Every finding on record at Archer Heights Healthcare

Based on interviews and record reviews, the facility failed to follow policy and procedure to ensure one [R1] of four [R3, R4, R7] residents were dressed and ready for medical appointments. Findings include,R1's clinical record indicates the following in part: R1 is a sixty-five-year-old, admitted with the following medical diagnosis cerebral infarction affecting left side, type II diabetes, iron deficiency, essential hypertension, heart failure, chronic kidney disease, urinary incontinence, and localized edema. Reviewed R1's face sheets, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status score [12], care plans, medication administration record, treatment administration record, and progress notes were reviewed. Reviewed facility's appointment calendar: Noted the following in part.7/6/26 R1has appointment an eye physician at 11:00AM, Transportation pick-up between 9:40AM to 10:10AM. Appointment was missed and rescheduled for 7/17/26at 1:50PM. 6/24/26 R1 had an appointment with eye physician at 11:25AM. [R1 went to appointment] R1 physician documented 6/24/26, document in part:Diagnosis with proliferative diabetic retinopathy in both eyes, damage to the retina. Noted bleeding in front of the retina hemorrhages in both eyes. Age related cataracts in both eyes and hypertensive retinopathy in both eyes.Plan: Fluorescein angiography on the next visit. Close follow up with the eye doctor is needed. Good control of diabetes and blood pressure.Mild damage from diabetes is already present and follow up is needed. R1's Care plan indicates the following in part:R1 has a self care deficit with ADL's and mobility, R1 requires touch assistance provided throughout the activity. During the survey dates of 7/14/26 to 7/16/26, nursing staff observed on all nursing floors answering call lights and providing care. On 7/14/26, at 11:05AM, R1 stated, One evening the nurse did not give me my pain medication on time. I had to wait four hours. I do not remember what day this happened nor who the nurse was. I did get my pain medication. On 7/6/26, my nurse assistant answered my call light but did not help me get dressed for my appointment on time. On 7/6/26, at 7:30AM, I told V26 [Certified Nurse Assistant] that I had an important medical appointment for my eyes at 11AM and my transportation would pick me up at 9:45AM and needed to up and dressed, V26 said okay but left out the room. I told her about my appointment again at 9AM. I called V27 [R1's Family Member] and told her I was not up and dressed and my transportation would be there. V27 called the facility, then a few minutes later V26 started to dress me. After I was dressed, I learned the transportation car had left me because I was not dressed on time. My last eye appointment on 6/24/26, the doctor told me I have bleeding behind my eyes and need more testing and eye injections. I do not want to go blind. The facility knew about my eye appointment, and I should have been ready when transportation got here. On 7/15/26 at 12:57 PM, V27 [R1's Family Member] stated, R1 is a diabetic. On R1's last eye appointment in June, the physician said R1 has bleeding behind her eye and needed several injections in each eye along with further testing. The facility knew about R1's appointment since June. R1 kept telling the nursing staff she had a eye appointment and needed to get up and dress. It was not until I called, they got her dressed, but it was too late, transportation left and her medical appointment was canceled. The appointment was rescheduled for 7/17/26. This can never happen again, I don't want R1 to go blind. On 7/14/26 at 11:15 AM V3 [Medical Record] stated, I been responsible to schedule resident appointments. Then the appointments are placed in the facility's calendar. V5 [Central Supply/Transportation] schedules the transportation services. On 7/14/26 at 12:30PM, V5 [Central Supply/Transportation] stated, I been responsible for transportation since 2/9/26. I looked on the facility calendar for appointment. I set up transportation through the residents' insurance. When I receive all the information, I will place it on the calendar. I make the envelopes include the resident face sheets, physician order, appointment information, address, and pick up times. Then I place the envelopes in a box at each nursing station. R1 transportation was set up. From my understanding, transportation arrived on time, R1 was not dressed, by the time she got ready, the transportation had to leave to get other residents on time to their appointments. On 7/14/26 at 1:07PM, V6 [Staffing Coordinator] stated, For residents' appointments I schedule the escorts. The escorts come about an hour earlier to ensure the residents are ready for their appointment and escort them to and from appointment. R1 had an appointment on 7/6/26, the escort called me and said R1 was not dressed and by the time they got downstairs, transportation had left. V27 [R1's Family Member] was upset, I promised V27 I will make sure R1 is dressed for her appointments. On 7/15/26 at 1:55PM, V7 [Licensed Practical Nurse] state, I was R1's nurse on 7/6/26. I knew she had an eye appointment, and I made sure V26 [Certified Nurse Assistant] was made aware of the appointment and picked up time. Unfortunately, R1 was not ready for her eye appointment. By time we got her dressed, transportation had left. R1's eye appointment was rescheduled for the next day 7/7/26, but they called back and changed the date to 7/17/26. On 7/16/26 at 2:36PM V22 [Receptionist] stated, I escorted R1 to her 6/24/26 appointment. The eye physician said R1 had bleeding behind the eyes and needed eye injections. I was the receptionist on 7/6/26, when V27 [R1's Family Member] called and said R1 called her because she was not dressed for her appointment. I went upstairs to her floor and told V7. By the time the nursing staff got R1 dressed the transportation driver left. On 7/16/26, at 3:28PM, V2 [Director of Nursing] stated, R1 missed her eye appointment on 7/6/26. My expectation for appointments is for the nurse to ensure certified nurse assistant has the resident up and dressed for the appointment.I have not received any concerns regarding call light response or medication being administered timely. Policy documented in part:Resident Handbook: Physician Appointments If you require consultation from an outside physician or specialist, these appointments will be arranged by your attending physician and the facility staff. Transportation for Residents dated 6/23:The facility will maintain a current list of transportation arrangements and services in order to promptly transfer residents.Designated personnel shall assist residents in obtaining transportation. Resident Escort Job Description:Main Duties: Assist residents in preparing for appointments [e.g, ensuring proper clothing, etc.]Certified Nursing Assistant:Carry out assignments for residents care including bathing, dressing

Based on observation, interview, and record review, the facility failed to ensure a comfortable environment by not maintaining resident room temperatures within the CMS (Centers for Medicare and Medicaid Services) required comfort range of 71 F (degrees Fahrenheit) to 81 F. This failure affected three (R4, R5, R6) of six residents reviewed for physical environment.Findings Include:On 7/5/26 between 9:55 AM and 10:37 AM, random temperature checks were conducted with V4 (Maintenance Director) in resident common areas and in randomly selected rooms across the first through fourth floors. All temperature readings were below 80 F except for R4's room, which measured 83.7 F. R4 was present in her room and was alert and oriented to person, place, and time. R4 was up and about with no observable signs or symptoms of feeling overheated or dehydrated. R4 reported feeling hot in her room and estimated the temperature to be above 80 F. R4 stated that she sleeps with no clothes on due to the heat and confirmed that she remains hydrated daily with staff regularly providing water. R4 also reported opening her window to allow a breeze to enter; her window was observed open. R4 stated she likes to let air come in. V4 stated that residents are continuously educated not to open windows during hot weather to prevent warm outside air from affecting room temperatures.On 7/5/26 at 1:49 PM, a second round of random temperature checks was completed with V4. All temperatures remained below 80 F except for the rooms of R4, R5, and R6. R5 and R6's room measured 82.9 F, and R4's room measured 82.8 F. At the time of assessment, all windows in these rooms were closed, and the air conditioning units were on but blowing minimal cool air. R4, R5, and R6 exhibited no signs or symptoms of dehydration. Their water pitchers were present and filled, and all residents appeared well-hydrated and not in distress. V1 (Administrator) provided fans for R5 and R6; R4 already had a fan in place. V1 also provided a receipt verifying the purchase of portable air-conditioning units intended to supplement the building's centralized AC (Air Conditioning) system.On 7/5/26 at 1:51 PM, R5 stated that when the outdoor temperatures increased last week, his room began to feel warm. R5 stated that he feels okay now, though still a little hot, but described it as tolerable. R5 stated that he receives juice and ice water every day and has no issues with hydration. R5 stated that the common areas are cooler than his room. R5 estimated that the temperature in his room feels like it is around above 80 degrees. R5 denied having any difficulty breathing and stated that a fan would help.On 7/5/26 at 1:56 PM, R6 stated that he feels hot in his room and estimated that it feels like 100 degrees. R6 stated that the temperature does not feel homelike or comfortable to him. R6 stated that he does not open his windows because doing so would make the room even hotter. R6 stated that he makes sure to drink water frequently throughout the day to stay hydrated. R6 stated that the heat is mainly an issue in his room and noted that while fans are available in other areas, having one in his room would be helpful. R6 stated that the AC is running but very little cool air is coming out.On July 6, 2026, beginning at 8:44 AM, additional random temperature checks were conducted with V4 across resident common areas and rooms from the first through fourth floors. R5 and R6's room measured 82.6 F. Both residents were present and reported feeling okay with the fans they had; each resident had their own fan and both declined the option to relocate. The windows were closed, and the air conditioner was producing minimal cool air. V4 stated that a portable AC unit would be delivered later that day. At 8:51 AM, R4's room measured 82.1 F. R4 declined the option to move, reporting she felt fine with the two fans she had, but the room temperature still does not feel comfortable. The windows were closed, sunlight was entering the room, and the AC was blowing limited cool air. V4 again confirmed that a portable AC unit was expected to arrive that day.On 7/5/26 at 9:43 AM, V4 (Maintenance Director) stated that over the past few days, several residents complained that their rooms felt hot and humid. Upon checking, V4 observed that the residents' windows were open approximately three inches, allowing warm air to enter. V4 stated that the residents are frequently reminded and educated not to open the windows when the temperature outside is too hot. V4 stated that he conducts daily rounds to monitor temperatures, including checking residents' rooms and hallways. V4 also verifies that the AC motors are functioning properly. V4 reported that he ensures the AC system is maintained every day. V4 stated if the AC stops working in any room or area, he replaces the necessary components. He added that the building operates on a single AC system, and if any fan within the system's ventilation stops functioning, he replaces it immediately. V4 stated that the facility's policy is to keep indoor temperatures between 70 and 80 degrees, not to exceed 81 degrees Fahrenheit.On 7/6/26 at 10:54 AM V1 (Administrator) stated that the facility's policy is to maintain indoor temperatures between 65 and 75 F. If temperatures exceed 85 F, the emergency preparedness plan is activated. V1 stated maintenance staff conduct random temperature checks throughout the building daily. If any readings are out of range, service technicians are called, residents are moved out of affected rooms, and staff monitor residents for any changes in condition while ensuring they remain well hydrated throughout the day.R4's clinical records show an admission date of 1/28/26 with included diagnoses but not limited to Other Asthma, Chronic Obstructive Pulmonary Disease. R4's Minimum Data Set (MDS) assessment dated [DATE] shows R4 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15.R5's clinical records show an admission date of 8/8/25 with included diagnoses but no limited to Type 2 Diabetes Mellitus and Cerebral Infarction. R5's MDS assessment dated [DATE] shows R5 is cognitively intact with BIMS of 14.R6's clinical records show an admission date of 3/7/24 with included diagnoses but not limited to Cerebral Infarction and Other Asthma. R6's MDS assessment dated [DATE] shows R6 is cognitively intact with BIMS of 13.The facility's Residents' Rights policy reads in part: Your facility must be safe, clean, comfortable and homelike.

Based on interview and record review, the facility failed to ensure proper food safety practices by permitting a dietary aide to continue working with an expired food handler certification. This failure has the potential to affect all 208 residents residing in the facility.On 4/27/2026 at 1:13 PM, V3 (Dietary Manager-Temporary) provided copies of V16 (Dietary Aide) state food and safety certificate issued on 10/31/2022 documents an expiration date of 3 years from the issue date (10/31/2025). On 4/28/2026 at 9:37 AM, Reviewed V16 (Dietary Aide) time cards dated for the 2 week time period of 3/29/2026 to 4/11/2026 which documents V16 worked 7:45 hours for eleven (11) shifts during that time period and V16 time cards dated for the 2 week period of 4/12/2026 to 4/26/2026 documents V16 worked eleven (11) shifts for seven hours and fifteen minutes to ten hours and thirty minutes.On 4/29/2026 at 10:49 AM, V33 (Registered Dietician) stated all staff should have a certification in food handling and I believe that is the policy; the purpose of dietary aides obtain a certification in food handling is to educate on hygiene, food storage, and temperature; and dietary staff should probably not be handling food on an expired license. On 4/29/2026 at 2:11 PM, V3 (Dietary Manager) stated I (V3) noticed that one person did not have an updated food handler certification. Surveyor verified with V3 one dietary aide (V16) has been working on an expired food handling certification since October 2025. Facility's policy titled Policy and Procedures for Food Handling with a revision date of 1/2025 documents the facility will promote food safety through proper food handling techniques and the purpose is to establish principles for dietary personnel to minimize or prevent infections related to food handling.Facility's Dietary Aide Job Description undated documents, in part, dietary aides adhere to all food safety and sanitation guidelines as per state (Illinois) regulations, CMS standards, and facility policies and must possess a valid Food Handlers certificate.

Based on observations, record reviews, and interviews, the facility failed to ensure that dietary staff followed the planned menu, therapeutic diets, or resident preferences. This failure has the potential to affect all 208 residents residing in the facility on an oral diet with one resident (R70) receiving a gastric tube and pleasure feed.On 4/27/2026 at 10:21 AM, R152 stated the food is terrible and he (R152) does not receive meat with every meal.On 4/28/2026 at 10:36 AM, V34 (Dietary Cook) stated the residents were fed eggs, toast, and oatmeal; some people get boiled eggs or no eggs depending on their ticket likes and dislikes; sausage didn't come in, so she (V34) did not make the egg casserole on the menu for today but made the other items on the menu; and the dietary supervisor tell us to cook what we have.On 4/28/2026 at 10:42 AM, V3 (Dietary Manager) verified with surveyor the freezer contains frozen pork breakfast sausage, sausage crumbles, chicken tenders, ground turkey and beef, burgers, bacon, ravioli and meat balls; 3 boxes of pork sausage crumbles with 1 box dated received 1/2/2026 and use by date 7/2026 and 2 boxes of sausage crumbles with a receive date of 4/14/2026 and use by date 7/2026.On 4/28/2025 at 10:53 AM, V3 (Dietary Manager-Temporary) stated the sausage crumbles are used to prepare the egg and sausage casserole on the menu for breakfast today 4/28/2026; V34 (Dietary Cook) should have followed the breakfast menu for today and prepared the egg and sausage casserole; the purpose of following the menu selections is to make we give enough protein and nutrients to the residents; and the effect of not providing enough protein in residents daily diet can result in weight loss along with other things. On 4/28/2026On 4/28/2026 at 1:46 PM, R152 stated he (R152) received a slice of toast, a boiled egg, and oatmeal for breakfast. Reviewed the dietary menu for the week of 4/26/2026 to 5/1/2026. On 4/28/2026 for breakfast the menu reads the following food items will be served for breakfast: choice of vitamin c juice (6oz), oatmeal or cold cereal (1/2 cup or 3/4 cup), egg & sausage casserole (1 piece=2 ounces of protein), Toast (1 slice), Jelly (1 each), Margarine (1 each), 2% Milk (8 ounces), coffee/tea (6 ounces), and condiments (1 each) and lunch menu selection for protein is 2 ounces of chicken and dinner menu selection of protein is 2 ounces of savory meatloaf.On 4/29/2026 at 10:49 AM, V33 (Registered Dietician) stated the menu comes from an outside food agency and is approved by a certified dietician; a food substitutions should be provide to replace the nutritional value and calorie intake on the menu; and if the food item is not replaced with the appropriate calorie intake it can cause lead to a resident losing weight.Facility's policy titled Menu Requirements with a revision date of 9/25/2023 documents, in part, menus are developed to meet the daily recommended intake national guidelines, regional food preferences, resident input.a table of the recommend daily or weekly amount from the different food groups or subgroups based on a 2,000-calorie diet below will be the base for planning menus: meat group- a total of 6 ounces a day by weight of quality protein to provide 38-42 g of protein daily.Facility's policy titled Menu Substitutions dated 10/11/2023 documents, in part, if a situation arises that makes an item on the menu unavailable, a substitute of similar nutritional value will be provided. Facility's dietary cook job description undated documents, in part, an overview of the facility is committed to providing high-quality, compassionate care to our residents and believe nutrition plays a crucial role in the well-being and recovery of our residents. Menu planning and execution responsibilities include collaborating with the dietary manager to plan and prepare nutritious, appealing meals that meet the dietary needs and preferences of residents, including those on therapeutic diets.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices by not monitoring and documenting refrigerator and freezer temperatures of stored foods daily. This failure affects all residents residing in the facility. On 4/27/2026 at 9:46 AM, surveyor observed the walk-in refrigerator cooler's thermometer reading was 41 degrees Fahrenheit with missing daily refrigerator tracking temperature entries on 4/19/2026, 4/24/2026, and 4/26/2026.On 4/27/2026 at 9:50 AM, walk-in freezer -3 degrees Fahrenheit. Observed missing daily refrigerator tracking temperature entries on 4/19/2026, 4/24/2026, and 4/26/2026. On 4/27/2026 at 9:53 AM, sandwich cooler temperature 36 degrees Fahrenheit with missing daily refrigerator tracking temperature entries and signatures for the following dates on 4/19/2026, 4/24/2026, and 4/26/2026.On 4/27/2026 at 9:59 AM, surveyors verified with V3 (Dietary Manager-Temporary) the walk-in refrigerator, refrigerator cooler, and walk-in freezer had missing daily log in temperatures. Requested copies of the walk-in refrigerator log, walk-in freezer, and refrigerator cooler logs and informed V3 not to fill in any of the missing entries.On 4/27/2026 at 1:13 PM, V3 (Dietary Manager-Temporary) provided surveyor with the walk-in refrigerator, walk-in freezer, and refrigerator cooler tracking logs with the temperatures and initials filled in on 4/19/2026, 4/24/2026, and 4/26/2026 but no times entered on 4/19/2026, 4/24/2026, and 4/26/2026. On 4/30/2026 at 2:16 PM, V3 (Dietary Manager-Temporary) stated the refrigerator/cooler/freezer logs are completed every morning and night; to make sure the temperatures are at the recommended standard temperatures of 41 degrees Fahrenheit and below zero degrees Fahrenheit for the freezer and to make sure the food don't go bad or spoil; the residents can get sick if the temperatures are not maintained; and the perfect explanation of daily tracking of temperatures is to prevent food borne illness. Facility's policy titled Storage of Refrigerated/Frozen Foods with a revision date of 4/26/2026 documents, in part, temperatures will be recorded on the refrigerator and freezer tracking logs at least two times a day.

Based on observation, interview, and record review the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was visibly posted for a resident (R231) requiring Enhanced Barrier Precaution; and failed to maintain infection control practices to prevent the potential spread of infection (staff placed soiled linen on the floor for one resident (R53) and staff failed to separate clean and soiled linen in the laundry processing area). These failures affected two residents (R53 and R231) and has the potential to affect all 208 residents reviewed for infection control.Findings include: On 4/27/26 at 2:15 pm, Surveyors and V14 (Laundry and Housekeeping Manager) conducted a tour in the laundry area and observed the laundry rooms clean processing area with three bags on the floor. V14 stated that the three bags on the floor were residents' soiled linen dropped off by the floor technicians. V14 stated that the soiled linen items should not be placed on the floor or in the clean laundry processing because it can cause contamination. The facility document dated 1/25 and titled Linen Handling documents, in part: Purpose: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganisms. Procedure: 2. Clean and soiled linen should remain separate on the nursing units and in the laundry processing area. Findings include: R53 face sheet shows that R53 has diagnosis which includes but is not limited to peripheral vascular disease. R53's Brief Interview for Mental Status (BIMS) dated 6/9/26 shows that R53 has a score of 9 which indicates that R53 has some cognitive impairment. R231 face sheet shows that R231 was admitted to the facility 4/24/26 in which R231 does not have a BIMS at this time. During this survey R231 was able to answer surveyors' questions appropriately. R231's face sheet shows that R231 has diagnosis which includes but is not limited to cellulitis of left lower limb, unspecified open wound left lower leg subsequent encounter and other injury of unspecified body [NAME]. R231 Physician Order Sheet (POS) shows active order dated 4/29/26 and does not document EBP orders for R231. On 4/27/26 at 10:32 am, R231 was observed in her room, in bed with a dressing to R231's left leg. Surveyor did not observe R231's room door with an EBP sign on the door. On 04/27/26 at 10:33 am Surveyor observed V10 (Certified Nursing Assistant, CNA) performing Activities of Daily Living (ADL) care with R53 and throwing R53's soiled linens on the floor next to R53's bed. On 4/27/26 at 10:33 am, Surveyor brought this observation to V10 (Certified Nursing Assistant, CNA), and V10 stated, I am about to get that off the floor (referring to the soiled linen observed on the side of R53's bed). On 4/27/26 at 11:10 am, V9 (Infection Preventionist ,IP, Licensed Practical Nurse, LPN) stated residents with wounds should have an EBP sign placed on the door and staff should be donning Personal Protective Equipment (PPE) (gown and gloves) when performing high contact care. V9 stated that an EBP sign is to prevent staff and the resident from transmitting infection. V9 also stated that residents soiled linen should not be placed on the floor and should be placed in a plastic bag to contain the linen and prevent staff and residents from tracking germs throughout the building. The facility's document 04/27/26 and titled Enhanced Barrier Precautions Tracking Log shows that R231 requires EBP due to wound. The facility's policy dated 4/28/25 and titled Enhanced Barrier Precautions and documents, in part: Purpose: Reduce the transmission of novel or targeted multi-drug-resistant organism (MDRO). It is the policy of the facility to ensure that additional appropriate PPE (Personal Protective Equipment) is utilize when indicated, to prevent the spread of multidrug-resistant organisms also known as MDRO's (Multi Drug Resistant Organisms) . Procedure: 4. Ensure that all necessary supplies are available in an enclosed clean labeled container outside the resident's room. 5. Ensure that proper receptacles are in placed to collect discarded EBP in the resident's room. The facility's policy dated 1/25 and titled Linen Handling (Nursing) documents, in part: Purpose: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganisms. Procedure: 6. Every effort will be made to ensure that soiled linens or clothing does not come into contact with uniforms, furniture, or other areas deemed clean. Soiled linens shall not be placed on the floor.

Based on observation, interview and record review, the facility failed to ensure that disposable razors were not at bedside and failed to ensure proper disposal of razors in accordance with facility protocol which affected 4 residents (R72, R102, R162, R211) of 4 residents reviewed for hazards in a total sample of 70 residents. Findings include: On 4/27/26 at 10:55am, R211 opened the top drawer of his bedside table which contained three disposable razors. On 4/28/26 at 10:31am, R211 indicated that he has been able to keep disposable razors at the bedside because staff does not ask for them back and that they're thrown in the garbage when he's done with them. R211's Face Sheet documents, in part, the following medical diagnosis: Long term use of Aspirin. R211's Physician Order Sheet (POS) documents an order for Aspirin 81 mg (milligrams) since 1/23/24. On 4/28/26 at 10:30am, R72 showed four disposable razors that were inside a bath basin. R72 stated that staff allows him to keep the razors and does not ask for them back. R72 indicated that he throws them away in the bathroom garbage can. R72's POS documents an order for a blood thinner which reads: Xarelto Oral Tablet 20 MG - Give one tablet by mouth one time a day for Afib (Atrial Fibrillation). R72 has been on the blood thinner since 11/13/25. On 4/28/26 at10:35am, R102 revealed that he had two disposable razors. R102 stated, Nurses are the ones that gave it to me and let me keep it. I throw it in the garbage can when I am done. R102's POS documents an order for Aspirin EC (enteric coated) Tablet Delayed Release 81 mg - Give one tablet by mouth one time a day for prophylaxis since 5/15/25. R102's Face Sheet documents a past medical history of Cerebral Infarction. R72, R102 and R211 all stated that they use their disposable razors without staff supervising them. On 4/28/26 at 10:47am, V19 (LPN -Licensed Practical Nurse) stated that there should not be razors at the bedside but if the residents are independent with no cognitive issues, they know the policy to dispose of razors safely. On 4/28/26, V2 (DON-Director of Nursing) and V18 (Director of Social Services) both indicated that disposable razors are not allowed to be kept at bedside even if the residents are alert. V2 indicated that residents on blood thinner medications need to be supervised. A facility policy dated March 2024 and titled, Policy on Contraband Materials, Inspection of Rooms and Use of Recording Devices documents, in part: The following items are NOT ALLOWED in resident rooms at any time and are not allowed on the resident's person unless permission has been granted from administration and supervision is being provided: razors and razor blades. Findings include: R162 face sheet shows that R162 has diagnosis which includes but not limited to paranoid schizophrenia, anxiety, insomnia, and major depressive. R162's Brief Interview for Mental Status (BIMS) dated 5/526 shows that R162 has a score of 12 which indicates that R162 is cognitively intact. R162's Minimum Data Set (MDS) dated [DATE] shows that R162 requires supervision or touch assistance for shaving. On 4/27/26 at 10:48 am, R162 was observed in his room lying in the bed with a shaving razor on his dresser. R162 stated that he shaves himself usually twice a week. R162 then stated that when he is done with using a razor for shaving he will toss the razor in the trash can in his room. R162 also stated that staff does not observe him shave or dispose of R162's shaving razor in a sharp's container when R162 completes shaving.

Based on interview and record review, the facility failed to ensure that psychotropic medication consents were obtained prior to the initiation/administration of medications and failed to ensure that the correct medical diagnosis was documented for the use of the psychotropic medications which affected 5 residents (R2, R5, R63, R163, R195) of five residents reviewed for unnecessary medications in a total sample of 70. Findings include: R2's Order Summary Report with active orders as 4/28/2026, documents in part, Olanzapine Oral tablet 5 mg with a start date of 4/6/26. R2's April 2026, Medication Administration Record documents that R2 received Olanzapine Oral Tablet 5mg from 4/6/26-4/27/26 with no consent R2's Psychotropic Consent Form was obtained after surveyor requested and was dated for 4/28/2026. R2 has a diagnosis of but not limited to Schizoaffective disorder, Bipolar disorder, and Hypertension. Policy and Procedure Psychotropic Medication with a revision date of 1/2025 documents, in part, psychotropic medication shall not be prescribed without the informed consent of the resident. Findings include: R5 has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Schizoaffective Disorders, Schizophrenia, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Generalized Anxiety and Post-Traumatic Stress Disorder. R5's Order Summary Report with active orders as of 4/29/2026 documents, in part, Risperidone Oral Tablet 1 MG and Mirtazapine Oral Tablet 15 MG with a start date 03/04/2026 and Sertraline HCl Oral Tablet 50 MG with a start date of 4/16/2026. R5's March 2026 Medication Administration Record documents that R5 received Risperidone Oral Tablet 1 MG and Mirtazapine Oral Tablet 15 MG in March 2026 and April 2026 with no consent. R5's April 2026 Medication Administration Record documents that R5 received Risperidone Oral Tablet 1 MG and Mirtazapine Oral Tablet 15 MG in March 2026 and April 2026 with no consent. R5's Pyschotropic Consent Form dated 4/28/2026 documents, in part, Psychotropic Consent 1. Psychotropic Medications: Risperidone Oral Tablet 1 MG and Mirtazapine Oral Tablet 15 MG with a start date 03/04/2026 and Sertraline HCl Oral Tablet 50 MG with a consent date of 4/28/2026. Policy and Procedure Psychotropic Medication with a revision date of 1/2025 documents, in part, psychotropic medication shall not be prescribed without the informed consent of the resident. Findings include: R195's psychiatric progress note dated 4/16/26 and authored by V38 (Psychiatric Nurse Practitioner) documents the following psychiatric diagnoses: PTSD (post traumatic stress disorder) with psychotic features, Schizoaffective disorder, Insomnia and three hospitalizations for Suicidal Ideation. None of these diagnoses are listed on R195's Face Sheet under Diagnosis Information. R195's Order Summary Report documents, in part, the following medication orders: Hydroxyzine 50 mg (milligrams) every eight hours for anxious with a start date of 2/24/26, Aripiprazole 20 mg one time a day for anxiety with a start date of 2/24/26, Mirtazapine 15 mg one time a day for anxiety with a start date of 2/24/26 and Trazodone 150 mg at bedtime for insomnia with a start date of 4/15/26. It was noted that R195 did not sign his Psychotropic Consent for Hydroxyzine, Apiprazole, Mirtazapine and Trazodone until 4/28/26. R195's February 2026, March 2026 and April 2026 Medication Administration Records (MAR) document that R195 continuously received his psychotropic medications without consent. R195's psychotropic consent also did not contain the psychiatric diagnoses of PTSD with psychotic features, schizoaffective disorder. It also did not document Insomnia. On 4/30/26 at 9:43am, V38 stated, Once I document the psychiatric diagnoses in my notes, it should be added to the resident's official diagnosis list. If it not part of the diagnosis list, then the facility will not know what to monitor the residents for. V38 continued to state that R195's Apiprazole (psychotropic medication) was ordered for schizoaffective disorder and not for anxiety. V38 said, It is not a first line medication for anxiety. V38 also indicated that R195's Mirtazapine was ordered for PTSD and should not be documented as a medication for R195's anxiety. V38 stated, When I order a psychotropic medication, I usually put a rationale for it. The facility should follow that. R63's Face Sheet documents, in part, the following pertinent diagnoses: Generalized Anxiety disorder and Alcohol Abuse with Alcohol Induced Mood disorder. R63's POS (Physician Order Sheet) documents the following psychotropic medication orders: Sertraline 50 mg one time a day for General Anxiety disorder with a start date of 1/22/26, Sertraline 25 mg one time a day with a start date of 3/5/26, Mirtazapine 7.5 mg every bedtime for Major Depressive disorder with a start date of 3/4/26 and Melatonin 3 mg every bedtime for Insomnia with a start date of 2/21/26. R63's medical diagnoses list does not document Insomnia or Major Depressive disorder. R63's electronic medical record (EMR) documents that psychotropic consents for Mirtazapine, Sertraline 25 mg and Melatonin were not obtained/signed until 4/28/26. There is a psychotropic consent for Sertraline 50 mg that shows that it was signed on 1/22/26. This was confirmed with V26 (ADON – Assistant Director of Nursing) who manages the psychotropic program. On 4/29/26 at 12:30pm, V26 stated, I did not change the dates on the consents. I think what happened is that I printed it from (R63's) medical record and it already had the date of 1/22/26 on it. V26 confirmed that the date should have been changed because she had R63 sign all four of his psychotropic consents on 4/28/26. On 4/29/26 at 9:27am, R63 also confirmed that he signed four medication consents on 4/28/26. R63's MAR's for January 2026, February 2026, March 2026 and April 2026 document that R63 continuously received his psychotropic medications without consent. R163's Face Sheet documents the following pertinent diagnoses: Anxiety disorder and Major Depressive disorder. R163's Report Summary and POS documents a psychotropic medication order for Mirtazapine 15 mg every bedtime for Major Depressive disorder with a start date of 3/13/25. R163 did not sign the Psychotropic Consent for Mirtazapine until 4/28/26. R163's MAR's for March 2026 and April 2026 document that R63 continuously received his psychotropic medications without consent. Also, this consent does not list Major Depression disorder under the diagnosis portion. On 4/29/26 at 12:30pm, V26 (ADON) stated, I have been the psychotropic nurse since December 2025. For this program, I monitor psychotropic consents and GDR (gradual dose reduction) program. The nurses can normally obtain consents for the psychotropic medications on admission. But I audit it. When resident comes in and is a new admission, if not obtained then I will obtain it from resident or family. Definitely should obtain consent before administering the medications to the resident and should definitely attempt to get the consent upon admission and when dosage is increased or decreased. Residents cannot receive psychotropic medications without consent. A facility policy dated 7/1/25 and titled, Policy and Procedure Psychotropic Medication Policy documents, in part: Policy: To establish the process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. Definitions: Psychotropic medication: medication that is used for or listed as used for antipsychotic, antidepressant, anti-maniac, or anti-anxiety behavior modification for behavior management purposes. Policy Specifications: 1. Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative. 2. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in the guidelines of recognized external review agencies.

Based on observation, interview, and record review the facility failed to ensure that a treatment administration cart was kept locked; and failed to label and discard expired insulin for two residents (R4, R173). These failures affected two residents (R4, and R173) and has the potential to affect all 60 residents on the second-floor unit at the facility. Findings include: On 4/27/26 surveyors were presented with a facility census of 60 residents residing on the second floor of the facility. On 4/29/26 at 10:02 am, Surveyor observed the second-floor treatment cart unlocked, unattended with chemical medication solutions accessible in the bottom treatment cart drawer and residents ambulating throughout the second-floor hallway. On 4/29/26 at 10:11 am, Surveyor brought this observation to V31 (Licensed Practical Nurse, LPN) and V31 stated, I had V32 (Certified Nursing Assistant, CNA, Wound Technician) bring me supplies from the cart because I was in the middle of a dressing change. She must have left it open. V31 then explained that the licensed nurse is authorized to access the treatment cart and that the treatment cart should remain locked at all times when not in use. V31 then explained if the treatment cart is left open and unattended, the residents can access the chemicals and injure themselves. The facility policy dated 5/1/2018 and titled Storage of Medications documents, in part: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medications supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication Aides) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. R173's has a diagnosis of but not limited to Diabetes Mellitus, Dementia, Hypertension and Depression. R173's Order Summary Report active orders as of 12/14/2022, documents, in part, Humalog Solution 100 Unit/ML. R4's has a diagnosis of but not limited to Diabetes Mellitus Type 2, Dementia, Hypertension, and Atrial Fibrillation. R4's Order Summary Report active orders as of 08/04/2025, documents in part Insulin Glargine 100 Unit/ ML Solution. On 4/29/26 at 12:37 PM Surveyor inspected V5 (License Practical Nurse -LPN) medication cart (cart 1) on the fourth floor and observed Humalog (Lispro) for R173 with no open and expiration dates written on the vial. The opening date on R173's Humalog (Lispro) box was 2/8/26. Surveyor also observed R4's Glargine vial with no open date and expiration date and the opening date on the Glargine box was 3/25/26. On 4/29/26 at 12:42 PM V5 (LPN), stated Insulin is kept for 30 days and the Insulin should be labeled with an open date, so we know when it expires and when to discard the insulin. On 4/29/26 at 1:08 PM V2 (Director of Nursing-DON) stated the nurses are expected to put the open and discard date on the insulin vial because they expire after 28 days. After the 28th day the nurses should dispose of them (insulin vials) in the sharps container or send them back to pharmacy and order more. On 4/29/26 at 2:02 PM via phone V41 (Pharmacist) stated insulin should not be used past 28 days after opening and that is standard across the board. If insulin is used a month past the used by date I would need to call the manufacturer help line to see what they say. Policy titled Storage of Medications with a revision date of 5/01/2028 documents, in part, Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier and outdate, medications are immediately removed from inventory, disposed of according to procedures for medication disposal, E. When the original seal of a manufacturer's container or vial is initially broken, the vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. G. No expired medication will be administered to a resident. H. All Expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.

Number of residents sampled: 70Number of residents cited: 3Based on observations, interviews and record reviews, the facility failed to provide feeding assistance for dependent residents receiving pleasure from eating and failed to clean and cut residents' nails. This failure affected three residents (R6, R54 and R70) out of 70 residents reviewed for ADL care. Findings include: On 04/27/2026 at 11:29 AM, R70 was lying in the bed extremely thin on a puree diet. V20 (Licensed Practical Nurse/LPN) placed a tray containing a puree meal on R70's bedside table then positioned R70 and R70's bed upward. V20 then placed the bedside table with R70's lunch over R70. Then left V20 to feed to R70. No one assisted R70 with his meal. On 04/27/2026 at 12:11 PM, R70 was still sitting upright with R70's untouched puree lunch still on the tray table. V4 (Certified Nursing Assistant/CNA) followed the surveyor and immediately entered R70's room. R70 had not eaten the puree food. V4 then asked R70 if R70 wanted the food and R70 pushed it away. V4 said R70 does not want it. V4 offered R70 the puree lunch again for confirmation and R70 pushed it away again with R70's left hand. (R70's right hand was not operable due to R70's stroke diagnosis.) V4 said, see! R70 does not want it. V4 did not offer R70 an alternative meal after V4 took R70's food tray and walked away. When surveyor asked R70 if R70 wanted something else, R70 facial expression lifted, R70 shook R70's head and said yes. On 04/27/2026 at 12:27 PM, V4 never returned to R70's room. V4 stated that R70 receives pleasure food sometimes and maybe that is why R70 was not hungry. V4 said they cannot offer alternatives to R70 because R70 receives a puree diet. V4 added we cannot offer R70 anything else without consulting the nurse for meal alternatives. On 04/27/2026 at 12:27 PM, V20 (Licensed Practical Nurse) stated that V20 was not aware that R70 did not eat R70's pureed lunch. V20 said R70 was pleasure fed earlier but V20 did not know who fed R70. On 4/28/2026 at 11:37 AM, V2 (Director of Nursing), V2 provided a list of residents requiring feeding assistance entitled Assistance with Meals List. R70 was on the list. V2 said residents on this list requiring feeding. On 4/28/2026 at 11:25 AM, V3 (Dietary Manager) stated meal tickets lists residents requiring feeding assistance. The three meal tickets that V3 provided did not indicate which residents require feeding. V3 said they did not know when the feeding status information was removed from the meal ticket. On 4/28/2026 at 11:46 AM, V4 dropped off R70's lunch tray and placed it on R70's bedside table. R70 was sitting upright and seemed ready to eat. R70's right arm seemed weak so R70 was using R70's left hand with difficulty. At 11:51 AM, R70 drank R70's water, looked at R70's food, then stared at the television. The food smelled appetizing. At 11:56 AM, R70's meal tray was still in R70's presence and R70 stared at the television. On 4/28/2026 at 12:03 PM, R70's puree food was still uncovered and untouched. R70 had difficulty answering the surveyor's questions on whether R70 needed eating assistance. R70 then pushed the tray away. On 4/28/2026 at 12:07 PM, R70 still has not been fed. At 12:16 PM, no floor nurse or assistant entered R70's room to feed R70 or check on R70. At 12:21 PM, R70 still not fed. At 12:27 PM R70 still not fed. On 4/28/2026 at 12:41 PM, V25 (Licensed Practical Nurse) said they have a lot of residents that require feeding but there are only two CNAs for V20's section of the floor. V4 was feeding R225 and V23 (CNA) was feeding R77 from approximately from 11:52 AM to 12:27 PM. On 04/28/2026 at 2:01 PM, V4 said when they receive new residents, the nurses usually let the CNAs know whether the resident is total care or require feeding assistance. V4 said R70 is total care, has a gastronomy tube and receives pleasure-eating. V4 stated if R70 pushes away the food tray, R70 does not want it. Otherwise, if R70 does, they assist him, and he opens his mouth, and they feed R70. On 04/28/2026 at 2:19 PM, V23 (CNA) of 20 years and dedicated to R70's floor stated V23 determines if a resident requires feeding assistance if the resident just sits there and does not touch their tray. V23 said that tells V23 the resident requires feeding. V23 stated based on V23's observation R70 has a tube feeding and receives a pleasure tray. V23 said it seems like R70's appetite decreased after R70 returned from surgery. V23 stated R70 does require feeding and R70 does not have special equipment or tools to help feed himself. On 04/28/2026 at 2:32 PM, V24 (CNA) stated V24 can tell if residents require feeding assistance if they are not eating enough. V24 said they watch the residents eating to see what they can do. V24 said if their efforts are low, the CNAs help them eat and they report decline in eating to the nurse. V24 said they observe the residents' eating patterns. V24 added they have a lot of residents needing assistance and they check their rooms to see if they need help. V24 said because there are so many residents that require feeding, they are not assigned residents to feed. V24 was not certain if R70 required total assistance because V24 works both sides of the floor. 04/28/2026 2:46 PM, V25 (LPN) stated nurses inform CNAs of the activities for daily living (ADL) status of new residents upon admissions and upon change of condition. V5 said sometimes the CNAs notify them of residents' change in eating. V25 stated R70 receives pleasure feed and has a gastronomy tube. V25 said R70 can eat independently and do everything by himself. V25 stated that speech therapy told them that R70 can eat independently. V25 said they will assist R70 if R70 requests or if they see R70 needing help. V25 added if residents require total assist and/or are the feeders list, we feed them. V25 said R70 is not on their feeders list entitled Assistance with Meals List because R70 does not require feeding assistance. On 04/28/2026 at 3:18 PM, V20 stated that R70 was not on the feeders list because R70 knows how to feed himself and R70 does not require eating assistance. V20 said R70 learned how to feed himself after finishing occupational therapy. V20 was adamant R70 knew how to himself because V20 said V20 witnessed it themselves. On 04/28/2026 at 3:42 PM, V30 (CNA) and V29 (Restorative Aide) weighed R70 using a Hoyer lift containing a scale. (They stated that the lift itself weighs nothing.) R70 weighed 126 lbs., experiencing a one-pound loss. V29 stated R70 has a gastronomy tube, receives pleasure food and requires eating assistance with all meals. V29 said this information is in R70's POC and nurses should know and inform the CNAs. V29 said they have a list of residents that requires and residents on that list should be fed. On 04/29/2026 at 10:12 AM, V33 (Registered Dietician) since September 2025 with facility stated that R70 has a gastronomy tube and receives puree pleasures meals. V33 said V33 works remotely, has not physically met R70 and does not know if R70 requires feeding assistance. On 04/30/2026 at 10:54 AM, V39 (Part-time Registered Dietician) stated that V39 was not familiar with R70's dietary or feeding assistance needs because R70 was new and only visited the facility once and did not get a chance to meet or assess R70. On 04/29/2026 at 12:58 PM, V2 stated it is expected that all residents on the floor's Assistance with Meals List are fed by either a nurse or CNA because all nurses are required to feed residents. V2 said R70 should not be on the list of feeders that V2 provided to the surveyor on the first day of the survey. V2 added it is expected that residents that are assessed as needing substantial assistance on the Minimum Data Sheet feed themselves if possible. R70's Face Sheet documents R70's diagnosis of congestive heart failure, dysphagia following cerebral infarctions, chronic kidney disease, chronic obstructive pulmonary disease and muscle wasting/atrophy. R70's Minimum Data Sheet (MDS) dated [DATE] shows R70 requires Substantial/Maximal Assistant meaning Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R70 documents a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. R70's weight chart indicated that R70 experienced a significant weight loss of 6% in one week: going from 130 lbs. on 4/7/2026 to 122 lbs. as of 4/14/2026. R70s care plan initiated on 1/22/2026 documents R70 is at High risk to potentially choke, aspire foods or liquids. R70s care plan initiated on 10/07/2025 states to Provide one-to-one staff intervention to promote proper nutritional intake. The facility failed to follow their Policy and Procedure Feeding and Assisting Residents to Eat policy dated 1/2026 which documents Assist the residents to obtain nutrients and hydration and Feed the resident slowly with a fork or spoon. Findings include: R6's face sheet dated 04/28/2026 documents in part that R6 was admitted to the facility on [DATE] with diagnosis of complete traumatic amputation between right hip and knee, chronic obstructive pulmonary disease, asthma, diabetes mellitus, congestive heart failure, schizoaffective disorder, anxiety ,major depressive disorder, insomnia, essential hypertension, heart failure, peripheral vascular disease, chest pain. R6's Minimum data set for Cognitive patterns dated 03/11/2026 documents in part that R6 brief interview for mental status score is 7 which means R6 has severe impairment; Self care section: gg documents that R6 requires partial/moderate assistance from staff for showers, baths, toileting, personal hygiene and hand washing. R6's care plan dated 05/21/2025 documents in part that R6 has self-care deficit; Intervention[staff to provide moderate assistance with hygiene task]. R54 face sheet dated 04/29/2026 documents in part that R54 was readmitted to the facility on [DATE] with diagnosis of muscle wasting and atrophy, protein calorie malnutrition, peripheral vascular disease, cataract, lack of coordination, essential hypertension, hidradenitis suppurativa. R54's Minimum data set for Cognitive patterns dated 02/11/2026 documents in part that R54 brief interview for mental status score is 13 which means R54 is cognitively intact. Self-care section: gg documents that R54 is dependent on staff for showers, baths, toileting, personal hygiene and hand washing. Staff does all the effort . R54's care plan dated 12/27/2023 documents in part that R54 has self-care deficit; Intervention[staff to provide total assistance in all aspects of hygiene]. On 04/27/2026 at 11:05 AM, R54 was observed in bed resting R54 was alert and responsive. R54 reports that he receives showers, and his wound care is done a few days during the week .R54 nails were observed long with dark color particles underneath the nails and R54 reports that he would like his nails to be cut.R54 states that he is unable to cut his nails or provide care to himself and that he depends on staff to provide all care and grooming for him. On 04/27/2026 at 11:10 AM, R6 observed in bed resting alert and responsive able to make all needs known to staff and denies pain or discomfort. R6 nails are long with dark color particles underneath the nails and R6 reports that he would like his nails to be cut.R6 has face full of facial hair but states that he prefers his face but does not want a shave at this time.R6 depends on staff for all care needs and grooming. On 04/28/2026 at 11:28 AM, R6 observed laying in bed alert and responsive with long nails and dark particles underneath the nails.R6 stated that he still wants to have his nails cut because they are too long. On 04/27/2026 at 11:28 AM,V6 ( Certified nursing assistant/ CNA) states that nail care for the residents should be done daily for checks and cut as needed. Long nails can cause skin tears to the resident and long nails can also cause the resident to scratch and cut the staff's skin. If a resident refuses grooming or nail care the aide is responsible to inform the nurse and the nurse documents. On 04/27/2026at 11:36 AM, V8 (Licensed Practical Nurse/LPN) stated if a resident refuses grooming or nail care the aide is expected to inform the nurse and the nurse would go into the room and attempt to redirect the behavior and encourage the resident to have grooming and nail care.V8 stated no aides have informed her that nail care or grooming was refused today.V8 states that R6 digs in his feces even though he is alert there are periods of confusion.R6 is constipated most days and tries to dig out feces from rectum. On 04/27/2026 at 12:10 PM, V2 ( Director of Nursing ) Showers are done 2x a week for residents, at that time the staff will check nails and see if they need to be trimmed or cleaned. Grooming is done daily and as needed. V2 stated if the resident refuses, the staff is responsible to inform the nurse who informs the nursing leaders so this behavior can be care planned.v2 stated the first floor is mostly alert and oriented residents that do not need much assistance and are independent, if residents need help, staff will provide it. On 04/28/2026 at 11:18 AM, V16 ( LPN) stated resident should receive nail care at least once a week to decrease risk for bacteria. If a resident's nails are too long, they can injure themselves or others. V16 stated she expects the aide to come and report to her if a resident refuses care or nails to be cut or cleaned. V16 would then attempt to speak with the resident to check if she can encourage the resident to change their mind but if the resident continues to refuse, V16 would document and educate resident. V16 stated no aides informed her that any resident has refused nail care or grooming today. Many residents on the first floor provides self-care. The residents that are dependent are the responsibility of the aides to provide care to those residents. Resident 54 receives bed baths from staff and R6 also receive grooming care and baths from staff .V16 stated she expects staff to wipe/wash the hands of residents prior to meals to decrease the risk for infection and make sure the hands are clean before eating. On 04/28/2026 at 11:30 AM, V17 (CNA) stated that if resident's nails are too long the resident can scratch themselves or scratch others. V17 stated that R6 has a habit of digging in his feces.V17 stated the dark debris under R6's nails could be feces and that she (V17) will clean and cut the nails of R6 today.V17 stated if a resident has dirt of feces under their nails that can cause them to become sick if their nails are not cleaned and the resident is eating foods. On 04/28/2026 at 12:47 PM, V9 ( LPN/Infection preventionist) stated residents that have debris or old food particles under their nails can be at risk for skin infection and or transferring bacteria to someone else. Residents can be placed at risk for gastro infections from eating and have old particles or debris under the nails .V9 reports that she expects staff to cut and clean under the resident's nails. Education is provided to staff to encourage residents to wash hands and nails before and after restroom and meals. Staff are educated to wipe surfaces clean before and after meals. Staff should wash the residents' hands with soap and water and check the nails of the dependent residents. Handwashing in service has been provided to staff.

