Every finding on record at Axiom Gardens of Mount Vernon

Based on interview, observation, and record review the facility failed to provide enough staff to supervise and attend to the needs of the residents in a timely manner. This failure has the potential to affect all 70 residents that reside in the facility.Findings include: 1. R53's admission record documents an admission date of 9/15/2025 with the following diagnoses in part; Cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, age-related physical debility. R53's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating that R53 is cognitively intact. Section GG documents R53 has an impairment of lower extremities on both sides, requires substantial to maximum assistance with transfers. R53's MDS documents R53 requires supervision or touching assistance with eating. R53's care plan documents that he requires supervision with meal consumption and has an ADL (Activities of Daily Living) self care deficit. R3's care plan documents R53 needs assistance or is dependent in: transfer, dressing and toilet use. On 3/16/26 at 9:10am, R53 was lying in bed and stated he participates in activities, and they are good when staff allows him to get in his chair. R53 stated if he gets up and, in his chair, he might as well plan on staying in it for the day. R53 stated if he doesn't get out of bed in the morning, he may as well plan on staying in there. R53 stated staff always tells him they need two people to transfer him, and someone is always on break or going on break or they do not have enough staff. On 3/16/26 at 12:50pm, R53 was observed lying in bed eating in his room alone, without supervision. On 3/17/26 at 10:03am R53 was observed lying in bed. On 3/17/26 at 1:07pm, R53 was observed lying in bed eating in his room alone, without supervision. On 3/17/26 at 2:27pm, R53 was lying in bed and stated he asked to get out of bed in the morning, and they told him that it was fine, but don't expect to get back into bed until after lunch. On 3/18/26 at 12:40pm, R53 was lying in bed and stated he did not even ask to get out of bed today. R53 stated what's the point They are just going to make him stay in the chair all day. R53 stated he starts hurting after a couple of hours of being stuck in his chair. On 3/18/26 at 12:47pm, R53 was observed lying in bed eating in his room alone, without supervision. On 3/19/26 at 12:33pm, R53 was observed lying in bed eating in his room alone, without supervision. At that time R53 stated that he always eats in his room alone if he stays in bed. R53 stated he does not have supervision when eating. On 3/19/26 at 2:46pm R53 was lying in bed. 2. R68's admission Record documents an admission date of 3/13/26 and a discharge date of 3/18/26, with the following diagnoses in part; cerebral atherosclerosis, blindness in right eye category 5, blindness in left eye category 5. R68's Minimum Data Set (MDS) was incomplete due to being a new admission. R68's care plan documents that she is at high risk for falls intervention to include anticipate and meet her needs, be sure her call light in within reach and encourage the resident to use it for assistance as needed, be aware of blindness. 03/16/2026 at 10:01AM R68's call light was observed on. V9 (Certified Nursing Assistant/CNA) responded promptly. V12 (Family Member) stated to V9 that R68 needed to use the restroom. V9 stated that she was the only one on the hall, R68 was a two assist and it would be a minute. V9 shut the call light off and left the room without toileting R68. On 3/16/2026 at 10:22am, V10 (CNA) stated that R68 had been toileted after breakfast and then laid down. V10 stated she had not been toileted since then. V10 stated that R68 is technically a one assist, but that morning she was having trouble with her legs, and they were using two. On 3/16/2026 at 10:24am, continuous observations of R68's room began. On 3/16/2026 at 10:41am, R68's call light came on. On 3/16/2026 at 10:42am, V10 answered R68's call light and toileted R68. On 3/19/2026 at 11:08am V9 stated they like to have three aides on the hallway, but there are only two at times. V9 stated there are residents on the hallway that require the assistance of two staff, if there is only one available, they can ask the nurse or a staff member from the other side. V9 stated R53 is set-up assistance for meals. On 3/19/2026 at 11:21am, V10 stated they should have 3 aides on the hallway, but sometimes they only have two. V10 stated if there are two aides on the hallway and they need assistance with a resident; they can get the nurse or a CNA from the other side depending on who's working. On 3/19/2026 at 1:16pm, V2 (Director of Nursing/DON) stated if a resident put on their call light to use the restroom and staff had to get another staff member to transfer, a 40 min wait time until they are toileted is not acceptable, they should be grabbing the nurse or another qualified staff member. V2 stated staffing should never prevent someone from getting out of bed. V2 stated her expectation for a resident requiring supervision at meals would be for them to be in the dining room if someone could not always be present in the room during the meal. 3. R69's admission record documents an admission date of 12/01/25 with diagnoses of unspecified focal traumatic brain injury with loss of consciousness, recurrent depressive disorders, anxiety disorder, personal history of traumatic brain injury, dementia, schizoaffective disorder, and convulsions. R69's MDS (Minimum Data Set) dated 12/10/25 documents in Section C a BIMS (Brief Interview of Mental Status) score of 99, which indicates R69 is severely cognitively impaired. Section GG documents eating as supervision and touching assistance and walking as supervision and touching assistance. R69's Care plan documents a focus area of : I am an elopement risk/wanderer related to Traumatic brain injury, date initiated 2/13/26. Interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television book. Know that he does not stay engaged and will wander off from activity/meal/task. Document wandering behavior and attempted diversional interventions in the behavior log. All initiated 2/16/26. Another focus area includes: I am at risk for fall/injury related to wandering/poor safety awareness, seizure potential. Date initiated 12/12/25. Interventions include staff to observe resident's whereabouts frequently throughout their shift. Date initiated 12/12/25. Another focus area includes: I have a behavior problem, entering other resident rooms and taking other resident items at times with a date initiated as 12/1/25. Interventions include redirect R69 when he is occupying other resident bed in other resident room, redirect R69 when he is wandering into other resident rooms and anticipate and meet the resident's needs. R69's Care plan did not address any concerns related to abuse or potential for abuse or any additional behaviors. R69's Care plan was revised on 3/17/26 to include a focus area of: I have a behavior problem, I take other resident food/resident trays at mealtimes. R69's psychiatry note dated 02/18/26 documents: chief complaint: staff report several concerning behaviors including wondering in and out of others rooms, pacing without rest, inappropriate sexual behaviors, stealing other residents things from there room as well as there (sic) food at mealtimes, digging in and eating things out of the trash. R69 becomes physically aggressive with any attempt a (sic) redirection. On 03/16/26 at 12:53PM observed R69 walking in the dining room. Observed R69 walk over to R14's table where he took R14's brownie off of R14's plate and began eating R14's brownie right in front of R14. On 03/17/26 at 12:06PM observed R69 grab R70's dessert of fruit crisp off the table. Observed R69 eating R70's fruit crisp as staff were trying to take R70's fruit crisp away from R69. On 03/17/26 at 12:10 PM R69 was directed out of the dining room by V6 (Licensed Practical Nurse) and V5 (Certified Nurse Aide/CNA). On 03/17/26 at 12:11 PM R69 left the dining room. On 03/17/26 at 12:11 PM V5 stated, there are no staff on the hallways to supervise R69. On 03/17/26 at 12:11 PM - 12:27 PM there were no staff observed on the hallways. On 03/17/26 at 12:26 PM R69 came out of R70's room with a bag of chips he opened and started eating and a square bottle of fingernail polish remover (that looked very similar to a drink bottle) in his hands. On 03/17/26 at 12:27 PM surveyor was able to convince R69 into giving the bottle of fingernail polish remover to her. On 03/17/26 at 12:31PM observed R69 in the dining room eating off R70's plate and R70 was trying to take the plate back and food was going all over the table. Observed R69 trying to eat the food off the plate and R70 was twisting and shaking his arm. On 03/17/26 at 12:42 PM V6 stated, R69 has come behind the nurses' station grabbed sodas and chips. R69 stated he can open them both and will walk the halls and eat and drink them. On 03/17/26 at 12:43 PM observed R69 in his room eating off a plate that had mashed potatoes and peas on the plate. R69's designated and assigned plate did not have peas and mashed potatoes on it. On 03/17/26 at 12:47 PM, V5 (CNA) stated that some days she will have to remove up to 15 different plates out of R69's room where he has stolen plates off of the table in the dining room or taken some other resident tray. On 03/17/26 at 1:09 PM R69 entered the dining room on the north side entrance, walked part way through the dining room and picked up a plate a resident had eaten off of. R69 then took a few bites off of the plate and walked on. R69 set that plate down, picked up another plate that a different resident had already eaten from started eating from that plate and walked out of the dining room with the plate of food back to his room and ate the rest of the food with no staff present in the dining room. On 03/17/26 at 1:12 PM R69 entered the dining room on the north side entrance, walked part way through the dining room and picked up a plate a resident had eaten from. R69 then took a few bites off of the plate and walked on. R69 then picked up a cup that a resident had already drank from, drank out of the cup and took both items back to his room, drinking out of the cup while walking down the hallway with no staff in the dining room. On 03/18/26 at 11:59AM observed R69 climb over the nurses' station countertop. R69 then got behind the nurse's station and moved the treatment cart away which was in the locked position from a closet door that was located behind the nurse's station. R69 then went inside of the door that had snacks, activity supplies, personal staff items and medical supplies. R69 grabbed a small open bag of potato chips out of the closet and started eating the potato chips. No staff were observed around the nursing station. On 03/18/26 at 12:04PM, V8 (Laundry) stated that she just saw R69 climbing over the countertop at the nurse's desk and she went and got a certified nurse assistant out of the dining room to help R69 since there was no staff around. On 03/18/26 at 12:14PM observed R69 take R14's nutritional ice cream off the table while R14 was eating his food on his plate. On 03/19/26 at 11:29 AM, R69 walked down the hall, stopped at the locked nurses' station, sat down on the counter, turned around on the counter facing into the nurses' station, put his feet on the floor inside the locked nurses' station and entered inside of the locked nurses' station. R69 moved the treatment cart and opened the closet. R69 opened plastic bags, opened boxes and looked through several items in the closet, with no staff in sight. On 03/19/26 at 11:31 AM, V16 (CNA) walked past the nurses' station but did not see R69 in the closet behind the locked nurses' station. On 0/19/26 at 11:32 AM, V5 (CNA) entered the east side unit from the side door, saw R69 behind the nurses' station, went behind the nurses' station, found a small bag of miniature marshmallows, handed R69 the marshmallows and R69 left the nurses' station. On 03/19/26 at 10:48AM, V6 (Licensed Practical Nurse) stated that she has observed R69 on several occasions climbing over the nurse's station and moving the treatment cart and getting into the closet to find himself a snack. On 03/19/26 at 10:35AM, V14 (CNA) stated that R69 has climbed over the nurse station multiple times, and he will move the treatment cart and get into the closet behind the nurse's station. V14 said that R69 will get into the closet and take out all kinds of things that he finds that might be a snack. V14 said that she has heard that he has also climbed into the kitchen window and tried to get food. V14 stated that she has never observed this but has heard about it. On 03/19/26 at 10:43AM, V4 (Dietary Manager) stated that he has observed R69 climbing into the kitchen from the serve out window and from the dirty dish window. V4 said that R69 has gotten into the kitchen and they had to get R69 out of the kitchen. V4 said that they have tried to keep the dirty dish window closed now or just half open so that R69 doesn't get into the window when staff is preparing the meals and doesn't see R69 trying to get into the kitchen. V4 said that R69 has done it several times, the last time was a couple of weeks ago. On 03/19/26 at 10:45AM, V15 (Dietary Aide) state that R69 has come into the kitchen several times when he has been working. V15 said that last time that R69 was in the kitchen was a couple of weeks ago. V15 said that R69 will crawl into the serving window or the dirty dish window. On 03/19/26 at 10:55AM observed the dirty dish window which appeared to be at least 3 feet off the ground as well at the serve out window. On 03/19/26 at 1:45PM, V1 (Administrator) stated that she feels like R69 climbing over the nurse's station and into the kitchen is more a hazard for the staff then the resident. V1 stated that, R69 is very agile and he is very hard to re-direct, so I feel like staff is more at risk with trying to get the resident out of the kitchen or trying to get him away from somewhere. Undated facility policy titled Corporate Compliance Plan, documents the following under the section titled, Quality of Care: The facility strives to consistently and fully comply with the various laws and regulations pertaining to the treatment, services and needs of residents to attain or maintain residents' highest practicable physical, mental and psychosocial well-being. Because they are so integral to maintaining this well-being, the following areas are deemed to be priorities for focus on quality of care . provide adequate staffing levels and sufficiently trained or supervised staff to properly deliver medical, nursing, and related services. Undated facility policy titled, Nurse staffing, documents the following: It is the policy of (Name of Facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. The Long-Term Care Facility Application for Medicare and Medicaid form dated 3/17/26 documents there are 70 residents currently residing in the facility.

