Every finding on record at Axiom Healthcare of Harrisburg

Based on observation, interview, and record review the facility failed to provide a sanitary homelike environment. This failure has the potential to affect all 18 residents on the 100 hall in the facility.Findings include:On 8/6/26 at 8:12 AM, a staff was overheard exclaiming Oh my God, there is s**t on the floor!On 8/6/26 at 8:24 AM, the men's bathroom on the 100 hall had 17 balls of feces lying on the floor approximately 2 feet in front of the toilet and the women's bathroom on the 100 hall had dried feces smeared on the toilet seat and lid.On 8/6/26 at 8:33 AM, V4 (Housekeeping supervisor) was observed cleaning the women's bathroom on the 100 hall.On 8/6/26 at 12:23 PM, V3 (R2's Family Member) said when visiting R2, who previously resided on the 100 hall, on several occasions observed the floors being dirty and unsanitary.On 8/6/26 at 8:34 AM, R7, R8, and R9's room, on the 100 hall, was observed to have a moderate amount of black dirt/debris dried on the floor throughout the room.On 8/6/26 at 8:37 AM, the 100 hall shower room was toured and observed with a black substance on the tile and grout around the wall close to the floor and approximately 1 foot up the wall, a toilet riser with dried feces on it was sitting in the bathtub, and the inside of the privacy curtain had a splattering of dried brown substance on it.On 8/6/26 at 8:42 AM, R4 and R6's room, on the 100 hall, had a moderate amount of black dirt/ debris dried on the floor throughout the room and the floor was very sticky.On 8/6/26 at 8:50 AM, the facility was toured with V1 (Administrator). The feces found lying on the floor in the men's bathroom on the 100 hall remains. V1 said the men's bathroom having feces on the floor, the toilet riser with dried feces in the tub, the privacy curtain with a splattering of a brown substance, and R4, R6, R7, R8, and R9's dirty floors were unacceptable. V1 said she was going to get V4 (Housekeeping Supervisor) to discuss the possible mold in the shower and to clean the feces from the floor in the men's bathroom.On 8/6/26 at 8:56 AM, V4 said she was aware of the mold in the shower, but was not sure what to do about it. V4 said she had used bleach, peroxide, and a mold and mildew spray on it but could not get rid of it. V4 said she scrubbed the area 3 times a week with a brand name sponge and that was best thing she had found to get some of the mold off.On 8/6/26 at 9:05 AM, V1 said she was going to speak with V11 (Regional Director of Operations) to see if the facility can get the 100 hall shower tiles replaced. V1 verified all residents residing on the 100 hall used the 100 hall shower room.The facility's undated Physical Plant & Environmental Policy & Guidelines documented in part . 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. Housekeeping. Routine daily room cleaning and sanitizing. Routine daily cleaning of all shower rooms and restrooms. Scheduled stripping and waxing of floors (if required floor type).The facility's 8/6/26 Midnight Census Report documented 18 residents residing on the 100 hall in the facility.

Based on interview and record review, the facility failed to staff a Director of Nursing (DON) and failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential of affect all 30 resident residing in the facility. Findings include: The facility schedule for April and May 2026 document on 04/04/26, 04/11/26, 04/12/26, 04/19/26, 04/25/26, 04/26/26, 05/02/26, 05/03/26, 05/10/26, and 05/23/26 the facility did not have a registered nurse working. On 05/28/26 at 3:55 PM, V1 (Administrator) stated they do not have a director of nursing and there are days that the facility does not have RN (Registered Nurse) coverage everyday. The facility room roster dated 05/26/26 documents 30 residents residing at the facility.The undated staffing policy documents: purpose: to ensure that the facility meets or exceeds the minimum staffing standards established under Illinois law, thereby safeguarding resident care, safety, and well-being.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled, failed to dispose of vials of multidose medications after open date had expired for greater than 30 days, and failed to dispose of expired medications. This has the potential to affect all 30 residents living in the facility. Findings include: 1. R3's admission Record documents an original admission date of 11/27/24. R3's Order Summary Report documents orders for Fluticasone Propionate Nasal Suspension 50 mcg (micrograms), 1 spray in both nostrils at bedtime for allergy (start date 3/11/25) and Glucagon Emergency Injection Solution Reconstituted 1 gm (gram) (start date 3/3/26). On 5/26/26 at 1:30 PM, expired medication for R3 was found in them medication cart; Glucagon Emergency Kit for low Blood Sugar expiration date of April 2026, Vitamin D2 50,000 units expired 10/9/25, and Vitamin D2 50,000 units expired 10/28/25. Opened mediations with no open dated for R3 was found in the medicine cart; Fluticasone 50 mcg nasal spray with no open date, Fluticasone 50 mcg nasal spray with no open date. V20 confirmed the expired medications were expired and that there was no open date on the nasal sprays and stated the nurse should write the open date on them when they are opened. 2. R28's admission Record documents an admission date of 11/6/24. R28's Order Summary Report documents an order for Systane drops, instill 1 drop in both eyes two times a day for dry eyes (start date) 1/29/25. On 5/26/26 at 1:31 PM, there was and an open bottle of Systane lubricant eye drops with an open date of 12/24/24 in the medicine cart for R28. V20 confirmed the open date and stated eye drops are only good for 30 days after opening. 3. R34's admission Record documents an admission date of 4/25/26. On 5/26/26 at 1:34 PM, R34 had a tube of calmoseptine ointment in the medication cart that had an expiration date of 6/1/23. V20 confirmed expiration date on ointment tube and stated that it looked like a tube that came from her home, and it should not be in the medication cart. 4. R5's admission Record documents an admission date of 11/29/25. R5's Order Summary Report documents orders for dorzolamide-timolol install 1 drop in both eyes two times a day for glaucoma, latanoprost optical solution install one drop in both eyes in the evening for glaucoma and fluticasone propionate nasal suspension 50 mcg spray 2 in both nostrils one time a day for allergies. On 5/26/26 at 1:33 PM, the following medications were observed to be in the medication cart for R5: open bottle of latanoprost optical solution dated as opened on 4/10/26, open bottle of dorzolamide-timolol eye drops with no open date, open bottle of dorzolamide-timolol with no open date, open bottle of dorzolamide-timolol with no open date, an open bottle of fluticasone propionate nasal spray 50 mcg with no open date, and an open bottle of fluticasone propionate nasal spray 50 mcg with no open date. V20 confirmed all the open bottles did not have an open date on them and stated they all should have an open date on them. 5. R7's admission Record documents an admission date of 6/9/21. On 5/26/26 at 1:35 PM, an expired card of Metformin 850 mg that belonged to R7 was found in the medicine cart, expiration date on the medicine was 1/31/26. V20 confirmed the expiration date and stated the medicine should not be in the medication cart. 6. On 5/26/26 at 1:28 PM, stock medications were observed in the medicine cart; open bottle of Geri-Lanta with an open date of 4/4/26 and an expiration date of 4/2026, an open bottle of melatonin 5 mg with no open date, and an open bottle of Advil PM with no open date and an expiration date of 9/25. V20 confirmed open dates and expiration date of the medications and stated medicine should be dated when opened and expired medications should not be left in the medication cart. 7. On 5/26/26 at 1:33 PM, an open bottle of latanoprost ophthalmic solution was observed to have no open date on it. The label on the box the bottle came in faded off so that you could not read who the eye drops belonged to. V20 confirmed that she did not know who it belonged to because the label was faded off and it did not have an open date on it. 8. On 5/26/26 at 1:55 PM, 2 open bottles of Tuberculin Purified Protein Derivative was observed in the medication refrigerator in the medication storage room, both bottles did not have an open date on them. V2 (Assistant Director of Nursing) confirmed the open bottles did not have an open date on them and stated they should have an open date on them because they are only good for 30 days after open. On 6/2/26 at 4:26 PM, V1 (Administrator) stated any resident living in the facility has the potential to get stock medication. The facility's Midnight Census Report dated 5/26/26 documents there are 30 residents currently living in the facility. A facility provided policy titled 5.3 Storage and Expiration Dating of Medications and Biologicals with revision date of 8/1/24 documents under Procedure, 10. Facility should ensure medications and biologicals that: (1) have an expired date on the label (2) have been retained longer than recommended by manufacturer or supplier guideline or (3) have been contaminated or deteriorated are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 11.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 21. Facility should ensure medications and biologics for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider.

Based on interview, observation, and record review the facility failed to provide a method for residents to contact staff for assistance if needed from the floor of the bathrooms for 15 (R6, R9, R10, R11, R12, R14, R15, R17, R18, R21, R26, R27, R30, R31, R36) of 15 residents reviewed for accessible call lights in the sample of 35. Findings include: On 05/26/26 at 9:16 AM the bathroom across from room [ROOM NUMBER] did not have a call light that was accessible from the floor, there was no string attached to the call light toggle switch. On 05/26/26 at 9:17 AM the bathroom across from room [ROOM NUMBER] did not have a call light that was accessible from the floor, there was no string attached to the call light toggle switch. On 05/26/26 at 9:18 AM the second bathroom on the left side of the 200 hall did not have a call light that was accessible from the floor, there was no string attached to the call light toggle switch. On 05/28/26 at 3:35 PM, V1 (Administrator) stated the shower rooms and all bathrooms in the facility should have call lights that are accessible by the residents from the floor if needed. The facility room roster dated 05/26/26 documents: R6, R9, R10, R11, R12, R14, R15, R17, R18, R21, R26, R27, R30, R31, R36 reside on the 200 hall and would utilize the 200 hall bathrooms.The undated facility policy titled, Physical Plant & Environmental Policy & Guidelines documents: The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Maintenance/Approved Contractors: Nurse Call Light systems and door signaling systems/wander guard systems

Based on interview, observation, and record review the facility failed to maintain cleanliness of resident rooms' floors and provide a safe, clean, and sanitary place for residents to shower for 29 (R2, R3, R5, R6, R8, R9, R10, R11, R12, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R26, R27, R28, R29, R30, R31, R35, R36, and R41) of 30 residents reviewed for environment in a sample of 35. Findings include: 1. On 5/26/26 at 9:12 AM, R2's room floor was covered in dots with dark brown and black stains and dried spills ranging in size from droplets to larger splatters. There were dark particles of unknown substances, some stuck to the floor throughout the room. The floor also contained what appeared to be skid marks possibly from wheelchair tires. The floor was also sticky throughout the room. On 5/26/26 at 11:58 AM, R2 who was alert to person, place and time, stated he thought the floor in his room was very dirty. R2 stated there is dirt and other unknown particles on the floor and the floors have a general appearance of dinginess. R2 stated his daughter had even commented on the dirtiness of the floors and even used a cleaning wipe on one tile to see if it would come clean. R2 stated it did look better after she scrubbed it. R2 pointed the floor tile out to this surveyor his daughter reportedly scrubbed, and it was cleaner and lighter in color than the surrounding floor. On 5/26/26 beginning at 12:21 PM, the floors in 5 resident rooms affecting R41, R29, R35, R3, R5, R19, R20, R22, R8, R23, R24, R28, and R16 were observed to all be dirty with dried spills of unknown origin, particles of unknown substances, stickiness, and skid marks from wheelchair tires noted throughout the floors in the above residents' rooms. On 5/26/26 at 1:44 PM, V19, Family Member stated she had concerns with the floor in her mom's (R34) room being dirty and not being mopped daily. On 5/26/26 at 8:39 AM, in R3's room the floors were very sticky and caused this surveyor's shoes to slip from under feet. The floor was covered in dark stains of unknown substances and marked up with multiple skid marks apparently from wheelchair tires. There were also dark, unknown particles of dirt and other substances on the floor. On 5/27/26 at 3:40 PM, V16, Housekeeping Supervisor, when asked about the dirty floors this surveyor had seen in multiple resident rooms, stated she has tried multiple cleaning agents to try and get the floors clean. V16 stated she has tried bleach, hydrogen peroxide and baking soda mixture, name brand cleaners and none of them worked to get the stickiness off the floors or the stains. V16 stated there are some rooms where the floors have been redone by stripping, buffing and waxing the floors. Those floors look much better she states and there were no stickiness or stains on them. When asked about the dirty floors in question, V16 stated the floors have looked like that since she started 1.5 years ago. V16 stated the floors in every room are swept and mopped once a day and then as needed. On 5/28/26 beginning at 12:21 PM, the floors in 5 resident rooms affecting R41, R29, R35, R3, R5, R19, R20, R22, R8, R23, R24, R28, R2 and R16 were observed to all be dirty as they were on Tuesday upon entry. They continued to have unknown pieces of food, dirt and particles as well as dark and blackened dried spills and stains of unknown substances with skid marks from wheelchair tires, and the floors were also very sticky. On 5/28/26 at 12:36 PM, V1, Administrator and V16 accompanied this surveyor to the resident rooms mentioned above. This surveyor pointed out the cleanliness of the floors pointing out dried spills and stains and dark to black colored unknown particles that were easily moved about the floor with the toe of his shoe. V1 and V16 both agreed there should not be stains and debris left on the floor after they have reportedly been swept and mopped. V16 stated she would get the floors in question cleaned as soon as possible. The facility's undated Physical Plant and Environmental Policy documents, 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. The policy also documents daily resident room cleaning and sanitizing and mopping up of spills as soon as possible. 2. On 05/26/26 at 9:16 AM in shower room on the 200 hall there was a black substance along the back wall between the wall and the floor of the shower stall that was approximately three inches up in the grout along the back wall. There was a black substance along the walls to the right and left of the back wall approximately twenty-four inches out from the back wall. There was also a dark pink substance that had built up on the side walls in the grout and in spots up to approximately ten inches up from the floor. On 05/26/26 at 9:21 AM the sink in R36's room was covered with plastic and did not work. On 05/26/26 at 9:23 AM the sink in R30's room was covered with plastic and did not work. On 05/26/26 at 9:26 AM the sink in R6's room did not work. On 05/26/26 at 3:05 PM, R6 who was alert and oriented, stated his sink has not worked for months. R6 stated, it worked when he came to the room but has not worked for a while. On 05/26/26 at 9:30 AM the sink in R27's room was covered in plastic and did not work. On 05/28/26 at 12:07 PM, V17 (Maintenance Director) stated the sinks in R6, R27, R30, and R36's rooms do not work due to drainage problems. On 05/28/26 at 3:35 PM, V1 (Administrator) stated the shower room should not have a buildup of black substances or dark pink substances. The facility room roster dated 05/26/26 documents: R6, R9, R10, R11, R12, R14, R15, R17, R18, R21, R26, R27, R30, R31, R36 reside on the 200 hall and would utilize the 200-hall shower room. The undated facility policy titled, Physical Plant & Environmental Policy & Guidelines documents: The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Maintenance/Approved Contractors: general plumbing: drains, faucets, showers are maintained. Housekeeping: routine daily cleaning of all shower rooms and restrooms and monthly scheduled shower room deep cleaning.

