. The order dated 5/1/23 indicates to monitor R7's Protime (PT)/International normalized ratio (INR) daily with a therapeutic goal of 2.5-3 and to adjust the dose accordingly as recommended by the physician. There is no documentation that R7's PT/INR was monitored routinely after 3/29/23, and there are no orders for routine PT/INR. There is no documentation in R7's medical record that attempts were made to obtain R7's PT/INR, that R7 refused laboratory draws, or that R7's physician was notified of refusals. R7's PT/INR on 3/29/23 was 25.6 and 2.42. R7's Laboratory Requisitions dated 4/5/23 and 4/12/23 documents R7 refused blood draw for PT/INR. R7's Laboratory Requisitions 4/19/23 and 5/10/23 documents R7 refused laboratory draw, but does not document what laboratory test was ordered. R7's Nursing Notes R7 went on a leave of absence from the facility on 4/23/23. R7's Physician Progress Note dated 5/10/2023 at 1:54 PM documents R7 readmitted to the facility and had been hospitalized for an elevated INR and R7's brain computed Tomography indicated an increase in R7's brain bleed. On 5/24/23 at 11:07 AM V2 Director of Nursing stated PT/INR should be done at least monthly or per physician's orders after an increase in dosage of Coumadin. At 3:33 PM V2 stated stated there were no orders to monitor PT/INR routinely and confirmed there were no PT/INR results after 3/29/23. V2 stated no one followed up on monitoring PT/INR after R7 readmitted to the facility. V2 stated R7 refused to have PT/INR drawn and the nurses should have notified the physician and documented in R7's medical record. V2 stated the facility does not have a policy on anticoagulant use/monitoring. The facility's Notification for Change in Resident Condition or Status revised 12/7/17 documents the physician will be notified of changes in resident's physical/emotional/mental conditions, refusal of treatment/medications, and transfer to hospital. Information related to the change in condition will be documented in the resident's medical record.

Based on interview and record review, the facility failed to provide treatment and services to promote wound healing for a resident. R1 was admitted to the facility with multiple burn wounds to R1's right front thigh, left front thigh, left rear knee, left rear lower leg, and back in which the facility failed to assess, monitor, obtain orders and provide treatments for R1's wounds. This failure affects one of three residents (R1) reviewed for wounds on the sample of five. These failures resulted in R1's open wounds on R1's back to deteriorate and become infected requiring hospitalization . Findings include: The facility's Skin Condition and Monitoring policy dated 3/16/23 documents it is the policy of the facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. This policy documents the nurse will assess and document the findings in the nurses notes and complete a skin evaluation. The nurse will then notify the physician and obtain a treatment order including type of treatment, location of area to be treated, frequency of treatment and cleansing of the wound. Any skin abnormality will have a specific treatment order until area is resolved. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include size, shape, depth, odor, color and presence of granulation tissue or necrotic tissue, treatment and response to treatment and prevention techniques in place for the resident. R1's Hospital Discharge Skin/Wound Assessments dated 4/7/23 at 8:00am document the R1's burn wounds including burn wounds to the Left posterior thigh and Back. These wound assessments document R1's dressing changes to each of these wounds as being changed on 4/6/23 and were dry and intact. R1's Admission/Readmission Nursing Evaluation dated 4/7/23 at 3:46pm documents R1 admitted to the facility with reason for admission as Tracheostomy care, wound care and an indwelling urinary catheter. This evaluation documents R1 has burn wounds to the right front thigh, left front thigh, left rear knee and left rear lower leg with measurements. There is no documentation of R1's multiple back wounds on admission to the facility. This evaluation documents R1 is alert and oriented to person, place, time and situation and communicates via communication board. R1's Electronic Clinical Physician Orders dated 5/18/23 at 6:10pm do not document orders for wound care/dressing changes for April 2023 and May 2023. R1's Electronic Treatment Administration Records (TAR) dated April 2023 and May 2023 do not document R1 received dressing changes to R1's multiple burn/skin graft wounds on R1's back or any other of R1's burn/skin graft wounds, including R1's lower extremities. There is no documentation of attempts by the facility to clarify/review post hospital visit needs for R1's wound treatments. R1's Hospital records document R1's wound counsult note for multiple wounds present on admission 4/11/23 and wound details as follows: 4/11/23 at 11:42pm, R1's lower thoracic spine wound was midline lower thoracic spine with partial thickness. The wound bed was clean, moist, pink. Periwound was scar tissue with a scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's left scapula multiple wound beds were clean, moist, and pink. The periwound was scar tissue and A scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's right scapula multiple wound beds were clean, moist, and pink. The periwound was scar tissue With a scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's multiple Left posterior leg wounds extending up to the posterior knee learned about was clean moist and pink with periwound of scar tissue. This wound contained a scant amount of serosanguineous drainage. 4/12/23 at 12:00am, R1's Right abdomen wound bed was clean with red hypergranulation and sutures, multiple areas. Red granulation was 76 to 100%. peri-wound is documented as scar tissue and that these wounds had small amount of serosanguineous drainage. This was cleansed with sterile normal saline and a border dressing applied. 4/12/23 at 12:00am, left lateral hip multiple wound beds were clean, dry, pink. peri-wound is documented as scar tissue with no drainage. 4/12/23 at 10:05am, left second toe dorsal pressure injury deep tissue and present on admission. The wound bed is dry and maroon and purple and color. peri-wound is intact with no drainage. 4/12/23 Left dorsal thigh multiple wound beds are clean, moist, and pink with no drainage and peri-wound as scar tissue. 4/12/23 at 10:09am, right thigh medial multiple wound beds clean, moist, pink with peri-wound documented as scar tissue and contained a scant amount of serosanguineous drainage. 4/12/23 at 10:10am, left lower back wound had full thickness with wound bed moist, pink, with slough. Red/granulation tissue 1-26%, yellow slough 51-75% with the peri-wound documented as scar tissue with a small amount of serosanguineous drainage. R1's Hospital Discharge Summary documents R1 discharged from the hospital on 4/25/23. This summary does not document wound care orders for R1's multiple wounds. R1's Hospital Discharge Instructions dated 4/25/23 do not document wound care/dressing change orders for R1' multiple wounds on R1's body. There is no documentation in R1's electronic medical record that the facility requested or obtained wound care orders upon readmission to the facility for R1's multiple wounds on multiple areas of R1's body. R1's Admission assessment dated [DATE] at 11:58am documents R1 readmitted to the facility on [DATE]. This assessment documents R1's admitting diagnosis as Respiratory Failure with reason for admission, tracheostomy. This assessment does not document R1's multiple skin wounds to R1's body. On 5/10/23 at 2:35pm, V5, emergency room Physician stated R1 admitted to the hospital on 5/3/23 with non-healing wounds and required a lot of cares/frequent wound care. V5 stated R1 is at an increased risk for skin breakdown as well as infection/decline to R1's wounds due to R1's history of burn wounds with skin grafts and current open wounds. R1's Hospital Nursing notes dated 5/3/23 at 9:55pm document R1 has poor skin turgor with breakdown, wounds with wound odor. These notes documents R1 has multiple open wounds to R1's back and legs bilaterally in area of previous burned skin. This note documents R1's dressings on R1's wounds were dated 4/27/2023 with purulent drainage noted. This note documents R1 has multiple dressings on legs, back and abdomen that were dated 4/27/2023. R1's wound dressings to R1's left hip, back, left thigh were draining yellow thick sanguineous and purulent drainage and had a foul odor. This note documents these dressings were soaked off with normal saline soaks, R1's wound dressings were removed and R1's wound beds were denuded with sanguineous, yellow thick green drainage noted in wound beds with a foul odor to R1's wounds. This note documents V12, R1's family stated R1's wounds were not that severe prior to admission to the facility. This note also documents 90% of R1's back is covered in full thickness open wounds with sanguineous drainage. R1's Hospital Therapy Notes dated 5/4/23 at 3:44pm document R1 has several open wounds from his previous burn injuries that have not been properly cared for and are infected. these notes document R1 would be appropriate to return to a skilled nursing facility, however it does not appear that (R1's) current facility has been able to provide the quality of care needed by (R1.) R1's Wound Consult note signed by V9, Wound Physician/General Surgeon dated 5/8/23 documents R1 has multiple raw areas on the back and behind the thigh that are still bleeding and that R1 needs to have operation on R1's wounds with potential skin grafts to wounds. On 5/10/23 at 1:00pm, V8, Licensed Practical Nurse (LPN)/Case Manager stated V9, Wound Physician/General Surgeon had recommended R1 go to surgery for skin grafting to R1's wounds. V8 was unsure if wound cultures were obtained but that V8 observed R1's wounds and they had slough and appeared infected. V8 stated when R1 came back to the hospital on 5/3/23, R1's wounds smelled awful and the worst V8 has ever seen. On 5/18/23 at 3:25pm, V2, Director of Nursing (DON) stated when R1 initially admitted to the facility on [DATE], R1 had fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate and petrolatum to R1's wounds to R1's legs including R1's front left thigh, left posterior knee, left lower posterior leg and R1's right thigh. V2 stated those dressings were removed and replaced. V2 stated R1 could not tolerate facility staff holding R1's leg up to wrap, so V2 tried to do (internet search engine) search to find a dressing that would not stick to R1's wounds. V2 stated R1's leg wounds had some serosanguinous drainage but no odor and R1's wounds did not appear infected on 4/7/23. V2 stated, normally don't change (wound dressings) for 3-5 days but R1 did not have orders when R1 admitted to the facility and R1 did not have wound dressings to R1's back or any open areas. V2 stated V2 completed the assessment of R1's skin and R1 had wounds to the thigh, back of knee, but not R1's back. V2 stated V2 and an additional staff member who V2 was unable to identify slightly turned R1 over to get to R1's leg but that V2 did not complete a full skin assessment to R1's back. V2 stated R1 had orders for fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate and petrolatum and that these orders were on R1's paperwork. V2 stated R1's electronic Clinical Physician Orders should document the wound care orders but do not. V2 stated V2 thought V2 put in R1's orders related to wound care/dressing changes, but (V2) working pretty late. V2 confirmed R1's wound care/dressing change orders were not entered in to R1's electronic medical record. V2 stated, looks like a partial skin assessment was completed when R1 readmitted to the facility on [DATE], but no detailed wound assessment. V2 stated V2 documented R1 had open burn wounds and asked staff (unsure of names of staff) to go back and document what staff found because V2 had other things to get done. V2 stated, Apparently I did not do a thorough (skin) assessment (on 4/7/23) if (V2) didn't see the wounds on (R1's) back.V2 stated V2 does not see documentation nor is V2 aware of any wound dressing changes being completed to R1's back while R1 was a resident at the facility.

Based on interview and record review, the facility failed to ensure a resident received proper tracheostomy care to prevent the tracheostomy from becoming occluded and assist in respiratory infection prevention. This failure affects one of two residents (R1) reviewed for tracheostomy care on the sample of five. These failures resulted in R1 becoming hypoxic and requiring hospitalization . Findings include: R1's Hospital records document an Assessment and Plan dated 3/30/23 at 2:08pm, including R1 has a history of Heart Failure, Chronic Hypoxemic Respiratory Failure status post Tracheostomy in March 2020. This plan documents R1 requires continuous trach collar at 26%, titrate supplemental Oxygen to maintain Oxygen Saturations of 90-96%. R1's Progress Notes dated as follows document: 4/7/23 at 2:00pm document R1 admitted to the facility and that R1 has a tracheostomy (trach.) 4/10/23 at 11:15am - Noted to have frequent cough with return of thick mucous. Holds on to hard suction catheter device and R1 will self suction. R1's Hospital records document on 4/11/23 at 2:00pm, R1 just left a LTAC (Long Term Acute Care facility) after a year long admission. These records document R1 admitted to the facility 4 days ago (4/7/23) and has now been in the Emergency Department twice. This note documents R1 is hypoxic on trach collar to 89%-91% with copious trach secretions. R1's emergency room physician note dated 4/11/23 at 8:00pm documents R1 presents with excessive trach secretions, cough. This note documents R1's labs are concerning with an elevated White Blood Cell count, and a Chest X-ray consistent with Pneumonia. This note also documents R1 required 1 hour worth of suctioning and trach care upon arrival to the hospital and that R1 is critically ill. The Hospitalist Admit Note dated 4/12/23 documents R1 admitted to the hospital on 4/11/23 with a chief complaint of Respiratory Failure. This note documents R1 arrived to the emergency room hypoxic on 8L (liters). Tracheostomy noted to produce copious sputum. The chest X-ray was concerning for left basilar pneumonia. R1 reported R1's symptoms began about 8 days ago, last Monday. This note documents R1 has a tracheostomy XLT (Extra Length Tracheostomy) tube, 6.0mm (millimeter) ID (Inner diameter)/11.0mm OD (Outer Diameter) tracheostomy in place. R1 is coughing, producing purulent-appearing yellow mucus through tracheostomy. R1's lungs had mild diffuse adventitious lung sounds. This note documents R1 has Bilateral Pneumonia (likely bacterial) in a patient with significant risk for Aspiration Pneumonia, Acute on Chronic Hypoxic Respiratory Failure (increased work of breathing and Oxygen Saturation under 90% prior to arrival to the hospital) secondary to Pneumonia and Lactic Acidosis secondary to above. R1's Hospital Medical Records document a Pulmonary Tracheostomy Tube change procedure note dated 4/24/23 documents R1 had a size #6 XLT cuffed tracheostomy tube in place with the cuff deflated. R1 had a size #6 Cuffless XLT Tracheostomy tube placed on this date. These hospital records document problems with tracheostomy care and suctioning at the facility. These notes document to consider standing tracheostomy suction and care order at the time of discharge. R1's Treatment Administration Record (TAR) dated April 2023 documents R1 is to receive: Oxygen - Oxygen at 8 L (liters) per trach collar every shift with a Start Date of 04/07/2023 6:00pm. There is no documentation of humidification administration with the Oxygen. Trach: Site care - Remove dressing from under flange, cleanse outer cannula and skin daily with Normal Saline (NS) and gauze. Cleanse under cannula with cotton applicator and replace dressing under the flange, every shift with a start date of 4/8/23 at 6:00am. There is no documentation of the care of R1's inner cannula or if the inner cannula was disposable. Trach: May Suction Tracheostomy to maintain O2 (Oxygen) saturations, when coughing or excess secretions noted as needed for secretions with a start date of 4/7/23 at 3:12pm. R1's TAR dated May 2023 documents R1 is to receive: Oxygen - Oxygen at 8 L per trach collar every shift with a Start Date of 04/07/2023 6:00pm. There is no documentation of humidification administration with the Oxygen. Trach: Site care - Remove dressing from under flange, cleanse outer cannula and skin daily with NS and gauze. Cleanse under cannula with cotton applicator and replace dressing under the flange, every shift with a start date of 4/8/23 at 6:00am. There is no documentation R1 received this trach site care on this TAR. There is no documentation of the care of the inner cannula or if the inner cannula was disposable. Trach: May Suction Tracheostomy to maintain O2 sats, when coughing or excess secretions noted as needed for secretions with a start date of 4/7/23 at 3:12pm. There is no documentation of respiratory therapy evaluation/care by the facility's respiratory company. There is no documentation of emergency equipment located at R1's bedside, including ambu bag or replacement tracheostomy tube. On 5/10/23 at 7:50am, V12, R1's Family stated V12 spent hours at the facility every day. V12 stated one unidentified nurse (per V12, unable to know most names due to no name tags) used the flexible suction catheter and attempted to place it in R1's mouth and suction down R1's throat. V12 stated R1 put R1's hands up and panicked. V12 stated V12 told the nurse R1 could not be suctioned that way and told the unidentified nurse how to suction R1 but the nurse wound not deep suction R1. On 5/10/23 at 1:48pm, V11, Respiratory Therapy Supervisor stated V11 received report from V10, Respiratory Therapist on R1. V11 stated R1's tracheostomy was completely occluded upon arrival to the emergency room and that R1's rigged up tubing with blue cap contained hard, crusted build-up inside the tube. V11 stated due to the condition of the tracheostomy and dressing around the tracheostomy, the facility had not been providing tracheostomy care for R1 as R1 required. V11 stated R1's thick copious secretions were signs R1 was not receiving humidification for R1's tracheostomy and should have been. V11 stated R1's tracheostomy dressing was so stuck to R1's skin that it had to be soaked multiple times to be able to remove it from around R1's tracheostomy and R1's skin under the tracheostomy dressing was red/irritated. V11 stated R1's tracheostomy showed signs it was severely neglected by the facility. The facility's Tracheostomy Care policy dated 3/29/2019 documents tracheostomy care should be performed once per shift or as often as required to maintain patency of airway and minimize risk of infection. This policy documents to remove old tracheostomy dressing, and to change a disposable inner cannula daily. This policy also documents to replace the drain sponge behind the tracheostomy plate if being used.

Based on interview and record review the facility failed to monitor and assess residents, timely identify and report changes in condition, and follow physician's orders for two of four residents (R2, R3) reviewed for change in condition in the sample list of six residents. This failure resulted in R2 having multiple hospitalization s for dehydration and acute kidney injury, and R3 being hospitalized for six days with pneumonia. Findings include: 1.) R2's March 2023 Physician's Orders Summary documents: R2 admitted to the facility on [DATE]. R2's diagnoses include Dehydration, Acute Kidney Injury, Hypertension, Coronary Artery Disease with stable Angina Pectoris, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage III, and systolic/diastolic Congestive Heart Failure. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderate cognitive impairment, requires limited assistance of two staff for eating, and has not had complaints of difficulty or pain with swallowing. R2's Care Plan dated 2/1/23 documents R2 is at risk for altered nutritional status with an intervention to record meal intakes and report changes in R2's usual patterns. R2's laboratory results dated [DATE] at 12:47 PM documents R2's potassium was 3.4 and Creatinine (kidney function laboratory test) was 1.3. R2's January 2023 Food and Fluid Intake Sheet documents R2's meal intake varied between 50 % and 100 %, and two entries of 25 %. R2's fluid intake varied between 240 and 480 cc (cubic centimeters) per meal. R2's February 2023 Food and Fluid Intake sheet documents R2's meal intakes averaged between 0 and 50 %. R2 refused 24 meals and fluid intake for 7 meals between 2/1/23 and 2/22/23. R3's March 2023 Food and Fluid Intake Sheet documents R2 refused 14 meals between 3/1/23 and 3/8/23. R2's fluid intake recorded on 3/1/23 was 480 cc, on 3/3/23 was 240 cc, on 3/4/23 was 360 cc, on 3/5/23 was 240 cc, on 3/6/23 was 0, and 3/7/23 was 120 cc. There is no documentation in R2's medical record that V19 was notified of R2's poor fluid/meal intakes in February prior to being hospitalized on [DATE] and in March 2023 prior to being hospitalized on [DATE]. R2's February 2023 Medication Administration Record (MAR) documents R2 received the following: Bumetanide (Bumex) (diuretic) 2 mg (milligrams) by mouth twice daily from 2/1-2/21/23, on 2/24/23, and 2/26/23-2/27/23. Acetazolamide (diuretic) 500 mg by mouth twice daily, and Eplerenone (diuretic) 25 mg by mouth daily. R2's Nursing Notes document the following: On 2/22/23 at 11:00 AM R2's potassium level was 2.4 (low). V19 Physician evaluated R2 and ordered for R2 to be transferred to the local emergency room . On 3/1/23 at 12:05 AM R2 complained of chest pain, vomited, and was transferred to the emergency room . R2 returned at 7:50 AM with diagnosis of gastroenteritis, low potassium and elevated Troponin level. R2 was given intravenous potassium at the hospital. On 3/5/23 during 6:00 PM - 6:00 AM shift, R2 had poor intake, complained of chest pain, vomited a small amount and Nitroglycerine was administered. This note does not document that V19 was notified. On 3/8/2 during 6:00 AM - 6:00 PM shift, R2 complained of chest pain, V19 was notified, and R2 was transferred to the local hospital. R2's Progress Note by V19 dated 2/23/23 documents R2 had mental status change, loss of appetite, hypokalemia (low potassium), and dehydration. V19 advised to send R2 to the hospital. R2's Hospital Discharge Summary dated 2/24/23 documents: R2 was admitted to the hospital on 2/22/23 and rehydrated by intravenous therapy, diuretics were held, and potassium was administered. This corrected R2's acute on chronic renal failure. R2 had acute dehydration that contributed to acute on chronic kidney failure with Creatinine (kidney function laboratory test) of 2.01 (high). R2's potassium was 2.6 (critically low). Discharge instructions include assessing diuretic therapy for acute hypokalemia cause, as R2's potassium has been corrected to 3.5 or higher (normal range), and orders for Bumetanide 2 mg by mouth once daily - hold if not eating/drinking. R2's After Visit Hospital Summary dated 3/2/23 documents: R2 was diagnosed with gastroenteritis and instructions to stay hydrated, take Zofran for nausea, and to follow up with R2's physician. Administer Zofran 4 mg (milligrams) by mouth as needed every 8 hours for nausea/vomiting for up to 15 doses. R2's March 2023 MAR does not document that Zofran was administered. This MAR documents Bumetanide was given daily from 3/2/23-3/8/23 and not held as ordered when R2's intake was poor and refusing meals between 3/1/23 and 3/8/23. There is no documentation in R2's medical record that R2's blood pressure was routinely monitored twice daily in February and March 2023. R2's Hospital History & Physical dated 3/8/23 documents: R2 presented with hypotension (low blood pressure) and Acute Kidney Injury likely secondary to dehydration. R2 received intravenous fluids for hydration and R2's diuretics were held. R2 reported having chest pain for the last week, nausea and vomiting, and pain with swallowing food. R2 reported avoiding drinking water due to the pain. R2 had previously admitted to the hospital for dehydration on 1/17/23. R2's blood pressure in the emergency room was 90/60. On 4/4/23 at 11:38 AM V10 Certified Nursing Assistant (CNA) stated in the beginning of March 2023, R2 was not eating/drinking very much, and the nurses and V2 Director of Nursing were aware. On 4/5/23 at 9:06 AM V16 CNA stated R2 had a poor appetite and fluid intake was poor in February and March 2023. R2 transferred R2's self when R2 first admitted , and then started sleeping a lot more and requiring a full mechanical lift to transfer. R2 had vomited last month on an unknown date. V16 reported R2's poor intakes and vomiting to an unidentified nurse. On 4/4/23 at 2:13 PM V2 Director of Nursing (DON) reviewed R2's February and March 2023 fluid/meal intakes and confirmed R2's refusals and poor intakes. V2 sated the nurses should have notified the physician of R2's poor appetite/fluid intakes. V2 stated R2 was transferred to the hospital on 3/2/23 for nausea/vomiting/diarrhea. V2 confirmed R2's 3/2/23 discharge instructions recommended to administer Zofran as needed for nausea/vomiting, and confirmed Zofran was not administered prior to V2's hospitalization on [DATE]. At 4:52 PM V2 stated changes in condition and physician notification should be documented on an Assess Intervene Monitor for Wellness form or nursing note in the resident's medical record. V2 stated vital signs should be done twice daily and documented on a log kept in a binder at the nurse's station. On 4/5/23 at 8:11 AM V2 stated V2 was unable to locate documentation that V19 was notified of R2's poor fluid/meal intakes or vomiting on 3/5/23. On 4/5/23 at 10:47 AM V2 stated V2 was unable to locate any vital sign logs for R2 in February and March 2023. At 11:55 AM V2 stated the nurses should have followed the physician's order to hold Bumex when R2 had poor intakes. On 4/5/12 at 10:13 AM V19 Physician stated R2's potassium was 2.4 on 2/22/23. The facility notified V19 of R2's behaviors, but V2 does not recall being notified of R2's poor appetite and fluid intake. V2 would have ordered labs and intravenous fluids if needed if V19 was notified. R2 was seen in the emergency roiagnom on [DATE] for gastroenteritis. If R2 was not eating and had nausea/vomiting, the facility should not have given R2's diuretics which would make R2 dry as a bone. The facility should have held R2's diuretic and notified V19. Diuretics make a person even drier, especially if they are not drinking. V19 evaluated R2 on 2/23/23 and R2 did not look good. R2 looked dehydrated and had altered mental status. V19 instructed the facility to transfer R2 to the hospital. Lack of appetite with poor food/fluid intake and vomiting causes decreased potassium levels and affects kidney function. R2's hospitalization s definitely could have been prevented if the facility had notified V19 of R2's decreased intakes and vomiting. The nursing home staff should have followed the Bumex order to hold when R2's intakes were poor. The facility also should have been monitoring R2's blood pressures closes, as low blood pressure indicates dehydration. They should have been obtaining R2's vitals more frequently once R2's intakes were poor. 2.) R3's Hospital Discharge Summary documents R3 admitted to the hospital on 3/5/23 with Pneumonia and discharged on [DATE]. R3 received aggressive antibiotic therapy, pulmonary toileting, and chest physiotherapy to help clear secretions. R3's Hospital Progress Note dated 3/6/23 documents R3's chief complaint was cough and increased difficulty breathing over the last 2-3 days. R3 had a loose sounding cough that R3 reported having for an unknown period of time. R3's Nursing Note dated 3/5/23 at 1:45 PM documents R3 was short of breath and lungs were coarse. The last recorded nursing note prior to 3/5/23 is dated 1/17/23. There is no documentation in R3's medical record that R3's lungs were assessed and vital signs obtained between 3/1/23 and 3/5/23. On 4/4/23 at 4:42 PM R3 stated R3 went to the hospital in March 2023 for pneumonia. R3 had a cough that started a few days prior to that, and then the nurses decided R3 needed to go to the hospital. On 4/4/23 at 12:01 PM V7 CNA stated a few days prior to R3 being hospitalized , R3 had a cough as if R3 was trying to clear phlegm. On 4/5/23 at 8:44 AM V13 CNA stated R3 had a cough, was short of breath, requested R3's oxygen be applied, and R3 was using a wheelchair instead of walking with a walker a few days prior to R3 going to the hospital on 3/5/23. V13 reported this to an unidentified nurse. On 4/5/23 at 11:33 AM V18 Medical Director/Physician stated: If a resident develops a cough, the nurse should examine the resident for fever, shortness of breath, assess lung sounds, and notify the physician so a Completed Blood Count and Complete Metabolic Profile (laboratory values) and chest x-ray can be ordered. On 4/4/23 at 4:52 PM V2 DON stated changes in condition and physician notification should be documented on an Assess Intervene Monitor for Wellness form or nursing note in the resident's medical record. V2 stated vital signs should be done twice daily and are documented on a log kept in a binder at the nurses' station. Vital signs are not documented in the resident's medical record routinely. On 4/5/23 at 11:55 AM V2 DON stated when a resident has a cough the nurses should assess lung sounds and pulse oximetry, and notify the physician. The facility's Notification for Change in Resident Condition or Status dated as revised 12/7/17 documents: The resident's physician will be notified when a resident has a change in physical/emotional/mental condition, a need to alter medical treatment and symptoms of infection. Information related to a resident's change in condition will be recorded in the resident's medical record.

