Every finding on record at Axiom Gardens of Flora

Based on interview and record review, the facility failed to ensure only staff with appropriate competencies provided resident care. This failure has the potential to affect all 62 residents living in the facility. The findings include:On 4/28/26 at 9:26 AM, V5 (Certified Nursing Assistant/CNA) stated Unit Aides (UA) can perform vital signs, answer call lights, make beds, and pass snacks and ice water, but they are not allowed to do any hands-on care.On 4/28/26 at 10:21 AM, R5, who was alert to person, place, and time, stated V8 (UA) helps them with their bed bath sometimes. R5 stated V8 helps them wash the areas of their body they cannot reach.On 4/28/26 at 10:29 AM, R12, who was alert to person, place, and time, stated (V8) works as another CNA when you all (public health surveyors) aren't here. R12 stated V8 has assisted CNAs provide incontinence care because R12 is a two person assist. R12 also stated that prior to this survey, V8 was working on the hall as another CNA, but once this surveyor entered the building they moved V8 to a different location. On 4/28/26 at 10:37 AM, R4, who was alert to person, place, and time, stated V8 has helped them transfer to their wheelchair. R4 also stated V8 has provided support for them during transfers, assisted them with incontinence care and rolling from side to side while in bed to get cleaned after an episode of incontinence.On 4/28/26 at 10:45 AM, R11, who was alert to person, place, and time, stated V8 has helped them with showering in the past.On 4/28/26 at 11:21 AM, R8, who was alert to person, place, and time, stated V8 has never helped them with showering, but has helped them get dressed including putting their underwear, socks, pants and shoes on in the morning. On 4/28/26 at 12:00 PM, V3 (CNA) stated prior to this survey, they were working with V8 as another CNA on the 100 hall. V3 stated the facility had 2 call-ins from CNAs leaving them short and only leaving V8 to assist them to perform CNA duties. V3 stated when this surveyor entered the building, administration moved V8 to another hall that did not have any residents who were 2-person assist. V3 stated V8 works as a CNA only when the facility is very short staffed on CNAs. V3 stated V8 has helped them do CNA work in the past. V3 stated V8 has helped them with transferring a resident using a mechanical lift, other types of transfers of residents, and dress residents while V3 has supported the resident. V3 stated they have also worked with the other Unit Aide, V16 on night shift who has performed CNA duties. V3 stated they have witnessed V16 escorting residents to the restroom who are known to be a 1-person assist with toileting. On 4/27/26 at 2:46 PM, V8 states that she is not involved in patient care.On 4/28/26 at 1:10 PM, this surveyor attempted to reach V16 by phone for an interview and was unsuccessful.On 4/28/26 at 1:51 PM, V2 (Director of Nurses) stated CNA job duties include assisting residents with their needs, including activities of daily living assistance like hygiene, bathing, transfers, and incontinence care. V2 stated working as a CNA requires certification by completion of a 6- or 8-week program or the person must be enrolled in the licensed practical nurse program at a college. V2 stated to work as a UA does not require any formal training or education. V2 stated UAs performing CNA duties is not acceptable because the UAs have not been properly trained and certified to provide that level of care. V2 stated UAs should not be used in place of CNAs but they may assist CNAs by making beds, stocking linens, other supplies, and passing ice water and snacks. V2 stated UAs can also brush hair and paint nails. V2 stated the reason UAs should not be providing resident care is because they are not properly trained or certified and they could cause injury or other adverse effects to residents. V2 stated she had not been made aware of or witnessed any UAs working in the place of CNA staff or performing CNA duties.The facility's job description for Unit Aide dated 11/1/24 documents, The Unit Aide work involves performing a variety of helper tasks assisting the nursing staff. The same document states essential duties for a UA include cleaning, assisting with cutting a resident's food up and opening cartons at mealtimes, and transportation of residents within the facility. Qualifications for this position listed on the document are the person must be at least [AGE] years of age, have long term care experience preferred and ability to understand, speak and read and write the English language.The facility's job description for CNA's dated 5/2/17 documents a CNA is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential duties listed for a CNA include assisting residents with eating, performing personal hygiene and bathing, and rolling, turning and repositioning in bed and transfers of residents. Qualifications for CNA's listed on this document are current certification as a Certified Nursing Assistant in accordance with the laws of the state of practice, must be at least [AGE] years of age, be certified in basic life support, and be able to understand, speak, read and write the English language. The facility's Daily Census 4/26/26 (with a print date of 4/27/26) documents there are a total of 62 residents residing in the facility.

Based on observation, interview, and record review the facility failed to implement fall prevention interventions for 2 of 3 residents (R1 and R2) reviewed for accidents/incidents in the sample of 12.The findings include:1. R1's admission Record documents an admission date of 1/21/22 with diagnoses including displaced fracture of right femur and dementia.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 00 indicating R1 is not cognitively intact and not aware of safety needs. The same MDS documents R1's mobility was supervision/touching assistance prior to her most recent fall on 4/12/26.R1's IDT (Interdisciplinary Team) Fall Committee Meeting Note dated 4/12/26 documents R1 had experienced an unwitnessed fall in the dining room on the same date.R1's X-ray report dated 4/12/26 documents an Impression of Acute hip fracture of right.R1's records from the local hospital document that R1 was admitted to the hospital on [DATE] and had surgical repair for a comminuted and displaced right hip intertrochanteric fracture on 4/14/26.R1's most recent Care Plan documents R1 has a focus area for an actual fall with serious injury with a revision ate of 11/21/23. Interventions for this focus area include resident experienced fall from sustaining a major injury, intervention for this event includes utilizing pillows and/or positioning device to aide and assist in positioning and bed parameter awareness only with an initiation date of 2/6/26 and experienced fall in DR (Dining Room) sustaining a major injury, intervention for this includes providing with hip protector clothing when out of bed and refer to therapy for evaluation and treatment if indicated with an initiation date of 4/12/26.On 4/27/26 at 1:07 PM, V3 (Certified Nursing Assistant/CNA) when asked about R1's fall precautions, stated they are aware R1 has only 1 pair of hip protector underwear that they know of, but that pair of underwear have been in the laundry since 2 days ago.On 4/27/26 at 1:16 PM, V4 (CNA) who was working on the hall R1 was residing on, stated they are not aware of R1 having any special underwear with built in hip padding.On 4/27/26 at 1:20 PM, this surveyor observed R1 in the large common area near her room sitting in her wheelchair with her legs off their prop and dangling and attempting to stand up from her wheelchair. This surveyor notified V15 (Social Services) who was passing by, and she assisted R1 to get her repositioned in her wheelchair and her legs elevated.On 4/27/26 at 1:41 PM, observed R1 lying in bed and R1 did not have hip protecting underwear on at that time. V3 was also present at that time. This surveyor asked V3 if R1 had her hip protector underwear on prior to lying down, V3 stated R1 had not had her hip protector underwear on since they had gotten there that morning and assisted R1 to get dressed for the day.On 4/28/26 at 10:14 AM, observed R1 lying in bed and R1 had no hip protector underwear on at this time. V14 (CNA) was also present at that time and witnessed R3 without her protective underwear. V14 stated they knew R3 was supposed to have hip protector underwear but did not know where they were at. V14 stated the last time they saw the hip protector underwear was last week on Tuesday or Thursday. V14 stated they observed them in a box at the nurse's station. V14 stated they had never placed the protective underwear on R1 or seen the underwear on R1 since R1 had returned from the hospital.On 4/28/26 at 10:16 AM, while still in R1's room, V6 (CNA) opened one of the drawers on R1's dresser and brought out a pair of the padded underwear. V6 stated R1 has 2 pairs of padded underwear. V6 stated they only put the padded underwear on R1 when she is up in her wheelchair because she has frequent urinary incontinence. V6 stated R1 did get up in her wheelchair to eat breakfast this morning. When this surveyor asked V6 if R1 had her padded underwear on when she was in her wheelchair for breakfast, V6 stated no, because one pair of padded underwear was in the washer at that time and the other pair weren't clean.2. R2's admission Record documents an admission date of 3/13/26 with diagnoses including atrial fibrillation, Parkinson's disease, dementia and unsteadiness on feet.R2's MDS dated [DATE] documents R2 has a BIMS score of 3 indicating R2 has impaired cognition and unaware of safety needs. The same MDS documents R2 is a substantial/maximum assistance for mobility.R2's most recent Care Plan documents R2 has a focus area for R2 being at high risk for falls related to poor cognition, impaired balance and safety awareness dated 3/19/26. Interventions for this focus area include ensuring resident is wearing appropriate footwear when up and following facility fall protocol both dated 3/19/26.R2's IDT Fall Committee [NAME] Note dated 4/13/26 documents R2 was found in the floor of his room by his bed attempting to ambulate with no assistance. New intervention documented in the fall investigation was for staff to always leave R2's door open for increased observation.On 4/27/26 at 2:41PM, observed R2's door to his room completely shut. When this surveyor knocked and opened R2's door, observed R2 lying on his bed. On 4/28/26 at 9:38 AM, observed R2's door again shut to his room. When this surveyor knocked and opened the door to the room observed R2 sitting on the side of his bed with his feet resting on the floor with his walker within reaching distance. On 4/27/26 at 1:23 PM, V5 (CNA) stated they could not remember any fall interventions for R2 specifically. V5 stated they did remember R2 is to be escorted when he is up ambulating. V5 stated they did know where to find fall interventions for the residents at a binder located at the front hall nurse's desk.On 4/28/26 at 1:51 PM, V2 (Director of Nurses) stated all CNAs can look in the communication book located at the nurse's station of the front hallway for any residents' specific fall precautions. V2 stated fall precautions for all residents can be looked up in CNA's electronic health records they have access to. V2 stated all nursing staff should be aware of resident's fall precautions or at least know where to find them. V2 stated nursing staff are always free to come and talk to them or V1 (Administrator) if they have any questions. V2 stated she does not remember all of R1's fall precautions but does remember R1 has padded underwear to protect her hips if she falls. V2 stated if R1 is out of bed she should have her padded underwear on, but when she is lying down, she doesn't have to wear them. V2 stated R2's fall precautions most recently implemented were for R2's door to remain open so he can be observed frequently. When asked if there was any reason why R2's door should have been shut those two times this surveyor observed it, V2 stated not unless care was being performed or R2 or his roommate had requested to have the door shut. V2 stated it would be shut upon request of R2 only after re-education had been given as well.The facility Fall Prevention Program policy dated 11/21/17 documents, Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained.

Based on interview and record review, the facility failed to implement infection tracking, contact tracing and environmental infection control precautions per its policy for one resident (R2) with a presumptive diagnosis of Scabies out of 7 residents reviewed for infection control in the sample of 7. Findings include:R2's admission Record documented an admission date of 8/8/26 and included diagnoses of Paranoid Schizophrenia and Unspecified Convulsions. R2's Minimum Data Set assessment dated [DATE] documented R2 has moderate deficits in cognition. R2's Care Plan dated 12/24/25 documented a problem area of I have a rash of the stomach, left hand, bilateral sides, and back related to allergies, Eczema, Psoriasis. Date Initiated: 12/24/2025. R2's Hospital Discharge summary dated [DATE] documented, Admitting Diagnoses: 1. Hypercapnia. 2. Dehydration. During the admission, she also required management for a diffuse pruritic rash resembling scabies, for which permethrin cream was applied and subsequently washed off (on 3/11/26). She was placed in isolation due to the history of MRSA (Methicillin- Resistant Staphylococcus Aureus) and current rash. R2's Hospital Transfer Orders for Receiving Facility document dated 3/13/26 documented, Patient isolation status: Contact. Possible Scabies. Nursing Progress Notes dated 3/13/26, authored by V5 (Registered Nurse/RN) documented the following: 1:35pm: Generalized rash on body, denies itching. 1:54pm: readmitted to (the facility), van by staff, skin pink, warm and dry, lung sounds diminished, respirations equal, abdomen soft and non-tender, bowel sounds active. Alert and able to make needs known. Propels self in wheelchair. Denies pain. A Resident Infection Control and Antimicrobial Log dated March 2026 contained no documentation that R2 had a rash and was treated with permethrin cream on 3/11/26. On 3/17/26 at 10:40AM, V17 (Housekeeping/Laundry) stated residents who have scabies are to be on contact isolation, their room is to be deep cleaned with all curtains removed and laundered, their clothing must be washed and dried on the hottest settings, and non-washable belongings should be bagged up. V17 stated she was not aware of any residents having scabies within the past 60 days nor has her department been notified of any resident's room or laundry requiring isolation processing. On 3/17/26 at 11:00AM, V16 (Advanced Practice Nurse/APN) stated she had not been informed that R2 had been treated at the hospital for scabies until she came to the facility today. V16 stated if the hospital diagnosed R2 with scabies, a skin audit should be done for any resident having contact with the affected resident, and treatment must include, in addition to topical medication, environmental cleaning and isolation laundry precautions as well as contact isolation for any residents found to be infected. V16 stated it is pointless to treat scabies without implementing infection control precautions. V16 stated several residents at the facility, including R2, have had ongoing issues with skin rashes. On 3/17/26 at 1:50PM, V3 (Assistant Director of Nurses/Infection Control Nurse) stated she did not add R2's scabies diagnosis and treatment to the facility's March 2026 Infection Control Log since the hospital had made the diagnosis and provided the treatment, not the facility. V3 confirmed there had been no follow up skin checks or contact tracing to see if other residents had been affected. On 3/18/26 at 8:45AM, V5 (Registered Nurse/RN) confirmed she had readmitted R2 to the facility on 3/13/26 following R2's hospitalization. V5 stated R2 went back into the same room with her roommate (R7). V5 stated she did not review R2's hospital discharge or transfer paperwork and did not get verbal report from the hospital. Therefore, V5 was unaware R2 had been diagnosed with and treated for scabies, so no infection control protocols such as contact tracing, environmental cleaning, or contact isolation had been implemented. V5 stated she did fax R2's discharge paperwork to V16's (APN) office, although she had not called V16 to report R2 had a rash upon readmission. A Scabies Control Policy dated 11/28/12 documented Purpose: To eliminate and treat irritated skin areas and prevent the spread of infection. 6. Inspect all residents who have had contact with the resident who has been diagnosed. 8. DON and Infection Control Nurse will assess situation to determine extent of preventative measures. Procedure: 5. Bag linen and clothing and send to laundry. Wash, using detergent and dry in a dryer which is at least 160 degrees Fahrenheit. 6. Thoroughly vacuum carpet, upholstery and unprotected mattresses. Unprotected pillows shall be washed, disinfected, and dried. 7. Disinfect all resident furniture, equipment, and personal care items at the conclusion of the resident's treatment, (and) some articles may need to be dry cleaned. 8. Treat all affected individuals at the same time, if possible. A Facility Matrix dated 3/17/26 documented a total of 62 residents living at the facility.

Based on observation, interview, and record review the facility failed to provide a functioning call light in the south hall shower room. This has the potential to affect all 36 residents that reside on the south hall reviewed for call lights in a sample 52. Findings include: On 02/26/26 at 11:50 AM, V2 (Director of Nursing) stated they use the two shower rooms on the south halls for all the residents on the south hall. On 02/26/26 at 12:24 PM, V21 (Certified Nursing Assistant/CNA) stated the shower room across from the nurses' station and the one next to it are both used to give showers to residents on the south halls.On 02/26/26 at 12:36 PM, the call light in the shower room across from the nurses' station on the south hall did no function and was not accessible from the floor. The shower stall had water on the floor and walls giving the appearance the shower stall had just been used.On 02/26/26 at 12:39 PM, V21 (CNA) stated it has been a couple days since the call light has worked in that shower room.On 02/26/26 at 12:53 PM, V24 (Maintenance) stated he does not have a work order for the call light in the shower room. V24 stated he was unaware it was not working. V24 flipped the switch of the call light a couple times and stated, the call light does not work. V24 stated he will look into getting it repaired and get a string on it to make sure it can be reached from the floor if needed. The undated facility policy titled, Preventive Maintenance and Inspections documents: in order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition. Routine inspections promote safety throughout the facility and aid in keeping fixtures and equipment in good working order and operating in accordance with manufacturer's guidelines. Regular inspection, testing, and replacement or repair of equipment and operational systems contribute to preservation of the facility's assets. Work orders and service requests: a system for work orders is established among all staff, elders, and employees that provides rapid communication regarding equipment problems. The Midnight Census report dated 02/23/26 documents that there are a total of 36 residents that reside on the south hall.

Based on interview and record review the facility failed to attempt non-pharmacological interventions prior to administering a PRN (as needed) psychotropic medication for 1 of 5 residents (R7) reviewed for unnecessary medications in a sample of 52.Findings include:R7's admission record documents R7 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia with behavioral disturbance, cerebrovascular disease and oral phase dysphagia.R7's MDS (Minimum Data Set) dated 1/5/2026 documented R7 has a BIMS (Brief Interview for Mental Status) score of 1 out of 15 total, which indicates R7 has severe cognitive impairment.R7's Care Plan documents a Problem of resident is/has potential to be physically aggressive towards staff during care with an initiation date of 7/19/23 with interventions including: Monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated: Intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, If response is aggressive, staff to walk away calmly and approach later with initiation dates 7/19/2023.R7's MAR (Medication Administration Record) documented on 1/30/2026, R7's physician ordered Lorazepam 0.5 mg (milligram) by mouth every 8 hours as needed for combativeness related to dementia with other behavioral disturbance. This same MAR documented R7 was administered the medication on 2/21/2026 at 4:14pm by V12 (Licensed Practical Nurse/LPN).There were no progress note are entries into R7's EMR (Electronic Medical Record) for the date of 2/21/2026.R7's behavior tracking dated 2/21/2026 documented with a check mark that R7 has no observable behaviors for that day.On 2/25/2026 at 1:00pm, V12 (LPN) said she did not attempt any non-pharmacological interventions prior to administering R7 the PRN lorazepam. V12 said she didn't know non-pharmacological interventions needed to be attempted prior to administering a PRN psychotropic medication to a resident. V12 said it is ok not to attempt any non-pharmacological interventions because R7 didn't take the PRN lorazepam very often and only took the medication once in a while.On 2/25/2026 at 2:15pm, V2 (Director of Nursing) said she expected the nursing staff to perform and document non-pharmacological interventions prior to administering a PRN psychotropic medication to any resident admitted to this facility.The facility policy titled Psychotropic Medication-Gradual Dose Reduction with revision date of 2/1/2018 documented the following: Purpose: to ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions.

Based on observation, interview, and record review the facility failed to perform nail care for 3 of 3 residents (R22, R44, and R68) reviewed for ADL (Activities of Daily Living) care in a sample of 52.Finding include:1. R44's admission Record documents an admission date of 02/26/21 with diagnoses including: adult pulmonary Langerhans cell histiocytosis, moderate protein calorie malnutrition, dementia, delusional disorders, anemia, Alzheimer's disease, hyper lipidemia, acute coronary thrombosis, altered mental status, depression, disorientation, hearing loss, and dysphagia. R44's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 01, indicating R44 has severe cognitive impairment. The same MDS documents R44's personal hygiene performance as substantial/maximal assistance indicating helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 02/23/26 at 3:00 PM, 02/24/26 at 12:32 PM, 02/25/26 at 12:35 PM, and 02/26/26 at 12:17 PM, R44's nails had a black substance under her fingernails of both hands. 2. R22's admission Record documents an admission date of 04/26/25 with diagnoses including: wedge compression fracture of unspecified thoracic vertebra, multiple fractures of pelvis without disruption of pelvic ring, fracture of unspecified part of left clavicle, other intervertebral disc degeneration of lumbar region with discogenic back pain only, Alzheimer's disease, muscle wasting and atrophy, dementia, and age related osteoporosis. R22's MDS dated [DATE] documents a BIMS score of 03, indicating R22 has severe cognitive impairment. The same MDS documents R22's personal hygiene performance as substantial/maximal assistance indicating helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 02/23/26 at 2:23 PM, 02/24/26 at 12:32 PM, 02/25/26 at 12:35 PM, and 02/26/26 at 12:17 PM, R22's nails had a black substance under her fingernails of both hands. On 02/26/26 at 12:18 PM, V22 (Family) stated R44's nails were dirty and need cleaned and R22 and R44 will eat with their fingers. On 02/26/26 at 1:07 PM, V19 (Certified Nursing Assistant/CNA) stated R22 and R44's nails are dirty and they do need to be cleaned. V19 stated nails are supposed to be cleaned on shower days and anytime they are noticed to be dirty in between. 3. R68's admission Record documents an admission date of 08/08/25 with diagnoses including: acute and chronic respiratory failure, severe sepsis with septic shock, encounter for other orthopedic aftercare, displaced fracture of second metatarsal bone, right foot, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, major depressive disorder, hyperaldosteronism, extrapyramidal and movement disorder, unspecified convulsions, anxiety disorder, and unilateral primary osteoarthritis of the left knee. R68's MDS dated [DATE] documents a BIMS score of 10, indicating R68 has moderately impaired cognition. The same MDS documents that R68 requires substantial/ maximal assistance with lower body dressing, dependent for putting on/taking off footwear, and partial/moderate assistance with personal hygiene. On 02/26/26 at 2:41 PM, R68 stated she needs her toenails trimmed. On 02/26/26 at 2:41 PM R68's toenails were observed to be long and in need of being trimmed. On 02/26/26 at 2:42 PM, V1 (Administrator) stated R68's toenails do need trimmed and she will get someone down to take care of it. The facility policy dated 01/25/18 titled, Nail Care documents: 1. Observe condition of resident nails during each time of bathing, note cleanliness, length, uneven edges, hypertrophied nails. 4. After bathing, use orange stick, and clean debris from around and under finger and toe nails.

Based on observation, interview, and record review the facility failed to provide supplementation to maintain or gain weight for residents with low body weights for 1 of 5 residents (R10) reviewed for nutrition in a sample of 52.Findings include:R10's admission Record documents an admission date of 01/02/26 with diagnoses including: chronic obstructive pulmonary disease, respiratory failure, severe protein calorie malnutrition, chronic diastolic heart failure, disorder of bilirubin metabolism, rhabdomyolysis, encephalopathy, hyperlipidemia, chronic cholecystitis, gastro esophageal reflux disease without esophagitis, neuromuscular dysfunction of bladder, and essential hypertension. R10's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 11, indicating R10 has moderate cognitive impairment. R10's Care Plan documents a focus area of R10 has pressure ulcers dated 01/14/26 with an intervention of monitor nutritional status, serve diet as ordered, and monitor intake and record dated 01/13/26. R10's Care Plan also documents a focus area of R10 is in a terminal condition and is receiving hospice services dated 01/14/26. R10's care plan does not document a focus area of nutritional status or weight status. On 02/25/26 at 9:50 AM, R10 stated he is tired of eggs, there are a lot of eggs here. R10 stated he gets what is on the ticket (the dietary ticket) but he does not get extra protein that he is aware of, or a drink that is thicker like a milk shake, or a little cup of anything that looks like ice cream. R10 stated, he will get milk sometimes and coffee, he does like coffee. R10 stated he eats the food but it is not that great to him. R10 stated the coffee is better than some he had at times when he was in the military though. R10 stated, he might try some of those other food items if he liked them, but he has never had them. On 02/26/26 at 1:52 PM, V9 (Dietary Manager) stated R10 is very thin and he was aware he admitted to the facility underweight but he did not give him any type of nutritional supplementation but he did refer him to V23 (Registered Dietician).On 02/26/26 at 2:26 PM, V1 (Administrator) stated R10 did admit to the facility very underweight and even though he is currently on hospice, he should have received some nutritional supplementation to either maintain weight or assist with weight gain. On 03/02/26 at 9:29 AM V23 (Registered Dietician) stated, R10 was admitted on [DATE] and she did his initial assessment on 01/24/26. V23 stated R10 was 75 inches tall and 121.3 pounds. V23 stated that is considered underweight for a male of his height. V23 stated an ideal body weight for someone of that height would be 176 - 215 pounds. V23 stated that R10 admitted underweight and was on hospice when she evaluated him, he did not have any weight loss then, so she was going to monitor to see if his weight was stable or if he had any weight loss before she recommended anything. V23 stated, she can see where R10 is down a couple pounds now and is about 118 pounds. R10's weights and vitals summary documents: on 01/02/26 at 2:55 PM R10's weight was 121.1 pounds and on 02/04/26 at 2:19 PM R10's weight was 119.0 pounds. R10's Nutrition assessment dated [DATE] documents: most recent height of 75 inches tall at 01/03/26 at 11:21 AM with a most recent weight of 122.3 pounds on 01/05/26 at 8:41 AM. R10's BMI (Body Mass Index) is listed as 15.3% (underweight). R10's oral/nutrition intake for food is listed as 26-75% of estimated needs met and physical/mental function is alert, hearing and vision are within normal limits. The nutritional approach adequate to meet nutritional needs as evidenced by: admission assessment: weight (1/5/26) 122.3 pounds with a BMI of 15.3 % (underweight), diet is regular with mechanical soft texture with nectar thick liquids and PO (per oral) intake is reported as 0-100% of meals with an average of 50% noted per the 14 ay look back report. R10 has a PEG (Percutaneous Endoscopic Gastrostomy) tube that is not currently in use. No skin breakdown is reported at this time. Hospice care services are in place. Continue current plan and V23 to follow up as needed. The facility document from the Guideline & Procedure Manual 2020 titled, Fortified food, Supplements, and Snacks documents: residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for fortified foods, snacks, or supplements in order to increase nutritional intake, Residents will be evaluated by the Registered Dietitian when additional nutritional intervention is warranted. Commercially prepared supplements, including (brand name supplement) products, will be ordered by the physician. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order. 2. resident classified as persons at risk and or with poor nutritional intake, declining intake, weight loss, and/or pressure ulcers will be referred to the Registered Dietician. The facility document from the Long Term Care Diet Manual 2022 titled, Unintentional Weight loss documents: unintentional weight loss can have serious implications for older adults. Studies indicate unintentional weight loss can lead to malnutrition, poor wound healing, risk of pressure ulcers, decline in function and inability to fight infection. Unintentional weight loss can be rapid or sometimes slow and insidious. It is important that systems are in place to detect, assess and develop and individualized plan of care for persons with unintentional weight loss. Other risk factor for unintentional weight loss include dementia, a low BMI (<18.5), dentition problems or poor condition of teeth, dysphagia, depression, Parkinson's disease, medications environmental factors, restrictive diets, treatments such as chemotherapy and radiation, COPD (chronic obstructive pulmonary disease), diarrhea and others.

