Every finding on record at Atrium Health Care Center

Based on interviews and reviews of records, the facility failed to provide person-centered baseline care plan to 1 out of 3 residents (R1) for a total of 3 residents reviewed for Comprehensive Resident Centered Care Plans. These failures resulted in lack of interventions needed for 1 resident (R1) necessary to perform daily activities.Findings include: R1 subject of the complaint was initially admitted in the facility on 06/15/2026 and was discharged from the facility on 06/23/2026. R1 medical diagnosis includes degenerative diseases of nervous system, tremors, neuralgia and neuritis, pain, cerebellar ataxia, dysarthria following cerebrovascular disease. On 08/12/2026 12:19 PM V3 (Certified Nursing Assistant) stated that she worked regularly with R1 and was able to identify R1's room when R1 was in the facility. V3 stated that R1 needs total assistance because R1 was very shaky. R1 needs help with eating, pushing R1's wheelchair, and all other needs of R1. V3 said that R1 is alert and oriented so that he can tell you what he needs. On 08/12/2026 at 03:25 PM V4 (Registered Nurse) stated that R1 has tremors everyday fluctuates from severe to not that shaky. V4 stated that R1 needs to be extensively assisted due to his tremors. V4 stated that CNAs (Certified Nursing Assistants) assist R1 with eating, using wheelchair as a means of locomotion, transferring and has a high fall risk because of the tremors. On 08/13/2026 V6 (Director of Rehabilitation) stated that R1 was admitted to therapy for both PT (Physical Therapy) and OT (Occupational Therapy) progressive degenerative syndrome (degenerative diseases of nervous system). V6 stated that R1 has tremors during assessment that affects performance with ADLs (toileting, transfers, eating, etc.) V6 stated that R1 needs intervention on fine motor control like grasping and releasing due to tremors. On 08/13/2026 at 01:11 PM V7 (MDS Coordinator / Nursing Care Plan Coordinator) stated that he saw R1 when he did MDS assessment observation during admission. V7 stated that R1 was sitting on his bed doing something on his cellphone when he noticed tremors. V7 was given a copy of R1's care plan provided by facility. After reviewing all 15 pages of the care plan. V7 stated that R1's care plan does not have anything specific to tremors. V7 stated that care plan needs to be individualized or person-centered. It means that a care plan needs to be specific to each person because every resident is different, it is tailored towards the ability of the person. On 08/13/2026 at 01:59 PM V2 (Director of Nursing) stated that care plan is part of the patient care that nursing staff follows (like interventions in the care plan). Care plan is an interdisciplinary or collaborative team effort. V2 stated that she met R1 one time, I observed shaking movement. Full care plan review does not address identified concern related to R1's tremors or shaking. Clinical notes of both V5 (Registered Nurse) and V8 (Licensed Practical Nurse) identified R1 to have severe tremors. V5 clinical notes dated 06/16/2026 Facility's policy on resident care planning with no date reads:Each resident has a resident care plan that is current, individualized, and consistent with the medical regimen. Under procedure, care plan includes assessment, diagnosis, planning and setting goals. Facility staff will utilize care plans to assure that each resident's need is met through appropriate and individualized staff interventions in a timely manner. Per CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2017: Care plan should be individualized, and resident centered. Planning of care requires implementing appropriate, individualized interventions and modifying them as appropriate.

Based on observation, interview, and record review the facility failed to ensure timely assessment, treatment, monitoring, and physician follow-up for a resident with a persistent lice infestation. This failure resulted in the resident (R5) experiencing ongoing symptoms, including scratching, and placed the resident and other residents at risk for continued infestation. This failure affected one out four residents reviewed for resident assessment, treatment, skin conditions, and infestations. Findings include:R5's Brief Interview for Mental Status (BIMS) dated 4/7/26 shows a score of 11 which indicated that R5 has some cognitive impairments. R5's face sheet shows that R5 has a diagnosis which includes but not limited to pediculosis due to pediculous humanus capitis, rash, and other nonspecific skin eruption.On 6/15/26 at 12:30 pm, Surveyor observed R5 in bed awake, alert, noted repeatedly scratching multiple areas of the body, including the chest, back bilateral arms, and legs. Multiple scabbed lesions of varying sizes were observed on the resident's skin in the locations being scratched. R5 stated that he cannot recall when he first had lice at the facility and then stated, It feels like bugs are still crawling on me. I am itching all the time. The resident continued scratching the affected area throughout the observation period while verbalizing discomfort. On 6/15/26 at 12:37 pm, V10 (Certified Nursing Assistant, CNA) stated that a few months ago (around April 2026) he observed R5's bed with multiple small insects. V10 stated that he asked a housekeeper what the insects were and the housekeeper informed V10 that the insects were lice. V10 explained that he took a picture of insects and reported the observation to the floor nurse (unsure of the nurse). V10 further stated that R5, R10, R11, and R12 clothing and room was disinfected while R5, R10, R11, and R12 were showered and treated with a medicated shampoo. V10 explained that he did not observe any insects in R5, R10, R11, and R12's room for about two weeks after the first sighting. V10 then explained two weeks after the first sighting he saw R12's bed with the same insects and reported the insects to the nurse (unsure of the nurse) and R5, R10, R11 and R12 were treated with medication/shampoo, rooms were disinfected and treated again. V10 stated the R5 continues to scratch his skin but denied currently seeing R5 with lice on his body the facility. When V10 was asked if he reports R5's itching to the nurse, V10 stated that he did not report R5's itching because he has not seen any bugs on R5. On 6/15/26 at 12:00 pm, V4 (Infection Preventionist, Registered Nurse, RN) stated that she is the facilities Infection Preventionist at the facility and then explained that she does not tract residents with parasitic infections such as lice at the facility. V4 stated that is the responsibility of the nurse and that the nurses on the unit monitor residents who contract lice. V4 also stated that she is not sure of residents with lice are placed on isolation at the facility. V4 also explained that if a resident has lice, it could be spread to other residents in the facility. V4 finally stated, I didn't know I was supposed to tract those residents (referring to residents with lice. On 6/15/26 at 2:23 pm, V6 (Register Nurse, RN) stated that she was R5's nurse at the facility and frequently cares for R5 at the facility. V6 stated that she was aware of R5 being treated for lice on 6/5/26 however have not observed R5 with lice. V6 explained that she sees R5 scratching that R5 has complained of being itchy however have not seen any bugs crawling on R5. V6 then stated that she would call R5's physician to inform him of R5's skin condition and continued itchiness. On 6/17/26 at 2:22 pm, V2 (Director of Nursing, DON ) stated that she began working in the facility February 2026 and vaguely remembers R5 being discussed in the morning meeting regarding treating R5 and his roommates for lice at the facility. V2 explained on 6/5/26 R5's was treated for lice after R5 was seen by V13 (R5's Physician). V2 stated that she does not recall any reports from the nursing staff regarding R5 having lice prior to V13 visiting R5 at the facility. V2 stated that when V13 reported treating R5 on 6/5/26 for lice V2 did not assess R5's or R5'S roommates for lice due to V2 having a phobia with bugs. V2 then stated that she informed the nurses to follow R5's physician orders to treat R5 with lice treatment shampoo and to follow the facilities policy for lice (bag the residents in the room belong, shower the residents, and notified the physician), when V13 made her aware of R5 having lice. V2 denied any knowledge of any R5 or any other residents in the facility with concerns for lice since 6/5/26. V5 explained if a resident goes without proper treatment for lice there is a potential for the resident to spread the lice to other residents in the facility. On 6/17/26 at 1:44 pm, V14 (Licensed Practical Nurse, LPN) stated that a CNA informed V14 that he saw lice in R5's bed over a month ago. V14 stated that he assessed R5 and observed R5 scratching black dots on R5's back and abdomen area but the black dots were not moving, and he could not determine if they were insects or parasites. V14 explained that he called R5's physician and informed him of what V5 (CNA) reported regarding seeing lice on R5 and R5's physician ordered treatment for a lice killing shampoo to be applied that day as well as a cream to be applied at night that required staying on R5 for hours (unsure of how many) then for R5 to shower. V14 also explained that all the residents in R5's room were showered, R5's room was treated with a lice spray, housekeeping deep cleaned R5's room, and every resident in the room's clothing was packed up, placed in a plastic bags and sent to be washed by laundry. V14 denied knowledge of observing or staff reporting the lice appearing for R5, R10, R11 or R12 since this insistence. V14 denied seeing insects or lice crawling on R5's bed since about a month ago however he continues to observe R5 in bed itching all the time. On 6/18/26 at 9:46 am, V13 (R5's Physician) stated he is R5's physician at the facility and last saw R5 a few weeks ago. V13 explained when he saw R5 he observed R5 scratching, very itchy, with body lice on his skin, and bed. V13 explained he ordered R5 and his roommates (R10, R11, and R12)to be treated for body lice with a topical treatment order to be applied and left on for 10 minutes then for R5 and his roommates (R10, R11, and R12) to be showered. V13 stated that the facility did not notify V13 regarding R5 having body lice and that he assessed R5 with the body lice during his visit with R5 and then informed V2 (DON) of his orders. V13 explained if a resident who has body lice is not reported, the resident will continue to be uncomfortable with itching, scratching and place the risk of spreading the infection to other residents. V13 stated that he has not received any follow up from the facility regarding R5 since ordering R5 to be treated for lice a few weeks ago. V13 could not recall R5 being treated for lice in April 2026 and only recalled treating R5 on 6/5/26. On 6/18/26 at 11:01 am, V1 (Administrator) stated that she is not aware of any residents in the facility who currently have body lice. V1 then stated that she was last made aware of a resident having body lice by the nursing staff two months ago with R5. V1 stated that she was informed that R5 was observed with body lice and was unsure if it was found by the nursing staff or housekeeping department. V1 stated that if body lice are sighted on a resident or in a resident's room the residents' physician is notified for a treatment, the treatment is implemented by the nursing staff, the residents are showered with a medication to kill the lice, and the residents clothing and furniture is cleaned with a disinfecting agent by housekeeping. V1 explained that lice infections should be tracked by V4 (Infection Preventionist, Registered Nurse, RN) to prevent the lice from spreading. V1 explained if a lice infection is not monitored or tracked the infection can spread and the resident infection can become worse. R5's progress notes dated 4/20/26 at 7:20 pm, and authored by V14 (LPN) documents, in part: During ADL (Activities of Daily Living) by staff, lice were discovered on resident's bed. A thorough body assessment was done. V13 (R5's Physician) with orders to treat resident with lice killing shampoo and body wash, bed cleaned with lice killing spray. Resident and other roommates clothing packed and sent to the laundry. Room was deep cleaned by the housekeeper. Resident with other roommates were thoroughly showered with lice killing shampoo and body wash. Staff will continue to monitor.R5's progress note dated 6/5/26 at 4:35 pm, authored by V13 (R5's Physician) documents in part: Noted bugs around him and bed . itching skin. Plan: Lice treatment and clean room.R5's Physician Order Sheet (POS) dated 4/21/26 shows order for R5 to receive permethrin 5% topical cream.R5's Physician Order Sheet (POS) reviewed.The facility undated and untitled policy for Lice Infestation documents, in part: Policy and Procedure for Scabies, Lice, Ticks, Mites, and Flea Infestation: Residents suspected of infestation or infection of scabies, lice, ticks, mites, fleas, or other arthropods shall be treated immediately.1. clinical indications or symptoms: a. Pruritus' . d. rash or trach marks commonly located on arm pits, thighs, wrist, hands, between fingers or toes or extremities. 2. Attending physician or designee is to be notified immediately of any suspected infection or infestation.The facility's undated policy titled Surveillance documents, in part: Assess: the data collection and investigation may require direct observations, Review of other infection reports (resident and employee health concerns), review of literature regarding cleaning agents, interviewing residents(s) and employee(s), review of policies and procedures, observation of employee performance, assessment of use and effectiveness of equipment and supplies . Plan: Analyze/Interpret resident record for documentation of: Assessment, Signs and symptoms, vital signs. Physician notification. Medication/Treatment Record. The facility's Monthly Infection Log dated April 2026, May 2026, and June 2026 reviewed shows that R5's lice infection was not monitored.

Based on interview, and record review, the facility failed to protect residents from physical abuse when resident-to-resident altercations occurred, resulting in R2 slapping R1 in the face; and R4 slapping R3 in the face. This failure affected four out of six residents reviewed for abuse. Findings include: 1. R3's Brief Interview for Mental Status (BIMS) dated 3/6/26 shows a score of 4 which indicated that R3 has some cognitive impaired. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, developmental disorder of speech and language, nicotine dependance, chronic obstructive pulmonary disease and hypertensive heart disease. R4's Brief Interview for Mental Status (BIMS) dated 3/12/26 shows a score of 15 which indicated that R3 is cognitively intact. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, major depressive disorder, schizoaffective disorder, bipolar type, primary insomnia, and hypertensive heart disease. The facility's initial reportable date 5/18/26 at 6:58 pm documents, in part: On 5/18/26 at approximately 6:12 pm it was reported that R4 had slapped co-resident, R3 on the right check area on first floor hallway near room114. Alleged incident occurred due to resident R4 experiencing delusions and believing that R3 was talking about him blowing his nose and making comments about his eye. Staff immediately intervened, separated residents, and both residents placed on immediate 1:1 staff monitoring. Skin assessment completed for both residents. Both residents noted with no injuries Police made aware. Physicians made aware with orders obtained to send resident R4 to the hospital for evaluation, safety of other residents is secured. Both residents and representatives called. Resident R3 representative informed of alleged incident. R4 representatives are unable to be contacted as contact number is not in service. Investigation is ongoing. Will follow up when competed. The facility's final reportable dated 5/25/26 at 5:36 pm, documents, in part: Based on further investigation interviews and statements, alleged incident was concluded to be founded. On 6/15/26 at 1:06 pm, Surveyor observed R3 sitting on the patio area, alert, nonverbal unable to answer any surveyors' questions. Surveyor did not observe R3 with any facial injuries or abnormalities. On 6/15/26 at 12:42 pm, R6 stated that about a month ago while R6 and other residents were waiting in the hallway on the first floor by the patio door for smoke break he witness R4 walk up to R3 and slap R3 in the face. R6 explained that R3 does not speak and did not know why R4 slapped R3 in the face. R6 stated that the incident took place as the residents were lined up along the patio door awaiting staff to come and that no staff was present to monitor the incident. On 6/15/26 at 1:08 pm, R9 stated, I saw him (referring to R3) get hit by another resident (unable to recall the residents name). R9 then stated, I don't know why he (referring to the resident that hit R3 (R4)) did that. He (referring to R3) is quiet and does not bother anyone. R9 also stated that the incident took place as the residents were lined up along the patio door awaiting staff to come and that no staff was present to monitor the incident. On 6/15/26 at 1:09 pm, V9 (Social Service) stated that the social service department is responsible for monitoring the residents during smoke breaks at the facility. V9 explained that residents who ambulate independently will line up forming a line along the wall outside of the smoke break patio door and when no staff is present to supervise the residents. V9 stated that he was not working on 5/18/26 the day of the incident between R3 and R4. V9 further explained when he returned to work on 5/19/26 he was informed that R4 was sent to the local hospital for slapping R3. V9 denied ever witness R3 and R4 in any previous incidents at the facility or during smoke break times. On 6/16/26 at 11:14 am, V3 (Social Services Director) stated that the social service department is responsible for monitoring the smoke breaks for the residents. V3 then stated that a social service staff should always be present during the resident's smoke breaks. V3 then explained when the resident's line up along the door of the patio area prior to the smoke break time there is not a staff member present to monitor the residents until the smoke time starts. V3 explained that the social service staff are bringing in residents from the front of the building when residents who ambulate began forming a line at the patio door before the social service staff can get to the patio area. V3 explained if residents are not supervised by the patio door, V3 stated; A fight can breakout. On 6/16/26 at 11:37 am, V11 (Psychiatric Rehabilitation Coordinator, PRSC) V11 explained that the residents have designated smoke break times and areas (the front of the facility for residents in wheelchairs and the patio areas for those residents who walk). V11 then explained that the social service staff will issue the residents the cigarettes and monitor the residents for smoke breaks. V11 further explained that residents who smoke on the patio will bring themselves down independently and form a line along the wall leading to the patio door independently. V11 explained that there is no one there to monitor the residents until a social service staff comes to begin the smoke break. V11 explained that R3 and R4 had an incident about a month ago when R4 hit R3. V11 then explained that during the time of the incident he was not present and was gathering the key to turn the patio door alarm and heard a commotion and residents saying Why did you do that? Why did you hit him? (referring to R4 hitting R3). V11 explained that when he went to the patio door area he separated R4 from R3 by removing R4 to the front receptionist desk area and took R3 to the first-floor nurse to be assessed. On 6/16/26 at 6:16 pm, V12 (Licensed Practical Nurse, LPN ) stated she did not witness the incident between R3 and R4 on 5/18/26. V12 then stated that on the evening of 5/18/26 she was informed by V1 (Administrator) that she needed to assess R3 because R4 hit R3 downstairs on the first floor. V12 stated that staff brought R3 upstairs on the elevator and she then assessed R3. V12 then explained during her assessment of R3 she did not observe any apparent swelling or visible injuries and then informed V13 (R3's Physician) of the incident as well as her assessment. V12 stated that R3's physician ordered a facial bone Xray for R3 and when the facility received the results of R3's Xray, the results recommended that R3 go to the local hospital for further evaluation. V12 then stated that R3 was sent to the local hospital and return to the facility however she does not know what the report of the local hospital revealed. On 6/17/26 at 1:29 pm, V14 (LPN) stated he was R4's nurse on the day of the incident with R3 and R4 on 5/18/26 at the facility. V14 stated that he did not witness the incident between R3 and R4 and was informed that R4 had a physical altercation hitting R3. V14 stated that he was informed that the altercation took place on the first floor when the residents were going to smoke. V14 explained when the smoke break time is announced by social service department the residents go to the designated area to smoke, and the social service then takes the residents out to smoke. V14 stated that residents should not be lining up for smoke break until social services inform the residents it is time to smoke and is there to supervise the resident. V14 then explained that after the altercation R4 was placed on 1:1 monitoring, informed R4's physician and R4 was sent to the local hospital for psychiatric evaluation immediately following the incident and has not returned to the facility. On 6/17/26 at 1:51 pm, V2 (Director of Nursing, DON ) stated she did not witness the incident between R3 and R4 on May 18, 2026. V2 stated that V1 (Administrator) informed V2 that R4 hit R3 in the face on the first floor (V2 could not recall any further details regarding where the incident occurred). V2 stated after R4 assaulted R3 he was sent local to hospital for psychiatric evaluation and has not returned to the facility. V2 explained that R3 was assessed for injuries with no injuries noted. V2 then explained that R3's physician was informed regarding the incident with orders for Xray of the facial bone. V2 then explained that initial report indicated a fracture of the facial bone and R3's physician was informed with orders to send R3 to the local hospital for further evaluation. V2 then explained that R3's local hospital Xray results were negative for facial fracture and R3 returned to the facility. V2 denied R3 having any further signs of pain or injury since the incident with R4. On 6/18/26 at 10:29 am, V1 (Administrator) stated that she is the facility's abuse coordinator. V1 stated that last month she was notified that R4 slapped R3 while the residents were in line for the smoke by the patio door. V1 explained that R4 stated that he felt that R3 was talking about him and then V1 then explained that R3 is a non-verbal resident. V1 explained that staff separate R3 and R4 and placed them on 1:1 monitoring, called R3 and R4's physician and R4 was sent to the hospital for evaluation. V1 explained that R3 had a Xray of the face and was sent to the hospital for further evaluation and returned to the facility with no finding/injuries noted. V1 explained that if a resident hit another resident that it is resident-to resident abuse. V1 also stated if staff leave residents unsupervised accidents or an incident can occur. V1 stated that staff should have needed supplies for the residents prior to the monitoring the residents for smoke break. V1 stated that residents are directed to line up for smoke break once the smoke break is announced for residents to attend and residents who line up prior to the announcement are redirected back to the unit until the smoke break begins. V1 explained that during the altercation with R3 and R4 V11 (Psychiatric Rehabilitation Service Coordinator, PRSC) was assigned to monitor the residents for the patio smoke break and left the residents who were in line to go to the nurses station to get the residents cigarettes and keys for the smoke break and did not observe the altercation with R3 and R4. R3's progress noted dated 5/18/26 at 6:41 pm, authored by V12 (LPN) documents, in part: Around 6:00 pm, staff reported to writer that co-resident hit resident on the face during smoke break residents immediately separated Administrator notified immediately. Upon assessment, no visible redness, swelling, discoloration, or open areas noted to the face at this time. No facial grimace or guarding of any body part noted. No change in LOC (loss of consciousness) noted, neuro (neurologic) assessment completed. Vital signs checked: BP (blood pressure) 127/80, P (pulse) 80, T (temperature) 98.3* F (Fahrenheit), RR (Respiratory Rate) 18, O2 (oxygen) sat (saturation) 98% room air. MD (Medical Doctor) notified Resident's next of kin made aware via voicemail . Call placed to schedule an X-ray of the facial bone tomorrow confirmation number of 49484847. Post incident chart initiated until 5/21/2026 3-11 pm shift. Will continue monitor. R4's progress note dated 5/18/26 at 7:16 pm authored by V14 (LPN) documents, in part: The SS (social service) reported to the NOD (nurse on duty) that resident was physically aggressive toward a co-peer without provocation. Per SS, resident was deluded into thinking that co-peer was making negative remarks against him hence, he slapped him. Resident put on 1 on 1 monitoring and physician notified with order to transfer resident to the local hospital for psychiatric evaluation. The police were also called for investigation. R4's Notice of Involuntary Transfer or Discharge Opportunity for Hearing for Nursing Home Resident dated 5/18/26 reviewed. The facility document dated 5/18/26 shows a signed statement by R4 documents in part: I was walking down the hallway. He said something about me always blowing my nose and was talking about my eye, so I smacked him. I had to stop him. I don't hit it people. The facility's document dated 5/18/26 shows policy record number JK260164, Incident: Battery simple, Victim R3. The facility policy dated 2026 and titled Facility Smoking Safety documents, in part: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy, 2. The facility initial reportable incident to the local state agency dated 05/12/2026 at 10:11 am, documents, in part: On 05/12/2026 at approximately 8:12 AM it was reported that resident R2 slapped co-resident R1 on the right cheek area in the hallway near room [ROOM NUMBER]. Incident allegedly occurred due to R1 blocking the doorway and accidentally bumped R2 with her wheelchair. The facility final reportable incident to the local state agency dated 05/19/2026 at 6:16 PM, documents, in part: Based on further investigation including interviews and statements, investigation was noted to be founded. R1 was sitting in the entryway of room [ROOM NUMBER] while R2 was attempting to enter the room. R1 attempted to move her wheelchair and, per R1 and R2, accidentally tapped R2 with the wheelchair. R2 then slapped R1 on the right cheek area while no words were exchanged. R1 has a diagnosis which includes but is not limited to schizoaffective disorder. R1 Brief Interview for Mental Status (BIMS) dated 04/16/2026 shows a score of 15 which indicated that R1 is cognitively intact. R2 has a diagnosis which includes but is not limited to schizoaffective disorder, restlessness and anxiety. R2 BIMS dated 05/12/2026 shows a score of 15 which indicates R2 is cognitively intact. On 06/15/2026 at 1:28 pm, R1 recalled having a recent incident with her roommate R2. R1 stated the incident happened during breakfast time in the doorway of their room. R1 said she was sitting in the doorway of her room when R2 began cursing at her and then slapped her on her face. R1 stated that during the incident V5 (Certified Nursing Assistant, CNA) was present, intervened, and separated them. When asked about any injuries sustained, R1 says she had no injuries from the altercation, also stated she was in tip-top shape. On 06/15/2026 at 1:02 pm, when R2 was asked regarding the incident that occurred 05/12/2026 with R1, R2 refused to speak with the surveyor, or answer any of the surveyors' questions. R2 stated That's in the past, my family and the facility have moved on from that. On 06/15/2026 at 12:32 pm, V5 (CNA) stated he witnessed the incident between R1 and R2 on 05/12/2026. V5 stated that he saw R2 slap R1 on her face but didn't recall which side of the face. V5 stated that he attempted to de-escalate the incident and separated them both to prevent R2 from slapping R1 a second time. After the incident V5 says he reported the incident to V6 (Registered Nurse, RN), social services, and V1 (Abuse Coordinator/Administrator). On 06/15/2026 at 2:06pm, V6 (RN) stated she was notified of the incident between R1 and R2 as she was arriving on the unit. V6 says she was told by V5 that R2 had slapped R1 on the face. V6 states she reported the incident, to V1 and V2 (Director of Nursing/DON). After the incident V6 assessed R1 and did not observe any injuries, notified both resident physicians, and resident representatives. R1 was moved to the 1st floor with all her personal belongings, and prescribed medications. On 06/16/2026 at 10:33am, V2 (Director of Nursing, DON) stated she did not witness the incident, and was informed regarding the incident with R1 and R2 on 05/12/2026 by V1. She stated it was reported that R1 allegedly bumped into R2 with her wheelchair and then R2 slapped R1. V2 stated that V1 is the abuse coordinator and conducted the investigation regarding R1 and R2s incident. On 06/16/2026 at 10:22am, V1 (Administrator) stated she was informed regarding R1 and R2 incident on 05/12/2026 around 8am about the incident by a staff member (she does not recall the staff member). She states it was reported that R1 was sitting in front of a doorway and accidentally tapped R2 with her wheelchair, and then R2 slapped R1. V1 stated that R1 was assessed for injuries and mental status change by V6, and no injuries were identified. V1 says the assigned doctor was called to inform of the incident. But no orders were given to send the resident to the hospital. V1 stated she contacted the police department to file a police report, but the actual report was not completed. V1 stated R1 chose not to speak about the incident, but R2 agreed to speak with the officer. R1's progress note dated 05/12/2026 at 3:38 pm authored by V6 documents in part On 7a-3p shift. At the beginning of the shift, staff reported to writer that co-resident slapped resident on the face during an altercation. Per staff the incident occurred due to resident blocking doorway with wheelchair and accidently tapping co-resident with wheelchair. R1's Physician Order Sheet dated 07/10/2024 documents in part Monitoring for itching, picking at skin, restlessness, agitation, hitting, kicking, spitting, cursing, elopement, stealing, delusions, hallucinations, refusing care, anxiety, insomnia, and depression. Every day and night shift R1's Behavior Care plan date 11/12/2025 documents, in part: R1 Potential for to exhibit inappropriate behavioral problem as evidenced by yelling/screaming, and potential physical Behavior. The resident displays behavioral symptoms related to severe mental illness, poor and/or ineffective coping skills, a history of non-compliance with recommendations from health care professionals. These behavioral symptoms are manifested by: Verbal abuse/aggression, physical abuse/aggression, socially inappropriate and/or maladaptive, disruptive behavior, refusing/resisting care, behavior that constitutes mental abuse, and a disturbed sense of entitlement. Conduct an evaluation of the behavioral symptoms to determine what strengths or abilities and needs are communicated via the behavior (e.g., verbal abuse often communicates a need to feel in control and assertive). R2's progress note dated 05/12/2026 at 4:26 pm, documents in part, It was reported by staff that this resident slapped a co-resident on the right cheek. Both residents were immediately separated and placed on 1:1 monitoring. R2's Behavior Care plan documents in part: Focus: Behavior Symptoms: Verbal/Physical Aggression dated 05/12/2026. R2 demonstrates behavioral distress r/t ineffective coping mechanisms, outward expressions of internal pain, poor verbal skills and inability to express herself in more appropriate language, poor self-esteem, feelings of helplessness and inadequacy, and being challenged by symptoms of SMI (schizoaffective disorder). Problems are manifested by verbally aggressive behavior when agitated (R2 will pace, shout, curse, and scream either at others or internal stimuli when symptomatic), use of profanity, and a history of physically aggressive behavior when agitated. She responds to staff redirection when offered most times, however, when experiencing a psychotic episode, she presents difficulty in accepting redirection and reality orientation. R2's untitled document dated 05/12/2026 signed by R2 documents, in part: The co-peer hit me with her chair, so I was going to hit her, but I told the nurse. The resident did it again, so I hit her in her face. R1's untitled document dated 05/12/2026 signed by R1 documents, in part: As I was sitting by the doorway of my room, my co-peer attempted to come out. I did not move fast enough; therefore, she slapped me in my face. The facility policy dated 1/2026 and titled Abuse and Retaliation Policy Prevention Program documents in part 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. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. Abuse means any physical or mental injury; retaliation; or sexual assault inflicted upon a resident other than by accidental means. 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 interview and record review the facility failed to ensure adequate supervision and monitoring of residents during a scheduled smoking break. This failure affected one resident (R3) resulting in resident-to-resident altercation occurring (R4 slapped R3) and has the potential to affect all 37 residents who smoke on the patio area in the facility. Findings include: R3's Brief Interview for Mental Status (BIMS) dated 3/6/26 shows a score of 4 which indicated that R3 has some cognitive impaired. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, developmental disorder of speech and language, nicotine dependance, chronic obstructive pulmonary disease and hypertensive heart disease. R4's Brief Interview for Mental Status (BIMS) dated 3/12/26 shows a score of 15 which indicated that R3 is cognitively intact. R3's face sheet shows that R3 has a diagnosis which includes but not limited to anxiety disorder, major depressive disorder, schizoaffective disorder, bipolar type, primary insomnia, and hypertensive heart disease. On 6/15/26 at 12:42 pm, R6 stated that about a month ago while R6 and other residents were waiting in the hallway on the first floor by the patio door for smoke break he witness R4 walk up to R3 and slap R3 in the face. R6 explained that R3 does not speak and did not know why R4 slapped R3 in the face. R6 stated that the incident took place as the residents were lined up along the patio door awaiting staff to come and that no staff was present to monitor the incident. On 6/15/26 at 1:08 pm, R9 stated, I saw him (referring to R3) get hit by another resident (unable to recall the residents name). R9 then stated, I don't know why he (referring to the resident that hit R3 (R4)) did that. He (referring to R3) is quiet and does not bother anyone. R9 also stated that the incident took place as the residents were lined up along the patio door awaiting staff to come and that no staff was present to monitor the incident. On 6/15/26 at 1:09 pm, V9 (Social Service) stated that the social service department is responsible for monitoring the residents during smoke breaks at the facility. V9 explained that residents who ambulate independently will line up forming a line along the wall outside of the smoke break patio door and when no staff is present to supervise the residents. V9 stated that he was not working on 5/18/26 the day of the incident between R3 and R4. V9 further explained when he returned to work on 5/19/26 he was informed that R4 was sent to the local hospital for slapping R3. V9 denied ever witness R3 and R4 in any previous incidents at the facility or during smoke break times. On 6/16/26 at 11:14 am, V3 (Social Services Director) stated that the social service department is responsible for monitoring the smoke breaks for the residents. V3 then stated that a social service staff should always be present during the resident's smoke breaks. V3 then explained when the resident's line up along the door of the patio area prior to the smoke break time there is not a staff member present to monitor the residents until the smoke time starts. V3 explained that the social service staff are bringing in residents from the front of the building when residents who ambulate began forming a line at the patio door before the social service staff can get to the patio area. V3 explained if residents are not supervised by the patio door, V3 stated; A fight can breakout. On 6/16/26 at 11:37 am, V11 (Psychiatric Rehabilitation Coordinator, PRSC) V11 explained that the residents have designated smoke break times and areas (the front of the facility for residents in wheelchairs and the patio areas for those residents who walk). V11 then explained that the social service staff will issue the residents the cigarettes and monitor the residents for smoke breaks. V11 further explained that residents who smoke on the patio will bring themselves down independently and form a line along the wall leading to the patio door independently. V11 explained that there is no one there to monitor the residents until a social service staff comes to begin the smoke break. V11 explained that R3 and R4 had an incident about a month ago when R4 hit R3. V11 then explained that during the time of the incident he was not present and was gathering the key to turn the patio door alarm and heard a commotion and residents saying Why did you do that? Why did you hit him? (referring to R4 hitting R3). V11 explained that when he went to the patio door area he separated R4 from R3 by removing R4 to the front receptionist desk area and took R3 to the first-floor nurse to be assessed. On 6/17/26 at 1:29 pm, V14 (LPN) stated he was R4's nurse on the day of the incident with R3 and R4 on 5/18/26 at the facility. V14 stated that he did not witness the incident between R3 and R4 and was informed that R4 had a physical altercation hitting R3. V14 stated that he was informed that the altercation took place on the first floor when the residents were going to smoke. V14 explained when the smoke break time is announced by social service department the residents go to the designated area to smoke, and the social service then takes the residents out to smoke. V14 stated that residents should not be lining up for smoke break until social services inform the residents it is time to smoke and is there to supervise the resident. V14 then explained that after the altercation R4 was placed on 1:1 monitoring, informed R4's physician and R4 was sent to the local hospital for psychiatric evaluation immediately following the incident and has not returned to the facility. On 6/18/26 at 10:29 am, V1 (Administrator) stated that she is the facility's abuse coordinator. V1 stated that last month she was notified that R4 slapped R3 while the residents were in line for the smoke by the patio door. V1 explained that R4 stated that he felt that R3 was talking about him and then V1 then explained that R3 is a non-verbal resident. V1 explained that staff separate R3 and R4 and placed them on 1:1 monitoring, called R3 and R4's physician and R4 was sent to the hospital for evaluation. V1 explained that R3 had a Xray of the face and was sent to the hospital for further evaluation and returned to the facility with no finding/injuries noted. V1 explained that if a resident hit another resident that it is resident-to resident abuse. V1 also stated if staff leave residents unsupervised accidents or an incident can occur. V1 stated that staff should have needed supplies for the residents prior to the monitoring the residents for smoke break. V1 stated that residents are directed to line up for smoke break once the smoke break is announced for residents to attend and residents who line up prior to the announcement are redirected back to the unit until the smoke break begins. V1 explained that during the altercation with R3 and R4 V11 (Psychiatric Rehabilitation Service Coordinator, PRSC) was assigned to monitor the residents for the patio smoke break and left the residents who were in line to go to the nurses station to get the residents cigarettes and keys for the smoke break and did not observe the altercation with R3 and R4. The facility document dated 5/18/26 shows a signed statement by R4 documents in part: I was walking down the hallway. He said something about me always blowing my nose and was talking about my eye, so I smacked him. I had to stop him. I don't hit it people.The facility policy dated 2026 and titled Facility Smoking Safety documents, in part: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy.The facility policy dated 1/26 and titled Resident Supervision Policy documents, in part: To ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent a voidable accident. Procedure: All residents will be supervised.

