Every finding on record at Avantara Aurora

Based on observation, interview, and record review, the facility failed to maintain the building environment and plumbing equipment in good repair by ensuring water pipes connected to resident toilets were free from leaks. This applies to 2 of 3 residents (R1 and R3) reviewed for toilet leaks. The findings include:Review of the Electronic Medical Record (EMR) showed that R1 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including reduced mobility, neuropathy, polyarthritis, and a stage 2 sacral pressure ulcer. R1 resided in room [ROOM NUMBER] until she was hospitalized on [DATE], and subsequently transferred to another facility.On May 19, 2026, at 10:30 A.M., an environmental tour of room [ROOM NUMBER] was conducted with the V2 (Assistant Director of Nursing). The room was occupied by a new resident, R4, who was observed in a reclining wheelchair wearing a cervical collar. R4 stated he was wearing the collar due to a broken neck sustained from a recent fall and noted that he independently uses the room's bathroom and toilet.During the tour, the following conditions were observed in room [ROOM NUMBER]'s bathroom: -The floor tiles surrounding the base of the toilet were severely warped. -There was a heavy accumulation of dark brown stains on and around the warped tiles.When questioned, V2 could not provide an explanation for the stained and warped flooring. V2 summoned V3 (Maintenance Director) to the room. V3 stated that the warped tiles and staining were caused by an ongoing water leak originating from the water pipe tubing connected to the toilet, which leaked every time the toilet was flushed. V3 stated the leak was finally repaired on the morning of May 19, 2026, adding that the replacement parts had been ordered, shipped, and delivered to the facility on April 17, 2026.On May 19, 2026, at 11:00 A.M., the Administrator (V1) stated that R1's family member had originally reported the toilet leak to administration on April 2, 2026. Both V1 and V3 failed to provide an explanation as to why the repair was delayed for over a month after receiving notification, and for over a month after the necessary repair parts had arrived at the facility.2. On May 19, 2026, at 11:15 A.M., an interview and environmental assessment were conducted in R3's room alongside V2. R3 was observed lying in bed. R3 stated he had a history of falls, including a prior fall that resulted in a forehead laceration. R3 stated that he uses a cane for ambulation and frequently utilizes his private bathroom. R3 reported that the water pipes connected to his toilet leaked every time the toilet was flushed, stating, The water goes down the toilet floor and becomes slippery. I'm worried I might fall again. To verify the report, V2 flushed the toilet. Active water leaks were observed pooling downward from both the top and the middle sections of the water pipe connected to the toilet structure.The facility's policy titled Equipment and Building Environment Maintenance dated July 2, 2025, was reviewed. The policy mandates that the facility must maintain all resident equipment and the physical building environment in safe, good repair. The policy explicitly dictates that the maintenance department is responsible for addressing and repairing building environment issues as soon as possible.

Based on interview and record review the facility failed to notify the Long-Term Care Ombudsman facility representative of non-emergent transfer and discharges monthly as the agency requested. This applies to 4 of 4 residents (R9, R12, R88, R89) reviewed for discharge in the sample of 23. The findings include:1.R89's EMR (Electronic Medical Record) showed R89 was admitted to the facility on [DATE], and discharged on February 14, 2026. R89 was selected for closed record planned discharge review. On [DATE], at 11:41 AM, V28 (Social Services Assistant) stated R89 was discharged back to the community senior living apartment, where she resided previously. Requested evidence of notification of discharge to the Long-Term Care Ombudsman representative and V28 referred surveyor to V3 (Assistant Administrator).On [DATE], at 11:45 AM, V3 stated the notification to the ombudsman occurs through email notification. V3 provided email notification of R89's discharge that occurred on [DATE], at 11:43 AM. V3 stated the last notification of non-emergent transfer and discharges to the ombudsman office occurred on February 9, 2026, also through email, submitted by V1 (Administrator). V3 stated she was unsure how often the Ombudsman's office is notified of transfer and discharges, but the notification happens by running a report through the EMR. 2. R88's EMR showed R88 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, unspecified dementia and hypertensive heart disease.R88 expired in the facility on [DATE], at 3:00 AM. R88's death certificate showed R88 expired due to cardiorespiratory arrest. The facility did not notify the ombudsman of the resident's death until [DATE], when surveyor requested to see ombudsman notification of discharge. 3. R9 was admitted to the facility on [DATE], and discharged to the hospital on [DATE].R9's discharge notification to the ombudsman did not occur until [DATE], when surveyor requested evidence of discharge notification to the ombudsman.R9 was readmitted to the facility on [DATE]. 4.R12's EMR showed admitted to the facility on [DATE], and discharged to the hospital on [DATE]. R12 had not yet returned to the facility.R12's transfer to the hospital notification to the ombudsman did not occur until [DATE]. The facility's report to the Ombudsman office, transfer/discharge report sent on [DATE], contained 74 records for discharge date s ranging from February 13, 2026, through [DATE]. On [DATE], 1:24 PM, V29 (Facility Ombudsman) stated the expectation is for facilities to send notification of non-emergent discharges and transfers to the ombudsman office monthly. V29 stated she just received a report from the facility today, [DATE], and prior to that had not received a report from the facility since February 9, 2026. The Facility was unable to provide a policy to address non emergent notification of transfer/discharge to the Ombudsman office.

Based on observation, interview and document review, the facility failed to follow their policy for proper controlled medication documentation, storage, and disposal.This applies to 2 of 4 residents (R40, R98) reviewed for controlled medication storage, labeling, and disposal in the sample of 23. Findings include:1. On May 13, 2026, at 2:38 PM, The facility's medication storage room was inspected in the presence of V20 (Nurse). V20 opened the medication storage refrigerator and there was a clear locked box that contained an unopened box of controlled medication (30 milliliters of morphine). V20 said she was new at the facility and was not aware there was any controlled medication stored in the refrigerator. The controlled medication box had a medication label that showed R98's name. V20 said she had worked two shifts on the unit, and they did not account for the controlled medication in the refrigerator at the beginning and end of shifts. V20 looked in the EMR (Electronic Medical Records) and said R98 was discharged from the facility on December 23, 2025. 2. On May 14, 2026, at 2:06 PM during medication cart inspection with V17 (Nurse), R40's controlled medication sheet did not match with the number of medications remaining in R40's medication bingo cart. R40's medication bingo card showed R40 had 18 tablets of controlled medication (hydrocodone-APAP 10-325 MG tablet) remaining. R40's controlled drug administration record sheet showed one tablet was signed out at 10:30 AM on May14, 2026 by V17. V17 said R40 had requested the medication at 10:30 AM and she did not administer the medication because the R40 went to therapy. R40's EMR medication administration record also showed the medication not administered. V17 said she was not supposed to document on the controlled drug administration record sheet if she did not pop the medication out of the medication bingo card.On May 14, 2026, at 2:45 PM, V2 (Director of Nursing/DON) said nurses must account for all controlled medications before and after each shift by counting the medications in the locked medication cart and the refrigerator. V2 said he was at fault for not disposing of the controlled medication for R98 after discharge from the facility a few months ago. V2 said R98's narcotic medication should have been disposed immediately after discharge. V2 said the facility's controlled medication recording practice was to document in the controlled drug administration record only when a medication had been removed from the medication bingo card. V2 also said the number and amount of the controlled medications must always match with the count recorded on the controlled drug administration record, and the medication administration record for each resident. V2 said, It's hard to tell if the staff are taking the medications or administering to the residents if the counts do not match. V2 also said there is potential for controlled medication diversion if medications are not disposed of and properly accounted for at the facility. The facility's policy titled, Medication Storage, Labeling, and Disposal with a revised date of July 2, 2025, showed, Policy Statement: It is the facility's policy to comply with federal regulations in storage, labelling, and disposal of medications. 6. Controlled meds should be disposed properly to prevent accidental exposure and diversion using Drug Buster or Rx Destroyer.

Based on observation, interview and record review, the facility failed to follow their policy for proper medication storage and labeling.This applies to 2 of 4 residents (R29, R43) reviewed for medication storage and labeling in the sample of 23. Findings include:1. On May 14, 2026, at 1:40 PM during medication cart inspection with V2 (Director of Nursing/ DON), R43's controlled medication (hydrocodone-APAP 5-325 MG tablet) bingo card pocket three were popped open with the tablet exposed. V2 said medications should not be left exposed and should have been disposed of by two nurses for infection control and to prevent medication diversion.2. On May 12, 2026, at 11:28 AM, during medication administration, a wrong eye drop medication not ordered for R29 was stored in R29's eyedrop medication bag with the correct pharmacy label. V17 administered the wrong eye drop to R29. R29's eye drops medication label and medication order showed, Difluprednate Ophthalmic Emulsion 0.05 percent. V17 administered an eye drop medication, Brinzolamide Suspension one percent Ophthalmic into R29's right eye.On May 12, 2026, at 11:42 AM, V2 (DON) said the nurses must follow and administer the residents' medications according to the doctor's orders and store all medications in the correct storage containers to avoid medication errorsThe facility's policy titled, Medication Storage, Labeling, and Disposal with a revision date of July 2, 2025, states, Policy Statement: It is the facility's policy to comply with federal regulations in storage, labelling, and disposal of medications.

Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 26 medication opportunities with 2 errors resulting in a 7.69% medication error rate. This applies to 2 of 6 residents (R16, R29) observed for medication administration in the sample of 23. The findings include:1. On May 12, 2026, at 11:28 AM, V17 checked the medication order on the EMAR (electronic medication administration records), which stated, Difluprednate ophthalmic emulsion 0.05 percent, instill one drop in the right eye four times a day for post-cataract surgery. V17 removed an eye drop medication from the medication cart; the label on the bag matched the order exactly. V17 administered one drop of the eyedrops to R29's right eye; it got onto R16's eyelash, and V17 administered another drop to R29's right eye. V17 was inserting the eye drop bottle in the medication bag, and the eye drop bottle label V17 administered to R29 showed, brinzolamide suspension one percent ophthalmic. V17 said she only checked the label on the eye drops bag, did not check the eye drop bottle, and now noticed she administered the wrong eye drop to R29. V17 said the brinzolamide suspension one percent ophthalmic was the only eye drop bottle R29 had in the medication cart.2. According to the EMR (Electronic Medical Records), R29 had multiple diagnoses, including gastrostomy status, hypertensive heart disease without heart failure, and paraplegia unspecified.R29's Physician Order Summary showed active orders for hydralazine HCl Oral Tablet 25 MG (milligrams), give one tablet via G-Tube (Gastrostomy tube) every eight hours as needed for HTN [hypertension] for SBP [systolic blood pressure] > [greater than] 160 AND Give one tablet via G-Tube four times a day for HTN.On May 12, 2026, at 12:44 PM, V16 was preparing the 12:00 Noon G-tube medication for R29. R29's EMAR showed, Administer hydralazine HCl Oral Tablet 25 MG, give one tablet via G-Tube every eight hours as needed for HTN for SBP > [greater than] 160 AND Give one tablet via G-Tube four times a day for HTN. R29's EMAR showed administration times for the hydralazine as four times a day for HTN (12:00 AM, 6:00 AM, 12:00, and 6:00 PM), AND every eight hours as needed for HTN for systolic blood pressure > [greater than] 160. V16 read the EMAR for R29's and said she would not administer R29's 12:00 Noon hydralazine because R29's SBP blood pressure was less than 160, and the order said to administer is greater than 160. On May 12, 2026, at 2:54 PM, V19, (Nurse Practitioner) said the resident's order stated to administer hydralazine HCl Oral Tablet 25 MG, give one tablet via G-Tube every eight hours as needed for HTN for SBP > [greater than] 160 AND Give one tablet via G-Tube four times a day for HTN. NP said the order clearly stated what the nurses should do, including AND Give one tablet via G-Tube four times a day for HTN.On May 12, 2026, at 11:42 AM, V2 (Director of Nursing) said the nurses must check the medication orders to ensure they are administering the correct medications, dosages, and frequencies to the residents at the right times. V2 said the nurse must follow and administer the residents' medications according to the doctor's orders. He said the eye drop V17 administered to R29 was not on R29's medication order as of May 12, 2026, at 11:58 AM, and it was discontinued on April 10, 2026. V2 also said the nurses must check the labels on the eye drop bottles, in addition to checking the pharmacy labels on the medication labels, to ensure both match the doctor's orders correctly. V2 also said nurses must always administer the correct medications to residents to prevent adverse reactions, unwanted side effects, and potential negative effects on residents' treatment regimens.The facility's policy titled, Medication Pass with a revised date of July 2, 2025, showed, Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.

