Every finding on record at Balmoral Home

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed for one resident (R1). This failures affected one of three residents reviewed for medication administration. Findings include: R1's Brief Interview for Mental Status (BIMS) dated 6/12/26 does not show a score of however during this interview R1 was able to answer surveyor's questions. R1 has a diagnosis which includes but not limited to chronic obstructive pulmonary disease, low back pain, essential hypertension, anxiety disorder, bipolar, primary insomnia, epilepsy, and hypoparathyroidism. R1's Physician Order Sheet (POS) dated 6/19/26 documents, in part: Nicotine Polacrilex Mouth/Throat gum 4 mg (Nicotine Polacrilex) give 1 gum by mouth every 2 hours as needed for smoking cessation. On 6/26/26 at 11:48 am, V7 (Licensed Practical Nurse, LPN) stated that R1 has orders to receive nicotine gum 1 piece of gum every 2 hours. V7 then explained that when she is assigned as R1's nurse, she will give 4 pieces of nicotine gum at time because R1 will constantly come to V7 every hour asking for nicotine gum. V7 then explained that on 6/26/26 at 8:00 am she gave R1 four pieces of nicotine gum so that R1 would not return to V7 for the rest of V7's shift requesting the nicotine gum. V7 further explained that she instructed R1 to take one piece of gum at 8:00 am, 10:00am and 12:00pm and 2:00pm. V7 explained that nurses should follow physician's orders so that the residents will not get harmed. V7 also explained that if R1 had four pieces of gum at one time R1 has the potential to take all four pieces and harm herself. On 6/26/26 at 11:57 am, R1 stated that V7 gave her four pieces of gum in the morning around 8:00 am. Surveyor observed R1 at 11:57 am with two pieces of Nicotine gum in R1's possession. R1 stated, I chew gum all day. R1 stated that she is supposed to get one piece of gum every 2 hours and that the nurses give R1 multiple pieces of gum at times. On 6/26/26 at 2:55 pm, V2 (Director of Nursing, DON ) stated that V7 reported to V2 that she gave R1 four pieces of nicotine gum at once so that R1 already has her nicotine gum when she needs another one. V7 stated that R1 has orders for 1 one piece of gum ever two hours and that V7 should not have administered 4 pieces of nicotine gum to R1. V7 explained that the resident may not be aware of when the next piece of nicotine gum is due. V7 stated that nurses should be following physician's orders to prevent any adverse reactions to the resident. V7 stated that if a nurse does not follow a physician order the resident can have side effects from the medications. V2 also denied R1 ever reporting concerns that she had a cold, and the nurse did not believe R1. The facility undated document titled Charge Nurse documents, in part: Primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities. Alarmed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the director of nursing services or nurse supervisor to ensure the highest degree of quality is maintained at all times . Drug Administration functions: prepare and administer medications as ordered by the physician.The facility's policy dated 9/2/25 and titled Administering Medications documents, in part: Policy Heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementations: 2. Medications are administered in accordance with prescriber orders, including any required time frame . 21. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. 22. If a resident uses PRN (as needed) medications frequently, the attending physician and interdisciplinary care team, with support from the consultant pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated.

Based on observation, interview and record review, the facility failed to follow standards of practice by not performing a proper nursing assessment of a resident's wound/skin condition, after a certified nursing assistant (C.N.A) notified the nurse of the existence of the wound/skin condition for 1 resident (R5) out of 3 residents reviewed for a skin assessments. This failure resulted in the delay of R5's wound treatment, for a wound that was septic, necrotic, infected with Fournier's gangrene, and required wound debridement.Findings Include:R5's face sheet documents that R5's diagnosis is not limited to peripheral vascular disease, type 2 diabetes mellitus, malignant neoplasm of overlapping sites of bladder, hypertensive heart disease without heart attack, hyperlipemia.R5's MDS (minimum data set) dated 01/01/2026, documents that R5's BIMS (brief interview for mental status) has a score of 14, indicating R5's cognition is intact.R5's hospital records with review date of 02/16/2026 documents in part, R5 presented with symptoms of sepsis, most likely related to skin infection, suspecting necrotizing infection, scrotum, inner thighs, complicated with acute kidney injury, and A-fib, RVR. Debrided by general surgery and urology in OR.On 05/19/2026 at 1:22 PM, R12 stated R5 was his roommate, and he was a very special friend of his. R12 stated R5 was independent, he did everything by himself. R12 stated he never seen any wound nurse treating R5 for wounds.On 05/20/2026 at 10:08 AM, V13 (Former Certified Nurse Aide) stated he used to work in the facility for 6 months but resigned from his position. V13 stated that on February 13th at approximately 7:00 PM, R5's brother was visiting R5, and asked V13 to check on him. V13 stated R5's brother was concerned that R5 was not talking much and was not being himself. V13 stated he checked on R5 and noticed that he was soiled. V13 stated while he was performing patient care, he noticed that R5 had an untreated wound to sacral area, and it was bleeding. V13 stated the surrounding area in the bottom had a discoloration, and he described it as black. V13 stated he told V17 (Registered Nurse) about the wounds bleeding, but she did not assess R5's wounds. V13 stated V17 pulled him to the side and told him not to mention anything about blood in front of R5's family members. V13 stated V17 checked R5's vital signs, then she called the ambulance. V13 stated V17 re-checked R5's vital signs 20 minutes after calling the ambulance. V13 stated he also rechecked R5's wounds, the brief was removed and there was still bleeding noticed from the bottom. V13 stated the wound appeared as it was untreated, and he does not recall a wound nurse ever treating R5's wounds.On 05/20/2026 at 1:58 PM, V17 (Registered Nurse) stated R5 is alert and oriented to person place and time. V17 stated R5 was independent and ambulatory. V17 stated R5 did not have any behavior, and they both had a good relationship. V17 stated on the day she sent out R5 to the hospital, she went to his room to assess his blood sugar, before she administered his diabetes medication. V17 stated when she entered R5's room, he was laying down on his bed, and this was out of his normal behavior. V17 stated she was concerned for R5's wellbeing and decided to check his vital signs. V17 stated when she checked the vital signs, R5's oxygen saturation was approximately 86-89% room air. V17 stated she had to put him on 3-4 liters of oxygen, which did help. V17 stated V13 began patient care on R5. This surveyor asked V17 if she was notified of any skin issues on R5. V17 stated R5 did not have any skin issues, he was ambulatory and independent. V17 stated there were no wounds or discoloration in the bottom.On 05/202/2026 2:19 PM, V20 (Certified Nurse Assistant) stated she was familiar with R5, and he was independent and did everything for himself. V20 stated R5 always refused a skin assessment. V20 stated she will always document the refusal on the shower sheets and notify the nurse. V20 stated she is not sure if R5 had any wounds because he always refused a skin assessment.On 05/21/2026 at 11:23 AM, this surveyor called V18 (Licensed Practical Nurse) did not answer, and a voicemail was left.On 05/21/2026 at 11:24 AM, this surveyor called V16 (Registered Nurse) did not answer, and a voicemail was left.On 05/21/2026 at 9:48 AM, V13 stated V17 did not assess R5's sacral wounds even after she was notified twice. V13 stated V17 was too busy trying to send out R5 to the hospital. On 05/22/2026 at 12:09 PM, V22 (LPN/ Wound Nurse) stated she had been working in the facility as a wound nurse for 2 months, but she has been working in the facility as an agency nurse since last summer. V22 stated R5 was ambulatory, independent and he was compliant with his medications. V22 stated she was never aware that R5 had a sacral wound. V22 stated he was never on the wound care list that she received in March, and by then R5 was not in the facility.On 05/21/2026 at 12:40 PM, V25 (Physician) started during R5's initial admission, there was a skin assessment that was completed. V25 stated R5 did have a redness discoloration on the sacral region, but there was no skin breakdown noted. V25 was sent to the hospital on one occasion, and when he returned from the hospital the redness in the sacral did get worse, however there was no skin breakdown. V25 stated R5 must have been sitting for long periods of time, and it made the redness worse. V25 stated R5 had a diagnosis of V25 stated R5 had an advanced metastatic cancer of the lungs. V25 stated the cancer was spreading into the liver and other organs, it was a malicious malignancy. V25 stated Fournier's gangrene can be caused by cancer spread to the skin, which is common in cancer patients. V25 stated it is very common for residents who have cancer to develop this skin condition. V25 stated if the resident sits for a long period of time, it will make the skin worse rapidly. On 05/22/2026 at 7:55 AM, this surveyor called V25 (Certified Nurse Assistant) did not answer, and a voicemail was left.This surveyor reviewed R5's electronic medical records, he did not have any records of having any wounds in the facility.Reviewed R5's shower sheets from December 2025 through January 2026, R5 refused all skin assessment.R's Labs reviewed from October 2025 through December 2025; there were no concerns.Policy titled Prevention of Pressure Injuries with review date of 09/01/2024, documents in part, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Monitoring: Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on staff interviews and record review, the facility failed to protect the right of the resident to access their personal funds without restriction by placing a resident on a money management program as a form of behavioral punishment. This failure affected 1 resident (R4) out of 4 residents reviewed for resident funds. Findings included:R4's Face Sheet documents resident is an [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, adult failure to thrive, pain in right hip, anemia, neuralgia and neuritis, retention of urine, nicotine dependance, cigarette non-compliance. Minimum Data Set Section (MDS) section C (dated 05/05/2025) documents that R4 has an Interview for Mental Status (BIMS) score of 15, indicating that R4's cognition is intact. R4's Care plan (dated 02/05/2024) states: SMOKING MANAGEMENT/NON-COMPLIANCE: Resident was reported using smoking materials in an inappropriate/risky manner (setting pieces of paper on fire in his room). Smoking materials were confiscated, and resident was placed on money/cigar management as a consequence. On 05/20/2026 at 9:15AM, during a complaint investigation survey, a review of R4's progress notes revealed that the facility restricted the resident from accessing their funds directly by placing the resident on a money management program as a consequence to R4 for smoking in his room. An interview with the resident was not obtained because R4 discharged from the facility on 07/30/2025. On 05/20/2026 at 10:23AM, V1 (administrator) stated, When a resident is caught smoking in their room, we have a policy, and the cigarettes and the lighter is confiscated. The resident's room is searched to make sure that the resident does not have any flammables. We have a policy for restricting residents who are smoking in their rooms. The consequences are that the resident will be instructed, educated and counseled about their inappropriate behavior. Further incidents with their non-compliance for the second offense may result in money management, a resident may not be able to take cash out from their trust fund for 2nd time offense. The written policy does not include a time frame for the money management, it is left to the discretion of the social worker, based on severity of the offense and the number of occurrences of the resident. The residents have not expressed any concerns about their trust fund money limitation when they are found to smoke in their rooms. On 05/20/2026 at 1:26PM, V2 (director of nursing) stated, On 07/09/2025, there was a note that R4 was smoking in his room on 07/08/2025. Based on the social worker notes, the money management was initiated as a consequence of smoking in his room, until 10/22/2025. Based on this, it is a repeated offense. R4's funds were restricted from 07/09/2025 until 10/22/2025. R4 was also smoking in his room on 12/11/2024 and 12/22/2024. R4 also smoked in his room on 11/11/2024. Per the facility's policy, residents with repeated offenses are placed on money management program, their funds are restricted. On 05/21/2026 at 10:37AM, V6 (social services director) stated, We don't have it happen a lot here, but when a resident is caught smoking in their room, social services meets with the resident. We ask them if they engaged in prohibited behaviors. We educate them on the importance of not smoking in their rooms, we don't want fires, and other residents can't tolerate the smell of smoke. That in general is why facilities are not allowing smoking inside. We confiscate smoking materials, and the smoking materials are held with staff under supervision. We let them know that they can have it under staff supervision. We draft a behavior contract, if they agree to sign it. Some residents will not agree to sign it. A behavior contract is a paper trail of continued behaviors, and that's a safety concern. We notify the physician, because the physician may put a resident on restrictions. I don't know a lot about the money management because this was implemented before I got here. I'm guessing the money program was initiated once a resident was caught smoking several times. The money program was used as tracking tool to see how much money a resident had on them to use towards cigarettes. The staff would be more involved with distributing cigarettes, opposed to the residents having free access. They would tell the trust fund/financial staff that instead of the money going directly to the resident, the money would go to a designated staff member. And a designated person would make the purchases for the resident. Or the other option is that a resident would get small amounts of their trust fund instead of the lump sum amount. When a facility oversees the resident's money, they receive supportive services with money distribution, so that it can be used for things they need for daily use. Something had to have happened for a resident to be on money management. I look at the money management program as a safety mechanism for instance a resident had been deemed to not keep up with their money, like they pass it out to their peers or they leave it in different places, so this is a safety tool. If the money management is used due to resident behaviors, then it can be viewed as a restriction of funds to decrease the behavior. We have not been doing that since. It was in place when I started working here. We have not actively been using it. R4 was discharged from the facility on 07/25/2026. R4 was placed on money management 3 or 4 times. On 05/21/2026 at 11:44AM, V1 (administrator) stated, I am the abuse prevention coordinator. There is physical, emotional, sexual, verbal, mental financial neglect, and confinement. An example of financial abuse is stealing. When there is stealing, it has to be reported to the supervisor, and the supervisor reports it to the abuse coordinator, and the abuse coordinator reports it to the state immediately. Restricting resident funds, we have a policy here when a resident smokes unsafely, they get educated and if they do it again, they may be placed on money management. The purpose of which is for the safety of the individual, to ensure that there is no more unsafe practices with smoking. So that would not be abuse. On money management, the residents don't have access to cash, but staff can help them with purchasing items requested. On 05/21/2026 at 11:58AM, V24 (business office manager) stated, The facility was managing R4's trust fund while the resident was here. R4's monthly income for 2024 was $1,196.00 from social security. Per Medicaid regulation, residents are allowed to keep $60 per month from their monthly income. In 2025, R4's monthly income was $1,226.00, and R4's monthly allowance was $60 per month. In November 2024, R4 had $75 available to him in his trust fund account. On 11/07/2024, R4 withdrew $60 and on 11/29/2024, R4 withdrew $15, and $0.23 remained in his account. In December 2024, R4's available funds were $60.23. On 12/05/2024, R4 withdrew $60 out of his trust fund account with $0.23 remaining. In July 2025, R4's available balance was $60.23 and R4 withdrew $60 on July 28, 2025. R4 discharged from the facility on 07/30/2025. After R4 discharged from the facility, his social security check funds came on 08/03/2025, and the funds were returned to the social security office. R4's Progress Note (Dated 11/11/2024) documents, Per nursing staff, resident was noted smoking inside his room on 11/9/24. Smoking materials were confiscated, and resident was placed on money/cigar management as a consequence till 11/23/24. Social worker met with the resident on 11/11/24 to further address his smoking non-compliance. Resident is currently able to receive 1 cigarette at a time during smoking break. Resident is closely monitored at this time. R4's Progress Note (Dated 12/11/2024) documents, Per nursing staff, resident was noted smoking inside his room on 12/11/24. Smoking materials were confiscated, and resident was placed on money/cigar management as a consequence till 01/11/25. Social worker met with the resident on 11/11/24 to further address his smoking non-compliance. Resident is currently able to receive 1 cigarette at a time during smoking break. Resident is closely monitored at this time. R4's Progress Note (dated 12/22/2024) documents, Per nursing report, resident was smoking inside his room on 12/21/24. Staff conducted a search, but no additional smoking materials were found. Smoking policy was reviewed. Resident remains not be able to handle own smoking materials at this time. Previously initiated money management was extended as a consequence till 2/18/25. Social worker met with the resident for follow up on 12/22/24. Patient is currently closely monitored. R4's Progress Note (dated 07/09/2025) documents, Per nursing report, resident was smoking inside his room on 07/08/24. Staff conducted a search, but no additional smoking materials were found. Smoking policy was reviewed; Rt remains not be able to handle own smoking materials at this time. Money management was initiated as a consequence till 10/22/25. Social worker met with the resident for follow up on 07/09/25. Rt is currently closely monitored and continuously directed to designated smoking areas. Policy on Trust Fund Distribution, Money Management and Financial Counseling (dated 02/01/2009) states in part: Residents of this facility have the right to manage their own financial affairs and handle their spending money. Residents have the right to have the facility keep their money in a trust account to safeguard and manage personal spending money. The facility reserves the right to utilize money management in situations in which the resident's behavior is overly self-destructive and/or dangerous to other individuals. Money management and financial counseling are psychiatric intervention techniques in practice across the United States and established as a viable strategy within the federal long-term care standards. This technique promotes increased responsibility while at the same time decreasing self-destructive behavior. This facility implements money management in situations including but not limited to: Resident inability to follow the rules addressing smoking safety (especially in situations in which hazardous use of smoking materials are likely to cause harm). This may include residents who continue to harm their personal health by smoking in spite of the physician's recommendation to stop. Residents who respond well to this intervention and show progress (i.e., enhanced responsibility) may earn the privilege of having self-management reinstated if the following criteria are met: The problem or problems that the money management is addressing are no longer being displayed by the resident (i.e., no further episodes of alcohol/drug use or hazardous smoking).The individual may be asked to agree to a trial time period (i.e., thirty days) to allow the team to more fully assess compliance with reasonable assurance that the problem is being held in check. Facility Safe Smoking Safety Policy (undated) states in part: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Consequences of non-compliance: Residents will be instructed, educated and counseled about their inappropriate behavior. Safe, appropriate behavior will be stressed. Documentation will be entered in the record accordingly. Further incidents of non-compliance may result in money management/monetary control intervention, loss of independent smoking privileges, which means smoking materials will be turned over to a designated staff member, held in a secure location and the resident will only be allowed to smoke when supervised by a responsible individual. And at the discretion of the organization.