Based on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 1 residents of 9 residents (R68) reviewed for call light response in a sample of 51. The findings include: R68's admission Record documents an admission date of 3/13/26 and a discharge date of 3/18/26, with the following diagnoses in part; cerebral atherosclerosis, blindness in right eye category 5, blindness in left eye category 5.R68's Minimum Data Set (MDS) was incomplete due to being a new admission.R68's care plan documents that she is at high risk for falls intervention to include anticipate and meet her needs, be sure her call light in within reach and encourage the resident to use it for assistance as needed, be aware of blindness.03/16/2026 at 10:01AM R68's call light was observed on. V9 (Certified Nursing Assistant/CNA) responded promptly. V12 (Family Member) stated to V9 that R68 needed to use the restroom. V9 stated that she was the only one on the hall, R68 was a two assist and it would be a minute. V9 shut the call light off and left the room without toileting R68. On 3/16/2026 at 10:22am, V10 (CNA) stated that R68 had been toileted after breakfast and then laid down. V10 stated she had not been toileted since then. V10 stated that R68 is technically a one assist, but that morning she was having trouble with her legs, and they were using two. On 3/16/2026 at 10:24am, continuous observations of R68's room began.On 3/16/2026 at 10:41am, R68's call light came on. On 3/16/2026 at 10:42am, V10 answered R68's call light and toileted R68.On 3/19/2026 at 11:08am V9 stated they like to have three aides on the hallway, but there are only two at times. V9 stated there are residents on the hallway that require the assistance of two staff. V9 stated if there is only one available, they can ask the nurse or a staff member from the other side.On 3/19/2026 at 11:21am, V10 stated they should have 3 aides on the hallway, but sometimes they only have two. V10 stated if there are two aides on the hallway and they need assistance with a resident; they can get the nurse or a CNA from the other side depending on who's working.On 3/19/2026 at 1:16pm, V2 (Director of Nursing/DON) stated if a resident put on their call light to use the restroom and staff had to get another staff member to transfer, a 40 min wait time until they are toileted is not acceptable, they should be grabbing the nurse or another qualified staff member. V2 stated staffing should never prevent someone from getting out of bed.The facility policy titled Dignity with a revision date of 4-23-2018 with a guideline that states: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on interview and record review, the facility failed to ensure effective pain management and treatment was provided in a timely manner for 1 (R1) of 3 residents reviewed for pain management in the sample of 5. This failure resulted in R1, who was admitted to the facility with a right femur fracture, and displaced trimalleolar and bimalleolar fractures of the right lower leg, experiencing prolonged, significant pain due to necessary pain medication not being available.The findings include:R1's admission Record documented an admission date of 02/14/26 and included diagnoses of fracture of unspecified part of neck of right femur, cellulitis of right lower limb, displaced Tri malleolar fracture of right lower leg, displaced bimalleolar fracture of right lower leg and end stage renal disease. R1's Discharge Minimum Data Set (MDS) dated [DATE] documented R1's short term memory was ok and cognitive skills for daily decision making regarding tasks of daily life was marked as independent. In the Functional Abilities and Goals section, this MDS documented R1 was dependent for toileting, rolling left to right, sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to chair transfer, toilet transfers, and tub/shower transfers. In the section titled Health Conditions, R1 was documented as receiving scheduled pain medications and was offered and/or declined PRN (as needed) pain medications. In the section titled Medications, the MDS documented R1 had an indication for and was taking opioid medication. R1's Care Plan was incomplete but in progress due to the recent admission. However, R1's Admission/re-admission Observation assessment dated [DATE] at 9:47PM documents under the section titled Neruological, R1 is oriented to person, place, time and situation. Under the section titled Pain, the following is documented: The Numeric Rating Scale for pain documents a pain level of 8 on a scale of 00 to 10 with the location specifying R1's right leg. Under coping it documents that R1 has PRN oxycodone to alleviate the pain. The question asking what makes the pain worse is left blank. Under lifestyle it documents R1's pain affects sleep by keeping her awake and affects her mood by feeling depressed. Under the section titled Treatments the medications oxycodone and acetaminophen are listed. In the section for Pain Care Planning, it documents a focus area of I have pain with a goal of I will not have an interruption in normal activities due to pain through the review date. Interventions selected document to 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, monitor/record pain characteristics PRN: Quality (e.g. sharp, burning), Severity (1-10 scale) Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors, Relieving factors, and Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. On 02/26/26 at 11:48AM, V15 (Family Member) stated that R1 arrived at the facility on (Saturday) 02/14/26 later in the evening after being discharged from a local hospital. V15 said that R1 had been in the hospital due to sustaining several fractures from a fall at her previous nursing home placement and was in horrible pain. V15 said that the facility did not get R1's oxycodone until around 2 days later. V15 stated that R1 was alert and could state that she was in pain the whole time until they were able to get her oxycodone. V15 said that they did give R1 some Tylenol but that didn't work at all for her pain. V15 said that she doesn't understand why it would take so long to get R1 pain medication. V15 verified that R1 was no longer at this facility as she wanted to discharge and go to another facility with in house dialysis so that she didn't have to be transported back and forth to dialysis due to the pain it would cause. R1's Order Summary Report documents an order for oxycodone Hcl (Hydrochloride) oral tablet 5mg (Milligrams) give 1 tablet by mouth every 4 hours as needed for pain take 1 tablet po (Orally) every 4 hours as needed with an order date of 02/14/26. The Order Summary Report also documents an order for Tylenol 325mg give 2 tablets by mouth every 4 hours as needed for mild pain with a start date of 02/15/26. R1's Order Summary Report documents an order for pain monitoring -ask resident pain level every shift with an order date of 02/16/26. R1's Medication Administration Record (MAR) for 02/01/26 to 02/28/26 documents oxycodone Hcl oral tablet given on 02/19/26 at 11:29AM with a pain level of 7 and 02/19/26 at 4:26PM with a pain level of 3. R1's Progress Notes dated 02/16/26 at 4:27PM document Have called pharmacy 3 times today to check if oxy (Oxycodone) rx (prescription) is in. Not in yet. Called (Physician Provider Company) x (times) 3 and on the last call they mentioned that the request was sent to (Nurse Practitioner) at 3:35PM. Informed the (Nurse Practitioner) that the cutoff for the pharmacy is at 6:00PM R1's MAR for 02/01/26 to 02/28/26 documents Tylenol 325mg (milligrams) give 2 tablet by mouth every 4 hours as needed for mild pain as administered on 02/15/26 at 2:22PM with a pain level of 3, on 02/16/26 at 12:27PM with a pain level of 5, on 02/19/26 at 6:43AM with a pain level of 5, and on 02/19/26 at 2:23Pm with a pain level of 4. R1's Vital Records document the following Pain Level Summaries:02/14/26 at 9:49PM a pain level of 502/15/26 at 2:22PM pain level of 3, 3:35PM pain level of 0, 4:35PM pain level of 0, 5:15PM pain level of 0, 11:03PM pain level of 002/16/26 at 9:22AM pain level of 5, 12:27PM pain level of 5, 3:15PM pain level of 1, 10:51PM pain level of 002/17/26 at 4:46AM pain level of 0, 9:27AM pain level of 4, 9:28AM pain level of 3, 10:55AM pain level of 0, 7:54PM pain level of 402/18/26 at 8:41PM pain level of 002/19/26 at 4:55AM pain level of 0, 6:43AM pain level of 5, 7:16AM pain level of 5, 8:37AM pain level of 3, 11:29AM pain level of 7, 2:15PM pain level of 4, 2:23PM pain level of 4, 4:24PM pain level of 3, 4:24PM pain level of 3, 4:25PM pain level of 3, 4:26PM pain level of 3, 5:28PM pain level of 3, 5:30PM pain level of 0, 7:05PM pain level of 0, 8:08PM pain level of 002/20/26 at 8:04AM pain level of 1. On 02/26/26 at 10:04AM, V2 (Director of Nursing/DON) stated that their new pharmacy is terrible. V2 said that their pharmacy has an emergency medication bank at the facility that does have narcotic pain medication, but oxycodone is not one of the medications in the emergency medication bank kit. V2 said that if they did have oxycodone in the emergency medication bank, they would have had to get a script then call the pharmacy and get a code and it can take up to 4 hours to call back with the code to get into the emergency medication bank kit. V2 said that R1 arrived at the facility on 02/14/26 after 5:00PM, so R1's medications would have missed the cut off to be delivered on Sunday morning. V2 said the bad thing about this is, if the nurses were having a problem with getting R1's oxycodone V2 doesn't know why they didn't call her. V2 said that she doesn't know for sure what day R1's oxycodone finally came in. V2 said that she knows the facility contacted the pharmacy several times trying to get R1's oxycodone pain medication. On 02/26/26 at 10:10AM, V3 (Assistant Director of Nursing/ADON) stated they tried to get ahold of the pharmacy about R1's oxycodone to see if they could get it since they didn't have it in the emergency medication bank kit. V3 said she thinks the reason why they didn't call and get an order for some other kind of pain medication that was in the emergency medication bank was because R1 was allergic to hydrocodone and that is mainly what they have in the emergency medication bank kit. On 02/26/26 at 10:24AM, V1 (Administrator) stated R1 came from an outside hospital and arrived on 02/14/26 later in the evening. V1 said if the facility gets a new resident and they have a controlled substance like oxycodone and don't have a prescription for the it, they can request it from the physician. V1 said they have several physicians they can call and they always have an on-call physician as well. V1 said they have an emergency medication bank kit at the facility they can pull from if it is past the cut off for the pharmacy delivery date. V1 said they also have emergency runs for medications, although they generally don't have to use it but they could have had R1's oxycodone delivered via emergency run. V1 said she doesn't think R1 came with a script for the oxycodone. V1 said the nurses should have gotten a hold of another provider to get a script for the oxycodone so they could have gotten the medication. On 02/26/26 at 10:34AM, V4 (Vice President of Operations) stated that the nurses should have gotten a hold of a physician and gotten a script for R1's oxycodone. V4 said that R1 should have come with a script from the hospital for the oxycodone. On 03/02/26 at 9:52AM, V5 (Registered Nurse) stated she took care of R1 for one day. V5 said she did call the pharmacy several times on 02/16/26. V5 said she doesn't like the new pharmacy and the pharmacy was acting like they didn't have a prescription for R1's oxycodone, but they did have a prescription for the oxycodone. V5 said she was calling the nurse practitioner and on-call physician trying to get a script and the pharmacy already had a prescription for it. V5 said the pharmacy told her they did find the prescription. V5 said R1 was in a lot of pain and V5 gave R1 some Tylenol because that is all she had to give R1 for pain. V5 said R1 did not get her oxycodone on 02/16/26. V5 said she did request an emergency run for R1's oxycodone, but the pharmacy did not do one. V5 said whoever put a 0 down on R1's pain level scale was not telling the truth because R1 was always having pain. V5 said there is no excuse why they didn't try to get R1 pain medication over the weekend. V5 said it was probably agency that was working. V5 said she doesn't know why the pharmacy did not bring R1's oxycodone when she requested the emergency run either. V5 stated they do have oxycodone 5mg in the emergency medication bank kit. V5 said she doesn't know why the hospital didn't send a script for the oxycodone when they discharged R1 to the facility. V5 said when she calls the physician or the on-call doctor they are usually pretty good about getting the prescription sent right away. V5 said R1 was crying when she worked and had a 10 out of 10 on the pain scale. V5 said she was trying everything she could to try to get R1's pain under control. V5 said she thought she took an oxycodone 5mg out of the emergency medication bank kit to give to R1. On 03/02/26 at 10:04AM, V2 (DON) was at the emergency medication bank and tried to log in to see if she could pull up the screen for oxycodone. V2 was able to pull up the screen on the emergency medication bank that showed oxycodone 5mg IR (Immediate release), however the quantity showed blind, which means the machine will not disclose the amount of medication in the bank. On 03/02/26 at 10:05AM, V2 stated she doesn't know if R1's oxycodone was IR or not. V2 stated if it wasn't, the nurses could have gotten a script for it to give R1 one until her oxycodone came in. V2 said she knew they dropped the ball on getting R1's oxycodone. V2 said to find out how many controlled substances they have in the emergency medication bank, they have to call V12 (Emergency Medication Bank Representative) and he will provide a code when there is an active script to be able to get the medication out of the emergency medication bank. On 03/02/26 at 10:19AM, V11 (Pharmacy Customer Service) stated R1 did not receive her oxycodone until 02/17/26 (three days after admission). V11 said they did not receive an active prescription for the oxycodone 5mg until 02/16/26 (two days after admission). V11 said no staff from the facility requested an emergency run of R1's oxycodone. V11 said the nurses at the facility could have requested to get the oxycodone out of the emergency medication bank. V11 stated she doesn't see where anyone from the facility requested to get oxycodone out of the emergency medication bank. V11 said the emergency medication bank should have oxycodone 5mg in it. On 03/02/26 at 10:29AM, V12 (Emergency Medication Bank Representative) stated he is the person who the facility would contact to access any medications out of the emergency medication bank. V12 stated the emergency medication bank does contain oxycodone 5mg IR at the facility. V12 stated no staff at the facility requested to get any oxycodone out of the emergency medication bank from 02/14/26 until now. V12 said if they had a prescription for the oxycodone, he could have given the facility a code and they would have had the oxycodone to give to R1. On 03/02/26 at 10:57AM, V7 (Agency Licensed Practical Nurse/LPN) stated she took care of R1 on 02/15/26. V7 stated she talked to V3 (ADON) about R1's oxycodone not being available. V7 said V3 told her R1's medication could be pulled from the emergency medication bank. V7 said she doesn't have access to the emergency medication bank because she is an agency nurse. V7 said she didn't get much report from the nurse working before her about R1. V7 said she did give R1 some Tylenol because she was really hurting. V7 said she called the pharmacy and tried to get R1's oxycodone and she let the night shift nurse know she called the pharmacy and requested R1's oxycodone. V7 said she feels like Tylenol did help manage R1's pain some. V7 said she talked to V3 about R1's oxycodone and V3 is who showed V7 the standing orders they had for Tylenol, so V7 was able to write an order for the Tylenol to be able to give R1 some. V7 said she thought they had oxycodone in the emergency medication bank but wouldn't have been able to pull it. V7 said even after she called the pharmacy and requested the oxycodone they still did not bring R1's oxycodone. On 03/02/26 at 11:24AM, V3 (ADON) stated she doesn't remember talking to V7 about R1's oxycodone. V3 said she does remember talking to V17 (LPN) on 02/14/26 about R1's medications. V3 said R1 arrived late on 02/14/26 and the orders wouldn't make it until the next day because R1 got to the facility too late. V3 said she told V17 to get a hold of the pharmacy for an emergency run to get R1's medications. V3 said she thought V17 told her they didn't have oxycodone in the emergency medication bank. V3 said when R1 was admitted to the facility V3 had only been in her position for about 2 weeks. V3 said evidently, they did not do an emergency run on R1's medications. On 03/02/26 at 12:49PM, V13 (Certified Nurse Assistant/CNA) stated she took care of R1 while she was at the facility maybe 2 days. V13 said she doesn't remember what days she worked, but she does remember that R1 was yelling out in pain. V13 said she knew the nurses didn't have R1's pain medication and they were trying to help R1 with the pain by having them reposition R1. V13 said she thought the repositioning did help some, but R1 was still in a lot of pain. On 03/02/26 at 12:51PM, V14 (CNA) stated she took care of R1 while she was at the facility. V14 said R1 was really hurting, especially when they had to change or reposition R1. V14 said R1 was hurting very badly, and the nurses didn't have R1's pain medications. V14 said R1 seemed to be in a lot of pain a lot of the time. V14 said they tried repositioning R1 to see if that would help the pain but most of the time, she didn't think it helped much at all. On 03/02/26 at 2:47PM and 4:00PM, surveyor attempted to contact V16 (Medical Director). A message was left with no return call. On 03/03/26 at 9:00AM, surveyor again attempted to contact V16 and left a message with no return call. On 03/04/26 at 1:20PM, V18 (V16's Nurse) stated the first time anyone from the facility requested a script for R1's oxycodone was on 02/16/26 at 3:49PM. V18 stated a prescription was sent over to the pharmacy at 4:47PM by one of their providers. V18 said they do not have record of any other request from the facility for a script for R1's oxycodone other than on 02/16/26. V18 said the facility also sent a pulse which is a communication system the facility uses, on 02/16/26 notifying the providers of a new admission for R1. The facility policy titled Pain Management Program with a revision date of 7/06/2018 documents under purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The Guidelines: It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program.