Based on interview and record review the facility failed to ensure that one resident (R1) was free from physical abuse when R2 struck R1 during an altercation in their shared room. This affected two of three residents (R1/R2) reviewed for abuse. Findings include: The facility initial reportable incident to the local state agency dated 2/12/26 at 9:54 pm, documents, in part: 2/12 2026 at approximately 804 PM it was reported that R1 and R2 displayed physical aggression in their room period staff overheard yelling and responded to residents' room as they are roommates. Resident immediately separated and both residents placed on one-to-one staff monitoring. Skin assessment completed for both residents. R1 noted with bump on right side of forehead in superficial scratch. R2 noted without injury redness swelling or bruising. Police made aware positions made aware with order to send both residents to the local hospital for an evaluation. Order noted and carried out. R1 to be sent to the local hospital and R2 to be sent to the local psychiatric hospital. To both residents being sent for evaluation, safety of other residents is secured. Both residents' representatives notified of incident and investigation process is ongoing. We will follow up when completed.The facility initial reportable incident to the local state agency dated 2/12/26 at 9:54 pm, documents, in part: R2 and R1 were in their room, as they are roommates. R2 had his television on in R1 complained about noise level, R2 pushed the dresser that is between both beds more towards the side of R1. R1 walked over towards the side of R2's bed. R2 struck R1 in the forehead. Staff overheard yelling coming from R1 and R2's room and responded immediately. Both residents were separated immediately and placed on one-to-one staff intervention. Charge nurse assesses both residents. R1 noted with bump on right side of forehead and superficial scratch. R2 two noted without any injury, redness, swelling, or bruising. Police may aware with report number JK147528. Physicians made aware with orders to send both residents to the hospital for an evaluation. Both residents remain on one-to-one monitoring until transported to hospital. Order noted and carried out. R1 was sent to the local hospital with IVD (involuntary discharge) and was readmitted . Counseling conducted with resident R1 upon return to refrain from engaging in aggressive behavior and to notify staff immediately of any issues or concerns. R2 was transported to local hospital with IVD, and was admitted , facility notified that resident will {sic} accept another facility and will be transferred. Physicians and representatives notified of outcome of investigation. Documentation completed at outcome of investigation.R1 has a diagnosis which includes but is not limited to: Paranoid schizophrenia.Brief Interview for Mental Status (BIMS) dated 3/5/26 shows a score of 12 which indicates cognitively intact.R2 has a diagnosis which includes but is not limited to: Psychosis not due to a substance, and schizophrenia.BIMS dated 12/26/25 shows a score of 13 which indicates cognitively intact.On 5/1/26 at 11:07 am, R1 stated he recalls being hit by R2 at the facility a few months ago. R1 then explained that R2 hit R1 in the face and then R1 shoved R2 back. R1 then stated that he does not recall what the altercation was regarding and that he has not seen R2 since the incident.On 5/1/26 at 11:32 am, V4 (Licensed Practical Nurse, LPN ) stated in February 2026 R1 and R2 had an altercation at the facility in their room. V4 explained that during the 3:00 pm-11:00 pm shift after dinner, around 7:00 pm - 8:00 pm R1 and R2 were in their room in bed. V4 then stated that he was sitting at the nurse's station with the other staff members when he heard a noise from R1 and R2's room. V4 then explained that he and the Certified Nursing Assistants (CNA's) went to R1 and R2's room and noted R1 and R2 physically engaging with each other. V4 further explained that the CNA's had already separated R1 and R2 when V4 entered R1 and R2's room and he observed R1 and R2 were still verbally arguing with each other regarding R2's television (TV). V4 explained that R1 and R2 were immediately separated and that staff placed R2 in the day room. Next, V4 explained that he cleaned R1's scratches and covered R1's injury, notified the administrator and called R1's physician, who gave orders to send R1 to the local hospital due to R1's face injury and bump to the head. V4 also explained that R2's psychiatrist was notified with orders for R2 to be sent to the local hospital for psychiatric evaluation. V4 also explained that the local police were informed, arrived at the facility and spoke with R2 ( R1 was already sent to the local hospital), and a report number (JK147528) was given. V4 denied any knowledge of R1 and R2 with prior altercations or ever seeing R1 or R2 in alterations with other residents. V4 also denied witnessing R1 or R2 having behaviors at the facility. V4 explained that If resident hits another resident it is physical abuse. On 5/1/26 at 3:29 pm, V1 (Administrator) stated that she is the abuse coordinator at the facility. V1 stated that staff report abuse to V1 immediately and V1 sends the initial report to the local state agency within two hours of the abuse being reported. V1 also stated that on 2/12/26 she received a call that R1 and R2 got into an altercation and were physically aggressive with each other. V1 then stated that R1 had scratches and a lump to his forehead during the altercation with R2. V1 stated if a resident hits another resident it is considered abuse. V1 also stated that staff immediately separated R1 and R2, notified V1, an initial reportable to the local state agency was made, R1 and R2's family were notified as well as the police and R1 and R2's physicians are notified with orders carried out. V1 explained that R1 and R2 were sent to the local hospital, R2 for psychiatric evaluation and R1 for medical attention due to injury to R1's face. V1 denied that R1 or R2 had any altercations prior to this incident or expressed desires to change room. V1 stated that R1 did not have any incidents while V1 was at the facility and that R2 was in a previous altercation at the facility but was not the aggressor. V1 stated that no staff witnessed the incident and both residents reported hitting each however, only R1 sustained injuries.R1's progress note dated 02/12/26 at 8:01 pm authored by V4 (LPN) documents, in part: Staff heard noise coming from resident's room, staff went to checked, noted that two residents appeared engaged in aggressive behavior. Staff intervened, separated the two residents and put them on 1:1 monitoring and Administrator immediately notified. One of the residents noted with multiple nail scratches to face and slight bump to his Rt (right) forehead. On assessment, face noted with nail scratches and slight bump to his Rt fore-head, area cleanse with NNS (normal saline solution) and dry dressing applied, and Neuro (neurology) checks initiated. V/s (vital signs) taken: BP (blood pressure) 113/76, P (pulse)/79, T (temperature)/97.6, R (respirations)/17, 02 (oxygen saturation) Sat 97% RA (room air), BS (blood sugar)117mg/dl (milligrams/deciliter). On interview, resident stated, He does not want me to watch my T.V (television) by tuning it off, so I tried to turn his off too. Teaching and education given to resident to always report any incident to the staff, nodded in understanding. (local) police was invited for investigation. Officer batch {sic} # 18400 and Beat {sic} 2432 investigated the incident, case J K 147528. Physician notified with order to transfer resident to hospital for medical evaluation. Resident contact/POA (power of attorney), notified via voice. Ambulance called with ETA (estimate time of arrival) of 40 mins (minutes), resident remain calm. At 9:20pm, 2 paramedics from Ambulance arrived facility, resident transferred in-route to the hospital. Endorse to oncoming Nurse to f/u (follow up) with disposition.R1's Physician Order Sheet (POS) dated 10/16/2023 documents, in part: Monitoring: Behavior Monitoring for the following itching, picking at skin restlessness, hitting, increase in complaints, biting kicking, spitting, cursing, elopement, stealing, delusions, hallucinations, psychosis, aggression.R1's Behavior Care plan documents, in part: R1 has diagnosis of Paranoid that contributes to their behavior symptoms. R1 demonstrates behavioral distress related to: ineffective coping mechanisms, poor verbal skills, poor self-esteem and feelings of inadequacy, and challenges of mental illness. The problems are manifested by attempting to become physically aggressive behavior when agitated 8/5/24. Resident has history of physical aggressive behavior necessitating his hospitalization before his transfer to this facility. Resident appears as baseline has not been physically aggressive since admission.R2's progress note dated 2/12/26 at 8:01 pm, documents, in part: Staff heard noise coming from resident's room, staff went to checked, noted that two residents appeared engaged in aggressive behavior. Staff intervened, separated the two residents and put them on 1:1 monitoring and Administrator immediately notified. On interview, resident stated, He was in my space, trying to tune off my TV. Teaching and education given to resident to always report any incident to staff, nodded in understanding. Chicago police was invited for investigation. J K 147528. Physician notified with order to transfer resident to hospital for psych (psychiatric) evaluation. All necessary documentation faxed to psych intake nurse at the hospital. Resident remain calm at this time, skin remain intact. Ambulance called with ETA of 1hr (hour). Resident's contact/sister, called on no response, message left via voice. At 9:50pm, 2 paramedics from Ambulance arrive facility, resident transferred in-route to the hospital. Endorse to oncoming Nurse to f/u.R2's POS dated 2/1/26- 2/28/26 shows orders for Monitoring Behavior: Monitoring for itching, picking at skin restlessness, agitation, hitting, kicking, spitting, cursing, elopement, stealing, delusions, hallucinations, refusing care, anxiety, insomnia, depression interventions . Every day and night shift for target behaviors document the number of episodes that the behavior occurs each shift.R2's Behavior Care plan documents in part: Focus: Alleged physical abuse/aggression 2/12/26.The facility's document dated 2/12/26 documents, in part: Number JK147528, Incident : Battery.R2's untitled document dated 2/12/26 authored by R2 documents, in part: R1 came up to me and told me that my television was his. I told him it wasn't. He (R1) started yelling at me (R2). We argued a little and he started walking towards me (R2). He (R1) pushed me (R2), and I (R2) hit him (R1).R1's untitled document dated 2/12/26 authored by R1 documents, in part: R1 asked R2 could he stop making noise. R2 got louder and pushed the dresser over towards R1. R1 got up out of bed and walked over by R2 and R2 hit R1 and R1 hit R2 back.The facility document dated 1/2026 and titled Abuse Retaliation Policy and Prevention documents, in part: 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. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents . This will be done by Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment . Abuse: Abuse means any physical or mental injury; retaliation or sexual assault inflicted upon a resident other than by accidental means . Physical abuse is the infliction of injury on a resident that occurs other than by accidental means, and that requires medical attention. Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to follow a care plan and provide a safe environment for a resident at risk for falls by failing to ensure items were away from a residents bed/space for one (R1) of three residents reviewed for falls. Findings include:R1's history includes but is not limited to heart disease, paranoid schizophrenia, hypertension, chronic pain, and history of falling.R1's Minimum Data Set (MDS), dated [DATE], documents, in part, for Section C. Brief Interview for Mental Status (BIMS) score is a 7 which indicates R1 has severe cognitive impairment. Section GG. Mobility: D. Sit to Stand is coded as a 3 which indicates partial/moderate assistance. I. Walk 10 feet is coded with a 3 which indicates partial/moderate assistance.On 4/10/26 at 12:10 pm, R1 noted in room lying in bed. R1's right upper eye lid is noted to be black with no swelling. R1's bed was noted in the lowest position with one floor mat on the right side. There was no floor mat on the left side of the floor.R1's progress notes dated 4/4/26 at 3:16 pm, documents, in part, Around 8:00 am, resident observed comfortably in bed. Alert and oriented x1, able to answer 'yes or no' questions. Scheduled medications administered as ordered and well tolerated. Around 12:00 pm, when staff went in the room to provide care, resident was observed with swelling and discoloration on her right upper eyelid. Skin remains intact. Assessed for pain, resident verbalized No.R1's progress note dated 4/4/26 at 11:46 pm, documents, in part, Resident returned from ER (Emergency Room) accompanied by two paramedics, resident is alert and oriented to self with periods of confusion. Resident noted with darkened area/discoloration over the eyebrow region. Resident returns with a diagnosis of periorbital contusion.R1's hospital visit summary dated 4/4/26 documents, in part, Reason for visit: eye trauma. Diagnosis: Periorbital contusion.R1's Fall Occurrence Report Investigation dated 4/4/26 documents, in part, Prior history of fall. Environmental Factors: Furniture, Description of Fall: fall when ambulating, Description of Fall: Resident noted with swelling to right eye. Bedside dresser noted close to right side of bed where resident hit her eye when she fell. The facility's Final Reportable Investigation form completed for R1, dated 4/4/26 documents , Investigation reveals that the resident attempted to get out of bed unassisted lost balance and fell. Hitting the right side eye on the edge of bedside dresser which results in the injuries sustained. Upon return to the facility safety measures was put in place where by the bedside dresser located close to the right side of bed was removed from the room. On 4/10/26 at 1:00 pm, V3 Certified Nursing Assistant (CNA) stated, I took care of R1 that morning. I did my morning rounds around 7:00 am, and at that time R1 was in bed sleeping. I did not see her face at that time because of her sleeping. In the afternoon I went to give her ADL (Activity of Daily Living) care, and that's when I noticed her face. Her face was swollen and reddish. I did not ask her what happened, I just called the nurse. The right eyelid was swollen and red. Her eye was not red, just her eyelid was swollen. The nurse came in, assessed her. She was the only one in the room at that time her roommates were in the day room. She does walk at times, but she needs help and will try to get up alone. I do round every 2 hours.On 4/10/26 at 1:20 pm V4 CNA stated, I tried to feed her that morning, but she did not eat. There was nothing on her face. Her eyes area was not swollen or redden.On 4/10/26 at 1:49 pm, V5 License Practical Nurse (LPN) stated, I sent R1 to the hospital. It was a Saturday I got report from the night nurse. I did not get in report of any fall or injury that R1 had gotten. I did my round I saw she was sleeping I let her sleep. I gave morning medications to R1 and there was nothing on her face. Her face was intact. It was around noon when the CNA said to come see her face. Her right eye was swollen with some discoloration. I originally thought she had an eye infection because she had that before. She is only alert and orientated x1. She only answers yes and no questions. I called the Nurse Practitioner (NP), who said to put an ice pack on it, and I did that, I told the Director of Nursing (DON), and she said to call him (NP) back to get an order to send to the hospital because we are unsure if she had fallen. I am not aware of her falling on my shift. She would have been able to get up off the floor by herself. She can walk with assistance.On 4/10/26 at 3:17 pm, V2 (DON) stated that the nurse was called by the staff around 12:30 pm on 4/4/26 while going to do ADL care that swelling and discoloration to R1's right eye lid area was noted. The nurse called the NP and got an order for an ice pack to be sent to the ER. R1 came back from the hospital, where she had an MRI (Magnetic Resonance Imaging), CT (Computed Tomography) and an X-ray that was all normal. We think that R1 had an unwitnessed fall and hit her eye on her dresser that was close to her bed. R1 is not supposed to get up by herself, but sometimes she does attempt to get up. R1 likes being in her room. I would say R1 is a risk for falling being in her room and attempting to get up. I was told R1 sometimes tries to get up. I would say it's not proper supervision to let her stay in the room. Proper supervision would be to put her in the day room to be closely monitored by staff, with frequent monitoring. I don't know how many floor mats should be on the floor. I have to consult with restorative.On 4/10/26 at 4;00 pm, V1 Administrator stated, When R1 came back from the hospital, I went to see what happened. I asked her if she did R1 fell, and she said yes. I talked to R1 that Sunday. She can answer yes or no questions. She does understand what is being asked. No staff stated that she had fallen. No staff picked her up off the floor. She can get up off the floor on her own. That day we thought it was medical with her eye because she had swelling with redness to the eye and has had an eye condition like that in the past. More interventions could be placed to prevent her from falling. Another floor mat, shifting her bed to be closer to the wall and increasing rounds.R1's Active Physician orders dated 6/13/25 documents, in part, May have floor mat to prevent fall related injuries.R1's care plan dated 4/1/26 Focus: At risk for falls related to incidence of use of psychotropic medication or new medication that may cause dizziness. Goal: Resident will be free of injury related to falls. Interventions: increased monitoring every 1-2 hours. 4/6/26 Focus: Fall with injury noted on 4/4/26. Interventions: Move dressers and other items that could cause injuries out from residents room or away from residents bed/space, Active -effective: 7/18/2022. Facility's policy titled, Resident Supervision Policy dated 7/2025, documents, in part, Policy: To ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent a voidable accident. Procedure: 1. All residents will be supervised . 6. Nurse will round their assignment hourly unless otherwise indicated that more often is required. 7. CNA will round his/her assignment every 2 hours unless otherwise indicated more often is required.Facility's policy titled, Fall and Safety Prevention Policy date revised 10/25 documents, in part, Policy: To ensure residents are assessed for potential fall risk and for equipment to ensure safety and prevention of injury such as floor mats, low beds, helmet and other needed devices. Procedure: . 8. The frequency of safety monitoring will be determined by the resident's risk factors and care plan.

Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse by a resident. This failure affected two (R1 & R2) residents out of 13 residents reviewed for abuse. Findings include:On 10/22/2025 at 3:44pm, R8 stated she was in her room adjacent to his (R2)'s room when she heard someone yelling 'nurse' 'nurse'. She drew the curtain and saw (R1) on the floor and a wheelchair turned on its side and (R2) punching (R1). She could not see where the punches landed on (R1). On 10/22/2025 at 3:58pm, V10 (Certified Nursing Assistant) stated he saw (R1) on the floor and the wheelchair beside him and (R2) was hitting (R1)'s back with his (R2) hand on a fist.On 10/21/2025 at 12:33pm, V3 (Licensed Practice Nurse) stated that particular day (10/14/2025). He (R1) went to the room to ask for (R3- R2's roommate), and he (R2) said (R3) was not in the room. On his (R1) way out, he calls him a b***h. He (R2) stated he comes out of his room, and he starts to hit him (R1). On 10/21/2025 at 2;21pm, V4 (Psychiatric Rehabilitation Services Assistant) stated he was called up to the floor between 2:30pm and 3:30pm. When he got to the floor, (R1) was sitting on his buttocks trying to get back into his wheelchair. (R2) was already separated from the situation. He (R2) said he (R1) came into the room looking for (R3). He (R2) stated to him (R1) that (R3) wasn't in the room. On his way out, (R1) was disrespecting him by calling him out name. On his way out, (R1) said B***h. And he (R2) said that he hit him (R1). V4 stated he told him (R2) he can't put his hands on others because that's physical abuse, that he can't be physical with anybody. Everybody needs to be safe, feel safe at all times because this is their home, and residents should always feel safe in their home.On 10/21/2025 at 2:54pm, V5 (Psychiatric Rehabilitation Services Coordinator) stated he (R1) said he was coming out of the room and out of nowhere he (R2) hit him all over his body. V5 stated (R2) said he (R1) has been calling him names. (R2) said (R1) called him b***h and n***o. That he (R1) came to the room and asked for (R3). He (R2) told him he (R3) was not in the room and as he (R1) was leaving the room, he called him a b***h again. (R1) was calling (R2) b***h and n***o and then in return, (R2) followed (R1) and hit him all over his body.On 10/22/2025 at 1:34pm V1 (Administrator) stated (R1) went to (R2)'s room to look for (R3). (R2) said he (R3) was not in the room and (R1) called him a b***h and he (R2) followed him outside and hit him on the cheek. V1 stated it is not expected for residents to be abused while at the facility. The reportable result was 'founded' because (R2) did admit he hit (R1). R1's Face sheet documented that R1's Diagnoses: (include but not limited to) hemiplegia, right hand osteomyelitis, and hypertensive heart disease. R1's (08/01/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact. R1's (10/14/2025) Progress Notes documented, in part Resident went to another residents room to ask for a fellow peer, the roommate responded to him saying the person he is looking for was not in the room, on his way out he called the resident in the room a B***H. This aggravated the resident and followed him on his way out the room and punched him, which made the both of them start to fight. Dr. (doctor) notified with order to send resident to hospital for psych evaluation. Authored by V3. R2's Face Sheet documented that R2's diagnoses: (include but not limited to) tumor of the bronchus and lung, Parkinson's disease, and schizophrenia. R2's (08/14/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R2's mental status as cognitively intact. R2's (10/14/2025) Progress Notes documented, in part Resident was in his room when another resident came to his room to ask for his roommate, resident stated i told him my roommate was not in the room but he still came in and went to his bedside and on his way out he called me a B***H, This aggravated the resident which led him to follow him on his way out the room and punched him, which made the both of them start to fight. NOD (nurse on duty) immediately went there to separate the fight and social services was called. Authored by: V3 (Licensed Practice Nurse) R2's (10/14/2025) Progress note documented, in part resident was petitioned to the hospital for psychiatric evaluation due to physical altercation with another resident. R2's (10/14/2025) Notice of Involuntary Transfer or Discharge and opportunity for hearing for Nursing Home Residents documented, in part Federal Proceeding. This facility seeks to transfer or discharge you pursuant to the regulations of the health care financing administrations for States and long term care facilities. As recorded in your clinic Importance with Section 4 eight 3.15 (c) of the federal regulations, the reason for this proposed transfer or discharge is: the safety of individuals in this facility is endangered.R1's (10/14/2025) Statement documented, in part Resident Name: (R1). Statement: (R1) stated he went into room to see (R3). On the way out, (R2) attacked him in the hallway. R2's (10/14/2025) Statement documented, in part Resident Name: (R2). Statement: (R2) stated (R1) came to his room looking for (R3). On his way out of the room, (R2) stated (R1) called him B***H so he attacked him in the hallway. He (R2) stated he hit him (R1) in jaw. R8's (10/14/2025) Statement documented, in part Resident Name: (R8). Statement: (R8) heard (R1) yelling for the nurse. She opened her curtain and saw (R1) on the floor and (R2) standing above (R1) and (R2) was punching (R1). V3's (10/14/2025) Statement documented, in part Saw (R2) and (R1) holding each other fighting. At this point, (R1) was on the floor and (R2) stood up over him. V10's (10/14/2025) Statement documented, in part Heard someone yelling for the nurse. When I (V10) got there with the nurse, (R2) was over (R1) hitting him (R1). The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. You must not be abused. Your facility must be safe. The (10/24/2022) Abuse Prevention Policy documented, in part This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of residents. Definitions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines).

Based on interviews and record review, the facility failed to ensure that one resident (R2) was free from abuse. This failure has affected one of four residents reviewed for abuse. Findings include: R2 is [AGE] year old with diagnosis including but not limited to: diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, heart failure and carcinoma of oral cavity. R2's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. On 6/10/2025 at 11:30 AM, R2 stated that R3 walked up to her (R2) and begun to choke her for no reason. She stated that she was not afraid of (R3), and that she felt safe in the facility and had no additional concerns. On 6/10/2025 at 11:30 AM, R10 and R11 both stated that they witnessed R3 grabbing R2 around the neck. On 6/11/2025 at 10:38 AM, V2 (DON/ Director of Nursing) stated that she was informed that on 4/25/2025, R3 had an altercation with R2 because she (R2) was looking at him (R3). R3 was discharged from the facility after the altercation. She (R2) shouldn't have gotten attacked. We do our best to keep all residents safe in the facility. R2's reported incident dated 4/25/2025 documents, R2 alleged that R3 grabbed her (R2) around neck; No redness, bruising or injuries were noted at the time of the assessment. R2 denied complaints of pain; R2 stated I'm ok, I'm safe, I want to stay at the facility. Facility Census dated 6/9/2024 excludes R3 as an active resident. Facility policy titled, Abuse Prevention Policy documents, this facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services and mistreatment by anyone including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) food items were stored according to manufacturer recommendations, c.) discard expired food based on use by date and guidelines, d.) sanitize kitchen equipment based on manufacturers' procedure directions. These failures have the potential to affect all 150 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:10 AM, during initial kitchen tour V5 (Dietary Supervisor) stated when items are delivered, they are labeled with a delivery date. When items are opened or prepared, they should be labeled with opened and/or preparation date and with a use by date. V5 stated all items should be used within seven days with day one being the preparation date, day seven being the use by date. At the end of day seven items should be discarded. V5 stated it is important for items to be labeled with a delivery date, opened date, and use by date so the kitchen staff knows when to discard items, so they are not served to the residents to prevent food borne illnesses. V5 stated manufacturer use by dates are followed and manufacturer storage guidelines are followed as listed on the product. On [DATE] at 9:12 AM, observed the following items in walk-in refrigerator: 1. An unlabeled plastic container with boiled eggs inside. There was no prepared or use by date on the container. V5 stated there is no way of knowing when the boiled eggs were prepared because they were not dated, and they should have been labeled with a prepared and use by date. 2. Small prepared container of tuna fish salad made with what appeared to be mayonnaise covered in plastic wrap. Observed milky-colored liquid pooling around the edges of the tuna fish salad. The container was not labeled with a prepared date or use by date. V5 stated the tuna fish salad should have been labeled and dated with a prepared and use by date. On [DATE] at 9:25 AM, observed in a reach-in refrigerator referred by V5 as the thaw-out reach in a container labeled as mechanical soft cold cut salad. The item was labeled with a preparation date of [DATE] and a use by date of [DATE]. V5 stated this was ground bologna mixed with mayonnaise and served to residents on mechanical soft diets. V5 stated it should have been thrown out on [DATE] and should not be served to residents because it could potentially make the residents sick if someone was to serve the item to them. On [DATE] at 9:30 AM - observed the following items being stored on the spice rack next to the tray line: 1.) Opened 48-ounce bottle of lemon juice, 50% filled. The lemon juice manufacturer label printed on the side of the bottle listed refrigerate after opening for best results. The bottle was not labeled with an open or use by date. V5 stated the spice rack is where the lemon juice bottle is usually stored, and she was not aware that it needed to be refrigerated once it had been opened. V5 stated when the bottle was opened it should have been labeled with an opened date, so the staff knows when to throw it out and it should be stored in the refrigerator based on the manufacturer label. 2.) Opened 1-gallon container of soy sauce, 75% filled. The soy sauce manufacturer label printed on the side of the soy sauce container read refrigerate after opening for quality. The soy sauce bottle was labeled with a delivery date [DATE] but was not labeled with an opened or use by date. V5 stated the soy sauce should have been labeled with an opened date and use by date when the item was opened and based on the manufacturer's guidelines the soy sauce should be stored in the refrigerator. On [DATE] at 10:18 AM, during pureed food preparation observations observed V27 (Cook) take the dirty blender parts to the three-compartment sink and wash, rinse and then quickly dip each blender piece into the sanitizing solution while still holding onto the item for the following time frame: blender lid (2 seconds), blade (3 seconds), blender container (2 seconds), 8-ounce spoodle (3 seconds). After quickly dipping each blender part into the sanitation solution V27 placed item on the side of the sink. Then, observed V27 retrieve a clean towel cloth and use the towel to hand dry each of the blender parts. On [DATE] at 10:21 AM, observed V27 take the hand dried blender parts and put them back on the base on the blender and proceed to prepare the pureed diced potatoes to desired consistency. On [DATE] at 10:25 AM, observed V27 take the dirty blender parts to the three-compartment sink and wash, rinse and then dip each piece into the sanitizing solution while still holding the item for the following time frame: blender lid (2 seconds), blade (2 seconds), blender container (2 seconds), measuring cup (2 seconds). On [DATE] at 10:27 AM, observed V27 retrieve a clean towel cloth and use the towel to hand dry each of the blender parts and place the parts back on the base of the blender for use. On [DATE] at 10:28 AM, V5 (Dietary Manager) stated items need to be fully submerged in the sanitizing solution in the third sink of the three-compartment sink for 60 seconds. V5 stated if the items are not fully sanitized for 60 seconds, then bacteria can grow, and this has the potential to cause food borne illness and could make the residents sick. V5 stated all items washed, rinsed, and sanitized in the three-compartment sink should be air dried. V5 stated a towel should not be used. V5 stated the poster attached to the wall over the three compartment is from the manufacturer of the sanitization solution the kitchen uses. On [DATE] at 10:30 AM, V27 stated he did not know the items he was cleaning needed to be left in the sanitizing solution for a full minute. V27 stated he knew the cleaned items should be allowed to air dry before using but he did not have a choice because he was in a rush to prepare the pureed food before the tray line could start and the kitchen only has the one blender to use for pureed preparation. On [DATE], facility provided list of diet orders for all residents in the facility. The diet order list indicates there is one resident receiving nothing by mouth (NPO). Facility provided copy of manufacturer's poster titled, Procedure for 3 Compartment Sink which documents in part, immerse utensils in SANITIZER SINK for a full minute and remove utensils from SANITIZER sink. Invert to drain. Let them air dry, do not wipe. Facility provided policy titled Manual Sanitizing in Three-Compartment Sink dated 2017 which documents in part, manufacturer's instructions on the wall poster above the three-compartment sink are followed and the length of the immersion time manufacturer's instructions are followed. Facility provided policy titled, Labeling and Dating Food dated 2017 which documents in part, to decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded and refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by and the discard/use by date will be a maximum of six days after preparation.