Based on interview and record review, the facility failed to ensure that residents were free of abuse/physical assault. This failure affected three residents (R3, R4, and R5) of five residents reviewed for resident-to-resident abuse in the facility.Findings include: R1's medical diagnoses include but are not limited to right heart failure, schizoaffective disorder, essential hypertension, type 2 diabetes. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 14, indicating R1's cognition is intact. R1's progress note dated 02/27/26 at 1:40pm documents in part, SSD (Social Service Director) made aware resident physically attacked peer unprovoked. R1's progress note dated 02/27/27 at 3:20pm documents in part, Resident was observed with physical/aggressive behavior to co resident by hitting and pushing him out of his wheelchair. R4's medical diagnoses include but are not limited to quadriplegia, schizophrenia, and traumatic brain injury. R4's MDS dated [DATE] has a BIMS score of 11, indicating R4's cognition is moderately impaired. R4's progress note dated 02/27/26 documents in part, SSD (Social Service Director) med with resident and conducted wellness check due to being involved in altercation with peer unprovoked. Both residents were immediately separated. R4's progress note dated 03/07/26 documents in part, Resident was involved in a disagreement with another resident that became physical. Staff intervened and physician was notified. Resident was placed on increased monitoring. Social services reviewed anger management and appropriate skills techniques with resident. R5's medical diagnoses include but are not limited to schizoaffective disorder, depression, insomnia, chronic obstructive pulmonary disease. R5's MDS dated [DATE] has a BIMS score of 15, indicating R5's cognition is intact. R5's progress note dated 03/07/26 documents in part, This nurse was called from down the hall, from in front of room [ROOM NUMBER], to come to room [ROOM NUMBER] d/t (due to) the two roommates fighting. Other resident stated that he was hit on the right side of his face twice by R4 without provocation. On 03/20/26 at 11:50am R5 stated that on the date of the incident, he was sitting in the hallway and R4 approached R5 and R4 hit R5 in the face two times. R5 stated that he did not hit R4 back but R5 stated that he did push R4 away from him. R5 stated that he was not injured during the incident. On 03/20/26 at 11:57am V8 (Licensed Practical Nurse/LPN) stated that R4 tries to hit people all the time. V8 stated that normally the staff could intervene and prevent R4 from hitting other residents. V8 stated that on the date of the incident between R4 and R5, she was sitting at the nurse's station and was unable to intervene before R4 and R5 hit each other. V8 stated that she rushed to R4 and R5 and separated them after they both hit each other. On 03/20/26 at 1:06pm V10 (Social Service Director) stated that R1 had a history of verbal aggression towards staff and other residents but had never been physically aggressive. V10 stated that she was not present for the incident between R1 and R4. V10 stated that she was informed of the incident between R1 and R4 and was told that R1 was the aggressor. V10 stated that the facility has a no tolerance for the behaviors of R1 and that R1 was involuntarily discharged from the facility. R1's care plan dated 10/06/25 documents in part, History of aggressive/inappropriate behavior. The resident has a history of aggressive/maladaptive behavior but has demonstrated stability during the admission screening process and is therefore considered appropriate for admission. The history includes conflicts/altercations with others, verbal or physical aggression towards staff. loud and intimidating towards his roommate. Pt (patient) will daily refrain from any verbally/physically aggressive towards others. R4's care plan dated 01/28/26 documents in part, Risk for violence related to dx (diagnosis) of schizophrenia as evidenced by behavioral changes, agitation, or difficulty with redirection. resident will maintain safe behavior through the review date. Resident will do no harm to self or others through the review date. Monitor resident behavior closely. Facility's final internal report for R1 and R4 dated 03/07/26 documents in part, Based on the internal report, residents and staff statements, the above allegations appear to be substantiated. Facility's final internal report for R4 and R5, dated 03/12/26 documents in part, On 02/27/26 R1 was allegedly physically aggressive towards R4. Based on the internal report, residents and staff statements the above allegations appear to be substantiated. As a result, R1 was transferred to the hospital and received and immediate IVD (Involuntary Discharge) due to the safety of individuals in this facility being endangered. Findings include: On 3/6/26 a facility reported incident was sent to Illinois Department of Public Health (IDPH) which included R2 and R3 were involved in an altercation on 3/6/26. On 3/13/26 the final incident investigation states that the altercation between R2 and R3 was substantiated. R2 was sent out to the hospital for evaluation and received an Involuntary Discharge (IVD) due to the safety of individuals in this facility being endangered. R2's admission record diagnoses include but are not limited to schizophrenia, heart failure, insomnia, and pulmonary hypertension. R2's Minimum Data Set (MDS), dated [DATE], documents in part, Section C. Brief Interview for Mental Status (BIMS) Score:11 which indicates that R2 has moderate impairment. R2's Section E. Behavior: E0100. Potential Indicators of Psychosis documents in part, A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli) B. Delusions (misconceptions or briefs that are firmly held, contrary to reality). R2's 3/5/26 progress notes documents in part, Patient (R2) hit roommate, Nurse Practitioner (NP) notified, instructed to send patient to hospital. R2's 3/6/26 Social Service Director (SSD) progress notes documents in part, made aware Resident physically attacked peer unprovoked. Staff immediately intervened physicians notified, CPD contacted, police report made, resident room moved and placed on one-to-one monitoring with staff until departure for Psych evaluation at hospital per physician order. Physicians notified IDT Interdisciplinary team recommend IVD due to the safety of individuals in this facility being endangered, R2's screening assessment for indicators of Aggressive and/or harmful behavior dated 12/11/25, documents in part, A. Risk Assessment: 4. History or recent episode of aggressive/agitated behavior (aggression toward others including destruction of property, fire setting or other violent acts) and or non-compliance with medications, treatment regimen, resisting care. It is coded a 1 which indicates moderate problem. 6. History of abuse/neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior. It is coded a 1 which indicates moderate problem. R2's screening assessment for indicators of Aggressive and/or harmful behavior dated 3/5/26, document in part, History or recent episode of aggressive/agitated behavior (aggression toward others including destruction of property, fire setting or other violent acts) and or non-compliance with medications, treatment regimen, resisting care. It is coded a 2 which indicates significant problem. 6. History of abuse/neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior. It is coded a 2 which indicates significant problem. R2's (3/5/26) care plan documented in part, Focus: Resident struck roommate. Nurse Practitioner (NP) for psych notified and instructed transfer to hospital for an evaluation. Interventions: Resident remains on 1:1 monitoring with staff; currently awaiting EMS arrival for transport. Residents relocated to ensure safety of all parties. All facility safety protocols initiated R3's admission record diagnoses include but are not limited to Alzheimer's, atrial fibrillation, Diabetes, hypertension, and osteoarthritis. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, Section C. Brief Interview for Mental Status (BIMS) Score:8 which indicates that R3 has moderate impairment. On 3/20/26 at 11:50 am, R3 stated that he was hit in the arm and face when he was in bed. R3 did an action with his fist that someone hit him in the arm and face. R3's progress noted dated 3/5/26 documented in part, Resident (R3) was hit by roommate R2. Redness was noted to the left side of face, and the Medical Doctor (MD) was notified. R3's 3/6/26 care plan documents in part, Focus: Alleged occurrence with peers. Goal: the resident will be treated with respect, dignity, and reside in the facility free of mistreatment (abuse/neglect) on an ongoing basis. Interventions: Provided with support-frequent check-ins. On 3/20/26 at 12:05 pm, V6 Certified Nursing Assistant (CNA) stated, I (V6) had heard about R2 hitting R3 but was not here. R2 does have aggressive behavior at times toward other residents. He (R2) would get in their face and would verbally threaten them. When he could not be redirected, the nurse would send him out to the hospital. On 3/20/26 at 12:10 pm, V7 CNA stated, I would take care of R2 in the facility. He would have aggressive behavior even before he hit his roommate. He would get in his face and would be screaming and cursing him. We would tell the nurse and sometimes he would have to be sent out to the hospital. We would try to redirect him, but he would be aggressive toward women staff with the men he would not be aggressive toward them. On 3/20/26 at1:22 pm, V10 Social Service Director (SSD) stated, I was told that R2 hit R3 while R3 was lying in bed. I was not in the building; I was told the next day. A meeting was held, and we decided not to let R2 come back to the facility because of being a danger to other residents. There was a safety concern for the other residents. R2 was redirectable when he would scream and yell, but he was not physically abusive. Staff would be fearful and timid of him because of the way he looks. Residents should not endure that behavior of aggression, screaming and threatening. He was sent out to the hospital after he hit his roommate. On 3/20/25 at 1:57 pm, V1 Administrator stated, I am the abuse coordinator. that the regulatory requirement for abuse is to separate them immediately. V1 stated that the administrator, doctor, family, should be notified and report to IDPH (Illinois Department of Public Health). Aggressive behavior is IVD and is a danger to others they will not come back. Abuse is not tolerated. I was not here the day R2 hit R3. I was notified right aware. And IDPH was notified. It was substantiated because of the redness on his (R3) face. All parties were notified, family, police and doctor. Screaming and yelling is a form of abuse. Abuse in-services are conducted with staff and were done a couple of months ago. On 3/20/26 at 3:20 pm, V4 Assistant Director of Nursing (ADON) stated, I (V4) was here when the incident between R2 and R3 happened. It happened after dinner. The nurse on the floor of the CNA both notified me. I went to the resident's room. R2 was not in the room, he was at the nurse's station. I asked him what happened, and he looked at me and did the action with his fist that he had hit someone. The staff moved R2 to another room, and I had the CNA do 1:1 monitoring. R2 was sent out to the hospital that day. I reported the incident to the administrator, who is the abuse coordinator. The nurse on duty called the police. On 3/21/26 at 1:20 pm, V11 Registered Nurse stated, I (V11) was notified by the CNA that R2 had hit R3. When I went into the room R3 had redness to his face and a scratch on his nose. R3 pointed to R2 that he had hit him. The two were separated. I called the doctor and the doctor said to send R2 out for an evaluation. R2 was agitated but at that time he was redirectable because he was put in another room. Facility's Resident Rights Policy Statement dated 9/1/24 documents in part, 1. Federal and state laws guarantee certain basis rights to all residents of this facility. These rights include the resident's right to: be free from abuse, neglect, misappropriation of property and exploitation. Facility's policy titled Abuse Prevention Program Facility Procedures dated 11/16/18, documents in part, IV. Establishing a Resident Sensitive Environment: This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.

