Every finding on record at Axiom Gardens of Nashville

Based on observation, interview, and record review, the facility failed to provide services in a manner which prevented elopement for 2 of 3 residents (R2 and R3) reviewed for safety/elopement in a sample of 12. This failure resulted in R2 exiting the locked memory care unit and observed outside the facility for an undetermined amount of time on 04/26/26 and R3 leaving the designated outdoor smoking area with no staff knowledge or supervision, walking a couple of blocks up the road and out of sight of the facility on 04/28/26. The Immediate Jeopardy began on 04/26/26 when the facility failed to provide services in a manner to prevent elopement for R2 and R3. This failure resulted in 1) R2 exiting the locked memory care unit and being observed outside the facility, unknown to staff; 2) R3 leaving the designated outside smoking area and found walking a couple of blocks away, without staff knowledge, in an areaobserved as being an active residential neighborhood with vehicles utilizing the roadway and no sidewalks. R3 was walking in the road, putting him at risk for preventable injuries and heading toward the main highway (a heavily trafficked roadway about 0.5 miles away). V1, Administrator, V2, Director of Nursing (DON), and V8, Social Services, were notified of the Immediate Jeopardy on 05/28/26 at 1:30 PM. The immediate jeopardy that began on 04/26/26 was not removed at the time of the survey exit because the facility failed to ensure R3 did not have access to the code for the 500-hall patio door and R3 was seen unsupervised by staff while outside on 06/01/26 from 1:00 PM-1:30 PM. Findings Include:1. R2's Face Sheet, admission date of 10/15/25, documents R2 has diagnoses of but not limited to Wernicke's Encephalopathy and alcohol dependence with alcohol induced persisting dementia. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is severely cognitively impaired (resident is rarely/never understood) and she requires substantial/maximal assistance or is dependent on staff for most of her activities of daily living (ADLs). R2's Care Plan, admission date of 10/15/25, documents R2 is an elopement risk/wanderer. She requires a wander guard r/t (related to) exit seeking, history of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on privacy or activities. Interventions include but are not limited to Staff to monitor location. Redirect R3 away from doors and from going outside of the facility. Report to hall nurse, DON (Director of Nursing), and administrator if resident leaves facility through a door. It also documents R2 has a Cognitive deficit- forgetful, difficulty with decisions, can say a few words, dementia, Communication deficit r/t dementia, aphasic (impaired ability to speak) at times. It also documents that R2 is at risk for personal injury r/t lack of regard for own safety. R2's Elopement Risk Assessment, dated 01/22/26, documents R2 is not sufficiently alert, oriented, coherent, or knowledgeable allowing him/her to be considered for independent outside privileges. R2 is not able to verbalize how to move/navigate/negotiate safely on community streets, she doesn't know the facility name incase of an emergency, doesn't know how to ask for/seek help in an emergent or problematic situation, is unable to verbalize understanding of potentially dangerous situations, such as walking alone after dark, straying into an alley, accepting rides from strangers, and she can't safely maneuver in community and isn't without debilitating physical impairment making her unsafe. It also documents that R2 has safety risks. R2 is at risk of eloping and should be placed on the elopement risk protocol. Rational for decisions: R2 was placed on the locked unit on 11/25/25 and has been doing well in that hall. R2 will attempt to exit seek off that hall but is easily re-directed. R2's Progress Notes, dated 4/26/2026 at 8:06 PM, documents R2 has had increased pacing and has escaped several times from the lockdown unit. The staff get her as soon as she breaches the door as the alarm sounds. She will not stay in bed and keeps pacing wanting to go down the hall to the doors. Her wandering behavior has increased over the last several days. R2's Progress Notes, dated 4/26/2026 8:07 PM, documents: Addendum: Clarification to previous note: R2 has increased pacing and exit seeking noted, staff redirects with success. Activities provided and effective for short periods. R2's Progress Notes, dated 4/28/2026 04:50 AM, documents R2 has been up all night. She has not been asleep at all. She is not able to be redirected. As needed (PRN) medication was given and not effective at all. She has been wandering all over the unit and into other residents' rooms, yelling loudly, clapping her hands, and being very disruptive to other residents on the unit. On 05/19/26 at 9:45 AM, R2 is pacing/walking up and down the hallway and she is wandering in and out of other resident's rooms and the bathroom. On 05/20/26 at 08:30 AM, R2 is up and walking/pacing in the hallway on the memory unit. She is walking in and out of other residents' rooms and was seen opening the main door on the memory unit. Housekeeping/Laundry and other staff were seen coming in and out of that door. On 05/19/26 at 1:45 PM, V11, Certified Nursing Assistant (CNA) said she was working back on the memory unit on April 26th, and she was the only CNA working on this day and the nurse that day was V17, Registered Nurse (RN). V11 said she was in a room with another resident changing and cleaning them up and V17 must have left the unit without letting her know. V11 said when she came out of the dirty utility room she just so happened to look up and see R2 out the window across the hall from the dirty utility room. She said there were no door alarms going off. V11 said she called the 200 hall to inform V17 of R2 being outside and no one answered the phone so she ran down to the 200 hallway and seen V17 standing at the nurses station and she told V17 R2 was out in the yard and V17 didn't do anything about it. She said she then ran outside and got R2 and took her back to the locked memory unit. V11 said she also reported it to V1, Administrator and V1 said to her I'm going to act like I didn't hear that. V11 said She thinks R2 left out the doors following the nurse, went down the 200 hallway and went out the door down at the end of that hallway because it's usually never locked or alarm on. V11 said R2 was walking back over to the memory unit from the 200 hallway outside. She said if she hadn't looked out the window when she did, she doesn't know what would have happened to R2 and she isn't sure how long R2 was even outside. V11 said there was another time she followed someone out the main doors to the memory unit and kitchen staff had to bring her back. On 05/27/26 at 2:30 PM, V1 Administrator said they have been doing a lot of different training and in-services. She said they had training in documentation due to staff not wording things the correct way and she had to have staff go in and correct what they had written. On 05/28/26 at 1:45 PM, V1, Administrator said no one informed her R2 had gotten out of the facility, and she thinks the staff let R2 out on purpose to try and set her up. She said she doesn't understand how she can be held responsible for this if she didn't know it had happened. On 06/01/26 at 12:38 PM, V16, Anonymous said she had documented in R2's chart and V9, Regional [NAME] President of Operations, and V32, Corporate told her she had to change the wording. She said V1 also stated that it is a reportable and the wording needed to be changed. V16 said V1 was made aware of R2 getting out of the facility on 04/26/26. 2. R3's Face Sheet, admission date of 10/28/19, documents R3 has diagnoses of but not limited to non-traumatic chronic subdural hemorrhage, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following cerebral infarction, alcohol dependence, and unspecified convulsions. R3's MDS, dated [DATE], documents R3 is severely cognitively impaired, and he is rarely/never understood. He requires supervision or touching assistance with ambulation of 10, 50, 150 feet, and he uses a wheelchair as a mobility device. R3's Care Plan, admission date of 10/28/19, documents R3 is an elopement risk/wanderer r/t impaired safety awareness was initiated on 04/29/26. Physical/verbal aggression. 04/28/26 resident pushed wheelchair ambulating away from facility. Interventions include but are not limited to on 04/28/26 elopement risk, staff to accompany R3 outside when he wants to sit on patio. It also documents R3 has a communication deficit r/t CVA (Cerebrovascular Accident) with aphasia (a language disorder caused by damage to the brain, usually from a stroke, head injury, or tumor and impairs a person's ability to speak) (can say help and unhuh), resident uses gestures, points, mumbles, and becomes agitated at times. It further documents R3 is at risk for falls r/t history of falls, psych med use, poor recovery balance, CVA, weakness. Interventions include but are not limited to Provide a safe environment: even floors free of spills and/or clutter, and adequate, glare free light. R3's Elopement Risk Assessment, dated 11/25/25, documents R3 cannot safely maneuver in the community has some physical impairment making it unsafe for R3. It also documents he appears to be capable of outside supervised pass privileges. A care plan for outside pass privileges including risk factors for non-compliance for adhering to pass policies and parameters is indicated. R3's Elopement Risk Assessment, dated 01/22/26, documents R3 cannot safely maneuver in the community has some physical impairment making it unsafe for R3. It also documents that he appears to be capable of outside supervised pass privileges and a care plan for outside pass privileges is indicated. R3's Progress Notes, dated 04/28/26 at 4:21 PM, documents R3 left the designated area while smoking. V8, Social Service Director (SSD) was able to provide supervision and attempted to prevent R3 from walking further and obtained assistance from V1, Administrator. R3's Progress Notes, dated 04/29/26 at 4:21 PM, documents intervention was implemented immediately to mitigate the risk of R3 potentially leaving designated areas. A staff member is to always be with resident while outside. R3's Elopement Risk Assessment, dated 04/29/26, documents R3 responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized, he becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility), he isn't sufficiently alert, oriented, coherent, and knowledgeable allowing him/her to be considered for independent outside pass privileges, he is not able to verbalize how to move/navigate/negotiate safely on community streets (cross safely, maintain a safe distance from cars, uses sidewalks, in a wheelchair, propels safely/carefully ect.). It also documents that R3 is at risk for elopement and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. On 06/01/26 at 1:00 PM, R3 was seen sitting out on the 500-hall patio by himself with no staff supervision noted. On 06/01/26 at 1:15 PM, R3 remains outside with no staff supervision. On 06/01/26 at 1:30 PM, R3 continues to sit outside by himself with no staff supervision. On 05/19/26 at 8:06 AM, This surveyor went down the independent hall to the exit door that leads to outside, this surveyor opened the door and no alarm sounded when the door was opened. On 05/27/26 at 9:28 AM- This surveyor asked V22, Licensed Practical Nurse (LPN) if she could put in the code for the 500-patio door. She said the code to get out the back door is 2020* she took this surveyor to the back door and pointed out the code is also written on a note that is posted by the keypad to turn off the alarm before going out and said the code for the door is right here. On 05/27/26 at 9:15 AM, V21, Dietary Aide said he was working the day R3 was out of the facility. He said he was leaving the facility for the day and he seen R3 a couple of blocks up the road (in an observed active residential neighborhood with vehicles utilizing the roadway, and no sidewalks which required R3 to walk in the road putting him at risk for preventable injuries) and there was no staff with the resident. He said he turned his car around and came back to the facility and asked V8, Social Services what R3's limit was and if he was supposed to be up the road. V21 said R3 wasn't on the main road (which is approximately 0.5 miles away from the facility and is a heavily trafficked roadway), but he was heading in that direction. On 05/27/26 at 9:50 AM, follow up interview with V21. He said when he came and got V8 to let her know R3 was up the road a couple of blocks V8 was in her office inside the building. On 05/27/26 at 9:22 AM, R1, who is cognitively intact with a Brief Interview of Mental Status (BIMS) of 14 out of 15 said he was sitting out on the patio and seen when R3 left the facility and walked up the street and around the corner. He said R3 didn't have any staff with him when he left, and he was not able to see R3 from the facility after he turned the corner. On 05/27/26 at 3:40 PM, V26, Medical Director said when it comes to the doors being locked/alarmed he would expect the alarms on the doors to be on. He said when it comes to the locked dementia unit residents being safe outside alone, he said not without staff being with them. He said as a general rule it wouldn't be a good idea unless they had family with them and staff need to know they are with family. V26 said he isn't sure if there is a policy for residents who leave the facility independently. He said the staff need to keep track of the residents and it's the facility's responsibility if something happens to the residents. He said with R3 and the change in his supervision he doesn't think it's a good idea for him to just wander off and hope that he comes back. He said R3 should have been accompanied by staff, and it makes him nervous R3 wasn't able to be seen from the facility. He said R3 could have been in grave danger with getting that far and that's not good. The facility's Code Pink- Missing Resident/Elopement policy, revision/review date of 11/15/18, documents Guidelines: 1) All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. 2) Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or she should: Make appropriate notations in the resident's medical record. Complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions as indicated. (1) Examples of interventions may include but are not limited to: (a) Wander guard bracelet (b) Increased monitoring such as 15-minute visual checks, 1:1 supervision (c) Evaluate for secured unit if available and appropriate. Review and update Elopement Risk binder as appropriate.

Based on interview and record review, the facility failed to ensure a safe resident environment and protection from physical abuse for 1 of 3 (R2) residents reviewed for resident-to-resident abuse in the sample of 3. This failure resulted in R2 being punched in the face by R1, leaving slight redness to her forehead. A reasonable person getting punched in the face would feel fearful, threatened, and intimidated. Findings include:R1's admission Record documents an admission date of 1/13/26 and a discharge date of 2/25/26 with included diagnoses of psychosis, transient alteration of awareness, cognitive communication deficit, dementia, and altered mental status. R1's Care Plan documents R1 has the potential to be physically aggressive punching/hitting related to dementia and poor impulse control. 1/18/26 R1 altercation with another resident, punched other resident in the shoulder two times. 1/21/26 R1 was rummaging through staff purse and hitting staff with fist. 1/27/26 R1 was grabbing residents and hit another resident. 1/29/26 R1 threw orange juice on another resident, hitting staff. (initiated 1/18/26) Interventions include in part medication review for physical behaviors directed towards other residents (initiated 1/18/26), staff to secure personal belongings in clean utility room or medication room (initiated 1/21/26), staff to redirect R1 away from other residents during grabbing or hitting behaviors (initiated 1/27/26), staff to redirect resident away from confrontations and supervise with visual checks every 30 minutes (initiated 1/27/26). R1's MDS (Minimum Data Set) dated 1/19/26 documents a BIMS (Brief Interview of Mental Status) of 03, indicating severe cognitive impairment. Section E documents under Behavioral Symptoms behaviors including physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others), and other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Under Impact on Resident, it documents these behaviors significantly interfered with the resident's participation in activities or social interactions and under Impact on Others, it documents these behaviors significantly intruded on the privacy or activity of others and significantly disrupt care or living environment. R2' admission Record documents an admission date of 7/3/24 with included diagnoses of vascular dementia, delirium due to known physiological condition, major depressive disorder, panic disorder, anxiety disorder. R2's MDS dated [DATE] documents a BIMS of 03, indicating severe cognitive impairment. Reviewed R2's Care Plan and it does not have a focus area for R2 being at risk for abuse. A facility incident document with date of incident 1/27/26 at 4:05 PM documents under Type/Nature of incident: Resident/Resident Altercation. Under Nursing Description, it documents While this nurse was on the 200 hall passing medications, CNA witnessed resident (R2) grabbing another resident (R1) in the doorway of the TV room while calling other resident (R1) a whole [sic], other resident (R1) swung and hit the resident (R2) in the face, knocking residents (R2) glasses to the floor, CNA came between them and separated them. Under Description of Action Taken it documents CNA immediately came between the residents and separated them, 2nd CNA came and alerted this writer of incident, this writer immediately reported this to the administrator. R1's Progress Note dated 1/27/2026 at 17:56, type: Behavior Note, created by V7 documents While this nurse was on the 200 hall passing medications, CNA witnessed another resident grabbing this resident in the doorway of the TV room while being called a whore, this resident swung and hit other resident in the face, knocking residents glasses to the floor, CNA came between them and separated them, this nurse immediately notified Administrator, (Physician), and POA. On 4/29/26 at 11:48 PM, V7 stated she was working when the incident happened between R1 and R2 on 1/27/26. V7 stated R1 hit R2 and knocked her glasses off her face. V7 stated she looked back at her messages to V8 (Physician) and she reported to him that R2 had slight redness to her forehead from R1 punching her. On 4/29/26 at 2:50 PM, V2 (Family Member/Power of Attorney) stated she was told R2 was hit in the face by another resident in January and it knocked her glasses off her face but that is all she knows about it. On 4/29/26 at 9:47 AM, V4 (Certified Nursing Aide/CNA) stated she doesn't remember if she was working when R1 and R2 had their altercation on 1/27/26. V4 looked at the daily schedule for 1/27/26 and her name is down as working, V4 stated she doesn't remember the incident. V4 stated R1 had behaviors a lot and they would try to redirect her, but it didn't always work. V4 stated R1 liked to sing so they would try to take her to sing or take her to play the keyboard that was in her room. On 4/29/26 at 9:50 AM, V5 (Activities Aide) stated she doesn't remember if she was working when R1 and R2 had their incident, but she just remembers that R1 punched R2 in the face. V5 stated R1 was very set in her ways and when she thought something had happened, even if it didn't, they had to go along with it to try and redirect her. V5 stated R1 had a lot of behaviors. On 4/29/26 at 9:55 AM, this surveyor attempted to interview R2 and due to her cognitive level, she was unable to recall the incident. On 4/29/26 at 11:35 AM, V1 (Administrator) stated she just started working at this facility last month and does not know any information regarding the incident between R1 and R2 from 1/27/26. A facility policy titled Abuse and retaliation Prevention and Reporting-ILLINOIS dated 1/8/26 documents under Policy: the facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, 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.

Based on record review, interview and observation the facility failed to perform treatments as ordered, assess, monitor and implement interventions for 3 of 3 residents (R2, R4, R22) reviewed for pressure ulcers in sample of 42. This failure resulted in R22 obtaining a stage 2 pressure ulcer and contributed to the decline of R4's pressure ulcers to left buttocks and coccyx. Findings include: 1. R4's Care Plan, dated 3/13/2026, documents that Potential for skin breakdown r/t (related to) incontinence, decreased mobility, DM (diabetes, PVD (peripheral vascular disease), frequently refuses to lay down, excoriated at times, Right foot drop. Refuses vascular studies 11/24/25 update: Enhanced Barrier Precautions, 9/12/24 Stage 3 R Heel, 8/31/25 Stage 4 Coccyx, 11/25/25 Stage 2 R Buttock, 12/2/25 Stage 3 L Buttock, 12/30/25 DTI L Heel HEALED, 3/3/26 12/30/25 Arterial L Great Toe HEALED, 2/10/26 3/11/26 Abrasion L inner ankle. Interventions: *2/10/26 Updated Tx: Left buttock clean with NS, apply Vashe dampened Kling wrap, cover with Silicone bordered super absorbent foam dressing. Change daily and PRN. Bilateral feet: Heel float boot to be worn to bilateral heels at all times. Check skin integrity each shift and document any abnormalities and update provider of any new findings. Cleanse open area to coccyx with NS, apply Santyl, pack with Calcium alginate with silver, cover with silcone bordered dressing. Change BID (twice daily) and PRN (as needed). Right buttock clean with NS, apply Santyl, Calcium alginate, cover with Silone bordered dressing. Change daily and PRN. Right heel clean with NS, apply betadine-soaked gauze, cover with 4x4 and ABD, wrap with Kerlix, secure with tape. Change daily and PRN. R4's Minimum Data Set (MDS), dated [DATE], documents that R4 is at risk for pressure injury, has unhealed pressure ulcers, 2 stage II pressure ulcer, 2 stage III, and 1 stage IV. R4's Infection Note, dated 3/3/2026 at 2:36 AM, documents Note Text: Resident remains on Contact Isolation r/t (related to) Pseudomonas to coccyx, urine, and left buttock. Isolation precautions maintained. No c/o pain or discomfort noted this shift. Dressings not changed per TAR (treatment administration record) due to SWM (Specialized Wound management) coming in the AM. Foley is patent draining clear yellow urine. Resident is resting comfortably in bed at this time. Heel protectors in place. Fluids encouraged, taken well. Call light and personal items within reach. POC (plan of care) continues. VS (vital signs) : T-98.1, P-82, R-18, BP-122/76, O2-94% on RA R4's Infection Note, dated 3/10/2026 12:15 AM, documents that Note Text: Resident remains on Contact Isolation r/t Pseudomonas to coccyx, urine, and left buttock. Isolation precautions maintained. No c/o pain or discomfort noted this shift. Dressings not changed per TAR due to SWM coming in the AM. Foley is patent draining clear yellow urine. Resident is resting comfortably in bed at this time. Heel protectors in place. Fluids encouraged, taken well. Call light and personal items within reach. POC continues. VS: T-98.1, P-72, R-20, BP-122/76, O2-96% on RA R4's Infection Note, dated 3/16/2026 8:54 PM, documents Note Text: Resident remains on Contact Isolation r/t Pseudomonas to coccyx, urine, and left buttock. Isolation precautions maintained. No c/o (complaints of) pain or discomfort noted this shift. Dressings not changed per TAR due to SWM coming in the AM. (Indwelling catheter) is patent draining clear yellow urine. Resident is resting comfortably in bed at this time. Heel protectors in place. Fluids encouraged, taken well. Call light and personal items within reach. POC continues. The facility's Weekly Wound Committee Review/Pressure Ulcer Cumulative Report, dated 3/12/2026, documents left buttocks 4.3x3.9x1.7, and coccyx 4.3x2.5x1.5 undermining at 12 measuring 1.9 cm. R4's Skin/Wound Note, dated 3/17/2026 at 6:40 AM, documents that Note Text: Seen by V38, Nurse Practitioner) this am R/T wounds. Rt (right) heel has improved and measures 1.4x1.2x0.1. Lt (left) buttock has declined and measures 4.5x4x2, treatment changed to betadine moist gauze covered with silicone bordered super absorbent foam dressing. Rt buttock stable measures 1.4x0.8x0.2 80% granulation / 20% slough. Coccyx declined and measures 5x2.5x1.5 with Tunneling @12 O'clock 1.8cm. Treatment to Coccyx Clean with NS or wound wash, apply betadine dampened gauze wrap, cover with silicone bordered foam dressing BID (twice daily) and PRN (as needed) . Lt ankle abrasion has improved and measures 1x1.6x0.1, treatment changed to xeroform and bordered dry dressing daily and PRN. Boot while in bed, air mattress, equagel cushion in w/c (wheelchair) all remain in place. Call placed to POA daughter with update and new treatment orders. R4's March Treatment Administration Record (TAR) documents Order date 12/2/2025 Right heel Cleanse wound with NS or WC apply betadine-soaked gauze to WB, cover with 4x4 and ABD, then wrap with kerlix from toes to knees, change daily and PRN every night shift for Wound Healing. 3/2/26, 3/9/26, and 3/16/2026 documents # 9. The TAR Chart Codes 9=Other / See Progress Notes. R4's March TAR documents order date 12/24/2025 Right heel Cleanse wound with NS or WC apply betadine-soaked gauze to WB, cover with 4x4 and ABD, then wrap with kerlix from toes to knees, change daily and PRN every night shift for Wound Healing. 3/2/26, 3/9/26, and 3/16/2026 documents # 9. The TAR Chart Codes 9=Other / See Progress Notes. R4's March TAR documents order date 2/4/2026 Coccyx: Clean with NS, pack with calcium alginate with silver, cover with silicone bordered dressing. Change BID and PRN every day and night shift for Unstageable pressure ulcer to coccyx. 3/2/26, 3/9/26, and 3/16/2026 documents # 9. The TAR Chart Codes 9=Other / See Progress Notes. R4's March TAR documents order date 2/10/2026 Lt buttock: Clean with NS, apply Vashe wash moist kling wrap, cover with silicone bordered super absorbent dressing. Change BID and PRN. every day and night shift for Unstageable Pressure Ulcer. 3/2/26, 3/9/26, and 3/16/2026 documents # 9. The TAR Chart Codes 9=Other / See Progress Notes. On 3/16/2026 at 1:00 PM observed R4's skin. R4's wound dressings to coccyx, left buttocks and left foot dated 3/15/2026 , right buttock dated 3/14/2026 and right foot dated 3/13/2026. Foul odor coming from dressing to left buttock and coccyx. At 2:44 PM no change in dressings. On 3/18/2026 at 11:15 AM V34, Licensed Practical Nurse stated that the wounds are to be completed as ordered. V34 stated that the treatments are split because of the amount. V34 stated that the heals are completed on the night shift and the other wounds are completed on the day shift. V34 stated that there have been times when she has returned to work and the wounds had not been completed. V34 stated that the facility has agency staff and that had been a problem. On 3/19/2026 at approximately 12:29 PM V14, [NAME] President of Operations, stated that the facility historically had problems with treatments being completed as ordered. On 3/19/2026 at 1:10 PM V38, Wound Nurse Practitioner, stated that she expects the treatments to be performed as order. V38 stated that the facility not doing the treatments as ordered would contribute to the decline in the wound. V38 stated that some of the dressings are performed on the night shift. V38 stated that she would understand if there were a problem, and the staff couldn't get to it until in the morning she would understand. V38 stated that this should not be the norm and that she would expect the treatments to be done per the orders. 2. R22's Face Sheet, admission date of 06/19/24, documents that R22 has diagnoses of but not limited to Vascular Dementia, unspecified severity, with other behavioral disturbance, peripheral vascular disease, hypertension (HTN), and the history of falling. R22's Minimum Data Set (MDS), dated [DATE], documents she is severely cognitively impaired, and she requires substantial/maximal assistance with bed mobility and with transferring. R22 is frequently incontinent of bladder and always incontinent of bowel. R22's Care Plan, admission date of 06/19/24, documents R22 wears adult undergarments r/t (related to) incontinence. Interventions include but are not limited to Assist to toilet q (every) 2 h (hours) and PRN (as needed) and monitor for skin breakdown. It also documents that R22 has a potential for skin breakdown r/t incontinence, confusion, and decrease mobility. 01/30/26 Stage 2: Coccyx12/11/25 Recommend use of bed positioning wedge for side lying in bed with 1-2 hour turning/repositioning for pressure relief to buttocks in bed, reposition every 1-2 hours and prn, and monitor for redness or discoloration to skin. R22's Progress Notes document the following Skin/Wound notes: On 12/08/25 at 8:54 PM, documents R22 noted to have shearing area measuring 1 x1.5 x 0 to coccyx. V30, Medical Director gave orders for Zinc cream to coccyx and bilateral buttock BID (twice a day) and PRN (as needed). On 12/23/25 at 7:18 PM, documents area assessed to coccyx and the area is healed. On 01/30/26 at 11:30 AM, documents the Certified Nursing Assistant (CNA) made the nurse aware there was a red area to R22's coccyx. The nurse assessed and measured the area, and it measured 1.5 x 1.5 x 0.1. Top layer of skin is gone with almost no depth noted. V30, Medical Director was made aware of the area to R22's coccyx and a new order to cleanse with normal saline (NS), cover with silicone bordered foam dressing every other day and PRN was ordered. On 02/10/26 at 2:08 PM, documents area to coccyx assessed and has declined. It currently measures 1.5 x 1.5 x U (unstageable) with wound base 100% slough. V30 was made aware and new orders of clean area with NS, apply xeroform, cover with silicone bordered foam dressing, to be changed daily and PRN. On 03/04/26 at 7:59 PM, documents wound to coccyx assessed. Area measures 1.4 x 1.0 x 0.3, very minimal amount of clear drainage noted, no foul odor. Wound base is 60% slough and 40% granulation tissue. Depth is no 0.2 cm (centimeters) deeper than last week with length and width remaining the same. V30 updated and new order to replace the xeroform with collagen and continue to cover with silicone bordered foam dressing daily and PRN. On 03/11/26 at 5:43 PM, Area to coccyx assessed and continues to measure 1.4 x 1.0 x 0.3. No odor and scant amount of clear drainage noted. V30 made aware and new orders to refer to the local wound management. On 03/17/26 at 7:30 AM, R22 was seen by V31, Wound Nurse Practitioner (NP). Area to coccyx measures 1.5 x 1 x 0.3, stage 3, 70% granulation/30% slough. Heavy serosanguinous drainage noted. Treatment changed at this time; clean with NS apply Santyl, then calcium alginate to wound base, cover with silicone bordered foam dressing to be changed daily and PRN. R22's Physician's Orders, dated 06/19/24 at 12:20 PM, documents Skin check weekly 6A-6P with showers on Monday & Thursday No redness, open areas, or excoriation @ (at) present skin integrity = WNL, Skin impairment = ABN, every day shift every Mon, Thu for skin management R22's Physician's Orders, dated 12/08/25 at 8:25 PM, documents Apply Zinc/Barrier Cream to coccyx and Bilateral buttocks BID and PRN. R22's Treatment Administration Record (TAR) for the month of January 2026, was reviewed and has no documentation for the day shift that treatment was completed on 01/2/26, 01/05, 01/11, 01/23, 01/24, and 01/25/26. No weekly skin check was completed on 01/05/26. R22's TAR for February 2026, was reviewed has no documentation on day shift showing the treatment was completed on 02/02/26, 02/03, 02/05, 02/08, 02/09/26, and it wasn't completed on the night shift on 02/12/2026. There is no documentation for weekly skin checks that were completed on 02/02/26, 02/05, 02/09, and 02/12/26. During observations on 03/17/26 from 9:30 AM through 12:39 PM, with checks done in 15-minute intervals R22 was seen without care plan interventions being followed. R22 was not assisted to the bathroom every two hours, and she was not repositioned in her chair while she was up. 3. R2's Face Sheet, admission date of 12/05/25, documents that R2 has diagnoses of but not limited to bilateral primary osteoarthritis of knee and dementia other diseases classified elsewhere, severe, with psychotic disturbance. R2's MDS, dated [DATE], documents that R2 is severely cognitively impaired, and she is dependent or requires substantial/maximal assistance with her activities of daily living (ADLs). R2's Care Plan, admission date of 12/05/25, documents that R2 has a potential for impairment to skin integrity related to incontinence, decreased cognition, and decreased bed mobility. 3/1/26 Coccyx DTI (deep tissue injury), 3/16/26 Bilateral Heels DTI. Goal: R2 will not develop alteration in skin integrity. Interventions include but are not limited to 3/1/26 Coccyx DTI Tx (treatment): clean area with NS (normal saline), apply skin prep BID (twice a day) and PRN (as needed) until healed, 3/16/26 Bilateral Heels: Skin prep bilateral heels BID and PRN daily, and assess/record changes in skin status. R2's Physician's Orders, dated 12/10/25, documents Skin Check weekly based on Braden. One time a day on shower day on Wednesday and Saturday AM. R2's Physician's Orders, dated 03/01/26, documents Cleanse DTI areas to coccyx with NS and apply skin prep BID and PRN every day and night shift for skin management. R2's Physician's Orders, dated 03/16/26, documents Apply Skin Prep to bilateral Heels BID and PRN every day and night shift for skin management. R2's Skin-Pressure/Diabetic/Venous/Arterial Wound Report, dated 03/01/26, New wound, discolored area DTI to coccyx. Wound 1: Acquired in-hours, pressure injury, deep tissue injury, 6.0x0.5xDTI 1x0.5DTI 1x0.5x DTI. Care Plan updated and interventions put into place pressure ulcer care, application of ointments/medication other than to feet, and reposition every two (2) hours and PRN. R2's TARs for the month of December 2025 were reviewed and they have no documentation a skin check was completed on 12/13/25 or 12/31/25. R2's TARs for the month of January 2026 were reviewed and they have no documentation a skin check was completed on 01/03/26, 01/10, 01/21, and 01/24/26. R2's TARs for the month of February 2026 were reviewed and they have no documentation a skin check was completed on 02/07/26 and the skin checks were discontinued on 02/21/26. R2's TARs for the month of March 2026 were reviewed and they documented weekly skin checks were started again on 02/25/26. There is no documentation for treatment for R2's coccyx was completed on day shift on 03/08/26. It also documents a treatment of Zinc to buttocks and coccyx ever shift for skin management was started on 03/03/26 and has no documentation the treatment was completed on day shift on 03/05/26, 03/08, 03/10, 03/13, 03/14/26, and no treatment was completed on the evening shift on 03/08/26. On 03/16/26 at 10:30 AM, R2 was lying in her bed on her back sleeping with her head slightly elevated. She did not have her heel protectors on at this time. During observations on 03/17/26 from 9:30 AM through 12:39 PM, with checks done in 15-minute intervals R2 was seen without care plan interventions being followed. R2 was not repositioned in bed. On 03/18/2026 at 12:05 PM V14, [NAME] President (VP) of operations said she would expect treatments to be completed and repositioning to be done. On 03/19/2026 1:02 PM, V38, Wound Nurse Practitioner (NP) said it's hard to answer any questions regarding R22 due to she just seen her for the first time on Tuesday (03/17/26). V38 said R22 had a Stage II pressure area that had stalled in its healing and then got worse so they reached out to her (V38) to come and see her. V38 said when she came in and seen her on 03/17/26 R22's wound was Stage III. V38 said residents who are up in their wheelchairs should be repositioned every two hours and she would expect the nurses to follow orders and to make sure care plan interventions were followed. On 03/20/2026 10:47 AM, V30, Medical Director said a Braden Risk assessment for skin breakdown should be completed. He said if a nurse calls and reports a skin issue and thinks zinc should be used, he will trust their judgement and order it. He said he trusts the nurse and it depends on their judgement on whether the treatment should be done or not. The facility's Pressure Ulcer Prevention, revision date of 01/15/18, documents Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin. It further documents 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. It also documents 7. Whenever possible, encourage residents to change position at regular intervals as able to promote circulation. Wheelchair residents may be instructed to shift weight from one buttock to the other.

