Every finding on record at Bella Terra Morton Grove

Based on interview and record review, the facility failed to properly assist a resident with a change of plane (standing to sitting) and failed to report fall incident timely to the nurse on duty. This deficient practice affects one resident (R1) of three residents reviewed for falls. Findings include:Facility reported incident initial report, dated on 7/24/26, reads : on 7/23/26, the nurse was notified by the CNA (Certified Nursing Assistant) that R1 slid while standing to transfer from wheelchair to shower chair. Per CNA, R1 was repositioned to the wheelchair with the help of another CNA and did not fall. R1 with mild pain on her left leg and left hip with a pain score of 3/10. Pain medication was offered but declined. No visible injury were identified, and the resident was able to demonstrate full range of motion in all extremities without pain or difficulty. R1 remained in the hospital at this time for observation. CT scan revealed acute mild to moderate superior and plate compression fracture of T12 with mild osseous retropulsion. Facility's Investigation Conclusion: Based on the information gathered from the residents and staff, the likely root cause of the incident was loss of balance due to left knee buckling during an assisted transfer from wheelchair to shower chair. Contributing factors include residence history of bilateral knee osteoarthritis, lower extremity weakness, generalized weakness, impaired mobility and balance.Hospital Record, dated 7/24/26, reads: [AGE] year-old female presented after witnessed fall in the nursing home. MRI Lumbar Spine without contrast with impression of acute/subacute compression deformity of T12 with retropulsion of posterior superior and plate into the central canal contributing to mild central canal stenosis.On 8/4/26 at 11:15AM, V5 (CNA) stated R1 grabbed the bar; V5 did not have the gloves yet still putting her gloves. R1 started to grab the bar and V5 told R1 to please wait. R1 continued to stand up and V5 told R1 to sit back. When R1 tried to sit back, R1 sat at the edge of the wheelchair at first. R1's bottom was touching the seat of the wheelchair. V5 told R1 to sit back, there was not enough support, and R1 continued to slide down the wheelchair, still holding the bar. V5 stated V5 grabbed R1's upper arm to stop her from sliding, however, R1's bottom was off the wheelchair and R1's lower back was touching the edge of the wheelchair. No gait belt at the time of the fall incident, I was still putting gloves and planning to put the gait belt after the gloves. However, (R1) abruptly stood up and loss her balance.V5 also stated V5 was behind R1 and V5 was at arm's length away from the door. V5 turned her back to face the door, opened it, and saw V6 passing by and asked V6 to help V5 to put R1 back on the wheelchair. V5 stated after the transfer, V5 continued to give R1 her shower. After the shower, R1 transferred from wheelchair back to her bed, using the transfer pivot. V5 stated R1 was holding to V5's arm, as V5 holding R1's into R1's upper arm to guide her for transfer pivot to bed. V5 denied using gait belt with this transfer. V5 stated after the transfer, V5 told the nurse what had happened in the shower room, and the nurse went to see R1, and then V5 went to attend to other residents. I did not call and report to the nurse, because (R1) was not on the floor. (R)1 did not hurt herself. R1 insisted to give her shower, and so V5 continued to give R1's shower. On 8/4/26 at 11:56AM, V6 (Central Supply Manager/CNA) stated V6 was walking in the hallway, saw V5 (CNA) peeking her head from the shower room and asked for help to sit R1 back in wheelchair. V6 went in the shower and observed R1 holding the shower bar, on a squat sitting position, wheelchair behind her. Her back is touching the wheelchair but not her bottom, her bottom was off the chair, only R1's back touching the wheelchair. V6 hold on to R1's under arm and able to seat her back on to the wheelchair. V5 assisted V6 to help put R1 back to her wheelchair. V6 verified there is no gait belt in use at the time of transfer to R1.On 8/4/26 at 12:30PM, V7 (Fall Coordinator) stated the Nurse (V4) told V7 that V5 (CNA) completed the shower first and transferred R1 back to bed then reported the incident to V4.On 8/4/26 at 1:38PM, V8 (Restorative Nurse) stated R1 is one person assist, gait belt with transfer. R1 is able to stand and pivot with one person assist with the use of gait belt for safety. For safe transfer, mechanical lift device is not needed. Just gait belt and one person assistant with transfer.On 8/5/26 at 10AM, V9 (Physician Assistant) stated R1 has osteoporosis, possible contributing factor, but cannot definitively say that the compression deformity was due to R1's fall. It is possible it was from the fall, but resident also have multiple comorbidities that could also contributed. The MRI result stated acute/subacute, meaning it is not known if the findings is newer and happened after the fall, or it was already present just recently.On 8/5/26 at 10:30AM, V2 (Director of Nursing/DON) stated, Change in plane is consider a fall accident. Staff are to report right away to the nurse. Best practice always will be that the nurse should have assessed resident for any changes or new onset of pain. (V5) should have reported it immediately so therefore the nurse can properly assess the situation. If a resident is assessed to have one person assist and with the use of gait belt for safety, best practice is to follow recommended functional ability assistance.On 8/5/26 at 11AM, V1 (Administrator) stated there is no specific policy that address the requires transfer technique after a fall incident; we follow restorative assessments and recommendation of safe transfer to chair or bed.R1's record reviewed. Restorative UDA Assessment, dated 7/14/26, reads: Transfer status: One person assist/touching assistanceFacility Clinical Guidelines for Accident and Incidents, with a reviewed date of 2/5/26, reads: The facility ensures proper investigation and reporting of all accident/incidents involving residents, employee, visitors, etc. occurring in the facility premises.Witnessing an accident involving a resident, employee or visitor must report SAS occurrence to the nurse or immediate supervisor as soon as possible so that the appropriate medical attention can be provided as needed.

Based on observation, interview, and record review the facility failed to ensure that a resident was free from physical abuse by staff for one of three residents (R2) reviewed for abuse when a Certified Nursing Assistant (CNA) thrust an unused folded incontinence brief into R2's face and mouth while he was lying in bed, resulting in a distressing moment for the resident, who was made to feel humiliated and afraid for his safety. Findings include:R2 is an eighty-four-year-old resident of the facility with medical diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side; reduced mobility; bladder-neck obstruction; and benign prostatic hyperplasia without lower urinary tract symptoms.On 07/23/2026 at 11:50 AM, video footage was reviewed from a camera in R2's room provided by V11 (Family Member). In the video, time-stamped on 06/30/2026 at 6:21 AM, the following was observed: R2 was seen awake and calmly lying in bed, face up, and the head of the bed inclined at about 45 degrees. V3 (Certified Nurse Assistant) entered R2's room holding what looked like a new folded incontinence brief with the right hand. R2 told V3 he did not wish to be changed, but instead asked V3 to check his, cateri. V3 was noted confused and unable to understand what R2 referred to. R2 pointed to his catheter on his right side. V3 moved to R2's right side and understood R2 meant to say, catheter. V3 yelled at R2, stating, I can't do catheter, who told you I don't know what to do? and You want to teach me my job? V3 took R2's catheter to the bathroom to empty it, then returned with R2. R2 pointed to his catheter, then V3 looked at the catheter, and told R2, You need to pronounce it right, 'catheter!' V3 told R2, Let me change you. R2 began to protest for V3 to leave his room, stating, Get out of here. V3 took the folded brief in her right hand and, on three separate occasions, thrust it into R2's face and mouth, pulling it back each time then repeating the same quick thrusting motion with her hand, placing the corner of the diaper at the opening of R2's mouth, as R2 tried to speak. Each time, R3 was seen trying to move his head away from the approaching incontinence brief. On the third thrust, R2 tried to push the brief away with his left hand, barely lifting his left arm off the bed. R2 was also seen trying to move his legs, as he cried for help, calling out, nurse, nurse! and I don't want you, please! A nurse entered the room, and R2 told the nurse, She put it in my mouth. I want you to report it V3 replied, I put this? motioning with the brief in her hand. The nurse replied, She was just checking you. R2 told both the nurse and V3, You two don't understand.On 07/23/2026 at 11:04 AM, R2 said V3 entered his room to change him one morning. R2 said he told V3 she did not need to change him because his diaper was not dirty, but V3 insisted, and would not leave his room. R2 said V3 began arguing with him; so, he began to cry for help, saying, Somebody help me, I need help! R2 said V3 then placed the folded incontinence brief in her right hand into his mouth, three separate times. R2 said he was trying to take the brief out of his mouth, and was resisting, but could not even move his legs. R2 said he was afraid he was going to get hurt, but God was with him that day. R2 said eventually, he was heard by two nurses, who came into his room. R2 said he then told the nurses what was going on, point by point, then the nurses told V3 to leave.On 07/23/2026 at 11:04 AM, R2 was handed a facial tissue and asked to demonstrate how V3 thrust the folded incontinence brief into his face. R2 took the tissue and placed it inside his mouth.On 07/23/2026 at 11:50 AM, V11 (Family Member) said in the video footage taken from R2's room on 06/30/2026 at 6:21 AM, one could see V3 put the diaper in R2's mouth, three times. V3 said R2 was defenseless, and she would not allow anyone to hurt R2.On 07/23/2026 at 10:00 AM, V1 (Administrator) said V3 was immediately suspended then terminated due to her behavior, customer service, and tone.The facility's final abuse report, dated 07/06/2026, stated the allegation of abuse regarding R2 on 06/30/2026 was substantiated by the facility.The police report from 07/01/2026 by V12 (Police Officer) stated V12 was dispatched on 06/30/2026 to the facility where R2 resided for a battery report. V12 stated V11 showed him a video in which it appeared V3 placed the diaper in/or around R2's mouth three times.The facility's Abuse and Retaliation Policy, revised 07/03/2026, states, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse.

Based on interviews and record review, the facility failed to not follow their Facilities Physician Orders Policy to ensure all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's order and failed to ensure to follow physician orders as it is written in the POS (physician order summary). This failure affected 1 resident (R8) out of 3 residents (R4 and R9) reviewed for Quality of Care/Treatment.Based on interviews and record review, the facility failed to not follow their Facilities Physician Orders Policy to ensure all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's order and failed to ensure to follow physician orders as it is written in the POS (physician order summary). This failure affected 1 resident (R8) out of 3 residents (R4 and R9) reviewed for Quality of Care/Treatment.On 7/17/2026 at 3:01PM, V10 stated it was reported to V10 on 6/8/2026 by the hospital nurse, R8 was having a dose of IV antibiotic for R8s bacterial meningitis, around 5:00PM before they transferred R8 to the facility. R8s next dose at the facility should have been around 9:00PM on 6/8/2026 because the medication Ampillcin IV is ordered every 4 hours. R8 did not get her medication that night on June 8, 2026.On 7/15/2026 at 1:56PM V3 (Director of Nursing/DON) stated R8 did not receive R8s scheduled Intravenous (IV) antibiotic medication as ordered by the physician on June 8, 2026, and June 9 2026 because the facility did not have R8s IV medication.On 7/17/2026 at 10:32 AM V14 (Infectious Disease Physician) stated R8 should have received R8s scheduled IV medication at the Nursing Facility but R8 did not.Record Review of R8s Hospital After Visit Summary dated 6/8/2026 documents medication list R8s last dose of Ampicillin 2 g, was administered on June 8, 2026, at 4:58PM. Ampicillin 2g injection into the vein every 4 hours for 31 doses through 6/13/2026.Record review of facilities census list for R8 actual admission on [DATE] at 7:00PM.Record review of facilities Physician Order Summary Report (POS) for R8 documents, Ampicillin Sodium Injection Solution Reconstituted 2GM (Ampicillin Sodium) Use 2 gram intravenously every 4 hours for bacterial meningitis; Sepsis, for 31 days, Administrations order date 6/8/2026, start date 6/9/2026.Record reviewed of R8s Medication Administration Record (MAR) documents June 2026- Ampicillin Sodium Injection Solution Reconstituted 2 gram intravenously every 4 hours for bacterial meningitis for 31 Administrations- Start Date 06/09/2026 2:00AM. June 9, 2026, times 2:00 AM, 6:00 AM, 10:00AM, 2:00PM documents NN indicating=Other/see progress notes.Record review of R8s progress note 6/9/2026 2:38AM and 6/9/2026 at 6:34AM Medication Administration Note Documents Ampicillin Sodium Injection Solution Reconstituted 2 GM- new admission- medication on order. 6/9/2026 09:03AM and 6/9/2026 at 1:01PM Medication Administration Note Documents Ampicillin Sodium Injection Solution Reconstituted 2 GM- On order. Policy and Procedures Titled: Physician Orders revised 7/8/2026Policy statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's order. The facility shall ensure to follow physician orders as it is written in the POS (physician order summary).Procedures: Physician orders will be carried out at a reasonable time.

Based on interview and record review, the facility failed to ensure monitoring and supervision of a bedbound, high fall-risk resident on strict COVID isolation, and failed to consistently implement required fall prevention interventions. This failure affected one (R1) of four residents reviewed for safety and supervision and resulted in R1 not being visually observed or assessed for a period of over two hours and culminated in R1 being found unresponsive on the floor and pronounced deceased in the facility. Findings include:R1 is a [AGE] year-old male, admitted in the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus with Hyperglycemia; COVID 19; Unspecified Injury of Head, Subsequent Encounter; Encounter for Surgical Aftercare following Surgery on the Nervous System; Syncope and Collapse; and Paroxysmal Atrial Fibrillation. MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 11 which means moderate impairment in cognition. MDS also recorded R1 uses wheelchair and had not attempted to walk due to medical conditions or safety concerns. R1's POS (Physician Order Sheet) recorded:[DATE] - Isolation-droplet precautions, Reason for isolation: COVID 19 positive every shift[DATE] - May need to use 2 1/2 partial bedrails to enhance functional independence and promote skin integrity. Fall risk evaluation dated [DATE] documented R1 scored 9, meaning high risk for fall. According to progress notes dated [DATE] documented at 9:12 AM, R1 was observed on the floor, unresponsive and not breathing. Vital signs taken, blood pressure 106/66; pulse rate 171; respiration was 0; oxygen saturation was 54% room air. Cardiopulmonary resuscitation (CPR) started; nonrebreather mask applied with 15 liters of oxygen; intravenous access was attempted to be started; additional help arrived; Automated External Defibrillator (AED) applied; shock was not advised twice. Paramedics arrived and took over. At 9:58 AM, R1 was pronounced dead. On [DATE] at 3:29 PM, V5 (Agency Certified Nursing Assistant, CNA) was asked regarding R1. V5 stated, On [DATE], I did not see him at all. My shift starts at 7AM to 3PM. When I arrived that morning, the night shift CNA was not there so I did not get any reports for residents. I asked the nurse on duty for reports for the group I had, she said she is not familiar, so I need to ask the night shift nurse. We did not go room to room. We did not go to his room. The only report I got for him was to check and change and he has COVID. Around 8-8:15 AM, I went to his room to pass his breakfast tray. When I went there, he was not in his bed. I thought he went out for an appointment. I didn't check the bathroom; I didn't go around the room. I didn't see him in the room. I did not check the other side of the bed. His bed, at the time, was not in a low position. There were no side rails up on both sides of the bed. I left and continued to pass the breakfast trays. I went back to his room an hour later to get his tray, but it was untouched. I asked the nurse, said he may be in dialysis, I said, Oh, ok, I will leave his tray and warm it up later. An hour later, they found him and came to let me know what was going on. It was my first time taking care of him.On [DATE] at 3:57 PM, V6 (Social Services Director) was interviewed regarding R1 and incident on [DATE]. V6 replied, On that day, I was doing rounds, between 9 to 10 AM. He was in isolation for COVID. I knocked, no response, so I entered the room. I didn't see him in the bed. So I went around the bed, I noticed his feet and legs sticking out from under the bed. Most of his body was under the bed. I found him in that space under the bed, between the window and the bed. I tried to call his name he did not respond. I called the nurses. They went to the room and took over from there. His bed was not in the lowest position. I don't know if he was high risk for fall. He was unresponsive at the time. On [DATE] at 10:35 AM, V7 (Licensed Practical Nurse, LPN/Rehab Nurse) was asked regarding R1's incident on [DATE]. V7 verbalized, It was V4 (Registered Nurse, RN) who was the nurse on duty for R1. R1 was COVID positive and was placed in a single room for isolation. I just finished passing morning medications and was sitting at the nurses' station, V6 came to me, and said he (R1) was on the floor in his room. It was around 9:15 AM. Myself and V4 responded to his room immediately. We noticed that he was laying between the heater and bed, more on under the bed, unresponsive. We didn't see his chest rising, no eyes opening, no verbalization, no communication. He was under the bed; the bed was not in lowest position. We called code and started CPR (cardiopulmonary resuscitation); he was full code. Oxygen was also administered. Paramedics came and took over. V7 was asked regarding R1's mobility and monitoring. V7 continued, He needs assistance with mobility, he was bedbound, unable to walk. He was not a dialysis patient. He was on isolation for COVID 19. We monitor residents on isolation every hour. Nurses do odd numbered times and CNAs do even numbered times. It was an agency CNA who worked with him (R1) at that time. When agency CNA comes in, I usually ask them if they have worked here before and if they verbalized, they were and know their assignments, I'll just tell them to call me if they have any questions. If they verbalized, they haven't been here, I print the census and I go from room to room and endorse accordingly. To my knowledge, they said he (R1) was last seen at 6:30 AM. V9 (LPN) mentioned during interview on [DATE] at 10:55 AM that R1 was alert, oriented to self and place, needs assistance, can't walk, bedbound. V9 also emphasized that every hour monitoring should be performed to residents on isolation; also making sure fall interventions such as bed in lowest position, side rails up as ordered; should be in place for fall risk residents. R1 is on strict isolation precautions and high risk for fall. On [DATE] at 11:34 AM, V4 was asked regarding R1 and incident on [DATE]. V4 stated, He was alert but spoke different language. He was in isolation, in a private room. He was COVID positive, on complete isolation; door is to be closed. On [DATE], I got reports in the morning that he was sleeping in bed comfortably during night shift and had no issues. I went to pass medications. I passed the medications until 9 AM. I have not physically seen him since I started working for the morning shift. My shift starts at 7 AM. But the CNA (V5) passed trays around 7:30 AM to 8 AM, I assumed she (V5) passed his tray and seen him. Around 9 AM, somebody called code blue, and everybody was rushing to his room. I went there, me and V7. He was on the floor, under the bed, unresponsive, pulseless. We called for help. CPR started. Paramedics were called, came in and took over. He passed away in the facility. For isolation residents, we monitor them every one to two hours for vital signs, making sure they are okay. He had COVID and coughing, unable to walk. I believed the CNA (V5) mentioned that he (R1) was not in his room. I was busy with medication passing that time and not thinking, and since I had another resident going out for an appointment that day and a dialysis patient, I told her (V5) that he (R1) might be in dialysis. I got mixed up with another resident, my mistake, and not thinking. I didn't check him (R1) in his room to verify. Since he was in isolation, he should be monitored every one to two hours. He was not a fall risk resident. For fall risk resident, we always make sure the bed at the lowest position. On [DATE] at 12:01 PM, V11 (RN/Fall Coordinator) was asked regarding R1's monitoring and fall interventions. V11 verbalized, Based on my evaluation he was a high fall risk. We implemented call light within reach, personal items within reach, no clutter on the floor, reminders to ask for assistance, bed in low position always, changing positions slowly especially when transferring, both quarter length side rails up all the time. He sometimes plays with the bed remote but we have to make sure his bed is in low position. He was alert, oriented, speaks little English. He was able to verbalize needs and wants. R1 was on isolation for COVID 19 positive. In preventing falls on residents on isolation, staff need to do rounds every one hour and check residents' status; make sure all the interventions in the care plan are followed, especially bed position, bedside table and personal items within reach. During change of shift, the outgoing staff should give reports to incoming staff related to residents. R1's care plan documented:1.High risk for falls related to decline in functional status, impaired balance during transitions, impulsivity or poor safety awareness, muscle weakness, syncope and history of falls prior to admission ([DATE]):Intervention: Prefer to keep the bed in the low position for safety. 2. Has an active COVID 19 diagnosis, requires a single room, strict isolation, and contact droplet precautions ([DATE]):Intervention: Monitor resident for change in condition especially with respiratory distress. 3. May need to use 2 1/2 partial bedrails to enhance functional independence and promote skin integrity ([DATE]):Interventions: Would like to utilize (2) partial siderails to define bed parameters; Would like to use (2) partial siderails (2) to prevent potential for injury related to medical condition. On [DATE] at 12:28 PM, V3 (Assistant Director of Nursing/Infection Control Preventionist) stated during interview, For residents on isolation or COVID positive, the doors should be closed; monitoring should be done every hour for COVID residents. We assigned the nurses to do the odd numbers for the hour rounding and CNAs will do the even number hours. We check the residents' condition, if they are having respiratory symptoms, we have to do vital signs, assess resident and notify physician and family regarding change in condition. We also have to check fall mats, call light, bed in lowest position, half side rails to make sure everything is in place for high fall risk residents. On [DATE], he (R1) was in isolation due to being COVID positive. He should be on strict isolation and monitored on an hourly basis. We have an internal policy called routine resident checks which was in service to staff. Staff shifts start at 7 AM to 3:30 PM; 3 PM to 11:30 PM and 11:00 PM to 7:30 AM. For isolation residents, we educated staff to do hourly rounds. They do the documentation for the hourly rounds in the progress notes. A review of R1's progress notes dated [DATE] showed no documentation that he was observed and monitored every hour that started [DATE] when he was placed on isolation precautions. On [DATE] at 10:25 AM, V14 (RN) was asked regarding R1's condition on [DATE] night shift. V14 stated, On [DATE], I was the night nurse for him. He had COVID, he was placed on isolation. He was bedbound, unable to walk. On [DATE], report was given to morning nurse V4. He (R1) had no concern during night shift, with stable vital signs, and took his medications without any problems. I saw him at 6:30 AM and he was in bed, lowest position, sleeping comfortably. No signs of distress were noted. He was in isolation, and we do hourly monitoring on him. We go to his room and check, assess him for any unusual signs. CNAs also do rounds alternating with nurses but I do it every hour. We don't document the hourly observation; we were told not to do documentation. On [DATE] at 2:15 PM, V13 (Medical Director) was interviewed regarding expectation on staff related to monitoring and fall prevention. V13 stated, Facility has a clear protocol for monitoring patients/residents. CNAs and nurses see patients/residents during rounds. Nurses distribute medications and able to see residents. CNAs has protocol for fall residents that they follow. Nurses and CNAs see residents at the beginning of their shift and see residents every two hours to check, especially incontinent residents, regardless if these residents are on isolation or not. Nurses has to check if patients/residents are not in room. When I do rounds and do not see resident in room, I ask nurses. Nurses should be aware where their residents are. V2 (Director of Nursing) also verbalized during interview on [DATE] at 11:20 AM, After endorsements, nurses need to do the hand off, meaning they need to check the residents physically after endorsements to check. For isolation residents, staff need to check every two hours, odd and even numbers meaning every hour. Staff need to see residents prior to start of shift. R1 was last seen at 6:30 AM. At 9:12 AM, R1 was observed on the floor, unresponsive and not breathing. At 9:58 AM, R1 was pronounced dead. R1's death certificate dated [DATE] recorded Cardiac Arrythmia; Atrial Fibrillation and Cerebrovascular Disease as causes of death. Facility's policy titled Routine Resident Checks dated [DATE], stated in part but not limited to the following:Purpose: Nursing staff will make structured and regularly scheduled routine resident checks to help proactively maintain resident safety, comfort, care needs and well-being. Procedures and Implementation:To promote the safety and well-being of our residents, nursing staff shall make initial rounds upon starting the shift and then routine checks on each unit at least every 2 hours (e.g.8 hour or 12 hour shift) and/ or as often as needed concordant to the resident's needs.Routine resident checks involve entering resident's room and/ or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concern, monitor vital signs as indicated and see if the resident is sleeping, needs toileting assistance, safe and etc. Facility's policy titled, Fall Occurrence dated [DATE] documented in part but not limited to the following:Policy Statement:It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Based on observation, interviews and record review, the facility failed to ensure that a cognitively and visually impaired resident (R1) of 3 residents reviewed in the sample of 3, was treated with respect and dignity during the provision of care. This failure resulted in physical harm when two Certified Nursing Assistants (CNAs) were observed on video being physically rough with R1, including forcefully pushing the resident's head and torso down on the bed while resident was actively resisting and crying out, threatening the resident to stop screaming, and slapping the resident's face during care. Findings include:R1 is a [AGE] year old with severe cognitive impairment, visual and verbal impairments, and with diagnoses including but not limited to Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. MDS (minimum data set) dated 5/22/25 showed R1 with severe cognitive impairment, with behaviors, and was dependent in performing activities of daily living. R1's care plan dated 5/13/25 reads in part, (R1) is High risk of being a recipient or perpetrator of mistreatment due to Dementia, Major Depressive Disorder. (R1) will be treated with respect, dignity and reside in the facility free of mistreatment through next review. Interventions: Conduct appropriate assessments to promote knowledge and understanding of the resident's past. Identify if there are behaviors or factors from the past that should be considered in treatment planning. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help her feel safe.A two minute video clip provided to surveyor by R1' family showed V6 (CNA) telling R1 resident You're wet, your wet! Put your head down, I told you to put your head down! R1 is heard shrieking loudly No! No! V6 was observed in the video pushing R1's head down and restraining his chest in order to prevent the resident from getting up while V7 (CNA) is at the foot of the bed removing and pulling the resident's pants and incontinence briefs in a swift and rough manner causing the resident to give a very audible shriek. R1 was shown screaming, visibly frightened, and resisting care. No nursing supervisor appeared to have been called, and the care continued despite the resident's clear distress. Near the end of the video, V6 says to R1 again, I told you not to scream and then proceeds to slap on the right side of the residents face, whereupon the video ends.On 6/16/25 at 9:40 AM, V1 administrator was asked to provide R1's incident reported to the Illinois Department of Public Health. Surveyor asked to view the video of the incident that was sent to facility by R1's family who had permission to install a surveillance camera in the room. V1 said he no longer possessed the video but was able to explain what he observed in the video when asked by the surveyor. V1 indicated that the two CNA's (V6 and V7) were seen changing the resident in bed and that the actions of V6 and V7 did not meet the standards of the facility so they were immediately suspended and then terminated. Surveyor asked V1 to clarify his meaning of not meeting the standards, V1 said that at one point in the video, V6 had slapped the resident on the cheek which was ultimately the deciding factor in terminating (V6). Surveyor asked if V7 (CNA) in the video he viewed warranted termination, V1 indicated only that it did not meet the facility standard but declined to go into detail except that (V7)was also terminated due to an abundance of caution. The facility's internal incident report showed however V7 was terminated due to not reporting the incident immediately to her immediate supervisor.Facility's internal incident report provided by V1 to surveyor, reads in part, On 5/22/25 around 2:25 PM family showed video footage of R1 having ADL (activity of daily living) done with him on 5/21/25 at around 2 PM. The video shows V6 (CNA) and V7(CNA) attempting to change (R1). (R1) was attempting to pick his head up while care was being done to him. V6 was redirecting him back to a laying position. V7 was on the other side removing R1's clothes. V5 LPN did a head to toe assessment, completed, resident did not have any abnormalities and did not complain of any pain and/or discomfort. (V6) and (V7) were both suspended. Police were notified. (This report failed to report the audible screams and resisting care of R1, the threats made towards R1 to stop screaming, and failed to report the face slap shown in the video.)On 6/16/25 at 10:20 AM, R1 was observed in the dining area attending an activity. R1 was seated in a wheelchair and seated behind a table. Surveyor asked how he was doing but the resident was unable to respond. V5 LPN was asked about R1 and said that R1 was non-verbal but had behaviors of screaming out mostly when he is in bed or during care but sometimes when he is seated in the dining room he would just scream out for no reason. Surveyor asked what staff did when R1 exhibited these behaviors, V5 said that they would try to calm him down but did not indicate how. On 6/16/25 10:30 V2 director of nursing said that V4 (assistant administrator) notified her about two CNA's assisting (R1). V2 described her observation of the video to surveyor and said, They are changing him in bed and (R1) has behavior of shouting. At the time of changing, he (R1) was also attempting to get up and the male CNA (V6) was trying to put him back to bed 2 times and he put his left hand on his forehead and the other had pushing on the resident's shoulder. I saw it twice (referring to the video). After that (R1) continues to be loud, They continued changing him and after changing him, I also saw V6 tapping the resident's cheek. R1 wasn't shouting after V6 tapped the resident's cheek but prior to that he was shouting. They repositioned him on the bed and that's all I saw. Surveyor asked if the actions of V6 and V7 rose to the level of abuse, V2 said, No and that V6's tap was more of a love tap directed at the resident. Surveyor asked if the two CNA's she viewed in the video were too rough with the resident, V2 declined to answer and said, It didn't meet our standard. echoing the same phrase V1 had stated to the surveyor. On 6/18/25 at 12:15 PM, V7 (CNA) said that she had asked V6 her coworker to help her change R1's diapers. V7 said she did not know what they did wrong and spoke with V1 administrator about the incident. Surveyor asked if she had any type of training on how to manage R1's behaviors, V7 indicated she did online training on abuse but did not get any specifics from anyone about R1. Surveyor asked what she should do if a resident resists care, V1 said that she didn't think R1 was resisting because the resident always cry out like he did when they changed him. Surveyor asked if she saw V6 push R1's head down or slap the resident's face, V7 said she did not because she was busy cleaning up the resident but indicated that they both may have been too rough with R1. Surveyor asked if she recalled ever getting trained on de-escalation of resident behaviors or any dementia training, V7 said she could not recall any but remembered just signing in on an inservice sheet. V7 said They floated me around but did not train me in dementia. Surveyor asked if the administrator or anyone showed them the video of when they were changing R1, V7 indicated she did not see the video. Surveyor asked if she was aware that her actions were being recorded in the room, V7 indicated that they were told and that there were signs saying so on the door.On 6/18/25 at 4:30 PM, V6 (CNA) said he should not have been terminated because he is a good CNA and was just helping another coworker out. Surveyor asked if he was aware R1 was confused and could not understand direction, V6 said that he knew this but indicated sometimes the resident listened to him. Surveyor asked if he pushed R1's head down on the bed and/or slapped him in the face, V6 said that he tried to push his head down because the resident kept trying to get up when they were changing him. V6 added that he gave the resident several light taps to the cheek but that he should not have done that looking back on it. Surveyor asked if he received any training on de-escalating of R1's behaviors or dementia training in general, V6 said he could not recall. Surveyor asked if a resident is resistant to care, what he would do in the future, V6 stated, (R1) wasn't resisting, that's how the resident is.Facility policy on resident rights reads in part but not limited to, No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, The Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the Community, nor shall a resident forfeit any of the following rights: Resident rights. The resident has a right to a dignified existence, self-determination, and those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Respect and Dignity. The resident has a right to be treated with respect and dignity, including the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience.