Based on interview and record review, the facility failed to supervise and prevent a resident who repeatedly stated she did not want to be in the facility from eloping from the facility. This failure affects one (R6) out of three residents reviewed for supervision in a total sample of three residents. Findings include: R6's MDS/Minimum Data Set, dated [DATE] documents that R6 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R6 is cognitively intact without any memory problems. R6's MDS documents that R6 ambulates via walking without any impairment and without assistive devices. R6 requires supervision with ADL/Activities of Daily Living care and mobility. R6 is continent of bowel and bladder. R6's progress notes are as follows: 02/24/2026 at 3:54PM written by V4 (ADON/RN) Received [AGE] year-old resident from hospital with admitting diagnosis of schizophrenia. R6 is AxOX3. Ambulatory without any assistive device. Orders verified with both MD. R6 on general diet, thin liquids. Upon assessment, no skin breakdown noted. Per R6, she really don't have any medications even before. 02/24/2026 at 7:00PM written by V13 (Social Worker) Writer met with R6 to establish relationship upon admission. R6 was not receptive to conversation. R6 repeatedly stated that she does not want to be here. R6 refused mental status exam. R6 was able to repeat correct date. Writer attempted to ask further questions about background and how she got here, which the R6 did not cooperate with. R6 will be monitored for issues adjusting to facility. Writer will continue to attempt to gather social services admissions information. 03/06/2026 at 2:51AM written by V14 (LPN) 11:30 pm During rounds R6 was lying quietly in bed. 1:40 am Back stairwell alarm sounded. Myself and the CNA ran to door and R6 was at the bottom of the stairs. V15/CNA took elevator to the 1st floor and noted R6 going thru the back door. He exited the front door but unable to locate R6. 1:55 am called 911 and gave a description of R6. Writer left facility and drove around trying to locate R6. I was unsuccessful. 2:02 am Called V3/DON also left a text message. 2:15 am Officer arrived. Face sheet and picture given. 2:27 am called administrator V1 informed of elopement 2:39 am Officer called and stated R6 was located, and she requested to go to the hospital. R6 also stated I might have frostbite. The officer stated we took her to hospital. 03/06/2026 at 3:30AM written by V14 2:35 am Nurse called from hospital. Stated R6 might return back to nursing home. 3:25 am Officer called stated who will pick her up? Informed officer hospital should send R6 back by ambulance/medicar. 03/06/2026 at 5:07AM written by V14 5:05 am Social worker called from hospital and stated R6 refuses to return. Spoke with RN informed writer the MD will see her. and notify us of the outcome. 03/06/2026 at 1:21PM written by V4 (ADON/RN) Follow up made with hospital, R6 discharged from there. Unable to tell where R6 was gone.R6's elopement assessment dated [DATE] at 5:06PM, documents a No answer to the question Does the resident verbalize a strong desire to leave? R6' care plan documents in part, Limited/Poor Discharge Potential: R6 requires assistance from staff with her care and benefits from their nursing home placement at this time. R6 is unable to care for herself in a less structured setting. R6 voices no interest in community re-entry at this time, see social service notes for additional details. Initial Facility Reported Incident dated 03/06/2026 documents that R6 eloped from the facility on 03/06/2026. Final Facility Reported Incident dated 03/12/2026 documents that the facility learned that R6 was taken to the hospital and was discharged from the hospital after refusing to return to the facility. On 03/21/2026 at 1:17PM, V15 (Certified Nursing Assistant/CNA) states he was working at the facility on 03/05/2026 during the 11:00PM-7:00AM shift. V15 states he was assigned to the third floor and to care for R6. V15 states he had a good rapport with R6 and R6 was cool and friendly. V15 states around 1:00AM to 2:00AM, he heard an alarm sound coming from one of the staircase doors on the third floor. V15 states each floor has staircase doors that require a code and if the code is not put in, then the doors will alarm when opened. V15 states none of the staff saw anyone exit through the staircase doors and only heard the alarm. V15 states other staff began checking residents' rooms and V15 went towards the alarm sound at the staircase door. V15 states once at the third-floor staircase door, he entered the code to stop the alarm and did not see anyone in the staircase. V15 states he then heard another alarm coming from the first floor. V15 states the alarm sound coming from the first floor has a different sound than the third floor, which is how V15 knew that someone had gone through the first-floor staircase door unauthorized. V15 states he went to the first floor and saw R6 standing next to one of the outside exit doors. V15 states R6 stayed at the exit door for about 2 minutes then pushed through the exit door. V15 states he then followed R6 outside and was located about 5-6 feet away from R6. V15 states R6 was calm and staying put and he was making sure R6 was safe. V15 states R6 then began to walk towards the main road. V15 states he did not have on a coat or hat and did not have his phone with him as a means for communication. V15 states he then went back into the facility to retrieve his items and a hat and coat because it was too cold outside. V15 states it took him less than two minutes to go back out to R6 but once he went back outside, R6 was not standing where she once was located. V15 states he then ran around the building to check all the exits doors to try and locate R6 but could not find her. V15 states the police arrived shortly after and he gave a description of R6 in order for the police to try and search for her. V15 states he and other staff members continued to try and search for R6 but still was unable to locate R6. V15 states he is not sure if R6 was hiding but R6 was gone, and staff could not find her either. V15 states there are no security guards who work in the facility. On 03/21/2026 at 2:30PM, V10 (Social Services Director/SSD) states she oversees a total of four social workers in the facility. V10 states there are two social workers who are new social workers. V10 states usually anyone from social services is responsible for completing the elopement risk assessments for the residents. V10 states she expects the elopement risk assessments to be completed within 3-7 days. V10 states this allows staff a chance to get to know the resident more and observe their behaviors. V10 states residents are identified to be at risk for elopement if they have a history of elopement, if they display behaviors such as exit seeking, staying near exit doors, if they verbalize things related to psychosis, and if they say things related to wanting to leave the facility. V10 states if a resident states they do not want to be in the facility, then this information would be brought up to the team to address it. V10 states they would ask questions, contact the doctor, and start a discharge plan for the resident. V10 states R6 never verbalized to her that she wanted to leave the facility. V10 states she was working on getting community access for R6 and things were going good. V10 states then she find out that R6 eloped on her birthday. V10 states to her knowledge, R6 did not tell anyone in the facility that she wanted to leave the facility. At 2:39PM surveyor makes V10 aware of the progress note written by V13/Social Worker on 02/24/2026 at 7:00PM and R6's desire to not be in the facility. V10 states V13 never made her aware that R6 did not want to be in the facility. V10 states she has to look more into this and follow up and what happened. V10 states that V13 is a new social worker in the facility and this is V13's first position as a social worker. V10 states if R6 informed V13 that she did not want to be in the facility then V13 should have informed V10. V10 states she would have immediately informed R6's doctor to discuss other discharge planning options for R6. V10 states if R6 made V13 aware that she did not want to be in the facility, then R6's elopement assessment should reflect that. V10 states if V13 would have informed her that R6 stated that she did not want to be in the facility, then things could have went a different way and R6's elopement would have been prevented. V10 states she could have initiated a safe discharge for R6. Facility policy undated, titled Wandering and Elopement documents in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observations, interviews and record reviews, the facility failed to provide wheelchairs to residents that were in safe and working condition to 3 (R12, R13 and R14) of 3 residents reviewed for concerns on properly functioning wheelchairs. This failure had the potential to result in accidents and safety hazards. Findings Include:R12's Face Sheet documents that R12 was admitted to the facility on [DATE] with a diagnosis of nontraumatic intracerebral hemorrhage, traumatic subdural hemorrhage epileptic seizures related to external causes, chronic kidney disease, and hypertensive heart disease without heart failure aneurysm of the descending thoracic aorta.R12's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment. R12's MDS dated [DATE] shows impairments to both R12's upper and lower extremities and requires substantial to maximum assistance in all activities of daily living (ADL) categories except eating and oral hygiene in which R12 requires supervision.R13's Face Sheet documents that R13 was admitted to the facility on [DATE] with a diagnosis of unspecified injury at unspecified level of cervical spinal cord, subsequent encounter, hemiplegia, unspecified affecting left nondominant side, and may use wheelchair for mobility.R13's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment. R13's MDS dated [DATE] shows impairments to both R13's upper and lower extremities and requires substantial to maximum assistance in all activities of daily living (ADL) categories except eating and oral hygiene in which R13 requires supervision.R14's Face Sheet documents that R14 was admitted to the facility on [DATE] with a diagnosis of weakness, cerebral infarction affecting right dominant side, hemiplegia and hemiparesis, and chronic respiratory failure with hypoxia.R14's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment. R14's MDS dated [DATE] indicates R14 needing moderate assistance to supervision.On 11/24/2025 at 11:49AM, R12 was dressed and sitting in R12's room in R12's wheelchair. R12 stated that R12's wheelchair is not working because it is hard for the wheels to move.On 11/24/2025 at 11:56 AM, V33 (Licensed Practical Nurse) stated that R12 had complained to V33 that R12's wheelchair was hard and when V33 asked, What do you mean by hard, R12 responds that it is just f-ing hard. V33 stated that V33 reported the wheelchair issue to maintenance for repair and that it was fixed. V33 added that R12 still complained that the wheelchair's wheels were hard to move.On 11/24/2025 at 12:35 PM, R13 was sitting near the nurse's station outside of R13's door. R13 said that the strap/seat belt of R13's wheelchair was broken due to R13's fall. R13 pointed to the right side of the chair near R13's lower back. R13's buckle strap was broken.On 11/24/2025 at 12:40 PM, R14 wheeled up to the nurse's station and when asked, R14 stated that R14's wheelchair was broken. R14 said that R14's brakes were not working and the rubber parts of R14's wheels kept coming off.On 11/24/2025 at 3:03PM, V28 (Restorative Aide) stated that a month ago R12 complained to V28 about R12's wheelchair and V28 notified maintenance. V28 said that after maintenance repaired it, R12 still complained that it was broken.On 11/25/2025 from 10:45 AM to 11:10 AM, V14 (Maintenance Supervisor) accompanied the surveyor to R13's and R14's rooms to inspect their wheelchairs. Upon observation, the right strap of the R13's seatbelt was tied to the elbow or cushion guard of the right armrest in a knot. After the nursing staff removed R13 from the chair, V14 explained that R13's seatbelt was not placed properly. V14 showed how the seatbelt strap was not fastened properly and how the material used to tie the knot was not secure. V14 added that screws should be added to firmly secure the seatbelt of the wheelchair.V14 stated that the rubber around R14's wheelchair wheels fall off as R14 enters the building. V14 stated that V14 witnessed the rubber falling off as R14 entered the facility and V14 repaired it. V14 said that it was a surprise to learn that R14's brakes were not working. There was blue tape tied around the breaks of R14 wheelchair. V14 explained that the smooth tape had no grip or traction which causes improper breaks. V14 said that R14's wheelchair may cause property damage, accidents and injury to R14.V14 added that R14's lack of breaks could cause R14 to run into a wall. V14 stated that this is an overall safety issue.On 11/25/2025 at 1:05 PM, V2 (Director of Nursing) stated that R12 was not pleased with R12 wheelchair and sought V2's assistance in receiving a new one. V2 said that V2 told R12 that R12 should wait to qualify for the wheelchair because R12 may later qualify for the walker and insurance may not pay for both.On 11/26/2025 at 1:40 PM, V1 (Administrator), V1 said the divider of R12's wheelchair was touching the wheel and the screw needed to be replaced and that was the reason why the wheels of R12's wheelchair was hard. V1 stated that it is important to make sure the wheelchairs are in good working condition for resident safety. V1 added that is important that wheelchairs of residents are kept functioning properly to receive the best quality of care.The facility undated policy titled Assistive Devices and Equipment reads Defective or worn devices are repaired or discarded, at resident's or family's discretion.