Based on interview, observation, and record review the facility failed to provide safe transfers for 3 of 14 residents (R1, R12, R50), to initiate fall interventions for a high fall risk resident for 1 of 14 residents (R2) resulting in R2 falling and fracturing her hip, to implement fall interventions for 1 of 14 residents (R22), and to keep door alarms activated, all reviewed for resident safety in the sample of 42. The findings include:1. R2's Face Sheet, admission date of 12/05/25, documents that R2 has diagnoses of but not limited to bilateral primary osteoarthritis of knee and dementia other diseases classified elsewhere, severe, with psychotic disturbance. R2's Minimum Data Set (MDS), dated [DATE], documents thatR2 is severely cognitively impaired, and she is dependent or requires substantial/maximal assistance with her activities of daily living (ADLs). Walking was not attempted due to medical conditions or safety concerns. R2's Electronic Medical Record, (EMR) was reviewed and no documentation was found that an admission fall risk assessment was completed. R2's Care Plan, admission date of 12/05/25, documents R2 is at risk for falls (date initiated: 01/04/26), interventions include but are not limited to evaluate fall risk on admission and as needed (PRN) and if resident is a fall risk, initiate fall risk precautions. It also documents that R2 is at risk for fall/injury related to (R/T) wandering/poor safety awareness (created date of 12/22/25). R2's Post Acute Care Transfer Report, dated 12/05/25 at 10:07 AM, documents Behavioral Interventions: 1:1 observation Safety High risk for falls, Physical aggression, Risk for elopement. R2's Progress Notes, dated 12/20/25 at 02:59 AM, documents that the nurse was notified by the Certified Nursing Assistant (CNA) the resident was found on the floor in her room. The nurse assessed R2 and helped the CNA assist her back to bed. There were no visible signs of injuries noted, and her vital signs (v/s) were within normal limits (WNL). R2 stated her right hip was sore. The physician and resident's sister was notified. R2's Fall-Initial Occurrence Note, dated 12/20/25 at 2:40 AM, documents that R2 had an unwitnessed fall in her room, she had taken off her tread socks, and she was trying to go to the bathroom. R2's Progress Notes, dated 12/20/25 at 04:23 AM, documents that R2 complained of (c/o) pain in her right hip of a 10 out of 10. The physician was notified and gave orders to send R2 to the local hospital. R2's Alleged Fall-Unattended report, dated 12/20/25 at 02:40 AM, documents that R2 was found on the floor in her room by the CNA. The nurse witnessed R2 on the floor with her tread socks sitting beside her. R2 said she was attempting to go to the bathroom. The nurse assessed R2 and helped the CNA assist R2 back to bed. There are no visible injuries and v/s are WNL. R2 complained of right hip soreness. R2 c/o worsening right hip pain, the physician was notified, and R2 was sent out to the hospital. R2's Report to Illinois Department of Public Health (IDPH) Regional Office Final Report, dated 12/26/25, documents that R2 has diagnoses of dementia, bilateral primary osteoporosis of knee, and hyperlipidemia. Description of occurrence: Alleged fall with injury, injuries: Right hip fracture, actions taken: Nurse assessed, neurological evaluation initiated, sent to local hospital emergency room department for evaluation and treatment, R2 then transferred and admitted to higher level of care hospital and received surgical repair of right hip fracture. Follow up/Final Report Summary: The was an unwitnessed fall in resident's room. Resident observed on floor on her buttocks after attempting to ambulate independently to the toilet. Prior to ambulation, resident had removed her non-skid socks resulting in inadequate traction. R2 resident, was readmitted on [DATE] from the hospital with intact staples to surgical site and post-surgical orders in place. Safety signage posted as a reminder to call for assistance. Staff to monitor to ensure appropriate footwear and/or non-skid socks and provide toileting assistance. Care plan updated to reflect current status. R2's Progress Notes, dated 12/22/25 at 10:44 AM, documents that R2 continues follow up (f/u) for recent fall and right hip fracture. R2 has staples to surgical site and are intact. R2's progress Notes, dated 12/31/25 at 02:10 PM, documents that R2 noted sitting on floor in front of wheelchair (w/c) in hallway. R2 stated she tried to get up and sat down on the floor. R2 was assisted back into her w/c. On 03/18/2026 at 2:35 PM, the facility was unable to provide R2's initial admission fall risk assessment. On 03/19/2026 at 7:25 AM, R2 is lying on her back in bed with her eyes closed. Her call light is attached to the sheet at the head of her bed off the side and out of reach of R2. 2. R22's Face Sheet, admission date of 06/19/24, documents that R22 has diagnoses of but are not limited to Vascular Dementia, unspecified severity, with other behavioral disturbance, peripheral vascular disease, hypertension (HTN), history of falling. R22's MDS, dated [DATE], documents she is severely cognitively impaired, and she requires substantial/maximal assistance with bed mobility and with transferring. R22 is frequently incontinent of bladder and always incontinent of bowel. R22's Care Plan, admission date of 06/19/24, documents R22 is at risk for fall and has had an actual fall r/t (related to) history of falling, dementia, fractures, restlessness/agitation, arthritis. Interventions include but not limited to bed pad alarm, keep in visual of staff when up in wheelchair, Batteries replaced on chair alarm, ensure alarm in place, resident placed near nurse's station, and Pressure pad alarm added to chair. R22's Fall Initial Occurrence note, dated 01/10/26 at 08:10 AM, documents R22 had an unwitnessed fall in the common bathroom. She fell from her w/c to the floor. R22 has a laceration above her right (R) eye. Resident was assessed for injury, assisted back into w/c, and then sent to the local ER for evaluation and treatment. R22's Local Hospital emergency room report, dated 01/10/26 at 9:51 AM, documents R2 is a [AGE] year-old female patient with extensive medical history (hx) including dementia who resides at the local nursing home and who reportedly sustained an unwitnessed fall this AM from her wheelchair. She was found to be lying on the floor, having hit her head. No loss of conscious (LOC) and she is not on any blood thinners. Last tetanus shot was 2020. Patient (Pt) appears to be at her baseline which is alert and oriented (A&O) times 1-2. She does have two lacerations along the right upper eye orbit. There are no other complaints of pain or any other distress noted. It further documents the laceration to R2's right eyebrow is 2.5 centimeters (cm) in length and 2 millimeters (mm) in depth. Laceration repaired with tissue adhesive. R22's Fall Initial Occurrence note, dated 02/03/26AM, documents R22 had an unwitnessed fall in the dining room on the 300 hallway. It also documents resident fell forward from her wheelchair (w/c), struck her head on the ground, loss of consciousness noted, three lacerations noted to resident's forehead. Resident was sent to the local emergency room (ER) via ambulance. Precipitating and contributing factors include but are not limited to recent fall, incontinence, and she is confused. She was brought to the nurse's station to monitor. R22's Local Hospital emergency room report, dated 02/03/26 at 9:09 AM, documents that R2 is a [AGE] year-old female that presents from local nursing home after sustaining a fall from her wheelchair. Emergency medical services (EMS) state the patient fell forward and hit her head on the floor. Patient had 60 minutes of LOC. Patient has multiple lacerations and hematoma to her forehead. The patient has a hx of dementia with multiple falls in the past. Patient cries out in pain with movement. No obvious injury besides her forehead. R2's lacerations were repaired with six (6) Steri-Strips and tissue adhesive. During observations on 03/17/26 from 9:30 AM through 12:39 PM, with 15-minute intervals R22 was seen without safety interventions in place or being followed. R22's chair/bed pull alarm monitor was not connected to the pull cord on her chair while she was in her chair. On 03/17/26 at 11:30 AM, R22 was placed in her room by self and wasn't in view of staff and her alarm wasn't in place. On 03/17/26 at 12:44 PM, V29, Certified Nursing Assistant (CNA) said R22's chair alarm was put on her because her daughter (V17) comes and helps her with her lunch, so she really doesn't need it when V17 is here. On 03/17/26 at 12:48 PM, V17, (R22's family member) was asked if she had removed the chair alarm when she came to the facility and she responded No. On 03/19/2026 at 7:20 AM, R22 is up and in her w/c and being taken down to the dining room for breakfast. The alarm device monitor was still attached to the head of R22's bed. The pull cord was seen on the back of R22's w/c. On 03/18/2026 at 12:05 PM V14, [NAME] President (VP) of Operations said she would expect fall interventions to be in place. On 03/20/2026 at 10:47 AM, V30, Medical Director said just because someone has dementia, wanders, and is now multiple psychotropic medications doesn't necessarily make them a fall risk. He said a fall risk assessment should be completed and he believes it's part of the initial assessment when someone is admitted . He said he would expect the staff to be aware of it if someone is a fall risk and he would expect fall interventions to be put in place to prevent future falls. 3. R12's admission Record, dated 3/19/26, documents R1 was originally admitted to the facility on [DATE] with diagnosis of acquired absence of left and right above knee amputation (AKA), Peripheral venous insufficiency, hypertension (HTN), chronic obstructive pulmonary disease (COPD), overactive bladder, congestive heart failure (CHF), major depressive disorder, peripheral vascular disease (PVD), Arteriosclerotic heart disease (ASHD), morbid obesity, nicotine dependence (cigarettes), falls, and polyneuropathy. R12's Care Plan, dated 3/2/26, documents: R12 is a smoker of cigarettes. Interventions: Instruct resident about the facility policy on smoking: locations, times, safety, medications, per MD (medical doctor) order, notify charge nurse immediately if it is suspected resident has violated facility smoking policy, resident will keep smoking materials in a secured location. 2/20/26: R12 can be rude to other residents at times, history of smoking used cigarettes out of disposer concerns. R12's MDS, dated [DATE], documents R12 is cognitively intact and is dependent on staff for bathing, toileting, and personal hygiene. R12's Smoking Safety Risk Assessment, dated 12/6/25, documents Does the resident currently smoke or use electronic smoking device? No. R12's Smoking Safety Risk Assessment, dated 3/4/26, documents Does the resident currently smoke or use electronic smoking device? No. This resident (R12) is safe to smoke unsupervised. On 3/16/26 at 9:34 AM, R12 was observed being placed in her wheelchair by V20, Certified Nursing Assistant (CNA), and V12, CNA. R12 is a bilateral AKA, requested her camouflage pull over gown to go out and smoke. V20 brought it to her and put it on R12. the gown had several burn marks noted on the front of her hood/gown from smoking. V12 then handed R12 her cigarette from her side table, mentioning that is her only one left, R12 asked for her lighter and V12 gave it to her from her side table also. On 3/17/26 at 9:33 AM, R12 stated there is no smoking times and she can go out and smoke whenever she wants and there is usually no staff outside with them. R12 stated she is waiting on someone to bring her some more cigarettes so she can go smoke. On 3/17/26 at 11:20 AM, The door leading to the smoking area at the end of the 200-Hall was opened, alarm sounding with V5, CNA, answering the alarm. When asked about the door alarm being on, and residents stating they can smoke anytime they want without the alarm sounding, V5 stated I think it depends on who is working if it's armed or not. On 3/17/26 at 11:25 AM, V26, Registered Nurse (RN), stated We shut the alarm off during smoking time so the residents can go smoke. When I'm here, I make sure the alarm is on when it's not smoke times. I don't know why we can't leave it off all the time so the residents can go outside, it is a fenced in area. 4. R1 admission record, dated 3/19/26, documents R1 was originally admitted to the facility on [DATE] with diagnosis of COVID, pneumonia, dysphagia, degenerative disease of nervous system, lumbar scoliosis, major depressive disorder, epilepsy, hypothyroidism, anxiety disorder, polyosteoarthritis, diverticulosis, cardiomegaly, falls, and osteoporosis. R1's Care Plan, dated 2/5/26, documents R1 requires restorative assistance with bathing, grooming, dressing related to immobility. 3/6/25: R1 requires assist with ADL's related to weakness, history of Ilieopubic fracture, rib fractures, history of falls, resident refuses foot board and foot pedals most times. Interventions: requires two staff participation with transfers per full body mechanical lift device, keep call light within reach and encourage use, answer promptly. 3/6/25: R1 is at risk for falls related to weakness, current fractures, neuropathy, osteoporosis. Interventions: Fall mat, high fall risk, keep call light within reach at all times and answer timely, assist with ADL's, follow facility fall protocol, review past falls and attempt to determine cause, anticipate needs, promote physical activity for strengthening, keep furniture in locked position, provide a safe environment: floors free of spills and/or clutter, adequate, glare free light, bed in low position at HS (hours sleep), assistive devices in place, personal/needed items within reach. R1's MDS, dated [DATE], documents R1 is cognitively intact and is dependent on staff for ADLs and transfers. R1 is always incontinent of both bowel and bladder. R1's last Fall Risk Assessment completed, dated 1/23/24, documents R1 is a High Fall Risk. On 3/16/26 at 1:20 PM, R1 was observed being transferred from her wheelchair to her bed. V20, CNA, and V12, CNA, used a full body mechanical lift device and lifted R1 off her wheelchair with the wheelchair unlocked, held R1 to her bed, and then lowered to the bed and detached from device. Both CNAs left the room with no placement of a fall mat and no fall mat seen in the room. 5. R50's admission Record, dated 3/19/26, documents R50 was originally admitted to the facility on [DATE], with diagnosis of Vascular dementia, Alzheimer's disease, major depressive disorder, irritable bowel syndrome (IBS), HTN, osteoporosis, generalized anxiety disorder, dysphagia, COPD, psychosis, COVID, contracture left and right hand, chronic respiratory. failure, and emphysema. R50's Care Plan, dated 4/16/25, documents R50 requires assist with ADL's r/t dementia, Alzheimer's, weakness. Intervention: Toileting Schedule: Every 2 hours and PRN (as needed). R50 wears adult undergarments r/t incontinence of bowel and bladder. Interventions: Assist with incontinence Q (every) 2H (hours) and PRN, keep clean, dry, free of irritating substances. R50 is at risk for falls r/t weakness, dementia. Interventions: Assist with ADL's, quarterly fall assessment, review past falls and attempt to determine cause, anticipate needs, promote physical activity for strengthening, keep furniture in locked position, provide a safe environment: even floors free of spills and/or clutter, adequate, glare free light, bed in low position at HS, assistive devices in place, personal/needed items within reach. R50's MDS, dated [DATE], documents R50 has a severe cognitive impairment and is dependent on staff for all ADLs and transfers. R50 is always incontinent of both bowel and bladder. R50's last Fall Risk Assessment completed, dated 8/6/21, documents R50 is a High Fall Risk. On 3/16/26 at 1:30 PM, R50 observed in geriatric chair with legs/arms slightly contracted, the full body mechanical lift device sling placed underneath her and was attached to the device. R50's wheelchair was unlocked while lifting R50 off her wheelchair to her bed and then lowered. The Facility's Fall Prevention Program Policy, dated 11/21/17, documents in part To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Methods to identify risk factors, methods to identify residents at risk, Assessment time frames, Use and implementation of professional standards of practice, Adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment, Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. 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. Safety interventions will be implemented for each resident identified at risk. The Facility's Smoking Safety Policy, dated 10/24/22, documents in part To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate [NAME] each resident that they are responsible for following each rule and on-going compliance with this policy. A Smoking Safety Assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The plan of care shall reflect the results of this assessment. This assessment will be completed upon admission, quarterly and with significant change. The following behaviors and/or conditions will jeopardize and/or cause revocation of the person's independent privileges: Self-harmful behaviors, such as burning clothing, hands, fingers, face or lips. This category includes residents who are generally careless while smoking and may present a significant risk of fire setting. 6.On 3/16/26 at 8:43 AM Surveyor tested the 200 hall exit door by opening it and the door alarm did not sound. Surveyor asked V5 CNA (Certified Nurse Assistant) why the exit alarm did not function and V5 replied because residents go out when they want for fresh air and it is a restraint if we keep the door alarm on. V5 then returned to the exit door with a key and used the key to activate the door alarm. V5 stated a key must be used to activate and deactivate the door exit alarms. On 3/18/26 at 7:50 AM Surveyor noted an exit door alarm sounding on the 100 hallway. On 3/18/26 at 7:51 AM V1 Administrator stated she expects all exit door alarms to always be on. On 3/18/26 at 8:01 AM Surveyor noted the exit door continued to alarm on 100 unit. Surveyor asked V1 Administrator what exit door alarm was sounding as the alarm on the 100 unit has been ringing for over 10 minutes. V1 stated she thinks it is from people entering the front door without putting the door alarm code in, but she would have to find out for sure. Surveyor asked how employees in other areas of the facility could hear the low buzzing exit alarm sounding. V1 stated she has an alarm company coming out to assess and repair the exit alarms as needed. V1 stated she is aware of the issues with the door alarms including the 300 hall/Memory Care Unit exit alarm not functioning properly and an alarm company is coming to make all necessary repairs. The Facility's Elopement Device policy dated 8/23/17 documents Purpose: To establish procedures for ensuring personal elopement devices are used in accordance with identified risk, physician orders, and to ensure the security system is inspected to identify malfunctions should they occur. Equipment includes exit door keypads. Responsibility: all facility staff. Procedures: Elopement alert devices will be used as an interventional tool to prevent resident elopements. It continues, the inspection and status of the test will be recorded on a facility approved log located at the front desk. Maintenance staff and manager on duty will be responsible for maintaining this log. In the event testing reveals a malfunctioning in the exit door security system, maintenance personnel will be notified and a staff member placed at the door to prevent unauthorized exits. The facility's CMS 761, dated 03/16/26, documented there are 56 residents residing at the facility.

Based on interview and record review, the Facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 56 residents living in the Facility.Findings Include:The Facility's February 2026 licensed nurse schedule was reviewed, and this schedule does not document a Registered Nurse (RN) worked at least eight hours on 2/7/26, 2/8/26, 2/21/26, and 2/22/26.The Facility's March 2026 licensed nurse schedule was reviewed, and this schedule does not document a RN worked at least eight hours on 3/7/26 and 3/8/26. On 3/18/26 at 12:23 PM V14 [NAME] President of Operations stated the facility did not have RN coverage every day in February and March of 2026. The Facility's undated Nurse Staffing policy documents it is the policy of the 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. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 3/16/26, documents that are 56 residents living in the facility.

Based on observation, interview and record review, the facility failed to document when a multi-dose use vial of Tuberculosis (TB) testing solution was opened, date a vial of insulin when opened, date stock medications when opened, and discard expired stock medications. This has the potential to affect all 56 residents in the facility.Findings include:On 3/16/26 at 9:27 AM the 300 hall medication storage room refrigerator was inspected and 1 open vial of tuberculin (TB) purified protein with an expiration date of 1/26 was observed. The vial nor the box it was in documented the date of when the vial was opened. The 300-hall medication cart was also checked at this time. 1 open vial of Lantus insulin was observed with R24's name on it. R24's insulin label documents expire 28 days after opening. No open date was documented on the vial. R9's open bottle of valproic acid did not document an open date. V6 LPN (Licensed Practical Nurse) was present during the inspection and stated the TB solution should have been labeled when it was initially opened and should have been disposed of. V6 also agreed R24's and R9's medication bottles should have been labeled with an open date. On 3/16/26 at 9:40 AM the 200-hall medication storage room and cart were checked with V6 LPN present. 1 bottle of senna plus with 60 tablets and an expiration date of 1/26 and 1 bottle of bisacodyl 5mg 100 tabs with an expiration date of 2/26 were observed on the storage room shelves. The 200-hall medication cart was also inspected at this time and an open 355 ml (milliliter) bottle of liquid antacid with no open date was observed in the 200-hall medication V6 stated the expired medications should have been discarded and the vials and bottles of medications should have been labeled with an open date when they were first opened.On 3/18/26 at 9:56 AM V7 ADON (Assistant Director of Nursing) stated the TB solution that was expired is used facility wide for residents. V7 agreed medications should be dated when opened. V7 also stated stock medications are used for all residents who have an order for them and expired medications should be disposed of promptly.The Facility's Medication Storage in The Facility policy dated 11/2021 documents medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. It continues, Procedures: H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. It continues, When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated, if applicable for medications requiring a shortened expiration date. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. It continues, G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 3/16/26, documents that are 56 residents living in the facility.

Based on observation, interview, record review, the facility failed to ensure foods were properly stored, labeled, dated, and discarded when expired, and failed to ensure food was prepared and handled in accordance with sanitary food services practices. This failure has the potential to affect all 56 residents receiving meals prepared by the dietary department. Findings Include: On 3/16/26 at 8:55 AM the kitchen was inspected with the following issues noted: The double door refrigerator contained 1 open bottle of nectar thickened apple juice approximately 1/4 used with no open date and 1 gallon of ranch dressing approximately 3/4 used with an expiration date of 12/2/25. V13 [NAME] agreed it was expired. The walk-in freezer was inspected, and Surveyor observed 1 box of open frozen chicken breast fillets with no open date and 1 box of cheese tortellini with no open date. V4 Dietary Manager was present and agreed the items were not properly labeled. On 3/16/26 at 12:04 PM V13 [NAME] was observed as he was plating food at the steam table with gloves on. V13 left the steam table, went and retrieved a bowl for the food processor, V13 then grounded up a hamburger patty, then brought the bowl back to the serving area, and picked up a sandwich bun with the same gloves on as he used when processing the hamburger patty. V13 then took the plate containing the ground hamburger patty on a bun and placed it in the microwave then pushed the microwave buttons to warm the plate of food. V13 then placed the warm plate of food on a tray and then took the food processor bowl to the dirty dish area. V13 returned, changed gloves without the benefit of hand hygiene, and continued to plate food. At 12:10 PM V13 was observed as he went to the double door refrigerator, opened it, and retrieved unwrapped cheese slices with the same gloves on as was used to open the refrigerator. V13 then retrieved 2 slices of bread and carried the unwrapped 2 slices of bread and the cheese and placed them in a skillet on the stove top. On 3/16/26 at 12:12 PM surveyor asked V4 Dietary Manager why the temperature log on the double door refrigerator was only completed for today 3/16/26. V4 stated that it is the cook's refrigerator, and that she got behind on filling that out. Surveyor then requested a copy of the March 2026 refrigerator log and it documents 1 temperature recorded for the month on 3/16/26.On 3/18/26 at 10:03 AM V1 Administrator stated she expects Dietary staff to change gloves and perform hand hygiene between touching surfaces and plating food. V1 stated she expects the Dietary staff to monitor and record refrigerator temperatures daily and to date food and drinks when opened to prevent foodborne illnesses. The Facility's Food Storage policy dated 2020 documents Procedure: General storage guidelines to be followed: All food items will be labeled. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after 7 days of storing under proper refrigeration. Keep potentially hazardous foods out of the temperature danger zone 41F (Fahrenheit) degrees to 135 F, or per state specific regulations. It continues, leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Refrigerated storage guidelines to be followed: Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 F or lower. The Facility's Refrigerator and Freezer Temperatures policy dated 2020 documents procedure: Dining services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift. Corrective actions are taken as necessary to ensure only safely stored foods are served to residents.As of 3/19/26 at 11:20 AM the Facility failed to provide a policy on plating/serving food. The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 3/16/26, documents that are 56 residents living in the facility.

Based on observation, interview, and record review, the facility failed to implement and follow its established water management program for prevention of Legionella growth, and failed to perform hand hygiene and glove changes during resident care. This failure has the potential to affect all 56 residents residing at the facility. Findings Include: 1.On 3/17/26 at 11:05 AM V27 Maintenance Director stated he does not know anything about Legionella nor the processes of the facility regarding prevention of Legionella. On 3/17/26 at 1:33 PM V1 Administrator stated she cannot find any facility legionella prevention and/or monitoring. V1 stated she started working at the facility as the Administrator just 7 days ago. V1 stated she educated V27 Maintenance Director today (3/17/26) and stated going forward V27 will follow the facility's Legionella Prevention policy and procedure. V1 stated V27 will start monitoring water temperatures weekly starting today. The Facility's Inservice Form dated 3/17/26 documents Inservice Title: Legionella Policy and Prevention Training. Summary of the Inservice – prevention, weekly temps, assessment of the building risk, and emergency water supplies. Expected outcomes of the inservice – Legionella prevention, weekly maintenance water temps, and risks. This Inservice Form is signed by V27 Maintenance Director. On 3/17/26 at 3:01 PM Surveyor asked V1 Administrator if V27 Maintenance Director or anyone of the facility was implementing any part of the Facility policy by assessing and monitoring for Legionella and V1 stated no, that is why she educated V27 today. On 3/18/26 at 7:53 AM V1 Administrator stated the 100-unit rooms are no longer in use. Surveyor asked if there has been any Legionella testing or preventative measures for the unused 100 unit and V1 stated no. The Facility's Water Management Program for Prevention of Legionella Growth policy dated 6/30/17 documents Purpose: To identify and reduce the risk of Legionella growth and spread. Legionella is found naturally in freshwater environments, like lakes and streams, but generally the low amounts in freshwater do not lead to disease. Legionella can become a health problem in building water systems. To pose a health risk, Legionella fist must grow (increase in numbers). Then it must be aerosolized so people can breathe in small, contaminated water droplets. Areas of potential risk include but are not limited to hot and cold-water storage tanks, water heaters, water filters, manual faucets, aerators, faucet flow restrictors, showerheads, pipes, valves, fittings, centrally installed misters and humidifiers, non-steam aerosol-generating humidifiers, infrequently used equipment including eyewash stations, and ice machines. Preventative maintenance will be performed as applicable. The following will be verified and documented at least once weekly: The domestic hot water boiler/storage tanks verified to be set between 140-160 degrees F (Fahrenheit). Thermostat indicating the temperature of water entering the circulating system at the mixing valve is 120 F or above. Eye wash stations will be inspected and flushed weekly. Ice machines will be inspected and cleaned internally at least every 3-6 months and as needed for leakages or contamination. It continues, even if the water entering your building is of high quality, it may contain Legionella. In some buildings, processes such as heating, storing, and filtering can degrade the quality of the water. The processes use up the disinfectant the water entered with, allowing the few Legionellae that entered to grow into a large number if not controlled. Actions may include one or more of the following as determined by the facility: adjusting water temperatures and temporary increase in monitoring, heat flush treatment, chemical flush treatment, routine flushing of water lines, water testing. The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 3/16/26, documents that are 56 residents living in the facility. 2. On 3/17/26 at 10:13 AM, V23, CNA, and V24, CNA, entered to provide incontinent care for R44, both donned gloves with no hand hygiene seen done. R44 was lifted off his wheelchair using a sit-to stand device, and while standing with his body bent over, his incontinent brief was removed which was wet with urine, V23 changed gloves after removing the soiled brief, then with no hand hygiene done, got a wet washcloth from the sink, no soap or cleaning spray used, briefly wiped R44's front side, penis and testicles, then using the same soiled gloves, got another wet cloth and wiped R44's buttocks. V23 continued to use soiled gloves she used to clean R44's buttocks to pull up R44's pants and lower him to his wheelchair, then controlled the device and wheelchair with same soiled gloves on. There was no hand hygiene done between the one glove change. 3. On 3/16/26 at 1:30 PM, V12, CNA, and V20, CNA, were observed performing peri-care on R50. R50's pants pulled down and brief unfastened and removed which appeared to be saturated in urine with strong urine smell. V20 used the same soiled gloves she took off the saturated brief with, got a wet cloth from a basin of water and wiped R50's vagina, then with same gloves on, got another cloth from basin of water and wiped R50's left buttock while turned to her right, R50 rolled over to her left side and wiped R50's right buttock. V20 got a dry washcloth and wiped R50's buttocks and anal area using the same soiled gloves. V20 then touched R50's pillows, sheet, and pulled the blanket over R50. No was no hand hygiene or glove changes done between soiled to clean areas. On 3/19/26 at 9:42 AM, V24, CNA, stated We check the residents before and after breakfast, lunch, and dinner. Most of our residents put their call lights on and will let us know when they have to use the restroom. restroom. When I'm doing peri-care, I change my gloves after I take off the dirty (incontinence brief) and any time after wiping a dirty area. I use hand sanitizer when changing my gloves. I do hand hygiene before and after resident care. On 3/19/26 at 9:50 AM, V9, CNA, stated I check my residents every two hours. Most of our residents use their call lights when they need assistance. assistance. When I am doing peri-care, I change my gloves before and after care, after wiping a dirty area and before getting a clean washcloth. I use hand sanitizer when I am changing my gloves and wash my hands before leaving the room.On 3/19/26 at 12:25 PM, V1 stated I would expect the staff to perform complete incontinent care, including cleaning all areas and performing glove changes and hand hygiene when necessary. The Facility's Glove Use - Nursing Policy, dated 12/5/24, documents in part, This facility will provide gloves of appropriate quality and size for nursing personnel and use appropriate type of gloves based on medical or surgical aseptic technique and in accordance with Universal/Standard Precautions and Transmission Based Precautions. Non-sterile gloves shall be worn for procedures involving contact with mucous membranes and for other resident care or diagnostic procedures requiring a sense of touch or that require contact with blood or body fluids that are visibly contaminated with blood. Examples include but are not limited to: Incontinence. 5. Gloves used for contact shall be removed and discarded after contact with each person, fluid item, or surface. care. 7. Hand hygiene will be performed after removing gloves. When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for cleaning your hands in the healthcare setting. Soap and water are recommended for cleaning visibly dirty hands. The Facility's Hand Hygiene/Handwashing Policy, dated 12/5/24, documents in part Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Examples of When to Perform Hand Hygiene (Either Alcohol Based Hand Sanitizer or Handwashing): Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed), after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, if hands will be moving from a contaminated-body site to a clean-body site during patient care, after glove removal. 4. On 3/16/2026 at 1:43 PM V11, CNA, applied R55's clean brief. V9, CNA, and V11 then assisted R55 into a standing position. V9 then using a wet washcloth cleansed R55's buttocks. With the same soiled gloves V9 then pulled up R55's brief and pants. With the same soiled gloves grabbed a hold of the gait belt and assisted R55 with transfer to wheelchair, touching the arm of the chair with soiled gloves. V9 then, with the same soiled gloves adjusted R55's clothes. 5. On 3/16/2026 at 1:00 PM observed V9, Certified Nurses Assistance (CNA) and V11, CNA, performed incontinent of care. R4 was incontinent of bowel. V9 cleansed stool from R4's anus and partial buttocks. V11 removed the soiled incontinent brief and placed it on the floor. With the same soiled gloves V9 pushed the mechanical lift back. V9 straightened the clean pad beneath R4. With the same gloves pulled R4's gown down, applied clean cover, and lowered bed using crank handle. The facility's Glove Use policy, dated 12/5/2024, documents Non-sterile gloves shall be worn for procedures involving contact with mucous membranes and for other resident care or diagnostic procedures requiring a sense of touch or that require contact with blood or body fluids that are visibly contaminated with blood. Examples include, but are not limited to: Incontinence care. 7. Hand hygiene will be performed after removing gloves. When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for cleaning your hands in the healthcare setting. Soap and water are recommended for cleaning visibly dirty hands

Based on observation, interview, and record review, the facility failed to ensure that residents and employees were offered COVID-19 vaccinations in accordance with current CDC (Centers for Disease Control) guidelines and facility policy. This deficient practice has the potential to affect all residents residing in the facility who were eligible for a COVID-19 booster. Findings Include: On 3/18/26 at 11:03 AM V7 ADON/IP (Assistant Director of Nursing/Infection Preventionist) stated she did not start working at the facility until November of 2025. V7 stated she is not aware of any residents being offered the COVID booster vaccination unless it was completed prior to her working at the facility. On 3/18/26 at 11:10 AM V14 [NAME] President of Operations stated this company does offer COVID booster vaccines although they did not take over this facility until November of 2025. V14 stated she would check with nursing to see if any residents were offered COVID booster vaccines prior to 11/2025. On 3/18/26 at 11:26 AM V14 stated she checked with Facility staff and no residents were offered COVID vaccines nor boosters last year. V14 stated she will set up a vaccine clinic as soon as possible. V14 stated she expects the Facility to offer COVID vaccines yearly and she expects staff to educate residents who decline any vaccine to be educated on a yearly basis. On 3/18/26 at 12:07 PM V14 stated the Facility did not offer any employees a COVID-19 vaccination in 2025.The Facility's COVID-19 Vaccination Guidelines policy dated 12/23/20 documents purpose: to minimize the risk of residents acquiring, transmitting, or experiencing complications from SARS-CoV-2 (COVID-19). Guidelines: The facility shall provide pertinent information about the significant risks and benefits of the vaccine to residents (or resident's legal representative) and employees; for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. Residents and their representatives have the right to refuse the COVID-19 vaccine in accordance with Resident Rights. Therefore, the facility cannot take any adverse action against a resident or representative who refuses the vaccine, including social isolation, denied visitation and involuntary discharge. As of June 5, 2023 employees are no longer required to receive the COVID-19 vaccine as a condition of employment or to have an approved religious or medical exemption if declined. However, the COVID-19 vaccine should still be offered, and education provided to those employees eligible to receive the vaccine and obtain vaccination history. Offering COVID-19 Vaccine & Education: When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident or staff member has already been immunized. Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine. In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses. A new consent should be obtained with each dose of the COVID-19 vaccine. The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision; and the resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and Each dose of COVID-19 vaccine administered to the resident, or If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following: That staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine; Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and The COVID-19 vaccine status of staff and related information as indicated by NHSN. If a staff member is not eligible for COVID-19 vaccination because of previous immunization at another location or outside of the facility, the facility should request vaccination documentation from the staff member to confirm vaccination status. The facility will educate and offer COVID-19 vaccinations to direct hire staff only and will not be required to provide education or offer the vaccine to contracted staff. If a resident or staff member requests vaccination against COVID-19, but missed earlier opportunities for any reason (including recent residency or employment, changing health status, overcoming vaccine hesitancy, or any other reason), the facility should offer the vaccine to that individual as soon as possible, including booster doses. If the vaccine is unavailable in the facility, the facility should provide information on obtaining vaccination opportunities (e.g. health department or local pharmacy) to the individual, however it is expected that the facility will provide evidence, upon request, of efforts made to make the vaccine available to its staff and residents. Similar to influenza vaccines, if there is a manufacturing delay, the facility should provide evidence of the delay, including efforts to acquire subsequent doses as necessary.The Department of Health and Human Services, Centers for Medicare & Medicaid Services, Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 3/16/26, documents that are 56 residents living in the facility.

Based on observation, interview, and record review the facility failed to perform catheter and complete incontinent care for 4 of 4 (R4, R11, R44, R50) residents reviewed for toileting in a sample of 42.Findings include: 1 R4's Care plan, dated 12/17/2025, documents that (R4) has a Hx (history) of UTI (urinary tract infection) and is At Risk for Recurrent/Chronic Urinary Tract Infection 12/3/25 Foley cath (catheter) placed due to pressure ulcers. 12/3/25 Indwelling urine cath care, peri care, and change per MD (doctor)orders. Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. R4's Minimum Data Set (MDS), dated [DATE], documents that R4 is cognitively impaired, always incontinent of bowel, has an indwelling catheter, and dependent on staff for toileting. On 3/16/2026 at 1:00 PM observed V9, Certified Nurses Assistance (CNA) and V11, CNA, performed incontinent of care. R4 was incontinent of bowel. V9 and V11 assisted R4 onto her left side. V9 using wet wash clothes wiped the anal area. V9 and V11 then assisted R4 onto her back. Pulled down R4's gown and applied covers. V9 and V11 did not cleanse R4's entire buttock or perform incontinent care. 2. R55's Care Plan, dated 2/10/26, documents that (R11) wears adult undergarments r/t incontinence. It also documents Assist to toilet q2h and PRN (as needed). R55's MDS, dated [DATE], documents that R55 is cognitively intact, frequently incontinent of urine, always incontinent of bowel, and dependent on staff for toileting. On 3/16/2026 at 1:27 PM observed V9 and V11 toileting R55. V9 and V11 assisted R55 from the wheelchair to the free-standing commode in room. V9 and V11 assisted R55 with pulling pants down revealing a heavily soiled urine soak incontinent brief. V9 and V11 assisted R55 onto the toilet. At 1:43 PM V11 applied R55's clean brief. V9 and V11 then assisted R55 into a standing position. V9 then using a wet washcloth cleansed R55's buttocks. V11 and V9 then pulled up R55's brief and pants. V9 and V11 did not cleanse R55's entire buttocks, peri area, groin, inner thighs, and labia. 3. R44's admission Record, dated 3/19/26, documents R12 was originally admitted to the facility on [DATE], with diagnosis of Type 2 Diabetes Mellitus (DM), Congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), Benign prostatic hyperplasia (BPH), Dysphagia, Malnutrition, Lumbar disc degeneration, first degree Atrial-Ventricular block, chronic kidney disease (CKD), Anemia, Polyosteoarthritis, Spinal stenosis, Dorsalgia, Trans Ischemic Attach (TIA)/Cerebral infarction without residual deficits, osteoarthritis, Hypertension (HTN). R44's Care Plan, dated 4/7/25, documents R12 is provided extensive assist with activities of daily living (ADL's) related to weakness. Interventions: R44 is non-ambulatory, requires assistance of 1-2 with hygiene, clothing adjustment, transfers, keep call light within reach and encourage use, answer promptly. 9/19/25: R44 has a history of urinary tract infections (UTI) and is at risk for recurrent/chronic UTIs. Interventions: Check at least every two hours for incontinence. Wash, rinse and dry soiled areas. R44's MDS, dated [DATE], documents R44 has a moderate cognitive impairment and is dependent on staff for ADLs and transfers. R44 is frequently incontinent of both bowel and bladder. On 3/17/26 at 10:13 AM, V23, CNA, and V24, CNA, entered to provide incontinent care for R44 while sitting in wheelchair. Both CNAs donned gloves with no HH seen done, a sit-to-stand device placed in front of R44, sling applied around R44 and then attached to the device. R44 was lifted off his wheelchair, incontinent brief removed and was wet with urine, V23 changed gloves with no hand hygiene done, then got a wet washcloth from sink, no soap or cleaning spray used, and while R44 was bent over standing, briefly wiped R44's front side, penis and testicles, then got another wet cloth and wiped R44's buttocks. V21, LPN, in room and applied cream to R44's buttocks which appeared to have slight rash. V24 applied clean brief to R44 and then pulled pants up. V23 continued to use soiled gloves she used to clean R44's buttocks to pull up R44's pants and lower him to his wheelchair, then controlled the device and wheelchair with same gloves on. There was no soap or peri-cleaner used, R44's anal area was never cleaned, and no hand hygiene done between the one glove change with soiled gloves. 4. R50's admission Record, dated 3/19/26, documents R50 was originally admitted to the facility on [DATE], with diagnosis of Vascular Dementia, Alzheimer's disease, Major depressive disorder, IBS, HTN, Osteoporosis, Generalized anxiety disorder, Dysphagia, COPD, Psychosis, COVID, Contracture left and right hand, chronic resp. failure, Emphysema. R50's Care Plan, dated 4/16/25, documents R50 requires assist with ADL's r/t dementia, Alzheimer's, weakness. Intervention: Toileting Schedule: Every 2 hours & PRN. R50 wears adult undergarments r/t incontinence of bowel and bladder. Interventions: Assist with incontinence q2h and PRN, Keep clean, dry, free of irritating substances. R50 is at risk for falls r/t weakness, Dementia. Interventions: Assist with ADL's, Quarterly fall assessment, Review past falls and attempt to determine cause, Anticipate needs, promote physical activity for strengthening, keep furniture in locked position, Provide a safe environment: even floors free of spills and/or clutter, adequate, glare free light, bed in low position at HS, assistive devices in place, personal/needed items within reach. R50's MDS, dated [DATE], documents R50 has a severe cognitive impairment and is dependent on staff for all ADLs and transfers. R50 is always incontinent of both bowel and bladder. On 3/16/26 at 1:30 PM, V12, CNA, and V20, CNA, were observed performing peri-care on R50. R50's pants pulled down and brief unfastened and removed which appeared to be saturated in urine with strong urine smell. V20 used same soiled gloves she took off the saturated brief with, then got wet cloth from a basin of water and wiped R50's vagina, then with same gloves on, got another cloth from basin of water and wiped R50's left buttock while turned to her right, R50 rolled over to her left side and wiped R50's right buttock. V20 got a dry washcloth and wiped R50's buttocks and anal area using the same soiled gloves. V20 then touched R50's pillows, sheet, and pulled the blanket over R50. No was no hand hygiene or glove changes done between soiled to clean areas. The Facility's Incontinence Care Policy, dated 4/20/21, documents in part, Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode. 2. Perform hand hygiene and put on non-sterilegloves. 4. Soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe. b) Rinse with remaining cloth using clean surfaces for all surface areas. Do not place soiled soapy cloths back in clean basin water until procedure completed. May drape soiled cloths over the side of the wash basin, or place directly in soiled linen plastic bag. c) Clean/rinse inner/upper thigh areas to remove urine moisture. 6. Gently pat area dry with a towel from anterior to posterior. 8. Using the final rinse cloth, from frontwashing, wash and rinse the peri-anal area. Pat dry. 9. Change gloves and perform hand hygiene. 12. Remove gloves and perform hand hygiene. The Facility's Glove Use - Nursing Policy, dated 12/5/24, documents in part, This facility will provide gloves of appropriate quality and size for nursing personnel and use appropriate type of gloves based on medical or surgical aseptic technique and in accordance with Universal/Standard Precautions and Transmission Based Precautions. Non-sterile gloves shall be worn for procedures involving contact with mucous membranes and for other resident care or diagnostic procedures requiring a sense of touch or that require contact with blood or body fluids that are visibly contaminated with blood. Examples include but are not limited to: Incontinence. 5. Gloves used for contact shall be removed and discarded after contact with each person, fluid item, or surface. care. 7. Hand hygiene will be performed after removing gloves. When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for cleaning your hands in the healthcare setting. Soap and water are recommended for cleaning visibly dirty hands. The Facility's Hand Hygiene/Handwashing Policy, dated 12/5/24, documents in part Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Examples of When to Perform Hand Hygiene (Either Alcohol Based Hand Sanitizer or Handwashing): Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed), after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, if hands will be moving from a contaminated-body site to a clean-body site during patient care, after glove removal.