Based on observation, interview, and record review the facility failed to follow the facility's policy and perform pain assessments to assist with pain management for 1 of 1 resident (R68) reviewed for pain in a sample of 52.Findings include:R68's admission Record documents an admission date of 08/08/25 with diagnoses including: acute and chronic respiratory failure, severe sepsis with septic shock, encounter for other orthopedic aftercare, displaced fracture of second metatarsal bone, right foot, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, body mass index of 50.0-59.9, major depressive disorder, and unilateral primary osteoarthritis of the left knee. R68's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 10, indicating R68 has moderately impaired cognition. Section J of the same MDS documents that R68 receives PRN (as needed) pain medication and receives non-medication interventions for pain. Under Pain Assessment Interview, it documents that R68 sated no to have you had any pain or hurting at any time in the last 5 days. R68's Care Plan documents a focus area of R68 has chronic pain relating to depression, fracture prior to admission to long term care, medical procedure, and surgical procedure and has Celebrex, Tylenol, and hydrocodone as ordered dated 9/23/25 with interventions including: Administer analgesia as per orders. Give 1/2 hour before treatments or care, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions per facility protocol. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function, identify, record and treat the resident's existing conditions which may increase pain and or discomfort examples include arthritis, neuropathies, cancer, osteoporosis, fractures, shingles, peripheral vascular disease, ulcers, contractures, parathesis relating to stroke, monitor/document for probable cause of each pain episode. Remove/limit causes where possible, monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls and report occurrences to the physician, monitor/record pain characteristics per facility protocol: quality (e.g. sharp, burning); severity (1 to 10 scale); anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors and relieving factors, monitor/record/report to nurse any sign or symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) body (tense, rigid, rocking, curled up, thrashing), monitor/record/report to nurse loss of appetite, refusal to eat and weight loss, monitor/record/report to nurse resident complaints of pain or requests for pain treatment, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (Range or Motion), withdrawal or resistance to care, provide the resident with reassurance that pain is time limited. Encourage to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound, provide the resident and family with information about pain and options available for pain management, discuss and record preferences, report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs or symptoms or complaints of pain or discomfort, the resident is able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain all dated 10/23/25.On 02/23/26 at 6:50 AM, R68 was observed lying in bed, with her face grimaced. R68 stated, she did not want breakfast today, it just hurts. R68 stated, she gets some pain medication and sometimes it helps and sometimes it doesn't. On 02/24/26 at 11:53 AM, R68 was observed in her wheelchair in the hallway by the nurses' station heading towards the dining room. R68 had a slight grimace on her face and was trying to shift in her wheelchair. R68 stated her back hurts.On 02/24/26 at 12:18 PM, R68 asked the CNA (Certified Nursing Assistant/CNA) in the dining room if she could move from her wheelchair to a regular chair to maybe help with her back hurting. R68 moved to a regular chair and stated, it was helping her back some. On 02/25/26 at 1:22 PM, R68 stated her back hurts, she is going to lay down and hopefully that will help her back. R68 stated she was given a pain pill but sometimes it still hurts. On 02/26/26 at 1:07 PM, V8 (Minimum Data Set Coordinator/MDS) stated, they do not have any pain assessments for R68 besides what is in the MDS. V8 stated, they will document a numerical value for her pain when they give her pain medication. On 02/26/26 at 1:18 PM, V19 (CNA) stated R68 does complain of pain at times, it seems like she has complained of more pain since she has returned from the hospital. The facility policy dated 07/06/18 titled, Pain Management Program the resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the present of pain. The pain management program includes the following components: documentation of pain assessment and monitoring, assessment of non-verbal residents for signs and symptoms of pain, and quality assurance audit activities to monitor the program's effectiveness. 1. pain assessment protocol will be initiated under any of the following situations: any indication of pain based on the pain assessment performed for each resident at the time of admission and with any condition change and/or incident associated with the potential of pain, when the MDS triggers an indication of pain, resident receives routine pain medication and/or pain in not controlled, an interdisciplinary process and care plan will be developed and implemented based on the assessed findings, pain rating scale, and pain relieving strategies (interventions), care plans will be reviewed and updated each time the resident's pain management plan if is found not to be effective and at least at each quarterly care conference. 10. documentation of assessments and the resident's response to the pain management plan will be made with each assessment.

Based on observation, interview, and record review the facility failed to follow guidelines consistent with current standard of practices to prevent/decrease risk of infection to wounds for 2 of 2 residents (R1 and R16) observed for infection control in the sample of 52.The findings include:1. R1's admission Record documents an admission date of 9/8/23 with diagnoses including but not limited to Type II Diabetes Mellitus, Atherosclerosis of both legs, and lymphedema.R1's Physician's Order Sheet (POS) with a print date of 2/26/26 documents a current physician's order for left lateral lower leg: cleanse with wound cleanser. Apply Santyl to wound bed, ABD (abdominal pad), (gauze wrapping), wrap with (elastic) wrap daily and PRN (as needed).R1's most recent Care Plan documents Resident has other potential/actual impairment to skin integrity r/t (related to) fragile skin Date Initiated: 7/12/2024 Revision on: 10/23/2025. Interventions for this focus area include but are not limited to, Follow facility protocols for treatment of injury. Date Initiated: 07/12/2024 Revision on: 8/19/2024. Another focus area documented on R1's care plan documents, I have a venous/stasis ulcer of the left leg and top of right foot r/t (related to) venous/ulcer stasis Date Initiated: 10/23/2025 Revision on: 10/23/2025. Interventions for this focus area include but are not limited to, Treatment as ordered Date Initiated: 10/23/2025.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 11 indicating R1 has moderately impaired cognition. The same MDS documents R1 is at risk for pressure ulcers and R1 has 2 venous/arterial ulcers.On 2/25/26 at 10:27 AM, R1 dressing change was observed to R1's venous stasis ulcer to left lateral calf region performed by V7 (Licensed Practical Nurse/Assistant Director of Nurses). V7 performed hand hygiene and donned gown and gloves appropriately and provided privacy by shutting the door to the room. V7 placed clean barriers down on surfaces being utilized with supplies on the barriers. V7 removed the old dressing with scissors. V7 then changed gloves but did not perform hand hygiene by using alcohol-based hand sanitizer or hand washing. V7 then cleansed the wound according to physician's orders with (brand name) solution and 4x4 gauze sponges and patted dry. V7 then changed gloves again but did not perform hand hygiene. V7 then applied Santyl ointment as ordered by physician. V7 applied abdominal/ABD pad, then wrapped leg with gauze wrap and (elastic wrap) for compression. V7 then gathered up her trash, disposed of it properly, removed gown and gloves, and performed hand hygiene.On 2/25/26 at 10:41 AM, V7 stated in relation to not performing hand hygiene between glove changes while doing R1's dressing change, she (V7) had forgotten to bring alcohol based hand rub with her into the room initially and didn't think she could stop and obtain some. V7 stated she should have performed hand hygiene between glove changes to decrease risk of infection to R1's wound. On 2/26/26 at 2:47 PM, V8 (Infection Preventionist) stated use of hand sanitizer between glove changes is expected while performing dressing changes. V8 stated V7 should have performed hand hygiene between glove changes. V8 stated not performing hand hygiene between glove changes during dressing changes could increase risk of infection.On 2/26/26 at 2:54 PM, V2 (Director of Nursing/DON) stated V7 should have performed hand hygiene between glove changes while performing dressing change. V2 stated not performing hand hygiene between glove changes increases risk for infection.2. R16's admission Record documents an admission date for R16 of 2/27/25. The same admission Record documents diagnoses including but not limited to cellulitis of right lower limb, type I diabetes, and non-pressure chronic ulcer of unspecified foot.R16's POS dated 2/26/26 documents current physician's orders including but not limited to, Contact/enhanced barrier precautions related to chronic wounds. Right plantar foot: cleanse with wound cleanser, pack wound with calcium alginate silver cover with ABD (abdominal pad) and wrap with (gauze wrap) daily and PRN (as needed) every day shift.R16's Care Plan documents a focus area for enhanced barrier precautions related to chronic wounds dated 6/17/25. Interventions for this focus area include but are not limited to gown and glove during high contact resident care activities dated 6/17/25.R16's MDS dated [DATE] documents R16 has a BIMS score of 15, indicating R16's cognition is intact. The same MDS documents R16 has a diabetic foot ulcer and infection of the foot.On 2/24/26 at 2:54 PM, V11 (Licensed Practical Nurse/LPN) was observed performing the dressing change on R16's diabetic ulcer of the right foot. V11 washed her hands, donned gown and gloves and supplies were already ready. V11 then removed R16's old dressing by cutting it off with scissors. Scissors were then placed on clean barrier V11 had placed down for her supplies. V11 then removed her gloves, performed hand hygiene with alcohol-based hand sanitizer and donned new gloves. V11 then cleaned R16's wound with wound cleanser and 4x4 sponges. V11 then performed hand hygiene and changed gloves. V11 then took the same scissors she had cut off the old bandage without sanitizing them and cut the sterile calcium silver alginate with those same bandage scissors. V11 then took the piece of calcium silver alginate section she had cut with the contaminated scissors and packed it into the wound. V11 then applied an abdominal pad and wrapped the bandage and foot with gauze wrap. V11 then cleaned her work area disposed of her trash properly, removed her gown and gloves and performed hand hygiene. On 2/24/26 at 3:09 PM, V11 stated in relation to using the contaminated scissors to cut the alginate, she should have either sanitized the scissors or used a different pair to cut the sterile alginate packing for the wound. V11 stated using contaminated scissors to cut clean or sterile packing could increase risk for infection in the wound.On 2/26/26 at 2:47 PM, V8 (Infection Preventionist) stated he would not consider it appropriate to use same scissors used to cut the old bandage off of R16's foot to then cut the sterile packing that would go into the wound. V8 stated to use the contaminated scissors would be increasing risk of infection to the wound.On 2/26/26 at 2:54 PM, V2 (DON) stated V11 should have either sanitized the scissors used to cut the old bandage away from R16's foot or used a clean pair to cut sterile calcium silver alginate that V11 used for packing in the wound.The facility's Infection Precaution Guidelines policy dated 11/28/12, documents Standard Precautions defined as combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions consist of a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. The same policy documents, Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment. Alcohol-based hand rub may be used if hands are not visibly soiled. The same policy also documents, Gather all equipment and supplies needed before going into the room. Only take needed supplies into the room. When possible dedicate the use of noncritical resident-care equipment to a single resident or cohort of residents infected or colonized with the pathogen requiring precautions. When use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident.

Based on interview and record review the facility failed to prevent the verbal, physical and sexual abuse of residents from another resident with a known history of abuse for 4 of 6 residents (R1, R6, R8 and R9) reviewed for abuse in the sample of 11. This failure would cause a reasonable person to experience feelings of fear, anxiety and anger while residing in their home. Findings include:1. R7's admission Records documents R7 was admitted on [DATE] with diagnoses to include: Dementia with agitation, lack of coordination, anxiety, depression. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 01, indicating R7 has severe cognitive impairment.R7's current Care Plan documents a focus area: I have behavior problems related to verbally/physically aggressive with staff during care, wander/elopement risk with an initiation date of 11/18/25. The only mention in R7's care plan about any resident to resident altercation is listed on 12/11/25 under intervention for this focus area: resident involved in altercation with another resident, intervention for this event is refer this resident to behavioral health.R8's admission Record documents an admission date of 1/14/25 with diagnoses including in part Alzheimer's disease, bipolar disorder, Parkinson's disease, and depression.R8's MDS dated [DATE] documents a BIMS of 00, indicating severe cognitive impairment.A final report sent to the state surveying agency on 12/17/25 documents on 12/11/25 at 2:55pm, R7 went up to R8 and hit her in the face and then called her a stupid b**ch. Residents were immediately separated. No injuries were noted. R7 was referred for medication review and a referral was sent to a local behavioral health center. Final report summary documented, During investigation, (V13) CNA (Certified Nursing Assistant) stated that (R7) walked into the Dining Room on the Dementia Unit where (R8) was sitting. She stated (R8) had been yelling when (R7) walked up to her and slapped her across the face and then yelled stupid b**ch. (V13) stated she immediately separated the residents. (R7) stated he was annoyed with her yelling. (R8) could not recall what happened.A facility document titled #782 Res/Res Altercation for R7 dated 12/11/25, prepared by V11 (Registered Nurse/RN) documents under Incident Description, Nursing Description: This RN was called into dining room by CNA who witnessed resident (R7) slap another resident (R8) on the left side of the face. Per CNA she was in the dining room talking with another resident and R8 was sitting close by talking out loud to herself. Resident (R7) walked up the hallway to the dining room to sit in his usual spot at the dining room table. (R8) was sitting at the same table. CNA thought resident (R7) was going to sit down. Instead, he took a step drew back and slapped resident (R8) across the left side of her face. Resident (R8) jumped up yelling he hit me. During the alteratio (sic) resident (R7) was calling the other resident a stupid b**ch and was attempting to slap her again. The CNA immediately intervened by stepping in the middle of the altercation. Under Resident Description it documents Resident (R7) stated he was annoyed with all the screaming and yelling resident (R8) was doing so he had to slap her to shut her up. Resident (R7) stated if the CNA had not stepped in between them, he would have slapped her again.A facility document titled #783 Res/Res Altercation for R8 dated 12/11/25 prepared by V11 documents under incident Description, Nursing Description: This RN Was called into dining room by CNA who witnessed resident (R7) slap resident (R8) on the left side of the face. Per CNA she was in the dining room talking with another resident and (R8) was sitting close by talking out loud to herself. Resident (R7) walked up the hallway to the dining room to sit in his usual spot at the dining room table. (R8) was sitting at the same table. CNA thought resident (R7) was going to sit down. Instead, he took a step drew back and slapped resident (R8) across the left side of her face. Resident (R8) jumped up yelling he hit me. During the alteration resident (R7) was calling resident (R8) a stupid b**ch and was attempting to slap her again. The CNA Immediately intervened by stepping in the middle of the altercation. Resident Description: Resident (R8) stated he was annoyed with all the screaming and yelling resident (R8) was doing so he had to slap her to shut her up. Resident (R8) stated if the CNA had not stepped in between them, he would have slapped her again. Under Resident Description it documents Resident Unable to give Description. Under Immediate Action Taken, Description it documents CNA intervened by standing in between the residents to prevent resident (R7) from hitting resident (R8) again. This RN immediately intervened by tending to resident (R8). This RN escorted resident (R8) to her room to deescalate the tension between the two residents. The resident (R8) was not harmed during the altercation. Administrator (V1) notified of alteration. Per direction from management either resident does not have to go to the hospital at this time. (Local Police Department) Police were called at this time by administrator (V1). Police decided to not visit facility at this time. In the same document under Statements, it documents a statement by an unnamed staff Per CNA (V13) 'I was in D.R. (dining room) talking to (name) and listening to (R8) carry on. (R7) came up the hall into the D.R. moved a chair in his usual spot and I thought he was going to sit down, and he took a step drew back and slapped (R8) across the left side of her face. (R8) jumped up yelling he hit me. As soon as (R7) slapped her I ran over and got in the middle of them because he was calling her a stupid b**ch and was gonna slap her again. (R8) then was taken back to her room and I stayed in the D.R. to watch (R7).On 1/13/26 at 11:23 AM, V13 (CNA) stated she was in the dining room with a different resident when R8 was in the dining room yelling out. V13 stated then R7 was walked into the dining room, and she thought he was just going to sit down like he usually does but the next thing she knew, R8 stood up and yelled and then R7 her in the face. V13 stated she went over and got in between R7 and R8. V13 stated R8 stated again that R7 hit her and R7 stated he hit her, and he will do it again because she won't shut up. V13 stated after she got them separated, she got another staff member to get the nurse for her, but she can't remember who the other staff member was. V13 stated the nurse handled it from there.2. R1's admission Record documents an admission date of 5/22/24 with diagnoses including in part major depressive disorder, generalized anxiety, dementia in other diseases classified elsewhere moderate with other behavioral disturbance, and unsteadiness on feet.R1's MDS dated [DATE] documents a BIMS of 11, indicating moderate cognitive impairment.A final report sent to the state surveying agency documents that on 12/16/25 at 5:45pm, R7 attempted to flip R1 out of her wheelchair and then began yelling and cussing at her. No injuries were noted. Staff immediately intervened and separated residents. R7 was provided sensory activities during signs of agitation. Final summary documents, During investigation, (V11) RN (Registered Nurse) stated that she was called to (R1's) room by (V12) CNA. (V12) stated that when she arrived to the room (R7) had been attempting to tip (R1) out of her wheelchair, staff was able to intervene and (R7) let go of (R1's) wheelchair but then proceeded to yell and cuss at (R1). (R7) was able to be redirected by (V11) RN. A facility document titled #790 Res/Res Altercation for R7 dated 12/16/25 documents under Incident Description, Nursing Description: This RN was notified by CNA that resident (R7) was in another resident's (R1) room trying to [NAME] the other resident (R1) out of her wheelchair. CNA immediately intervened by standing in between resident (R7) and the other resident's (R1) wheelchair. Resident (R7) yelling and cussing at this time at CNA, and other resident (R1). As RN walked in resident (F7) walked out of the resident's (R1) room cussing and yelling 'next time I will hurt her'. In the same document it documents under Statements, 12/16/25 - Resident (R7) very agitated throughout the day. Around 3pm he was banging doors stating, I got to get out of this damn place, swinging. Had try (sic) to go out the north door going outside banging on the door handle, hit the window let me out of here. Also was verbally distressed yelling in dining room at other residents and staff. Resident was directed back to his room.On 1/12/26 at 11:06 AM, V12 (CNA) stated R1's call light was on and when she went into the room to answer it R7 was in her room and had a hold of her wheelchair by the handles trying to tip it over. V12 stated she reached out for R7's hand and asked him to come with her and she walked him out of the room. V12 stated she took R7 back to his room and turned on football for him. V12 stated after R7 was calmed down she got the nurse, but she can't remember who the nurse was that day.3. R9's admission Record documents R9 was admitted on [DATE] with diagnoses including in part Parkinson's disease with dyskinesia, Alzheimer's disease, chronic pain syndrome, and depression.R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 06, indicating severe cognitive impairment.A final abuse report sent to the state surveying agency dated 1/2/26 documents on 12/28/25 around 5:45pm, R7 allegedly grabbed R9 by the neck. No injuries were noted. The final summary documents, (V9 Certified Nursing Assistant/CNA) reports she was feeding residents in the dining room of the Dementia Unit when (R7) got up and went towards (R9) and her then grabbed (R9's) neck. (V9) was able to immediately separate residents. It is believed that (R7) was overstimulated by the noise in the dining room. (R7) was immediately sent to the emergency room for evaluation of physical behavior. (R9) resumed activities with no ill effects.A facility document titled #799 Res/Res Altercation for R7 dated 12/28/25 documents under incident description: R7 was eating in the dining room, stood up and went to R9 and grabbed him by the throat. In the same document under immediate Action Taken it documents Staff able to separate residents. The resident (R7) still visibly agitated. Notified admin (administration), ADON (Assistant Director of Nursing), and local police department. Administered IM (intramuscular) Ativan per MAR (Medication Administration Record). Unable to redirect resident. Sending the ER (Emergency Room) for evaluation/treatment. Under Statements it documents, statement by V9 (CNA) on 12/28/25 I was feeding residents and Resident (R7) got up and went towards another resident (R9) and grabbed him by the neck. Went towards residents and yelled for other CNA to assist. Was able to separate residents. Other CNA was able to redirect this resident and a statement by V32 (CNA) Other CNA yelled for me for help stated that resident (R7) had put his hands around another residents (R9) neck. Resident (R7) flailing arms around trying to hit anyone. Was able to get resident (R7) away from situation and notified nurse.A facility document titled #800 Res/Res Altercation for R9 dated 12/28/25 documents under Incident Description, Nursing Description: Another resident (R7) grabbed this resident (R9) by the throat. This resident (R9) was eating dinner when the other resident (R7) involved walked up and put his hands around this residents (R9) throat.R9's progress note dated 12/28/25 at 6:43 PM, created by V8 (Assistant Director of Nursing/License Practical Nurse) documents Spoke with wife (name) regarding altercation with another resident. She voiced understanding. Informed that resident will continue to be monitored.On 1/12/26 at 10:51 AM, V9 (CNA) stated R7 was agitated most of the day the day of the incident with him and R9. V9 stated R7 was bickering most of the day with everyone and when he was in the dining room, he was mouthing everyone, R9 turned to R7 and said something to him then R7 stood up and grabbed R9 by the throat and pushed him out of the dining room door into the hallway, R9 was in his wheelchair at the time. V9 stated she removed R8's hand from R9's neck and told them to stop and yelled for help and the nurse and some other staff came in and took over the situation. V9 stated she doesn't remember who came in to help.On 1/13/26 at 11:12 AM, V8 (Assistant Director of Nursing) stated she did not witness the incident between R7 and R9. V8 stated she was in her office, and someone yelled at her, so she went to the unit, and she took R7 to the family room on the unit and shut the door and talked with him. V8 stated she did give R7 a dose of intramuscular Ativan. V8 stated R7 told her he couldn't do this anymore and she asked what this was, and he told her he was just really agitated and didn't know what to do. V8 stated she asked R7 if he wanted to watch a movie, and he said yes so, she turned on a movie. R8 stated shortly after that it was time for dinner, and she asked him if he wanted to eat in the family room or go to the dining room and he requested to eat in the dining room with the other residents, so she walked with him into the dinner room. V8 stated R7 started eating dinner in the dining room with the other residents and then she left.4. R6's admission Record documents an admission date of 9/17/25 with diagnoses including in part anxiety disorder, anoxic brain damage, catatonic disorder due to known physiological condition, and depression.R6's MDS dated [DATE] documents a BIMS of 02, indicating severe cognitive impairment.R6's Care plan documents R6 is a risk for abuse/neglect with an initiated date of 9/25/25.A final incident report sent to the state surveying agency documents that on 12/28/25 around 10:50pm, R7 allegedly walked up behind R6 and grabbed her breast. No injuries were noted. Residents were immediately assessed and R7 was placed on one-on-one supervision. Final summary documents, During investigation, (V10) CNA stated that (R7) walked up behind (R6) and reached around from her back and grabbed her breast. (V10) immediately separated residents. (R7) was placed on one-on-one supervision. (R6) resumed normal activity with no ill effects. (R7) was admitted to (name of local behavioral hospital) on 12-29-25.A facility document titled #802 Res/Res Altercation for R6 dated 12/28/25 documents under Incident Description, Nursing Description: A male resident grabbed this resident's (R6) breast. Under Resident Description it documents Resident (R6) unable to give description. In the same document under Statements, it documents a stated by V10 (CNA) I witnessed resident (R7) reach around from the back and grope (R6)'s breast. Told him to let go and he said no and then I removed hand from breast.On 1/13/26 at 10:07 AM, V10 (CNA) stated on the day of the incident between R7 and R6, R7 was agitated all day that day. V10 stated R7 was kind of targeting R6 all day, following her around. V10 stated R7 was walking around, and he came up behind R6 and reached around her and grabbed her breast. V10 stated she redirected R7 to step away from R6 and he listened and walked away.On 1/13/26 at 10:14 AM, V26 (CNA) stated she did not witness the incident between R7 and R6, but R7 was agitated most of the day prior to the incident. A facility policy titled Abuse Prevention and Reporting-Illinois dated 11/28/16 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. This same policy defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. In the same policy it documents under Protection of Residents: Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employes of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents.

