Every finding on record at Belhaven Nursing & Rehab Center

Based on observation, interview, and record review, the facility failed to store, maintain, and follow their mealtimes when serving meals. This has the failure at affect 202 residents that receive food from the kitchen.Findings include:On 8/22/2026, at 12:08 PM, R1 stated, we just had a resident council meeting about their concerns with the state. They have cold food and want better meals. I think the food is cold. There is no microwave, and they have not replaced it. There was a roach in my cerealOn 8/22/2026, mealtimes were provided. Lunch is supposed to be served at 11:45 AM for all three floors.On 8/22/2026, lunch was not served until 12:30-12:45 PM.On 8/22/2026, at 1:07 PM, R6 stated, I have been a resident here three years. The food is cold when I get it.On 8/22/2026, at 1:12 PM, R7 and R8 stated, the food is cold. Lunch and dinner are late. Lunch is supposed to be served at 12:00PM.On 8/22/2026, at 3:55 PM, V3 (Dietary Aide) and V4 (Dietary Aide) stated, the milk is not expired.On 8/22/2026, at 9:38 AM, V14 (Dietary Aide) stated, I have been here since January 2026. I have seen roaches come out of the hot water heater room in the kitchen. I feel like they need to change the door to metal versus wood. That would be the smart solution. I have heard residents complain about cold food and late food. Sometimes, no aides come for twenty minutes when lunch is brought up. All the residents look at us to be served. It is the job of the aides to serve the food. I ask for help as soon as I deliver the food.On 8/23/2026, at 9:25 AM, there were 10 skim milks with expiration dates of 8/15/2026. There were also 50 cartons of skim milk with expiration dates of 8/19/2026.On 8/23/2026, at 9:31 AM, V13 (Dietary Manager) stated, I expect staff to check the dates and use the first milk that is going to be expired first. I have not heard of any pest issues. I have not seen any roaches. No staff have complained recently. Lunch is supposed to be served at 11:45 AM.On 8/23/2026, at 9:35 AM, the door that leads to the hot water heater, in the kitchen, is all damaged from water exposure with holes in it. When the door was opened, there were two traps with 12 roaches on it. One roach is alive with many baby roaches.On 8/23/2026, at 12:40 PM, lunch was served between 12:30 -12:45 pm.On 8/23/2026, at 12:57 PM, a test tray was provided. The test tray had meat, carrots, and mashed potatoes. The meat had a temperature of 135 degrees Fahrenheit. The carrots had a temperature of 120 degrees Fahrenheit. The mashed potatoes were within the normal range. V13 stated, the meat is supposed to have a temperature of 145 to 165 degrees Fahrenheit. The carrots are supposed to have a temperature of 145 to 165 degrees Fahrenheit.On 8/23/2026, at 1:15 PM, V16 (Maintenance Supervisor) stated, A few days ago, I was made aware of roaches in the door in the kitchen. The administrator informed me of the door with the roaches. I followed up with her and I was instructed to remove the door. I ran out of time that day. To be honest, it slipped my mind.On 8/24/2026, at 9:30 AM, V8 (Ombudsman) stated, the facility just had a resident council meeting. The residents have been complaining about late food and cold food. Basically, the food is horrible.Pest control service report dated 6/24/2026, notes there were 5 to 10 German cockroaches in the kitchen.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program. This has the potential to affect all residents that reside in the facility.Findings include:On 8/22/2026, at 12:08 PM, R1 stated, there was a roach in my cereal.On 8/22/2026, at 9:38 AM, V14 (Dietary Aide) stated, I have been here since January 2026. I have seen roaches come out of the hot water heater room in the kitchen. I feel like they need to change the door to metal versus wood. That would be the smart solution.On 8/23/2026, at 9:35 AM, the door that leads to the hot water heater, in the kitchen, is all damaged from water exposure with holes in it. When the door was opened, there were two traps with 12 roaches on it. One roach was alive with many baby roaches.On 8/23/2026, at 1:15 PM, V16 (Maintenance Supervisor) stated, A few days ago, I was made aware of roaches in the door in the kitchen. The administrator informed me of the door with the roaches. I followed up with her and I was instructed to remove the door. I ran out of time that day. To be honest, it slipped my mind. I've seen dead roaches on mouse traps in resident rooms and one time in the pantry, on the 1st or 2nd floor.Pest control service report dated 6/24/2026, notes there were 5 to 10 German cockroaches in the kitchen.

Based on observation, interview and record review, the facility failed to ensure an effective working call light system and failed to monitor its call light system. This failure affects a total of 67 residents reviewed for a call light system in the facility. Findings include: On 08/22/2026 at 12:06PM, surveyor located on the third floor of the facility and observes a call light illuminated at the nurses station, no audible sound is heard for the illuminated call light.On 08/22/2026 at 12:49PM surveyor observes another resident's call light illuminated at the nurses' station. Surveyor observes V7 (Licensed Practical Nurse/LPN) and V9 (LPN) at the nurses' station and surveyor makes V7 and V9 aware that a residents' call light is illuminated. V7 states she is the nurse responsible for the resident's room whose call light is illuminated. V7 goes to the resident's room and observes that the call light is activated but there is no light illuminated above the residents' room door. V7 states there should be a light illuminated above the residents' room door and an audible sound heard at the nurses' station whenever a resident activates their call light. V7 is observed testing three other residents' room for an audible sound when the call light is activated. V7 states she does not hear an audible sound coming from any of the call lights that were activated. V7 states she will make the maintenance department aware that the call light system is not functioning correctly.On 08/22/2026 at 1:02PM, V9 (LPN) states she will use the computer system to fill out a work order to alert the maintenance department that the call light system needs to be repaired.On 08/22/2026 at 1:10PM, R9 states this morning at approximately 2:00AM, she had to press the call light for her roommate R11. R9 states no one came to answer the call light until after 4:00AM.On 08/23/2026 at 1:27PM, V16 (Maintenance Director) states the facility uses an online computer work order system to alert him when something needs to be repaired in the facility. V16 state he was made aware yesterday on 08/22/2026 that the call light system was not functioning properly. V16 states he saw in the computer system that V9 (LPN) put in a work order for the call light system repair on 08/22/2026 at 1:04PM. V16 states he has contracted a vendor to repair the call light system, and the work is expected to be completed today.On 08/23/2026 at 1:51PM, V19 (Contracted Vendor/Operations Manager) states the facility contacted him on 08/22/2026 at approximately 6:00PM-7:00PM to inquire about repairs to their call light system. V19 states he arrived to the facility today at approximately 11:00AM to begin repairs to the facility's call light system. V19 states the facility's third floor call light system required a new audio speaker. V19 states upon assessment, the old speaker was no longer working so he replaced it with a new one. V19 states the facility's call light system now has an audible sound heard once a residents' call light is activated.Facility census dated 08/22/2026 documents that a total of 67 residents reside on the 3rd floor of the facility. Facility document undated, titled Call Light and Resident Call System documents in part To ensure residents can summon staff assistance at all times and receive a prompt, safe, and respectful response-supporting resident rights, quality of care, and compliance with CMS physical environment requirements for a resident call system.The facility will maintain a functioning resident call system that allows residents to call for staff assistance from: Each resident's bedside, and Toilet and bathing facilities. Call lights are everyone's responsibility. Any staff member who sees/hears a call light will respond immediately or ensure help arrives right away.

Based on interview and record review, the facility failed to administer a resident's prescribed medications in a timely manner according to the physician orders. This failure affects one (R3) resident out of three residents reviewed and caused R3 to not receive his prescribed blood thinner medication timely and consistently, putting R3 at risk for developing blood clots. Findings include: R3's Facesheet documents in part that R3 has diagnoses not limited to: paraplegia, hypertension, hemiplegia and hemiparesis following a cerebral infarction, and contracture of unspecified joint. R3's MDS/Minimum Data Set, dated [DATE] documents that R3 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R3 is cognitively intact. R3's POS/physician order sheet documents in part the following order: Apixaban Oral Tablet 2.5 MG- Give 1 tablet by mouth two times a day for blood thinner. R3's POS documents that R3 is scheduled to receive his Apixaban medication daily at 9:00AM and 5:00PM. On 08/22/2026 at 11:03AM, R3 states on 07/31/2026, 08/07/2026, 08/14/2026, and 08/15/2026, V6 administered his medications late during the 3:00PM to 11:00PM shift. R3 states this is ongoing and V6 is always late to work and always administers his medications late. On 08/22/2026 at 4:20PM, V5 (Licensed Practical Nurse/LPN) states he has not cared for R3 in approximately 5-6 months. V5 states if R3 inquires to him about his medications, then he lets another nurse administer medications to R3 because V5 will not do it. V5 states he has been informed by management to stay away from R3 and avoid any engagement with R3 due to R3's constant allegations against him. V5 states he does not talk to R3 and does not provide care for R3 at all.On 08/23/2026 at 11:16AM, V6 (Licensed Practical Nurse/LPN) states he has been working at the facility for approximately 5 years, and he mainly works on the second floor during the 3:00PM-11:00PM shift. V6 states he arrives late to the facility because he is coming from his other job. V6 states he usually arrives to the facility at approximately 4:15PM. V6 states everyone knows that he has another job, and he usually calls the facility to let them know that he will be arriving late. V6 states he usually tells the other nurse on duty that he is in route, and the other nurse covers for him until he arrives at the facility. V6 states R3 is scheduled to receive medications at 5:00PM and 9:00PM. V6 states he usually starts his 5:00PM medication administration pass at approximately 5:30PM. V6 states it takes him approximately 1.5 hours to complete this medication administration pass. V6 states he usually starts his 9:00PM medication administration pass at approximately 8:30PM. V6 states it takes him approximately less than 1 hour to complete this medication administration pass.On 08/23/2026 at 2:43PM, V17 (Director of Nursing/DON) states during the 3:00PM-11:00PM shift, there are two nurses scheduled on the second floor of the facility. V17 states the protocol for administering medications when a scheduled nurse is late to work is as follows: When a nurse is late, once they arrive they should begin performing the medication administration pass. V17 states if nurses administer medications late then the medical doctor should be notified. V17 states she expects the nurses to arrive on time for their scheduled shift so that the residents may receive their medications on time. V17 states if a nurse is consistently late then this is an overall problem. V17 states she is aware that V6 (LPN) has another job, but she has never been made aware that V6 is habitually late for his scheduled shifts. V17 states if she was made aware then she would have asked another nurse to cover for V6 until he arrived or she would have also covered the shift until V6 arrived. V17 states if V6 is late to work then the nurse covering for V6 should administer medications until V6 arrives to the facility. On 08/23/2026 at 2:57PM, V18 (R3's Medical Doctor/MD) states he is responsible for medications that are prescribed to R3 in the facility. V18 states he is familiar with R3 and R3 is prescribed Apixaban to prevent blood clots. V18 states if R3 does not receive his prescribed Apixaban on time and consistently, then there is potential for R3 to develop blood blots in the legs and develop a pulmonary embolism (blood clot in the lungs). V18 states he has never been made aware that R3 has been receiving his Apixaban medication late in the facility. V18 states he expects the nurses to inform him when R3 or other residents receive their medications late in the facility. R3's Medication Administration Audit Report was reviewed from 07/01/2026 to 08/22/2026 and documents that R3's scheduled Apixaban medication was administered late on the following dates: 07/01/2026 through 07/05/2026, 07/07/2026 through 07/20/202607/24/2026, 07/25/2026, 07/28/2026, 07/31/202608/01/2026 through 08/03/2026, 08/07/2026, 08/08/2026, 08/11/2026, 08/14/2026, 08/15/2026, 08/17/2026, 08/19/2026 Review of the facility's nursing schedule documents that V6 (LPN) was scheduled to work in the facility on 07/31/2026, 08/07/2026, 08/14/2026, and 08/15/2026. Review of V6's time clock punches dated 07/01/2026 to 08/20/2026 documents that V6 arrived late to his scheduled shift on the following dates: 07/03/2026 through 07/06/2026, 07/08/2026 through 07/11/202607/13/2026 through 07/15/2025, 07/17/2026 through 07/20/202607/22/2026 through 07/24/2026, 07/27/2026 through 07/29/202608/01/2026, 08/02/2026, 08/05/2026 through 08/07/2026, 08/10/2026 through 08/12/2026, 08/14/2026 through 08/16/2026, 08/19/2026, 08/20/2026. Facility policy undated titled Medication Administration documents in part, Purpose: To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration. Policy: Unless otherwise specified by the physician. Medications will be administered within 60 minutes before or after the facility's dosing schedule. Medication Administration Record will be signed after each medication administered to the resident. Medications that are refused by the resident or are not administered for other reasons will be coded on the day of no administration. The reason for not administering the medication will be documented on the Medication Administration Record.

Based on interview and record review, the facility failed to provide a bed hold notice and an involuntary discharge notice to a resident's state guardian when being sent out of the facility. This failure affects one of three residents (R2) reviewed for admission, transfer, discharge.Findings include:R2 is a [AGE] year-old female. R2's diagnoses are but not limited to dementia with behaviors, bipolar, anxiety disorder, hypertension, and violent behavior. R2's BIMS (Brief Interview for Mental Status) could not be completed because R2 was only in the facility for two days.R2 was admitted to the facility on [DATE]. R2 was sent out of the facility on 7/24/2026.Progress note dated 7/25/2026, note writer spoke with nurse at local hospital. Facility informed R2 being admitted with diagnosis of aggressive behavior and bipolar disorder.On 8/23/2026, at 9:08 AM, V7 (LPN) stated, the nurse must send a petition. The petition is completed if the resident is causing harm to themselves or others. The nurse must call the psychiatrist and provide the bed hold. The social work department is involved.On 8/23/2026, at 12:10 PM, V21 (Social Services Director) stated, I believe I did the petition for R2.On 8/23/2026, at 1:45 PM, V1 (Administrator) stated, if the created date, in the system, is 7/27/2026, it means that R2 did not get her bed hold notice. R2 hit a family member. I expect staff to follow the process if someone is being sent out. I expect them to notify the family, doctor, and the next of kin. The involuntary petition should be filled out correctly.On 8/23/2026, at 2:32 PM, V23 (DON) stated, I was doing rounds. R2's roommate's family came to let us know R2 was in the room being mean. I went in to see what was going on. R2 was removed and the other roommate was removed. I left. I called V21 up and V21 and another social worker took care of R2. R2 was being aggressive. I did not do the bed hold or IVD (Involuntary Discharge). I do not know if R2 is coming back. Staff call the physician and the psychiatrist. V21 sends out the IVD. Social services work with the departments as well. Explanations are given. The petition is sent with a face sheet. The petition is given to the ambulance staff not the residents. The guardian is called. The expectation is the bed hold notification is completed the same day. I would expect staff to complete it that day.On 8/24/2026, at 11:19 AM, V27 (State Guardian) stated, I do not see that we ever got the involuntary discharge from the facility. A previous state guardian filed the complaint. I just got this case transferred back to me. They sent R2 to a local hospital and I forwarded the message to the appropriate guardian. R2 is at another facility.On 8/24/2026, at 12:28 PM, V28 (ADON) stated, I did not send R2 out. I am the ADON (Assistant Director of Nursing). I completed R2 bed hold assessment. If the bed hold assessment does not get done sometimes, I will do it.On 8/24/2026, at 12:48 PM, V29 (Agency Nurse) stated, I remember that day. I do remember an incident that happened. The administrator told me to write a statement. If I'm not mistaken, the DON (Director of Nursing or the administrator was going to petition R2 out. I do not recall sending anything with the resident, but I do remember I was told to make a statement.Review of R2's medical record notes, the bed hold assessment was not completed until 7/27/2026, three days after R2 was sent out. There is no documentation that R2's guardian was provided with a bed hold notice or given an IVD with the chance to appeal.On 8/23/2026, the facility provided IVD notice. It is dated 7/24/2026. R2 was sent for emergency inpatient admission due to presenting signs and symptoms of physical aggression toward another resident's family member. It was completed by V21 on 7/24/2026.Facility policy title Guidelines for Resident Bed Holds and Readmissions to the facility, undated, notes facilities must make all residents aware in writing of their policies relating to holding beds during any resident absences from the facility for a period of 24 hours or longer. Before the facility transfers a resident to a hospital, the facility will provide written information to the resident and or the resident's responsible party/POA that specifies the following: the reason for the transfer, the duration of the State's bed hold policy, if any during which the resident is permitted to return and resume residency at the nursing facility.Facility policy titled Guidelines for Discharge/Transfer, undated, notes to process an involuntary discharge, the facility must complete the State's Notice of Transfer/Discharge and forward by hand-delivery to the resident or by certified mail/return receipt requested to the resident's responsible party/POA or interested family member.

Based on review of records and interviews, the facility failed to follow abuse reporting procedures for 7 out of 7 residents (R1, R2, R4, R5, R6, R9 and R10) for a total of 7 residents reviewed for reporting of abuse procedure in the facility. These failures are not in accordance with their abuse policy and have the potential to affect 7 residents (R1, R2, R4, R5, R6, R9 and R10) in proper determination of abuse allegation that will help with preventing abuse.Findings include: On 08/04/2026, V1 (Administrator) presented three (3) initial abuse incidents reported that were transmitted to State agency: Dated 07/30/2026 involving R1 and R2,Dated 08/02/2026 involving R2 and R4 andDated 08/02/2026 involving R6 and R5. All three (3) abuse initial reports are identical with the same verbiage documented as follows: Under brief description of incident: documented as follows:R1 allegedly made contact with R2. Under immediate action taken documented as follows:Staff immediately intervened and separated R1 and R2. R1 was placed on 1:1 monitoring. R1 and R2 were assessed. Physicians and families of R1 and R2 were notified. Investigation initiated, final report to follow. On 08/04/2026 at 02:31 PM, V1 upon reviewing all three (3) abuse initial report confirmed that all reports were identical as to brief description of incident and immediate action taken. V1 stated that it will be different when she submits the final report. V1 reviewed their facility's abuse policy on reporting procedures. V1 was asked the reason that all three (3) reports are identical. V1 stated that each incident is unique to each other that report from the nurse should reflect initial reports that facility sent to State Agency. Per facility's staff statements and resident records each abuse incident alleges different situations as follows: Abuse incident dated 07/30/2026 involving R1 and R2, per V15 (Licensed Practical Nurse) and V7 (Certified Nursing Assistant) stated that there was an allegation from R2 that R1 spilled coffee at him. Abuse incident dated 08/02/2026 involving R2 and R4. R4 alleges that R2 pushed his glasses at his face, hurting him. Clinical notes of V3 (Registered Nurse) dated 08/02/2026 documents that R2 has physical aggression, verbal aggression and change of personality. R2 cannot be redirected. Writer (V3) was informed that R2 hit another resident (R4). V1 (Administrator) stated that R2 touched R4's face. Abuse incident dated 08/02/2026 involving R6 and R5. V10 (Registered Nurse) stated that R5 was pushed by R6 as witnessed by R8. R8 confirmed that she witnessed R6 pushing R5. V1 (Administrator) stated confirmed that R6 pushed R5 to the floor. V17 (Certified Nursing Assistant) stated that she witnessed R6 pushing R5 to the floor. All this information was not included in all three (3) abuse incident reports transmitted to State agency. On 08/06/2026 at 02:45 PM, V1 (Administrator) stated that R9 was transferred to another floor because he went into female area then went into R10's room. V1 denies that there was sexual contact between R9 and R10. On 08/07/2026 at 01:47 PM, V16 (Social Service Coordinator) stated that although there was no sexual contact between R9 and R10. R9 hints that he likes touching if he has a partner in a sexual way. On 08/07/2026 at 02:28 PM, V1 stated that V16 did not notify her. I will report it today. V1 provided initial report dated 08/05/2026 with transmittal date 08/07/2026. Abuse Policy dated 01/06/2026: Employees are required to immediately report any incident, allegation or suspicion of potential abuse against a resident they observe, hear about, or suspect to the Administrator. The facility will not tolerate abuse or mistreatment against a resident by anyone. Any alleged violations involving mistreatment, abuse, etc. against residents must immediately report such incident to the charge nurse who will immediately report the allegation to the Administrator, regardless of the time lapse since the incident occurred. Reporting procedure will be followed as outlined in the policy: The name of the resident(s) involved,The date and time that the incident occurred,Where the incident took place,The name(s) of all individuals suspected of committing the incident, if known,The name(s) of any witnesses to the incident,The type of abuse that was allegedly committed or the reasonable suspicion of a crime against a resident.Other information that may be requested by the Charge Nurse. Upon receiving reports of physical or sexual abuse, the Charge Nurse will immediately examine the resident. Findings of the examination must be recorded in a separate Incident Report and the resident's medical record. This report shall be made immediately, but no later that two (2) hours after the allegation is made. If the events that cause the allegation involve abuse or resulted in serious bodily injury, or not less than 24 hours if the event cause the allegation do not involve abuse and did not result in serious in serious bodily injury. The Charge Nurse must complete an incident report and endeavor to obtain a written, signed and dated statement for the person reporting the incident. A complete copy of the incident report and written statements from the witnesses, if any, will be provided to the Administrator or DON is the Administrator absence within 24-hour of the occurrence of such incident. Abuse allegations involving one resident upon another will be reported to IDPH.

Based on interviews and review of records, the facility failed to provide interventions related to incidents involving aggressive behavior towards other residents for 5 out of 9 residents (R1, R2, R4, R5 and R6) for a total of 9 residents in the sample. These failures have the potential to affect 5 residents (R1, R2, R4, R5 and R6) due to lack of interventions that may prevent recurrent of similar incidents.Findings include: After full care plan review, the following identified concerns related to resident's behavior were not addressed in the care plan: Incident dated 07/30/2026 involving R1 and R2, per staff statements V15 (Licensed Practical Nurse) on 08/04/2026 at 12:46 PM, V7 (Certified Nursing Assistant) on 08/04/2026 at 08/04/2026, V8 (Certified Nursing Assistant) on 08/04/2026. Social service notes by V9 (Social Service Director) dated 07/30/2026 documents that R1 was seen due to behavioral incident of inappropriate behavior. No notes documented on R2's electronic health record related to the incident dated 07/30/2026. On 08/06/2026 at 11:31 AM V9 said, Whenever there is an incident for inappropriate behavior, care plan needs to be updated, and intervention placed. Incident dated 08/02/2026 involving R2 and R4. Per clinical notes of V3 (Registered Nurse) dated 08/02/2026 documents that R2 has physical aggression, verbal aggression and change of personality. R2 cannot be redirected. Writer (V3) was informed that R2 hit another resident (R4). On 08/04/2026 at 01:34 PM R4 confirmed that R2 pushed him in his face, and it hurts because he was wearing glasses. Incident dated 08/02/2026 involving R6 pushing R5 on the floor. On 08/05/2026 at 11:20 AM V10 (Registered Nurse) stated that CNA told him that R5 and R6 had a fight. It was witnessed by another resident, V10 pointing at R8 who was sitting at another table. V10 asked R8 to join us at the same table. R8 stated that R6 was coming into the dining room, told R5 to get up and R6 pushed R5. R5 could not do nothing, R6 pushed R5 so hard and R5 fell on the floor. R8 stated that he told R6 not to do that to R5 that it was wrong. Now R5 is angry with me. V10 was asked if R8 statements are accurate. V10 confirmed what R8 stated. V10 said it is accurate. After leaving the dining room at the hallway, R5 was seen limping while walking. V10 who was there was notified and saw R5 limping. V10 stated that he will address it. 08/05/2026 at 01:15 PM, V2 (Assistant Director of Nursing) stated that when an incident happens that a resident hit the floor there needs monitoring after the incident. Nurses on the floor need to monitor the resident and chart/document for 72 hours. V2 denies having personal knowledge about the incident between R5 and R6. On 08/05/2026 at 02:30 PM, review of R1, R2, R4, R5 and R6 care plan with V11 (Restorative Nurse / Licensed Practical Nurse) stated that she reviews care plan together with Care Plan Coordinator that is not in the facility currently. V11 confirmed after full review each care plan that there were no interventions on R1, R2, R4, R5 and R6 related to incidents of identified behavioral concerns that occurred. On 08/06/2026 at 02:07 PM V12 (Director of Nursing) stated that 72-hour charting to incidents like R5's fall. V12 stated that nurses do not do care plan immediate intervention because that is done by MDS coordinator or restorative. V12 stated that since R5 refused X-Ray it cannot be determined of his limping while walking and pain. Review of R5's full care plan does not include pain. Per CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2017: Care plan should be individualized, and resident centered. Planning of care requires implementing appropriate, individualized interventions and modifying them as appropriate. Incident dated 08/02/2026 related to R6 pushing R5 that resulted in fall. Policy and Guidelines for Incidents, Accidents or Fall dated 01/30/26 provides as follows: Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. Some occurrences will require a more extensive investigation process. These include but are not limited to:Suspected/alleged abuseSuspected/alleged neglect

Based on observations, interviews, and review of records, the facility failed to maintain accurate resident records for 4 out of 9 residents (R2, R4, R5 and R6) for a total of 9 residents reviewed for resident record documentation. These failures have the potential in affecting 5 residents (R1, R2, R4, R5 and R6) in their care needs as reflected by accurate documentation.Findings include: After reviewing behavioral concerns identified by the facility, the following incidents were not accurately documented in the resident records: Incident dated 07/30/2026 involving R1 and R2, per staff statements V15 (Licensed Practical Nurse) on 08/04/2026 at 12:46 PM, V7 (Certified Nursing Assistant) on 08/04/2026 at 08/04/2026, V8 (Certified Nursing Assistant) on 08/04/2026. Social service notes by V9 (Social Service Director) dated 07/30/2026 documents that R1 was seen due to behavioral incident of inappropriate behavior. No notes documented on R2's electronic health record related to the incident dated 07/30/2026. Incident dated 08/02/2026 involving R2 and R4. Per clinical notes of V3 (Registered Nurse) dated 08/02/2026 documents that R2 has physical aggression, verbal aggression and change of personality. R2 cannot be redirected. Writer (V3) was informed that R2 hit another resident (R4). No notes documented on R4's electronic health record related to the incident that described what happened. Incident dated 08/02/2026 involving R6 pushing R5 on the floor. On 08/05/2026 at 11:20 AM V10 (Registered Nurse) stated that CNA told him that R5 and R6 had a fight. It was witnessed by another resident, V10 pointing at R8 who was sitting at another table. V10 asked R8 to join us at the same table. R8 stated that R6 was coming into the dining room, told R5 to get up and R6 pushed R5. R5 could not do nothing, R6 pushed R5 so hard and R5 fell on the floor. R8 stated that he told R6 not to do that to R5 that it was wrong. Now R5 is angry with me. V10 was asked if R8 statements are accurate. V10 confirmed what R8 stated. V10 said it is accurate. After leaving the dining room at the hallway, R5 was seen limping while walking. V10 who was there was notified and saw R5 limping. V10 stated that he will address it. No notes documented on R6's electronic health record related to the incident that described what happened. 08/05/2026 at 01:15 PM, V2 (Assistant Director of Nursing) stated that when an incident happens that a resident hit the floor there needs monitoring after the incident. Nurses on the floor need to monitor the resident and chart/document for 72 hours. V2 denies having personal knowledge about the incident between R5 and R6. On 08/06/2026 at 02:07 PM V12 (Director of Nursing) stated that 72-hour charting to incidents like R5's fall. V12 stated that nurses do not do care plan immediate intervention because that is done by MDS coordinator or restorative. V12 stated that since R5 refused X-Ray it cannot be determined of his limping while walking and pain. Review of R5's full care plan does not include pain. Policy and Guidelines for Incidents, Accidents or Fall dated 01/30/26: Documentation of the physical and mental status of the resident(s) involved will be completed each shift (every 8 hours minimally) over at least the next 72 hours or until the resident(s)'s condition improves. Neuro checks will be completed after any head trauma as well as after any unwitnessed fall (even if the residents state they did not hit their head) as per policy. The occurrence is to be communicated shift to shift as part of the report until the resident is stabilized and at least 72 hours post fall. Some occurrences will require a more extensive investigation process. These include but are not limited to:Suspected/alleged abuseSuspected/alleged neglect

Based on observations, interviews, and review of records facility failed to maintain residents right to be free from all forms of abuse for 2 out of 7 residents (R4 and R5) for a total of 7 residents reviewed for facility's abuse program. These failures affected 2 residents (R4 and R5) on their rights from being physically abused. Findings include:a.On 08/04/2026 at 01:34 PM R4 stated that R2 bumped into him and pushed him in his face so that it hurts because he was wearing glasses. R4 during conversation was wearing glasses with transparent lens. R4 stated that R2 talks loudly during lunch time at the dining room. R4 [AGE] year-old resident, initially admitted in the facility on 03/03/2026. R4 can express his thoughts well within topic during conversation. R4 BIMS score was 10.R4's medical diagnosis includes but are not limited convulsions and cataracts. R4's progress notes dated 8/2/26 notes he was allegedly involved in an incident. R4's BIMS dated 7/17/26 for cognition documents a score of 10, indicating moderate cognitive impairment. R4's care plan indicates he has vision impairments. On 08/04/2026 at 02:31 PM, V1 (Administrator) confirmed that R4 told her that R2 touched his face. Clinical notes of V3 (Registered Nurse) dated 08/02/2026 documents that R2 has physical aggression, verbal aggression and change of personality. R2 cannot be redirected. Writer (V3) was informed that R2 hit another resident (R4). According to V1, V3 (Registered Nurse) was a possible witness but she is not sure. Called V3 contact information multiple times, 8/4/2026 at 2:22 PM and on 8/7/2026 at 12:12 PM, did not answer voice prompt said voice mail box full. R2 [AGE] year-old resident, initially admitted in the facility on 03/20/2026 and discharged on 08/02/2026 due to agitated aggressive restless behavior. R2 medical diagnosis includes but are not limited to schizophrenia disorder, depressive type and generalized anxiety disorder. R2's BIMS dated 7/29/26 identifies a cognition score of 10, indicating moderate cognitive impairmentAbuse investigation report for incident of 8/2/26 notes R2 was observed pacing on the unit and made alleged contact with R4. According to the report there were no witness.R2's progress notes dated 8/2/26 at 11:42AM notes observed R2 yelling, screaming, cursing throughout the unit. Multiple attempts to deescalate the resident and redirect with unsuccessful attempts. Writer notified by staff that resident allegedly hit another peer while in dining area. R2's progress notes dated 7/8/26 note history of agitated behaviors including a risk of harming self resulting in hospitalization.R2's care plan lacks focus for behaviors and interventions to address and reduce risk of behaviors. b.On 08/05/2026 at 10:32 AM with R7 translating statements of R5 from Polish to English. R7 stated that R5 is saying that he slipped and strained his muscle all around the hip pointing at the left side grimacing with pain. When R6 was mentioned, R5 face frowned. R7 then stated that R5 stated that R6 told him to sit at another table when he walked to the dining room. There was no other person in the dining room. On 08/04/2026 and 08/05/2026, dining room was seen with residents and staff all through the day. On 08/05/2026 at 11:20 AM V10 (Registered Nurse) stated that CNA (Certified Nursing Assistant) told him that R5 and R6 had a fight. V10 stated that it was witnessed by another resident, V10 pointing at R8 who was sitting at another table. V10 asked R8 to join us at the same table. R8 stated that R6 was coming into the dining room, told R5 to get up and R6 pushed R5. [R5] could not do nothing, [R6] pushed [R5] so hard and [R5] fell on the floor. R8 stated that she told R6 not to do that to R5 that it was wrong. Now R5 is angry with me. V10 was asked if R8 statements are accurate. V10 confirmed what R8 stated. After leaving the dining room at the hallway, R5 was seen limping while walking. V10 who was there was notified and saw R5 limping. V10 stated that he will address it. Per clinical notes of V10 dated 08/02/2026 it documents that R5 fell as a result of being pushed to the ground by another resident. It was reported by the witness which V10 confirmed that it was R8.R5 [AGE] year-old resident, initially admitted in the facility on 04/01/2025 with medical diagnosis that includes but not limited to amnesia, major depressive disorder, alcohol abuse, and encephalopathy. R5 has severe cognitive impairment per Minimum Data Set brief interview of mental status (BIMS) never or rarely understood.R6is [AGE] year old with diagnosis including but not limited to Encephalopathy, Traumatic Brain Injury, and Dementia. R6's cognitive assessment dated [DATE] indicates a score of 9, moderately impaired.Progress note for R6 dated 8/2/26 (late entry) by Licensed Social Worker documents R6's mood agitated and anxious. Summary of session notes patient is complex due to exhibiting agitation with disorganized thought process requiring frequent reassurance and redirection.R6's care plan notes he requires mediation to help manage and alleviates behavior disturbances and agitation. Additionally, At risk for Delirium and impaired communication, and conflict with other persons.During conversation with R8 on 8/5/26 resident was able to clearly state her thoughts within topic. Per R8 annual assessment dated [DATE] documents that R8 are oriented on all three (3) person, place, and time. On 08/05/2026 at 11:50 AM V1 (Administrator) confirmed that R6 pushed R5 to stop R5 from sitting on the chair. V1 stated what R6 did was not intentional, some people use their hands to talk. V1 made aware that a resident (R8) witnessed what happened. V1 stated that R8 may be confused when asked what day it is. V1 stated that to be considered abuse it must be intentional. V1 noted and stated that if someone pushes, I will feel hurt although it is not intentional. 08/05/2026 at 01:15 PM, V2 (Assistant Director of Nursing) stated that when an incident happens that a resident hit the floor there needs monitoring after the incident. Nurses on the floor need to monitor the resident and chart or document for 72 hours. Usually, we do 72-hour charting to make sure residents are okay after the fall. I did not know that R5 was limping. I will check on him if X-Ray needs to be done. Review of R5 clinical records does not reflect any documentation that monitoring was done after R5 was pushed to the floor. On 08/06/2026 at 10:47 AM V17 (Certified Nursing Assistant) stated that she saw R6 pushed R5 but when R6 was asked, he denies pushing R5. V17 stated that R5 complained with hip pain and informed V10 (Registered Nurse/Agency). On 08/06/2026 at 02:07 PM V12 (Director of Nursing) stated that nurses need to do 72-hour charting to incidents like R5's fall. V12 stated that R5 refused X-Ray currently pain and limping of R5 cannot be determined for lack of X-Ray result. Abuse Policy dated 01/06/2026: It is the policy of this facility to prohibit and prevent resident abuse. Abuse is the willful infliction of injury resulting physical harm or pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical harm includes hitting, slapping, pinching, kicking etc. Upon receiving reports of physical or sexual abuse, the Charge Nurse will immediately examine the resident. Findings of the examination must be recorded in a separate Incident Report and the resident's medical record. The nursing staff is additionally responsible for reporting on a facility Incident Report the appearance of bruises, lacerations or other abnormalities as they occur. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the Administrator or in the absence of Administrator, the Director of Nursing.

Based on interview and record review, the facility failed to supervise and assist one resident (R1) with feedings that required feeding assistance. This failure affected one resident (R1) out of three residents reviewed.Findings include:R1's medical diagnoses include but are not limited to essential hypertension, epilepsy, anxiety disorder, chronic obstructive pulmonary disease.R1's Minimum Data Set, dated [DATE] has a Cognitive Skills for Daily Decision Making scored of 2, which indicates R1's cognition is moderately impaired. R1's Nutritional Risk Review dated 03/19/26 documents in part, E. Physical Functioning: 1. Eating: self-performance 4. Total dependence. 2 Eating: Support provided 2. One-person physical assist. Plan of Care 8. Narrative Progress Note: Res (resident) dependent at meals.R1's Functional Abilities and Goals assessment dated [DATE], documents in part, A5a. Eating: Task: GG - Eating (Substantial/max).R1's care plan with revision date 12/09/25, documents in part, I require a mechanically altered diet. I will have no chewing or swallowing problems daily through next review. Observe for chewing and or swallowing problems. Observe meal consumption of all meals.R1's progress note dated 03/06/26, documents in part, Resident is 1:1 (one to one) feeder and requires lots of redirection and encouragement to finish meals.On 06/27/26 at 9:44am, V7 (Certified Nursing Assistant/CNA) stated that on the day that R1 coded, she had seen him last when she was passing out food trays and then again when she found R1 unresponsive. V7 stated that R1 fed himself and that R1 ate in his room alone on the day R1 was found unresponsive. V7 stated that she knows if a resident is a feeder if she comes to pick the meal tray up and the resident has not touched the food. V7 stated that she was unaware the R1 was to receive one-to-one feeding assistance and that R1 always fed himself. V7 stated that R1 always ate his food really fast and she has had to tell R1 to slow down with eating.On 06/27/26 at 11:08am, V10 (Restorative Consultant) stated that R1 needed assistance with meals and assistance with feeding. V10 stated that a resident that requires feeding assistance is not safe to eat in the room by themselves and eating by themselves is a choking hazard.On 06/27/26 at 11:17am, V11 (Licensed Practical Nurse/LPN) stated that R1 always fed himself. V11 stated that staff would give R1 his tray, make sure R1's head of the bed was elevated, and go back to his room to encourage him to eat more if R1 was not finishing his meal. V11 stated that it was never communicated to him that R1 required 1:1 feeding assistance.On 06/27/26 at 11:41am, V2 (Director of Nursing/DON) stated that she did enter a note in R1's record stating the R1 required one-to-one assistance. V2 stated that one-to-one assistance does not mean consistent observations with meals and doesn't mean that R1 needs someone to sit with him during the entire meal.On 06/27/26 at 1:00pm V1 (Administrator) stated that a resident that requires 1:1 feeding assist should never eat in a room by themselves. V1 stated that a resident that requires 1:1 feeding could pocket their food and choke. V1 stated that if it is documented that a resident requires substantial/mas assist, that means full assistance should be provided to the resident and staff should sit with the resident for the duration of the meal. V1 stated that 1:1 does not mean leave the resident and come back to assist the resident if needed. Facility's policy titled Guidelines Standard Supervision dated 05/17/23 documents in part, Purpose: This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. Procedure:. 2. A staff member that has been assigned to care for the resident will visualize the resident at the start and end of the shift, during meals times, and at a minimum every two hours between.

Based on observation, record review and interview the facility failed to ensure that one resident's (R13's) preferred diet was followed. This failure has affected one of 5 residents reviewed for dietary services.Findings include: R13 is [AGE] year old with diagnosis including but not limited to: anxiety disorder, essential hypertension, paraplegia, contracture of unspecified joint and periodontal disease.R13's Minimum Data Set (MDS) documents, in part, a BIMS (Brief Interview of Mental Status) score is 14, which indicates cognitively intact. On 5/12/26 at 10:15 am, Ham was observed on R13's meal tray in his room. At that time R13 stated the following, They (facility) never follow my meal ticket. I've complained several times about consistently getting ham when I don't eat pork and my meal ticket clearly says no ham. On 5/13/26 at 10:00 am, V5 (Dietary manager) stated the following, With the meal tickets, the dietary aides follow the meal tickets on the line as they prepare the trays. We serve renal, CCHO (Consistent Carbohydrate), mechanical, cardiac. It is important to follow the diet to ensure that everyone is getting what they are supposed to get according to their health issues. It is important to follow the preferred diet so that the residents will eat. To make sure that they are receiving the proper nutrition. I do not expect for ham to be on the tray if a resident does not eat pork and has special dietary orders for no ham. On 5/12/26 at 10:44 am, V22 (CNA) removed R13's meal tray and stated the following, His meal ticket says, 'No Ham'.On 5/13/26 at 10:00 am, V5 (Dietary manager) stated the following, It is important to follow the diet to ensure that everyone is getting what they are supposed to get according to their health issues. It is important to follow the preferred diet so that the residents will eat. I do not expect for ham to be on the tray if a resident does not eat pork and has special dietary orders for no ham. Facility Resident Council Meeting minutes for March 2026 documents, in part, Residents complain of staff not serving meals to the residents on the units according to residents' diets and their meal tickets.R13's Meal Ticket documents the following: As part of R13's special instructions: No ham. Facility policy titled Dietary Preferences, Nutritional Requirements, and Portion Management documents the following: The facility will make every reasonable effort to accommodate each resident's cultural, religious, and personal dietary preferences while ensuring that all meals meet the resident's nutritional requirements as determined through comprehensive assessment and care planning.