Based on observation, interview, and record review the facility failed to have an active contract with a [CONDITION(S)] center, regularly communicate with the [CONDITION(S)] center to coordinate care, and assess [CONDITION(S)] access sites for three (R35, R42, R57) of three residents reviewed for [CONDITION(S)] in the sample list of 47. Findings include: The facility's [CONDITION(S)] policy dated as revised January 2022 documents: [CONDITION(S)] is an artificial kidney treatment that eliminates wastes, removes excess fluid, filters electrolytes in the blood, and controls blood pressure. A [MEDICATION(S)] catheter is a flexible tube inserted into a vein under the collarbone, and is covered with a dressing that is only removed for [CONDITION(S)]. Infection can occur at the place where the catheter enters the body, and it is important to keep the dressing clean and dry when the catheter is not in use. A graft is a permanent [CONDITION(S)] access that is surgically inserted and connected to an artery. Blood flows from the artery and through the graft creating a thrill (buzzing sensation) that is felt, and a bruit (roaring sound) that is heard through a stethoscope. During [CONDITION(S)], needles are placed into the graft. The needles are removed after [CONDITION(S)] and firm pressure is maintained over the puncture site for 15-20 minutes. A bandage should remain in place until the evening of [CONDITION(S)] or until the bleeding has stopped. Complications for fistulas and grafts include bleeding, clotting, and weakened areas along the graft. When clotting is present the bruit and thrill will be absent and surgery is required to remove the clot. The thrill is to be checked every shift and recorded on the treatment sheet. If the thrill is absent, notify the physician as soon as possible. Notify the physician of any signs or symptoms of infection. 1.) On 9/18/22 at 1:28 PM R35 stated R35 started receiving [CONDITION(S)] in August 2022. R35 goes to a [CONDITION(S)] center three times weekly. The nurses do not assess R35's [CONDITION(S)] access site regularly. R35's Minimum Data Set (MDS) dated [DATE] documents R35 is cognitively intact. R35's Care Plan dated 8/18/22 documents R35's [CONDITION(S)] shunt needs monitored, R35 receives [CONDITION(S)] for fluid overload, has [CONDITION(S)] shunt port site to right chest, and receives [CONDITION(S)] three times weekly. Interventions include monitoring the access site for signs of infection and bleeding, obtain assessment and treatment information from center regularly, refer to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's August 2022 and September physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's August 2022 Treatment Administration Record (TAR) does not document an entry to monitor/assess R35's access site. R35's September 2022 TAR documents to monitor R35's [CONDITION(S)] catheter for infection twice daily, and only documents this was completed on 3 times between 9/1 and 9/20/22. R35's Nursing Notes document R35 readmitted to the facility on [DATE] with a catheter for [CONDITION(S)] to R35's right chest. R35's medical record does not consistently document ongoing communication/coordination with the [CONDITION(S)] center or the [CONDITION(S)] center's contact information, or that R35's weight is recorded/monitored regularly. The facility's Monthly Weight Grid dated October 2021-September 2022 does not list R35. 2.) On 9/18/22 at 9:45 AM R42 stated R42 recently admitted to the hospital with an infection to R42's [CONDITION(S)] port, and returned to the facility last night. On 9/20/22 at 8:51 AM R42 stated the nurses do not assess R42's [CONDITION(S)] access site. on R42's chest. R42 had a [CONDITION(S)] access catheter and dressing to the left lower neck. R42's MDS dated [DATE] documents R42 is cognitively intact. R42's Care Plan dated 7/19/22 documents R42 receives [CONDITION(S)] for Chronic Kidney Disease three times weekly. Interventions include monitoring the shunt to the right chest for infection and bleeding, and to notify the [CONDITION(S)] center of changes in condition, fluid status, cognition, and Activities of Daily Living needs. The [CONDITION(S)] center and contact information is not recorded in R42's medical record. R42's August and September 2022 POS do not include orders for routine monitoring of the [CONDITION(S)] access site, weight monitoring, or frequency of [CONDITION(S)]. R42's August and September TARs do not consistently document that R42's [CONDITION(S)] access site is monitored/assessed twice daily as scheduled. R42's Infectious Disease Physician's Report dated 9/16/22 documents R42 admitted to the hospital on 9/8/22 and R42 has [CONDITION(S)] secondary to [CONDITION(S)] ([CONDITION(S)] (multidrug resistant organism) infection of the hemodialysis line. R42's medical record does not document routine communication/coordination with the [CONDITION(S)] center, the [CONDITION(S)] center and contact information, or that R42's weight is obtained/monitored regularly. The facility's Monthly Weight Grid dated October 2021-September 2022 does not list R42. On 9/20/22 at 12:53 PM V10 Dietary Manager stated residents who receive [CONDITION(S)] should have weights recorded at least on [CONDITION(S)] days. V10 confirmed R35's and R42's weights are not recorded on the facility's weight report. On 9/20/22 at 2:14 PM V49 Licensed Practical Nurse (LPN) stated: V49 assesses the [CONDITION(S)] access sites only on the days that the residents go to [CONDITION(S)], and this is not documented anywhere. There are no communication forms sent with the residents to [CONDITION(S)] or returned from [CONDITION(S)]. We don't know what goes on at [CONDITION(S)]. On 9/20/22 at 3:23 PM V49 and V20 Registered Nurse (RN) confirmed there is no contact information for the [CONDITION(S)] center in R35's and R42's medical records. The phone number for the [CONDITION(S)] center, provided by the facility, was not for the center where R35 and R42 receive [CONDITION(S)]. On 9/20/22 at 3:52 PM V1 Administrator stated V1 thought the facility had an active contract with ([CONDITION(S)] center), but neither the facility nor ([CONDITION(S)] center) have been able to locate a contract. R35, R42, and R57 are the only residents who receive [CONDITION(S)], and they all use the same [CONDITION(S)] center company. On 9/20/22 at 4:53 PM V2 Director of Nursing stated: The certified nursing assistants are responsible for obtaining weights. V2 thinks that weights were previously recorded on paper, given to V3 Assistant Director of Nursing, and the weights were never recorded in the charts. The nurses are suppose to fill out a communication form that is sent to [CONDITION(S)] and then [CONDITION(S)] is suppose to complete the form and send back with the resident. You won't find the forms in the chart, because the nurses haven't been using them. [CONDITION(S)] hasn't been sending documentation consistently. Nurses should be assessing the access sites every shift and should be documented on the TAR. 3.) R57's Medical Record (current) documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's Care Plan dated (undated) documents the following: Diabetes-(start date 5/7/22) Resident will maintain accu-check and fasting blood sugar of 60-300 unless otherwise ordered by MD. Insulin Dependent: Administer insulin as ordered. Rotate insulin injection sites. Monitor blood glucose levels thru capillary checks per MD order-See POS for monitoring frequency, rotate draw site. Notify MD if beyond ordered parameters below 60 and/or above 500. Monitor and record daily meal intakes. Resident with [CONDITION(S)] shunt needs monitored (start 7/17/22). [CONDITION(S)] for Chronic Kidney Disease. [CONDITION(S)] Schedule every Monday, Wednesday, and Friday. Shunt will remain patent for next 90 days. Monitor fistula for signs of infection redness, swelling, drainage, pain. Monitor site for bleeding; if bleeding occurs apply pressure x 10 minutes, if bleeding persists, notify MD and seek discharge to acute care. Keep site covered, maintain privacy and dignity as able. Monitor bruit and thrill daily, notify MD of changes to auditory assessment of site of left forearm. There is no documentation in R57's medical record of monitoring R57's blood glucose, weight, or fistula site. There is no documentation in R57's medical record of communication between the facility and R57's [CONDITION(S)] center. On 9/18/22 at 10:04am, R57 stated staff have not been checking R57's blood glucose. R57 stated blood glucose is supposed to be checked three times a day with meals. On 9/20/22 at 10:10am, R57 stated the facility does not monitor R57's fistula or weight. R57 stated fistula and weight is monitored at [CONDITION(S)]. R57's September Treatment Administration Record (TAR) was noted in R57's medical record with no treatment order to check for bruit and thrill of R57's left forearm fistula site. The facility failed to provide this document as requested. On 9/20/22 at 12:05pm, V2 DON stated nurses are supposed to check the site every shift. V2 confirmed there is no order to monitor R57's blood glucose or fistula site. V2 stated this [missing previous orders] happens when a resident goes out to the hospital, comes back and the order isn't carried over.

Based on observation, interview, and record review the facility failed to administer antibiotics, insulin, cardiac medications, and anticoagulants as ordered resulting in significant medication errors for four (R278, R42, R57, R34) of four residents reviewed for medications in the sample list of 47. Findings include: The facility's Medication Administration dated as revised 11/18/17 documents medication administration includes verifying the medications with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Pharmacy Medication Orders and Residents Charts policy dated October 2006 documents: Whenever possible, the licensed nurse receiving the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Transcription includes transcribing the order to the following: 1. The medication box on the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication box on the Medication Administration Record (MAR), PRN (as needed) Administration Record, or Treatment Administration Record, (if applies). F. The transcribed order is then communicated to pharmacy via fax of the telephone order or written order. 1.) On 9/18/22 at 8:03 AM R278 was lying in bed. R278 had a peripherally inserted central catheter (PICC) line to the right arm and an elastic bandage dressing covering R278's right foot. R278 stated: R278 admitted to the facility from the hospital on 9/16/22. R278 had a right foot amputation and was receiving intravenous antibiotics. R278's nursing notes document R278 admitted to the facility on [DATE] at 6:30 PM. R278's Hospital After Visit Summary for hospital admission 9/6/22 documents: R278 was hospitalized for [CONDITION(S)] (bone infection) and R278's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R278's hospital discharge orders included [MEDICATION(S)] 25 milligrams by mouth daily. Taking your medications as prescribed is one of the most vital aspects of reducing your risk for stroke. Do not stop your prescribed medications or begin taking over-the-counter or herbal medications without first speaking with your physician. R278's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R278's Medication Administration Record (MAR) dated 9/16/22 does not document [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were administered as ordered on 9/17 and 9/18. This MAR does not document R278s' blood glucose levels with sliding scale [MEDICATION(S)] was administered as ordered at 8:00 PM on 9/16/22 and 6:00 AM on 9/17/22. This MAR documents [MEDICATION(S)] was not administered at 6:00 AM on 9/17/22 and 9/18/22. The facility's emergency medication kit list dated 9/14/22 documents the kit includes six [MEDICATION(S)] 5 mg tablets, six [MEDICATION(S)] 75 mg tablets, six [MEDICATION(S)] Extended Release 25 mg tablets, and six [MEDICATION(S)] ([MEDICATION(S)]) 5 mg tablets. On 9/18/22 at 2:08 PM V48 Licensed Practical Nurse (LPN) stated medications are delivered by the pharmacy on night shift. V48 stated R278's medications were delivered early this morning on night shift. V48 stated R278's medications are scheduled at 6:00 AM, and V48 did not administer the medications. There were packages of [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] in the medication cart that contained a label with a dispensed date of 9/17/22. On 9/19/22 at 10:08 AM V3 Assistant Director of Nursing stated the nurses have to call the pharmacy to have medications delivered on off hours and weekends. On 9/19/22 at 10:28 AM V3 stated: Nurses are expected to sign the MAR when medications are administered. If medications are not given or refused, the nurse should circle the nurse's initials on the MAR and document they notified the pharmacy and the physician. The nurses should be using the emergency medication kit for medications that are in the supply. R278's [MEDICATION(S)] and [MEDICATION(S)] should have been taken from the emergency kit. The facility does not have an emergency insulin kit. R278's medication orders must have missed the cutoff time for R278's medications to be delivered on 9/16/22. 2.) R42's Hospital Discharge Instructions dated 9/17/22 document R42's orders include [MEDICATION(S)] (lowers phosphorus) 800 mg PO three times daily with meals, [MEDICATION(S)] (antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's Medication Administration Record (MAR) with an admitted [DATE] does not document [MEDICATION(S)] was administered as ordered between 9/17/22 and 9/19/22. The [MEDICATION(S)] order was not transcribed to R42's MAR. On 9/18/22 02:08 PM V48 LPN stated: R42's [MEDICATION(S)] was not available for administration. V48 contacted the pharmacy and was told the medicaiton would be delivered by tomorrow. On 9/19/22 at 8:20 AM R42 asked V49 LPN about R42's antibiotic. V49 told R42 that R42 was on isolation due to an infection in R42's stools. V49 administered R42's morning medications, but did not administer [MEDICATION(S)] and [MEDICATION(S)] as ordered. V49 stated the pharmacy had not yet delivered [MEDICATION(S)], so V49 could not administer the antibiotic. On 9/19/22 at 10:05 AM V3 Assistant Director of Nursing (ADON) stated: [MEDICATION(S)] is about $700, so V3 assumes that is why the medication hasn't been delivered yet. The nurses should have notified V2 DON. The nurses are responsible for transcribing the hospital discharge orders onto the resident's POS and MAR. 3.) R34's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This same POS documents the following orders: Accu-check. Once daily at 11am and record site and result. [MEDICATION(S)] (fast acting insulin) 100 units/ml (milliliter). Inject 8 units Sub-Q (subcutaneous) twice daily with lunch and dinner. Site of injection. [MEDICATION(S)] (long acting insulin) Flextouch 100 units/ml. Inject 18 units Sub-Q every bedtime. Site of injection. R34's Medication Administration Record (MAR) dated 9/1/22 through 9/30/22 does not document Accu-checks being done on 9/2/22; incomplete documentation (missing site, result, or both) for Accu-checks on 9/1/22, 9/3/22 through 9/15/22, 9/17/22 and 9/18/22; [MEDICATION(S)] not administered at lunch or dinner 9/2/22; not administered at dinner on 9/12/22, 9/13/22 and 9/15/22 and incomplete documentation (missing injection site) for 9/3/22, 9/4/22, 9/8/22, 9/9/22, 9/10/22, 9/12/22, 9/13/22, 9/14/22, 9/15/22, 9/17/22, and 9/18/22; [MEDICATION(S)] Flextouch not administered on 9/14/22 and no injection site documented 9/1/22 through 9/18/22. R34's Care Plan dated 7/10/22 documents the following: Diabetes- Needs monitored for hyper/hypoglycemic reactions. Resident will maintain accu-check and fasting blood sugar of 60-300 unless otherwise ordered by MD. Administer insulin as ordered. Rotate insulin injection sites. Assess for signs of local irritation at injection site. Monitor blood glucose levels thru capillary checks per MD order. See POS for monitoring frequency, rotate draw site. Notify MD if beyond ordered parameters below 60 and/or above 500. On 9/18/22 at 10:27am, R34 stated did not receive R34's insulin about a week ago and my blood sugar was around 150. The nurse said it [blood sugar] was too low. 4.) R57's Medical Record (current) documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's MAR dated 9/8/22 documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 12 units at night. This same record documents R57 was not administered [MEDICATION(S)] on 9/9/22 and there is no injection site documented 9/8/22 through 9/18/22. R57's Care Plan dated (undated) documents the following: Diabetes-(start date 5/7/22) Resident will maintain accu-check and fasting blood sugar of 60-300 unless otherwise ordered by MD. Insulin Dependent: Administer insulin as ordered. Rotate insulin injection sites. Monitor blood glucose levels thru capillary checks per MD order-See POS for monitoring frequency, rotate draw site. Notify MD if beyond ordered parameters below 60 and/or above 500. There is no documentation in R57's medical record of monitoring R57's blood glucose. On 9/18/22 at 10:04am, R57 stated staff have not been checking R57's blood glucose. R57 stated blood glucose is supposed to be checked three times a day with meals. On 9/20/22 at 12:05pm, V2 DON confirmed there is no order to monitor R57's blood glucose. V2 stated this [missing previous orders] happens when a resident goes out to the hospital, comes back and the order isn't carried over.

Based on observation, interview and record review, the facility failed to follow registered dietician recommendations and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R49 sustaining a 9.10% weight loss in one month and put R49 at risk for aspiration pneumonia. Findings Include: R49's MDS (Minimum Data Set) dated 8/8/22 documents R49 is alert and oriented, independent with decision making and has a Gastrostomy Tube. R49's Request for Diet Change dated 6/6/22 by V47 RD (Registered Dietician) documents R49 remains on tube feeding and flush as ordered with no tolerance concerns noted. Requested to evaluate change in feeding schedule to allow for therapy. At this time, will suggest to change tube feeding and flush to 2 Cal HN at 50 ml (milliliter) per hour for 17 hours with flush to stay at 250 ml water every six hours. This request was accepted by V60 Physician. Please monitor weights weekly and monitor tolerance with increased rate. It does not document what hours R49's enteral nutrition should be ran. R49's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These orders do not document what hours R49's enteral nutrition should be ran. R49's Interdisciplinary Resident Screen dated 9/12/22 by V45 Regional ST (Speech Therapy) documents a bedside swallow evaluation is not appropriate at this time due to R49 being NPO secondary to pharyngeal dysphagia. [CONDITION(S)] and Gastrostomy Tube in place. A video swallow study is warranted to safely assess R49's swallowing. The facility weight log documents the following weights for R49: August 2022 - 147.2 pounds, September - 133.8 pounds. This calculates to a 9.10% weight loss between August and September {1 month}. R49's MAR (Medication Administration Record) for June, July and September 2022 do not document R49's ordered weekly weight. R49's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's Medical Record does not contain any Intake/Output tracking or Enteral Flow Record to document the amount of enteral nutrition received each day. On 9/18/22 at 7:53 AM, R49 was lying in bed, without enteral feeding running, eating a popsicle. No staff were present. A sign hanging on the wall above R49's head of bed that reads R49 is NPO. On 9/18/22 at 10:07 AM, R49 stated R49's enteral feeding runs a couple hours a day. On 9/19/22 at 8:57 AM, R49 was lying in bed without enteral feeding running. On 9/19/22 at 1:27 PM V20 RN (Registered Nurse) entered R49's room and delivered a cup of italian ice {frozen dessert in pre-packaged cup} to R49 stating R49 can have items that melt like italian ice, freeze pops and ice chips but that R49 doesn't eat food. The sign remained above R49's bed documenting R49 is NPO. R49's enteral feeding was not running. R49 started eating the italian ice and V20 left the room, leaving R49 alone. On 9/19/22 at 1:52 PM, R49 was holding the empty italian ice container and stated R49 ate it all. On 9/19/22 at 2:00 PM, R49 was at the Nurses Station requesting hot chocolate. V20 RN stated V20 would have to check and see if R49 could have it. At this time, V8 Activity Director walked by and stated V8 could get R49 some. On 9/19/22 at 2:10 PM, R49 was lying in bed with V20 present as V20 was providing cares. The sign documenting R49 is NPO was still on the wall above R49's bed. V8 brought a cup of hot chocolate into R49's room and left it on the bedside table for R49, and V20 did not instruct V8 that R49 could not have liquids. R49's enteral nutrition was not running. At this time, V20 stated R49's enteral feeding is to run from 1:00 pm - 6 am. V20 completed cares on R49 and left the room. On 9/19/22 at 2:53 PM, R49's cup of hot chocolate was empty. R49 stated I (R49) drank it all. On 9/19/22 at 3:29 PM, R49 was lying in bed and enteral feeding was not running. On 9/20/22 at 9:18 AM, V3 ADON (Assistant Director of Nursing) stated V3 was not able to find any Intake/Output documentation for R49. On 9/20/22 at 9:31 AM, V8 Activity Director stated V8 was not aware R49 was NPO explaining, V8 was just trying to help as V8 heard R49 requesting hot chocolate. V8 stated V8 had observed R49 drinking hot chocolate again later in the day. On 9/20/22 at 10:01 AM, V2 DON (Director of Nursing) stated prior to V2 starting at the facility, the floor staff had decided that popsicles were okay for R49 to have, because it was kind of like ice but R49 should not have had the italian ice or hot chocolate. On 9/20/22 at 1:36 PM, V45 Regional ST stated V45 does not know where R49's original order for NPO with ice chips only if nursing or ST were present came from because R49 hasn't been seen by ST at the facility but based on R49's complexity, V45 thinks it was an order based off of a prior video swallow test. V45 stated popsicles and italian ice are not in the same category as ice chips, explaining they would all be considered a thin liquid but the popcile and italian ice would not be a small amount and that hot chocolate would not be acceptable for R49 either; unless the physician said that was okay, it would not be okay to give it. V45 stated when V45 got the recommendation for a swallow evaluation, V45 didn't feel it would be safe to evaluate R49 without a video swallow because you can't see exactly what is going on without the video and (R49) has difficulty swallowing. V45 explained R49 could aspirate of popciles, italian ice and hot chocolate leading to aspiration pneumonia. On 9/21/22 at 2:28 PM, V47 RD stated without having access to R49's chart for review, V47 does not know what would cause R49's weight loss however it is theoretically possible that without the facility following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The enteral feeding needs that I (V47) have calculated are what (R49) needs to maintain (R49's) weight as R49 is NPO. The facility Enteral Feedings Policy dated February 2008 documents enteral feedings will be provided when it has been determined that oral feedings are not sufficient to meet the physical requirements and the resident/responsible party and physician deem enteral nutritional support is appropriate. The Dietician/Consultant will monitor all diet orders for tube feedings and will recommend as appropriate changes in product according to resident needs. This policy includes a Enteral Flow Record that is to be completed each day that documents the time the feeding started, rate, and shift total of infusion.