Based on interview and record review the facility failed to ensure they maintained sufficient staff to meet the needs of the residents timely for 4 of 4 residents (R4, R7, R11, and R13) reviewed for staffing in the sample of 21. This failure has the potential to affect all 70 residents who currently reside at the facility.Findings Include:The facility Resident List Report dated 11/16/25 documents 70 residents currently reside at the facility.1.R13's admission Record with a print date of 11/18/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include spastic quadriplegic cerebral palsy and epilepsy.R13's MDS (Minimum Data Set) dated 8/24/25 documents R13 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates he is cognitively intact. This same MDS documents R13 requires substantial/maximal assistance with toileting and bathing.R13's current Care Plan documents a Focus area of I have an ADL (activities of daily living) self-care performance deficit. Date Initiated: 01/31/2025. This Focus area includes the following interventions. Bathing/Showering: The resident requires max assist twice a week and as necessary. Date Initiated: 01/31/2025.Resident will put self in floor and urinate and defecate on a pad, resident refuses to use a bedpan or the toilet. Respect resident wishes, provide care as needed, ensure resident safety. Date Initiated: 01/31/2025. Toilet Use: The resident requires max assist staff for toileting. Date Initiated: 01/31/2025.R14's admission Record with a print date of 11/18/25 documents R14 was admitted to the facility on [DATE]. R14's MDS dated [DATE] documents a BIMS score of 15, indicating R14 is cognitively intact.On 11/17/25 at 12:48 PM, R14 stated they have two certified nursing assistants (CNAs) working on the hall she and her son (R13) reside on. R14 stated she and R13 share a room. R14 stated it takes them forever to answer the call lights when they need help. R14 stated on Friday night (11/14/25) it took the CNAs approximately one and a half hours to assist R13 after he had an incontinent episode, because they only had two CNAs working and they were busy providing care to other residents. R14 stated R13's normal shower days are Tuesday and Friday, and no one asked R13 if he wanted a shower on Friday, 11/14/24 so he didn't get one. R14 stated R13 asked for a shower on Saturday, 11/15/25 and unknown staff told R13 they didn't have enough staff to assist him with a shower. R14 stated R13 did get a shower on 11/16/25.On 11/17/25 at 1:15 PM, R13 stated he sat in feces for almost two hours on Friday (11/14/25) because they didn't have enough staff to help him timely. R13 stated he normally takes showers on Tuesday and Friday, and he wasn't offered a shower on Friday (11/14/25). R13 stated he asked if he could get one on Saturday (11/15/25) and staff told him they didn't have time. R13 stated he finally got one on Sunday (11/16/25).The facility Shower Schedule dated 10/7/2025 documents R13 is to get assistance with bathing on Tuesday and Friday nights.On 11/18/25 at 6:38 PM, V18 (Certified Nursing Assistant/CNA) stated she worked on Friday night 11/14/25 and provided care to R13. V18 stated R13 had a bowel movement between 6:30 and 7:00 PM and had to wait approximately 30 minutes for the CNAs to clean him up. When asked why he had to wait that long, V18 stated because there were only two CNAs for approximately 40 residents, and they had to put the residents who were at risk for falls to bed first so they wouldn't fall. V18 stated they usually have two CNA's covering two halls on night shift. When asked if that was enough to meet the needs of the residents timely, V18 stated, to be honest, no. V18 stated they try their best to answer call lights timely and prioritize the bathroom lights first. V18 stated showers are hard to get to with only two CNAs per hall, especially if they need more than set up or assistance so they don't always get done.On 11/18/25 at 7:12 PM, V17 (CNA) stated she worked 6 pm to 6 am beginning on the night of Friday, 11/14/25. V17 stated she provided care to R13 on that night and he had to wait approximately 30 minutes for them to clean him up after he had a bowel movement. V17 stated that is not typical for a resident to have to wait that long but the nurse was sending a resident out to the hospital. V17 stated thirty minutes is too long to wait. When asked if 2 CNAs could meet the needs of the residents, V17 stated, three would be better. V17 stated sometimes they don't get the showers done.On 11/18/25 at 10:32 PM, V16 (Agency Registered Nurse/RN) stated she worked on Friday, 11/14/25 night shift from 6 pm to 6 am. V16 stated she had never seen it take an hour or more for the staff to answer call lights and/or assist with incontinence care. V16 stated she wasn't aware of a specific incident with R13, but it was reasonable that with only two CNAs it could take up to 30 minutes to answer a call light. V16 stated if the two CNAs are providing assistance to a resident who needs more care they may be in that room for 20 minutes or more. V16 stated then it could take longer for other residents to get assistance and/or for call lights to be answered. V16 stated it takes longer to answer the call lights especially during the time frame of getting residents back to their rooms from the dining room after supper during the same time medications are being administered, and residents are needing to be assisted to bed. V16 stated she had never seen it take an hour but thirty minutes, I can see that.2. R4's admission Record with a print date of 11/18/25 documents R4 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, anemia, and diverticulitis.R4's MDS dated [DATE] documents a BIMS score of 11, indicating R4 has a moderate cognitive deficit. This same MDS documents R4 is dependent on staff for toilet hygiene, requires substantial/maximal assistance for toilet transfer, and is occasionally incontinent of bowel and bladder.R4's current Care Plan documents a Focus area of, I have limited physical mobility. Date Initiated: 02/25/2025. This Focus area includes the following intervention. Urinal at bedside per resident request. This Care Plan does not address a Focus area, or interventions related to level of assistance required for incontinence care.On 11/16/25 at 7:27 AM, R4 stated sometimes it takes up to 45 minutes for the staff to answer the call lights. When asked if he had any negative outcome when it took the staff longer, R4 stated, I pi**ed and s**t. R4 stated when it happens, they say it is because they don't have enough staff. R4 stated he had been left soiled for up to three hours. When asked why it took that long for staff to assist him, R4 stated they say they will be right back and then never come back. R4 stated someone else eventually comes in and assist him.3. R7's admission Record with a print date of 11/18/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, diabetes, aortic aneurysm, hypertension, and heart failure.R7's MDS dated [DATE] documents a BIMS score of 15, indicating R7 is cognitively intact. This same MDS documents R7 is dependent on staff for toilet hygiene, frequently incontinent of bowel and occasionally incontinent of bladder.R7's current Care Plan documents a Focus area of Resident is usually able to perform ADL's with max assist from 2 staff. Date Initiated: 08/30/2023. This Focus area includes the following interventions. Resident has requested to have urinal at bedside at all times for independence with voiding. Date Initiated: 12/18/2024. This same Care Plan documents a Focus area of, The resident has bowel incontinence. Date Initiated: 08/30/2023. This Focus area includes the following interventions. Check resident every two hours and assist with toileting as needed. Date Initiated: 08/30/2023.Provide bedpan/bedside commode. Date Initiated: 08/30/2023.On 11/16/25 at 6:57 AM, R7 stated sometimes they are short staffed. R7 stated they use agency staff and sometimes that is not good. R7 stated the longest it had taken them to answer his call light was 45 minutes and that is when they were short staffed and slammed with call lights. R7 stated he had to lay in feces for 45 minutes on an unknown but recent day.4. R11's admission Record with a print date of 11/18/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include displaced fracture, bipolar disorder, chronic kidney disease, major depressive disorder, and anxiety disorder.R11's MDS dated [DATE] documents a BIMS score of 12, indicating a moderate cognitive deficit. This same MDS documents R11 requires partial/moderate assist of staff for bathing.R11's current Care Plan does not document a Focus area related to activities of daily living and/or an intervention related to bathing.On 11/16/25 at 9:42 AM, R11 stated she is supposed to get showers on Wednesday and Saturday. R11 stated she normally gets them but last night she didn't because they didn't have enough staff.The facility Shower Schedule dated 10/07/25 documents R11 is scheduled for bathing on Wednesday and Saturday nights.The facility Daily Assignment Sheet dated 11/15/25 documents R11's name under night shift showers. This sheet does not indicate R11 was assisted with bathing.On 11/18/25 at 6:38 PM, V18 (CNA) stated they don't have enough staff to meet the needs of the residents timely. V18 stated they aren't always able to answer call lights timely, provide incontinence care timely, and showers don't always get done as they should.On 11/16/25 at 5:54 AM, V8 (CNA) stated they sometimes have four CNAs in the facility from 6 pm to 6 am and that is not enough to meet the needs of the residents timely. V8 stated they are sometimes able to do showers and other times they are not. V8 stated she worked 6 pm to 6 am beginning on 11/15/25 and ending on the morning of 11/16/25. V8 stated she was responsible for the two halls R11 and R13 reside on. V8 stated they call those halls Southeast and Southwest. V8 stated there was a call in and when she got to work at 6 pm she was the only CNA working on those two halls. V8 stated she called another staff person in, but it took her awhile to get to the facility. V8 stated they had the staffing issue, then had to send a resident to the hospital. V8 stated she wasn't able to get people in bed when they wanted to and there was only one person who got their shower that night. V8 stated there are times residents are left soiled longer than they should be. V8 stated there are times call lights can't be answered timely because there isn't a staff member available to answer them.On 11/6/25 at 5:39 AM, V6 (CNA) stated they didn't have enough staff to meet the needs of the residents timely. V6 stated she works on the Alzheimer's unit and there are about 12 residents back there. V6 stated they typically have two CNAs but sometimes there is only one and they are responsible for the Alzheimer's unit and the independent unit. V6 stated there are residents who have behaviors, and it is very stressful. V6 stated sometimes they can't get the showers done.On 11/16/25 at 12:48 PM, V9 (Registered Nurse) stated they don't have enough staff to meet the needs of the residents timely. V9 stated call lights are answered as fast as they can be.On 11/18/25 at 9:38 AM, V19 (CNA) stated they are able to answer call lights timely if they have enough staff. When asked if they had enough staff to meet the needs of the residents timely V19 stated, Not all the time. V19 stated he works day shift and on 11/15/25 they only had three CNAs on the 100 halls. V19 stated on 11/16/25 (the day this surveyor entered the facility) they had six CNAs on the 100 halls. V19 stated they normally have four CNAs on those halls on day shift. V19 stated it is hard to answer call lights timely when there are less than four CNAs especially around mealtimes.On 11/18/25 at 10:24 AM, V2 (Director of Nurses) stated they have enough staff to meet the needs of the residents timely. V2 stated they have four CNAs and two nurses on night shift. V2 stated there are 43 residents on the 100 halls (southeast and southwest) and of those 43 residents 18 require assist of two staff for ADL's. V2 stated there is an 8 pm medication pass time that runs from 7 pm to 9 pm. When asked if two CNAs could get residents from the dining room after the evening meal, cleaned up, in bed, and answer call lights timely, V2 stated, They do.On 11/19/25 at 2:00 PM, V1 (Administrator) stated the facility runs 12-hour shifts and they try to have 5-6 CNAs on day shift and 4-5 on night shift. V1 stated she felt like they had the staff they needed based on their census. V1 stated based off the minimum staffing calculator they fall within those guidelines. V1 stated the calculator shows they should have 3.28 CNAs for night shift and 5.74 for evening shift. V1 clarified they don't run an evening shift, but the traditional evening shift would include the time frames of 6 pm to 10 pm, when the facility is running four CNA's and the calculator, she used to calculate they should be running 5.74 CNAs. V1 then stated the calculator is just a suggestion and they have the staffing numbers to meet the needs of the residents.The Facility Assessment Tool dated 9/5/24 documents under Staffing Plan, 3.2 Based on our resident population and their needs for care and support, the facility utilizes the minimum staffing calculator to determine staffing needs.

Based on observation, interview, and record review the facility failed to ensure food was served at a palatable temperature. This has the potential to affect 9 of 9 (R1, R10, R14-R20) residents served room trays on the long-term care units reviewed for dining in the sample of 21.Findings Include:On 11/19/25 at 2:55 PM, V1 (Administrator) provided this surveyor with the list of residents who are served meals in their room on the long-term care units. This list documents R1, R10, and R14-20 were served room trays.The facility Concern/Complaint Form dated 10/21/25 documents under Concern/Compliment: this resident (R21 who no longer resides at the facility) states that the vegetables are cold when being delivered on the hall.vegetables are not warm when reaching resident room.Dietary Manager in serviced with staff and educated them to prevent reoccurrence. There are no temperatures of the food documented on this form.On 11/16/25 at 7:27 AM, R4 stated he is served his meals in his room at times and the temperature of the food sucks.On 11/18/25 at 9:28 AM, V20 (CNA) stated the food is sometimes served cold. V20 was not able to recall a specific resident/time of the complaint but did say she sometimes eats at the facility and the food is cold at times.On 11/18/25 at 9:38 AM, V19 (CNA) stated the food is hot for the residents who eat in the dining room but the residents who eat in their rooms get colder food.On 11/16/25 at 12:39 PM, this surveyor and V10 (Dietary Manager/DM) followed the uninsulated cart carrying room trays including a test tray to the long-term care units. As the last room tray was being served to the residents, V10 (DM) used the facility thermometer to check the temperature of the food located on the test tray. The temperatures were as follows; pureed ham - 138 degrees Fahrenheit (F), mechanical soft ham 128 degrees F, pureed zucchini 115 degrees F, ham slice 112 degrees F, mashed potatoes 138 degrees F, and zucchini- 125 degrees F.On 11/16/25 at 1:04 PM, V10 (DM) stated the temperature of each of the foods on the food trays delivered to the residents should be 135 degrees F.On 11/17/25 at 2:39 PM, V10 (DM) stated they split the halls for hall trays up and that fixed the issue with the food not holding temperatures for the hall tray delivery times.The facility Monitoring Food Temperatures for Meal Service dated 2020 documents, Guideline: food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. g. Meals that are served on room trays may be periodically checked at the point of service for palatable temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees F or greater to promote palatability for the resident. Any complaint regarding food temperatures by residents will be documented on the Food Temperature Log. Complaints will be investigated by conducting a test tray for that meal to determine if foods are remaining above 120 degrees F. The investigation is recommended to be completed within 72 hours of the complaint.

Based on interview and record review the facility failed to ensure residents received timely incontinence care for 3 of 3 (R4, R7, R13) residents reviewed for dignity in the sample of 21.Findings Include: 1.R13's admission Record with a print date of 11/18/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include spastic quadriplegic cerebral palsy and epilepsy.R13's MDS (Minimum Data Set) dated 8/24/25 documents R13 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates he is cognitively intact. This same MDS documents R13 requires substantial/maximal assistance with toileting. R13's current Care Plan documents a Focus area of I have an ADL (activities of daily living) self-care performance deficit. Date Initiated: 01/31/2025. This Focus area includes the interventions of, Resident will put self in floor and urinate and defecate on a pad, resident refuses to use a bedpan or the toilet. Respect resident wishes, provide care as needed, ensure resident safety. Date Initiated: 01/31/2025. Toilet Use: The resident requires max assist staff for toileting. Date Initiated: 01/31/2025.R14's admission Record with a print date of 11/18/25 documents R14 was admitted to the facility on [DATE]. R14's MDS dated [DATE] documents a BIMS score of 15, indicating R14 is cognitively intact. On 11/17/25 at 12:48 PM, R14 stated they have two certified nursing assistants (CNAs) working on the hall she and her son (R13) reside on. R14 stated she and R13 share a room. R14 stated it takes them forever to answer the call lights when they need help. R14 stated on Friday night (11/14/25) it took the CNAs approximately one and a half hours to assist R13 after he had an incontinent episode, because they only had two CNAs working and they were busy providing care to other residents. On 11/17/25 at 1:15 PM, R13 stated on Friday (11/14/25) he sat in feces for almost 2 hours because they didn't have enough staff to help him timely.On 11/18/25 at 6:38 PM, V18 (Certified Nursing Assistant/CNA) stated she worked on Friday night 11/14/25 and provided care to R13. V18 stated R13 had a bowel movement between 6:30 and 7:00 PM and had to wait approximately 30 minutes for the CNAs to clean him up. When asked why he had to wait that long, V18 stated because there were only two CNAs for approximately 40 residents, and they had to put the residents who were at risk for falls to bed first so they wouldn't fall. On 11/18/25 at 7:12 PM, V17 (CNA) stated she worked 6 pm to 6 am beginning on the night of Friday, 11/14/25. V17 stated she provided care to R13 on that night and he had to wait approximately 30 minutes for them to clean him up after he had a bowel movement. V17 stated that is not typical for a resident to have to wait that long but the nurse was sending a resident out to the hospital. V17 stated thirty minutes is too long to wait. 2. R4's admission Record with a print date of 11/18/25 documents R4 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, anemia, and diverticulitis.R4's MDS dated [DATE] documents a BIMS score of 11, indicating R4 has a moderate cognitive deficit. This same MDS documents R4 is dependent on staff for toilet hygiene, requires substantial/maximal assistance for toilet transfer, and is occasionally incontinent of bowel and bladder. R4's current Care Plan documents a Focus area of, I have limited physical mobility. Date Initiated: 02/25/2025. This Focus area includes the following intervention. Urinal at bedside per resident request. This Care Plan does not address a Focus area, or interventions related to level of assistance required for incontinence care. On 11/16/25 at 7:27 AM, R4 stated sometimes it takes up to 45 minutes for the staff to answer the call lights. When asked if he had any negative outcome when it took the staff longer, R4 stated, I pi**ed and s**t. R4 stated when it happens, they say it is because they don't have enough staff. R4 stated he had been left soiled for up to three hours. When asked why it took that long for staff to assist him, R4 stated they say they will be right back and then never come back. R4 stated someone else eventually comes in and assist him. 3. R7's admission Record with a print date of 11/18/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, diabetes, aortic aneurysm, hypertension, and heart failure. R7's MDS dated [DATE] documents a BIMS score of 15, indicating R7 is cognitively intact. This same MDS documents R7 is dependent on staff for toilet hygiene, frequently incontinent of bowel and occasionally incontinent of bladder. R7's current Care Plan documents a Focus area of Resident is usually able to perform ADL's with max assist from 2 staff. Date Initiated: 08/30/2023. This Focus area includes the following interventions. Resident has requested to have urinal at bedside at all times for independence with voiding. Date Initiated: 12/18/2024. This same Care Plan documents a Focus area of, The resident has bowel incontinence. Date Initiated: 08/30/2023. This Focus area includes the following interventions. Check resident every two hours and assist with toileting as needed. Date Initiated: 08/30/2023.Provide bedpan/bedside commode. Date Initiated: 08/30/2023.On 11/16/25 at 6:57 AM, R7 stated sometimes they are short staffed. R7 stated they use agency staff and sometimes that is not good. R7 stated the longest it had taken them to answer his call light was 45 minutes and that is when they are short staffed and slammed with call lights. R7 stated he had to lay in feces for 45 minutes on an unknown but recent day. On 11/18/25 at 10:32 PM, V16 (Agency Registered Nurse/RN) stated she worked on Friday, 11/14/25 night shift from 6 pm to 6 am. V16 stated she had never seen it take an hour or more for the staff to answer call lights and/or assist with incontinence care. V16 stated she wasn't aware of a specific incident with R13, but it was reasonable that with only two CNAs it could take up to 30 minutes to answer a call light. V16 stated if the two CNAs are providing assistance to a resident who needs more care they may be in that room for 20 minutes or more. V16 stated then it could take longer for other residents to get assistance and/or for call lights to be answered. V16 stated it takes longer to answer the call lights especially during the time frame of getting residents back to their rooms from the dining room after supper during the same time medications are being administered, and residents are needing to be assisted to bed. V16 stated she had never seen it take an hour but thirty minutes, I can see that. On 11/18/25 at 10:24 AM, V2 (Director of Nurses) stated they have enough staff to meet the needs of the residents timely. When asked if two CNAs could get residents from the dining room after the evening meal, cleaned up, in bed, and answer call lights timely, V2 stated, They do. V2 denied any complaints or concerns related to care being provided timely. On 11/19/25 at 2:00 PM, V1 (Administrator) stated she would expect call lights to be answered, and incontinence care provided in a timely manner. When asked what she considered timely, V1 stated it would depend on what the CNAs were doing when the call lights were going off. V1 stated she would expect them to be answered as quickly as possible. The facility Incontinence Care policy dated 11/28/12 documents, Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent residents will be checked periodically with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.The facility Call Light policy dated 11/28/12 documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner.

Based on interview and record review the facility failed to ensure residents were assisted with showers and toileting for 4 of 4 (R4, R7, R11 and R13) residents reviewed for activities of daily living in the sample of 21.Findings Include:1.R13's admission Record with a print date of 11/18/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include spastic quadriplegic cerebral palsy and epilepsy.R13's MDS (Minimum Data Set) dated 8/24/25 documents R13 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates he is cognitively intact. This same MDS documents R13 requires substantial/maximal assistance with bathing.R13's current Care Plan documents a Focus area of I have an ADL (activities of daily living) self-care performance deficit. Date Initiated: 01/31/2025. This Focus area includes the interventions. Bathing/Showering: The resident requires max assist twice a week and as necessary. Date Initiated: 01/31/2025.R14's admission Record with a print date of 11/18/25 documents R14 was admitted to the facility on [DATE]. R14's MDS dated [DATE] documents a BIMS score of 15, indicating R14 is cognitively intact.On 11/17/25 at 12:48 PM, R14 stated they have two certified nursing assistants (CNAs) working on the hall she and her son (R13) reside on. R14 stated she and R13 share a room. R14 stated R13's normal shower days are Tuesday and Friday. R14 stated R13 did not get a shower on Friday. R14 stated no one asked him if he wanted one. R14 stated he asked them if he could get one on Saturday and they told him they didn't have enough staff to give him one. R14 stated he did get a shower on Sunday when he asked again.On 11/17/25 at 1:15 PM, R13 stated he normally takes showers on Tuesday and Friday. R13 stated he didn't get offered a shower on Friday and when he asked if he could get one on Saturday, they told him they didn't have time. R13 stated he finally got one on Sunday.The facility Shower Schedule dated 10/7/2025 documents R13 is to get assistance with bathing on Tuesday and Friday nights.2. R11's admission Record with a print date of 11/18/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include displaced fracture, bipolar disorder, chronic kidney disease, major depressive disorder, and anxiety disorder.R11's MDS dated [DATE] documents a BIMS score of 12, indicating a moderate cognitive deficit. This same MDS documents R11 requires partial/moderate assist of staff for bathing.R11's current Care Plan does not document a Focus area related to activities of daily living and/or an intervention related to bathing.On 11/16/25 at 9:42 AM, R11 stated she is supposed to get showers on Wednesday and Saturday. R11 stated she normally gets them but last night she didn't because they didn't have enough staff.The facility Shower Schedule dated 10/07/25 documents R11 is scheduled for bathing on Wednesday and Saturday nights.The facility Daily Assignment Sheet dated 11/15/25 documents R11's name under night shift showers. This sheet does not indicate R11 was assisted with bathing.On 11/16/25 5:54 AM, V8 (Certified Nursing Assistant/CNA) stated they sometimes have four CNAs in the facility from 6 pm to 6 am and that is not enough to meet the needs of the residents timely. V8 stated they are sometimes able to do showers and other times they are not. V8 stated she worked 6 pm to 6 am beginning on 11/15/25 (Saturday) and ending on the morning of 11/16/25 (Sunday). V8 stated there was only one person who got their shower that night.3. R4's admission Record with a print date of 11/18/25 documents R4 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, anemia, and diverticulitis.R4's MDS dated [DATE] documents a BIMS score of 11, indicating R4 has a moderate cognitive deficit. This same MDS documents R4 is dependent on staff for toilet hygiene, requires substantial/maximal assistance for toilet transfer, and is occasionally incontinent of bowel and bladder.R4's current Care Plan documents a Focus area of, I have limited physical mobility. Date Initiated: 02/25/2025. This Focus area includes the following intervention. Urinal at bedside per resident request. This Care Plan does not address a Focus area, or interventions related to level of assistance required for incontinence care.On 11/16/25 at 7:27 AM, R4 stated sometimes it takes up to 45 minutes for staff to answer the call lights. When asked if he had any negative outcome when it took the staff longer, R4 stated, I pi**ed and s**t. R4 stated when it happens, they say it is because they don't have enough staff. R4 stated he had been left soiled for up to three hours. When asked why it took that long for staff to assist him, R4 stated they say they will be right back and then never come back. R4 stated someone else will eventually come in and assist him.4. R7's admission Record with a print date of 11/18/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, diabetes, aortic aneurysm, hypertension, and heart failure.R7's MDS dated [DATE] documents a BIMS score of 15, indicating R7 is cognitively intact. This same MDS documents R7 is dependent for toilet hygiene, frequently incontinent of bowel and occasionally incontinent of bladder.R7's current Care Plan documents a Focus area of Resident is usually able to perform ADL's with max assist from 2 staff. Date Initiated: 08/30/2023. This Focus area includes the following interventions. Resident has requested to have urinal at bedside at all times for independence with voiding. Date Initiated: 12/18/2024. This same Care Plan documents a Focus area of, The resident has bowel incontinence. Date Initiated: 08/30/2023. This Focus area includes the following interventions. Check resident every two hours and assist with toileting as needed. Date Initiated: 08/30/2023.Provide bedpan/bedside commode. Date Initiated: 08/30/2023.On 11/16/25 at 6:57 AM, R7 stated sometimes they are short staffed. R7 stated they use agency staff and sometimes that is not good. R7 stated the longest it had taken them to answer his call light was 45 minutes and that is when they are short staffed and slammed with call lights. R7 stated he had to lay in feces for 45 minutes on an unknown but recent day.On 11/18/25 at 6:38 PM, V18 (CNA) stated they don't have enough staff to meet the needs of the residents timely. V18 stated they aren't always able to answer call lights timely, provide incontinence care timely, and showers don't always get done as they should.On 11/18/25 at 7:12 PM, V17 (CNA) stated they have two CNAs on the units she works on and three would be better. V17 stated showers don't always get done as they should, and incontinence care is not always provided timely.On 11/18/25 at 10:32 PM, V16 (Agency Registered Nurse/RN) stated she had never seen it take an hour or more for the staff to answer call lights and/or assist with incontinence care. V16 stated it was reasonable that with only two CNAs it could take up to 30 minutes to answer a call light. V16 stated if the two CNAs are providing assistance to a resident who needs more care they may be in that room for 20 minutes or more. V16 stated then it could take longer for other residents to get assistance and/or for call lights to be answered. V16 stated it takes longer to answer the call lights especially during the time frame of getting residents back to their rooms from the dining room after supper during the same time medications are being administered, and residents are needing to be assisted to bed. V16 stated she had never seen it take an hour but thirty minutes, I can see that.On 11/18/25 at 10:24 AM, V2 (Director of Nurses) stated they have enough staff to meet the needs of the residents timely. V2 stated they have two CNAs on the southeast and southwest halls and two on the Alzheimer's unit and northeast halls on night shift. V2 stated they also have two nurses on night shift. V2 stated there are 43 residents on the southeast and southwest halls and 18 of them require assist of two staff for ADL's. V2 stated there is an 8 pm medication pass that goes from 7 pm to 9 pm. When asked if two CNAs could get residents from the dining room after the evening meal, cleaned up, in bed, and answer call lights timely, V2 stated, They do. V2 denied any complaints or concerns related to care being provided timely.On 11/19/25 at 2:00 PM, V1 (Administrator) stated she hadn't had any complaints/concerns brought to her related to showers not being done, incontinence care not being provided timely, and/or call lights not being answered timely. V1 stated it should all be done in a timely manner. When asked what she would consider timely, V1 stated it would depend on what the CNAs were doing when the call light went off. V1 stated she would expect it to be answered as quickly as possible.The facility Incontinence Care policy dated 11/28/12 documents, Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent residents will be checked periodically with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.The facility Call Light policy dated 11/28/12 documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner.

