Every finding on record at Bria of Chicago Heights

Based on observations, interviews and record reviews, the facility failed to provide a safe environment for one (R3) of one resident reviewed for abuse. R3 was allegedly hit in the nose by another resident R9 at the facility before the staff could separate them. The facility abuse coordinator investigated the incident but did not substantiate the event during the facility investigation. R3 was a [AGE] year-old male with Brief Interview of Mental Status (BIMS) score of 8, which would indicate moderate cognitive impairment. Diagnosis includes in part: diabetes Type 2, Dementia unspecified with mood disturbance. The complaint alleges that R3 was hit in the nose by his peer R9 and that he was not sent to the hospital, and that R3 was trying to snap his own nose back into place and that there was still bleeding, also that he was not sent out to the hospital, that he only hadx-rays. R3 has since expired and his closed records were reviewed during the survey and staff members were interviewed. Investigation findings confirm that R3 was involved in an altercation with another resident (R9) in the dining room. The facility investigation showed that R3 was the aggressor and that other resident was sent out to the hospital after the incident for a psych evaluation. [DATE] 5:00PM Conference room: V1 (administrator) is the abuse coordinator and stated that R3 being hit in the nose and his loss of consciousness at the facility in the dining room were two different incidents and on two different occasions. This was confirmed by record review. V1 stated that he conducted the investigation into the confrontation and as per the abuse policy, the police were notified, and came to the facility, however the police did not make a report. V1 stated that there was contact made between another resident and R3, however it was related to R3 approaching and invading the other resident's (R9) personal space. R3 was hit in the nose during the incident and was sent for a medical evaluation and returned to the facility. V1 concluded in his final report that the incident was unsubstantiated because the other resident did not show intent to hurt R3, but after further reflection, V1 stated that he should have substantiated the event. Two other CNAs and another a SW aide were first on the scene and separated the two residents. [DATE] 4:45PM: Phone attempts were made to contact the CNAs and SW to get their statements, and this surveyor was unable to reach them. Months after the incident with (R9) his peer R3 had another incident in the dining room where he collapsed and was taken to the hospital. The facility abuse policy reads in part: The facility will establish an environment that promotes resident sensitivity, resident security and the prevention of mistreatment. The abuse policy also states in part: That physical abuse includes hitting, slapping, pinching, kicking and controlling behaviors through corporal punishment.

Based upon interview and record review the facility failed to follow policy procedures, failed to ensure that fall risk assessments were accurate, failed to utilize the falling star program for identified high risk residents, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, failed to provide supervision, and/or failed to ensure that responsible staff are aware of root cause of fall - to prevent additional falls for three of three residents (R1, R3, R4) reviewed for falls. These failures resulted in R1 sustaining an unwitnessed fall on 11/10/25 which resulted in facial injuries and anterior wedge compression fracture of L1 vertebral body. Findings include:The falling star program guidelines state residents will automatically be placed on the Falling Star Program if: at the discretion of the IDT (Interdepartmental Team) based on risk factors (BIMS score 0-7, unsteady gait, >2 antipsychotic medications, poor safety awareness, 10 or higher score on fall evaluation form). 1.R1's diagnoses include frontotemporal neurocognitive disorder, Alzheimer's disease, unsteadiness on feet, and abnormalities of gait/mobility.R1's (8/1/25) BIMS (Brief Interview Mental Status) determined a score of 5 (severe impairment) and inattention is present/fluctuates. R1's (8/1/25) functional assessment affirms resident requires supervision or touching assistance for walking. R1's (6/18/25) fall risk assessment determined a score of 10 (high risk). R1's (7/16/25) fall risk assessment (1 month later) determined a score of 8 (at risk) however confused not selected as warranted. R1's (9/3/25) care plan states resident is at high risk for falls related to recent fall, cognitive deficits, and use of psychotropic medication. Interventions: encourage resident to keep room free of obstacles/clutter, keep frequently used items within reach, promote placement of call light within reach, rounding at a minimum of every 2 hours [Falling star program was excluded].R1's (11/10/25) 3:00pm incident report states resident was seen 15 minutes before incident, writer took him to the room and sat him on the bed. Resident was observed by CNA (Certified Nursing Assistant) standing behind the room door, holding onto door handle. On examination noted abrasion on bridge of nose, below left eyelid and hematoma on left side of his head. Writer Nurse was notified. Nurse Practitioner notified and together assessed resident. Resident is alert x1 and unable to verbalize. Roommate is alert oriented x2-3 later stated that resident fell in the room. Medical doctor notified and order received to transfer resident to hospital for further evaluation. Statements: Unwitnessed fall. R1's (11/10/25) post fall risk assessment (documented at 8:17pm) determined a score of 8 however History of falls in the past 1- 6 months was not selected. On 11/12/25 at 1:15pm, surveyor inquired about R1's (11/10/25) incident. V2 (DON/Director of Nursing) stated, He (R1) had a fall in his room. He has frontal lobe dementia and ambulates; he had one slipper on and one off when the aide found him. The roommate said that he fell and got his self up in the doorway. He's supposed to come back from the hospital later today. We (staff) sent him out because his eye looked red and there was a bruise on his forehead. On 11/12/25 at 2:58pm, surveyor inquired about R1's (11/10/25) incident. V4 (Registered Nurse) stated, On the 10th around 2:50pm or thereabout I (V4) saw him (R1) moving toward the exit door, so I said don't go there. He (R1) walked hurriedly towards his room, I was closely following him and held his hand because the way he walks is a shuffled gait and such a speed as if he was falling. He (R1) himself opened the door and entered. I watched him move towards his bed and he sat on the bed. At that time, his roommate (R2) was in bed covered and resting. I came out and closed the door then I went to my station [R1 was left sitting on the bed and the door was closed - therefore supervision was not provided]. After I attended to other nursing issues around 3 or a little after, one of the CNAs (V6) called and said she saw (R1) has a bruise on the bridge of his nose and some drainage from the right eye. I said what happened, she (V6) said the call light was on and (R1) was standing behind the door holding the handle and she saw drainage coming from his eye. I tried to dab it, and he say it hurts. I further examined him and saw a hematoma on the forehead right side. It was like an abrasion here (bridge of nose) and underneath the right eye you could see like tears running but it was mixed with blood so there must have been some lacerations somewhere that was mixed with the tears. I went looking for the roommate (R2) and said what happened to (R1) he (R2) said I (R2) didn't push him or anything he fell to the ground in his room. On 11/17/25 at 11:21am, R1 was observed lying in bed asleep (alone) in the room. Only one (1) floor mat was adjacent R1's bed however the other side of R1's bed was roughly 1.5 feet away from the wall. V9 (Family) subsequently entered R1's room. Surveyor inquired about R1's (11/10/25) incident. V9 responded, He's (R1) nonverbal and doesn't talk. Before he fell, he would be in the dining room to keep an eye on him. I got a call that he fell around 3:00pm, 3:30pm. They (staff) said that he got up and saw his face was red and swollen. They called the ambulance. The right side of his lip was swollen, and he had a little broken skin on the right eyelid. He likes to walk around but has a shuffled gait and is bent over when he walks. I try to tell him to hold the rail when he walks, he doesn't listen. He gets up and he's gone but I slow him down. There is a definite progression with his walking, a significant decline. I was upset that he fell but he's a sundowner, he's quick. They (staff) sit out there (hallway) and watch him because he's a real go [NAME] you almost need a sitter. On 11/17/25 at 11:17am, V7 (CNA) was assigned to R1. Surveyor inquired how R1 ambulates. V7 stated, I (V7) been here for 2 weeks. The report I got was to feed him and change him, restorative would assist him with getting out the bed and walking and affirmed she was unsure. On 11/17/25 at 12:15pm, V8 (Licensed Practical Nurse) was assigned to R1. Surveyor inquired about R1's fall prevention interventions. V8 stated, He (R1) walks around, and we (staff) monitor him because we don't like him to stay by himself. We redirect him to the dining room when he's up so people can see him. On 11/17/25 at 12:20pm, surveyor inquired about R1's fall prevention interventions. V7 (CNA) stated, He's a 2 person assist to get up and make sure his pad is on the floor. Surveyor inquired if R1 has any other fall preventions interventions. V7 responded, No ma am, it's a strongly with a 2 person assist.On 11/17/25 at 1:57pm, surveyor inquired about R1's risk for falls (prior to 11/10/25). V11 (Restorative Director) reviewed R1's EMR (Electronic Medical Records) and stated, His (R1) fall risk assessment was an 8 on 7/16 (2025), it was a 10 on 6/18/25 (one month prior). The one on 7/16 for his mentation they have impaired judgment marked and for the one on 6/18 they have confused and impaired judgment which can kinda fall into the same thing. The score is based off of what they (staff) have clicked. Surveyor inquired if R1 is confused with impaired judgment. V11 responded, He's alert to his self, he's nonverbal so it's kinda hard to necessarily say. He definitely has impaired judgment and he's dementia but is really tricky with him. Surveyor inquired about R1's functional status. V11 replied, He (R1) has a steady gait [R1 has a shuffled gait per V4 and V9] but needs 2-person care because he's resistant. He's ambulatory without assist [R1's functional assessment affirms supervision, or touching assistance is required for walking] but his safety awareness is poor. Surveyor inquired if R1 has a shuffled gait. V11 stated, No [incongruent with V4 and V9's statements]. Surveyor inquired if R1 is bent over while walking. V11 responded, No, not necessarily he walks up and down the hallway fine [incongruent with V4's statement]. Surveyor inquired about R1's fall prevention interventions prior to (11/10/25). V11 replied, Prior to him falling we had encouraged and offered rest periods when walking long distances, keep the room free from obstacles and clutter, monitor resident for tolerance and endurance [falling star program was excluded]. Surveyor inquired about the root cause of R1's (11/10/25) fall. V11 stated, From my understanding the roommate said he tripped and fell when he was in the room and got his self-up. I didn't talk to the roommate, collectively we (DON, ADON/Assistant Director of Nursing) get together and discuss the falls. It was unknown how he fell. The roommate reported that he fell. Surveyor inquired if leaving R1 in the room with the door closed would be appropriate if he's a high risk for falls. V11 replied, He wasn't necessarily a high risk for falls prior to the fall, he does have poor safety awareness. To be left alone with the room closed; if he was resting that would be ok but for a long period of time, I don't think that would be okay. I wouldn't necessarily close the door. Surveyor inquired what care plan interventions were added (post 11/10/25 fall). V11 responded, We put him on the falling star program which means if no ones in the room with him and he's not resting he shouldn't be in the room by himself. It's a certain protocol we have for the falling star, when we see a star on the door, he's a high fall risk, they get hourly rounding or every 30 minutes, so we know when they last saw him and what he was doing. Surveyor inquired if R1 was on the falling star program prior to 11/10/25 fall. V11 replied, No, he got added after he fell. Surveyor inquired why R1 was not on the falling star program prior to 11/10/25. V1 stated, There was no indications that he would fall or a need to be on the program. Like I said he has poor safety awareness when he walks around, and he was at risk for falls but not a high fall risk. Surveyor inquired what fall risk score is considered high risk. V11 responded, 10 or higher [R1's 6/18/25 fall risk assessment determined a score of 10 - therefore high risk]. R1's (11/10/25) History & Physical states facility staff found the patient on the floor with swelling to the right side of his face. He is nonverbal at baseline and unable to provide further history. X-ray impression: anterior wedge compression fracture of L1 vertebral body is new compared to 7/14/25 and favored to be acute. On 11/17/25 at 4:21pm, surveyor inquired what fall prevention interventions should be implemented for a resident identified at high risk for falls. V12 (Medical Director) stated, Physical therapy to determine if they are high risk or low risk and help make them walk. Surveyor inquired about potential harm to a resident that sustains an unwitnessed fall. V12 responded, It could be anything of course; head injury is the worst especially if they have a bleed or something like that. 2.R3's diagnoses include altered mental status, muscle weakness, reduced mobility, hemiplegia and hemiparesis following cerebral infarction. R3's (10/16/25) BIMS determined a score of 8 (moderate impairment) with disorganized thinking.R3's (10/16/25) functional assessment affirms resident is dependent on staff for tub/shower transfer. Toilet transfer and walking were not attempted due to medical condition or safety concerns. R3's (10/17/25) fall risk assessment determined a score of 12 (high risk).R3's (1/28/23) care plan states resident is at high risk for falls secondary to hemiplegia and hemiparesis, interventions: keep bed in lowest position.On 11/17/25 at 11:17am, V7 (CNA) was seated in the hallway directly across from R3's room however she (V7) provided no redirection or assistance to lower R3's bed - which was noted to be in high position - while he (R3) was lying in bed.On 11/17/25 at 11:57am, (40 minutes later) R3 was lying in bed however the bed remained elevated (waist high) therefore not in lowest position per care plan intervention. R3 stated I'm (R3) in bed most of the time because I had a stroke. Surveyor inquired if R3 can walk R3 responded, No. 3.R4's diagnoses include morbid obesity, muscle weakness, reduced mobility, abnormal posture, hypertension, and altered mental status. R4's (10/2/25) BIMS determined a score of 13 (cognition intact).R4's (10/2/25) functional status affirms resident is dependent on staff for chair/bed to chair transfers. Toilet transfer and walking were not attempted due to medical condition or safety concerns. R4's (7/14/21) care plan states resident is at high risk for falls due to gait/balance problems, muscle weakness, and psychoactive drug use that may potentiate falls.On 11/17/25 at 12:07pm, R4 was lying in bed. R4 stated I'm (R4) here (in bed) all the time. I'm supposed to get up every Monday, Wednesday, and Friday but I'm not doing it. R4 also affirmed that she's incontinent, doesn't walk, and requires 2 persons assist with transfers.R4's (7/29/25) fall risk assessment determined a score of 9 (at risk) however elimination status was not marked (2 points) and predisposing factors none was selected however R4 is diagnosed with Hypertension (2 points) - therefore the assessment was scored incorrectly.On 11/17/25 at 3:00pm surveyor relayed concerns with R4's (7/29/25) fall risk assessment score. V2 (DON) affirmed R4 is likely high risk for falls due to diagnoses and inability to walk. The fall prevention and management policy (revised 10/2018) states the facility will identify and evaluate residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. Facility guideline following a fall incident: A fall risk evaluation is completed by the Nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interviews and record reviews, the facility failed to prevent a resident injury, and failed to determine the origin of the injury. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining left eye swelling and discoloration, discolorations to chest and right leg, scratches to face and chest area, and complaints of chest pain which were identified by the emergency room staff when R1 presented to the hospital for agitation. Findings include: On 6/24/25 at 2:30 PM, V7 (Complainant) stated that R1 presented to the emergency room on 6/22/25 at 1:02 AM with bruising and swelling to left eye, bruising to mid chest area, bruising to right leg, and scratches to face and chest area. V7 stated that the bruising on R1's chest appeared to be a heel print from being kicked in the chest. V7 stated that R1 stated V3 (Nurse) beat him up because R1 would not give V3 the bottle of rubbing alcohol which was his. V7 stated that R1's injuries were consistent with a person being assaulted. V7 stated that R1 also complained of chest pain. On 6/22/25 at 12:30 PM, V4 CNA (Certified Nurse Aide) stated that the incident happened after dinner on 6/21/25. V4 denied R1 exhibiting any behaviors prior to 6/21. V4 stated that V4 was rounding on his assigned residents when V4 observed R1 pouring rubbing alcohol into a cup. V4 stated that V4 immediately informed V3 (Nurse). V4 stated that V3 went to R1's room to speak with R1. V4 stated that R1 was verbally aggressive and threw the cup of rubbing alcohol at V3. V4 stated that V4 went to R1 and R2's room two hours later to provide resident care to R2. V4 stated that R1 pulled the privacy curtain open to see who the person was that told on R1. V4 stated that R1 walked towards V4, R1's gait was unsteady, wobbly. V4 stated that as V4 was opening the door to get staff assistance, R1 hit him on his left side of neck/shoulder area. V4 stated that V4 informed V3 that R1 was being verbally and physically aggressive. V4 stated that V3 informed him she was going to handle the situation with V5 (Assistant Administrator). V4 stated that R2's family member brought in the bottle of rubbing alcohol earlier on 6/21 and R1 took the bottle of rubbing alcohol from R2's belongings. On 6/23/25 at 10:00 AM, V6 CNA stated that V6 heard V4 CNA asking for help, he was having difficulty with R1. V6 stated that she was walking down hallway and heard V4 say don't hit me, V6 entered room to try to calm R1 down. V6 stated that V6 went on other side of the privacy curtain to speak with R1. V6 stated that R1 told her to get out and head butted her on her lower lip. V6 stated that V6 ran out of R1's room due to her lip bleeding. V6 stated that V3 and V5 were approaching R1's room as she was exiting room. V6 stated that R1 is cranky, he can be verbally inappropriate at times. V6 denied R1 ever being physically aggressive prior to that evening. V6 stated that she did not see R1 anymore that evening. On 6/23/25 at 10:15 AM, V3 (Nurse) stated that she was at nurses' station when V4 CNA informed her that R1 was pouring rubbing alcohol into cup. V3 stated that she went to R1's room, saw cup 1/2 full of rubbing alcohol. V3 stated that V3 asked R1 what he was going to do with it, R1 did not respond. V3 stated that V3 asked R1 to give her the cup. V3 stated that R1 held the cup and threw the liquid at her, V3 pulled the curtain to block liquid. V3 stated that most of the liquid hit curtain, only a little got on her clothes. V3 stated that R1 was verbally aggressive with her, but she was able to take the bottle of rubbing alcohol with her out of room and placed it at the nurses' station. V3 stated that V3 then heard a scream, V3 rushed to R1's room with V5 (Assistant Administrator) to find V6 CNA screaming. V3 stated that V3 observed V6's lip bleeding; V6 stated that R1 head butted her. V3 stated that V3 and V5 walked with R1 to the social services' office. V3 stated that afterwards V3 called the physician and obtained orders for medication injection and to send R1 to the hospital for evaluation. V3 stated that R1 stayed in the office with V5 on 1:1 monitoring until the ambulance crew transported R1 to the hospital. V3 stated that V3 is not sure how R1 got the bruises. V3 did not report an injury of unknown origin to the Administrator. V3 stated that R1 is alert and oriented x 3, his baseline. On 6/23/25 at 12:10 PM, V5 (Assistant Administrator) stated that V5 was working in his office on Saturday, 6/21, completing needed work. V5 stated that V3 (Nurse) informed V5 that they found a bottle rubbing alcohol in R1's possession. V5 stated that this bottle belonged to resident's roommate, R2. V5 stated that later R1 was becoming verbally and physically aggressive with staff and V5 saw V6 (CNA) was bleeding from her lower lip. V5 stated that V5 went to R1's room to de-escalate the situation. V5 stated that with re-direction V5 was able to get R1 to exit his room and agree to go to the social services office. V5 stated that while V5 was walking to the office with R1, R1 attempted to exit a back door at the facility. V5 stated that V5 was able to get R1 into the office to monitor R1 1:1. V5 stated that V5 sat with R1 until the ambulance crew arrived to transport R1 to the hospital for behaviors. V5 stated that R1 left the facility around 6:00 PM. V5 stated that V5 left the facility between 7:00 PM and 7:30 PM. V5 denied any staff member hitting R1. V5 denied R1 having any injuries prior to transporting to the hospital. On 6/23/25 at 3:00 PM, V1 (Administrator) stated that V1 was informed that R1 was being aggressive with staff on 6/21. V1 stated that staff are CPI (Crisis Prevention Institute) trained. V1 stated that this is not used very much at this facility. V1 stated that it is possible R1 could have sustained bruising when staff were trying to de-escalate the situation with R1. R1 has diagnoses including but not limited to stroke with hemiplegia affecting left non-dominant side, unsteadiness on feet, abnormalities of gait and mobility, major depressive disorder, bipolar disorder, delirium, anxiety disorder, suicidal ideations, and schizoaffective disorder. R1's outside ambulance report, dated 6/21/25, noted staff called for transport to hospital at 6:11 PM for a resident being aggressive with staff. The outside ambulance crew were dispatched to the facility at 11:29 PM and arrived at R1 at 00:05 AM. R1 noted with contusion to left eye, complaints of chest pain, and injury to right leg. R1 is claiming that staff struck him in the face and kicked him in the chest. R1's hospital record, dated 6/22/25 notes R1 presented to the emergency room at 1:21 AM for aggressive behavior/uncooperative behavior. R1 noted with hematoma (localized collection of blood) of left upper eye with swelling to affected orbit. R1 with noted bruising to chest area and right leg. R1 complained of chest pain, 10 out of 10. Per report, R1 found consuming rubbing alcohol in room to which altercation ensued with staff and R1. R1's medical record, dated 1/7/25, notes R1 exhibited physical aggression. R1's medical record does not note the details of this physical aggression. R1's medical record does not note any other incident of physical aggression until 6/21/25. On 4/25/25, Psychiatric Nurse Practitioner noted R1 is being seen for follow up visit: R1 is adherent with medication with encouragement from staff; fair hygiene and states I am doing well. Objective: R1 is AO x 2-3, fair grooming with good hygiene has no overt indication of depressive signs/symptoms. Fair insight/judgment; normal speech, apathetic fair concentration but denies suicidal/homicidal ideation. Assessment: He presents cooperative; fairly guarded endorses normal sleeping habit. Nursing staff reports R1 is adherent with medication and without exacerbation. R1's screening assessments for indicators of aggressive and/or harmful behaviors, dated 10/29/24, 1/3/25, 1/7/25, 2/3/25, and 5/5/25, note R1 is at minimal risk for aggression. The facility's abuse policy, revised 1/31/25, notes the nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered.