Based on interview, observation, and record review, the facility failed to provide the residents a meal that was palatable, attractive, and at a safe and appetizing temperature for 5 of 14 residents (R12, R23, R32, R35, R37) reviewed for palatable meals in the sample of 42.The findings include: 1. R12's admission Record, dated 3/19/26, documents R1 was originally admitted to the facility on [DATE].R12's minimum data set (MDS), dated [DATE], documents R12 is cognitively intact.On 3/16/26 at 9:34 AM, R12 stated she eats in her room and the food is cold. R12 stated they served her a cold hot dog a couple weeks ago and she made them warm it up. 2. R23's admission Record, dated 3/19/26, documents R23 was originally admitted to the facility on [DATE].R23's MDS, dated [DATE], documents R23 is cognitively intact.On 3/16/26 at 9:55 AM, R23 stated eats in her room and food is not tasty and usually cold. R23's breakfast plate on bedside table with eggs and hashbrowns, there was no lid on the plate and the food cold. R23 stated they will bring it in even if I'm sleeping and leave it on my table. 3. R32's admission Record, dated 3/19/26, documents R32 was originally admitted to the facility on [DATE].R32's MDS, dated [DATE], documents R32 has a moderate cognitive impairment.On 3/16/26 at 10:45 AM, R32 stated he eats in room and some of the food is delicious, and some you can't cut with a chainsaw. R32 stated food needs seasoning and is warm half time and cold the rest.4. R35's admission Record, dated 3/19/26, documents R35 was originally admitted to the facility on [DATE].R35's MDS, dated [DATE], documents R35 has a moderate cognitive impairment.On 3/16/26 at 11:12 AM, R35 stated the food is mostly cold, especially the breakfast. R35 stated she feels the food is getting worse.5. R37's admission Record, dated 3/19/26, documents R37 was originally admitted to the facility on [DATE].R37's MDS, dated [DATE], documents R37 has a moderate cognitive impairment.On 3/16/26 at 10:07 AM, R37 stated she eats in the dining room, and the food doesn't taste good at all and sometimes it is warm at best and sometimes it is cold.5. On 3/17/26 at 12:04 PM, a test plate was delivered to the conference room with a plastic lid covering the plate. The plate itself was not hot or warm to touch. It included Corned Beef, Cabbage, Carrots, Potatoes, and a piece of cake. Corned Beef temperature was at 113 degrees Fahrenheit (F). with a very bland and cold to taste.Carrots temperature was at 122 degrees F. with a very bland taste and slightly warm.Potatoes temperature was 132 degrees F. and tasted seasoned and was warm to taste. Cabbage temperature was 134 degrees F. and tasted mushy, was bland had no flavor, and was warm to taste.Cake temperature was 65 degrees F. and tasted dry to taste.On 3/19/26 at 12:40 PM, V4, Dietary Manager, stated I have had some resident complaints of cold food and bland food and there is not much I can do. I encourage residents to eat in the dining room where the food comes straight from the steam table, but most insist on eating in their room. Maybe we could have more staff helping to deliver the trays in resident rooms, or maybe deliver so many trays at a time, instead of a cart full. The food cart that is used is not heated. I have tried to educate the dietary staff on proper food temperatures and timing. I advised them not to put the food on the steam table too early and to wait until residents are ready to eat.On 3/19/26 at 1:30 PM, Upon reviewing the Facility's Resident Council Meeting minutes done monthly, they mention that the Food Advisory Committee meets to discuss dietary issues. When questioned about this, V1, Administrator, brought in the Food Advisory Committee minutes which were dated 2014 through 2016. V1 stated I guess they haven't been documenting the issues or complaints since then. I will have (V4, Dietary Manager) sit in on these meetings and documents concerns so they can be addressed.The Facility's Serving Temperatures for Hot and Cold Foods Policy, dated 2020, documents in part 1. Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods. These are minimum serving/holding temperatures and may vary based on state regulations. Each facility should check their state specific regulations for the minimum hot food holding and serving temperatures. Hot foods served at higher temperatures, based on resident preference, must be done cautiously because foods served too hot may potentially decrease food quality and possibly contribute to resident burns. 8. Plates or trays prepared first are served first. No more than four plates or trays are prepared at once.

Based on interview, observation, and record review, the facility failed to maintain privacy for 1 of 14 residents (R27), to maintain a clean resident refrigerator with temperature checks for 1 of 14 residents (R4) and to maintain the safety of the environment related to the presence of hazards in the resident room for 1 of 14 residents (R30) reviewed for a homelike environment in the sample of 42.The findings include: 1. R27's admission Record, dated 3/19/26, documents R27 was originally admitted to the facility on [DATE]. R27's Minimum Data Set (MDS), dated [DATE], documents R27 is cognitively intact. On 3/16/26 at 10:55 AM, R27 seen sitting in chair in room with walker in front of her. R27's door to her room is missing hinge in middle and the door will not close with several inches of door extending past the door frame when trying to close the door. R27 stated I wish they would fix that door. I have told people about it several times and no one is fixing it. On 3/17/26 at 9:45 AM, R27 in wheelchair with walker in front of her, R27's door is still not fixed, R27 stated It upsets me because this is my home, and anyone can just come in. It is not a problem during the day if I am just sitting here, but at night the door doesn't close, and I don't have any privacy. On 3/18/26 at 9:50 AM, V1, Administrator, stated V28, Maintenance Director, has only been here since October or November. I am finding maintenance requests that were signed off by him and the previous administrator and now finding out those things were not really fixed. I knew nothing about (R27's) door not closing. Upon showing V1 R27's door, V1 stated That isn't even the correct door for that door frame. It looks like he cut it on the side where hinges go, is missing one hinge, and cut it along the top crooked. I see that the door extends past the door frame and is unable to be closed. This is not only a privacy issue, but a fire safety issue. I will have this fixed today. On 3/19/26 at 12:25 PM, V1 stated I would expect all staff to report any equipment or building issues that need addressed to maintenance so that it will be repaired. I can tell you that some things were reported and were not getting taken care of by (V27, Maintenance Director). The Facility's Resident Rights Policy, dated 1/4/19, documents in part To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Privacy and confidentiality. The Facility's Refrigerators in Resident Rooms Policy, dated 2020, documents in part In keeping with the home-like environment for residents, some residents will request to have a refrigerator in the room. Residents and/or responsible party that request to have a refrigerator in the room will be counseled on food safety guidelines. Resident and/or responsible party will agree to allow periodic safety checks by staff and allow staff to discard outdated food per safety guidelines. 2. Each refrigerator shall have a temperature log with daily entry. Each refrigerator will have an inside thermometer. The refrigerator temperature will be maintained at or below 41 degrees F. If the temperature is not maintained at 41 degrees F or below, the food will be discarded. 3. The housekeeper will enter the temperature once daily. Any temperatures not in range will be immediately reported to the Housekeeping Supervisor or Nursing Supervisor and Maintenance. 8. The housekeeping department will clean and sanitize the refrigerators at least once a month or as required. 9. Housekeeping Supervisor will conduct at least monthly quality assurance audit of refrigerators to monitor adherence to procedure. 2. R30's Minimum Data Set, dated [DATE], documents that R30 is cognitively intact. On 3/16/2026 at 9:21 AM R30 stated that the sink in the bathroom is loose and falling over. R30 stated that water is coming from under the sink and coming up through the floor in the bedroom. R30 stated that she does a lot for herself and that its scary when trying to provide care for herself because she doesn't want to fall. R30 stated that its not safe or clean in the bathroom so she uses it as little as possible because she doesn't want to fall. R30 stated that she has told maintenance and the administrator, and nothing has been done. On 3/16/2026 at 9:21 AM observed white pedestal sink detached from the wall. When touching the sink, it moved freely waving back and forth, with top moving and wobbling on top of the pedestal. Observed braces to wall. Sink not attached. Observed bath towels on the floor at the base of the sink. Observed bath blankets on the floor in resident room. On 3/17/2026 at 10:03 AM V27, Maintenance, stated that the previous maintenance guy did not connect all of the pipes. V27 stated this caused the water to leak at the base of the sink and in R30's room. V27 stated that the sink is not attached properly and is unsafe. V27 stated that there was a different sink and was replaced with this sink. V27 stated that the residents were using the sink to stand and pulling from the wall. V27 stated that the previous administrator thought the pedestal would be better, but it was not installed properly. V27 stated that the way the sink is currently not safe. V27 stated that (R30) is independent with moving about the room and water on floor is not safe. 3. On 03/16/2026 at 9:36 AM observe a refrigerator in R4's room. No temperature log observed. The thermometer located in the refrigerator not working. The refrigerator was not plugged in. Observed mold and dead bugs on the 2-plastic container of peaches, 2 containers of cappuccino, 5 coke zero cans, door, and shelving in the refrigerator fridge. On 3/16/2026 at 1:07 PM V11, CNA, stated that the refrigerator was not plugged in and should be. V11 stated that there are dead bugs and mold on containers and in the refrigerator. V11 stated that she is not sure who takes care of the refrigerators. On 3/16/2026 at 1:08 PM V9, CNA, stated that the refrigerator does have mold and bugs in the refrigerator. V9 stated that on Sundays R4's family would come and stock the refrigerator and she assumed it was cared for by the family. V9 stated that she doesn't work on Sundays and is not sure if the family comes. On 3/19/2026 at 9:23 AM V35, Housekeeper, stated that she checks the refrigerator from time to time but the Housekeeping Supervisor (V36) handles the residents' refrigerator. On 3/19/2026 at 10:27 AM V36 stated that she is not sure who does the refrigerator in rooms. V36 stated that there should be a Temperature log on the refrigerator dated for each day of the week. V36 stated that housekeeping is to check the temps daily. V36 stated that they have had admissions and room changes and the log may have not been applied. V36 stated that she doesn't have any previous temperature logs from resident's room refrigerators. V36 stated that the refrigerators are cleaned as need by housekeeping. On 3/19/2026 at 10:56 AM V14, [NAME] President of Operations, stated that they don't have daily temperatures for the refrigerator in the resident's room. V14 stated that they are fixing that now. On 11/15/2026 at 11:15 AM V36 opened R4's refrigerator. The refrigerator contained the following mold and dead bugs on the 2-plastic container of peaches, 2 containers of cappuccino, 5 coke zero cans, door, and shelving in the refrigerator fridge. V36 stated that Oh my. This should have been checked and cleaned a long time ago. V36 then started removing items from the refrigerator. V36 stated that she did not know that it was like that. At 11:18 AM V36 stated that the refrigerator was not working. V36 stated that she would be cleaning the refrigerator and notifying the family for a replacement. V36 stated that she doesn't believe that R4 has taken anything out of the refrigerator but if she wanted to she couldn't due to the conditions. 4. R49's MDS, dated [DATE], documents that R49 is cognitively intact. On 3/16/2026 at 9:30 AM observed R49 in wheelchair rubber wheel on wheelchair missing. Plastic wheel frame not touching floor. On 3/16/2026 at 9:45 AM observed the rubber wheel lying on the floor beneath the window in R49's room. On 3/16/2026 at 9:45 AM R49 stated that his wheelchair wheel is broken and causes him a problem with trying to propel himself in the wheelchair. R49 stated that he likes moving about but the wheel is hard to move with his weight and the wheel not touching the floor. R49 stated that the frame slides and keeps rolling in the air. R49 stated that the rubber wheel is on the floor next to the window. R49 then pointed to floor under window in his room. R49 stated that he has told the maintenance main repeatedly and nothing has been done. The facility's Refrigerators in Resident Rooms Guideline: In keeping with the home-like environment for residents, some residents will request to have a refrigerator in the room. Residents and/or responsible party that request to have a refrigerator in the room will be counseled on food safety guidelines. Resident and/or responsible party will agree to allow periodic safety checks by staff and allow staff to discard outdated food per safety guidelines. Procedure: 1. The Housekeeping Department will keep a current list of rooms with resident refrigerators. 2.Each refrigerator shall have a temperature log with daily entry. Each refrigerator will have an inside thermometer. The refrigerator temperature will be maintained at or below 41 degrees F. If the temperature is not maintained at 41 degrees F or below, the food will be discarded. 3. The housekeeper will enter the temperature once daily. Any temperatures not in range will be immediately reported to the Housekeeping Supervisor or Nursing Supervisor and Maintenance. 4. The Dining Services Manager or Registered Dietitian will in-service the housekeeping staff regarding the correct use of thermometer, correct refrigerator temperature guidelines, and the policy to discard leftover food after three days. 5. All food in the refrigerator will be labeled with the common name and use by date. 6. All food will be monitored when daily temperature check is performed. Any food item past its use by date will be discarded by staff or resident. The resident and/or the resident's responsible party will be educated on food safety and leftover food to be discarded after three days. 7. Residents and/or resident's responsible party will be notified of discarded food items as required. 8. The housekeeping department will clean and sanitize the refrigerators at least once a month or as required. 9. Housekeeping Supervisor will conduct at least monthly quality assurance audit of refrigerators to monitor adherence to procedure. The facility's Physical Plant & Environmental Policy & Guidelines, not dated, documents that Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean, and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort, and home-like surroundings for residents. A well-maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (National Fire and Protection Association) codes. This includes making certain a safe and hospitable environment as possible is maintained in the event of an emergency for sheltering in place. Maintenance/ Approved Contractors: Routine care and repairs to interior finishings - repairing ceiling/wall damage, painting, floor, General plumbing - drains, faucets, showers are maintained, Wheelchair and bed maintenance, Secured exterior doors.

Based on interview and record review, the facility failed to prevent sexual abuse to a resident by an employee and failed to prevent physical abuse of a resident from another resident for 2 of 3 residents (R7, R22) reviewed for abuse in the sample of 42.Findings Include:1.R22's admission Record print date of 3/18/26 documents R22 has diagnoses including vascular dementia with behavioral disturbance, peripheral vascular disease, anxiety, supraventricular tachycardia, heart disease, and osteoarthritis. R22's MDS (Minimum Data Set) dated 1/31/26 documents R22 is severely cognitively impaired and requires substantial to maximal assistance with transfers. The Facility's undated Preliminary 24-hour Abuse Investigation Report documents an offense was alleged against R22 by an employee. The Facility's undated Final Abuse Investigation Report documents name of resident abuse: (R22). The original allegation: unknown date and time. Allegedly this incident happened in her room. This was reported to Administrator by Activity Director. Unit Aide (V19) did kiss this resident on the mouth/lips. No injuries noted. The Unit Aide in his statement stated he did kiss her only once on the mouth. Through thorough investigation, talking to staff and residents, this incident did occur. Based on the known facts, the following conclusions have been determined about the original allegation: This incident was substantiated. The Facility's Human Resource Notice of Corrective Action for V19 and dated 1/15/26 documents Employee Explanation: He stated he did kiss (R22) on the lips like he would for his grandma.2. R7's admission Record with print date of 3/19/27 documents R7 has diagnoses including end stage renal disease, chronic obstructive pulmonary disease, major depressive disorder, hyperkalemia, type 2 diabetes mellitus, and anxiety disorder. R7's MDS dated [DATE] documents R7 is cognitively intact and independent with ADLS (activities of daily living). R7's progress note dated 12/12/25 at 2:27 PM documents R7 was outside smoking, R33 came outside and began yelling at R7. R33 then came back into the facility and went to his own room. As R7 was coming into the facility and passed R33's room, R33 opened the door and threw a cup of coffee on R7. Residents were separated immediately and assessed for injuries. No injuries were noted at this time. R7 states that he was outside smoking and R33 came out and started harassing him. He stated this is not the first time. He then said he came into the facility and walked past R33's room where he threw a cup of coffee at him. The facility's Report to IDPH (Illinois Department of Public Health) dated 12/12/25 documents this writer continued investigation with interviewing staff and residents, this was witnessed incident. During thorough investigation, this writer concluded that R7 was outside and R33 went outside and started yelling at R7 on 200 hall. R33 went back in his room. When R7 came back in from smoking outside, R33 threw coffee on R7 and R7 pushed R33 in the chest, pushed him away with open hands. The pushing happened in the doorway of R33's room. On 3/19/26 at 11:41 AM V14 [NAME] President of Operations stated the abuse to R22 by V9 and the abuse between R33 and R7 did occur.On 3/19/26 at 12:58 PM R7 stated R33 did throw coffee on him and he did not have any injuries. The facility's Abuse and Retaliation Prevention and Reporting policy dated 1/8/26 documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, 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 ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. This will be done by conducting pre-employment screening of employees and pre-admission screening of residents, orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, retaliation, and misappropriation of property; establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. It continues, abuse means any physical or mental injury, retaliation, or sexual assault inflicted upon a resident other than by accidental means.

Based on observation, interview, and record review, the facility failed to ensure a resident's medication regimen was free from chemical restraint for 1 of 5 residents (R2) reviewed for unnecessary medications in a sample of 42. Findings Include: On 03/16/26 at 10:30 AM, R2 was lying in her bed on her back sleeping with her head slightly elevated. On 03/17/26 from 9:30 AM through 12:30 PM, with checks done in 15-minute intervals R2 was seen lying in her bed sleeping. On 03/19/2026 at 12:15 PM, R2 is sitting up in her wheelchair in the dining room with her meal tray in front of her. She only ate about half of her lasagna and R2 was just sitting and staring out the dining room window. R2's Face Sheet, admission date of 12/05/25, documents R2 has diagnoses of but not limited to bilateral primary osteoarthritis of knee and dementia other diseases classified elsewhere, severe, with psychotic disturbance. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is severely cognitively impaired, and she is dependent or requires substantial/maximal assistance with her activities of daily living (ADLs). R2's Physician's Orders, documented the following: Dated 12/05/25, Divalproex Sodium Oral Capsule Delayed release sprinkle 125 milligrams (mg), give two (2) capsules by mouth in the morning and give four (4) capsules by mouth in the evening related to unspecified dementia, severe, with agitation. Dated 12/05/25, clonazepam Oral Tablet 0.5 MG (Clonazepam) *Controlled Drug*Give one (1) tablet by mouth two times a day related to unspecified dementia, severe, with agitation. Dated 12/05/25, Melatonin Oral Tablet 5 MG (Melatonin), Give 1 tablet by mouth at bedtime for insomnia. Dated 12/05/25, Memantine HCl Oral Tablet 10 MG (Memantine HCl), Give 1 tablet by mouth two times a day related to unspecified dementia, severe, with agitation. Dated 12/05/25, Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride)Give 1 tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, severe, with psychotic disturbance. Dated 12/20/25, Mirtazapine 7.5 MG Tablet, Give 7.5 mg by mouth one time a day for depression Dated 12/05/25, Celexa oral tablet 10mg, give 1 tablet by mouth in the morning for depression. Dated 10/05/25, Haloperidol Lactate inj Dated 01/21/26, RisperDAL Oral Tablet 0.5 MG (Risperidone), Give 1 tablet by mouth two times a day related to unspecified dementia, severe, with agitation. On 03/19/2026 at 7:35 AM V16, Certified Nursing Assistant (CNA) stated when breakfast comes, they try to wake up the residents but sometimes they won't wake up. V16 said R2 does sleep a lot. On 03/19/2026 at 12:09 PM, V18, Activities Assistant said R2 has been in bed and sleeping a lot lately. She said a while back there was a time for a week, she didn't want to get up out of bed. On 03/19/2026 at 12:40 PM, V37, (R2's Family Member) said the last time she saw R2 she felt like R2 was on too much medication. V37 said R2 seemed like she was snowed. V37 said she came to see R2 back in Feb. on R2's birthday and R2 was walking around and everything but the last time she saw R2 she didn't even want to get up out of bed. V37 stated when R2 was at home with her R2 wasn't on any type of psychotropic medication. The only type of medications she took were for like blood pressure and high cholesterol. V37 stated that's why when the facility called her recently, she wouldn't agree to anything new until she had someone go over R2's medications with her and explain them to her and they figure out what is necessary and what is not. She said she doesn't feel like it's necessary for R2 to be on several different medications for behavior. V37 stated R2 now has new areas to her heels and to her bottom and she thinks it's because R2 is lying in her bed all the time.

Based on interview, observation, and record review, the facility failed to provide a Bed Hold for 1 of 14 residents (R60) who was transferred to the hospital from the facility reviewed for proper transferring or discharging of a resident in the sample of 42.The findings include: R60's admission Record, dated 3/19/26, documents R60 was admitted to the facility on [DATE] and was discharged on 3/6/26 after being admitted to the hospital. R60's Progress Note, dated 3/4/26 at 5:37 AM, documents Resident had difficulty breathing. Restless and yelling out. Went in to check on him and saw him struggling to breath efficiently, checked O2 (oxygen) and it was 88. Grabbed oxygen and started on 2L (liters). Placed on 3L to get O2 up to 96. Listen to lung sounds. Wheezing in lower right lobe with mix of Stridor. Resident was more comfortable with the O2 on. Called Dr (doctor), he leaned towards sending him out to hospital if family agreed. Called first emergency contact and had to leave a voice message. Called second contact and she agreed to send to hospital. Continued checking O2 till ambulance arrived. Send papers with them and called hospital to give them report. Also called (family member) and let her know what was going on.R60's Progress Note, dated 3/4/26 at 548 AM, documents Transported by EMS (emergency medical service) to (Local Hospital). Left facility at 0445 (4:45 AM). Gave report to hospital as EMS was leaving facility.On 3/19/26 at 9:05 AM [NAME], V34, Licensed Practical Nurse (LPN), stated When we transfer a resident, we should send the residents information, medication list, DNR (do not resuscitate), and we send two bed holds that go with the resident, one for hospital to send back. If (R60) didn't get one, it was because it was a new nurse working and she didn't know to do it. On 3/19/26 at 11:41 AM, V14, [NAME] President of Operations, stated There was a new nurse working and she transferred (R60) without doing the bed hold, so we do not have one for him.On 3/19/26 at 1:50 PM, V1, Administrator, stated This is the only policy we have for discharging or transferring a resident. We have a folder that instructs the nurse what to do and this includes the bed hold, with copies of the bed hold in the folder.V1 provided a copy of the Medicaid Bed Hold Policies by State, undated, which documents in part Illinois: The Nursing Home Care Act requires a nursing facility to hold a bed for a maximum of ten days when a resident is hospitalized . The facility must hold a bed (not necessarily that specific bed) for up to 10 days during a hospitalization. On the 11th day there is no requirement to hold a bed, but the resident is still a resident and should receive the next available bed when they are ready to return even if there is a waiting list. There is no requirement under the Nursing Home Care Act to hold a bed for ten days during therapeutic home visit. However, the client is still considered a resident and must be given the next available bed when they are ready to return even if there is a waiting list.V1 also provided a copy of the note that is placed on the folder for the nurses. This documents Nursing: The bed hold form MUST be given to the residents at the time they leave the facility for the hospital. Nursing MUST document in the medical record/progress note that the bed hold form was sent with the resident. Before sending the bed hold form that is signed, please ensure a copy is made and put in the outbox.The Facility's Notice of Transfer and Discharge Policy, dated 5/8/23, documents in part Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.The Facility's Bed Hold and Return to Facility Policy, dated 9/16/17, documents in part To ensure that residents and/or resident representatives are notified of the facility bed-hold policy and conditions for return to facility upon admission and at the time of a transfer from the facility. The facility bed hold policy will be given to the resident and/or resident representative as follows: Upon admission to the facility, at the time of a transfer from the facility, if the bed-hold policy under the State plan or the facility's policy were to change.

