Every finding on record at Avantara Lake Zurich

Based on observation, interview, and record review the facility failed to ensure dishes were air-dried prior to stacking. This has the potential to effect all residents receiving food from the kitchen. The findings include: Centers for Medicare and Medicaid Services form 671 dated 5/4/26 shows there are 143 residents residing in the facility. Facility Diet Type Report dated 5/4/26 shows only one resident has an order of NPO (nothing by mouth) and does not receive food from the kitchen. On 5/4/26 at 10:55 AM, V11 (Dietary Aide) was on the clean, outfeed side of the dish machine. V11 was removing trays from the dish racks immediately out of the dish machine without allowing it to air dry. V11 would place the trays on an adjacent cart in a manner that allowed them to air dry. When V11 ran out of room, V11 began stacking the trays top to bottom, on top of the row of previously placed trays, while still wet and did not allow them to air dry. V11 also stacked insulated plate tops with the tops facing down, stacking additional insulated plate tops directly on top of the last on the bottom rack of the cart. At 11:07 AM, V10 (Food Service Director) told V11 that the plate tops needed to be stacked differently and V11 inverted the plate tops, draining all the water that accumulated in them. On 5/4/26 at 11:04 AM, V10 said when dishes come out of the dish machine, they should be allowed to air dry before stacking. Facility provided Cleaning and Sanitation Food Safety policy dated 11/11/24 states, . 5.2.4. Air-Drying. After sanitizing using either a manual or mechanical process, air-dry all equipment and utensils. Provide ample space to facilitate self-draining of equipment and utensils so that they can air-dry properly.

Based on observation, interview, and record review, the facility failed to ensure residents were treated in a dignified manner for 4 of 30 residents (R152, R12, R14, and R113) reviewed for dignity in the sample of 30.The findings include: 1. On May 4, 2026, during the lunch meal, V13 and V16 Certified Nursing Assistants (CNA) were feeding residents at one of the tables. V13 and V16 were talking to each other in spanish in front of english-speaking residents. Staff were also observed speaking across the dining room to each other in spanish. The dining room was full of residents eating their lunch meals including R12, R14, and R113. 2. On May 5, 2026, at 12:45 PM, V19 Registered Nurse (RN) was standing next to R152 feeding him the lunch meal. There was an empty chair next to V19. On May 6, 2026, at 9:34 AM, V13 CNA said staff should be sitting when they are feeding the residents so that they are eye level with the residents. V13 said if a resident is spanish speaking, then staff can speak to them in spanish. V13 said english should be spoken in the dining room because this is the residents' home and the residents may think that staff are talking about them if staff don't speak in english. At 9:45 AM, V2 Director of Nursing said that staff should be sitting down to feed residents and staff should be speaking english so that everyone is able to understand them. V2 said this is done to provide dignity to the residents. The facility's Privacy and Dignity Policy revised July 3, 2025, shows, It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times.

Based on observations, interviews, and record review, the facility failed to ensure pressure relieving interventions were in place and failed to ensure ordered treatments were in place for five of eight residents (R113, R75, R9, F26, and R31) reviewed for pressure injuries in the sample of 30. The findings include:1. R113's admission Record shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, bipolar disorder, anxiety disorder, dementia, and major depressive disorder. R113's Pressure Injury Risk assessment dated [DATE], shows she is high risk for developing pressure injuries. R113's Skin and Wound note dated April 11, 2026, shows R113 was seen by the wound care nurse practitioner for new wound evaluation. R113 had a deep tissue pressure injury to her left heel that measured 6.5 centimeters (cm) X 5 cm and a deep tissue pressure injury to her right heel that measured 4.5 cm X 4 cm. R113's Order Summary Report dated May 5, 2026, shows orders for Wound Care left and right heel: Cleanse with wound cleanser, pat dry then apply betadine, cover with a foam dressing every-day shift. R113's Care Plan does not show that R113 has any behaviors of refusing treatment or removing wound care dressings. On May 5, 2026, from 9:45 AM-10:30 AM, R113 was sitting in a high back wheeled recliner in the facility dining room. R113's feet and heels were on the footrest of the high back wheeled recliner. R113 had one shoe on her left foot and the shoe for R113's right foot was off, but laying on its side right next to R113's right foot. R113 was crying out, moaning, and saying her right foot was hurting. At 10:30 AM, R113 told V14 (Memory Care Director) that she had to use the bathroom. V15 (Certified Nursing Assistant-CNA) and V18 (Hospice CNA) brought R113 to her room to use the bathroom. V18 placed R113's right shoe back onto her foot. While V18 was putting R113's shoe back onto her right foot, R113 screamed in pain. V15 asked R113 if she wanted pain medication, and R113 said yes. V15 went out into the hall and got R113's nurse. V29 (Licensed Practical Nurse-LPN) came and administered morphine to R113. R113 said the pain was bad when V29 asked how bad her pain was rated. R113 was transferred back into bed by V15 and V18. V18 removed R113's shoes and R113 cried again in pain when her shoes were removed. V15 removed R113's socks so that R113's heels could be observed. There were [NAME] areas noted to R113's bilateral heels that were larger than a half dollar size. These dark areas were mainly to the back of R113's heels where the back of the shoes would be pressing against these areas if R113 had shoes on. There were no dressings in place to R113's bilateral heels. R113 cried again in pain when V15 placed her heel boots onto her heels still with no dressings in place. R113 did not refused the heel protectors, nor did she try and remove them. At 1:11 PM, R113 was observed sitting in her wheelchair in the dining room. R113 had foam dressings to her heels that were observable over her socks. R113 did not have any shoes on her feet. R113 was not complaining, crying, or moaning of any pain to her heels. R113 was not making any movements or attempts to remove the dressings to her heels. R113 said her lunch meal was very good. R113's Progress Note dated May 5, 2026, at 11:59 AM, entered by V29 (LPN) shows that R113 was removing her dressings and her heel protectors. R113's legs were elevated on a pillow, and the dressings and heel protectors were reapplied. On May 6, 2026, at 9:34 AM, V13 (Restorative CNA) said R113 should not wear shoes if she has pressure injuries on her heels because shoes would irritate the heels. V13 was not aware that R113 had pressure injuries to her heels. At 9:45 AM, V2 (Director of Nursing) said if shoes are causing R113 pain, then she should not have shoes on. V2 said that R113 self-propels herself at times if she is up in the wheelchair. V2 said that R113 could still self-propel herself if she had nonskid socks on. On May 6, 2026, at 11:41 AM, V9 (Wound Care Nurse) said R113's pressure injuries to her bilateral heels were first identified on April 7, 2026, as deep tissue injuries that measured left heel 6.5 cm X 5 cm and right heel 5.5 cm X 4 cm. V9 said interventions that are in place for R113 include adding extra protein to her diet, turning and repositioning, offloading her heels, and an air mattress. V9 said that R113 should have a dressing in place to her heels at all times. V9 said that R113 used to propel herself in the wheelchair. V9 said that if R113 does not have dressings in place to her heels, then she should not have shoes on. If the shoes are what caused the pressure injury itself, then she should not have shoes on at all. V9 said that R113 should not have shoes on if she is in a high back wheeled recliner because she cannot self-propel herself in that type of chair. 2. On 5/4/26 at 9:25 AM, R75 was sitting up in her wheelchair. R75 had gripper socks on and dressings were visible above the sock around R75's ankles. R75's heels were resting directly against the platform on the footrests of the wheelchair. R75's bed had a low air loss mattress on which was set to 250 pounds. At 9:35 AM, V21 (CNA) came into the room and took R75's gripper socks off. R75's heels wrapped in gauze dressing with part of heel on bottom exposed. R75's gauze dressing on the left heel had some dried brownish blood On 5/4/26 at 12:17 PM, V9 (Wound Care Nurse) performed dressing changes for R75. V9 removed R75's left heel gauze dressing (which had dried brownish blood on it) and revealed a tan foam dressing stuck to the wound. V9 had to loosen the foam dressing with wound cleanser to remove it. V9 then cleansed the wound and applied a blue foam dressing and then wrapped the heel in gauze dressing. V9 repeated the same procedure to R75's right heel. V9 then lifted R75's pant leg to change the dressing to R75's pressure injury on her left knee. R75 had a band aid on her left knee with red skin surrounding the band aid. V9 removed the band aid, cleansed the wound, applied Medi honey to the wound and then covered the knee wound with an adherent foam dressing (covered the entire wound plus the surrounding reddened area). R75 said the foam dressing got ripped off over the weekend and they just put the band aid on. On 5/5/26 at 9:08 AM, R75 was in her wheelchair with her heels flat against the footrest platform. R75's low air loss mattress was set at 300 pounds. R75 said last night when they put her to bed the mattress was not plugged in and she felt like a hot dog in a bun because the mattress was folded up around her and she was resting on the bed frame. R75 said her tailbone was sore from sitting on the hard bed underneath. On 5/6/26 at 9:25 AM, V9 said low air loss beds should be plugged in and on to be working correctly. The staff should check the power cord and that the cords underneath have not got disconnected to make sure the bed is on. V9 said if the air mattress is not on it could cause a pressure injury from resting directly on bed frame. V9 said R75 should have blue foam dressing on her heels which is antimicrobial and a foam dressing on her knee not a band aid per the doctors' orders. R75's heels should be aligned on wheelchair platform cushion, so they are not directly resting flat against it to prevent direct pressure on the heels. R75's Physician orders for May 2026 shows Offload heels dated 3/30/26, Left heel and right heel-pressure-stage 3- cleanse with wound cleanser, pat dry the apply blue foam, secure with gauze wrap, Left knee-pressure-stage 3- cleanse with wound cleanser, pat dry then paint with Medi honey, cover with bordered foam dressing. R75's Weights and Vitals Exceptions dated 5/5/26 shows R75 most recent weight on 5/5/26 was 152.7 pounds. 3. On 5/4/26 at 10:17 AM, R9 was in bed watching TV. R9 was wearing socks only and her heels were resting directly on the air mattress. R9's green padded heel protection boots were in her wheelchair, and a pair of purple waffle heel protectors were on top of R9's closet. R9 said they don't put the boots on all the time. On 5/4/26 at 12:05 PM, R9 was still in bed with her heels on the air mattress without heel protector boots. On 5/5/26 at 8:53 AM, R9 was sitting up in bed eating breakfast. R9's mattress appeared lumpy and deflated. R9's heels (without heel protector boots) were in a deflated section of the mattress resting on the bed frame. R9 said it felt like she was sitting in a hard spot on the bed. R9's air mattress controller was not on. At 8:57 AM, V20 (CNA) came into the room and turned on the power button on the air controller and the bed began visibly inflating. V20 said the mattress was not turned on, but it should be. R9's Physician Orders (POS) dated 3/30/26 shows an order check air mattress if functioning properly every shift and as needed. R9's Wound Note dated 4/30/26 shows The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. The patient continues on an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus. R9's Care Plan dated 4/15/25 shows off loading of bilateral heels when in bed every shift and as needed. On 5/6/26 at 9:25 AM, V9 said air mattresses should be plugged in and on to be working correctly. V9 said if the air mattress is not on, it could cause a pressure injury from resting directly on bed frame. V9 said R9 is at high risk for pressure injuries due to immobility. R9 should have her heels offloaded with heel boots when in bed. 4. On 5/4/26 at 9:47 AM, R26 was sitting up in bed eating breakfast. R26's air mattress was set at 320 pounds. R26 said she was in pain due to her scoliosis, and the bed is very hard, it hurts her back. On 5/5/26 at 9:01 AM, R26 was sitting up in her bed eating breakfast. R26's air mattress was still set at 320 pounds. R26 said the bed was so hard, it caused her back and hip to hurt. R26's Physician Orders (POS) for May 2026 shows R26 has diagnoses of chronic pain syndrome, scoliosis, unspecified osteoarthritis, other idiopathic scoliosis, presence of right artificial hip joint, and disorder of bone density and structure. This same POS dated 3/30/26 shows orders low air loss mattress and check air mattress if functioning properly as needed. R26's Weights and Vitals Exceptions dated 5/5/2026 shows 5/4/26 weight: 89.8 pounds. R26's Care Plan dated 4/22/26 shows R26 had potential for pressure ulcer development related to Skin Braden Score of 13 (high risk). The facility's Skin Care Regimen and Treatment Formulary Policy dated 7/3/25 shows It is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatment for resident with skin breakdown. Treatment Protocol for Deep Tissue Injury: Foam dressing, Relieve pressure. 5. On 5/4/26 at 9:47 AM, R31 was in bed lying on an air mattress. R31 said his bed was uncomfortable and hard. The air mattress pump weight setting was set at 350 pounds. R31's Weight and Vitals report for 4/29/26 showed R31's weight was 248.6 pounds. R31's Wound Note dated 4/28/26 showed R31 was on an air mattress and to ensure the settings are maintained at an appropriate level based on the resident's body habitus. On 5/6/26 at 9:12 AM, V9 (Wound Care Nurse) said air mattress pumps should be set to the resident's weight. If the air mattress is set above the resident's weight the air mattress would provide too much air pressure causing the mattress to be firmer.

Based on observation, interview, and record review, the facility failed to ensure a resident's skin was cleansed after an incontinent episode for one of four residents (R74) reviewed for incontinence in the sample of 30. The findings include:R74's admission Record shows she was admitted to the facility on [DATE] with diagnoses including insomnia, chronic kidney disease, Alzheimer's disease, dementia, and mood disorder. R74's Care Plan initiated on June 6, 2023 shows, Keep skin clean and dry. R74's Minimum Data Set (MDS) dated [DATE] shows she is not cognitively intact. R74 has not exhibited behavior of rejecting care. R74 requires substantial/maximal assistance with toileting hygiene and personal hygiene. R74 is frequently incontinent of urine and always incontinent of bowel.On May 4, 2026 at 11:06 AM, R74 was walking the halls throughout the memory care unit. R74's pants were wet past her knees towards the inside of her legs. V15 Certified Nursing Assistant (CNA) and V13 CNA brought R74 to her room to change her pants. V15 removed R74's soiled brief and soiled pants. V15 wiped R74's buttocks area, but did not wipe from the front of R74 nor did she cleanse R74's legs from the soiled pants. V15 then placed new pants, new brief, and R74's shoes on. On May 6, 2026 at 9:34 AM, V13 CNA said the front and back areas on residents should be cleaned when they are incontinent. At 9:45 AM, V2 Director of Nursing said residents front and back areas should be cleaned. V2 said residents' legs should be cleaned if they get soiled. This is all done to make sure the residents are fully clean and to prevent infection. The facility's Incontinence and Perineal Care policy revised June 30, 2025, shows, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Maintain clean technique.