Based on observation, interview and record review, the facility failed to develop an effective analgesic regimen, reassess a residents unrelieved pain, develop a care plan for pain management or notify the physician of unrelieved pain in accordance with facility policy.This applies to 1 of 1 resident (R94) reviewed for pain management.The Findings include:R94's, EMR (Electronic Medical Record) showed R94 was[AGE] years old and admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease with dependence on hemodialysis, aftercare follow a right hip replacement, diabetes type 2 and Barrett's esophagus disease.R94's BIMs (Brief Interview for Mental Status) assessment dated [DATE], showed R94 was cognitively intact. On May 11, 2026, at 11:01 AM, R94 was sitting up in bed, using foam abduction pillow between both legs and stated she is uncomfortable when sitting up in a chair and especially uncomfortable while in dialysis. R94 explained that she recently had hip surgery.On May 14, 2026, at 9:05 AM, R94 was sitting up in the chair with her legs extended and elevated. R94 stated she had pain of 7 out of 10 and stated the medication was not helping and she wished someone would do something about it.On May 14, 2026, at 9:10 AM, V6 (RN) was informed of R94's reported pain of 7 out of 10. V6 stated R94 had just received Tramadol 25 mg (milligrams) at 8:17 AM, almost an hour earlier. V6 stated R94 is only on Tramadol 25 mg and that might not be enough for R94.R94's pain assessment completed on May 7, 2026, showed R94 had no pain. R94's pain score record showed R94's admission pain score documented was 3 on May 7, 2026, at 9:29 PM. R94's documented pain scores ranged between 0-7 from May 7, 2026, through May 14, 2026. R94's May MAR (Medication Administration Record) showed R94 had prescribed Tylenol 500 mg 2 tablets administered three times a day between morning and bedtime and had Tramadol 25 mg ordered as needed every 6 hours as needed prescribed for pain. As of May 14, 2026, 9:15 AM, Tramadol had only been administered 4 times since admission. There was an additional order for Tylenol to be given as needed, but no indication of when either Tylenol or Tramadol should be administered.R94's care plan for pain initiated on May 7, 2026, was not individualized, with blank spaces for medication name, type of pain, and reason for pain. The care plan did not include a pain score goal for R94.On May 14, 2026, at 1:04 PM, V2 (DON) stated if an initial pain score is documented as a 3, the initial pain assessment should reflect that initial pain score. V2 stated if a resident's pain is not relieved, the physician/healthcare provider should be contacted.The facility's policy titled Pain, dated July 29, 2025, showed it is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is potential for pain. The policy showed the residents will be assessed for pain upon admission and if the resident experiences unrelieved pain, despite pharmacological and nursing measures the resident's physician will be called and informed.

Based on observation, interview and record review the facility failed to perform a nutrition assessment and implement interventions for a resident experiencing poor appetite and oral intake, hyperkalemia, and significant weight loss. This applies to 1 of 1 residents (R1) reviewed for nutrition in a sample of 23. The findings include: Social Services progress note, dated May 11, 2026, shows R1's cognition was intact. Hospital nephrology note, dated April 9, 2026, shows R1 experienced hyponatremia, volume overload with edema, high blood potassium, acute kidney injury, and required temporary hemodialysis with her last dialysis treatment on April 2, 2026. Review of R1's Care Plan shows R1 was at risk alteration in nutritional status related to congestive heart failure and morbid obesity and approaches included monitoring for weight loss, obtaining and reporting abnormal labs, weigh as order, and provide diet as order. R1's fluid care plan showed R1 was at risk for adverse reactions related to dehydration or potential fluid deficit due to congestive heart failure, hypertension and diuretic use. The care plan shows R1 was to be encouraged to drink fluids of choice and monitor for signs of dehydration including weight loss, monitor labs as ordered and obtaining and monitoring weights as ordered by the physician. On May 11, 2026 at 11:10 AM, R1 stated she recently returned to the facility from the hospital after being admitted for low blood sodium levels. R1 stated she had no appetite, did not feel like eating, and had not talked to a dietitian at the facility about her poor oral intake. At 12:42 PM during lunch, R1 had no meal tray and stated she did not want to eat because her stomach was upset On May 12, 2026 at12:08 PM just prior to lunch being served, R1 stated she was not hungry and stated she did not eat breakfast earlier that morning. R1 stated staff offered her an oral supplement that morning which was the first time R1 was offered a supplement while at the facility. R1 stated her appetite was very poor, was losing weight at home for a few months prior to coming the facility, and stated if she did not eat a meal at home she would drink two oral nutritional supplements to try to prevent weight loss. R1 stated she enjoyed hot dogs, lunch meat, and chili. At 12:15 PM, V24 (CNA- Certified Nursing Assistant) and V22 (CNA) offered R1 her meal tray and R1 refused the tray. V24 and V22 stated R1's meal intake was variable and V22 offered her a nutritional supplement when she did not eat. After V22 was informed R1 enjoyed hotdogs, V22 offered a hot dog to R1 and R1 accepted the offer. V22 ordered the meal item from the kitchen and R1 ate 100% of the hot dog. Review of R1's clinical record, dated April 9-May 4, 2026, shows several reports that R1 experienced poor oral intake/appetite and diarrhea. The record shows R1 experienced persistent hyperkalemia and hyponatremia and had multiple physician orders for doses of lokelma to reduce elevated blood potassium levels between April 9, 2022 to May 10, 2026. The record showed R1's potassium on April 30, 2026 was elevated to 6.7 milliequivalents per liter. On May 4, 2026, R1 was readmitted to the hospital for low serum sodium and elevated blood potassium levels and R1 returned to the facility on May 10, 2026. Medical Professional note, dated April 23, 2026, shows, Resident evaluated for persistent hyperkalemia and hyponatremia. Recent labs show potassium previously elevated up to 6.8 milliequivalents per liter despite treatment with lokelma. Sodium remains low. Patient is currently on multiple medications contributing to electrolyte abnormalities including dual loop diuretics and potassium-elevating agencies. Likely multifactorial with significant contribution from medications (diuretics and possible SIADH). Hold furosemide, bumetanide, spironolactone, amiloride, losartan and sertraline x1day. Administer lokelma. POS (Physician Order Sheet) show R1 had physician orders for a Low Concentrated Sweets Diet until May 10, 2026 at the facility. The POS shows a physician order for R1 to be weighted upon Admission/readmission weekly for four weeks and then monthly. Facility Weights and Vitals Summary, printed May 14, 2026, shows R1's facility weights included 230.6 pounds (April 10, 2026), 191.4 pounds (May 1, 2026), and 214.2 pounds (May 12, 2026). R1's April 10, 2026 weight showed R1 lost 16.9% since April 10, 2026. R1's May 12, 2026 weight shows R1 lost 7.9% since April 10, 2026. The summary fails to show weekly weights were performed as ordered by the physician. On May 14, 2026 at 10:32 AM, V2 (Director of Nursing) stated there were no weekly weights as ordered by the physician documented in R1's clinical record. Review of meal intake, dated April 9, 2026 to May 14, 2026, shows R1 ate less than 75% of her meals 29 of 54 meals served at the facility. R1 refused her meal a total of 7 times. Review of R1's clinical record, dated 4/9/26 to 5/11/26, shows R1's only nutrition documentation was written by V21 a CDM (Certified Dietary Manager) on April 13, 2026. The assessment shows R1 was receiving a Low Concentrated Sweets Diet, it was unknown if R1 had previous weight loss, R1 was eating 26-75% of her meals, and R1 was identified as being malnourished. The note shows recommendations were made for double protein to provide extra calories and to restrict her diet to No Added Salt due to having a congestive heart failure diagnosis. Review of R1's clinical record showed no evidence that a dietitian performed a nutrition assessment of R1's clinical condition. On May 12, 2026 at 3:14 PM, V21 (Certified Dietary Manager) stated she normally emails the dietitian her recommendations for residents and the dietitian either carries out the recommendation or chooses a different approach. V21 stated she did not remember V23 calling her about R1 On May 13, 2026 at 1:56 PM, V23 (Dietitian) stated she visits the facility once a week and assesses new admitted residents unless V21 sees the resident. V23 stated sometimes she notes on residents seen by V21 and sometimes she does not. V23 states sometimes she visits residents but does not put a note in. V23 stated she spoke with R1 when R1 arrived at the facility, asked for R1's food preferences. V23 stated both she and V21 complete nutrition assessments. V21 refers any high risks to V23 and V23 completes the assessments. If V21 has any recommendations, she lets V23 know and V23 either carrys out the recommendation if she agrees with the recommendation or V23 will change the recommendation. V23 stated R1 should have been referred to V23 by V21 because she was high nutritional risk. V23 stated R1's critical lab values should have been referred to her so she can follow up and make changes as appropriate. V23 stated she spoke with R1 when she was having variable intake but declined supplements because she had diarrhea. V23 stated she declined V21's double portion recommendation because R1's intake was variable but did not recommend any further interventions. On May 13, 2026 at 1:38 PM, V1 (Administrator) stated new resident admissions should be seen first on admission by the dietary supervisor. V1 state V21 (CDM) and V23 (RD) share the workload of residents. V1 stated residents to go to the hospital and are readmitted to the facility should be seen by V21 or V23 as soon as possible on readmission. V1 stated the facility meets weekly to discuss residents at nutrition risk and discuss weights. V1 stated if anything nutrition wise is discussed, they communicate it to V23 and she meets with the residents the next time she visits. On 5/13/26 at 2:31 PM, V2 (Director of Nursing) stated the dietitian reviews all resident labs during initial assessment and when she visits every week. V2 stated if there were critical labs that needed review by the dietitian, the nurses would call V23. Facility Weight Policy, revised 7/3/25, shows, The significant weight changes (monthly 5%, quarterly 7.5% and every 6 months (10%) will be assessed and addressed by the IDT (Interdisciplinary Team) which includes but not limited to the dietitian, physician, medical specialist, speech therapist, nutritionist, and nurses. Nutrition Assessment Policy/Procedure, dated 2017, shows, The consultant dietitian provides in-depth nutrition assessments for clients whose nutrition conditions(s) may place them at nutrition risk. Nutrition assessment data may include body mass index, usual body weight, height, weight, diagnosis, diet, level of mobility, self-help required, vision, oral status, alertness, food preferences, nutrition-related lab values, skin condition, client's appearance and an estimation of needs. The healthcare community and the dietitian work together in determining level of nutritional risk. Medical conditions which may place clients at nutrition risk includes; Enteral or parenteral tube feeding, Pressure injury, Dialysis, Significant weight loss. The dietitian will provide random checks of the nutrition screens/ assessments completed by food and nutrition services personnel and this will be noted on the dietary consultant report. Facility Nutrition Assessment In-Depth Policy/Procedure, dated 2017, shows, The dietitian provides in-depth nutrition assessments for clients whose medical condition(s) may place them at nutrition risk. The healthcare community refers clients determined to be at nutritional risk to the dietitian. Medical conditions which may place clients at nutritional risk include but are not limited to the following: Enteral or parenteral tube feeding, pressure injury, dialysis, and significant weight loss. In-depth nutrition assessment may include the same data as ais included in nutrition assessment. An in-depth nutrition assessment also includes analysis of the data to identify nutrition-related problems and to determine, when possible, their causes. The dietitian exercises clinical judgment to determine the best nutrition approach(s) by recommending interventions appropriate to the individual. The dietitian may follow up on the clients who are at nutritional risk on a monthly or more frequent basis. Nutrition approaches are re-evaluated as needed to determine if they continue to be appropriate. Facility Nutritional Assessment document, undated, shows, Nutritional assessment is the process of gathering information from a multitude of sources and includes the organization and evaluation of the information to make a judgement regarding the individual's nutritional status that includes determination of nutritional needs, care planning with interventions, and monitoring a resident's response to the interventions and nutritional status Early screening and evaluation of nutritional status allows the health professional to identify early screening and evaluation of nutritional status allows the health professional to identify early deficiency states, to recognize those who are at increased nutritional risk, and to implement nutritional interventions in a timely manner Facility Interventions for Weight Loss Policy/Procedure, dated 2017, shows Interventions are provided to address a decline in a client's appetite and food intake, a significant weight loss or an insidious weight loss trend. Nutrition interventions can be initiated by a member of the healthcare team prior to assessment of the client's nutrition status by the dietitian. Certified Dietary Manager, Certified Food Protection Professional Scope of Practice, dated 2025, shows individuals with CDM certificates are qualified to gather and apply nutrition data such as gathering routine nutrition screening data, calculating nutrient intake and distinguishing between routine and at-risk residents. The document shows a CDM can identify nutrition issues and review/verify clinical documentation, and identify when further intervention is needed for referral to the RD.