Based on review of records, interviews and observations facility failed to follow preventive measures to address sacral pressure ulcer care for 1(R2) out of 3 residents for a total of 3 residents reviewed for skin care. This failure resulted to one resident (R2) sustaining pressure ulcer deterioration. Findings include: R2 is [AGE] years old, initially admitted on [DATE]. R2's medical diagnosis includes Parkinson's disease and muscle weakness. R2 was seen on 04/08/2025 at 12:30 PM, in his room alert and verbally able to response within topic during conversation. R2 replied when asked if he has wounds, Yes, I have on my back. R2 stated that dressing was not change yesterday and today. But was changed a couple of weeks ago. R2 was seen laying on his back. When asked if staff are turning him (R2) on his side? R2 replied, No, they don't turn me on my side. They turn me when they change my dressing on my back. But not daily. R2's feet seen pushing on the footrest without heel protector. Per V6 (Nurse Practitioner Wound) clinical notes dated 03/12/2025, 03/21/2025 and 03/26/2025 R2's sacral pressure ulcer was deteriorating. V6 ordered to place R2 on side lying position every two (2) hours. And to turn and reposition every two (2) hours. R2's Treatment Administration Record (TAR) for March and April 2025 documents that multiple days for full eight (8) hours shift of turning and repositioning every two (2) hours were not signed as being performed. Both facility skin assessments and V6's sacral pressure ulcer assessment documents substantial increase in size. V6 assessment documents, from 0.25 square centimeters on 02/26/2025 to 0.50 square centimeters on 03/12/2025 an increase of 100%. Then further increase in size to 0.80 on 03/26/2025. R2's pressure ulcer was staged as 2 on 12/05/2025 by V16 (Nurse Practitioner Wound) later became stage 3 that indicates wound deterioration. Discrepancy of R2's March and April treatment administration records (TARs) were identified. TAR provided by facility on 04/08/2025 does not document signing of turning and repositioning as ordered by physician for the whole eight-hour shift on multiple days. TAR provided by facility on 04/09/2025 was modified by signing all days that were not signed including physician order for turning and repositioning. R2's wound plan of care document turning and repositioning as part of intervention for pressure ulcer prevention and improvement. On 04/09/2025 at 10:55 AM, V7 (Assistant Director of Nursing / Wound Coordinator) stated that included on R2's intervention to treat sacral pressure ulcer is to turn and reposition. And that a pillow is placed on his side to relieve pressure. V7 when asked about purpose of turning and repositioning said, It lift off prolonged pressure. V7 stated that resident who stays for a long time in the same position will get redness or stage one (1) pressure ulcer. V7 said, It is very important to reposition. On 04/09/2025 at 11:58 AM, V2 (Director of Nursing) V2 stated that R2's sacral pressure ulcer reopened on 11/19/2024. V2 stated that there are many factors that may cause worsening of pressure ulcers. Lack of turning and repositioning can cause worsening of pressure ulcer. V2 stated that she cannot explain the modification of R2's treatment administration record. And will take responsibility of documents discrepancies. On 04/09/2025 at 01:00 PM, R2's sacral pressure ulcer was seen with V7. V7 stated that V6 just did the dressing change with R1 sacral pressure ulcer. Pressure ulcer was seen about the size of a penny around half centimeter deep. Appearance of R2's sacral pressure ulcer consistent with stage 3 category. Pressure ulcer staging dated 05/12/2014 CMS attachment training reads and Section M on Minimum Data Set (MDS) assessment: Stage 2 is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as intact or open/ruptured blister. Stage 3 is defined as full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. On 04/09/2025 at 01:10 PM, V6 (Wound Nurse Practitioner) stated that R2's sacral pressure ulcer decline, as it increased in size on 03/12/2025. V6 stated that R2 needs to be turn and repositioned every two (2) hours and needs to be clean and dry. V6 said, The importance of turning and repositioning to heal a pressure ulcer is like 80% of how to heal pressure ulcers. V6 stated when treating pressure ulcer, the problem is pressure. Therefore, it is important to relieve the pressure. V6 also stated that R2 needs low air loss mattress (LAL) because it helps with the moisture. And currently R2 uses Alternating Pressure (AP) mattress. Preventive measures for sacral pressure ulcer ordered by physician that were not established during review: - Reposition every 2 hours order date 12/01/2024. - Apply heel protector all the time order date 11/05/2024. - Low air loss (LAL) mattress order date 11/2024, R2 was using alternating pressure (AP) mattress. Prevention of Pressure Injury policy not dated reads: The purpose of this procedure is providing information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Under mobility / repositioning, reposition all residents with the risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines.

Based on review or records and interview the facility failed to provide accurate treatment administration record for 1(R2) out of 5 residents for a total of 5 residents reviewed. This failure resulted to inaccurately representing one (1) resident (R2) treatment of pressure ulcer care in the facility. Findings include: R2 is [AGE] years old, initially admitted in the facility on 03/01/2010. R2 medical diagnosis includes Parkinson's disease, bipolar disorder and muscle weakness. On 04/08/2025 at 12:30 PM, R2 was seen in his room alert and verbally able to response within topic during conversation. R2 replied when asked if he has wounds, Yes, I have on my back. R2 stated that dressing was not change yesterday and today. But was changed a couple of weeks ago. R2 was seen laying on his back. When asked if staff are turning him (R2) on his side? R2 replied, No, they don't turn me on my side. They turn me when they change my dressing on my back. But not daily. R2's feet seen pushing on the footrest without heel protector. At the nurse station with V13 (Licensed Practical Nurse) a copy of R2's treatment administration record (TAR) for the month of March and April 2025 a copy was provided. At 01:05 PM went back to nurse station, V2 (Director of Nursing) was requested to provide a copy of R2's physician order sheets included in the chart binder of R2. V2 was informed that earlier a copy of R2's TAR was received from V13. V2 then provided a copy of R2's physician order sheet. At 04/08/2025 at 02:31 PM, an email was sent to V1 (Administrator) and V3 (Assistant Administrator) requesting resident records that includes R2's TAR for the month of March and April 2025. The following day 04/09/2025 at 09:29 AM, facility provided R2's TAR for the month of March and April 2025. Comparing R2's TAR for the month of March and April 2025 provided on 04/08/2025 from R2's TAR for the month of March and April 2025 provided the following day 04/09/2025. Multiple discrepancies were noted as to documentation on treatment services provided. Multiple treatment orders were not signed as being performed including application of abdominal binder, application of heel protector, repositioning of R2 every 2 hours on the original document provided on 04/08/2025. Document provided by facility the following day 04/09/2025, all areas that were not signed was filed up and signed. On 04/09/2025 at 11:58 AM, V2 (Director of Nursing) was made aware R2's two different copies of treatment administration record (TAR) for March and April 2025. After seeing the two (2) documents stated, I can see that many days in the TAR were not signed. I will not say who signed those blank on the TAR. But I will take responsibility. At 02:25 PM, V1 (Administrator) stated that this incident on discrepancies of R2's record will be reviewed and investigated. Per V6 (Nurse Practitioner for Wound) clinical notes dated 03/12/2025, 03/21/2025 and 03/26/2025, document that R2's sacral pressure ulcer was deteriorating. Charting and Documentation policy dated 09/01/2024 reads: Information documented in the resident medical record includes treatment and services performed. Documentation in the medical record will be objective (not opinionated or speculative, complete, and accurate.