Based on observation, interview and record review, the facility failed to obtain and/or follow orders for tracheotomy care, perform hand hygiene to prevent contamination during [CONDITION(S)] care, ensure extra [CONDITION(S)] tubes and supplies were at bedside and in working order, and failed to date and change oxygen tubing for six of 6 residents (R11, R49, R57, R72, R42 and R182) reviewed for respiratory care on the sample list of 47. These failures resulted in psychosocial harm to R182 when the oxygen tubing became disconnected from the [CONDITION(S)] tubing, causing R182 to panic due to being scared R182 was not going to be able to breath. Findings Include: The facility Tracheotomy Care Policy dated 3/29/2019 documents [CONDITION(S)] ([CONDITION(S)]) care should be performed, once per shift or as often as required to maintain patency of the airway and minimize the risk of infection. When the [CONDITION(S)] tube is fenestrated, inner cannula is to be in place during suctioning or bagging. A replacement [CONDITION(S)] tube is to be kept at the head of the bed at all times, clearly visible. When providing [CONDITION(S)] cares: obtain a new [CONDITION(S)] kit, suction the resident if needed, remove the old [CONDITION(S)] dressing, open the new kit, obtain the proper size inner cannula and open package, remove oxygen source, unlock, remove and discard the disposable inner cannula, replace inner cannula with sterile disposable inner cannula and replace the appropriate oxygen source, all while using Universal Precautions. With a sterile swab and sterile water and/or 1/4 to 1/2 strength [MEDICATION(S)] solution, cleanse the area immediately adjacent to the stoma and the base of the [CONDITION(S)] tube. Take extra precaution not to allow solution to enter the stoma. With a gauze 4 by 4 soaked in sterile water, rinse the area just cleaned. Dry the stoma area with a gauze 4 by 4. Replace sponge behind the [CONDITION(S)] plate and replace oxygen. To change the neck ties/collars: thread the long narrow fastener tabs through the flanges on the [CONDITION(S)] tube, bringing it back over the flange and adhere it to the soft material on the band. 1.) R182's Nursing Progress Notes dated 9/2/22 document R182 was admitted to the facility with a [CONDITION(S)] present and 5 liters of oxygen being bled into it. On 9/20/22 at 2:29 PM, V2 DON (Director of Nursing) stated [CONDITION(S)] care is to be completed twice a day. If they are admitted without orders, the admitting nurse should call and get orders, specific to the resident. Care consists of removing the inner cannula and cleaning it or if it has disposable inner cannula, replacing it, cleaning around the site and changing the collar. There should be an extra [CONDITION(S)] at the bedside. V2 stated R182's neck is too big and our [CONDITION(S)] collars aren't big enough to go around it. V2 explained the contract RT (Respiratory Therapy) company uses came to evaluate R182 three or four days after admission and ordered supplies but they haven't came in yet. V2 also stated the facility does not have an extra [CONDITION(S)] for R182. V2 explained V46 (R182's family) was to bring it in but didn't. On 9/21/22 at 10:02 AM R182 was lying in bed with oxygen being bled into R182's [CONDITION(S)]. The oxygen tubing was not dated and there was no extra [CONDITION(S)] at R182's bedside. R182 stated, V182 does not feel the facility provides [CONDITION(S)] care as often as they should, they only do it when I ask. R182 also stated the facility does not have an extra [CONDITION(S)] for R182 or the right [CONDITION(S)] collar, therefore it has not been changed since admission. R182's white [CONDITION(S)] collar was discolored with a brown substance around the insertion site/stoma. R182's also stated R182 had a problem with the oxygen humidifier tubing that is bled into R182's [CONDITION(S)] tubing; it had popped off during the night, a few days prior. R182 stated R182 put R182's the call light on and it took staff over 30 minutes to get to R182. R182 explained R182 was banging R182's cup on the overbed table to try and get staff's attention. R182 further explained, I'm (R182) new to having a [CONDITION(S)] and was very concerned. I (R182) was scared that I (R182) wasn't going to be able to breath and started to panic. R182 stated since staff were not answering R182's call light, R182 called V46 (R182's Family) and requested for V46 to call the facility to summons help. R182's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R182's TAR (Treatment Administration Record) dated September 2022 does not document when [CONDITION(S)] care has been provided. On 9/21/22 at 10:57 AM, V20 RN (Registered Nurse) performed [CONDITION(S)] care on R182 using distilled water. The old 4 by 4 gauze had a moderate amount of yellowish/brownish secretions on it. V20 did not change out the soiled [CONDITION(S)] collar. On 9/21/22 at 11:02 am, V46 confirmed that on 12/16/22 around 12:30 am - 1:00 am, one of R182's tubes from the [CONDITION(S)] to the Oxygen had fallen out and R182 used the call light for help, but nobody was coming so R182 had video called V46 asking V46 to call the facility and ask for help. (R182) was starting to panic. I (V46) called the facility and nobody answered. I (V46) then called (R182) back and (R182) said nobody had came in {to R182's room}. We {V46 and R182} went back and forth like that for 20 minutes and still no answer. I (V46) was calling (R182) back to tell (R182), just to call 911 because (R182) was so scared when I (V46) got a text from (R182) saying staff finally came in. 2.) R49's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/18/22 at 7:53 AM, there was no extra [CONDITION(S)] visible at R49's bedside. On 9/18/22 at 10:15 AM, R49 was lying in bed with oxygen being bled into R49's [CONDITION(S)] at six liters. The oxygen tubing was not dated. On 9/19/22 at 1:25 PM, R49 stated staff only complete [CONDITION(S)] care and suctioning every few days. R49 also stated staff have changed R49's [CONDITION(S)] once, a long time ago. Humidifier on humidified oxygen running into [CONDITION(S)] was empty. R49's MDS (Minimum Data Set) dated 8/8/22 documents R49 is alert and oriented. R49's TAR (Treatment Administration Record) dated May 2022 - September 2022 does not document R49's [CONDITION(S)] was changed monthly as ordered or that [CONDITION(S)] care is completed every shift as ordered. On 9/19/22 at 2:09 PM, V20 RN (Registered Nurse) entered R49's room to perform [CONDITION(S)] care. V20 stated R49's extra [CONDITION(S)] and down sized [CONDITION(S)] should be hanging on the wall but it isn't there. V20 checked all of R49's drawers in R49's room and couldn't find the extra [CONDITION(S)]. At this time, V20 stated R49's oxygen should be humidified and confirmed the humidifier was empty. V20 set up [CONDITION(S)] care supplies on the overbed table with a hand towel on it. V20 did not disinfect the table prior to setting up the supplies and did not change out the hand towel. V20 then grabbed an open, undated bottle of normal saline from R49's bedside table, that was 3/4 used. V20 opened the [CONDITION(S)] cleaning tray, applied left sterile glove, opened used normal saline bottle with V20's right hand then placed it on the hand towel. V20 then applied the right sterile glove, picked up the normal saline and poured it into the cleaning tray (with sterile gloves on). V20 dipped the sterile applicator into the normal saline and cleansed around the [CONDITION(S)] insertion site. V20 then took a pipette and dipped it into the normal saline and cleaned around the hard plastic flange of [CONDITION(S)] stating, these are normally used to clean the inner cannula but (R49) gets so much build up around the [CONDITION(S)], I (V20) like to use it to clean it off. V20s scrubbed the flange around the [CONDITION(S)] and cleansed off a moderate amount of dark brown crusted substance. V20 then stated V20 was done with [CONDITION(S)] cares. When asked about cleaning the inner cannula, V20 stated it was replaced last week when RT (Respiratory Therapy) was at the facility so there was no need to clean it. On 9/20/22 at 2:29 PM, V2 DON (Director of Nursing) stated [CONDITION(S)] care is to be completed twice a day. Care consists of removing the inner cannula and cleaning it or if it's a disposable, replacing it, cleaning around the site and changing the collar. There should be an extra [CONDITION(S)] at the bedside. 3.) On 09/18/22 at 8:34 AM R11 was lying in bed wearing oxygen at 2 L (liters)/Minute per nasal cannula. The oxygen tubing was not labeled with a date. The refillable humidification bottle was dated 6/1/22. On 9/20/22 at 8:26 AM R11 was lying in bed wearing oxygen at 2 L/minute. There was no date on the tubing. R11's September 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's August and September 2022 Treatment Administration Records (TARs) only document R11's oxygen tubing was changed once between 8/1 and 9/20/22. On 9/20/22 at 4:53 PM V2 Director of Nursing stated oxygen tubing should be changed weekly and recorded on the TAR, and should be labeled with a date. 4.) On 09/18/22 at 9:45 AM R42 was lying in bed wearing oxygen at 2.5 L/minute per nasal cannula. There was no date labeled on the tubing or refillable humidification bottle. R42's September 2022 POS does not include orders for oxygen or to change the oxygen tubing regularly. R42's August and September TARs do not document a schedule for changing R42's oxygen tubing, or administration of oxygen. R42's Nursing notes document R42 used oxygen periodically in June, July, August, and September. R42's Hospital Discharge Orders dated 6/23/22 documents R42 was diagnosed with Pneumonia and treated with antibiotics. 5.) On 9/18/22 at 9:26 AM and on 9/20/22 at 9:00 AM R72 was lying in bed wearing oxygen at 3 L/minute per nasal cannula. The oxygen tubing was not labeled with a date, and the refillable humidification bottle was dated 6/1/22. R72's Care Plan dated 8/8/22 documents R72 uses inhalers and oxygen as needed with interventions to administer oxygen as ordered. R72's September 2022 POS documents to administer oxygen at 2 L/minute per nasal cannula as needed, and to change the oxygen tubing weekly on Saturdays. R72's TAR documents R72's oxygen tubing was changed once between 8/6/22 and 9/20/22. 6.) R57's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS does not document any orders for oxygen. On 9/18/22 at 10:06am, R57's was resting in bed with 4 liters of oxygen continuously supplied via nasal cannula and an oxygen concentrator. The oxygen tubing was not dated. R57 stated staff do not change R57's oxygen tubing and R57 usually wears oxygen at night. On 9/20/22 at 10:10am, R57's was resting in bed with 4 with liters of oxygen continuously supplied via nasal cannula and an oxygen concentrator. The oxygen tubing remained undated. R57 confirmed that the oxygen tubing had not been changed at this time. R57's Hospital Pulmonary Progress Note dated 9/8/22 documents: Plan: Can discharge home with supplemental oxygen PRN (as needed) to maintain O2 (oxygen) saturation >90%. R57's Care Plan does not document a focused care area or parameters for R57's oxygen use. R57's Treatment Record (September 2022) fails to document any oxygen tubing changes or humidifier bottle changes for R57. The facility Oxygen Therapy Policy (August 2003) documents: Oxygen therapy may be used provided there is a written order by the physician. The order must state liter flow per minute, mask or cannula, time frame. Change oxygen tubing/mask/cannula/and/or [CONDITION(S)] mask on a weekly basis. Date tubing changes and document on the treatment sheet. If humidification is indicated, date prefilled bottles when changed. If using unfilled humidifier bottles; empty, rinse and refill daily with distilled water, and wash with soap and water as needed. Humidifier changes and cleaning is to be documented on the treatment sheet at the time of occurrence.

Based on observation, interview and record review the facility failed to provide behavioral health services and interventions to meet the needs of one (R14) of nineteen initial residents sampled in a total sample list of 47. This failure resulted in ongoing behaviors which resulted in R14 harming R14's self. Findings include: The facility assessment reviewed date 5/22 documents, Common Diagnosis, Physical or Medical Conditions Accepted (to the facility) but not limited to: Psychiatric/Mood Disorders: [CONDITION(S)] (Hallucination, Delusions, et.) Impaired Cognition, Mental Disorder, Depression, [CONDITION(S)] Disorder ([CONDITION(S)]/Depression), [CONDITION(S)], Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Intervention. Resident Support/Care Needs: Mental health and behavior: Manage the medical conditions and medication-related issue casing psychiatric symptoms and behavior, identify and implement intervention to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment care of individuals with depression, trauma/Post Traumatic Stress Disorder, other psychiatric diagnoses, intellectual or developmental disabilities. Include dementia management training and resident abuse prevention training. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. On 2/21/22 R14 was admitted to the facility with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Minimum Data Set, dated dated dated [DATE] documents R14 as severely cognitively impaired. On 9/21/22 at 10:30AM, R14 laid in bed. V34 Unit Aid was sitting outside of R14's room in eye view of R14. R14 appeared tired and disheveled. V34 Unit Aid said that R14 had to be watched all of the time because of his behaviors. R14's progress notes document the following: 2/23/22 Requires assist with all activities of daily living. Will yell out for whatever he wants even when he has the item. 2/28/22 Up in chair and very agitated today. Was one to one and cursing, throwing things and spitting. Yells loudly and strips off clothing. 3/10/22 Resident agitated, wanting to leave facility and slapped (unknown) peer. 3/16/22 Resident punching and screaming at staff. 3/14/22 Attempts to stand and transfer self despite unsteadiness. Takes roommates walker but does not use properly. Requires assist with activities of daily living and can be resistive. Takes medications and can be feisty at times with cares. Up walking without assistance. Resists care and screaming that he wants to go home. Resident hitting staff, pulled shade off of window again. Screaming about going home. Throwing pillow and blankets on the floor. 4/6/22 Resident very agitated throughout the day. Up and walking around without wheelchair. Resident throwing items from nursing cart. Asking for staff that are not working. 4/7/22 Resident showed aggressive behavior, slapping staff and spitting. 4/21/22 Attempts to hit staff and self at times. 5/4/22 R14 was in another resident room (in the last room on the A wing) and when staff attempted to redirect, became violent, swinging and hitting staff, looking for a woman. R14's 5/28/22 incident report documents that at approximately 5:30PM, R14 became enraged and punched a glass picture frame in the hallway of the facility resulting in glass in the right hand with a possible fracture. R14 was sent to the local hospital for evaluation and treatment. R14 was then sent to another local hospital and was returned to the facility at 6:00AM on 5/29/22 with orders to see orthopedics and to have the foreign body (glass) removed. R14's 6/6/22 progress notes document, Resident agitated, spitting, combative, throwing objects. Having (unknown) peer to peer altercations. R14's 8/25/22 incident report documents R14 peer to peer altercation. On 9/21/22 at 1:20PM, V4 Memory Care Unit Coordinator stated, I have been doing individual training with staff on dementia/behavioral care. Most of the staff that I've trained no longer work here. Maybe half have the training. On 9/21/22 at 12:00PM V1 Administrator stated, I know that R14 has behaviors, can be agitated and aggressive. The staff try to redirect him and it doesn't always work. He is on one to one observation until we can get him discharged . We haven't had psychiatric services since he has been here (February 2022). In the spring of 2019 they just stopped coming and it hasn't restarted yet. We have a new company starting soon, but we have to get the consents signed before they will come. When they come (R14) will be first on the list to see them. I don't know if he was screened before he was admitted or not. We are just pushed so hard to take any admission that we are accepting residents with more and more behavioral issues because our corporation wants us to. On 9/21/22 at 12:55PM, V2 Director of Nursing stated, The staff lack the training to manage the behavioral needs of the residents. That is one reason we are excited to have the new behavioral health company starting. They are going to provide staff education and training as well as psychiatry for the residents.

Based on record review and interview the facility failed to ensure one resident (R1) was not subjected to physical and sexual abuse by another resident (R2). These failures resulted in R1 experiencing bruising, pain and swelling to R1's right eye area and emotional distress as verbalized by (R1) stating (R1) felt ashamed after being sexually abused by R2. These failures affected two residents (R1, R2) out of three residents reviewed for abuse in a sample list of ten residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/11/22, the facility remains out of compliance at a severity level two. The facility is in the process of educating staff on identifying and reporting abuse and evaluating the effectiveness of their corrective action interventions to ensure R1 is protected. Findings include: R1's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 6 out of 15 possible points indicating R1 is severely cognitively impaired. This same MDS documents R1 requires limited assistance of one person for bed mobility and extensive assistance of one person for transfers, dressing, toileting and personal hygiene. R1's Initial Incident Report to Illinois Department of Public Health dated 8/25/22 documents Reported to (V1) Administrator that [AGE] year old female with Brief Interview for Mental Status (BIMS) score of 6 alleged to (R10) Hospice (Certified Nurses Aide) that an unidentified male at this time entered (R1's) room Sunday (8/21/22) evening and attempted to inappropriately touch (R1's) chest. (R1) then struck (R2's) hands away and reports that (R2) struck back at (R1). Investigation immediately investigated. R1's Final Incident Report to Illinois Department of Public Health dated 8/29/22 documents The facility received an allegation of a physical altercation between (R1) and (R2). It was reported that (R2) entered (R1's) room at some point in the evening and began to inappropriately touch (R1) on chest area. (R2) was escorted out of (R1's) room per staff on Tuesday (8/23/22) evening. R1's Assess, Intercommunicate, Manage (AIM for Wellness) report dated 8/25/22 documents darkness under Right eye. Right eye slightly puffy. V16 Hospice Physician statement dated 8/25/22 documents Spoke with (R1) in (R1's) room and (R1) was noted to have a bruised eye. When asked what occurred (R1) stated (R2) came into room on Sunday 8/21/22 at evening time and said, 'it's party time' and began trying to touch (R1's) breasts and buttock area and (R1) told (R2) firmly to stop. (R2) proceeded to try to touch (R1's) genital area but because (R1) was wearing an incontinence brief (R2) then stuck (R2's) hand under (R1's) pants and tried to reach down (R1's) incontinence brief but (R1) yelled 'Stop' and 'Help' and swatted (R2) away. (R1) stated (R2) then slapped (R1's) Left cheek and 'punched' Right eye. (R1) has had bruising and pain around Right eye. Head, Ears, Eyes, Nose, Throat (HEENT): Positive for Ecchymosis around Right eye with tenderness on palpation. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as being severely cognitively impaired with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This same MDS documents R2 requires limited assistance with bed mobility and transfers. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/4/22 at 10:30 AM R1 stated (R2) walked into my room Sunday night (8/21/22). (R2) walked over to me and shook (R2's) hips and said 'it's party time'. (R2) grabbed my boobs and crotch. I started to bat (R2's) hands away with my hands and that is when (R2) slapped me. (R2) used his open hand to slap the Left side of my face by my Left eye. (R2) kept putting (R2's) hands down the front of my incontinence brief. I yelled 'stop' and 'help' over and over. I swatted (R2's) hand away again and (R2) used (R2's) closed fist to punch me in the Right eye. The Left eye hurt but it didn't bruise. (R2) blackened my Right eye. It hurt awful. I felt so ashamed but (R2) didn't know what (R2) was doing. (R2) is not right in the head. I reported this to (V12) Certified Nurse Aide (CNA) the next day (8/22/22). I also told (V8) Social Worker from Hospice a few days later. I do not want anything to happen to (R2). (R2) is out of (R2's) mind. I feel sorry for (R2). Apparently (R2) thought I was (R2's) girlfriend. I don't want (R2) to get in trouble or go to jail. I just don't want (R2) in my room again. (R2) came to my room the next day. (R2) stood inside the doorway and apologized and then left with staff. I have not seen (R2) since then. On 9/4/22 at 1:45 PM V12 Certified Nurse Aide (CNA)/CNA educator stated V12 walked into R1's room on 8/22/22 to check on R1 and noticed R1 had a bruise around R1's Right eye. V12 stated I asked (R1) how (R1) got that black eye and (R1) told me (R2) hit (R1) in the eye. I told (V6) Registered Nurse (RN) about (R1's) black eye and allegations. Later that same day (V13) Unit Aide arrived and V13 reported to me that (R1) had told (V13) that (R2) hit (R1) in the eye after touching (R1) breasts and trying to put (R2's) hands down (R1) incontinence brief. On 9/4/22 at 4:15 PM V1 Administrator stated I was notified on 8/25/22 that there was an allegation of abuse between (R1) and (R2). I immediately came into facility and started the investigation. (R2) was moved to another room on another hall. One to one supervision was initiated. We (facility) notified Hospice and they came into assess and talk with (R1). The investigation started 8/25/22. No one told me about this incident prior to 8/25/22. On 9/5/22 at 9:15 AM V15 Unit Aide stated V15 was working on 8/22/22 when R1 called V15 into R1's room. V15 stated after I was in (R1's) room, (R1) asked me 'how bad is (R1's) eye?' (R1's) Right eye was red underneath, so I asked (R1) what happened. (R1) told me that (R2) hit (R1) and (R2) put (R2's) hands down (R1's) pants Sunday (8/21/22) night. On 9/5/22 at 10:00 AM V8 Hospice Social Worker stated V8 was notified by the Hospice supervisor on 8/25/22 to come to facility and talk with R1. V8 stated V8 was notified on 8/25/22 that there was an allegation of abuse and that V8 should speak with R1 that day. V8 stated V8 came to the facility on [DATE], which was not a regularly scheduled visit with R1. V8 stated I have gotten to know (R1) quite well through our conversations. V8 stated R1 is able to verbalize needs and reports to staff of any abuse would be accurate. V8 stated (R1) just gets confused on the dates, not what happens. V8 stated R1 told V8 that R2 had touched R1's breasts and tried to put R2's hands down R1's incontinence brief. V8 stated R1 told V8 that R1 did not want anything to happen to R2 because R2 did not know what R2 was doing. V8 stated I tried to pin (R1) down on what date this incident occurred because (R1) can sometimes get dates mixed up. (R1) told me what programs (R1) was watching on television and those programs are (R1's) favorite shows that are only on Sunday evenings. So I know (R1) was right about the date the incident occurred. (R1) knows the television shows inside and out. (R1) has favorites shows (R1) watches and knows what days they air. On 9/6/22 at 1:30 PM V1 Administrator stated We (facility) now see that (R2) did actually abuse (R1) on 8/21/22. The facility Abuse Prevention Program Policy revised 11/28/2016 documents the following The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility is committed to protecting residents from abuse including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual family members or legal guardians, friends, or any other individuals. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish or pain. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident Protection Investigation Paths: Possible Sexual Abuse: Definition: Sexual Abuse is non-consensual sexual contact of any type with a resident. If the allegation is physical contact that did not involve penetration, proceed directly with investigation procedures in Step 5 and interview of witnesses in Step 6. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. An Immediate Jeopardy situation was identified on 9/8/22/22. V1, Administrator, was notified of the Immediate jeopardy on 9/8/22 at 3:49 PM. The Immediate Jeopardy was identified to have begun on 8/21/22 when the facility failed to ensure a resident (R1) was free from physical and sexual abuse from another resident (R2). On 9/11/22, the surveyor confirmed through interview, record review and observation, the facility took the following actions to remove the Immediate Jeopardy: 1. All available Facility, Hospice and Agency staff were educated on 8/25/22 and 9/9/22 to recognize resident sexual and physical abuse. This was confirmed by V1 Administrator, V2 Director of Nurses (DON), V14 Social Service Director and V25 Care Plan Coordinator on 9/11/22. V1 Administrator is in the process of in servicing staff not available on 8/25/22 and 9/9/22 to ensure all Facility staff, Agency staff and Hospice staff are educated before they clock in for their next shift. 2. Immediate Change to Facility Systems: The facility has policies and procedures based on current standards of practice. As part of the re-education, the facility is educating staff regarding Abuse identifying, reporting and reporting suspicion of a crime. 3. The facility has implemented schedules for staff to provide one to one coverage for (R2) and follow up from V14 Social Service Director (SSD) to ensure (R2) is being monitored. The facility has provided one to one daily visits with (R1). The facility has updated careplans for both (R1) and (R2). This was confirmed as completed by V1 Administrator, V2 Director of Nurses (DON) and V14 Social Service Director (SSD) on 9/11/22. 4. Monitoring: The Administrator or designee will monitor all resident's that are at risk for abuse. Ongoing Abuse prevention, protection measures, and reporting reasonable suspicion of a crime in servicing with facility staff, Agency staff and Hospice staff will be completed by V1 Administrator. This was confirmed by V1 Administrator on 9/11/22.