Based on interview and record review, the facility failed to obtain and provide necessary controlled prescription pain medication in a timely manner for 1 (R1) of 3 residents reviewed for pharmacy services in the sample of 5.The findings include:R1's admission Record documented an admission date of 02/14/26 and included diagnoses of fracture of unspecified part of neck of right femur, displaced Tri malleolar and bimalleolar fractures of right lower leg, cellulitis of right lower limb, and end stage renal disease. R1's Discharge Minimum Data Set (MDS) dated [DATE] documented R1's short term memory was ok and cognitive skills for daily decision making regarding tasks of daily life was marked as independent. In the Functional Abilities and Goals section, this MDS documented R1 was dependent for toileting, rolling left to right, sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to chair transfer, toilet transfers, and tub/shower transfers. In the section titled Health Conditions, R1 was documented as receiving scheduled pain medications and was offered and/or declined PRN (as needed) pain medications. In the section titled Medications, the MDS documented R1 had an indication for and was taking opioid medication. R1's Care Plan was incomplete but in progress due to the recent admission. However, R1's Admission/re-admission Observation assessment dated [DATE] at 9:47PM documents under the section titled Neruological, R1 is oriented to person, place, time and situation. Under the section titled Pain, the following is documented: The Numeric Rating Scale for pain documents a pain level of 8 on a scale of 00 to 10 with the location specifying R1's right leg. Under coping it documents that R1 has PRN oxycodone to alleviate the pain. The question asking what makes the pain worse is left blank. Under lifestyle it documents R1's pain affects sleep by keeping her awake and affects her mood by feeling depressed. Under the section titled Treatments the medications oxycodone and acetaminophen are listed. In the section for Pain Care Planning, it documents a focus area of I have pain with a goal of I will not have an interruption in normal activities due to pain through the review date. Interventions selected document to 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, monitor/record pain characteristics PRN: Quality (e.g. sharp, burning), Severity (1-10 scale) Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors, Relieving factors, and Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. R1's Medication Administration Record (MAR) for 02/01/26 to 02/28/26 documents oxycodone Hcl oral tablet given on 02/19/26 at 11:29AM with a pain level of 7 and 02/19/26 at 4:26PM with a pain level of 3. R1's Progress Notes dated 02/16/26 at 4:27PM document Have called pharmacy 3 times today to check if oxy (Oxycodone) rx (prescription) is in. Not in yet. Called (Physician Provider Company) x (times) 3 and on the last call they mentioned that the request was sent to (Nurse Practitioner) at 3:35PM. Informed the (Nurse Practitioner) that the cutoff for the pharmacy is at 6:00PM R1's Care Plan was incomplete but in progress due to the recent admission. However, R1's Admission/re-admission Observation assessment dated [DATE] at 9:47PM documents under the section titled Neruological, R1 is oriented to person, place, time and situation. Under the section titled Pain, the following is documented: The Numeric Rating Scale for pain documents a pain level of 8 on a scale of 00 to 10 with the location specifying R1's right leg. Under coping it documents that R1 has PRN oxycodone to alleviate the pain. The question asking what makes the pain worse is left blank. Under lifestyle it documents R1's pain affects sleep by keeping her awake and affects her mood by feeling depressed. Under the section titled Treatments the medications oxycodone and acetaminophen are listed. In the section for Pain Care Planning, it documents a focus area of I have pain with a goal of I will not have an interruption in normal activities due to pain through the review date. Interventions selected document to 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, monitor/record pain characteristics PRN: Quality (e.g. sharp, burning), Severity (1-10 scale) Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors, Relieving factors, and Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. On 02/26/26 at 10:04AM, V2 (Director of Nursing/DON) stated that their new pharmacy is terrible. V2 said that their pharmacy has an emergency medication bank at the facility that does have narcotic pain medication, but oxycodone is not one of the medications in the emergency medication bank kit. V2 said that if they did have oxycodone in the emergency medication bank, they would have had to get a script then call the pharmacy and get a code and it can take up to 4 hours to call back with the code to get into the emergency medication bank kit. V2 said that R1 arrived at the facility on 02/14/26 after 5:00PM, so R1's medications would have missed the cut off to be delivered on Sunday morning. V2 said the bad thing about this is, if the nurses were having a problem with getting R1's oxycodone V2 doesn't know why they didn't call her. V2 said that she doesn't know for sure what day R1's oxycodone finally came in. V2 said that she knows the facility contacted the pharmacy several times trying to get R1's oxycodone pain medication. On 02/26/26 at 10:10AM, V3 (Assistant Director of Nursing/ADON) stated they tried to get ahold of the pharmacy about R1's oxycodone to see if they could get it since they didn't have it in the emergency medication bank kit. V3 said she thinks the reason why they didn't call and get an order for some other kind of pain medication that was in the emergency medication bank was because R1 was allergic to hydrocodone and that is mainly what they have in the emergency medication bank kit.On 02/26/26 at 10:24AM, V1 (Administrator) stated R1 came from an outside hospital and arrived on 02/14/26 later in the evening. V1 said if the facility gets a new resident and they have a controlled substance like oxycodone and don't have a prescription for the it, they can request it from the physician. V1 said they have several physicians they can call and they always have an on-call physician as well. V1 said they have an emergency medication bank kit at the facility they can pull from if it is past the cut off for the pharmacy delivery date. V1 said they also have emergency runs for medications, although they generally don't have to use it but they could have had R1's oxycodone delivered via emergency run. V1 said she doesn't think R1 came with a script for the oxycodone. V1 said the nurses should have gotten a hold of another provider to get a script for the oxycodone so they could have gotten the medication. On 02/26/26 at 10:34AM, V4 (Vice President of Operations) stated that the nurses should have gotten a hold of a physician and gotten a script for R1's oxycodone. V4 said that R1 should have come with a script from the hospital for the oxycodone. On 02/26/26 at 11:48AM, V15 (Family Member) stated that R1 arrived at the facility on (Saturday) 02/14/26 later in the evening after being discharged from a local hospital. V15 said that R1 had been in the hospital due to sustaining several fractures from a fall at her previous nursing home placement and was in horrible pain. V15 said that the facility did not get R1's oxycodone until around 2 days later. V15 stated that R1 was alert and could state that she was in pain the whole time until they were able to get her oxycodone. V15 said that they did give R1 some Tylenol but that didn't work at all for her pain. V15 said that she doesn't understand why it would take so long to get R1 pain medication. V15 verified that R1 was no longer at this facility as she wanted to discharge and go to another facility with in house dialysis so that she didn't have to be transported back and forth to dialysis due to the pain it would cause. On 02/26/26 at 1:36PM V8 (Licensed Practical Nurse/LPN) stated that they do have a problem at times with getting controlled prescription pain medications from the pharmacy. V8 said that since they have had the new pharmacy this has been a problem. V8 said that when a new resident comes into the facility, sometimes the pharmacy will deliver the new residents' medications on time and other times they do not. V8 said that it is not a problem with the provider writing the prescriptions, they are always good at writing the prescriptions, it is the pharmacy. On 03/02/26 at 9:52AM, V5 (Registered Nurse) stated she took care of R1 for one day. V5 said she did call the pharmacy several times on 02/16/26. V5 said she doesn't like the new pharmacy and the pharmacy was acting like they didn't have a prescription for R1's oxycodone, but they did have a prescription for the oxycodone. V5 said she was calling the nurse practitioner and on-call physician trying to get a script and the pharmacy already had a prescription for it. V5 said the pharmacy told her they did find the prescription. V5 said R1 was in a lot of pain and V5 gave R1 some Tylenol because that is all she had to give R1 for pain. V5 said R1 did not get her oxycodone on 02/16/26. V5 said she did request an emergency run for R1's oxycodone, but the pharmacy did not do one. V5 said whoever put a 0 down on R1's pain level scale was not telling the truth because R1 was always having pain. V5 said there is no excuse why they didn't try to get R1 pain medication over the weekend. V5 said it was probably agency that was working. V5 said she doesn't know why the pharmacy did not bring R1's oxycodone when she requested the emergency run either. V5 stated they do have oxycodone 5mg in the emergency medication bank kit. V5 said she doesn't know why the hospital didn't send a script for the oxycodone when they discharged R1 to the facility. V5 said when she calls the physician or the on-call doctor they are usually pretty good about getting the prescription sent right away. V5 said R1 was crying when she worked and had a 10 out of 10 on the pain scale. V5 said she was trying everything she could to try to get R1's pain under control. V5 said she thought she took an oxycodone 5mg out of the emergency medication bank kit to give to R1. On 03/02/26 at 10:04AM, V2 (DON) was at the emergency medication bank and tried to log in to see if she could pull up the screen for oxycodone. V2 was able to pull up the screen on the emergency medication bank that showed oxycodone 5mg IR (Immediate release), however the quantity showed blind, which means the machine will not disclose the amount of medication in the bank. On 03/02/26 at 10:05AM, V2 stated she doesn't know if R1's oxycodone was IR or not. V2 stated if it wasn't, the nurses could have gotten a script for it to give R1 one until her oxycodone came in. V2 said she knew they dropped the ball on getting R1's oxycodone. V2 said to find out how many controlled substances they have in the emergency medication bank, they have to call V12 (Emergency Medication Bank Representative) and he will provide a code when there is an active script to be able to get the medication out of the emergency medication bank. On 03/02/26 at 10:19AM, V11 (Pharmacy Customer Service) stated R1 did not receive her oxycodone until 02/17/26 (three days after admission). V11 said they did not receive an active prescription for the oxycodone 5mg until 02/16/26 (two days after admission). V11 said no staff from the facility requested an emergency run of R1's oxycodone. V11 said the nurses at the facility could have requested to get the oxycodone out of the emergency medication bank. V11 stated she doesn't see where anyone from the facility requested to get oxycodone out of the emergency medication bank. V11 said the emergency medication bank should have oxycodone 5mg in it. On 03/02/26 at 10:29AM, V12 (Emergency Medication Bank Representative) stated he is the person who the facility would contact to access any medications out of the emergency medication bank. V12 stated the emergency medication bank does contain oxycodone 5mg IR at the facility. V12 stated no staff at the facility requested to get any oxycodone out of the emergency medication bank from 02/14/26 until now. V12 said if they had a prescription for the oxycodone, he could have given the facility a code and they would have had the oxycodone to give to R1.On 03/02/26 at 10:57AM, V7 (Agency Licensed Practical Nurse/LPN) stated she took care of R1 on 02/15/26. V7 stated she talked to V3 (ADON) about R1's oxycodone not being available. V7 said V3 told her R1's medication could be pulled from the emergency medication bank. V7 said she doesn't have access to the emergency medication bank because she is an agency nurse. V7 said she didn't get much report from the nurse working before her about R1. V7 said she did give R1 some Tylenol because she was really hurting. V7 said she called the pharmacy and tried to get R1's oxycodone and she let the night shift nurse know she called the pharmacy and requested R1's oxycodone. V7 said she feels like Tylenol did help manage R1's pain some. V7 said she talked to V3 about R1's oxycodone and V3 is who showed V7 the standing orders they had for Tylenol, so V7 was able to write an order for the Tylenol to be able to give R1 some. V7 said she thought they had oxycodone in the emergency medication bank but wouldn't have been able to pull it. V7 said even after she called the pharmacy and requested the oxycodone they still did not bring R1's oxycodone. On 03/02/26 at 11:24AM, V3 (ADON) stated she doesn't remember talking to V7 about R1's oxycodone. V3 said she does remember talking to V17 (LPN) on 02/14/26 about R1's medications. V3 said R1 arrived late on 02/14/26 and the orders wouldn't make it until the next day because R1 got to the facility too late. V3 said she told V17 to get a hold of the pharmacy for an emergency run to get R1's medications. V3 said she thought V17 told her they didn't have oxycodone in the emergency medication bank. V3 said when R1 was admitted to the facility V3 had only been in her position for about 2 weeks. V3 said evidently, they did not do an emergency run on R1's medications. On 03/04/26 at 1:20PM, V18 (V16's Nurse) stated the first time anyone from the facility requested a script for R1's oxycodone was on 02/16/26 at 3:49PM. V18 stated a prescription was sent over to the pharmacy at 4:47PM by one of their providers. V18 said they do not have record of any other request from the facility for a script for R1's oxycodone other than on 02/16/26. V18 said the facility also sent a pulse which is a communication system the facility uses, on 02/16/26 notifying the providers of a new admission for R1. The facility policy titled Medication Administration undated documents under Procedures, #21 - If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Like medications are not to be Borrowed from one resident for another. The Pharmacy policy titled Medication Orders Controlled substance prescriptions documents under policy: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription to ensure delivery of medication. The director of nursing and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medications. The Pharmacy policy titled Medication ordering and Receiving from Pharmacy #4 Stat and emergency medications are ordered as follows: during regular pharmacy hours, the pharmacy is notified of the emergency or stat order; the order is then phoned, sent electronically, or faxed to the pharmacy. The nurse must call the pharmacy to request a STAT order. STAT medications are delivered within 4 hours of verbal order by nurse for a STAT order, unless extenuating circumstances arise and facility is notified. If available, the initial dose is obtained from the emergency kit, when necessary. B. if after hours, medications should be ordered as outlined in the emergency pharmacy service and kits policy.