Based on interview and record review the facility failed to ensure medications were available to be administered as ordered for 3 of 3 (R1, R7, and R9) residents reviewed for pharmacy services in the sample of 21.Findings Include:1.R1's admission Record with a print date of 11/17/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include epilepsy, schizophrenia, anxiety disorder, bipolar disorder, viral hepatitis, post-traumatic stress disorder, phantom limb syndrome with pain, hypertension, and absence of right and left fingers, and right and left lower legs.R1's MDS (Minimum Data Set) dated 10/22/25 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact.R1's Order Summary Report dated 11/18/25 includes a physician order for dicyclomine 10 mg (milligrams) two capsules four times daily for bowel movement, with a start date of 3/27/25.R1's current Care Plan does not document a Focus area related to the dicyclomine and/or bowel movements/constipation.R1's MAR (Medication Administration Record) dated 10/01/25 to 10/31/25 documents a physician order for dicyclomine 10 mg administer two capsules four times daily. This same MAR documents a 9 in the signature spot on the following dates and times. 10/6- 5 pm and 8 pm, 10/07- 8 pm, 10/8- 9 am, 12 pm, and 8 pm, 10/9- 12 pm and 8 pm, 10/10- 9 am and 8 pm. This same MAR documents 2's on 10/7- 12 pm and 5 pm, 10/9- 9 am and 5 pm, and 10/10 - 12 pm and 5 pm. The Chart Codes documented on the MAR indicates a 2 means Drug Refused and the 9 means other/See Progress Notes.R1's Progress Notes document in the corresponding medication administration notes the dicyclomine was unavailable for administration from 10/06/25 until 10/10/25.R1 no longer resided at the facility and was unable to be reached via telephone for an interview during the survey.On 1/16/25 at 5:19 AM, V4 (Licensed Practical Nurse/LPN) stated they switched pharmacies in 10/2025, and it was a struggle getting medications filled at the time, but it was getting better. V4 stated R1 did miss medications during that time frame and him not getting his medications as ordered was a genuine concern and frustrating.On 11/18/25 at 10:24 AM, V2 (Director of Nurses/DON) stated R1 did not receive the dicyclomine as ordered from 10/06/25 through 10/10/25. V2 stated it wasn't available for R1 to take because they were waiting on the pharmacy to deliver it.2. R8's admission Record with a print date of 11/18/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include diffuse traumatic brain injury, traumatic hemorrhage of cerebrum, open wound of head, serotonin syndrome, delirium, and depression.R8's MDS dated [DATE] documents a BIMS score of 15, indicating R8 is cognitively intact.R8's current Care Plan documents a Focus area of I am on pain medication therapy r/t (related to) TBI (traumatic brain injury) .Date Initiated: 9/17/2025. This Focus area includes the intervention to administer analgesics as ordered by the physician.R8's Order Summary Report dated 11/19/25 includes a physician order for lidocaine external patch 5% apply to affected area topically one time daily with a start date of 9/5/25.R8's MAR dated 10/1/25 to 10/31/25 includes physician orders for lidocaine 5% patch administer to affected area one time daily and an order for Lyrica 150 mg twice daily. This same MAR documents a 9 for the administration of the lidocaine patch on 10/17, 10/18, 10/20, and 10/21 and a 9 for the administration of the Lyrica on 10/5 and 10/06/25. This indicates a corresponding progress note related to this medication administration date.R8's Progress Notes document on the corresponding medication administration notes the lidocaine patch was unavailable for administration on 10/17, 10/18, 10/20, and 10/21 and documents the Lyrica was unavailable for administration on 10/05 and 10/06/25.On 11/16/25 at 9:32 AM, R8 stated the facility has had some issues with getting his medications as ordered from the pharmacy.On 11/18/25 at 10:24 AM, V2 (DON) stated the physician ordered a 5 % patch instead of the 4% patch they normally use. V2 stated they had to order them from the pharmacy instead of the over-the-counter ones they normally use, and they weren't available in the emergency drug kit. This surveyor reviewed R8's MAR and progress notes with V2 and asked if they weren't available on 10/17, 10/18, 10/20, and 10/21 how was it administered on 10/19/25. V2 stated she didn't know and would have to check with the nurse (V16 Agency Registered Nurse) who signed it out. V2 stated R8 was receiving the lidocaine patch for surgical after care/brain surgery. V2 stated R8 admitted to the facility on [DATE] with the order in place at the time of admission. When asked why over a month later the patch wasn't available, V2 stated, It had to be a pharmacy issue. V2 stated there was no documentation in R8's record why the medication was not available. V2 stated she didn't know what, if anything, was done to obtain the patches since there was no documentation. V2 stated R8's Lyrica was unavailable for administration on 10/05 and 10/06/25. V2 stated she thought R8 needed a new prescription before the pharmacy would fill it. When asked if it was acceptable practice for R8 to go without the Lyrica and the Lidocaine patch V2 stated, No, it is not. V2 stated she wasn't aware of any negative outcome related to R8 not getting his medications.3. R7's admission Record with a print date of 11/18/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension.R7's MDS dated [DATE] documents a BIMS score of 15, indicating R7 is cognitively intact.R7's Order Summary Report dated 11/19/25 documents a physician order for Sudafed 30 mg every 12 hours as needed with a start date of 11/05/25.R7's MAR dated 11/1/25 to 11/30/25 documents a physician order for Sudafed 30 mg every 12 hours as needed with a start date of 11/05/25. This same MAR does not document administration of the Sudafed from 11/05/25 to 11/10/25.On 11/16/25 at 6:57 AM, R7 stated he waited 3 to 4 weeks to get the insurance to approve his new sinus medication, but he was getting it now.On 11/18/25 at 10:24 AM, V2 (DON) stated when the physician first wrote the order for R7's Sudafed they didn't put a dosage on the prescription, so they had to get a new order with the dosage and resend it to the pharmacy. V2 stated once they got the new prescription to the pharmacy it came back as an over-the-counter prescription, so the facility had to pay for it. When asked if she knew why that took five days and if that was an acceptable length of time, V2 stated they were still getting used to the new pharmacy.On 11/16/25 at 12:48 PM, V9 (Registered Nurse) stated they had issues with medications not being available to administer when they switched pharmacies. V9 stated if a resident doesn't get their medication, it should be charted.On 11/18/25 at 10:24 AM, V2 (DON) was unable to locate documentation R1, R7, and/or R8's physicians were notified the medications were not available to see if they wanted to prescribe a different medication/dosage. V2 stated it was not acceptable practice for residents to not be administered medications as ordered. V2 stated she had in serviced the nursing staff what to do if a medication is unavailable.The Pharmacy policy dated 1/2018 documents under Policy-Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies.

Based on interview and record review the facility failed to ensure the menu met the resident's individual nutritional needs and preferences for 1 of 3 (R8) residents reviewed for dietary services in the sample of 21.Findings include:On 11/16/25 at 12:43 PM, R8 stated he didn't get a meal tray last night at the evening meal (11/15/25). R8 stated he normally eats in his room, and he wasn't sure why they didn't serve him supper. R8 stated at approximately 8:45 pm they made him three peanut butter and jelly sandwiches. R8 stated he would have rather had the chicken and French fries they served for the evening meal.R8's admission Record with a print date of 11/18/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include diffuse traumatic brain injury, traumatic hemorrhage of cerebrum, open wound of head, serotonin syndrome, delirium, and depression.R8's MDS (Minimum Data Set) dated 9/16/25 documents a BIMS (Brief Interview for Mental Status) score of 15 indicating R8 is cognitively intact.R8's current Care Plan documents a Focus area of, I have a nutritional problem or potential problem r/t (related to) TBI (traumatic brain injury), depression Date Initiated: 09/01/2025. This Focus area includes the interventions of, Encourage PO (by mouth) intake of meals and snacks. Date Initiated: 09/17/2025.Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Date Initiated: 09/17/2025.R8's Order Summary Report dated 11/19/25 documents a physician order for a no added salt regular texture diet.The facility Diet Spreadsheet Dated Week 3 25-26 Saturday documents the menu for Dinner as, chicken tenders platter, French fries, ketchup, buttered peas, bread/margarine, banana's with whipped topping, milk/beverage.On 11/16/25 at 1:09 PM, V11(Dietary Aid) stated she worked 11/15/25 and R8's tray was made and sent out the window but somehow didn't get to him. V11 stated they made him peanut butter and jelly sandwiches around 7 pm. When asked if this had ever happened before V11 stated they send the trays out and then the residents say they don't get them. V11 was unable to provide this surveyor with any specific dates and/or residents this had occurred with other than R8.On 11/16/25 at 1:12 PM, V12 (Cook) stated he worked 11/15/25 and wasn't sure what happened with R8's dinner meal tray. V12 stated two tickets may have gotten stuck together. V12 stated an unknown CNA told him R8 didn't get a meal tray, and he made him three peanut butter and jelly sandwiches around 7 pm.On 11/16/25 at 12:48 PM, V9 (Registered Nurse) stated R8's food is always messed up but was unable to provide this surveyor with specific details.On 11/17/25 at 2:39 PM, V10 (Dietary Manager) stated the nursing staff were aware R8's tray was served to the wrong person who was on the same diet as R8, but they didn't tell the dietary staff R8 needed another tray. On 11/19/25 at 2:20 PM, V10 (Dietary Manager) stated to his knowledge three peanut butter and jelly sandwiches were the only food R8 was served on the night of 11/15/25. V10 stated that was not an acceptable substitution for chicken tenders, French fries, buttered peas, and bananas. V10 stated R8 should have been offered a starch, vegetable, and a dessert.The facility policy titled Dining Options for Meal Service dated 2020 includes, Staff will monitor the resident's food and fluid intake for adequate consumption and offer appropriate meal substitutions to residents when needed.

Based on interview, and record review, the facility failed to provide the correct textured diet for 1 of 19 (R2) residents reviewed for diet in a sample of 19. This failure resulted in R2 choking and being sent to the hospital. Findings include: R2's admission Record documents an admission date of 10/28/2024 with diagnoses including in part dementia and dysphagia oropharyngeal phase. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R2's most recent Care Plan documents a focus area of R2 has nutritional problem or potential nutritional problem and interventions include in part provide and serve diet as ordered, dated 6/9/23. R2's Diet order dated 3/12/25 11:48 PM through 6/14/25 3:16 PM documents regular diet, mechanical soft texture, nectar/mildly thick consistency. R2's diet order dated 6/14/25 3:16 PM through 6/18/25 2:02 PM documents regular diet, pureed texture, nectar/mildly thick consistency. R2's current diet order started 6/18/25 2:03 PM documents regular diet, pureed texture, honey/moderately thick consistency. R2's progress note titled Health Status Note dated 6/13/25 at 12:43 PM documents Resident (R2) was sitting in the dining room eating his lunch and he ended up getting choked on a piece of sausage and went unresponsive. He was still breathing. Staff was able to remove the piece of sausage, and he is now alert and sitting up. Notified (Nurse Practitioner) who was in the dining room at the time of the event who gave orders to send to (local hospital) ER (Emergency Room). Called EMS (Emergency Medical Services) at 1235 (12:35 PM) for transport. Called to (Local Hospital) ER and gave report to RN (Registered Nurse) at 1238 (12:38 PM). Called POA (Power of Attorney) and updated her on resident (R2) being transferred to hospital. She said she would call back later to check on him if she hasn't heard anything. Transfer record, POLST (Physician Orders for Life-Sustaining Treatment), order summary, and bed hold policy sent with EMS. R2's progress note titled Health Status Note dated 6/13/25 at 12:43 PM documents EMS arrived and resident (R2) is leaving on stretcher at this time to (local hospital). R2's progress note titled Health Status Note dated 6/14/25 at 3:17 PM documents Resident (R2) noted to be having difficulty chewing and swallowing during lunch. Nursing intervention in place to downgrade diet to pureed and have ST (Speech Therapy) to eval (evaluate) and treat. Wife notified. R2's incident report titled Choking dated 6/13/25 at 12:43 PM documents under Incident Description; Nursing Description: It was brought to my attention that (R2) was down in the dining room choking on lunch. Upon entering the dining room, I observed (R2) laying on the ground with multiple staff members and NP (Nurse Practitioner) in the dining room. (R2) was purple in color but he was still breathing at the time. Resident Description: (R2) states that he got choked on the bread and sausage. Description: Staff performed Heimlich/abdominal thrusts which was successful. On 6/25/25 at 1:53 PM, V3 (Certified Nursing Assistant/CNA) stated R2 was served a whole bratwurst but can't remember if it was on a bun. V3 stated while she was passing trays someone yelled out that R2 was choking. V3 stated R2 was blue/purple in the face and was staring off so she yelled for help. V3 stated the nurse came and started the Heimlich maneuver. V3 stated the nurse did the Heimlich maneuver until she got tired then she took over. V3 stated the Heimlich maneuver was not working so they laid R2 on the floor on his side and started back thrusts then V2 (Director of Nursing) came in and did a finger sweep and pulled out a piece of the bratwurst and there was still a piece in his mouth that he started chewing. V3 stated his color returned to normal and he started breathing again. V3 stated she does not know what diet R2 had ordered at the time. On 6/26/25 at 12:37 PM, V4 (Speech Therapist) stated she saw R2 prior to the choking incident and he was ordered to be on a mechanical soft diet and thickened liquids. V4 stated she was not at the facility the day of R2's choking incident but she was told he received a whole bratwurst on a bun. V4 stated a whole bratwurst is not considered a mechanical soft texture diet. V4 stated she was in the facility the next day and saw R2 and that time nursing had downgraded R2 to a pureed diet when he came back from the hospital. V4 stated the goal for R2 is to get him back to a mechanical soft diet and she will be trying that diet with R2 today. On 6/26/25 at 1:17 PM, V9 (Dietary Aide) stated she was working the day R2 choked, and she served R2 a whole brat on a bun. V9 stated R2 was ordered mechanical soft textured diet. V9 stated R2 should have received the bratwurst and bun mechanical soft texture and not whole on a bun. On 6/26/25 at 1:42 PM, V2 (Director of Nursing) stated she was notified that there was an emergency in the dining room and when she arrived in the dining room and saw R2 laying in the floor and R2 was choking. V2 stated staff were doing abdominal and back thrust and it was not working so she did a finger sweep in R2's mouth and pulled out a piece of bratwurst and some gummed up bread. V2 stated the staff sat R2 up then they performed another back thrust and R2 then started coughing. V2 stated EMS arrived shortly after that and took R2 to the local emergency room. On 6/26/25 at 2:11 PM, V12 (Cook) stated she was working the day R2 choked. V12 stated she served R2 a whole bratwurst on a bun that day. V12 stated R2 was ordered for a mechanical soft diet and received the incorrect diet texture. V12 stated R2 was supposed to get his bratwurst and bun with mechanical soft texture. On 6/26/25 at 2:44 PM, V1 (Administrator) stated she was not working the day R2 choked. V1 stated she was informed R2 was served a regular texture diet, bratwurst on a bun. V1 stated R2 should have been served mechanical soft texture diet. R2's emergency department notes from local hospital dated 6/13/25 documents R2 presented from a local nursing home after a choking episode. The nursing home did the Heimlich maneuver, and they were able to expel the sausage the patient choked on. Patient did have an episode of non-responsiveness at the facility, but he was more alert once EMS arrived. The facility Diet Spreadsheet for Day 20 documents the mechanical soft diet served for 6/13/25 was ground bratwurst on bun with gravy (no raw vegetables), potato salad, baked beans, and soft chopped watermelon (no seeds). The facilities recipe for mechanical soft texture diet for 6/13/25 titled Ground Bratwurst on Bun with Gravy documents under 3. Place prepared bratwurst in a washed and sanitized food processor. Pulse/grind to the size and texture of finely ground beef. 4. Place in steam table pan and add a small amount of prepared broth or gravy to keep moist. The facility policy titled Diet Summary dated 2022 documents under Dental Soft (Mechanical Soft) Diet: Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) and should be mixed or served with gravy, broth, or another type of moistening agent.

Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for 2 of 3 residents (R2, and R3) reviewed for abuse in the sample of 3. The failure resulted in R3 receiving a fractured coccyx after an incident where R1 pushed R3 down. Findings Include: R1's Admission Record documents that R1 is an [AGE] year-old make that was admitted to the facility on [DATE]. Diagnoses listed are chronic obstructive pulmonary disease, spondylosis, unspecified dementia, anxiety disorder, hyperlipidemia, insomnia, and repeated falls. R1's MDS (Minimum Data Set), dated 02/07/2025, documents that R1 has a BIMS (Brief Interview for Mental Status) of 05, indicating that R1 has severe cognitive impairment. R1's care plan with a revision date of 02/07/2025 has a focus area of, I have a behavior problem. The interventions listed for the focus area are administer medications as ordered, anticipate and meet resident's needs, assist the resident to develop more appropriate ways of coping and interacting, encourage resident to express feelings, caregivers to provide opportunity for positive interaction and attention, stop and talk when passing, if reasonable discuss the residents behavior and explain why the behavior is inappropriate/unacceptable, intervene as necessary to protect the safety and rights of others, approach and speak in a calm manner, minimize potential for resident's disruptive behaviors by offering tasks which divert attention, and monitor behavior episodes and attempt to determine underlying cause. Consider time of day, location, persons involved and situations. R3's Admission Record documents that R3 is an [AGE] year-old male that was admitted to the facility on [DATE]. Diagnoses listed are Parkinson's disease, unspecified dementia, Alzheimer's disease, anemia, insomnia, and depression. R3's MDS (Minimum Data Set), dated 02/21/2025, documents that R3 has a BIMS (Brief Interview for Mental Status) score of 06, indicating that R3 has severe cognitive impairment. R3's Care Plan with a revision date of 02/22/2025 has a focus area of, I have a behavior problem. The interventions listed for this focus area are, Explain all procedures to the resident before starting and allow the resident to adjust to changes, if reasonable discuss the resident's behavior and explain/reinforce why behavior is inappropriate or unacceptable, Intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from the situation and take to an alternate location, monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved and document behaviors, and provide a program of activities of interest to accommodate residents status. 1. A final incident report sent to the state surveying agency titled Report to (state surveying agency) Regional Office documented on 03/21/2025 at 7:15 P.M. R3 was in the hallway preaching loudly when R1 became agitated. R1 then pushed R3 causing R3 to fall into the handrail and bump his right elbow and back of his neck. An abrasion to R3's right elbow was noted. R1 and R3 were immediately separated and assessed for injuries. A referral to psychiatry was made to address R1's agitation. R3's Behavior Note dated 03/21/2025 timed 8:52 P.M. authored by V13 (Registered Nurse/RN) documented at approximately 7:15 P.M. R3 was in the hallway preaching loudly when a peer suddenly became agitated and pushed R3. R3 fell into the handrail and bumped his right elbow and the back of his neck. R3 was assisted to a stand. R3 was assessed by the RN. R3 has a small new abrasion to the right elbow. No apparent injuries seen or reported to the back of the neck. R3 stated he did not hit his head. R3 denies pain. R3 has unsteady gait and gross tremors that appear to be at his baseline. R3's range of motion appears to have some limitations due to stiffness and tremors, but do not seem to be impaired from the fall. No signs and symptoms of distress. R3 escorted by standby assist to his room. Assistant director of nurse, on-call admin, MD local police, and V12 (Family Member) POA notified, and all appropriate charting completed. At 7:59 P.M. a local official took verbal statement on the incident from this RN on-site. R3's Health Status Note with a date of 03/22/2025 and a time of 2:54 P.M. authored by V14 (Licensed Practical Nurse) documented, R3 complaining of tenderness to left buttock. Assessed area, no signs or symptoms of swelling, bruising, or abrasions. Informed R3 he may be sore for a while. Pain medications given and helped alleviate discomfort. On 04/15/2025 at 12:39 P.M. V2 (Assistant Director of Nursing/Interim Director of Nursing) stated V12 (Family Member) took R3 to an appointment on 03/25/2025 to V15 (Physician). At that appointment R3 told V15 he was pushed down by another person and landed on his buttock. R3 complained of pain in the sacral area at the appointment. V15 ordered an x-ray of the sacrum and coccyx. V12 took R3 to a local hospital to get the x-ray completed on 03/25/2025. R3's Hospital report dated 03/25/2025 documents, Clinical history: patient was pushed down by another person on Saturday. He landed on his bottom. C/O (complaint of) sacral area pain. X-ray of Sacrum and Coccyx were obtained. Impression: Suspected contour irregularity and oblique/transverse radiolucent line of the first segment of the coccyx might be a non-displaced fracture. Correlates with clinical findings. New. R3's Health Status Note dated 03/26/2025 timed 9:56 A.M. authored by V16 (Licensed Practical Nurse) documented that V9 (Nurse Practitioner) examined R3. Resident claimed they are experiencing no pain. Ordered placed for a CBC (Complete Blood Count) and a CMP (Comprehensive Metabolic Panel). R3's Health Status Note dated 03/27/2025 timed 8:11 P.M. authored by V7 (Registered Nurse) documented R3 had a witnessed fall with head involvement. R3 was standing in the dining room, lost balance, struck the edge of the table with his back and hitting his head on the floor. R3 was sent to local hospital for evaluation post fall. A fax transmission from the local hospital dated 3/28/25 at 12:19 PM for R3 documents, Emergency Department notes for 3/27/25 to include: R3 is an [AGE] year-old with a significant past medical history that presents today with a fall. R3 recently had a fall a few days ago and they did not get the result of the x-rays back yet. The lumbar x-ray showed spondylitic degenerative changes. The x-rays of the coccyx showed a small fracture non-dislocated. Discussed with R3's wife he needs to sit on a donut padding the next few weeks. A final incident report sent to (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/03/2025 at 4:00 P.M. R3 and R1 was in an alleged resident to resident altercation. R1 was in dining room prior to altercation. R1 was observed by V5 (Activity Assistant) leaving the dining room. V5 then heard R3 yell that he was pushed. V5 immediately went to R3's room and R1 was standing in R3's room. R1 was immediately redirected by V5. R3 stated to V5 that he was standing at his closet when R1 came into his room and pushed him. R1 was unable to recall the incident. R3's AIM for Wellness - Event Record dated 04/03/2025 with a time of 5:37 P.M. authored by V10 (Licensed Practical Nurse) documented that at 4:15 P.M. R3 was looking for something in his closet. R3 stated that he was pushed by R1. Residents were immediately separated. A final incident report sent to (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/03/2025 at 5:00 P.M. R3 had a follow up appointment where the physician ordered an X-ray. Results were reported to us today by the spouse. After investigation it was determined that R3 had an altercation with another resident on 03/21/2025 where he was pushed down. At the time of the incident R3 was not complaining of any pain. On 03/25/2025 wife took R3 to a doctor appointment where he was complaining of buttocks pain. The physician ordered an x-ray of the coccyx. Results were made aware to the wife and relayed to the us on 04/03/025. R3's Health Status Note dated 04/03/2025 timed 6:11 P.M. authored by V2 (Registered Nurse/Interim DON) documented Spouse took resident to a follow up appointment on 3/26 where V15 (Physician) ordered an x-ray. Results were reported to us today of a fracture to the coccyx. Notified V9 (Nurse Practitioner) and awaiting additional orders at this time. On 04/16/2025 at 9:31 A.M. R3 was observed to be ambulating in the hallway. R3 stopped V10 (Licensed Practical Nurse) and complained of pain to his coccyx area. R3 asked V10 for pain medication for the pain in his tail bone. On 04/15/2025 at 2:21 P.M. V7 (Registered Nurse/Former DON) stated R1 was not aggressive when he first arrived at the facility. V7 stated he often becomes angry with redirection. V7 stated they were unable to figure out the why R1 is having the increase in behaviors. V7 stated the family lives over by (name of nearby town) and the facility sent a referral over to the facility there and R1 was denied because of behaviors. V7 stated she is unsure what interventions were put into place and when that she would have to refer to the care plan. V7 stated she is not sure what caused R1 to push R3 down. V7 stated at the time of the incident R3 was not complaining of any pain. V7 stated the wife took him to an appointment where R3 told the doctor about his pain. The doctor ordered an x-ray, and the wife took R3 to the local hospital to get the x-ray before returning to the facility. When the wife brought R3 back, she did not tell the facility about the x-ray. V7 stated that the wife came in on 04/03/2025 and was telling the administrator about it. V7 stated she was not aware of what occurred after that. V7 stated that V1 (Administrator) does the investigations and reports, and she is not aware of any of the outcomes. V7 stated she was not aware that the Emergency department report dated 03/28/2025 documented the fracture of the coccyx. V7 stated that she was never given that information. On 04/15/2025 at 3:25 P.M. V5 (Activity Assistant) stated that she was doing an activity on the locked unit and saw R3 run out of his room. R1 was in his room and R3 was stating that R1 pushed him. V5 stated she did not see it but only knows what R3 told her. V5 stated they have been unable to determine the cause of R1's behavior. V5 stated she has noticed it is worse after lunch. V5 stated besides attempts at redirection, the nurses can give R1 medication when he is becoming aggressive. On 04/16/2025 at 9:19 A.M. V10 (Licensed Practical Nurse) stated that she has taken care of R1 before. V10 stated that R1 would get an angry look and then would have behaviors without warning. V10 stated she is not sure what was triggering R1's behaviors. V10 stated it appears that R1 has issues with other male residents. V10 stated she tried to keep R1 and R3 separated when she works because of the number of resident-to-resident altercations they have had. V10 stated the right approach with R1 will change his behavior. V10 stated she does not know the root cause of what was causing R1 to have behaviors and hit other residents. V10 stated she was never made aware if they did any blood work or urine tests to see if that was causing the change in behaviors. V10 stated that when R1 first arrived he would be resistive to care and combative with staff at times. V10 stated that just in the last month he started having resident to resident altercations. On 04/16/2025 at 9:34 A.M. V11 (Certified Nurse Assistant/CNA) stated she has taken care of R1 in the past. V11 stated that R1 was easily triggered by little things. V11 stated there was no warning when R1 was going to have a behavior it was like a light switch going on and off. V11 stated that in the late afternoon to early evening hours R1 would be worse because of sun downing. V11 stated she was never made aware of what was the cause of the behaviors that R1 was having. On 04/16/2025 at 10:15 A.M. V1 (Administrator) stated the incident that happened on 03/21/2025 involving R1 and R3, occurred because R3 was loudly preaching in the hall and that upset R1. R1 went up to R3 and pushed him down. V1 stated the intervention to prevent this from occurring again was to consult psych on R1's behaviors. V1 stated the incident on 04/03/2025 between R1 and R3 was not witnessed by staff. V1 stated that V5 (Activity Assistant) heard R1 state he needed to use the restroom. V1 stated that V5 heard R3 out in the hallway stating that R1 had pushed him. V1 stated that they could not determine a root cause as to why R1 went into R3's room and pushed him. V1 stated they placed a large sign on R1's door alerting him to his room. V1 stated that R1 is a resident who wonders around the facility. V1 stated that R1 did see the psych nurse practitioner and his Haldol was increased. V1 stated that on 03/26/2025, R3's wife took him to a podiatrist doctor appointment. At that appointment the wife told the podiatrist that R3 was complaining about pain in his buttock region. The podiatrist gave the wife of R3 an order to take him to a local hospital and get an x-ray. V1 stated that R3's wife brought him back from the appointment and did not tell the facility that she had taken him to a local hospital for an x-ray of his coccyx. V1 stated on 03/27/2025 R3 had a fall and was to the emergency department for evaluation. V1 stated that upon R3 arriving back to the facility they were still not made aware of the results of the x-ray. V1 stated on 4/03/2025, R3's wife told her that when he was in the emergency department on 03/28/2025, the emergency department looked at the x-ray and had informed her of the new fracture to his coccyx. V1 stated after R3's wife told her of the new fracture, R3's facility nurse practitioner was made aware. 2. R2's Admission Record documents that R2 is a [AGE] year-old male that was admitted to the facility on [DATE]. Diagnoses listed are chronic obstructive pulmonary disease, type 2 diabetes mellitus, paroxysmal atrial fibrillation, unspecified dementia, and senile degeneration of the brain. R2's MDS (Minimum Data Set) dated 03/30/2025, documents that R2 has a BIMS (Brief Interview for Mental Status) of 09, indicating that R2 has moderate cognitive impairment. R2's care plan with a date initiated of 08/29/2024 has a focus area of Behavior Management. The interventions listed for the focus are: attempt an alternative time to provide care if refused, consult pastoral care if needed, encourage participation in self-calming behaviors such as breathing exercises, meditation or guided imagery, ensure the safety of resident and others, establish boundaries with resident, evaluate medication schedule and possible pharmacologic cause of behavior, initiate visual supervision during acute episode, provide emotional support, reorient resident to person, place, and time, and utilize diversion techniques. A final incident report sent to the (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/05/2025 at 9:00 P.M. R1 and R2 had an alleged resident to resident altercation. During the investigation, V4 (Certified Nurse Assistant/CNA) stated that R1 was walking by R2, when R1 shoved R2 to the floor. R1 then took R2's walker and hit him with it. V4 stated she immediately intervened and separated the residents. Neither resident is able to recall incident due to cognitive state of mind. R2's Health Status Note dated 04/06/2025 timed 9:01 A.M. authored by V17 (Licensed Practical Nurse) documented, It was reported to this nurse from V2 (ADON/RN/Interim DON) that on 04/05/25 at approximately 2100 (9:00PM) another resident pushed R2 to the ground, took his walker and started hitting him with it. No injuries observed this am. On 04/15/2025 at 10:55 A.M. V6 (CNA) stated she is an agency CNA, and this is her 4th shift at the facility. V6 stated that R2 ambulates around the facility. V6 stated she was not here the day the incident happened between R1 and R2. On 04/15/2025 at 12:39 P.M. V2 (ADON/Interim Director of Nursing) stated R1 was an elopement risk when he first arrived at the facility. V2 stated the longer that R1 had been here he has become more aggressive with staff and residents. V2 stated that one intervention was to have local psych see R1. V2 stated other interventions the facility has done for R1 are medication changes. The Haldol R1 was on went from as needed to scheduled. V2 stated other interventions were trying to keep him separated from his peers, and finally the decision was made to send a referral to out of state behavior hospital because the facility had exhausted all other options. V2 stated that once R1 became aggressive, they referred him to out of state behavior hospital. V2 stated that she does not recall R1 ever being on 1-1 with staff. V2 stated they attempted to move him off the locked unit, but he kept going out all the doors, so they had to move him back. V2 stated she doesn't see any other behavior modifications listed in the care plan for R1. V2 stated after the incident on 04/05/2025, the facility decided a referral to out of state behavior hospital would be the best intervention for R1. V2 stated that R1 was sent to out of state behavior hospital on 04/08/2025 and is not aware of any other interventions put in place to prevent a new behavior from occurring, V2 stated she would have to ask V1 (Administrator) as she does the investigations. V2 stated that R3 went to a doctor appointment with his wife. V2 stated that he had not been complaining to staff of any pain since the resident to resident with R1 when R1 pushed R3, and he fell on [DATE]. At the appointment R3 complained of pain and the doctor ordered an x-ray of the coccyx. The wife took R3 to a local hospital to complete the x-ray. V2 stated upon R3 returning to the facility, the wife nor the doctor notified the facility of an order for an x-ray. V2 stated the facility was notified by the wife on 04/03/2025. V2 stated that V9 (Nurse Practitioner) was made aware of fracture on R3. V2 stated that V9 ordered labs for R3. V2 stated that V9 saw R3 again on 04/09/2025 and there is an order for physical therapy to eval. On 04/15/2025 at 1:35 P.M. V8 (Unit Aide) stated that R1 would get combative sometimes for no reason. V8 stated she is not sure why he would get aggressive and combative. V8 stated she was never told or concluded about why R1 was having behaviors. V8 stated they would try to talk him down. V8 stated she was not working on the days that R1 was involved with the resident-to-resident altercation. On 04/15/2025 at 2:21 P.M. V7 (RN/Former DON) stated R1 was not aggressive when he first arrived at the facility. V7 stated he often becomes angry with redirection. V7 stated they were unable to figure out the why R1 is having the increase in behaviors. V7 stated she is not sure what the cause of R1 pushing R2 down and hitting him with his walker. V7 stated she knows there was a referral made to an out of state behavioral hospital for R1 after this incident. On 04/16/2025 at 10:15 A.M. V1 (Administrator) stated the incident on 04/05/2025 between R1 and a peer, where R1 pushed a resident down in the hallway and hit them with their walker, has no root cause. V1 stated that there was no reason or causative factors to contribute to R1's behavior. V1 stated that a referral was sent the next day to an out of state behavior facility for R1. V1 stated that was the only intervention put in place besides monitoring R1. V1 stated that R1 did see the psych nurse practitioner and his Haldol was increased. On 04/16/2025 at 2:40 P.M. V9 (Nurse Practitioner) stated she is in the facility weekly or more often to see the residents. V9 stated she is not sure why R1 is having an increase in behaviors. V9 stated one incident he attacked a resident for preaching in the hallway and the other incident he pushed someone down. V9 stated she is not sure why if any contributing factors have been determined. V9 stated that when an incident occurs, she comes to the facility and evaluates the residents involved. V9 stated that R1 has returned from the out of state behavioral hospital and that facility has completed some medication changes. Facility policy titled Abuse Prevention and Reporting -Illinois with a revision date of 10/24/2022, documented under section titled Guidelines - This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Protection of Residents: Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including but not limited to, the separation of residents.