Based on record review, interview and observation the facility failed to immediately protect one resident (R1) from potential further sexual and physical abuse by another resident (R2) with known aggressive behaviors by failing to implement corrective action to ensure the alleged perpetrator (R2) did not have continued unrestricted access to the victim (R1) and by failing to report the allegation to the abuse coordinator. These failures affected two residents (R1, R2) out of three residents reviewed for abuse in a sample list of ten residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/11/22, the facility remained out of compliance at a severity level two. The facility is in the process of educating all staff on identifying abuse, protection measures to be taken after abuse is reported and reporting abuse immediately to abuse coordinator. Findings include: R1's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 6 out of 15 possible points indicating R1 is severely cognitively impaired. This same MDS documents R1 requires limited assistance of one person for bed mobility and extensive assistance of one person for transfers, dressing, toileting and personal hygiene. R1's Initial Incident Report to Illinois Department of Public Health dated 8/25/22 documents Reported to (V1) Administrator that [AGE] year-old female with Brief Interview for Mental Status (BIMS) score of 6 alleged to (V10) Hospice (Certified Nurses Aide) that an unidentified male at this time entered (R1's) room Sunday (8/21/222) evening and attempted to inappropriately touch (R1's) chest. (R1) then struck (R2) away and reports that (R2) struck back at (R1). Investigation immediately investigated. R2's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS) dated [DATE] documents R2 as being severely cognitively impaired. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/4/22 at 9:45 AM R2 was walking independently in R2's room. There were no staff members in R2's room from 9:45 AM-9:57 AM. No staff were observed for the entire length of R2's hall. On 9/4/22 at 10:30 AM R1 stated (R2) walked into my room Sunday night (8/21/22). (R2) walked over to me and shook (R2's) hips and said 'it's party time'. (R2) grabbed my boobs and crotch. I started to bat (R2's) hands away with my hands and that is when (R2) slapped me. (R2) used his open hand to slap the Left side of my face by my Left eye. (R2) kept putting (R2's) hands down the front of my incontinence brief. I yelled 'stop' and 'help' over and over. I swatted (R2's) hand away again and (R2) used (R2's) closed fist to punch me in the Right eye. The Left eye hurt but it didn't bruise. (R2) blackened my Right eye. It hurt awful. I felt so ashamed but (R2) didn't know what (R2) was doing. (R2) is not right in the head. I reported this to (V12) Certified Nurse Aide (CNA) the next day (Monday). I also told (V8) Social Worker from Hospice a few days later. I do not want anything to happen to (R2). (R2) is out of (R2)'s mind. I feel sorry for (R2). Apparently (R2) thought I was (R2's) girlfriend. I don't want (R2) to get in trouble or go to jail. I just don't want (R2) in my room again. (R2) came to my room the next day. (R2) stood in the doorway and apologized and then left with staff. I have not seen (R2) since then. On 9/4/22 at 1:45 PM V12 Certified Nurse Aide (CNA)/CNA educator stated V12 walked into R1's room on 8/22/22 to check on R1 and V12 noticed R1 had a bruise around Right eye. V12 stated I asked (R1) how (R1) got that black eye and (R1) told me (R2) hit (R1) in the eye. I told (V6) Registered Nurse about (R1's) black eye and allegation. Later that same day (V13) Unit Aide arrived and V13 reported to me that (R1) had told (V13) that (R2) hit (R1) in the eye after touching (R1's) breasts and trying to put (R2's) hands down (R1's) incontinence brief. On 9/4/22 at 2:00 PM V10 Hospice Certified Nurse Aide (CNA) stated I was there on 8/24/22 to give (R1) a shower. I see (R1) twice a week. I noticed (R1) had discoloration under (R1)'s Right eye so I asked (R1) about it. (R1) told me '(R2) hit me'. I did not report this to (V1) Administrator but did report this to (R1's) Hospice Nurse Manager. I asked (V11) Certified Nurse Aide (CNA) if (V11) knew anything about it before I left that day. (V11) said it was being taken care of. On 9/5/22 at 9:15 AM V15 Unit Aide stated V15 was working on 8/22/22 when R1 called V15 into R1's room. V15 stated after I was in (R1's) room, (R1) asked me 'how bad is (R1's) eye?' (R1's) Right eye was red underneath so I asked (R1) what happened. (R1) told me that (R2) hit (R1). I reported this immediately to V12 CNA. I did not report this alleged abuse to (V1) Abuse Coordinator. (V12) told me that (V12) had already told (V6) Registered Nurse. On 9/5/22 at 9:45 AM V6 Registered Nurse (RN) stated (V12) Certified Nurse Aide (CNA) reported to me on 8/22/22 that (R1's) eye was bruised. I assessed both of (R1)'s eyes. (R1's) Right eye was red a little bit all the way around on top of lid and on bottom lid. I asked (R1) if (R1) eye hurt and (R1) told me no. I didn't ask (R1) what happened to it. Why would I ask that? I did not report (R1)'s Right eye redness to (V1) Abuse Coordinator. On 9/6/22 at 3:20 PM V9 Certified Nurse Aide (CNA) stated V9 was working the evening of 8/23/22. V9 CNA stated Tuesday (8/23/22) evening I was walking by (R1's) room and (R1) asked me to come in. (R1) was not yelling and did not seem upset. I saw (R2) standing just inside (R1's) doorway. I escorted (R2) out of (R1's) room without any difficulty. V9 stated We (staff) have to watch (R2). We (staff) are always finding (R2) in other resident rooms. On 9/5/22 at 10:00 AM V8 Hospice Social Worker stated V8 was notified by the Hospice supervisor on 8/25/22 to come to facility and talk with R1. V8 stated V8 was notified on 8/25/22 that there was an allegation of abuse and that V8 should speak with R1 that day. V8 stated V8 came to facility on 8/25/22, which was not a regularly scheduled visit with R1. V8 stated I have gotten to know (R1) quite well through our conversations. V8 stated R1 is able to verbalize needs and reports to staff of any abuse would be accurate. On 9/4/22 at 3:30 PM V14 Social Service Director stated V14 was made aware of the incident with R1 and R2 on Thursday 8/25/22. V14 stated to be honest I did not make any notes or talk to either R1 or R2 about this incident. I told (V1) that I would catch up on Tuesday (9/5/22). I wasn't even aware that there was any kind of abuse. I was just told 8/25/22 that (R1) was upset and something happened. I did not know what. I did not update the behavior tracking sheets for (R2). On 9/4/22 at 4:15 PM V1 Administrator stated I was made aware on 8/25/22 of an allegation of abuse from (R2) to (R1). (R2) was moved to another room on another hall. 1:1's were initiated on (R2) on 8/25/22. We notified Hospice and they came into assess and talk with (R1). The investigation started 8/25/22. No one told me about this incident prior to 8/25/22. On 9/5/22 at 11:00 am V2 Director of Nurses stated V2 could not provide documentation that the facility immediately implemented interventions to protect R1 from R2 after R1 reported to staff on 8/22/22 that R2 sexually and physically abused R1 on 8/21/22. V2 further stated V2 could not provide documentation that R2 was consistently monitored on a one to one basis after R2 was placed on one to one monitoring on 8/25/22. On 9/6/22 at 1:00 PM V17 Medical Director stated R2 has had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V17 stated (V3) Registered Nurse (RN) texted me on Sunday 9/4/22 that a Public Health Surveyor was in the facility to investigate this abuse between residents. That was the first time I had been made aware of any type of incident. If the facility would have notified me of this allegation of physical and sexual abuses, I would have definitely given the order to send (R2) to the emergency room . (R2) is not appropriate for this facility. I do not believe (R2) is a danger to any other females that reside in the facility but (R2) could definitely be a danger to (R1) again. V17 stated the facility should have immediately placed an intervention for (R2) that would work. The continual monitoring obviously did not work since (R2) entered (R1)'s room again two days later. On 9/6/22 at 1:30 PM V1 Administrator stated We now see that (R2) did actually abuse (R1) on 8/21/22. Since (R2) was not on continuous monitoring or have any type of interventions in place at that time, (R2) was able to enter (R1's) room again on 8/23/22. I originally thought that (R2) had assaulted (R1) on 8/23/22 when (V9) CNA redirected (R2) out of (R1's) room but that must have been when (R2) came back to (R1) to apologize. (R2) should have not been allowed to be in (R1's) room with (R1) after assaulting (R1). The facility Abuse Prevention Program Policy revised 11/28/2016 documents the following The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility is committed to protecting residents from abuse including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual family members or legal guardians, friends, or any other individuals. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish or pain. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident Protection Investigation Paths: Possible Sexual Abuse: Definition: Sexual Abuse is non-consensual sexual contact of any type with a resident. If the allegation is physical contact that did not involve penetration, proceed directly with investigation procedures in Step 5 and interview of witnesses in Step 6. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. The facility Abuse Prevention Program Policy revised 11/28/2016 also states Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator and Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. An Immediate Jeopardy situation was identified on 9/8/22/22. V1, Administrator, was notified of the Immediate jeopardy on 9/8/22 at 3:49 PM. The Immediate Jeopardy was identified to have begun on 8/22/22 when facility staff failed to implement interventions to protect R1 after R1 alleged that R2 sexually and physically abused R1 and staff failed to report the allegation to the abuse coordinator. On 9/11/22, the surveyor confirmed through interview, record review and observation, the facility took the following actions to remove the Immediate Jeopardy: 1. All available Facility, Hospice, and Agency staff were educated on 8/25/22 and 9/9/22 on the facility abuse policy emphasizing the need to immediately protect a resident after an allegation of abuse and reporting the allegation to the abuse coordinator. This has been confirmed by V1 Administrator, V2 Director of Nurses (DON), V14 Social Service Director and V25 Care Plan Coordinator on 9/11/22. V1 Administrator is in process of in servicing staff not available on 8/25/22 and 9/9/22 to ensure all facility staff, hospice staff and agency staff are educated before they clock in for their next shift. 2. Immediate Change to Facility Systems: The facility has policies and procedures based on current standards of practice. As part of the re-education, the facility is educating staff regarding identifying abuse, protecting the resident and reporting abuse to the abuse coordinator. 3. The facility has implemented schedules for staff to provide one to one coverage for (R2) and follow up from V14 Social Service Director (SSD) to ensure (R2) is being monitored. The facility has provided one to one daily visits with (R1). The facility has updated careplans for both (R1) and (R2). This has been confirmed as completed by V1 Administrator, V2 Director of Nurses (DON) and V14 Social Service Director (SSD) on 9/11/22. 4. Monitoring: The Administrator or designee will monitor all resident's that are at risk for abuse. Ongoing Abuse prevention and protection measure education with facility staff, Agency staff and Hospice staff will be completed by V1 Administrator. This was confirmed by V1 Administrator on 9/11/22.

Based on observation, interview and record review the facility failed to monitor weights, monitor pulse oximetry levels, complete skin assessments, label a wound dressing with a date, and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R7 being unnecessarily put at risk for developing exacerbation of [CONDITION(S)]. Findings include: 1.) On 8/3/22 at 9:11 AM R7 was sitting in a recliner in R7's room wearing oxygen per nasal cannula at 4 liters/minute. R7's bilateral lower extremities were in a dependent position and were edematous/swollen. R7 lifted R7's abdominal folds, and the skin was red/intact at this time. R7 stated: R7 was unable to wear R7's slippers due to R7's [CONDITION(S)]. The facility was suppose to order another inhaler, Trelegy, over a week ago, but it never came in. R7 gets short of breath at times and making it difficult to do therapy. R7 is borderline diabetic, and the facility has only checked R7's blood glucose level twice. R7 has not been weighed since R7 admitted to the facility on [DATE]. R7 had admitted to the facility with open area to R7's coccyx and abdominal folds. R7's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Hospital Discharge Summary dated 7/13/22 documents orders to weigh R7 daily, check blood glucose four times daily before meals and at bedtime, administer Budesonide 0.25 mg (milligram)/2 ml (milliliter) nebulizer twice daily, and [MEDICATION(S)]-[MEDICATION(S)] 0.5-2.5 mg/3 ml nebulizer four times daily as needed for shortness of breath. R7's Admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation that the hospital discharge orders for daily weights, blood glucose checks, Budesonide, and [MEDICATION(S)]-[MEDICATION(S)] were transcribed to R7's July and August 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation in R7's medical record that this medication was ordered prior to 8/1/22. There is no documentation in R7's medical record that daily weights or blood glucose were obtained as ordered, or that Budesonide and [MEDICATION(S)]-[MEDICATION(S)] were administered. R7's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's July 2022 Treatment Administration Record (TAR) documents R7's skin was checked daily, but does not record if R7's skin was intact or open. R7's shower sheet dated 7/25/22 does not document if R7's skin is intact or if R7 has an open/red/excoriated areas. R7's Nursing Notes document R7's dependent [CONDITION(S)] is first recorded on 7/18/22. There is no documentation that R7 had [CONDITION(S)] prior to 7/18/22. There is no documentation in R7's medical record that R7's pulse oximetry levels were routinely monitored. On 8/3/22 at 2:12 PM V3 Assistant Director of Nursing stated skin assessments are completed weekly by the nurses. On 8/3/22 at 3:20 PM V3 stated the skin assessments are documented on the TAR or shower sheet. V3 confirmed the skin assessments should document whether the skin is intact, open, and if there were any new problem areas. On 8/3/22 at 4:32 PM V3 stated pulse oximetry should be obtained twice daily. On 8/3/22 at 2:39 PM V2 Director of Nursing stated: Trelegy was ordered on 8/1/22 after V11 (R7's Family) told V2 that the Trelegy was ordered about a week ago and that R7 had not received the medication. V2 could was unable to locate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 admitted with orders for nebulizers, but the nurses said they didn't administer the nebulizers due to COVID-19 (human coronavirus infection). The nurses should have administered R7's nebulizer treatments or contacted the physician to get alternate orders. R7's hospital discharge orders included to check blood sugar three times daily and at bedtime. V2 received and implemented orders to check R7's blood sugars as of today. order for blood glucose levels were not implemented as ordered. On 8/3/22 at 4:02 PM V2 DON confirmed there is no documentation that R7 had [CONDITION(S)] prior to 7/18/22. V2 stated the nurses should have followed up with the physician and documented in the medical record. On 8/3/22 at 4:30 PM V2 confirmed R7's medical record did not document pulse oximetry readings. On 8/4/22 at 8:30 AM V2 stated there were no documented weights in R7's medical record for July/August 2022. On 8/4/22 at 11:40 AM V15 Physician stated: V15 was not aware that R7 had missed doses of medications or that R7 had [CONDITION(S)] to bilateral lower extremities. R7 has [CONDITION(S)] (CHF). The facility should have continued to monitor R7's weight daily as ordered. R7 has been in and out of the hospital multiple times in the last few months. V15 was told the facility had COVID-19 (Human Coronavirus Infection) and could not administer nebulizers, so V11 (R7's Family) requested Trilegy inhaler for R7 instead of the nebulizers. V15 gave the order for Trelegy to the facility over a week ago, and V11 complained to V15 that it took awhile before R7 received the medication. The facility should have administered R7's medications as ordered. Not monitoring weights for a patient with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2.) On 8/3/22 at 2:12 PM V21 Certified Nursing Assistant (CNA) and V3 Assistant Director of Nursing (ADON) cleansed R12's abdominal folds. There was a linear, pink, open wound to R12's left abdominal fold. V3 applied a barrier cream to the wound. V3 stated R12's wound was identified on 8/2/22 during R12's bedbath, and is related to moisture/heat or friction. V3 stated the nurses are responsible for completing skin assessments weekly, and R12 should has daily skin assessments. On 8/3/22 at 3:20 PM V3 Assistant Director of Nursing stated skin assessments should be documented on the TAR or a shower sheet. V3 confirmed the skin assessments should document if the skin is intact, open, and any new problem areas. V3 stated V3 has R12's wound measurements and assessment from 8/2/22 written on a note, and has not documented the information in R12's medical record yet. R12's July 2022 and August 2022 TARs do not document skin assessments were completed daily or weekly. R12's shower sheets dated 7/23/22 and 7/28/22 do not document the status of R12's skin integrity. The Facility's Weekly Wound Tracking dated 8/3/22 documents R12's abdominal wound measured 0.4 cm (centimeters) long by 3.5 cm wide by 0.1 cm deep. There is no documented assessment/description of R12's abdominal wound in R12's medical record, prior to 8/3/22. 3.) R6's August 2022 TAR documents: Cleanse R6's left and right leg wounds with normal saline, dry, apply [MEDICATION(S)] and cover with a dry dressing daily. Daily cleanse R6's right foot wound with normal saline, dry, apply [MEDICATION(S)] and alginate, cover with an abdominal pad, wrap up to knee with gauze, and apply a stretch stockinet over the gauze. Daily cleanse R6's left foot wound with normal saline, dry, apply [MEDICATION(S)], cover with abdominal pad, wrap up to knee with gauze, and apply a stretch stockinet over the gauze. On 8/3/22 at 1:21 PM V3 ADON entered R6's room to administer R6's wound treatments. V3 removed R6's undated wound dressings from R6's bilateral lower extremities (BLE). R6 had open wounds to the right shin, left inner posterior knee, top of left foot, top of right foot. V3 stated the wounds are vascular and R6 picks at R6's skin/wounds. V3 confirmed R6's BLE wound dressings were not labeled with a date. On 8/3/22 at 2:18 PM V3 stated wound dressings should be labeled with a date. 4.) On 8/4/22 at 7:55 AM R13 stated sometimes the facility doesn't obtain R13's weight, and R13 should be weighed at least twice weekly. R13 stated R13 goes to [CONDITION(S)] three times weekly. R13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There are no orders to obtain R13's weight routinely. There are no documented weights for July/August 2022 in R13's medical record. On 8/3/22 at 3:20 PM V2 DON stated residents who receive [CONDITION(S)] should have weights obtained weekly. On 8/4/22 at 8:30 AM V2 DON stated weight monitoring is an area that needs improvement. V2 provided a monthly weight report that documents R13's weight was 157.4 pounds in July 2022. This report does not document the date this weight was obtained, or document R13's August weight. V2 confirmed there were no other recorded weights for R13 in July/August 2022. V2 stated R13's August weight is 168.4 pounds. V2 stated V2 was unable to locate documentation for how often R13 should be weighed. 5.) On 8/4/22 at 12:18 PM R5 stated: R5 has not been weighed in the facility, other than on admission in April 2022 and this past Monday (8/1/22). R5 thought the facility is suppose to weigh R5 weekly. R5 receives [CONDITION(S)] three times per week. There are no orders in R5's medical record to obtain R5's weight regularly. There are no documented weights recorded for July/August 2022. On 8/4/22 at 8:30 AM V2 confirmed there were no documented weights for July/August 2022 in R5's medical record. V2 provided a copy of the facility's monthly weight report that does not list R5 or documented weights for R5 for April-August 2022. V2 stated on 7/5/22 R5 weighed 110 pounds, and on 8/3/22 R5 weighed 129 pounds. V2 stated V2 was unable to locate documentation/orders for how frequent R5 should be weighed. 6.) R14's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/3/22 at 10:05 AM V10 Licensed Practical Nurse (LPN) obtained R14's blood glucose level of 282. 7.) R9's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There are a total of 56 entries that do not document the results of R9's blood glucose level. R9's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/3/22 at 10:50 AM V10 LPN obtained R9's blood glucose level of 294. V10 stated this is R9's noon blood glucose check, since V10 did not complete R9's morning blood glucose check timely. On 8/4/22 at 2:08 PM V2 DON stated the nurses should be recording blood glucose results on the MAR. V2 confirmed R14's and R9's MARs were missing documentation of blood glucose results. The facility's Medication Administration policy dated as revised 11/18/17 documents to notify the physician if a scheduled dose of medication was not administered or available. The facility's Nursing Documentation Guidelines policy revised January 2005 documents vital signs are to be completed every shift for 3 days for newly admitted and readmitted residents, and to document vital signs in the medical record. Weekly skin observations should be completed and documented for residents at moderate and high risk for skin impairment. Weights should be recorded with the date and time the weight was obtained. The facility's Resident Weight Monitoring policy dated March 2019 documents: weights will be monitored at least monthly, significant weight changes are reviewed weekly, and new admissions/re-admissions weights will be obtained weekly for 4 weeks.

Based on record review and interview, the facility failed to ensure that R22 received the scheduled services for hemodialysis per physician orders. R22 is one of three residents reviewed for hemodialysis in the sample of twenty-three. Findings include: R22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R22 has orders for hemodialysis three times a week, Tuesday, Thursday and Saturday. R22's Nursing Notes dated [DATE] document R22 as being positive for Covid. R22's Nursing Notes dated [DATE] document that (R22) remains on isolation protocols per Covid positive. There is no further documentation on R22's condition or status in the Medical Chart between [DATE] and [DATE]. R22's Nursing Note dated [DATE] at 7:40 am and documents that R22 reported being short of breath. R22's Medical Record had no documentation of R22 receiving or not receiving scheduled [CONDITION(S)] treatments on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. R22's Nursing Notes dated [DATE] at 8:00 am document the following: Noted to be very lethargic et (and) confused, skin cool et clammy. Responds only to name unable to sit up on bed. O2 (oxygen) 88% on 2 L (liters). (Local) ambulance here to transport to (local hospital) ER (emergency room ). An emergency room Note dated [DATE] at 9:30 am documents the following: Prior to patients (R22) arrival, (V11) from (Nursing Home) called to give report regarding why sending patient (R22) in to the ER for treatment. (V11) stated that (R22) recently had Covid but has been out of quarantine for 2 days. However, throughout this Covid illness had missed [CONDITION(S)], as ([CONDITION(S)] center) would not run (R22) and (R22) has not had a treatment in 11 days. This writer questioned (V11) if the [CONDITION(S)] situation was referred to management at their facility but (V11) was unsure. (V11) continued to give patient (R22) update including that (R22) is oriented at their facility but is having oxygen desaturations to 88% and requiring 2 L O2 per NC (nasal Canula) when (R22) is normally not on O2. I Called (V25, Assistant Administrator) at ([CONDITION(S)] center) to inquire about missed [CONDITION(S)] sessions. (V25) stated that they had arranged for (R22) to go to a facility in Chicago but the (Nursing Home) had told them they could not get (R22) there. (V25) further indicated that (R22) was scheduled to come back to the Kankakee facility on Tuesday [DATE]th but (R22) did not show up. (V25) stated (V25) called (Nursing Home) to inquire about (R22) coming back on that date but they did not bring (R22) in for (R22's) session. On [DATE] at 2:30 pm, V25 confirmed that R22 could not have [CONDITION(S)] in R22's usual location due to R22's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V25 stated this was communicated to the facility (Nursing Home on [DATE]) and that the [CONDITION(S)] center would work on finding R22 a place that could accommodate R22's isolation. V25 stated V25 was able to find a [CONDITION(S)] chair in Chicago that had an isolation room available for R22 and a call was made to the facility (Nursing Home) the next day ([DATE]) and V25 spoke with V11 Registered Nurse. V25 stated V25 communicated to V11 that R22 could have [CONDITION(S)] at a different location in Chicago. V25 stated V11 told V25 that the facility (Nursing Home) could not transport R22 there. R22's Medical Record does not document any communication between V25 and V11 about [CONDITION(S)] appointment refusals by R22, missed [CONDITION(S)] appointments, or a location change that had been arranged. A facility report titled Nursing Daily Assignment Sheet dated [DATE] documents V11 as the Registered Nurse assigned to R22's care. On [DATE] at 9:00 am, Physician, V28 stated the facility did not notify V28 of any kind of transportation problems or that R22 would not be receiving R22's ordered [CONDITION(S)] treatments. V28 stated (R22) could have died in (R22's) bed. I am the Attending Physician and I should have been notified. On [DATE] at 2:00 pm, V3 Assistant Director of Nursing and Interim Director of Nursing confirmed that [DATE] was R22's last [CONDITION(S)] day before being admitted to the hospital on [DATE]. V3 stated We have had problems with (V11's) documentation and communication in the facility and we are addressing that.