Based on interview, observation, and record review the facility failed to ensure residents were free from resident to resident physical abuse for 2 of 4 residents (R1 and R2) reviewed for abuse in the sample of 6. This failure resulted in R1 sustaining a nasal fracture during and altercation with R2. R1's admission Record documents an admission date of 7/2/2025 and includes diagnoses of Encephalopathy, Unspecified Dementia with other behavioral disturbances, unspecified dementia with agitation, and convulsions.R1's MDS (Minimum Data Set) dated 7/11/2025 includes a BIMS (Brief Interview for Mental Status) score of 2 suggesting R1 has severe cognition impairment. Section E-Behaviors documents R1 does not hallucinations or delusions. R1 has no behaviors of wandering. Section GG -Functional Abilities documents R1 has no impairment with upper or lower extremities. R1's care plan documents a focus area of: R1 is at risk for abuse with date initiated 7/3/25. Goal: R1 will remain free of abuse, mistreatment or otherwise improper care throughout residency at facility (date initiated 7/3/25). Interventions including, observe resident in the company of peers (date initiated 7/10/25), provide reassurance when negative feelings occur (date initiated 8/4/25), notify abuse coordinator of any abuse immediately (date initiated 7/3/25). R2's admission Record documents an admission date of 3/5/2025 and includes diagnoses of Vascular Dementia without Behavioral Disturbance, Psychotic or Mood Disturbance, Anxiety and Insomnia.R2's MDS (Minimum Data Set) dated 5/26/2025 includes a BIMS (Brief Interview for Mental Status) score of 99 suggesting R2 has severe cognition impairment. Section E- Behaviors documents R2 does not have hallucinations or delusions, and no behaviors exhibited for wandering. Section GG - Functional Abilities documents R2 has no impairment to upper and lower extremities and no assistive devices used for mobility. R2 only requires supervision/ touching assistance with ADLs (Activities of Daily Living).R2's Care Plan documents a focus area of: I have a behavior problem (physical aggression) with date initiated of 5/1/25. Interventions include: Monitor for evidence of agitation (initiated 5/1/25), Monitor when approached by confused residents (initiated 5/1/25), Monitor for entering other residents' room (initiated 8/4/25) and Provide 1:1's as need (no date).A final report sent to IDPH (Illinois Department of Public Health) dated 8/6/25 by V1 (Administrator) documents on 8/1/2025, R1 went to the nurse's station with blood coming from his nose and it appeared crooked. V9 (Licensed Practical Nurse/LPN) stated R1 saw R2 and began charging stating R2 had hit him. Residents were immediately separated and sent to local emergency rooms. Follow up/summary documents R1 sustained a fracture to his nasal bone as a result of the alleged peer to peer incident. According to housekeeper, V7 he saw R2 go into R1's room prior to the altercation. R2 was asked if he had struck R1 and he stated got him back. R2 was also noted with blood on his hand. Both residents reside on our locked dementia unit and have a recent BIMS score of 99 due to not being able to complete assessment. Following return from their respective hospitals, both residents completed and telehealth with psychiatry group. No medication changes were made. Care plans were updated to reflect R2 will be encouraged to participate in 1 on 1 activities. R1's care plan reflects that he was sent to emergency room due to abuse from another resident. Staff will be educated to assure that residents do not enter other rooms. Report was authored by V1 and dated 8/6/2025. On 8/8/2025 at 12:22PM, R1 was observed walking in the hallway outside of his room. Observed R1's nose with slight edema and a light purple bruise noted to the bridge of his nose. R1 was asked what happened to his nose. R1 stated, A man hit me in my f***ing nose. R1 was asked if he knew why the other resident hit him and R1 stated, No. R1 stated he did not know the man's name that hit him either. R1's EMR (Electronic Medical Record) progress notes document on 8/1/2025, R1 appears to have been involved in an altercation with a peer. Event was first noted on 8/1/2025 at 3:20 PM. Just prior to or at the time of the event R1 appears to have been walking down the hall. R1's account of the event is R2 punched him in the face. V7 saw resident come down hall with nosebleed yelling that guy hit me. R1's Hospital Report dated 8/1/25 documents, Patient history obtained from nursing home nurse who is with the patient as well as the patient's self, they gotten to a punch fight, he was punched by another resident. And has deviation and bleeding of the nose. That occurred just prior to arrival. No other injuries appreciated. No other complaints, patient states that the pain is moderate, bleeding controlled, will controlled in the emergency room but there is obvious deformity of the nasal bones. XR (x-ray) Nasal Bones Complete. Impression: 1. Acute appearing transverse fracture through the mid nasal bone with minimal depression at the fracture site. Overlying soft tissue swelling.On 8/8/2025 at 12:29PM, via phone interview V7 (Housekeeping) stated he works in housekeeping and was on the unit the day of the incident with R1 and R2. V7 stated he saw R1 walk up to the nurse's station and saw his nose bleeding. V7 stated R1 then stated, He hit me and broke my nose. V7 stated R2 was walking up the hall behind R1. V7 stated when R1 saw R2 he went to him and hit him in the chest. V7 stated the nurse was there and we separated the two residents.On 8/8/2025 at 12:33PM, via phone interview V9 (LPN) stated he was the nurse working the unit the evening that R1 and R2 had a peer-to-peer incident. V9 stated R1 came up to the nurse's station and his nose was bleeding and crooked. V9 said the next thing that happened was R2 came walking up behind R1 and when R1 saw R2 he went towards him. V9 stated he did not see R1 hit R2 as he was trying to get to them to separate them. V9 stated he did not see R2 hit R1 either but R2 had blood on his hand and in between fingers. V9 stated he assessed both residents and made notifications. V9 stated both residents were sent to separate hospitals. V9 stated R1 was sent to the emergency room to get checked for his injury to his nose and R2 was sent to a different hospital for a Psychiatric Evaluation. V9 stated he was off shift when the residents returned from the hospital.On 8/8/2025 at 1:05PM, V2 (Director of Nursing) stated she was in the facility the evening the incident occurred between R1 and R2. V2 stated she came over immediately and helped send both residents out to the hospital. V2 stated both residents ambulate independently. V2 stated sometimes R2 wanders into other residents' room but he is monitored to redirect when he does go into other rooms. V2 stated R2 doesn't talk much and when he does, he mumbles. V2 stated R1 talks but uses curse words a lot. On 8/8/2025 at 10:25AM, R2 was noted to be resting in bed with his eyes open. R2 was asked how he was doing and he mumbled something but not understandable. R2 would not answer any questions. On 8/8/2025 at 12:15PM, R2 was observed in his room walking around with only underwear on. R2 was asked a couple questions with no answers given. R2's Psychiatry Note dated 8/5/2025 documents the type of visit is an acute visit. Chief Complaints shows recent peer altercation. The history of present illness shows R2 is a [AGE] year-old male with a history of insomnia and dementia. The staff request due to recent altercation in which R2 ended up hitting another resident on the memory unit. At present R2 is pleasantly confused and a poor historian due to dementia. R2's speech described as word salad/mumbled. No medication changes were made at this time.R1 Psychiatry Note dated 8/5/2025 documents the type of visit is an acute visit. Chief complaint shows recent peer altercation. History of present illness shows R1 is a [AGE] year-old male with history of dementia, seen per staff request due to recent altercation in which another resident on the memory unit hit him. Will continue current regimen for now.Policy titled Abuse Prevention and Reporting-Illinois dated 10/24/2022, documents, the facility affirms the right of our resident to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services y staff or mistreatment. This will be done by establishing an environment that remotes resident sensitivity, resident security and prevention of mistreatment. Abuse definition means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury.