Based on record review and interview, the facility failed to follow their abuse policy for two residents (R5,R6) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation where residents became abusive to each other. Staff did not intervene in time resulting in R5 and R6 engaging in a physical altercation that lead to R5 sustaining a facial laceration, laceration of the scalp, and a fracture of his nasal bone.Findings IncludeOn 3/31/26 at 11:30 am V10 CNA (Certified Nurse Aide) stated she was working on the floor doing rounds and heard someone say a fight. V10 stated she went into the room and saw R6 standing over R5 punching him. V10 stated she was able to separate R6 from R5 and escorted R6 down the hallway while calling for assistance. V10 stated the nurse came to R5 and R6's room and looked at R5. V10 stated R6 told them that he was on the phone and R5 turned the television up too loud. V10 stated R6 told them that he asked R5 to turn the television down but R5 cursed him out so then they started to fight.On 3/31/26 at 12:30 pm V7 LPN (Licensed Practical Nurse) stated she was working at the facility when she heard some commotion coming from R5 and R6's room. V7 stated she went into their room and saw R5 on the floor bleeding from the head and rendered first aid to him. V7 stated she asked R5 what happened, but he did not tell her how he fell. V7 stated she asked R6 what happened and told her they got into an argument about the television. V7 stated R6 told her R5 got up in his face so he hit R5 and R5 fell on the floor. V7 stated before that incident they had never had an altercation with each other or any other residents. V7 stated called the physician and got order to send residents out to the hospital for evaluation. On 4/2/26 at 10:30 am V17 (Doctor) stated she was made aware that R5 and R6 had an altercation back in January. V17 stated the result of that altercation was that R5 did sustain some injuries, a couple of lacerations and closed nasal fracture. V17 stated R5 is stable now, in no distress and he will not have any long-lasting side effects from his injuries. V17 stated R6 is normally calm but with residents like him that have background in drug abuse their coping mechanism that they used on the outside don't work in a nursing home when there are disagreements, and R6 understands that now. On 3/27/26 at 11:00 am R5 stated that he walked into his old room and R6 was on the phone arguing with his girlfriend. R5 stated he asked R6 if he could lower his voice. R5 stated R6 walked over towards him with his cane and hit him in the face with his cane. R5 stated he fell down and R6 punched him a few more times and then the aide pulled him away. R5 stated he is not scared of R6 and has no issue with R6. R5 stated he feels fine and feels safe staying in the facility.On 3/27/26 at 11:45 am R6 stated he was in his room when R5 came in and turned his television up really loud. R6 stated he told R5 to turn the television down because it was too loud. R6 stated R5 did not turn the television down and asked R5 to turn the television down but R5 walked towards and told him to shut the F*** up. R6 stated he got mad and thought that R5 was going to hit him, so he punched him first. R6 stated R5 fell and when R5 tried to get back up punched R5 again. R6 stated before he could hit R5 again the aide came in between them and asked him to leave the room. R5 's 1/28/2026 20:47 Nursing Progress Note Text reads : Writer was notified by the CNA (certified nurse assistant) that the resident had a physical altercation with his roommate. Writer came to resident room. Resident was observed on the floor with blood coming out of his nose and from the back of his head. Writer assess resident from head-to-toe b/p-129/79,p-81,t-97.3,rr-18,02sat-98% r.a. Resident was noted with a busted lip and blood coming from the back of his head. Writer and CNA assisted resident back to the chair. Writer started to wipe the blood to see where it was coming from. Writer place clean gauze on resident lip and the back of his head. Writer called Dr. and received new order to send resident out to the emergency room via 911.Writer called Administrator. Resident was placed on 1:1 until 911 arrived to transport resident to the emergency room at Hospital. Writer notified family. Writer made [NAME] aware as well. Police report #Jk130831. R5's hospital record dated 1/28/26 reads 55y male w who presents to ED with chief complaint battery. Patient states he was punched in the face at his NH. Physical Exam: Has 1/2 laceration to the posterior scalp and 3 cm vertical laceration of the left upper lip and face involving the [NAME] border. Does not go through and through the lip. Computed Tomography HEAD without intravenous contrast Final Result: Acute on chronic fracture of the nasal bones with new fracture of the nasal process of the left maxillary bone. Laceration Repair: wound was thoroughly cleansed, irrigated, and explored. No evidence of foreign body was noted. The wound was closed with 2 staples suture with good approximation. The wound was closed with 6 5 O Nylon suture with good approximation. Denies LOC. Denies any other injuries. emergency room Diagnosis: 1. Facial laceration, initial encounter 2. Laceration of scalp, initial encounter 3. Closed fracture of nasal bone, initial encounter. R5's 1/29/2026 01:03 General Progress Note Text reads: Resident is alert and oriented x2/3.Resident returned back from hospital with 5 stitches on the lip,3 staples to the back of his head,1 dissolvable stitch to inner lip and nasal fracture. No new orders. Will continue to monitor. Resident is currently on 1:1 supervision.R6'S 1/28/2026 20:45 Incident Note Text reads: Resident was in his room alert and stable. Resident was noted coming out of his room very agitated and in distress. Resident stated I was trying to relax in my room and my roommate came from outside drunk and we got into an argument cause he had turned the TV full blast and I told him to turn it down and he got mad and he came at me and he hit me in my face, so I defended myself. Writer assess resident from head to toe, vitals b/p-132/78,p-81,rr-18,t-97.5,02 sat-98%r.a.Resident does not express that he's in any pain. No injuries were noted. Writer and CNA assisted resident apart from his roommate and was placed on 1:1 supervision. Writer called Dr. and received new order to continue to monitor resident. Writer called Administrator. Writer notified family (daughter) and left a voicemail to give the facility a callback. Writer made [NAME] aware as well. Police report #Jk13083.Facility's abuse policy reads this facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure environment. Abuse means any physical or mental injury, retaliation, or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means, and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interviews and reviews, the facility failed to maintain a safe, comfortable home-like environment for one [R1] of four [R5, R7, R8] residents reviewed for smoking. Findings include,R1 was reviewed as a close record. R1 no longer resides in the facility. R1 intake details read: R1 reported, R7 constantly smoke in our room.R1's clinical record indicates in part: R1's medical diagnosis of anxiety disorder, bipolar disorder, paraplegia affecting right side, cerebral infarction, and asthma. Reviewed R1's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively intact, care plans, medication administration record, treatment administration record, and progress notes. R7's clinical record indicated the following in part: R7's medical diagnosis of nicotine dependence, cognitive communication, dementia, major depressive disorder, memory deficit following cerebral infarction, and chronic osteomyelitis. Reviewed R7's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score Indicates R7 is cognitively intact, care plans, medication administration record, treatment administration record, and progress notes. R7's Smoking Risk Review dated 1/28/26R7 has been continually educated on the importance of following facility policy and refraining from smoking in the room. Recommendations and outcome: R7 may not be capable of handling, carrying any smoking materials and requires supervision when smoking.R7's Smoking Contract dated 1/28/26, documented in part:R7 will not smoke anywhere else in the building. R7 will surrender all smoking materials to the facility. R7 will not carry on him, or possess in R7's room, or clothes any smoking materials.Consequences of violating smoking policy will result in losing smoking privileges. Further violations will be under review, may include involuntary discharge.R7's census documents R7 were R1's roommate from 1/23/26 through 1/27/26. R7's Care plain in part:R7 has a behavior of smoking cigarettes in his room dated 6/13/25.R7's social service progress notes documented in part R7 were observed smoking in his room on the following dates:6/13/25, 6/14/25, 6/19/25, 6/25/25, 8/20/25, 10/3/25, 10/17/25, 11/20/25, 1/25/26, 1/28/26, 2/12/26, and 2/13/26. V5 [Social Service Director] progress note:1/25/26 at 5:21PM- V5 met with R7 due to staff reporting R7 was smoking in his room. A room search was conducted with consent and R7 verbalized that he was smoking in the room. [R7 was roommates with R1 on 1/25/26 per R7's Census Report]. On 2/21/26 at 1:45 PM, R7 stated, I smoke in my room because I don't feel like getting up to go outside, and now its cold outside. I know the rules. I don't suppose to smoke in my room, but I don't care. On 2/21/26 at 10:18 AM, V11 [Licensed Practical Nurse] stated, I was R7's nurse on the first floor when he was roommates with R1. R7 smoked in the room. R1 did complain of smoking, because R1 had a diagnosis of asthma, and he did not want his asthma to flare up. R7 was moved to the third floor. On 2/21/26 at 2:10 PM, V11 [Licensed Practical Nurse] stated, R7 smokes in his room. However, we make rounds on him all the time to make sure he is not smoking and during smoke times we offer assistance to get him up so he can go outside and smoke. On 2/21/26 at 3:00 PM, V2 [Director of Nursing] stated, I spoke with R1, regarding R7 smoking in their room. I completed a room change for R7 the same day. Nursing staff implemented interventions such as frequent rounds to ensure R7 is not smoking in the facility, encourage and assist R7 to attend outdoor smoking during designated times. R7 did admitted he was smoking in the R1 and his room. On 2/21/26 at 3:15 PM, V1 [Administrator] stated, R1 notified me that R7 was smoking in their room. R7 has a room change and is currently on a smoking contract. R7 has violated, and R7 agreed to be discharged to another facility. I responded to R1's concerns immediately. Policy documented in part:Facility Smoking Safety PolicyTo provide a safe and healthy living environment with respect for the health and well-being need of each resident.Smoking is only allowed in designated areas established by management. The interior of the facility will remain smoke-free at all times.

Based on observation, interview and record review, the facility failed to follow their infection control policies and procedures for one of three residents (R3) in the sample of five.Findings include:1.17.2025 at 3:45 PM, observed V7 (CNA-Certified Nursing Assistant) walking out of R3's room down the hallway with gloves on her hands. V7 returned to R3's room, then came back out, walked down the hallway, with gloves on, to the linen cart and removed a facecloth from the cart. V7 returned to R3's room and performed incontinence care. V7 was not wearing a gown while performing incontinence care. The privacy curtain was not pulled around R3's bed, the door to the room was open. EBP (Enhanced Barrier Precautions) sign posted on R3's door documents, in part: Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Changing briefs or assisting with toileting. A soiled brief was noted on the floor next to R3's bed.1.17.2026 at 4:02 PM, V7 said, I believe R3 is on EBP. Surveyor asked V7 what is EBP? V7 said, pointing to isolation cart outside R3's room, EBP is the protective stuff for the face, the gown. V7 said, I was wearing gloves in the hallway. V7 said, I shouldn't have had gloves on in the hallway.1.17.2026 at 4:03 PM, V8 (LPN-Licensed Practical Nurse) said, R3 is on EBP. To prevent the spread of infection, staff should wear a gown and gloves while performing care. Soiled linen/incontinent products should not be thrown on the floor but placed in a bag and disposed of properly.1.17.2026 at 4:15 PM, V9 (LPN) said, staff should wear gown and gloves when performing incontinence care to prevent the spread of infection.1.17.2026 at 4:44 PM, V2 (DON) said, gown and gloves should be worn during resident care (incontinence care) when a resident is on EBP to prevent the spread of microorganisms. Soiled linen/incontinent products should be bagged and disposed of properly to prevent the spread of microorganisms.R3's facesheet documents R3 is a [AGE] year-old admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus with Foot Ulcer, Unspecified Kidney Failure, Dependence on Renal Dialysis and Acquired Absence of Right Leg Above Knee. R3's MDS (Minimum Data Set of 12.5.2025) documents a BIMS (Brief Interview for Mental Status) of 13 (cognitively intact).Enhanced Barrier Precautions policy (Revises 4.28.2025) documents, in part: Purpose: Reduce the transmission of novel or targeted multi-drug-resistant-organisms (MDRO). Procedure 1. Enhanced Barrier Precautions (EBP) require the use of gowns and gloves during high contact resident care activities. High-contact resident care activities include: Changing briefs or assisting with toileting. 7. Adhere to other infection control practices such as: Hand hygiene.Infection Control Policy (Issue Date 1.2024) documents, in part: 15. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments.

Based on observation, interview, and record review the facility failed to ensure a homelike environment due to uncleanliness of resident's rooms noted with paper, trash, and debris throughout residents' rooms. This failure affected 4 of 5 residents (R1, R2, R4, R6, and R7) reviewed for homelike environment.R1's Minimum Data Set Section C dated 11/3/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R2's Minimum Data Set Section C dated 9/4/2025 documents a BIMS (Brief Interview Mental Status) Score of 6 which is indicative of a severely impaired cognition.R4's Minimum Data Set Section C dated 10/27/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R6's Minimum Data Set Section C Dated 10/1/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R1's care plan dated 8/21/2025 documents, in part, no focus for hoarding.R2's Care Plan dated 9/17/2025 documents, in part, no focus for hoarding.R4's Care Plan dated 11/11/2025 documents, in part, no focus for hoarding.R6's Care Plan was reviewed and requested from the facility's administrator but was not received; documents, in part, no focus for hoarding. On 11/10/2025 at 2:34 pm, R1 stated the housekeeper does not come and sweep the floor or mop in his room. R1 stated he has asked the housekeeper to clean his room several times throughout the last 2 weeks, but no one has done any cleaning. Surveyor observed trash on the floor and under his (R1's bed). Surveyor observed a plastic medication cup with R2's room and bed number and PM written on side of the cup, a white paper medication cup with R2's last name, napkins, and plastic silver ware wrappings under R2's bed (R1's roommate). Surveyor noted trash and debris throughout R1's and R2's room. On 11/10/2025 at 2:41 pm, R2 stated he (R2) there is trash all over the floor in his room all the time.On 11/12/2025 at 11:05 am, V8 (Regional Nurse Consultant) housekeeping cleans rooms daily changing bed linens once per day and as needed. V8 stated the floor nurses must ensure the unit stays clean and that housekeeping makes frequent rounds.On 11/12/2025 at 1:12 pm, V14, Housekeeper, was observed standing in the hallway with a cleaning cart by R6's and R7's room. Surveyor entered R6's and R7's room and observed the following items by R6's bed: 3 empty water bottles, 2 empty nutritional supplement bottles, paper, napkins, an undated breakfast meal tray slip that was stuck to the floor, salt and pepper paper wrapping, 1 plastic cup, 2 brown paper towels and a butter cup. V14 entered the room and verified the above-named items on R6's floor. V14 stated R6's family brings R6 many grocery items and R6 is a hoarder. V14 stated she cleaned R6's room this morning. V14 stated the purpose of cleaning residents' rooms daily is to keep a clean environment and to prevent residents from getting sick due to not maintaining infection control measures. On 11/12/2025 at 2:22 pm, R6 stated housekeeping cleaning her (R6's) room about 10 days ago; my (R6's) room was not cleaned this morning; she (R6) went to the bathroom two times recently and noticed stool on the toilet and when she reported it to the staff the bathroom was not cleaned for a long time; and she reported the uncleaned toilet several times because she needed to use the toilet urgently. R6 stated she could not recall the dates the incidents occurred or which staff she reported the uncleanliness to. On 11/12/2025 at 2:40 pm, R4 stated his (R4's) room is cleaned daily except for when V14 (Housekeeper) is assigned to clean his room. R4 stated he had put trash on the floor and left his room intentionally to see if V14 would sweep the trash up and when he returns to his room the trash remained on the floor. Facility Policy titled Policy and Procedure for Safe, Clean, Comfortable and Homelike Environment dated 10/24 documents, in part, The facility will provide a safe, clean, comfortable, and homelike environment to the residents while taking into consideration a person-centered care, where residents' independence is promoted.Facility Policy titled Housekeeping dated 7/2025 documents, in part, To provide guidelines to maintain a safe and sanitary environment forresidents, facility staff and visitors.

Based on observation, interview, and record review, the facility failed to ensure proper administration of medication due to a resident standing at the medication cart taking medication without a nurse's observation to ensure the resident swallowed the medication. This failure affected 1 of 1 resident (R5).The findings include:R5's Physician Order Sheet dated 11/12/2025 does not document a focus for self-administration of medication.R5's Minimum Data Set Section C dated 11/5/2025 documents a BIMS (Brief Interview Mental Status) of a 15 which is indicative of an intact cognition.On 11/12/2025 at 12:32 pm, surveyor observe the medication cart across from the nursing station and R5 putting a medication cup containing several tablets in her mouth followed by drinking water without a nurse present. On 11/12/2025 at 12:33 pm V10, LPN walked pass the surveyor and went behind the nurse's station. V10 stated she (V10) was done passing medication. V10 stated she (V10) did not observe R5 take her medication because she (V10) was doing multiple tasks at one time. V10 stated the purpose of observing residents take their medication is to make sure the resident swallows the medication. On 11/12/2025 at 10:57 am, V2 (Director of Nursing) stated self-administration of medication requires a physician's order, resident education, a care plan, and an assessment to ensure the resident understands the process. V2 stated the purpose of these interventions are necessary for safety and to ensure the resident benefits from the prescribed medication. On 11/12/1015 at 11:02 am, V2 (Director of Nursing) explained that nurses receive comprehensive training in hand hygiene, vital signs, and safe medication administration. V2 stated nurses must not leave medication cups at the bedside due to safety concerns. V2 stated while some residents keep plastic medication cups for personal reasons such as for lotion, nurses are required to check that medications are swallowed. On 11/12/2025 at 2:49 pm, R5 stated she (R5) was standing at the medication cart when V10 handed R5 her medication and V10 walked away for a couple of seconds to take care of something else. R5 stated I poured my own water and swallowed my medication followed by drinking the water. R5 stated V10 never gives her (R5) medication and walks away, she (V10) was just busy at the time. Facility Policy titled Medication Policy dated 10/25/2014 documents, in part, Medications are administered in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility have sufficient staff and a medication distribution system to ensure safe administration of medication without unnecessary interruptions.

Based on observation, interview and record review, the facility failed to provide a clean, safe, and comfortable environment for all 196 residents residing in the facility. Findings include: On 07/01/25, at 10:55 AM, R2 stated the facility is dirty. R2 stated that there are a lot of flies/gnats everywhere inside the facility including in his room, the hallway, the bathrooms, and shower room. R2 stated his garbage is not emptied every day. R2 said, go look inside my bathroom. There is a can of soda that I drank and put into the garbage three days ago and it is still sitting in there. R2 stated the shower room is always dirty and that is unsanitary because that is where he goes to get clean. On 07/01/25, at 11:00 AM, observed can of soda in R2's bathroom trash can and garbage filled half way to the top of the trash can. On 07/01/25 at 11:25 AM, observed the following in the shower room on 2nd floor including empty plastic wrappers, crumbled up brown paper towels, brown soiled/wet toilet paper, a plastic straw, an empty bottle of shampoo, a wet washcloth lying on a shower chair, three small pieces of a dark brown solid material next to the toilet bowl and a towel balled up in the corner which had brown stains on it. Tiny black flying insects were seen flying around the shower drain. The shower drain was covered in a thick coating of hair. In the shower stall farthest to the right observed the ceiling tiles to be speckled with dark patches of black to gray fuzzy material and the grout in between the shower tiles on the walls were covered in a black material that appeared damp and embedded into the crevices. The plastic shower curtain had three to four patches of light brown material stuck on it. Also, in the area where shower chair is used observed handheld shower head attached to a pole however the pole was only attached to the wall at the top, it was not anchored at the bottom so that it the bottom of the poll could easily swing back and forth. On 07/01/25, at 11:27 AM, V15 (Certified Nursing Assistant) observed the condition of the 2nd floor shower room and stated, it looks dirty in here. V15 stated this is the only shower room on the unit and is used by the residents to take showers. V15 stated some residents have their own showers in their room but many residents still like to take showers in the shower room and usually use this one pointing to the shower stall on the far right. V15 observed black/gray spots covering two of the ceiling tiles over that shower stall and dark black material covering most the grout in between the tiles in the same shower stall. V15 stated, that looks like mildew. V15 observed that the pole for the shower head was not fully attached to the wall. V15 stated that has been like that for a while. On 07/01/25, at 11:36 AM, V16 (Housekeeper) stated she prioritizes cleaning the dining room first, then the nursing station, the employee bathroom and she starts cleaning the resident rooms. She eventually works her way toward the shower room. V16 stated she cleaned the shower room yesterday and it looks this dirty every day. V16 viewed the black spots on the ceiling tile above the shower stall and the black material in the grout on the walls of the shower stall and said, I don't know if that is mildew or mold but if it is mold it could make you sick by breathing that stuff in. V16 stated she always wipes down the tile walls but the black material on the grout does not wipe off. V16 observed hanging plastic shower curtain in the shower stall with areas of light brown material stuck it and said, that looks like feces. V16 stated she noticed the metal pole was not attached to the wall but did not say anything about it because she thought the Maintenance Director was doing his own monitoring and that is the type of thing he can and should fix. On 07/01/25, at 11:46 AM, V8 (Housekeeping Director) observed the condition of the shower room. V8 said, it does not look clean in here. V8 stated it looks like some type of material is growing on the ceiling tiles over the shower stall used by the residents and that the black stuff on the grout looks like mold. As surveyor was talking to V8, V8 was swatting away small flying black insects from her face. On 07/01/25, at 11:55 AM, V17 (Maintenance Director) stated he does walk throughs of the unit and talks to the residents and staff to see if there are any problems or if anything needs to be fixed. V17 stated no one told him there were any problems in the shower room so he did not know anything needed to be fixed. V17 stated he needs to make sure things are safe for the residents. V17 observed the dangling pole with the shower head attached to it and stated that the pole should be securely attached to the wall on both ends. As V17 was talking to the surveyor he was swatting small black flies away from his face using his hand/arms. V17 stated those black flies are gnats and they can come from the drains, and they are attracted to water and food. V17 stated the maintenance department treats the drains once a month and he did this 2 weeks ago. V17 observed the ceiling tiles and stated that looks like dust. V17 observed the grout and shower curtain and stated that should not be there and should be cleaned by the housekeeping staff. V17 observed the solid material on the floor next to the toilet bowl and stated, it could be feces. On 07/01/25, at 12:10 PM, R9's garbage can in his room was overflowing with garbage containing empty food containers, plastic drink bottles and tissues/paper. R9 stated that garbage has been there for two to three days. R9 stated his room had not been cleaned since Saturday, 06/28/25. R9 stated he likes to keep his room as clean as possible and wished his room could be cleaned more often, at least every couple of days. R9 said, getting it cleaned daily would be great! R9 stated none of the housekeepers asked him on Sunday or Monday if he wanted his room cleaned. R9 stated if they had he would have told them yes because he likes keeping his room clean and does not like it when the garbage piles up. R9 stated, I don't want to get flies in my room. R9 stated he uses the shower room to take showers because he has to use a shower chair when he showers. R9 stated the shower room is dirty and he has found dirty diapers on the floor, poop on the shower chair and wet/used towels on the floor. On 07/01/25, at 12:25 PM, R10 stated he has a garbage can in his room that is covered with a swinging lid top and inside the garbage can it is full of fruit flies. R10 stated the gnats or fruit flies must be attracted to the food inside of it. R10 is not sure how often his garbage can is emptied but he does not think it is done every day. On 07/01/25, at 12:39 PM, R10 brings surveyor to R10's room. Surveyor observed tall plastic garbage can near the entrance of R10's room with a swing top lid on it. The swing top lid was in the closed position. R10 said, watch this and then quickly took his hand and tapped the top of the swing lid on the garbage can and a swarm of small black winged flying insects erupted from the rim of the garbage can flying around as R10 tried to swat them away. Some of them landed and settled on the wall of R10's room and on the outside of the garbage can. R10 said, see what I mean? R10 stated again he's not sure when the last time the garbage can was emptied. On 07/01/25, at 12:44 PM, V18 (Certified Nursing Assistant) entered R10's room and observed all the tiny black flying insects hovering around R10's garbage can and along the wall in R10's room. V18 said, those are fruit flies or gnats, and they are unsanitary. V18 stated they are attracted to the food inside the garbage can. V18 stated housekeeping should be emptying the garbage cans in the residents' rooms every day. V18 stated she does not know if the garbage cans were emptied yesterday but based on the amount of garbage in that garbage can it does not look like it has been emptied in a while. V18 stated the facility wants to provide a clean and homelike environment for the residents to live in and no one wants flies like that in their home and they should not be in there. On 07/01/25, survey team observed that the 4th floor dining room floor was sticky and could see food particles and debris on the floor. On 07/02/25, at 10:23 AM, observed garbage in R2's bathroom to still be half full and still contain what appears to be the same can of soda seen on 07/01/25. R2 stated see? That is the same can of soda I put in there over the weekend. Why hasn't this garbage been emptied yet? On 07/02/25, at 10:27 AM, V16 (Housekeeper) stated yesterday she got pulled off the floor to treat the grout in the shower stalls to remove the mold that was there and that because of that she was not able clean the rooms at R2's end of the hall. V16 stated that is why she started at this end of the hallway this morning since those rooms were not cleaned yesterday. On 07/02/25, at 10:31 AM, during unit walk through observed tiny black flying insects in the hallway on the 3rd floor. On 07/02/25, at 10:40 AM, observed in the 1st floor shower room that the hand shower nozzle attached to a hose was dangling by the hose along the wall from the water outlet and was not mounted on anything. There was no poll to mount it on. Observed plastic pieces that appeared where an old pole may have been. Also, observed a showed bed with a full-length drain pan underneath the sling attached to the shower bed. In the full-length drain pan there was a large amount of murky brown tinted liquid with brown solid particles floating in the liquid and there was a foul odor coming from the liquid. Also, observed tiny black flying insects in the shower room area. On 07/02/25, at 10:45 AM, V22 (Certified Nursing Assistant) observed the condition of the 1st floor shower room. V22 stated because the detachable shower head does not have anything to be attached to on the wall, the resident using the shower would need to turn on the water and use the detachable shower head to wet their body first, then let go of the shower head to wash their body with soap and then pick the shower head back up to wash the soap off of themselves and then put the shower head back down again while they lather up their hair with shampoo and then pick the shower head back up when they want to rinse the shampoo out. V22 stated this means there is no way the residents can be covered by constant running water the entire time they are in the shower because they need their hands free to give themselves a shower properly. V22 stated she reported the problem directly to someone in maintenance to make them aware that it needed to be fixed. V22 observed the brown stained liquid with solid particles floating in the liquid pooling in the sling of the shower bed. V22 said, that could be feces. V22 stated that shower bed is used when giving R11 a shower. V22 stated she does not know who is supposed to clean that, but it needs to be cleaned, it should not have been left like that. V22 stated that has been like that for approximately one week. On 07/02/25, at 10:51 AM, V23 (Maintenance Assistant) observed the handheld shower nozzle attached to a hose dangling in the shower stall, not attached to anything. V23 stated this problem was not reported to him. V23 stated there should be a poll mounted on the wall so that the handheld shower nozzle can be attached to it so the residents can adjust to the height comfortable for them and so they can have continuous water on them while they are taking a shower, so they do not get cold. V23 observed liquid material in the shower bed under the sling in the drain pan and said, that doesn't look clean. On 07/02/25, at 11:01 AM, V25 (Housekeeper) stated she cleans the shower room every day as part of her daily responsibilities. V25 stated in the shower room she cleans the toilet, sink, shower head and stalls, sweeps/mops the floor and empties all the garbage containers. V25 observed the liquid material in the shower bed under the sling in the drain pan and stated, I don't clean that. When the CNAs give a shower, they are supposed to clean up afterwards. V25 stated that does not look clean and should not be left there. I can see brown liquid with stuff floating around in the liquid. On 07/02/25, at 1:30 PM, surveyor went to wash hands in the basement staff bathroom and when surveyor turned on the water tiny flying black insects flew out of the drain into the air. On 07/02/25, at 1:45 PM, V2 (Director of Nursing) stated he wants the facility to be free from accidental hazards to always keep the residents safe and all equipment should be in good working order. V2 stated the facility should be clean because this is where the residents live. V2 stated the residents have the right to live in a place free of garbage, debris, feces, dirty floors, garbage and free from pest/insects. V2 stated there should be no fruit flies or gnats in the facility because it is not sanitary. V2 said, I don't see them in my home, and I don't want them in here. On 07/02/25, at 2:51 PM, V17 (Maintenance Director) stated all equipment should be in working order to make sure the residents are safe and comfortable here. V17 stated it is everyone's responsibility to report any problems to the maintenance department. V17 stated he was not aware that the shower rails or shower head holder needed to be fixed or that it was broken and needed to be replaced. V17 stated if he had known that was a problem he would have fixed those areas right away. V17 stated he was not aware that there was a gnat problem, otherwise he would have called the pest control company immediately. V17 stated gnats are not going to go away on their own, they need to be treated and kill because otherwise they will continue to multiply. On 07/02/25, at 2:09 PM, V1 (Administrator) stated the facility wants to provide a clean, safe, and homelike environment for their residents. V1 stated it is important for the resident's well-being, infection control and safety. V1 stated the facility should be free from environmental hazards to keep the residents and the staff safe. V1 stated the purpose our pest control policy is to identify any pest problem and treat for pests to prevent the spread of them. V1 stated pests include insects like gnats and fruit flies. V1 stated pests/insects will not go away on their own and if the staff are seeing pests in the buildings, then they should be reporting that so the pest control company can treat for that. V1 stated the shower room drain should not be covered in hair or have any black/moldlike substance because that is unsanitary, there should be no feces like material on the floor or on the shower curtains or in the shower bed, and shower parts should be in good working order for resident comfort and safety. R2 has a diagnosis including but not limited to Hepatic Encephalopathy, Other Cervical Disc Degeneration, Cervicothoracic Region, Generalized Anxiety Disorder, Esophageal Varices Without Bleeding, Repeated Falls, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region, Type 2 Diabetes Mellitus Without Complications, Insomnia, Major Depressive Disorder, Recurrent, Primary Insomnia, Alcohol Use, In Remission. R2's Brief Mental Status Interview (BIMS) dated 06/04/25 documents score of 15/15 indicating intact cognition. R9 has a diagnosis including but not limited to Paraplegia, Unspecified, Other Specified Diabetes Mellitus Without Complications, Age-Related Nuclear Cataract, Bilateral, Regular Astigmatism, Left Eye, Nicotine Dependence, Unspecified, With Unspecified Nicotine-Induced Disorders, Opioid Use, Uncomplicated, Bipolar Disorder, Generalized Anxiety Disorder, Primary Insomnia, Weakness, Opioid Abuse, Other Psychoactive Substance Use, Unspecified With Psychoactive Substance-Induced Sleep Disorder, Polyneuropathy, Bipolar Disorder, Current Episode Manic Without Psychotic Features, Moderate, Attention-Deficit Hyperactivity Disorder, Other Type, Suicidal Ideations, Anxiety Disorder, Insomnia, Tachycardia, Major Depressive Disorder. R9's BIMS dated 04/30/25 indicates intact cognition. R10 has a diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified, Unspecified Chronic Bronchitis, Other Asthma, Bronchitis, Not Specified As Acute Or Chronic, Hypoxemia, Hypertensive Heart Disease With Heart Failure, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Non-St Elevation Myocardial Infarction, Essential (Primary) Hypertension, Peripheral Vascular Disease, Alcohol Dependence, In Remission, Generalized Anxiety Disorder, Mixed Hyperlipidemia, Alcoholic Polyneuropathy, Major Depressive Disorder, Weakness. R10's BIMS score dated 05/01/25 indicates intact cognition. R11 has a diagnosis including but not limited to Muscle Wasting And Atrophy, Not Elsewhere Classified, Multiple Sites, Unspecified Protein-Calorie Malnutrition, Age-Related Nuclear Cataract, Bilateral, Limitation Of Activities Due To Disability, Need For Assistance With Personal Care, Difficulty In Walking, Other Lack Of Coordination, Cutaneous Abscess Of Right Axilla, Hidradenitis Suppurativa, Muscle Weakness (Generalized), Nutritional Anemia, Unspecified, Essential (Primary) Hypertension, Unspecified Osteoarthritis. R11's BIMS score dated 05/05/25 indicates intact cognition. R11's MDS (Minimum Data Set) dated 05/05/25 indicates R11 is dependent on staff for all ADL and mobility and is always incontinent of urine/bowel. Facility provided document titled, Illinois Long-Term Care Residents' Rights for People in Long-Term Care Facilities dated 11/2018 which documents in part, your facility must be safe, clean, comfortable, and homelike. Facility provided document titled, Housekeeping Guidelines dated 07/2021 which documents in part, the purpose is to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors and housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner and pest control services will be monitored by the housekeeping personnel and shall report any problems or needs concerning pest control to the Administrator and contact will be made to outside service. Facility provided job description titled Housekeeping Assistant dated 07/2024 documents in part the primary purpose of this job is to perform the day-to-day activities of the Housekeeping Department at accordance with current federal, state, and local standards, guidelines, and regulations governing the facility, and as may be directed by the Administrator and or the Director of Housekeeping, to assure that the facility is maintained in a clean, safe, and comfortable manner. Facility provided document titled, Preventative Maintenance Program dated 11/2023 which documents in part, purpose is to conduct environmental/safety audits to identify areas of concern within the facility and the preventative maintenance program will review the following areas including but not limited to all facility areas are kept clean and in safe condition, ceiling tiles are free from watermarks or spots, drains are clean and free of debris. Facility provided document titled, Safety and Supervision of Residents dated 11/2024 which documents in part, our facility strives to make the environment as free from accident hazards as possible. Facility provided document titled, Pest Control Policy dated 11/2024 which document in part, the purpose is to prevent or control insects and rodents from spreading disease, and the facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents and garbage and trash containers shall be emptied when full and cleaned prior to returning to the appropriate area.

Based on observation, interview, and record review, facility failed to follow their policy to ensure a call light was within reach for one (R4) out of three residents reviewed for call lights in a total sample of 9. Findings include: R4's MDS (Minimum Data Set) section C (Cognitive Patterns) dated May 28, 2025, documents R4's Brief Interview for Mental Status (BIMS) as 15/15 indicating R4 has intact cognitive functional abilities. MDS Section GG-Functional abilities documents R4 requires Substantial/maximal assistance with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, Lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet, and R4 is a two person assist. On 06/04/2025, at 12:03 PM, R4 was observed trying to sit up in bed, alert, oriented to person, place, time, and situation. R4 was observed trying to get himself into a sitting position and was observed looking for something. R4 stated he was looking for his call light to get staff's attention to get him up and out of bed. R4 was tired of staying in bed and his back was hurting him. R4 stated he could not find his call light. R4 was observed with left hand contractures. On 06/06/2025, at 12:10 PM, V11 (Certified Nursing Assistance-CNA) and surveyor observed R4's call light hanging on top of R4's overhead light far from R4's reach. R4 stated he could not reach the call light. V11 stated R4 would not be able to reach the call light where it was placed. Therefore, he would not be able to use it to get staff's attention for his needs. V11 stated if call lights are not within reach, residents are unable to make their needs known. R4 could have fallen and hurt himself trying to adjust himself or reach for the call light. On 06/04/2025, at 12:24 PM, V3 (Assistant Director of Nursing-ADON) stated call lights should be within residents' reach for residents to use in case of an emergency or to get their needs met. If residents cannot reach the call light in an emergency their needs will not be met and the resident could experience negative outcomes such as falls. On 06/05/2025, at 9:34 AM, V2 (Director of Nursing-DON) stated resident's call lights should be within reach so that the resident can use it to reach staff in case of an emergency or if the resident needs help from staff. V2 stated if the call light is not within resident reach, the resident will not be able to reach staff. R4's fall care plan documents: Be sure call light is within reach and encourage the resident to use it for assistance as needed. Staff to respond promptly to all requests for assistance. Facility's call light policy dated 1/25 documents: All residents shall have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the resident's physician for one (R8) out of three residents in a total sample of nine residents reviewed. Findings include: On 06/04/2025, at 9:42 AM, surveyor located on the second floor of the facility with V7 (Licensed Practical Nurse/LPN). V7 observed with a medication cart and performing a morning medication administration pass. V7 has R8's eMAR/electronic medication administration record deployed on the computer. Surveyor observes the following order for R8 Procardia XL Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine)- Give 1 tablet by mouth one time a day for HTN (high blood pressure). Can hold if blood pressures are persistently 130/80 mmHg. V7 states it is important to measure a resident's blood pressure reading prior to administering any medications that will lower a resident's blood pressure. V7 states this is to establish the resident's blood pressure in an effort to prevent the administration of unnecessary blood pressure medications. V7 states if a resident is administered blood pressure medications and their blood pressure is already low, then this can cause the resident's blood pressure to drop too low. V7 states this can potentially cause a resident to go into cardiac arrest. R8's eMAR documents that R8 is prescribed the antihypertensive blood pressure medication: Procardia XL Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine). R8's eMAR documents that R8's blood pressure reading was not assessed and documented prior to the administration of his antihypertensive medication Procardia on the following dates: 05/11/2025, 05/15/2025, 05/17/2025, 05/18/2025, 05/21/2025, 05/22/2025, 05/26/2025, 05/29/2025, 05/31/2025. On 06/05/2025, at 10:05 AM, V2 (Director of Nursing/DON) states medications should be administered per physician orders. V2 states if a resident is given blood pressure medication and their blood pressure is already low, then the resident's blood pressure could further decrease. V2 states the resident could also become dizzy, faint, and then require emergency medical services. V2 states blood pressure parameters are established by the physician. V2 states blood pressure medications should not be administered outside of the physician orders and parameters. V2 states if blood pressure parameters are not ordered, then the physician should be notified to receive blood pressure parameters. V2 states she does not expect the nurses to administer blood pressure medications to residents without first assessing the resident's blood pressure. Facility document dated 10/25/2014, titled Medication Administration documents in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 4) FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration. 12. When possible, the medication administration record (MAR) should contain supplemental information to help assure accurate dosing. 2) Medications are administered in accordance with written orders of the prescriber.