Failures at this requirement required more than one Deficient Practice Statement. A.) Based on observation, interview, and record review the facility failed to ensure R12 was not subjected to physical violence by another resident, (R11). R11 forcibly held a pillow over R12's face, impeding R12's breathing. R11 and R12 are two of ten residents reviewed for abuse in a sample list of 23 residents. An Immediate Jeopardy situation was identified on 6/29/22. The Immediate Jeopardy was identified to have begun on 6/20/22 when R11 was found over R12 with a pillow, pressing down on R12's face, impeding R12's breathing. While the immediacy was removed on 6/30/22, the facility remains out of compliance at a severity level 2. The facility continues to monitor the effectiveness of their behavior management/supervision plan and revised new resident admission screening policy implementation. Findings include: On 6/23/22 at 12:00PM V12, Certified Nurse's Aide (CNA) stated I was checking residents on the Dementia Unit on 6/20/22 at about 1:30AM. I went into the resident's room where (R11) and (R12) were roommates. (R11) was straddling (R12). (R11) was holding a plastic pillow without a pillowcase on (R12's) face. The pillow was interfering with (R12's) breathing. (R12) was too weak to push (R11) off him. (R12) did not lose consciousness. (R12) was visibly shaken. I was able to get (R11) off (R12). I called (V13), Licensed Practical Nurse. She called Emergency Medical Services. (R11) was taken to the hospital and has not returned. R11's hospital discharge date d 6/17/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's hospital transfer sheet dated 6/17/22 documents during hospitalization (R11) had recurrent episode of agitation and was started on [MEDICATION(S)] (antipsychotic) 25 milligrams twice daily. (R11) should follow-up with a facility doctor within 2-3 days. There is no documentation to support a facility doctor followed up on this as ordered. There is no documented Care Plan for R11 from 6/17/22 until he left the facility 6/20/22. Hospital Critical Care note also contained in R11's 6/17/22 transfer sheet documents (R11's) son reports that they have had difficulty managing with the patient at home. He (R11) does become angry and combative when questioned regarding his insulin and therefore is unclear if (R11) is compliant with his medication. On 6/29/22 at V20, (R11's) family member stated (R11) was getting violent at home before he fell and went to the (hospital). I asked him to show me his glucose monitor so I could get him the right test strips. (R11) got angry and pulled a knife from the sink and tried to cut me with it. We told the nurses at the hospital, so they knew. (While at the hospital) (R11) pulled (family member) (V21's) hair and would not let go. The nurses had to make him let go. The facility (nursing home) never talked to me to find out if (R11) had any aggressive behaviors. I thought the hospital would tell them. R11's nurse's note dated 6/17/22 at 7:00PM documents (R11) admitted and began wandering. Unable to assess or take vital signs related to language difference (R11's dominant language is Spanish). (R11) cannot be redirected. R11's nurse's note dated 6/17/22 at 10:00PM documents (R11) has moved furniture in his room blocking door to bathroom. There are no subsequent nurse's notes for (R11) until 6/20/22 at 1:30AM which documents CNA (Certified Nurse's Aide) (V12) called nurse (V13) to (R11's) room. (CNA) stated (R11) has a pillow over roommate's (R12's) head. Witness Statement was obtained. Emergency Medical Services were called after resident (R11) was removed to ensure roommate's safety. Resident (R11) threw (soda) pop can at CNA (V12). On 6/23/22 at 3:30pm, V1, Administrator confirmed that the facility is rushed to look at prospective (resident) admits and are not always aware of behaviors that may not be safe for the facility. V1 confirmed that Nursing looks at the medications and documented notes. V1 also confirmed that Nursing should have seen that R11 was started on [MEDICATION(S)] (anti-psychotic) in the hospital. V1 stated My opinion of (R11's) incident was because of the language barrier. (R11) was brought to a strange place and could not understand English and we did not have a communication tool in place. R11's Nursing Admission Assessment by V3, Acting Director of Nursing confirmed R11 spoke limited English. dated 6/17/22 at 2:00PM documents Dominant Language: Spanish Limited English. On 6/23/22 at 1:00PM V3, Acting Director of Nursing stated (R11) spoke only a little English. R12's Activity Admission Care Plan (unsigned) dated 6/17/22 documents (R12) is Alert, Cooperative, and Forgetful. R12's Activity Admission Care Plan (unsigned) dated 6/17/22 also documents under the heading Identified need Plan Areas: Intellectual challenges, wandering, cognitive/memory (issues), and communication. R12's psychosocial assessment dated [DATE] by V22, Dementia Director documents the only behaviors exhibited by (R12) are Wanders/Paces. On 6/27/22 at 3:00PM R12 was sitting on the patio. He was not able to verbalize his name or where he was. He has no recollection of the incident with R11 when questioned. R12 appeared weak and frail. He can ambulate but displayed a shuffling unstable gait. Both his ankles were edematous. He muttered to himself, but he is unaware of his surroundings. On 6/29/22 at 11:00 a.m. V1, Administrator was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) V1, Administrator and V3, Acting Director of Nursing were in serviced by Regional Director of Clinical Operations concerning abuse procedures. This is documented on an in-service sign-in sheet dated 6/29/22. Per interview with V3 all staff who have not been in-serviced will be required to take this training prior to returning to work for next scheduled shift 2.) In-servicing of all staff concerning Abuse Prevention and reporting reasonable suspicion of a crime By V1 and V3 is documented on an in-service sign in sheet dated 6/29/22. 3.) Paperwork dated 6/29/22 was presented by V1 to document R11 was being involuntarily discharged and is not going to return to the facility. 4.) The facility notified the local police department 6/28/22 of the incident 6/20/22 involving R11 and R12. The local police were observed to be at the facility talking to V1. 5.) The facility's admission policy was updated to include a prescreen for the possibility of violent behaviors. The facility provided a copy of this policy 6/30/22. 6.) V1 provided a copy of the sign-in sheet for an in-service she provided to the members of the facility's Quality Assurance Team 6/29/22 regarding prescreening residents for harmful or violent behaviors. 7.) The facility assessed all residents for possible vulnerability to physical violence and some room changes were initiated related to resident safety and compatibility. This was verified to be in place on 6/30/22. B.) Based on record review and interview, the facility failed to ensure R1, R4 and R5 were not subjected to physical abuse by R3 on two occasions. The facility failed to ensure R2 was not subjected to physical abuse by R1. The facility failed to ensure R20 was not subjected to physical abuse by R21. R1, R2, R3, R4, R5, R20 and R21 are seven of ten residents reviewed for physical abuse in the sample list of 23. Findings include: 1.) A Facility Reported Incident dated 4/20/22 documents that R3 grabbed R1's face while R3 was being assisted back to R3's room to get a snack. R1 was sitting in the hall at this time. R3 and R1 were separated by V10, Certified Nursing Assistant (CNA). A statement by V10 documents the following: On 4/20/22, (R3) walked out of (R3's) room and I met (R3) in the hallway and asked if (R3) was hungry, (R3) said yes. So I went to walk (R3) to sit down to eat and (R3) went in the opposite direction and went to (R1) and started rubbing (R1's) head, (R1) started swinging on (R3) and I intervened between them and took (R3) away from the situation. On 6/23/22 at 11:05 am, V10 confirmed that R3 grabbed R1's head and also pulled R1's hair. V10 stated (R3) just deliberately walked over to (R1) and grabbed (R1). (R1) swatted (R3) away and I was able to separate them. 2.) A Facility Reported Incident dated 6/6/22 documents R3 striking another resident (R4) in the head/shoulder area while R4 was sitting in R4's wheelchair. R3 then struck another resident (R5) in the back area during this time. A statement dated 6/6/22 by V11, Registered Nurse documents the following: (R3) became agitated cursing and grabbing at items to break. Distracting ineffective. (R3) then double fisted (R4) on the shoulders. Residents were separated. (R3) then went out the patio door and when approached (R3) then turned and hit (R5) on the shoulders and back. On 6/17/22 at 11:15 am, V1 Administrator stated (R3's) actions of striking others are behaviors, but yes it is abuse. On 6/21/22 at 11:05 am, R5 who is alert and oriented to person, place and time confirmed that R3 struck R5 with R3's double fist. R5 stated It really shook me up, I was scared of (R3). I don't want to be anywhere near (R3). On 6/21/22 at 12:36 pm, R4 confirmed that R3 had purposely struck R4 with double fists. R4 stated (R3) is a bully. On 6/23/22 at 11:15 am, V11 confirmed witnessing R3 striking both R4 and R5 with R3's fists. V11 stated (R3) intentionally walked over to (R4) and clasped both of (R3's) hands together making a double fist and struck (R4) and (R5) hard around their shoulders, head and back. R3's Face Sheet (current) includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Sets dated 2/28/22 and 4/14/22 document R3 with no behaviors and is not able to complete the Brief Interview for Mental Status (BIMS) section. R3's Care Plan (current) documents R3 has impaired communication related to intellectual delay. On 6/23/22 at 3:45 pm, R3 during interview had a speech impediment but R3 was understandable and was able to tell this writer where R3 is, R3's name and R3's needs. 3.) A Facility Reported Incident dated 6/5/22 documents R1 began yelling at R2 and then kicked R2 in the shin. A statement dated 6/5/22 by V3, Former Assistant Director of Nursing, (now Director of Nursing) documents the following: I came in to check email and supplies. I was met by peer stating (R1) was going after (R2). Responded to A Hall Resident Room and saw (R1) foot kicking (R2) on front of shin. (R1) was verbally yelling at (R2). Separated immediately. (R1) returned to (R1's) room. (R1) stated (R2) was in (R1's) room and (R1) was tired of it. R1's Face Sheet (current) includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set, dated dated dated [DATE] documents R1 as being mildly cognitively impaired. On 6/16/22 at 10:00 am V3 confirmed that V3 witnessed R1 kick R2 in the leg. V3 stated (R1) knows exactly what (R1) is doing. (R1) thinks (R1) owns that alcove where both of their rooms (R1 and R2) were located. (R1) kicked R2 deliberately. On 6/21/22 at 10:55 am R1 was sitting in the hall and when asked a question, R1 told writer to get the (expletive) away from me. On 6/21/22 at 2:30 pm, R2 is not able to form words but is able to respond with head movements. R2 nods up and down in the yes gesture that R1 did kick R2 in the leg. R2 also nods in the yes gesture that it was a hard kick and it hurt. R2 nods yes that R2 is afraid of R1. On 6/23/22 at 3:35 pm V3 confirmed that R1 and R3 are mobile throughout the facility and are not on 1:1 supervision. 4.) R21's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's Social Service Note dated 6/6/22 documents Resident observed being aggressive in hall. Staff redirected. R21's Social Service Note dated 6/8/22 documents (R21) irritated today. (R21) angry toward anyone who would approach her. R20's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] R21's Incident Report dated 6/19/22 documents (R21) struck (R20) across the face with an open hand. knocking (R20's) glasses off (R20's) face. On 6/27/22 at 2:39PM V17, CNA (Certified Nurse's Aide) stated I was working 6/19/22. I was in a resident's room when I heard a noise from the dining area. I went there as soon as I could. I saw (R21) raise her hand up and slap (R20) hard enough to knock (R20's) glasses off. I separated the residents and called the nurse. (R21) and (R20) are both very confused and (R21) will hit at staff sometimes. On 6/27/22 at 3:00PM V3, Acting Director of Nursing stated (R21) was seen striking (R20) in the face and knocking off (R20's) glasses. They both have Dementia. (R20) was not injured.

Based on record review, observation and interview the facility failed to provide staff supervision for two of four residents (R4 and R5) reviewed for falls/safety/supervision on the sample list of 33. This failure resulted in R4 and R5 falls, both sustaining head lacerations that required emergency treatment with staples. Findings include: The facility policy Fall Prevention dated as revised 11/10/18 documents the following: Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes /desires for maximum independence and mobility. Responsibility: All staff. Procedure: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. A visual prompt may be placed on the name plaque by the entrance to the resident's room. If used, any Assistive device such as walker or cane will be identified with the same visual prompt to match the prompt at the entrance to the room. This system provides staff a visual alert to monitor those at risk for falls. (Blank) indicated high risk for falls. The facility should signify what the visual prompt will be and if none is used signify N/A (not applicable). All staff must observe residents for safety. If a resident is a high risk code are observed up or getting up, help must be summoned or assistance be provided to the resident. 1) R4's Physician Order Sheet dated 12/01/21- 21/31/21 documents the following diagnoses: Frontal Temporal Dementia with Behavioral Disturbance, Anxiety, Agitation, [CONDITION(S)] Disorder and Depression. R4's Care Plan dated 9/10/21 documents the following: Problem/Need, Plan, Resident has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include Dementia as evidence by poor safety awareness has related diagnosis/condition/history includes Dementia. Goal, Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors through next 90 days. Approach, Keep call light within reach at all times, Answer promptly and notify resident that help is on the way. R4's Minimum Data Set (MDS) dated [DATE] documents the following: R4 cognitive status is severely impaired. The same MDS documents R4 requires staff assistance physical staff assistance with transfers, and to stabilize when transitioning surface to surface and moving from seated to standing position. On 12/8/21 at 5:20 am, V16, Certified Nursing Assistant (CNA) ambulated R4 to the bathroom. R4 had a two-inch laceration to his head. V16, CNA stated R4 had a fall a couple weeks ago got a head laceration that required staples. R4's Fall Risk assessment dated [DATE] documents R4 is at high risk for falls = high risk if greater than 10 points. R4's scored is documented as 14 (high risk). R4's Nurse Progress Note dated 11/3/21 at 3:30 am documents R4 was found on the floor with blood on his head. R4's A.I.M. (Assess, Intercommunicate Manage) Wellness Fall Note dated 11/03/21 documents an (unidentified) Physician was notified at 3:30 am and gave orders to: Apply pressure to (R4's) head/send to ER (emergency room ), (Private) Memorial Hospital/(Private) Hospice notification. R4's Nurse Progress Note dated 11/3/21 at 5:30 am documents R4 received 10 staples to his head. R4 Nurse Progress Note dated 11/3/21 at 6:30 am documents R4 returned to the facility via ambulance. R4's Hospital Discharge Instruction dated 11/3/21 documents the following Diagnosis: Scalp Laceration Discharge Instructions: Keep wound clean and dry. The staples (number not identified) can be removed after seven days. 2) R5's Physician Order Sheet dated 12/1/21 documents the following diagnoses: Depression, [CONDITION(S)] Related to Anxiety. R5's Care Plan dated 10/12/21 documents the following: Problem/Need, Plan, Has risk factors for falls: Balance, Assistive devices, Needs assistance with transfers. Medical condition, Meds (medication) , Poor safety awareness, Vision problems, and Behaviors put resident at risk. Goal, Will have no falls through admission and care plan review. Approach: Assess cognitive deficits and accommodate forgetfulness regarding safety and environmental hazards. Observe for behaviors that put that place resident at risk for injury. R5's Minimum Data Set (MDS) dated [DATE] documents the following: R5 has a Brief Interview of Mental Status (BIMS) score of six out of 15, severe cognitive impairment. The same MDS documents R5 requires physical staff assistance with transfers, and to stabilize when transitioning surface to surface and moving from seated to standing position. On 12/8/21 at 5:00 am, R5 had one staple on a laceration at the back of R5's head. R5 stated I fell and hit my head, but I can't remember where I was, or if anybody was with me. I think my sister helped me up. R5's Fall Risk assessment dated [DATE] documents R5 is at high risk for falls = high risk if greater than 10 points. R5's score is documented as 17. R5's Nurse Progress Note dated 12/5/21 at 7:50 pm documents R5 was found on the floor in supine position and was positive for blood on the back of R5's head. R5's A.I.M. (Assess, Intercommunicate Manage) Wellness Fall Note dated 12/5/21 (unknown time) documents an (unidentified) Physician was notified at 7:55 pm and gave orders to: Send to (R5) ER (emergency room ) at (Private) Memorial Hospital, after assessing resident and obtaining vital signs. The same A.I.M for Wellness note documents R5 had head pain with the intensity of pain score rating of eight-nine out of 10 (10 being the worst pain level by scale). R5's Nurse Progress Note dated 12/5/21 at 10:30 pm documents the following: Informed by (Private) Hospital emergency room : one staple on back of head, CT scan cleared for discharge. R5's Hospital Discharge Instruction dated 12/5/21 Diagnosis: Simple Laceration of Scalp. Discharge Instructions: Staple to be removed after seven days. On 12/8/21 at 4:00 am V14, Registered Nurse (RN) stated the following: What happen with (R4) was, I was watching call lights and getting medication pass set up outside B-Hall (Memory Care Unit), while (V9, previous Certified Nursing Assistant/ CNA) was doing rounds (room checks and care) on C-Hall and A-Hall. (R4) fell and we didn't know it. (R4) fell in his room and we had no idea how long he was on the floor. Neither (V9, CNA) or I (V14, RN) had been over there (B-Unit) in about an hour and a half. It takes about 45 minutes to do each A-Hall and C-Hall rounds. (V9, previous CAN) found (R4) on the floor of his room on B-Unit, after doing rounds outside the B-Unit. (R4) had a lot of blood coming from his head and blood on the floor. He was alert but has Dementia and could not say what happened. I applied pressure, got vital signs, did neuros (neurological) assessments, and sent him to the hospital. He got (treated) with at least five staples in his head and came back to the facility. V14, RN also stated the following: What happen with (R5), it was change of shift, days to evening. I was receiving report from days and passing meds (medication) outside the unit (B, locked memory care). There was no CNA on memory care after 6:30 pm end of shift until (V8, CNA) went over to B-unit and found (R5) on the floor. (V8, CNA) had been doing rounds on A-Unit and C-Unit. Around 7:45 pm Sunday (12/5/21), (V17, RN) said (V8, CNA) found (R5) on the floor. I went to B-Unit immediately. (R5) was on the floor and had a laceration to her head. I did vital signs, neuro (neurological assessment), applied pressure to the wound and sent her out (to the hospital). (R5) came back (from the emergency room ) with one staple to her head. V14, RN also stated I have been complaining about staffing to (V4, previous Director of Nursing) and (V7, Social Service Director, Assistant Administrator) weekly for about three months. I complained to (V4, previous Director of Nursing and V7, SSD) that it is not safe for the residents and residents are not receiving the quality of care that they should. There are times between 6:00 pm and 8:00 pm I have no CNA (Certified Nursing Assistant) for the entire building. V14, RN also stated: When it is just me (V14, RN,) I cannot adequately provide care, answer call lights and do (administer) meds (medication). On 12/8/21 at 10:30 am V8, Certified Nursing Assistant (CNA) stated the following: I have had to work alone on evenings a couple of times (unidentified) for and hour or two until the nurse (unidentified) could get another staff member in here to work. I have had to do (full mechanical lift) transfers alone. The evening (12/5/21), (R5) fell . I did rounds on B-Unit (Memory Care locked unit) after I completed rounds on A and C units. I (V8, CNA) found (R5) in (R14's) room on the floor about 8:00 pm or 9:00 pm. (R14) was trying to get (R5) up (from the floor). I called for help and the nurse (V14, RN) came and assessed (R5) and sent her to the ER. On 12/8/21 at 4:20 pm V18, Physician/Medical Director stated I (V18) am not aware that one CNA (Certified Nursing Assistant) was taking care of all residents on their own. This was never reported to me. For the quality of care required for these residents, nursing staff should meet the minimum staffing requirements. I am not sure what that is for this facility. Staffing should be based on the level of care needed. Incontinence care should be provided or offered several times per shift. Several of the residents in this facility require a skilled level of care. There should always be enough staff working to maintain a safe environment. Falls do happen despite all we do to prevent them. It should never be because there was not enough staff to supervise these residents. The memory care unit (B-Unit) would require constant staff supervision due to the residents on that unit's inability to recognize safety precautions. I am aware the (R1, R4, R5, R9) have had falls in the facility. Each of those falls were reported and orders were given to send to the hospital for evaluation and treatment. Most recent, (R4 and R5) both fell resulting in lacerations to the head which required ER (emergency room )evaluation and treatment. I did not realize there was no supervision on the unit at the time of these falls. Of course those injuries could have been prevented had the (R4 and R5) not fallen. On 12/7/21 at 4:05 pm V23, Memory Care Unit Coordinator stated All residents should be supervised but the memory care unit (B-Unit) residents more so because they can not remember to put on their call light for staff assistance. (R4) fell in the last month which resulted in a laceration to (R4's) head. He had to get numerous staples in the back of his head. No one knows what really happened because there were no staff working on B-Hall (Memory Care Unit) that night. The night shift is consistently short staffed. The night CNA's (Certified Nursing Assistance) working A and C halls, outside the B unit (locked memory care) are supposed to provide the care and check on the residents. I don't know if that is happening. Frequently the day shift CNA's complain that residents are not being changed (incontinence care). There are odors of urine when I come in each morning. I am not a Nurse or CNA so I cannot provide personal care. (R5) had a fall a couple days ago which also resulted in staples to the back of her head. (R5) is not supposed to get up on her own. There was not a staff member over here (B-Unit) when (R5) fell . How long (R5) was on the floor is unknown. Staff do transfer residents by (full mechanical lift) with only one staff member because even on evenings there are not always two staff available. V23 also stated I am leaving (facility employment) in two days which is directly related to the facility not providing staff to care for the residents on B-Unit. Management (unidentified) is totally aware and have done nothing to get more staff.

Based on observation, interview and record review, the facility failed to assess and report a change of condition to the physician and family for one of three residents (R6) reviewed for improper nursing on the sample list of 22. This failure resulted in R6 becoming verbally unresponsive and being admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: The facility Notification of Change in Resident Condition or Status Policy dated 12/7/2017 documents, the facility shall promptly notify appropriate individuals (Administrator, DON (Director of Nursing), Physician, Guardian, Power of Attorney, etc) of changes in the resident's medical/mental condition and/or status. The Charge Nurse or Nursing Supervisor will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, a need to transfer the resident to a hospital/treatment center, or any symptoms of an infectious process. On 7/7/21 at 12:23 pm, R6 was sitting up in the Dining Room R6 was not verbally responsive. R6's MDS (Minimum Data Set) dated 6/15/21 documents R6 has severe cognitive impairment but has clear speech and is able to make R6's needs known and is able to understand others. On 7/7/21 at 1:10 pm, V4, Agency CNA (Certified Nursing Assistant) and V5, CNA entered R6's room. V4 and V5 provided transfer instructions/request to R6 and R6 did not respond verbally or physically. V4 and V5 repeated instructions several times and R6 still did not respond. V4 and V5 transferred R6 from the wheelchair to the bed, and R6 still did not respond verbally or physically. At this point, V4 stated, this isn't like (R6), I (V4) don't know what is going on with (R6). Normally (R6) will talk to you. (R6) is able to follow some instruction. V5 agreed with V4's statement. R6's Progress Notes dated 7/7/21 does not document R6's change in mental status and does not document that V16, Physician or V21, R6's Family was notified of the change in condition. R6's next Progress Note dated 7/9/21 {2 days later} at 8:30 am by V18, RN (Registered Nurse) documents R6's blood glucose levels as high and that R6 appears lethargic and not answering back verbally to questions and instructions. Monitoring accordingly. At 11:50 am, V18 documents there have been no changes since previous assessment. At 1:20 pm, V16, Physician notified and orders received to send R6 to the ER (emergency room ). R6's Hospital History and Physical dated 7/10/21 documents R6 was sent to the hospital for [CONDITION(S)] and found to have [CONDITION(S)], [CONDITION(S)], and UTI (Urinary Tract Infection). R6's Laboratory Values dated 7/9/21, while at the hospital, documents the following: Sodium Level of 158 (Critical High) with a normal range of 135-145 Potassium Level of 3.4 (Low) with a normal range of 3.5-5.5 BUN (Blood Urea Nitrogen) Level of 37 (High) with a normal range of 8-25 [MEDICATION(S)] Level of 2.16 (High) with a normal range of 0.70-1.50 Glucose Level of 432 (High) with a normal range of 70-110 R6's Urinalysis dated 7/9/21 and resulted on 7/11/21 documents greater than 100,000 Escherichia Coli in R6's urine. R6's Discharge Summary dated 7/12/21 documents R6's [CONDITION(S)] was resolved with Intravenous Hypotonic fluids and that R6's UTI is still being treated with an oral ABT (antibiotic) versus an Intravenous ABT which R6 received while in the hospital. On 7/13/21 at 8:20 am, V18, RN stated V18 was R6's nurse on 7/7/21 and that staff did not report a change of condition to V18 on 7/7/21. V18 stated on 7/9/21, V18 noticed R6 was lethargic and not responding as usual, and had a high blood glucose level when checked. V18 stated V18 gave the ordered medication but when V18 reassessed R6 several hours later and there was no change {improvement in condition}, V18 notified V16, Physician and R6 was sent to the Hospital. V18 stated, that was the first I knew of any change of condition with R6. On 7/13/21 at 9:24 am, V16, Physician stated V16 was first notified of R6's change of condition; decrease LOC (Level of Consciousness) and high blood glucose levels on 7/9/12. V16 stated when notified, V16 told the facility that we{staff}could either do blood work there at the facility, or if they truly felt (R6) had a change in condition, we could send (R6) to the hospital because they are able to do things more quickly. R6 was sent to the ER. V16 stated with a Critical {high} NA (Sodium) level, (R6) was dehydrated. R6 has Alzhiemers, and R6 doesn't drink enough, so R6 isn't able to hydrate R6's self. V16 also stated, with high blood sugars, R6 will be urinating more, which will cause dehydration. The facility really needs to observe and monitor (R6) better due to (R6's) mental status and (R6) not being able to do that for R6's self. The high NA level is the cause of the mental change (non-verbal) and the elevated BUN and [MEDICATION(S)] is from dehydration. I (V16) should have been notified sooner and we {facility} could have managed (R6) better, I (V16) could have ordered labs {laboratory tests} and started {R6} on IV (Intravenous) fluids at the facility, before it got to the point of being sent out to the hospital. V16 stated V16 always tell the nurses if they {nurses} feel something is wrong, do not hesitate to call me (V16). If they had called sooner with the change, further issues could have been prevented with prompt treatment.