Based on observation, interview, and record review, the facility failed to ensure Wound Nurse Practitioner (NP) orders were followed and implemented in a timely manner, failed to ensure low air loss mattress was maintained in well working order, and failed to ensure wound dressings were changed per NP orders for 1 of 3 residents (R2) in a sample of 9. This failure resulted in R2 having worsening of wounds which became infected leading to R2 being hospitalized several times, requiring surgical debridement and Intravenous (IV) antibiotics due to infections of Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli.This failure resulted in R2's wounds worsening and becoming infected. R2 was hospitalized several times, during which R2's wounds required surgical debridement and Intravenous (IV) antibiotics due to multiple infections with Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli.The Immediate Jeopardy began on 08/21/25 when the facility failed to ensure Wound Nurse Practitioner (NP) orders were followed and implemented in a timely manner, failed to ensure low air loss mattress was maintained in proper working order, and wound dressings were changed per NP orders. V1, Administrator, and V2, Director of Nursing (DON) were notified of the Immediate Jeopardy on 12/05/25 at 8:30 AM. Abatement number one on 12/05/25 was accepted. The Immediate Jeopardy was removed on 12/05/25, but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of the in-service trainings.Finding Include:R2's Face Sheet, print date of 12/04/25, document R2's admission date was 05/15/2023 and that R2's diagnoses include a pressure ulcer of right buttock, stage 3, dependence on renal dialysis, chronic kidney disease, stage 4 (severe), and chronic combined systolic and diastolic (congestive) heart failure. Note the State Survey Agency survey event PGW811 exit 7/17/2025 cites an Immediate Jeopardy on current resident, R2 for failing to timely identify, assess and monitor, and provide treatment to prevent the worsening of pressure ulcers.R2's Minimum Data Set (MDS), dated [DATE], section M documents R2 did not have any pressure ulcers/injuries at that time.R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires substantial/maximal assistance for rolling left to right, sitting to lying and lying to sitting. R2's Care Plan, admission date of 08/18/25, documented Potential for skin breakdown r/t (related to) incontinence, Hx (history) weeping L/E's (lower extremities), ace wraps for edema, morbid obesity, OAB (overactive bladder), resident is at increased risk for unavoidable skin breakdown r/t autoimmune disease pyoderma gangrenosumStage 3 R (right) buttockStage 3 R posterior thighStage 3 L (left) buttockStage 3 L posterior thighStage 3 L proximal buttockR lateral calf skin tearGoal: R2's will have wounds show improvement through next review and Interventions included but are not limited to Low Air Loss Bariatric Mattress for pressure reduction Per wound clinic/V13, Nurse Practitioner (date initiated 10/15/25), monitor for redness or discoloration to skin, keep skin dry and well lubricated, and weekly skin checks.R2's Hospital Visit records dated 08/13/25, document Assessment and Plan: Active Problems: Decubitus ulcer of right buttock, stage 3 and Infected decubitus ulcer, stage III. 1. Infected decubitus ulcer stage 3/ulcer right buttock stage 3- consult to wound nurse, cultures wound. It further documented R2 was admitted with multiple diagnoses which give rise to active medical issues or baseline comorbidities. Given the complexity of the situation, pending testing, follow-up labs, and ongoing medical interventions it is anticipated the patient will require admission as an impatient spending at least two midnight(s) in the hospital.R2's Wound Care report, dated 08/21/25, documented the following History of Present Illness (HPI). R2 has pressure ulcers to her buttocks; hematoma/trauma to her right lateral calf; abrasion to her left knee; and avulsion of nail to her left 5th toe. It also documented R2 had developed pressure ulcers to the bilateral buttocks and thighs and on 08/13/25 she was admitted into the hospital due to worsening infection of the wounds. She received IV vancomycin and had a wound culture done during her hospitalization which was positive for Methicillin-resistant Staphylococcus aureus (MRSA- is a type of staph bacteria resistant to several common antibiotics making infections harder to treat.). Wound #2 pressure ulcer was located on her right buttock and posterior thigh. Initial wound measurements were 20 centimeters (cm) length x 12cm width x 0.2cm depth. Post debridement measurements were 20cm x 12cm x 8cm depth. Wound #6 Left buttock was a chronic pressure injury/pressure ulcer. Initial wound measurements were 16cm x 8cm x 0.3cm. Post debridement measurements were 16cm x 8cm x 8cm. Wound orders: for Wound #2 (right buttock and posterior thigh) were given as followed: Apply a thick layer of Silvadene over the wounds, cover with abdominal (ABD) pad, secure with tape. Change daily and as needed if soiled or dislodged. Wound #6 (left buttock) pack the depth of the wound with silver alginate rope. Apply Silvadene over the rest of the open wound, cover with ABD pad, secure with tape, change daily and as needed if soiled or dislodged. Additional orders: Off-loading/Pressure relief Specialty Bed/Mattress for Pressure Reduction- Low air loss mattress, and limit time in the chair, encourage patient to lay in bed on her low air loss mattress to relieve pressure from wounds. Return in one week.R1's August 2025 Treatment Administration Record (TAR) was reviewed and documents the above wound order did not start until 08/26/25 and the wrong treatment for the right buttocks and right posterior thigh were put in place, a wrong treatment was completed and was then corrected on 08/27/25. This TAR does not document a skin check was completed on 08/26/25. R1's Wound Care Report, dated 08/26/25, documented R1's wounds measured as follows: Wound #2- Right buttock and posterior thigh 23cm x 14cm x 0.3cm after debridement and Wound #6- Left buttock 11.5cm x 9cm x 3.7cm after debridement. Dressing orders did not change. Additional orders: Specialty bed/mattress for pressure reduction- Low air loss mattress. Other order: Heel float boots to bilateral feet-similar to (soft support) boots. Not cushioned bootie type. R2's Physician's Orders, dated 08/26/25 at 10:45 AM, documented Right Buttock and R posterior thigh- Cleanse areas with (wound cleanser) or similar, apply Silver Alginate over the wounds, cover with a large gauze pad and secure with tape every night shift for wound care and every 6 hours as needed for wound careR2's Physician's Orders, dated 08/26/25 at 10:52 AM, documented Left buttock - Cleanse area with (wound cleanser) or similar, Pack the depth of the wound with Silver Alginate rope, Apply Silvadene (ointment) over the rest of the open wound, cover with large gauze type pad and secure with tape every night shift for wound healing. R2's Physician's Orders, dated 08/27/25 at 11:38 AM, documented Right Buttock and R posterior thigh- Cleanse areas with (wound cleanser) or similar, apply Silvadene over the wounds, cover with large gauze pad and secure with tape every night shift for wound care and every 6 hours as needed for wound care.R2's Wound Care Report, dated 09/02/25, was reviewed with no new orders noted. Wound #6- Left buttock measures 11.5cm x 11cm x 3.5cm with a moderate amount of drainage noted with odor. Wound #7- Right buttock (separated from thigh on 09/01/25) measures 11cm x 11.5cm x 0.5cm. It has a large amount of drainage noted which has an odor. Wound #8- Right, Posterior leg- thigh separated from buttock 09/01/25 measures 3.5cm x 5cm x 0.1cm. R2's General Surgery Consult, dated 09/02/25 at 12:04 PM, documented R2 was sent by the local wound center for evaluation of decubitus ulcer of her left buttock. It further documented R2 has a decubitus ulcer overlying her left buttock. It had narcotic and fibrinous exudate overlying the wound and the wound center has requested surgical debridement.R2's Surgical Report, dated 09/02/25 at 1:47 PM, documented R2 had debridement of left buttock performed by V43, Physician/Surgeon. R2's Wound Care Report, dated 09/09/25, documented new post debridement wound measurements are as follows: Wound #6- Left buttock 5.7cm x 9.5cm x 4cm, Wound #7- Right buttock measures 9.5cm x 15cm x 0.3, Wound #8- Right posterior leg 9.5cm x 15cm x 0.3cm, and Wound #9- Left, posterior leg, this is a [NAME] Grade 3 diabetic ulcer acquired on 09/07/25 measurements are 1cm x 2.5cm x 0.3cm. Wound treatment to R2's left buttock, left posterior thigh, right buttock, and right posterior thigh. Cleanse wound and peri wound with a non-cytotoxic wound cleanser. Apply half strength dakins moist gauze to wound, cover with large gauze pad, secure with tape, change daily and as needed of soiled or dislodged.R2's Wound Care Report, dated 09/16/25, documented on 09/02/25- Patient returns for follow up visit. She has been referred to V43 for surgical debridement of buttock/thigh wounds. She may be going to surgery this afternoon. The left buttock continues with large amounts of fibrin/slough/necrotic tissue. She has not received her low air loss mattress or heel float boots as of yet. Cover sheet documented Please note dressing changes are daily except for lower right leg. Orders included. Orders for Wound #6 and #7 Left and Right buttock cleanse wound, and peri wound with a non-cytotoxic wound cleanser, pack wound with half strength dakins moist gauze, cover with large gauze pad, secure with tape, change daily and as needed if soiled or dislodged. Wound #8 Right posterior leg (thigh) and wound #9 left posterior leg (thigh)cleanse wound, and peri wound with non-cytotoxic wound cleanser, apply half strength dakins moist gauze to wound, cover with ABD pad, secure with tape, change daily and as needed if soiled or dislodged. Right and left buttock and thigh wounds separated on 09/01/25. Additional orders Off-Loading/Pressure relief- Specialty Bed/Mattress for Pressure Reduction- Low air loss mattress. It also documented the patient's potential to heal is fair. It also documented under the care plan under section 07. Dressing selection: Patient states dressings not being changed per frequency of order. R2's Wound Care prescription, dated 09/19/25 signed at 9:46 AM, documented Cipro (antibiotic medication) 500 milligrams (mg) tablets take one tablet oral twice daily for seven days. On 12/23/25 at 10:38 AM, V13, NP said she started R2 on Cipro due to the culture she had gotten on 09/16/25 from her wound had come back growing she believes pseudomonas.R2's Wound Care Report, dated 09/23/25, documented R2 there for a follow up visit. The left buttock has new areas of breakdown around the current ulcerations with purple areas where the mechanical lift may have pinched the patient's skin. She is on Cipro currently due to culture growing pseudomonas. R2 reports she doesn't like her new mattress as it is hard to turn in it. She reports she has not been sitting in her chair or recliner and she goes to dialysis three times a week. Wound post debridement measurements for this visit are as follows: Wound #6 Left buttock, 6.2cm x 11.5cm x 2.2cm. Wound #7 Right buttock, 6.2cm x 11cm x 2cm. Wound #8 Right posterior leg, 3cm x 4.5cm x 0.3cm. Wound #9 Left posterior leg, 2.6cm x 6.5cm x 1cm. Dressing Orders: Wound #6, #7, #8, and #9. Cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply barrier ointment to protect surrounding skin, apply silver alginate to the wound bed, cover with super absorbent pad and large gauze and, secure with tape, change daily and as needed if soiled or dislodged.R2's TARs for September 2025 were reviewed and had no documentation R2's dressing changes had been done for left buttock, left posterior thigh, right buttock, and right posterior thigh, on 09/01/25, 09/15/25, and R2 refused on 09/22/25. On 09/03/25, 09/05, and 09/24/25, documented #9 other/see progress notes. It also had no documentation a skin assessment was completed on R2 on 09/22/25. R2's Wound Care visit report, dated 09/30/25, documented Wound #6 Left buttock- measures 6.5cm x 12.8cm x 1.3cm, undermining (the skin and tissue under the wound edges have separated, creating a pocket or shelf beneath the surface, making the wound appear smaller than it actually is) has been noted at 9:00 and ends at 2:00 with a maximum distance of 1.4cm. The wound has a moderate amount of drainage with mild odor noted. Wound #7 Right buttock- measures 7cm x 12cm x 0.2cm. There is a large amount of drainage noted which has no odor. Wound #8 Right Posterior leg- measures 2.8cm x 5cm x 0.2cm. Moderate amount of drainage noted with no odor. Wound #9 Posterior leg- 2.5cm x 5.2cm x 0.3cm with a moderate amount of drainage noted. Wound #10 Proximal buttock (upper)- an acute pressure ulcer acquired on 09/21/25, measuring 4.3cm x 10.1cm with no measurable depth, post debridement measurements for wound #10 are 4.3cm x 10.1cm x 0.3cm. Wound dressings for wound #6, #7, #8, #9, and #10, cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply barrier ointment to protect surrounding skin, apply (brand name) moist gauze to the wound bed, cover with large gauze pad, secure with brief, change daily and as needed if soiled or dislodged.R2's Wound Care visit report, dated 10/14/25, documented Wound #6- Left buttock, measures 6cm x 10.8cm x 1.3cm, undermining noted starting position at 9 o'clock and ending position at 2 o'clock. Wound #7- Right buttocks, measures 6.5cm x 10cm x 0.2cm. Wound #8- Right, posterior leg, measures 2.8cm x 5cm x 0.2. Wound #9- Left, posterior leg, measures 2.3cm x 6cm x 0.5cm, tunneling noted at 9 o'clock. Wound #10- Left, proximal buttock (upper), 4.5cm x 10.5cm x 1.1cm. New wound orders noted for wound #6, 7, 8, 9, and 10 are cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply clobetasol ointment to peri wound skin with every dressing change, apply betadine moist gauze to the wound bed, cover with ABD pad, secure with brief, change daily and as needed if soiled or dislodged.R2's Physician's Orders, dated 10/14/25, documented Low air Loss Bariatric mattress for pressure reduction per wound clinic NP. R2's Wound Care Visit, dated 10/28/25, documented wound measurements after debridement Wound #6- Stage 3 to Left, buttock 6cm x 9cm x 1.3cm undermining noted at 9:00 and ends at 1:00. Wound #7- Stage 3 to Right buttock 6.5cm x 9.5cm x 0.3cm. Wound #8- Stage 3 to Right, posterior leg measures 2.7cm x 5cm x 0.3cm. Wound #9- Stage 3 to Left, Posterior leg measures 6cm x 9cm x 1.1cm with undermining noted at 9:00 and ends at 1:00. Wound #10- Stage 3 to Left, proximal buttock (upper), 6.9cm x 6.5cm x 0.2cm. Dressing orders did not change. R2's TARs for October 2025 were reviewed and had no documentation R2 had dressing changes done on her left proximal buttock and left posterior thigh on 10/03/25 and on her left and right buttock, left proximal buttock, and right posterior buttock and thigh on 10/15/25. There was also no documentation a skin assessment was completed on 10/15/25.R2 was in the local hospital from admission date of 11/05/25 and expected discharge date of 11/14/25. Hospital record was reviewed and documented R2 spent several days in the Intensive Care Unit (ICU). Date of service 11/12/25 at 7:46 AM, documented Patient complains of pain from the wound on her lower back. She has extensive ulcer, status post incisional debridement. Patient was transferred from ICU after being treated for septic shock, anemia and other comorbid conditions.R2's Medicine Progress Note, date of service 11/13/25 at 5:12 PM, documented R2 is receiving a broad-spectrum antibiotic for wound infection, which grew multiple organisms including Pseudomonas, Enterococcus faecalis and Extended-Spectrum Beta-Lactamase (ESBL) Escherichia (E) coli. It further documented assessment and plan: 1. Extensive decubitus ulcer in lower back/butt, 2. Ulcer on heels and legs -status post (s/p) debridement, - wound culture grew E coli ESBL, Pseudomonas and Enterococcus faecalis, -on Meropenem (IV antibiotic medication), continue on current antibiotic. It also documented 5. Acute medical conditions that resolved/improved *septic shock. Microbiology: Wound cultures: ESBL E coli, Pseudomonas aeruginosa, Enterococcus faecalis, Proteus mirabilis, and MSSA (methicillin-susceptible Staphylococcus aures, a type of staph bacteria. A common type of staph bacteria that lives harmlessly on the skin and in the nose of many people but can cause infections if it enters the body.R2's Wound Care Report, dated 11/25/25, documented Wound #6- Stage 3 to Left, buttock 10.2cm x 11cm x 1cm. Wound #7- Stage 3 to Right buttock 6.7cm x 9cm x 0.3cm. Wound #8- Stage 3 to Right, posterior leg measures 3cm x 6cm x 0.3cm. Wound #9- Stage 3 to Left, Posterior leg measures 2.5cm x 5cm x 0.2cm. Wound #10- Stage 3 to Left, proximal buttock (upper), 11cm x 8cm x 1cm. New wound orders were cleanse wound and peri wound with a non-cytotoxic wound cleanser, apply silver alginate to the wound bed, cover with super absorbent pad, secure with tape, change three times weekly and as needed if soiled or dislodged for wound #6, 7, 8, 9, and 10. R2's TARs for November 2025 were reviewed and documented the following: Left, proximal buttock upper there is no documentation wound care was completed on 11/03/25 and 11/24/25 and on 11/25/25 and 11/27/25 documented #9 other/see progress notes. Left buttock no documentation wound care was completed on 11/03/25 or 11/24/25 and on 11/25/25, 11/26, and 11/27/25 it documented #9 other/see progress notes and 11/30/25 documented R2 refused. Right thigh no documentation wound care was completed on 11/03/25 and 11/24/25, and on 11/25/25, 11/26, and 11/27/25 documented #9 other/see progress notes. Left Posterior thigh wound had no documentation wound care was completed on 11/03/25 and 11/24/25, on 11/25/25 and 11/26/25 it documented #9, and on 11/30/25 it documented R2 refused. There was no documentation skin assessments were completed on 11/03/25 and 11/24/25, on 11/26/25 and 11/28/25 #9 was documented on the skin assessment. On 11/18/25 at 2:00 PM, Outside of R2's door lying on the floor was a machine (air pump) that went to an old air loss mattress. The control panel was hanging out of the machine by the wires, and it didn't have any hose connected to it.On 12/01/25 at 11:00 AM, V28, LPN and V29, CNA went in to turn R2 so a skin check could be completed. When R2 was turned onto her right side by V28 and V29 the dressings to R2 wounds were dated 11/28/25. The cloth incontinent pad that was under R2 had large rings of drainage from where her wounds had drained. Some of the dressings and tape had drainage on them. V28 and V29 was then assisted onto her left side and the dressings on her right side were dated 11/28/25. There was a strong odor also noted when R2 was assisted in rolling over. On 11/18/25 at 1:50 PM, V8, Certified Nursing Assistant (CNA) said R2's bed had a connection device that had three tubes on it that would connect to the machine, and it would keep coming off. V8 said sometimes when they would just be walking by R2's room and look in they would see that the tube had come disconnected and they would have to go in the room and hook it back up. V8 said the bed R2 has now she just got it three or four days ago.On 11/18/25 at 2:05 PM, V7, Licensed Practical Nurse (LPN) stated R2 should be on an air loss mattress to help prevent wounds. She said the plug had an issue something about the hose would pop off and the plug was loose.On 11/19/25 at 10:41 AM, V9, R2's family member #1 said her biggest issue is with R2's bed. She said R2 is supposed to have an air loss mattress but the one she had was literally held together with duct tape. V9 said they told the Director of Nursing (DON) about it, and she said they had a piece ordered. V9 said R2 would sink in the mattress, and it would make R2's bed sores hurt because the mattress wasn't properly aired up. V9 said they had to change R2's room because the bed she got was bigger than her original bed and it wouldn't fit in her old room. V9 said she has pictures of where the bed was broke, and she would send them to this surveyor. On 11/24/25 at 10:10 AM, R2 said the wound care nurse in nearby local town is the one who recommended switching her to an air loss mattress, but she isn't sure when she did that. She said the mattress she had before she got this one was softer, but they had trouble keeping air in it. R2 said whatever was supposed to be putting air into the bed wasn't working right and it kept coming off. R2 said when the air would go out of the old bed it was just like laying on the floor. She said when the air would go out of the mattress, she couldn't handle it her pain was so bad. She said it was a 10 with 10 being the worst and it was a burning type of pain where her sores are. R2 said she didn't want to be around people because she knew she was a crab-a**, and it hurt too much to sit up in her wheelchair. She said she would just have to grit her teeth and bare it before they got her better pain medication. On 12/02/25 at 10:55 AM, V31, R2's family member #2 said he messaged/sent pictures to the DON about the bed not working. He said he likes to have things in writing when it comes to the facility, so he has proof. He said this didn't start because his mom didn't want to lay down in her bed it was because they put her in a wheelchair that was to small and then sent her to dialysis. He said his mom has always slept in her recliner but now she stays mostly in her bed because of the wounds. V31 said R2 didn't get the low air loss mattress until she came back from the hospital this last time. He said that is why she had to be moved to the 500 halls. V31 said he isn't sure what day R2 got the bed, but it didn't work. The hose that connected to the mattress would keep coming off and they used duct tape to try and keep it in place. V31 said they have changed R2's pain medication also. He said she is in extreme pain due to (d/t) her wounds and so they started her on morphine and after the dressing changes is when she has the most pain.On 11/19/25 at 12:42 PM, This surveyor reviewed pictures provided by V9, R2's family member #1 and they correspond with V31, R2's family member #2, V7, LPN, and V8, CNA interviews that the hose that keeps the bed inflated comes disconnected and causes the mattress to lose air. On 12/04/25 at 2:45 PM, V2, DON stated R2's old bed had an issue with the hose coming off. She said when she was made aware of the situation, she notified maintenance, and they were supposed to order a new part. V2 said they tried to order the part, and they couldn't get it, so they rented R2 a new bed until hers came in. She said whatever day the order is written is the day they got R2 a new bed. V2 said the maintenance man who was working at the facility at the time is no longer with them, they had to let him go due to them having issues with him.On 12/23/25 at 10:20 AM, V15, Anonymous, said she took R2 to the wound clinic a couple of times. She said the one time she took R2 the dressings were dated 9/12 and 9/14. V15 said R2 was supposed to have a special type of boot the NP wanted and V1 went out and just got R2 some cushioned heel protectors. She said she was so embarrassed them thinking the facility is neglecting the residents. V15 said V13 had asked her if she had gotten the mattress, she had wanted R2 to get also. V15 said she asked V13 for copies of the orders so she could give them to the facility. V15 said every time she would take R2 to the appointment when they came back, she would hand over any orders to the DON. V15 said she told the facility R2 was supposed to have a new mattress, but they just don't listen. V15 said she would go down and visit R2 often and she had went into R2's room multiple times and found the mattress flat and R2 lying on the metal bed frame. She said the CNAs would have to get R2 up out of bed because the bed was flat.On 12/01/25 at 10:38 AM, V13, Wound NP said she first seen R2 back in August of this year and on the first visit she wrote an order for R2 to get a low air loss mattress. She said sure it could be painful for R2 if the air loss mattress wouldn't stay inflated and R2 was laying on the hard bed. She said to be 100% truthful she isn't sure if R2's wounds are actually pressure. She said her and her colleagues thought R2 could possibly have what is called Calciphylaxis (a rare, serious disease. It involves a buildup of calcium in small blood vessels of fat tissues and skin. Symptoms include blood clots, lumps under the skin and painful open sores called ulcers. If an ulcer becomes infected, it can be life-threatening.). V13 said she feels like R2 has skin failure related to her renal failure. She said R2's skin is so fragile she is having them use just paper tape on R2. She said R2 has had surgical debridement due to an infection and it can be pretty life threatening and life expectancy is shortened due to the infection. On 12/02/25 at 2:10 PM, V13, Nurse Practitioner (NP) said when R2 first came to see her R2's wound were labeled as pressure ulcers but due to her renal disease, some of her labs, some of the medications (such as Prednisone) not helping the wound in healing, and the progression of the wounds they thought R2 wounds were more related to Calciphylaxis. V13 said she would expect the facility to implement the orders she gives and if a low loss air mattress isn't properly inflating it can cause issues by putting more pressure on R2's wounds and it can cause her pain. V13 said she just recently changed R2's dressing orders from daily to three times a week and PRN if soiled or becomes dislodged. V13 said she would expect the nursing staff to follow her orders and if the dressing becomes soiled even if it was changed the day before to change it again. V13 said some of the risk for not changing dressings like they are ordered would be further skin breakdown from the moisture and infection especially because R2's is on her bottom. On 12/23/25 at 10:38 AM, V13, Wound NP said she originally thought R2 had Pyoderma Gangrenousm at first but after trying to treat her wounds with Prednisone and it not working, they decided it was Calciphylaxis and not Pyoderma Gangrenousm. She said sometimes you must try different treatments and other things to try to eliminate what it could be. V13 said she remembers writing for R2 to have a low air loss mattress and cushioned heel boots and she got them around 9/9/25. She said when she came back the following week for her follow up R2 reported to her that her (R2's) new mattress feels like she is laying on the hard frame of the bed. She said she instructed the caregiver who was with R2 to check the mattress for proper inflation every shift. V13 said if they had R2 on a bed that wasn't working properly she would expect the facility to immediately get her a different bed and putting R2 on a different mattress while they were getting her a new bed/mattress. V13 said she started R2 on Cipro on 9/19/25 because she had cultured R2's wound and she believes it was positive for pseudomonas.The facility's policy Pressure Ulcer Prevention, revision date of 1/15/18, documented Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositing measures. May use lotion on dry skin. It further documented 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protection bony prominences as indicated. It also documented 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds.The Immediate Jeopardy began on 08/21/25 was removed on 12/08/25 when the facility took the following actions to remove the immediacy as confirmed by the surveyor during onsite verification: Facility wound care policy was reviewed by [NAME] President of Operations and was found to be in compliance with state and federal regulations. Director of Nursing or designee initiated in-servicing, for all nursing staff, on the wound care policy and procedures on 12/05/25. In-servicing will be completed by the start of each staff members next shift. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures on 12/05/25. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on 12/5/25 to ensure that all wound orders are carried out and all interventions are in place. Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly times 4 weeks beginning 12/5/25. The Director of Nursing or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand wound care policies and procedures beginning 12/5/25. Maintenance Director checked all Low Air Loss (LAL) mattresses on 12/5/25 to ensure proper functioning. Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning. IDT team on 12/5/25 (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly. R2's mattress was replaced with a new mattress on 11/14/25.

Based on observation, interview, and record review, the facility failed to ensure new care plan interventions were implemented to prevent new/worsening pressure ulcers. The facility failed to ensure skin assessments were completed, ensure supplies for wound care were available, and complete wound treatments as ordered for 1 of 3 residents (R1) reviewed for wounds in a sample of 10. This failure resulted in R1 developing a stage II pressure ulcer to her right buttock on 11/25/25, a stage III pressure ulcer to her left buttock on 12/02/25, and worsening/decline to the wound on R1's right heel resulting in R1 requiring antibiotic treatment. The Immediate Jeopardy began on 11/25/25 due to the facility's failure to assess, treat, and complete skin assessments to prevent and/or treat pressure wounds for R1. This failure resulted when V47 (Nurse Practitioner) discovered a Stage II pressure wound to R1's right buttock, which the facility was not aware of. Additionally, on 12/2/25, V47 discovered a Stage III pressure wound to R1's left buttock that the facility was not aware of. V1, Administrator and V2, Director of Nursing (DON) were notified of the Immediate Jeopardy on 12/11/25 at 1:55 PM. Abatement number one and two were not accepted. Abatement number three on 12/12/25 was accepted. The Immediate Jeopardy was removed on 12/12/25, but noncompliance remains at Level Two as additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include:On 12/09/25 at 8:15 AM, R1 was up in the day area in her wheelchair, and she was observed in 15-minute intervals from 8:15 AM to 1:25 PM until she was laid down in bed. During this time R1 did have her float boots on and she was cooperative with care. At 9:45 R1 was leaning forward in her wheelchair. At 10:00 AM the certified nursing assistant (CNA) was going to take R1 and lay her down in bed but due to her having physical therapy they decided to leave her up in her wheelchair. R1 was then taken down to physical therapy at 10:17 AM. After therapy was completed, she was brought back to the day area on the 500 hallways and left in her chair due to it being so close to mealtime. At 11:45 AM, V7, Licensed Practical Nurse (LPN) said R1 eats better when she is up in her wheelchair, so she needed to stay up for lunch. 1:15 PM R1 remained in her wheelchair leaning forward in the day area on the 500 halls. At 1:25 PM V26, CNA and V45, CNA assisted R1 back to bed via mechanical lift. On 12/09/25 at 1:25 PM, Once R1 was placed in bed they removed R1 pants and then unfastened R1's incontinent brief and R1's brief was full of bowel movement (BM), V45 did incontinent care and cleaned R1 up. While R1 was on her left side a red area was noted on R1's right hip. When R1 was rolled over onto her right side there was another reddened area seen on R1's left hip. V26 said the area to R1's right side is where she had an open area at one time, but it has healed up. She said it could also be red because R1 had been sitting up in her chair and it's over a bony area. During incontinent care there was an indention on R1's right labia from sitting on the indwelling catheter and then an indention on back of R1's right leg/thigh from where R1 had been sitting on the indwelling catheter bag tubing. V26 said R1 was gotten up between 7:00 AM and 7:30 AM. She said she likes to make R1 a priority and get her laid down as soon as she can because of her wounds.R1's Face Sheet, print date of 12/11/25, documented diagnoses including type II diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, pressure ulcer of right heel stage II, pressure ulcer of sacral region, stage 4, peripheral vascular disease. R1's Minimum Data Set (MDS), dated [DATE], documented she is moderately cognitively impaired with a BIMS of 09 out of 15 and she requires substantial/maximal assistance with rolling left and right and is dependent on staff for sit to lying and lying to sitting. R1 is always incontinent of bowel and bladder. R1's Care Plan, admission date of 11/20/24, documented Potential for skin breakdown r/t (related to) incontinence, decreased mobility, DM (diabetes mellites), PVD (peripheral vascular disease), frequently refuses to lay down, excoriated at times, right foot drop, left great toe amputation, tendon repair left ankle, arterial ulcer right hallux, Refuses vascular studies. R1 will develop no further break down thru next review. Goals include but are not limited to Air mattress, monitor for redness or discoloration to skin, local wound care management consult and tx (treat) weekly, and Weekly skin checks.11/24/25 update: Enhanced Barrier PrecautionsStage 2 Right (R) lateral footStage 3 R heel - History (Hx) Methicillin-resistant Staphylococcus aureus (MRSA)Stage 4 Coccyx Revision on: 11/24/25R1's Behavioral Tracking for November 2025 and December 2025 were reviewed and R1 had no behaviors documented refusing to lay down or refusing treatments/care. R1's Wound Management Notes, dated 11/04/25, documented a wound culture was completed to R1's right heel on 10/14/25 and showed pseudomonas aeruginosa. R1's 10/2025 Treatment Administration Record (TAR), documented on 10/27/25- #9 other/see progress notes.R1's Progress Notes were reviewed and have no documentation for the day of 10/27/25.R1's Progress Notes, dated 10/28/2025 at 12:41 AM, in part stated Medication Administration Note: Rt. (right) heel on hold; local wound management coming in the morning (AM).R1's Progress Notes, dated 10/28/2025 at 12:42 AM, in part stated Medication Administration Note: Coccyx on hold; local wound management coming in the AM. R1's Progress Notes, dated 10/28/2025 at 07:00 AM, documented R1 was seen by V47, Wound Nurse Practitioner (NP) for wound assessment and treatment. R1's coccyx wound had declined and was measuring 1.5 centimeters (cm) x 0.6cm x 0.4cm. R1's Progress Notes, dated 10/31/2025 at 5:35 PM, documented a new order was received from the local wound management. New order for R1's right heel; cleanse with normal saline (NS) or wound cleanser (wc), apply (antibiotics) Streptomycin 80 milligrams (mg)/Meropenem50mg/Flucytosine 150mg (3 capsules total) mixed with six pumps of (brand name gel) to wound bed, cover with 4x4, wrap with kerlix. Change daily and as needed (PRN) x 30 days. R1's November 2025 TAR was reviewed and documented #9- other/see progress notes on 11/1/25.R1's Progress Notes, dated 11/2/2025 at 05:42 AM, Medication Administration Note in part states medications not available for wound to Rt. heel.R1's TAR, dated 11/03/25 did not have any documentation wound care had been completed for the wounds to R1's Rt. heel and coccyx and there was no documentation a skin check had been completed.R1's Progress Notes, dated 11/04/2025 at 06:00 AM, documented R1 was seen by V47, NP for assessment and treatment. Coccyx wound declined and measures 3cm x 2.5cm x 0.5cm, 70% granulation 30% slough. New order to apply a thin layer of antibiotic to wound bed (WB) (same as Rt heel) and calcium alginate cover with foam silicone bordered dressing to be changed daily and PRN. R1's Skin-Pressure/Diabetic/Venous/Arterial wound report, dated 11/05/25, documented R1 did not have any new wounds. Wound #1 was a stage 3 pressure injury to her right heel measuring 4cm x 6vm x 0.vm2 and was unchanged but did show signs of infection. Wound #2 was a stage 4 pressure injury to R1's coccyx that was first observed on 08/31/25. It measures 3cm x 2.5cm x 0.5cm and the overall impression of wound #2 is it is worsening and is showing signs of infection.R1's Physician's Orders, dated 11/05/25 at 10:00 PM, documented Cleanse open area to coccyx with NS, apply a thin layer of antibiotic; Streptomycin 80mg/Meropenem 50mg/Flucytosine 150mg. Apply calcium Alginate to Wound bed and then cover with silicone bordered dressing. Change daily and PRN until healed every nightshift for skin management.R1's Shower Sheet, dated 11/06/25, had no documentation of her having any abnormal findings. No shower sheets after 11/06/25 were provided to this surveyor.R1's TAR, dated 11/10/25, documented #9- other/see progress notes.R1's Progress notes were reviewed and there is no documentation for 11/10/25 regarding wound care to R1's coccyx.R1's TAR, dated 11/11/25, documented #2- refused her treatment.R1's Progress Notes, dated 11/11/25 at 04:22 AM, documented Orders- Administration Note in part states Local wound care management coming in the morning AM.R1's Skin-Pressure/Diabetic/Venous/Arterial Wound Report, dated 11/11/25 at 5:13 PM, documented Right heel stage 3 pressure ulcer was measuring 3.5cm x 6cm x 0.2cm. Pressure injury to coccyx was measuring 2.5cm x 2.5cm x 0.4cm. Right Lateral Foot was measuring 1.3cm x 0.5cm x 0cm. R1's TAR, dated 11/14/25, had no documentation R1's wound to her coccyx, to her right heel, and to her right lateral foot had been completed.R1's Progress Notes, dated 11/16/2025 at 04:11 AM, in part states supplies are not available for wound care to R1's Rt. heel. R1's TAR, dated 11/17/25, documented #9 other/see progress notes.R1's Progress Notes, dated 11/17/2025 in part stated local wound care management is coming in the AM for wound care and assessment. R1's TAR, for 11/24/25, had no documentation treatments for R1 were completed to her coccyx and Rt. heel and her skin assessment was not completed. R1's Wound Assessment Report, dated 11/25/25, documented R1 had a new stage II pressure area to her Right buttock measuring 2.0cm x 2.0cm x 0.10cm. New order was put into place.R1's Progress Notes, dated 11/25/2025 at 06:45 AM, documented R1 was seen by V47, NP for wound assessment. New area noted to Rt Buttock 2.0cm x 2.0cm x 0.1cm Stage 2 Pressure injury. New orders to clean Rt buttock with NS, apply collagen sheet and cover with a silicone bordered foam dressing. R1's Skin-Pressure/Diabetic/Venous/Arterial wound report, dated 11/25/25, documented R1 had a new stage 2 pressure injury to her right buttock measuring 2.0cm x2.0cm x 0.1cm and it was first observed on 11/25/25.R1's TAR, dated 11/25/25, documented #9 other/see progress notes.R1's 11/25/25 progress notes were reviewed and no documentation regarding wound care was noted, but her progress notes dated 11/26/2025 at 03:26 AM, documented unable to do treatments as there was a continuous 1 x 1 for this hall that could not be left alone.R1's TAR, dated 11/29/25, had no documentation treatments for R1's coccyx, Rt. buttock and Rt. heel were completed. R1's TAR, dated 12/1/25, documented #9 other/see progress notes for wound to Rt. buttock and coccyx. There was no documentation for the wound to her Rt. heel. R1's Progress Notes, dated 12/1/2025 at 05:36 AM, in part stated there were no supplies for wound care to R1's coccyx.R1's Progress Notes, dated 12/1/2025 at 8:02 PM, documented the local wound management was coming in the AM to assess. R1's Progress Notes, dated 12/2/2025, documented R1 was seen and assessed by V47, Wound NP. Coccyx worsening and measures 3.0x0.5x0.4. Rt heel worsening and measures at 4.0x6.0x0.2. Rt Buttock worsening and measures 2.5x2.0x0.2. New area noted to the Lt buttock, Stage 3 pressure ulcer measuring 3.5x2.5x0.2. New orders received for Lt buttock, Rt buttock, and coccyx: Clean with NS, apply Santyl, cover with silicone bordered foam, change daily and PRN. This nurse along with local wound management assessed air mattress and wheelchair cushion at this time. The current wheelchair cushion was changed out for an Equagel cushion. The current air mattress was inflated at the time of service. Local wound management suggested we order a new mattress. R1's Wound Management Note, dated 12/02/25, documented Wound: 1 right distal heel is worsening. Wound: 2 coccyx is worsening. Wound: 5 right buttock is worsening. Wound: 6 left buttocks newly found on 12/02/25. Impression/Plan: Recommend a low air loss mattress vs. air overlay. Recommended to check roho wheelchair (w/c) to ensure it is working properly. Wound goals: adequate offloading to alleviate pressure for optimal wound healing. Complete adequate wound hygiene with dressing changes to prevent infection.R1's Skin-Pressure/Diabetic/Venous/Arterial wound report, dated 12/02/25, documented R1 had a new stage 3 pressure injury noted to her left buttock. It was first observed on 12/02/25 and measured 3.5 x 2.5 x 0.2. Wound #1 to R1's right heel was worsening and measuring 4.0 x 6.0 x 0.2 with a moderate amount of serosanguinous drainage noted. Wound #2 to R1's coccyx was worsening with measurements of 3.0 x 0.5 x 0.4 and a moderate amount of serosanguinous drainage. Wound #4 to R1's right buttock was worsening and measuring 2.5cm x 2.0cm x 0.2cm with a moderate amount of serosanguinous drainage.R1's Progress Notes, dated 12/3/2025 at 5:00 PM, documented Note Text: New order received to place an indwelling catheter to facilitate wound management and healing by preventing urine contamination to wound areas. Stage 4 wound to coccyx and stage 2 to Rt buttock have both declined in the last week. New area, stage 2 to Lt buttock noted this week. Call placed to power of attorney (POA) with no answer, voicemail (VM) left.On 12/23/25 at 10:20 AM, V1, Administrator said she would expect the nurse to follow up and get the treatment changes made right away and document it. She would expect the nurse to do an assessment on any resident who came back from the hospital and to document it. She said if there weren't supplies to complete a treatment, she would expect the nurses to notify the doctor they weren't able to complete the treatment and maybe he would change it until they were able to get the correct supplies in. She would also expect to be notified if the nurses didn't have the proper supplies for wound care and she would get what was needed right away. V1 said she would expect the nurses to continue with the current treatment for the wound until it was time for the new order to start. V1 said she would expect the maintenance department to keep equipment in good working condition. She said V48, Maintenance director is proactive about getting things done and looking for things to make sure they are working properly.On 12/11/2025 at 11:52 AM, V47, Wound Nurse Practitioner (NP) said R1 has a diagnosis of diabetes, and she is not compliant with care. She said the wound to R1's coccyx will open and close, but she has had that wound since being admitted to the facility. V47 said yes, she would expect the facility to have found the new wound on R1's left buttock during routine care. She said she was here making her rounds, and they went to turn R1 over and when they did that's when they found the wound to her Lt. buttock. V47 said the staff should be repositioning residents while they are up in their chairs. She said she would expect to be notified if the facility didn't have the supplies to complete the treatment that was ordered. She said she would expect the nurse to do a full body assessment upon readmission and document any wounds the resident had. V47 said the night shift does the treatments, and they are usually done towards the end of the shift. She said so they usually just wait for her to come in Tuesday morning and complete them. V47 said new interventions should have been put into place after a new wound has been found. She said while she was here doing her rounds, they inspected R1's bed and she was on an air overlay, so she suggested they get R1 a low air loss mattress and she also got a new wheelchair cushion. V47, NP agreed the lack of identifying, treating, and preventing new pressure wounds can for sure cause the wounds to worsen, get infected, and there is always a risk for death.The facility's policy Pressure Ulcer Prevention, revision date of 1/15/18, documented Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositing measures. May use lotion on dry skin. It further documented 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protection bony prominences as indicated. It also documented 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. The Immediate Jeopardy began on 11/25/25 and was removed on 12/16/25 when the facility took the following actions to remove the immediacy: Facility pressure ulcer prevention policy was reviewed by [NAME] President of Operations and was found to be in compliance with state and federal regulations on 12/11/25. R1 was seen by Wound Care Provider on 12/2/25 and received new treatment orders, LAL (low air loss) mattress ordered, and wheelchair cushion replaced. Director of Nursing or designee initiated in-servicing, for all facility and Agency nursing staff (agency staff will be in-serviced through shift key portal before they are able to pick up any more shifts) to include RNs, LPNs and CNA's, on the pressure ulcer prevention policy and procedures on 12/11/25. In-servicing will be completed by the start of each staff members next shift. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention on 12/11/25. Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on 12/11/25 to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly. Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's beginning 12/11/25 on identifying all newly acquired pressure areas timely by completing assessments timely and accurately. All nursing staff will be educated by the beginning of their next shift. Completed on 12/12/25. Director of Nursing or designee will conduct audits of skin assessments weekly beginning 12/11/25 to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process. The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas 12/11/25. Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed completed on 12/12/25. For R1 the skin assessment was missed on readmission on [DATE] and was completed on 10/28/25. The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined. The DON or designee will review all new admissions to ensure that all assessments are completed beginning 12/11/25. The DON or designee educated all facility and agency nurses beginning on 12/11/25 of how and when to complete skin assessments. All facility and agency nurses will be educated by the beginning of their next shift. R1 has had a full skin assessment performed by the ADON on 12/11/25 to ensure all areas of concern have been identified and addressed appropriately. All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee on 12/11/25 that all residents need to be turned and repositioned at least every two hours and as needed. All in-servicing will be completed by the beginning of the staff member's next scheduled shift. IDT team on 12/11/25 (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity. IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review.