Based on interview and record review, facility failed to protect residents from physical abuse. This failure affected three residents (R2, R3, R5) of ten residents reviewed for abuse. This failure resulted in R1 slapping R2 on the smoking patio, R4 punching R3 in the face causing R3 to bleed from her mouth, R6 punching R5 in the face, and R6 pulling R5's hair resulting in R5 being pulled down to the ground by her hair. Findings include: Facility's Final Investigation Report (dated 04/14/2025) states in part: On April 08,2025, staff observed an interaction between residents R1 and R2 that involved a brief verbal and physical exchange. R1 allegedly made contact with R2's wheelchair when he was trying to maneuver his walker on the smoking patio. R2 allegedly responded by making a remark to R1. R1 then allegedly made soft physical contact with R2. A head-to-toe assessment was completed, and no injuries were noted. Staff responded promptly, calmly separated the residents, and ensured the safety and well-being of both individuals. No further incidents have occurred. The physician ordered for R1 to be sent for psychiatric evaluation at the hospital. R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Muscle wasting and atrophy, dysphagia, oropharyngeal phase, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus without complications, asthma. Minimum Data Set Section (MDS) section C (dated April 22, 2025) documents that R1 has an Interview for Mental Status (BIMS) score of 15, indicating that R1's cognition is intact. Care plan (dated 01/15/2025) documents that R1 presents with moderate to intense anger related to verbal expressions of distress, persistent worry and frequent complaints. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Limitation of activities due to disability, difficulty in walking, lack of coordination, pain in right lower leg, pain in left lower leg, muscle wasting and atrophy. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R2 has an Interview for Mental Status (BIMS) score of 11, indicating that R2 has a mild cognitive impairment. Care plan (dated 04/01/2025) documents that R2 has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior. On 05/13/2025, at 1:40 PM, surveyor observed R2 sitting in his bed. Surveyor conducted an interview with R2 pertaining to the physical altercation with R1 that took on 04/08/2025, on the outside smoking patio. R2 stated, R1 hit me in the face outside while I was smoking. I did not know R1 prior to the incident. We did not have an argument, R1 just hit me in the face out of the blue. R1 said that I was sitting in his spot. We have not had any more incidents after that. On 05/13/2025, at 2:00 PM, V3 (social worker) stated, On 04/08/2025, I was passing out the cigarettes to the residents on the 1st floor dining hall during the smoke break. A resident walked up to me and told me that R1 hit R2. I went outside to the patio. I asked R2 what happened and R2 said nothing happened. I asked everybody else on the patio what happened, and they all said nothing. I went to speak to the residents on the left side of the patio and the residents said that R1 hit R2. I went back inside to resume passing out cigarettes and then R2 came inside and told me that R1 hit him. R2 explained to me what happened. I told him to stay by my side until the smoke break is over. I asked R2 if he was okay, and R2 said that he was fine. After the smoke break, I reported this to the social service director, V4, and administrator. V4 (social service director) and I went to the administrator's office to watch the footage of what occurred between R1 and R2. After watching the footage, it was true that R1 hit R2. V4 and I went to speak to R1 and to hear his side. R1 said that R2 hit R1, and that R1 hit R2 in self-defense, which was not true. R2 did not have any injuries. R2 was stable and not in distress. R1 did display aggressive behavior towards staff but not residents. R1 and R2 did not have any prior encounters or any prior issues. R2 is known to use foul language towards other residents and staff, however, there was no prior encounters between R1 and R2. On 05/14/2025, at 9:46AM, V1 (administrator) stated, On 04/08/2025, during a smoke break on the smoking patio, R2 was sitting in his wheelchair blocking the walkway. R1 was trying to walk past R2 with his walker. While R1 was passing R2, R1 bumped R2's wheelchair. R2 had words with R1 about R1 bumping R2's wheelchair. R1 and R2 were at each other's face. While arguing, R1 slapped R2. The smoke attendant immediately intervened. At first, the smoking attendant did not witness R1 slapping R2, but R2 reported being slapped to the smoking attendant. The two residents were immediately separated. R1 was checked to see if he was injured. The smoking attendant notified the nurse. There were no prior incidents between R1 and R2. R1 and R2 have not had any other incidents after the altercation. On 05/14/2025, at 10:42 AM, surveyor observed R1 lying in his bed. Surveyor conducted an interview with R1 pertaining to the physical altercation with R2 that took on 04/08/2025, on the outside smoking patio. R1 stated, I'm on oxygen and I normally sit by the door on the smoking patio. All the residents know that I sit there because that's my usual spot. I noticed several times that R2 would be sitting there in his wheelchair. I offered R2 a cigarette a few times so that R2 can move out of my spot, but he would continue to sit there. I confronted R2 about why he keeps on sitting in my spot. When I confronted R2, R2 told me, F*** Y**. I stood up and went to sit on the opposite side of R2, but R2 continued to argue with me. I said to R2 that R2 wasn't having a problem with me when I kept giving him cigarettes so that he can move out of my spot. R2 called me a B****, and I told R2 that he's a B****. That's when R2 said, What are you going to do about it, and R2 tried to swing on me. Luckily, I moved out of the way so R2 did not punch me. That's when I punched R2 in self-defense. R2 and I never had any issues or arguments prior to the physical altercation. R2 and I are fine now, and we don't hold any grudges. We are both men and we both don't hold grudges. On 05/14/2025, at 12:02 PM, V4 (social service director) stated, I did not witness the incident that occurred on 04/08/2025, between R1 and R2. I reviewed the video footage. From the footage it appeared like R1 and R2 were arguing. R2 had his hands up in self-defense. R1 punched R2. I did not see in the footage that R2 was trying to hit R1 at all. I am not aware of R1 and R2 having any conflicts prior to this incident. R1's Progress Note (dated 04/08/2025) documents, Resident allegedly displayed violent/aggressive behavior towards peers. Resident was placed on 1:1 with a staff member. Doctor was notified and gave an order to send resident to the community hospital for a psychiatric evaluation. Ambulance was called estimated time of arrival is 60 minutes. R1's Progress Note (dated 04/08/2025) documents, Resident sent to community hospital for psychiatric evaluation. Resident transported by ambulance. R2's Progress Note (dated 04/08/2025) documents, R2 was involved in a peer-to-peer disagreement in the smoke break area. Body assessment completed. No injuries noted. Police notified. Physician notified. R2 is own responsible party. Social services notified. Director of nursing and administrator notified. Facility Final Incident Investigation Report (dated 05/01/2025) documents in part: On April 25, 2025, it was reported that R3 and R4 were involved in a peer-to-peer altercation in their room. R3 and R4 both agreed that R3 [NAME] water on R4 and then R4 made contact with R3 as she was trying to not get the water thrown on her. Staff immediately intervened and separated the two residents. A body assessment was performed. R3 was noted to be free from any injury and was in good spirits. R4 was very upset and wanted to go against medical advice (A.M.A.) because she didn't mean to make contact. R4 was sent out to the hospital for the incident as she was crying hysterically and was unable to control her emotions. R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Dysphagia, oropharyngeal phase, dementia in other diseases classified elsewhere, unspecific severity, with anxiety, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, essential (primary) hypertension, weakness, metabolic encephalopathy. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R3 has an Interview for Mental Status (BIMS) score of 12, indicating that R3's cognition is intact. Care plan (dated 03/03/2025) documents that R3 is at risk for seizure activity related to seizure disorder and receives medication for management. R4's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Muscle wasting and atrophy, paranoid schizophrenia, hallucinations, major depressive disorder, psychoactive substance abuse, uncomplicated. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R4 has an Interview for Mental Status (BIMS) score of 12, indicating that R4's cognition is intact. Care plan (dated 02/25/2025) documents that R4 uses psychotropic medications and has potential for falls and or drug related movement disorder 2/2 adverse effects of medication. On 05/13/2025, at 2:36 PM, surveyor observed R3 lying in bed. Surveyor interviewed R3 pertaining to the physical altercation that took place on 04/25/2025, between R3 and her roommate, R4. R3 stated, On 04/25/2025, R4 punched me really hard. We were roommates. R4 came to my side of the bed while I was lying down. She punched me really hard causing me to bleed from my mouth. Prior to the physical altercation, R4 and I always argued. R4 was always starting with me. R4 threatened me with a knife before and we had many arguments. On 04/25/2025, that's when R4 came to my side of the bed, and she punched me. I was bleeding. The staff knew that we had arguments before the physical altercation, and they interviewed on many occasions. I feel safe in the facility now that R4 is gone. On 05/13/2025, at 2:41 PM, V3 (social worker) stated, On 04/25/2025, the nurse on duty requested for social services to come to R3 and R4's room. R3 and R4 were roommates at the time. As I walked in, there was two certified nursing assistants and a nurse in R3 and R4's room. The nurse informed me that R4 hit R3. I called V4 (social service director) immediately to come to the room as well. V4 and I spoke to R3 to see what happened. R3 said that R4 came to R3's side of the bed and hit R3 in her mouth. It was obvious that R3 got hit by R4 because there was blood on R3's mouth. R3 is alert and oriented and R3 was able to tell me what happened. R3 and R4 were separated by staff. Prior to the physical altercation on 04/25/2025, R3 and R4 had verbal arguments because they were not getting along. There was conflict between R3 and R4 before R4 got physical with R3. Prior to the physical altercation, R3 and R4 had to be separated during verbal arguments a few times, but it was not physical, it was verbal. R3 and R4 would argue and then they would act as if it never happened. When it comes to moving rooms, the admission director is in charge or moving residents. I asked R3 and R4 if they wanted to change rooms and they both refused to change rooms. R3 came from the 4th floor and R3 was refusing to move back to the 4th floor. There was no other female room that was available for R4 to move to at the time they argued. R3 and R4 had about 3 verbal arguments that had to be separated by staff. After the physical altercation, R4 was sent to the hospital for psychiatric evaluation. When I requested to have R3 and R4 placed in different rooms, the admission director told me that there is no other place to move R4. On 05/14/2025, at 9:56 AM, V1 (administrator) stated, On 04/25/25, R3 was lying in bed and R4, who was R3's roommate at the time, came to R3's bedside to talk to R3. They were having a conversation and R3 did not like the way the conversation was going. R3 threw water at R4. When R3 threw water at R4, R4 stuck her hands out in self-defense. The staff heard R3 yelling and then R4 started yelling. Staff went into the room and immediately intervened. R4 started spiraling and going into psychosis. R4 was sent out the hospital for psychiatric evaluation and she did not return back to the facility. R4 was a resident in a wheelchair just like R3. I was not aware that R3 and R4 had several prior conflicts. If I was aware, I would make sure that R3 and R4 are separated in different rooms. V6 (admissions director) is the one that is responsible to assigning a different room to residents. On 05/14/2025, at 11:24AM, V6 (admissions director) stated, R3 and R4 had conflict. I am only aware of one conflict between R3 and R4 and that's the incident that turned physical on 04/25/2025. Prior to 04/25/2025, I did not have any knowledge of there being a conflict between R3 and R4. R3 and R4 were roommates. I was never asked to do any room changes for either R3 or R4. On 05/14/2025, at 12:05 PM, V4 (social service director) stated, I am aware of small bickering between R3 and R4 before the physical altercation that took place on 04/25/2025. R3 and R4 would argue and make up after that. I am not aware of staff having to intervene to stop R3 and R4 from arguing. I am not aware of a room change being requested for R3 and R4 prior to the physical altercation. I think that R3 has moments of responding to auditory illusions and R3 and R4 were not understanding one another. On 05/14/2025, at 3:24 PM, V8 (licensed practical nurse) stated, I was nurse on duty on 04/25/25, when the incident occurred between R3 and R4. From what I remember, the certified nursing assistant told me that something happened in the room. I went into R3 and R4's room. I remember R4 being really angry and upset because R3 was saying that R4 is not able to have kids. R4 said that R3 and R4 were arguing back and forth. R4 told me that they basically had an altercation. I saw a little bit of dried blood on R3's lip. R4 denied hitting R3, but R4 claimed that R3 pushed her. I told R4 that I'm going to be sending R4 out because she should not have touched R3. I filed a police report and R4 was sent to the hospital for psychiatric evaluation. R3 told me that basically R4 hit R3. I am not aware of any prior incidents between R3 and R4. On 05/14/2025, at 11:39 AM, V11 (certified nursing assistant) stated, On 04/25/2025, I was working on the 2nd floor. V12 (certified nursing assistant) was assigned to R3 and R4. I heard V12 informing the nurse that R3 said that R4 hit her and that R3 was bleeding. I did not see the incident and I did not see anything else. R3's Progress Note (dated 04/25/2025) documents, Writer was told by staff that resident was hit in the mouth by another resident. Nurse assessed resident and found no injuries. The police were called and the other resident sent out for evaluation. Director of nursing, abuse coordinator, hospice was notified, and family. No new orders given. Will continue plan of care. R4's Progress Note (dated 04/25/2025) documents, Resident was involved in a peer-to-peer altercation with another resident. Resident assessed. No injuries noted. Resident is responsible party. Police notified. Physician notified. Director of nursing and administrator notified. R4's Progress Note (dated 04/25/2025) documents,R4 discharged to community hospital 04/25/2025, 12:00 AM. Reason for transfer: behavior-psychosis. Vitals were stable. The following people were notified of transfer: Physician, Nurse Practitioner. Yes - Current reconciled medication list provided to the subsequent provider. Facility's Final Investigation Report (dated 04/02/2025) documents in part: On March 27, 2025, staff observed an interaction between residents R5 and R6 that involved a brief verbal and physical exchange. R5 allegedly made a comment toward R6, and R6 allegedly responded by making soft physical contact with R5. A head-to-toe assessment was completed, and no new injuries were noted. Staff responded promptly, calmly separated the residents, and ensured the safety and well-being of both individuals. R5's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Muscle wasting and atrophy, acquired absence of right leg below knee, acquired absence of left leg below knee, bipolar disorder, major depressive disorder, essential (primary) hypertension. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R5 has an Interview for Mental Status (BIMS) score of 13, indicating that R5's cognition is intact. Care plan (dated 05/12/2025) documents that R5 presents with moderate to intense anger related to: Symptoms of mood distress (i.e., anger, sadness, loss of interest, lack of pleasurable experiences, poor appetite or excessive eating, impaired sleep), This problem/need is manifested by: Poor listening skills (often becoming angry, defensive, oppositional when assistance & suggestions are provided)., This problem/need is manifested by: Verbal expressions of distress., This problem/need is manifested by: Persistent worry. R6's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Metabolic encephalopathy, type 2 diabetes mellitus, altered mental status, peripheral vascular disease, essential (primary) hypertension. Care plan (03/27/2025) documents that R6 has diabetes mellitus & the potential for complications related to: History of uncontrolled diabetic status. On 05/13/2025, at 2:50 PM, surveyor observed R5 sitting in her wheelchair. Surveyor interviewed R5 regarding the physical altercation that took place in the 1st floor dining room on 03/27/2025, between R5 and another resident, R6. R5 stated, R6 kept calling me names. R6 and I had an argument and R6 came at me and punched me in my cheek. After that, R6 grabbed me by my hair and I fell out of my wheelchair to the ground. I did not know R6 before this altercation occurred. R6 and I did not have any issues prior to the fight. We were swearing at each other, and I think that's why R6 hit me. R6 is the one that escalated the argument into physical violence. I feel safe in the facility. I can't recall why the argument started. On 05/14/2025, at 10:06 AM, V1 (administrator) stated, On 03/27/2025, R5 called R6 a bi***. R6 was standing right by R5. R6 pushed R5. Staff were right there because it took place in the dining room and staff immediate intervened. R5 apologized to R6 right away. R5 said that R5 was experiencing anxiety and regret about the situation. R6 also apologized to R5. The staff who witnessed the incident reported that they witnessed R6 pulling R5 by her hair and they witnessed R6 punching R5. R5 and R6 did not have any prior issues. R6 was a new admission to the facility. R6 discharged herself against medical advice the same day that the incident occurred. R5 initiated the incident by calling R6 out of her name and R6 responded with physically hurting R5. On 05/14/2025, at 1:05 PM, V10 (certified nursing assistant) stated, On 03/27/2025, it was early morning, and the breakfast trays were coming up to the 1st floor. I was with the trays. When I went into the dining room, I saw commotion going on. When I asked what happened, the residents in the dining room reported that R6 pulled R5's hair and that R6 punched R5. I did not see the incident, but the other residents told me that's what happened. On 05/14/2025, at 2:05 PM, V9 (licensed practical nurse) stated, On 03/27/2025, I was doing my medication administration on the 1st floor. I heard yelling coming from the dining room. I went into the dining room, R5 and R6 were no longer fighting, but I was informed by other residents that R5 and R6 were fighting. I separated R5 and R6 immediately. It was reported to me by R6 that R5 called R6 a B****. R6 said that she punched R5 and pulled R5's hair. R5 told me that R5 slid out of her chair when R6 pulled R5's hair. R5 told me that R5 called R6 out of her name and R6 responded by pulling R5's hair and punching R5. R5 did not appear to have any blood and R5 did not complain of any pain. R5 and R6 apologized to each other and R5 and R6 did not have any prior conflict. R6 was a new resident to the facility. R5's Progress Note (dated 03/27/2025) documents, Patient involved in physical altercation with another patient. Patients separated and later apologized and reconciled. No injuries involved. Patient in stable condition. R6's Progress Note (dated 03/27/2025) documents, Patient involved in physical altercation with another patient. Patients separated and later apologized and reconciled. No injuries involved. Patient in stable condition. Abuse Prevention Policy (dated 01/2024) documents in part: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Resident Rights Policy (revised 11/2018) states in part: You must not be abused, neglected, or exploited by anyone-financially, physically, verbally, mentally or sexually.

Based on observations, interviews, and record reviews, the facility failed to provide sanitary drinking water and ice by not maintaining their water and ice machines. This has the potential to affect all 199 residents that receive hydration orally. Findings include: On 5/14/2025, at 10:50 AM, V9 (Nurse) showed surveyor the ice and water machine inside the first-floor nourishment room. V9 stated residents are free to grab water and ice from the machine. The machine had streaks of white and tan mineral buildup along the front panel, around the spout where the water and ice dispense, and around the collection tray. There was also white mineral buildup on the counter under the machine. The machine was continuously dripping throughout the interview. V9 stated housekeeping is supposed to clean the machine daily. On 5/14/2025, at 11:17 AM, V13 (Nurse) stated second floor staff get the residents' drinking water and ice from the first or third floor nourishment area. On 5/14/2025, at 11:33 AM, the ice machine in the third-floor nourishment room had white and gray mineral build-up on the inside left wall. There was also white and tan residue on the door of the ice machine. On 5/14/2025, at 11:35 AM, V14 (Nurse) stated third floor staff get the residents' drinking water from the sink in the third-floor dining room. On 5/14/2025, at 11:39 AM, V15 (Certified Nurse Aide-CNA) stated the sink in the third-floor dining room is used for handwashing. V15 gets the residents' drinking water from the first-floor machine or from the sink in the clean utility room. V15 showed the surveyor the sink and it had mineral buildup. V15 stated staff use the same sink for handwashing. On 5/14/2025, at 11:46 AM, V16 (CNA) stated getting the residents' drinking water from the third-floor dining room sink. V16 gets the ice from the nourishment room in the first or third floor. On 5/14/2025, at 12:06 PM, V17 (Nurse) stated the residents receive tap water from the fourth -floor utility room sink. On 5/14/2025, at 12:10 PM, V5 (CNA) stated getting the residents' drinking water from the fourth-floor dining room sink. V5 showed the surveyor the sink and there was a moist towelette and small face towel on top of the sink. V5 stated one of the residents must have left the items there. V5 stated staff and residents also use the same sink for handwashing. V5 stated staff get ice from the kitchen, first floor, or third floor machines. On 5/14/2025, at 12:23 PM, V18 (Nurse) stated getting the residents' drinking water from the med room or the faucets. V18 showed the surveyor the med room sink. There's white, tan, and brown mineral buildup around the faucet base. On 5/14/2025, at around 2:39 PM, V24 (Maintenance Director) stated he has not called outside company for maintenance work for the water/ice machine on the first floor. V24 believes the last time the facility called an outside company to inspect the machine was before V24 started working for the facility in November 2024. V24 and surveyor went to nourishment room. V24 stated part of the problem is how the staff get the water and ice and how they leave it. V24 stated CNA was just in there and look at how they leave it. The collection tray was filled with ice. V24 stated the piece of panel supporting the machine is also old and dissolving. V24 pointed to the part that the panel was split open and brown residue was coming out of. On 5/15/2025, at 10:57 AM, V20 (First-Floor Housekeeper) stated V30 is supposed to clean the ice/water machine on the first floor daily. V30 stated it is hard to clean it because V30 can't get the mineral buildup off the machine or counter. V30 stated the machine is not good and leaks all the time. On 5/15/2025, at 12:25 PM, V2 (Director of Nursing) did not know when the first-floor ice/water machine was last serviced for maintenance and inspection. V2 stated staff expects maintenance to keep everything fixed and in working condition. V2 also expects housekeeping to keep everything clean and tidy. V2 stated staff are to get residents' drinking water from the kitchen or the first-floor machine. V2 stated staff should not be getting it from where they wash their hands. On 5/15/2025, at 12:37 PM, V27 (Dietary Director) stated [V27] was not in charge of the first-floor water/ice machine maintenance. On 5/15/2025, at 12:45 PM, V1 (Administrator) stated [V1] did not know who was responsible for the first-floor ice/water machine maintenance. V1 stated the facility had a meeting yesterday after the survey team pointed out the issues and moving forward it will be a combination of maintenance and housekeeping that will oversee it. On 5/16/2025, at 11:30 AM, V1 reported that out of the 200 residents in the facility, only one was NPO (nothing by mouth) - R21. When survey team asked for facility's residents' rights policy, facility provided the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities document (Rev. 11/18). It documents in part: Your facility must be safe, clean, and comfortable and homelike. Facility's Preventative Maintenance Program policy (11/14; review date of 11/2023), documents in part that it is the Maintenance Director and/or Housekeeping Director's responsibility to conduct regular environmental tours/safety audits to identify areas of concern within the facility. They are to do random rounds to review all facility areas are kept clean and in safe condition. Facility's Policy & Procedure Chest/Ice Scoop/Ice Machine Cleaning and Disinfecting (issued 8/2020) documents in part: The ice chest shall be cleaned and sanitized routinely by the Dietary Department. The ice machine will be cleaned and disinfected monthly by the Dietary department.

Based on interview and record review, the facility failed to ensure that residents do not have access to alcohol and other illicit drugs while at the facility. This failure affected one resident (R1) and has the potential to affect four other residents (R2, R5, R6, and R11) reviewed for adequate supervision and access so alcohol/illicit drugs at the facility. As a result, R1 got drunk and consented to sexual activity that she claimed happened while under the influence of alcohol and illicit drugs. R1 reported that the sexual activity caused emotional harm to her(R1) and R1 was sent to the hospital. Findings include: R1's records show the following: Progress notes dated 4/25/25 at 11:00pm written by V7(RN/Registered Nurse) states in part that R1 was suspected to be intoxicated. V7 notified the Nurse Practitioner who gave an order to hold all R1's medications for the night. Progress notes dated 4/28/25 at 6:35pm written by V3(Social Services Director) states in part that R1 was tested for drugs because R1 admitted to using drugs recently. Test results showed that R1 had cocaine and marijuana in her system. On 5/1/25 at 12:05pm, R1 stated (R2) is a friend. He's nice and respectful. We smoke and drink together. On this Friday night, we were drinking and I got very drunk and went to my room to lay down. In the middle of the night, I felt somebody penetrated me; I felt there was a chain on the neck of the person. The next day when I woke up at 5am, I was naked. I did not give consent to have sex with anyone. When I asked the nurse, the nurse told me that I was intoxicated and throwing things around in my room. So, I did not tell her that I thought someone raped me. So, on Monday, I told the staff that supervise us during smoking, and also told the nurse (V5/LPN/Licensed Practical Nurse). So, they called the ambulance, but I went to my sister's house on a pass and told my sister. My sister called here and spoke with the nurse, and the nurse told me to come back to the facility. I returned about 3pm when my pass was over. I was sent to the hospital and did all the tests and came back here. Inquired from R1 if R1 had been drinking and smoking anything outside of the official smoking time that is supervised by staff. R1 responded that she(R1) and other residents usually drink and smoke pot (Marijuana) together. On 5/1/25 at 11:45am, R2(male resident/alleged sexual abuser) stated I was chilling and (R1) came into my room around 10:00PM. She and I were getting intimate together in my room. We then went into the bathroom and smoked a blunt and she gave me oral sex. It was just the two of us in the bathroom. After she gave me oral sex, she went to her room. She came back down to my room and told me that her roommate was asleep so we could have sex in her room. After we smoked a blunt, we had sex. I left her room and went back to my room. We both agreed to the oral sex and intercourse. I texted her thank you and she sent me a heart emoji. R2 added that R1 was her normal self and was cracking jokes and chilling before and after the intercourse. R2 stated that R1 told him not to tell anyone that they had sex because she has a boyfriend. R2 stated that R1 did not appear intoxicated or impaired to him, and she(R1) put herself into bed and the sex was not aggressive. R2 stated that this was not the first time, and it was consensual. On 5/7/25 at 9:16 am, V7(RN) was interviewed and stated I was the nurse on the unit that Friday night. I saw (R1) in her bed when I did my rounds. I saw some of her things like water bottle and plate on the floor. I did not see her go into anybody's room and I did not see anybody go into her room. She did not report anything to me. But when I came to work on Monday evening, and I heard about what happened, I was surprised. I was the nurse for Friday night and Saturday night, and I was surprised that all throughout my 12 hours shift on Friday and Saturday, she(R1) did not tell me anything unusual happened. On 5/7/25 at 10:41am, V8 (CNA/Certified Nurse Assistant) stated I was the aide on that unit for the night. I made rounds to check everyone up to 4 times, and each time, I saw her(R1) in her bed. The last time I made my rounds, she(R1) asked me for water, and I went to get her water. I did not see anyone go into her room, and I did not see her go into anybody's room. I did not hear any screaming or yelling or nothing. It's my first time of working on that unit. On 5/5/25 at 2:00pm, V12(Receptionist/Director of Admissions) was interviewed about how some residents were able to bring alcohol/drugs into the building. V12 stated We check their bags but not their person. If anyone brings in drug or alcohol, we let them have a seat in the lobby and call social services staff so take it from there. On 5/8/25 at 2:25pm, V11(R1's Physician/Medical Director) was interviewed about residents getting access to alcohol/drugs and becoming intoxicated and the possible effects on the residents. V11 stated They notified me about the situation, and I spoke with (R1). (R1) told me that she got the alcohol from outside. I suggested that the facility puts her on Pass Restriction, and anyone else who comes back to the facility with alcohol or is intoxicated. V11 added Alcohol intake will increase the sedation for anyone on pain medication, and there are other side effects on other medications the patient is taking. I'm concerned about this situation just like you're concerned. I'm glad you called me, and they(facility) are working on making sure the patients don't have access to alcohol or drugs. R1's other records: Care Plan dated 5/1/25 states in part that resident has a substance abuse and chemical dependency issue with marijuana. Face sheet shows diagnoses which include but are not limited to Major Depressive Disorder, And Generalized Anxiety Disorder. BIMS (Basic Interview for mental status) score dated 2/28/25 shows 15(Cognitively Intact). Community Survival Skills assessment dated [DATE] states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. R2's Records reviewed are as follows: Care Plan dated 5/1/25 states in part: The resident has a history of substance abuse/chemical dependency related to: Clinical depression & anger (substance abuse often indicates an attempt at self-medicating). Face sheet shows diagnoses which include but are not limited to Depression and Bipolar Disorder. BIMS score dated 3/14/25 shows 15(Cognitively Intact). Community Survival Skills assessment dated [DATE] and 3/25/25 states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. R5's Records reviewed are as follows: Face sheet shows that R5 was originally admitted to the facility on [DATE] with diagnoses which include but are not limited to Cirrhosis of The Liver, Chronic Viral Hepatitis C, Alcohol Dependence with Withdrawal, and Generalized Anxiety Disorder. Progress notes/History of Present Illness dated 5/1/25 written by V11(Medical Director/Physician) states that R5 (with a diagnosis of Alcohol Liver Disease) was sent to and admitted to the outside hospital for alcohol withdrawal/abuse and has Cirrhosis of the Liver. This note also states that patient was medically stabilized and discharged to this facility to continue sub-acute care with skilled nursing and medical supervision. Progress Notes dated 4/24/25 states that R5 was taking a medication called Acamprosate Calcium 666 mg(milligrams) every 8 hours related so alcohol dependence with withdrawal. Care Plan dated 11/29/24 states in part: The resident has a history of substance abuse/chemical dependency related to: Clinical depression & anger (substance abuse often indicates an attempt at self-medicating). BIMS (Basic Interview for mental status) score dated 4/9/25 shows 15(Cognitively Intact). Community Survival Skills assessment dated [DATE] and 3/13/25 states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. However, records show that resident has access to Alcohol and drinks alcohol. R6's Records reviewed are as follows: Care Plan dated 10/22/24 states in part: Resident has a history of substance abuse/chemical dependency related to: Poorly developed ability to control impulses., Allowing negative, inappropriate persons to influence his/her use of substances. Face sheet shows diagnoses which include but are not limited to Alcohol Use, Cocaine Use, Schizoaffective Disorder, Bipolar Disorder, and Generalized Anxiety Disorder. BIMS score dated 4/15/25 shows 15(Cognitively Intact). Community Survival Skills assessment dated [DATE] states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. However, records show that resident has access to Alcohol and drinks alcohol. R11's Records reviewed are as follows: Progress notes dated 5/1/25 at 5:47pm written by V10(LPN) states in part: Writer was informed that resident was being aggressive to staff members and under the influence by social services. Patient is being sent to the Hospital. Face sheet shows diagnoses which include but are not limited to Opioid Abuse, Cocaine Abuse, Major Depressive Disorder, And Fatty Liver. Community Survival Skills assessment dated [DATE] and 3/13/25 states that resident appears able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. Care Plan dated 11/26/24 states in part that how R11 has a history of substance abuse and chemical dependency with marijuana. On 5/5/25 at 12:38pm, V1(Administrator) was notified about the concern that some residents at the facility have access to alcohol and some residents occasionally get intoxicated. V1 responded that staff can only search residents' bags and not the person. V1 added that now, if a resident is found with alcohol, or drugs, we would take their pass away. Also, we have a certified alcohol dependence counselor that comes five days a week. This will help the residents. V1 explained that all the residents that are known to have drank alcohol or have unauthorized access to alcohol or drugs have been documents to sign (Resident Coduct and Behavior Contract) with the House Rules and the resident who refused to consent to obeying the rules (R5) left the facility against medical advice (AMA). V1 stated that the issue of residents having access to alcohol or drugs is now under control because some residents' passes have been restricted. Facility's Policy on Contraband Materials, Inspection of Rooms, and Use of Recording Devices states in part: This organization follows federal standards concerning removal of contraband. This policy includes but are not limited to alcohol, illicit drugs, weapons, and smoking materials. #5 states: This policy recognizes that residents have attempted to hide/conceal contraband articles in undergarments in the past. If this appears to be the case and staff assesses and suspects that these items may cause harm, staff are directed to contact the administrator or the administrative representative for instructions on how to proceed. #7 states: The Facility may choose, at its discretion, to involve sniffing dogs if residents are suspected to be trafficking drugs inside the facility. Facility's document titled Resident Smoking Conduct, and Behavior Contract states in #3: Refrain from refrain from any type of substance abuse in the facility and while in the community while out on pass. #5 states: Refrain from bringing contraband into the facility including but not limited to alcohol, marijuana, heroin, cocaine, vape pens, illegal substances, and any sharp or dangerous objects. Facility's Policy 9/2021 with latest revision 11/2024 states in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. #1 states in part: Our facility-oriented approach to safety addresses risks for groups of residents.

Based on observation, interview, and record review the facility failed to manage a resident's pain and administer pain medication that was documented given. This failure affected one resident (R114) reviewed for medications in a sample of 128. Findings include: R114's admission diagnoses include but not limited to COPD (Chronic Obstructive Pulmonary Disease), atherosclerosis of coronary artery bypass graft, peripheral vascular disease, pacemaker, and bilateral below the knee amputations. R114's Brief Interview of Mental Status (BIMS) score is 15. R114 is cognitively intact. On 3/24/25 at 12:05 pm, R114 stated, I have not gotten my pain medication since Thursday night (3/20/25). I get morphine pills for the pain in my legs. They say they don't have it and have to reorder it. On 3/25/25 at 10:56 am, this surveyor inquired to V32 LPN (License Practical Nurse) if R114 got his pain medication of morphine today? V32 looked in the computer at the MAR (Medication Administration Record) and V32 stated that R114 got his pain medication this morning at 6:00 am. It was documented that it was given by the night nurse, and the next dose is not due until 2:00 pm this afternoon. Surveyor went into R114's room and stated that his pain medication was documented given at 6:00 am this morning. R114 stated, They are lying, I did not get my morphine this morning. The last time I got it was Thursday night (3/20/25). The surveyor went to V32 and asked to see R114's narcotic sheet for his pain medication. V32 looked in the narcotic book and could not find R114's narcotic sheet for the morphine and there was no morphine medication in the narcotic drawer for R114. V32 stated, I don't think it came in from pharmacy yet. Surveyor inquired to V32 when the narcotic sheet is complete where does it go? V32 stated that the completed narcotic sheets go to the DON (Director of Nursing). R114's MAR for March 2025 was reviewed, and all scheduled doses of morphine was documented given on Friday 3/21/25, Saturday 3/22/25, and Sunday 3/23/25 at 6:00 am, 2:00 pm, and 10:00 pm. Monday 3/24/25 morphine was documented given at 6:00 am, not given at 2:00 pm and documented given at 10:00 pm. R114's Order Summary Report Active Orders as of 3/25/25 documents in part, Morphine Sulfate Oral Tablet 15 MG (Milligram). Give 1 tablet by mouth every 8 hours for moderate pain in bilateral BKA (Below Knee Amputation). R114's care plan documented in part, R114 is at increased risk for alteration in pain/discomfort R/T (Related to) Neuropathy and is receiving medication for treatment. Goal: R114 will verbalize pain relief after medication within 1 hour. Interventions: Administer analgesic medications as ordered . On 3/25/25 1:43 pm, V2 DON stated, The narcotic sheets are given to me when the sheet is completed, and I put it in a folder and file it. Surveyor inquired to V2 if a narcotic sheet was given for R114. V2 stated that she has to check her mailbox. V2 stated that the sheet could be still in the narcotic book. Surveyor and V2 went to the 3rd floor and checked the narcotic book and the drawer of narcotics. The narcotic sheet was not in the narcotic book and the pain medication was not the narcotic drawer. V2 went into R114's room and R114 stated to V2 that he has not gotten his pain medications since Thursday night (3/20/25). On 3/26/25 at 12:15 pm, Surveyor inquired to V39 (License Practical Nurse) if V114 morphine medications were administered on Saturday (3/22/25), Sunday (3/23/25), and Monday (3/24/25). V39 LPN stated If I signed the medication out, then I gave it. There was morphine in the cart. I do not know how many was left. The morphine medication on the bingo card was low so, I told the nurse to tell the NP (Nurse Practitioner) when she come in on Monday. On 3/26/25 at 2:57 pm, V2 DON stated, On 3/18 morphine came in for R114. I do not know how many pills came in. I cannot find the narcotic sheet for 3/18. It is missing. We are investigating right now. Surveyor asked V2 when a resident does not get their scheduled pain medication than what can happen to them? V2 stated, When a resident doesn't get their pain medication then they are still in pain and is not being provided pain management. On 3/27/25 at 9:18 am, V46 RN (Registered Nurse) stated Morphine medications came in for R114 on 3/18/25. I (V46) received the medication because I was working the 1st floor and the nurse on the 3rd floor was not around, so I did not want the pharmacy to take the medication back. I signed for the medications then I walked to the third floor and gave V39 the medications. I put the medication in V39's (LPN) hand. I did not see how many pills was on the bingo card. On 3/27/25 at 10:33 am, V45 RN stated, I worked Friday the 21st from 7:00 pm to 7:00 am. I gave R114 his morphine Friday night and Saturday morning dose. I remember the medication was almost gone. On the 24th I reordered the morphine. I remember when I gave the morphine, it was one or two tablets left on the bingo card. Surveyor inquired to V45 when the narcotic sheet is full what happens to the sheet? V45 stated The completed narcotic sheets are placed in a red bin at the nurse's station, only nurses and CNAs (Certified Nursing Assistants) go behind the nurses' station. I did not put the morphine narcotic sheet for R114 in the red bin, because medications were still on the bingo card. Surveyor asked V45 did he document that R114 got the 10:00 pm scheduled dose of morphine medication on 3/24/25? V45 stated I did give R114 his scheduled nighttime dose of morphine on 3/24/25. On 3/27/25 at 11:55 am, Surveyor inquired to V14 LPN if V14 administered morphine for pain to R114 on 3/22/25 the 2:00 pm dose? V14 stated, If I documented that I gave the medication then I gave it. When I came back to work on Monday (3/24/25) R114 had no morphine in the narcotic box. The NP (Nurse Practitioner) was on the floor, and I ask her how many scripts she signed for R114's morphine? The NP said 60/90 was ordered, so I reordered the medication. R114 told me he had not gotten his morphine medication over the weekend. Some nurses don't click the medications given when they give the medications. They go to the nurse's station and sit down to chart then just click given. There was no morphine medication for R114 here on Monday morning (3/24/25). On 3/26/25 at 3:20 pm V48 Pharmacist stated that R114 had an order for morphine 15 mg every 8 hours. The medication was delivered to the facility on [DATE] around 4:00 am. The quantity was 28 tablets, so the medication should have lasted until March 27th. On 3/27/25 at V47 NP stated, I (V47) do attend to R114's care. I saw R114 Monday or Tuesday of this week. R114 told me he was not getting the scheduled morphine medication. I called the pharmacy and they said he still had scripts for 120 tablets left. I asked them if they could send the medication tonight. R114 is getting pain medication for bilateral below the knee amputations and is still having phantom pain. R114 does still need the morphine. If R114 does not get the morphine he is still in pain, he cannot sleep, he is restless and have involuntary leg trimmers. The nurses are expected to give ordered medication 1 hour before or 1 hour after scheduled medications ordered by the providers. I make rounds Monday to Friday and always ask the nurses if they need anything. If R114 is not getting his schedule pain medications, pain management is not effective. R114's pharmacy packings slip dated 3/18/25 delivery time 4:24 am, documents in part, Morphine Sulfate Tab 15 MG Quantity 28. Received by V46 RN. R114's pharmacy packing slip dated 3/26/25 delivery time 4:52 am, documents in part Morphine Sulfate Tab 15 MG Quantity 21. Facilities policy dated 10/25/2014 titled Controlled Substance Storage documented in part, 4. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Forms . G. Current controlled substance accountability records are kept in the MAR, or designated book. Completed accountability records are submitted to the director of nursing and kept on file for 5 years at the facility. Facilities policy titled Medication Administration and dated 10/25/2014 documents in part, B. Administration: 2. Medications are administered in accordance with written orders of the prescriber. D. Documentation: The individual who administers the medication dose records the administration on the residents MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented . Facility's policy titled Policy and Procedure Physician Orders documents in part, Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. Facility's job description titled Charge Nurse documents in part, Job Summary: Organize and assign all jobs to be done on his/her shift so that the workload is evenly divided among his/her employees on the basis of staff size and qualifications pass medications at the appropriate times . 12. Administer all medications. Maintain a current and annual report of narcotics received and used. 13. Daily review the document of dispensing controlled substances and narcotics .

Based on observation, interview, and record review the facility failed to correctly administer antibiotics intravenous piggy bag via PICC line for one resident (R2). This failure resulted in V8 (Untrained LPN) observed administering improper treatment via PICC line to R2, putting R2 at risk of air embolism. This was identified as an immediate jeopardy which begin on 04/14/25 at 11:55am when V8 was noted in the medication room reconstituting IVPB, Ertapenem Sodium Solution Reconstituted 1GM (Gram) and proceeded to administer it via a peripherally inserted central catheter (PICC line). V1 (Administrator) was informed of the immediate jeopardy and a template was presented on 04/24/25 at 10:11am. On 04/28/25 an acceptable removal plan was received after revision from the original plan submitted on 04/24/25. On 04/30/25 the surveyor confirmed by observation, interview, and record review to confirm that the removal plan was initiated, and the immediacy was removed on 04/30/25. However, the non-compliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of in-services training. Findings include: R2 is a [AGE] year-old resident with diagnosis that includes complete traumatic amputation of two or more right lesser toes, sequela, sleep apnea, other chronic osteomyelitis, right ankle and foot, sequela of cerebral infarction, and low back pain. R2 was admitted to the facility on [DATE]. On 04/14/25 at 11:55am, V8 Licensed Practical Nurse (LPN) was noted in the nursing medication room preparing an IVPB, V8 mixed the powdered with the fluid from the IVPB 250ml (milliliter) then proceeded to R2 's room. V8 informed the surveyor that the IVPB medication was due to be administered at 7:30am and R2 has been complaining of not getting the medication since admission and because V8 is the only nurse on the floor the medication is late, and she must administer it now. At 12:11pm, V8 proceeded to R2's room and without hand hygiene removed the cap from the PICC line and attached the flow meter without priming the line which causes air bubble in the line. V8 then attached the line to the PICC line not attempting to remove the air bubble from the line or flushing the PICC line before administration. The surveyor asked V8 about the facility PICC IV medication policy, infection control prevention and control V8 stated as you can see (referring to the surveyor) I am the only nurse on the floor and I have to pass my medicine, this is the first time I will give this IV (Referring to the IVPB), I am not even trained in doing this s***. After running the fluid, the air space will go away. V8 did not initial the IVPB and did not put the time of administration. V8 did not attempt to remove the air. V8 did not flush the PICC line to assure patency of the PICC. R2 then told V8 stated that V8 need to flush the line to let the air out and the IV fluid will flow well, V8 continued administering the medication. V8 left R2'room and V8 was observed sitting at the nurse's station without returning to R2's room. At 12:30pm V8 was still sitting at the nurse's station. At 12:32pm, V29 (MDS Coordinator) was shown and made aware of the surveyor's observation. V29 stated I am not supposed to touch the PICC line and paged and call V1 (Administrator) and V2 DON (Director of Nurse's) to come to the floor. At 12:36pm, V1 and V2 were shown the IVPB settings with no name, no time of administration, and the surveyor made both V1 and V2 about the observation. V2 stated to the surveyor you cannot make this up, V2 stated that there is an RN (Registered Nurse in the building including self that V8 can call to mix and administer the IVPB medication. V2 stated the PICC line should be flushed before and after use to establish patency. At 12:38pm, V8 then walked into R2's room with a syringe filled with clear liquid and use it to flush the IVPB connecting tubing without attempting to remove the air putting R2 at risk for air embolism. R2's medical record MAR (Medication Administration Record) showed V8 documentation that the IVPB medication was administered at 8:33am. when this was shown to V2, V2 stated I know she (V8) did not give at 8:33am because you (referring to the surveyor) showed us (referring V1 and self). R2's admission report dated 4/11 (4/11/25) presented showed documentation that R2 has a PICC line on the right arm. R2's interim plan of care did not address the issue of IV antibiotics until 04/15/25. Intervention listed includes but not limited to monitor placement of catheter daily and before and after each use. On 04/15/25 at 9:37am, V2 stated that regarding the LPN training documentation V2 stated that I (V2) am now in servicing (Educate) the nurses on the on the PICC and the PIV lines. V23 (Nurse Consultant) who was present stated that we (facility) are still searching for the ones that was done previously but have not found it. V2 is just a new (DON) not quite 2months ago. On 04/15/25 at 11:49am, the surveyor asked V22 NP (Nurse Practitioner) about the difference between PIV and PICC lines, V22 stated that the PIV goes into the small vein and the PICC goes to the big veins. The surveyor asked what can happen when administering medication into the vein without following infection prevention practices like hand hygiene before and after care. V22 stated that infection can be spread to others and the patient. The wound can deteriorate with more infection. If there is air in the tube delivering the medication what can happen to the resident. Air embolism can happen which can be detrimental to the resident, brain, heart, respiratory distress, and possible death. The facility procedure on this matter should be followed. The nurse must flush the line (PICC) before attaching the medication. The surveyor asked V22 that in your professional opinion should an LPN be administering medication through the PICC or reconstitute medication. V22 stated I (V22) don't think so. It should be an RN doing that. On 04/15/25 at 1:18pm, interview with V2 (DON) on whether an LPN is allowed reconstitute IVPB medication via PICC. V2 stated that (V8) is not supposed to mix the IVPB medication without an RN or give it. V2 stated air should not be in the flow line she (V8) should have prime the IV line. As at 04/17/25 at 4:30pm, the facility was unable to present any documented training or certification that showed that V8 was trained in administration of PICC line IVPB medication and no competency documentation presented for all the LPN on staff at the facility. The facility storage of Medication Administration policy presented with effective date 10/25/2014 documented that personnel authorized to administer medications do so only after they are being properly oriented to the medication management system in the facility. The facility Policy and Procedure Intravenous Therapy presented with reviewed date 1/2025 listed procedure includes but limited to all personnel inserting IV's or administering IV fluids and medications will have had training in the procedure. The qualification must include an adequate return demonstration of IV skills. Record shall contain evidence of competency. On 04/30/25, the surveyor made observations, conducted interviews and received documents to confirm the following removal plan was initiated: 1. R2 is no longer residing at the facility. 2. R2 was discharged home on 04/22/25. 3. No residents were listed having IV-line medication as at 04/30/25. 4. All LPN (licensed Practical Nurses in-serviced/educated on not working outside of their scope of practice by not administering any medication through the PICC line. 5. Facility licensed Registered Nurses were re-educated on facility policy on PICC line infusion. 6. LPN will alert the RN (Registered Nurse) on need to administer medication via the PICC line. 7. RN must reconstitute any IV antibiotic medications. 8. RN must ensure that proper hand hygiene is conducted prior to start of intravenous medication administration. 9. The RN must ensure that the PICC line is flushed prior to the start of IV medications. 10. The RN must complete education on PICC line upon hire and a yearly competence will be provided. 11. Weekly audit by DON/or designee.