Based on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times and ordered routes). There were 30 opportunities with 6 errors resulting in a 20 % error rate. This applies to 3 of 4 residents (R102, R107, R162) observed in the medication pass.The findings include: 1.On 5/4/26 at 10:45 AM, V22 (Registered Nurse) was observed during morning medication pass. V22 prepared R107's medications including acetaminophen 325 mg (milligrams) two tablets, Colace 100 mg one tablet, spironolactone 25 mg one tablet, apixaban 2.5 mg one tablet and carbidopa-levodopa 25-100 mg one tablet. Six pills were in the medication cup. V22 entered R107's room and gave her the medication cup. R107 stated, I'm missing one, there's only six pills. I usually have 7 pills in the morning. V22 replied, No you have all your medications. V22 went back to her medication cart and did not check R107's EMAR (electronic medication administration record) to verify if R107's medications and signed off the medications. R107's Medication Administration Record (MAR) dated May 2026 shows orders for morning medication pass include: Colace 100 mg, spironolactone 25 mg, apixaban 2.5 mg, acetaminophen 325 mg two tablets, carbidopa-levodopa 25-100 mg and furosemide 20 mg. (A total of 7 pills, V22 did not administer R107's furosemide and signed off the EMAR it was administered). 2. On 5/4/26 at 10:52 AM, V22 prepared R107's morning medications including multivitamin tablet, bumetanide 2 mg give two tablets twice a day, doxycycline hyclate 100 mg one capsule three times a day and did not administer Ipratropium-albuterol inhalation solution. At 11:01 AM, V22 said she was not going to administer R107's nebulizer treatment because he is lying flat and he needs to be sitting up. She said she would come back to administer his nebulizer after the staff transfer him. V22 said morning med pass if from 7:30 AM to 9:30 AM, she is late passing medications because she has a lot of patients. There are two nurses for this unit, one on each side. V22 said she has 9 more residents to give morning medications too. On 5/4/2026 at 1:43 PM, R107 was sitting in his wheelchair in his room. He said he did not get his nebulizer treatment yet. On 5/5/26 at 8:50 AM, R107 was in his room lying in bed. He said he received his nebulizer treatment only twice yesterday. R107's MAR dated May 2026 shows orders including multivitamin one tablet give in the evening daily, doxycycline 100 mg give one tablet twice a day scheduled at 9:00 AM, Bumex 2 mg give two tablets twice a day AM pass, and Ipratropium-Albuterol Inhalation solution 0.5-2.5, one application inhale orally three times a for15 minutes at 9:00 AM. (R107's MAR shows V22 signed of the albuterol was administered, however R107 did not receive the medication). The facility's Medication Pass revised 7/25 states, It is the policy of the facility to adhere to all Federal and State Regulations with medication pass procedures. 3. R162's Order Summary Report dated May 5, 2026, shows R162 was admitted to the facility on [DATE], with diagnoses including vitamin B12 deficiency anemia. An order was entered on April 27, 2026, for cyanocobalamin (vitamin B12) injection solution 1000mcg (micrograms)/ml (milliliter) inject one ml intramuscularly every day shift every Monday for supplement. On May 4, 2026, at 9:56 AM, V12 (Registered Nurse) administered vitamin B12 oral tablet to R162 instead of the ordered injection. On May 6, 2026, at 10:30 AM, V2 (Director of Nurses) said R162's doctor is aware that the nurse administered an oral tablet of vitamin B12. V2 said the nurse got nervous and missed the verification of the medication.

Based on observation, interview and record review the facility failed to provide incontinence care to residents that require staff assistance with toileting. This applies to 2 of 30 residents (R17 and R14) reviewed for activities of daily living in the sample of 30. The findings include: 1. R17's face sheet shows she had diagnoses of type 2 diabetes, hypertension, COPD, asthma, osteoporosis and chronic kidney disease. On 5/4/26 at 11:08 AM, V22 (Registered Nurse) said R17 has redness to her buttock from being saturated. On 5/4/26 at 1:00 PM, R17 was lying in her bed. She said she is soiled and needs to be changed. She was last changed by the overnight staff. She said she has a sore on her bottom and V9 (Wound Nurse) has been putting cream on her bottom. On 5/4/26 at 1:20 PM, V9 (Wound Nurse) said R17 has a history of pressure injury to her bottom. R17 has redness to her bottom, she gets medicated cream to her bottom. R17 is incontinent of bowel and bladder and should be changed frequently. V9 entered R17's room, he asked R17 do you need to be changed? V9 stated, It's all wet here we are going to need to change all of this. V26 (Wound Care CNA) entered the room to assist. V9 and V26 removed R17's soiled incontinent brief, urine soaked through the pad and the sheet, a strong smell of urine was present. R17's buttocks had redness to her inner cheeks. R17's current care plan shows she is alert and oriented, incontinent of bowel and bladder. Interventions include remind, offer and assist with toileting, staff to provide prompt peri care every shift and as needed. The facility's Incontinence and Perineal Care Policy revised 6/2025 states, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident to prevent infection and skin irritation and to observe the resident's skin condition. Do round at least every two hours to check for incontinence during shift. 2. R14's Face Sheet shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia, major depressive disorder, and scoliosis. R14's Minimum Data Set (MDS) dated [DATE], shows R14 is not cognitively intact, does not reject cares, is dependent on staff for toileting hygiene and personal hygiene, and is always incontinent of bowel and bladder. R14's Care Plan initiated July 20, 2021, shows, Keep skin clean and dry. On May 5, 2026, R14 was observed in the dining room at the same spot, at various times from 9:22 AM-1:20 PM. V17 Certified Nursing Assistant (CNA) brought R14 to her room at 1:24 PM. V17 said R14 was already up in her chair when she got to the facility for her shift at 7:00 AM. V17 said that R14 has not gotten out of her chair since then. V17 and V15 CNA transferred R14 out of her high back wheeled recliner into her bed using at mechanical lift. There was a urine odor and R14's incontinence brief was wet with urine and soiled with stool. V15 said that incontinence care should be done at least every two hours. On May 6, 2026, at 9:45 AM, V2 Director of Nursing (DON) said incontinence care should be provided as often as the residents need it, but at least every two hours. The facility's Incontinence and Perineal Care policy revised June 30, 2025, shows, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Do rounds at least every two hours to check for incontinence during shift.

Based on observation, interview and record review the facility failed to ensure a resident and their personal property were respected. This applies to 1 of 30 residents (R76) reviewed for resident rights in the sample of 30. The findings include: R76's face sheet shows she has diagnoses including type 2 diabetes, chronic kidney disease, hypertension, atrial fibrillation, CHF, and acquired absence of right leg below the knee. On 5/5/26 at 9:02 AM, loud yelling was heard in the hallway coming from R76's room. Get out, Get out repeatedly. V23 (Licensed Practical Nurse) was outside of R76's room. He said the housekeeper and V25 (Regional Relations Director) are in her room trying to throw items away from R76's fridge. Food items can only be in the fridge for 72 hours and should be discarded. V25 remained in the room during the escalation. V3 (Guest Relations) entered R76's room. R76 was heard from the hallway agitated. V25 came out of R76's room upset and asked to speak to V23. V23 said V25 reported R76 was physically aggressive with her and needed to be sent out for psych evaluation. On 5/5/26 at 10:18 AM, V3 (Guest Services) said we have to ensure the food items in the fridge are not expired. During morning rounds V25 was in R76's room explaining expired food items need to be thrown away. R76 had a plate of onions and tomatoes wrapped without a date with drippings that needed to be thrown out. V23 was trying to show R76 there were drippings on the tomato and onions, and it needed to be thrown away. R76 was very upset and yelling at staff to get out of her room. When he entered R76's room he saw R76 strike V25 in the back like a shove, enough to cause V25 to stumble. When a resident is upset, normally we try to de-escalate and re-approach the resident. The situation escalated after the staff did not leave the room and continued to remove items from her fridge. At the end of the day, this is the resident's home. He said the situation could have been handled in a different way. We removed R76's fridge to clean it and will be returning the fridge to her tomorrow. R76 has a history of getting irate and has behaviors. Staff should de-escalate and re-approach the resident if they are having behaviors. On 5/5/26 at 12:10 PM, R76 was in her room sitting in her wheelchair. She said the staff don't care what they do to you. R76 said she was sleeping in her bed when V25 came in her room and woke her up. I was sleeping she (V25) flips on the light and says I'm doing an inspection and opened my fridge. R76 said V25 said she has to check for dates and expired food in my fridge. I asked her not to go in there and she did it anyway. R76 said I've had the fridge in my room for over two years and they never have inspected my fridge before. R76 said V25 opened my fridge door without asking, she told me this is what I'm doing. R76 said I got myself in my wheelchair went over to her fridge and told V25 I could clean the fridge myself. We were arguing back and forth, I told her to get out and she would not leave my room. R76 said she pushed V25 on her lower back to get her away from my personal property. V25 told me she was going to tell my nurse and get me hospitalized . R76 said if they want us to respect them, they should respect us. V25 was making a huge deal and exaggerating about the items in my fridge. R76 said there was condensation coming from the top of my fridge. R76 said I had some lunch meat, cream cheese, shredded cheese, pudding, pickles and water bottles. R76 said the lunch meat was bad and I threw it out. V25 was not listening, it was bad enough I was woken up, whatever V25 wanted, I could have done myself. You're invading my things; it was terrible and very unprofessional. V3 removed my fridge so they could clean it and they would return it tomorrow. On 5/5/26 at 1:20 PM, V23 (LPN) said R76 is doing better than this morning. R76 prefers certain staff, who she likes. R76 has verbal behaviors, but usually not physical. When she has behaviors, we walk away and re-approach her when she is calm. V23 said after V25 left the room he went in the room with V3 to remove the fridge for cleaning. We talked to her in a calm manner, and she was fine. R76 was cooperative with him and V3. On 5/6/26 at 8:48 AM, V25 (Regional Relations Director) said on 5/5/26, she was doing rounds, she knocked on R76's door and explained she would be checking the fridge for spoiled food. V25 said she opened R76's fridge and told her looks like you have a spoiled food. V25 said there was a plate with spoiled tomato and onions with liquid over the wrapping. R76 became verbally aggressive towards me, she left the room and brought housekeeping staff to clean R76's fridge. V25 said she returned back to R76's room and continued removing the spoiled items from her fridge when R76 came in her wheelchair and punched me in the back enough to startle me. V25 said she was trying to talk to R76, but she was mainly yelling at me to GET OUT, GET OUT. My primary focus was the safety of the food. I know if she ate the food she would become ill. I could have left R76's room sooner. I did not want her to eat any of those items. R76 has a temper, has behavior and hoards food. I wanted to make sure she was safe, and that's why she remained in the room for the safety of the resident. On 5/6/26 at 12:50 PM, V28 (Ombudsman) said she received a call from R76 yesterday. R76 was upset about how the situation was handled. R76 reported to her V25 came into her room, turned on the lights and stated she was doing an inspection, then went through her things without her consent. R76's current care plan shows R76 has behaviors of anger and depression interventions include educating staff on manipulative behaviors, staff involved in her care should discuss the behavior, refer to consulting psychiatrist or clinical social worker. R76's EHR (electronic health records) shows there was no documentation regarding the incident on 5/5/26. The Residents admission Packet, section Resident Rights and Obligations revised 2025 states. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident, the facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.The resident has the right to treated with respect and dignity.the right to retain and use personal possessions, including furnishings.

Based on observation, interview, and record review, the facility failed to ensure staff changed gloves and performed hand hygiene to prevent cross contamination, and failed to ensure staff wore the required personal protective equipment for enhanced barrier precautions for three of 30 residents (R74, R17, and R64) reviewed for infection control in the sample of 30. The findings include: 1.R74's admission Record shows she was admitted to the facility on [DATE], with diagnoses including insomnia, chronic kidney disease, Alzheimer's disease, dementia, and mood disorder. R74's Minimum Data Set (MDS) dated [DATE], shows she is not cognitively intact. R74 has not exhibited behavior of rejecting care. R74 requires substantial/maximal assistance with toileting hygiene and personal hygiene. R74 is frequently incontinent of urine and always incontinent of bowel. On May 4, 2026, at 11:06 AM, R74 was walking the halls throughout the memory care unit. R74's pants were wet past her knees towards the inside of her legs. V15 (Certified Nursing Assistant-CNA) and V13 (CNA) brought R74 to her room to change her pants. V15 removed R74's soiled brief and soiled pants. V15 the wiped R74's buttocks area but did not wipe from the front of R74 nor did she cleanse R74's legs from the soiled pants. V15 then placed new pants, new brief, and R74's shoes on. V15 did not change her gloves nor did she perform hand hygiene. On May 6, 2026, at 9:34 AM, V13 (CNA) said gloves should be changed when going from dirty items to clean. At 9:45 AM, V2 (Director of Nursing) said residents front and back areas should be cleaned. V2 said gloves should be changed and hand hygiene should be performed every time staff touch contaminated items to prevent spread of organisms, The facility's Incontinence and Perineal Care policy revised June 30, 2025, shows, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Maintain clean technique. Wash the perineal area and gently dry after the procedure. Remove gloves and dispose. Wash hands. Put on a new set of clean gloves to put on clean briefs/incontinent pads, to make resident comfortable, groom, and change clothing. 2. On 5/4/26 at 1:20 PM, V9 (Wound Nurse) provided peri-care to R17 and with the same contaminated gloves applied barrier cream to her buttocks. V9 continued to touch several surfaces before removing his gloves. On 5/5/26 at 1:11 PM, V20 (CNA) said gloves should be changed after providing incontinence and new gloves should be used when applying barrier cream. The facility's Hand Hygiene Policy revised 6/25 states, Hand hygiene is important in controlling infections. Hand Hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC Guidelines in regards to hand hygiene .before and after assisting a resident with toileting. before moving from work on soiled body site to a clean body site on the same resident . 3. R64's Face Sheet printed on 3/6/26 showed R64 was admitted to the facility with diagnoses hemiplegia, hemiparesis following cerebral infarction, dysphagia and has a feeding tube. R64's Care Plan printed on 5/6/26 showed R64 requires enhanced barrier precaution related to having a feeding tube. On 5/4/26 at 1:00 PM, an Enhanced Barrier Precaution (EBP) sign on R64's door documents staff must wear gloves and gown for high-contact resident care activities that include device care or use of feeding tube. At this time, V12 (Registered Nurse Supervisor) entered the room and donned only gloves then administered enteral feeding. On 5/4/26 at 1:14 PM, V12 stated confirmation that R64 was on EBP and V12 should have worn standard precautions, gown and gloves, when administering R64's enteral feeding. V12 stated V12 was nervous and did not put on a gown, which is required. On 5/6/26 at 9:55AM, V2 (Director of Nursing) stated that EBP are initiated for residents who meet the criteria, that includes residents with feeding tubes. V2 stated that the facility's process is that EBP signage is posted on or near the resident's room door to alert staff of precautions. V2 stated that the PPE (personal protective equipment) for EBP is gown and gloves and must be used during tube feeding administration. V2 stated the purpose of EBP is to prevent infection. The facility's Enhanced Barrier Precaution (reviewed/revised 9/16/25) policy documents that enhanced barrier precautions is an infection control intervention designed to reduce transmission of organisms that employs targeted gown and gloves use during high contact resident care activities that includes device care use of feeding tubes.