Based on observation, interview and record review, the facility failed to supervise and monitor a cognitively impaired resident with known behaviors of ingesting non-edible, toxic items from obtaining those items. This failure affects one of three residents (R2) reviewed for supervision in a total sample of three residents. Findings include: 03/08/2025, 9:53 AM, R2 was sitting on a chair next to her bed. R2's overbed table was next to her with her personal items within reach. A 4 oz (ounce) baby powder bottle and liquid soap in a clear cup on were her overbed table. 03/08/2025, 11:03 AM, with V2 (Assistant Administrator) present, R2's overbed table observed with baby powder. V5 (Certified Nursing Assistant) entered the room. R2 was questioned who gave you the powder. R2 pointed to V5 and stated that young lady. R2 states that she got the liquid soap from someone at the nurse's station but cannot recall who. 03/08/2025, 10:51 AM, via telephone, V6 (Certified Nursing Assistant) states that she has worked for the facility for three years. V6 reports that she usually works the morning shifts and usually works on the second floor. V6 states that she is familiar with R2. V6 continues to report that R2 needs reminders to take a shower. We make sure she showers. She likes to hold food, but you can't just take away the old food, when she is around, because she is a fighter. V6 states you need to make sure you don't give her baby powder and lotion because she thinks they are condiments and consume them. V6 says it is salt and pepper. 03/08/2025, 11:06 AM, V5 (Certified Nursing Assistant) states that R2 requires minimal assist. Staff provides set up, and gets her the things she needs. She asks for soap. Normally, staff don't give her baby powder. She can do it herself, we just don't give her powder. V5 states that she was changing R1 this morning and R1 had a lot of items on her overbed table. V5 stated I borrowed R2's table. V5 states that the reason R2 cannot have the baby powder within reach is because R2 will probably apply too much powder on herself. V5 states that she denies ever seeing R2 put powder on her food. V5 states I was not made aware that she can put powder on her food. It would be safer for her not to have any powder if that is the case. V5 states I was not aware that she would eat it. I just thought she would sprinkle too much powder on her body. It was a mistake and not intentionally done. 03/08/2025, 12:06 PM, V4 (Director of Nursing) states that it is not safe for an individual to consume soap, lotion, and/or baby powder because it is not to be eaten. V4 states that if she knew R2 had a history of ingesting these certain items, staff should not provide any of those items, unless supervision is provided. V4 states that it is important to not give lotion, liquid soap, or baby powder to the resident without supervision because if there is a history, the resident might take it again and God knows what might happen. V4 stated she might send the resident to the emergency room to check if they are safe to come back. V4 states these items might have a toxic effect or the resident might be allergic. R2's current face sheet documents R2 is a [AGE] year-old individual admitted to the facility on [DATE], and has diagnoses not limited to: paranoid schizophrenia, anxiety disorder, extrapyramidal and movement disorder, unspecified. R2's MDS/Minimum Data Set, dated dated dated [DATE], documents that R2 has a BIMS/Brief Interview for Mental Status score of 08/15, indicating that R2 has moderate cognitive impairment. R2 presents with inattention and disorganized thinking behavior, fluctuates (comes and goes, changes in severity). R2's current care plan documents in part, R2 has alteration in thought process related to: diagnosis : schizoaffective disorder -paranoid type as evidenced by: Pt. (patient) noted with visual and auditory hallucination. On 8/24/23, R2 was observed sprinkling baby powder on her potato chips. On 9/3/23, Rt (resident) seen by a staff drinking a thick liquid substance from a cup. When asked, resident said it was milk but upon checking staff noted it was body lotion. Staff was able to retrieve cup from resident & discarded it. R2 displays socially inappropriate and maladaptive behavior a mental illness diagnosis of Schizophrenia. Per ADON (assistant director of nursing), resident has been observed washing her hair and body with toilet water. Staff will monitor the resident when she is has possession of cups and is ingesting proper liquids. R2's psychiatric progress note dated 02/11/2025, 9:33 PM, documents in part behavior is manageable. Resident has regular habit of putting stuff on her forehead. Resident has history of pica (Compulsively swallowing non-food items) but the behavior does not show recently. Facility document dated 01/24, titled policy on resident rights, respect and dignity documents in part, a resident has the right to receive services in a facility environment that is safe, clean, and comfortable with adequate space for all activities.

Based on observation, interview and record review, the facility failed to ensure medications were stored at proper temperatures in two of three medication refrigerators reviewed for medication storage; failed to secure Schedule II controlled drugs and other controlled drugs subject to abuse in a separately locked compartment separate from non- controlled drugs; and failed to ensure medications including controlled drugs of two of two residents (R159 and R262) that expired are disposed timely. These failures have the potential to affect 47 residents residing on first floor and 56 residents residing on third floor of the facility. Findings include: The ([DATE] email correspondence with V10 (Assistant Administrator documented that there were 47 residents on the first floor and 56 residents on the 3rd floor. On [DATE], at 11:10 AM, during rounds with V12, Licensed Practical Nurse (LPN) on the 1st floor medication refrigerator was noted with frost in freezer area of the refrigerator and temperature was 42 degrees Fahrenheit. V12 confirmed temperature to be 42 degrees Fahrenheit. On [DATE], at 11:15 AM, V12 LPN stated this is her first first time working 1st floor because V12 work from an agency, and V12 wasn't for sure of the correct refrigerator temperature range. On [DATE] at 11:58 am during rounds with V7 LPN on the 3rd floor, medications refrigerator was observed with thick white frost in the freezer area of the refrigerator. V7 stated the refrigerator get defrosted weekly by the night nurse. Refrigerator temperature noted to be 42 degrees. V7 confirmed temperature to be 42 degrees Fahrenheit and stated that V7 will have this refrigerator defrosted today. On [DATE] 12:58 PM, medication refrigerator on the 1st floor was noted to be at 48 degrees Fahrenheit. V18 (LPN) confirmed temperature to be 48 degrees Fahrenheit. On [DATE] at 12:26 PM. V2 DON stated the refrigerator freezer for medication get defrosted whenever necessary. Facility presented undated policy with the title: Medical Refrigerator Management and Defrosting Protocol/Policy. Temperature Monitoring: Medical refrigerators should be monitored regularly (minimum of once per shift) to ensure they maintain the temperature range of ,d+[DATE]-degree Fahrenheit; Temperature logs must be maintained, and any deviations outside of the acceptable range should be reported immediately. Defrosting Procedures: Frequency of Defrosting: Defrosting must be performed when ice accumulation reaches ,d+[DATE] inch (1.27cm) on the cooling coils; If the refrigerator's cooling performance decreases (e.g., temperature fluctuations, higher- than usual compressor running time)., defrosting should be carried out immediately, regardless of ice buildup, Defrosting should also be performed on a scheduled basis at least once every three months to prevent excessive buildup and as needed. On [DATE], at 11:54 AM, observed the 1st floor medication refrigerator unlocked and easily accessible to all other residents and staff. The following controlled medications for R159 were inside the medication refrigerator: 1 bottle of 0.25 ml of Morphine Sulfate, Lorazepam 0.25ml- PRN - 1bottle- unopen and an unopened box symptom relief kit with R159 name on the label. V12 LPN stated that R159 already expired, and the controlled medications for expired residents are supposed to be given to V2, Director of Nursing (DON). V12 stated for the regular medications the nurses will return the medications to the pharmacy. On [DATE], at 12:16 PM, the 3rd floor medication refrigerator was observed to be unlocked and accessible to other residents and staff. The following controlled medications for R262 were inside the medication refrigerator symptom kit which contained Ativan, hydromorphone. Facility presented undated policy with the title: Controlled Substances; Policy Interpretation and Implementation which documents: Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. 51772 Findings include: On [DATE] at 11:40 am, surveyor observed medication refrigerator on 1st floor was not locked and easily accessible to other staff and residents. Observed the following R159's controlled medications in unlocked refrigerator stored inside the bottom drawer not in a separate locked container: Morphine Sulfate 0.25 millimeter (ml) bottle, Lorazepam 0.25 millimeter (ml). An unopened Symptom Kit containing: Ativan and Hydromorphone. Interviewed V12 Licensed Practical Nurse (LPN) on [DATE] at 11:40 am, V12 LPN stated that she did not have the key to the unlocked refrigerator and did not want to lock the refrigerator to prevent inability to access the controlled medications if needed and further stated that confused patients could walk in the nursing station and access the refrigerator. Facility Controlled Medication Policy states Controlled substances are stored in the medication room in a locked container, separate from the containers for any non-controlled medications. Access to controlled medications remains locked at all times and access is recorded.

Based on observation, interview, and record review the facility failed to assess a resident for safe self-administration of medications. This failure affected one resident (R148) and has the potential to affect all 56-residents residing on the second floor. Findings Include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were 56 residents on the second floor. R148's admission diagnoses include but not limited to dermatitis, atrial fibrillation, congestive heart failure, and dementia. R148's Brief Interview of Mental Status (BIMS) score is 11 which indicates R148 has moderate cognitive impairment. On 12/1/24 at 10:30 am, observation of Zinc oxide 20% ointment in a long white tube on R148's nightstand. On 12/2/24 at 1:10 pm observation of Zinc oxide 20% ointment and triamcinolone acetonide 0.5% ointment in long white tubes on R148's nightstand. On 12/3/24 at 12:25 pm, observation of triamcinolone acetonide 0.5% ointment on R148's nightstand in a container with toothpaste. On 12/3/24 at 12:30 pm, surveyor inquired to V14 RN (Registered Nurse) if R148's triamcinolone acetonide ointment should be at the bedside. V14 stated, It should not be at the bedside. It should be in the treatment cart. It should not be at the bedside because he (R148) could eat it or think its toothpaste. On 12/3/24 at 1:10 pm, V2 DON (Director of Nursing) stated that an assessment has to be done for self-administration of medication. There should also be doctors order for self-administration. Medications should not be left at the bedside without an assessment and a doctor's order to self-administer. On 12/3/24 at 3:16 pm, surveyor requested R148's assessment to self-administer medications. At 3:51 pm, V2 (DON) replied via email, No assessment for self -administration of medication for R148. R148's (12/3/24) active physician orders documents in part, Zinc Oxide creme twice daily to groin and buttock, DX (Diagnosis) Dermatitis. Triamcinolone Acetonide 0.5% ointment apply small amount topically to affected areas (groin, perineal) twice daily as needed for rashes. R148's care plan documents in part, Focus: Altered thought process related to dx (diagnosis) of Dementia. Focus: Cognitive Loss/Disorientations/Impaired Judgment. The resident demonstrates cognitive impairment related to a diagnosis of dementia. Symptoms are manifested by impaired decision making, poor logic and poor agility to understand cause and effect. Facility's policy (undated) and titled, Self-Administration of Medication documents in part, Policy: Self-administered medications will be encouraged f it is desired by the resident, safe for the resident and other resident of the facility. Ordered by the attending physician . Facility's policy (undated) and titled, Medication Administration documents in part, Policy: 5. The medication is to remain in the container until administration time. Facility job description titled License Practical Nurse documents in part, Essential Duties and Responsibilities: Carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures. Facility job description titled Registered Nurse documents in part, Essential Duties and Responsibilities: Carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures.

