Every finding on record at Avenora Elmhurst

Based on observations, interviews and record review, the facility failed to provide adequate supervision to a resident with impaired upper extremity range of motion. This failure resulted in the resident spilling hot oatmeal on self and acquiring a burn. The facility also failed to follow their policy to ensure that immediate treatment procedures are followed after a burn incident.This applies to 1 of 1 resident (R1) reviewed for accidents and supervision in the sample of 3.The findings include:R1's face sheet showed that he was a [AGE] year old male admitted on [DATE], with multiple diagnoses including acute lymphoblastic leukemia, personal history of non-Hodgkin lymphomas, other pancytopenia, pressure ulcer of sacral region, stage 3, other symptoms and signs involving the musculoskeletal system, other specified disorders of muscle, type 1 diabetes mellitus, adult failure to thrive.R1's 5-day MDS (minimum data set) dated April 26, 2026, showed that R1 was cognitively intact and required set up or clean up assistance for eating. The same MDS also showed that R1 had impairment on both upper extremities (shoulder, elbow, wrist, hand) for functional limitation in range of motion. Facility incident report dated April 26, 2026, included that on April 25, 2026, V5 CNA (Certified Nursing Assistant) stated R1 reported he believed he had spilled some coffee or oatmeal on himself. V3 RN (Registered Nurse) completed an assessment on his abdomen and did not note any burns or open sores.On April 26, 2026, V6 (CNA) stated R1 was scratching his abdomen area and had reported that he accidentally spilled coffee or oatmeal on himself. When V3 checked his abdomen area, she noted a paste/cream on top of an open skin area.On May 8, 2026, at 10:09 AM, V7 (RN) stated that R1 left the facility around 40 minutes ago for chemo treatment and should only be back at around 5:00 PM. At 2:37 PM, and at 5:05 PM, R1 was reached by telephone while still out at his appointment and provided additional information on return to the facility. R1 stated I spilled hot oatmeal on myself. My wife was with me and had just put a new shirt on me and I could not pull it all the way down and my belly was exposed. The oatmeal was hot, and it came like that from the kitchen. First, they brought me the wrong tray and then they had to bring me the right tray. I got two boiled eggs and a bowl of oatmeal. She (V5 CNA) just brought me the tray and set it down on the table and left. My wife handed me the bowl of oatmeal and was doing other things. I may have held it cockeyed, and it must have tipped over. We called the nurse by pushing the button. The CNA came out and she went and got the nurse. When asked if the CNA had positioned the bedside table over his bed, R1 pointed to the bedside table that was on the left side of his bed and stated It was just as it is now. She just dropped the tray there. They usually just do that. R1 was asked whether it would be better if he was seated upright on side of bed with his feet down, R1 stated that he is very weak and unable to move much. R1 stated that he is not used to eating food propped in bed and holding it over his chest. R1 remarked I have never had to eat in bed before. I am used to sitting up and eating at the kitchen table. When asked whether he has spilled food before at the facility, R1 stated that he has occasionally and now he puts a towel over his abdomen to catch spills. R1 was told that the CNA (V5) stated that she was present when he spilled the oatmeal, R1 raised up his right hand and remarked I swear to God she wasn't there. It was my wife that handed me the bowl of oatmeal.On May 8, 2026, at 2:49 PM, V13 (R1's spouse) stated It was about two weeks ago. The oatmeal came down from the kitchen and I noticed it was a little watery than usual and he must have spilled it. I may have stepped out of the room when it happened. The (chemo) treatment has taken a toll on him and has done something to his hands. Sometimes he is not steady, and they have to understand that. After the nurse looked at it (abdomen), I did put some toothpaste around the area as it has helped before.On May 8, 2026, at 2:15 PM, V10 (Occupational Therapist) stated that R1 is weak on both upper extremities. V11 (Therapy Director) was present during the interview and contributed some information. V10 stated He is able to feed self. When he first got here, he was weaker and the family (wife) told me that she was assisting to feed him. He was severely deconditioned and guarded with weakness and his fine motor skills were impaired and the nurse was helping with pills in his mouth instead of grasping them with his fingers. With good positioning, he was able to feed self. It was more challenging when he first got here. He would have benefitted from supervision initially for eating. The wife is often there at breakfast. When I assessed him on April 20, 2026, his grip strength was below average for his age and gender. The grip strength on his right hand was 9, and left hand was 4. The norms for a [AGE] year-old are average grip strength of 91 for the right dominant hand and 76 for the left hand, and he was well below that. I assessed him next on April 22, 2026, and was focusing on grip strategies, sitting balance/staying up in wheelchair and working on [mechanical lift] transfers as he was not safe for transfers. V10 added that when R1 first came in he was totally dependent on staff as he was very deconditioned and could only sit up after about 10 days of admission.Multiple staff were interviewed related to reported incident of April 26, 2026.On May 8, 2026, at 4:14 PM, V5 (CNA) stated that she had brought R1 his breakfast tray on the morning of April 25, 2026. V5 stated I had put a bowl of oatmeal on the table, and I told him that it was hot. He pulled the table and the bowl toppled over and some of it dropped on his belly. He can feed himself. I usually just set it up for him. His wife was not present. I did not see her. I called the nurse and the nurse put something on it. I did not see the area red. The nurse did not see oatmeal on the resident, as I wiped it with a paper towel.On May 8, 2026, at 10:12 AM, V6 (CNA) stated He was coming back from an appointment around 5:00 PM (on April 26, 2026), and when I was transferring him back to bed, I noticed like a burn mark with an open area at the top left side of his stomach with a white paste over it. I had worked a double and stayed over for night shift. I did not see the burn mark earlier as I had not changed him in the morning as his wife had got his top half of him dressed and I had only put his pants on before he went out to his appointment. I asked him what happened and when did it happened, and he had told me that he had spilled oatmeal on his stomach a day or two before I saw the burn mark. He does not drink coffee. He said that he had told the nurse about it when it happened and she had applied some type of ointment on it. Anytime, I see an open area, they (nurse) always apply a dressing over it. So, I asked him if the nurse was aware of the open area. The wife told me that she herself had applied toothpaste over the burn mark after the nurse applied a cream as she did not like that. I came and told the nurse who was here for the morning and also the on-coming nurse about it. The second shift nurse was V3 (RN). She told me that she had applied cream on the bottom of his stomach area as that's what the resident and the wife told her where he had spilled the oatmeal. I told her that I saw the burn mark on top area. When he comes back from the hospital, he likes to eat in bed. He eats breakfast in bed as well. He can feed himself. I just set everything up for him at meals and open everything and sit him upright for his meals. He can express his needs.On May 8, 2026, at 10:54 AM and 2:10 PM, V3 (RN) stated It was a Saturday (April 25, 2026), the CNA (V5) told me that he (R1) spilled the coffee or oatmeal on his abdomen and told me to go and check. It was around after breakfast. I checked his whole abdomen and there was nothing there, no redness or anything and his skin was intact. I just cleaned it with normal saline around his abdomen. His skin was dry, and I put some barrier cream on his abdomen area and his hands. I endorsed the next shift nurse to monitor any changes. I worked from 7:00 AM to 3:30 PM. I put my progress notes in the risk management, and I did not call the doctor as there was no redness or skin tear, his clothes were not wet or anything. He (R1) did not mention anything to me after that on my shift and neither to night shift. I endorsed the next shift to monitor and call the doctor with any changes. I came on Sunday (April 26, 2026) as I worked on 3:00-11:00 PM shift and after getting report, the CNA V6 came and said that there was something on his (R1) belly to check his abdomen and I saw an open area on left upper abdomen. I called the wound nurse as she was working on 2nd floor. We both checked the area, and we saw a whitish (color) paste on the abdomen and the resident said that his wife or daughter put some toothpaste on the area. We measured the area and informed the wound doctor and got the treatment orders. I put everything on my (incident) report. The resident can feed himself. We sit him upright. He prefers to eat in his room while watching television. He is alert and oriented and does not need supervision. The wife comes in majority of the time for breakfast.On May 8, 2026, at 4:03 PM, V4 (Wound Nurse) stated I was working on the building on April 26, 2026, Sunday at around 3:00 PM and the nurse (V3) reported to check the abdomen site. He said that he spilled some coffee or oatmeal accidentally on the abdomen. On the left upper abdomen, I saw a full thickness wound with an open superficial area. There was toothpaste on the abdomen but not in the wound. I called his (primary care) doctor and she gave me treatment orders. I called the wound doctor, and he agreed with the treatment and he follows him (R1) every Wednesday. He had no pain or signs of infection. I did not know about this earlier. I am not there all the time. I usually work on Wednesdays for wounds and some days on the floor.On May 8, 2026, at 1:54 PM, V2 (DON) stated This incident was reported to me the same day it happened. I told them to notify the doctor and keep an eye on it for any changes. If someone spilled a hot liquid, I would exam the site and look for redness, blistering, and oozing of fluid. I would call the doctor on whatever the appearance is and get recommendations. I would call the doctor first for directions before any further treatment.On May 8, 2026, at 3:45 PM, V14 (Wound Doctor) stated that he saw R1 related to a burn on his abdomen. V14 stated that only pressure sores are staged and not burns. V14 stated that R1 had a full thickness wound that was superficially open to less than one ml (milliliter). V14 stated that the facility should follow their policy protocols for any injury with burns in order that the area is covered and safe until they get orders. V14 stated that V4 (wound nurse) had texted him about getting orders for the burn after she became aware of it.Wound Evaluation and Management Summary dated April 29, 2026, showed as follows:Focused wound exam (site 2): Burn Wound Abdomen Full Thickness.Etiology-Burn, Further etiology detail-Hot liquid, Duration- greater than 2 days, Estimated time to heal-1-4 weeks, Wound size (length/width/depth) 3.1 x 4.9 x 0.1 cm (centimeter), Surface area-15.9 cm2, Exudate-light serrous.Policy and Procedure for Burns (effective date January 4, 2025) included:First Aide for Burns: A. Relieve pain. B. Prevent contaminationB. Treatment: 1. Apply a thick, dry, sterile dressing or bandage to keep the air out.

Based on observation, interview and record review the facility failed to develop and implement a plan of care to prevent the development of a pressure ulcer for a resident who was identified as being at risk for pressure ulcers. This failure resulted in R6 developing an infected eschar covered left heal pressure ulcer. This failure applies to 1 of 2 residents (R6) reviewed for pressure ulcers in the sample of 15.Findings Include:R6's admission record showed he was admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and aphasia. R6's Minimum Data Set, dated [DATE] showed that R6 was dependent on the facility for assistance with all functional abilities.R6's November 14, 2025 Braden score for predicting pressure ulcer risk evaluation showed resident to be at moderate risk for developing pressure ulcers. There were no interventions noted on evaluation. On January 5, 2026, R6's name did not appear on the facility's list of residents who had pressure ulcers. R6 did not have a care plan for preventing pressure ulcers or skin alterations.On January 5, 2026 at 10:27 AM, R6 was in bed wearing socks and no heel boots. R6 legs were flat on bed and R6's heels were not elevated.On January 5, 2026, at 1:05 PM, R6 was calling out from his room for help. R6 was lying in bed with both heels resting on the bed. R6 stated his foot hurt. R6 did not have on any heel protectors, nor was his feet elevated. Surveyor found V22 (Registered Nurse) and informed her that R6 stated his foot hurt. V22 entered R6 room and asked R6 if he had pain and he said he had some foot pain. V22 asked which foot and resident pointed to the left one with his hand. Surveyor asked V22 if we could take off R6's sock and take a look at his foot. V22 asked resident and he said it was okay. V22 began to take off resident sock while pressing her thumb on his heel and the resident screamed in pain and called her a derogatory name in Spanish. When V22 took R6's sock off, there was left heel pressure ulcer found that was covered in dark and black eschar (necrotic tissue) with a small amount of redness around the edges. V22 stated she was not aware that resident had a wound on that foot. R6 progress note written by V22 dated On January 5, 2026, at 1:41 PM showed the following: R6 complained of pain to his left leg. V22 checked on the skin and found a round shaped wound to R6's left heel with black discoloration in between and R6 complained of pain when touching it. On January 5, 2026, at 2:44 PM R6's eschar covered left heal wound measured 2.5 centimeters (cm) in length and 2.0 cm in height. On January 8, 2026, at 10:41 AM, V10 (Certified Nursing Assistant/CNA) stated R6 normally eats 100% of food and asks for water. V10 stated R6 requires a full body mechanical lift to transfer. V10 stated R6 stays in bed majority of the. V10 stated she never saw R6 with heel boots on. V10 stated she has never had any direction to put heel boots on R6 or anything under him elevating his feet or heals. V10 stated she is always assigned to him when she is working, and she works 5 days a week. R6's Wound Evaluation Management summary wound exam dated January 7, 2026, showed the following: an unstageable (due to necrosis) of the left heal full thickness pressure wound. Wound size 1.1 cm width x 0.6 cm, no depth measured due to nonviable tissue and necrosis. Surface area 0.66 cm^2, exudate: light purulent, 100% thick adherent black necrotic tissue (eschar). Pain described as moderate On January 7, 2026, at 11:21 AM V12 (Wound Care Doctor) stated he found a necrotic pressure ulcer to R6's left heel. V12 stated he also found some purulent drainage and prescribed and antibiotic. On January 7, 2026, at 11:55 PM V12 stated that R6 right heel wound was caused by pressure. On January 8, 2026, at 11:30 AM, V12 stated that the purulent drainage that he found on January 7, 2026, when assessing R6's wound signified an infected wound, so the antibiotic prescribed was to treat the infection. R6' has a physician antibiotic order dated January 7, 2026: Doxycycline Hyclate oral tablet 100 milligrams. Give 1 table by mouth two times a day for infection on left heel for 7 days. The facility's Pressure Ulcer Prevention & Treatment policy effective January 4, 2025 showed that the facility should implement preventive measures and keep skin clean, free from pressure and dry for residents at moderate risk for developing pressure ulcers.

Based on interview and record review the facility failed to ensure all the required members of the QA (Quality Assurance) Committee were in attendance at the meetings over the past year in accordance with their policy. This has the potential to apply to all 42 residents who reside in the facility as identified on form 671 completed by V3 (owner, former Administrator) on January 5, 2026. The findings include:In response to the request for QA meeting attendance sheets since the last annual survey,V3 provided four QA meeting attendance sheets. The attendance sign in sheets for the QA meetings were dated February 19, 2025, May 11, 2025, August 2, 2025, and November 19, 2025. On January 7, 2026, at 2:50 PM, a meeting to review the past years' QA activities was held with V1 (Administrator), V2 (Director of Nursing) and V3. V1 was asked who the required members of the QA committee are and V1 replied, the Medical Director, Administrator and Director of Nursing and managers of the departments. V1 was asked to identify the Medical Director's signature on the attendance sheets. V1 was unable to identify the medical Directors signature on any of the QA meeting attendance sheets. V3 replied that the Medical Director had not attended any of the QA meetings during the year of 2025. The facility's policy Quality Assurance and Assessments dated December 1, 2025, showed the Quality Assurance Committee is made up of all department heads, the facility administrator, and the medical director.