Based on observation, interview, and record review the facility failed to ensure staff wear proper PPE (Personal Protective Equipment) during high contact resident care activities for 1 (R1) resident on Enhanced Barrier Precautions (EBP) reviewed for infection control on the total sample of 61. Findings include: On 4/29/25 at 1:05 PM Surveyor conducted medication administration observation with V10 (LPN) and stated R1 is NPO (nothing by mouth) and has G-tube (Gastrostomy Tube). Observed R1 lying in bed, on moderate high back rest with G-tube feeding Nepro at 60ml (milliliter) flush 100ml every 8hrs (hours) infusing via pump. V10 prepared Valproic acid 250mg (milligrams) 5ml and administered medication via G-tube wearing gloves. Observed EBP (Enhanced Barrier Precautions) signage posted on the wall over R1's head part. V10 wore gloves during medication administration via G-tube but she did not wear gown. On 4/30/25 At 10:28am V2 (DON / Director of Nursing) stated she has been working in the facility for a year. She said staff should observe EBP when resident has indwelling medical devices such as G-tube. V2 said if staff is performing high care resident activities such as G-tube medication administration, nurse should wear proper PPE such as gloves and gown to prevent cross contamination and prevent transmission of infection. She said if the nurse who administered medication via G-tube and not wearing proper PPE (Personal Protective Equipment) could potentially cross contaminate other residents she is taking care of or assigned to. On 4/30/25 At 11:56am V4 (Infection Preventionist / IP NURSE) stated she has been working in the facility for 2 years. She said EBP are for residents with MDRO (Multidrug-resistant bacteria), with indwelling medical devices such as G-tube, indwelling urinary, dialysis catheter, open draining wounds. EBP signage is kept by door entrance or head of the bed to alert staff that resident is on EBP. V4 said when administering medication, feeding thru G-tube, staff must wear proper PPE such as gown and gloves to prevent cross contamination. Stated if staff is not wearing proper PPE it could cause potential cross contamination of other residents assigned to staff. R1's face sheet showed last admitted on 2/20/2025 with diagnoses not limited to Encounter for attention to gastrostomy, Hyperlipidemia, Cerebral infarction, End stage renal disease, Dependence on renal dialysis, Hypertensive heart disease. MDS (Minimum Data Set) dated 2/27/2025 showed R1's cognition was severely impaired. R1's physician orders dated 4/29/25 showed orders not limited to: Resident is placed on Enhanced Barrier Precautions due to Rt chest permcath for dialysis/Indwelling Foley Cath/ Wounds on the Sacrum/Peg-tube for feeding effective 2/20/25. Valproic acid 250mg/5ml give 5ml by G-tube route every 8 hours Care plan dated 2/21/2025 showed in part: R1 is on Enhanced Barrier Precautions. Staff will wear PPE before entering resident's room. Facility's EBP signage showed in part: Providers and staff must wear gloves and gown for the following high-contact resident care activities: Device care or use - feeding tube. Facility's Enhanced Barrier Precautions policy dated 10/24 showed in part: EBP involve gown and glove use during high contact resident care activities. During care: Gown and gloves for these resident care activities: Feeding tubes.

Based on observation, interview and record review, the facility failed to prepare pureed food in appropriate diet consistency form based on recipe and spreadsheet. This failure has the potential to affect four residents on pureed diets (R9, R15, R68, R75) prepared in the facility kitchen. Findings Include: On 04/30/25 at 11:06 PM, observed lunch tray line in progress. Desserts were already portioned out and on resident's meal trays. Observed regularly prepared gelatin without canned fruit on R9, R15, R68, R75's lunch trays. The regularly prepared gelatin without canned fruit was not pureed and the gelatin appeared firm and stiff, holding its shape in large, spooned portions in the bowl. On 04/30/25 at 11:10 AM, V5 (Dietary Manager) stated the regular diets are receiving prepared gelatin mixed diced pears for dessert and the pureed diets are receiving regularly prepared gelatin but without the diced pears. On 04/30/25 at 11:11 AM, V27 (Cook) stated he prepared regular gelatin with diced pears for the regular diets and the regular gelatin without dice pears for the pureed diets. V27 stated he did not puree the gelatin. On 04/30/25 at 12:45 PM, V20 (Registered Dietitian) stated some of the reasons residents are on pureed diets is because they are missing teeth and cannot chew and/or they have swallowing issues. V20 stated those residents receiving pureed diets typically are at higher nutritional risk. V20 stated it is important for the cook to follow the recipes and the spreadsheets to make they are serving the food in the correct consistency. V20 stated if the spreadsheets list pureed gelatin to be served than it should have been prepared following the recipe for pureed gelatin and served in a pureed form. V20 stated the potential problem of a the resident on a pureed diet receiving regular gelatin is that the resident could choke or aspirate. R9's diagnosis which includes but not limited to Dysphagia and has a physician order dated 01/04/25 for pureed diet with thin liquids. R9's MDS (Minimum Data Set) from 02/06/25 indicates resident is rarely/never understood. BIMS (Brief Interview for Mental Status) not able to be conducted. R9's meal ticket documents in part, R9 is on a pureed diet. R15's diagnosis which includes but not limited to Dysphasia oral phase, Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease, Unspecified Convulsions, Adult Failure to Thrive, Gastro-Esophageal Reflux Disease with Esophagitis and has a physician order dated 03/13/25 for pureed diet within thin liquids. R15's MDS dated [DATE] documents BIMS score 05/15 indicating severe cognitive impairment. R15's meal ticket documents in part, R15 is on a pureed diet. R68's diagnosis which includes but not limited to Dysphagia oral phase, Cerebral Infarction due to Thrombosis of Unspecified Precerebral Artery, Seizures, Cognitive Communication Deficit and has a physician order dated 01/04/25 for pureed diet on nectar thick liquid. R68's MDS dated [DATE] indicates resident is rarely/never understood. BIMS (Brief Interview for Mental Status) not able to be conducted. R68's meal ticket documents in part, R68 is on a pureed diet with nectar thick liquids. R75's diagnosis which includes but not limited to Dysphagia, Oropharyngeal Phase, Unspecified Intellectual Disabilities, Convulsions, Dementia, Gastro-Esophageal Reflux Disease without Esophagitis and has a physician order dated 02/17/25 for level 1 puree with mildly thickened liquid nectar. R75's MDS dated [DATE] documents BIMS score 08/15 indicating moderately impaired cognition. R75's meal ticket documents in part, R75 is on a pureed diet with nectar thick liquids. Facility provided document titled Daily Spreadsheet titled CCA Kosher Menu - Fall 2024/Winter 2024-2025 Week 4 Wednesday which indicates pureed diets to be served pureed fruited red Jello (#10 scoop) at lunch. Facility provided recipe titled Pureed Fruited Jello (gelatin) dated 07/18 which documents in part, as part of preparation procedure to measure portion of regular fruited Jello (gelatin) and pureed fruited Jello (gelatin) in food processor or blender until blended smoothly. Add thickener in small amounts as needed to reach desired consistency. Facility provide policy titled Pureed/Dysphagia Diet dated 2010 documents in part, food will be provided in a form designed to meet individual needs. The texture of the food may be altered to pureed consistency. Standardized recipes for pureed food will be followed. Facility provided policy titled Standardized Recipes dated 2010 documents in part, standardized recipes will be available in the kitchen and will be used in food preparation. All foods will be prepared according to standardized recipes provide by the menu source and standardized recipes include number of servings, ingredients, preparation directions, and serving sizes.

Based on observation, interview and record review, the facility failed to properly date opened multi-dose inhaler for 1 (R27) resident, ensure that multi-dose insulins and antibiotic medication were stored properly at appropriate temperature for 4 (R12, R33, R57, R205) residents and discard expired multi-dose vial injection reviewed for medication storage and labeling. The findings include: On [DATE] at 9:34 AM Surveyor inspected 3B medication cart with V6 (Licensed Practical Nurse / LPN) and found the following medications inside the medication cart: - R205's Penicillin G 4ml (milliliter) injection with Pharmacy label indicated keep in refrigerator do not freeze. Medication was found inside the medication cart and was not refrigerated. - R27's opened multi-dose Ventolin HFA inhaler with no open date label. V6 said once inhaler is opened it should be dated to know when to discard. On [DATE] at 9:41am 3rd floor medication room inspected with V6 and found the following inside the refrigerator with temperature logged at 40F: - R12's Lantus insulin vial kept in fridge with open date on [DATE]. Pharmacy label showed: Refrigerate until opened. Discard 28 days after opening at room temperature. R12's Fiasp flex (Aspart) insulin with open date on [DATE]. Pharmacy label showed: Refrigerate until opened. Discard 28 days after opening at room temperature. - R33's Basaglar insulin with open date on [DATE]. Pharmacy label showed: Refrigerate until opened. Discard 28 days after opening at room temperature. R33's Humalog insulin with open date on [DATE]. Pharmacy label showed: Refrigerate until opened. Discard 28 days after opening at room temperature. - R57's insulin aspart with open date on [DATE]. Discard date - [DATE]. Pharmacy label showed: Refrigerate until opened. Discard 28 days after opening at room temperature. On [DATE] at 10:01am 2nd floor medication room inspected with V7 (RN / Registered Nurse) and found inside the refrigerator: Opened house stock multi-dose Tuberlicin PPD Mantoux injection (Tubersol) vial with date opened [DATE] expiry date [DATE]. V7 said expired medication should be discarded. On [DATE] At 10:28am V2 (DON / Director of Nursing) stated she has been working in the facility for a year. She said unopen Insulin are supposed to be stored in the fridge, should be labeled with open date and discard date. V2 said medications should be stored properly according to pharmacy recommendation so not to affect the potency of the medication. She said insulin should not be administered cold to resident. V2 said nurses are expected to date every time they open inhaler, to know when it was opened and when to discard it. She said multi-dose inhaler should be discarded after 30 days of opening. She said Tuberlicin / mantoux injection should be dated once opened and discarded after 30 days to make sure potency is not affected. R12's physician orders dated [DATE] showed order not limited to: - Lantus U-100 insulin 100unit/ml inject 60 units subcutaneous route once daily at bedtime. - Fiasp flexTouch U-100 insulin 100unit/ml inject 25 units subcutaneous route 3 times per day with each meals. R27's physician orders dated [DATE] showed order not limited to Ventolin HFA inhaler 90mcg/actuation aerosol inhaler inhale 1 puff by inhalation route every 4 hours as needed. R33's physician orders dated [DATE] showed order not limited to: - Humalog U-100 insulin 100unit/ml inject 18 units subcutaneous route every day at 7am, 11am, 4pm. - Basaglar insulin KwikPen U-100 insulin 100unit/ml inject 60 units subcutaneous route once daily at bedtime. R57's physician orders dated [DATE] showed order not limited to Insulin aspart U-100 100unit/ml inject subcutaneous route insulin sliding scale. Facility's storage of medications policy dated ,d+[DATE] showed in part: Outdated medication are immediately removed from inventory, disposed according to procedures for medication disposal. All medications are maintained within the temperature ranges. Room temperature 59F to 77F. Refrigerated 36F to 46F. Medications and biologicals are stored at their temperature and humidity according to the united states pharmacopeia guidelines for temperature ranges. Facility's medication storage guide dated ,d+[DATE] showed in part: Fiasp, Lantus, Humalog U, Basaglar pen opened at room temperature (59F to 86F). Tuberlicin PPD, Mantoux injection (Tubersol) - keep refrigerated. Once vial is entered, the multi-dose vial should be discarded 30days after opening.

Based on observation, interview and record review, the facility failed to follow their policy to ensure controlled medication that require refrigeration are stored within a locked box within the refrigerator to decrease the possibility of loss or diversion for 1 (R68) resident reviewed for medication storage and labeling in a sample of 61. Findings include: On 4/29/25 09:55 AM Surveyor inspected 2nd floor medication room with V7 (RN / Registered Nurse) and found R68's Lorazepam solution kept inside unlock refrigerator. Lorazepam was not kept / stored inside a lock box. R68's face sheet showed last admitted on 7/26/2024 with diagnoses not limited to Cerebral infarction due to thrombus, Hypothyroidism, Seizure, Heart failure, Hypertensive heart disease with heart failure, Vascular dementia, Dysphagia. MDS (Minimum Data Set) dated 1/28/2025 showed R68's cognition was impaired. R68's physician orders dated 4/29/25 showed order not limited to Lorazepam 2 mg/mL oral concentrate, give 0.25 milliliter (0.5 mg) by oral route every 2 hours for 14 days as needed. On 4/30/25 At 10:28am V2 (DON / Director of Nursing) stated she has been working in the facility for a year. She said Lorazepam is a controlled medication and should be kept / stored in lock box or locked refrigerator according to the regulations. V2 said it could be easily accessible to other staff if controlled medication was not stored / locked properly. Facility's storage of medications policy dated 11/2020 showed in part: Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator.

Based on observations, interviews, and record reviews the facility failed to provide podiatry services for one (R355) of six residents reviewed for foot care in a sample of 61. Findings include: On 04/29/25 at 10:57 AM, observed R335 lying in bed without socks on. R335's toenails were long, extending far past his toes and were jagged. R335 said, my toenails are really long and when I put on my socks my long toenails get snagged on them, so I have to be really careful when I put them on. R355 stated he's been living here since February 2025, and no one has cut his toenails since his been living at the facility. R355 stated the last time he remembers a podiatrist cutting his nails was in October 2024. R355 said, that is why they are so long! and no one has asked me if I'd like my toenails cut or offered to cut them for me since I've been here. I'd like for someone to cut them because they are too long and need to be cut. On 04/29/25 at 12:06 PM, V13 (Licensed Practical Nurse) stated the CNAs only cut fingernails, not toenails and there is a podiatrist who comes to the facility to cut the residents toenails twice a month. V13 stated she does not know the last time the podiatrist was here but there is a binder kept at the nursing unit for the staff to write down the name of the resident(s) who need to have their toenails cut. Observed V13 searching the nursing unit but unable to locate the binder. On 04/29/25 at 12:09 PM, V13 observed R355 toenails and said, those are too long and need to be cut. V13 stated the resident's nails should be kept trim and the problem with the toenails being too long is they can rip which would hurt the residents. On 05/01/25 at 8:58 AM, V2 (Director of Nursing) stated the facility contracts out for podiatry services to come the facility to cut all the resident's toenails. V2 stated the podiatrist is on site twice a month and when they come into the building, they check the podiatry binder located on the nursing unit for any new residents they need to see. V2 stated whoever is listed on the podiatry log gets seen that day by the podiatrist. V2 stated at the end of the day when the podiatrist gives her a list of the residents who they have seen they email her their assessments. V2 stated maintaining toenails is part of grooming and should be checked by nursing staff daily when doing ADL (Activities of Daily Living) care. V2 stated even if a resident requires limited assistance or supervision with personal hygiene, it is still the nursing staff's responsibility to view resident's toenails and alert the nurse if their toenails need to be cut. V2 stated it is important for resident's toenails to be cut trim for infection control prevention because germs can be hiding under the nailbed and to prevent possible injury related to pulled nail. V2 stated R355 was admitted [DATE] and he is a diabetic. V2 stated she is not sure if podiatry has seen R355 yet and R355 should have been seen by now because it has been 2.5 months since he was admitted to the facility. On 5/01/25 at 10:08 AM, V2 viewed R355's toenails. V2 stated R355's toenails are long, and they need to be cut. V2 stated she already has a call into the podiatrist to let them know R355 needs to be seen. On 05/01/25 at 10:09 AM, R355 stated my toenails bite! and is someone going to be able to help me? I really need them cut. R355 diagnosis not limited to Diabetes Mellitus, Cerebrovascular Disease, Hypertensive Heart Disease with Heart Failure, Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side. R355's MDS (Minimum Data Set) from 02/24/25 BIMS (Brief Interview for Mental Status) score is 15/15 indicating intact cognition and R355 requires supervision or touching assistance with personal hygiene. Facility policy titled Resident Fingernail/Toenail Care revised January 2025 which documented in part, activity of daily living is important for maintaining resident's cleanliness, proper hygiene and dignity and resident needing toenail care/trimming, will be performed by outside Podiatrist. Staff will identify resident that is need of toenail care service during daily ADL care. Facility provided copy of Podiatry Services provided listing names of residents seen by podiatry up to 04/11/25 date. R355's name was not on this list.

Based on observation, interview, and record review the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times for two residents (R7, R41) reviewed for dignity in the total sample of 61. Findings include: On 04/29/25 at 11:28 AM during the dining observation in the third-floor dining room there were seven tables that seated two -four residents for dining. V19 (Certified Nurse Assistant) was observed passing out the meal trays to the residents at multiple tables without completing the service of the meals at one table before serving a meal tray to another table. R7 was served his (R7) meal tray at 11:42 AM. R7 waited 7 minutes to be served after the first residents meal tray was served at the same table that seated four residents. V19 served multiple meal trays at different tables and two resident rooms before serving R7. R41 was seated across from R7. At 11:44 AM R41 asked about her meal tray. On 04/29/25 at 12:02 PM When surveyor asked V19 (Certified Nurse Assistant) why the residents were served at multiple tables before completing the service to one table at a time. V19 responded, because sometimes the residents do not come at the same time. The meal trays are not aligned, and it is difficult. I was stretching my neck to see where the person is sitting. We would serve one table at a time, that's what we would do before. The residents will sit awkwardly and to keep the place calm we don't say anything. On 04/30/25 at 11:37 AM V5 (Dietary Supervisor) stated all residents should be served table by table. All residents at one table should be served before going to another table. The residents normally sit at the same table. We try to keep the trays together table by table. It could be an issue of dignity. Document Titled Residents' Rights for People in Long-Term Care Facilities undated document in part: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Policy: Titled The Dining Experience dated 2017 document in part: Meals served will respect the clients' dignity as an individual. Procedure: Meals are served at approximately the same time to all the clients sitting at a table. Titled The Dining Experience reviewed 11/24 document in part: Meals served will respect the residents' dignity as an individual. Procedure: Meals are served at approximately the same time to all the residents sitting at a table.

Based on observations, interviews and record reviews, the facility failed to ensure a medication error rate of less than 5% for 3 (R73, R125, R149) of 9 residents observed during medication administration. Surveyor observed 4 errors during 28 medication administration opportunities. This resulted in a medication error rate of 12.49%. The findings include: On 4/29/25 at 9:20AM Surveyor conducted medication administration observation with V8 (Licensed Practical Nurse / LPN) and she prepared the following medications for R73: 1. Celecoxib 200mg (milligram) 1 capsule. 2. Docusate sodium 100mg 1 capsule. 3. Vitamin C 500mg 1 tablet 4. Allopurinol 100mg 2 tablets 5. Acetaminophen 500mg 2 tablets 6. Folic Acid 100mg 1 tablet 7. Imbruvica 420mg 1 capsule 8. Vitamin D3 25mcg (micrograms) 1000iu (unit) 1 tablet 9. Iron tablet fe so4 (iron) 325mg 1 tablet 10. Miralax powder 17gm (gram) mixed with 1 cup water. 11. Fluticason Ellipta 100cmg/25mcg. R73 inhaled / puffed once. 12. Aspirin 81mg 1 tablet On 4/29/25 09:28 AM V8 administered prepared meds to R73 and taken orally. V8 handed Fluticason Ellipta 100cmg/25mcg to R73 and inhaled / puffed once. R73's MAR (medication administration record) and POS (Physician Order Sheet) reviewed and showed the following medication orders not limited to: 1. Celebrex 200mg give 1 capsule by oral route 2x per day. 2. Aspirin 81mg give 1 capsule by oral route 2x per day. 3. Risperidone 0.25mg tablet give 3 tablets (0.75mg) by oral route once daily at 9AM. Medication was not given during medication administration observation. 4. Docusate sodium 100mg give 1 capsule by oral route 2x per day. 5. Allopurinol 100mg give 2 tablets by oral route once daily. 6. Vitamin C 500mg give 1 tablet by oral route 3x per day. 7. Acetaminophen 500mg give 2 tablets by oral route 3x per day. 8. Folic acid 1mg give 1 tablet by oral route once daily. 9. Polyethylene glycol give 17grams by oral route 2x per day mixed with 8oz of water. 10. Imbruvica 420mg give 1 capsule by oral route once daily. 11. Breo Ellipta 100mcg-25mcg/dose powder inhale 1 puff by inhalation route once daily. 12. Vitamin D3 1000 unit give 1 tablet by oral route once daily. 13. Ferrous sulfate 325mg give 1 tablet by oral route once daily with breakfast at 9AM. 14. Oyster shell calcium 500mg 1250mg give 1 tablet by oral route 2x per day at 9am and 5pm. Medication was not given during medication administration observation. On 4/30/25 at 8:55 AM Surveyor conducted medication administration observation with V29 (RN / Registered Nurse) and she prepared the following medications for R125: 1. Vitamin D 25mcg 1000iu 1 tablet 2. Famotidine 10mg 2 tablets V29 administered medications to R125 and taken orally. R125's MAR and POS reviewed and showed the following medication orders not limited to: 1. Vitamin D3 25mcg give 2 tablets by oral route once daily at 9am. V29 (RN) administered Vitamin D 25mcg 1 tablet to R125 during medication administration observation. 2. Famotidine 10mg give 2 tablets by oral route once daily. On 4/30/25 at 9:13 AM V31 (LPN / Licensed Practical Nurse) checked R149's BP (Blood Pressure) = 132/73; HR (Heart Rate = 70/min) and prepared the following medications: 1. Amlodipine 10mg 1 tablet 2. Gabapentin 100mg 1 capsule 3. Fluticasone 50mcg nasal spray. V31 handed Fluticasone nasal spray to R149 and sprayed twice in each nostril during medication administration observation. 4. Carbamazepine 200mg 1 tablet 5. Folic Acid 400mcg 1 tablet R149's MAR and POS reviewed and showed the following medication orders not limited to: 1. Folic acid 400mg give 1 tablet by oral route once daily. 2. Gabapentin 100mg give 1 capsule by oral route 3 times per day. 3. Fluticasone propionate 50mcg/actuation 1 spray by intranasal route in both nostrils once daily at 9am. R149 sprayed twice in each nostril during medication administration observation. 4. Carbamazepine 200mg give 1 capsule by oral route 2 times per day. 5. Amlodipine 10mg give 1 tablet by oral route once daily. On 04/30/25 03:24 PM V2 (DON / Director of Nursing) stated nurses are expected to follow 5 Rs (Right resident, medication, route, dose and time) in giving medication to make sure giving medication as ordered by physician. If medication is missed, depending on the types of medication could have an effect with resident. V2 said if the nurse missed Risperidone, potentially resident could have behavioral issues. V2 said if medication was missed or not given according to doctor's order could have a potential harm / effect with the resident, medication has purpose which was prescribed to the resident. Facility's medication administration policy (undated) showed in part: Check all medications against the MAR prior to administration. Follow the medication specific instructions specifically.

Based on interview, and record review, the facility failed to follow their policy of requesting a fingerprint-based background check within 72 hours of receiving the residents' name based criminal history background check for two of two residents (R9, R10) reviewed for Abuse Prevention. Findings include: On 04/14/2025 at 12:05pm during the Identified Offender Program review with V9 (Business Office Manager) observed R9's (03/26/2025) name based Criminal History Report's result: HIT and R10's (04/03/2025) name based Criminal History Report's result: HIT. This surveyor requested to see R9's and R10's fingerprinting consent, schedule, receipt, result and risk assessment. V9 stated (V3 - Social Service Director) is responsible for scheduling the fingerprinting of the residents. On 04/14/2025 at 1:24pm, V3 presented this surveyor R9's and R10's unsigned and undated 'Nursing Home Resident Applicant Fingerprinting Consent Forms'. V3 stated when I get the CHIRP result with HIT that is the only time we order for fingerprinting of our residents. I inform (Fingerprint Service Provider) via email. (Fingerprint Service Provider) can only do so many. They were here on 3/21/2025. I am not sure when I emailed (Fingerprint Service Provider) for their (R9 and R10) fingerprinting. Maybe on 4/8/2025. If the CHIRP came out with a 'hit', the expectation is to schedule the fingerprinting within 72 hours. V3 stated I will find out for you the purpose of scheduling the fingerprinting within 72 hours. On 04/14/2025 at 2:19pm inside V3's office, V3 checked the email she sent out to (Fingerprint Service Provider) and stated I don't have it in my email. I did not send an email to (Fingerprint Service Provider) to schedule the fingerprinting of (R9). For (R10), I emailed (Fingerprint Service Provider) on 04/08/2025. I know I am behind in scheduling their fingerprinting. On 04/14/2025 at 2:37pm, this surveyor presented V1 (Administrator) the CHIRP results of R9 and R10 and inquired when the facility should schedule the fingerprinting of these residents. V1 stated R9's fingerprinting should have been scheduled on 03/29/2025 and R10's fingerprinting should have been scheduled on 04/06/2025. On 04/14/2025 at 2:40pm, this surveyor presented V1 the facility provided Identified Offender Policy and Procedure and inquired if facility follows its policy of requesting a fingerprint-based background check within 72 hours. V1 stated No. On 04/15/2025 at 12:22pm, V1 (Administrator) stated burglary is a qualifying offense that necessitate for us to schedule fingerprinting within 72 hours. Prostitution Class 4 is also a qualifying offense. On 04/15/2025 at 1:16pm, V1 stated if the residents who have 'HIT' on the CHIRP were not scheduled for fingerprinting within 72 hours, we put all of the residents to potential harm. It is part of our abuse prevention program, checking the criminal backgrounds of our residents. R9's (04/08/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R9's mental status as cognitively intact. R9's (03/26/2025) Criminal History report documented, in part Criminal History Data: Prostitution. Class 4. R10's (03/31/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R10's mental status as cognitively intact. R10's (04/03/2025) Criminal History report documented, in part Criminal History Data. Burglary. Class 2. The (undated) Identified Offender Facility Policy and Procedure documented, in part Policy Statement. It is the policy of this facility to establish a resident sensitive and resident secure environment. In accordance with the provisions of the Nursing Home Care Act, this facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. Identified offender: Any person who has been convicted of, found guilty of, any of the statute citation numbers listed in the identified offender conviction list or any of the statute citation numbers listed in the Sex offenses list of the department Identified Offenders program. Identifying Offenders. 3. Conduct a Criminal history background check: Within 24 (sic) hours of admission, request a name-based Uniform Conviction Information Act (UCIA) Criminal History background check for any resident seeking admission to the facility. 4.b. If the UCIA response contains convictions that match the Identified Offender or Sex Offender statute citation numbers, the resident is an identified offender and must be reported to Identified Offenders Program. 5. Request a live scan UCIA fingerprint check: d. the fingerprint-based background must be requested within 72 hours after receiving the name-based background check and must be conducted within five business days after receiving the name-based results.

Based on interview and record review the facility failed to ensure that staff are aware of the requirements for involuntary (psychiatric) admission, failed to provide resident a petition for involuntary admission and failed to explain the rights of admittee for one of four residents (R1) reviewed for transfer/discharge. Findings include: R1's (2/5/25) petition for involuntary/judicial admission states resident was in an alleged physical altercation with co-peer, both patients were separated however he continues to attempt to become physical. Resident had to be removed from the area to a lower floor but would not comply to separate from co-peer therefore MD (physician) was made aware with order to send to hospital to prevent provoking and harm to others. [Page 3 was endorsed by V7/Social Service Director]. Page 4 states Within 12 hours of admission to the facility under this status and/or completion of a new petition, I gave the respondent a copy of this petition (IL462-2005). I have explained the Rights of admitted to the respondent and have provided him or her with a copy of it. I have also provided him or her with a copy of Rights of Individuals Receiving Mental Health and Developmental Services (IL462-2001) and explained those rights to him or her (405 ILCS 5/3-609). I certify that I provided respondent with a copy of this form. Date/Time of Admission to Mental Health Facility/Psychiatric Unit: ____. Date/Time Petition Completed: ____. Signed: ____. Page 5 states I certify that I provided respondent with a copy of this form. On: ____. Time: ____. Signature: ____. On 3/13/25 at 11:30am, surveyor inquired why R1 was sent to the hospital on or about 2/5/25, V7 stated I (V7) think that's the incident between him (R1) and (R2). He (R1) was the aggressor. Surveyor inquired about the requirements for involuntary petition, V7 responded We (staff) did the petition for him to go out. I (V7) wrote a petition, they (staff) had to call the doctor to get the order for an evaluation. Once I write the petition I give it to the nurses, the nurses do the rest. Surveyor inquired who receives the petition for involuntary/judicial admission, V7 replied Usually it goes to the ambulance driver. We make 3 copies one for the hospital, one for the ambulance and the other one I'm not sure. Surveyor inquired if R1's (2/5/25) petition for involuntary psychiatric admission was signed by the Nurse to determine if R1 received a copy and/or was made aware of his rights, V7 stated No. Surveyor inquired if R1's involuntary petition was documented in the progress notes, V7 responded It should be a note. R1's (2/5/25) progress notes state MD (Medical Doctor) gave order to transfer resident to hospital for psych (psychiatric) evaluation. Call placed to hospital, report given to intake Nurse with Petition, face sheet and POS (Physician Order Sheets) was faxed to hospital as requested. [Petition provided to R1 and/or explanation of rights were excluded]. On 3/17/25, surveyor requested the facility policy for Involuntary (Psychiatric) Admission however the involuntary discharge policy (revised 01/06) was provided which states to ensure compliance with State and Federal regulations and guidelines for involuntary discharge/transfer. A resident can only be involuntarily discharged /transferred for the following reasons: the safety of individuals would otherwise be endangered. If a 30-day notice is issued, the resident will be given a copy of the notice. [Notice requirements for Involuntary/Judicial Admission are excluded].