Based on observation, interview, and record review ,the facility failed to administer physician's ordered treatments and wound interventions, monitor and assess wounds, perform hand hygiene during a wound treatment, and assess for and implement nutritional recommendations for four of four residents (R1, R2, R3, R4) reviewed for skin conditions in the sample list of six residents. This failure resulted in R1's right diabetic heel wound deteriorating and requiring mechanical debridement. Findings include: The facility's Skin Condition Monitoring policy revised January 2018 documents: Upon identification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurse's notes and complete the QA (Quality Assurance) form for Newly Acquired Skin Condition. The Nurse will then implement the following procedure: a. Notify the physician and obtain a treatment order. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: a. Characteristic 1. Size 2. Shape 3. Depth 4. Odor 5. Color 6. Presence of granulation tissue or necrotic tissue. b. Treatment and response to treatment. Observe and measure pressure ulcers at regular intervals. c. Prevention techniques that are in use for the resident. The facility's Nutritional Assessment policy revised March 2019 documents residents will have a comprehensive nutritional assessment upon admission, annually, and with significant changes in condition. This policy documents the Dietitian will complete a resident's nutritional assessment that includes food allergies or intolerances, ability to chew and swallow, mental, emotional, psychological issues, physical appearance, noting any signs of malnutrition and dehydration, and height and weight including any changes, vitamin and mineral supplements, food and fluid intake, history of drug/[CONDITION(S)], ability to eat, level of mobility, hearing and vision, cultural or religious food preferences, medications, significant lab values, skin condition, use of catheters, colostomies, feeding tubes or intravenous fluids, calculation of energy, protein and fluid needs, assessment of diet adequacy, nutritional needs, goals, and approaches, and educational needs. 1.) R1's Admission Minimum Data Set (MDS) dated [DATE] documents: R1 is cognitively intact, uses extensive assistance of two staff for bed mobility, transfers, and extensive assistance of one staff for dressing. R1 did not admit to the facility with pressure ulcers or diabetic foot ulcers. R1's Care Plan dated 3/30/21 documents R1 admitted with skin breakdown with interventions to refer to R1's Physician's Orders for treatments, assess and measure wounds weekly and as needed, wound consult as needed, evaluate nutritional needs and refer to the Registered Dietitian as needed, and notify the physician if the condition worsens or if no improvement noted with current treatment. R1's March 2021 Physician's Orders document R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's March orders do not document any orders for wound treatments. R1's April 2021 Physician's Orders documents the following orders: On 4/3/21 apply a skin protectant to bilateral heels twice daily for 14 days and protective heel boots at all times. On 4/7/21 cleanse R1's right heel wound, right knee wound, and right lateral side wound with [MEDICATION(S)] twice daily for 14 days, cleanse R1's perineal area with (topical foam solution) and apply antifungal powder twice daily and as needed for 14 days. On 4/14/21, cleanse right lateral side wound with wound cleanser, apply hydrogel and collagen, covered by a dry dressing daily and as needed, and cleanse breasts with (topical foam solution) and apply [MEDICATION(S)] cream twice daily and as needed for 14 days. On 4/16/21 cover heel with Santyl, calcium alginate, foam pad, and gauze wrap daily, and apply [MEDICATION(S)], antifungal ointment, and [MEDICATION(S)] to buttocks twice daily. R1's Nursing Admission assessment dated [DATE] documents to refer to the attached shower sheet for wound and skin assessments and measurements. The shower sheet dated 3/25/21 documents the following skin issues: R1's right lateral rib was bruised with avulsed (torn) skin that measured 19.5 cm (centimeters) by 9.5 cm. R1's right lateral knee scab measured 5 cm by 2 cm. R1's left breast was excoriated and red, and the area measured 6 cm by 2 cm. R1's Shower Sheets document: On 3/28/21 R1 had open areas to R1's right flank and right knee. On 4/9/21 the areas to bilateral breasts, abdomen, and groin are circled with a description all red. R1's Nursing Note dated 4/3/21 at 5:30 PM R1's bilateral heels were red and soft and orders were received to apply a skin protectant twice daily for 14 days and heel protectors in place at all times. R1's Initial Wound Evaluation & Management Summary by V7 Wound Physician dated 4/7/21 documents: R1 had scabbed wounds to the right lateral knee that measured 3 by 4 cm and right flank that measured 2.5 by 1.5 cm, orders to apply [MEDICATION(S)] daily for 30 days, and recommendations to off-load wound, reposition side to side and front to back in bed every 1 to 2 hours. This summary also includes recommendations to elevate R1's legs and float R1's heels. R1's Wound Evaluation & Management Summaries document: On 4/14/21 R1's right lateral knee wound measured 2.5 by 3.4 cm, and R1's right flank wound measured 2.5 cm by 1.5 cm by 0.1 cm. R1 had a diabetic right heel wound was a fluid filled blister that measured 2.8 cm by 3.4 cm by no measurable depth. R1's right heel wound treatment order was [MEDICATION(S)] daily and V7 recommended R1 wear pressure relieving boots to bilateral lower extremities when in bed. On 4/21/21 R1's right lateral knee wound measured 2.3 by 3.3 cm. R1's right flank wound measured 2.4 by 1.3 by 0.3 cm, apply collagen covered by a bordered gauze dressing daily. R1's diabetic wound to the right heel deteriorated and measured 7 cm by 8.5 cm by 0.2 cm with 50 % black necrotic (dead) tissue and required mechanical debridement (removal of dead tissue.) R1's medical record does not contain measurements of R1's right heel wound between 4/14/21 and 4/16/21 when the treatment order changed from a skin protectant to Santyl. R1's March 2021 Treatment Administration Record (TAR) does not document any treatments were administered to R1's breasts, right flank wound, or right knee wound. R1's April 2021 TAR does not document the following treatments were administered: R1's skin protectant to R1's bilateral heels on day shift on 4/5 and 4/6/21, and evening shift on 4/3 and 4/4/21. R1's heel boots on day shift 4/1, 4/2, 4/8-4/11, 4/13, 4/15, 4/16, 4/20, 4/22, 4/24-4/25/21, and evening shift on 4/2, 4/4, and 4/8-4/25/21. [MEDICATION(S)] to R1's right heel on day shift 4/8-4/11, and 4/13/21, and evening shift on 4/7/21-4/13/21. [MEDICATION(S)] to R1's right knee wound on day shift on 4/1, 4/3, 4/4, 4/6, 4/8-4/11, 4/13, 4/15, 4/16, 4/20, 4/22, 4/24-4/25/21, and on the evening shift on 4/1-4/25/21. [MEDICATION(S)] to R1's lateral side on day shift on 4/1, 4/3, 4/4, 4/6, 4/8-4/11 and 4/13/21, and evening shift on 4/1-4/13/21. Antifungal powder to perineal area on day shift on 4/1, 4/3, 4/4, 4/6, 4/8-4/11, 4/13, 4/15, 4/16, 4/20-4/22, 4/24-4/25/21, and evening shift on 4/1-4/6, 4/8-4/25/21. Hydrogel, collagen, and dry dressing to R1's right lateral side on 4/15, 4/16, 4/20, 4/22, 4/24-4/25/21. [MEDICATION(S)] cream to breasts on day shift on 4/15, 4/16, 4/20, 4/22, 4/24-4/26/21, and evening shift on 4/14-4/25/21. Santyl, silver alginate, and gauze wrap to the right heel on 4/20, 4/22, 4/24, 4/25, and 4/26/21. [MEDICATION(S)], antifungal and [MEDICATION(S)] cream on day shift on 4/20, 4/22, and 4/25/2, and on the evening shift on 4/17-4/25/21. R1's Nutritional assessment dated [DATE] and signed by V14 Registered Dietitian (RD), includes a check list of risk factors which includes skin breakdown. This assessment does not document R1 has skin breakdown, and does not assess R1's caloric/nutritional/fluid needs. This assessment documents wt (weight) pending for full assessment. There are no other documented nutritional assessments in R1's medical record after 3/26/21. On 6/21/21 at 9:58 AM V13 (R1's Family Member) stated R1 admitted to the facility at the end of the March 2021 following a hospital stay. R1 developed a bed sore to the right heel that was down to the bone and infected. R1 did not admit to the facility with the wound. R1 admitted to the facility with a [MEDICATION(S)] infection under R1's breasts, abdomen, and groin that looked worse when R1 discharged from the facility at the end of April 2021. V13 stated R1 was suppose to have antifungal cream applied to the areas and V13 was not sure that the cream was being applied. R1 also had friction sores all over R1's body upon discharge. On 6/22/21 at 11:00 AM V14, RD stated V14 is in the facility two to three times per month to complete resident nutritional assessments. V14 stated the facility sends V14 an electronic mail with a list of resident referrals including new admissions, or residents with new weight loss or wounds for V14 to evaluate. V14 was uncertain if V14 was made aware that R1 had skin issues or if V14 was notified after 3/26/21 to evaluate R1. V14 stated V14 provides a copy of V14's nutritional recommendations to V1 Administrator and V2 Director of Nursing after each visit. V14 expects the facility to implement V14's recommendations within one week. On 6/22/21 at 1:35 PM V7,Wound Physician stated R1's right heel wound was a diabetic wound and pressure was a contributing factor since R1 was bed bound. V7 recommended to keep R1's heels elevated in bed at first, and then changed to pressure relieving boots. R1's wound declined and required debridement. V7 stated once a blister forms, the underlying tissue becomes compromised and contributes to a decline along with small vessel disease, pressure, and decreased appetite. V7 stated V7 would expect V7's orders to be implemented as written, unless the facility notified V7 of a resident's noncompliance or if the facility did not have the ordered wound care supplies. V7 stated is not acceptable for treatments not to be administered and that absolutely can contribute to a decline or worsening of the wound, or a delay in improvement. On 6/22/21 at 2:35 PM V2, Director of Nursing (DON) stated referrals are made to V14 if the resident is newly admitted , has a feeding tube or fluid restriction, or if a resident admits with or develops new wounds. V2 confirmed R1's Nutritional Assessment does not document that V14 was aware of R1's impaired skin, and R1's medical record does not document that V14 completed an assessment for R1 after 3/26/21. V2 confirmed R1's medical record does not document wound treatments to R1's right flank and right knee were not implemented until 4/7/21 after V7 assessed R1. V2 stated V2 thought that R1 had returned from the local emergency room with the right heel wound, but was V2 was unable to locate documentation. V2 stated R1's right heel wound started as a blister that V2 attributed to V2's overall decline and refusal to get out of bed. 2.) On 6/21/21 at 8:47 AM R2 stated R2 admitted to the facility with wounds to R2's feet. R2 stated R2's wound treatments are daily and the nurses only administer R2's wound treatments on Thursdays and Fridays. R2's MDS dated [DATE] documents R2 is cognitively intact. June 2021 Physician's Orders document R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's orders do not include orders for a protein supplement for wound healing or treatment orders for R2's right and left heel wounds. R2's May 2021 Physician's Orders documents an order dated 5/12/21 cleanse right medial foot wound with [MEDICATION(S)] and leave open to air. R2's Telephone Order dated 3/26/21 document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation that this order was transcribed to R2's Physician's Orders Sheets and Medication Administration Records (MARs) after 3/26/21. R2's April-June 2021 MARs do not document that R2 received Prostat 30 ml twice daily as ordered. R2's Dietary Notes signed by V14, RD, documents the following: On 3/26/21 V14 recommended the addition of Prostat Advanced Wound Care 30 ml twice daily to aid in wound healing. On 4/27/21 V14 documents R2 receives Prostat Advanced Wound Care 30 ml twice daily. R2's Wound Evaluation & Management Summaries by V7, Wound Physician, document the following: On 4/14/21 R2's wound to the distal medial right foot was scabbed and measured 2 cm long by 1.5 cm wide, R2's diabetic wound to the right heel measured 1.2 cm long by 1.1 cm wide by 0.1 cm deep, and R2's diabetic wound to the left heel measured 2.2 cm by 2.2 cm by no depth. On 5/5/21 R2's left diabetic heel ulcer was healed, R2's right distal medial foot wound measured 1.2 cm by 0.8 cm by 0.1 cm, and R2's right heel diabetic wound is scabbed and measured 5.5 cm by 7.5 cm by 0 depth. R2's right medial foot wound treatment was cleanse with [MEDICATION(S)], apply collagen and hydrcolloid dressing daily and as needed. V7's treatment orders for R2's diabetic right heel wound was to apply [MEDICATION(S)] daily. On 5/12/21 R2's right medial foot wound measured 1 by 0.7 cm and V7 ordered [MEDICATION(S)] daily. On 5/19/21 R2's right heel diabetic wound healed, and R2's right medial foot wound measured 0.8 cm by 0.6 cm by 0.2 cm. On 5/26/21 R2's right medial foot wound measured 0.7 cm by 0.5 cm by no depth and V7 ordered [MEDICATION(S)] daily. On 6/16/21 R2's distal medial right foot scabbed wound measures 0.4 cm long by 0.3 cm wide. This summary documents a treatment order to apply [MEDICATION(S)] daily and recommendations to elevate R2's legs, float heels, off load wound, and reposition side to side and front to back every 1 to 2 hours if able. There are no documented measurements or assessments of R2's right and left diabetic heel wounds in R2's medical record after 5/19/21. R2's April 2021 TAR does not document the following: [MEDICATION(S)] was administered to R2's left heel wound on day shift on 4/5 and 4/8/21, and evening shift on 4/2-4/4, and 4/8-4/11/21. [MEDICATION(S)] was administered to R2's medial foot wound on day shift on 4/5, 4/8, 4/11, 4/27, 4/30/21 and evening shift on 4/2-4/4, 4/8-4/11, 4/21, 4/22, 4/24, 4/25, and 4/27-4/30/21. [MEDICATION(S)] was administered to R2's bilateral foot wounds on day shift on 4/15/, 4/16, 4/19, 4/20, 4/27, and 4/30/21, and the evening shift on 4/15-4/18, 4/20-4/25, and 4/27-4/30/21. R2's May 2021 TAR does not document the following: [MEDICATION(S)] was applied to R2's bilateral heels on day shift 5/6, 5/7, 5/10, 5/11, 5/20, 5/27, 5/28, and evening shift on 5/1, 5/2, 5/5-5/8, 5/11-5/17, 5/19-5/23, 5/26-5/31/21. [MEDICATION(S)], collagen, and [MEDICATION(S)] was administered to R2's right medial foot wound on day shift on 5/6-5/9/21, and [MEDICATION(S)] was not administered on the evening shift from 5/12-5/17, 5/19-5/23, and 5/26-5/31/21.R2's June 2021 TAR does not document [MEDICATION(S)] was applied to R2's bilateral heel wounds on day shift on 6/3 and 6/5/21, and evening shift on 6/3-6/5, 6/7, 6/9-6/12, and 6/16-6/19/21. This TAR does not document an entry to record the administration of R2's right distal medial foot wound. On 6/21/21 at 11:34 AM V5, Registered Nurse (RN), entered R2's room to administer R2's wound treatments. V5 applied [MEDICATION(S)] to a small scabbed area to R2's left heel, right inner heel, and right inner foot near R2's great toe. On 6/22/21 at 2:35 PM V2, DON, stated R2 admitted to the facility with bilateral heel wounds, believed to be diabetic wounds. V2 stated V2 was the nurse who transcribed the telephone order for V14's recommendation for Prostat 30 ml twice daily, and the order was not transcribed onto R2's Physician's Orders Sheets and MARs. 3.) R3's Care Plan dated 5/19/21 documents R3 has arterial ulcers to R3's left leg, left foot, and right foot with interventions that include measure and monitor wound weekly, administer treatments as ordered, and dietary consult for nutrition and hydration recommendations. R3's Nursing Note dated 4/19/21 documents R3 is alert and oriented to person, place, and time. R3's Physician's Orders dated 6/1/21-6/30/21 documents an order dated 6/11/21 for multivitamin once daily and a nutritional supplement 60 ml by mouth twice daily. R3's Physician's Orders dated 5/1/21-5/31/21 documents the following: An order dated 5/5/21 to cleanse R3's left calf wound with [MEDICATION(S)], apply collagen, cover with a [MEDICATION(S)] dressing every 3 days and as needed, cleanse left medial foot wound with [MEDICATION(S)], apply collagen, cover with [MEDICATION(S)] dressing and change every 3 days and as needed, cleanse right medial foot wound with [MEDICATION(S)], apply Collagen, cover with [MEDICATION(S)] dressing and change every 3 days and as needed, and heel protector boots on at all times. An order dated 5/12/21 documents to cleanse R3's left calf wound with [MEDICATION(S)] twice daily and leave open to air. R3's Telephone Order dated 3/17/21 documents to cleanse R3's groin with (foam solution), apply [MEDICATION(S)] ointment and antifungal powder twice daily and as needed. R3's Telephone Order dated 5/26/21 document orders to cleanse R3's left lateral ankle wound and right medial foot wound, apply hydrogel and collagen, and cover with a dry dressing daily. R3's Dietary Services Communication form dated 5/14/21 documents V14 gave recommendations for a multivitamin daily and a nutritional supplement 60 ml twice daily. There is no documentation in R3's medical record that V14's recommendation was implemented prior to 6/11/21 (28 days later.) R3's March 2021 TAR and April 2021 TARs do not document R3's antifungal powder was administered on day shift on 3/20, 3/21, 3/23, 3/25, 3/26, 3/29, 3/30, 4/1, 4/3, 4/6, 4/8-4/11, 4/13, 4/15, 4/16, 4/20, 4/22, 4/24-4/26, 4/29, and 4/30/20, and on the evening shift on 3/17-3/30/21, and 4/2-4/4, 4/6-4/26/21, and 4/28-4/30/21. R3's May 2021 TAR does not document R3's left calf wound treatment was administered on day shift on 5/14, 5/17-5/25, 5/30, and 5/31/21, and on evening shift on 5/12-5/16, 5/18-5/21, 5/24, 5/25, and 5/27-5/31/21. This TAR does not document R3's right medial foot treatment and left medial foot treatments were administered on 5/8-5/11, 5/14, and 5/17-5/24/21. R3's June 2021 TAR does not document the following: R3's heel boots were implemented on day shift 6/1, 6/3-6/8, 6/10, 6/13-6/15, 6/17, 6/19, 6/20/21, and evening shift on 6/3-6/8, 6/10-6/15, 6/17-6/21/21. R3's left calf wound treatment was administered on day shift on 6/1, 6/3-6/8, 6/10, 6/13-6/15/21, and the evening shift on 6/2-6/7, 7/9-6/15/21. R3's left ankle and medial foot wound treatments were administered on 6/1, 6/3-6/8, 6/10, 6/13-6/15, 6/19, and 6/20/21. R3's Wound Evaluation & Management Summaries by V7 document the following: On 5/5/21 R3's left calf arterial wound measured 1.4 cm long by 1.4 cm wide by 0.1 cm deep, R3's left lateral ankle arterial wound measured 0.5 cm long by 0.6 cm wide by 0.2 cm deep, and R3's right foot arterial wound measured 0.5 cm long by 0.7 cm wide by no depth. R3's left ankle wound resolved on 5/12/21. On 6/16/21 R3's left distal, posterior, medial calf arterial wound measured 0.8 cm long by 0.8 cm wide by 0.1 cm deep. R3's right foot arterial wound measured 0.6 cm long by 0.4 cm wide by 0.2 cm deep. R3's treatment orders for R3's calf wound and right foot wound are documented to apply collagen, and a bordered gauze dressing daily. There are no documented measurements or assessments of R3's left lateral foot wound after 5/12/21 in R3's medical record. On 6/21/21 at 12:01 PM V4, Licensed Practical Nurse, entered R3's room, washed V4's hands, and applied gloves. R3 was lying in bed with R3's heels floated on a pillow and R3 was not wearing pressure relieving boots. R3 had dressings to R3's outer left foot near the ankle and inner right foot that were dated 6/18/21. V4 confirmed the dressings were dated 6/18/21. V4 removed R3's left foot wound dressing which had a small amount of tan drainage. R3's wound was a small circular shape and pink. V3 cleansed R3's wound, changed gloves, applied hydrogel and collagen covered with a bordered foam dressing. V4 changed V4's gloves and removed the dressing to R3's right foot. There was a small amount of tan drainage and R3's wound was pink, and a small circular shape. V4 cleansed R3's wound, changed gloves, applied hydrogel and collagen covered with a bordered foam dressing. V4 did not perform hand hygiene when V4 changed gloves or between administering each wound treatment. V4 applied R3's nonskid socks, floated R3's heels on a pillow, covered R3 with blankets, and left R3's room. V4 did not apply R3's pressure relieving boots. On 6/21/21 at 12:18 PM V4 stated hand hygiene should be performed before and after treatments, and Alcohol Based Hand Rub should be used between glove changes. V4 confirmed hand hygiene was only completed before and after R3's wound treatments. On 6/21/21 at 1:55 PM, V4 stated R3 wears heel protectors when in bed and confirmed R3 was not wearing heel protectors before or after R3's wound treatment administration. On 6/21/21 at 1:30 PM V9, V11, and V12 Certified Nursing Assistants (CNAs) entered R3's room. R3 was not wearing pressure relieving boots. V9, V11, and V12 provided incontinence care for R3 and transferred R3 with a full mechanical lift from the bed to the wheelchair. V9, V11, and V12 did not apply R3's pressure relieving boots. V9 pushed R3 in the wheelchair into the hallway. On 6/21/21 at 3:50 PM, R3 was sitting in a wheelchair in the hallway and R3 was not wearing pressure relieving boots. R3 stated R3's pressure relieving boots went missing about two weeks ago. On 6/21/21 at 4:57 PM and 6/22/21 at 9:03 AM, R3 was not wearing pressure relieving boots while R3 was sitting in R3's wheelchair. On 6/21/21 at 4:57 PM V12 ,CNA stated R3 has heel protectors that are lying on R3's bed. R3 only wears heel protectors when R3 is in bed. On 6/21/21 at 2:35 PM V2 confirmed V14's recommendation on 5/14/21 for R3 to have a multivitamin daily and nutritional supplement 60 ml twice daily was not implemented until 6/11/21. V2 confirmed R3 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated: R3 frequently refuses to wear them, and refusal of care would be documented in nursing notes or behavior logs. Hand hygiene should be completed before and after wound treatments, and when changing gloves and moving from soiled to clean areas during a wound treatment. 4.) R4's Physician's Orders Sheet (POS) dated 5/1/21-5/31/21 documents an order dated 5/26/21 to cleanse R4's abdominal folds and buttocks, and apply a skin protectant cream twice daily and after perineal care. R3's April, May and June 2021 POS do not document an order to apply antifungal powder twice daily and as needed for 14 days to R4's perineal area. R4's April 2021 TAR documents an entry dated 4/7/21 to apply antifungal powder twice daily and as needed to R4's perineal area for 14 days. This TAR does not document antifungal powder was administered on 4/8, 4/12, 4/13, 4/15, 4/16, 4/19, and 4/20/21 on day shift, and on 4/8-4/11, 4/15-4/18, and 4/20/21 on the evening shift. R4's May 2021 TAR does not document R4's abdominal fold treatment was administered on the day shift on 5/27, 5/28, and 5/31/21, and on the the evening shift on 5/25-5/31/21. R4's June 2021 TAR does not document R4's abdominal fold treatment was administered on the evening shift on 6/3, 6/4, 6/5, 6/7, 6/9-6/12, and 6/16-6/19/21. On 6/21/21 at 8:36 AM V5, RN, stated R4 has fungal areas to R4's abdominal folds. On 6/22/21 at 9:53 AM, R4 was lying in bed. R4 stated R4 has redness to R4's abdominal folds. On 6/22/21 at 11:10 AM V8 and V9, CNAs, entered R4's room and provided incontinence care for R4. V9 cleansed R4's abdominal folds and applied a skin protectant cream to R4's abdominal folds and perineal area. R4's skin was intact and without redness. V9 stated R4's skin used to be red and raw, but the skin protectant has helped. R4 stated the night shift staff have not been applying R4's skin protectant cream. On 6/22/21 at 2:35 PM V2 was unable to locate R4's original order from 4/7/21 for antifungal powder. V2 stated the order is not on R4's April 2021 Physicians Orders Sheet, and V2 could not locate a telephone order or written order. V2 stated the nurses are to sign out the TAR when treatments are administered and V2 expects the nurses to follow physician's orders. V2 stated the floor nurses are responsible for completing wound assessments and measurements upon admission, readmission and when a new wound is identified. V2 stated wounds are measured and assessed weekly by V7 and documented in V7's progress notes. V2 confirmed V2 provided all of R1's, R2's, and R3's wound measurements between 2/25/21 and 6/21/21. On 6/22/21 at 3:57 PM V2 and V3 Social Services confirmed there is no documentation that R2 or R3 refuse wound treatments or interventions.