Based on interview, observation, and record review the facility failed to provide activities of daily living assistance with bathing and eating assistance for 4 (R7, R21, R28, R34) of 5 residents reviewed for activities of daily living in a sample of 35. Findings include: 1.R34's admission record dated 5/29/26 documents an admission date of 4/20/26. R34's admission record documents diagnoses including fracture of left hip, congestive heart failure, and acute pulmonary edema. R34's most recent care plan documents a focus area for impaired physical mobility related to musculoskeletal impairment dated 4/21/26. Interventions for this focus area include encouraging and assisting in active range of motion exercises to affected and unaffected extremities dated 4/21/26. Another focus area for R34 is she had a deficit in self-care (dressing and grooming) related to limited mobility dated 4/21/26. Interventions for this focus area include allowing for adequate time for task completion dated 4/21/26. R34's minimum data set (MDS) dated [DATE] documents she is dependent for showering/bathing, lower body dressing and tub/shower transfers. R34's MDS documents R34 has a brief interview for mental status (BIMS) score of 15 indicating resident is cognitively intact. On 5/26/26 at 9:18 AM, R34 wrote to this surveyor (she is deaf/mute, and this surveyor did not know American Sign Language) she has not had a shower in 2 weeks to 1 month. R34 wrote she had been here since about mid-April of this year. Resident's hair appeared greasy/oily and slicked back as though it has not been washed in some time. R34 was making gestures and facial expressions indicating she feels dirty. On 5/26/26 at 1:44 PM, V19 (Family Member) stated things have been improving for her mom, but she is concerned because her mom, R34, had complained to her she had not had a shower but one time in the last month since arriving at the facility. On 5/26/26 at 2:33 PM, this surveyor reviewed R34's shower documentation in her electronic health record. Shower documentation documents R34 only had a shower one time between 4/29/26 and 5/25/26 on 5/15/26. There is documentation for a refusal of a shower on 5/22/26. There was no documentation from R34's admission date of 4/20/26 to 4/28/26 of showers or even showers being offered in R34's electronic health record. Record documents R34 was out of facility for hospitalization from 4/22/26-4/25/26. The rest of the dates inputted from 4/29/26-5/25/26 document showers were not applicable. There is a column in shower documentation if a resident refuses a shower that was left blank. On 5/27/2026 at 10:21 AM, this surveyor reviewed R34's shower documentation in her electronic health record which documents R34 received a shower yesterday (5/26/26) evening. On 5/27/2026 at 11:19 AM, V12 (Certified Nursing Assistant/CNA) stated R34 frequently refuses a shower. V12 stated she believes R34 fears using the mechanical lift which is the only safe way to transfer her due to her large size. V12 stated R34 frequently does bed baths if she refuses a shower. On 5/27/2026 at 11:23 AM, This surveyor went with V12 when she asked R34 if she wanted a shower today. R34 indicated she did want a shower. V12 told this surveyor and R34 she would try and get R34 a shower today. When asked R34 denied getting a shower last night as her electronic health record documents. R34 gestured to her body and hair indicating she felt dirty and needed/wanted a shower. R34's hair remained greasy/oily in appearance and slicked back from her forehead. On 5/28/26 at 8:18 AM, R34 indicated she did get a shower last night. R34 signed thank you indicating she was thankful for this surveyor helping her obtain a shower. At that time it was noted R34's hair appeared clean and combed and not greasy/oily like it had the previous two days. On 5/28/26 at 3:01 PM, V7(MDS coordinator/Registered Nurse/RN) stated when asked why NA would be marked on R34's task for bathing/showering, the only reason it would be marked if R34 was out of the facility at the time. V7 confirmed with this surveyor R34 was not out of the facility during the dates of 4/29/26-5/25/26 in question. V7 stated there was no excuse for a resident to go almost a month without a shower. On 5/28/26 at 8:55 AM, V1 (Administrator) stated when asked about the many nonapplicable checks marked in R34's shower documentation from 4/29/26 to 5/25/26 she stated she could not explain why. V1 stated she looked for written refusals, but she could not find any in R34's electronic health record or written refusals waiting to be scanned into the electronic health record. 2. R21's admission Record documents an admission date of 4/24/25 with included diagnoses of dizziness and giddiness, hypertension, vertigo of central origin, primary generalized osteoarthritis, history of falling, and non-pressure chronic ulcer of left lower leg. R21's MDS dated [DATE] documents a BIMS of 15, indicating intact cognition. Section GG documents under Self-Care R21 is substantial/maximal assistance with showering/bathing. R21's Care Plan documents R21 has an ADL (Activities of Daily Living) self-care performance deficit related to limited range of motion initiated 5/12/25 with included interventions of bathing/showering: avoid scrubbing and pat dry sensitive skin, check nail length and trim and clean on bath day and as necessary, and provide sponge bath when a full bath or shower cannot be tolerated initiated 5/12/25. R21's shower documents titled Shower/Abnormal Skin Report provided by V1 documents on 2/9/26 shower given, 2/12/26 shower given, 2/19/26 shower given, 3/2/26 shower given, 3/16/26 shower given, 3/23/26 shower given, 3/30/26 shower given, 4/2/26 had no documentation if a shower was given, 4/6/26 shower given, 4/9/26 shower given, 4/13/26 shower given, 4/20/26 shower given, 4/23/26 shower given, 4/30/26 shower given, 5/4/26 shower given, 5/25/26 shower given. R21's electronic bathing: self-performance documentations provided by V1 documents on 5/15/26 not applicable, 5/19/26 total dependence, 5/22/26 not applicable, 5/25/26 not applicable. On 5/26/26 at 9:08 AM, R21 stated he doesn't get his showers as often as he should. R21's document titled Concern/Compliment Form dated 3/16/26 documents under Nature of Concern/Compliment: R21 asked if he could take a shower today because he hasn't had one since last week. Under Summary of Pertinent Findings: Substantiated is circled and it documents Looked through shower sheets. Under Corrective Actions Taken it documents Moving to day showers. R21's document titled Concern/Compliment Form dated 1/7/26 documents under Nature of Concern/Compliment: R21 stated he has not had a shower in a week. Under Summary of Pertinent Findings: Substantiated is circled and it documents Looked through shower sheets. Under Corrective Actions Taken it documents R21 was given a shower and the director of nursing is looking over shower sheets and talking to certified nursing aides. 3. R7's admission Record documents an admission date of 06/09/21 with diagnoses including: palobular emphysema, heart failure, chronic kidney disease, gastro-esophageal reflux disease, major depressive disorder, bipolar disorder, dementia, generalized anxiety, muscle wasting and atrophy, lack of coordination, type 2 diabetes mellitus, and nondisplaced type II dens fracture. R7's minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 07 indicating R7 is cognitively severely impaired. R7's functional abilities documents R7's ability to shower/bathe as documented as dependent. R7's care plan has a focus area of R7 is usually able to perform ADLs with moderate hands on assist related to dementia, fatigue and anticipate continued decline dated 11/11/25 with an intervention including: bathing/showering: resident requires hands on assist of 1 caregiver and non-weight bearing in bathing/showering. Gather and place hygiene items to allow resident completion of cares. Encourage participation in bathing dated 02/29/24. R7's shower documentation does not document any showers for 03/05/26, 03/09/26, 03/12/26, 03/16/26, 03/26/26, 04/02/26, and 04/16/26. On 05/28/26 at 2:12 PM V1 (Administrator) stated, that is all the shower documentation the facility has for R7. V1 stated, all residents should get at least two showers a week. Facility's shower/tub bath policy dated 11/28/12 documents a resident will be offered a shower/tub bath at least 2 times weekly and/or as frequently as they request or need one. The same document documents this is to ensure a resident's cleanliness and to maintain proper hygiene and dignity. 4. R28's admission record documents an admission date of 11/06/24 with diagnoses including: chronic obstructive pulmonary disease, acute candidiasis of vulva and vagina, depression, anxiety disorders, dementia, low back pain, lack of coordination muscle wasting and atrophy, and repeated falls. R28's Minimum Data Set, dated [DATE] documents should a brief interview of mental status be conducted with no (resident is rarely/never understood) indicated. R28's eating ability is documented as: supervision or touching assistance indicating: helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R28's care plan documents a focus area of R28 requires staff assistance with ADLs (activities of daily living) related to current mobility status dated 11/14/24 with an intervention of assist with meal preparation/set up/eating dated 01/03/2025. R28's Physician Order Summary documents R28 is on a regular diet with regular texture with a start date of 1/29/25. On 05/28/26 at 7:48 AM, R28 was eating her hot cereal and French toast casserole with her fingers, R28's silverware was still wrapped in her napkin. At 7:53 AM R28 was trying to drink her frozen nutritional ice cream, when the frozen nutritional ice cream would not come out of the cup R28 set it back down and went back to eating her hot cereal with her fingers. During this time, R28 dropped hot cereal onto herself and the table and had food all over her hands. During this time there were no verbal cues, touching, steadying and/or contact guard assistance from staff. At 8:07 AM, V16 (Housekeeping) unwrapped R28's silverware and stated, R28 never uses her silverware. At 8:07 AM R28 picked up her spoon and used it to take a few bites of her hot cereal then put the spoon back down and took a drink of her beverage then started eating her French toast with her fingers. At 8:15 AM R28 was trying to eat her nutritional ice cream again by picking it up and drinking it, when the nutritional ice cream did not come out, R28 put the container back down. At 8:15 AM this surveyor showed R28 where the spoon was and R28 started using the spoon to eat her nutritional ice cream. After eating some of her nutritional ice cream, R28 set the spoon down and started eating the hot cereal that had dropped onto the table off of the table. At 8:20 AM R28 was then looking at her fingers and surveyor picked up R28's napkin, R28 took the napkin and wiped her mouth and wiped her fingers off and set the napkin back down. During this time there was no assistance or intervention from staff. At 8:22 AM R28 started eating the rest of her nutritional ice cream with her fingers. At 8:25 AM V13 (Certified Nurse Aide) picked up R28's spoon and put it into R28's nutritional ice cream. R28 used the spoon to take two bites and then set the spoon down. R28 felt around her plate with her fingers, then picked up the nutritional ice cream and started eating the nutritional ice cream with her fingers. On 05/28/26 at 1:11 PM R28 picked up the fruit cup container and spilled approximately half the liquid in the fruit cup into her beef stew/soup. R28 ate a couple of pieces of fruit with her fingers and set it back down. R28 then started eating pieces of vegetable out of the soup/stew with her fingers. During this time there was no intervention or assistance from staff. At 1:22 PM V13 left the resident she was assisting at a different table and handed R28 her spoon then returned to the resident she was assisting. At 1:22 PM R28 took a couple bites of the stew/soup with the spoon and set it back down. At 1:25 PM R28 started eating pieces of vegetables and meat out of the stew/soup with her fingers and then started eating the fruit out of the fruit cup with her fingers. R28 continued eating her lunch with her fingers. At 12:32 PM surveyor stopped observing R28 and at this time there had been no further assistance/intervention by any staff. On 05/28/26 at 4:05 PM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) stated if a resident has mobility issues, any diagnoses including dementia the tray should be set up for the resident including the silverware unwrapped. V7 stated, any resident that looks like they need assistance, including if the resident is eating with their fingers. On 05/28/26 at 4:17 PM, V1 (Administrator) stated if a resident appears they need assistance they should be receiving it especially if their MDS indicates supervision or touching assistance including verbal cues and/or touching steadying assistance. V1 stated, residents should not be eating with their fingers unless on a finger food diet and should not be eating their hot cereal with their fingers or eating their hot cereal off of the table that has dropped onto the table. V1 stated, R28 should have received assistance with her meal and her silverware should have been unwrapped for her. V1 stated, they do not have an ADL policy for eating assistance.

Based on observation, interview, and record review the facility failed to follow proper infection control practices for 5 of 9 (R6, R11, R27, R34, R35) residents observed for infection control in a sample of 35. Findings include:1.R35's admission record dated 6/1/26 documents an admission date of 2/11/26. R35's admission record documents diagnoses including type II diabetes R35's physician order sheet dated 6/1/26 documents an order for insulin glargine: inject 15 units subcutaneously with a start date of 3/3/26. On 5/27/26 at 7:53 AM, observed V9, Licensed Practical Nurse/LPN administer physician ordered insulin subcutaneously to R35 without disposable gloves to resident's left lower abdominal region. On 5/27/26 at 8:25 AM, V9 stated yes, disposable gloves should be worn during the administration of insulin. V9 stated gloves should be worn as personal protection and to stop the transmission of any infections to or from the individual being administered the subcutaneous injection. 2.R34's admission record dated 5/29/26 documents an admission date of 4/20/26. R34's admission record documents diagnoses including pressure ulcer of left heel, unstageable, pressure ulcer of sacral region, stage 3, and pressure ulcer of unspecified part of back, stage 3. R34's physician order sheet dated 5/29/26 documents an order to Cleanse wound with Vashe. Apply Santyl (nickel thick) to wound bed, then apply Calcium Alginate with foam border dressing daily and as needed with a start date of 5/23/26. R34's physician order sheet documents wound to medial back: cleanse wound with Vashe. Apply Santyl (nickel thick) to wound bed, then apply Calcium Alginate and cover with a foam border dressing daily and as needed. R34's physician order sheet documents an order for left plantar, posterior heel: cleanse wound with wound cleanser. Apply Betadine to wound and leave open to air. R34's most recent care plan documents a focus area for pressure ulcers to L (left) heel, medial back and coccyx regions dated 5/28/26. Interventions for this focus area include administering treatments as ordered dated 5/28/26 and to follow facility protocols and procedures to prevent further skin breakdown dated 5/28/26. R34's minimum data set/MDS dated [DATE] documents she has current skin breakdown and at risk for further skin breakdown. On 5/28/26 at 8:18 AM, Observed dressing changes/treatments performed by V6, Licensed Practical Nurse/LPN assisted by V12, Certified Nurse Aide/CNA on R34. Both V6 and V12 applied disposable gowns and gloves before performing care. V6 placed a clean barrier on table being used and then her supplies. R34 rolled to right side with assistance of V12. V6 removed the old dressings from the 2 pressure ulcers. There were no signs and symptoms of infection to either of the two pressure ulcers. R34 had 2 pressure ulcers, one to mid coccyx region in a butterfly shape crossing over to both buttocks and a 2nd one to the upper lumbar/lower thoracic spine midline. V6 then cleaned both wounds using 4x4 gauze sponges and wound cleanser. V6 did not change gloves between cleaning of each separate wound or perform hand hygiene. V6 then changed gloves but did not perform hand hygiene and then applied Santyl ointment and calcium alginate and an island dressing to both wounds. V6 again did not change gloves or perform hand hygiene between the two separate pressure ulcers. V6 then changed gloves but did not perform hand hygiene. V6 then moved to the pressure ulcer of the left heelV6 cleansed the wound with 4x4 gauze sponges and then applied betadine without changing gloves or performing hand hygiene going from clean to dirty activity. On 5/28/26 at 8:37 AM, V6, when asked about when glove changes should be performed during treatments/dressing changes, V6 stated gloves should be changed between wound sites and from moving from dirty to clean procedures. When asked about when hand hygiene she be done, V6 stated before and after procedures. On 5/27/2026 at 10:43 AM, V2, Assistant Director of Nurses/ADON stated yes, gloves should be worn during administration of insulin. V2 stated gloves should also be changed between moving from dirty to clean procedures of dressing changes/wound treatments and hand hygiene should be performed between each glove change. She stated it was facility policy but more importantly to prevent transmission of infections and diseases from one person to another. Facility's Infection Prevention and Control Policy dated revised 11/28/17 on page 2 documents, All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections. Same document reads on page 2, All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments. 3. R27's admission Record documents an original admission date of 10/31/25 with included diagnoses of pressure ulcer of unspecified part of back, unstageable. R27's MDS (Minimum Date Set) dated 5/7/26 documents a BIMS (Brief Interview of Mental Status) of 12, indicating moderate cognitive impairment. Section M, Skin Conditions documents R27 has one or more unhealed pressure ulcer/injury and R27 has one stage 4 pressure ulcer that was present upon admission. R27's Order Summary Report documents an order for Enhanced Barrier Precautions; every shift related to unstageable pressure ulcer of unspecified part of back with an order date of 5/28/26. R27's Care Plan documents a focus area of enhanced barrier precautions initiated 5/28/26 with included intervention of gown and glove during high contact resident care activities (such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use, wound care (any chronic skin opening) initiated 5/28/26. On 5/27/26 at 10:39 AM, V6 (Licensed Practical Nurse/LPN) stated R27 has a wound vac in place on her wound on her back currently. Observed V6 and V5 (Certified Nursing Aide/CNA) provide incontinence care for R27 and observed wound vac in place on R27's back. During care V8 (CNA) entered the room to assist. During this observation V6, V5, and V8 were observed not wearing a gown. Enhanced barrier precautions sign was observed on R27's door. On 5/28/26 at 1:43 PM, V5 stated R27 is on enhanced barrier precautions but she forgot to put on a gown when providing care on 5/27/26 during this surveyors observation. V5 stated she should have worn a gown. On 5/28/26 at 1:45 PM, V6 stated she doesn't think R27 is on enhanced barrier precautions, then V6 looked in R27's electronic medical record and stated there isn't an order for enhanced barrier precautions. V6 stated she didn't wear a gown during care because she didn't think R27 was on enhanced barrier precautions. On 5/28/26 at 1:57 PM, V2 (Assistant Director of Nursing) stated R27 should be on enhanced barrier precautions due to her pressure ulcer and all staff should wear a gown and gloves when providing care. 4. R11's admission Record documents an admission date of 10/31/25 with included diagnoses of anterior dislocation of right hip and obstructive and reflux uropathy. R11's MDS dated [DATE] documents a BIMS of 15, indicating intact cognition. R11's Care Plan documents a focus area of R11 has an alteration in urinary elimination as evidenced by indwelling catheter with initiation date of 5/27/26. R11's orders document Foley catheter care every shift and as needed, follow protocol for indwelling urinary catheter maintenance/care with a start date of 5/27/26 and maintain indwelling foley catheter until seen by local urology with a start date of 5/27/26. On 5/28/26 at 11:09 AM, observed urinary catheter care on R11 that was provided by V13 (CNA). V13 washed her hands then applied gloves. V13 emptied the urinary catheter bag then started urinary catheter care without changes gloves. V13 wet a washcloth in a wash basin filled with water then added body soap to the washcloth and cleaned around R11's urinary catheter. V13 then got another washcloth, wet it then added soap to it and cleaned near R11's buttocks, stool was on the washcloth after cleaning. V13 then took another washcloth, wet it with water then rinsed the soap off of R11 using the wet washcloth. R11 then used a dry towel to dry R11. During this entire observation V13 did not change her gloves and was not observed wearing a gown during care. There was no enhanced barrier sign observed on R11's door and there was no available PPE (personal protective equipment) near the door. On 5/28/26 at 1:34 PM, V13 stated R11 isn't on enhanced barrier precautions or any kind of contact precautions that she is aware of and that is why she didn't wear a gown when she provided care. V13 stated she should have changed her gloves during urinary catheter care but she forgot. On 5/28/26 at 1:55 PM, V2 stated R11 should be on enhanced barrier precautions because she has a urinary catheter, and all staff should wear a gown and gloves when caring for her. 5. R6's admission Record documents an original admission date of 11/27/24 with included diagnoses of end stage renal disease. R6's MDS dated [DATE] documents a BIMS of 15, indicating intact cognition. R6's Order Summary Report documents an order for sevelamer carbonate 800 mg (milligram) tablets, give 2400 mg by mouth three times a day. On 5/27/26 at 12:08 PM, V6 (License Practical Nurse) was dispensing Sevelamer Carbonate 800 mg, and she dumped too many pills into the medicine cup. V6 grabbed the extra pills out of the medicine cup with her bare hands and put them back into the pill bottle. On 5/27/26 at 12:11 PM, V6 stated she should not have touched the pills with her bare hand then put them back into the pill bottle. An undated facility policy titled Medication Administration documents under Procedure: 11. Avoid touching medication. If contact with the medication is likely, prepare medication using gloves. A facility policy titled Enhanced Barrier Precautions dated 5/7/24 documents under Guidelines: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of personal protective equipment to donning of gown and gloves during high contact resident car activities that provide opportunities for transfer of multi-drug-resistant organisms (MDRO) to staff hands and clothing. EBP are indicated for resident with any of the following: chronic wounds and/or indwelling medical devices, even if the resident is not known to be infected or colonized with MDRO. Examples of chronic wound include in part: pressure ulcers. Indwelling medical deice examples include in part: Urinary catheters.