Based on observation, interview, and record review, the facility failed to have a water management program according to their policy and failed to follow standard infection control practices related to hand hygiene and gloving during provisions of incontinence care, medication administration and wound care. The facility also failed to ensure staff are wearing full personal protective equipment (PPE) when providing care for residents who are on Enhance Barrier Precaution (EBP). This applies to all 42 residents in the facility. Findings Include:F880 Form CMS (Centers for Medicare and Medicaid Services)-671 (Long Term Care facility application for Medicare and Medicaid) dated January 5, 2026, showed the facility had a total census of 42 residents. 1.During the survey, the facility did not have documentation to show water flow schematics of the facility and did not have documentation of an assessment identifying where high-risk water flow areas were in the facility. The facility did not have documented risk assessments or control measures established to handle potential hazards. It was revealed the facility did not have a plan in place to assess, mitigate risk, and or monitor for Legionella and other waterborne pathogens. On January 7, 2026, at 1:00 PM V3 (Owner) said he has an outline of what the water management program plan should be. V3 said he does not have a water management program that contains a facility assessment, mapping of the facility water flow, control measures to be taken, or any testing measures identified. V3 said that he was cited regarding lack of water management plan in previous survey and had not developed water management plan. On January 7, 2026, at 2:00 PM V23 (Maintenance Director) said he does not take care of water management program. V23 said V3 takes care of water management program. V23 said he does not know about Legionella testing. V23 said he test water temperature in the boiler room for hot water heaters but does not record the temperature. V23 said he only takes the hot water in the residents' rooms, however, does not record temperature results. V23 said he does not keep temperature logs for hot water tanks. V23 said did not have a plan in place to assess or monitor for Legionella or other water borne pathogens. On January 7, 2026, at 2:42 PM, V2 (DON/IP) said he does not have anything to do with the Water Management Program. V2 said he knows what Legionella is however is not in charge of the program. V2 said V3 oversees the Water Management Program. The facilities water management plan policy dated October 8, 2025, showed the Water Management Team will maintain documentation that describes the facility's water system, review water temperatures, flow patterns and conduct annual and situational review's following construction, water shut down, or illness cases. A risk assessment of building water system components will be conducted to identify where Legionella bacteria growth and prevent Legionnaires disease within the facility. The risk assessment will be completed by facility Water Management Team which includes the Administrator, Maintenance Director, Infection Preventionist and Nursing Leadership. 2. R27's EMR (Electronic Medical Record) showed R27 was admitted to the facility on [DATE], with diagnosis of pressure ulcer of sacral, pressure ulcer of left buttock stage 4, type 2 diabetes mellitus, essential hypertension, pressure ulcer of left heel stage 2, open wound left foot, non-pressure chronic ulcer of other part of right foot, hyperlipidemia, pressure ulcer of left heel stage 3. R27's care plan, dated December 05, 2025, showed R27 required EBP (Enhanced Barrier Precautions) related to pressure ulcers. Direct care staff and visitors to follow EBP. Direct care staff will perform hand hygiene upon entering and leaving the room after tasks. Direct care staff to utilize gowns and gloves for all personal care. On January 5, 2026, at 11:04 AM V4 (Registered Nurse) after applying PPE (Personal Protective Equipment) entered room of R27 with wound care supplies in hand. V4 walked over to R27's nightstand and laid closed package wound supplies on the nightstand surface without cleaning it. V4 opened Dukal Xerfoam dressing and left it inside packaging and laid it on nightstand. V4 opened gauze sponges and laid them on the unclean surface of the nightstand without packaging. V4 opened sterile sodium chloride and laid it on unclean surface of nightstand. V4 Opened Silicone boarded foam dressing removed it from its package and laid it on the unclean surface of the nightstand. V4 pulled out a marker dated and signed boarded foam gauze. V4 left the room did not remove gown, removed gloves did not perform hand hygiene before leaving. V4 turned R27 onto her left side removed the brief and soiled wound dressing applied new gloves but did not perform hand hygiene. V4 applied new gloves and cleaned pressure ulcer with sterile sodium chloride solution with gauze sponges from unclean surface of the nightstand. V4 used unpackaged gauze dressing that were lying on nightstand to dry the wound. V4 applied xeroform dressing to pressure ulcer on sacral area changed gloves did not perform hand hygiene. V4 applied new gloves and applied Opitfoam Silicone Boarded Foam dressing to wound. V4 laid R27 on her back and left the room removed gloves and gown did not perform hand hygiene. V4 returned said she applied the wrong dressing to the sacral area. V4 applied new gown, and gloves did not perform hand hygiene. V4 said Xeroform is ordered for R27's right and left legs and calcium alginate is to be applied to lower back sacral area. V4 removed xeroform and disposed of it in the garbage. V4 applied new gloves without performing hand hygiene, cleaned wound with sterile sodium chloride solution. V4 opened package for calcium alginate wound dressing and silicone foam boarded dressing and applied to sacral area without changing gloves or performing hand hygiene. On January 7, 2026, at 9:17 AM V2 (DON/Director of Nursing) said per facility policy residents with wounds are put on EBP. V2 said a sign hangs on the outside of the door with instructions for staff and visitors before entering. V2 said before entering the room the nurse should preform hand hygiene and put on PPE when providing direct care with residents. V2 said the nurse before starting the dressing change should lay all wound care supplies on clean sterile drape inside the room on a flat surface. V2 said if gloves get soiled during dressing change the nurse should replace gloves and provide hand hygiene before applying new gloves. V2 said if at any point during the dressing change the nurse removes gloves, the nurse should also preform hand hygiene before putting on new pair of gloves. V2 the reason the nurse should put preform hand hygiene after removing gloves is to minimize the risk for infection. V2 said nursing staff should be doffing inside the room and preforming hand hygiene before coming out. The facility's policy title Enhanced Barrier Precautions with an effective date of October 1, 2025, showed, purpose to establish protocols minimize the risk of infection transmission in healthcare setting, especially for patients who are at high risk .1. Patients requiring Enhanced Barrier Precautions will be identified and communicated to all involved healthcare providers. Risk factors include but are not limited to recent surgery, and wounds.2. All healthcare personnel must wear gowns and gloves when entering the patient's room for providing care such as turning, feeding, wound dressing, and any other activities which will come in touch with patients.3. Hand hygiene must always be performed before and after patient contact, as well as after removing gloves. Alcohol-based hand rubs are preferred unless hands are visibly soiled. The facility's policy titled Handwashing with an effective date of November 16, 2025, showed . 1. The purpose of hand washing to prevent the spread of bacteria and viruses by direct contact. 2. Handwashing indications.F. Before and after touching wounds.I. After taking off gloves as needed. 3. On January 05, 2026, at 1:50 PM, V27 and V28 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R12 who was wet with urine. V27 and 28 cleaned R12's perineum, applied barrier cream, repositioned resident, placed off-loading heel boots to bilateral extremities, adjusted bed height, and checked siderails, both wore same gloves all throughout the care and without hand hygiene. 4. On January 5, 2026, at 2:09 PM, V27 and V28 (Both CNA) provided incontinence care to R20 who was wet with urine and had a small bowel movement. After cleaning and applying barrier cream and new incontinence brief, they repositioned R20, and adjusted height of bed. V27 wore layers of gloves, and she removed it with each task, while V28 changed her gloves in between task. V27 and V28 did not perform hand hygiene in between tasks. 5. On January 5, 2026, at 2:22 PM, V27 and V28 (Both CNA) provided incontinence care to R39 who had a bowel movement. V27 and V28 both cleaned and assisted R39 to different tasks without performing hand hygiene in between. 6. On January 6, 2026, at 9:39 AM, V19 (Nurse) administered medications to R21. Prior to medication administration, V19 checked R21's vital signs without wearing any gloves, then she prepared the medications, touched other surfaces, and administered the medications to R21 without hand hygiene. 7. On January 6, 2026, at 1:20 PM, R6's bedroom has a signage in his bedroom door showing he was on Enhance Barrier Precaution (EBP). V2 (Director of Nursing/DON) said that it is due to R6's wound. On January 6, 2026, at 1:25 PM, V19 (Nurse) administered medications to R6 while wearing a pair of gloves. V19 removed her gloves after she administered the medications, then she touched R6's left wrist to assessed it, and then she when at the foot of R6's bed and placed the off-loading boots to R6's bilateral lower extremities without wearing any PPE. On January 6, 2026, at 5:05 PM, V2 (Director of Nursing/DON) stated when staff are providing care to a resident such as incontinence care and administration of medication, the staff must perform hand hygiene and change gloves in between tasks to prevent spread of potential infection and prevent potential contamination of medication. The staff must also wear complete PPE such as gloves and gown for residents on EBP when having direct contact with resident during care to prevent spread of infection. The facility's policy and procedure dated November 16, 2025, showed the purpose of this policy is to reduce the risk of healthcare-associated infections by ensuring effective hand hygiene practices are followed at all times. In addition, all staff must perform hand hygiene before and after every resident contact, before aseptic tasks, after exposure to body fluids, after touching resident surroundings, before and after glove use.

Based on observation, interview, and record review, the facility failed to provide hygiene/grooming care for residents who require assistance with activities of daily living (ADL) care. This applies to 4 of 6 residents (R20, R30, R36, R38) reviewed for ADL care in the sample of 15. The findings include: 1. Face sheet shows R20 is 60 years-old who has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and muscle wasting and atrophy, not elsewhere classified, multiple sites. R20's Minimum Data Set, dated [DATE], shows R20 is alert and oriented, and requires extensive assistance to total dependence on staff for ADL care. On January 5, 2026, at 10:36 AM, R20 was resting in bed, displaying long dirty fingernails with brown/black substances underneath nails, and unkept facial hair (beard and mustache). On January 6, 2026, at 10:12 AM, R20 was resting in bed. R20 remained with long dirty fingernails and unkept overgrown facial hair (Beard and mustache), and his eyes were crusty R20 said he wanted someone to clip his nails and trim his facial hair. 2. Face sheet shows R36 is 64 years-old who has multiple medical diagnoses including Parkinson's disease and abnormalities of gait and mobility. R36's MDS shows he is alert and oriented On January 5, 2026, at 10:52 AM, R36 was sitting on his wheelchair in the dining room, wearing dirty red shirt and blue joggers which were stained with unidentified substance and crumbs all over. R36 had long uneven fingernails dirty fingernails with black/brown substances underneath nails, and unkept facial hair. On January 6, 2026, at 10:10 AM, R36 was in the dining room and wearing the same dirty stained red shirt and blue joggers. R36 remained with long dirty fingernails and unkept overgrown facial hair (beard and mustache). R36 said it would be nice if staff would clip his nails and trim his facial hair. On January 6, 2026, at 2:17 PM, R36 remained with unkept facial hair and long dirty fingernails. R36 stated that he can't trim or shave his facial hair and can't his own nails, he needs a staff to do it for him. On January 6, 2026, at 2:15 PM, V29 (Certified Nursing Assistant/CNA) stated that R36 used to be more independent but now he requires assistance with grooming and hygiene because his condition has been declining. 3. Face sheet shows R38 is 85 years-old who has multiple medical diagnoses including vascular dementia and abnormalities of gait and mobility. MDS dated [DATE], shows, R38 has severe cognitive impairment and requires maximum assistance with ADL care. On January 6, 2026, at 10:30 AM, R38 was in the dayroom attending groups. R38 displayed overgrown facial hair/whiskers on her chin and wearing soiled pants stained with unidentified substance. On January 6, 2026, at around 1:10 PM, R38 was observed in the hallway just outside the second-floor dayroom, she was still wearing the same soiled pants. On January 6, 2026, at 5:13 PM, V2 (Director of Nursing/DON) stated that staff are expected to provide grooming and hygiene to residents including clipping their nails, trimming or shaving facial hair, and ensure that residents are wearing clean clothes to promote comfort and dignity. 4. R30 is an [AGE] year-old male with a diagnosis including Dementia, Protein Calorie Malnutrition, Depression, Anxiety Disorder, and Anorexia who was admitted to the facility 10/21/2024. On January 05, 2026, at 10:30 AM R30 was lying in his bed wearing a gown, with his hair extremely oily. On January 06, 2026, at 1:10 PM R30 was in his room lying in his bed with extremely oily hair and a thick large layer of white flakes on the front of his shirt. V7 (Certified Nursing Assistant) said the flakes are probably dandruff and she hasn't seen R30 showered since she started working at the facility three months ago. On January 06, 2026, at 1:23 PM V19 (Licensed Practical Nurse) said R30 consistently refuses showers. R30's point of care bathing reports from 12/10/2025 – 01/06/2026 shows missing information for bathing on most days and two refusals. R30's current care plan shows he needs supervision or touching assisting for showering or bathing. On January 07, 2026, at 1:41 PM V2 (Director of Nursing) said there should be personalized care plan interventions in place to encourage residents to participate in bathing and grooming, refusals should be care planned and there should be interventions in place to address refusal of bathing and grooming. V1 (Administrator) said appropriate interventions for refusal of bathing and grooming would include preferences of bathing times, toiletries, days, and family support which V2 agreed with.

Based on observation, interview, and record review, the facility failed to date and label insulin and eye drop medications when it was opened to determine expiration of the medications and failed to discard expired insulin. This applies to 6 of 6 residents (R3, R12, R18, R26, R42, R45) reviewed for medication storage in the sample of 15. The findings include: On [DATE], at 3:32 PM, medication cart inspection was conducted with V17 (Nurse) and the following were observed. R3's Humulin R 500 Kwik Pen was open and not dated. Pharmacy recommendation shows to discard this medication 31 days after it was opened.R12's Insulin Aspart Flex Pen was opened on [DATE], and his vial of Insulin Deglu[DATE] units/ml was open and not dated. Pharmacy recommendation shows to discard Insulin Aspart 28 days after it was opened, and for Deglu[DATE] days after.R18's Insulin Lispro was open and not dated. Pharmacy recommendation shows to discard this insulin 28 days after it was opened.R42's Clear Eye Natural Tears eye drop solution was open and not dated. The label indicated to date the medication when it was opened.R45's Timolol Maleate Eye Drops 0.25% was open and not date. There was an instruction in the medication wrapper from the pharmacy to label/date the medication when it was opened. R26's Genteal Tear Drops 0.1-0.3-0.2% was open and not dated. There was an instruction in the medication wrapper from the pharmacy to label/date the medication when it was opened. One Insulin Aspart Flex Pen observed that was open, not dated, and not labeled with resident's name. On [DATE], 5:14 PM, V2 (Director of Nursing/DON) stated should label/date insulin and eye drop medications to determine expiration date. On [DATE], at 4:32 PM, V2 (DON) stated according from the pharmacy the reason they placed a sticker for labeling on the wrapper of the eye drop medications is to remind staff to place a date of when it was opened. This indicate to discard this eye drop medication 28 days after it was opened to prevent contamination on the eye drops medication and potential infection on the resident.

Based on observations, interviews, and record reviews the facility failed to develop care plan interventions for a resident that refuses personal care and meals. This failure applies to 1 of 3 (R30) residents reviewed for care planning in a total sample of 15. The findings include: R30 is an [AGE] year-old male with a diagnosis history including Dementia, Protein Calorie Malnutrition, Depression, Anxiety Disorder, and Anorexia who was admitted to the facility 10/21/2024. On January 05, 2026 at 10:30 AM R30 was lying in his bed wearing a gown, with his hair extremely oily. R30 exhibited agitation when asked how he was feeling. On January 06, 2026 at 1:10 PM R30 was in is his room lying in his bed with extremely oily hair and a thick large layer of white flakes on the front of his shirt. V7 (Certified Nursing Assistant) said the flakes are probably dandruff and she hasn't seen R30 showered since she started working at the facility three months ago. On January 06, 2026 at 1:23 PM V19 (Licensed Practical Nurse) said R30 consistently refuses showers. R30's point of care bathing reports from 12/10/2025 - 01/06/2026 shows missing information for bathing on most days and two refusals. R30's current care plan does not include interventions for refusing bathing/showering. On January 05, 2026 at 12:41 PM R30 was in his room not eating his lunch meal and said maybe he'll eat later. At 12:50 PM R30's meal tray was removed from his room and most of his meal was untouched. On January 05, 2026 at 1:05 PM V10 (Certified Nursing Assistant) said R30 is a very picky eater, when she asked if he was done eating, he said yeah, and she didn't ask if he wanted any alternative choices because usually if R30 wants something different he'll ask for it. V10 said R30 didn't eat any of his meal and has a poor appetite. On January 06, 2026 at 12:35 PM R30 was in his room eating a piece of bread and said he was not interested in eating the rest of his meal. R30's meal included turkey and gravy, baked sweet potato, peas, pumpkin mousse, and a dinner roll. On January 06, 2026 at 1:03 PM V7 (Certified Nursing Assistant) removed R30's meal tray without offering alternative foods or cueing and prompting him to eat and only asking was he done with his meal. R30's meal was untouched. V7 said she didn't ask R30 if he wanted any other alternative foods, he doesn't eat much and just drinks a lot. R30's Nutritional Risk assessment dated [DATE] shows he is underweight, with increased nutritional needs for underweight status. R30 would benefit from gradual weight gain. R30's current care plan does not include interventions for refusing meals. On January 07, 2026 at 1:41 PM V25 (Minimum Data Set Coordinator) said the dietitians implement and are responsible for nutrition care plans. V2 (Director of Nursing) said there should be personalized care plan interventions in place to encourage residents to participate in bathing and grooming, refusals should be care planned and there should be interventions in place to address refusal of bathing and grooming. V1 (Administrator) said appropriate interventions for refusal of bathing and grooming would include preferences of bathing times, toiletries, days, and family support which V2 agreed with. On January 07, 2026 at 2:08 PM V3 (Administrator) said that according to V26's (Dietitian) progress notes R30 is at high risk for malnutrition, R30 averages 50-75% meal intake, and 25% of the time R30 eats less than 50% of his meals. V2 (Director of Nursing) said he believes R30 has a history of refusing meals, R30 should have personalized care plan interventions in place to maintain good food intake. V3 said it is important that R30 maintains good food intake. V2 said personalized nutrition interventions for R30 due to poor food intake may include preferences on mealtimes, and offering snacks from the nursing station. The facility's Care Planning Policy received 01/07/2026 states: A resident care plan is a tool to guide all health personnel, residents, and families/resident representatives in seeking out and attempting to fulfill the total needs of the resident and aid in understanding him/her as a unique person with specific problems, needs, goals and interventions.Objectives include: To provide the resident with more complete care. To help staff become more conscious of the resident's total needs. To assist the resident (to) overcome any problems encountered and in setting his goals. To assist in the prevention of unnecessary problems.Purposes include: To provide a plan of care that is oriented to each resident. To develop an awareness of each resident and their needs list (including): Physical, Medical, Mood/Behaviors, Nutritional, Choices. Resident should have individualized interventions. Approaches to problems should be specific to the resident.