Based on interview and record review the facility failed to notify the physician of resident having pain after a resident-to-resident altercation with a fall for 1 (R3) of 1 resident reviewed for quality of care in the sample of 3. Findings Include: R3's Admission Record documents that R3 is an [AGE] year-old male that was admitted to the facility on [DATE]. Diagnoses listed are Parkinson's disease, unspecified dementia, Alzheimer's disease, anemia, insomnia, and depression. R3's MDS (Minimum Data Set), dated 02/21/2025, documents that R3 has a BIMS (Brief Interview for Mental Status) score of 06, indicating that R3 has severe cognitive impairment. A final incident report sent to the (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 03/21/2025 at 7:15 P.M. R3 was in the hallway preaching loudly when R1 became agitated. R1 then pushed R3 causing R3 to fall into the handrail and bump his right elbow and back of his neck. An abrasion to R3's right elbow was noted. R1 and R3 were immediately separated and assessed for injuries. A referral to psychiatry was made to address R1's agitation. R3's Behavior Note dated 03/21/2025 timed 8:52 P.M. authored by V13 (Registered Nurse/ RN) documented at approximately 7:15 P.M. R3 was in the hallway preaching loudly when a peer suddenly became agitated and pushed R3. R3 fell into the handrail and bumped his right elbow and the back of his neck. R3 was assisted to a stand. R3 was assessed by the RN. R3 has a small new abrasion to the right elbow. No apparent injuries seen or reported to the back of the neck. R3 stated he did not hit his head. R3 denies pain. R3 has unsteady gait and gross tremors that appear to be at his baseline. R3's range of motion appears to have some limitations due to stiffness and tremors, but do not seem to be impaired from the fall. No signs and symptoms of distress. R3 escorted by standby assist to his room. Assistant director of nurse, on-call admin, MD local police, and V12 (Family Member) POA notified, and all appropriate charting completed. At 7:59 P.M. a local official took verbal statement on the incident from this RN on-site. R3's Health Status Note with a date of 03/22/2025 and a time of 2:54 P.M. authored by V14 (Licensed Practical Nurse) documented R3 complaining of tenderness to left buttock. Assessed area, no signs or symptoms of swelling, bruising, or abrasions. Informed R3 he may be sore for a while. Pain medications given and helped alleviate discomfort. On 04/15/2025 at 12:39 P.M. V2 (Assistant Director of Nursing/Interim Director of Nursing) stated V12 (Family Member) took R3 to an appointment on 03/25/2025 with V15 (Physician). At that appointment R3 told V15 he was pushed down by another person and landed on his buttock. R3 complained of pain in the sacral area at the appointment. V15 ordered an x-ray of the sacrum and coccyx. V12 took R3 to a local hospital to get the x-ray completed on 03/25/2025. R3's Hospital report dated 03/25/2025 documents, Clinical history: patient was pushed down by another person on Saturday. He landed on his bottom. C/O (complaint of) sacral area pain. X-ray of Sacrum and Coccyx were obtained. Impression: Suspected contour irregularity and oblique/transverse radiolucent line of the first segment of the coccyx might be a non-displaced fracture. Correlates with clinical findings. New. R3's Health Status Note dated 03/26/2025 timed 9:56 A.M. authored by V16 (Licensed Practical Nurse) documented that V9 (Nurse Practitioner) examined R3. Resident claimed they are experiencing no pain. Ordered placed for a CBC (Complete Blood Count) and a CMP (Comprehensive Metabolic Panel). R3's Health Status Note dated 03/27/2025 timed 8:11 P.M. authored by V7 (Registered Nurse) documented R3 had a witnessed fall with head involvement. R3 was standing in the dining room, lost balance, struck the edge of the table with his back and hitting his head on the floor. R3 was sent to local hospital for evaluation post fall. A fax transmission from the local hospital dated 3/28/25 at 12:19PM for R3 documents, Emergency Department notes for 3/27/25 to include: R3 is an [AGE] year-old with a significant past medical history that presents today with a fall. R3 recently had a fall a few days ago and they did not get the result of the x-rays back yet. The lumbar x-ray showed sponylitic degenerative changes. The x rays of the coccyx showed a small fracture non-dislocated. Discussed with R3's wife he needs to sit on a donut padding the next few weeks. A final incident report sent to (state surveying agency) titled Report to (state surveying agency) Regional Office documented on 04/03/2025 at 5:00 P.M. R3 had a follow up appointment where the physician ordered an X-ray. Results were reported to us today by the spouse. After investigation it was determined that R3 had an altercation with another resident on 03/21/2025 where he was pushed down. At the time of the incident R3 was not complaining of any pain. On 03/25/2025 wife took R3 to a doctor appointment where he was complaining of buttocks pain. The physician ordered an x-ray of the coccyx. Results were made aware to the wife and relayed to the us on 04/03/025. R3's Health Status Note dated 04/03/2025 timed 6:11 P.M. authored by V2 (Assistant Director of Nursing/Interim Director of Nursing) documented Spouse took resident to a follow up appointment on 3/26 where V15 (Physician) ordered an x-ray. Results were reported to us today of a fracture to the coccyx. Notified V9 (Nurse Practitioner) and awaiting additional orders at this time. On 04/15/2025 at 2:05 P.M. V2 (Assistant Director of Nursing/Interim Director of Nursing) stated that she was not aware of R3's emergency department visit documents being in the electronic chart. V2 stated that when a resident goes out to the emergency department, the records get faxed back. The nurse who receives the records are supposed to review them and make sure there is nothing new. Once that is completed, the nurse will give the documents to medical records for them to scan into the chart. V2 stated she was not aware that the emergency department documents that the facility received on 03/28/2025 documented that R3 had a fractured coccyx. On 04/15/2025 at 2:21 P.M. V7 (Registered Nurse) stated she was not aware that the Emergency department report dated 03/28/2025 documented the fracture of the coccyx. V7 stated that she was never given that information. V7 stated she was the nurse who sent R3 to the hospital after the fall and when she received report from the hospital, they did not tell V7 that R3 had a new fracture to the coccyx. On 04/16/2025 at 10:15 A.M. V1 (Administrator) stated he was not aware of a document in R3's medical record that is dated 03/28/2025 with a faxed time of 12:19 on it documenting R3's new fracture. V1 stated that she was made aware by the wife on 04/03/2025 and she went into R3's electronic medical records at the hospital and pulled the x-ray report. On 04/16/2025 at 2:40 P.M. V9 (Nurse Practitioner) stated she is in the facility weekly or more often to see the residents. V9 stated she is not sure why R1 is having an increase in behaviors. V9 stated one incident he attacked a resident for preaching in the hallway and the other incident he pushed someone down. V9 stated she is not sure why if any contributing factors have been determined. V9 stated that when an incident occurs, she comes to the facility and evaluates the residents involved. V9 stated that if she would have known that R3 was complaining of pain to coccyx she could have ordered the x-ray to be done here and possibly increased the dose of pain medications and frequency. V9 stated besides pain management there is no treatment for a fractured coccyx. V9 stated that she has seen R3 frequently lately due to falls and she always asks if he is in pain. V9 stated that she probably would not have given R3 a stronger pain medication due to his age and other health related issues, but V9 stated she could have increased the tramadol or even scheduled it to where he wouldn't have to ask for it. V9 stated she was never made aware by the facility that R3 was complaining of pain following the incident on 03/21/2025. Facility Policy titled Physician -Family-Notification-Change in Condition with a revision date of 11/13/2018 documented under the section titled Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner.

Based on interview and record review, the facility failed to ensure residents are free from neglect for one (R15) of 15 residents reviewed for neglect in the sample of 15. Findings include: R15's Face Sheet documented an original admitted [DATE] and readmitted [DATE] and included diagnoses of morbid obesity, diabetes type 2, and congestive heart failure. R15's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R15 has no deficits in cognition. This MDS also documented R15 has limited range of motion in both lower extremities and is totally dependent on staff for transfers. R15's Care Plan documented a Focus Area of Resident is usually able to perform ADLs (Activities of Daily Living) with maximum assist from 2 staff initiated on 8/30/23, with a corresponding intervention also initiated on 8/30/23 of Assist to transfer resident using mechanical (lift) and 2 staff members. Explain all procedures prior to starting. Advise resident what is expected of him/her during the transfer. Reassure Resident of safety as needed. Keep hand on Resident to reassure of safety if needed. Ensure lift sheet is intact and correct size for resident. May leave lift sheet under Resident if comfort in placing/removing sheet is problematic. There were no problem areas in the Care Plan to indicate R15 reports falsehoods about staff or displays manipulative behavior. There was no documentation in R15's Nursing Progress Notes about issues with R15's 3/26/25 mechanical lift transfer as documented below. On 4/3/25 at 2:55pm, R15 was alert and oriented to person, place, and time. R15 stated on Wednesday 3/26/25 on the 6pm to 6am shift, V19 (Agency Certified Nursing Assistant/CNA) was transferring him from his wheelchair to the shower chair using a mechanical lift. R15 stated there were no other staff members present. R15 stated as the mechanical lift sling was moving, he was experiencing back pain and was complaining to V19 that R15 didn't feel V19 was doing the transfer correctly. R15 stated V19 was mad, threw up his hands, yelled, That's it, I quit, and walked out of the room shutting the door, leaving R15 elevated several inches away from the shower chair. R15 stated he could not reach the call light and yelled for help for about 10 minutes, until two other staff members responded and lowered him into the shower chair. R15 stated he was not injured nor emotionally traumatized by the event, as several years ago at a different facility he was dropped during a mechanical lift transfer, so nothing phases him anymore. R15 stated the following day in the afternoon, V1 (Administrator) asked him about the event, and asked him if he would be willing to work with V19 again, to which R15 stated no he would not as he didn't feel safe in his care after what happened. R15 stated he has not seen V19 since then. On 4/3/25 at 3:15pm, V23 (Registered Nurse/RN), stated when she came in on 3/27/25at 6:00am, R15 had reported to her that the previous evening, V19 left R15 hanging in a mechanical lift sling during a transfer because V19 was mad at R15. V23 stated she reported the incident to V1 that morning when V1 arrived. On 4/3/25 at 3:50pm, V1 stated she found out about the incident when she arrived for work the morning of 3/27/25. V1 stated she talked to R15 and staff about what had happened, but there was no incident report about the event as R15 told V1 he did not feel V19 had neglected or abused him. V1 stated R15 was verbally abusive to V19 and V19 left the room to de-escalate R15. V1 stated V19 has not been back to the facility as he got in an argument with another employee and V1 told him he is not welcome back. On 4/3/25 at 4:05pm, V20 (Agency RN) stated, on 3/26/25 during the 6pm to 6am shift, unsure of the time, she and V21 (CNA) were standing at the nurses' station when V19 approached, stated that R15 was, Being nitpicky about his (Mechanical lift) transfer and that he didn't want to further escalate him so V19 left the room. V20 stated within seconds, she and V21 entered the room and saw that R15 was in the mechanical lift sling, positioned several inches above the shower chair. V20 stated R15 was not injured, nor did he seem upset. V20 stated she and V21 lowered R15 into the shower chair and proceeded with his care. V20 stated V19 worked the remainder of his shift but did not go back into R15's room. V20 stated she did not notify management about what happened. On 4/3/25 at 6:00pm, V21 corroborated V20's account of the incident. V21 stated she did not notify management about the incident. V21 stated after the event, staff were re-educated on safe mechanical lift transfers. On 4/4/25 at 7:45am, V19 stated he was performing the transfer without other staff present as, That's just the way he always does it. V19 stated he had worked with R15 previously with no issues. V19 stated R15 was becoming verbally aggressive during the transfer, saying V19 wasn't doing it right, so V19 decided to calm the situation down and he would leave and get other staff to continue care. V19 stated when he left the room, R15 was already sitting in the shower chair but was still in the sling. V19 stated less than a minute elapsed between him leaving the room and other staff relieving him. V19 stated V1 later told him he could not return to the facility because, They didn't want me to get in trouble because of (R15) lying on me. He makes stuff up about staff. An Abuse Prevention and Reporting Policy dated 10/24/22 documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: Filing accurate and timely reports. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish .Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness, of a resident .including deprivation of goods and services by staff.