Based on interview and record review the facility failed to prevent a resident to resident physical assault. This affected two of four (R48, R70) residents reviewed for physical abuse. This failure resulted in R48 assaulting R70 in the face with a shoe on 4/8/25. R70 sustained purple discoloration to the right eye lid and petechia above the eyebrow. Findings include: On 5/28/25 at 1:15pm R70 observed alert to person, place, time and situation. R70 stopped surveyor and stated the facility has mixed residents with mental illness with residents that have medical problems. R70 said R48 hit her in the face with a shoe and she sustained a bruise to the eye. R70 said this was last month. R70 showed surveyor a picture on her cellular phone. The image was of R70's face, there was a dark purple discoloration to the right eye lid and petechia above the eyebrow. R70 said V1 (Assistant Administrator) was aware, and she told her son about it. R70 said this happened the day the rooms were changed. Review of R70's progress notes noted that R70 and R48 had a verbal altercation and R48 was relocated to another room. On 5/28/25, R48 is not interview-able. The data information on R70 phone denotes that image was taken on 4/14/2025 at 9:33am. On 5/28/25 at 2:59pm V26 (R70's son) said that R70 did report to him that a resident hit her in the face with a shoe. V26 said that matter should be investigated. On 5/28/25 at 3:30pm V1 (Assistant Administrator) said R70 did inform him that R48 hit her in the face with a shoe. V1 said how does a bruise come a week later. V1 said he did see the bruise to R70's right eye, and when he asked R70 about it, R70 replied I told you what happened. V1 restated that R70 said R48 hit her with a shoe. V1 said he is not a medical professional. V1 said R70 also fabricates stories. V1 said he does not know how R70 sustained the bruise to the right eye and petechia to forehead. V1 said he did not report the injury of unknown origin to the State Department. V1 said he did not reach out to the Administrator for guidance regarding the bruise to R70's eye and reported injuries. V1 said he thought the matter was resolved with he separated R70 and R48's room. V1 said the injury of unknown origin should have been reported to the State Department. V1 said he did not investigate R70's allegation of physical assault when alleged. V1 said the allegation was not investigated. On 5/28/25 at 4:20pm V2 (Administrator) said she was not aware of the bruise to R70's right eye. V2 said there is nothing documented in R70's medical records about the bruise to the right eye. V2 agreed that V1 should have reported the injury to the State Department. Facility policy for abuse with last review date 9/2024 denotes in-part the facility affirms the right of our residents to be free from abuse, neglect, mistreatment or misappropriation of resident property or mistreatment.

A. Based on interviews and records reviewed the facility failed to prevent one dependent resident receiving narcotic medication known to the cause side effect of constipation from developing a large stool burden. This affected one of one resident (R41) reviewed for quality of care and hospitalization s. This failure resulted in R41 being transferred to the hospital and admitted for a diagnosis of Sterocoral Colitis secondary to severe constipation. B. Based on interview and record review, the facility failed to follow physician' s orders for obtaining monthly laboratory draws for seizure medications levels for residents identified with seizure disorders. This affected two residents (R94 and R6) reviewed for following physician orders. Findings include: On 2/23/25 hospital History and Physical identifies R41's chief complaint constipation. R41 is being admitted for Sterocoral Colitis, Urinary Retention, and UTI. According to National Institutes of Health, they define Sterocoral as a rare inflammatory form of colitis that occurs when impacted fecal material leads to distention of the colon. R41 returned to the facility on [DATE]. R41's diagnosis include but are not limited to malignant neoplasm of right breast and constipation. On 05/28/25 at 1:06 PM R41 in bed observed twice, both times R41 was non-responsive. On 5/29/25 at 11:31AM V12, LPN, said R41 called 911, it happened before for bowels. V12 said R41 was on a narcotic that she took everyday, she took 2 a day. V12 said R41 was educated that a side effect of the narcotic was constipation. V12 said R41 was on a stool softener. V12 said R41 gets agitated when she can't go, it was not her first time not being able to go. V12 said R41 panics about not being able to have a bowel movement. V12 said R41 has a prescription for bowel care daily. V12 said in the past I have given her lactulose one time to go. V12 said R41 has a cancer diagnosis. V12 said if residents complain of not having a bowel movement we assess for distended abdomen or blood in the stool. V12 said I would ask R41 when she pooped last, and I would encourage fluids. V12 said we try to avoid using an enema on R41 because she might bleed. V12 said we discuss the care for R41 bowels with the Nurse Practitioner. V12 said we would document in the progress notes the assessment we did. (The facility provided V12 as an assigned nurse to R41 during 2/20/25-2/23/25.) On 5/29/25 at 9:59AM V22, LPN said R41 didn't tell me she needed anything on 2/23/25. V22 said R41 just called 911. I saw the ambulance came in; I was surprised. We went to her room and R41 transferred to the hospital. She never told me anything was wrong in the beginning. There was nothing told to me in report and no pain reported. V22 said R41 left, I didn't get an assessment. On 5/29/25 at 12:36PM V19, Nurse Practitioner, said R41 had breast cancer, and she had pain to the breast. V19 said R41 was on norco for pain management. V19 said constipation can be a side effect of the norco. V19 said constipation can be related to norco, immobility being in a wheelchair and age. V19 said R41 had bowel concerns for at least 1 year that I have been coming to the facility. V19 said R41 was on a bowel regimen with medications and providing adequate hydration. V19 said to monitor R41 she was verbal and could report her bowel concerns. V19 said the CNAs will report if a resident is not going. V19 said R41 was obsessive about her bowels. V19 said I would expect nurses to confirm with CNAs and give PRNs if needed if R41 was reporting the need to have a bowel movement. V19 said they should document symptoms and give the PRN if needed. V19 said R21 would probably present with pain or discomfort in the abdomen and possibly some tenderness. V19 said R21 would have been able to report that to us. V19 said the ER visits could have been avoided if treated in the facility for bowel care. On 5/30/25 at 9:49AM V3, Director of Nursing, reviewing R41's Documentation Survey Report for Bowel Continence with the surveyor and said the report shows R41 had small bowel movements on 2/21/25 and 2/22/25 day shifts and evening shifts. V3 said monitoring for constipation includes monitoring the stool output and how much she is going. V3 said the interventions were not effective in preventing constipation. At 10:30AM V3 said the only documentation with an assessment for R41 I have is the SBAR that was provided already, there was no progress notes documented. The only bowel related policy we have is for Retraining and 3 day assessments for new admissions. While reviewing the Medication Administration Record (MAR) for R41 with the surveyor, 2/1/25-2/23/25, V3 said R41 was not given as needed (PRN) Dulcolax suppository, enema or lactulose. R41 has Dulcolax suppository, enema, and lactulose available for administration on her MAR. V3 said the PRN constipation medication would be given based on assessment. At 10:43AM V3 said R41 had no inhouse labs for 2/1/25-2/23/25. R41's care plan states she has a bowel elimination problem (constipation) related to decreased GI motility. Interventions include assess and monitor bowel routine. Assess and monitor medication which may cause diarrhea. Give medication as ordered. Monitor for signs and symptoms of GI distress. Monitor medications which may contribute to constipation. Observe for decreased bowel sounds. R41's cognitive pattern assessment for 1/1/25 identifies a score of 13 and on 4/2/25 14, both are cognitively intact scores. R41's MDS 1/1/25 identify she uses a wheelchair. R41's requires substantial to maximum assist for toileting hygiene and is dependent for toilet transfers. R41 is always incontinent of stool. 39340 R94 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder, anxiety and conversion disorder with seizures or convulsions. R94's physician orders document monthly Tegretol(Carbamazepine) level dated 2/14/25. Carbamazepine extended release 100 mg. Give one tablet two times a day for conversion disorder with seizures. R94 carbamazepine level dated 2/19/25 was 5.3 normal. There was no level drawn for March. R94 carbamazepine level dated 4/11/25 documents 2.6 low. Reference range for carbamazepine is (4.0 -12). There were no carbamazepine levels for May. R94's Nurse Practitioner (NP) note dated 4/11/25 documents: Tegretol level 2.6. Conversion disorder with seizures or convulsions Give additional dose of Carbamazepine ER 100 mg x 1 Continue Zonisamide and current dose of Carbamazepine Seizure precautions. On 5/29/25 at 12:04PM, V19 (NP) said she ordered monthly Carbamazepine levels to ensure R94's medication is at a therapeutic level. V19 said it is recommended to check monthly. If levels are low medication level would be rechecked in a month and if still low medication change would be initiated. V19 said she did order one time dose of Carbamazepine after April results. V19 said she was unable to find any other lab results for R94's Carbamazepine level after April. V19 said she would expect her orders to be followed, and another lab draw to have occurred for May to follow up. V19 said if the therapeutic level is low, it can put the resident at higher risk for seizures. On 5/30/25 at 10:18AM, V24 (Pharmacist) said if the carbamazepine level is low it is recommended to adjust the dose and recheck the level within a week to see if there are any changes. If only a one-time dose of carbamazepine was given it would not have any long term effect on therapeutic levels and it would be expected to recheck the level within a week. R6's medical record notes R6's primary diagnosis is unspecified convulsions. R6's POS (physician order sheet), dated 2/14/25, notes an order for monthly lacosamide, Keppra, phenobarbital, and valproic levels. R6's medical record, dated 10/23/24, notes R6's lacosamide level was 5.7 (normal range 5-10); Keppra level was 5.51 (normal range 10-40); phenobarbital level was 30.3 (normal range 15-40); and valproic acid level was 49.1 (normal range 50-100). There is no documentation found in R6's medical record noting these laboratory tests were completed and reported monthly or that the physician was notified laboratory testing was not done. Facility policy titled physician orders revised 1/2023 document: Physician orders are followed as written. Follow through with orders by making appropriate contact or notification (lab or pharmacy).