Based on interview and record review the facility failed to follow policy procedures, failed to ensure that osteomyelitis was included in diagnoses, failed to schedule medication as directed, and failed to administer medications as ordered for one of four residents (R3) reviewed for medication administration. Findings include: R3 was admitted to the facility on [DATE] with diagnosis of local infection (due to central venous catheter) and discharged AMA (Against Medical Advice) on 2/16/25. R3's (2/14/25) progress notes state at 3:05pm, resident was admitted into the facility with diagnosis of acute osteomyelitis (bone infection) - which was excluded from the diagnoses. Medications verified with medical doctor with order to continue with hospital medications. R3's (2/14/25) POS (Physician Order Sheets) include the following antibiotics: Cefepime 1 gram IV every 8 hours for 1 month [Start Date/Time: 2/15/25 12:00am] and Vancomycin 750 milligrams IV every 8 hours for 1 month [Start Date/Time: 2/15/25 12:00am]. R3's (February 2025) MAR (Medication Administration Record) affirms the following: Cefepime was administered on 2/15/25 at 6am (6 hours after the prescribed start time). Vancomycin was scheduled for 9am, 12pm, and 5pm administration (every 3-5 hours - not every 8 hours as directed). R3's Vancomycin was marked * (not administered) on 2/15 at 9am (awaiting delivery) and administered on 2/15/24 at 12pm (12 hours after the prescribed start time). R3's Vancomycin was also administered on 2/15/25 at 5pm (within 5 hours therefore not as directed). On 3/18/25 at 11:46am, surveyor inquired about staff requirements for new admissions, V2 (Director of Nursing) stated Call the doctor for any orders or reconcile any orders they are coming with. Surveyor inquired when R3's Vancomycin was started by the facility V2 reviewed R3's (February 2025) MAR and responded On the 15th at 12pm [roughly 21 hours after admission]. Surveyor inquired if R3's Vancomycin was scheduled for administration every 8 hours (as directed) V2 replied No. Surveyor inquired when R3's Cefepime was started by the facility, V2 stated It was started on the 15th at 6am [roughly 15 hours after admission]. The (undated) medication administration policy states complete the pass within 2 hours (1 hour before/1 hour after). Check all medications against the MAR prior to administration. Follow the medication instructions specifically.

Based on interview and record review the facility failed to follow policy procedures, failed to assess/document skin integrity impairments, failed to ensure that the facility wound report was accurate, failed to obtain descriptive treatment orders (including wound locations/medication/type of dressing), and failed to follow physician orders for one of four residents (R3) reviewed for pressure ulcers. Findings include: R3 was admitted to the facility on [DATE] and discharged AMA (Against Medical Advice) on 2/16/25. R3's (2/14/25) progress note [entered 2/18/25 - 4 days later] states at 3:05pm, resident was admitted into the facility with diagnosis of acute osteomyelitis and discharge diagnosis of pressure injury of right hip (stage 4) complicated by deep penetrating ulcer on the left buttock with osteomyelitis of ischial tuberosity and inferior [NAME] of left ischium. Resident's wound was debrided on 2/3/25 and is on wound vac for the stage 4 wounds with continuous pressure of 125/125. Dressing dry and intact [R3's skin assessment is excluded]. The (February 2025) facility wound report excludes R3. R3's (2/15/25) POS (Physician Order Sheets) include wound dressing change schedule every day at 11:00pm-7:00am however wound location(s) and required medication/dressings are excluded. R3's (February 2025) TAR (Treatment Administration Record) states wound dressing change Start Date: 2/15/25 [wound locations and prescribed treatments are excluded]. On 2/15/25, * is documented (indicating not administered). On 3/18/25 at 11:46am, surveyor inquired about staff requirements for new admissions V2 (Director of Nursing) replied We expect them (staff) to do a head-to-toe assessment, call the doctor for any orders or reconcile any orders they are coming with. Surveyor inquired who's responsible for obtaining wound care orders V2 stated The wound nurse. Surveyor inquired about R3's wounds V2 responded I know he came in with a wound, but I did not assess her. Surveyor inquired about R3's wound assessment (which was requested and not received) V2 replied It was done but she V11 (Prior Wound Care Nurse) didn't put a note there, I don't know why [The facility provided no evidence during this survey that R3's wound was assessed by staff]. Surveyor inquired about R3's prescribed treatment V2 reviewed R3's (February 2025) POS and stated Wound dressing change every day at 11pm-7am on the night shift. I don't see any order here; it just say wound dressing change. Surveyor inquired if R3's treatments were documented on the (February 2025) TAR V2 responded On the 15th it say wound dressing change not administered and affirmed that dressing changes were also not documented on 2/14 and 2/16. Surveyor inquired if R3's wound locations (right hip/left buttock) and/or treatments for each wound are on the on the TAR V2 replied No. Surveyor inquired if R3 received a wound vac at the facility V2 stated We ordered a wound vac that Friday (2/14/25) because at the time that he (R3) came we don't have it, but I know we ordered one. At 1:11pm, V2 affirmed that R3's wound vac was received by the facility on 2/15/25 at 1:49pm. The delivery invoice #4717645 affirms a wound vac pump, canister with tubing and large dressing kit were delivered on the stated date and time [roughly 23 hours after admission] however R3's progress notes affirm implementation and/or use of the wound vac on or about that date/time was not documented. On 3/18/25 at 12:13pm, surveyor inquired about staff requirements for residents admitted with wounds V9 (Wound Care Nurse) stated A good assessment of the patient on admission because they (staff) see the patient before me (V9). They let me know what is going on with the patient. I (V9) assess the patient myself and have a good record of assessment, know the history of the patient, have good documentation, and I need to call the wound doctor to get orders. Surveyor inquired what's required in a treatment order V9 responded I need the prescription of what should be used for the treatment of the wound and what the patient is taking to improve the wound healing. Surveyor inquired about concerns with R3's (2/15/25) treatment orders V9 reviewed R3's (February 2025) POS and replied, I can't really see the location of the wound here and I can't see a prescription for the wound. The wound assessment policy (revised 11/18) states it is the policy of this facility to do a systemic ongoing wound assessment on all wounds in order to determine the response to nursing care and treatment modalities. The presence of wounds, ulcers and/or other skin abnormalities will be indicated on the admission nursing assessment. A comprehensive wound assessment will be documented on the pressure sore log and/or other skin log will contain the following information: wound classification, wound location, pressure ulcer staging or description of the extent of tissue damage, description of wound bed, drainage, margins/surrounding skin, odor., and wound measurements.

Based on interviews and record reviews, the facility failed to keep two (R8, R10) of six residents free from abuse. This failure resulted in R8 and R10 sustaining a swollen and bruised eye. Findings include: 1. R10's clinical record document in part the following: R10 is a fifty-year-old with the medical diagnosis of schizophrenia, hypertensive heart disease with heart failure, acute ischemic heart disease, abnormalities of gait and mobility, and essential hypertension. R10's minimum data set brief interview of mental status dated 5/1/24 scored [8], indicates cognition is mildly impaired. R10's care plan: -2/5/24: R10 has a diagnosis of mental illness, impaired decision making, inability to understand course of treatment. -5/15/24: R10 has not been the perpetrator of abuse, and he will remain safe, free from abuse and mistreatment. R10's After Visit Summary from emergency room dated 5/12/24: -R10 was seen for assault, injury to head/eye -Apply timolol maleate 0.5% solution to left eye -Acetaminophen to decrease pain -Apply ice to eye 15-20 minutes every hour R11's clinical record indicates in part: -R11 is a fifty-seven-year-old male admitted [8/21/21] with schizophrenia, deaf, non-speaking, restlessness, and agitation. MDS dated [DATE] indicates R11 is cognitively intact. Abuse risk assessment dated [DATE], R11 has a history of aggressive behavior. R11's care plan documents the following in part: -8/21/21: R11 has a history of physical aggression. R11 exhibits physical aggression behavior toward staff members when agitated, shoving, and pushing staff away. -4/19/23- R11 was readmitted to facility after being sent out for becoming physically aggressive toward another resident and staff. -6/7/23 - R11 was sent out after an episode of aggression -7/30/23- R11 was physical aggressive to another resident. [R11 has a documented history of aggressive behavior.] On 7/2/24 at 12:20 PM, R10 stated, I was hit in my eye for no reason by another resident. I went to the hospital, and I was okay. That man is not here any longer and I feel safe being here. On 7/2/24 at 12:33 PM, V18 [R10's Family Member] stated, The nurse called me on 5/12/24, and told me that R10 was hit in the eye by another resident and was sent to the emergency room . Later I was told by the facility nurse that R10 returned back to the facility, and he was okay. On 5/13/24, I came to visit R10 and noted his left eye was black, purple, and swollen around his eye. R10 told me R11 hit him in the eye for no reason. On 7/2/24, at 12:46 PM, R12 [R10's roommate] stated, R10 and I were roommates on 5/12/24. Around 5PM, the certified nurse assistant clean R10 up and placed a gown on him. R10 took his under brief off and walked out the room. R10's gown was open at the back side, and I could see buttocks. Another resident R11, (R11) cannot talk and is deaf. R11 walked R10 back into the room, then R11 walked out. A few minutes later, R10 walked back out the room with his gown on and open in the back. R11 for the second time walked R10 back into the room and pushed down on his shoulders, to make R10 sit down in the chair. R10 tried to get back up, then R11 hit R10 in his eye. I have not been abused at this facility, and I feel safe being here. On 7/2/24 at 12:53 PM, V15 [Certified Nurse Assistant] stated, I worked on 5/12/24, on first shift. Before I left, I cleaned R10 up and placed him on a gown and under brief, because he wanted to take a nap. I was not there when the incident occurred with R10 and R11. On 7/3/24 at 3:11 PM, V9 [Certified Nurse Assistant] stated, I was R10's CNA on 5/12/24, I worked second shift. R12 [R10's roommate] told me that R10's gown was open at the back side, and his buttocks was exposed, R10 kept walking in and out of their room. Another resident R11, (R11) cannot talk and is deaf. R11 walked R10 back into the room, then R11 walked out. A few minutes later, R10 walked back out the room with his gown on and open in the back. R11 walked R10 back into the room again and pushed R10 to make him sit down in the chair. R10 tried to get back up, then R11 hit R10 in his eye. R10 is a quite resident that like to walk around. R11 is aggressive and will hit staff and other residents. R10 and R11 both was sent out to the hospital. R10 ended up with a black eye, and R11 was discharged to anther facility. On 7/3/24 at 10:35 AM V7 [Social Service Director] stated, I am familiar with R11 and his behaviors. R11 has a documented history of aggressive behaviors towards other residents and staff. R11 was easily agitated and striking out hitting others. On 5/12/24, R10 was coming out his room without all his clothing on. R11 got agitated that R10 would not stay in his room and struck him in the eye. R11 and his family agreed for R11 to discharge to another facility due to his aggressive behaviors. On 7/3/24 at 9:15 AM, V2 [Director of Nursing] stated, R10 walks around the unit, and R10 is quiet and easily re-directed. R10 does not have a history of aggressive behavior. The investigation findings were R11 got agitated with R10 trying to make him stay in his room. R10 came back out of his room and R11 took R10 back into his room and hit him in the eye. R10 was sent out to the hospital for treatment and evaluation. R10 eye was dark, black, red, and swollen. R11 was sent out for a psychological evaluation due to his aggressive behavior. R10 returned with no new orders, R11 returned to the facility as well. We moved R11 to another floor and monitored him closely for behaviors. R11 have a documented history of aggressive behaviors, prior to hitting R10. R11 would be aggressive towards other residents and staff members. R11 was discharged to another facility that was equipped to handle aggressive behaviors, R11 and his family agreed to the transfer. On 7/3/24 at 10:52 AM, V1 [Administration] stated, The incident between R10 and R11 was substantiated. During the investigation it was found that R11 did hit R10 in the eye. V11 was transferred to another facility, R11's family and R11 agreed another facility would be better for R11 due to aggressive behaviors. All staff complete abuse training upon hire, annually and as needed with an event of abuse occurrence. The last abuse training was about a two weeks ago. Reviewed facility's in-service dated 6/27/24, staff educated on abuse of all types and reporting abuse. Policy documented in part: Abuse Prevention Program dated 11/23 -This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion. -Abuse is any physical or mental injury or sexual assault inflicted upon a resident. -Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. -Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigations 40061 2. R8's 05/09/2024 MDS (Minimum Data Set) Assessment documents in part that R8 was cognitively intact. R8's Social Service - Abuse Risk Assessment created 04/22/2024 documents in part: Due to current situation the resident has the potential for abuse, monitoring and evaluation needed [NAME] to extreme behavior of pacing, wandering and entering area without permission. R8's comprehensive care plan contains a focus for abuse. Goal effective 05/09/2024 documents in part: [R8] will remain safe, will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect) through next review. R9's 03/21/2024 MDS (Minimum Data Set) Assessment documents in part that R9 is cognitively intact. R9's Care Plan Activity Report documents in part a focus of R9 having socially inappropriate behavior. Resident exhibits socially inappropriate behavior as evidenced by making threats, screaming, shouting and making demands. Resident become physically agitated towards staff and peers (effective 01/04/2024). The goal was for R9 to show a decrease in episodes of socially inappropriate behaviors towards peers and staff. Facility's initial Facility Reported Incidents form dated 06/02/2024 10:22 AM documents in part: On 06/02/2024 at approximately 8:00 AM on the third floor [R8] alleged that [R8] was hit in the face by [R8's] roommate [R9]. Swelling and discoloration noted to resident's right eye. First aid provided per physician order. V6 (Quality Assurance Nurse) filled out R8's Statement form dated 06/02/2024. It documents in part: [R8] told this writer that [R9] hit [R8] on the face while [R8] was going through [R9's] stuff. V6 filled out R9's Statement form dated 06/02/2024. It documents in part: [R9] stated to this writer that [R9] hit [R8] because [R8] was going through [R9's] belongings and [R8] had no business doing that. V24's (Minimum Data Set/Care Plan Nurse) written statement dated 06/07/2024 documents in part: On June 2nd, 2024, at about 7:30 AM at the end of my night shift and on my way out; [R9] called my attention to see the swollen eye of [R9's] roommate [R8]. Upon interview, [R9] admitted that [R9's] roommate was going through [R9's] stuff and that triggered [R9] to punch [R8] in the face. Facility's investigation summary for the final Facility Reported Incident documents in part: Conclusion: Based on records review, and interviews, the facility was able to substantiate that the alleged incident occurred. On 07/02/2024 at 12:36 PM, V13 (Nurse) stated R8 was alert and oriented to person, place, and time. R8 had behaviors of going through other people's belongings and taking things. V13 stated R9 was alert and oriented to person, place, time, and situation. V13 stated R9 was easily mad and agitated. V13 stated R8 and R9 were roommates. V13 witnessed them screaming at each other before for whatever reason. V13 did not witness R8 and R9's incident but saw R8 about two days after the incident. V13 stated R8's eye was swollen up to the lateral side of the eyebrow. There was purple discoloration underneath the eye. On 07/02/2024 at 1: 43 PM, V15 (Certified Nurse Assistant) stated R8 was alert and oriented. R8 had behaviors of going through other people's belongings to steal things. On 07/02/2024 at 1:48 PM, V17 (Certified Nurse Assistant) stated R9 was alert and oriented. R9 was manipulative and liked fighting. On 07/03/2024 at 9:40 AM, V6 (Quality Assurance Nurse) stated first interviewing R9 after the incident. R9 informed V6 that R8 kept going through [R9's] belonging to take things but wouldn't stop. V6 stated during the interview R9 said [R9] hit R8. R9 demonstrated hitting R8 with a closed fist. After R9's interview, V6 interviewed R8. R8 had discoloration underneath the eye and minimal swelling. R8 stated going through R9's belongings. R9 came up to R8 and then R9 hit R8. V6 stated facility ordered a facial x-ray for R8 and hospital evaluation but R8 declined hospitalization . R8's Order Info documents in part an order that started on 06/02/2024 at 10:57 AM to Apply icepack to right lower black eye. R8's Progress Note dated 06/02/2024 at 8:08 AM document in part X-ray of facial bones. On 07/03/2024 at 9:53 AM, V24 (MDS/Care Plan Coordinator) stated V24 was leaving and in the elevator after working night shift when R9 brought R8 to V24. R9 said to look at R8's face which was swollen. R9 stated hitting R8. R9 stated R8 was bothering [R9] in bed. R8 went to R9's side and started going through R9's stuff. On 07/03/2024 at 10:56 AM, V1 (Administrator) stated R8 was alert and oriented to person, place, and time. V1 stated R8 was at risk for abuse because R8 had behaviors of wandering and stealing other people's belongings. V1 stated R9 was alert and oriented to person, place, and time. R9 was verbally aggressive to everybody including other residents. V1 stated the facility's investigation showed that R8 was going through R9's belongings. R9 got upset and hit R8.

Based on observation, interview, and record review the facility failed to ensure safe practices when turning a resident in bed during resident care for 1 (R7) of three residents reviewed for falls. The facility also failed to ensure fall preventions were added to the care plan after R7's fall. This failure resulted in R7 falling out of bed and sustaining a laceration to the scalp. Findings Include: R7 has diagnosis not limited to Quadriplegia, Osteomyelitis, Hyperlipidemia, Muscle Spasm, Constipation, Postherpetic Polyneuropathy, Type 2 Diabetes Mellitus, Angina, Anxiety Disorder, Thiamine Deficiency, Vitamin D Deficiency, Bipolar Disorder, Schizophrenia, Chronic Pain, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Buttock, Stage 4 and Essential (Primary) Hypertension. R7's MDS (Minimum Data Set) Section C - Cognitive Pattern BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Section GG - Functional Abilities and Goals: Functional Limitations in Range of Motion; 2. Impairment both sides. A. Upper extremity. B. Lower extremity. Mobility: A. Roll left and Right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. Dependent. During record review R7 has two documented falls from the bed. Document Titled Accident/Incident Log Form document in part: R7 falls dated 04/09/24 no injury and 05/29/24 laceration. Progress note dated 04/09/24 06:33 am document in part: Resident observed in bed at 4 am sleeping with no distress or any discomfort noted at this time. Staff responded to resident while yelling out for help at 5:30 am. Resident was observed lying on the floor in a supine position next to his (R7) bed. Resident is alert and oriented x 3. When asked what happened, resident stated My pillow fell could not control my movement and fell to the floor and hit my head. Dr. (doctor) called with order to transfer resident to hospital for further evaluation. Progress note dated 05/29/2024 07:04 am document in part: Resident alert and oriented x 2-3 with no distress or any discomfort noted at this time. Writer was in resident room for wound care treatment. During repositioning resident slip to the floor. Head to toe assessment completed, a laceration was noted to the middle of the head with mild bleeding. Site was cleansed with normal saline and pressure applied the site. Dr. notified with order to send resident to the hospital for further evaluation. Progress note dated 05/29/24 08:04 am document in part: Resident received on bed, alert and oriented x 2. Upon nurse-to-nurse report, resident has pending order to be transferred to ER (emergency room ) due to fall. Progress note dated 06/06/24 07:21 pm document in part: Re-admitting R7 from hospital. Resident discharge with laceration of the head. Document titled: Facility Reported Incidents Initial: dated 05/29/24 document in part: During repositioning resident accidentally slip to the floor. Head to toe assessment completed, a laceration was noted to the middle of the head with mild bleeding. Site was cleaned with normal saline and pressure applied to the site. Doctor notified with order to send resident to hospital for further evaluation. Document Titled Accident document in part: Summary: Severity: Incident resulted in hospitalization and temporary harm. Outcome: Laceration. Accident Type: Fall. V22 (Licensed Practical Nurse) witness statement document in part: Writer was in resident (R7) room for wound care treatment. During repositioning residents slipped to the floor. Head to toe assessment completed, a laceration was noted to the middle of the head with mild bleeding. Site was cleanse with normal saline and pressure applied to the site. Doctor notified with order to send resident to hospital for further evaluation. V9 (Certified Nurse Assistant) witness statement document in part: I was with the nurse (V22 Licensed Practical Nurse) to help to turn the resident (R7) to be able to clean his wounds. The resident (R7) was flipped to my end and had a grip on him (R7) for the nurse to clean his wound. I held him after he was clean on that side, flipped him back towards the side of the nurse. She (V22) held him for me to turn to her side to have a grip on him (R7) but unfortunately, he flipped out of the grip from the nurse while she was trying to turn for me to be able to hold or have a grip on the resident for her to treat the other part of the resident wound. Document Titled Facility Reported Incidents Final: date 06/04/24 document in part: Incident Description: Resident sustained a laceration to the mid-part of the head. Based on the facility investigation during repositioning, resident had a fall and bump his head against a drawer which resulted in him having a laceration to the mid-part of the head. Resident care plan and assessment will be updated upon readmission. Care Plan document in part: At risk for falls related to dx (diagnosis) of quadriplegia and he totally dependent on 2-person assistance in bed-mobility, transfer, and toileting. Updated: 10/12/22: Fall with no injury noted 10/11/22; sent to the hospital for evaluation Updated: 04/09/24: Fall with c/o (complaint of) hitting his head noted; sent to the hospital for evaluation. Updated: 05/30/24: Fall with injury noted on 05/29/24; sent to the hospital for evaluation. Interventions: Anticipate resident needs in relation to present ADL (Activities of Daily Living) function. Effective 04/10/24. Evaluate pattern of falls if fell more than once. Effective 04/10/24. Investigate cause of fall immediately. Effective 10/17/23. Medication regimen review as it relates to falls. Effective 04/10/24. Monitor for side effects of psychotropic medications such as dizziness, drowsiness, etc. Effective 04/10/24. Notify MD for any behavioral changes that may contribute to falls. Effective 04/10/24. Provide education on safety techniques. Effective 04/10/24. Provide low bed as ordered. Effective 04/10/24. Provide reality orientation. Effective 04/10/24. Review with interdisciplinary team the continued need for psychotropic drug use. Effective 04/10/24. R7's Fall Risk assessment dated [DATE] document in part: History of Falls (Past 3 Months) Fall 1-2x's. Gait and Balance: Not able to perform function. History of Falls: 2. Total: 12 High Risk! R7's Hospital Record dated 05/29/24 - 06/06/24 document in part: Wound 05/29/24 scalp. History: R7 presented from NH (Nursing Home) with fall. HEENT (Head, Eye, Ear, Nose, Throat) Comments: Scalp laceration. On 07/02/24 at 12:18 PM R7 was observed lying in a bariatric bed (a specialized bed made specifically to accommodate larger and heavier patients. It is wider than regular medical beds) on a low air loss mattress. Surveyor asked R7 about his fall and R7 responded I don't want to talk about it. On 07/03/24 at 10:24 AM Surveyor entered R7 room and asked to get clarity about his fall that occurred on 05/29/24. Surveyor asked R7 was he in the bed that he is currently in when the fall occurred, R7 responded yes. The surveyor asked did he fall off the right side of the bed near the window, R7 responded yes. The surveyor asked R7 did the nurse move away from the bed when the fall occurred, R7 responded yes. That's enough. R1 refused to answer any additional questions. On 07/02/24 at 12:20 PM V20 (Certified Nurse Assistant) stated When R7 need changing he is a 2 person assist and a feeder. When R7 did have a fall, he had a Laceration to the center of head that was not too deep. R7 is on fall precautions, lower bed and cushion supports by the side of the body. On 07/02/24 at 01:28 PM V21 (Registered Nurse) stated R7 is a 2 person assist. R7 had a fall last month and had a cut in the middle of the head. The nurse cleaned the cut with normal saline and dressed it before the ambulance came. On 07/02/24 at 01:36 PM Per telephone interview V22 (Licensed Practical Nurse) stated I was in there in R7 room with (V9) certified nurse assistant and we were changing R7 position. I was by the window side of R7 bed trying to come to the door side. We turned R7 already and R7 just slipped out of the bed. I was trying to go to the other side of R7 bed when he slipped out and fell out of the bed to the floor. R7 was on his side turned toward me and slipped out of my hand and fell down. I am not sure if R7 was in the same bed that he is in now, I go there to do the wound dressing. R7 was by the edge of the bed when R7 slipped out of my hand. R7 was too heavy and fell out of the bed. We assessed R7 and the laceration was on top of R7 head. I assessed R7 while he was on the floor. We held onto R7, put one hand under R7 arm pit and one arm under R7 legs to put him back in bed. I put a gauze and pressure to R7 head to cover the laceration up, called the doctor then the ambulance. R7 hit his head on the floor and drawer. I don't know how R7 got the laceration rather it was on the drawer or on the floor. R7 is not a fall risk. R7 is a 2 person assist. I did not see any mats on the floor. I was just doing wound care. On 07/02/24 at 01:49 PM Per telephone interview V9 (Certified Nurse Assistant) stated At about 05:30 am it was time to care for R7. V22 (Licensed Practical Nurse) also come around to take care of the resident wounds as well as empty urine bag. V22 was there to clean R7 wound. R7 was turned towards me in the bed on the (left) door side. The nurse tried to clean R7 then I tried to turn R7. In the process when I tried to turn R7 over I was trying to walk to the other side of the bed while the nurse held onto R7. I shouted hey, hey, hey because R7 was falling. We have to pull R7 close. I was going behind V22 and that space was so narrow. When I was trying to trade places with V22, R7 moved. R7 can move a little. V22 was holding onto R7 wrist and waist. I was behind V22 when she (V22) was trying to move out to trade places with me. R7 was almost flipping off the bed and V22 was trying to hold onto R7 when he fell . Before I got there, R7 was almost on the floor and before I could get positioned to prevent R7 from falling to the floor he (R7) was falling. We put R7 back in bed with our arms under R7 arm pit and the other person picked him (R7) up from the legs. R7 doesn't get out of the bed so I don't consider him a fall risk. R7 is able to move his arms. On 07/03/24 at 08:53 AM V2 (Director of Nursing) stated according to V22 (Licensed Practical Nurse) they (V22 and V9 Certified Nurse Assistant) were going to dress R7 wounds. V22 and V9 were both on each side of R7's bed. V22 said she (V22) was going to move to the other side of the bed and trade places with V9. There was a mistake and the resident (R7) slipped and hit his head on the bed side table drawer. They were supposed to be doing a 2 person assist. I expect if the resident is a one person or 2-person assist they are supposed to do it accordingly. They turned and repositioned the resident (R7) and when V9 were exchanging places with V22 that is when the resident fell out of the bed. This could have been avoided if the nurse could have been standing there completing before attempting to change places with V9. That is the same bed that R7 was in when the fall occurred. R7 jerks and is in a bariatric bed. There was an In-service given to the staff, certified nurse assistance and nurses. R7 cannot turn by himself but he has spontaneous movements that the staff is aware of. R7 is a quadriplegic and is considered a fall risk. R7 was on the low air loss mattress.'' Surveyor asked when R7 returned from the hospital why was he not interviewed. V2 responded, when R7 came back he (R7) is the type of person that will not speak to you. R9 sustained a laceration to the scalp when he fell . On 07/03/24 at 09:24 AM V24 (MDS/Care Plan Coordinator) stated if a resident has a fall that would be a change in condition. We update the care plan if there is a new intervention. When the standard does not work, we update the intervention every three months. After R7's last fall the care plan is not reflecting any new interventions. On 07/03/24 at 09:30 AM V6 (Restorative Nurse/Infection Preventionist/Quality Assurance) stated R7 fall was discussed in the meeting and from my understanding V22 (Licensed Practical Nurse) was trying to do wound treatment for R7 and there was another staff with her (V22). From the understanding she (V22) did one side of the wound treatment and was going to the other side of the bed when the bed moved and R7 fell . The low air loss mattress moved. The resident (R7) was close to the edge of the bed when the mattress moved and that is how R7 accidentally fell . R7 is a 2 person assist and has no side rails. R7 does not move by himself and has to be turned by someone. R7 would be considered a fall risk. R7 has had 2 falls. I am not sure how R7 fell out of the bed in April. On 07/03/24 at 11:04 AM V26 (MDS Nurse) stated R7's fall was reviewed but V24 (MDS/Care Plan Coordinator) did not put it in the care plan intervention. The care plan focus was updated but there were no interventions in writing. The staff received an in-service. In the care plan focus it has R7 is a 2 person assist. There were two staff rendering care when R7 fall happened. According to our policy the care plan is completed quarterly, with a change, fall, skin break down or anything. Document Titled Record of Inservice's dated 05/29/24 document in part: Turning and Repositioning with 2 persons assist. Policy: Titled Facility Policy Regarding Resident Falls undated document in part: Overview: This facility is committed to minimizing resident falls so as to maximize each resident's physical, mental, and psychosocial well-being. It is this facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All residents' falls will be assessed, and the resident's existing plan of care will be evaluated for needed changes. Policy: For residents who have been identified at risk for falls upon admission, the interdisciplinary plan of care shall include initial interventions to prevent injuries and accidents from falls. Facility Response to a Resident Falls with an Injury: The Fall Risk Assessment shall be reviewed and revised as needed. The resident's plan of care shall be updated if additional care interventions as necessary. Quality Improvement Measures for Resident Falls: Based on recommendations from the Quality Improvement Committee, facility-specific staff training shall be provided for all appropriate staff. Titled Transfer and Bed Mobility undated document in part: Policy: Proper body mechanics are essential to maintain health and wellness of the resident and the employees. Procedure: 2. Before repositioning resident make sure that resident is positioned in the center of the bed. 6. Before beginning the activity, mentally practice the skill so that you can foresee any possible problem areas. 8. When you begin the movement, be sure to keep your feet shoulder width apart to give yourself a stable base to work with. 9. Make sure to keep the person or object ass close to your body as possible. Titled Resident Care Planning undated document in part: Policy: Each resident has a resident care plan that is current, individualized, and consistent with the medical regimen. Following interdisciplinary team conferences completed quarterly and as needed, the interdisciplinary team update goals and actions that were discussed. Each discipline is responsible for reassessing the resident's care plan needs and reactivating care plans upon his/her return. Staff will utilize care plans to assure that each resident's need are met through appropriate and individualized staff interventions in a timely manner.