Based on interview and record review, the facility failed to provide necessary assistance and supervision during toileting, for a resident that had limited ability to sit unsupported, was cognitively impaired, with known impulsivity, and at high risk for falls, to prevent a fall that resulted in injury. This applies to 1 of 2 residents (R9) reviewed for falls in the sample of 23. R9's EMR (Electronic Medical Record) showed R9 was readmitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, kidney transplant status, type 2 diabetes, abnormal posture and hypertensive heart disease.R9's MDS (Minimum Data Set) dated April 23, 2026, showed R9 was severely cognitively impaired and required assistance with ADL's including supervision with eating and oral hygiene, substantial assistance with upper body dressing, bed mobility and transfer, and dependent on staff for toileting, bathing, and lower body dressing. R9's care plan initiated on March 13, 2026, for toilet use showed R9 required staff participation of 1 to assist with toileting and high risk for falls due to history of falls, gait deviations and poor safety awareness. R9's fall care plan interventions included to ensure staff keep call light within reach and respond promptly to requests.R9's Occupational Therapy Evaluation and Plan of Treatment dated April 17, 2026, showed R9 had left side flaccid paralysis and had poor sitting balance with inability to right himself during self-care activities and baseline assessment showed R9 was dependent on staff for toileting tasks.R9's fall risk assessment that was part of R9's readmission assessment, dated April 16, 2026, showed R9 had a fall at home prior to admission, and had a risk score of 8, indicating a high risk for falls. R9's incident report dated April 30, 2026, showed R9 had an unwitnessed fall while left unattended in the bathroom. The report showed in response to a loud thud, staff found R9 had fallen from the toilet onto the floor and was lying face down on the floor. The nurse called 911 and R9 was taken by ambulance to the hospital.R9's physician orders showed R9 received anticoagulant medication daily initiated on April 17, 2026.R9's physician progress note dated May 4, 2026, showed R9 sustained injury to left eye with significant periorbital edema, ecchymosis, and severe subconjunctival hemorrhage due to the unwitnessed fall.On May 13, 2026, at 12:15 PM, V2 (DON) stated he responded to the loud noise in R9's room on April 30, 2026, around breakfast time. V2 stated 911 was called when R9 was found lying on the floor in the bathroom with his head on the floor, because R9 was receiving anticoagulant medication. V2 stated the safest option for R9 while in the bathroom was for staff to remain with R9 to prevent fall due to R9's poor safety awareness and previous falls.On May 13, 2026, at 12:20 PM, V13 (CNA, Certified Nursing Assistant) stated she was R9's assigned CNA on the day shift on April 30, 2026. V13 stated she was serving breakfast trays when she entered R9's room with R9's tray and R9 requested to go to the bathroom. V13 stated she got assistance from V8 (CNA). V13 stated V8 assisted to transfer R9 from the bed to the wheelchair and from the wheelchair to the toilet. V13 stated both V13 and V8 left the room leaving R9 unattended on the toilet. V13 stated she then continued to distribute breakfast trays and had assisted the resident in the room next to R9's when she came out of that room and saw V14 (CNA) and V2 running into R9's room.On May 13, 2026, at 12:27 PM, V14 stated on the morning of April 30, 2026, around breakfast time, V14 was standing in the nurses' station when she heard a loud noise coming from R9's room. R9's room was located across from the nurses' station. V14 stated she ran to the room and V2 was also present and found R9 lying face down on the floor. V14 stated there was no staff in the room when she entered the room.On May 13, 2026, at 12:30 PM, V15 (PTA Physical Therapy Assistant) stated R9 required maximum assistance of 1 and perhaps 2 staff depending on how much R9 assists with the transfer. V15 stated R9 does not stand long and tends to be impulsive and lacks safety awareness. V15 stated R9 is encouraged to use the call light but is inconsistent using it. V15 stated R9 is weak and prefers to lay down. V15 stated even when R9 is seated he often extends his feet and pushes forward in a movement that would result in sliding out of the chair. V15 stated due to R9's weakness, impulsivity, and lack of safety awareness, R9 would need to be supervised when in the bathroom. V15 stated R9s mobility has essentially not changed since admission, despite receiving therapy. V15 stated R9 is at high risk for falls.The facility's policy titled Fall Occurrence dated June 30, 2025, showed the policy of the facility is to ensure that residents are assessed for risk for falls, that interventions are put in place and revised as necessary and those that are identified as high risk for falls will be provided fall interventions.

Based on observation, interview and record review, the facility failed to provide grooming/hygiene for a resident who required assistance for ADL (Activities of Daily Living) care.This applies to 1 of 1 resident (R43) reviewed for ADL care in the sample of 23. The findings include:On May 11, 2026, at 11:47 AM, R43 was in bed. R43 had about 0.5 to one CM (centimeters) long facial mustache and chin hair. R43 said she doesn't like facial hair and would like to get it shaved, but she couldn't do it by herself.On May 12, 2026, at 11:21 AM, R43 was in bed and still had the same facial hair. R43 said she asked, but no one assisted her with shaving her facial hair. R43 said she forgot the name of the staff she asked to assist her with shaving her facial hair.On May 13, 2026, at 2:41 PM, R43 was in bed and still had the same facial hair. R43 said she asked one of the CNAs (Certified Nursing Assistants) to assist her with shaving her facial hair, but they still haven't done so.According to the EMR (Electronic Medical Records), R43 had multiple diagnoses including reduced mobility, other fatigue, other chronic pain, and vascular dementia, with unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.R43's Minimum Data Set, dated [DATE], showed R43 had mild cognitive impairment and was dependent on staff for shower, bathing, and personal hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands.R43's Care Plan initiated on August 14, 2023, showed R43 had an ADL Self Care Deficit and Impaired Mobility due to impaired balance, weakness, and pain. The care plan interventions included that R43 required total assistance from staff with personal hygiene care. On May 12, 2026, at 12:13 PM, V2 (Director of Nursing) said the CNAs always ask residents if they want to be shaved, and if they do, the CNAs will do it for them. V2 said the CNAs shave the residents daily, every 3 days, as needed, and as requested by the residents. V2 said the CNAs are supposed to assist the residents with shaving as part of hygiene and grooming, and to support dignity.The facility's policy titled, General Care with a revision date of June 30, 2025, showed, Policy Statement - It is the facility's policy to provide care for every resident to meet their needs.

Based on observation, interview and record review, the facility failed to serve portions of pureed pork in amounts indicated on the planned/approved facility menus. This applies to 2 of 2 residents (R73 and R99) reviewed for pureed diets in the sample of 23. The findings include:Facility document, dated May 14, 2026, shows R73 and R99 had physician orders for pureed diets. On May 12, 2025 at 11:47 AM during lunch service, V26 (Cook) provided one #8 scoop (4 fluid ounces) of pureed pork on each plate when serving two pureed diet lunches. When questioned regarding the serving size, V25 (Food Service Director) examined the diet spread sheet and stated the serving size pureed pork planned on the menu was 2-#10 scoops (approximately 7 fluid ounces total). V25 stated the first two pureed plates did not have enough pureed pork and instructed V26 to provide the third pureed plate with 2-#8 scoops (8 fluid ounces) of pureed pork. After the third/final plate of pureed pork was served, V26 used the #8 scoop and retrieved approximately 6 fluid ounces of pureed pork from the pan on the steamtable. V26 stated she originally pureed a total of three portions of pureed pork to serve at lunch. Facility Daily Spreadsheet Week 4 Tuesday shows the puree diets were to be served two #10 scoops of pureed breaded pork cutlet. Facility Pureed Breaded Pork Cutlet recipe, printed February 13, 2026, shows one serving of pureed breaded pork cutlet was to be served using two #10 scoops. Facility Serving Portions Policy/Procedure, dated 2017, shows Food shall be served in portions indicated on the cycle menu and on the standardized recipes.