Based on interviews and record reviews the facility failed to administer the influenza vaccine during influenza season, failed to screen residents for and offer the pneumococcal vaccine to residents. This failure affected 4 of 5 residents (R38, R68, R78, and R93) reviewed for influenza and pneumococcal vaccines in a sample of 48. Findings include: On 5/28/25 at 10:57 AM, V16 (Infection Prevention Nurse) stated that residents are educated and offered the influenza and pneumococcal vaccines. V16 stated that she is responsible for educating and obtaining consent/refusals for vaccinations. V16 stated that an outsourced clinic comes to this facility and administers residents' vaccinations. On 05/29/25 1:14 PM, V16 stated that when she started working here in March 2025, she was informed by previous IP nurse that if resident refused flu and/or pneumonia vaccine, they were not provided any education. V16 stated that she is unable to provide any documentation of education provided to the residents that refused vaccination(s). 1.R38's medical record, dated 10/22/24, notes R38 received education for the influenza and pneumococcal vaccinations and consented to receive both vaccines. R83 only received the pneumococcal vaccination. It is documented in R38's medical record R38 refused the influenza vaccine. There is no documentation noting R38 refused the influenza vaccine during 2024 influenza season. R38's POS (physician order sheet), dated 9/13/23, notes an order for annual influenza vaccine. 2.R68's medical record does not note any documentation that R68 received education or was offered the influenza or the pneumococcal vaccinations. R68's medical record notes R68 refused both vaccinations. R68's POS, dated 11/8/22, notes an order for pneumococcal vaccine per facility policy. It also notes an order for annual influenza vaccine. 3.R78's medical record, dated 10/21/24, notes R78 received education for the influenza and pneumococcal vaccinations and consented to receive both vaccines. R78 only received the pneumococcal vaccination. It is documented in R78's medical record R78 refused the influenza vaccine. There is no documentation noting R78 refused the influenza vaccine during 2024 the influenza season. R78's POS, dated 4/13/23, notes an order for annual influenza vaccine. 4.R93's medical record, dated 10/22/24, notes R93 received education for the influenza and pneumococcal vaccinations and consented to receive both vaccines. R93 only received the pneumococcal vaccination. It is documented in R93's medical record R93 refused the influenza vaccine. There is no documentation noting R93 refused the influenza vaccine during 2024 influenza season. R93's POS, dated 10/7/24, notes an order for annual influenza vaccine. This facility's immunization record policy, revised 9/5/23, notes if the vaccines have not been given, the health care provider will be contacted for an order. If the vaccine is contraindicated, the physician or nurse will document why in the medical record. The resident or resident responsible party will be contacted for consent. If the resident or responsible party refuses the vaccine, then documentation in the resident's electronic medical record shall include education regarding why the vaccine is important. The vaccine will be documented on the eMAR (electronic medication administration record) as given. This facility's pneumococcal vaccination policy, revised 03/23, notes all current residents or the resident's responsible party will be screened yearly and offered the pneumovax PPSV23 and/or PCV13, PV15, and PCV20. This facility's influenza vaccination policy, reviewed 9/2023, notes annually all residents or resident responsible parties will be asked if they want to receive the influenza vaccine. If the resident or responsible party signs the consent, the health care provider will be contacted for an order. The influenza vaccine will be administered and documented in the eMAR.

Based on interview and record review the facility failed to follow their abuse policy and investigate an injury of unknown origin. This affected two of four residents (R48, R70) both reviewed for abuse policy and investigation. This resulted in a 44-day delay in investigating an injury of unknown origin to R70's face. Findings include: On 5/28/25 at 1:15pm R70 observed alert to person, place, time and situation. R70 stopped surveyor and stated the facility mixed residents with mental illness with residents that have medical problems. R70 said R48 hit her in the face with a shoe and she sustained a bruise to the eye. R70 said this was last month. R70 showed surveyor a picture in her cellular phone. The image was of R70's face, there was a dark purple discoloration to the right eye lid and petechia above the eyebrow. R70 said V1 (Assistant Administrator) was aware, and she told her son about it. R70 said this happened the day the rooms were changed. Review of R70 progress notes noted that R70 and R48 had a verbal altercation and R48 was relocated to another room. On 5/28/25 R48 is not interview-able. The data information on R70's phone notes that the image was taken on 4/14/2025 at 9:33am. On 5/28/25 at 2:59pm V26 (R70's son) said R70 did report to him that a resident hit her in the face with a shoe, V26 said that matter should be investigated. On 5/28/25 at 3:30pm V1 (Assistant Administrator) said R70 did inform him that R48 hit her in the face with a shoe. V1 said how does a bruise comes a week later. V1 said he did see the bruise to R70 right eye, and when he asked R70 about it, R70 replied I told you what happened. V1 restated that R70 said R48 hit her with a shoe. V1 said he is not a medical professional. V1 said R70 also fabricate stories. V1 said he does not know how R70 sustain the bruise to the right eye and petechia on the forehead. V1 said he did not report the injury of unknown origin to the State Department. V1 said he did not reach out to the Administrator for guidance regarding the bruise to 's eye and reported injuries. V1 said he thought the matter was resolved with he separated R70 and R48's room. V1 said the injury of unknown origin should have been reported to the State Department. V1 said he did not investigate R70's allegation of physical assault when alleged. V1 said the allegation was not investigated. 5/28/25 at 4:20pm V2 (Administrator) said she was not aware of the bruise to R70's right eye, V2 said there is nothing documented in R70's medical records about the bruise to the right eye. V2 was agreeable that V1 should have reported the injury to the State Department. Facility policy for abuse with last review date denotes in-part external reporting, when an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator or designee shall notify Department of Public Health regional office immediately by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated. The report shall include the following information, if known at the time of the report: name, type of abuse, date time location and circumstances of allegation. This report shall be made immediately. As used herein the term immediately in relation to reporting abuse, neglect, mistreatment or misappropriation of resident property and suspicious of a crime shall be defined as following management of the immediate risk to the resident or residents, including the administration of necessary medical attention, and establishing the safety of the resident or residents involved or not later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the event caused suspicion do not result in serious injury.

Based on interview and record review the facility failed to follow the abuse policy and procedures and immediately report an injury of unknown origin. This affected two of four residents (R48, R70) reviewed for reporting abuse and injury of unknown origin. This failure resulted in a 44 day delay in reporting an injury of unknown origin. Findings include: On 5/28/25 at 1:15pm R70 observed alert to person, place, time and situation. R70 stopped surveyor and stated the facility mixed residents with mental illness with residents that have medical problems. R70 said R48 hit her in the face with a shoe and she sustained a bruise to the eye. R70 said this was last month. R70 showed surveyor a picture in her cellular phone. The image was of R70's face, there was a dark purple discoloration to the right eye lid and petechia above the eyebrow. R70 said V1 (Assistant Administrator) was aware, and she told her son about it. Review of R70's progress notes noted that R70 and R48 had a verbal altercation and R48 was relocated to another room. On 5/28/25 R48 is not interview-able. The data information on R70's phone denotes that image was taken on 4/14/2025 at 9:33am. On 5/28/25 at 2:59pm V26 (R70's son) said R70 did report to him that a resident hit her in the face with a shoe, V26 said that matter should be investigated. On 5/28/25 at 3:30pm V1 (Assistant Administrator) said R70 did inform him that R48 hit her in the face with a shoe. V1 said how does a bruise come a week later. V1 said he did see the bruise to R70's right eye, and when he asked R70 about it, R70 replied I told you what happened. V1 restated that R70 said R48 hit her with a shoe. V1 said he is not a medical professional. V1 said R70 also fabricate stories. V1 said he does not know how R70 sustain the bruise to the right eye and petechia on forehead. V1 said he did not report the injury of unknown origin to the State Department. V1 said he did not reach out to the Administrator for guidance regarding the bruise to R70's eye and reported injuries. V1 said he thought the matter was resolved with he separated R70 and R48's room. V1 said the injury of unknown origin should have been reported to the State Department. V1 said he did not investigate R70's allegation of physical assault when alleged. V1 said the allegation was not investigated. On 5/28/25 at 4:20pm V2 (Administrator) said she was not aware of the bruise to R70's right eye, V2 said there is nothing documented in R70's medical records about the bruise to the right eye. V2 was agreeable that V1 should have reported the injury to the state department. Facility policy for abuse with last review date denotes in-part external reporting, when an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator or designee shall notify Department of Public Health regional office immediately by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated. The report shall include the following information, if known at the time of the report: name, type of abuse, date time location and circumstances of allegation. This report shall be made immediately. As used herein the term immediately in relation to reporting abuse, neglect, mistreatment or misappropriation of resident property and suspicious od a crime shall be defined as following management of the immediate risk to the resident or residents, including the administration of necessary medical attention, and establishing the safety of the resident or residents involved or not later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the event caused suspicion do not result in serious injury.

Based on record review and interviews, facility staff failed to accurately code a Minimum Data Set (MDS) for two of three residents (R75, R99) reviewed for accurate assessment. R75 was not being treated for a stage 3 pressure ulcer, and R99 was transferred to the community and not the hospital. Findings include: 1. On 5/28/25 at 12:45pm during an interview R75 said he does not have any pressure ulcers, R75 said he has never had a pressure ulcer while a resident at the [NAME] Chicago Heights. On 5/28/25 at 12:51pm V7 (Wound Care Coordinator) said R75 has never been diagnosed or treated for a stage 3 pressure ulcer while a resident of the [NAME] Chicago Heights facility. V7 said R75 has never had any pressure ulcers while a resident at the facility. V7 said she does not have any documents to present to surveyor noting that R75 does not have pressure ulcers and R75 has not been treated for a stage 3 pressure ulcer. Review of R75 MDS dated [DATE] section M for skin, number of unhealed pressure ulcers, it is documented that R75 has one unhealed pressure ulcer, number of stage 3 pressure ulcers- one is documented. Review of R75 current physician order sheet, and April 2025 physician order sheet, there are no wound treatments orders noted. 05/30/25 12:43 PM V11 (MDS Coordinator) said MDS assessments should be accurate, it should reflect the care that the facility is providing. 40066 2. On initial review of the R99's MDS dated [DATE], it statesR99 was a planned discharge to the hospital. Progress notes for R99 dated 4/17/25 state R99 expressed intent to leave the facility against medical advice (AMA). At 1:26PM R99 verbalized understanding of what AMA is and signed the form. On 5/29/25 at 10:36am V1, Assistant Administrator, said R99 left the facility AMA. V1 said I spoke with him, and he had said he wanted to leave. V1 said I spoke with R99 regarding his need for medication. V1 said R99 said he did not want to be here. V1 said we advised R99 about AMA. V1 said R99 verbalized his understanding, and he did sign the form. On 5/29/25 at 11:44am V11, MDS nurse V11 said I modified it (the MDS) today. V11 said I thought R99 went to the hospital. V11 said I saw the progress notes today. V11 said it was an error on my part. Surveyor reviewed Release of Responsibility form dated 4/17/25 with R99's name on it. Facility submitted an MDS dated [DATE] stated the discharge was unplanned and was discharged to home.

Based on interview and record review, the facility failed to refer one resident who was later identified with serious mental illness for a level II preadmission screening. This affected one of one resident (R66) reviewed preadmission screening. Findings include: R66 was admitted to the facility on [DATE] with a diagnosis of alcoholic polyneuropathy, liver disease. R66 documents a diagnosis of major depressive disorder dated 9/30/22 and schizoaffective disorder dated 10/5/22. R66's preadmission screening and resident review (PASRR) level one screen outcome dated 9/8/22 documents no level II required-no Severe mental illness, intellectual disability. The level I screen indicates that a PASRR disability Is not present because e of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings a new screen must be submitted On 5/29/25 at 10:51AM, V1(Assistant Administrator) said they review resident preadmission screening and resident review (PASRR) prior to admission and quarterly, V1 said they review to see if there are any changes with the resident and if there are any changes a new screening would be recommended. V1 verified that R66 had a diagnosis of major depressive disorder and schizoaffective disorder. V1 said a referral should have been sent for a new screening. V1 was asked to provide any additional documentation a screening was conducted. Facility failed to provide any additional screening for R66 during the survey.

Based on interviews and records reviewed the facility failed to review and revise the resident's wound care interventions. This affected one of three residents (R42) reviewed for care plan review and revisions. The findings include: On 05/29/25 at 11:00 AM V7, Wound nurse said R42 had one pressure ulcer on his ankle and it was found on 4/4/25 and documeted as a stage 3. On 5/29/25 at 12:35PM Wound Care Nurse, said R42's skin impairment needs to be identified in the care plan to specify the staging of the wound. I added the pressure ulcer stage 3 to the care plan. V7 said actual vs risk for skin impairment are different and will have different interventions. V7 said, it is important to know the history of a resident's skin impairments. The goal will be to resolve and prevent decline or complications. V7 was asked why the goal is not specified on the care plan, V7 did not answer the question. R42's MDS Skin Conditions dated 4/22/25 identifies he had a stage 3 pressure ulcer. The area was identified as healed on 5/23/25 in the progress notes. The goal identified is to maintain adequate skin integrity. Interventions for 2025 include notify MD and monitor for adequate for urine output. The surveyor reviewed R42's care plan in the facility and requested a copy on 5/29/25. The facility provided a copy of the care plan that states it was revised on 5/29/25. R42's care plan states at risk for skin complication r/t incontinence, immobility, weakness, skin pressure S 3 to the ankle. When the surveyor reviewed the care plan on the morning of 5/29 it did not include skin pressure S 3 to the ankle. No history of impairment was listed.

Based on interviews and record reviews, the facility failed to follow its medication regimen review policy to ensure the outside pharmacist identified and reported the absence or inadequate indications for use of a medication. This failure affected 2 residents (R6 and R68) out of 3 residents reviewed for medication review in a sample of 48. Findings include: On 5/29/25 at 11:25 AM, V18 ADON (Assistant Director of Nursing) stated that the medication, apixaban, is a blood thinner. V18 stated that it is not used to treat tachycardia (increased heart rate) as is noted in R68's physician orders. V18 stated that she will correct R68's medical record now. On 5/30/25 at 10:30 AM, V24 (pharmacist) stated that apixaban is prescribed for persons with history of blood clots, traumatic brain injury, atrial fibrillation, or stroke. V24 stated that it is not used to treat tachycardia. V24 stated that benztropine mesylate is prescribed to treat movement disorder. V24 stated that she is not aware what other symbolic functions refers to as a diagnosis. R6's POS (physician order sheet), dated 6/5/24, notes an order for benztropine mesylate 1mg oral two times a day related to other symbolic functions. V25's (Consultant pharmacist) pharmacist clinical review and recommendations, dated 11/5/24 - 4/4/24, does not note any irregularities noted. R68's medical record does not note a diagnosis of tachycardia. R68's POS, dated 11/8/2022, notes an order for apixaban 2.5mg (milligrams) two times a day related to tachycardia, unspecified. R68's medical record, dated 2/28/25-5/29/25, notes R68's pulse rate ranges from 62-83 beats/minute. On one occasion, 5/10/25 at 10:59 PM, R68's pulse is documented as 94 beats/minute. V25's (Consultant Pharmacist) pharmacist clinical review and recommendations, dated 11/5/24 - 4/4/24, does not note any irregularities noted. This facility's consultant pharmacy services provider agreement, undated, notes the consultant pharmacist review the medication regimen of each resident at least monthly and documenting the review and finding in the resident's medical record. The consultant pharmacist is responsible for completing orders, including diagnoses and resident information. The pharmacist reviews the physician order and compares with resident profile for appropriate drug for indication (diagnosis).

Based on interview and record review, the facility failed to follow their transmission-based isolation policy by not relocating one resident's roommate after a resident was found to have Extended-Spectrum Beta-Lactamases (ESBL) in the urine and failed to discontinue the isolation order after treatment was completed. This affected two of two residents (R1, R38) reviewed for transmission-based precautions. Findings include: R38 was admitted to the facility on [DATE] with a diagnosis of dysuria, weakness, hernia, major depressive disorder, and ulcerative colitis. R38's Minimum Data Set, dated dated dated [DATE] under toileting hygiene documents substantial. Maximal assistance. Under section H documents no indwelling catheter and under urinary incontinence documents frequently incontinent. R38's physician order dated 3/22/25 created 3/25/25 documents: Contact Isolation related to Extended-Spectrum Beta-Lactamases (ESBL) in the urine. No discontinued or stop date. On 5/28/25 at 10:51AM, V16 (Infection Prevention RN) said once an infection is suspected a resident will be placed on isolation while results are pending, if results come back positive than the resident is placed on appropriate isolation. Roommate would be moved or resident with infection would move to another room. V16 said R38 required contact isolation in March for an infection of her urine which indicated Extended-Spectrum Beta-Lactamases (ESBL) and R1(R38's roommate) was moved to another room while on medication. V16 was unsure why there was still an order for contact isolation, but the order should be discontinued and R38 would be placed on enhanced standard precautions. R1 was admitted to facility on 12/2/20 with a diagnosis of Alzheimer's disease, dementia, bipolar. Age related bilateral cataracts and schizoaffective disorder. R1's brief interview for mental status dated 3/31/25 documents a score of 7/15 which h indicates moderately impaired cognition. R1's census and medical record do not document any room changes in March. Facility census sheets dated 3/22/25- 3/29/25 document R1 remaining in the room with R38. Census sheet documents open beds available. Facility policy titled transmission-based isolation precautions revised 3/24 documents: It is the policy of this facility to follow and implement isolation precautions according to the recommendations of the centers for disease control and prevention in order to aid in the prevention and transmission of pathogens. Contact precautions are used for residents with suspected or known infections of colonized microorganism that can transmitted by direct contact with the patient or resident or indirect contact. Also includes infections or colonization with multidrug resistance organisms (MDRO) IE Extended-Spectrum Beta-Lactamases (ESBL). Guidelines for isolation for MDRO; isolate residents who are infected with drainage that cannot be contained. Maintain contact isolation precautions for high risk residents including those who are totally dependent on Nursing aides for Activities of daily living. Discontinue isolation once residents has been treated.