Based on observation, interview, and record review, the facility failed to apply a recommended device for residents with limited range of motion to prevent further contracture. This applies to 2 of 3 residents (R12, R39) reviewed for limited range of motion in the sample of 15. The findings include: 1. Face sheet shows R12 is 59 years-old who has multiple medical diagnoses including history of traumatic brain injury, and history of transient ischemic attack (TIA), and cerebral infarction without residual effect. R12's Minimum Data Sheet (MDS) dated [DATE], shows he has impairment on both upper and lower extremities, and dependent on staff for activities of daily living (ADL) care. R12's care plan with a target date of March 24, 2026, shows R12 has impaired right lower extremity. R12 requires assistance and use of right foot orthopedic shoe when out of bed and right lower extremity immobilizer when in bed. On January 5, 2026, at 10:33 AM, R12 was in the dayroom attending exercise activity, sitting on his powered wheelchair. R12 was not wearing shoes and was only wearing a pair of socks on his feet. On January 5, 2026, at 1:23 PM, R12 remained in the dining room and still wearing only a pair of socks on his feet. On January 5, 2026, at 1:50 PM, V27 and V28 (Both Certified Nursing Assistants/CNA) transferred R12 from wheelchair to bed via mechanical lift and proceeded to provide incontinence care. After they provided the incontinence care, they left R12 resting in bed, however, they did not apply the leg immobilizer. On January 6, 2026, at 10:23 AM, R12 was in the day room attending groups, wearing a regular sneaker shoe on his right foot, and only sock on his left foot. On January 6, 2026, after lunch time, R12 was observed multiple times in bed resting without a leg immobilizer. On January 6, 2026, at 2:55 PM, V29 (CNA) stated that R12 had an orthopedic shoe and an immobilizer. V29 was unable to find orthopedic shoe, but she found the leg immobilizer in plastic bin. V29 said she doesn't put the orthopedic shoe and leg immobilizer because night shift does it. It is supposed to be on when up on wheelchair. 2. Face sheet showed R39 is 70 years-old who has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R39's MDS dated [DATE], shows R39 has impairment on one side of his upper extremity and impairment on both sides of his lower extremities. R39 requires assistance from staff for ADL care and mobility. R39's care plan with a target date of April 7, 2026, shows that R39 has a restorative range of motion program to promote flexibility and prevent contractures. This same care plan shows interventions to provide assistance for R39 to apply the right hand spilt after morning care for at least 4 hours. On January 5, 2026, from 10:36 AM to 2:30 PM, R39 was observed multiple times resting in bed. R39's right hand was noted to be stiff, and the hand splint was not applied. R39 replied yes, when asked if he wanted to wear his splint. Later at 2:22 PM, R39 was resting in bed, there was no splint on his right hand. V27 and V28 (Both CNA) provided incontinence care to R39 and after completion of care, they left R39 in bed resting without applying the hand splint.

Based on observation, interview, and record review the facility failed to manage a residents pain by not administering analgesic medication as prescribed. This applies to 1 of 1 resident (R9) reviewed for pain management in the sample of 15. The findings include: R9's face sheet showed R9 was admitted to the facility on [DATE], was [AGE] years old, and had multiple diagnoses including chronic obstructive pulmonary disease with dependence on oxygen, generalized osteoarthritis, acute on chronic congestive heart failure, unspecified hearing loss, and osteoporosis. R9's MDS (Minimum Data Set) dated December 2, 2025, showed R9 was moderately cognitively impaired, required a pain management program, and required assistance with ADLs including supervision with upper body dressing, set up assistance with eating, and partial assistance with oral hygiene, toilet hygiene, bathing, lower body dressing, bed mobility and transfer. R9's care plan for pain was initiated on June 15, 2024, and the interventions included provide analgesic as ordered. On January 7, 2025, at 10:07 AM, R9 was in her room and complained of pain score of 10/10. R9 stated she told staff yesterday that she needed her 3 day patch prescribed for pain and also stated why do I have to go through this torture when medication is supposed to be given as ordered. R9 asked the surveyor not to leave her room until staff treated her pain and expressed staff do not provide her the medication as ordered and thought the presence of the surveyor would help staff respond more quickly. V20 (Agency RN) then came to the room. R9 was assessed and found to have a Lidocaine patch dated January 5, 2026, to her lower back and Fentanyl patch on her left shoulder dated January 2, 2026. R9's physician orders showed R9 had an order initiated on November 28, 2025, for a Lidocaine patch to be placed near her low back daily at 8:00 AM and removed at bedtime and an order for Fentanyl 25 mg. (milligram) patch be placed every 72 hours initiated on December 9, 2025. R9's January 2026 MAR (Medication Administration Record) showed the Fentanyl 25 mg patch was scheduled to be given on January 2, and then January 5,2026, with removal of the old patch scheduled at 11:44 and replacement of the new patch scheduled for 11:45. The Lidocaine patch was scheduled daily at 8:00 AM and removal at bedtime. The MAR indicated a 2 code for the administration of the Fentanyl patch for the scheduled dose on January 5, 2026, and no documentation of notification made to the physician regarding refusal. The legend for code 2 indicated a 2 means resident refused. R9's Individual Patient Narcotic record showed the facility received 5 Fentanyl 25 mg patches on December 29, 2025, and the last time the Fentanyl patch was signed out was January 2, 2026, at 12:00 PM and there was 1 left in the supply. On January 7, 2026, at 10:31 AM, V2 (DON) stated the expectation is for staff to administer medications as prescribed and notify the physician if a resident refuses medication and also expects staff to reorder medication a week before the supply is depleted. On January 7, 2026, at 10:43 AM, V2 confirmed there was no supply of Lidocaine patches available to be administered to R9. On January 7, 2026, at 1:30 PM, R9 was asked if she had refused administration of her patch and R9 replied why would I refuse, the 3 day patch helps lower my pain and I knew it had not been changed and I was asking staff to change it yesterday, but no one listened to me. The Facility's policy titled Physician Orders, dated January 4, 2025, showed if a resident refused a medication, the nurse must reattempt at a later time and after three attempts will be made and if the resident still refuses, the nurse will educate the resident and notify the physician of the resident's refusal.

Based on interview and record review, the facility failed to provide written documentation of residents' transfer or discharge from the facility. This applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for inappropriate discharges in a sample of 4. The findings include: 1. R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hydronephrosis, Stage 3 chronic kidney disease, dementia, unsteadiness on feet, disorders of the muscle, alcohol abuse, hypertension, and hyperlipidemia. R1 was transferred to the hospital and discharged from the facility on April 16, 2025. On May 8, 2025 at 2:43 PM, V8 (Family Member) said she did not want R1 to be discharged from the facility but upon transfer to the ER (emergency room ) on April 16, 2025, was told he would not be allowed to return. V8 said she was in the process of having R1 transferred to a different facility and did not want him sent to the hospital. V8 said she would have wanted R1 to return to the facility to wait for placement at another facility instead of keeping R1 in the hospital to wait to be accepted to a different facility. On May 8, 2025 at 3:30 PM, V2 (DON/Director of Nursing) said R1 was discharged from the facility on April 16, 2025 due to behaviors. V2 said R1 was not allowed to come back to the facility due to his behaviors. V2 said he did not give R1 or his representative an involuntary discharge notice, involuntary judiciary petition, or written notice of a bed hold. V2 said he was not aware he needed to do so, as he was new to the facility. V2 said the nurses transferring the residents should provide the necessary written documentation to the resident. On May 8, 2025 at 11:42 AM, V3 (CEO/Chief Executive Officer) said they were not able to take R1 back because of his psychotic behaviors. V3 said he was not appropriate for a skilled nursing facility level of care and needed more behavioral health care. V3 said she denied him because another resident complained of feeling unsafe and because they were not equipped to able to manage his behaviors while he was in the facility. V3 said they did not give R1 or the representative the involuntary discharge notice, involuntary judiciary petition, and was unable to find written documentation of the bed hold notification. V3 said the bed hold policy was only provided and reviewed with the residents upon admission. R1's progress notes showed the following: On April 16, 2025 11:26 PM, V2 wrote, Called [Name] (POA/Power of Attorney) when Assigned RN (Registered Nurse) informed writer. Addressed her concern that Assigned RN did not have to call 911 to send resident to ED (Emergency Department) since she only lives 2-3 minutes away. She also addressed that her family was at the facility during dinner time and resident was alright. POA also addressed her concern that a facility was waiting for resident to be admitted and just waiting for that referral to be approved. POA also informed writer multiple times regarding the hospital bills that they have to address to. On April 16, 2025 at 11:38 PM, Resident up around 8:30 PM started walking in the hallway and cross the room into the other female resident's room, urinated on floor in the resident's room, assisted resident with 2 assist to come out of female resident's room, resident agitated and started walking through the end of hallway trying to push the door. Entered to another resident's room took banana and trying to sleep in other resident's room bought out with difficulty with 2 assist during the time resident hit the CNA (Certified Nurse Assistant) as was agitated and was combative to come out of the room. Resident bought to room with 2 assist and assisted nursing station, resident wouldn't sit at one place then assisted back to bed trying to hit another CNA, so called 911 as per MD (Medical Doctor) order to send ER (emergency room ) for further eval for combative behavior. DON (Director of Nursing) notified, daughter notified was not happy and started screaming at the writer and said you couldn't wait until morning to send him out. DON made aware. The facility was unable to provide written documentation provided to R1 or R1's representative. 2. R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses including venous insufficiency, vascular dementia, obsessive-compulsive disorder, anxiety, gastro-esophageal reflux disease, osteoporosis, depression, hypertension, weakness, and dysphagia. R2 was transferred to the hospital on May 8, 2025. R2's EMR showed a progress note on May 8, 2025 at 8:33 AM, which documented the following Around 8:30 am noted resident lethargic, increased perspiration. Resident confused, verbally responsive .Resident POA (Power of Attorney) Daughter [Name] was informed and she agreed to send resident to ER. Resident was transfer to [Name] Hospital ER around 9 am at stable condition by [Company Name] ambulance. Report was given. DON informed. On May 8, 2025 at 1:08 PM, V6 (LPN/Licensed Practical Nurse) said she had transferred R2 to the hospital. V6 said she had given the paramedics copies of the face sheet and the medication list. V6 said she did not give R2 or her representative the written notice of bed hold as it was not her job title and she had never done it. V6 said possibly V2 (DON) would give the resident the document. On May 8, 2025, the facility was unable to provide a copy of the written notice of bed hold given to the resident or representative. 3. R3's face sheet showed he was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer, anemia, hyperlipidemia, peptic ulcer, low back pain, chronic kidney disease, history of falling, and spinal stenosis. R3's EMR showed a progress note on March 27, 2025 at 4:26 PM, which documented the following, Upon further discussion with [Name] NP (Nurse Practitioner) and Administrator, it was best for resident to be transferred to acute care hospital for further care of his wounds. Assigned RN was informed and was able to transfer patient. On May 8, 2025 at 1:08 PM, V6 said she transferred R3 to the hospital and did not give R3 or his representative the written notice of bed hold. On May 8, 2025, the facility was unable to provide a copy of the written notice of bed hold given to the resident or representative. 4. R4's face sheet showed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, hypothyroidism, depression, adult failure to thrive, dysphagia, type 2 diabetes mellitus, bipolar disorder, and anorexia nervosa. R4's EMR showed a progress note on at 5:15 PM, the progress note showed, . Resident has midline on LUE (Left Upper Extremity) patent, left hand noted swollen elevated on pillows, cholecystostomy tube with 10 ML (Milliliters) output with resistance noted during flushing MD (Name) and 911 called @ 9.17 PM with ETA (Estimated Time of Arrival) of 5 to 7 minutes. POA notified @ 5.18 PM approximately. paramedics staff arrived @ 5.17 PM, all required documents required for transfer along with report provided to paramedics. paramedics left facility @ 5.26 PM. DON notified. On May 8, 2025 at 1 PM, V5 (RN/Registered Nurse) said when she sends the residents to the hospital, she gives the paramedics two face sheets, the advanced directive, and the medication list. V5 said she calls the POA and notifies them of the transfer. V5 said residents are allowed to return to the facility but if their care cannot be managed at the facility, they could not accept the resident. V5 said for example, if the resident required a psych unit, the facility does not accept them back. V5 said the admission coordinator and the social services team gets the doctors from the hospital. V5 said the bed hold notice should be given to the resident by the social worker since nursing does not deal with the bed hold policy. On May 8, 2025, the facility was unable to provide a copy of the written notice of bed hold given to the resident or representative. The facility's Bed Hold policy dated January 4, 2024 showed Medicaid residents properly admitted , have a right to return to the facility to the first available bed after a hospital transfer .If there is not a return, written notification will be provided with the reason for non-admittance and appeal rights and contract determination. The facility's Discharge Policy dated January 4, 2023 showed The resident, physician, representative will be notified of discharge.