Based on observation, interview, and record review, the facility failed to implement person-centered dietary interventions to support independent eating, maintain dignity, and promote adequate nutritional intake for one resident (R112) with a diagnosis of dementia and a preference to eat meals using their hands in the sample of 30.The findings include:R112's Face Sheet printed on 3/6/26 showed R112 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and moderate protein calorie malnutrition.R112's Care Plan printed on 5/6/26 showed R112 has an alteration in neurological status related to dementia with an intervention to accommodate eating issues in order to maximize independence and nutritional intake as well as an alteration in nutritional status related to dementia with an intervention to consider finger foods.On 5/4/26 at 12:45 PM, during the lunch meal, R112's meal was lemonade, broth soup, turkey stuffing casserole, green beans, and spaghetti noodles. R112 was observed attempting to consume non-finger foods with his hands, resulting in food being spread on the resident's hands, clothing, table surface and floor. No finger foods or clothing protector was offered nor was R112 encouraged or cued to use utensils.On 5/5/26 at 8:59 AM, during the breakfast meal, R112's meal was scrambled eggs, a slice of toast, fortified cream of wheat, orange juice, and a nutrition juice. R112 was observed eating with his fingers. R112 did not attempt to use utensils, resulting in food being on R112's hands, clothing, on the floor and in R112's drinks. V19 (Registered Nurse) and V27 (Certified Nursing Assistant-CNA) interacted with R112 during the meal but did not offer a clothing protector or finger foods, nor encourage the use of utensils.On 5/5/26 at 12:36 PM, during the lunch meal, R112's meal was coffee, milk, juice, baked ziti in meat sauce, and steamed broccoli. R112 was observed attempting to consume non-finger foods with his hands, resulting in food being on the resident's hands (which became reddish orange in color), on the resident's clothing, the table surface and on the floor. No finger foods or clothing protector were offered. V14 (Memory Care Manager) asked R112 if he wanted to use his hands over a fork and R112 stated yes. V14 did not encourage the use of utensils nor offered R112 finger foods. When a CNA attempted to feed R112 baked ziti with a fork, R112 took a bite, but when the CNA attempted again, R112 said no. R112 finished the meal by using his fingers.On 5/5/26 at 1:02 PM, V14 (Memory Care Manager) stated that R112 feeds himself, prefers to eat with his fingers and typically refuses a clothing protector. V14 stated that she was not aware that R112's care plan has an intervention of finger foods. V14 stated that she will speak with the dietician to assess R12's dietary needs.On 5/6/26 at 9:55 AM, V2 (Director of Nursing) stated that the facility honors a resident's preference to feed themself independently, with encouragement and prompting, in attempt to not take away their remaining ability. V2 stated that finger foods (e.g., snack foods, chicken nuggets) can be an intervention for those that self-feed. V2 stated that a clothing protector is offered to provide more dignity than if clothes were dirty, however the resident has a right to refuse.The facility's Residents' Rights for People in Long-term Care Facilities' pamphlet (undated) showed that residents have the right to participate in their own care and the facility must make reasonable arrangements to meet the residents' needs and choices.The facility's Privacy and Dignity Policy revised July 3, 2025, shows, It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times.

Based on observation, interview, and record review the facility failed to ensure residents consumed their medications when medications were administered for 2 of 6 residents (R164 and R33) reviewed for pharmacy services in the sample of 30.The findings include:1. On 05/04/2026 at 10:47 AM, R164 was in her room in bed. A clear plastic medication cup was sitting on the table in R164's room. There were four pills in the cup. No staff were present in R164's room. R164 said she was not sure if the pills were hers.On 05/04/2026 at 10:49 AM, V7 (Registered Nurse- RN) said R164 did not self-administer medications.R164's Care Plan (undated) did not indicate R164 could self-administer medications. 2. On 05/04/2026 at 10:25 AM, R33 was in her room. On the bedside table was a clear plastic medication cup that contained two white ovel pills. No staff were present in R33's room. R33 stated she would take the pills later. On 05/04/2026 at 10:44 AM, V6 (RN) said R33 did not self-administer medications.R33's Care Plan (undated) did not indicate R33 could self-administer medications.On 05/05/2026 at 12:23 PM, V8 (RN) said nurses should not leave medications unattended when administering medications. V8 added that when nurses administer medications they should stay with the resident to make sure they consume the medication.

Based on observation, interview, and record review the facility failed to ensure a resident was treated in a dignified manner for 1 of 5 residents (R1) reviewed for dignity in the sample of 5. The findings include: On 8/26/25 at 9:54 AM, R1 was in bed in her room. R1 moved slowly as she sat up in bed. R1 said the first night she was here, she had to go to the bathroom and couldn't find her call light. R1 said she uses the bedpan since she has a broken pelvis and is working with therapy on getting up to the bathroom. R1 said no one was coming to check on her and she ended up going in her brief. R1 said she was sitting in urine and yelling for someone to come help her. R1 said she was so frustrated and humiliated, and she called 911 to get help. R1 said while she was on the phone with 911, the nurse came in and asked if she called 911 and what she needed. R1 said she needed to be changed and then staff came to help her. R1 said at first, she was frustrated and humiliated but then it became scary that no one was there to help her. R1 said she felt helpless and that is why she called 911. On 8/26/25 at 11:49 AM, V5 Licensed Practical Nurse said he received a call from the police that the resident in room [ROOM NUMBER] needed help and couldn't find her call light. V5 said he went to R1's room and asked her if she called 911 and what she needed. V5 said R1 told him she couldn't find her call light and she had needed to use the bedpan and be changed. V5 said he told R1 he would send the Certified Nursing Assistant (CNA) to help her and then left the room to go back to the police who were holding on the phone.On 8/26/25 at 12:14 PM, V7 CNA said he was told by V5 that R1 had called the police and needed to be changed. V7 said when he went into R1's room, her call light was tied to the bed rail, but R1 said she didn't see it there. V7 said R1 was very frustrated about not being able to use the bedpan and being wet. V7 said R1's brief was wet with urine. V7 said R1 is alert and oriented. On 8/26/25 at 11:07 AM, V4 Registered Nurse said she took care of R1 on day after her admission. V4 said she got in report from the nurse that R1 had called the police because she couldn't find the call light, but the call light was beside her. V4 said R1 reported to her that she was waiting for over an hour for someone to come around, no one was coming and she needed help, couldn't find the call light so she called 911. V4 said R1 is a former nurse, is alert and oriented, and knows when she needs to use the bed pan. V4 said R1 was very frustrated and should not have to feel like that.R1's Progress Note dated 8/20/25 shows admitted a [AGE] year old female from hospital via stretcher accompanied by paramedics. Primary diagnosis is closed fracture of left inferior pubic ramus non-surgical. Resident is alert and oriented times three.The facility's Privacy and Dignity Policy dated 7/3/25 shows It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times.

Based on observation, interview, and record review, the facility failed to ensure the front entrance to the facility was safely supervised and/or secured to prevent 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6 from exiting the facility unbeknown to the staff. This failure resulted in R1 leaving the facility in the early morning hours and crossing four lanes of a major east-west arterial road where the speed limit is 50 miles per hour (MPH) wearing only a hospital gown, a brief, and shoes. R1 became hypothermic and was admitted to the hospital with an acute subdural hematoma, hypothermia due to cold environment, and unwitnessed fall. The Immediate Jeopardy began on [DATE] when staff could not find a resident in the facility. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 4:20 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. The findings include: On [DATE] during travel to the facility, the noted speed limit of the four-lane highway directly in front of the facility was 50 miles per hour. R1's Admission Record dated [DATE] shows R1 was admitted to the facility on [DATE]. R1's diagnoses include, but are not limited to, traumatic subdural hemorrhage, metabolic encephalopathy, myocardial infarction (heart attack), nontraumatic intracerebral hemorrhage, abnormalities of gait and mobility, lack of coordination, weakness, contusion and laceration of the right cerebrum, need for assistance with personal care, malignant neoplasm of the large intestine and history of falling. R1's Minimum Data Set, dated dated dated [DATE] shows R1's cognition is severely impaired and R1 has no broken or loosely fitting full or partial denture or obvious or likely cavity or broken natural teeth. R1's care plan initiated on [DATE] shows R1 is at risk for altered thought processes and will be free from any injury related to accidents. R1's care plan initiated on [DATE] shows R1 is at high risk for falling and interventions include staff providing a safe environment. This same care plan also shows R1 has an alteration in neurological status and is at risk for altered thought process. On [DATE] at 11:15 AM, V11, CNA, said she saw R1 last around 3:30 AM on [DATE] where he was in bed, asleep, and dry. V11 said R1 was wearing a hospital gown and a diaper. V11 said she noticed R1 was not in his room at about 4:15 AM. V11 said she immediately asked the nurse if he had gotten R1 out of bed and the nurse answered, No, R1 should be in his bed. V11 said they both started looking for R1. V11 said she did not think R1 had gotten outside because she would have heard the alarms if he had gone through the doors going outside, and she had not heard any alarms. V11 said they continued to look for R1 for another 20 to 30 minutes and then someone called the Administrator, V1. V11 said at that point about an hour had gone by and they were told to keep searching for R1. V11 said they still could not find R1. V11 said she ended up checking the door alarms to see if the door alarm would go off, and it did not go off; the alarm was not triggered, and they realized the alarm was not turned on or it was not working. V11 said they were even more terrified now and they searched outside by the pond and all around the facility. V11 said it was very cold outside and R1 was wearing only a hospital gown and a diaper when she put him to bed. V11 said the police were eventually called and they found R1 across the four-lane highway where she believes the speed limit is 45 MPH. On [DATE] at 2:21 PM, V5, Registered Nurse (RN), said he was R1's nurse on [DATE] going into [DATE] during the night shift. V5 said he noticed V11 was looking for R1 and asked if he knew where R1 was. V5 said they both started looking for R1. V5 said R1's bed alarm did not sound and the door alarms for the building did not go off. V5 said it was cold outside that night and he had to get his coat when he went outside to look for R1. V5 said the police eventually found R1 across the four-lane highway outside of a fast-food restaurant. On [DATE] at 10:00 AM, V1 said she was informed on [DATE] by phone at about 5:13, AM that staff could not find R1. V1 said she was driving to the facility and on the way, she received a call from the police that R1 had been located across the four-lane highway from the facility. V1 said when she later reviewed the video, she could see R1 walking out the front door of the facility and turning left wearing a gown, a diaper, and shoes. V1 said the video has no sound, so she cannot say if the door was alarmed or not. V1 said the police called an ambulance for R1 and he was taken to the hospital. V1 acknowledged that a human body temperature of 93.2 degrees Fahrenheit (F) is considered hypothermia. V1 said R1 had a tooth knocked out and an abrasion. On [DATE] at 3:00 PM, V1 said the video she reviewed from [DATE] showed R1 exiting the facility through the front door between 4:05 AM and 4:10 AM. On [DATE] at 1:24 PM, V13, Medical Director said he would be very concerned about a person's body temperature of 93.2 degrees F. V13 said hypothermia can cause a heart attack, a stroke, or respiratory arrest, then eventually death. V13 said it was cold outside when R1 eloped, and he could have died . On [DATE] at 1:52 PM, V2, Director of Nursing (DON), said R1 had a head injury from his fall when he eloped. V2 said the doors are all alarmed from 8:00 PM until 8:00 AM and a code is needed to enter or leave during those hours. On [DATE] at 11:25 AM V14, Nurse Practitioner (NP), said hypothermia is a body temperature being lower than normal. V14 said a normal human body temperature is 98.6 degrees F. V14 said the dangers of hypothermia include death. The police report dated [DATE] shows police were dispatched on [DATE] at 5:41 AM to the facility for a missing adult. Police officers who were originally at the facility left and went to where R1 had been found across the highway from the facility by other police officers. The report describes R1 as wearing a hospital gown, being confused, and having small cuts on his arms and legs with a bloody mouth. R1's Emergency Department (ED) notes dated [DATE] show R1 presented via ambulance for an unwitnessed fall outside of his living facility. R1 had a missing tooth with dried blood and abrasions to his upper and lower extremities consistent with a fall. R1's rectal temperature was 93.2 degrees F. R1's ED diagnoses are acute subdural hematoma, hypothermia due to cold environment and unwitnessed fall. R1 was admitted to the hospital from the ED on [DATE] at 9:52 AM. The facility's Elopement Policy (reviewed [DATE]) shows it is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility The Immediate Jeopardy that began on [DATE] was removed and the deficient practice was corrected on [DATE] when the facility conducted a full house audit of all residents to identify those who are an elopement risk on [DATE], conducted in-services with all staff on the elopement policy which was completed by [DATE], evaluated and inspected the front door alarm system and found it to be in good working condition on [DATE]. A lock box was installed on [DATE] over the kill switch which is located in the ceiling. Only supervisory/authorized staff have access. A new code panel was installed on the internal set of glass doors requiring a code to exit the facility on [DATE]. All other exit doors were checked and found to be fully engaged and functioning on [DATE]. All bed/chair/personal alarms were checked and found to be in good working condition on [DATE]. The doors equipped with the Wander Guard system were checked and properly functioning on [DATE]. A QA audit tool was initiated on [DATE] for maintenance to check the alarmed doors and wander guard equipped doors for proper functioning three times a day for 12 weeks. All staff were in-serviced on the importance of immediately responding to exit door alarms and completed by [DATE]. All staff were in-serviced on ensuring that the front exit door alarm is consistently activated between 8:00 PM and 8:00 AM. This in-service was completed between [DATE] and [DATE]. A QA audit tool was initiated on [DATE] to ensure that the front alarm door is properly functioning. It will be done three times a week for 12 weeks. An emergency QAPI meeting which was attended by the Medical Director via phone was held around 2:00 PM or 3:00 PM on [DATE]. The Medical Director was in agreeance with the plan of correction developed by the committee. All trends identified will be discussed in the monthly QAPI meeting until resolution. These corrections were implemented and/or completed prior to the start of the current survey.