Based on observation, interview, and record review, the facility failed to ensure R4 was adequately supervised, failed to ensure door alarms were turned on, and respond in a timely manner to alarms to prevent elopement for 2 of 4 residents (R4, R9) reviewed for safety in a sample of 9. These failures resulted in a severely cognitive impaired resident (R4) repeatedly eloping from the facility despite being identified as an elopement risk, and multiple failures of disabling of door alarms and delayed responses contribute to R4's elopements into unknown and unsafe conditions that include walking in middle of road and getting in a strangers vehicle.The Immediate Jeopardy began on 10/16/25 when the facility failed to properly supervise a resident (R4) to prevent an elopement from the facility. V1, Administrator, and V2, Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/25/2025 at 12:58 PM. Abatement number one on 11/25/25 was not accepted. Abatement number two was accepted on 11/26/25 at 10:27 AM. The Immediate Jeopardy was removed on 11/26/25, but noncompliance remained at a Level Two at that time as additional time is needed to evaluate the implementation and effectiveness of the in-service training. On 12/01/25 at 12:02 PM, V1 Administrator was made aware the immediacy removal had been rescinded due to additional elopement incidents for R4 and R9. Abatement one through four on 12/01/25 were not accepted. Abatement number five was accepted on 12/01/25. The Immediacy was removed on 12/02/25 but the facility noncompliance remains at level two as additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings Include:The facility's daily census roster dated 11/17/25, documented the facility had 59 total residents.On 11/24/25 at 8:00 AM, when coming into the facility and coming down the 100 hallway the alarm was going off.On 11/24/25 at 8:10 AM, V1, Administrator went down and turned/reset the alarm off at this time.On 11/24/25 at 8:46 AM, R4 was seen walking up the 100 hallway then turned around and came back.On 11/24/25 at 8:50 AM, R4 went up the 100 hallway. She came back down the hallway at 8:55 AM. No staff were seen checking on her. On 11/24/25 at 10:00 AM, the door in the day area at the end of the 100 hallway that led to the outside was cracked a little. This surveyor opened the door up and no alarm sounded when the door was opened.On 11/24/25 at 10:05 AM, R4 was seen being taken by 500 hallway staff back towards the 200 hallway.On 11/24/25 at 11:39 AM, the door to the outside on the 100 hallway remains cracked open and two residents are outside smoking. On 11/24/25 at 1:58 PM, R6 and R7 were seen going out the 200-hallway door to the outside and when they opened the door there was no alarm that sounded. R4's Face Sheet, print date of 12/02/25, documented R4 has diagnoses including Alcohol dependence with alcohol induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, stage3.R4's Minimum Data Set (MDS), dated [DATE], documented R4 is severely cognitively impaired and is independent with ambulation. R4's Progress Notes, dated 10/15/2025 at 5:13 PM, documented Social Services Note Text: Resident admitted via family vehicle. Resident admitted from another facility. Resident is ambulatory and wanders all day/night. Resident is on 15-minute checks as the wander guard will be placed 10/16/2025 depending on how resident does overnight. Resident doesn't wear glasses, denture, or hearing aids. Resident is pleasant, but on the go. Resident arrived approx. 4:55pm.R4's Progress Notes, dated 10/15/2025 at 5:23 PM, documented Social Services Note Text: Code Alert was placed on resident by director of nursing (DON) at approx. 5:20pm.R4's Elopement Risk Assessment, dated 10/16/25 at 9:04 AM, documented R4 was an elopement risk, and the following interventions were to be used: Door Alarm Band, Identification (ID) bracelet on, frequent checks, and redirection.R4's Baseline Care Plan, dated 10/16/25 at 12:10 PM, documented R4 was cognitively impaired, uses a wander guard for safety, and is an elopement risk. It further documented R4 was transferred from another facility. She is alert, ambulates independently and frequently throughout facility, wearing code alert for wandering, closely watched by staff, on 15-minute checks, diagnoses included chronic obstructive pulmonary disease (COPD), alcoholic dementia, and bipolar.R4's Progress Notes, dated 10/16/2025 at 8:15 PM, documented Nurses Note Text: Around 1815 (6:15 PM), resident was found by CNA (Certified Nursing Assistant) outside by the dumpster. Door alarm and wander guard were sounding. CNA heard the alarm and immediately went to check on alarm. Alarm sounded until this nurse turned it off. Doors at the top of 500 hall were closed to help resident stay on the hall while meds were being passed and residents were being put to bed. Another CNA has walked around with resident. Snacks and fluids have been offered, taken well.R4's Elopement Risk Assessment, dated 10/28/25 at 10:29 AM, documented R4 was independent with locomotion on and off the unit, was moderately cognitively impaired, had prior exit seeking behavior, had a change in room, recent hospitalization, has contributing diagnoses of Alzheimer's disease and dementia other than Alzheimer's disease, is an elopement risk with the following interventions to be used: door alarm band, clothing marked with identification, photograph and description readily available, and psych referral. R4's Care Plan, with admission date of 10/15/25, documented on 11/12/25 the following problem, goal, and interventions were initiated: R4 is an elopement risk/wanderer r/t (related to) exit seeking, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities. R4's safety will be maintained through the review date, and interventions include but are not limited to staff to monitor location, redirect R4 away from doors and from going outside of the facility. Report to hall nurse, DON, and administrator if resident leaves facility through a door, and Wander Alert: wander guard on left ankle.R4's Progress Notes, dated 11/17/25 at 5:41 PM, documented R4 was noted to be walking outside of building on 500 patio doors. Noted resident was sitting in visitor van. Resident taken out of van and taken back to room. No injuries noted. Does have code alert on. R4's Progress Notes, dated 11/28/2025 at 04:24 AM, documented Note Text: Resident was walking up and down the hallway was in and out of other's rooms. As this nurse was up the hall passing medications, heard the door to the outside close and when this nurse and CNA looked over resident was out the back door, were able to redirect resident back in without any difficulties. Door alarm did not sound attempted to lock door and lock is broken at this time. CNA on another hall also tried to lock door with no success. DON aware of door.The facility's accident, incident, and fall log for the past two months was reviewed with no documentation noted about R4 getting out of the facility. On 11/18/25 at 2:05 PM, V7, Licensed Practical Nurse (LPN) said R4 is an elopement risk, if there is a way to get out, she will find it. She said she was here when R4 got out. She said there was one day she got out twice. She said she was sitting at the nurse's station on the 500-hallway working and when she looked up from the desk and looked out the window R4 was walking in the back area. V7 said jumped up and went out and got her and brought her back inside. She said R4 was just in her socks. V7 said later in the day she was working at the desk while V3, Registered Nurse (RN) was down on the 500-hallway taking care of a Peripherally inserted central catheter (PICC) line and hanging intravenous (IV) antibiotics for her and she looked out the window again and seen R4 had gotten back outside. V7 said she ran outside again and brought R4 back into the building. V7 said she asked R4 to show her how she was getting outside. V7 said R4 took her (V7) down the 100 hallway and through the set of doors and if you go off to the right there are doors that lead to the 400 hallway and then there is a door that will lead outside and that was where she was getting out. V7 said the alarm was working but it was so far away no one was able to hear it going off. V7 said then there was the time R4 went out the doors right down the hallway. She said she went out with another resident's family, the alarm went off, and so they ran down to get her and by the time they got there R4 had gotten into the visitor's van and V8, CNA had to remove her. V7 said the facility closed the doors on the 100 hallway and 400 hall and she doesn't think R4 has gotten out since. V7 said if you let R4 out of your site for two minutes she's gone.On 11/18/25 at 1:50 PM, V8, CNA said the reason R4 keeps getting out is because she looks like a worker and family members are letting her outside. She said you can't tell her from the workers here at the facility. V8 said one of the other resident's family was going out the door and R4 went out with them. She said the alarm went off and she ran down to get R4 and by the time she got to her R4 had gotten into their van.On 11/25/25 at 10:11 AM, V11, Primary Care Physician (PCP)/Medical Director said he was made aware of R4 getting out of the facility. He said he knew she had gotten out more than once also.On 11/25/25 at 10:50 AM, V3, Registered Nurse (RN) said R4 has gotten out on several occasions. She said one-time R4 had gotten out from the 400 hallway, was seen in between the two buildings, staff went out and got R4 and brought her back in, then they looked out the window again and R4 was back outside so they went back out and got her again and brought R4 back in. She said when R4 finds a way out she will go back to that way to get out again. V3 said each time R4 has had an incident they have made administration aware. V3 said R4 doesn't know what is going on and she worries constantly about R4 especially now with the weather getting cold. V3 said R4 could fall outside where no one can see her and freeze. V3 said it's hard to protect R4 due to not being able to watch R4 continuously. V3 said she has never had this kind of situation because if a resident wonders they will usually put them on the locked unit to keep them safe. V3 said most of the alarms are always on. V3 was questioned about the 200-hallway door alarm being off and she said the smokers go out there and it's been like that for a long time. V3 said when you go out that door and it shuts you can't open that door from the outside it only opens from the inside. On 11/25/25 at 11:05 AM, V15, Anonymous said about two weekends ago she was working and was doing stuff out in the dining room. She said she seen R4 wandering around in the halls, and she could see R4 in a mirror and she was heading toward the 500 hallways. V15 said she didn't see or hear R4 for a minute and she got this feeling, so she got up to check on R4 and found her outside standing in the middle of the street in front of the facility. She said cars sometimes fly by on that street. V15 said she text V1 and told her what was happening and asked if she needed to do anything else and V1 never responded. V15 said if R4 had a wander guard on it didn't go off. V15 said she is concerned about R4, and she absolutely feels R4 is at risk for something to happen to her. On 11/24/25 at 2:35 PM, V14, R4's family member said she was not aware of R4 getting out of the facility and no one ever called her and notified her of this. She said there was one day when her sister was at the facility to visit and asked how R4 was doing, and they told her sister oh by the way she got out of the facility. She said then the next day her sister contacted her and let her know but she is R4's guardian. She said she has never been notified of anything when it comes to R4 not even at her old facility. V14 said she would like to be notified about a lot of things.2. R9's Face Sheet, print date of 12/02/25, documents R9 has diagnoses of but not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, hemiplegia, unspecified affecting right dominant side, chronic kidney disease, stage 3, and cognitive communication deficit.R9's MDS, 09/01/25, documented R9 is moderately cognitively impaired with a BIMS of 12 out of 15 and he requires partial/moderate assistance with transfers and supervision/touching assistance with walking.R9's Care Plan, admission date of 12/12/24, documented R9 is at risk for personal injury and an elopement risk related to lack of regard for own safety, confusion. 11/21/25 resident set off door alarm. Staff followed resident outside of door. No injuries. Goal: R9 will not leave facility without (w/o) assist or obtain injury to self with attempt to leave facility thru next review. Interventions include but are not limited to 11/21/25 elopement attempt. staff educated to redirect resident when he is near doors, wander guard is in place, 15-minute checks, refer to code yellow binder, and if attempts to leave facility, verbally redirect to area away from door.R9's Elopement Risk Assessment, dated 06/06/25, documented R9 is a high risk for elopement. R9's Physician's Orders, dated 07/23/25 at 1:36 PM, documented Code Alert check every day shift every Tuesday for safety.R9's Progress Notes, documented the following:On 11/21/2025 at 04:41 AM, Behavior Note Text: Exited out of 500 patio doors with his shirt off. CNA followed behind him and redirected him back inside. Currently sitting in the sitting room, in front of the nurse's station, sleeping in w/c.On 11/21/2025 at 06:33 AM, Behavior Note Text: Alarm went off and CNA followed up with resident. Was found standing outside, in the rain, with shirt off. 2nd CNA assisted with getting the resident to sit in his w/c. Resident was successfully brought back in the facility without injury.On 11/21/2025 at 11:11 AM, Health Status Note Text: Resident is follow up (f/u) from incident last shift. Resident seems to be doing fine with no recollection of leaving facility. V11, Primary Care Physician/Medical Director in this morning and N.N.O (no new orders) at this time. Resident currently in front of nursing station watching tv (television). Care is ongoing.On 11/26/2025 at 03:37 AM, Behavior Note Text: This writer noting that resident has been up all night; resident will not go to bed (unsure if he slept all day or not); resident has gone in to other residents rooms, resident is trying to seek out doors on the unit (has a wander guard on), resident has shown some aggression towards staff, resident has tried to stand from WC, resident has gotten up from WC and walked down hall, resident has required a 1 x 1 for the entirety of the shift; for residents safety, this writer has stayed with resident for 2/3 of the shift and tried to redirect when behaviors were inappropriate; resident is not compliant with redirection and has become very agitated and demanding to go home; resident does not believe wife is here and does not believe he lives here either; resident has been shown personal belongings in room and attempts have been made to toilet resident and offerings of food and drink; resident denies pain and continues to demand that he is going home and he is going home now; this writer noting that for residents safety he has been monitored in the TV room and several attempts have been made to keep resident from standing; resident is unsteady on feet and at this time is very tired; resident will not go to room and does not want to discuss going to bed; will relay to AM shift for continuation of care.On 11/29/2025 at 07:20 AM, Plan of Care Note Text: Unit aid V27 notified this nurse that resident was outside sitting on the ground screaming help. Went outside with aidsV25 and V30 and assessed resident for injuries. Back against chair sitting up. No injuries noted. Aids assisted in getting resident in chair and bringing inside. Vital signs within normal limits. Power of Attorney (POA) notified, V2, DON notified. V11, PCP notified with NNO. Administrator notified. Put resident on one on one with unit aid V27.On 12/01/25 at 12:10 PM, V27, Unit Aide said she was working the day R9 was found outside. She said she was working the 300 hallway, and they asked her to run the food tickets over to the 500 hallway. While she was over on the 500 halls, they asked her for help, so she helped them with what they needed. She said she was on the back part of the hallway going by R2's room and she heard someone yelling help (x's 3) so when she made a left there was a door to the outside and she saw R9 sitting on the ground beside his wheelchair leaning towards the left. V27 said she immediately went and got the nurse so she could assess R9 and then the two CNAs came and got R9 up off the ground and into his wheelchair. V27 said there was snow on the ground, and it was cold outside. She said R9 was dressed in a long-sleeved black shirt, pajama pants, non-skid socks, and house shoes. He didn't have on any jacket or coat. V27 said she did not hear any type of loud alarm going off when she found R9, and she doesn't know how long R9 was outside before she found him. V27 said the first thing she did for R9 when they brought him inside was to get him a blanket so he could warm up.The facility's Code Pink- Missing Resident/Elopement, reviewed date of 11/15/2018, documented the following: Guidelines: 1) All personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. 2) Should an employee observe a cognitively impaired resident leaving the premises or attempting to exit the premises, he or she should: Attempt to prevent the departure without use of force. Obtain assistance from other staff members in the immediate vicinity, if necessary. Instruct another staff member to inform the Charge Nurse or Director of Nursing services of the resident's attempt to leave the premises. Be courteous in preventing the departure and returning the resident to the facility Notify the attending physician of the resident's attempt to leave the facility Contact legal representative/responsibility party and inform him/her of the incident. Make appropriate notations in the resident's medical record. Complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions as indicated. The Immediate Jeopardy began on 10/16/25 and was removed on 12/02/25 when the facility took the following actions to remove the immediacy. Facility Elopement Policy was reviewed by Regional Director of Operations on 11/25/25 and was found to be in compliance with state and federal regulations. Facility Administrator or designee initiated in-servicing, for all staff, on the elopement policy and procedures on 11/25/25. In-servicing will be completed by the start of each staff members next shift. Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately on 11/25/25. In-servicing will be completed by the start of each staff members next shift. Maintenance Director or designee will conduct an audit of all facility door alarms on 11/25/25 and to be completed weekly to ensure they are adequately functioning and audible to staff areas. Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance beginning 11/25/25. The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures beginning 11/25/25. IDT team on 11/25/25 (Admin, DON, SSD, MDS, DM) has assessed R4 and care plan updated to reflect new interventions for R4 being placed on the locked unit. IDT team on 11/25/25 (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement. Completed on 11/25/25. R4 was placed on the locked unit 11/25/25. All facility exit door keys were removed and placed in secured location 12/1/25. Facility Administrator or designee initiated in-servicing for all staff on 12/1/25 to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift. Maintenance Director replaced the door lock to 300 Hall door to courtyard on 12/1/25 and is functioning properly.

Based on observation, interview, and record review, the facility failed to ensure a low air loss mattress was in proper working order for 1 of 3 residents (R2) reviewed for essential equipment, safe operating condition in a sample of 10. This resulted in R2 being in extreme pain due to R2 having multiple pressure ulcers/injuries, the mattress not staying properly inflated, and R2 laying on a hard metal bed frame. Findings Include: R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires substantial/maximal assistance for rolling left to right, sitting to lying and lying to sitting.R2's Face Sheet, print date of 12/04/25, documented R2 has diagnoses including pressure ulcer of right buttock, stage 3, dependence on renal dialysis, chronic kidney disease, stage 4 (severe), and chronic combined systolic and diastolic (congestive) heart failure. R2's Care Plan, admission date of 08/18/25, documented Potential for skin breakdown r/t (related to) incontinence, Hx (history) weeping L/E's (lower extremities), ace wraps for edema, morbid obesity, OAB (overactive bladder), resident is at increased risk for unavoidable skin breakdown r/t autoimmune disease pyoderma gangrenosumStage 3 R (right) buttockStage 3 R posterior thighStage 3 L (left) buttockStage 3 L posterior thighStage 3 L proximal buttockR lateral calf skin tearGoal: R2's will have wounds show improvement through next review and interventions include but not limited to Low Air Loss Bariatric Mattress for pressure reduction Per wound clinic/V13, Nurse Practitioner (date initiated 10/15/25), monitor for redness or discoloration to skin, keep skin dry and well lubricated, and weekly skin checks.On 11/18/25 at 1:50 PM, V8, Certified Nursing Assistant (CNA) said R2's bed had a connection device that had three tubes on it that would connect to the machine, and it would keep coming off. V8 said sometimes when they would just be walking by R2's room and look in they would see that the tube had come disconnected and they would have to go in the room and hook it back up. V8 said the bed R2 has now she just got it three or four days ago.On 11/18/25 at 2:00 PM, Outside of R2's door lying on the floor was a machine (air pump) that went to an old air loss mattress. The control panel was hanging out of the machine by the wires, and it didn't have any hose connected to it. On 11/18/25 at 2:05 PM, V7, Licensed Practical Nurse (LPN) stated R2 should be on an air loss mattress to help prevent wounds. She said the plug had an issue something about the hose would pop off and the plug was lose.On 11/19/25 at 10:41 AM, V9, R2's family member #1 said her biggest issue is with R2's bed. She said R2 is supposed to have an air loss mattress but the one she had was literally held together with duct tape. V9 said they told the Director of Nursing (DON) about it, and she said they had a piece ordered. V9 said R2 would sink in the mattress, and it would make R2's bed sores hurt because the mattress wasn't properly inflated. V9 said they had to change R2's room because the bed she got was bigger than her original bed and it wouldn't fit in her old room. V9 said she has pictures of where the bed was broke, and she would send them to this surveyor. On 11/24/25 at 10:10 AM, R2 said the wound care nurse at a local facility is the one who recommended switching her to an air loss mattress, but she isn't sure when she did that. She said the mattress she had before she got this one was softer, but they had trouble keeping air in it. R2 said whatever was supposed to be putting air into the bed wasn't working right and it kept coming off. R2 said when the air would go out of the old bed it was just like laying on the floor. She said when the air would go out of the mattress, she couldn't handle it her pain was so bad. She said it was a 10 with 10 being the worst and it was a burning type of pain where her sores are. R2 said she didn't want to be around people because she knew she was a crab-a**, and it hurt too much to sit up in her wheelchair. She said she would just have to grit her teeth and bare it before they got her better pain medication. On 12/02/25 at 10:55 AM, V31, R2's family member #2 said he messaged/sent pictures to the DON about the bed not working. He said he likes to have things in writing when it comes to the facility, so he has proof. He said this didn't start because his mom didn't want to lay down in her bed it was because they put her in a wheelchair that was to small and then sent her to dialysis. He said his mom has always slept in her recliner but now she stays mostly in her bed because of the wounds. V31 said R2 didn't get the low air loss mattress until she came back from the hospital this last time. He said that is why she had to be moved to the (specific hall location). V31 said he isn't sure what day R2 got the bed, but it didn't work. The hose that connected to the mattress would keep coming off and they used duct tape to try and keep it in place. V31 said they have changed R2's pain medication also. He said she is in extreme pain due to (d/t) her wounds and so they started her on morphine and after the dressing changes is when she has the most pain.On 11/19/25 at 12:42 PM, This surveyor reviewed pictures provided by V9, R2's family member #1 and they correspond with V31, R2's family member #2, V7, LPN, and V8, CNA interviews that the hose that keeps the bed inflated comes disconnected and causes the mattress to lose air. On 12/04/25 at 2:45 PM, V2, DON stated R2's old bed had an issue with the hose coming off. She said when she was made aware of the situation, she notified maintenance, and they were supposed to order a new part. V2 said they tried to order the part, and they couldn't get it, so they got R2 a new bed. V2 said the maintenance man who was working at the facility at the time is no longer with them, they had to let him go due to them having issues with him.On 12/23/25 at 10:20 AM, V1, Administrator said she would expect the maintenance department to keep equipment in good working condition. She said V48, Maintenance director is proactive about getting things done and looking for things to make sure they are working properly.On 12/01/25 at 10:38 AM, V13, Wound Nurse Practitioner (NP) she first seen R2 back in August of this year and on the first visit she wrote an order for R2 to get a low air loss mattress. She said sure it could be painful for R2 if the air loss mattress wouldn't stay inflated and R2 was laying on the hard bed. She said to be 100% truthful she isn't sure if R2's wounds are pressure. She said her and her colleagues thought R2 could possibly have what is called Calciphylaxis (a rare, serious disease. It involves a buildup of calcium in small blood vessels of fat tissues and skin. Symptoms include blood clots, lumps under the skin and painful open sores called ulcers. If an ulcer becomes infected, it can be life-threatening.).On 12/02/25 at 2:10 PM, V13, Wound NP said she would expect the facility to implement the orders she gives and if a low loss air mattress isn't properly inflating it can cause issues by putting more pressure on R2's wounds and it can cause her pain.The facility's Preventive Maintenance and Inspections policy, not dated, documented In order to provide a safe environment for residents, employes, and visitors, a preventative maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition. Routine inspections and promote safety throughout the facility and aid in keeping fixtures and equipment in good working order and operating in accordance with manufacturer's guidelines. Regular inspection, testing, and replacement or repair of equipment and operational systems contribute to preservation of the facility's assets. Preventive maintenance (PM) is the care and servicing by personnel for the purpose of maintaining fixtures, equipment and facilities in a satisfactory operating condition by providing for systematic inspection, detection, and correction of incipient failures either before they occur or before they develop into major defects. Maintenance includes tests, measurements, adjustments, and parts replacements that are performed specifically to prevent faults from occurring.

Based on interview and record review, the facility failed to ensure their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 60 residents residing in the facility. Findings include:The Facility assessment dated [DATE] did not include the following in the plan: identification of current Administrator nor current DON (Director of Nursing), identifying resources to provide necessary care and services the residents require during both day-to-day operations and emergencies (including nights and weekends) and emergencies; evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans; pertinent information about the resident population the facility serves may include race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy or other factors that affect access to care and health outcomes related to health equity; physical environment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents; evaluations of the facility's training program to ensure any training needs are met for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment did not include an evaluation of applicable policies and procedures, facility based and community-based risk assessment, utilizing an all-hazards approach that evaluates the facility's ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or natural disaster, and contingency plan for events or an all-hazards approach. On 12/2/25 at 10:52 AM Surveyor asked V1 Administrator if she has additional information on the Facility Assessment as the one provided does not address all required components including facility and community risk assessments and resources. V1 stated the Facility Assessment that was provided is all the information she has. On 12/2/25 at 1:47 PM V1 Administrator stated the facility does not have a policy for the Facility Assessment. The facility's daily census report, dated 12/2/25, documented there are 60 residents residing in the facility.

Based on observation, record review, and interview, the facility failed to timely identify, assess and monitor, and provide treatment to prevent the worsening of pressure ulcers for 1 of 3 residents (R2) reviewed for pressure ulcers in a sample of 3. This failure resulted in R2 developing two unstageable pressure ulcers requiring debridement at the bedside and being started on an antibiotic treatment related to pressure ulcer infection. The Immediate Jeopardy began on 05/12/25 when due to the facility's failure to assess and monitor and provide progressive treatment, R2 developed an opened area to her buttocks which went untreated, worsened to R2 developing two unstageable pressure ulcers requiring bedside debridement and acquiring an infection which required antibiotic treatment. V1, Administrator was notified of the Immediate Jeopardy on 07/11/25 at 1:45 PM. The Immediate Jeopardy was determined to not be removed on 7/17/25, upon review of the implementation of the facility's abatement plan. The surveyor confirmed through observation, interview, and record review, that the facility did not assess all facility's residents' current skin condition and did not revise R2's Care Plan with interventions related to R2's pressure ulcers as per the facility's Abatement Plan. Findings include:On 07/09/25 at 10:50 AM, V7, Licensed Practical Nurse (LPN) did R2's dressing change at this time. R2's old dressing was removed from the left (Lt.) buttock/ischium with a moderate amount of bloody drainage noted to the old bandage. Wound bed was red/granular, and the wound was 5 centimeters (cm) x by 6cm. No odor or signs of infection noted. Old dressing removed from the right (Rt.) buttock/ischium with a moderate amount of drainage noted. The wound measured 14cmx9cm with yellow/tan/eschar covering the wound bed. There was a foul odor noted when the dressing was removed. R2's Face Sheet, print date of 07/11/25, documented R2 was admitted to the facility on [DATE] and has diagnoses of but not limited to chronic kidney disease, stage 4 (severe), dependence on renal dialysis, morbid obesity, hypertension (HTN), Atrial Fibrillation, and Type II Diabetes Mellitus. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15, she independent with most of her activities of daily living (ADLs), and is frequently incontinent of bladder and always continent of bowel. MDS section M-skin dated 04/09/25, documented R2 did not have any pressure areas at this time, a formal assessment instrument/tool should be done, clinical assessment to be done, she is at risk for developing pressure ulcers/injuries, and she should have a pressure reducing device for her chair and her bed. R2's MDS- Ancillary Assessment, dated 04/09/25, documented R2's Braden Scale Assessment score was a 17= Mild Risk (9 or below=severe risk, 10-12=high risk, 13-14=moderate risk, and 15-18=mild risk).R2's MDS- Ancillary Assessment, dated 07/02/25, documented R2's Braden Scale Assessment score was 17.R2's last Braden Scale Assessment prior to the two above was completed on 06/05/23 with a score of 19.R2's Care Plan, admission date of 05/15/23, documented Potential for skin breakdown related to (r/t) incontinence, history (Hx) weeping lower extremities (L/E's), ace wraps for edema, morbid obesity, overactive bladder (OAB), Lt. Buttock stage 3, Rt. Buttock stage: unstageable (U). (An unstageable wound, specifically referring to a pressure ulcer, means the depth of tissue damage cannot be determined because the wound bed is obscured by slough (yellow, tan, tray, green, or brown) or eschar (tan, brown, or black). These are full-thickness injuries, but the extent of the damage below the surface cannot be seen.) Goal: R2 will develop no skin breakdown thru next review. Interventions include but are not limited to reposition self every two hours and as needed (PRN), monitor for redness or discoloration, and weekly skin checks.R2's Physician's Orders, dated 04/28/25 at 4:15 PM, documented skin check 6P-6A with showers on Monday, Wednesday & Friday. No redness, open areas, or excoriation at (@) present skin integrity = within normal limits (WNL) skin impairment = abnormal (ABN) every night shift every Mon, Wed, Fri for skin management.R2's Treatment Administration Record (TAR) for the month of May 2025 regarding weekly skin checks documented on 05/12/25 ABN. R2's Progress notes were reviewed for 05/12/25 and there was no documentation regarding R2's abnormal skin assessment. R2's Shower Sheet, dated 05/12/25, documented by V10, Certified Nursing Assistant (CNA) found a small open area to the back of R2's left thigh. V6, Licensed Practical Nurse (LPN) signed off on the shower sheet. R2's Electronic Medical Record (EMR) was reviewed and there was no documentation on 5/12/25 noting if the nurse was notified of R2's opened area, the physician was notified of the new skin condition, no measurements or wound description, and no wound assessment or evaluation done. R2's TAR dated 05/26/25, documented R2's skin check for this day was WNL.R2's Shower Sheet, dated 05/26/25, documented V10, CNA noted redness and bleeding to R2's Rt. and Lt. back thigh area. V12, LPN signed off on the shower sheet.R2's EMR was reviewed and there was no documentation regarding the nurse being notified of the open areas to R2's bilateral thighs, the physician being notified, no wound measurements or wound description, and no wound assessment or evaluation done.On 05/28/25 R2's two shower sheets above were signed off by V5, Former Wound Nurse.R2's Progress Notes, dated 5/28/2025 at 2:35 PM, documented Skin/Wound Note, Note Text: while this writer was reviewing shower sheets, redness and bleeding was noted, this writer went to residents' room and talked with resident. Resident stated some discomfort to right and left under folds of coccyx, open areas noted to both right and left under folds of coccyx, contacted MD (Medical Director), MD gave order to apply cal (calcium) alg (alginate) cover with dry dressing. ETAR (electronic treatment administration record) updated at this time.R2's Physician's Orders, dated 05/28/25, documented Left under fold of coccyx and Right under fold of coccyx- Cleanse area with NS (Normal Saline) or WC (Wound Cleanser) apply Cal Alg cover with dry dressing until healed every night shift for wound and as needed (PRN).R2's TAR/weekly skin checks, for the month of June 2025 was reviewed and documented on 06/02/25, ABN skin check. There was no documentation in R2's EMR regarding the abnormal skin check. On 06/20/25, R2's TAR/weekly skin check had open written in the space provided and there was no documentation in R2's EMR regarding any skin issues. On 06/23/25, R2's TAR/weekly skin check documented the letter o in the space provided. There was no progress notes noted regarding any skin issues. R2's TAR/weekly skin check for the date of 06/30/25, documented ABN and there were no progress notes regarding any abnormal skin findings. On 07/16/25 at 12:07 PM, V6, Infection Control Preventionist (ICP)/Wound Nurse stated if there is an abnormal finding on the weekly skin check there should be a progress note attached to it explaining why it is abnormal. R2's Progress Notes, dated 06/25/25 at 10:32 AM, documented MD gave order for resident to be evaluated by wound management.On 07/07/25 at 3:15 PM, This surveyor gave V1, Administrator a list of things that would be needed the next day. The wound care log for the past three months was one of the documents requested.On 07/08/25 at 8:35 AM, V2, Director of Nursing (DON) brought in wound care log for May and July 2025. She said the June log was jammed in the printer, and she would bring it as soon as she got it printed out.Wound care log dated 05/29/25, documented R2's wound measurements to her left buttock was 2x1x0.1 and was a stage 2. Right buttock measurements were 2.2x1.4x0.1 and was a stage 2. There was no wound care log for the month of June 2025 provided to this surveyor.R2's Physician's Orders, dated 07/01/25 at 11:19 AM, documented to contact wound management for evaluation and treatment.R2's Wound Assessment Report completed by V8, Wound Nurse Practitioner (NP), dated 07/01/25, documented R2's wound to her left buttock measured 8.0 centimeters (cm) x 4.0cm x 0.2cm and was a stage three pressure ulcer. R2's wound to her right buttock measured 14cm x 13cm and was unstageable. It also documented R2's wound to her right buttock had heavy purulent exudate (drainage that is thick, opaque, and tan, yellow, green, or brown in color is purulent. This is never a normal occurrence in the wound bed and is often associated with infection or high bacteria levels). Wound Care Education Institute. R2's Weekly Wound Assessment, dated 07/01/25, in R2's EMR documented onset date of 05/28/25, Lt. Buttock measurements 8.0x4.0x2.0 and the wound was unstageable. The Rt. buttock measurements for the wound were 14x13xUTD and the wound was unstageable. R2's Physician's Orders, dated 07/01/25, documented Left lower buttock/ischium and Right lower buttock/ischium- Cleanse area with NS or WC apply Silver Alginate, cover with silicone dressing. Change daily and PRN every night shift for wound.Wound care log dated 07/02/25, documented R2's wound measurements to her left buttock was 8x4x0.2 stage 2 and her right buttock measurements were 14x13x Unable to determine (UTD).R2's Weekly Wound Assessment, dated 07/08/25, documented R2's wounds were measuring Lt. Buttock: 8x5x0.2 and it was unstageable and the Right buttock: 14x13xUTD and was unstageable.R2's EMR was reviewed and there were no other weekly wound assessments done on the wounds to R2's Rt. and Lt. buttocks for the months of May 2025 and June 2025.R2's Progress Notes, dated 07/08/25 at 8:41 AM, documented R2 was seen by wound specialist (V8). R buttock has improved and measures 14x13xUTD. L buttock has declined and measures 8x5x0.2. Both wounds were debrided with a scalpel and forceps by V8. Awaiting final culture report on wounds.R2's wound culture that was collected on 07/02/25 documented R2 has Pseudomonas Aeruginosa in her wound. (This infection is a condition that can affect your skin, blood, lungs, GI tract and other parts of your body. Pseudomonas Aeruginosa bacteria are common in the environment, especially water, soil and produce. Symptoms vary according to where the infection is in your body. Treatment usually includes at least one type of antibiotic. A Pseudomonas Aeruginosa infection can be challenging to get rid of. It's rare for a Pseudomonas Aeruginosa infection to develop in people with a healthy immune system. But it can be serious and potentially deadly if you have a weakened immune system (immunocompromised). Common causes of weakened immune system include diabetes and kidney disease. Cleveland Clinic 2025).R2's Physician's Orders, dated 07/08/25 at 11:28 AM, documented Cipro Oral Tablet 250 milligrams (MG) (Ciprofloxacin HCl) Give 250mg by mouth two times a day for seven days for Skin management; Wound until 07/15/25.On 07/08/25 at 2:35 PM, V7, LPN said skin assessments are usually done on the resident's shower days. She said the CNA will fill out the shower sheet and then the nurse will sign off on it. V7 said if she had someone with a new skin issue, she would contact the doctor and get an order for it until they can be seen by the wound nurse. She said if it an excoriation issue she will check her medication administration record (MAR) and see if they have some kind of cream ordered or if they have an anti-fungal powder ordered before contacting the doctor. She said if it was for an open wound, she would go down and assess the wound, do the initial measurements, call the doctor to get an order put into place, and then she would give it over to the wound nurse. She said the wound nurse would be the one to do all the measuring of the wounds after that and is also the one who makes rounds with wound Nurse Practitioner (NP). On 07/09/25 at 9:00 PM, V13, LPN said the last time she seen R2's wound was a long time ago. She said she usually works the other hallways, and it just so happened they put her down there that day. She thinks it was when the wounds first started but she can't remember. She said the wound on the left was smaller and the one on the right was much bigger and looked like a bruise, maybe there was an underlying wound or something but there was no open area and had no depth. She said she hasn't worked over there since and hasn't seen the wounds recently.On 07/09/25 at 9:10 PM, V10, CNA said she assisted R2 with her shower (05/12/25) and was drying her off when she noticed the towel had blood on it, so she looked and R2 had a small open area to her left buttock/thigh area. She said she always fills out the shower sheet and hands it to the nurse so she can review it. If there are any new skin issues, she lets the nurse know so they can go down and assess it and inform the wound nurse of any new wounds and that is what she did. V10 said she isn't sure if the nurse that night went down and assessed R2's wound or not. On 05/26/25 She said when she was drying off R2 and seen the blood on the towel she thought maybe the other side had opened. She said it was hard to remember because it was a while back. She said she would have done the same thing as she did for the other wound, she found on R2. V10 said she hasn't seen R2's wounds recently but she assisted R2 with her shower the day before yesterday (07/07/25) and the wounds had bandages on them, so she didn't get to see them.On 07/10/25 at 9:00 AM, V5, Former Wound Nurse said when there is a new skin issue found the CNAs are to document it on the shower sheets, the floor nurse is to assess the wound, notify the physician, get an order for a treatment, and write it on the shower sheet. She said because of the floor nurses and agency nurses it's not being done. V5 said with R2 she was reviewing the shower sheets and seen R2's. She said she called the doctor and got an order put into place. V5 said she can't check the shower sheets every day. She said they could go weeks or however long without being checked. V5 said she was having to do her job and the floor nurses' job, and she just couldn't do it all. V5 said she informed V1, Administrator and V2, Director of Nursing (DON) and they didn't pay any attention to her, and nothing was done. V5 said she was sure things would have been different if there had been a treatment order done for R2 when it was first seen.On 07/08/25 at 12:16 PM, V8, Wound Nurse Practitioner (NP) said it depends on the facility's policy on how often skin assessments are to be done. She said they usually do them on the resident's shower days. V8 said they should be doing weekly assessments on everyone and on the residents who have wounds they should be doing a weekly wound report regardless of if they receive her services or not.On 07/10/25 at 8:55 AM, V8, NP/Wounds said she wasn't aware R2's wounds started on 05/12/25. She said R2's condition could have been different if they had a treatment put into place at that time. She said she would have had a better chance of healing and a better prognosis than now. V8 said R2 also has more of a chance of getting an infection. V8 said from 05/12/25 to 05/26/25 the wound had plenty of time to get worse.On 07/17/25 at 12:33 PM, V2, Director of Nursing, DON stated the CNAs are to do head to toe skin assessments twice a week with the resident's shower. If they find a new area or worsening area they are to report it to the nurse immediately. The nurses are to do assessments whenever they do a treatment, and the other skin checks come from the CNAs. V2 said if the CNA were to find a new area, she would expect the nurse to go down and look at it then contact the doctor or the wound nurse for further treatment.The facility's policy and procedure Prevention of Pressure Ulcers, not dated, documented Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. It further documented General Guidelines: 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. It also documented 5. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. It further documented Interventions and Preventive Measures: General 9. Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form for any signs and symptoms of irritation or breakdown. 10. Report any signs of a developing pressure ulcer to the physician. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. It also documented Additional Factors that Indicate Residents at Risk: The following are additional clinical conditions, treatments, and abnormal lab values that indicate that a resident is at risk for pressure ulcers: 1. Impaired/decreased mobility and decreased functional ability; 2. Co-morbid conditions, such as end stage renal disease, terminal cancer or diabetes mellitus.The facility's policy and procedure Resident Examination and Assessment, with a revised date of 02/2014, documented Purpose: The purpose of the procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. It further documented Physical Exam 8. Skin: a. intactness; b. moisture; c. color; d. texture; and e. presence of bruises, pressure sores, redness, edema, rashes. It also documented Documentation The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. It also documented Reporting 2. Notify the physician of any abnormalities such as, but not limited to e. wounds or rashes on the resident's skin; and f. worsening pain, as reported by the resident. 3. Report other information in accordance with facility policy and professional standards of practice.The facility's policy and procedure Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised date of March 2014, documented Assessment and Recognition 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.The facility's policy Pressure Ulcer Risk Assessment, revised date of September 2013, documented Purpose The purpose of the procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Review current Braden Scale or facility risk assessment tool. It further documented General Guidelines 4. If pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected. It also documented 6. Once a pressure ulcer develops, it can be extremely difficult to heal. It further says 9. Pressure ulcers are a serious skin condition for the resident. 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation of breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment 1. Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, quarterly, annually and with significant changes. 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will perform routine skin inspections (with daily care). b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. It further documented Identifying Residents at Risk 4. Diagnoses and Conditions that increase risk for pressure ulcers: f. Chronic or end stage renal, liver, or heart disease, g. Diabetes. It also documented Documentation The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment conducted (for example, admission Assessment, Weekly Skin Integrity tool.) 2. The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any changes in the resident's skin (i.e., the size and location of any red or tender areas), if identified. It also documented 12. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. 13. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated.