Based on interview and record review, the facility failed to accommodate resident food preferences by not offering menu alternatives or substitutes during weekend meal service.These failures have the potential to affect all 188 residents receiving food prepared in the facility's kitchen. Findings include:On 03/17/26 at 11:05 AM, R7 stated someone from the activity department comes around Monday through Friday to ask him what he wants to eat for lunch and dinner that day. R7 stated on the weekend this does not happen. R7 stated if he receives food that he does not like on the weekend he asks one of the CNAs (Certified Nursing Assistants) to call down to the kitchen to get a substitution however the CNAs tell him that the kitchen does not do substitutions on the weekend so whatever he gets served is what he has to eat.On 03/17/26 at 1:25 PM, R12 stated he can only get a menu substitution Monday through Friday. V12 stated on the weekend he only gets what is posted on the regular menu, no substitutions are available. V12 stated he wished there were menu substitutions available on the weekend to provide some variety in case he does like the regularly scheduled meal being served.On 03/17/26 at 1:31 PM, R13 stated he asked for a menu substitution at lunch, and he received the item he requested. R13 stated Monday through Friday there are menu substitutions available for lunch and dinner that he can order ahead of time if he does not like the main meal being served. R13 stated menu substitutions are not available on the weekends, only during the week. R13 stated if he does not like the food served to him over the weekend, he will ask for something else to eat but the staff tells him they do not have any other food to give him, so he just goes hungry and he does not like that. R13 stated he wants to eat something, and he cannot eat food if he does not like it. R13 stated he feels the kitchen should have substitutions available for him to eat on the weekend.On 03/17/26 at 1:54 PM, R14 stated Monday through Friday the dietary staff gives out menu substitutions in case he does not like the scheduled meal but menu substitutions not available on the weekend. R14 stated on the weekend he has to eat whatever they serve because no substitutions are available. R14 stated he does not know why substitutions are not available on the weekend, but he would like to have menu substitutions available because he does not always like what is being served and does not want to go hungry.On 03/18/26 at 2:07 PM, R16 stated if he does not like what is being served, he can request a menu substitution Monday through Friday but on the weekends no menu substitutions are available. R16 said, you have to eat what they got. R16 stated over the weekend if he receives something he does not like he calls his family for money so he can buy snacks from the vending machine and/or order out for food to be delivered so he has something to eat.R7's MDS (Minimum Data Set) dated 01/13/26 indicates intact cognition.R12's admission MDS in progress dated 03/13/26 indicates intact cognition.R13's MDS dated [DATE] indicates intact cognition.R14' s MDS dated [DATE] indicates intact cognition.R16' s MDS dated [DATE] indicates intact cognition.On 03/17/26 at 1:15 PM, V31 (Dietary Aide) stated menu substitutes are available and offered to residents Monday through Friday. V31 stated there are no food substitutions made or offered to residents on the weekend. V31 stated if a resident does not like the food served to them over the weekend, he will try to give the resident something different to eat but this is dependent on what food is available (if any). V31 said, We try to give the resident something, but it may not be what they want.On 03/19/26 at 11:10 AM, V41 (Activity Aide) stated she works Monday through Friday and every other weekend. V41 stated when she is working Monday through Friday, she meets with the residents on the 2nd floor to tell them what is being served that day for lunch and dinner. V41 stated if they do not want to eat what is being served, she provides them with a list of alternatives/substitutions that are available, they tell her what they want to eat, and she writes their selection down on a form and then gives this to the kitchen. V41 stated she only offers the resident menu substitutions during the week Monday through Friday, not on the weekend. V41 stated she does not know why menu alternatives are not offered to the residents over the weekend, she was told that was the process when she was first hired and that is what she still does. V41 stated on the weekend the residents only get offered what is being served on the posted menu, no alternatives are offered.On 03/19/26 at 11:16 AM, V42 (Activity Aide) stated Monday through Friday she asks the residents on the 3rd floor what they would like to eat for lunch and dinner that day. V42 stated the residents can select the posted menu meal or a menu alternative from a list of available items. V42 stated she does not do this on the weekends, only during the week. V42 stated she was trying to figure out why they do not offer menu substitutions to the residents on the weekends, but she does not know the reason. V42 stated on the weekends residents will come to her and ask if there are any menu substitutions available and she has to tell them they are not being offered on those days. V42 stated this means the only items available for them to eat is the posted menu entree. V42 stated she is sure the residents would like a choice of what they want to eat on the weekends.On 03/19/26 at 10:17 AM, V37 (Regional Food Service Manager) stated menu alternatives are available daily at every meal and the options are posted on every unit. V37 stated the activity department asks the residents what they want to eat for lunch and dinner that day, that information is sent down to the kitchen and then the dietary staff writes on the resident meal ticket what menu alternative they want if any. V37 stated this is done daily. The system is in place so that residents have choices of what they want to eat and to communicate to the kitchen staff if the resident(s) want something else to eat so the kitchen can prepare the requested food for them. V37 stated it is important to give the residents choices and different food options. V37 stated it is unlikely that all the residents are going to like the one dish so that is why the kitchen gives them at least six different choices per meal. V37 stated the kitchen does not want to force the residents to eat something they do not like. V37 said, we want them to have choices.On 03/19/26 at 11:57 AM, V40 (Dietary Manager) stated menu alternatives are offered and available every day. The activity staff tells the residents what we have serving for lunch and dinner and then ask them if that is what they want to eat or if they would like one of the menu alternatives. V40 stated she thinks this is done by the activity staff every day but V40 does not work on the weekends. V40 stated she was under the impression the process for menu selections Monday through Friday is the same on the weekends (Sat/Sun). V40 stated it is important for the residents to have different menu choices in case the resident does not like what the kitchen is serving so the residents have menu substitutions. V40 stated it is important to offer the residents choices because they have a right about what they want to eat. V40 stated the residents should have a choice every day they are served a meal not just Monday through Friday.On 03/19/26, V1 provided list of diet orders for all residents in the facility. The diet order list indicates there are two residents receiving nothing by mouth (NPO).Facility provided policy titled, Menu Selection/Alternative undated which documents in part, residents will be able to choose foods they wish to have from the items available and an alternative menu with choices is available daily.Facility provided policy titled, Dietary Preferences, Nutritional Requirements, and Portion Management undated which documents in part, the facility will make every reasonable effort to accommodate each resident's cultural, religious and personal dietary preferences while ensuring that all meals meet the resident's nutritional requirements and the facility recognizes each resident's right to self-determination in dietary choices and when menu items conflict with (these) preferences appropriate substitutions will be offered when available.Facility provided document titled, Always Available Menu which documents the following items: Cheeseburger on Bun, Hamburger On Bun, Grilled Cheese Sandwich, Peanut Butter & Jelly Sandwich, Deli Sandwich, Chef Salad.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions during food delivery by not covering food/utensils during transport and by food service staff not wearing hair restraints during meal service and in the kitchen. These failures have the potential to affect all 188 residents receiving food prepared in the facility's kitchen. Findings include:On 03/17/26 at 11:20 AM, R7 stated his food is not always covered and this really bothers him because he does not want anyone talking while they are carrying his meal tray because some of their spit may go on his food. R7 stated his juice, the dessert and silverware are never covered with anything. R7 reports finding two black hairs on top of the bread of his grilled cheese sandwich (meal and date unspecified).On 03/17/26 at 12:35 PM, observed during lunch distribution on the 2nd floor in the unit dining room two Dietary Aides (V31 & V32) portioning out food from a portable steam table and putting food on plates. V31 was not wearing a hair restraint to cover the hair on his head or a beard protector to cover his facial hair.On 03/17/26 at 12:37 PM, observed V28 (Certified Nursing Assistant) and V29 (Certified Nursing Assistant) pouring pink liquid into cups and then putting the cups on the resident meal trays. V28 and V29 stated these trays were being prepared for the residents who eat their meals in their rooms. The drink cups were not covered with a lid or plastic. Observed on resident trays in open cart eating utensils sitting on top of paper napkins. The utensils were not covered.On 03/17/26 at 12:38 PM, V28 and V29 stated the drink cups and silverware are never covered during transport, only the plate of food is covered with plastic wrap.On 03/17/26 at 12:40 PM, observed V32 (Dietary Aide) using plastic wrap to cover plates of food. V32 stated he wraps the plates of food for those residents who eat in their room. Then, observed V32 put the wrapped plates of food on meal trays which were in an opened wheeled cart for transport. Other trays already on the opened wheeled cart had plated food wrapped in plastic wrap, however none of the drink cups were covered with a lid or plastic wrap and the eating utensils were also not covered with anything. There was no cart covering put over the opened carts before leaving the dining room.On 03/17/26 at 1:20 PM, V31 (Dietary Aide) V31 stated all the meal trays are prepped in the kitchen with meal tickets, napkins, utensils, and desserts and they are then delivered to the nursing unit in open carts where the kitchen staff then adds the hot food and the nursing staff add the drinks. V31 stated for any trays going to residents who eat in their room the dietary aides cover their food with plastic wrap. V31 stated they do this for sanitary reasons because stuff can fall into the food during transport. V31 stated the cups of juice drink are never covered and the utensils are also not covered, only the plate of food is covered. V31 stated the meal trays are always transported in open carts to residents' rooms, no cart cover is used.On 03/18/26 at 8:54 AM, observed CNA distributing breakfast trays room by room on the 1st floor from an opened wheeled cart that was not covered. The trays on the cart had plastic wrap over the plate of food but drink cups, utensils and bowls of cereal were not covered. The trays were left unattended as the CNA went into resident rooms to deliver trays and set up residents.On 03/18/26 at 1:10 PM, observed on the 3rd floor hallways open carts with resident trays on them. The main plate of food was covered in plastic wrap but the dessert, container of red salsa, cups of drink and silverware were not covered. The opened carts were not covered in any type of cart cover.On 03/18/26 at 1:12 PM, V27 (Certified Nursing Assistant) stated she has been working in the facility since 2017. She has worked in the housekeeping and dietary department, and she has now been working as a CNA for the past two years. V27 observed one of the open carts in the 3rd floor hallway with meal trays on it. V27 stated the food cart should be covered with a cover which goes over the entire cart for infection control reasons. V27 stated all the items on the tray should be covered because if someone coughs or sneezes it could contaminate the food on the tray and that is not sanitary. V27 stated the kitchen is only covering the plate of food but they are not covering any of the other items on the tray.On 03/19/26 at 9:57 AM, V37 (Regional Food Service Manager) stated all the food delivery carts are open, they do not have doors which can be closed. V37 stated the food delivery carts should be covered in a large plastic cover that goes over the entire cart. V37 stated it is important for the delivery carts to be covered during transportation because the food should not be exposed. V37 stated this is for sanitation issues to prevent cross contamination and minimize risk to the residents. V37 stated he does not want anything falling onto the trays to minimize risk of infections. V37 stated the food delivery carts should be covered when traveling long distances and/or if left unattended by staff and/or if left in areas where the residents could touch or come in contact with the trays. V37 stated if the CNAs are leaving the trays in the hallway in the open food delivery cart while they go into a resident's room to deliver meal tray, then the cart is left unattended.On 03/19/26 at 11:42 AM, in main kitchen observed V31 (Dietary Aide) prepping the lunch trays wearing a hairnet to cover the hair on his bed but did not have a beard protector on to cover his facial hair. Also, observed V44 (Dietary Aide) in the kitchen near the food preparation area without wearing a beard protector to cover his facial hair.On 03/19/26 at 11:45 AM. surveyor asked V40 (Dietary Manager) if V31 and V44 should have beard protectors covering their facial hair. V40 looked at V31 and V44 and stated yes, they should be wearing a beard protector to cover their hair on their face. V40 stated she expects staff in the kitchen to always wear hair restraints when they are in the kitchen and when they are upstairs portioning out the food because they are dealing with food and there is a potential for their hair to fall into the food. V40 stated hair falling into a resident's food would contaminate the food and the residents do not want to see hair in their food, it would make them not eat their food. V40 stated a beard covering should be worn if the staff has a mustache or beard or goatee or any kind of facial hair. V40 stated food carts should be covered with a large plastic cover during transport because the desserts, cereal, bowls, drinking cups and silverware do not get covered. V40 stated the carts get covered to protect the food from cross-contamination so nothing from the air can land on the food. V40 stated for example if someone was coughing/sneezing as they walk by the trays on the cart that could contaminate the food and that is why everything should be covered up. V40 stated once the trays are made in the dining room and go to the hallways for distribution the carts should be covered again with the large plastic covers for the same reason.On 03/19/26, V1 provided list of diet orders for all residents in the facility. The diet order list indicates there are two residents receiving nothing by mouth (NPO).Facility provided policy titled, General Infection Control in Dining Services undated which documents in part, the dining department follows all local, state and federal regulations in order to assure a safe and sanitary department and staff shall wear hair restraints such as hat, hair coverings or nets that are designed and worn to effectively keep their hair from contacting exposed food.Facility provided policy titled, Hair Restraints/Jewelry/Nail Polish dated 07/22/23 documents in part, food and nutrition services employes shall wear hair restraints and beard guards and hairnet, hat or hair restraint will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated.

Based on interview and record review, the facility failed to keep the residents free from abuse. This deficient practice affected one (R6) of three residents reviewed for abuse.Findings Include:Facility Reported Incident submitted to the IDPH (Illinois Department of Public Health) dated 12/09/25 documents in part, R1 reported V21 (Licensed Practical Nurse) snatched his cigarette out of his mouth and broke it on 12/07/25.R6's electronic health record (EHR) shows R6 admitted to the facility 02/13/24 and had a planned discharge from the facility on 03/05/25. R6's diagnosis includes but is not limited to Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Hyperlipidemia, Polyneuropathy, Chronic Kidney Disease, Schizoaffective Disorder, Bipolar Type, Rheumatoid Arthritis, Gout, Nicotine Dependence, Major Depressive Disorder, Anemia. R6's MDS (Minimum Data Set) dated 02/05/26 reveals R6 is cognitively intact, uses a wheelchair device for mobility and is dependent on staff for transfers.R6 has a care plan in place which documents in part, R6 has a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase (his) susceptibility to abuse/neglect and that R6 will be treated with respect, dignity, and reside in the facility free from mistreatment (i.e. abuse/neglect).On 03/19/26 at 10:52 AM, R6 stated via telephone interview he was wheeling himself down the hallway on his way to go outside for smoke break. R6 stated his cigarette was in his mouth but the cigarette was not lit. R6 stated he was not trying to smoke in the building, he had the cigarette in his mouth because he needed both of his arms to push himself in his wheelchair. R6 stated when he got close to the nursing station the nurse (V21) snatched the cigarette out of his mouth and broke it and then threw it at him. R6 stated V21 said, you shouldn't have it in your mouth! R6 then reported V21 told him she was going to call the police. R6 stated that is what she was threatening to do, she was trying to scare him, but she did not scare him. R6 stated he thinks the nurse was fired over the issue, he never saw the nurse after that.On 03/18/26 at 9:16 AM, V22 (Certified Nursing Assistant) stated on that day R6 was not smoking in his room, he had a cigarette dangling from his mouth (it was not lit) and he was propelling himself in his wheelchair toward the patio to go outside to smoke at the designated smoking time. V22 stated she was sitting at the nursing station when she saw V21 walk up to R6 and snatched the cigarette out of R6's mouth and broke the cigarette in half. V22 stated V21 did not say anything to R6 before she snatched the cigarette out of R6's mouth. V22 stated V21 then went off on him (R6). V22 stated R6 started to curse at V21 and then V21 told R6 she was going to call the cops on him as a threat to scare him. V21 stated this was around 6:00-6:30 PM. V22 stated she texted the Director of Nursing (V2) right away and notify her what was going on. V22 stated she reported it because the way the nurse snatched R6's cigarette out of his mouth and then threatened him was emotional/mental abuse. V22 stated V2 indicated her she would handle it and she thinks V2 might have called and talked to V21 but V21 did not get sent home that night, V21 finished out her shift. V22 stated based on the training she received on abuse V21 should have been sent home as soon as the abuse was reported. V21 stated she reported it to V2 because she did not have V1's phone number. V22 stated R6 went outside to smoke and calmed down, there was no change in his behavior or mood afterwards. V21 stated the next day when she came into work she wrote a statement, and administration took care of it. V21 stated she thinks that is why the nurse (V21) does not work here anymore.On 03/18/26 at 11:35 AM, V23 (Certified Nursing Assistant) stated via telephone interview she remembers seeing R6 wheeling himself down the hallway with a cigarette hanging out of his mouth. V23 stated R6 was doing this because he needed both of his hands to propel himself in his wheelchair. V23 stated the cigarette was not lit. V23 stated the nurse (V21) saw him by the nursing station and she immediately got up and she snatched the cigarette out of his mouth, broke it and told R6 he was not supposed to have the cigarette in his mouth. V23 stated V21 was being very rude to R6. V23 stated R6 was explaining that he had the cigarette in his mouth because he needed both hands to wheel himself outside and that the cigarette was not lit. V23 stated R6 was upset that V21 had broken his cigarette, and he said he was going to report her (V21). V23 stated she heard V21 yelling at R6 that the police were going to come get him. V23 stated V21 was being verbally/mental abusive to R6 by intimidating and threatening him. V23 stated V22 texted V2 that night and told her what happened. V23 stated the next day she wrote down her statement and she gave it to V2. On 03/18/26 at 10:43 AM, V2 (Director of Nursing) stated via telephone interview that mental/emotional abuse would be speaking down to a resident, using humiliation, and/or threats of any kind. V2 stated V1 is the abuse coordinator for the building and should be notified immediately of any abuse allegation. V2 stated if V1 is not available or in the building then the staff should contact V2 so she can follow the proper procedure for abuse. V2 stated if staff-to-resident abuse is witnessed, suspected or reported the staff should be immediately separated from the resident and the staff would immediately be removed from the building. V2 stated this is important because the facility wants to be able to provide safety and protection for the residents from the abuser; they do not want the abuse to continue. V2 stated the incident with R6 and V21 happened a while back so the details are foggy. V2 stated she does not remember the time or dates. V2 stated she does not remember receiving a call or text from V22 (CNA). V2 stated she does remember that R6 came and told her what happened, and she does remember asking V22 and V23 to write down their statement on the day R6 reported the allegation to her. V2 stated if the CNAs had called her the night it happened, she would have followed the process and she would have immediately had the nurse (V21) removed from the building. V2 stated R6 reported that he was on his way to smoke break, and he told V2 that V21 took the cigarette out of his mouth and broke it. V2 stated V21 thought R6 was trying to smoke and she (V21) did not want R6 to light it in the hallway and she was worried he was going to light it. V2 stated she does not remember R6 telling her that V21 had threatened him but if V21 threatened to call the police on R6 that would be considered a threat because it would intimidate the resident and that would be emotional abuse. V2 stated V21 was suspended pending the outcome of the investigation. V1 did the investigation and staff was able to tell them what happened and their story leaned toward what R6 was saying so V21 was terminated.Facility provide copies of V22 and V23's signed written statements which reflect the date of 12/09/25.Three attempts was made to contact V21, however, unable to leave a message because the voicemail had not been set up yet.On 03/19/26 at 2:11 PM, V1 (Administrator) stated he is the abuse coordinator for the facility and the main goal for the abuse program is to prevent abuse, keep the residents safe and free from abuse. V1 stated examples of emotional/mental abuse could be intimidation, humiliation, threatening punishment, and/or making belittling comments. V1 stated abuse can be defined as the willful intent to hurt or cause harm.V1 stated it is his expectation that the staff report abuse immediately if they see it or suspect or hear rumors of abuse. It is not the staff's responsibility to determine if abuse happened or not, only to report abuse. If a staff member sees staff to resident abuse they must separate the victim and the offender. It is important to separate them for their safety to make sure the abuse does not continue. V1 stated if a staff member is involved, they must leave the building immediately and they are put on administrative leave and are not allowed to return pending the outcome of the investigation. If V1 is not in the building when the abuse occurs his number is posted at the front desk and if the staff cannot find V1's phone number, then they go to the next person in the chain of command which would be the Director of Nursing (DON). After contact is made with the DON or the Assistant Director of Nursing (ADON) then one of them would call V1. V1 stated they can call him any time of day (even in the middle of the night). V1 stated R6 came to his office on Tuesday, 12/09/25 and told him that he was pushing himself in his wheelchair down the hallway to go out to smoke on 12/07/25. V1 stated R6 said his cigarette was hanging from his mouth but it was not lit. R6 told me that V21 (LPN) snatched the cigarette out of his mouth and broke it and then threw it at him. R6 was pissed off and frustrated with the nurse for doing that. V1 stated R6 gave the statement to the DON on 12/09/25 stating it happened on 12/07/25. V1 interviewed V21 over the phone, and V21 denied the whole interaction. Based on the investigation V1 conducted and interviews V1 decided to terminate R6, and she was not allowed to return to work at the facility.V1 stated he thinks V21's actions could be considered intimidating and humiliating, which would be a form of abuse. V1 stated he was not aware of V21 saying she was going to call the police on R6. V1 stated if V21 was also threatening to call the police this could also be intimating and threatening. V1 stated by V21 snatching the cigarette out of R6's mouth that would be considered willful intent and threatening the resident by saying she was going to call the police is also willful intent because she was trying to scare the resident.V1 stated if the CNA (V22) who observed the altercation reported it to V2 right away then she did the correct thing but V2 should have called V1 or reported it herself to IDPH. V1 stated more importantly the nurse (V21) should have been removed from the facility right away based on the abuse policy and abuse protocol. V1 stated the first time he heard anything about the altercation was on Tuesday, 12/09/25 and that is when he reported it to IDPH.Facility provided copies of V21's timecard which showed that V21 worked on 12/07/25 from 3:00 PM to 9:01 PM and from 9:31 PM to 7:30 AM and on 12/09/25 from 3:00 PM to 5:00 PM.V21's employee file reviewed with appropriate background checks conducted and active Illinois License on file. V21's employee file indicates V21 was hired on 08/09/23 and terminated on 12/22/25.Facility provided document titled Your Rights and Protections as a Nursing Home Resident undated, documents in part, at a minimum Federal law specifies that nursing homes must protect and promote the following rights of each resident and (you) have the right to be free from abuse and neglect.Facility policy dated 01/2019 titled Abuse Prevention Program documents in part, this facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members and abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment and willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental abuse includes but not limited to humiliation, harassment, threats of punishment. If you suspect abuse separate the alleged perpetrator and assure all residents safety and notify the Administrator and Director of Nursing immediately.

Based on interview and record review the facility failed to submit the final investigation for staff to resident abuse to the Illinois Department of Public Health (IDPH) within the required five business days for (R6) out of three residents reviewed for abuse.Findings Include:Facility Reported Incident submitted to the IDPH (Illinois Department of Public Health) dated 12/09/25 documents in part, R1 reported V21 (Licensed Practical Nurse) snatched his cigarette out of his mouth and broke it on 12/07/25. R6's electronic health record (EHR) shows R6 admitted to the facility 02/13/24 and had a planned discharge from the facility on 03/05/25. R6's diagnosis includes but is not limited to Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Hyperlipidemia, Polyneuropathy, Chronic Kidney Disease, Schizoaffective Disorder, Bipolar Type, Rheumatoid Arthritis, Gout, Nicotine Dependence, Major Depressive Disorder, Anemia. R6's MDS (Minimum Data Set) dated 02/05/26 reveals R6 is cognitively intact, uses a wheelchair device for mobility and is dependent on staff for transfers.R6 has a care plan in place which documents in part, R6 has a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase (his) susceptibility to abuse/neglect and that R6 will be treated with respect, dignity, and reside in the facility free from mistreatment (i.e. abuse/neglect).On 03/19/26 at 10:52 AM, R6 stated via telephone interview he was wheeling himself down the hallway on his way to go outside for smoke break. R6 stated his cigarette was in his mouth but the cigarette was not lit. R6 stated he was not trying to smoke in the building, he had the cigarette in his mouth because he needed both of his arms to push himself in his wheelchair. R6 stated when he got close to the nursing station the nurse (V21) snatched the cigarette out of his mouth and broke it and then threw it at him. R6 stated V21 said, you shouldn't have it in your mouth! R6 then reported V21 told him she was going to call the police. R6 stated that is what she was threatening to do, she was trying to scare him, but she did not scare him. R6 stated he thinks the nurse was fired over the issue, he never saw the nurse after that.On 03/18/26 at 9:16 AM, V22 (Certified Nursing Assistant) stated on that day R6 was not smoking in his room, he had a cigarette dangling from his mouth (it was not lit) and he was propelling himself in his wheelchair toward the patio to go outside to smoke at the designated smoking time. V22 stated she was sitting at the nursing station when she saw V21 walk up to R6 and snatched the cigarette out of R6's mouth and broke the cigarette in half. V22 stated V21 did not say anything to R6 before she snatched the cigarette out of R6's mouth. V22 stated V21 then went off on him (R6). V22 stated R6 started to curse at V21 and then V21 told R6 she was going to call the cops on him as a threat to scare him.On 03/18/26 at 11:35 AM, V23 (Certified Nursing Assistant) stated via telephone interview she remembers seeing R6 wheeling himself down the hallway with a cigarette hanging out of his mouth. V23 stated R6 was doing this because he needed both of his hands to propel himself in his wheelchair. V23 stated the cigarette was not lit. V23 stated the nurse (V21) saw him by the nursing station and she immediately got up and she snatched the cigarette out of his mouth, broke it and told R6 he was not supposed to have the cigarette in his mouth. V23 stated R6 was upset that V21 had broken his cigarette, and he said he was going to report her (V21). V23 stated she heard V21 yelling at R6 that the police were going to come get him. V23 stated V21 was being verbally/mental abusive to R6 by intimidating and threatening him. V23 stated V22 texted V2 that night and told her what happened. V23 stated the next day she wrote down her statement and she gave it to V2 (Director of Nursing).On 03/19/26 at 2:11 PM, V1 (Administrator) stated he is the abuse coordinator for the facility and the main goal for the abuse program is to prevent abuse, keep the residents safe and free from abuse. V1 stated examples of emotional/mental abuse could be intimidation, humiliation, threatening punishment, and/or making belittling comments. V1 stated abuse can be defined as the willful intent to hurt or cause harm. V1 stated once abuse is reported to V1 he submits an initial report to Illinois Department of Public Health (IDPH) within two hours of notification, and the final report must be submitted to IDPH within five business days. V1 stated R6 came to his office on Tuesday, 12/09/25 mid-day and told him that he was pushing himself in his wheelchair down the hallway to go out to smoke on 12/07/25. V1 stated R6 said his cigarette was hanging from his mouth but it was not lit. R6 told V1 that V21 (LPN) snatched the cigarette out of his mouth and broke it and then threw it at him. V1 stated R6 gave the statement to the DON on 12/09/25 stating it happened on 12/07/25. V1 stated the first time he heard anything about the altercation was on Tuesday, 12/09/25 and that is when he reported it to IDPH. V1 stated the final report was submitted to IDPH on Friday, 12/19/25 at 3:40 PM. V1 stated the final report to IDPH should have been submitted on Tuesday, 12/16/25. V1 stated he was late submitting the final report because IDPH was in the facility that week conducting the facility's annual survey and there was a lot going on.Facility provided initial report submitted to IDPH involving R6 and V21 via email which was time/date stamped Tuesday, 12/09/25, 5:23 PM.Facility provided final report submitted to IDPH involving R6 and V21 via email which was stamped time/date Friday, 12/19/25, 3:40 PM.Facility provided policy titled Abuse Prevention Program dated 01/2019 which documents in part, the final investigation report will be completed within five (5) working days of the reported incident and the Administrator is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident.

Based on interview and record review, the facility failed to ensure residents are free of any significant medication error for one (R1) of four residents reviewed for improper nursing care. The findings include:R1's admission record / face sheet shows admission date on 7/21/25 with diagnoses not limited to Spastic hemiplegic cerebral palsy, Cerebral infarction, Hemiplegia affecting left nondominant side, Lennox-gastaut syndrome, Essential (primary) hypertension, Other seizures, Hemiplegia and hemiparesis following cerebral infarction affecting left Non-dominant side, Atherosclerotic heart disease, Type 2 diabetes mellitus. MDS (Minimum Data Set) dated 3/5/26 shows R1's cognition is intact.On 3/17/26 At 11:38AM Observed R1 up and about, Ambulatory with walker, alert and oriented x 3, verbally responsive. She stated she has been residing in the facility since July 2025. Observed R1 wearing helmet, she said for safety because of her seizure disorder. R1 stated she missed doses of her anti-seizure medications (phenobarbital, Keppra and Lyrica) due to medications were not available or out of it. She said when she is not taking her anti-seizure medications then she is having seizure episodes. She said she had seizure episode about couple of weeks ago because she missed doses of Keppra, Phenobarbital and Lyrica. On 3/17/26 At 11:54AM V7 (Certified Nursing Assistant / CNA) stated she has been working in the facility for 10 years and regularly assigned on the 2nd floor. She stated she is assigned to R1 and had seizure episode about 2-3 weeks ago. She said she observed R1 Shaking in her wheelchair in the dining room. V7 stated it was a quick seizure activity; she was not hospitalized . On 3/18/26 On 3/18/26 at 9AM V26 (LPN / Licensed Practical Nurse) stated he is following doctor's order and 5 R'S (right resident, medication, route, dose and time) in giving medications to residents. He stated he checked MAR (Medication Administration Record), follow physician order in giving meds. V26 said he then sign / initial MAR after giving medications to document that medications were given. He said if MAR is not signed or initial, it could mean that medication was not given. V26 said he is regularly working on the 2nd floor and has been assigned to R1. He said R1 has seizure disorder and last seizure activity was about 2-3 weeks ago in the dining room. On 3/18/26 at 10:15AM V2 (Director of Nursing / DON) stated nurses should follow doctor's order and 5 rights (right resident, medicine, time, dose, route) in giving medications to residents. She stated nurses are expected to sign or initial in MAR after giving medications to residents to document or validate that medication was administered to the resident. V2 stated if MAR was not signed, it could possibly mean that medication was not given to the residents. She stated standard nursing practice if it is not documented it was not given. V2 stated If anti-seizure medication was not given it could potentially affect the therapeutic level of the medication and could suppress the effectiveness of the medication that could lead to seizure activity. R1's Nursing Progress Note dated 2/22/26 shows in part: R1 observed in the dining room with jerking movements of bilateral upper and lower extremities lasted 1 minute, R1 assisted to room resident in bed seizure precautions in place.R1's POS (Physician Order Sheet) shows active order not limited: Pregabalin Oral Capsule 200 MG (Pregabalin) Give 200 capsule by mouth two times a day related to OTHER SEIZURES. Scheduled for 9AM and 5PM. Phenobarbital Oral Tablet 100 MG (Phenobarbital) Give 100 mg by mouth two times a day related to OTHER SEIZURES. Scheduled for 9AM and 5PM. Keppra Oral Tablet 1000 MG (Levetiracetam) Give 1 tablet by mouth two times a day for seizures. Scheduled for 6AM and 6PM. March MAR (Medication Administration Record) shows no signature / initial on 3/9/26, 3/16/26 and 3/17/26 indicating Keppra was not given to R1. March MAR shows no signature / initial on 3/16/26 indicating Phenobarbital was not given to R1. March MAR shows no signature / initial on 3/16/26 indicating Pregabalin (Lyrica) was not given to R1. February MAR shows no signature / initial on 2/8/26 and 2/9/26 indicating Keppra was not given to R1. February MAR shows no signature / initial on 2/9/26 indicating Phenobarbital was not given to R1. February MAR shows no signature / initial on 2/9/26 indicating Pregabalin (Lyrica) was not given to R1. Care plan dated 1/26/26 shows in part: R1 is at risk for seizure activity related to: Lennox Gastaut Syndrome. Administer medication as directed and follow pharmaceutical recommendations. Facility's drug administration - general guidelines policy (undated) shows in part: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's MAR at the time the medication is given. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Facility's tips for safe medication administration policy (undated) shows in part: Follow good clinical practices for administration of medications: Sign out medications as soon as they are given. Document if the medication is refused and the reason.Facility's medication administration policy (undated) shows in part: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. Document medication administration with initials in appropriate spaces on Medication Administration Record (MAR).Facility's guidelines for physician orders (following physician orders) policy dated 6/18/23 shows in part: all physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received.

Based on observation, interview, and record review the facility failed to ensure resident call lights were responded to in a timely manner for one resident (R7) out of five reviewed for call lights.Findings include:On 03/17/26 at 11:45 AM, R7 complained that his call light does not get answered right away and sometimes it can take the staff over an hour to respond to his call light.On 03/17/26 at 12:53 PM, observed the call light system monitor screen at the 2nd floor nursing station which read R7's room [ROOM NUMBER] minutes. Observed the light outside R7's room to be on.On 03/17/26 at 1:11 PM, observed call light system monitor screen at the 2nd floor nursing station which read R7's room [ROOM NUMBER] minutes. Observed the light outside R7's room to be on.On 03/17/26 at 1:45 PM, observed the light outside R7's room to be turned off. R7 stated someone came inside to turn off his call light but it took them a long time to check on him.On 03/18/26 at 12:46 PM, observed the call light system monitor screen at the 2nd floor nursing station which read R7's room [ROOM NUMBER] minutes. Observed V26 (Licensed Practical Nurse) sitting at the nursing station. V26 stated that when a resident triggers their call light in their room the resident's room number pops up on the call light monitoring system screen and the system keeps track of the number of minutes from which time the resident triggered their call light. V26 stated the light outside the resident's room also lights up once they trigger their call light. V26 observed the call light system monitor screen and stated that means that R7 triggered his call light 62 minutes ago. V26 stated he bet someone already went in to check on R7, but they forgot to turn off the call light in R7's room.On 03/18/26 at 12:48 PM, observed the light outside R7's room to be on indicating R7's call light had been activated.On 03/18/26 at 12:50 PM, observed R7 lying in his bed with a bucket of grayish water on his bedside table. R7 stated V29 (Certified Nursing Assistant) came into his room at 10:50 AM to give him the bucket of water so he can bathe himself, but he is not able to wash his feet on his own so he triggered the call light to get some help. R7 stated he triggered his call light over one hour ago and no one had been inside his room to see what he needed. R7 stated no one has been in his room since V29 brought him the bucket of water at 10:50 AM.On 03/18/26 at 12:54 PM, V29 stated the last time she was in R7's room was around 10:50 AM when she came to bring R7 a bucket of water. V29 stated she was busy helping to pass out meal trays in the dining room. V29 stated that any of the staff can answer the residents' call lights, it is not only the responsibility of the assigned Certified Nursing Assistant (CNA) to do it. V29 stated it is important to answer the residents' call lights right away because they may be in distress and for safety reasons. V29 stated the staff does not know what type of help the resident needs or if they are in any type of danger or unsafe situation unless the staff goes into the resident's room to check on them. V29 stated someone should have responded to R7's call light right away, he should not have had to wait over one hour for help.On 03/18/26 at 1:00 PM, V26 stated call lights should be answered as soon as possible to see what the resident needs to prevent a fall and/or injury. V26 stated the staff does not know what the residents needs unless they check on them. V26 stated that even if it is a resident who pulls the call light a lot the staff still need to check on the resident regardless of how many times they pull it. V26 stated R7 does use his call light a lot but someone should have checked on R7 when he activated his call light. V26 stated that R7 should not have had to wait that long for help, that should not have happened. On 03/18/26 at11:00 AM, V2 (Director of Nursing) stated via telephone interview that call lights should be responded to with 15 minutes. V2 stated the purpose of the call light is so the residents can alert the staff to get them to go into the resident's room so the staff can provide assistance to the resident. V2 stated the staff does not know why the residents triggered their call light unless they go check on them. V2 stated if the staff takes longer than 15 minutes to respond to the residents' call light then the potential problem is a delay in providing a service for the residents.R7 diagnosis includes but not limited to: Paraplegia, Encounter for Attention To Colostomy, Contracture, Unspecified Joint, Other Intestinal Obstruction Unspecified As To Partial Versus Complete Obstruction, Urinary Tract Infection, Presence Of Urogenital Implants.R7's MDS (Minimum Data Set) from 01/13/26 indicates intact cognition and substantial/moderate assistance is required for toileting, shower/bathing self, lower body dressing, personal hygiene and for chair/bed to chair transfer.R7's care plan in place which documents in part (R7) at risk for falls related to generalized weakness, paraplegia and interventions include but not limited to place call light within reach and encourage (me) to use it for assistance as needed.Facility provided policy titled Call Light undated which documents in part, call lights are to be answered promptly by staff who see that the call light has been activated.Facility provided document titled Job Description for Certified Nursing Assistant dated 04/01/23 which documents in part under role responsibilities - care: responds to/answers resident call lights promptly.

Based on interviews and record reviews, the facility failed to prevent R1's fall, failed to care plan R1's need for mechanical lift transfers, failed to have two staff members during a mechanical lift transfer for R1, and failed to notify R1's representative of a fall for one of five residents reviewed for improper nursing care.Findings include: R1's admission Record documents in part diagnoses of osteoporosis, Alzheimer's disease, dementia, dysphagia, displaced fracture of left femur, and history of falling. V29 is R1's responsible party and power of attorney. R1's 12/29/2025 Quarterly MDS (Minimum Data Set) assessment documents in part that R1 is severely cognitively impaired. R1 is dependent on staff for bed-to-chair transfers. R1's 'Care Plan Report' documents in part that R1 is at risk for fall related to generalized weakness, changes in environment, and adjustment to facility (initiated 1/13/2026). Goal included I will have a safe environment maintained through next review and I will have fall interventions in place that will help reduce my risk for falls and injury through the next review. The target date is 5/14/2026. Interventions include to follow facility Fall Protocol and staff to anticipate and meet R1's needs (initiated 1/13/2026). R1's care plan also documents in part that R1 is at risk for self-care deficit and requires assistance with ADLs (Activities of Daily Living) to maintain the highest possible level of functioning (initiated 1/13/2026). Intervention initiated on 1/13/2026 documents in part that R1 may occasionally receive an increase in assist with transfers due to fluctuation in needs. However, during multiple interviews with staff including V4 (Nurse), V5 (Certified Nurse Aide-CNA), V10 (CNA), V11 (CNA), V12 (Anonymous Staff), and V18 (Nurse), staff stated R1 has been dependent with transfers requiring mechanical lifts for more than a year. Focus for mechanical lift transfers was not added to R1's comprehensive report until 2/6/2026. On 2/11/2026 at 2:44 PM, V4 (Nurse) stated hearing a thud while conducting end of shift rounds. When V4 entered R1's room, R1 was on the floor and V11 (CNA) was in the room with a mechanical lift. V4 stated did not witness how R1 got to the floor. V4 stated did not notify V29 or other family members about R1 being on the floor. During a telephone interview with V11 (Certified Nurse Aide) on 2/11/2026 at 4:10 PM, V11 stated being at the facility for a little over a month. V11 stated [V11] took care of R1 on 2/3/2026. V11 prepped R1 to transfer from bed to chair. V11 stated [V11] used a mechanical lift without another staff assisting. V11 stated when R1's legs lifted off the bed, R1 started to slide. V11 realized during the transfer that the machine [V11] was using was the weight machine and not a mechanical lift used for resident transfers. V11 stated when moving R1, R1 kind of slid down slow. V11 paused the transfer and called for help. V11 stated V2 (Director of Nursing) and V3 (Assistant Director of Nursing) happened to be walking by the room. V11 stated V2, V3, along with V11 lowered R1 to the floor. V11 stated [V11] was misinformed about doing a lift alone if comfortable to operate it alone. V11 stated it was no excuse because mechanical lifts are supposed to be operated with two staff members. V11 stated after the incident facility administration in-serviced [V11] on facility's protocol. During an anonymous staff interview on 2/11/2026 at 4:42 PM, V12 (Anonymous Staff) stated the facility protocol is to do a two-person assist when using a mechanical lift for transfers. V12 stated CNAs (Certified Nurse Aides) learn that upon hire during orientation. V12 stated V11 received that training. On 2/13/2026 at 11:38 AM, V2 (Director of Nursing) stated V2 and V3 were doing rounds when they heard V11 calling for help. V2 saw V11 transferring R1 on a mechanical lift unassisted. R1 was in the sling off the bed. V2 stated R1 did not look comfortable. V2 stated V2, V3, and V11 lowered R1 to the floor. V2 and V3 then went to grab a different lift to assist R1 off the floor. During a follow-up interview with V2 at 1:31 PM, V2 stated the facility was calling R1's incident an 'assisted transfer' to the floor. V2 stated facility was not calling it a fall. V2 stated [V2] did not inform V29 or R1's family about staff placing R1 on the floor until 2/6/2026. On 2/13/2026 at 12:46 PM, V3 (Assistant Director of Nursing) stated V2 and V3 were rounding the unit when they heard V11 call for help. V3 saw V11 attempting to transfer R1 with mechanical lift without assistance. V3 stated R1's legs did not look secure on the mechanical lift. V3 stated did not inform V29 or R1's family about the incident. V2 filled out facility's incident report regarding R1's 2/3/2026 incident. V2 documented it as Other incident. It documents in part: Upon making rounds on the unit, writer observed CNA using [mechanical] lift to transfer resident to [chair]. CNA appeared to be need assistance with transfer and writer, along with [Assistant Director of Nursing] assisted resident to the floor safely. V11's statement reads I transferring [R1] in the [lift] when I wasn't comfortable with how [R1's] lower half was positioned in the sling. V3's statement reads While rounding with [V2], we heard help, We entered [R1's room] and observed [V11] attempting to use the [lift] alone. [V2] immediately stated we needed to lower [R1] down due to the position of [R1's] lower body in the pad. Facility notified V29 about investigation on 2/6/2026. Facility's conclusion was that it was not a fall. Stated Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 229; Issued 4/25/25) documents in part: Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Facility's Guidelines for Incident/Accidents/Falls, dated 6/30/23, documents in part that the nurse will notify the resident's responsible party. The resident's responsible party will be kept informed of any orders received or interventions put into place. Resident Handling Policy 'Limited Lift' reads The Resident Handling Policy exists to ensure a safe working environment for resident handlers. The policy is to be reviewed and signed by all staff that perform or may perform resident handling. Mechanical Lift Transfer - Full Lift/[redacted brand name] (2 Caregivers). This policy is to be followed at all times. V11 signed this policy on 12/31/2025. V11 also completed a Validation of Competency Mechanical Lift on 12/31/2025 which included placing the equipment in position with the assistance of a 2nd caregiver.