Based on observation, interview, and record review the facility failed to ensure food was handled in a manner to prevent cross-contamination and failed to ensure a cook performed hand hygiene in a manner to prevent cross contamination. This affects all the residents residing in the facility. The findings include: The facility's CMS Form 671 dated 1/14/25 showed there were 138 residents residing in the facility. On 1/14/25 at 12:35 PM, V6 (Cook) washed his hands, walked with dripping hands to the box of gloves, near the steam table, and applied gloves with wet hands. V6 touched the exterior surfaces of the gloves with his dripping hands numerous times, in an attempt to apply the gloves. V6 went to the walk in-freezer and obtained a large box of frozen vegetable mix, containing several smaller plastic bags of vegetable mix. V6 obtained steel steamer pans from the shelves with the same gloves. V6 opened an individual bag of frozen vegetable mix and placed half of the bag into each steamer pan. V6 used his gloved hands to open the dirty trash can lid (there was food debris noted all over the top of the lid) and dispose of the plastic bag. V6 then obtained another bag of frozen vegetable mix, opened it and dumped the contents into the steamer pans. V6 used his contaminated gloves to spread the frozen vegetables in the steamer pan. V6 then used the same contaminated gloves to open the dirty trash can lid and dispose of the plastic bag. V6 continued this process to place 8 individual bags of frozen vegetables into steamer trays with the same contaminated gloves. V6 loaded the steamer trays of frozen vegetables into a cart with the contaminated gloves, then touched the walk-in freezer handle with the contaminated gloves, entered the freezer and obtained a box of frozen carrots. V6 placed them on his work station and turned to obtain additional clean steamer trays with is contaminated gloves. V6 obtained a stainless steel dish to scoop the diced carrots out of the box and into the steamer tray. V6 used the contaminated gloves to spread out the diced carrots. At 12:40 PM, V5 (Food Service Director) asked to speak with V6 and took him into the walk-in refrigerator. When V6 exited the walk-in, he was removing his contaminated gloves. V6 said the frozen vegetable mixes and frozen carrots were for the dinner meal today. V6 stated, I'm trying to get myself organized. At 12:44 PM, V6 washed his hands in the rear, food preparation sink. The kitchen had a designated handwashing station that was not it use. V6 did not dry his hands and walked to the box of gloves with dripping, wet hands and applied gloves. At 12:54 PM, V6 obtained a thermometer and reached into a large, stock pot of soup, cooking on the stove. V6 did not have gloves on and said he was checking the temperature of the chicken soup. At 1:03 PM, V27 (Cook) and V28 (Dietary Aide) were discussing the need for a mechanical soft hamburger. V6 stated, Speaking of hamburgers, and went to wash his hands. V6 applied gloves with dripping wet hands, obtained a baking sheet and sprayed it with non-stick cooking spray. V6 walked past the garbage can and touched the dirty lid with his gloved, right hand. V6 used the contaminated glove to open the walk in freezer, obtained 6 frozen frozen hamburger patties, and placed them on the baking sheet. V6 exited the freezer and walked to the oven. V6 used his contaminated glove to open the oven and turn the dial on the oven. V6 said he is the main evening cook and he's worked at the facility since September 2024. On 1/14/25 at 1:08 PM, V5, (Food Service Director) said there is a separate hand washing station for a reason. This (rear sink) is considered a food prep sink. V6 said the staff should not be washing their hands in the food prep sink because it increased the risk of cross-contamination and potential food borne illness. During this interview, V6 walked to the food prep sink and started washing his hands. The surveyor alerted V5 to V6 washing his hands in the food prep sink and V5 replied, He knows he's not supposed to do that. That's why he corrected himself and moved to the handwashing sink. The surveyor asked V5 what the proper technique was for hand washing. V5 said the staff use water and soap, lather for 30 seconds, rinse their hands, and dry their hands with a paper towel. V5 said staff should dry their hands to prevent bacteria from remaining on their hands. The surveyor asked V5 if the hands should be dry when applying gloves. V5 replied, Yes, of course. During this interview, V6 left the handwashing station with dripping wet hands and started to apply gloves. V5 told V6, You can't do that. Your hands have to be dry when you apply gloves. V6 replied, The water lubricates hands. it's the only way I can get the gloves on. V5 told V6, Dry hands, dry gloves. V5 said food should never be touched with contaminated gloves. V5 said if the garbage can is touched, then the gloves should have been removed and V6 should have washed his hands and applied clean gloves before touching the food. V5 said that's a cross-contamination issue. The surveyor explained that V6 touched the frozen vegetables multiple times with the same contaminated gloves. V5 replied, That's unacceptable. The [corporate contractor's] Hygiene Standards and Procedures revised 8/13/24 showed, Purpose: The Centers for Disease Control and Preventions (CDC) has reported that poor hygiene is one of the top five risk factors contributing to foodborne illness in food service environments. The CDC identified the main risk factors to be insufficient or improper hand washing and the improper use of disposable gloves. Pathogenic microorganisms, and physical and chemical contaminants (including allergens) can be introduced and cause foodborne illness, injury, or allergic reactions if food, drinks, and food-contact surfaces/equipment come in contact with the following: Hands that are not washed and gloved . Scope: The [corporate contractor] Hygiene Standards and Procedures apply to: All employees engaged in food preparation, production, or service . 4.1.1. Hand & Arm Hygiene: All employees and visitors entering into a food preparation, production, service, and warewashing area must wash their hands with soap and warm water and adhere to the standards stated below. Employees must wash hands when starting work, as well as: .Handwash after . Handling garbage, handling dirty equipment and utensils . Where to Handwash: Wash hands in designated handwash sinks. Do not wash hands in the food preparation sink, warewashing sink, or utility sink . 4.1.4. Disposable Gloves: Disposable gloves must be worn to protect food and food-contact surfaces from cross-contamination. Their intended use is not to protect employees from cross contamination. When to wear disposable gloves: Disposable gloves must be worn by everyone handling exposed foods that are raw or ready-to-eat, or engaged in food production in all production and service areas . How to use: Follow proper handwashing procedures before and after using gloves . The undated Chef (Cook) Job Description showed responsibilities to include: Prepare food in accordance with standard recipes, and special diets and following sanitary regulations as well as with established policies and procedures; Follow established Infection Control and Universal Precautions policy and procedure while performing tasks. The undated [corporate contractor's] Hand Washing, Chemical Use, and PPE Policy showed the proper handwashing process was: Wet hands with warm water; Lather hands with soap, making sure to get in between fingers, under nails and in any folds or crevices. Lather up past the wrist; Massage in lather for 30 seconds; Rinse thoroughly, and dry with paper towels; Use paper towel to turn off valves on sink and to open door to avoid re-contaminating hands.

Based on observation, interview, and record review the facility failed to ensure contact/droplet isolation precautions were maintained (R99, R131), failed to ensure enhanced barrier precautions were posted (R113), and failed to ensure personal protective equipment (PPE) was worn in a manner to prevent cross contamination (R131, R52, R32) for 5 of 5 residents reviewed for infection control in the sample of 27. The findings include: 1. R99's face sheet printed on 1/15/25 showed diagnoses including but not limited to influenza virus with respiratory manifestations, elevated white blood cell count, and dementia. R99's order summary report showed an order start dated 1/11/25 for: Maintain at all times: strict droplet isolation precautions due to an active infection. Single room, resident alone and not cohorted with a roommate. Resident remains in the room at all times. All services are done in the room. Every shift for 7 days. On 1/14/25 at 11:42 AM, R99's room had isolation signage, instructions for donning and doffing PPE, and a PPE supply bin outside of her room. The room was viewed from the doorway and R99 was not present. The isolation sign clearly showed STOP-CONTACT & DROPLET PRECAUTIONS. The sign showed to report to the nurses's station before entering the room. On 1/14/25 at 11:54 AM, V11 (Registered Nurse) was questioned regarding R99's isolation precautions and where abouts. V11 verified R99 was still on contact/droplet isolation. V11 said she was seated in the group dining room. V11 said R99 is allowed out of her room because she has dementia and is a fall risk. V11 said R99 does not understand she needs to stay in her room or wear a mask outside of it. This surveyor observed R99 in the dining room without any mask and was slowly self-propelling around the area. Multiple tables were filled with residents awaiting lunch. At 12:11 PM, R99 was at a four top table with other residents seated with her. At 12:52 PM, R99 and the table mates were eating lunch together. On 1/14/25 at 12:33 PM, V12 (Housekeeper) was in R99's room cleaning and was wearing the required PPE. V12 was able to indicate that PPE was required based on the signage and supplies posted outside resident rooms. On 1/15/25 at 9:42 AM, R99 was in the group dining room again and self-propelling her wheelchair. R99 was seated at a group table for breakfast and ate with the other residents. R99's room was still marked as contact/droplet isolation. On 1/15/25 at 1:14 PM, V3 (Infection Control Preventionist) said R99 was diagnosed with influenza on 1/10/25 and put on contact/droplet isolation. V3 said contact isolation is necessary so other residents are kept away from any areas that R99 touches. V3 said droplet isolation is required to contain any of R99's sneezing or coughing. Other residents can get sick if they breathe in the germ droplets. V3 stated R99 needs to stay in her room and avoid other residents for the seven days as ordered. V3 said R99 should not be eating in the main dining room and meals should be delivered to her room. V3 said R99 does have dementia but can understand the need to stay in her room. V3 said a mask is necessary if there is any reason to leave the room. V3 said she had concerns with R99 eating with other residents. It is a very vulnerable population and the potential to spread influenza is very high. The facility's Influenza Management and Surveillance policy revision dated 8/28/24 states under the containment section: a. Implement Standard and Droplet Precautions for all resident with suspected or confirmed influenza. Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility .Place patients with suspected or confirmed influenza in a private room or area. 2. R113's face sheet printed on 1/16/25 showed diagnoses including but not limited to Parkinson's disease, chronic kidney disease, disorders of the brain, and dysphagia (difficulty swallowing). R113's January 2025 order summary report showed medications, liquid nutrition, and water flushes were being given via G-tube (gastrostomy tube-surgically placed device to supply direct access to the stomach). On 1/14/25 at 11:37 AM, a gastrostomy feeding tube pump and supplies were next to R113's bed. A bagged piston syringe was hanging from the pole and was dated 1/14. There was no isolation signage or PPE bin outside of the room. On 1/15/25 at 9:36 AM, the feeding tube pump and supplies were next to R113's bed. There was still no isolation signage or PPE bin outside the door. On 1/15/25 at 1:14 PM, V3 (Infection Control Preventionist) stated any resident with a feeding tube needs to be on EBP precautions (enhanced barrier precautions). Staff need to wear gloves and gowns while providing any care. A mask is needed right now too due to the influenza in the building. V3 said EBP precautions signs and PPE should be right outside resident doors. There is no way staff know to wear the PPE if the signs are not up to indicate what is needed during cares. V3 said R113 is on the dementia unit and it is possible another resident moved the items. V3 said staff should be checking daily that the signs and bins are still outside EBP rooms. The facility supplied enhanced barrier precaution sign showed staff must wear gloves and a gown for high-contact resident care activities. The sign included the use of a feeding tube. 34491 3. R131's Admission Record, provided by the facility on 1/16/25, showed he had diagnoses including bipolar disorder, seizures, and influenza due to identified novel influenza A virus with other respiratory manifestations. The onset date was 1/10/25. The record also showed R131 had a cough, with an onset date of 1/9/25. R131's Order Summary Report, provided by the facility on 1/16/25, showed an order dated 1/10/25 to Maintain at all times: Strict droplet isolation precautions due to an active infection. Single room, resident alone and not cohorted with a roommate. Resident remains in the room at all times. Services are done in the room every shift for 7 days. R131's facility assessment dated [DATE] showed he had moderate cognitive impairment, required set-up or clean-up assistance for eating, and partial to moderate assistance with showering/bathing. R131's care plan, initiated on 1/10/25, showed R131 required strict droplet/contact precautions related to Influenza A. The care plan showed Observe isolation precautions as clinically indicated. Use appropriate protective equipment. Utilize proper hand washing technique. Discard all infected waste in the appropriate biohazard container placed in the resident's room. On 1/14/25 at 12:38 PM, R131 was sitting in his room, in a wheelchair. Signage on the door to R131's room showed he was on contact/droplet precautions. The sign showed prior to entering the room, staff should clean their hands and don the following PPE (personal protective equipment): gloves, gown, and face protection. The signage showed staff should make sure their eyes, nose, and mouth are fully covered before entering. The signage also showed staff should remove all the PPE before exiting the room and clean their hands. V14 (Agency CNA-Certified Nursing Assistant) entered R131's room carrying R131's lunch tray. The only PPE worn by V14 was a surgical face mask. V14 exited R131's room and walked back down to the dining room to pass lunch trays to other residents. V14 did not perform hand hygiene prior to entering or exiting R131's room, did not wear the PPE listed on the signage, and did not discard the face mask he wore into the room. At 12:42 PM, V14 was walking back up the hall after delivering a meal tray to another resident. This surveyor asked V14 the name of the resident that was on contact/droplet isolation that he delivered the tray to previously as there were two names on the wall outside the room. V14 entered the room again wearing only the face mask, walked up to the resident, bent over and asked the resident his name. V14 exited the room and identified the resident as (R131). V14 did not clean his hands prior to entering or exiting R131's room again, did not wear the PPE listed, and did not discard the mask worn into the room prior to exiting the room. On 1/15/25 at 2:12 PM, V15 (CNA) entered R131's room wearing gloves and a surgical face mask. V15 grabbed towels and items needed for R131's shower, and propelled R131 down the hall to the shower room. R131 had a surgical mask on while he was being transported to the shower room. At 2:20 PM, V15 was in the shower room giving R131 a shower. R131 did not have a face mask on. V15 had a face mask and gloves on. No other PPE was worn by V15. 4. R52's Admission Record, provided by the facility on 1/16/25, showed she had diagnoses including cerebral infarction (stroke), bipolar disorder, and schizophrenia. R52's facility assessment dated [DATE] showed she was cognitively intact and dependent on staff for toileting and personal hygiene. R52's ADL (activities of daily living) care plan, initiated on 4/2/24, showed she requires assistance with bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting. On 1/15/25 at 2:42 PM, V15 and V16 (CNAs) went into R52's room to provide incontinence care. V15 donned two pairs of gloves. V15 cleaned R52's vaginal area, then V15 and V16 rolled R52 onto her right side. V15 cleaned R52's buttocks area, removing barrier cream that was on R52's buttocks, then applied new barrier cream. V15 removed the top pair of gloves, leaving the pair on that was under the top pair. V15 put a brief on R52, placed pillows under R52's legs to offload her heels, and covered R52 up. At 2:50 PM, V16 was asked if she would have done anything different than V15. V16 said she would not have double gloved. V16 said she was going to say something to V15, but she did not want to say it in front of this surveyor and the resident. V16 said V15 should have removed the gloves used for incontinent care, performed hand hygiene and applied new gloves before touching the resident or her blankets and pillows. At 2:52 PM, V16 was asked what PPE should be worn when entering a resident's room when they are on contact/droplet isolation. V16 said staff were told by management that if they were just going to go into a resident's room on contact/droplet to drop a tray off, as long as they did not touch anything or the resident, such as boosting the resident up, then they did not have to wear a gown or goggles/face shield. they could just wear a face mask and gloves. V16 said when giving a resident who is on contact/droplet a shower, staff should wear full PPE including N95 and goggles, gown and gloves. On 1/15/25 at 1:46 PM, V3 (Infection Preventionist-IP/LPN) said if a resident is on contact/ droplet isolation, the resident stays in their room. If staff are providing care, they need to wear PPE. We are dealing with an influenza outbreak. V3 said if staff are passing a meal tray, or just going in to ask the resident a question, if they are not providing any direct care, they need to wear a surgical mask and gloves. V3 said upon exiting the room, staff hands should be sanitized, and the mask should be changed, so they do not spread the infection to others. V3 said R131 is positive for Influenza A. On 1/15/25 at 2:25 PM, V9 (Registered Nurse-RN) said if a resident is on contact/droplet isolation, staff should wear a mask, gown, and gloves, even if going into the room really quick. V9 said all of these should be removed prior to exiting the isolation room and hand hygiene should be performed. On 1/15/25 at 2:58 PM, V3 (Infection Preventionist- IP/LPN) said when staff are giving a resident on contact/droplet isolation a shower, they should wear full PPE- including a gown, gloves, goggles or face shield, and an N95 mask. V3 said the CNA should not have double gloved; she should have removed the gloves after incontinent care, performed hand hygiene, and put new gloves on before touching the resident or her environment to prevent cross-contamination. The facility's policy and procedure titled Hand Hygiene, with a revision date of 7/30/24, showed Hand hygiene is important in controlling infections. Hand hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC (Center of Disease Control) guidelines in regards to hand hygiene .1. Hand hygiene using alcohol-based hand rub is recommended during the following situations .c. Before and after entering isolation precaution settings unless the infectious organism is C. Difficile or Norovirus. d. Before and after assisting a resident with meals .f. Before and after assisting a resident with toileting .h. After contact with blood, body fluids, or surfaces contaminated with blood and body fluids. i. After removing gloves including during wound dressing change. The facility's policy and procedure titled Incontinent and Perineal Care, with a revision date of 7/31/24, showed It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's condition .4. Perform hand hygiene before the procedure. Put on gloves and appropriate personal protective equipment if indicated .6. Wash the perineal area and gently dry after the procedure. 7. discard disposable items into designated containers/plastic bag. 8. Remove gloves and dispose to designated plastic bag. Wash hands. 9. Put on new set of clean gloves to put on clean briefs/incontinent pads, to make resident comfortable, groom and change clothing . The facility's policy and procedure titled infection and Prevention Control, with a revision date of 11/21/24, showed 13. While on transmission-based precaution, the resident may only leave the room to participate in required and necessary procedures, like appointments, dialysis, etc. as long as the infection is contained .Precautions to Prevent Transmission of Infectious Agents and Transmission Based Precaution .2. Contact Precaution-intended to prevent transmission of infectious agents spread by direct contact with patient or the environment. Examples of infectious organisms requiring contact precaution are C. Difficile, Scabies, Norovirus, etc. and are outlined in CDC Appendix A (type and duration of precautions recommended for selected infections and conditions) a. Single room is required .b. Use of gown and gloves is necessary prior to room entry. Face protection may be necessary if performing activity with risk of splashing or spraying .c. Residents are restricted to leave the room except for medically necessary procedures and appointments. The policy showed 3. Droplet Precaution-intended to prevent transmission through close respiratory or mucous membrane contact with respiratory secretions. Examples of infectious organisms requiring Droplet precaution includes Covid-19, Flu, Rubella, Monkey Pox, etc . a. Single room is required .b. Eye protection, and mask should be worn for close contact with the resident. If there are infectious material that can be transmitted through contact, then gloves and gown should also be used. c. Resident is restricted inside the room and may wear mask when transported outside of the room for medically necessary procedures and appointments. 20042 5. On 1/14/25 at 11:06 AM, R32 stated they put medication in his penis this morning because he couldn't pee. R32 stated his catheter was not draining all last night and this morning. R32 stated his groin hurt this morning until the nurse injected something into his catheter and it started draining. R32 stated it feels wet where the urine drains out of his stomach (suprapubic catheter) and he wanted the nurse notified. At 11:15 AM, V17 RN (Registered Nurse) was notified R32 complained that his catheter was leaking. V17 put gloves on, stopped outside R32's room door and shut the isolation container drawer that was under the enhanced barrier precaution sign. V17 did not put a gown on and walked into R32's room. V17 went over to R32 and asked him if he felt wet. R32 replied, yes. V17 pulled back R32 covers and pulled down his incontinence brief in front. R32 did not have a dressing over his suprapubic catheter. Urine was draining out around the catheter tubing and the skin was reddened. R32 complained of some pain. V17 walked around to the catheter drainage bag, lifted the bag up and there wasn't any drainage in the bag. There was sediment in the catheter tubing. V17 removed his gloves and left the resident's room. V17 was stopped outside of R32's room and asked why there was an EBP (enhanced barrier precaution) sign up. V17 stated the sign was due to the resident having a catheter. V17 stated a gown, gloves and mask were to be worn in the resident's room. V17 stated the EBP was in place to prevent infection/contamination etc for residents. On 1/14/25 at 11:33 AM, V13 LPN (Licensed Practical Nurse) went into R32's room with gloves on. V13 did not put a gown on. R32 had saline, gauze and a drain sponge. V13 went over to R32 and pulled his incontinence brief down in the front. R32 had drainage around the tubing that was going to the right side and left side of his groin area. V13 took the saline, put it on the gauze and cleaned around the reddened urostomy site. R32 made a noise and stated, that burned. V13 apologized and stated it needed to be cleaned. V13 discarded the gauze. V13 picked up the new gauze, put saline on it and cleaned around the urostomy again. R32 waved his hand over the suprapubic catheter ostomy site to dry it and decrease the burning sensation. V13 applied a drain sponge under the suprapubic catheter and secured it with tape. V17 was in the room, with gloves on and no gown. V17 wrote on the dressing with a black marker the date the dressing was changed. On 1/15/25 at 2:15 PM, V3 (Infection Control Nurse) stated for EPB anybody with a catheter, feeding tube, intravenous access, and wounds are automatically put on EBP to protect the resident from spreading infection. When there is any close contact like shower, dressing, changing, wound care, catheter care, etc the staff are to wear all PPE (personal protective equipment) to protect the resident. V3 stated she always posts and EPB sign in front of the residents room. V3 stated she has PPE outside of the room and posts donning and doffing signs. V3 stated if anyone is handling a catheter and/or the dressing around catheter then they have to wear the gown and gloves. The Care Plan dated 12/17/24 for R32 showed, R32 is on Enhanced Barrier Precautions. Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs (multidrug resistant organism) to staff hands and clothing. The Face Sheet dated 1/15/25 for R32 showed diagnoses including obstructive and reflux uropathy, chronic kidney disease, benign prostatic hyperplasia, moderate protein calorie malnutrition, atrial fibrillation, peripheral vascular disease, heart disease, spinal stenosis, hypertension, atherosclerotic heart disease, hyperlipidemia, lack of coordination, diarrhea, and chronic obstructive pulmonary disease. The facility's Enhance barrier Precaution policy (7/26/24) showed, the facility will use enhance 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. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDROs (extensively drug resistant organism) to staff hands and clothing.