Based on observation, interview and record review, the facility failed to follow their policy for contact isolation precaution and infection prevention practices during medication administration.This applies to 2 of 7 residents (R83, R93) reviewed for infection control in the sample of 23. Findings include:1. R93's POS (Physician Order Summary) dated May 4, 2026, showed an active order for Strict Contact Isolation for (positive) C-Diff [Clostridioides difficile - a bacteria that causes life-threatening diarrhea] every shift. The same POS also showed an order for Vancomycin HCI Oral Capsule 125 MG (Milligram), give one capsule by mouth four times a day for C-Diff for 10 days, start date: May 4, 2026, and end date: May 14, 2026.On May 11, 2026, at 12:49 PM, R93 had a sign on the door that says, STOP. CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before entry. Discard gloves before room exits. Put on a gown before room entry. Discard gown before room exit. V18 (Regional Guest Relations Director) took a meal tray into R93's room without wearing any gown and gloves. V18 came out of R93's room and performed hand hygiene using alcohol-based hand sanitizer. V18 said she did not need to wear any PPE before entering R93's room because she only wanted to deliver a meal tray, and she had already sanitized her hands after leaving R93's room.On May 13, 2026, at 2:54 PM, V2 (Director of Nursing/DON) said the staff must wear proper PPE (Personal Protective Equipment) as stated on the isolation signage posted on the resident's door, which includes a gown and gloves. V2 said staff delivering a meal tray must wear gowns and gloves before entering the room. V2 said R93 was on contact isolation precautions for C-Diff, and that performing hand hygiene with hand sanitizer alone after exiting the room is not appropriate. V2 said the staff must perform hand hygiene using soap and water after exiting the room.2. On May 12, 2026, at 10:21 AM, V17 (Nurse) was preparing medications for R83 while touching different surfaces on the medication cart with her bare hands. V17 popped R83's medication out of the bingo card, and it dropped on the medication cart. V17 picked up the medication with her bare hands without performing hand hygiene and administered it to R83.On May 12, 2026, at 11:42 AM, V2 (DON) said if the medication is dropped on the med cart, the nurses are not to administer it to the residents to prevent the spread of infection from potential contamination of the medication cart surface. The facility's policy titled, Infection Prevention and Control with a revised dated, June 30, 2025, showed Policy Statement: The facility has established a policy to identify, record, investigate, control, test, and prevent infections in the facility. Precautions to Prevent Transmission of Infections agents and Transmission Based Precaution: . 2. Contact Precaution - intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or environment. Examples of infectious organ isms requiring contact precaution are C. Difficile, .b. Use of Gown and glove is necessary prior to room entry.

Based on observation, interview and record review, the facility failed to follow their planned menu resulting in lunch entrees being served to residents with inadequate protein. This applies to all 78 residents in the facility receiving General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft diets at the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 3/14/25 documents that the total census was 79 residents. The facility's Order Listing Report of 3/12/25 showed 1 NPO (nothing by mouth) resident. The facility's Daily Spreadsheet, dated Week 1 Wednesday, shows residents with General, Mechanical Soft, Pureed, No Added Salt, Low Concentrated Sweets all received either regular, ground or pureed portions of ham. The spread sheet shows each resident receiving the ham were to be served the equivalent of a 3-ounce portion of ham. On 3/12/25 at 11:50 AM, V24 (Cook) was observed plating food for a regular diet, and she placed one slice of ham on the plate. On 3/12/25 at 11:58 am V17 (Dietary Director) weighed 2 slices of ham from 2 different lunch trays and each slice of ham weighed 2 ounces. V17 said that he does not have a slicer to cut meat and because of that he is unable to cut an accurate amount of protein to serve to the residents. On 3/12/25 at 12:15 PM V8 (Dietician) said that the ham is to be 3 ounces served weight. V8 said that if this is not done, residents will not be getting enough protein and that can cause malnourishment or prevent wound healing. V8 said that the facility needs a slicer to get an accurate amount and portion size of protein to meet the requirements. The facility's kitchen policy with revised date of 8/16/2024 showed that all food items in the menu and recipe will be followed.

Based on observation, interview, and record review the facility failed to properly secure resident medications. This applies to 5 out of 5 residents (R15, R22, R24, R40, R43) reviewed for medications in a sample of 24. The findings include: 1. On 3/11/2025 at 10:17 AM and 3/12/2025 at 12:22 PM, a medication cup with 2 capsules of fish oil and 1 capsule of turmeric was observed on R43's bed side table. She said she usually takes the medication when her tummy feels better because she had hyperacidity. R43 said nurses usually leave the medication there so she can take it when she wants to. Review of R43's POS (Physician Order Sheet) shows order for fish oil and turmeric but there are no orders for resident to self-administer medication and medication to stay at the bedside. On 3/13/25 at 12:10 PM, V2 said there are no residents with orders for medication to stay at the bedside, no orders to self-administer medication. She said she expects nurses to take unlabeled medication from resident rooms. She said if a resident wants to take medication, nurses should ask order from physician. 2. On 3/11/2025 at 10:12 AM, a tube of unlabeled Calmoseptine ointment was observed on R15's nightstand. Review of R15's POS showed there was no order for medication, medication to stay at bedside and there was no order for resident to self-administer medication. 3. On 3/11/2025 at 10:27 AM, a bottle of unlabeled TUMS Antacid 72 chews observed on R22's nightstand on the right side of her bed. The bottle was half empty. Review of R22's POS showed there was no order for medication, medication to stay at bedside and there was no order for resident to self-administer medication. 4. On 3/11/2025 at 10:52 AM, a bottle of Antifungal powder- Miconazole nitrate 2% powder was seen on R24's nightstand. On 3/13/25 at 12:10 PM, V2 (DON-Director of Nursing) said R24 is unable to apply it to herself. Review of R24's POS showed an order for antifungal powder. There was no order for medication to stay at the bedside, and no order that R24 to self-administer medication. 5. On 3/11/2025 at 11:12 AM, a bottle of unlabeled Docusate Sodium 50 mg observed on top of R40's drawers. Review of R40's POS showed there was no orders for Docusate Sodium, no orders for medication to stay at the bedside, and no orders for resident to self- administer medication. Facility's Policy on Medication Storage, Labeling, and Disposal dated and revised 8/16/24 documents that medications should be stored safely under appropriate environmental controls and medications will be secured in a locked storage area. Facility's Policy on Self-Administration of Medication dated 12/3/15 and revised on 6/6/24 documents resident may store the medication at bedside if there is a physician order to keep it at bedside.

Based on observation, interview, and record review the facility failed to implement transmission-based precautions for a resident with an acute contagious gastrointestinal infection and adhere to enhanced-barrier precautions. This applies to 6 out 6 residents (R184, R183, R65, R51, R46, and R40) reviewed for infection control in a sample of 24. The findings include: 1. On 3/11/25 at 12:06 PM there was no isolation sign on the door to R183 & R184 shared room. R183 was in her wheelchair very upset saying that she has had 3 bowel movements in her brief since she was in physical therapy, and nobody has come to change her brief. R183 said that she has been having diarrhea for the last week. On 3/12/25 at 11:08 AM, CNA (Certified Nurse's Assistant) said that R183 has been having loose stools for at least the last four days. On 3/13/25 at 11:27 AM, V2 DON (Director of Nursing) said that R183 has had loose stools for about a week and that R183 was started on antibiotics on Friday 3/7/25 for pneumonia and the antibiotics can cause loose stools and C diff (acute contagious gastrointestinal infection). V2 said that the facility moved R184 out of the room with R183 on 3/11/25 around 11 PM because of the loose stools they suspected R183 had C-Diff. R183's electronic health record showed that her mental cognition is intact. R183's 3/10/25 physician's order at 2:53 PM showed, obtain stool for C-DIFF and on 3/11/25 physician's order shows strict contact isolation (C-Diff). R183's 3/7/25 physician's order showed amoxicillin-Pot Clavulanate (Antibiotic) tablet 875-125mg every 12 hours for 10 days. The start date was 3/7/25 and the end date was 3/17/25. R183's Follow up Question report of 3/1/25 - 3/13/25 showed that R183 started having loose stools on 3/4/25 and continued through 3/13/25 with a total of 17 recorded episodes of loose stools in 10 days. R183's 3/1/25 - 3/31/25 EMAR (electronic Medication Administration Record) showed an order on 3/10/25 at 5pm to obtain stool sample for C-DIFF, and the sample was obtained on 3/11/25 at 5:44 am. The facility's Infection Control policy with the revised date of 2/10/25 shows, if the resident with infection needs transmission-based precaution, the facility will provide the transmission-based precaution setup required. If the resident needs to be quarantined, the facility will also provide the set up similar to the setup for isolation room. A sign will be provided outside the room of the resident on a transmission-based precaution indicating the type of precaution contact, droplet, or EBP (enhance barrier precaution). The facility shall comply with infection control recommendations provided by the IDPH (Illinois Department of Public Health) or certified local health department, including but not limited to testing plan, infection control assessment, training or other measures designed to reduce incidence of infection. Contact precautions intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. Examples of infectious organisms requiring contact precautions are C-Diff, scabies, norovirus, etc. and are outlined in CDC (Center for Disease Control) appendix A (Type and Duration of Precautions Recommended for Selected Infections and Conditions) a. Single room is required. If not available cohorting with a resident with the same organism may be done. 46380 2. On 3/11/25 at 1:05 PM, V4 (CNA-Certified Nurse Assistant) and V5 (CNA) provided incontinent care to R40. R40 had an EBP (Enhance Barrier Precaution) signage on his door and had a PPE (Personal Protective Equipment) bin by his door. V4 and V5 provided care using only gloves and surgical mask. On 3/11/25 at 1:20 PM, V6 (RN-Registered Nurse) was observed providing wound care to R40. She was assisted by V4. R40 had open wounds on his right buttock and coccyx. V4 and V6 were only wearing gloves and surgical mask throughout wound care. On 3/13/25 at 12:10 PM, V2 (DON-Director of Nursing) said residents with open wounds are put on EBP. She said when providing care to residents with wounds, staff are expected to wear gown, gloves, and mask. She said this is to prevent infection and cross contamination. 48944 3. On 3/11/2025 at 11:10 AM, R51's room door had an Enhanced Barrier Precautions (EBP) sign. The sign instructed staff to wear gloves and gown when providing high-contact care activities. V9 (Registered Nurse/RN) said she was going to infuse R51's scheduled IV (intravenous) antibiotic via his left upper arm PICC (Peripherally Inserted Central Catheter) line. V9 was wearing gloves but not a gown when she administered R51's IV infusion. R51's care plan said he required the implementation of EBP due to his surgical wound and PICC line initiated on 2/21/2025. The care plan's goal was to prevent the spread of infection. 4. On 3/13/2025 at 12:05 PM, R46's room door had an EBP sign. V20 (Agency RN) said she was changing R46's gastrostomy tube y-connector port. V20 was wearing gloves but not a gown. V20 then proceeded to infuse R46's scheduled bolus gastrostomy tube feeding. R46's care plan said he required the implementation of EBP due to his g-tube for nutrition initiated on 1/21/2025. The care plan's goal was to prevent the spread of infection. 5. On 3/13/2025 at 1:10 PM, R65's room door had an EBP sign. V20 (Agency RN) said she was going to infuse R65's scheduled bolus gastrotomy tube feeding. V20 donned gloves but failed to don a gown. R65's care plan said she required the implementation of EBP due to her g-tube for enteral nutrition and her open right toe wound initiated on 5/01/2024. The care plan's goal was to prevent the spread of infection. On 3/12/2025 at 9:40 AM, V3 (Infection Preventionist/IP Nurse) said staff was expected to don proper PPE (Personal Protective Equipment) when providing high-contact care activities to residents under EBP including central lines, feeding tubes, and wound care. V3 said EBP practices were implemeted to prevent the spread of infections and protect residents and staff. The facility's policy titled Enhanced Barrier Precautions dated 7/26/2024, said The facility will use Enhanced Barrier Precautions (EBP) to reduce transmission of multi-drug resistant organisms in the nursing homes. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDROs as well as residents with wounds and/or indwelling medical devices.