Based on review of records and interviews facility failed to maintain resident rights to be free from all forms of abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. These failures are not in accordance with facility's abuse policy and affected 2 residents (R1, R2) both experiencing physical abuse.The findings include:R1 is a [AGE] year-old resident, initially admitted in the facility on 03/27/2022. R1's medical diagnosis includes hemiplegia and hemiparesis following cerebrovascular disease.R2 is a [AGE] year-old resident, initially admitted in the facility on 01/06/2026. R2's medical diagnosis includes schizophrenia, schizoaffective disorder, major depressive disorder. R2 has intact cognition with BIMS score of 15 dated 01/13/2026.Per V2 (Director of Nursing) clinical notes dated 01/20/2026 documented R2 made contact with R1. R1 complained of pain in her left arm. X Ray was performed on R1's left arm.Per incident report dated 01/20/2026 R2 made contact with R1 during disagreement inside their room. R2 attempted to adjust the heat on R1's side of the room. R1 stated that R2 smells. R2 made contact with R1's leg. R1 reacted by using her Reacher. R2 sustained minor skin alteration to the left side of her nose. Police report was included for incident of simple battery.Per social service notes by V9 (Social Worker) dated 01/20/2026, R2 was sent to the hospital for psychiatric evaluation due to aggression towards R1 and not easily redirected. Per census history, R2 returned to facility on 01/26/2026 on the same floor, different room to R1. Per clinical notes of V8 (Licensed Practical Nurse) dated 01/27/2026, R2 was observed with agitation and aggression. R2 was transferred to hospital for evaluation and treatment and was discharged from the facility.On 02/04/2026 at 01:29 PM, V1 (Administrator/Abuse Coordinator) stated that R1 and R2 had an argument because R1 does not want R2 to be on her side of the room because R2 smells. V1 stated that R1 told him that R2 hit her leg with her hand. In retaliation, R1 hit R2 with her reacher, an equipment used to grab things far from reach using arm. R1 was in her wheelchair when the incident happened. V1 stated that R1 and R2 were roommates during that time it happened on 01/20/2026. V1 stated that R2 was sent to the hospital after the incident and came back to the facility on [DATE] but was discharged the next day 01/27/2026. V1 reviewed facility's abuse prevention policy and facility incident final report. V1 stated that final report concluded that R2 did hit R1 and that it is under the definition of physical abuse. V1 stated that police report documents that the incident that happened was simple battery.On 02/04/2026 at 02:51 PM, V2 (Director of Nursing) stated on the day of the incident R2 told her (V2) that R1 was screaming because she (R2) wanted to turn the heat off. When she (V2) went into the room, R1 told her that R2 hit her on the leg and later changed to her arm. R1 complained of left arm pain and Xray was done. V7 (Family of R1/POA) was informed about Xray result without injury. R1 stated that she feels safe if R2 does not come near her. R2 was admitted in the facility with behavior more verbally than physical aggression. R1 and R2 were roommates since R2 was admitted . V2 stated that R1 has left side weakness and cannot block R2 when R2 hits her on the left side. R2 on the other hand has no limitation as to ambulation, movement and does not have any disability. R2 came back to the facility after the incident and was discharged the next day due to another aggression. Both V1 and V2 stated that R2 does not maintain proper hygiene and has an intimidating characteristic.Abuse Prevention Program dated 03/01/2021:It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse means hitting, slapping, pinching, kicking, etc.

Based on review of records and interview facility the failed to follow abuse reporting policy for 2 out of 4 residents (R1, R2) in a total sample of 4 residents reviewed. This failure has the potential to affect R1 and R2 in timely determination of abuse incidents and providing necessary interventions to prevent possible recurrence.The findings include:R1 is a [AGE] year-old resident, initially admitted in the facility on 03/27/2022. R1's medical diagnosis includes hemiplegia and hemiparesis following cerebrovascular disease. R2 is a [AGE] year-old resident, initially admitted in the facility on 01/06/2026. R2's medical diagnosis includes schizophrenia, schizoaffective disorder, major depressive disorder. R2 has intact cognition with BIMS score of 15 dated 01/13/2026.Facility's initial abuse reportable incident report was submitted by facility dated 01/20/2026 between R1 and R2. Per report it was alleged that R2 made contact with R1. Final report was sent on 02/04/2026 at 11:49 AM, which is the current date. In the final report it was concluded that R2 did made contact with R1 due to disagreement. R1 retaliated and made contact with R2 with her reacher which is an equipment used to grab things.Per social service notes by V9 (Social Worker) dated 01/20/2026, R2 was sent to the hospital for psychiatric evaluation due to aggression towards R1 and not easily redirected. Per census history, R2 returned to facility on 01/26/2026 on the same floor, different room to R1. Per clinical notes of V8 (Licensed Practical Nurse) dated 01/27/2026, R2 was observed with agitation and aggression. R2 was transferred to hospital for evaluation and treatment and was discharged from the facility.On 02/04/2026 at 01:29 PM, V1 (Administrator/Abuse Coordinator) stated that R1 and R2 had an argument because R1 does not want R2 to be on her side of the room because R2 smells. V1 stated that R1 told him that R2 hit her leg with her hand. In retaliation, R1 hit R2 with her reacher, an equipment used to grab things far from reach using arm. R1 was in her wheelchair when the incident happened. V1 stated that R1 and R2 were roommates during that time it happened on 01/20/2026. V1 stated that R2 was sent to the hospital after the incident and came back to the facility on [DATE] but was discharged the next day 01/27/2026. V1 stated that final report was sent today 02/04/2026 because he forgot to send it. Final was sent today to be honest I forgot there were many things going on during that time. I did not follow my policy to send the initial and final report within 5 days. V1 reviewed facility's abuse prevention policy and facility incident final report. V1 stated that final report concluded that R2 did hit R1 and that it is under the definition of physical abuse. V1 stated that police report documents simple battery.Abuse Prevention Program dated 03/01/2021:Abuse allegations involving one resident upon another resident will be reported to IDPH.The investigator will submit a final report of the conclusion of the investigation in writing within 5 working days of the incident.The final investigation report shall contain the following:Name, Age, Diagnosis and mental status of the resident allegedly abused, neglected, or exploited.The original allegation (note day, time, location, specific allegation, by whom, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries.Facts determined during the process of the investigation, review of medical records and interview of witnessesConclusion of the investigation based on known factsIf there is a police report, attached the police reportIf the allegation is determined to be valid and the perpetrator is an employee, include on a separate sheet the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions, and status (still working, suspended or terminated)Attach a summary of all interviews conducted, with the names, addresses, phone numbers, and willingness to testify of all witnesses.The administrator or DON in the absence of the Administrator will review the report. The Administrator or DON in the absence of the Administrator is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident.

Based on interview and record review, the facility failed to ensure that one resident (R1) with a pressure ulcer, received the necessary treatment and services to promote wound healing and prevention of new wounds. This failure resulted in R1's wound worsening and requiring hospitalization for wound infection. Findings include: R1's medical diagnoses include but are not limited to hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus without complications, aphasia, cognitive communication deficit, essential hypertension, pressure ulcer of sacral region. R1's Minimum Data Set (MDS) dated [DATE] has a Cognitive Skills for Daily Decision Making scored as moderately impaired. R1's care plan dated 01/07/25 documents in part, R1 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues .turn and reposition resident from side to side as ordered .monitor for signs and symptoms of infection and report to MD (medical doctor) as indicated .administer wound care treatments per MD orders. R1's physician order with a start date of 06/27/24 documents in part, Turn and reposition from side to side every 1-2 hours every shift for wound prevention. R1's treatment administration record dated 01/2025 and 02/2025 for the turn and reposition order show multiple dates of no documentation. R1's physician order start date 01/16/25 and end date 01/25/25 documents in part, Sacrum 1. Cleanse with 0.125% Dakins solution. 2. Apply Collagen, Calcium Alginate to base of the wound. 3. Secure with superabsorbent. 4. Change daily and PRN (as needed) every day shift. R1's treatment administration record for 01/2025 shows no documentation for 01/20/25 and 01/21/25. On 03/04/25 at 12:22pm V8 (Director of Nursing/DON) stated that legally if it's not documented then it's not done. V8 stated that her expectations for staff is to document everything that they do. R1's wound assessment documentation dated 01/31/25 measure 5.5 centimeters length by 4 centimeters width by 2 centimeters depth, odor not present. R1's wounds assessment documentation dated 02/25/25 measures 8 centimeters length by 9.5 centimeters width by 4.2 centimeters depth, odor strong, which shows R1's wound had gotten larger. R1's wound culture results collected on 02/25/25 were positive for many white blood cells, gram negative rods, gram positive rods, proteus mirabilis and Escherichia coli. R1's emergency room report dated 02/25/25 documents in part, CT (Computed tomography) pelvis with contrast final result .osteomyelitis at the S5 and proximal coccygeal levels .Exam is a large approximately 10-centimeter sacral decubitus wound that goes down to muscle, base of this has gray muscular tissue, has foul odor, concern for infection .Case request operating room: Debridement sacral wound. On 03/03/25 at 12:17pm V2 (Licensed Practical Nurse/LPN) stated that she would change R1's wound if it became soiled. V2 stated that the treatment cart was located on a different floor, so if she had to change R1's wound dressing, she would improvise with whatever dressings that she had. V2 stated that she noticed R1's wound had an odor and was infected a week prior to R1 being sent to the hospital on 02/25/25. On 03/03/25 at 2:41pm V6 (Wound Care Coordinator) stated that R1's wound had declined. V6 stated that if R1 needed a PRN (as needed) dressing change, the same supplies should be used that are used for R1's routine dressing change. V6 stated that R1 developed a new wound on her anterior lower leg. V6 stated that she thinks R1's new wound was developed due to R1's leg rubbing against the heel protectors. R1's Nurse Practitioner's (NP) progress note dated 02/25/25 documents in part, Wound specific history of a chronic stage 4 pressure ulcer to sacrum which has been refractory to many different topical treatments, wound vac, and recently failed skin sub due to frequent fecal contamination .Wound cultures obtained x2 over the last week were rejected by lab, staff states this is due to lab not having staff to pick up samples causing delay in testing .Seen today for reassessment of sacral wound. Wound cultures retaken today .contacted ID (infectious disease) NP directly to discuss patient case, ID NP agreed with recommendations for starting broad spectrum IV (intravenous) antibiotic therapy for likely OM (osteomyelitis) of sacral wound. On 03/04/25 at 11:09am V7 (Wound Care Nurse Practitioner/WCNP) stated that R1's wound had gotten worse over the past month. V7 stated that she suspected that R1's wound was a Kennedy ulcer and to rule out Kennedy ulcer, an infection workup needed to be done. V7 stated that she did multiple wound cultures on R1's wound but they were rejected by the lab due to staffing issues. V7 stated that she did consult with the infectious disease NP because she thought R1 may have osteomyelitis. V7 stated that R1 developed a new wound on her left anterior lower leg. Facility's policy titled Treatment/Services to Prevent/Heal Pressure and Non-Pressure wounds dated 11/2/23 documents in part, Policy: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs .Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: 1b. A resident with pressure ulcers or non-pressure wounds receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new wounds from developing .5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure and non-pressure wound. Facility's undated job description for Licensed Practical Nurse documents in part, A. Role Responsibilities - Administrative Duties: 1. Directs the day to day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility. 2. Ensures that all nursing personnel assigned to you comply with the written policies ad procedures established by the facility .B. Role Responsibilities - Charting and Documentation: 11. Performs routine charting duties as required and in accordance with established charting and documentation policies and procedures. 12. Signs and dates all entries made in the resident's medical record .Role Responsibilities - Nursing Care: 7. Reviews the resident's chart for specific treatments, medication orders, diets as necessary .15. Administers professional services such as catheterization, tube feedings, suction, applying and changing dressing/bandages. Facility's undated job description for Certified Nursing Assistant documents in part, A. Role Responsibilities - Care: Position resident in correct and in proper body alignment.

Based on interview and record review, the facility failed to follow their policy on abuse to protect residents' rights to be free from physical abuse. This failure resulted in: 1-R2 and R3 engaging in a verbal altercation that resulted in R2 pushing R3 causing R3 to fall while in the dining room. 2-R5 hitting R4, resulting in R4 sustaining a swollen lip and R4 was sent to the hospital. Findings Include: On 12/31/24, at 10:34 AM, R3 stated yes, R2 pushed R3 from the wheelchair in the dining room and R3 fell on R3's buttocks. On 12/31/24, at 10:54 AM, R2 stated that R2 has been in this facility for 3 years and R2 has a sitting spot in the dining room. R2 stated that R2 cannot remember the incident on 11/19/24 between R2 and R3, but R2 was sent to [NAME] Park Hospital for eight days. R2 stated that R2 served R2's time in the hospital, and R2 is not ready to talk to the surveyor about the incident again. On 12/31/24, at 10:39 AM, R5 stated that R5 does not want to talk about the incident of 11/10/24. R5 later stated that R5 was having a verbal altercation with R4 over a jacket in the dining room, and R5 hit R4 in the face. R5 stated that R5 was wrong for hitting R4. 12/31/24, at 11:30 AM, R4 stated that R5 punched R4 in the face during a verbal altercation with R5 over a jacket in the dining room, and R4 stated that R4 did not hit R5 with R4's cane. R4 stated that R4 does not have any contact with R5 since the incident, and R4 is safe in this facility. On 12/31/24, at 10:48 AM, V11 (Certified Nursing Assistant/CNA) stated that V11 has been in the facility for fifteen years and that pushing is a form of physical abuse. V11 stated that V11 was preparing breakfast trays ready for residents in the dining room when V11 observed R2 pushed R3 from R3's wheelchair and R3 fell on the floor. 12/31/24, at 1:09 PM, V13 (Licensed Practical Nurse/LPN) stated that V13 has been in this facility for one year and half, and that V13 is familiar with R2, R3, R4, and R5. V13 stated that physical, mental, sexual, verbal, and financial are types of abuse, and that the administrator is the abuse coordinator. V13 stated that around breakfast time on 11/19/24, V13 heard commotion between R2 and R3 in the dining room, and V13 observed R3 sitting on the floor in front of R3's wheelchair. V13 stated that R2 stated that R2 pushed/flipped R3 out of R3's wheelchair because R3 was sitting at R2's preferred seat. V13 separated R2 and R3, and the physician was notified with order to send R2 and R3 to the hospital for evaluation. V13 stated that R2 and R3's family members were notified. V13 stated that around 2:00 PM on 11/10/24, V13 heard commotion between R4 and R5 in the dining room. V13 observed R4 and R5 punching each other, and V13 separated R4 and R5 to provide one-on-one monitoring. V13 stated that the physician was notified, with order to send R4 and R5 out to the hospital for evaluation, and R4 and R5 families were notified. V13 stated that there was no staff in the dining room during the incident, but staff should be in the dining room to monitor resident for safety. On 01/02/25, at 11:37 AM, V2 (Director of Nursing) stated that V2 has been in the facility for about one month, and that the administrator is the abuse coordinator. V2 stated that, now that the administrator is on vacation, V2 is the abuse coordinator. V2 stated that the facility has zero tolerance for abuse, and when there is a resident to resident, or staff to resident abuse, V2 will investigate immediately. V2 stated that V2 is not sure how often the abuse in-service is done, but V2 stated that in-service on abuse is done after an abuse allegation. V2 stated that V2 has not joined the facility when the incidents between R2 and R3, and R4 and R5 occurred. V2 stated that pushing, and punching are forms of physical abuse. V2 stated that it is V2's expectation that staff will visually provide supervision to resident while in a common area like the dining room to prevent incidents that can lead to fall or physical contact. V10 (CNA), V12 (Housekeeper), and V14 (Social Service Director) all stated that pushing, and punching are forms of physical abuse, and they will report abuse immediately to the administrator- the abuse coordinator. R2, R3, R4, and R5's section GG (Functional Abilities) shows that R2, R3, R4, and R5 require supervision. Progress note dated 11/10/24, documents in part: R4 was assessed by staff on duty, and R4 was observed with a laceration to the bottom lip, order to send R4 to the hospital. On 11/19/24, documents in part: Resident (R3) verbalized some distress, nurse received MD (Medical Director) order for R3 to be sent to the hospital for an evaluation. R2's care plan revision dated 11/19/24, R2 was reported with socially inappropriate aggression towards peer in his wheelchair. R5's care plan revision dated 12/31/24, R5 exhibited violent behavior towards peer, and R5 becomes easily agitated at least twice weekly. Witness statement dated 11/10/24, documents in part; Upon entering the dining room both residents (R4 and R5) were engaging in a physical altercation. On 11/19/24, documents in part: I didn't see what happened but observed R3 sitting on the floor and R2 standing over R3. Abuse Policy dated 01/2019 documents in part: It is the policy of this facility to prohibit and prevent resident abuse. R3's Police report dated 11/19/24 documents in part. Battery Simple R4's hospital record dated 11/10/24 documents in part; Diagnoses: Assault, Swollen lip.

Based on interview and record review, the facility failed to provide appropriate supervision to four (R2, R3, R4, and R5) residents while in the dining room out of four residents reviewed for supervision. This failure resulted in 1-R2 and R3 engaging in a verbal altercation that resulted in R2 pushing R3 causing R3 to fall. 2-R5 hitting R4, resulting in R4 sustaining a swollen lip and R4 was sent to the hospital. Findings Include: On 12/31/24, at 10:34 AM, R3 stated yes, R2 pushed R3 from the wheelchair in the dining room and R3 fell on R3's buttocks. On 12/31/24, at 10:54 AM, R2 stated that R2 has been in this facility for 3 years and R2 has a sitting spot in the dining room. R2 stated that R2 cannot remember the incident on 11/19/24 between R2 and R3. R2 stated that R2 was sent to a local hospital for eight days and that R2 served R2's time in the hospital, and R2 is not ready to talk to the surveyor about the incident again. On 12/31/24, at 10:39 AM, R5 stated R5 does not want to talk about the incident of 11/10/24. R5 later stated that R5 was having a verbal altercation with R4, and R5 hit R4 in the face. R5 stated that R5 was wrong for hitting R4. 12/31/24, at 11:30 AM, R4 stated that R5 punched R4 in the face during a verbal altercation with R5 over a jacket in the dining room, and R4 stated that R4 did not hit R5 with R4's cane. R4 stated that R4 has not have any contact with R5 since the incident, and R4 is safe in this facility. On 12/31/24, at 10:48 AM, V11 (Certified Nursing Assistant/CNA) stated that V11 has been in the facility for fifteen years and that pushing is a form of physical abuse. V11 stated that on 11/19/24 when V11 was preparing breakfast trays ready for residents in the dining room, V11 observed R2 pushed R3 from R3's wheelchair and R3 fell on the floor. 12/31/24, at 1:09 PM, V13 (Licensed Practical Nurse/LPN) stated that there was no staff in the dining room during the incident, and V13 stated that staff should be in the dining room to monitor resident for safety. On 01/02/25, at 11:06 AM, V14 (Social Service Director) stated that all residents in the facility should be supervised, and there should be visual supervision of residents when in the dining room to prevent resident from physical altercation, fighting, falling and to watch out for triggers. On 01/02/25, at 11:37 AM, V2 (Director of Nursing) stated that it is V2's expectation that staff will visually provide supervision to resident while in a common area like the dining room to prevent incidents that can lead to fall or physical contact. V9 (CNA), V14 (Social Service Director), V18 (CNA), and V19 (CNA) stated that staff should provide visual supervision for residents when in the dining room for safety, to prevent resident from falling and fighting. R2, R3, R4, and R5's section GG (Functional Abilities) shows that R2, R3, R4, and R5 require supervision. Abuse Policy dated 01/2019 documents in part: It is the policy of this facility to prohibit and prevent resident abuse. Facility Policy titled Standard Supervision and Monitoring dated 5/17/23 documents in part. Purpose: This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. Procedure: A staff member that has been assigned to care for the resident will visualize the resident during mealtimes.

Based on observation, interview, and record review the facility failed to ensure that the medications were safely locked up in the treatment cart when not in use to prevent tampering and accidental hazard; failed to ensure that resident medications were not left at bed side for two residents (R9 and R10); failed to ensure that adequate supervision is offered to one resident (R2) in the sample reviewed for falls. This failure affected R9 and R10 whose medications were left at bedside without physician order, and R2 who had a fall resulting in a laceration to the head. This has the potential to affect all 163 residents residing in the facility. Findings include: On 10/15/24 at 10:17am, R8's bed noted to be placed in high position and not in good working condition. R8 stated I (R8) cannot get out of the bed; I do not want to fall. When this observation was shown to V5, V5 stated the bed control is broken and I will have to let the maintenance department know because R8 can fall off of the bed. V5 did not know when the bed had been broken, the beds are not supposed to be this high. Broken beds are to be reported to maintenance for repair. V5 stated I am just seeing this now as you are speaking about it. On 10/15/24 at 10:23am, R9 noted in bed and noted on the over bed side table a medication cup with one pill capsule, which V5 LPN (Licensed Practical Nurse) identified as Gabapentin 400mg. V5 stated the night shift nurse is supposed to give that at 6am this morning. V5 stated that the nurse must have left it there. The surveyor asked V5 what the facility policy and professional standard regarding medication administration is. V5 stated that the nurse should have made sure the medication was swallowed and no medication should be left at the resident's bed side unless on self-administration of medication program. At 10:25am V5 stated I know what the medication is, it is for neuropathic pain. At 10:30am, on R10's bed side dresser two medication cups noted with medications, a total of five tablets. V7 LPN (Licensed Practical Nurse) assigned to R10 stated I (V7) did not give this type of medication this morning. And I (V7) don't know what the medications are. The surveyor then asked for V2 DON (Director of Nurses) to be called to the floor. At 10:35am, V2 identified three tablets of the medications to be Flexeril and the remaining two as Gabapentin. V7 stated the night nurse must have left them there because she did not give R10 any medication that look like this. R10's order summary report showed that R10 has a physician order with a starting date 10/07/24 for Cyclobenzaprine HCL (Flexeril) oral tablet 10mg give 1tablet by mouth one time a day for pain and Gabapentin capsule 300mg (milligram) give 1 capsule by mouth one time a day for pain. Each medication was scheduled to be administered one time a day at 9:00pm (2100). R10's MAR (Medication Administration Record) showed documentation that this medication was administered at the scheduled time. At 10:42am, R13 observed in bed, and a blood draw (collection) needle noted visible to the hallway on the over the bed table. V23 CNA (Certified Nurse Aide) who was present in the room at the time of observation stated that the nurse must have left it there (referring to the blood draw). At 10:45am, when shown to V7 (LPN). V7 stated I (V7) did not put it there and I (V7) don't even know what it is and who left it there. R12 stated one of the nurses must have left it there it's for my IV (Intravenous) site. Pointing to the right arm. At 10:48am, V2 stated the facility staff both the CNAs and the Nurses are to make rounds at least every couple of hours at least 2hrs and the rounds includes getting these things (blood draw inserting collection set) out of the resident rooms. It is safety issues. If seen it should be removed. On 10/23/24 at 4:10pm, V2 (Director Of Nursing) presented a copy of Department of health and Human Services Center for Medicare and Medicaid Services print out on Medication Storage and Labeling task that documented that medication and biologicals should be secured (locked) in storage locations that includes but not limited to medication carts. And a Daily Rounds sheet that indicated that med carts should be locked. V2 stated the facility does not have a medication storage policy but this print out guidelines are what the facility follows. R2's medical record showed that R2 was originally admitted to the facility on [DATE] and the latest admitted is documented as 09/22/24. Listed diagnosis include but not limited to Fracture of unspecified part of neck of left femur, initial encounter for closed fracture, weakness, unsteadiness, need for assistance with personal care, Wernicke's encephalopathy, encounter for surgical after care following surgery on digestive system, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R2 had un-witnessed fall on 09/13/24 with injuries that includes a Fracture of unspecified part of neck of left femur. R2 returned to the facility on [DATE] and had an unwitnessed fall on 09/26/24 with injury, laceration to the head. R2 was sent to the local emergency room for fall and laceration to the head. On 10/25/24 at 11:20am, R2 observed in the dining room on a wheelchair. R2 was unable to recall what happened on both fall incidents of 09/13/24 and 09/9/26/24. R2's Medical Record Progress noted date 09/26/24 timed 3:02pm (15:02) showed V16 documentation describing what happened to R2. V16 documented that she was summoned to (R2's) room, observed R2 on the floor lying on the left side, small laceration noted to the left side of the head with small amount of bleeding noted. Area cleaned with normal saline (NSS) and dressing applied and bleeding stopped. On 10/15/24 at 3:16pm, V14 CNA (Certified Nurses Aide) stated that she was the CNA for R2 on the day of the fall of 09/13/24. V14 stated that R2 was walking with the rolling walker in the hallway, and she (V14) noted R2 slumped to the floor before she (V14) could get to R2. On 10/16/24 at 11:39am, V16 stated that I (V16) was on duty when the CNA (referring to V17) called me at around 3pm. V16 stated that I (V16) was going to make my last round at the end of the shift when the (V17) called me to come and see R2 because R2 was on the floor. When I got there R2 was on the floormat. R2 bed was in a low position because R2 was on fall precaution. I (V16) and other CNA got R2 up into bed, full assessment was done, there was a skin tear on the left side of the head, and it was bleeding, I (V16) applied pressure dressing with 4x4 did the vitals and neuro checks was done. We (referring to staff) got R2 comfortable, and I (V16) called the doctor and the family. R2 was sent to the hospital. When asked who found the resident on the floor. V16 stated V17 the 3pm to 11pm CNA found R2 when she was making her shift change rounds. V16 stated that the staff did not know when R2 fell , and I (V16) was at the nurse's station when I was called. On 10/16/24 at 11:57am, V18 (CNA) stated that yes, I was the morning shift CNA (Certified Nurses Aides), I had left the floor when R2 was found on the floor. When asked about R2 during the morning shift, V18 stated that I (V18) can't give you accurate description on how R2 was before the fall, I (V18) cannot recall anything before they said R2 fell . The surveyor asked whether R2 needs help/ supervision with ADLs (Activities of Daily Living), V18 replied I (V18) don't know. ADLs is very wide and I cannot recall. The surveyor asked again what care they rendered to R2 (referring to the day of incident. V18 stated I don't know, I cannot recall. The surveyor asked V18 where R2 was when you left the floor. V18 stated I (V18) don't know. V18 then walk away from the surveyor. On 10/16/24 at 3:30pm to 3:40pm, V22 (Physician) stated that he (V22) is familiar with R2. V22 stated that R2 had fall incidents, R2 was sent to the hospital, had fracture and had surgery. V22 stated that R2 has Dementia and if they have dementia, they are not going to call for help they just get up and go because they don't have good minds. And we cannot restrain them. They need assistance to walk. The nursing home does not have the staff capacity to supervise them. They cannot use restrain; in the hospital we are allowed to restrain. The surveyor asked V22 about the second fall incident,V22 stated Yes, I'm aware. The surveyor asked V22 in your professional opinion and clinical opinion whether the level of supervision in the facility was appropriate for R2. V22 stated that is why I (V22) said they should follow their policy. They (facility) has a policy and they need to follow the policy. I (V22) think they follow it. There is no video. I (V22) don't think anyone can answer that question. On 10/17/24 at 1:14pm, V1 (Administrator) stated that the nursing staff are expected to know the residents' needs as they care for them (residents). Provide services and care according to their plan of care. The staff are to make rounds every two-hour paying attention to the ADLs (Activities of Daily Living) and individual needs. V2 (Director Of Nursing) stated that no sharp objects should be left at the bedside and medication are not to be left in the resident room without an order to do so. The facility Self-Administration of Medications by Residents with no date documented that the policy will be encouraged if it is desired by resident, safe for he resident and other residents of the facility, ordered by the attending physician and approved by the interdisciplinary team. Listed procedure includes but not limited to a physician order is obtained to self-administer medications. The facility policy on Medication Administration dated 07/11 documented that the purpose of this policy is to administer all medication safely and appropriately to aid residents to overcome illness, relieve illness, relieve, and prevent symptoms, and help in diagnosis. Listed procedure includes but not limited to place needles and syringes in sharps container and remain with the resident to ensure that the medication is swallowed. The facility policy on Guidelines Standard Supervision and monitoring dated 5/17/23 documented that the purpose of this policy is to emphasizes a proactive intervention promoting enhance physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. The facility presented a copy of Department of health and Human Services Center for Medicare and Medicaid Services print out on Medication Storage and Labeling The facility policy on Incident/Accident Facility Responsibility presented with no date documented that all documentation is to be kept in the investigation of incident binder in the DON's office divided into reportable versus nonreportable incident. The facility Accident Incident Reporting Policy version 080317 documented that the purpose of this policy is to ensure that accidents and incidents that occur with residents are identified, reported, investigated, and resolved. To provide a database to study the causes of accidents/incidents and to aid in implementing corrective actions to prevent reoccurrence when possible.

Based on observation, interviews and record review the facility failed to follow Medical Doctor's orders for PRN (as needed) wound dressing change and wheel chair cushion to prevent the worsening of a wound for one patient (R1) who has a facility acquired stage four pressure wound. This failure has resulted in R1's facility acquired DTI (deep tissue injury) to progress to a Stage 4 pressure wound. And the facility failed to follow Medical Doctor's orders for PRN wound dressing change for one patient (R6) with a stage 4 pressure wound observed to be saturated with feces. This failure could result in worsening of R6's wound. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Unspecified osteoarthritis, unsteadiness n feet, cognitive communication deficit, Hemiplegia and Hemiparesis following cerebral infarction. R6 is [AGE] year old with diagnosis including but not limited to: Hidradenitis suppurativa, overactive bladder, repeated falls and hereditary and idiopathic neuropathy. R6's BIMS (Brief interview of mental status) score is 13, indicating cognitively intact. During investigation on 09/23/2024 at 10:15 AM, Surveyor observed R1's incontinent brief being changed by V9 CNA (Certified Nurse Assistant). At that time, Surveyor observed a saturated wound dressing removed from R1's sacrum. R1's dressing appeared wet and had yellowish and brownish bodily fluid on it. On 09/23/2024 at 10:15 AM, V9 CNA (Certified Nurse Assistant) stated that R1's wound dressing was dirty. On 09/23/2024 at 10:21 AM V6 LPN (Licensed Practical Nurse) said, R1 has a PRN (as needed) wound care treatment order. Any nurse can change R1's wound, not just the wound care nurse. I did not know that R1's dressing needed to be changed. On 09/23/2024 at 12:41 PM, R1 was observed sitting in the first floor dining room her wheelchair. At that time, R1 did not have a donut cushion in her wheel chair. On 09/24/24 at 6:15 AM, R6 was observed lying in bed and Surveyor noted a strong odor of feces in R6's room. At that time, Both V14 (CNA) and V13 (CNA) went into R6's room to get him (R6) cleaned for a Doctor's appointment. On 09/24/24 at 6:25 AM, after gathering incontinent supplies, V14 (CNA) pulled R6's bed sheet back. At that time, a brown, thick liquid substance was observed on R6's bed sheet and on R6's perineal (Private) area. On 09/24/24 at 6:25 AM, V14 (CNA) said, He (R6) had a large bowel movement. At that time, V13 and V14 proceeded to roll R6 on his side to clean him. On 09/24/24 at 6:25 AM, R6's brief, bed pad and bed linen was saturated with a brown, thick, liquid substance. At that time, R6's sacral wound appeared to be the size of a football and was also filled with a brown, thick, liquid substance. Surveyor inquired about the brown substance adhered to R6's wound. On 09/24/24 at 6:25 AM, V13 said that the brown substance observed on R6 was feces. Surveyor inquired about R6's wound care orders. On 09/24/24 at 6:36 AM V3 (WCC/ Wound Care Coordinator) said, R6 has PRN wound care orders. R6's wound should never be full of feces. This could worsen the wound. I come in early in the morning to start my wound care treatments, but I am not here to do treatments 24 hours a day. On 09/24/24 at 6:40 AM V5 (LPN/ Licensed Practical Nurse) said, I am R6's assigned nurse. I did not know that his wound dressing needed to be replaced or that he had a bowel movement. Surveyor inquired about R1' wound. On 09/25/2024 at 12:04 PM, V3 (WCC) said, R1's wound is facility acquired. From her (R1) initial wound assessment to now, her wound has worsened. If the wounds are changed and if the wound is clean, that promotes the healing of the wound. I am currently the only wound care nurse in the building and I do the daily dressing changes, but sometimes the wounds require more frequent dressing changes depending on how they are draining or if they become saturated with urine or feces. R1 has PRN (as needed) wound care orders that the assigned nurse is to follow when I am not available. Surveyor inquired about the possible contributing factors of R1's wound decline. On 09/25/2024 at 12:04 PM, V3 (WCC) said, R1's wound may have worsened for multiple reasons. Apart from the wound care, turning and repositioning to offload the wound is important. I created a get up schedule for R1. She (R1) is scheduled to get out of bed on Mondays, Wednesdays and Fridays and up in her wheelchair. She (R1) has an order for a donut cushion since April of 2024 and I informed the previous Restorative Director about the donut cushion. I have not seen a donut cushion for R1 as of today. Restorative orders all cushions. On 09/25/2024 at 12:30 PM, R1 was observed sitting in her wheel chair in the first floor dining room. At that time, there was no donut cushion observed in R1's wheel chair. On 09/25/2024 at 1:15 PM, V6 (LPN) said, I see that R1 has an order for a donut cushion but I was not aware of that order. I believe the restorative department orders the wheelchair cushions. Surveyor inquired about PRN wound care orders. On 9/25/2024 at 1:30 PM, V19 (WCC) said, The PRN dressing change is for times when the dressing may become soiled in between regular dressing changes. Surveyor asked if a wound that is not cleaned, with saturated dressing or covered with feces would heal properly. On 9/25/2024 at 2:20 PM, V19 (WCC) said, If a wound is not cleaned as needed, the healing process could be impeded. It all depends on the length of time the wound was not cleaned and the number of occurrences. Surveyor inquired about the difference between DTI (Deep tissue injury) and a stage 4 wound. On 9/30/2024 at 2:20 PM, V19 (WCC) said, A DTI is a deep tissue injury, technically an injury with intact skin. A stage 4 wound is the deepest level of pressure wounds, with an open area on the skin. Surveyor inquired about the donut cushion for wheelchairs. On 9/30/2024 at 2:20 PM, V19 (WCC) said, The donut cushion is like an inner tube with no middle and can help to offload the wound area. A standard wheelchair cushion is square and foam. On 9/25/2024 at 1:40 PM, V2 (DON/ Director of Nursing) said, Restorative usually orders the supplies. I didn't know that R1 had an order for a donut cushion. The difference between the regular cushion and the donut cushion is that the donut cushion has a hole in it in order to relieve pressure from her (R1) sacral area while she is up in a chair. Surveyor inquired about the purpose of PRN (as needed) wound care orders. On 9/25/2024 at 1:40 PM, V2 (DON) said, My expectations are that the wound dressings are changed per doctors' order and as needed. If the CNA (Certified Nurse Assistant) notices that a dressing is removed or is soiled, they should let the assigned nurse know so that the wound dressing can be changed. The floor nurses are responsible for PRN wound treatments and keeping the integrity of the wound for healing. The purpose of PRN (as needed) wound orders is to minimize the risk of the wound deteriorating and or becoming infected. Nurses should be checking the integrity of the wound each shift. It is not only the wound care nurse's responsibility to keep the wound clean and dry. R1's Section M of MDS (Minimal Data Set) dated 07/12/2024 documents: R1 has one or more unhealed pressure injuries; R1 is at risk for developing pressure injuries; R1 requires a pressure reducing device for wheelchair; R1 requires pressure ulcer care; R1 requires nonsurgical dressing. R1's Section GG of MDS dated [DATE] documents, R1 requires maximal assistance with personal hygiene. R1's facility wound care evaluation dated 09/25/2023 documents a facility- acquired suspected DTI (deep tissue injury) to the sacrum region with the following measurements: 6.6 cm (centimeters) in length; 7.1 cm in width; and 0.2 cm in depth. R1's wound care report dated 09/27/2023 documents an Unstageable DTI (deep tissue injury) to the sacrum region with the following measurements: 6.5 cm in length; 7 cm in width; and 0.2 cm in depth. R1's wound care report dated 04/09/2024 documents a Stage Four Pressure Wound to the sacrum region with the following measurements: 5.5 cm in length; 5 cm in width; and 2.8 cm in depth. R1's Weekly Wound Evaluation dated 09/19/2024 documents a Facility- Acquired Stage Four Pressure Wound to the sacrum region with the following measurements: 6.8 cm in length; 5.4 cm in width; and 1.6 cm in depth. R1's Order Summary Report dated 09/23/2024 documents, apply Metronidazole powder as needed to sacrum for wound care; cleanse sacrum with NSS (normal saline solution), pat dry and cover with dry dressing. R1's Order Summary Report dated 09/23/2024 documents, donut cushion while up in wheel chair for sacral wound. R6's facility wound care evaluation dated 09/14/2024 documents, R6 has a stage four sacral wound with the following measurement: 22.5 cm in length; 17.0 cm in width, and 1.8 cm in depth. R6's Section GG of MDS dated [DATE] documents, R6 is dependent on staff for personal hygiene. R6's Order Summary report dated 09/25/2024 documents the following active order: Cleanse sacrum with nss (normal saline solution) Dakin's 1/4 solution, dry and apply calcium alginate and cover with dry dressing as needed for wound care. R6's care plan dated 09/17/2024 documents, R6 has a self-care deficit and requires assistance with ADLs (Activities of daily living) to maintain the highest possible level of functioning; R6 has an alteration in skin integrity and is at risk for additional and/ or worsening of skin integrity issues related to Hidradenitis Suppurative, diabetes, comorbidities and sacral wound to sacrum. R6's care plan dated 09/17/2024 documents the following interventions: R6's skin to be checked during routine care on a daily basis. Facility policy titled Treatment/ Services to prevent/ Heal Pressure and Non-Pressure wounds documents, the facility will ensure that based on the comprehensive assessment of a resident: a resident with pressure ulcers or non-pressure wounds receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new wounds from developing; Interventions will be implemented in each resident's plan of care to prevent and prevent healing of the pressure and non-pressure wound. Facility policy titled Physician Orders documents, it is the policy of the facility to follow the orders of the Physician.