Based on observation, interview, and record review the facility failed to ensure that medications were signed out when administered for four residents (R8, R43, R81, and R97). This failure affected four residents in the sample of 57 residents. Findings include: On 12/02/24 at 8:58 am, Surveyor requested to observe medication pass on the first floor Team 2 cart with V18 (Licensed Practical Nurse, LPN) and V18 stated that V18 completed the 9:00 am medication pass. Surveyor and V18 reviewed R8, R43, R81, and R97's Medication Administration Record (MAR) and observed R8, R43, R81 and R97's medications not signed out for the 9:00 am medication pass. V18 stated, I (V18) gave them, but I (V18) did not get a chance to sign them out. I (V18) was going to sign them in a few minutes. R8's MAR presented by the facility on 12/02/24 shows the following medications for R8's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Anastrozole 1 mg tablet by mouth Aspirin Enteric Coated (EC) 81 mg tablet by mouth Daily Vite tablet by mouth Docusate Sodium 100 mg capsule by mouth Vitamin D 1000IU (units) tablet by mouth Oyster Shell 500 with Vitamin D 200 mg by mouth Quetiapine Fumarate 100 mg by mouth Vitamin C 500 mg tablet by mouth R43's MAR presented by the facility on 12/02/24 shows the following medications for R43's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Amantadine 100 mg (milligram) tablet by mouth Carbidopa-Levodopa 25 -100 mg tablet by mouth Eliquis 5 mg tablet by mouth Entacapone 200 mg tablet by mouth Lamotrigine 25 mg tablet by mouth Levetiracetam 100 mg tablet by mouth Potassium Chloride 10 % liquid by mouth Tamsulosin 0.4 mg capsule by mouth Valproic Acid 250 mg/5ml (milliliter) by mouth R81's MAR presented by the facility on 12/02/24 shows the following medications for R81's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Citalopram 10 am tablet by mouth Quetiapine Fumarate 100 mg by mouth Quetiapine Fumarate 50 mg by mouth Tradjenta 5 mg tablet by mouth Vitamin D3 25 mcg tablet by mouth R97's MAR presented by the facility on 12/02/24 shows the following medications for R97's were not signed after being administered by V18 for the 9:00 am medication pass on 12/02/24: Aripiprazole 15 mg tablet by mouth Aspirin 81 mg tablet by mouth Bethanechol 25 mg tablet by mouth Brimonidine 0.2% eye drop ophthalmic Docusate Sodium 100 mg by mouth Famotidine 40 mg tablet by mouth Farxiga 10 mg tablet by mouth Flovent 110 mg inhaler by inhalation Gabapentin 300 mg capsule by mouth Hydroxyzine 25 mg capsule by mouth Polyethylene Glycol 3350 powder by mouth Potassium Chloride Extended Release (ER) 10 meq (milliequivalents) by mouth Dry Eye Relief eye drops ophthalmic solution Topiramate 25 mg by mouth Vitamin D3 25 mcg (micrograms) by mouth On 12/02/24 at 10:01 am, Surveyor asked V18 regarding the facility's policy for medication administration and V18 stated, Medications should be signed out when given. When V18 was asked regarding the importance of signing out medications when given V18 stated, If medications are not signed out when given they can be misconstrued as not given and another nurse can administer the medications again. On 12/03/24 at 8:47 am, V2 (Director of Nursing, DON) was asked regarding the facility's policy for medication administration and V2 stated, Medication should be signed out immediately after the medication is given. If the nurse gives the medication and does not sign out medication the medication can be double dosed. The facility's undated policy titled Medication Administration documents, in part: Policy: 4. Nursing personnel administer and record all medications. The facility's undated document titled The Licensed Practical Nurse (LPN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . Complete the required documentation and evaluation by the local, state, federal and facility policies. R8's Brief Interview for Mental Status (BIMS) dated 10/28/24 shows that R8 has a BIMS score of 15 which indicates that R8 is cognitively intact. R8's Face sheet shows that R8 has diagnosis which include but not limited to schizoaffective disorder, malignant neoplasm, metabolic syndrome, and hypothyroidism. R43's Brief Interview for Mental Status (BIMS) dated 10/20/24 shows that R43 has a BIMS score of 15 which indicates that R43 is cognitively intact. R43's Face sheet shows that R43 has diagnosis which include but not limited to schizoaffective disorder, Parkinson's, epilepsy, and hypothyroidism. R81's Brief Interview for Mental Status (BIMS) dated 10/21/24 shows that R81 has a BIMS score of 15 which indicates that R81 is cognitively intact. R81's Face sheet shows that R81 has diagnosis which include but not limited to paranoid schizophrenia, major depression, and generalized anxiety. R97's Brief Interview for Mental Status (BIMS) dated 10/08/24 shows that R97 has a BIMS score of 15 which indicates that R97 is cognitively intact. R97's Face sheet shows that R97 has diagnosis which include but not limited to Parkinson's disease without dyskinesia, major depressives disorder, chronic obstructive pulmonary disease, and schizoaffective disorder bipolar type.

Based on observation, interview, and record review the facility failed to ensure that a resident (R120) smoke at a designated smoking area; and failed to ensure that environment was free from hazards (razors) for three residents (R36, R116 and R148). These failures have the potential to affect all 47 residents on the first floor, and all 56 residents on the second floor at the facility. Findings include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were 47 residents on the first floor. On 12/01/24 at 10:40 am, Surveyor observed R116 in R116's room holding 3 shaving razors in R116's right hand. R116 stated that R116 was given the 3 razors from staff 3 days ago to shave R116's head. R116 stated that R116 receives razors from staff to shave R116's head and face. When R116 was asked regarding where does R116 store the razors in R116's hand R116 stated in R116's room. On 12/01/24 at 11:29 am, V12 (Licensed Practical Nurse, LPN) was asked regarding residents with razors and V12 stated that residents cannot have razors due to safety. V12 stated that a resident who does not know how to use the razor can get the razor, cut themselves and bleed. When V12 was asked regarding who monitors the residents that shave themselves and V12 stated that V12 was a agency nurse working at the facility and that V12 did not know. On 12/03/24 at 8:49 am, Surveyor questioned V2 (Director of Nursing DON) regarding residents with shaving razors and V2 stated that residents cannot have razors in their possession due to safety. When V2 was asked regarding who was responsible for monitoring the residents who shave themselves with razors and V2 stated that it is all the nursing staff responsibility to monitor residents who are able to shave themselves with a razor. R116's Brief Interview for Mental Status (BIMS) dated 10/29/24 shows that R116 has a BIMS score of 15 which indicates that R116 is cognitively intact. The facility's undated policy titled Hazard Policy: Proper Disposal of Sharps documents, in part: Purpose: To establish procedures for the safe handling and disposal of sharps, including razors, needles, and other sharp objects, to minimize risk of injury and ensure compliance with local, state, and federal regulations . Policy Statement: All sharps must be disposed of in accordance with established guidelines to ensure the safety f residents, staff, and visitors. Under no circumstances should sharps be discarded in regular trash or recycling bins. On 12/01/24 at 10:52 am, Surveyor observed R120 in R120's bathroom with a lighter and cigarette smoking a cigarette. When R120 saw this Surveyor at R120's bathroom door R120 immediately turned on the water from the bathroom sink in R120's bathroom and put the cigarette out in R120's bathroom sink. This Surveyor brought this observation to V12 (Licensed Practical Nurse, LPN). Surveyor and V12 went back to R120's bathroom where R120 was still sitting and observed R120 still in R120's bathroom smoking another cigarette in R120's bathroom. R120 then immediately placed the cigarette under the running water in R120's bathroom sink, putting out the cigarette in R120's hand. When V12 was asked regarding residents smoking in the residents room V12 stated that residents cannot smoke in the resident due to the resident risking the safety of the other residents and the potential to start a fire. On 12/01/24 at 11:15 am, Surveyor asked V8 (Social Service Director) regarding residents smoking in the residents rooms and V8 stated that safe smokers are allowed to have smoking materials such as lighters and cigarettes in the residents room but the resident should not be smoking in the residents room even if the resident is assessed as a safe smoker. When V8 was asked regarding what could happen if a resident smokes in the residents room and V8 stated, There is a potential for a fire or the resident to burn themselves. When V8 was asked regarding who is responsible for monitoring the residents who smoke and V8 stated, It is all the staff responsibility. R120's face sheet shows that R120 has a diagnosis of schizoaffective disorder, hypothyroidism, and major depressive disorder. R120's Brief Interview for Mental Status (BIMS) dated 9/26/24 shows that R120 has a BIMS score of 15 which indicates that R120 is cognitively intact. R120's progress note dated 12/01/24 and authored by V8 documents in part: Per nursing report, R120 was smoking inside his (R120) room on 12/0124. Smoking materials were confiscated and staff-initiated cigar management as a consequence . R120 is unable to handle own smoking materials at this time. R120's Smoking Risk Review dated 12/01/24 documents, in part: 12. May not be capable of handling/carrying any smoking materials and requires supervision when smoking. The facility undated document titled Facility Smoking Safety Policy documents, in part: Policy Objective: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Guidelines 1. Smoking is only allowed in designated areas established by management. If indoor smoking is prohibited by state or local law the interior of the facility will remain smoke-free at all times. The designated area(s) will be outside in accordance with state/local standards. The organization has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety, and security reasons . 3. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan of care. R120's care plan dated 12/01/24 documents, in part: Focus: Smoking management/noncompliance. The resident was smoking in a day room on 2/13/21. 11/8/21, 9/8/23 smoking in a washroom. 2/1/24 smoking in room. Date Initiated: 02/15/2021. Revision on: 12/01/2024. Intervention: 12/1/24 smoking materials were confiscated and staff-initiated cigar management as a consequence (resident is scheduled to d/c (discharge) from the facility on 12/6/24). SW (social worker) met with the resident 1:1 (one to one) to address the above. He (R120) is unable to handle own smoking materials at this time. Nursing staff and front desk staff were informed of the above. Patient is currently monitored for compliance. Date Initiated: 12/01/2024. 45644 Findings Include: R148's admission diagnoses include but not limited to osteoarthritis, atrial fibrillation, congestive heart failure, and dementia. R148's Brief Interview of Mental Status (BIMS) score is 11 which indicates R148 has moderate cognitive impairment. On 12/1/24 at 10:30 am, observed a razor in R148's room lying on the nightstand. R148 stated that he uses the razor to shave his head. On 12/3/24 at 12:20 pm, V14 RN (Registered Nurse) stated that R148 should not have a razor in his (R148) room. It is considered a contraband because it is a sharp. After the staff use the razor, they should dispose it for safety. On 12/3/24 1:10 pm, V2 DON (Director of Nursing) stated that razors should not be at a resident's bedside. Razors should be discarded in the sharp's container for safety because someone can get injured. R148's care plan documents in part, Focus: Altered thought process related to dx (diagnosis) of Dementia. Focus: Cognitive Loss/Disorientations/Impaired Judgment. The resident demonstrates cognitive impairment related to a diagnosis of dementia. Symptoms are manifested by impaired decision making, poor logic and poor ability to understand cause and effect. 43351 Findings include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were 56 residents on the second floor. On 12/01/24 at 11:09am on the second floor, there was a razor on R36's bed side table. This observation was pointed out to V5 (Maintenance Director). V5 stated there is a razor on his (R36) bedside table. On 12/01/24 at 11:15 AM, this observation was also pointed out to V6 (Director of Clinical Special Projects). V6 stated the resident is not allowed to have a razor in their room for safety. The razor should not be in here because the resident can use the razor to cut themselves and other residents. On 12/02/2024 at 9:40am, V2 (Director of Nursing) stated there should be no razor inside the resident's room because it is a safety issue for the resident, staff, and other residents. The resident may use the razor to cut themselves, other residents, or staff. R36's Admission Record documented that R36's diagnoses (include but not limited to) schizoaffective disorder and type 2 diabetes mellitus. R36's (09/17/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for Daily Decision Making: 2 - Moderately impaired - decisions poor, cues/supervision required. The (undated) Hazard Policy: Proper Disposal of sharps documented, in part Purpose: To Establish procedures for the safe handling and disposal of sharps, including razors, needles, and other sharp objects to minimize risk of injury and ensure compliance with local, state, and federal regulations. Scope: this policy applies to all staff, residents, and visitors at the facility. Definitions. Sharps: items capable of puncturing or cutting skin, such as needles, scalpels, broken glass, and razors. Policy Statement: All sharps must be disposed of in accordance with established guidelines to ensure the safety if residents, staff, and visitors. Procedures: 2. Disposal of Razors and other sharps. Disposable Razors: After use, razors must be placed directly into an approved sharp container. Residents who are alert and oriented may use disposable razors under supervision or independently as appropriate. After use, they should return the razor to staff for proper disposal in a sharp container. Staff will verify that the razor is disposed of safely and according to policy.