Based on interview and record review the facility staff failed to immediately notify the nurse when a resident had a change in condition and could no longer stand and/or bear weight on her leg after a transfer. This resulted in a delay in care and treatment for R1 who had a hip dislocation. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: The Incident Report for R1 dated 2/1/25 showed, R1 complained of pain in her left leg and stated her left leg got twisted when she was being transferred after her shower. The nurse assessed R1's left leg and noted it was swollen and had poor alignment. R1 was sent to the hospital. On 2/25/25 at 11:07 AM, R1 was sitting in a wheelchair in the dining room for an activity. R1 had an abductor pillow between her legs that was not properly placed. The abductor pillow did not line up on each side with her legs. The abductor pillow was crooked and the straps were not securely in place. R1 stated she had the pillow because she had hip surgery. R1 was questioned regarding an incident in the shower that occurred on 2/1/25. R1 stated she was in the shower, standing, and there was one CNA (Certified Nursing Assistant) with her. R1 stated her leg slid and twisted. R1 stated she could not stand up after her shower and she had a lot of hip pain. On 2/25/25 at 11:24 AM, V4 RN (Registered Nurse) stated, she told V5 CNA to give R1 a shower because V3 (R1's brother/POA - power of attorney) requested it. V4 stated the shower was between 2:30 PM - 3:30 PM. V4 stated it was the end of her shift so she left. V4 stated R1 said her leg was twisted or something during the transfer in the shower room. On 2/25/25 at 11:47 AM, V5 CNA stated she took R1 into the shower room and had R1 stand up at the grab bar in the shower room. V5 was asked if she applied a transfer belt around R1. V5 stated she had a transfer belt on R1. V5 stated she transferred R1 from her wheelchair to a shower chair alone. V5 stated she told R1 to grab the bar on the wall in the shower room. V5 stated she did R1's shower and put her clothes on her. V5 stated she asked R1 to stand and R1 stated she couldn't stand so she didn't try to stand her. V5 stated she called V7 CNA to help her transfer R1. V5 stated V7 helped transfer R1 to her wheelchair. V5 stated R1 was taken to her room and sat in her wheelchair for a few minutes and then was transferred to bed. V5 stated she never told the nurse that R1 couldn't stand after her shower because V4 RN had already left. V5 stated she did not tell V8 RN, the oncoming nurse, that R1 could not stand after her shower. V5 stated she didn't tell the nurse that R1 couldn't stand because sometimes residents just say that because they don't want to stand. V5 stated she told V8 RN that R1 had pain. On 2/25/25 at 3:17 PM, V8 RN stated, she worked 2/1/25 on the 3:00 PM - 11:00 PM shift. V8 stated she did not know R1 had a shower and the CNA did not notify her that R1 had a change in condition. V8 stated she was passing medication between 4:00 PM - 6:00 PM and heard R1 shouting. V8 stated R1 does that to get attention so she did not check on her and asked the CNA to go and see what R1 needed. The CNA stated R1 had pain so she went in and R1 said her leg was hurting. R1 told her she took a shower and when she was transferred her leg flipped or twisted and she was in pain. V3 (R1's brother) was sitting in the room and he said R1's foot did not look properly aligned. V8 stated she looked at R1's foot and it was turned in. She also noted swelling and a sore to her heel. V8 looked at her phone and the messages to the physician. V8 stated she contacted the doctor at 5:58 PM and at 6:09 PM she received an order from the doctor to get an X-ray. The X-ray couldn't be done right away. V8 stated she medicated R1 for pain. At 8:47 PM she notified the doctor the x-ray could not be done until the next day. V8 stated she received an order to send R1 to the hospital. V8 stated R1 went to the hospital at 9:15 PM. On 2/25/25 at 1:50 PM, V1 (Administrator) stated the CNA should have reported R1's change in condition to the nurse so she could take further intervention and contact the medical doctor. On 2/25/25 at 2:17 PM, V13 NP (Nurse Practitioner) stated when R1 had a change in condition with her shower the first thing the CNA should have done was contact the nurse so the nurse could assess the resident. V13 stated she would expect the nurse to be notified right away and did not know why anyone would wait to notify the nurse. V13 stated notifying the nurse is important so the nurse can find out why there is a change and then contact them (physician/NP). V13 stated waiting longer than an hour to send a resident out is too long. V13 stated it was important to send the resident out right away to make sure nothing else going on and so the situation did not become worse. On 2/25/25 at 2:25 PM, V2 DON (Director of Nursing) stated, the CNA should have called for the nurse and informed her of what's going on. V2 stated that have been done right away. V2 stated there was a delay in care. V2 it was a big span of time and a lot could happen during that time. The Face Sheet dated 2/25/25 for R1 showed diagnoses including left femur fracture, joint replacement surgery, dislocation of left hip prosthesis, osteoporosis without current pathological fracture, osteoarthritis, abnormalities of gait and mobility, hypertension, hyperlipidemia, morbid obesity, bipolar disorder, schizphrenia, and major depressive disorder. The Facility's Ethic's - Patient's Change of Condition policy (1/10/25) showed, if patient's condition should change suddenly, it is the obligation of the charge nurse to notify the attending physician and responsible family member of the patient's condition change. The policy does not show any time frames for staff notification to the nurse or the nurse's time frame for notification to a provider.

Based on observation, interview, and record review, the facility failed to identify a pressure injury prior to becoming unstageable, failed to implement offloading, and failed to develop and implement a care plan after the development of pressure ulcers for 1 of 5 residents (R14) reviewed for pressure in the sample of 16. This failure resulted in R14 developing two unstageable pressure injuries, one to each heel. The findings include: R14's face sheet showed a [AGE] year old female admitted to the facility on [DATE] from a local hospital. R14's 6/7/24 history and physical showed she was admitted post fall to a local hospital with a right distal femur fracture and surgical repair. R14 had significant weakness and deconditioning. This note showed no skin lesions and incision sites to the right hip and knee. On 10/08/24 at 10:19 AM, R14 was in her room in a wheelchair barefoot. There were blue protective boots on a chair in the room. R14's feet rested on the bottom metal bar of the bedside table in front of her. R14's feet were dependent and purple in color. At 1:06 PM, R14 was eating in her room. Her feet remained uncovered and on the table legs. On 10/09/24 at 10:21 AM, R14 was in a wheelchair attending the resident council meeting. R14's feet were bare, in a dependent position and purple in color. On 10/09/24 at 12:22 PM, V6 wound doctor said R14's heel wounds were pressure injuries and the other wounds were vascular. V6 said of course he'd expect offloading to be part of her interventions. R14's medical record active orders dated 10/9/24 documents, Heel protectors on bilateral lower extremities every shift, start date: 8/20/2024. On 10/10/24 at 10:10 AM, V4 Registered Nurse (RN) said on 6/24/24 she changed R14's right heel dressing as it was dirty. V4 was unable to explain why there was a dressing there, what soiled it, and the rationale for it's replacement. V4 said somebody put a dressing there (to the right heel) and it was dirty so I changed it. V4 then said the skin was intact. It was there for protection. V4 was unable to locate wound assessments for R14's right and left heel wounds prior to the physician assessment on 6/26/24. V4 said somebody must have seen something for the wound doctor to look at her heels. If there's a new area you are supposed to do a risk management note-do wound assessments, measurements. I put them on the wound list . I think the night nurse, V17, told me they found something new and asked me to put R14 on the wound list. At some point someone told me about both wounds and I put her on the wound list. V17 should have done some kind of note/assessment and get a treatment order from the doctor. We can put interventions in place. It's important to put interventions in place and get treatment orders to prevent further deterioration of wound. An initial assessment is important to have a baseline for comparison. V6 wound doctor did R14's first wound assessments on 6/26/24. On 10/10/24 at 11:26 AM, V2 Director of Nursing (DON) said an initial wound assessment should be done by the primary nurse who identified a wound for best practice. The assessment should include the type of wound, measurements, maybe a photograph to make sure it's documented. The doctor should be notified. Interventions should be implemented and wound treatment orders should be obtained. Complications that may occur if this is not done include worsening of the wound, infection, advancement to sepsis and it can become a sentinel event. It's a liability issue. Residents here have multiple comorbidities to consider. It's a liability issue if they come in without a wound and develop one here. R14's 6/5/24 admission skin assessment showed no pressure injuries to her heels. R14's 6/5/24 pressure injury risk assessment showed she was at risk for developing a pressure injury. R14's 6/24/24 health status note authored by V4 RN showed a dressing was applied to the right heel as it was soiled. This note showed R14 was at the facility for skilled rehab post hospitalization after a fall with right femur fracture. R14's 6/25/24 6:00 AM health status note authored by R17 nurse showed surgical sites to the right hip and knee were healed and a wound treatment was done to both heels. As of 6/25/24 at 6:00 AM, R14's medical record had no documented assessment of either heel wound. R14's 6/26/24 wound physician initial wound evaluation showed an unstageable (due to necrosis) pressure injury to the right and left heels. The right heel wound measured 3.2 centimeters (cm) X 2.5 cm X depth not measureable due to the presence of nonviable tissue and necrosis. The left heel wound measured 1.8 cm X 1.4 cm X depth not measureable due to presence of nonviable tissue and necrosis. Debridement of the right heel was initiated but was stopped due to pain. The left heel was debrided. This note showed an additional right dorsal foot wound due to infection and a left leg wound due to infection. The physician note recommended to off-load the wounds and float heels while in bed. R14's June 2024 treatment administration record (TAR) showed wound treatment orders were initiated for the the right heel wound on 6/24/24. R14's June 2024 medication administration record (MAR) showed wound treatment orders for the left heel were not started until 6/27/24. R14's wound care plan (as of 10/10/24) had no mention of any pressure injuries and no interventions to offload pressure. The facility's 1/4/24 Pressure Ulcer Prevention & Treat Policy showed residents with actual alterations in skin integrity will have a plan of care developed to address measures to promote rapid healing of the wound. Residents who have actual alteration in skin integrity will be assessed for need for further measures to aid in rapid healing of wounds. Assessment and characteristic of wound must be documented every other day during wound dressing changes. Documentation guidelines B. A problem (real or potential will be entered on the resident care plan and will include prevention/treatment measures. Any change in the skin integrity status of the resident will be documented in the progress notes, the physician will be notified, and the patient care plan will be updated. When there is a decubitus ulcer being treated, the skin integrity report sheet will be initiated and descriptive information will be completed weekly by the nurse. This information will include: the specific location of the decubitus, the stage and measurement of the decubitus, the presence/absence of odor, the presence/absence of drainage, color, amount, consistency, or any change in drainage since previous measurement, and the presence of granulation.

Based on interview and record review, the facility failed to identify a significant weight loss, failed to notify a resident's physician and/or dietician for a significant weight loss, failed to develop care plan interventions to address a resident's significant weight loss. These failures apply to 1 of 2 residents (R27) reviewed for nutrition in the sample of 16. This resulted in R27 sustaining a 5.87% weight loss in 1 week. The findings include: R27's electronic face sheet printed on 10/10/24 showed R27 has diagnoses including but not limited to hydrocephalus, hypertension, mood disorder, dementia with behaviors, and major depressive disorder. R27's facility assessment dated [DATE] showed R27 has severe cognitive impairment and has experienced no weight loss. R27's weight log showed, 7/23/24 167lbs 8/1/24 157.2lbs. (5.87% weight loss in 1 week). R27's nursing progress notes and dietician notes showed no notification to either R27's physician or dietician regarding his significant weight loss of 5.87% in one week. R27's dietician note dated 8/15/24 showed, Add (supplement) twice daily and obtain weekly weights for 4 weeks. R27's care plan dated 9/29/24 showed, (R27) receives regular diet, regular texture, thin liquids. Diagnosis includes dementia, hypertension. Unplanned significant weight loss. R27's care plan showed no interventions related to R27's significant weight loss on 8/1/24. R27's medication administration record for August 2024 showed R27 was ordered a supplement twice daily on 8/15/24 and accepted the supplement for the remainder of the month. On 10/10/24 at 10:25AM, V2 (Director of Nursing) stated, I haven't been here much more than a month so I'm not sure how things were handled previously. I currently monitor all the weights and meet with the dietician on a weekly basis to discuss any significant weight changes. (R27's) weight loss was a significant weight loss that should have been addressed immediately. The earlier you identify the weight loss, the better chance you have at getting the resident to gain the weight back. Now we are playing catch up with his weight loss because he was refusing so much of his meals. There's no reason why interventions should not have been put in place. On 10/10/24 at 12:15PM, V16 (dietician) stated, (R27) initially had a pretty significant weight loss but his weight has started to improve now that we started (appetite stimulant). He has started feeding himself and accepting help with meals. When his initial weight loss was identified, I ordered supplements for him, but he was refusing them. I wasn't notified right away about his weight loss; I think it was about 10 days to 2 weeks later that I found out about it and started the supplements right away. I also asked for the facility to reweigh him so that we could determine if it was a true weight loss or not. If they would have called me, I would have given them the order for the supplements. The facility's policy titled, Procedure and Timeline for Monthly Resident Weights dated 1/30/24 showed, III the dietician may continue tracking weekly weights for residents with a weight loss trend, or who are identified to be at increased nutritional risk. The nurse and dietician will communicate recommendations for changes to weight orders as appropriate .V. The names of residents who exceed the above guidelines after re-weighing will be shared with the IDT and charted on by the dietician identifying risks, barriers to weight maintenance and an appropriate nutrition intervention if applicable .

Based on observation, interview, and record review, the facility failed to ensure kitchen utensils were stored correctly and change gloves while handling equipment/utensils to prevent cross contamination. This failure has the potential to affect all 33 residents in the facility. The findings include: The Long-Term Care Facility Application for Medicare and Medicaid form dated 10/8/24 for the facility showed a census of 33 residents. On 10/8/24 at 11:51 AM, V9 (Cook) had gloves on and was checking the temperature of the food. After she would check the temperature she would take the pan of food to the steam table, come back and check the temperature of the next food item. This was done for the zucchini, gravy, pureed sweet potato, pureed turkey, regular sweet potato, mechanical soft sweet potato, mechanical soft turkey, and turkey crunch. V9 never changed her gloves. V9 touched the counters in the kitchen near the steam table with the same gloves on. V9 went over to the drawer under the stainless steel counter, opened the drawer, the scoops were in the drawer in all different directions. V9 rummaged through the drawer, withdrew 3 different scoops and handed them to V10 (Kitchen staff). The utensils drawer under the other side of the counter near the stove had scoops, ladles, and spatulas facing all different directions in the drawer. On 10/8/24 at 12:09 PM, V10 (Kitchen Staff) stated the scoops should be lined up in order of size in drawer. V10 confirmed the handles of the scoops and other utensils should be facing the same direction towards the opening of the drawer for infection control and to prevent cross contamination. V10 stated she is not the dietary manager. V1 (Administrator) was in the dietary office when V10 was questioned and stated V10, V8 (kitchen staff) and the dietician handle the kitchen operations right now. On 10/10/24 at 10:26 AM, V1 Administrator stated he did not have a policy for the storage of kitchen utensils and the prevention of cross contamination in the kitchen. The facility's Sanitation and Infection Control policy (1/30/24) showed to keep kitchen and storage areas neat and orderly. The policy did not state how utensils, scoops, ladles, etc. were to be stored to prevent cross contamination.

Based on observation, interview, and record review the facility failed to have policy and procedures in place for residents (R28, R186, & R10) on enhanced barrier precautions. The facility failed to have a policy or plan for legionella. This failure has the potential to affect all 33 residents in the facility. The findings include: 1. The Long-Term Care Facility Application for Medicare and Medicaid form dated 10/8/24 for the facility showed a census of 33 residents. On 10/10/24 at 10:26 AM, V1 (Administrator) stated the water treatment service reports that he has were from the water treatment company that comes in and checks the chemicals for their water. V1 stated he did not have a legionella policy or water treatment plan. On 10/10/24 11:33 AM, DON (Director of Nursing) stated the facility has a water treatment plan but it did not contain anything regarding legionella. The facility's Water Treatment System policy (1/4/24) showed the facility uses a reverse osmosis (RO) system to purify the water. The water treatment system purifies the water by removing contaminants through five processes as applicable: water softening, carbon absorption, reverse osmosis, resin based mixed-bed deionization, and post-submicron filtration. The policy explained what each of the five processes were. The policy did not have a water management plan. 36186 2. The facility face sheet for R10 shows diagnoses to include dysphagia and gastrostomy. The Physician Order Sheet (POS) dated October 2024 shows orders for a gastrostomy tube (G tube) for feedings, fluids and medication administration. The facility face sheet for R186 shows diagnoses to include retention of urine and neutropenia (low white blood cells). The POS dated October 2024 for R186 shows orders for his urinary catheter. The facility face sheet for R28 shows diagnoses to include urinary tract infections and obstructive and reflux uropathy (backflow of urine). The POS dated October 2024 shows orders for his urinary catheter. On 10/8/2024 to 10/10/24 no signs showing the residents were on enhanced barrier precautions were observed on the doors to the rooms for R10, R186 and R28. No personal protective equipment (PPE) was observed near the room and the staff were observed entering and exiting the rooms without wearing PPE. On 10/9/24 at 12:50 PM, V2 Director of Nursing said she first heard of enhanced barrier precautions the day before. V2 said the facility does not have a policy or a system set up for this. V2 said she believed the precautions included increased hand washing for residents who are neutropenic. On 10/9/24 at 1:41 PM, V4 Registered Nurse said enhanced barrier precautions are for residents with wounds, urinary catheters, feeding tubes and tracheostomies. V4 said the facility does not have a protocol for this. V4 said the staff should be wearing gloves when going into the room and signs should be on the doors. The facility did not have a policy for enhanced barrier precautions. The implementation of personal protective equipment uses in nursing homes updated 7/12/2022 from the Centers for Disease Control shows enhanced barrier precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.