Based on interview and record review, the facility failed to ensure residents were free from resident to resident physical abuse for 2 (R3 and R4) of 3 residents reviewed for abuse in the sample of 4. Findings Include: R3's admission Record documented R3 was admitted to the facility on [DATE] and included diagnoses of unspecified dementia, essential hypertension, unspecified protein-calorie malnutrition, atrial fibrillation, osteoarthritis of knee, adult failure to thrive, and unspecified macular degeneration. R3's Minimum Data Set (MDS) assessment dated [DATE], documented that R1 has a Brief Interview for Mental Status (BIMS) score of 11, indicating R3 is moderately impaired. R3's Care Plan with a date of 05/01/2025 included a focus area of I have a behavior problem (Physical altercation with roommate.) The interventions listed are administer meds as ordered, anticipate and meet residents needs, arrange placement with compatible roommate, and monitor for evidence of agitation. R4's admission Record documented R4 was admitted to the facility on [DATE] and included diagnoses of vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and primary insomnia. R4's MDS assessment dated [DATE], documented a BIMS score of 99 indicating that R4 was unable to complete the interview. R4's Care Plan with a date of 03/25/2025, included a focus area of I have impaired cognitive function/dementia or impaired thought processes related to a diagnosis of vascular dementia. The interventions listed are use the residents preferred name, identify yourself, face the resident when speaking, engage the resident with simple, structured activities that avoid overly demanding tasks, monitor and report any changes in cognitive function, and review medications. The facility's Final Abuse Investigation Report with no date documented on 05/01/2025 at 5:00 A.M, V15 (Certified Nurse Assistant/CNA) was walking in the hall and witnessed R4 and R3 entangled on the floor of their room. R3 was observed having skin tears on the outer side of both hands and R4 had a swollen nose. R3 and R4 were separated immediately. R3 reported that he was sleeping and that a man jumped on top of him. R4 did not have a recollection of the event. Residents are no longer roommates and there have been no further incidents. On 05/23/2025 at 9:35AM, V13 (Licensed Practical Nurse/LPN) stated that he was the nurse that came on shift on 05/01/2025 at 6:00 AM and the incident occurred before he arrived. V13 stated that R3 and R4 were sharing a room at the time of the incident. V13 stated that R3 was always stating that people were stealing his stuff, and everyone was out to get him. V13 stated it is very rare for R4 to have behaviors. V13 stated R4 gets frustrated because he is not able to make his needs known. V13 stated that he feels that R3 was the aggressor in the incident. V13 stated that R3 always talks about being a marine and whipping people. V13 stated he feels that R4 sat on the edge of R3's bed causing R3 to become agitated and that is when the incident occurred. V13 stated that neither resident was sent out to seek treatment. V13 stated that R3 was moved to the non-locked side of the facility in a room by himself. V13 stated that R4 has had no behaviors since the incident with R3. On 05/23/2025 at 9:50AM, R3 was alone in his room in bed and stated he was in an altercation about a year and a half ago. R3 stated he does not remember being in an altercation with anyone the last couple of months. R3 stated that someone tried to beat up on him but he handled it. R3 stated I worked him over. On 05/23/2025 at 9:57 AM, V1 (Administrator) stated that after the incident with R3 and R4, R4 was evaluated by psych and medications were adjusted. V1 stated that after the incident the residents were immediately separated and R3 was moved off the locked dementia side of the facility. V1 stated that R3 can be territorial and would get upset when residents would wonder in his room. On 05/23/2025 at 10:36 AM, V14 (CNA) stated that R4 is a pleasant resident and does not cause any trouble. V14 stated that R4 gets frustrated when you have to wake him up but other than that he will allow staff to provide care for him. V14 stated she has never witnessed R4 be aggressive with any other resident. V14 stated that after the incident, R3 stated he worked (R4) over real good. On 05/23/2025 at11:13 AM, V15 (CNA) stated that she was the aide working on the locked dementia unit the night the altercation occurred between R3 and R4. V15 stated she was doing bed checks on the middle hall and heard someone yelling help. V15 stated that she could tell it was coming from the front hall so she went to the front hall. V15 stated she entered R3 and R4's room and observed R3 and R4 entangled on the floor in an altercation. V15 stated she removed R4 from on top off R3. V15 stated she and R4 left the room and went to the nurses station. V15 stated that she has never observed R4 being combative with anyone. V15 stated that R3 did not like R4 in his room because R4 would rummage through his personal belongings. V15 stated that before the incident occurred, R3 had voiced that he would like a different room because he did not like R4 in there and was going to kick R4 out of the room. V15 stated she is not sure if the nurses reported this to V1 or not. On 05/23/2025 at 3:19 PM, V16 (LPN) stated she was the nurse the night the incident occurred between R3 and R4. V16 stated it was reported to her by V15 (CNA) that R3 and R4 had been entangled together on the floor. V16 stated that R3 explained that R4 kept coming over to his bed and R3 told him to quit. R4 explained to V16 that they just went at it. V16 stated that R3 always thinks someone is out to get him and does not like having roommates. V16 stated that R3 didn't like that R4 would rummage through his things. 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, observation and record review, the facility failed to follow current CDC (Center for Disease Control) guidelines for proper PPE (Personal Protective Equipment) use and failed to effectively sanitize floors during COVID outbreak. This has the potential to affect all 53 residents living in the facility. The Findings Include: 1. On 3/27/25 at 11:00 am, V14 (Housekeeping Supervisor) said they use (Brand Cleaner) Lavender all purpose neutral cleaner when they mopped the floor currently and during the COVID outbreak. V14 said she is unsure if it kills COVID or not. On 3/26/25 at 2:30pm, V12 (Housekeeping) said there was cleaner in her mop water as she was moping. V12 said it is (Brand Cleaner) Lavender All Purpose Neutral Cleaner. V12 said she doesn't know if it kills COVID or not. On 3/27/25 at 10:37 am, V16 (floor cleaner manufacturer representative) said that (Brand Cleaner) Lavender All Purpose Neutral Floor Cleaner has zero kill time for COVID. V16 said it is just a multi purpose floor cleaner and does not kill COVID. On 3/27/25 at 1:00pm, V1 (Administrator) said she was not aware the cleaner they were using to mop the floors did not kill COVID. 2. On 3/26/25 at 2:00pm, V6 (Activity Assistant Aide) said she wore just a surgical mask when going in the COVID positive resident rooms during the outbreak. On 3/27/25 at 10:00am, V8 (Social Services Director) said that staff wore surgical masks when caring for COVID positive residents. V8 said she doubled her surgical mask. V8 said she asked the nurse for N95 and goggles and was told there was none. V8 said PPE supplies were kept where the time clock is and there was none. On 3/26/25 at 12:50pm, V9 (CNA/Certified Nurse Assistant) said she did not wear a N95 mask and face shield/goggles during the Covid outbreak. V9 said there was only surgical masks and that another CNA called and asked and was told there was none. On 3/26/25 at 1:20 pm, V10 (CNA) said they all wore surgical masks during the COVID outbreak. V10 said they did not have anything but gowns, gloves and surgical masks. On 3/26/25 at 2:30pm, V11 (CNA) said she and everybody wore surgical masks when their residents had COVID. V11 said there was not any N95 masks or eye/face shields. V11 said they did have gowns and gloves. On 3/27/25 at 2:40pm, R3 who was alert to person, place and time, said that he did have COVID back when everyone had it. R3 said that staff did not wear anything but a regular mask. R3 said they did not wear anything over their eyes or wear a gown. On 3/27/25 at 12:30pm, R7 who was alert to person, place and time, said she did have COVID when everyone had it. R7 said staff just wore regular masks. On 3/27/25 at 2:00pm, V2 (DON/Director of Nurses) said she does not know why staff were not wearing the proper PPE when it was available. V2 said all of the staff have been trained on wearing the proper PPE. A facility matrix printed 3/28/25 documents there are 53 residents living the facility. Facility Document labeled Infection Prevention and Control Program (revised 12/5/24) documents .All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments. Employees disregarding the facility's policies and procedures shall be retrained as necessary, disciplined, and may be discharged for repeated non-compliance The facility shall assure that necessary training, equipment and supplies are maintained to carry out an effective Infection Control Program. According to the CDC website at https://www.cdc.gov/covid/hcp/infection-control/index.html#:~:text=HCP%20who%20enter%20the%20room,and%20sides%20of%20the%20face), Healthcare Provider who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on interview, observation, and record review the facility failed provide respectful dining service by serving residents at the same table at the same time, keeping residents from taking food from other residents for 8 (R4, R9, R10, R24, R29, R39, R42, R44) of 21 residents reviewed for dining in a sample of 39. Findings include: 1. R24's admission record dated 03/13/25, documents an admission date of 09/30/24 with diagnoses in part of diabetes mellitus and vitamin d deficiency. R24's MDS (Minimum Data Set) dated 01/06/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 99 which indicates severely impaired cognition. Section GG documents eating as setup and clean-up assistance. Section K documents no weight loss or weight gain. R24's Care Plan with date revised date of 10/20/24 documents a focus area of R24 (resident) has potential nutritional problem r/t (related to) edentulous, receives therapeutic diet. Interventions include in part: provide and serve diet as ordered. On 03/10/25 at 12:00PM, R24 stated he was going to leave the dining room because he wasn't served a tray and everyone else at his table was. On 03/10/25 at 12:02PM, V11 (Certified Nurse Assistant/CNA) started talking to R24 asking him not to leave the dining room that kitchen was working on the lunch trays and that she would see if she could get R24's tray. On 03/10/25 at 12:34PM, R24 was upset and yelling out that he thinks it's crap he has been waiting so long on his food. R24 stated that everyone else at his table got food, why does he not get any food. On 03/10/25 at 12:36PM R24's tray was served. 2. R29's admission record dated 02/20/25 documents an admission date of 12/01/22, with diagnoses in part of unspecified dementia, severe, with other behavioral disturbance, anxiety disorder, and major depressive disorder recurrent. R29's MDS (Minimum Data Set) dated 12/18/24 documents in Section C a BIMS (brief interview for mental status) score of 5 which indicates severely impaired cognition. Section GG documents eating as supervision or touching assistance. Section I documents non-Alzheimer's dementia. R29's Care Plan documents a focus area of risk for malnutrition with a date initiated of 06/27/24. Interventions in part of provide supervision during meals. Another focus area of R29 (resident) has impaired cognitive function/dementia or impaired thought processes as evidenced by impaired memory, disorganized thought processes date initiated 06/27/24. Interventions include in part of cue, reorient, and supervise as needed, keep the resident's routine consistent and try to provide consistent care as much as possible in order to decrease confusion. On 03/10/25 at 12:12 PM, R29 was sitting at the table with R39. R29 took R39's lemon dessert and spoon. R29 ate all R39's dessert. R29 was the only resident at the table who did not have a plate of food. Staff was made aware that R29 ate all R39's dessert and at 12:17 PM, V11 (Certified Nursing Assistant/CNA) brought R39 another dessert. R29 did not have a plate of food yet at this time. R29 took the new dessert that R39 was served and ate all that dessert as well. Staff never intervened to stop R29 from eating R39's desserts. On 03/10/25 at 12:35PM R29 was served a plate of food. 3. R44's admission record dated 02/20/25, documents an admission date of 08/07/24, with diagnoses in part of bipolar disorder, current episode manic severe with psychotic features and other frontotemporal neurocognitive disorder. R44's MDS (Minimum Data Set) dated 02/14/25 documents in Section C a BIMS (brief interview for mental status) score of 99 which indicates severely impaired cognition. Section GG documents eating as set-up and clean-up assistance. Section I document non-Alzheimer's dementia and bipolar disorder. R44's Care Plan with a revision date of 08/20/24 documents a focus area of R44 (resident) is known to display fluctuations in mood related to dementia, bipolar disorder. Interventions include in part monitor/document/report PRN (as needed) any risk for harm to self: suicidal plan, past attempts at suicide, risky actions, stocking pills, saying goodbye to family, giving away possessions or writing a note, intentionally harmed, or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness. Focus area of R44 (resident) has impaired cognitive function/dementia or impaired thought processes as evidenced by BIMS score of 99, Dementia. Interventions include in part keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, provide a program of activities that accommodates R44's abilities. Focus area of Behavior Management with interventions of ensure the safety of R44 and others, initiate visual supervision during acute episodes, monitor for repeatedly approaching others, redirect as needed and utilize diversion techniques as needed. On 03/10/25 at 12:17PM, V13 (Licensed Practical Nurse) brought R44 over to a table in the dining room where R10 was sitting prior. R10's plate was still sitting on table in front of R44. V11 (CNA) removed R10's plate from in front of R44 but did not clean the table. R44 was observed eating the food off the table with her fingers saying how hungry she was. R44 continued to eat food remains from the table with her fingers. R44 ate all the food remains off the table. On 03/10/25 at 12:20PM, R44 started touching R39's chicken who was sitting at the table with her. R44 kept rubbing and touching all over R39's chicken while R39 was trying to eat. R39 stopped eating all together. On 03/10/25 at 12:40PM, R44 was served her tray. 4. R9's admission record dated 03/13/25, documents an admission date of 05/11/2022 with diagnoses in part of unspecified dementia, other psychotic disorder not due to a substance or known physiological condition and major depressive disorder. R9's MDS (Minimum Data Set) dated 02/06/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 8 which indicates severely impaired cognition. Section GG documents eating setup and clean-up assistance. Section K Documents no weight gain or loss. R9's care plan with a revised date of 08/16/24 documents a focus area R9 (resident) has the potential nutritional problems of weight loss r/t cognitive deficits. Interventions include in part provide, serve diet as ordered. Monitor intake and record q (every) meal. On 03/10/25 at 12:30PM, R9 was waiting on her tray and was asking where his food was. R9's tablemates were served at 12:08PM she had still not received a tray. On 03/10/25 at 12:40PM, R9's tray was served. 5. R42's admission record dated 03/13/25, documents an admission date of 07/19/24 with diagnoses in part of unspecified dementia, unspecified severity with other behavioral disturbance, altered mental status, other frontotemporal neurocognitive disorder, and personal history of traumatic brain injury. R42's MDS dated [DATE] documents in Section C a BIMS score of 99 which indicates severely impaired cognition. Section GG documents eating as supervision and touching assistance. Section I documents non-Alzheimer's dementia. R42's care plan with revision date of 07/13/24 documents a focus area of resident is usually able to perform ADL's (activities of daily living) with supervision and cues as needed. Interventions include in part eating the resident is able to feed self with supervision. Another focus area of function/dementia or impaired thought processes as evidenced by BIMS=3 r/t dementia. Interventions for this focus area include in part cue, reorient, and supervise as needed, engage the resident in simple, structured activities that avoid overly demanding tasks, and provide a program of activities that accommodates the resident's abilities. On 03/10/25 at 12:36PM, R42 was observed taking R4's plate away from her. R42 started eating off R4's plate he ate all her mashed potatoes. V11 (CNA) removed R4's plate away from R42. R42 was sitting at the same table as R4 who was served at 12:17PM. R42 was served at 12:45PM. On 03/10/25 at 12:42PM, V11 (CNA) stated that she didn't know why all the tables were not being served at the same time. V11 stated when the residents sat down at the tables, she put all of the resident dietary lunch cards together in a group so everyone at a table would be served at the same time. V11 said that she handed the kitchen the dietary cards in that order. V11 said whoever was working in the kitchen must have separated out the lunch dietary cards and they were just serving whoever they want to serve. V11 said several of the residents are getting upset because they are having to watch their tablemates eat while they wait. V11 said she doesn't know why they did this, but it is making several of the residents mad and they are wanting to leave, or they are taking other residents' food from them. On 03/10/25 at 11:50 AM through lunch service V5 (Dietary) took a group of the dietary cards rearranged them to put the regular diet cards together, the mechanical soft diets together and puree diets together and was calling to V6 (Dietary) what kind of diet he needed and would then deliver that tray to the window.