Based on observation, interview, and record review the facility failed to have a dressing in place for the suprapubic catheter and failed to ensure the dressing change to the suprapubic catheter was done as ordered for 1 of 3 residents (R32) reviewed for catheters in the sample of 27. The findings include: On 1/14/25 at 11:06 AM, R32 stated they put medication in his penis this morning because he couldn't pee. R32 stated his catheter was not draining all last night and this morning. R32 stated his groin hurt this morning until the nurse injected something into his catheter and it started draining. R32 stated it feels wet where the urine drains out of his stomach (suprapubic catheter) and he wanted the nurse notified. At 11:15 AM, V17 RN (Registered Nurse) was notified R32 complained that his catheter was leaking. V17 put gloves on and walked into R32's room. V17 went over to R32 and asked him if he felt wet. R32 replied, yes. V17 pulled back R32 covers and pulled down his incontinence brief in front. R32 did not have a dressing over his suprapubic catheter. Urine was draining out around the catheter tubing and the skin was reddened. R32 complained of some pain. V17 walked around to the catheter drainage bag, lifted the bag up and there wasn't any drainage in the bag. There was sediment in the catheter tubing. V17 removed his gloves and left the resident's room. On 1/14/25 at 11:24 AM, V17 went to V22 RN (Registered Nurse/Nurse Manager) and stated R32's catheter was leaking. V22 stated R32 was supposed to have a dressing in place around the suprapubic catheter. V22 stated that R32 did not have one in place and he hasn't done the dressing yet. The surveyor asked V22 about dressings, wound care/bosomy care and she confirmed that the care provided should be according to the physician's orders. On 1/14/25 at 11:33 AM, V13 LPN (Licensed Practical Nurse) went into R32's room with gloves on. V13 did not put a gown on. R32 had saline, gauze and a drain sponge. V13 went over to R32 and pulled his incontinence brief down in the front. R32 had drainage around the tubing that was going to the right side and left side of his groin area. V13 took the saline, put it on the gauze and cleaned around the reddened urostomy site. R32 made a noise and stated, that burned. V13 apologized and stated it needed to be cleaned. V13 discarded the gauze. V13 picked up the new gauze, put saline on it and cleaned around the urostomy again. R32 waved his hand over the suprapubic catheter ostomy site to dry it and decrease the burning sensation. V13 applied a drain sponge under the suprapubic catheter and secured it with tape. The Physician Order Summary Report dated 1/15/25 showed, wound care to catheter site, clean with normal saline, pat dry, apply skin prep then cover with a dry dressing two times per day and as needed if soiled. Suprapubic catheter: Monitor skin integrity around stoma. The Care Plan dated 12/17/24 for R32 showed, R32 is at risk for alteration of bowel and bladder functioning related to decreased strength and endurance. With suprapubic 18 french, 30 ml (milliliters) for retention of urine, BPH. Ostomy: maintain the ostomy site to keep it clean and dry to prevent irritation. Ostomy: perform ostomy care daily and as needed per physician's order. The Face Sheet dated 1/15/25 for R32 showed diagnoses including obstructive and reflux uropathy, chronic kidney disease, benign prostatic hyperplasia, moderate protein calorie malnutrition, atrial fibrillation, peripheral vascular disease, heart disease, spinal stenosis, hypertension, atherosclerotic heart disease, hyperlipidemia, lack of coordination, diarrhea, and chronic obstructive pulmonary disease. The facility's Indwelling Catheter policy (7/31/24) did not show care of a suprapubic catheter to include site care and dressing changes.

Based on observation, interview, and record review the facility failed to ensure least restrictive interventions were provided prior to the implementation of a physical restraint and failed to release the restraint during supervised activities for 1 of 2 residents reviewed for restraints in the sample of 27. The findings include: On 1/14/25 at 1:05 PM, R90 was sitting in his wheelchair at a table in the dining room. R90 had a lap belt restraint in place and secured closed. At 1:07 PM, R90 was served his lunch and his lap belt restraint remained intact. V21 CNA (Certified Nursing Assistant), V18 CNA, and V19 CNA were in the dining room passing trays and assisting residents. R90's lap belt restraint was not released during the supervised meal. On 1/15/25 at 12:05 PM, R90 was sitting in his wheelchair in front of the nurses's station with his lap belt restraint in place and secured closed. R90 was waiting to leave for an appointment. The surveyor directed R90's attention to his restraint and asked him what it was and if he could remove it. R90 stated he did not know what it was and that they put it on him. R90 was asked if he could remove the seat belt and he stated no. R90 touched the restraint and stated he did not know how or why he had it. On 1/16/25 at 10:16 AM, V2 DON (Director of Nursing) stated R90 had a self releasing seat belt and depending on the day he is able to release it. V2 stated R90 could not consistently remove the seat belt on command. V2 stated R90 had the seat belt in place for his safety. V2 stated the seat belt was in place because R90 was restrained in the hospital, had a history of agitation, and he had a fall within 24 hours of admission to the facility. V2 stated V24 RN (Registered Nurse/Restorative Nurse) does all of the assessments for restraints. V2 confirmed that least restrictive measures should be put in place prior to the use of a restraint. On 1/16/25 at 10:27 AM, V24 RN (Registered Nurse/Restorative Nurse) stated R90 was admitted to the facility on [DATE] and had a fall on 12/6/24. R90 had an alarm in place initially and after the fall the placed a cushion lap restraint on his wheelchair. V24 stated R90 was able to take the cushion lap restraint off and throw it. V24 stated they switched immediately to the self release restraint buckle on that same day. V24 stated R90 can release the restraint on good days. On bad days because of his cognitive deficits he cannot remove the restraint. V24 stated R90 cannot remove the self release buckle on command. V24 stated the restraint should be released when R90 is in the dining room and staff is with him. V24 stated in dining room before lunch they have activity staff and the restraint is to be released. V24 stated the restraint should be released at meals. V24 stated R90 came in at risk for falls. If a resident has a history of falls they try to initiate something. V24 confirmed there is an adjustment period when a resident is admitted to the facility and the resident needs to get acquainted with the environment. V24 stated when R90 first came in he was agitated and they had to keep an eye on him. On 1/16/25 at 10:37 AM, R90 was sitting in a wheelchair with his restraint buckle in place and closed. R90 was playing a ring toss game with V25 (Activity Aide). R90 was observed continuously from 10:37 AM - 11:08 AM at the supervised activity with his restraint not released. On 1/16/25 at 11:16 AM, V20 CNA stated R90 has the lap belt so he doesn't fall. V10 stated she doesn't do anything with the belt other than to make sure it is on. V20 stated when R90 first came in he was getting up from his chair every 5 minutes. R90 wouldn't stay sitting so the lap belt was put on him. Now R90 sits all of the time. The Face Sheet dated 1/16/25 for R90 showed diagnoses including dementia, insomnia, anxiety, paranoid personality disorder, dysphagia, weakness, transient ischemic attack, history of falling, hypertension, anemia severe protein calorie malnutrition, atherosclerotic heart disease, restlessness and agitation. R90's Care Plan showed, admitted : 12/5/2024. R90 is at high risk for falls related to history of fall. Self release belt while up in chair. May remove during activities of daily living and care. Date initiated: 12/5/2024. Bed and chair alarm to alert staff when resident attempts to get out of bed unassisted, so staff can assist resident and prevent falls - date initiated 12/5/24. Lap cushion restraint initiated but resident able to remove item from wheelchair. Self release belt initiated - date initiated 12/6/24. The facility's Restraints policy (8/19/24) showed, it is the facility's policy to ensure that each resident is not restrained for the purposes of discipline or convenience. The facility will utilize non-restraining interventions first before trying restrain-type devices which would be considered as last resort. Physical restraint is defined as manual method, physical or mechanical device, equipment or material that meets all of the following criteria: A) attach or adjacent to the resident's body; B) that the individual cannot intentionally remove easily, and; C) restricts freedom of movement or normal access to one's body.

Based on observation, interview, and record review the facility failed to ensure daily weights were done for a resident with congestive heart failure for 1 of 1 residents (R80) reviewed for weights in the sample of 27. The findings include: R80's face sheet showed she was admitted to the facility 8/21/24 with diagnoses to include Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes, Hyperlipidemia, anxiety disorder, hypertension, and need for assistance with personal care. R80's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires substantial to maximum assistance from staff for most cares. R80's care plan initiated 8/22/24 showed, [R80] has altered cardiovascular status related to hypertension, congestive heart failure,and atrial fibrillation . Vital signs as ordered and PRN (as needed). Notify physician of any abnormal readings . R80's January 2025 Physician Order Sheet showed an order dated 8/21/24 to Monitor weight daily before breakfast. Notify MD of a 2 lb weight gain in one day or 5 lb weight gain in one week. R80's January 2025 eMAR (electronic Medication Administration Record) showed weights documented 1/1/25 and 1/3/25. There were 14 of 16 weights that were not completed for R80. On 1/16/25 at 12:08 PM, V9 RN (Registered Nurse) said R80 is not a daily weight. V9 said residents are usually on daily weights to monitor fluid changes for heart issues such as Congestive Heart Failure. On 1/16/25 at 12:20 PM, V2 DON (Director of Nursing) and V26 ADON (Assistant Director of Nursing) were interviewed together. V26 said verified R80 has an order to be weighed daily with parameters to notify the physician for changes. V26 said R80 has a diagnosis of Congestive Heart Failure. V26 said the CNAs (Certified Nursing Assistants) complete the daily weights and report to the nurses who document them daily. V26 said the nurses would be monitoring the weights and notifying the physician of changes. V26 said R80's daily weight is not being done daily as it is ordered. The facility's policy and procedure with revision date of 2/27/24 showed, . Congestive Heart Failure Clinical Protocol . It is the policy of this facility to ensure implementation of the following clinical protocols for all residents/patients who are admitted with primary diagnosis of Congestive Heart Failure . Hydration and Fluid Balance . 3. Obtain and record the daily weight as ordered .