Based on observation, interviews and record review the facility failed to ensure that one patient's (R6) pain was managed with prescribed medication every four hours as ordered. This failure has resulted in R6 experiencing pain of 10 on a scale of 1-10 during wound care and ADLs (Activities of daily living). Findings include: R6 is [AGE] year old with diagnosis including but not limited to: Hidradenitis suppurativa, overactive bladder, repeated falls and hereditary and idiopathic neuropathy. R6's BIMS (Brief interview of mental status) score is 13, indicating cognitively intact. On 09/24/24 at 6:15 AM, R6 was observed lying in bed and Surveyor noted a strong odor of feces in R6's room. At that time, Both V14 (CNA/Certified Nurse Assistant) and V13 (CNA) went into R6's room to get him (R6) cleaned for a Doctor's appointment. On 09/24/24 at 6:25 AM, V13 and V14 proceeded to roll R6 on his side to clean him. At that time, R6's sacral wound appeared to be the size of a football and was also filled with a brown, thick, liquid substance. On 09/24/24 at 6:25 AM R6 yelled out, Oh! It hurts. Surveyor asked if R6 was ok. On 09/24/24 at 6:25 AM, R6 reported a pain level of 10 on a scale of 1-10. Surveyor left the room to go and get the wound care nurse and R6's assigned nurse for medication. On 09/24/2024 at 6:31 AM, V15 LPN (Licensed Practical Nurse) said that he (V15) was the assigned nurse for R6 and that R6 had run out of prescribed pain medication (Norco). At that time, V15 said that R6 was already given a Tylenol at 6:00 AM and that He (R6) missed his scheduled Norco for 2 AM and 6 AM. R5 is supposed to get the Norco every four hours. Surveyor inquired about the difference between Norco and Tylenol. On 09/24/2024 at 6:31 AM, V15 LPN said, Well the Norco is much stronger, but all R6 only has available is the Tylenol right now. I am waiting for R6's Norco order to be refilled. At that time, V13 CNA and V14 CNA, proceeded to turn and clean R6 again to clean him (R6). On 09/24/2024 at 6:31 AM, R6 yelled out again. On 09/24/2024 at 6:31 AM, V3 (WCC/ Wound Care Coordinator) said, R6 needs pain medication. I've never seen him in this much pain. At that time, V13 and V14 continued to render incontinent care as R6 grimaced and moaned. On 09/25/2024 at 12:04 PM, V3 (WCC) said, R6 was definitely in pain on yesterday (09/24/2024) and I have never seen him (R6) like that before. He is usually in good spirits and smiling. I can tell that R6 was uncomfortable. Surveyor inquired about the expectations regarding medication availability for residents. On 9/25/2024 at 1:40 PM V2 (DON/ Director of Nursing) said, When the nurse get down to about 5 tablets of a controlled medication such as Norco, the medication is supposed to be ordered at that time. When the nurse is proactive with re-ordering the prescribed medication, this can ensure that the medication does not run out and is available for the resident when needed. Surveyor inquired about pain management and wound care. On 9/25/2024 at 1:30 PM at 1:40 PM, V2 (DON) said, Pain should be managed before the wound care is performed. If the alternative medication was not effective, the doctor should be notified. In order to meet the resident's needs. The resident must be comfortable. Surveyor inquired about R6's MAR (Medication Administration Record). On 9/25/2024 at 1:40 PM, V2 (DON) said, When a medication is administered, it will reflect on the MAR as a checkmark and the Nurse's initial. If there is no checkmark, the medication was not administered for whatever reason indicated. Surveyor inquired about R6's pain. 09/25/2024 at 4:00 PM, R6 said, Sometimes when I pass gas, I have a bowel movement and I have to wait over an hour to be cleaned. I just try to stay still and not move because the pain shoots back up to a 10 when I move. It makes me feel terrible. On 09/27/2024 at 2:50 PM, V10 (NP/Nurse Practitioner) said, I specialize in pain management and physical therapy. At that time, Surveyor inquired about the purpose of R6's schedule Norco for every four hours. On 09/27/2024 at 2:50 PM, V10 (NP) said, The Norco is necessary for severe pain management. It could help with pain from wounds. Surveyor asked if Norco would be more effective than Tylenol. On 09/27/2024 at 2:50 PM, V10 (NP) said, The Norco would be more effective than Tylenol during wound care. Pain is subjective. If a patient reports a pain level of 10 on a 1-10 pain scale, I (V20) can't argue with that. R6's care plan dated documents, R6 is at increased risk for alteration in pain / discomfort related to recent surgery, chronic disease process and skin or tissue impairment; Interventions include administration of analgesic medication as ordered per pan of care. R6's Order Summary Report documents the following active order: Hydrocodone-Acetaminophen (Norco) oral tablet 10-325 MG; give one tablet by mouth every four hours for pain. R6's Nursing Progress Note dated 09/24/2024 and written by V15 (LPN) documents, Hydrocodone- Acetaminophen (Norco) not available for resident. R6's Medication Administration Record for period of 09/01/2024- 09/30/2024 documents five missed doses of R6's scheduled Norco on 09/24/2024 for the following times: 0200, 0600, 1000, 1400, 1800 and 2200. Facility policy titled Guidelines for Pain Management documents the following: It is the intent of the facility to promote resident independency, comfort, and to preserve resident dignity in an ongoing effort to promote the highest level of quality for their lives; to maintain and effective pain management plan to provide residents the mean to receive necessary comfort, exercise greater independence, and therefore enhance their overall welfare an well-being. Facility policy titled Guidelines for Pain Management documents the following methods to achieve goals of pain management: Monitor the efficacy of any medications being used for pain management and control; preventing and minimizing anticipated pain when possible.

Based on interview and record review, the facility failed to: adequately supervise and monitor a resident(R2) who has a history of physically assaulting other residents, and failed to provide the appropriate intervention when R2 refused to sleep and paced the hall all night on 2 consecutive days; and failed to supervise R1 who has weakness due to paralysis. As a result, R2 physically attacked R1, and R1 sustained injuries to the head and face and was hospitalized for 2 days. Findings include: On 3/18/24 at 11:20am, V1(Administrator) presented the facility's report of incident submitted to the state agency on 3/10/24. Both the initial and final reports were reviewed. This report states that the facility investigated the allegation that R2 made contact with R1, and that R2 has Dementia and was not aware of the incident. R1 was sent to the hospital for evaluation and determined to have a subdural hematoma. On 3/18/24 at 11:45am, R1 was observed in the hallway and later in the room. R1 was asked if his former roommate hit him on the face some time ago. R1 responded and nodded Yes. R1 was asked if he(R1) is still feeling any pain on the nose and the head from the assault, and R1 nodded No. On 3/18/24 at 12:44pm, V1 stated that she(V1) completed the final investigation on the incident where R2 allegedly assaulted R1, and it was not witnessed by any staff. V1 explained that staff were not sure whether it happened on 11-7 shift(night) or 7-3 shift(morning). V1 added (R2) was sent to the hospital and refused to come back here. R1's records show the following: Face sheet shows diagnosis which include but are not limited to Hemiplegia, and History of Accidental Discharge from Firearms/Gun. MDS section C (BIMS-Basic Interview for Mental Status) shows a score of 99 (unable to participate in the assessment due to being non-verbal). Progress notes dated 3/10/24 at 3:30pm written by V11(LPN/ Licensed Practical Nurse) states in part: Resident accused roommate of attacking him in his sleep. Incident went unwitnessed. Resident noted to have scratches on front of face. Progress notes dated 3/14/24 at 11:00am written by V18(Nurse Practitioner) states in part: Chief Complaint/Reason for this Visit: Abrasions on face, forehead hematoma HPI Relating to this Visit / Consultation / Evaluation: 41 y/o male s/p (status post) hospitalization for facial abrasions, forehead hematoma following altercation with peer, readmitted to LTC (long term care) facility. Care plan dated 10/30/23 states in part: Self-Care Deficit with impaired Dressing and Grooming abilities and would benefit from participation in a Dressing/Grooming Restorative Nursing Program as evidenced by the following risk factors and potential contributing Diagnosis: Diabetes Mellitus, General Weakness and/or fatigue, Hemiparesis, Impaired Communication, Impaired ROM and/or Loss of Functional Movement, Right hemiplegia. R2's records show the following: Face sheet shows diagnosis which include but are not limited to Dementia, Schizophrenia, Seizures, Cerebral Infarction, Opioid Abuse, and Strange and Inexplicable Behavior. MDS section C (BIMS-Basic Interview for Mental Status) shows a score of 10(Moderate Cognitive impairment). POS (Physician Order Sheet) dated 10/03/23 states Behavior Monitoring (verbal aggression, hitting, pushing). Document interventions attempted every shift for behavior monitoring. MDS (Minimum Date Set) dated 1/19/24, Section E(Behavior) shows that R2 has Psychosis, Hallucinations, and physical behavioral symptoms directed toward others. Recorded history of physical aggression towards others: Progress notes dated 9/21/23 at 1:51pm written by V16(RN) and at 8:07pm written by V17(LPN) both show that R2 was physically aggressive toward another resident and was sent to the hospital for evaluation. Progress notes dated 2/25/24 at 3:44pm written by V11(LPN) - Resident noted to go inside peer's room and punch her in the arm while sitting in her wheelchair. Housekeeper witnessed him walking away from resident with fist in air, while resident was screaming he just punched me! Resident was redirected to bedroom where he was put on 1:1 with a CNA (Certified Nurse Assistant) until ambulance picked him up. Care plan dated 2/7/24 states in part: History of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process & is therefore considered appropriate for admission. The history includes Conflicts/altercations with others, Verbal, or physical aggression, Acting impulsively, erratically. The resident has a diagnosis of: Strange & Inexplicable behavior. 5/27/2023 - Resident was physically aggressive towards staff. 01/18/24 - Resident made physical contact with his roommate. 01/19/24 - Resident is making frequent attempts to enter his peer's room when behaviors are being redirected, he is becoming verbally and physically aggressive toward staff. Care plan dated 10/20/23 and revised on 2/25/24 states that R2 had inappropriate physical contact with another resident on 9/21/23, 1/3/24, 1/18/24 and 2/25/24. Care plan dated 4/20/23 intervention states in part: If behavioral symptoms are observed, record and document on behavioral tracking form. Report abnormalities to medical doctor. On 3/20/24 at 1:54pm, V21(Nurse Practitioner) was interviewed about the interventions to put in place for a resident with diagnosis of Dementia with Agitation, with history of hitting other residents, who has refused medications a few times, and refused to go to bed and pacing during the night. V21 stated The nurse needs to notify the doctor or Nurse Practitioner. We generally get the state guardian or POA involved and the psychiatric Doctor, if a resident is refusing to take their medication and becoming aggressive, and the POA is not cooperative about injections, then, we'll send the patient to the hospital or maybe find another place that can better assist with their needs. When we send them out to the hospital, the hospital has a little more autonomy to administer chemical restraints to help the patient calm down and we can revise the plan to get another facility that will better serve the patient. Meanwhile, the patient can be monitored frequently and every 2 hours rounding to keep them and others safe. The assigned nurse for 11pm-7am shift on 3/9/24, V15, (LPN-Licensed Practical Nurse) and the assigned nurse for 7am-3pm shift on 3/10/24 (V11/LPN) both stated that they did not know when the incident happened. On 3/19/24 at 11am, V15 stated I worked the 11-7 shift, and when I gave medication to (R1) at 5:30am, I did not see any injury on his face. I did not know when it happened. His roommate(R2) was walking up and down the hall all night and did not sleep. My shift ended at 7:30am and I left around 7:45am. I did not assess him(R1) because I was not aware of any incident or injury. I heard about it the next day when I came to work. R2's progress notes do not contain any documentation to show that R2 did not sleep all night on 3/9/24 and the previous night. Also, there is no documentation to show any intervention from staff regarding R2 not sleeping and pacing the hall all night on 2 consecutive days. On 3/19/24 at 11:20am, V11(LPN) stated When I came in on 7-3 shift, the 11-7 nurse(V15) was gone, so I did not receive any shift report of what happened on night shift. Later, the CNA (Certified Nurse Assistant) called me to see (R1) in his room, I went and saw the bruises on his face and nose. Usually, (R1) follows direction and understands what you ask him to do, but he(R1) cannot speak, he only nods to say yes or no. I used sign language and asked when and how it happened, he signed that it was his roommate that hit him and it happened before now, so I believe it happened on the night shift, or during change of shift. I immediately called the Doctor, Administrator, DON (Director of Nursing), and the daughter. I spoke with the daughter on phone and asked her to inform the brothers, who usually come on Sundays to take him out. The Nurse Practitioner answered for the doctor and ordered to send him out to the hospital. V11 explained that R1 uses a wheelchair and needs some assistance while R2 walks around without assistance. The Pay-Roll records show that V15(night nurse) clocked out at 7.30am and V11(day nurse clocked in at 8am). So, there was a 30-minute gap when there was no nurse for that side of the hall. On 3/21/24 at 9:32am, V22(CNA) stated (R2) was up all night, he would go into his room and come right back out. He was up all night the previous night also. I worked with the same nurse(V15) the previous night. The surveyor inquired from V22 if V22 notified the nurse that R2 did not sleep and was pacing, and if the nurse called the doctor to let them know that R2 has been up all night for 2 days in a row. V22 responded that the nurse(V15) was aware, and they both tried to redirect R2, but R2 refused redirection. On 3/21/24 at 10:08am, V2(Director of Nursing) was asked about the appropriate intervention when R2 had been pacing all night and refused to sleep 2 days in a row. V2 responded that the nurse should have called the doctor and should have documented it in the progress notes. V2 added The nurse did not inform me. I will in-service staff to let them know that such should be reported so the interdisciplinary team will do the appropriate intervention. Hospital Records dated 3/12/24 written by V19(Hospital Physician Assistant) and reviewed by V20(Hospital Physician) states in part: [AGE] year-old male presents after he was attacked by a roommate in the middle of the night. Facility's undated policy on Standard Supervision and Monitoring states in part, #2: A staff member that has been assigned to care for the resident will visualize the resident at the start and end of the shift, during mealtimes, and at a minimum every two hours in between. Facility's policy on Accident Incident Reporting Policy with revision date 08/03/17 states in #11: The occurrence is to be communicated shift to shift as part of the unit report until the resident is stabilized. Facility's undated policy on Behavior Monitoring states in part: Long term residents that have new behaviors will be referred to social services by using a social service referral form and then the social service director will initiate a target behavior monitoring log for 30 days.

Based on observation, interview and record review, the facility failed to ensure that residents were free of abuse/physical assault. This affected two (R1, R3) of three residents reviewed for physical abuse with injuries. R4 hit R3 and R3 sustained injuries to the forehead and lips. As a result, R3 was sent to the hospital. And R2 physically attacked R1, R1 sustained injuries to the head and face and was hospitalized for 2 days. Findings include: 1. R4's records show the following: Face sheet shows diagnoses which include but are not limited to Homicidal and Suicidal Ideation, and Bipolar Disorder with Manic Episode. MDS (Minimum Date Set) dated 3/8/24, Section E(Behavior) shows that R4 has verbal behavioral symptoms directed toward others. MDS section C (BIMS-Basic Interview for Mental Status) shows a score of 15(Cognitively Intact). POS (Physician Order Sheet) dated 9/8/23 shows order for Divalproex Sodium Oral Tablet Delayed Release 500 MG; Give 750 mg by mouth two times a day for mood disorder. MAR (Medication Administration Records) shows missing entries for R4's mood stabilizer medication (Divalproex 750 mg) on the following dates: 2/5/24 at 5pm, 2/6/24 at 5pm and 3/6/24 at 5pm. There were no entries for Behavior Monitoring on the evening shifts on the dates listed above. Care plan dated 2/22/24 states in part: Active Socially Inappropriate Behavior: Resident displays socially inappropriate and maladaptive behavior related to: A history of dysfunctional behavior, anger, agitated depression., Communicating anxiety & restlessness. 9/13/23 - Resident threatened to shoot his nurse with a 9mm gun. 2/6/2024 - Resident was reported yelling at staff and refusing redirection. 2/22/24-Resident became agitated with staff. Care plan dated 9/18/23 states in part: Displays conflictual, difficult behavior with other persons related to: A difficult time adjusting to life in the long-term care facility., History of substance abuse, General intolerance, and limited ability to deal with frustration. R4's progress notes dated 3/8/24 at 7:28am written by V14 states in part: Resident came out of room and stated his roommate tried to hit him and he hit his roommate a few times. Administrator/DON/MD/Police notified. Resident then left the facility. On 3/18/24 at 1:20pm, R3 was observed in the hallway propelling self in the wheelchair. The surveyor asked R3 about the incident with his former roommate. R3 stated He hit me on the head and busted my lips. It was a lot of pain, and I went to the hospital. But now I'm okay. R3 again verbalized that he(R3) feels safe at the facility. On 3/20/24 at 1:54pm, V21(Nurse Practitioner) was interviewed about resident-to-resident assault for a resident with a history of aggressive behavior who has refused or missed medications a few times. V21 stated in part: The nurse needs to notify the doctor or Nurse Practitioner if the resident is refusing medications. We generally get the state guardian or POA involved and the psychiatric Doctor, if a resident is refusing to take their medication and becoming aggressive, and the POA is not cooperative about injections, then, we'll send the patient to the hospital or maybe find another place that can better assist with their needs. When we send them out to the hospital, the hospital has a little more autonomy to administer chemical restraints to help the patient calm down and we can revise the plan to get another facility that will better serve the patient. Meanwhile, the patient can be monitored frequently and every 2 hours rounding to keep them and others safe. On 3/21/24 at 11:40am, V2(Director of Nursing) was asked if the MAR could be left blank without any entries to show if the resident refused the medication or if the medication was administered and the nurse forgot to sign. V2 stated that there should be no missing entries on the MAR because there is a code to enter if the resident refused the medication or if the resident is out of the facility. V2 added, Nurses have to initial the MAR for Behavior Monitoring for residents with behaviors. Sometimes, they (nurses) leave the MAR blank if the resident is out of the building, but it should not be left blank. I will in-service the nurses. On 3/21/24 at 11:45am, V1 (Administrator) stated I could not get any interview from (R4) because he(R4) left AMA (against medical advice). V1 had earlier presented the facility's initial and final incident investigation report that states in part: During the investigation, it was determined that R4 did make contact with R3. R4 and R3 misunderstood each other leading to the contact. R3 was noted with swelling to his face and was sent out to the hospital for evaluation. R3 returned with a nasal fracture of indeterminate age, only receiving pain medication with no new orders. R4 who is alert and oriented times 3 decided to discharge from the facility. The police took no further action. R3's records show the following: Face sheet shows diagnoses which include but are not limited to Hemiplegia and Hemiparesis, Cerebral Infarction, Bipolar Disorder, Generalized Muscle Weakness. Care plan dated 12/14/23 states in part that R3 is weak due to history of fracture of bi -lateral lower extremities. BIMS score dated 2/1/24 is 14(Cognitively Intact). R3's progress notes dated 3/8/24 at 4:50am written by V14 (LPN, Licensed Practical Nurse) states in part: Resident came out of room and stated his roommate was verbally and physically abusive to him, noted swelling to left forehead and busted lip, ice applied to forehead and lip cleaned. Administrator notified, police notified/MD (Medical Doctor) and family notified. Order given to send resident to the hospital for evaluation. 2. On 3/18/24 at 11:20am, V1(Administrator) presented the facility's report of incident submitted to the state agency on 3/10/24. Both the initial and final reports were reviewed. This report states that the facility investigated the allegation that R2 made contact with R1, and that R2 has Dementia and was not aware of the incident. R1 was sent to the hospital for evaluation and determined to have subdural hematoma. On 3/18/24 at 11:45am, R1 was observed in the hallway and later in the room. R1 was asked if his former roommate hit him on the face some time ago. R1 responded and nodded Yes. R1 was asked if he(R1) is still feeling any pain on the nose and the head from the assault, and R1 nodded No. On 3/18/24 at 12:44pm, V1 stated that she(V1) completed the final investigation on the incident where R2 allegedly assaulted R1, and it was not witnessed by any staff. V1 explained that staff were not sure whether it happened on 11-7 shift(night) or 7-3 shift(morning). V1 added (R2) was sent to the hospital and refused to come back here. R1's records show the following: Face sheet shows diagnosis which include but are not limited to Hemiplegia, and History of Accidental Discharge from Firearms/Gun. MDS section C (BIMS-Basic Interview for Mental Status) shows a score of 99 (unable to participate in the assessment due to being non-verbal). Progress notes dated 3/10/24 at 3:30pm written by V11(LPN/ Licensed Practical Nurse) states in part: Resident accused roommate of attacking him in his sleep. Incident went unwitnessed. Resident noted to have scratches on front of face. Progress notes dated 3/14/24 at 11:00am written by V18(Nurse Practitioner) states in part: Chief Complaint/Reason for this Visit: Abrasions on face, forehead hematoma HPI Relating to this Visit / Consultation / Evaluation: 41 y/o male s/p (status post) hospitalization for facial abrasions, forehead hematoma following altercation with peer, readmitted to LTC (long term care) facility. Care plan dated 10/30/23 states in part: Self-Care Deficit with impaired Dressing and Grooming abilities and would benefit from participation in a Dressing/Grooming Restorative Nursing Program as evidenced by the following risk factors and potential contributing Diagnosis: Diabetes Mellitus, General Weakness and/or fatigue, Hemiparesis, Impaired Communication, Impaired ROM and/or Loss of Functional Movement, Right hemiplegia. R2's records show the following: Face sheet shows diagnosis which include but are not limited to Dementia, Schizophrenia, Seizures, Cerebral Infarction, Opioid Abuse, and Strange and Inexplicable Behavior. MDS section C (BIMS-Basic Interview for Mental Status) shows a score of 10(Moderate Cognitive impairment). POS (Physician Order Sheet) dated 10/03/23 states Behavior Monitoring (verbal aggression, hitting, pushing). Document interventions attempted every shift for behavior monitoring. MDS (Minimum Date Set) dated 1/19/24, Section E(Behavior) shows that R2 has Psychosis, Hallucinations, and physical behavioral symptoms directed toward others. Recorded history of physical aggression towards others: Progress notes dated 9/21/23 at 1:51pm written by V16(RN) and at 8:07pm written by V17(LPN) both show that R2 was physically aggressive toward another resident and was sent to the hospital for evaluation. Progress notes dated 2/25/24 at 3:44pm written by V11(LPN) - Resident noted to go inside peer's room and punch her in the arm while sitting in her wheelchair. Housekeeper witnessed him walking away from resident with fist in air, while resident was screaming he just punched me! Resident was redirected to bedroom where he was put on 1:1 with a CNA (Certified Nurse Assistant) until ambulance picked him up. Care plan dated 2/7/24 states in part: History of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process & is therefore considered appropriate for admission. The history includes Conflicts/altercations with others, Verbal, or physical aggression, Acting impulsively, erratically. The resident has a diagnosis of: Strange & Inexplicable behavior. 5/27/2023 - Resident was physically aggressive towards staff. 01/18/24 - Resident made physical contact with his roommate. 01/19/24 - Resident is making frequent attempts to enter his peer's room when behaviors are being redirected, he is becoming verbally and physically aggressive toward staff. Care plan dated 10/20/23 and revised on 2/25/24 states that R2 had inappropriate physical contact with another resident on 9/21/23, 1/3/24, 1/18/24 and 2/25/24. The assigned nurse for 11-7, V15, (LPN-Licensed Practical Nurse) and the assigned nurse for 7-3 shift on 3/10/24 (V11/LPN) both stated that they did not know when the incident happened. On 3/19/24 at 11am, V15 stated I worked the 11-7 shift, and when I gave medication to (R1) at 5:30am, I did not see any injury on his face. I did not know when it happened. His roommate(R2) was walking up and down the hall all night and did not sleep. My shift ended at 7:30am and I left around 7:45am. I did not assess him(R1) because I was not aware of any incident or injury. I heard about it the next day when I came to work. On 3/19/24 at 11:20am, V11(LPN) stated When I came in on 7-3 shift, the 11-7 nurse(V15) was gone, so I did not receive any shift report of what happened on night shift. Later, the CNA (Certified Nurse Assistant) called me to see (R1) in his room, I went and saw the bruises on his face and nose. Usually, (R1) follows direction and understands what you ask him to do, but he(R1) cannot speak, he only nods to say yes or no. I used sign language and asked when and how it happened, he signed that it was his roommate that hit him and it happened before now, so I believe it happened on the night shift, or during change of shift. I immediately called the Doctor, Administrator, DON (Director of Nursing), and the daughter. I spoke with the daughter on phone and asked her to inform the brothers, who usually come on Sundays to take him out. The Nurse Practitioner answered for the doctor and ordered to send him out to the hospital. V11 explained that R1 uses a wheelchair and needs some assistance while R2 walks around without assistance. Hospital Records dated 3/12/24 written by V19(Hospital Physician Assistant) and reviewed by V20(Hospital Physician) states in part: [AGE] year-old male presents after he was attacked by a roommate in the middle of the night. Facility's undated Abuse Prevention Policy states in part: It is the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Facility's undated policy on Behavior Monitoring states in part: Long term residents that have new behaviors will be referred to social services by using a social service referral form and then the social service director will initiate a target behavior monitoring log for 30 days. Facility's policy with latest revision 9/25/13 titled Abuse Prevention Program states in part: It is the policy of this facility to prevent resident abuse, neglect, mistreatments, and misappropriation of resident's property. #4 states: Physical Abuse: Hitting, slapping, pinching, kicking etc. It also includes controlling behavior through corporal punishment. #1 - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm or pain or mental anguish or deprivation by an individual .#2 - Physical Abuse is defined as hitting, slapping, pinching, kicking etc. It's also includes controlling behavior through corporal punishment.

Based on interview and record review the facility failed to recognize, evaluate, and address weight loss; and the facility failed to consistently implement interventions, monitor the effectiveness of interventions and revise them as necessary. These failures resulted in 1 resident [R3] of 4 [R5, R6, R10] residents sent to the emergency department with a diagnosis severe sepsis related to health care aspiration pneumonia, dehydration, low blood oxygen, and significant weight loss [ >10% change over 6 months]. Findings Include: R3's clinical record indicates he is a [AGE] year old with the following medical diagnosis of dysphagia, oropharyngeal phase, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, lack of coordination, weakness, unsteadiness, aphasia, cerebral infarction due to unspecified occlusion or stenosis, essential (primary) hypertension, need for assistance with personal care, limitation of activities due to disability, and personal history of covid-19. R3's minimum data set brief interview for mental status score [10] indicates R3 was mildly cognitively impaired dated 1/5/24. R3's weights documented in part: - R3 admission weight dated 1/8/2019 212 lbs.(pounds) -1/30/20-204.2 lbs. -2/10/21- 188.4 lbs. -1/20/22-172.6 lbs. -1/10/23-141.2 lbs. -7/10/23 -130.8 lbs. -8/11/23-128.0 lbs. -9/5/23-124.8 lbs. -10/1/23-119.6 lbs. -11/22/23-111.8 lbs. -12/12/23 112.2 lbs. -1/9/24 106.8 lbs. -1/29/24 101.6 lbs. Last six months from 7/10/23 to 1/29/24 R3 lost 29.2 lbs. [-22.32% significant weight loss] R3's progress notes indicates in part: V8 [Registered Nurse] Note: On 2/1/24 at 08:40 AM, R3 is alert, slow to respond. Blood pressure 100/62, respirations 16, temperature 96.7, SPO2 [blood oxygen] 89% room air, head of bed elevated, 2 Liter oxygen initiated via nasal cannula. Hydration initiated R3 pocketing fluid in his mouth, nebulizer treatment rendered. Physician notified, gave order to send R3 to hospital emergency room , family made aware. V17 [Nurse Practitioner] Note: On 2/1/24 at 10 AM, Staff concern R3 is lethargy, malnutrition, chest congestion, less responsive, and progressive per nurse, no other or new medical complaints or staff concerns at this time. R3's hospital record indicates in part: Dated 2/1/24. Admitting Diagnosis of sever sepsis related to health care aspiration pneumonia, and dehydration. Upon R3's arrival to emergency department, R3 was lethargic, hypoxic [low blood oxygen levels] a non-rebreather mask was placed, and tachycardic [elevated heart rate]. V10 [ Registered Dietitian] 1/15/2024 21:08 Weight Note. Note Text: Follow-up on weights. R3 with noted significant weight loss x 6 mos. 18.6# (14.2%). Current weight 106.8 BMI 16.7 undernourished. On no added salt [NAS] pureed diet with honey thick liquid [HTL]. Oral intake variable. Diet supplemented 3 x day. Limited assistance at mealtime. On weekly weights x 4 weeks per recommendation. No pressure injury noted. Per MD notes R3 has declined. Needs to remain on pureed honey thick liquids due to coughing with his oral intake related to dysphagia. Meds reviewed and noted. No recent lab to assess. Will continue to monitor. Recommendation: Fortified pudding. Continue weekly weights. [V10 noted R3 limited assistance at mealtime, coughing with meals, and weekly weights, recommended pudding that was already put in place on 10/11/23, no new intervention was put in place] V4[ Registered Dietitian 11/28/2023 16:53 Dietary Progress Note Note Text: WEIGHT WARNING: Value: 111.8 Vital Date: 2023-11-22 12:30:00.0 -7.5% change [ 10.4%, 13.0] -10.0% change [ 13.2%, 17.0] NUTRITION: RD Weight Review - follow up Previously reviewed R3 for significant weight loss for three months and recommended adding supplement TID. Supplement currently in place, as well as double portions at all meals and additional pudding and sandwich/snack of choice at HS. Res now at 111.8#, BMI 17.5 - additional 4.6lbs. weight loss x 1 month, now triggers for significant weight loss x 3 and 6 months, underweight per BMI. oral intakes at meals tend to be either at 26-50% or 76-100%. Would now recommend adding additional super cereal at bedtime due to further weight loss. V4[ Registered Dietitian 11/14/2023 22:36 Dietary Progress Note Note Text: WEIGHT WARNING: Value: 116.4 Vital Date: 2023-11-10 09:05:00.0 -7.5% change [ 9.1%, 11.6] -10.0% change [ 11.0%, 14.4] NUTRITION: RD [Registered Dietitian] Weight Review Past medical history: hemiplegia/hemiparesis, COPD, aphasia, chronic pain, hyperlipidemia, and hypertension. Weights: current weight 116.4#, BMI 18.2 - R3 is underweight, triggered for significant weight loss for 3 months. Diet: NAS, pureed, HTL, double portions at all meals, 1/2 cup pudding at all meals, sandwich/snack of choice at bedtime. R3's oral Intake: varied intakes noted per amount eaten task. Skin: no known areas of pressure. Review: R3 with poor appetite per chart review, varied intakes noted at meals recently. R3's weight loss likely due to decreased oral intakes, not meeting estimated current needs. R3 is underweight per BMI, weight continues to trend down. Would recommend adding additional supplement TID for added nutrition to promote weight gain. Continue to offer food preferences at meal, add resident to weekly weights. Will continue to closely monitor oral intake and weight changes and further make additional recommendations as needed. Plan: Continue to follow with registered dietician available for consult as needed. Supplement 3x a day, and weekly weights. V4[ Registered Dietitian -On 10/11/2023 21:46 Dietary Progress Note Note Text: WEIGHT WARNING: Value: 119.6 Vital Date: 2023-10-10 13:59:00.0 -7.5% change [ 8.6%, 11.2] NUTRITION: RD Weight Review Past medial history of hemiplegia/hemiparesis, COPD [chronic obstructive pulmonary disease], aphasia, chronic pain, hyperlipidemia, and hypertension. R3 Weights: current weight of 119.6 pounds and BMI 18.7 - R3 with significant weight loss for 3 months. Diet: NAS [No added salt, pureed, honey thick liquid [HTL], double portions at all meals, 1/2 cup pudding at all meals, supplement drink three times per day. R3's oral Intake: mostly at 26-50% or 76-100% per amount eaten task. [ R3 was not evaluated or assessed by a registered dietician from 3/23 to 9/23 a total of 7 months] -On 2/9/2023 08:07 Dietary Progress Note Note Text: NUTRITION: RD WEIGHT REVIEW Value: 135.4 Vital Date: 2023-02-08 17:24:00.0 -10.0% change [ 23.2%, 40.8] Weight loss reflecting significant changes x 180 days. Was seen by speech with diet downgrade. Meal portions modified. Records of amount eaten showing varied oral intake. Past medical history of hemiplegia and hemiparesis, chronic obstructive pulmonary disease, dysphagia, aphasia, and hypertension. On 2/27/24 at 9:41 AM, V29 [R3's Family Member] stated, I spoke with a nurse, four to five days prior to R3 being sent to the hospital, that R3 looks like he lost a lot of weight, and weak. I do not remember the day or time. I do not remember the nurse. After every feeding the staff were to clean out his mouth, to remove any left-over food. The hospital nurse told me that when R3 arrived at the hospital he had food in his mouth, staph infection in nose, bed sores, and pneumonia. The nursing staff should have been cleaning out his mouth. Nursing staff, dietician, speech therapist and the physician should have recognized R3 was losing weight and not swallowing his food before he got aspiration pneumonia and lost 100 pounds. The doctor at the hospital told me that R3's food was not going all the way into his stomach, some food was going into R3's lungs, which caused R3 to have aspiration pneumonia and sepsis. The doctor and speech therapist at the hospital told me that is why R3 lost weight, because he cannot swallow due to his dysphagia, and R3 needs a gastric feeding tube for his nutrition. The facility nurse, physician, or speech therapist never offered me or R3 a gastric feeding tube for his nutrition. No one at the facility notified me R3 was losing weight. At the hospital R3's weight was 100 pounds for a grown man. R3 used to weigh close to 200 pounds. The facility should have done something or offered us a gastric feeding tube for R3 before all the weight loss and decline in health, the facility let R3 slowly starve. On 2/27/24 at 11:25 AM, V3 [Speech Therapist] stated, I been working here for five months. There is only one speech therapist here at this facility. I first saw R3 on 8/30/23. R3 was evaluated because he had difficulty swallowing, dysphagia. Some of R3's symptoms were pocketing food in his mouth, some of his food was spilling out of his mouth instead of him swallowing the food, which makes R3 high risk of aspiration. R3 had a stroke and was diagnosed prior to his admission to the facility with dysphagia and oropharyngeal; which means R3 has difficulty initiating a swallow, unable to chew, and will hold food making R3 high risk of aspiration, weight loss, due to R3 not able to eat enough calories. The goal during speech therapy was for V3 to train the staff on feeding and 1 to 1 feeding assistance and aspiration precautions. Such as, R3 sitting up, feeding R3 slow, small bites, no straws, and to make sure R3's mouth was clear before giving him another bite of food. I trained staff verbally, whoever was working with him at the mealtime. I did not train all the certified nurse assistants or nurses; I did not have them sign a training in-service form. I worked with R3 three times per week and sat and fed R3 maybe one meal. R3 speech therapy ended on 10/27/23, due to insurance cut. At the time of discharge from speech therapy, R3 still actively had moderate dysphagia, needed one to one feeding assistance with every meal, cues, and close monitoring for aspiration. I was aware of R3's weight loss, I did not recommend a gastric feeding tube, or video swallow. I did not speak with the family to see if they wanted R3 to be treated more aggressive by getting a gastric feeding tube. I did not recommend a video swallow; the physician or dietitian could have made those recommendations as well. I thought the dietician and physician monitored R3's weight closely. Again, I have not seen R3 since 10/7/24. If R3 had further decline, he should have been referred for speech therapy again. On 2/27/24 at 11:45 AM, V4 [Former Registered Dietitian] stated, I covered the facility from October 2023 to November 2023, the facility did not have a registered dietician on site. Reviewing my documentation from October 2023, R3 had past history medical diagnosis of hemiplegia/hemiparesis, chronic obstructive pulmonary disease, and dysphagia. In October 2023 R3's weight was 119 pounds which was a significant weight loss in three months. R3's diet was no added salt, pureed, thick liquids, double portions at all meals, pudding, supplements three times per day. R3's food intakes varied, and was not adequate, which lead to R3's weight loss. R3 already had multiple supplements in place, but his weight continued to trend down with additional supplements. I did not recommend a video swallow or gastric tube, because I was only filling in two months. There was no dietician on site in this facility. I cannot recommend or down grade any one's diet, I am not a speech therapist. The speech therapist and physician should have been monitoring R3's weight and swallowing capabilities closely. A dietitian should have been monitoring R3 weekly with weekly weights, or at least monthly to assess R3's weight and intake. My last assessment I completed for R3 was in November 2023. I noted R3 lost three more pounds, R3 was underweight [BMI-18.2], poor appetite, and various amounts of meal intake. R3's weight loss was likely due to decrease oral intake, not meeting estimate current needs. R3's weight continued to trend down. I sent my recommendations to the director of nursing, but I did not recommend gastric feeding tube, or video swallow. The director of nursing was made aware of R3's weight loss, and she should have notified the physician. Any resident that is trending down with their weight should be monitored at minimum monthly. On 2/27/24 at 2:12 PM V10 [Registered Dietitian] stated, I started working here 1/1/24. R3 was noted with significant weight loss for six months of 18.6 pounds which is 14.2%. R3's last weight obtained was evaluated by me as 106.8 pounds which made R3 undernourished. R3's diet was no added salt, pureed foods with honey thick liquid. R3's intake was poor and varied. R3's diet was also supplemented with a shake three times per day. I recommended R3 on weekly weights for 4 weeks, R3 did not have any pressure ulcers. However, when I reviewed R3's clinical record the physician noted R3 has declined. I also noted R3 used to weigh 212 pounds upon his admission in 2019 and had a steady decline with his weight. Upon my assessment R3 could not swallow foods. In the physician documentation I did not see any aggressive recommendation, such as a gastric feeding tube. I did not make the recommendation of video swallow or feeding tube, the physician and speech therapist makes those type of recommendations, I just worked with R3 in January 2024. Due to R3's weight loss he should have been followed closely and he is high risk for aspiration. Weekly weights are done so the dietitian can intervene with new interventions to stop, the weight loss. The facility did not complete weekly weights as recommended starting on 11/14/23. I recommended weekly weight again on 1/15/24, R3 missed a total of 7 weights. From 11/14/23 to 1/29/24. Weekly weights help the dietitian accurately assess the resident weight and implement interventions right away to prevent further weight loss. My plan was to monitor R3's weekly weights for one month, then to recommend a gastric feeding tube. R3 needed to be monitored weekly. However, I could not consistently implement interventions, and monitor the effectiveness of current interventions for weight loss due to the fact there were no weekly weights completed for R3. On 2/27/24 at 1:02 PM, V8 [Registered Nurse] stated, I have been working here for sixteen years. R3 has been on my unit for a year or more. I worked on 1/31/24 double shift [7AM-3PM and 3PM-11PM] and 2/1/24 day shift [7am to 3PM]. R3 was alert and oriented x 1-2. During meals, R3 would have difficulty swallowing his food. R3 had weakness, and dysphagia from a past stroke. I would assist R3 with some of his meals every so often, to help out the certified nurse assistants [CNA] sometimes. R3 was a one to one feed assist, he needed to be in a sitting upright position, fed him slowly, and I had to check his mouth to make sure he swallowed the food. R3 often pocketed his food, I would remove the food, stop feeding and give him a supplement shake. On 1/31/24, I did not feed R3 any meals, and I did not receive any concerns from R3's CNA. R3 normally has a cough, that was not abnormal for him. R3 never ate all three meals, and when he ate it was usually less than 50% of the meal, that was his normal. On 2/1/24 upon the start of my shift, prior to the resident's breakfast, R3 appeared to be lethargic, unable to swallow his thicken liquid, just running out of his mouth, and I could hear chest congestion. R3's oxygen was low [89% room air] and I started oxygen 2 Liters per nasal cannula. I notified V17 [Nurse Practitioner], V17 gave an order to send R3 out to hospital for evaluation. V2 [Director of Nursing], and R3's family member was notified of the change in condition and transfer to hospital. On 2/27/24 at 1:56 PM, V9 [Certified Nurse Assistant-CNA] stated, I was R3's CNA on 2/1/24 day shift [7AM to 3PM]. Upon making rounds R3 was not looking good. R3 was weak, and tired. I called for the nurse to check on R3. The nurse told me to get R3 ready because he was going to the hospital. R3 did not have any breakfast. When I got R3 ready for the hospital, I did not check his mouth because I did not feed him anything. I worked with R3 for about a year. During that time R3 had a poor appetite, and lost weight. R3 would sometimes hold food in his mouth. I would tell R3 to spit out the food. R3 needed to be encouraged to swallow. On 2/28/24 at 10:16 AM, V22[ Licensed Practical Nurse] stated, I was very familiar with R3. I was R3's nurse on 1/31/24 second shift [3PM to 11 PM]. R3 is on aspiration precautions and ate dinner as normal, the CNA did not report any issues regarding R3. His [R3] vital signs were normal, R3 was able to swallow his medications without a problem. On 2/28/24 at 2:28 PM, V30 [Registered Nurse] stated, I am familiar with R3. I was R3's nurse on 1/30/24 night shift [11PM to 7AM]. R3 was not scheduled for medication at 6AM medication pass, he usually sleeps at night. R3 did not have any change of condition during my shift, nor did he eat or drink throughout the night. On 2/28/24 at 10:26 AM, V27 [Certified Nurse Assistant] stated, I was R3's Certified Nurse Assistant that worked with R3 on 1/31/24 on second shift [3PM to 11PM]. R3 is a one-to-one feed assist, the bed was in low position, and R3 was sitting up in bed while I feed him dinner. R3 was not coughing during his meal. He ate less than 50% of his dinner, which is usual. No, I did not check his mouth after eating, because he did not eat enough dinner, there was no food in his mouth. On 2/27/24 at 2:37 PM, V7 [Assistant Director of Nursing] stated, I been working here for two years. R3 is on my nursing unit that I manage. R3 is alert and oriented. R3 noted a decline in his health for about a year, he is much slower to respond and weight loss. V2 and I record the weights from the restorative aide into each resident's chart. I did notice R3 was having some weight loss, but V2 [Director of Nursing] and the dietitian were overseeing the weight loss. If there was any weight loss, V2 or I would notify the physician, and family. I do not recall notifying the physician or family regarding R3's weight loss, because the physician was here reviewing R3's chart. R3 was noted to be pocketing his food on and off since last year, and his diet was downgraded. R3 at times was not able to swallow his food, coughing and pocketing his food. Some signs of aspiration are fever, coughing, pocketing food and lung congestion. On 2/1/24, R3 had signs of aspiration and was sent to the hospital. On 2/27/24, at 1:31 PM, V2 [Director of Nursing] stated, I been working here since 7/22. There were times last year the facility did not have an on-site registered dietician. The registered dietician would review the resident's charts and email me recommendations. The floor nurse or I would notify the physician of the recommendations. The restorative aide would obtain the facility resident's weights, V7 [Assistant Director of Nursing] and I would enter the weights in each resident chart. I entered R3's weights on 9/5/2023 [124.8 Lbs.], 10/10/2023 [ 119.6 Lbs.], 11/10/2023 [116.4 Lbs.], 12/12/23 [112.2lbs.], 1/9/24 [106.8lbs.], and 1/29/24 [101.6lbs.]. During the times I entered R3's weights there was a total of 23.2 pounds weight loss in four months. Every time there was a weight loss, I did not notify the physician. The dietician and physician should have been looking at the resident's chart and weights. As nurses we report what we see. I could not make recommendations; it is out of my nursing scope. It is the physician's responsibility to address the weight loss. I have not received any concerns from R3's family regarding weight loss concerns. Weights were given to the dietician, to also address weight loss. R3 did not have a video swallow, nor was R3 or R3's family member offered a gastric feeding tube. I did not make R3's family aware of R3's weight loss, nor did I see documentation that R3's family member was made aware. On 2/28/24 at 4:10 PM, V17 [R3's Nurse Practitioner] stated, R3 was admitted to the hospital with a diagnosis of aspiration pneumonia. That is when food goes down into the lungs instead of the stomach. I was not made aware of R3's weight loss, poor intake, coughing while eating, and holding food in his mouth. Once those issues presented, R3 should have been sent to the hospital for a complete a video swallow and evaluation. Then R3 and R3's family should have been offered a gastric feeding tube. R3 should have been offered a gastric feeding months ago. R3's aspiration pneumonia, and significant weight loss was avoidable. If I was made aware I would have sent R3 to the hospital immediately for a video swallow and offered a gastric tube. Policy documents in part- Change of Condition Policy dated 7/23/13. -Ensure the resident's attending physician and representative is notified of changes in the resident's condition and or status. -Notify the physician when there is a significant change in the resident physical, mental or psychosocial status -Notify the physician deemed necessary or appropriate in the best interest of the resident -Notify the physician when there is a significant change of condition is a decline and impacts more than one area of the resident's health status - Any change in the resident condition will be reported to the MD and the Director of Nursing for further interventions. Weight Protocol Policy dated 3/19/14. -Ensure that all residents are weighed and any resident who is nutritionally at risk as a result of weight loss, decrease or poor appetite. -All weekly weights will be brought to the meeting and discussed with a new intervention recommended. -Weekly weights will be completed 2 days prior to the meeting.