Based on interview, observation, and record review the facility failed to refer to residents in a dignified manner and assist residents with dining to maintain a dignified dining experience for 3 (R9, R28, and R31) of 6 residents reviewed for dining in a sample of 35. Findings include:1. R28's admission record documents an admission date of 11/06/24 with diagnoses including: chronic obstructive pulmonary disease, acute candidiasis of vulva and vagina, depression, anxiety disorders, dementia, low back pain, lack of coordination muscle wasting and atrophy, and repeated falls. R28's Minimum Data Set, dated [DATE] documents should a brief interview of mental status be conducted with no (resident is rarely/never understood) indicated. R28's eating ability is documented as: supervision or touching assistance indicating: helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R28's care plan documents a focus area of R28 requires staff assistance with ADLs (activities of daily living) related to current mobility status dated 11/14/24 with an intervention of assist with meal preparation/set up/eating dated 01/03/2025. R28's Physician Order Summary documents R28 is on a regular diet with regular texture with a start date of 1/29/25.On 05/26/2026 at 12:38 PM, R28 was eating her ice cream with her fingers. At 12:42 PM V7 (Minimum Data Set Coordinator/Care Plan Coordinator) cued R28 to use her silverware and showed her how to use the spoon. At 12:44 PM R28 was eating with her spoon upside down, R28 was unable to get much food onto the utensil in that manner, but attempted to eat that way for several minutes. At approximately 12:49 PM R28 started eating with her fingers again. R28 was not approached, cued, or assisted again after V7's attempt to cue R28. On 05/27/2026 at 12:21 PM, R28's lunch was placed in front of her and her silverware was not unwrapped. R28 picked up the silverware, still wrapped in the napkin and attempted to utilize the silverware. R28 put the wrapped silverware in the middle of her plate in her food, left the silverware set there for approximately 30 seconds, then R28 picked up her napkin wrapped silverware and began to eat the napkin wrapped around her silverware and the food that was on it. At 12:30 PM, V1 (Administrator) came out of an office and and removed the wrapped silverware from R28's mouth and began to assist her. At 12:31 PM V1 asked V13 (CNA) to assist R28. On 05/28/26 at 7:48 AM, R28 was eating her hot cereal and French toast casserole with her fingers, R28's silverware was still wrapped in her napkin. At 7:53 AM R28 was trying to drink her frozen nutritional ice cream, when the frozen nutritional ice cream would not come out of the cup R28 set it back down and went back to eating her hot cereal with her fingers. During this time, R28 dropped hot cereal onto herself and the table and had food all over her hands. During this time there were no verbal cues, touching, steadying and/or contact guard assistance from staff. At 8:07 AM, V16 (Housekeeping) unwrapped R28's silverware and stated, R28 never uses her silverware. At 8:07 AM R28 picked up her spoon and used it to take a few bites of her hot cereal then put the spoon back down and took a drink of her beverage then started eating her French toast with her fingers. At 8:15 AM R28 was trying to eat her nutritional ice cream again by picking it up and drinking it, when the nutritional ice cream did not come out, R28 put the container back down. At 8:15 AM this surveyor showed R28 where the spoon was and R28 started using the spoon to eat her nutritional ice cream. After eating some of her nutritional ice cream, R28 set the spoon down and started eating the hot cereal that had dropped onto the table off of the table. At 8:20 AM R28 was then looking at her fingers and surveyor picked up R28's napkin, R28 took the napkin and wiped her mouth and wiped her fingers off and set the napkin back down. During this time there was no assistance or intervention from staff. At 8:22 AM R28 started eating the rest of her nutritional ice cream with her fingers. At 8:25 AM V13 (Certified Nurse Aide) picked up R28's spoon and put it into R28's nutritional ice cream. R28 used the spoon to take two bites and then set the spoon down. R28 felt around her plate with her fingers, then picked up the nutritional ice cream and started eating the nutritional ice cream with her fingers. On 05/28/26 at 1:11 PM R28 picked up the fruit cup container and spilled approximately half the liquid in the fruit cup into her beef stew/soup. R28 ate a couple of pieces of fruit with her fingers and set it back down. R28 then started eating pieces of vegetable out of the soup/stew with her fingers. During this time there was no intervention or assistance from staff. At 1:22 PM V13 left the resident she was assisting at a different table and handed R28 her spoon then returned to the resident she was assisting. At 1:22 PM R28 took a couple bites of the stew/soup with the spoon and set it back down. At 1:25 PM R28 started eating pieces of vegetables and meat out of the stew/soup with her fingers and then started eating the fruit out of the fruit cup with her fingers. R28 continued eating her lunch with her fingers. At 12:32 PM surveyor stopped observing R28 and at this time there had been no further assistance/intervention by any staff. On 05/28/26 at 4:05 PM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) stated, if a resident has mobility issues, any diagnoses including dementia the tray should be set up for the resident including the silverware unwrapped. V7 stated, that would be for any resident that looks like they need assistance, including if the resident is eating with their fingers. On 05/28/26 at 4:17 PM, V1 (Administrator) stated, if a resident appears they need assistance they should be receiving it especially if their MDS indicates supervision or touching assistance including verbal cues and/or touching steadying assistance. V1 stated, residents should not be eating with their fingers unless on a finger food diet and should not be eating their hot cereal with their fingers or eating their hot cereal off of the table that has dropped onto the table. V1 stated, R28 should have received assistance with her meal and her silverware should have been unwrapped for her. 2. On 05/27/26 at 12:39 PM, V16 (Housekeeping Supervisor) stated while standing in the dining room, approximately two feet from the door of the kitchen, all that we have left is the feeders loud enough for staff and residents to hear from several feet away. On 05/27/26 at 12:40 PM trays were brought out to R9 and R31 and staff sat down and started assisting them to eat their lunch. On 05/28/26 at 1:09 PM, V17 (Maintenance Director) stated while standing in the dining room approximately three feet from the door of the kitchen, only the feeders are left loud enough for staff and residents to hear from several feet away. On 05/28/26 at 1:10 PM trays were brought out to R9 and R31 and staff sat down and started assisting them to eat their lunch. The undated facility policy titled Resident's Rights Policy documents: 1. to live a dignified existence and engage in self-determination.

Based on interview and record review the facility failed to ensure a resident's right to make treatment decisions was honored for 1 or 5 (R27) residents reviewed for residents right to make treatment decisions in a sample of 35. Findings include:R27's admission Record documents an original admission date of 10/31/25 with included diagnoses of anxiety disorder, depression, insomnia, panic disorder, and persistent mood disorder. R27's MDS (Minimum Date Set) dated 5/7/26 documents a BIMS (Brief Interview of Mental Status) of 12, indicating moderate cognitive impairment. Section I documents Active Diagnoses in the last 7 days of anxiety disorder, depression, and insomnia. R27's Order Summary Report documents Viibryd oral tablet 40 mg (milligrams), give 1 tablet by mouth in the morning related to depression with an order dated of 10/31/25 R27's Care Plan documents R27 has a diagnosis of depression (initiated 11/4/25) with included intervention of administer medications as ordered by physician (initiated 11/4/25). R27's Psychotropic Medication Consent-Antidepressant for medication: Viibryd was signed by R27 on 1/27/26. On 5/28/26 at 1:55 PM, V2 (Assistant Director of Nursing) stated the only consent for Viibryd they have is dated for 1/12/26. V2 stated she doesn't have a psychotropic medication consent for Viibryd from when she started the medication on 10/31/25. V2 stated she doesn't know why there isn't one from then because she wasn't working at this facility at that time. V2 stated there should be a consent for Viibryd prior to administering it for the first time. A facility policy titled Psychotropic Medication-Gradual Dosage Reduction dated 2/1/18 documents under Guidelines: Informed consent shall be obtained as follows: a. Psychotropic medication shall not be administered without the informed consent of the resident or the authorized resident representative.

Based on observation, interview, and record review the facility failed to develop a plan of care for indwelling urinary catheter use and for psychotropic medication use for 2 of 2 (R11, R27) residents reviewed for care plan development in a sample of 35. Findings include:1. R11's admission Record documents an admission date of 10/31/25 with included diagnoses of anterior dislocation of right hip and obstructive and reflux uropathy. R11's MDS (Minimum Data Set) dated 5/6/26 documents a BIMS of 15, indicating intact cognition. Section H documents R11 does not have an indwelling catheter and under urinary continence it documents R11 is occasionally incontinent. On 5/27/26 at 1:33 PM, V7 (MDS/Care Plan Coordinator) stated she didn't realize R11 wasn't care planned for her urinary catheter and must have forgotten to add it to the care plan. V7 stated R11 should be care planned for her urinary catheter. V7 stated R11 came back from the hospital on 5/7/26 with the indwelling urinary catheter. R11's orders document Foley catheter care every shift and as needed, follow protocol for indwelling urinary catheter maintenance/care with a start date of 5/27/26 and maintain indwelling foley catheter until seen by local urology with a start date of 5/27/26. R11's Care Plan documents a focus area of R11 has an alteration in urinary elimination as evidenced by indwelling catheter with initiation date of 5/27/26. 2. R27's admission Record documents an original admission date of 10/31/25 with included diagnoses of anxiety disorder, depression, insomnia, panic disorder, and persistent mood affective disorder. R27's MDS (Minimum Date Set) dated 5/7/26 documents a BIMS (Brief Interview of Mental Status) of 12, indicating moderate cognitive impairment. Section I documents under Active Diagnoses in the last 7 days; anxiety disorder, depression, insomnia, and pressure ulcer of unspecified part of back, unstageable. On 5/27/26 at 2:58 PM, V7 (MDS/Care Plan Coordinator) stated she doesn't know why R27 isn't care planned for persistent mood affective disorder, anxiety disorder, or panic disorder but she will get it added to the care plan. V7 stated R27 should have been care planned for persistent mood affective disorder, anxiety disorder, and panic disorder. R27's Care Plan documents focus areas of R27 has a mood problem related to persistent mood affective disorder diagnosis initiated 5/27/26, R27 has episodes of insomnia initiated 10/31/25, R27 has a diagnosis of depression initiated 11/4/25, R27 has depression initiated 10/31/25. R27 has an additional focus area of surgical wound care initiated 10/31/25. There is no focus area related to a pressure ulcer noted.On 6/1/26 at 11:20 AM, V7 (MDS/Care Plan Coordinator) stated R27's wound on her back is a pressure ulcer and she was admitted to the facility with it. V7 stated at one point the doctors were going to do a surgical procedure on the pressure ulcer to help with the healing process but they decided not to, so V7 never had surgery on her pressure ulcer on her back. V7 stated she doesn't know why R27's pressure ulcer isn't care planned, and it should be. V7 stated R27 should not be care planned for a surgical wound since she does not have one. A facility policy titled Comprehensive Care Plan dated 11/17/17 documents under Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. In the same documents it documents under Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review the facility failed to ensure that staff providing cardiopulmonary resuscitation (CPR) had an up-to-date certificate for 1 of 1 (R39) resident reviewed for CPR in a sample of 35. Findings include:R39's admission Record documents an admission date of [DATE] and a discharge date of [DATE] with included diagnoses of hypertension and atherosclerosis of native arteries of extremities. R39's Care Plan documents R39 is a full code, attempt resuscitation, CPR, including intubation and mechanical ventilation initiated [DATE]. R39's Progress Note dated [DATE] at 8:29 AM documents Resident (R39) noted to be unresponsive at approximate 7: 40am. No pulse nor respirations. CPR started. Ambulance called & arrived at approximately 8am. On [DATE] at 10:59 AM, V4 (Certified Nurse's Aide/CNA) stated V18 (CNA) and she were both working on the day R39 passed away. V4 stated they were in the dining room and V18 got her attention and said he thinks something is wrong with R39 because she was sitting in her chair in the dining room with her head laid back. V4 stated she and V18 grabbed R39 and took her to her room in her wheelchair and yelled for the nurse. The nurse told them to start CPR. V4 stated the nurse came down and assessed R39 and found no pulse or breathing so they did CPR. V4 stated she did the breathing with the bag mask and V18 did compressions. V4 stated someone took over compressions for V18 and V21 (License Practical Nurse) took over bagging from her. V4 stated they did CPR until EMS (Emergency Medical Services) arrived then they took over. On [DATE] at 11:03 AM, V18 stated he and V4 were in the dining room when he noticed something didn't look right with R39. V18 stated he and V4 yelled for the nurse and took R39 to her room. V21 told them to start CPR, and she came to the room with the crash cart. V18 stated he was doing compressions and V4 was giving breaths with the bag then V22 (Business Office Manager) took over compressions and V21 took over breaths with the bag until EMS arrived and took over. V18 stated his CPR certificate expired in [DATE]. V22's (Business Office Manager) Certificate of Completion in recognition of successful completion in CPR/AED/First Aid documents a completion date of [DATE], and documents the certificate is valid for 2 years. V18's (Certified Nurse's Aide/CNA) Nation CPR Foundation card documents date of [DATE] and documents the card is valid for 2 years. V4's (CNA) Certificate of Completion in recognition of successful completion in CPR/AED/First Aid documents a completion date of [DATE], and documents the certificate is valid for 2 years.On [DATE] at 1:43 PM, V22 stated she helped with CPR on R39 on [DATE], she did compressions. V22 stated her CPR certification expired and that it expired in Aug of 2025. On [DATE] at 2:18 PM, V1 (Administrator) stated any staff member that is going to be performing CPR should have a valid CPR certification.