Based on observation, interview, and record review the facility failed to correctly administer antibiotics intravenous piggy bag via PICC line for one resident (R2). This failure resulted in V8 (Untrained LPN) observed administering improper treatment via PICC line to R2, putting R2 at risk of air embolism. This was identified as an immediate jeopardy which begin on 04/14/25 at 11:55am when V8 was noted in the medication room reconstituting IVPB, Ertapenem Sodium Solution Reconstituted 1GM (Gram) and proceeded to administer it via a peripherally inserted central catheter (PICC line). V1 (Administrator) was informed of the immediate jeopardy and a template was presented on 04/24/25 at 10:11am. On 04/28/25 an acceptable removal plan was received after revision from the original plan submitted on 04/24/25. On 04/30/25 the surveyor confirmed by observation, interview, and record review to confirm that the removal plan was initiated, and the immediacy was removed on 04/30/25. However, the non-compliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of in-services training. Findings include: R2 is a [AGE] year-old resident with diagnosis that includes complete traumatic amputation of two or more right lesser toes, sequela, sleep apnea, other chronic osteomyelitis, right ankle and foot, sequela of cerebral infarction, and low back pain. R2 was admitted to the facility on [DATE]. On 04/14/25 at 11:55am, V8 Licensed Practical Nurse (LPN) was noted in the nursing medication room preparing an IVPB, V8 mixed the powdered with the fluid from the IVPB 250ml (milliliter) then proceeded to R2 's room. V8 informed the surveyor that the IVPB medication was due to be administered at 7:30am and R2 has been complaining of not getting the medication since admission and because V8 is the only nurse on the floor the medication is late, and she must administer it now. At 12:11pm, V8 proceeded to R2's room and without hand hygiene removed the cap from the PICC line and attached the flow meter without priming the line which causes air bubble in the line. V8 then attached the line to the PICC line not attempting to remove the air bubble from the line or flushing the PICC line before administration. The surveyor asked V8 about the facility PICC IV medication policy, infection control prevention and control V8 stated as you can see (referring to the surveyor) I am the only nurse on the floor and I have to pass my medicine, this is the first time I will give this IV (Referring to the IVPB), I am not even trained in doing this s***. After running the fluid, the air space will go away. V8 did not initial the IVPB and did not put the time of administration. V8 did not attempt to remove the air. V8 did not flush the PICC line to assure patency of the PICC. R2 then told V8 stated that V8 need to flush the line to let the air out and the IV fluid will flow well, V8 continued administering the medication. V8 left R2'room and V8 was observed sitting at the nurse's station without returning to R2's room. At 12:30pm V8 was still sitting at the nurse's station. At 12:32pm, V29 (MDS Coordinator) was shown and made aware of the surveyor's observation. V29 stated I am not supposed to touch the PICC line and paged and call V1 (Administrator) and V2 DON (Director of Nurse's) to come to the floor. At 12:36pm, V1 and V2 were shown the IVPB settings with no name, no time of administration, and the surveyor made both V1 and V2 about the observation. V2 stated to the surveyor you cannot make this up, V2 stated that there is an RN (Registered Nurse in the building including self that V8 can call to mix and administer the IVPB medication. V2 stated the PICC line should be flushed before and after use to establish patency. At 12:38pm, V8 then walked into R2's room with a syringe filled with clear liquid and use it to flush the IVPB connecting tubing without attempting to remove the air putting R2 at risk for air embolism. R2's medical record MAR (Medication Administration Record) showed V8 documentation that the IVPB medication was administered at 8:33am. when this was shown to V2, V2 stated I know she (V8) did not give at 8:33am because you (referring to the surveyor) showed us (referring V1 and self). R2's admission report dated 4/11 (4/11/25) presented showed documentation that R2 has a PICC line on the right arm. R2's interim plan of care did not address the issue of IV antibiotics until 04/15/25. Intervention listed includes but not limited to monitor placement of catheter daily and before and after each use. On 04/15/25 at 9:37am, V2 stated that regarding the LPN training documentation V2 stated that I (V2) am now in servicing (Educate) the nurses on the on the PICC and the PIV lines. V23 (Nurse Consultant) who was present stated that we (facility) are still searching for the ones that was done previously but have not found it. V2 is just a new (DON) not quite 2months ago. On 04/15/25 at 11:49am, the surveyor asked V22 NP (Nurse Practitioner) about the difference between PIV and PICC lines, V22 stated that the PIV goes into the small vein and the PICC goes to the big veins. The surveyor asked what can happen when administering medication into the vein without following infection prevention practices like hand hygiene before and after care. V22 stated that infection can be spread to others and the patient. The wound can deteriorate with more infection. If there is air in the tube delivering the medication what can happen to the resident. Air embolism can happen which can be detrimental to the resident, brain, heart, respiratory distress, and possible death. The facility procedure on this matter should be followed. The nurse must flush the line (PICC) before attaching the medication. The surveyor asked V22 that in your professional opinion should an LPN be administering medication through the PICC or reconstitute medication. V22 stated I (V22) don't think so. It should be an RN doing that. On 04/15/25 at 1:18pm, interview with V2 (DON) on whether an LPN is allowed reconstitute IVPB medication via PICC. V2 stated that (V8) is not supposed to mix the IVPB medication without an RN or give it. V2 stated air should not be in the flow line she (V8) should have prime the IV line. As at 04/17/25 at 4:30pm, the facility was unable to present any documented training or certification that showed that V8 was trained in administration of PICC line IVPB medication and no competency documentation presented for all the LPN on staff at the facility. The facility storage of Medication Administration policy presented with effective date 10/25/2014 documented that personnel authorized to administer medications do so only after they are being properly oriented to the medication management system in the facility. The facility Policy and Procedure Intravenous Therapy presented with reviewed date 1/2025 listed procedure includes but limited to all personnel inserting IV's or administering IV fluids and medications will have had training in the procedure. The qualification must include an adequate return demonstration of IV skills. Record shall contain evidence of competency. On 04/30/25, the surveyor made observations, conducted interviews and received documents to confirm the following removal plan was initiated: 1. R2 is no longer residing at the facility. 2. R2 was discharged home on [DATE]. 3. No residents were listed having IV-line medication as at 04/30/25. 4. All LPN (licensed Practical Nurses in-serviced/educated on not working outside of their scope of practice by not administering any medication through the PICC line. 5. Facility licensed Registered Nurses were re-educated on facility policy on PICC line infusion. 6. LPN will alert the RN (Registered Nurse) on need to administer medication via the PICC line. 7. RN must reconstitute any IV antibiotic medications. 8. RN must ensure that proper hand hygiene is conducted prior to start of intravenous medication administration. 9. The RN must ensure that the PICC line is flushed prior to the start of IV medications. 10. The RN must complete education on PICC line upon hire and a yearly competence will be provided. 11. Weekly audit by DON/or designee.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse and verbal abuse. This failure affects 2 residents (R8, R15) reviewed for abuse. This failure caused harm to R8, evidenced by R8 sustaining a laceration to the back of R8's head that required closure with staples and hospitalization . Findings include: 1. R8's progress notes (dated 2/18/2025) documents in part, Patient fell in dinner are hit the back of head. Small laceration with mild blood drainage noted. Patient vitals with in normal limits BP 122/70 HR 70 Sp02 98.5 Resp 18. Patient is being sent to (Hospital) for Head CT.Neuro Checks normal . On 2/19/2025, V9 (Nurse Practitioner) documented, Per (Hospital) nurse, Admitting Dx: anemia (9.8 hemoglobin at ER, f/u hemoglobin on 2/19/25 is 12.7). CT head result is unremarkable. She needed staples on her head. Planned for endoscopy. Not sure about discharge plan yet. Will f/u. R8's hospital records (admitted [DATE]) document in part, .At the nursing home, patient fell down. According to the nurse practitioner at the nursing home, the patient was trying to take a meal tray from another resident and he pushed her. And she fell down. Patient was sent to the emergency room for further evaluation. Patient was found to have a laceration of the scalp and she was also anemic she was admitted for further evaluation . Record review of investigation to the state survey agency (SSA) and supplementary investigative documents for R8's fall with injury documents in part, .Analysis and Conclusion . On 2/18/2025, (R8) was ambulating around the unit. (R8) ambulated into the dining room where (R8) lost (R8's) balance and fell to the floor. Staff nursing (were) made aware and immediately went to assess the (R8). While on the floor the (R8) was observed with an open area to the back of (R8's) head. The nurse cleansed the area and applied a pressure dressing to the site. (R8's) guardian and physician were made aware, and an order was received to transport the (R8) to the local hospital where (R8) was later admitted with a diagnosis of anemia. (R8) returned to the facility on [DATE] 21:45 and was noted to have a staple to the back of (R8's) head . This report was completed by V2 (Director of Nursing). Written witness statements gathered from V26 (Licensed Practical Nurse) and V27 (Licensed Practical Nurse) affirms that V26 and V27 did not witness the incident. V26 documents that V14 (Certified Nursing Assistant) told V26 what happened but did not describe what happened. On 3/11/2025 at 11:34 PM, V9 (Nurse Practitioner) affirmed that V9 is a provider for R8 and was made aware of the incident by V27. V9 affirmed that V9 was not in the building at the time of the incident. V9 explained that V27 told V9 that R8 was pushed to the ground by another resident and sustained a laceration to the back of R8's head. On 3/11/2025 at 12:24 PM, V27 (Licensed Practical Nurse) affirmed that V27 was assigned to care for R8 on the day of the incident. V27 recalled that V27 had come back from break and there was a lot of commotion but that R8 had already fallen. V27 did not see R8 fall. Other staff were claiming that R12 had pushed R8 but V27 could not recall who the staff members were that stated that. V27 stated that V27 did report that R8 was pushed to V9 because that is what I (V27) thought happened at the time. (V2) completed an investigation and that's not what happened according to the investigation. I don't know what happened because I (V27) wasn't there. On 3/11/2025 at 12:40 PM, V2 (Director of Nursing) affirmed that V2 completed the investigation into the incident. V2 said it was reported to V2 by V26 that R8 had fallen in the dining room. V2 stated that V2 did see the laceration near the crown of R8's head but that R8 was in the process of being sent out. V2 stated the root cause of the fall was R8's anemia. V2 denied knowledge of R8 being pushed to the ground. Surveyor reviewed the hospital records and investigative documents with V2 and V1 (Administrator). V2 affirmed that the hospital records indicated that R8 was pushed to the ground. V2 stated, I did not look at those (hospital records). On 3/12/2025 at 10:44 AM, V14 (Certified Nursing Assistant) affirmed that V14 was in the dining room for the dementia unit (4th floor) during the time of the incident. V14 explained that V14 was feeding another resident when V14 observed R8 go up to R12 across the dining room. R8 was attempting to take food off of R12's plate. V14 tried to get up and intervene but V14 was across the room and could not intervene before R12 pushed R8 to the ground. V14 affirmed that R8 did hit R8's head against the ground. On 3/13/2025 at 12:55 PM, V26 (Licensed Practical Nurse) explained that V26 was on duty the day of the incident and heard a commotion in the dining room. V27 was not on the floor so V26 responded to the dining room and saw R8 lying on the ground bleeding from R8's head. V26 provided first aide and took R8 to R8's room. Surveyor inquired if V14 told V26 that R8 was pushed. V26 responded, No, I do not know anything about (R12) pushing (R8). Surveyor noted to V26 that R12's name was not brought up within the interview, and inquired why V26 would bring up R12's name in response. V26 did not initially respond. Surveyor asked again for an accurate answer if V14 had told V26 that R12 pushed R8 to the floor and V26 affirmed that V14 and other staff had mentioned that they thought R8 was pushed to the ground by R12. V26 stated that V26 told V2 that V14 and other staff said R8 was pushed to the ground by R12. Record review of R8's admission record documents in part the following diagnosis: unspecified dementia with behavioral disturbance, pseudobulbar affect, generalized anxiety disorder, peripheral vascular disease, unspecified lack of coordination, repeated falls. Record review of R8's minimum data set (dated 3/6/2025) documents a brief interview of mental status summary score of of 0, indicating that R7 has severe cognitive impairment and is unable to understand others. Record review of R12's admission record documents in part the following diagnosis: chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, emphysema, anemia, other speech disturbances, and restlessness and agitation. Record review of R12's minimum data set (dated 2/5/2025) documents in part a brief interview of mental status summary score of 9, indicating that R12 is cognitively impaired. Record review of R12's care plan identifies that R12 has a history of physical and verbal aggression. 2. On 3/11/2025 at 11:35 AM, R9 stated that R3 was, crazy and always up to something. R9 explained that the other day (3/9/2025), R9 witnessed R3 yelling at R15, accusing R15 of taking R3's clothes. R3 began to yell louder and threaten R15, saying he was going to beat his a**. R3 came to R15 who was sitting by the nurse's station in the hallway and slapped the s*** out of him across the face . (R3) hit him so hard. After the hit, V17 (Licensed Practical Nurse) came over and separated R3 and R15. R3 was unsure if V17 actually saw the hit but remembered V17 was in the area. On 3/11/2025 at 12:40 PM, V1 (Administrator) stated that R3 and R15 had a verbal disagreement a few days prior and that R3 was sent via petition as a result from the verbal disagreement. V1 affirmed that verbal disagreements do not warrant psychiatric admission. V1 stated that V1 was aware that R3 was yelling at R15. V1 denied knowledge of any other aspect of the incident outside of the yelling (ie. R3 striking R15). V1 stated that yelling at another resident is not abuse. V13 (Nurse Consultant) stated that yelling could be abuse, it depends. On 3/12/2024 at 12:43 AM, V22 (Licensed Practical Nurse) stated that V22 was familiar with both R3 and R15. V22 stated that V22 heard that R3 had hit R15 in the past few days but couldn't recall where V22 heard it from. V22 stated that R3 has a lot of behaviors, like physical aggression and verbal aggression. On 3/12/2025 at 1:37 PM, R15 stated that R15 was hit by R3 in the past couple of days. R15 stated, It was later in the day a couple days ago. (R3) thought I was wearing (R3's) jacket. I told him [NAME] man, it's my jacket. (R3) was yelling at me, threatening me to take the jacket off or (R3) was gonna hit me. I told (R3) if you hit me, you will go to jail. Then next thing I know, (R3) smacked me across the face really hard. It hurt bad, man. I don't know if any staff were around when it happened, but I remember (V17) coming up to me after, I told her to call the police. The police came and filled out an incident report. On 3/13/2025 at 2:31 PM, V19 (Social Services Director) stated that R3 and R15 had an incident and that R3 was in the process of being transferred to the hospital because of the incident. V19 affirmed that V19 was aware that R3 had hit R15 in the head because R15 told V19. V19 explained that V19 told V1 that R15 was hit in the head and that V1 was doing (V1's) due diligence and following up. V19 was unaware if V1's investigation was able to substantiate the incident. On 3/13/2025 at 3:02 PM, V17 (Licensed Practical Nurse) recalled the incident that occurred between R3 and R15. V17 explained that V17 was in the dining room with another patient and V17 heard yelling in front of the nurse's station. V17 could hear R3 and R15 yelling and V17 could hear R3 yell, I (R3) am gonna whoop yo a** if you (R15) don't give me that shirt!. V17 went over to R3 and R15 and separated them. V17 stated that V17 was not aware of R3 hitting R15. V17 recalled that once the residents were separated, V17 reported the incident to V2 (Director of Nursing) and V1 (Administrator). V17 affirmed that threatening could be verbal abuse. Record review of R3's progress notes documents in part that on 3/9/2025, R3 was noted to be having a verbal disagreement with peer. R3's provider ordered R3 to be evaluated for psychiatric admission. R3 was sent to the hospital and returned later on 3/9/2025 in stable condition. R3 was sent to the hospital again for behaviors on 3/10/2025. No care interventions were noted to be added within R3's progress notes after 3/9/2025. Record review of R3's care plan documents in part that on 2/23/25 and 2/25/25 R3 displayed verbal and physical aggressive behaviors. An intervention of petition out for psychiatric admission was added to the care plan on 2/23/25. No other appropriate, person-centered care plan interventions were added to address R3's aggressive behaviors. Record review of R3's face sheet documents in part a diagnosis of epilepsy, chronic obstructive pulmonary disease, paranoid schizophrenia, delusional disorder, and drug induced akathisia. Record review of R3's minimum data set (dated 1/2/2025) documents in part a brief interview of mental status summary score of 13, indicating R3 is cognitively intact. Record review of R15's face sheet documents in part a diagnosis of degenerative disk disease of the lumbar region, chronic obstructive pulmonary disease, and osteoarthritis. Record review of R15's minimum data set (dated 2/5/2025) documents in part a brief interview of mental status summary score of 15, indicating that R15 is cognitively intact. Record review of facility abuse policy titled, Policy and Procedure Abuse Prevention Program (1/2024) documents in part, .Definition Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Record review of facility provided document titled, RESIDENTS' RIGHTS for People in Long-Term Care Facilities documents in part, .Your rights to safety You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually .

Based on observation, interview, and record review the facility failed to assure that one resident (R1) with a surgical wound was provided the necessary treatment and services to promote wound healing and pain control. This failure resulted in R1's wound worsening and having avoidable pain. Findings include: R1's diagnoses include but are not limited to surgical amputation, chronic obstructive pulmonary disease, asthma, paranoid schizophrenia, complete traumatic amputation of left foot, superficial frostbite of left toes, hallucinations, major depressive disorder, kidney failure, essential hypertension, bacterial pneumonia. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R1's cognition is intact. On 03/10/25 at 12:00pm R1 observed sitting on bed with dressing to left foot. R1's left foot dressing observed to be secured in place with band-aides, unraveling and with what appeared to be dark dirt-like substance in multiple areas of the bandage. R1's bandage observed to have no date. On 03/10/25 at 12:04pm, R1 stated on 03/03/25 she asked V18 (Licensed Practical Nurse/LPN) for pain medication and V18 did not give her pain medication V18's entire 12-hour shift. R1 stated that she was in pain for the entire shift. R1 stated that the wound dressing on her left foot has not been changed since Friday 03/07/25 and should be changed every day. R1 stated that the facility does not have enough staff to change her wound dressing on the weekend. R1's active physician order documents in part, Oxycodone Capsule 5mg (milligram) give 1 capsule by mouth every 6 hours as needed for analgesics related to partial traumatic amputation of left foot, level unspecified. R1's active physician order documents in part, Site: left foot: Cleanse with NSS (normal saline solution) pat dry, apply xeroform, ABD (abdominal gauze), wrap with kerlix and secure with tape daily or as need (prn). R1's Controlled Drug Receipt form shows multiple dates and times from 03/03/25 through 03/10/25 that nurses removed oxycodone from locked medication storage. Record review of R1's Medication Administration Record (MAR) showed no documentation that the medication was administered to R1. R1's Treatment Administration Record (TAR) for left foot wound dressing show no documentation for 03/02/25, 03/06/25, 03/08/25, 03/09/25 and 03/10/25. On 03/10/25 at 12:56pm V6 (LPN) stated that she was R1's nurse over the weekend and did not change R1's wound bandage. V6 stated that she gave R1 supplies to change her own dressing. V6 stated that she does not know if R1 has been assessed to change her own bandage. V6 stated that R1 had never refused care. On 03/11/25 at 1pm V2 (Director of Nursing/DON) stated that when medications are administered, the medications should be documented on the Medication Administration Record (MAR) and if medications are not documented on the MAR they should be assumed as not given. V2 stated that daily wound dressings are expected to be changed daily. V2 stated that not doing wound care as ordered by the physician can lead to deterioration of the wound. V2 stated that R1 is not capable of changing her own wound dressing and if the wound care nurse is not available then the nurses should be doing the wound care. On 03/11/25 at 2:26pm R1 stated that she informed the doctor at her clinic appointment that the facility was not changing her left foot wound as ordered. R1 stated that the clinic gave her a bag full of wound supplies so that she can have supplies for her dressing change. R1 stated she was informed her wound was not doing well and may need further amputation. R1 stated that she is afraid of losing her whole foot. R1's after visit document dated 03/11/25 at 11:29am documents in part, Patient is not improving and may need further amputation. On 03/12/25 at 12:28pm V12 (Wound Care Nurse) stated that resident's wound dressings should have a date on them. V12 stated that placing dates on the dressing lets the staff know when the last time the wound dressing was changed. V12 stated that she has been requesting to have a wound care nurse to do dressing changes on the weekend, but the facility has not hired anyone yet. V12 stated that when a wound is changed, there should be documentation in the resident's treatment administration record (TAR). V12 stated that when wound dressings are not changed as ordered that it could lead to infection and deterioration of the wound. V12 stated that R1 has not refused a dressing change. On 03/12/25 at 11:52am V18 (LPN) stated that R1 always wants pain medication. V18 stated that R1 is always moving around, so V18 is unsure if R1 was really in pain when R1 asked for pain medication. V18 stated that medication should be documented on the MAR when given. V18 stated that she is not sure why R1's pain medication is not documented on the MAR. R1's care plan dated 02/25/25 documents in part, R1 has potential/actual impairment to skin integrity related to surgical wound, left foot amputation .R1 will have no complications to left foot surgical site through next review .wound care per MD (medical doctor) orders. Facility's Policy titled IIA2 Medication Administration dated 10/25/2014 documents in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a mediation distribution system to ensure safe administration of medications without unnecessary interruptions .B. Administration .2. Medications are administered in accordance with written orders of the prescriber .D. Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the resident's MAR (medication administration record) directly after the medication is given .5. When PRN (as needed) medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. Complaints or symptoms for which the medication was given. c. Results achieved from giving the dose and the time results were noted. D. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. Facility's policy titled Pressure Ulcer and Skin Condition Assessment Policy dated 10/2020 documents in part, Policy: It is the policy of this facility that pressure and other ulcers, will be assessed and measured at least every seven days by a licensed nurse and recorded on the facility approved wound assessment form .Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring interventions are implemented .Standards .7. A notation will be made in the nurse notes, treatment administration record .8. Dressings which are applied to pressure ulcers, skin tears, wounds, lesions or incisions shall include the date of the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. Facility's policy titled Residents' Rights dated 11/18 documents in part, Your right to safety .Your facility must provide services to keep your physical and mental health at their highest practical levels.

Based on interviews and record review, the facility failed to ensure two residents (R2 and R7) were free from abuse from a resident (R3) with a known violent behavior by failing to perform R3's background checks and ensure fingerprint order was obtained for a new resident (R3) within the required time frames; failed to identify R3's known behaviors placing other residents at risk for abuse; failed to ensure a care plan was developed for R3's known violent behavior. These failures resulted in R3 physically assaulting 2 residents (R2 & R7) and causing multiple facial fractures to one resident (R7). This was identified as an immediate jeopardy began on 9/26/24. On 10/21/24 at 1:06 PM, the administrator was notified of the immediate jeopardy. The facility presented an abatement plan to remove the immediacy on 10/22/24 at 2:12pm. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 10/24/24 at 3:11pm. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented another revised abatement plan on 10/28/24 at 1:34pm, and the survey team accepted the abatement plan on 10/28/24. The immediate jeopardy was removed on 10/28/24 at 1:34 PM. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings Include: R3's clinical record indicated in part the following: On 8/21/24, R3 was admitted with medical diagnosis that includes but not limited to aphasia following cerebral infarction; major depressive disorder, recurrent, unspecified; essential (primary) hypertension; unspecified psychosis not due to a substance or known physiological condition; other specified diabetes mellitus without complications; polyosteoarthritis, unspecified; arthropathy, unspecified; gastro-esophageal reflux disease without esophagitis; long term (current) use of aspirin; insomnia, unspecified; hyperlipidemia, unspecified; vascular dementia, unspecified severity, with other behavioral disturbance; bipolar disorder, current episode mixed, unspecified; cerebral infarction, unspecified; dysphagia, oropharyngeal phase; cognitive communication deficit; other Alzheimer's disease. R3's Referral records, the facility received prior to R3's admission, fax date of 8/16/24, documents, in part, (R3) with a history of dementia, depression, and anxiety was transferred from a local nursing home for direct admission. He (R3) was involved in a physical altercation with a fell ow resident . He (R3) remains anxious, irritated, confused, and bizarre, with no recollection of why he (R3) is being treated. Due to his (R3) dysregulated mood, aggression, and confusion, he (R3) poses a danger to himself and others . Verbal aggression during pt (patient) care . On 10/16/24 at 11:50am, when asked if the facility was aware of R3's history of aggression and prior physical altercation at the preceding facility R3 was residing at, V9 (Nurse Consultant) replied, In R3's referral it did state R3 had an altercation with another resident, but it did not state who hit who. R3's CHIRP (Criminal History Information Response Process), dated 8/27/24, documents, in part, HIT . (R3) . FELONY CONVICTION(S) . Date of Arrest: 03/10/1997 THEFT/CONTROL/FIREARM/2ND . V9's (Nurse Consultant) e-mail, dated 10/16/24 at 11:04am), documents, in part, Spoke with the social service director (R3) was not fingerprinted. On 10/17/24 at 2:51pm, V17 (Social Work Consultant) and this surveyor reviewed R3's criminal background check as follows: V17 confirmed R3 was admitted on [DATE] and the Resident Background Check form was initiated for a CHIRP (Criminal History Information Response Process) on 8/27/24 which is greater than 24 hours from R3's admission. V17 confirmed there were no fingerprints completed for R3 even though R3 had multiple arrests including theft with a firearm. V17 said, The CHIRP is run within 24 hours of admission of a new resident. Once we (facility) get the CHIRP back we (facility) have 72 hours to schedule fingerprints, 72 hours to put it in portal, and then a forensic investigator comes out. The investigator interviews and gives a criminal analysis within 45 days showing what their (residents) risk level is. They (criminal investigators) make recommendations for plan of care implementations. I (V17) do just believe it was a lapse in timing with transitioning employees coming in for the reason R3's CHIRP was not done, and the fingerprints were not ordered. There was a new person coming in and there was a lot going on. R3's progress note, dated 9/7/2024 at 1:41pm, transposed by V3 (Licensed Practical Nurse/LPN), documents, in part, Resident (R3) combative with all staff when asked to remain in his wheelchair for safety; refused blood glucose check and midday medicine pass; attempted to open secured doors on the unit. Resident (R3) used vulgar language with Writer. Family notified. R3's progress note, dated 9/26/2024 at 7:20am, transposed by V5 (Licensed Practical Nurse/LPN) documents, in part, Informed by CNA (certified nursing assistant) upon rounds resident (R3) had a cane in his hand and blood was coming from roommates head. All staff proceeded to room . When asked what happened, resident (R3) stated, I (R3) thought someone was in my house. I (R3) didn't know he (R2) was supposed to be here. No concerns at this time. On 10/15/24 at 12:46pm, with translator V6 (Certified Nursing Assistant/CNA) present to translate for R2, this surveyor inquired about the altercation with R2 and R3 on 9/26/24. R2 replied, R3 hit me on the head with my cane. I (R2) was in the bathroom and R3 came up behind me and told me to get out of his apartment, grabbed my cane, and hit me in the head with it. I (R2) turned and seen R3. I (R2) am positive it was my roommate. I (R2) was bleeding from my head. R3 hit me good. The nurses took me to a different a room and I (R2) no longer stayed with R3. I (R2) wasn't happy R3 was still here. I (R2) would see him walking around even though the nurses tried to keep him in the wheelchair. Didn't know if he (R3) would try to attack me (R2) again. When asked if R2 feels safe here at the facility, R2 replied, I (R2) don't want to answer cause we don't know. R2's Face Sheet, documents, in part, medical diagnosis including but not limited to peripheral vascular disease, unspecified; other specified soft tissue disorder; and constipation, unspecified. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, R2's Brief Interview for Mental Status (BIMS) score is 13 which indicates R2 is cognitively intact. V10's (CNA/certified nursing assistant) Facility Reported Incident of 9/26/24 Witness Statement, dated 9/26/2024, documents, in part, I (V10) walked into (R2's) room he (R2) was walking out saying (R3) hit him with his cane. (R3) came out of the room yelling, get him out of my apartment. R2's Facility Reported Incident of 9/26/24 Witness Statement, dated 9/26/2024, documents, in part, (R3) hit him (R2) head. On 10/16/24 at 1:10pm, V10 (Certified Nursing Assistant/CNA) said, I know R2. That morning (9/26/24) I (V10) just came in. I (V10) came in and did my rounds. I (V10) was coming back down the other hall and saw R2 staggering out of the room with a bleeding wound on his head. R2 said he (R3) was hitting him. R3 was cursing and yelling. R3's baseline is if you tell him (R3) what to do he'd get agitated. R3 was regularly agitated, every other day. We try to talk to him (R3) and calm him down. Just a lot of foul language. Yeah, I (V10) felt like he (R3) could do something like again cause he (R3) didn't listen. On 10/17/24 at 2:15pm, V5 (Licensed Practical Nurse/LPN) said, Yes, I (V5) am familiar with R3. I (V5) was there 9/26/24 with the R2 and R3 altercation. (R3) has moments of anxiousness and combativeness. CNA came and got me and showed me the opening on R2's head with blood. R2 said R2 was hit with a cane by R3. R3 is aggressive 50/50 percent of time. R3 had some bad days and some chill days. At times I (V5) was worried R3 would hurt other residents. Not sure what R3 was capable of. There are other residents are more helpless than me and can be harmed by R3. Upon review of R3's EMR (Electronic Medical Record), this surveyor observed the following: 1. Record review of R3's Minimum Data Set (MDS) dated [DATE] documents in part a brief interview of mental status summary score of 10 indicating R3 has cognitive impairment, documents R3 has behavioral symptoms and wandering. 2. Record review of R3's CAA (Care Area Assessment) Worksheet (dated 8/28/24) documents in part R3 had behavioral symptoms and wandering. V8 signed the CAA worksheet stated R3's behaviors would be addressed within R3's Care Plan. 3. Record review of state final reportable of the physical abuse investigation occurred between R2 and R3 on 9/26/24, documents in part the R2 and R3's care plans were updated after the incident. 4. Record review of R3's care plan documents in part R3's aggressive behaviors were addressed on 10/10/24 after the incident between R3 and R7. R3's care plan was not updated with the MDS dated [DATE] in response to the CAA worksheet completed by V8 or after the final report and investigation of the incident occurred between R2 and R3. 5. Inaccuracy of R3's Screening Assessment for Trauma Factors Including Abuse/Neglect, dated 10/10/24 with a lock date (changes were made) of 10/16/24. R3's Screening Assessment for Trauma Factors Including Abuse/Neglect documents, in part, Question 1. History of Abuse/Neglect including physical, sexual, verbal, emotional, financial, domestic violence, involuntary seclusion and/or unexplained injuries prior to admission. Answer NO. This answer is not accurate as evidenced by prior to admission R3 was in a physical altercation at the previous facility he (R3) resided at with another resident. Documented in hospital records prior to R3's admission is a history of aggression both verbal and physical. Question 2. History of presences of dysfunctional behavior (e.g., provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. Answer Unable to be determine. This answer is not accurate as evidenced by R3's criminal history and R3 invading R2's space when R3 hit R2 ion the head with a cane on 9/26/24. 6. Inaccuracy of R3's Screening assessment for indicators of aggressive and/or harmful behaviors. R3's Screening assessment for indicators of aggressive and/or harmful behaviors,' documents, in part, Question A. 1. General awareness, insight, judgement, reasoning, memory, concentration and orientation, including diagnosed dementing illness (i.e. Alzheimer's Disease, Vascular Dementia NOS, Pick's Disease, OBS, Substance Induced Dementia). Answer 0. This answer is not accurate as evidenced by R3's diagnosis of Alzheimer's disease and vascular dementia. Question D 1. History of Abuse/Neglect including physical, sexual, verbal, emotional, financial, domestic violence, involuntary seclusion and/or unexplained injuries prior to admission. Answer NO. This answer is not accurate as evidenced by prior to admission R3 was in a physical altercation at the previous facility he (R3) resided at with another resident. Documented in hospital records prior to R3's admission is a history of aggression both verbal and physical. Question D 2. Factors increase resident's vulnerability (e.g. dementia, confusion, disorientation, poor insight/poor judgement, poor communication skills, poor ambulation or inability to ambulate/propel wheelchair, frailty/weakness, history of exploitation, heavy care needs, unable to make needs known, on psychotropic meds)? Answer Unable to be determine. This answer is inaccurate as evidenced by R3's diagnosis of vascular dementia. Question D 3. Psychiatric history and/or mental health diagnosis, including psychotic symptoms (e.g. delusional thoughts, hallucinations) and possible misinterpretation of events and the intentions of peers? Answer Unable to be determine. This answer is inaccurate as evidenced by R3's mental health diagnosis including but not limited to bipolar disorder, current episode mixed, unspecified; Alzheimer's disease; dementia; major depressive disorder. Question D 6. History of presences of dysfunctional behavior (e.g., provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. Answer Unable to be determine. This answer is not accurate as evidenced by R3's criminal history and R3 invading R2's space when R3 hit R2 ion the head with a cane on 9/26/24. On 10/22/24 at 9:53 AM, V8 (Social Services Director) stated the social services department is responsible for creating a plan of care for residents with behaviors. Inappropriate behaviors, aggression, or refusal/combativeness to care would all be care planned by the social services department. V8 reviewed R3's plan of care and affirmed R3's behaviors were not care planned until after both incidents (9/26 and 10/10). V8 stated R3's aggressive behaviors should have been addressed in R3's care plan upon admission when the history of aggression/abuse was identified. V8 did not know why the R3's behaviors were not addressed in R3's care plan. On 10/22/24 at 9:57 AM, V8 (Social Services Director) stated the screening for aggressive behavior is to be completed with every MDS (quarterly, annually significant change) and if aggressive behavior occurs. V8 did not know why the aggression screening assessment was not completed after R3's incidents of violent behavior on 9/26 and 10/10. V8 stated these assessments are important because they help to trigger staff to develop a plan of care to address the aggression. On 10/15/2024 at 11:50 AM, V9 (Registered Nurse Consultant stated, If documentation cannot be produced, then it didn't happen. On 10/15/24 at 3:18 PM, R7 recalled a few days ago, R7 was sitting by R7's bed and R7's back was turned away towards the door. R7 stated R7 began getting punched in the head from behind with a closed fist, many times. R7 stated R7 tried to grab the person punching R7 to prevent getting punched further but R7 stated R7 was in a daze from the punches and I almost got knocked out. R7 remembered having face pain at the time of the incident and staff came in and broke up the fight. R7 stated R7 was sent to the hospital to see if R7 was injured. R7 stated, I don't know if I feel safe here anymore. In R7's EMR (electronic medical record), V3's (Licensed Practical Nurse/LPN) progress note, dated 10/10/2024 at 1:07pm, documents, in part, (R7) is the receiver in a physical altercation with peer. (R7) was knocked down to the floor by peer. In R3's EMR (electronic medical record), V3's (Licensed Practical Nurse/LPN) progress note, dated 10/10/2024 at 2:42pm, documents, in part, Writer and staff heard yelling in the hall from a resident's room. All staff reported to another resident's room where (R3) was observed punching the resident out of his wheelchair to the floor. When removing (R3) from the room he became combative with his CNA (certified nursing assistant) striking her. Writer intervened and the resident became combative with writer using verbal aggression and vulgar language to staff. Resident petitioned out to (Hospital) via 911. POA (power of attorney) Family. In R3's EMR (electronic medical record), V3's (Licensed Practical Nurse/LPN) progress note, dated 10/10/2024 3:04pm, documents, in part, Resident sent to (Hospital). Family notified. In R3's EMR (electronic medical record), V4's (Licensed Practical Nurse/LPN) progress note, dated 10/10/2024 3:59pm, documents, in part, (R3) discharged to: 10/10/2024 3:08 PM. Reason for transfer: Physical aggression . The following people were notified of transfer: Physician Family Yes - Current reconciled medication list provided to the subsequent provider. In R7's EMR (electronic medical record), V5's (Licensed Practical Nurse/LPN) progress note, dated 10/11/2024 at 1:44am, documents, in part, (R7) returned from hospital with two fractures to cheek and fracture to nose. R7's Face Sheet, documents, in part, medical diagnosis including but not limited to fracture of unspecified part of neck of right femur, sequela; other cervical disc degeneration, unspecified cervical region; fusion of spine, cervical region; and seizures. R7's Minimum Data Set (MDS), dated [DATE], documents, in part, R7's Brief Interview for Mental Status (BIMS) score is 07 which indicates R7 has severe cognitive impairment. R7's hospital records, dated 10/10/24, documents, in part, Sent from (Facility) after assaulted by another resident there. Apparently, this resident was punching multiple other residents and punched this patient in the head, knocking him out of his wheelchair. On 10/10/24 at 9:30 PM, R7's hospital records document a CT (computed tomography scan was completed) and documents the following findings: fracture of the nasal bones, small fracture of the lateral wall of the right orbit, small fracture of the right arm of the zygomatic arch, dehiscence of the floor of the right orbit. These fractures are of indeterminate age; clinical correlation is recommended. At 9:46 PM, R2's physician documented, Likely mix of new and old injuries. V3's (Licensed Practical Nurse/LPN) Facility Reported Incident of 10/10/24 Witness Statement, dated 10/11/2024, documents, in part, Writer and staff heard yelling in the hall from a resident's room (R7's room). All staff reported to room where the yelling was heard; Upon arrival (R3) had punched (R7) out of his wheelchair to the floor. When staff attempted to remove (R3) he became combative with his CNA (certified nursing assistant) taking a swing striking her. Writer intervened and the residents became combative with writer using verbal aggression and vulgar language with threats. V15's (CNA/certified nursing assistant) Facility Reported Incident of 10/10/24 Witness Statement, dated 10/11/2024, documents, in part, (R3) was very aggressive he (R3) was about to hit me (V15) so I (V15) step out of the room. Using abusive language toward everybody. R7's Facility Reported Incident of 10/10/24 Witness Statement, dated 10/10/2024, documents, in part, (R3) went to (R7's) room and hit him (R7) on the side of the face. On 10/16/24 at 11:50am, V1 (Administrator) said, I (V1) got abuse training on hire and multiple times after. Training began with HR (Human Resource), then I (V1) reviewed companies' policies on physical, emotional, negligence, misappropriation of funds, sexual, verbal, and mental abuse. Abuse is causing any king of harm falls under those categories. Abuse is harm with intent. When someone willfully is doing any of those actions. Making a choice to cause harm. We (facility) did not substantiate abuse for either incident because dementia residents do not have the mental capacity to make a choice to harm. On 10/16/24 at 11:50am, V9 (Nurse Consultant), In R3's referral it did state R3 had in an altercation with another resident, but it did not stay who hit who. We've (facility) been cited every month for abuse. I (V9) started being in the building every day. When asked what was put into place after R3 hit R2 with a cane, V9 replied, behavior monitoring, offer activities, sister visiting more to assist with behaviors. When asked for the documentation of R3's behavior monitoring, V9 replied, I (V9) need to see if V8 (Social Service Director) has the behavior monitoring sheets upstairs. When asked if R3 has ever seen a therapist, V9 replied, I'm not sure. I'll have to check with social service team. Assessments are done on admission, updated when changes. The assessment should indicate if there were changes and if aggressive to staff or residents. No behavior monitoring for R3 could be produced by the facility by the end of the survey. On 10/17/24 at 11:33am, V15 (Certified Nursing Assistant) said, Yes sir, I (V15) am familiar with R3. R3 had his moments when we (staff) couldn't tell R3 anything cause R3 would get upset/agitated and call us (staff) names like, 'You bitch'. Even if you (staff) tried to calm R3 down R3 wouldn't calm down. Yes, R3 would be physical. R3 would get aggressive with me (V15). R3 would grab my hand and try punching me. I (V15) was working day (10/10/24). I (V15) heard a little commotion and went towards R7's room. I (V15) tried to help him (R3) calm down. R3 was very aggressive. R3 grabbed my hand. R3 kept coming at me. R3 walks. R3 stands up from his wheelchair. R3 won't sit down. I (V15) just heard R3 screaming. R7 was complaining of pain in face. We (staff) didn't know when R3 would get upset. When R3 just got the urge R3 would just get aggressive. I (V15) was worried R3 would hurt me. R3 was a strong guy. Yes, I (V15) was definitely worried R3 would hurt the other residents. I (V15) believe, everyone (all employees) knew R3 would get upset. There was no training for R3. You (staff) can have a conversation with R7. He (R7) remembers almost everything. Just can be a little forgetful but R7 would not forget anything like this. Since happened R7 always brings it up. I (V15) would say R7 remembers things, sometimes forget things, but he remembers most things. I (V15) don't think R7 would make up a story of what happened to him (R7). R3 is not appropriate to have a roommate. R3 was aggressive toward staff since the beginning. On 10/17/24 at 12:03pm, V3 (Licensed Practical Nurse/LPN) said, Yes, I (V3) am familiar with R3. He'd (R3) get up from the chair and curse you out. Gets very vulgar and then more vulgar. We (staff) try to redirect R3. R3 has swung at me (V3) before but never actually made contact. I (V3) was sitting at the nurse's station, heard someone yelling, CNAs (certified nursing assistants) and I (V3) got up and went to see what was happening. R3 was up over, standing over R7. I (V3) assessed R7, helped him up, and removed R3 from the room. R3 got aggressive with the CNA and me. R3 was full of aggressiveness, vulgarity, and more aggression. R3 struck the CNA. R3 walked up on me with his fist and swung, but I (V3) backed up. R3 continued being vulgar. My documentation, I (V3) admit, sucked. I (V3) asked if a resident's daughter visiting witnessed it and the family member said yes. When I (V3) asked the family member if she (family member) seen R3 strike R7, she (family member) said yes. The family member was in tears. Staff was with R3 in the dining room but R3 will roll out of the dining room, we'll watch him role out, but R3 has right. R3 has the freedom to roll back and forth. Residents have the freedom to roll around. I (V3) have been worried R3 would hurt me. I (V3) have been concerned R3 would hurt other residents. I (V3) never notified anyone; I (V3) just diffused the situation. R3 was 50/50 percent aggressive all of the time. R3 could be decent and then would just snap. On 10/17/24 at 12:19pm, V16 (CNA), said, I (V16) was working 10/10/24. I (V16) heard yelling, ran, and the other nurse followed. R7's wheelchair was flipped over and R3 was standing over R7. R7 said R3 punched him (R7) and knocked him (R7) over. R7 is pretty much oriented, forgets here and there, but for the most part R3 remembers even like missing a shoe. No, R7 wouldn't make up a story. Half of the time R3 is aggressive. On 10/22/2024 at 10:48am, V18 (Medical Director) said, I (V18) was the attending physician for R3. R3 had Bipolar, dementia, anxiety depression, Psych issues. Medically ok. Main reason was psych issues as far as I (V18) remember. I (V18) did his (R3) admission, and he (R3) had some altercation at other facility and's why other facility transferred him out to our facility. Based on R3's history of aggression towards other residents, I (V18) don't know if he (R3) had a roommate. When asked if it was appropriate for R3 to have a roommate, V18 replied, Difficult to answer. There are a lot of psych, and they can have behaviors and stabilize. When I'm (V18) admitting a patient I (V18) assume they are stabilized. With identified behaviors prior to admission, the facility should have increased R3's supervision and observation. Yeah, when we see there R3 required increased monitoring. Nursing homes don't have a lot of staff, so if we (facility) can't care for them appropriately, we (facility) send them to the hospital. I (V18) was aware of 10/10/24 altercation with R2 and R3. We sent R3 out. No, I (V18) don't remember a change of condition. When I (V18) went in the room R3 was using vulgar language. Being hit in the head and falling out of a wheelchair cause facial fractures definitely caused harm to (R7). The severity of harm happens after a resident is hit in the head can vary depending on the velocity of the hit, the size of the resident. Facial fractures can be caused by a punch to the head or falling out of a wheelchair. R3's plan of care should have been developed to address those behaviors. Dementia and psych are very challenging. We try to control the behaviors but if it's out of control we (facility) send them out. If the Plan of care isn't done, the resident's aggressive behaviors can continue. We (facility) need to address it because other residents are at risk. If a resident is assessed incorrectly, can harm be caused? is a hard question. Behaviors change. If behaviors changed the assessments should be redone. On 10/28/24 at 1:10pm, V9 (Nurse Consultant) said, We (facility) do not have an assessment policy or a policy specifically for completing the aggression screening and trauma assessment. We (facility) follow the RAI (Resident Assessment Instrument) guidelines for Assessments. Record review of R3's medication administration record (October 2024) documents in part R3 has an order for Seroquel (Quetiapine Fumarate) give 1 tablet by mouth every 8 hours as needed for agitation for 14 days began on 10/1/2024. The medication administration record indicates this medication was not given in on 10/10/24 when R3 displayed agitation. Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 3 MDS Items [B] (dated October 2024) documents in part the following: 9. Behavioral Symptoms In the world at large, human behavior varies widely and is often dysfunctional and problematic. While behavior may sometimes be related to or caused by illness, behavior itself is only a symptom and not a disease. The MDS only identifies certain behaviors but is not intended to determine the significance of behaviors, including whether they are problematic and need an intervention. Therefore, it is essential to assess behavior symptoms carefully and in detail in order to determine whether, and why, behavior is problematic and to identify underlying causes. The behavior CAA focuses on potentially problematic behaviors in the following areas: wandering (e.g., moving with no rational purpose, seemingly being oblivious to needs or safety), verbal abuse (e.g., threatening, screaming at, or cursing others), physical abuse (e.g., hitting, shoving, kicking, scratching, or sexually abusing others), other behavioral symptoms not directed at others (e.g., making disruptive sounds or noises, screaming out, smearing or throwing food or feces, hoarding, rummaging through other's belongings), inappropriate public sexual behavior or public disrobing, and rejection of care (e.g., verbal or physical resistance to taking medications, taking injections, completing a variety of activities of daily living or eating). Understanding the nature of the issue/condition and addressing the underlying causes have the potential to improve the quality of the resident's life and the quality of the lives of those with whom the resident interacts. When this CAA is triggered, nursing home staff should follow their facility's chosen protocol or policy for performing the CAA. This CAA is triggered when the resident is identified as exhibiting certain troubling behavioral symptoms . The information gleaned from the assessment should be used to determine why the resident's behavioral symptoms are problematic in contrast to a variant of normal, whether and to what extent the behavior places the resident or others at risk for harm, and any related contributing and/or risk factors. The next step is to develop an individualized care plan based directly on these conclusions. The focus of the care plan should be to address the underlying cause or causes, reduce the frequency of truly problematic behaviors, and minimize any resultant harm. Facility policy titled Behavior Management for Agitated Behavior (undated), documents in part, Targeted Behavior: Agitated Behavior, which represents a danger to self and others, due to Alzheimer's disease with anxiety, dementia, mental illness or other illnesses. Preventative Measures: .2. When resident's voice is loud, offer drink, food, toileting, take for a walk, or redirect to activity of interest .3. Observe resident for behavior escalation of anxiety, aggression such as loud voice tone, hand ringing, swearing, yelling, and/or other irritability. Interventions if Behaviors Escalates and/or Reoccurs: 1. Remove from problem area, separate from other, when necessary, APPROACH from the front . 4. If uncontrolled anger, aggression or anxiety cannot be redirected, i.e. the resident is in danger of harming self or others after attempting the above interventions, administer physician ordered medication for anxiety for the symptoms being exhibited. **** .6. Document all interventions attempted and administered and the resident's response to medical interventions . 8. Monitor the response to drug therapy 1:1 until dangerous symptoms are reduced. If the resident responds to the medication by becoming quiet and anxiety free and aggressive acts have minimized, i.e. no longer harm to self and others 1:1 monitoring will be discontinued . Facility policy titled Abuse Prevention Facility Policy and Procedure dated 1/4/2018, documents in part: . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services needed to attain or maintain physical, mental or 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 or 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 the individual must have intended to inflict injury or harm . II. Pre-Admission Screening of Potential Residents: this facility shall check and review the criminal history background for any resident seeking admission to the facility in order to identify previous criminal convictions. This facility will: - request a Criminal History Background Check within 24 hours after admission of a new resident, - check for the residents and sex offender registration website. www.isp.state.il.us - Check for the resident's name on the Illinois department of Corrections sex registrant search page. www.idoc.state.il.us - While the background or fingerprint checks, and/or Identified Offender Report and Recommendations are pending, the facility shall take steps necessary to ensure safety . IV. Establishing a Resident Sensitive Environment This facility desires to prevent abuse, neglect exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality [TRUNCATED]