Based on observation, interview and record review the facility failed to ensure that Nurses documented weekly skin checks in the EMR (Electronic Medical Records), failed to ensure that shower/skin checks included skin integrity impairments, failed to document skin integrity impairments upon re-admission, failed to ensure accurate skin integrity impairment/ interventions were on the care plan, failed to timely notify the Physician of resident change in condition, and failed to ensure treatment orders were obtained for one of three residents (R2) reviewed for change in condition. These failures resulted in R2 sustaining lower extremity redness, edema, and pain for several days. On (11/3/23) a family member requested R2 be sent to the ER (emergency room ) for evaluation and R2 was subsequently diagnosed with cellulitis, soft tissue infection, hypoglycemia, and pneumonia. Findings include: On 11/7/23, IDPH (Illinois Department of Public Health) received allegations that R2's leg wounds were not properly treated at the facility and are infected; and that R2 sits in soiled diapers all day. R2 was diagnosed with low glucose and pneumonia. R2's diagnoses include dementia, and (11/10/23) local infection of the skin/subcutaneous tissue. R2's progress notes state (11/3/23) Daughter at bedside requesting resident be sent to ER (emergency room ) for evaluation. Doctor notified with orders to send to ER. (11/10/23) Admit from hospital. Admitting diagnoses: hypoglycemia, soft tissue infection, and right lower lobe pneumonia. Skin intact. Doctor notified of re-admission; orders verified. R2's hospital (11/3/23) history & physical states patient presented from skilled nursing facility due to concerns for altered mental status. Family states patient has been acting more tired and lethargic over the past few days. Family also stated he noticed increased redness, discoloration and swelling to the patient's legs over the past 2 months but has been worse over the past few days. Per patient, she states she's been having increasing lower extremity pain and redness over the past few days. On ED (Emergency Department) arrival, patient was hypoglycemic with a blood glucose of 39. Patient was noted to have evidence of pneumonia on chest x-ray. Given patient's presence of lower extremity swelling and redness, lower extremity dopplers were obtained which were negative for acute deep vein thrombosis. CT (Computed Tomography) of bilateral lower extremity demonstrating findings suspicious for cellulitis in left lower extremity. Also notable for fluid identified between the muscle bellies and bilateral thighs and calf muscles with no gas identified, suggestive of findings of necrotizing fasciitis (flesh eating disease which occurs when bacteria enter the body through a break in the skin) of the left thigh and calf. R2's (11/11/23) facility history & physical states patient was sent to the hospital with change in mental condition and lethargy. Patient was evaluated in the ER with chest x-ray showing small bilateral pleural effusion and focal consolidation. Patient was treated for cellulitis in lower extremities. Please refer to nursing notes for full skin assessment [R2's November 2023 Nursing Progress notes exclude skin assessments post 11/10/23 entry]. On 11/28/23, R2's most current weekly skin assessment was requested by surveyor. The facility provided R2's weekly skin check dated 9/28/23 (2 months prior) and November 2023 showers/skin checks which were documented 11/3, 11/6, 11/10, 11/13, 11/17, 11/20, 11/24, and 11/27 however skin integrity impairments (re: swelling, discoloration and/or cellulitis) are excluded. R2's (November 2023) POS (Physician Order Sheets) exclude treatment orders (post 11/10/23 admission). R2's (November 2023) TAR (Treatment Administration Record) includes (10/24/23) orders to wrap bilateral legs with ace bandages (for swelling) however the order was discontinued 11/4/23. [Dressings to absorb exudate and/or topical medication to prevent further infection and/or heal skin are excluded]. R2's (9/25/23) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R2's (9/25/23) functional status affirms (2 persons) physical assist is required for bed mobility, personal hygiene, and toilet use. On 11/28/23 at 2:40pm, V14 (Certified Nursing Assistant) removed R2's incontinence brief (as requested) which was dry however multiple small pink scars (from prior skin integrity impairment) were noted on R2's buttocks. Surveyor inquired if R2 was currently experiencing a burning sensation or pain on the groin or buttocks R2 affirmed she was not. R2's bilateral lower extremities (below the knee) exhibited hyperpigmentation with shriveled skin and scattered pink scarring (from prior skin integrity impairment and subsiding edema). On 11/30/23 at approximately 11:30am, surveyor inquired why R2's weekly skin assessment (provided by the facility) was from September and not current. V1 (Administrator) affirmed it was R2's most current weekly skin assessment documented in the EMR (Electronic Medical Record). R2's (9/18/23) care plan states resident is at risk for alteration in skin integrity related to impaired cognition, incontinence, mobility status and dementia. Resident requires assistance with ADL's (Activities of Daily Living) as evidenced by dementia, weakness, and communication deficit. Observe for any skin integrity issues and report to medical doctor. [R2's comprehensive care plan excludes actual skin integrity impairments]. On 11/30/23 at 12:07pm, surveyor inquired why R2 was transferred to the hospital on 11/3/23. V9 (Assistant Director of Nursing) replied, Altered mental status. She (R2) did get admitted with pneumonia and I believe it was for altered mental status. Surveyor inquired about the required frequency for resident skin assessments. V9 stated, They (Nurses) should be doing weekly checks. They (CNAs) should be doing care and if they notice anything they should notify the Nurse right away so she can get orders. They (Nurses/CNAs) should be marking that (skin integrity impairments) on the shower sheets as well, whether its new or old it should be marked. Surveyor inquired about the requirements for resident re-admission. V9 responded, On admission the skin assessment should be done by the admitting Nurse, the Wound Care Nurse would then see the resident. They (Nurses) should complete the body assessment on them (residents) and do a reconciliation for the medications with the doctor. Surveyor inquired if R2 was prescribed ace wraps to the lower extremities upon (11/10/23) re-admission. V9 replied, I have to double check on that cause I'm not sure if there was an order for that or not, or if wound care was continuing with that order. If it was an active order, they should have continued doing them. Surveyor inquired what cellulitis is. V9 stated, Its inflammation, it's edema we normally treat it with antibiotics. Surveyor inquired about treating the skin. V9 responded, At the nursing home, it (cellulitis) would be treated by wound care if its open, and they wrap the legs. On 12/4/23 at 9:26am, surveyor inquired about the required frequency for resident skin assessments. V19 (Wound Care Coordinator) stated, It should be weekly. Surveyor inquired who's responsible for the weekly skin assessments. V19 responded, The Nurses. When they (residents) get their showers, the Nurse will go in and check the skin, it's in the computer it will pop up on the date that its due or they will note it on the shower sheet. On admission or re-admission, the floor nurse does the initial skin assessment. The next day we (Wound Care Nurses) come in, we assess the resident and call the doctor to get orders if they have any issues with their skin. Surveyor inquired if V19 was aware that R2 was readmitted (11/10/23) with cellulitis. V19 replied, No, her skin is intact since I've been here. Never no skin issues, as far as any open areas. I've been here since July of 2022. Surveyor inquired how cellulitis presents. V19 stated, Red and warm, sometimes it could weep. Surveyor inquired about standard treatments for cellulitis. V19 responded, Antibiotics. If it was external sometimes, we could use an antibiotic ointment. On 12/4/23 at 1:55pm, surveyor inquired about staff requirements for resident change in condition. V20 (Medical Director) stated, If the resident has a change in condition, it would be notifying the patients family, POA (Power of Attorney) or whoever is in charge of that person and of course they would be notifying the Physician of the change in condition. Surveyor inquired how cellulitis presents. V20 responded, cellulitis can be very subtle like a macule (flat, distinct, discolored area of skin) with erythema (redness) or papules, (firm lumps on the skin less than 1cm-centimeter), nodules (firm lumps on the skin greater than 1cm) or edema (swelling (caused by too much fluid trapped in the body's tissue) with blisters on the skin. Surveyor inquired about standard treatments for cellulitis. V20 replied, if it's a local cellulitis, it would be a local topical antibiotic [R2's diagnoses include local skin infection]. We would also order wound care nurse or the wound care team to see the patient. Surveyor inquired about potential harm to a resident with untreated cellulitis, edema and tenderness. V20 stated, A local cellulitis can become generalized and can spread. The (5/20/23) guidelines for preventive skin care states residents will have the results of their Weekly Skin Assessments used as an indicator as to their specific preventive skin care needs. Appropriate skin care is provided by staff each shift and/or as necessary. Should a caregiver notice any alteration in a resident's skin to include a scratch, skin tear, redness, rash any broken skin or any other unusual observation this will be reported immediately to the Charge Nurse for assessment and appropriate follow-up to include physician notification as indicated. The abuse prevention policy (revised 01/2019) states in part; neglect/mistreatment means the failure to provide, or willful withholding of, adequate medical care, that is necessary to avoid physical harm, or mental anguish of a resident.

Based on observation, interview and record review, the facility failed to monitor (R2) who is cognitively impaired and recently had a hip surgery from a fall; failed to provide individualized fall prevention interventions for two residents (R2 and R12) according to the care plan; and failed to supervise a resident (R12) who had repeated falls. As a result of this facility failure, (R2) fell and sustained a right hip fracture which required surgery. Findings include: R2's Face Sheet shows R2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. R2's diagnoses include but are not limited to Dementia, Osteoarthritis, Abnormalities of gait and mobility, and Muscle weakness. R2's records reviewed include but are not limited to the following: BIMS (Brief Interview for Mental Status) score dated 10/1/2020 could not be determined due to severely impaired cognition. Fall Risk Evaluation dated 1/19/23 shows a score of 8 (at risk for falls). MDS (Minimum Data Set) section G with effective date 10/1/2020 shows that R2 needs extensive assistance with two persons for bed mobility, transfer, personal hygiene and toilet use. Mobility Devices records a wheelchair. Care Plan dated 1/19/23 states that R2 is at high risk for falls related to medical diagnoses; Intervention states in part to provide a safe environment and bed mobility position devices. However, there was no bed mobility position device observed on R2's bed on 2/14/23. A bed wedge was put in place after the surveyor prompted staff on 2/15/23. On 2/14/23 at 11:25am, R2 was observed in bed. R2's room is one from last room at the end of the hall farthest from the nursing station. Inquired from V12 (LPN/Licensed Practical Nurse) about the fall prevention interventions for R2 and why R2's room is so far away from the nursing station. V12 responded, R2 was previously on the second floor and was recently moved to the third floor. Again on 2/15/23 at 12:45pm, R2 was observed in the same room almost at the end of the hallway far away from the nursing station and not within view of staff. Nursing progress notes dated 1/19/23 at 12:40pm written by V19 (LPN/Licensed Practical Nurse) states in part: Writer was called to the dining room by staff. Resident was observed lying on her back. Writer was told resident slide out her wheelchair. Body assessment completed no visible injury noted. Resident complained of pain to the right leg, PRN Tylenol 500mg was given for pain. Stat X-Ray ordered for the right hip, knee, and leg. 72-hour neurological check initiated. On 2/15/23 at 10:50am, V19 was interviewed regarding R2's fall and if it was okay to wait till the next day after the fall to get X-Ray on the resident. V19 corroborated the above progress notes and stated: On that day, I was called to the dining room, and I saw (R2) already on the floor by the wheelchair. I don't remember the CNA (Certified Nurse Assistant) in the dining room at that time. I did body assessment and gave her pain medication. I called for the X-Ray on the day of the fall, but when I got back to work the next day and found that the X-Ray was not done, I told the ADON (Assistant Director of Nursing/V51) about it. I also called the (X-Ray company) and the (X-Ray company) said they could not come because they were backed up. So, the resident was sent to the hospital per doctor's order the next day. On 2/16/23 at 2:02pm, V51 (ADON/Assistant Director of Nursing) was interviewed regarding R2's fall of 1/19/23 and why R2 was not sent to the hospital on the very day R2 fell . V51 responded, when she (V51) was told that the Stat X-Ray was not done on that day (1/19/23), the doctor was called and R2 was sent to the hospital. V51 explained that at the hospital, they found that R2 had a fracture of the hip. V51 was also interviewed about the current fall prevention interventions for R2 after returning to the facility from the hospital with a healing hip fracture. V51 stated, I know that the resident should be closer to the nursing station to be monitored frequently, but that was the room available after she came back from the hospital. We will find a room closer to the nursing station. On 2/17/23 at 2:36pm, V51 stated that R2 has been moved to a room closer to the nursing station. Hospital Records dated 1/21/23 shows X-ray of Femur results: Right Femur and Right Hip X-Rays: Indication: Right hip pain status post fall. There is an acute comminuted and impacted intertrochanteric fracture of proximal right femur with mild varus angulation. Physician progress notes dated 1/26/23 written by V20 (Medical Doctor/MD) states in part: The patient is an [AGE] year-old female, long-term resident of the facility. She had a fall in the facility when she landed to her right side sustained right hip pain and the patient was sent to the hospital. She was found to have right hip intertrochanteric fracture and underwent right hip open reduction internal fixation with intermedullary nailing. On 2/17/23 at 2:20pm, V54 (Medical Director) was interviewed regarding R2's fall injury and the delay in getting X-Ray after R2 complained of pain in the hip. V54 stated, if the X-Ray company did not show up after a few hours, the nurse should let me know and then we can send the resident to the hospital. Inquired from V54 if it was okay for the resident to wait till the next day before being sent to the hospital, V54 responded, No, that should not wait till the next day. Communication needs to exist between the nurse, the lab and the doctor. V54 was asked about fall prevention interventions for a resident who was sent to the hospital due to a fractured hip and returned to the facility. V54 stated, Interventions need to be in place to prevent another fall. We want to make sure the resident is close to the nursing station so they can see if the resident is trying to get up. Facility's Fall Prevention and Management Program version 080317 states in part: The purpose of our Fall Prevention and Management Program is to: Provide appropriate interventions to prevent falls. Through an interdisciplinary approach, this facility will provide fall prevention assessment, implement interventions to prevent falls as much as possible, and manage pos-fall treatment. #3B states: Implement individualized approaches/interventions based upon resident risk. 41611 R12 is a [AGE] year-old male who has a diagnosis of but not limited to Covid-19, Type 2 Diabetes Mellitus with Ketoacidosis without coma, Chronic Obstructive Pulmonary Disease, Gout, Hyperkalemia, Hypertension and Altered Mental Status. R12 has a Brief Interview of Mental Status score of 15 that indicates cognitively intact. Incidents By Incident Type for January 2023 that documents that R12 had 3 falls on 1/15/2023, 1/18/2023, 1/26/2023. R12's local hospital record dated 1/15/2023 when R12 was sent to the hospital for a fall. R12 had no injuries and was sent back to the facility. R12's MDS (Minimum Data Set) section G dated 1/08/2023 for bed mobility documents that R12 needs extensive assistant and is a two plus person assist. R12's care plan dated 1/02/2023 documents new interventions added after each fall such as mattress changed to air mattress (initiated 1/19/2023), routine items within reach, frequent rounds related to poor safety awareness and keep bed in lowest position, educated family member to communicate with nursing when implementing a device for comfort to prevent undesirable events (1/19/2023), bed mobility positioning devices and staff to anticipate and meet my needs. Surveyor reviewed R12's Order Summary Report that list orders for floor mats and side rails as of 1/26/2023. R12's Restorative Nursing Review dated 01/02/23 indicates ability to sit up unassisted (poor) and ability to maintain sitting balance (full) Recommendations for Restorative Nursing Programming: he has reduced movement/activity, has gout in both hands/fingers making it difficult to turn/reposition self in bed. AROM and/or AAROM Restorative Nursing Program: To preform 10 reps x2 sets to all extremities 6-7 days/week with focus on flexibility/extension as tolerated w/verbal cues from staff. On 2/14/2023 at 1:10pm R12 stated that his last fall was sometime last month and that he had sat up in his bed and was trying to lay back down when he slid out of the bed onto the floor. R12 stated that there were no floor mats. On 2/14/2023 at 1:30pm surveyor observed R12 in the bed with no floor mats on either side of the bed and no side rails. On 2/15/2023 at about 10:46am surveyor observed R12 in the bed with no floor mats down on either side of the bed and no side rails. On 2/15/2023 at 1:15pm surveyor observed R12 in the bed with no floor mats down on either side of the bed and no side rails. Surveyor inquired about the other two falls that occurred in January 2023. R12 stated he wanted to sit up for a little while and went to lay back down, legs were hanging over the side and he slide out of the bed on both occasions. On 2/16/2023 surveyor reviewed R12's side rail assessment dated [DATE] by V9 (Restorative Nurse) that documents based upon the above review findings: The resident will not use side rails at this time. This was the only side rail assessment that had been completed as of 2/16/2023. On 2/16/2023 at 2:10pm V2 (DON) stated that nurses are to follow the doctors order and Interventions that are put into place which would include bed in lowest position, non-skid mat to the wheelchair, resident room moved closer to the nurse's station, fall mats, bed bolster, scoop mattress, midline in the bed, respond to call light more frequently, gotten them up when they are awake, more frequent rounds. V2 stated, side rails are not recommended for fall prevention, but we use them for bed mobility. Undated job description titled Registered Nurse states, in part, carries out restorative programs, monitors assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies, and operates all equipment and use all supplies in a safe manner and according to established procedures. Undated job description titled Certified Nursing Assistant states, in part, performs restorative and rehabilitative procedures as instructed, follows established safety precautions in the performance of all duties and operates all equipment and use all supplies in a safe manner and according to established procedures.

Based on observation, interview and record review, the facility failed to follow their practice for falls and send a resident out to the hospital for further evaluation after the resident had an unwitnessed fall. This failure resulted in R313 being evaluated 19 hours later and was subsequently diagnosed with a subdural hematoma. The facility failed to secure the crash cart oxygen tank in a secured oxygen holder at the nurse's station on the first floor and in (R146's) room. This failure has the potential to affect all residents on the first floor. Findings Include: R313 is the subject of this investigation. R313 was sent out to hospital on [DATE] and expired in the hospital on [DATE]. On [DATE] the facility reported incident that was sent to the state agency was reviewed. The final report dated [DATE] documents, in part, Conclusion: Resident (R313) has a BIMS (Brief Interview of Mental Status) of 7 and could not state what occurred. Staff reports, resident (R313) had a fall, resident (R313) was observed on the floor near his (R313) bed. R313's admission diagnoses include but not limited to Dementia, Cognitive Communication Deficit, Muscle Wasting and Atrophy, Abnormalities of Gait and Mobility, Anemia, Psychotic Disturbance, Anxiety and Psychosis. R313's ([DATE]) Minimum Data Set (MDS), documents, in part, that R313's Brief Interview for Mental Status (BIMS) score of 7 which indicates R313's has severe cognitive impairment. Functional Status for Bed Mobility and toilet use ,d+[DATE] coding (extensive assistance/one-person physical assist). R313 transferred to local hospital on [DATE] at 10:47pm by EMS (Emergency Medical Service) unresponsive. R313's Local fire department run sheet, dated [DATE] at approximately 10:20pm documents in part, Dispatch to the scene of the [AGE] year-old male who is found unresponsive and not breathing by a staff member at the nursing home he (R313) resides in. Per staff they were doing their night rounds and found him (R313) unresponsive. They called 911, upon our arrival patient (R313) found lying in bed breathing at 1 (Breaths) per minute however unresponsive. Primary assessment was completed, however secondary assessment findings were bruises to his chest, upper abdominal area, small bruises to left side neck and right hand. The history of the bruises is unknown, Patient (R313) vitals were within normal range. CSS (Canadian Stroke Scale) was incomplete due to unresponsive. Patient (R313) also had signs of incontinence. Patient (R313) remained unchanged during transport and able to protect own airway. Patient (R313) transferred to local trauma hospital without incident. Progress notes dated ([DATE]) at 3:39 am Late Entry documents Type: General Note: Upon doing rounds the resident (R313) noted on the floor on his (R313) knees in praying position on the side of his (R313) bed. Resident was head to toe assessed and placed back in bed. V/S (Vital Signs) are bp (blood pressure),d+[DATE] t (temperature)96.3 rr (respiration) 16 hr (Heart rate) 71 sao2(spo2, oxygen saturation) 98. Abrasion noted on left knee. Site cleaned and treated with bacitracin. The resident was given prn (as needed) pain medicine. Md (Medical Doctor) called, a new order for 72 hr (hour)neuro checks and close monitoring put in place and carried out. Progress notes [DATE] at 11:31 pm documents Type: Nursing Progress Notes: During rounds resident (R313) was observed unresponsive by CNA (Certified Nursing Assistant), CNA notified writer and writer went and assessed resident. The writer performed sternum stimulation and resident had no reaction. Writer checked vitals: BP (Blood Pressure)-,d+[DATE], P (Pulse)-83, T (temperature)-97.2, BS (Blood Sugar)-407, O2 (Oxygen)98. Due to not being responsive resident was sent out via 911 emergency. Resident (R313) taken to local hospital for evaluation and treatment. R313's ([DATE]) Fall Report (no date or time) documents, in part, Incident Location: Residents room, Nursing Description: Upon doing rounds resident visually noted kneeling on the floor, beside his bed, in praying position with call light within reach. Resident Description: Resident stated, I want to get up. Injuries observed at time of Incident: swelling to left Knee. R313's mental status indicated Alert with periods of (blank space). Predisposing Physiological Factors indicated Confused, Incontinent, Impaired Memory. (Report prepared by V29, Registered Nurse). R313's ([DATE]) Fall Risk Review documented, in part, Conclusion: Total Score 10. (A score of 10 or above represents High Risk. R313's ([DATE]) emergency room report documents, in part, diagnoses but not limited to Subdural hematoma. CT (Computed tomography) of head result indicated Large right holohemisphere acute on chronic or hyperacute subdural hematoma with marked mass effect, midline shift, herniation as described. CT of chest documents in part, Left posterior rib Fracture, possible nondisplaced fracture of the superior endplate of T12 (part of the thoracic spine). Hemoglobin and Hematocrit (H/H) 5.4 and 17.7, (Normal hemoglobin level 13XXX,d+[DATE].0, Normal hematocrit level 39XXX,d+[DATE].0), a clinical indication of bleeding out. R313 was intubated (assistant breathing) and admitted to Neuro Critical Care Unit (NCCU). R313's ([DATE]) hospital discharge summary documents, in part, presenting to hospital after being found unresponsive. He (R313) was intubated for airway protection. Stat CTH (CT of Head) demonstrated a 3.9 cm (Centimeter) mixed density R (right) SDH (Subdural Hematoma) with 2.2 cm MLS (Midline Shift). Neurosurgery team was consulted, no surgical intervention offered given futility (Any treatment that, within a reasonable degree of medical certainty, is seen to be without benefit to the patient). Called to bedside for absence of respirations. Time of Death 3:00 PM. R313 ([DATE]) death certificate stated cause of death was subdural hemorrhage. On [DATE] at 10:29 am V22 LPN (License Practical Nurse) stated that R313 had an unwitnessed fall on the previous shift and neuro checks were initiated because of the fall. V22 stated that V35 (Certified Nursing Assistant, CNA) was making rounds in R313's room and noticed R313 not responding to anything, like R313 was asleep. V22 stated that V35 called V22 into R313's room and V22 performed a sternal rub on R313 with no response to tactile stimuli. V22 stated that R313 was unresponsive, a rapid response was called and 911. V22 stated that the Physician, (V31) DON (Director of Nursing), and family were notified of change in condition. On [DATE] at 11:30 am V29 (Registered Nurse) stated that the V30 CNA (Certified Nursing Assistant) said that R313 was in the room on the floor [DATE]. V29 stated, they did do not remember who the CNA was. V29 stated that V29 went into the room and saw R313 on the floor in a kneeling position. V29 stated a head-to-toe assessment was done and V29 saw an abrasion on R313's knee. V29 stated that R313 had no other bruises anywhere on R313's body. V29 stated that R313 did not tell V29 that R313 had fallen or is in any pain. Surveyor inquired if R313 told V29 that R313 hit R313's knee? V29 stated R313 did not tell V29 that R313 hit R313's knee. V29 stated that V29 saw the abrasion on R313's knee. Surveyor inquired if R313 did not tell you (V29) R313 hit R313's knee could R313 not tell V29 that R313 hit R313's head? V29 stated, No, R313 would have told me if he (R313) hit his head. V29 stated that V31 (Physician) was called, and orders was given to do neuro checks. V29 stated that since R313 was in a kneeling position, and it was unwitnessed the facility treats the incident as a fall. Surveyor inquired whether R313 should have been sent out to hospital for an evaluation because of an unwitnessed fall and R313's being cognitively impaired? V29 stated, No R313 was fine. On [DATE] at 1:23pm V2 (DON) stated that she (V2) received a call from V22 that R313 was unresponsive and had fallen earlier on the night shift. V2 stated that she was not notified of R313's fall until the change in condition, which was several shifts later. V2 stated that she should have been notified of the initial fall. V22 stated that an unwitnessed fall should have been sent out especially a resident who is cognitively impaired. V2 stated that R313 cannot articulate if he (R313) did or did not hit his (R313) head. V2 stated that sometimes the doctor makes decisions on what the nurse articulate to them. V2 stated, a reasonable nurse would have sent R313 to the hospital for an unwitnessed fall and if I (V2) was notified of the initial fall, I (V2) would have had R313 sent out to the hospital for evaluation. On [DATE] at 3:40pm, V30 (CNA) stated that R313's call light was on and V30 went into the room to answer the call light. V30 stated that R313 was on his (R313) knees on the floor between bed A and bed B. V30 stated she waited for V29 to come into the room before V30 moved R313 back to bed. V29 came into the room and R313 was put back to bed. V30 stated that R313 was hesitant and nervous to be moved back to bed. V30 stated R313 said, Oh my knee, when moved back to bed. V30 stated that R313 was very confused. V30 stated that after R313 was put back to bed V30 left out of the room. On [DATE] at 5:20pm V31 (Physician) stated that R313 had a fall then got worse and was sent out to hospital. V31 stated that if a resident is stable, they can watch and do neuro checks in the facility. V31 stated that neuro checks are done to assess for change in condition. Surveyor inquired, if there is a bleed in the head will there be a change in the pupils? V31 stated, yes there will be a change in the pupils if there is a bleed in the head. V31 stated that he did not recall if V31 told the nurse to send R313 out to the hospital. On [DATE] at 1:35 pm V35 (CNA) stated that on [DATE], V35 went to put R313 to bed. R313 was sitting on the chair in R313's room. V35 stated that R313 was not looking good. V35 stated that R313 was too sleepy and would not wake up, so V35 went to get (V22). V22 came into the room and R313 was sent out to the hospital. V35 stated that V35 didn't know what happened after V22 went into the room because V35 never went back into the room. V35 just saw R313 leaving out to go to the hospital. On [DATE] at 2:30 pm V31 stated that a subdural Hematoma is usually related to an injury such as a fall. V31 stated that R313's Cat Scan said acute on chronic subdural hematoma. V31 stated that it is a possibility that a new bleed could start with an injury. Surveyor inquired of V31, if R313, who has a severe cognitive impairment, should have been sent out to hospital for an evaluation? V31 stated, Yes R313 probably should have been sent out, I (V31) do not remember if I (V31) told the nurse to send out R313. R313's ([DATE]) Neuro Check Flowsheet documents, in part, Perl (pupils equal and reactive to light), Pupil response left and right B (Brisk, reacts quickly) size (4), which indicates normal response. Last neuros check documented was [DATE] at 3:00 pm. All neuro checks documented indicated a normal assessment. R131 ([DATE]) Care Plan documented, in part, (R313) is at risk for falls as evidenced by the following risk factors and potential contributing Diagnosis: Cognitive Impairment, Communication Deficits, decrease strength and endurance. On [DATE] R313 had a fall. On [DATE] R313 had a fall. On [DATE] R313 had a fall. R313's ([DATE]) Physician order set documents in part, may cleanse left knee abrasion with normal saline, pat dry and apply bacitracin ointment. Initiate neuro check per protocol. Facility Registered Nurse Job Description undated documents, in part, Position Summary: The Registered Nurse provides direct nursing care to the residents. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. E. Role Responsibilities- Nursing Care: 8. Implement and maintains establish nursing objectives and standards. Facility Licensed Practical Nurse Job Description undated documents in part, Position Summary: The Licensed Practical Nurse provides direct nursing care to the residents. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. E. Role Responsibilities- Nursing Care: 8. Implement and maintains establish nursing objectives and standards. Facility Certified Nursing Assistant Job Description undated documents in part, provides each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. Nursing Care Role Responsibility: 27. and ensure that residents who are unable to call for help are checked frequently. Facility's Policy ([DATE]) titled, Incident, Accident, Falls Policy, documents, in part, Procedure: The nurse will notify the resident's attending physician/ Nurse Practitioner, DON, Administrator and the resident's responsible party. 47303 On [DATE] at 11:45 AM Surveyor observed a free- standing oxygen tank at the bedside in R146's room. V16 (Licensed Practical Nurse) was interviewed and asked if she (V16) saw anything out of order. V16 stated, The oxygen tank is not supposed to sit outside of a stand. It could be hazardous if the tank falls over. It could possibly cause an explosion. R146's ([DATE]) order details documented, in part O2, 4L/ NC (nasal cannula)/ concentrator . R146's ([DATE]) quarterly MDS (Minimum data sheet) indicates that R146 is receiving supplemental oxygen. R 146's ([DATE]) care plan reads in part, Administer O2 PRN (as needed) for SOB (shortness of breath). Facility's policy named; Oxygen Therapy (revised ,d+[DATE]) reads in part: Oxygen tank must be safely secured in an oxygen tank stand. Never lay tank on its side or have it standing freely at the bedside.

Based upon observation, interview and record review the facility failed to follow the fall prevention policy, failed to provide (R1, R3) supervision, and failed to implement fall prevention interventions for three of four residents (R1, R3, R4) reviewed for falls. These failures resulted in R1 sustaining (9/19/22) fall with eyelid laceration, periorbital hematoma, subarachnoid hemorrhage, and subdural hemorrhage. Findings include: The facility fall log affirms R1 fell on [DATE] and 9/19/22. R1 is [AGE] years old with diagnoses which include Alzheimer's disease, weakness, age related physical debility, lack of coordination, [CONDITION(S)], and [CONDITION(S)]. R1 was admitted to the facility 8/25/22 transferred to the hospital 9/19/22 (post fall) and did not return. R1's (9/1/22) BIMS (Brief Interview Mental Status) determined a score of 5 (severely impaired). R1's (9/1/22) functional assessment affirms (2-person) physical assist is required for bed mobility and transfers. R1's (8/26/22) incident report states upon making rounds resident observed on floor next to bed. Resident stated she was just moving around the bed and rolled out of bed. R1's care plan states resident is at risk for falls. Interventions: (8/26/22) Follow the facility fall protocol. Nursing staff will complete a fall risk assessment per facility fall protocol. Low bed provided [side rails and/or floor mats are excluded]. R1's (8/28/22) fall risk assessment determined a score of 11 (High Risk). On 10/5/22 at 9:25am, surveyor inquired about R1's (9/19/22) incident V2 (Director of Nursing) stated. The Nurse called me and said she (R1) had a fall that was unwitnessed, so we sent her (R1) out. She (R1) was in the low bed that day. Surveyor inquired if R1 sustained any injuries post (9/19/22) fall V2 responded, She (R1) had a subdural hematoma. On 10/5/22 at 12:55pm, surveyor inquired about R1's fall prevention interventions. V10 (Licensed Practical Nurse) stated Her bed was in low position, and we (Staff) were doing 2 hour rounds on her cause she was confused. Surveyor inquired about R1's (9/19/22) incident. V10 responded, The CNA (Certified Nursing Assistant) called me to the room and told me that she (R1) was observed on the floor. She (R1) had a laceration to her upper right brow. She was next to her bed on the floor laying on the side where the laceration was. She wasn't really able to tell me what happened because she is intermittently confused. Surveyor inquired if predisposing situation factors should be selected on the incident report. V10 replied, Yes, those are filled out. Surveyor advised that nothing was selected for predisposing situation factors on R1's (9/19/22) incident report V10 stated, It should have been filled out for low bed. R1's (9/19/22) incident report states: writer observed resident laying on floor next to bed on right side. Resident unable to give description. Injury: laceration/eyebrow (right). Predisposing physiological factors: confused, incontinent, gait imbalance. [Predisposing situation factors affirm low bed use, side rail use and/or safety mat at side of bed were NOT selected]. R1's (9/19/22) history & physical states patient presented from nursing home after mechanical fall and altered mental status. Diagnoses: traumatic subarachnoid hemorrhage, traumatic subdural hematoma, right periorbital (eyelid) laceration, periorbital hematoma. R1's (9/19/22) head CT (Computed Tomography) includes trace right sided subarachnoid and subdural hemorrhages. On 10/6/22 at 1:47pm, surveyor inquired about potential harm to a resident that sustains an unwitnessed fall. V12 (Medical Director) stated, I would definitely do a CT of the head and send them to the hospital. Surveyor inquired why a head CT would be ordered. V12 responded, To look for any type of hemorrhage or hematoma. The facility fall log affirms R3 fell on [DATE], 8/23/22 and 9/3/22. R3 is [AGE] years old with diagnoses which include dementia, [CONDITION(S)], and [CONDITION(S)] (affecting left side). R3's (9/15/22) BIMS determined a score of 99 (Resident was unable to complete interview). R3's (9/15/22) functional assessment affirms (2-person) physical assist is required for bed mobility and transfers. R3's (9/3/22) incident report states writer observed resident laying on floor mat rolling around. Resident unable to give description. No witnesses found. R3's care plan states resident is at risk for falls. Interventions: (9/6/22) Resident will be placed in common area when up. On 10/4/22 at 10:36am, R3 was observed (unsupervised) in the bedroom atop of a modified wheelchair (lying almost completely flat) with left leg dangling over the edge. R3's call light was out of sight (behind the curtain) and out of reach (dangling from the wall). V4 (Licensed Practical Nurse) subsequently entered R3's room, surveyor inquired about safety concerns. V4 stated, He don't got a call light next to him. He's lying flat in the chair but he's moving side to side. I'll go talk to the Nurse and see what's going on. V4 placed V4's left leg onto the chair and left the room without providing R3 call light access. [R3 was not placed in a common area while up]. On 10/4/22 at 10:41am, V5 (Restorative CNA) entered R3's room surveyor inquired about safety concerns V5 stated The way he's postured, he's not sitting up in the chair and the leg is off the chair. Surveyor inquired about the location of R3's call light. V5 responded, It should be up above the bed. V5 located a call light string (behind the curtain) and attempted to place it near R3 however there was no clip to secure the string. Surveyor inquired if there was a clip on the call light string to maintain placement within reach V5 replied Not at the moment and placed the call light string on the bed (out of reach). Surveyor requested to inspect R3's sacral wound. V5 then exited the room without providing R3 call light access and/or repositioning the resident. R4 is [AGE] years old with diagnoses which include [CONDITION(S)] disease, weakness, unsteadiness on feet and difficulty in walking. R4's (9/16/22) fall risk assessment determined a score of 9 (moderate risk). R4's (8/19/22) care plan states resident is at risk for falls, could benefit from use of nonrestrictive side rails. Interventions: place call light within reach. R4's (8/17/22) BIMS determined a score of 13 (cognitively intact). R4's (8/17/22) functional assessment affirms (2-person) physical assist is required for bed mobility and transfers. On 10/4/22 at 10:58am, R4 was lying in bed without call light access. Surveyor inquired about the location of R4's call light. V5 (Restorative CNA) stated, 'It's right here then grabbed the string which turns R4's over bed lighting on/off. Surveyor advised that the string to which V5 was referring was not for call light access. V5 subsequently located the call light (dangling from the wall) and placed it within R4's reach. The (8/3/17) fall prevention policy states this facility will provide fall prevention assessment, implement interventions to prevent falls as much as possible, and manage post-fall treatment. This facility will achieve these goals through interventions that are implemented based upon the identified risk factors. Reassessment of risk after a fall with modification and/or additional interventions as appropriate.