Based on interview and record review the facility failed to monitor a residents vital signs for 1 of 1 (R39) resident reviewed for vital sign monitoring in a sample of 35. Findings include:R39's admission Record documents an admission date of [DATE] and a discharge date of [DATE] with included diagnoses of hypertension and atherosclerosis of native arteries of extremities. R39's Care Plan documents R39 is a full code, attempt resuscitation, CPR (cardiopulmonary resuscitation), including intubation and mechanical ventilation initiated [DATE]. R39's Medication Administration Report documents Cardizem CD (controlled delivery) oral capsule extended release 24-hour 180 mg (milligrams), give 1 capsule by mouth 1 time a day for hypertension was given on [DATE] at 7:17 AM and Metoprolol Tartrate oral tablet 50 mg, give 1 tablet by mouth 2 times a day for hypertension was given on [DATE] at 7:23 AM. R39's document titled Blood Pressure Summary documents the following blood pressures, [DATE] at 1:00 PM 132/60, [DATE] at 2:45 PM 130/64, [DATE] at 11:25 AM 149/86, [DATE] at 12:54 PM 116/81, [DATE] at 1:35 PM 129/78, [DATE] at 3:00 PM 124/80, [DATE] at 10:35 AM 126/78, [DATE] at 5:44 PM 98/64, [DATE] at 9:27 AM 118/72, [DATE] at 10:10 AM 118/68, and [DATE] at 10:48 AM 96/61. R39's document titled Pulse Summary documents the following pulse readings, [DATE] at 1:00 PM 92, [DATE] at 2:43 PM 90, [DATE] at 11:25 AM 100, [DATE] at 12:54 PM 116 warnings: high of 100.0 exceeded, [DATE] at 1:35 PM 110 warnings: high of 100.0 exceeded, [DATE] at 3:11 PM 90, [DATE] at 10:34 AM 82, [DATE] at 5:44 PM 96, [DATE] at 9:275 AM 90, [DATE] at 10:10 AM 82, [DATE] at 10:48 AM 102 warnings: high of 100.0 exceeded. R39's document titled O2 (oxygen) Sats (saturation) Summary) documents the following O2 levels, [DATE] at 2:45 PM 98%, [DATE] at 11:25 AM 94%, [DATE] at 12:54 PM 94%, [DATE] at 10:38 AM 95%, [DATE] at 9:27 AM 96%, [DATE] at 10:10 AM 97%, and [DATE] at 10:48 AM 90%. R39's Progress Note dated [DATE] at 10:57 AM documents resident sent to ER (emergency room) r/t (related to) left leg red c (with) edema, confused, left knee mottled, not eating nor drinking well, jerking movements R39's Progress Note dated [DATE] at 4:53 PM documents Placed call to (town name) Medical Center to check status. Nurse (name) states resident was admitted for Altered Mental Status and cellulitis. Nurse states Hgb (hemoglobin) slightly low, CBC (complete blood count) to be done in AM and potentially being discharged back to nursing home if labs acceptable. R39's Progress Note dated [DATE] at 2:19 PM documents Resident arrived via facility vehicle around 1300 (1:00 PM). Resident sent with paperwork from (local hospital name). New order for Cardizem CD 180 mg. A & o (alert and orientated) x 1 same as baseline. Vitals: BP (blood pressure) 127/61, P (pulse) 92, T (temperature) 97.6, RR (respiration rate) 18, O2 (oxygen) 96%. Pain 0/10 at this time. Skin clear. Lung sounds clear. Bowel sounds active in all 4 quadrants. (V15, physician) and admin (administrator) notified. R39's Progress Note dated [DATE] at 10:00 AM created by V21 (Licensed Practical Nurse/LPN) documents Vitals: T 98.2 - [DATE] 10:48 Route: Temporal Artery BP 96/61 - [DATE] 10:48 Position: Lying r (right)/arm P 102 - [DATE] 10:48 Pulse Type: Regular R 16 - [DATE] 10:48 O2 90 % - [DATE] 10:48 Method: Room Air W (weight) 94.8 lb (pounds) - [DATE] 13:33 Scale: Bath Pain: Indicators of pain: None. Neurologic: PERRLA (pupils are equal in size, round in shape, reactive to light, and able to adjust focus). Resident follows commands. Denies weakness, tremors, numbness or tingling. EENT (eyes, ears, nose and throat): Ability to hear (with hearing aid or hearing appliances if normally used): Adequate. Ability to see in adequate light (with glasses or other visual appliances if normally used): Adequate. Resident has dentures. Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. Mood and Behavior: Mood is pleasant, no unwanted behaviors witnessed. Cardiovascular: Skin warm and pink with brisk capillary refill (< 3 seconds). No edema present. Respiratory: Lungs clear throughout bilaterally. No difficulty breathing. No cough noted. Right lung clear. Left lung clear. Gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x4. Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Nutrition: Taking nutrition and hydration orally. No complaints of thirst. No signs / symptoms of a swallowing disorder. Mucous membranes moist. Genitourinary: No urinary complaints. Resident is incontinent of urine. Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. No skin issues identified. R39's Progress Note dated [DATE] at 8:29 AM documents Resident (R39) noted to be unresponsive at approximate 7:40am. No pulse nor respirations. CPR started. Ambulance called & arrived at approximately 8am. R39's Progress Note dated [DATE] at 10:40 AM documents Resident released to mottician [sic] at this time. On [DATE] at 11:39 AM, V21 (Licensed Practical Nurse/LPN) stated she took vitals on R39 on [DATE] and she didn't notify V15 (Medical Director) of the vitals because she didn't think they were out of range even though the blood pressure was a slight change from her normal and the oxygen saturation was lower than she usually runs. V21 stated she would notify the doctor if the oxygen were below 90% or if blood pressure were below 90/50. V21 stated she was on the hallway passing medication when the CNA's yelled for her. V21 stated she checked R39's code status and told them to start CPR (Cardiopulmonary Resesation). V21 stated she can't remember if it was her or the other nurse on duty that assessed R39 first. V21 stated she took over providing ventilation to R39 with the bag. V21 stated V18 (Certified Nurse's Aide/CNA) was doing compressions but someone took over for him, but she doesn't remember who took over doing compressions. V21 stated she did not take any repeat vitals or do any increased monitoring of R39 after the vitals she took on [DATE] at 10:00 AM because she felt like they were in range. V21 stated she gave R39 her medicine that morning and did not check her vitals prior to giving R39 her blood pressure medication. On [DATE] at 10:59 AM, V4 (Certified Nurse's Aide/CNA) stated V18 and her were both working on the day R39 passed away. V4 stated they were in the dining room and V18 got her attention and said he thinks something is wrong with R39 because she was sitting in her chair in the dining room with her head laid back. V4 stated she and V18 grabbed R39 and took her to her room in her wheelchair and yelled for the nurse. The nurse told them to start CPR. V4 stated the nurse came down and assessed her and found no pulse or breathing so they did CPR. V4 stated she did the breathing with the bag mask and V18 did compressions. V4 stated someone took over compressions for V18 and V21 (License Practical Nurse/LPN) took over bagging from her. V4 stated they did CPR until EMS (Emergency Medical Services) arrived then they took over. V4 stated she had just given R39 a drink at her table in the dining room about 5 minutes prior to them finding her unresponsive. On [DATE] at 11:03 AM, V18 (CNA) stated they were in the dinner room, and he thought she didn't look right so him and V4 yelled for the nurse and took R39 to her room. V21 told them to start CPR, and she came to the room with the crash cart. V18 stated he was doing compressions and V4 was giving breaths with the bag then V22 (Business Office Manager) took over compressions and V21 took over breaths with the bag until EMS arrived and took over. V18 stated his CPR certificate expired in [DATE].On [DATE] at 11:08 AM, V23 (LPN) stated some residents get their vitals checked every shift and some get them checked monthly. V23 stated that anyone with COPD or respiratory issues gets their oxygen and respirations checked every shift. V23 stated they are supposed to check residents blood pressure prior to giving blood pressure medications and it is the nurses responsibility to get vital signs. On [DATE] at 12:55 PM, V15 (Medical Director) stated he expects to be notified of any blood pressure that is above 180 systolic and any oxygen below 90%. V15 stated the low blood pressure could be different for each resident but considering R39 didn't usually have a blood pressure like what it was on [DATE] and her oxygen was at 90%, which was lower than normal for R39, V15 stated he would expect a follow up recheck of the vitals and some kind of monitoring after that reading. V15 stated the nurse should have rechecked the vitals prior to giving Metoprolol and Cardizem on the morning of [DATE] but he doesn't think even if they did recheck them and could have done an intervention it would have changed the outcome of death. On [DATE] at 1:35 PM, V20 (Regional Director of Clinical Reimbursement) stated blood pressure should be taken prior to administrating a blood pressure medication. V20 stated a nurse should not use the blood pressure reading from the day prior for the current days medication. A facility policy titled Vital Sign Monitoring with revision date of [DATE] documents under Guideline: The following are guidelines for normal parameters. Physician should be notified of abnormal results based on baseline results, clinical judgement and condition of the resident. If resident receives anti-hypertensive medications, blood pressure may be obtained weekly, daily, or with each medication administration according to physician orders.

Based on interview, observation, and record review, the facility failed to implement pressure reducing devices for 1 of 3 residents (R3) reviewed for pressure ulcers in the sample of 35. Findings include:R3's admission record documents an original admission date of 11/27/24. Diagnoses listed on this document include type II diabetes, vascular dementia, muscle wasting/atrophy and peripheral vascular disease.R3's physician order sheet documents orders for R3 to float right heel while in bed with a start date of 4/20/26 and to have a heel protector on right heel with a start date of 4/20/26.R3's current care plan documents R3 is care planned for current pressure ulcers with a start date of 5/7/26. Interventions for this focus area include providing wound care as ordered dated 5/7/26.R3's minimum data set (MDS) dated [DATE] documents R3 is dependent for repositioning in bed. R3's MDS documents R3 is at risk for pressure ulcers, and he has unhealed pressure ulcers.On 5/26/26 at 11:50 AM, R3 was in bed did not have a heel protector on his remaining right foot (left leg had been amputated above the knee). R3 did not have a pillow under the left leg to help keep pressure off the right heel. There was an intact dressing noted to the bony prominence of the outer aspect of R3's right ankle. This surveyor was unable to visualize the right heel at the time. On 5/27/26 at 10:45 AM, R3 was in bed and did not have a heel protector on the right foot but did have a pillow near the bottom of the bed to prop his leg up with. Given the position of R3's leg and the fact the pillow was flat R3's leg may not have been receiving relief of pressure. R3 had his right leg externally rotated away from center line causing pressure to the outer aspect of the right ankle. R3 did have a dressing on the bony prominence of his right ankle on the outer aspect. This surveyor was unable to visualize the right heel at this time. R3 stated sometimes the staff elevate his right foot off the bed, but he was not sure if they do it all the time. R3 stated he was not sure if he was supposed to be wearing a pressure-reducing device on his right foot to reduce pressure to the heel and ankle.On 5/27/26 at 2:03 PM, a dressing change and treatment to the outer aspect of the right ankle for R3 was performed by V9 (Licensed Practical Nurse/LPN) who was assisted by V2, (Assistant Director of Nurses/ADON/LPN). Enhanced Barrier Precautions were followed and both staff wore disposable gowns and proper personal protective equipment. V9 removed the old dressing to the outer aspect of the right ankle. The right ankle wound had a wound bed with a white center and the very edge of the peri wound was bright red. The wound bed was the approximate size of a pencil eraser and depth was approximately 1-2 millimeters. There were no foul drainage or signs and symptoms of infection. V9 performed glove changes and hand hygiene between dirty and clean aspects of the dressing change and treatment of wound. The wound was cleaned with wound cleanser. Sureprep (a skin protecting medicated liquid) was applied to the peri wound area. At this time R3 had no heel protector on the right foot. R3 did have a pillow under his right lower leg, but it was so flat it did not prevent his right ankle/heel from touching the bed. V2 stated she didn't believe R3 had an order for a heel protector to be applied to the right foot. On 5/27/26 at 3:37 PM, V2 stated she was not sure if R3 had an order for a heel protector to be applied to his right foot. When this surveyor showed V2 the current order on R3's physician's order sheet she agreed R3 should have been wearing one. V2 stated if a pressure reducing device such as heel protector is ordered it should be implemented. V2 stated if an ordered pressure reducing device was not implemented timely it could cause further skin breakdown and further risk of infection.Facility's pressure ulcer policy dated revised 1/15/28 documents to use pillows and pads to protect bony prominences.

Based on interview, observation, and record review the facility failed to implement fall interventions to assist in preventing falls for 3 (R7, R28, and R32) of 4 residents reviewed for falls in a sample of 35. Findings include:1.R7's admission Record documents an admission date of 06/09/21 with diagnoses including: palobular emphysema, heart failure, chronic kidney disease, gastro-esophageal reflux disease, major depressive disorder, bipolar disorder, dementia, generalized anxiety, muscle wasting and atrophy, lack of coordination, type 2 diabetes mellitus, and nondisplaced type II dens fracture.R7's minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 07 indicating R7 is cognitively severely impaired. R7's functional abilities documents R7's ability to transfer from chair to bed or bed to chair and sit to stand as: substantial/maximal assistance indicating helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort.R7's care plan documents a focus area of risk for falls dated 08/19/25 with interventions listed of: call don't fall sign placed for resident reminder to ask for staff assistance prior to getting up. Resident educated on need to wait for assistance dated 12/22/25 and assist resident with ambulation and transfers, utilizing therapy recommendations dated 08/19/25. R7's care plan documents a focus area of R7 is at risk for falls dated 02/15/26 with interventions listed of: assist resident with ambulation and transfers, utilizing therapy recommendations dated 02/15/26 and chair pad alarm dated 05/21/26.R7's care plan documents a focus area of R7 has had an actual fall dated 07/19/24 with a revision date of 05/20/26 with interventions including: 05/17/26 new intervention: initiate purposeful rounding to ensure anticipated needs remain met and provide frequent verbal reminders to request assistance prior to transfers dated 05/20/26 and 09/20/24 new intervention: for prevention of this type includes a fall mat beside the bed when in bed dated 05/20/26.On 05/27/26 at 11:17 AM, R7 was lying in her bed, there was no fall mat next to her bed, the mat was folded up and leaning perpendicular on the other side of the room. There was no pressure pad in the bed, and there was not any call don't fall signs in R7's room.On 05/27/26 at 2:37 PM, R7 was lying in her bed, there was no fall mat next to her bed, the mat was folded up and leaning perpendicular on the other side of the room. There was no pressure pad in the bed, and there was not any call don't fall signs in R7's room.On 05/28/26 at 1:10 PM, V5 (Certified Nurse Aide/CNA) stated, she is not sure what purposeful rounding would be or how it would be different than regular rounding.On 05/28/26 at 1:11 PM, V13 (CNA) stated, she does not know how purposeful rounding is different than regular rounding.On 05/18/26 at 4:05 PM, V7 (Minimum data Set Coordinator/Care Plan Coordinator) stated a resident with a BIMS of 7 would not be able to re-educate but you could remind them frequently. V7 stated, the fall mat should be in place when R7 is in bed. V7 stated, they should only use each intervention once. V7 stated, the bed pad would not have been in the bed this week because they gave R7 a scoop mattress and you cannot have a bed pad alarm with a scoop mattress. R7's care plan documents a focus area of R7 requires the use of a scoop mattress that does not prevent free movement to assist with positioning, fall reduction and postural support dated 05/26/26 with an intervention of anticipate resident's needs and respond promptly with a date initiated of 05/26/26.On 06/01/26 at 1:20 PM, V1 (Administrator) stated they do not have a policy with not having a pressure alarm with a scoop mattress to her knowledge.2.R32's admission record documents an admission date of 09/26/25 with diagnoses including: hypothyroidism, arthritis, gastritis, obstructive and reflux uropathy, displaced fracture of proximal phalanx of right lesser toe, displaced fracture of distal phalanx of right lesser toe, and persistent mood disorder. R32's MDS dated [DATE] documents a BIMS score of 13 indicating R32 is cognitively intact. R32's sit to stand ability, chair/bed to chair transfer ability, and toilet transfer is documented as dependent indicating helper does all the effort, helper does none of the effort to complete the activity or the assistance of two or more helpers are required for the resident to complete the activity.R32's care plan documents a focus area of risk for falls dated 12/05/25 with interventions including: alleged fall, unattended 12/18/25 new intervention: call don't fall sign initiated to remind resident to use call light and wait for staff assistance prior to getting up and education provided to resident dated 12/18/25. fall mat in place while resident is in bed dated 03/31/26, staff to re-enforce education that resident utilize call light for assistance getting out of bed. R32's care plan documents a focus area of R32 is at risk for fall from weakness and tiredness dated 11/11/2025 with interventions including: staff to perform purposeful rounding, ensure toileting needs are met upon rounds, ensure R32 is positioned in center of bed upon rounds dated 05/12/26.On 05/26/26 at 3:20 PM there was no call don't fall sign in R32's room.On 05/28/26 at 7:20 AM, R32 was still in bed, there was no fall mat next to her bed and there was no call, don't fall sign visible in her room.On 05/28/26 at 1:10 PM, V5 (CNA) stated she is not sure what purposeful rounding would be or how it would be different than regular rounding.On 05/28/26 at 1:11 PM, V13 (CNA) stated she does not know how purposeful rounding is different than regular rounding. On 05/28/26 at 4:05 PM, V7 (Minimum data Set Coordinator/Care Plan Coordinator) stated R32 should have a fall mat in place while in bed and R32 should have a call don't fall sign visible in her room.3.R28's admission record documents an admission date of 11/06/24 with diagnoses including: chronic obstructive pulmonary disease, acute candidiasis of vulva and vagina, depression, anxiety disorders, dementia, low back pain, lack of coordination muscle wasting and atrophy, and repeated falls. R28's Minimum Data Set, dated [DATE] documents should a brief interview of mental status be conducted with no (resident is rarely/never understood) indicated. Section GG documents R28's ability to sit to stand, lying to sitting, and chair/bed to chair transfer is substantial to maximal assistance.R28's care plan documents R28 does not understand mobility limits due to cognitive limitations and is at risk for falls and risks for injury from falls dated 11/14/24 with an intervention of tab alarm dated 07/11/25.On 5/28/26 at 11:23 AM, R28 was lying in bed with her pull tab alarm going on. During constant observation at 11:26 AM the alarm sound started becoming lower while making a different sound, then the alarm sound stopped. There were no staff members observed on the hall from 11:23 AM until 11:29 AM. This surveyor stopped V11 (CNA) and notified her that R28's pull tab alarm had gone off and then stopped and was still unhooked, but no one was in the area. V11 then reattached the pull alarm and it was blinking red and made a screeching sound when reattached.On 05/28/26 at 11:30 AM, V11 stated it sounded different than it usually does so maybe the battery is going dead.On 05/28/26 at 11:32 AM, V11 stated she would notify V17 (Maintenance Director) to check on R28's alarm. V11 stated she thinks V17 oversees checking batteries on the alarms.On 05/28/26 at 11:36 AM, V17 stated he does not check the alarm batteries, he just changes them when he is told about them.On 05/28/26 at 11:42 AM, V6 (Licensed Practical Nurse) stated she does not know who checks the batteries for the alarms or when they are checked.On 05/28/26 at 4:05 PM, V7 (Minimum data Set Coordinator/Care Plan Coordinator) stated the batteries for the alarms should be checked on the night shift.