Based on observation, interview, and record review, the facility failed to follow policy of reconciling controlled substances at the end of each shift. This failure has a potential to affect all 4 residents receiving controlled substances on the 1st floor. Findings include: Facility presented list of residents taking controlled medications on first floor which totaled 4 residents. On 12/1/24 at 11:40 am, during facility rounds with V12 Agency Licensed Practical Nurse(LPN) document called Controlled Substance Check Form did not have signatures of a narcotic shift to shift count for 12/1/2024. V12 stated she did not count narcotics with the night nurse at the start of her shift. 12/03/24 at 01:40 PM The Director Of Nursing (DON) V2 stated that the Nurses need to count narcotic medications between incoming and outgoing nurses at the end of each shift. V2 also stated if the nurses did not do the narcotic shift to shift count they will all be in trouble and they will have to investigate any discrepancies. Facility presented an undated policy titled Controlled Substances which documents: 1. Controlled medication are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. 2. Policies and Procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist.

Based on observation, interview and record review, the facility failed to label and date oxygen equipment (oxygen tubing and nebulizer mask per the facility's policy. These failures affected two residents (R54 and R126) reviewed for oxygen equipment, in a total sample of 57 residents. Findings include: R54's diagnoses include but are not limited to heart failure, type 2 diabetes mellitus without complications, chronic kidney disease stage 3, essential hypertension, atrial fibrillation, acute respiratory failure, anxiety disorder, chronic obstructive pulmonary disease, morbid obesity. R54's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 8 which indicates R54's cognition is moderately impaired. R54's physician order dated 05/10/24 documents in part, change oxygen tubing and humidifier weekly or as needed. R54's care plan dated 03/04/23 documents in part, CHF: the resident has congestive heart failure .Give oxygen as ordered by the physician. R126's diagnoses include but are not limited to atrial fibrillation, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, bipolar disorder current episode manic without psychotic features, schizophrenia, muscle weakness, acute kidney failure. R126's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score 14 which indicates R126's cognition is intact. R126's physician orders dated 10/31/24 documents in part, change nebulization cup and tubing weekly or as needed. On 12/01/24 at 10:28am observed R126's nebulizer mask sitting on nightstand undated. On 12/01/24 at 10:53am V17 (Licensed Practical Nurse/LPN) stated that there is no date on R126's nebulizer mask but it should have a date on it. V17 discarded nebulizer mask into trash can. On 12/01/24 at 11:10am observed R54 with nasal canula undated. On 12/01/24 at 11:11am V13 (LPN) stated that R54 has no date on nasal cannula tubing. V13 stated that oxygen tubing is changed weekly on Sundays by the night shift and that the tubing should have a date on it. On 12/03/24 at 09:42am V2 (Director of Nursing/DON) stated that oxygen tubing should be dated and changed weekly and/or as needed. V2 stated that oxygen tubing is dated to prevent infection from long term use. Facility's undated policy titled Oxygen Administration documents in part, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration .Steps in the procedure: 11. O2 (oxygen) equipment should be changed and dated weekly.

Based on interview and record review the facility failed to refer one resident (R126) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR). This deficient practice affected one resident (R126) in a total sample size of 57 residents. Findings include: R126's admitted to the facility is 10/11/24. R126's PASRR (Preadmission Screening and Resident Review) level 1 outcome dated 08/29/24 documents in part, No level II required - No SMI (serious mental illness). R126's diagnoses on 10/11/24 include but are not limited to bipolar disorder current episode manic without psychotic features, schizophrenia, essential hypertension. R126's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score 14 which indicates R126's cognition is intact. On 12/03/24 at 11:19am V10 (Assistant Administrator/AA) stated that level 2 PASRR's are done when the resident has a mental diagnosis. V10 stated that a diagnosis of schizophrenia and bipolar should be included on the level 1 PASRR which would trigger for a level 2 PASRR to be done. V10 stated that PASRR's are done to make sure that residents are placed in the appropriate facilities and that it is a requirement to do the PASRR. V10 stated that if the serious mental illness diagnosis is not on the PASRR from the hospital then the facility should redo the level 1 PASRR immediately and include the diagnoses. Facility's policy dated 12/2023 titled Pre-Admission Screening and Resident Review documents in part, In accordance with Federal and State of Illinois regulatory standards and recommended practices, this organization requires each resident to be screened for Level 1 prior to or shortly thereafter admission. The facility will expect Maximus to properly complete Level 2 if a PASRR condition (SMI) exists .Policy: It is the policy of this facility to: 1. Comply with Federal, State and appointed screening agency in standards addressing the PASRR assessment/screening process.

Based on observation, interview, and record review the facility failed to ensure that medication that fell on the floor was not administered to a resident (R55). This failure affected one resident (R55) in the sample of 57 residents. Findings include: On 12/01/24 at 12:34 pm, Surveyor observed V12 (Licensed Practical Nurse, LPN) administer medication to R55 during the first floor noon medication pass. Surveyor observed V12 drop R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet on the floor next to R55's wheelchair, then pick up R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet from the floor next to R55's wheelchair and then administer R55's Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet to R55 orally. On 12/01/23 at 12:52 pm, Surveyor asked V12 regarding administering medications that have falling on the floor to a resident and V12 stated that if a medication falls on the floor the nurse should discard the medication and give the resident another pill. When V12 was asked regarding the importance of discarding medications that fall onto the floor and V12 stated, I (V12) gave it to her (R55) because I (V12) did not want her (R55) to curse me out. If a medication is given to a resident that has fallen on the floor that can be infection control. It (referring to the medication) can have germs on it. On 12/03.24 at 8:48 am, Surveyor asked V2 (Director of Nursing, DON) regarding the facility's expectation for administering medications that have fallen onto the floor and V2 stated that If a nurse drop a residents medication on the floor the nurse should through the medication out due to infection control. V2 also stated that residents should not receive medications that have been dropped on the floor due to the medication containing germs. R55's Brief Interview for Mental Status (BIMS) dated 10/08/24 shows that R55 does not have a BIMS score indicated. However, during this survey, R55 was able to answer questions appropriately. R55's Physician Order Sheet (POS) shows that R55 has an order for Divalproex Sodium DR (Delayed Release) 500 mg (Milligram)1 tablet by mouth three times a day. The facility's undated document titled The Licensed Practical Nurse (LPN) documents, in part: Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . Administer clinical care according to the standard of care and in accordance with local, state, federal and facility policies, and procedures. The facility's undated policy titled Infection Prevention and Control Program documents, in part: Purpose: To ensure the facility established and maintains an infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Policy: The facility must establish an Infection Prevention and Control Program under which it 4. Infection Prevention and Control Program standards apply to all facility employees, contracted staff, consultants, volunteers . Program and Procedures: F. Preventing, identifying, report, investigating, and controlling infections and communicable diseases-based on the facility assessment.

Based on observation, interview and record review the facility failed to provide a comfortable environment to one resident (R162). This failure affected one resident in a total sample size of 57 residents. Findings include: On 12/01/24 at 10:58am, surveyor entered R162's room and felt cold from a decrease in temperature. On 12/01/24 at 11:00am, R162 stated that he that he had been complaining of the cold temperature in his room since Wednesday 11/27/24. On 12/01/24 at 11:11am, V13 (Licensed Practical Nurse/LPN) stated that R162's room is as cold as the weather outside. V13 stated that a room that is too cold is an immediate need. On 12/01/24 at 11:56am, V5 (Maintenance Director) stated that no one had informed him that R162's room was cold. V5 checked R126 room with hand thermometer. Hand thermometer showed temperature 61 degrees Fahrenheit. V5 stated that R126's room temperature should be at least 68 degrees Fahrenheit. V5 stated that R126's room is cold due to a crack in the window. On 12/02/24 at 09:11am, V5 used handheld thermometer to check R126's room temperature which registered at 68 degrees Fahrenheit. V5 stated that he placed tape over crack in the window to prevent the breeze from coming into the room. R162 has diagnoses of presence of right artificial hip joint, type 2 diabetes mellitus without complications, hyperlipidemia, muscle wasting and atrophy not elsewhere classified multiple sites, difficulty in walking, unilateral primary osteoarthritis right hip. R162's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R162's cognition is intact. Facility's policy dated 10/2024 titled Cold Weather documents in part, Policy: For the safety and comfort of the residents, and staff the cold weather policy will be followed whenever extreme outdoor temperatures, power failure or heating plant malfunctions cause facility temperatures and humidity to rise beyond acceptable health and comfort levels .Procedure: Building manager will monitor the facility's main heating plant and individual room units to ensure that all are working at peak performance .When an uncomfortable building temperature is perceived by staff, resident or visitors, the building manager will take temperature readings at various locations of the building making sure to cover all residents and staff areas. Adjustments will be made to make all residents as comfortable as possibly .If temperatures of 65 degrees F (Fahrenheit) or lower are found readings will be taken every 2 hours. Temperatures will be documented on the Facility temperature form. The cold weather emergency plan will be followed to ensure the comfort and safety of all residents. Facility's policy dated 01/05/24 titled Policy on Resident Rights, Respect an Dignity documents in part, A resident has the right to receive services in a facility environment that is safe, clean, and comfortable with adequate space for all activities. Facility's policy dated 04/2014 titled Quality of Life - Homelike Environment documents in part, Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible .Policy Interpretation and Implementation .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include g. comfortable temperatures.

Based on observation, interview, and record review, the facility failed to ensure the Daily Nursing Staffing was posted daily and failed to ensure the Daily Nursing Staffing was completed appropriately. These failures have the potential to affect all 159 residents residing at the facility. Findings include: The (12/01/2024) Facility daily census was 159. On 12/01/2024 at 12:00pm by the reception area with V9 (Scheduler). This surveyor requested V9 to provide the Daily Staffing Posting for 12/01/2024. V9 looked around the reception area and stated it is not here. V9 inquired if this surveyor was looking for the Daily Staffing Schedule. This surveyor requested to see the Daily Staffing Schedule. On 12/01/24 at 12:05 PM by the first-floor nurse's station, V9 pulled a document from a clipboard and showed this surveyor the Daily Staffing Schedule for 12/01/2024. The form did not indicate the current number of residents and there were no hours for Registered Nurses, Licensed Practice Nurses and CNAs for each shift. This surveyor inquired for the total number of hours for registered nurse, licensed practice nurse and CNAs for each shift. V9 stated I have been here for 2 years, and nobody told me I need to put the total hours of the nurses and CNAs in the Daily Staffing Schedule. (V1 - Administrator) must have the document you are asking for. V9 also stated the Daily Staffing Schedule has a space for Total Census but it is not filled out. On 12/01/24 12:12 PM, V1 (Administrator), pointing to the Daily Staffing Schedule, stated the Daily Staffing Schedule is the Daily Staffing Posting. Nobody told us that we need to put the total number of nursing hours in the Daily Staffing Schedule. The hours (pointing to the shifts 7:00am - 3:30pm, 3:30pm - 12MN (midnight), and 12MN - 8:30am) are already written and that is already the nursing hours. On 12/02/2024 at 9:35am, V2 (Director of Nursing) stated the Daily Staffing Posting includes the total nursing hours on each shift and should be posted daily. That is the regulations. This surveyor requested V2 to show this surveyor the Daily Staffing posting. On 12/02/2024 at 9:37am, there was a Daily Staffing that was posted by the glass door between the reception area and the first-floor nurse's station. The Daily Staffing did not indicate the RN hours, LPN hours and CNA hours for the evening shift and the night shift. This observation was pointed out to V2 (Director of Nursing). V2 stated the daily staffing is not completed appropriately; there is no total nursing hours for the evening shift and the night shift. The (undated) Facility Nursing Home Staffing Policy documented, in part Purpose: To ensure transparency and compliance with federal and state regulations by maintaining and posting accurate daily staffing information, including licensed nurses and Certified Nursing Assistants (CNAs) in the building. Policy Statement: the facility is committed to providing appropriate staffing to meet the needs of residents and will publicly post current staffing levels daily, in a visible and accessible location within the facility and required by applicable laws and regulations. Procedure: 2. Posting Requirements: Location: the staffing information will be posted at the main entrance or another highly visible area with the facility. Content: the posting will include: Date and shift (morning, afternoon, night). Number of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on duty. Number of Certified Nursing Assistants (CNAs) on duty. Total number of residents in the building. Format: the information will be presented in a clear, readable format and updated at the beginning of each shift. The (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) State Operations Manual documented, in part S483.35(g) Nurse Staffing Information. S483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.