Based on observation, interview, and record review the facility failed to ensure supervision of a resident while taking medications for 1 of 1 resident (R1) reviewed for medication administration. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, hypertensive urgency, unsteadiness on feet, neuromuscular dysfunction of bladder, iron deficiency anemia, generalized anxiety disorder, hypertension, chronic congestive heart failure, and generalized osteoarthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment. On 10/18/24 at 10:15 AM, R1 was sitting in her recliner in her room visiting with her niece and a friend. There were several pills scattered on the floor in front of R1's chair and under her bed. R1's breakfast tray was on the bedside table in front of her. R1 said when the nurse brought her medications in earlier she did not have any water to take them so she waited until her breakfast tray was delivered to take them. R1 said her hands are not working very well because she just got back the day before (10/17/24) and has been very shaky. R1 said when she tried to take her medications she accidentally knocked the cup of medications over and they fell on the floor. On 10/18/24 at 10:20 AM, V4 RN (Registered Nurse) said R1 usually does okay with taking her pills but today she was shaky so she should have stayed with her. On 10/18/24 at 3:39 PM, V11 RN said it is not acceptable to leave medications at a resident's bedside for safety reasons. V11 said she stays while the resident takes their medications to ensure they take them. On 10/18/24 at 3:10 PM, V2 DON (Director of Nursing) said R1 is not a resident who can take her medications independently. V2 said if a resident is able to take their medications independently they are assessed specifically for that and R1 would not be able to. V2 said nursing stays with the residents as they take their medications to ensure they are taking them. The facility's policy and procedure revised 8/16/24 showed, Medication Pass . 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 maintain an indwelling catheter and provide catheter care for residents in a manner to prevent cross contamination for 2 of 3 residents (R1, R2) reviewed for catheters in the sample of 5. The findings include: 1. R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, hypertensive urgency, unsteadiness on feet, neuromuscular dysfunction of bladder, iron deficiency anemia, generalized anxiety disorder, hypertension, chronic congestive heart failure, and generalized osteoarthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment and has an indwelling catheter in place. R1's October 2024 Physician Order sheet showed, . suprapubic catheter: Change dressing around stoma daily . Suprapubic catheter: Record Urine output every shift . R1's care plan initiated 4/3/24 showed, [R1] is at risk for alteration of bowel and bladder functioning related to: indwelling catheter use . Interventions: . Catheter care every shift and as needed . Monitor urine/catheter output every shift . R1's September and October 2024 eMAR (electronic Medication Administration Record) and eTAR (electronic Treatment Administration Record) showed no documentation for catheter care being completed, no outputs recorded, no dressing changes around the suprapubic catheter stoma site, and no evidence of drainage bag changes. On 10/18/24 at 2:10 PM, R1 was transferred from her chair into her bed for incontinence care by V5 CNA (Certified Nursing Assistant) and V9 CNA. R1's catheter bag had very little urine collected in the bottom of the bag and a minimal amount of urine visualized in the catheter tubing. When R1 was positioned in bed to start incontinence care V5 removed R1's pants and noticed R1's catheter tubing was kinked just below the insertion site. V5 unkinked R1's tubing and urine began to flow into the catheter tubing and drainage bag. V5 said, Now we have lots of urine. When care was completed for R1, V9 checked R1's catheter drainage bag and reported there was 400 cc of urine in the bag (10 minutes after the kink in the tube was straightened). During incontinence care R1's bed linens had been pushed into a pile at the bottom of her bed. R1's urinary catheter bag was placed on top of the pile of linen during cares putting it above the level of R1's bladder and R1's catheter tubing was noted to be filled solidly with urine from the drainage bag back up to the insertion site of the suprapubic catheter. On 10/18/24 at 2:44 PM, V5 CNA said R1's tubing had been kinked before they started incontinence care. V5 said, There was barely any urine in the bottom of drainage bag but when we got the kink out the urine started draining really well. R1's 10/14/24 General Progress Note entered at 8:32 AM showed, Patient alert and oriented x 3. Early this morning at 6AM during medication pass, patient appeared lethargic, though verbal. Refused morning medication . R1's 10/14/24 General Progress Note entered at 8:45 AM showed, Received in report that resident is confused (not usual mentation) this AM (morning) and c/o (complains of) generalized pain; went in to assess; alert to self (praying out loud) . supra pubic catheter draining cloudy yellow urine; resident is grabbing lower right abdomen/groin and complains of pain at this time . R1's 10/14/24 General Progress Note entered at 10:50 AM showed, . ambulance here to transport resident to hospital . R1's Acute Care Hospital documents showed R1 was admitted to the hospital on 10/14/24 and discharged back to the facility on [DATE]. The same document showed, . Hospital Course: . admitted through the emergency room and was found to have a urinary tract infection and AKI (acute kidney injury) . On 10/18/24 at 9:35 AM, V7 (R1's Power of Attorney) said R1 and R2 share a room and both have catheters. V7 said over a period of time she often saw multiple catheter bags in their bathroom all unlabeled as to whose catheter bag it was and no way to know. V7 said she recently went into the bathroom and there was a catheter drainage bag that was full of urine hanging over the toilet. V7 said she has been relaying her concerns regarding the catheter bags to V8 (Guest Services) and he has said he was taking her concerns to V2 DON (Director of Nursing). V7 said she had not heard back from V2 regarding her concerns until this week. V7 said R2 (R1's roommate) put labels up in the bathroom to try and help the staff know they are placing the right catheter bag on the right resident. V7 said they started labeling the catheter bags recently because R1's catheter drainage bag was put onto R2's and R2's catheter drainage bag was put on R1. V7 said R1 just got back from the hospital 10/17/24 and that was the first time the DON spoke with her regarding her concerns with the catheters. V7 said both R1 and R2 have recently been hospitalized with urinary tract infections. On 10/18/24 at 1:42 PM, V8 (Guest Services Director) said he meets with residents and relays concerns to the appropriate department. V8 said V8 (R1's Power of Attorney) has brought photos to him of the catheter bags hanging in the bathroom and wanted to discuss with nursing. V8 said from his understanding this issue was resolved a couple of months ago. On 10/18/24 at 10:36 AM, R2 said she had concerns regarding how their catheters are handled. R2 said she put post it notes up in the bathroom trying to label which bag was hers and which bag would be her roommates. R2 said a few weeks ago she was in her bed and looked over at R1's catheter bag that was hanging from her bed frame and she saw her (R2's) name on the bag. R2 said she could very clearly see her own name. R2 said there is a specific CNA who has mixed the catheter bags up frequently over the last couple of months but also agency staff have mixed the bags up. R2 said the staff do not do catheter care unless she is incontinent of stool and it gets up around the insertion site. R2 said the only time her catheter is cleaned is during her showers. R2 said she has been bringing her concerns regarding the catheter bags to many staff members for months. R2 said she did not know staff were supposed to cleaning her catheter until she was in the hospital and they told her. On 10/18/24 at 3:39 PM, V11 RN (Registered Nurse) said, staff should be monitoring residents with catheters to ensure there are no kinks in their tubing preventing the urine from draining properly. If the CNAs (Certified Nursing Assistant) notice the resident is not having their usual amount of urine draining they would check themselves and see if their tubing is kinked. When catheter tubing is kinked the urine would back up into the bladder and could cause an infection. The resident's absolutely cannot share catheter drainage bags because of cross contamination. The drainage bag needs to be maintained below the level of the bladder to drain properly. I would say they should hook the drainage back on the bed frame while they are providing care to make sure it is below their bladder. On 10/18/24 at 3:10 PM, V2 DON (Director of Nursing) said she was not made of aware of concerns regarding R1 and R2's catheter bags until 10/17/24. V2 said she spoke with V8 (R1's Power of Attorney) and R2 regarding the concerns and said R2 told her it was one time that they almost put on her roommates catheter bag but she stopped the CNA before she did it. V2 said catheter care should be documented on the resident's eTAR along with outputs. V2 said catheter care should be done with all incontinence care and at least per shift. V2 said dressing changes for suprapubic catheters should be done as ordered and documented on the eTAR. V2 said the facility's protocol for changing catheter drainage bags would be as needed but usually every week or month. V2 said there should be an area on the resident's eTAR to document catheter drainage bag changes. V2 said applying another resident's catheter drainage bag to a resident would be an issue for cross contamination. V2 said if a resident had a physician order for catheter changes it would appear on the resident's eTAR. The facility's policy and procedure revised 8/19/24 showed, Urinary Catheter Care . Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infections . General Guidelines: . Observe the resident's urine level for noticeable increased or decreases . Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks . the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 2. R2's face sheet showed she was admitted to the facility 3/13/24 with diagnoses to include bilateral primary osteoarthritis of hip, anxiety disorder, obstructive reflux uropathy, hypertension, permanent atrial fibrillation, and congestive heart failure. R2's facility assessment dated [DATE] showed she has no cognitive impairment and has an indwelling catheter in place. R2's care plan initiated 9/2/24 showed, [R2] is at risk for alteration of bowel and bladder functioning related to . catheter use Foley catheter in place . Interventions: Catheter care every shift and as needed . R2's October 2024 Physician Order Sheet showed, . Change Foley catheter every 30 days or PRN (as needed) . R2's September and October 2024 eMAR and eTAR showed no evidence of catheter care and showed no upcoming catheter changes scheduled to reflect the order for catheter changes every 30 days. R2's 10/6/24 note entered at 6:12 PM showed, Writer called to follow up resident status at [acute care hospital]. The resident has been admitted for fever/altered mental status/UTI (Urinary Tract Infection) as per ED (emergency department) nurse. R2's acute care hospital documents showed she was admitted to the hospital on 10/6/24 and returned to the facility on [DATE]. The same documents showed, . Hospital Course: . admitted through the emergency room for urinary tract infection and electrolyte imbalance . Her Foley catheter was changed and urine became clear as compared to when it was very dark and cloudy when she came in .

Based on observation, interview, and record review the facility failed to ensure accurate assessments were completed for a resident at risk for elopement, failed to ensure quarterly elopement risk assessments were completed, failed to ensure a resident at risk for elopement did not leave the facility unsupervised, failed to ensure exit doors were completely shut with alarm activated, and failed to maintain elopement risk signs and book to ensure they were complete and accurate for 2 of 3 residents (R1 and R2) reviewed for elopement in the sample of 19. The findings include: 1. R1's face sheet. showed he was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of prostate, hypertension, malignant neoplasm of kidney, hypercalcemia, emphysema, cognitive communication deficit and mile protein-calorie malnutrition. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was independently ambulatory. R1's 8/27/24 Admission Assessment showed, . Elopement Risk Evaluation . 1. No. Resident has the ability to make decision for self and therefore if resident wants to leave facility, it will not be an elopement but could be a discharge or AMA (against medical advice) . R1's 8/29/24 Nursing Note showed he had a wanderguard in place to his left ankle. This note was entered 2 days after R1's assessment that showed he was not a risk for elopement. R1's 9/2/24 Elopement Risk Evaluation showed he was a high risk for elopement. R1's Physician Order Sheet showed an order started 9/12/24 to monitor the placement of R1's wanderguard each shift. No documentation was found regarding monitoring the placement of R1's wanderguard prior to 9/12/24. R1's 9/15/24 Incident Report Form showed R1 had eloped the facility and sustained no injuries. The same Incident Report showed, Elopement: . Resident removed his wanderguard by cutting it . Exit door was noted to be unlocked which allowed the resident to leave without activating the alarm . At around 12:45 PM, [another resident] notified first floor nursing staff that while he was smoking on the patio one of the male patients went over the ramp and took off. [The other resident] gave the patients description and the information on which direction the patient was going. [R1] was identified as the patient who took off immediately after a unit search was conducted. Patient was not located within the facility premises in which a code yellow was immediately announced. Nurse assigned drove around the area and noted the patient walking inside the [nearby gas station]. Nurse went inside the gas station/grocery store and approached the patient who at the time was trying to buy a cigarillo. Nurse told the patient that he is not allowed to leave the facility without the staff's knowledge or supervision and that he needs to come back to the facility. At first patient was insisting that he needs to go to the store to buy cigarette. Patient completed his purchase and willingly got inside the nurse's car and returned to the facility without any resistance. Patient remained alert, conversant, not in any distress and with no visible injury noted. Patient was closely monitoring and a new wander guard was applied . Family notified 9/16/24 at 3:10 PM (24 hours after the incident) . Physician notified 9/16/24 at 3:40 PM (24 hours after the incident) . R1's care plan initiated 9/16/24 (the day after R1 eloped from the facility) showed, Wandering/Elopement Risk: [R1] demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming. Attempting to leave the facility without a responsible escort (elopement). The resident is a new admission and not familiar with his/her environment . [R1] to be frequently monitored through next review date . [NAME] to be placed on unit with exit and stairwell alarms . Place personal safety alarm and/or wander alert: on [R1] right leg . Staff to provide [R1] photo for potential for elopement list; staff to educate other staff, to be aware of [R1] wander elopement/risk. On 10/3/24 at 9:57 AM, V9 RN (Registered Nurse) said she was working the day that R1 eloped the facility. V9 said she saw him and chatted briefly at the nurses station. V9 said R1 would walk around the facility taking strolls on the unit and sit in the dining room. V9 said another resident was on the patio having a smoke break and he saw R1 step over the chain across the sidewalk V9 said she believes it was just R1 and another resident out on the patio that day. V9 said when she ran to look at the camera after the other resident reported it R1 left the patio was completely empty. On 10/3/24 at 1:56 PM, V4 (Social Services Designee) said R1 had expressed that he wanted to go home. V4 said the facility was working with R1's son to determine if he was going home to stay with him or if they were considering another facility. V4 said R1 would walk around the facility. V4 said her initial assessment of R1 was on 9/2/24 but she forgot to lock the assessment so it did not flow through to the care plan and she never went and carried it through. R1 said the wanderguard was placed because staff were telling her R1 was lingering around the double doors and verbalizing that he wanted to go home. V4 is unsure of who placed the wanderguard or when it was placed. On 10/3/24 at 2:00 PM, V21 (Social Services Director) said R1 was ambulatory and it was decided he would need a wanderguard. V21 said R1 was usually standing in his doorway or was near the nursing station. V21 said R1 had strong verbalizations about wanting to go home. V21 said R1's room was right across the hall from her office and he would often ask when he was going to be able to go home or state that he wanted to go home. V21 said R1 was not someone that would be able to be unsupervised on the patio. On 10/3/24 at 11:37 AM, V18 (R1's son) said the facility called and notified him of R1 leaving the facility on 9/16/24 (the day after the incident). V18 said his dad thought he was in Mexico and was trying to go to somebody's house. V18 said he is not sure when R1's wanderguard was placed. V18 said he picked his dad up one day to go to lunch and he showed him the bracelet on his ankle. V18 said no one at the facility notified him they were placing a wanderguard on R1. On 10/3/24 at 1:47 PM, V2 DON (Director of Nursing) said the patio door has alarms on it. V2 said she believes R1 cut off his wanderguard and went out the patio door with another resident. On 10/3/24 at 2:40 PM, V1 Administrator said she spoke with R1 on 9/16/24 and he said he cut off his wanderguard. V1 said R1 went to the patio with someone else's family member and went out behind them. R1 then stepped over the chain across the exit from the patio and left. V1 said the receptionist has a button to open the patio door. V1 said the receptionist opened the door for the other residents family and R1 trailed them out the door. The facility's policy and procedure revised 7/26/24 showed, Policy Statement: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care . 2. All residents who are at risk for possible elopement/wandering shall be accompanied by staff or responsible part when leaving the residents unit and/or facility grounds . Procedure for missing residents and/or elopements: . Should a resident walk away from the facility and not be located by staff, the following procedure shall be initiated immediately . 4. Contact the resident's family or responsible part and attending physician . When a resident is found: . Document in a nursing progress note the status of the resident on return, including an assessment, evaluation and follow-up actions related to the resident's elopement. 20042 2. The Incident Report Form dated 9/23/24 for R2 showed, she had an elopement but remained in the building. R2 did not sustain any injury. The description of the incident showed, resident was noted walking on second-floor north hallway by nurse V23. V23 called the clinical manager right away to report. Resident was assessed for any injury, nothing was noted. She (R2) stated she was trying to go to her room. She was unaware that she was on a different floor. Resident was escorted back to third floor ambulating without difficulty or pain. The Progress Notes for R2 in her electronic medical record did not show any documentation that she had an elopement from third floor to the second floor or if there were any additional attempts at elopement. The only documentation of the elopement was on the Incident Report form (see above) that was not a part of the resident's medical record. On 10/2/24 at 11:43 AM, V4 (Social Services) stated she thought R2 eloped from the third floor on 9/23/24 and went to the second floor. V4 stated R2 was not assessed at high risk for elopement when this happened. V4 stated they use wander devices for residents. V4 stated a code has to be entered for the elevator. If a resident with a wander device gets on the elevator an alarm will go off. V4 stated the exit doors if they are pushed on hard enough they will open and an alarm will go off. V4 stated there is a code at the exit doors that can be entered for the alarm not to sound and then the door can be opened. V7 (Memory Care Manager) was present during the interview and stated staff should not put a code in and walk away from the exit doors. On 10/2/24 at 12:16 PM, V8 RN (Registered Nurse) stated she was not working when R2 got off the floor. V8 stated that it was the first time she was aware of R2 doing anything like that. V8 stated she looks at the pictures posted at the nurse's desk to know who is an elopement risk. On 10/3/24 at 10:14 AM, V5 LPN (Licensed Practical Nurse/ acting Assistant Director of Nursing) stated it was on 9/23/24, later in the day, around 5:00 PM and she was on the second floor at the time. V5 stated she saw R2 walking down the hall on the second floor and knew that she was from the third floor. V5 stated she took R2 to the elevator and took her back upstairs. V5 stated R2's room is near the exit door on the third floor. V5 stated she filled out the incident report but did not turn it in to V2 DON (Director of Nursing) until 10/2/24 because V2 had been off sick. V5 stated they do the Incident Reports so they know what happened and what was done to correct it. On 10/3/24 at 11:00 AM, V15 RN (Registered Nurse) stated she did not have any orientation when she came to the facility. V15 stated she heard something beeping when she was in the back hall. V15 stated when she went to the elevator by the nurse's station she saw someone bringing R2 back. V15 stated she has seen many staff not close the exit door tightly and they should so no one gets off the floor. V15 stated R2 was not strong enough to push the exit door open herself. V15 stated the CNA's (certified nursing assistants) are always using the exit door and not shutting it all of the way. On 10/3/24 at 1:47 PM, V2 DON (Director of Nursing) stated if a resident gets out of the building or off their unit/floor they will call a code yellow, it is paged overhead three times. They do a head count and start a search for the resident. When the resident is found a code yellow all clear is announced. V2 stated Elopement Risk Assessments are done at admission, quarterly and as needed. V2 stated it is important to do the assessments to see if someone goes from low risk to high risk so interventions can be put in place such as a wander device. V2 stated the Elopement Risk that is posted and in the elopement books should match and be dated. On 10/3/24 at 2:34 PM, V11 CNA stated she was in the dining room when R2 eloped from the third floor. V11 stated R2 was on her assignment that evening but she had to take her turn monitoring the dining room. V11 stated she was told R2 went out the emergency exit door by her room, was found on the second floor, and brought back to the third floor. V11 stated R2 had a second attempt at an elopement later. R2 was at the nurse's station while she was putting residents to bed because R2 was too awake to go to bed. V11 stated the nurse put R2 in her room and an alarm was heard going off. V11 stated she found R2 at the door trying to leave again. V11 stated the wander devices only work for the elevator. V11 stated the exit doors are alarmed but a code can be put in before opening the door and it disables the alarm for a period of time. V11 stated if the door doesn't shut after awhile the alarm activates again. The Face Sheet dated 10/3/24 for R2 showed diagnoses including Alzheimer's disease, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, adjustment disorder, insomnia, major depressive disorder,, vertigo, paroxysmal atrial fibrillation, moderate protein calorie malnutrition, hypertension, atrial flutter, nontraumatic intracerebral hemorrhage, generalized anxiety disorder, history of falling, syncope, and collapse. R2's Care Plan dated 8/20/24 showed it on 9/25/24 the care plan was updated to include that she is a wandering/elopement risk and attempted to leave the facility without a responsible escort (elopement). R2 demonstrates signs and symptoms of mood distress such as poor appetite, insomnia (often up at night wandering and pacing), and anxiety. The 9/23/24 Elopement Risk Evaluation for R2 showed she has the physical ability to leave the facility, has a firm desire/intent to leave the facility; is not alert, oriented or have the decisional capacity; resident has attempted or has an actual elopement in the last year; roams or wanders throughout the facility and does not respond favorably to staff redirection; resident attempts to leave facility unsupervised and does not respond favorably to staff redirection. Interventions - personal safety alarm device, exit and stairwell alarms, frequent monitoring, identification bracelets, utilization of check in and check out log; recreational activities, music, exercise. The assessment showed there is risk for elopement. The previous elopement risk evaluation was dated 1/17/23 and showed low risk - interventions - exit and stairwell alarms, secured unit, frequent monitoring, identification bracelets, check in/out log, recreational activities . Low Risk 0-3 (stable and is not risk for elopement). R2 did not have any Elopement Assessments between 1/17/23 and 9/23/24. The Facility's Elopement policy (8/27/24) showed, All residents shall be reviewed for safety awareness impairment and elopement/wandering concerns upon admission, readmission, quarterly, significant change in condition, and as needed. Residents identified at risk for elopement/wandering will have a plan of care implemented to address their elopement/wandering behaviors. When a resident is found: initiate elopement precautions, update plan of care, update the Elopement Risk Evaluation, and individualize the interventions for the resident. Designate a staff member to monitor the location of the resident at regular intervals during each shift for 72 hours. Document in a nursing progress note the status of the resident on return, including an assessment, evaluation, and follow up actions related to the resident's elopement. 3. On 10/2/24 at 10:53 AM, there was a sheet of paper posted at the third floor nurse's station labeled Elopement Risk with R1 and R8 - R18's pictures with their name under each picture. There wasn't a date on the Elopement Risk sign that was posted The Elopement Binder at the third floor nurse's station had a different Elopement Risk paper with R2, R8-R10, and R13-R19's pictures with their name under each picture. The Elopement Risk form with pictures in the binder was not dated. The Elopement Risk sign posted at the nurse's station and in the Elopement Book did not match. R1 and R12 were on the Elopement Risk sign at the nurse's desk but not on the Elopement Risk in the elopement book. R2 was not on the Elopement Risk sign hanging up at the nurses desk but was on the Elopement Risk in the Elopement binder. On 10/2/24 at 10:59 AM, V4 (Social Services) stated she updated the Elopement Risk signs that are posted and in the binders. V4 stated she updates the information on Fridays and the updates were not done last Friday (9/27/24) because she had to leave early. V4 was unable to state when the Elopement Risk signs in the binder and posted at the nurses station were last updated and that they were not dated. On 10/3/24 at 1:47 PM, V2 DON (Director of Nursing) stated the Elopement Risk that is posted at the nurses desk and in the elopement books should match and be dated. The Facility's Elopement policy (8/27/24) showed, residents at risk for elopement shall be identified in the Elopement Book. The book will have a list of all residents assessed to be at risk for elopement with their name, room number, and photo. The book will be located at the receptionist desk or/and each nursing station. The book will be updated whenever a new resident is added or taken off the list.