Based on observation, interview, and record review the facility failed to safely secure a resident during transport for 1 of 3 residents (R2) reviewed for accidents in a sample of 3. This failure resulted in R2 sustaining a 3 by 5 inches laceration to her left leg that became infected and required a wound vac. The findings included: R2's Admission record documents an admitted to the facility of 9/08/2023 with diagnoses including morbid (severe) obesity due to excess calories, unspecified atherosclerosis of native arteries of extremities, bilateral legs, lymphedema, not elsewhere classified, other specified and diabetes mellitus with diabetic autonomic (poly) neuropathy. R2's Minimum Data Set (MDS) dated [DATE], documents in Section C, Cognitive Patterns, that R2 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R2 is cognitively intact. The same MDS section GG0170, Mobility documents the use of a motorized scooter and section I8000, Active diagnoses documents lymphedema, not elsewhere classified. R2's care plan documents a focus area of, The resident has limited physical mobility with a documented intervention of the resident uses a motorized wheelchair with supervision from staff. On 8/07/2024 at 11:33 AM, R2 was observed sitting in her recliner in her room reading a book. R2's left leg had an ace bandage wrap applied around her left lower leg with a wound vacuum in place. R2 had a scant amount of reddish colored drainage in the wound vacuum line. On 8/07/2024 at 11:35 AM, R2 stated that V12 (Social Service Director) had been transporting her in the facility van to her eye appointment. R2 stated V12 did not buckle her scooter in the van because they were not going very far from the facility. R2 stated she held on to the cup holders on both sides of her in the van during transport to and from the eye appointment. R2 stated on the way back to the facility from her eye appointment, V12 missed the street to turn on to go back to the facility and slammed on the brakes to make a turn into the local diner parking lot. R2 stated when V12 hit the van brakes, her scooter went forward, and she hit her left lower leg on a metal piece on the seat in front of her. R2 stated after hitting the seat with her leg, she looked down and she noticed she was bleeding and that there was a gash in her leg. R2 stated she requested V12 take her to the emergency room . R2 stated when they arrived at the emergency room , a nurse came outside, applied some gauze to her leg and took her in to be evaluated. R2 stated she is under the care of a wound physician at this time to help her leg heal. R2 stated that she had never asked staff to not buckle her in. On 8/08/2024 at 11:20 AM, V1 (Administrator) stated she had not been aware that R2 was not secured in the facility van during her transport on 7/12/2024. V1 stated her previous Director of Nursing and Assistant Director of Nursing handled this investigation because she went on vacation. V1 stated V12 (Social Service Director) did tell her before that R2 did not want her scooter buckled in because it caused her scooter to be pushed backwards and she did not like it. V1 stated that V12, V13 (Director of Nursing/DON) and V14 (Assistant Director of Nursing/ADON) are no longer employed at the facility. On 8/08/2024 at 2:00 PM, V13 (DON) stated V14 (ADON) is the person who interviewed R2 about this incident. V13 stated, she was made aware after the incident by V1 that R2's scooter was not secured in the van during transport. On 8/08/2024 at 2:10 PM, V14 (ADON) stated she was in V1's office when V12 called V1 to notify her of the incident with R2's leg. V14 stated, V12 did call V1 upon arrival to the local emergency room with R2. V14 stated, V12 notified V1 that she made a quick turn in the van which caused R2 to slide forward, hitting her leg on a metal piece on the passenger seat in front of her that caused a gash to R2's left lower leg. V14 stated, the facility had been using a van from a company that was not the normal van used for transporting residents, and when R2 and V12 returned to the facility after the emergency room visit, V1 and herself went out to the van to evaluate what caused the incident to happen. V14 stated, when they arrived at the van, R2 was observed sitting in her power chair in the back of the van, however, R2's power chair does not fit into the lock mechanisms for the wheels, like the wheelchairs would. V14 stated, R2's power chair did not have the emergency brake on either. V14 stated, she explained to V12 (Social Services Director) that she should have notified them prior to leaving the facility with R2 about her wheels not locking into place so they could have made other arrangements for transporting her. V14 stated, V12 said her and R2 were in a hurry to get to the appointment because they were running behind. R2's Statement provided with investigation documents from the facility dated 7/12/2024 documents When she turned my scooter wasn't locked in. I flew up against the seat. My leg was cut on the seat belt. My scooter just went with me. V12's statement provided with investigation documents from the facility dated 7/12/2024 documents in part, I passed (Name of Street) since I felt turn would be too sharp and tapped brakes in prep to turn into the parking lot of (local restaurant). As I tapped brakes (R2's) motorized scooter came forward to settle between the two seats. (R2) made a pained sound and I finished pulling to complete stop in parking lot. R2's local Hospital emergency room report dated 7/12/2024 documented left lateral mid leg with significant subcutaneous gash of 3 inches by 5 inches. Wound was irrigated and attempted wound closure not successful. Adaptive dressing, oral antibiotic (Cephalexin 500 milligrams orally 4 times a day) and outpatient follow up. R2's Order Summary Report dated 7/12/2024 documented referral to local wound clinic related to laceration on left lower leg below the knee. R2 ' s Progress Note dated 7/12/2024 at 2:55 PM documented to keep compression dressing on for a few days, watch for signs and symptoms of infection, Cephalexin 500 milligrams by mouth every day for seven days, elevate legs as much as possible. R2's orders from the local Wound Center Physician dated 7/17/2024 at 1:00 PM, documented wound cleanser to site one time a day and bacteria identified in unspecified specimen by anaerobe culture, left lower leg, done at wound center. R2's orders from the local Wound Center Physician dated 7/24/2024 at 2:00 PM, documented wound cleanser to site one time a day. R2's orders from the local Wound Center Physician 7/30/2024 at 12:45 PM documented, wound vac to wound continuously at 125 millimeter of mercury pressure. Change three times weekly and Cephalexin 500 milligram tablet, four times daily for 14 additional days. R2's Order Summary Report dated 7/12/2024 documented to elevate legs as much as possible every day and night shift for wound. The facility policy titled Van Usage Policy and Procedure (undated) documents under Procedure step 3 c. wear seat belts anytime the vehicle is in motion and require all passengers to wear seatbelts. d. Ensure all residents and wheelchairs are safely secured.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for the treatment of Type II Diabetes Mellitus for 3 (R3, R19, R20) of 4 residents reviewed for labs in the sample of 21. This failure resulted in abnormal lab values not being immediately communicated with the physician and R3 experiencing altered mental status requiring transport to the Emergency Department where a blood glucose level of 819 was found. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 2/8/23 when abnormal Hemoglobin A1c results for R3 were reported to the facility and staff did not complete the facility procedure of notifying the physician of these values until 3/20/23. V1 (Administrator) was notified of the Immediate Jeopardy on 10/4/23 at 1:10 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 10/5/23 but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. Review of R3's Admission Record documented his initial admitted to the facility as 9/16/21. R3's Primary Physician is listed as V13 (Physician) and Power of Attorney for care is V5 (Family Member). R3's Cumulative Diagnosis Log includes but is not limited to the following diagnoses: coronary artery disease; Dementia; Chronic Kidney Disease, Stage 3; Peripheral Neuropathy; Hypertension; Diabetes Mellitus II, with the date identified listed as 12/8/22. Facility policy titled, (company) Notification for Change in Resident Condition or Status with an issue date of 7/1/12 documents, The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON (Director of Nursing), Physician, Guardian, HCPOA (Health Care Power of Attorney, etc.) of changes in the resident's medical/mental condition and/or status. The procedures stated, 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: .m. Abnormal lab findings .3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status .5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Facility policy titled, (company) Laboratory Tests with a reviewed date of 9/27/17 documents the facility policy as, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medications(s), wishes of the resident and family and current standards of practice. A pharmacy consultation report dated 1/27/23 stated, (Name) R3 has diabetes and does not receive medications, but an A1c (Glycated Hemoglobin) is not available in the medical record in the past 6 months. Fasting blood sugar on 11/16/22 was 213. Recommended was, Please monitor A1c on the next convenient lab day. V13 (Physician) is documented on this form as accepting these recommendations, and labs will be drawn on 2/8/23 as well as an additional order given for an A1c to be drawn in July 2023. R3's lab results documented a specimen collection date of 2/8/23, with a H (high) Hemoglobin A1c result of 9.9. The normal reference range of 4.8 % - 5.6 % is listed on this same document. The lab documented R3's estimated average glucose level to be 237, correlating with these A1c results. This lab document noted a handwritten comment of faxed 2-8-23. These labs are documented as being faxed to the facility from the local hospital on 2/8/23 at 12:42 PM as evidenced by the fax server time stamp. R3's Physician Progress note made by V13 (Physician), dated 2/8/23 documented he was seeing R3 for a routine evaluation. V13 documented R3's blood sugar levels as being controlled, running about 150. V13 documented the last A1c level was on 11/16/22 with a value of 7.3. V13 gave no new orders regarding this evaluation and does not note lab results from 2/8/23. The first documented communication with V13 regarding the 2/8/23 A1c level is on 3/20/23. Review of R3's 3/20/23 Physician Progress note made by V13 documented R3 was a diabetic with his A1c being a little high at 9.9. V13 documented R3 is post-covid, and he will look at R3 when he is well. The Disposition listed on this same note documented R3 ordered a chest x-ray and labs, which included an A1c and complete metabolic panel (CMP). R3's lab results documented a specimen collection date of 3/22/23, with a H A1c level of 10.3. The normal reference range of 4.8% - 5.6% is listed on this same document. The lab documented R3's estimated average glucose level to be 249, correlating with these A1c results. This lab document noted a handwritten comment of faxed (V19 (Registered Nurse) initials). Additional lab results with a collection date of 3/22/23, document an actual glucose level of 259. The normal range listed for this lab value is (70-100). The A1c lab is documented as being faxed to the facility from the local hospital on 3/22/23 at 11:08 AM as evidenced by the fax server time stamp. The glucose lab is documented as being faxed to the facility on [DATE] at 8:01 AM as evidenced by the fax server time stamp. No definitive documented communication can be confirmed that V13 was ever notified of these results. R3's Physician Progress note made by V13 on 4/3/23 documents, We looked at the laboratory . although specific labs review is not noted. No new orders were documented on this progress note. R3's Skilled Progress Note dated 3/22/23 made by V19, documented communication with V13 regarding an abnormal chest x-ray result, but no mention of labs. Nurse's Notes dated 5/15/23 at 6:00 PM documented, Resident (R3) very confused and not himself. Was reported that he was unable to feed self and dumped 2 glasses of water r/t (related to) unable to grasp items. Resident incontinent at this time. Resident unable to form sentences and speaking garbled words. Vitals obtained and blood sugar. Blood sugar reading HI >600. (Name) V13 notified and send to hospital order given. (relationship/name) V5 notified. Ambulance service called. Report called and given to ER (emergency room ) dept. (department). Awaiting ambulance at this time. The next Nurse's Note is dated 5/15/23 at 6:50 PM, Ambulance service here along with (name/relationship) V5. Resident put on transport cart without difficulty. Both (all) departed at 7:05 PM. Will follow up with ER dept. R3's document titled, ED (Emergency Department) Events dated 5/15/23 documented the first provider evaluation was done by V23 (APRN-CNP/Advanced Practice Registered Nurse - Certified Nurse Practitioner) at 7:18 PM. Chief complaint is listed as altered mental status. V23 documented, R3 presented to the ED with EMS (Emergency Medical Services). EMS reported upon their arrival they found R3 appearing sedated and confused with some slurred speech. V23 also documented, Last known normal is unclear, as staff at the nursing home report he has been progressively more confused over the past couple of days. R3's initial labs listed in this same document note R3's Glucose level as 819 HH (extremely high). The reference range listed for the glucose level is 70 - 100 mg/dL (milligrams per deciliter). The Clinical Impressions as of 5/16/23 at 1:44 AM are listed as: Altered Mental Status, unspecified altered mental status type; Type 2 Diabetes Mellitus with hyperglycemia, without long-term current use of insulin; Dehydration. The Plan documents an insulin drip was initiated, and glycemic control was achieved. V23 noted review of R3's clinical chart documented an A1c level of greater than 7 for the past year, most recently 10.3 on 3/22/23, with no initiation of diabetic medications. R3 is documented as being admitted to hospital for continued glycemic monitoring and initiation of diabetic medications prior to discharge back to the nursing home. R3 is documented as now being conversant and oriented to person, place, time, and situation once glycemic control was achieved. R3's Medicine Discharge Summary documented an admitted to the local hospital for R3 as 5/15/23 and discharge date of [DATE]. R3's Admission and Discharge Diagnosis include the diagnosis of Uncontrolled diabetes mellitus with hyperglycemia. The Hospital Course documents R3 was transported to the ED with a workup completed for a possible stroke, but no acute intercranial problems were discovered. R3's Glucose level was found to be 819, and includes the notation of, Looking back at the nursing home patient had hemoglobin A1c done 2 months ago was 10.3 which gives an average of 249. The patient was not started on medications. R3's A1c listed as being completed in the hospital on 5/16/23 at 5:17 AM document a A1c level of then 13.8. Discharge medications include the addition of subcutaneous use of insulin glargine and insulin lispro. R3's Progress Note dated 6/5/23 documented V13 (Physician) was examining R3 on this date due to a hospitalization when his blood sugar went to 800. The note goes on to say, Let me look at his sugars. We are going to go back and find out what his sugars are. We have a hemoglobin A1c too high. It is 10.3 and this was on 3/22 So, hemoglobin A1c is too high. Now, let's look at blood sugars. Now, we are going to the computer. I assume some electronic medical records. We are having trouble finding the sugars. They have totally thinned the charts getting ready for electronic medical record. They are not here. So, we are still searching. They are bound to be some place. The disposition listed in this note included new lab orders, one being an A1c. Lab results documented a specimen collection date of 6/14/23, with a H A1c level of 10.5. The normal reference range of 4.8% - 5.6% is listed on this same document. The lab documented R3's estimated average glucose level to be 255, correlating with these A1c results. This lab document noted a handwritten comment of faxed (V19 (Registered Nurse) initials). Additional lab results with a collection date of 3/22/23, document an actual glucose level of 130. The normal range listed for this lab value is (70-100). Review of R3's Clinical Record documented V13 was notified of the 6/14/23 lab results on 6/15/23, with medication order changes given. Lab results document a specimen collection date of 7/12/23, with a H A1c level of 7.9. The normal reference range of 4.8% - 5.6% is listed on this same document. The lab documented R3's estimated average glucose level to be 180, correlating with these A1c results. This lab document noted a handwritten comment of faxed. The A1c lab is documented as being faxed to the facility from the local hospital on 7/12/23 at 7:40 AM as evidenced by the fax server time stamp. The first documented communication with V13 regarding the 7/12/23 A1c level is on 8/7/23. V13 had no new orders at this time. On 10/3/23 at 9:54 AM, V13 stated he doesn't recall being notified of R3's 3/22/23 A1c level of 10.3 or glucose level of 259. V13 stated he cares for a lot of people though, so the facility should document their communication with him. V13 stated that those levels would have been results he would have had further orders for, at minimum, repeat orders. V13 was notified of his 4/3/23 progress note in which he stated he reviewed lab but does not specify which ones. V13 stated it can be suggested the 3/22/23 labs were not presented to him, given there were no new orders. V13 stated at any rate, he would expect to be notified of abnormal lab results immediately. V13 stated that uncontrolled blood sugar can lead to complications and even possible death, although he states it would have to be severe and may be a stretch. V13 confirms that a glucose level of 819 is critical and would require immediate intervention. V13 also stated he has no nurse practitioner who works with him and completes resident examinations himself. V13 stated that labs listed in the disposition section of his notes are orders he is giving. On 10/3/23 at 10:23 AM, V9 (Licensed Practical Nurse/LPN) stated the process for labs is that all labs are faxed to the physician, and if they are abnormal a call is made to notify the physician of the level. V9 stated if the labs are normal, they are placed in the resident's record after being faxed for the physician review the next time they are in the facility. V9 stated that V13 is easy to get a hold of and a good communicator with the facility. V9 stated that R3 was not having his glucose monitored except for via labs prior to his May 2023 hospitalization . On 10/3/23 at 10:59 AM, V2 (Director of Nursing) stated that the local hospital is the only entity the facility utilized for lab testing. V2 stated the process for labs in the facility is that once labs are ordered the labs are obtained as indicated. V2 stated the hospital will fax the results of the labs to the facility. V2 stated that a nurse on duty should then fax the lab results to the physician and call the physician if the lab results are abnormal. V2 stated that the labs are always faxed to the physician so that the physician can keep a copy in their record too. V2 stated that routine labs with normal values would be placed in the resident's record for the physician to review during the next time they make rounds in the facility. V2 stated that abnormal lab values that are phoned to physician would have that communication documented in the progress notes. V2 stated that she believes it was just an error on the nurse's part that communication with the physician regarding R3's abnormal glucose/A1c labs was not documented. V2 stated that V13 is good about responding and communicating with the facility. V2 stated that glucose readings obtained by finger prick in the facility are documented on the MAR (Medication Administration Record). V2 stated that no concerns had been brought to her attention which may suggest R3 was experiencing hyperglycemia prior to his May ER visit and hospitalization . V2 confirms it is her expectation that the facility immediately contacts the physician regarding any abnormal labs or change in resident status and document such communication. V2 confirmed that lab samples obtained are obtained in a fasting nature, as they are sure to have them drawn before breakfast. On 10/3/23 at 11:35 AM, V19 (Registered Nurse/RN) stated when a physician orders labs, they are obtained, and the physician is called if the results come back abnormal. V19 stated if the results are normal, they are placed in the resident's chart for review the next time the physician is in. V19 stated that all lab results are faxed to the physician office once the facility receives them so the physician can have a copy in their records. V19 stated that generally a note should be made in the resident's progress notes that the physician has been notified of any abnormal labs and any new orders, but you know how life goes. V19 stated prior to R3's hospitalization she cannot say R3 was experiencing any signs of hyperglycemia specifically due to his intermittent confusion making it hard to tell. On 10/3/23 at 11:46 AM, V20 (RN) stated that she was the staff member who sent R3 to the hospital in May for altered mental status. V20 stated the something was just off and R3 wasn't himself. V20 stated that she was doing an evaluation trying to figure out if there was something she could note being wrong. V20 stated R3's vital signs were normal, but a finger prick glucose test was taken and just read high. V20 stated that she repeated the test, again receiving the reading of high. V20 stated she notified V13 who gave orders to send R3 to the hospital for evaluation. V20 stated that when the hospital faxes the facility lab results from specimen draws, the nurse on duty reviews the labs and faxes all the labs to the physician. V20 stated if something is an abnormal level, the physician is notified immediately by phone. V20 stated that staff are suppose to make a progress note, documenting the physician communication. On 10/3/23 at 12:47 PM, V21 (Health Information at out-of-town hospital) stated that she is one staff member who worked with V13's office. V21 stated in reviewing R3's records they received from the nursing home, she can see where an A1c level dated 2/8/23 was faxed to V13's office. V21 stated the only lab values V13's office received from the facility dated 3/22/23 was a Vitamin B12 level. On 10/3/23 at 11:59 AM, V1 (Administrator) stated that a change in resident status or abnormal lab results should be communicated to the physician immediately with the communication documented in the progress notes of the resident record. V1 confirms that although requested, the facility is unable to provide communication with V13 immediately upon the receipt of R3's abnormal lab values from 2/8/23, 3/22/23, and 7/12/23. On 10/4/23 at 11:26 AM, V18 (Certified Nurse Assistant) stated she worked with R3 the day he was sent to the ED. V18 stated she recalls R3 urinating a lot that day and just being out of it. V18 stated that nursing staff were aware and were monitoring him. V18 stated she had taken his Vital Signs a couple times, and they were fine. R3's Clinical Record via paper and Electronic Health Record documented no immediate communication with V13 regarding the abnormal lab results from the 2/8/23, 3/22/23, and 7/12/23 specimens. R3's Medication Administration Record via paper and Electronic Health Record documented R3 was not having his glucose monitored via fingerstick, nor receiving any medication therapy for diabetes from 2/1/23 until 5/20/23, when R3 returned from the hospital. R3's current Active Orders as of 9/28/23 documented R3 receives blood glucose monitoring four times a day. R3 is documented as receiving subcutaneous insulin glargine and insulin aspart medications for treatment of diabetes mellitus. R3's Care Plan documented a problem area of Diabetes with an initiation date of 12/8/22. Interventions include obtaining labs as ordered, and physician notification as needed. 36384 2. R19's admission record documents an admitted [DATE]. This same document includes the following diagnosis Type 2 Diabetes Mellitus. R19 has labs dated 8/23/23 with abnormal values compared to the reference range. These labs include an elevated glucose. At the bottom of the page an unsigned note written in 'faxed' and dated 8/23/23. No further documentation is found in the chart regarding following up with the physician to ensure labs were received and if any new orders are to be carried out. 3. R20's admission record documents an admitted as 6/26/22. This same document includes the following diagnosis: type 2 diabetes mellitus. R20's lab result dated 5/10/23 includes labs with abnormal ranges. These abnormal labs include an elevated glucose level. The lab results are dated 5/10/23 by V9 (LPN) as faxed to V13. On 10/5/23 at 11:30 AM, V9 stated that prior to 10/5/23 the policy was to just fax the lab results to the physician's office and no further documentation was done. The surveyor confirmed through interview and record review that the Immediate Jeopardy that began on 2/8/23 was removed on 10/5/23 when the facility took the following actions to remove the immediacy: 1) The Regional Director on 10/4/2023 in-serviced the Administrator, Director of Nurses (DON) and Assistant Director of Nurses (ADON) on the Notification for Change in Resident Condition or Status Policy and the Lab Policy and the importance of follow up on lab results and direct communication via telephone or during onsite provider visit until all licensed nurses are setup and trained on utilizing the secure communication app. 2) The Facility Director of Nursing, ADON and Administrator initiated in-servicing for all licensed nurses on 10/4/2023 on the Notification for Change in Resident Condition or Status Policy and the Lab Policy and directly communicating lab results on all residents as they are received. All nurses will be in-serviced by the nursing leadership prior to their next scheduled shift. 3) Facility QA team will complete a review audit of all labs received with regional clinical director on 10/5/2023. The Regional Director and Administrator verified with the Nurse Practitioner (NP) who was on site on Monday and Tuesday with the Nurse Practitioner that she has been notified of lab results and has communicated any changes to the (resident's) orders to staff. Her notes will also reflect any labs reviewed or new orders that were communicated with the staff. Nursing leadership will verify with the NP that all lab results have been promptly communicated with her. 4) R3's recent labs completed on 9/20/2023 have been reviewed and communicated to the physician. R3's labs were completely reviewed by physician at his previous visit on 8/7/2023 with no changes noted to be needed at that time and physician notes show that labs had been previously reviewed on his in-house visits to the facility. Two recent care plan meetings have been held with the family and resident (R3) regarding resident care needs with the most recent meeting having been completed on 10/2/2023. 5) Facility Administrator, DON, ADON and Regional Director initiated a facility wide lab audit on 10/4/2023 starting with requesting a list of all labs draws completed on 9/27/2023 from (local hospital) which was the last date labs were drawn at facility. 4 residents lab draws were completed, and the facility verified with NP who is on-site today that all current labs have been communicated directly and she's responded to those lab results. 6) Facility QA team is completing a lab audit going back to February 2023 to ensure that all lab results have been directly communicated to the physician and addressed and documented. Any further issues or abnormal labs noted in the lab and chart audit that facility staff cannot verify via documentation or physician notes will be relayed to the current provider to be addressed immediately and documentation completed. Lab audit of all 58 current in house residents is projected to be completed by 10/5/2023. 7) The following Quality Assurance programs have been implemented to ensure compliance: The facility DON, ADON or designee will complete a lab audit of all ordered and received labs for 4 weeks to ensure that all have been communicated with the physician and documentation is noted in resident chart. Regional Director or Regional Clinical Director will review the lab audit weekly with facility and make recommendations based on the outcome and review of the audit findings. The facility's QA team will review lab results daily at their Morning QA meeting as part of the review of the updated 24 hour report.

Based on interview and record review the facility failed to administer an antibiotic as ordered by the physician for 1 (R3) of 6 residents reviewed for medication administration in a sample of 18. This failure caused a delay in treatment of [REDACTED]. Findings include: On 10/21/20 at 2:45 PM, V25 (Family Member) stated R3 went to the hospital on [DATE] and was diagnosed with [REDACTED]. V25 stated R3 was sent back to the facility that evening with orders to start taking an antibiotic. V25 stated during a phone conversation with the facility on 10/08/20, V29 (Family Member/Power of Attorney/POA) became aware staff did not know R3 was supposed to be taking an antibiotic. V25 stated there was a 3-day delay in R3 receiving this medication and R3 got worse as a result to the point she had to go back to the hospital and had [MEDICAL CONDITION] and her kidneys had started to shut down. R3's hospital record dated 10/05/20 documents diagnoses, in part for Today's Visit as urinary tract infection without hematuria; Start taking [MEDICATION NAME] 500 mg (milligram) tablet 1 by mouth once daily for 7 days. A handwritten note on this hospital record under this antibiotic order documents, noted 10/08/20 by V22 (Registered Nurse/RN). R3's nurse's notes document the following, in part: 10/08/20 - 2:30 PM - V29 called to check on resident's condition r/t (related to) ER (emergency room ) visit on 10/05. Upon review of chart discovered med discrepancy. [MEDICATION NAME] 500 mg was ordered for 7 days to treat UTI. Admin (administrator) notified and MAR (Medication Administration Record) and POS (physician's orders [REDACTED]. R3's POS dated 10/01/20 to 10/31/20 documents a handwritten note under physician's orders [REDACTED]. R3's October MAR indicated [REDACTED]. This MAR indicated [REDACTED]. On 10/16/20 at 1:33 PM, V3 (Registered Nurse/RN) stated, We get new orders, but they are received on the front side office fax machine. Due to Covid-19 someone from the 'clean side' will bring our faxes around to our outside door when we get one, since all the residents reside on the Covid-19 wing at this time. R3's record documents a hospital admission on 10/13/20 and discharge back to facility on 10/15/20 for end of life/comfort care with the following diagnoses, in part: Acute [MEDICATION NAME] with hematuria,[MEDICAL CONDITION], and [MEDICAL CONDITION]. On 10/23/20 at 10:04 AM, V19 (Physician) stated, .the delay in antibiotic directly contributed to R3 going septic. ABX (antibiotics) treat the bug in the urine and if not given the infection goes to the blood stream. This could have been avoided . V19 confirmed he oversees V14's (Master of Physician Assistant Studies/Physician Assistant - Certified/ MPAS/PA-C) notes and the facility should be following her orders. V19 stated, V14 is 'my right hand'.