Based on interview and record review, the facility failed to accurately complete assessments that identify R3's aggressive behaviors and blindness. These failures resulted in R3 physically assaulting 2 residents (R2 & R7) and causing multiple facial fractures to one resident (R7). These failures caused harm and affected 3 residents (R2, R3, and R7) reviewed for assessment accuracy. Findings include: R3's admission record documents in part that R3 was admitted on [DATE] and had the following active diagnosis: cerebral infarction, cognitive communication deficit, bipolar disorder, other Alzheimer's disease, vascular dementia with other behavioral disturbance, major depressive disorder, unspecified psychosis not due to a substance or a known physiological condition, and legal blindness. R3's background check dated 8/27/24 documents in part that R3 has a convicted criminal history of forgery, theft, and violating probation. R3's Minimum Data Set (MDS) dated [DATE] documents in part a brief interview of mental status summary score of 10 indicating that R3 has cognitive impairment. R3 has behavioral symptoms that occurred 1 to 3 days and has adequate vision. The coding of B1000: Vision indicating that R3 has adequate vision is inaccurate as R3 is legally blind. R3's progress notes completed on 8/28/24 by V18 (Physician, Medical Director) identified that R3 had .behavioral issues (and) was transferred from the nursing home to the hospital after a physical altercation with a fell ow resident. Patient (R3) was admitted in the hospital seen by psych adjusted medication and discharged to this facility to continue skilled nursing medical supervision. R3's Screening Assessment for Trauma Factors Including Abuse/Neglect, dated 10/10/24 with a lock date (changes were made) of 10/16/24. R3's Screening Assessment for Trauma Factors Including Abuse/Neglect documents, in part, Question 1. History of Abuse/Neglect including physical, sexual, verbal, emotional, financial, domestic violence, involuntary seclusion and/or unexplained injuries prior to admission. Answer NO. This answer is not accurate as evidenced by prior to admission R3 was in a physical altercation at the previous facility he (R3) resided at with another resident. Documented in hospital records prior to R3's admission is a history of aggression both verbal and physical. Question 2. History of presences of dysfunctional behavior (e.g., provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. Answer Unable to be determine. This answer is not accurate as evidenced by R3's criminal history and R3 invading R2's space when R3 hit R2 ion the head with a cane on 9/26/24. R3's Screening assessment for indicators of aggressive and/or harmful behaviors. R3's Screening assessment for indicators of aggressive and/or harmful behaviors,' documents, in part, Question A. 1. General awareness, insight, judgement, reasoning, memory, concentration and orientation, including diagnosed dementing illness (ie. Alzheimer's Disease, Vascular Dementia NOS, Pick's Disease, OBS, Substance Induced Dementia). Answer 0. This answer is not accurate as evidenced by R3's diagnosis of Alzheimer's disease and vascular dementia. Question D 1. History of Abuse/Neglect including physical, sexual, verbal, emotional, financial, domestic violence, involuntary seclusion and/or unexplained injuries prior to admission. Answer NO. This answer is not accurate as evidenced by prior to admission R3 was in a physical altercation at the previous facility he (R3) resided at with another resident. Documented in hospital records prior to R3's admission is a history of aggression both verbal and physical. Question D 2. Factors that increase resident's vulnerability (e.g. dementia, confusion, disorientation, poor insight/poor judgement, poor communication skills, poor ambulation or inability to ambulate/propel wheelchair, frailty/weakness, history of exploitation, heavy care needs, unable to make needs known, on psychotropic meds)? Answer Unable to be determine. This answer is inaccurate as evidenced by R3's diagnosis of vascular dementia. Question D 3. Psychiatric history and/or mental health diagnosis, including psychotic symptoms (e.g. delusional thoughts, hallucinations) and possible misinterpretation of events and the intentions of peers? Answer Unable to be determine. This answer is inaccurate as evidenced by R3's mental health diagnosis including but not limited to bipolar disorder, current episode mixed, unspecified; Alzheimer's disease; dementia; major depressive disorder. Question D 6. History of presences of dysfunctional behavior (e.g., provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. Answer Unable to be determine. This answer is not accurate as evidenced by R3's criminal history and R3 invading R2's space when R3 hit R2 in the head with a cane on 9/26/24. R3's progress notes dated 9/7/2024 documents in part that R3 was combative with staff, refusing medications (including insulin) and blood glucose testing. On 9/26/24 at 7:20 AM, R3 was observed with a cane in R3's hand and blood was noted from R3's roommate's (R2) head. On 9/26/24, R3 had another altercation with another peer in the dining room and was verbally aggressive and combative with staff. Subsequently, R3 was sent to the hospital for a psychiatric evaluation and returned on 9/28/24. On 10/10/2024, R3 was observed punching another resident (R7) out of the wheelchair and on to the floor. R3 additionally struck the CNA and was verbally aggressive to the nurse. R3 was sent to the hospital for psychiatric admission on 10/10/24. R2's progress notes indicate staff observed R2 bleeding from an open area to R2's head and that R2's roommate (R7) was holding a cane. R2 stated, I was in the bathroom and the man just came in there and hit me in the head with my cane and said I wasn't supposed to be in his apartment. R2's open area on R2's was cleaned, dressing applied, and neurological checks were initiated. R7's progress notes documents in part on 10/10/2024 that R7 is the receiver of physical aggression by a peer (R3) and R7 was knocked down to the floor by a peer (R3) and was transferred to the hospital for evaluation. R7 returned on 10/11/2024 with fractures to the cheek and nose. R7's hospital records dated 10/10/2024 document in part that computed tomography (CT) scans were completed and fractures were identified to the nasal bones, lateral wall of right orbit, right zygomatic arch and dehiscence of the floor of the right orbit. On 10/22/24 at 9:56 AM, V8 (Social Services Director) affirmed V8 supervises the social services department and is familiar with R3. V8 stated the incident that occurred between R2 and R3 on 9/26 was partially because R3 was blind and couldn't realize who R2 was. V8 stated the screening assessment for indicators of aggressive and/or harmful behaviors should be completed on admission, quarterly and as needed if aggressive/harmful behaviors happen. V8 reviewed R3's electronic health record, including R3's diagnosis list, progress notes, care plan, and assessments, including the screening assessment or aggressive behaviors dated 9/11/24. V8 affirmed the assessment is incorrect and stated the assessment does not identify R3's criminal background, history of abuse (physical altercation from prior facility), R3's dementia diagnosis, R3's psychiatric history, dysfunctional behavior, wandering. V8 stated the screening assessment for indicators of aggressive and/or harmful behaviors assessment is important to be completed and completed accurately because the screening drives the plan of care for the resident and identifies needs. V8 affirmed the assessment being completed inaccurately can cause the resident's aggressive behavior to be unidentified and unaddressed. On 10/22/24 at 10:48 AM, V18 (Medical Director) stated, If residents are assessed incorrectly what harm could be caused is a hard question because behaviors change. V18 stated if behaviors change, behavioral assessments should be redone. On 10/22/24 at 11:08 AM, V20 (MDS Coordinator, Licensed Practical Nurse) stated that one of focuses/purposes of the MDS is to identify resident needs and drive the care plan. V20 confirmed R3 was legally blind and was visually impaired. V20 reviewed R3's 8/28/24 MDS and stated that R3's vision in B1000 should have been coded as impaired. V20 stated that if assessments are not completed accurately, care needs may not be developed in the care plan. V20 reviewed R3's care plan and affirmed that R3's blindness was not addressed on the care plan and affirmed that if B1000 was coded correctly, a Care Area Assessment (CAA) would have triggered for visual function. On 10/28/24 at 1:10pm, V9 (Nurse Consultant) said, We (facility) do not have an assessment policy or a policy specifically for completing the aggression screening and trauma assessment. We (facility) follow the RAI (Resident Assessment Instrument) guidelines for Assessments. Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 3 MDS Items [B] (dated October 2024) documents in part the following: .B1000: Vision .Coding Instructions Code 0, adequate: if the resident sees fine detail, including regular print in newspapers/books. Code 1, impaired: if the resident sees large print, but not regular print in newspapers/books. Code 2, moderately impaired: if the resident has limited vision and is not able to see newspaper headlines but can identify objects nearby in their environment. Code 3, highly impaired: if the resident's ability to identify objects nearby in their environment is in question, but the resident's eye movements appear to be following objects (especially people walking by). Code 4, severely impaired: if the resident has no vision, sees only light, colors or shapes, or does not appear to follow objects with eyes.

Based on interview and record review, the facility failed to develop a plan of care to address R3's known aggressive behaviors and history of aggressive behaviors. These failures resulted in R3 physically assaulting 2 residents (R2 & R7) and causing multiple facial fractures to one resident (R7). These failures caused harm and affected 3 residents (R2, R3, and R7) reviewed for care planning. Findings include: R3's Referral records, that the facility received prior to R3's admission, fax date of 8/16/24, documents, in part, (R3) with a history of dementia, depression, and anxiety was transferred from a local nursing home for direct admission. (R3) was involved in a physical altercation with a fell ow resident . (R3) remains anxious, irritated, confused, and bizarre, with no recollection of why (R3) is being treated. Due to (R3's) dysregulated mood, aggression, and confusion, (R3) poses a danger to (R3) and others . Verbal aggression during pt (patient) care . On 8/21/24, R3 was admitted with medical diagnosis include but not limited to aphasia following cerebral infarction; major depressive disorder, recurrent, unspecified; essential (primary) hypertension; unspecified psychosis not due to a substance or known physiological condition; other specified diabetes mellitus without complications; polyosteoarthritis, unspecified; arthropathy, unspecified; gastro-esophageal reflux disease without esophagitis; long term (current) use of aspirin; insomnia, unspecified; hyperlipidemia, unspecified; vascular dementia, unspecified severity, with other behavioral disturbance; bipolar disorder, current episode mixed, unspecified; cerebral infarction, unspecified; dysphagia, oropharyngeal phase; cognitive communication deficit; other Alzheimer's disease. Record review of R3's Minimum Data Set (MDS) dated [DATE] documents in part a brief interview of mental status summary score of 10 indicating that R3 has cognitive impairment, documents that R3 has behavioral symptoms and wandering. Record review of R3's CAA (Care Area Assessment) Worksheet (dated 8/28/24) documents in part that R3 had behavioral symptoms and wandering. V8 (Social Services Director) signed the CAA worksheet stated that R3's behaviors would be addressed within R3's Care Plan. R3's progress note, dated 9/26/2024 at 7:20am, transposed by V5 (Licensed Practical Nurse/LPN) documents, in part, Informed by CNA (certified nursing assistant) upon rounds that resident (R3) had a cane in his hand and blood was coming from roommates head. All staff proceeded to room . When asked what happened, resident (R3) stated I (R3) thought someone was in my house, I (R3) didn't know (R2) was supposed to be here . No concerns at this time. On 10/15/24 at 12:46pm, with translator V6 (Certified Nursing Assistant/CNA) present to translate for R2, this surveyor inquired about the altercation with R2 and R3 on 9/26/24. R2 replied, (R3) hit me on the head with my cane. I (R2) was in the bathroom and (R3) came up behind me and told me to get out of (R3's) apartment, grabbed my cane, and hit me (R2) in the head with it. I (R2) turned and seen R3. I (R2) am positive it was my roommate. I (R2) was bleeding from my head. R3 hit me good. The nurses took me to a different a room and I (R2) no longer stayed with R3. I (R2) wasn't happy that R3 was still here. I (R2) would see (R3) walking around even though the nurses tried to keep (R3) in the wheelchair. Didn't know if (R3) would try to attack me (R2) again. When asked if R2 feels safe here at the facility, R2 replied, I (R2) don't want to answer cause we don't know. On 10/16/24 at 1:10pm, V10 (Certified Nursing Assistant/CNA) said, I know R2. That morning (9/26/24) I (V10) just came in. I (V10) came in and did my rounds. I (V10) was coming back down the other hall and saw R2 staggering out of the room with a bleeding wound on (R2's) head. R2 said (R3) was hitting (R2). (R3) was cursing and yelling. (R3's) baseline is if you tell (R3) what to do (R3) get agitated. (R3) was regularly agitated, every other day. We try to talk to (R3) and calm (R3) down. Just a lot of foul language. Yeah, I (V10) felt like (R3) could do something like that again cause (R3) didn't listen. On 10/17/24 at 2:15pm, V5 (Licensed Practical Nurse/LPN) said, Yes, I (V5) am familiar with R3. I (V5) was there 9/26/24 with the R2 and R3 altercation. (R3) Has moments of anxiousness and combativeness. CNA came and got me and showed me the opening on R2's head with blood. R2 said R2 was hit with a cane by R3. R3 is aggressive 50/50 percent of time. R3 had some bad days and some chill days. At times I (V5) was worried R3 would hurt other residents. Not sure what R3 was capable of. There are other residents that are more helpless than me and can be harmed by R3. On 10/15/24 at 3:18 PM, R7 recalled a few days ago, R7 was sitting by R7's bed and R7's back was turned away towards the door. R7 stated that R7 began getting punched in the head from behind with a closed fist, many times. R7 stated that R7 tried to grab the person punching R7 to prevent getting punched further but R7 stated that R7 was in a daze from the punches and I almost got knocked out. R7 remembered having face pain at the time of the incident and that staff came in and broke up the fight. R7 stated that R7 was sent to the hospital to see if R7 was injured. R7 stated, I don't know if I feel safe here anymore. In R7's EMR (electronic medical record), V3's (Licensed Practical Nurse/LPN) progress note, dated 10/10/2024 at 1:07pm, documents, in part, (R7) is the receiver in a physical altercation with peer. (R7) was knocked down to the floor by peer. In R3's EMR (electronic medical record), V3's (Licensed Practical Nurse/LPN) progress note, dated 10/10/2024 at 2:42pm, documents, in part, Writer and staff heard yelling in the hall from a resident's room. All staff reported to another resident's room where (R3) was observed punching the resident out of his wheelchair to the floor. When removing (R3) from the room he became combative with his CNA (certified nursing assistant) striking her. Writer intervened and the resident became combative with writer using verbal aggression and vulgar language to staff. Resident petitioned out to (Hospital) via 911. POA (power of attorney) Family. In R7's EMR (electronic medical record), V5's (Licensed Practical Nurse/LPN) progress note, dated 10/11/2024 at 1:44am, documents, in part, (R7) returned from hospital with two fractures to cheek and fracture to nose. Record review of R3's care plan documents in part that R3's aggressive behaviors were addressed on 10/10/24 after the incident between R3 and R7. R3's care plan was not updated with the MDS dated [DATE] in response to the CAA worksheet completed by V8 or after the final report and investigation of the incident that occurred between R2 and R3. Record review of state final reportable of the physical abuse investigation that occurred between R2 and R3 on 9/26/24, documents in part the R2 and R3's care plans were updated after the incident. This is inaccurate as the care plan was not updated until 10/10/2024 to address R3's behaviors. On 10/22/24 at 9:53 AM, V8 (Social Services Director) stated that the social services department is responsible for creating a plan of care for residents with behaviors. Inappropriate behaviors, aggression, or refusal/combativeness to care would all be care planned by the social services department. V8 reviewed R3's plan of care and affirmed that R3's behaviors were not care planned until after both incidents (9/26 and 10/10). V8 stated that R3's aggressive behaviors should have been addressed in R3's care plan upon admission when the history of aggression/abuse was identified. V8 did not know why the R3's behaviors were not addressed in R3's care plan. On 10/22/2024 at 10:48am, V18 (Medical Director) stated,R3's plan of care should have been developed to address those behaviors (aggression). Dementia and psych are very challenging. We try to control the behaviors but if it's out of control we (facility) send them out. If the Plan of care isn't done, the resident's aggressive behaviors can continue. We (facility) need to address it cause other residents are at risk. On 10/22/2024 at 11:08 AM, V20 (MDS Coordinator, LPN) stated the facility does not have a care plan coordinator, all departments are responsible for developing their plan of care according to the MDS triggered CAAs. V20 reviewed R3's MDS dated [DATE] and affirmed that R3 had a behavioral symptoms CAA trigger and that V8 signed affirming V8 would develop the plan of care. V20 reviewed R3's plan of care and confirmed that R3's violent behavior was not addressed until after the incident on 10/10/2024 by V8. V20 stated that R3 should have had a care plan to address R3's violent behavior. Facility policy titled, CHANGE IN RESIDENT'S CONDITION (reviewed 11/2023), documents in part, . RESPONSIBLE PARTY: RN, LPN, Social Services . 5. The Care Plan for the residents will be updated as indicated. Facility policy titled, CARE PLAN (undated) documents in part, A. POLICY: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status . 1. The residents comprehensive care plan initiated upon admission within 24 hours. 2. A comprehensive care plan is developed within 7 days of the completion of the comprehensive assessments and trigger legend (which is completed within 14 days of admission . a. Concerns, needs and/or strengths have a corresponding goal. The format for a goal is who, what, how, and when. Goals are resident oriented, specific problem- oriented goals relative to medical and nursing diagnosis, realistic, measurable, and directed towards increased functional levels . b. When a change occurs in a resident's condition the Care Plan Coordinator is notified by a member of the interdisciplinary team. The care plan is then reviewed and updated . 9. The Care Plan Coordinator has responsibility for each resident's care plan. A. the care plan coordinator is responsible for coordinating each resident's care plan and for ensuring that the appropriate information is available to all staff . b. The Interdisciplinary Team is responsible for the implementation of resident care management. 10. All interdisciplinary team departments are responsible for charting that reflects the care plan concerns, problems, needs and/or strengths, approaches, progress, or lack of progress with possible reasons for new problems . Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 3 MDS Items [B] (dated October 2024) documents in part the following: .9. Behavioral Symptoms In the world at large, human behavior varies widely and is often dysfunctional and problematic. While behavior may sometimes be related to or caused by illness, behavior itself is only a symptom and not a disease. The MDS only identifies certain behaviors but is not intended to determine the significance of behaviors, including whether they are problematic and need an intervention. Therefore, it is essential to assess behavior symptoms carefully and in detail in order to determine whether, and why, behavior is problematic and to identify underlying causes. The behavior CAA focuses on potentially problematic behaviors in the following areas: wandering (e.g., moving with no rational purpose, seemingly being oblivious to needs or safety), verbal abuse (e.g., threatening, screaming at, or cursing others), physical abuse (e.g., hitting, shoving, kicking, scratching, or sexually abusing others), other behavioral symptoms not directed at others (e.g., making disruptive sounds or noises, screaming out, smearing or throwing food or feces, hoarding, rummaging through other's belongings), inappropriate public sexual behavior or public disrobing, and rejection of care (e.g., verbal or physical resistance to taking medications, taking injections, completing a variety of activities of daily living or eating). Understanding the nature of the issue/condition and addressing the underlying causes have the potential to improve the quality of the resident's life and the quality of the lives of those with whom the resident interacts. When this CAA is triggered, nursing home staff should follow their facility's chosen protocol or policy for performing the CAA. This CAA is triggered when the resident is identified as exhibiting certain troubling behavioral symptoms . The information gleaned from the assessment should be used to determine why the resident's behavioral symptoms are problematic in contrast to a variant of normal, whether and to what extent the behavior places the resident or others at risk for harm, and any related contributing and/or risk factors. The next step is to develop an individualized care plan based directly on these conclusions. The focus of the care plan should be to address the underlying cause or causes, reduce the frequency of truly problematic behaviors, and minimize any resultant harm .

Based on interview and record review, the facility failed to provide and ensure adequate supervision to a resident (R3) with a known violent behavior. These failures resulted to R3 physically assaulting 2 (R2 & R7) residents and causing multiple facial fractures to one resident (R7). Findings include: On 10/15/24 at 12:46pm, with translator V6 (Certified Nursing Assistant/CNA) present to translate for R2, this surveyor inquired about the altercation with R2 and R3 on 9/26/24. R2 replied, R3 hit me on the head with my cane. I (R2) was in the bathroom and R3 came up behind me and told me to get out of his apartment, grabbed my cane, and hit me in the head with it. I (R2) turned and seen R3. I (R2) am positive it was my roommate. I (R2) was bleeding from my head. R3 hit me good. The nurses took me to a different a room and I (R2) no longer stayed with R3. I (R2) wasn't happy that R3 was still here. I (R2) would see him walking around even though the nurses tried to keep him in the wheelchair. Didn't know if he (R3) would try to attack me (R2) again. When asked if R2 feels safe here at the facility, R2 replied, I (R2) don't want to answer cause we don't know. R2's Face Sheet, documents, in part, medical diagnosis including but not limited to peripheral vascular disease, unspecified; other specified soft tissue disorder; and constipation, unspecified. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2's Brief Interview for Mental Status (BIMS) score is 13 which indicates R2 is cognitively intact. R7's hospital records, dated 10/10/24, documents, in part, Sent from (Facility) after assaulted by another resident there. Apparently, this resident was punching multiple other residents and punched this patient in the head, knocking him out of his wheelchair. On 10/10/24 at 9:30 PM, R2's hospital records document that a CT (computed tomography scan was completed) and documents the following findings: fracture of the nasal bones, small fracture of the lateral wall of the right orbit, small fracture of the right arm of the zygomatic arch, dehiscence of the floor of the right orbit. These fractures are of indeterminate age, clinical correlation is recommended. At 9:46 PM, R2's physician documented, Likely mix of new and old injuries. R7's Face Sheet, documents, in part, medical diagnosis including but not limited to fracture of unspecified part of neck of right femur, sequela; other cervical disc degeneration, unspecified cervical region; fusion of spine, cervical region; and seizures. R7's Minimum Data Set (MDS), dated [DATE], documents, in part, that R7's Brief Interview for Mental Status (BIMS) score is 07 which indicates R7 has severe cognitive impairment. R3's Referral records, that the facility received prior to R3's admission, fax date of 8/16/24, documents, in part, (R3) with a history of dementia, depression, and anxiety was transferred from a local nursing home for direct admission. He (R3) was involved in a physical altercation with a fell ow resident . He (R3) remains anxious, irritated, confused, and bizarre, with no recollection of why he (R3) is being treated. Due to his (R3) dysregulated mood, aggression, and confusion, he (R3) poses a danger to himself and others . Verbal aggression during pt (patient) care . On 10/16/24 at 11:50am, when asked if the facility was aware of R3's history of aggression and prior physical altercation at the preceding facility R3 was residing at, V9 (Nurse Consultant) replied, In R3's referral it did state that R3 had an altercation with another resident, but it did not state who hit who. R3's progress note, dated 9/7/2024 at 1:41pm, transposed by V3 (Licensed Practical Nurse/LPN), documents, in part, Resident (R3) combative with all staff when asked to remain in his wheelchair for safety; refused blood glucose check and midday medicine pass; attempted to open secured doors on the unit. Resident (R3) used vulgar language with Writer. Family notified. On 8/21/24, R3 was admitted with medical diagnosis include but not limited to aphasia following cerebral infarction; major depressive disorder, recurrent, unspecified; essential (primary) hypertension; unspecified psychosis not due to a substance or known physiological condition; other specified diabetes mellitus without complications; polyosteoarthritis, unspecified; arthropathy, unspecified; gastro-esophageal reflux disease without esophagitis; long term (current) use of aspirin; insomnia, unspecified; hyperlipidemia, unspecified; vascular dementia, unspecified severity, with other behavioral disturbance; bipolar disorder, current episode mixed, unspecified; cerebral infarction, unspecified; dysphagia, oropharyngeal phase; cognitive communication deficit; other Alzheimer's disease. R3's progress note, dated 9/26/2024 at 7:20am, transposed by V5 (Licensed Practical Nurse/LPN) documents, in part, Informed by CNA (certified nursing assistant) upon rounds that resident (R3) had a cane in his hand and blood was coming from roommates head. All staff proceeded to room . When asked what happened, resident (R3) stated I (R3) thought someone was in my house, I (R3) didn't know he (R2) was supposed to be here . No concerns at this time. On 10/15/24 at 12:46pm, with translator V6 (Certified Nursing Assistant/CNA) present to translate for R2, this surveyor inquired about the altercation with R2 and R3 on 9/26/24. R2 replied, R3 hit me on the head with my cane. I (R2) was in the bathroom and R3 came up behind me and told me to get out of his apartment, grabbed my cane, and hit me in the head with it. I (R2) turned and seen R3. I (R2) am positive it was my roommate. I (R2) was bleeding from my head. R3 hit me good. The nurses took me to a different a room and I (R2) no longer stayed with R3. I (R2) wasn't happy that R3 was still here. I (R2) would see him walking around even though the nurses tried to keep him in the wheelchair. Didn't know if he (R3) would try to attack me (R2) again. When asked if R2 feels safe here at the facility, R2 replied, I (R2) don't want to answer cause we don't know. V10's (CNA/certified nursing assistant) Facility Reported Incident of 9/26/24 Witness Statement, dated 9/26/2024, documents, in part, I (V10) walked into (R2's) room he (R2) was walking out saying (R3) hit him with his cane. (R3) came out of the room yelling, get him out of my apartment. R2's Facility Reported Incident of 9/26/24 Witness Statement, dated 9/26/2024, documents, in part, (R3) hit him (R2) head. On 10/16/24 at 1:10pm, V10 (Certified Nursing Assistant/CNA) said, I know R2. That morning (9/26/24) I (V10) just came in. I (V10) came in and did my rounds. I (V10) was coming back down the other hall and saw R2 staggering out of the room with a bleeding wound on his head. R2 said he (R3) was hitting him. R3 was cursing and yelling. R3's baseline is if you tell him (R3) what to do he'd get agitated. R3 was regularly agitated, every other day. We try to talk to him (R3) and calm him down. Just a lot of foul language. Yeah, I (V10) felt like he (R3) could do something like that again cause he (R3) didn't listen. On 10/17/24 at 2:15pm, V5 (Licensed Practical Nurse/LPN) said, Yes, I (V5) am familiar with R3. I (V5) was there 9/26/24 with the R2 and R3 altercation. (R3) Has moments of anxiousness and combativeness. CNA came and got me and showed me the opening on R2's head with blood. R2 said R2 was hit with a cane by R3. R3 is aggressive 50/50 percent of time. R3 had some bad days and some chill days. At times I (V5) was worried R3 would hurt other residents. Not sure what R3 was capable of. There are other residents that are more helpless than me and can be harmed by R3. Supervision, usually in bed, during the day they do dining room time. We did some in-services about the behaviors . R3 specifically no, but just about behaviors in general. We just would keep an extra eye on him (R3). There was no special written down supervision for (R3). Upon review of R3's EMR (Electronic Medical Record), this surveyor observed the following: 1. Record review of R3's Minimum Data Set (MDS) dated [DATE] documents in part a brief interview of mental status summary score of 10 indicating that R3 has cognitive impairment, documents that R3 has behavioral symptoms and wandering. 2. Record review of R3's CAA (Care Area Assessment) Worksheet (dated 8/28/24) documents in part that R3 had behavioral symptoms and wandering. V8 signed the CAA worksheet stated that R3's behaviors would be addressed within R3's Care Plan. 3. Record review of state final reportable of the physical abuse investigation that occurred between R2 and R3 on 9/26/24, documents in part the R2 and R3's care plans were updated after the incident. 4. Record review of R3's care plan documents in part that R3's aggressive behaviors were addressed on 10/10/24 after the incident between R3 and R7. R3's care plan was not updated with the MDS dated [DATE] in response to the CAA worksheet completed by V8 or after the final report and investigation of the incident that occurred between R2 and R3. On 10/22/24 at 9:53 AM, V8 (Social Services Director) stated that the social services department is responsible for creating a plan of care for residents with behaviors. Inappropriate behaviors, aggression, or refusal/combativeness to care would all be care planned by the social services department. V8 reviewed R3's plan of care and affirmed that R3's behaviors were not care planned until after both incidents (9/26 and 10/10). V8 stated that R3's aggressive behaviors should have been addressed in R3's care plan upon admission when the history of aggression/abuse was identified. V8 did not know why the R3's behaviors were not addressed in R3's care plan. On 10/22/24 at 9:57 AM, V8 (Social Services Director) stated that the screening for aggressive behavior is to be completed with every MDS (quarterly, annually significant change) and if aggressive behavior occurs. V8 did not know why the aggression screening assessment was not completed after R3's incidents of violent behavior on 9/26 and 10/10. V8 stated these assessments are important because they help to trigger staff to develop a plan of care to address the aggression. On 10/15/2024 at 11:50 AM, V9 (Registered Nurse Consultant stated, If documentation cannot be produced, then it didn't happen. the survey. On 10/17/24 at 11:33am, V15 (Certified Nursing Assistant) said, Yes sir, I (V15) am familiar with R3. R3 had his moments when we (staff) couldn't tell R3 anything cause R3 would get upset/agitated and call us (staff) names. You bitch. Even if you (staff) tried to calm R3 down R3 wouldn't calm down. Yes! R3 would physical. R3 would get aggressive with me (V15). R3 would grab my hand and try punching me. I (V15) was working that day (10/10/24). I (V15) heard a little commotion and went towards R7's room. I (V15) tried to help him (R3) calm down. R3 was very aggressive. R3 grabbed my hand. R3 kept coming at me. R3 walks. R3 stands up from his wheelchair. R3 won't sit down. I (V15) just heard R3 screaming. R7 was complaining of pain in face. We (staff) didn't know when R3 would get upset. When R3 just got the urge R3 would just get aggressive. I (V15) was worried that R3 would hurt me. R3 was a strong guy. Yes, I (V15) was definitely worried that R3 would hurt the other residents. I (V15) believe, everyone (all employees) new R3 would get upset. There was no training for R3. You (staff) can have a conversation with R7. He remembers almost everything. Just can be a little forgetful but R7 would not forget anything like this. Since that happened R7 always brings it up. I (V15) would say R7 remembers things, sometimes forget things, but he remembers most things. I (V15) don't think R7 would make up a story of what happened to him (R7). R3 is not appropriate to have a roommate. R3 was aggressive toward staff since the beginning. On 10/17/24 at 12:03pm, V3 (Licensed Practical Nurse/LPN) said, Yes, I (V3) am familiar with R3. He'd (R3) get up from the chair and curse you out. Gets very vulgar and then more vulgar. We (staff) try to redirect R3. R3 has swung at me (V3) before but never actually made contact. I (V3) was sitting at the nurse's station, heard someone yelling, CNAs (certified nursing assistants) and I (V3) got up and went to see what was happening. R3 was full of aggressiveness, vulgarity, and more aggression. R3 struck the CNA. R3 walked up on me with his fist and swung, but I (V3) backed up. R3 continued being vulgar. My documentation, I (V3) admit, sucked. Staff was with R3 in the dining room but R3 will roll out of the dining room, we'll watch him role out, but R3 has that right. R3 has the freedom to roll back and forth. Residents have the freedom to roll around. I (V3) have been worried that R3 would hurt me. I (V3) have been concerned that R3 would hurt other residents. I (V3) never notified anyone; I (V3) just diffused the situation. R3 was 50/50 percent aggressive all of the time. R3 could be decent and then would just snap. On 10/17/24 at 12:19pm, V16 (CNA), said, I (V16) was working 10/10/24. I (V16) heard yelling, ran, and the other nurse followed. R7's wheelchair was flipped over and R3 was standing over R7. R7 said R3 punched him (R7) and knocked him (R7) over. Half of the time R3 is aggressive. On 10/22/2024 at 10:48am, V18 (Medical Director) said, I (V18) was the attending physician for R3. R3 had Bipolar, dementia, anxiety depression, Psych issues. Medically ok. Main reason was psych issues as far as I (V18) remember. I (V18) did his (R3) admission, and he (R3) had some altercation at other facility and that's why other facility transferred him out to our facility. Based on R3's history of aggression towards other residents, I (V18) don't know if he (R3) had a roommate. When asked if it was appropriate for R3 to have a roommate, V18 replied, Difficult to answer. There are a lot of psych, and they can have behaviors and stabilize. When I'm (V18) admitting a patient I (V18) assume they are stabilized. With identified behaviors prior to admission, the facility should had increased R3's supervision and observation. Yeah, when we see there R3 required increased monitoring. Nursing homes don't have a lot of staff, so if we (facility) can't care for them appropriately, we (facility) send them to the hospital. I (V18) was aware of 10/10/24 altercation with R2 and R3. We sent R3 out. No, I (V18) don't remember a change of condition. When I (V18) went in the room R3 was using vulgar language. Being hit in the head and falling out of a wheelchair cause facial fractures definitely caused harm to (R7). The severity of harm that happens after a resident is hit in the head can vary depending on the velocity of the hit, the size of the resident. Facial fractures can be caused by a punch to the head or falling out of a wheelchair. R3's plan of care should have been developed to address those behaviors. Dementia and psych are very challenging. We try to control the behaviors but if it's out of control we (facility) send them out. If the Plan of care isn't done, the resident's aggressive behaviors can continue. We (facility) need to address it cause other residents are at risk. If a resident is assessed incorrectly, can harm be caused? is a hard question. Behaviors change. If behaviors changed the assessments should be redone. Facility policy titles, Policy and Procedure Supervision Policy, dated 1/2024, documents, in part, Additional supervision may be required in order to meet the specialized needs of residents. Additional supervision may be but not limited to 1: 1 supervision, 15-minute checks, 30- minute and so forth. Purpose To ensure resident safety. Additional supervision is followed per the plan of care in accordance with an individualized resident focused approach.

Based on interviews and record reviews, the facility failed to intervene and protect 4 residents (R2, R3, R4, R5) from verbal and physical abuse out of 4 residents reviewed for abuse. These failures resulted in; 1.) R2 attempting to run out the facility after an incident with another resident (R3). R2 then struck a window, resulting in a laceration to the right arm, R2 was sent to the local hospital and received sutures; 2.) R4 and R5 became verbally aggressive and then physically aggressive to one another. Findings Include: 1.) R2's clinical records show an admitted [DATE] with diagnoses that included but not limited to schizoaffective disorder and bipolar disorder. R2's minimum data set (MDS) dated [DATE] shows R2 had moderately impaired cognition and required supervision with walking. R2's progress notes dated 8/16/24 at 5:48 PM written by V3 (Licensed Practical Nurse/LPN) reads in part: [R2] noted receiving verbal and sexual inappropriate remarks from peer. Peer stated to [R2], Come here, and push me my b**ch. Staff and [R2] requested multiple times for peer to stop and was redirected to the dining room. Peer returned to the nursing station and began to provoke [R2]. Staff attempted to redirect [R2]; however, [R2] was non-compliant and unable to be redirected. [R2] began to swing [R2's] belt and hit peer in the head. Staff separated the residents for safety precautions. [R2] was assessed, and no injury was noted. The residents were placed on a 1 on 1 monitoring. [R2] then ran down the hall away from staff and broke the window resulting in an injury to right arm. R2's hospital AFTER VISIT SUMMARY dated 8/17/24 to 8/19/24 revealed R2 received sutures for R2's right arm laceration. R3's clinical records show an admitted [DATE] with diagnoses that included but not limited to paraplegia and schizoaffective disorder, bipolar type. R3's MDS dated [DATE] shows R3 was cognitively intact, not ambulatory, and used a wheelchair as primary mode of locomotion. R3 was discharged from the facility on 8/22/24. The facility's final abuse report on R2 and R3 with incident date of 8/16/24 timed 6:00 PM reads in part: On 8/16/24, R3 propelled himself towards R2 and asked R2 to push R3 while in the wheelchair. R2 declined and R3 started to make homosexual comments towards R2 saying, Push me now, my b****, push me now. R2 grew upset and pulled off R2's belt and started to swing it in R3's direction. R3 would continue to taunt R2 as R2 would swing the belt. Facility staff was attempting to de-escalate R2 while attempting to move R3 from the direction of R2 as R2 swung R2's belt. As staff attempted to separate the two, R2's belt made contact with R3 and hit R3 on R3's forehead. R2 was taken to the social service office and allowed to vent R2's frustrations. R2 became worked up and ran out of the social service office in fear the police would come and arrest R2. Facility staff immediately followed R2 while maintaining distance to so R2 would not feel threatened. The facility staff attempted to verbally de-escalate R2 when R2 punched the window causing an injury to R2's right arm. First aid was rendered, and emergency ambulance was called and transported R2 to the local hospital. On 9/10/24 at 11:06 AM, interviewed V3 (Licensed Practical Nurse) about the incident between R2 and R3 on 8/16/24. V3 stated R3 was being antagonistic the entire day and was making comments towards R2. R2 became upset. R3 called R2 the B word. R2 tried to hit R3 with the belt. V3 stated R2 was extremely anxious after the incident, was pacing the hallway and said, Oh my God what did I do. When I'm like this I can't calm down. V3 stated R2 was kicking the door. R2 would not calm down. V3 stated R2 banged the window on the 3rd floor and that's when R2's right arm had a laceration. V3 stated R2 was bleeding a lot and emergency paramedics, and the police were called. V3 stated R3 has done things to multiple residents before like swearing at the residents. On 9/10/24 at 11:29 AM, interviewed R2 and stated R2's been in the facility for couple of years. V2 stated there was a resident that bothered R2 before and it was the same resident that bothered R2 during the incident on 8/16/24. R2 stated R3 kept going at the nurses' station bothering V3. R2 stated, R3 was told by multiple nurses to stop bothering them. [R3] was going to the nurses' station and none of us are allowed by the nurses' stations. I told [R3] to get the f*** away from the nurses' station. I wheeled [R3] in the day room. [R3] was calling me his B****. I went to go get my belt I wrapped my belt around my hand with the metal part hanging and I started attacking and swinging at [R3] with the belt. I hit [R3] on the head. I don't think [R3] bled but I did hit [R3] with the belt. It was [V3] and [V5 Behavioral Technician] and other people were trying to stop me. After that V5 tried to bring me to the nurses' station. I was very upset, so I swung at [V5]. [V5] tried to stop me then I was on the ground. I was in the Social Service office. I tried to grab the coffee maker. I felt very scared and very angry. The other nurse gave me a shot to calm me down and then after that I got up and ran in the dining room started throwing chairs in there. I don't think I hurt anyone in the dining room. After that I went to the elevator, I was planning to run out the door, but they stopped me, so I ran down the hall and I hit the window with my right elbow. I busted the window. I fell to the ground I was crying because it hurt really bad. I tried to climb out the window, but they stopped me. I had blood all over. They called the ambulance, and they took me to [local hospital] and they did the MRI [Magnetic Resonance Imaging] and surgery. I had an open wound and they stitched it. I had to stay in the hospital for a couple of days. They told me they closed the wound in surgery. On 9/10/24 at 12:05 PM, interviewed V5 (Behavioral Technician) and stated R2 was very upset about the incident that happened with R3. V5 stated R2 was pacing so V5 called R2 to V5's office. V5 stated R2 ran out of V5's office and went to the dining room and started throwing chairs then R2 ran down the hall and broke the window. V5 stated R2 was bleeding and was crying. On 9/11/24 at 11:20 AM, interviewed V2 (Acting Director of Nursing/Regional Nurse Consultant) about R2 and R3's incident on 8/16/24. V2 stated from the investigation R3 came to the nurses' station and antagonizing R2. R3 called R2 You're my B****, Come push me my B****. V8 (Certified Nursing Assistant) re-directed R2 into the dining room area. R3 left after that to smoke. When R3 came back up R3 started antagonizing R2 again. V2 stated, From my understanding there were at the nurses' station. [R2] was hitting [R3] with the belt. The staff separated them. [R3] went down again. The nurse ran down to get [V5]. They were able to get [R2] to calm down. [R2] was scared and was panicking thinking that [R2] was going to jail. [R2] ran down the hall and [R2] tried to run out the door. When [R2] could not get the door opened, [R2] started hitting the window. [R2] injured his right arm. They both went to the hospital. [Local hospital] sutured [R2's] wound. V2 stated verbal abuse is not just through language but also through body language if the resident presents with negative disposition, if the resident is talking down to another resident and intimidating, cursing, yelling, using profanity. V2 stated physical abuse is hitting, pushing, smacking with intent to the person. On 9/11/23 at 12:54 PM, interviewed V8 (Certified Nursing Assistant) about R2 and R3's incident on 8/16/24. V8 stated, R3 was antagonizing R2 saying gay comments like I want to make you my B****. I want you to be my boyfriend. V8 stated it happened for 2-3 hours. V8 stated R3 was also inappropriately touching R2. R3 was grabbing R2's hands trying to grab R2's behind. V8 stated, I saw [R3] doing that, and I kept redirecting them. But [R3] would come back and would do it again. Finally, [R2] got upset and took a belt and was hitting [R3] and told [R3] to stop touching [R2]. We separated them and then [R3] went to the first floor. [R3] came back up and at this point [R2] was still upset. We tried to calm [R2] down. [R2] felt like he let us down. [R2] said he didn't want to go to jail. I was called again by the time I made it out [R2] was trying to go out the door, but [R2] could not open the door, so [R2] hit the window with his right arm. [R2] was bleeding really bad. [R2] was laying on floor. I called the code through the receptionist. Police and paramedics came. On 9/12/24 at 10:34 AM, V1 (Administrator) stated V1 is the abuse coordinator and any kind of form or suspected or hint of abuse it must be reported to V1 as soon as possible. V1 stated V1 has two hours to report and to begin initial investigation. V1 stated abuse in-service in done with all staff at least annually. V1 stated the types of abuse are physical, neglect, misappropriation of funds, verbal, sexual, and secluding resident. V1 stated an example of physical abuse between resident to resident is if there is a determination that there is willful act to harm the other resident in any kind of physical attack. V1 stated an example of verbal abuse is any kind of verbal attack. A willful intent to cause harm such as cursing and using profanities directed towards the resident. V1 stated first if there is resident to resident altercations, the staff need to separate the resident. They cannot see each other. V2 stated residents have the right to be free of abuse while residing in the facility. 2.) R5's clinical records show an admitted d of 2/11/16 with included diagnoses but not limited to chronic obstructive pulmonary disease, heart failure, and cerebral infarction. R5's MDS dated [DATE] shows R5 is cognitively intact, does not walk, and uses a wheelchair. R4's clinical records show an admitted [DATE] with included diagnoses but not limited to paraplegia, bipolar disorder, and attention-deficit hyperactivity disorder. R4's MDS dated [DATE] shows R4 was cognitively intact, did not walk, and used a wheelchair. R4 was discharged from the facility on 8/2/24. R4's progress notes dated 8/2/24 at 1:30 PM written by V15 (Social Service Consultant) reads in part: R4 was noted leaving the patio from the smoke break when R4 stopped in the dining room to converse with a R5. R4 stated they were conversing about floor-to-floor movement and R5 alleged that visitation is cancelled on all units due to R4 being alleged to have violated the substance use policy. R4 stated the conversation then led to an argument due the disagreement. R4 then stated that argument became physical when R5 pushed R4. The facility's final abuse report on R4 and R5 with incident date of 8/2/24 at 9:20 AM reads in part: While leaving from smoke break, R4 observed R5 entering the smoking area and started to call R5 a snitch. R5 asked R4 to leave R5 alone. As R5 continued to propel himself toward the patio to smoke, R4 grabbed R5's wheelchair and continued to taunt R5. R5 grew angry and stood quickly from R5's wheelchair and started to fall. R5 grabbed R4's wheelchair causing them both to fall onto the floor. On 9/10/24 at 12:05 PM, interviewed V5 (Behavioral Technician) regarding R4 and R5's incident on 8/2/24. V5 stated V5 did not witness the incident but heard that R4 started the situation. R4 antagonized R5. V5 stated R4 was verbally abusive to R5. V5 stated R5 does not bother anybody. V5 stated R5 could not take what was said by R4 and R5 pushed R4. V5 stated that R4 has always been verbally abusive towards staff and residents. On 9/10/24 at 3:08 PM, a phone interview conducted with V15 regarding R4 and R5's incident on 8/2/24. V15 stated V15 did not witness what happened and was reported back to V15 that something happened with R4 and R5. V15 stated, I believe the activity aide [V24] was there during smoke break. I believe it was the end of smoke break. From my conversation with [R4], [R4] said that [R4] was having friendly conservation with [R5]. [R5] was saying that somebody put [R4] on observation. [R5] was telling [R4] that [R4] is not on observation. You're off the floor now how can you be on observation. [R4] went behind [R5's] wheelchair kinda yanking it. [R4] alleges [R4] was playing around. [R5] stood up from [R5's] wheelchair. [R5] said [R5] swung [R5's] hands backwards and made [R4] fall. [R4] said [R5] made physical contact. On 9/11/24 at 9:51 AM, interviewed R5. R5 was alert and able to verbalize needs. R5 stated R4 was coming in from the patio and R5 was at the dining room waiting to go out to smoke. R4 was yelling at R5. R4 was cursing at R5. R5 stated R4 pushed R5 from the front, so R5 pushed R4 back and R4's wheelchair tipped over. R4 fell on the ground. R5 stated V24 was there passing out cigarettes. 9/11/24 at 11:20 AM, interviewed V2 (Acting Director of Nursing/Regional Nurse Consultant) and stated when there's abuse, they call the code, staff come, they try to separate the resident, all staff come and help, notify family, physician, and if it escalates notify the police. If it becomes aggressive, call 911. Called V24 (Activity Aide) multiple times from 9/11/24 to 9/13/24 but V24 did not answer calls from surveyor. Surveyor left messages to no avail. The facility's policy titled; Abuse Prevention Program Facility Policy and Procedure dated 1/4/18 reads in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. Orientation and training of employees include staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation or resident property. How to assess, prevent and manage aggressive, violent and/or catastrophic reactions or residents in a way that protects both residents and staff. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The facility's policy on residents' rights with no date reads in part: The residents have the rights to safety and must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.