Based on interview and record review the facility failed to have an effective pest control policy/program, by not ensuring the facility was free of pest to include (rodents and flying insects). This affected two of two residents (R18, R15,) reviewed for pest control practices. This has the potential to affect the entire facility. Findings include: On 5/28/25 surveyor was informed that Resident # 18 came out her room screaming saying there was a mouse in the room. On 5/28/25 R83(Resident Council President) said R18 was screaming about a mouse. R83 said her and R18 heard the mice in the room a few days ago, they made V5 (Maintenance Director) aware and he put traps down. R83 said this morning V4 (Housekeeping) removed the trap with the mouse on it. On 5/28/25 at 12:37pm V4 (Housekeeping) said he did remove the mouse trap with a mouse on it this morning from R83 and R18's room, under R18 bed. V4 said the facility should be pest free. On 5/27/25 at 1:57pm there were many flies observed in R15's room, landing on the soiled linen that was on the floor. V28(CNA) and housekeeper were summoned to make observation, both identified the flies. Facility policy titled Pest Control with last review date 8/2024 denotes in-part the facility shall maintain an effective pest control program. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.

Based on interview and record review the facility failed to ensure that the assigned staff, thoroughly assisted and documented the resident concerns and grievances during the monthly resident council meeting from 01/22/2025 to 5/21/2025. This has the potential to affect all 99 of the residents in the facility reviewed for grievance and resident concerns. Findings include: According to the CMS 671 dated 05.28.25, there were 99 residents residing in the facility. On 5/28/25 request and approval was given to review resident council meeting minutes. There were no documented concerns noted on the records for the meetings from 01/19/2025 to 05/23/2025. During the hosted resident council meeting R83 (President) reviewed the documents presented by V2 (Administrator) and stated that the documents were not correct and the residents in fact mentioned concerns during the March, April and May meetings, and the concerns were not listed on the documents. R83 said this is an issue and that V27 (Activity Director) should be writing down the concerns for the meetings. R83 said one concern that was mentioned was about one particular Nursing staff's behavior of waking other residents up when giving medications to the room mates, talking loudly at night and leaving resident room lights on during the overnight shift. R83 said the facility did address that matter right away, however it should have been documented in the minutes. R83 said residents made suggestions related to food. Review of the facility concerns and grievances from 01/01/2025 to 5/27/2025, there was a total of three listed concerns. The concerns that were listed were not related to what was mentioned by R83. R83, R69, R89, and R44 asked what are their rights as a resident living in the long term care, all said the resident rights are not being reviewed. Using a reasonable person concept the facility failed to document all the resident concerns. On 5/30/25 at 12:12pm V27 (Activity Director) said the residents did mention concerns in the last resident council meeting, V27 said she can't recall what they were. V27 said she is responsible for typing the meeting minutes, she removes the concerns and gives them to Social Services. V27 was made aware that the minutes were requested for review on 5/27/25. V27 said she thinks the resident rights are reviewed during the resident council meetings, but she can't be certain. V27 was asked how are repeated concerns being monitored if the minutes are not being documented. V27 was made aware that the presented minutes appear as if the residents are not having concerns. Facility policy tilted Grievance/concerns last review date denotes in-part, it is the policy of the facility to allow and encourage residents and their representative to express grievances and concerns they may have regarding the facility, services and staff. Any staff member in the facility may receive a grievance or concern from a resident or family member. If possible, upon receiving the grievance or concern, attempt to resolve the grievance, or direct the resident or family member to the appropriate department head or the administrator. If the administrator or appropriate department-head are not available, the staff member will gather as much information as possible about the grievance or concern and complete a facility concern form. The staff member will submit the concern form to the appropriate department head designee for resolution. The department head is responsible for investigating the grievance or concern and speaking with the resident or family member who made the complaint regarding both the concern and possible resolution. The administrator will be the designated grievance officer will review and complete form and action taken and do any follow up necessary. Grievances and concerns will be discussed at the monthly QAPI meeting.

Based on observation, interview, and record review, the facility failed to adequately monitor and supervise a newly admitted resident with a known history of falls, confusion, and assessed to be at risk for falls. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a laceration to her left eyebrow that required transfer to local hospital and treatment with sutures after a fall in the facility hallway. Findings include: R3 is a [AGE] year-old female admitted to the facility on [DATE]. R3's past medical history includes, but not limited to: unspecified dementia without psychotic disturbance, mood disturbance and anxiety, essential primary hypertension, hypothyroidism, etc. Fall risk assessment dated [DATE] scores resident as 21, indicatind a high risk for fall due to impaired memory or judgement, unsteady gait, and history of falls in the past 1 -6 months, status post fall and/or fracture in the past 6 months. Minimum data set assessment (MDS) dated [DATE] section C (cognitive pattern) documented that R3 has a memory problem, and R3's cognitive skills for daily decision making are moderately impaired. R3 was also assessed as having inattention with disorganized thinking. Section GG (Functional status) of the same assessment documented that R3 required partial to moderate assist for all Activities of daily Living (ADL) care and requires supervision for walking 10 to 50 feet. Interim fall care plan dated 6/14/2024 documented that R3 is at risk for falls, interventions include call light within reach, provide clutter free environment, provide proper well-maintained footwear. There was no provision for any type of assistive device for the resident. Progress note dated 6/16/2024 at 1:03AM states the following: Staff reported to the writer that the resident was observed on the floor of the hallway sitting with a laceration to her left eyebrow with moderate bleeding. Pressure applied to area. PROM performed to bilateral upper and lower extremities without limitation. Resident transferred to wheelchair with standby assist. Resident unable to give statement of incident, 911 called for transportation to the hospital. Ambulance run sheet dated 6/16/2024 states in part: dispatched to location for fall victim, crew found patient at the nursing station in wheelchair, nurse stated that patient was walking in the hallway when she fell and one of the residents came and told the nurse, staff did not witness the fall, patient had a 2 inch laceration above her left eyebrow. Hospital record dated 6/16/2024 documented in part: chief complaint fall, diagnosis laceration to left eyebrow, bleeding controlled. Under history, the document states in part: [AGE] year-old female brought by ambulance for evaluation of facial laceration. Patient was found on the floor in the hallway at her facility. She has a history of frequent falls, and she has known dementia. R3 underwent a laceration repair, length was documented as 4 inches, requiring some sutures. On 7/16/2024 at 2:30PM, V3 (DON) said that she is not very familiar with R3, she came to the facility on a Friday and fell a day or two later, the family stated that resident sustained some injuries requiring sutures, facility was unable to obtain the hospital records because resident was not returning to the facility. V3 stated that she spoke to the nurse that was assigned to the resident and she said that resident was very confused, she was ambulatory with an unsteady gait, she was alerted by the CNA that the resident fell in the hallway, the fall was not witnessed. On 7/16/2024 at 4:32PM, V20 (LPN) said that she recalls R3, she was alert with some confusion, ambulatory with an unsteady gait. Resident will be considered a fall risk due to her unsteadiness, her fall incident occurred on the night shift between 12:00 and 1:00AM, R3 was not yielding to redirection and was continuously walking up and down the hallway. V20 said that she was notified by another nurse that the resident was on the floor, when V20 arrived at the scene, she noted moderate amount of blood coming from a laceration to the resident's left eyebrow, V20 applied pressure to the site and assessed the resident, no other injuries were noted. V20 said that the bleeding continued, she called the doctor and received an order to send the resident to the hospital, V20 called 911 and notified the daughter/POA. On 7/17/2024 at 1:55PM, V24 (RN) stated that she is the fall coordinator for the facility. When residents are newly admitted , the admitting nurse evaluates the resident and initiates a baseline care plan and any required interventions, the entire care plan will then be completed according to facility policy. V24 said that R3 was admitted to the facility on a Friday evening and had a fall incident on Sunday. Residents should be monitored during the night shift, the CNAs are supposed to stay close to resident's rooms for monitoring and to see the call lights. Nurses and CNAs are also supposed to round every 1 to 2 hours on residents, resident interventions should be individualized and for a new resident that is confused, and being a fall risk, staff could have tried putting her on a one-to-one supervision or have her sit in a wheelchair and put her in the nursing station. On 7/17/2024 at 11:18AM, V27 (CNA) said that he works the 11:00 PM to 7:00 AM shift and was assigned to R3 the day she had a fall, he did not witness the fall incident because he was in another room with another resident, he was informed that the resident fell by another staff. V27 added that the CNAs are supposed to monitor the hallway, but they usually do that after rounds, while they are rounding, he does not think that anyone monitors the hallway because all the CNAs are rounding at the same time. Fall prevention and management policy revised 07/2022 stated in part that the facility is committed to maximizing each resident's physical, mental and psychological well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies and facilitate as safe an environment as possible. Under guidelines, the policy states: a fall risk evaluation will be completed upon admission, readmission and quarterly, significant change and after each fall. Residents at risk for falls will have fall risk identified in the interim plan of care and the ISP with interventions implemented to minimize fall risk.

Based on interviews and record reviews the facility failed to follow their policy and procedures for protecting residents from abuse by not ensuring staff were monitoring residents in the dining area who were at risk for abuse and with a history of aggression and by not ensuring adequate staff supervision was provided for residents involved in a physical altercation. This failure applied to two of five residents (R4 and R5) reviewed for abuse. Findings include: R4 is a [AGE] year-old male with a diagnosis's history of Schizophrenia, Delusional Disorders, Bipolar Disorder, Dementia, and Legal Blindness who was admitted to the facility 05/24/2024. R4's most current care plan documents he has a history of mood swings, impulsive behavior, related to a diagnosis of Bipolar Disorder and is at risk for abuse related to severe mental illness. R4's progress notes dated 6/19/2024 document he was involved in an argument with another resident in the Dining Hall while waiting for breakfast. The argument, as per eyewitness report, escalated within minutes and R4 was hit in the face. R4 was hit below his right eye and left forehead & sustained redness and swellings. The physician was notified and gave orders to send R4 to local hospital for evaluation. R4 was given pain medication for complaint of pain to the right eye. R4's Hospital Report dated 06/19/2024 documents he was evaluated at the emergency room by a physician at 11:25 AM due to being the victim of an assault by another resident at the facility, he reported he was punched multiple times in the face, head, and lower neck just before arriving to the emergency room and was observed with a headache, facial strain, contusion, and minor head injury, R4 was discharged back to the facility with diagnoses including being a victim of assault batter, minor head injury, contusion (bruise) to the face, and myofascial cervical strain (pain around a certain area of the face that is sensitive to pressure) with instructions to apply a cool compress to the area and use over the counter acetaminophen for symptom relief. R5 is a [AGE] year-old male with a diagnosis's history of Schizoaffective Disorder who was admitted to the facility 04/25/2024. R5's current care plan initiated 04/26/2024 documents he has a history of aggressive, inappropriate, and/or maladaptive behavior. R5's progress note dated 6/19/2024 documents R5 was involved in an argument with another resident in the Dining Hall while waiting for breakfast. The argument, as per eyewitness report, escalated within minutes and R5 slapped the other resident in his face. Facility Reported Incident Investigation Report for incident of 06/19/2024 documents R4 reported R5 became verbally abusive to him and asked R5 to leave him alone, R5 refused which resulted in a verbal altercation, R5 then hit him, R4 was then observed with a swollen right eyebrow; V22 (Social Services) reported that R5 exhibits delusional behaviors sometimes; R5 has been observed with delusional behaviors since admission and his admission paperwork shows a history of aggressive behaviors, delusions, erratic behaviors, and poor impulse control. Witness statement from V18 documents on 06/19/2024 she entered the dining room in response to a commotion and observed chairs knocked over and a resident on the floor, observed R5 screaming and yelling at R4, observed R4 run towards R5 and threaten to hit him, observed R4 's right eye swollen, observed R5 become verbally abusive to R4 which resulted in a verbal altercation, observed R5 then physically attack R4 and knocking things down, she was the only Certified Nursing Assistant in the room while attempting to stop R5, she could not stop R5 and began screaming to the top of her lungs for over a minute before other staff entered the dining area, it took two staff to stop R5, she observed R4 leaned over a chair being hit in the head and back of his neck. On 07/16/2024 at 10:36 AM V11 (Certified Nursing Assistants) stated she was present on the day of the physical altercation with R5 and R4. V11 stated she heard a commotion coming from the dining room while taking care of a resident she was preparing for breakfast. V11 stated when she arrived to the dining room R5 was yelling at R4 and R4 was agitated but R4 is blind and couldn't see. V11 stated she believes they were arguing before she came in the dining room because she heard R5 yelling which made her go in the dining room. V11 stated this incident occurred just prior to breakfast and there were more than ten residents in the dining room at the time. On 07/16/2024 at 11:11 AM V15 (Housekeeping Assistant Manager) stated on 06/19/2024 he was buffing the floors in the hallway on the east side of the building and heard a lot of arguing in the dining area and responded to see what was going on. V15 stated he went into the dining room and saw R5 and R4 were continuously arguing. V15 stated V11 (Certified Nursing Assistant) and another newer Certified Nursing Assistant whose name he could not recall were already in the dining room with R5 and R4. V15 stated they were both trying to de-escalate the situation and calm the residents down. V15 stated at this time V11 had to leave the dining area to return to a resident she was assisting, and he told her it was fine to leave, and he and the Certified Nursing Assistant will take care of the situation. V15 stated he and the female Certified Nursing Assistant were redirecting R5 and R4 and attempting to calm them down. V15 stated the situation then de-escalated for a few minutes and both residents were quiet, so he went to report the incident to V14 (Nurse Supervisor). V15 stated while reporting the incident to V14 they heard really loud arguing coming from the dining room so they both returned to the dining room quickly. V15 stated when he and V14 arrived to the dining room R5 and R4 were grabbing each other. V15 stated the female certified nursing assistant was still in the dining area with R5 and R4 and she was trying to push R5 and R4 apart but couldn't get them apart. V15 stated he and V14 were able to physically separate R5 and R4. V15 stated he believes the certified nursing assistant didn't want to get hurt during the altercation. V15 stated if an activities aide is not present with the residents in the dining area, then a certified nursing aide is present because the residents have to be monitored at all times. V15 stated he didn't hear any staff calling out for help during this incident. On 07/16/2024 at 12:03 PM V18 (Certified Nursing Assistant) stated on 06/19/2024 while in a resident's room she heard commotion, she headed to the dining area and she and another coworker V15 (Housekeeping Assistant Manager) arrived there at the same time. V18 stated when she arrived to the dining room, she could tell that there had been an altercation and that R4 was yelling and said to R5 why did you hit me. V18 stated while R4 was saying this he was moving towards R5 as if he wanted to hit him back. V18 stated she did observe R4 with a red bruise near his right eye when he made the statement about R5 hitting him. V18 stated there were no other staff present before she and V15 arrived to the dining room, there were more than five residents present and more were coming in and out of the dining area as well. V18 stated she and V15 diffused the situation, V15 helped R4 back to his chair, R5 was walking towards the door to leave out and she picked up the knocked over chairs. V18 stated while V15 went to go get the nurse she remained in the dining room. V18 stated R5 then returned to the dining area, began cursing at R4 and threatening to hit him again. V18 stated R4 told R5 to do it and R5 ran over to where R4 was sitting. V18 stated she tried to stop R5, but he rushed through her and began punching R4 who had stood up when he heard R5 approaching. V18 stated R4 also struck back at R5. V18 stated R4 then tried to run away, she screamed for help, and R5 began striking R4 again from the back while he was running away. V18 stated she called for help again and then multiple staff came into the dining room and separated R5 and R4. V18 confirmed she screamed for over a minute before any staff came into the room during the incident. V18 stated there should always be more than one staff present with residents when they are in the dining room because you never know when situations like this could happen. V18 stated it was challenging to attempt to separate R5 and R4 during a physical altercation and protect another female resident who was present from being hurt from the fall out. V18 stated there is supposed to be at least one staff in the dining room monitoring the residents, but it was so early in the morning, we were changing shifts, and we were getting people up to go to the dining room and it was a lot. V18 stated she was in the middle of preparing a resident to come in the dining room whose room was directly next to the dining room and that is how she was able to hear the commotion. On 07/16/2024 at 1:03 PM V4 (Assistant Administrator) stated there are usually two activity aides in the dining area and they are always there except during their breaks. V3 (Director of Nursing) stated there is usually a CNA (Certified Nursing Assistant) in the dining room in the morning while other aides bring residents to the dining area for breakfast. V4 stated if an altercation occurs and there is a commotion a code is called, and staff respond quickly to assist. V4 stated the facility is small and the kitchen is also close by the dining area therefore staff should be able to respond immediately for any commotion or disruptions. V4 stated there should always be at least one staff in the dining area for supervision of the residents. V4 stated if there is only one staff present during an altercation, the staff should attempt to separate the residents while calling for help. V4 and V3 agreed that if there is only one staff present during a physical altercation it could be challenging for the staff present to separate the residents in the altercation. On 07/16/2024 at 2:11 PM V17 (Licensed Practical Nurse) stated at about 8 AM on 06/19/2024 while preparing to pass medication at the nurse's station she heard commotion coming from the dining room and as she approached the dining area V15 (Housekeeping Assistant Manager) and V14 (Registered Nurse) were with R5 and R4 who were already separated after an altercation. V17 stated she took R4 to his room and assessed him and asked what was going on and he responded that he didn't know what was going on, why it happened, or what the argument was about but wanted to call his family and the police. On 07/16/2024 at 2:21 PM V23 (Resident Representative) stated R4 expressed that his back was hurting after the physical altercation he had at the facility. V23 stated R4 said he was going to file a complaint about the person that attacked him. The facility's Abuse Policy received 07/16/2024 states: It is the policy of this facility to prevent abuse of our residents. Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation.