Based on observation, interview and record review, the facility failed to implement infection control procedures to prevent the potential spread of a highly contagious disease to residents and staff. The facility failed to follow facility policy and local health department guidance to develop a COVID-19 Unit, move residents (R1-R4, R9-R30, and R40) testing positive away from asymptomatic residents (R5-R8, and R31-R57) testing negative and failed to designate staff to care for residents testing positive for [MEDICAL CONDITION]. This failure affects 31 residents (R5-R8, R31-R57) and all residents (57) at the facility. An additional 21 residents (R31-R44, R48, and R,[DATE]) subsequently tested positive for COVID-19 after being exposed to COVID-19 at the facility. These failures resulted in an immediate jeopardy. While the immediate jeopardy was removed on [DATE], the facility remains out of compliance at a severity level 2. The facility is in the process of re-educating key management personnel and direct care staff related to COVID-19 infection control measures. Findings include: The facility's COVID-19 Cohorting of Residents policy dated [DATE] documents Purpose: To minimize interactions of infectious individuals from non-infected individuals. 1. Identify space within the facility to be dedicated to monitor and care for residents with COVID-19. Ideally this space should be physically separated from other rooms that house residents without confirmed COVID-19. (Separate floor, wing or cluster of rooms) 2. Identify HCP (Health Care Providers) who will be assigned to work only within the dedicated area, when in use. The policy also documents, Move resident to COVID-19 designated area if test results are positive for [DIAGNOSES REDACTED]-CoV2 (COVID-19). This policy documents Counsel all residents to restrict themselves to their room, as much as possible. This policy documents the facility may determine it is safest for residents on the memory care unit with COVID-19 to remain on the memory care unit with dedicated staff. 1. The facility's undated floor plan documents D Hall is the facility's designated COVID-19 unit. The facility's Nurses Midnight Census dated [DATE] documents a census of 57 residents. The facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents between ,[DATE] and [DATE] the facility has had a total of 25 staff and 47 residents test positive for COVID-19. The COVID-19 laboratory test report provided by V1, Administrator on [DATE] documents COVID-19 test results as follows: On [DATE] R5, R7, R8, R31, R32, R36, R37, R42, R43, R45, R55 and R56 tested negative. On [DATE] R1-R3 and R9-R30 tested positive. On [DATE] R6, R33-R35, R38, R41, R44, R48, R49, R52-R54, and R57 tested negative. On [DATE] R45-R48 and R57 tested negative. On [DATE] and [DATE] R45 and R49 tested negative. On [DATE] R5-R8, R31-R39, R41-R44, R52-R56 tested positive. On [DATE] R48 and R57 tested positive. R4's COVID-19 test dated [DATE] documents R4 tested positive. R40's COVID-19 laboratory results dated [DATE] documents R40 tested positive. The facility's Nurses Midnight Census dated ,[DATE], ,[DATE]-,[DATE], ,[DATE], ,[DATE], and [DATE] document: Between ,[DATE] and [DATE] COVID-19 positive residents R1-R3, R9, R11, R13-R24, R26, R30, and R40 resided on the A, B, and C Halls with negative residents R5-R8, R31-R39, R41-R57. Between ,[DATE] and [DATE] COVID positive residents R1-R3, R8, R13-R24, R26, R30-R44, and R52-R56 resided on the A, B, and C Halls with negative residents R45-R49 and R57. Between ,[DATE] and [DATE] COVID-19 positive residents R4, R9-R12, R25, and R27-R30 resided on the D Hall. The facility's Midnight Census dated [DATE] provided by V1 Administrator documents R50 and R51 refuse COVID-19 testing. There is no documentation in R50's or R51's medical record that R50 or R51 have symptoms of COVID-19. R55's Death Certificate signed by V20, Physician, documents R55's date of death as [DATE] and cause of death as Acute [MEDICAL CONDITION], Pneumonia, and COVID-19 Infection. On [DATE] between 8:13 AM and 9:40 AM a tour of the facility was conducted. R45, R46 and R47 (COVID-19 negative residents) were comingled on the A Hall with R1, R2, R3, R6, R7, R8, R13-R18, and R39 (COVID-19 positive residents.) R48, R49, and R57 (COVID-19 negative residents) were comingled on the C Hall with R5, R22-R24, R26, R37, R40-R43, R52, and R54 (COVID-19 positive residents.) Asymptomatic residents R50 and R51 were comingled on the B Hall with R19, R21, R32, R34, R35, R38, R44, and R53 (COVID-19 positive residents). There were no sections within the A, B, and C Halls identifying where COVID-19 positive rooms were located. The doors to D Hall were closed with signs documenting limited employee access and to report to the nurse prior to entering. On [DATE] at 8:15 AM V4, Licensed Practical Nurse (LPN) stated on [DATE] A Hall and D Halls were considered to be a COVID-19 units. V4 stated COVID-19 positive residents were moved away from negative roommates, but continued to reside on the same hallways with negative residents since the negative residents were already considered to be exposed. On [DATE] at 9:10 AM V19, LPN stated the facility has not followed proper precautions to prevent the spread of COVID-19. V19 stated after [DATE] COVID-19 positive residents were still residing on the same hallways as the negative/asymptomatic residents throughout the building. On [DATE] at 10:50 AM V1 stated V1 has been communicating regularly with V18, Local Health Department Director of Clinical Nursing Services. V1 stated initially D hall was the facility's designated COVID-19 unit. V1 stated on [DATE] over twenty residents had tested positive and D Hall was full, so the facility chose to place positive residents on isolation and remain in their room per V18's guidance. On [DATE] at 11:33 AM V1 confirmed not all COVID-19 positive residents on [DATE] and [DATE] were transferred to the D Hall (the facility's dedicated COVID-19 unit). V1 confirmed after [DATE] COVID-19 positive and negative residents continued to be comingled on the A, B, and C Halls within the facility. On [DATE] at 6:10 PM V2, Director of Nursing (DON) stated V2 is the facility's Infection Preventionist. V2 confirmed COVID-19 positive residents were comingled on the same halls with negative residents between ,[DATE] and [DATE]. On [DATE] at 3:53 PM V18 stated the facility should have a designated area for COVID-19 negative residents to reside away from positive residents. V18 stated cohorting COVID-19 positive residents away from negative residents was reviewed with V1. V18 stated on [DATE] V1 reported a large influx of COVID-19 positive residents and told V18 the facility still had dedicated units for COVID-19 positive residents. 2. The facility's Nurse and Certified Nursing Assistant (CNA) Schedules dated [DATE] - [DATE] and the facility's Nursing Daily Assignment Sheets dated ,[DATE]-[DATE] do not document the facility had designated staff assigned to provide care for COVID-19 positive residents. On [DATE] between 8:13 AM and 1:30 PM V5, V6, V14, CNAs, were observed entering multiple resident rooms throughout the A, C, and D Halls. V17, CNA was observed entering resident rooms located on the B Hall. V7 Registered Nurse (RN) was the only nurse observed working on all of the halls located in the facility. V15 Housekeeper entered multiple resident rooms on A Hall and V16 Housekeeper entered multiple resident rooms on C Hall. On [DATE] at 12:35 PM V5, CNA stated V5 provides direct resident care on all of the halls within the facility. On [DATE] at 1:10 PM V14, CNA stated V14 has been working on all of the halls, providing direct resident care, since the beginning of November. On [DATE] at 8:15 AM V4, LPN stated the facility does not have dedicated staff assigned to provide care for COVID-19 positive residents and confirmed nurses and CNAs provide care for COVID-19 positive and negative residents residing on the same halls throughout the facility. On [DATE] at 9:10 AM V19, LPN stated V19 often is the only nurse assigned to work dayshift and confirmed V19 provides care to both COVID-19 positive and negative residents. On [DATE] at 3:53 PM V18 stated the facility should have dedicated staff to care for COVID-19 positive residents and staff should not be caring for both negative and positive residents. On [DATE] at 11:33 AM V1 confirmed the facility does not have dedicated staff assigned to provide care for COVID-19 positive residents and stated the CNAs and nurses cross over to assist and provide care on all of the halls within the facility. 3. The facility's COVID-19 Control Measures policy revised [DATE] documents contact and droplet precaution signage will be posted on the resident's door. This policy documents for Droplet Precautions an N95/facemask, gloves, gown, and goggles/face shields (Personal Protective Equipment {PPE}) are worn when entering the resident's room, and PPE will be removed upon leaving the room. This policy documents to perform hand hygiene after contact with the resident, the resident's environment, or the resident's respiratory secretions. On [DATE] at 8:32 AM V15, Housekeeper, was cleaning R7's room (COVID-19 positive) while wearing gloves, gown, surgical mask over top of N95, and eye protection. There was no isolation signage posted on R7's door. V15 left R7's room and did not perform hand hygiene, remove V15's potentially contaminated gown and surgical mask, or disinfect V15's eye protection. V15 entered resident rooms located on the A Hall while still wearing the potentially contaminated gown, surgical mask, and eye protection worn in R7's room. On [DATE] at 8:55 AM V15 stated staff should be changing gowns, surgical masks, and gloves upon leaving isolation rooms otherwise the same gown, masks, and eye protection are worn in and out of resident rooms who are not on isolation. V15 stated R1, R2, and R3 were the only residents on isolation located on V15's assigned A Hall. On [DATE] at 9:33 AM V6 and V14 ,CNAs, were in R1's room providing care. There was a sign located on R1's door to report to the nurse prior to entering. V6 was wearing a gown, gloves, a cloth mask covering an N95 over top of another cloth mask, and eye protection. V14 was wearing a gown, gloves, surgical mask over an N95, and eye protection. V14 removed V14's gloves upon leaving R1's room and did not perform hand hygiene. V6 and V14 did not remove their potentially contaminated gowns, surgical or cloth masks, or disinfect eye protection. V6 carried clean linens against V6's potentially contaminated gown. V6 and V14 entered the D Hall while wearing the potentially contaminated masks, gowns, and eye protection worn in R1's room. On [DATE] at 12:18 PM V6 confirmed V6 did not change V6's cloth mask and gown, or disinfect V6's eye protection upon leaving R1's room. V6 stated all of the residents in the facility are being treated as presumed positive for COVID-19. V6 confirmed V6 carried clean linens against V6's potentially contaminated gown and stated V6 placed the (potentially contaminated) linens on the linen cart located on the D Hall. On [DATE] at 11:20 AM R7 was sitting in the dining room and was not wearing a mask. No staff were observed to encourage R7 to wear a mask or redirect R7 back to R7's room. On [DATE] at 9:55 AM R7 was not wearing a mask while sitting in a wheelchair near the nurse's station. V6 stated R7 refuses to wear a mask and R7 will not stay in R7's room. On [DATE] at 12:04 PM V5, CNA entered R37's room (COVID-19 positive) to deliver R37's meal tray wearing a surgical mask over an N95 mask, eye protection, gown and gloves. There was no isolation signage posted on R37's door. After prepping R37's meal tray V5 left R37's room without performing hand hygiene, and changing V5's potentially contaminated gown, or surgical mask. V5 did not disinfect V5's eye protection. V5 continued to serve resident meals on the C Hall while still wearing the potentially contaminated gown, eye protection, and surgical mask. On [DATE] at 12:30 PM V5 CNA entered R8's room (COVID-19 positive) to deliver R8's meal tray wearing a surgical mask over an N95 mask, eye protection, gown and gloves. V5 did not change V5's potentially contaminated gown and surgical mask, and did not disinfect V5's eye protection. On [DATE] at 12:35 PM V5 confirmed V5 did not change V5's gown or surgical mask and did not disinfect V5's eye protection. V5 stated V5 was not sure which residents were on isolation and COVID-19 positive. On [DATE] at 12:39 PM V16, Housekeeper left R5's room (COVID-19 positive) while wearing a gown, surgical mask over an N95 mask, and eye protection. V16 did not remove V16's potentially contaminated gown and surgical mask or disinfect V16's eye protection, and brought R5's oxygen cylinder to the oxygen storage room on A Hall. There was no isolation signage posted on R5's door. On [DATE] at 9:08 AM V16 stated isolation rooms are identified by having a sign posted on the resident's door. V16 stated gloves and gowns are to be changed upon leaving an isolation room. On [DATE] at 1:10 PM V14, CNA left R5's room wearing a gown, surgical mask, an N95 mask, and eye protection. On [DATE] at 1:20 PM V14 stated R5 was not on isolation and there were no isolation linen or waste containers in R5's room. V14 confirmed V14 had not changed V14's gown and surgical mask and did not disinfect V14's eye protection upon leaving R1's and R5's rooms. V14 stated V14 was not sure which residents were on isolation for COVID-19. V14 stated the facility does not always provide a supply of gowns, so the staff had been wearing one gown each shift to go in and out of all the resident rooms. On [DATE] at 8:15 AM V4, LPN stated V4 was instructed to wear a universal gown throughout the facility and was not instructed to change V4's gown between residents. On [DATE] at 9:10 AM V19, LPN stated around [DATE] V19 was instructed to wear a universal gown all day and to change the gown at the end of the shift since all residents were considered to be exposed and on isolation. On [DATE] at 10:50 AM V1 stated staff should wear a gown, gloves, eye protection (face shield/goggles), and a surgical mask over top of an N95 mask when entering a COVID-19 positive resident room. V1 stated gloves, gowns, and surgical masks should be changed upon leaving the room, and eye protection is disinfected at the end of each shift. On [DATE] at 3:18 PM V1 stated isolation rooms should have signage posted on the door and isolation bins for laundry and waste. V1 stated staff should encourage residents to wear a face covering and redirect them to their rooms. On [DATE] at 6:10 PM V2 DON stated since the facility is under quarantine V2 would expect staff to change PPE prior to entering COVID-19 negative rooms, and not upon leaving positive resident rooms. V2 stated residents who have tested positive for COVID-19 are placed on contact/droplet isolation precautions and isolation signage should be posted on the resident's door. 4. The facility's Cleaning and Transportation of Food Trays For Residents In Isolation policy dated [DATE] documents Dishes and/or food trays from any resident's room which are visibly contaminated by blood or body fluids should be placed in a clear plastic bag before returning to the dietary department or placing on the food cart for return. On [DATE] at 1:20 PM V5, V6, and V14 CNAs were collecting resident meal trays from A, C, and D halls. The meal trays containing used disposable utensils and dishes were removed from resident rooms and placed onto carts located in the hallways. There was no bag covering the meal trays or the carts, and the carts were then taken down the hallways to the kitchen. On [DATE] at 1:32 PM V13, Dishwasher disposed the used disposable utensils and dishes into the kitchen's waste container. On [DATE] at 3:18 PM V1 stated disposable dishes and utensils are to be thrown away prior to removing meal trays from an isolation room, and any dishes/utensils that are not disposable should be placed in a plastic bag and taken to the kitchen. 5. The facility's COVID-19 Control Measures policy revised [DATE] documents residents will be monitored for new onset of fever, cough, shortness of breath, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, and loss of taste and/or smell, and obtain vital signs and pulse oximetry two times daily. R1-R4's Medical Records do not document COVID-19 symptom monitoring, vital signs, and pulse oximetry were completed per facility policy. The facility's [DATE] Vital Signs logs provided by the facility do not consistently document R1-R4's vital signs and pulse oximetry were obtained twice daily. On [DATE] at 11:33 AM V1 stated COVID-19 symptom monitoring should be recorded in the nursing notes. V1 stated V1 had no additional vital signs and symptom monitoring to provide, and confirmed vital signs and symptom monitoring was not completed for R1-R4 per the facility's policy. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to move COVID-19 positive residents (R1-R4, R9-R30, and R40) away from COVID-19 negative/asymptomatic residents (R5-R8, and R31-R57), and failed to designate staff to care for residents testing positive for [MEDICAL CONDITION]. A total of 31 residents were unnecessarily exposed to COVID-19 and an additional 21 residents (R31-R44, R48, and R,[DATE]) subsequently tested positive for COVID-19 after being exposed to COVID-19 at the facility. R55 subsequently expired after testing positive for COVID-19. On [DATE] at 8:26 AM V1 was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On [DATE] at 11:00 AM V1 and V21 Social Services Director confirmed COVID-19 positive residents R57 and R48 were transferred to the designated COVID-19 unit on D Hall on [DATE]. 2.) On [DATE] at 11:34 AM V2 DON confirmed the facility had designated CNAs assigned to the COVID-19 unit beginning on ,[DATE] and designated nurses assigned to the COVID-19 unit as of [DATE]. 3.) On [DATE] at 1:40 PM V1 confirmed staff received training provided by V1, V2, and V22 Regional Director of Operations on COVID-19 Infection Control Measures, contact/droplet precautions, proper use of PPE, and cohorting COVID-19 positive and symptomatic residents on ,[DATE], ,[DATE], ,[DATE] and [DATE]. V1 and V2 received training provided by V21 on [DATE]. 4.) On [DATE] at 12:00 PM COVID-19 Reminders/Practices was posted at the time clock and nurse's stations. On [DATE] at 11:51 AM V1 confirmed staff were provided a copy of the COVID-19 Reminders/Practices at the in-services held on ,[DATE] and [DATE]. 5.) On [DATE] at 11:51 AM V1 stated V1 reviewed the facility's Abatement Plan with V20 Medical Director on the evening of [DATE]. 6.) On [DATE] at 11:34 AM V2 stated V2 has been conducting random COVID-19 symptom assessments for COVID-19 negative residents and assessments were completed on [DATE]. 7.) On [DATE] at 11:34 AM V2 stated on [DATE] V1 and V2 started reviewing staff and resident COVID-19 symptoms, transmission based precautions, and room changes at the facility's morning Quality Assurance meetings.

Based on interview and record review the facility failed monitor and provide physician ordered [MEDICAL TREATMENT] to residents with end stage [MEDICAL CONDITION]. This applies to two of five resident (R2 and R3) reviewed for [MEDICAL TREATMENT] treatment in a sample of eight. This resulted in R2 and R3 being hospitalized in intensive care for fluid overload. Finding include: 1. R2's Physicians Order Sheet (POS) dated 5/18/2016 documents a [DIAGNOSES REDACTED]. The POS also documents [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R2 is cognitively intact. On 6/7/16 at 1:30pm, R2 stated, I didn't refuse treatment but there was no nurse so I didn't get [MEDICAL TREATMENT] on 5/16/16. I was hospitalized for [REDACTED]. R2's progress note dated 5/16/2016 at 9:00 PM, documents R2 complained of shortness of breath, nebulizer treatment given as ordered with little relief. At 9:45PM, R2 was transferred to the local hospital via ambulance. There was no documentation of R2 not receiving [MEDICAL TREATMENT] or monitoring of R2's medical condition after [MEDICAL TREATMENT] not received on 5/16/2016 in R2's clinical record. R2's Early Termination of [MEDICAL TREATMENT] form dated 5/16/2016 is not signed by R2. The signature line is blank. R2's emergency room Documentation documents Vital signs: Blood Pressure-198/78, Pulse-78, and Respiratory Rate- 30. R2 states R2 is short of breath and has been since this morning, with shortness of breath worsening with movement. The onset of symptoms was sudden and constant this morning [MEDICATION NAME] all day with no alleviating or exacerbating factors. R2 also stated I did not receive my scheduled [MEDICAL TREATMENT] today. Critical Care: The high probability of sudden, clinically significant, or life threatening deterioration required my full and direct attention, intervention and personal management while R2 was critical. R2 was admitted to intensive care. R2's hospital History and Physical dated 5/16/2016 documents (R2) did not receive [MEDICAL TREATMENT] as scheduled on 5/16/2016. R2 subsequently began having significant shortness of breath. R2 was admitted to the intensive care unit with significant bilateral crackles (to lungs), [MEDICAL CONDITION] and possible Reactive Luekocytosis. R2 was dialyzed and three liters (3000 cubic centimeters) of fluid was removed. On 6/8/2016, Z1 (Nephrologist) stated R2 was admitted to the intensive care unit on 5/16/2016 for fluid overload due to not receiving [MEDICAL TREATMENT] on 5/16/2016. Z1 further stated I was not informed that (R2) had not received [MEDICAL TREATMENT] that day until (R2) arrived at the hospital. (R2) was dialyzed and 3 liters of fluid were removed at that time. If I had been notified I would have checked weight fluctuation since last [MEDICAL TREATMENT] day 5/13/2016, had electrolyte laboratory draw completed and asked about residents respiratory status. After laboratory results were back I would have had the facility transfer (R2) to the emergency room if laboratory result were significant and have arranged for (R2) to have [MEDICAL TREATMENT] elsewhere. Since I was not informed, none of the monitoring was completed and (R2) ended up in intensive Care (ICU). It was critical the facility inform me immediately of the missed [MEDICAL TREATMENT] for (R2) since that was three days in a row that (R2) was not dialyzed. (R2) typically receives [MEDICAL TREATMENT] five days a week Monday through Friday. (R2) would not have had the severe breathing difficulty or ended up in the hospital for three days if I had been informed. I should have been informed of (R2) not receiving [MEDICAL TREATMENT] on 5/16/2016 PERIOD! 2. R3 's Physicians Order Sheet dated 5/18/2016 documents a [DIAGNOSES REDACTED]. The POS also documents [REDACTED]. The MDS dated [DATE] documents R3 has a Brief Interview for Mental Status (BIM's) score of 11 out of 15 with deficits in temporal orientation and recall. On 6/7/16 at 12:40pm R3 stated, I never refused [MEDICAL TREATMENT]. They have me sign all kinds of stuff that I can't read because I can't see. R3's progress note dated 5/17/2016 at 2:00AM, documents R3 was complaining of shortness of breath with rapid respirations of 28. R3 was transported to the local hospital via ambulance at 2:20AM. There was no documentation of not receiving [MEDICAL TREATMENT] or monitoring of medical condition after refusal in R3's clinical record on 5/16/2016. R3's emergency room Physicians Documentation report dated 5/17/2016 documents the following: (R3) states that (R3) is short of breath. (R3) missed [MEDICAL TREATMENT] on Monday (5/16/2016) because there was no nurse that showed up at the [MEDICAL TREATMENT] center. This is the second patient I have had tonight like this requiring admission. Onset of symptoms sudden and progressive all day today since missing [MEDICAL TREATMENT]. factors. Critical Care: The high probability of sudden, clinically significant, or life threatening deterioration required my full and direct attention, intervention and personal management while (R3) was critical. (R3) was admitted to intensive care with condition serious. R3's hospital History and Physical dated 5/17/2016 documents The patient (R3) stated I did not receive my scheduled [MEDICAL TREATMENT] on 5/16/2016. The patient (R3) was placed on 15 liters of oxygen via non-rebreather mask to maintain saturations above 90%. The patient was admitted to the intensive care unit for continued management. (R3's) blood pressure was also noted to be significantly elevated with a systolic blood pressure greater than 200. On 6/8/2016 at 10:00AM, Z1 (Nephrologist) stated I was not informed that (R3) did not receive [MEDICAL TREATMENT] on 5/16/2016 until the 2:00AM admit to the hospital on [DATE]. (R3) was admitted to the intensive care unit with a [DIAGNOSES REDACTED]. Again I would have ordered laboratory tests, checked weight fluctuation and respiratory status. I would have had (R3) transferred to the emergency room and arranged for (R3) to be dialyzed. (R3) has never refused treatment before and is very aware of what will occur if (R3) does refuse. I was told the facility did not have a [MEDICAL TREATMENT] nurse that day so neither (R2 or R3) received [MEDICAL TREATMENT]. This again was an unnecessary hospitalization in (R3's) case [MEDICAL CONDITION] secondary to Fluid Overload. It is critical I am informed when a patient does not receive [MEDICAL TREATMENT] so this does not occur. (R3) would not have had the severe breathing difficulty/ fluid overload if I had been notified. On 6/8/2016 E2, (Director of Nursing) stated I schedule the [MEDICAL TREATMENT] staff for the facility. I give the Administrator (E1) the days no nurse is scheduled. (E1) then faxes the contractual [MEDICAL TREATMENT] company for a nurse to work if none available at the facility per our back up plan, somehow this fell through the cracks and the contractual [MEDICAL TREATMENT] company was not notified until the morning of 5/16/2016. The contractual [MEDICAL TREATMENT] nurse (Z2) was at the facility at 9:00AM to train new staff for [MEDICAL TREATMENT]. (Z2) was told to run the [MEDICAL TREATMENT] unit as the nurse on 5/16/2016 by contractual [MEDICAL TREATMENT] company at 11:00 AM. On 6/7/2016 at 11:00AM, Z2 stated When I got to the facility on [DATE] I was told (R2, R3 and R4) all refused their [MEDICAL TREATMENT] treatments before I arrived. I told the facility staff the Early Termination of [MEDICAL TREATMENT] Against Medical Advice form must be signed by those patients per protocol. I did not talk to (R2, R3, or R4) myself. I did not call the doctor or case manager that day to inform them that (R2, R3 and R4) refused [MEDICAL TREATMENT], since (R2, R3 and R4) all refused before I arrived. The facility should have notified the contractual [MEDICAL TREATMENT] Case Manager as per [MEDICAL TREATMENT] protocol. On 6/8/2016 at 8:35AM, Z3 (Contractual [MEDICAL TREATMENT] Nurse Case Manager) stated I am to be notified any time a [MEDICAL TREATMENT] patient refused treatment, has a systolic blood pressure of less than 90, or if a patient has any issues in [MEDICAL TREATMENT]. I then notify the patient nephrologist of the given information and receive any new orders which are then faxed to the facility. I was not informed that anyone refused [MEDICAL TREATMENT] on 5/16/2016, therefore the nephrologist was not notified. I learned of (R2 and R3) not receiving [MEDICAL TREATMENT] on 5/16/2016 a couple of days later (5/18/2016). The facility [MEDICAL TREATMENT] policy Adverse Occurrence Reporting dated 2015 documents the case manager is to be promptly notified of any unexpected event that is inconsistent with the routine operation.