Based on interview and record review the facility failed to ensure that necessary treatment and services consistent with professional standards of practice were adhered to for 1 resident (R7). The facility: 1.) Failed to assess, monitor, and document on R7 post fall. 2.) Failed to inform physician of R7's fall incident in a timely manner. 3.) Failed to send R7 who sustained head, injury while on anticoagulant, to the hospital in a timely manner. R7 fell on [DATE] and was subsequently sent to the hospital on 8/5/24 sustaining a subdural hematoma. Findings include: R7's face sheet documents in part medical diagnoses including but not limited to traumatic subdural hemorrhage with loss of consciousness, atrial fibrillation, long term current use of anticoagulants, and spondylolisthesis lumbar region. R7's Minimum Data Set (MDS) dated [DATE] shows R7 is cognitively intact. On 9/10/24 at 11:04 AM, R7 stated R7 fell from R7's bed. R7 stated R13 (R7's roommate) called the nurse, but the nurse did not respond until after an hour. R7 stated that was a wrong thing for the nurse to do. R7 could have gotten sicker, and R7 felt bad. On 9/10/24 at 11:24 AM, R13 stated that R7 fell few weeks ago. R13 stated R13 observed R7 falling from R7's bed. R13 helped to get R7 off the floor. R13 walked to the nurses' station to inform the nurse that R7 had fallen and that R13 asked for some ice to apply to R7's right forehead but the nurse and the Certified Nursing Assistant/CNA did not give R13 any ice. R13 came back to R13's room to pull the call light, the nurse came to attend to R7 after an hour. R13 stated the facility sent R7 to the hospital few days later. On 9/11/24 at 10:11 AM, V17 (Licensed Practical Nurse/LPN) stated V17 worked on 7/28/24, 7AM-7PM. V17 did not witness a fall, but a CNA told V17 that R7 may have fallen. V17 did not remember the CNA. Surveyor asked if V17 observed any bruise on the forehead of R7. V17 stated that V17 did not observe any bruise on R7 on 7/28/24. V17 stated R7 complained of headache and pain on 8/5/24. V17 stated later R7 reported that R7 had fallen some days ago. V17 called V46 (R7's Nurse Practitioner/NP) with the order to send R7 to the nearest hospital for evaluation. V17 stated a resident with a head injury post fall should be sent to the hospital immediately for evaluation. V17 stated the fall happened prior to 8/5/24, but it was not reported to V17. On 9/11/24 at 11:30 AM, V8 (CNA) stated V8 recalled someone telling V8 that R7 had fallen. V8 stated that V8 cannot remember the staff and the date of the incident, but V8 noticed a knot size swelling on the right side of R7's head and it was covered with something like a bandage. On 9/11/24 at 11:40 AM, V3 (LPN) stated when a resident reports a head injury post fall, V3 will be calling the doctor immediately. On 9/11/24 at 12:50 PM, during the second interview, surveyor asked if V17(LPN) observed any skin abrasion on R7's forehead. V17 stated V17 did not observed any bruise or abrasion on R7's head. Surveyor and V17 reviewed the nurse's note of 7/28/24 at 6:41 PM which shows that V17 documented observing bruise on R7's forehead. V17 was shocked and V17 stated, yes, that is my documentation. On 9/11/24 at 1:27 PM, V39 (Restorative Director) stated that when V39 came to the facility on Monday 7/29/24, V17 (LPN) told V39 that R7 fell on Sunday 7/28/24. V39 informed V38 on Monday 7/29/24 during the morning meeting. V39 stated that V39 observed small dry blood on R7's right forehead. V39 stated that the doctor should be notified immediately post fall with head injury. On 9/11/24 at 1:39 PM, via telephone interview V22 (CNA) stated that before lunch time on 7/28/24, R13 told V22 that R7 had a fall. V22 told V17 (LPN) that R7 could have fallen. On 9/11/24 at 3:03 PM, via telephone interview with V38 (Former Director of Nursing) stated that R7 had a fall on 7/28/24. V38 stated that V17 told V38 that R7 had a fall. V38 stated R7 had a raised knot on R7's forehead. V38 stated it is V38's expectation that 72 hours follow up charting will be done every shift, and neuro check should be done to monitor any changes in condition. V38 stated R7 is at risk for fall, so R7 should be monitored more frequently to prevent another fall. V38 stated that R7 was sent to the hospital on 8/5/24 due to complaint of headache. On 9/12/24 at 10:16 AM, R14 stated R14 has no concerns with quality of care. On 9/12/24 at 10:50 AM, V2 (Acting Director of Nursing/Regional Nurse Consultant) stated that R7 fell on [DATE] and R7 was not sent to the hospital because there was no order from V46 (R7's Nurse Practitioner/NP) to send R7 out to the hospital. V2 stated it is V2's expectation that the nurse will assess R7, start a neuro check per protocol and do 72 hours follow up charting after a fall incident with abrasion on the forehead. V2 stated the facility has no policy on head injury. On 9/12/24 at 11:19 AM, via a telephone interview, surveyor asked V46 (R7's NP) what could happen if a resident has a bruise on the head after a fall. V46 stated that it could lead to a hematoma, the resident can lose consciousness, and could have a lifelong impact on the resident's mobility. V46 stated a resident on a blood thinner with head abrasion or bruise should be sent to the hospital immediately because this could cause subdural hematoma. V46 stated V46 was not notified on 7/28/24 that R7 had a fall incident. V46 stated R7 was on a blood thinner Apixaban 5 mg tablet daily so V46 would have sent R7 to the hospital immediately for evaluation to conduct a CT-Scan to rule out any internal bleeding, if V46 was notified of a fall on 7/28/24. V46 stated V17 called V46 on 8/5/24 to report a bump and abrasion on R7's head and that R7 had a fall few days ago. V46 gave order to send R7 out to the hospital on 8/5/24. On 9/12/24 at 12:30 PM, V17 (LPN) stated that V17 notified V46 of the abrasion on R7's head on 7/28/24. When surveyor asked V17 if V17 was notified of R7's fall incident on 7/28/24 V17 stated that V17 was not comfortable to answer the surveyor and V17 walked away. Medical Administration record (MAR) from 7/1/24 to 8/4/24 shows R7 received Apixaban 5 mg tablet by mouth every evening for paroxysmal atrial fibrillation. R7's electronic health record (EHR) was reviewed, 72 hours follow up charting and neuro checks were not completed. Reviewed Facility Reported Incident witness statement dated 7/28/24. Reviewed Hospital Record dated 8/7/24, documents in part, OSH CT head showed (Right Subdural Hematoma) R SDH. Reviewed Neurological Assessment policy dated 3/23, documents in part; Residents will have a neurological assessment completed when they experience a head injury. Reviewed Change in Resident's Condition policy dated 2/1/22 documents in part; It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP, and resident's responsible party of a change in condition.

Based on interview and record review, the facility failed to monitor a diabetic resident's foot; failed to assess and report a new skin alteration on a diabetic resident's foot; and failed to provide activities of daily living (ADL) care as assessed for a diabetic resident which affected R2 in the sample of three residents reviewed for improper nursing care. These failures resulted in R2's nurse practitioner (V4) assessing for R2's right lower leg redness and swelling; removing R2's moist right sock to see multiple maggots crawling from R2's right foot wound (base of big toe); and R2 being transferred to the hospital for further evaluation of gangrene infection which required surgical amputation of R2's right big toe. Findings include: R2's Admission Record documents, in part, diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease and with diabetic peripheral angiopathy without gangrene, dementia, hypertension, hyperlipidemia, peripheral vascular disease, retention of urine, difficulty in walking, lack of coordination, and need for assistance with personal care. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, R2's Brief Interview of Mental Status (BIMS) score 15 which indicates R2 is cognitively intact, and R2's Behavior for Refusal of Care with no refusals of care. R2's Functional Ability and Goals (dated 5/17/24 and 7/29/24) documents, in part, the following: Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self and Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear is appropriate for safe mobility are coded as 2 which signifies Substantial/maximal assistance-Helper (staff) does more half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R2's Mobility documents, in part, a manual wheelchair for R2; and for R2's Sit to stand, Chair/bed-to-chair transfer, and Toilet transfer, R2 is coded as 2 which signifies Substantial/maximal assistance-Helper (staff) does more half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R2 was discharged to the hospital on 7/30/24, and no longer resides in the facility. On 9/3/24 at 12:39 pm, V4 (Nurse Practitioner, NP) stated V4 is R2's nurse practitioner in the facility, works Monday through Friday, and routinely visits R2. V4 stated, The most recent thing I remember was when I was rounding on (R2). I asked, 'How are you?' (R2) said (R2) was going to bathroom and was in (R2's) wheelchair. I saw one leg a little swollen, so I wanted to see (R2's) toes, and then I saw maggots. When asked where was V4 when assessing R2 on 7/29/24, V4 stated it was in R2's room. V4 stated R2 was propelling self via wheelchair to the bathroom. V4 stated on 7/29/24, V4 observed R2's right shin was with redness, shiny. Something was wrong. V4 stated V4 asked R2 about what happened to R2's right leg as V4 was examining R2's leg, and R2 said, Oh, that hurts. V4 stated V4 was alarmed with R2 having pain, so V4 wanted to fully assess R2's right foot and toes with R2 wearing socks. V4 stated, When I open it (sock), just wow (V4 is making motion with V4's hands of an explosion). When asked to explain what V4 means by this, V4 stated, (R2) had on a thicker sock. I opened up the sock, and there's maggots running out from wound on right big toe. V4 stated V4 informed the nurse (V5, Licensed Practical Nurse, LPN), Director of Nursing (former) and V16 (Wound Care Physician Assistant). V4 stated, This was a concern to me. Everyone was made aware immediately. V4 stated on 7/29/24, V4 ordered antibiotics, pain management, maggot medication, and stat laboratory (lab) blood work. When asked about details of what V4 observed on 7/29/24 with R2's right foot, V4 stated, There were maggots, I remember. Maggots, they came from the wound, and I opened up the sock, and they were crawling. They were just there. There were no maggots in the bed. They were inside the sock, crawling. Many of them. When asked about how many maggots did V4 see, V4 stated, 10 or higher. When asked about the characteristics of R2's right big toe wound, V4 stated, It was moist. It looked like when you dipped skin in water for hours without drying it. Foot was swollen. V4 stated the right big toe wound didn't have pus-like discharge, but it was moist. V4 stated the wound was under the right big toe joint and looked similar to a corn callous. V4 stated, The maggots were in there only, eating part of (R2's) foot. It developed from there, the moist part. V4 stated on 7/30/24, V4 assessed R2 in the facility and R2's labs were abnormal, so V4 ordered for transfer to the hospital. V4 stated, I don't want to wait. (R2) could have possible gangrene or osteomyelitis going on. V4 stated R2's white blood cell (WBC) count and C-reactive protein (CRP) count were elevated indicating infection. V4 stated, I was concerned with gangrene with diagnosis and (R2) may need MRI (magnetic resonance imaging). It was a concern for amputation. I sent (R2) to hospital for higher level of care. When asked about care specific for a diabetic resident's skin, especially feet, V4 stated, We do routine foot exam. We have to do it. Podiatrist for cutting the nails. We have a consult for podiatry. When asked about the expectations of staff to assess a diabetic resident's skin, V4 stated, We have to check the skin. Check more on foot for exam. There is a chance of neuropathy or infection. If they (residents) have a sore, then they will not feel the sore. V4 stated, Every day, we need to clean and put new socks on. When asked what V4 expects of staff to be doing to prevent R2 from developing a diabetic wound with maggots, V4 stated, If we (staff) clean (R2) and check (R2's) feet every day. I expect and to change (R2's) socks every. Change every day and open cleaning it. (R2) can help with (R2) upper body, but not bottom part with socks. I don't think (R2) can do that. V4 stated V4 would not expect R2's diabetic wound to ever have a maggot infestation. V4 stated R2's mobility is via a manual wheelchair and R2 propels R2's self in the hallways. V4 stated V4 has never been notified by nursing staff R2 has been noncompliant with wearing socks or shoes while up in the wheelchair. In R2's Progress Notes, dated 7/29/24 at 7:25 pm, V4 (NP) documents, in part, APC (Advanced Practice Clinician) noted with right shin area, below knee redness, edema + (plus), while opening (R2's) sock, noted a lot of maggots crawling, coming from under right great toe small skin area opening, no pus discharge at present, right foot great toe surrounding skin noted moist, macerated, and white skin discoloration. In R2's Progress Notes, dated 7/30/24 at 2:42 pm, V4 (NP) documents, in part, F/u (follow up) lab, will Transfer to (hospital) on 7/30/24 (per {V27, Attending Physician}) due to acute right foot ulcer (DM {diabetes mellitus}-2), CRP 224, WBC 34 (prior to IV antibiotic). R2's Hospital Records documents, in part, R2's hospital diagnoses of Right foot wound, Gangrene, and s/p (status post) right hallux (big toe) amputation 7/31/24. On 9/3/24 at 12:09 pm, V5 (LPN) stated V5 is very familiar with R2, and R2 is alert, orientated with periods of confusion and propels self by wheelchair. V5 stated R2 will transfer R2's self to the wheelchair and the toilet, and we (staff) did assist with bathing and bed bathing. V5 stated on 7/29/24, V5 was called back to R2's room by V4 (NP). V5 stated with R2's sock on, R2's foot would get moist, and V4 observed R2's right foot skin (on 7/29/24) as real moist, like (R2's) skin was in water too long. V5 stated R2's right foot wound had white looking drainage, but V5 is not good with (wound) treatments. V5 stated V4 saw R2's foot was swollen and's why V4 had checked on R2's right foot. V5 stated, I didn't see that they (feet) were swollen. V5 stated V4 provided orders that V4 carried out. V5 stated R2's skin don't take too long for breakdown, with (R2) being diabetic and all the other conditions. When asked why it is important for staff to check a diabetics skin, like R2, V5 stated, The same, so they (diabetic residents) don't end up with an amputation, and they don't know they got it, and they are not left untreated. V5 stated with R2 being up and about, it's hard to tell if something is going wrong. It's easier when (R2) is in bed. V5 stated CNA (Certified Nursing Assistants) perform the ADL care, and when CNAs are bathing/showering residents, the CNA will call the nurse to come do a full body skin check. V5 stated shower/bed baths are given twice a week. In R2's Progress Note dated 7/29/24 at 6:24 pm, V5 (LPN) documents, in part, Resident was noted with a small wound to the right foot, great toe, red in color slightly swollen, with small amount of drainage. NP (V4) saw resident and order ABT (antibiotics) and stat labs, CBC, CMP (comprehensive metabolic panel), CRP. Family may aware. On 9/3/24 at 2:49 pm, V5 (LPN) stated R2 wore nonskid socks when R2 propelled R2's self in the wheelchair and did not wear shoes. V5 stated V5 could not recall the exact date of the last time V5 performed a full body assessment for R2 during bed bath or shower. When asked if V5 has received a report from a CNA about R2 having new skin alteration on right foot, V5 stated, No, no report of (R2) skin. V5 stated, If something did happen (to R2), in one or two days, there can be breakdown. On 9/3/24 at 12:29 pm, V6 (CNA) stated V6 normally works on R2's floor and is assigned as R2's primary CNA. V6 stated R2 was alert and (R2) needed assistance. V6 stated at times, R2 would refuse showers, and V6 would tell the nurse. When asked how you handle R2's refusal of a shower, V6 stated V6 will tell the nurse, then go back a second time to see if R2 wants it, and if R2 refused again, V6 would tell the nurse so it's documented. V6 stated, (R2) needed assistance. (R2) would be able to get up and go to the bathroom. (R2) needed help to put clothes on. When asked if V6 checked R2's skin on the feet, V6 said yes, and V6 would take the socks off to check. When asked if R2 had a skin alteration on R2's feet recently near the end of July 2024, V6 stated, I saw one. It was near right toe. I told the nurse. V6 stated V6 could not remember which nurse V6 notified. V6 stated V6 could not confirm if the date was 7/29/24 (with new right big toe wound). This surveyor stated survey will view the CNA assignment schedules to confirm if V6 was working on 7/29/24. When asked to describe what V6 observed on R2's right foot on this unknown date late July 2024, V6 stated, Nothing but a little, like it was like a skin tear on the side of her toe. There was redness. No drainage. V6 stated, I took them (socks) off, when I was getting (R2) ready. Assisting to get (R2) up with dressing. V6 stated, I reported (R2's) skin tear to nurse. When asked how often is V6 checking R2's skin, V6 stated, It's a daily thing with care. Facility document dated 7/29/24 day shift (7 am - 3 pm) and titled Daily Assignment Sheet documents, in part, V6 was not working or assigned to R2. V17 was assigned as R2's primary CNA, and V5 (LPN) was R2's primary nurse. On 9/4/24 at 12:25 pm, V17 (CNA) stated V17 works routinely on R2's floor and confirmedV17 was assigned as R2's primary CNA on 7/29/24. V17 stated R2 was a 1 person staff assist for transfer and needed assistance with dressing for ADL care. V17 stated R2 would propel R2's self with R2's feet when in the manual wheelchair and would wear slippers. When asked on 7/29/24, did V17 notice any redness or swelling to R2's right lower extremity, V17 stated, Not I can recall. When asked if V17 checked R2's skin during ADL care on 7/29/24, V17 stated, No, I can't even remember that day. (R2) normally like goes to the bathroom on (R2) own with assist. I can't even remember looking at (R2's) feet. V17 stated V17 will document skin alterations on the shower sheet and report it to the nurse. When asked what is V17 looking for on a resident's skin, V17 stated, To look to see basically any wounds, open wounds or open sores or marks need attention. On 9/3/24 at 1:47 pm, V7 (Wound Care Coordinator) stated R2 was a diabetic and V7 had provided R2's last wound care treatment in June 2024 where a left heel deep tissue injury was healed. V7 stated V7 was informed on 7/29/24 by V4 (NP) R2 had a new right foot wound. V7 stated V7 performed R2's wound care treatment on 7/30/24, and R2's right big toe wound was sloughy. Almost all of it. I was thinking how (R2) doesn't feel this. (R2) has diabetic neuropathy. It was yellow tissue. It was a pink crack itself. This surveyor and V7 viewed R2's Treatment Nurse Initial Skin Alteration Review (7/30/24, authored by V7). V7 confirmed the measurement to the right big toe wound was 8 by 11 centimeters (cm). V7 stated the wound was from the right big toe to hallux by ball of the foot. V7 stated, I didn't understand how (R2) didn't feel it. It looked really mangled. V7 stated V7 classified R2's wound as a non-pressure, diabetic wound. When asked what that means, V7 stated it did not come from pressure. (R2) moves (R2's) feet. Nothing is sitting on (R2's feet), so it's not the cause of the wound. V7 stated, This kind of wound does not gradually happen. They (staff) need to watch out for diabetic hands and feet and handle them carefully. (Diabetic residents) with neuropathy, and they (staff) must do the care. Staff see the feet and wash the feet then they would see it (wound). They have to be actually doing it. When asked in V7's professional wound care training, how can a wound be infested with maggots, V7 stated if there is a wound and if wound is lacerated or open, the fly can deposit eggs. V7 stated even if the wound is covered, the fly can sit on top of covering (dressing or sock) and lay eggs 27 layers down to infiltrate the area. When are skin assessments being done by staff (nurses/CNAs), V7 stated, They should have skin checks twice a week with showers. CNA and nurses are responsible. If there's an alteration of skin, nurse will let us (wound care) know. I will use assessment tool. R2's Treatment Nurse Initial Skin Alteration Review, dated 7/30/24, V7 documents, in part, R2's right great toe extending to plantar hallux wound as a non-stageable, non-pressure injury/diabetic, acquired in the facility with the size of wound being 8 cm by 11 cm by unknown depth with small amount of exudate and peri wound area as edematous and macerated. On 9/4/24 at 1:18 pm, V2 (Director of Nursing, DON/Regional Nurse Consultant) stated, Skin should be assessed daily. Staff identify issues during care. CNAs will notify the nurses. If CNA sees something during AM care or PM care, CNA sees the alteration of skin and will notify nurse. When asked how often skin assessments are done, V2 stated, Weekly skin assessments. When asked when a CNA or nurse is assessing a resident's skin, what are they looking for, V2 stated, Open areas, if they see blister or redness. V2 stated bed baths or showers are given weekly, and if the resident refuses, then the staff must figure out which day is a good for an alternate day. V2 stated the treatment nurse (V7, Wound Care Coordinator) collects the paper shower sheets from the floors to review. This surveyor showed V2 the shower sheet for R2 from 7/24/24 with no documentation of what was done (no skin check or bath/shower was checked). When asked what was done for R2 on this date, V2 stated, I don't know. I can't answer. V2 stated when residents refuse care, the resident is educated, and the CNA will alert the nurse. V2 stated social services staff will speak to the resident and the refusal of care will be care planned for. When asked about diabetic resident's skin checks, V2 stated, Again staff should be monitoring overall for skin dryness, redness, excessive moisture. Look at the feet, and the podiatrist is supposed to be seeing them. For diabetics, we want to make sure resident doesn't have skin alteration because of different issues with their health. The toenails are to be clipped. It takes a while for them (diabetics) to heal. V2 stated V2 expects staff to assess everyone, not just diabetics. When asked why it takes longer for diabetics skin to heal, V2 stated, Diabetes affects every organ in the body. Tissue perfusion and not getting oxygen to the organs. Edema which can prevent fluid coming in from intra and extra vascular space which can affect healing as well. R2's Complete Care Plan, with last care plan review date of 8/8/24, documents, in part, a focus of R2 has actual impairment to skin integrity related to comorbidities and medical diagnosis of diabetes mellitus type 2 shows interventions of keep hands and body parts from excessive moisture (initiated 5/11/24) and monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. (the rest) to MD (doctor) (initiated 5/11/24). R2's Complete Care Plan does not include a focus for refusal of care. On 9/4/24, R2's Shower Sheets for July 2024 were requested from V2 and provided to this surveyor by V7 (Wound Care Coordinator). R2's Skin Monitoring: Comprehensive CNA Shower Review, dated 7/17/24, signed by V6 (CNA) documents, in part R2 received a shower with assist. R2's Shower Sheets (titled as Skin Observation Worksheets) dated 7/21/24 documents R2 refused a bath/shower and on 7/24/24, no documentation is observed R2 received a shower and skin check, skin check or a bath/shower was refused. Facility policy dated September 2022 and titled Bath/Shower Schedule documents, in part, Policy: A bath or shower will be given to each resident by a Certified Nurse Assistant one time per week as scheduled and prn, per resident preference. Procedure: 1. Charge Nurse makes schedule for Certified Nurse Assistant to include baths or showers are scheduled for respective date and shift. 2. Bath and shower schedule is posted on each floor. 3. Certified Nurse Assistants give bath or shower as scheduled. 4.If resident refuses bath or shower, the Charge Nurse is notified for intervention, follow-up, and documentation. 5. Certified Nurse Assistants are to notify the Charge Nurse of resident's skin changes noted. 6. Bath/Shower sheets are to be completed by the Certified Nurse Assistant upon each bath/ shower scheduled whether accepted or declined. 7. Bath/Shower sheets will be maintained by the facility for the current and entire last month and then may be discarded. Facility policy dated September 2023 and titled Activities of Daily Living (ADL) documents, in part, Purpose: To preserve ADL function . Interventions may include (depending on an assessment based on individualized need): . Dressing: . Selecting, obtaining, putting on, fastening . and taking off all items of clothing, and putting on and removing . socks and shoes. Facility policy dated November 2022 and titled Foot Care Assessment documents, in part, Policy: It is the policy of the nursing department to perform an assessment of the resident's feet at the time of admission, updated quarterly, and when significant change occurs. Purpose: To identify treatable conditions, prevent infections, provide treatment, and comfort. Facility policy dated October 2020 and titled Pressure Ulcer and Skin Condition Assessment Policy documents, in part, Policy: It is the policy of this facility pressure and other ulcers, (diabetic, arterial, venous) will be assessed and measured at least every seven days by a licensed nurse and recorded on the facility approved wound assessment form. Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring interventions are implemented. Standards: . 3. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the licensed nurse who will perform the initial assessment. Facility policy dated 2/1/22 and titled Change in Resident's Condition documents, in part, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP and resident's responsible party of a change in condition. Responsible Party: RN, LPN, Social Services. Policy: Nursing will notify the resident's physician or nurse practitioner when: . b. There is a significant change in the resident's physical, mental or emotional status. c. There is a pattern of refusing treatment or medication . e. It is deemed necessary or appropriate in the best interest of the resident. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. 3. Once the physician/NP has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents. 5. The Care Plan for the resident will be updated as indicated. Facility job description (undated) titled Certified Nursing Assistant documents, in part, Job Summary: The purpose of this position is to assist the nurses in the providing of resident care primarily in the area of the daily living routine . Main Duties: A. Support the facility's philosophy of care and strive to achieve its goals and objectives . C. Carry out assignments for resident care including (but not limited to): a) bathing b) dressing . H. Report any changes in resident's condition . to the charge nurse of the unit . M. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. Facility job description (undated) titled Charge Nurse documents, in part, Job Summary: . Care for the clinical nursing needs of residents on his/her wing . Job Requirements: . 2. Excellence in all aspects of quality nursing including exceptional care . Main Duties: A. Support the facility's philosophy of care and strive to achieve its goals and objectives . D. Supervise all aides in performing their duties by checking work closely to ascertain assignments have been completed . F. Make daily rounds on the wing to ensure individual Care Plans are being followed and assess each resident's status in accord with his/her Care Plan . P. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duties . R. At all times abide by policies of the facility and ascertain employees under his/her supervision do the same . U. Prepare . reports, events and observations using the EMR (electronic medical record) system.

Based on interview and record review, the facility failed to keep a resident (R5) free from abuse in a sample of 6 residents reviewed for abuse. This failure resulted in R4 running over R5's foot with a wheelchair, resulting in R5's foot swelling and pain with a score of 7-9 on a scale of 10. Findings include: R4 is [AGE] years old with diagnosis of, but not limited to: Schizoaffective Disorder Bipolar Type, Paraplegia, Suicidal Ideation, Mood Affective Disorder, Auditory Hallucinations, Visual Hallucinations, Major Depressive Disorder, Tourette's Disorder. R5 is [AGE] years old with diagnosis of, but not limited to: Asthma, Difficulty in Walking. Facility initial reportable (8/23/24 at 1:59 pm) to state agency regarding R4 and R5 documents in part: Incident Date: 8/22/24 at 9:45 am. Brief Description of Incident: Alleged Resident to resident physical altercation. R4's (8/22/2024 at 12:33 pm) documents in part: Resident was observed by writer having physical aggression with another peer on same floor, safety precaution in place. Both residents were separated and redirected by writer. Resident was put on 1/1. No injuries noted. Call placed to MD. New order to send to hospital for psychiatric evaluation. Mother, Administrator, DON, Social service Dir. made aware. Will continue with plan of care. R5's (8/22/2024 at 12:53 pm) progress note documents: Resident noted with right foot pain, r/t (related to) foot being ran over by peer wheelchair. Resident assessed by writer, vitals stable, pain level 7/10. PRN (as needed) pain medication was given. Call placed to MD. New order for x-ray of right foot. ALL parties made aware will continue with plan of care. On 8/24/24 at 8:40 am R5 was observed in her room. R5 said, on Thursday R4 ran over her right foot on purpose. R5 said, R4 came to the nurses station too late to smoke as his smoking time had passed. R5 said, staff told R4 he cannot smoke now, and he got upset. As R4 was leaving he ran over my foot. R5 said, she told R4, You just ran over my foot. R5 said, her foot still hurts, as R4 ran it over with a wheelchair. R5 said, R4 had behaviors and he should have been watched by staff as she and R4 had words a day before. On 8/26/24 at 11:05 am, R5 was observed on the smoking patio. R5 was observed to have a boot on her right foot. R5 said, she went to the hospital few days ago and they gave her the boot to wear for few days. R5 said, she is still feeling pain to her foot, her pain is at 9/10. R5 said, R4 ran over her right foot, and she had previous right hip injury. R5 said, her foot is swollen, and she needs to keep it elevated. On 8/24 at 9:03 am, V17 (LPN) said, she has been here since November. V17 said, the incident between R4 and R5 happened on Thursday (8/22/24) and V17 was the nurse. V17 said, residents were getting medications at the nurses station. R5 was standing here with another resident talking. R5 was given a chair to sit down. V17 said, R4 came from his room he was flying in the wheelchair, and he ran over R5's foot. V17's back was turned away. V17 said, when this happened 2 other resident said, (R4) you could have said excuse me! R4 said F*** Y**. V17 said, R5 got up and started walking away to her room. V17 said, she called social services and went down to R5 to ask what happened. V17 said, R5 said R4 ran over her right foot, her pain was 7/10 and V17 called the doctor. V17 said, the director of nursing ordered x-ray of right foot. She called psych doctor about R4, and he petitioned him to hospital. R4 was on this floor a short time. R4 was petitioned prior to this incident to the hospital due to behaviors. On 8/24/24 at 9:38 am, V21 (Social Services) said, after the incident between R4 and R5 happened, R4 was placed on 1:1 monitoring before he went out to the hospital. V21 said, he walked with R4 and sat with R4 until the ambulance came. V21 said, no one beat R4 up in the facility, he was petitioned out due to the incident with R5. V21 said, R4 had lots of behaviors. R4 would antagonize other residents and would say it never happened. On 8/26/24 at 11:37 am with V1 (Administrator) and V20 (Regional Consultant) present, V1 said V1 is the abuse coordinator. V1 said, when there is abuse resident to resident, staff to resident, staff is suspended. The abuse investigation is initiated, an initial reportable is sent, police are called if warranted, and family and doctor also are called. V1 said, the incident happened on 8/22/24 between R4 and R5, however the facility reported the incident (send e-mail) on 8/23/24 at 1:59 pm. With the state agency new portal the facility has not been using it. Surveyor asked V1 if the regional email was working for state agency. V1 confirmed it was working, however he sent the incident on 8/23/24. On 8/26/24 at 1:11 pm V1 said (with V20 Consultant present) regarding R4 and R5, before the 22nd, they were not happy with each other. R5 assumed that R4 cut here in line in front of her. V1 said, they had tension between them, next day they were passing each other in the hall, he (R4) rolled her (R5) foot. R5 is saying it was done on purpose and R4 said it was accident. R4 maintained that he didn't do it on purpose. R4 did have interaction with R5 before. V1 said, when R4 came to the facility he was complimentary. Over time he started to exhibit behaviors. If something wasn't his way, he would annoy staff. Some people he got annoyed. R4 would manipulate a situation and blame others. Some residents he had no issues with and other residents he rubbed the wrong way. V1 said, R4 is currently in the hospital, he will not be permitted to return to the facility. R4's care plan (5/23/24) documents in part: R4 displays manipulative behavior which is disruptive, insensitive and disrespectful to staff and peers. This behavior is related to: Anger and depression., Poor self-esteem, diminished self-worth. Symptoms/problems are manifested by: On-going conflictual relationships, engaging in deceitful/disrespectful practices (confabulation, lying, dishonesty) for personal gain, frequent threats to call state survey agency officials, ombudsman, attorneys, placing unjustified calls to police, and threatening to report staff. R4 has a diagnosis & history of severe mental illness (SMI). R4's problems & symptoms are manifested by: Display of known risk factors (e.g., wandering, elopement risk, poor safety awareness, aggressive behavior, self-harm behavior, suicidal ideation), Poor contact with reality, poor judgment, poor insight, impaired decision making. (6/1/24) R4 demonstrates behavioral distress related to: Ineffective coping mechanisms., Problems are manifested by: Verbally abusive behavior when agitated, use of profanity, demeaning statements, verbal threats & yelling at others. Facility's Abuse Prevention Program documents in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Residents' Rights for People in Long-term Care Facilities documents in part: You must not be abused, neglected, or exploited by anyone financially, physically, verbally, mentally or sexually.