Based on observation, interviews and record review, the facility failed to train/monitor staff on behavior de-escalation, failed to protect a cognitively and visually impaired resident from abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3.This failure resulted in physical and emotional harm inflicted on a vulnerable resident when two Certified Nursing Assistants (CNAs) were observed on video footage being physically rough with R1, including forceably pinning the resident's head and torso down on the bed while resident was actively resisting and crying out, threatening the resident to stop screaming, and slapping the resident's face during care. Findings include: R1 is a [AGE] year old with severe cognitive impairment, visual and verbal impairments, and with diagnoses including but not limited to Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. MDS (minimum data set) dated 5/22/25 showed R1 with severe cognitive impairment, with behaviors, and was dependent in performing activities of daily living. R1's abuse risk assessment dated [DATE], 4/18/2025, and 5/22/2025 all scored at 3 and 4 demonstrating At Risk with any score above a 2. R1's care plan dated 5/13/25 reads in part, (R1) is High risk of being a recipient or perpetrator of mistreatment due to Dementia, Major Depressive Disorder. (R1) will be treated with respect, dignity and reside in the facility free of mistreatment through next review. Interventions: Conduct appropriate assessments to promote knowledge and understanding of the resident's past. Identify if there are behaviors or factors from the past that should be considered in treatment planning. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help her feel safe. On 6/16/25 at 9:40 AM, V1 administrator was asked to provide R1's abuse incident reported to the Illinois Department of Public Health. Surveyor asked to view the video of the incident that was sent to facility by R1's family who had permission to install a surveillance camera in the room. V1 said he no longer possessed the video but was able to explain what was observed in the video when asked by the surveyor. V1 indicated that the two CNA's (V6 and V7) were seen changing the resident in bed and that the actions of V6 and V7 did not meet the standards of the facility so they were immediately suspended and then terminated. Surveyor asked V1 to clarify his meaning of not meeting the standards, V1 said that at one point in the video, V6 had slapped the resident on the cheek which was ultimately the deciding factor in terminating V6. Surveyor asked if V7 (CNA) in the video he viewed warranted termination as well, V1 indicated only that V7 did not meet the facility standard but declined to go into detail except V7 was also terminated due to an abundance of caution. The facility's internal incident report showed however V7 was terminated due to not reporting the incident immediately to her immediate supervisor as per the facility's abuse policy. Facility's internal incident report provided by V1 to surveyor, reads in part, On 5/22/25 around 2:25 PM family showed video footage of R1 having ADL (activity of daily living) done with him on 5/21/25 at around 2 PM. The video shows V6 (CNA) and V7(CNA) attempting to change (R1). (R1) was attempting to pick his head up while care was being done to him. V6 was redirecting him back to a laying position. V7 was on the other side removing R1's clothes. V5 LPN did a head to toe assessment, completed, resident did not have any abnormalities and did not complain of any pain and/or discomfort. (V6) and (V7) were both suspended. Police were notified. (This report failed to discribe the audible screams and resistance to care of R1, the threats made towards R1 to stop screaming, and failed to report the face slap shown in the video.) On 6/16/25 at 10:20 AM, R1 was observed in the dining area attending an activity. R1 was seated in a wheelchair and seated behind a table and appeared withdrawn and looking down at the table. Staff did not appear to try to engage the resident in any activity. Surveyor asked the resident how he was doing but the resident was unable to respond. V5 LPN was asked about R1 and said that R1 was non-verbal but had behaviors of screaming out mostly when he is in bed or during care but sometimes when he is seated in the dining room he would just scream out for no reason. V5 indicated that R1 had been relatively calm, almost withdrawn lately. Surveyor asked what staff did when R1 exhibited these screaming behaviors, V5 said that they would try to calm him down but did not indicate how. Surveyor asked if she was the nurse that assessed R1 after the incident involving the two CNA's on the video, V5 indicated she assessed the resident but that it was the following day of the incident so she really did not see any physical signs so that was what she wrote in her report. On 6/16/25 10:30 V2 director of nursing said that V4 (assistant administrator) notified her about two CNA's assisting (R1). V2 described her observation of the video to surveyor and said, They are changing him in bed and (R1) has behavior of shouting. At the time of changing, he (R1) was also attempting to get up and the male CNA (V6) was trying to put him back to bed 2 times and he put his left hand on his forehead and the other had pushing on the resident's shoulder towards the bed. I saw it twice (referring to the video). After that (R1) continued to be loud. They continued changing him and after changing him, I also saw V6 tapping the resident's cheek. R1 wasn't shouting after V6 tapped the the resident's cheek but prior to that he was shouting. They repositioned him on the bed and that's all I saw. Surveyor asked if the actions of V6 and V7 rose to the level of abuse, V2 said, No and that V6's tap was more of a love tap directed at the resident. Surveyor asked if the two CNA's she viewed in the video were too rough with the resident, V2 declined to answer and said, It didn't meet our standard. echoing the same phrase V1 had stated to the surveyor. A two minute video clip provided to surveyor by R1' family showed V6 (CNA) repeatedly telling the confused resident R1 You're wet, your wet! Put your head down, I told you to put your head down! R1 is heard shrieking loudly No! No! V6 was observed in the video pushing R1's head down and restraining his chest in order to prevent the resident from getting up while V7 (CNA) is at the foot of the bed removing and pulling the resident's pants and incontinence briefs in a swift and rough manner causing the resident to give a very audible shriek. R1 was shown screaming, visibly frightened, and resisting care. No nursing supervisor appeared to have been called, and the care continued despite the resideint's clear distress. Near the end of the video, V6 says to R1 again, I told you not to scream and then proceeds to slap the the right side of the residents face whereupon the video ends. On 6/18/25 at 12:15 PM, V7 (CNA) said that she had asked V6 her coworker to help her change R1's diapers. V7 said she did not know what they did wrong and spoke with V1 administrator about the incident. Surveyor asked if she had any type of training on how to manage R1's behaviors, V7 indicated she did online training on abuse but did not get any specifics from anyone about R1. Surveyor asked what she should do if a resident resists care, V1 said that she didn't think R1 was resisting because the resident always cry out like he did when they changed him. Surveyor asked if she saw V6 push R1's head down or slap the resident's face, V7 said she did not because she was busy cleaning up the resident but indicated that they both may have been too rough with R1. Surveyor asked if she recalled ever getting trained on de-escalation of resident behaviors or any dementia training, V7 said she could not recall any but remembered just signing in on an inservice sheet. V7 said They floated me around but did not train me in dementia. Surveyor asked if the administrator or anyone showed them the video of when they were changing R1, V7 indicated she did not see the video. Surveyor asked if she was aware that her actions were being recorded in the room, V7 indicated that they were told and that there were signs saying so on the door. On 6/18/25 at 4:30 PM, V6 (CNA) said he should not have been terminated because he is a good CNA and was just helping another coworker out. Surveyor asked if he was aware R1 was confused and could not understand direction, V6 said that he knew this but indicated sometimes the resident listened to him. Surveyor asked if he pushed R1's head down on the bed and/or slapped him in the face, V6 said that he tried to push his head down because the resident kept trying to get up when they were changing him. V6 added that he gave the resident several light taps to the cheek but that he should not have done that looking back on it. Surveyor asked if he received any training on de-escalating of R1's behaviors or dementia training in general, V6 said he could not recall. Surveyor asked if a resident is resistant to care, what he would do in the future, V6 stated, (R1) wasn't resisting, that's how the resident is. Abuse policy revised 4/24/25 titled Abuse and Neglect reads in part, It is the policy of the facility to provide professional care and services in an environment that is free from any types of abuse, corporal punishment, neglect or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Types of abuse and examples: 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means. Examples: Hitting, slapping, twisting, squeezing, and roughly handing. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. Training: Train employees, through orientation and on-going sessions on issues related to abuse prohibition, neglect, exploitation, misappropriation of property such as Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents.

Based on observation, interview, and record review, the facility failed to implement the care plan interventions related to behavioral management for one (R1) of 3 residents reviewed for care plans in the sample of 3 cognitively impaired residents. Two Certified Nursing Assistants (CNAs) did not follow the care-planned strategies for managing care-resistant behavior, resulting in a care interaction that placed the resident at risk for emotional distress and escalation. Findings include: R1 is a [AGE] year old with severe cognitive impairment, visual and verbal impairments, and with diagnoses including but not limited to Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. MDS (minimum data set) dated 5/22/25 showed R1 with severe cognitive impairment, with behaviors, and was dependent in performing activities of daily living. R1's care plan dated 5/13/25 reads in part, (R1) is High risk of being a recipient or perpetrator of mistreatment due to Dementia, Major Depressive Disorder. (R1) will be treated with respect, dignity and reside in the facility free of mistreatment through next review. Interventions: Conduct appropriate assessments to promote knowledge and understanding of the resident's past. Identify if there are behaviors or factors from the past that should be considered in treatment planning. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help her feel safe. Another care plan dated 3/6/24 reads in part, Verbally physically aggressive behavior.(R1) demonstrates behavioral distress Being challenged by a dementia related illness, Ineffective coping mechanisms, Poor self-esteem, feelings of inadequacy, Poor verbal skills and inability to express self in more appropriate language. He frequently screams/yells when receiving shower or being toileted despite staff's re-direction and encouragement. Goal: (R1) will refrain from verbally and/or physically aggressive behavior following staff interventions through next review. Interventions: Compliment resident on successfully completing meals and group activities without inappropriate behavior. Explain Rules of Conduct and each person's obligation to treat others with dignity and respect at all times. Intervene by speaking calmly and professionally in a soft tone of voice. Staff should avoid raising own voice, since this tends to make him more upset. This may cause the situation to escalate. Facility's internal incident report provided by V1 to surveyor, reads in part, On 5/22/25 around 2:25 PM family showed video footage of R1 having ADL (activity of daily living) done with him on 5/21/25 at around 2 PM. The video shows V6 (CNA) and V7(CNA) attempting to change (R1). (R1) was attempting to pick his head up while care was being done to him. V6 was redirecting him back to a laying position. V7 was on the other side removing R1's clothes. V5 LPN did a head to toe assessment, completed, resident did not have any abnormalities and did not complain of any pain and/or discomfort. (V6) and (V7) were both suspended. Police were notified. (This report failed to document the audible screams and resistance to care of R1, the threats made towards R1 to stop screaming, and failed to report the face slap shown in the video.) On 6/16/25 at 10:20 AM, R1 was observed in the dining area attending an activity. R1 was seated in a wheelchair and seated behind a table and appeared withdrawn and looking down at the table. Staff did not appear to try to engage the resident in any activity. Surveyor asked the resident how he was doing but the resident was unable to respond. V5 LPN was asked about R1 and said that R1 was non-verbal but had behaviors of screaming out mostly when he is in bed or during care but sometimes when he is seated in the dining room he would just scream out for no reason. V5 indicated that R1 had been relatively calm, almost withdrawn lately. Surveyor asked what staff did when R1 exhibited these screaming behaviors, V5 said that they would try to calm him down but did not indicate how. Surveyor asked if she was the nurse that assessed R1 after the incident involving the two CNA's on the video, V5 indicated she assessed the resident but that it was the following day of the incident so she really did not see any physical signs so that was what she wrote in her report. On 6/16/25 10:30 V2 director of nursing said that V4 (assistant administrator) notified her about two CNA's assisting (R1). V2 described her observation of the video to surveyor and said, They are changing him in bed and (R1) has behavior of shouting. At the time of changing, he (R1) was also attempting to get up and the male CNA (V6) was trying to put him back to bed 2 times and he put his left hand on his forehead and the other had pushing on the resident's shoulder towards the bed. I saw it twice (referring to the video). After that (R1) continued to be loud. They continued changing him and after changing him, I also saw V6 tapping the resident's cheek. R1 wasn't shouting after V6 tapped the the resident's cheek but prior to that he was shouting. They repositioned him on the bed and that's all I saw. Surveyor asked if the actions of V6 and V7 rose to the level of abuse, V2 said, No and that V6's tap was more of a love tap directed at the resident. Surveyor asked if the two CNA's she viewed in the video were too rough with the resident, V2 declined to answer and said, It didn't meet our standard. echoing the same phrase V1 had stated to the surveyor. A two minute video clip provided to surveyor by R1' family showed V6 (CNA) repeatedly telling the confused resident R1 You're wet, your wet! Put your head down, I told you to put your head down! R1 is heard shrieking loudly No! No! V6 was observed in the video pushing R1's head down and restraining his chest in order to prevent the resident from getting up while V7 (CNA) is at the foot of the bed removing and pulling the resident's pants and incontinence briefs in a swift and rough manner causing the resident to give a very audible shriek. R1 was shown screaming, visibly frightened, and resisting care. No nursing supervisor appeared to have been called, and the care continued despite the resident's clear distress. Near the end of the video, V6 says to R1 again, I told you not to scream and then proceeds to slap the the right side of the residents face whereupon the video ends. On 6/18/25 at 12:15 PM, V7 (CNA) said that she had asked V6 her coworker to help her change R1's diapers. V7 said she did not know what they did wrong and spoke with V1 administrator about the incident. Surveyor asked if she had any type of training on how to manage R1's behaviors, V7 indicated she did online training on abuse but did not get any specifics from anyone about R1. Surveyor asked what she should do if a resident resists care, V1 said that she didn't think R1 was resisting because the resident always cry out like he did when they changed him. Surveyor asked if she saw V6 push R1's head down or slap the resident's face, V7 said she did not because she was busy cleaning up the resident but indicated that they both may have been too rough with R1. Surveyor asked if she recalled ever getting trained on de-escalation of resident behaviors or any dementia training, V7 said she could not recall any but remembered just signing in on an inservice sheet. V7 said They floated me around but did not train me in dementia. Surveyor asked if the administrator or anyone showed them the video of when they were changing R1, V7 indicated she did not see the video. Surveyor asked if she was aware that her actions were being recorded in the room, V7 indicated that they were told and that there were signs saying so on the door. On 6/18/25 at 4:30 PM, V6 (CNA) said he should not have been terminated because he is a good CNA and was just helping another coworker out. Surveyor asked if he was aware R1 was confused and could not understand direction, V6 said that he knew this but indicated sometimes the resident listened to him. Surveyor asked if he pushed R1's head down on the bed and/or slapped him in the face, V6 said that he tried to push his head down because the resident kept trying to get up when they were changing him. V6 added that he gave the resident several light taps to the cheek but that he should not have done that looking back on it. Surveyor asked if he received any training on de-escalating of R1's behaviors or dementia training in general, V6 said he could not recall. Surveyor asked if a resident is resistant to care, what he would do in the future, V6 stated, (R1) wasn't resisting, that's how the resident is.