Based on interview and records review, the facility failed to provide safe and adequate care for a resident (R1) of 3 residents reviewed for incontinence care and bed mobility, who requires two person-assist for incontinence care and bed mobility. This failure resulted in R1 falling out of bed, hitting his head on the bedside dresser, being transferred to the hospital on 2 different occasions post fall, and being diagnosed with post-concussion syndrome. Findings include: R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Quadriplegia, chronic embolism and thrombosis of deep veins lateral upper extremity, schizo-affective disorder, cocaine abuse, iron deficiency anemia, pain, unspecified, low back pain, essential (primary) hypertension, constipation, nasal congestion, allergy, unspecified, changes in skin texture, pain in left shoulder. MDS section C (dated 03/08/2024) documents that R1 has a BIMS score of 15, indicating that R1's cognition is intact. MDS section GG (dated 03/08/2024) documents that R1 was scored as 1; indicating that R1 is dependent for personal hygiene. (1): Dependent is defined as; Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Care plan (updated 05/19/2024) documents that R1 is at risk for falls related to incidence of use of psychotropic medication or new medication that may cause dizziness. R1's Restorative Functional Assessment (dated 03/06/2024) documents, Resident has maintained current level of functioning when performing daily ADLs (activities of daily living), resident is with DX (dagnosis). of Quadriplegia and remains dependent on staff times 2 when performing bed mobility, maneuvering and repositioning while in bed. Remains dependent on staff when performing transfers from surface to surface with (mechanical) lift and 2 persons assist from staff for safety. Resident is non-ambulatory and uses motorized wheelchair for locomotion on and off unit with supervision from staff. Able to communicate needs to staff verbally in a clear voice, able to understand and be understood. Has decreased range of motion (ROM-range of motion) o BUE/BLE (Bilateral Upper Extremities/Bilateral Lower Extremities) related to DX (diagnosis) of quadriplegia, incontinent of B/B (bowel and bladder). Dependent on staff when performing daily ADLs to maintain dressing, bathing, grooming and personal hygiene care. Supervision Policy (dated 2023) states: To ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The facility affirms that all residents will be supervised based on their individual needs. On 06/05/2024 at 10:40am, during a complaint investigation, surveyor observed R1 lying in bed, with the call light within reach. R1 was observed to have two bilateral side rails to prevent R1 from falling out of bed. R1's personal items were observed to be within reach. R1's bed was observed to be in high position, and when surveyor attempted to lower the bed into lower position, the bed did not move into lower position. On 06/05/2024 at 10:40am, R1 stated, On 05/19/2024, there was only one certified nursing assistant (C.N.A) and he came to change me. He turned me on my right side, and he basically dropped me on the ground. The side rails were not on my bed either when the fall took place. The side rails were placed after I had the fall. As I was falling to the ground, I hit my head on the dresser. I told them I hit my head. I went to the hospital. When I went to the hospital, they did a CT scan, and it was negative. When I returned from the hospital, I was in a lot of pain. My head would not stop hurting. I felt nauseous and loopy, and my head was hurting severely, non-stop. I requested to be sent to the hospital again. They sent me back to the hospital on 05/21/2024. When I got to the hospital, they managed my pain, they gave me pain medication, and they told me in the hospital that I had concussion from hitting my head during the fall. Most of the time, when the C.N.As perform ADL care, it is usually one C.N.A assisting me. After the fall, it's usually one C.N.A. that cleans me. Depends on what shift it is, sometimes it's two C.N.As, depending on what shift it is. What's crazy is that when he was turning me, I was telling the C.N.A, [NAME], you're going to drop me, and he told me, Oh I'm not going to drop you., and then I rolled off the bed. The thing is that my bed will not go any lower, it's broken and won't go to a lower position, so I am always at this height. I fell from this height because my bed will not go any lower to the ground. There was no mat when I fell . I never had a landing mat here. I am still experiencing headaches. On 06/05/2024 at 11:27am V3 (certified nursing assistant) stated, I take care of R1 for a while now. R1 is a two-person assist for ADL/incontinence care, as well as transfers. R1 is a two-person assist for everything. I have been taking care of R1 for a while and R1 has always been a two person assist for bed mobility and everything else. On 06/05/2024 at 12:34pm V6 (restorative nurse) stated, Prior to the fall incident on 05/19/2024, R1 was a two-person assist for incontinence care and transfers. On 05/19/2024 when R1 fell , he should have been cared for by 2 staff members. After R1's fall occurrence, R1 is still a 2-person assist for incontinence care and transfers. It was not safe for one C.N.A to provide R1 incontinence care because R1 is a quadriplegic and R1 needs a 2 person assist. After the fall, we put 2 half side rails for R1's bed, for support and repositioning. When R1 is rolled to either his right or left side, the bilateral half side rails will prevent R1 from rolling out of bed, and R1 can feel a little more secure. R1 does not have landing mats ordered because R1 is a two-person assist and he is a quadriplegic, so the landing mats are not needed. On 06/06/2024 at 11:03am V1 (administrator) stated, I was not aware that R1 experienced a concussion from the fall he had. They did not tell me that he had a concussion. I know that R1 was sent out to the hospital and R1's CT scan was negative, but I did not know that he had a concussion. On 06/06/2024 at 12:11pm V2 (director of nursing) stated, R1 requires the assistance of 2 staff members for ADL care and transfers. When the fall occurred on 05/19/2024, there was an overnight C.N.A. that was providing care for R1. According to the report that I received, there was only one C.N.A. that was providing care for R1, when he fell . It is not safe for one staff member to provide ADL/incontinence care for R1. On 06/06/2024 at 12:20pm V11 (R1's physician) stated, It is ok for one CNA for incontinence care. He needs help and one person is enough. I don't think that he needs bed rails. On 06/06/2024 at 6:23pm V9 (certified nursing assistant) stated, R1 had a fall on 05/19/2025 while I was providing care for him, and it was about 5:30am or 5:40am. It was the first time I was working with R1 on the 3rd floor. I have seen other people caring for R1, and usually there is only one staff member providing incontinence care for R1. In the process of doing R1's incontinence care, in the process of trying to clean R1, I turned R1 to his right side, which is the R1's stronger side of the body. After I was done cleaning R1's right side properly, I tried to put a diaper on behind him, and in the process of putting the diaper behind R1, the bed flipped, and R1 fell out of bed, falling to the right side of the bed. R1 hit his head on the dresser while he was in the process of falling out. I tried to stop him from falling and I tried to prevent the fall, but I could not because of his weight. This was the first time I ever took care of R1. I have seen one person work with R1 before. From what I have seen, it's usually only one person caring for R1. I think there was a rail on the left side of the bed. I never seen two people caring for R1, it's always just one person providing care to R1. R1's Progress Note (dated 05/19/2024) documents, Prior to the incident at 5am resident was seen lying in bed comfortably, alert and oriented x3 and verbally responsive. At 5.45am during morning ADLs care, the CNA called for the nurse and upon getting to resident's room, resident was observed on the floor in a right lateral position next to the bed. Physical assessment completed BP (blood pressure) 132/78, P (pusle) 80, R (respirations) 18, Spo2 97% on room air, Temp (temperature) 98.2 F temporal. Pain assessed, verbalized pain at 7/10 on pain scale. Neurological assessment initiated. Resident remains alert and oriented x3. Resident stated that he hit his head when he fell . Range of motion on all extremities within normal limit. Resident skin remains intact. Resident transferred back to bed by two person assist via (mechanical) lift. Resident is wheelchair bound, required assistance of two person with grooming and ADLs. Head to toe assessment done, no discoloration, no injury, no swelling noted, at the moment. Dr. notified with orders to send resident to community hospital for evaluation. Ambulance contacted and ETA (estimated time of arrival) is 60 mins (minutes). Resident's POA (Power of Attorney) contacted on. DON (director of nursing) made aware. Resident remains comfortable in his room, call light within reach. Staff will continue to monitor. Awaiting ambulance for pickup. Endorsed to incoming nurse to follow up. R1's Progress Note (dated 05/19/2024) documents, At 12:40 pm, resident arrived from the hospital via ambulance and accompanied by 2 crew members. Alert /oriented x3 and verbally responsive. Per hospital reports: the following labs was done with negative result: CBC with diff and lactic acid. imaging test done are: ct cervical spine wo (without) contrast, ct head wo contrast, EKG 12 lead, rhythm strip, xr (xray) )ankle rt 3+ views, xr femur 2+ view, xr forearm rt (right) 2+ views, xr humerus rt 2+ views and xr tibia fibula rt 2+ views. Resident head to toe assessment done. V/s (vital signs) taken BP (blood pressure) 148/98 Pulse 66, O2 95% RA (room air), Resp (respirations) 18, Temp (temperature) 98.6. Resident's contact (mother) notified. Resident is in his room on his chair with call light placed within reach. No follow up appointment. 72 hrs (hours). post ER (emergency room ) visit initiated. R1's Progress Note (05/21/2024) documents, 72 hours post fall: Resident received in bed, AO (alert/oriented) x3, verbally responsive and able to make needs known. medication taken whole and well tolerated with no adverse effects noted. Resident complains of pain and rates it a 6 on the scale of 0-10, says his head and face hurts. Pain medication given to help alleviate pain. Continuous monitoring during this shift. R1's Progress Note (dated 05/21/2024) documents, Transfer to hospital: Resident's family member called to express concern about resident complaint of pain and demands resident should be sent to the hospital. Resident is in stable condition right now and all vitals are within resident's normal limit, but resident complains of banging headache and face pain. Physician has been notified and has given order to be sent to community hospital for further evaluation. Ambulance has been called and ETA states 4pm for pick up. DON notified, incoming nurse also notified and will follow up. R1's Progress Note (dated 05/21/2024) documents, At 8pm, a call was placed to hospital ER. Per ER (emergency room ) nurse, resident will be returning to the facility later tonight and resident has been cleared but has Post concussion syndrome. Pick up time is 9.30pm. Endorsed to incoming nurse to monitor return. R1's Progress Note (dated 05/21/2024) documents, At 10.15pm, resident returned to the facility via ambulance on a stretcher. Resident head to toe assessment done. V/s taken BP 132/72, Pulse 72, O2 97% RA, Resp 18, Temp 98.2. Resident has orders for Bacitracin 500 unit apply topically twice a day. Resident also has orders for Butalbital acetaminophen caffeine every 4hrs for 10 days and PRN (as needed) . MD (physician) notified, order noted and carried out. Resident's mother notified. Resident is in his room on the bed, plan of care ongoing and call light call light placed within reach. DON notified. No follow up appointment. 72 hrs post ER visit initiated. R1's Progress Note (dated 05/31/2024) documents, Resident may have bilateral half side rail for repositioning and support as per MD's order. R1s Physician Order (dated 05/21/2024) states: Butalbital 50 mg (milligrams)-acetaminophen 325 mg-caffeine 40 mg-codeine 30 mg cap. Give 1 tablet by oral route every 4 hours as needed. Episodic tension-type headache, intractable. R1's Emergency Department Record (dated 05/21/2024) states: Patient's headache is likely due to post concussive syndrome from his fall the other day (pg.1). Post-concussive syndrome is a group of symptoms that affect your nerves, thinking, and behavior. PCS develops shortly after a concussion and can last for weeks to months (pg.8).

Based on interview and record review the facility failed to ensure the right of resident to be free of abuse for two (R4, R8) of six residents reviewed for abuse in the sample. This failure resulted in R4 being hit in the mouth sustaining facial trauma and R8 being hit in the nose resulting in bleeding and pain. Findings include: 1) R4 is a [AGE] year old male resident with a diagnosis including Schizophrenia, Deaf non speaking and Restlessness and agitation. R4 has a unscorable BIMS (Brief Interview for Mental Status). R4 is care planned for behavior symptoms concerning inappropriate personal boundaries due to diagnosis of Schizophrenia active 6/1/21. Symptoms are manifested by inappropriate touching. R4 will sneak up behind others and tap or grab them at the shoulders or back. R4 will also in attempt to joke with others steal their hats and run away from them. R4 requires ongoing supervision, cueing, and prompting from staff to remain on task and behave in a respectful and appropriate manner. R5 is a [AGE] year old male with a diagnosis including COPD, Schizophrenia and Blindness of left eye. R5 has a BIMS (Brief Interview for Mental Status) score 15/15. R5 is care planned for Aggressive Behavior (2/12/24). R5 has a diagnosis of disorganized schizophrenia which presents with paranoid and delusional though due to this resident can become aggressive due to believing that an individual is trying to harm him in some way. R5 was discharged from the facility on 4/29/24. Review of R4 and R5 progress notes show the following . On 3/27/24 R4 progress notes state R4 was in a alleged unprovoked incident with co peer (R5) in which staff had to intervene to prevent physical harm. R4's care plan was updated and abuse risk assessment was completed. Resident was standing by the nursing station during medication administration at about 8:00 am, when a co-resident (R5) physically assaulted him (R4) by punching him in the mouth, which resulted in mild bleeding in the mouth. R5 alleged that R4 made a go at him. No one witnessed R4 making a go at it. Resident returned from ER (emergency room ). Resident came with the DX (diagnosis): Facial trauma, initial encounter. Doctor and DON (Director of Nursing) notified of resident returned to facility. On 3/27/24 progress note shows according to staff R5 became agitated and ended up in an alleged unprovoked incident with co peer (R4) in which staff had to intervene to prevent physical harm. R5's care plan was updated and aggression/ harm assessment was completed. Facility incident report dated 3/27/24 shows that on 3/27/24 at approximately 8AM on the third floor R4 was hit in the mouth by resident R5. R4 was noted with a small amount of bleeding from mouth. Complaints of pain noted. First aid was provided. Both R4 and R5 were sent to the hospital. R5 did not return to the facility. Conclusion: Based on record review, and interviews, the facility was able to substantiate that R5 made physical contact with R4 hitting him in the mouth. R4 was transferred for medical evaluation R5 was transferred psychological evaluation. R4 progress note dated 3/27/24 shows including R4 returned from hospital with two paramedics. R4 came with the diagnosis of facial trauma , initial encounter . On 5/1/24 at 11:07AM V8 (CNA) stated I was on the floor when the incident between R4 and R5 took place. R4 was in the medication line when R5 walked by and punched R4 in the mouth. R4 had bleeding from mouth. R4 was treated and sent to the hospital. R5 was sent to the hospital for evaluation. On 5/2/24 at 10:46AM V6 (Social Service) stated I interviewed both R4 and R5 and confirmed that R5 hit R4 in the mouth causing injury of bleeding from the mouth . Chicago Police report (JH202906) shows on 3/27/24 incident of simple battery was filed with victim R4. 2) R8 is a [AGE] year old female with a diagnosis including Schizoaffective disorder and Paranoid schizophrenia. R8 has a BIMS (Brief Interview for Mental Status) score of 15/15. R8 is care planned for behavior symptoms: Socially Inappropriate Behavior, Manipulative behavior and Resists care, Physical aggression. R8 goes into other residents rooms without permission. R8 was not available for interview during investigation. R9 is a [AGE] year old male with a diagnosis including Paranoid schizophrenia, Restlessness and agitation. R9 has a BIMS (Brief Interview for Mental Status) 15/15. R9 is care planned for: exhibits physically aggressive behavior towards staff and others and Resisting care. R9's 4/22/24 progress notes documents at around 4:20am, resident was seen on his way out of a co-residents room (R8's room), writer asked what happened and resident stated I told her not to come to my room she won't listen so I hit her nose, I don't care. Immediately resident left the resident room went back to his room. R8 refused vital sign . Facility incident report dated 4/22/24 shows on 4/22/24 at approximately 4:20AM on the 3rd floor R8 alleged that she was hit on the nose by co resident R9. Bleeding was noted with complaints of pain. First aid was provided. Doctor ordered R8 transfer for medical evaluation. R8 refused. Incident report shows based on record review, and interviews, the facility was able to substantiate that the alleged incident occurred. R8 refused medical evaluation. On 4/30/24 at 10:52 AM R9 stated yes there was an incident between me and R8. It was late at night and R8 came into my room and started taking my things. I jumped up from my wheelchair and grabbed my things back from her. R8 fell on the floor. The nurses came in. They took her out. I don't know if she got hurt when she fell . That's all I know. R8's progress note dated 4/22/24 shows R8 received up and about with no distress or discomfort noted at this time. Resident seen wandering from room to room all through the night and was redirected severally. At 4:20am, writer heard a loud noise from resident room. Writer immediately went to the room. On getting to the room noted resident nose bleeding. Resident was assisted in a sitting position tilt head slightly forward, pressure was applied to stop the bleeding, first aid measure was applied, cleaned with normal saline. Vital signs was checked B/P (blood pressure) 120/76, P (pulse) 78, R (respirations) 18, T (temperature) 97.4 O2 (Oxygen saturation) 98%. Co-resident (R9) was seen coming out of resident R8's room. Upon interview co-resident (R9) stated I told her not to come to my room she won't listen so I hit her nose. Resident was placed on another floor and placed on one to one supervision. Doctor was made aware with order to transfer resident to the ER (emergency room ). Call was placed to ambulance with ETA (estimated time of arrival) of 45 mins (minutes). Administrator made aware, DON made aware. Resident contact on file Public health law surrogate made aware. At 6:15am 2 paramedics arrived at the facility to transport resident to the hospital to be checked for medical evaluation, but resident refused and stating I do not want to go and I have the right to refuse. Despite teaching and encouragement resident continue to refuse. Police was activated as part of facility's protocol. At around 6:55am police arrived the facility and the police states it's a medical situation and she has the right to refuse if she choose not to go to the hospital. On 5/2/24 at 12:14PM R15 stated, I am the roommate of R8. I saw R9 come into our room on 4/22/24 or around that date and pound her (R8) on the face. There was a lot of blood coming from her nose. I don't know why he just came into the room and did that. He (R9) left the room right after he hit her (R8). On 5/2/24 at 11:50AM V9 (Physician) stated R9 is not my patient but R8 is. She (R8) refused to go to the hospital when I gave order. R8 was hit in the nose by R9 and received injury. Facility policy titled Abuse Prevention Program includes statement : Policy This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.

Based on interview and record review, the facility failed to that ensure that a resident was free from physical abuse. These failures affected R2 who was physically scratched in the face by R1 and affected R6 who was physically kicked and scratched on the neck by R7 when reviewed for resident to resident physical assault, for four (R1, R2, R6, R7) of six residents reviewed in the sample of 6. Findings include: On 3/12/24 at 2:49 pm, R2 stated that on 2/16/24 in the evening, R2 had turned the overhead lights on in the room to write. R2 stated that R2's former roommate, R1, walked and turned off their room lights. R2 stated that R2 went back to turn on the overhead lights (by switch on the wall in their room), and R1 attached me (R2) and tried to scratch my eyes out. R2 said that there were scratches from R1 on R2's right cheek and face. R2 said that the door was open and that both R1 and R2 were standing in room. R2 stated that R1 didn't say any words to R2 prior to scratching R2, and that it happened so quickly. R2 stated that V12 (Certified Nursing Assistant, CNA) then entered R1 and R2's room and separated R1 from their room. R2 stated that R2 called the local police department for R1 attacking R2. R2's Admission Record, documents, in part, diagnoses of osteoarthritis, hypertensive heart disease with heart failure, pain, residual schizophrenia, cerebral infarction, abnormalities of gait and mobility, bilateral primary osteoarthritis of knee, hypertension, and sleep disorder. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 9 which indicates that R2 has moderate cognitive impairment. R2's written statement, dated 2/20/24, documents, in part, Statement (R2): Incident 2/16/24, that R1 attacked me (R2) and attempted to blind me in both eyes. Fingernails to right and left eyes. Scratches right eye. Left eye OK. 911. Police report. On 3/13/24 at 3:20 pm, V12 (CNA) stated that on 2/16/24 around 8:30 pm, V12 responded to R1 and R2's room where R1 and R2 where standing arguing about the lights in the room, and V12 removed R1 from their room. V12 stated that after the incident, R2 had a cut on R2's face. On 3/13/24 at 3:30 pm, V11 (Licensed Practical Nurse, LPN) stated that on 2/16/24, V11 responded to R1 and R2 in their room, and that V12 was standing in between R1 and R2 where V12 removed R1 from the room. V11 stated that R2 then walked to the nurse's station while phoning the local police department about R1 and R2's incident, and V11 observed scratches all over (R2's) face. When asked about R1's cognition, V11 stated that there is a language barrier and that if R1 does not get (R1's) way, (R1) gets angry. In R2's Progress Note, dated 2/17/24 at 8:26 am, V13 (LPN) documents, in part, that R2 with scratch on (R2's) right upper and lower eyelid, check and right side of (R2's) nose and that V13 rendered first aide care to R2's facial scratches. R1's Admission Record, documents, in part, diagnoses of encounter for surgical care following surgery on digestive system, paranoid schizophrenia, seizures, dry eye syndrome, pain, hypothyroidism, visual discomfort, seborrheic dermatitis, acne keloid, chronic allergic conjunctivitis, thiamine deficiency, hyperlipidemia, convulsions, hypokalemia, psoriasis, and hypertensive heart disease. R1's MDS, dated [DATE], documents, in part, a BIMS score of 14 which indicates that R1 is cognitively intact. In R1's Progress Note, dated 2/17/24 at 12:39 pm, V24 (Psychiatric Rehabilitation Service Director-Assistant, PRSD-A) documented, in part, Writer made aware that (R1) has a police report against (R1) regarding a verbal and physical altercation with roommate (R2) and that R1 was being transferred to the hospital on 2/17/24 (no return to facility). R1 no longer resides in the facility and is unable to be interviewed by this surveyor. Police department report, dated 2/16/24, for incident of domestic battery was reviewed with name of victim as R2. On 3/14/24 at 3:39 pm, V1 (Administrator) stated that V1 is the abuse coordinator for the facility. V1 stated that V1 performed the physical abuse investigation for the 2/16/24 incident of R1 and R2. V1 stated that V1 interviewed both R1 and R2, reviewed staff statements and R2's physical assessment and concluded that the physical assault from R1 towards R2 was substantiated. Facility document, titled Preliminary 24-hour Incident Investigation Report, submitted to the state agency on 2/17/24, for incident category of Physical Abuse, V1 (Administrator) documents, in part, that on 2/16/24 at approximately 11:00 pm, R2 alleged that R2 was scratched on the face by R1 during a verbal altercation about their room lights. V1 documents, in part, in the facility's Final Report, dated 2/22/24, Based on record review, and interviews, the facility was able to substantiate that the alleged incident occurred. On 3/12/24 at 2:42 pm, R6 stated that on 2/24/24 around 2:00 pm, after lunch in the day room (dining room), R7 kicked me (R6) and pushed me down and called me names. R6 stated that R6 was standing in the day room and that R7 was sitting in a chair. R6 stated that R6 was walking by R7 in the day room, and R7 kicked me (R6) in the leg and pushed me down to the floor with (R7's) hands and scratched my neck. R6 said that R6 didn't say anything to R7 beforehand and was simply walking by R7. R6 said that other residents were in the day room but couldn't remember which resident, and that no staff was there. R6 stated that R6 got away from R7 in the day room and went to the nurse's station and told V4 (LPN) that R7 attached me. R6's Admission Record, documents, in part, diagnoses of bipolar disorder, psychosis, insomnia, nicotine dependence, hyperkalemia, urinary continence, chronic obstructive pulmonary disease, and nasal congestion. R6's MDS, dated [DATE], documents, in part, a BIMS score of 9 which indicates that R6's cognition is moderately intact. On 3/12/24 at 2:18 pm, when asked about an incident with R6 in the day room on 2/24/24, R7 stated that R7 knows who R6 is and that a few weeks ago, R7 broke (R7's) nail lifting up R7's left hand. R7 stated that R7 was sitting in the chair watching television (TV) in the day room, and R6 was walking in front of R7 with R6 stepping close to R7's shoes. When asked if R6 contacted R7's shoes when R6 was walking near R7, R7 said almost but (R6) didn't. R7 stated, I kicked (R6). I scratched (R6's) face and broke my nail. R7 stated that R7 grabbed R6 by the shirt and scratched R6's face. On 3/12/24 at 2:07 pm, V4 (LPN) stated that on 2/24/24, V4 was sitting at the nurse's station when residents were coming right there (pointing to nurse's station desk) with a commotion that caught my attention. V4 stated that V4 was on way to the day room where there was fighting there. V4 stated that V4 separated R6 from R7 and that R6 has a scratch visible on the left side of R6's neck. V4 stated that from talking to both R6 and R7, R7 said that R7 was sitting in day room watching TV, and R6 was walking back and forth in front of R7, and (R7) hit (R6). V4 stated that V4 separated R6 and R7, that first aide was rendered to R6 and that R7 was transferred to the hospital. In R6's Progress Note, dated 2/24/24 at 2:23 pm, V7 (LPN) documents, in part, that upon interview (R6) alleged that (R7) hit and scratched (R6) with R6 assessed and noted with scratch mark to the neck. R7's Admission Record, documents, in part, diagnoses of schizoaffective disorder bipolar type, venous insufficiency, pulmonary embolism without acute cor pulmonale, hypertension, constipation, vitamin D deficiency, schizophrenia, anxiety disorders, insomnia, type 2 diabetes mellitus, morbid obesity due to excess calories, chronic pain, constipation, major depressive disorder, schizophrenia, heartburn, and insomnia. R7's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R7 is cognitively intact. In R7's Progress Note, dated 2/24/24 at 3:33 pm, V24 (PRSD-A) documents, in part, (R7) has been physically agitated towards (R6). (R7) notified the writer that (R7) was upset because (R6) kept walking passed (past) (R7) while (R7) was watching television. (R7) informed writer that (R7) tripped (R6) and grabbed (R6) by the shirt. On 3/14/24 at 3:39 pm, V1 (Administrator) stated that V1 performed the physical abuse investigation for the 2/24/24 incident of R6 and R7. V1 stated that V1 interviewed both R6 and R7, reviewed staff and resident statements and R6's physical assessment and concluded that the physical assault from R7 towards R6 was substantiated. Facility document, titled Preliminary 24-hour Incident Investigation Report, submitted to the state agency on 2/24/24, for incident category of Physical Abuse, V1 (Administrator) documents, in part, that on 2/24/24 at approximately 2:00 pm, R6 alleged that R6 was hit and scratched by R7 as R6 walked by with scratches noted to right side of R6's neck. V1 documents, in part, in the facility's Final Report, dated 2/29/24, Based on record review, and interviews, the facility was able to substantiate that the alleged incident occurred. On 3/18/24 at 1:01 pm, V1 (Administrator) stated, Residents have the right to be free from abuse of any kind. Facility policy dated 11/22/2017 and titled Abuse Prevention Program - Policy, documents, in part, that Residents have the right to be free from abuse . Abuse means any physical or mental injury . inflicted upon a resident other than by accidental means . 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. Facility policy (undated) and titled Resident's Rights, documents, in part, Purpose: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of this Community, nor shall the resident forfeit any of the following rights: . 14. The right to be free of abuse.