Based on observations, interviews and record reviews, the facility failed to treat residents with dignity while providing care. This applies to 2 of 2 residents (R183 and R184) reviewed for dignity in a sample of 24. The findings include: 1. On 03/11/25 at 12:46 PM, V15 (Nurse) was standing over R184 feeding her. On 3/12/25 at 12:37 PM V15 said that she shouldn't have stood over R184 while feeding her because it is a dignity issue. 2. On 03/12/25 at 10:43 AM V15 (Nurse) entered R183's room after knocking. V18 CNA (Certified Nurses' Assistant) and V19 (R183's Daughter) were providing incontinence care for R183 and the curtain was not pulled. R183 was naked from the waist down and could be seen from the hall. On 03/12/25 at 11:33 AM, R183, who's cognition is intact, said that she wants the curtain and the door closed while staff are providing care for her. On 03/12/25 at 11:17 AM V18 CNA (Certified Nurse's Assistant) said that she should have closed R183's curtain to provide privacy. On 03/13/25 at 11:27 AM V2 DON (Director of Nursing) said that V15 should not have been standing over R184 while feeding her, and V18 should have had the curtain pulled while providing incontinence care. V2 said that these things should have been done for dignity. The facility's Privacy and Dignity policy dated 8/16/24 showed that the facility will ensure that the residents' privacy and dignity is respected by the staff at all times. The policy shows that during care that requires prior privacy such as incontinence care, the privacy curtain will be drawn to provide full visual privacy. Door may also be closed to provide additional layer of privacy during care. The policy shows that residents will not be addressed in an undignified manner by staff at all.

Based on observation, interview, and record review the facility failed to change a resident's PICC (Peripherally Inserted Central Catheter) line dressing as ordered. This applies to 1 out of 3 residents (R51) reviewed for central intravenous (IV) lines in a sample of 24. The findings include: On 3/11/2025 at 10:45 AM, R51 said he was receiving IV antibiotic infusions for his right foot wound infection. R51 had an intravascular (IV) central catheter to his left upper arm. R51's IV catheter had a transparent dressing dated 3/03/2025 (eight days earlier). The right lower corner of R51's transparent PICC line dressing was loose and no longer adherent to his skin. At 11:10 AM V9 (Registered Nurse/RN) said she was going to infuse R51's scheduled IV antibiotic. V9 initiated R51's IV infusion and failed to assess the dressing's integrity. On 3/13/2025 at 10:25 AM V3 (Assistant Director of Nursing/ADON) said central catheter dressings should be changed every 7 days and as needed (PRN) for infection control and prevention. V3 said nurses should assess PICC line dressings every shift to ensure their integrity and if compromised they should be changed. R51's Order Summary Report dated 3/13/2025 showed a 2/12/2025 order for Change PICC line dressing every night shift every Sunday and as needed. R51's ETAR (Electronic Treatment Administration Record) for March 2025 showed documentation that R51's scheduled PICC dressing was not completed on 3/09/2025 (Sunday). The facility's Intravenous Therapy policy dated 1/03/2025, said It is the facility's policy to ensure that intravenous policy and procedure are compliant to federal standard of care. 1. All IV access will be assessed by the nurse .2. Dressing Change .c. All central line dressing (PICC lines, single and multi-lumen central catheters inserted in subclavian, jugular, or inguinal area) will be changed every 7 days and prn.

Based on observation, interview, and record review, facility failed to implement measures to prevent re-opening of pressure ulcer for a resident with known skin alterations to the right buttocks and coccyx. The facility also failed to then assess, report, and initiate pressure ulcer treatments. This applies to 1 out of 1 (R40) resident reviewed for pressure ulcer in a sample size of 24. The findings include: On 03/11/25 at 02:24 PM, during incontinent care, a wound dressing was noted on R40's right buttock. Multiple open areas were noted on R40's coccyx. R40 did not have any wound dressing on his coccyx. Wound on right buttock appeared red in color with yellow tissue noted around the wound area. Wounds on his coccyx appeared red in color with whitish tissue noted in the wound. R40 appeared frail, unable to fully bend knee and is totally dependent on staff for bed mobility, transfers, and incontinence care. R40 transfers from bed to wheelchair using the mechanical lift. On 3/11/25 at 2:40 PM, V6 (RN-Registered Nurse) provided wound care to R40. V6 measured R40's wounds. Wound on right buttock measured 3.5 cm (centimeters) x 2 cm. Right buttock wound appeared reddish with yellowish areas noted. V6 did not measure the wound's depth. V6 said right buttock wound is a stage 3. V6 measured the cluster wound on R40's coccyx. Wounds on coccyx appeared reddish with yellowish areas noted. Measurement was 6.5 cm x 7 cm and V6 did not measure the depth. V6 said wound on coccyx was stage 3 pressure ulcer. On 3/12/25 at 9:41 AM, R40 was noted sitting on his wheelchair in the resident's lounge area. On 3/12/25 at 11:45 AM, R40 was still sitting on his wheelchair in the resident's lounge area. On 3/12/25 at 11:45 AM, V10 (CNA-Certified Nurse Assistant) said he got R40 up from bed on 3/12/25 around 7:50 AM and R40 has not gone back to bed since that time. On 3/12/25 at 9:55 AM, V6 said she did not document about the wound findings seen on 3/11/25 at 2:40 PM into R40's EHR (Electronic Health Record). She said she did not inform the physician and she did not obtain new treatment orders. She said she informed V3 (ADON-Assistant Director of Nursing/IP- Infection Preventionist/ Wound Care Nurse) of R40's wounds. At 10:11 AM, V3 said V6 informed him of R40's wounds on 3/11/2025. He said he did not assess the wounds and did not inform the physician of wounds. On 3/13/25 at 8:26 AM, V7 (NP- Nurse Practitioner) confirmed she saw R40 on 3/6/2025. She said R40 had MASD ( Moisture Associated Skin Damage) on coccyx and right buttocks. She confirmed she does not measure MASD and documented her measurements as 0cm x 0cm x 0cm. She said she will assess R40 later. On 3/13/25 at 12:10 PM, V2 (DON-Director of Nursing) said she expects nurses to call the physician immediately for any skin breakdown and obtain treatment orders. She said she expects nurses to document about findings in the EHR. She said she expects nurses to remind the CNAs to follow the care plan to heal or prevent pressure ulcers. Review of R40's EHR (Electronic Health Record) documents the following: R40's EHR documents original admitted [DATE]. R40 was readmitted to facility on 10/24/24. R40's MDS (Minimum Data Set) dated 12/27/2024 shows he had two stage 3 pressure ulcer that were not present upon admission and he has severely impaired cognitive functions. R40's Braden Scale assessment done on 2/26/25 showed he is at high risk for pressure ulcers. R40's POS (Physician Order Sheet) shows an order dated 1/16/2025 to place patient on the wheelchair not more than two hours with pressure relieving cushion. R40's wound care plan shows an intervention that he should not be on his wheelchair for more than two hours. On 3/12/25, R40's Progress Notes was reviewed. V6 did not document about the re-opened wounds on the right buttocks and coccyx found on 3/11/25. There was no documentation that R40's physician was informed about the re-opened wounds or that treatment orders were obtained. Facility's Wound Care Guidelines (reviewed 1/24/25) stated prevention of skin breakdown includes inspection of the skin every shift with care for signs of breakdown. Policy includes educating clinical staff and developing appropriate treatment plan. It states that the resident's skin alteration/breakdown (pressure ulcer, arterial, diabetic, venous ulcers etc.) shall be documented in the resident's clinical records in accordance with the facility's policy and in compliance to current regulatory standards. It is documented to initiate wound care treatment upon identification of the wound with physician's order and to refer to facility's Wound Care Specialist timely for all pressure injuries and/or wounds.

Based on observation, interview, and record review the facility failed to administer enteral feeding as ordered, and failed to change and label enteral feeding tube equipment for residents receiving gastrostomy tube feedings. This applies to 3 out of 4 (R46, R11, and R23) reviewed for enteral feeding in a sample of 24. The findings include: 1. On 3/12/2025 at 11:30 AM, R46 said he was receiving gastrostomy tube (g-tube) feedings. R46's g-tube pump had an opened but unlabeled bottle of Jevity 1.5 that was connected to a bag of water that was dated 3/10/2025 (two days earlier). The feeding's tubing tip was uncovered. On 3/13/2025 at 8:45 AM, R46's g-tube pump was hanging an opened bottle of feeding dated 3/13/2025 without an opened time. The feeding's connected bag of water was dated 3/10/2025 (three days earlier). The feeding's tubing tip was uncovered. At 12:15 PM, V20 (Agency Registered Nurse/RN) said she was going to administer R46's scheduled bolus g-tube feeding via a pump. V20 said she reviewed R46's order and determined she had to administer a total of 200 ml (milliliters). V20 said she believed the feeding bottle was opened and hung by the prior shift at 6 AM. V20 proceeded to connect the feeding tubing to R46's g-tube without priming the tubing. Then the feeding pump stopped to alarm that there was an error with the infusion. V20 then disconnected and primed the feeding tubing. V20 then reconnected R46s to his feeding. V20 started R46's feeding infusion without checking for placement or flushing his tube with water prior. R46's g-tube insertion site did not have a dressing. R46 said his feeding leaked at times and he had a scab that was uncomfortable. V20 said she was unsure if R46's g-tube site required a dressing. At 1:25 PM, V20 said she was going to stop the pump and disconnect R46's g-tube feeding. V20 reviewed the feeding pump and said he received a total of 211 ml of enteral feeding. V20 proceeded to disconnect R46's feeding without flushing his tube with water afterward. R46's Order Summary Report dated 3/13/2025 showed an order for Enteral Feed Order every 6 hours GT Jevity 1.5 at 400ml to run for 2 hrs at 200 ml/hr Bolus feeding 12 am, 6 am, 12 pm, 6 pm Water flush 90 ml before and after each bolus feeding. The report also showed additional orders of every evening shift change feeding set and tubing daily and cleanse enteral tube feeding site with soap and water and apply drain sponge dressing daily every day shift. 2. On 3/11/2025 at 10:00 AM, R11's g-tube pump was hanging an open bottle of Jevity 1.5 dated 3/10/2025 without an open time. The feeding's connected bag of water and tubing was not dated. The feeding's tubing tip was uncovered. On 3/13/2025 at 8:45 AM, R11's g-tube pump was hanging an open bottle of feeding dated 3/13/2025 without an open time. The feeding's tubing tip was uncovered. R11's Oder Summary Report dated 3/13/2025 did not show orders for instructions on changing his enteral feeding equipment (set and tubing) and providing care to his g-tube insertion site. 3. On 3/11/2025 at 10:40 AM, R23 said he was receiving g-tube feedings. R23 had an open g-tube feeding bottle of Jevity 1.5 dated 3/11/2025 without an open time. On 3/13/2025 at 9:50 AM, V8 (Registered Dietician) said she reviews and enters enteral feeding orders to ensure residents are receiving their required nutritional g-tube feedings. V8 said enteral feeding bottles are required to be labeled before being hung, with the resident's name, feeding instructions, open date, and time opened. V8 said enteral feeding sets (water bags) and tubing were for one-time use and should be discarded after 24 hours. V8 said it is recommended that when a new feeding bottle is started, a new set of equipment should also be started to ensure safe administration of enteral feedings. The facility's Enteral Tube Feeding Care policy dated 7/26/2024, said 1. Nurse to check in the POS/MAR the order for enteral feeding interventions .c. Rate d. Duration .3. Check that Feeding bag is properly labeled to include: a. Resident's name b. Formula (if it is not a closed system) and rate of feeding administration c. Date and time feeding was started .5. Flush the enteral tube with 15 to 30 cc of water before starting the enteral feeding and after stopping the enteral feeding to ensure that enteral formula in the enteral tubing is pushed to the stomach. 6. Change feeding bags daily and PRN. Use new enteral tubing daily and PRN every time a new feeding bag is started .8. Enteral tube stoma care: Site must be cleaned and covered with a dry gauze daily.