Based on interview and record review the facility failed to provide urinary catheter care for 1 of 1 (R11) resident reviewed for urinary catheter care in a sample of 35. Findings include:R11's admission Record documents an admission date of 10/31/25 with included diagnosis of obstructive and reflux uropathy. R11's MDS (Minimum Data Set) dated 5/6/26 documents a BIMS of 15, indicating intact cognition. Section H documents R11 does not have an indwelling catheter and under urinary continence it documents R11 is occasionally incontinent. R11's Progress Note dated 5/7/26 at 11:07 AM documents Received report that res (R11) will be coming back to facility today. Res was admitted for UTI (urinary tract infection). Res (resident) will be on atb (antibiotics) when she arrives back. Res Gabapentin has been increased. Hospital has D/C'd (discontinued) tramadol and initiated Norco. Res has a Foley catheter for urinary obstruction. R11's Progress Note dated 5/7/26 at 11:34 AM documents Resident receiving Norco at (local hospital). D/c allergy to Norco per (V15/Medical Director) orders. Keeping Foley catheter in for 7 days per (V15's) orders for urinary obstruction. ADON (V2/Assistant Director of Nursing) notified. R11's Progress Note dated 5/14/26 at 2:46 PM documents urinary catheter out at this time. R11's Progress Note dated 5/14/26 at 8:31 PM documents Order from (V15) to monitor urinary out put for (R11) after Cath (catheter) D/C. If she does not urinate by 2 am or experiences bladder discomfort and retention to recath (R11) with a 16f (French) cath. R11's Progress Note dated 5/19/26 at 12:15 PM documents Remove Foley catheter 7 days from 5/14/26 per (V15's) orders. Catheter to be removed 5/21/26. R11's Progress Note dated 5/27/26 at 9:21 PM documents Confirmed order per (V15) to maintain indwelling catheter until seen by (Local medical group) Urology. MD (V15) states referral has been sent. Staff to follow up with (local medical group) referral line to schedule appointment.R11's Progress Note dated 5/28/26 at 9:33 AM documents Called referral department at (local medical group) in (local town), was told there was no appointment set at this time, still working on it. Did call and LVM (left voicemail) with urology in (local town). On 5/26/2026 at 12:18 PM, R11 stated she has a urinary catheter, and the staff have never provided catheter care for her. R11 stated no one has ever asked her to do catheter care or asked her if she cleans it herself. R11 stated she sprays a tissue with perineal cleanser and wipes her vagina area, but she doesn't think she gets it very good because she can't always reach it very good. R11 stated she cleans her vagina with the perineal cleanser about every other day. R11 stated her catheter is an infection risk and she feels like someone needs to provide catheter care for her. R11 stated she feels like she might have a urinary infection right now. R11 stated she was supposed to be referred to urology because she was retaining urine when they removed the catheter, but she hadn't heard anything else about an appointment. On 5/27/26 at 9:35 AM, V4 (Certified Nursing Aide/CNA) stated she has never done urinary catheter care on R11. V4 stated she worked yesterday, and she didn't do catheter care on R11 because she was too busy because they were working short staffed. On 5/27/26 at 9:39 AM, V5 (CNA) stated she has never done urinary catheter care on R11 because R11 is pretty independent, and she thinks R11 likes to do it herself. On 5/27/26 at 1:33 PM, V7 (MDS/Care Plan Coordinator) stated she didn't realize R11 wasn't care planned for her urinary catheter or that it wasn't in her MDS. V7 stated she must have forgotten to add it to the care plan and MDS. V7 stated V7 should be care planned for her urinary catheter and it should be in her MDS. V7 stated she will get it added now. V7 stated she doesn't know why R11 still has a urinary catheter since there was an order to removed it on 5/21/26. V7 stated she would look into it. On 5/27/26 at 11:32 AM, V6 (Licensed Practical Nurse/LPN) stated R11's urinary catheter has been removed once and she did not urinate, so the doc gave an order to reinsert. It was supposed to be removed again on 5/21/26 and she doesn't know why it wasn't removed. On 5/27/26 at 11:35 AM, V14 (Social Services Director) stated she didn't know V14 had a urinary catheter, and she didn't know she needed a referral to urology. V14 stated she is in charge of making referral appointments. On 5/27/26 at 11:52 AM, V15 (Medical Director) stated he put a referral into the electronic charting system that the hospital uses for R11 to see urology and told a nurse, but he doesn't remember who he told. V15 stated he thinks he put it in over this past weekend but thinks he told a nurse prior to that. V15 stated the way the referral works is he puts it into the electronic system, and the staff call about an appointment. On 5/28/26 at 11:00 AM, V7 stated she found a discontinued order that states R11's urinary catheter was put back in on 5/15/26 at 2:39 AM and there is an order administration note that goes along with that order that documents a new urinary catheter was placed but there is no progress note that documents why the urinary catheter was put back in. V7 stated she was first aware of R11 having a urinary catheter on 5/21/26. V7 stated there is a discontinued order in R11's electronic medical chart that states to leave the urinary catheter in until urology consultation and that order was put in the system by V2 (Assistant Director of Nursing). V7 stated she called V15 on 5/27/26 to confirm that R11's urinary catheter is to stay in until urology consult. V7 stated she was informed at that time that he sent in a referral for R11 to see urology already and that staff are to follow up with the local hospital referral line to schedule the appointment. On 5/28/26 at 1:55 PM, V2 stated she doesn't know anything about R11's urinary catheter or V15 giving an order to send R11 to urology or to keep her urinary catheter in. This surveyor showed V2 a discontinued order that was discontinued by V2 on 5/21/26 to remove the urinary catheter and it documents V2 discontinued that order with a reason documented as to stay until urology consultation. V2 stated she does not remember anything about that order or ever documenting that. V2 stated she doesn't remember talking with V15 regarding R11's urinary catheter. R11's Care Plan documents a focus area of R11 has an alteration in urinary elimination as evidenced by indwelling catheter with initiation date of 5/27/26. R11's orders document Foley catheter care every shift and as needed, follow protocol for indwelling urinary catheter maintenance/care with a start date of 5/27/26 and maintain indwelling foley catheter until seen by local urology with a start date of 5/27/26. A facility policy titled Urinary Catheter Care dated 2/14/19 documents under Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Under Guidelines: 17. The date of the catheter insertion shall be documented in the nurses notes and treatment record.

Based on observation, interview, and record review the facility failed to provide preferred food preferences for 1 of 1 (R12) resident reviewed for food preferences in a sample of 35. Findings include:R12's admission Record documents an admission date of 8/1/23 with included diagnoses of type 2 diabetes, vitamin D deficiency, hypomagnesemia, hypokalemia, and dementia. R12's MDS (Minimum Date Set) dated 3/13/26 documents a BIMS (Brief Interview of Mental Status) of 08, indicating moderate cognitive impairment. R12's Care Plan documents R12 has nutritional problem or potential nutritional problem, Regular Diet related to Diet restrictions with diabetes. Regular diet with mechanical meat and thin liquids Date Initiated: 12/07/2024 Revision on: 03/03/2026 with included interventions of Mighty Shake with meals sugar free/diabetic mighty shake (Initiated 3/3/26). R12's Physician Orders documents mighty shake with meals, sugar free, diabetic mighty shake (start date 1/29/26). On 5/26/26 at 12:28 PM, R12 was served mech soft ground meat with gravy on the meat, mashed potatoes with gravy, peas and carrots, and an orange mighty shake. R12's meal ticket documented that she does not like gravy and does not like orange mighty shakes. R12 stated she doesn't really like gravy on her food, and she does not like the orange supplement at all. R12 stated she would like a new plate of food if it were possible that doesn't have gravy on it and she would like a different flavor of supplement. This surveyor let V10 (Dietary Manager) know that R12 was requesting a different supplement and food without gravy. V10 asked R12 if she would like food without gravy and R12 replied she didn't really like gravy, but she could eat it but R13 stated she can't drink the orange mighty shake because she doesn't like it at all. V10 asked R12 if she liked chocolate and she said oh yes! I really do like the chocolate one. V10 went and told the cook in the kitchen that R12 needed a chocolate shake. Then V10 went back to passing trays to other residents. After constant observation R12 still had not received her chocolate mighty shake and R12 did not touch the orange supplement. R12 rolled away from the table and went back to her room at 12:54 PM. At that time food trays were already finished being passed and no kitchen staff was in the kitchen. On 5/27/26 at 2:00PM, V10 (Dietary manager) stated on 5/26/26 when she told the cook in the kitchen that R12 needed a chocolate mighty shake she told him to take it out to her. R10 stated she didn't go into the kitchen and get it herself because there was a cook and a dietary aide in there that could take it to her. V10 stated R12 is to get the mighty shake with her meal, and it should be a flavor R12 likes and will drink. V10 stated she should have gotten the chocolate supplement for R12. On 5/29/26 at 2:18 PM, V1 (Administrator) stated if a resident has preferences and dislikes on their meal ticket then it should be followed by the kitchen staff. V1 stated if they have a dislike then it should not be sent out from the kitchen to the resident. A facility policy titled On Tray Dietary Policies and Procedures Manual dated 2026 documents under Procedure: 6. Food and beverage preferences and meal add-ons should be noted on the tray ticket and honored at all meal services, as required by CMS guidelines.

Based on observation, interview and record review the facility failed to provide double protein as ordered for 2 of 2 residents (R21, R32) reviewed for diets in the sample of 35. Findings include:1.R21's admission record documents an admission date of 04/24/25 with diagnoses including: cardiomegaly, vertigo of central origin, rhabdomyolysis, peripheral vascular disease, and dislocation of right acromioclavicular joint. R21's order summary report documents a dietary order dated 04/29/25 of: regular diet, regular texture, 2 times protein at breakfast, fortified pudding at lunch/supper and may substitute nutritional ice cream for fortified pudding as needed with an end date listed as indefinite. The Facility's diet spreadsheet dated week 1 day 5 documents regular diet breakfast: assorted juice 6 ounces, choice of cereal 6 ounces, bacon 2 strips, French toast 2 slices, syrup 1 each, milk 8 ounces, and hot beverage 8 ounces. On 05/28/26 at 7:39 AM, R21 did not receive double protein with his breakfast. R21 received two pieces of bacon, cold cereal, and French toast casserole. 2. R32's admission record documents an admission date of 09/26/25 with diagnoses including: hypothyroidism, arthritis, gastritis, obstructive and reflux uropathy, displaced fracture of proximal phalanx of right lesser toe, displaced fracture of distal phalanx of right lesser toe, and persistent mood disorder. R32's order summary report documents a dietary order dated 12/15/25 of: controlled carbohydrate diet with regular texture, with 2 times protein at breakfast with an order status of active. The diet spreadsheet dated week 1 day 5 documents CCHO (LCS) (consistent carbohydrate) (low concentrated sweets) diet breakfast: assorted juice 6 ounces, choice of cereal 6 ounces, bacon 2 strips, French toast 1 slice, diet syrup 1 each, milk 8 ounces, and hot beverage 8 ounces. On 05/28/26 at 7:40 AM, R32 did not receive double protein with his breakfast. R32 received two pieces of bacon, cold cereal, and French toast casserole. On 05/28/26 at 2:05 PM, V10 (Dietary Manager) stated, she is trying to train new people in the kitchen but the residents should receive the extra protein and supplements they are directed to have. V10 stated, those items are listed on the meal tickets, they just need to read and pay attention to the tickets. The facility policy dated 2020 titled, Fortified Foods, Supplements, and Snacks documents: Residents classified as Persons at Risk (PAR) and/or with poor nutritional intake, declining intake, weight loss, and/or pressure ulcers will be referred to the Registered Dietitian. The recommended protocol for residents requiring additional protein and/or calories is high calorie foods offered and/or Fortified Foods if the resident can consume 50% or greater of most meals.