Based on interviews and records reviews the facility failed to prevent a cognitively impaired resident who requires supervision in the community that has a behavior of wandering from leaving the facility unauthorized without staff knowledge. This affected 1 of 3 (R6) residents reviewed for safety, supervision, and elopement. This failure resulted in R6 leaving through his bedroom window without staff knowledge. The Immediate Jeopardy began on 5/7/24. V1 Administrator was notified on 5/16/24 at 12:04PM of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 05/16/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R6's diagnosis, include but are not limited to Encephalopathy, Drug Induced Subacute Dyskinesia, Malaise, Reduced Mobility, Adjustment Disorder, Type 2 Diabetes Mellitus, Seizures, and Hypertension. R6's Cognitive patterns assessment dated [DATE] indicates score of 8. Additionally, R6 displays fluctuating inattention and disorganized thinking. Facility Reported Incident Form titled Initial Report states on 5/4/24 at 4:00PM it was reported to the A. Admin that resident is missing from the facility by the social service staff, green protocol had been initiated and resident was not found in the facility. A review of the Fire Department Run sheet dated 5/7/24, call received at 6:17AM, states R6 arrived ambulatory to the fire station stating he was experiencing double knee pain. Patient transported to the hospital. On 5/7/24 at 2:21 PM R6 said he went to the church, he slept downstairs around the church, in a stairway at the church. R6 said he did not have medicine. R6 said he opened the window and left the facility. R6 said he left when his roommate was sleeping at 7:00 AM, as the sun was rising. R6 said the windows were not supposed to open like that. On 5/9/24 at 10:35AM surveyor met with R6. R6 observed able to stand, turn, and ambulate without assistance. R6 difficult to understand, speech slurred, but some words understandable. R6 said yes he left and he got a ride and then went to the hospital because he was told to go there. R6 asked if he knows his address or the facility address, R6 said no to both. On 5/9/24 at 11:41AM V5, Certified Nursing Assistant (CNA), said on 5/4/24 around 3:00PM the nurse asked me if I had seen R6. V5 said the nurse asked me to look for R6. V5 said I left at 3:00PM and R6 was not found. On 5/9/24 V7, Licensed Practical Nurse, said on 5/4/24 in the afternoon around 2:00 or 2:30PM I did not see R6 in his room. V7 said I raised alarm and asked the CNA about him. V7 said a code purple was initiated. V7 said I notified Social Service Department that I don't see R6. V7 said when I checked R6's room, there was no one in the room, his roommate was in the dining room. V7 said I didn't look at the window. V7 said when I went outside, I saw a footprint on the ground about 2 feet from the window. V7 said at baseline R6 is very sneaky and goes around the facility. V7 said R6 has periods of confusion at times, and he can be hard to redirect due to his confusion. On 5/9/24 at 10:49AM V3, Social Worker, said, no one is a high risk of elopement in the building. V3 said I would know if they are at high risk for elopement. V3 said they have to make an attempt multiple times to exit to place them on high risk for elopement with a monitor. V3 said I was called in Saturday 5/4/24 and I was made aware R6 left. V3 said I came to the facility, and we did a room head count and we drove around the area looking for R6. V3 said R6's baseline behavior is confused, he talks slow, and he speaks loud. On follow up interview on 5/10/24 at 9:31AM V3 said a cognitive (BIMS) score of 8-12 is moderate cognitive impairment. (R6's score is 8). V3 said R6's behaviors include anger and tone changes, he will curse, is socially inappropriate, and uses inappropriate words. V3 said R6 wanders in the facility. At 10:59 V3 said I have to find out what score from the elopement assessment indicates the person is at risk. On 5/9/24 at 11:14AM V4, Social Services, said on 5/4/24 we were searching for R6. V4 said I became aware by the nurse at 3ish (3:00PM), I instantly checked R6's room and toilet, looking for him. V4 said I called a code purple immediately. V4 said when I looked in R6's room I saw the tv remote on the bed, his blankets on the bed, and all his personal possessions still there. V4 said R6 got out thru the window, but it was no longer open. V4 said R6 could open the window enough to get out. V4 said R6's window screen had returned to how it was supposed to be. V4 said R6 did not have an accomplice that I am aware of. V4 said we don't have any high risk elopement residents. V4 said R6's window led outside to the front of the facility. V4 said R6 went without medication while away. V4 said R6 was gone from Saturday 5/4/24 until Tuesday 5/7/24. V4 said according to GPS the hospital where R6 was located is about 6.7miles from here. On 5/9/24 at 12:38PM V6, Maintenance Director, said on Saturday, 5/4/24, I was called in and the Administrator asked me to help with the windows. V6 said I had some corner L shaped brackets here and used some regular screws. V6 said I have the screen for R6's former room in my office. V6 said the screen was on the mulch on the ground when I got here. V6 showed the surveyor the L shaped metal bracket screwed into the windowsill. On 5/10/24 at 12:35PM V6 said on Saturday 5/4/24, about 20 windows didn't have L brackets, none of the outside facing windows had them before I installed them. V6 said all the windows were resident rooms. V6 said the reason I put the bracket is to keep the window from opening so wide, this is a safety mechanism. V6 said before Saturday the windows had nothing in place to prevent them from opening so wide, 49-50 inches. V6 said I do rounds everyday, I check windows, make sure they are not wide open. V6 said I never noticed them to be open so wide. V6 said they should not have them wide open, to prevent this issue from happening again. V6 said I have always checked the windows and I would close them to prevent someone from getting out. V6 said in the past I had seen windows open so wide. V6 said the installed brackets allow the window to open roughly 3-4 inches. V6 said I never mentioned to anyone if I saw a window open wide. V6 said the windows are not new. V6 said I work Monday thru Friday and I check the windows Monday thru Friday. V6 said no one is here over the weekend to do my rounds. V6 said I would hope staff would check the windows. V6 said I don't remember if R6's window was open when I came in Saturday 5/4/24. On 5/10/24 at 10:13AM V2, Director of Nursing, said on 5/4/24 I was notified that code purple was called for R6. V2 said I was not able to come in, but I had phone calls to figure out what was going. V2 said when R6 was found the hospital called and said he was found. V2 said from the phone calls, it was determined that V5 was the last person to see R6 around 1:30PM. V2 said I am not aware what R6 was doing or where he was last seen. V2 said it was determined that R6 got out by the window in his room, because the screen was out. V2 said I would say no for community pass for R6. V2 said R6 gets frustrated and impatient with communication, he is aphasic. V2 said R6's attention span is not focused, his attention and patience is short. V2 said R6 has a psyche background, his thought process can be unorganized. V2 said when R6 returned he look tired. V2 said R6 said he went out the window. V2 said I would describe R6 as a wanderer, he is not typically in one place, you have to look for him. V2 said R6 needs supervision while out of the facility. On 5/10/24 at 11:09AM V12, Assistant Administrator, said I got a call at home around 3ish, that they could not find R6. V12 said I came in to assist with the search. V12 said we could not find R6 in the building or neighborhood. V12 said I looked at the camera footage for the front door and back doors and he was not seen. V12 said there is no front door outside camera. V12 said R6 was last in the facility around 1:30PM. V12 said the CNA reported she last saw R6 at 1:30PM while changing the roommate. V12 said when I came to the facility, we saw the screen in the mulch, and we thought R6 went out the window. V12 said R2 can open the window. V12 said we were notified R6 arrived to the hospital in an ambulance. V12 said when he returned, R6 told me he went to the fire department and was taken to the hospital and that he was tired. V12 said I did not speak with the fire department. V12 said I am not sure which fire department he presented at. V12 said I don't think R6 knows the phone number to the facility. V12 said R2 could not be unsupervised in the community. On 5/10/24 at 11:40AM V1, Administrator, asked for the surveyor to follow her to show me something. V1 escorted the surveyor to R6's room at the time of elopement. V1 said I asked V6 to remove the L bracket so I can show you how R6 got out the window. V1 opened the window fully (as measured before) and climbed one foot on the adjacent bed, stepped onto the window ledge, and jumped down onto the raised landscaped area with mud and mulch. V1 said and V12 found this screen (V6 was replacing the window screen) right here. The surveyor noted the screen frame is bent. On 5/14/24 at 12:46PM V13, Doctor, said if R6's pass states R6 needs supervision while in the community, then R6 should not be in the community unsupervised. R6's Order Summary Report documents may go out on pass with medication with family. R6's progress notes dated 5/4/24 states in part, R6 not in room. Dining room and surrounding areas checked. Social Services immediately notified. R6's progress noted dated 5/7/24 at 10:45AM R6 returned from hospital. R6 Behavior assessment dated [DATE] documents delusions and wandering occurs 1 to 3 days during the assessment period. R6's Elopement Evaluation dated 2/29/24 notes a score of 3. Evaluation includes, the resident has demonstrated or presents with the physical ability to leave the building no. On 5/7/24 R6's score is 19. R6 exhibited elopement behavior has evidence by leaving the facility unauthorized. R6's Community Survival Skills Evaluation dated 2/29/24 states R6 needs supervision to access the community. R6's care plan initiated 4/2/24 states, R6 displays poor boundaries with staff and co-peers as evidenced by his wandering tendencies. R6 has poor perception of personal space. R6 is socially inappropriate towards peers and staff. Interventions include: Encourage resident to participate in groups/activities/events throughout the facility. Redirect resident appropriately when seen displaying inappropriate boundaries. Staff to be consistent with setting limits in order to maintain boundaries. R6's care plan initiated 5/7/24 states R6 had an unauthorized departure from the facility. Interventions include R6 applauded on all progress made towards goal. R6 will be reeducated on supervision policy. Facility provided hospital records dated 5/7/24 at 6:30AM note R6 reason for visit is knee pain. Medications given Ketorolac. The facility elopement guideline dated 9/2023 defines elopement as a situation where a resident who cannot recognize normal dangers and hazards outside the facility leaves the facility without staff knowledge. The survey team confirmed by observation, interview, and record review the immediate Jeopardy was removed on 5/16/24. The Immediate Jeopardy that began on 05/07/24 was removed 05/16/24 when the facility took the following actions to remove the immediacy. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. A. Identification of Residents Affected or Likely to be Affected: -On 5/16/24, nine (9) other residents were identified as wanderers and were added to the elopement list following the completion of the reassessment. - All nine (9) residents were also added to the elopement binder. - The Care plans were reviewed and updated accordingly for all nine (9) residents. Eight (8) of the nine (9) residents were moved to rooms with windows that lead to a courtyard and are not directly accessible to the exterior/exit areas of the facility. One (1) resident refused the room change; however, her room is located directly across from social services office and her windows have been secured. - There is a total of 11 residents on the elopement list/binder as of 5/16/24. - The facility has a total of 81 windows, all 60 windows were secured to only open three (3) inches except for 21 windows. The 21 windows were not secured because they do not lead/have access to exit the premises as they lead to the patio/courtyard which is within the facility. The maintenance director assessed and secured all external windows that are accessible to exit the premises on 5/4/24. - On 5/4/24, the Asst. Administrator initiated an in-service/training on elopement protocol to staff. - The trainings on elopement prevention mentioned in the section (a-h) are new and have been integrated in the facility's policies and procedures regarding elopement prevention. - The facility does not utilize agency staff at this time, nonetheless, if the need arises in the future, the DON/ADON/Charge nurse will provide training on elopement prior to start of shift. 1. On 5/7/24, the IDT (Interdisciplinary Tteam) which includes the DON (Director of Nursing), unit manager, social services director, activity director reviewed R6's care plans to ensure that wandering behavior and elopement risks are addressed. Resident was moved to another room, with window that opens to a secured courtyard. The window was secured so it does not open fully. R6's - elopement assessment was completed by the social services director on 5/7/24. R6 was added to the elopement binder. Nurse Practitioner also completed an evaluation upon return to the facility on [DATE]. Furthermore, R6 was placed on one-to-one supervision for 72 hours which started on 5/7/24. 2. Resident head count of the whole facility was completed by the DON/clinical managers on 5/16/24. There was no concern identified. Headcount is done during shift change as part of the nurse-to-nurse shift reporting and when completing the midnight census. 3. Elopement/Wandering assessment will be completed for all residents. The assessment will be completed by the DON (Director of Nursing), unit manager, Administrator and Social Services. This will be completed on 5/16/24. 4. Any resident who is identified with wandering behavior/ elopement risk will have care plans developed. This will be completed by the IDT on 5/16/24. 5. The elopement binders will be updated and will have elopement binders in all nursing stations, kitchen, front desk, and department head offices. The elopement binder is not new, but it is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit-seeking behavior/risk for elopement. 6. The Maintenance Director/Environmental staff will assess all windows of the facility and will secure windows and prevent the windows from fully opening to prevent a resident from using the window to exit the building. The Maintenance Director/MOD (Manager on Duty) will conduct rounds of all windows daily to ensure windows are always secure. The QAPI team conducted an Ad-Hoc QAPI meeting on 5/16/24 and decided to secure the windows to only allow 3-inch opening to prevent a resident from using the window to elope. An Ad-Hoc resident council meeting is scheduled on 5/17/24 to discuss the new standard of securing the windows in the facility. The facility utilized an L-bracket (also called corner brackets or angle braces) which is fastened to the window frame to prevent the window from fully opening and only allow the 3-inch opening. The residents are not able to tamper with the security of the windows. 7. The Administrator will provide training to the IDT regarding development of care plans to address residents who are identified with exit-seeking /wandering behaviors and elopement risk. The training will be completed on 5/16/24. 8. The DON/Administrator/Social Services Director will provide education to the staff on 5/16/24. The education items include but not limited to: a) Code Purple b) Use of the elopement binders c) Exit-seeking behaviors and interventions d) Elopement risk and wandering and interventions e) Policy on missing resident f) Responding to alarms and g) Resident safety and supervision h) Reporting to the Administrator/Maintenance Director any concern related to windows. The training will be completed on 5/16/24. Any staff who are not available, on vacation or leave of absence will have training completed at the start of their shift upon return to work. To measure knowledge retention, posttests will also be started on 5/17/24. The Administrator/Director of Nursing/Social Services Director will conduct posttests of five (5) random staff to evaluate knowledge retention. Five (5) posttests per week for four (4) weeks will be completed, starting on 5/17/24. The acceptable score of the post-test is 100%. Any staff who will not meet the acceptable score will receive additional training. The Administrator/Director of Nursing/Social Services Director will provide the staff with training on specific areas based on the results of the post tests. To ensure that all staff are trained prior to the start of their next shift if off duty, the DON/Administrator will notify the staff to meet with their supervisor/charge nurse/DON when they return to work. The supervisor/charge nurse/DON will ensure that the training is done before starting their work shift. The Administrator/DON/Social Services Director will provide the training. If the DON/Social Services Director are not available, a trained nurse will provide the training. The facility will conduct the same training quarterly for four (4) quarters, and then annually thereafter. The training will also be included in the orientation of new employees. At this time, the facility is not utilizing agency. In the future, if the facility will use agency, the DON/Social Services Director/Administrator will provide the same training to the agency staff. B. Actions to Prevent Occurrence/Recurrence: 1. Ad-Hoc QAPI meeting was completed on 5/16/24 which were participated by the leadership team which includes the Director of Nursing (DON), Unit Manager (UM), Risk Manager (RM), Social services Director (SSD), Admissions Director, Minimum Data Set (MDS) Coordinators, Maintenance Director, Business office Manager (BOM), Rehabilitation Manager, Human Resource Director and the Activities Director (AD). The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events. 2. Elopement drill will be completed on 5/16/24 by the Maintenance Director and Administrator. This will also be completed daily, for the seven (7) days, and will be done at different shifts. After seven (7) days, the elopement drills will be done weekly for three (3) months, then monthly thereafter. The elopement drills will be completed per policy, as indicated above. 3. All exit doors in the facility will also be checked by the Maintenance Director on 5/16/24 to ensure all doors were locked and secure and that delayed egress was functioning properly. Door checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The door checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed. The Maintenance Director/Environmental Service Director/MOD will also conduct window checks daily. Window checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The window checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed. 4. Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/ exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD (manager on duty)/charge nurse, DON will also conduct weekend clinical meetings to review new or worsening exit seeking/wandering behaviors and ensure interventions are in place to prevent elopement. 5. New admissions will be reviewed by the DON, Risk Manager, Wound Nurse or MDS for elopement risk and any resident identified as being at risk will be updated into the facility elopement books. 6. The QAPI team will hold a weekly Ad-Hic QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional corrective actions are necessary based on concerns identified. The Administrator/Social Services Director/DON will conduct audits of the Elopement Binder daily for three (3) months to ensure that identified elopement risk are included in the binder. Additionally, the Administrator/Social Services Director/DON will also review five (5) residents weekly for three (3) months to ensure that residents who are identified with new and/or worsening exit-seeking behaviors and wandering are being addressed in the care plans. After three (3) months, the QAPI team will determine if additional monitoring or corrective actions are necessary. To evaluate the effectiveness of the removal plan, QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities.