Based on interviews and record reviews the facility failed to follow their fall policy to study fall causations, provide corrective actions to prevent reoccurrences, failed to provide adequate supervision and failed to develop specific fall interventions for 1 [R1] of 3 residents reviewed for falls. This failure resulted in R1 sustaining traumatic subarachnoid hemorrhage. Findings Include: R1's clinical record documents in part; R1 is a [AGE] year-old with the medical diagnosis of traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, dementia, unspecified severity, with other behavioral disturbance, malignant neoplasm of prostate, secondary malignant neoplasm of bone, muscle weakness (generalized), unsteadiness on feet, abnormalities of gait and mobility, cognitive communication deficit, acute kidney failure, altered mental status, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, anemia, protein-calorie malnutrition, osteoarthritis of knee, retention of urine, and osteoarthritis of hip. Minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is moderately impaired. R1's care plan indicated R1 had falls on the following dates: - 12/07/2023: Unwitnessed fall: R1 observed at his bed side with laceration on his right side of the head noted with laceration of 2x 0.3x 0.1cm (centimeters), received sutures at hospital. Intervention: Implement fall prevention measures, encourage the use of mobility aids, and collaborate with physical therapy for strengthening exercise. Clean and dress the wound appropriately, monitor for signs of infection, and administer prescribed medications. -01/08/2024 15:07 Resident was observed naked sitting on the floor by his bed side. Intervention: Provide regular mobility assistance to the resident to prevent independent attempts at transferring. - 01/08/2024 19:13 R1 was observed by staff lying on the floor. Resident was lying at the entrance of his room on his left side. R1's x-ray showing bleeding at the arachnoid. Intervention: Physical therapy and occupational therapy referral. - 01/21/2024 R1 was observed sitting on the floor. Resident Verbalized: Resident stated I worked all day and as I was walking home, I got tired and just sat on the floor. Intervention: Implement interventions to manage and cope with dementia-related behaviors. R1's fall assessment dated [DATE] indicated: R1 is a high fall risk due to past falls, impaired transfers, can not walk unassisted, and impaired mental status. Scored 75.0 indicates R1 is a high fall risk. R1's facility reported final report dated 1/12/24 documents in part: On 1/8/24 at 6:50 PM, R1 was observed by staff lying on his left side on the floor near the doorway. During investigation, staff were interviewed, all claimed R1 was confused and disoriented and hard to redirect. R1's CT scan revealed small subarachnoid bleeding on the left fissure. Based on the information and interviewed, R1 is lacking safety awareness due to progression of disease process. Interviews: On 2/17/24 at 12:52 PM, V4 [Licensed Practical Nurse] stated, I am familiar with R1. He has cancer that has spread to the bones and goes to cancer treatments. R1 can state his needs at the moment, but he has dementia with aggressive behaviors at times and impulsive. R1 needs continuous monitoring, supervision and re-direction. I was R1 nurse on 12/7/23 when he had a fall. I was the end of the hallway completed blood sugar checks and staff told me R1 was on the floor. I observed R1 next to his bed on the floor with no clothes on. During the body assessment I noted a laceration above his eyebrow. R1 was sent to the hospital and received sutures. On 1/8/24, R1 was readmitted back to facility from having stomach pains. The ambulance transporters placed R1 into bed, I completed his body assessment and noticed R1 was very confused, trying to remove his clothing and kept trying to get up from bed. I called V3 [Director of Nursing] and asked if R1 could be moved closer to the nursing station, V3 told me she would move R1 closer. I was at the nursing station completing R1's admission paperwork when I heard R1's roommate yelled out for help. R1 had a fall and was only back in the facility for an hour. I observed R1 lying on the floor next to his bed without any clothes on. I completed body assessment and R1 was placed back into bed. I notified V3, physician and state guardian of the fall. R1 fall interventions is to keep his room free of clutter and move R1 closer to the nursing station. I cannot remember if the bed was in low position, there was no floor mats on the floor next to R1's bed. After his falls on 1/8/24, when R1 returned to the facility on [DATE], I would put R1 in his wheelchair and push him with me from room to room to complete my medication pass. To ensure he did not fall, while I was down the hall. R1 needs one to one monitoring to prevent falls. On 2/17/24 at 1:23 PM, V3 [Director of Nursing] stated, R1 has cancer to the bones, he is not easy redirected, R1 like to be naked and takes his clothes off and is very aggressive. R1 has been in and out the hospital. 12/7/23, R1 trying to get out of bed, and fell trying to get to wheelchair, impulsive behavior. The intervention was to implement fall prevention measures, encourage the use of mobility aids, and collaborate with physical therapy for strengthening exercise. On 01/08/2024 at 15:07 R1 was observed naked sitting on the floor by his bed side. Intervention was to provide regular mobility assistance to the resident to prevent independent attempts at transferring. On 01/08/2024 at 19:13 R1 was observed by staff lying on the floor. Resident was lying at the entrance of his room on his left side. R1's x-ray showing bleeding at the arachnoid. The intervention was physical therapy and occupational therapy referral. On 01/21/2024, R1 was observed sitting on the floor. The intervention was to implement interventions to manage and cope with dementia-related behaviors. After every fall there should be a nursing intervention in place specific to the resident to prevent another potential fall. Our minimum data set coordinator [MDS] places fall interventions in the care plan. The nursing team discus our options and MDS coordinator places in the care plan. R1 interventions are not specific as they should have been. Some specific care plans would be low bed, call light in reach, or place floor mats next to the bed. I do not know why R1 do not have those interventions in his care plan or specific interventions. The nursing staff should know what basic fall intervention are to implement. Some nurses take R1 with them during their medication pass. There is no reason why the nurse should not take the R1 with them while passing medications, its part of the nurse job, if the CNAs are busy. On 2/17/24 at 3:10 PM, V5 [Social Service Director] V5 stated, R1 is declined significantly since admission due to spreading cancer, very confused restless and compulsive. R1 need continuous monitoring and cues. R1 has state guardian as of January 2024. There are times when R1 behavior and cognition goes up and down not all the time sometimes when he needs 1:1 sitting. On 2/17/24 at 6:00 PM, V6 [Agency Licensed Practical Nurse] stated, R1 was alert he tell you the basic things, like bathroom, and hungry at times. R1 was very confused on 1/8/24. I received report from V4 that R1 had a fall around 3PM, and he was moved to another room closer to the nursing station. R1 need very close monitoring and supervision. When I checked on R1, he was in bed sleeping. V8 [Certified Nurse Assistant] told me he took R1 his food tray and R1 did not eat any of his food. V8 and I went to R1's room to warmed up his food, and positioned R1 in a sitting up position so he could eat dinner. V8 went to help another resident, and I went down the hall to look for a wheelchair. On my back down the hallway, near his room I observed R1 lying on the floor in front of his bedroom door in the hallway. I completed a body assessment, check R1's vital signs, completed range of motion. I did not see any apparent injuries. I called R1's physician I received an order to send R1 back to the hospital, because he had two falls upon with in hours of R1 being readmitted back to the hospital. V8 or I could not stay with R1 continuously, we have to care and tend to other residents on the floor. R1 has another fall on 01/21/2024. Nursing staff observed R1 on the floor. R1 said he was tired after getting off the floor then sat down. I completed head to toe assessment, no apparent injury. V9 [R1's Facility Physician] order x-rays they were negative for fracture. I was taking care of other residents and R1 got out of bed. R1 need to have one to one monitoring. On 2/17/24 at 6:35PM, V8 [Certified Nurse Assistant] stated, R1 is confused and needs a lot of monitoring. R1 was sleeping for a while and did not wake up to eat dinner. V6 and I went to R1's room and woke him up to position up in bed so he can eat. I warmed up his dinner and R1 started to eat. I left out R 1's room to assist another resident. I heard the V6 call out for assistance. I observed R1 lying on the floor outside his doorway. R1 told me he was trying to go watch the football game. I kept monitoring R1, but R1 got up so fast when I was down the hall. On 2/18/24 at 10:01 AM, V9 [R1's Facility Physician] stated, I was notified on 1/8/24 that R1 was readmitted back to the facility and had fallen twice with in a few hours, I gave an order to send R1 back to the hospital for further evaluation. R1 medically and cognitively declined when his cancer had spread to the bone and possible brain. The nursing staff should take into consideration that R1 needs close monitoring and supervision to help prevent falls. R1 fall could have been prevent only if he had one to one supervision, the facility is not capable to provide one to one supervision all the time. Administration maybe consider R1 needs a facility that is capable to provide very close monitoring. On 2/18/24 at 10:15 AM, V1 [Administrator] stated, V3 completed the fall investigations, and (State Survey Agency) report. I read over the report, I am familiar with R1 and his falls. R1 had a declined secondary to cancer now to the bones. There were times R1 was one to one and staff stayed in the room, there is no order for one to one or any intervention. The nursing staff are all aware that R1 is a high fall risk and need close monitoring, the staff has done their best. The hospital should have sent him back to the facility unstable. Policy: Documents in part: Fall [No Date] -To ensure that all incidents that occur with residents are identified, reported, investigated and care plans reviewed, to provide appropriate medical interventions with residents involved in fall incidents as deemed necessary by the health care providers, to study fall causations and to provide corrective actions to prevent reoccurrence when possible. -Resident's care plans will be reviewed and updated as necessary by the interdisciplinary

Based on observation, interview and record review the facility failed to implement pressure relieving measures to prevent the development of pressure ulcers for one resident (R16) of three residents ) sampled for monitoring pressure ulcers of a total sample of 30. Which resulted in an increase in size from the initial measurement of one of the pressure ulcers. Findings Include: R16 is [AGE] years old with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] affects the brain and spinal cord and symptoms vary, including numbness or abnormal sensation in any area and decreased ability to move parts of the body. R16 has developed contractures in both legs which interfere with R16's bed mobility and transfer. R16 is alert and oriented to person and place with difficult to understand speech. R16 has a suprapubic catheter and the Oct., Nov., and Dec., 2011 Braden Scale for predicting pressure sore risk assessed R16 to be at moderate risk. E15 (Nurse) performed R16's wound care on 01/25/12 at 9:40 AM. The left foot wound in the plantar area was first noted (facility acquired) on 9/05/11 . On 01/22/12 the stage 3 plantar wound measured 3.0 x 2.5 x 0.2 cm, an increase in size from the initial measurement of 1.5 x 1.5 x 0cm. During dressing change, the wound was red with two tan spots that appeared to be slough. According to the Weekly Decubitus Report, the healing process was not consistent. On 12/24/11, the wound bed was documented to be macerated and not healing. The second wound was located on the right knee. This wound measured 1.5 x 1.5 x 0.3cm and had recently undergone a surgical debridment during the 01/03/12 hospitalization . The tissue surrounding the wound was red and inflamed. This wound was acquired 12/17/11. On 01/25/12 at 9:55 AM, E stated that R16 attended an outside wound clinic for wound care. E15 stated that the wounds were unavoidable because of the leg contractures. During telephone conversation on 01/25/12 at 12:00 PM, Z1, Primary Care Physician stated that the wounds are being taken care of at the wound care clinic. Z1 also stated that the wounds were unavoidable due to bilateral knee contractures and the [DIAGNOSES REDACTED]. The POS (Physician order [REDACTED]. a. Apply a vitamin fortified ointment to the buttocks, heel, hips and sacrum every shift PRN (as necessary. b. Gel mattress. c. Up in chair or wheel chair daily as tolerated. Review of the comprehensive care plan dating back to 03/02/11 showed no preventive pressure relieving measures to address avoiding pressure ulcers. The comprehensive care plan did not address complications that often put patients with [MEDICAL CONDITION] at higher risk for developing skin problems due to decreased sensation and decreased mobility. The initial reference to the then existing pressure wounds was on 11/30/11 related to pressure ulcer treatment.