Based on interview, observation and record review, the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R8, R23, R24, and R28) reviewed for room size in a sample of 35.Findings include:On 5/28/26 at 8:20 AM, V1 (Administrator) measured R28, R24, R23, and R8's room that is dually certified (Medicare and Medicaid) for 4 beds per room, R28, R24, R23, and R8's room measured 302.8 sq. ft. (75.7 sq. ft. per bed). R28, R24, R23, and R8 were in their room. There were four beds, four nightstands, and two dressers and four wheelchairs in the room. On 05/28/26 at 2:47 PM, R24 who was alert and oriented, stated she does not have a problem with the room size. On 05/28/26 at 2:48 PM R23 who was alert and oriented, stated she does not have a problem with the room size. On 05/28/26 at 2:49 PM R8 who was alert and oriented, stated she does not have a problem with the room size. On 05/28/26 at 8:23 AM, V1 stated there are 10 rooms that measure less than 80 square (sq.) feet (ft.) of living space per bed these rooms include: 103, 104, 105, 106, 107, 108, 109, 110, 211, and 212. The facility room roster dated 05/26/26 documents R28, R24, R23, and R8 reside in one of the waivered rooms. Resident Council Minutes were reviewed for the past year and did not contain any concerns related to room size.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 4 (R1, R2, R3, and R4) of 7 residents reviewed for abuse out of a sample of 7. This failure would result in a reasonable person such as R3 and R4 feeling vulnerable, threatened, fearful or distressed due to R2's presence in the facility and not receiving adequate protection from aggressive behaviors.Findings include:R2's admission Record documented an admission date of 11/10/25 and included diagnoses of anxiety disorder, depression, and dementia. R2's MDS dated [DATE] documented a BIMS score of 6, indicating R2 was severely cognitively impaired.R2's Care Plan included a Focus Area of Potential for aggressive behavior r/t (related to) dementia initiated on 11/17/25, with corresponding interventions that included to encourage participation in activities, monitor labs as ordered, observe residents location and change in aggression level, remove from area when resident shows increased aggression, and resident moved to different room on 11/17/25. All interventions have a date initiated of 11/17/25 with no further additions noted after that date.1. A Report to IDPH (Illinois Department of Public Health( Regional Office marked as Final documents a Date of Incident/Accident as 11/17/2025 with at time of 1:00 AM and names R3 and R2 as the residents involved. Under Description of Occurrence is documented Alleged Resident to Resident Physical Altercation. No injuries were noted, and the report indicates Residents Immediately Separated and an investigation was initiated. Under Follow Up/Final Report Summary, the report documented Allegation of resident to resident altercation was substantiated. (R2) woke up confused, he walked across the room and grabbed roommates (R3's) legs and was accusing (R3) of sleeping with (R2's) sister. (R3) awoke to his legs being grabbed (R2) (sic). (R2) then slipped landing on (R2's) knees while he still had a hold on (R3's) legs. (R3) yelled for help staff arrived as (R3) struck (R2) in the back of head to get (R2) to release (R3's) legs. Staff immediately separated residents and completed full body assessments on both residents. No injuries noted on either resident. Staff initiated an intervention of moving residents to separated rooms away from each other. The report documents it was completed by V1 (Administrator) on 11/21/25.R3's admission Record documented an admission date of 11/27/24 and included diagnoses of vascular dementia, bipolar disorder, depressive disorder, and anxiety disorder. R3's MDS dated [DATE] documented a BIMS score of 11, indicating R3 was moderately cognitively impaired.Additional facility investigation documentation labeled #128 Res/Res Altercation dated 11/17/25 at 1:00 AM documents the incident location as Resident's Room and V14 (Licensed Practical Nurse/LPN) prepared the report. V14's statement documents Staff heard yelling from residents room. Upon entering room, observed resident (R2) on the floor holding onto foot of roommate (R3) and (R3) hitting (R2) in the head. R3's statement documents Resident stated upon entering the room that 'He (referring to R2) came over here and started attacking me.' This nurse asked him (R3) to clarify what he meant by 'attack' to which the resident (R3) stated 'He grabbed by foot and wouldn't let go.' (R3) also stated that he no longer wanted to be roomed with the resident (R2) anymore. This report documented no injures observed post incident.2. A Report to IDPH Regional Office marked as Final documents a Date of Incident/Accident as 12/15/2025 with at time of 3:25 AM and names R4 and R2 as the residents involved. Under Description of Occurrence is documented Alleged Resident to Resident Physical Altercation. No injuries were noted, and the report indicates Residents Separated, Police called and an investigation was initiated. Under Follow Up/Final Report Summary, the report documented: (R2) was found to have hit (R4) in back of her head, resident confused at time not understanding what he (R2) had done. (R4) was not injured and stated it did not hurt her just stunned her and she (R4) is not afraid. (R2) has followed up with psychiatrist and has had a medication change. The report documents it was completed by V1 (Administrator) on 12/17/25.R4's admission Record documented an admission date of 11/5/24 and included diagnoses of schizoaffective disorder, anxiety disorder, dementia, and depressive disorder. R4's MDS dated [DATE] documented a BIMS score of 12, indicating R4 was moderately cognitively impaired.Additional facility investigation documentation labeled #152 Res/Res Altercation dated 12/15/2025 at 3:30 AM documents the incident location was the dining room and V14 (LPN) prepared the report. The incident description documents CNA (Certified Nursing Assistant) staff stated that agitated resident hit this resident on the top of the head with facility signage that was removed from the wall. Resident description documents Resident (R4) didn't state much about the incident but said 'it was a shock more than anything, he does crazy things.' This nurse asked resident if she was in any pain to which she stated no. Under Injuries observed at time of incident documents injury location as top of scalp. Mental status is documented as alert and oriented to person, situation, place and time. The injuries report post incident documents No Injuries Observed Post Incident. Under Statements, V14 (LPN) documented I did not personally see this incident occur but after talking with this resident (R4), she seemed more shaken up than anything. Residents vitals and neuro assessments were all within normal limits. No visible injuries were noted to residents face or scalp. V15's (CNA) statement documents (V16/CNA) got me from (room number) to come to dining room to help with an agitated resident that was combative. Resident was sitting on piano bench and began hitting me, swinging with fists and a board off the wall. He hit me in right ribs and breast. He grabbed a heavy Christmas decoration and threw it at me. He got up chasing mr on foot at me, I got the w/c (wheelchair) and got him to sit. V16's (CNA) statement documents Client in dining room, became combative with staff by standing up and swinging upper body and arms with closed hands resulting between contact between staff and patient. 1:1 given client redirected, no injuries noted. On the way back from nurses desk another client approached the same area resulting in an altercation between said aggressive patient and other client. Top of patient's head smacked at contact made 1:1 give, nurse notified. No injuries noted.3. A Report to IDPH (Illinois Department of Public Health) Regional Office marked as Initial & Final documents a Date of Incident/Accident as 02/03/2026 with no time documented and names R1 and R2 as the residents involved. Under Description of Occurrence is documented Alleged resident to resident altercation. No injuries were noted and the report indicates an investigation was initiated. Under Follow Up/Final Report Summary, the report documented: (Name of R1's) daughter reported to the Administrator that on December 16, 2025 that resident (name of R2) grabbed her father's blanket and hit his back. The daughter reported this to Admin weeks after the incident occurred. The daughter spoke to the nurse on duty at the time of the incident and stated that (name of R2) was bothering her and her father (R1) and asked if he (R2) could be moved. At the time of the incident resident's daughter did not mention any hitting. By the time the incident was reported (name of R2) had been sent to inpatient psychiatric care. (Name of R2) has since returned to the facility with no further incidents. Residents and staff interviewed with no concerns identified. The report documents it was completed by V1 (Administrator) on 02/03/2026.R1's admission Record documented an admission date of 3/25/25 and included diagnoses of chronic obstructive pulmonary disease, panlobular emphysema, and dysphasia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. On 2/4/26 at 10:29 AM, V3 (Licensed Practical Nurse/LPN) said she was working on 12/16/25. V3 said she was down the hall with the medication cart administering medications to other residents when V9 approached her and told her R2 was yelling at V9 (Family Member). V3 said she told V9 she would take care of it and went to the dining room. V3 said when she got to the dining room R2 was sitting in his wheelchair about 3 tables away from R1 and was yelling at V9. V3 said she assisted R2 to the other side of the dining room away from R1. V3 said V9 did not report any physical incident to her at the time. V3 said V9 had only told V3 that R2 was being verbally abusive to V9. V3 said about a month after this incident, V1 came to V3 asking when V9 had reported to V3 on the date of this incident. V3 said she did not tell V9 to report what had happened on 12/16/25 to V1.On 2/4/26 at 3:20 PM, R1 was alert and oriented to self, time, and place. R1 said he was not sure of the exact date of the incident with R2. R1 said he was sitting in the dining room after the evening meal talking to V9 (Family Member) when R2 came up behind R1 and rammed R2's wheelchair into R1's wheelchair and R2 started punching R1 in the back. R1 said he told R2 to stop and get away from R1. R1 said another male resident sitting in the dining room yelled at R2 to stop. R1 said he thought the other resident yelling scared R2 and caused R2 to stop and roll away from R1. R1 said he was not sure of the other male resident's name. R1 said V9 immediately went to get a nurse, so R1 assumed the facility was aware of the incident. R1 said a nurse came to the dining room and assisted R2 back to R2's room.On 2/4/26 at 3:39 PM, V9 said she had been told by various staff R2 could become physically aggressive. V9 said on 12/16/25, V9 and R1 were sitting in the dining room when R2 came up behind R1 and hit R1's wheelchair with R2's wheelchair. V9 said R1 told R2 to stop when R2 started punching R1 in the back and started pulling on R1's blanket. V9 said R7 was sitting at a table on the far side of the dining room and used a stern voice to tell R2 to stop. V9 said R2 stopped punching R1 and R2 rolled his wheelchair back away from R1. V9 said after the incident, V9 went to get V3 (LPN) and informed V3 of what had happened. V9 said V3 came to the dining room and R2 was still close to R1 sitting in his wheelchair. V9 said V3 assisted R2 back to R2's room. V9 said V3 told V9 to report what happened to V1 (Administrator) and V9 sent V1 an email describing the events. V9 said after she sent V1 the email on 12/16/25, V9 returned to the facility the next day and did not see R2. V9 said she thought R2 was no longer in the building due to the email V9 had sent to V1 and thought it was taken care of. V9 then said on 1/6/26, she visited the facility and saw R2 had returned to the facility. V9 said she spoke with V2 (Director of Nursing/DON) on 1/6/26 regarding her concerns with R2 being back in the facility after R1 and R2's physical altercation and the need for R1 and R2 to be kept apart. V9 said later that day on 1/6/26, V1 (Administrator) called V9 and yelled at V9 for about 20 minutes saying V1 only had 24 hours to report the incident and asking why V9 didn't report this to V1. V9 said she told V1 she had sent V1 an email on the day the incident had happened. V9 said V1 said she had not received any email from V9 about this incident so V9 told V1 she would forward the previously sent email.On 2/5/26 at 10:12 AM, V7 (Certified Nursing Assistant/CNA) said he could not recall a specific date with any incident between R1 and R2. V7 said he did recall an incident when R2 grabbed R1's wheelchair and R2 had to be redirected away from R1. V7 said R2 had a lot of conflict with a lot of residents. V7 said he had seen R2 raise his fist like he was going to hit another resident, but staff had intervened prior to R2 making contact. V7 said he had not witnessed the event between R1 and R2 on 12/16/25 but had come to the dining room after V9 spoke with V3. V7 said he did not recall what V9 said at that time. V7 said later on V9 had asked staff to keep R2 away from R1 because R2 had hit R1 in the past.On 2/5/26 at 10:23 AM, V8 (CNA) said she did not witness the incident between R1 and R2. V8 said in the past she had seen R2 get physically aggressive with other residents and it was common for (R2) to get aggressive.On 2/5/26 at 1:42 PM, V1 (Administrator) said she was not aware of the incident occurring on 12/16/25 between R1 and R2 until 1/6/26 when V9 came to speak with V1. V1 said she did not report the incident at that time because V1 thought it was unfounded. V1 said she reported the 12/16/25 incident on 2/3/26 after V9 sent a letter to corporate.R7, who was determined to be present in the dining room at the time of the 12/16/26 incident between R1 and R2, was unable to be interviewed due to being discharged prior to this investigation and did not answer the phone or return a phone call.An email communication dated 1/6/26 at 3:53 PM from V9 to V1 documented in part .Here's my original email. (CC'ing (V2/DON) since I talked to her about it today.) It never registered that you didn't receive my email since everything in this email was resolved the next day and hasn't been an issue since. I just assumed you took care of it! . This email chain also contained the original email from V9 to V1 dated 12/16/25 at 9:55 PM documenting in part . you probably will get a report on this in the morning from the nursing staff but the nurse tonight (V3's name) asked me to report directly to you. The first two incidents are related: (R1) was attacked or harassed by (name of R2) twice today. The first instance happened earlier in the day when I wasn't there. (R1) said that (name of V7) intervened. The second happened at dinnertime, when I was there. First, (name of R2) rolled up to the table, invading his (R1's) personal space. When (R1) didn't move (he was actively eating his dinner) (name of R2) started pushing his chair and I asked (name of R2) to move away from (R1). (Name of R2) them (sic) hit him (R1) in the back and started yelling at him. (Name of R2) pushed him (R1), slapped/hit him, yelled at him, and yanked his blanket. (Name of R7) yelled at (Name of R2) very loudly and I went to get a nurse or a CNA to help. (Name of V3) responded. For the last month or so, I have been actively trying to keep (R1) as far away from (Name of R2) as possible: ensuring CNAs do not put them at the same table and making sure they are as far away from each other in the dining room as possible, as I have been told by multiple nurses and CNAs that (name of R2) is combative, aggressive, and dangerous. One told me one day that it was inevitable that someone was going to get hurt with (name of R2) in the building. I want to make sure that (name of R2) never touches (R1) ever again. If he (R2) threatens or touches (R1) in an aggressive way ever again, I will file a report against him (R2).The facility presented a letter dated 1/31/26 from V9 documenting in part . I am writing to formally address two major issues that require immediate action. 1. Resident-to-Resident Assault (Unreported and Mishandled). On December 16, 2025 (R1) was assaulted by another resident during dinnertime. I witnessed the incident. The resident approached (R1), invaded (R1's) space, pushed (R1's) wheelchair, hit (R1) yelled at (R1), and pulled (R1's) blanket. Another resident intervened verbally, and I immediately sought staff assistance. (V3) responded promptly, and I was instructed to email the Site Administrator, (V1), with a full account, which I did that same evening. I received no response, but when the aggressor was absent from the facility the following days, I reasonably assumed the incident had been addressed. On January 6, 2026, I learned from (V1) that the resident had been temporarily away for treatment related to aggression and had returned with what was descried as a clean slate. Upon seeing this resident back in the facility, I alerted department heads to keep (R2) away from (R1). I was repeatedly told to speak with (V1). I subsequently forwarded the original email, complete with timestamp, proving the report was made the night of the assault. To my knowledge, no formal report has been filed by the facility, and no meaningful safeguards have been implemented.On 2/6/26 at 2:45 PM, V1 (Administrator) said the resident to resident abuse allegation investigations between R2 and R3 and R2 and R4 were substantiated because they were found to have happened. V1 said the intervention put in place for R3 was R2 was moved out of R3's room. V1 said the intervention put in place for R4 was R2 was referred to psychiatry for a medication change.The facility's revised 10/24/22 Abuse Prevention and Reporting-Illinois policy documented in part . This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services be staff or mistreatment. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Identifying occurrences and patterns of potential mistreatment. Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Filing accurate and timely reports. Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other that by accidental means. Abuse is a willful infliction of injury. with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview, and record review the facility failed to timely report a resident to resident abuse allegation for 1 (R1) of 7 residents reviewed for abuse in the sample of 7.Findings include:R1's admission Record documented an admission date of 3/25/25 and included diagnoses of chronic obstructive pulmonary disease, panlobular emphysema, and dysphasia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. R2's admission Record documented an admission date of 11/10/25 and included diagnoses of anxiety disorder, depression, and dementia. R2's MDS dated [DATE] documented a BIMS score of 6, indicating R2 was severely cognitively impaired.A Report to IDPH (Illinois Department of Public Health) Regional Office marked as Initial & Final documents a Date of Incident/Accident as 02/03/2026 with no time documented and names R1 and R2 as the residents involved. Under Description of Occurrence is documented Alleged resident to resident altercation. No injuries were noted and the report indicates an investigation was initiated. Under Follow Up/Final Report Summary, the report documented: (Name of R1's) daughter reported to the Administrator that on December 16, 2025 that resident (name of R2) grabbed her father's blanket and hit his back. The daughter reported this to Admin weeks after the incident occurred. The daughter spoke to the nurse on duty at the time of the incident and stated that (name of R2) was bothering her and her father (R1) and asked if he (R2) could be moved. At the time of the incident resident's daughter did not mention any hitting. By the time the incident was reported (name of R2) had been sent to inpatient psychiatric care. (Name of R2) has since returned to the facility with no further incidents. Residents and staff interviewed with no concerns identified. The report documents it was completed by V1 (Administrator) on 02/03/2026.On 2/4/26 at 10:29 AM, V3 said she was working on 12/16/25. V3 said she was down the hall with the medication cart administering medications to other residents when V9 approached her and told her R2 was yelling at V9. V3 said she told V9 she would take care of it and went to the dining room. V3 said when she go to the dining room R2 was sitting in his wheelchair about 3 tables away from R1 and was yelling at V9. V3 said she assisted R2 to the other side of the dining room from R1. V3 said V9 did not report any physical incident to her at the time. V3 said V9 had only told V3 R2 was being verbally abusive to V9. V3 said about a month after this incident V1 came to V3 asking when V9 had reported to V3 on the date of this incident. V3 said she did not tell V9 to report what had happened on 12/16/25 to V1.On 2/4/26 at 3:20 PM, R1 was alert and oriented to self, time, and place. R1 said he was not sure of the exact date of the incident with R2. R1 said he was sitting in the dining room after the evening meal talking to V9 (Family Member) when R2 came up behind R1 and rammed R2's wheelchair into R1's wheelchair and R2 started punching R1 in the back. R1 said he told R2 to stop and get away from R1. R1 said another male resident sitting in the dining room yelled at R2 to stop. R1 said he thought the other resident yelling scared R2 and caused R2 to stop and roll away from R1. R1 said he was not sure of the other male resident's name. R1 said V9 immediately went to get a nurse, so R1 assumed the facility was aware of the incident. R1 said a nurse came to the dining room and assisted R2 back to R2's room.On 2/4/26 at 3:39 PM, V9 said she had been told by various staff R2 could become physically aggressive. V9 said on 12/16/25, V9 and R1 were sitting in the dining room. V9 said R2 came up behind R1 and hit R1's wheelchair with R2's wheelchair. V9 said R1 told R2 to stop when R2 started punching R1 in the back and started pulling on R1's blanket. V9 said R7 was sitting at a table on the far side of the dining room and used a stern voice to tell R2 to stop. V9 said R2 stopped punching R1 and R2 rolled his wheelchair back away from R1. V9 said after the incident V9 went to get V3 (Licensed Practical Nurse/ LPN) and informed V3 of what had happened. V9 said V3 came to the dining room and R2 was still close to R1 sitting in his wheelchair. V9 said V3 assisted R2 back to R2's room. V9 said V3 told V9 to report what happened to V1 (Administrator) and V9 sent V1 an email describing the events. V9 said after she sent V1 the email on 12/16/25, V9 returned to the facility the next day and did not see R2. V9 said she thought R2 was no longer in the building due to the email V9 had sent to V1 and thought it was taken care of. V9 said on 1/6/26 she returned to the facility and saw R2 had returned to the facility. V9 said she had spoken with V2 (Director of Nursing/ DON) on 1/6/26 with her concerns with R2 being back in the facility after R1 and R2's physical altercation and the need for R1 and R2 to be kept apart. V9 said later that day on 1/6/26 V1 called V9 and yelled at V9 for about 20 minutes saying V1 only had 24 hours to report it and asking why I didn't report this to V1. V9 said she told V1 V9 had sent V1 an email on the day the incident had happened. V9 said V1 told V9 V1 had not received any email from V9 about this incident. V9 said she told V1 V9 would forward the previously sent email.On 2/5/26 at 1:42 PM, V1 said she was not aware of the incident occurring on 12/16/25 between R1 and R2 until 1/6/26 when V9 came to speak with V1. V1 said she did not report the incident at that time because V1 thought it was unfounded. V1 said she reported the 12/16/25 incident on 2/3/26 after V9 sent a letter to corporate.An email communication dated 1/6/26 at 3:53 PM from V9 to V1 documented in part .Here's my original email. (CC'ing (V2/DON) since I talked to her about it today.) It never registered that you didn't receive my email since everything in this email was resolved the next day and hasn't been an issue since. I just assumed you took care of it! . This email chain also contained the original email from V9 to V1 dated 12/16/25 at 9:55 PM documenting in part . you probably will get a report on this in the morning from the nursing staff but the nurse tonight (V3's name) asked me to report directly to you. The first two incidents are related: (R1) was attacked or harassed by (name of R2) twice today. The first instance happened earlier in the day when I wasn't there. (R1) said that (name of V7) intervened. The second happened at dinnertime, when I was there. First, (name of R2) rolled up to the table, invading his (R1's) personal space. When (R1) didn't move (he was actively eating his dinner) (name of R2) started pushing his chair and I asked (name of R2) to move away from (R1). (Name of R2) them (sic) hit him (R1) in the back and started yelling at him. (Name of R2) pushed him (R1), slapped/hit him, yelled at him, and yanked his blanket. (Name of R7) yelled at (Name of R2) very loudly and I went to get a nurse or a CNA to help. (Name of V3) responded. For the last month or so, I have been actively trying to keep (R1) as far away from (Name of R2) as possible: ensuring CNAs do not put them at the same table and making sure they are as far away from each other in the dining room as possible, as I have been told by multiple nurses and CNAs that (name of R2) is combative, aggressive, and dangerous. One told me one day that it was inevitable that someone was going to get hurt with (name of R2) in the building. I want to make sure that (name of R2) never touches (R1) ever again. If he (R2) threatens or touches (R1) in an aggressive way ever again, I will file a report against him (R2).The facility presented a letter dated 1/31/26 from V9 documenting in part . I am writing to formally address two major issues that require immediate action. 1. Resident-to-Resident Assault (Unreported and Mishandled). On December 16, 2025 (R1) was assaulted by another resident during dinnertime. I witnessed the incident. The resident approached (R1), invaded (R1's) space, pushed (R1's) wheelchair, hit (R1) yelled at (R1), and pulled (R1's) blanket. Another resident intervened verbally, and I immediately sought staff assistance. (V3) responded promptly, and I was instructed to email the Site Administrator, (V1), with a full account, which I did that same evening. I received no response, but when the aggressor was absent from the facility the following days, I reasonably assumed the incident had been addressed. On January 6, 2026, I learned from (V1) that the resident had been temporarily away for treatment related to aggression and had returned with what was descried as a clean slate. Upon seeing this resident back in the facility, I alerted department heads to keep (R2) away from (R1). I was repeatedly told to speak with (V1). I subsequently forwarded the original email, complete with timestamp, proving the report was made the night of the assault. To my knowledge, no formal report has been filed by the facility, and no meaningful safeguards have been implemented.The facility's revised 10/24/22 Abuse Prevention and Reporting-Illinois policy documented in part .External Reporting. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. If there is a suspicion that a crime has been committed. and does not involve serious bodily injury, then a report to local law enforcement and Department of Public Health as soon as possible but within 24 hours of within 24 hours of when the suspicion was formed. The initial report to Department of Public Health shall include the following information, if known at the time of the report:. Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom the property was misappropriated. Type of abuse reported. Date, time, location and circumstances of the alleged incident. Five-day Finial Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The final investigation report shall contain the following: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom the property was misappropriated. The original allegation. A summary of facts determined during the process of the investigation, review of medical record and interviews of witnesses. Conclusion of the investigation based on facts.