Based on interviews, record reviews, and observations the facility failed to have an effective pest control program to ensure the facility is free from pests. This failure affected five of five residents (R9-R13) reviewed for pest control. The findings include: On 5/15/24 at 10:25AM R10 said there are roaches in the room, I call staff when I see them, and they come kill them. I see them at night. I haven't seen any bugs today. R10 said I saw them by the corner, by the wall. On 5/15/524 at 10:35AM the surveyor observed a dead, dark, elongated bug on its back on the floor in the dining room, near the radio speaker. Several residents were in the dining room participating in a bowling game at this time. On 5/15/24 at 10:56AM V6, Maintenance, said pest control comes twice a month and as needed. V6 said if there are any complaints in between treatment then I will call the exterminator to come out. V6 said I got a bug complaint by the residents in room [ROOM NUMBER], yesterday, she described the bug as a water bug or a roach. V6 said there have not been other bug complaints. V6 said if there are pest control issues, then staff will write in the book for me to follow up. V6 brought the mentioned book for review. Surveyor noted nothing is written in it. V6 said he did not empty the book today. On 5/15/24 at 12:33PM V7, LPN, said I see roaches in the evenings and mornings when I get here. I report this to administration. I don't fill out a paper for it. When I got here this morning there was one dead, like it had been squished on the floor. On 5/15/24 at 1:15PM V17, CNA, said I have seen a jumbo water bug on the halls. They move fast. V17 said today I did see a bug in the shower room this morning with R11, we were in the shower room and R11 said look at the bug. On 5/15/24 at 1:43PM R12 said I see ants everyday. R12 said I see roaches. I just squish them. R12 said I see the bugs in the room and the hallway. On 5/15/24 at 1:48PM R13 said I see roaches in my room and in the hallways. R13 said we try to kill them, just squish them. On 5/15/24 at 2:27PM V1, Administrator, said the exterminator is scheduled twice a month. V1 said if anyone sees a bug we will call for an exterminator to come out. V1 said V6 will call the exterminator. V1 said I don't know when the last time a sighting was reported. V1 said V6 should call that day, the day it is reported or seen. V1 said if staff and residents are not reporting them we won't know to call the exterminator. Review of R9's progress notes dated 5/12/24 documents she came out of her room and stated she has killed cockroaches. Review of concerns and grievances dated 3/12/24 notes a water bug reported by R9 and on 5/13/24, R9 reported the room has too many bugs in it. Pest control service records reviewed with service dates of 3/4/24; 3/25/24;4/1/24; 4/22/24; and 5/6/24. 5/6/24 service record notes cockroach evidence. Review of Pest Control policy dated 9/2023 states, in part, the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review the facility failed to have the State inspection survey results readily available and accessible to residents, family members and legal representatives. This deficient practice affects all ten (R3, R9, R17, R27, R52, R58, R60, R66, R85 and R94) residents reviewed for Resident rights to Survey results in a sample of 20 residents. Findings include: On 4/18/24 at 10:23am during Resident council meeting held with ten residents in attendance, all ten residents stated that they are not aware of where the State Inspection results binder is located. All stated that they have not seen the signage for the location of the survey results. On 4/18/24 at 11:05am, V28(Office Manager) stated that she does not know where the State Inspection Survey results binder is and has not seen it at the front desk. She was unable to locate the Survey results binder at the front desk during the interview. On 4/18/24 at 11:10am, V1(Administrator) stated that the binder is usually located at the front desk. V1 and V21 (Assistant Administrator) both could not find the binder after looking for approximately five minutes. V1 stated I will look for it. Facility's policy on Resident Rights with no review date states: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conducts and responsibility during the stay in the facility . 6. Information and Communication. k. The resident has the right to: i. Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and plan of correction in effect with respect to the facility .

Based on interview and record review the facility failed to follow the fall prevention and management policy to develop and reevaluate individualized interventions to minimize the risk for falls with injuries. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 falling from bed, subsequently noted with pain and a large red bruise to the right thigh. An Xray shows impacted [NAME]- cervical fracture of femoral neck. R1 was sent to the local hospital for treatment. Findings include: R1's face sheet denotes diagnosis of muscle wasting, malaise, unsteadiness on feet, weakness, unspecified dementia, age related nuclear cataract, lack of coordination, vitamin d deficiency, abnormality of gait and mobility. R1 MDS dated [DATE] denotes BIMS score of 6 (cognitive impairments). R1's follow-up investigation report denotes fall with injury, age 80, BIMS 6, mental status alertx1, dementia, schizophrenia, unsteadiness of feet, anxiety, current location of victim- (hospital name). Resident sustained subdural hematoma and impacted [NAME] cervical fracture of the right femoral neck with varus. Subdural hematoma and impacted [NAME] cervical fracture as reported to V9 (physician) and POA. Resident alert x1, able to state that he fell , however not able to elaborate on details. Summary of witness- Roommate upon interview the resident roommate (R5) stated that he observed resident trying to transfer from bed to wheelchair and that is when resident fell . (R5) stated resident got himself back on his bed. When R5 was asked if he informed anyone of the fall, he stated no. R5 stated he thought resident (R1) was okay. R5 also stated he does not remember the time or day of when the fall occurred. SC (LPN) writer states upon doing rounds she noticed resident grimacing and in pain. Upon further assessment SC noticed a large red area on inner right thigh and patient shook upon touch. Vitals assessment, ROM assessed with pain to touch on right leg. PRN (as needed) Tylenol given, NP (Nurse practitioner) made aware with STAT Xray orders given and ordered to start Keflex 500 mg (milligrams) PO (by mouth) TID x 7 days, and STAT labs, CBC, CMP for next day. Bed positioned lowest to the floor with call light and floor mats in place at this time. STAT X ray obtained, new orders to send patient to ER for further evaluation. V8 (LPN) stated resident slept throughout the night upon her constant rounding on her shift. Follow up call placed to ER (emergency room ) staff informed our staff that the patient sustained a subdural hematoma and fracture, then was transferred to (different hospital) hospital for further treatment. Resident is able to stand and pivot with and without assistance. Per hospital report resident sustained subdural hematoma and impact basal cervical fracture of the right femur neck with varus. Residents still at (different hospital) hospital at this time. After a thorough investigation was conducted by reviewing of statements medical records and observation it is concluded that it was an anticipated fall resulting in a subdural hematoma and or fracture. Per resident roommate resident fell while attempting to transfer himself from bed to wheelchair. Root cause analysis; due to the residents diagnosis of unspecified dementia with behavior disturbance resident gain a false sense of independence due to recently being on physical therapy. Care plan updated rounding at a minimum of Q 2 hours and prompt assistance to change in positions toileting offering fluids and ensure resident is warm and dry. R1's incident report dated 7/11/23 denotes in-part resident noted in bed with redness to inner right thigh, with shakes and facial grimacing. Resident states with confusing I fell and put myself back to bed. Making AM rounds resident lying in bed seen with very large red bruise on inner right thigh and shakes with pain when touched, notified NP (Nurse Practitioner) who ordered Xray of right leg and hip to r/o (rule out) fracture, and for Keflex 500mg po TID (three times a day) for 7 days, also ordered a CBC and CMP for tomorrow. Resident vitals 152/88 HR (heart rate)70, temp 97.2, 92% RA, 18 resp. Tylenol given for pain, DON (Director of Nursing) also notified. (Radiology company) phoned for x-ray. Technician arrived in facility for Xray at 930am. Resident was later sent out to (hospital name) or further evaluation. Phoned residents responsible party to inform her that he was sent out for evaluation (phone number). Injury type, bruise, right thigh. Pain ,6. Mental status, confused/forgetful. Predisposing factors confused incontinent. R1's radiology report dated 7/11/23 denotes in-part right hip Xray, 2 views, findings right hip, Examination reveals what appears to be an impact [NAME] cervical fracture of the right femoral neck with varus deformity and some demineralization degenerative arthritis changes. R1's progress note dated 7/11/23 at 8:07am denotes in-part upon making AM rounds resident lying in bed seen with very large red bruise on inner right thigh and shakes with pain when touched, notified NP (Nurse Practitioner) whom ordered Xray of right leg and hip to r/o (rule out) fracture, and for Keflex 500mg po TID (three times a day) for 7 days, also ordered a CBC and CMP for tomorrow. Resident vitals 152/88 HR (heart rate) 70, temp 97.2, 92% RA (room air), 18 resp. Tylenol given for pain, DON (Director of Nursing) also notified. (Radiology company) phoned for x-ray. Technician arrived in facility for Xray at 930am. Resident was later sent out to (hospital name) or further evaluation. Phoned residents responsible party to inform her that he was sent out for evaluation (phone number). On 8/12/23 at 12:31pm V1 (Nurse) said she was the morning nurse caring for R1 when she was summoned to the room to look at R1's thigh. V1 said she noticed a red bruise to R1's right thigh extending down R1's leg. V1 said R1 was in a lot of pain, noticed with facial grimacing. V1 said she notified the Nurse Practitioner who gave orders for Xray and antibiotics. V1 said she gave R1 Tylenol for pain. V1 said R1 had increased pain, and that's when R1 was sent to the hospital for evaluation. V1 said the radiology company came and did R1's X-ray but due to the increase pain, R1 was sent to the hospital before the results came back. V1 said her shift originally started on another unit and she was moved to the unit that R1 was on. V1 said R1 was in severe pain, R1 was shaking and grimacing. On 8/12/23 at 3:50pm V3 (DON-Director of Nursing) said R1 had a fall from his bed. V3 said R1's roommate at that time saw R1 get himself up from the floor and get back in bed. V3 said the roommate was coming from the bathroom and observed R1 pick himself from the floor. The roommate said she did not know why he did not inform the nurse. V3 said she observed R1 with redness to the right inner thigh. On 8/12/23 at 11:47am V6 (CNA-Certified Nursing Aide) said he did not work with R1 on 7/10/23, V6 said he is familiar with R1, V6 said he has worked with R1 in the past and he's learned R1's behavior of trying to get out of bed when he's wet, so he makes sure he keeps R1 dry when he works with him. V6 said R1 has behaviors of trying to get out of bed when he's wet. V6 said he has seen R1 wheel himself out of his room in the mornings when he's getting ready to leave for his shift (11pm-7am). V6 said he does not know if staff has gotten R1 up or not in the morning when he sees him up in his wheelchair. On 8/12/23 at 11:50am V2 (CNA- Certified Nursing Aide) said he worked with R1 on 7/10/23 during the 11PM -7AM shift, V2 said he did not see R1 fall, he did not pick R1 up from the floor. V2 said R1 does have behaviors of trying to get out of bed. V2 said R1 is not on the morning get up list for the night shift. V2 said he changed R1 at 5:00am and last saw R1 around 7:00am before his shift ended. On 8/12/23 at 3:27pm V8 (Nurse) said she was the nurse responsible for R1's care on 7/10/23 on the 11:00pm-730am shift. V8 said she did not see R1 fall, she did not assist with picking R1 up from the floor. V8 said R1 does try to get out of bed. V8 said she saw R1 sleeping that night, she saw R1 at 1am, 3am, 5am and before she left for her shift. V8 said R1 was sleeping every time except for the time she was summoned in his room by V1. V8 said V1 summoned her to R1's room to look at R1's thigh on the morning of 7/11/23. V8 said she noticed R1's right thigh with redness. V8 said she went home after making her observation. On 8/13/23 at 10:02am V4 (CNA- Certified Nursing Aide) said she worked with R1 on 7/10/23 during the 3-11pm shift. V4 said she did not witness R1 fall. V4 said R1 is a resident that like's to watch the news, eat his meals, and lay in bed. V4 said R1 does have behaviors of trying to get out of bed. V4 said she put R1 to bed after dinner on 7/10/23 and provided incontinence care to R1 around 930pm. V4 said that was the last time she saw R1 for her shift. On 8/12/23 at 2:28pm V7 (MDS Nurse) said she initiated the care plans for medical diagnosis, R1's plan of care reviewed with V7 denoting alteration in hematological status related to vitamin D deficiency with initiated date of 9/1/2022, interventions fall risk assessment and increase vigilance for falls. V7 said she developed that intervention for R1 because R1 is at risk for falls. V7 said she don't do the fall care plans. V7 said vigilance for falls means checking on the resident as needed, V7 said she don't have a time frame, it's just as needed. On 8/12/23 at 2:56pm V5 (Restorative Nurse) said she was the restorative nurse, V5 said she initiates the fall care plans, updates the fall care plans, she does the fall evaluations also. V5 said R1 was able to stand and pivot with staff assist and cueing, V5 said there were days that R1 needed more assist from staff like touching and guiding with transfers. V5 said R1 was able to sit at the bed side. V5 said R1 had poor safety awareness that's why he needed assist with standing, pivoting, and transfers. V5 said she was not aware of R1's behavior of trying to get out of bed. V5 said the Nurses and CNAs should make her aware of R1's behaviors. V5 said R1 is a high fall risk now with a score of 13, and a prior score of 11. V5 said trying to get out of bed is not the same as a fall. V5 said trying to get out of bed puts R1 at risk for falls. V5 said the facility cannot physically restrain a resident to keep them in bed. V5 said if the staff would have made her aware of R1 trying to get out of bed she would have implemented putting more eyes on R1. V5 said more eyes on R1 means having someone in the room with him or having someone near his room. V5 said she would have implemented checking on R1 every two hours. V5 was asked how they are checking on R1 every two hours different from the standard every two-hour check that the staff were doing before the fall? V5 said she would have implemented every two-hour checks on R1. V5 said the interventions that were initiated on 7/12/23 after R5 left the facility was to be put in place upon his return to the facility. R1 did not return to the facility. On 8/13/23 at 10:31am V9 (physician) said he was made aware of the incident regarding R1 sustaining a hip fracture. V9 said the nurse observed R1 with a bruise to the thigh, the nurse practitioner was made aware, the Nurse practitioner order Keflex and Xray. V9 said the Nurse practitioner initially thought it was cellulitis based on what the nurse reported that's why Keflex was ordered. V9 said R1 received an Xray and was sent to the hospital for further evaluation. V9 said a fracture is the result of trauma unless there's an underling condition that the resident is not aware of. V9 said R1 was doing fine before this fracture. V9 said initially the facility did not know what happened to R1's leg. V9 said during the facility investigation it was determined that R1 had a fall. R1's roommate at that time saw R1 get up from the floor. R1's fall risk assessment dated [DATE] denotes a score of 11, R1 has unsteady gait and/or use of ambulatory device, R1 has confusion, R1 is 75 and above for age, R1 has medications drugs that have a diuretic or increase GI mobility, Drugs that affect the thought process, Drugs that create a hypotensive effect. R1 is incontinent. R1 fall risk assessment did not denote predisposing condition of hypertension. R1's plan of care with initiation date of August 2022 denotes in part fall, resident is high risk for falls cognitive deficits and use of psychotropic medications secondary to unspecified dementia with behavior disturbance, the goal is to remain free from injury related to falls through the next review date, interventions are to document signs and symptoms of adverse effects of medications on resident, encourage appropriate use of assistive devices, position, keep frequently used items within reach, monitor for any changes in condition, monitor resident for tolerance and endurance, scheduled task accordingly. Interventions with initiation date of 7/12/2023 denotes falling star program, floor mats in place while in bed, keep bed in lowest position R1 has a false sense of independence due to recently being on physical therapy, resident to be educated on seeking staff for assistance, the importance of complying with safety measures and possible complications of non-compliance, rounding at a minimum of Q (every) 2 hours and prompt or assist for change in position, toileting, offer fluids and ensure resident is warm and dry. R1's care plan for alteration in hematological status related to vitamin D deficiency with initiated date of 9/1/2022 denotes in-part, interventions fall risk assessment and increase vigilance for falls. R1 MDS dated [DATE] denotes BIMS score of 12 (cognitively intact). Facility policy titled fall prevention and management with last review date 7/2022 denotes in-part this facility is committed to maximizing each resident physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All falls shall be reviewed, and the resident existing plan of care shall be evaluated and modified as needed. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP (individualized service plan) with interventions with interventions implemented to minimize fall risk. Facility policy titled comprehensive care plan with last review date 3/2023 denotes in-part the facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the residents medical, nursing, mental and psychosocial needs. The comprehensive care plan should drive the care and services provided for the residents and allow for highest level of physical, mental, and psychosocial function based on the comprehensive MDS assessment. The comprehensive care plan should be reviewed with the residents and / or resident representative and changes made as appropriate.