Based on interview and record review, the facility failed to monitor a cognitively impaired resident (R1), who was assessed to be at high risk for elopement and who had an electronic monitoring safety device on the right ankle; the facility staff failed to respond to alarms which may have sounded as R1 exited the building; and the facility failed to follow their elopement risk policy and procedures to prevent elopement. These failures affected R2, who speaks predominately Mandarin Chinese with limited understanding of English, who eloped from the facility on 9/12/23 without staff knowledge or supervision, has not returned to the facility and has not been located by the local police department which places R1 at a potential risk for harm when reviewed for improper nursing care in the sample of 16 elopement risk residents (R1, R3, R4, R6, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19 and R20). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 9/12/23 at 1:00 pm when R1's last known physical sighting in the facility was documented, and the Code Green (elopement/missing resident) protocol was not documented as activated until 9/13/23 at 12:09 am when R1 was not in the facility and confirmed not to be on a supervised community pass. On 9/26/23 at 11:58 am, V1 (Administrator) and V2 (Director of Nursing, DON) were notified of the Immediate Jeopardy. The survey team confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/3/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's Resident Face Sheet documents, in part, R1's diagnoses of schizoaffective, disorder bipolar type; pain; and hypokalemia. R1's admission to the facility from the hospital was documented as 8/18/23. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, R1's Brief Interview of Mental Status (BIMS) score 6 indicating R1 has severe cognitive impairment. R1's Wandering Behavior coded as a 2 for Behavior of this type occurred 4 to 6 days, but less than daily. R1's Wandering Impact coded as Yes for the question: Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g. {for example}, stairs, outside of the facility)? In R1's Social Services - Elopement Risk Assessment Tool, completed on 8/21/23, V5 (Assistant Social Services Director) documents, in part, the following statements apply: 1) R1 attempted to or has an actual elopement in the last year. 2) R1 roams or wanders throughout the facility and does not respond favorably to staff redirection. 3) R1 attempts to leave the facility unsupervised and does not respond favorably to staff redirection. 4) R1 verbalizes a strong desire to leave the facility and has the ability to do so. With the above statements applying to R1, R1 was placed on the elopement risk prevention program with a corresponding plan of care with the following interventions: 1) Personal safety alarm devices. 2) Staff aware of resident on wander/elopement risk. 3) Exit and stairwell alarms. 4) Photo on potential elopement list. 5) Utilization of a check in/out log. 6) Psychological counseling/group. 7) Recreational activities. V5 documented in the comments field: (R1) has been assessed and will be added to the elopement prevention program. (R1) IS considered an elopement risk. IDT (intradisciplinary team) and floor staff have been made aware. On 9/19/23 at 2:28 pm, V6 (Registered Nurse, RN) stated V6 was R1's assigned nurse on 9/12/23 from 7:00 am to 3:00 pm. Surveyor asked how does V6 know who the elopement risk residents are. V6 stated, there is a list for elopement risk and electronic monitoring safety device residents, and V6 checks this posted list daily. V6 stated, I (V6) check and make sure that the (electronic monitoring safety device) is in place and working. If I see it's not working, I will call maintenance. Surveyor asked how V6 knows if the electronic monitoring safety device is working. V6 stated, If I see it blinking. Red blinking. V6 stated, V6 checks the electronic monitoring safety device on the residents wearing them when V6 is leaving and when V6 does rounds at the end of V6's shift to make sure it's in place. V6 showed this surveyor the Elopement Risk list posted at the 3rd floor nurse's station with 16 residents' (including R1's) photo, names gender, age, and height. Regarding 9/12/23 incident, V6 stated at 7:00 am, V6 did rounds, verified that R1's electronic monitoring safety device was functioning on the right ankle and noted R1 was on the 3rd floor. Surveyor asked about R1's orientation and activity. V6 stated, R1 was alert and oriented x 2 (person and place), walked around the floor, and R1 took R1's protein nutritional drink scheduled at 9:00 am. When asked if V6 saw R1 eating lunch, V6 stated, I (V6) did not see (R1). The CNA saw (R1). (R1) ate. Surveyor asked how often is V6 doing rounds to check on R1. V6 stated, Mostly CNAs do rounds. I (V6) do rounds. I saw (R1) at 2:00 pm, in (R1's) room and R1 was sleeping in bed. V6 stated, I didn't want to bother (R1). V6 stated, it's the last time that V6 saw R1 on the day shift on 9/12/23. V6 stated, The CNA does a rounds sheet. Nurses do visual checks. CNAs go room by room and check it on paper. V6 stated, R1 is not to go out on pass unsupervised. V6 stated, Elopement risk residents can't have a pass. Surveyor asked if a resident is going out on pass to the community, what is V6's role. V6 stated, V6 will have to sign a paper that is co-signed by the social services staff, and this independent pass only applies to residents who are oriented, taking their meds and are compliant with their behaviors. V6 stated, residents with the electronic monitoring safety devices can leave the floor to go to other floors in the facility but are not able to leave the facility by themselves. V6 stated, with R1's elopement on 9/12/23, it was not the first time that R1 had tried to leave the facility with it being the 2nd or 3rd time. On 9/19/23 at 2:40 pm, V7 (Certified Nursing Assistant, CNA) stated, V7 worked on the 3rd floor as a CNA (not assigned to R1) on 9/12/23 from 7:00 am to 3:00 pm. V7 stated, V7 started V7's shift by checking the board to see the Elopement Risk list residents and then did morning rounds. V7 stated, I (V7) saw (R1) eat breakfast and lunch, and I did rounds at 1:00 pm, and (R1) was asleep. I saw (R1) at 2:00 pm to give a snack in (R1's) room, and (R1) was just waking up. V7 stated that on 9/12/23, R1 was sometimes walking around the 3rd floor and would sometimes go downstairs off the floor. V7 stated that V7 did walking rounds, final rounds, at 2:30 pm and R1 was walking on the 3rd floor. V7 stated, R1 does not speak English well and speaks primarily Chinese. V7 stated, V7 only understands a little bit of English, and R1's English language is not clear. V7 stated, R1's electronic monitoring safety device was located on R1's ankle and it was blinking which indicates the sensor is working. V7 stated, residents with electronic monitoring safety devices can go downstairs to the 1st floor and then back up to the 3rd floor. When asked if R1 can go outside of the facility on pass, V7 stated, No, (R1) can't go on pass with bracelet (electronic monitoring safety device) on. On 9/19/23 at 2:50 pm, V8 (CNA) stated that V8 was R1's assigned CNA on 9/12/23 from 7:00 am to 3:00 pm. V8 stated, V8 is familiar with R1 and R1 is alert and oriented x 1 (person). V8 stated, R1 was added to the Elopement Risk list when R1 was admitted and V8 checks the Elopement Risk list daily because it can be updated. V8 stated, V8 checks the (electronic monitoring safety devices) of the Elopement Risk list residents on the 3rd floor to make sure it's there and if it's blinking. V8 stated, V8 does rounds every 2 hours at 7:00 am, 9:00 am, 11:00 am and 1:00 pm. V8 stated, I (V8) fill out the (rounds) paper. If I can't find them, they (residents) may be out on pass or downstairs or on the patio. I check each room. If I don't see the resident, I would ask the other CNA on the floor. Sometimes the resident went out to the hospital or is on the patio. Surveyor asked how does V8 know if resident is on the patio, V8 stated, We (CNAs) go to the patio to check and would tell the nurse that we can't find the resident if the resident is not on the patio. When asked about R1's activity during the day shift on 9/12/23, V8 stated V8 redirected R1. R1 would be sitting in a chair in the hallway by the nurse's station and then R1 would walk into the day room, followed by walking to the opposite hallway on the floor and then into R1's room. V8 stated, V8 checked R1's (electronic monitoring safety device) on R1's ankle on the morning on 9/12/23 and that it was blinking. V8 stated, I (V8) served (R1) lunch. (R1) came and sat down in the dining room. Surveyor asked what time was the last rounds V8 performed to check on R1 on 9/12/23. V8 stated, (V7) did the last CNA rounds around 2:30 pm. When asked when the last time V8 saw R1 on 9/12/23. V8 stated, It was 1:00 pm, and (R1) was sleeping. V8 stated, (R1) speaks little English with using a few words to communicate in English. V8 stated, R1 would tell V8 that V8 wants to go out of the building, and V8 would instruct R1 to tell social services staff who will talk to R1. Facility document (undated and received from the facility on 9/19/23) titled Elopement Risk documents, in part, the photos, names, gender, race, and height of 16 residents: R1, R3, R4, R6, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20. In R1's Progress Note, dated 8/18/23 at 8:29 pm, V32 (Licensed Practical Nurse, LPN) documents, in part, R1 is alert and oriented x 2 to self and place, verbally responsive, and (R1) is not fluent in English, occasionally uses gestures to communicate with staff. On 9/20/23 at 11:50 am, V3 (RN) stated, V3 floats to different floors in the facility and works the 7:00 am to 3:00 pm shift or the 3:00 pm to 11:00 pm shift. Surveyor asked how does V3 know who the elopement risk residents are where V3 is working. V3 stated, I (V3) know by their (electronic monitoring safety devices), and the list of picture faces at the nurse's station. I check it, and I know them. Their faces. I check it at the beginning of the shift. Surveyor asked if a resident has an electronic monitoring safety device, what are V3's responsibilities as the charge nurse on the floor. V3 stated, For me to do rounds and make sure that the (electronic monitoring safety device) are on. Check on their leg to see if it's on. Most of the time, it blinks red. V3 stated, when the electronic monitoring safety device is blinking red, it's working and V3 also checks the residents' skin integrity under the bracelet. When asked how often V3 perform resident rounds, V3 stated, At the beginning of my shift and end of my shift. When asked who does rounds in middle of V3's shift, V3 stated, Most of the times, the CNAs do. When asked how does V3 know who can go out of the facility and with what type of community pass, V3 stated, Family and CNA will come take (residents) out on pass. Residents can go out on individual pass. I (V3) know, if not on (electronic monitoring safety device), then they can take the individual pass. Resident has to tell me (to go out on individual pass), and I have to sign the pass. V3 stated, on 9/12/23 for the 3:00 pm to 11:00 pm shift, V3 was assigned as R1's nurse and V3 was the charge nurse (only one nurse) for the 3rd floor. V3 stated, V3 was not familiar with R1 and had worked as R1's nurse one shift prior to 9/12/23. V3 stated, the 3rd floor CNAs who regularly work there are familiar with R1. V3 stated, on 9/12/23, I (V3) came in late because I had to go and pick up my kids from school and came in around 3:30 pm. (V6, RN) was ready to leave. V3 stated, (V6) gave me report. (V6) said a resident was out on pass, (R5). When asked if any other resident was reported by V6 to be out on pass from the 3rd floor on 9/12/23, 3:00 pm to 11:00 pm, V3 stated, No. When asked what did V3 do after nursing report, V3 stated, I (V3) went to do rounds. I noticed most residents on the 3rd floor don't stay. Most of the time, I work on the 2nd floor. Most (2nd floor residents) are bed bound or sit in the day room. On 3rd floor, they move from one floor to another. They be on the 1st floor activities or on smoke break. Wander around building. 50% or more (3rd floor residents) are not in the (3rd floor) day room. Some residents are in (3rd floor) day room or downstairs doing activity. When asked where was R1 on V3's initial rounds on 9/12/23, V3 stated, (R1). I (V3) didn't see (R1) in (R1's) room. I assumed, maybe, (R1) was in day room or walking. (R1) was not in the day room, so I assumed (R1's) downstairs on 1st floor doing activities. When asked did V3 call downstairs to the 1st floor to verify R1's location, V3 stated, No, I (V3) did not call downstairs. They (residents) come back themselves to the floor when it's time to eat. Surveyor asked when it was time to eat dinner on 9/12/23, did R1 come back to the 3rd floor? V3 stated, I (V3) was busy with an admission. I didn't notice (R1). There's one nurse on the floor. I have a lot of responsibility. I was so busy, and the admission came early. That day, I left late. I left the facility late from the admission. The CNAs are the ones that pass trays. CNAs are supposed to let me know what percentage of food they (residents) eat. V3 stated, V10 (CNA) or V11 (CNA) who were working on 9/12/23 from 3:00 pm to 11:00 pm did not report to V3 that R1 did not eat dinner on 9/12/23. V3 stated, when V18 (CNA) for the night shift came and told me (V3), (R1) is not in bed. I was like, 'Come on.' My CNA (V10) didn't tell me. V3 stated, When I (V3) came in (for the 3-11 pm shift), I was doing rounds. (V6) told me that (R5) was out on pass. When I went to pass meds, I saw (R5) in (R5's) bed. (R5) said (R5) was fine. (R5) said, 'I don't want my meds,' but I give (R5) the meds. I saw (R5). This is (R5). So was (V6) trying to tell me it was (R1) out on pass. I can't assume that a resident just walked out of the building not being noticed with security downstairs. Is (V6) trying to say (R1) instead of (R5)? Surveyor asked how did V3 clarify which resident was out on pass on 9/12/23. V3 stated, When I (V3) called (V6) and confirmed that it was (R5). I called (V6) at home. Time was late in the night. After 11:00 pm at end of the shift. When asked did R1 go out on pass on 9/12/23, V3 stated, (V6) confirmed it was (R5) and not (R1) who was out on pass. V3 stated, V18 (CNA) came early for the 9/12/23 11:00 pm to 7:00 am shift and informed V3 that R1 was not in R1's bed. V3 stated, this was before 11:00 pm and V4 (LPN) who was the night shift nurse had not arrived yet to the facility. Surveyor asked what did V3 do when V3 confirmed that R1 was not in facility and not out on pass. V3 stated, I (V3) called (V2, DON). (V2) said, 'Oh, let me call you back. Let me call (V1, Administrator).' I had told (V2) that I assumed that (R1) was out on pass. (V2) said (R1) is not on individual pass to go out. I thought then that maybe family came into get (R1). When asked did V3 speak to V2 after the first phone call with V2, V3 stated, No. (V2) called back to (V4) who was there. (V2) did not call me back at facility. (V2) called me the next morning at home, and (V2) said (V1) wanted to talk to me. (V1) asked me questions. (V1) told me to come in. I was off on Wednesday (9/13/23). I come to (facility). I write a statement. I went in. This surveyor read statement V3's authored statement and asked if when V3 wrote a resident, was this (R5), and V3 said Yes. I (V3) assumed (R5) was (R1). When this surveyor read V3's authored progress note (9/12/23 at 11:56 pm), this surveyor asked V3 if V3 was informed at or before 11:00 pm by V18 (night CNA) that R1 was not in R1's bed, why was V3 documenting that R1 was still out on pass 1 hour later? V3 stated, That's why I (V3) left the building late. I was doing admission. I lost track of time. It was late charting documenting. I was busy with my admission. I didn't sign it (note) until end of shift. V3 stated, V3 didn't sign the authored progress note initially because V3 wasn't sure if R1 was out on pass, and That's when I (V3) called (V6). Was it (R5) or (R1)? V3 checked V3's personal phone and stated, V3 phoned V6 on 9/13/23 at 12:01 am. V3 stated, I (V3) called (V6). I am thinking (R1) is still out on pass at 11:56 pm. I was busy with my admission. When asked if V3 performed resident rounds at the end of 9/12/23 3:00 pm to 11:00 pm shift, V3 stated, V18 had started the rounds before V3 and V18 said R1 was not there. V18 stated, V10 (CNA) had already left the facility at that time. V3 stated, I (V3) didn't see (R1) at all (on 9/12/23) when I did rounds. I am not going to lie. I didn't see (R1). V3 stated, when V3 completed V3's 3:00 pm to 11:00 pm shift on 9/12/23, V3 left the facility and that the Code Green was not called yet. In R1's Progress Note, dated 9/12/23 at 11:56 pm, V3 (RN) documents, (R1) remains out on pass. V3's signed witness statement for V3's 3:00 pm to 11:00 pm shift on 9/12/23 documents, When I (V3) came in for my shift, I realized (R1) was not in (R1's) room. (V6, RN) reported to me that a resident (R5) was out on pass. So, I assumed (R1) was out on pass. R1's Physician's Orders Statement (POS) documents, in part, the following orders dated 8/21/23: (R1) may wear (electronic monitoring safety device) for elopement precautions and Check (electronic monitoring safety device) placement/function/skin integrity q (every) shift. R1's POS (printed 9/19/23) does not contain an order for community pass privileges. R1's Treatment Administration Record (TAR), dated September 2023, documents, in part, for the order of Check (electronic monitoring safety device) placement/function/skin integrity q shift on 9/12/23 for the 3:00 pm to 11:00 pm shift, V3 did not complete (not performed) this order for the documented reason of Out on Pass. On 9/21/23 at 3:52 pm, V6 (RN) stated, on 9/12/23, V6 did give verbal shift to shift nursing report to the oncoming nurse, V3, and updated the 24-hour nursing report in the electronic medical record (EMR). V6 stated it's a standard of practice to report residents who are on 72-hour monitoring, residents who are out on pass, or if there were incidents during the shift. V6 stated, I (V6) gave report to (V3) and told (V3) that (R5) was the first time out to the community so watch for (R5) and monitor (R5) when (R5) comes back. V6 stated V6 gave report to V3 around 3:45 pm on 9/12/23 because V3 came late to work. V6 stated, I (V6) didn't leave. I have to wait. V6 stated, when residents return from independent pass, staff does rounds to make sure that residents are back. V6 stated, R5 went out on pass around 2:00 to 2:30 pm on 9/12/23 and didn't return to the facility before V6 left the floor. V6 stated, from 3:00 pm to 3:45 pm, V6 was in the nurse's station and received no other information from CNA staff about R1 or R5's whereabouts. V6 stated, V6 communicated with V2 (DON) at 12 midnight on 9/13/23, it was a sudden call, so I (V6) picked it up. V6 stated, V2 asked V6 about R1 or R5 being out on pass, and V6 told V2 it was R5. It was R5's first time out on pass and V6 put it in the 24-hour sheet and physically told V3, 'watch for (R5).' V6 stated, V2 said 'Okay' and asked if V6 did rounds when V6 was leaving the shift to see R1. V6 said No, but (V6) saw (R1) that day. Surveyor asked if V6 communicated with V3 that night (9/12/13). V6 stated, When (V2) called me, I (V6) was not at ease. I called (V3) to see what happened on (V3's) shift. (V3) stated (V3) mixed (R5) and (R1). Facility document dated 9/12/23 and titled Community Pass Sign In/Out, documents, in part, R5 was out on pass from 2:30 pm (out-time) to 3:15 pm (in-time) on 9/12/23 with R5's printed name and signature noted. R1's name/signature is not documented on this 9/12/23 Community Pass Sign In/Out document. R5's Out on Pass Assessment, completed on 9/4/23, documents, in part, that R5's pass level determination is independent. On 9/20/23 at 1:04 pm, V10 (CNA) stated, V10 worked the 3:00 pm to 11:00 pm shift on 9/12/23 on the 3rd floor and was assigned as R1's CNA. V10 stated, V10 came to work on 9/12/23 around 2:50 pm and started room to room rounds. V10 stated, around 3:00 to 3:10 pm, V10 checked in R1's room, and R1 was not there. V10 stated, V10 looked around the 3rd floor and in other rooms and didn't see R1. V10 stated, By that time, residents want to eat. I (V10) didn't see (R1) before dinner. If (R1) want to come back. I keep the food. This is (R1's) food. [sic]. When asked on 9/12/23 at 3:00 pm to 3:10 pm, did V10 tell a nurse that R1 was not on the floor, V10 stated, Nurse wasn't here. I didn't see a nurse. The food comes, (R1) did not come. I didn't see (R1). I keep (R1's) tray. (R1) assigned to me. [sic] V10 stated when V10 started V10's shift on 9/12/23, V3 (RN) was not there on the floor. V10 stated, at 4:00 pm, all residents come to the dining/day room to watch television and get ready for the dinner meal. V10 stated, (R1) didn't come. When asked if V10 informed V3 at 4:00 pm R1 was not on the floor, V10 stated, (V3) goes around, make their rounds. 4 pm rounds are for the nurse. V10 stated, V10's next resident rounds are at 5:00 pm, and 5 pm is for trays. I (V10) don't see (R1) in dining room. I tell (V3, RN). I tell (V3) that (R1) didn't come. I tell (V3) that I didn't see (R1). When asked what time V10 told V3, V10 stated, I (V10) tell (V3) I didn't see (R1) and that this is (R1's) dinner. I keep the food. 7 pm, time to pack up the trays. (R1's) tray is at nurse's station. I put it (R1's uneaten tray) in tray to go. Everyone eat their food except (R1), and I put all the trays back. (R1's) tray is the only one not eaten. V10 stated, on 9/12/23 at 7:00 pm, V10 informed V3 that R1 did not eat R1's tray and V10 did not see R1. V10 stated, on 9/12/23 at 8:00 pm, V10 went to do rounds and clean the residents. I packed the trays and then change everybody. I didn't see (R1). When asked when was the last time V10 checked in R1's room on 9/12/23, V10 stated it was at 10:00 pm and V10 did not see R1. Surveyor asked if V10 told V3 at 10:00 pm R1 was not in R1's room. V10 stated, I (V10) didn't tell (V3) again because (V3) knows. (V3) knew. I leave at 11 pm. At 10 pm, I did rounds. Everyone was there except for (R1). V10 stated, V10 knows R1 is confused and walks around the building. Surveyor asked V10 if R1 is an elopement risk resident. V10 did not answer the question. When asked which residents are at risk for elopement, V10 stated, CNAs do rounds on the 1st, 2nd, and 3rd floors. When asked when V10 arrived on the 3rd floor on 9/12/23 at 2:50 pm for V10's shift, how did V10 know who the residents are who wander or are trying to exit the building (elope), V10 stated, I don't know. When this surveyor stated, R1 was an elopement risk resident, V10 stated, I didn't know that. This surveyor read V10 the authored witness statement for V10, and V10 verified that it was V10's statement for the 9/12/23 shift despite V10 dating the witness statement as 9/5/23. V10's signed witness statement for V10's 3:00 pm to 11:00 pm shift on 9/12/23 documents, in part, I (V10) came in for my shift, I made rounds. Found out that (R1) was not in room. I thought maybe (R1) was still in the building. I indicated 'out' on the round sheet so (before) dinner and after dinner, (R1) was still not around, so I keep the food and alert (V3, RN). CNA Assignment Sheet dated 9/12/23 for the 3:00 pm to 11:00 pm shift documents, in part, V10 was assigned as R1's CNA. On 9/20/21 at 1:40 pm, V11 (CNA) stated V11 floats to different floors and works the 3:00 pm to 11:00 pm shift. V11 stated V11 worked on the 3rd floor on 9/12/23 from 3:00 pm to 11:00 pm and was not assigned as R1's specific CNA on that faithful day. V11 stated, V11 came to the floor around 3:15 pm on 9/12/23, and (V10) did first rounds. I didn't do rounds first because I usually confirm my place. (V10) did overall rounds. (V10's) permanent there. (V10) knows the residents. V11 stated, I (V11) didn't work with (R1) that day but V11 remembers R1 from a previous shift. When asked on 9/12/23, did V11 see R1 in the building, V11 stated, I (V11) didn't notice (R1). (R1) is not on my side. I am concentrating on the people who I am assigned to. That day, I am assigned to side B. V11 stated, V10 was on side A hallway on the 3rd floor and V11 was concentrating on the B side. Surveyor asked how does V11 know who the elopement risk residents are. V11 stated, They have something on their leg. Person can alarm that someone is leaving the building. I can go to nurse's station (to see the elopement risk list) with name of residents that something's on their leg. When asked if V11 checked the posted elopement risk on 9/12/23, V11 stated, Yes. I (V11) did look at it on my 3 to 11 (shift). I was on B side. Just when I walk in, then I will check names. They have (electronic monitoring safety devices) on them. I only look at the residents assigned to me. V11 stated, I (V11) do rounds every 2 hours. I fill out the (rounds) sheet. When asked if V11 communicated with V10 during the 9/12/23 3:00 pm- 11:00 pm shift about R1 not being on the floor, V11 stated, I (V11) only face my area where I am working. Facility document titled Resident Hourly Checklist and dated 9/12/23, documents, in part, that on the 7:00 am to 3:00 pm shift, R1's last documented observation is at 1:00 pm with an S documented for sleeping. V6 (RN), V7 (CNA), and V8 (CNA) are the staff verifying the resident hourly checklist for the 7:00 am to 3:00 pm shift. For the 3:00 pm to 11:00 pm shift, R1 is documented as O indicating Off unit check with Receptionist/Social Services for 3:00 pm, 5:00 pm, 7:00 pm, and 9:00 pm. The lines of Staff Verifying Form and Name of Nurse on shift from the 3:00 pm to 11:00 pm shift is blank with no documentation. Daily Nursing Schedule dated 9/12/23 documents, in part, that on the 3rd floor, for the 7:00 am to 3:00 pm shift, V6 (RN), V7 (CNA), and V8 (CNA) are assigned; for the 3:00 pm to 11:00 pm shift, V3 (LPN), V10 (CNA), and V11 (CNA) are assigned; and for the 11:00 pm to 7:00 am shift, V4 (LPN), V18 (CNA) and V30 (CNA) are assigned. On 9/21/23 at 3:34 pm, V4 (Licensed Practical Nurse, LPN) stated, V4 works primarily on the 3rd floor on the 7:00 am to 3:00 pm and 11:00 pm to 7:00 am shift and V4 worked on 9/12/23 from 11:00 pm to 7:00 am. V4 stated, V4 is familiar with R1 and that R1 is alert, oriented and R1 will exercise and will walk around. V4 stated, V4 had brief conversations with R1 with R1 saying Hi. V4 stated when V4 arrived on 9/12/23 for the 11pm-7am shift, V4 did V4's rounds to go around to all residents, and V4 did not see R1. V4 stated, I (V4) went right away to (V3) and asked, 'What happened? (R1's) not here' and (V3) said, '(R1's) not in the building. (R1's) out on pass.' V4 stated V4 informed V3 that R1 doesn't have pass privileges to be out on pass, and V4 asked V3 if V3 reported this to V2 (DON) or if V3 was doing something about it. V4 stated, V4 knows R1 should not be out on pass and then called V2 to report R1 was missing. V4 stated, V4 then called a Code Green overhead and staff working checked the 2nd and 3rd floors and the patios and by the exit doors. V4 stated, V4 called back V2 on the phone to report R1 was missing, and V4 called 911 to file a missing person report. V4 stated, V4 arrived to work on 9/12/23 around 11 something. V4 stated, it was 10 minutes after 11:00 pm and by that time, the CNA (V18) had already gone around on V18's rounds where R1 was not present. When asked what a nurse or CNA does when they normally do rounds, V4 stated, We go around to every residents room to make sure that they are awake, alert and to account for all residents and that no one is missing. V4 said, since V4 came in a little late to work, V4 did V4's tour of the floor, going room to room to check that everyone is present, and I (V4) did not see (R1) in bed. V4 stated, V3 told V4 that R1 was out on pass, and I (V4) know (R1) does not have pass privileges. V4 stated, V4 asked V3 while still at the nurse's station, Did you (V3) report to (V2, DON)? Even if (R1's) out on pass, it's past 8:00 pm, and (R1's) not back. V4 stated, if a resident who is out on pass has not returned to the facility by 8:00 pm, nurses are to report to V2 and the physician. V4 stated, V3 kept saying, (R1's) out on pass. V4 said, V4 reported to V2 what V3 said and a Code Green was called overhead. V4 stated, all staff came to the floor, and staff searched all over the facility. V4 stated, head counts were done of residents on 1st, 2nd, and 3rd floors. V4 stated, some staff went outside the facility to search for R1. V4 stated, after the search for R1, an officer from the local police department came to the facility where V4 provided R1's description of R1 and R1's picture. This surveyor read V4's progress note, dated 9/13/23 at 12:44 am. When asked if R1 was wearing an electronic monitoring safety device, V4 stated, Yes. When asked why R1 was wearing an electronic monitoring safety device, V4 stated, (R1's) an elopement risk. It's on (R1's) POS. (R1's) on the (electronic monitoring safety device) list posted at the nurse's station. V4 stated, R1 had an electronic monitoring safety device and was not to be out on pass. In R1's Progress Note, dated 9/13/23 at 12:44 am, V4 documents, in part, (V4) received endorsement from (V3) stating (R1) was out on pass, @ (at) 12:09am, (V4) notified (V2, DON) that (R1) had not returned from pass, at which time (V2) said (V2) was not aware (R1) was out on pass. (V2) instruct (V4) to initiate A CODE GREEN. Conducted head count on all unit. (R1) was not accounted for. Facility thoroughly searched both inside and outside and surrounding vicinity of facility searched thoroughly for up to 2 miles. (R1) is responsible for self. (V28, Attending Physician) and (V31, Psychiatrist) notified. (V1, Administrator) notified. Called (Call) placed to surrounding hospital to alert them. Missing person report filed with the (local police department) with (police report number), copied of Face sheet and picture given to (local police department). V4's signed witness statement for V4's 11:00 pm to 7:00 am shift on 9/12/23 documents, At 11:00 pm, during rounds for the beginning of the shift, (R1) was not in the unit. (V3, RN) told me (V4) that (R1) is out on pass. (R1) is on supervised pass privileges. (V2, DON) notified. Code Green initiated. Resident head count conducted. (R1) no accounted. Missing person report filed with (local police department). On 9/25/23 at 3:54 pm, V18 (CNA) stated, V18 floats to all 3 floors and works the 11:00 pm to 7:00 am shift. V18 stated, V18 is familiar with R1. When asked on 9/12/23 for the assigned 11:00 pm to 7:00 am shift, what time did V18 arrive, V18 stated, When I (V18) came to work, I remember it was 10:30 to 11:00 pm. I go to the rooms and check everywhere to see that my residents are intact, and I discover that (R1's) not on (R1's) bed. I got (V3, RN) and say [sic], 'I did not see (R1) on bed.' (V3) said, 'According to (V5), (R1) is out on pass.' When asked if V18 informed any other staff that R1 wasn't present in the facility on 9/12/23, V18 stated, V18 told V4 that V18 did not see R1. V18 stated, staff tried to find R1 with a Code Green being called in the facility. V18 stated, R1 did not return to the facility at 7:00 am when the shift ended. On 9/20/23 at 10:58 am, V13 (Receptionist) stated, V13 works Monday through Friday from 8:00 am to 4:30 pm and V13 was working on 9/12/23. V13 stated, I (V13) am responsible for keeping my eyes on the door, who's coming in and out, though I do man the fax machine and make copies of doctors' orders. Anyone who is coming into the bay area. (Front lobby). V13 stated, the front door at the entrance of the

Based on observation, interview, and record review the facility failed to monitor, supervise, and assist one resident (R109) with history of multiple falls with injuries resulting in left arm fracture, acute nasal fracture, and acute intracranial hemorrhage with a hematoma; the facility also failed to provide 2-person assistance during bedside care for 1 resident (R129) who required total assist. This failure resulted in R109 falling off the bed during bedside care. These failures apply to 2 out of 4 residents (R109 and R129) from a total sample of 30 residents reviewed for accidents and supervision. R109 was hospitalized and treated for injuries. Findings include: 1. R109 was [AGE] years old, initially admitted on [DATE]. R109's medical diagnoses include pain in joint, history of falling, physical fracture of lower end of ulna, left arm and fracture of nasal bones. R109's Brief Interview for Mental Status (BIMS) scored dated 11/24/2022 was 12, indicating moderate cognitive impairment. On 03/07/2023 at 11:15 AM. R109 was seen inside her room. R109 was alert and verbal speaking in Spanish. When asked if she fell (pointing to the floor), R109 said, Si. When asked if she went to the hospital because of the fall, R109 said, Si. V11 (Licensed Practical Nurse/LPN) said that R109 speaks Spanish but understand English. R109 was seen walking up and about without any assistance and supervision from the staff. Per R109's Fall Care Plan R109 has had multiple falls with injuries. The Care Plan At risk for falls related to use of Antidepressant medications indicates R109 has potential for falls due to possible adverse reactions of the medications. R109's falls includes the following dates: 09/12/2018 without injury 06/25/2021 with injury. R109's notes reads that R109 sustained right knee skin abrasion 11/01/2021 with injury. R109's notes reads that R109 sustained left eye wound with staples 05/19/2022 with injury. R109's notes read that R109 sustained left arm fracture 06/29/2022 complaint of pain with no injury 12/28/2022 with major injury. R109's notes read that R109 sustained Acute nasal fracture and Acute right anterior Parafalcine Subdural Hematoma. On 03/09/2023 at 02:35 PM. V2 (Director of Nursing) said R109 was scheduled for a colonoscopy, and R109 had to drink a solution to clean out her bowels. So, she (R109) lost a lot of fluids related to the increased bowel movements, which made her (R109) become dizzy. That is why she (R109) fell . R109 sustained a broken nose bridge when she fell on [DATE]; she went to the hospital and was admitted for fracture on her nose. R109 also has another fall prior to 12/28/2022 where she got an arm fracture. V2 stated, I think R109's gait is steady, so she walks independently. It happened early in the morning around 6AM. In my investigation, R109 fell because of the bowel prep. Of course, staff need to know that R109 needs monitoring due to taking the bowel prep. On 03/09/2023 at 03:18 PM. R109 was not observed in her room. No staff were observed at the Nurse's Station. After few minutes R109 was seen coming out of the restroom by herself and went directly to bed. A few minutes later, V18 (Registered Nurse) arrived at the Nurse's Station. V18 said, Yes, R109 is my resident and she walks independently. R109's gait is sometimes steady and sometimes not steady. Surveyor requested V18 to come with surveyor to observe R109 walk in her room with stand by assist to see if R109's gait is steady. Upon entering the room, R109 was on her bed lying on her left side. R109 was found grimacing with pain and rubbing the right side of her hips. V18 then requested for R109 to walk, but R109 repeatedly said in Spanish Dolor. V18 then said, I am not fluent in Spanish, but I think R109 is telling me that she refused to walk and is saying pain. I don't think she can walk right now. If you can wait, I will find staff who speaks Spanish and talk to R109 again. V19 (Housekeeper) was in the hallway and was asked if she is fluent in speaking Spanish to interpret R109's statements. V19 agreed and spoke to R109 in Spanish. V19 said, R109 said that she fell inside the bathroom, and that R109 has pain due to the fall. R109 said that she went to the toilet to pee but was not able to because she fell . R109 tried to hold onto or grab on something to hold but was not able to and fell . V18 was asked if R109 is being assisted when transferring from bed and getting up. V18 said, R109 is not being assisted but she is independent when transferring or only supervision. V18 was asked also about R109's mobility in bed and asked if staff are helping R109. V18 said, No she (R109) is independent. Or again we just supervise her (R109). On 03/09/23 at 03:50 PM. V2 (Director of Nursing) said, No one told me that anything happened with R109. V2 was informed about the incident and said, Staff must be aware of R109's ability to transfer. It depends on the nurse working, but I agree they should know the residents' ability to perform ADLs (Activities of Daily Living). I think R109 needs to be assessed by a therapist to determine her ability to perform her ADLs. R109's functional status assessment dated [DATE] reads that R109 needs assistance with bed mobility and transfers, and supervision when walking. Functional limitation in Range of Motion (ROM) reads that R109's lower extremities are impaired on both sides. On 03/10/23 at 10:26 AM. V14 (Restorative Coordinator) said, I code R109 for supervision because if I code any higher than that she needs equipment. Yes, R109 has impairment of both lower extremities because of left arm fractures, pain and the joint. That, that based on the assessment, placed resident at risk of injury. R109's MDS (Minimum Data Set) dated 11/24/2022 under Section G (Functional Abilities and Goal) during admission reads that R109 was assessed to need supervision or assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) on rolling left and right, sit to lying, lying to sitting on side of the bed, sit to stand, transfers, toilet transfer. And Setup or clean-up assistance (helper assists only prior to following the activity) on walking 10, 50 and 150 feet. R109's Care Plan on ADLs (Activity of Daily Living) shows: Range of Motion in part reads: R109 demonstrates the following areas of deficit secondary to diagnosis of joint pain, impaired functional strength. R109's Care Plan of Falls under interventions do not show a review after each fall to determine effectiveness of interventions. R109's CT (Computerized Tomography) dated 12/28/2022 in part reads: CT of the head finds R109 sustained an acute intracranial hemorrhage with a parafalcine hematoma. CT of the facial bones finds R109 sustained fracture through the nasal spine and the nasal bone with surrounding soft tissue edematous changes. R109's notes by V21 (Licensed Practical Nurse) dated 12/28/2022, read in part that R109 fell in the hallway. During assessment R109 blood was coming out of R109's nose and mouth. R109's notes by V11 (Registered Nurse) dated 12/29/2022, read in part that V11 received a report from the hospital that R109's admitting diagnosis was intracranial bleeding. R109's hospital records dated 5/20/2022 read in part: R109's diagnosis includes closed fracture of distal end of left radius. R109's notes dated 05/19/2022 by V22 (Licensed Practical Nurse), read in part that R109 fell and verbalized pain on his wrist. R109's notes dated 05/20/2022 by V23 (Licensed Practical Nurse), read in part that R109 came back in the facility with fracture on her left arm. On 03/10/2023 at 03:09 PM. V15 (Medical Doctor) said, R109 has a fainting problem that may cause R109 to fall. But staff allows her to walk by herself. R109 even goes to smoke on the outdoor area of the facility by herself. I think R109 needs a therapy assessment if nursing staff said that her (R109) gait is sometimes unsteady. Parafalcine is a bleeding of tissue in the brain. I have to review the CT scan result to remember. If it (CT) does mention acute intracranial bleeding, then it is bleeding in the brain. It may have been small bleed. Facility Policy Regarding Residents Falls not dated, reads in part: This facility is committed to minimizing resident falls, to maximize each resident's physical, mental and psychosocial well-being. All resident falls will be assessed, and the resident's existing plan of care will be evaluated for needed changes. The resident plan of care shall be updated if additional care interventions are necessary. 45002 2. On 03/08/23 at 01:13 PM, R129 stated he (R129) fell while being turned in bed by one Certified Nursing Assistant /CNA (V17) back in October 2022. On 03/09/2023 at 12:46, V2 (Director of Nursing) stated R129 fell when V17 was trying to change him (R129). V2 stated only one person was assisting to change R129 when he (R129) fell . When R129 is repositioned in bed, he (R129) requires at least 2 people. V2 stated, According to his MDS, he (R129) is a total assist and is required to have at least two people reposition him. There was no injury when he (R129) fell . But he (R129) was sent out. V17 was the CNA changing R129 when he fell on [DATE]th, 2022. When R129 went out to the hospital, the CT or X-ray did not show any injury. On 03/09/2023 at 01:05 PM, V14 (Restorative Coordinator) stated, We do passive range of motion on R129, if he (R129) allows us to. His (R129) bed mobility status is total assist. That means it takes two people to reposition him (R129) because he (R129) is unable to help. He (R129) refuses to get out of bed. Anytime he (R129) needs to be changed, there absolutely has to be two people to change him (R129). On 03/09/2023 at 3:55 PM, V17 (Certified Nursing Assistant) stated that R129 fell when he (V17) was changing him (R129). V17 stated, R129 soiled the whole bed. So, I (V17) was holding him (R129) up with one hand and trying to clean him (R129) up. All of a sudden, he (R129) slid down. I received an inservice from V2 (Director of Nursing) that R129 requires 2 people when changing him. R129's MDS Section C, Cognitive Patterns (02/10/2023) documents in part: BIMS score is 15. This means R129 is cognitively intact. R129's MDS Section G, Functional Status (02/10/2023) documents in part: Bed Mobility: Self Performance is scored at a 4, Support is scored at a 3. A score of 4 under self-performance means, total dependence; Full staff performance every time during entire 7-day period. A Support score of 3 means, two or more-person physical assist. Facility's fall risk policy documents in part: During the MDS review process, all residents shall be assessed for the potential for falls. For residents who have been identified at risk for falls upon admission, the interdisciplinary plan of care shall include interventions to prevent injuries and accidents from fall.