Based upon observation, interview and record review the facility failed to ensure that (R1 and R5's) fall risk assessments were accurate, failed to implement fall prevention interventions and failed to ensure that supervision was provided to four of five residents (R1, R2, R3, R5) reviewed for falls. These failures resulted in: R1's (7/2/22) fall with mandibular fractures which require surgical intervention & tooth extraction; R3's (6/11/22) facial laceration which required [MEDICATION(S)] repair; and R2's (7/18/22) fall with an 1- inch open area to the head & head/neck pain. Findings include: 1. R1's diagnoses include dementia, weakness, acquired absence of right great toe, acquired absence of other right toes, difficulty in walking, abnormalities of gait/mobility and history of falling. R1's (3/23/22) BIMS (Brief Interview for Mental Status) determined a score of 99 (resident was unable to complete the interview). R1's (4/18/22) functional assessment affirms extensive (1-2 persons physical assist) is required for bed mobility, transfer, dressing, toilet use and personal hygiene. One (1) person physical assist is required for walking. Functional limitation in range of motion (which place resident at risk of injury) includes impairment of lower extremity on one side. Balance during walking is marked not steady. R1's (4/26/22) fall risk assessment determined a score of 7 (moderate risk) however ambulation is marked independent, gait/balance is marked normal and health conditions that predispose resident to be at risk for falls is marked none which are incongruent with aforementioned diagnoses and/or functional assessment. R1's (4/28/22) fall care plan includes the following interventions: anticipate and meet needs, increased supervision when up and keep in engaged supervised activities. R1's (7/2/22) incident report states writer observed swelling on right side of face. Resident unable to give description. Predisposing physiological factors: confused, incontinent. R1's progress notes state (7/2/22) observed swelling to right side of forehead. Doctor was notified received orders to send resident to hospital for evaluation. (7/3/22) Hospital called writer informed that patient has diagnosis of mandible fracture. [R1 did not return to the facility]. R1's (7/3/22) Facial Bones CT (Computed Tomography) includes reason for exam: trauma. Impression: Comminuted and displaced fracture involving the right mandibular body as well as right mandibular molar. Additional non-displaced fracture involving the left mandibular symphysis as above. Regional soft tissue swelling at the site of both fractures right greater than left. On 7/26/22 at 11:57am, surveyor inquired about R1's (7/2/22) incident. V2 (Director of Nursing) stated the nurse (V6/Licensed Practical Nurse) called me and said the CNA (Certified Nursing Assistant) saw swelling on (R1's) face when sitting in the dining room. (V6) assessed (R1) called the doctor and sent (R1) to the hospital. They (staff) called the hospital for an update and said (R1) had a mandible fracture. We interviewed the staff to see if (R1) had any incidents they told me no. When I asked the CNA if he had appropriate footwear she couldn't recall. Staff said he had an unsteady gait because he had amputated toes. We determined that it was a fall. On 7/27/22 at 9:40am, surveyor inquired if R1 walks or is wheelchair bound V8 (CNA) stated He walks by himself however (4/18/22) functional assessment affirms R1 requires 1 - person physical assistance. Surveyor inquired about R1's (7/2/22) facial swelling V8 responded when I went into the dining room to take him to his room (because he was sleeping) his face was really swollen. I brought him to the nurse's station and let the nurse know. Surveyor requested a description of R1's swelling V8 replied It was real, real swollen like real big (on the right side). Surveyor inquired if R1 was able to recall how the injury was incurred V8 stated He really don't communicate. I really don't know what happened, I worked the day before (6:30am-2:30pm) and his face was not like that. R1's (7/3/22) hospital history & physical includes history of present illness: [AGE] year old male presenting after unwitnessed fall. Presents with right mandibular angle fracture and non-displaced left mandibular parasymphysis fracture. Plan: recommend surgical intervention for open reduction internal fixation of right mandibular angle and left mandibular parasymphysis with extraction of tooth #31 and any other necessary teeth. 2. R3's diagnoses include Alzheimer's disease, weakness, age related physical debility, lack of coordination and unsteadiness on feet. The facility incident log affirms R3 fell five (5) times within the past 3 months (5/6/22, 5/20/22, 6/11/22, 6/17/22, 7/20/22). R3's (4/19/22) BIMS determined a score of 99. R3's (6/18/22) functional assessment affirms total dependence (2 - person physical assist) is required for transfers and walking did not occur. R3's (7/20/22) fall care plan includes the following fall prevention interventions: (1/1/22) brand name non-slip device to wheelchair. (5/6/22) Resident to be in common area when up. Staff to make sure resident is in common area when up for increased supervision. (5/20/22) Brand name non-slip device re-applied to wheelchair. (6/17/22) Staff to offer frequent round when in room. R3's (6/11/22) incident report states CNA stated that resident fell forward out of the wheelchair hitting her face on the floor before he could get to her and observed bleeding laceration over right eyebrow. Injury: forehead swelling/laceration. Incident location: Resident's room. R3's (6/11/22) hospital history & physical includes right eyebrow laceration approximately 3 centimeters. Skin closure: glue. On 7/25/22 at 2:55pm, R3 was observed in a wheelchair in her room (near the end of the hallway) propelling herself while unattended by staff. The non-slip device was observed in R3's lap. Surveyor subsequently inquired about R3's fall prevention interventions V3 (Licensed Practical Nurse) entered the room and stated When she's (R3) in the wheelchair we have the wheels locked however R3's wheels were not locked. Surveyor inquired if R3 was ambulatory V3 responded She can stand and she can walk with assist. V3 placed R3's non-slip device on the over bed table and instructed R3 to stand while holding onto her arm (without a gait belt and/or additional assistance). R3 proceeded to move her buttocks forward while leaning on the back of the wheelchair (clearly unable to stand without 2 - person assist). Surveyor inquired where R3's non-slip device was located V3 replied There it go right there (pointing to the over bed table) she done took it out. Surveyor inquired why R3 was unsupervised by staff while in the wheelchair V3 stated Her daughter was here. Surveyor inquired if R3's daughter was still in the facility V3 responded Not now and proceeded to place R3 in the supervised dining area (without the non-slip device on R3's wheelchair). On 7/25/22 at 3:08pm (13 minutes later), R3 was observed propelling herself in the wheelchair (in the hallway) while unattended by staff. 3. R2's diagnoses include dementia, [CONDITION(S)], lack of coordination and abnormalities of gait/mobility. R2's (5/2/22) BIMS determined a score of 99. R2's (5/2/22) functional assessment affirms 1 - person physical assist is required for transfers, walking, and toilet use. R2's (5/2/22) fall care plan includes the following interventions be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. R2's (7/18/22) progress note states writer heard a loud boom. Went into patient's room, noticed resident supine on the floor next to bed. Resident unable to state what happened in English. Noted resident holding back of head. Body assessment done, noted 1 - inch open area to left top head, no bleeding noted. Assisted resident to standing position, resident unable to stand. Placed back in bed. Ambulance called. [R2 did not return to the facility]. On 7/27/22 at 11:12am, surveyor inquired about R2's (7/18/22) fall. V2 stated they (staff) said the patient tried to get out the bed and he (R2) fell . According to the nurse (V9/Licensed Practical Nurse) they (staff) heard a boom, when she (V9) went into the room he (R2) was on the floor and affirmed the fall was unwitnessed. On 7/27/22 at 2:40pm, surveyor inquired about R2's (7/18/22) fall/injury V14 (CNA) stated I was in the middle of doing rounds and I heard a thud. I followed where I heard the noise coming from and found him on the ground. He was sitting on his butt (near the bed), and he was holding his head. As she (V9) looked through his hair she (V9) said it was like a little small gash. He's able to communicate sometimes but you got to kind of guess what he's talking about. He speaks Spanish so there's somewhat of a language barrier. I know a little bit of Spanish and I'm able to communicate the basic things. He was trying to get in the bed, and he fell . I could tell he was having pain by his facial expression, and he was holding his head. R2's (7/18/22) hospital history & physical includes head CT clinical indication: trauma with head and neck pain. 4. R5's diagnoses include dementia, cognitive communication deficit, hypertension, muscle wasting/atrophy, restlessness, agitation, weakness, unsteadiness on feet and abnormalities of gait/mobility. The facility incident report affirms R5 fell on [DATE] and 7/2/22. R5's (5/13/22) BIMS determined a score of 6 (severely impaired cognition). R5's (5/13/22) functional assessment affirms 1 person physical assist is required with transfers and walking. R5's (7/2/22) fall risk assessment (post fall) determined a score of 3 (low risk) however history of falls within the last 3 months is marked no, ambulation is marked independent, and health conditions that predispose resident to be at risk for falls is marked none which are incongruent with aforementioned diagnoses, fall incident(s) and/or functional assessment. R5's (5/13/22) care plan states staff to provide resident with bed in the lowest position and bed mobility positioning devices. Monitor frequently and offer assistance with transfer. R5's (6/24/22) progress notes state resident observed sitting on bedroom floor on buttocks. Resident stated I stood up and sat down on the floor. R5's (7/2/22) incident report states observed resident sitting on the floor next to bed. Resident stated I was sitting on edge of bed and just slid to the floor. On 7/25/22 at 3:07pm, R5 was asleep in bed however the bed was not in low position and positioning devices were not in use. On 7/25/22 at 3:10pm, surveyor inquired about R5's fall prevention interventions V4 (CNA/Certified Nursing Assistant) entered R5's room and stated, I didn't know he fell R6 (Roommate) responded He (R5) was about to fall off the bed on the floor this morning and advised that R5's mattress was coming off of the bed at the time. Surveyor inquired about the height of R5's bed V4 replied It don't look like it's in the lowest, it's not even plugged up. Surveyor inquired if V4 could lower R5's bed V4 replied You can't if you don't see the cord. V5 (CNA) subsequently searched for R5's device to lower the bed and stated It's a cord but it's not plugged in proceeded to plug in the device then lowered the bed. On 7/28/22 at 1:38pm, surveyor inquired about the importance of scoring fall risk assessments properly V15 (Medical Director) stated it's certainly important because we want to prevent as many falls as we can. We definitely want to minimize the falls especially with dementia patients or a weak patient. Surveyor inquired about the importance of following fall prevention interventions V15 responded the importance is that this is an action taken, like this was a problem with a plan put in place. To decrease falls we have to implement it, this is an action taken to correct the problem. Surveyor inquired about potential harm to a resident with dementia that has an unwitnessed fall V15 replied fall will lead to injuries, it could be fractures could be injury to the brain or internal bleeding can happen. They may be on the floor for a longer length of time, they could get rhabdomyolysis leading to dehydration, kidney failure or other things. The main injuries would be fractures, laceration, internal bleeding or external depending where they get hurt. The (8/3/17) fall prevention policy states identify risk factors. Implement individualized approaches/interventions based upon resident risk. Staff should visually check residents to ensure safety, assist with care needs, and prevent unsafe transfers whenever possible. Signs and symptoms of fracture include: swelling.

Based on observation, interview and record review, the facility failed to do a thorough investigation on all falls reviewed, failed to determine the root cause of the falls, failed to do a fall assessment after a fall, failed to monitor and document vitals following a fall and/or failed to ensure fall interventions were in place for dementia residents (R2, R3) who are high risk for falls in order to minimize the risk of injury. In addition the facility failed to follow their fall prevention policies for 3 (R1, R2, R3) of 3 residents reviewed for falls and major injuries in the sample of 6 residents. These failures resulted in R1 and R2 sustaining a head lacerations requiring a hospital visit for sutures. The findings include: On 6/21/22 at 11:30 AM, R3 is in a regular hospital bed that is 18 inches off the floor with one floor mat to the left of R3 and bed. There were bed bolsters on the mattress, but the bolsters were deflated and not correctly fitting the mattress. R3 has an overbed table over her as she sits up at a 45 degree angle in the bed. There is an empty supplement bottle with a straw and a 4 ounce water bottle with a straw. R3 is oriented to self only. At 2:10 PM, R3 is in bed with bed at the same height and bolsters still deflated and not correctly on the mattress. This was pointed out to V7, assigned certified nurse aide/C.N.A. On 6/22/22 at 9:30 AM, 10:28 AM and 12:55 PM, R3 was in the bed, bed is 18 inches from the floor and one floor mat to the left of bed. The bed bolsters were deflated and not on the bed correctly. At 9:30 AM, the deflated bolsters were pointed out to V11 (C.N.A.). At 10:28 AM, the deflated bed bolsters were pointed out to V10 (Restorative Licensed Practical Nurse/L.P.N.) and at 12:55 PM accompanied by V22 (Diet technician), R3's bed bolster were still deflated and not fitting the mattress correctly. R3 is a [AGE] year old dementia resident per the significant minimum data set (MDS) dated [DATE]. R3's cognition/ brief interview mental score (BIMS) is a 5 indicating R3 is orient to self only. R3 requires extensive to total assistance with her activities of daily living, is non-ambulatory and is frequently incontinent of bowel and bladder. R3 was admitted to the facility on [DATE] per face sheet and MDS. R3's admission fall assessment 2/5/22 documents no vision problems yet R3's diagnoses include bilateral [CONDITION(S)] per MDS. The fall assessment score would be 11 due to having impaired vision and not the score of 9. A score of 10 and above is high risk for falls. R3 had a fall on 5/2/22 at 2:27 A.M. which required a hospital visit and 3 sutures to the left scalp per incident report. Facility failed to do another fall assessment after this fall. The facility's incident report documents R3 was found on floor by staff when doing rounds. No one is sure how long R3 was on the floor. The incident report documents it was unwitnessed and the facility failed to do an investigation to determine how and why the fall occurred. There were no staff or resident interviews. The facility's final report documents under conclusion: R3 returned from the hospital with a diagnosis of urinary tract infection along with antibiotic therapy and 3 sutures to left scalp. On 6/23/22 at 8:28 AM, V21 (R3's power of attorney of healthcare) stated she spoke to R3 after the fall. R3 told V21 that the overbed table was removed and she was feeling for it and then fell out of the bed. V21 stated that R3 uses the overbed table to gage how far to go in the bed due to her bilateral [CONDITION(S)]. On 6/21/22 at 4 PM, V1 (administrator) was given 3 names (R1, R2, R3) along with fall incident dates that needed to be reviewed. V1 was told to have all the information together including faxes, emails, interview statements, fall assessments, and recommended fall interventions together when presented tomorrow morning. On 6/22/22 at 9 AM, V1 was reminded about the incident reports. V1 stated that he is waiting on V3 (Assistant Director of Nursing/A.D.O.N.) to come in. V1 stated V3 called to say she would be late. At 11 AM, asked V1 to ask V3 where the reports are so you can get them. V1 responded he did get the reports but there are pages missing. V1 stated he was waiting to get all the papers. At 12:25 PM, V1 gave what papers he had, and other papers were given piece by piece. At 1 PM in V1's office, V1, V3 and V23 (Regional Nurse Consultant) were all present. Asked why the fall investigations have not been thoroughly investigated. V1 stated they were investigated but the documentation has been scattered and difficult to find. V1 stated the undated statement by V24 (L.P.N.) was lost so he called today to get another interview with V24. V23 stated that the facility had V26, a traveling D.O.N working at that time and had to reach out to him for some paperwork. V24's undated statement documents that R3 was found on the floor, half on floor mat and other half of R3 on the bare floor. R3 was bleeding from the head. V24 was not sure what R3 hit her head on but guessed it was the rail of the overbed table. There were no other statements or staff interviews or any attempt to ask R3 what happened. On 6/22/22 at 1 PM, V1 stated the interview was over the phone today due to losing the original documentation. There are no fall care plans on the floor for R1, R2 or R3. On 6/22/22 at 3:40 PM, V10 (Restorative L.P.N.) stated that she does not keep the fall care plans on the floor but in a binder in her office. Asked V10 how is staff to know what fall interventions are to be in place if the care plans are in an office. V10 stated I will bring you the care plan for R2 and presented it. V10 was asked about R3's bed being 18 inches from the floor and if that is safe since R3 had a fall requiring sutures. V10 became defensive and stated she cannot be everywhere. V10 left the room and never returned. Only R2's care plan was presented. On 6/21/22 at 2 PM, R1 stated he had a fall from his bed and sustained a laceration to the back of the head. R1 claims that he reported the fall to V16, (11 PM to 7 AM shift Licensed Practical Nurse/LPN) and she did nothing. R1 stated it was V25 (LPN) who assessed him and sent him out to the hospital to get several sutures. R1 stated he fell from the bed due to the bed wheels' lock not holding. R1 showed how the bed moves even with the lock on wheels. R1 stated the facility presented device to put under the wheels to prevent bed from moving but R1 says he can't lift the bed to put the device back into place when it dislodges. V25's (L.P.N.) nurses note 5/15/22 documents R1 walking by V25 as she was passing medications. Asked R1 to take his meds and R1 responded he was not going to take them because he fell last night between 4 AM to 5 AM. V25 assesses R1 and finds a 2 inch laceration with dried blood on the back of his head. R1 was sent out 911. V25's written statement concurs with nurses' note. Review of the facility's incident report 5/15/22 lacks interviews and how R1 sustained the laceration falling out of bed. The fall care plan was not available due to V10 keeping the care plans in her office. V10 never presented the care plan when requested. The incident report documents finding R1 on the floor near the bed with laceration to the back of the head. This contradicts V25's progress note and written statement. On 6/22/22 at 2 PM in V1's office, V1, V3 and V23 (Regional Nurse Consultant) were all present. V23 stated at the time of R1's fall, the facility was using V25 (Regional Traveling Director of Nursing) who conducted the investigation. R1 is a [AGE] year old with diagnoses that include [CONDITION(S)], mental disorder and injury to lower back per the quarterly MDS 6/3/22. R1 requires limited assistance to supervision for his activities of daily living. R1 is assessed to have a BIMS of 15 indicating oriented times person, place and time. There was no documentation seen on monitoring R1 for 72 hours after a fall involving R1's head. There is only documentation seen for 5/16/22. Both R1 and R3 lacked documentation of their physical and mental status for each shift following the incident for a minimum of 72 hours. R2 is an [AGE] year old with a BIMS of 9 which indicates R2 is still able to be interviewed per the significant MDS 4/15/22. R2 suffers from delusions and requires total to extensive assistance with her activities of daily living. R2 is non-ambulatory and requires the use of a wheelchair and is frequently incontinent of bowel and bladder. R2 has had 3 falls in the facility with no injuries. The falls were on 3/30/22 at 5 am, 5/25/22 at 4:33 PM and on 6/8/22 at 7:58 PM. The fall assessments dated 4/29/21 documents high risk for falls, 3/30/22 documents high risk for falls but the assessment is inaccurate in regards to R2's vision. R2 is blind in one eye and has bilateral [CONDITION(S)]. The assessment documents adequate vision. Another fall assessment done on 6/6/22 documents high risk. The 3/30/22 fall investigation documents it was unwitnessed and R2 found on the floor with no injuries but no investigation as to how the fall occurred. The forms for documenting the fall were blank especially under the PREDISPOSING SITUATION FACTORS such as bed alarm, low bed, locked bed wheels, etc. The intervention for this fall is to ensure all personal items are within reach. The 5/25/22 fall investigation documents fall is unwitnessed. R2 is found on floor next to her bed. R2 stated that she had been on the floor for some time. There was no investigation as to when R2 was last observed and no staff statement from assigned CNA. The rest of the incident report is blank and incomplete. The recommendation is to exchange R2's bed for a low bed. The nurses note 5/26/22 documents the hospice being contacted and asking them to order a low bed and floor mat. There is no documentation when bed and floor mat were implemented. The 6/6/22 fall is finding R2 on the floor mat with her pillow and blanket. The incident report is incomplete and there is no root cause as to why R2 is getting out of bed. The facility's policy labeled ACCIDENT INCIDENT REPORTING POLICY documents the purpose is to ensure that accidents and incidents that occur with residents are identified, reported, investigated and resolved. To provide data base to study the cause of the accidents/incidents and to provide assistance in implementing corrective actions to prevent re-occurrence when possible. Under procedures: when possible, a descriptive statement may be obtained from resident or any witnesses. Utilize the witness statement form. (This form was not seen in any of the investigations reviewed.) The report is to be completed as fully as possible before the nurse ends the shift. A description of the circumstances surrounding the incident/accident may be provided. Only facts may be documented not conjecture. Documentation of the resident's physical and mental status may be completed each shift following the incident for minimum of 72 hours or until the condition symptoms improve. Neurochecks may be completed as indicated. The occurrence is to be communicated shift to shift as part of the unit report until resident is stabilized. A more extensive investigation procedure is required for the following occurrences: Fall with significant injury. The resident care plan is revised as necessary to prevent or minimize further accidents/incidents when possible. This policy was not followed. The facility's policy labeled POST FALL MANAGEMENT PROTOCOL documents under section III of Accident/Incident Report and Investigation : to complete risk management after each fall which includes predisposing environmental factors, predisposing psychological factors, predisposing situational factors and witnesses. Under the section for Investigation of the Fall : interview resident, staff and others as appropriate. And analysis of the findings. Fall risk and care plan are reviewed and updated. Review interventions to prevent falls. This policy was not followed.

Based on observation, interview and record review, the facility failed to provide incontinence care to dependent residents in a timely manner resulting in residents being allowed to lay in their urine and feces for several hours and the staff being found in offices and common bathrooms instead of performing their duties and/or watching their cell phones at the nurses' station on the floor for 2 residents (R2, R3) of 2 residents reviewed for incontinence care in the sample of 6 residents. This failure resulted in R2's backside developing 3 small (quarter inch in size) open areas from laying in a disposable brief for an extensive period of time. The findings include: On 6/21/22 at 11:30 AM, in R2's room, V6 (hospice certified nurse aide/C.N.A.) was providing incontinence and personal care to R2. V6 stated she works and cares for R2 every Tuesday and Thursday. V6 stated that R2 recalls V6 from last Thursday. V6 stated when she comes in on her assigned Tuesday and Thursday mornings, R2 is always found saturated with urine and feces all over her body. V6 pointed to the soiled linen and soiled disposable brief on the floor. V6 stated the disposable brief was heavily saturated and soiled with feces and brown discolored urine stains. The ammonia smell from the urine was so bad that V6 and surveyor's eyes were burning from the ammonia smell. V6 stated the soiled disposable brief weighs about 7 pounds. The linen, hospital gown and bed pad were saturated and smelling of ammonia. R2 stated no one changes her during the night. V6 pointed to 3 red openings on R2's backside and stated it is from R2 laying in a saturated disposable brief for long periods of time. V6 stated the 3 red openings were not there on Thursday. On 6/21/22 at 1:45 PM, V8 (restorative certified nurse aide/ C.N.A.) and V4 (Licensed Practical Nurse/L.P.N.) were asked about any open areas on R2. V8 stated R2 has one wound on the outer aspect of her leg. V4 confirmed that the wound is vascular. There was no wound seen on R2's legs. V4 stated that R2's skin is checked on her shower days, Wednesday and Friday evenings. On 6/21/22 at 11:40 AM, in R3's room with V7 (C.N.A.) who stated it is her first day of work. V7 stated she is an orientee and has no idea who is to be training and assisting her. V7 stated R3 was changed this morning and it was not too bad. Asked if disposable brief was stained with dark yellow urine discoloration, V7 stated yes. On 6/22/22 at 9:30 AM, V11 (C.N.A.) stated R3 has no skin breakdown. At 1 PM, V11 stated he changed R3's brief around 9:45 to 10 AM. V11 stated when he removed R3's brief it was heavily soiled and weighed about 6.5 pounds. V11 stated that he understood there was no night shift C.N.A. on the floor. Informed V1 (Administrator) of what V11 stated and V1 stated he would look into it. An answer was never provided. At 4:30 PM, V1 stated that V17 (scheduler) is being demoted from the position. V1 stated he is given the planned staff schedule but never given the actual worked schedule. On 6/22/22 at 2:48 PM, V17 stated he has been doing the staff schedule for 5 months. V17 provided a staff schedule with check marks by staff's names. V17 stated the receptionist will check staff members' names as they come in the front door. Asked V17 how does he know which staff members are going to which floor if staff do not initial by their name that they are on this floor. Asked V17 for a scheduling policy. V17 stated there is no policy for scheduling. The staffing V17 provided for 6/21/22 was inaccurate. It documents 4 CNAs names but lacks V7's name. Informed V17 that there were 3 C.N.A. on the floor per V4 (L.P.N.) and V5 (Registered Nurse/R.N.). They were V7, V9 (Agency C.N.A.) and another C.N.A. who was never identified or seen. The staffing reflected nurses V5 and V27 on the 3rd floor for 7 AM to 3 PM shift. Informed V17 that it was V5 and V4 that were the nurses on the floor. The 6/22/22 schedule for 7 to 3 shift nurses was inaccurate for the 3rd floor. Scheduled is V5 and V28 (nurse) but V5 and V29 (agency L.P.N.) were the nurse seen on the 3rd floor. During rounds on 6/21/22 between 11:30 AM to 12:05 PM on the 3rd floor, V8 (Restorative CNA) was found in the common bathroom. Asked what he was doing, V8 responded getting a tissue. There was no tissue in his hands. Later during the noon meal, V8 was to feed R2 for restorative eating. At 1:45 PM, V8 stated he forgot to feed R2. On 6/22/22 at 12:55 PM, accompanied by V22 (Dietary Technician), upon exiting the elevator, both V29 (Agency L.P.N.) and V5 (Registered Nurse) were sitting at the 3rd floor nurses' station watching a cell phone. Asked what they were doing, V29 stated they are watching a gospel show. Asked them if they are on break and both had no response. Looking for V8 (restorative C.N.A.) during the noon meal, V8 was not out on the floor assisting with meals. V8 was found in the restorative office with V10 (restorative L.P.N.). Asked what he was doing, V8 responds what do you mean? Informed V8 that it is lunch time and is he not supposed to assist with meals? V8 had no response and left the room. Review of the facility's grievances show many complaints about the lack of care provided to the residents. V21 (R2's niece) complained on 3/25/22, 5/25/22 and 6/16/22 about the lack of linens and supplies (gowns, towels, flat sheets), poor grooming, bathing and hygiene and the room smelling. V21 documented that staff informed her that were no linens available. There were other complaints from R8 (dated 1/18/22 1/19/22), R9 (same dates as R8), R10 (date 4/1/22), R11 (1/17/22), R12 (1/17/22), R13 (1/18/22) and R14 (1/11/22) about the lack of care, leaving resident in wheelchair overnight, no staff to provide care and medications not being provided. R10 through R14 are no longer residents. There are too numerous of complaints to document from other residents and family members complaining about the lack of care. The policy labeled INCONTINENCE/CONTINENCE ASSESSMENT documents if resident is and determined to have total true incontinence related to dementia with the loss of susception for need to void, resident is not a candidate for incontinence management program. Implementation of an appropriate incontinence product will be indicated on resident's care plan. R2's care plan (4/15/22) and R3's care plan (4/27/22) for incontinence care documents to toilet resident at regular intervals throughout the day at a minimum of 2 to 3 hours and to record on unit tracking log. The care plans do not address the type of incontinent product to be used. R3 does have a history of urinary tract infection per the 5/2/22 fall incident. Both have care plans on skin integrity due to incontinence.

Based on observation, interview and record review, the facility failed to ensure all residents are receiving all their planned meals and the required assistance for feeding, failed to determine the root cause of significant weight loss and failed to follow their nutritional and weight policies for 2 (R2, R3) of 3 residents reviewed for weight loss and feeding assistance in the sample of 6 residents. These failures resulted in R2 and R3 having significant weight loss due to inadequate oral intake and then placed on hospice due the significant weight loss. The findings include: On 6/21/22 at 1:40 PM, R2 stated she did not have lunch as R2 laid in the bed. R2's noon meal was found on the dietary cart, untouched. At 1:45 PM, V8 (Restorative Aide) stated he usually feeds R2 because R2 is on the restorative list for eating. V8 stated he fed R2 her breakfast but forgot to feed her the noon meal. V8 stated that R2 ate 40% of her breakfast which consisted of coffee, juice and one egg. Asked V8 if 40% is accurate statement since R2 ate one egg? V8 had no response. V8 stated he does not document the amount of food that is consumed by R2. V8 stated he verbally tells the nurses the amount. V8 stated he understands R2 is to be fed all her meals. A grilled cheese sandwich was sent up on disposable plate along with a juice cup. There were no utensils, napkins, condiments or cup provided to R2. V8 was present in R2's room and agreed utensils and cup should have been provided. On 6/22/22 at 1:06 PM, in R2's room, there were 2 trays of food and V11 (Certified Nurse Aide/C.N.A.) was asking R2 to eat. R2 refused and when she heard the name of the oral supplement, R2 stated she would take that. Asked V11 about V8, the restorative aide who is the one responsible to feed R2. V11 stated not to know where V8 is now. At 1:12 PM, V8 was found in the restorative office with V10 (Restorative Licensed Practical Nurse/L.P.N.). Asked V8 what he was doing? V10 had a bewildered look and stated, what do you mean? Informed it is lunch time and trays are on the floor and is it not his responsibility to feed R2. V8 had no response. Review of R2's weights document her weight to be 86.8 pounds (#) on 6/9/22. R2's weight was 92.8 # on 5/9/22, 96.8 # on 4/14/22, 93.6 # on 3/31/22, 91.6 # on 3/25/22 and 88.4 # on 3/17/22. R2's weight stays in the 80's fluctuating between 80.6 # to 88 # from March to January of 2022. On 12/8/21, R2's weight was 91.8 #. R2 is 62 inches tall, and her ideal body weight is between 131 # to 159 #. R2 has been a resident in this facility since 10/27/20 per the minimum data sets (MDS). Review of V19's (Registered Dietician) progress notes 5/30/22 and 4/29/22 addresses the significant weight fluctuations. The 6/17/22 dietary assessment documents the weight loss reverses the previous weight gain resulting in significant weight changes of 5% in 30 days, 7.5% in 90 days and 10% in 180 days. The 5/30/22 assessments documents R2 being placed on hospice on 4/14/22. On 6/21/22 at 11:30 AM, V7 (CNA) stated she is assigned to R3. V7 stated this is her first day on the floor and is an orientee. Asked where her trainer was, V7 stated she does not know. Later at 2:10 PM at the 3rd floor nurses' station, asking nurses (V4, V5) who is assigned to R3 and who is training V7? No one knew at first then stated it is V9 (Agency CNA). Asked where V9 is? No one knew and then V9 popped up. Asked V9 how often she works this floor, V9 stated a couple of times only. Asked V9 how she knows which residents need assistance, V9 responded, Only knows what the nurses tell her. If she is not told, it does not get done. Turned to nurses V4 and V5 and asked both of them if it makes any sense to have an agency aide training an orientee. Neither responded. Asked about R3's meal intake, V9 stated she fed R3, and she ate 50% after struggling to remember who is R3. On 6/22/22 at 9:30 AM, V11 (C.N.A.) stated he is the usual CNA assigned to R2 and R3 and works a couple of days a week. V11 stated R3 can feed herself but requires set-up. V11 stated R3 ate 100% her breakfast. At 12:45 PM, V11 gave R3 her pureed food which was not a pudding consistency but thinning and spreading on the disposable plate along with plasticware and disposable 6 ounce cup of lemonade. V11 handed R3 the plastic fork and R3 took one bite and said yuck. R3 asked for her ice cream. V11 removed a cup of prepared ice cream (which was from an outside vendor) from R3's refrigerator and gave it to R3 along with plastic spoon. R3 enjoyed eating the ice cream. V11 stated that V21 (R3's family member) provides the ice cream, pudding and apple sauce due to R3 not liking the facility's food. Review of R3's weights document 114 # when admitted to the facility on [DATE]. On 3/8/22, R3's weight was 115.8 #, on 3/17/22 it was 122.2 #, on 3/25/22 the weight is 119.2 # . There was no April '22 weight. On 5/12/22, R3's weight is down to 98.2 #. Then on 6/9/22, R3's weight is up to 101.6 #. R3 is 62 inches tall. Review of V22's (Dietary Technician) dietary admission assessment dated [DATE] documents malnourished. The next dietary assessment is dated 4/25/22 and V22 documents the March weight of 119 # because there is no April weight. V19's (Registered Dietician/R.D.) dietary assessment dated [DATE] documents significant weight gain with 5 % in 30 days and 7.5 % in 90 days. V19's recommendations is to provide double portions protein/meat all meals, a supplement shake daily, weekly weights and NAR (Nutrition At Risk) review. Staff to feed and assist with all meals, monitor oral intake, weights, labs and skin. V19's assessment dated [DATE] documents the significant weight loss of 7.5 % in 90 days and 10 % in 180 days. V19 documents R3 being put on hospice care. The June '22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .S.) documents R3 was put on hospice on 5/24/22. Review of R2's and R3's meal intake in the electronic medical record shows no documentation as V8 had stated earlier. In addition, both R2 and R3 have vision problems and require assistance per significant MDS dated [DATE] and 4/27/22, respectively. R2 is blind in one eye per MDS. Review of R2's and R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 is to receive Ensure 4 times a day, 0900, 1300, 1700, 2100 per physician order. R2 did not receive her 1700 and 2100 shake on 1st, 2nd, 3rd, 4th, 7th, 11th, 12th, 17th, 18th and 21st. The 2100 shake not provided on the 6th and 20th and the 0900 and 1300 shakes not provided on the 19th. R3's order is 1 can of Glucerna three times a day. R3 did not receive her 1700 and 2100 supplement for June 1st, 2nd, 3rd, 4th, 7th, 11th, 12th, 17th, 18th and 21st of 2022. No documented explanation. Nor are the missed supplemental shakes documented in any dietary progress note which would contribute to the weight loss. On 6/22/22 at 12:35 PM, V22 (Diet Technician) stated she questions the accuracy of the weights. V22 stated the weights going up and then to suddenly go down makes no sense. V22 stated the facility has had problems with having consistency with staff taking and recording the weights, inaccurate scales that were not calibrated and no consistency with staff taking weights. V22 stated the facility is aware and is trying to resolve the issues but it has been a struggle. On 6/23/22 at 8:28 AM, V21 (R2's and R3's power of attorney for healthcare) stated that the reason both R2 and R3 were placed on hospice is due to the significant weight loss which was discussed in the care plan meetings. On 6/23/22 at 9:04 AM, V19 (R.D.) stated that inadequate oral intake would definitely impact the weight loss. V19 stated she was in the facility and asking the nurses about resident's weight loss in which no one could give her any information as to why the weight loss is happening. V19 stated that this really frustrated her so much she was shouting at the nurses. V19 stated she was unaware of the missed supplements for June '22. V19 stated that both R2 and R3 were placed on hospice due to significant weight loss. The facility's policy labeled NUTRITION AT RISK (NAR) documents the facility will have a systematic interdisciplinary effort to identify, track, intervene and monitor residents that are at high risk for weight loss and dehydration. The facility's policy labeled CLINICAL NUTRITION DOCUMENTATION documents the facility will have a systemic and interdisciplinary approach for obtaining and monitoring weights. The facility will designate a trained staff member to obtain all weights. Weights will be obtained upon admission, readmission to facility, then weekly for 4 weeks and then monthly unless otherwise ordered. Monthly weights are to be obtained no later than the 5th of each month with re-weights obtained by the 7th. Nursing will notify the dietician or designee of any significant weight changes. Significant weight change is defined as: 5 % in 1 month, 7.5 % in 3 months and 10 % in 6 months. Significant weight change refers to percentage of body weight not related to an explainable event such as, resolution of [CONDITION(S)], etc. A reweigh will be obtained and recorded for all significant weight changes. The facility designee will record the method used to obtain the weight and any adaptive devices weighed, record the weights and any re-weights in the electronic medical record.

Based on observation, interview and record review, the facility failed to ensure [CONDITION(S)] medications were administered per physician orders for one (R1) of 3 residents reviewed for [CONDITION(S)] medications. This failure resulted to R1 exhibiting withdrawal symptoms such as agitation and crying. Findings include: On 03/24/22 at 10:00 AM, V25 (R1's Power of Attorney) who is also her (R1) sister, stated that R1 was prescribed [MEDICATION(S)] from 2019 onwards and then discontinued on 3/3/2022. The facility psychiatrist then ordered [MEDICATION(S)] as an alternative. V25 stated that she (V25) didn't give consent for [MEDICATION(S)] and wanted to talk to the physician, but no physician called her back. V25 stated, R1 did not receive any [MEDICATION(S)] or [MEDICATION(S)] for 2 weeks. V25 stated that R1 received her next [MEDICATION(S)] on 3/19/2022. V25 also stated that she (V25) visited R1 on 3/16/2022 and she saw R1 had thrown up on her clothes and was crying. R1 stated that the CNA told her that R1 has been crying for past three days and she (R1) started throwing up. That very day, she scheduled an appointment with her psychiatrist at an outside clinic. R1 left for the appointment with V19, Certified Nursing Assistant/CNA. On 03/24/2022 V2 (Director of Nursing) stated she (V2) is unsure why R1's [MEDICATION(S)] was discontinued without anything to replace it. V2 stated the nurse who signed off on the doctor's discontinue order did not follow and make sure another medication other than [MEDICATION(S)] was ordered. That nurse does not work at the facility anymore. V2 stated that it was not right R1 was off of her [MEDICATION(S)] for two weeks without any alternative therapy because she could have withdrawal symptoms. On 03/24/2022 at 03:15 PM, V20 (Psychiatrist) stated [MEDICATION(S)] is a benzodiazepine. Depending on the dose if you stop benzodiazepine abruptly you could have withdrawal symptoms. V20 also stated no one from the facility failed to mention to her (V20) that V25 refused the [MEDICATION(S)] for R1. When V19 (Certified Nursing Assistant) took R1 to her (R1) appointment on 3/16/22, V19 stated that R1 was tearful and agitated in the ambulance. On 03/24/2022 at 2:00 PM, V21 (Primary Care Physician) stated that being off of her (R1) [MEDICATION(S)] for two weeks can probably lead to withdrawal symptoms such as agitation and crying depending on the dose. R1's physician orders documents in part: [MEDICATION(S)] Tablet 0.5 MG ([MEDICATION(S)]) Give 0.5 mg by mouth two times a day for agitation; start date 12/29/2019, discontinue date 3/3/2022. [MEDICATION(S)] Tablet 0.5 MG ([MEDICATION(S)]) Give 0.5 mg by mouth two times a day for agitation; start date 3/19/2022 17:00; revision date 3/19/2022. [MEDICATION(S)] HCl Tablet 5 MG Give 1 tablet by mouth two times a day for anxiety; start date 3/7/2022 17:00; Discontinue 3/7/2022. Reviewed R1's Medication Administration Record. No [MEDICATION(S)] and [MEDICATION(S)] nor any other medication for agitation/anxiety was administered from 3/3/22 to 3/19/22. R1's medical diagnosis list documents in part: [CONDITION(S)], unspecified. Facility's [CONDITION(S)] Drug Usage Policy documents in part: Dosage reduction of antipsychotics, anxiolytics, and hypnotics are attempted per CMS guidelines unless clinically contraindicated. The Physician weights the risk versus the benefits and documents it in the medical record. If the gradual dose reduction is causing an adverse effect on the resident or is deemed a failure, the gradual dose reduction is discontinued. Documentation of this decision and the reason for it are included in the clinical record. Dosage reduction is contraindicated for residents with severe mental illness such as but not limited to [CONDITION(S)], [CONDITION(S)], and mental illness with psychotic features. Dosage reductions are not attempted for residents that have a history of recurrence of psychotic features which have been stabilized with a maintenance dose of a [CONDITION(S)] medication without incurring a significant side effect. Facility's Behavioral Management Program documents in part: Acceptable diagnosis: 1. [CONDITION(S)]. The committee will continue to routinely review the resident as long as the resident continues to receive antipsychotic medications. The committee will recommend that initiation when applicable or a gradual dose reduction unless clinically contraindicated in an effort to maintain the resident at the lowest possible dose or to discontinue the medication. Clinically contraindicated means that the resident need not undergo a GDR if: the resident has a specific condition (diagnosis #1-10 above) which has been stabilized with antipsychotic medications without significant side effects. Facility's Medication Administration Policy documents in part: Procedure: Prior to administering medications, review the resident's Medication Administration Record. Read each order entirely. If there is any discrepancy notify physician.