Based on interview and record review the facility failed to report allegations of abuse and failed to educate employees as to whom to report allegations of abuse to, if the allegation concerns the administrator. On 12-29-14, 4-2-15 and 4-6-15 facility staff had knowledge of situations that would require immediate reporting of suspicion of verbal, mental and/or physical abuse by E1 (Administrator) to R1 and R2. These failures resulted in 55 in house residents being put at risk of potential abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/14/15, the facility remains out of compliance at a Severity Level 2 as the facility continues to evaluate and monitor the effectiveness of their staff training on abuse prevention and reporting requirements. Findings include: The facility Data Sheet dated 4-8-15, documents a census of 55 residents. 1. During interviews regarding abuse allegations, it was reported to this surveyor that R2 was disruptive in the dining room and E1 (Administrator) removed R2 into the hallway. E1 sat R2 in the floor and spoke harshly to her as follows: a. E12 (Certified Nurse Aide) was interviewed on 4/9/15 at 9:15 am. E12 said she witnessed E1 "physically" place R2 on the floor from her wheelchair. E12 said she is unsure of the date this occurred but thinks it was a "couple of months ago." E12 said the nurses and other residents did not witness this. E12 said R2 was yelling out and squirming but was not attempting to get out of the wheelchair. E12 said E1 pushed R2's wheelchair into the hallway and alone transferred her onto the floor. E12 said she heard E1 "harshly" tell R2, "If you're going to act like a baby you can lay in the floor and have a fit like a baby." b. E11 (Certified Nurse Aide) was interviewed on 4/9/15 at 9:30 am. E11 said she did not witness E1 placing R2 in the floor. E11 said she saw R2 sitting on the floor and heard E1 "rudely" tell R2, "if you are going to act like a baby you can lay in the floor and have a fit like a baby." E11 said the other witnesses to this incident were E10 and E12. E11 said she used a gait belt and assisted E1 to transfer R2 back into the dining room. E11 said she is unsure of the date but this happened a "couple months ago." c. E14 (Registered Nurse) was interviewed on 4/10/15 at 9:30 am and said E1 told her R2 was yelling in the dining room so she "sat her ass in the floor" and told R2 "if you're going to act like a baby, you can crawl like one." d. E2 (Registered Nurse) was interviewed on 4/9/15 at 11:55 am and said E1 told her R2 "was throwing a fit and acting like a baby so I put her ass in the floor" and told R2 " if you are going to act like a baby you can sit in the floor like a baby." E2 said E1 told her E11 and E12 seen me do this and I am surprised they didn't throw a fit. e. On 4/9/15 at 9:55 am, E10 (Certified Nurse Aide) said someone told her she had witnessed the incident where R2 was placed on the floor but she said, I just can't remember anything about it. f. E7 (Licensed Practical Nurse) was interviewed on 4/9/15 at 8:30 am. E7 said she has never heard of or seen abuse in the facility. After receiving the final investigative report on 4/16/15 from the facility indicating E7 was a witness to the incident, E7 was interviewed again by telephone on 4/16/15 at 12:45pm. E7 said she had been in the dining room when R2 was "acting up". E7 said R2 was trying to hit her head on the table. E7 said she later went to the nurse desk near the dining room and witnessed E1 trying to ambulate R2 in the hallway but R2 was lifting her feet up so E1 sat her in the floor. E7 said she "did not go over there." E7 said she heard E1 tell R2, if you are done throwing a fit we can go to your room and discuss this. E7 said she only heard some of the conversation and there may have been a lot more going on. E7 said what she did see she did not consider abuse. g. On 4/10/15 at 3:00pm, E16 (Social Service Director) said she initiates the behavior tracking for the residents. E16 said she reads all completed behavior tracking and nurse notes related to R2. E16 said she has never seen a behavior of R2 attempting to throw herself in the floor in the dining room except for this "isolated" event documented on the Behavior Tracking by E1. h. On 4/10/15 at 10:35 am, E1 (Administrator) said she sat R2 in the floor because she was attempting to throw herself out of the wheelchair in the dining room. E1 said she told R2, "Stop acting like a child. If you're acting like a child you are going to be treated like a child" and told her to act like an adult. E1 said R2 didn't have any more behaviors on this day. i. During the investigation an attempt to interview R2 was made four times. The first time on 4/10/15 at 10:00 am. R2 would not make eye contact with this surveyor and did not converse. The second time was with E2 present(who was identified by staff as having a good relationship with R2) on 4/10/15 at 10:10 am, R2 placed a blanket over her head and did not respond to questions or conversation. The third time on 4/14/15 at 2:50pm with R2's grandmother present. Staff indicated R2's grandmother may make R2 more comfortable during the interview. R2 was tearful. R2 did not carry on a conversation with this surveyor but did say "no" when asked if she has ever been mistreated and "no" when asked if she remembered ever being sat on the floor. Then R2 asked for her medication. The fourth time on 4/15/15 at 9:40 am. When asked if she could remember ever being sat in the floor R2 said "no." R2 had visible tremors and did not make eye contact or carry on a conversation with this surveyor. 2. During interviews regarding abuse interviews it was reported to this surveyor that E1 (Administrator) crushed candy and placed it in applesauce then gave it to R2 and told her to shut up because she was yelling out, as follows: a. On 4/10/15 at 9:30 am, E14 (Registered Nurse) said E1 told her R2 was yelling for her medication so she placed candy in applesauce and when R2 started to yell again she put it in her mouth and said "now, shut up." E14 said she observed E1 come from R2's room and E1 walked directly to her (E14) and told her (E14) this. E14 said she was attempting to give R2 her medication after this incident and R2 told her she had already taken her medicine. E14 said she had to explain to her she had taken candy and encourage her to take her pills. E14 said this happened on Thursday, April 2nd 2015. b. On 4/9/15 at 3:20pm, E2 (Registered Nurse) said on Thursday, 4/2/15 she heard R2 cursing and yelling for her medicine. E2 said E1 told her she crushed some candy and put it in applesauce then when R2 opened her mouth to yell she gave it to her and told R2 "shut up." c. On 4/10/15 at 10:35 am, E1 (Administrator) said she did put candy in applesauce and give it to R2. E1 said R2 is demanding and yells out so she gave her the candy and R2 stopped yelling. E1 said she did not tell R2 that it was her medicine and she did not tell R2 to shut up but she told her to "hush, stop yelling." 3. During interviews regarding allegations of abuse, the allegation was made that E1 (Administrator) sprayed water in R1's face to stop R1 from yelling during R1's shower, as follows: a. On 4/9/15 at 9:15 am, E12 (Certified Nurse Aide) said E1 told her when she (E12) is giving R1 a shower and he is yelling out to spray him in the face with water and he will quit yelling. b. On 4/9/15 at 9:30 am, E11 (Certified Nurse Aide) said E1 told her when she (E11) is giving R1 a shower to spray him in the face with water when he is yelling and he will stop yelling. c. On 4/10/15 at 9:30 am, E14 (Registered Nurse) said E1 told her she (E1) gave R1 a shower and R1 was yelling so she told R1 if he yelled one more time she would spray him in the face with water. E14 said E1 told her, R1 yelled again so she sprayed him in the face and he didn't yell any more after that. d. . On 4/9/15 at 11:55 am, E2 (Registered Nurse) said E1 told her she (E1) gave R1 a shower on 4/6/15 and R1 was yelling so she sprayed water in his face and he stopped yelling. 4. During interviews with employees regarding who to report abuse allegations to the following statements were reported: a. E2 (Registered Nurse) said on 2/14/15 at 11:00 am during interview, when the facility holds inservices on abuse, the employees are told to notify E1 (Administrator) of all allegations of abuse but the employees have never been told who to notify if the abuse allegation is concerning the administrator. R2 said she knew these things were abuse but was unsure what to do in this situation. b. E6 (Certified Nurse Assistant) was interviewed on 4/9/15 at 11:20 am. E6 said she was not sure who to notify of abuse if the allegation is about the administrator. c. E11 (Certified Nurse Assistant) said on 4/9/15 at 9:30 am she was unsure who to report an abuse allegation to if it involves the administrator. d. E12 (Certified Nurse Assistant) said at 9:15 am on 4/9/15 that she was unsure who to notify of abuse allegations if the administrator were involved because the administrator is "top dog." E12 said she felt sorry for R2 during the incident in the hallway and it "was not right" but she (E12) did not know who to report it to. e. E14 (Registered Nurse) said at 9:30 am on 4/10/15, she knows to report abuse to the administrator but does not know who to tell if the allegation involves the administrator. E14 said she needs her job but had to tell the surveyor of the incidents with R1 and R2 because she does not think it is right the way E1 treats the residents. Recent abuse investigations dated 2/2/15, 3/2/15 and 3/13/15 were reviewed on 4/8/15. There were no investigations completed on R1 or R2. E1 (Administrator) said on 4/8/15 at 2:10pm there were no investigations completed related to R1. E17 and E18 (Regional Directors) were notified of the Immediate Jeopardy on 4/14/15 at 9:40 am. The Immediate Jeopardy was determined to have begun on 12/29/14 when R2 was talked to harshly and sat in the floor by E1 (Administrator). The facility failed to identify and report alleged allegations of abuse and failed to educate employees of who to contact if allegations were made against the Administrator. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy. On 04/08/15 the following was initiated / completed: 1. 2:45 pm - Regional Director was made aware of the alleged abuse involving E1, Administrator. Regional Director initiated investigation per protocol including suspension of the Administrator. 2. Regional Director spoke to IDPH surveyor and advised that the Administrator removed herself from the facility after being made aware of the allegation and will remain off pending the outcome of investigation. 3. 3:30 pm - Initial notification of alleged abuse was submitted to IDPH. On 04/09/15 the following was initiated / completed: 1. Regional Director and Regional Nurse conducted interviews with 11 staff members. 2. Regional Director and Regional Nurse conducted interview with male resident involved in alleged abuse with no concerns voiced. 3. Social Service Director conducted interviews with 10 alert residents related to care and treatment with no concerns voiced. On 04/10/15 the following was initiated / completed: 1. Regional Director submitted final report to IDPH. After thorough review of the " facts " , the allegation of abuse was unsubstantiated. 2. Regional Team noted that Complaint Procedure is posted in the front hallway that clearly identifies chain of command, including phone numbers for facility staff, Regional Director and Petersen Health Care. 3. 5:21 pm - Regional Director was made aware of additional concerns identified during IDPH complaint visit involving Administrator. 4. Regional Director initiated a second investigation and Administrator remains suspended. 5. Regional Director submitted initial report for 2nd allegation to IDPH. 6. 6:10 pm - Regional Director notified resident ' s mother of allegation of abuse. Resident ' s mother reports no concerns with care and treatment. Also, reports that resident has voiced no concerns to her about care and treatment. On 04/13/15 the following was initiated / completed: 1. Regional Director and two Regional Nurses began interviewing 100% of all staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. There were 35 staff interviews conducted with 8 remaining. 2. Regional Nurse and Social Service Director interviewed 16 residents related to care and treatment by staff including Administrator, with no concerns voiced. On 04/14/15 the following was initiated / completed: 1. 9:40 am - IDPH advised of Immediate Jeopardy for F223, F225, F226, and F490. 2. Regional Director and Regional Nurses completed 100% all staff interviews (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. 3. 11:42 am - Regional Director made follow-up call to resident ' s mother who continues to state there are no concerns with care and treatment at the facility. 4. 11:49 am - Regional Director interviewed female resident involved in alleged abuse, related to care and treatment provided by facility staff including E1. There were no concerns voiced and resident reports that the administrator has cared for her. 5. 2:00 pm - Regional Director and Regional Nurses initiated 100% staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) in-service on facility Abuse Policy including prevention, screening, orientation, identification, reporting and Behavior Monitoring program, including tracking, interventions, communication, and care plan updates. 6. Resident care plan was reviewed and updated to reflect behavior interventions. 7. Resident Council is being educated on Abuse Prevention Policy. 8. Regional Director and Regional Nurses are completing investigation based on " facts " obtained through staff, resident and family interviews for final IDPH report. Facility Management and the Regional staff will ensure that all new employees will be trained and educated on policy and procedure for Abuse Prevention per facility protocol during their orientation process. The facility is also re-assessing our current staff for educational needs and standards of practice. Those who refuse to abide by policy and procedure have been issued disciplinary action and/or termination of employment. The Q.A. team, including Administration, Nursing Management, and the Interdisciplinary Team will assure compliance through the daily Quality Assurance Process. The Administrator will monitor effectiveness of staff training on Abuse Prevention policy as part of the Quality Assurance Program. The Administrator shall receive copies of all in-service materials and the Medical Director is reviewing the Removal Plan for F223, F225, F226, and F490.

Based on interview and record review the facility failed to follow their policy and procedure of Abuse Prevention Program by not protecting the resident from abuse, not reporting allegations of abuse and not educating employees on who to report allegations of abuse to in all situations. The facility also failed to identify in their policy who the facility staff are to report allegations of abuse to, if the allegations directly involve the Administrator. On 12-29-14, 4-2-15 and 4-6-15 facility staff had knowledge of situations that would require immediate reporting of suspicion of verbal, mental and/or physical abuse by E1 (Administrator) to R1 and R2. This has the potential to affect all 55 residents residing in the facility at this time. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/14/15, the facility remains out of compliance at a Severity Level 2 as the facility continues to evaluate and monitor the effectiveness of their staff training on abuse prevention and reporting requirements. Findings include: The Facility Data Sheet dated 4/8/15 documents a resident census of 55. 1. During interviews regarding abuse allegations, it was reported to this surveyor that R2 was disruptive in the dining room and E1 (Administrator) removed R2 into the hallway. E1 sat R2 in the floor and spoke harshly to her as follows: a. E12 (Certified Nurse Aide) was interviewed on 4/9/15 at 9:15 am. E12 said she witnessed E1 "physically" place R2 on the floor from her wheelchair. E12 said she is unsure of the date this occurred but thinks it was a "couple of months ago." E12 said the nurses and other residents did not witness this. E12 said R2 was yelling out and squirming but was not attempting to get out of the wheelchair. E12 said E1 pushed R2's wheelchair into the hallway and alone transferred her onto the floor. E12 said she heard E1 "harshly" tell R2, "If you're going to act like a baby you can lay in the floor and have a fit like a baby." b. E11 (Certified Nurse Aide) was interviewed on 4/9/15 at 9:30 am. E11 said she did not witness E1 placing R2 in the floor. E11 said she saw R2 sitting on the floor and heard E1 "rudely" tell R2, "if you are going to act like a baby you can lay in the floor and have a fit like a baby." E11 said the other witnesses to this incident were E10 and E12. E11 said she used a gait belt and assisted E1 to transfer R2 back into the dining room. E11 said she is unsure of the date but this happened a "couple months ago." c. E14 (Registered Nurse) was interviewed on 4/10/15 at 9:30 am and said E1 told her R2 was yelling in the dining room so she "sat her ass in the floor" and told R2 "if you're going to act like a baby, you can crawl like one." d. E2 (Registered Nurse) was interviewed on 4/9/15 at 11:55 am and said E1 told her R2 "was throwing a fit and acting like a baby so I put her ass in the floor" and told R2 " if you are going to act like a baby you can sit in the floor like a baby." E2 said E1 told her E11 and E12 seen me do this and I am surprised they didn't throw a fit. e. On 4/9/15 at 9:55 am, E10 (Certified Nurse Aide) said someone told her she had witnessed the incident where R2 was placed on the floor but she said, I just can't remember anything about it. f. E7 (Licensed Practical Nurse) was interviewed on 4/9/15 at 8:30 am. E7 said she has never heard of or seen abuse in the facility. After receiving the final investigative report on 4/16/15 from the facility indicating E7 was a witness to the incident, E7 was interviewed again by telephone on 4/16/15 at 12:45pm. E7 said she had been in the dining room when R2 was "acting up". E7 said R2 was trying to hit her head on the table. E7 said she later went to the nurse desk near the dining room and witnessed E1 trying to ambulate R2 in the hallway but R2 was lifting her feet up so E1 sat her in the floor. E7 said she "did not go over there." E7 said she heard E1 tell R2, if you are done throwing a fit we can go to your room and discuss this. E7 said she only heard some of the conversation and there may have been a lot more going on. E7 said what she did see she did not consider abuse. g. On 4/10/15 at 3:00pm, E16 (Social Service Director) said she initiates the behavior tracking for the residents. E16 said she reads all completed behavior tracking and nurse notes related to R2. E16 said she has never seen a behavior of R2 attempting to throw herself in the floor in the dining room except for this "isolated" event documented on the Behavior Tracking by E1. h. On 4/10/15 at 10:35 am, E1 (Administrator) said she sat R2 in the floor because she was attempting to throw herself out of the wheelchair in the dining room. E1 said she told R2, "Stop acting like a child. If you're acting like a child you are going to be treated like a child" and told her to act like an adult. E1 said R2 didn't have any more behaviors on this day. i. During the investigation an attempt to interview R2 was made four times. The first time on 4/10/15 at 10:00 am. R2 would not make eye contact with this surveyor and did not converse. The second time was with E2 present(who was identified by staff as having a good relationship with R2) on 4/10/15 at 10:10 am, R2 placed a blanket over her head and did not respond to questions or conversation. The third time on 4/14/15 at 2:50pm was with R2's grandmother present. Staff indicated R2's grandmother may make R2 more comfortable during the interview. R2 was tearful. R2 did not carry on a conversation with this surveyor but did say "no" when asked if she has ever been mistreated and "no" when asked if she remembered ever being sat on the floor. Then R2 asked for her medication. The fourth time on 4/15/15 at 9:40 am. When asked if she could remember ever being sat in the floor R2 said "no." R2 had visible tremors and did not make eye contact or carry on a conversation with this surveyor. 2. During interviews regarding allegations of abuse, it was reported to this surveyor that E1 (Administrator) crushed candy and placed it in applesauce then gave it to R2 and told her to shut up because she was yelling out, as follows: a. On 4/10/15 at 9:30 am, E14 (Registered Nurse) said E1 told her R2 was yelling for her medication so she placed candy in applesauce and when R2 started to yell again she put it in her mouth and said "now, shut up." E14 said she observed E1 come from R2's room and E1 walked directly to her (E14) and told her (E14) this. E14 said she was attempting to give R2 her medication after this incident and R2 told her she had already taken her medicine. E14 said she had to explain to her she had taken candy and encourage her to take her pills. E14 said this happened on Thursday, April 2nd 2015. b. On 4/9/15 at 3:20pm, E2 (Registered Nurse) said on Thursday, 4/2/15 she heard R2 cursing and yelling for her medicine. E2 said E1 told her she crushed some candy and put it in applesauce then when R2 opened her mouth to yell she gave it to her and told R2 "shut up." c. On 4/10/15 at 10:35 am, E1 (Administrator) said she did put candy in applesauce and give it to R2. E1 said R2 is demanding and yells out so she gave her the candy and R2 stopped yelling. E1 said she did not tell R2 that it was her medicine and she did not tell R2 to shut up but she told her to "hush, stop yelling." 3. During interviews regarding allegations of abuse, the allegation was made that E1 (Administrator) sprayed water in R1's face to stop R1 from yelling during R1's shower, as follows: a. On 4/9/15 at 9:15 am, E12 (Certified Nurse Aide) said E1 told her when she (E12) is giving R1 a shower and he is yelling out to spray him in the face with water and he will quit yelling. b. On 4/9/15 at 9:30 am, E11 (Certified Nurse Aide) said E1 told her when she (E11) is giving R1 a shower to spray him in the face with water when he is yelling and he will stop yelling. c. On 4/10/15 at 9:30 am, E14 (Registered Nurse) said E1 told her she (E1) gave R1 a shower and R1 was yelling so she told R1 if he yelled one more time she would spray him in the face with water. E14 said E1 told her, R1 yelled again so she sprayed him in the face and he didn't yell any more after that. d. . On 4/9/15 at 11:55 am, E2 (Registered Nurse) said E1 told her she (E1) gave R1 a shower on 4/6/15 and R1 was yelling so she sprayed water in his face and he stopped yelling. 4. During interviews with employees regarding who to report abuse allegations to, the following statements were reported: a. E2 (Registered Nurse) said on 2/14/15 at 11:00 am during interview, when the facility holds inservices on abuse, the employees are told to notify E1 (Administrator) of all allegations of abuse but the employees have never been told who to notify if the abuse allegation is concerning the administrator. R2 said she knew these things were abuse but was unsure what to do in this situation. b. E6 (Certified Nurse Assistant) was interviewed on 4/9/15 at 11:20 am. E6 said she was not sure who to notify of abuse if the allegation is about the administrator. c. E11 (Certified Nurse Assistant) said on 4/9/15 at 9:30 am she was unsure who to report an abuse allegation to if it involves the administrator. d. E12 (Certified Nurse Assistant) said at 9:15 am on 4/9/15 that she was unsure who to notify of abuse allegations if the administrator were involved because the administrator is "top dog." E12 said she felt sorry for R2 during the incident in the hallway and it "was not right" but she (E12) did not know who to report it to. e. E14 (Registered Nurse) said at 9:30 am on 4/10/15, she knows to report abuse to the administrator but does not know who to tell if the allegation involves the administrator. E14 said she needs her job but had to tell the surveyor of the incidents with R1 and R2 because she does not think it is right the way E1 treats the residents. Recent abuse investigations dated 2/2/15, 3/2/15 and 3/13/15 were reviewed on 4/8/15. There were no investigations completed on R1 or R2. E1 (Administrator) said on 4/8/15 at 2:10pm there were no investigations completed related to R1. The Abuse Prevention Program policy dated 11/11/11 documents "This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment" and "employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. The policy does not document who is to be notified if the administrator is the alleged perpetrator of the abuse, neglect and/or mistreatment of [REDACTED]. A Complaint Procedure was noted hanging on the facility wall near the administration office. It documents, "It is the policy of the facility to provide the best nursing care in a manner and environment that promotes maintenance of enhancement of each resident's quality of life. In order to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident, we need to have good lines of communication. This will assure that your concerns are addressed in a timely manner. Please direct any questions to any of the following at any time." This document then lists the chain of command and their phone numbers. E1 is fifth on this list then the regional director (E18) is sixth. This document does not say anything related to reporting abuse. E17 and E18 (Regional Directors) were notified of the Immediate Jeopardy on 4/14/15 at 9:40 am. The Immediate Jeopardy was determined to have begun on 12/29/14 when R2 was talked to harshly and sat in the floor by E1 (Administrator). The facility failed to identify and report alleged allegations of abuse and failed to educate employees of who to contact if allegations were made against the Administrator. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy. On 04/08/15 the following was initiated / completed: 1. 2:45 pm - Regional Director was made aware of the alleged abuse involving E1, Administrator. Regional Director initiated investigation per protocol including suspension of the Administrator. 2. Regional Director spoke to IDPH surveyor and advised that the Administrator removed herself from the facility after being made aware of the allegation and will remain off pending the outcome of investigation. 3. 3:30 pm - Initial notification of alleged abuse was submitted to IDPH. On 04/09/15 the following was initiated / completed: 1. Regional Director and Regional Nurse conducted interviews with 11 staff members. 2. Regional Director and Regional Nurse conducted interview with male resident involved in alleged abuse with no concerns voiced. 3. Social Service Director conducted interviews with 10 alert residents related to care and treatment with no concerns voiced. On 04/10/15 the following was initiated / completed: 1. Regional Director submitted final report to IDPH. After thorough review of the " facts " , the allegation of abuse was unsubstantiated. 2. Regional Team noted that Complaint Procedure is posted in the front hallway that clearly identifies chain of command, including phone numbers for facility staff, Regional Director and Petersen Health Care. 3. 5:21 pm - Regional Director was made aware of additional concerns identified during IDPH complaint visit involving Administrator. 4. Regional Director initiated a second investigation and Administrator remains suspended. 5. Regional Director submitted initial report for 2nd allegation to IDPH. 6. 6:10 pm - Regional Director notified resident ' s mother of allegation of abuse. Resident ' s mother reports no concerns with care and treatment. Also, reports that resident has voiced no concerns to her about care and treatment. On 04/13/15 the following was initiated / completed: 1. Regional Director and two Regional Nurses began interviewing 100% of all staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. There were 35 staff interviews conducted with 8 remaining. 2. Regional Nurse and Social Service Director interviewed 16 residents related to care and treatment by staff including Administrator, with no concerns voiced. On 04/14/15 the following was initiated / completed: 1. 9:40 am - IDPH advised of Immediate Jeopardy for F223, F225, F226, and F490. 2. Regional Director and Regional Nurses completed 100% all staff interviews (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. 3. 11:42 am - Regional Director made follow-up call to resident ' s mother who continues to state there are no concerns with care and treatment at the facility. 4. 11:49 am - Regional Director interviewed female resident involved in alleged abuse, related to care and treatment provided by facility staff including E1. There were no concerns voiced and resident reports that the administrator has cared for her. 5. 2:00 pm - Regional Director and Regional Nurses initiated 100% staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) in-service on facility Abuse Policy including prevention, screening, orientation, identification, reporting and Behavior Monitoring program, including tracking, interventions, communication, and care plan updates. 6. Resident care plan was reviewed and updated to reflect behavior interventions. 7. Resident Council is being educated on Abuse Prevention Policy. 8. Regional Director and Regional Nurses are completing investigation based on " facts " obtained through staff, resident and family interviews for final IDPH report. Facility Management and the Regional staff will ensure that all new employees will be trained and educated on policy and procedure for Abuse Prevention per facility protocol during their orientation process. The facility is also re-assessing our current staff for educational needs and standards of practice. Those who refuse to abide by policy and procedure have been issued disciplinary action and/or termination of employment. The Q.A. team, including Administration, Nursing Management, and the Interdisciplinary Team will assure compliance through the daily Quality Assurance Process. The Administrator will monitor effectiveness of staff training on Abuse Prevention policy as part of the Quality Assurance Program. The Administrator shall receive copies of all in-service materials and the Medical Director is reviewing the Removal Plan for F223, F225, F226, and F490.