Based on observation, interview, and record review, the facility failed to maintain the kitchen freezer in a safe operating condition This failure affects all 33 residents in the facility. The findings include: The Long-Term Care Facility Application for Medicare and Medicaid form dated 10/8/24 for the facility showed a census of 33 residents. On 10/8/24 at 9:57 AM, during the initial tour of kitchen with V9 (cook) and V8 (kitchen staff) the walk in refrigerator door handle was broke; it was loose and didn't latch to keep the door tightly closed. The freezer door handle was broke and did not latch the door tightly closed to keep the freezer sealed. V9 and V8 were not sure when the handles broke; maybe over the weekend and maintenance doesn't work weekends. V9 and V8 stated maintenance was coming to fix it. On 10/8/24 at 12:09 PM, V10 stated she was not the dietary manager. V1 (Administrator) was in the kitchen and stated V10, V8 (kitchen staff), and the dietician handle the kitchen operations right now. On 10/8/24 at 12:17 PM, one of the panels of the plastic curtain at the entrance of the freezer inside the door was missing. The freezer had ice build up on the plastic curtain at the entrance of the walk in freezer. There was ice built up a on shelf to the left side of the freezer near the door. There was a large long ice icicle hanging from the ceiling of the back left side of the freezer. The case for the thermometer inside the freezer was present but not the thermometer itself. V10 (kitchen staff) stated that maybe the ice in the doorway of the freezer was preventing it from closing all of the way. V10 (kitchen staff) wasn't aware that the thermometer was gone. V9 (cook) stated she records the freezer temperature from the thermometer on the outside of the freezer; not the inside. V10 stated the freezer shuts off for a few minutes every once in awhile and then comes back on and she doesn't know why. On 10/9/24 at 9:11 AM, V7 (Maintenance) stated he has only worked at the facility 1 month and he is over the whole building. V7 stated he has not seen the maintenance books or logs for anything because he has only been here a month. V7 stated he doesn't know anything about the maintenance books and logs. V7 stated he would have to talk to his supervisor, V1 (Administrator). V7 stated he was told about the door handles to the freezer and refrigerator yesterday (10/8/24); he doesn't know what needs to be done; maybe order parts. V7 was not aware of any other problem with the freezer. On 10/9/24 at 9:15 AM, V1 (Administrator) stated, he doesn't know anything about the handles to the freezer or refrigerator. V1 stated maintenance is done when there is a problem and he is not aware of any problem to the freezer. V1 stated if there is condensation present for the freezer then there will be ice resent which makes sense if the door is not sealing all of the way. V1 stated he was not aware of any ice build up in freezer or missing freezer curtain panel. The facility's Equipment and Maintenance policy (1/30/24) showed, the food service director will instruct dietary employees in the use and care of equipment. He/she will also order repairs and replacement of equipment and maintain records.

Based on observation, interview, and record review, the facility failed to treat two residents (R13,R20) with dignity. This applies to 2 residents outside of the sample reviewed for dignity. The findings include: 1) R13's electronic face sheet printed on 10/10/24 showed R13 has diagnoses including but not limited to dementia without behaviors, bipolar disorder, type 2 diabetes, and major depressive disorder. R13's facility assessment dated [DATE] showed R13 has severe cognitive impairment. On 10/9/24 at 1:36PM, V5 and V13 (Certified Nursing Assistants) provided incontinence care to R13 in the bathroom. V13 removed R13's incontinence brief and stated, Oh, she's pooping while R13 was in the standing mechanical lift. V5 then handed V13 the trash can and stated, Here, put this under her in case she goes more. V5 placed the garbage can underneath R13 while she was standing in the lift and continued providing incontinence care. V13 stated she is unsure of why they did not put R13 on the toilet and could not state why she put the trash can underneath of R13. V13 stated she could see how this would be a dignity concern as she would not want a garbage can placed under her while she was having a bowel movement. V13 then stated, Oh well, at least I know better for next time. On 10/10/24 at 10:25AM, V2 (Director of Nursing) stated, It is absolutely unacceptable to place a trash can underneath a resident when they should be providing toileting assistance. There is no reason why you would place a trash can under a resident for any reason unless it was an emergency. The aides should have placed R13 onto the toilet so that she could have a bowel movement in a dignified manner. These residents are already vulnerable as they have low cognitive functioning, and this specific practice is degrading. The Illinois Long-Term Care Ombudsman Program Residents' Right for People in Long-Term Care Facilities dated 11/18 showed, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. 2) R20's electronic face sheet printed on 10/10/24 showed R20 has diagnoses including but not limited to dementia, encephalopathy, dysphagia, and altered mental status. R20's facility assessment dated [DATE] showed R20 has severe cognitive impairment. On 10/8/24 at 12:36PM, R20's meal tray was positioned across the table from him. R20 then pulled his tray over in front of him and began drinking the water off his tray. V14 (Restorative Director) took R20's water out of his hand and pushed his meal tray out of his reach. R20 stated, I'm very hungry and V14 stated, We will feed you soon, but you can't have your tray right now and turned around to feed another resident. R20 then picked up a paper towel roll and was attempting to drink from it stating, I'm so thirsty. On 10/9/24 at 1:28PM, R20 was waiting for his lunch meal (all other residents on the unit were served lunch between 12:15-12:30PM). V15 (Registered Nurse) went and retrieved R20's meal tray and stated, He can't eat until we are ready to feed him because he will make a big mess and just put his hands in his food. It's just easier when we feed him. On 10/10/24 at 10:25AM, V2 stated, All of our residents should be encouraged to be as independent as possible. If (R20) has an issue getting his food to his mouth or using his silverware, then we should be providing adaptive equipment for him and attempting to let him use it. There is no reason why he should have had to wait for his meals just because staff were busy. They were in the dining room and able to supervise him. This is definitely a dignity concern as he had to watch all of the other residents receive their meals before he was allowed to get his.

Based on observation, interview, and record review, the facility failed to ensure 2 residents (R27 & R26) were free from restraints. This applies to 1 of 1 residents (R27) reviewed for restraints in the sample of 16 and 1 resident (R26) outside of the sample. The findings include: 1) R27's electronic face sheet printed on 10/10/24 showed R27 has diagnoses including but not limited to hydrocephalus, hypertension, mood disorder, dementia with behaviors, and major depressive disorder. R27's facility assessment dated [DATE] showed R27 has severe cognitive impairment and does not utilize any restraints. On 10/8/24 at 11:10AM, V18 (Certified Nursing Assistant-CNA) removed R27's foot pedals off his wheelchair, pushed him up to the dining room table and locked both of his wheels. V18 stated R27's behavior is a little unpredictable so that's why he moved him over to the table and locked his wheelchair. V18 stated R27 has been a little more active today & is a fall risk & tries to stand on his own. R27 was trying to move his wheelchair backwards and was unable to do so due to his wheelchair being locked. R27 was then tipping his wheelchair due to becoming frustrated that he could not move his chair independently. On 10/8/24 at 12:08PM, R27 was sitting near the exit door near the dining room. V15 (Licensed Practical Nurse) moved R27 away from the exit door, pushed him over to the table and locked both of his wheels. Again, R27 attempted to move his wheelchair away from the table and was unable to do so. On 10/8/24 at 1:30PM, V15 pulled R27 away from the table, provided him with a nutritional supplement, and then pushed him back up to table and locked both wheels on his wheelchair. V15 stated if R27 does not have his wheelchair locked he will be all over the unit and they are unable to keep track of him. On 10/9/24 at 11:06AM, R27 was sitting at the dining room table with both of his wheels locked on his wheelchair. V13 (CNA) asked R27 to unlock the wheels on his wheelchair and R27 was unable to comprehend what V13 was asking him to do and was unable to unlock the wheels of his wheelchair. V13 stated R27's wheels remain locked because he moves around the unit too much and they need to keep all the residents in one space. 2) R26's electronic face sheet printed on 10/10/24 showed R26 has diagnoses including but not limited to Alzheimer's disease, lack of coordination, altered mental status, dementia with behaviors, and cognitive communication deficit. R26's facility assessment dated [DATE] showed R26 has mild cognitive impairment; however, throughout the course of the survey, R26 was unable to be interviewed due to cognitive impairment. On 10/8/24 at 12:34PM, R26 was pushed up to the table in his wheelchair with both brakes locked. R26 was pushing back from the table and unable to move due to his wheelchair being locked. R26 continued to try to remove himself from the table and was unable to do so. On 10/8/24 at 1:27PM, R26 was again attempting to move his wheelchair away from the table and was unable to do so due to both wheels being locked. On 10/9/24 at 9:28AM, R26 was at the dining room table and was attempting to push back from the table to pick up a piece of an activity he had dropped. R26 was unable to move his wheelchair due to both wheels being locked. On 10/9/24 at 11:01AM, R26 stated, I can't move, help me to move so I can go somewhere. R26 was attempting to move his wheelchair forward and was unable to do so due to both wheels being locked. On 10/9/24 at 11:06AM, V13 asked R26 to unlock the wheels on his wheelchair. R26 stated, Ok and then proceeded to play with the wheels on his chair and was unable to unlock the wheels after several requests by V13. V13 stated she is unsure if R26 can unlock his wheelchair but stated it's good because otherwise he will be all over the unit if he's not kept in one place. On 10/10/24 at 10:25AM, V2 (Director of Nursing) stated, If a resident is placed in a position and held there then that is considered a restraint because they are not able to move independently. If (R26) and (R27) are attempting to move their wheelchair then staff should unlock them and allow them to move around. We can't keep residents in one area just for our convenience. The facility's policy titled, Physical and Chemical Restraints dated 1/4/24 showed, I. It shall be the policy of this facility to discourage the use of physical and chemical restraints for the purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. II. A Physical Restraint is defined as any manual method, physical or mechanical device-material or equipment (attached or adjacent to the resident's body) that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .

Based on observation, interview, and record review, the facility failed to provide timely incontinence care to 1 resident (R26) outside of the sample reviewed for activities of daily living. The findings include: R26's electronic face sheet printed on 10/10/24 showed R26 has diagnoses including but not limited to Alzheimer's disease, lack of coordination, altered mental status, dementia with behaviors, and cognitive communication deficit. R26's facility assessment dated [DATE] showed R26 is always incontinent of bladder. On 10/8/24 at 1:35PM, V18 (Certified Nursing Assistant-CNA) was notified by surveyor that R26's pants appeared wet. V18 and V13 (CNA) provided incontinent care to R26. V18 stated R26 was toileted at approximately 9:30AM this morning but hasn't been checked since then. R26 was placed in a standing mechanical lift and when he was lifted out of the wheelchair, the back of R26's pants were saturated with strong smelling urine and his wheelchair seat was wet with urine. V18 removed R26's incontinence brief that was saturated with urine. V18 laughed and stated, Wow, I guess he really was wet. V18 then continued incontinence care and placed a clean sheet over R26's wheelchair seat. V18 stated he placed the sheet there so that if he gets too busy it'll be easier to see if (R26) soiled himself again. On 10/10/24 at 10:25AM, V2 (Director of Nursing) stated, All residents should be checked and changed every 2 hours and as needed. (R26) is one of the residents who cannot tell you if they need to go to the bathroom, so we must be especially diligent with that population and ensure we are checking them every time we encounter them. If staff are interacting with (R26) then they should be asking him if he needs any of his basic needs which includes toileting assistance. By allowing (R26) to sit in his urine for an extended period of time, staff are increasing the likelihood of an infection. The facility's policy titled, Incontinence and Catheter Management dated 1/4/24 showed, I. Policy: In accordance with regulatory requirements and professional practice standards the facility will ensure that: B. A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible .

Based on observation, interview, and record review the facility failed to use a gait belt to transfer a resident (R16) and failed to provide supervision during mealtimes for a resident with a diagnosis of dysphagia (R28). These failures apply to 2 of 4 residents (R16, R28) reviewed for safety and supervision in the sample of 16. The findings include: 1) R16's electronic face sheet printed on 10/10/24 showed R16 has diagnoses including but not limited to osteoarthritis, dementia without behaviors, and dysphagia. R16's facility assessment dated [DATE] showed R16 has severe cognitive impairment, lower extremity impairment, and requires substantial assistance with transfers. R16's care plan dated 9/7/24 showed, (R16) has potential for pain/discomfort related to arthritis on the right knee .handle resident gently when repositioning and transferring, particularly if pain is related to joint problems. On 10/8/24 at 12:13PM, V13 (Certified Nursing Assistant-CNA) was attempting to have R16 stand in the bathroom with the use of the bar next to her toilet. R16 was unable to stand on her own. V13 obtained the standing mechanical lift and V18 (CNA) arrived in the room and stated, Here, I can just get her to stand on her own by myself. V18 then lifted R16 underneath her arms to stand at the bar. R16 was yelling My knee hurts! I can't stand! V18 then grabbed R16 under her arms and placed her on the toilet. R16 was yelling obscenities at V18 following the transfer. When 16 was finished, V18 lifted her under her arms again and R16 was unable to fully stand up. V18 then used his back to push on R16's back to hold her steady while he pulled up her pants. Throughout the remainder of the transfer, R16 continued yelling at V18 that he didn't know what he was doing. On 10/10/24 at 10:25AM, V2 (Director of Nursing) stated, Any resident that requires assistance with transfers should have a gait belt applied to them. The gait belt is supposed to provide additional support to the resident while also ensuring that it is a safe transfer for both the resident and the staff member. (V18) is lucky that the transfer didn't end up in an injury for both him and the resident. The facility's policy titled, Gait Belt for Transfer dated 10/20/23 showed, I. Purpose: To ensure resident and staff safety during ambulating and transferring . 36186 2. The facility face sheet for R28 shows diagnoses to include type 2 diabetes mellitus, subarachnoid hemorrhage, and chronic kidney disease. The Physician order sheet dated October 2024 for R28 shows an order for maintain aspiration precautions during meal and drinking fluid was obtained on October 3, 2024. On 10/8/2024 at 1:40 PM, R28 was observed lying in bed with his lunch tray in front of him. R28 was alone in his room. On 10/9/2024 at 1:00 PM, R28 was observed alone in his room with his lunch tray in front of him. No staff were observed near R28's room or entering his room to check on him. On 10/9/2024 at 1:20 PM, V4 Registered Nurse said R28 rarely eats his meals, he mostly eats what his wife brings him. When meal trays are passed to the rooms, the Certified Nursing Assistants (CNA) are to be monitoring the residents. On 10/10/2024 at 10:17 AM, V5 CNA said if a resident needs help with feeding we stay and assist them after bringing them their meal tray. V5 said residents on aspiration precautions should be monitored while eating. V5 said he doesn't usually work on this unit and was not familiar with how R28 eats his meals. On 10/9/2024 at 12:50 PM, V2 Director of Nursing said if a resident is on aspiration precautions, they should be observed while eating. V2 said R28 refuses to get up for meals, refuses a speech evaluation and refused to have a diet other than a regular diet. V2 said his wife comes and helps him at mealtimes. The nursing progress note dated 10/3/2024 for R28 shows the resident was not compliant with nectar thick liquids and had refused his speech therapy referral. The hospice staff were notified and an order for aspiration precautions was obtained. The care plan for R28 dated 8/11/2024 for his diet shows no interventions of aspiration precautions in place for him. The facility policy for aspiration precautions dated 1/4/2024 shows to establish guidelines that minimize the risk of aspiration in patients with swallowing difficulties, ensuring their safety, and promoting optimal health outcomes. Supervision: patients will be supervised during meals and snacks by trained staff to monitor for signs of aspiration or distress.