Based on interviews and record review the facility failed to monitor, supervise and prevent a cognitively impaired and total care dependent resident (R1) from serious injury. This failure resulted in R1 obtaining subdural bruising and bleeding with multiple serious traumatic injuries resulting in neck fractures and hospitalization . This failure affects one of four residents (R1) in a total sample of fourteen residents. Findings include: R1 is an [AGE] year old female resident. R1's diagnoses are, but not limited to: heart failure, kidney disease, [CONDITION(S)], [CONDITION(S)], lung disorders, major depressive disorder, anxiety disorder, [CONDITION(S)], dysphagia and dementia. Physician order statement (POS) notes R1 is taking a blood thinner. Minimum data set (MDS) dated [DATE], notes that R1's mental status is impaired. MDS also notes R1 requires extensive two person assistance with transferring and walking. Care plan dated 9/14/2021, notes R1 is a high risk for falls related to: history of falls, cognitive impairments, decreased safety awareness, unable to use the call light or request staff assistance, requires ADL (activities of daily living) assistance for transfers and mobility, incontinence, decreased strength and endurance, use of anti-[CONDITION(S)] meds and dementia. R1's care plan dated 9/14/2021, notes staff need to anticipate and meet R1s needs and has the potential for abnormal bleeding due to the daily use of a blood thinner. Care plan intervention dated 10/7/2021, notes to keep R1 in a common area. Care plan intervention dated 12/10/2021, notes R1 requires frequent rounding. Fall incident report dated 12/8/2021, notes R1 was found by a night nurse on the floor lying on R1's right side in R1's room. The report also notes that R1 is impulsive, incontinent, has impaired memory and is agitated and anxious. Fall incident report dated 12/10/2021, notes R1 was observed laying on the floor on R1's right side. R1 attempted to get out of bed without assistance. R1 was unable to give a description of what happened. Upon assessment R1 was noted with a raised area and discoloration to the right side of R1's forehead. Fall incident report also notes R1 is forgetful, has a gait imbalance, impaired memory and confusion. Progress note dated 10/5/2021, notes staff witnessed R1 scooting out of bed. Progress note dated 10/8/2021, notes R1 was very anxious attempting to get out of bed using the side rail to move to the edge of the bed. Progress note dated 10/9/2021, notes R1 using both hands on side rail scooting toward the edge of the bed. Progress note dated 10/11/2021, notes R1 pulling on side rails of bed, pulling legs out of bed. Progress note dated 10/11/2021, notes R1 is experiencing anxious behaviors and making attempts to get out of bed independently. Due to R1's dementia diagnosis education is not successful. Staff has been educated when R1 appears anxious, R1 should be kept at the nursing station for close supervision. R1 will also be placed on a low bed. Progress note dated 10/13/2021, notes R1 with both legs dangling from bed trying to get out of bed. Progress note dated 12/9/2021, notes R1 sent to local hospital for evaluation of red raised area at the top center area of forehead secondary to fall on 12/8/2021. Progress note dated 12/10/2021, notes R1 returned to facility. Upon making rounds R1 observed lying on right side next to bed. R1 had a raised area with discoloration to right side of head. Progress note dated 12/11/2021, notes R1 has multiple large red swellings on R1's face from falls. Progress note dated 12/12/2021, notes R1 has bruising to the forehead, R1 sent to local hospital for evaluation. Progress note dated 12/13/2021, notes R1 was admitted to local hospital for subdural bleeding. Medical record dated 12/09/2021, notes in part: R1 arrived via 911 with complaint of unwitnessed fall at 11:00PM on 12/8/21. R1's head had bruising. R1 has large right subdural swelling and bleeding and extensive right frontal lateral scalp bruising. R1 has neck fractures. On 1/5/2022, at 3:26PM, V18 (Licensed Practical Nurse) stated, a CNA (Certified Nursing Assistant) found R1 on the floor and reported it to V18. We did a full body assessment and put R1 back in bed. No bruises or injuries were observed at that time. No one saw the fall. R1 had a history of falls. Interventions included: bed in low position, frequent rounds, pad on the floor, and stay up later. Typically, staff leave them (fallers) up later and close to the nursing station. R1 is a high fall risk. I was in-serviced on fall precautions. R1 was totally dependent, could not walk or feed self. We fed R1 and crushed R1's medications. On 1/6/2022, at 11:28AM, V2 (Director of Nursing) stated, the root cause, after speaking to the nurse and observing the environment, R1 turned to R1's right side and fell out of the bed. Staff did an assessment. R1's cognitive status was poor. R1 was not very alert. R1 was confused and demented. R1 fell from bed. R1's fall interventions included; bed in low position and frequent rounding. The nurse said they just left out of the room, heard R1 fall, then went back into the room. The nurse noted a bruise on R1's head. The following day or two, the nurse noted hematoma was larger. The nurse called the doctor and R1 was sent to a local hospital. The emergency room did brain scan that discovered a subdural bleed. R1's care plan noted to keep R1 in the common area to keep an eye on R1. Also, to keep R1 close to the nurse's station for visibility. On 1/6/2022, at 12:35PM, V20 (Medical Doctor) stated, A subdural hematoma is something that can result from falls, injuries and trauma. Residents have to be careful with taking anticoagulants (blood thinners) and falls; there is a high risk for bleeding. If the resident is on anticoagulants and there is a trauma, then that is reason to send the resident out to the emergency room . On 1/6/2022, at 1:23PM, V21 (Nurse Practitioner) stated, R1 was being treated for dementia, cardiac, and kidney disease. The anticoagulants were being used as a preventive measure due to the cardiac issues. In general, anticoagulants with a fall/trauma could cause bruising, bleeding. Generally, if R1 hit R1's head, dependent on duration and dose of the anticoagulant, could cause hematoma. On 1/6/2022, at 1:38PM, V22 (Medical Doctor) stated, R1 had a fall, went to the emergency room , came back to the facility and fell in the morning. After the second fall, I was in the facility and assessed R1. I told the nurse to send R1 out to the emergency room . The nurse said R1 just came back from the emergency room . I will keep an eye on R1 and see if there is change in condition. The nurse said I will do an x-ray of the skull. I told the nurse that the x-ray will not tell what is going on inside the brain. I told the nurse to do neuro checks and if there is a change in condition, send R1 to the emergency room . On 1/6/2022, at 6:24PM, V24 (Licensed Practical Nurse) stated, The paramedics brought R1 into the room and put R1 in bed. I was in the hallway. I went to the nursing station to sign paperwork with the paramedics. I was away from R1's room for approximately 10 minutes. I went back to the room and saw R1 on the floor, laying on the right side, face touching the floor. R1 was put back in bed. I assessed R1 and took vitals. I called the doctor who ordered a skull x-ray, I started neuro checks. R1 did not complain of pain. This happened in the middle of the night, not sure of the exact time. My shift was 10:30PM-6:30AM. R1 was calm, relaxed, alert, and was talking. R1 is a fall risk. Interventions included low bed and floor mats. The interventions were not in place. Bed was not all the way down and the mats were not in place. Yes, I was aware of the interventions. I was waiting for the paramedics to put R1 in bed and to sign the paperwork. On 1/6/2022, at 6:46PM, V25 (Licensed Practical Nurse) stated, R1 is a fall risk. R1 is sometimes agitated, anxious and confused. R1 needs supervision. On 1/7/2022, at 11:56AM, V27 (Certified Nursing Assistant) stated, I cared for R1 a couple times. R1 is a total dependent, R1 couldn't assist in R1's care. R1 could try to turn to either side. R1 was a feeder. R1 was a fall risk. I have not been in-serviced on fall risks. R1 needed supervision. On 1/7/2022, at 12:18PM, V28 (Licensed Practical Nurse) stated, R1 is a fall risk. R1's bed should be in low position and keep R1 visible as much as possible. There should be written interventions to follow. The common area means to have residents near the nursing station or dining room to keep watch over them. R1 liked to scoot out of the bed. R1 needed supervision.

Based on observation, interview and record review the facility failed to follow physician orders, failed to ensure that prescribed pain medication was available, and failed to address pain for one of four residents (R4) reviewed for pain. These failures resulted in R4's pain rated 9 on a scale of 1-10. Findings include: R4's (9/21/21) BIMS (Brief Interview for Mental Status) determined a score of 13, indicating intact cognition. On 11/8/21 at 1:51pm, R4's incontinence brief was inspected by V3 (Licensed Practical Nurse/LPN) as requested. R4 moaned and stated, That hurts while being turned. V3 failed to assess R4's pain. R4's (11/3/21) POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/8/21 at 2:05pm, a 12mcg [MEDICATION(S)] patch was observed on R4's right arm. Surveyor inquired about the location of R4's pain. R4 stated, My hips and legs. Surveyor asked R4 to rate R4's current pain level on a scale of one to ten. R4 responded, Its 9 right now. Surveyor inquired about pain medication availability. R4 stated, Sometimes they are out of it. R4's controlled-substance records document that [MEDICATION(S)] (12mcg) patches were signed out on 11/3/21 and 11/6/21, however a 40mcg patch is prescribed. On 11/9/21 at 9:17am, V2 (Director of Nursing) presented R4's pain medication delivery manifest. [MEDICATION(S)] 40mcg was not included. Surveyor inquired if R4's [MEDICATION(S)] 40mcg patches were received by the facility. V2 responded, No. R4's [MEDICATION(S)] 40mcg orders were received 6 days prior. On 11/9/21 at 1:02pm, surveyor asked R4 to rate R4's pain level. R4 responded, It's a 9. On 11/9/21 at 1:28pm, surveyor inquired why staff documented in the MAR (Medication Administration Record) on 11/3/21 and 11/6/21 that R4 received 40mcg of [MEDICATION(S)] (which was unavailable) and 12mcg patches were signed out. V2 responded, I can't tell you and confirmed that she was unaware. On 11/10/21 at 10:55am, surveyor requested R4's current pain level. R4 stated, It's an 8. On 11/10/21 at 10:58am, surveyor inquired about R4's pain. V7 (LPN) stated, R4's pain is about a 7. I gave the [MEDICATION(S)] at 9:30. I told him I'll be back to check on him at 11:30. Surveyor stated that R4's pain level was rated 9 for the past 2 days, is currently rated 8 and inquired if the physician was notified of the uncontrolled pain, V7 responded, No, not yet. On 11/10/21 at 11:13am, surveyor inquired about R4. V8 (Hospice Nurse) stated, R4 has ankylosing spondylitis which causes a lot of pain. Our goal of care is to keep him comfortable. Surveyor inquired about R4's pain. V8 responded, R4 did state that he wanted to die because he's in so much pain. On 11/23/21 at 9:49am, surveyor inquired about managing pain with [MEDICATION(S)] patches. V20 (Medical Director) stated, The transdermal takes a little while because it's a slow release medicine. It may be 3 to 4 days before they take effect. Surveyor inquired about potential harm to R4 if pain medication orders were not followed. V20 stated, Harm is if the pain would not be better. The (undated) Management of Pain policy states pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does. The Nurse will complete a physical evaluation of the resident that includes an objective observation of the painful area. Document of the MAR (Medication Administration Record)/pain flow sheet the effectiveness of pain medication. Effectiveness should be measured 1-2 hours after administration. The (undated) Ten Rights for Administration of Medications includes the right dose: verify against the MAR.

Based on observation, interview and record review the facility failed to ensure that all pressure ulcers are on the weekly pressure ulcer report, failed to ensure that wound care staff stage wounds appropriately, failed to obtain appropriate treatment orders and failed to implement preventive interventions for one of three residents (R4) reviewed for pressure ulcers These failures resulted in R4 sustaining a stage 4 right shoulder pressure ulcer which required surgical intervention. Findings include: R4's wound assessments include a right shoulder skin tear (identified 9/6/21) measuring 3.5 x 3.0 x 0.1cm (centimeters). R4's (9/7/21) physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/23/21 at 9:59am, surveyor relayed concerns regarding Santyl orders received for R4's skin tear. V20 (Medical Director) stated, A skin tear is superficial, so we need wet to dry dressing. I don't think it needed debridement. The (9/21/21) functional assessment documents that R4 requires extensive (one person physical assist) with bed mobility. R4's (9/21/21) BIMS (Brief Interview for Mental Status) determined a score of 13, indicating intact cognition. On 11/8/21 at 1:51pm, R4 was observed lying on his back in a fetal position due to severely contracted lower extremities. No repositioning devices were observed in place. R4's upper extremities appeared weak, as R4 had difficulty pulling the string to activate the call light. R4 stated that he lies in bed all day due to bent up legs and confirmed he requires staff assistance with turning and repositioning. On 11/9/21 at 12:58pm, surveyor inquired about R4's right shoulder wound. V6 (Wound Care Coordinator) stated, R4 has a tear that declined. Review of the 11/4/21 pressure ulcer report did not include R4. R4's 11/2/21 (Initial) physician wound evaluation includes: (stage 4) pressure wound of the right shoulder full thickness 6 x 4 x 1cm. The wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of a biofilm (a thin, slimy film of bacteria that adheres to a surface). Surgical debridement was performed today on this wound. Recommendations: off-load wound. R4's (11/4/21) nurse wound assessment includes right shoulder skin tear. It was not documented as a stage 4 pressure wound. R4's (3/25/21) care plan includes increased risk for impaired skin integrity with the following preventive interventions: reposition resident frequently when in bed or wheelchair. The care plan was not updated to include to off-load the wound. On 11/9/21 at 1:04pm, R4 was observed lying in bed. There were no repositioning devices in place. V6 (Wound Care Coordinator) removed the dressing from R4's right shoulder. A large (deep) wound was observed with muscle exposed. Surveyor inquired about the stage of R4's wound. V6 stated, He (R4) was seen by the Wound Doctor (V9) today. V9 just staged it and refrained from answering the question. Surveyor inquired again about the stage of R4's wound. V6 responded, Like I said, it was a skin tear. I think she (V9) did 4 (stage 4). On 11/9/21 at 1:26pm, surveyor inquired how R4's right shoulder skin tear developed into a stage 4 pressure ulcer. V2 (Director of Nursing) stated, It originally started off as a skin tear from the wheelchair. On 11/16/21 at 3:13pm, surveyor inquired about R4's right shoulder wound. V9 (Wound Physician) stated, The wound was debrided, so there must have been some biofilm. Surveyor inquired what causes wounds to decline. V9 responded, I would say there are a lot of reasons why the wound would change; the clinical status or nutritional status of the patient, the treatment itself may not be an appropriate so it might need adjusted, offloading or repositioning is also important, and wound hygiene. All of those things can affect the wound. Surveyor inquired about potential harm to a resident if the wound was not off-loaded and/or appropriate treatments are not implemented. V9 stated, The wounds can decline. The (5/19/17) Wound Management Program states a pressure injury is any lesion caused by unrelieved pressure that results in damage to the underlying tissues. The presence of any wounds, injuries, and/or other skin abnormalities will be identified upon admission/readmission or identification of a new wound, pressure injury or other skin abnormality. Residents who are unable to turn and reposition independently will be assisted to turn and reposition every two hours or as appropriate.

Based on interview and record review, the facility failed to ensure a resident with known aggressive behavior did not physically abuse two of three residents (R6 and R8) reviewed for abuse. This failure resulted in R6 being held in a choke hold, hitting his head resulting in a laceration to the forehead that required 13 staples to close. Findings include: Facility's final incident report (for incident of 05-22-2021) documents R5 and R6 had a disagreement and made physical contact with each other. R6 was sent to hospital for evaluation, treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 was sent to hospital for psychiatric evaluation. During interview on 07-08-2021 at 10:10 AM, R6 said, I saw R5 hit R8. He went around the desk and moved at me in a threatening manner. I put my arms around him (to protect myself). He had his hands around my throat. We fell backwards to the floor. That's when I hit my head. I had to get 13 staples. I heard he (R5) beat up two of his roommates. He's (R5) so young, so full of anger, so violent. Why was he here? Why would you (facility) put me in a position to be injured? You knew this guy has violent tendencies. During interview on 07-08-2021 at 11:07 AM, R8 confirmed R5 hit him. During interview on 07-07-2021 at 11:20 AM, V5 (Certified Nursing Assistant/CNA) said, I was his (R5) sitter that shift. He was fine all night, then around 4:00 AM, he started pacing in his room, exhibiting threatening behavior towards me. He put his plastic gloves (exam) on, was throwing air punches at me. He said he put the gloves on so he wouldn't leave fingerprints. I told the nurse (V18/Licensed Practical Nurse/LPN). V18 told me to follow him. R5 was threatening R8. He (R5) has a very, very big history of aggression. During interview on 07-07-2021 at 11:49 AM and 5:09 PM, V6 (CNA) said, I was coming on the first floor to clock out. He (R5) was just out of control. He and the other guy (R6) were in the corner. R5 had R6 in a choke hold. R5's hands were wrapped around R6's neck; R6 could have passed out R5 was holding him so tight. During interview on 07-08-2021 at 2:00 PM, V23 (LPN) said, R5 did have outbursts, could get violent. I believe he was hearing voices. He would throw air punches at people but would also make verbal threats ('I'm going to beat you're a**; I'll kill you in your sleep'). He threatened both staff and residents. He had a 1:1 sitter to engage him and to re-direct, to prevent anything from happening, to keep him safe as well. During interview on 07-07-2021 at 8:48 AM, V18 (LPN) said, V5 told me R5 was up, agitated. R5 wanted to smoke, said 'I'm going to smoke and nobody is going to stop me.' R5 was in the hallway, walking into residents' rooms, grabbing stuff (exam gloves). I had him sitting at the Nursing Station, he was jumping up, shadow boxing me, saying crazy things. I went to answer a call light; when I came back R5 and R6 were locked together, like a wrestling hold. A few days before the incident, R5s behavior started to escalate. He was talking crazy ('I'm God; I'm Jesus Christ'). When he puts on his gloves, that means his behavior is escalating. R5's medical record (Face Sheet, Minimum Data Set) documents R5 is a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 is moderately cognitively impaired. Care plans for behavioral symptoms and cognitive impairment (updated 05-10-2021) document R5 has behaviors including verbal and physical abuse/aggression; and poor ability to control anger and frustration. Progress Note dated 05-22-2021 at 6:25 AM documents, Resident 1:1 monitoring. Resident insists on going out to smoke. Staff attempted to redirect resident. Resident became increasingly agitated with staff. Staff continue to redirect resident which proved to be unsuccessful. Staff nurse was preparing PRN med for agitation. When another resident (R6) attempted to redirect resident by touching him, (R5) reached out and became in tangled with each other that resulted them on the ground. Residents sent to the hospital. Progress Note dated 04-13-2021 at 1:52 PM documents R5 became physically aggressive with R5's roommate. Facility's Abuse Prevention Program Policy and Procedure (Revised 01/2019) states under Policy, This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals.

Based on interview and record review, the facility failed to perform life sustaining cardiopulmonary resuscitation (CPR) on a full code status resident who was unresponsive without breathing or a pulse and failed to notify emergency medical services (EMS) personnel for one (R1) of three residents reviewed. This failure affected R1 who was full code status, did not receive the required CPR and expired and has the potential to affect all 140 residents in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] at approximately 4:18 pm when V2 (Director of Nursing/DON) stated that V3 (Licensed Practical Nurse/LPN) did not perform life sustaining CPR for R1 who was unresponsive without breathing or a pulse, and R1's documented physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at approximately 11:25 am, V1 (Administrator) and V2 (DON) were notified of the Immediate Jeopardy. The immediacy was removed when the abatement plan was accepted on [DATE] at 3:28 pm. A revisit was performed to verify the abatement plan on [DATE] where concerns were noted. The facility addressed these concerns on [DATE], and the abatement plan was verified as implemented on [DATE] at 2:58 pm. Findings include: R1 was a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:35 pm, V3 (LPN) stated she was R1's primary nurse on [DATE] for the 3:00 pm to 11:00 pm shift. V3 stated that on [DATE], she first observed R1 in a wheelchair when he was returning from an outside appointment around 4:00 pm and was accompanied by V6 (Certified Nursing Assistant in Training/CIT). V3 stated that V6 needed assistance getting R1 from the wheelchair back to bed and that nothing seemed off with R1. When this surveyor asked if R1 was alert at this time, she stated that R1 was okay when V3 and V6 transferred him from the wheelchair to the bed. V3 stated that R1 did say hello to her but did not hold a conversation. V3 stated that after R1 returned from his outside appointment, she did check in R1's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated, I thought that (R1) was a DNR because of his decline and that he wasn't well for a while. V3 stated that she then began passing medications to residents down R1's hallway. V3 stated that at 5:00 pm, V6 and V12 (Certified Nursing Assistant/CNA) came out of R1's room, informing her that something seems wrong with (R1). V3 stated that she entered R1's room, along with V6 and V12, and that R1 was not responsive and slumped over in the bed. V3 stated that he had a faint pulse when she assessed him and questioned whether R1 had agonal breathing but didn't really see (R1's) chest move. V3 stated that she shook him and called his name, but R1 didn't respond. V3 stated that she went out to the hallway to her medication cart to get the electronic, wrist blood pressure cuff and pulse oximeter machine and returned to check R1' s vital signs. V3 stated that the blood pressure readings on both of R1's wrists registered as error and that she tried to obtain a reading on several of R1's fingers for his oxygen saturation levels and heart rate. V3 stated that no readings registered on the pulse oximeter machine. V3 stated that she went out of R1's room to the hallway to ask for help from V7 (LPN) by telling her that she couldn't get any vital signs for R1. V3 stated that she and V7 made an assessment of R1 by checking for carotid and brachial pulses and for active breathing. V3 stated that she and V7 found no pulse or active breathing for R1. V3 stated that she and V7 pronounced R1's death on [DATE] at 5:07 pm. V3 stated that she then notified V1 (Administrator), V2 (DON), V9 (Family Member), V10 (Family Member) and V13 (Medical Director) of R1's death. On [DATE] at 3:35 pm, when this surveyor asked V3 the code status of R1 on [DATE] at 5:07 pm, V3 stated, O. M. G. (R1) was a full code. V3 stated that she rechecked R1's code status after he expired when she printed up R1's face sheet for V11 (Assistant Funeral Director) to sign for release of R1's body and then saw under advance directives that R1's code status was a full code. V3 stated that she then checked the code status binder at the nurse's station where DNR code status residents are listed and that R1 was not in the binder. V3 stated that when a resident is a full code status and is found unresponsive, she will initiate CPR immediately, call 911 and to check the code status of the resident. V3 stated that she must start CPR right away for a full code. It is vital. We have only minutes to restore circulation and prevent full brain damage. V3 stated that on [DATE], she did not initiate CPR for R1 and did not activate EMS by calling 911. V3 reiterated that she thought that R1 was a DNR code status. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, that R1's type of assessment for discharge reporting is death in facility. On [DATE] at 3:03 pm, V7 (LPN) stated that on [DATE], she was called to R1's room by V3 who informed her that V3 could not obtain any vital signs for R1 and that he was a DNR code status. V7 stated that since V3 said that R1 was a DNR code status, no further treatment was needed, and she left R1's room. V7 stated that a code blue was not called overhead in the facility for R1 on [DATE]. V7 stated that no CPR was performed for R1 on [DATE]. On [DATE] at 8:32 am, V12 (Certified Nursing Assistant/CNA) stated that on [DATE] when R1 returned from his outside appointment with V6 (CIT), V6 asked her for help in transferring R1 from his wheelchair to the bed. V12 stated that she went into R1's room along with V6 and that R1 was sitting in his wheelchair, slumped over with his head leaning forward. V12 stated that V6 tried to shake R1, but R1 was unresponsive. V12 stated that she called for V3 (LPN) who was right outside the door to alert her about R1. V12 stated that V3 was shaking and talking to R1 for responsiveness and tried to feel for a pulse and couldn't feel it. V12 stated that she, V3 and V7 transferred R1 from the wheelchair to his bed and placed him on his back. V12 stated that R1 was not responsive or moving during the manual transfer. V12 stated that V3 went outside R1's door and then V3 and V7 came back into R1's room. V12 stated that V3 used a stethoscope and stated that R1 had no pulse and he's passed away. V12 stated that on [DATE], CPR was not performed on R1 and that no code blue was called for R1 in the facility. In R1's progress note, dated [DATE] at 5:00 pm, V3 documented, Upon medication rounds, (R1) observed in bed slumped over, unresponsive to tactile stimulation, No rise (and) fall of chest, no breathing, no pulse, no blood pressure (BP); two nurses pronounced expiration at 5:07 pm. (V13/Medical Director) informed. (V9, V10, Family Members) both aware; plan to send (funeral home services) as soon as possible. (V9, V10) will arrange to pick up belongings in am. On [DATE] at 3:49 pm, V2 (DON) stated that on [DATE], she had already left the facility and received a phone call from V3 after 5:00 pm. In this phone call, V2 stated that V3 informed her that she found R1 with no rise or fall of his chest, couldn't obtain any vital signs and that R1 was a DNR code status. V2 stated that on [DATE], she received an allegation of R1 having an injury of unknown origin from V9 (Family Member). V2 stated that she timely reported the allegation to the state agency and started an investigation. V2 stated that after she performed a thorough investigation with multiple interviews and reviewing of R1's records, she concluded that R1 did not have any alleged bruising to his body when he left the faciity on [DATE] after his passing. However, V2 stated that during R1's record review for the investigation, she saw that R1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated that on [DATE], when she questioned V3 about R1's code status, V3 informed her that R1's code status was listed as a DNR on the face sheet that V11 (Assistant Funeral Director) signed for the release of R1's body to the funeral home. V2 stated that R1's face sheet that V11 signed documented full code status under advance directives. V2 stated that on [DATE], V3 did not perform CPR or any resuscitative measures for R1 who was a full code status. V2 stated that she took disciplinary action and that V3 did receive a three day suspension. In facility document, titled Employee Disciplinary Action Form and dated [DATE], V2 documented that V3 (LPN) received a suspension for the described incident: (V3) failed to properly follow facility protocol for code blue. All employees must follow facility policy and procedures. Any further trends noted will lead to further disciplinary action not excluding termination. Employee will receive a 3 day suspension days [DATE], 18 of 2021. Both V2 and V3 signed this document on [DATE]. This surveyor reviewed R1's face sheet, which is titled as Admission Record, that V11 (Assistant Funeral Director) signed on [DATE] at 9:15 pm for release of R1's body. This copy of R1's signed face sheet documents two smudged, nonvisible areas noted to be covered with a substance blocking the information under the advance directive section. Review of this copy of R1's face sheet signed by V11 contradicts both V2's and V3's previous statements of them viewing full code for R1's code status under the advance directive section of this signed face sheet. On [DATE] at 1:01 pm, this surveyor showed V2 the copy of R1's face sheet signed by V11 and asked V2 to explain what R1's code status was under the advance directive section of this signed face sheet. V2 stated, I don't know what that is. This surveyor then requested to review R1's original copy of the face sheet that was signed by V11 for release of R1's body. On [DATE] at 1:33 pm, V2 presented this surveyor with the same copy of R1's signed face sheet by V11 for the release of R1's body that included the two smudged, nonvisible areas under the advance directive section. V2 stated that V3 would have put this copy in her mailbox after V11 signed it on [DATE], and V3 could have given V11 the original copy of R1's signed face sheet. V2 stated that normally the facility keeps the original version of the signed face sheet for release of the body and would give a copy of the original to the funeral home staff. R1's care plan, titled Comprehensive Person-Centered Care Plan and dated [DATE], documents, in part that R1's physical and psychosocial needs are met in fulfillment of my rights and my desire to retain control and autonomy over my health care decisions, I have executed a Full Code. Goals/Objectives: My wishes for Full Code status .will be honored and clearly delineated in the medical record in compliance with state law. On [DATE] at 10:05 am, V2 (DON) stated that a facility nurse is required to look in the code status binder each shift for the resident's code status. V2 stated, They should know the code status of the residents they are caring for. V2 stated that nurses can also locate a resident's code status in the EMR when they view the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated that CNA's can find the code status of a resident by asking the nurse or to look in the code status binder. On [DATE] at 10:50 am, V13 (Medical Director) stated that he was R1's attending physician and that R1's main health problem was seizures. V13 stated that since he did not have access to R1's EMR during this interview, he could not recall R1's code status. V13 stated, If you look in the (EMR), you will see it right there. This surveyor informed V13 that his order, dated [DATE], is in R1's EMR as a full code status resident. V13 stated that if a resident has a full code status and is found unresponsive, the expectation of the facility staff is to start resuscitation, CPR, and call 911 to get help to the resident. V13 stated that staff caring for a resident in a long term care facility should know the code status of the residents. V13 stated that he does recall being notified by a nurse (V3) of R1's expiration on [DATE], but V13 did not recall the details of this notification. V13 then stated that what happened with R1 should be documented in the EMR. This surveyor then informed V13 that with interviews and record review, R1 was a full code status and expired in the facility on [DATE] without facility staff performing any life sustaining resuscitative measures or calling 911 when R1 was found unresponsive. When this surveyor asked V13 what effect this could have on R1, he stated, Well, what actually occurred (to R1). This surveyor asked V13 what occurred to R1 as meaning, cause death, and V13 stated, Yes. Facility policy and procedure, titled Medical Emergency (Code Blue) and dated ,d+[DATE], documents, in part: Purpose: To provide care and services to residents in accordance with Advance Directives that have been discussed with the resident or resident's legal representative in advance of medical emergencies including medical interventions used to restore circulatory and respiratory function. Procedure: 1. The licensed nurse will be notified when any resident is determined to be non-responsive and a Code Blue will be called. 2. The resident ' s Code status will be identified within the resident ' s medical record . 5. Residents that do not have a signed DNR and DNR order will have CPR initiated and maintained. 6. If a resident is determined to be a Full Code (No DNR), 911 will be contacted at the initiation of CPR. CPR will continue until such time that EMS has arrived at the facility and assumes treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Memo, S&C: ,d+[DATE]-NH, with revised date of [DATE], documents, in part: .Initiation of CPR: Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [CONDITION(S)] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a DNR order. Facility policy and procedure, titled Advanced Directive Life Sustaining Treatment and End of Life Care Policy and Procedure and dated [DATE], documents, in part: It is the policy of this healthcare facility to assure residents and their families have the right to self-determination and the ability to make health care decisions and to appoint an agent to make decisions. It is the policy of this facility to provide residents information on advance directives including the Power of Attorney for Health Care and Living Will. The facility also educates residents and families about their rights concerning the right to refuse or accept medical or surgical treatment and to formulate advance directives including Do Not Resuscitate orders (DNR) and, in situations, in which the individual lacks decisional capacity and has not appointed a POAHC, the Surrogate Decision Maker for Health Care. Staff will review this material with the resident and family and provided needed education at the time of admission. Staff are responsible for following this policy/procedure and honoring the individual's advance directive choices. Definitions used in this policy: 1. Advance Care Planning - a process used to identify and update the resident's preferences regarding care and treatment at a future time including a situation in which the resident subsequently lacks the capacity to do so; for example, when a situation arises in which life sustaining treatments are a potential option for care and the resident is unable to make his or her choices known . 3. Cardiopulmonary Resuscitation (CPR) - refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased . 8. Life Sustaining Treatment - treatment that, based on reasonable medical judgment, sustains an individual's life and without which the individual will die. The term includes both life-sustaining medications and interventions such as mechanical ventilation, kidney [CONDITION(S)], and artificial hydration and nutrition . 11. Treatment - refers to intervention provided for purposes of maintaining/ restoring health and well-being improving functional level, or relieving symptoms. Policy and Procedure: 1. Upon Admission: A. Designated staff will review Advance Directive options and the Statement on Illinois Law addressing Advance Directives and Life Sustaining Treatment with the resident and/or representative. Staff will provide the resident and/or representative with information regarding advance care planning which will address types of Advance Directives, treatment options and refusal of treatment. Information will be reviewed and the resident and/or representative will be asked to sign and acknowledge that they have received the information on Advance Care Planning. An Advance Directive form (as provided by the healthcare facility) will be completed with resident and/or legal representative to verify treatment options as well as code status (full code vs. DNR using the POLST {Practitioner Orders for Life Sustaining Treatment} document). Appropriate information will be added to Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident ' s Advance Directive choices/options shall be reviewed periodically, for example, during the re-assessment process, as appropriate. According to CMS, the facility shall Identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. C. Discussion of Advance Directives and treatment options/refusals shall be addressed in appropriate chart documentation as well as care planned during the admission process. D. Staff shall initiate a resident choice discussion concerning the DNR option or Full Code. E. The facility shall document the individual's choices on the POLST and communicate the resident's choices to the interdisciplinary team through paper or virtual chart communication and/or team meetings, as appropriate . G. If the resident is unable or chooses not to initiate any type of Advance Directive the resident shall be viewed as a Full Code and shall receive appropriate life sustaining treatment interventions such as CPR . 4. Review of Advanced Directives: A. Advance Directive information should be reviewed periodically during the resident's stay. B. The staff shall review treatment options with the resident or legal representative to determine if the wishes remain the same or if changes are desired. This may occur in person, by telephone or email communication. C. The chart should be updated to record that advance directives were reviewed and the outcome of the conversation. It is expected that Social Service staff shall document this conversation. Facility policy, titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of admission, the facility must have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility document, titled Job Description, Position Title: Licensed Practical Nurse (undated), documents, in part: Position Summary: The Licensed Practical Nurse provides direct nursing care to the residents, and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position has delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. Essential Job Functions: A. Role Responsibilities - Administrative Duties: 1. Directs the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility. 2. Ensures that all nursing personnel assigned to you comply with the written policies and procedures established by does facility. 3. Reviews the department's policies, procedure manuals .periodically . E. Role Responsibilities - Nursing Care: .7. Reviews the resident's chart for specific treatments, medication orders, diets, etc. as necessary. 8. Implements and maintains established nursing objectives and standards . 21. Ensures that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes. Facility document, printed on [DATE] and titled, Daily Census, documents that the total residents in the facility is 140. The Immediate Jeopardy was identified on [DATE] at approximately 4:18pm to have begun on [DATE] when R1 expired. On [DATE] at approximately 11:25 am, V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy. This surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy. On [DATE], this surveyor was presented with in-service reports performed by V1 (Administrator), V2 (Director of Nursing/DON), V4 (Social Services Director/SSD), V8 (LPN), and V43 (Regional Nurse Consultant) for all licensed nurses, non-licensed nursing staff, social services staff and interdisciplinary department team (IDT) members identified in the abatement plan. In-service reports, dated [DATE], [DATE], [DATE] and [DATE], documented that the facility educated all staff on the following: location of the code status binder; how to complete a POLST form; where to find code status in resident's medical record; licensed nurse will be made aware of unresponsive resident; check code status for an unresponsive resident; call a code blue, initiate CPR for a full code resident, crash cart take to area of code blue, call 911 and maintain CPR until EMS arrives; code blue drills; notify physician and family of change in condition; prohibiting and prevention of resident abuse; and conducting necessary audits for compliance relating to F678. Prior to the identification of the Immediate Jeopardy, in-service reports, dated [DATE] and [DATE], were initiated by V2 (DON) and V4 (SSD) for the location of and information in the 411 binder; meanings of a DNR and a full code status; licensed nurse will be made aware of unresponsive resident; check code status for an unresponsive resident; call a code blue, initiate CPR for a full code resident, crash cart take to area of code blue, call 911 and maintain CPR until EMS arrives. On [DATE] at approximately 11:40 am, V1 (Administrator) stated that no facility staff is on vacation or a leave of absence and that the facility has had one newly hired employee (V44/Admissions Director) who is not listed as an IDT member. On [DATE], during the revisit, a sample of twelve residents were selected from current, newly admitted and readmitted residents for review of code statuses as addressed in the abatement plan. On [DATE], V33 (LPN), V35 (LPN) and V36 (LPN) were interviewed, and they stated that they were in-serviced by V2 (DON) on where to find a resident's code status in the code status binder and in the EMR if a resident is unresponsive; location of the binder; check the binder daily; how to complete a POLST form; how to place an physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff stated that they took tests related to code statuses, CPR and abuse after the in-services. On [DATE], V32 (CNA), V37 (CNA) and V38 (CNA) were interviewed, and they stated that they were in-serviced by V2 (DON) on where to find a resident's code status in the code status binder and in the EMR if a resident is unresponsive; location of the binder; inform the nurse if a resident is unresponsive; initiate CPR for a full code status resident when indicated, call a code blue, call 911, and continue CPR until EMS arrives. On [DATE], V39 (Social Services) was interviewed and stated that she was in-serviced by V4 (SSD) on the location of the code status binder; how to complete a POLST form; the meanings of a DNR and a full code status; uploading the POLST form into the EMR; placing a paper copy of the POLST form into the binder; complete a POLST form for newly admitted residents; and review the advance directives quarterly. On [DATE], V20 (Wound Care Nurse), V40 (Housekeeping Supervisor) and V42 (Human Resources Manager), who were identified as members of the IDT team in the abatement plan, were interviewed, and they stated that they were in-serviced by V2 (DON) for the location of the code status binder; the meanings of a DNR and a full code status; and the process of initiating CPR for a full code resident. V42 added that he performs audits for staff to be current for their CPR certifications and will provide notices one month prior to expiration. On [DATE] at 3:05 pm, V2 (DON) was interviewed and confirmed that she performed the aforementioned in-services to all staff including licensed staff, non-licensed staff and IDT members for all shifts in the facility. V2 stated that she conducted a mock, code blue scenario for a DNR and a full code status resident, who was found unresponsive, and that staff then performed their roles and actions as in-serviced. V2 stated that she and V4 (SSD) also trained staff that after completing a POLST form for a resident, a physician or nurse practitioner must sign the POLST form within 24 hours to validate the POLST form. V2 stated that she performs the daily audit of reviewing newly admitted and readmitted residents for a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], V4 (SSD) was interviewed, and she stated that she and V2 (DON) performed in-services to all licensed staff and non-licensed staff on the location of the code status binders on each floor; the meaning of a POLST form for code status; and how a POLST form is to be completed. V4 stated that if a resident refused to complete a POLST form, then the resident is a full code status, and resident refused is written on the POLST form in binder. V4 stated that she performs daily audits of each code status binder to verify that each resident's code status order in the EMR matches the POLST form in the binder. V4 stated that she performs daily reviews of the list of DNR and full code residents in the binders and will update the lists when there are new admissions in the facility or when a resident chose to change the code status. On [DATE], all staff interviewed on the floors were able to clearly identify where the code status binder is located on each floor and the contents of the code status binder. On [DATE], code status binders were observed located at each of the three nurse's station attached to the east wall in a pocket slot. The three floors' code status binders contained a list for DNR and full code residents for each floor. Paper copies of POLST forms for the listed DNR and full code residents were observed in each binder. On [DATE], no POLST form was observed for R8 in either of the three code status binders in the facility. On [DATE], further record review indicated that R8 did not have a POLST form uploaded in the EMR. On [DATE] at 2:58 pm, the facility addressed this concern for R8 with presenting a POLST form, dated [DATE] and signed by V22 (Nurse Practitioner) on [DATE]. Therefore, the immediacy was removed on [DATE]. Based on observation, interview and record review conducted on [DATE] and [DATE], the facility completed measures on the abatement plan including providing education to staff on where to find a resident's code status on a POLST form in the code status binder on each floor; where the POLST form is uploaded in the EMR; how to place a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to perform life sustaining cardiopulmonary resuscitation (CPR) on a full code status resident who was unresponsive without breathing or a pulse for one (R1) of three residents reviewed. This failure to follow the professional standards of practice affected R1 who was full code status, did not receive the required CPR and expired and has the potential to affect all 140 residents in the facility. Findings include: R1 was a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:35 pm, V3 (Licensed Practical Nurse/LPN) stated she was R1's primary nurse on [DATE] for the 3:00 pm to 11:00 pm shift. V3 stated that on [DATE], she first observed R1 in a wheelchair when he was returning from an outside appointment around 4:00 pm and was accompanied by V6 (Certified Nursing Assistant in Training/CIT). V3 stated that V6 needed assistance getting R1 from the wheelchair back to bed and that nothing seemed off with R1. When this surveyor asked if R1 was alert at this time, she stated that R1 was okay when V3 and V6 transferred him from the wheelchair to the bed. V3 stated that R1 did say hello to her but did not hold a conversation. V3 stated that after R1 returned from his outside appointment, she did check in R1's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated, I thought that (R1) was a DNR because of his decline and that he wasn't well for a while. V3 stated that she then began passing medications to residents down R1's hallway. V3 stated that at 5:00 pm, V6 and V12 (Certified Nursing Assistant/CNA) came out of R1's room, informing her that something seems wrong with (R1). V3 stated that she entered R1's room, along with V6 and V12, and that R1 was not responsive and slumped over in the bed. V3 stated that he had a faint pulse when she assessed him and questioned whether R1 had agonal breathing but didn't really see (R1's) chest move. V3 stated that she shook him and called his name, but R1 didn't respond. V3 stated that she went out to the hallway to her medication cart to get the electronic, wrist blood pressure cuff and pulse oximeter machine and returned to check R1' s vital signs. V3 stated that the blood pressure readings on both of R1's wrists registered as error and that she tried to obtain a reading on several of R1's fingers for his oxygen saturation levels and heart rate. V3 stated that no readings registered on the pulse oximeter machine. V3 stated that she went out of R1's room to the hallway to ask for help from V7 (LPN) by telling her that she couldn't get any vital signs for R1. V3 stated that she and V7 made an assessment of R1 by checking for carotid and brachial pulses and for active breathing. V3 stated that she and V7 found no pulse or active breathing for R1. V3 stated that she and V7 pronounced R1's death on [DATE] at 5:07 pm. V3 stated that she then notified V1 (Administrator), V2 (Director of Nursing/DON), V9 (Family Member), V10 (Family Member) and V13 (Medical Director) of R1's death. On [DATE] at 3:35 pm, when this surveyor asked V3 the code status of R1 on [DATE] at 5:07 pm, V3 stated, O. M. G. (R1) was a full code. V3 stated that she rechecked R1's code status after he expired when she printed up R1's face sheet for V11 (Assistant Funeral Director) to sign for release of R1's body and then saw under advance directives that R1's code status was a full code. V3 stated that she then checked the code status binder at the nurse's station where DNR code status residents are listed and that R1 was not in the binder. V3 stated that when a resident is a full code status and is found unresponsive, she will initiate CPR immediately, call 911 and to check the code status of the resident. V3 stated that she must start CPR right away for a full code. It is vital. We have only minutes to restore circulation and prevent full brain damage. V3 stated that on [DATE], she did not initiate CPR for R1 and did not activate EMS by calling 911. V3 reiterated that she thought that R1 was a DNR code status. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, that R1's type of assessment for discharge reporting is death in facility. On [DATE] at 3:03 pm, V7 (LPN) stated that on [DATE], she was called to R1's room by V3 who informed her that V3 could not obtain any vital signs for R1 and that he was a DNR code status. V7 stated that since V3 said that R1 was a DNR code status, no further treatment was needed, and she left R1's room. V7 stated that a code blue was not called overhead in the facility for R1 on [DATE]. V7 stated that no CPR was performed for R1 on [DATE]. On [DATE] at 8:32 am, V12 (CNA) stated that on [DATE] when R1 returned from his outside appointment with V6 (CIT), V6 asked her for help in transferring R1 from his wheelchair to the bed. V12 stated that she went into R1's room along with V6 and that R1 was sitting in his wheelchair, slumped over with his head leaning forward. V12 stated that V6 tried to shake R1, but R1 was unresponsive. V12 stated that she called for V3 (LPN) who was right outside the door to alert her about R1. V12 stated that V3 was shaking and talking to R1 for responsiveness and tried to feel for a pulse and couldn't feel it. V12 stated that she, V3 and V7 transferred R1 from the wheelchair to his bed and placed him on his back. V12 stated that R1 was not responsive or moving during the manual transfer. V12 stated that V3 went outside R1's door and then V3 and V7 came back into R1's room. V12 stated that V3 used a stethoscope and stated that R1 had no pulse and he's passed away. V12 stated that on [DATE], CPR was not performed on R1 and that no code blue was called for R1 in the facility. In R1's progress note, dated [DATE] at 5:00 pm, V3 documented, Upon medication rounds, (R1) observed in bed slumped over, unresponsive to tactile stimulation, No rise (and) fall of chest, no breathing, no pulse, no blood pressure (BP); two nurses pronounced expiration at 5:07 pm. (V13/Medical Director) informed. (V9, V10, Family Members) both aware; plan to send (funeral home services) as soon as possible. (V9, V10) will arrange to pick up belongings in am. On [DATE] at 3:49 pm, V2 (DON) stated that on [DATE], she had already left the facility and received a phone call from V3 after 5:00 pm. In this phone call, V2 stated that V3 informed her that she found R1 with no rise or fall of his chest, couldn't obtain any vital signs and that R1 was a DNR code status. V2 stated that on [DATE], she received an allegation of R1 having an injury of unknown origin from V9 (Family Member). V2 stated that she timely reported the allegation to the state agency and started an investigation. V2 stated that after she performed a thorough investigation with multiple interviews and reviewing of R1's records, she concluded that R1 did not have any alleged bruising to his body when he left the faciity on [DATE] after his passing. However, V2 stated that during R1's record review for the investigation, she saw that R1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated that on [DATE], when she questioned V3 about R1's code status, V3 informed her that R1's code status was listed as a DNR on the face sheet that V11 (Assistant Funeral Director) signed for the release of R1's body to the funeral home. V2 stated that R1's face sheet that V11 signed documented full code status under advance directives. V2 stated that on [DATE], V3 did not perform CPR or any resuscitative measures for R1 who was a full code status. V2 stated that she took disciplinary action and that V3 did receive a three day suspension. In facility document, titled Employee Disciplinary Action Form and dated [DATE], V2 documented that V3 (LPN) received a suspension for the described incident: (V3) failed to properly follow facility protocol for code blue. All employees must follow facility policy and procedures. Any further trends noted will lead to further disciplinary action not excluding termination. Employee will receive a 3 day suspension days [DATE], 18 of 2021. Both V2 and V3 signed this document on [DATE]. This surveyor reviewed R1's face sheet, which is titled as Admission Record, that V11 (Assistant Funeral Director) signed on [DATE] at 9:15 pm for release of R1's body. This copy of R1's signed face sheet documents two smudged, nonvisible areas noted to be covered with a substance blocking the information under the advance directive section. Review of this copy of R1's face sheet signed by V11 contradicts both V2's and V3's previous statements of them viewing full code for R1's code status under the advance directive section of this signed face sheet. On [DATE] at 1:01 pm, this surveyor showed V2 the copy of R1's face sheet signed by V11 and asked V2 to explain what R1's code status was under the advance directive section of this signed face sheet. V2 stated, I don't know what that is. This surveyor then requested to review R1's original copy of the face sheet that was signed by V11 for release of R1's body. On [DATE] at 1:33 pm, V2 presented this surveyor with the same copy of R1's signed face sheet by V11 for the release of R1's body that included the two smudged, nonvisible areas under the advance directive section. V2 stated that V3 would have put this copy in her mailbox after V11 signed it on [DATE], and V3 could have given V11 the original copy of R1's signed face sheet. V2 stated that normally the facility keeps the original version of the signed face sheet for release of the body and would give a copy of the original to the funeral home staff. R1's care plan, titled Comprehensive Person-Centered Care Plan and dated [DATE], documents, in part that R1's physical and psychosocial needs are met in fulfillment of my rights and my desire to retain control and autonomy over my health care decisions, I have executed a Full Code. Goals/Objectives: My wishes for Full Code status .will be honored and clearly delineated in the medical record in compliance with state law. On [DATE] at 10:05 am, V2 (DON) stated that a facility nurse is required to look in the code status binder each shift for the resident's code status. V2 stated, They should know the code status of the residents they are caring for. V2 stated that nurses can also locate a resident's code status in the EMR when they view the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated that CNA's can find the code status of a resident by asking the nurse or to look in the code status binder. On [DATE] at 10:50 am, V13 (Medical Director) stated that he was R1's attending physician and that R1's main health problem was seizures. V13 stated that since he did not have access to R1's EMR during this interview, he could not recall R1's code status. V13 stated, If you look in the (EMR), you will see it right there. This surveyor informed V13 that his order, dated [DATE], is in R1's EMR as a full code status resident. V13 stated that if a resident has a full code status and is found unresponsive, the expectation of the facility staff is to start resuscitation, CPR, and call 911 to get help to the resident. V13 stated that staff caring for a resident in a long term care facility should know the code status of the residents. V13 stated that he does recall being notified by a nurse (V3) of R1's expiration on [DATE], but V13 did not recall the details of this notification. V13 then stated that what happened with R1 should be documented in the EMR. This surveyor then informed V13 that with interviews and record review, R1 was a full code status and expired in the facility on [DATE] without facility staff performing any life sustaining resuscitative measures or calling 911 when R1 was found unresponsive. When this surveyor asked V13 what effect this could have on R1, he stated, Well, what actually occurred (to R1). This surveyor asked V13 what occurred to R1 as meaning, cause death, and V13 stated, Yes. Facility policy and procedure, titled Medical Emergency (Code Blue) and dated ,d+[DATE], documents, in part: Purpose: To provide care and services to residents in accordance with Advance Directives that have been discussed with the resident or resident's legal representative in advance of medical emergencies including medical interventions used to restore circulatory and respiratory function. Procedure: 1. The licensed nurse will be notified when any resident is determined to be non-responsive and a Code Blue will be called. 2. The resident's Code status will be identified within the resident's medical record .5. Residents that do not have a signed DNR and DNR order will have CPR initiated and maintained. 6. If a resident is determined to be a Full Code (No DNR), 911 will be contacted at the initiation of CPR. CPR will continue until such time that EMS has arrived at the facility and assumes treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Memo, S&C: ,d+[DATE]-NH, with revised date of [DATE], documents, in part: .Initiation of CPR: Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [CONDITION(S)] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a DNR order. Facility policy and procedure, titled Advanced Directive Life Sustaining Treatment and End of Life Care Policy and Procedure and dated [DATE], documents, in part: It is the policy of this healthcare facility to assure residents and their families have the right to self-determination and the ability to make health care decisions and to appoint an agent to make decisions. It is the policy of this facility to provide residents information on advance directives including the Power of Attorney for Health Care and Living Will. The facility also educates residents and families about their rights concerning the right to refuse or accept medical or surgical treatment and to formulate advance directives including Do Not Resuscitate orders (DNR) and, in situations, in which the individual lacks decisional capacity and has not appointed a POAHC, the Surrogate Decision Maker for Health Care. Staff will review this material with the resident and family and provided needed education at the time of admission. Staff are responsible for following this policy/procedure and honoring the individual's advance directive choices. Definitions used in this policy: 1. Advance Care Planning - a process used to identify and update the resident's preferences regarding care and treatment at a future time including a situation in which the resident subsequently lacks the capacity to do so; for example, when a situation arises in which life sustaining treatments are a potential option for care and the resident is unable to make his or her choices known . Cardiopulmonary Resuscitation (CPR) - refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased .8. Life Sustaining Treatment - treatment that, based on reasonable medical judgment, sustains an individual's life and without which the individual will die. The term includes both life-sustaining medications and interventions such as mechanical ventilation, kidney [CONDITION(S)], and artificial hydration and nutrition . 11. Treatment - refers to intervention provided for purposes of maintaining/ restoring health and well-being improving functional level, or relieving symptoms. Policy and Procedure: 1. Upon Admission: A. Designated staff will review Advance Directive options and the Statement on Illinois Law addressing Advance Directives and Life Sustaining Treatment with the resident and/or representative. Staff will provide the resident and/or representative with information regarding advance care planning which will address types of Advance Directives, treatment options and refusal of treatment. Information will be reviewed and the resident and/or representative will be asked to sign and acknowledge that they have received the information on Advance Care Planning. An Advance Directive form (as provided by the healthcare facility) will be completed with resident and/or legal representative to verify treatment options as well as code status (full code vs. DNR using the POLST {Practitioner Orders for Life Sustaining Treatment} document). Appropriate information will be added to Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Advance Directive choices/options shall be reviewed periodically, for example, during the re-assessment process, as appropriate. According to CMS, the facility shall Identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. C. Discussion of Advance Directives and treatment options/refusals shall be addressed in appropriate chart documentation as well as care planned during the admission process. D. Staff shall initiate a resident choice discussion concerning the DNR option or Full Code. E. The facility shall document the individual's choices on the POLST and communicate the resident's choices to the interdisciplinary team through paper or virtual chart communication and/or team meetings, as appropriate . G. If the resident is unable or chooses not to initiate any type of Advance Directive the resident shall be viewed as a Full Code and shall receive appropriate life sustaining treatment interventions such as CPR .4. Review of Advanced Directives: A. Advance Directive information should be reviewed periodically during the resident's stay. B. The staff shall review treatment options with the resident or legal representative to determine if the wishes remain the same or if changes are desired. This may occur in person, by telephone or email communication. C. The chart should be updated to record that advance directives were reviewed and the outcome of the conversation. It is expected that Social Service staff shall document this conversation. Facility policy, titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of admission, the facility must have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility document, titled Job Description, Position Title: Licensed Practical Nurse (undated), documents, in part: Position Summary: The Licensed Practical Nurse provides direct nursing care to the residents, and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position has delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. Essential Job Functions: A. Role Responsibilities - Administrative Duties: 1. Directs the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility. 2. Ensures that all nursing personnel assigned to you comply with the written policies and procedures established by does facility. 3. Reviews the department's policies, procedure manuals .periodically . E. Role Responsibilities - Nursing Care: .7. Reviews the resident's chart for specific treatments, medication orders, diets, etc. as necessary. 8. Implements and maintains established nursing objectives and standards . 21. Ensures that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes. Facility document, printed on [DATE] and titled, Daily Census, documents that the total residents in the facility is 140.