Based on observation, interviews, and record review, the facility failed to ensure that services provided to one (R1) of 3 residents in the sample of 3 with cognitively impairment met professional standards of quality; specifically two Certified Nursing Aides (CNAs) did not follow the established plan of care for managing care-resistant behavior, engaged in physically rough handling of the resident during care, and failed to utilize person-centered behavior interventions resulting in care interaction that did not meet accepted clinical practice standards. Findings include: R1 is a [AGE] year old with severe cognitive impairment, visual and verbal impairments, and with diagnoses including but not limited to Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. MDS (minimum data set) dated 5/22/25 showed R1 with severe cognitive impairment, with behaviors, and was dependent in performing activities of daily living. R1's care plan dated 5/13/25 reads in part, (R1) is High risk of being a recipient or perpetrator of mistreatment due to Dementia, Major Depressive Disorder. (R1) will be treated with respect, dignity and reside in the facility free of mistreatment through next review. Interventions: Conduct appropriate assessments to promote knowledge and understanding of the resident's past. Identify if there are behaviors or factors from the past that should be considered in treatment planning. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help her feel safe. Another care plan dated 3/6/24 reads in part, Verbally physically aggressive behavior.(R1) demonstrates behavioral distress Being challenged by a dementia related illness, Ineffective coping mechanisms, Poor self-esteem, feelings of inadequacy, Poor verbal skills and inability to express self in more appropriate language. He frequently screams/yells when receiving shower or being toileted despite staff's re-direction and encouragement. Goal: (R1) will refrain from verbally and/or physically aggressive behavior following staff interventions through next review. Interventions: Compliment resident on successfully completing meals and group activities without inappropriate behavior. Explain Rules of Conduct and each person's obligation to treat others with dignity and respect at all times. Intervene by speaking calmly and professionally in a soft tone of voice. Staff should avoid raising own voice, since this tends to make him more upset. This may cause the situation to escalate. Facility's internal incident report provided by V1 to surveyor, reads in part, On 5/22/25 around 2:25 PM family showed video footage of R1 having ADL (activity of daily living) done with him on 5/21/25 at around 2 PM. The video shows V6 (CNA) and V7(CNA) attempting to change (R1). (R1) was attempting to pick his head up while care was being done to him. V6 was redirecting him back to a laying position. V7 was on the other side removing R1's clothes. V5 LPN did a head to toe assessment, completed, resident did not have any abnormalities and did not complain of any pain and/or discomfort. (V6) and (V7) were both suspended. Police were notified. (This report failed to document the audible screams and resistance to care of R1, the threats made towards R1 to stop screaming, and failed to report the face slap shown in the video.) On 6/16/25 at 10:20 AM, R1 was observed in the dining area attending an activity. R1 was seated in a wheelchair and seated behind a table and appeared withdrawn and looking down at the table. Staff did not appear to try to engage the resident in any activity. Surveyor asked the resident how he was doing but the resident was unable to respond. V5 LPN was asked about R1 and said that R1 was non-verbal but had behaviors of screaming out mostly when he is in bed or during care but sometimes when he is seated in the dining room he would just scream out for no reason. V5 indicated that R1 had been relatively calm, almost withdrawn lately. Surveyor asked what staff did when R1 exhibited these screaming behaviors, V5 said that they would try to calm him down but did not indicate how. Surveyor asked if she was the nurse that assessed R1 after the incident involving the two CNA's on the video, V5 indicated she assessed the resident but that it was the following day of the incident so she really did not see any physical signs so that was what she wrote in her report. On 6/16/25 10:30 V2 director of nursing said that V4 (assistant administrator) notified her about two CNA's assisting (R1). V2 described her observation of the video to surveyor and said, They are changing him in bed and (R1) has behavior of shouting. At the time of changing, he (R1) was also attempting to get up and the male CNA (V6) was trying to put him back to bed 2 times and he put his left hand on his forehead and the other had pushing on the resident's shoulder towards the bed. I saw it twice (referring to the video). After that (R1) continued to be loud. They continued changing him and after changing him, I also saw V6 tapping the resident's cheek. R1 wasn't shouting after V6 tapped the the resident's cheek but prior to that he was shouting. They repositioned him on the bed and that's all I saw. Surveyor asked if the actions of V6 and V7 rose to the level of abuse, V2 said, No and that V6's tap was more of a love tap directed at the resident. Surveyor asked if the two CNA's she viewed in the video were too rough with the resident, V2 declined to answer and said, It didn't meet our standard. echoing the same phrase V1 had stated to the surveyor. A two minute video clip provided to surveyor by R1' family showed V6 (CNA) repeatedly telling the confused resident R1 You're wet, your wet! Put your head down, I told you to put your head down! R1 is heard shrieking loudly No! No! V6 was observed in the video pushing R1's head down and restraining his chest in order to prevent the resident from getting up while V7 (CNA) is at the foot of the bed removing and pulling the resident's pants and incontinence briefs in a swift and rough manner causing the resident to give a very audible shriek. R1 was shown screaming, visibly frightened, and resisting care. No nursing supervisor appeared to have been called, and the care continued despite the resident's clear distress. Near the end of the video, V6 says to R1 again, I told you not to scream and then proceeds to slap the the right side of the residents face whereupon the video ends. On 6/18/25 at 12:15 PM, V7 (CNA) said that she had asked V6 her coworker to help her change R1's diapers. V7 said she did not know what they did wrong and spoke with V1 administrator about the incident. Surveyor asked if she had any type of training on how to manage R1's behaviors, V7 indicated she did online training on abuse but did not get any specifics from anyone about R1. Surveyor asked what she should do if a resident resists care, V1 said that she didn't think R1 was resisting because the resident always cry out like he did when they changed him. Surveyor asked if she saw V6 push R1's head down or slap the resident's face, V7 said she did not because she was busy cleaning up the resident but indicated that they both may have been too rough with R1. Surveyor asked if she recalled ever getting trained on de-escalation of resident behaviors or any dementia training, V7 said she could not recall any but remembered just signing in on an inservice sheet. V7 said They floated me around but did not train me in dementia. Surveyor asked if the administrator or anyone showed them the video of when they were changing R1, V7 indicated she did not see the video. Surveyor asked if she was aware that her actions were being recorded in the room, V7 indicated that they were told and that there were signs saying so on the door. On 6/18/25 at 4:30 PM, V6 (CNA) said he should not have been terminated because he is a good CNA and was just helping another coworker out. Surveyor asked if he was aware R1 was confused and could not understand direction, V6 said that he knew this but indicated sometimes the resident listened to him. Surveyor asked if he pushed R1's head down on the bed and/or slapped him in the face, V6 said that he tried to push his head down because the resident kept trying to get up when they were changing him. V6 added that he gave the resident several light taps to the cheek but that he should not have done that looking back on it. Surveyor asked if he received any training on de-escalating of R1's behaviors or dementia training in general, V6 said he could not recall. Surveyor asked if a resident is resistant to care, what he would do in the future, V6 stated, (R1) wasn't resisting, that's how the resident is.

Based on observation, interviews and record reviews, the facility failed to ensure that two Certified Nursing Assistants (CNA's) demonstrated the necessary competency in dementia care and behavior management techniques for one (R1) of 3 residents reviewed in the sample of 3, who exhibited care-resistant behaviors, did not apply de-escalation strategies as directed in the resident's care plan, placing the resident at risk for increased agitation and emotional distress. Findings include: R1 is a [AGE] year old with severe cognitive impairment, visual and verbal impairments, and with diagnoses including but not limited to Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. MDS (minimum data set) dated 5/22/25 showed R1 with severe cognitive impairment, with behaviors, and was dependent in performing activities of daily living. R1's care plan dated 5/13/25 reads in part, (R1) is HIGH risk of being a recipient or perpetrator of mistreatment due to Dementia, Major Depressive Disorder. (R1) will be treated with respect, dignity and reside in the facility free of mistreatment through next review. Interventions: Conduct appropriate assessments to promote knowledge and understanding of the resident's past. Identify if there are behaviors or factors from the past that should be considered in treatment planning. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him feel safe. A two minute video clip provided to surveyor by R1' family showed V6 (CNA) telling R1 resident You're wet, your wet! Put your head down, I told you to put your head down! R1 is heard shrieking loudly No! No! V6 was observed in the video pushing R1's head down and restraining his chest in order to prevent the resident from getting up while V7 (CNA) is at the foot of the bed removing and pulling the resident's pants and incontinence briefs in a swift and rough manner causing the resident to give a very audible shriek. R1 was shown screaming, visibly frightened, and resisting care. No nursing supervisor appeared to have been called, and the care continued despite the resident's clear distress. Near the end of the video, V6 says to R1 again, I told you not to scream and then proceeds to slap on the right side of the residents face, whereupon the video ends. Facility's internal incident report provided by V1 to surveyor, reads in part, On 5/22/25 around 2:25 PM family showed video footage of R1 having ADL (activity of daily living) done with him on 5/21/25 at around 2 PM. The video shows V6 (CNA) and V7(CNA) attempting to change (R1). (R1) was attempting to pick his head up while care was being done to him. V6 was redirecting him back to a laying position. V7 was on the other side removing R1's clothes. V5 LPN did a head to toe assessment, completed, resident did not have any abnormalities and did not complain of any pain and/or discomfort. (V6) and (V7) were both suspended. Police were notified. (This report failed to report the audible screams and resisting care of R1, the threats made towards R1 to stop screaming, and failed to report the face slap shown in the video.) On 6/16/25 at 10:20 AM, R1 was observed in the dining area attending an activity. R1 was seated in a wheelchair and seated behind a table. Surveyor asked how he was doing but the resident was unable to respond. V5 LPN was asked about R1 and said that R1 was non-verbal but had behaviors of screaming out mostly when he is in bed or during care but sometimes when he is seated in the dining room he would just scream out for no reason. Surveyor asked what staff did when R1 exhibited these behaviors, V5 said that they would try to calm him down but did not indicate how. On 6/18/25 at 12:15 PM, V7 (CNA) said that she had asked V6 her coworker to help her change R1's diapers. V7 said she did not know what they did wrong and spoke with V1 administrator about the incident. Surveyor asked if she had any type of training on how to manage R1's behaviors, V7 indicated she did online training on abuse but did not get any specifics from anyone about R1. Surveyor asked what she should do if a resident resists care, V1 said that she didn't think R1 was resisting because the resident always cry out like he did when they changed him. Surveyor asked if she saw V6 push R1's head down or slap the resident's face, V7 said she did not because she was busy cleaning up the resident but indicated that they both may have been too rough with R1. Surveyor asked if she recalled ever getting trained on de-escalation of resident behaviors or any dementia training, V7 said she could not recall any but remembered just signing in on an inservice sheet. V7 said They floated me around but did not train me in dementia. Surveyor asked if the administrator or anyone showed them the video of when they were changing R1, V7 indicated she did not see the video. Surveyor asked if she was aware that her actions were being recorded in the room, V7 indicated that they were told and that there were signs saying so on the door. On 6/18/25 at 4:30 PM, V6 (CNA) said he should not have been terminated because he is a good CNA and was just helping another coworker out. Surveyor asked if he was aware R1 was confused and could not understand direction, V6 said that he knew this but indicated sometimes the resident listened to him. Surveyor asked if he pushed R1's head down on the bed and/or slapped him in the face, V6 said that he tried to push his head down because the resident kept trying to get up when they were changing him. V6 added that he gave the resident several light taps to the cheek but that he should not have done that looking back on it. Surveyor asked if he received any training on de-escalating of R1's behaviors or dementia training in general, V6 said he could not recall. Surveyor asked if a resident is resistant to care, what he would do in the future, V6 stated, (R1) wasn't resisting, that's how the resident is.

Based on interviews and record review, the facility failed to provide a sufficient number of nursing staff to ensure call lights were answered in a timely manner to assist with activities of daily living care, toileting, and overall care. This failure has the potential to affect all 154 residents currently residing at the facility. Findings include: On 04/14/2025 at 10:00 AM, V2, the Director of Nursing, presented the survey team with a facility matrix report, showing 154 current residents. R153 is an alert and oriented [AGE] year-old resident of the facility, with a BIMS score of 15 with diagnosis including heart failure; paroxysmal atrial fibrillation; need for assistance with personal care; and other abnormalities of gait and mobility. On 04/14/2025 at 12:50 PM, R153 told the surveyor that on the weekends, her unit only had one nurse and one CNA, and that was not enough. R153 said that about two weekends ago, it took five hours for her to get a dry diaper. When asked by the Surveyor how she determined the wait time, R153 responded she timed it, starting at 4:00 PM until 9:00 PM, and pointed at the clock on her wall, directly in front of her bed. R153 said when the CNA finally arrived, she was told the previous CNA on shift had left without providing a report. Lastly, R153 said that if a nurse had simply entered her room that day and told her they were having trouble with staff, she would not have been speaking to the Surveyor. R16 is an alert and oriented [AGE] year-old resident of the facility, with a BIMS score of 15 with diagnosis including spinal stenosis, lumbar region with neurogenic claudication; morbid (severe) obesity due to excess calories; type 2 diabetes mellitus with diabetic polyneuropathy; and post-laminectomy syndrome. On 04/14/2025 at 1:15 PM, R16 told the surveyor that the facility was understaffed on weekends and had addressed the issue with the facility director when he first arrived. R16 said he has had to wait for staff to respond to his call light, anywhere from forty to sixty minutes, about five different times, so far, during his stay at the facility, mostly during the 3:00 PM to 11:00 PM shift. R16 said that if the facility staff would communicate and tell him there was a delay, he would be fine, but they haven't. Lastly, R16 said he has been greatly concerned that if something serious were to happen to him, staff may take forty to sixty minutes to respond to his call light. On 04/16/2025 at 1:00 PM, the surveyor spoke with V23, a family member of R100 and R48. V23 told the Surveyor that R48 told her that at around 7:00 PM on a Saturday, about one month ago, she found R100's diaper soiled. V23 said that R48 called her on her mobile phone so V23 could call the facility's front desk in order to notify the staff that R100 had a wet diaper because R48 had had no success locating any staff to help. V23 said she, then, called the front desk and the receptionist transferred the call to the nurse's station, but no one would answer. V23 said she called the front desk about three or four times, and each time, the receptionist would apologize for no one answering the phone at the nurse's station, even saying, they may not be doing their job. V23 also said that R48 told her that on weekends, she has looked out of her room in search of staff, and the hallway has appeared empty. R48 is an alert and oriented [AGE] year-old resident of the facility, with a BIMS score of 6. Her pertinent medical diagnosis include, but are not limited to, type 2 diabetes mellitus with diabetic neuropathy, unspecified; age-related osteoporosis without current pathological fracture; anemia; and hypertension. On 04/16/2025 at 1:22 PM, R48 told the surveyor that she called V23 on the phone about a month ago, at about 8:00 PM, to let her know R100 had a wet diaper and no staff was available to help. R48 said she pushed the call light button two times but no staff answered the call. V48 said about one and a half hours later, at around 9:30 PM, she confirmed that a male CNA was changing R100's brief. R48 also shared that on a different occasion, she walked to the bathroom, unassisted, because no staff answered her call light for help to use the bathroom. On 04/15/2025 at 2:00 PM V8, an RN, told the surveyor that she has been receiving complaints from residents regarding overnight lights staying on. V8 added that, in some cases, she has even seen, herself, a delay in CNA response time to resident call lights. V8 said she has shared the complaints with V10, the CNA supervisor. On 04/16/2025 at 1:40 PM, V9, an RN, told the surveyor that agency staff on weekends bring a different vibe; so, she feels like she has to watch them a little more. V9 also said she has had to reinforce to staff the importance of answering call lights in a timely manner, in the past. On 04/16/2025 at 12:30 PM, V2 told the surveyor that sometimes she has received complaints, from both residents and their families, regarding prolonged call light response. V2 said the majority of the complaints come from phone messages left over the weekend by family members of residents. On 04/16/25 at 10:14 AM, V1 Administrator, told the surveyor he has not received any notification from staff regarding residents complaining to them of prolonged call light response time on the weekends. During resident council held on 4/15/25 at 1:06 PM, R60, R1, R20, R89, 121 , R54, R24, R121, R54, R28, R59, R90, and the resident council president R84 and family member were present during the resident council meeting task. Surveyor asked the group about call light responses and the unanimous concern was the long wait times for staff to attend to their call lights. Surveyor asked what was considered long, resident group indicated that there were wait times between 30 to over 3 hours with weekends being the worst wait times. The facility's call light policy, revised 07/26/2024, states, in part, It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance, and the facility shall answer call lights in a timely manner.

Based on interview and record review, the facility failed to follow their visitation policy allowing residents to receive 24-hour visitation privileges. This failure has the potential to affect all 154 residents currently residing in the facility. Findings include: Per daily census dated 4/14/2025 shows there were 154 residents residing in the facility. On 4/14/2025 at 12:45PM, V25 (Family Member/POA) said the facility is restricting my visiting hours and making me leave by 8:00PM. V19 (Nursing Supervisor) comes around at 7:50PM and waits for me to leave. She will tap her phone showing me the time and will not leave R113's room until I leave the facility. I feel as if I am being punished because I make sure the staff is caring for R113 and they want me gone. On 4/15/2025 at 1:00PM the resident council meeting was held which included: R60, R1, R20, R89, R121, R54, R24, R28, R59, R84, and R90. The residents agreed that at 8:00PM, the facility makes any visitors leave. At 1:30PM, V19 said our visitation policy states that all visitors need to leave once the receptionist is gone for the day, which is 8:00PM. At 7:50PM, the receptionist will check the sign-in sheet to let me know what visitors are still in the building. At this time, I will go around and remind the visitors that visiting hours are over and it is time to leave. At 3:15PM, V24 (Receptionist) said I was told that our visitation policy states that visitation ends at 8:00PM every day. At 7:50PM, I check who is still in the building and let the manager on duty or V19 aware of who is still here. They will then make rounds and let the remaining visitors know that visitation is ending and politely ask them to leave. Visitation Policy with last revision date of 8/19/2024 states in part but not limited to the following: It is the policy of this facility to allow authorized visitation of the resident in the facility at any given time. Visiting hours if from 8:00AM daily but 24-hour access is available to immediate family, other relatives, and other authorized persons visiting with the consent of the resident.