Based on interviews, observations, and record reviews the facility failed to prevent verbal and mental abuse for 4 out of 6 residents (R3, R4, R6, R7). This failure resulted in R3, R4, R5 and R7 experiencing psychosocial harm. Using the reasonable person concept, R3, R4, R6 and R7 experienced psychosocial harm with feelings of shame, embarrassment, humiliation or insignificance. Findings include: 1 R3 was admitted to the facility on [DATE] with diagnosis of, in part, atherosclerosis of extremities (bilateral legs), unsteadiness on feet, and unspecified displace fracture of right humerus. R3's MDS dated [DATE], documents she is cognitively intact, and requires partial/moderate assistance from staff for upper and lower body dressing as well as putting on/taking off footwear. R3's Care Plan dated 12/3/24, documents she requires assistance with activities of daily living (ADL's) related to (r/t) weakness, arthritis, history of falls, fracture of right humerus, osteoporosis and for staff to provide privacy and offer choices where available. The Care Plan continues to document R3 is at risk for falls r/t weakness, arthritis and for staff to provide a safe environment. On 1/28/25, R3's statement for the facility's investigation on alleged abuse occurring 1/24/25, documented that V3 was inappropriate with her by not helping her get out of bed and dressed because she did not want to get dressed in the bathroom. R3 stated V3 said she couldn't help because she had to do something else. On 2/10/25 at 9:40 AM, R3 stated V3 had treated her poorly a couple weeks ago. R3 stated she needed help getting up and dressed so she requested help from V3. R3 stated V3 told her she needed to get dressed in the restroom. R3 stated she told V3 she didn't want to get dressed in the restroom because there's no room but V3 told her she didn't have time and made her get dress in there. R3 stated that V3 was forceful and very rushed while putting stockings on her in the restroom, then left her in her chair to eat breakfast with just her undershirt on. R3 stated she asked V3 if she could help her put a button up shirt over her undershirt but V3 told her no, she didn't have time. R3 stated V3 left her feeling exposed and cold without her button up on. On 2/10/25 at 9:29 AM, R2 stated V3, Certified Nursing Assistant (CNA), left a couple weeks ago and did not treat the lady next door (R3) properly. R2 stated she wouldn't have allowed V3 to take care of her family the way she took care of R3. R2 stated that V3 wouldn't allow R3 to get dressed in her room, that she needed to go in the restroom to get dressed but R3 told V3 there wasn't enough room for her in there, she would prefer getting dressed in her bedroom. R2 stated V3 preceded to make R3 get dressed in the restroom. R2's Minimum Data Set (MDS) dated [DATE], documented she is cognitively intact. V5, CNA, made a handwritten witness statement included in the facility's abuse investigation for 1/24/25. V5 ' s statement included the following: R3 extremely upset. Stated she needed her shower, wasn't done on night shift previous day. Was still in p.j.'s (pajamas) at 9:00 AM. Stated V3 refused to do her shower or get her dressed for the day. R3 told V3 she doesn't like to get dressed in the B.R. (bathroom) because it's cold in there. V3 said she was going to dress her in there anyways. V5's statement continued to document, R4 rang light this morning to get up. V3 came in with an attitude and said it's you ringing again? R4 said yes, it's me again. I ' m ready to get up. V3 told R4 okay, well you can get up by yourself. R4 was almost in tears and stated I do need help. I have one leg shorter than the other. V3 said okay, hurry up, I don't have all day. V5's statement also included, R2 stated instead of working this morning, V3 was in the hallway complaining all morning about how this hall needs two people and she wasn't doing any showers. Residents ring and she doesn't answer the lights in a timely manner or when fall alarms go off she doesn't come to answer them. Has a very off-putting attitude. 2. R4 was admitted to the facility on [DATE] with diagnosis of, in part, heart failure, chronic obstructive pulmonary disease, hemiplegia and hemiparesis. R4's MDS dated [DATE], documented she is cognitively intact and requires partial/moderate assistance with all transfers. R4's Care Plan dated 1/14/25, documented she requires assistance at all times with ADL's r/t weakness, knee pain, unsteady balance and for staff to provide one assist with transfers and does not ambulate at this time. (R4 is afraid of falling when ambulating r/t history of fractures from fall). The facility's investigation for the alleged abuse occurring on 1/24/25, documented R4 stated she needs help getting out of bed and V3 asked R4 why she can't do that herself. R4's statement continued to say she told V3 she would if she could. On 2/10/25 at 9:45 AM, R4 stated V3 left a couple weeks ago; she was rude. R4 stated she told V3 she needed help getting up and V3 told her she can do it herself and refused to help her. R4 stated she continued to ask V3 for help until she finally gave in to help her. R4 stated V3 made her feel terrible. R4 stated she reported V3 to V1, Administrator, and V1 told her she would take care of it, soon after, V3 was gone and did not work at the facility any longer. On 2/10/25 at 9:50 AM, V2, CNA, stated V3 was the impatient type of person and wasn't sure if she should have been helping people with dementia. 3. R6 was admitted to the facility on [DATE] with diagnosis of, in part, Alzheimer's disease with early onset, hypertension and epilepsy. R6's MDS dated [DATE], documents she requires set-up and clean-up assistance with dressing. R6's MDS indicated R6 is not interviewable. R7 was admitted to the facility on [DATE] with diagnosis of, in part, congestive heart failure, Alzheimer's disease and vascular dementia. R7's MDS dated [DATE], documented he requires supervision/touching assistance from staff for toileting transfers and substantial/maximal assistance for toileting hygiene. R7 MDS indicated R7 was not interviewable. On 2/10/25 at 9:49 AM, R5 stated she had witnessed V3 treat other resident's poorly before she stopped working at the facility. R5 stated she heard V3 yell at R6 because R6 walked out of her room without getting dressed in the clothes she laid on her bed. R5 stated R6 needed assistance getting dressed, she has some sort of dementia and doesn't do that by herself. R5 stated she heard V3 also yell at R7 because he peed on the floor and she slipped in it. R5 stated R7 had an accident, he couldn't help it and it was wrong for her to treat him that way. R5 stated she wanted to have a come to Jesus talk with V3 because of the poor way she treated the other residents, she couldn't believe the way V3 was treating them, it was horrible. R5 stated she reported to V3, to V1, Administrator and she started an investigation, shortly after, V3 did not come back to work. R5's MDS dated [DATE] documented she is cognitively intact. The facility's investigation for alleged abuse occurring on 1/24/25, documented R5 stated she heard V3 tell the resident next door (R7) with a raised voice, You peed on the floor and I almost slipped and fell . R5's statement continued to document she heard V3 yelling at R6, I laid you out clothes, why did you come out without changing them? The facility's investigation on the alleged abuse allegations occurring on 1/24/25 documented that it was verified V3 engaged in behaviors that constituted abuse or neglect. On 2/10/25 at 1:20 PM, V1, Administrator, stated she was notified of concerns involving V3 by V5 on 1/24/25. V1 stated she does not expect any of her staff to be treating the resident's the way V3 was. V1 stated V3's behavior and actions were inappropriate, and she was terminated following her investigation. The facility's Abuse Policy dated 1/12/17, documented, It is the policy of this facility to provide each resident with an environment that is free from any type of abuse, neglect or misappropriation of property. Each resident has the right to be free from exploitation, verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy defined abuse as, The will infliction of injury; unreasonable confinement; intimidation; punishment with resulting physical harm, pain, or mental anguish; or deprivation by an individual, mental, and psychosocial well-being and includes verbal abuse, sexual abuse, physical abuse and mental abuse. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services.

Based on observation, interview, and record review, the Facility failed to implement progressive fall interventions in 2 of 11 residents (R18, R25) reviewed for accidents and hazards in the sample of 40. This failure resulted in R18 sustaining lacerations requiring emergency room (ER) transfer and repair with sutures and R25 sustaining bruising to forehead. Findings include: 1-R18's Face Sheet documents R18 was admitted to the facility on [DATE] with diagnoses including weakness, polyneuropathy, right foot drop, lack of coordination, abnormalities of gait and mobility, age-related cognitive decline, and muscle wasting and atrophy. R18's Minimum Data Set (MDS) dated [DATE] documented R18 was moderately cognitively impaired and ambulated via wheelchair. R18's Undated Care Plan documents R18 is at risk for falls related to weakness, incontinence, history of falls, and leaning when tired. R18's 4/17/24 Progress Note documents R18 was found lying on the floor next to her bed on her right side with a significant amount of blood on the floor next to her left foot. R18 stated she was attempting to sit up on the side of the bed and lowered herself to the ground. There was bleeding between left great toe and left second toe and on underside of left great toe. Emergency Services were contacted. R18's 4/17/24 Fall Investigation documents R18 was found on floor next to her bed lying on her right side. There was bleeding to the space between her left great toe and left second toe and the underside of her left great toe. There was blood on the floor by her foot. R18 stated she was attempting to sit up on the side of the bed and lowered herself down onto the floor. Resident was sent to (Local Hospital). R18's 4/18/24 Progress Note documents R18 returned to the facility at approximately 2:20 AM with diagnosis of closed displaced fracture of proximal phalanx (bone at the base) of left great toe. There were new orders for the antibiotic Bactrim DS every 12 hours for 10 days for toe wound. The ER nurse reported R18 had 7 sutures to the laceration between left great toe and left second toe. An orthopedic surgery referral was made with plan to remove sutures in two weeks. R18's Fall Risk assessment dated [DATE] documented R18 was at high risk for falls. R18's 4/18/24 Fall Investigation does not document any progressive interventions for R18's 4/17/24 fall. R18's Care Plan does not document any new interventions for R18's 4/17/24 fall. R18's Progress Notes for the month of April 2024 do not document any new interventions for R18's 4/18/24 fall. R18's 8/30/24 Progress Note documents R18 was sent to the ER for alleged fall. R18's 8/30/24 Fall Investigation documents R18 was observed lying on her right side on a floor mat next to her bed. R18 was hallucinating and attempted to get up and stand and fell down. There was a large red bump on the right side of her forehead and a left second toe laceration with bleeding. R18 was sent to the hospital. R18's 8/30/24 ER Notes document R18 had a forehead laceration and a 2 cm (centimeter) by 2 mm (millimeter) left second toe laceration with persistent bleeding that required repair with four sutures. On 12/18/24 at 3:25 PM, V12, MDS/Care Plan Coordinator, stated she was unable to provide documentation that progressive interventions were added for R18's falls on 4/17/24 or 8/30/24. On 12/19/24 at 10:53 AM, V19, Certified Nursing Aide (CNA), and V20, CNA, transferred R18 from wheelchair to bed via mechanical lift. There was no fall mat or visible fall intervention in R18's room. V19 stated the only fall intervention in place for R18 is the call light (within reach). On 12/20/24 at 9:20 AM, V1, Administrator, and V2, Director of Nursing (DON), stated they are aware they need to work on implementing post-fall interventions. On 12/20/24 at 9:00 AM, V21, Medical Director (MD), stated he would have expected the Facility to put something in place to help prevent subsequent falls. 44953 2-R25's Face Sheet undated documents her admitting diagnosis as Unspecified Sequelae of Unspecified Cerebrovascular Disease, Vascular Dementia Moderate with Anxiety, Unspecified Convulsions. R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact, toilet transfer, dependent, chair/bed to chair transfer dependent. Incident report dated 5/3/24 documents R25 was just transferred to wheelchair using a mechanical lift. The mechanical lift bar was unhooked. Bar on machine turned around bumped resident on the right upper forehead. Noted area raised 4 cm circle with purple bruise. On 12/19/24 at 10:00 AM V13 Social worker stated she was the administrator at that time and was unaware of the incident. On 12/20/24 at 9:50 AM V6 Registered Nurse stated she could not remember the incident or the staff involved. The facility policy Safe Lifting and Movement of Residents revised December 2013 documents in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The Facility's Falls Policy revised 9/2012 documents, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on observation, interview, and record review, the Facility failed to implement nutritional interventions to prevent weight loss in 1 of 3 residents (R37) reviewed for nutrition in the sample of 40. This failure resulted in R37 sustaining significant, severe weight loss at the one, three, and six month marks. Findings include: R37's Face Sheet documents R37 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anemia, right hip pain, weakness, constipation and dehydration. R37's Minimum Data Set (MDS) dated [DATE] documented R37 was severely cognitively impaired, had impairment on one side upper extremity, and was dependent with bed mobility and transfer. R37's Care Plan initiated 6/18/24 documents R37 has a nutritional deficit. Documented interventions include, Provide and serve supplements as ordered. R37's Monthly Weight Report documents R37 weighed 99.0 pounds in June 2024 and 93.2 pounds in July 2024. This reflects a weight loss of 5.8 pounds or 5.8% body weight loss in one month. R37's Monthly Weight Report documents R37 weighed 88.0 pounds in September 2024. This reflects a weight loss of 11.0 pounds or 11.0% body weight loss in three months. R37's Monthly Weight Report documents R37 weighed 83.4 pounds in December 2024. This reflects a weight loss of 15.6 pounds or 15.7% body weight loss over 6 months. R37's Order Summary Report documents 5/23/24 order for regular diet with mechanical soft texture. On 12/19/24 at 9:59 AM, V14, Registered Dietitian (RD) stated recommendations for dietary changes are documented in both resident Progress Notes and on the Nutritional Care Form which she provides to the V1, V2 and V4 after each visit. R37's Progress Notes for the month of September 2024 do not contain any documentation from V14. The Facility's 9/19/24 Nutritional Care Form documents the Action to change R37's diet order in (Electronic Health Record) to reflect dietary meal sheet with supplement three times daily. R37's 10/24/24 Progress Note by V14 documents, Recs (Recommendations): Initiate extra protein with all meals. The Facility's 10/24/24 Nutritional Care Form documents the Action to change R37's diet order in (Electronic Health Record) to reflect dietary meal sheet which has supplement ordered three times daily. The Action column does not document giving R37 additional protein with meals. R37's Progress Notes from November 2024 do not contain any documentation from V14. The Facility's 11/26/24 Nutritional Care Form does not contain any documentation from V14 regarding R37. R37's 12/18/24 Dietary Meal Sheet for Breakfast documents mechanical soft diet with supplement three times daily. There is no documentation to provide an additional protein serving. On 12/17/24 at 12:20 PM, R37 was sleeping in bed in her room. She appeared very thin with muscle wasting and orbital wasting. There was no meal tray in the room. On 12/18/24 at 8:50 AM, R37 was feeding herself French toast in the dining room with adaptive utensils. There was no nutritional supplement on R37's tray. On 12/18/24 at 9:05 AM, V5, Dietary Aid, stated R37 refused her supplement today and refuses them the majority of the time. On 12/18/24 at 2:07 PM, V2, Director of Nursing (DON), stated there has not been good communication with V14. She stated she requested some information on weight loss from V14 a couple of weeks ago and has not yet received that information. On 12/19/24 at 9:55 AM, V2 stated she was unable to provide any documentation of meal or supplement intakes for R37, because the Facility's documentation is minimal. On 12/19/24 at 9:59 AM, V14 stated residents with weight loss are considered High Risk and are seen monthly, but she did not see R37 last month and was unaware R37 continued to lose weight or refuse nutritional supplements. She stated the Facility does not consistently track meal or supplement intakes for residents and would expect to be notified of significant weight losses between visits so they can be addressed. She stated she previously recommended adding double protein portions at meals for R37, but did not add that to the Action list for the Facility, so it was never implemented. On 12/19/24 at 10:45 AM, V4, Dietary Manager, stated R37 does not take nutritional supplements very well. V14 stated she was unsure if she had ever seen R37 in person, and her weight loss was significant over one and six months and would not be desirable. On 12/20/24 at 9:20 AM, V1, Administrator, and V2 stated this is a concern that will be addressed. On 12/20/24 at 9:00 AM, V21, Medical Director, stated he expects physician orders to be followed and supplements to be given as prescribed. The Facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy revised 9/2012 documents, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria 1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe. Strategies to increase a resident's intake of nutrients and calories may include fortification of foods (for example, protein added to mashed potatoes), increasing portion sizes at mealtimes, and providing between-meal snacks and/or nutritional supplementation. The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals.

Based on interview and record review, the facility failed to provide supervision/monitoring to prevent an elopement for 1 of 11 residents (R2) reviewed for supervision to prevent elopement in the sample of 11. This failure resulted in Immediate Jeopardy on 10/15/2024 with R2, eloping from the facility sometime between 3:00 PM to 4:00 PM. R2 was found by a passerby at approximately 4:30 PM, was assessed at the local hospital and returned to the facility. The Immediate Jeopardy began on 10/15/2024, when R2 eloped from the facility. On 10/22/2024 at 2:18 PM V1, Administrator and V30, Medical Records Director were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 10/29/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's Admission Assessment, dated 10/4/2024 at 9:45 AM, documents R2 was admitted from home. She was assessed to have clear speech and was orientated to person only, confused and agitated. Elopement Risk Assessment documents supervision with walk in room and locomotion on and off unit, decisions regarding tasks of daily life: moderately impaired. Behaviors: anger facility placement and verbalizing statements about leaving. Resident experienced new admission. Contributing diagnoses: Alzheimer's disease, dementia other than Alzheimer's disease, dementia other than Alzheimer's disease. Resident assessed as an elopement risk. R2's Late Entry Nurse Progress Note, dated 10/4/2024 at 10:31 AM, documents (R2) was admitted on [DATE] at 9:45 AM . from home. (R2) is unaware that family wants this to be a long-term placement as she is unsafe at home due to her progressing dementia. (R2) is confused and thinks she is at the hospital and will go home as soon as the doctor evaluates her. Resident is alert to self. R2's Nurse Progress Note, dated 10/5/2024 at 2:40 PM, documents (R2) has been anxious this day, pacing the hallway and voicing that she does not understand why she is here, she fears her family may be sick and why did they leave her here. She asks for mom and dad. Resident's POA (Power of Attorney) came to visit resident and resident became very upset and crying. R2's Nurse Progress Note, dated 10/7/2024 at 12:29 AM, documents 1 milligram (mg) Ativan administered for increased anxiety. R2's Nurse Progress Note, dated 10/7/2024 at 2:21 PM documents (V6), Medical Director documents (R2's) primary diagnosis is Alzheimer's disease. Currently she is generally awake, alert and pleasant, however she is adamant about going home, she cannot understand why she is here at the facility. (R2) is becoming increasingly forgetful and in addition she has had a problem with anger outburst and very hostile behaviors which previously were out of character for her. R2's Skilled Nursing Admission Documentation, dated 10/8/2024, documents alert to person only and confused. (R2) was assessed independent with bed mobility, transfers, eating and toilet use. A note documents: resident alert to self, able to make needs known. Resident anxious this morning, carrying her purse saying she needs to leave, becoming agitated. PRN (As Needed) Ativan administered and effective. Ambulates independently, with steady gait. R2's Nurse Progress Note, dated 10/10/2024 at 2:03 PM, documents (R2) continues to seek exit today and asking for (V12) and husband able to redirect at this time. R2's Nurse Progress Note, dated 10/11/2024 at 1:01 AM, documents (R2) had an episode prior to HS (bedtime) that was long lasting where she was exit seeking and yelling out for her daughter, staff unable to redirect easily and PRN Ativan was given. She calmed after about an hour and the PRN dose was effective. Closely monitored by memory care staff. R2's Admission Minimum Data Set (MDS) dated [DATE], documents resident understood and understands. Brief Interview for Mental Status (BIMS) score of 5 (severely cognitively impaired.) Physical, verbal, and other behavioral symptoms (hitting or scratching self, pacing, rummaging or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Rejection of care occurred 1 to 3 days. Change in behavior or other symptoms were worse. No mobility devices. R2's Nurse Progress Note, dated 10/14/2024 at 2:00 PM, documents completed the admission MDS and assessment with (R2). (R2) is confused as to time, place and situation. (R2) was able to answer the MDS questions without issues. The questions about her history were a little more confusing for her. She is new to the facility and is on the unit. She packs her belongings every day and waits for (V12) to pick her up. (R2) was able to talk about her past and growing up. We will continue to try to get her involved in activities. R2's Nurse Progress Notes, dated 10/15/2024 at 6:40 PM, documents (R2) returned to facility via EMS via stretcher. (R2) alert and oriented to self. Speech clear. No injuries observed from previous incident. (V8), Medical Director notified of (R2's) return. R2's Admission Assessment, dated 10/15/2024 at 6:40 PM documents elopement risk assessment walk in room supervision on and off unit, moderately impaired decisions regarding tasks of daily life, behaviors include: prior exit seeking, packing belongings, repeatedly opening doors/settings off alarms of secured doors, resisting redirection from staff and verbalizing statements about leaving. Contributing diagnoses include Alzheimer's disease, depression and anxiety disorder. Interventions documented include ID bracelet on, clothing marked with identification and frequent checks. R2's Nurse Progress note, dated 10/15/2024 9:42 PM, documents frequent checks on resident. V7, CNA Written Statement, dated 10/15/2024 at 5:15 PM, documents I was on the hall working and was last in contact with (R2) around 4:00 PM. She asked about going home and I instructed her we would have dinner in about 30 minutes if she could wait. I then checked on another resident and then moved onto another resident and escorted her to the bathroom where I then began to change her. I was notified of (R2) being gone around 4:45 PM. V4, LPN Written Statement, dated 10/15/2024 at 5:44 PM, documents this nurse had just finished med pass on a (different hall than R2 resided) hall, med cart parked at nurse's station when phone rang. (V9), Unit Aide answered phone at 5:40 PM. (V9) informed this nurse that police were on the phone and (R2) was in their custody, they had found her in a field and (V9) transferred the call to Administrator's office. This nurse immediately went to Administrator's and DON's offices to notify them. This nurse then went to (the hall R2's room was located) hall, head count performed. All residents accounted for except (R2). V9, Unit Aide Written Statement, dated 10/15/2024 at 6:00 PM, documents I, (V9) was passing supper when the phone rang at 4:50 PM. I answered the call from the local police department who stated they found one of our residents in a field. I made the resident's nurse aware the Administrator the police were on the phone. R2's Care Plan, updated 10/16/2024 documents focus: the resident is at risk for elopement posing a safety concern. Goal: the resident will not leave the facility without a responsible person accompanying them. Interventions: develop a plan for immediate action if elopement occurs. Educate the family and engage resident in activities such as folding washcloths/towels, washing tables in dining room to give a sense of purpose. Have photo and description readily available. Implement continuous monitoring and whereabout tracking preform elopement risk assessment on admission and quarterly secure exits, windows and potential escape routes changing codes to locked unit train staff of elopement prevention and immediate response. V1, Administrator typed statement dated 10/16/2024, documents this writer was informed around 4:30 PM on 10/15/2024 from the local Sherriff's Office that someone had called the sheriff's department about a person that was observed at the corner South Grand and [NAME] Street. Resident had been sent to local hospital Resident did return from hospital at 6:40 PM. Hospital stated no injuries. This writer also spoke with (V12) to keep her updated and told her (R2) had returned from hospital. Prior to (R2's) returning to the facility, facility provided POA information at 5:07 PM on the 15th. This writer informed the Medical Director of incident that same day. Investigation continues. 10/16/2024 left message for IDPH (Illinois Department of Public Health) to return my call. Informed my receptionist of this. On 10/15/2024 Administrator had maintenance screw all the windows on (hall R2 resides on) hall to only open 2-3 inches. There was a window left open in a vacant room. On 10/16/2024, DON and Administrator surveyed the area where (R2) was observed at. Maintenance and Administrator also surveyed the grounds of the facility with no real findings. Spoke to (V14) at 11:00 AM on 10/16/2024, Assistant Director of Nurses at hospital to thank her and the hospital for the assistance with (R2). On 10/17/2024 at 9:00 AM, R2's door was closed. Upon opening R2's bedroom door she was observed sitting on her bed with a black purse next to her. R2 told the State surveyor she wanted to go home, and she doesn't belong here, and she didn't know where her family was. R2 didn't recall being outside or at a hospital within the last few days and she was alert to name only at that time. No identification bracelet on. On 10/17/2024 at 11:20 AM, V3 Social Service Coordinator stated that (R2) was initially admitted on [DATE], (R2) was very confused and thought this was a doctor's office and as soon as she was seen by the doctor she could go home. (R2) is severely cognitively impaired and wanders up and down the memory locked unit hall from one door to the other and constantly tries to get out of the locked unit. V3 didn't see or assess (R2) on 10/15/2024 and wasn't told (R2) was exhibiting behaviors on that day. Upon admission, (R2's) family told her (R2) is no longer safe to be at home because her husband is frail with a heart condition and can't take care of (R2) anymore and she was afraid (R2) would leave the house unsupervised and would get harmed in some way. (R2's) family voiced they were afraid she would get out of the facility and get harmed in some way. On 10/17/2024 at 12:20 PM, V4, LPN (Licensed Practical Nurse) stated she worked on 10/15/2024 and was assigned to (R2) from 6:00 AM to 6:30 PM. V4 states she works with 1 CNA (Certified Nurse Aide) on the memory care locked unit and she is also assigned to other residents on three additional halls so although she is the assigned nurse to the locked unit, she is not back on the locked unit at all times when she is off the unit administering medications to other residents there is 1 CNA assigned to the unit for 11 residents who are very active and multiple residents are ambulatory and have behaviors and it is hard for her and the CNA to keep track of the residents let alone her being off the unit and leaving 11 residents with 1 CNA. Staffing has been like that for the year she has worked at the facility and even though she doesn't agree with it, it's how her schedule is set for the day to be assigned to multiple halls. V4 recalled she administered morning medication to (R2), and she took it, but she didn't recall seeing (R2) after that. V4 left the locked unit between 3:25 PM - 3:30 PM to pass evening medications on other halls and didn't recall seeing the resident at that time. V4 found out the resident was not at the facility at approximately 4:50 PM on 10/15/2024 because she was on a hall passing evening medications and overheard (V9) talking to the police on the phone and when (V9) transferred the call to (V1), (V9) told her that (R2) was in police custody, and she was found walking in a field. When she found out (R2) eloped she went to the locked unit she went and did a head count she noted the window (in R2's room) was wide open and a recliner was propped up against the window as well. All residents were accounted for at that time except for (R2). V4 didn't know how (R2) got out of the facility or if (R2) went out the window. V4 stated she never observed (R2) playing with the windows on the locked unit or anything like that. On 10/17/2024 at 1:30 PM, V7, CNA stated he worked on 10/15/2024 from 6:00 AM to 6:30 PM and was assigned to (R2) on the locked unit. V7 was the only CNA assigned to the locked unit with (V4), LPN and when (V4) had to administer medications to residents on other hall V7 was the only employee assigned to the locked unit. V7 stated he was getting residents ready for supper and that consists of toileting residents and washing their hands. V7 assisted (R2) to the bathroom and the last time V7 saw (R2) was at 3:00 PM. V7 stated he didn't know (R2) was not at the facility until (V4), LPN came and told him to do a head count of residents because the police called and reported (R2) was found walking in a field and was in police custody. V7 assisted with the head count and (V4) showed him a window in room [ROOM NUMBER] was wide open and a recliner was propped up against the window. V7 stated there are 4 or 5 residents that are exit seekers and several are transferred via sit to stand lifts, so they need 1:1 care he has to stay there with them. V7 stated he didn't hear any door alarms while he was caring for the residents in the bathroom. While he provides 1:1 care he tries to make sure all residents are safe prior to going into the bathroom but he's only 1 person and can't leave a resident on the toilet alone so he does the best he can. No other staff are there to keep an eye on the residents when he is providing 1:1 care to a resident. V7 stated he was familiar with (R2) and her wanting to always go home but she was calmer the day of 10/15/2024, she still voiced she wanted to go home but she wasn't hanging out at the exit door like she has in the past. V7 stated (R2) is alert to name only and she is extremely confused at all times. When she exit seeks and says she wants to go home V7 tells her let's eat the next meal and go from there to redirect her. V7 recalled what (R2) wore on 10/15/2024, it was pants with a t-shirt with a sweater over the t-shirt and house shoes. On 10/17/2024 at 11:40 AM, V10, Activities/Unit Aide stated she worked on the locked unit on 10/15/2024 and left at 3:00 PM and (R2) was on the unit at that time because she recalled saying bye to her. V10 was familiar with (R2) and stated (R2) always says she's going home and she's always packing her bag. V10 stated (R2) looks out the windows often but she never saw her playing or attempting to open a window. On 10/17/2024 at 11:05 AM, V2, DON stated that (R2) was admitted on [DATE] and ever since then she has wanted to go home every minute of every day. V2 knew (R2) wanted to go home prior to her eloping from the facility. (R2) was initially admitted to the facility on the memory care locked unit due to her diagnoses of dementia and early onset Alzheimer's disease. V2 stated (R2's) family was concerned (R2) would leave the facility without anyone knowing and get harmed in some way. Prior to (R2) eloping the facility she expected staff to encourage (R2) in social activities on the unit, assist with activities and monitor for worsening behaviors. After (R2) returned from the elopement she expected staff to reassess her elopement risk to see if it changed and she wasn't aware staff didn't document a reassessment of (R2's) elopement risk. Interventions that were added to (R2's) care plan after she returned to the facility included in-servicing staff on how to prevent future elopements, educate family, involve the resident in folding wash cloths and towels, 15-minute checks for 72 hours and increase monitoring of resident as needed. Staff working on the memory care locked until on 10/15/2024 reported seeing (R2) last at 4:00 PM that day. She was aware after the police called the facility at approximately 4:40 PM that the resident was found walking in a field behind the hospital, she didn't know how the resident got out of the facility. After she was aware (R2) eloped she had the memory care locked unit do a head count to ensure all other residents were there and the nurse noted a window (in R2's room) was wide open and there was a recliner pushed against the windowsill. On 10/17/2024 at 1:10 PM, V2 stated an elopement risk assessment should be completed after a resident elopes to see if the elopement risk has changed. There is no initial care plan done upon a resident's admission and a MDS is done at days 4 and 14 then a care plan is documented at day 21 after a resident is admitted . The memory care unit is a locked unit for confused residents and there is 1 nurse and 1 CNA assigned to the unit. The nurse is also assigned to other halls as well so she's not always on the unit, but the assigned CNA is always on the unit. There are 11 residents that reside on the locked unit with 4 of the 11 residents are ambulatory and V2 didn't know how many residents exit seek or set door alarms off. (R2) was readmitted the same day she eloped which was 10/15/2024. (V2) was not at the facility when (R2) was readmitted to the facility via EMS but she knew (R2) didn't sustain any injuries. On 10/16/2024 at 1:30 PM, V5, Maintenance Man stated he just started working as the maintenance man at the facility, before that he worked in the kitchen. V5 was aware a resident was found in a field a few days ago but didn't know how she got out of the facility. The Administrator asked him to screw all the windows shut so they only open approximately 2 inches one day after (R2) was readmitted to the facility. On 10/17/2024 at 10:50 AM, V1, Administrator stated she was here at the facility on 10/15/2024 from approximately 8:00 AM to 6:30 PM. She was not aware (R2) was missing from the facility until the police called the facility at approximately 4:30 PM on 10/15/2024 and they stated the resident was found walking in a field near the local hospital. V1 stated doesn't know how (R2) got out of the facility or what time she left the facility. (R2) was seen by a staff member at 3:00 PM on 10/15/2024 and that was the last time staff saw here before she eloped. After V1 was notified that the resident was not at the facility staff did a head count on the memory until and during that it was noted a window in (R2's room) was found wide open with a recliner pushed up again the heat register. V1 and other staff don't know if (R2) went out the window to get out of the facility but since then they have screwed the windows shut on the memory unit so the windows only open 2 inches so residents cannot go out the window. (R2) was transported via EMS to the hospital and then back to the facility at approximately 6:30 PM on 10/15/2024 with no injuries. (R2's) has a low BIMS score and has diagnosis of dementia and early onset Alzheimer's disease. V1 stated R2 was found wandering in a field 0.6 mile from the facility. Review of the streets surrounding the facility showed there were multiple cars driving by a curvy busy country road with no sidewalks and deep ditches on both sides of the road. There was also a pond within 150 feet of where the resident was found. (R2) was initially admitted to the facility on [DATE] and since then she's stated she wants to go home and that's why she's on the memory locked unit because she doesn't have safety awareness and to be kept safe. When (R2) states she wants to go home she expects staff to redirect her. Since she returned to the facility staff have (R2) on 15-minute checks for 72 hours and all residents every 2 hours for 72 hours. On 10/18/2024 at 8:46 AM, R2 was observed sitting on her bed dressed with house shoes on. She was packing her clothes into a plastic hospital bag and stating to call her family because she needs to go home today. No identification bracelet on. On 10/18/2024 at 9:00 AM, R2 was observed sitting on her bed her house shoes were under the bed and she now had tennis shoes on. R2 again stated tell them I am going home today and to call her family. No identification bracelet on. On 10/18/2024 at 10:48 AM, V8, Police Officer who responded to the 911 call stated no report was made for this incident because he saw it as a medical situation. 3 police officers responded to an elderly woman (R2) walking in a bean field behind the local hospital on 10/15/2024 at 4:31 PM. The resident stated her last name and police dispatch called the local nursing home and they stated the resident resided at the facility and they didn't know she was missing. The resident was pleasantly confused at that time and had notable dementia. V8 couldn't recall what (R2) was wearing or if she had shoes on or not. (R2) was transferred to the local hospital via EMS at that time. No police report was documented because this was considered a medical transport issue. On 10/18/2024 at 9:05 AM, V6, Medical Director stated that (R2) is alert to person only and has poor safety insight. (R2) has diagnoses including dementia and early onset Alzheimer's disease. (R2) is not safe to be outside by herself due to poor safety awareness due to being confused and has anxiety often. V6 stated (R2) never wanted to be at the facility and her family told her once the doctor sees her, she can go home, and she continues to say she wants to go home. V6 didn't know how (R2) eloped from the facility but thinks she followed a family out the locked door and went out the main door of the facility. V6 wasn't aware there was a window left wide open in room [ROOM NUMBER] on the locked unit after the resident eloped. On 10/25/2024 at 2:00 PM, V1, Administrator stated (R2) now has a Electronic wandering bracelet on her ankle. V1 stated the facility had the electronic wandering system in place when (R2) was initially admitted to the facility but no one put the Wander Guard bracelet on her. V1 expected staff to assess all new residents for elopement risk and if they are determined to be an elopement then an electronic monitoring bracelet should be applied within hours of the resident being admitted to the facility. The memory care locked unit doors are not equipped for the electronic system, but all other exit doors to the facility are protected so if (R2) had the electronic wandering bracelet on, the alarm would have sounded. The Facility's Undated and Untimed Final Investigation documents (V2) was notified on 10/15/2024 at or around 4:30 PM that the local Sheriff's Office had responded to a call regarding an individual in the area of South Grand and [NAME] Street In Nashville, Illinois. This individual was identified as (R2) a memory care resident of the facility. Sheriff's Deputies transported (R2) to the local hospital per department policy, Facility investigation began Immediately and (State Survey Agency) and the facility Medical Director were notified. Facility shared pertinent medical Information regarding the resident with local hospital, including the power of attorney Information on file at the facility, at or around 5:07 PM on 10/15/2024. The resident's family was immediately notified of the elopement and was notified again when (R2) returned to the facility at 6:40 PM on 10/15/2024. The results of the investigation are as follows: (R2) was observed by staff safe and secure in her assigned room on the locked memory care unit of the facility at 4:00 PM on 10/15/2024. Following the notification by the Sheriff's Department of the discovery of the resident at 4:30 PM, the facility conducted a search of the memory care unit and discovered a window ajar in an unoccupied resident room on the unit. While a conclusive determination cannot be made with the evidence at hand, It Is suspected that (R2) exited the facility by 1 of the 2 methods: 1. Following the check on (R2) 4:00 PM she may have at some point entered the unoccupied room on the locked memory care unit and was able to open a window and exit the facility. 2. (R2) followed a visitor through the unit's secured door, with the visitor not being aware that she was a resident. She was then able to exit the facility. A search of the facility grounds and the area that the resident was found revealed no additional findings. (R2) sustained no injuries as a result of the elopement. Facility staff have been reeducated on elopement policies and procedures. The door codes to enter the locked memory care unit of the facility have been changed and distributed to staff. A new notification system has been Implemented for families to utilize to gain entry to the locked memory care unit with posted Instructions at the entrance. The facility maintenance department as inspected all windows along the locked memory care unity of the facility as has modified their operation to only allow for the window to open 2-3 Inches, per life safety codes. (R2's) care plan was updated to reflect her current status and to include the use of a Wanderguard device which was Implemented Immediately. Beginning on 10/15/2024 all memory care residents were put on 15-minute checks to continue for a period of 72 hours. Upon the expiration of the 72 hours, (R2) wlll continue to be on 15-mlnute checks while other residents will be on 2 hour checks for a continued period of-14 days and then QA Team will review. All residents of the memory care unit were reevaluated for elopement risk and statuses were updated accordingly. Elopement policies and procedures, and this incident in particular will be included in the next QA meeting to be held on 10/20/2024. R2's Hospital Emergency Department documentation dated 10/15/2024, documents chief complaint: patient presents with altered mental status. [AGE] year-old female patient resident of local nursing home for the past 5 days only with a past medical history of dementia, high blood pressure, high cholesterol and anxiety who was found wandering in a field in heavy clothing with house shoes and socks, carrying one shoe in her hand. Patient was found by a passerby who noted that patient was confused so 911 was called. Police found out that patient was a resident of local nursing home and patient was not able to say where she lived. EMS transported to ER for evaluation. We called nursing home to request paperwork and information about contacting family. We called (V12) for more information and found out that patient was just placed into the nursing home on Friday, and she had been trying/wanting to leave ever since. Previously patient was at home being cared for by her [AGE] year-old frail husband. (V12) not able to come to ER because she was taking the patient's husband to the ER for another health matter. Physical exam: awake, alert, confused, asking about parents and her missing daughter. Neurological: mental status: she is alert. Mental status is at baseline. She is disoriented and confused. Psychiatric: perception is normal, she is inattentive. Thought content is delusional. Cognition and memory is impaired. She exhibits impaired recent memory and judgement is impulsive and inappropriate. Medical Decision Making: [AGE] year-old patient with dementia found wandering in a field several blocks from nursing home where she is a new resident in the locked dementia unit. Patient found walking by a passerby and when patient was confused, they called 911. Patient checked over with no physical abnormality noted. Patient ambulatory with steady gait and had no complaints of pain, nausea, dysuria, fever or any other complaints. Patient was disoriented which (V12) confirms is her baseline. Problems addressed: confusion: chronic illness and dementia. Risk details: called patient's (V12) to discuss findings and the decision to discharge. (V12) unable to come get patient because she is with patient's husband in another ER right now. Decision made to use EMS for transport due to high elopement risk via other means as evidenced by her escape from locked unit in the nursing home and her baseline severe dementia confusion. The facility's Elopement Prevention Policy, dated 1/1/2024, documents the facility will implement individualized interventions to strive to prevent elopement. We define elopement as follows: a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. Procedure: upon admission, quarterly, and after an elopement event or attempt, and with a change in condition, each resident will undergo a comprehensive elopement risk assessment using a validated tool. Assessment results will be documented in the resident's medical record and used to develop an individualized care plan for residents identified to be at risk for elopement. The interdisciplinary Team (IDT) will work with the resident and/or family to identify and implement appropriate individualized elopement prevention interventions based on assessment findings to reduce the risk of elopement while maximizing dignity and independence. Interventions may include but are not limited to electronic monitoring/alarm system, environmental modifications, protected list of names and photographs of those at risk for elopement, psychosocial interventions, regular rounds, resident/family education, staff interventions, and structured group activities. Communicate interventions during shift report and daily clinical rounds to the caregiving team. Review and revise the elopement plan of care admission, quarterly and after an elopement event or attempt and with a change in condition. The IDT will educate residents and their families about fall risks and prevention strategies. Analyze elopement incident date to identify trends and develop quality improvement initiatives. Provide regular training for all staff on elopement prevention, risk assessment, and post-elopement event management. Ensure staff competency through ongoing education and practical assessments. The QAPI Committee will review elopement incidents and outcomes regularly to ensure compliance with the policy and identify areas for improvement and implement quality improvement projects based on data analysis and feedback from staff and residents. The Immediate Jeopardy that began on 10/15/24 was removed on 10/29/2024, when the facility took the following actions to remove the immediacy: Proposed Removal Plan: The following actions have been taken to abate the risk of future elopements: The issue has been determined to have the potential to affect all memory care residents and any other residents within the facility that have been identified as an elopement risk. (R2) was evaluated at local hospital following the elopement and again upon returning to the facility on [DATE]. No injuries were observed at that time. (R2's) responsible party, attending physician, and State Survey Agency were all notified on 10/15/2024. All residents on the memory care unity were placed on 15-minute checks for a period of 72 hours, beginning on 10/15/2024. At the expiration of the 72 hours, residents were placed on a 2-hour check, with the exception of (R2) remained on 15-minute checks, for a time period of 14 days and QA team will review to see if any changes need to be made. (R2) care plan was reviewed and updated to assess exit seeking triggers and none were identified. The care plan was updated to include the use of a electronic monitoring device. The electronic monitoring device, which is present on all exterior doors of the facility, was tested and determined to be in working order. The electronic monitoring alert system was tested and determined to be functioning properly and the electronic monitoring bracelet was placed on the resident. These items were all completed on 10/15/2024. The facility has conducted updated risk assessments on all current residents, which was completed on 10/22/24 by MDS. This risk assessments included identifying exit seeking triggers, if any. No new elopement risks were identified. The facility's administrative and clinical teams, led by the administrator met to review all elopement policies and procedures. Current policies and procedures were determined to be satisfactory, and no changes were proposed. [TRUNCATED]