Based on interviews and record reviews, the facility failed to properly monitor, supervise, and intervene for four residents (R1, R12, R14, R15) with known substance use disorder and history of using illicit substances/narcotics and overdose in the facility. These failures resulted in: 1. R1 testing positive for heroin use and suspected to be under the influence of an unknown substance. 2. R12 testing positive for cocaine and suspected to be under the influence of an unknown substance. 3. R15 being found unresponsive in the facility due to suspected drug use, admitting to drug use, testing positive for heroin, and having to be transferred to the hospital due to an overdose of drug use. 4. R14 was found unresponsive in the facility, transferred to the hospital, and expired with suspicion of drug overdose. This was identified as an Immediate Jeopardy began on [DATE]. On [DATE] at 2:38 pm V1 (Administrator) and V2 (Director of Nursing) were notified of the immediate jeopardy. The facility presented an abatement removal plan on [DATE] at 4:45 PM and wasn't approved. The facility submitted a revised abatement plan and was approved on [DATE] at 10:42 AM. Findings include: 1. R1's Face sheet documents R1 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: need for assistance with personal care, adult failure to thrive. No diagnoses of history of substance abuse listed on R1's face sheet. R1's nurse practitioner's note dated [DATE] 4:10 PM documents in part, R1 is a [AGE] year-old male with significant medical history of OUD (opioid use disorder), takes suboxone (used to treat opioid use disorder). R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating R1 is moderate cognitively intact. [DATE] 11:39 AM R1 stated, About two weeks ago, they accused me of dealing drugs, but one resident was just giving me my money back, and they said it was drug transaction. Surveyor questioned R1 if he knew if illegal drugs are getting inside the facility, R1 responded, Someway they are getting in here. When R1 was asked if he knew which residents were bringing the drugs inside the facility, R1 stated, Some people on the 3rd floor and 1st floor leave, but I can't say the names. R1 stated drug exchanges would occur in the smoking area and in resident's rooms too. Surveyor questioned R1 if he has taken any drugs recently and R1 responded, I took methadone two to three weeks ago; I didn't get it from R12. R1 stated, Another resident gave it to me here, he did it as a favor. I was going through withdrawals, I don't want to say his name. [DATE] 10:12 AM V11 (insurance care coordinator) stated R1 informed her last week he got methadone from another resident and the medication caused him to feel extremely drowsy. [DATE] 1:57 pm surveyor questioned V3 (Licensed Practical Nurse/LPN) what the procedure says the facility does when a resident is suspected of being under the influence. V3 responded that staff notify social services and social services will have the resident do a drug test if the resident allows it. V3 stated if the resident refuses, then staff will document and just continue to monitor the resident. V3 stated, Really, we just monitor after that. V3 stated she is not sure what social services do. V3 stated the nurse will notify the attending provider and they usually want to hold the resident's medication, whatever else the doctor orders. Surveyor questioned V3 if a change in condition assessment would need to be completed when a resident is suspected of possible substance use. V3 responded she thinks yes but V3 stated she hasn't completed one for R1 being under those circumstances. [DATE] 11:50 AM V4 (Certified Nursing Assistant/CNA) stated she has been working for the facility for four months now. V4 stated residents can go on their own to smoke. V4 stated when there is an extra CNA, then the CNA will be the one going with him. [DATE] at 12:07 PM V17 (Social Service Director) stated R1 has had urine drug tests and tested negative recently. V17 stated the urine drug test is a five-panel test detects for opiates, amphetamines, cocaine, marijuana, phencyclidine. [DATE] 2:00 pm V31 (social services behavioral tech) stated the urine drug test is the 5-panel urine test. V31 stated, It takes like two minutes; methadone wouldn't be able to be tested in the urine test. Surveyor questioned V31 if there are any residents suspected of doing methadone that do not have an order for methadone. V31 responded, No. Surveyor questioned V31 if there are any allegations there is drug trafficking inside the facility. V31 responded, Yes. Surveyor questioned what the facility has done about it. V31 responded, For now, the most we can do is search rooms, around the areas. We can't search them. We can ask them to take things out their pockets, but they have the right to say no. Also searching residents' belongings that visitors brought when they came. We will search the belongings. Residents with independent community pass, they get asked what they have. If they break the rules, their independent pass becomes a supervised pass like a family member or staff member will go out with them. They won't be able to go out alone. They get 30 day supervision. After 30 days, we will get another screening even if they went out with supervised, if it comes clean, then they get the independent pass back. [DATE] 12:38 PM, surveyor questioned V34 (insurance care coordinator) regarding what happened on [DATE] with R1. V34 stated R1 was sitting in the hall, slumped over, and did not respond to V34. V34 stated a nurse told V34 R1 was high. V34 stated R1 was the only resident in the hallway. V34 stated she did not ask the nurse for her name, but V34 stated she knows what she looks like. R1's community survival skills assessment dated [DATE] documents, R1 does not appear to be capable of unsupervised outside pass privileges at this time. R1's social services note dated [DATE] 2:39 PM documents in part, Met with R1 to discuss alleged drug trafficking in the facility. R1 was asked to take a urine drop and he admitted he would test positive for heroin. R1 didn't have abuse substance care planned until [DATE]. R1's social service note dated [DATE] 3:28 PM documents in part, R1 is noted going out on pass independently and with visitors to purchase/use drugs. R1 has been noted to drop dirty for substances. R1 admitted to getting drugs while in the community. 2. R12's Face sheet documents R12 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: opioid dependence with withdrawal. [DATE] at 4:28 PM R12 stated R14 was her friend and R12 stated she knew R14 was in R14's room doing drugs because R12 stated R14 would say it was helping her. R12 stated she has not done used any illegal drugs. [DATE] 2:49 PM V32 (Licensed Practical Nurse/LPN) stated she has been working for the facility for ,d+[DATE] months. V32 stated she has retrieved a crack pipe. V32 stated she thinks R12's mom brings R12 the drugs. V32 stated she is not sure if they are searching the visitor's items when they come into the facility. [DATE] at 3:50 PM V32 (LPN) stated she suspects R12 of using because of what goes on here. The area we are in is a high drug use area. I've never seen any residents do drugs or any transactions. I'm from Chicago. We know there is something going on in here. I don't know what they are doing downstairs. They need to monitor what comes inside. R12's behavior note dated [DATE] 2:03 PM documents in part, The resident (R12) was drug tested [DATE] and tested positive for cocaine. R12 didn't have the abuse substance care planned until [DATE]. R12's physician order set dated [DATE] documents, Supervision: Resident (R12) may access the community with supervision from staff and family. Per record review, on [DATE], [DATE], [DATE], R12 observed by staff and suspected of using substance abuse. R12's progress note dated [DATE] documents in part, V35 informed writer (V1) R12 admitted to having THC (tetrahydrocannabinol) in her system and she doesn't take cocaine, only distributes it. R12's nursing progress note dated [DATE] 09:48 PM documents in part, She (R12) is noted with slurred speech, drowsiness to the point she is almost unable to balance in her rollator. 30-minute monitoring is initiated per facility staff. Will continue to monitor and follow up at a later time. R12's behavior note dated [DATE] 4:42 PM documents, Resident (R12) was observed of suspected substance abuse. When asked by staff to give a urine sample the resident (R12) declined using vulgar language. Resident (R12) then became verbally aggressive threatening staff. 3. R15's Face sheet documents R15 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: opioid abuse with intoxication, opioid use. R15's Minimum Data Set (MDS), dated ,d+[DATE] /2024, documents R15 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R15 is cognitively intact. R15's hospital record dated [DATE] documents in part, Pt (patient) was admitted to NH (nursing home) the day before yesterday for opioid withdrawn and anemia. Per nursing home report, pt was normal round this am (morning). Later he was found unresponsive and improved with Narcan. R15's progress note dated [DATE] 8:37 PM documents in part: admitted /Time:[DATE] 9:00 PM admitted From: Hospital Primary Admitting Dx: opioid dependence, AMS, anemia. No Narcan PRN (as needed) order documented in R15's record since admission, Narcan PRN order active on [DATE]. No care plan documenting addressing R15's overdose incident on [DATE]. R15's progress note dated [DATE] 12:41 PM documents in part, Upon AM rounds resident noted guarding ABD (abdomen) stating he is sick. After further assessment resident verbalized, he needed some help and is interesting in a Methadone program. Writer called nurse practitioner and made him aware of resident c/o ABD pain and the desires for methadone treatment. R15's physician order set dated [DATE] through [DATE] documents the patient may attend an outside methadone clinic for opioid use disorder management. No documentation in R15's care plan regarding R15's interest in Methadone program. R15's progress note dated [DATE] at 4:39 PM documents in part, Writer (V36/LPN) was informed R15 had a fall. Speech was incoherent. Unable to complete a sentence. Eyes were constricted bilateral. Skin was dry and pale. Writer (V36) administer Naloxone Nasal Spray 4mg on left nostril. R15 became fully alert after 2 minutes of administration. R15's speech became clear. Activity more evident by resident being able to sit up on his wheelchair with no assistance. R15 attended his methadone clinic today for refills. R15's community survival skills assessment dated [DATE] documents R15 does not appear to be capable of unsupervised outside pass privileges at this time. R15's community survival skills assessment dated [DATE] documents R15 does not appear to be capable of unsupervised outside pass privileges at this time. R15 didn't have the abuse substance care planned until [DATE]. R15's progress note dated [DATE] at 4:59 PM documents in part, writer (V36) was notified by the resident's (R15) roommate the resident was on the floor. Speech was slur (sic). Answered with short responses. R15 stood up with minimal assistance from the writer (V36). Due to suspicion of opioid abuse, writer (V36) administered Narcan 0.4mg left nostril. After 4 minutes, R15 became more active. After questioning the resident of what lead to his fall, R15 confess to have drugs on his system. R15 stated he got a hold of heroin when he went out to the methadone clinic. R15's Methadone medication note dated [DATE] 05:24 AM documents in part resident (R15) very lethargic and hard to arouse. Per MD (medical doctor) give this dose at 9am. Made oncoming shift aware. R15's social services note dated [DATE] 3:04 PM documents in part, the resident was asked to take a urine screen and he fully self-disclosed he had been using heroin. No documentation in R15's chart regarding signs/symptoms of intoxication/inebriation. No vital signs or any assessment taken on [DATE]. [DATE] 12:55 PM V2 stated via email there are no vital signs for R15 for the month of April. R15's social service note dated [DATE] 11:54 AM documents in part, the resident (R15) got honest about what quitting requires as well as what obstacles stand in the way of sobriety. No individualized care plan including addressing R15's obstacles noted. R15's substance abuse assessment dated [DATE] documents in part: R15 admitted to using heroin in the facility in his room on [DATE]. No documentation of any follow-up interventions and treatment recommendations noted in R15's care plan or medical record after R15 admitted to using heroin in the facility. R15's progress note dated [DATE] 12:08 PM documents in part, At 1140am, the writer was notified of a Rapid response at the first-floor dining room, during smoke break. Resident presented sitting on his four-wheel rollator. Unconscious, mouth open, heavy drooling. Resident was transferred to the floor, left lateral position, due to sudden jerking of the body. Vitals: B/P:,d+[DATE] P:62 R:16. Pulse ox was unable to be obtain. Oxygen placed, 3L via non-re breather mask. Suction as needed. Paramedics arrived at 1150. The resident is to be transferred to the nearest hospital. R15's hospital record dated [DATE] documents in part, reason for visit: overdose . per EMS (emergency medical services) pt was given Narcan became responsive and presented with agonal breathing. Pt endorses snorting heroine. [DATE] at 12:15 PM R15 observed in his room, sitting on his bed, rollator walker next to R15. R15 stated he feels safe. When questioned R15 what happened on [DATE]st, 2024, R15 stated he had drank his methadone drink that day. R15 stated he kept throwing up and R15 stated he was feeling sick. R15 stated, I had got on the elevator. I saw a small package; it was something white in a small green bag and I used it. When questioned what it was, R15 stated, I snorted it, the heroin. R15 stated he denies any staff were in the elevator with him. R15 stated he then went outside to the smoking patio on the first floor. R15 stated it was crowded and then he blanked out. R15 stated in December, the same thing happened to him. R15 stated he was feeling sick, and he kept throwing up the methadone. R15 stated he obtained heroin from another resident in the facility that is no longer in the facility. R15 stated it is tempting to know R15 may be able to access the drug inside the facility since it is known residents can access it inside the facility. R15 stated there is no specific individual is selling it. [DATE] 10:40 AM V2 (Director of Nursing/DON) stated no escort was with R15 since R15 has not been using drugs until his recent incident. V2 stated R15 was getting independent passes. V2 stated at one-point R15 was going by himself because his health improved, and he didn't need assistance. [DATE] at 10:20 V36 (LPN) via telephone stated she has been working for the facility for eight years. V36 stated she usually works on the third floor. V36 stated, I had to send him out, I gave him the Narcan. Since he is on the program. Surveyor questioned V36 how she thought he obtained the heroin, V26 responded she is not sure. [DATE] 12:06 PM surveyor questioned V43 (Medical Director) on her thoughts about a resident with history of abuse in the facility and being able to go to the methadone clinic on their own. V43 stated, This is like a home, it is a right, is against their freedom, is why we can put them on supervised pass. V43 stated she didn't know what was going on in the facility. V43 stated residents could have brought the illicit drugs back after the methadone clinic if the resident went on their own. 4. R14's Face sheet documents R14 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: opioid abuse, major depressive disorder. R14's care plan documents in part date initiated [DATE], Visitor restriction due to ongoing substance abuse, per physician order. R14's community survival skills assessment dated [DATE] documents R14 does not appear to be capable of unsupervised outside pass privileges at this time. Per record review on [DATE], R14 left the facility unaccompanied to an appointment at 9:15 AM and returned to the facility at 9:49 PM. R14's progress note dated [DATE] 2:57 PM documents in part, Resident (R14) went out on an appointment this morning. Resident (R14) left the facility around 9:15A. The resident was transferred by insurance health care. The writer (V36) called transportation regarding the resident's ride; writer (V36) was informed the resident (R14) has not requested a pick at the moment. R14's progress note dated [DATE] 5:11 PM documents in part, Writer (V36) contacted location where resident (R14) attended. Location stated the resident (R14) had left around 2:00 PM, accompanied by a male. R14's progress note dated [DATE] 9:49 PM documents, resident (R14) has returned to facility. R14's social service noted dated [DATE] 12:32 PM documents in part, Staff conducted a room search and found heroin and contraband in the residents (R14) room. The resident (R14) was drug tested and was POSITIVE for heroin. R14'S physician progress note dated [DATE] 1:45 PM documents in part, Opioids: Patient reports using 5 bags per day since I was [AGE] years old. R14's general note dated [DATE] 11:10 PM documents in part, resident (R14) was observed on the floor in her room, blood glucose was 50, BP ,d+[DATE], T97.2, 02 92, slow breathing glucagon 1mg (milligrams) given, 911 and code blue was called. At 11:12pm resident become unresponsive CPR was stated till the CFD arrive at the facility. R14's nursing progress noted dated [DATE] 12:08 AM documents in part, Police officers are in the facility for face sheet and stated they will be heading to the hospital to obtain a report. R14's nursing progress note dated [DATE] 02:10 documents in part, Call received from Medical Examiner's office. Made aware the resident (R14) has passed away at the hospital. Requested face sheet be faxed. R14's emergency department records dated [DATE] 12:47 AM documents in part Patient (R14) presents in ED (emergency department) in cardiopulmonary arrest from nursing home, reportedly hypoglycemia, last seen well at 7:30 PM, 2mg (milligrams) Narcan given. [DATE] 1:40 PM R16 stated, Yes it's sad, R14 overdosed in the facility and died , they couldn't find her for several hours. [DATE] 10:37 AM surveyor questioned V30 (LPN) what happened to R14. V30 responded, I really could only say when the rapid response was. It was on the third floor. I went in the room, knowing she is diabetic. I checked her sugar; it was 21 or 26. Immediately I asked the nurse. She said she had previously given her (R14) the glucose gel, and I gave glucagon. V30 stated the police were in the facility maybe because the fire department came due to staff calling 911. Surveyor questioned V30 if there were any concerns of R14 doing substances in the facility. V30 responded, This facility is a drug rehab facility; we must be aware of the residents if they are possibly under the influence of drugs. As for her (R14) drug use, she has a history of it. To be honest I didn't work with her. I can't speak on if she was on any drugs. [DATE] 9:08 AM V33 (LPN) stated she was the nurse working the morning shift the day R14 passed away. V33 stated, She was the best I've seen her, she was moving fast, at first she was slow. V33 stated R14 was involved in her care and R14 was on top of checking her sugars. Surveyor questioned V33 if she thought there is drug exchanges going on in the facility. V33 responded, With the demographics we have in the facility, there are chances and risk of it. Surveyor questioned V33 what the importance of interventions are. V33 responded, Just so we can avoid the overdose. V33 stated the facility should have a security checking who is coming in the facility. [DATE] 11:40 AM V17 (Social Services Director) stated R14 was drug seeking a couple months ago. V17 stated she knows R14 would test positive. V17 stated because R14 would go out on pass with her husband, and she would return intoxicated. V17 stated R14 would be honest and say she got high with her husband. V17 stated social services department is responsible for the substance use part of the residents' care plans. Surveyor questioned V17 if R14's care plan should have been updated when she tested positive for heroin in [DATE]. V17 stated, yes although it was not updated. V17 stated R14 was open about herself but if it was about someone else, she wouldn't tell V17 anything. V17 stated R14 did not say from where she got a hold of the heroin. V17 stated the facility needs to take this under control. [DATE] at 12:40 PM V39 (previous social worker) stated he remembers R14 testing positive for heroin and cocaine in her drug urine test. V39 stated R14 told him R14 stated her husband gave it to her. V39 stated R14's husband was a drug abuser too. V39 stated a thirty-day pass restriction means only family and staff can take them out on pass and residents can't go out on her own. [DATE] 11:36 AM V2 (Director of Nursing) stated the facility does not have a police report for [DATE] regarding R14. V2 stated the police officer asked for a face sheet but did not provide any record number. [DATE] 08:41 AM V37 (medical examiner assistant) stated R14's toxicology report is pending, and it can take up to 90 days but V37 stated it can be sooner. [DATE] at 10:20 V36 (Licensed Practical Nurse/LPN) stated, The first time R14 arrived, she was taking methadone, but she was having kidney issues because her blood sugar levels were going down. They stopped giving her the medication. The last time I saw her she was excited she was going home; I was shocked about her death. I didn't see her as somebody would seek but I know she suffered from depression. V36 stated R14 was compliant with her medications and blood sugar checks. Facility document dated [DATE] titled, Alcohol/substance use/abuse policy, documents in part, Documentation will be placed in the chart regarding signs/symptoms of intoxication/inebriation. Facility document dated [DATE] titled, Alcohol/substance use/abuse policy, documents in part ,Management of individuals who use and/or appear inebriated/impaired .It is the policy of the nursing facility to provide a safe and healthy living environment. The facility shall with the individual to provide appropriate treatment referrals to enable the individual to work on abstinence, sobriety, personal improvement and reducing chances of recidivism. Appropriate interventions are strongly recommended to persons with substance abuse problems. Facility document dated ,d+[DATE] titled CARE PLAN documents in part, All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. Facility document dated [DATE] documents in part Guideline: Change in Resident's Condition. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. The care plan for the resident will be updated as indicated. On ,d+[DATE] to [DATE] the surveyor confirmed, by reviewing the staff in-service list included in the approved Abatement Plan, resident council meeting minutes held on [DATE] the following residents' care plans regarding substance abuse history, physician order sets, substance abuse disorder assessments: R19, R20, R21, R22, R23, R24, R25, interviewing R15, R17, R18 and confirming these residents were accompanied to the methadone clinic and back to the facility, interviewing R1, V10 (LPN), V40 (restorative aide), V7 (LPN) V41 (Social Service Director), V42 (Certified Alcohol and Drug Counselor), and V43 (Medical Director), the immediacy was removed on [DATE]. The immediate Jeopardy began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: o Education was initiated on 8.1.2024 by the administrator, DON, ADON, and social service director and completed on 8.5.2024. o All staff (administrator, HR director, dietary manager, business office manager, activity director, social service director, medical records coordinator, staffing coordinator, housekeeping director, mental health tech, restorative aides, cooks, laundry, RN, LPN, and C.N.As.) were educated via phone with the same training as the staff educated in person. However, the staff who received the in service over the phone were notified they would also be required to attend the in-person training before the beginning of the next shift. Upon completion of the in-person in-service, the staff will sign the in-service sheet. The administrator and/or social service director will complete weekly spot checks to ensure the facility staff are knowledgeable of the content. Any staff was not able to attend the in service due to a planned vacation or leave of absence will be in-service on their next day to work prior to the start of their shift. The administrator, social service director, assistant social service director, DON, or ADON will lead this in-service session. Education includes: o Substance abuse and prevention is a process attempts to prevent the onset of substance use or limit the development of problems associated with using psychoactive substances. o Staff are to ensure the safety of residents and monitor residents by room search, supervise visits, and search for belongings. o Anyone appears under suspension will be placed on 1:1, notify the administrator, DON, and MD, and administer Narcan and CPR if noted without a pulse. o The facility staff will escort residents to the methadone clinic to retrieve their methadone supply. o Upon admission to the facility, residents' admission packet and PASSR screen will be reviewed by the social service director. The Social Service Director will educate the social service department on the resident's diagnosis and discuss therapeutic programming and care plan development. o The resident's SMI/Substance Abuse Disorder assessment will be conducted, and care plan interventions will be added to allow staff to adequately supervise and provide care to reduce the risk of substance use/or overdose. o Staff nurses must complete mouth checks to ensure residents receive their scheduled dose of methadone and prevent residents from providing it to others. o o We will provide an order for Narcan to anyone with a history of substance abuse or who has a prescription for narcotic analgesics. o The facility staff is responsible for preventing the entry of contraband into the facility and removing it from any resident who has it on them. o The facility staff will assist in preventing residents from obtaining illicit drugs within the facility. o The facility staff is responsible for properly assessing and planning care for residents who have a history of substance abuse. Prevention of illegal substances in the facility: o Each unit will place signs in the lobby alerting staff, residents, and visitors to the facility's policy of searching belongings for contraband. This information will also be provided to each resident in writing and during the impromptu resident council meeting. o Upon admission and readmission, the receptionist will obtain residents belongings to be searched, washed, and inventoried prior to their being delivered to the unit. o Residents returning from therapeutic home leave will be thoroughly searched for contraband as well as their belongings. o Random room searches will be conducted to monitor for illicit drugs. o Residents who refuse to be searched will be placed on 1:1s, and the resident's family, physician, and local police will be contacted to make them aware of the behavior, and an order will be obtained to petition the resident to the hospital. The facility will properly assess residents by: o Ensuring the resident with a history of substance abuse is properly assessed and diagnosed will be achieved through staff education with the social service department. The Social Service Department will be educated by the Social Service Director on the requirement of assessing and identifying diagnoses of substance abuse disorder upon admission to the facility. The presence of substance use disorders will be assessed through resident/family interviews and record reviews. The assessment will be documented through the completion of the SMI/substance abuse disorder assessment in the resident's electronic health record. Upon identification of a staff member to adequately supervise and provide care to reduce the risk of substance use and/or overdose, the social services department assesses residents to determine appropriate placement into programs offered in and outside of the facility. System put into place [DATE]-[DATE]. o The Social Service Department updated SMI/substance abuse assessment and care plans. Completed [DATE]. o Social Service Director to review new admissions, hospital discharges, and PASSR screens to identify any substance abuse disorders. The social service department will meet to discuss the residents' plan of care. o The social workers will then determine the programming (behavior health groups, (MAT) medication-assisted treatment, and Narcotics Anonymous) the resident will need to be placed in, which is offered by the facility. o Care plans will be implemented with interventions to address the risk of overdose in the care plans for those residents who are known for substance abuse and/or have had an overdose incident. o A system to ensure residents who may be engaged in illicit drug activity will be achieved through staff education regarding the signs and symptoms of substance abuse, including frequent leaves of absence from the facility, odors, needle marks, and changes in resident behavior such as drowsiness, slurred speech, lack of coordination, and mood changes, particularly after interaction with visitors or absence from the facility. o Staff are to report any signs or symptoms of substance abuse to the charge nurse. The charge nurse will complete an assessment, contact the physician, and obtain an order for drug testing. o The facility hired a CADC (Certified Alcohol and Drug Counselor), with a start date of [DATE]. In-Services began on [DATE] and ended on [DATE]. o Education on the signs and symptoms of substance abuse. o Educated to report any signs of symptoms of substance abuse to the charge nurse. o Educated on the contraband policy and illicit drug policy to ensure contraband/illicit drugs are not brought into the facility. o The administrator will give the Social Service Department and/or designee (RN, LPN, C.N. As) the go ahead to conduct a room search immediately after the decision has been made. o Illegal items found during the search will be confiscated by the facility and given to law enforcement for further disposition. o Contraband is not illegal will be labeled and stored in a secure location. o Upon admission/readmission, the resident's property will be searched for contraband/illicit drugs prior to the items being taken to the unit. Those residents with substance use disorder diagnoses will have an SMI/[TRUNCATED]

Based on interviews and record reviews, the facility failed to provide the appropriate treatment to attain the highest practical mental and psychosocial well-being and ensure a resident received physician ordered medication timely for treatment of opioid dependence for 1 (R85) out of 1 resident reviewed in a sample of 35. This failure resulted in R85 feeling anxious and having trouble sleeping. Findings Include: R85's progress notes dated 5/24/24 at 7:09 PM documents R85 was readmitted from acute hospital. R85's clinical records show a diagnosis not limited to Opioid Dependence. R85's Minimum Data Set (MDS) dated [DATE] shows R85 is cognitively intact. R85's physician orders dated 5/24/24 show an order of: Suboxone Sublingual Film 2-0.5 MG (Buprenorphine HCl-Naloxone HCl Dihydrate). Give 1 film sublingually one time a day related to Opioid Dependence. R85's May Medication Administration Record (MAR) shows R85 did not receive the ordered Suboxone medication until 5/28/24. R85's progress notes from 5/25/28 to 5/27/28 shows Suboxone medication was on order and no documentation that staff followed up the order from pharmacy. There was no documentation that the doctor was notified of R85 not receiving the Suboxone. Progress notes dated 5/28/24 at 1:12 PM written by V19 (Licensed Practical Nurse/LPN) shows V19 called Pharmacy and will deliver Suboxone medication in the evening. On 5/28/24 at 11:01 AM, R85 was resting in bed alert and able to verbalize needs. R85 stated the facility is short in staff. R85 stated, I don't get my medications, especially on weekends. They are really bad. If I could walk, I would walk out of here. Night shift is really bad. When I press the call light it would be hours until they see me. If I ask for a nurse, it would be hours until they come in and help. Sometimes I don't get my medications until the next day. I came back Friday from the hospital and the medications I'm supposed to get I have not gotten it. I'm supposed to get Suboxone for anxiety attacks and drug withdrawal. I feel anxious. I haven't been sleeping since Friday. They always say let me see and check, but they never came back. On 5/28/24 at 12:48 PM, V19 (LPN) stated R85 has not gotten R85's Suboxone. V19 stated that for the Pharmacy to deliver R85's medication, it required a script to be faxed to Pharmacy. V19 stated the script was faxed yesterday (5/27/24). V19 stated, I have not called the Pharmacy I will call today to follow up on the medication. On 5/29/24 at 10:01 AM, V27 (Family Nurse Practitioner) stated that V27 assessed R85 and that R85 came back from the hospital Friday and was waiting for the medication Suboxone. V27 stated R85 has history of opioid and heroine abuse and Suboxone helps with that. V27 stated R85 is using the Suboxone to get rid of the addiction and manage withdrawal and anxiety. V27 stated R85 should be taking the medication every day; if not, R85 might get anxious and get agitated. V27 stated V27 saw R85 on Monday (5/27/24) and R85 was still waiting for the Suboxone. V27 stated that yesterday (5/28/24), V27 asked V19 to follow up on the medication. On 5/30/24 at 09:11 AM, V2 (Director of Nursing) stated that prescription scripts are required to be faxed to pharmacy for them to deliver the residents' narcotic medications. V2 stated the expectation is that once the nurse receives the narcotic medication order from the doctor, they must obtain the script from the doctor or the nurse practitioner and send the script to pharmacy immediately. V2 stated R85 has history of substance abuse. V2 stated if the medication is not delivered on time, the nurse must follow up from pharmacy to find out what happen. If resident comes in the evening the nurse should be following up the next morning. V2 stated, The doctor should give something to calm them until they get the medication. The nurse should have called the doctor that [R85] was not getting the Suboxone. V2 stated if R85 does not get the Suboxone as ordered, it could potentially make her agitated or exhibit negative behaviors. The facility's policy titled; RECEIVING CONTROLLED SUBSTANCES dated 10/25/14 reads in part: B. Controlled substances prescribed for a specific resident are delivered to the facility on ly if a valid prescription has been received by the pharmacy prior to dispensing. The facility's Physician Orders policy dated 1/24 documents in part that medications will be ordered from the pharmacy to ensure prompt delivery.

Based on observations, interviews and records review, the facility failed to provide proper pain management to one(R2) of three residents reviewed for pain management. This failure caused R2 pain and suffering. Findings include: R2 is a [AGE] year-old individual admitted to the facility on [DATE]. R2 diagnosis as documented in R2's current face sheet include but not limited to: Lower back pain, Acute Osteomyelitis, Psychoactive substance abuse, discitis unspecified, Lumbosacral region, lower back pain, auditory hallucinations, visual hallucinations, etc. On 12/23/2023 at 10:04am, R2 was observed in the hallway walking to his room. R2 was oriented to person, place, time, and situation. R2 said he has not been receiving his pain patch, and the last time he got it was last week. R2 said even today, he has not received his pain patch. R2 said he thought the nurses were ignoring his requests for the pain patch because he has a history of drug abuse, and they think he is seeking drugs. R2 said that's not the case and he is in severe pain especially at night, and this makes him feel so bad. R2 said two weeks ago, he was in so much pain and the medications he was on were not working, and he was not getting his pain patch, therefore he asked his mother to buy over the counter pain patches for him and bring it to him. R2 said she did, and he used the pain patches at night to relieve the pain, but he run out of the pain patches his mom brought. R2 said even today, he has not received his pain patch. On 12/23/2023 at 9:45am, V3(Licensed Practical Nurse-LPN) said R2 has not been getting his pain patch (Lidocaine HCl External Patch 4 %) because it is not available. V3 said when a medication is not available, the nurse should call and notify doctor, so that new orders can be given. V3 said resident pain should be controlled. On 12/23/2023 at 1:40pm, Review of R2's medication administration record by V1 (Director of Nursing-DON-RN) and surveyor documented R2 has not received his pain patch (Lidocaine HCl External Patch 4 % one time a day for back pain) since 12/11/2023 to date, 12/23/2023. V1 said R2 has not been receiving his pain patch because pharmacy did not send it. V1 said pain medications, including pain patches should be given as ordered, and if there is an issue with the medications/pain patch, the physician should be notified. V1 said the resident's pain should be controlled, and residents pain concerns should be addressed, and their providers notified of any issues with medications so that other orders can be given. V1 said R2's providers were not notified of R2's pain patch not available. Review of R2's nursing notes do not document R2's physician was notified of R2's pain patch not available. R2's current Physician Order Sheet (POS) dated 12/02/2023 11:29: Medication Lidocaine HCl External Patch 4 %. Apply to lower back topically one time a day for back pain. R2's electronic Medication Administration Record(eMAR) documents R2's pain patch was not given from 12/11/2023 to date, 12/23/2023 as documented/signed with a 9(Which means -other, see nursing notes per legend interpretation). Facility Policy Titled: PAIN MANAGEMENT PROGRAM, no date, documents: -It is the policy of the facility to facilitate resident independence, promote resident comfort, preserve, and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. -The resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medications.

Based on observation, interview, and record review, the facility failed to ensure resident's environment remains free of accidental hazards. This failure affected R1 who had an acute fracture of the distal phalanx due to toilet seat instability and no grab bar and has the potential to affect all 63-resident residing on the 3rd floor of the facility. Findings include: R1 's medical record showed documentation R1 was admitted to the facility on [DATE] with diagnosis includes but not limited to fracture of unspecified fracture of shaft of left fibula, Major depressive disorder single episode, specified, Laceration without foreign body unspecified subsequent encounter for closed fracture with routine healing, unspecified multiple injuries subsequent encounter, and Fracture of unspecified phalanx of the left index finger subsequent encounter for fracture with routine healing. On 09/18/23 at 12:15pm, R1 observed sitting on the bed with left index finger blackish in color with a finger (immobilizer). R1 stated on 08/27/23, I was in the shower room in the hallway and as I was getting up, there was nothing to grab on to (Grab Bar). The toilet seat was wobbly, so as I was trying to get up, my pants got caught in between the seat and the top cover. As I was trying to get it off, my finger got caught in-between the toilet seat and the top lid and I injured myself. I thought I was going to lose my finger. Now they fixed the toilet seat, but it is still wiggling (referring to not stabilized). According to R1's medical record Left finger(s), 2 + X-ray report with date of service listed as 08/29/23 two days after the incident showed documentation under findings and impression: The alignment is normal. Acute fracture of distal phalanx, distally. The joints are well preserved. The soft issues are unremarkable. Impression: Fracture of distal phalanx, distally. The joints are well preserved. The soft issues are unremarkable. R1 was not referred for ortho consult until 08/30/23 or to place immobilizer. R1's MDS (Minimum Data Set) dated 06/26/23 documented R1's BIMS (Brief Interview for Mental Status) score was 15. Transfer and toileting scored at 2/2 showing for ADL self-performance and support, R1 is at limited assistance with one-person physical assist. Functional limitation impaired on one side and impairment on both extremities bilaterally. According to facility investigation, the facility concluded R1 is alert and oriented times 4. R1 stated he was on the toilet when R1 attempted to get off the toilet R1's pant fell . R1 stated R1 sat back down on the toilet and his finger got caught under the toilet seat. R1 went out to the local hospital for follow up, returned with splint and band aid to left index finger. Follow up appointment with Ortho (orthopedic consultation) at 1:00 pm 09/11/2023. On 09/19/23 at 3:36pm, V16 CNA (Certified Nurse's Aide) identified self as CNA assigned to R1 on 08/27/23. V16 stated, in the beginning of the shift R1 was not back from the community pass. V16 stated R1 returned to the facility around 7:15pm. V16 stated she saw R1 carrying some of his belongings and after dropping off the things, R1 asked to go in the shower room toilet. V16 stated, once R1 came out, R1 reported he had hurt (injured) his (R1)'s finger. V16 stated she did not see R1's finger until after the shower at the nurse's desk. V16 stated the finger was bruised with purple color. R1 then reported it to the nurse (referring to V15). On 09/19/23 at 3:53pm V1 stated, I don't have any work order for the repairing of the (environment issues). (Former Long-Term owner) really neglect this building. On 09/22/23 at 1:21pm, V15 LPN (Licensed Practical Nurse) stated she is familiar with R1. V15 stated, R1 was out on day pass (referring to incident of 08/27/23). When R1 came back I didn't see R1 come off the elevator. R1 came from the opposite way (of R1's room) where the shower room was. R1 came to the nurse's station and said he slammed his finger in the toilet seat. V15 stated, I assessed the finger. R1 denied pain but there was swelling and it was purple in color. It seems like it was a day or two days old. I took a picture and sent it to the (V25) NP (Nurse Practitioner). (V25) ordered X-ray and pain management. I ordered the X-Ray the same day 08/27/23 it happened. X-Ray (outside X-ray service) came the next day. (R1) said he couldn't take the X-ray till after his appointment. V15 stated, In my opinion, because R1 was not showing any pain and there was no commotion heard from the shower room. The toilet is next to the nurse's station, the incident did not happen in the facility. V15 stated the facility protocol/policy on resident coming back to community pass is to chart them in, do the skin assessment, chart them back into the system that they are back. The surveyor asked V15 whether V15 followed the guideline. V15 replied, I did not because I did not see (R1). The first time I saw (R1) was after the injury. On 09/20/23 at 3:20pm, V25 NP (Nurse Practitioner) stated she was not the NP notified on the day of the incident on 08/27/23. V25 identified the NP notified as V26 who ordered finger x-ray and when the x-ray result came R1 was sent to the local hospital emergency roiagnom on [DATE]. V25 stated when she saw and assessed the finger it looks like trauma to the finger, like someone banged or smashed the finger. V25 stated when she saw and assessed the finger it was already immobilized so she could not put a time frame on the injury. On 09/20/23 at 3:56pm, V2 DON (Director of Nurse's) stated the nurse's responsibility when a resident returns from a community pass is to complete an assessment and to make sure there was no abnormalities or injuries. The nurses should also chart the resident back into the system (Computer documentation). V2 stated that looking at R1's medical record, there was no documentation done. V2 stated. It is what it is. (V15) should have documented better. The facility housekeeping guideline documents, the purpose is to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors. Standards listed include the Administrator and Environmental Services Director will routinely make visual quality control observations to ensure a high level of sanitation is maintained. Trash will be removed from all areas of the facility daily and as needed to prevent spillage and odor. The facility policy titled Safety and Supervision of Residents presented with review date 9/2022 indicated the facility is striving to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The facility job description for Maintenance Director indicated the primary purpose of this job position is to plan, organize, develop, and direct the overall operation of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure the facility is maintained in a safe and comfortable manner. The facility job description for Maintenance Assistant indicated the primary purpose of this job position is to maintain the grounds.

Based on interview and record review the facility failed to follow physician orders, failed to timely renew a controlled substance prescription, and failed to administer (available) pain medication to one resident (R69) of 81 residents in the sample. These failures resulted in R69 sustaining pain rated 10/10 for several weeks. Findings include: R69's diagnoses include malignant neoplasm of colon and chronic pain. R69's Physician Orders include (1/31/23) Tramadol 50mg (milligrams) every 6 hours as needed for moderate to severe pain, and (7/29/22) Acetaminophen 650mg for general discomfort. (5/31/22) Pain assessment every shift. On 4/25/23 at approximately 10:35am, V69 alleged (during resident council meeting) that her (prescribed) Tramadol was unavailable at the facility. On 4/25/23 at 12:04pm, surveyor inquired about R69's Tramadol availability. V22 (Licensed Practical Nurse) stated, The Nurse Practitioner came yesterday and wrote a prescription that was faxed to pharmacy. We're waiting for them (pharmacy) to send it because we don't have it. Surveyor inquired if the facility had and emergency medication box. V22 responded, Yes, it's on the 1st floor. Surveyor inquired if Tramadol is in the emergency box. V22 replied, I'm not for sure. On 4/25/23 at 12:04pm, surveyor inquired about R69's current pain level. R69 stated, It's a 10. Surveyor inquired if V22 (currently assigned to R69) inquired about R69's pain level today. R69 responded, No. Surveyor inquired when Tramadol was last available. V69 replied, It was about 2 weeks ago. She's (Nurse) been giving me Tylenol extra strength and that ain't doing a [NAME] thing. The other day my right knee was hurting so bad I was contemplating surgery. Surveyor advised that most of R69's (April 2023) pain assessments were documented as 0 R69 replied, They didn't even ask me on the days they wrote those numbers cause it's always a 10. My back and my knees have chronic arthritis. R69's (April 2023) Medication Administration Record affirms Tramadol was last administered on 4/6/23 (roughly 3 weeks ago). On (4/22/23) R69's pain was rated 10 however Acetaminophen 650mg (prescribed for general discomfort) was administered. On 4/25/23 at 12:20 pm, surveyor inquired if Tramadol was available in the emergency medication box. V2 (Director of Nursing) referred to the list (hanging from the emergency medication box) and stated, Yes. V2 showed surveyor the medication list and affirmed that Tramadol 50mg (10 pills) are available. On 4/26/23 at 1:37pm, surveyor inquired about potential harm to a resident experiencing pain who does not receive Tramadol as prescribed. V40 (Medical Director) stated, It depends on what type of pain that the patient may have. They should take Tramadol on time. The attending physician needs to do the refill on time. Our protocol is we're (Physicians) in the nursing home every week, the staff need to let us (Physicians) know at least 3-4 days ahead of time. The pain management policy (reviewed 3/22) states pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management includes the following: observing for the potential for pain and implementing approaches to pain management. Observe, verify and confirm the resident's pain and consequences of pain at least every shift for acute pain or significant changes in levels of chronic pain and at least daily in stable chronic pain.

Based on observations, interviews and review of records the facility failed to protect the resident's right to be free from sexual abuse for 2 (R3, R4) out of 3 residents reviewed for abuse. The facility failed to place safeguards in place for both residents (R3, R4) after sexual abuse incident. Both residents (R3, R4) remained on the same floor accessible to each other. These failures resulted in 1 resident (R4) who is severely cognitive impaired, to be sexually touched by another resident (R3). Findings includes: R3 is [AGE] years old, initially admitted on [DATE]. R3's medical diagnosis includes Alcohol Dependence with Alcohol-Induced Persisting Dementia. R3's brief interview of mental status (BIMS) dated 12/20/2022 assessment reference date (ARD) was 6 which means R3 has moderate impairment with his cognition. R4 is [AGE] years old, initially admitted on [DATE]. R4's medical diagnosis includes Dementia, Delusional Disorder, and Wandering. R4's brief interview of mental status (BIMS) dated 01/04/2023 assessment reference date (ARD) was 0 which means R4 has severe impairment with her cognition. Per resident census provided by facility, R3 and R4 reside on the same floor. Observation showed R3 and R4 rooms were found on the same floor. On 03/21/2023 at 11:03 AM. R4 was seen walking back and forth the hallway wandering, going in and out of other residents' rooms. R4 was not able to respond to the questions asked within topic during interview. R4 was talking or mumbling but not able to make connection to the questions being asked. On 03/21/2023 at 11:10 AM. V5 (Licensed Practical Nurse) stated R3 uses wheelchair for ambulation. R3 can transfer independently from chair to bed, or from chair to toilet. R3 was seen in the hallway on his wheelchair able to wheel himself. R3 then went to the toilet and said that he would talk to writer after he is done. R3 then called writer to come into his room. R3 was calm and able to answer questions with yes or no at first. After R4 was mentioned and R3 was asked if he could speak English, R3 became agitated and did not want to answer questions. All questions were answered by R3 with No. On 03/21/2023 at 11:50 AM during lunch time R4 was observed in the dining room eating. On 03/21/2023 at 12:11 AM after lunch, R4 was seen approaching residents at different tables who were conversing. R4 was talking or mumbling words towards other residents. R4 was observed unable to converse with other residents due to her cognitive state. V8 (Certified Nursing Assistant) said, R4 walks around wandering, sometimes in and out of peoples' room. That is her usual routine. Even during nighttime, R4 does the same thing. On 03/21/2023 at 12:20 PM. R3 was observed sitting in his wheelchair near the entrance / exit of the dining room where R4 was after eating lunch. R4 was seen going near R3 mumbling / talking with R3 for a while until staff came and redirected R4. On 03/21/2023 at 02:25 PM. V3 (Certified Nursing Assistant/CNA) said, I saw it directly, I was taking care of a resident and when I came out of the room, I saw R3 at his door in a wheelchair and R4 was next to him (R3). R3 was holding R4's hand when R3 put R4's hand between his (R3) legs. Then I saw that the other hand of R3 was on R4's breast. Immediately I ran to them, and I told them it was not proper. I immediately reported to V5 (Licensed Practical Nurse) and V5 called the V4 (Social Worker) immediately. V4 went to 4th floor and spoke to V5. R3 can tell you his thoughts. R3's action is deliberate. If R3 tells R4 to do things, R4 will follow R3. Whatever R3 asked R4, R4 is going to do it. R4 does not know what she was doing. R4 cannot give consent to what R3 was making her (R4) do. On 03/21/2023 at 02:31 PM. V1 (Administrator) was informed that R3 and R4 were on the same floor and that it was observed R4 was routinely wandering everywhere on the floor. Due to proximity of both residents interaction could not be avoided. V1 said, I am new to this position, and I see what you mean. We think that R3 will have the same problem even if we transfer him into another floor but I think you are right, R3 needs to be transferred to avoid recurrence of the same incident. Yes, I agree with you that any person who is cognitively intact being touched by another person in a sexual way without his or her consent will feel violated. On 3/22/2023 at 12:30 AM. V11 (Social Service Director) said, I am aware of what happened between R3 and R4. R3 was being sexually inappropriate with R4. R4 was confused and cannot give consent. I know R4 cannot understand, but any reasonable person having the right cognition, will really feel violated and upset. On 3/23/2023 at 10:30 AM. V14 (Nurse Practitioner) said, R4 cannot give consent, she (R4) mumbles non-sensible words. I remember R4, she is the resident with short hair. In terms or medical needs, R4 is maintaining the same needs. R3 is Spanish speaking resident, sometimes I have medical students with me and R3 can answer with short sentences. If it happens to me what happened to R4, I would feel violated. On 3/23/2023 at 10 45 AM. V4 (Social Worker) said, I was the manager on duty (MOD), I was doing my rounds, checking how many CNAs and nurses were on each floor. Making sure everybody was where they are supposed to be. I was approaching the 4th floor when they told me what happened. V5 (LPN) told me to talk to V3 (CNA). V3 told me V3 witnessed R3 had his hand on R4's breast and proceeded to move R4's hand inside his pants. R4 has dementia, severely impaired, she did not respond. Yes, R4's orientation is 0. I talked to R3 with V3 (CNA) translating. I believe that R3 does know that he was wrong. R4 cannot give consent. Any reasonable person would feel bad. If it happens to me, I will surely feel really traumatized. We did a 3-day wellbeing. R3 and R4 were not seen by the psychiatrist or psychologist. Initial Facility Reported Incident dated 02/25/2023 with Final report dated 02/28/2023, in part reads: Witness statement confirmed that R3 was observed touching the breast of R4 and putting R4's hand on R4's penis. At the conclusion of this investigation, it is determined that unwanted touching is substantiated. R3's notes dated 02/25/2023 by V5 (LPN), in part reads: V5 was informed by staff that she (V5) witnessed R3 exhibiting inappropriate behavior towards another resident (R4). Signed interview of V3 (Certified Nursing Assistant), with V5 (Social Worker) taking the statement dated 2/25/2023, in part reads: V3 saw R4 in the doorway with R3 with one of his (R4) hands her (R3) breast and the other hand of R4 put R3's hand on his penis. Signed interview of V3 (Certified Nursing Assistant) with V4 (Social Worker) interviewer dated 2/25/2023, in part reads: R3 with his hand put R4's hand on his penis. R3's other hand was on R4's breast. Plan of Care of both R3 and R4 documents potential for abuse, to wit: R3's Care Plan reads in part as follows: - R3 can make decision regarding which activity that he enjoys dated 03/22/2023. - R3 was target of aggression and R3 becomes increasingly agitated or upset dated 04/04/2022. R4's Care Plan reads in part as follows: - R4 was target for sexual inappropriate behavior by another peer dated 02/25/2023. - R4 at risk for abuse related to physical and/or communication challenge as evidence by R4 being verbal but has difficulty communicating, rarely understood dated 10/09/2022. - R4 at risk for abuse related to behavior problem as evidenced by R4 wandering, has impaired cognition/dementia dated 10/09/2022. - R4 wandering in and out of peers' room dated 10/09/2023. - R4 socially inappropriate behavior urinates in inappropriate places dated 10/09/2022. - R4 inappropriate behavior, R4 likes to remove clothes in front of others dated 07/03/2022. Abuse Policy not dated, in part reads: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of resident from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. The facility prohibits abuse, neglect misappropriation of property, and exploitation of its resident, including verbal, mental, sexual, or physical abuse. Sexual abuse is non-consensual sexual contact of any type with a resident.

Based on review of records and interviews the facility failed to provide person-centered plan of care for resident who stayed in wheelchair for long period of time and failed to provide accurate assessment for a resident who acquired pressure ulcer in the facility for 1 out of 4 residents (R1) reviewed for improper nursing care. These failures resulted in 1 resident (R1) pressure ulcer to develop into stage 4 and become infected. Findings include: R1 is [AGE] years old, initially admitted on [DATE] and was discharged on [DATE]. R1's medical diagnosis includes paraplegia. Based on brief interview of mental status (BIMS) with assessment target date (ARD) 01/18/2023 scored 15 which means R1's cognition was intact. R1's active wounds at the time of discharge (02/04/2023) are as follows: - Left Achilles/posterior lower leg identified on 09/03/2022, categorized as vascular, arterial insufficiency. - Right Achilles identified on 01/05/2023, categorized as vascular, arterial insufficiency. - Right Ischial Tuberosity identified on 06/30/2022, categorized as pressure ulcer. Facility Wound Assessment for Right Ischial Tuberosity/Right Buttocks (Facility-Acquired) are as follows: - Initial assessment dated [DATE] pressure ulcer was classified as unstageable. Area of 7.00 centimeter squared. Necrotic Soft, Adherent Tissue 80% and Red/Bright Pink Tissue 20%. - assessment dated [DATE] pressure ulcer was classified as stage 3. Area 5.23 centimeter squared. Red/Bright Pink 90% and Deep Maroon 10%. V17's (Wound Doctor) assessment for Right Ischial Tuberosity/Right Buttocks (Facility-Acquired) are as follows: - assessment dated [DATE], 01/24/2023 and 01/31/2023 all reads in part as follows: The wound is currently classified as Category/Stage 4 wound with etiology of Pressure Ulcer and is located on the Right Ischial Tuberosity. There is muscle and fat layer (Subcutaneous Tissue) exposed. Per National Pressure Ulcer Advisory Panel (NPUAP) dated 2016 definition of Stage 4 Pressure Ulcers are as follows: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. On 03/23/2023 at 01:15 PM. V7 (Wound Coordinator / Licensed Practical Nurse) said, We did not follow what is charted by V15, because when I asked V16, she said that we will follow our inhouse doctor (V17). We do not use doughnut. R1 does not listen, R1 stayed on the wheelchair for a long time. When asked to be repositioned, R1 refuses. V7 was asked if the identified problem of R1 sitting on the wheelchair for prolonged time was addressed or care planned. V7 said, I don't have specific documentation or care plan about R1 sitting on his wheelchair for a long period of time. I just notice that my assessment for R1's Right Ischial Tuberosity was stage 3 and V17's (Wound Doctor) assessment was stage 4. I think I missed that; it should have been stage 4. I think V17 did a debridement that is why it was staged as stage 4. V7 was reminded that her assessment was dated 02/02/2023 and V17's assessment was dated 01/31/2023. After V17 did debridement, the wound became lowered in stage from 4 to 3. V7 said, I am not sure it may be a simple debridement. Yes, debridement is performed by V17 in the facility. R1's care plan by V7 (Wound Coordinator / Licensed Practical Nurse) dated 10/31/2022 (Pressure Ulcer was identified 06/30/2022) for Right Ischial Tuberosity/Right Buttocks pressure injury under interventions, in part reads: Monitor for infection - Peri-wound erythema- increased drainage and increased pain, peri-wound swelling, exposed bone, pressure wound deterioration. R1's notes dated 12/09/2022 by V16 (Nurse Practitioner) reads: V10 (Wound Nurse / Licensed Practical Nurse) reported that R1 is having foul smell discharge from wound from last 2 to 3 days. Evaluated wound with V10, noted pus discharge. Kept on antibiotic Doxycycline 100 MG for 10 days. V16's order dated 12/09/2023 are as follows: Doxycycline Antibiotic Oral Tablet 100 MG, give 1 tablet by mouth every 12 hours for wound infection - right ischial, foul smell for 10 days. R1's notes dated 01/03/2023 by V15 (Licensed Practical Nurse) reads: R1 returned from appointment at Wound Care Clinic Medical Doctor with wound care order: Keep pressure off wounds. Wound are caused by undue continual pressure. Sit on a doughnut devise to offload pressure from wounds when resting. On 03/23/2023 at 01:55 PM. V7 said, We did not follow what is charted by V15, because when I asked V16 she said that we will follow our inhouse doctor (V17). We do not use doughnut. R1 is not compliant, he sits on his wheelchair for a long time and will not listen. V7 was asked if R1 being not compliant was addressed, since R1 developed and worsen and even got infection on his Right Ischial Tuberosity/Right Buttocks pressure ulcer. V7 said, I might have a care plan. Later V7 said, I don't have a care plan specific to R1 being non-compliant and sitting on his wheelchair for a long time. On 03/23/2023 at 2:45 PM. V16 (Nurse Practitioner) said, V10 (LPN) called me and told R1 was having funky smell on the wound or bad smell on the wound for 2 to 3 days. I did an assessment, V10 opened the dressing, and then I pressed on the wound, blood was coming out. Ordered antibiotics for the wound's foul smell. The order for antibiotic was for R1's wound infection. I saw he has been sitting longer in wheelchair. R1 needs to be repositioned, frequently changing diaper to avoid moisture, even stool can go inside, dressing also needs to be changed often. All of these can be done by facility so its avoidable. I want to cover everything to avoid septicemia because there is also pus coming out of R1's suprapubic area, R1 has suprapubic catheter and also in his penis. On 03/24/2023 at 10:34 AM. V17 (Wound Doctor) said, Yes, I saw R1's Right Ischial Tuberosity pressure ulcer. When there is foul smelling on the wound we consider infection, but there are many factors that may cause foul smell. Like bowel movement if the resident is incontinent. Pus discharges, some may look at discharges and may call it pus, but it is not pus. But if it is genuinely pus, it means contamination or infection. In my current assessments, I staged the wound as 4 because of exposure of muscle or necrotic muscle tissue. I am not comparing my initial assessment on 07/05/2022 to my assessment on 01/31/2023. Prolonged sitting on the wheelchair can cause worsening of R1's pressure ulcer. That is why offloading is necessary. The origin of R1's pressure ulcer was pressure to the specific part of his body. That is why it is called pressure ulcer. I did not know if R1 got it before he came in the facility. V17 was informed that per R1's documentation it was facility acquired. V17 said, Oh, well those wounds are caused by prolonged pressure. Per facility policy for Wound Evaluation and Documentation dated as revised 12/19, in part reads: When the Wound Care Team assesses the resident, they will take a photo, complete Braden, measure the wound, review the orders, and update any notes and care plans as appropriate.

Based upon observation, interview and record review the facility failed to follow the skin management policies, failed to transcribe physician orders correctly, failed to follow physician orders, failed to provide timely wound care and failed to offload wound for one of five residents (R5) reviewed for pressure ulcers. These failures resulted in R5's (stage 4) coccyx pressure ulcer exposed (without a dressing) and increased depth of R5's coccyx wound. Findings include: On 2/9/23 and 2/17/23, IDPH (Illinois Department of Public Health) received concerns regarding pressure ulcers. The (2/21/23) facility wound report affirms R5 has a stage 4 coccyx pressure ulcer. R5's (2/10/23) assessment for potential skin integrity impairment determined a score of 12 (high risk). R5's (1/27/23) BIMS (Brief Interview Mental Status) determined a score of 11 (moderately impaired). R5's (1/27/23) functional assessment affirms (1 person) physical assist is required for toilet use and (2 person) physical assist is required for bed mobility. R5's care plan includes (1/20/23) resident is incontinent of bowel and bladder requires total assist from staff. (1/21/23) Resident has pressure injury, site: coccyx. Intervention: pressure redistribution mattress. Remind/assist resident to reposition frequently. (1/30/23) Resident requires assistance with bed mobility. On 2/21/23 at 1:11am, R5 was lying atop of a LALM (Low Air Loss Mattress) on his back and there were no repositioning devices present. An incontinence brief, 4 sheet layers and a pad were between R5 and the LALM. R5 affirmed he has a wound On my backside, however was unsure of treatment frequency. V7 (Certified Nursing Assistant) affirmed she was assigned to R5 and just returned from lunch break. V7 removed R5's incontinence brief (as requested). The (stage 4) sacrum wound was exposed, there was no dressing present. Surveyor inquired about R5's dressing. V7 stated, There's not one on there now. Surveyor inquired if V7 told the Nurse that R5's dressing was off. V7 responded, I didn't see anyone today and didn't tell them. If there's not one on there, I try to find someone to put one on. I didn't get a chance to tell the wound Nurse. R5's (2/21/23) coccyx dressing administration was documented on the TAR (Treatment Administration Record) at 5:28pm (over 4 hours after surveyor observation). On 2/22/23 at 9:44 am, R5 was lying atop of a LALM on his back and there were no repositioning devices present. An incontinence brief and 4 sheet layers were between R5 and the LALM. Surveyor inquired when R5's incontinence brief was last checked and/or changed R5 stated, Last night, evening time. On 2/22/23 at 9:47 am surveyor inquired about R5's coccyx treatment orders. V6 (Wound Care Nurse) accessed the EMR (Electronic Medical Record) and stated he has dressing changes Monday's, Wednesday's, Friday's, and PRN (as needed). Surveyor inquired if changing dressings only 3 times weekly would be appropriate considering R5 is incontinent of bowel and bladder and has a stage 4 (open) coccyx wound. V6 responded, It's whatever the Doctor says, I really couldn't tell you that. I would have to get the order from the Doctor. It all depends on whatever the Doctor decided. On 2/22/23 at 9:50 am, V17 (Certified Nursing Assistant in Training) affirmed that she's currently assigned to R5. Surveyor inquired when R5's incontinence brief was last checked and/or changed. V17 stated, I haven't changed him. I don't know if anybody's changed him or not. A student is coming to do him. V17 proceeded to exit the room. On 2/22/23 at 10:01 am, surveyor inquired what's allowed on top R5's LALM (while in use). V6 responded, It's either a sheet and a diaper or a pad and diaper, you can only have 2. Surveyor inquired how many sheet layers were currently beneath R5. V6 responded, Look like it's four and he has the diaper. Surveyor requested to inspect R5's sacrum wound. V6 pulled back the sheet and stated, Oh, my God. He (R5) had a bowel movement, it came a little bit outside you can see it. R5 had bowel movement on his thighs, sheet and mattress. V6 removed R5's sacrum dressing and stated, He got poop up under there, it's under the rim. Thank God it's not on the wound. On 2/22/23 at 2:27 pm, surveyor relayed that both times surveyor observed R5 he was lying on his back. V2 (Director of Nursing) stated, He should be getting repositioned. Surveyor inquired about appropriate wound care orders for residents with stage 4 wounds. V2 responded, It actually just depends on whatever the order the doctor gives. I just had a meeting last Friday (2/17/23) with the wound care coordinator (V16) to make sure the residents have appropriate treatment orders. So, I just asked her (V16) if she can go through all the wounds for me and let me know if she felt that everybody is getting the appropriate treatment and she (V16) told me she would. She (V16) hasn't gotten back to me yet. Surveyor inquired if treatments prescribed only 3 times weekly is appropriate for an incontinent resident with a stage 4 (open) coccyx wound. V2 replied, I'm not a wound care nurse, so I really can't answer that question. R5's (2/7/23) physician order details (per wound assessment) state coccyx: cleanse wound with saline, apply skin prep, apply silver alginate, cover with dry dressing change (daily) and prn. Complicating factors affecting wound healing and prevention include impaired mobility - reposition every 2 hours. Incontinence - evaluate every 2 hours. R5's (2/7/23) physician orders affirm coccyx treatments were entered in the electronic medical record to be changed daily Monday, Wednesday, Friday and PRN (not daily as prescribed). R5's (February 2023) TAR affirms coccyx treatments were administered on Monday, Wednesday and Friday (not daily as prescribed). On 2/27/23 at 3:41 pm, surveyor inquired about the required frequency for (open) stage 4 coccyx wound treatments. V21 (Physician) stated, It depends on how much drainage it is. Once a day is ok if it's not that much drainage, but the standard will be once a day. Surveyor inquired about potential harm to an incontinent resident with stage 4 (coccyx) wound, without a dressing in place. V21 responded, In that case, it is possible that the urine or the stool can go to the wound and the wound can get infected. R5's (2/17/23) coccyx wound assessment includes exudate: light serosanguinous. Undermining present. Tunneling unknown. 3.1 x 2.5 x 0.7cm (centimeters). R5's (1/20/23) initial wound assessment affirms the wound measured 5.0 x 4.5 x 0.5cm therefore the depth increased 0.2cm. [Wound undermining occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface]. The skin management: specialty mattress policy (reviewed 3/22) states limit the amount of linen placed between the support surface and the resident. The skin management: dressing application policy (reviewed 1/22) states dress wound as directed.