Based on observation, interview, and record review, the facility failed to ensure that staff provide scheduled shower and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected four (R41, R70, R108 and R129) of eight residents reviewed for ADL care. Findings include: R129 is [AGE] years old and have resided at the facility since 2024, face sheet listed the following past medical history: metabolic encephalopathy, chronic obstructive pulmonary disease, pain in left shoulder, chronic kidney disease stage 4, bilateral primary osteoarthritis of left hip, obstructive sleep apnea, type 2 diabetes, etc. 04/14/25 12:40PM, R129 was observed in her room sleeping and unable to answer any questions, noted with contracture to both hands, heel boots noted on a chair at the side of the room, no splint noted on both hands. Resident's hair was observed to be thick and matted, dry skin noted all over resident's body. 04/15/25 11:50AM, R129 was observed again in bed, awake and alert, stated that she is doing okay. R129's hair was still matted, dry and flaky skin all over her face and body, both legs look dark with flaky skin, her face was very dirty, and she had long fingernails on both hands with brownish substances underneath. Surveyor asked resident if she get her showers or bed bath and she said that sometimes staff will wash her up in bed, she does not receive any showers and cannot remember the last time her hair was washed. R129 asked surveyor if she can help her with her grooming because it is poor. Minimum Data Set (MDS) assessment dated [DATE], section C (cognition) scored R129 with a BIMs score of 5, section GG (functional status) of the same assessment coded R129 as being dependent to needing substantial/maximal assistance from staff for all activities of daily living. Resident have the following order dated 12/24/2024, Skin assessment weekly on shower day every day shift every Mon, Thu. Care plan initiated 8/27/2024 states the following: resident requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) related to Musculoskeletal impairment. Goal: Resident will be assisted with ADLs as needed. Interventions include assist resident with shower/bathing per schedule, Encourage participation in ADL's, etc. 04/15/25 at 12:03PM V13 (LPN) said that R129 hair is all crumpled up and needed to be washed and combed, she will get the C.N.A to trim her nails. V13 was asked if she ever saw resident get a shower and she said that she have seen them bring her to the shower room but have not actually witnessed her being showered. V13 added that the certified nurse assistants (C.N. As) are supposed to document the showers in the computer under task. 04/16/25 at 12:33PM, V2 (DON) said that residents are scheduled for showers two times a week and as needed, part of Activities of Daily Living (ADL) care is washing their hair and trimming the fingernails when needed. If a resident prefers a bed bath, then it will be documented as their preference and refusal of ADL care should also be documented. Facility does not have any documentation that resident refuses showers or preferred bed baths. Surveyor requested documentation of resident's showers and skin assessments and received 2 skin assessments dated 12/92/2024 and 3.24/2025. ADL shower and monitoring document presented by facility showed that for the question, did resident take a shower, bath or bed bath, the response was no, for the months of January, February, March, and April 2025. Except on 1/23/2025, 2/13/2025 and 2/20/2025 when the response was yes. Shower and hygiene policy revised 8/19/2024 states in policy statement: it is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident, and observe the condition of resident's skin. Under procedures. The policy states in part, 1. Administer resident shower once weekly and/or as necessary. Any resident who needs hygienic care will be provided care to promote hygiene (facial, body, perineal care, etc.) 3. Shower refusal by the resident shall be relayed by the assigned C.N.A to the charge nurse. 11. Documentation (Shower log/CNA assignment sheet) a. Date and shift the shower /bath was performed. D. If the resident refused the shower and /or if shower was not administered and interventions taken e.g. bed bath/re-scheduling the shower schedule consistent to facility protocol. 46344 On 4/14/2025 at 11:10AM, R70 was observed to be laying in bed. This surveyor noted resident to be unkempt with long beard. R70 said I have not gotten a shower or been groomed in over a month. Said sometimes the staff will wipe my armpits with wipes but I have not gotten a shower or bed bath in over a month. R70 showed this surveyor his nails which were observed to be very long. Said I want my beard shaved and my nails cut. Facility Report titled ADLs (Activities of Daily Living) Shower/Bathing shows the last time R70 received a shower was on 2/21/2025. There is no documentation of shower/bathing after 3/7/2025. 34516 On 04/14/25 at 10:23 AM R41 was observed in bed and appeared uncomfortable. R41's face was wet with perspiration and in need of washing. The resident's thinning hair appeared greasy and matted on the side of his head where he slept. R1 stated, I can do some things myself but I need help to shower or to wash my face and comb my hair but it's not easy getting that help here. Care plan dated 7/8/24 reads in part, (R41) requires assistance with ADL's (bed mobility, transfers, dressing, personal hygiene, eating and toileting). On 04/15/25 09:22 AM R108 was in a bed that was on the ground, with his feet outside of his sheets. His feet did not have any socks and revealed toe nails that were long and in need of trimming. Resident had matted hair and there was a noticeable body and urine odors present in the room. Per V6 (LPN) R108 only receives bed baths. R108's care plan reads in part, Functionally Incontinent of both Bowel and Bladder related to Physical Limitations and Cognition. R108 will remain free from skin breakdown due to incontinence and brief use, I would like the Activity staff notify nursing if I had an incontinent episode during activities. I prefer to use disposable briefs. I would like the staff to check me for incontinence episode every 2 hours and as needed. I would also need assistance to wash, rinse and dry my perineum. I would also need assistance to change clothing after incontinence episodes. There were no care plans to address bathing and grooming found in R108's medical record when requested.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from threats and mental abuse. This failure applied to one of one (R113) residents reviewed for abuse and resulted in psychosocial and emotional harm to R113 as evidenced by emotional distress and physical anxiety. Findings include: R113 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R113 has multiple diagnoses including but not limited to the following: Moyamoya disease, dysphagia, altered mental status, conversion disorder with seizures, transient cerebral ischemic attack, and cerebral aneurysm. On 4/14/2025 at 12:45PM, V25 (family member/POA) said we have a camera in R113's room to ensure R113 is being cared for properly. On 3/13/2025 at around 5AM, V20 (Certified Nursing Assistant) was changing R113's incontinence brief and had her completely naked. She had had a bowel movement. V20 rolled R113 on her left side which caused her to be in pain. R113 started kicking and swinging her arms which is her way of communicating that she is in pain. V20 then told R113 No, no, you better stop, or I am going to leave you here like this. Which to me means V20 is threatening R113 that she is going to leave her in a vulnerable condition, naked and lying in poop. It is to be noted that at this time R113 starting hysterically crying and observed heightened distress. R121 and V25 attempted to console and calm down R113. V25 said See, anytime we talk about this she gets extremely upset. On 4/15/2025 at 10:45AM, R121 said I was present when V20 was changing R113 on 3/13/2025. I was laying in bed when I heard R113 pounding on the side of the bed. She does this to communicate that she is in pain. I asked V20 to stop because she is in pain. I told her that R113's left shoulder hurts her and you have R113 laying on her left shoulder. V20 told me Let me do my job. R113 then started kicking her legs and kicked V20. V20 then told R113 If you do not stop, I will leave you here like this. R113 was naked and uncovered when V20 said this. I felt as if this was a threatening statement. Per MDS (Minimum Data Set) dated 4/5/2025 shows R121 has a BIMS (Briefs Interview of Mental Status) of 15, meaning resident is cognitively intact and alert and oriented. At 1:50PM, V25 showed this surveyor the video of R113 and V20. It is to be noted that the video was dated 3/13/2025. The video showed V20 changing R113's incontinence brief. R113 was observed to be in bed, in her room, naked and laying on her left side. R113 started banging on the bed and kicking her legs. V20 then said No, no, don't do that or I will leave you here like this in poo. Observed R121 laying in the bed across the room from R113. V25 said I showed this video to V1 (Administrator) where he watched and heard the audio. I do not feel like anything was done about this. She is still working in the facility where she can treat another resident like this. On 4/16/2025 at 9:45AM, V1 said V25 told me that she had a video that she wanted me to see. When I watched the video, I observed V24 changing the resident and R113 swinging her arms and kicking during care. R113 has a behavior of doing this. Asked V1 if she feels as if V1 is vulnerable to abuse because of these behaviors in which he said 'I guess so, yeah'. Asked V1 if the staff receive any sort of training on how to take care of residents with behaviors such as R113 in which he could not answer. Facility Abuse Policy with last revision date of 7/1/2024 states in part but not limited to the following: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Mental abuse includes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolation (involuntary, imposed seclusion) or deprivation to provoke fear of shame.

Based on interview and record review, the facility failed to properly investigate an allegation of abuse. This failure applied to one of one (R113) resident reviewed for abuse. Findings include: R113 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R113 has multiple diagnoses including but not limited to the following: Moyamoya disease, dysphagia, altered mental status, conversion disorder with seizures, transient cerebral ischemic attack, and cerebral aneurysm. On 4/14/2025 at 12:45PM, V25 (family member/POA) said we have a camera in R113's room to ensure R113 is being cared for properly. On 3/13/2025 at around 5AM, V20 (Certified Nursing Assistant) was changing R113's incontinence brief and had her completely naked. She had had a bowel movement. V20 rolled R113 on her left side which caused her to be in pain. R113 started kicking and swinging her arms which is her way of communicating that she is in pain. V20 then told R113 No, no, you better stop, or I am going to leave you here like this. Which to me means V20 is threatening R113 that she is going to leave her in a vulnerable condition, naked and lying in poop. On 4/15/2025 at 10:45AM, R121 said I was present when V20 was changing R113 on 3/13/2025. I was laying in bed when I heard R113 pounding on the side of her bed. She does this to communicate that she is in pain. I asked V20 to stop because she is in pain. I told her that R113's left shoulder hurts her and you have R113 laying on her left shoulder. V20 told me Let me do my job. R113 then started kicking her legs and kicked V20. V20 then told R113 If you do not stop, I will leave you here like this. R113 was naked and uncovered when V20 said this. I felt as if this was a threatening statement. R121 said at no time did anyone interview me about this incident. I thought this was strange and not right because I was an eyewitness. I feel as if the facility is not doing anything about this incident. Per MDS (Minimum Data Set) dated 4/5/2025 shows R121 has a BIMS (Briefs Interview of Mental Status) of 15, meaning resident is cognitively intact and alert and oriented. At 1:50PM, V25 showed this surveyor the video of R113 and V20. It is to be noted that the video was dated 3/13/2025. The video showed V20 changing R113's incontinence brief. R113 was observed to be in bed, in her room, naked and laying on her left side. R113 started banging on the bed and kicking her legs. V20 then said No, no, don't do that or I will leave you here like this in poo. Observed R121 laying in the bed across the room from R113. V25 said I showed this video to V1 (Administrator) where he watched and heard the audio. I expressed my concern with what she verbally said to [NAME] and the aggressiveness she used to change her. I do not feel like anything was done about this. She is still working in the facility where she can treat another resident like this. On 4/16/2025 at 9:45AM, V1 said V25 told me that she had a video that she wanted me to see and she was unhappy with the care. When I watched the video, I observed V24 changing the resident and R113 swinging her arms and kicking during care. R113 has a behavior of doing this. Asked V1 if she feels as if V1 is vulnerable to abuse because of these behaviors in which he said 'I guess so, yeah'. V1 said V20 was doing regular care and I did not see any sort of abuse in the video. This surveyor asked V1 if he listened to the audio of the video and he said 'I may have, yes, but I can't remember.' Then said V20 told R113 that if she does not stop this behavior, she will have to step out and get the nurse. I remember V25 being concerned about what V20 said to R113. Facility Reported Incident dated 3/25/2024 states in part but not limited to the following: Date and time alleged incident occurred: During 11-7 shift on 3/19/2025. On 3/25/2025 at 1:50PM, V25 (family member/POA) told V1 (Administrator) that she felt as if V24 (Certified Nursing Assistant) last week did not treat R113 appropriately during care. V25 showed V1 a video of V24 changing R113 and R113 was laying on her left side. V25 felt this was abuse as she felt she should on be changed on her right side. It is to be noted that at no point does the facility reported incident discuss the verbal statement V24 made towards R113. It also does not show any interview from R121, R113's roommate that was present at the time of alleged incident. The report also shows a date of an alleged event of 3/18/2025 when the video observed is clearly dated 3/13/2025. It is also to be noted that on 4/14/2025, this surveyor requested complete investigation for alleged incident of abuse with V20 and R113. Per witness statements received, no interview was noted with R121. On 4/16/2025 after interview with V1, this surveyor was provided with new, updated witness statements that were not originally presented on 4/14/2025. Facility Abuse Policy with last revision date of 7/1/2024 states in part but not limited to the following: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Investigations: Interview all involved person including victim, perpetrator, witnesses, and other who might have knowledge of the allegation. Thorough documentation of the investigation.

Based on observation, interview, and record review, the facility failed to ensure that staff provide ordered service to a resident with decreased range of motion by failing to apply ordered splints to resident's hands. This failure affected one (R129) of one resident reviewed for rehabilitation services. Findings include: R129 is [AGE] years old and have resided at the facility since 2024, face sheet listed the following past medical history: metabolic encephalopathy, chronic obstructive pulmonary disease, pain in left shoulder, chronic kidney disease stage 4, bilateral primary osteoarthritis of left hip, obstructive sleep apnea, type 2 diabetes, etc. 04/14/25 12:40PM, R129 was observed in her room sleeping and unable to answer any questions, noted with contracture to both hands, heel boots noted on a chair at the side of the room, no splint noted on both hands. Resident's hair was observed to be thick and matted, dry skin noted all over resident's body. 04/15/25 11:50AM, R129 was observed again in bed, awake and alert, stated that she is doing okay. R129's hair was still matted, dry and flaky skin all over her face and body, both legs look dark with flaky skin, her face was very dirty, and she had long fingernails on both hands with brownish substances underneath. Resident had contracture on both hands and her nails on the left hand were digging into her palm and she was unable to open her hands. Physician order dated 3/11/2025 reads as follows: Nursing /Rehab: Assistance with Splint or brace: Resident will be assisted in left- and right-hand palm protector for at least 2-4 hours or as tolerated, may take off for showers, ADLs, check the skin for any redness and/or any skin concerns and report to NOD/MD. Care plan initiated 8/27/2024 states the following: resident requires assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting) Musculoskeletal impairment. Intervention include assist with application of appliances if needed (hearing aid, eyeglasses, dentures). Minimum Data Set (MDS) assessment dated [DATE], section C (cognition) scored R129 with a BIMs score of 5, section GG (functional status) of the same assessment coded R129 as being dependent to needing substantial/maximal assistance from staff for all activities of daily living. 04/15/25 at 12:03PM V13 (LPN) who is the assigned nurse for R129 said that she is not aware of any splints for the contracture on resident's hands, the only thing resident have is the neck pillow that she is aware of. 04/15/25 at 2:20PM V18 (Restorative Aide) said that he provides restorative care to resident every time he works Monday through Friday, V18 was asked if he provided any restorative care to resident yesterday (4/14/2025) and he said no, the last time was on Sunday. Resident verbalized that no one provided any restorative care to her on Sunday. Surveyor asked V18 about resident's contracture on both hands and if he noticed the fingernails that is digging into her palm, and he said yes, her nails need to be trimmed and the resident was supposed to have a splint on both hands to prevent further contracture. V18 looked around and found one splint on resident's side table and stated that she was supposed to have 2, he does not know what happened to the other one. V18 also said that all the staff are aware that resident is supposed to use the splints and they are supposed to assist resident with putting them on. Restorative nursing policy revised 8/19/2024 stated in policy statement: It is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Under procedure, the policy states in part: #3 nursing and restorative services may include the following: C contracture prevention and management:(i)PROM/AROM exercises.(i) splint/orthotic management.

Based on interview and record review the facility failed to notify resident's family member of discontinuation of medication after holding the hypertensive medication. The facility also failed to notify the physician of increase in resident's blood pressure. This deficiency affects one (R1) of three residents reviewed for Notification for change in condition. Findings include: On 3/11/25 at 2:39PM, V6 Family members said that R2's amlodipine (antihypertensive medication) was completely stopped when she only gave permission to old it for 4 days as discussed with V23 Nurse Practitioner. On 3/11/25 at 2:50PM, Reviewed R2's medical records with V3 Director of Nursing (DON). R2 is admitted on [DATE] with diagnosis listed in part but not limited to Hypertension, Cardiomyopathies, Sick sinus syndrome, Heart failure, Chronic kidney disease, Cardiac pacemaker, Dementia, severe with mood disturbance, Type 2 Diabetes mellitus, Abnormalities of gait and mobility. Physician order sheet indicated Amlodipine Besylate give 1 tablet by mouth one time daily for Essential hypertension. Progress notes dated 2/2/24 documented by V24 RN indicated that he notified V23 Nurse Practitioner (NP) of change in condition because of BP (Blood Pressure) taken at 9:20am was 124/64 and at 10:00am at 118/mmHg. V24 documented V23 ordered to stop amlodipine. V6 Family member notified, did not consent to stop. Request to put amlodipine on hold for 4 days, V6 to call cardiologist and update facility. V24 RN notified V23 NP. February Medication administration record (MAR) for 2/1 and 2/2/25 indicated no blood pressure parameters for administration of Amlodipine. Amlodipine was not given after 2/2/25. Daily blood pressure obtained from 2/1/25 to 2/27/25 indicated ranges of blood pressure from 118/65 to 168/mmHg. Informed V3 DON of R2's Increased episodes of blood pressure after Amlodipine were discontinued on 2/2/25 on the following dates without notification of physician or Nurse Practitioner: 2/3/25- 143/99; 2/4/25- 161/79; 2/5/25- 146/84; 2/6/25- 149/67; 2/8/25- 168/81; 2/9/25- 156/82; 2/14/25- 147/80. V3 said that the nurse should notify the primary care physician or NP of increased BP. V3 DON said that V24 RN was following order of V23 NP of discontinuing amlodipine on 2/2/25. On 3/11/25 at 3:31PM, V23 Nurse Practitioner said that she was covering NP for R2's primary care physician. She was called by the nurse on 2/2/25, and she spoke with V6 Family member. She said that she ordered on hold the amlodipine for 4 days as she discussed with V6 Family member. She denied ordering to discontinue the amlodipine. She said that she will not discontinue a cardiac medication of resident who has hypertensive with cardiac medical issues whom she has not seen R2. She was not notified of R2's discontinued amlodipine and episode of increased in BP after discontinued. Facility's policy on Notification of change of condition revised 8/16/24 indicated: Policy statement: The facility will provide care to resident and provide notification of resident change in status. Procedures: 1. The facility must immediately inform the resident; consult with the resident's physician and if known, notify the resident's legal representative or an interested family member when there is: b. A significant change in the resident's physical, mental or psychosocial status. c. A need to alter treatment significantly (need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.

Based on observation, interview, and record review the facility failed to provide necessary treatment and care in a timely manner to resident with language barrier who has been refusing to get up for Restorative walking program, scheduled shower, and complaint of severe pain (during therapy evaluation) after a fall incident to identify fracture of sacrum. This deficiency affects one (R1) of three residents reviewed for Quality of care. Findings include: On 3/11/25 at 12:17PM, Rounds made to R1 with V4 Fall coordinator. Observed R1 sleeping in bed. R1 opened her eyes when called but will go back to sleep. She is lethargic but arousable. V16 Receptionist at bedside said that she was directed to do 1:1 supervision/monitoring to R1 at 10:00AM. V16 said that she does not document monitoring dome to R1, she just informed the floor nurse every hour. V4 said that R1 was placed on 1:1 every hour monitoring. She pointed the monitoring form for today started at 3/11/25 at 12AM placed by the window. V4 handed the hourly monitoring form to surveyor. Reviewed monitoring form and informed V4 that no monitoring form was done from 12AM. Surveyor asked V18 Receptionist, why she did not document her 1:1 hourly monitoring started at 10:00AM. V18 said that she did not know about the monitoring form, no one told her how to document. V16 said that since she started at 10:00AM, R1 has been sleeping. On 3/11/25 at 11:54AM, Reviewed R1 medical records with V3 DON (Director of Nursing). R1 is readmitted /27/24 with diagnosis listed in part but not limited to Fracture of Sacrum, subsequent encounter for fracture with routine healing, Fall subsequent encounter, Acute pain due to trauma, Anemia in chronic kidney disease, Type 2 Diabetes mellitus with diabetic neuropathy arthropathy, Heart failure, chronic kidney disease stage 4, Cardiac pacemaker Supravalvular aortic stenosis. Physician order sheet for January and February 2025 indicated that R1 has hydrocodone-acetaminophen oral tablet 5-325mg give 1 tablet by mouth every 6 hours as needed for pain (PRN) up to 7 doses. Lidocaine external patch 4% apply to affected area (lower back) topically in AM, on for 12 hours and off at bedtime (HS). Admission pain assessment indicated no pain complaint. MDS/resident assessment dated [DATE] indicated Section J-no pain and Section N- no administration of prn pain medication. Fall assessment indicated that she is at high risk for fall. Comprehensive care plan indicated that she is at risk for acute and chronic pain due to current medical conditions. She has some difficulty in expressing self and understanding others due to language communication barrier. She has impaired thought processes related to impaired decision making. She has impaired self-care deficit and impaired mobility. She is at high risk for falls related to decline in functional status, impulsivity to poor safety awareness, muscle weakness from recent hospitalization . R1 has history of unwitnessed falls:1) 1/16/25 at 8:00PM indicated that nurse heard a scream from room. Nurse and CNA (Certified Nurse Assistant) went to the room and observed R1 on the floor, lying on the floor next to her bed. R1 claimed that she was trying to get her phone because someone was calling her, and her phone was charging in the wall by the fridge. 2) 2/8/25 at 8:10PM, Nurse was alerted to R1's room due to a loud noise and call for help. R1 was observed sitting on the floor near the door. R1 was asked what happened, but due to language barrier was not understood. Daughter was called to assist with translation. Daughter translated that R1 would like to sit. Daughter came to see R1. R1 complained of left hip pain. She cannot ambulate with walker due to pain. Nurse offered pain medication. Nurse Practitioner recommended to transfer R1 to hospital for evaluation, but Daughter refused and preferred X-ray to be done at the facility. Care planned was updated. Therapy to evaluate and treat R1 to increased strength and mobility and prevent further falls. Xray was done on 2/9/25 indicated no fracture. R1's post fall comprehensive pain assessment dated [DATE] but signed 2/15/25 indicated no pain. R1's post fall comprehensive pain assessment dated [DATE] but signed 2/16/25 indicated no pain. R1's post fall incident 72 follow up (2/9/25 to 2/11/25) for fall incident 2/8/25 indicated no pain but signed and locked date 2/17/25. Informed V3 DON that all pain assessment was completed after the resident was discharged to the hospital on 2/13/25. R1's Pain assessment every shift documented in MAR (Medication administration Record) indicated no complaint of pain in all shifts from 3/9/25 to 3/13/25. MAR indicated that R1 was only given twice of as needed pain medication (Hydrocodone-Acetaminophen orally) from 3/8/25 to 3/13/25. R1's Restorative program log from 2/9/25 to 2/13/25 indicated refusal of walking program after the fall incident on 2/8/25. R1's shower and bathing documentation indicated that she refused shower scheduled on 2/10/25 after the fall on 2/8/25. Informed V3 DON that there is no documentation in the progress notes of reason of R1 refusal of treatment and care. V3 said that R1 has the right to refuse treatment and care. R1's Physical therapy (PT) evaluation and plan of treatment dated 2/12/25 indicated: Evaluation only. Reason for referral: Patient is [AGE] years old female resident of this facility status fall referred to PT for eval only and treatment x1 to establish functional baseline and appropriate restorative program for functional maintenance. Other system/condition assessment: Patient has pain that interferes/limits functional activity? YES (Patient complaint of severe pain both lower extremities. Nurse on duty informed and aware. Pain assessment method-Patient verbalized pain level. Is skilled therapy needed to address pain? Nursing to address. R1's Facility reported incident dated 2/13/25 reported to IDPH on 2/14/25 indicated that R1 is observed with facial grimacing and guarding of her lower back. R1 was sent out to the hospital due to intractable pain on lower back. R1 was admitted at orthro unit with diagnosis of closed fracture of the sacrum. CT of thoracic spine was done with impression of acute left sacral ala fracture 182 series 2 with adjacent presacral soft tissue. R1 returned to facility on 3/7/25. R1's comprehensive care plan indicated that she has some difficulty in expressing and understanding others. Her primary language is (URDU- an Indo-[NAME] language spoken in Pakistan and parts of [NAME]). She primarily speaks a different language than many of the caregivers, becoming frustrated when unable to understand a message or convey her message. Interventions: Involve a translator to ais in communication. In some situation a family member may serve as a translator. As Necessary, have the translator assist in developing a personalized communication board or book. Utilize appropriate augmentative devices, i.e., communication board/flash cards, pads, etc. Help acquire and learn to us appropriate devices. On 3/11/25 at 1:10PM, V5 Restorative Nurse said that she is not aware that R1 has been refusing to get up for the restorative walking program after she fell on [DATE] not until 2/13/25. V5 said that if resident refused restorative treatment program, she expects the restorative aide who provides the treatment to report to her so that she could document reason for refusal, assess the resident and inform family member of refusal of program. On 3/11/25 at 1:25PM, V17 Restorative Aide (RA) said that R1 refused to get up for the restorative daily walking program. She was not able to participate due to pain and wanted to stay in bed to sleep. She did not inform V5 Restorative Nurse and R1's family of R1 refusal of walking program. V17 said that R1 has language barrier. She used hand gestures to communicate to R1. She did not use translator or communication board. She said that she only notified V5 of R1's refusal on 2/13/25. On 3/11/25 at 1:30PM, Rounds made to R1's room with V17 RA. Observed R1 sleeping in bed. Remains lethargic but arousable. Observed V18 CNA at bedside. V18 said that she was asked by her supervisor to be a sitter to R1 while the receptionist is on break. V18 said that she does not know why she has to monitor R1 because R1 has been sleeping since she arrived. She said that there is no monitoring documentation endorsed to her. On 3/11/25 at 1:46PM, V19 Restorative Aide said that R1 refused to get up for the restorative daily walking program after she fell on [DATE]. She was not able to participate due to pain and wanted to stay in bed to sleep. She did not inform V5 Restorative Nurse and R1's family of R1 refusal of walking program. V17 said that R1 has language barrier. She used hand gestures to communicate to R1. She did not use translator or communication board. On 3/12/25 at 11:18AM, V21 Family member denied that they refused R1 to be sent out to the hospital for evaluation due to lower back pain after the fall incident on 2/8/25. V21 said that she is the responsible party for R1. She said her other sister probably the one they spoke to. She said that R1 was in so much pain after the fall and the medication was not effective. R1 was crying in pain. She said that they requested R1 to be sent to the hospital on 3/13/25 due to severe pain. She said that she was not notified of R1 refusal of shower and restorative program due to pain. On 3/12/25 at 12:08PM, V20 CNA said that she is regular CNA for R1, she said that after she fell on [DATE] she complained of pain on her lower back. She cannot get up and stand up. She reported her pain to the floor nurse. She cannot remember the name of the nurse. On 3/12/24 at 12:13PM, V9 RN said that she took care of R1 on 2/11/25 (she was off from 2/8 to 2/10/25. She said that she was not endorsed to her during nursing report that R1 fell on [DATE]. She learned it from R1's family member. R1 complained of severe pain of 10/10 to her lower back and gave prn pain medication. She did not call her doctor because everyone knows that she complaint of pain. On 3/12/25 at 2:30PM, Informed V1 Administrator and V2 DON of above concerns identified in Pain management. The inconsistency of pain assessment. Documentation of pain assessment after the R1 was discharged . Communication among IDT (Interdisciplinary team) of resident refusal of treatment due to pain. Implementation of care plan and policy on communication barrier. Because of these they failed to provide necessary treatment and care in a timely manner to resident with language barrier who has been refusing to get up for Restorative walking program, scheduled shower, and complaint of severe pain (during therapy evaluation) after a fall incident to identify fracture of sacrum. Facility unable to provide policy on Reporting and documentation of reason of resident refusal to treatment and care. Facility's policy on Pain revised 1/30/25 indicated: Policy statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. For pain complaints and for situations/incidents that might result to pain (ex: fall incident, altercation, cuts, bruises, wound care, etc.) the nursing staff may document in any part of the resident's medical record that may include nurses' notes, incident report, medication administration record, etc.) Procedures: 1. Upon admission and readmission, the nurse will assess resident for pain. For those identified with pain upon admission/readmission assessment, an order for pain medication will be obtained from the physician. A paper-based assessment or UDA is available for use. The pain medication ordered will be administered to the resident as soon as possible. After administration of prn pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer the lack of relief. Facility's policy on Quick reference guide for language line solutions/How to access an interpreter. *When receiving a call 1. Use your phone's conference feature to place the limited English proficient (LEP) speaker on conference/hold 2. Dial [PHONE NUMBER] 3. Provide your client ID# 4. Select the language you need b. Press 2 for all other language and state the name of the language you need. Press 0 for agent assistance if you do not know the language. 5. Provide your facility name: 6. Brief the interpreter. Summarize what you wish to accomplish and provide any special instructions. 8. Say End of call to the interpreter when your call is completed.

Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices after providing shower to a resident in the shower room. This deficiency affects one of three common shower rooms in resident's unit reviewed for resident clean environment. Findings include: On 3/11/25 at 2:39PM, V6 Family member said that the common shower room shared by residents is dirty and not cleaned. Resident's soiled clothes, towels and wash cloths are left in the shower room. On 3/11/25 at 10:58am Observed shower room by [NAME] Unit with soiled resident clothing on the floor, towels, and wash clothes. Showed observation to V7 Housekeeping supervisor. V7 said that the CNA (Certified Nurse Assistant) should place all soiled clothes, towels, and wash clothes in plastic bag not on the floor after shower. Informed observation to V11 LPN (Licensed Practical Nurse). V11 said that V12 CNA should place all soiled clothes, towels, and wash clothes in plastic bag not on the floor after shower for infection control. On 3/11/25 at 11:26AM, V1 administrator said that V6 Family member already presented the concerns last month and they addressed it already. Presented copy of grievance/concern form completed by V22 Social Service Director dated 2/21/25. Informed V1 of above observation made and concern of shower room in [NAME] unit is dirty with soiled resident clothing, towels, and wash clothes on the floor. On 3/11/25 at 11:54AM, Informed V3 DON (Director of Nursing) of above concern. Requested for policy. On 3/11/25 at 12:09PM, V12 CNA said that he gave shower to R6. He forgot to place the soiled resident's clothing, used towels and wash cloths in the plastic bag after giving shower to R6 instead of leaving it on the floor. He said that he should not leave the soiled clothing, towels, and wash cloths on the floor in the shower room. It should be place in plastic bag then put it in soiled utility room. On 3/11/25 at 2:30PM, V3 DON that aftercare after providing shower to the resident is to gather all soiled clothing, towels and wash cloths used and placed it in plastic bag not on the shower floor. V3 said that they don't have policy. Facility unable to provide policy on Aftercare after providing resident shower and maintaining resident clean environment.

Based on observation, interview, and record review, the facility failed to provide appropriate staffing for Certified Nursing Assistants in two units within the facility. This failure applied to three of three (R1, R2, R3) residents reviewed for staffing and has the potential to affect 29 residents currently residing in the two units (Suites North and Suites South). Findings include: Per Facility Census dated 11/4/2024 shows there are currently 29 residents residing in two units, [NAME] Suites North and Suites South-total Census of 152 residents residing in the facility. On 11/4/2024, during the course of this survey, R1, R2, and R3 all resided in the Suites North unit. Facility Assessment Tool 2024 with last review date of 7/10/2024 states in part but not limited to the following: The tool is used to inform staffing decisions to ensure that there is enough staff with appropriate competencies and skill sets necessary to care for its residents needs. Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of residents at any given time. Direct care staff: CNAs (Certified Nursing Assistants): 1 CNA per 11 Residents for the day shift, 1 CNA per 11 Residents for the evening shift, and 1 CNA for 13 residents for the night shift. The Daily Schedule dated 10/6/2024-11/3/2024 shows that one CNA worked on Suites South and one CNA worked on Suites North for all shifts, including the day shift, evening shift, and night shift. It is to be noted that on 11/4/2024, Suites North had 14 residents, and Suites South had 15 residents. On 11/4/2024 at 10:05 AM, R1 was interviewed regarding care within the facility. R1 said she feels that the CNAs have too much to do and that they are assigned too many residents for one CNA to take care of. She says sometimes she has to wait for her call light to be answered for an extensive period of time. R1 says the facility staff has never given her a shower, but the hospice staff is the only staff member who has ever provided her with a bed bath. Hospice provides this to residents, however, only once a week. At 10:45 AM, R2 was observed to be lying in bed in a gown sleeping. It is to be noted that R2 had facial hair on the upper lip and chin. At 10:55AM, R3 was observed in her room lying in bed in a gown with V9 (a Family Member) at her bedside. V9 said there is not enough staffing of CNAs on this unit, and there seems to be a shortage. She says there are times when she will come visit her, and she is not yet dressed or ready for the day. At 11:15 AM, V5 (Licensed Practical Nurse) was interviewed regarding staffing on the North Suite unit. V5 said I am the regular nurse assigned to this unit. Says we do use a lot of agency staffing over here and the current CNA that is working is an agency CNA. V5 said having agency CNAs on this unit can be difficult because they do not know the resident and their needs. V5 also said that R2 requires a mechanical lift and requires two-person assistance with transferring. Says this slows me down on medication pass because I am the one that is required to help assist the CNA. At 12:35PM, V5 said that when both units, Suites North and Suites South, are full, we are supposed to have another CNA who splits rooms from both units. However, we are currently full and only have one CNA working. V5 said I had a discharge today and am getting a new admission already. V5 also said that I had worked in this unit for two years and had never had more than one CNA work on it. At 3:05 PM, V11 (Registered Nurse) was interviewed regarding the staffing of Suites South. V11 said there is only one CNA assigned to the South unit today, which is typical staffing. V11 said it can get difficult when all the beds are full and we only have one CNA working. When there is an agency CNA assigned, it can be extra difficult to provide adequate care to the residents. V11 said we have two residents on this unit who require two-person assistance, which means I am expected to help assist the CNAs with this, as well as residents who need assistance with feeding at meals. At 1:45 PM, V3 (Nursing Scheduler/CAN Supervisor) was interviewed regarding the staffing needs of CNAs. V3 said, I was told by administration that I am to staff one CNA on Suites North and one CNA on Suites South for each of the three shifts. However, everything is based on the Census, so when that section is full, and we have over 150 residents, we staff another CAN on this unit to split residents between Suites North and Suites South. A review of the Payroll-Based Journal Staffing Data Report for FY Quarter 3 2024 (April 1 - June 30) indicates that the facility was triggered for an area of concern related to the One Star Staffing Rating.

Based on interviews and records reviewed, the facility failed to ensure fall prevention interventions were utilized to include nonskid footwear and other appropriate interventions for 1 resident (R3) and provide assistance to one resident (R2) during transfer from wheelchair to bed. R3 has a cognitive communication disorder, poor safety awareness, and impaired cognition. R2 has a history of alcohol abuse, gait disorder, and neuropathy. These failures affected two of three (R2, R3) residents reviewed for falls. These failures resulted in harm, with R2 sustaining a laceration requiring two sutures to the left eyebrow region, and R3 was admitted to the hospital for Subdural Hematoma and received 7 staples to the left occipital region. The findings include: 1. IDPH facility reported an incident for R3 states on [DATE]. The nurse on duty observed the resident standing by the bed and attempting to walk. Nurse attempted to get to the resident to prevent him from falling. Resident fell on the floor between the bed and night stand. The nurse noted a laceration of approximately half an inch on the left posterior head and minimal bleeding on the lower mouth. The resident was taken to the emergency room , and the facility notified that the resident was admitted with a diagnosis of Subdural Hematoma. On [DATE] at 1:37 PM, V6, Certified Nursing Assistant (CNA), said around 11:00 AM, I saw Physical Therapy bringing R3 to his room, and therapy put R3 back to bed; the nurse and I checked him. V6 said I did not see R3 fall but saw him on the floor. R3 was between the bed and the nightstand. V6 said R3 kept asking us to get him up, but we left him in the position on the floor, and he kept trying to get up. V6 said it was out of his behavior for him to get up unassisted. V6 said R3 did not use a walker with her. V6 said R3 had a regular wheelchair. V6 said I don't remember what kind of shoes R3 had. V6 said R3 fell between 11:00 AM and 12:00 PM. V6 said I don't remember getting R3 up that day. V6 said the night shift usually takes R3 to dialysis in the morning before she gets on the unit. V6 said I didn't put shoes or socks on R3. V6 said R3 did make some urine but had not used the urinal or been incontinent at the time of the fall. V6 said that generally, R3 was alert and oriented, but that day, R3 was out of his behavior. On [DATE] at 2:20 PM, V3, Licensed Practical Nurse, said [DATE] R3 went to dialysis that morning; he was already off the unit when V3 came in; dialysis starts at 6:00 AM. V3 said around 10:00 or 10:30 AM, R3 was in bed with the CNA, making him comfortable. V3 said I checked R3 and he said he was just tired. V3 said at 11:00 AM, when I passed R3's room, he was in bed sleeping. Then he called me and wanted to be changed about 11:,d+[DATE]:30 AM, and the CNA went to change him. V3 said while V6 was changing R3, I was at the desk, then V6 went to take the next patient to dialysis, and I remained at the desk. V3 said at 12:00 PM, I went to do blood sugar checks. V3 said I saw R3 was standing out of the bed, already losing his balance. V3 said, I was too late. He fell . V3 said R3 was trying to reach for the chair in the room, but he still fell . V3 said R3 had blood in his left hand and bottom lip. I called 911 and left him on the floor with V6. V3 said there was blood on the pillowcase V6 had placed under R3's head. V3 said R3 was bleeding from the back of his head. V3 said I had not seen R3 get up on his own before. V3 said sometimes R3 will shoot us away if we help him. V3 said R3 had fallen Friday before [DATE]. V3 said when I came in for my shift, the night nurse said they found him on the foot of the bed on [DATE]. V3 said on [DATE], R3 had a gown on, and he was barefoot. V3 said R3 came to us because he had fallen in the past. V3 said R3 may have had a bowel movement and still makes urine. V3 said R3 was in a regular bed, and it did not go to the floor. V3 said R3 had no walker or cane, just a wheelchair. V3 said we did not have floor mats in place for R3. V3 said it was not like R3 to get up on his own. On [DATE] at 12:48 PM V2, Fall Coordinator, said R3's behavior he was non complaint with cares, he was new to dialysis, had depression, and he had multiple falls at home. V2 said on [DATE], R3 stood up to try to go to the bathroom; he is weak from hospitalization and dialysis. V2 said R3 did not call for help, he fell and intervention was to continue therapy. V2 said on ,d+[DATE] 24, R3 was seen at 11:30 AM in bed resting; the nurse did not wake him. V2 said R3 had already had dialysis on [DATE]. V2 said the nurse went in to check R3's blood sugar at 12:10PM. V2 said R3 had taken a step from the bed and fell and hit his head. V2 said V3 witnessed the fall. V2 said R3 fell between the bed and nightstand and he hit his head on the nightstand. V2 said R3 said I was going to go sit in my wheelchair and he thought he could do it. V2 said R3 was noted bleeding and R3 remained on the floor until ambulance came for him. V2 said the hospital notified us that R3 had a Subdural Hematoma and was in the intensive care unit for care. V2 said R3 died in the hospital of cardiac arrest and aspiration pneumonia. On [DATE] at 2:36 PM, V4, Director of Rehab, said R3 was on caseload from [DATE] through [DATE]. V4 said R3 required moderate assistance for transfers. V4 said R3 was ambulating with minimal therapist assistance with a rolling walker. V4 said the CNA would need to use a gait belt, give cues, and some assist to get him to stand. V4 said barriers for therapy for R3 were poor motivation, behavior, and he was refusing to participate in therapy. V4 said R3's balance fluctuated and is not the best, especially after dialysis, and poor after treatment related to fatigue. V4 said for residents on case load we will tell the nurse the level of support the resident needs and if they are a high fall risk we encourage them to have their walker. V4 said for R3 staff should not be using the walker with him. On [DATE] at 3:00 PM, V5 Restorative Nurse said R3's orientation fluctuated; he was incontinent, but he was not producing urine. R3's diagnosis include but are not limited to End Stage Renal Disease, Dependency on Renal Dialysis, Adjustment disorder with Mixed Anxiety and Depressed Mood, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Anemia, Type 2 Diabetes Mellitus, Hypertension, Congestive Heart Failure, and Presence of Cardiac Pacemaker. R3 was admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. Incident report dated [DATE] for R3 states around 4:45AM patient observed lying on his back on the floor next to bed. Patient stated he was trying to go to the washroom when he lost his balance. Blood pressure 91 / 50 pulse 105. Mental status oriented to person and place, lack of safety awareness. Post-fall investigation states activity at the time of incident: attempting to stand or transfer to get out of bed. Mental status at the time of the incident: poor safety awareness. The factors that contributed to the incident: attempting to stand transfer without assistance. Resident at risk for falls: fall risk score 16, resident has a history of falls, multiple files prior to admission. Interventions used to bed in the lowest position, call light within reach, and education to use call light for assistance. Root cause analysis states that the resident recently started dialysis and was hospitalized due to multiple falls and episodes of dizziness. The resident is currently here for therapy for strengthening. Per resident he got up from his bed to go to the washroom and lost his balance. Per staff, the call light was next to the resident but was not activated. Resident fell because resident unsafely transferred himself without assist despite unsteady gait and balance. Resident has a BIMS (cognition assessment) score of 10, which indicates moderate cognitive impairment, so he forgets to use the call light at times. Interventions: continue with skilled therapy for strengthening. The incident report dated [DATE] states that the nurse went to the patient's room. Observed R3 standing by the bed and attempting to walk but began to lose balance. The nurse attempted to get to the resident to prevent him from falling, but the resident fell between the bed and the nightstand. The resident stated I was trying to go sit in the chair. I thought I could do it myself. R3 noted with a laceration approximately half inch on the left posterior head and mild bleeding of the lower mouth. Blood pressure ,d+[DATE] pulse 74. R3 remained on the floor until paramedics arrived. Injury observed: laceration back of the head. Mental status: alert with periods of forgetfulness. Post-fall investigation states resident injury: Subdural Hematoma. Activity at the time of incident: attempting to stand or transfer to get out of bed. Mental status: poor safety awareness. Environmental factors: attempting to stand transfer without assistance. Date of last fall: [DATE]. Interventions: bed in the lowest position, call light within reach, skilled therapy. R3 was sent to the hospital post-fall with injury via 911. R3 was admitted with a diagnosis of Subdural Hematoma. Root cause analysis: R3 has poor decision-making skills. He overestimated himself to perform tasks independently and unsafely transferred himself without assistance despite unsteady gait and balance, causing him to lose balance and fall. R3 has poor safety awareness and impulsive behavior. On [DATE] at 6:00 AM R3 went for dialysis. Increased weakness, fatigue, and dizziness are mild symptoms after dialysis treatment, which may have contributed further to his fall. R3's Cognitive assessment dated [DATE] notes a score of 10. R3's behavior assessment dated [DATE] notes he has verbal behavioral symptoms directed towards others (threatening, screaming, cursing). Behaviors put the resident at significant risk for physical illness or injury. Significantly interfere with care. No rejection of care was exhibited. Functional abilities notes toileting and personal hygiene R3 requires substantial/maximal assistance with helper doing more than half the effort. Standing, transfer from chair to bed, bed to chair, and toilet R3 was dependent on staff. R3's bowel and bladder assessment noted R3 was always incontinent of bowel and bladder. R3's appliances assessment notes he has an indwelling catheter, external catheter, ostomy, and intermittent catheterization. R3's Admission assessment, dated [DATE], notes a fall risk evaluation of 4, low risk. The assessment notes that R3 is continent of bowel and bladder. The resident has a short-or long-term memory problem. The resident is able to walk with assistance or an assistive device. Gait is not applicable. The history of falls states no, and it is unknown if the resident has fallen in the past three months. R3's care plan dated [DATE] states at high risk for falls related to decline in functional status, impaired balance during transitions, impulsivity or poor safety awareness, multiple falls prior to admission and muscle weakness from recent hospitalization s. Goal states R3 will be free of falls through next review date. Interventions dated ,d+[DATE] include call light and reach and encourage to use for assistance. Staff to provide a safe environment. Therapy to evaluate and treat as ordered to increase strength and mobility and prevent further falls. Keep needed items within reach, such as urinal. Intervention dated [DATE] states continue with skilled therapy. The speech therapy evaluation and plan of treatment dated [DATE] state that memory and safety awareness have been declining recently. The patient is memory impaired. The reason for therapy is that the patient presents with moderate problem-solving and safety awareness skills. Barriers likely to impact discharge to the next level of exasperation of cognitive impairment include lack of insight into the condition and risk factors. The physical therapy evaluation and plan of treatment dated [DATE] states, Has the patient fallen in the past year? Yes, six times per patient. The patient feels unsteady when standing and worries about falling. R3's hospital record dated [DATE] notes he received 7 staples to the left occipital side. R3 was admitted to the intensive care unit (ICU) for the management of Subdural hematoma. R3 did not return to the facility. 2. IDPH facility reported incident for R2 states on [DATE] nurse heard resident calling for help. Nurse observed resident sitting on the floor in his room. Resident stated I was trying to transfer myself but missed the bed, I hit my face on the side of the wheelchair and landed on the floor. R2 sent to hospital for evaluation of laceration on the left eyebrow measuring 1.0 X 0.3 centimeter with bleeding. R2 returned after few hours with diagnosis of laceration of forehead. Observed with sutures on left eyebrow. On [DATE] at 12:03 PM V8, RN, said on [DATE] I was passing medications, I heard someone calling for help. V8 said when I saw R2 he was kneeling at the side of the bed. V8 said I saw blood on the left eyebrow. V8 said R2 said I want to transfer myself. V8 said R2 thinks he can do things by himself, but he refuses to use the call lights. V8 said R2's roommate said R2 transferred himself. V8 said R2 hit his eyebrow on the bedside table. V8 said R2's call light is always in his reach and we have to remind him to use it. V8 said supervision is what we do for R2. V8 said R2 said he wanted to get into the bed. V8 said R2's mental status is causing him to fall. V8 said sometimes he understands direction. V8 said R2's current roommate wants the door closed, so it gets closed. V8 said R2 will transfer himself on and off the toilet. On [DATE] at 12:37 AM V9, CNA, said R2 refuses when you help him. V9 said R2 will stand up, closes the door and he just keeps doing what he was doing. V9 said R2 transfers himself, he wants to be independent. V9 said R2 gets up to walk into the bathroom. V9 said I will try to open the door for R2, and he sometimes wants the door open. V9 said I don't know if R2 would use the urinal or commode. V9 said if R2 falls he will try to stand up by himself. On [DATE] at 2:02PM R2 interviewed in tv room, no staff observing the area, only as they walk past. R2 said I don't know why I keep falling. R2 said my knee, (points at left knee) hurts or gives out. R2 Speaks in low soft tone. On [DATE] at 12:28 PM V1, LPN said R2 was trying to go to the bathroom by himself on [DATE]. V1 said I had just talked to R2 in the hall. V1 said R2 did not ask for assistance, he never told me he had to use the washroom. V1 said I was doing medication pass when he went past me. V1 said then I heard something and I saw R2 on the floor in the room. V1 said I don't recall what he said. On [DATE] at 12:48 PM V2 Fall Coordinator, said R2 is very alert he knows when to call. V2 said R2 gets mad if you try to help him. V2 said I called the daughter to ask what we can do. V2 said I speak with R2 often to call for assistance, but he won't call. V2 said R2's leg is unstable and we have him working with physical therapy to work with safety. V2 said the plan for R2 is he needs frequent checking on even if he refuses. V2 said R2 is alert, he can press the call light, and we continue to remind him. V2 said R2's room is close to the nurses' station, to keep checking on him. V2 said R2 has fallen in the common areas and in his room. On [DATE] at 1:05 PM, V2 said that on the fall risk assessment, a score of 8 or more is high risk, 7 or below is low risk, and everyone is at risk. V2 said 10 is a high risk. V2 said a history of alcohol abuse places someone at risk for cognition or balance problems. V2 said I can use the BIMS to determine the resident's cognition. V2 said a new BIMS (cognition assessment) is not usually done with a fall, only for changes in behavior. On [DATE] at 2:36PM V4, Director of Rehab, said R2 has been seen with therapy. V4 said R2 was last seen [DATE] thru [DATE] and prior to that [DATE] to [DATE]. V4 said for [DATE] R2 had another fall and we recommend to see him again to educate on safety and body mechanics. V4 said R2 participates with interventions but he demonstrates poor safety awareness and poor insight to deficits. V4 said R2 required assist with ambulation for safety. V4 said R2's deficits include he is impulsive. V4 said at the time of discharge in [DATE] R2 has the ability to transfer with moderate assist and ambulate with moderate assist. V4 said R2 assistive devices include a wheelchair and rolling walker. V4 said R2 has poor carryover and is very challenging. V4 said the responsibility of activating the call light for help should not be on him. V4 said we anticipate him resisting and declining assistance. V4 said we have done extensive education and reminders for R2 to use the call light. V4 said when ambulating R2 leans back and we prefer staff just wheel him up to the toilet. On [DATE] at 3:00 PM V5, Restorative Nurse, said R2 can propel in the wheelchair by himself. V5 said R2 can stand by himself, but he needs supervision because of poor bilateral lower extremity strength. V5 said R2 is able to stand but not safe alone. V5 said R2 does not use a walker or a cane to ambulate, he can't walk. V5 said I can't remember if R2 is using a walker. V5 said the urinal could be helpful for R2. V5 said R2 was not offered a urinal. On [DATE] at 2:21 PM, V5 said R2 restorative programs include active range of motion, dressing, and grooming. V5 said R2 was not walking with nursing before last week. V5 said the the MDS is incorrect for [DATE], R2 was not walking with a walker at that time. V5 said his endurance was poor when R2 was walked last week; he has a crisscross gait pattern, and he needs cueing, hands-on assistance, and a wheelchair to follow. V5 said R2's posture is poor he looks down when walking. On [DATE] at 1:51 PM, V10, the Physician said R2's neuropathy could affect his ability to know where he is putting his feet to walk. R2's history of alcohol abuse may cause him to have some cognitive issues. Proprioception (perceiving location of movement) and cognition can be affected. R2 can be more impulsive due to the alcohol affects on his frontal lobes and cerebral effects. V10 said R2 can be alert and oriented and have less ability to compensate for balance. V10 said we can do a neuropsyche consult to see if there could be subtle issues affecting impulsivity and following instructions. R2 diagnosis include, but not limited to history of Maxillary Fracture ([DATE]), Zygomatic Fracture ([DATE]), Fall ([DATE]), Laceration ([DATE]), Alcohol Abuse, Hypertension, and Vitamin D Deficiency. R2 admitted to the facility on [DATE]. Progress notes dated [DATE] written by V10, Physician, documents R2 with history of gait disorder likely from alcohol abuse and neuropathy seen earlier today due to fall few days ago. R2's fall risk evaluation dated [DATE] indicates score of 10, high risk. Mobility the residents gate described as unsteady. On [DATE], R2's incident report states that the nurse was informed that the resident slid out of his chair and was on his bottom in the dining room. Mental status forgetful. On [DATE], R2's incident report states that at approximately 11:45 AM, the nurse heard a little commotion. The nurse went to the resident's room. The resident was sitting on their buttocks and fell unwitnessed. The resident stated I was trying to go to the bathroom. Mental status lack of safety awareness and forgetful. Post fall investigation states activity at the time of incident: attempting to stand or transfer. Mental status: poor safety awareness. Environmental factors: attempting to stand transfer without assistance. Fall risk: resident at risk for falls evaluation score 10. Resident has history of falls last fall [DATE]. Interventions bed in lowest position, call light within reach, education to use of call light. Root cause analysis: states resident with history of hypertension alcoholism was brought by family for continued weakness and falls at home. Patient has become increasingly difficult to care for self. Was a functional alcoholic. A cognition score of 15 indicates intact cognition. Resident fell on [DATE] because resident unsafely transferred himself to the bathroom without any assisted device and staff assistance call light was not utilized. Resident is non-compliant and overestimated self to perform task independently causing him to fall. Intervention resident will be provided with visual prompts to ask for help to help him communicate his needs. On [DATE] R2's incident report states nurse heard resident calling for help. Nurse observed resident sitting on the floor. Resident said that he transferred himself from wheelchair but unable to reach the bed and, hit his left eyebrow at the edge of the bedside table and sustained a small laceration with bleeding. Residents said I transferred from my wheelchair but missed the bed. Laceration on the left eyebrow measuring 1.0 by 0.3 centimeters with bleeding. Set to emergency room for evaluation and treatment via 911 Mental status alert with periods of forgetfulness lack of safety awareness. Post fall investigation states resident was last seen on his wheelchair he propelled himself to his room. Resident verbalized he is OK and does not need any further assistance. Nurse reminded resident to press call light when needed. Activity at the time of incident: attempting to stand or transfer. Mental status: poor safety awareness. Environmental factors attempting to stand transfer without assistance. Resident at risk for falls evaluation score 13. Fall interventions in place bed in lowest position, call light within reach, visual prompts provided. Resident was sent to hospital post fall and returned to the facility with stitches to left eyebrow. Root cause analysis: according to the resident, he was unable to reach the bed and hit his left eyebrow at the edge of the bedside table and sustained a laceration with bleeding. Resident was last seen sitting on his wheelchair. Resident is aware about the call light use but prefers to do task independently. He is assessed at high risk for falls and noted to be overestimating his capability at this time to perform task independently resulting in fall. R2's care plan dated [DATE] states he is at high risk for falls related to impaired balance during transitions, impulsivity or poor safety awareness, history of multiple falls and recent falls. Goal R2 will be free of falls through next review date. Interventions include I have periods of forgetfulness-staff to provide me a safe environment. Re-educate to use call light and remind to ask for assistance. R2's care plan, dated [DATE], states that the resident is noncompliant with the call light and transferring. I may not necessarily understand my physical limitations. I am noted to be non-compliant, omitting to use my call light or asking for assistance prior to transferring. I display poor decision-making and poor judgment. Interventions include anticipating resident needs. R2's cognitive assessment score on [DATE] is 15. No behaviors were exhibited on the behavior assessment dated [DATE]. The functional abilities assessment on [DATE] notes that R2 requires substantial to maximal assistance with hygiene and is dependent on staff for toileting. Our two mobility devices include a [NAME] and a wheelchair. The assessment on 10424 indicates that R2 ambulates with assistance. R2's quarterly restorative assessment dated 93024 indicates he requires assistance with ambulation and transfer and has a fear of falling. R2's resident education, dated [DATE], educated the resident regarding orientation to the call light. This is the last resident education documentation provided for R2. A list of R2's incidents include fall on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. R2's physical therapy discharge summary dated [DATE] notes restorative program range of motion program active range of motion on both lower extremities as tolerated. R2's physical therapy discharge summary dated [DATE] states a restorative program for ambulation and passive range of motion. Ambulation 150 feet using a rolling [NAME] with minimal assistance and close wheelchair follow for safety. R2's hospital record dated [DATE]: Laceration Repair on the left eyebrow with 2 sutures. The facility Fall Occurrence policy dated [DATE] states it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. The interventions will be reevaluated and revised as necessary.