Based on interviews and record review the facility administration failed to follow their policy and procedures related to abuse regarding the reporting and investigating of allegations of abuse and the protection of R1 and R2 from abuse. The facility administration failed to educate employees as to whom to report allegations of abuse to, if the allegation concerns the administrator. On [DATE], [DATE] and [DATE] facility staff had knowledge of suspicion of verbal, mental and/or physical abuse by E1 (Administrator) to R1 and R2. The facility administration also failed to ensure that all licensed nursing staff maintain a current license, while performing nursing duties. These failures have the potential to affect all 55 residents currently residing in the facility. These failures resulted in an immediate jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to evaluate and monitor the effectiveness of their staff training on abuse prevention and reporting requirements. Findings include: The Facility Data Sheet dated [DATE], documents a census of 55 residents residing in the facility. 1. During interviews regarding abuse allegations, it was reported to this surveyor that R2 was disruptive in the dining room and E1 (Administrator) removed R2 into the hallway. E1 sat R2 in the floor and spoke harshly to her as follows: a. E12 (Certified Nurse Aide) was interviewed on [DATE] at 9:15am. E12 said she witnessed E1 "physically" place R2 on the floor from her wheelchair. E12 said she is unsure of the date this occurred but thinks it was a "couple of months ago." E12 said the nurses and other residents did not witness this. E12 said R2 was yelling out and squirming but was not attempting to get out of the wheelchair. E12 said E1 pushed R2's wheelchair into the hallway and alone transferred her onto the floor. E12 said she heard E1 "harshly" tell R2, "If you're going to act like a baby you can lay in the floor and have a fit like a baby." b. E11 (Certified Nurse Aide) was interviewed on [DATE] at 9:30am. E11 said she did not witness E1 placing R2 in the floor. E11 said she saw R2 sitting on the floor and heard E1 "rudely" tell R2, "if you are going to act like a baby you can lay in the floor and have a fit like a baby." E11 said the other witnesses to this incident were E10 and E12. E11 said she used a gait belt and assisted E1 to transfer R2 back into the dining room. E11 said she is unsure of the date but this happened a "couple months ago." c. E14 (Registered Nurse) was interviewed on [DATE] at 9:30am and said E1 told her R2 was yelling in the dining room so she "sat her ass in the floor" and told R2 "if you're going to act like a baby, you can crawl like one." d. E2 (Registered Nurse) was interviewed on [DATE] at 11:55am and said E1 told her R2 "was throwing a fit and acting like a baby so I put her ass in the floor" and told R2 " if you are going to act like a baby you can sit in the floor like a baby." E2 said E1 told her E11 and E12 seen me do this and I am surprised they didn't throw a fit. e. On [DATE] at 9:55am, E10 (Certified Nurse Aide) said someone told her she had witnessed the incident where R2 was placed on the floor but she said, I just can't remember anything about it. f. E7 (Licensed Practical Nurse) was interviewed on [DATE] at 8:30am. E7 said she has never heard of or seen abuse in the facility. After receiving the final investigative report on [DATE] from the facility indicating E7 was a witness to the incident, E7 was interviewed again by telephone on [DATE] at 12:45pm. E7 said she had been in the dining room when R2 was "acting up". E7 said R2 was trying to hit her head on the table. E7 said she later went to the nurse desk near the dining room and witnessed E1 trying to ambulate R2 in the hallway but R2 was lifting her feet up so E1 sat her in the floor. E7 said she "did not go over there." E7 said she heard E1 tell R2, if you are done throwing a fit we can go to your room and discuss this. E7 said she only heard some of the conversation and there may have been a lot more going on. E7 said what she did see she did not consider abuse. g. On [DATE] at 3:00pm, E16 (Social Service Director) said she initiates the behavior tracking for the residents. E16 said she reads all completed behavior tracking and nurse notes related to R2. E16 said she has never seen a behavior of R2 attempting to throw herself in the floor in the dining room except for this "isolated" event documented on the Behavior Tracking by E1. h. On [DATE] at 10:35am, E1 (Administrator) said she sat R2 in the floor because she was attempting to throw herself out of the wheelchair in the dining room. E1 said she told R2, "Stop acting like a child. If you're acting like a child you are going to be treated like a child" and told her to act like an adult. E1 said R2 didn't have any more behaviors on this day. i. During the investigation an attempt to interview R2 was made four times. The first time on [DATE] at 10:00am. R2 would not make eye contact with this surveyor and did not converse. The second time was with E2 present(who was identified by staff as having a good relationship with R2) on [DATE] at 10:10am, R2 placed a blanket over her head and did not respond to questions or conversation. The third time on [DATE] at 2:50 pm with R2's grandmother present. Staff indicated R2's grandmother may make R2 more comfortable during the interview. R2 was tearful. R2 did not carry on a conversation with this surveyor but did say "no" when asked if she has ever been mistreated and "no" when asked if she remembered ever being sat on the floor. Then R2 asked for her medication. The fourth time on [DATE] at 9:40am. When asked if she could remember ever being sat in the floor R2 said "no." R2 had visible tremors and did not make eye contact or carry on a conversation with this surveyor. 2.During interviews regarding abuse allegations, it was reported to this surveyor that E1 (Administrator) crushed candy and placed it in applesauce then gave it to R2 and told her to shut up because she was yelling out, as follows: a. On [DATE] at 9:30am, E14 (Registered Nurse) said E1 told her R2 was yelling for her medication so she placed candy in applesauce and when R2 started to yell again she put it in her mouth and said "now, shut up." E14 said she observed E1 come from R2's room and E1 walked directly to her (E14) and told her (E14) this. E14 said she was attempting to give R2 her medication after this incident and R2 told her she had already taken her medicine. E14 said she had to explain to her she had taken candy and encourage her to take her pills. E14 said this happened on Thursday, [DATE]nd 2015. b. On [DATE] at 3:20pm, E2 (Registered Nurse) said on Thursday, [DATE] she heard R2 cursing and yelling for her medicine. E2 said E1 told her she crushed some candy and put it in applesauce then when R2 opened her mouth to yell she gave it to her and told R2 "shut up." c. On [DATE] at 10:35am, E1 (Administrator) said she did put candy in applesauce and give it to R2. E1 said R2 is demanding and yells out so she gave her the candy and R2 stopped yelling. E1 said she did not tell R2 that it was her medicine and she did not tell R2 to shut up but she told her to "hush, stop yelling." R2's [DATE] physician's orders [REDACTED]. www.johnhopkins.org documents Limbic Encephalitis as "The limbic areas of the brain control many functions including memory, learning, and emotions such as aggression" and "The term "Limbic Encephalitis" (LE) is used when the limbic areas of the brain are inflamed (swollen) or not functioning properly. The symptoms of Limbic Encephalitis include memory loss, [MEDICAL CONDITION], confusion, disturbances of sleep and psychological disturbances such as altered personality or behaviour." R2's Minimum Data Set ((MDS) dated [DATE] documents R2's Date of Birth as [DATE] and an admission date of [DATE]. The MDS also documents R2 has little interest or pleasure in doing things, feeling down, depressed or hopeless and thoughts that she would be better off dead or of hurting herself in some way. It also documents R2 has verbal behavioral symptoms directed towards others ( threatening others, screaming at others, cursing at others)and other behavioral symptoms not directed towards others. (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R2's Behavior Monitoring Record dated [DATE] documents "trying to throw self out of chair at lunch. Resident to hall with staff. R2 continued to attempt to put self on floor while standing with staff. Staff sat her in the floor. Explained why it was not appropriate to yell at staff and throwing self on floor. R2 walked to dining room. No behaviors the rest of lunch." 3. During interviews regarding allegations of abuse, the allegation was made that E1 (Administrator) sprayed water in R1's face to stop R1 from yelling during R1's shower, as follows: a. On [DATE] at 9:15am, E12 (Certified Nurse Aide) said E1 told her when she (E12) is giving R1 a shower and he is yelling out to spray him in the face with water and he will quit yelling. b. On [DATE] at 9:30am, E11 (Certified Nurse Aide) said E1 told her when she (E11) is giving R1 a shower to spray him in the face with water when he is yelling and he will stop yelling. c. On [DATE] at 9:30am, E14 (Registered Nurse) said E1 told her she (E1) gave R1 a shower and R1 was yelling so she told R1 if he yelled one more time she would spray him in the face with water. E14 said E1 told her, R1 yelled again so she sprayed him in the face and he didn't yell any more after that. d. On [DATE] at 11:55am, E2 (Registered Nurse) said E1 told her she (E1) gave R1 a shower on [DATE] and R1 was yelling so she sprayed water in his face and he stopped yelling. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 was admitted to the facility on [DATE] and R1's [DIAGNOSES REDACTED]. R1's Date of Birth is documented as [DATE] as documented on the MDS. R1's Care Plan for Behavior dated [DATE] and Behavior Monitoring Records from [DATE] through [DATE] do not document yelling out in the shower as a problem. R1's MDS documents R1 has a score of 04 for the Brief Interview for Mental Status indicating he has a Severely Impaired cognitive status. There are no mood or behaviors documented on this MDS. The MDS documents that R1 requires two assist and is totally dependent with bathing. R1's Shower/Abnormal Skin Report with the date of [DATE] documents E1's initials as the Certified Nurse Aide giving the shower on this day. 4. During interviews with employees regarding who to report abuse allegations to, the following statements were reported: a. E2 (Registered Nurse) said on [DATE] at 11:00am during interview, when the facility holds inservices on abuse, the employees are told to notify E1 (Administrator) of all allegations of abuse but the employees have never been told who to notify if the abuse allegation is concerning the administrator. R2 said she knew these things were abuse but was unsure what to do in this situation. b. E6 (Certified Nurse Assistant) was interviewed on [DATE] at 11:20am. E6 said she was not sure who to notify of abuse if the allegation is about the administrator. c. E11 (Certified Nurse Assistant) said on [DATE] at 9:30am she was unsure who to report an abuse allegation to if it involves the administrator. d. E12 (Certified Nurse Assistant) said at 9:15am on [DATE] that she was unsure who to notify of abuse allegations if the administrator were involved because the administrator is "top dog." E12 said she felt sorry for R2 during the incident in the hallway and it "was not right" but she (E12) did not know who to report it to. e. E14 (Registered Nurse) said at 9:30am on [DATE], she knows to report abuse to the administrator but does not know who to tell if the allegation involves the administrator. E14 said she needs her job but had to tell the surveyor of the incidents with R1 and R2 because she does not think it is right the way E1 treats the residents. 5. The following information was obtained during interviews regarding allegations of abuse: a. On [DATE] at 9:30am, E14 (Registered Nurse) said E1 told her a nurse was working with an expired nursing license and if anyone told this to anyone else she would "burn down their damn house." E14 said E1 is not approachable and the employees are intimidated by her. E14 said E1 calls them names. b. On [DATE] at 11:55am, E2 (Registered Nurse) said E1 was leaving on [DATE] after the abuse investigation was initiated and told her, "you tell the cna's (Certified Nurse Aides) to keep their mouths shut about me or I will kill them and burn their houses down. E2 said all the staff are intimidated by E1 and are scared to tell her things. c. On [DATE] at 1:15pm, E4 (Registered Nurse) said on [DATE] E1 was leaving the facility after the abuse investigation was initiated, E1 stepped back into the facility and said tell the cna's if they say anything about me I will kill them and burn down their houses. On [DATE] at 10:15am, E4 said E1 had made a telephone call to her about something and E1 told her it had been a hectic day and R2 had been yelling so she gave her candy in applesauce and told her, "now, shut up." d. E11 (Certified Nurse Aide) said E1 is uncaring. E11 said E1 had an inservice for all cna's. (Certified Nurse Aides) E1 told them to write their concerns and complaints down on a piece of paper. After they were finished writing E1 told them to wad it up and cram it up their butts because she doesn't care about their complaints. The Abuse Prevention Program policy dated [DATE] documents "employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. The policy does not document who is to be notified if the administrator is involved in the investigation. The Complaint Procedure was noted hanging on the facility wall near the administration office. It documents, "It is the policy of the facility to provide the best nursing care in a manner and environment that promotes maintenance of enhancement of each resident's quality of life. In order to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident, we need to have good lines of communication. This will assure that your concerns are addressed in a timely manner. Please direct any questions to any of the following at any time". This document then lists the chain of command and their phone numbers. E1 is fifth on this list then the regional director (E18) is sixth. This document does not say anything related to reporting abuse. 6. On [DATE] at 8:50am, E7 (Licensed Practical Nurse) said she didn't realize she hadn't renewed her nursing license for 2015. E7 said she worked as an Licensed Practical Nurse from February 2015 until [DATE] without a current license, then had them renewed on [DATE]. On [DATE] at 1:00pm, E17 (Regional Director) said it was noticed in [DATE] that E7's nursing license had expired. E17 said E7 worked as a nurse if she was on the nurse schedule. A document from the Illinois Department of Financial and Professional Regulation with the date of [DATE] documents, "This is to advise you that E7 holds a Licensed Practical Nurse license in the State of Illinois." The Nursing schedule for the facility for the month of February 2015 documents R7 as working 15 times. The Nursing schedule for the month of [DATE], from the 1st through the 23rd, documents E7 as working 8 times The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy. On [DATE] the following was initiated / completed: 1. 2:45 pm - Regional Director was made aware of the alleged abuse involving E1, Administrator. Regional Director initiated investigation per protocol including suspension of the Administrator. 2. Regional Director spoke to IDPH surveyor and advised that the Administrator removed herself from the facility after being made aware of the allegation and will remain off pending the outcome of investigation. 3. 3:30 pm - Initial notification of alleged abuse was submitted to IDPH. On [DATE] the following was initiated / completed: 1. Regional Director and Regional Nurse conducted interviews with 11 staff members. 2. Regional Director and Regional Nurse conducted interview with male resident involved in alleged abuse with no concerns voiced. 3. Social Service Director conducted interviews with 10 alert residents related to care and treatment with no concerns voiced. On [DATE] the following was initiated / completed: 1. Regional Director submitted final report to IDPH. After thorough review of the " facts " , the allegation of abuse was unsubstantiated. 2. Regional Team noted that Complaint Procedure is posted in the front hallway that clearly identifies chain of command, including phone numbers for facility staff, Regional Director and Petersen Health Care. 3. 5:21 pm - Regional Director was made aware of additional concerns identified during IDPH complaint visit involving Administrator. 4. Regional Director initiated a second investigation and Administrator remains suspended. 5. Regional Director submitted initial report for 2nd allegation to IDPH. 6. 6:10 pm - Regional Director notified resident ' s mother of allegation of abuse. Resident ' s mother reports no concerns with care and treatment. Also, reports that resident has voiced no concerns to her about care and treatment. On [DATE] the following was initiated / completed: 1. Regional Director and two Regional Nurses began interviewing 100% of all staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. There were 35 staff interviews conducted with 8 remaining. 2. Regional Nurse and Social Service Director interviewed 16 residents related to care and treatment by staff including Administrator, with no concerns voiced. On [DATE] the following was initiated / completed: 1. 9:40 am - IDPH advised of Immediate Jeopardy for F223, F225, F226, and F490. 2. Regional Director and Regional Nurses completed 100% all staff interviews (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. 3. 11:42 am - Regional Director made follow-up call to resident ' s mother who continues to state there are no concerns with care and treatment at the facility. 4. 11:49 am - Regional Director interviewed female resident involved in alleged abuse, related to care and treatment provided by facility staff including E1. There were no concerns voiced and resident reports that the administrator has cared for her. 5. 2:00 pm - Regional Director and Regional Nurses initiated 100% staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) in-service on facility Abuse Policy including prevention, screening, orientation, identification, reporting and Behavior Monitoring program, including tracking, interventions, communication, and care plan updates. 6. Resident care plan was reviewed and updated to reflect behavior interventions. 7. Resident Council is being educated on Abuse Prevention Policy. 8. Regional Director and Regional Nurses are completing investigation based on " facts " obtained through staff, resident and family interviews for final IDPH report. Facility Management and the Regional staff will ensure that all new employees will be trained and educated on policy and procedure for Abuse Prevention per facility protocol during their orientation process. The facility is also re-assessing our current staff for educational needs and standards of practice. Those who refuse to abide by policy and procedure have been issued disciplinary action and/or termination of employment. The Q.A. team, including Administration, Nursing Management, and the Interdisciplinary Team will assure compliance through the daily Quality Assurance Process. The Administrator will monitor effectiveness of staff training on Abuse Prevention policy as part of the Quality Assurance Program. The Administrator shall receive copies of all in-service materials and the Medical Director is reviewing the Removal Plan for F223, F225, F226, and F490.

Based on interview and record review, the facility failed to prevent episodes of staff to resident abuse for 2 of 2 residents (R1 and R2) from the sample of 7. On [DATE], [DATE] and [DATE] facility staff had knowledge of situations regarding verbal, mental and/or physical abuse by E1 (Administrator) to R1 and R2. This failure resulted in an immediate jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to evaluate and monitor the effectiveness of their staff training on abuse prevention and reporting requirements. Findings include: 1. During interviews regarding abuse allegations, it was reported to this surveyor that R2 was disruptive in the dining room and E1 (Administrator) removed R2 into the hallway. E1 sat R2 in the floor and spoke harshly to her as follows: a. E12 (Certified Nurse Aide) was interviewed on [DATE] at 9:15 am. E12 said she witnessed E1 "physically" place R2 on the floor from her wheelchair. E12 said she is unsure of the date this occurred but thinks it was a "couple of months ago." E12 said the nurses and other residents did not witness this. E12 said R2 was yelling out and squirming but was not attempting to get out of the wheelchair. E12 said E1 pushed R2's wheelchair into the hallway and alone transferred her onto the floor. E12 said she heard E1 "harshly" tell R2, "If you're going to act like a baby you can lay in the floor and have a fit like a baby." b. E11 (Certified Nurse Aide) was interviewed on [DATE] at 9:30 am. E11 said she did not witness E1 placing R2 in the floor. E11 said she saw R2 sitting on the floor and heard E1 "rudely" tell R2, "if you are going to act like a baby you can lay in the floor and have a fit like a baby." E11 said the other witnesses to this incident were E10 and E12. E11 said she used a gait belt and assisted E1 to transfer R2 back into the dining room. E11 said she is unsure of the date but this happened a "couple months ago." c. E14 (Registered Nurse) was interviewed on [DATE] at 9:30 am and said E1 told her R2 was yelling in the dining room so she "sat her ass in the floor" and told R2 "if you're going to act like a baby, you can crawl like one." d. E2 (Registered Nurse) was interviewed on [DATE] at 11:55 am and said E1 told her R2 "was throwing a fit and acting like a baby so I put her ass in the floor" and told R2 " if you are going to act like a baby you can sit in the floor like a baby." E2 said E1 told her E11 and E12 seen me do this and I am surprised they didn't throw a fit. e. On [DATE] at 9:55 am, E10 (Certified Nurse Aide) said someone told her she had witnessed the incident where R2 was placed on the floor but she said, I just can't remember anything about it. f. E7 (Licensed Practical Nurse) was interviewed on [DATE] at 8:30 am. E7 said she has never heard of or seen abuse in the facility. After receiving the final investigative report on [DATE] from the facility indicating E7 was a witness to the incident, E7 was interviewed again by telephone on [DATE] at 12:45pm. E7 said she had been in the dining room when R2 was "acting up". E7 said R2 was trying to hit her head on the table. E7 said she later went to the nurse desk near the dining room and witnessed E1 trying to ambulate R2 in the hallway but R2 was lifting her feet up so E1 sat her in the floor. E7 said she "did not go over there." E7 said she heard E1 tell R2, if you are done throwing a fit we can go to your room and discuss this. E7 said she only heard some of the conversation and there may have been a lot more going on. E7 said what she did see she did not consider abuse. g. On [DATE] at 3:00pm, E16 (Social Service Director) said she initiates the behavior tracking for the residents. E16 said she reads all completed behavior tracking and nurse notes related to R2. E16 said she has never seen a behavior of R2 attempting to throw herself in the floor in the dining room except for this "isolated" event documented on the Behavior Tracking by E1. h. On [DATE] at 10:35 am, E1 (Administrator) said she sat R2 in the floor because she was attempting to throw herself out of the wheelchair in the dining room. E1 said she told R2, "Stop acting like a child. If you're acting like a child you are going to be treated like a child" and told her to act like an adult. E1 said R2 didn't have any more behaviors on this day. i. During the investigation an attempt to interview R2 was made four times. The first time on [DATE] at 10:00 am. R2 would not make eye contact with this surveyor and did not converse. The second time was with E2 present(who was identified by staff as having a good relationship with R2) on [DATE] at 10:10 am, R2 placed a blanket over her head and did not respond to questions or conversation. The third time on [DATE] at 2:50pm with R2's grandmother present. Staff indicated R2's grandmother may make R2 more comfortable during the interview. R2 was tearful. R2 did not carry on a conversation with this surveyor but did say "no" when asked if she has ever been mistreated and "no" when asked if she remembered ever being sat on the floor. Then R2 asked for her medication. The fourth time on [DATE] at 9:40 am. When asked if she could remember ever being sat in the floor R2 said "no." R2 had visible tremors and did not make eye contact or carry on a conversation with this surveyor. 2. During interviews regarding allegations of abuse it was reported to this surveyor that E1 (Administrator) crushed candy and placed it in applesauce then gave it to R2 and told her to shut up because she was yelling out, as follows: a. On [DATE] at 9:30 am, E14 (Registered Nurse) said E1 told her R2 was yelling for her medication so she placed candy in applesauce and when R2 started to yell again she put it in her mouth and said "now, shut up." E14 said she observed E1 come from R2's room and E1 walked directly to her (E14) and told her (E14) this. E14 said she was attempting to give R2 her medication after this incident and R2 told her she had already taken her medicine. E14 said she had to explain to her she had taken candy and encourage her to take her pills. E14 said this happened on Thursday, [DATE]nd 2015. b. On [DATE] at 3:20pm, E2 (Registered Nurse) said on Thursday, [DATE] she heard R2 cursing and yelling for her medicine. E2 said E1 told her she crushed some candy and put it in applesauce then when R2 opened her mouth to yell she gave it to her and told R2 "shut up." c. On [DATE] at 10:35 am, E1 (Administrator) said she did put candy in applesauce and give it to R2. E1 said R2 is demanding and yells out so she gave her the candy and R2 stopped yelling. E1 said she did not tell R2 that it was her medicine and she did not tell R2 to shut up but she told her to "hush, stop yelling." R2's [DATE] physician's orders [REDACTED]. www.johnhopkins.org documents Limbic Encephalitis as "The limbic areas of the brain control many functions including memory, learning, and emotions such as aggression" and "The term "Limbic Encephalitis" (LE) is used when the limbic areas of the brain are inflamed (swollen) or not functioning properly. The symptoms of Limbic Encephalitis include memory loss, [MEDICAL CONDITION], confusion, disturbances of sleep and psychological disturbances such as altered personality or behaviour." R2's Minimum Data Set ((MDS) dated [DATE] documents R2's Date of Birth as [DATE] and an admission date of [DATE]. The MDS also documents R2 has little interest or pleasure in doing things, feeling down, depressed or hopeless and thoughts that she would be better off dead or of hurting herself in some way. It also documents R2 has verbal behavioral symptoms directed towards others ( threatening others, screaming at others, cursing at others)and other behavioral symptoms not directed towards others. (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). R2's Behavior Monitoring Record dated [DATE] documents "trying to throw self out of chair at lunch. Resident to hall with staff. R2 continued to attempt to put self on floor while standing with staff. Staff sat her in the floor. Explained why it was not appropriate to yell at staff and throwing self on floor. R2 walked to dining room. No behaviors the rest of lunch." 3. During interviews regarding allegations of abuse, the allegation was made that E1 (Administrator) sprayed water in R1's face to stop R1 from yelling during R1's shower, as follows: a. On [DATE] at 9:15 am, E12 (Certified Nurse Aide) said E1 told her when she (E12) is giving R1 a shower and he is yelling out to spray him in the face with water and he will quit yelling. b. On [DATE] at 9:30 am, E11 (Certified Nurse Aide) said E1 told her when she (E11) is giving R1 a shower to spray him in the face with water when he is yelling and he will stop yelling. c. On [DATE] at 9:30 am, E14 (Registered Nurse) said E1 told her she (E1) gave R1 a shower and R1 was yelling so she told R1 if he yelled one more time she would spray him in the face with water. E14 said E1 told her, R1 yelled again so she sprayed him in the face and he didn't yell any more after that. d. . On [DATE] at 11:55 am, E2 (Registered Nurse) said E1 told her she (E1) gave R1 a shower on [DATE] and R1 was yelling so she sprayed water in his face and he stopped yelling. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 was admitted to the facility on [DATE] and R1's [DIAGNOSES REDACTED]. R1's Date of Birth is documented as [DATE] as documented on the MDS. R1's Care Plan for Behavior dated [DATE] and Behavior Monitoring Records from [DATE] through [DATE] do not document yelling out in the shower as a problem. R1's MDS documents R1 has a score of 04 for the Brief Interview for Mental Status indicating he has a Severely Impaired cognitive status. There are no mood or behaviors documented on this MDS. The MDS documents that R1 requires two assist and is totally dependent with bathing. R1's Shower/Abnormal Skin Report with the date of [DATE] documents 1's initials as the Certified Nurse Aide giving the shower on this day. 4. The following information was obtained during interviews regarding allegations of abuse: a. On [DATE] at 9:30 am, E14 (Registered Nurse) said E1 told her a nurse was working with an expired nursing license and if anyone told this to anyone else she would "burn down their damn house." E14 said E1 is not approachable and the employees are intimidated by her. E14 said E1 calls them names. b. On [DATE] at 11:55 am, E2 (Registered Nurse) said E1 was leaving on [DATE] after the abuse investigation was initiated and told her, "you tell the cna's (Certified Nurse Aides) to keep their mouths shut about me or I will kill them and burn their houses down. E2 said all the staff are intimidated by E1 and are scared to tell her things. c. On [DATE] at 1:15pm, E4 (Registered Nurse) said on [DATE] E1 was leaving the facility after the abuse investigation was initiated, E1 stepped back into the facility and said tell the cna's if they say anything about me I will kill them and burn down their houses. On [DATE] at 10:15 am, E4 said E1 had made a telephone call to her about something and E1 told her it had been a hectic day and R2 had been yelling so she gave her candy in applesauce and told her, "now, shut up." d. E11 (Certified Nurse Aide) said E1 is uncaring. E11 said E1 had an inservice for all cna's. (Certified Nurse Aides) E1 told them to write their concerns and complaints down on a piece of paper. After they were finished writing E1 told them to wad it up and cram it up their butts because she doesn't care about their complaints. E17 and E18 (Regional Directors) were notified of the Immediate Jeopardy on [DATE] at 9:40 am. The Immediate Jeopardy was determined to have begun on [DATE] when R2 was talked to harshly and sat in the floor by E1 (Administrator). The facility failed to identify and report alleged allegations of abuse and failed to educate employees of who to contact if allegations were made against the Administrator. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy. On [DATE] the following was initiated / completed: 1. 2:45 PM - Regional Director was made aware of the alleged abuse involving E1, Administrator. Regional Director initiated investigation per protocol including suspension of the Administrator. 2. Regional Director spoke to IDPH surveyor and advised that the Administrator removed herself from the facility after being made aware of the allegation and will remain off pending the outcome of investigation. 3. 3:30 pm - Initial notification of alleged abuse was submitted to IDPH. On [DATE] the following was initiated / completed: 1. Regional Director and Regional Nurse conducted interviews with 11 staff members. 2. Regional Director and Regional Nurse conducted interview with male resident involved in alleged abuse with no concerns voiced. 3. Social Service Director conducted interviews with 10 alert residents related to care and treatment with no concerns voiced. On [DATE] the following was initiated / completed: 1. Regional Director submitted final report to IDPH. After thorough review of the " facts " , the allegation of abuse was unsubstantiated. 2. Regional Team noted that Complaint Procedure is posted in the front hallway that clearly identifies chain of command, including phone numbers for facility staff, Regional Director and Petersen Health Care. 3. 5:21 pm - Regional Director was made aware of additional concerns identified during IDPH complaint visit involving Administrator. 4. Regional Director initiated a second investigation and Administrator remains suspended. 5. Regional Director submitted initial report for 2nd allegation to IDPH. 6. 6:10 pm - Regional Director notified resident's mother of allegation of abuse. Resident ' s mother reports no concerns with care and treatment. Also, reports that resident has voiced no concerns to her about care and treatment. On [DATE] the following was initiated / completed: 1. Regional Director and two Regional Nurses began interviewing 100% of all staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. There were 35 staff interviews conducted with 8 remaining. 2. Regional Nurse and Social Service Director interviewed 16 residents related to care and treatment by staff including Administrator, with no concerns voiced. On [DATE] the following was initiated / completed: 1. 9:40 am - IDPH advised of Immediate Jeopardy for F223, F225, F226, and F490. 2. Regional Director and Regional Nurses completed 100% all staff interviews (including nursing, housekeeping/laundry, dietary, maintenance, and administration) related to ANY allegation of abuse. 3. 11:42 am - Regional Director made follow-up call to resident ' s mother who continues to state there are no concerns with care and treatment at the facility. 4. 11:49 am - Regional Director interviewed female resident involved in alleged abuse, related to care and treatment provided by facility staff including E1. There were no concerns voiced and resident reports that the administrator has cared for her. 5. 2:00 pm - Regional Director and Regional Nurses initiated 100% staff (including nursing, housekeeping/laundry, dietary, maintenance, and administration) in-service on facility Abuse Policy including prevention, screening, orientation, identification, reporting and Behavior Monitoring program, including tracking, interventions, communication, and care plan updates. 6. Resident care plan was reviewed and updated to reflect behavior interventions. 7. Resident Council is being educated on Abuse Prevention Policy. 8. Regional Director and Regional Nurses are completing investigation based on " facts " obtained through staff, resident and family interviews for final IDPH report. Facility Management and the Regional staff will ensure that all new employees will be trained and educated on policy and procedure for Abuse Prevention per facility protocol during their orientation process. The facility is also re-assessing our current staff for educational needs and standards of practice. Those who refuse to abide by policy and procedure have been issued disciplinary action and/or termination of employment. The Q.A. team, including Administration, Nursing Management, and the Interdisciplinary Team will assure compliance through the daily Quality Assurance Process. The Administrator will monitor effectiveness of staff training on Abuse Prevention policy as part of the Quality Assurance Program. The Administrator shall receive copies of all in-service materials and the Medical Director is reviewing the Removal Plan for F223, F225, F226, and F490.