Based on interview and record review the facility failed to follow their policy to monitor and supervise a resident that exhibited destructive behavior. This deficient practice affected one resident (R5) in a sample of 4 residents (R2, R3, R4 and R5) reviewed for physical abuse. This failure led to R5 being physically assaulted by his roommate (R4) and sustaining facial trauma, feeling traumatized as a result of the incident, and not feeling safe in the facility requiring R5 being transferred to a local hospital for further evaluation and treatment of injuries sustained from the assault. Findings include: R4 is a [AGE] year-old man with diagnoses including but not limited to: [CONDITION(S)], [CONDITION(S)], and Cognitive Communication Deficit. R4's BIMS Score (Brief Interview for Mental Status) is 15 meaning the resident is Cognitively Intact. R5 is a [AGE] year-old man with the diagnoses including but not limited to: Difficulty in walking, Chronic Respiratory Failure, Pain in Right Hip, Abnormal Posture, Repeated Falls, Muscle Weakness, Muscle Wasting and Atrophy, Weakness, Reduced Mobility. R5's BIMS Score (Brief Interview for Mental Status) is 15 meaning the resident is Cognitively Intact. On 4/21/21 at 11:33 am R5 was observed in his room. R5 was observed to be wheelchair bound. R5 stated on 4/10/21 he was in the hallway playing a game. When he returned to the room, R4 broke the televisions in their room (both R4's and R5's televisions). R5 stated R4 and he were roommates. R5 stated due to that incident, staff dismissed (put R4 in room next door) him to the room next door however R4 kept coming in back to the room (kept coming into room with R5). R5 stated on 4/13/21 he was in his wheelchair watching television with his back to the door. R4 came in, did not say anything and started swinging and hitting him. R5 stated R4 pulled him out of the wheelchair to the floor, got on top of him, put both of his knees on R5's arms so R5 could not protect himself and R4 was hitting his head and face. R5 stated all he could do was to yell for help while R4 was punching his face and head. R5 stated he was bleeding, had bruised lips and eyes. R5 stated, Look at me. I am still bruised under my eye. R5 was observed with dark discoloration under his left eye. R5 stated he was traumatized at that time with the experience and he should not be abused in a nursing facility and that he should be feeling safe here. On 4/21/21 at 11:09 am V4 (Social Service Director) stated on 4/12/21 in the morning V2 (Director of Nursing/DON) told her about the incident between R4 and R5. V4 stated R4 had a wander guard and was on the elopement list. V4 stated R4 was not placed on 1:1 supervision, there was no reason for that. V4 stated all staff will be making sure that the resident mood will be stable, and she was doing random checks and was making sure R4 was doing well and did wellness check. V4 stated regarding monitoring residents CNA's and nurses are always on the unit and they monitor residents, however she was not sure how often residents are to be monitored. On 4/21/21 at 12:01 pm, V22 (Nurse Practitioner) stated she was in the facility on 4/13/21 and was called to R5's room. V22 stated upon entry there was blood on the floor and R5 was picked up off the floor by staff. V22 stated both residents were separated by then. V22 stated she did an assessment on R5 because he was bleeding. V22 stated R5 had multiple trauma points; R5 had blood in nasal and oral cavity. V22 stated the trauma R5 sustained were all facial. R5's vital signs were stable. V22 stated she asked R5 how he obtained the trauma and R5 told her that R4 came into the room, pulled him out of the wheelchair and started to hit him. V22 stated R5 was sent out for hospital evaluation. On 4/21/21 at 1:09 pm V2 (DON) stated on 4/13/21 upon entering R4 and R5's room, she observed R5 on the floor, and there was blood on the floor also. V2 stated R4 was removed by staff already by the time she got to the room. V2 stated she was the nurse assigned to both residents that day. V2 stated R4 was never moved to a different room, his room number never changed. V2 stated on 4/10/21 R4 had a behavior where he broke the televisions in his room and staff took him to the common area, where he calmed down, and after he calmed down and did not exhibit any other behaviors he was able to come back to the room. V2 stated on 4/13/21 R4 and R5 were roommates and nothing was changed. On 4/21/21 at 1:37 pm V25 (Registered Nurse) stated she was familiar with R4 and he has not shown any behaviors in the past. V25 also stated R4's room has not changed prior to the 4/13/21 incident. V25 stated on 4/13/21 both residents had a word exchange and R4 physically assaulted R5. V25 stated when she got to the room, V2 was in the room with R5. V25 stated R4 was removed from the room and she observed R4 was breathing heavy and was swaying back and forth. V25 stated R4 stated he wanted to be left alone, however he started to pace more, so she stayed on the unit with R4 because she wanted to make sure he was fine. V25 stated R4 was monitored, but he got more agitated and his behavior escalated so she called V27 (Psychiatrist) and informed the doctor that R4 was getting more aggressive and they got petition for him to go out for hospital evaluation. V25 also stated in the meantime R4 got [MEDICATION(S)] because it was a 45-minute process, and he got transferred to the hospital due to escalation in behavior. On 4/22/21 at 11:03 am V27 (Psychiatrist) stated on 4/13/21 she was made aware of R4's change in status related to behavior, incident between R4 and R5 and she gave an order for hospital evaluation and [MEDICATION(S)]. V27 further stated she was not made aware on 4/10/21 of R4's behavior of being loud and disruptive (surveyor made V27 aware of R4's 4/10/21 progress note by V3/Licensed Practical Nurse). V27 stated she would have placed R4 on PRN (as needed) medication and close behavior monitoring due to change of condition. V27 stated she should have been made aware of the 4/10/21 incident by the facility and was not. V27 stated R4 is in his 20's living in a facility with an older population so any change in behavior she should be made aware. V27 stated when there is a change in condition related to behavior, she should be made aware and not a medical doctor or nurse practitioner. On 4/22/21 at 11:10 am V2 (DON) stated when there is change in condition from baseline medical or behavior, then the nurse practitioner or physician needs to be made aware. V2 stated nurses need to call the doctor and let them know what is going on, follow orders if any and call the resident's family. V2 stated nurses are to document that they called the physician and document any orders given and in general what happened and who they spoke to in the resident's chart (progress notes). On 5/6/21 at 2:10 pm V2 stated she was aware of the 4/10/21 incident regarding R4 breaking the televisions in his room. V2 stated R4 was removed from the room to the room next door where he calmed down and relaxed and ate his meal. V2 stated the physician should have been notified because he had a behavior incident. V2 stated when it was discovered R4 broke the televisions, staff took him next door to find out what happened and that R4 was removed from the situation. V2 stated R4 was sorry he did it, calmed him down and there was no reason for room change because R4 was calm and remorseful. V2 stated when there is such an incident, staff need to deescalate the situation, separate the residents and find out why he broke the televisions. V2 stated R4 was redirected and was able to calm down, but yes doctor or nurse practitioner should have been made aware. R4's (4/10/2021 at 6:34 pm) Nursing Progress Note by V3 (Licensed Practical Nurse/LPN) documents: Resident loud and disruptive and destroyed 2 TV sets, behavior frightened neighbor (referring to R5); 2 nurses conquer resident move into room XXX, until further notice; Ambulatory, gait steady, appetite poor ate no dinner; Nurse talked to resident and stated he didn't mean to break the TV's, but is happy to move; Will continue to monitor. R4's (4/10/21) review of physician notes and orders affirm physician was not notified and no orders to address resident's behavior were given. V3 was not available for interview. Surveyor attempted to reach her multiple times on 4/22/21 at 11:55 am, 11:57 am and 12:30 pm and 4/28/21 at 10:45 am, 10:47 am, 10:59 am, 3:10 pm and 3:25 pm. V1's (Administrator) (4/28/21) e-mail to surveyor documents V3 was out of the facility on suspension. R5's (4/13/2021) progress note by V22 (Nurse Practitioner) documents in part: Pt (Patient) seen and examined today for head/Facial trauma from another pt in the facility. Writer was called into pt's room, pt noted on the floor with blood on the floor next to pt's bed, pt transferred to his bed with aide of 2-3 staffs, upon assessment, pt noted with bloody discharge from his nasal and oral cavities, lacerations and swelling to pt's upper lip, and multiple swollen and trauma points. Upon asking pt how he sustained facial and head trauma, stated another pt in the facility approached him while he was sitting on his wheelchair watching a movie, dragged him down to the floor from which he hit his head to the floor and started punching him around his face and head, stated the other pt placed his knees on his hands restraining him, Trauma to facial and head region noted, Bil (bilateral) eye blood shot red, no other bodily harm noted, VSS (Vital Signs Stable) at this time, pt placed on high fowler's position and encouraged to let staff know of any change in condition. Pt alert and oriented x3-4, verbally responsive and able to answer all questions with no difficulty, stated he blacked out for a moment while he was being hit by the other pt, but regained consciousness right after. Review of facility census affirms R4's was in the same room as R5 since 3/5/21, R4's room number did not change after 4/10/21 incident. R4 and R5 remained roommates. Facility's Standard Supervision and Monitoring policy documents in part: The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. 5. The physician/psychiatrist will be notified for further evaluation and treatment to further assess and treat the resident if increased supervision and guidance is required.

Based on interview and record review the facility failed to ensure that residents are free from physical abuse. This deficient practice affected one resident (R5) in a sample of 4 residents (R2, R3, R4 and R5) reviewed to physical abuse. This failure resulted in R5 being physically assaulted by his roommate (R4) with R5 sustaining facial trauma, feeling traumatized as a result of the incident, and not feeling safe in the facility requiring R5 being transferred to a local hospital for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R4 is a [AGE] year-old man with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's BIMS Score (Brief Interview for Mental Status) is 15 meaning the resident is Cognitively Intact. R5 is a [AGE] year-old man with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's BIMS Score (Brief Interview for Mental Status) is 15 meaning the resident is Cognitively Intact. On 4/21/21 at 11:33 am R5 was observed in his room. R5 was observed to be wheelchair bound. R5 stated on 4/10/21 he was in the hallway playing a game. When he returned to the room, R4 broke the televisions in their room (both R4's and R5's televisions). R5 stated R4 and him were roommates. R5 stated due to that incident, staff dismissed him to the room next door, however R4 kept coming in back to the room. R5 stated on 4/13/21 he was in his wheelchair watching television with his back to the door, R4 came in, did not say anything and started swinging and hitting him. R5 stated R4 pulled him out of the wheelchair to the floor, got on top of him, put both of his knees on R5's arms so R5 could not protect himself and R4 was hitting his head and face. R5 stated all he could do was to yell for help while R4 was punching his face and head. R5 stated he was bleeding and had bruised lips and eyes. R5 stated, Look at me. I am still bruised under my eye. R5 had dark discoloration under his left eye. R5 stated he was traumatized at that time with the experience and he should not be abused in a nursing facility. R5 stated he should be feeling safe here. On 4/21/21 at 12:01 pm, V22 (Nurse Practitioner) stated she was in the facility on 4/13/21 and was called to R5's room. V22 stated upon entry there was blood on the floor and R5 was picked up off the floor by staff. V22 stated both residents were separated by then. V22 stated she did an assessment on R5 because he was bleeding. V22 stated R5 had multiple trauma points and that R5 had blood in nasal and oral cavity. V22 stated the trauma R5 sustained were all facial. R5's vital signs were stable. V22 stated she asked R5 how he obtained the trauma and R5 told her that R4 came into the room, pulled him out of the wheelchair and started to hit him. V22 stated R5 was sent out for hospital evaluation. On 4/21/21 at 12:29 pm V1 (Administrator) stated he was the abuse coordinator in the facility. V1 stated he did the abuse investigation regarding R4 and R5. V1 stated facility will take R4 back, however he will be placed on the first or the third floor and not the same floor as R5. V1 stated on 4/13/21 R4 and R5 had a verbal disagreement between them. V1 stated when he interviewed R5, the resident told him he slid from wheelchair and R4 hit him in the face. V1 stated R4 and R5 will not be on the same floor, if R4 wants to go to another facility that will be his choice however R4 will not be able to go to the same floor as R5 resides on. V1 stated when R4 returns to the facility, he will be monitored by staff one to one. V1 stated he was not told R4 was relocated to another room prior to 4/13/21 and said on 4/13/21 both residents were roommates. On 4/21/21 at 1:09 pm V2 (Director of Nursing/DON) stated on 4/13/21 upon entering R4 and R5's room, she observed R5 on the floor, and there was blood on the floor. V2 stated R4 was already removed by staff by the time she got to the room. V2 stated she was the nurse assigned to both residents that day. V2 stated R4 was never moved to a different room, his room number never changed. V2 stated on 4/10/21 R4 had a behavior where he broke the televisions in his room and staff took him to the common area, where he calmed down, and after he calmed down and did not exhibit any other behaviors he was able to come back to the room. V2 stated on 4/13/21 R4 and R5 were roommates and nothing was changed. On 4/21/21 at 1:37 pm V25 (Registered Nurse) stated she was familiar with R4 and he has not shown any behaviors in the past. V25 also stated R4's room has not changed prior to the 4/13/21 incident. V25 stated on 4/13/21 both residents had a word exchange and R4 physically assaulted R5. V25 stated when she got to the room, V2 was in the room with R5. V25 stated R4 was removed from the room and she observed R4 was breathing heavy and was swaying back and forth. V25 stated R4 said he wanted to be left alone, however he started to pace more, so she stayed on the unit with R4 because she wanted to make sure he was fine. V25 stated R4 was monitored, but he got more agitated and his behavior escalated so she called V27 (Psychiatrist) and informed the doctor that R4 was getting more aggressive and they got a petition for him to go out for hospital evaluation. V25 also stated in the meantime R4 received [MEDICATION(S)] because it was a 45-minute process, and he got transferred to the hospital due to escalation in behavior. On 4/22/21 at 11:03 am V27 (Psychiatrist) stated on 4/13/21 she was made aware of R4's change in status related to behavior incident between R4 and R5 and she gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V27 further stated she was not made aware on 4/10/21 of R4's behavior of being loud and disruptive (surveyor made V27 aware of R4's 4/10/21 progress note by V3/Licensed Practical Nurse). V27 stated she would have placed R4 on PRN (as needed) medication and close behavior monitoring due to change of condition. V27 stated she should have been made aware of the 4/10/21 incident by the facility and was not. V27 stated R4 is in his 20's living in a facility with an older population, so any change in behavior she should be made aware. V27 stated when there is a change in condition related to behavior, she should be made aware and not a medical doctor or nurse practitioner. On 4/22/21 at 11:10 am V2 (DON) stated when there is change in condition from baseline medical or behavior, then the nurse practitioner or physician needs to be made aware. V2 stated nurses need to call the doctor and let them know what is going on, follow orders if any and call the residents family. V2 stated nurses are to document that they called the physician and document any orders given and in general what happened and who they spoke to in the resident's chart (progress notes). On 5/6/21 at 2:10 pm V2 (DON) said she was aware of the 4/10/21 incident regarding R4 breaking the televisions in his room. V2 stated R4 was moved to the room next door where he calmed down and relaxed and ate his meal. V2 stated the physician should have been notified because he had a behavior incident. V2 stated when it was discovered R4 broke the televisions, staff took him next door to find out what happened, R4 was removed from the situation. V2 stated R4 was sorry he did it, calmed him down and there was no reason for room change because R4 was calm and remorseful. V2 stated when there is such an incident, staff need to deescalate the situation, separate the residents, and find out why he broke the televisions. V2 stated R4 was redirected and was able to calm down, but yes doctor or nurse practitioner should have been made aware. On 5/6/21 at 2:19 pm V34 (Operations Director) stated V34 is temporarily filling in for V1 because V1 is on leave. V34 stated in general he will look at situation and from that he would see if the facility would do a reportable. V34 stated resident televisions are property of the facility, so the roommate's property was not destroyed. V34 stated V1 would call and make him aware of any reportable he was sending to state agency and he is aware of the reportable from 4/13/21 regarding R4 and R5. V34 stated reportable is made and it depends on the circumstances, if there is physical contact for sure the facility will do a state reportable. V34 stated he was not aware of the damage to televisions on 4/10/21. On 5/6/21 at 2:28 pm V1 (Administrator) stated he was aware of one television broken in R4's room and it was by accident. V1 stated R4 was walking by and the television fell , and the resident felt remorseful. V1 stated that because it was an accident, abuse did not take place a so state reportable was not done. R4's (4/10/2021 at 6:34 pm) Nursing Progress Note by V3 (Licensed Practical Nurse/LPN) documented: Resident loud and disruptive and destroyed 2 TV sets, behavior frightened neighbor (referring to R5); 2 nurses conquer resident move into room XXX, until further notice; Ambulatory, gait steady, appetite poor ate no dinner; Nurse talked to resident and stated he didn't mean to break the TV's, but is happy to move; Will continue to monitor. V3 was not available for interview. Surveyor attempted to reach her multiple times on 4/22/21 at 11:55 am, 11:57 am and 12:30 pm and 4/28/21 at 10:45 am, 10:47 am, 10:59 am, 3:10 pm and 3:25 pm. V1's (Administrator) (4/28/21) e-mail to surveyor documents V3 was out of the facility on suspension. R5's (4/13/2021) progress note by V22 (Nurse Practitioner) documents in part: Pt (Patient) seen and examined today for head/facial trauma from another pt in the facility. Writer was called into pt's room, pt noted on the floor with blood on the floor next to pt's bed, pt transferred to his bed with aide of 2-3 staffs, upon assessment, pt noted with bloody discharge from his nasal and oral cavities, lacerations and swelling to pt's upper lip, and multiple swollen and trauma points. Upon asking pt how he sustained facial and head trauma, stated another pt in the facility approached him while he was sitting on his wheelchair watching a movie, dragged him down to the floor from which he hit his head to the floor and started punching him around his face and head, stated the other pt placed his knees on his hands restraining him, Trauma to facial and head region noted, Bil eye blood shot red, no other bodily harm noted, VSS at this time, pt placed on high fowler's position and encouraged to let staff know of any change in condition. Pt alert and oriented x3-4, verbally responsive and able to answer all questions with no difficulty, stated he blacked out for a moment while he was being hit by the other pt, but regained consciousness right after. Review of facility census affirms R4's was in the same room as R5 since 3/5/21, R4's room number did not change after 4/10/21 incident. R4 and R5 remained roommates. Facility's Abuse Prevention Program documents in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on interview and record review, the facility failed to promptly and properly assess, monitor, and document the pain of a resident who complained of pain in the shoulder and collar bone after a fall. This affected one (R1) of three residents reviewed for pain management. This failure resulted in R1 having a sleepless night and having a bad mood the whole of the next day. Findings include: R1's MDS (Minimum Data Set) dated 11/12/2020 shows that R1's BIMS (Brief Interview for Mental Status) score is 14 out of 15 (cognitively intact). On 1/12/21 at 11:15am during resident observation on the second floor of the facility, R1 was interviewed regarding his pain after he fell on [DATE]. R1 stated that he was on the floor and two male staff (V4 and V5, Certified Nurse Assistants/CNAs) came to move him back to bed, using the mechanical lift. R1 explained that one of the men held him on his arms and the other one held him on the legs, and they put him on the mechanical lift before putting him in bed. R1 added that he complained of pain in his shoulder and collar bone area to the male staff (V4), but the nurse did not come to see him or give him any pain medication. R1 stated that his pain level at that time was 8 out of 10, and the pain was so much that he could not sleep. R1 was asked about how many hours he stayed awake because of the pain. R1 stated he could not sleep all night, and the pain made him to have a bad mood the whole day and that was why he told his family about it. R1 added that it was the following morning that the nurse gave him Tylenol. R1 stated that the Tylenol helped him a little bit. Again, R1 was asked to rate the pain after the Tylenol was given the next morning, and R1 stated that the pain went down to about 5. R1 insisted that no one gave him Tylenol on the day he fell and that it could have helped his pain if he got the pain medicine. Again, on 1/13/21 at 11:19am, R1 was asked the same questions as the previous day, and R1 gave the same answers, using the same pain rate numbers. On 1/12/21 at 11:30am, V4 (CNA) was interviewed regarding the occurrence with R1. V4 stated that after R1 was put back in bed, R1 told him about the pain and he went and told V8 (Licensed Practical Nurse/LPN) that R1 was in pain. V4 added that V8 is a part-time nurse who does not come frequently, and she was not working today (Tuesday). Two attempts to reach V8 on phone were unsuccessful on 1/12/21. On 1/13/21 at 12:05pm, V8 was interviewed regarding why R1 was not assessed and the pain was ignored two weeks ago on 12/29/20 after R1 fell , since R1's pain assessment and progress note documentation show yesterday's date (1/12/21) after the surveyor was told that she (V8) was off work. V8 responded that she was off yesterday (1/12/21) but she (V8) was told that she had to come into the facility to complete R1's pain assessment and finish up her documentation on the resident because of risk management. V8 stated that was the reason she came to the facility and did the documentation. V8's documentation for 12/29/20 that showed created date of 1/12/21 include: Pain Review, Fall Risk Review, Daily Skilled Nursing Notes, and E-MAR Pain medication documentation. R1's progress notes show that V8 made an electronic Medication Administration Record [REDACTED]. This entry shows that it was actually created on 1/12/21 at 11:58am. In addition, V8 made a Pain Review assessment dated [DATE] at 2:31pm with lock date 1/12/21 at 2:44pm regarding R1's post-fall pain that happened on 12/29/20 (two weeks ago). In addition, V8 made a Daily Skilled Nursing Notes created on 1/12/21 at 12:43pm (with the same Effective Date of 12/29/20). On 1/12/21 at 3:10pm, V2 (Nurse Consultant) was asked about these discrepancies in the time of documentation of the Pain Review assessment, Daily Skilled Nursing Notes, and the E-MAR progress notes; V2 stated that it could be that V8 started the pain assessment but did not complete it at that time. The late entry Pain Review signed by V8 on 1/12/21 that was presented by V2 shows the following incomplete assessment: #B - Pain frequency states not assessed; #C - Pain effect on function states unable to answer and not assessed. There was no record to show that the Physician or the Nurse Practitioner was notified of R1's fall or the resultant pain from the fall. On 1/13/21 at 11:35am, V9 (Nurse Practitioner) was asked if she was notified of R1's fall and the resultant pain on the shoulder and collar bone area. V9 stated that she was not notified, and that the expectation is that the nurse should notify the nurse practitioner, especially because the resident complained of pain from the fall. V9 added that if she was notified, she would have done an assessment to determine if the resident should be sent to the hospital or if he should get a different pain medication. On 1/13/21 at 11:25am, V11 (LPN) was asked what she would do if a resident fell and complained of pain on the shoulder and collar bone area. V11 stated that she would do a head to toe assessment, assess the pain on a scale of 0-10, give a prn (as needed) pain medication, document the assessment and notify the doctor, and go back to the resident after about an hour to see if the pain medication was effective. V3 (Infection Control Nurse) was asked the same question and V3 gave the same answers but added that she would ask the doctor or nurse practitioner if an X-Ray of the area should be done to make sure the resident did not have any dislocation, since he complained of pain. R1's care plan dated 11/12/20 with problem statement Alteration in comfort states in part, under interventions Complete pain assessment; Record response to [MEDICATION NAME] and adjuvant therapies, adjusting medications as needed; Medicate resident as ordered per plan; Observe resident for effectiveness of pain relief. Most of the care plan approaches/interventions were not done until two weeks later. On 1/12/21 at 3:30pm, V1 (Administrator) presented the facility policy Pain Management. This undated document states in part: Promptly and accurately assessing and diagnosing pain; Encouraging residents to self-report pain; Increasing comfort and reducing depression and anxiety in residents; Monitoring treatment efficacy and side effects; Preventing and minimizing anticipated pain when possible. A standard format for assessing, monitoring, and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. The facility did not follow this policy.

Based on observation, interview and record review, facility failed to follow the plan of care and ensure there was a working bed alarm in place and failed to follow the minimum data set assessment and provide a minimum of 2 people for bed mobility while providing direct resident care for safety for 1 of 3 (R3) residents reviewed for accidents and falls during care. This failure resulted in R3 being transported to the local hospital with a 17cm laceration to the right lower leg requiring sutures. Findings include: Incident report dated 9/6/17 states that resident had a fall and was observed on the floor with a laceration to her right lateral leg. Nursing Progress Note from 9/6/17 indicates that R3 was found lying on the floor on back and noted with blood underneath right lower leg, pressure dressing was applied to right lower leg, 911 was called immediately and R3 was sent out to local hospital for evaluation. Family and MD were made aware. E9 (certified nursing aide) was the staff member providing care for R3 at the time of the incident, however E9 was not available for interview during this survey with multiple attempts made by the survey team. Medical records reviewed indicate that R3 was admitted to local hospital on [DATE] the record indicates that R3's primary impression was blunt trauma of multiple sites and a 17cm laceration to the right leg secondary to fall requiring multiple sutures. R3 was noted to remain in the hospital for observation due to being on anti-coagulant therapy. R3 was hospitalized and received sutures to repair 17cm laceration to the right lower leg. Interview with E8 (Licensed Practical Nurse), 10/2/17 at 1pm, stated that she was in the room attending to R3's roommate and E9 (Certified Nursing Assistant) was in the room providing direct care to R3. E8 said that E9 had rolled R3 close to her and lowered the bedrails on the bed to give R3 a bath; that's why the rails are up now; so R3 doesn't fall. E8 said that she left the room and was then called back to R3's room about five minutes later because E9 reported to her that R3 had fallen out of the bed. E8 said that E9 told her she had gone to the bathroom (which is inside the room) to wet a towel and while she was in the bathroom she heard the heard a loud noise and came from the bathroom and saw that R3 had fallen from the bed to the floor. When asked if R3 is able to move around in the bed, E8 again stated that R3 does move around and that's why the side rails are up; so R3 doesn't fall. Observation on 10/2/17 at 2:45pm with E3 (Assistant Director of Nursing) and E5 (Restorative Nurse), R3 lying in bed with bilateral quarter side rails up, bed in low position, bilateral floor mats in place, bed alarm on side of bed. When tested , bed alarm did not sound. E3 checked the bed alarm and found that it was not connected to the pad and therefore not working. At this time, E5 stated that the restorative aide is responsible for checking the bed alarms to make sure they are in working condition every morning while providing range of motion exercises. E5 stated that no one had made her aware that R3's bed alarm was not working. Fall risk care plan for R3 indicates interventions 9/8/17 low bed, bilateral floor mats, and bed alarm. Interview with E5 (Restorative Nurse), 10/3/17 at 12:25pm, stated R3 is a two person assist for everything, ADL's, etc. R3 needs two people for assistance with everything because sometimes R3 can't follow instructions and gets confused and can be combative too. That's what the sign above R3's bed means, that R3 is a mechanical two people assist for bed mobility (pointing to sign above R3's bed that has the letters M and B-2 below it). A review of the MDS (Minimum Data Set) dated 7/31/17 indicates for bed mobility that R3 is coded 3 (extensive assistance) for self-performance and is coded 3 (two+ person physical assist) for support. Side rail assessment dated [DATE] indicates that R3 is extensive assist for bed mobility. Interview with E2 (Director of Nursing) on 10/4/17 at 9:43am, stated there were no fall interventions in place for R3 prior to the fall on 9/6/17 and E2 did not investigate why there was not another CNA in the room with E9 for providing R3's care.