Based on observation, interview, and record review the facility failed to thoroughly assess, follow physician orders, and implement interventions to prevent and/or treat pressure ulcers for 1 of 1 (R78) residents reviewed for pressure ulcers in the sample of 26. This failure resulted in R78's Stage 4 pressure ulcer not being treated as ordered by the physician from 3/11/25 to 3/20/25 (nine days) and unstageable pressure ulcers to bilateral heels not being assessed and/or treated from 3/11/25 to 3/20/25 (9 days). Findings Include: R78's Admission Record with a print date of 3/20/25 documents R78 was admitted to the facility on [DATE] with diagnoses that include hypertension, benign neoplasm of prostate, and vascular dementia with a diagnosis of muscle wasting and atrophy identified on 2/15/25. R78's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates a moderate cognitive deficit. This same MDS documents R78 is at risk of developing pressure ulcers and documents R78 has one Stage 1 pressure ulcer and two unstageable pressure ulcers. The Skin and Ulcer/Injury Treatments on this MDS are documented as, Pressure reducing device for bed, Turning/repositioning program, Pressure ulcer/injury care, Application of nonsurgical dressings, Applications of ointments/medications, and Application of dressings to feet. R78's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents a score of 16, which indicates R78 is not at risk of developing pressure ulcers. R78's current Care Plan documents a Focus area of I have pressure ulcer to coccyx, r/t (related to) Immobility Date Initiated: 02/15/2025. This Focus area includes the following interventions implemented on 2/15/25, Administer medications as ordered. Monitor/document for side effects and effectiveness Administer treatments as ordered and monitor for effectiveness Assess/record/monitor wound healing Weekly Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declined to MD (physician) .Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning .Follow facility policies/protocols for the prevention/treatment of skin breakdown .Inform the resident/family/caregivers of any new area of skin breakdown .Monitor nutritional status. Serve diet as ordered, monitor intake and record .Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage .Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated The resident needs assistance, reminder to turn/reposition at least every 2 hours, more often as needed or requested. Res (resident) will refuse at times Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate R78's Order Recap Report dated 2/1/25 to 3/31/25 includes the following physician orders: Start date 3/11/25 Heel protectors and heels floated when in bed every day and night shift. Start date 2/16/25 and end date 2/28/25.Coccyx 4 x (by) 5 cm (centimeter) shearing. Cleanse with NS (normal saline). Pat dry. Apply zinc barrier cream q (every) shift and PRN (as needed) until healed as needed for shearing and every day and night shift for shearing. Start date 3/14/25. Cleanse site to sacrum with NS or wound cleanser and pat dry. Apply Border gauze daily every day shift for [sic] promote wound healing. Start date 3/11/25 end date 3/13/25. Cleanse site to coccyx with NS or wound cleanser and pat dry. Apply Border gauze daily every day shift. Start date 2/16/25 end date 2/28/25. B/L (bilateral) heels: deep tissue injury: skin prep q shift until healed. every day and night shift for deep tissue injury. Start date of 3/11/25 and end date of 3/13/25. Apply Border gauze dressing to Right hip daily every day shift. Start date of 2/16/25 and end date of 2/28/25. Right ankle; pressure area: skin prep daily and cover with foam dressing daily and PRN until healed. as needed for pressure area. And every day shift for pressure area. Start date 2/16/25 and end date of 2/28/25. Resident to wear B/L heel protectors and float heels when in bed as resident tolerates. Deep tissue injury. every day and night shift for deep tissue injury. On 03/17/25 at 9:25 AM, R78 was lying in his bed wearing heel protector boots on bilateral feet, with a sheet covering portions of his body. R78 stated he had a pressure ulcer on his buttocks that he acquired during a recent hospital stay. R78's Skin-Other Skin Condition Report dated 2/15/25 documents an area on coccyx, right buttock, and left buttock with no description, assessment, and/or measurements of the areas. R78's Skin-Pressure/Diabetic/Venous/Arterial Wound Report dated 2/16/25 identifies the report as an admission assessment with the following assessment of the pressure areas documented, 1. unstageable pressure area to coccyx that measures 4 x (by) 5 x 0 cm (centimeters), 2. Stage 1 pressure injury to left hip that measures 7 x 6 x 0 cm, 3. deep tissue injury to bilateral heels with no measurements, described as deep red and mushy. 4. right ankle closed pressure area that measures 5 x 5 cm. R78's Progress Notes document: 2/18/25 .New skin issue. Location: Rear left trochanter (hip) Pressure ulcer/injury. Wound was present on admission. Signs and symptoms of infection: None. Painful: No. Measurements not documented as part of this assessment. Reason measurements not documented as part of this assessment: Measurements not due at this time. Skin Note: admitted with pressure areas to L (left) hip, bilat (bilateral) ankles, bilat heels, coccyx. There is no assessment and/or measurement of the areas documented in this progress note. 2/26/25 .Skin #001: skin issue has not been evaluated. Location: Rear left trochanter (hip) Issue type: Pressure ulcer/injury. Wound was present on admission. #002 Skin issue has not been evaluated. Location: Rear left trochanter (hip) .Issue type: Pressure ulcer/injury. Wound was present on admission. (duplicate of issue#001) #003: New skin issue. Location: Left heel .Reddened Red wound was present on admission. #004: New skin Issue: Location. Right heel .red wound was present on admission. #005: New skin Issue. Location: right plantar foot .Right ankle issue type: Pressure ulcer/injury Unstageable .Wound was present on admission. Measurements not documented as part of this assessment. There is no further assessment or measurements documented in this progress note. 2/27/25 (V6/Wound Specialist) here and seen res (resident) new orders received. 2/27/25 Resident experiencing altered LOC (level of consciousness) .MD (Physician) notified. T.O. (telephone order) Send to ER (emergency room ) for eval (evaluation) R78's Order Recap Report dated 2/1/25 to 3/31/25 includes the following physician order with a start date of 2/27/25 and an end date of 2/28/25. Silvadene External Cream 1% (Silver Sulfadiazine) apply to sacrum topically every day shift for wound cleanse with wound cleanser pat dry and apply Silvadene, collagen, calcium alginate and dry dressing to wound on sacrum. R78's Wound Specialist note dated 2/27/25 documents, Patient seen on 2/27/25, however, I couldn't put an official note for lack of vital information on the visit of 2/27/25. The patient had an open area on the buttock that measured 3 x 2 with a treatment of Silvadene, collagen, calcium alginate, and dry dressing. R78's Admission/Re-Admission Observation dated 3/11/25 documents the following assessment under skin integrity, Right trochanter (hip) 6 x 6 cm Unstageable, Sacrum 3 x 2 cm Stage 1. There is no other skin assessment documented on this report. R78's Wound Specialist Report dated 3/13/25 documents a Stage 4 pressure ulcer to R78's coccyx that measured 2.5 x 1.6 x 0.4 cm with an order for a treatment of calcium alginate, collagen powder, silver Sulfadiazine and a gauze island dressing to be applied daily. R78's Progress Notes document: 3/14/25 .Skin Issue: #001: Skin issue has been evaluated. Location: Left heel .red wound was present on admission .#002: Skin issue has been evaluated. Location: Right heel red wound present on admission .#003: Skin issue has not been evaluated. Location: Right plantar foot Pressure ulcer/injury Unstageable .Wound was present on admission. #004: Skin issue has not been evaluated. Location Rear left trochanter (hip) .Pressure ulcer/injury. Wound was present on admission There are no description/assessment/measurements of the pressure ulcers in this progress note. R78's Progress Notes do not document assessment and/or measurements of R78's pressure ulcers. On 03/19/25 at 11:00 AM, V8 (Licensed Practical Nurse) removed a dirty bandage from R78's sacrum that was dated 3/18/25. V8 changed her gloves and hand sanitized then cleaned the area that was open with red/pink tissue in the center of the wound and surrounding the open area. V8 cleaned the area with wound cleanser and covered with a border foam dressing. V8 stated that was the only treatment R78 had. This surveyor asked to observe R78's hip and heels. R78's left hip was free of obvious skin breakdown. R78's right hip had an approximate softball size discolored area on the bony prominence. V8 touched the area and stated it was blanchable and stated V6 (Wound Specialist) had seen the area and it healed out. R78's right heel was observed, and the skin appeared within normal limits, but it was slightly mushy when touched by V8. V8's right outer ankle was red and irritated looking when V8 touched the area it blanched. V8 lifted R78's left leg up out of the boot. R78's left heel was mushy and not in a normal heel shape. The heel was indented and appeared very soft. V8 pushed on the left heel and the skin and underlying tissue held the indented shape after V8 pushed on it. V8 stated it was mushy and did not blanch. R78 stated he always wears the boots to prevent skin breakdown. On 03/19/25 at 11:40 AM, when asked to see the wound log, V2 (Director of Nurses) stated she was behind on it. When asked if she had seen R78's pressure areas, V2 stated she had once but she was off sick last week, so she didn't see them last week. This surveyor reviewed R78's physician orders with V2 and they do not document an order for treatment to the left heel, right ankle, or right hip since his admission back to the facility on [DATE]. V2 stated she would have to review his record before she could give this surveyor any information related to the pressure areas. On 03/19/25 at 1:52 PM, V8 (LPN) stated R78's heels have been soft since he returned from the hospital on 2/27/25. V8 stated R78 had a treatment to his right hip but it looks better since they discontinued the treatment. This surveyor reviewed V6 (Wound Specialist) note dated 3/13/25 and asked why the new treatment order was not followed. V8 stated she didn't have access to V6's orders and/or progress notes. V8 stated V2 (Director of Nurses) usually prints off V6's progress notes and gives them to the nurse working on the floor so they can process any new orders. On 03/19/25 at 4:27 PM, V2 (Director of Nurses) stated she would expect the nurse's to complete thorough assessments and to obtain and follow physician orders. V2 stated she is not normally behind on the wound log but right now she is. V2 stated the treatment V8 administered to R78 was not the most recent physician order. V2 stated she called V10 (Physician) and notified him they had not followed V6's most recent treatment recommendations. When asked if R78's pressure ulcer/injuries had improved or declined, V2 stated she would say the area on R78's coccyx looked more like a pressure and not a shear as it was originally classified, so she would say it had worsened. V2 stated she didn't think the area on his hip had worsened and it was blanchable when she assessed him. V2 stated she also assessed R78's heels. V2 stated they were soft not blanchable and not in good shape. V2 stated the left heel was definitely mushy and could rapidly deteriorate. When asked if R78's heels had improved or declined, V2 stated she wouldn't be able to tell because they did not have a previous thorough assessment. R78's Skin-Other Skin Condition Report dated 3/19/25 documents the following pressure ulcers, Right trochanter (hip)- 6 cm x 6 cm brown discoloration blanchable, not open, no drainage, Right ankle (outer) -2 cm x 1.5 cm reddened area, blanchable, not open, no drainage, Right heel - 6 cm x 5 cm soft, mushy heel, not open non blanchable, Left heel - 2 cm x 2 cm soft, mushy heel, not open, non-blanchable, sacrum- 1.5 cm x 1 cm x 0.1 cm, stage 4 pressure ulcer, scant amt (amount) of drainage, no odor, 100% granulation tissue. Under Treatment/Pain Assessment this report documents, Awaiting treatment orders for areas except coccyx. Coccyx treatment order clarified from (V10/Physician) d/t (due to) unable to contact (V6/Wound Specialist) at this time. (V10) notified of (V6's) order from 3/13/25 but order in place in facility not matching order from (V6). (V10) clarifies order to cleanse coccyx with wound cleanser, pat dry, apply SSD 1%, collagen, calcium alginate, cover with border gauze daily. Order processed. On 3/20/25 at 9:56 AM, V6 (Wound Specialist) stated when he first saw R78 he didn't have access to the electronic records and his notes fell through the crack. V6 stated he saw R78 two weeks later and put a progress note in the system. V6 stated he assessed the pressure area on R78's buttocks and thought he looked at his heels. V6 stated floating his heels would be the treatment for the pressure areas on his heels although if the nurse wanted it, he could prescribe skin prep, although it isn't really advised. V6 stated the facility skin checks only mark when there is an actual open area and not when it is just red. V6 stated he would expect the facility to implement his orders and recommendations for interventions. V6 stated the area would heal much faster if they followed his current treatment orders. The facility Pressure Injury and Skin Condition Assessment policy dated 11/28/12 documents, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse and documented in the resident's clinical record 7. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes .10. Pressure injuries and other ulcers (arterial, diabetic, venous) will be measured at least weekly and recorded in centimeters in the resident's clinical record. 11. A wound assessment for each identified open area (sic) will be completed and will include: a. Site location, b. Size (length x width x depth) c. Stage of pressure ulcer d. Odor e. Drainage f. Description g. Date and initials of the individual performing the assessment 18. A licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. If observations are acute, physician and responsible will be notified by charge nurse