Based on observation, interview, and record review, the facility failed to have effective interventions in place to prevent residents from developing new and worsening pressure ulcers for residents assessed to be at risk for developing pressure ulcers and who are totally dependent on staff for care. This failure applied to four (R2, R3, R5, and R6) of five residents reviewed for pressure ulcers and resulted in R2 and R3 developing facility acquired wounds; resulted in R5 being at an increased risk of Stage 4 pressure ulcer worsening or becoming infected and not progressing toward healing; and resulted in an increased risk for R6 to develop pressure ulcers as a result of untimely implementation of care plan interventions. Findings include: R5 is a [AGE] year-old female who was admitted to the facility on [DATE], with past medical history including, but not limited to intervertebral disc stenosis of neural canal of lumbar region, muscle wasting and atrophy, reduced mobility, morbid (severe) obesity due to excess calories, etc. 9/23/2022 at 12:45PM, R5 was observed in her room, alert and awake and stated that she has been in the facility since July 2022; she came from the hospital. R5 had her lunch tray, but stated that she has not been changed, she will usually call the staff, but she does not know who her assigned CNA (Certified Nurse Assistant) is, so she's not sure who to call. R5 stated that she was last changed around 5:00AM this morning, when asked if she need to be changed now, she said yes. 9/23/2022 at 12:50PM, V5 (CNA) stated that she is the assigned CNA for R5 and that she has not changed R5 yet. V5 stated that R5 will usually call when she needs to be changed. At 1:22PM, surveyor observed V5, and another staff member provide incontinence care for R5. Surveyor noted that R5 was wearing three incontinence briefs and they were visibly soaked with urine and large amount of bowel movement that went towards resident's back. Surveyor questioned why R5 had on three incontinence briefs and V5 said, We always do what she tells us to do. V5 and the other staff member who was assisting her cleaned R5 with two wet towels. Surveyor did not see that soap or water were used while providing incontinence care. V5 was about to put a clean incontinence brief on R5 when surveyor asked her if the resident had been washed up and she said, she gets a bed bath, it is scheduled, I am not sure if she gets one today. R5 stated that she gets her bed bath MWF, meaning that she was supposed to get one today. V5 said, Okay then we will give her a bed bath now. Care plan dated 7/15/202 states in part, R5 is incontinent of bowel and bladder secondary to morbid (severe obesity) low back pain, muscle wasting, etc. Interventions include check and change as needed, provide peri care after each incontinent episode. R5 requires assist with daily care needs, interventions include assist resident with ADLs, Encourage/Assist with turning and repositioning every two hours and as needed. Keep clean and dry after each incontinent episode. MDS assessment dated [DATE] coded R5 as total dependence with two persons physical assist for transfers and toilet use and extensive assist with two persons physical assist for bed mobility, dressing and personal hygiene. 9/24/2022 at 1:06PM, V14 (LPN/Wound care) said that she provided wound care to R5 around 6:00AM when she rounded with the wound care doctor, resident had one incontinence brief and a pad under her, she is not sure if night shift staff changed her again after the dressing change. V14 was asked if she has seen R5 or any other resident wearing more than one incontinence brief at a time, and she said that she has addressed that issue in the past; she educated the resident and the CNAs. V14 added that R5 should not be wearing more than one incontinence brief at a time because she has a stage 4 pressure ulcer to her right buttock. On 9/23/2022 at 12:50PM, surveyor was conducting random observation in the unit when she heard a resident screaming for help. R6 was observed lying in bed, awake and alert and stated that she needs to be changed. Surveyor told her that she will inform the staff. At 12:55PM, observed incontinence care with V5 (CNA) for R6 and noted resident's incontinence brief visibly soiled and brown in color. V5 stated that she changed resident around 6:00AM this morning because she worked night shift. V5 added that she has not changed R6 today since 6:00AM, she normally changes her residents after lunch. Surveyor asked V5 if it is the standard practice for night shift to change residents early in the morning and morning shift will change them after lunch and she said yes. She added that she is also assigned to R3, and she has not changed him either. Review of medical record for R6 shows a care plan in place for ADL care deficit, interventions include to Assist resident with ADLs, monitor for changes with daily care abilities and provide assist if needed, monitor skin integrity during routine care and report abnormal findings, etc. Facility Minimum Data Set assessment (MDS) for R6, dated 8/23/2022, section G (functional status) coded R6 as total dependence with two staff assist for transfer and toilet use and extensive assist with two- person physical assist for bed mobility, and personal hygiene. R3 is a [AGE] year-old male who has resided at the facility since 2014, with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 9/23/2022 12:00PM during random observation in the unit, R3 was observed in his room sleeping and could not awake to answer any questions. Resident was lying on his back; room appears cluttered with personal items. At 12:50PM, V5 (CNA) said that she is assigned to the resident, she has not changed him yet, she normally changes all her residents after lunch, night shift will change them in the morning and the day shift changes them after lunch. At 1:50PM, observed two staff members in resident's room with his door closed, stated they just finished changing resident. Surveyor asked if any of them is the assigned CNA for resident and they said no. Per record review, R3 was admitted to the facility with intact skin per initial skin assessment dated [DATE] documented an intact skin. R3 had a Braden score of 17 indicating at risk for alteration in skin integrity. Further review of medical record shows that R3 is currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care assessment dated [DATE] documented a stage 3 pressure ulcer to the coccyx, in-house acquired, measuring 2.7 x 4.1 x 0.9cm. Most current wound assessment dated [DATE] documented a stage 3 in-house acquired pressure ulcer to the coccyx measuring 4.0 x 4.8 x 1.1cm. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan dated 1/31/2019 for at risk for skin complications states to observe and assess regularly, skin assessments weekly. ADL care plan dated 4/28/2020 includes, R3 requires assistance from staff with ADLs. Resident has a dx/hx of [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Resident is an extensive assistance of two staff members for bed mobility, toileting and transfer, Resident is supervision with set up for meals. Resident has functional incontinence of bowel and bladder, etc. Interventions include Monitor for changes with daily care abilities and provide assist if needed, monitor skin integrity during routine care and report abnormal findings, stage 3 pressure injury to coccyx; Assist and encourage resident to turn and reposition every one to two hours and PRN (as needed). R3 is coded as needing extensive assist with two persons physical assist for transfer, bed mobility, toileting, dressing and personal hygiene. R2 is a [AGE] year-old female who has resided at the facility since 2018, with a past medical history including but not limited to Chronic obstructive pulmonary disease, [CONDITION(S)] disorder, heart failure, pulmonary hypertension, constipation, morbid severe morbid obesity, pressure ulcer of buttock unstageable, pain etc. R2 is no longer at the facility. Review of R2's medical records shows an initial skin assessment dated [DATE] with intact skin. Skin assessment dated [DATE] showed an in-house acquired pressure ulcer with no site or measurement. Medical record documents that on 7/31/2020, R2 has an abrasion to the left buttock, in-house acquired measuring 2.2cm x 0.8cm. Wound care assessment for R2 dated 8/14/2020 documented an in-house acquired abrasion to the right buttock measuring 3.5cm x 2.0cm. R2 has a care plan dated 9/07/2018 for at risk for new or worsening skin breakdown, interventions include educate resident, family and care givers the causes of skin breakdown including frequent repositioning, remind and assist resident to change position frequently, at least every two hours. R2's ADL care plan include assisting resident with ADL, keep clean and dry after each incontinent episode. MDS assessment dated [DATE] coded R2 as extensive assistance with two persons physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. 9/23/2022 at 3:48P V2 (DON) stated that her expectation for staff during incontinence care is for them to introduce themselves to the resident, ask them if they are wet, if yes, inform them that they are going to provide incontinence care. She added that they are supposed to provide privacy, perform hand hygiene, and make sure resident is cleaned properly. If a resident has a bowel movement, they should be cleaned with soap and water, residents should not be wearing more than one incontinence brief under any circumstance. V2 added that residents should be changed every two hours or as needed. V2 also said that the CNAs should know their assignments once to arrive on their shift; they can arrange with the residents the time they would like to have their showers or bed baths. A document provided by V2 (DON) titled, Incontinence Care Guideline (revision date of 3/2022), states in part, incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. Under general, the policy states: clean peri area with appropriate cleanser and dry. Appropriate cleanser can mean soap and water, peri wash, etc. Cleansing should always be from front to back.

Based on observations, interviews and record reviews, the facility failed to ensure one (R6) of 3 residents reviewed for abuse was free from assault and serious injury. Findings include: Initial Incident Report dated [DATE] documents, It was reported that R5 and R6 were involved in a physical altercation. Both residents were immediately separated, emergency contact notified and investigation initiated per facility protocol. R5 was noted with a laceration to the left side of the forehead above the eye area and first aid was immediately administered. R6 was noted with a laceration to the back of his head and first aid was immediately administered. Nurses' notes dated [DATE] documents, resident (R6) was involved in an altercation with another resident (R5). Both parties were separated and taken to different locations for safety. The resident (R6) was observed with blood on the back of his head. The area was cleansed. Also attempted to take the resident's vital signs and offered pain medication however he (R6) refused both. Stated that he (R6) was okay and wanted to be left alone. Nurses' notes dated [DATE] documents R6 transported by ambulance to community hospital. Hospital Emergency discharge date d [DATE] documents, R6 with history of [MEDICATION(S)] head injury, scalp laceration. Nurses' notes dated [DATE] documents, R6 noted with 3 sutures intact to posterior region of head upon arrival to nursing home. Nurse Practitioner notes dated [DATE] documents, R5 laceration site cleansed with saline; no active bleeding noted; steri-strips applied to approximated edges left forehead laceration site. Current Face Sheet documents, R5 admitted on [DATE]. R5 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current Face Sheet documents, R6 admitted on [DATE]. R6 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] At this time of this investigation on [DATE] at 9:00am, R5 and R6 continue to reside in rooms adjacent to each. On [DATE] at approximately 11:05AM, R5 requested to speak with writer. R5 was sitting in a wheelchair in the dayroom. R5 is a double below the knee [CONDITION(S)]. R5 observed with reddened eye and steri-strip stiches to the left eyebrow. At this time, R5 stated that nurses and CNAs were very nice and provided good care to him. R5 was asked about the injury to his left eyebrow. R5 stated he got into a fight with another resident (R6) a few days ago. R5 stated R6 had been very verbally abusive to him and staff. R5 stated that his own mother was a crack head and had abused drugs for years until she died . R5 said, R6 called my mother names and talked about her. I became very angry, had argument in the dayroom with R6. R6 hit me, I don't know with what, but I was bleeding. When asked R5 who hit who first, R5 said, I hit him first because I was angry when he said something about my mother, and he is always cursing at the female staff. R5 stated he took the armrest off of his wheelchair and hit R6 in the head. R5 said, when R6 came to R6 hit me in the eye. We were separated by staff, and I was sent to the hospital. I'm still in the room next door to his room. We apologized to each other; we get along now, just don't say anything to each other. R5 stated that R6 and he did not get along since he's been at the facility and argue a lot. R5 stated he was tired of R6 being verbally abusive to female staff and staff did not deserve that, but R6 would continue on with being mean, cursing at everyone, staff and other residents. On [DATE] at approximately 1:30pm, V1(Administrator) stated, R5 and R6 had a physical altercation on the evening of [DATE] in the dayroom and she has begun and submitted an initial investigation report to IDPH on [DATE]. V1 stated the investigation is ongoing. V1 provided the initial report of the investigation to survey team. On [DATE] at 2:30pm, V8 (Social Worker) stated that the incident between R5 and R6 happened on the evening shift on [DATE]. V8 commented that R5 and R6 had a physical altercation, R6 was sent to the hospital and came back to the facility the next day. V8 stated that R6 reported that R5 was aggressive towards him, and he (R5) retaliated. V8 said, R5 and R6 both have [CONDITION(S)]. R6 hallucinates a lot, responds to auditory hallucinations, responds to internal stimuli. V8 stated R5 apologized to R6. V8 commented that before the incident R5 would react to R6. V8 further comment that she would explain to R5 that R6 was not talking to him but talking out loud to himself. V8 stated that she would also talk with R6 because he could get loud. Behavior Care Plan dated [DATE] documents, R5 expresses maladaptive behavioral symptoms related to attention seeking and making false allegations, also repetitive complaints not regarding care. R5 makes false allegations when seeking attention. Interventions: Behavioral expectations: respectful conduct, no profanity or yelling. R5 with history of aggressive, inappropriate, maladaptive behavior. The history includes: Physical Aggression, Verbal Aggression, Socially inappropriate. R5 has a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff will intervene when any inappropriate behavior is observed. Behavior Care Plan dated [DATE] documents, R5 with history of aggressive, inappropriate, maladaptive behavior. Goal: R5 will behave in a manner consistent with resident conduct policies through the next review. Staff will monitor well-being of others. R5 will have zero episodes of abuse and neglect throughout next review. Current Behavior Care Plan for R6 documents, R6 with history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior. Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has a history of verbal and physical aggressive behaviors. While at the nursing station during interviews on [DATE] at approximately 2:50pm, with V9(CNA), V10(CNA) and V11(LPN) and V12(CNA) stated they were not at work when the physical altercation happened between R5 and R6. They stated the incident happened on the evening shift and they heard about what happened. At this time, V12 said, R5 flirts and is grabby with the women; know them (R5 and R6) to be aggressive. V9 said, I've not known them to argue before. They said the incident happened in the dining room. Their (R5 and R6) rooms are next to each other. R6 is legally blind. V10 said, R6 is 'in and out'. R6 can be verbally aggressive, R6 may curse somebody out. R6 don't like people bumping him. He, (R6) will spazz out. R6 is a below the knee [CONDITION(S)]. V11 said, V6 is always aggressive, try to help him. R6 makes noise yelling, using profanity, is verbally abusive towards women. V11 stated, both R5 and R6 are aggressive. R5 will remove hand rest on his wheelchair, uses it as a weapon, threatens you with it. Told me he may hit people with it. On [DATE] at approximately 4:00pm, R6 was resting in bed. R6 said, I'm doing ok. When asked about the incident involving a physical altercation with R5, R6 showed writer metal stitches on back of his head. R6 said, they (staff) gave him (R5) a weapon. What he (R5) did was done badly. He (R5) him me with it. I punched him (R5) with my fist. When asked if R5 felt safe at the facility, R5 said, I feel safe a little bit, not all the way because of what happened. He (R5) hit me before and staff was around, didn't do anything before. The don't do their job all the way. On [DATE] at 4:10pm, V1 (Administrator) and V13 (Social Worker) stated R5 is not in his room at this time. R5 is being moved to another room. On [DATE] at approximately 4:15pm with V1, V13 and V14 (Restorative Nurse), observed R5 demonstrate how he removes armrest from his wheelchair. R5 easily removed armrest from his wheelchair. The armrest was not locked in place. R5 placed armrest back on to his wheelchair. R5 was escorted back to the dayroom. At this time, V14 stated that they do not have any wheelchairs with unremovable or lockable armrest. V14 stated all our wheelchairs are the same. V14 stated the armrest is removable so that a resident can transfer between surfaces. At this time, V1 said, We will find a way to make sure R5 cannot remove the armrest to ensure he cannot use it as a weapon again. V14 will order R5 a new wheelchair that does not have the removable armrest. On [DATE] at 8:50am, V1 said, We secured R5 will chair armrests with a zip lock to make sure he cannot remove it. We're ordering R5 another wheelchair. Abuse Policy revision date ,d+[DATE] documents impart: This facility affirms the right of our residents to be free from abuse, mistreatment. This facility therefore prohibits abuse, neglect and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, and record review, the facility failed to follow the abuse policy, current plan of care and protect a resident assessed to be at risk for abuse from being physically attacked by another resident for one of three residents (R2) reviewed for physical abuse. This failure resulted in R2 being pushed to the ground and punched by R7, R2 was sent to the local hospital, and treated for [REDACTED]. Findings include: A review of the facility incident report dated 5/18/2018 indicates that R2 was struck by R7 in the hallway. R2 was assessed to have a small laceration to the right eyebrow. The incident report indicated that V27 (housekeeper) witnessed the incident. The report indicated that V27 said that R2 was walking closely behind R7, R7 then turned around and struck R2 in the lower body, causing R2 to go to the floor, R7 was noted to have struck R2 in the right side of her face. A review of R2's clinical record indicates that R2 is [AGE] years old with a [DIAGNOSES REDACTED]. R2's current plan of care dated 5/11/2018 indicates that R2 has a behavior of wandering. A review of the abuse/neglect screening dated 5/10/2018 indicated that R2 was identified to be vulnerable for abuse due to dementia, increased safety risk, impaired insight and judgement, verbally aggressive behaviors, and mental cognitive impairment related to making delusional statements, walking into peer personal space. A review of the R2's current plan of care origination date of 3/20/15 and revised on 5/18/2018, R2 is identified to be at risk for abuse/neglect. The goal is indicated that R2 will remain safe and will be free from abuse/neglect through the next reporting period. The noted intervention includes Assure resident that he/she is in a safe and secure environment with caring professionals. A review of R2's clinical record social service notes dated 5/18/2018 at 12:49pm documents that R2 was approached by a resident peer in a hostile manner; the resident peer was physically aggressive toward R2. The note then documents that R2 was sent to the hospital for evaluation. The nursing notes dated 5/18/2018 1:00pm documents R2 was struck and pushed down by roommate. R2 sustained a skin tear to the right brow. The wound was noted to be cleaned, steri-strip applied, and ice pack was applied. R2 was assisted to her feet and seated and transported to the hospital by ambulance team. On 12/11/18 at 5:10pm V27 (housekeeping staff) said she saw on 5/18/2018 that R2 was walking behind R7 and R7 turned and pushed R2 down and then punched R2 in the body. V27 said R2 hit her head on a metal ramp leading out to the patio area. V27 said that she noted R2 bleeding from the right side of her forehead. V27 said R2 was not verbally aggressive or noted to be provoking R7 prior to the attack. A review of R2's hospital records dated 5/18/18 shows clinical impression: laceration to face without complication, the hospital record indicated that EMS driver stated that R2 was hit in the face by another resident at the facility, R2 is noted to be irritable, and does not want the CT-Scan, R2 is noted to be pacing back and forth in the hallway. A review of the Facility's policy title Abuse Prevention Program documents that the facility affirms the right for their residents to be free from abuse/neglect and misappropriation of property. The policy also document(s) the purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse.