Based on observation, interviews and record reviews, the facility failed to follow a resident care plan related to use of helmet for one (R3) of five residents reviewed for falls and injuries. This failure resulted in R3 sustaining a right subdural hematoma after a fall incident. Findings include: R3 is a [AGE] year-old female, admitted in the facility on 02/16/23 with diagnoses of Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Unspecified Fall Subsequent Encounter and Epidural Hemorrhage with Loss of Consciousness Status Unknown, Subsequent Encounter. According to MDS (Minimum Data Set) dated 11/10/23 under Section C, R3 has BIMS (Brief Interview of Mental Status) score of 3, which means severe cognitive impairment. R3's Fall risk evaluation notes dated 07/05/23, 07/27/23 and 01/30/24 recorded a score of 17 - 18 which means high risk for falls. According to incident report dated 01/30/24, at around 6:30 AM, V14 (Certified Nurse Assistant, CNA) came into R3's room with all the materials needed for her (R3) to be changed and observed her (R3) on the floor next to her bed lying on her back. V14 immediately called V13 (Licensed Practical Nurse, LPN) and responded immediately. R3 verbalized I don't know how it happened. I didn't hit the back of my head only my forehead. She (R3) complained of pain on forehead with a 3.0 cm (centimeters) laceration with bump, was given Tylenol for pain. Moderate bleeding was noted on the forehead. Pressure dressing and ice pack were administered to control the bleeding and was sent to the emergency room for further evaluation and management. On 03/05/24 at 3:35 PM, V14 was interviewed regarding R3's fall on 01/30/24. V14 replied, Around 5:45 AM to 6 AM, I went to her (R3's) room to change her (R3). She (R3) was still lying in bed. I told her (R3) that it is time to get changed. I went to grab some supplies in the cart. The cart was in front of her (R3's) room. While I was walking to grab the supplies, I heard her (R3) falling on the floor. I immediately came to her (R3) and saw her (R3) on the floor. It happened so fast. When I saw her (R3) on the floor, I noticed a laceration on her (R3's) forehead. She (R3) was not wearing the helmet. I put a pillow on her (R3's) head and left to go get V13. He (V13) came and did an assessment. V13 was also interviewed regarding R3. V13 stated, On 01/30/24, she (R3) had a fall. It happened early morning. V14 was to change R3. She (R3) was still in bed. She (V14) went out of the room and when she (V14) came back, she (R3) was already on the floor. She (V14) called me and I came into the room. She (R3) was on the floor. Her (R3's) forehead was bleeding. I put pressure on the forehead to stop the bleeding. When the bleeding stopped, I put a band aid, I applied cold pack. I asked if she (R3) has any pain, she (R3) said yes and I gave Tylenol. She (R3) was not wearing the helmet. I called paramedics as ordered and she (R3) was sent out. R3's Hospital Records dated 01/30/24 recorded: CT (Computerized Tomography) Head without contrast final result - Right Convexity Acute Subdural Hematoma measuring up to 6 mm (millimeters) in thickness. On 03/04/24 at 12:00 PM, R3 was observed in the small dining room attending activities, in her wheelchair. R3 was alert, and able to respond yes when called by name and stated she was doing fine. She was observed wearing a soft helmet. She (R3) is able to verbalize needs and wants. Per V11 (CNA), R3 always wear the helmet even when in bed and sleeping. R3 is also able to tell staff if she wanted to go to the bathroom. R3 was asked regarding fall incident on 01/30/24, stated she don't remember anything about the fall and refused to answer further questions. On 03/05/24 at 10:54 AM, she (R3) was again observed in the small dining room attending activities, sitting in her wheelchair with her soft helmet on. She (R3) stated she wants to go to the bathroom. V11 provided assistance. On 03/05/24 at 4:23 PM, V12 (Fall Coordinator) was asked regarding R3. V12 verbalized, She (R3) is alert, has impulsive behavior and has history of falls prior to coming to facility. That is why she (R3) wears the helmet 24 hours a day, even while sleeping. She (R3) has a behavior of removing the helmet. We have to always redirect her (R3) not to remove it. Staff has to make sure that the helmet is on. She (R3) has to be educated and reminded that she (R3) needs the helmet on at all times. On 01/30/24, she (R3) had a fall, early in the morning. I talked to V14, she (V14) said that she (V14) was doing rounds room to room and looked at R3. She (R3) was awake, and bed was at the lowest position, she (R3) was not in any distress. Her (R3) helmet was not on and was removed. Since she (R3) was in bed, she (V14) went outside to grab the supplies from the cart. The cart was outside the hallway by the door. When she (V14) went to grab the supplies, she (V14) turned and saw her (R3) on the floor. The cause of her (R3's) fall was she (R3) has this impulsive behavior. All staff were aware of her (R3) impulsiveness. Staff to make sure helmet is on at all times. On 03/06/24 at 3:08 PM, V10 (LPN) and V11 stated during interviews that R3 is alert, oriented to self and place but confused. V10 stated, She (R3) forgets things. She (R3) has a behavior of standing and walking to the bathroom without assistance. When she (R3) is in bed, she (R3) will yell for help, won't use the call light. Staff has to go there right away. If not, she (R3) is going to go by herself, right away. She (R3) is wearing the soft helmet. She (R3) came with the helmet, because she (R3) has previous history of head injuries. The helmet protects the head. V11 also added, She (R3) wears the helmet during my shift. Both also verbalized, If it happened that (R3) was not wearing the helmet, (R3) will look for it and ask for it. Even when (R3) sleeps, (R3) still must wear the helmet. During our shift, we have never seen (R3) removing the helmet. R3's care plans documented the following: (Date initiated 03/01/23) General behavior symptoms: Frequently removes helmet Interventions: Conduct a review of the behavioral symptoms to determine what strengths or abilities and needs are communicated via the behavior (example verbal behavior or verbal aggression often communicates a need to feel in control and assertive) Give psychoactive medication as ordered. Record behavioral symptoms (example, verbal/physical aggression, inappropriate behavior) and side effects (example, tardive dyskinesia, anticholinergic effects) Refer R3 to the consulting psychiatrist for a psychiatric evaluation, as warranted. (Date initiated 02/21/23) R3 admitted with soft helmet, on at all times for medical necessity. R3 can take it off upon command and put it back on Interventions: Staff to monitor any negative or adverse effects noted, including skin breakdown, signs and symptoms of delirium, fall/accidents/injuries, agitation, weakness. (Date initiated 06/13/23) At risk for falls related to cognitive impairment, decline in functional status, depression, impaired balance during transitions, impulsivity or poor safety awareness and recent fall Interventions: I have periods of forgetfulness, I would like staff to frequently reorient me to my surroundings. R3's hospital records dated 01/31/24 under History and Physical Note also documented that she has a history of left-sided stroke with craniotomy and subsequent cranioplasty back in 2010. On 03/06/24 at 3:26 PM, V15 (Nurse Practitioner) was asked regarding R3 and use of helmet during fall incidents. V15 replied, (R3) had a fall and had history of craniotomy, has neurocognitive issue. The soft helmet protects the head for injuries during falls. (R3) does not have normal protection of the head due to craniotomy. During fall incidents, the soft helmet can possibly protect (R3) from developing the subdural hematoma. The soft helmet reduces the risk of head injuries to happen during fall. Staff has to do a lot of redirections since (R3) has a behavior of removing it from time to time. (R3) must be redirected and monitored that she wears the helmet at all times. V2 (Director of Nursing) also verbalized during interview on 03/06/24 at 3:40 PM, (R3) has Dementia, and has behavior of impulsiveness. (R3) must wear the soft helmet at all times, even when sleeping. (R3) has a behavior of removing her helmet, so staff has to do redirection and monitor if she wears the helmet at all times. Back in 2010, she had a history of traumatic brain injury. admitted back to us in 2022 and had the helmet on. We continued the helmet. Wearing the helmet is part of the fall intervention due to history of brain injury which was caused by a previous fall. Her fall incident last 01/30/24, (R3) sustained laceration on the forehead and was diagnosed with right sided subdural hematoma. The CNA (V14) mentioned that she saw her (R3) that morning that (R3) was not wearing the helmet while in bed. She (V14) should redirect the resident to put the helmet back on at that time before she gets the supplies. Staff has to follow what is being care planned on R3. If the care plan states (R3) should be wearing the helmet, (R3) should be wearing the helmet at all times. If (R3) removes the helmet, staff has to redirect and asked her (R3) to put the helmet back on. Staff has to monitor her (R3) for any untoward behaviors. Facility's policy titled Fall Occurrence dated 07/17/23 stated in part but not limited to the following: Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Based on interview and record review the facility failed to notify the physician of an opened surgical wound for treatment orders. This affected one of three residents (R1) reviewed for quality of care of a surgical site. This failure resulted in R1's wound becoming infected with live insect larva and being sent to the local hospital for evaluation and treatment. Findings include: R1 face sheet show diagnosis of encounter for orthopedic aftercare following surgical amputation. Acquired absence of other left toe. On 10.29.23 at 3:07PM V4 (wound care coordinator) said she was the wound care coordinator, V4 she does initial wound assesses with measurements for new admission and readmitted residents Monday through Friday. V4 said she does the rounds with the wound doctor, input initial orders and order changes, she develops initial care plans for wounds and update the wound care plan, she completes MDS assessment for wounds. V4 said R1 had a left 5th toe amputation surgical wound upon admission. V4 said R1 was followed by the ortho (orthopedic) surgeon for orders and recommendations for wound care treatments. R1 was receiving betadine to the 4th and 5th toe, and the wound was open to air (no treatment dressing applied). V4 said the facility did not notice R1 wound to be infected. V4 said she was made aware that R1 was being sent to hospital for infection by the ortho clinic on 9.22.23. V4 said she conducted a weekly wound assessment on R1 on 9.19.23 and R1 wound was clean and did not have signs of infection, which is drainage, swelling, redness, odor, and R1 did not complain of pain. V4 said R1 did not voice any concerns about his wounds that would indicate there was an infection. V4 said R1's daughter in-law informed her that the maggots were inside the scabs of the surgical wound, and they were not visible and that they would not have seen it. V4 said the clinic sent R1 to hospital evaluation. V4 said R1 did not return to facility after hospital stay. V4 said they provided wound care treatments as ordered by the ortho physician. V4 said she did not see the maggots in the wound she cannot speak to how that happened. Review of R1 weekly wound assessments documentation dated 9.19.23 with V4 in comparison to prior week wound assessment, V4 said on 9.19.23 the scab came off R1 wound and the proximal local (closet to the head). V4 said there was a small opening. V4 said she did not notify the ortho surgeon V11, she did not notify the medical doctor V6. V4 said she did not have any concerns to notify the providers about. V4 was asked did R1 have a surgical wound, and if that surgical wound needed a covering since it had opened. V4 restated that V11 wanted the wound to be open to air. V4 said the wound opened a little. Review of the wound assessment picture, there is an area where there is no dark scab, and the wound is open. On 10.30.23 at 10:17am V10 (Assistant working with ortho physician V11) said they were in clinic, but she can assist surveyor. V10 said the doctor wanted to be notified of all wound changes, V10 said the doctor should have been notified of all wound changes. V10 said the nursing home did not notify the ortho doctor when R1 surgical wound opened on 9.19.23. V10 said the doctor would have recommended to cover the surgical site with a dressing. On 10.30.23 at 10:43am V6 (Medical Doctor) said R1 was followed by the ortho physician, and she would have referred the nurse to the ortho for any changes in condition. R1 progress note dated 9.22.23 denotes in-part resident was scheduled today am for follow up appointment with V11 orthopedic Surgery. Resident left facility via wheelchair with assist and transportation in stable condition around 7:00 am. Around 10:00 am received call from V11 office and spoke with Registered Nurse V10. Received information that resident was sent to Hospital ER (emergency room ) for evaluation and treatment due to wound infection on left foot. Around 10:10 am spoke with ER regarding resident status and received information that resident is admitted with (diagnosis): wound infection on left foot. V6 was informed. Wound nurse informed. Resident POA (power of attorney) notified. DON (director of nursing), ADON (assistant director of nursing) aware. R1 orthopedic post operative visit dated 9.22.23 denotes in-part focused examination of the left lower extremity, there are two open wounds along the prior incision line quarter size near the distal aspect of the toe, there are visible maggots within the distal wound, numerous , live, protruding, there is surrounding erythema, there is malodor in the base of the wound there is devitalized necrotic tissue, proximal incision wound dime size 2 maggots seen within the wound bed. R1 care plan dated 8.3.2023 denotes in-part apply R1 is at risk for additional skin breakdown, R/T (related/to) chronic A-fib (atrial fibrillation), gangrene, PVD (peripheral vascular disease) , HTN (hypertension), acute kidney failure, thrombocytopenia, R1 was admitted with left 5th toe amputee, left 4th toe necrotic diabetic wound, R1 will not develop signs and symptoms of infection on the wound site. wound treatment as ordered by the physician, check skin every shift, report abnormalities to the nurse. Keep skin clean and dry, use lotion on dry skin. Monitor document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to MD (medical doctor). Facility's change in condition policy titled change in condition/ physician notification with last revised date 7.28.23, denotes in-part the facility will provide care to residents and provide notification of resident change in status. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in S483.12(a).