Based on interview and record review the facility failed to notify the physician of residents [MEDICAL TREATMENT] status for two of five residents (R2 and R3) reviewed for [MEDICAL TREATMENT] in a sample of eight. This resulted in R2 and R3 being admitted to the intensive care unit with fluid overload. Findings include: 1. R2's Physicians Order Sheet (POS) dated 5/18/2016 documents a [DIAGNOSES REDACTED]. The POS also documents [REDACTED]. R2's progress note dated 5/16/2016 at 9:00 PM, documents R2 complained of shortness of breath, nebulizer treatment given as ordered with little relief. At 9:45PM, R2 was transferred to the local hospital via ambulance. No other documented notes present in R2's medical record for 5/16/2016. R2's Early Termination of [MEDICAL TREATMENT] form dated 5/16/2016 is not signed by R2. The signature line is blank. On 6/8/2016, Z1 (Nephrologist) stated R2 was admitted to the intensive care unit on 5/16/2016 for fluid overload due to not receiving [MEDICAL TREATMENT] on 5/16/2016. Z1 further stated I was not informed that R2 had not received [MEDICAL TREATMENT] that day until (R2) arrived at the hospital. (R2) was dialyzed and 3 liters of fluid were removed at that time. If I had been notified I would have checked weight fluctuation since last [MEDICAL TREATMENT] day 5/13/2016, had electrolyte laboratory draw completed and asked about residents respiratory status. After laboratory results were back I would have had the facility transfer (R2) to the emergency room if laboratory result were significant and have arranged for (R2) to have [MEDICAL TREATMENT] elsewhere. Since I was not informed, none of the monitoring was completed and (R2) ended up in intensive Care (ICU). It was critical the facility inform me immediately of the missed [MEDICAL TREATMENT] for (R2) since that was three days in a row that (R2) was not dialyzed. (R2) typically receives [MEDICAL TREATMENT] five days a week Monday through Friday. (R2) would not have had the severe breathing difficulty or ended up in the hospital for three days if I had been informed. I should have been informed of (R2) not receiving [MEDICAL TREATMENT] on 5/16/2016 PERIOD! 2. R3 's Physicians Order Sheet dated 5/18/2016 documents a [DIAGNOSES REDACTED]. The POS also documents [REDACTED]. R3's progress note dated 5/17/2016 at 2:00AM, documents R3 was complaining of shortness of breath with rapid respirations of 28. R3 was transported to the local hospital via ambulance at 2:20AM. No other progress noted document in the clinical record for R3 on 5/16/2016. On 6/8/2016 at 10:00AM, Z1 (Nephrologist) stated I was not informed that (R3) did not receive [MEDICAL TREATMENT] on 5/16/2016 until the 2:00AM admit to the hospital on [DATE]. (R3) was admitted to the intensive care unit with a [DIAGNOSES REDACTED]. Again I would have ordered laboratory tests, checked weight fluctuation and respiratory status. I would have had (R3) transferred to the emergency room and arranged for (R3) to be dialyzed. (R3) has never refused treatment before and is very aware of what will occur if (R3) does refuse. I was told the facility did not have a [MEDICAL TREATMENT] nurse that day so neither (R2 or R3) received [MEDICAL TREATMENT]. This again was an unnecessary hospitalization in (R3's) case [MEDICAL CONDITION] secondary to Fluid Overload. It is critical I am informed when a patient does not receive [MEDICAL TREATMENT] so this does not occur.(R3) ended up in intensive Care (ICU). It was critical the facility inform me immediately of the missed [MEDICAL TREATMENT] for (R3) since that was three days in a row that (R3) was not dialyzed. (R3) typically receives [MEDICAL TREATMENT] five days a week Monday through Friday. (R3) would not have had the severe breathing difficulty/ fluid overload if I had been notified. On 6/8/2016 at 8:35AM, Z3 (Contractual [MEDICAL TREATMENT] Nurse Case Manager) stated I am to be notified any time a [MEDICAL TREATMENT] patient refused treatment, has a systolic blood pressure of less than 90, or if a patient has any issues in [MEDICAL TREATMENT]. I then notify the patient nephrologist of the given information and receive any new orders which are then faxed to the facility. I was not informed that anyone refused [MEDICAL TREATMENT] on 5/16/2016, therefore the nephrologist was not notified. I learned of (R2 and R3) not receiving [MEDICAL TREATMENT] on 5/16/2016 a couple of days later (5/18/2016). The facility [MEDICAL TREATMENT] policy Adverse Occurrence Reporting dated 2015 documents the case manager is to be promptly notified of any unexpected event that is inconsistent with the routine operation.

Based on interview and record review the facility failed to apply an assistance device to prevent an accident for R6 by failing to ensure a bed exit alarm was in place as ordered for one of three residents (R6) reviewed for falls in the sample of seven. This failure resulted in R6 falling and sustaining a dislocated shoulder and fractured hip that required surgery. Findings include: The Minimum (MDS) data set [DATE] documents that R6 is severely cognitively impaired and requires extensive assistance with transfers and activities of daily living. The physician's orders [REDACTED]. E6's (Licensed Practical Nurse) Nurses Note dated 5/1/15 documents This nurse summoned to resident room, resident observed on floor next to wheel chair.resident unable to state what happened.no signs or symptoms of pain. The left shoulder X-Ray report dated 5/3/15 documents (R6) anterior shoulder dislocation. The right hip X-ray dated 5/4/15 documents (R6) acute complete mildly angulated and displaced subcapital hip fracture. The Final Five Day Report dated 5/8/15 documents (R6) obtained a dislocated shoulder and hip fracture from her fall on 5/1/15. The Hospital Discharge Summary documents that R6 was admitted to the hospital on [DATE] and a right hip hemiarthroplasty (surgery) was performed. The Discharge Summary documents no treatment was required for R6's dislocated shoulder. On 5/21/15 at 11:40 AM E13 Certified Nurses Aide (CNA) stated that on 5/1/15 at 11:00 AM she transferred R6 to her bed, placed the wheel chair at the end of R6's bed and then went to lunch. E13 stated when she returned from her lunch break at 11:30 AM R6's room door was closed and when she tried to open the door R6 was laying on the floor next to the wheelchair directly behind the door and she then called E6 to R6's room. On 5/21/15 at 10:40 AM E6 stated she found R6 laying on her left side behind the door. At that time E6 stated that R6 did not have an exit alarm on her bed when she fell and she should have had one on her bed. On 5/21/15 at 12:00 PM E2 Director of Nurses stated that R6 was in the bed furthest from the door and traveled approximately 15 to 20 feet before she fell . At that time E2 stated that the CNA who transferred R6 to her bed prior to the fall did not notice that the exit alarm was not in place on R6's bed. E2 stated that R6's injuries of a dislocated left shoulder and fractured right hip were investigated as injuries of unknown origin and determined to be the result of the 5/1/15 fall.

Based on interview and record review the facility neglected to follow their smoking policy regarding supervising smoking for 7 of 7 residents (R 1, 2, 3, 4, 5, 10 and 11) in the sample of 11. This neglect resulted in second [MEDICAL CONDITION] the left and right side of R2's face while being left unsupervised while smoking and using oxygen. These failures resulted in an Immediate Jeopardy situation for R2. While the immediacy was removed on 01/05/15, the facility remains out of compliance at a severity level two. Additional time is needed for the facility to implement new policies and monitor the effectiveness of staff training and quality assurance on existing policies. Findings include: The Smoking Policy which is not dated states "It is the policy of (the facility) smoking is only permitted outside the facility according to the following guidelines. There will be no smoking inside the facility by either residents on (sic) staff. Guidelines: 1. Smoking will be permitted by residents and staff in an approved outside location, 2. Residents must always be accompanied by a staff member to smoke and may not keep his/her own smoking materials. 3. Outside area must be at least 15' from any entrance. 4. Metal ashtrays shall be provided in smoking area..." R2's Nurse's Notes dated 01/04/2015 at 04:30 PM documents, "Resident brought to the nurses station. Res. (resident) had face charred from being outside smoking with O2 (oxygen) on her face. Hair slightly singed on/above L (left) ear. 0 (no) blisters observed at this time. Black char to upper lip, nares, L (left) side of face & temple. Cool cloth applied. Ambulance summoned. Report phoned to ...ER (emergency room ) (local hospital)." On 01/13/2015 at 10:55 AM E4, Licensed Practical Nurse, stated, "I was working that night. It was around 04:30 PM. The girls pushed her (R2) up to the desk right after it happened. She (R2) told me she (R2) was putting the cigarette out when it (fire) started. She (R2) admitted having the oxygen on. I (E4) sent her (R2) out as soon as I could." R2's local hospital notes dated 01/04/2015 at 1709 (05:09 PM) document "Triage Note/History: Pt (patient) to ER for facial burn. States was smoking with oxygen on and burnt rt (right) and lt (left) side of face. No difficulty breathing, pulse ox (oxygen concentration) 98% on room air." On 01/12/2015 at 10:05 AM, (during the hospitalization from injuries sustained during a fall on 01/10/2015), R2 stated "I (R2) was coming from the dining room. It was around 04:30 PM. I (R2) was the third or fourth one out to smoke. I (R2) don't remember who pushed me out but I went out right in front of my room mate. There were no staff outside as we smoked our cigarettes. I (R2) used to light my own cigarettes and did that day as well. As I (R2) took the last drag of the cigarette and pulled it away from my face, the tubing and everything went up in a blaze. I (R2) tried to pull the oxygen tubing off my face but it took two tries to get it off. My room mate started to scream for help and then she (room mate) rubbed some snow on my skin to help cool it down.." On 01/12/2015 at 01:30 PM, R1 stated "I (R1) was sitting right next to her (R2) when this all happened. I (R1) can't tell you who was responsible for taking her (R2) outside and leaving the oxygen on her (R2)...I don't remember who helped her (R2) out. I did tell her (R2) "You've got your your oxygen on, don't light that cigarette! She (R2) lit it anyway, then burst into flames. I (R1) don't know...maybe she (R2) didn't hear me (R1). I (R1) screamed for help then grabbed handfuls of snow to try to help her (R2)...try to stop the burning." On January 11, 12 and 13, 2015 between 09:00 AM and 04:00 PM, Residents 1, 2, 3, 4, 5, 10 and 11 stated that before the incident on January 4th, they could smoke at their lesuire. All cigarettes, lighters, loose tobacco and rolling papers were kept in their rooms and when they wanted they would go out for a smoke or two. These residents all agreed that staff would not be present. On 01/13/2015 at 01:05 PM, E17, Medical Director, stated "These residents have minds of their own, doing things that they (residents) shouldn't. We (staff) advise them not to smoke...but they (residents)still do. Unfortunately that day smoking with the oxygen on happened and the resident was burned. It was an isolated incident and we're not sure how it (the oxygen on the patio) got by the staff. Safe guards are in place now. She (R2) was attended to by the Wound Doctor from the emergency room and is being monitored closely." The wound assessment dated [DATE] documents, "[MEDICAL CONDITION] degree. Color/consistency: pink/yellow Adherent. Wound edges: Attached, well defined. Exposed bone: No. Exposed Tendon: No. Exposed Muscle: No. Exudate: Serous. Amount: Moderate. Odor: absent." On 01/11/2015 at 10:30 AM, E1, Administrator, stated, "Our staff know to be outside, monitoring and keeping the residents safe during smoke break. No staff were out on the patio with them when this happened." On 01/12/15 at 03:30 PM an Immediate Jeopardy was identified. The Immediate Jeopardy situation began on 01/04/2015 at 04:30 PM when R2 who was using medical oxygen, went to the patio to smoke, unsupervised by staff. E1, Administrator, was notified of the Immediate Jeopardy on 01/12/2015 at 03:35 PM. It was confirmed through interview and record review that the facility took the following actions to remove the immediacy: On 01/05/2015- The facility staff were in-serviced on safe smoking precautions by the Administrator and the Director of Nursing. On 01/04/2015 the facility staff were in-serviced on residents not smoking with oxygen on by the Director of Nursing. The facility staff were in-serviced on the Aim for Wellness Program by the Director of Nursing on 01/05/2015. Smoking Assessments and care plans were updated on all residents who smoke on 1/05/15. Scheduled smoking program was initiated with staff supervision on 1/05/15. All smoking materials are to be kept in the medication room and dispersed by a nurse on 1/05/15. Residents that smoke were educated on safe smoking precautions on 1/05/15. All resident rooms were searched and smoking materials were removed on 1/05/15. The code to the patio door was changed and the button to disable the alarm at the nurse's station was disabled on 1/05/15. Smoking aprons were ordered 01/06/2015. As part of the facility's ongoing quality improvement program, the following measures will be taken to ensure the practice does not recur: ~ IDT to conduct random round to ensure residents and staff are following the assigned smoking times. ~IDT to conduct random rounds to ensure the residents and staff are [MEDICATION NAME] safe smoking practices and not smoking with oxygen in place. ~Administrator or designee will educate new staff members and new residents on the assigned smoking schedule. ~Administrator or designee will in-service staff on safe smoking precautions monthly for six months. ~ Administrator or designee will in-service staff on residents not smoking with oxygen on monthly for six months. ~ Administrator or designee will in-service staff on the AIMS for Wellness program monthly for six months. ~Administrator and/or Director of Nursing will conduct random chart audits to ensue the smoking assessments are completed upon admission, quarterly and as needed for the residents who smoke.

Based on observation, interviews and record review, the facility failed to provide adequate supervision and monitoring of cigarette smoking for one (R2) of 11 residents reviewed for smoking practices while using oxygen. This failure resulted in second degree facial burns from R2's use of tobacco through inhalation, while having been administered medical oxygen therapy by nasal canula, resulting in the oxygen tubing igniting and catching fire. As a result, R2 was hospitalized with second degree burns to the face. These failures resulted in an Immediate Jeopardy situation for R2. While the immediacy was removed on 01/05/15, the facility remains out of compliance at a severity level two. Additional time is needed for the facility to implement new policies and monitor the effectiveness of staff training and quality assurance on existing policies. Findings include: The Smoking Policy which is not dated states "It is the policy of (the facility) smoking is only permitted outside the facility according to the following guidelines. There will be no smoking inside the facility by either residents on (sic) staff. Guidelines: 1. Smoking will be permitted by residents and staff in an approved outside location, 2. Residents must always be accompanied by a staff member to smoke and may not keep his/her own smoking materials. 3. Outside area must be at least 15' from any entrance. 4. Metal ashtrays shall be provided in smoking area..." R2's Nurse's Notes dated 01/04/2015 at 04:30 PM documents, "Resident brought to the nurses station. Res. (resident) had face charred from being outside smoking with O2 (oxygen) on her face. Hair slightly singed on/above L (left) ear. 0 (no) blisters observed at this time. Black char to upper lip, nares, L (left) side of face & temple. Cool cloth applied. Ambulance summoned. Report phoned to ...ER (emergency room ) (local hospital)." On 01/13/2015 at 10:55 AM, E4, Licensed Practical Nurse stated "I (E4) was working that night. It was around 04:30 PM. The girls pushed her (R2) up to the desk right after it happened. She (R2) told me (E4) she (R2) was putting the cigarette out when it (fire) started. She (R2) admitted having the oxygen on. I (E4) sent her (R2) out as soon as I could." R2's local hospital notes dated 01/04/2015 at 1709 (05:09 PM) document "Triage Note/History: Pt (patient) to ER for facial burn. States was smoking with oxygen on and burnt rt (right) and lt (left) side of face. No difficulty breathing, pulse ox (oxygen concentration) 98% on room air." On 01/12/2015 at 10:05 AM, (during the hospitalization from injuries sustained during a fall on 01/10/2015), R2 stated, "I (R2) was coming from the dining room. It was around 04:30 PM. I (R2) was the third or fourth one out to smoke. I (R2) don't remember who pushed me (R2) out but I (R2) went out right in front of my room mate. There were no staff outside as we (residents) smoked our cigarettes. I (R2) used to light my own cigarettes and did that day as well. As I (R2) took the last drag of the cigarette and pulled it away from my face, the tubing and everything went up in a blaze. I (R2) tried to pull the oxygen tubing off my face but it took two tries to get it off. My room mate started to scream for help and then she (room mate)rubbed some snow on my skin to help cool it down.." On 1/12/15 at 10:05 AM, while R2 was in the local hospital, R2's facial burn wounds were pinkish-yellow in color, well approximated, with no drainage or odor. On 01/12/2015 at 01:30 PM, R1 stated "I (R1)was sitting right next to her (R2) when this all happened. I (R1) can't tell you who was responsible for taking her (R2) outside and leaving the oxygen on her (R2)...I don't remember who helped her (R2) out. I (R1) did tell her (R2) "You've got your your oxygen on, don't light that cigarette! She (R2) lit it anyway, then burst into flames. I (R1) don't know...maybe she (R2) didn't hear me. I (R1) screamed for help, then grabbed handfuls of snow to try to help her (R2)...try to stop the burning." On 01/12/2015 at 02:46 PM E5, Laundry Aide stated "I (E5) was coming down the hallway pushing (R1) out to smoke. I (E5) held the door open for E6, Certified Nursing Assistant (CNA), who was pushing (E2) outside to smoke. We (E5 and E6) pushed them out and came back in together." Multiple attempts were made to contact E6, CNA, without success. The facility's investigation dated 01/05/2015 conducted for R2's burns sustained while smoking on the patio records E6's statement. This hand written/signed statement is dated 01/04/2015 at 04:30 PM and records "I (E6) had gone into (R1 & R2's) room because their call light was on. (R1) wanted to get up so she (R1) could go outside. After I (E6) got (R1) up, (R2) wanted ice in her (R2's) cup. I (E6) got her (R2) ice and gave her (R2) the cup. I (E6) then went down to (another resident's) room because the bathroom light was on. Until I (E6) had gone on my lunch break at 04:30 PM, I (E6) had not seen (R2) until she (R2) was at the nurses station." On 01/12/2015, E6's personnel file showed no disqualifying events or past disciplinary actions for similar infractions. E6's personnel file included a Notice of Termination dated 01/06/2015 at 01:30 PM. It listed under the Reasoning section: "Employee verbally gave DON (Director of Nursing) notice that she (E6) is quitting effective 01/06/2015 at 01:30 PM." It listed under the "Notes" section: "Employee is terminated 01/06/2015 at 01:30 PM." On 01/13/2015 at 01:05 PM, E17, Medical Director stated, "These residents have minds of their own doing things that they shouldn't. We (Staff) advise them not to smoke...but they (residents) still do. Unfortunately that day, smoking with the oxygen on happened and the resident was burned. It was an isolated incident and we're not sure how it (the oxygen on the patio) got by the staff. Safe guards are in place now. She (R2) was attended to by the Wound Doctor from the emergency room and is being monitored closely." The wound assessment dated [DATE] documents "Facial burns second degree. Color/consistency: pink/yellow Adherent. Wound edges: Attached, well defined. Exposed bone: No. Exposed Tendon: No. Exposed Muscle: No. Exudate: Serous. Amount: Moderate. Odor: absent. On January 11, 12 and 13, 2015 between 09:00 AM and 04:00 PM, Residents 1, 2, 3, 4, 5, 10 and 11 stated that before the incident on January 4th, they could smoke at their lesuire. All cigarettes, lighters, loose tobacco and rolling papers were kept in their rooms and when they wanted they would go out for a smoke or two. These residents all agreed that staff would not be present. On 01/11/2015 at 10:30 AM E1, Administrator stated "Our staff know to be outside, monitoring and keeping the residents safe during smoke break. No staff were out on the patio with them when this happened." On 01/12/15 at 03:30 PM an Immediate Jeopardy was identified. The Immediate Jeopardy situation began on 01/04/2015 at 04:30 PM when R2 who was using medical oxygen, went to the patio to smoke, unsupervised by staff. E1, Administrator, was notified of the Immediate Jeopardy on 01/12/2015 at 03:35 PM. It was confirmed through interview and record review that the facility took the following actions to remove the immediacy: On 01/05/2015- The facility staff were in-serviced on safe smoking precautions by the Administrator and the Director of Nursing. On 01/04/2015 the facility staff were in-serviced on residents not smoking with oxygen on by the Director of Nursing. The facility staff were in-serviced on the AIMS for Wellness Program by the Director of Nursing on 01/05/2015. Smoking Assessments and care plans were updated on all residents who smoke on 01/05/2015. Scheduled smoking program was initiated with staff supervision on 01/05/2015. All smoking materials are to be kept in the medication room and dispersed by a nurse on 01/05/2015. Residents that smoke were educated on safe smoking precautions on 01/05/2015. All resident rooms were searched and smoking materials were removed on 01/05/2015. The code to the patio door was changed and the button to disable the alarm at the nurse's station was disabled on 01/05/2015. Smoking aprons were ordered 01/06/2015 and have yet to arrive. As part of the facility's ongoing quality improvement program, the following measures will be taken to ensure the practice does not recur: ~ IDT to conduct random round to ensure residents and staff are following the assigned smoking times. ~IDT to conduct random rounds to ensure the residents and staff are practicing safe smoking practices and not smoking with oxygen in place. ~Administrator or designee will educate new staff members and new residents on the assigned smoking schedule. ~Administrator or designee will in-service staff on safe smoking precautions monthly for six months. ~ Administrator or designee will in-service staff on residents not smoking with oxygen on monthly for six months. ~ Administrator or designee will in-service staff on the AIMS for Wellness program monthly for six months. ~Administrator and/or Director of Nursing will conduct random chart audits to ensue the smoking assessments are completed upon admission, quarterly and as needed for the residents who smoke.

Based on interview and record review the facility failed to implement fall prevention interventions for one of three residents (R3) reviewed for falls, in a sample of three. This failure resulted in R3 rolling out of bed, and falling to the floor, resulting in a Frontal Head Laceration and a Subarachnoid Hemorrhage. Findings include: 1. The physician's orders [REDACTED]. The assessment states that R3 requires extensive assist with eating, bed mobility, is incontinent of bowel and bladder and has a history of falls. The Care Plan dated 12/8/11 identifies the following interventions for R3: "Alarm device to bed and chair (pressure alarm) to alert staff when (R3) is attempting self transfer..." ; "High/Low electric bed to be positioned closer to floor level when (R3's) in it (with mat to floor on Lt(left) side of bed)" and "May have (laptop cushion) device to w/c (wheelchair) when up for safety purposes..." The Nurse's Notes dated 1/5/12 at 3:00am states R3 was found on her hands and knees on the floor on the right side of the bed. E2, Director of Nurses (DON) stated on 3/21/12 at 10:15am that R3's bed position was changed after she rolled out of bed. E2 stated before the fall, R3's floor mat was on the left side of the bed, but after the fall was moved to the right side. E2 stated R3's bed was moved next to the wall (left side) and the floor mat placed on the right side of R3's bed. The Nurse's Notes dated 3/3/12 at 4:25pm state, "...(R3) lying on floor next to her bed on her left side. Approx (approximate) 3 1/2 cm(centimeter) gaping laceration on Rt.(right) side of scalp-temporal region....transport to ER...." The History and Physical dated 3/3/12 states that R3 has a [DIAGNOSES REDACTED]." E7, CNA, stated on 3/20/12 at 3:35pm that he and E4, CNA, put R3 to bed to change her as she had been incontinent. E7 stated they changed R3 and both left the room, leaving R3 in bed. E7 stated at that time R3 was lying on her side facing the wall, the bed was in low position and the floor mat was in place. E7 stated he came back into the room without E4 and started to get R3 ready to get up. E7 stated he moved the floor mat from the side of the bed, and put it between the dresser and wall. E7 stated he then walked over to the door of the room, looked out, and when he turned around, R3 was on the floor with blood under her head. When asked what position the bed was in, E7 stated, "low position." When asked if he was sure the bed was in low position as the written statements by E6, RN and E8, LPN (Licensed Practical Nurse), both stated the bed was in the regular position, not low, E7 stated, "I thought the bed was in low position, but evidently it was raised, it was up." E7 stated that R3 does roll around in bed by herself and thought she had rolled out of bed once before while residing on a different hall. E6, RN(Registered Nurse) stated on 3/21/12 at 10:30am that she was walking down the hall on 3/3/12 when she heard E7 call for help and was first in the room. E6 stated when she got into R3's room, R3 was lying on the floor with a lot of blood around her head. E6 stated R3's bed was in "an elevated position, normal bed height, but it is supposed to be a low bed." E6 stated staff had raised the bed in preparation for getting R3 up and the floor mat was not on the floor. E6 stated, "It looked like a raised bed and she (R3) rolled out of bed." E8, LPN, stated on 3/21/12 at 10:00am that E7 came and got her and when she went into R3's room E6 was applying pressure to the laceration on R3's head. E8 stated there was a pool of blood on the floor. E8 stated R3's bed "was not in low position." E8 stated the bed was "about 3 feet off the floor." E8 stated, "(E7) said (R3) rolled out of bed, the other CNA (E4) left and (E7) went to the door to see, (R3) turned (herself) and was on the floor." E8 stated that R3 was able to "roll herself around in bed." The undated "Conclusion" states, "It is our conclusion that while the CNA (E7) is at fault for removing the floor mat, raising the resident's (R3) bed, and stepping away from the bed, this is not the cause of the resident's fall. The shifting of the air within the mattress is the direct cause of (R3's) fall...." E2 stated on 3/20/12 at 3:05am R3 was on an air mattress at the time of the fall. E2 stated he re-enacted the incident and while he was laying on the air mattress, when he rolled to the side, the air mattress, "held me for a minute, then I felt the mattress push me out of the bed." E2 stated, "Staff (E7) made the mistake of pulling the (floor) mat away, bed was up and (E7) stepped away." 2. The Nurse's Notes dated 1/26/12 at 6:00am state, "(R3) fell forward out of w/c, struck L(left) forehead, received 4 (inch) bump with blue bruising; 2 superficial tears to bridge of nose....." The Quality Care Reporting Form dated 1/26/12 states, "fell out of w/c, recommend inservice for staff to ensure (laptop cushion) is in place when (R3) is up in w/c." E5, CNA(Certified Nurse Aide), stated on 3/21/12 at 11:10am that she heard R3 hit the floor as she came around the corner of the hall. E5 stated the laptop cushion was not on R3 when she found her. E2 stated on 3/21/12 at 10:15am that the laptop cushion was not put in place when staff got R3 up in the wheelchair that morning(1/26). 3. The Nurse's Notes dated 2/17/12 at 6:00am state, "(R3).....on floor, laying on left side next to w/c....Laceration observed to left cheek and nose.......transfer to ....ER(emergency room ) for eval (evaluation)." The Quality Care Reporting Form dated 2/17/12 states, "fell out of w/c. Recommend staff inservice to place (laptop cushion) correctly." E2 stated on 3/21/12 at 10:15am that staff placed the laptop cushion on R3's wheelchair "backwards." E2 stated because of how the laptop cushion is shaped when it is hooked to the arm of the wheelchair backward, there is then room for R3 to "maneuver and (R3) slid under the (laptop cushion)", landing on the floor.