Based on interview and record review, the facility failed to prevent mental and physical abuse by a staff member for 1 of 3 residents (R28) reviewed for abuse. This deficient practice resulted in R28 feeling sad, scared, and crying hysterically. Findings include: 1. R28's Care Plan, dated 10/10/23, documented, (R28) has Diagnosis of Dementia with agitation, has anxiety about daughter not being here, daughter restricted from visiting per adult protective services. Assist gently and kindly. If resident becomes agitated or combative; stop care, assure safety, and re approach in 10-15 minutes. R28's Minimum Data Set (MDS), dated [DATE], documents R28 is severely impaired cognitively. R28's Detailed Incident Summary, dated 12/21/2023, documented, The investigation resulted in a conclusive finding that V11, Certified Nurse's Assistant (CNA), did make contact with R28, which is by definition abuse. The investigation specifically revealed R28 has a diagnosis of unspecified dementia unspecified severity with other behavioral disturbance and agitation, anxiety disorder, and depression. (R28) had a recent medication change for medications prescribed for those diagnoses. Throughout the day (R28) was exhibiting signs of agitation and anxiety, which manifested in her pointing and shaking her finger at staff. She (R28) engaged in this behavior with staff member V11, who mirrored her behavior, and made physical contact with her person(R28) at that time. The report documented V11 did not follow facility policy for the circumstances. V5's, Housekeeper, written statement, dated 12/16/2023, documented, (V11, Certified Nurse Assistant (CNA)), was disrespectful, tells (sic) (R28) to let go of another resident's wheelchair. (R28) then raised her index finger, told (V11) she didn't want to be talked to disrespectfully and started crying. (R28) stated she was just trying to help. (V11) then reciprocated (R28's) behavior and raised his (V11) index finger at her (R28) and then hit her (R28) with his (V11) index finger. I'm not sure if his actions caused any harm to the resident, but I (V5) still believe all residents should be treated with respect. She (R28) was crying. We tried to calm her (R28) down by taking her to her room and talking about other things like the rain, her shoes, what was on TV. etc. She (R28) still remembered what happened about 5 minutes later, which means it probably had a significant impact on her. She (R28) mentioned how she didn't want to be treated like this anymore. On 1/2/24 at 2:47 PM V2, Interim Director of Nursing, stated she was not here when the incident occurred. V2 stated she was informed there was an allegation of abuse. V2 stated the allegation was investigated, and it was found that R28 had been agitated all day and having behaviors. V2 stated R28 got in V11's face, shaking her finger and V11 did the same and then hit R28. V2 stated 'touching is touching' and is abuse. V2 stated V11 was suspended when first learning of allegation. V2 stated attempts were made to contact V11 without success. V2 stated V11 was terminated, and a message was left on his phone. V2 stated if a resident is having a behavior, she would expect them to intervene and try to calm them, distract them and/or come back later. On 1/4/2024 at 9:21 AM V10, Registered Nurse (RN), stated she was working the unit on another hall. V10 stated she was on the other hall when V6, Housekeeper, reported to her V11, CNA, pointed his finger in R28's face and hit her (R28's) face. V6 stated R28 had been having episodes of increased anxiety. V6 stated she (R28) was difficult to redirect and would only be distracted for short periods of time. V10 stated she is not sure exactly where on the hall it occurred. V6 informed her R28 initially shook her finger at V11 and said, 'don't touch me'. V11 proceeded to put his finger in R28's face and hit R28 in the face. V11 stated she went to the hall and made sure R28 was safe and escorted V11 out of the building then notified the V2, Director of Nursing, and V1, Administrator. On 1/4/2023 at 9:50 AM V6, Housekeeper, stated she went on the unit to check her rooms. V6 stated R28 was walking up the hall holding on to another resident's wheelchair. V6 stated V11 attempted to remove R28's hands from the wheelchair and told R28 to let go in a mean tone of voice. V6 stated R28 said No. V6 stated V11 then told R28 to let go, again in a mean voice. V6 stated then R28, while shaking her finger at V11, stated No and don't touch me either. V6 stated V11 then pointed his finger at R28 and bopped her (R28) on the nose, face. V6 stated the hit to the face was deliberate and with some effort. V6 stated it was not accidental. V6 stated initially she was shocked but then redirected R28 to her room. V6 stated R28 was hysterical and holding on to V6. V6 stated she didn't expect R28 to remember it, but she did. V6 stated R28 appeared scared and stated, Did you see what he did to me? V6 stated she walked R28 past V11 and R28 grabbed tightly to V6 and told her she was scared and to not leave her. The facility's Abuse Prevention policy, dated 5/3/2017, It is the policy of this facility to provide each resident with an environment is free from any type of abuse, neglect, or misappropriation of property.

Based on observation, interview, and record review, the facility failed to ensure there were foot pedals on a wheelchair while transporting 1 of 1 (R2) resident reviewed for accidents in a sample of 41. This failure resulted in R2 sustaining a right femur fracture. Findings include: On 1/2/24 at 12:28 pm, R2 was observed wearing a cast from hip to ankle on her right leg. V17, CNA (Certified Nurse Assistant), stated R2 was still in a cast from the fracture she sustained last summer. On 1/4/24 at 2:30 pm, V25, CNA, stated he recalled the incident with R2's leg fracture. V25 stated he remembers R2 having foot pedals in her room, but they were not always on her wheelchair. On 1/4/24 at 2:40 pm, V19, CNA, stated R2 was supposed to have foot pedals on her wheelchair at the time R2's leg was fractured. On 1/8/24 at 11:08 am, V26, CPC, (Care Plan Coordinator), stated she does not recall if R2 was supposed to have foot pedals on her wheelchair at the time R2 sustained the leg fracture. On 1/9/24 at 11:00 am, V1, Administrator, stated R2's foot pedals were not on her wheelchair at the time of the leg fracture because R2 could self-propel. V1 stated staff are not supposed to push residents in wheelchairs without foot pedals being on and is why the therapy department re-educated staff on proper use of foot pedals. R2's face sheet, dated 1/4/24, documented R2 was admitted to the facility on [DATE]. R2's medical diagnosis includes nondisplaced supracondylar fracture without intercondylar extension of lower end of right femur, Alzheimer's disease, Parkinson's disease, diabetes mellitus, and osteoarthritis. R2's MDS, dated [DATE], documented R2 was severely cognitively impaired. R2's Nurse's, note dated 7/22/23 at 5:26 pm, documented, (R2) was being assisted in a wheelchair to the dining room, staff member stated I went to push her, and her right knee and lower leg went back under the wheelchair like it should. She complained of pain in right knee. R2's Nurse's note, dated 7/22/23 at 10:17 pm, documented, (R2) complained of right knee pain after getting into bed. Administered prn (as needed) Tylenol per order also provided an ice pack for 15 minutes. R2's Nurse's note, dated 7/23/23 at 8:45 am, documented, (R2's) physician did visit facility and ordered (R2) to be sent to a regional hospital for evaluation. R2's Nurses note, dated 7/23/23 at 2:30 pm, documented, (Regional hospital) called facility and reported (R2) was admitted to the regional hospital for a right femur fracture above her artificial knee. Daughter called and stated, they were going to cast her leg because there was no out alignment of bones. Going to keep her to monitor condition. She will be coming back when able. Stated, she drops her feet when she is pushing her. She understands this could happen. I don't blame anyone. The facility did not have a policy on how to transport residents in wheelchairs.

Based on observation, interviews and record reviews, the facility failed to prevent/and or contain COVID-19 when the facility failed to 1. Ensure disinfectant used to treat non-porous surfaces for Covid-19 was utilized per manufacturer guidelines to complete the required contact time for effective disinfection and that high touch areas were cleaned and disinfected per current standards of practice 2. Ensure residents who tested positive for Covid-19 were isolated per current standards of practice to prevent the spread of Covid-19. 3. Ensure residents who had been exposed to Covid-19 had appropriate signage on the door, PPE available to staff, and bins to dispose of PPE in when exiting room [ROOM NUMBER]. Ensure residents who were exhibiting symptoms of Covid-19 were assessed and placed in isolation precautions according to current standards of practice. 5. Ensure staff wore appropriate PPE (personal protective equipment) to prevent the spread of Covid-19. These systemic failures resulted in 72 residents (R1-R3, R5-R19, R21, R22, R24, R25, R28-R32, R33-R69, and R74-R81) testing positive for Covid-19, with death being the result for ten of these residents (R1, R8, R14-R16, R30, R31, R54, R57, and R66) who were confirmed positive for Covid-19. These failures have the potential to affect all 83 residents residing in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ was identified to have begun on [DATE], when the facility received R33's positive test result and failed to complete effective facility disinfection practices to kill Covid-19. As of [DATE] the facility has had 72 resident cases of Covid-19 and 10 deaths (R1, R8, R14-R16, R30, R31, R54, R57, and R66) associated with Covid-19. The facility was notified of the Immediate Jeopardy on [DATE] at 12:31 PM. The surveyor confirmed by observations, record review, and interview the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: On [DATE] at 9:16 AM, V1 (Administrator) stated the facility census on [DATE] was 83. The facility resident Covid-19 testing logs document one staff member tested positive Covid-19 on [DATE] and all residents were tested for Covid-19 with negative test results on [DATE], [DATE], [DATE], and [DATE]. The facility resident test log documents on [DATE] that R33 tested positive for Covid-19. The facility resident test log documents on [DATE] 34 residents tested positive for Covid-19 (R1, R2, R3, R7, R11, R12, R13, R14, R15, R16, R24, R28, R29, R30, R31, and R35-R53). The log documents on [DATE] all positive residents were moved to the Covid-19 unit. The residents on the Alzheimer's unit who tested positive were placed in rooms behind a zipper wall but remained on the memory care unit due to wandering and their safety. The log documents staff, residents, families, IDPH, and local health department were all notified. The facility resident test log documents on [DATE] residents on memory care tearing zipper wall down. Danger of being tangled in it, falling. Spoke with V3 (local health department administrator). Okay with treating all of memory care as Covid-19 positive. Due to the risk of moving residents off and not being secured with locked doors. The facility resident test log documents on [DATE], 25 residents tested positive for Covid-19 (R5, R6, R8, R9, R10, R17, R21, R22, R25, R,[DATE]), R10, R22, and R54 reside on the memory care unit. On [DATE] at 1:30 PM, V1 (Administrator) confirmed R33 was the first resident in house that tested positive. V1 stated the residents were not tested in October of 2020 because the facility did not have any staff test positive for Covid-19. V1 stated after she (V1) tested positive on [DATE] they began testing the residents weekly and have not stopped. V1 stated R33 had been treated at the emergency room and when she returned to the facility was placed on the yellow unit for 14 days. During that time frame R33 tested positive for Covid-19. V1 stated R33 was then moved to the dedicated Covid-19 unit and was the only resident over there until [DATE] when residents began testing positive. R1's clinical record documents a positive Covid-19 test date of [DATE]. R1's clinical record does not indicate R1 was being treated for [REDACTED]. R1's medical record documents R1 expired at the facility on [DATE]. R1's Certificate of Death Worksheet confirms the date of death of [DATE] and lists the cause of death as [MEDICAL CONDITION] and diabetes. On [DATE] at 3:12 PM, V25 (Physician) stated he would consider Covid-19 to be a contributing factor in R1's death even though it is not listed on R1's death certificate. R8's medical record documents a positive Covid-19 test date of [DATE]. R8's medical record does not indicate R8 was being treated for [REDACTED]. R8's medical record documents R8 expired at the facility on [DATE]. R8's Certificate of Death Worksheet confirms the date of death of [DATE] and lists cause of death as pneumonia and Covid-19. R14's medical record documents a positive Covid-19 test date of [DATE]. R14's medical record does not indicate R14 was being treated for [REDACTED]. R14's medical record documents R14 expired at the facility on [DATE]. R14's Certificate of Death Worksheet confirms the date of death of [DATE] and lists cause of death as pneumonia and Covid-19. R15's medical record documents a positive Covid-19 test date of [DATE]. R15's medical record documents R15 was receiving hospice services that were discontinued on [DATE] related to resident being stable. R15's medical record does not document end of life services between [DATE] and [DATE] when R15 tested positive for Covid-19. R15's medical record documents R15 expired at the facility on [DATE]. R15's Certificate of Death Worksheet confirms the date of death of [DATE] and lists the cause of death as pneumonia and Covid-19. R16's medical record documents a positive Covid-19 test date of [DATE]. R16's medical record does not document R16 was receiving end of life services prior to R16's positive Covid-19 diagnosis. R16's medical record documents R16 expired at the facility on [DATE]. R16's Certificate of Death Worksheet confirms the date of death as [DATE] and lists the cause of death as diabetes and hypertensive [MEDICAL CONDITION]. R30's medical record documents a positive Covid-19 test date of [DATE]. R30's medical record does not document R30 was receiving end of life services prior to R30's positive Covid-19 diagnosis. R30's medical record documents R30 expired at the facility on [DATE]. R30's Certificate of Death Worksheet confirms the date of death as [DATE] and lists cause of death as pneumonia and Covid-19. R31's medical record documents a positive Covid-19 test date of [DATE]. R31's medical record does not indicate R31 was receiving end of life services prior to R31's positive Covid-19 diagnosis. R31's medical record documents R31 expired at the facility on [DATE]. R31's Certificate of Death Worksheet confirms the date of death as [DATE] and lists the cause of death as pneumonia and Covid-19. R54's medical record documents a positive Covid-19 test date of [DATE]. R54's medical record does not indicate R54 was receiving end of life services prior to R54's positive Covid-19 diagnosis. R54's medical record documents R54 expired at the facility on [DATE]. R54's Certificate of Death Worksheet confirms the date of death as [DATE] and lists the cause of death as pneumonia, Covid-19. R57's medical record documents a positive Covid-19 test date of [DATE]. R57's medical record does not indicate R57 was receiving end of life services prior to R57's positive Covid-19 diagnosis. R57's medical record documents R57 expired at the facility on [DATE]. R57's Certificate of Death Worksheet confirms the date of death as [DATE] and lists the cause of death as sudden cardiac death, [MEDICAL CONDITION], and [MEDICAL CONDITION]. R66's medical record documents a positive Covid-19 test date of [DATE]. R66's medical record does not indicate R66 was receiving end of life services prior to R66's positive Covid-19 diagnosis. R66's medical record documents R66 expired at the facility on [DATE]. R66's Certificate of Death Worksheet confirms the date of death as [DATE] and lists the cause of death as pneumonia, Covid-19. 1. On [DATE] at 6:53 AM, R20 is observed self-propelling out of the room labeled Men's restroom located across from the nurse's station on the 100 hall. (The facility Covid-19 test log documents R20 tested positive for Covid-19 on [DATE]). On [DATE] at 11:52 AM V1 (Administrator) confirmed there are resident rooms that do not have bathrooms on this hall and those residents share the restroom labeled Men's restroom in the hallway across form the nurse's station. On [DATE] at 6:54 AM, V10 (housekeeper) was observed wiping down the room labeled Men's Restroom on the 100 hall (this is the same restroom R20 was observed exiting at 6:53 AM). V10 wiped down the door handles and light switches with a rag taken out of a cleaning bucket sitting on top of the housekeeping cart. V10 confirmed the bucket contained Quat 64 and that it is premeasured for use. After wiping down the surfaces V10 then put the rag back in the bucket on top of the cleaning cart. V10 got the same rag out of the bucket and sprayed the sink and commode down with Quat 64 (which according to the EPA website has a 10 minute contact time). After spraying the sink and commode with Quat 64, V10 wiped them down with the rag removed from the cleaning bucket on top of the cart. V10 then used the same rag to wipe down the toilet handle and the handrails on either side of the commode. V10 put the rag back in the solution in the bucket on top of the cleaning cart. V10 removed a bag of what appeared to be dirty disposable dinner ware from the trash can sitting across from the nurse's station. V10 sprayed bleach cleaning solution inside the trash can and wiped it down with a rag. V10 used the same rag and wiped down the door handles of the soiled utility room and the trash can lid inside the soiled utility room. V10 confirmed she used the same rag to clean the inside of the trash can holding the soiled dinnerware, the doorknobs of the soiled utility room and the trash can lid. At 7:59 AM on [DATE], V10 (housekeeper) sprayed Quat 64 on a rag and wiped down the surfaces in R32's (tested positive for Covid-19 on [DATE]) room. V10 then enters R18's (R18 tested positive for Covid-19 on [DATE]) room and uses the same rag to wipe down the surfaces in R18's room. When asked if she used the same rag, V10 stated she sometimes uses the same rag and then stated, I probably shouldn't do that. I have clean rags in my closet. V10 sprayed a clean dry rag with Quat 64 and then wiped down the door handles and light switches in R18's room. The areas appeared to dry almost immediately. When asked what the kill time was for Quat 64 V10 stated, I think it is ,[DATE] minutes. When asked if the surfaces stay wet for ,[DATE] minutes V10 stated if she really soaks her rag it will. V10 then wiped down the doorknob again and stated it was still wet. This surveyor touched the doorknob and it was dry to touch within seconds of V10 wiping it down. V10 then confirmed the doorknob was dry to touch. V10 sprayed down the bathroom in R18's room and wiped it down with the rag removed from the solution on top of the cleaning cart V10 confirmed it was the same rag she used to clean R32's room and the Men's restroom. On [DATE] at 12:15 PM, V15 (Housekeeper) entered R9's (tested positive for Covid-19 on [DATE]) room. V15 sprayed the sink and the commode with Quat and wiped it with a dry rag. When asked how long the areas stay wet V15 stated, I don't know. Should I wipe it until it dries. When asked how long it should stay wet V15 stated she didn't know. When asked if she was trained on how to use the cleaning products to kill [MEDICAL CONDITION] V15 stated we were told how to protect ourselves from [MEDICAL CONDITION]. When asked if the facility had changed the way they cleaned? V15 stated we are supposed to try to wipe the handrails down twice daily. V15 confirmed she had not wiped down the doorknobs or light switches when cleaning R9's room and stated she doesn't get to wipe the handrails down twice per shift. V15 stated, We try. On [DATE] at 1:15 PM, V13 (Certified Nursing Assistant/CNA) stated they have a housekeeper on the 300 hall 3 days a week and a gentleman picks up a little bit the other days. V13 stated he tries to clean the high touch areas every two hours. When asked about the red stain on the handrail V13 stated R2 (who tested positive for Covid-19) scratched her face, picked at it, and causes it to bleed. V13 stated he was pretty sure it was R2's blood because he saw her picking at her face and coming from her old room when he was passing lunch trays (lunch trays are passed at approximately 11:30 AM). On [DATE] at 1:25 PM, V16 (Licensed Practical Nurse/LPN) stated nursing staff are not able to clean but someone comes around every other weekend and sprays with the disinfectant gun. (V16 stated at 12:55 PM she works every weekend). When asked how often V16 stated housekeeping staff sometimes spray twice per shift. V16 stated nursing staff use disinfectant spray on the high touch areas when they have time. On [DATE] at 12:57 PM, V23 (housekeeper) stated he works five days per week. V23 stated the housekeeping staff had been cleaning high touch areas weekly and then started using the disinfectant spray gun daily about three weeks ago. V23 stated housekeeping staff also wipe down the handrails but he has not been doing that since he has been using the disinfectant spray gun daily. V23 stated prior to using the disinfectant gun he was wiping down all the handrails monthly. On [DATE] at 9:02 AM, V21 (housekeeper) stated they typically clean the handrails at the end of each shift. On [DATE] at 1:15 PM, a red stain that appears to be blood was observed on the handrail outside of room [ROOM NUMBER] extending approximately three feet. On [DATE] at 10:49 AM, when asked what interventions had been implemented to prevent the spread of Covid-19, V20 (housekeeping supervisor), stated the facility implemented the use of the disinfectant spray gun that is sprayed three times per shift. V20 stated they have three employees trained on how to use the gun. V21, V23, and V24 (housekeepers). V20 stated housekeeping staff are to change their rags between each room. V20 stated they are using Quat 64 and it has a kill time of ten minutes. V20 stated she would expect staff to leave Quat 64 for ten minutes prior to wiping it off, use a new rag in each room, and clean high touch areas. On [DATE] at 4:15 PM, V1 (Administrator) stated the facility uses an air gun to spray disinfectant on the high touch areas in the facility. When asked how often that is done V1 stated in the morning and twice in the evening. V1 stated all handrails are sanitized by V23 (housekeeper) who is there five days a week. V1 stated when V23 is not in the building the manager on duty does it. The EPA (environmental protection agency) List N Advanced Search Page located at the following website: https://www.epa.gov/pesticide-registration/list-n-advanced-search-page-disinfectants-coronavirus-covid-19 documents to kill [DIAGNOSES REDACTED]-CoV-2 (Covid-19), follow disinfection directions for the following pathogens [DIAGNOSES REDACTED]-CoV-2. The following EPA website https://www.epa.gov/sites/production/files/,[DATE]/documents/disinfectants-onepager.pdf lists six steps for safe and effective disinfectant use that includes; Step 4: Follow the contact time. You can find the contact time in the directions. The surface should remain wet the whole time to ensure the product is effective. The following website https://www3.epa.gov/pesticides/chem_search/ppls/[DATE].pdf documents MAQUAT 64-NHQ EPA number ,[DATE] is (for use as a ) (an effective one-step) sanitizer (and cleaner) on hard, non-porous, non-food contact surfaces To disinfect, all surfaces must remain wet for 10 minutes. 2.On [DATE] at 6:15 AM, V2 (Director of Nurses) stated the facility started out with one Covid-19 unit and then had some residents test positive for Covid-19 on the Alzheimer's unit (R2 and R3 tested positive on [DATE]). V2 stated they attempted to put a plastic zip barrier up but the residents on the Alzheimer's unit were pulling it down, so they are considering all the Alzheimer's unit a Covid-19 unit. On [DATE] at 11:51 AM, V1 (Administrator) stated the facility test results from [DATE] came back on [DATE] with two positive residents (R2 and R3) on the Alzheimer's unit. V1 stated they moved R2 and R3 to an area of the unit by themselves and put up a zipper wall barrier. V1 stated they could not keep R2 and R3 behind the zipper wall and so they rapid tested everyone on the unit and had four more residents test positive (R11, R12, R13, and R28). V1 stated she spoke with V3 (local health department administrator) and they took the zipper wall down because the residents were pulling it down and getting tangled in it. When asked why they didn't move the residents who tested positive to the Covid-19 unit V1 stated it is not secure. There are three doors that go outside that are not locked so we were afraid they would elope if we transferred them to that unit. On [DATE] at 1:03 PM, V3 (local health department administrator) stated V1 (Administrator) spoke with her related to concerns about moving residents diagnosed with [REDACTED]. V3 stated the facility tried the barrier on the Alzheimer's unit and the residents were tearing it down. V3 stated they don't have the staff to do 1:1 with the residents who are positive. V3 stated the facility is trying to keep the residents who are positive isolated in their rooms. V3 stated the facility did inform her and they are doing the next best thing since they don't have staff to do 1:1 with the residents. The facility resident roster not labeled dated [DATE] documents R2, R3, R10, R11, R12, R13, R22, R23, R28, R54, R66, R68, and R70-R75 reside on the Alzheimer's unit. The facility resident testing log documents positive Covid-19 test results for R2 and R3 on [DATE], R,[DATE] on [DATE], R66 on [DATE], and R10, R22, R23, R28, R54, R68, R73 on [DATE], and R74 and R75 on [DATE]. This indicates 15 residents out of 18 residents residing on the Alzheimer's unit tested positive for Covid-19 between [DATE] and [DATE]. On [DATE] at 8:45 AM, R11 was observed lying in her bed in her room. V2 (Director of Nurses) entered R11's room and covered R11 with a sheet. V2 exited R11's room, removed her gloves and washed her hands. V2 did not change her gown or her N95 and did not change and/or clean her eye protection. There was no signage on the door indicating R11 was on isolation precautions and/or no disposal bins to dispose of used PPE. The facility testing log indicates R11 tested positive for Covid-19 on [DATE]. On [DATE] at 8:45 AM, R2 was observed ambulating in the hallway and standing next to the nurse's station. R2 was not redirected or asked to wear a mask by V2 (DON), V12 (Licensed Practical Nurse/LPN) or V13 (Certified Nursing Assistant/CNA). R22 was observed ambulating in the hallways and standing within three feet of R2 at times with no redirection by V2, V12, or V13. At 9:00 AM V12 (LPN) stated R2 was one of the first residents who tested positive for Covid-19 on the unit she resides on. The facility testing logs documents R2 tested positive for Covid-19 on [DATE] and R22 tested positive for Covid-19 on [DATE]. On [DATE] at 12:45 PM, R2 and R10 were observed sitting in a group room less than three feet apart. V13 (CNA) confirmed R2 had tested positive for Covid-19 and R10 had tested negative for Covid-19 on the last facility test date ([DATE]). The residents were not redirected/encouraged to return to their room, sit more than six feet apart, or wear a mask. On [DATE] at 12:55 PM, when asked about positive residents being near negative residents V16 (LPN) stated we can't stop them, and we can't move them to the Covid-19 unit, and we can't keep them contained. On [DATE] between 12:58 PM and 1:15 PM, R2 (COVID Positive) was observed walking down the hallway using the handrails to steady herself, walking into the room on the hall labeled Female restroom, ambulating between the common area and the nurse's station and sitting within three feet of R10 (R10 tested positive for Covid-19 on [DATE] after this observation) in the common area. At 1:10 PM, R2 is given a drink by V16 (LPN) with no prompting or redirection observed. On [DATE] at 1:15 PM when asked what had been implemented to prevent the spread of Covid-19 on the unit V13 (CNA) stated they had tried a zipper wall until they determined the whole unit probably had Covid-19 so they moved the wall to the outside of the unit. V13 stated they did have a staff member one to one with R2 for a few days, but the staff member was scared of Covid-19 so he didn't think that helped. V13 stated he sits with R2 in his free time and constantly attempts to redirect her. V13 stated he had also moved the couch out of the common area and would spread the chairs six feet apart when he got to work but the residents would move the chairs closer. V13 stated R2 and R10 wander and R2 will fall asleep at times in chairs in other resident rooms. When asked about signs on the doors of resident rooms who had tested positive V13 confirmed there is no signage on the door of the rooms for the residents who are on isolation precautions after testing positive for Covid-19. V13 stated staff wear the same PPE (personal protective equipment) when providing care to residents who have tested negative for Covid-19 and residents who have tested positive for Covid-19. On [DATE] at 1:25 PM, V16 (LPN) stated they made the Alzheimer's unit a Covid-19 unit because they knew the residents who reside on this unit were going to get it. On [DATE] at 1:25 PM, R10 was heard coughing. When asked if that was a new cough for R10, V16 (LPN) stated yes, V16 (LPN) then made a phone call and stated R10 was to be rapid tested . The facility Covid-19 test log documents R10 tested positive for Covid-19 on [DATE]. R10's daily vital sign sheet documents R10's temperature on [DATE] on 6 am-2 pm shift was 99.1 and on 10 pm - 6 am shift was 99.2. On [DATE] at 9:16 AM, V2 (Director of Nurses) stated R10 had a low grade temp on [DATE] but they didn't do anything different because they were treating the whole hall like it was Covid-19 positive. On [DATE] at 9:16 AM when asked about using the same PPE to care for Covid-19 positive and Covid-19 negative residents on the Alzheimer's unit V1 (Administrator) stated we put the zipper wall up outside the unit. That is where the staff change their PPE. V1 (Administrator) stated unfortunately the residents who were Covid-19 positive on that unit were ambulatory, and we don't have the staff to do 1:1 with the residents who have tested positive for Covid-19. On [DATE] at 9:16 AM, when asked about interventions to prevent the spread of Covid-19 on the unit, V2 (Director of Nurses) stated we would put masks on the residents, and they would rip them off. When asked why staff were not observed redirecting Covid-19 positive residents V2 stated this surveyor was only on the unit for approximately thirty minutes, maybe the staff redirected them before you got there. Reminded V2 this surveyor was on the unit on two separate days and no observations were made of staff redirecting Covid-19 positive residents to stay in their room or not be within 6 feet of residents who had tested positive for Covid-19. When asked about signage on the doors of residents who were on isolation precautions V2 stated all the staff are well aware of which residents were positive for Covid-19 and which residents were negative. 3. The facility face sheet documents R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5's MDS (Minimum Data Set) dated [DATE] documents R5 is independent with cognitive skills for daily decision making. On [DATE] at 6:30 AM, R5 was observed standing at the door of his room with no mask requesting ice. R5 stated to this surveyor his wife (R30) tested positive and since he was with her, he has to be quarantined. R5 stated he just stays in his room. There was no signage observed on R5's door or near his room noting that R5 was on isolation precautions. There were no disposal bins for PPE (personal protective equipment) and no PPE noted outside or on the door of R5's room. On [DATE] at 12:00 PM observed R5's room and the room (R25's) across the hall from R5's room to have signs on the doors that said, Do Not Enter. These signs were not on the doors during observation on [DATE]. The facility test log documents R25 tested positive for Covid-19 on [DATE]. On [DATE] at 11:51 AM, V1 (Administrator) stated on [DATE] R5 visited with his wife R30 in a common area. V1 stated on [DATE] they received the facility Covid-19 test results and R30 tested positive for Covid-19. V1 stated R5 also had a window visit with his daughter and had passed her his cell phone through the window. V1 stated R5 refused to move to the yellow zone (an area designated for residents with potential exposure to Covid-19). V1 stated we instructed R5 to stay in his room and he did. V1 stated R5 tested positive for Covid-19 on [DATE] and was moved to the Covid-19 unit. On [DATE] at 9:16 AM, V2 (Director of Nurses) stated she was not aware of the situation with R5 and R30. V2 stated she spoke with V1 (Administrator) and was told R5 refused to go to the yellow zone for 14 days after he was exposed to Covid-19. V2 stated staff do not go in his room. R5 is very independent and does not want staff in his room. V2 stated they had put signs on R5's door but R5 must have taken them down. When asked about PPE V2 stated if staff had to go in his room, they would step into the solarium which is next to his room and change gowns leaving their clean gown in the solarium. When asked where they would dispose of the dirty PPE when exiting R5's room V1 (Administrator) who was in the interview stated staff would take it to the soiled utility room to dispose of it. V1 stated the soiled utility room is located a few doors down from R5's room. 4. R9's facility admission record sheet dated [DATE] documents R9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R9's MDS (Minimum Data Set) dated [DATE] documents R9 is independent with cognitive skills for daily decision making. On [DATE] at 12:25 PM, while doing observation of V15 cleaning R9's room, R9 was observed sitting in her room in a chair and was coughing. When asked if the cough was new for R9, V9 (unit aid) stated yes and she had told V12 (LPN) that morning. V9 (unit aid) was unable to recall the time she had reported R9's cough to V12 (LPN). On [DATE] at 12:26 PM V12 (LPN) stated she hadn't heard R9 coughing until just now. V12 stated she wasn't coughing when she gave R9 her medication that morning. V12 stated V9 had not reported to her R9 was coughing. V12 stated they were going to do a rapid test to see if R9 tested positive for Covid-19. There was no signage on R9's door and no PPE or disposal bins in or near R9's room indicating R9 was placed on isolation precautions after she developed the symptom of coughing. On [DATE] at 9:16 AM when asked what her expectations would be when R9 developed a cough and V9 (unit aid) reported it to V12 (LPN), V2 stated she would expect the nurse to assess R9 when she was told of R9 developing the new symptoms of coughing. The facility Covid-19 test log documents R9 tested positive for Covid-19 on [DATE]. 5. On [DATE] at 1:50 PM, V17 (CNA) was observed in the hallway on the Covid-19 unit. V17 was wearing a gown, N95, and eyeglasses. V17 stated she tested positive for Covid-19 last Monday and only works on the Covid-19 unit. When asked if she wears eye protection, V17(CNA) stated since she has already tested positive for Covid-19 she doesn't think she needs to. On [DATE] at 1:55 PM, V18 (CNA) was observed with a N95 mask and gown on standing behind the nurse's station on the Covid-19 unit. V18 pulled down her N95 and ate a cookie and took drinks from a cup. V18 was not observed to be wearing eye protection. When asked about eye protection V18 stated she wears eyeglasses and she was not aware she was supposed to be wearing eye protection. V18 stated she is new and will be working on both Covid-19 units and the non-Covid-19 units. On [DATE] at 1:55 PM, V19 (LPN) was observed behind the nurse's station on the Covid-19 unit wearing glasses, N95 mask, and a gown. When asked about eye protection V19 stated she had eye protection on. V19 stated she wears goggles when she is in a room providing care to the residents. On [DATE] at 6:15 AM, V2 (Director of Nurses) stated staff wear gowns, eye protection, and N95 throughout their shift and they have a clean N95 that is used when they are working off the covid-19 unit and a dirty N95 that is used when they are working on the covid-19 unit. On [DATE] at 4:15 PM, V1 (Administrator) stated staff are supposed to wear eye protection however two of the staff observed not wearing eye protection on the Covid-19 unit have tested positive for Covid-19 and eye protection is for the staff not the residents. V1 stated V18 (CNA) who was observed not wearing eye protection on the Covid-19 unit was just intimidated by talking to this surveyor and had been given eye protection to wear prior to beginning work at the facility. On [DATE] at 1:18 PM, V4 (Medical Director) stated he was aware the facility was experiencing an outbreak of Covid-19. When asked if he would agree the facility should follow current CDC guidelines in relation to cleaning, cohorting residents, isolation precautions, and PPE, V4 (Medical Director) stated he would certainly agree and expect CDC guidelines to be followed. V4 stated some of the residents on the Alzheimer's unit can become hostile with redirection but it would certainly be worth making the best effort possible. When asked if eyeglasses were appropriate eye protection V4 stated he had not seen that and wearing eye protection is not a bad idea. When asked what he would expect the facility to do if someone became symptomatic V4 stated he would expect them to be quarantined as soon as possible and then be tested . The facility policy Emergency Procedure-Pandemic Coronavirus dated [DATE] documents under Infection Prevention and Control, Cleaning and disinfection for pandemic coronavirus follows the general principles used daily in health care settings (1:10 solution of bleach in water or any other EPA approved product). Infection Prevention and control policies require staff to use Standard and/or Droplet Precautions (i.e., mask for close contact with symptomatic residents). The IPCC (Infection Prevention Control Committee) shall develop procedures to cohort symptomatic residents or groups using one or more of the following strategies: confining symptomatic resident and their exposed roommates to their room. Placing symptomatic residents together in one area of the facility. Under increased transmission based precautions the policy documents under Isolation Halls Defined, Facili(TRUNCATED)