Based on observation, interview, and record review the facility failed to provide supervision to prevent a dependent resident from falling for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of seven. This failure resulted in R3 falling on 7/9/23 in her bathroom and sustaining a displaced intertrochanteric fracture of her right femur which required surgical intervention. The findings include: R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include bipolar disorder, nontraumatic chronic subdural hemorrhage, anxiety disorder, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, anemia, end stage renal disease and unspecified falls. R3's facility assessment 6/18/23 documents R3 has severe cognitive impairment, requires extensive assistance of 1-2 staff members for all cares, and has a history of falls. R3's care plan initiated 6/14/23 showed, [R3] has impaired cognitive function related to traumatic subdural hemorrhage . Interventions . Break tasks into one step at a time. Cue, orient, and supervise her as needed. R3's care plan initiated 6/13/23 documents, [R3] requires assistance with ADL's (activities of daily living) (bed mobility, transfers, dressing, walking, personal hygiene, eating, and toileting). admitted [R3] to this facility on 6/13/23 from [acute care hospital] status post fall with left frontal lobe subdural hematoma, had hematoma drained and presents with incision on left frontal lobe . period of forgetfulness, able to follow commands, pleasant and cooperative with care, needs cueing, demonstrations, and encouragement from staff for task . Resident needs extensive assist of 1 staff for ADLs . Interventions . Resident on trial for sensor pad alarm in bed to notify staff when there's an attempt to get out of bed without calling for staff assistance . R3's care plan initiated 6/14/23 documents, [R3] is high risk for falls related to anxiety disorder, decline in functional status, impaired balance during transitions, impulsivity, poor safety awareness, fall in the last month and recent fall . Interventions . I have period of forgetfulness. I would like staff to frequently reorient me to my surroundings . R3's fall investigation dated 7/9/23 documents, Around 8:20 AM, CNA went to the resident to serve resident breakfast tray. Resident asked CNA to take her to the bathroom to use the toilet. CNA assisted resident on the toilet and gave residents privacy by closing the door partially and placing call light within reach. While CNA was waiting on resident, CNA heard a noise and responded immediately. When the CNA opened the washroom door, CNA observed the resident laying on the floor on the right side facing the door. Nurse on duty was near resident room and also heard the noise and immediately responded . resident displays signs of pain when moving right left . R3's acute care hospital documentation operative notes showed R3 was admitted to the acute care hospital on 7/9/23 after she sustained a right hip fracture and underwent a surgical repair of her right hip on 7/10/23. R3's July 2023 Physician Order Sheet documents a 7/17/23 order for Right Hip- Cleanse with NSS (normal saline solution), pat dry, apply Betadine paint and cover with bordered gauze dressing daily and as needed. On 7/29/23 at 9:56 AM, R3 was lying in bed. R3 was agitated and tearful asking for her husband. On 7/29/23 at 12:59 PM, V10 CNA (Certified Nursing Assistant) said, If a resident with dementia and confusion needs to go to the bathroom we have to stay with them for their safety. On 7/29/23 at 1:11 PM, V9 CNA said, It was breakfast time, I took her tray into the room and she was trying to get up and go to the bathroom. She was assisted to the bathroom . she said she wanted privacy. I was in the bedroom, she started screaming like something was wrong. It happened so quick. She was on the toilet saying something in her language and the next she was on the floor. The nurse heard it too and came in. On 7/29/23 at 2:16 PM, V3 (Fall Coordinator) said, [R3] was admitted to use with a chronic subdural hemorrhage. I looked at the referral and she had lots of falls . very confused and impulsive. If she wants to get up she gets up. She is unsteady. She has poor safety awareness . The CNA took her to the toilet and she insisted on closing the door to the bathroom for privacy. The CNA didn't close the door all the way because she knew she was impulsive. She gave her the call light. [R3] can sometimes use the call light. The facility's policy and procedure revised 5/17/23 titled Fall Occurrence showed, . Policy Statement, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary .

Based on observation, interview and record review the facility failed to follow its policy in using restraints and failed to prevent a physical restraint from being used for staff convenience for one resident (R140) in the sample of 31 residents reviewed for restraints. These failures resulted in psychosocial harm in that, a reasonable person would react to such physical restraint with feelings of agitation, anxiety, frustration, fearfulness, humiliation, and punishment. Findings include: On 3/28/23 at 4:43pm, Observed R140 sitting on chair with walker in front of her. The frame of the walker is tied together with the arm rest of the chair extending around the back of the chair with plastic rope. Call light is not within reach. Called V17 Agency CNA assigned to her. V17 said that she tied R140 to her walker and chair to prevent her from getting out of chair and to prevent falling. She cannot watch her because she has to give a shower to another resident. V17 added that R140's family requested it and has been doing it to prevent her from falling if no one can watch her. On 3/28/23 at 4:48pm, Called V18 Agency Nurse and showed observation made. V18 said that she is not aware of restraining R140 to her chair and walker with rope. She said, this is a restraint, this is not right and not acceptable. V18 called V3 DON and V5 Fall coordinator. On 3/28/23 at 4:52pm, Showed observation made to R140 to V3 DON and V5 Fall Coordinator. V3 and V5 said that they are not aware that R140 is being restrained to chair and walker. Both said that they don't allow restraints in the facility. Both said that V15 Family member did not to talk to them about wanting R140 to be restrained. On 3/29/23 at 12:40pm, V15 Family member said that no one called her to explain what new fall prevention interventions were implemented for R140 to prevent her from falling again. Review of R140's medical records did not indicate that V15 requested R140 to be restrained. Facility's policy on Restraints indicates: It is the facility's policy to ensure that each resident is not restrained for the purposes of discipline or convenience. The facility will utilize non-restraining interventions first before trying to restrain -type devices which will be considered as last resort. Physical restraint is defined as any manual method, physical or mechanical device equipment or material that meets all the following criteria: a. attached or adjacent to the resident's body b. that the individual cannot intentionally remove easily and c. restricts freedom of movement or normal access to one's body. 46560

Based on observation, interview and record review the facility failed to provide adequate supervision to residents who are at high risk for fall and has history of falls. This failure caused one resident ( R117) to be hospitalized for surgery due to a fracture. The facility also failed to implement fall preventive intervention care plan. This deficiency affects 2 (R48, R117) residents in a sample of 31 reviewed for Fall prevent management. Findings include: 1. On 3/28/23 at 4:59pm, R117 was lying in bed moaning and restless. R117 is admitted on [DATE] with diagnosis list in part but not limited to Aftercare following joint replacement surgery, Displaced fracture of base of neck of right femur, Alzheimer's disease, Epilepsy and epileptic syndromes with complex partial seizures, Parkinson's disease, Neurocognitive disorder with [NAME] bodies, old myocardial infarction. The Fall assessment dated [DATE] indicated he is at high risk for fall. Care plan indicated he is at high risk for falls related to Alzheimer's disease, cognitive impairment, fatigue, weakness, seizures disorder, use of hypnotics, non-compliant with using his walker when ambulating, history of falls and recent falls. He has impaired cognitive function due to dementia. He has ADL self-care performance deficit. Intervention: Transfer- requires staff supervision to limited x 1 staff. There were no interventions in place for ambulation/locomotion in care plan. R117's MDS quarterly assessment dated [DATE] indicated that he needs limited assistance in transfers, supervision in walking in the room and locomotion on the unit. R117's Incident Report documents that the resident had an unwitnessed fall on 9/13/22 where the resident was found lying on the floor in the hallway, and a witnessed fall on 3/3/23 where the resident tripped in the dining room and hit his head on the door. R117 was sent to the hospital and admitted with minimally displaced and angulated right femoral neck fracture. A post fall investigation was done and indicated R117 needs supervision from staff when ambulating due to an unsteady gait and muscle weakness. The care plan updated but it was not indicated in care plan that he needs supervision when ambulating and assistance in transfers. R117's hospital records dated 3/3/23 indicated: X-ray of the right femur reveal minimally displaced and angulated right femoral neck fracture, with angulation of the right hip. A right hip replacement was done on 3/6/23. On 3/29/23 at 2:31pm, Review R117's medical records with V5 Fall Coordinator. Informed concerns of inadequate supervision for both falls. R117's MDS quarterly assessment dated [DATE] indicated that he needs limited assistance in transfers, supervision in walking in room and locomotion in unit. No intervention in place for ambulation/locomotion on care plan. Both post fall investigations indicated that R117 needs supervision from staff in ambulation due to unsteady gait, muscle weakness, and poor safety awareness. 2. On 3/28/23 at 4:29pm, R48 was sleeping in bed and there was afolded floor mat on the side of the dresser. The bed was not in the lowest position. The bed was pushed against the wall. V26 Agency nurse was shown the observation of R48. V26 said that R48 does not use the floor mat, it was brought to the facility by the hospice staff. V26 said that R26 is a fall risk due to her morphine medication and she is on hospice care. Asked V26 if the bed is in the lowest position, she said no. V26 said that she has to check R48's chart to see if her bed needs to be in the lowest position. On 3/29/23 at 3:00pm, R48 was sitting in the wheelchair. V5 Fall Coordinator assisted R48 to stand up to check the placement of the non-skid mat on the seat of her wheelchair. There was no mat found. V5 said that she should have a non-skid mat in place as part of the fall prevention interventions. On 3/29/23 at 4:10pm, R48 was observed sleeping in bed with a folded floor mat on the side of the dresser. The bed is not in the lowest position. The bed is pushed against the wall. Called V7 Restorative Nurse and V23 RN was standing outside R48's room and was shown the observations made. Both staff members said that R48's bed should be in the lowest position and the floor mat should be on the floor when the resident is in bed. V7 adjusted the bed to the lowest position and placed the floor mat on the right side of the bed. R48 is admitted on [DATE] with diagnosis listed in part but not limited to Parkinson's disease, Restlessness and agitation, Dementia, Depression, Anxiety, Wedge compression fracture of the second lumbar vertebrae. Fall assessment dated [DATE] indicated that she is at high risk for fall. Care plan indicated: She is at high risk for fall related to anxiety disorder, depression, Parkinson's disease and recent falls. A non-skid mat is to be added to her wheelchair to minimize her risk for sliding. She demonstrates cognitive impairment related to dementia and Parkinson's. R48's Incident Report documents unwitnessed falls where the resident slid from the wheelchair on 5/12/22 and 7/29/22, and a witnessed fall from the wheelchair on 3/23/23. On 3/29/23 at 10:30am, V30 CNA and V24 RN were interviewed and V30 said she was fixing the new low air loss (LAL) mattress that was placed on R48's bed when she slid from the wheelchair when trying to pick up something. V30 said that she landed on the folded mattress. Both V30 and V24 said that R48 is not using a floor mat brought by hospice care. On 3/29/23 at 2:31pm, R48's medical records were reviewed with V5 Fall Coordinator. V5 was informed of concerns of inadequate supervision related to falls. On fall incident dated 5/12/22, the care plan was updated but not based on the root cause analysis of the fall. R48 slid from the wheelchair and forgot to unlock her wheelchair. V5 said that she was not the fall coordinator at the time of the incident. V5 said that she has not done the post fall investigation yet. V5 provided updated fall care plans for R48 pending completion of post fall investigation. New fall intervention implemented: Place the bed in the lowest position and floor mats. Facility's policy on Fall occurrence indicated: It is the policy of the facility to ensure that the resident are assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised ad necessary. Procedure: 2. Those identified as high risk for falls will be provided fall interventions. 5. The Fall coordinator will review the incident report and may conduct her own fall investigation to determine the reasonable cause of fall. 6. The nurse may immediately start interventions to address falls in the unit, even prior to fall coordinator's investigation. 8. The fall coordinator will add the intervention in the resident's care plan. 10. The interventions will be re-evaluated and revised as necessary.

Based on observation, interview and record review, the facility failed to provide the necessary physician ordered treatment and services to promote healing of existing pressure ulcers and prevent the further development and worsening of pressure ulcers. This failure affected 3 (R1, R3, R4) reviewed for pressure ulcers in the sample; with this failure causing R1 moisture associated skin damage, R3 with worsening sacral stage 4 pressure ulcer, and R4 with a worsening stage 3 left sacral pressure ulcer. Findings include: 1. R1 is a cognitively impaired [AGE] year old resident with diagnosis, listed in part with [CONDITION(S)], malignant neoplasms, diabetes and major depressive disorder. On 4/11/22 at 11:10 AM, R1 was observed in bed on an air mattress and multiple padding and sheets strewn about her bed. The bed was raised waist high and underneath the bed were two blue boots (heel protectors) that were not applied to R1's feet to protect her ankles. On R1's bedside table was a green triangular and elongated wedge cushion. R1 was asked if anyone came to place the boots on her and about the wedge cushion, R1 stated, My granddaughter wants those on me, but there's no one here today. Surveyor asked what she meant about no one being here today, R1 stated, Well I just saw them earlier today and then no more. On 4/11/22 at 1:34 PM, R1's family stated, I was visiting my grandmother one day and she was complaining of some pain on her backside, and when we called for help and the aide came to change (R1), I noticed this large open bed sore on her butt. I asked the aide at the time if she ever saw that, and she told me she never did. I was really upset about this, and I complained to the nurse (I cannot recall her name). I don't know why this was never communicated to me at the time. I literally had to ask the nurse to call the doctor, otherwise it did not seem she was even aware of the new wound until I had to say something. I mean, don't they notice this when they bathe her or when they change her diaper? That tells me none of these things are happening, and my grandmother is somewhat confused and really can't speak up for herself. R1's care plan dated 3/28/22 reads in part, (R1) has potential for pressure injury development or impairment to skin integrity related to generalized weakness, and diabetes. 3/28/22 (R1) is noted with MASD (moisture associated skin damage) on sacrum extending to buttocks. Goal: (R1) will maintain skin integrity. Interventions: Keep skin clean and dry; Skin check every shift during routine care and showers; turn and reposition every 2 hours and as needed and as tolerated. R1's MDS (minimum data set) assessment dated [DATE] shows R1 with no pressure ulcers but, assessed as at-risk for development of pressure ulcers. This same MDS assessment showed R1 on a turning and repositioning program along with pressure reduction mattress for her bed and chair. A wound assessment dated [DATE] written by V14 (wound doctor) reads in part (R1). Patient presents with a wound on her buttock. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. (R1) has a wound buttock for at least 1 day duration. Wound size 10 centimeters by 10 centimeters by not measurable centimeters depth. Interview with V10 (wound coordinator) on 4/11/22 at 11:30 AM affirm R1 sustained a pressure ulcer while in the facility on 3/31/22. V10 stated, R1 had a MASD (moisture associated skin damage). She's incontinent and wears a diaper and she has to be turned and repositioned often. We are treating it now. Surveyor asked whether R1's new wound was facility acquired, V10 stated, Yes it is and it's new. On 4/11/22, at 3:30 PM, surveyor returned to observe R1 but, instead watched as the resident was being transported out to the hospital. V5 (LPN) was asked about R1's transfer and stated, We noticed a change in condition with her, so we transferred her to the hospital after I called the doctor. Records show R1 was sent out due to shortness of breath. #2. R3 is an alert and oriented 78- year-old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (minimum data set) assessment dated [DATE] shows R3 requiring extensive assistance with a minimum 2 persons for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture.) This same MDS assessment shows R3 as being at high risk for developing pressure ulcers/injuries, and with the facility plan for R3 to have a pressure reduction mattress, pressure ulcer/injury care, and on a turning/repositioning program. On 4/13/22 at 10:21 AM, V10 (LPN- Licensed Practical Nurse/ Wound Coordinator) was observed outside R3's room. Surveyor asked to observe a wound treatment and inquired as to which resident she was going to do treatment on. V10 stated, I'm about to do (R3). I'll be back because I have to get something. V10 proceeded to go off the unit and surveyor waited for V10 to return. Surveyor noticed V11 (LPN/Treatment nurse) already in R3's room, so surveyor entered R3's room and saw that V11 (LPN Treatment nurse) hurriedly trying to do wound treatments on R3's lower extremities. R3 was flat on his back with both legs exposed, and V11 applying treatment ointment on to R3's heels. Surveyor asked V11 to describe the wounds as she was conducting treatment, V11 stated, I know they are pressure ulcers but, I don't know what kind. I know that both heals are pressure ulcers, and the one on his sacral area is a stage 2. Surveyor asked if she was trained on how to conduct wound care, V11 stated, Not really. I was a patient care tech in the hospital, and became an LPN and work here now. I usually follow the wound doctor (V14), when she rounds here every Monday. Surveyor asked whether V14 ever described the wounds she was treating for patients in order for her (V11) and other treatment nurses to learn about wounds, V11 stated, I don't know. I just watch but I don't really listen. V10 (LPN/Wound coordinator) returned and joined V11 (LPN/Treatment nurse) and surveyor who were already in R3's room. V10 stated, Okay I'm ready to show you the wounds. V10 asked V11 to turn R3 to his side so they could begin treatment on R3's sacral area. V11 turned R3 to his right side and slowly removed and peeled away R3's incontinence brief which was stuck to R3's buttocks. On R3's incontinence brief was a large mound of brown bowel movement that spread in between R3's buttocks, up and around his testicles and penis area. Fecal matter was also present in and around the large open sacral wound that appeared in the size of a soft ball. The sacral wound appeared reddened and inflamed with black areas around its circumference. Surveyor asked whether they (V10 and V11) asked the nursing aide before starting wound care on their patients, V10 stated, They are supposed to get them cleaned up first but, I don't know who the aide is today. V10 walked to the door of the room and shouted down the hall to the nurse and asked for an aide to come help. No one came. V10 and V11 ended up cleaning R3 before proceeding with the treatment. Surveyor asked if they knew who the aide that was assigned to care for R3, V10 and V11 stated, We don't know. It could be agency aide. After cleaning up R3, surveyor asked V11 to describe the wound they were about to treat, V11 stated, R3's sacral wound is a stage 2. V10 corrected V11 and stated, No, it's a stage 4. Surveyor asked V10 to describe the wound, V10 stated, It's a stage 4 to the sacrum measuring about 10 centimeters by 11 centimeters, and 0.5 in depth. It's been stable, and there is no undermining or tunneling. Surveyor asked what the black edges were around the wound, V10 stated, It's necrotic (dead, nonviable) tissue. Surveyor asked if she was sure there was no undermining of R3's wound as V10 was able to place her fingers under and around the circumference of the wound. V10 stated, Yes you're right it is undermining. It wasn't there before. Surveyor asked if that is an indication of decline in the wound, V10 stated, It is. Surveyor asked what the cause could be for the decline, V10 stated, I don't know. Surveyor asked what preventative measures R3 had to help heal wounds and prevent the formation of other wounds, V10 stated, They're supposed to be turning and repositioning him at least every 2 hours and keep him clean and dry. Surveyor asked if this is what they observed for R3, V10 stated, No, it doesn't seem that way. I'll make sure to inform my manager. Surveyor asked again if this could be a reason for the decline in R3's wound, V10 stated, I guess so. At the end of R3's wound observation, surveyor walked over to V12 (RN) who was sitting at the nursing station. Surveyor asked if R3 was her patient and asked about R3. V12 stated, Yes he's mine. I don't know much about R3, I am only a PRN (as needed) nurse, and this is my first time working on this unit. Surveyor asked who the nursing aide that was assigned to care for R3, V12 stated, Let me check the schedule. It's V13 (CNA) that's assigned to him, do you want to talk to him? Surveyor asked how many residents were assigned to her and to V13, V12 stated, I only have one CNA and there are 19 residents here on this unit. Surveyor asked what kind of residents were on her unit and the type of care they had, V12 stated, They are mostly heavy care long term residents here. Surveyor asked what she meant by heavy care, V12 stated, They need maximum assistance to do most things. Surveyor spoke to V13 (CNA) who came walking down the hall and asked about R3. V13 stated when asked, I changed R3's diaper at around 7:45 AM this morning when I got in. Surveyor asked if he saw him later after that, V13 stated, No, I was doing other residents. #3. R4 is a cognitively impaired and developmentally disabled [AGE] year-old resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's care plan dated 3/31/22 reads in part, (R4) is at risk for additional skin breakdown related to functional [CONDITION(S)], toxic [CONDITION(S)], major depressive disorder. Interventions: Keep skin clean and dry; Off load heels as ordered; Turn and reposition as needed; Wound MD consult. R4's MDS (minimum data set) assessment dated [DATE] shows R4 requiring total dependence in bed mobility with a minimum of 1-person physical assist to perform this function. This same MDS assessment shows R4 to be at risk for further development of pressure ulcers, and placed on skin and ulcer treatments, and for a pressure reducing device for chair and for bed however, does not place R4 on a turning and repositioning program required to off-load pressure due to her inability to perform bed mobility as R4 is totally dependent to perform this function. On 4/13/22 at 10:55 AM, Surveyor requested V10 (LPN/Wound Coordinator) and V11 (LPN/Treatment nurse) to observe wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was lying atop an air mattress on her bed. R4's hair was disheveled, matted, and she was dressed in a bluish-gray, and urine stained hospital gown. A feeding pump was heard beeping continuously to the left of R4's bed indicating that pump needed attending to. R4's bed linens were in disarray and crumpled all over and under R4's body. Under R4's upper left shoulder were 2 green incontinence pads that were folded over to create 4 layers. Under R4's buttocks were two more green incontinence pads folded over twice to create 4 layers. A crushed, yellow stained wet pillow was observed directly under R4's buttocks with more linens and sheets that were scrunched up around R4. Surveyor asked V10 about the abundance of linens, V10 stated, No this isn't right. She should not have all this padding, sheets and linens under her. We've had inservices (training) about this. Surveyor asked the rationale for limited use of padding and sheets, V10 stated, It defeats the purpose of pressure reduction when you have all these pads under her. Surveyor noticed a yellow circular stain under R4 where the pillow was removed. Surveyor asked if that was urine, V10 stated, No it looks like her feeding tube was leaking. Surveyor asked about the linens again and observed V10 turning the air mattress pump on. Surveyor asked if the air mattress was deflated and turned off, V10 stated, Yes. I don't know why this was turned off. I'll find out from the CNA. At 11:07 AM, V13 (CNA-certified nurses' aide) entered the room and was asked about the air mattress that was turned off and the alarming feeding pump, V13 stated, I didn't notice any of that when I last saw her. Surveyor asked when the last time he came in to care for R4, V13 stated, I checked in on her at 7:30 AM. Surveyor asked if he did any incontinence care for R4 when he came in around 7:30 AM, V13 stated, No, I just checked to see if she was okay. The night shift must have turned off the air mattress this morning and also put all those pads under her because I didn't do that. Surveyor asked if there were any other aides in his section that cared for R4, V13 stated, No, I'm the only CNA assigned here. There's one other one but she's in the front section in the other unit. Surveyor asked how many residents he took are of today, V13 stated, I think I have 17 or 19 or something like that. Surveyor asked whether he turns and repositions residents, V13 stated, I wasn't told to do that by the nurse. Surveyor asked whether the computer system they use prompts them to turn and reposition residents, V13 stated, Yes I think so, but we just check that off. Surveyor asked V10 (Wound coordinator) to proceed with the wound care after R4's incontinence brief was removed. V10 showed surveyor R4's wounds and stated, She (R4) has an unstageable pressure ulcers to her left ischium, left lower buttocks, left sacrum area, and right sacrum area. She also has a DTI (Deep tissue injury) on her right hip with necrosis (dead non-viable tissue) and has a stage 3 pressure ulcer on her right ischium. Surveyor asked whether R4's wounds had shown improvement or worsened, V10 stated, I can't say. The doctor usually determines that. Surveyor asked whether they used PUSH (Pressure Ulcer Scale for Healing) scores to measure progress in the wounds, V10 stated, Yes we do but I'd have to check to see what that is and let you know. Surveyor asked about the mattress pump settings on the bed and asked V10 if there was any inservice training provided to the nurses and nurses' aides about their maintenance and how to make the beds up, V10 stated, I know that we were all taught to minimize the amount of sheets on the bed. Surveyor asked about the settings on the pump which had an option of static mode to be on or off, V10 stated, That button should be at off mode. If it's turned on to static-mode that means it is not on alternating pressure. I don't even know why it's turned on or even have that button to begin with. Records provided to surveyor showed R4's left sacrum wound to have a PUSH score on 3/25/22 to be at a 10 (PUSH scores are from 0 to 17. 0=healed. The higher the number up to 17 means it has worsened). R4's wound records show measurements of the wound at 1.5 centimeters by 1.0 centimeters and an unknown depth and overall measurement area at 1.5 centimeters. R4's wound assessment of the left sacrum dated 4/4/22 showed a decline in the wound with a PUSH score = 12 and with an increase in size: 2.00 centimeters by 2.00 centimeters x unknown depth and area increasing in size to 4.00 centimeters. The latest assessment dated [DATE] showed a worsened PUSH score of 14 and with an increase in measurement: 3.00 centimeters x 3.00 centimeters by 0.1 centimeters depth and area size of 9.00 centimeters with the wound showing [CONDITION(S)] (reddening as result of injury or irritation) and Maceration (breaking down of skin resulting from prolonged exposure to moisture). Wound progress: Deteriorated. On 4/13/22 at 2:05 PM surveyor interviewed V14 (wound doctor). Surveyor asked whether the nurses she rounds with should be familiar with treatment methods to prevent and treat pressure ulcers, V14 stated, I found that in the nursing homes I visit and round in, that nurses know nothing about wound care and that's pretty uniform across all the facilities I go into. Surveyor asked during her wound rounds whether specific wound care nurses should be educated and know the rationale for the treatments she orders, V14 stated, No I wouldn't. Surveyor asked the importance of repositioning residents to off load pressure, V14 stated, Repositioning is definitely important but if you're referring to (R3), he refuses to be repositioned and the son also requests that (R3) not be turned because he has pain issues. In fact, I have documented that in my wound notes. Surveyor mentioned that wound care was observed with R3 who was not at all resistant to being turned and repositioned during wound care. V14 stated, Well I just know that he doesn't like that. Surveyor asked whether in general, if turning and repositioning residents were an important factor in preventing and/or healing of wounds, V14 stated, In general, yes it's important to turn and reposition patients as its going to be off-loading to the wound. Surveyor asked about linens and other padding on top of an air mattress, V14 stated, I ask that blankets and chucks (incontinence pads) aren't layered on the bed. I discussed this with staff and not layering of them on the bed. Surveyor asked what the rationale is for not over-layering of linens and pads, V14 stated, It defeats the purpose of the air mattress and will cause pressure on the skin. Surveyor asked if moisture or wetness on the skin can cause skin damage, V14 stated, Yes I heard about the pillow underneath (R4). It's meant to be used as a wedge to off-load pressure so I approve of that. Surveyor informed V14 that the pillow observed was immediately under R4 and was observed wet. V14 stated, Well if it was wet that would definitely not be good as it can cause skin breakdown. Surveyor asked if the alternating mattress on the bed should be placed on a static mode, V14 stated, I would prefer them to be alternating not static otherwise it's not beneficial. I don't even know why there's even an option to turn it to static mode. Surveyor asked V10 (Wound Coordinator) a policy for the air mattresses but was not provided one during the survey. V10 stated, I checked and we don't have one for that just a wound policy. Policy dated 7/28/21 titled, Skin Care Treatment Regime reads in part, It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, topical skin treatment must be obtained from the patient's physician. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. Residents who are not able to turn and reposition themselves will be turned and repositioned every 2 hours unless specified in the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Residents with Stage III and/or IV pressure ulcer will be placed in specialized air mattresses like low air loss mattress with an incontinent brief if they are incontinent only, incontinence pad which will also act as repositioning aid, and either a flat sheet or a fitted sheet which are all necessary to prevent infection control issue.