Based on observation, interview, and record review the facility failed to safely position a resident (R1) in bed during care and safely transfer the resident after a fall. This failure resulted in the resident falling out of bed and sustaining multiple rib fractures. The facility also failed to identify a resident's (R2) transfer status in the plan of care, safely transfer the resident, and apply a wheelchair positioning device for the resident with a known behavior of unsafely leaning to the side. This applies to 2 of 4 (R1 and R2) residents reviewed for safety. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease, dementia, age-related osteoporosis with recurrent pathological fracture, osteoarthritis, acquired absence of the right upper limb, abnormalities of gait and mobility, and muscle weakness. R1's MDS (Minimum Data Set) dated 8/05/2024 showed R1 was cognitively intact and dependent on facility staff for assistance with bed mobility and toileting. The EMR showed R1 was transferred to the hospital on 8/05/2024 and was not readmitted to the facility. On 8/28/2024 at 3:00 PM, V11 (Certified Nurse Assistant/CNA) was interviewed regarding R1's fall incident on 8/05/2024. V11 said on 8/05/2024 at 4 AM she was going to render incontinence care to R1 in bed. V11 said she turned R1 on her right side away from her. V11 said she then turned away from R1 to gather incontinence supplies and left R1 unsupervised. V11 said R1 then fell out of bed on the floor. V11 continued to say she then immediately assisted R1 into a standing position and transferred her back to bed. V12 (Agency Registered Nurse/RN) was not able to be reached for an interview during this survey. V12's untitled witness document dated 8/05/2024 said she was notified by V11 (CNA) that R1 fell out of bed while receiving incontinence care. The statement said R1 was in bed when she went to assess R1 after the fall. The statement continued to say R1 verbalized generalized pain and had sustained a skin tear to the left elbow, an abrasion to the left shin, and a bruise to the right knee. On 8/27/2024 at 12:35 PM, V2 (Director of Nursing/DON) said R1 was transferred to the hospital for further evaluation because she was complaining of acute generalized pain after her fall. V2 said the hospital informed the facility R1 had sustained multiple bilateral rib fractures. V2 said she expected the nursing staff to follow fall prevention precautions during bed mobility to ensure the safety of residents. V2 said V11 (CNA) should have not positioned R1 away from her nor should have left her unattended when she was rendering incontinence care. V2 continued to say V11 also should have not transferred R1 after she fell without having been assessed by the nurse. R1's imaging hospital records dated 8/05/2024 showed R1 sustained Right 6th-10th rib fracture deformities and left 9th-10th rib fracture deformities. The facility's initial and final report titled Serious Injury Incident Report dated 8/05/2024 said R1 rolled out of bed when receiving incontinence care. The report said R1 was complaining of pain and was sent to the hospital and was treated for rib fractures. R1's Fall Risk Evaluation dated 5/03/2024 showed R1 was at risk for falls. On 8/28/2024 at 10:10 AM, V1 (Administrator) said the facility did not have policies regarding bed mobility and positioning. The facility's policy titled Fall Management Program dated 1/18/2024 showed Definition: Fall management program is an interdisciplinary quality improvement design to assist in providing individualized, person center-care and improving fall care process and outcomes through quality improvement tools and education. Purpose: to prevent and/or decrease the number of falls and reduce injuries resulting from falls. 2. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with multiple diagnoses including acute kidney failure, obstructive reflux uropathy, sepsis, hypotension, bilateral inguinal hernia, hepatomegaly, benign prostatic hyperplasia, constipation, pressure ulcers to right and left heel, congestive heart failure, and muscle disorder. R2's MDS (Minimum Data Set) dated 6/28/2024 showed R2 was severely cognitively impaired and dependent on facility staff for assistance with transfers and mobility. On 8/27/2024 at 11:27 AM, R2 was sitting in his reclining geriatric wheelchair. R2 did not have his wheelchair supportive arm device in place. V8 (CNA) and V10 (CNA) said they were going to transfer R2 to bed. V8 and V10 used a total mechanical lift machine to transfer R2. R2's legs were contracted in a fixed position and flexed towards his right side. R2 had a dressing to his right heel and bruising to his right inner arm and right lateral torso area extending to his anterior chest area. V9 (RN) came to R2's room to assess his bruises. V9 said R2 had a pressure ulcer to his right heel and his arm and torso bruising was noted last week. V8 and V9 said R2 did not have a recent fall or incident. They continued to say R2 had the tendency to lean on his right side when in his chair and was receiving blood thinners which they believed possibly caused the bruising. On 8/27/2024 at 1:50 PM, R2 was in the dining room sitting in his reclining geriatric wheelchair. R2 did not have his wheelchair positioning supportive arm device in place. On 8/28/2024 at 8:37 AM, R2 was in the dining room sitting in his reclining geriatric wheelchair. R2 did not have his wheelchair positioning supportive arm device in place. On 8/28/2024 at 11:55 AM, V9 (RN) was interviewed regarding R2's transfer status. V9 said she was not sure what was R2's transfer status. V9 looked in R2's EMR and said she was not able to find R2's transfer status. V9 then looked at the facility's posted transfer status list and said it did not show R2's transfer status. On 8/28/2024 at 4:30 PM, V8 (CNA) was interviewed regarding R2's transfer status. V8 said he was not sure what was R2's transfer status because he could not find it in R2's EMR nor on the facility's posted transfer status list. V8 said R2's transfer status varied, and he makes a judgment call daily when transferring R2. V8 said he sometimes transfers R2 quickly with one or two-person assistance and sometimes he uses the total mechanical lift by himself to transfer R2. On 8/28/2024 at 9:50 AM, V16 (Director of Rehab) said R2 was discharged from therapy on 7/10/2024 with a recommendation to continue to be transferred with the use of a total mechanical lift because of his weakness, foot wound, and lower leg contractures. On 8/29/2024 at 11:10 AM, V2 (DON) said R2 was observed leaning unsafely to his right side when in his chair. V2 said R2's bruise most likely occurred due to his poor trunk control and unsafe positioning. V2 said she expected the staff to ensure R2's wheelchair positioning arm device was in place to assist R2 be properly positioned and prevent him from sustaining any further injuries. V2 said R2's transfer status has always been total mechanical lift with a two-person assist. V2 said she reviewed R2's care plan and the facility's posted transfer status list and they did not indicate R2's transfer status. V2 said residents' care plans should identify their transfer status to ensure staff are aware on how to safely transfer residents. V2 said she expected staff to follow residents' transfer status and when using the total-mechanical lift a two-person assistance was required for safety. R2's 7/10/24 Physical Therapy/PT Discharge Summary report said R2 was dependent on transfers and required the use of a mechanical lift. R2's document titled Follow Up Question Report dated 8/28/2024 (during the survey) showed R2's transfer documentation from 7/29/2024 through 8/28/2024. The document showed R2's transfer support provided varied from one-person physical assistance and two-person physical assistance. The document continued to show R2's transfer self-performance also varied from total dependence, extensive assistance, and limited assistance. R2's care plan dated 8/28/2024 said R2 was at risk for bruising and injury because he favored his right side and leaned over on the right side of his wheelchair. The care plan showed an intervention to Place right side arm rest bolster on the chair. Check and reposition resident while in (reclining geriatric) chair as needed for comfort. R2's care plan continued to show R2 required the use of the mechanical device (lift) for safe transfers which was initiated on 8/28/2024 (during the survey). On 8/28/2024 at 10:10 AM, V1 said the facility did not have policies regarding bed mobility and positioning. The facility's policy titled (mechanical) Lift dated 1/04/2024 showed Purpose: A. To move a resident safely with as little physical effort as possible .

Based on interview and record review, the facility failed to protect R1, a resident with dementia from sexual activity from R2, another resident with dementia with known sexual behaviors and a history of wandering into other resident's rooms. This failure resulted in R1 experiencing sexual abuse at the facility when R2 went into R1's room at night and went into R1's bed and sexually assaulted her in her bed. R1 is unable to give consent to the sexual activity and a reasonable person would not want to be touched without consent. This applies to 1 of 3 residents (R1) reviewed for sexual assault in the sample of 3. This failure resulted in an immediate jeopardy. The findings include: The immediate jeopardy began on May 22, 2024, when R2 sexually assaulted R1 on the overnight shift during the hours of 12:45 AM-2:00 AM as documented on the Police Incident Report. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on May 30, 2024, at 2:27 PM. The facility presented an abatement plan on May 31, 2024 to remove the immediacy. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented the revised abatement plan on May 31, 2024 and the survey team accepted the abatement plan. The facility reported that they will be ready on June 03, 2024 for onsite verification. The immediate jeopardy began on May 22, 2024 and removed on June 03, 2024 after onsite verification of implementation of abatement plan to remove the immediacy. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on June 3, 2024, but remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the measures taken. Facility census roster dated May 21, 2024, showed that R1, R2 and R3 resided in the Dementia Unit. Facility Incident Report dated May 22, 2024, included as follows: Writer received notification from V16 (R1's family) that an inappropriate event allegedly occurred in R1's room on an overnight shift between 0100-0300. V16 states that there is a video recording of another resident going into R1's room and touching her inappropriately Facility investigation dated May 22, 2024, included interviews and written statements from V7 (Certified Nursing Assistant) that V7 found R2 fully naked in bed on the morning of May 22, 2024, and that on May 20, 2024 at 6:40 AM, when V7 was giving R2 a shower he asked her to touch his private area. On May 28, 2024, at 10:09 AM, V14 (Police Detective) stated that he reviewed the video recordings taken on May 22, 2024 and confirmed that the allegation of R1's family was seen recorded on camera. V14 stated that the report is in the preliminary stages and the Final Report will quantify details. Police Incident Report dated May 23, 2024, showed there was evidence of sexual assault by R2 to R1 on May 22, 2024 time stamped between 12:45 AM to 2:00 AM. The Police Report included the following information summary: On May 23, 2024, at 11:27 AM, the police dispatched to the facility based for a Sexual Assault report. V16 (R1's family) reported to Police that R1 was sexually assaulted while R1 was a patient at the facility. V16 stated that she is R1's Power of Attorney because R1 has been diagnosed with Dementia leaving V16 to care for her. V16 stated that while R1 lived with her, she had camera's all over the house to keep an eye on R1 at all times. V16 stated that R1's dementia had worsened, so she admitted R1 to the facility on [DATE], so that she could receive the care that she needs. V16 stated that she had placed a camera in plain view in R1's room on May 21, 2024, to observe R1's bed area and her room, so that she could check on her from time to time throughout the day. V16 stated that during the early morning hours on May 22, 2024, she checked the camera footage which shows a periodic still image and observed a male sitting on R1's bed. V16 called the facility and spoke with a representative and asked who was in her mother's room to which she was advised that nobody was in her mother's room. V16 later reviewed video footage in which she stated she observed the following in summary: - - At approximately 12:45 AM, R1 appears to be attempting to dress herself but is struggling to get her bra on. - A male enters her room and initially appears to attempt to help R1with her bra. - The male appears to hear someone walking by in her opinion and moves away from R1 before coming back to her. - V16 stated the male then begins to touch R1 in her private areas. - The male eventually exposes his penis while touching R1. - V16 advised that at one point the male's back is facing the camera with his pants down but it cannot be seen what he's doing. - Eventually the male gets into bed with R1 and under the covers while naked. - V16 stated she could not tell what the male is doing under the covers or whether or not any penetration occurred with R1. During police interview with V16, she advised that she wanted to have a sexual assault kit completed on R1 and that she wanted an ambulance to take R1 to the hospital to have this done. An ambulance was requested at the scene and R1 subsequently transported to the hospital. Police Incident Supplement Report dated May 27, 2024, included the following information summary: On May 23, 2024, V11 (Police Officer) and V13 (Police Officer) responded to the facility to process the scene for to assist with documentation and collection for evidence. Apart from taking digital photos of R1's room, including bed, bedding, security camera and two articles of worn clothing, the room was scanned using a forensic light-source, with varying wavelengths to see evidence of biological fluid. Multiple items were collected from R1's bed including piece of clothing and bedding and taken to the station and checked for possible biological/DNA evidence using the forensic light-source (495 nm (nanometer) wavelength with a yellow/orange filter). Digital photos of all the possible biological stains, under lowlight conditions were taken. The stains were checked using a Sirchie Seminal ID AP (Identification Acid Phosphatase) presumptive test for semen and seminal fluid. The white fitted sheet contained a larger stain about halfway down from the top, proximal to the center of the sheet. This stain was also tested and returned with some positive purple specks (indicating a positive test), on the filter paper. Hospital records dated May 23, 2024, included that R1 was admitted to the hospital for sexual assault of adult and that R1's forensic examination at the hospital was released to law enforcement for further testing. R1's EMR (Electronic Medical Records) showed that R1 was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain, not elsewhere classified, unspecified dementia, unspecified severity, with other behavioral disturbance, schizoaffective disorder, adult failure to thrive, epilepsy, unspecified, not intractable, without status epilepticus. R1's initial baseline care plan on admission showed that R1 was cognitively impaired. R1's nursing progress notes showed that R1 was sent to the local hospital emergency roiagnom on [DATE], as part of an ongoing investigation and did not return to the facility. Nursing progress notes since admission recorded that R1 is alert with confusion, non-compliant with using her walker, walks independently with rollator & needs supervision due to unsteady gait and that R1 goes into other resident's rooms. R2's EMR showed that R2 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension, adjustment disorder, unspecified, weakness. R2's EMR continues to show R2 was discharged to home on May 22, 2024, at around 11:00 AM. R2's quarterly MDS (Minimum Data Set) on February 5, 2024, showed that R2 was severely impaired in cognition and required supervision or touching assistance for sit to stand and walk 10 feet and chair/bed-to-chair transfer. R2's care plan, initiated on November 16, 2023, shows that R2 has a history of wandering. Facility had multiple interventions (initiated on November 16, 2023) including to identify if there are triggers for wandering and to engage the resident in purposeful activity. Facility did not have documentation that staff implemented these interventions. As of May 22, 2024, the facility did not have a care plan in place for R2 regarding inappropriate sexual behaviors. Nursing progress notes in last one month (dated April 18, May 9 and May 20, 2024) recorded that R2 goes from room to room and 'checks on other residents' and also included that he was redirected to bed after 1:00 AM during one of these episodes. Nursing progress notes dated April 25, 2024, included that R2 was assisted by CNA in the shower and inappropriate behavior noted during shower and reported. On May 29, 2024, at 9:18 AM, V7 (CNA) stated that when she went into R2's room on May 22, 2024, at around 8:30 AM to get him up for breakfast she found him fully naked stretched out in bed. V2 verified that R2 was 'very inappropriate' with her when she was giving him a shower on May 20, 2024, at 6:40 AM. V7 stated He is does that every time when I give him personal care or give him a shower. I have told the facility about it. He does that to everybody. He has tried to pull me on top of him in the shower. He sits in the shower chair. I have reported his (R2) inappropriateness in the stand-up meetings that is conducted by V1 (Administrator) about a couple of months ago. The facility does nothing about it. He (R2) knows what he is doing and is just taking advantage. On May 28, 2024, at 9:38 AM, V15 (Registered Nurse/RN) stated that R2 has made comments to her I am looking at you. I am liking you. V15 stated that when R2's daughter came to discharge him home, she said that he has even hit on her. On May 25, 2024, at 9:29 AM, V1 (Administrator) stated that an allegation was brought to his attention on May 22, 2024 at around 11:00 AM by the family of R1. The family stated that R2 touched R1 and there is no rape. V1 stated that the family said that they had a camera in R1's room, and somebody walked into the room and touched R1. V1 stated that facility was not aware of the camera in the room. V1 stated that R1's family came in and identified R2 who resided a couple doors (room's) down from R1's room. V1 stated that the facility does not have cameras. V1 stated that he requested the camera footage from the family and has not received it yet. V1 stated that it happened at the overnight shift and the staff (1 nurse and 1 CNA) were making rounds and they could have been in another room. V1 stated that there was no screaming to alert to know that the person needed attention. V1 stated that the facility did a body check and there were no marks or bruises on R1. V1 stated that R1's family called the Police (on May 23, 2024) and wanted to have R1 sent to the hospital. V1 stated that he has not got any reports from the hospital. V1 stated that both R1 and R2 have Dementia and are not able to communicate adequately and R2 denied everything. V1 stated that both R1 and R2 are in the Dementia unit and residents with Dementia tend to wander and are hard to control. On May 25, 2024, at 9:04 AM and 11:59 AM, V4 (Registered Nurse) stated that she worked on the previous night (May 21, 2024) of the alleged incident during the 3:00 PM -11:00 PM shift on the 2nd floor where R1 and R2 resided. V4 stated that R1 is very confused and was wandering all over the unit and not listening. V4 stated that R1 even went into R3's room who was on isolation sat there for 10 minutes and was hard to redirect. V4 stated that R1 then went into R2's room and sat there for about 10 minutes and was watching television and eating candy despite attempts to take her out of the room. V4 stated that R2 was waiting patiently outside the room and said to let R1 finish the candy. V4 stated that R1 eventually came out of R2's room after 10-15 minutes of giving R1 Ativan (anti-anxiety medication) as R1 was calmer and sat in the hallway. V4 stated that R2 has been at the facility 2-3 years and wheels himself around and sometimes walks with an unsteady gait. V4 stated that R2 is very curious when someone is yelling or moaning and will come to the nurse's station and report it to staff. V4 stated that 2-3 weeks ago V6 (Licensed Practical Nurse/LPN) said that R2 was sexually inappropriate with her. V4 stated that R2 told V6 to come sit with him and let him hug her and that she corrected him. V4 added that R2 has Dementia and is impulsive but not on purpose or intention. V4 stated that about a month ago, V8 (CNA) reported to her that she saw him masturbating in his room. On May 25, 2024 at 11:31 AM, V3 (LPN) stated that she was working on May 21, 2024-May 22, 2024 on the 11:00 PM-7:00 AM shift. V3 stated that she received a report from V4 (RN) that R1 did not want to go to bed and that she went into R3's room. V3 stated that R1 was still sitting in front of R3's room between 11:00 PM -12:00 AM and V5 (CNA) was also working on the floor. V3 stated that when she went to talk to R1 to go to her room, she noticed that she had poop on herself and V10 (Agency CNA) from the 1st floor helped V5 clean R1 and put her to bed around 12:00-1:00 AM at nighttime. V3 stated that she went back to the nurse's station and that R2 was sitting around the nurse's station in the hallway at that time. V3 added that R2 usually sits there during the day and sometimes at night when he doesn't want to sleep. V3 stated that she saw him wheeling himself in the hallway towards his room but did not see him go into his room. On May 25, 2024, at 4:32 PM, V5 (CNA) stated I worked Tuesday night on the 11:00 PM to 7:00 AM shift. When I came in, (R1) was seated in the hallway and I asked staff why she was up and not sleeping. She was smelling of feces. The CNA from the agency (V10) that took care of her the previous shift on 2nd floor was still there on the first floor as she was doing a double shift. She said that she tried earlier to change (R1), and she refused. She came up to help me change (R1). I tried to be nice to (R1) and she agreed to be changed and we took her to her room, changed her and put her to bed. It was around 11:35 PM. I was at the computer doing charting. (R2) was up all night in his wheelchair going back and forth to the dining room to watch TV (television) and come back to the nurse's station and went to his room (not sure). I saw him back at the nurse's station at around 2:30 AM. Between 2:00-2:30 AM, V10 (CNA) came from downstairs to assist me change and check the residents. The nurse at some point went to the bathroom. I saw him (R2) sleeping in his bed at 4:00 AM when I did my rounds. Facility floor plan showed that R1's room was on the same side of the hallway as R2's room with another resident's room in between their rooms and that R3's room was directly in front of R1's room. The floor plan also showed that the nurse's station was not in direct view of R1's and R2's rooms. Facility Policy and Procedure titled Ethics Preventing Resident Abuse (effective January 11, 2023) showed as follows: Policy: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. 1. Preventing resident abuse is a primary concern for this facility. It is our goal to achieve and maintain an abuse free environment. 2.n. Identifying areas within the facility that may make abuse and/or neglect more likely to occur (e.g. secluded areas) and monitor these areas on regularly scheduled basis. Facility Policy and Procedure titled Abuse Prevention (effective January 5, 2024) included as follows: Prevention: The facility shall work to prevent abuse by: A. Training all staff to recognize and report abuse. B. Care planning appropriate interventions. K. Monitoring residents with needs and behaviors which might lead to sexually aggressive behavior such as unwelcome advances or inappropriate touching/grabbing. Facility Policy and Procedure titled Reporting Abuse to Facility Management (effective January 5, 2024) included as follows: Policy interpretation and Implementation- 7. To assist one in recognizing incidents of abuse, the following definitions of abuse are provided: c. Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. The surveyor confirmed through interview and record review that the facility took the following actions to remove the immediacy. 1.Facility wide abuse in-service, which was initiated on May 30, 2024 and ongoing. Information included to recognize and report sexual behaviors and that Dementia residents are at high risk for abuse as they are unable to communicate or give consent. 2.A skin check was conducted on each resident on Dementia floor by staff, with attention directed specifically at potential areas on bodies, most vulnerable for abuse. 3.A three questions survey was conducted with each resident of the Dementia floor, to rule out additional occurrences and responses entered in resident charts with notification of V1 and V2 of any additional findings. 4.Abuse prevention questionnaire implemented to be completed by staff upon admission, quarterly and as needed. 5.Nightly hallway security implemented. Nursing staff to ensure one person is always sitting in the hallway monitoring resident's movements (audit tools attached). 6.Continued screening of background checks with denial of potential abusers. 7.Families of Dementia residents contacted for wellness checks and no additional concerns or reports of suspected abuse provided by families. 8. Quality Assurance to be completed by Director of Nursing (audit tool attached). 9.Emergency Quality Assurance conducted with Medical Director and interdisciplinary staff to discuss implementation of abatement plan.