Based on observation, interview, and record review, the facility failed to follow physician's orders and weigh a resident weekly. The facility also failed to implement interventions for residents with weight loss. This failure resulted in R76 having a significant weight loss. This applies to 5 of 7 residents (R76, R40, R13, R10, and R53) reviewed for weight loss in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R76 was admitted to the facility on [DATE], with multiple diagnoses including stroke, type 2 diabetes, protein-calorie malnutrition, dysphagia, and gastrostomy status. R76's MDS (Minimum Data Set) dated March 23, 2024, showed R76 had moderate cognitive impairment. R76's nutrition care plan dated March 28, 2024, showed, Resident is at risk for alteration in nutritional status related to tube feeding, dysphagia. The care plan continued to show multiple interventions dated March 28, 2024, including Obtain weight as ordered. R76's order summary report dated April 10, 2024, showed an order dated March 20, 2024, for weight upon admission/readmission, weekly times four, then monthly, every day shift every Monday for 28 days weekly times four. R76's Weight and Vitals Summary dated April 10, 2024, at 10:15 AM, showed on March 20, 2024, at 2:12 PM and 4:37 PM, R76 weighed 141.1 pounds. The facility does not have documentation to show R76 was weighed weekly times four weeks. On April 10, 2024, at 2:21 PM, V4 (ADON/Assistant Director of Nursing) and V8 (CNA/Certified Nursing Assistant) weighed R76 in her wheelchair on the scale. R76's weight, including the weight of her wheelchair was 196.8 pounds. V4 said R76's wheelchair weighed 64.6 pounds and R76 weighed 132.6 pounds. On March 20, 2024, R76 weighed 141.1 pounds, on April 10, 2024, R76 weighed 132.6 pounds which is a 6.02% (percent) weight loss. On April 10, 2024, at 1:22 PM, V17 (Physician) said R76's weight loss could have been prevented if facility staff followed physician's orders and weighed R76 weekly as ordered. V17 continued to say interventions could have been put in place to prevent R76's significant weight loss. On April 10, 2024, at 11:26 AM, V13 (Registered Dietician) stated R76 is on tube feeding and an oral diet. V13 continued to say she assessed R76 on March 21, 2024, and has not seen R76 since March 21, 2024. V13 said R76 only has a weight from admission and should have been weighed weekly times four weeks. On April 10, 2023, at 2:19 PM, V2 (DON/Director of Nursing) said the expectation is facility staff follow physician orders for weighing a resident weekly. R76's Dietary Evaluation dated March 21, 2024, by V13 showed R76 at risk for malnutrition. 2. R10's EMR showed R10 was admitted to the facility on [DATE], with multiple diagnoses including right femur fracture, type 2 diabetes, dementia, and multiple pressure ulcers. R10's MDS dated [DATE], showed R10 was cognitively intact. R10's nutrition care plan dated March 5, 2024, showed, Resident is at risk for alteration in nutritional status related to therapeutic diet. The care plan continued to show multiple interventions dated March 5, 2024, including Obtain weight as ordered. R10's Weights and Vitals Summary dated April 10, 2024, at 10:14 AM, showed on February 26, 2024, R10 weighed 140 pounds. On March 19, 2024, R10 weighed 121 pounds which is a 13.57 % weight loss. A progress note dated March 19, 2024, at 2:17 PM, by V13 showed Noted resident had emesis after hip surgery- fluid shifts could also be the cause of weight loss. Variable oral intake also noted. Suggest [nutritional supplement] 237 mL (milliliter) three times a day. Notes labs, KUB (Kidney, Ureter, Bladder X-Ray) ordered. RD (Registered Dietician) to follow up with resident March 21, 2024, when in facility. A progress note dated March 21, 2024, at 7:32 PM, by V13 showed Please start weekly weights time four weeks to monitor. R10's Order Summary Report dated April 10, 2024, showed an order dated March 26, 2024, for Weights weekly times three weeks, one time a day every Monday for three weeks. R10's Weights and Vitals Summary dated April 10, 2024, at 10:14 AM, showed R10's last weight was obtained on March 26, 2024. The facility does not have documentation to show R10 was weighed after March 26, 2024. On April 10, 2024, at 11:23 AM, V13 said she was notified of R10's significant weight loss on March 19, 2024. V13 continued to say one of R10's interventions in response to the significant weight loss was weekly weights for four weeks. V13 said the facility did not obtain R10's weekly weights as ordered. 3. R53's EMR showed R53 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, and dysphagia. R53's MDS dated [DATE], showed R53 was cognitively intact. R53's weight loss care plan dated March 28, 2024, showed Unintended weight loss/gain, [R53] has the following conditions and risk factors that put him at risk for unintended weight loss/gain: COPD (Chronic Obstructive Pulmonary Disease), malnutrition/failure to thrive. The care plan continued to show multiple interventions date March 28, 2024, including Provide regular diet to meet the nutritional needs of the resident by: 1. Liberalize the diet; 2. Providing supplements. R53's order summary report dated April 10, 2024, showed an order dated August 24, 2023, for [Nutritional supplement] three times a day, [nutritional supplement] or equivalent, 237 mL, three times a day. R53's April 2024 MAR (Medication Administration Record) showed V6 (RN/Registered Nurse) documented R53 did not received his nutritional supplement on: April 3, 2024, at 9:00 AM and 1:00 PM due to the supplement being unavailable. April 4, 2024, at 9:00 AM and 1:00 PM due to the supplement being unavailable. April 8, 2024, at 9:00 AM and 1:00 PM due to the supplement being unavailable. April 9, 2024, at 9:00 AM and 1:00 PM due to the supplement being unavailable. On April 9, 2024, at 12:38 PM, V6 said sometimes [nutritional supplement] is out of stock. V6 continued to say if the [nutritional supplement] is unavailable then she just waits for more [nutritional supplement] to be restocked. On April 9, 2024, at 1:57 PM, V19 (RN) said the nutritional supplements are kept in the supply room. V19 opened the supply room and multiple nutritional supplements were stocked in the supply room. On April 10, 2024, at 11:30 AM, V13 said R53 has had ongoing weight loss while residing in the facility. V13 continued to say R53 should receive a nutritional supplement three times a day. V13 said if the facility does not have R53's ordered nutritional supplement, V13's expectation is R53 will receive an equivalent nutritional supplement. V13 continued to say the facility stocks a house supplement and R53 should have received the house supplement in place of the ordered supplement. V13 said the facility's house supplement has not been out of stock in the month of April. A progress note dated March 14, 2023, at 11:03 AM, by V13 showed BMI (Body Mass Index) 16.7 (Underweight) . Resident has [nutritional supplement] 237 mL three times a day, [mirtazapine] to increase appetite, food brought in by family. Encouraged resident to consume 75 to 100% of supplements . 35267 4. Face sheet, dated April 10, 2024, shows R13's diagnoses included malignant neoplasm of the pancreas, dysphagia, schizophrenia, bipolar disorder, cerebral infarction, and anxiety disorder. Care plan initiated May 21, 2022 and resolved on February 22, 2024, showed R13 was at risk for alteration in nutritional status related to her tube feeding and oral diet. Care plan, initiated February 22, 2024, showed Actual weight loss: R13 has experienced weight loss and is at risk for continued weight loss. Has experienced progressive weight loss . Interventions, initiated March 9, 2024, included Determine food preferences through one-to-one interview and/or family interview. POS (Physician Order Sheet), printed April 9, 2024, showed R13 had physician orders for the following nutrition supplements: 1. (Nutritional supplement) to be provided twice daily since May 23, 2023 2. (Nutritional supplement) or equivalent to be provided twice daily since October 24, 2023 The POS also showed R13 had physician orders for her g-tube (gastrostomy tube) to be flushed with water daily. Review of R13's weights show the following: 151.6# (Pounds) August 1, 2023 146.2# September 21, 2023 137.2# October 9, 2023 131.4# November 3, 2023 - 13% weight loss in 3 months 128.4# November 20, 2023 132.0# December 11, 2023 134.2# January 4, 2024 126.8# February 5, 2024 116.6# March 7, 2024 125.9# April 3, 2024 MARs (Medication Administration Records), dated August 2023 to February 2024, showed R13 had an order for enteral nutrition g-tube feedings to supplement her oral nutritional intake. The MARs show R13 received the enteral nutrition feedings August 2023 until September 30, 2023 however R13 intermittently refused her supplemental enteral nutrition feedings during those months. The MARs show R13's enteral nutrition feedings were placed on hold from October 1 to November 16, 2023 and then resumed November 17, 2023 until February 11, 2024 when all g-tube feedings were discontinued and R13 was placed on hospice. Physician note, dated February 5, 2024, shows R13 lost significant weight in six months, was diagnosed with failure to thrive, and the physician instructed the dietitian to follow R13. Review of R13's POS, nutrition assessments and progress notes, dated September 21, 2023 to April 10, 2024, showed no new nutrition interventions were recommended or implemented for R13 to prevent further weight loss. Nutrition assessment, dated October 12, 2023, shows R13 began refusing her enteral feedings. No new nutrition interventions were identified for R13 to prevent further weight loss. Nutrition note, dated January 31, 2024, showed R13's oral intake at meals was reported as good. Nutrition assessment, dated February 12, 2024, shows R13 had good oral intake and was consuming 75-100% of her meals and was continuing to refuse her enteral feedings. On April 9, 2024, at 11:15 AM, V14 (Licensed Practical Nurse) stated R13 formerly received enteral feedings via her g-tube but R13 began to refuse all enteral g-tube nutrition and wished to have her g-tube removed. V14 stated R13 was only receiving an oral diet for some time. V14 stated R13 did eat her meals but did not eat as much as she used to eat. V14 stated R13 needed staff assistance to eat and would sometimes refuse meals. At 11:50 AM, V14 stated R13 was not drinking the physician ordered nutritional supplements and some days refused the nutritional supplements. V14 stated R13 used to receive milkshakes from her POA (Power of Attorney) but the POA no longer brought milkshakes to R13. V14 stated she gives R13 chocolate or vanilla pudding as much as she is able because R13 likes pudding. On April 10, 2024, V13 (Dietitian) stated on August 12, 2023, she recommended weekly weights to monitor R13 for further weight loss. V13 reviewed R13's weights and stated the facility did not weigh R13 weekly. V13 stated when R13 began refusing her tube feedings, V13 did not implement any further interventions to prevent further weight loss. V13 stated she did not talk to R13 during the time R13 was losing weight and did not obtain any food preferences or discuss R13's menu with R13. V13 stated there were several different options for supplements the facility could offer if a resident did not like nutritional supplement. V13 stated she was unaware R13 was not drinking her nutritional supplement. V13 stated if R13 was not taking her nutritional supplement, the facility staff could offer a different supplement but was not aware if R13 was offered alternatives to the nutritional supplement. V13 also stated the facility had the option of placing resident food preferences on their meal trays to be given at each meal. V13 stated if the CNAs (Certified Nursing Assistants) fill out resident menus they should write in the resident food preferences or any extra items at each meal. On April 10, 2024 at 2:22 PM, V1 (Administrator) stated the facility had no policy regarding addressing residents at nutrition risk, residents with significant weight loss, or frequency of dietitian assessments of residents with tube feedings. On April 10, 2024 at 01:38 PM V1 (Administrator) and V2 (Director of Nursing) stated they conduct nutrition at risk meetings at the facility. V1 stated they discuss residents who had experienced significant weight loss. V1 stated the facility dietitian should be meeting with the residents to assess what foods they like to eat. V2 stated resident food preferences should be provided on the resident meal trays at meals and not be left to the CNAs (Certified Nursing Assistants) to write in on resident meal tickets when CNAs assist selecting the daily menus. 5. Face sheet, printed April 10, 2024, shows R40's diagnoses included depression and legally blind. Care plan, August 19, 2023, showed R40 was assessed to be malnourished and interventions included, Monitor food and hydration intake/consumption. Monitor weight in accordance to policy and plan of care. Offer nutritional supplements as ordered and monitor compliance. Care plan, dated August 11, 2023, showed R40 was at high risk for development of skin breakdown. Care plan interventions includes Encourage good nutrition and hydration in order to promote healthier skin. POS, printed April 9, 2023, shows R40 had the following physician orders for nutrition supplements: Nutritional supplement three times a day since August 24, 2023 Nutritional supplement AWC (Advanced Wound Care) two times a day 30 milliliters since March 13, 2024 Review of R40's weights showed the following: 144.6# August 12, 2023 133.6# August 17, 2023 144.6# August 19, 2023 140.0# September 6, 2023 135.2# October 9, 2023 131.0# November 6, 2023- 9.4% weight loss in three months 131.0# November 11, 2023 131.9# November 20, 2023 131.9# November 27, 2023 132.4# December 13, 2023 134.2# January 5, 2024 120.8# February 4, 2024 - 16% weight loss in six months 122.0# February 12, 2024 121,0# March 7, 2024 120.2# April 3, 2024 On April 9, 2024 at 1:28 PM during lunch, R40 ate approximately 75% of her lunch and drank approximately half of her nutrition supplement. R40 stated she enjoyed her lunch that day. Review of R40's nutrition progress notes and POS, dated August 24, 2023 to March 13, 2024, showed no new nutrition interventions were recommended/implemented for R40 to prevent further weight loss. Nutrition progress note, dated August 12, 2023, shows V13 (Dietitian) recommended R40 to be weighed weekly. Review of R40's weights show R40 was not weighed weekly. Nutrition note, dated April 2, 2024, shows R40 was eating an average of 75% of her meals however R40's April 3, 2024 weight showed R40 continued to lose weight. On April 9, 2024 at 11:22 AM, V14 (Licensed Practical Nurse) stated R40 did not always drink her supplement and preferred them served on ice. R40 used to have a visitor who brought her outside food she liked, but no longer received the food from her visitor. V14 stated R40 was always fed by staff. Physician note, dated March 26, 2024, showed R40 was diagnosed with severe protein calorie malnutrition. On April 10, 2024 at 10:50 AM, V13 (Dietitian) stated R40 was receiving nutritional supplement as ordered during the course of her weight loss, but V13 did not recommend any new nutrition interventions for R40 to prevent further weight loss between August 2023 and February 2024. V13 stated she requested to have R13 reweighed during the time she was losing weight. V13 stated she had not discussed food preferences with R40 or R40's nurses recently.