Based upon observation, interviews and record review, the facility failed to follow the facility Falls Management Policy, failed to provide supervision, and failed to address injuries of unknown origin in a timely manner for one of four residents (R13) reviewed for falls. The facility failed to ensure hazardous chemicals were stored in a locked area and not accessible to four of 18 residents (R8, R9, R10, R11) in the sample. These failures resulted in R13 sustaining a fracture to the right fifth metacarpus and distal ulna on 1/19/23 and has the potential to affect 62 (2nd floor) residents reviewed for hazardous chemicals. Findings include: R13 is an [AGE] year-old with diagnosis including but not limited to: Dementia, Wandering, Persistent Mood Disorder, Disorientation, Encephalopathy, Long Term use of Anticoagulants, Unspecified fall and Fracture of right femur. R13 was admitted [DATE]. R13's 2/14/23 BIMS (Brief Interview for Mental Status) states, 'Resident is rarely/ never understood' and Daily Decision Making is Severely Impaired. R13's 9/18/21 fall risk assessment determined a score of 14 (moderate risk) and includes multiple falls. On 1/19/2023 initial facility reported incident states writer noted patient in wheelchair with a small abrasion with scant bleeding to right eyebrow. Third finger with broken nail and scant amount of blood. Resident unable to give description. Nurse Practitioner made aware with new orders for left hand/wrist x-ray. R13's 1/19/23 incident report includes level of pain 3. R13's 1/19/23 progress notes affirm stat left hand/wrist x-ray was ordered. R13's left wrist x-ray date of service was 1/23/23 (4 days later). Acute fracture of the distal ulna and 5th metacarpus are inclusive. On 2/23/23 at 10:50 am surveyor inquired about the 1/19/23 incident. V2 (Director of Nursing) said, R13 had a fall that was unwitnessed. We didn't send him out but the facility NP (V19) went up and assessed R13. The x-ray company lets us know that sometimes, due to availability, stat x-rays are not always done on the day ordered. The x-ray may be done on the next day. R13's x-rays were done on 1/20/23. I reached out to the x-ray company on 1/20/23 to get the results and was told that their files were corrupted and unreadable. I was told that the company would have to come back out and do another x-ray. On 1/23/23, I followed up with the x-ray company again about R13's x-ray and was finally given results via computer. Per the x-ray, R13 had a left wrist and left third finger fracture. R13's fall risk assessments exclude 1/19/23 fall risk assessment post fall. On 2/23/23 at 12:15 pm, V20 (R13's daughter) said, R13 hurt himself in the facility but we don't know how. R13 fractured his Left wrist somehow. R13 falls a lot here. I don't think that R13 knows how to use the call light or call for help. Surveyor observed, R13 was verbally unresponsive at this time. On 2/23/23 at 12:35 pm, surveyor inquired about the 1/19/23 incident. V18 (Unit Manager) said, I noticed R13 propelling down the hallway bleeding from his finger. R13 was also holding his wrist. V19 (Nurse Practitioner) came to assess R13 and ordered stat x-rays. V19 did not send R13 out to the hospital at that time. Sometimes when we order stat x-rays, the company does not come until the next day depending on their availability. R13 was sent out to hospital on 1/22/23 because R13 appeared to have a GI (Gastrointestinal) bleed (therefore x-ray was obtained after hospital admission). On 2/23/23 at 1:45pm V19 (Nurse Practitioner) said, the Dementia floor Manager (V18) called me on 1/19/23 and said that a patient had an injury. V18 was not sure where the injury came from but said that R13 was bleeding from his finger and holding his wrist. I assessed R13 and ordered stat x-rays and pain medication. I did not feel the need to send R13 to the hospital at that time. When I re-evaluated R13 on 1/20/23, I realized that the x-ray results had not been received yet. On 2/23/23 at 3:00 pm, V1 (Physician) said the potential risks for unwitnessed falls or injuries or unknown origin could result in possible head injury. Generally, I ask if the patient is having symptoms and I consider the Nurses' judgement prior to sending a patient to the hospital. For joint pain, I recommend sending the patient out to the Hospital because getting an x-ray at the facility can take long and it may be a time sensitive event. If there is a fracture, it should be treated as soon as possible. Patients with injuries of unknown origin may be at increased risk of hematoma if taking an anticoagulant (blood thinner). On 2/27/23 at approximately 3:00pm, the IOUO (injury of unknown origin) policy was requested however the IOUO investigation policy (reviewed 6/21) was received. The IOUO investigation policy excludes required actions of the facility staff. The falls management policy (reviewed 6/22) states a fall risk will be completed on admission, readmission and quarterly, with each significant change and after each fall. 32819 The (2/20/23) census includes 62 (2nd floor) residents. R8, R9, R10 and R11 reside on 2nd floor. On 2/21/23 at approximately 1:26pm, wallpaper paste remover, (brand name) disinfectant bleach wipes, disinfectant cleaner, joint compound and paint cans were observed atop of an (unattended) utility cart in the 2nd floor hallway. A large bag of foaming alcohol hand sanitizer and (brand name) disinfectant bleach wipes were also observed atop of a housekeeping cart in the (2nd floor) hallway. R8, R9, R10 and R11 were in the hallway at this time (near both carts). Surveyor inquired where unattended chemicals should be stored. V9 (Housekeeping) removed disinfectant cleaner from an (unlocked) compartment on the housekeeping cart and stated, I put em (sic) down here. Surveyor inquired if V9 has a key to the housekeeping cart. V9 responded, My boss have a key. Surveyor inquired (again) if V9 has a key to the housekeeping cart. V9 replied, No. R8's (12/30/22) BIMS (Brief Interview Mental Status) determined a score of 12 (moderately impaired). R9's (2/1/23) BIMS determined a score of 8 (moderately impaired). R9's diagnoses include Alzheimer's disease. R10's (2/6/23) BIMS determined a score of 10 (moderately impaired). R11's (11/07/22) BIMS determined a score of 15 (cognitively intact). On 2/21/23 at 1:32pm, V10 (Maintenance) was observed painting the hallway. Surveyor relayed concerns regarding chemicals left unattended on the utility cart. V10 alleged he was watching the cart, however the utility cart was at the opposite end of the hallway. Surveyor inquired how V10 was watching the utility cart while (facing the wall) painting. V10 stated, I am watching it because I'm right by it. It's in my peripheral. Surveyor inquired what peripheral means. V10 responded, Peripheral means I can see it. I don't know if you know but some people can chew bubble gum and walk at the same time, like I can. Surveyor inquired what V10 was doing prior to interview. V10 stated, I'm painting the wall. On 2/22/23 (the following day) at approximately 9:38am, a large bag of foaming alcohol hand sanitizer was observed (again) atop of an (unattended) housekeeping cart in the 2nd floor hallway (near room [ROOM NUMBER]). R10 was in the hallway near the housekeeping cart at this time. The (undated) housekeeping equipment policy states proper attention should be given to daily use and storage of all items. Each cart should be kept locked.

Based on observation, interviews and record review the facility failed to follow the facility policy and the Minimum Data Set (assessment) to ensure the correct number staff are providing physical assistance to residents. This affects 2 out of 3 (R1, R2) for a total of 3 residents reviewed for safety. These failures resulted to R1 sustaining a C6 neck fracture and R2 being left unattended and at risk for falls. Findings include: On 9/29/2022 R1, R2, and R3 were reviewed for the allegation of facility's failure to provide safety that resulted to resident injury. R1 was not in the facility during survey review. Per clinical progress notes: R1 fell on [DATE] and was sent to the hospital. Per CT scan result, R1 had a C6 fracture. Notes written by V4 (Nurse Practitioner) include: R1 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of [CONDITION(S)] and [CONDITION(S)] following Cerebral Infraction affecting left non-dominant side. On 9/29/2022 at 11:44 AM. V4 stated, I was the one who sent R1 out. Staff told me R1 fell on the floor and hit his knees. When I talked to R1, he said that he slightly hit his head on the drawer of his right side. R1 said also he hit his knees. I was not happy because R1 was taking 2 blood thinners medicine and had nausea and dizziness for 2 hours. Yes, the drawer was on R1's right side. R1 has medical diagnosis of [CONDITION(S)] with left sided weakness on both upper and lower extremities. R1 requires total assistance for all care. I don't know how it was possible for R1 to turn to his right when he has weakness on his left. An investigation must be done. Yes, as a result of the fall, R1 has a neck fracture. On 9/29/2022 at 12:22 PM, V2 (Director of Nursing) stated, There was only 1 Certified Nursing Assistant helping R1 at that time which was V7. A fall could have been avoided if the MDS assessment was followed and 2 staff assisted. R1 was being cleaned by V7. V7 was turning R1 on his right side when R1 fell . I think R1's dominant side is his left. After reading R1's medical diagnosis V2 stated, Oh, I mixed it up his weakness is on his left side. I think you are right; it would not be possible for him to turn to his right and fall by himself. Yes, the fall could have been avoided if there were 2 staff helping R1. On 9/29/2022 at 12:40 PM, V11 (Restorative Nurse) said, R1 needs total, or at the very least, extensive assistance with 2-persons for bed mobility and transfers. R1 wouldn't be able to turn to his right because he has left sided weakness. R1 has medical diagnosis of [CONDITION(S)] or [CONDITION(S)]. It would not be possible. Yes, R1 needs 2-persons helping him during incontinence care. On 9/29/2022 at 6:28 PM, V3 (Licensed Practical Nurse/LPN), stated she was the nurse assigned to R1 and that she was informed by V7 (Certified Nursing Assistant) that R1 fell when he was reaching for something. V3 stated she does not know R1's capacity related to bed mobility and V3 is not familiar with R1's activities of daily living (ADL). On 9/29/2022 at 6:52 PM, V7 (Certified Nursing Assistant) said, Yes, I was the CNA (Certified Nursing Assistant) that was present when R1 fell . I was changing him, turning him to his right side of the bed. R1 was trying reach and grab on to the closet or drawer with his right hand and he fell . I was not sure if R1 hit his head. I think he said no when I asked if he hit his head. R1 was on the floor, and it is hard to describe but he was like in a fetal position. R1's head was near the closet or drawer. I (V7) always perform incontinence care with R1 by myself. Every time I perform incontinence care or transfer residents, I 'kind of' assess them to see if I can do it by myself. It is also always a good thing if another CNA will help me. I agree, R1's fall could have been prevented if another CNA was helping me. R1's Minimum Data Set, dated dated dated [DATE] under functional status, documents R1 needs 2-person physical assistance, total dependence on bed mobility and transfers. R1's care plan dated 10/4/2021 states: self-deficit and assistance with ADLs identified problem. The use of mechanical lift on all transfers for intervention. Care plan dated 7/22/2022 modified on 9/14/2022 states, limited physical mobility and generalized weakness identified problem. Care Plan dated 10/4/2021 modified on 9/14/2022 states, decreased ability to transfer self from wheelchair to chair/bed due to decreased functional mobility and generalized weakness. Related to left side [CONDITION(S)]/[CONDITION(S)]/contracture. Requires mechanical (Hoyer) lift 2-person assist. On 9/29/2022 at 11:28 AM, writer observed a walker in R2's room and R2's bed in low position. There was no occupant on R2's bed. R2 was found on toilet alone. V6 (Licensed Practical Nurse) was asked if it was safe for R2 to be in the toilet by himself. V6 said, Oh yes, he (R2) can go to toilet by himself. He does not need help. He does not need assistance when in the toilet. R2's MDS dated [DATE] states, functional status R2 needs 1-person assist on toileting. Per R2's Fall Event dated 2/26/2022 by V9 (Registered Nurse), R2 had a fall which R2 stated he hit his head. R2's care plan dated 3/23/2020 revised on 7/20/2022 identifies fall as a problem due to poor safety awareness and impulsiveness. Intervention includes allowing nursing staff to assist with transfers to ensure safety and for R2 to ask staff for assistance. On 9/29/2022 at 12:22 PM, V2 (Director of Nursing) was informed R2 was left alone in the toilet even though per R2's assessment, R2 needs assistance during toilet. V2 stated, I have to check on this, nursing staff needs to follow the residents' assessments. I need to in-service both nursing staff and MDS (Minimum Data Set) staff. Facility's Fall Management guidelines dated 6/21/2022 in part reads: Facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. The facility will identify and evaluate those residents at risk for falls, plan for prevention strategies, and facilitate as safe an environment as possible.

Based on interview and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affects 5 (R1, R2, R3, R4, R5) of 5 residents reviewed for care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] These failures resulted in R1, who was sent to the hospital emergency room with a pre-existing gangrene wound, being diagnosed with Diabetic Ketoacidosis with Coma Associated with Type 2 Diabetes. R1 was admitted to the Intensive Care Unit. The Facility's failure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . While the immediacy was removed on 2/10/2022, the facility remains out of compliance at a severity level 2. Findings include: 1. R1's face sheet shows that R1 is a [AGE] year old resident originally admitted on [DATE] and readmitted on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's wound care progress notes dated 2/1/20 at 9:16pm written by V11 (Registered Nurse/RN) documents that R1 was admitted with diabetic foot ulcers on the right and left feet. On 1/26/22 at 11:45am, V2 (Director of Nursing/DON) presented R1's complete care plan. Upon review, there was no care plan to address R1's Diabetes. On 1/26/22 at 12:10pm, V12 (Care Plan Nurse) was asked about R1 being care planned for Diabetes. V12 went through R1's records and stated that there was no care plan for R1's Diabetes. V12 stated, Floor Nurses usually put in the initial care plan, and I do the quarterly reviews. The old care plan from the previous admission is there, but when he (R1) was readmitted on [DATE], the floor nurse did not re-activate the diabetes care plan, so it did not come through. He (R1) should have a care plan for Diabetes but somehow it was missed. On 1/25/22 at 3:08pm, V3 (Hospital Case Worker) documented that on 1/19/2022, R1 arrived in the Hospital emergency room with Diabetic Ketoacidosis, Lactic Acidosis, and other medical issues. On 1/26/22 at 4:30pm, V3 stated that R1 was still admitted to the ICU (Intensive Care Unit) of the hospital. On 2/2/22 at 10:51am, V13 (Hospital Social Worker) stated that R1 was discharged from the hospital and sent to another nursing home. R1's Hospital emergency room records dated 1/19/22 document the following: (Patient Information) shows the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/23/22 at 5:33pm, V4 (Hospital Physician) wrote in part: I have seen, examined, and evaluated the patient. Patient is a [AGE] year old nursing home resident with a history of Hypertension, [CONDITION(S)] ([CONDITION(S)]) and Diabetes Mellitus. Patient presents with tachypnea (abnormally rapid breathing) to the Emergency Department and is subsequently intubated, mechanically ventilated. Patient presents with Lactic Acidosis of 18, [CONDITION(S)] 339 (abnormal level) and Beta Hydroxybutyrate 5.2 (abnormal level), Multi-system Organ Dysfunction, Etiology appears likely to be initially due to Diabetic Ketoacidosis which patient likely experienced at the nursing home, Patient likely experienced osmotic diuresis due to elevated blood sugars with resulting AKI (Acute Kidney Injury), Patient's AKI secondary to osmotic diuresis associated with ketoacidosis at the nursing home, We will proceed with the DKA (Diabetic Ketoacidosis) Protocol. On 1/31/22 at 1:24pm, V9 (Facility's Physician for R1) was asked for his professional opinion about the possible effects of not checking blood glucose levels and administering insulin to a resident according to doctor's orders, as well as possible complications. V9 was also asked about the possible complications if a diabetic resident did have blood glucose monitoring or insulin administered as scheduled. V9 stated, The complications of uncontrolled blood sugars could be infections, diabetic feet, diabetic ketoacidosis, hyperosmolar state or coma. If the sugar is very high, the patient will get infection sooner than others. High sugars weaken the immune system. If the patient has diabetic ulcer or pressure ulcer, there will be infection on the wound and it will delay the healing. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS dated 7/13/2021 documents the following: Insulin NPH Suspension100 units per ml (milliliters) Inject 30 units subcutaneously one time a day related to Type 2 Diabetes. R1's POS dated 11/28/2021 documents: [MEDICATION(S)] R Solution 100 units per ml. Inject as per sliding scale subcutaneously two times a day for Diabetes. R1's MAR (Medication Administration Record) for 11/1/21 to 11/30/21 showed that R1 did not get the scheduled blood sugar check and scheduled insulin at 9am on November 2, 3, 4, 8, 10, 16, 17, 18, 19, and 23, 2021. R1's MAR (Medication Administration Record) for 11/1/21 to 11/30/21 showed that R1 did not get the scheduled blood sugar check and scheduled insulin at 8pm on the November 1, 3, 4, 5, 7, 9, 11, 12, 15, 19, and 24, 2021. R1's MAR (Medication Administration Record) for December 2021 showed that R1 did not get the scheduled blood sugar check and scheduled insulin at 9am on December 2, 4, 6, 16-20, 22-27, and 29- 31, 2021. R1's MAR (Medication Administration Record) for January 2022 showed that R1 did not get the scheduled blood sugar check and scheduled insulin at 8pm on January 1, 7, 11, 12, 14, 15, 17, and 18, 2022. On 1/26/22 at 1:58pm, V2 (Director of Nursing) was interviewed about the procedure for nurses to record blood sugars and insulin doses that residents refused. V2 stated that there is a chart code on the MAR for when a resident refused any medication, and that the MAR box should not be left blank for any reason. V2 added that she (V2) was not aware that nurses were missing blood sugar checks and insulin administration, and that she appreciates that the State Surveyor brought this to her attention. V2 stated that she (V2) would start to in-service the nurses about this. On 2/2/22 at 1:48pm, V2 was interviewed about the facility's practice for blood sugar monitoring and insulin administration both in general and specifically for R1. V2 stated that there is usually a blood sugar check before the scheduled insulin will be given. V2 stated that R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 added that if the nurse could not check the blood sugar or could not administer the insulin because the resident refused, the nurse should document it in the MAR and progress notes and also notify the doctor. On 2/1/22 at 3:11pm, V10 (Registered Nurse/RN) was interviewed about R1's condition on 1/19/2022 when V10 called 911 and sent R1 to the emergency room . V10 stated that at R1's baseline, R1 was someone who moved independently with his wheelchair and would also go around by himself. V10 stated R1 would normally use the call light to ask staff for assistance. V10 stated when V10 saw R1 in bed with a bowel incontinence episode and labored breathing, V10 checked R1's vital signs. V10 stated R1's oxygen saturation was 44 percent, heart rate (pulse) was 22, and respiration was 32. V10 stated he knew it was an emergency, and he called 911 immediately. V10 was asked about checking and recording residents' blood sugars and giving insulin to residents, and whether or not R1 was refusing blood sugar checks and insulin. V10 stated that R1 did not refuse blood sugar checks or insulin for V10, but V10 could not tell if R1 refused for other nurses. V10 added that if a resident refuses blood sugar check or insulin, as well as any other medication, it should be documented on the MAR or in the progress notes, and the doctor and family should be notified. R1's progress notes dated 1/19/22 at 01:37 written by V10 corroborates the above interview with V10. R1's progress notes from October 2021 to current date were reviewed. There was no record that R1 refused blood sugar checks or insulin, and no record that R1's physician or family was notified of R1's refusal of blood sugar checks or insulin administration. 2. R2's POS dated 7/25/21 documents: Insulin [MEDICATION(S)] Solution 100 units per ml (milliliters) 46 units subcutaneously at bedtime (9pm). R2's MAR for 12/1/21 to 12/31/21 shows missing entries for scheduled blood sugar checks and scheduled insulin at 9pm December 10, 13, 14, 18, 19, 23, 24, and 28, 2021. R2's MAR for January 2022 also shows missing entries for January 1, 2, 5, 6, 11, 16, and 21, 2022. On 1/26/22 at 1:36pm on the third floor, V6 (Licensed Practical Nurse/LPN) stated R2 takes her insulin and blood sugar checks religiously, and R2 does not refuse. V7 (Unit Manager) also stated that R2 is very compliant with insulin and blood sugar checks. R2's Care plan dated 5/13/2019 states that R2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention states in part: Glucose Monitoring, Diabetes medication as ordered by the doctor. 3. R3's POS dated 12/22/2021 documents: Insulin [MEDICATION(S)]-yfgn Solution 100 units per ml (milliliters) 11 units subcutaneously one time a day (9am). R3's MAR shows a missing entry for January 8, 2022. R3's January 2022 MAR also shows missing blood sugar checks at 5pm and 9pm for January 1, 5, 13, 14, 20, and 21, 2022. On 1/26/22 at 1:48pm on the second floor, V8 (LPN) stated that R3 does not refuse blood sugar checks or insulin. R3's Care plan dated 11/15/2021 documents that R3 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention states in part: Give Diabetes medication as ordered by the doctor. 4. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MAR for 12/1/21 to 12/31/21 shows missing entries for scheduled blood sugar checks and scheduled insulin at 9pm on December 10, 13, 14, 18, 19, 22, 23, 24 and 28, 2021. R4's MAR for 1/1/22 to 1/23/22 shows that R1 did not get the scheduled 9pm blood sugar check and insulin on January 1, 2, 5, 6, 7, 9, 13, 14, 16, and 21, 2022. On 1/26/22 at 1:36pm on the third floor, V6 (LPN) stated R4 usually takes his insulin and blood sugar checks and does not refuse. R4's care plan dated 3/6/2015 documents that R4 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention states in part: Glucose monitoring. 5. R5's POS dated 11/30/21 documents [MEDICATION(S)] Solution 100 units per ml (milliliters) 14 units subcutaneously at bedtime (9pm). R5's MAR for 12/1/21 to 12/31/21 shows missing entries for 9pm on December 3, 4, 5, 8, 12, 14, 17-23, 25-29, and 31, 2021. There were also missing entries for January 1-6, 8-11, 13-17, 21, and 23-31, 2022. On 1/26/22 at 1:31pm on the fourth floor, V5 (LPN) was interviewed regarding R5's blood sugar checks and insulin administration. V5 stated that R5 does not talk, does not refuse any medication, and does not refuse blood sugar checks. R5's care plan dated 11/26/2018 states that R5 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention states in part: Glucose monitoring. Facility Medication Administration policy, dated 7/14, states in #18: If medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider. Facility Charge Nurse document states under Duties and Responsibilities: Drug Administration Functions: Prepare and administer medications as ordered by the physician. Sign and date all entries made in the resident's medical record. Facility Insulin Administration policy, dated 10/03 and revised 7/14, documents in #9: Record on the MAR that insulin was given and site, rotating the site. Facility Blood Glucose Monitoring policy, dated 11/2018 and revised 11/2019 and 5/2021, documents in #12: Refer to any Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 (Administrator) was informed of the immediate jeopardy on 2/8/2022. On 2/14/22, the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the immediate jeopardy: 1. On 2/14/22, V2 (Director of Nursing) presented the list of all residents in the facility that have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This list includes R2, R3, and R4. A review of the MAR (Medication Administration Records) and POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes for all three residents also showed that the Nurse Practitioner assessed the residents for possible adverse effects of missing blood sugar checks and insulin administration. R1 and R5 were currently not at the facility. 2. R2, R3, and R4 were observed on the nursing units with no concerns. Progress notes of R2, R3, and R4 showed that they were assessed by the Nurse Practitioner (NP) regarding missed blood glucose monitoring and insulin administration, and there were no adverse outcomes related to missing blood sugar monitoring or insulin medication administration. 3. On 2/14/22, four nurses at the facility were observed and interviewed as follows: V17 (Licensed Practical Nurse/LPN) and V8 (LPN) on the second floor, V16 (Registered Nurse/RN) on the third floor, and V5 (LPN) on the fourth floor. These nurses were interviewed regarding the in-services and the specific interventions the facility mentioned in the Removal Plan presented. All four nurses stated that last week, they were re-trained on Diabetes Monitoring, Insulin Administration, Documentation, and Notification procedures to follow in case a resident refuses blood sugar check and insulin administration. 4. Records of staff in-services conducted on 2/8/22 and 2/9/22 were reviewed that showed that Nurses were in-serviced by V2 (Director of Nursing) on timely monitoring of blood sugars and administering insulin to residents as ordered. 5. Records were reviewed of random daily medication audits to ensure blood sugars and administration of insulin medications were completed and passed as ordered by Health Care Providers. Also, medication administration audit was completed from the previous day to ensure there were no missed or late medication administration. 6. The facility presented an updated care plan for residents who had missed blood sugar checks and insulin administration. These were reviewed w

Based on interview and record review, the facility failed to safely transfer one resident (R2), while using the mechanical lift, subjecting this resident to leg fracture. This failure affects one of three residents reviewed for falls in a total sample of three residents. This failure resulted in R2 suffering an acute fracture of his right leg bone. Findings include: R2 is an [AGE] year-old male. R2's diagnoses include weakness, fracture of the right leg bone, severe [CONDITION(S)] disc disease, severe arthritis, and weakening of his bones. Review of R2's Minimum Data Set (MDS) dated [DATE], notes that R2's is alert and oriented. R2 is a two person assist with transferring. Incident report dated 06/21/2021, notes R2 stated V4 (CNA) bumped his right leg against the mechanical lift during transfer. R2 complained of mild pain. X-ray ordered. X-ray noted right leg fracture. The x-ray documents severe arthritis to both of his hip joints and his lower spine. On 08/04/2021, at 5:30PM, V2 (Director of Nursing) stated, R1 has [CONDITION(S)] bone disease in both joints and other bone disorders. After I reviewed everything, I told the CNA she should have had another person to transfer. On 08/04/2021, at 5:47PM, R2 stated, V4 (CNA) was working the mechanical lift. My lift pad was taken down to laundry to be washed. V4 grabbed another resident's lift pad to use to lift me up. She came in the room by herself and there is always supposed to be two people. They break this rule all the time. She was pushing and jerking the lift versus walking with it. She raised the lift all the way up. My feet came forward and my torso came forward. I started falling. I hit my wheelchair and I had to get my butt correctly positioned in my chair. I heard a crack in my groin. I stated something is wrong. She got nervous. I told the nurse she dropped me. That my hip was cracking. I asked for an ambulance. I was taken to a local hospital. I was diagnosed with a broken hip and thigh bone. She did not know what she was doing. I was set up for hip surgery. I have a metal hip. I do not want to see anyone else get hurt. On 08/06/2021, at 1:42PM, V4 stated, R1 was complaining about not being able to get up. I found a different mechanical lift pad. I got him up. His left foot tapped the mechanical lift. He did not have any complaints of pain. I proceeded to put him into his wheelchair. R1 is a two-person assist. I went to go get help but transferred him by myself. R1 is supposed to be a two-person mechanical lift. I lifted him because the facility was short staffed. On 08/06/2021, at 1:45PM, V5 (Nurse Practitioner) stated, R2 has some bone disorders. Someone that has [CONDITION(S)] bone diseases are more prone to fractures. I expect staff to follow the policy and procedures when they are safely transferring the residents. R2's care plan notes, R2 exhibits decreased ability to transfer himself from the wheelchair to his bed due to decrease functional mobility and generalized weakness. He requires the mechanical lift with a two-person assist. X-ray dated 06/21/2021, notes R2 has acute fracture of his right leg bone. Facility Policy titled Safe Patient Lifting Policy, undated, notes the Safe Lifting Policy exists to ensure a safe working environment for resident handlers.

Based on interview and record review the facility failed to follow their Active and Passive Range of Motion Protocol and failed to initiate a treatment plan to prevent further decrease in range of motion for 1 of 3 residents (R2) reviewed for restorative services in a total sample of 9. This failure resulted in R2 developing a severe right lower extremity muscle contracture, or a tightened muscle that cannot stretch normally. Findings Include: The Face Sheet documents that R2 was admitted to the facility with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents that R2 requires 1-2 person physical assist with all activities of daily living. The Physical Therapy assessment dated [DATE] documents that R2 had bilateral knee flexion contractures vs hamstring tightness and impaired muscular strength deficits. R2's range of motion and strength was impaired. R2 is dependent with basic mobility and has unstable and unpredictable characteristics. R2 reached the maximum potential with physical therapy and was referred for restorative services and range of motion. The Restorative assessment dated [DATE] documents that R2 was receiving restorative services for transfers as the resident is able to scoot/pivot, and the resident is receiving services for assistance with eating only; there were no services to address the resident's impaired mobility and range of motion. The Nurse's Notes dated 2/2/19 documents that R2 was hospitalized related to a fall. The hospital records dated 2/2/19 documents that R2 had a significantly contracted right leg with pain and grimacing on movement. On 2/14/19 at 2:30pm V8 (Restorative Nurse) stated The resident was being seen for restorative. R2 was on a transfer and eating program. Staff would go in and assist the resident with transferring from the bed to the wheelchair. The resident required 2 person assist with transferring due to weakness and behaviors of grabbing on to the wheelchair. R2 was unable to do any other transfers other than staff assisting the resident to the wheelchair. I saw the resident weekly and did a quarterly assessment. I never noticed any contractures. The resident was not on a program for range of motion. On 2/20/19 at 1:10pm V9 (Physician) stated I don't recall if the resident had any contractures, but any resident with decreased range of motion would benefit from a restorative program for prevention. The Active and Passive Range of Motion Protocol documents that range of motion is performed on any resident who has a functional limitation or loss of voluntary movement to an extremity. A Joint Mobility Form is completed for all residents, if decreased range of motion or voluntary movement is present then passive or active range of motion is initiated.

Based on interview and record review the facility failed to follow their Falls Policy and failed to implement interventions to maintain the safety of a cognitive impaired resident with impulsive behaviors for 1 of 3 residents (R2) reviewed for falls in a total sample of 9. This failure resulted in R2 falling out of the bed and sustaining a laceration to the left eye, bilateral brain bleeds, and a possible right [MEDICAL CONDITION]. Findings Include: The Face Sheet documents that R2 was admitted to the facility with a [DIAGNOSES REDACTED]. The Physical Therapy assessment dated [DATE] documents that R2's range of motion and strength was impaired. R2 is dependent with basic mobility and has unstable and unpredictable characteristics. The Incident Report dated 2/2/19 at 5:39am documents that R2 was found on the floor on the side of the bed with a laceration to the left eye. The MD and family were notified and the resident was transferred to the local hospital for evaluation and treatment. The Hospital Records dated 2/2/19 were reviewed and documents that a CT scan of the head was done and showed that R2 had a right frontal and left parietal subdural hematoma. An x-ray of the right lower extremity showed a possible right femoral neck fracture. R2 also had a laceration to the left eye. The last Fall Risk Assessment done by the facility was dated 6/13/17 and documents the resident as a low fall risk. The most recent care plan documents the resident has impulsive behaviors related to dementia but no interventions were put into place. On 2/7/19 at 2:30pm V4 (CNA) stated I was changing another resident and I heard R2's voice. When I went in, R2 was on the floor on the side of the bed. I called the Nurse and the resident was sent out to the hospital. R2 is able to move around in bed but is not able to walk. The resident moves a lot from side to side. There were no interventions in place at the time of the fall. On 2/8/19 at 11:15am V5 (Nurse) stated Around 5:15pm the resident was observed lying on the left side on the side of the bed. R2 had a raised area on the side of the left eye. There were no interventions in place at that time. R2 can move around in bed but is not ambulatory. On 2/20/19 at 1:10pm V9 (Physician) stated The right frontal and left parietal subdural hematomas can occur as a result of a fall. There is always a risk for injury with cognitively impaired residents and even with interventions in place things can still happen. I don't recall if the resident had any interventions in place at the time of the fall. The Falls Policy documents that the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. A Fall Risk will be completed on admission, readmission and quarterly. Residents at risk for falls will have Fall Risk identified on the plan of care with interventions implemented to minimize fall risk.

Based upon observations, record reviews and interviews the facility failed to ensure that 1 resident (R1) in the sample of 6 was free from Mental Abuse when E6 (administrator) refused to allow R1 to enter the facility when returning after hospitalization and further instructed facility staff to throw R1 ' s personal belongings into the garbage. R1 observed his belongings removed from the facility and placed on the facility parking lot. R1 returned to a local hospital emergency room twice before the facility allowed readmission. This failure to allow R1 to return to the nursing home multiple times and removing R1 ' s personal belongings to the parking lot caused R1 mental distress and resulted in an Immediate Jeopardy for R1. E3 (Risk Manager/Acting Director of Nursing) was notified of the Immediate Jeopardy on 5/19/11 at 11:38am. The Immediate Jeopardy was determined to have begun on 5/17/2011. Findings Include: R1 is a [AGE] year old male and the physician progress notes [REDACTED]. "Pt. (patient) C/O (complains of) numbness in upper R (Right) leg and testicles. Pt. C/O sharp pain above groin and abdomen. Pt. is unhappy with his medical progress and states he is very anxious. Vitals BP (blood pressure) 112/40 P-(pulse) 114 R-(Respiration) 18 Lungs-Rales wheezing.....Assessment of plan Hiatal Hernia" The nurses notes dated 5/17/11-11am, in part denotes the following: "C/O pain lower abdomen...states has two nodules that are full of fluid that needs draining also has numbness/soreness in groin area...Contacted MD (medical doctor) regarding pain management. Spoke with MD- send resident to hospital for evaluation of lower abdomen pain groin area. VS B/P-119/92; P- 114; T-97.5" R1 was transferred to the emergency room . Z1 (Director of ER) was interviewed on 5/18/11 at 9:48am and stated, "R1 is still here. They (referencing Nursing Home) refused to take him back last night. We have documentation saying no beds are available and refused to take R1 back. We have contacted our Social Service department to help R1." An onsite visit was conducted on 5/18/11, and E1 (Registered Nurse/Restorative) during the entrance conference stated, "I am covering the building, E3 (acting director of nursing) is out, and E6 (administrator) is off today." E1 was interviewed regarding the discharge, and alleged refusal of R1 by the night nurse on 5/17/11 to allow R1 to return. E1 stated," R1 was discharged [DATE] to hospital complained of lower back pain, I do not know about refusal, I will call the hospital now. In the presence of surveyor, E1 called and spoke to Z4 (identified as supervisor nurse) and requested R1 return to nursing home. E1 after ending call stated," they are sending R1 back now, I spoke with Z4. E2 (Admission Director) was interviewed on 5/18/11 regarding the failure to accept R1's return to the nursing home and stated," Z5 (hospital social service case manager) called and asked me why on 5/17/11 R1 couldn't come back. I gave the call to E3 (risk manager)." E1 returned to surveyor on 5/18/11-3:00pm after prompting regarding if R1 had returned and stated," the hospital was working on a shelter for R1, and they just sent R1 there. R1 is not coming back." Z1 was interviewed on 5/19/11 and stated, "The person E1 who spoke to me on 5/18/11 and told me to send R1 back, later after R1 was enroute called and left a message on my voicemail and told me not to send R1 back. E1 said her administrator said no. Then R1 was returned, R1 was upset, and later that evening called and asked us to return R1." E1 on 5/19/11 was interviewed regarding Z1's statement that R1 was returned to nursing home, and refused admission again. E1 stated," Oh, yes, R1 came back in building with 2 paramedics the afternoon. I saw R1 in lobby, E3 took over, I do not know what happened." Below outlines in part the documentation of the hospital and ambulance company provided by Z1 that sequence the events of R1 returning to the nursing home and the refusal to accept: ER Documentation 5/17-5/18/2011: 5/17/11-17:15 hours-NH (nursing home called to give report. Per E7 (nurse), zero bed available anymore. 1840 hour -Z6 (emergency room Doctor) spoke with Risk management, here talked to E7 at nursing home, discussed this is against the law- Awaiting call back. 1916 hour- awaiting CB (call back) from RN supervisor at NH (Nursing home). 2010 hour -NH contacted and notified that pt. is returning. 2115 hour-per ambulance company, NH refused to accept pt. Pt. returned to ED (Emergency Department). Called NH , Nurse busy having lunch will return call. 2155 hour-Z7 at IDPH spoke with E7 and was given reassurance that hospital would be contacted for transfer back to NH. 2310 hour- Pt. becoming visibly upset.....Pt request to obtain a few personal important items from NH. Called NH for requests and placed on hold, repeatedly spoke with E8 (operator) who states," I don't know what's going on, why they keep hanging up. CPD (Chicago Police Dept) called. 2315 hour-Pt escorted to NH per Z8 (Officer-beat 1052)... NH would not allow pt. to enter the nursing home. Nursing Supervisor (E7) pt. has been discharged ...pt. not allowed to obtain any personal effects. Per Z8 pt. requested to speak with E7 and E7 refused to speak with pt. 2350 hour-Z9 (ER/Nurse) - spoke with E9 who states pt. discharged ...asked about proper notification/procedure and E9 stated," I'm not going into no details about this. That's all I know so he can't come here." Attempted to ask about personal belongings and the phone was hung up on me. Called back and repeatedly placed on hold with no response. 5/18/2011- 0005 hour- pt. upset...pt to remain in ED until proper placement can be obtained. 1622 hour-.ambulance called stating they are refusing pt. pt. not to be accepted. pt to return ....hospital. 1745 hour- pt. arrived back post sent to nursing home. Spoke with E3 who told to send back to nursing home. 1750 hour- pt sent back to ...nursing home per Risk management. Ambulance Report-5/18/11- ...walked in with pt. on our stretcher, staff looked at us, shook their heads, and went into the backroom.....A lady at the nursing home named (E1) asked to speak to me in a backroom. E1 (RN restorative) introduced me to E3 (Director of Nursing). E1 and E3 told me spoke to hospital- not accepting pt. back. I (ambulance driver/Z10) called ...ER pt. RN and was informed nursing home had accepted....Medical control contacted...told to bring pt. back ....ER. Then a guy (E6) came up to me (Z10), As I was sitting doing my report, asked how I was doing. I stated, I am upset, and E6 said I really don't care, you need to get out of the lobby and leave now. E6 then instructed E10, to throw pt. stuff out 7 boxes of his personal items. Police called due to E6 threatening me and throwing pt stuff out in the garbage. Our pt is distraught and worried. Officers Z2 and Z3 arrived and told them they could not throw his stuff in garbage. E3 stated," she would take care of it." Police asked E3 who she was, and she stated, "I'm the DON (director of nursing)." When police asked why pt. couldn't stay there. E3 said,"....been here since 2008, uses drugs and alcohol, no medical reason. I told E3 and Z2 and Z3 pt going back to ...ER. As soon as we arrived in ER charge nurse told us we can take pt. back.....we did a total of 3 transports. On 5/19/11 at 11:00am R1 was observed in room seated in a wheelchair and stated, " they did me wrong, wouldn't let me come back, twice, kicked me out, sent me back to the ER. R1 was asked, who would not let you come back and stated," E3, E6 and E2. I had to lay on the cart for 2 days in the emergency room , didn't get my medicine-then they took me back last night." Client observed shaking, uncontrollable crying, face redden. E4 (R1's nurse) contacted, after prompting, Vital Signs taken of R1 revealed increase Pulse -of 102; B/P-138/90. E4 stated," R1 was upset, just thinking about what has happened over past 2 days, that's what he told me." On 5/23/11 at 5:48pm Z2 and Z3 (Police Officers) were interviewed and stated," responded to a call that the ambulance driver was assaulted by a staff; felt threatened, and they backed off when we got there. It was about the nursing home refusing to take a patient in also. Guy named (E6) said he was in charge and an Asian lady. The guy was asking for his personal items. They had put them outside on the parking lot. It was getting ready to rain, we couldn't make them take back the patient, but we asked them to bring his personal items back in and they, E6 and the Asian lady said they would. I will testify to my statements." The facility failed to follow their abuse policy that in part depicts deprivation by an individual of goods or services that are necessary to attain and/or maintain mental and psychosocial well-being. In addition, the mental abuse denotes threats of deprivation. The Immediate Jeopardy was removed on May 19, 2011 at 2:40pm when it was confirmed R1 was allowed re-admission the facility, but remains at a scope/severity Level 2. The facility took the following steps to remove the Immediate Jeopardy: 1. R1 current living in the facility. 2. Initial investigation of psychological harm. 3. In-serviced regarding admission and re-admission policy. 4. Staff Education pertaining to admission process. 5. Creation of a QI tool for admission referrals and admissions 6. Issues reported Quality Improvement Meeting .

Based on observation, record review and interview, the facility failed to provide a two person assistance during care of 1 (R6) resident of 30 sampled residents which resulted in R6 falling from her bed and sustaining a fractured femur. The findings include: R6 is a [AGE] year old female who is bed-bound with a right below the knee amputee who was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].S.). R6 is oriented times three per 3/21/11 nurses' note. On all days of the survey, R6 was seen in her room in the bed with the exception when she left the facility for dialysis and doctor appointments in a wheel-chair on 3/22/11 and on stretcher with paramedics on 3/24/11. On 3/23/11 at 10:10 a.m., R6 stated she has a broken right femur and showed the right swollen stump to the surveyor. She stated she remembers falling but can not say exactly how it happened. R6 stated she had an eye injection the day before the incident, and is blind in that eye so she was keeping her eyes closed. R6 stated she remembers a nurse aide being present and the feeling of falling from the bed and landing face down. R6 stated some days she has more pain than other days but this day she was okay. R6 stated the medication does work. Review of the incident dated 3/12/11 documents R6 was receiving care from R12 (nurse aide) while in the bed. E12 had turned R6 onto her left side, there was a half rail R6 was holding onto when she loss her grip and fell face down (prone position) on to the floor. E13 (nurse) was summoned. R6 was assessed and found to have a swollen right stump and verbalizing pain to the area. R6 was sent to the hospital and x-rayed. R6 had sustained a femur fracture to the right stump. Review of the minimum (MDS) data set [DATE] documents R6 requires a 2 person assistance when being bathed or receiving hygiene. This assessment was done one month before her fall. It documents R6 requires extensive assistance in dressing, bathing, and hygiene. It also documents R6 is non-ambulatory. Review of the fall assessments dated 4/2/10, 3/2/10, 8/26/10, 11/15/10 document high risks for falls. There was no current fall assessment in chart. Review of the care plan reflects no care plan for falls. The care plan documents R6 is extensive care. On 3/25/11 at 9:40 a.m. during a meeting with administration staff, Z4 (facility's consultant) stated that prior to the fall, R6 was a one person assist with bed mobility but since her return to the facility, R6 is requesting 2 person assist while in bed due to fear of falling.