Based on interview, and record review, the facility failed to ensure residents were free from mental abuse per facility policy. This failure resulted in R1 and R7 becoming fearful of being involuntarily discharged by V1. This applies to 2 of 5 residents (R1 and R7) reviewed for abuse in a sample of 7. The findings include: 1. Face sheet, printed 9/20/22, shows R7 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS(Minimum Data Set Assessment), dated 7/26/22, shows R7 was cognitively intact. Review of R7's care plan provided 9/21/22 shows no concerns with behavioral outbursts. Progress notes for R7, dated 8/1/22 - 9/13/22 were reviewed and failed to show R7 had any yelling or behavior outbursts documented in the clinical record. On 9/15/22 at 3:26 PM, R7 stated on 8/26/22 she had [CONDITION(S)] for her [CONDITION(S)] and returned to the facility in a bad mood. R7 stated she never yells at staff, but she became aggravated when a CNA (Certified Nurse Assistant) would not provide her ice chips due to her fluid restriction. R7 stated she yelled at the CNA and later apologized to the CNA for yelling. R7 stated the next day, V1 came into her room while she was in her wheelchair and V1 sat on her bed. R7 stated V1 told her, Unless I change my attitude, I will have to leave. R7 stated V1 then said his main concern was R7 eating ice chips. R7 stated V1 was nasty and threatening in the way he said it. V7 stated He was calm but like he meant business. But I was scared. R7 stated she became angry, felt very unwanted, felt like V1 wanted to throw her out of the facility, and R7 wanted an apology from V1. R7 stated she felt , like [V1] wanted to throw me out! Just throw me out! R7 stated she was unable to fall asleep for a few nights, would toss and turn in bed, and kept thinking about the incident. R7 stated she was concerned that if V1 kicked her out of the facility, she was not sure where she would go. R7 stated she considered which children she could live with but was concerned because her children were very busy. R7 she was also concerned because she sold her condo and felt she had nowhere to go. R7 sated her son called the ombudsman because he was very concerned about her welfare. R7 stated she spoke again with V1 and stated, I told [V1] you hurt me very bad. I was very upset. On 9/14/22 at 4:28 PM, V6 (Ombudsman) stated on 8/26/22, R7 complained that V1 told her, Things are going to have to change or you are not appropriate here. V6 stated she told V1 that she had residents approaching V6 about things V1 was saying at the facility and told V1 that what he said made them feel there was a threat they would be discharged . V6 stated V1 apologized to R7. On 9/21/22 at 3:26 PM, V1 stated he was the facility abuse coordinator. V1 stated if a resident or staff accused V1 of abuse, the resident/staff would not necessarily have to report the abuse directly to V1. V1 stated the accuser could tell a different staff person who would ultimately tell V1 of the allegation. V1 stated at that point V1 would assign another staff to investigate V1's alleged abuse. V1 stated never told R7 if her behavior did not change, she would have to leave the facility. V1 stated V6 never told V1 that R7 felt she may need to leave the facility if her behavior did not change. V1 stated, No, that was never conveyed to me. V1 stated V6 stated R7 was upset and hurt by the conversation they had about R7 needing to follow her fluid restriction. V1 stated V6 told V1 it would go a long way to clear the air with her which was what I did. V1 stated he did not write a grievance regarding R7's/V6's concerns about their conversation. Review of facility concern logs and abuse investigations, dated 1/1/22 to 8/20/22, fail to show any concerns reported regarding R7. Resident rights document provided within the facility admission packet shows facility residents have the right to make their own choices, the facility must treat residents with dignity and respect, residents must not be abused/neglected/exploited, the facility must ensure that residents are free from retaliation, residents may participate in developing a person-centered care plan that states all the services your facility will provide including the facility making reasonable arrangements to meet your needs and choices, and residents have the right to request, refuse and/or discontinue any treatment. Facility Policy and Procedure Manual Ethics - Abuse Prevention, effective 5/8/22, shows, The facility shall have zero tolerance for abuse, physical, mental, sexual, or verbal in regard to the care of residents. Abuse means the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish The policy states, The facility shall work to prevent abuse by: .B. Investigating all reports of abuse immediately C. Reporting all investigations of abuse to the Illinois Department of Public Health immediately and completing investigations within five days. D. Separating all employees accused of abuse from the accuser during investigation and permanently severing employment on all sustained findings of abuse. E. Provide adequate staffing and support for direct care staff, which shall include rotation of assignments away from verbally abusive residents I. Project residents during investigation If an employee is involved, remove from current schedule until the investigation is complete The policy shows, Identification, Abusive Situations . B. Events such as: .2. Fear of certain individuals . C. Patterns of behavior Employees who are alleged to be abusive towards residents without substantiation shall have each reported allegation kept in their personnel file for comparison. V. Investigation of Abuse A. All incidents and allegations of abuse shall be reported to the Administrator. The policy fails to show any alternative contact to whom abuse should be reported if the abuser is allegedly the Administrator. The policy shows, E. Conduct of Investigation . 3. Interview of all parties shall be in private. 2. Face sheet, dated 9/13/22, shows R1 was admitted to the facility on [DATE] and R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS, dated [DATE], shows R1 was cognitively intact, R1 was totally dependent on staff for bathing, required the extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and R1 required the extensive assistance of one staff for eating. MDS, dated [DATE], shows R1 remained cognitively intact and required total assistance from staff for transfers, eating, bed mobility, bathing, and hygiene. On 9/13/22 at 11:10 AM, R1 stated V1 was very evasive, elusive, and R1 never got straight answers from V1. R1 stated V1 did not like that R1 complained about the quality of nursing care at the facility and R1 felt V1's objective was to pronounce R1 mentally incompetent so V1 could control R1. V1 stated When the manager of the nursing home behaves the way he does, deceives, lies, manipulates- if he can't be ostracized from the profession, he needs to be closely managed and supervised. R1 stated everything V1 has done to R1 was about complete control - including repetitively requesting R1 submit to a psychological evaluation, denying hospice services, and proceeding with an involuntary discharge because R1 complained about the care R1 was receiving at the facility. On 9/13/22 at 10:11 AM, R1 stated he was being involuntarily discharged from the facility because he was told the facility did not have the ability to assist R1 with his ongoing deteriorating condition. R1 stated if V1 would have been able to document he was failing mentally, the facility would not have to been forced to deal with R1's deteriorating condition as R1 requested. R1 stated he asked V1 if he could hire a private caregiver to help him at the facility which V1 did not allow. R1 stated the involuntary discharge came out of the blue and R1 had concerns regarding retaliation from V1. R1 stated if he brings up an issue of concern, V1 takes a defensive stance. R1 stated there were several excellent caregivers at the facility, but R1 also expressed concerns to V1 about other caregivers who left him in pain and refused to turn him when requested. R1 stated it was his understanding V1's reason for discharging R1 from the facility because R1's body was deteriorating. R1 stated, V1 basically just wants to get rid of me. On 9/15/22 at 2:31 PM, V14 (R1's family member) stated on admission, R1 and the family wanted to clarify in the admission contract what would cause and involuntary discharge prior to signing the contract - which delayed the signing of the contract. V14 stated that was the first time V1 verbally threatened to involuntarily discharge R1 if V14 did not sign and return the contract to V1. V14 stated she was attempting to clarify terms of the contract for R1 who wanted to be the individual to sign the contract. V14 stated V1 provided the information in writing to clarify what would cause an involuntary discharge. V14 stated nothing in that clarification was similar to why V1 ever stated R1 must be involuntarily discharged . V14 stated R1 was threatened by V1 to be involuntarily discharged three times - once (verbally) when R1 did not sign his admission contract fast enough, second (verbally) when no staff explained to R1 why he needed to use a different mechanical lift instead of his usual mechanical lift and R1 refused, and third (in writing) after V1 blocked R1's preferred hospice from meeting with R1. Progress note written by V1 on 8/11/22, shows, Involuntary discharge paperwork filed for resident. Please see form in miscellaneous tab for more information. Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, dated 8/11/22, shows the facility determined they would transfer or discharge R1 on 9/10/22 due to, your welfare cannot be met in this facility, as documented in your clinical record by your physician. On 9/13/22 at 3:03 PM, V1 stated R1's involuntary discharge was initiated after talking to V5 (Primary Physician). V1 stated V5 wrote a note in the clinical record which stated R1's needs could not be met at the facility. V1 stated R1 did not perceive his needs are being met. V1 stated examples of R1's needs which were not perceived to be met included staff not being timely and not adequately giving R1 a bath. V1 stated R1 was upset with the way the facility staff were giving baths even when the facility staff even took time to make sure they adjusted temperatures to R1's preferences. V1 stated he never spoke to R1 about his baths. V1 stated in general R1 was unhappy with the facility CNA response time. V1 stated the facility far exceeded the hours of care required for R1's needs and were adequately staffed to provide for R1's care needs. V1 stated R1 perceives his needs were not being met and R1 was unhappy and was thus being involuntarily discharged from the facility. On 9/14/22 at 3:29 PM, V5 (Primary Physician) stated he was aware V1 was attempting to involuntarily discharge R1 from the facility. V5 stated he told R1 there was no medical reason R1 had to leave the facility. V5 stated his progress note was in no way intended to justify an involuntary discharge of R1. V5 stated he never said anything about R1 having to leave the facility. V5 stated, That was not my intent or impetus for writing the note. V5 stated he was told by V1 that the facility was not able to sustain the level of care R1 required and, since R1 had been at the facility, the facility had to allocate more hours to R1 for showers, turning, and pericare. V5 stated V1 told V5 that R1 required three times the nursing care of any resident. V5 stated R1 had essentially required total assistance with care since he was admitted due to his disease. V5 stated he was aware R1 feels that V1 intimidated R1 which is why V5 suggested R1 would be happier at a different facility. V5 stated he did not feel V1 was intimidating R1 and felt V1 was doing all he could to help R1. V5 stated he thought the involuntary discharge was essentially about R1's complaints of care - that R1 was complaining he was getting one bath a week and wanted two a week. V5 stated R1 was complaining the call light response time was a problem, especially on second shift, and that staff were in a hurry to do things. V5 stated R1's primary concern with care involved second shift nursing staff. 8/10/22 Physician Visit Note patient continues to have a gradual decline despite appropriate facility and medical staff interventions. Pt is clearly unhappy with current situation and not amenable to any interventions offered. Patient would likely benefit from transfer to a facility where he perceives his needs are being met. Of note, he has declined all Behavioral Health Services. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .we discussed care at length. We discussed progressive terminal nature of the disease and his frustrations with his dependence in all ADLs (Activities of Daily Living) He is inconsistent at times during the conversation, alternating between the care being 'excellent' and the 'best' he will get anywhere to the care is 'terrible' and 'no one cares for him' at the facility. I reinforced the importance that he is comfortable where he is. I did previously present him with a handful of facilities to look at as alternatives to [facility]. He states his daughter did this, however, they did not work his progressive disease progress, it is important that he in a facility where he is completely comfortable. Will touch base with administration as well as there is an involuntary discharge pending. On 9/14/22 at 2:58 PM, V6 (Ombudsman) stated V1 stated R1's level of care was unsustainable with his condition which was why R1 was being discharged . V6 stated she told V1 that R1 had the condition and care requirements when he was admitted to the facility. V6 then stated V1 stated R1 was being involuntarily discharged because nothing was ever good enough for R1. V6 stated V1 stated he was not discharging R1 to a different facility but to R1's daughter so she can take him home and be in charge of R1. Review of facility concern logs and abuse investigations, dated 1/1/22 to 8/20/22, fail to show any concerns reported regarding R1/R1 Family. Facility Assessment Tool, reviewed 6/15/22, shows the facility's resident disease/condition profile included the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment shows, Clinical needs, staff availability, staff training, equipment availability, medication availability, and resident interactions are all considered prior to admission. For those residents that are current residents and develop a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If the facility is unable to care for a resident safely, the resident is not admitted , or transferred to a setting that is more appropriate. The assessment shows the facility cares for residents dependent on dressing, bathing, transfers, eating, toileting, and mobility. The facility services and care offered by the facility based on resident needs include bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment. The facility also offers assistance/services of transfers, ambulation, restorative nursing, contracture prevention/care, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. The assessment shows the facility provides pain management, ostomy care, [CONDITION(S)] care, ventilator care, bariatric care, and end of life care. The facility assessment shows, Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff are caring for the resident have this information. Record and discuss treatment and care preferences. Hospice contract, signed by V1 (Administrator) and V20 (Hospice Administrator), shows the facility and R1's preferred hospice service had a contract signed and effective on 4/18/2021. The contract term was for one initial year which was then automatically renewed for a successive one year unless one party provided thirty days' notice of termination, or unless immediate termination/termination for cause occurred per contract definitions. On 9/15/22 at 10:25 AM, V21 (Hospice Administrator) stated to date the hospice service had not received, or provided, any notification of cancellation of the contract between the hospice and the facility. V21 stated the contract is automatically renewable every year unless a 30-day notice is provided by either party. On 9/13/22 at 11:00 PM, V1 stated he never had a contract with R1's preferred hospice at the facility. Physician note, dated 6/14/22, shows .Discussed concerns regarding care. Numerous concerns regarding nursing, we discussed at length. He did not feel hospice was what he wanted nor was palliative care which I felt would be much more appropriate. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . VA Hospice Referral, dated 8/15/22, shows R1 was ordered hospice evaluation and treatment on 8/15/22 at 11:31 AM. On 9/12/22 at 1:27 PM, V14 stated she approached V1 regarding utilizing their preferred hospice service and V1 told V14 that R1 was not a candidate for hospice, that V1 was going to block R1's admission to hospice, and that V5 (Primary Physician) would agree with V1. V14 stated the facility initially refused to release R1's medical information to the hospice per R1's request. V14 stated R1 had to personally demand his medical records so V14 could provide them to the hospice and eventually the facility provided the records. V14 stated V1 told V14, You don't know about this industry. This is my facility and my call, and your dad is not a candidate. V14 stated she approached the Veteran's Administration (VA) as well as the VA-associated hospice and scheduled an evaluation on 8/15/22 by the VA-associated hospice which R1 and V14 preferred to use. V14 stated the facility was aware their preferred hospice was coming to see R1 however when the hospice was visiting with R1, V1 came to the room and stated he did not give permission for R1's preferred hospice to visit R1. V14 stated V1 told the hospice representative, Who are you and what are you doing in my building? I did not give you permission to be here. It's my facility and I can tell you who comes and who goes, and you need to leave. V14 stated she told V1 the hospice and the facility already had an established relationship and contract, but V1 refused to let the hospice visit with R1. V14 stated R1 feels it is wrong and wants to pursue this hospice because he knows that the facility denying him access to his preferred hospice is wrong. V14 stated R1 is terrified regarding retaliation. V14 stated he did have good, established relationships with some direct care facility staff and R1's wife was there at the facility with dementia, and R1 did not want to start over in a different facility. V14 stated, If you heard some of the bullying that comes out of his mouth to dad and me, you wouldn't believe he was in this industry. On 9/15/22 at 2:31 PM, V14 stated the facility was aware R1 had approval from a VA physician to begin hospice with R1's preferred hospice at the time the hospice visited the facility. V14 stated as of 9/15/22, R1 was still in a holding pattern with hospice. V14 stated V1 claimed the hospice was not certified to work at the facility and V1 claims he does not know that hospice service. V14 stated V1 previously insisted on a meeting with their preferred hospice which was scheduled at the facility. V14 stated the hospice attended the meeting at the facility to reintroduce themselves to their business partners, but V1 would not attend the scheduled meeting. Email correspondence, dated 9/8/22, shows V18 (Preferred Hospice Representative) stated she met with V19 (Admissions) and V4 (Office Staff) at the facility on 6/15/22, but V1 was too busy to join the meeting. The email shows during the meeting V18 asked V19 why R1's medical records were not being provided to the hospice and V18 was told by the facility R1's records were not provided was because V1 and V5 .did not feel that [R1] was appropriate and that is why they could not share his medical records or want a hospice evaluation done. [V18] asked what the protocol was for moving forward and [V19] stated that V1 and V5 had to approve it The email shows V14 was the individual who provided the hospice R1's medical records. V18 stated on 8/15/22 R1/R1's family and their preferred hospice met in R1's room for V18 to provide hospice program information as the hospice was waiting for a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The email shows V18 and V19 discussed the full contract between hospice and the facility which was signed 4/2021. The email shows V4 (Office Staff) confirmed she did receive a copy of the existing contract when the hospice initially requested medical records for R1. On 9/13/22 at 10:11 AM, R1 stated recently a hospice chosen by R1 and his daughter, who at the time had an active contract with the facility, visited R1 to discuss hospice services. R1 stated his daughter and the hospice met with R1 in his room when V1 appeared in R1's room and denied the preferred hospice from any further contact with R1. R1 stated V1 told R1 that R1 did not have the right to approve or coordinate with a specific hospice for R1's care. R1 stated V1 told the hospice representative, 'I tell you when and if you can come, you don't come on your own!' and that is when the sparks start flying. R1 stated V1 told the individuals present only V1 could approve a hospice. R1 stated the conversation became difficult and V1 threatened to call the police who eventually arrived, and the hospice left. R1 stated V1 came to his room recently and stated he was offering R1 three different hospices from which to choose. R1 stated he told V1 he did not want to discuss hospice with V1 any further. R1 stated he would never talk to V1 regarding a psychiatric evaluation or hospice again. On 9/13/22 at 3:03 PM, V1 stated at one-point R1 and his family asked for hospice to be initiated. V1 stated after speaking with V5 (Primary Physician), it was determined hospice was not appropriate for R1 at that time. V1 stated approximately a month later, V1 and V5 determined R1 would be appropriate for hospice and V5 wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated when he confronted the family-chosen hospice company in R1's room, V1 stated R1 did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated he did not tell the hospice to leave R1's room, but that they left on their own. V1 stated residents were uncomfortable and V1 felt threatened by V14 which was why he called the police. V1 stated after he got physician orders, he brought R1 a list of facility-approved hospices from which to choose. V1 stated he documented that visit in the clinical record. V1 stated he did not care which hospice R1 chose, but that the facility has policies/procedures as to how to include a hospice within the facility. V1 stated the facility must have a contract for the facility to accept a hospice involvement for a resident. V1 stated he did not care which hospice a family used but they must follow policies/procedures of the facility when utilizing hospice. Progress note written by V1 on 9/2/22 shows, This writer spoke with resident regarding the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He said no thank you, not at this time. He stated he would let me know if he changes his mind. Email correspondence between V1 and V6 (Ombudsman), dated 9/2/22, shows V1 communicated to V6 that he provided R1 with three choices of hospice, none of which were R1's preferred choice for hospice. The email shows V1 stated he did not have a contract with R1's preferred hospice. On 9/14/22 at 3:29 PM, V5 (Primary Physician) stated V1 told V5 that V1 removed R1's choice of hospice out of the facility because the hospice was not contracted at the facility. V5 stated V1 told V5 he was attempting to get the hospice of R1's choice contracted so that R1 could utilize the hospice of his choice. V5 stated he and V1 had several conversations about working with the hospice of R1's choice so that R1 could utilize the hospice service. Email correspondence, dated 9/15/22, shows V21 (Hospice Administrator) wrote on 8/15/22, the hospice nurse arrived at the facility to meet R1 and R1's family to discuss hospice after receiving a verbal order from R1's Primary Care Physician and after speaking to the VA to obtain authorization. The email shows during the informational meeting between R1's preferred hospice and R1/R1's family, the hospice representative was told by a member of the facility leadership that she would have to discontinue the appointment, or he was going to call the police. The email shows the representative concluded the appointment. Physician note, dated 8/23/22 shows, FTT (Failure to Thrive) - slow decline with accelerated weight loss - ok to proceed with hospice per family wishes POS, printed 9/14/22, shows a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/14/22 at 2:58 PM, V6 (Ombudsman) stated she spoke with V1 a few weeks prior and told V1 that R1 wanted to utilize the hospice of his choice which was the hospice that was removed from the facility the day the police were called to R1's room. V1 told V6 the hospice was not contracted with the facility and V6 asked if they could be approved. V6 stated V1 told her that he could agree to a contract, but he would not. V1 could not trust them because they came into the facility without V1's permission. V1 told V6 that he would ask V5 for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 stated she asked why he would not offer R1's choice for hospice and V1 replied the reason was because he did not have a contract. V6 stated V1 never answered her question about pursuing a contract so R1 to use the hospice of his choice. Facility policy/procedure Hospice Policy, dated 1/5/18, shows Elmhurst will coordinate hospice services with resident's hospice of choice that is contracted with the facility for resident's overall quality of care Resident and resident representative has the preference to choose the Hospice of their choice and the facility will contract with that particular Hospice company. 4. On 9/13/22 at 10:11 AM, R1 stated he reported a CNA to the facility and V1 who refused to turn R1 in bed several times when he was in pain. R1 stated he asked the CNA to turn him to relieve his pain and the CNA refused to do so and walked out of the room. R1 stated V1 later walked into R1's room with V3(CNA) and confronted R1 about his allegation with V3 present. R1 stated V1's approach was extremely unprofessional and felt V1 wanted to believe V3's story and prove R1 was wrong. R1 stated V1 was unprofessional, cold, callous, and inconsiderate. R1 stated there were many very good caregivers at the facility, but when he reported concerns to V1, V1 became defensive and difficult toward R1. On 9/14/22 at 9:11 AM, V10 (Former MDS Coordinator) stated R1 was very intelligent, alert and oriented but could not physically control his body due to his condition. V10 stated she was interviewing R1 for an assessment and R1 reported to V10 that V3 (CNA) was mean to him overnight. V10 stated she reported the allegation to V1 verbally. V10 stated she followed up with R1 a week later regarding his concerns. V10 stated R1 was very upset because V1 brought V3 into R1's room to confront R1 about his allegation in front of V3. V10 stated V3 continued to work with R1 after the confrontation as well. On 9/13/22 at 3:03 PM, V1 stated he did not recall R1 ever complaining about care from V3 (CNA) and did not recall any complaint regarding V3. V1 denied bringing V3 into R1's room to confront R1 about his concerns with V3's lack of assistance. V1 stated, That would be unprofessional Review of facility grievance logs and abuse investigations dated 1/1/22 - 9/20/22, show no concerns identified at the facility by R1. Email correspondence with V1, dated 9/20/22, shows V1 confirmed there were no facility grievances or abuse investigations regarding R1 from 1/1/22 - 9/20/22. 5. POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS also shows a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician note, dated 8/23/22, shows, Continue to offer BH (Behavioral Health) services, patient has so far declined. Initial psychiatric assessment, dated 4/6/22, shows [R1] is referred by [his] primary care physician (PCP) for isolated behavior given his terminal illness. No prior psych history and not on any psychotropics. Pt (patient) met in room, pt had several questions about this visit and was agreeable to talk about his condition. Patient states he has a terminal illness and lost some weight due to muscle wasting, no strength on his legs and in a lot of pain, hardly sleep at night states he is adjusting with is problem and denies any need of medications Pt was recommended to start on [MEDICATION(S)] initially, per facility request changed to [MEDICATION(S)] given patent's terminal illness and adjustment difficulty. However, family was agreeable, but patient refused to be on antidepressant. Patient doesn't think he need to be on any medication even if he has sleeping difficulty. Psychiatric Subsequent Assessment, dated 5/6/22, shows R1 was seen for symptoms of depression by V15 (Psychiatric Nurse Practitioner). On 9/13/22 at 10:11 AM, R1 stated within three weeks of his stay at the facility, V1 wanted to have a psychological evaluation performed on R1. R1 stated V1 began with welcoming conversations but R1 stated he later felt V1 wanted to test R1 to see how mentally impaired R1 was. R1 stated when V1 asked if R1 would submit to a psychological evaluation, R1 stated he felt like he misunderstood V1 and asked, Don't you mean a physical evaluation? R1 stated V1 never gave a straight answer. R1 stated V1 approached R1 several times requesting R1's permission for a psychiatric/psychological evaluation and R1 stated he never gave consent for a psychiatric/psychological examination. R1 stated his relationship with V1 went downhill after that. R1 stated V1 was antagonistic, argumentative, and demanding. R1 stated there were dozens of incidents and conflict with V1 since his admissio [TRUNCATED]