Based on interview and record review the facility failed to ensure a resident with a history of falls and right sided weakness was safely transferred. This failure resulted in R1 sustaining a fall, hitting her head on the bedside table, and falling on her left side during a transfer. R1 was sent out to the local hospital and CT showed acute displaced fracture of the right ilium and right acetabulum. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 5. The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE]. R1's diagnoses include hemiplegia and hemiparesis following cerebral infarct affecting right dominant side, osteoarthritis, low back pain, overactive bladder, unsteadiness on feet, weakness, contusion of scalp, fracture of right pubis, history of falling and presence of left artificial hip joint. R1's undated Admission/Hospital Report documents she is alert and oriented x2, maximum two person assist and right sided weakness. R1's Final Incident Report dated 2/15/24 documents (R1) admitted to the facility on [DATE] after a fall at home on 2/6/24 resulting in a contusion of the scalp and acute non-displaced right inferior pubic rami fracture. She can verbalize her needs and requiring one person assist, she is weight bearing as tolerated and uses the wheelchair for locomotion .At around 9:00 AM breakfast was served (R1) only drank a cup of hot tea and told V7 (Certified Nursing Assistant) to take her back to her room .V7 assisted her from the wheelchair using the gait belt, (R1) stood up holding the rail and with right hand but lost her balance .(R1) reached for the tray table with her left hand and the table moved .(R1) hit the left side of her head on the tray table and she landed on her left side .911 was called and she was sent out to the local hospital .A subtle acute nondisplaced fracture of the right ilium .no surgical intervention was indicated. R1's CT report dated 2/15/24 documents acute mildly displaced fracture of the right inferior pubic ramus (present on admission). Subtle acute displaced fracture of the right ilium with fracture lines involving the iliac wing, anterior and medial acetabulum. On 3/4/24 at 10:48 AM, V7 (CNA) said she gets report from the nurse and physical therapy how a resident transfers. She was told R1 was a one person transfer. On 2/15/24, in the morning R1 did okay getting up. I took her to the dining room and around 9:00 AM, she said she felt nauseous. I wheeled her back to her room. I was trying to get her back in bed. R1 grabbed the bedrail with her right side and lost her balance and grabbed the table with her left hand and fell on her left side. I was positioned behind her with the gait belt holding on to the back of her pants during the transfer. Therapy instructs us to stand in front of the resident or to the side of them. She was a new admit, I had not seen her walk yet. In the morning she seemed alert and oriented, but then she could not recall who I was. I would probably have a second person with me to transfer and be positioned in front of her holding on to the gait belt. Max assist usually means transfer with two people. On 3/4/24 at 11:08 AM, V5 (Licensed Practical Nurse-LPN) said R1 was alert and oriented x2 with periods of forgetfulness. She was a one person assist with transfers and would complain of pain. On 2/15/24, I heard V7 scream. I entered the room and saw R1 lying on the floor beside her bed. R1 said she was in pain but could not tell me what happened. 911 was called and she was sent out to the local hospital. V7 reported she was transferring R1 back to bed and she lost her balance while getting up. Therapy instructs us to stand in front of the resident during transfers. Max assist usually means two person assist with transfers. On 3/4/24 at 12:33 PM, V3 (Unit Manager) said R1 was admitted to the facility with a right pelvis fracture. She had a fall at home and hit her head. She was a fall risk. Fall risk assessments are done at admission with interventions put in place. R1 had a history of a stroke with right sided weakness. On 2/15/24, I was notified of R1's fall. I entered the room and was lying on her left side. She was complaining of right hip pain. 911 was called and she was sent out to the local hospital. She sustained a new fracture and did not require surgical intervention. On 3/4/24 at 11:20 AM, V4 (Physical Therapist) said he did R1's therapy evaluation on 2/14/24. R1 did not receive any therapy services yet. She was admitted with a right pubis fracture. R1 required max assist with bed mobility and transfers. She requires more than 75 % assistance could assist with some portion of the transfer. Max assist could be max assist with one staff or two staff it depends on the resident's limitations. It should be documented if a resident requires one or two persons assist. We instruct the staff to always have the resident pushing off the seated surface and reaching for the armrest. For safety staff should be positioned in front or to the side of the resident with a gait belt during transfers. Staff should make sure the bed side table is out of reach of the during transfers. R1's nurses note dated 2/13/24 documents R1 admitted to the facility; contusion related to fall at home .stroke with right sides weakness, sciatica, chronic back pain. Weight bearing as tolerated with max assist for transfers .per husband R1 has had multiple falls at home. R1's Fall Risk assessment dated [DATE] shows she is HIGH RISK for falls. R1's care plan initiated on 2/14/24 shows his is high risk for falls related to multiple fall incidents at home with interventions to provide 2-[NAME] assistance during transfers as my strength and balance varies throughout the day to prevent further falls (2/15/24). R1's care plan did not show her transfer status until 2/15/24. R1's Therapy Evaluation dated 2/14/24 documents R1 with a recent fall resulting in a pelvic fracture on the right side. At this time, she is having difficulty with overall mobility and activities of daily living .(R1) anxious due to pain in right lower extremity. Does patient feel unsteady when standing and walking: yes does patient worry about falling yes. Transfers sit to stand= substantial/maximum assistance, chair/bed to chair transfer=substantial/maximum assistance. R1's Fall Occurrence Policy revised 2023, states, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are reevaluated and revised as necessary those identified as high risk for falls will be provided fall interventions .

Based on observation, interview and record review the facility failed to ensure R1 was transferred in a safe manner to prevent an injury. This failure resulted in R1 being transferred to bed and sustaining a skin tear that resulted in 35 staples and 9 sutures to his right lateral/back leg. R1's skin tear has turned into a large wound on his right leg that has not healed and requires additional wound care management. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet list his diagnoses to include: [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side, unsteadiness on feet, abnormal posture, need for assistance with personal care, unspecified mononeuropathy of left lower limb, [CONDITION(S)] (chronic) (peripheral), [CONDITION(S)] of left lower limb, and unilateral primary [CONDITION(S)], right knee. On November 2, 2022 at 10:05 AM, R1 was sitting in his electric wheelchair. His right leg was wrapped with a bandage. R1 was asked about the incident with his right leg. He stated, V4 Certified Nursing Assistant was transferring him to bed from his wheelchair. He told her that she was too close to the bed rail and she said no it will be ok and transferred him anyway. When she sat him down on the bed he hit his leg on the bed rail. He felt the skin on his leg rip. There was blood everywhere. He ended up going to the emergency room and received 32 staples and 6 stitches to his right leg. He also stated, V4 CNA was transferring him by herself with no gait belt. They use the belts downstairs (in therapy) but not up here (on the floor). He still has the wound on his leg because it has not healed and has some drainage. It hurts when they touch it and occasionally when he is in bed it will twitch. R1's final facility incident report dated October 10, 2022 shows, II: Type of incident: laceration (cause was witnessed), Date of incident: 10/4/2022, Time of Incident: 8:16 PM, Location of incident: R1's room, Type of injury: right calf laceration, Final Investigation/Conclusion: R1 is a [AGE] year old male that was initially admitted to the post-acute unit for rehab and bilateral leg [CONDITION(S)]. He is currently a resident the facility in the long-term care unit. R1 is alert and oriented x 3 and able to communicate all his needs to staff. Around 8:16 PM, V4 CNA reported to the nurse on duty the resident had a right leg skin tear that occurred during transfer from the wheelchair to the bed. RN (Registered Nurse) assess the resident and a skin tear 19 cm (centimeters) was observed with moderate bleeding to the right lower extremity calf . R1 stated, My leg hit the side frame of the bed during the transfer. R1 was transferred to the local hospital ER (emergency room ) around 8:30 PM and he returned to the facility around 1:00 AM. Staples with sutures were used for closure of the skin tear. Upon final investigation, R1 does have a history of [CONDITION(S)] and [CONDITION(S)] post [CONDITION(S)] ([CONDITION(S)]/stroke). Right sided weakness, right knee [CONDITION(S)] and fragile thin skin may have contributed to the incident . On October 4, 2022, V4 CNA refused to talk with this surveyor. V1 Administrator stated, V4 did not feel comfortable talking with IDPH (Illinois Department of Public Health). She gave her statement of what happened. V4 CNA's witness statement dated October 5, 2022 shows, Date & Type of event: skin tear 10/4/22, Name of resident: R1, Name of witness: V4 CNA: I transferred the resident to the bed and as I sat him down I noticed the bleeding on his right calf. On November 2, 2022 at 11:01 AM, V5 Assistant Director of Nursing stated, R1 was currently in therapy because his transfers were declining and becoming more difficult to transfer. On November 2, 2022 at 11:26 AM, V6 Therapy Program Director stated, they had been working on transfers with R1. He would fluctuate on his ability to transfer well. He was a max assist of two people at the time of the incident. They were going to do caregiver training the next day for a max assist of one person with a disc transfer but the incident happened and they never did. He is now a hoyer lift with two people. R1's incident report dated October 4, 2022 shows, At 8:16 PM V4 CNA reported that R1 had a skin tear on the right lower leg, this writer entered resident's room immediately to assess. The resident was sitting on the bed and upon assessment of his legs, this writer noted a skin tear approximately 7.5 inches on the back (slightly) outer side of his right lower leg, with moderate amount of bleeding R1 said, my leg hit the side frame of the bed when I was transferred to bed. R1's local ER department encounter dated October 4, 2022 shows, HPI (history of present illness): R1 is a [AGE] years old male who presented with avulsion of large portion of skin of right calf. Struck railing of bed during transfer. He had a stroke on that side and requires much assistance with transfers. Laceration Repair: Leg location: right lower leg, Length: 19 cm, Skin repair: Repair method: sutures and staples: 35 staples and 9 sutures. R1's wound assessment details report dated October 5, 2022 (the day after incident) shows, Wound Information: Type: skin tear, Measurements: Size (cm): 16 X 10 X 0 (Length X Width X Depth), Current plan & comments: large skin tear approximated with staples and sutures from yesterday R1's wound assessment details report dated October 18, 2022 shows, Wound Information: Type skin tear, Measurements: Size (cm): 11 X 10 X 0 (L X W X D), Current Plan & Comments: Orders received from local hospital to remove sutures and staples from skin tear today. The distal half of wound had previously blistered around the suture and staple approximation of skin tear. In regards to that, R1's physician was called and notified of the skin breakdown around the sutures and staples and was asked if it was still okay to remove them. Orders received to remove the sutures and staples as previously ordered and to apply xeroform and a dry dressing to the wound. R1's wound assessment details report dated November 1, 2022 shows, a large wound on the right lower, postero-lateral leg. The wound was approximately a softball size, elongated wound. The tissue was yellow and white inside of the wound and around the edges. On November 2, 2022 at 12:47 PM, V9 Wound Care Nurse (WCN) stated, she had called R1's physician when it blistered and let him know what was going on with the wound but R1's physician refused to have a wound consult. She informally asked the wound care physician that comes to the facility about R1's wound. He replied that the skin flap from the skin tear did not take and caused a wound. V9 WCN stated, the wound needs to be debrided. She was asking R1's primary physician for a consult or orders today for the wound because it is not healed and looks worse. R1's current order summary provided on November 2, 2022 shows, wound care to opened blisters on distal lateral aspect of right lower leg every evening shift for opened blisters on distal lateral aspect of right lower leg. Cleanse wounds with saline, pat dry. Apply xeroform to wounds, cover with dry dressings. Secure in place with wrap gauze. R1's current order summary provided on November 2, 2022 also shows, PT/OT (physical therapy/occupational therapy) evaluation and treat for general weakness and transfer safety. Order start date: November 9, 2022. R1's daily evaluation dated October 1, 2022 shows, C. Functional Status: Transfer: self performance: extensive assist, Transfer: support provided: two plus persons physical assist. R1's Minimum Data Set, dated dated dated [DATE] shows, he is cognitively intact and requires extensive assist of two people for transfers. R1's care plan date initiated July 27, 2022 shows, Focus: R1 has an ADL (activities of daily living) self care performance deficit and impaired mobility related to decreased strength and endurance . Interventions: Transfer: R1 uses bed rails, walker, brace, assistive device to transfer. Transfer: R1 requires encouragement, specify physical assistance with transferring. The facility's gait belt policy last revised July 28, 2022 shows, Policy Statement: The facility will use gait or transfer belts to assist residents needing limited to total assistance during transfers and walking. Procedures: 1. Staff will use a gait/transfer belt on residents who need limited to total assistance with transfer or walking. 3. Residents who need extensive to total assistance of 1 or more staff might also need the aid of a mechanical lift transfer.