Based on observation, interview and record review the facility failed to follow its policy related to unintended weight loss and failed to follow care plan interventions for weight loss. The facility also failed to follow its policy for providing resident with double portion during meals for 1 (R60) out of 11 residents reviewed for nutrition status. These failures resulted in (R60) having continuous significant weight loss. Findings include: R60 was [AGE] years old, initially admitted on [DATE]. R60's medical diagnoses include Dysphagia and Dementia. R60's Brief Interview for Mental Status dated 01/18/2023 scored '99 indicating that R60 was not able to be interviewed due to rarely or never understood. On 03/07/2023 at 11:36 AM. Food carts that contained trays for lunch from the kitchen arrived on the floor. Facility staff were distributing trays. R60 received his tray between 11:36 AM to 11:46 AM. At 11:56 AM R60 was seen wheeling his wheelchair going out of the dining room to his room. None of the staff encouraged R60 to eat. R60's tray was seen inside the cart. There was ground beef that was barely touched; the scoop formation was still intact. There was a single slice of bread that was still whole. Less than 10% of his food was consumed. Upon checking R60's meal ticket, it read that R60 was supposed to receive double portions. V11 (Registered Nurse/RN) was asked why R60's tray did not have double portions. V11 collected the tray and brought it to the Nurse's Station. V11 said, Let me notify V6 (Dietary Manager) about it. She (V6) can answer your questions better. V6 (Dietary Manager) said, I don't know why R60's tray does not have double portions. But I will notify the cook, because it is clear that R60's meal ticket has double portions on it. But as to encouraging R60 to eat during meals, it is the CNA (Certified Nursing Assistant) who encourage the residents to eat. Dietary staff delivers the cart with the tray and collect the cart once residents finish eating. V11 (RN) said, Yes, R60 needs to be encouraged, and I don't know why trays were collected in such a short time. R60's monthly weights were reviewed. R60's weights declined consistently. R60's weights are as follows: 3/10/2022 - 185 LBS 4/10/2022 - 175 LBS 5/10/2022 - 173 LBS 6/10/2022 - 171 LBS 7/10/2022 - 163 LBS 8/10/2022 - 162 LBS 9/10/2022 - 164 LBS 10/4/2022 - 159 LBS 10/10/2022 - 155 LBS 11/2/2022 - 149 LBS 11/10/2022 - 145 LBS 12/10/2022 - 150 LBS 12/20/2022 - 144 LBS 1/10/2022 - 149 LBS 2/10/2022 - 150 LBS On 03/09/2023 at 12:52 PM. V2 (Director of Nursing/DON) said, After dietary staff deliver the cart with the trays to the floors, it is mainly the CNAs (Certified Nursing Assistants) who distribute the trays. The nurse and the CNA should know who are those residents that need help during meals. The nurse also needs to supervise the CNA regarding the care of the residents. On 03/09/2023 at 01:18 PM. with V2 (DON) present, R60's weight was taken on a chair weighing scale. The result was 139 pounds. Compared to prior weight taken on 2/10/2023, R60 lost 19 pounds in 1 month. R60's loss was a 7.33% weight loss in one more (more than 5% which is within category of significant weight loss). V10's (Registered Dietician) assessment notes for R60 are as follows: Most current assessment notes dated 12/029/2022 read in part: R60's ideal body weight 89 kilograms or 196.211 pounds. And based on R60's history of weights, R60 has significant weight loss -12.2% X 3 months, -15.79% X 6 months. Assessment notes dated 11/10/2022 in part reads: R60's ideal body weight 89 kilograms or 196.211 pounds. And based on R60 history of weights, R60 has significant weight loss -8.8% X 1 month, -10.5% X 3 months, --16.2% X 6 months. Assessment notes dated 10/14/2022 read in part: R60's ideal body weight 89 kilograms or 196.211 pounds. And based on R60's history of weights, R60 has significant weight loss -5.49% X 1 month, -11.43% X 6 months. For the period of 9 months (4/1/2022 to 12/09/2022) R60 was assessed to have significant weight loss. All assessments V10 noted for R60 to have double portions. R60's Care Plan related to Nutritional Status (Therapeutic Diet, Unplanned weight loss/Protein calories malnutrition) reads to add double portions with all meals with a goal to complete at least 75% or more of meals. Interventions include monitor and record intake at each meal. On 03/10/2023 at 09:46 AM. V10 (Registered Dietitian) said, Yes, double portions will help R60 with his weight. The role of the staff to offer to resident and encourage resident to eat during mealtime is important. Ideally 75% consumption of R60's meal will benefit him. R60's ideal body weight is 89 kilograms or 198 pounds. I am looking at my notes right now. Yes, R60 has significant weight loss. When recommendations are not being followed it will not be effective and R60 will continue to decline or lose weight. R60's Physician Order does not reflect V10's recommendations. R60's diet order related to diet or nutrition was mechanical soft with thin liquid diet and {Nutritional Supplement} 237 ML 3 times a day. On 03/10/2023 at 02:35 PM. V20 (Medical Doctor) said, There was back and forth communication about R60 significantly losing weight, but I cannot remember the specifics. I am not sure why V10's recommendation does not reflect with my order. I have a Nurse Practitioner that helps me. But since you brought it to my attention, I will give the order and attend to it vigorously. Yes, when staff in the facility do not encourage R60 to eat, it will affect his weight and it will continue to decline. Facility policy related to unintended weight loss/gain (undated), reads in part: This policy provides a guide for monitoring risk factors for unintended weight loss/gain and providing interventions for those residents with unintended weight loss/gain once it has been identified. Any significant weight change of 5% or more in a month, 7.5% in 3 months, or 10% or more in 6 months will be reported to the Dietitian and Physician. Residents who have been determined to have weight loss/gain will be added to the weekly weight list, and the list will be given to Dietitian. The Nutrition Intervention will be determined by the Dietitian and approved by the doctor. Double/Large Portion Policy dated 2017, reads in part: Increased portions are available for clients requiring extra calories. The diet is ordered for double or large portion. Double portions are served as one and a half servings of food on the plate and two servings of bread. Salad, dessert and beverage are served as standard portions.

Based on interview and record review, the facility failed to supervise and protect a resident (R2) from physical abuse of another resident (R3). As a result, R3 pushed R2 resulting in R2 falling to the ground and sustaining a left [MEDICAL CONDITION]. This failure affected one (R2) of 4 residents reviewed for abuse in total sample of 5 residents. Findings include: R2 is an alert, oriented, ambulatory [AGE] year old female who requires limited assistance with her dressing, toilet use, and hygiene but otherwise is independent with her activities of daily living (ADLs). R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's care plan addresses concerns with poor hygiene, diminished motivation and not recognizing a problem when it exists. R2 left on 5/19/20 per the MDS with return anticipated but never returned. On 8/11/20 at 3:40 PM, V12 (R2's brother/guardian) stated he is upset that his sister was not protected from R3. V12 stated he googled R3 and found out that R3 was a convicted felon with murder, attempted rape and kidnapping charges in his past. V12 stated that he should have been told of R3's background and believes that R3 should never have been in the nursing home. R3 is an alert, oriented, ambulatory [AGE] year old male who requires limited assistance with hygiene but otherwise independent with his ADLs. R3 was admitted on [DATE] with [DIAGNOSES REDACTED]. R3 is an identified offender spending significant time in prison for the murder of his father and the attempted sexual assault and kidnapping of his mother per the criminal history analysis report (CHAR) and care plan. R3 is care planned for his verbal and physical aggression toward other residents and staff, his non-compliance with medication, non-compliance with his course of treatment and activities of daily living. R3 is impulsive, has poor boundaries with others and no insight into his mental illness. R3 is no longer in the facility. R3 left on 5/13/20 returning to the facility on [DATE] per MDS and nurses' notes. R3 was given an involuntary notice and told he would be sent back to the hospital and not allowed back to this facility. The hospital would assist with re-locating R3 to another facility. This was confirmed by V5 (Psychiatric Rehabilitation Service Director/PRSD) on 8/18/20 at 12:35 PM and V1 (Administrator) on 8/18/20 at 12:08 PM. Review of nurse's notes/social service notes (5/13/20, 5/14/20), facility's incident report (5/13/20, 5/19/20) and the facility's investigation (5/13/20) and staff and resident interviews, document that the following occurred: On 5/13/20 at 4:30 PM in the 3rd floor dining room, R3 and R2 were both in the unsupervised 3rd floor dining room. R12 was also present and witnessed the incident. On 8/18/20 at 10:20 AM in the presence of V1 (Administrator) per R12's request, R12, an oriented male, stated there were no staff supervision in the dining room and maybe 5 other residents present along with R2 and R3. R12 stated that R2 was walking and moaning to self when R3 walked past her and told her to shut the f . up. R2 was quiet momentarily but started to moan again. R3 then moved fast toward R2's backside and pushed her with incredible force landing her onto the floor. R12 stated that many of the residents are afraid of R3 because of his size and his aggression toward others. R12 stated that R2 was in pain and could not walk so she was carried back to her room by staff. On 8/18/20 at 1:34 PM, V10 (Certified Nurse Aide/CNA) stated that R2 was in so much pain R2 could not stand or walk, so she was carried back to room. V10 stated he was not in the dining room but on his way to the pantry when he saw R3 push R2 causing R2 to land on the floor. V10 stated he called for V9 (Licensed Practical Nurse/LPN) to come, assess and assist R2 off the floor. On 8/18/20 at 11:12 AM, V9 (LPN) concurred that she assisted V10 with assessing and carrying R2 back to her room. V9 stated that R2 was in pain but refused pain medication. V9 stated due to the pain and refusal of medications, V9 called the physician and received order for x-ray to the left knee which came back negative. V9 stated that R2 would walk daily throughout the day and she was not getting up but staying in the bed. V9 stated R2's left leg became swollen and another order was received to x-ray the entire left side of the body. A fractured left hip was found. R2 was sent to the hospital. V9 stated that R3 is a bully and threatens everyone on a daily basis that he was going to kill them. R3 was non-compliant with medication since day one of admission which the administrator, Director of Nursing and psychiatrist were all aware of. R3 does not interact with anyone in the facility and has no friends or family involvement. Meanwhile, R3 was being monitored 1:1 by V11 (CNA) following the altercation. On 8/18/20 at 11:04 AM, V11 stated that R3 was taken to his room immediately after the altercation with R2. V11 stated he remained with R3 for an hour and half until paramedics arrived. V11 stated R3 was highly manic, speaking very fast and saying that R2 should not have been in the way. V11 stated R3 continued to pace the room and curse, saying a lot of random stuff. V11 stated that R3 is very unpredictable and uncontrollable. V11 stated that R3 was very happy to leave the facility with the paramedics, saying finally getting out of here. V11 stated that R3 knew right from wrong. On 8/18/20 at 12:35 PM, V5 (PRSD) stated, R3 should never have been placed in this facility. From day one, R3 refused medications, denied he was mentally ill, would verbally threaten staff daily by saying 'I will kill you in 30 days,' then each day he would count down saying 'I will kill you in 29 days,' then 28 days and so on. V5 stated that R3 refused any and all counseling and re-directions. V5 stated she and others were afraid to be alone with him. V5 stated R3 was a large man, smelled terribly due to his refusal for hygiene/bathing and would say sexually explicit things to staff when they were alone with him or passing by. V5 stated that the city police came into the facility on e day and gave R3 a restraining order for a woman in the community. V5 stated he presented as a hater of women because he would refer to his ex-wife as a w***e. V5 described R3 as consistently angry and not compliant with anything in the facility. V5 stated there were so many red flags for why R3 should not have been placed in a nursing home, such as his background of murder, attempted rape and kidnapping and non-compliant with medications before entering the facility. V5 stated that R3 did know right from wrong but had poor impulse control and poor decision-making. V5 stated she was present on 5/27/20 when R3 returned to the facility and V1 (Administrator) presented R3 with involuntary discharge papers. V5 stated that R3's response was Oh, wow. I should have killed her. V1 did confirm this statement on 8/18/20 at 12:08 PM. During interview on 8/18/20 at 11:30 AM with V7 (Psychiatric Rehabilitation Service Counselor/PRSC) and at 11:45 AM with V6 (PRSC), both stated the same information as V5 stated above. Both V7 and V6 stated R3 paced a lot in the facility and would not listen to re-directions. Both stated that if they tried to talk to R3 about his non-compliance with medications and his hygiene, R3 would be verbally aggressive threatening them that he would kill them if they did not quit asking him about meds and his refusal to follow his treatment plan. R3's homicidal ideation was noted throughout R3's clinical record along with discharges to the hospital. Both V7 and V6 stated to be fearful of R3 due to his size and his sexually explicit comments to staff. V7 stated when she was conducting an interview with R3 at admission, R3 put up his middle finger, touched V7's forehead and called her b***h with no provocation. V7 stated R3 was antagonist with everyone. V6 stated that R2 was really hurt, in pain and crying after the incident. V6 stated has never seen R2 in that state after she was pushed by R3. On 8/19/20 at 8:23 AM, V8 (former PRSC) concurred with V6's and V7's statements. V8 stated V8 was afraid of R3 due to his size, unpredictability, his refusal to take any medications, no insight into his mental illness and his sexually charged statements to others. R3's social service and nurses' progress notes dated 5/13/20, 5/14/20, 5/27/20 confirm the above statements. Notes related to refusal to take medications from month to month and R3's homicidal ideation include dates of 4/15/20, 4/8/20, 3/30/20, 3/23/20, 3/21/20 and 1/5/20. R3's sexually explicit language was noted 4/14/20, his physical aggression with other residents where R3 was kicking and pushing other residents' wheelchair into each other while in the dining room were noted on 2/17/20, his attempts to elope on 2/19/20, 2/3/20 and 1/5/20. On 1/5/20, R3 was taken out of the facility by the city police due to R3's threats of harming anyone who tried to stop him from leaving the facility. R2's in-house x-rays (5/13/20 and 5/19/20) confirmed the findings of no fracture of knee and a [MEDICAL CONDITION], respectively. On 8/20/20 at 9:45 AM, V12 (R2's brother/guardian) stated that there was surgery done for the fractured left hip but there was no surgery for [REDACTED]. The facility's ABUSE PREVENTION POLICY documents residents have the right to be free from abuse. The facility prohibits abuse of its residents, including verbal, mental, sexual or physical abuse. The facility has a no tolerance philosophy.

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-,[DATE]-NH revised on [DATE], Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview, and record review, the facility failed to: restrict staff from working after receiving positive COVID-19 test results; screen all staff prior to the beginning of their shift for all the potential signs and symptoms of COVID-19; increase monitoring and restrict residents that had been exposed to COVID-19 from coming in contact with residents that had not been exposed, for three residents (R9, R10, and R11); and failed to increase monitoring of confirmed COVID-19 positive residents for eight residents (R1, R2, R3, R4, R5, R12, R7, and R13). This resulted in actual harm for four residents (R1, R2, R3, and R4) with confirmed [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19, when: R1 and R2 died in the facility, R3 was hospitalized and died , and R4 was hospitalized , after the facility failed to increase monitoring of vital signs and respiratory signs and symptoms. The facility's failures had the potential to affect all 145 residents in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ began on [DATE], when the facility received R3's confirmation of COVID-19 and failed to increase monitoring of R3's temperature, oxygen saturation, and respiratory status. The facility is located in a county with sustained community transmission, many active cases of COVID-19 and many deaths have occurred. The facility had 88 confirmed cases of COVID-19 and five associated deaths at the time of the survey. The Administrator was notified of the Immediate Jeopardy [DATE] at 11:30 am. Findings include: 1. According to the Centers for Disease Control's (CDC), Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection ., retrieved [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html. According to the Illinois Department of Public Health's (IDPH), COVID-19 Control Measures for Long Term Care Interim Guidance, .If patients have been screened and their testing is POSITIVE for COVID-19 OR if patients have signs/symptoms of a respiratory [MEDICAL CONDITION] infection: Obtain Vitals (temperature, heart rate, respirations) AND pulse oximetry every 4 hours (Q4hours) {twice a shift}. Blood pressure can be taken every 8 hours ., retrieved [DATE] from https://www.dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/coronavirus/long-term-care-guidance. Review of the Centers of Disease Control and Prevention (CDC) guidelines titled, If You Are Immunocompromised, Protect Yourself From COVID-19 last reviewed on [DATE], specified, Many conditions and treatments can weaken a person's immune system ('making them immunocompromised'). Some of these include: Cancer Bone marrow transplant Solid organ transplant Stem cells [MEDICAL CONDITION] treatment Genetic immune deficiencies HIV Use of oral or intravenous corticosteroids or other medicines called immunosuppressants that lower the body's ability to fight some infections .) Risk of Severe Illness from COVID- 19 People with weakened immune systems are at higher risk of getting severely sick from [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19. They may also remain infectious for a longer period of time than others with COVID-19, but we cannot confirm this until we learn more about this new virus . Review of Medscape Medical titled Almost 90% of Covid-19 Admission Involve Comorbidities by(NAME)Frankl, dated [DATE] indicated, The hospitalization rate for COVID-19 is 4.6 per 100,000 population, and almost 90% of hospitalized patients have some type of underlying condition, according to the Centers for Disease Control and Prevention . The hospitalization rate, based on COVID-NET data for [DATE]-28, increased with patient age. Those aged [AGE] years and older were admitted at a rate of 13.8 per 100,000, with 50- to [AGE] year-olds next at 7.4 per 100,000 and 18- to [AGE] year-olds at 2.5, they wrote. The patients aged [AGE] years and older also were the most likely to have one or more underlying conditions, at 94.4%, compared with 86.4% of those aged ,[DATE] years and 85.4% of individuals who were aged ,[DATE] years, the investigators reported. Hypertension was the most common comorbidity among the oldest patients, with a prevalence of 72.6%, followed by cardiovascular disease at 50.8% and obesity at 41%. In the two younger groups, obesity was the condition most often seen in COVID-19 patients, with prevalences of 49% in 50- to [AGE] year-olds and 59% in those aged ,[DATE] . Review of National Center for Biotechnology Information (NCBI) article, titled Oxygen Saturation by Dr. Brant B. Hafen, updated [DATE], specified, Oxygen saturation is an essential element in the management and understanding of patient care. Oxygen is tightly regulated within the body because hypoxemia (lack of oxygen) can lead to many acute adverse effects on individual organ systems. These include the brain, heart, and kidneys . Pulse oximetry can provide a rapid tool to assess oxygenation accurately. It is particularly useful in emergencies for this reason. Cyanosis (bluish discoloration to the skin) may not develop until oxygen saturation reaches about 67%. As such, pulse oximetry is extremely useful because the signs and symptoms of hypoxemia may not be visible on physical examination . The human eye's ability to detect hypoxemia is poor. The presence of central cyanosis, blue coloration of the tongue and mucous membranes, is the most reliable predictor; it occurs at an oxyhemoglobin saturation (measures how well oxygen is available in the blood for an individual) of about 75%. Pulse oximetry provides a convenient, noninvasive method to measure blood oxygen saturation continuously. It can also help to eliminate medical errors . a. Review of R1's electronic medical record (EMR) medical diagnoses, revealed R1 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R1's Progress Notes revealed the following: [DATE] at 6:44 pm, COVID-19 Lab result received, Detected (positive) Dr. (doctor) .made aware with order to continue to monitor temp . [DATE] at 4:33 pm, At 4:03, pm, on rounds, resident noted lethargic, non responsive to name. With absence of vitals. Code blue immediately called with CPR (cardiopulmonary resuscitation) initiated. 4:05 pm, 911 called, 4:15 pm, 911 crew arrived on unit with CPR still in progress . Review of R1's Report of Laboratory Results, date reported [DATE], revealed R1 was positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of the facility's resident temperature log and R1's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R1's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. Review of the facility's Infection Tracking, dated [DATE], revealed R1 died in the facility on [DATE]. b. Review of R2's EMR medical diagnoses, revealed R2 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R2's Progress Notes revealed the following: [DATE] at 6:01 pm, COVID-19 Lab result received, Detected (positive) Dr (doctor) .made aware with order received to monitor resident on droplet /contact precautions with all services rendered in the room. Resident currently asymptomatic, Temp (temperature): will continue to monitor resident for symptoms of Co-vid 19 like fever, chills, coughing, SOB, sore-throat, wheezing, rapid pulse, repeated shaking with chills, headache, loss (sic) of taste or smell. [DATE] at 2:53 pm, .At 2:20pm, during rounds resident was noted unresponsive code blue called, CPR (cardiopulmonary resuscitation) initiated. At 2:25pm, 911 arrived in the building, CPR continued. At 2:37pm resident prounced (sic) dead by 911 paramedics . Review of R2's Report of Laboratory Results, date reported [DATE], revealed R2 was positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of the facility's resident temperature log and R2's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R2's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. c. Review of R3's EMR medical diagnoses, revealed R3 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R3s Progress Notes revealed the following: [DATE] at 3:30 pm, COVID-19 Lab result received, Detected (positive) Dr. (doctor) .made aware with order to continue to monitor temp (temperature) and 02-sat (oxygen saturation) . [DATE] at 11:21 am, At 11:20am, resident noted lethargic but responsive to touch only .02-sat (oxygen saturation) 90% on room air. NP (nurse practitioner) .made aware with order to transfer to .Hospital ER (emergency room ) for medical evaluation. Order noted. Resident reassessed with [REDACTED]. [DATE] at 7 pm, At 6:00 pm, received a call from nurse .that resident is admitted (to the hospital) with DX (diagnosis) of positive COVID-19, bilateral pneumonia, acute [MEDICAL CONDITION] with apoxia (sic), [MEDICAL CONDITION] and [MEDICAL CONDITION] (low blood sodium) . Review of R3's Report of Laboratory Results, date reported [DATE], revealed R3 was positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of the facility's resident temperature log and R3's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R3's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. Review of the facility's Infection Tracking, dated [DATE], revealed R3 died at the hospital on [DATE]. d. Review of R4's EMR medical diagnoses, revealed R4 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R4's Progress Notes revealed the following: [DATE] at 5:56 pm, COVID-19 Lab result received, Detected (positive) Dr (doctor) .made aware with order received to monitor resident on droplet /contact precautions with all services rendered in the room. Resident currently asymptomatic, Temp (temperature): will continue to monitor resident for symptoms of Co-vid 19 like fever, chills, coughing, SOB, sore-throat, wheezing, rapid pulse, repeated shaking with chills, headache, loss (sic) of taste or smell. [DATE] at 10:58 pm, Resident received in the room alert, verbally responsive and oriented to self and place with episode of forgetfulness and confusion. Redirection provided as needed. Resident noted with elevated temp. 100.6 .On continuous oxygen 2L via N/C (nasal cannula), pulsating at 78% (oxygen saturation below 90% is considered low) .911 called .resident transferred to nearest hospital . [DATE] at 6:43 am, .hospital informed that resident is admitted with DX of Covid19 infection . Review of R4's Report of Laboratory Results, date reported [DATE], revealed R4 was positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of the facility's resident temperature log and R4's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R4's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. e. Review of R5's EMR medical diagnoses, revealed R5 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R5's Progress Notes revealed the following: [DATE] at 11:04 pm, At 3:00 pm .readmitted from .Hospital .readmitted with DX (diagnosis) of [DIAGNOSES REDACTED] (low blood calcium, Pneumonia due to [DIAGNOSES REDACTED] associated COVID-19, Septic Shock and UTI (urinary tract infection) . Review of the facility's resident temperature log and R5's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R5's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. f. Review of R12's EMR medical diagnoses, revealed R12 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R12's Progress Notes revealed the following: [DATE] at 2:13 pm, .resident Temp (temperature) = 102.2 .MD (medical doctor) notified . [DATE] at 4:08 pm, .COVID-19 Lab result received. Detected critical (positive) .Dr. (doctor) .made aware with order to continue to monitor temp and O2 (oxygen)-sat (saturation) . Review of the facility's resident temperature log and R12's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R12's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. g. Review of the R7's EMR medical diagnoses, revealed R7 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R7's Progress Note, dated [DATE] at 7:35 pm, revealed, Readmission note: readmitted .from .hospital .with admitting dx. (diagnosis) of Upper respiratory infection and positive for Covid-19 . Review of the facility's resident temperature log and R7's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R7's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. h. Review of the R13's EMR medical diagnoses, revealed R13 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R13's Progress Notes revealed the following: [DATE] at 11:04 am, 1045am resident noted with lethargy and coughing .o2 sat (oxygen saturation) 90% room air, notified Dr (doctor) .with order to transfer to .hospital . [DATE] at 9:22 pm, Per ER Nurse resident is admitted with Dx (diagnosis) of Covid19 . [DATE] at 9:21 pm, At 7 pm readmitted .from .Hospital .Resident with Dx (diagnosis) of Covid19 . Review of the facility's resident temperature log and R13's EMR, dated [DATE] to [DATE], revealed no evidence the facility was monitoring R7's temperature, oxygen saturation, and respiratory signs and symptoms at the frequency recommended by the CDC and IDPH guidance for confirmed COVID-19 positive residents. During an interview on [DATE] at 1:30 pm with the Administrator, when asked why Employee (E1) was allowed to work until 7:30 pm after the DON became aware of E1's positive COVID-19 test results that afternoon, the Administrator stated, I assume with the concern with CNA (certified nursing assistants) staffing it was probably just overlooked at the time. When asked if the known COVID-19 positive staff, that were allowed to work, were in contact with residents and staff that were negative for COVID-19 or had an unknown COVID-19 status, the Administrator agreed that the logistics of the facility did not allow for the known positive staff to only interact with known confirmed COVID-19 positive residents and staff, and the Administrator stated, When I rethought this I was also concerned about that fact. During an interview on [DATE] at 4:06 pm with the Administrator and the Vice President of Quality Assurance (V.P. of Quality Assurance), the V.P. of Quality Assurance confirmed that there was no evidence in records to indicate the facility increased monitoring after R1, R2, R3, R4, R5, R12, R7, and R13 were confirmed to have [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. During the same interview, when asked what is the risk to the resident if the facility does not increase monitoring for residents with confirmed COVID-19, the V.P. of Quality Assurance stated, By not increasing the monitoring it does not allow us to know .We put the resident at risk .When the resident is identified positive the identification of worsening condition could be missed. During the same interview on [DATE] at 4:06 pm, with the Administrator and the V.P. of Quality Assurance, when asked if increased monitoring of known COVID-19 positive residents could have avoided the outcomes of hospitalization and/or death for R1, R2, R3, and R4, the Administrator and V.P. of Quality Assurance confirmed that increased monitoring by nursing staff could have potentially avoided the residents' outcomes. At the time of the interview: R1 and R2 had died in the facility; R3 died after being transferred to the hospital; and R4 had been hospitalized for [REDACTED]. 2. According to the CDC's, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, . Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them ., retrieved [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html. a. Review of R8's Progress Note, dated [DATE] at 5:37 pm, revealed, 5pm On assessment resident noted with elevated temperature of 100.9 noted with wheezing to bilateral lower lobes with shortness of breath .o2 (oxygen) desaturated at 80% (values under 90% are considered low) .Dr (doctor) .was notified .gave order for the resident to be transferred to .hospital for evaluation . Review of the facility's Infection Tracking, dated [DATE], revealed R8 had a positive COVID-19 test collected on [DATE]. Further review revealed R8's symptom onset was [DATE]. Review of the facility's Census Detail Report, dated [DATE], revealed that R8 had three roommates, R9, R10, and R11, at the time when R8 had onset of symptoms associated with COVID-19. Review of R9, R10, and R11's EMRs revealed no evidence that the facility increased monitoring or restricted R8's roommates from coming in contact with other residents after possible exposure to COVID-19 per the CDC guidance. Further review of the facility's Infection Tracking, dated [DATE], revealed the following: R9 had a positive COVID-19 test collected on [DATE] and the facility initiated contact and droplet isolation for R9 on [DATE]. R10 had a positive COVID-19 test collected on [DATE] and the facility initiated contact and droplet isolation for R10 on [DATE]. R11 had a positive COVID-19 test collected on [DATE] and the facility initiated contact and droplet isolation for R11 on [DATE]. 3. Observation on [DATE] at 12:10 pm through the kitchen door windows revealed the Dietary Supervisor standing and talking to Employee (E2). The Dietary Supervisor and E2 were standing within six feet of one another and neither the Dietary Supervisor nor E2 were wearing a face covering to prevent the transmission of COVID-19. During a follow-up interview on [DATE] at 12:15am, with the Dietary Supervisor, when asked why neither the Dietary Supervisor nor E2 were wearing masks while standing within six feet of one another and talking, the Dietary Supervisor stated, I just came out of the bathroom. When asked what the facility's instructions were regarding the wearing of masks around other staff members, the Dietary Supervisor stated, As long as we are not right on top of each other. I feel like I'm in trouble here. When asked what the recommended distance is to don the mask, the dietary supervisor stated, within six feet. The Dietary Supervisor then confirmed that the Dietary Supervisor and E2 were within six feet of each other and neither were wearing masks. 4. Review of the facility's Employee Temp Log and time cards, dated [DATE] to [DATE] revealed the following: [DATE], there was no evidence Nursing Assistant (NA1) had been screened for an elevated temperature or signs and symptoms of COVID-19 prior to starting her shift. In addition, there was no evidence Licensed Practical Nurse (LPN1) and LPN2 were screened for signs and symptoms of COVID-19 prior to starting their shifts. Further review revealed no evidence E5 was screened for an elevated temperature prior to starting his shift. [DATE], there was no evidence LPN1, NA2, NA3, NA4, E3, or E4 had been screened for an elevated temperature or signs and symptoms of COVID-19 prior to starting their shifts. In addition, there was no evidence LPN3 was screened for signs and symptoms of COVID-19 prior to starting her shift. [DATE], there was no evidence the Administrator had been screened for an elevated temperature or signs and symptoms of COVID-19 prior to starting his shift. In addition, there was no evidence NA6, NA4, NA7, or NA8 were screened for signs and symptoms of COVID-19 prior to starting their shifts. [DATE], there was no evidence NA5 had been screened for an elevated temperature or signs and symptoms of COVID-19 prior to starting her shift. In addition, there was no evidence E2 was screened for signs and symptoms of COVID-19 prior to starting her shift. E2 is the employee that was observed standing within six feet and talking to the Dietary Supervisor without face coverings on [DATE] at 12:10 pm. 5. Review of NA9's Report of Laboratory Results, date reported [DATE], revealed NA9 tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of NA9's timecards revealed NA9 was allowed to work on [DATE], [DATE], and [DATE] despite the positive test result on [DATE]. Review of NA10's Report of Laboratory Results, date reported [DATE], revealed NA10 tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of NA10's timecards revealed NA10 was allowed to work on [DATE] and [DATE] despite the positive test result on [DATE]. Review of NA11's Report of Laboratory Results, date reported [DATE], revealed NA11 tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of NA11's timecards revealed NA11 was allowed to work on [DATE], [DATE], and [DATE] despite the positive test result on [DATE]. Review of NA12's Report of Laboratory Results, date reported [DATE], revealed NA12 tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of NA9's timecards revealed NA12 was allowed to work on [DATE] and [DATE] despite the positive test result on [DATE]. Review of NA13's Report of Laboratory Results, date reported [DATE], revealed NA13 tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of NA13's timecards revealed NA13 was allowed to work on [DATE], [DATE], and [DATE] despite the positive test result on [DATE]. Review of E1's Report of Laboratory Results, date reported [DATE], revealed E1 tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of E1's timecards revealed E1 was allowed to work on [DATE] until 7:30 pm despite the positive test result on [DATE]. Review of Assistant Director of Nursing's (ADON) Report of Laboratory Results, date reported [DATE], revealed the ADON tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of the ADON's timecards revealed the ADON was allowed to work on [DATE] despite the positive test result on [DATE]. Review of NA14's Report of Laboratory Results, date reported [DATE], revealed NA14 tested positive for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] associated with COVID-19. Review of NA14's timecards revealed NA14 was allowed to work on [DATE], and [DATE] despite the positive test result on [DATE]. During an interview on [DATE] at 4:15 pm, with the Administrator, revealed, when asked why NA9, NA10, NA11, NA12, NA13, E1, the ADON, and NA14 were allowed to work after receiving positive results for [DIAGNOSES REDACTED]-CoV-2, the Administrator stated, I'm Jewish and Friday is the Sabbath so I leave early. The DON (Director of Nursing) received the results Friday ([DATE]). We (the Administrator and the DON) discussed and CDC guidance says staff could work on COVID positive units. The Administrator confirmed that the facility did not have a unit dedicated only to confirmed COVID-19 positive residents. During the same interview, the Administrator stated, We would have been short a CNA (certified nursing assistants) if we didn't (allow the confirmed positive staff to work). When asked why E1, a dietary staff member, was allowed to work until 7:30 pm on [DATE] after receiving positive results for [DIAGNOSES REDACTED]-CoV-2, the Administrator offered no explanation. During an interview on [DATE] at 4:06 pm, with the Administrator and the V.P. of Quality Assurance, when asked what was the risk of allowing confirmed COVID-19 positive staff to continue to work, the Administrator stated, Risk of infection being spread. When asked the risk of not screening all employees prior to their shift, the Administrator confirmed that these failures could also increase the risk of [MEDICAL CONDITION] being spread. Review of the facility's Infection Prevention and Control Policy and Procedure: Coronavirus Disease (COVID-19), revision date [DATE], revealed: Coronavirus Disease (COVID19) is a [MEDICAL CONDITION] respiratory infection that emerged from an animal source but now seems to be spreading from person-to-person via droplets. The incubation period (from time of exposure to an infectious agent until signs and symptoms appear) is estimated at ,[DATE] days but can range from ,[DATE] days. Symptoms of [MEDICAL CONDITION] include fever, cough, shortness of breath, severe lower respiratory infection/[DIAGNOSES REDACTED] and may also include nasal congestion, sore throat, diarrhea, and nausea. While some individuals ill with [MEDICAL CONDITION] may be asymptomatic or have mild illness, older individuals, particularly those with underlying health conditions, have shown greater susceptibility to [MEDICAL CONDITION] and often experience much more serious illness and outcomes. This potential for more serious illness among older adults, coupled with the more closed, communal nature of the nursing home environment, represents a risk of outbreak and a substantial challenge for nursing homes .The facility will follow and implement recommendations and guidelines in accordance with the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and the Illinois Department of Public Health (IDPH) to include identification and isolation of any suspected cases . The Administrator was notified that the Immediacy was removed on [DATE], after the surveyor verified implementation of an acceptable removal plan on [DATE] at 3:37 pm that included: 1. Observations of the facility's employee screening process. 2. Review of In-Service Education records dated [DATE] and verifying interviews with staff regarding: increased monitoring of confirmed COVID-19 residents, employee screening, and circumstances in which employees should not be allowed to work. 3. Review of resident records and resident logs to verify appropriate temperature, oxygen saturation, and respiratory symptom monitoring for confirmed COVID-19 residents. After removal of the Immediacy, the noncompliance remained at the level of actual harm that is not Immediate Jeopardy until sustained compliance is verified.