Based on interview, observation and record review, the facility failed to provide accurate skin assessments and/or ensure preventative treatment and services were implemented to prevent the development of pressure ulcers for 1 of 5 residents (R1) reviewed for pressure ulcers in a sample of 7. This failure resulted in R1 developing unstageable DTI's (deep tissue injuries) to the right and left heel with undetermined thickness. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE]. R1's Physician's orders dated 12/4/23-12/31/23 list some of R1's diagnoses as UTI (urinary tract infection), A-Fib (Atrial fibrillation), HTN (hypertension), seizure disorder, dementia, AKI (Acute kidney injury), and HLD (hyperlipidemia). R1's MDS (Minimum Data Set) dated 12/8/23 documents a BIMS (Brief Interview for Mental Status) score of 03, indicating R1 has severe cognitive impairment. This same MDS, in Section GG, documents R1 is dependent for rolling left and right in bed, sit to lying, lying to sitting on the side of bed, chair/bed to chair transfers. Section M documents R1 is at risk of developing pressure ulcers/injuries and has one or more unhealed pressure ulcers/injuries. Section M also documents R1 was given a pressure reducing device for the bed and put on a turning and repositioning program. R1's section M contained no other documentation regarding pressure ulcers. R1's care plan dated 12/18/23 document a focus category of dependent for transfer/mobility-Unable to assist/Assists only minimally and includes documented interventions of Bed Mobility-The resident is totally dependent on staff for repositioning and turning in bed and T&P (turn and position) q (every) 2 hours while awake. The focus category documents per Braden Risk Score-High, resident has risk factors may lead to pressure ulcer formation. The following interventions are documented: CNA (Certified Nurse Assistant) to assess skin during cares and head to toe during shower/bed bath, report any reddened or open areas to nurse, daily skin check for impairment/issues, report any new areas of impairment to practitioner for follow up, encourage/assist to prop pressure areas to avoid contact skin to skin or prolonged contact with surfaces, as resident allows, float heels while in bed, as resident allows while awake, turn and reposition, as resident allows while sleeping, turn and reposition, pressure reducing cushion while in bed, and pressure reducing cushion while up in chair. R1's Nursing Admission assessment dated [DATE] documents the following for pressure areas: small area on back et (and) along spine, small area on sacrum, areas to bilateral heels signed by V8 (LPN/Licensed Practical Nurse). R2's Braden Scale for Predicting Pressure Ulcer Risk dated 12/4/23 documents a score of 8, which indicates R1 is at high risk for developing pressure ulcers and is signed by V8. The same assessment under wound review documents Y (yes) to the question of Does the resident currently have an unresolved pressure ulcers? (If yes, please see weekly wound measurement) Under Skin Treatment Review: Indicate all used in the last 7 days float heels is marked as being used. V8's nurse progress note dated 12/4/23 at 10:00pm, documents a Body Assessment was completed, and R1 has reddened pressure areas on back, spine, sacrum, et (and) bilateral heels. Right heel has a 0.5 x 1 cm (centimeter) scabs intact. R1's nursing summary dated 1/16/24 and signed by V8 notes for skin care, pressure relief mattress and heel protectors and notes heels are soft. R1's Braden Scale for Predicting Pressure Ulcer Risk documented by V9 (LPN/Licensed Practical Nurse) dated 12/11/23, 12/18/23, 12/25/23 and 1/1/24, all document a score of 15, which indicates R1 is at high risk of developing pressure ulcers. The wound review section for all of the above dates has a line drawn through the column which asks, Does the resident currently have any unresolved pressure ulcers? R1's Physician's Orders dated 12/4/23 to 12/31/23 documents R1 is a moderate skin risk and documents an order of weekly skin assessment with note on Monday shift 2-10. R1's Physician's orders dated 1/1/24-1/31/24 document an order dated 12/4/23 for weekly skin assessment with note on Monday 2-10 shift and a new order dated 1/29/24 for daily skin checks on 6-2 shift. R1's Skilled Progress notes from 12/4/23 to 1/22/24 indicate there was no documentation of wound location, measurements, drainage or treatment. A Skilled Progress note dated 1/23/24 at 1:30pm by V9 documents N.O. (new order) received from wound physician to apply betadine to bilateral heels bid (twice a day), son notified. A Skilled Progress Note dated 1/30/24 at 9:00am by V7 (RN/Registered Nurse) documents pressure areas to bilateral heels remain but appear to be improving. Tx (treatment) to bilateral heels performed. There was no documentation noted from 1/23/24 to 1/30/24 of wound location, measurements, drainage or treatment. R1's TARS (Treatment Administration Record) dated 12/4/23-12/31/23 document weekly skin assessments on Monday 2-10 shift. Initials indicating assessment were completed were documented on the following dates: 12/4/23, 12/11/23, 12/18/23, 12/19/23, and 12/25/23. The back of the TAR documents a skin assessment on 12/19/23 and notes skin assessment performed post shower and no new areas observed and signed by V7. There were no other skin assessments documented on the back of the TAR or in the nurse progress notes. There was no documentation noted under location, stage, diameter, depth/shape/type, color or drainage. R1's TARS dated 1/1/24-1/31/24 were reviewed and document skin assessments were initialed as being completed on the following dates: 1/1/24, 1/8/24, 1/15/24, 1/22/24, and 1/23/24. The skin assessment on the back of the TAR on 1/1/24, 1/8/24, 1/15/24, and 1/22/24 all document no new skin issues under progress/comments. On 1/23/24 under progress/ comments it documents Skin assessment performed post shower. Pressure areas remain to bilateral heels. No new areas observed. There was no documentation noted under location, stage, diameter, depth/shape/type, color or drainage. R1's Initial Wound Evaluation and Management Summary dated 1/25/24 by V12 (Wound Physician) documents R1 has an unstageable DTI of the right heel, undetermined thickness. Etiology is noted as pressure with a duration of > (greater than) 6 days. The wound measurement to the right heel is noted as 2.5 x 3 x not measurable cm (centimeters), exudate: none and skin: intact with purple/maroon discoloration. The same evaluation also documents an unstageable DTI of the left heel, undetermined thickness, with a documented etiology of pressure with a duration of > 6 days. The wound measurement of the left hell is noted as 0.9 x 0.9 x not measurable cm, exudate: none, skin: intact with purple/maroon discoloration. On 1/26/23 at 8:30am, R1's skin check, completed by V9 (LPN), was observed. There were no wounds observed to R1's back or spine. R1's coccyx is lightly reddened. R1's left heel has an approximately 1-centimeter (cm) x 1 cm black area, then a 4 cm x 3 cm boggy area around bottom of heel and is darker pink in color. R1's right heel has 4 cm x 3 cm black area with a small area of yellow tissue in the middle. There was no drainage noted from either wound. The surrounding tissue on both wounds is light red. On 1/26/24 at 8:40am, R1 was observed lying in bed without heel protectors on. V10 (CNA/Certified Nurse Assistant) then applied heel protectors. On 1/26/24 at 9:00am, V1 (Administrator) said she did not have any wound notes or wound assessments on R1 prior to 1/25/24. On 1/26/24 at 12:51pm, V8 (LPN) said she admitted R1 to the facility. V8 said R1 did not have an open area on her left heel but did have a scabbed area on her right heel. V8 said R1's heels were boggy. V8 said R1 had heel protectors on at first, then she wasn't wearing them. V8 said she did not contact the physician regarding the open areas on R1's body when she admitted her. V8 said she did not look at R1's heels and did not measure them after she admitted her. V8 said she did sign off as doing a skin assessment but did not do an assessment or look at her heels. V8 said she would consider heels to be a part of a skin assessment. On 1/26/24 at 12:31pm, V7 (RN/Registered Nurse) said she was shown R1's wounds by Physical Therapy. V7 said R1 usually gets her showers on the evening shift, and she usually does not do the skin checks on her since they are done on 2-10 shift. V7 said she did report the wounds to V9 (Licensed Practical Nurse/ LPN) and he was supposed to get ahold of the V12 (Wound Physician). V7 said she knew R1 was admitted to the facility with a wound as she did read her admission assessment. V7 said she did not call the physician since she assumed V9 called him. On 1/26/24 at 9:05am, V9 (Licensed Practical Nurse/LPN) said he guesses they just dropped the ball on R1's wound care. V9 said he asked staff if they saw an ulcer on R1's feet because some were charting it and some were not. V9 said he became aware of the ulcers on her heels on 1/23/24 and he called physician and V12 (Wound Physician). V9 said the wound physician came to see R1 on 1/25/24. On 1/26/24 at 9:30am, V9 said they just missed the wounds and he just found out about them. V9 said the wounds were not charted on due to staff thinking he knew about them, and he didn't or he would have notified the physician and got orders for wound care. On 1/26/24 at 10:14am, V5 (LPN) said she was aware of the open areas on R1's heels. V5 said she did keep R1's heels floated. V5 said she was aware on 1/18/24 as her and V9 spoke about it, and she did not call the physician. V5 said she figured someone else had called him. V5 said she just did a check mark on R1's skin assessment and did not do a note or an assessment. V5 said she did pass it on about her heels and guesses she didn't know where it went from there. V5 said she thinks it was on 1/18/24. V5 said she would expect a resident's heels to be a part of a skin assessment. On 1/26/24 at 11:30am, V6 (Regional Quality Assurance) said she would expect heels to be a part of a skin assessment and it to be documented on the back of the TAR (Treatment Administration Record) or in the nurses note. The facility policy titled Pressure Sore Prevention Guidelines (Revised 4/06) document The nurse will complete a skin assessment on all residents upon admission then weekly for four weeks .The following guidelines will be implemented for any resident assessed at a Moderate Risk or High Risk, Some Interventions listed for high risk include turn and reposition every 2 hours, special mattress, positioning devices prn (as needed), daily skin checks. The same document notes turn and reposition every 2 hours, weekly skin checks, care plan entry. The same document states Any resident scoring a high or moderate risk for skin breakdown will be noted on the treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet. A facility policy titled Decubitus Care/Pressure Areas (revised 5/07) documents it is the facility policy to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. The document lists the procedure as 1. Upon notification of skin breakdown, a newly acquired skin condition report will be completed and forwarded to the Director of nursing. 2. The pressure area will be assessed and documented on the Treatment Administration Record. 3. Complete all areas of the TAR-Document the size, stage, site, depth, drainage, color, odor and treatment (upon obtaining from the physician), Document the status of the pressure ulcer, Document the color, 4. Notify the physician for treatment orders, 5. Documentation of the pressure area must occur upon identification and at least once a week on the TAR.

Based on record review, interview and observation, the facility failed to follow physician orders to provide nutritional supplements for a resident with significant weight loss for 1 (R9) of 2 residents reviewed for weight loss in the sample of 21. This failure resulted in R9 having a 10.89 percent (significant weight loss) over a 6-month time period. The findings include: R9's Profile Face Sheet documents that R9 was admitted to the facility on [DATE], and notes that R9 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R9's MDS Section G for Activities of Daily Living regarding level of assistance needed for Eating is documented as Supervision - oversight, encouragement, or cueing and support provided is coded as Setup help only. R9's Care Plan, with a start date of 10/7/16 notes a problem/need area of Nutrition and documents R9 currently receives a regular diet, which she is able to feed herself with setup from staff. Per resident's choice (R9) eats most meals in her room. The care plan also documents as of 5/1/20 resident to continue to eat meals in room per social distancing guidelines and CDC recommendation of non-communal dining related to Covid 19. A corresponding intervention notes to provide R9 ample time to eat; Encourage resident to eat 75-100% of meals; Record Meal Intake; Note and report changes in resident usual patterns with a start date of 12/9/19. Review of R9's medical record documents the following recorded weights over the last year: October 2020 - 140.0 lbs. November 2020 - 139.80 lbs. December 2020 - 138.80 lbs. January 2021 - 138.70 lbs. February 2021- 135.4 lbs. March 2021 - 134.80 lbs. April 2021- 130.40 lbs. May 2021- 122.40 lbs. June 2021- 125.90 lbs. July 2021- 124.30 lbs. August 2021- 121.0 lbs. September 2021- 114.60 lbs. October 2021- 116.2 lbs. R9's Dietary Notes dated 4/28/21 by V5 (Registered Dietician) document an April weight of 130.4 lbs. (pounds) with a BMI (Body Mass Index) of 19.7%. V5 notes R9 has had a gradual weight loss (down 10 lbs.) x (times) 6 months, with recommendations for R9 to receive a MVI (Multivitamin) with minerals and magic cup bid (twice per day). R9's physician's orders dated 5/1/21-5/31/21 document that the MVI with minerals and magic cup bid were ordered. R9's Dietary Notes dated 5/26/21 by V5 document a May 2021 weight of 122.4 lbs. with a BMI of 18.7%. V5 documents a significant weight loss of (6.13%) x 1 month, (9.6%) x 3 months, and (12.45%) x 6 months. V5 notes the previous recommendation of magic cup in her 4/28/21 note was added on 5/12/21, and documents in the current note that she will additionally recommend adding med pass tid (three times daily). R9's physician's orders dated 6/1/21-6/30/21 note 60cc (cubic centimeter) med pass tid was ordered. R9's Dietary Notes dated 7/29/21 by V5 again note a significant weight loss in 6 months of 10.38%. V5's recommendations were to add Vitamin C, [MEDICATION(S)] for 6 weeks, and to increase med pass to 120cc three times daily. R9's physician's orders dated 8/1/21-8/31/21 indicate that the physician ordered the recommendations on 8/9/21. The same physician's orders document that on 8/17/21 orders were noted to discontinue vitamin C until dietary assessment. R9's Dietary Notes dated 8/31/21 by V5 note a weight of 121 lbs. with a BMI of 18.4%. V5 documents a significant weight loss in 6 months of 10.64%. V5's recommendations are to d/c (discontinue) the magic cup due to poor acceptance, add Vitamin C, and increase med pass to 150cc tid. R9's physician's orders dated 9/1/21 to 9/30/21 indicate that there were no physician's orders for these recommendations. R9's Dietary Notes dated 9/29/21 by V5 document a September weight of 114.6 lbs. with a BMI of 17.4%. V5 documents a significant weight loss of (5.29%) x 1 month, (8.98%) x 3 months, and (14.99%) x 6 months. This note additionally documents that V5's 8/31/21 recommendations were pending. V5 documents she will re-recommend and additionally recommend increasing med pass to 180cc qid (4 times daily) and 7.5 mg (milligrams) [MEDICATION(S)] to increase appetite. R9's October physician's orders indicate no orders for the recommendations made. On 10/14/21 at 2:20pm, V2 (Licensed Practical Nurse/LPN - Minimum Data Set/MDS Coordinator) said that V3 (Dietary Manager) is new to this process, and the orders were not processed. V2 said she is going to develop a system to ensure this is being done. On 10/14/21 at 2:30pm, V3 (Dietary Manager) stated that the nurses process the dietician's recommendations. V3 said that she gave the recommendations to an agency nurse, who said he would put them in the chart. V3 also said that she is new in this position. On 10/14/21 at 2:45pm, V1 (Administrator) said her expectation is that the nurse will fax the recommendation to the physician and then process the order if the physician agrees with the recommendation. V1 said the nurse evidently did not send the recommendations to the physician. On 10/15/21at 8:30am, V5 (Registered Dietician) stated that she really cannot answer any questions regarding this since she is not at the facility. On 10/15/21 at 10:30am, V10 (Physician) said he really could not say if not getting the supplements would cause R9 to lose weight. V10 said that R9 is alert and oriented and makes her needs known. V10 also said that usually R9's appetite is fair. V10 said he will be at the facility tomorrow to assess her weight loss. On 10/14/21 at 12:00pm, R9 was eating her lunch in the dining room. She was using built up utensils and appeared to have a fairly good appetite. There was about 50% of food left on her tray at the end of her meal.