Based on interview and record review, the facility failed 1) to provide the identified level of assistance needed for safe transfers and 2) failed to correctly apply roll-control bolsters for fall prevention for 2 of 21 residents (R59 and R329) reviewed for accidents in the sample of 36. This failure resulted in R329 falling in the shower room during a transfer and sustaining a tibial fracture. The Findings Include: 1. R329's admission record documents an initial admission date of [DATE] and includes the following Diagnoses: [REDACTED]. R329's quarterly Minimum Data Set ((MDS) dated [DATE], documents a BIMS (Brief Interview of Mental Status) score of 8, which indicates moderate cognitive impairment. On 11/19/19 at 11:00 AM during initial tour, R329 was alert and oriented to person, place and time, and stated that he had been dropped in the shower and broke his leg a little while ago. R329 was observed at this time in his wheelchair with his left leg in an immobilizer. An event report documents that R329's fall was witnessed, occurred on 8/20/19, and was reported to the nurse at 10:30 AM. The description of the fall was as follows: Resident was being transferred from wheelchair to shower chair and the chair moved. The resident leaned forward and was put on the floor. Left knee area was possibly twisted. After the fall 2 CNA's (Certified Nurse Assistants) and nursing got R329 up to shower chair. Noted area 2 inches below left knee was swollen and complained of some pain. Doctor was called and an X-Ray was ordered and ice applied. The investigation into the fall on the event report also documents that the floor was wet in the shower room. R329's Nurses notes document on 8/20/19 at 1:52 PM, X-Ray was here and they were waiting the results of the left knee scan. At 2:30 PM, X-Ray results were received that R329 had an acute mildly distracted [MEDICAL CONDITION] left tibial diaphysis, superimposed upon a site of an old fracture. The physician was notified of these results and R329 was sent to the emergency room . The quarterly MDS dated [DATE] documents R329's functional status as extensive assist, with two plus persons physical assist for transfer. Transfer is described on this form as how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. The bathing was also coded as a 2 plus person extensive assist. R329's fall risk assessment dated [DATE] (previous to the fall) had a score of 16. Per the assessment it considers a score of 10 or above represents a high risk for fall. Skilled nurses notes prior to the fall that occurred on 8/20/19 document daily that R329 was an extensive assist of two plus persons for transfers. On 11/20/19 at 1:15 PM, V3 (Certified Nurse Assistant) stated that she was the staff member with R329 in the shower when he fell . V3 stated that she was alone with the resident transferring him that day. She went on to state that she usually uses a gait belt, and that morning R329 stated that he felt like he was strong enough that only one person needed to help him transfer. On 11/20/19 at 2:00 PM, V2 (Director of Nursing) stated that they consider him a 1-2 person assist depending on now he is feeling for the day (strength wise), and that this is common; that they do this with most residents. On 11/21/19 at 10:00 AM, V5 (Physical Therapist Assistant) clarified a therapy communication/in-service to nursing staff document dated 9/25/18 was the most recent document with therapy recommendations for transfer status, prior to R329's fall on 8/20/19. The current functional status of this document lists that the transfers for R329 were limited to 2 persons due to non-weight bearing status of the left lower extremity. On 11/21/19 at 10:30 AM, R329 stated that he typically has 2 CNA's help transfer him since he cannot bear weight on that left leg. He was unable to bear weight on that leg prior to this fall, due to a previous injury to the same leg. R329 stated that he is not ever asked how he is feeling for the day to determine if he needs 1 or 2 CNA's to help with transfers. R329 went on to state that it is typically only when V3 is working that she tries to do it all herself, and that is what happened the day of the fall. R329's current care plan has a focus area of cognitive deficit where it then lists that the resident has some confusion at times, poor decisions, and disorganized thoughts as side effects from a past stroke. Further review of care plan in its entirety and medical record does not document that R329 is to be asked prior to transfers/showering questions on strength to determine if 1-2 people are needed for assistance. During exit conference on 11/22/19 at 2:00 PM, V2 provided a previous undated care plan that documents prior to R329's fall he required an assist of 1-2 staff for transfers depending on how he was feeling. V2 went on to state that there is no formal way to measure how the resident is feeling, it is just determined by staff during morning ADL's (Activity of Daily Living). V2 was unable to determine when R329's previous status changed from a 2 person extensive assist to a 1-2 staff assist. 2. physician's orders [REDACTED]. R59's Plan of Care with a focus area of Resident is at risk for falls r/t dementia, hx (history) of falls, unaware of limitations, psych med use. Interventions include, Bed Bolsters x's 2 with an initiation date of 1/18/19. The Accident Log Dated (MONTH) 2019 documents for R59 on 7/15/19 at 1:00 AM R59 sustained a fall from bed with no injuries noted. R59's Event Report dated 7/15/19 at 1 AM documents, When this nurse came from West Wing to 300 hall the resident was noticed sitting on the floor beside her bed. Her front bolster, bed pad and covers were on the floor with her. She was sitting on a fall mat beside her bed. The root cause states, The back bolster was not fastened properly to the bed so when she moved the front bolster, bed pad, and covers slid off the bed- she had a fall mat beside her bed and was sitting on that. She did not hit her head. Interventions Implemented are listed as, Bed re-made & bolsters applied properly. An additional note on this same document states, Staff to be retrained on bolsters- main. (maintenance) has checked all bolsters in building to ensure attached correctly. An In-service Education Program Attendance Sheet dated 7/16/19 with a program title of Proper Application of Bolsters is documented as being complete. On 11/21/19 at 9:06 AM, V1 (Administrator) states R59's normal cognitive status is confused. V1 states R59 does not have the cognitive ability to remove her bed bolsters. V1 confirms the 7/15/19 fall investigation for R59 determined the bed bolster was not correctly applied to the bed, causing it to come off. V1 states the facility in-serviced staff on correctly applying the bolsters.

Based on interview and record review, the facility failed to ensure Indwelling Urinary Catheter placement in the bladder before inflating bulb for 1 of 5 residents (R2) reviewed for Indwelling Urinary Catheter care in the sample of 19. This failure resulted in R2's hospitalization for surgical removal of catheter with the bulb improperly inflated in the urethra. Findings include: R2's Face Sheet documents an admission date of [DATE] with the [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition, The MDS further documents R2 is total Dependence in all ADLS, ROM impairment upper and lower extremities both sides and has an Indwelling Urinary Catheter. R2's Physician order [REDACTED]. R2's Nurses Note by V17, Licensed Practical Nurse (LPN), dated 8/9/18 at 2:30 AM documents, Changed (Indwelling Urinary Catheter) 18 Fr. With 5 cc (cubic centimeter) bulb, After insertion noted bleeding small amount coming out around tubing at tip of penis. (Indwelling Catheter) removed. Peri care provided and reinserted #18 fr. With 30 cc inflated with 20 cc of normal saline, CNA (Certified Nurses Aide) did rounds and reported looked like catheter was coming out. Attempted to remove catheter and bulb would not deflate after several attempts. Will monitor for urine return. No complaints of pain or discomfort. R2's Nurses Note by V11, Register Nurse (RN), dated 8/9/18 at 3:00 AM, documents: Noted catheter would not deflate, Bulb cut back to catheter and with syringe could not get water from bulb. Catheter would not come out. V16 (Physician) Nurse called. Stated Dr. wants him (R2) to go to the emergency room to get (Indwelling Catheter) removed. R2's Resident Emergency Transfer Form, signed by V11, dated 8/9/18, documents: Reason for transfer: Changed (Indwelling Urinary Catheter), Inserted for UA, Balloon 20 cc. No urine, tried to deflate, no water will come out. Stuck. The local hospital report, dated 8/9/18, documents, Continuous charting: (R2) arrived to ED (Emergency Department) via EMS (Emergency Medical Service), from (name of facility) Report received from RN (V11) (V11) states she attempted to change the patient's (Indwelling Urinary Catheter) at approximately 2:45 AM. (V11) states after the (Indwelling Catheter) was placed, there was no return of urine. (V11) attempted to remove the (Indwelling Catheter) but was unable to remove the 20 cc of water from the (Indwelling Catheter) balloon. Upon arrival, notable dried blood at entrance of Urethra. (Indwelling Catheter) is not draining urine in ED. Port to remove water from balloon has been cut prior to arrival to ED. Attempts to remove water from balloon was ineffective. No attempt to remove (Indwelling Catheter) made. The local hospital report, dated 8/9/18, continues, 04:55 AM- Patient to radiology for CT (computerized tomography) scan. Results: Pelvic Contents: Bladder well distended, mildly inflamed. Small amount of calcified debris in the dependent bladder. (Indwelling Catheter) balloon is inflated within the urethra. Mild surrounding inflammation but no frank urethral rupture. Impression: 1. (Indwelling Catheter) balloon lies retroflexed within the urethra. No frank urethral rupture identified. The local hospital report, continues, 8/9/18 at 5:51 AM- Attempt made by FNP (Family Nurse Practitioner) and this nurse to un-kink cath tubing unsuccessful. Call placed to another hospital for possible transfer to Urology. At 6:30 AM Patient was accepted to out of town hospital as patient may need an open procedure that requires another facility. The local hospital report, continues, Diagnosis: [REDACTED]. Impression: There is a complication of the urinary catheter likely due to improper insertion technique. The catheter was found kinked in the urethra in the shaft of the penis and the 20 cc balloon was inflated in the urethra. It was unable to be deflated or advanced. Plan: Due to the fact that the balloon of the catheter was unable to be deflated and the catheter was also unable to be advanced, as well as the CT shows a moderately distended bladder, and there is surrounding inflammation of the tissue in the penis and around the urethra, there is need for the consult of Urology. He has a [MEDICAL CONDITION] bladder and will need another catheter placed. Fluro (fluoroscopy) or OR (Operating Room) will likely be needed for (R2) ER discharge: 8:38 AM: Transfer to Hospital, Vitals Pulse 80, resp 20, B/P 122/77. Oxygen Sats 98%, Patients condition is stable. R2's operative report from receiving hospital, dated 8/9/18 at 2:20 PM, documents, Preoperative Diagnosis: [REDACTED]. Operative procedure: Urethroscopy, deflation of the (Indwelling Urinary Catheter) balloon and removal of (Indwelling Urinary Catheter), cystoscopy, (Indwelling Urinary catheter) placement. History: 36 y/o quadriplegic male with [MEDICAL CONDITION] bladder who has a chronic (Indwelling Urinary Catheter), An attempt at the nursing home to place a new catheter was unsuccessful. The balloon unfortunately was accidentally inflated in the urethra. An attempt to deflate the balloon was unsuccessful. On 11/13/18 at 9:50 AM, V17, LPN, stated, I remember the incident-The doctor had ordered a UA C&S and wanted a new 'fresh' (Indwelling Urinary Catheter) placed in for the specimen. (R2) had been treated for [REDACTED]. (R2) had not been drinking much. I removed the existing (Indwelling Urinary Catheter) without any issues. I went to insert the new one- blood started to come out with urine, and blood came out of his penis so I removed the (Indwelling Urinary Catheter) and did peri care and disposed of the catheter, I waited about ½ hour and the bleeding had stopped. I inserted the new (Indwelling Urinary Catheter) using sterile technique, I maybe got a dribble of urine and I Inflated the balloon. I told (V22, CNA) to watch for urine output. About 20-30 minutes later, (V22) came and got me and told me the tubing was out of (R2's) penis more from when it was inserted. I tried to deflate the balloon, but was unable to. I had another nurse (V11) come to assist me and she tried to deflate the balloon by cutting the water port, but still was unable to remove the catheter. (V11) called the doctor and we sent him out before a problem occurred. On 11/13/18 at 9:25 AM, V11, RN stated, I came in that night to replace (V17). She had put in a (Indwelling Urinary Catheter) and couldn't get it out. I couldn't either. I cut the port to remove the water from the bulb and I still couldn't get it out. I knew there was a problem so I sent him out. I'm unsure if there was any urine present in the tubing or bag. I knew his bladder would start filling up . He did not seem in any distress. On 11/14/18 at 9:30 AM, V1, Administrator, along with V2, Director of Nursing, voiced concerns that R2's Catheter could have been in place when at the facility and there were Ambulance staff, the local hospital and numerous people involved that could have dislodged the catheter including R2 himself. On 11/15/18 at 9:19 AM, when asked if urine should be to flowing prior to inflation of the catheter bulb, V2 stated I did my investigation. (V17) stated that when she inserted the first catheter there was blood noted in the urine. V2 also stated that V17 said that R2 had not been drinking a lot and wasn't expecting to see a lot of urine output after the first attempt because the first attempt emptied the bladder. V2 again voiced that she believes that R2 could have moved his arms and tugged on the (Indwelling Urinary Catheter) by accident, he wasn't able to grasp things with his fingers, but he could have gotten his arm around it somehow. V2 stated there was a period of time after the second insertion that no one was present. On 11/16/18 at 10:25 AM, V23, Medical Assistant to V24, R2's Surgeon, stated Before inflating an Indwelling Catheter bulb you must ensure the tube is in the bladder by evidence of urine flow. The facility's undated Catheter Insertion policy and procedure documents, Indwelling Urinary Catheters may be inserted by licensed nurse upon the order of a Physician. physician's orders [REDACTED]. It continues under Procedure for Male, 16. Raise penis upright, then gently advance catheter until urine flows. Place free end of catheter in sterile container. It continues, B. For (Indwelling Catheter), carefully: 1) take a pre-filled syringe and insert into lumen for balloon inflation. 2) Withdraw catheter slightly to be sure balloon has inflated.

Based on observation, interview, and record review the facility failed to assess and identify risk factors to prevent the formation of pressure ulcers, and provide pressure relief, turning and repositioning for residents at risk for pressure ulcers for 4 of 9 residents (R2, R5, R6, R10) reviewed for pressure ulcers in the sample of 17. This failure resulted in R6's developing a stage four pressure ulcer. Finding Include: 1. R6's Original Care Plan, with admission date of [DATE], documented R6 had a history of [REDACTED]. The type written Care Plan documented Potential for skin breakdown r/t (related to) decrease in mobility, occ (occasional) urinary incont, use of depends, [MEDICAL CONDITION], hypoalbumenia, dementia, NIDDM (Non insulin dependent diabetes mellitus). admitted with wounds, skin fragile bruises and tears easily, dry skin. The type written care plan documented interventions as Weekly skin checks; however, next to this typed written intervention was an undated hand written intervention which documented Resident Reports any concerns. R6's Annual Minimum Data Set (MDS), dated [DATE], documents R6 is independent for personal hygiene, toilet use, bathing, dressing, and transfers. R6's MDS also documents a Brief Interview for Mental Status (BIMS) score of ten, which represents moderate cognitive impairment. The MDS documented she was not at risk for pressure ulcers. R6's Quarterly MDS, dated [DATE] documented the same as above. R6's Braden Scale-For predicting pressure ulcer risk, dated 8/30/17, documented she had a score of 22, which total score of 15-18 represents mild risk for skin breakdown. There was no documentation in R6's Nurse's Note from 9/7/17 through 9/16/17 regarding R6's skin condition. R6's Nurse's Note, dated 9/17/17, documented R6 was independent with transfers, had bowel and bladder control and was independent with bed mobility. This Note had no documentation regarding her skin condition. R6's Nurse's Note, dated 09/24/17, documented Received call Friday 09-22-17 around 6:00 PM. Told this signee that when she took her mom home and was helping c (with) shower, the daughter saw a rash over a big part of the body Arms/legs ABD (abdomen) area. Not sure if she should bring res back or stay at home. POA (Z5) decided to keep res at their house. This signee suggested getting a [MEDICATION NAME] lotion for the rash, to try the lotion on a small area first to make sure it wouldn't make worse. 2nd call about blisters. Ask if they were open and or bleeding. POA (Z5) stated that one was bleeding. Suggested again to bring res (resident) home. The Note documented the Z5 and R6 arrived back at the facility around 5:30 PM on 9/24/17. The Note documented Res stated her bottom hurt. Open area to coccyx. Wound care nurse scheduled to look at area 1st AM. There was no description of the pressure ulcer or measurements of the pressure ulcer documented in this note. On 11/15/17 at 11:20 AM Z5, R6's family member stated I took (R6) home for a visit, and when I showered (R6) she had a rash on her abdomen and open areas on her butt, and the facility stated they were not aware. R6's physician's orders [REDACTED]. There was no documentation in R6's record that an assessment was completed on R6's pressure ulcer on 9/25/17 (Monday). R6's Treatment Administration Record (TAR), dated August 2017, documented Zinc Oxide, apply to left buttock/coccyx three times daily PRN Prevention. This was also documented on the September 2017 TAR. During these two months, no staff documented the Zinc Oxide was applied to R6's buttocks/coccyx. R6's September 2017 TAR documented that Skin Checks needed to be completed weekly. R6's TAR documented that skin checks were completed on 9/7, 9/13, and 9/26/17. The TAR documented on 9/26/17 Coccyx- Stage II pressure ulcer 1.7 x (by) 0.5 x 1 cm (centimeter). NS (Normal Saline) [MEDICATION NAME] packing strips, dry drsg. (dressing) daily (and) PRN (as needed). In addition, R6's TAR documented R6's physician's orders [REDACTED]. R6's Wound Care Consultant Wound Care form, dated 10/03/17, documented R6 Presents to me today at SNF (Skilled Nursing Facility) for re-admission assessment. When she was initially admitted she had an area at this site which had healed. Area has re-opened and staff is requesting assessment. The Form documented R6 had a Stage IV pressure ulcer to her sacrum. The Form documented the pressure ulcer measured 2.0 centimeters (cm) in length, 1.0 cm in width and 1.5 cm in depth with undermining 2.0 cm from 12 o'clock and 1.5 cm from 1 o'clock to 11 o'clock. On 11/17/17 at 9:40 AM E2, Director of Nursing (DON) stated R6 had a Stage II pressure ulcer approximately three years ago. E2 stated R6 came from home with the pressure ulcer and it healed. E2 stated R6 is independent, showers herself, but staff ask her after each shower did she have any rashes or open areas. E6 stated R6 did not tell us anything was wrong because R6 was embarrassed. E2 stated R6 would take her incontinent briefs and dry them, and reuse them, because she didn't want her family, Z5, to know she was incontinent. E2 stated staff now go in, and ask R6 to off load or change positions. E2 stated R6 also puts the pressure relieving cushion in the chair upside down and needs a reminder to put the cushion in the chair correctly. E2 stated the staff now goes in and removed all of the already used diapers. On 11/17/17 at 9:55 AM Z7, Nurse Practitioner stated Honestly I don't know how she got it (pressure ulcer). She (R6) is very independent. 2. On 11/14/17 at 9:57 AM, E4 and E7, Certified Nurse's Assistants (CNA), repositioned R2 in bed. R2 was lying on a pressure redistributing air mattress. E4 and E7 removed a soiled cloth incontinent pad, and replaced it with a clean one, leaving 2 clean cloth incontinent pads on the top of the mattress under R2. On 11/15/17 at 9:08 AM, R2 was sitting up in wheelchair with no heel protector on the left foot. On 11/15/17 at 9:11 AM, E8, Registered Nurse (RN), removed a band-aid from R2's left heel, dated 11/12/17. R2's Physician order [REDACTED]. R2's Pressure and Stasis Ulcer Risk assessment dated [DATE] documents devices to be put in place (in part) are heel protectors, and air mattress. R2's Minimum Data Set (MDS), dated [DATE], documents R2 requires extensive assistance of 2 or more people for bed mobility. R2's POS dated 11/1/17 documents soft dressing daily to left heel for prevention. R2's POS documents heel protector to left heel when up out of bed. R2's Care Plan dated 6/6/17 documents heel protectors, especially to left heel, when up OOB (out of bed). R2's Care Plan dated 6/6/17 documents pressure redistributing mattress-air mattress. Facility Pressure Ulcer Cumulative Report dated 11/06/17 documents location left buttock, stage 2, measures [MEDICAL CONDITION], serosanguinous drainage, first observed 10/25/17, treatment date 11/6/17, healed. On 11/16/17 at 2:15 PM, E2, Director of Nursing (DON) stated it is not acceptable for staff to use multiple cloth incontinent pads on an air mattress. We have large bariatric pads that we use so there is just one. On 11/16/17 at 12:20 PM, Z1, Customer Service Representative from (Medical Equipment Supply Company) stated We recommend using a fitted sheet or a flat sheet. The thin disposable incontinent pads can be used for short periods of time, but nothing other than the fitted or flat sheet is really recommended. 3. R5's MDS dated [DATE] documented R5's BIMS score as 7, indicating severe cognitive impairment. The MDS also documented R5 had three Stage 3 pressure ulcers. The facility's Pressure Ulcer Cumulative Report dated 11/06/2017 documented R5 had the following pressure ulcers: Right (Rt) ankle lateral 1.3 cm x1 cm facility acquired on 10/16/2107; Rt heel Stage 3 pressure ulcer facility acquired on 9/29/2017, measuring 2.0 cm [MEDICAL CONDITION] cm x 3 cm, with 7.5 cm x 6. 5cm undetermined depth and serosanguine drainage; Left heel, Stage 3, 1.6 cm x 2 cm x 0.3 cm with moderate yellow drainage facility acquired on 9/29/2017; and Left hip stage pressure ulcer, measuring 3.7 cm x 3 cm x 0.3 cm facility acquired on 10/31/2017 (.9cm x .5cm undetermined depth). On 11/14/2017 R5 remained in the wheelchair without benefit of repositioning from 9:30 AM until 12:35 PM based on 15 minute or less observation intervals. On 11/14/2017 at 9:30 AM R5 was sitting up in room with no heel protectors on left or right foot. On 11/14/2017 at 10:49 E11 RN applied R5's heel protectors. On 11/14/2017 at 12:42 PM E5 CNA removed R5's adult brief and stated that R5's buttocks was not usually that red. E5 pressed on R5's buttock and the area did not blanch. The buttock remained red. E5 stated that R5's testicles were not normally that red either. R5's Care Plan dated 10/26/2017 documents (in part), Focus Potential for skin breakdown related to incontinence, decreased mobility, and frequent falls/skin tears. Goal Resident will develop no skin breakdown thru next review. Staff to maintain skin integrity and prevent infection thru next review. Interventions: Reposition every 1 and 1/2 hours. 4. R10's admission MDS dated [DATE] documented R10 admitted [DATE] with the [DIAGNOSES REDACTED]. The MDS further documented that R10 was at risk of developing pressure ulcers and did not have any pressure ulcers upon admission. R10's Care Plan dated 2/17/17 documented Potential for skin breakdown related [DIAGNOSES REDACTED]. Goal: Resident will develop no skin breakdown thru next review. Interventions: Reposition every 1 and 1/2 hours. R10's current MDS dated [DATE] documents total dependence for bed mobility and transfer. On 11/14/17 R10 remained in the geriatric wheel chair without benefit of repositioning from 9:30 AM until 1:10 PM based on 15 minute or less observation intervals. R10's Braden Scale-For Prediction Pressure Sore Risk dated 5/9/17,7/25/17 and 10/17/17 documents a score of 13 placing R10 at a moderate risk for pressure sores. R10's Physician order [REDACTED]. R10's Pressure and Stasis Ulcer Risk assessment dated [DATE] documents: Right buttock Stage II. R10's Treatment Record documents Healed coccyx dated 11/7/17. On 11/16/17, E2 (DON) stated I talked to E7 (CNA) who said he placed a pillow behind R10's head and repositioned R10's chair for lunch. E2 (DON) stated yes when asked if the facility was using the repositioning of the geriatric wheel chair as offsetting. E2 (DON) presented a written statement from E7 (CNA) dated 11/14/17 that reads: I think R10 was repositioned around 10:00AM because he had no pillow behind his head while sitting in his chair. He was then repositioned while sitting at the table for lunch. The facility's Policy Prevention and Management of Wounds undated, documented Wound assessment: In consideration for promoting healing the resident's clinical condition along with the ulcer is assessed. Communication between departments is essential to provide adequate nutrition, positioning and medical intervention to best meet each resident's individual needs. In efforts to identify areas that may contribute to formation of pressure ulcers or impede healing of an ulcer a review of the resident's; *Current history and physical, *Medicine regimen, *Nutritional and hydration status,*Cognition, inappropriate behaviors and compliance, with support and treatments,*Positioning and need for assistive devices (transfers, splints, pressure reducing, pressure relieving .), *Mobility, *Exposure to moisture,*Infection. The Policy continued to documented 1. An initial assessment is performed by a licensed nurse at admission or if not present at admission at the time of discovery of the wound to include type, location, periwound condition, size (length (head to toe), width (side to side) and depth), undermining, sinus tracts, tunneling, exudates, odor, necrotic tissue, pain, and presence or absence of granulation tissue and epithelization.The Policy documented Note: Evidence of healing should occur within 2 (two) to 4 (four) weeks. If no progress is made review the treatment plan, development of acute medical condition, significant change in functional status. If no change in treatment is warranted, then documentation to support the lack of change should be made. The Policy documented 3. Daily and as needed (PRN) observations are made by a licensed nurse of the ulcer site if the wound is visualized or if the dressing and periwound if dressing remains intact and a dressing change is not indicated. Dressing should have date and time of dressing change and initials of the person performing dressing change. Documentation of this observation is made on the Treatment Administration Record (TAR). Documentation when a change in wound status is observed is made on (TAR). Physician and family notification is made if a change in treatment plan is necessary.

Based on observation, interview and record review the facility failed to provide adequate restorative services for the prevention and or treatment of [REDACTED]. This failure resulted in R10 developing bilateral knee contractures. Findings include: R10's Physician order [REDACTED]. R10's Admission MDS dated [DATE] documents in part, R10 has no impairment to his lower extremity and both R10 and direct care staff believe R10 is capable of increased independence under Functional Rehabilitation Potential. R10's Initial Restorative assessment dated [DATE] documents in part, Range of Motion, Left Knee minimal limitation, Right Knee minimal limitation. Restorative Recommendation: Transfer Restorative, Dressing/Grooming Restorative. R10's Minimum Data Sets ((MDS) dated [DATE], 6/29/16, 8/30/16, and 11/16/16 all document R10 does not have any impairment to his lower extremities and requires extensive assistance with one person assist for ambulation. R10's Restorative Nursing Program Physical Therapy Communication Sheet dated 4/11/16 documents in part, Current Functional Status: ambulated >200 feet with wheeled walker very limited assist. Transfers limited. Therex with theraband and omnicycle both lower LE's. Goals: Ambulates with wheeled walker >200 feet limited. Exercise both LE's. Treatment/Recommendations: See above goals. R10's Physical Therapy (PT)- Therapist Progress & Discharge Summary, dated 4/12/16, documents in part, Treatment Diagnosis: [REDACTED]. R10's PT- Therapist Progress & Discharge Summary, dated 6/29/16, documents in part, Gait Tasks: Assistive Devices. Explanation: Progress Ceased. Prior Level as of 6/21/16, the patient (R10) requires front wheeled walker and contact guard assist (contact with patient due to unsteadiness) for safe ambulation for 100 feet. ROM (range of motion): Knee, Explanation: Progress Ceased. End of Goal Status as of 6/29/16 - Goal not met. The patient (R10) demonstrates AAROM (active assistive range of motion) of L knee minus 40 degrees of full extension and R knee minus 35 degrees of full extension. Analysis of Functional Outcome/Clinical Impression: Improvement in strength, balance, and impaired coordination allows patient (R10) to tolerate higher levels of challenges in gait, transfers, and dynamic standing balance. Impact on Burden of Care/Daily Life: the patient (R10) continues to demonstrate decreased strength, balance, and impaired coordination. The deficits increase the risk of falling and increase the reliance on the nursing staff for sit < > stand, surface to surface transfers, and gait. Discharge Plans & Instructions: D/C to SNF with Restorative Exercise Program. R10's Restorative Progress Documentation signed 6/29/16 documents in part, Resident (R10) remains on transfer/ambulation program, limited extensive assist noted varies daily. Verbal cues for safety and direction. Can be impulsive at times. Gait slow unsteady. No decline noted. R10's Restorative Progress Documentation signed 8/30/16 documents in part, Current programs maintained. No decline noted. Resident (R10) remains unsteady. Verbal cues required for safety. No complaint of pain. On 11/28/16 at 2:45 PM, R10 was lying on his bed on top of the covers in his room with his knees and legs up in a fetal position. On 11/29/16 at 4:00 PM, R10 was lying on his bed on top of the covers in his room with his knees and legs up in a fetal position. On 12/1/16 at 9:50 AM, R10 was lying in bed with his legs and knees up in the fetal position. At that time R10 stated he cannot stretch out his legs very far and then tried to extend his leg out. He was able to extend it to about 45 degrees. R10 stated I could get out of here if I could only straighten out my legs. On 11/30/16 at 2:00 PM, E23, Speech Therapist, stated that R10 was recently getting physical therapy but had been discharged due to not progressing. E23 then stated R10 had contractures to both lower extremities. On 11/30/16 at 2:10 PM, E22, Restorative Nurse, stated that R10 was on a restorative ambulation and safe transfer program. E22 stated that R10 is walked two times a day and can walk 150 feet on a good day. E22 stated that she fills out the mobility sections of the Minimum Date Set (MDS) and the section on Range of Motion. E22 stated that R10 does not have any lower extremity contractures and none have been documented on R10's MDS. On 11/30/16 at 2:20 PM, E15 and E16 Certified Nursing Assistants (CNA's) walked R10 down the hall with a wheeled walker followed behind by E22 with R10's wheelchair. During ambulation R10 walked 3 steps hunched over with knees bent on his tip toes. After walking just a few steps he would sit back in his wheelchair to rest. R10 ambulated this way three separate times. During ambulation E15 and E16 would have to remind him to try and walk flat footed. On 12/1/16 at 10:00 AM, E22 stated that she does an intial restorative assessment on residents when they are admitted to the faciltiy and does not do any further assessments. E22 stated that she bases a continued restorative program on therapy recommendations which are done on a quarterly basis. E22 stated that R10 can do AROM (active range of motion) with his legs but he is not on a leg exercise program. On 12/1/16 at 10:10 AM, E21, Physical Therapy Assistant, stated that R10 does have contractures in both of his lower extremities. E21 stated that R10 cannot stretch out his legs. On 12/1/16 at 12:50 PM, E21 stated that R10 was discharged from physical therapy in November because he was not progressing and was not getting any better. E21 stated that it would be a waste of Medicare and his money to keep him in physical therapy. E21 stated that when R10 was discharged from the program she instructed him to try and keep his legs straight and showed him exercises he could do in his room. E21 stated that at that time he couldn't stretch his legs out. E21 stated that upon discharge she wrote a recommendation for restorative exercises and active range of motion for his legs. R10's Physical Therapy Plan of Care dated 11/8/16 documents in part, R10's start of care as 11/8/16. Reason for referral: The patient (R10) was referred to therapy with increased assistance needed with gait, transfers, and dynamic standing balance. Therapy Necessity: Therapy necessary for decreased strength, balance, and impaired coordination. Without therapy patient at risk for falls and increased reliance on the nursing staff for sit < > stand, surface to surface transfers, and gait. When he was last seen for therapy, he was able to ambulate 100 feet with w/w (wheeled walker) and CGA (contact guard assist). Gait, Distance: Prior Level - 150 feet, Current Level - 5 feet. Gait, Level Surfaces: Prior Level - modified independence, Current Level - maximum assistance (76-99% assist). Transfers; Prior Level - modified independence, Current Level - moderate assistance. Underlying Impairments- ROM: R LE (right lower extremity) minimum 55 degrees of full extension. L LE (left lower extremity) 60 degrees of full extension. Rehab Potential: Good. Frequency/Duration: 3 times a week for 12 weeks. R10's PT (physical therapy) Therapist Progress & Discharge Summary dated 11/16/16 documents in part, ROM: General. The patient (R10) will increase AAROM (active assistive range of motion) of BLE (bilateral lower extremity) knee extension to minus 50 degrees of full extension to increase level of independence. Explanation: Progress Ceased. End of Goal Status as of 11/16/16 - Goal not met. The patient (R10) demonstrates RLE minus 55 degrees of full extension and L LE minus 60 degrees of full extension. Impact on Burden of Care/Daily Life: The patient (R10) continues to demonstrate decreased strength, balance, and impaired coordination. The deficits increase the risk of falling and increase the reliance on the nursing staff for sit < > stand, surface to surface transfers, and gait. Discharge Plans & Instructions: D/C (discontinue) to SNF (skilled nursing facility) with Restorative Exercise Program. R10's Restorative Nursing Program Physical Therapy Communication Sheet dated 11/16/16 documents in part, Current Functional Status: Ambulates few steps with wheeled walker, ext X2. Stretching knees into extension. AROM (active range of motion) both LE's (lower extremities). Goals: ambulate with wheeled walker ext X2 distance as tolerated, AROM both LE's. Precautions/Problems/Approaches: contracted knees into flexion. R10's Restorative Progress Documentation signed 11/16/16 documents in part, Transfer/Dressing program continued. Extensive to limited assist of 1-2 staff required. Varies daily verbal cues for safety required. No decline noted. R10's Restorative Progress Documentation signed 11/18/16 documents, Therapy recommendation reviewed. Resident (R10) to remain on current program. Resident (R10) remains able to ambulate with extensive assist verbal cues required and encouragement provided many breaks for rest. On 12/1/16 at 2:25 PM, E22, stated that she did not have any Restorative Nursing Program Physical Therapy Communication Sheets for R10 in between the dates of 4/11/16 and 11/16/16. R10's Care Plan dated 11/22/16 documents, Decline in ability to walk. Therapy as needed. R10's Care Plan does not address R10 being on a Restorative Exercise Program. R10's Amubulation and Mobility Check blank check sheet documents in part, Ambulation up to 150 feet twice daily with wheeled walker limited assist of 1 staff, may part in group exercise. The Facility's Restorative Nursing Programs Policy undated documents in part, All residents will be encouraged to maintain or improve their functional status through participation in restorative programs. Procedure: 1) All residents will be assessed for functional status within 14 days of admission with re-evaluation of status at least quarterly and as needed. 2) Based on the assessment and the determination of the resident's capability to improve functional ability.