Based on observation, interview, and record review the facility failed to ensure residents with a history of weight loss or at risk for nutritional problems received ordered supplements with meals for 6 of 6 residents (R7, R12, R17, R19, R23, R35) reviewed for nutrition in a sample of 39. Findings Include: On 03/11/24 between 11:40 AM and 12:25 PM, R7, R12, R17, and R23 did not receive a health shake or a nutritional ice cream with the lunch meal. On 03/12/25 between 11:43 AM and 12:27 PM, R7, R17, R19 and R23 did not receive a nutritional ice cream with the lunch meal. 1. R23's admission record documents an admission date of 11/09/21 with diagnoses including: dementia, cerebral infarction, delusional disorders, hallucinations, vitamin D deficiency, hereditary and idiopathic neuropathy, muscle wasting and atrophy and fatigue. R23's care plan documents a focus area noting: the resident has a potential nutritional problem of weight loss r/t (relating to) CVA (cerebrovascular accident), dementia with behaviors, and delusional disorder dated 08/23/24 with interventions including: provide, serve diet as ordered dated 06/13/24 and RD (registered dietician) to evaluate and make diet change recommendations PRN ((pro re nata (as the situation demands)) dated 06/13/24. R23's Nutritional assessment dated [DATE] documents a current weight of 157.2 pounds, section titled, Evaluation of Current Weight documents: -10.48% weight loss x six months with a nutritional status stating: significant weight loss noted x 6 months. BMI (Body mass index) WNL (within normal limits) for age, BMI 23.27 normal (23.0 - 29.9). The section titled, Dietitian Nutritional Assessment documents: Due to significant weight loss and varying PO (per oral) intake will recommend to add a health shake TID (three times a day) with meals to provide additional nutrition and RD to follow up as needed. R23's Nutritional Care Form by V19 (Registered Dietician /RD) dated 01/27/25 documents: RD note (weight) January wt (weight): 147.8 # (pounds) w/ (with) significant weight loss x 1 mo (5.98%) and x 6 mo (17.8%). BMI: (body mass index) 21.82 (underweight). Diet rx (prescription): regular with PO (per oral) intake approximately 50 - 100% breakfast, approximately 50-75% lunch and approximately 75-100 % supper per Jan intake log. Meds reviewed. No new labs. No pressure injuries reported. Note 12/19/24 RD is pending. Will re-recommend and add nutritional ice cream BID (twice a day). RD to follow up PRN. Diet order change to health shake three times a day with meals and nutritional ice cream twice a day. R23's nutrition/dietary note dated 2/21/25 at 1:20 PM documents: RD note (weight review) February wt (weight) 155# with sig (significant) wt (weight) loss noted x 6 mo (months) (11.02%) BMI: 27.8%, nutritional ice cream two times a day and health shake with meals. Despite wt loss x 6 mo, wt x 1 mo is up approximately 4.87% with supplements added recently. Will only recommend to clarify (brand) of nutritional ice cream to (brand) of nutritional ice cream. R23's order summary report dated 03/13/25 documents an order dated 01/29/25 with no end date listed of nutritional ice cream two times a day and an order dated 01/29/25 with no end date listed of health shake with meals. R23's Weights and Vitals documents a weight on 2/11/25 a weight of 156.8 pounds and on 03/11/2025 of 144.3 pounds. Which documents a 7.97 % weight loss within one month. 2. R12's admission record documents an admission date of 06/13/19 with diagnoses including: Alzheimer's disease, dementia, muscle wasting and atrophy, unsteadiness on feet, and encounter for palliative care. R12's current Physician Order sheet documents an order dated 01/23/25 with no end date noted for nutritional health shake with meals. R12's care plan has a focus area of: The resident (R12) has a potential nutritional problem needs staff to feed each meal r/t (relating to) dementia, Alzheimer's disease dated 08/06/24 with an intervention listed as: provide, serve diet as ordered dated 06/13/24 and RD (registered dietician) to evaluate and make diet change recommendations PRN dated 06/13/24. 3. R19's admission record documents an admission date of 07/27/25 with diagnoses including: cerebral atherosclerosis, major depressive disorder, anxiety disorder, history of falling, moderate dementia with psychotic disturbance, peripheral vascular disease, muscle wasting and atrophy, and encounter for palliative care. R19's current Physician Order sheet documents an order dated 01/29/25 of nutritional ice cream for two times a day for breakfast and lunch with no end date documented. R19's care plan documents a focus area dated 08/14/24 documenting: the resident has unplanned/unexpected weight loss r/t (related to) dementia, and cerebral atherosclerosis with an intervention of: give the resident supplements as ordered with an initiated date of 06/13/24. 4. R7's admission record documents an admission date of 06/30/23 with diagnoses including: dementia, major depressive disorder, rheumatic aortic stenosis with insufficiency, type 2 diabetes mellitus, spinal stenosis, spondylolisthesis, muscle weakness, and age-related osteoporosis. R7's current Physician Order sheet dated 03/13/25 documents an order for nutritional ice cream one time a day with a start date of 01/30/25 with no end date noted. R7's care plan documents a focus area dated 12/16/24 documents: the resident has a potential nutritional problem r/t (relating to) dementia dated 12/17/24, change (specific brand) nutritional ice cream to (specific brand) nutritional ice cream with an intervention listed of: provide, serve diet as ordered with a date initiated of 06/13/24. 5. R17's admission record documents an admission date of 05/15/19 with diagnoses including: Alzheimer's disease, major depressive disorder, dementia, vitamin D deficiency, and vitamin B12 deficiency. R17's current Physician Order sheet dated 03/13/25 documents an order dated 01/23/25 with no end date noted documenting nutritional ice cream two times a day. R17's care plan documents a focus area indicating the resident has a potential nutritional problem of not consuming enough calories r/t dementia dated 09/09/24 with interventions listed as: provide, serve diet as ordered and RD to evaluate and make diet change recommendations PRN both dated 06/13/24. 6. R35's admission record dated 03/13/25, documents an admission date of 09/21/24 with diagnoses in part of unspecified dementia unspecify severity with other behavioral disturbance, major depressive disorder, and type 2 diabetes mellitus. R35's MDS (Minimum Data Set) dated 01/14/25 documents in Section C a BIMS (Brief Interview for Mental Status) of 12 which indicates moderately impaired cognition. Section GG eating as setup or clean-up assistance. Section K document no weight loss and no weight gain. R35's Physician Orders documents on 1/29/25 a supplement for a magic cup (nutritional ice cream) is ordered one time a day. R35's Care plan with a revised date 06/25/24 with a focus area of R35 (resident) has the potential nutritional problem. Interventions include in part provide and serve diet as ordered. On 03/11/25 at 11:57AM R35 was served her lunch tray no nutritional ice cream served with lunch tray. On 03/11/25 at 12:00PM, V8 (Activity Assistant) was reviewing R35's dietary lunch card and V8 stated that R35 should have gotten a nutritional ice cream with her lunch. V8 said that he was going to go to the kitchen window to get R35 nutrition ice cream. V8 asked the kitchen staff for the nutrition ice cream. V8 stated that the kitchen staff told him they were out of nutrition ice cream and didn't have any substitute for the ice cream. On 03/12/25 at 12:20PM, R35 was served her lunch tray no nutritional ice cream served with lunch tray. On 03/12/25 at 12:47 PM, V6 (Dietary) stated on 03/11/25 the facility did not have any health shakes or nutritional ice cream and on 03/12/25 the facility was still out of nutritional ice cream. On 03/12/25 at 1:56PM, V8 (Activity Assistant) stated that he was helping in kitchen and that they were out of nutritional supplement still. V8 said they have been without nutritional ice cream for at least 2 days. V8 said that he looked in the freezer and refrigerator himself to check to see if they have any and he said that the facility doesn't have any nutritional ice cream. V8 said that on 03/11/25 that the facility didn't have any nutritional ice cream or nutritional supplements. V8 said that they did get nutritional supplements in today, but still no nutritional ice cream. On 03/12/25 at 1:58PM V6 (Dietary) stated they didn't have any nutritional ice cream in the facility, and they had been out for 2 days now. V6 said they were also out of nutritional supplement, but that a truck came in today and they received the nutritional supplement. V6 said he didn't know when they would be getting the nutritional ice cream in. V6 said if they were going to get the nutritional ice cream, he would have thought it would have been today when the truck came in. V6 stated that he has not given the resident who are to receive nutritional ice cream or supplements any kind of nutritional substitute. On 03/13/25 at 3:30 PM, V1 (Administrator) stated, if the kitchen does not have any nutritional shakes or nutritional ice cream, they should make fortified pudding or an equal replacement to give as a substitute until they get more supplements in. On 03/17/25 at 3:27 PM, V19 (Registered Dietician) stated if the facility was out of the supplements she recommended for a resident with weight loss, she would expect them to give a substitution, for example a fortified pudding or another substitution. If the resident was to receive multiple supplements, she would want a substitution given. The facility can always call her for any recommendations if they need some. The undated facility policy titled, Nutritional/Dietary Supplements documents: Nutritional/dietary supplements are provided to residents per clinician order. The dietary department should maintain a current list of residents and their ordered supplement(s). Nursing services delivers and documents the consumption of ordered nutritional/dietary supplements on the MAR (medication administration record) per facility guidelines or state requirements. The facility policy dated 2022 titled, Unintentional Weight Loss documents: 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.

Based on interview and record review the facility failed to have a physician perform a comprehensive evaluation within 30 days post admission for 5 of 5 residents (R2, R13, R48, R49, and R102) reviewed for physicians' visits in a sample of 39. Findings include: 1.) R2's admission Record documents an admission date of 01/20/25 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, heart failure, liver cell carcinoma, anxiety disorder, major depressive disorder, anemia, and hereditary and idiopathic neuropathy. 2.) R102's admission record documents an admission date of 02/12/25 with diagnoses including neurocognitive disorder with Lewy bodies, dementia, metabolic encephalopathy, acute systolic heart failure, chronic kidney disease stage 1, chronic atrial fibrillation, and depression. 3.) R49's admission record documents an admission date of 02/07/25 neurocognitive disorder with Lewy Bodies, hyperlipidemia, and gastro-esophageal reflux disease with esophagitis. 4.) R13's admission record documents an admission date of 01/30/25 with chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, atherosclerosis of native arteries of extremities, psychosis not due to a substance or known physiological condition, schizoaffective disorder, and tobacco use. 5.) R48's admission record documents an admission date of 01/22/25 with diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, hypothyroidism, anxiety disorder, bipolar disorder, hypertension, aortic aneurysm, and diaphragmatic hernia. On 03/13/25 at 3:45 PM, V1 (Administrator) stated V21 (Medical Director) has not physically been in the building since January 15, 2025 and has not seen R2, R102, R49, R13 or R48 in person for a comprehensive admission assessment. They have all seen the nurse practitioner.

Based on interview, observation, and record review, the facility failed to ensure residents with dementia received the necessary person-centered care and services consistent with the resident goals and symptomology for 5 of 8 residents (R23, R29, R32, R42, R44) reviewed for dementia care in the sample of 39. Findings include: 1. R32's admission record dated 3/13/25, documents an admission date of 05/17/23 with a diagnosis in part of unspecified dementia, unspecified severity with agitation. R32's MDS (Minimum Data Set), dated 3/01/25, documents a BIMS (Brief Interview for Mental Status) score of 99 which indicates severely impaired cognition. Section GG document set-up and clean up assistance with eating. Section I documents non-Alzheimer's dementia. R32's Care Plan with a revised date of 09/24/24 documents a focus area of risk for malnutrition r/t (related) dementia. 09/23/24 Remeron daily as ordered. Interventions include in part: Provide supervision during meals, R32 has another focus area of resident has impaired cognitive function/dementia or impaired thought processes. Interventions include in part keep the resident routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. On 03/10/25 at 12:10PM, R153 got up from the table after he was done eating lunch leaving his plate on the table. R32 walked into the dining room and sat down at the table where R153 had been eating at. R32 started to eat off the plate that R153 left on the table. R32 ate the rest of R153's chicken and mashed potatoes. V11 (Certified Nurse Assistant/CNA) took R153's plate away from R32 and told him that he couldn't eat that. V11 asked R32 if he ate the food on R153's plate and he answered yes. On 03/10/25 at 12:35PM, R32 was served his lunch plate. 2. R29's admission record dated 02/20/25, documents an admission date of 12/01/22, with diagnoses in part of unspecified dementia, severe, with other behavioral disturbance, anxiety disorder, and major depressive disorder recurrent. R29's MDS (Minimum Data Set) dated 12/18/24 documents in Section C a BIMS score of 5 which indicates severely impaired cognition. Section GG documents eating as supervision or touching assistance. Section I documents non-Alzheimer's dementia. R29's Care Plan documents a focus area of risk for malnutrition with a date initiated of 06/27/24. Interventions in part of provide supervision during meals. Another focus area of R29 (resident) has impaired cognitive function/dementia or impaired thought processes as evidenced by impaired memory, disorganized thought processes date initiated 06/27/24. Interventions include in part of cue, reorient, and supervise as needed, keep the resident's routine consistent and try to provide consistent care as much as possible in order to decrease confusion. On 03/10/25 at 12:12PM, R29 was sitting at the table with R39. R29 took R39's lemon dessert and spoon. R29 ate all R39's dessert. R29 was the only resident at the table who did not have a plate of food. Staff was made aware that R29 ate all R39's dessert and at 12:17PM staff brought R39 another dessert. R29 did not have a plate of food yet at this time. R29 took the new dessert that R39 was served and ate all that dessert as well. Staff never intervened to stop R29 from eating R39's desserts. On 03/10/25 at 12:35PM, R29 was served a plate of food. 3. R44's admission record dated 02/20/25, documents an admission date of 08/07/24, with diagnoses in part of bipolar disorder, current episode manic severe with psychotic features and other frontotemporal neurocognitive disorder. R44's MDS (Minimum Data Set) dated 02/14/25 documents in Section C a BIMS score of 99 which indicates severely impaired cognition. Section GG documents eating as set-up and clean-up assistance. Section I document non-Alzheimer's dementia and bipolar disorder. R44's Care Plan with a revision date of 08/20/24 documents a focus area of resident is known to display fluctuations in mood related to dementia, bipolar disorder. Interventions include in part monitor/document/report PRN (as needed) any risk for harm to self: suicidal plan, past attempts at suicide, risky actions, stocking pills, saying goodbye to family, giving away possessions or writing a note, intentionally harmed, or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness. Focus area of resident has impaired cognitive function/dementia or impaired thought processes as evidenced by BIMS score of 99, Dementia. Interventions include in part keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, provide a program of activities that accommodates (R44's) abilities. Focus area of Behavior Management with interventions of ensure the safety of (R44) and others, initiate visual supervision during acute episodes, monitor for repeatedly approaching others, redirect as needed and utilize diversion techniques as needed. On 03/10/25 at 12:20PM, R44 started touching R39's chicken. R44 kept rubbing and touching all over R39's chicken while R39 was trying to eat. R39 stopped eating all together. On 03/12/25 at 1:45PM, R44 was in the dining room sitting at the table with R35. No staff present in the dining room. R44 kept touching R35's arm. R35 told R44 to leave her alone and stop touching her that she wasn't in the mood for it today. R35 told R44 not to touch her again she wasn't kidding. R44 continued to touch and talk to R35 telling her how beautiful she was and kept touching her face and rubbing R35's arm. R35 told R44 to stop messing around and asked R44 if she wanted to fight. R44 responded That would be a good thing. R35 then responded with I don't think so. On 3/12/25 at 1:50PM, R44 got up from the dining room table and started to walk toward the hallway trying to get in other resident's rooms. R44 then went back into the dining room and sat next to R35 again touching R35's arm and trying to rub her face. On 03/10/25 at 12:17PM, (V13 Licensed Practical Nurse/LPN) brought R44 over to a table in the dining room where R10 was sitting prior. R10's plate was still sitting on the table in front of R44. V11 (Certified Nursing Assistant/CNA) removed R10's plate from the table in front of R44, but did not clean the table. R44 was observed eating the food off the table with her fingers saying how hungry she was. R44 continued to eat food remains from the table with her fingers. R44 ate all the food remains off the table. On 03/12/25 at 2:00PM, V12 (LPN) stated that R44 is not on one on ones. V12 was not aware that R44 was in the dining room with R35. V12 said that none of the residents have any special intervention on the dementia care unit. V12 stated that no resident on the dementia care unit has any individualized care plans either. V12 said that they do the best they care with what they have to work with. V12 said she was going to send someone to the dining room to get R44 so that R35 didn't do anything to her. V12 said a lot of the residents on the dementia care unit have behaviors, and they just do what they can. On 03/12/25 at 2:05PM unknown staff went and got R44 from the dining room and sat R44 by the nurse's station. R44 started to touch R1 getting in her face telling R1 she was beautiful and hugging all over her. Unknown staff removed R44 from R1's personal space. R44 kept getting up close to several other residents. Unknown staff just kept moving her away from the other residents. No other interventions tried at that time other than redirection. R44's progress note dated 03/08/25 by V12 (Licensed Practical Nurse/LPN) documents, (R44) up, grabbing food and drinks out of peers hands. Staff unable to redirect. (R44) keeps going up to peers that are asking her to stop! and go away! (R44) needs to have 1:1 intervention when awake to keep her from getting hurt by her peers. CNA staff must stay right with her to keep her from agitating peers and them lash out at her. Very difficult for staff to keep this resident safe from peers when she is awake. Progress note dated 03/12/25 by V12 (LPN) documents (R44) is up, keeps touching peers and getting in their personal space. Very difficult to redirect. (R44) will not follow request by peers to back up or to stop touching me. Staff has to keep redirecting her away from peers. (R44) keeps going right back to getting in her peers' space. Received all scheduled meds per MAR (Medication Administration Record) with some difficulty. No s/s (signs and symptoms) of distress or discomfort observed. 4. R23's admission record dated 03/13/25, documents an admission date of 11/09/21 with diagnoses in part of unspecified dementia severe with other behavioral disturbance, delusional disorder, and other hallucinations. R23's MDS (Minimum Data Set) dated 02/01/25, documents in Section C a BIMS should not be attempted related to resident is rarely/never understood. Staff assessment documents short- and long-term memory problems. Section GG documents sit to stand as partial/moderate assistance and walking as supervision or touching assistance. Section I documents non-Alzheimer's dementia. R23's Care Plan with a revision date of 08/16/24 with a focus of resident has behavior problems r/t dementia, hallucinations, delusional disorder, amnesia. Interventions include in part anticipate and meet the resident's needs, intervene as necessary to protect the right and safety of others, approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed and provide a program of activities that is of interest and accommodates resident's status. On 03/11/25 at 11:30AM, R23 was found lying in R29's bed asleep. R29 was sitting in her room in her recliner. V13 (LPN) and an unknown (CNA) was sitting up at nurse's station and was asked if that was R23 in R29's bed. V13 answered it could be. On 03/11/25 at 11:45AM, R23 was still laying in R29's bed. 5. R42's admission record dated 03/13/25, documents an admission date of 07/19/24 with diagnoses in part of unspecified dementia, unspecified severity with other behavioral disturbance, altered mental status, other frontotemporal neurocognitive disorder, and personal history of traumatic brain injury. R42's MDS dated [DATE] documents in Section C a BIMS score of 99 which indicates severely impaired cognition. Section GG documents eating as supervision and touching assistance. Section I documents non-Alzheimer's dementia. R42's care plan with revision date of 07/13/25 documents a focus area of resident is usually able to perform ADL's (activities of daily living) with supervision and cues as needed. Interventions include in part eating the resident is able to feed self with supervision. Another focus area of function/dementia or impaired thought processes as evidenced by BIMS=3 r/t dementia. Interventions for this focus area include in part cue, reorient, and supervise as needed, engage the resident in simple, structured activities that avoid overly demanding tasks, and provide a program of activities that accommodates the resident's abilities. On 03/10/25 at 12:36PM, R42 was observed taking R4's plate away from her. R42 started eating off R4's plate and he ate all of her mashed potatoes. V11 (CNA) removed R4's plate away from R42. R42 was sitting at the same table as R4 who was served at 12:17PM. R42 was not served until 12:45PM. On 03/12/25 at 1:57PM, V17 (CNA) stated that they do not do any one on one's with any residents. V17 said that she was not aware of any individualized care plans for any resident. V17 stated when a resident has a behavior she tries to redirect if she can. V17 said that she is not aware of any special activities that they do for the residents. On 03/12/25 at 1:59PM, V18 (CNA) stated that they do not do one on ones for any residents on the dementia care unit. V18 said that when a resident has a behavior that they redirect the resident when they can. On 03/13/25 at 1:00PM, V7 (MDS Coordinator) stated that none of the dementia care residents have individualized dementia care plans. V7 said all the dementia care plans are just basic care plan that they aren't individualized for each dementia resident's needs. V7 asked if she should be doing individualized care plans for each dementia resident. V7 said she would do what she could to help divert behaviors or mood problems. V7 said she knew nothing about doing the individualized care plans, but that she would work on it. On 03/13/25 at 2:30PM, V14 (Activity Director) stated that all the residents at the facility have the same activities. V14 said that the dementia care unit does not have separate activities from the other unit. V14 said that she will take the other residents over to the locked unit for activities. V14 said that she doesn't have individualized activities just for the residents with dementia. V14 said that she does try to involve all the residents in the activities but sometimes the residents on the dementia unit all will get up and leave. V14 stated that she has stuff on the dementia care side that residents can do but that the staff on the dementia side won't ever do the activities with the residents. V14 said that when a resident has a behavior or mood problems that all the certified nurse assistants do is redirect the resident. V14 said that the certified nursing staff will not do any activities with the residents to see if that will help the behaviors. V14 said the certified staff will redirect the resident or sit them at the nurse's station. V14 said that when a resident is having a behavior, or they are having problem with a resident the certified staff will try to come get her or the activity assistant. V14 said they might be in the middle of an activity or something and the certified staff won't doing anything with the resident they want me or my assistant to help take care of the behavior. V14 said that certified staff could be doing something with the residents to such as an activity to see if it helps the behavior, but they won't. On 03/13/25 at 2:35PM, V8 (Activity Assistant) stated that the certified nursing staff from the dementia care locked unit will try to come get him when a resident is having a behavior. V8 said they will come get me and see if I will go over to do an activity with the resident or see if I can help with the resident behavior. V8 said that he might be busy and if he is that none of the staff will do anything to help the resident with the behavior, they just wait for him or redirect the resident. V8 said that the certified nursing staff could do an activity with the resident the same as he could, but they don't think that is their job. On 03/13/25 at 2:47PM, V15 (Social Service Director/SSD) stated that she doesn't know of any extra things they do for the dementia care unit residents. V15 said that she doesn't know if the dementia care residents have any individualized care plans. V15 said that if they did that V7 (MDS) would know. V15 said that she doesn't know of anything special they do for the dementia care residents on the locked unit. V15 stated that they need to do more individualized care with the dementia care residents to help with their behaviors, but she said that they would need more staff to be able to do that. On 03/13/25 at 2:57PM, V16 (CNA) stated that they have not received any special training on dementia care residents. V16 said he has worked at the facility for 6 months. V16 stated they don't do anything special with the residents on the dementia care unit. V16 said he is not aware of any activity supplies that are available for them to use to help divert residents' behaviors. V16 said they just try to redirect resident when they can and then chart the behavior. V16 said that other places he has worked use to do the training on dementia care. V16 said that he notices the residents have more behaviors in the evening time. V16 said that they usually will try to redirect the resident or put them up at the nurse's station or turn on the television for them. V16 said that sometime when they pass out snacks that will help the resident behaviors. On 03/13/25 at 3:26pm, V2 (Director of Nursing) stated she was not sure about individualized interventions or activities for residents with dementia or if they are care planned for them, that would be a question for activities or the care plan nurse. V2 stated that staff recently had completed the dementia live training with one of the hospice groups. The facilities policy titled Dementia Unit Admission/discharge Criteria and Program documents, The dementia unit, housed in a wing of this facility, addresses special needs of individuals with dementia who could possibly pose a risk to themselves outside of a secured unit. The goal of this program is to provide a safe environment for the individual, while offering activities that support the best quality of life possible. The program will offer a person-centered approach. Person centered care encompasses four major elements, and these are identified as the core values of this unit. A value base that asserts the absolute value of all human lives regardless of age and cognitive ability, an individualized approach, recognizing uniqueness, understanding the world from a perspective of the service user, providing a social environment that supports psychosocial needs. In order to assure the best possible outcome, a team consisting of the Director of Nursing, Director of Social Service, Director of Activities, Nursing staff (which may be RN (Registered Nurse), LPN, QMA (Qualified Medication Aide) and CNA), medical director, psychiatric nurse practitioner, and counseling consult will work together to develop plans of care that allow the resident to experience the best quality of life possible. admission Guidelines for Dementia Unit document in part, The secured dementia unit exists to provide residents with the cognitive or Alzheimer's/Dementia related diagnosis a safe and comfortable environment where staff has been trained to care for their special needs.