Based on interviews and record reviews, the facility failed to follow wound physician's wound treatment recommendation. One resident (R1) of three residents reviewed for skin alteration. R1 did not have a treatment order documented as completed for the left foot, 4th toe from 7/26/21 to 8/3/21. This failure resulted in R1 being transferred in a local hospital for left foot pain. R1 presented to hospital with clinical impression of critical ischemia of foot, open wound on left foot, and infestation by maggots. Findings Include: R1's initial admitted is 6/19/21. R1 was sent to local hospital on 7/18/21 for complication of AV (Arteriovenous) Fistula. R1 returned to the facility on [DATE]. R1 Skin Evaluation (Quarterly + Comprehensive) dated 7/26/21 at 13:00 (1pm) shows that there were two skin alterations identified. One in left arm surgical incision and one in left fourth toe vascular/arterial insufficiency. Additional Skin/treatment note reads in part: Treatment resumed to left fourth. Right fifth toe healed. New surgical incision on left arm. Treatment applied as ordered. Reviewed July 2021 Treatment Administration Record of R1. There is no noted treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record was reviewed. V7 (Wound Doctor) came and saw R1 on 7/26/21. Wound doctor note reads in part: Site 2 Arterial wound of left, fourth toe with a wound size of 1 x 1 x Not measurable cm (length x width x depth), surface area of 1.00 cm^2, exudate: none, Scab: dried fibrinous exudate (scab), wound progress: no change. Dressing treatment plan [MEDICATION(S)] apply once daily. This mentioned recommendation on 7/26/21 was not carried out until 8/4/21. Wound visit on 7/26/21 was also the last time wound doctor saw R1 in the facility. Other Mondays that wound doctor was in the facility R1 was not available. On 8/24/21 at 2:09 pm, interviewed V7 (Wound Doctor) and stated V2 (DON) does wound rounds with me because there is no wound treatment nurse at this time in the facility. Left 4th toe has a scab and as long it stays dry, it should be fine. Because the wound etiology is arterial, our goal is to prevent infection and drainage. On 8/2/21, I was on vacation and I did not do wound rounds that Monday. I came in the same week on Friday and I did not see R1. R1 was not available, either R1 was on [CONDITION(S)] or therapy. On 8/9/21, if I don't have documentation, I did not see R1 that Monday also, either R1 was not in room, either doing therapy or [CONDITION(S)]. On 8/24/21 at 11:05am, V2 (Director of Nursing) stated R1 came in with two wounds in left foot, 4th and 5th toes. 5th toe was healed on July 12th 2021 and 4th was still open. Dry and fibrinous exudate, scab 7/12/21. Resident came back on 7/25/21 (was hospitalized on [DATE]) with wound vacuum on left upper arm. Seen by wound doctor on 7/26/21, and left 4th toe had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Fourth toe was dry and necrotic during the wound nurse round when R1 was not seen by the wound doctor. On 8/15/21, R1 was sent in the hospital. R1 had pain in toes and was sent on 8/15/21 to the local hospital. The pain was not relieved, which concerned the nurse and R1 was sent out to the hospital for evaluation. R1 was taking pain medication but was ineffective. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21 AT 3:15PM, V8 (nurse) stated R1's left 4th toe was really open and the 3rd and 5th were moist, but I am not sure if they were opening. Definitely there was an opening on the left 4th toe. I noted a small opening. I'm was just concerned about R1's severe pain. R1 had requested a second dose of pain medication which was very unusual for R1. That R1 had left foot pain, not tolerable prompted me to call the doctor. Severe pain. No odor, no swelling and no redness, just opening and drainage. Nurse's note reviewed and on 8/15/21 at 2100 (9pm), V8 documentation reads in part: complaint of severe pain in left toes, noted open areas with small amount of drainage on 3rd, 4th, and 5th. Call placed to V10 (Nurse Practitioner), covering for R1's attending physician and informed. Ordered to send R1 to hospital emergency room for evaluation and treatment. Area cleansed with soap and water, dry dressing applied. Medicated for pain. Nurses noted dated 8/16/21 at 10:14 am reads in part: called local hospital emergency room , talked to nurse that R1 admitted for left 4th toe wound with maggots. Hospital record reviewed. Emergency notes reads in part: Seen by vascular surgery residents. They did some debridement of the wound and removed the maggots. Emergency Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21 at 11:05am, V2 stated I don't know what happened with the wound doctor recommendation on 7/26/21, I gave those to the nurses. I think what happened was the nurses got comfortable and continued to do the [MEDICATION(S)] treatment to R1 but did not place the order in R1's chart. I know it is not documented anywhere but I know the nurses are doing the treatment. On 8/25/21 at 2:00 pm, V10 (Nurse Practitioner) stated For wound treatment, I would refer to the wound doctor recommendation because they know more and they have the expertise when it comes to wounds. This is the first time this happened in my career, to hear one of my patients developed maggots in their wound. I know maggots came from flys, they used to have windows open in the facility, but I don't want to assume that it started because of that. On 8/25/21 at 2:55pm, V7 stated The etiology of maggots developing is that the wound is infected. The point of [MEDICATION(S)] treatment recommendation is to keep the wound dry. The wound on the 4th left toe probably got wet and that causes the infection. I recommended [MEDICATION(S)] because it has anti-septic property, and it would keep the area clean and dry. On 8/25/21 at 10am, requested policies from V2 for comprehensive skin assessment, treatment administration, and skin documentation policy. Facility was unable to provide requested policies. Per V2, We don't have those policies, whatever we have is in that wound care program policy. Wound Care Program policy with last reviewed date of April 2021 reads in part: Timely identification of residents assessed to be at risk for skin breakdown. Facility shall develop a plan of care and implement intervention according to the resident's Braden Scale and Clinical Evaluation or identified individual risk factors. Documentation: The resident's skin alteration/breakdown (pressure ulcer, arterial, diabetic, venous ulcers and etc.) shall be documented in the resident's clinical records in accordance to the facility's policy and in compliance to current regulatory standards.Wound assessment for pressure, diabetic, venous and arterial wounds: wound assessment documentation shall include but are not limited to type of wound and/or ulcer, location, date, stage,(if applicable), length, width, and depth; wound bed description, wound edge description and if presence exudate, undermining, tunneling, and wound related pain.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. These failures resulted in R1's transfer to a local hospital twice with large amounts of bloody urine output, 1600 cubic centimeters (cc) on 9/27/18 with a [DIAGNOSES REDACTED]. Findings include: R1's Admission Record documents the following medical Diagnosis: [REDACTED]. R1 was admitted to the facility on [DATE]. R1's Progress Note which was dated 9/20/18 and authored by V17 (APN-Advanced Practitioner Nurse) documents, in part: On 8/09 patient pulled out indwelling catheter causing hematuria. Urology was consulted. CBI (continuous bladder irrigation) performed and resolved. (Indwelling urinary catheter) re-inserted. R1's medical record indicates that he was admitted to the facility with an indwelling urinary catheter. This note also documents: [MEDICAL CONDITION] with hematuria. (Indwelling urinary catheter). Voiding trials when appropriate. On 1/24/19, V2 (Director of Nursing) confirmed that R1 had a [DIAGNOSES REDACTED]. On 1/28/19 at 12:30pm, V25 (Nurse Practitioner, Urology) indicated that [MEDICAL CONDITION] would be a reason to keep an indwelling urinary catheter. R1's Order Recap Report documents a physician order [REDACTED]. On 1/28/19, V2 (DON-Director of Nursing) confirmed that 9/24/18 was the date R1's urinary catheter was discontinued. V2 also confirmed that there is no documentation in R1's medical record regarding R1's voiding trial, PVR (post void residual) results, bladder scans and assessment of bladder progress after the catheter was discontinued. On 1/24/19 at 3:40pm, V18 (Nurse Supervisor) stated, Voiding trial is for three days on every shift after the (urinary catheter) is pulled out. I got a parameter for him. Bladder scan is done after they urinate. Look for signs and symptoms of difficulty urinating, like distended abdomen. V18 indicated that when an order is entered for discontinuation of urinary catheter then a batch order is generated which includes PVR and bladder scans. V18 confirmed that there was no batch order for bladder scans and PVR's to be performed for R1 after the indwelling catheter was discontinued. V18 indicated that the nurses would not receive notification to do bladder scans and monitor PVR's. R1's Physician order [REDACTED]. On 1/28/19, V2 stated that after removal of indwelling urinary catheter, If the post void residual is greater than 350 cc in the bladder, the nurse should straight cath(eterize). V2 indicated that the purpose of the PVR is to see how much urine the bladder is retaining. V2 indicated that the bladder scan and PVR's are a part of nursing standards of practice. V2 stated, Only the CNA's (Certified Nurse Assistants) were charting that (R1) was voiding. R1's Bladder Continence record dated 9/24 - 9/26 denotes that R1's urinary episodes were not closely monitored. There is no charting for any night shifts from 9/24 to 9/26 and for evening shift on 9/25 regarding R1's number of urinary episodes. This documentation was confirmed with V2 on 1/28/19 at 3:05pm. On 9/26/18, R1's Physician order [REDACTED]. On 9/27/18 at 3:47am, V20 (LPN-Licensed Practical Nurse) documented: Noted with minimal bleeding from penis, perineal care provided. V20 continues to document that vital signs are stable. There is no documentation that indicates that V20 monitored R1's change in condition or that R1's vital signs were monitored. On 9/27/18 at 7:02am, V20 documents that the bleeding stopped. V20 did not notify V19 regarding R1's change in condition. V20 did not recognize that bleeding from the penis could be a sign of difficulty urinating. It is not documented that R1's bladder was assessed. On 1/24/19 at 11:17am, V21 (RN-Registered Nurse) indicated that she was the day shift nurse on 9/27/18. V21 stated, (R1) was changed by night shift at 6:30am. They told me that he had been bleeding from penis. They told me minimal. I saw the CNA from night shift was gathering towels and it was more than minimal. (R1's) diaper was completely saturated with blood. His baseline is to be very responsive. He was lethargic. Pale. Called (V19) as soon as possible. V15 (LPN) and V21 (RN) both indicated that they do not know the facility protocol regarding voiding trials. On 1/23/19 at 11:43am, V3 (ADON-Assistant Director of Nursing) stated that the facility does not have a policy regarding voiding trials. R1's progress notes document that R1 was transported out of the facility at 9:00am and was admitted to a local hospital on [DATE] with a [DIAGNOSES REDACTED]. R1's emergency room documentation dated 9/27/18 at 11:16am states that an indwelling urinary catheter was inserted without difficulty. RESULT: 1600 cc of grossly bloody urine. A CT (Computerized Tomography) scan of Abdomen and Pelvis was performed. IMPRESSION: 1) Right renal [MEDICATION NAME] with no obvious obstruction. 2) Enlarged prostate gland. The urology consultation note documents that R1 stated he felt better after urinary catheter was inserted. On 1/23/19 at 5:03pm, V22 (Nurse Practitioner) indicated that she was not told specifically about R1 having blood in urine. V22 indicated that there should be more strict intake and output monitoring for residents with diuretics, [MEDICAL CONDITIONS], IV's (intravenous), indwelling urinary catheters and [MEDICAL CONDITION]. When V22 was asked if residents with urinary issues should be assessed closely when urinary catheters are discontinued, V22 stated, I agree, should be monitored closely. V22 indicated that there is a potential for retaining urine when urinary catheters are discontinued and when the resident has prostate issues. On 10/2/18, R1 was readmitted to the facility with a [DIAGNOSES REDACTED]. This order also reads: 1 week void trial with PVR monitoring (10/9/18). The hospital urology consult note documents that R1 stated that he had a urologist at another local hospital. There no documentation that the facility followed the orders and arranged for a urology follow up with R1's urologist. There is no documentation that R1's urinary catheter was discontinued and a voiding trial was performed. On 1/28/19 at 10:59am, V23 (Unit Secretary) indicated that she is in charge of scheduling appointments. V23 indicated that she could not find a urologist that would come and see R1. V23 did not contact R1's urologist. V23 stated, We did ask several urologists. I didn't document any of the urologists that I tried to call. I get facesheet and go through Google and try to find a urologist like that, that's close to this area. On 1/28/19 at 11:06am, V26 (Receptionist for V27 (Urologist) confirmed that the facility did not attempt to make a follow up appointment with V27. R1's urinary issues and use of an indwelling urinary catheter are not care planned. This was confirmed with V2 on 1/23/19. R1's Progress Notes document that beginning on 10/27/18, R1 began to complain of abdominal pain. On 10/24/18, R1 had a KUB (kidney, ureter, bladder) exam that revealed constipation. R1's progress notes indicate that issue was resolved on 10/25/18. It is also documented that R1 was having bowel movements (bm) daily. On 10/27/18, R1's abdomen was hard to touch. Stool softeners were given and R1 had a bm. It is not documented that R1's urinary catheter was assessed. It is documented that R1 had a medium bm on 10/28. On 10/30/18 at 11:02pm, R1 complained of abdominal pain and again R1 was given stool softeners. It is documented that R1 was observed with blood in catheter bag and that R1 was seen pulling on his urinary catheter. On 10/31/18 at 12:06am, there was sediment noted in the urinary bag. There is no documentation that indicates R1's physician was called regarding the sediment in the urinary bag. At 2:15am, R1 was found unresponsive and transferred to a local hospital with the [DIAGNOSES REDACTED]. R1's hospital records documented that R1's indwelling urinary catheter was exchanged with an immediate result of 3000 cc (3 liters) of bloody urine. The urology consultation note dated 10/31/18 documents an impression: Malfunctioning (indwelling urinary catheter). During interviews, V2 (DON), V15 (LPN), V18 (Nurse Supervisor), V21 (RN), V24 (Nurse Practitioner) and V25 (Nurse Practitioner, Urology) all indicated that abdominal distention can mean that the resident is experiencing urine retention. There is no indication in the documentation that R1's urinary catheter was assessed for placement despite R1's behavior of pulling at the urinary catheter. On 1/28/19 at 12:30pm, V25 (Nurse Practitioner, Urology) confirmed that their urology service saw R1 in the emergency room in (MONTH) (YEAR). V25 stated, Part of voiding trial protocol is to check post void residual to make sure they're emptying their bladder appropriately. With [MEDICAL CONDITIONS], the risk is high of retaining urine. PVR done after a patient urinates. Chronic (indwelling urinary catheter) should not have [MEDICAL CONDITION]. In theory should not have urine sitting in bladder because urine is constantly draining. Should not have [MEDICAL CONDITION]. When (indwelling urinary catheter) is discontinued, bleeding could be a sign of difficulty urinating. A urologist should see a resident with [MEDICAL CONDITION] because may not need the (urinary) catheter. And can better manage the case with complicated history. We were aware (R1) had a urologist at (local hospital). It's written in the discharge note. Abdominal distention can occur if you retain a large amount of urine. If you have a large back up of urine, it can definitely cause Acute Kidney Damage and [MEDICAL CONDITION]. The facility does not have a policy or protocol regarding voiding trials when an indwelling urinary catheter is discontinued. A facility policy dated (MONTH) 20, (YEAR) and titled, Notification for Change of Condition documents: Procedures: 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: c. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). A facility policy dated (MONTH) 13, (YEAR) and titled, Indwelling Catheter documents: Policy Statement: It is the facility's policy to ensure that no resident will have indwelling urinary catheter, unless condition shows that there is a medical reason to justify the use of the indwelling catheter. 4. A care plan for the use of the indwelling catheter will be made per policy.