Based on observation, interview, and record review, the facility failed to follow their pressure ulcer prevention policy/protocol; failed to apply wound treatment as ordered by physician; failed to follow the plan of care pressure sore prevention interventions and failed to ensure proper functioning of low air loss mattresses through use of multiple sheets for two (R66 and R141) of three residents in the sample of 30 reviewed for pressure ulcers. This failure resulted in R141's Stage 2 pressure ulcer on the sacrum to progress to a Stage 4 pressure ulcer. Findings include: 1. R66 is a [AGE] year old, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Facility's weekly pressure sore log dated 04/22/2017 to 04/28/2017 documented that R66 developed a Stage Two pressure ulcer on the sacral area in on 04/26/2017. R66's Stage Two pressure ulcer on the sacrum is a facility-acquired pressure sore. R66's MDS (Minimum Data Set) dated 01/17/2018 documented the following: Section C: BIMS score of 15 which means cognitively intact cognition. Section G: Needs extensive assistance from one person physical assist during transfer, dressing, toileting, hygiene and bathing. Section H: Incontinent of bladder and bowel Section M: M0150 - At risk of developing pressure ulcers; M0300 - has one Stage 4 pressure ulcer; M1200 - Skin and Ulcer treatment: pressure reducing device for chair; pressure reducing device for bed; pressure ulcer care. Braden Score dated 01/11/2018 documented that R66 scored 11 which means high risk. Wound Care Specialist Evaluation notes dated 03/14/2018 documented: Stage 4 Pressure Wound Sacrum with measurements 2.8cm x 1.5cm x 1.0cm. Treatment: dry protective dressing apply once daily for 30 days, Calcium Alginate apply once daily for 30 days, Santyl apply once daily for 30 days, Mupirocin apply once daily for 30 days. R66's POS (Physician order [REDACTED].>03/03/2018 - pressure relieving devices per facility policy 03/03/2018 - may use low air mattress for wound management 03/03/2018 - Cleanse sacral wound with dakins solution, rinse with normal saline solution, apply [MEDICATION NAME] followed by santyl ointment then pack with calcium alginate and cover with dry gauze dressing daily on 3-11 and PRN (when needed). R66's care plan dated 03/26/2018 documented: Skin Integrity: Presence of Skin Breakdown - Provide pressure-relieving device(s) as appropriate; Apply local treatments as ordered by MD (Medical Doctor). On 03/26/18 at 11:01 AM, R66 was observed in bed, alert, awake, on low air loss mattress. The mattress was covered with a top sheet. Under R66's lower back, a cloth underpad was placed. R66 was wearing an incontinent brief. V19 (Certified Nurse Aide, CNA) assisted by V16 (CNA) were about to do an incontinence care on R66. V19 removed R66's incontinent brief and it was observed that R66 had a bowel movement (BM). The dressing on R66's sacral wound was fully soiled with BM. V19 removed the soiled wound dressing. While V16 started to provide incontinence care on R66, V19 notified V11 (Registered Nurse,RN) regarding soiled wound dressing. At 11:20 AM, V11 came into R66's room and told R66 that (V11) will clean the wound. However, V19 observed that R66 had another episode of BM. V11 left R66's room without covering R66's sacral wound. V19 started to provide incontinence care again on R66. V19 was observed spraying perineal cleanser on buttock areas and skin surrounding wound and wiped the buttocks with a towel towards the wound area. After V15 dried R66's buttocks and genital area, (V15) put on a new incontinent brief on R66, then (V15) called V11. Prior to wound care treatment, R66 asked for pain medication. V11 administered the pain pill on R66 at 11:25 AM. V11 stated,You (R66) will need to wait for like 30 to 45 minutes before the pain pill kicks in, then I will clean your wound. R66's wound was still uncovered, not cleansed and was resting on the incontinent brief. At 12:17 PM, V11 performed wound care treatment on R66. V11 washed her hands and, donned gloves and removed R66's incontinent brief. R66's wound was not covered. V11 started cleansing R66's wound with dakins solution. When V11 cleansed the inner portion of R66's wound, a brown-colored matter soiled the gauze that was used to clean it. Subsequently, V11 removed gloves, donned new gloves, and cleansed R66's wound with dakins solution again. V11 removed gloves, donned gloves and rinsed R66's wound with normal saline solution. V11 removed V11's gloves again, donned new gloves and cleansed R66's wound with saline again. V11 removed gloves, donned new gloves, dry the wound area, removed (V11) gloves again and donned new gloves. At this time, V11 applied the [MEDICATION NAME] on R66's wound followed by the application of santyl. V11 removed gloves, donned new gloves and applied the calcium alginate. V11 removed gloves again, donned new gloves, and covered R66's wound with dry gauze. V11 removed gloves, took a marker and wrote the date and shift on the the gauze. There was neither hand washing nor hand hygiene observed on V11 during the entire wound care treatment on R66. On 03/28/2018 at 9:43 AM, R66 was observed lying in bed, awake, on low air loss mattress. The mattress was covered with a fitted sheet. A cloth underpad was placed under R66's lower back. R66 was wearing an incontinent brief. At 10:05 AM, V20 (CNA) was observed providing incontinence care on R66. R66 had a BM and the lower part of the wound dressing was soiled with BM. R66 was lying on bed, on a low air loss mattress. A top sheet was observed covering the mattress. A cloth underpad was placed under R66's lower back. R66 stated that he (R66) is to be put on to the wheelchair. R66 was asked regarding cushion or any pressure relieving device placed on the wheelchair seat. R66 stated, There is no cushion, its just the seat. And the seat has the gel. At 2:20 PM, R66 was observed in R66's room, was sitting in the wheelchair. R66 was also observed sitting on a sling and cloth under pad while in the wheelchair. R66 stated, I am waiting to be transferred to bed, I need to be changed. R66's low air loss mattress was observed covered with a fitted sheet. A cloth underpad and a blanket folded into fourths were also placed on the middle part of R66's bed. Subsequently, V15 (CNA) and V16 came into R66's room. V15 and V16 transferred R66 from wheelchair to bed via mechanical transfer lift. It was observed that the sling that R66 was sitting on while in the wheelchair was part of the mechanical lift device equipment. Also, a cloth underpad was observed placed under the sling, therefore, R66 was sitting on the cloth underpad and the sling while in the wheelchair. V15 was asked regarding wheelchair cushion, stated, When (R66) is sitted in the wheelchair, its just the wheelchair seat, the underpad and the sling. At this time also, V15, assisted by V16 is about to perform an incontinence care on R66. When V15 removed R66's incontinent brief, it was observed that the wound dressing was marked, 3/27/18, 3-11 shift. Therefore, R66's wound dressing that was soiled at the bottom part with BM in the morning was not changed. R66 stated, They have not changed my wound dressing today, they will change it within 24 hours. V16 verbalized, It will get changed if the dressing is fully soiled or if any part of it was soiled, it needs to get changed. The nurse needs to be notified. At 2:35 PM, V20 was asked regarding R66's soiled dressing. V20 stated, If (R66) had a BM and (R66) wound dressing got soiled, the nurse needs to be informed. I did not notify the nurse regarding (R66) soiled dressing this morning because the nurse will change it anyway before R66 gets into the wheelchair. At 2:43 PM, V11 was interviewed regarding soiled wound dressing. V11 stated that any soiled wound dressing needs to be changed when needed. V11 also stated that CNAs need to notify nurses regarding soiled wound dressing. V11 was also asked regarding hand washing during wound care treatment, stated, If I touched an area that is not clean, once I removed my gloves, I need to wash my hands for 20 seconds or use a hand sanitizer. 2. R141 is an [AGE] year old, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] Section M documented: M0150 - R141 is at risk of developing pressure ulcers; M0210 - R141 has no pressure ulcer. R141's Nursing Weekly assessment note dated 01/03/2018 documented that R141 was reported to have a small opening to sacral region, area assessed noted small Stage 2 opening to sacral region with measurements: 1.5cm (centimeters) x 1.0 x 0.1 treated with duoderm every two days. Braden Scale dated 02/22/2018 documented that R141 scored 12 which means high risk. R141's MDS dated [DATE] documented the following: Section C - BIMS (Brief Interview for Mental Status score of 3 which means severe impairment cognition. Section G - Total dependence from two persons physical assist during transfer, and toileting. Total dependence from one person physical assist during dressing, eating, hygiene and bathing. Section H - Incontinent of both bladder and bowel Section M - M0150 - At risk of developing pressure ulcers; M0210 has a Stage 1 or higher pressure ulcer unhealed; M1200 - Skin and ulcer treatments: pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care. R141's POS (Physician order [REDACTED].>02/14/2018 - pressure relieving mattress effective 1/22/2018 02/21/2018 - may use Geri chair (reclining chair) 02/22/2018 - may have low air mattress 02/14/2018 - apply baza cream to buttocks twice a day PRN (when needed) 02/14/2018 - apply baza cream with each incontinence 02/28/2018 - Cleanse Stage 4 sacral wound with dakins solution, rinse with normal saline solution, apply santyl and [MEDICATION NAME] ointment, then pack with calcium alginate dressing and cover with dry gauze dressing daily on 3-11 shift and PRN R141's care plan documented: Skin integrity: presence of Skin breakdown - 03/20/2017: Provide pressure reducing mattress; 03/20/2017: Use skin protectant/skin barrier when performing perineal care; 02/22/2018: Air loss mattress as ordered. Assistive Device Geri chair (reclining chair) - 02/21/2018: Provide teaching and proper uses of device. R141's Wound Care Specialist Evaluation Notes documented: 01/24/2018 (Initial Evaluation post hospitalization due to right foot [MEDICAL CONDITION]) - Stage 2 Pressure Wound Sacrum: 4.0cm x 7.5cm x 0.1cm treated with [MEDICATION NAME] every two days and as needed, Silver Alginate every two days and as needed. 01/31/2018 - Stage 2 Pressure Wound Sacrum: 3.2cm x 3.5cm x 0.1cm treated with [MEDICATION NAME] every two days and as needed, Silver Alginate every two days and as needed. 02/14/2018 - Patient not seen due to a non-wound related hospitalization since last visit. Per Facility's Admission, Discharge, Transfer Activity Detail Report, R141 was readmitted back into the facility on [DATE]. 02/21/2018 - Stage 3 Pressure Wound Sacrum: 4.5cm x 5.5cm x 0.1cm; Wound progress - Deteriorated; Surgical Excisional Debridement was performed; Treatment: dry protective dressing once daily, Mupirocin once daily, Santyl once daily; Recommendation: reposition per facility protocol, off-load wound and low air loss mattress. 02/28/2018 - Stage 4 Pressure Wound Sacrum: 3.5cm x 5.5cm x 0.6cm, undermining 1.5cm. at 7 o'clock with moderated serous discharge; Wound progress- Deteriorated; Surgical Excisional Debridement was performed; Treatment: dry protective dressing once daily, Mupirocin once daily, Santyl once daily, Calcium Alginate once daily; Recommendation: rinse wound with ¼ strength Dakin's solution with every dressing change. On 03/27/18 at 12:32 PM, V16 assisted by V15 was observed transferring R141 from the reclining chair to bed. The reclining chair was observed to have a cloth underpad and a folded drawsheet. Neither cushion nor any pressure relieving device was observed on the reclining chair. Subsequently, incontinence care was provided by V15 and V16 on R141. After the provision of incontinence care on R141, there was no application of baza cream as ordered to buttocks was observed applied. At 1:08 PM, R141 was in bed, on low air loss mattress. The mattress was covered with a fitted sheet. A blanket folded into halves was placed under R141's lower back. On top of the folded blanket was a cloth underpad. R141 was wearing an incontinent brief. Wound care was observed on R141 performed by V11 assisted by V16. R141's sacral wound has moderate serous discharge and beefy red in appearance. V11 removed the old dressing on R141's sacral wound. V11 removed gloves, donned new gloves and cleansed R141's wound with Dakins solution. V11 removed gloves, donned new gloves, cleansed the wound with normal saline solution then removed gloves again and donned new gloves. At this time, V11 applied santyl on R141's wound, then removed gloves, donned new gloves and applied the [MEDICATION NAME]. V11 removed gloves again, donned new gloves. V11 mentioned, It has a little tunneling so I will pack the alginate inside the wound. V11 started to insert the calcium alginate on R141's sacral wound. The calcium alginate was long enough to fit inside R141's wound so V11 tried to cut the calcium alginate with a bandage scissor but the alginate fell off. It was observed that the alginate that fell off had some white and clear substances (santyl and [MEDICATION NAME]) on it. V11 took a new calcium alginate and cut it short and placed it inside R141's sacral wound.V11 removed gloves, donned new gloves and covered R141's wound with dry dressing. There was neither handwashing nor use of hand sanitizer observed on V11 during wound treatment on R141. On 03/28/2018 at 9:45 AM, V16 and V18 (CNA) was observed performing incontinence care on R141. R141 was still in bed, on low air loss mattress. The mattress was covered with a fitted sheet. A cloth underpad and a blanket folded into fourths were observed placed under R141's lower back. R141 was wearing an incontinent brief. V16 was asked regarding bed sheets for R141's mattress. V16 stated, This is an air mattress, we put only a plain sheet and a pad. At 10:00 AM, V16 and V18 transferred R141 from bed to reclining chair. It was observed that the reclining chair seat has an underpad and a folded drawsheet, R141 was sitting on it. There was no pressure relieving device observed on the reclining chair. At 3:00 PM, V3 (Wound Care Nurse) was interviewed regarding pressure sores. V3 stated, I do weekly rounds with V21 (Wound Physician). The floor nurses are doing the daily and PRN wound treatment. I am responsible for monitoring the pressure wounds based on the reports from the floor nurses and monitor staff in implementing interventions for wound care prevention. If those interventions are not effective in preventing pressure ulcers, I will notify V21. V3 further stated, There should be no fitted sheet covering the low air loss mattress. Only the underpad and the incontinent brief. A cushion should be placed on the reclining chair as a pressure relieving device, like a wedge place on the side or on the back while sitted in the reclining chair. The wheelchair has the gel foam cushion. V3 was also asked regarding wound treatment orders. V3 stated, If wound dressing got soiled, it needs to be changed. The CNAs need to notify nurses regarding soiled dressings. All wounds need to be covered at all times. Skin treatment as ordered should be carried out. At 3:15 PM, V21 was interviewed regarding pressure sore. V21 stated, I expect that facility is implementing the wound care preventions in order to minimize the risk of developing pressure sores. For R141, it is a concern because it was a little deteriorating, from Stage 2 to Stage 4 with some undermining. Facility's policy titled, Pressure Ulcer Prevention and Guidelines (revised date (MONTH) (YEAR)) reads: Policy: It is the policy of this facility to ensure based on an Admission Comprehensive Assessment that residents at risk for skin break down are assessed and that preventative measures are implemented. Procedure: 4. Residents assessed for severe/high risk (score of 12 or below) the following preventative measures will be implemented upon admission: B. Preventative mattress; C. Cushion in the wheelchair and/or geri chair (reclining chair). Facility's policy on Resident Care Planning (revised date 09/17) reads: Staff will utilize care plans to assure that each resident's need are met through appropriate and individualized staff interventions in a timely manner. The low air loss mattress user manual documented that the mattress is supplied with a cover sheet that protects the cells against unexpected contamination, and makes cleaning of the mattress easier.

Based on observation, interview and record review, the facility failed to notify a physician after identifying a worsened pressure sore, provide adequate pain medication and relief prior to wound treatment and follow physician's orders [REDACTED]. These deficient practices resulted in a decline in condition of pressure ulcer for one resident (R6) of two residents reviewed for pressure sores in a sample of 24. Findings include: On 3/23/15, the facility provided a document dated 3/23/15 and titled, "Residents with Decubitus Ulcers." R6 was listed as a resident with left heel and right heel decubitus ulcers that were facility acquired. R6's "Other Skin Condition Weekly Status Report" dated 3/20/15 documents the following identification dates: 'mid back wound 12/26/14, right heel 2/12/15 and left heel 2/12/15". On 3/24/15 at 9:35am, E3 (Assistant Director of Nursing-ADON) stated, "The mid back is a skin tear, left heel is unstageable and right heel is unstageable. Standardly, the night nurses do the treatments. But I'm the treatment nurse for day shift. I assess weekly and do rounds with the nurses." E3 indicated the wound care doctor does the measuring of the wounds every Friday. E3 performed R6's wound care to her mid back on 3/24/15 at 9:40am. R6's Resident Medication Administration Record [REDACTED]. As E3 removed the dressing on R6's mid back, R6 complained of pain. R6 grimaced and stated, "Oh my god that hurts." E3 did not acknowledge R6's verbal expression of pain. E3 continued to cleanse the mid back wound with normal saline. R6 continued to complain of pain, bringing her right hand up to her face. E3 confirmed that R6's mid back wound is classified as a skin tear. E3 stated, "We identified her mid back as a pressure area but classified due to root cause which was a skin tear." There was visible tunneling noted in the wound. E3 stated, "That tunneling is new." E3 indicated that the wound did not look like that on the previous Friday. E3 confirmed that R6's wound care is performed daily. E3 stated, "The night nurse did not tell me about any change in condition. But, that is a change." As E3 applied the Santyl and [MEDICATION NAME] to R6's mid back wound, R6 verbally complained of pain. E3 asked, "Are you okay?" R6 shook her head no. E3 continued to finish up the wound treatment. At 9:53am, E3 unwrapped R6's right heel dressing. The wound was pink with granulation tissue and a small area of slough. R6 stated, "Oh my god" and then started to cry. R6 stated, "It's hurting so bad." R6 started to shake her right hand in the air. E7 (CNA-Certified Nurse Assistant) stated, "It's ok. We're almost done." At 9:54am, R6 asked E7, "When will it stop hurting?" E7 replied, "I don't know." E3 stated, "Sorry, Ms. (R6)" and continued with the wound care treatment on her right heel. E3 then turned to the surveyor and stated, "It's bad. It's continuously declining." As E3 applied the Santyl and [MEDICATION NAME] to R6's right heel, R6 started to cry. E7 again replied, "It's almost done." E3 stated, "She was already medicated with Tylenol. You have to consider her age when ordering pain medication." E3 stated, "She always complains like this during treatment." At 9:59am, E3 unwrapped R6's left heel dressing. R6 did not complain of as much pain. R6 stated, "This one doesn't hurt as much. " The left heel wound had eschar that covered the wound. E3 painted the wound with [MEDICATION NAME]/Iodine swabs, first around the perimeter of the wound and then on the wound bed. R6's Physician order [REDACTED]. R6's Left Heel Care Plan dated 2/16/15 documents: Interventions: Nursing to do treatment as order(ed). Treatment as ordered per wound doctor. On 3/24/15 at 4:15pm, E21 (LPN-Licensed Practical Nurse) stated, "I worked the 11pm-7am shift on Monday night (3/23-3/24). (R6's) dressing change was done at 4:30am. Wound looks like it was healing. No drainage. In the middle was a very small hole. So I put cream on it as ordered. My job is to just do the treatment. I think the supervisor knows. I told (E3) what it looks like. I told her there was a hole. If change in wound, call the doctor. Tell them the status of the wound. May change wound treatment. Yesterday night was the first time I saw the dot. I just do the dressing. I don't know if I document it." On 3/25/15 at 10:10am, E3 stated, "If a significant change occurs, then they notify me. (The tunneling) had to have developed in the last shift. I was not aware of the tunneling." On 3/25/15 at 10:28am, E3 stated, "If she (night nurse) assessed any changes, she should have documented it then let me know. She reported to me yesterday (3/24) that the wound was healing fine. I had no knowledge of the wound decline." E3 continued, "Yes, I heard her (R6) say, "I wish I [MEDICAL CONDITION]. I wish I could die. I have pain." But she was already medicated. Based on the wound care observation, the doctor changed her pain medication to [MEDICATION NAME] 600 mg by mouth three times a day." E3 indicated that E21 did not document the wound treatment in a progress note. E3 indicated that E21 just signed the Treatment Administration Record indicating that the treatment was performed. On 3/25/15 at 3:45pm, Z1 (Wound Care Physician) stated, "No, I was not notified until yesterday in the afternoon. If I was aware of the tunneling, would have started packing with calcium alginate." Z1 continued, "The wounds get better and worse. Tunneling is a decline in the condition of the wound. If pain, she should definitely be on medications that help. If crying or expressing pain, treatment should be stopped and her pain reassessed. Give pain med and then go back and finish dressing. She should be medicated before each wound treatment. Not notified that pain was ever an issue." Z1 stated, "Skin prep forms another barrier. Skin prep is not [MEDICATION NAME]. My current order is skin prep for her left heel." On 3/26/15 at 11:00am, E3 stated, "Our facility skin prep is [MEDICATION NAME]/Iodine, [MEDICATION NAME]." E3 confirmed that the physician order [REDACTED]. E3 could not confirm the staging of the mid back, left heel and right heel at this time. E3 indicated that the wound doctor is the person that stages the wounds. R6's MAR for January 2015, February 2015 and March 2015 document that she receives [MEDICATION NAME] sporadically and not daily prior to wound treatments. R6's Physician order [REDACTED]. On 3/25/15 at 1:38pm, E7 (CNA) stated, "I usually always help with wound care. She always complains of pain. Especially with dressing changes." E7 confirmed that R6 is very alert. R6 discussed the pain on 3/25/15 at 1:39pm. R6 stated, "It hurts all the time. Even if they give me plain Tylenol, it still hurts. Tylenol doesn't help me one bit. The right heel hurts more than the left heel when they do my treatment. I didn't know that pain in that right foot until I came here. Pain is pain. When I complain of pain, they never stop. They keep going. I cannot explain the pain, so sharp. When they're done doing the treatment, the pain goes away. If they get stronger pain medication, I would be so grateful. Sitting here, right now, I have no pain." R6's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 12 out of a possible score of 15. This indicates that the resident is alert. R6's Pain Management Care Plan dated 3/10/15 documents: Resident will have pain managed to a tolerable level of as evidenced by pain rating of (blank) on a scale of 1-10. Interventions: On-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain and alleviating an(y) aggravating factors. A facility policy dated 9/20/12 and titled, "Pressure Ulcer Prevention and Guidelines" documents: Procedure: A. (2) Any changes in the skin integrity will be recorded on the skin check assessment tool. (3) The skin check assessment tool will be referred to the treatment nurse for follow up with the Physicians as indicated. A facility policy with a revised date of 1/2/14 and titled, "Pain Assessment Management" documents: "Purpose: 1. To ensure that resident with complaints of pain are properly identified and assessed. 2. To ensure that appropriate pain management is provided. Procedure: 4. Residents identified to need pain management will be referred to MD and corresponding care plan will be followed."