Based on observation, interview and record review, the facility failed to follow their planned menu/recipes resulting in lunch entrees being served to residents with inadequate protein. This applies to all 66 residents in the facility receiving General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft diets at the facility. The findings include: Long-Term Care Facility Application for Medicare and Medicaid, dated April 8, 2024, showed the facility census was 71 residents. Client List Report, printed April 9, 2024, showed all but five residents in the facility received either a General, Low Concentrated Sweets, No Added Salt, Pureed or Mechanical Soft diet. Facility Daily Spreadsheet, dated Week 2 Monday, shows residents with General, Mechanical Soft, Pureed, No Added Salt, Low Concentrated Sweets all received either regular, ground or pureed portions of Chicken Alfredo. The spread sheet shows each resident receiving the Chicken [NAME] were to be served the equivalent of a six fluid ounce portion of chicken with [NAME] sauce and a separate 1/2 cup equivalent of pasta. On April 8, 2024 at 12:15 PM during lunch service, with V12 (Food Service Manager) V11 (Cook) was serving portions of Chicken [NAME] from full steam table pan. The chicken, mushrooms, [NAME] sauce and noodles were all mixed in the pan and the mixture was being served to resident plates using a six fluid ounce spoodle. A six fluid ounce sample of the mixture was plated, and the chicken was removed from the mixture and weighed. The total amount of chicken in the six fluid ounce serving weighed 0.75 ounces. V12 reviewed the lunch spread sheet and stated the chicken should have weighed two ounces in one serving of Chicken Alfredo. Review of the facility Chicken [NAME] recipe shows the prepared menu item was to consist of pulled/diced chicken, mushrooms, [NAME] sauce and milk and was to provide a total of two ounces weight of chicken in each serving. The recipe does not show the noodles were to be added to the Chicken [NAME] prior to being served on resident plates. The recipe shows one serving of the Chicken [NAME] was to be served with a six-ounce spoodle and placed over cooked fettuccini or linguini noodles. Review of Ground and Pureed Chicken [NAME] recipes both show each serving of ground or pureed Chicken [NAME] was prepared using an initial six fluid ounce portion of Chicken Alfredo. The recipes showed each serving of Chicken [NAME] was to be prepared without the noodles added. On April 10, 2024 at 11:02 AM, V13 (Dietitian) stated she did not closely monitor the menus/food production in the kitchen and only performs a walk-through of the kitchen during her visits. V13 reviewed the menus and spreadsheets and stated the Chicken [NAME] should have been served in a six fluid ounce serving separately from the noodles at lunch on April 8, 2024. V13 stated the pureed and ground diets should also have received the Chicken [NAME] and the noodles separately when served to the residents. Facility Kitchen Policy, reviewed July 23, 2023, showed, 8. Menu a. All food items in the menu and recipe will be followed. In the event that change is needed, the dietitian may be consulted first to approve the change and ensure that the change is appropriate.