Based on interview, observation, and record review the facility failed to process the returning and/or destroying of unused medication for 4 of 4 (R12, R16, R32, R156) residents reviewed for medications storage in the sample of 39. Findings include: 1. R32's admission record dated 3/13/25, documents an admission date of 05/17/23 with a diagnosis in part of unspecified dementia, unspecified severity with agitation. R32's Physician orders documents order for Ipratr-albuter 0.5mg (milligrams)-3mg/ml (milliliters) ordered on 01/10/24. On 03/12/25 at 9:45AM, R32 had an open box of ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5mg/3mg/3ml in the medication room refrigerator that expired on 02/2025. 2. R156's admission record dated 03/13/25, documents an admission date of 01/14/2019 and a discharge date of 02/25/25 with diagnoses in part of Alzheimer's, Dementia severe with other behavior disturbances, anemia, and hyponatremia. R156's Immunization record documents no Shingrix vaccine was given to R156. On 03/12/25 at 10:30AM there was a Shingrix vial kit 50mcg (micrograms)/0.5ml vial in medication refrigerator with an expiration date of 10/02/23 with R156's name on it. 3. R16's admission record dated 03/13/25, documents an admission date of 08/02/22 with diagnoses in part of chronic obstructive pulmonary disease, cerebral infarction, Crohn's disease, seizures, white matter disease, solitary pulmonary nodule, and personal history of malignant neoplasm of ovary. R16's immunization record documents on 09/08/22 one dose of Shingrix was given to R16. On 03/12/25 at 10:30AM, R16's Shingrix vial kit 50mcg (micrograms)/0.5ml vial second dose was in medication refrigerator with an expiration date of 10/06/23. 4. R12's admission record dated 03/13/25, documents an admission date of 06/13/2019 with diagnoses in part of Alzheimer's, dementia, and encounter for palliative care. R12's immunization record documents on 09/11/22 one dose of Shingrix vaccine was given to R12. On 03/12/25 at 10:30AM, R12's Shingrix vial kit 50mcg (micrograms)/0.5ml vial second dose was in medication refrigerator with an expiration date of 10/06/23. 5. On 03/12/25 at 10:30AM the medication refrigerator had Vaxneuvance 0.5ml syringes (stock) order date 10/15/22 with an expiration 11/30/22, Stock Pneumovax 23 vials 0.5ml 2 vials expired 05/06/24, and Stock Prevnar 20 syringes 0.5ml expired 02/28/25. On 03/12/25 at 10:40AM, V2 (Director of Nursing) stated that pharmacy checks their medications for any medications that are expired. V2 said that pharmacy was in not too long ago and checked the refrigerator and carts for expired medication and gave her a report stating that no expired medications were found. V2 stated that she was going to have the expired medication that were found taken care of either sent back or destroyed. On 03/13/25 at 10:45AM, V20 (Licensed Practical Nurse/LPN) stated that pharmacy comes in and checks the medication carts and medication refrigerator often for expired meds. V20 stated that V2 gave her the last pharmacy check dated 01/16/25 and it doesn't show any expired refrigerated meds. A paper with a handwritten date of 01/16/25 with facility pharmacies name titles General medication storage Audit documents there was no check mark next to expired refrigerated meds are not present. The facility policy titled Disposal/Destruction of Expired or Discontinued Medication with a revision date of 07/10/24 documents under procedure: 4. Facility should place all discontinued or outdated medications in a designated, secure location which solely for discontinued medication or marked to identify the medication are discontinued and subject to destruction. 7. Facility should dispose of discontinued medications, outdated medications, or medications left in facility after a resident has been discharged or deceased , in a timely fashion, no more then 90-days of the date the medication was discontinued by physician/prescriber, or sooner per applicable law.

Based on observation, interview, and record review the facility failed to follow the approved menu for portion sizes and items to be served for 8 of 21 residents (R2, R5, R7, R10, R11, R12, R14, R44) reviewed for dining in the sample of 39. Findings include: 1. On 03/10/25 between 11:50 AM and 12:15 PM while observing the plating of the lunch meal R5, R7, R10, and R44 were served a number 12 scoop (2 2/3 ounces) of ground chicken. The facility document titled Diet Spreadsheet documents day 16 Monday dental soft (mech (mechanical) soft) ground fried chicken w/ (with) gravy #8 dipper (4 ounces). R7's current Physician Orders dated 03/13/25 documents an order for regular diet with mechanical soft texture with an order date of 01/23/25. R5's current Physician Orders dated 03/13/25 documents an order dated 01/29/25 of CCD (controlled carb (carbohydrate) diet), mechanical soft texture with a start date of 01/29/25 and no end date listed. R10's current Physician Orders dated 03/13/25 documents an order dated 01/29/25 with no end dated listed of regular diet, mechanical soft texture. R44's current Physician Orders dated 02/20/25 documents an order dated 01/23/25 listing regular diet, mechanical soft texture. 2. On 03/10/25 between 11:45 AM and 12:25 PM no residents were served margarine during the lunch meal. The facility's document titled, Diet Spreadsheet documents day 16 Monday lists: regular diet: cornbread/margarine 3 x 2-1/2 svg (serving)/1 tsp (teaspoon), dental soft (mech soft) cornbread/margarine 3 x 2-1/2 svg (serving)/1 tsp (teaspoon), pureed: pureed cornbread/margarine #10 scoop/1 tsp. On 03/11/25 between 11:40 AM and 12:13 PM no residents were served margarine during the lunch meal. The facility document titled, Diet Spreadsheet documents day 17 Tuesday lists: regular diet: bread/margarine 1 slice/1 tsp (teaspoon), dental soft (mech soft) bread/margarine 1 slice/1 tsp, CCHO (LCS) (consistent carbohydrate (low concentrate sweets)) 1 slice/1 tsp. On 03/12/25 between 11:45 AM and 12:27 PM no residents were served margarine during the lunch meal. The facility document titled, Diet Spreadsheet documents day 18 Wednesday lists: regular diet: dinner roll/margarine 1 each/1 tsp (teaspoon), dental soft (mech soft) soft dinner roll/margarine 1 each/1 tsp, CCHO (LCS) (consistent carbohydrate (low concentrate sweets)) dinner roll/margarine 1 each/1 tsp. On 03/13/25 at 10:17 AM, R11 stated she would like butter with her bread and cornbread. R11 was alert and oriented to person, place, and time. On 03/13/25 at 11:22 AM, R14 stated he would like butter with his bread, cornbread, and other items. R14's was alert to person, place, and time. On 03/13/25 at 11:26 AM, R10 stated he would like butter with his bread and cornbread. R10's MDS (Minimum Data Set) dated 01/22/25 documents a BIMS (Brief Interview for Mental Status) score of 12 indicating he is moderately cognitively intact. On 03/13/25 at 11:24 AM, R2 stated he would like butter with his bread, cornbread, and other items. R2's MDS dated [DATE] documents a BIMS score of 13 indicating he is cognitively intact. On 03/13/25 at 11:35 AM, R12 stated she would like butter with her bread and cornbread. R12's MDS dated [DATE] documents a BIMS score of 12 indicating she is moderately cognitively intact. On 03/13/25 at 3:13 PM, V1 (Administrator) stated, residents should be served the portion size indicated on the spreadsheet. The undated facility policy titled, Portion Control documents: 2. Serve portions according to the menu spreadsheet 3. Use scoops, spoodles, ladles, and scales to serve proper menu portions on the tray line.