Based on interview and record review the facility failed to ensure emergency services were immediately initiated for resident's (R150, R149) having a significant change in condition. This failure contributed to R150 expiring in the facility on (MONTH) 24, 2019 and R149 expiring in the hospital on (MONTH) 10, 2019. This applies to 2 residents (R150, R149) outside of the sample of 30 reviewed for necessary care and services. The findings include: R150's Facesheet printed (MONTH) 8, 2019 showed R150 was admitted to the third floor of the facility on (MONTH) 22, 2019 and discharged on (MONTH) 24, 2019. The Facesheet showed R150 as a Full Code/Attempt Resuscitation/CPR (cardiopulmonary resuscitation) under R150's Advanced Directives. R150's Clinical Note dated (MONTH) 24, 2019 showed at 5:45 AM, R150 was found unresponsive in bed with no blood pressure by V12 Registered Nurse (RN) with oxygen saturations (levels) of 81%. This Note showed R150's condition continued to deteriorate as R150 developed faint pulses and continued low oxygen levels as V12 RN placed a call to MD (V14) and MD stated he will be in facility shortly. This Note showed R150 remained in the facility with 911/Emergency Services not initiated by V12 RN until 7:18 AM, after receiving an order from V32 Nurse Practitioner (CNP) to send R150 to the hospital emergently. This Note showed ambulance personnel arrived at the facility at 7:25 AM and while paramedics were trying to stabilize resident to transport him hospital, resident arrested and CPR initiated with no success. Time of death 8:19 AM. On (MONTH) 8, 2019 at 11:45 AM, V12 RN was asked why there was a delay in sending R150 to the hospital on (MONTH) 24, 2019, V12 stated, I was waiting to send him out until I got an order from the physician (V14) to do so. Yes, he (R150) was unresponsive the whole time . Looking back, I should have called 911 and had him sent to the hospital immediately. On (MONTH) 8, 2019 at 11:30 AM, V13 Third Floor Nurse Manager stated, I was not here when the incident happened with (R150). I'm not sure why (R150) was not sent to the hospital immediately. I guess the nurse was waiting for the doctor to call back and give the order to send him to the hospital. R149's Facesheet printed (MONTH) 8, 2019 showed R149 was discharged from the facility on (MONTH) 10, 2019. R149's Clinical Note dated (MONTH) 10, 2019 showed at 5:25 AM, R149 was noted to be lethargic by facility staff with oxygen levels of ,[DATE]%, a low blood pressure of ,[DATE], and a slow pulse of 44 beats per minute. This Note showed 911/Emergency Services was not called until 5:55 AM, after R149's nurse received an order from V32 CNP to send R149 to the hospital emergently. At 7:20 AM, the facility received a call from the hospital informing us that resident expired. On (MONTH) 8, 2019 at 10:50 AM, V2 Director of Nursing stated, I don't know why there was a delay in calling 911 for (R150) or (R149). Staff should call 911 right away if a resident is unstable with a change in condition or is found unresponsive and is a full code. They do not need an order from a doctor to send a resident to the hospital when they are unstable . On (MONTH) 8, 2019 at 11:00 AM, V14 Physician stated, If a resident is found unresponsive with no blood pressure and is a full code, they are to be sent out to the hospital immediately via 911 and staff should not wait to hear from me. In regards to (R150), I don't even remember getting a phone call about him. I would never say I am on the way to the facility and wait to do anything or send a resident out until I got there. I am not aware of this incident with (R150) at all. He should have been sent out immediately via 911. When V14 was asked about the incident with R149 on (MONTH) 10, 2019, V14 stated, She (R149) should have been sent out immediately with her change in condition. Even though she was a DNR (do not resuscitate), she was with it mentally and could talk. She should have been sent out ASAP. On (MONTH) 8, 2019, V8, V9 and V33 RN's each stated if a resident is found unresponsive or a resident becomes unstable after experiencing an acute change in condition, 911/Emergency Services should be called immediately.

Based on observation, interview, and record review the facility failed to safely transfer a resident by allowing a resident's leg to hit the exposed edge of a bed rail during a transfer. This failure resulted in R1 receiving a nine inch laceration to her right leg that required sutures to close. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: On 4/22/19 at 10:30 AM, R1 had a gauze roll dressing to her right leg. The dressing covered the majority of R1's lower right leg. On 4/22/19 at 3:22 PM, V3 (Certified Nursing Assistant- CNA) said she and V5 (CNA) transferred R1 from a wheelchair to bed. V3 said when R1 was sitting at the edge of the bed they noticed blood on the floor and on R1's right pant leg. V3 said R1's leg was bleeding and it bleed, A lot. V3 said R1's leg must have hit something during the transfer that caused R1's leg to bleed. R1's Clinical Note entered on 4/13/19 shows on 4/12/19 R1 received a laceration to her right leg during a transfer. The laceration was nine inches long and the bleeding subsided within 5-6 minutes. On 4/22/19 V2 (Director of Nursing) and V9 (Clinical Manager) said R1's laceration was caused by R1 hitting her leg on the bed rail during the transfer. V2, V3, and V9 said the bed rail was missing a plastic cap that went on the end of the metal bed rail. On 4/22/19 at 11:05 AM, V2 said with the plastic cap missing the exposed end of the bed rail was sharp. V2 said R1 hit her leg on the exposed end of the bed rail. V2 said R1 was sent to the emergency room and received sutures to close the laceration. R1's emergency room note date on 4/12/19 shows R1 sustained a 9 inch long laceration and received a running suture to close the laceration.

Based on interview and record review the facility failed to follow safety protocols when transporting dietary carts, for one of three sampled residents, (R2). This failure resulted in R2 sustaining a hip fracture with hospitalization , surgical intervention, severe pain, and lengthy recovery, including Occupational and Physical Therapy. Findings include: Nursing Note of 7-23-2011 at 11:05am. is, "(R2) was observed on the floor in a side lying position at the hallway near the dining room. Assessment done. (R2) alert complained of severe back pain. 11:15am. Paramedics arrived and report given. 2:00pm., Follow-up at (Hospital) emergency room , (R2) admitted with a [DIAGNOSES REDACTED]." The 7-29-2011 Final Report is, "(R2) ambulates without assisted device and tends to pace in the unit with her friend most of the time. On 7-23-2011 at approximately 11:00am., dietary staff was pushing cart out of the dining room in preparation for meal. (R2) walked in the direction of the cart, and staff did not notice (R2), and was unable to stop cart. Cart accidentally hit (R2), causing her to lose her balance and fall. (R2) returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Physician order [REDACTED]., (Microgram) patch every 72 hours." (According to Lexi-Comp 12th Edition, Geriatric Dosage Handbook, page 595, Fentanyl is a narcotic analgesic used in the management of moderate to severe pain). "Norco 325/10mg., (Milligram) every 4 hours as needed for pain." (According to Lexi-Comp 12th Edition, Geriatric Dosage Handbook, page 744, Norco is a narcotic, combination analgesic used for relief of moderate to severe pain). "Tylenol 325mg., two tablets, four times a day, as needed. Change right hip dressing every day." "R2's 7-27-2011 Physician order [REDACTED]. Comprehensive Pain Assessment of 7-27-2011 contains documentation that R2's "Pain onset date is 7-23-2011" and pain is "increased by moving hip or bilateral lower extremities." R2's Care Plan was updated on 7-27-2011, to include "Potential for pain occurrence related to fall incident with complaint of right hip pain." Physical Therapy Evaluation of 7-28-2011 includes documentation that R2 was assessed and requires four weeks, of six times a week, Physical Therapy due to "difficulty with gait" after hip fracture of 7-23-2011 with surgical right hip pinning. The Occupational Therapy Evaluation of 7-28-2011 contains documentation that R2 was assessed and requires five time a week, for two to four weeks, of Occupational Therapy after right hip pinning and fracture of 7-23-2011. E3, (Assistant Administrator) on 8-2-2011 at 8:45am., stated, "We have three floors residents reside on, with a dining room on each floor, and one main kitchen. A dietary staff member, (E9/Dietary Aide), has been terminated, as the result of one incident. (E9) was pushing a cart out of the third floor dining room, and he bumped (R2) with the food cart, and the ambulatory resident fell . (E9) was pushing a two tiered cart with the beverage cart, after the meal, and bumped (R2). (R2) fell and was admitted to the hospital with [REDACTED]. We did an investigation of this incident." On 8-2-2011 at approximately 12:50pm. E1, (Administrator) provided the investigation supporting documentation from the 7-23-2011 incident in which R2 sustained a fractured right hip. Investigation interviews/statements with three staff members, E10, (CNA), E11, (Housekeeping), and E12, (Activity Aide), were conducted on 7-23-2011. E10, E11, and E12 affirmed E9, (Dietary Aide) had ear phones on, was pushing two carts with beverage racks stacked so high, he could not see over them. All three employees affirmed that E9 did not hear R1, when she tried to alert him, that he was going to run into R2 with the cart. Additionally, E10, E11, and E12 affirmed they heard a loud thud and R2 was in severe pain. E6, (CNA/Certified Nursing Assistant) on 8-2-2011 at 12:05pm. stated, "On 7-23-2011, I was coming from my break and I heard a loud thud, and a loud yell from (R2). When I turned around I saw (R1), (R2's) roommate, she was upset, hitting (E9), kitchen aide. I walked over, (E9) had two tray carts, with the glass cases, stacked pretty high, obstructing his front view. (E9) had a cart in front and behind him, he was pushing and pulling. I noticed one ear phone dangling from his shirt. (R2) was yelling very loud, my back, my back. (R2) was crying. The paramedics arrived in approximately ten minutes. Employees are not allowed to wear headphones, it's in the Employee Handbook. (E9) has had high racks of glasses before, on the cart. We are supposed to move one at a time, (carts). (E9) was only aware the cart hit (R2) when (R1) was hitting him." E9, (Dietary Aide)'s 7-23-2011 written statement, (No time documented), is, "I was just leaving the dining room, after putting the trays and utensils in the dining room. I was walking out the doorway with two carts full of stuff. About a foot from the door, (R2) was there and I didn't see her, until the cart stopped moving, and I saw (R2) falling." On 8-9-2011 at 9:45am. E1, (Administrator) stated, "(E9/Dietary Aide) did not follow Policy and Procedure. We felt this was an accident. We sent (E9) home and discipline was imposed by terminating his employment. This week we revamped, and determined how we could provide further safety measures regarding the dietary three tiered carts and dish/glass delivery. We broke down the process, stop, look, and listen, on visual access to three tier carts. We have two staff members involved in delivery of carts that require additional supervision. This morning we finalized this training. We also have a visual reminder on the cart or posted. We will continue to provide ongoing, observation, training, and auditing of the dining delivery system. I will provide you with a copy of the new policy." E9, (Dietary Aide)'s personnel file contains documentation that includes "Acknowledgement of Review/Receipt," by (E9's) signature of "Safety Policies." The Employee Handbook, includes revised 7-30-3002 "Disciplinary Actions: Violating safety standards which could result in injury to employees or damage to equipment." Termination/Discipline Notice of 7-27-2011 is, "Discharge for misconduct and violation of company policy. (E9/Dietary Aide), on multiple occasions has failed to comply with company policy regarding conduct and safety." The 8-2010 Accident and Incident Documentation and Investigation Policy is: "Policy, The investigation process is utilized following any event resulting in an actual or potential injury to a resident. The investigation process assists the interdisciplinary team to develop plans or programs to prevent further incidents. Procedure, 10. Report to the Illinois Department of Public Health as required." In-service Training was provided to staff on 7-23-2011 at 5:00pm., for "Review of safety measures during use or transport of equipment." On 7-25-2011 a Safety In-Service was provided to staff. The 7-25-2011 In-Service outline is as follows: "We are to transport only one cart at a time. No more than one cart at a time per person is to be taken up or down stairs. No headphones allowed at anytime. You must be able to see around and above your cart. No stacking items on top of carts. If there is any injury done to any resident, while one of the above actions is taking place, there will be finite consequences." On 8-2-2011 at 12:05pm. E6, (CNA) stated, "I did attend the Safety Awareness Training meeting on the 23rd at 5:00pm., they stressed about not having ear phones, electrical devices." E8, (Dietary Staff), on 8-2-2011 at 12:40pm., was leaving the third floor dining room, with the three tier cart, with eleven beverage racks, (approximately 55 inches in height), obscuring E8's vision. Outside of the third floor dining room on 8-2-2011 at 10:40am. two dietary staff had five beverage racks, on top of the three tier cart, obscuring their view.