Based on observation, interview and record review, the facility staff failed to immediately report multiple allegations of physical abuse and theft per the facility policy. This failure resulted in the psychosocial harm of a resident who was repeatedly exposed to his alleged abuser and showed symptoms of fear, anger and behaviors. This applies to 3 of 3 residents (R30, R37 and R13) reviewed for abuse in a sample of 12. The findings include: 1) Face sheet, undated, shows R30 was admitted on (MONTH) 12, (YEAR) and [DIAGNOSES REDACTED]. ADL (Activities of Daily Living) care plan, dated (MONTH) 25, (YEAR), shows R30 required the extensive to total assistance of one to two staff for all ADLs and required one to one feeding for all meals. MDS (Minimum Data Sheet), dated (MONTH) 19, (YEAR), shows R30's cognition was severely impaired. Facility email dated (MONTH) 27, (YEAR), showed R30 moved rooms for continuous monitoring related to falls. On (MONTH) 9, (YEAR) at 11:49 AM, V12 (Family) stated on an afternoon prior to (MONTH) 27, (YEAR), V12 entered R30's room and he (R30) seemed really frustrated. V16 (CNA) had just finished feeding the resident dinner and stated, Your dad has been really crazy today. He spit his food at me. R30 stated to his family, That [***] just hit me in the mouth. Later when V16 came into R30's room and he began shouting, No! No! Get her away from me! V12 stated she reported R30's allegation and his apparent frustration to V23 (Registered Nurse) that evening who only replied, He's been screaming all day V12 stated V16 continued to be assigned to the resident (R30) after the family member reported the incident to V23 and after the family member requested V16 not to be assigned to R30. V12 stated the resident would yell when V16 was near him and would yell, Get the hell away from me! R30 would use his hand and swat V16 out of the room or push V16 away. V12 stated R30's hygiene began to deteriorate and V16 told the family member, He won't let me by him. He don't want us to touch him. He don't want us to clean him up V12 stated she thought V23 told facility administration about the alleged abuse and would ask staff why V16 would still be assigned to R30. On (MONTH) 2, (YEAR) the family member (V12) discussed her concern with V18 (CNA). V18 suggested that she should report the information to a supervisor. V12 stated, No one seemed to want to hear what I wanted to say. No one took action. No one asked who, when . On (MONTH) 5, (YEAR) when V12 and the resident (R30) were outside visiting, a man approached the family member (V12) and reported an investigation was beginning for R30 and asked if V12 wanted to file a police report to which V12 answered yes. V15 (Admissions) provided a facility concern form to V12 in an envelope. V12 was told to fill out the concern form, and then return it to the facility. V12 stated R30 allows other CNAs, other than V16, to care for him. V12 stated R30 has shown a great amount of anger and frustration. Facility Nursing Assignment schedules, dated (MONTH) 27, (YEAR) to (MONTH) 5, (YEAR), show V16 worked shifts on the same floor as R30 on (MONTH) 27, 28, 29, and 30, (YEAR), and (MONTH) 1, 2, 3, and 5, (YEAR). On (MONTH) 8, (YEAR) at 10:18 AM, V2 (Director of Nursing) stated on (MONTH) 5, (YEAR) the housekeeper went to clean R30's room, and R30 reported to housekeeper a CNA (Certified Nursing Assistant) was hitting resident. V2 stated she spoke with V13 (another Family member) who reported R30 stated an aide hit him approximately a week and a half ago. V2 stated V10 (Restorative Nurse, Manager) reported the CNA to the agency and asked if the family wanted to file a police report, which the family declined to do. On (MONTH) 8, (YEAR) at 11:10 AM, V18 (CNA) stated on (MONTH) 5, (YEAR), V19 (Housekeeping) told V18 that R30 stated he was slapped by his aide. V18 stated she remembered earlier that week R30's family repeatedly told her (V18) that V16 slapped R30. V18 stated she then approached V15 (Admissions / Manager on Duty, for (MONTH) 5, (YEAR)) to report the current and prior allegations of abuse regarding R30. V18 stated the allegations of abuse began approximately a week and a half ago when family members (V12 and V13) both told V18 on different occasions that R30 reported being slapped by the CNA. Both family members stated the Aide who slapped the resident was V16 and gave a description of the CNA. V18 stated the family members reported R30 recognizes V16's voice and the voice makes R30 crazy and R30 says get that [***] out of here! when he hears it. V18 stated the family members noticed his behaviors escalate when he hears her voice. V18 stated that multiple staff members including V20 (CNA) and V21 (CNA) reported being told about abuse allegation by R30's family on (MONTH) 2, (YEAR). V18 stated she told V15 (Admission) about V20 and V21's knowledge of the abuse allegations on (MONTH) 2, (YEAR). V18 stated she first reported it to facility administration on Saturday after V19 (Housekeeper) approached her (V18) and told her of R30's allegations. V18 stated V19 was panicking and was not sure what to do with the information. On 05/08/18 at 11:21 AM, V19 (Housekeeper) stated on (MONTH) 5, (YEAR), the resident (R30) told him (V19) he was being hit by his aide. He (V19) stated he could not remember to whom in the facility he needed to report allegations of abuse. He (V19) stated, I don't think I reported it to anybody. I didn't know who to talk to. I just found the first person I saw. V19 stated he later wrote the concern on a facility concern form. On 05/08/18, V15 (Admissions) stated V19 (Housekeeping) did not verbally report the abuse allegation to facility management prior to getting the concern form. On 05/08/18 at 10:48 AM, V10 (Restorative Nurse, Manager) stated she sent V16 home on (MONTH) 5, (YEAR) however V10 did not call the agency and report V16's allegation of abuse. On 05/08/18 at 11:02 AM, V17 (CNA Scheduler) stated she did not call the CNA agency to report the allegation of abuse against V16. On 05/08/18 at 11:51 AM, V22 (Staffing Agency Regional Support) stated no one reported any allegation of abuse against V16 until 05/08/18. V22 stated since the allegation was reported earlier that day, the agency suspended V16 until the investigation was over or pending the outcome On (MONTH) 8, (YEAR) at 1:11 PM, V1 (Acting Administrator) stated the allegation a staff member hitting/slapping a resident in the face should have been reported to the police per the facility policy on physical abuse allegations. Initial Report of Allegation of Alleged Physical Abuse, dated (MONTH) 5, (YEAR), shows IDPH (Illinois Department of Public Health) was notified regarding an allegation of physical abuse, date unknown, by V16 on (MONTH) 5, (YEAR). The Report shows the family requested the police not be notified. Concerns and Resolutions Form, dated (MONTH) 5, (YEAR), shows R30 stated a CNA slapped him (R30) in the mouth for spitting out food/beverage to V21 (CNA) on (MONTH) 2, (YEAR). Concerns and Resolutions Form, dated (MONTH) 5, (YEAR), shows on (MONTH) 2, (YEAR) at 9:00 PM, R30's family told V20 (CNA) an aide hit R30 in the mouth at some time. Concerns and Resolutions Form, dated (MONTH) 5, (YEAR), shows R30's two family members (V12 and V13) V18 (CNA) on two occasions that an agency aide slapped him. V18 stated they both gave the same description of the aide and pointed the aide out. V18 stated V12 and V13 tells her all the time about the abuse and (MONTH) 2, (YEAR) was the last time she heard the allegation. Concerns and Resolutions Form, dated (MONTH) 5, (YEAR), shows R30 reported he was being hit by his aide to V19 (Housekeeping). 2. Face sheet, undated, shows R37 was admitted on (MONTH) 24, (YEAR) and his [DIAGNOSES REDACTED]. MDS, dated (MONTH) 24, (YEAR), shows R37's cognition was intact. Nursing notes written by V23 (RN -Registered Nurse), dated (MONTH) 20, (YEAR), shows, late entry 4/19/18 (at) 2100 (9:00 PM) resident wheeled himself to nurses station and reports missing forty dollars and IPOD and his identification card after V18 (CNA) gave the shower. Stated that he will call police to report. Explained not to call police we need investigation here in facility first. This RN searched the stuff that resident stated missing unable to find in his room. 2130 (9:30 PM) notified V10 (Restorative Nurse, Manager) on call RN about the complaint of the resident, received instruction to tell resident that we have to investigate in the AM, our administrator will see him. Resident verbalized understanding Left message note to social services . Endorsed to next shift. On (MONTH) 8, (YEAR) at 2:28 PM, V1 (Acting Administrator) stated he spoke with R37 and followed up on the (MONTH) 20, (YEAR) missing items. V1 stated R37 verified the items were still missing. V1 confirmed no abuse report, concern form, or investigation was begun regarding the allegation of R37's missing items. V1 confirmed the allegations of missing items were not reported to IDPH or the police. 3. On (MONTH) 8, (YEAR) at 12:21 PM, R13 stated during (MONTH) (YEAR), R13 reported to the facility that she was missing two gift certificates, money and a credit card during her stay at the facility. Review of abuse investigation, dated (MONTH) 11, (YEAR), shows R13's POA (Power of Attorney) called the facility to inform the Social Worker that R13's credit card was allegedly flagged for unauthorized credit card transactions. The report shows a police report was filed by the POA and Discover credit card company opened up an investigation. The facility did not contact the police regarding the missing money/credit card/gift certificates. Facility Policy Reporting and Investigation of Abuse, Neglect and /or Misappropriation of Resident Property, dated (MONTH) 28, (YEAR), shows, Physical abuse is defined as infliction of injury on a patient/resident that occurs other than by accidental means and that required (whether or not actually given) medical attention and includes hitting, slapping, pinching, kicking, etc Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent The administrator/designee, on becoming aware of alleged abuse, neglect and/or misappropriation of a resident's property, shall report the matter immediately by telephone to the following: v. Local police department (if sexual or physical abuse) Facility Policy Reporting Reasonable Suspicion of a Crime, dated (MONTH) 14, 2012, shows, It is the policy of (the facility) to report any reasonable suspicion of a crime to the local law enforcement agency and the Department of Public Health All crimes or suspicion of a crime against a patient or resident shall be immediately reported to the ministry designee for investigation. The person(s) who are reporting may also notify the local law enforcement agency and the Department of Public Health either by telephone, fax or email The ministry cannot prohibit an individual reporting directly to the local law enforcement agency or the Department of Public Health if a multiple-person report is filed F. If the investigation reveals no serious bodily injury, the ministry will report the incident not later than twenty-four hours after forming the suspicion to the ministry's local law enforcement and the Department of Public Health. G. Examples of non-bodily injury suspicion of a crime may include but not limited to: 1) Theft or resident property J. Each ministry will coordinate with their local law enforcement agency to determine what actions are considered to be a reportable crime. A list will be maintained, at the ministry, as a guideline to be utilized for reporting. No list of reportable crimes was included as an attachment.

Based on observations, interviews and record reviews, the facility failed to provide one resident (R2), who has impaired cognitive status, weak physical condition and at risk for falls, with the appropriate supervision, monitoring and safety measures. This failure resulted in the resident having an avoidable fall, while left unsupervised, sustaining a fractured hip and requiring medical treatment. This failure applies for one (R2) out of four residents, reviewed because of their high risk for falls and fall occurrences. Findings include: Review of R2's Admission Face Sheet documented R2 is an [AGE] year old female recently readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Before her admission to the facility, R2 had fallen at home and sustained " compression fracture of C2 and T7. Review of R2's Hendrich II Fall Risk Assessment, dated 2/17/2012, documented staff assessed R2 at risk for falls. The facility staff based this assessment on the following risk factors observed in R2's condition, such as: " Confusion/Disorientation/Impulsivity " and inability " to rise without assistance ... " Review of R2's care plan, dated 2/17/2012, also documented R2 is at risk for falls because of confusion, impaired mobility and history of falls. Review of the plan of for R2 documented nursing intervention to monitor R2, use chair and bed alarms. But, this plan of care lacks specific nursing interventions, monitoring method or safety measures to supervise R2, which would prevent a confused, disoriented and impulsive resident from falling. R2's documented goal was not to have any fall with serious injury. However, review of the facility's incident reports had documentation of two fall occurrences for R2. R2's Incident Report, dated 3/06/2012, documented R2 fell in the bathroom, after a CNA (certified nurse aide) left her on the toilet. R2's son was present in the room and was documented as being told to " watch her " . But there was no indication staff ensured he knew what to do to safety monitor her. No injury noted at the time of this fall. Also, R2 was documented as confused and disoriented and had inability to understand directions. R2 had a second fall occurrence on 3/23/2012 at 4:40 PM. The Final Report for this 3/23/2012 incident documented the following: " R2 ... is alert and pleasantly confused. She is moderately impaired with disorganized thinking and short term/long term memory deficits. R2 ... rarely understands what is said to her and rarely can make herself understood ... R2 requires extensive one person physical assist with bed mobility, transfer, toileting, locomotion on and off unit, personal hygiene, eating and dressing ... Incident: On 3/23/2012, at approximately 4:40 PM, R2 non restraint chair alarm was sounding. Upon hearing the alarm, nurse ran to investigate and noted resident to be on side lying position on the floor ... " However, there is no indication staff was closely supervision/monitoring R2. At first R2 was thought not to have any injury. Later on 3/24/2012 R2 was sent to the hospital and assessed to have a fractured right hip. However, there is no evidence R2 was being closely supervised by the nursing staff at the time of this fall. Review of the facility's Fall Prevention Program documented the following instructions for staff: " Procedure ... F. The patient/resident/significant other will be educated in standard safety precautions, fall prevention interventions and activity limitations. 1. All education will be documented ... VI ... C. Document all factors contributing to the fall, interventions currently in place and implementation of any additional safety measures and assessment of patient/resident ... " However as stated above R2's care plan lack specific nursing interventions to address R2's confused mental status and impulsive behavior with appropriate safety measures. E13 was the CNA, who assisted R2 to the bathroom the day she fell on [DATE], and worked with R2 on 3/23/2012. E13 was interviewed on 4/27/2012 at 12:26 PM. E13 described R2 as confused most of the time. E13 said the plan to keep confused resident like R2 safe is to supervise and monitor them or R2 at the nursing station. E13 said we sit them (confused residents at risk for fall) at the nursing station for close observations. E12 also said the residents should be engaged and distracted so they don't get up and fall. On 3/06/2012, E13 said she asked R2's son to watch her while she went to get an item for R2. But, E13 did not give R2's son any specific instructions to ensure R2 was appropriately monitored. So, R2 did not get the supervision she required to remain safe from falling. Surveyor interviewed the nurse (E6), who was responsible for the care of R2 on 3/23/2012, by phone on 4/27/2012. E6 reported R2 was placed in the area near the nursing station so staff could monitor her (R2) closely. But, E6 said she was not at the nursing station when R2 stood up from her wheel chair and fell . E6 stated she and the other nurse were down the hallway passing medications. E6 told surveyor she did not see R2 get up and fall. E6 said another nurse came and told her R2 had fallen. When E6 said she got to the area near the nursing station, E6 said she saw R2 lying on the floor with the assistance director of nursing and activity staff by her. When asked about the CNAs on duty, E6 told the surveyor the CNA s were not at the nursing station. E6 described the CNAs as helping residents getting ready for dinner in their room or taking residents to the dinning room downstairs. So, nursing staff were not in the area near R2 to supervise or monitor her, which could prevent R2 from falling. The assistant director of nursing E9 was interviewed on 4/27/2012 at 3:38 PM in the first floor conference room. E9 stated she witnessed R2 fall on 3/23/2012. E9 said she just came off the elevator and witnessed R2 as she stood up and fell . E9 told surveyor she was too far away to redirect or prevent R2 from fall. E9 did not identify any nursing staff supervising or monitoring R2 to prevent her from falling. E9 reported the nurses were down the hallway passing medications. The second witness to R2's fall on 3/23/2012 was the director of activity (E12). E12 was interviewed on 4/27/2012 at 11:38 AM in the first floor conference room. E12 also reported she was coming off the elevator too. E12, " As I came off the elevator. I saw her (R2) stand up. I could not get to her in time ... We could not yell at her ... " E12 also reported that the nurses were down the hallway passing medications and the CNAs were not at the nursing station. E12 said that the CNAs were getting residents up in their rooms or taking them downstairs to the dinning room for the evening meal. During the Daily Status Meeting with the director of nursing on 4/27/2012, the surveyor expressed concerns regarding lack of supervision/monitoring of R2 when she fell on [DATE]. E2 stated E9 and E13 witnessed R2, but could not reach her before the accident. However, E2 did not provide any evidence to support R2 received the supervision/monitoring she (R2) required to prevent her from falling, while left by the nursing station.