Based on observation, interview, and record review the facility failed to have assessments and/or physician's orders for lap restraints for 2 (R12 and R19) of 2 residents reviewed for restraints in a sample of 39. Findings include: 1. R12's admission record documents an admission date of 06/13/19 with diagnoses including: Alzheimer's disease, dementia, muscle wasting and atrophy, unsteadiness on feet, and encounter for palliative care. R12's order summary report dated 03/13/25 does not document any order for a lap cushion. R12's current care plan does not document a focus area documenting a lap cushion. R12's hospice team visitation log dated 10/15/24 documents problem/intervention/goal: leans forward in wheelchair/lap cushion when up in wheelchair/pt (patient) will not fall out of wheelchair. 2. R19's admission record documents an admission date of 07/27/24 with diagnoses including: cerebral atherosclerosis, major depressive disorder, anxiety disorder, history of falling, moderate dementia with psychotic disturbance, peripheral vascular disease, muscle wasting and atrophy, and encounter for palliative care. R19's order report documents an order dated 03/13/25 of lap cushion while up in wheelchair for positioning. R19's care plan documents a focus area dated 12/13/24 of resident (R19) does not understand mobility limits due to cognitive limitations. Fall mat at bedside, with an intervention with a date initiated of 11/01/24 with a revision date of 01/03/25 of lap cushion to assist in position maintenance. R19 hospice team visitation log dated 07/25/24 documents problem/intervention/goal: high fall risk, leans forward when in wheelchair/lap cushion when up in wheelchair/pt (patient) will not have any falls. On 03/13/25 at 8:45 AM, V1 (Administrator) stated, they do not have any assessments for R12 and R19's lap cushion. She believes they were both initiated as fall interventions for R12 and R19. On 03/12/25 at 12:10 PM, R12 and R19 were being assisted with lunch and they both had lap restraints intact. On 03/13/25 from 11:45 AM to 12:15 PM, V19 was being assisted with lunch with her lap restraints intact. On 03/13/25 at 12:07 PM, V9 (Certified Nurse Assistant) stated, R19 should have her lap restraint removed during meals. V9 stated R19 would not be able to remove the lap restraint if she was asked to do so. The facility policy dated 05/24/18 titled, Restraints documents: 1. residents that are admitted with a physician's order for restraint use shall have a restraint use assessment performed and a physician order obtained for the release of restraints with supervision during the assessment process, as appropriate, or an order to discontinue use. 2 periodic assessments shall address the resident's status in an effort to reduce or eliminate restraints whenever possible and assure the restrictive method is used which allows the resident to function at their highest practicable level. 3 the use of restraints will be reviewed by the interdisciplinary team periodically and at least quarterly thereafter. 4 restraint assessments are performed at a minimum with the initial application, change in type of restraint and change in the resident's condition which affects how the resident responds to current treatment.

Based on interview and record review the facility failed to perform fall risk assessments timely and implement effective interventions to prevent falls for 1 of 6 residents (R17) reviewed for falls in a sample of 39. Findings include: R17's admission record documents an admission date of 05/15/19, with the following diagnoses in part, Alzheimer's disease, unspecified dementia, unspecified severity, with other behavioral disturbances. R17's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 99, indicating R17 was unable to complete interview. Fall investigation dated 12/23/24 documents R17 was being walked to the dining room with 2 CNAs (Certified Nursing Assistants). This fall investigation documents the following interventions were implemented, Frequent reminders to have help and assist with ambulation when needed. Fall investigations dated 02/13/25 and 02/22/25 for R17 documents no new interventions were implemented. R17's most recent fall risk assessment is dated 12/23, with no year documented. This assessment documents that R17 is at high risk for falls. R17's old care plan documents an intervention dated 05/23/24 as the most recent fall intervention. R17's current care plan, located in her electronic medical record, documents five fall interventions, all with an initiation date of 03/10/25. On 03/13/25 at 11:18am, V7 (MDS/Care Plan Coordinator) stated interventions should be listed on the care plan, that is the only place it would be. V7 stated the interventions listed on the fall investigation report for R17 from 12/23/24 were not appropriate interventions. On 03/13/25 at 2:17pm, V2 (Director of Nurses) stated she did not see any interventions for R17's falls on 02/13/25 and 02/22/25 anywhere in the medical record. V2 stated she was not sure why there was 5 interventions dated for 03/10/25, because there was no reason for her to have had 5 interventions with that initiation date. V2 stated that the most recent fall risk assessment they had for R17 was from 12/23/24. V2 stated that interventions of frequent reminders to have help and assist with ambulation as needed for V17's fall on 12/23/24 would not be appropriate interventions for a fall that occurred while she was being assisted by two staff members with ambulation. Facility Policy titled Fall Prevention Program with a revision date of 11/21/17 documents the following: A Fall Risk Assessment will be performed at least quarterly, and with each significant change in mental or functional condition and after any fall incident . Accident/Incident reports involving falls will be reviewed by the Interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions.

Based on observation, interview, and record review the facility failed to ensure that tables were properly cleaned and sanitized, prior to residents eating on them for 3 of 16 (R32, R41, and R44) reviewed for dining in the sample of 39. Findings include: 1. R32's admission record dated 3/13/25, documents an admission date of 05/17/23 with a diagnosis in part of unspecified dementia, unspecified severity with agitation. R32's MDS (Minimum Data Set), dated 3/01/25, documents a BIMS (Brief Interview for Mental Status) score of 99 which indicates severely impaired cognition. Section GG document set-up and clean up assistance with eating. Section I documents non-Alzheimer's dementia. On 03/10/25 at 12:10PM, R153 got up from the table after he was done eating leaving his plate on the table. R32 walked into the dining room and sat down at the table spot that R153 had been eating at. R32 started to eat off the plate that R153 left on the table. R32 ate the rest of R153's chicken and mashed potatoes. V11 (Certified Nurse Assistant/CNA) took R153's plate away from R32 and told him that he couldn't eat that. V11 asked R32 if he ate the food on R153's plate and he answered yes. Table area where R32 sat down at was soiled with food. No staff observed cleaning or sanitizing table area. On 03/10/25 at 12:35PM, R32 was served his plate over top of food soiled table. 2. R44's admission record dated 02/20/25, documents an admission date of 08/07/24, with diagnoses in part of bipolar disorder, current episode manic severe with psychotic features and other frontotemporal neurocognitive disorder. R44's MDS (Minimum Data Set) dated 02/14/25 documents in Section C a BIMS score of 99 which indicates severely impaired cognition. Section GG documents eating as set-up and clean-up assistance. Section I document non-Alzheimer's dementia and bipolar disorder. On 03/10/25 at 12:17PM, V13 (Licensed Practical Nurse) brought R44 over to a table in the dining room where R10 was sitting prior. R10's plate was still sitting on table in front of R44. V11 (CNA) removed R10's plate from in front of R44 but did not clean the table. R44 was observed eating the food off the table with her fingers saying how hunger she was. R44 continued to eat food remains from the table with her fingers. R44 ate all the food remains off the table. On 03/10/25 at 12:40PM R44 was served her tray. The table was still soiled with food no staff cleaned or sanitized table prior to delivering tray or after tray was delivered. 3. R41's admission record dated 03/13/25, documents an admission date of 12/04/24 with diagnoses in part of unspecified dementia with agitation, Wernicke's encephalopathy, convulsions, and anxiety. R41's MDS (Minimum Data Set) dated 12/23/24 documents a BIMS score of 99. Section GG documents eating as supervision and clean-up assistance. On 03/12/25 at 11:50AM, R41 sat down at a table where someone else was sitting and eating at prior. R41 was trying to eat off the plate that was sitting on the table. R41's table area was soiled with food. On 03/12/25 at 11:52AM, V8 (Activity Assistant) removed the plate from R41. V8 took the dirty plate away from the table and placed the plate in the dirty dish area. V8 did not wipe the table off. On 03/12/25 at 12:00PM, R41's tray was served over top of soiled food table. No staff cleaned or sanitized table prior to place plate on table. On 03/10/25 at 12:42PM, V11 (CNA) stated that all tables should be wiped down and sanitized before a resident sits down to eat. V11 said that anytime a resident sits down to eat that the area should be cleaned for the next resident. On 03/12/25 at 1:56PM, V8 (Activity Assistant) stated that all table should be wiped down and clean prior to any resident sitting down to eat. On 03/12/25 at 1:58PM, V6 (Dietary Aide) stated that all tables should be cleaned and sanitized prior to any resident sitting down to eat. V6 said that if another resident was sitting at the spot another resident wants to sit at then that spot should be cleaned prior to them sitting down and the food removed from the table. The facility policy titled Resident Dining Services under procedures 11. Staff should clean and sanitize dining room tables after resident leaves table.

Based on observation, interview, and record review the facility failed to provide Enhanced Barrier Precautions according to professional standards of practice for 3 out of 3 residents (R13, R22, R38) reviewed for infection control in a sample of 39. Findings include: 1. R38's admission record documents an admission date of 12/24/24 with the following diagnoses in part, local infection of the skin and subcutaneous tissue and necrotizing fasciitis. R38's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 15, indicating R38 is cognitively intact. R38's Order Summary Sheet dated 03/13/25 documents the following active treatment orders; Wound Cleansing Site: Cleanse BLE (Bilateral Lower Extremities) with saline. Apply xeroform, cover with calcium alginate, ABD (abdominal) pad and wrap with gauze, every day shift related to necrotizing fasciitis. Wound Cleansing Site: Cleanse left heel with normal saline or sterile water, apply calcium alginate, and cover with dry dressing every day shift for food wound. R38's medical record, including care plan, does not include measures to put enhanced barrier precautions in place. On 03/10/25 at 10:50am, No enhanced barrier precautions posted on or around R38's door. No PPE (Personal Protective Equipment) observed near R38's door. On 03/10/25 at 12:24 PM, No enhanced barrier precautions posted on or around R38's door. No PPE observed near R38's door. On 03/11/25 at 11:04AM, No enhanced barrier precautions posted on or around R38's door. No PPE observed near R38's door. On 03/12/25 at 8:47AM, No enhanced barrier precautions posted on or around R38's door. No PPE observed near R38's door. 2. R22's admission record documents an admission date of 09/10/24 with the following diagnosis in part, Idiopathic aseptic necrosis of unspecified toe(s). R22's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 13, indicating R22 is cognitively intact. R22's Order Summary Sheet dated 03/13/25 documents the following active treatment orders; Wound cleansing site: Left lateral calf and left anterior knee. And R (right) forearm. Wipe with skim prep daily every day shift for skin tear. Wound cleansing site: Left lateral calf and R forearm. Wipe with skin prep daily every day shift for skin tear. R22's medical record, including care plan, does not include measures to put enhanced barrier precautions in place. 3. R13's admission record documents an admission date of 01/30/25 with the following diagnosis in part, unspecified atherosclerosis of native arteries of extremities, unspecified extremity. R13's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 13, indicating R13 is cognitively intact. R13's Order Summary Sheet dated 03/13/25 documents the following active treatment order; Betadine surgical scrub external solution (Povidone-Iodine). Apply to bilat (bilateral) feet topically one time a day every Mon, Wed, Fri for post amputation bilat feet through metatarsal bone. Apply betadine wet to dry to bilat surgical sites on feet, cover with Adaptec, 4x4, kerlix, cast padding and ace wrap. R38's medical record, including care plan, does not include any enhanced barrier precautions in place. On 03/12/25 at 10:00AM, V20 (Licensed Practical Nurse/LPN) asked what kind of trash bag she needed for the wound trash. V20 stated she didn't know what kind of trash bag she needed, if she needed a regular bag or a red biohazard bag. V20 said that R38 is not on enhanced barrier precautions, she didn't know what enhanced barrier precautions were. V20 stated none of her residents are on enhanced barrier precautions. On 03/12/25 at 10:20am, V1 (Administrator) stated that she didn't know what enhanced barrier precautions was and that she didn't have anyone in the facility that was on enhanced barrier precautions. V1 stated she didn't know that resident with wounds, urinary catheters, feeding tube, central lines and tracheostomy requires any special precautions. She said that they just use standard precautions for all residents. On 03/12/25 at 10:25am, V2 (Director of Nursing/DON) stated that she did not know anything about enhanced barrier precautions and that they didn't have anyone at the facility that was on enhanced barrier precautions. She said that she would look up the enhanced barrier precautions and put it in place. On 03/12/25 at 1:43PM, isolation bins were observed outside of R13, R22, and R38's doors and enhanced barrier precaution signs were also posted. On 03/12/25 at 3:45PM, V2 stated that they did put up enhanced barrier signs and PPE on R13, R22 and R38's rooms. V2 stated those are the only resident that would need enhanced barrier precautions related to wounds. V2 stated that no other resident in the facility qualifies for enhanced barrier precautions. Facility policy titled Enhanced Barrier Precautions, with a revision date of 05/07/24 documents that enhanced barrier precautions are indicated for residents with chronic wounds.

Based on interview and record review the facility failed to maintain/offer influenza vaccinations for one (R34) resident of 5 residents reviewed for immunizations in a sample of 39. Findings include: R34's admission Record documents an admission date of 09/12/24 with diagnoses including Parkinson's disease, dementia, major depressive disorder, anxiety disorder, and cognitive communication deficit. R34's Minimum Data Set, dated [DATE] documents a brief interview of mental status score of 99 indicating resident was unable to complete the interview. R34's current Physician's orders dated 03/17/25 documents an order stating: immunization: may have annual flu vaccine with consent unless contraindicated with an order date 09/16/2024 with no start date or end date noted. R34's electronic medical record does not contain any documentation that R34 received an influenza vaccination in 2024, nor does it contain documentation that R34 was offered the vaccine or refused. On 03/11/25 at 3:30 PM, V2 (Director of Nursing) stated, she does not have any information for R34's influenza vaccination for 2024. V2 stated the only information she could find was where he received his influenza vaccination on 08/24/23. V2 stated most of the residents received the vaccination in October 2024, she does not know why he did not receive his then.