Based on interview, and record review, the facility failed to conduct a comprehensive assessment after a report of change in ability to walk and stand for 1 of 3 residents (R1) reviewed for comprehensive assessments. This failure resulted in R1 having difficulties with weight bearing, and walking for 2 days, before being assessed with [REDACTED]. Findings include: A review of the incident report dated 11/22/2018 R1 was found on the floor in (R4's) room seated with legs straight. Full body assessment performed L[NAME] (level of Consciousness) within normal limits ROM ( range of motion) performed x 4 extremities no limitation, or signs or symptoms of injuries noted at this time. R1 assisted to standing position with staff assistance, and ambulated throughout the hallways. The incident report is written by V9 (nurse). A review of the progress note of R1 dated 11/22/2018 documents that R1 had behavior episode. See behavior evaluation for details. On 12/27/18 at 11:33am V9 (Licensed Practical Nurse-LPN) said she was informed by R5 that R1 was sitting on the floor in his room, V9 said she did not get R1 up, R1 was assisted off the floor by V37 (activity aide). V9 said V37 brought R1 to her and she assessed him, and V9 said R1's (ROM)range of motion was within normal limits. V9 said R1 did not fall, he sat himself on the floor, V9 said she did not see him sit himself on the floor. Surveyor attempt to clarify the discrepancies in incident report documentation and verbal statement of what happened, V9 said whatever the report said then that's what happened. On 12/27/18 at 3:40pm V39 (Certified Nursing Assiatant- CNA) said 11/22/2018 after dinner R1 had difficulties walking when trying to assist him back to his room to bed. I had to stand behind him and guide him with force, R1 was holding on to wall, having trouble bearing weight on the left side and placing his weight to his right side. V39 said that R1 is usually independent with walking and doesn't require the assistance of the walls or the rails. V39 said that he reported to V9 (nurse) that R1 had difficulties with walking, and required assistance to get him back to his room. V39 said once R1 was placed in bed he remained there the remainder of the shift, V39 said that staying in bed was not R1's normal behavior because R1 likes to walk around the nursing unit. On 12/28/18 at 10:59am V9 said that V39 reported that he was having a difficult time assisting R1 back to his room, V9 also said she saw when V39 had to use force to assist R1 with walking to his room after dinner V9 said she thought R1 was resisting care, V9 said she did not assess R1 at that time when she noticed V39 using force to assist R1 with walking. On 12/27/18 at 7:50am V33 (CNA) said R1 did not fall when he worked with him on 11/22/18 (11p-7am shift). R1 did not get up and ask for snack on 11/22/18. I was not aware of any behavior R1 had that day. I did not know that he was on behavior monitoring. R1 walked a lot, he wandered. R1 slept the entire night when I worked with him, I didn't noticed anything abnormal. R1 did not complain of pain when I worked with him. R1 did not use a wheelchair when I worked with him. On 12/18/18 at 9:28am V28 (CNA) said she worked with R1 on 11/23/18 on 7am-3pm shift. V28 said upon starting her shift R1 was in the bed and she requested that V6 assist help getting R1 out of bed since she worked with him the night prior. V28 said she helped to put R1 in a wheel chair. Resident was in his room all day sitting in wheelchair. V28 said she thought R1 was different because he usually walks around the nursing unit, but, that day he was sitting in a wheelchair and falling asleep the entire shift, he only ate 50% of his lunch and R1 usually eats 100% of meals, V28 again said R1 didn't seem right. V28 said she reported it to V22 (nurse) and V22 said she would check on R1 and keep an eye on him. A review of V28's documentation on 11/23/2018 indicated a NA, V28 said when she documented on 11/23/18 NA-(not applicable) it means resident did not walk. V28 said she changed his brief he didn't seem to be in discomfort. I did my rounds on R1, I changed him after breakfast, before and after lunch, R1 was noted mumbling a lot, and I could not understand his mumbling. The only thing I noticed was R1 was not walking as he normally does. According to V1 (Administrator) she said that V22 (Nurse) no longer works for the facility, several phone attempts were made to contact V22, unsuccessfully. A review of the progress notes during V22's shift on 11/23/2108 documented no entries/assessments in regards to V28 reporting R1's change in condition with walking. On 12/14/18 at V7 (CNA) said he worked with R1 on 11/23/18 (3-11pm shift), R1 did not fall when he worked with him, V7 said R1 was in the bedroom for the entire shift sitting in a chair and that wasn't like R1. R1 did not walk around that shift, it was unlike R1 because R1 walked continuously. V7 said he did not inform anyone that he thought R1 was not his usual self he thought it was his medicine. V7 said R1 had behavior of sitting his self on the floor. V7 said R1 was not displaying signs of pain. Review of V7 point of care documentation shows R1 was independent for walking in room. V7 said that's was an error, R1 did not walk on 11/23/18 during 3-11pm shift. V7 said he should have reported to the nurse that R1 was not up ambulating as he usually does. On 12/14/18 at 9:50am V6 (CNA) said she worked with R1 on 11/23/18 11pm-7am shift. V6 said R1 was in the bed when she arrived on for her shift. V6 said R1 usually gets up at night and ask for something to eat, and he did not get up on 11/23/18 (11-7a shift), V6 said that was unusual for R1. V6 said she changed R1's brief around 1:00 am and she didn't notice anything wrong with R1. V6 said she checked on R1 several times that night and he was ok laying in the bed in a fetal position. V6 said in the morning around 6:45am when it was time to get R1 up he didn't want to be bothered, saying leave me alone and not wanting to get dressed, pulling the covers over his head. V6 said as she tried to stand R1 up, R1 kept leaning/falling back to the bed. V6 said she struggled to put R1's pants on because of this. V6 said someone helped her pull R1 pants up but she don't know who. V6 said once R1 was dressed she helped R1 back into bed. V6 said she did not inform anyone of what happened because she thought he was tired and didn't want to be bothered and it was time for her to go home. V6 said R1 did not have a fall on her shift. V6 said she did not get any report that R1 was on behavior monitoring. On 12/14/18 at 12:40pm V8 Certified Nursing Assistant-(CNA) said she worked with R1 on 11/24/18 (7am-3pm shift), V8 said when she was providing care and tried to stand R1 up he did not want to stand, she notice he was in pain and she informed the nurse (V5). V8 said V5 said I have to order an x-ray because R1 fell .

Based on interview, and record review, the facility failed to follow their fall care plan intervention that included frequent rounds, staff assistance, and failed to develop effective interventions to include undefined safety cues to meet the impaired cognitive status to prevent the incidents of falls for 1 of 3 (R2) resident reviewed for fall prevention. This failure resulted in R2 having 3 falls in 8 days, and the third fall R2 was sent to the local hospital where she was assessed to have a brain bleed, and bilateral acute subdural hematoma. Findings include: A review of R2's clinical record indicates that R2 is [AGE] years old with a [DIAGNOSES REDACTED]. R2's fall risk evaluation dated 1/16/18 score shows 8, fall risk evaluation dated 4/16/18 shows score of 8. According to fall risk evaluation a score of 10 or greater indicates high risk for fall. A review of R2 progress notes dated 7/7/18 at 10:45pm documents received resident alert at start of shift, alert but confused, laying on floor voluntary R2 added I just want to lay here-indication of her confused state. On 1/2/18 at 3:08pm V16 (Nurse) said he found R2 on the floor and R2 stated she just want to lay here therefore he did not consider R2 to have fallen. V16 said R2 was confused. V16 said he did not see R2 lay herself on the floor. V16 said he did not initiate the facility's fall policy. V16 said he did not report the occurrence to the physician. A review of R2's clinical record there was no fall risk assessment completed, nor was the current plan of care reviewed, or revised with fall prevention interventions the last documented fall revision was dated 7/26/2017 and last intervention promote call light placement documented was dated 10/4/2016. A review of R2's fall incident report dated 7/9/18 with revision date of 8/28/18 show incident description shows resident observed on her right side on the floor by the side of her bed. Resident appeared to be resting. Resident assessed, no pain observed, and noted to have redden area to right cheek. Injury type: bruise, injury location: face. R4 (roommate/witness) stated that R2 rolled out of bed onto the floor and appeared to have been sleeping. The incident report notes documented R4 stated that the resident rolled out of the bed onto the floor while she was sleeping. Resident laying on her right side and noted to have a redden area to right cheek. No complaints of pain/discomfort. Will continue to monitor. A review of the nursing notes dated 7/9/2018 9:01am documents that R2 is exhibiting weakness, and only able to walk a few steps and requires rest breaks, the note documents R2 is given a wheelchair and requires staff assistance for safe locomotion. Nursing note 12:15pm documents R2 still exhibits decreased activity tolerance, and endurance. Staff to provide assistance as needed. 12:20pm nursing notes documents R2 has had a fall. Please see post fall evaluation for details. A Review of the POS [REDACTED]. The post fall evaluation documents that R2 physician was notified on 7/6/2018 at 0600am and the emergency contact was notified on 7/6/2018 at 0700am. On 12/14/18 3:35pm R4 said that R2 didn't fall out of the bed, R4 said that I didn't tell anyone that R2 fell out of the bed. R4 said that she never saw R2 just lay on the floor. R4 was assessed to be alert and oriented x 3 during this interview. A review of the care plan dated 7/10/2018 documents that R2 is at risk for falls, with new interventions to include regular rounds, staff assistance, safety cues, promote placement of call lights. On 12/12/18 1:30pm V12 (restorative nurse) said she would not describe specific in regards to safety cues noted on the care plan. V12 said that she would be that specific. A review of the physical therapy evaluation dated 7/11/2018 documents R2 with dementia, Alzheimer's, muscle weakness, abnormalities of gait and mobility, and unsteadiness on feet. The therapy evaluation documents that R2 requires assistive device related to worsening gait and unsteadiness. The evaluation also documents that R2 requires contact guarded assistance and is more confined to a wheelchair. On 12/12/18 at 9:29am V35 (physical therapy) said that R2 was confused had impaired visual perception, posture deficits, head leaning forward, balance deficits, and able follow single step commands. V35 also said that R2 was referred due to being unsafe and unsteady gait, and unsteadiness promoting R2 for use of wheelchair. 12/12/18 2:20pm V16 said he don't remember all the details about R2's falls it's been awhile. I remember the roommate saying she stumbled coming back from the toilet. I found her on the floor when I was doing my rounds, I did my assessment and put her back to bed. Resident was able to talk but confused. I noticed the bruise on her face but it was old. I called the doctor, monitor her for change in condition, I believe I did neuro checks. A review of R2's fall incident report dated 7/15/18 at 7:45am with revision date of 8/13/18 shows incident description: resident observed on the floor when summoned by staff, resident on right side position on the floor. Resident unable to tell what happened to her. Three staff put resident back in bed, assessment done from head to toe. No visible injury noted. Denies pain, Nurse Practitioner on call for V19 (medical doctor) made aware. Resident will be sent out to hospital for evaluation. A review of R2's progress notes 7/15/18 at 8:45am R2 had a fall. See post fall evaluation. A Review of the POS [REDACTED]. The post fall evaluation documents that R2 physician was notified on 7/15/2018 at 08:45am and the emergency contact was notified on 7/15/2018 at 08:47am. There is no note or document reviewed with a description of why R2 was initially sent to the hospital. The progress notes dated 2:55pm documents local Ambulance Company called for transport to local hospital, the note documents R2 was being sent to the local hospital for a change in mental status. The progress notes documents that R2 left the facility in stable condition at 3:09pm A review of R2's hospital record dated 7/15/18 shows arrival time 3:43pm, at 3:48pm is documented that patient admits from the facility with complaints of fall. Patient was found at 8:00am lying on her right side on the ground. Patient is poor historian with a history of dementia. The hospital notes also documents that R2 is non-verbal, with a history of dementia and psychiatric disease. R2' fall is noted to be unwitnessed and downtime unknown, the local hospital documents they will obtain a CT imaging of the brain and cervical spine. The hospital records documents that R2 is assessed to have brain bleed, bilateral acute subdural hematoma, and a 10mm right to left midline shift, and recommends emergent transfer to another acute hospital.