Based on interview and record review the facility failed to assess and monitor a resident for signs and symptoms of [DIAGNOSES REDACTED], notify the physician of a significantly low blood sugar level, and monitor a resident after a significant drop in blood sugar. As a result of the facility failure, R1's blood glucose dropped to critically low levels requiring hospitalization . This applies to one resident of three (R1) reviewed for blood sugar monitoring. Findings include: The face sheet showed R1 was a [AGE] year old resident who was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The progress note dated 5/18/15 at 4:38 pm showed R1's blood glucose level was 57mg/dl. There was no documentation to show that R1's low blood glucose level was treated and that the physician was notified of this low blood glucose level. On 5/18/15 at 11:19pm, the progress note shows that at 10:30pm, R1 was noted with hallucinations, he was sweating and had increased lethargy. R1's blood glucose level was checked and it was 22mg/dl (normal 80), and [MEDICATION NAME] was given. The physician was notified and orders were received to repeat [MEDICATION NAME] doses when blood glucose level was 50 or below. After 30 minutes, R1's blood glucose level was 48mg/dl. Another dose of [MEDICATION NAME] was given at 11:00pm and R1's blood glucose was to be checked again at 11:30pm and R1 to be monitored closely. A review of R1's record did not show any evidence that R1's blood glucose level was checked at 11:30pm and that R1 was closely monitored. The progress note dated 5/19/15 at 5:00am shows that at 3:00am facility's nurse heard R1 mumbling words. R1's blood glucose level was 33mg/dl. R1 was given juice (kind of juice not documented) with sugar and R1's blood glucose at 4:50am was 96mg/dl. R1's blood glucose level was rechecked 1 hour and 50 minutes after R1 was given the juice with sugar and there was no documentation to show that the physician was notified of R1's low blood glucose level noted at 3:00am. The next documentation on the progress note is on 5/19/15 at 8:55am which states that R1's blood glucose level was 47mg/dl. The physician was paged. On 5/19/15 at 9:23am, R1's blood glucose level was 50mg/dl. R1 was encouraged to eat a peanut butter and jelly sandwich, but the resident refused. On 5/19/15 at 9:40am, R1 was found unresponsive, paramedics were called and R1 was transferred to the local hospital. On 5/26/15 at 3:32pm, E8 (Nurse) who worked on 5/18/15 during the 3-11pm shift) stated on 5/19/15 at 10:30pm, R1 appeared to be hallucinating. R1's blood glucose level was 22mg/dl. She gave [MEDICATION NAME] and notified the physician and received an order to repeat the [MEDICATION NAME] if R1's blood sugar level was less than 50mg/dl and to monitor closely. E8 further stated that she gave the 2nd dose of [MEDICATION NAME] at or around 11:00pm as R1's blood glucose level was at 48mg/dl. She stated she gave report to E4 (oncoming night nurse) and informed E4 that R1's blood glucose level should be checked around 11:30pm. E8 also stated the resident's blood glucose level should be checked 30 minutes after the administration of [MEDICATION NAME] according to the pamphlet insert of [MEDICATION NAME] that she read. On 6/1/15 at 10:05am, E4 acknowledged getting report about R1's condition from E8. E4 stated she heard R1 mumbling words at 3:00am; R1's blood glucose level was 33mg/dl; she gave juice with sugar and R1's blood glucose level was 96mg/dl at 4:00pm. E4 did not say that she notified the physician of R1's low blood glucose level. On 6/2/15 at 10:30am, Z1 (Physician) stated he would have expected to be notified when the blood glucose level was below 70mg/dl as per his orders. He acknowledged being notified on 5/18/15 at 10:30pm and gave orders for [MEDICATION NAME] and he was notified when R1 was found unresponsive the morning of 5/19/15. On 6/1/15 at 10:02am, E3 (Director of Nursing) stated that the nurse should have informed the doctor every time the BS levels were low. E3 stated she would have expected the nurses to be checking frequently and documenting the condition of the resident beginning with recognition of the low blood sugar of 57 on 5/18/15 at 4:38pm. E3 went on to add that she doesn't recall any recent in-service regarding management of Diabetic residents given to nursing staff. On 6/4/15 at 3:00pm, Z2 (Pharmacist) stated that residents who receives [MEDICATION NAME] for low blood glucose levels, should be monitored 15 minutes after administration. [MEDICATION NAME] can be administered 1 more time after waiting 15 minutes if necessary. In addition, Z2 stated once the resident's blood glucose level is within normal limits, oral glucose tablets, gel or food is to be taken to prevent another drop. Review of the Training/In-service provides did not produce any related in-service for the past 4 years except for how to use the '[MEDICATION NAME]' in November 2014. Review of the Standards of Medical Care in Diabetes - 2014, the standards state for [DIAGNOSES REDACTED], glucose is the preferred treatment for [REDACTED]. Once the levels return to normal, the individual should consume a meal or snack to prevent recurrence of [DIAGNOSES REDACTED]. [MEDICATION NAME] should be prescribed for all individuals at significant risk of severe [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] unawareness or 1 or more episodes of severe [DIAGNOSES REDACTED] should trigger re-evaluation of the treatment regimen. [MEDICAL CONDITION] prevention is a critical component of diabetes management.